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Nursing considerations for pregnancy

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A complete overview of pregnancy for student nurses, paramedics, and ancillary healthcare. Covers the major disorders and emergencies of pregnancy.
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Nursing considerations for pregnancy

  1. 1. Nursing Considerations for Pregnancy and Antepartum Care Information compiled from ati review modules, kaplan study guides, and other sources. Assembled by Tentance
  2. 2. Presumptive Signs of Pregnancy Changes that are experienced by the woman that make her think that she may be pregnant. These changes may be subjective symptoms or objective signs. Signs may also be a result of physiological factors other than pregnancy - diseases like peristalsis, pelvic congestion, and tumors. Amenorrhea Fatigue Nausea and vomiting Urinary frequency Breast changes – Darkened areola, enlarged Montgomery’s tubules Quickening – slight fluttering movements of the fetus felt by a woman, usually between 16 to 20 weeks of gestation. Uterine enlargement Linea nigra Chloasma (mask of pregnancy) Striae gravidarum
  3. 3. Probable Signs of Pregnancy changes that make the examiner suspect a woman is pregnant (primarily related to physical changes of the uterus). Signs can be caused by physiological factors other than pregnancy. Abdominal enlargement related to changes in uterine size, shape, and position Cervical changes Hegar’s sign – softening and compressibility of lower uterus Chadwick’s sign – deepened violet-bluish color of vaginal mucosa secondary to increased vascularity of the area Goodell’s sign – softening of cervical tip Ballottement – rebound of unengaged fetus Braxton Hicks contractions – false contractions, painless, irregular, and usually relieved by walking Positive pregnancy test Fetal outline felt by examine
  4. 4. A nurse understands that a client is demonstrating probable signs of pregnancy when which of the following signs are observed by a primary care provider? (Select all that apply.) Chloasma Goodell’s sign Ballottement Chadwick’s sign Quickening
  5. 5. A nurse understands that a client is demonstrating probable signs of pregnancy when which of the following signs are observed by a primary care provider? (Select all that apply.) Chloasma Goodell’s sign Ballottement Chadwick’s sign Quickening Goodell’s, Chadwick’s, and Ballottement are probable signs of pregnancy
  6. 6. Confirming Pregnancy Hear the fetal heartbeat (about 8 weeks by doppler and by 20 weeks with auscultation) Palpation of fetal movement Outline of fetal skeleton by sonogram or x-ray (done only if absolutely necessary late in pregnancy) Pregnancy test - checks for HCG (human chorionic gonadotropin) Immunologic tests can detect HCG in woman’s urine by 2 wk after missed period; cannot measure the amount of HCG; false readings may occur with inappropriate timing, handling error, or some medications
  7. 7. Human Chorionic Gonadotropin HCG can be detected 6 to 11 days in serum and 26 days in urine after implantation. Production of hCG begins with implantation, peaks at about 60 to 70 days of gestation, and then declines until around 80 days of pregnancy, when it begins to gradually increase until term. Higher levels of hCG can indicate multifetal pregnancy, ectopic pregnancy, hydatidiform mole (gestational trophoblastic disease), or a genetic abnormality such as Down syndrome. Lower blood levels of hCG may suggest a miscarriage or ectopic pregnancy. Some medications (anticonvulsants, diuretics, tranquilizers) can cause false-positive or false-negative pregnancy results. Urine samples should be first-voided morning specimens.
  8. 8. Pregnancy Hormones Human chorionic gonadotropin (hCG): confirms pregnancy; maintains pregnancy; continues secretion of progesterone and estrogen from corpus luteum during first trimester; causes morning sickness; peaks at end of first trimester, then drops; high levels associated with hydatidiform mole. Estrogen: secreted during last two trimesters; promotes vasodilation; softens cervix; helps prepare breasts for lactation; causes sodium and water retention; increased estriol levels in maternal saliva may indicate preterm labor Progesterone: inhibits uterine contractions; promotes smooth muscle relaxation, causing decreased GI motility and increased bladder capacity; promotes sodium loss Human placental lactogen (hPL) or human chorionic somatomammotropin (hCS): diabetogenic (diminished insulin efficiency); decreases maternal utilization of glucose, providing more glucose for fetal growth; affects lipid and protein metabolism; helps prepare breasts for lactation
  9. 9. Hydatidiform mole Degenerative anomaly of the trophoblastic villi (embryo fails to develop beyond a primitive state). Can lead to a cancerous growth (choriocarcinoma). Characterized by Elevated HCG levels Uterine size greater than expected for dates No FHR Minimal dark red/brown vaginal bleeding with passage of grapelike clusters at approximately 16 weeks of gestation No fetus by ultrasound Hyperemesis Pregnancy induced hypertension, edema, proteinuria (symptoms of pre-eclamsia) Risk factors include - low protein intake, under 18 years old, older than 35 years old.
  10. 10. Medically treated with curettage to completely remove all molar tissue, which can become malignant. Pregnancy is discouraged for 1 year, and HCG levels are monitored during that time (if levels continue to be elevated, may require hysterectomy and chemotherapy) Nursing Care Measure fundal height. Assess vaginal bleeding and discharge. Assess gastrointestinal status and appetite. Assess the client’s extremities and face for edema. Administer chemotherapy for choriocarcinoma in the event of an abnormal rising hCG titer, an enlarging uterus, and findings of malignant cells. Medications - Administer RhO(D) immune globulin (RhoGAM) to the client who is Rh-negative. Discharge instructions Advise the client to bring any clots or tissue passed to the provider for evaluation. Provide client education about the disease and emotional support regarding the loss of an anticipated pregnancy. Instruct the client to use reliable contraception for 12 months because a pregnancy would make it impossible to monitor the decline in hCG levels. Instruct the client about the critical importance of follow up because of the increased risk of choriocarcinoma..
  11. 11. A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea and vomiting and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected for the duration of pregnancy. Which of the following complications should the nurse suspect? A. Hyperemesis gravidarum B. Threatened abortion C. Hydatidiform mole D. Preterm labor
  12. 12. A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea and vomiting and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected for the duration of pregnancy. Which of the following complications should the nurse suspect? A. Hyperemesis gravidarum B. Threatened abortion X C. Hydatidiform mole D. Preterm labor Hydatidiform mole (gestational trophoblastic disease) exhibits a uterine size that increases abnormally fast. The trophoblastic tissue causes abnormally high levels of hCG that result in excessive nausea and emesis. There is no fetus present on the ultrasound. There may be scant or profuse dark brown or red vaginal bleeding that first occurs in the second trimester, usually around the 16th week of gestation. Hyperemesis gravidarum is accompanied by weight loss and dehydration. Threatened abortion occurs in the first trimester and is indicated by spotting to moderate bleeding, but the uterus is not abnormally enlarged. Preterm labor presents prior to 37 weeks of gestation and is accompanied by pink-stained vaginal discharge and uterine contractions that become more regular.
  13. 13. Estimating Delivery Date Nägele’s rule – take the first day of the woman’s last menstrual cycle, subtract 3 months, and then add 7 days and 1 year. Remember how many days there are in each particular month when adding 7 days. Assumes a 28 day cycle and no recent use of oral contraceptives. McDonald’s method – measure uterine fundal height in centimeters from the symphysis pubis to the top of the uterine fundus (between 18 to 30 weeks of gestation). Then estimate gestational age to be equal to that of the fundal height. At 20 weeks it should be at the umbilicus; at 36 weeks it should be at the xiphoid process. Ultrasound - used up to 11 weeks gestational age, taken by crown to rump measurement. Mother must have a full bladder to move uterus into abdominal cavity for visualization.
  14. 14. Gravida and Para Gravidity – number of pregnancies. Nulligravida – a woman who has never been pregnant. Primigravida – a woman in her first pregnancy. Multigravida – a woman who has had two or more pregnancies. Parity – number of pregnancies in which the fetus or fetuses reach viability (approximately 20 to 24 weeks or fetal weight of more than 500 g [2 lb]) regardless of whether the fetus is born alive or not. Nullipara – no pregnancy beyond the stage of viability. Primipara – has completed one pregnancy to stage of viability. Multipara – has completed two or more pregnancies to stage of viability. Abortion - pregnancy that terminates before viability.
