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ACUTE BIOLOGIC CRISISHIGH RISK PREGNANCY
Definition: One in which a concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the mother and/or fetus.
Many factors enter into the categorization of high risk.
No tool is perfect because the concept of high risk is avery individualized one
The woman identified this way needs closeobservation during pregnancy to see that pregnancy isprogressing well
The infant born of a woman identified this way needsclose observation in the neonatal period until it isconfirmed that no anomalies exist
The failure to identify risk potential in pregnancy leadsto increased perinatal mortality
ASSESSMENT FOR A FIRST PREGNANCY VISIT :1. HEALTH HISTORY
Purpose :a.To establish rapportb.To gain information about the woman’s physical andpsychosocial healthc.To obtain a basis for anticipatory guidance for thepregnancy
A. Demographic Data
: Name, age, address, telephonenumber, health insurance
B. Chief Concern
– Reason why the woman has come to thehealth care setting.1.Was the pregnancy planned?2.Inquire date of last menstruation3.Ask if she has had a pregnancy test4.Elicit information about signs of early pregnancy5.Observe for discomforts of pregnancy6.Has she been exposed to contagious diseases7.Has she taken any medicine that might be harmful tofetal growth
C. Family Profile
– helps to know the woman earlier 1.Identify support persons, Family composition2.What is her occupation, source of income, Nutrition, sleeppattern, hobbies, living conditions
D. Past Medical History
– important because a past conditionmay become active during or immediately following pregnancy.1. Any abdominal surgery, kidney, heart, etc.
E. Gynecologic History
– her past experience with her reproductive system may have some influence on how well sheaccepts a pregnancy.1.When was her menarche2.What is the length and duration of menstrual cycle
F. Obstetric History
:1.Review pregnancy briefly.2.Determine woman’s status with respect to the number of times she has been pregnant (gravida) and thenumber of children above the age of viability she haspreviously delivered (para).3.A more comprehensive system for classifyingpregnancy status (GTPAL or GTPALM) providesgreater detail on the pregnancy history. By thissystem, the gravida classification remains the same,but para is broken down into :T : The # of full-term infants born (37 weeks or after)P : The # of preterm infants born (infants bornbefore 37 weeks)A : The # of spontaneous or induced abortionsL : The # of living childrenM : Multiple pregnancies
G. Typical Day History
Information about a woman’s currentnutrition, elimination, sleep, recreation andinterpersonal interactions can be elicited best byasking the woman to describe a typical day of her life.
H. Review of Systems
– Brief review of all body systemsa.Head – Ask about headache, head injury, seizures,dizzinessb.Eyes – Inquire about vision, eyeglasses, eye diseasesc.Ears – Infection, discharges, paind.Nose – Bleeding, discharges, colds, allergy, sinusese.Mouth and pharynx –Dentures, teeth, toothache,bleeding, pain, surgeryf.Neck – stiffness, massesg.Breast – lumps, secretion, pain, tendernessh.Respiratory – cough, wheezing, asthma, SOBi.Cardiovascular – heart murmur, history of heart disease,HPN j.G.I.T – pre-pregnant weight, diarrhea, constipation,hemorrhoids, ulcer k.Genito-urinary – infection, STD’sl.Extremities – varicose veins, pain or stiffness of joints,fracturesm.Skin – rashes, acne, psoriasis
 I. Support Persons Role
Questions asked to the support person : Currenthealth status, feelings and concern about thepregnancy, knowledge of pregnancy and childbirth
2. PHYSICAL EXAMINATIONA. Baseline Data :
to establish a baseline for futurecomparison- Weight, Height, BP, PR, RR
-
FHR : 120-160 beats/min
-
10-12 weeks (Doppler)
-
18-20 weeks (Stethoscope)
-
Fundic height:12-14 weeks – Symphysis pubis20-22 weeks – Umbilicus36 weeks - Xiphoid process40 weeks - Xiphoid process 
B. System Assessment
 
1. General Appearance and Mental Status
Physical examination always begins with inspection of generalappearance to form a general impression of the woman’s health andwell-being.
A physical examination at a first prenatal visit typically includesinspection of body systems, with emphasis on changes that occur with pregnancy.
General appearance is important because it reveals how peoplefeel about themselves by the manner in which they dress, speak andbody posture they assume 
2. Head and Scalp
Examine head for symmetry, normal contour and tenderness
Examine hair for distribution, thickness, excessive dryness or oiliness, cleanliness, or the use of hair dye.
