Introduction to Maternity and

Pediatric Nursing, Fourth

Edition

Chapter 5
Nursing Care of Women with
Complications During
Pregnancy
High Risk Pregnancy Causes
Relate to the pregnancy itself
Occurs because the woman has a
medical condition
Results from environmental hazards
Arise from maternal behavior or
lifestyle

Assessment of Fetal Health
Nurses responsibility
Preparing patient properly for test
Explaining reason for test
Clarifying and interpreting results in
collaboration with other HCPs
Providing support to patient


US Images
4D US Images
AFI



Kick Count Assessment Tool
Doppler Ultrasound Blood Flow
Assessment
AFP


Amniocentesis
NST
Percutaneous Blood Sampling
Danger Signs in Pregnancy
Sudden gush of fluid from vagina
Vaginal bleeding
Abdominal pain
Persistent vomiting
Epigastric pain
Swelling of face and hands
Severe, persistent headache
Danger Signs in Pregnancy
Contd
Blurred vision or dizziness
Chills with fever > 100.4 degrees
Painful urination or reduced urine
output
Pregnancy-Related
Complications
Hyperemesis Gravidarum
Manifestations
Persisitent N/V
Significant weight loss
Dehydration: dry tongue and mucous
membranes, decreased turgor, scant
concentrated urine, high hematocrit
Electrolyte and acid-base imbalance
Unusual stress, emotional immaturity,
passivity, ambivalence
Treatment
Correct electrolyte imbalances and
acid-base imbalances with oral or IV
fluids
Antiemetic drugs
Possibly parenteral nutrition

Pregnancy-Related
Complications
Nursing Care
Focus is on teaching
Avoid foods that trigger N/V
Eat small, frequent meals
Teach about intake and output
Provide support to the mother

Pregnancy-Related
Complications
Bleeding Disorders of Early
Pregnancy
Abortion
Specific care depends on whether abortion
induced or spontaneous
Treatment
Cervical cerclage
Suturing of cervix to help maintain threatened
pregnancy
Counseling
Administration of oxytocin to help control blood loss
Rhogam given if mother Rh negative

Bleeding Disorders of Early
Pregnancy
Nursing Care for Abortion
Physical care
Documents amount of bleeding
Pad count
Vital signs
Instruct pt. To remain NPO if actively bleeding
Instructions
Report increased bleeding
Monitor temp every 8 hours x 3 days
Take iron supplement
Resume sex as prescribed by HCP
Appointment with HCP at assigned date and time

Bleeding Disorders of Early
Pregnancy
Emotional Care for Abortion
Acknowledge grief
Provide for spiritual support
Bleeding Disorders of
Early Pregnancy
Ectopic Pregnancy
Occurs when fertilized egg is implanted outside
uterine cavity
95% in fallopian tube
May result from
Hormonal abnormalities
Inflammation
Infection
Adhesions
Congenital defects
Endometriosis
Use of intrauterine contraception due to inflammation
Failed tubal ligation
Bleeding Disorders of
Early Pregnancy
Zygote cannot survive for long
May die and be reabsorbed
May rupture tube creating a surgical emergency
Manifestations
Lower abdominal pain
Light vaginal bleeding
If rupture occurs
Sudden, severe abdominal pain, vaginal bleeding and
hypovolemic shock
Referred shoulder pain

Bleeding Disorders of Early
Pregnancy
Treatment for Ectopic Pregnancy
Test for hCG
Transvaginal US
Laparoscopic exam
Medical treatment
No action if being reabsorbed
Methotrexate (if tube not ruptured) inhibits cell division
Sugery to remove pregnancy from tube or entire
tube if damage is severe

Bleeding Disorders of Early
Pregnancy
Nursing Care for Ectopic Pregnancy
Vital signs
Assessment of lung and bowel sounds
IV fluids
Blood replacement as necessary
Antibiotics
Pain management
NPO
Indwelling catheter
Bed rest
Emotional support
Bleeding Disorders of Early
Pregnancy
Hydatidiform Mole
Molar pregnancy
Occurs when the chorionic villi abnormally increase
and form vesicles
May be complete (no fetus) or partial (only part of
the placenta has vesicles)
May cause
Hemorrhage
Clotting abnormalities
Hypertension
Later development of choriocarcinoma