  15. 15. GTPAL Gravidity Term births (38 weeks or more) Preterm births (from viability up to 37 weeks) Abortions/miscarriages (prior to viability) Living children
  16. 16. Physiological Changes Uterus Changes in size, structure, and position to become a thin-walled, muscular abdominal organ capable of containing the fetus, placenta, and amniotic fluid In the early months of pregnancy, growth is partly due to formation of new muscle fibers and enlargement of preexisting muscle fibers After the first trimester, the increase in size is partly mechanical due to the pressure of the developing fetus By 36 weeks, the top of the uterus and the fundus will reach the xiphoid process. The full-term pregnant uterus and its contents weigh about 12 lb
  17. 17. Cervix Undergoes increased blood supply, edema, and hyperplasia of the cervical glands contributing to: Softening (Goodell’s sign) about 6 weeks. A blue-violet color (Chadwick’s sign) about 6–8 weeks Increased friability (bleeds easily after Pap smear and intercourse) Distention of cervical mucosa glands with mucus, the “mucous plug” that seals the endocervical canal and inhibiting the ascent of bacteria and other substances into the uterus Vagina and external genital organs Enlarge, soften, thicken, and develop blue-violet hue as a result of increased vasculature Vaginal secretions become alkaline, causing an increased risk of vaginitis Connective tissue loosens in preparation for labor and delivery
  18. 18. Breasts Enlarge early in pregnancy, causing progressive feelings of heaviness, fullness, and tenderness Nipple and areola become larger, darker in color; blood vessels enlarge and become prominent beneath the skin Body mass Changes with weight gain; total desirable weight gain in pregnancy (for average woman) is about 23–28 lb; 3–4 lb (1.36–1.81 kg) during the first trimester, followed by an average of slightly less than one pound per week for the rest of the pregnancy Pulmonary In the later months of pregnancy, the enlarged uterus causes the diaphragm to be displaced upward, putting pressure on the lungs and causing shortness of breath
  19. 19. Skin Pink or reddish streaks (striae gravidarum) may occur on breasts, abdomen, buttocks, and/or thighs as a result of fat deposits, which cause stretching of the skin Increased pigmentation can occur on the face as blotchy brown areas on the forehead and cheeks (chloasma or “mask of pregnancy”) and on the abdomen as dark line from the symphysis pubis to the umbilicus (linea nigra) Minute vascular spiders may occur The umbilicus is pushed outward, and by about the seventh month its depression disappears and becomes a darkened area on the abdominal wall Sweat and sebaceous glands are more active
  20. 20. Musculoskeletal Change in the center of gravity, decreased muscle tone, and increased weight- bearing cause an accelerated lumbosacral curve, which may lead to lower back pain and difficulty with locomotion Progesterone-produced relaxation and increased mobility of the pelvic joints may cause discomfort and difficulty in walking The vertical abdominal muscles may separate (diastasis recti) Cardiac Change in size and shape with resulting cardiac hypertrophy to accommodate increased blood volume and increased cardiac output. Heart sounds change to accommodate the increase in blood volume with a splitting of S1 and S2, with S3 heard following 20 weeks of gestation. Murmurs may also be auscultated. Heart size and shape will return to normal shortly after delivery Blood Total volume increases by about 30%, normal blood pressure is maintained by peripheral vasodilation
  21. 21. RBC production increases; WBC count increases; clotting factors increase while fibrinolytic activity decreases Hemoglobin and hematocrit levels decrease slightly in response to hemodilution (increased plasma content); hemoglobin less than 10 g/dL or hematocrit less than 35% may indicate anemia The increased blood volume creates the need for the heart to pump more blood through the aorta (about 50% more blood per minute) resulting in increased heart rate; occasional palpitations can be felt Peripheral edema in last 6 weeks: caused by venous stasis Digestion Nausea and vomiting may occur in the first trimester; vomiting that is excessive or persists beyond this time (hyperemesis gravidarum) may require medical management; appetite usually improves as pregnancy advances Progesterone-induced relaxation of smooth muscle tone, reduction in total acidity of gastric juices, and pressure from the growing uterus may cause heartburn, flatulence, and constipation Aversions or cravings for certain foods or unusual substances (pica) may occur
  22. 22. Carbohydrate metabolism is increased to meet the needs of fetus and the metabolic needs of mother to support tissue expansion The first half of pregnancy Maternal glucose is moved across the placenta by active transport; causing maternal glucose levels to fall slightly; her pancreas responds by decreasing production of insulin Maternal insulin does not cross the placenta By the 8th week the fetus’s own insulin production is consistent with the amount of glucose received from the mother The second half of pregnancy The placental hormones impede the mother’s ability to utilize insulin; the resulting demand for added insulin can be met by a normally functioning pancreas
  23. 23. Urinary system Urinary output is increased and has a low specific gravity; possible tendency to excrete glucose Reabsorption of sodium and decreased water output (latter half of pregnancy) is a compensatory mechanism to maintain increased blood volume Ureters become dilated (especially the right ureter) due to the pressure of the enlarged uterus The dilated ureters are unable to propel urine as efficiently, resulting in stasis of urine and possible urinary tract infection Urinary frequency may occur early in pregnancy and later again when “lightening” occurs, result of increased pressure on the bladder from the enlarged uterus
  24. 24. Hormonal ChangesPlacental 1) Estrogen - enlargement of uterus, breasts, genitals; growth of glandular tissue, ducts, alveoli, and nipples; fat deposition; increased elasticity of connective tissue; altered thyroid function; altered nutrient metabolism; sodium and water retention by kidneys; hypercoagulability of blood; vascular changes 2) Progesterone - development of decidua; decreased contractility of the uterus; decreased gastric motility (sphincters relaxed); increased sensitivity to CO2 in respiratory center; decreased tone of smooth muscle; development of secretory portions of lobular- alveolar system in breasts; sodium excretion 3) Human chorionic somatomammotropin and human placental lactogen; anabolic effect; insulin antagonist Pituitary gland Anterior lobe secretes prolactin hormone after delivery of the placenta Posterior lobe secretes oxytocin during labor and lactation
  25. 25. Vital Sign Changes Blood Pressure First Trimester - measurements are within the prepregnancy range Second Trimester - decreases 5 to 10 mm Hg for both the diastolic and the systolic Third Trimester - should return to the prepregnancy baseline range after 20 weeks Position of the pregnant woman may also affect her blood pressure. While supine, blood pressure may appear to be lower due to the weight and pressure of the gravid uterus on the vena cava, which decreases venous blood flow to the heart. Maternal hypotension and fetal hypoxia may occur, which is referred to as supine hypotensive syndrome or supine vena cava syndrome. Signs and symptoms include dizziness, lightheadedness, and pale, clammy skin. Encourage the client to engage in maternal positioning on the left-lateral side, semi-Fowler’s position, or, if supine, with a wedge placed under one hip to alleviate pressure to the vena cava.
  26. 26. Pulse Increases 10 to 15/min around 20 weeks of gestation and remains elevated throughout the remainder of the pregnancy. Respirations Increase by 1 to 2 breaths per min. Respiratory changes in pregnancy are attributed to the elevation of the diaphragm by as much as 4 cm as well as changes to the chest wall to facilitate increased maternal oxygen demands. Fetal heart tones Are heard at a normal baseline rate of 110 to 160/min with reassuring FHR accelerations noted, which indicates an intact fetal CNS.
