Maternal and child health nursing

1. HYPERTENSION DURING
PREGNANCY

2. What is high blood pressure (hypertension)?
• Blood pressure is the force of blood pushing
against blood vessel walls.
• The heart pumps blood into the arteries
(blood vessels) that carry the blood
throughout the body.
• High blood pressure, also called hypertension,
means that the pressure in the arteries is
above the normal range.

3. How is high blood pressure (hypertension) during
pregnancy different from high blood pressure at
other times?
§ Mothers with high blood pressure during pregnancy are at a
higher risk of complications before, during and after the birth.
§ Not only is the mother’s health in danger, but the baby can be
impacted by high blood pressure during pregnancy.
§ High blood pressure during pregnancy can affect the
development of the placenta, causing the nutrient and oxygen
supply to the baby to be limited.
§ This can lead to an early delivery, low birth weight, placental
separation (abruption) and other complications for the baby.

4. What are the different forms of high blood
pressure (hypertension) during pregnancy?
• Chronic hypertension: High blood pressure which is present
prior to pregnancy.
• Chronic hypertension with superimposed
preeclampsia: Preeclampsia, which develops in someone who
has chronic hypertension (high blood pressure before
pregnancy).
• Gestational hypertension: High blood pressure is noted in the
latter part of pregnancy, but no other signs or symptoms of
preeclampsia are present. Some women will later develop
preeclampsia, while others probably have high blood pressure
(chronic hypertension) before the pregnancy.

5. • Preeclampsia: A condition only found in the
latter half of pregnancy and results in
hypertension, protein in the urine, and
generalized swelling in the mother. It can
impact other organs in the body and also
cause seizures (eclampsia).

6. Who is at higher risk of developing high blood
pressure (hypertension) during pregnancy?
• Is under age 20 or over age 40
• Has a history of chronic hypertension (high blood pressure before
becoming pregnant)
• Has had gestational hypertension or preeclampsia during past
pregnancies
• Has a family history of gestational hypertension
• Has diabetes or gestational diabetes
• Is overweight
• Has an immune system disorder, such as lupus
• Has kidney disease
• Is expecting multiple babies
• Had in vitro fertilization
• Is African American

7. Assessment
• Classic signs of PIH : Hypertension,
proteinuria, and edema
• other manifestation
• pulmonary edema (accumulation of fluid in the
lungs) may occur with severe cases
• HELLP syndrome (hemolysis, elevated liver
enzymes, low platelet) present in severe
preeclampsia and mild DIC

8. Symptoms of PIH
Hypertension
Type
Symptoms
Gestational
hypertension
Blood pressure 140/90 or systolic pressure elevated 30 mm HG or
diastolic pressure elevated 15 mm Hg above prepregnancy level;
No proteinuria or edema; blood pressure returns to normal after
birth
Mild pre-
eclampsia
Blood pressure 140/90 or systolic pressure elevated 30 mm Hg or
diastolic pressure elevated 15 mm Hg above prepregnancy level;
Proteinuria of 1-2+ on a random sample; weight gain over 2 lb per
week in second trimester and 1 lb per week in third trimester;
mild edema in upper extremities or face
Severe pre-
eclampsia
Blood pressure of 160/110; proteinuria 3-4+ on a random sample
and 5g on a 24-hour sample; oliguria (500 mL or less in 24 hours
altered renal function tests; elevated serum creatinine more than
1.2 mg/dL); cerebral or visual disturbances( headache, blurred
vision); pulmonary or cardiac involvement; extensive peripheral
edema; hepatic dysfunction; thrombocytopenia; epigastric pain
Eclampsia Seizure or coma accompanied by signs and symptoms of pre-
eclampsia

9. diagnostics
• laboratory test for patient’s with PIH
• hemoglobin and hematocrit – detects
hemoconcentration to indicates severity of GH
• platelets – thrombocytopenia
• urine for protein – proteinuria confirms GH
• serum creatinine – elevated creatinine and oliguria
• serum uric acid – elevated transaminase confirms liver
involvement

10. complications
• maternal
o increased intraocular (IOP) leading to retinal detachment
o HELLP syndrome
• Fetal
o fetal hypoxia
o usually small for gestational age – due to decrease placental
perfusion
o may be born prematurely
o newborn may be born oversedated due to maternal
medications that cross the placenta barrier
o may have hyper magnesemia due to maternal treatment of
MgSO4
o fetal death