Bleeding Disorders of Early
Pregnancy
Chromosome abnormalities are common
May occur in women at ages of extreme
reproductive life
Manifestations
Bleeding
Rapid uterine growth
Failure to detect FHR activity
Signs of hyperemesis gravidarum
Unusually early PIH
Snowstorm pattern on US with no evidence of fetus
Bleeding Disorders of Early
Pregnancy
Treatment for Hydatidaform Mole
Vacuum aspiration and D&C
Level of hCG is tested until undetectable and
levels followed for at least 1 year
Women advised to delay conception until
follow-up care complete
Rhogam given if mother Rh negative

Bleeding Disorders of Early
Pregnancy
Nursing Care for Hydatididaform Mole
Observe for bleeding and shock
Emotional support
Education on reasons to delay pregnancy
Contraception education

Bleeding Disorders of Late
Pregnancy
Placenta Previa
Placenta develops in the lower part of
the uterus versus the upper part
There are 3 degrees of previa
Marginal reaches within 2-3 cm of
cervical opening
Partial placenta partially covers the
cervical opening
Complete or Total completely covers the
opening

Bleeding Disorders of Late
Pregnancy
A low-lying placenta is near the cervix
Not a true placenta previa
May or may not be accompanied by bleeding
May be discovered during a routine exam


Bleeding Disorders of Late
Pregnancy
Manifestations of Placenta Previa
Bright red, painless vaginal bleeding
Risk of hemorrhage increases with nearing of
labor
Fetus often in abnormal presentation
Fetus may have anemia
Mother may be more at risk postpartum for
infection and hemorrhage
Vaginal organisms can easily reach placenta site
Lower portion of uterus has fewer muscles
resulting in weaker contractions

Bleeding Disorders of Late
Pregnancy
Treatment
Depends on length of gestation and amount
bleeding
Goal is to maintain pregnancy as long as
safely possible
Mother encouraged to lie on side or with
pelvic tilt to avoid supine hypotension
Delivery by C-section if total or partial
May deliver vaginally if low-lying or marginal
Bleeding Disorders of Late
Pregnancy
Nursing Care
Observe for vaginal blood loss
Observe for S/S of shock
Vital signs q 15 minutes if actively bleeding
and oxygen administered
NO VAGINAL EXAMS
Continuos fetal monitoring
Prepare for Cesarean if indicated
Supportive Care

Bleeding Disorders of Late
Pregnancy
Abruptio Placentae
Permanent separation of placenta from
implantation site
Predisposing factors include
Hypertension
Cocaine or Alcohol Use
Smoking
Poor Nutrition
Abdominal Trauma
Prior History of Abruption Placentae
Folate deficiency
Hypertension During Pregnancy
Manifestations of Abruptio Placentae
Bleeding with abdominal or low back pain
Bleeding may be concealed at first
Dark red vaginal bleeding when blood leaks
past placenta
Uterine tenderness and firm
May have cramp-like contractions
Fetus may or may not be in distress
Fetus/Neonate may have anemia or
hypovolemic shock

Hypertension During Pregnancy
Disseminated Intravascular Coagulation (DIC)
May complicate abruptio placentae
Large clot behind placenta consumes clotting
factors which leaves mother deficient
Clot formation and destruction occurs at the same
time
Mother may bleed from all orifices due to depletion
of clotting factors
Postpartum hemorrhage may occur
Infection likely due to damaged tissue being
susceptible to bacteria
Hypertension During Pregnancy
Treatment
1
st
Choice Immediate Cesarean
Blood and clotting factor replacement if necessary
After delivery problem quickly resolves
Nursing Care
Prepare for C-section
Close, continuous monitoring of mother and baby
Observe for S/S shock
Prepare for compromised infant
Prepare for grieving if infant dies