  27. 27. Psychological Changes First trimester - maternal ambivalence, even in planned pregnancy, is usual; there may be some anticipation and concern related to fears and fantasies about the pregnancy Second trimester - usually increased maternal feelings of physical and emotional well- being; mother is often described as self-absorbed and introverted Third trimester - possible new fears related to labor and delivery and fantasies about the appearance of the baby; feelings of awkwardness, clumsiness, and decreased femininity related to changes in body image Paternal reactions - may parallel those of mother; some may experience physical symptoms of pregnancy (Couvade syndrome) Sibling adaptation - age and experience related
  28. 28. Nursing Interventions Offer acknowledgement and encouragement in the sharing of feelings regarding the pregnancy by providing an atmosphere free of judgment. Discuss with the client the expected physiological changes and a possible timeline for a return to the prepregnant state. Assist the client in setting goals for the postpartum period in regard to self-care and newborn care. Refer the client to counseling if the body image concerns begin to have a negative impact on the pregnancy.
  29. 29. Provide education about the expected physiological and psychosocial changes. Common discomforts of pregnancy and ways to resolve those discomforts can be reviewed during prenatal visits. The mother should be encouraged to keep all follow-up appointments and to contact the primary care provider immediately if there is any bleeding, leakage of fluid, or contractions at any time during the pregnancy
  30. 30. Prenatal Care Begins with an initial assessment and then continues throughout pregnancy. In an uneventful pregnancy, prenatal visits are scheduled every month for 7 months, every 2 weeks during the eighth month, and every week during the last month. Initial prenatal visit: Determine estimated date of delivery based on the last menstrual period. A vaginal ultrasound may be done to establish the estimated date of delivery. Obtain medical and nursing history to include: past medical health, family history, social supports, and review of systems (to determine risk factors) and past obstetrical history. Perform a physical assessment to include a client’s baseline weight, vital signs, breast and pelvic examination. Have the client empty her bladder prior to the exam. Assess for evidence of domestic violence (e.g., partner answers questions for woman, injuries to breast/abdomen, multiple health care visits).
  31. 31. Obtain initial laboratory work to induce blood type, Rh factor, HIV status, hepatitis B, venereal disease research laboratory, rubella status, urinalysis, and Papanicolaou test. An indirect Coombs’ test will determine if a client is sensitized to Rh-positive blood. Ongoing prenatal visits include: Monitoring weight, blood pressure, and urine for glucose, protein, and leukocytes. Monitor a client for the presence of edema. Monitoring fetal development. Fetal heart rate (FHR) is a significant predictor of fetal well-being and should be monitored at all routine prenatal and any acute care visits. FHR can be heard by Doppler at 10 to 12 weeks of gestation or heard with an ultrasound stethoscope at 16 to 20 weeks of gestation. Listen at the midline, right above the symphysis pubis, by holding the stethoscope firmly on the abdomen. Start measuring fundal height after 12 weeks of gestation. Between 18 and 30 weeks of gestation, the fundal height measured in centimeters should equal the week of gestation. Have the client empty her bladder and measure from the level of the symphysis pubis to the upper border of the fundus.
  32. 32. Begin assessing for fetal movement between 16 and 20 weeks of gestation. A regular pattern of 10 movements in 20 min to 2 h twice/day is a good indicator of fetal well-being; less than 10 movements in a 3 hour period should be reported Providing education for self-care to include ways to manage common discomforts of pregnancy (nausea and vomiting, fatigue, backache, varicosities, heartburn, activity, sexuality). Perform or assist with Leopold maneuvers to palpate presentation and position of the fetus. Assist the provider with the pelvic examination. Performed to determine the status of the mother’s reproductive organs and birth canal. Pelvic measurements determine whether the pelvis will allow for the passage of the fetus at delivery. The nurse should encourage the mother to empty her bladder and take deep breaths during the examination. Assess for costovertebral angle tenderness, which is indicative of renal infection. Administer RhO(D) immune globulin (RhoGAM) IM around 28 weeks for clients who are Rh-negative.
  33. 33. Leopold’s Maneuvers 1. Cup your hands around the top of the fundus for the fetal part presenting there. The head will feel firm and rounds, the breech will feel softer and less defined. 2. Position your palms on the side of the abdomen and feel for the fetus’s spine. Other parts will feel like nodules. 3. Use your dominant hand to grasp the lower part of the patient’s abdomen between index and thumb and press inward over the inlet to the true pelvis. Note movement and determine if presenting part is engaged (no movement). If head is presenting part, determine flexion or extension. 4. Face the patient’s feet and place both hands on opposite sides of uterus to determine cephalic positioning. If cephalic prominence is on the same side as arms and legs, the baby is in vertex position. If cephalic prominence is on the same side as the back, head is extended and face is presenting. Always check for fetal distress after Leopold’s Maneuvers by reassessing heart rate via doppler. Maneuver Walkthrough from ATI
  34. 34. Planning/Implementation Teach expectant mother or parents: Anatomy and physiology of pregnancy, labor, and birth Physiologic changes and related discomforts occurring during pregnancy (e.g., nausea, vomiting, backaches, varicosities, hemorrhoids, constipation, leg pain) Changes in nutritional needs and how to meet them; consider cultural and personal preferences To avoid alcohol, tobacco, contact with secondhand smoke (causes maternal and fetal vasoconstriction resulting in intrauterine growth restriction) To check with health care provider before taking over-the-counter (OTC), prescription drugs, herbs; (e.g., nonsteroidal antiinflammatory drugs (NSAIDs) considered harmless may be teratogenic to fetus) Importance of adequate fluid intake, moderate exercise to promote circulation and prevent stasis
  35. 35. Importance of continuing breast self-examination throughout pregnancy To notify health care provider when membranes rupture and/or regular contractions are 5 to 10 minutes apart Teach monitor for and report complications: Visual disturbances; edema of face, fingers, or feet; persistent, severe headaches; epigastric pain; seizures (eclampsia) Persistent, severe vomiting (e.g., hyperemesis gravidarum) Signs of infection (e.g., burning on urination) Unusual vaginal discharge, including blood (e.g., placenta previa) Abdominal pain (e.g., abruptio placentae) Absence of or decrease in fetal movements after initial presence (nonreassuring fetal sign) Signs and symptoms of preterm labor (e.g., rupture of membranes) Respond to questions (e.g., bathing, douching, work, sex, exercise)
  36. 36. Evaluation/Outcomes Expectant mother Keeps weight gain within recommended limits Abstains from alcohol, drugs, and tobacco Adjusts to physiologic changes associated with pregnancy Identifies signs of complications Attends childbirth classes with partner/coach Fetus Survives intrauterine period Maintains growth and development within acceptable parameters
  37. 37. Common Laboratory Tests Blood type, Rh-factor, and presence of irregular antibodies Determines the risk for maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal hyperbilirubinemia. For mothers who are Rh-negative and not sensitized, the indirect Coombs’ test will be repeated between 24 to 28 weeks of gestation. CBC with differential, Hgb, and Hct Detects infection and anemia. Hgb electrophoresis Identifies hemoglobinopathies (sickle cell anemia and thalassemia). Urinalysis with microscopic examination of pH, specific gravity, color, sediment, protein, glucose, albumin, RBCs, WBCs, casts, acetone, and human chorionic gonadotropin Identifies diabetes mellitus, gestational hypertension, renal disease, and infection.
  38. 38. One-hour glucose tolerance (Oral ingestion or IV administration of concentrated glucose with venous sample taken 1 hr later [fasting not necessary]) Identifies glycosuria; done at initial visit for at-risk clients, and at 24 to 28 weeks of gestation for all pregnant women (> 140 mg/dL requires follow up). Three-hour glucose tolerance (Fasting overnight prior to oral ingestion or IV administration of concentrated glucose with a venous sample taken 1, 2, and 3 hr later) Used in clients with elevated 1-hr glucose test as a screening tool for diabetes mellitus. A diagnosis of gestational diabetes requires two elevated blood-glucose readings. Papanicolaou (PAP) test Screens for cervical cancer, herpes simplex type 2, and/or human papillomavirus. Vaginal/cervical culture Detects streptococcus ß-hemolytic, Group B (routinely obtained at 35 to 37 weeks of gestation), bacterial vaginosis, or sexually transmitted infections (gonorrhea and Chlamydia).