Look for chloasma (extra pigment on the skin)
3. Eyes
Edema in the eyelids
Spots before the eyes
Diplopia (double vision)- may indicate PIH
4. Nose
Increased level of estrogen associated with pregnancy maycause nasal congestion.
5. Ears
The nasal stuffiness that accompanies pregnancy may lead toblocked Eustachian tubes and therefore a feeling of fullness or dampening of sound during early pregnancy.
6. Sinuses
Sinuses should feel nontender 
7. Mouth, Teeth and Throat
Pregnant woman is prone to vitamin deficiency because of therapid growth of the fetus.
Assess carefully for cracked corners of the mouth that wouldreveal vitamin A deficiency.
Assess carefully for pinpoint lesions with an erythematous baseon the lips; these suggest a herpes infection
Gingival hypertrophy may result from estrogen stimulationduring pregnancy.
Teach all women not to neglect good dental hygiene whilepregnant
8. Neck
Slight thyroid hypertrophy may occur with pregnancy becausethe overall metabolic rate is increased.
Encourage a woman to continue to use iodized salt duringpregnancy and to eat seafood at least once weekly to supply enoughiodine for thyroxine production with this increased rate.
9. Lymph Nodes
No palpable lymph nodes should be present.
10. Breasts
 
As pregnancy begins, the breast undergo the following :Breast areola darkens; Montgomery’s tubercles becomeprominent; Breast size increases; breast tone affirms; secondaryareola may develop surrounding the natural one; blue streakingof veins becomes prominent; colostrums may be expelled asearly as the 16
th
week of pregnancy; any supernumerary nipplealso may become darker.
All women should be instructed on monthly breast self examination.
11. Heart
Heart rate should range from 70 to 80 beats/minute.
No accessory sounds or murmurs should be present.
Because of the breast size , it may be difficult to hear thewoman’s heart beat during pregnancy
Many women notice occasional palpitations (heart skippinga beat) during pregnancy, especially when lying supine. Teachpregnant woman to rest or sleep on their side (left side is best) toavoid this problem.
12. Lungs
Late in pregnancy, diaphragmatic excursion is lessenedbecause the diaphragm cannot descend as fully as usualbecause of the distended uterus.
13. Back
Assess the spine for any abnormal curve that wouldsuggest scoliosis.
14. Rectum
Assess the pregnant woman’s rectum closely for hemorrhoidal tissue, which commonly occurs from pelvicpressure preventing venous return.
15. Extremities and Skin
Assess the upper extremities. Many women develop palmar erythema and itching early in pregnancy from a high estrogenlevel and perhaps subclinical jaundice.
Assess the lower extremities carefully for varicosities, fillingtime of the toenails (should be under 5 seconds) and edema.
Assess the gait of pregnant women to see that they arekeeping their pelvis tucked under the weight of their abdomen.
MEASUREMENT OF FUNDAL HEIGHT AND FETAL HEARTSOUNDS
12-14 weeks of pregnancy – uterus ispalpable over the symphysis pubis as a firmglobular sphere
20-22 weeks – reaches umbilicus
36 weeks – xiphoid process
40 weeks – often return to 4 about 4 cmbelow the xiphoid due to lightening
Auscultate for fetal heart sounds (120 to 160beats/minute. These can be heard at 10 to 12weeks if Doppler is used. 18 to 20 weeks if regular stethoscope is used.
Palpate for fetal outline and position after the 28
th
week.
PELVIC EXAMINATION
> Reveals information on the health of both internal andexternal reproductive organs
a. EXTERNAL GENITALIA
– note for :1.Signs of inflammation2.Irritation3.Infection4.Herpes simplex II virus infection5.Rectocele6.Cystocele
b. INTERNAL GENITALIA
1. Cervix should be in the center and color should be almostpurple when pregnant.
Retroverted Uterus – cervix positioned anteriorly
Anteverted Uterus – cervix positioned posteriorly.1.Nulligravida – woman who is not or never has beenpregnant, the cervical os is round and small.2.A woman who has had a previous pregnancy, the cervicalos has a slitlike appearance.3.If the woman had a cervical tear during a previous birth,the cervical os may appear as a transverse crease.4.If a cervical infection is present, a mucus dischargemaybe present. With infection, the epithelium of thecervical canal often enlarges and spreads onto the areasurrounding the os. Giving the cervix a reddenedappearance called erosion. This area bleeds easily if touched.