Hypertension During Pregnancy
Hypertension During Pregnancy
High blood pressure in pregnancy (PIH)
Preeclampsia
PIH + proteinuria
Eclampsia
PIH + proteinuria + convulsions/seizures
Toxemia old terminology

Hypertension During Pregnancy
Cause unknown
Birth only definitive cure
Usually develops after 20
th
week, but research
has shown that it is determined
at implantation
Vasospasm is main characteristic
May increase risks of further complications


Hypertension During Pregnancy
Risk Factors for PIH
1
st
pregnancy
Obesity
Family history of PIH
>40 years or <19 years
Multifetal pregnancy
Chronic hypertension
Chronic renal disease
Diabetes mellitus
Hypertension During Pregnancy
If mild to moderate BP readings (systolic <160mm
Hg and diastolic <110 mmHg) identified
medications typically not used to treat
Treated/Monitored with diet modification,
daily weights, activity restriction, BP monitoring,
fetal kick counts, frequent monitoring for
proteinuria

Hypertension During Pregnancy
Medication is started if BP exceeds moderate
range
Drugs of Choice
Methyldopa (Aldomet)
Labetalol
Nifedipine (Procardia)

Hypertension During Pregnancy
Manifestations of PIH
Vasospasm impede blood flow to mother and placenta
resulting in:
Hypertension
Typically should not occur in pregnancy due to hormonal
changes which decrease resistance to
blood flow
Edema
Occurs when fluid leaves blood vessels and enters tissues
Proteinuria
Develops as reduced blood flow damages kidneys


Hypertension During Pregnancy
Other Manifestations of Preeclampsia
CNS HA
Eyes Visual disturbances
Urinary Tract Decrease UOP
Respi9ratory Pulmonary Edema
GI and Liver Epigastric pain and N/V, elevated
liver enzymes
Blood HELLP hemolysis, elevated liver
enzymes, low platelets


Hypertension During Pregnancy
Eclampsia
Woman has one or more generalized seizures
Facial muscles twitch, then contraction of all muscles
Effects on Fetus
Decreased oxygen availability which may
result in fetal hypoxia
Meconium
IUGR
Fetal Death


Hypertension During Pregnancy
Treatment of PIH
Prevention
Management as discussed previously
Drug Therapy
Magnesium Sulfate (anticonvulsant and
antihypertensive)
Antihypertensive Drug Therapy if BP
> 160/100 mg Hg


Hypertension During Pregnancy
Nursing Care
Assist to obtain PNC
Help cope with therapy
Provide care/Monitor
Administer meds
Postpartum Care

Blood Incompatibility
Rh and ABO Incompatibility
Rh blood factor = Rh+
No Rh blood factor in erythrocytes = Rh-
Rh+ person can receive Rh- blood if all other
factors compatible because factor is not
present
Rh incompatibility only occurs if the mother is
Rh- and fetus is Rh+
Blood Incompatibility
Rh- is autosomal recessive triat both parents must
pass on this gene to the fetus
Rh+ is dominate gene
Rh+ person can inherit two Rh+ genes or one Rh+
and one Rh-
Rh- mother does not have the factor and therefore if
her fetus does her body may respond with antibody
production as a defense mechanism (isoimmunization)
Typically occurs at delivery and would therefore
affect subsequent pregnancies
Blood Incompatibility
Manifestations
If mother produces anti-Rh anitbodies no outward
manifestation
Labs reveal increased antibody titers
When maternal anti-Rh antibodies cross the
placenta fetal erythrocytes are destroyed
(erythroblastocis fetalis)


Blood Incompatibility
Nursing Care
Prevent antibody production
Rhogam at 28 weeks and w/in 72 hours of delivery
if mother Rh- and baby Rh+
May also be given after amniocentesis as a
precaution
Not effective if sensitization has already occurred
If antibody production occurs fetus is monitored
carefully
Coombs test
Amniocentesis
Percutaneous umbilical sampling test
Intrauterine transfusion if severely anemic