  39. 39. Rubella titer Determines immunity to rubella. PPD (tuberculosis screening), chest screening after 20 weeks of gestation with positive purified protein derivative Identifies exposure to tuberculosis. Hepatitis B screen Identifies carriers of hepatitis B. Venereal disease research laboratory Syphilis screening mandated by law. HIV Detects HIV infection (recommended for all pregnancies) Screening for toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes virus (TORCH) Screening for a group of infections capable of crossing the placenta and adversely affecting fetal development.
  40. 40. Maternal serum alpha-fetoprotein (MSAFP) Screening occurs between 15 to 22 weeks of gestation. Used to rule out Down syndrome (low level) and neural tube defects (high level). The provider may decide to use a more reliable indicator and opt for the Quad screening instead of the MSAFP at 16 to 18 weeks of gestation. This includes AFP, inhibin-a, a combination analysis of human chorionic gonadotropin, and estriol.
  41. 41. Nursing Assessment Nurses play an integral role in assessing the mother’s knowledge, previous pregnancies, and birthing experiences. Assessment in prenatal care includes obtaining information regarding: Reproductive and obstetrical history (contraception use, gynecological diagnoses, and obstetrical difficulties). Medical history, including the woman’s immune status (rubella and hepatitis B). Family history, such as genetic disorders. Any recent or current illnesses or infections. Current medications, including substance abuse and alcohol consumption. The nurse should display a nonjudgmental, matter-of-fact demeanor when interviewing a mother regarding substance abuse and observe for signs and symptoms such as lack of grooming.
  42. 42. Prepregnancy weight (may indicate long-term malnutrition and depleted nutrient stores), recent weight gain or loss (may denote at-risk situation), adequacy of diet, vitamin supplements. Psychosocial history (a client’s emotional response to pregnancy, adolescent pregnancy, spouse, support system, history of depression, domestic violence issues). Any hazardous environmental exposures; current work conditions. Current exercise and diet habits. A nurse should ascertain what a client’s goals are for the birthing process. The nurse should discuss various birthing methods, such as Lamaze, and pain control options (epidural, natural childbirth).
  43. 43. Assess for proper nutritional status Weight gain should be within expected parameters Increased nutrient requirements Calories - 300 kcal/day; may need adjustment for prepregnant under/overweight. There should be no attempt at weight reduction during pregnancy Carbohydrates - needed to prevent unsuitable use of fats/proteins for added energy needs; important to avoid “empty” calorie sources Proteins - 60 g/day; additional increase for adolescent/multiple pregnancies; efficient use requires complete protein (contains all essential amino acids; animal sources) or protein source complemented with other protein sources, e.g., legumes, grains, nuts Iron - to a total of 30 mg/day of elemental iron; usually requires supplement Calcium - 1,200/day; best obtained from dairy products; if milk is disliked or poorly tolerated, calcium supplement may be necessary Sodium—should not be restricted without serious indication; excess should be discouraged 24-h recall/diet diary may be used to help evaluate high-risk woman
  44. 44. Health Promotion Teaching Stress healthy behaviors that promote the health of the pregnant woman and her fetus. Avoid all over-the-counter medications, supplements, and prescription medications unless the obstetrician has knowledge of it. Alcohol (birth defects) and tobacco (low birth weight) are contraindicated. Substance abuse of any kind is to be avoided during pregnancy and lactation. Encourage the client to receive a flu vaccine during the fall months. Encourage smoking cessation. Treat current infections. Obtain genetic testing and provide counseling. Ascertain maternal exposure to hazardous materials.
  45. 45. Exercise during pregnancy yields positive benefits and should consist of 30 min of moderate exercise (walking or swimming) daily if not medically or obstetrically contraindicated. Avoid the use of hot tubs or saunas. Consume at least 2 to 3 L of water each day from food and beverage sources Food restrictions Shrimp, salmon, pollack, catfish, canned light tuna; no more than one to two servings a week. Albacore white tuna; no more than 6 ounces in one week. Privately caught fish: check with local health department before eating. Foods to avoid (due to high risk of food poisoning) Raw fish, especially shellfish; soft-scrambled eggs; foods made with raw or lightly cooked eggs. Unpasteurized juices and milk. Foods made from soft cheeses (e.g., brie, feta, Camembert, Roquefort, queso blanco, queso fresco, Panela). Raw sprouts. Herbal supplements and teas. Fish high in mercury (shark, swordfish, king mackerel, tilefish). Raw or undercooked animal products. Cold cuts must be reheated before eating.
  46. 46. A nurse is teaching a group of clients who are pregnant about behaviors to avoid during pregnancy. The nurse determines that a client needs further instruction when the client states, A. “I can have a drink of wine with dinner.” B. “Smoking is a major cause of low birth weight in babies.” C. “Signs of infection should be reported to my primary care provider.” D. “I should not take over-the-counter medications without checking with my primary care provider first.”
  47. 47. A nurse is teaching a group of clients who are pregnant about behaviors to avoid during pregnancy. The nurse determines that a client needs further instruction when the client states, X A. “I can have a drink of wine with dinner.” B. “Smoking is a major cause of low birth weight in babies.” C. “Signs of infection should be reported to my primary care provider.” D. “I should not take over-the-counter medications without checking with my primary care provider first.” No alcohol should be consumed during pregnancy. All medications should be approved with the primary care provider. Signs of infection or any concerns should be reported to the primary care provider. Smoking is a major cause of low birth weight infants
  48. 48. Psychosocial Teachings The transition to the maternal role includes hormonal and psychological aspects. Hormonal changes may cause emotional lability, with unpredictable mood changes and increased irritability, tearfulness, and anger alternating with feelings of joy and cheerfulness. A feeling of ambivalence about the pregnancy, which is a normal response, may occur early in the pregnancy resolving before the third trimester. It consists of conflicting feelings (joy, pleasure, sorrow, hostility) about the pregnancy. These feelings can occur simultaneously whether the pregnancy was planned or not.
  49. 49. A client who is at 8 weeks of gestation tells the nurse that she isn’t sure she is happy about being pregnant. The nurse should respond to the client by stating, A. “I will inform the primary care provider that you are having these feelings.” B. “It is normal to have feelings during the first few months of pregnancy.” C. “You should be happy that you are going to bring new life into the world.” D. “I am going to make an appointment with the counselor for you to discuss these thoughts.”
  50. 50. A client who is at 8 weeks of gestation tells the nurse that she isn’t sure she is happy about being pregnant. The nurse should respond to the client by stating, A. “I will inform the primary care provider that you are having these feelings.” X B. “It is normal to have feelings during the first few months of pregnancy.” C. “You should be happy that you are going to bring new life into the world.” D. “I am going to make an appointment with the counselor for you to discuss these thoughts.” Ambivalence during the first trimester is a normal response. The client usually overcomes ambivalence before the second trimester. The other responses are nontherapeutic statements
  51. 51. First Trimester Teaching Topics Physical and psychosocial changes Common discomforts of pregnancy and measures to provide relief Lifestyle changes: exercise/stress/nutrition, sex, dental care, over-the-counter and prescription medications, tobacco, alcohol, substance abuse (discuss strategies to decrease or discontinue use), and STDs (encourage safe sexual practices) Possible complications and signs to report Fetal growth and development Prenatal exercise Expected laboratory tests
  52. 52. Second Trimester Teaching Topics Benefits of breastfeeding. Common discomforts and relief measures Lifestyle changes: sex and pregnancy, rest and relaxation, posture, body mechanics, clothing, seat-belt safety, and travel Fetal movement Complications (preterm labor, gestational hypertension, gestational diabetes mellitus, premature rupture of membranes) Childbirth preparation
  53. 53. Third Trimester Teaching Topics Childbirth classes or birth plan. Breathing and relaxation techniques (deep cleansing breaths at one-half the usual respiratory rate during contractions can promote relaxation of the abdominal muscles, which lessens the discomfort of uterine contractions) Discussion regarding pain management during labor and birth (natural childbirth, epidural) Signs and symptoms of preterm labor and labor Labor process Infant care Postpartum care Fetal movement/kick counts to ascertain fetal well-being. Mothers should be instructed to count and record fetal movements or kicks daily.