Trichomoniasis – a protozoal infection, generally gives signs of redness; a profuse, whitish, bubbly discharge; and petechialspots on the vaginal walls.
Candidal (Monilial) infection – presents with thick, white vaginalpatches that may bleed if scraped away.
A gonorrheal infection – presents with a thick, greenish-yellowdischarge and extreme inflammation.
Chlamydia infection – shows few symptoms.
Carcinoma of the cervix appears as an irregular, granular growth at the os.
Cervical polyps (red, soft, pedunculated protrusions) also maybe seen occasionally at the os.
c. PAPANICOLAOU SMEAR
Weapon for detecting cervical cancer 
American Cancer Society recommends a pap smear every 3years in women who have had 2 consecutive negative tests.
Recommended more frequently to women who were exposedto diethylstilbestrol (DES) in utero, who have multiple sexualpartners, who have a history of human papillomavirus (HPV),cigarette smokers, who were sexually active before age 21
d. VAGINAL INSPECTION
A culture for gonorrhea, chlamydia or group B streptococcusmay be taken. All these organism can cause disease in the NBso it is best if they can be eradicated during pregnancy
Any areas of inflammation, ulceration, lesions or dischargeshould be noted
Vaginal examination is critical for a woman whose mother tookDES during her pregnancy. Female children of mothers whotook DES are prone to develop adenosis or overgrowth of cervical endothelium (which is possibly associated with vaginalcancer).
e. EXAMINATION OF PELVIC ORGANS
A bimanual (two-handed) examination is performed to assessthe position, contour, consistency, and tenderness of pelvicorgans
Abnormalities that can be noted by bimanual examinationinclude ovarian cysts, enlarged fallopian tubes (perhaps frompelvic Inflammatory Disease) and an enlarged uterus.
An early sign of pregnancy (Hegar’s sign) is elicited onbimanual examination.
f. RECTOVAGINAL EXAMINATION
To assess the strength and irregularity of the posterior vaginalwall
e. ESTIMATING PELVIC SIZE
It is hard to see from the outward appearance of a womanwhether her pelvis is adequate for the passage of a fetus.
Pelvic measurements should be taken if the woman is pregnantand if she has never given birth vaginally
In sonogram, estimations may be made by a combination of pelvic pelvimetry and fetal sonogram
Estimation of pelvic adequacy must be done at least by the 24
th
week of pregnancy, because by this time, there is danger thatthe fetal head will reach a size that will interfere with safepassage and birth if the pelvic measurements are small
Once a woman has given birth vaginally, her pelvis has beenapproved adequate, and it is not necessary to take pelvicmeasurements.Types of Pelvis> Categorized into 4 groups :
•
Gynecoid : normal female pelvis
•
Anthropoid : Ape-like pelvis
•
Platypelloid : Flattened pelvis
•
Android : Male pelvis
PELVIC MEASUREMENTS
Internal pelvic measurements give the actual diameters of theinlet and outlet through which the fetus must pass. Thefollowing measurements are made most commonly :
1. The Diagonal Conjugate
– The distance between the anterior surface of the sacral prominence and the anterior surface of theinferior margin of the symphysis pubis. The most usefulmeasurement for estimation of pelvic size, because it suggests theanteroposterior diameter of the pelvic inlet.
2. The True Conjugate – Conjugate Vera
.The measurement between the anterior surface of the sacralprominence and the posterior surface of the inferior margin of thesymphysis pubis.
3. The Ischial Tuberosity
– The distance between the ischialtuberosities, or the transverse diameter of the outlet. A diameter of 
 
11 cm is considered adequate because it will allow the widestdiameter of the fetal head.
3. LABORATORY ASSESSMENT
•
Blood Studies
•
Urinalysis
•
Tuberculosis Testing
•
Ultrasound
IDENTIFYING THE HIGH-RISK PREGNANCY
Some women enter pregnancy with a chronic illness that,when superimposed on the pregnancy, makes it high risk.
Other women enter pregnancy in good health but thendevelop a complication of pregnancy that causes it tobecome high risk.
A combination of particular instances – poverty, lack of support people, poor coping mechanisms, geneticinheritance, or past history of pregnancy complications cancause a pregnancy to be categorized as high risk.
FACTORS THAT CATEGORIZE A PREGNANCY AS HIGHRISKA. Infections During Pregnancy
•
Maternal infections during pregnancy maycontribute significantly to fetal morbidity andmortality.