11. treatment
• prevention
• correcting of some risk factors reduces the risk for
PIH development
oimproving diet
oearly and regular prenatal checkups allows PIH to be
diagnosed promptly so that it is more effectively
managed

12. § management
• birth or delivery of the baby is the cure for PIH
• treatment of PIH depends on the severity of the
hypertension and on the maturity of the fetus
• focuses on:
§ maintaining blood flow to the woman’s vital organs and
the placenta
§ preventing convulsions
• conservative treatment of PIH includes the
following:
§ activity restriction to allow blood that would be
circulated to skeletal muscles to be conserved for
circulation to the mother’s vital organs and the placenta
• woman should remain on bed rest on her side to improve flow
to the placenta

13. § maternal assessment of fetal activity (kick counts)
• should report a decrease in movement or if none occur during a
4-hour period
§ blood pressure monitoring two to four times per day in
the same arm and in the same position
§ daily weight measurement on the same scale, in the
same type of clothing, and the same time of day to
observe for sudden weight gain
§ checking urine for protein with a dipstick using a first-
voided, clean-catch specimen

14. Drug therapy
§ magnesium sulfate (MgSO4)
• an anticonvulsant given to prevent seizures (main purpose)
• may slightly reduce blood pressure
• usually given intravenously (IV)
• administration continues for at least12-24 hours postpartum
because the woman remains at risk for seizures
• is excreted by the kidney
• poor urine output may allow serum levels of magnesium to
reach toxic levels
• excess magnesium fist causes loss of the deep tendon reflex
(DTR) followed by respiratory depression
• if levels continue to rise, system collapse and death may
occur
• calcium gluconate - antidote MgSO4
o should be available at patient’s bedside

15. • inhibits uterine contractions
• women receiving the drug must also receive oxytocin to
strengthen labor contractions
• increased risk for postpartum hemorrhage because the
uterus does not contract firmly
• effective managing preterm labor
• the nurse should alert the newborn nursery stuff when MgSO4
has been administered during labor, because if the newborn is
treated with aminoglycosides, an interaction can occur and
result in paralysis of the newborn

16. § antihypertension drugs
• goal is gradual reaction of blood pressure to normal levels
• nurse should watch for sudden hypotension
• hydralazine and labetalol are the drugs often used
• dietary management
o high-protein diet
o moderate salt and fluid intake of 6-8 glasses per day

17. o moderate salt and fluid intake of 6-8 glasses per day
Drugs Used in Pregnancy-Induced Hypertension
Drug Indication Dosage Comments
Magnesium
sulfate
Pregnancy
risk
Category B
Muscle relaxant;
prevents seizure
Loading dose 4-6 g
Maintenance dose
1-2 g/h IV
Infuse loading dose slowly over 15-30 min.
Always administer as a piggyback infusion
Assess respiratory rate, urine output, deep
tendon reflexes, and clonus every hour.
Urine output should be over 30 mL/hour and
respiratory rate over 12/min. Serum
magnesium level should remain below 7.5
mEq/L.
Observe for CNS depression and hypotonia
in infant at birth and calcium deficit in the
mother.
Hydralazine
(Apresoline )
Pregnancy risk
Category C
Antihypertensive
(peripheral
vasodilator);
used to decrease
hypertension
5-10 mg/IV Administer slowly to avoid sudden fall in
blood pressure.
Diazepam
(Valium)
Pregnancy risk
Category D
Halt seizures 5-10 mg/IV Administer slowly. Dose may be repeated q
5-10 min (up to 30 mg/hour).
Observe for respiratory depression or
hypotension in mother and respiratory
depression and hypotonia in infant at birth.
Calcium
gluconate
Pregnancy risk
Category C
Antidote for
magnesium
intoxication
1 g/IV (10 mL of a
10% solution)
Have prepared at bedside when
administering magnesium sulfate.
Administer at 5 mL/min.