  54. 54. It is recommended that mothers count fetal activity 2 or 3 times a day for 60 min each time. Fetal movements of less than 3 in/hr or movements that cease entirely for 12 hr indicate a need for further evaluation. Diagnostic testing for fetal well-being (nonstress test, biophysical profile, ultrasound, and contraction stress test).
  55. 55. Discomforts of Pregnancy Nausea and vomiting may occur during the first trimester. The mother should eat crackers or dry toast 1/2 to 1 hr before rising in the morning to relieve discomfort. Instruct the mother to avoid having an empty stomach and ingesting spicy, greasy, or gas- forming foods. Encourage her to drink fluids between meals. Breast tenderness may occur during the first trimester. The client should wear a bra that provides adequate support. Urinary frequency may occur during the first and third trimesters. The client should empty her bladder frequently, decrease fluid intake before bedtime, and use perineal pads. The client should be taught how to perform Kegel exercises (alternate tightening and relaxation of pubococcygeal muscles) to reduce stress incontinence. Fatigue may occur during the first and third trimesters. She should be encouraged to engage in frequent rest periods.
  56. 56. Urinary tract infections (UTI) are common during pregnancy because of renal changes and the vaginal flora becoming more alkaline. UTI risks can be decreased by encouraging the client to wipe the perineal area from front to back after voiding; avoiding bubble baths; wearing cotton underpants; avoiding tight-fitting pants; and consuming plenty of water (8 glasses per day). She should urinate before and after intercourse to flush bacteria from the urethra that can be introduced during intercourse. Advise her to urinate as soon as the urge occurs because retaining urine provides an environment for bacterial multiplication. Advise her to notify her primary care provider if her urine is malodorous or contains blood or pus. Hemorrhoids may occur during the second and third trimesters. A warm sitz bath, witch hazel pads, and topical ointments applied to the area will help relieve discomfort.
  57. 57. Heartburn may occur during the second and third trimesters due to the stomach being displaced by the enlarging uterus and a slowing of the gastrointestinal tract motility and digestion brought about by increased progesterone levels. The client should eat small frequent meals, not allow the stomach to get too empty or too full, sit up for 30 min after meals, and check with her primary care provider prior to using any over-the-counter antacids. Constipation may occur during the second and third trimesters. The client should be encouraged to drink plenty of fluids, eat a diet high in fiber, and exercise regularly. Backaches are common during the second and third trimesters. The client should be encouraged to exercise regularly, perform pelvic tilt exercises (alternately arching and straightening the back), use proper body mechanics using the legs to lift rather than the back, and use the side-lying position. Shortness of breath and dyspnea may occur because the diaphragm is elevated about 4 cm by the enlarged uterus. This limits diaphragm expansion on inspiration. The client should maintain good posture, sleep with extra pillows, and contact her primary care provider if symptoms worsen.
  58. 58. Leg cramps during the third trimester may occur due to the compression of lower extremity nerves and blood vessels by the enlarging uterus, causing poor peripheral circulation as well as an imbalance in the calcium/phosphorus ratio. Homans’ sign should be checked and if it is negative, she should extend the affected leg, keeping the knee straight and dorsiflexing the foot (toes toward head). Massaging and applying heat over the affected muscle or a foot massage while the leg is extended can help relieve cramping. She should notify her physician if cramping is frequent. Varicose veins and lower extremity edema can occur during the second and third trimesters. She should rest with her legs elevated, avoid constricting clothing, wear support hose, avoid sitting or standing in one position for extended periods of time, and should not sit with her legs crossed at the knees. She should sleep in the left-lateral position and exercise moderately with frequent walking to stimulate venous return. Gingivitis, nasal stuffiness, and epistaxis (nosebleed) can occur as a result of elevated estrogen levels causing an increased vascularity and proliferation of connective tissue. The client should gently brush her teeth, observe good dental hygiene, use a humidifier, and use normal saline nose drops or spray.
  59. 59. Braxton Hicks contractions, which occur from the first trimester onward, may increase in intensity and frequency during the third trimester. Inform her that a change of position and walking should cause contractions to subside. If contractions increase in intensity and frequency (true contractions) with regularity, she should notify her physician. Supine hypotension occurs when a woman lies on her back and the weight of the gravid uterus compresses her ascending vena cava. This reduces blood supply to the fetus. She may experience feelings of lightheadedness and faintness. Teach her to lie in a side-lying or semi-sitting position with her knees slightly flexed.
  60. 60. A nurse is teaching a group of women who are pregnant about measures to relieve backache during pregnancy. The nurse should teach the women which of the following? (Select all that apply.) Avoid any lifting. Perform Kegel exercises twice a day. Perform the pelvic rock exercise every day. Use good body mechanics. Avoid constrictive clothing.
  61. 61. A nurse is teaching a group of women who are pregnant about measures to relieve backache during pregnancy. The nurse should teach the women which of the following? (Select all that apply.) Avoid any lifting. Perform Kegel exercises twice a day. X Perform the pelvic rock exercise every day. X Use good body mechanics. Avoid constrictive clothing. The pelvic rock or tilt exercises stretch out the muscles of the lower back and help relieve lower back pain. Good body mechanics will help prevent injury to the back that can occur from using incorrect muscles. Lifting can be done, but use the knees to lift rather than the back. Kegel exercises are done to strengthen the perineal muscles. Avoiding constrictive clothing will help prevent vaginitis, heat rash, or varicoses.
  62. 62. A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. The nurse in the prenatal clinic provides teaching that should include which of the following? A. Eat crackers or plain toast before getting out of bed. B. Wake during the night to eat to prevent an empty stomach. C. Skip breakfast and eat lunch after nausea has subsided. D. Eat a large supper to prevent an empty stomach in the morning.
  63. 63. A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. The nurse in the prenatal clinic provides teaching that should include which of the following? X A. Eat crackers or plain toast before getting out of bed. B. Wake during the night to eat to prevent an empty stomach. C. Skip breakfast and eat lunch after nausea has subsided. D. Eat a large supper to prevent an empty stomach in the morning. Nausea and vomiting may occur during the first trimester. The client should eat crackers or dry toast ½ to 1 hr before rising in the morning to relieve discomfort. Instruct the client to avoid an empty stomach, spicy, greasy, or gas-forming foods. Encourage her to drink fluids between meals.