Pregnancy Complicated
by Medical Conditions
Diabetes Mellitus
Preexisting (Type I or Type II with
onset before pregnancy)
Gestational (GDM occurs only during
pregnancy)

Pregnancy Complicated
by Medical Conditions
Pathophysiology of DM
Pancreas produces insufficient insulin or cells
resist effect of insulin
Cells cannot receive glucose
Body metabolizes proteina and fat for energy
Ketones and acid accumulate
Person loses weight
Person experiences fatigue and lethargy
Fluid moves to tissues to dilute excess glucose
leading to increased thirst resulting in tissue
dehydration and glycosuria (glucose-bearing urine)

Pregnancy Complicated
by Medical Conditions
Effect of Pregnancy on Glucose Metabolism
Increased resistance of cells to insulin
Increased speed of insulin breakdown
Gestational Diabetes Mellitus
Maternal Links to GDM
Maternal Obesity (>198 lbs.)
Previous macrosomic infant
Maternal age > 25 years
Previous unexplained stillbirth or infant with congenital
anomalies]
Family history of DM
Fasting glucose > 135 mg/dl or postmeal > 200 mg/dl


Pregnancy Complicated
by Medical Conditions
Treatment of Diabetes During Pregnancy
Identification
Diet Modification
Monitoring
Ketone Monitoring
PO antidiabetic agents
Insulin
Exercise
Fetal monitoring
May indicate early delivery

Pregnancy Complicated
by Medical Conditions
Nursing Care for Diabetes During Pregnancy
Self-care/Management
Emotional Support
Encourage Breastfeeding

Pregnancy Complicated by
Medical Conditions
Heart Disease
Affects small percentage of pregnant women
Manifestations
Increased clotting causes predisposition to
thrombosis
If cannot meet demand leads to CHF
Priority of care is limiting demands on heart throughout
pregnancy, labor, delivery and postpartum period

Pregnancy Complicated by
Medical Conditions
Nursing Care for Heart Disease
Teach self-management to patient
Teach S/S of CHF
Diet modification
Teach about eliminated stress
Pregnancy Complicated
by Medical Conditions
Anemia
Hgb levels < 10.5-11.0 g/dl in pregnancy
4 types in pregnancy
Iron-deficiency
RBCs small and pale
Prevention iron supplements
Treatment elemental iron supplements
Folic acid-deficiency
Large, immature RBCs
Iron-deficiency anemia may also be present
Prevention folic acid supplement
Treatment 1mg/day supplement over the amount
of preventative supplement

Pregnancy Complicated
by Medical Conditions
Sickle cell disease
Abnormal Hgb that causes erythrocytes to become
sickle-shaped during hypoxia or acidosis
Autosommal recessive trait
Approx 1/12 African Americans has the trait
Pregnancy may cause crisis
Risk to fetus occulsion of vessels leading to
preterm birth, IUGR, fetal death
Thalasemia
Genetic trait that causes abnormality in one of two
chains of Hgb ,alpha or beta
Pregnancy Complicated
by Medical Conditions
Nursing Care for Anemias During
Pregnancy
Nutrition education
Education about changes in stool pattern and
characteristics
Taught to avoid dehydration

Pregnancy Complicated
by Medical Conditions
Infections
TORCH - Devestating infections for fetus
T toxoplasmosis
O other infections
R rubella
C cytomegalovirus
H herpes simplex virus

Pregnancy Complicated
by Medical Conditions
Viral Infections
Cytomegalovirus May be asymptomatic in
mother, but serious problem in infant
Mental retardation
Seizures
Blindness
Deafness
Dental abnormalities
Petechiae (blueberry muffin rash)

No effective treatment, therapeutic abortion may be
offered if early in pregnancy

Pregnancy Complicated
by Medical Conditions
Rubella mild virus with low fever and rash,
but effects on fetus can be devastating
Microcephaly
MR
Congenital cataracts
Deafness
Cardiac defects
IUGR