18. Magnesium Sulfate
• Action: Magnesium sulfate is a central nervous
system depressant that acts to block
neuromuscular transmission of acetylcholine to
halt convulsions. It also halts premature labor, as
it relaxes smooth muscle.
• Pregnancy Risk Category: A
• Dosage : Initially, 2-6 g IV administered in a
250-mL solution over a 20-minute period,
followed by individually calculated IV infusion
at a rate to maintain designated serum levels
ü therapeutic range: 5.0-8.0 mg/100 mL
ü patellar reflex disappears: 8-10 mg/100 mL
ü cardiac conduction defects occur: More than 20 mg/100 mL

19. • Possible Adverse Effects: Flushing, thirst;
with toxicity, absence of deep tendon reflexes,
respiratory depression, cardiac arrhythmias,
cardiac arrest, and decreased urine output
• Nursing Implications
• administer continuous infusion piggybacked
into a main IV line so it can be discontinued
immediately without interfering with fluid
administration.
• Always use an infusion control device to
maintain a regular flow rate.

20. • Assess maternal blood pressure and fetal heart
rate continuously with bolus IV administration.
• Assess deep tendon reflexes every 1-4 hours
during continuous infusion. Use patellar reflex. If
patient has received epidural anesthesia, use
biceps reflex.
• Monitor intake and output every hour during
continuous infusion. Urine output should be 30
mL/hr or greater.
• Assess client’s level of consciousness, including
ability to respond to questions, every hour.

21. • Obtain serum magnesium levels as indicated,
usually every 6-8 hours.
• Keep calcium gluconate, the antidote for
toxicity, readily available at the bedside.
• Maintain serum blood levels ( for
anticonvulsant use) at 5-8 mg/100 mL. If blood
serum levels rise above this, respiratory
depression, cardiac arrhythmias, and cardiac
arrest can occur.

22. • Do not administer additional doses and stop
infusion if deep tendon reflexes are absent or if
respiratory rate is less than 14 or urine output is
less than 30 mL/hr.
• This drug may cause respiratory depression int eh
newborn if administered close to birth. Alert
neonatal care personnel about this possibility.
• Magnesium sulphate may cause osteoporosis in
the mother if given over a long time.
Supplemental calcium can prevent this outcome.

23. Nursing Care
• Focuses on:
– assisting woman to obtain pregnancy care
– helping the woman cope with therapy
– caring for the acutely ill woman
– administering medications

24. § goal: assisting women to obtain prenatal care and
recognizing early s/s
• check BP
• monitor for non dependent pathologic edema
(periorbital and hands)
• monitor urine for proteinuria (usually the last of the
triad of symptom to appear)
§ goal: helping the woman cope with therapy
• daily weight measurements
• help client understand the importance of bed rest
• maintain normal sodium intake
• avoid use of diuretics
• monitor for ominous signs of deteriorating condition
(see clinical manifestation)

25. § goal: caring for the acutely ill
• modify environment to ensure rest and quit (to reduce
the risk of seizures)
§ eliminate noise, bright lights other harsh stimuli
§ minimize number of personnel giving care
§ initiate painful and/or intrusive procedures after sedation
§ promote comfort at bed rest
• administer IV MgSO4 as indicated
• have emergency items readily available (O2, suction
machine, sedatives, antidote – calcium gluconate)
• if seizure occurs focus is to prevent injury and restore
oxygenation to the mother and fetus
§ turn to the side to prevent aspiration of secretions
§ do not forcibly hold the client’s body
§ protect client by clearing the area from hard objects

26. § after seizure:
• clear secretion
• administer oxygen by face mask
• reorient client to the environment
§ goal: administering medications
• review hospital protocols for MgSO4
administration
• monitor blood pressure, pulse and respirations q
hourly; temperature q 4hrs
• deep tendon reflexes checked q 1-4 hours
• report immediately s/s of magnesium toxicity
§ absent deep tendon reflex
§ respiration under 12 breaths/min
§ urine output less than 30ml/hr
§ serum magnesium levels above 8mg/dl
• administer antidote if indicated

27. § goal: antepartum home care
• exercise may have to be decreased
• avoid weight loss programs
• discontinue smoking and alcohol intake
• daily blood pressure measurement
• daily weight checks
• monitor fetal lucks and uterine activity
• balanced diet with sufficient protein to replace loss