  64. 64. Fetal Development Ovum (10–14 d) implantation HCG is secreted by cells of chorionic villi to ensure continued estrogen and progesterone secretion; progesterone is absolutely necessary for implantation and maintenance of decidua Possible abnormal events Spontaneous abortion/ectopic pregnancy Maternal infection, e.g., rubella, resulting in multiple anomalies Genetic defects before 3 wk may result in spontaneous abortion
  65. 65. Fetus (19 wk to term) - Fetal heartbeat can be heard Refinement of organ systems Growth in body size and organ maturity Possible abnormal events Preterm delivery (before 38 wk) - survival dependent on CNS maturity to maintain body temperature and respirations, lung development, and availability of clinical technology Intrauterine growth retardation (IUGR) or small for gestational age (SGA) Poor organ system development
  66. 66. Embryo (13 d through 8 wk) Organ development Cell growth and tissue differentiation, resulting in formation of all body systems Possible abnormal events Time of highest mortality Malformations related to genetic defects, poor maternal health, teratogens (nongenetic factors that can cause fetal malformations)
  67. 67. Birthing Methods Dick-Read method - “childbirth without fear.” Uses controlled breathing and conscious and progressive relaxation of different muscle groups throughout the entire body. This method instructs a woman to relax completely between contractions and keep all muscles except the uterus relaxed during contractions. Lamaze - the mission of Lamaze International is to promote a healthy, natural, and safe approach to pregnancy, childbirth, and early parenting by advocating and working with health care providers, parents, and professional childbirth educators. Leboyer - “birth without violence.” Environmental variables are stressed to ease the transition of the fetus from the uterus to the external environment (dim lights, soft voices, warm birthing room). Water births are based on this method. Bradley – stresses the partner’s involvement as the birthing coach. This method emphasizes increasing self-awareness and teaching the woman to deal with the stress of labor by tuning into her own body. The mother is encouraged to trust her body and use natural breathing, relaxation, nutrition, exercise, and education throughout her pregnancy
  68. 68. Ultrasound Visualizes the fetus, placenta, amniotic fluid Can be used to diagnose a pregnancy in the first 6 weeks and to monitor the fetal growth and intrauterine environment throughout the course of pregnancy Diagnostic adjunct to amniocentesis No known harmful effects to mother and fetus The mother should drink fluid and refrain from voiding prior to test
  69. 69. Amniocentesis Amniotic fluid is aspirated by a needle inserted through the abdominal and uterine walls Indicated early in pregnancy (14–17 wk) to detect inborn errors of metabolism, chromosomal abnormalities, open NTD (neural tube defect); determine sex of fetus and sex-linked disorders after 28 wk; determine lung maturity after 30 weeks Indicated for pregnant women 35 years and older; couples who already have had a child with a genetic disorder; one or both parents affected with a genetic disorder; mothers who are carriers for X-linked disorders Preprocedure - the patient’s bladder should be emptied; ultrasonography (x-ray only if necessary) is used to avoid trauma from the needle Postprocedure - monitor for signs and symptoms of hemorrhage, labor, premature separation of placenta, fetal distress, amniotic fluid embolism, infection, inadvertent injury to maternal intestines/bladder or fetus; RhoGam is indicated for Rh– mothers
  70. 70. Chorionic Villus Sampling Transcervical aspiration of chorionic villi Allows for first trimester (8–12 weeks) diagnosing of genetic disorders (Down syndrome, sickle cell anemia, PKU, Duchenne muscular dystrophy) comparable to amniocentesis (except for neural tube defects) Preprocedure - there should be full bladder; ultrasound is used like in amniocentesis; Postprocedure - monitor for signs and symptoms of hemorrhage, labor, premature separation of placenta, fetal distress, amniotic fluid embolism, infection, inadvertent injury to maternal intestines/bladder or fetus; RhoGam is indicated for Rh– mothers
  71. 71. Non-stress test evaluates FHR by electronic fetal monitor (EFM) in response to fetal movement (FM) as early as 27 weeks Mother should eat 2 hours before and may be given snacks during to enhance fetal movement. Monitor for maternal hypotension 1. Indicated 1–2 times per week for high-risk pregnancy 2. Interpretation a. Reactive - FHR accelerations of 15 or more BPM lasting 15 or more seconds with at least 2 FM in a 20-min period; monitor NST 1–2 times/wk b. Nonreactive - any one of the above criteria is not met; continue EFM and additional testing; immediate delivery may be necessary; report decelerations c. Unsatisfactory - inadequate FM despite snacks/gentle pushing baby/vibroacoustic stimulation or unable to interpret data; repeat NST within 24 hours
  72. 72. Estriol Levels Serial 24 hour maternal urine samples or serum specimens to determine fetoplacental status Falling estriol levels usually indicate deterioration.
  73. 73. Biophysical Profile Assessment tool for fetal breathing movements, body movements, muscle tone, amniotic fluid volume by ultrasound, and FHR reactivity by NST With a score of 0–2 for each 8–10 is considered normal
  74. 74. Contraction Stress TestEvaluates FHR in response to contractions initiated by endogenous (nipple stimulation) or exogenous oxytocin (IV Pitocin) Performed after 28 weeks, mother placed in the semi-Fowler’s or side-lying position Indications - intrauterine growth retardation (IUGR), diabetes, postdates (greater than 42 weeks), nonreactive NST, abnormal biophysical profile Contraindication - third-trimester bleeding, previous cesarean delivery with classic incision, potential for preterm labor Interpretation a. Negative - no late decelerations with at least three contractions lasting 40–60 s in a 10- min period; repeat as necessary or in 1 week b. Positive - late decelerations with at least 50% of contractions; potential fetal risk and cesarean may be necessary c. Suspicious - late decelerations in less than half of contractions, repeat stress test in 24 hours d. Unsatisfactory—inadequate contraction pattern or tracing
  75. 75. Percutaneous Umbilical Blood Sampling Aspirated cord blood Tests for genetic conditions, chromosomal abnormalities, fetal infections, hemolytic or hematological disorders. Performed in the second and third trimesters Location identified by ultrasound
  76. 76. TORCH Test Series group of maternal systemic infections that can be transmitted across the placenta or by ascending infection (after ROM) to the fetus; infection early in pregnancy may produce significant and devastating fetal deformities, whereas later infection may result in overwhelming active systemic disease and/or CNS involvement, causing severe neurological impairment or death of newborn a. Toxoplasmosis (protozoa; transplacental to fetus)—discourage eating undercooked meat and handling cat litter box b. Other 1) Syphilis 2) Varicella/shingles (transplacental to fetus or droplet to newborn)—caution susceptible woman about contact with the disease and zoster immune globulin for exposure 3) Group B beta-hemolytic Streptococcus (direct or indirect to fetus during labor and delivery)— treated with penicillin
  77. 77. 4) Hepatitis B (transplacental and contact with secretions during delivery)—screen and immunize maternal carriers; treat newborn with HBIg 5) AIDS (as with hepatitis)—titers in newborn may be passive transfer of maternal antibodies or active antibody formation c. Rubella (transplacental)—prenatal testing required by law; caution susceptible woman about contact; vaccine is not given during pregnancy d. Cytomegalovirus (CMV)—transmitted in body fluids; detected by antibody/serological testing e. Herpes type 2 (transplacental, ascending infection within 4–6 h after ROM or contact during delivery if active lesions)—cesarean delivery if active lesions
  78. 78. Danger Signs and what they mean 1.Gush of fluid from the vagina - rupture of amniotic fluid, prior to 37 weeks of gestation 2. Vaginal bleeding - placental problems such as abruption or previa 3. Abdominal pain - premature labor, abruptio placenta, or ectopic pregnancy 4. Changes in fetal activity - decreased fetal movement may indicate fetal distress 5. Persistent vomiting - hyperemesis gravidarum 6. Severe headaches - pregnancy-induced hypertension 7. Elevated temperature - infection 8. Dysuria - urinary tract infection 9. Blurred vision - pregnancy-induced hypertension 10. Edema of face and hands - pregnancy-induced hypertension
  79. 79. 11. Epigastric pain - pregnancy-induced hypertension 12. Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, increased thirst and urination, and headache - hyperglycemia 13. Concurrent occurrence of clammy pale skin, weakness, tremors, irritability, and lightheadedness - hypoglycemia
  80. 80. A woman who is pregnant should promptly report which of the following symptoms to the primary care provider? A. Vaginal bleeding B. Swelling of the ankles C. Heartburn after eating D. Faintness when lying on back
  81. 81. A woman who is pregnant should promptly report which of the following symptoms to the primary care provider? X A. Vaginal bleeding B. Swelling of the ankles C. Heartburn after eating D. Faintness when lying on back Vaginal bleeding during pregnancy is always a dangerous sign and the client should notify her primary care provider. Swelling of the ankles is a normal occurrence that can be relieved by the client elevating her lower extremities and not sitting or standing for prolonged periods of time. Heartburn frequently occurs because of the slowed gastrointestinal motility and compression of the stomach by the enlarging uterus. Supine hypotension, which can be experienced by the client as a faintness felt when lying on the back, occurs because of the gravid uterus compressing the ascending vena cava. This compression can be detrimental to the fetus. Supine hypotension is easily rectified by instructing the client to lie on her side or in a semi-sitting position.
  82. 82. Prenatal Complications Increased risk for complications Lack of prenatal care, age less than 18 or older than 35, conception within two months of previous delivery, fifth or subsequent delivery, pre-pregnant weight 20% more or less than normal and/or minimal or no weight gain, fetal anomaly Adolescence Pregnant state may interfere with normal physical growth and maturation. There may be lack of family acceptance or support, isolation from peers, delayed or no prenatal care, and increased medical and obstetrical risks; requires support for feelings, assistance with decision-making, regular monitoring of health status, instruction in nutrition.