•
Infections in this category may be caused byvarious viruses. Other organisms like bacteria,spirochetes, protozoa, or yeast may also causematernal infections, which are harmful to thedeveloping fetus. Even though the infection inthe mother may be very mild, the effects on thefetus may be catastrophic.
•
Most organisms cross the placenta and infect thefetus, causing birth anomalies. The fetus mayalso acquire the organism as it travels the birthcanal during labor, causing illness after birth.
SEXUALLY TRANSMITTED DISEASES AND PREGNANCY
Spread through sexual contact with an infected partner.
All STD’s can be prevented to some extent by the use of safer sex practices.
Treatment begins with determining the causative organismso the appropriate antibiotic or antifungal medication can beprescribed.Nursing Diagnosis : Pain related to vulvar irritation secondary toexistence of STD
1. THE WOMAN WITH CANDIDIASIS
Candidiasis causes a vaginal infection spread by the fungusCandida.Assessment :1. Thick, cream cheeselike vaginal discharge and extremepruritus.2. Vagina appears red and irritatedEtiology :1. Occurs more frequently during pregnancy because of theincreased estrogen level present during pregnancy.2. Occurs frequently to women being treated with an antibioticfor another infection.3. Occurs frequently in women with gestational diabetes4. Mostly seen in women with HIV infectionDx : Diagnosed by microscopic analysisTreatment : Local application of an antifungal cream such asmiconazole cream (Monistat) or oral fluconazole (Diflucan)Complications :1. If untreated during pregnancy, it may cause a candidalinfection, or thrush, in the NB.
2. THE WOMAN WITH TRICHOMONIASIS
A single-cell protozoan spread by coitus.Assessment :1.A yellow-gray, frothy, odorous vaginal discharge.2.Vulvar itching, edema, and rednessDx: Diagnosed by examination of vaginal secretions on a wetslide that has been treated with Potassium Hydoxide (KOH).Treatment :Topical clotrimazole instead of metronidazole because of its possibleteratogenic effects if used during the first trimester of pregnancy.Etiology :
Probably associated with preterm labor, premature rupture of membranes and post cesarean section infection
3. THE WOMAN WITH BACTERIAL VAGINOSIS (GARDNERELLAINFECTION)
Local infection of the vagina by the invasion, most commonly, of Gardnerella organisms.Assessments :1. Discharge is gray and has a fishlike odor 2. Intense pruritusTreatment :1. Metronidazole for non pregnant women.2. Because Metronidazole is contraindicated during the firsttrimester, women are usually treated with a topical creamComplications :1. Untreated bacterial infections are associated with amniotic fluidinfections, perhaps, preterm labor and premature rupture of membranes.
4. CHLAMYDIA TRACHOMATIS
One of the most common types of vaginal infections seenduring pregnancy.> Infection is caused by a gram-negative intracellular parasiteAssessment :1. Heavy gray-white vaginal dischargeDx: Diagnosis is made by culture of the organism from vaginalsecretions using a specific chlamydia culture kit.Treatment :1. Therapy is usually with tetracyclines but contraindicated duringpregnancy because of possible long bone deformities; Erythromycinand Amoxicillin are used instead.
It is important that chlamydia infections be treated because theyare associated with PROM, preterm labor and endometritis inthe postpartal period.
An infant who is born while a chlamydia infection is present inthe vagina can suffer from conjunctivitis or pneumonia after birth.
5.SYPHILIS
A systemic disease caused by the spirochete Treponemapallidum.Assessment :
1.
The 1
st
stage results in a painless ulcer (chancre) on thevulva or vagina.2.Hepatic and splenic enlargement, headache, anorexia,and maculopapular rash on the palms of the hand and thesoles of the feet ( secondary syphilis; occurring about twomonths after initial infectionComplications :1. Spontaneous Abortion2. Preterm Labor 3. Stillbirth4. Congenital anomalies in the NBDx: All pregnant women are screened for syphilis by VDRL, RPR or FTA-ABS antibody reaction test.Treatment :1. One injection of Benzathine penicillin G is the drug of choiceduring pregnancy
6.THE WOMAN WITH GONORRHEA
A sexually transmitted disease caused by the gram-negativecoccus Neisseria gonorrhea.Assessments :1. May not produce symptoms in some women2. A yellow-green vaginal discharge may be present
Gonorrhea is associated with spontaneous abortion, pretermbirth, and endometritis in the postpartal period.
Also a cause of pelvic infectious disease and infertility.Dx : Diagnosis is made by culture of the organism from the vagina,rectum or urethraTreatment :
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