Treatment Immunization prior to pregnancy
Pregnancy Complicated
by Medical Conditions
Herpes virus type 1 and type 2 type 2
affects pregnancy
Infection in infant can be localized or
widespread, may cause death or neurological
complications

Treatment and Care Avoid contact with
lesions, if active outbreak Cesarean delivery
Pregnancy Complicated
by Medical Conditions
Hepatitis B transmitted by blood and body
fluids, can also cross placenta
Treatment and Care screen during pregnancy,
infants born to women who are Hepatitis B+ should
be given Hepatitis B immune globulin (HbIG),
followed by Hep B vaccine
Pregnancy Complicated
by Medical Conditions
HIV causitive organism of AIDS, cripples
immune system
Acquired one of three ways
Sexual contact with infected person
Parenteral or mucous membrane exposure to
infected body fluids
Perinatal exposure (20% - 40% chance of infecting
infant)
Transplacentally
Contact with infected maternal secretions at birth
Breastmilk

Pregnancy Complicated
by Medical Conditions
Nonviral Infections
Toxoplasmosis caused by Toxoplasma
gondii, a parasite that may be in cat feces in
raw meat and transmitted through the
placenta
Possible S/S in newborn
Low birth weight
Enlagred liver and spleen
Jaundice
Anemia
Inflammation of eye structures
Neurological damage

Pregnancy Complicated
by Medical Conditions
Treatment and Nursing Care
Cook all meats thoroughly
Wash hands after handling raw meat
Avoid litter boxes , soil and sand boxes
Wash fresh fruits and veggies well
Group B streptococcus leading cause of perinatal
infections. Organism found in womans rectum, vagina,
cervix, throat or skin. Woman usually asymptomatic, but can
be transmitted to baby at delivery.
Diagnosis
+ culture of womans vagina or rectum at 35-37 weeks
gestation
Treatment
Antibiotics to mother prior to delivery
Antibiotic therapy to infant after delivery

Pregnancy Complicated
by Medical Conditions
TB
S/S
fatigue
weakness
loss of appetite and weight
Fever
Night sweats
Treatment and Nursing Care
Isoniazid and Rifampin to mother for 9 months
Infant may have preventative therapy for 3 months
Pregnancy Complicated
by Medical Conditions
Sexually Transmitted Diseases
Prevention is by safe sex with protection of condom
Herpes
HIV
Syphilis
Gonorrhea
Chamydia
Trichomoniasis
Genital Warts



Pregnancy Complicated
by Medical Conditions
Urinary Tract Infections
More common in pregnancy due to pressure
on urinary structures keeps bladder from
emptying completely and because ureters
dilate and lose motility under influence of
relaxing effects of progesterone and relaxin
Cystitis infection of bladder
S/S
Burning with urination
Increased frequency and urgency
May have slightly elevated temp


Pregnancy Complicated
by Medical Conditions
Pyelonephritis infection of kidney(s)
S/S
High fever
Chills
Flank pian
N/V
Treatment for UTIs
Antibiotic therapy
Nursing Care
Teach to wipe front to back
Intake adequate fluid
Urinate before and after intercourse
Teach S/S


Pregnancy Complicated
by Medical Conditions
Substance Abuse the use of illicit or
recreational drugs during pregnancy .
Treatment and Nursing Care
Identify substance abused
Educate on potential effects of drug
Use nonjudgmental approach
Pregnancy Complicated
by Medical Conditions
Trauma During Pregnancy
Manifestations of Battering
May enter late to prenatal care
May make up excuses
Treatment and Nursing Care
Provide for privacy
Be nonjudgmental
Offer resources
Assessment of maternal and fetal
well-being
Effects of a High-Risk Pregnancy
on the Family
Disruption of Roles
Financial Difficulties
Delayed Attachment
Loss of Expected Birth Experience
References
Introduction to Maternity & Pediatric Nursing; Fourth Edition,
2003; Gloria Leifer, Ma, RN; Associate Professor Obstetrics,
Pediatrics, and Trauma Nursing; Riverside Community
College; Riverside, California; Saunders

The END!!!