  83. 83. Substance use and abuse 1. Drugs (including alcohol) - may be increased risk of maternal nutritional deficits, sexually transmitted diseases (STDs), AIDS, delayed/no prenatal care, withdrawal symptoms, and fetal intrauterine growth retardation (IUGR), anomalies, spontaneous abortions, death, signs and symptoms of withdrawal or addiction in neonate. Nursing interventions - educate, reinforce, counsel, and/or refer as necessary; emphasize that a safe level of alcohol has not been identified, or the converse, that there is no safe level of alcohol. 2. Cigarettes - increased incidence of intrauterine growth retardation (IUGR), preterm births, low Apgar scores, spontaneous abortions, SIDS. Nursing interventions - as with drugs
  84. 84. Urinary Tract Infections Characterized by urinary frequency and urgency, dysuria, and sometimes hematuria. Manifested in upper urinary tract by fever, malaise, anorexia, nausea, abdominal/ back pain. Can be asymptomatic. Confirmed clinically by >100,000/ml bacterial colony count by clean catch urine. Treated pharmacologically with sulfa-based medications (Sulfamethoxazole), nitrofurantoin, and cephalexin.
  85. 85. Gestational Diabetes Interaction of diabetes and pregnancy may cause serious problems for mother and fetus Pre-existing diabetes during pregnancy - long-standing diabetes and/or poor control before conception can increase risk of maternal infections, pregnancy-induced hypertension, hydramnios (greater than 2,000 ml amniotic fluid) and consequent preterm labor, macrosomia (large for gestational age but may have immature organ systems), and, in more severe cases, congenital anomalies, intrauterine growth restriction, prematurity, and respiratory distress syndrome in the neonate. Untreated ketoacidosis can cause coma and death of mother and fetus Gestational diabetes - the mother usually has a normal response to glucose before and after pregnancy; the abnormal response is usually noted after 20 wk, when insulin need accelerates, bringing about symptoms. Some women will need exogenous insulin but majority are controlled by diet - oral hypoglycemics must not be used because they may be teratogenic and increase the risk of neonatal hypoglycemia
  86. 86. Assessment Risk factors for gestational diabetes - obesity, family history of diabetes; patient history of gestational diabetes, hypertension/PIH, recurrent UTIs, monilial (yeast) vaginitis, polyhydramnios; previously large infant (9 lb/4,000 g or more), previously unexplained death/anomaly or stillbirths; glycosuria, proteinuria on two or more occasions Diabetes screening - at 24–28 weeks for all pregnant women Screen blood glucose level 1 hour after 50 g concentrated glucose solution Three-hour glucose tolerance test; normal findings: FBS: 80–100 mg/dL 1 hour: <190 mg/dL 2 hours: <165 mg/dL 3 hours: <145 mg/dL If two or more abnormal findings, significant for diabetes Glycosylated hemoglobin (HbA1c) - measures control over the past 3 months; elevations (>6–8%) in first trimester are associated with increased risk of congenital anomaly and spontaneous abortion; in the last trimester with macrosomia
  87. 87. Management Requires close medical and obstetrical supervision throughout the pregnancy Strict insulin regulation to maintain blood glucose levels between 60 and 120 g/dL to prevent hyperglycemia or hypoglycemia Oral hypoglycemics must not be used because they may be teratogenic and increase the risk of neonatal hypoglycemia Routine home glucose monitoring Regulated physical activity Diet individualized to diabetic and pregnancy needs
  88. 88. Pregnancy-Induced Hypertension Hypertension that started before the mother got pregnant needs to be carefully managed during the pregnancy. Hypertension that manifested during the pregnancy could be Pre- Eclampsia or Eclampsia, the latter having tonic-clonic seizures. Assessment Increased risk in African Americans, greater than 35 years old or less than 17 years old primigravida, multiple fetuses or history of diabetes and renal disease, family history of PIH; prenatal screening at each visit for symptomatology Treatment Mild (at home) - bedrest in side-lying position, well-balanced diet (less than 6 grams of sodium per day, moderate to high protein intake), discontinue smoking, weigh daily, instruct patient/family member to look for and report immediately any of above signs of worsening; record FM; NST 1–2 times/ wk; monitor HELLP lab work, uric acid (indicative of worsening), and BUN (monitor kidney functioning)
  89. 89. Moderate to severe hypertension (treated in hospital) - absolute bed rest, seizure precautions, strictly controlled diet, antihypertensives and anticonvulsants; strict I and O and daily serum electrolytes to maintain fluid and electrolyte balance; maternal and fetal status must be monitored frequently and routinely; emotional support/counseling for unexpected course/outcomes Eclampsia (an obstetrical emergency) may be maternal recurrence, cerebral hemorrhage, DIC, and fetal hypoxia - ensure patent airway (suction and O2 as necessary); monitor mother for signs and symptoms of cerebral hemorrhage, placenta abruptio, pulmonary edema; may require invasive hemodynamic monitoring; IV with large-bore needle, type and cross-matched blood available for emergency transfusion; monitor fetal status; magnesium sulfate IV; immediate delivery if signs and symptoms do not subside Labor induction with IV oxytocin (administered simultaneously with magnesium sulfate), or in severe cases, cesarean delivery may be indicated In cases of severe hypertension, seizures may still occur 24–48 hours postpartum; monitor magnesium sulfate or hydralazine may be continued postpartum
  90. 90. Pre-Eclampsia and Eclampsia (No prior incidence of hypertension) May progress from mild, which can usually be managed as outpatient, to severe, which requires hospitalization; characterized by a triad of symptoms which are high BP, edema, and proteinuria. Mild a. Elevated BP - 140/90 or +30/+15 mm Hg on two consecutive occasions at least 6 hours apart as compared with first-trimester BPs b. Edema - generalized edema that does not clear overnight, or more significantly, facial; sudden weight gain (>4.5 lb/wk) c. Proteinuria - +1– +2 in two consecutive tests at least 6 h apart or 300 mg/L in a 24-h specimen
  91. 91. Severe a. BP 150–160/100–110, increased edema, +3 - +4 proteinuria b. Complaints of headache, visual changes, epigastric pain, extreme irritability; sudden onset generalized edema c. Hyperreflexia d. HELLP - hemolysis (significantly decreased Hct), elevated liver enzymes (SGOT, SGPT), low platelet count - increased risk Eclampsia - tonic-clonic seizures, hypertensive crisis, or shock occurs. Pre-Eclampsia and Eclampsia are managed similarly to Pregnancy Induced Hypertension.
  92. 92. Medications for PIH Magnesium sulfate Flushing, sweating Symptoms of toxicity: sudden drop in BP, respirations <12/min, urinary output <25-30 ml/hr, decreased/ absent Deep Tendon Reflexes, toxic serum levels, CNS depressant, anticonvulsant Monitor BP, P, R, FHR at least every 15 min; assess magnesium sulfate levels and Deep Tendon Reflexes prior to administration, and mental status frequently; have resuscitation equipment and calcium gluconate/chloride (antidote) in room Hydralazine (Apresoline) Tachycardia, palpitations, Headache, Nausea and vomiting, Orthostatic hypotension, Vasodilator Maintain diastolic BP 90-100 mm Hg for adequate uteroplacental flow; monitor FHT and neonatal status.