28. § goal: postpartum care
• close monitoring for 48 hours due to continued
risk for seizure
• may require antihypertensive drugs specifically
methyldopa or labetalol
• because other drugs may have adverse effects on
the breastfeeding infant
• diuretics is still discouraged because it will
decrease milk production

29. Nursing Interventions( Summary )
Intervention for mild PIH: Rationale:
1. Assess maternal VS and fetal heart rate.
-to detect any increase which is warning that a women’s
condition is worsening.
2. Encourage elevation of edematous arms
and legs.
-to increase venous blood return.
3. Encourage compliance with bed rest in a
lateral recumbent position.
-to increase evacuation of sodium and encouraging diuresis and
lateral recumbent position can avoid uterine pressure on the
vena cava and prevent supine hypotension syndrome.
4. Provide emotional support.
-this can make a women underestimate the severity of the
situation.
5. Support patient with bed rest and darken
the room if possible.
-because a bright light can trigger seizures.
6. Obtain daily hematocrit levels as ordered.
-to monitor blood concentration and help to the extent of
plasma loss to interstitial space or extent of the edema.
7. Obtain blood studies (CBC, platelets
count, liver function, BUN and creatinine,
and fibrin degregation).
-to assess for renal and liver function and the development of
disseminated intravascular coagulation which often
accompanies severe vasospasms.
8. Obtain daily weights at the same time
each day.
-to evaluate tissue fluid retention.
9. Raise side rails. -to help prevent injury if seizure should occur.
10. Support nutritious diet of moderate to
high in protein and moderate in sodium.
-to compensate for protein she is losing in her urine.
11. An indwelling catheter may be inserted
as ordered.
-to allow accurate recording of output and comparison with
intake.
12. Oxygen administration to the mother
may be given as ordered.
-to maintain adequate fetal oxygenation and prevent fetal
bradycardia.
13. Administer medication for seizures and
hypertension episodes as ordered.
-to prevent seizures and hypertension.

30. Intervention for severe PIH: Rationale:
1. Maintain patient’s airway by not putting a
tongue blade between a women’s teeth during
seizures.
-to prevent broken of teeth which could then be aspirated.
2. Turn a woman on her side. -to allow secretions to drain from her mouth.

31. Discharge Plan
Exercise
1. encourage patient’s on deep breathing exercises.
2. move extremities when lying.
3. elevate the head part when sleeping, to promote increase peripheral circulation
4. encourage overall passive and active exercises programduring pregnancy to prevent need for
cesarean birth.
5. exercises like tailor sitting, squatting, kegel exercise, pelvic rocking, and abdominal muscle
contraction will promote easy delivery.
Treatment:
1. use of drugs
2. catheterization
3. obtaining labs. (CBC, platelets count, liver function, BUN and creatinine, and fibrin degregation)

32. HealthTeaching:
1. Encouragepatient foesodiumrestriction.
2. Encouragetoavoidfoodsrichinoil andfats.
3. Encouragepatient tolimit her dailyactivitiesandexercises.
OngoingAssessment:
1. Observecarefullyfor symptomsat prenatal visit.
2. Giveinstructionabout whatsymptomstowatchforsoshe canalert her clinicianifadditional
symptomsoccur betweenvisits.
Diet:
1. lowfatsandsodiumdiet,restrictionif possible.
2. highinprotein,calciumandiron.
3. Adequatefluidintake
Sex:
1. limit sexual activity
2. sexual intercourseat 2ndtrimester shouldbeavoided.

33. Symptoms of tonic-clonic seizure
Manypersons with generalized tonic-clonic seizures have vision, taste, smell, or sensorychanges, hallucinations,
or dizziness before the seizure. This is called an aura.
The seizures usuallyresult in rigid muscles. This is followed by violent muscle contractions and loss of alertness
(consciousness). Other symptoms that occur during the seizure may include:
• Biting the cheek or tongue
• Clenched teeth or jaw
• Loss of urine or stool control (incontinence)
• Stopped breathing or difficulty breathing
• Blue skin color
After the seizure, the person may have:
• Confusion
• Drowsiness or sleepiness that lasts for 1 hour or longer
• Loss of memory(amnesia) about the seizure episode
• Headache
• Weakness of one side of the body for a few minutes to a few hours following seizure (called Todd
paralysis)