  93. 93. Diazepam (Valium) Risk of neonatal depression if given within 24 h of delivery Sedative, anticonvulsant Monitor Fetal Heart Tones and neonatal status Methyldopa (Aldomet) May mask symptoms of preeclampsia; risk of maternal orthostatic hypotension and decreased pulse and BP in neonate for 2-3 days. Risk for fetal hemolytic anemia. Used for chronic HTN Monitor maternal, fetal, and neonatal vital signs, monitor maternal mental status. Propranolol (Inderal) Decreased heart rate, depression, hypoglycemia Take apical rate before giving Monitor BP, EKG
  94. 94. Vaginal Bleeding Is always abnormal. First trimester Spontaneous abortion Vaginal bleeding, uterine cramping, and partial or complete expulsion of products of conception Ectopic pregnancy Abrupt unilateral lower quadrant abdominal pain with or without vaginal bleeding
  95. 95. Second trimester Gestational trophoblastic disease Uterine size increasing abnormally fast, abnormally high levels of hCG, nausea and increased emesis, no fetus present on ultrasound, and scant or profuse dark brown or red vaginal bleeding Incompetent cervix Painless bleeding with cervical dilation leading to fetal expulsion Third trimester Placenta previa Painless bleeding as the cervix dilates Abruptio placenta Vaginal bleeding, sharp abdominal pain, and tender rigid uterus Preterm labor Pink-stained vaginal discharge, uterine contractions becoming regular, cervical dilation and effacement
  96. 96. Spontaneous Abortion Risk Factors for Spontaneous Abortion Chromosomal abnormalities (about 50% of the time), Maternal illness, like insulin dependent diabetes mellitus, Advancing maternal age, Chronic maternal infections, Maternal malnutrition, Trauma or injury, Anomalies in the fetus or placenta, Substance abuse. Assessment Vaginal spotting or moderate to heavy bleeding with or without pain in early pregnancy. Passage of tissue (products of conception). Mild to severe uterine cramping. Backache. Rupture of membranes. Dilation of the cervix. Fever. Abdominal tenderness. Signs and symptoms of hemorrhage such as hypotension.
  97. 97. Nursing Interventions for Spontaneous Abortion Performing a pregnancy test. Using the lay term miscarriage, abortion will sound insensitive. Placing her on bed rest with sedation for threatened, inevitable, and incomplete abortions. Advising her to avoid coitus with threatened abortion. Avoiding a vaginal exam. Assisting with an ultrasound. Administering analgesics and blood products as prescribed. Determining how much tissue has passed and saving all passed tissue for examination. Count pads, observe color of bleeding. Administering intravenous oxytocin (Pitocin) or prostaglandin via vaginal suppository as prescribed to expulse products of conception in late, incomplete, inevitable, or missed abortions. Administering broad spectrum antibiotics as prescribed for treatment of septic abortion.
  98. 98. Assisting with termination of pregnancy (D&C, D&E) as indicated based on duration of pregnancy. Administering RhoGAM as indicated to Rh negative women. Providing client education and support. Discharge Instructions Notify provider of heavy, bright red vaginal bleeding. Take antibiotics as prescribed if prescribed. Tell her a small amount of discharge is normal for 1-2 weeks. Refrain from sexual intercourse or placing anything in the vagina for 1-2 weeks. Provide contacts for bereavement support groups. Instruct her to avoid pregnancy for 2 months.
  99. 99. Ectopic pregnancy Implantation outside uterus (commonly in fallopian tube), potentially life-threatening hemorrhage Second most frequent cause of bleeding in the first trimester. Assessment: One or two missed menses, unilateral lower quadrant pain after 4–6 weeks of normal signs and symptoms of pregnancy, pain described as “stabbing”, referred shoulder pain due to blood irritating the diaphragm or phrenic nerve, bleeding (if evident) may be gradual oozing to frank bleeding, may be palpable unilateral mass in adnexa; low HCG levels, rigid and tender abdomen, signs and symptoms of hemorrhage, nausea vomiting. Necessary to be alert for signs and symptoms - investigate risk factors that compromise fallopian tube patency, especially PID, Intrauterine Device, multiple sexual partners, recurrent episodes of gonorrhea, infertility
  100. 100. Nursing Management Monitor Hb and Hct Replace fluids that are lost and maintain electrolyte balance Prepare to administer methotrexate (MTX) Prepare mother for surgery (laparoscopy and/or laparotomy) Adequate blood replacement (type and X match, IV with a large-bore needle) postoperatively, monitor for infection and paralytic ileus, support for emotional distress, RhoGam for an Rh-negative woman Methotrexate (MTX) Methotrexate is used to inhibit cell division and enlargement of the embryo. It also prevents rupture of the fallopian tube to preserve it. Avoid alcohol, sun exposure, and folic acid
  101. 101. A woman arrives in the emergency department with abrupt, sharp right-sided lower- quadrant abdominal pain, and bright red vaginal spotting. She has missed one menstrual cycle. She tells the nurse that she cannot be pregnant because she has been using an intrauterine device. The nurse should suspect which of the following? A. Missed abortion X B. Ectopic pregnancy C. Severe preeclampsia D. Hydatidiform mole
  102. 102. A woman arrives in the emergency department with abrupt, sharp right-sided lower- quadrant abdominal pain, and bright red vaginal spotting. She has missed one menstrual cycle. She tells the nurse that she cannot be pregnant because she has been using an intrauterine device. The nurse should suspect which of the following? A. Missed abortion X B. Ectopic pregnancy C. Severe preeclampsia D. Hydatidiform mole Signs and symptoms of an ectopic pregnancy include unilateral lower-quadrant abdominal pain with or without bleeding. A missed abortion occurs when products of conception are retained and there is a brownish discharge. Severe preeclampsia does not have vaginal bleeding unless initiated by worsening complications and presents with an epigastric, right upper quadrant pain. Hydatidiform mole causes dark brown bleeding in the second trimester and is not generally accompanied by abdominal pain.
  103. 103. Incompetent Cervix Painless bleeding with cervical dilation leading to expulsion
  104. 104. Preterm Labor Pink-tinged vaginal discharge, uterine contractions becoming regular, cervical dilation and effacement
  105. 105. Abruptio Placentae Premature separation of normally implanted placenta; may be marginal (near edge) with dark red vaginal bleeding or central (at center) with concealed bleeding; life threatening to fetus and mother Abdominal pain; uterine rigidity and tenderness; rapid signs and symptoms of maternal shock and/or fetal distress Manage signs and symptoms; prepare for immediate delivery usually, cesarean section Postoperatively monitor for complications Infection Renal failure DICs
  106. 106. A nurse is providing care for a client who is diagnosed with a marginal abruptio placenta. The nurse is aware that which of the following findings are risk factors for developing the condition? (Select all that apply.) Maternal hypertension Blunt abdominal trauma Cocaine abuse Maternal age Cigarette smoking
  107. 107. A nurse is providing care for a client who is diagnosed with a marginal abruptio placenta. The nurse is aware that which of the following findings are risk factors for developing the condition? (Select all that apply.) X Maternal hypertension X Blunt abdominal trauma X Cocaine abuse Maternal age X Cigarette smoking Maternal hypertension, blunt abdominal trauma, cocaine abuse, and cigarette smoking are risk factors for abruptio placenta. Maternal age is not an associated risk for this condition. However, it is a risk factor for placenta previa.
  108. 108. Disseminated intravascular coagulation Massive hemorrhage initiates coagulation process causing clotting in peripheral vessels (may result in tissue damage from multiple thrombi), which in turn stimulate fibrinolytic activity, resulting in decreased platelet and fibrinogen levels. Assessment: Symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis, hematuria, etc.) Nursing Interventions include Monitor PT, PTT, and Hct Protect from injury No IM injections Early anticoagulant therapy is controversial
  109. 109. Placenta Previa May be low-lying in lower segment, marginal at border of internal cervical os, or partial or complete obstruction of the os Characterized by painless vaginal bleeding, which is usually slight at first and increases in subsequent unpredictable episodes; usually soft and nontender abdomen Management Hospitalization initially - bed rest side-lying or modified Trendelenburg position for at least 72 hours; ultrasound to locate placenta; no vaginal/rectal exam unless delivery would not be a problem (if becomes necessary, must be done in OR under sterile conditions); amniocentesis for lung maturity; monitor for changes in bleeding and fetal status; daily Hb and Hct; 2 units of cross-matched blood available Home if bleeding ceases and pregnancy to be maintained—limit activity; no douching, enemas, coitus; monitor FM; NST at least every 1–2 wk Delivery by cesarean if evidence of fetal maturity, excessive bleeding, active labor, other complications

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