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Y  



 

  

  
 
! 
"

 


 

«..Causes
Y   

«..Causes
O „elate to the pregnancy itself
O Occurs because the woman has a medical
condition
O „esults from environmental hazards
O Arise from maternal behavior or
lifestyle
 
# Y  

O   !


  

x ÷reparing patient properly for test


x Explaining reason for test
x Clarifying and interpreting results in
collaboration with other HC÷s
x ÷roviding support to patient
 Images
i  Images
AFI AMNIOTIC FLI IN EX
ëick Count Assessment Tool
oppler ltrasound Blood Flow
Assessment
AF÷ AL÷HA FETO ÷„OTEIN
performed at about 15-
15-20 weeks of pregnancy.
Amniocentesis
N T non-
non-stress test
is an objective recording of the fetal heart rate variation with
spontaneous movement..
÷ercutaneous Blood ampling
anger igns in ÷regnancy

O udden gush of fluid from vagina


O Vaginal bleeding
O Abdominal pain
O ÷ersistent vomiting
O Epigastric pain
O welling of face and hands
O evere, persistent headache
anger igns in ÷regnancy
O Blurred vision or dizziness
O Chills with fever > 100.i degrees
O ÷ainful urination or reduced urine
output
÷regnancy--„elated Complications
÷regnancy
Y !    $ % & 
x Manifestations
¦ ÷ersisitent N/V
¦ ignificant weight loss
¦ ehydration: dry tongue and mucous membranes,
decreased turgor, scant concentrated urine, high
hematocrit
¦ Electrolyte and acid-base imbalance
¦ nusual stress, emotional immaturity,
passivity, ambivalence
÷regnancy--„elated Complications
÷regnancy

x ] 

¦ Correct electrolyte imbalances and


acid-base imbalances with oral or IV
fluids
¦ Antiemetic drugs
¦ ÷ossibly parenteral nutrition
÷regnancy--„elated Complications
÷regnancy

x 
 
¦ Focus is on teaching
¦ Avoid foods that trigger N/V
¦ Eat small, frequent meals
¦ Teach about intake and output
¦ ÷rovide support to the mother
Bleeding isorders of Early ÷regnancy
 

x pecific care depends on whether abortion induced or


spontaneous
x ] 

¦ Cervical cerclage
¦ uturing of cervix ² to help maintain threatened
pregnancy
¦ Counseling
¦ Administration of oxytocin to help control blood loss
¦ „hogam given if mother „h negative
Cerclage
x 
   

¦ ÷hysical care
¦ ocument amount of bleeding
¦ ÷ad count
¦ Vital signs
¦ Instruct pt. To remain N÷O if actively bleeding
¦ Instructions
¦ „eport increased bleeding
¦ Monitor temp every 8 hours x 3 days
¦ Take iron supplement
¦ „esume sex as prescribed by HC÷
¦ Appointment with HC÷ at assigned date and time
¦ Emotional Care for Abortion
¦ Acknowledge grief
¦ ÷rovide for spiritual support
O  !  


x Occurs when fertilized egg is implanted outside
uterine cavity
¦ Ñ5% in fallopian tube
x May result from
¦ Hormonal abnormalities
¦ Inflammation
¦ Infection
¦ Adhesions
¦ Congenital defects
¦ Endometriosis
¦ se of intrauterine contraception ² due to inflammation
¦ Failed tubal ligation
x  ygote cannot survive for long
¦ May die and be reabsorbed
¦ May rupture tube creating a surgical emergency
x 
  

¦ Lower abdominal pain
¦ Light vaginal bleeding
¦ If rupture occurs
¦ udden, severe abdominal pain, vaginal bleeding and
hypovolemic shock
¦ „eferred shoulder pain
x ] 
 !  


¦ Test for hCG
¦ Transvaginal 
¦ Laparoscopic exam
¦ Medical treatment
¦ No action if being reabsorbed
¦ Methotrexate (if tube not ruptured) ² inhibits cell
division
¦ urgery to remove pregnancy from tube or entire
tube if damage is severe
M  

  
  
x Nursing Care for Ectopic ÷regnancy
¦ Vital signs
¦ Assessment of lung and bowel sounds
¦ IV fluids
¦ Blood replacement as necessary
¦ Antibiotics
¦ ÷ain management
¦ N÷O
¦ Indwelling catheter
¦ Bed rest
¦ Emotional support
O Y & & 

x  ! 


¦ Occurs when the chorionic villi is 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
x Chromosome abnormalities are common
x May occur in women at ages of extreme
reproductive life
x Manifestations
¦ Bleeding
¦ „apid uterine growth
¦ Failure to detect FH„ activity
¦ igns of hyperemesis gravidarum
¦ nusually early ÷IH
¦ nowstorm pattern on  with no evidence
of fetus
Y    

åMolarµ ÷regnancy
] 
Y & & 

¦ Vacuum aspiration and 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
¦ „hogam given if mother „h negative
x 
  Y & & 

¦ Observe for bleeding and shock


¦ Emotional support
¦ Education on reasons to delay pregnancy
¦ Contraception education
O 
 %

x ÷lacenta develops in the lower part of


the uterus versus the upper part.

x There are 3 degrees of previa

¦ Marginal ² reaches within 2-3 cm of


cervical opening
¦ ÷artial ² placenta partially covers the
cervical opening
¦ Complete or Total ² completely covers the
opening
x 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
x 
  

 %

¦ Bright red, painless vaginal bleeding


¦ „isk 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
x ] 

¦ epends 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
¦ elivery by C-section if total or partial
¦ May deliver vaginally if low-lying or marginal
O 
 
x Observe for vaginal blood loss
x Observe for / of shock
x Vital signs q 15 minutes if actively bleeding
and oxygen administered
x '($) *
x Continuous fetal monitoring
x ÷repare for Cesarean if indicated
x upportive Care
O ! 

x ÷ermanent separation of placenta from


implantation site
x ÷redisposing factors include
¦ Hypertension
¦ Cocaine or Alcohol se
¦ moking
¦ ÷oor Nutrition
¦ Abdominal Trauma
¦ ÷rior History of Abruption ÷lacentae
¦ Folate deficiency
x 
  
! 

¦ Bleeding with abdominal or low back pain


¦ Bleeding may be concealed at first
¦ ark red vaginal bleeding when blood leaks past
placenta
¦ terine tenderness and firm
¦ May have cramp-like contractions
¦ Fetus may or may not be in distress
¦ Fetus/Neonate may have anemia or
hypovolemic shock
x "  
&)
 %     

+"),

¦ 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
¦ ÷ostpartum hemorrhage may occur
¦ Infection likely due to damaged tissue being
susceptible to bacteria
x ] 

¦ 1st Choice ² Immediate Cesarean


¦ Blood and clotting factor replacement if necessary
¦ After delivery problem quickly resolves

x 
 

¦ ÷repare for C-section


¦ Close, continuous monitoring of mother and baby
¦ Observe for / shock
¦ ÷repare for compromised infant
¦ ÷repare for grieving if infant dies
   !   


  

O Maternal equelae: Abruption, amniotic infection,


post-partum infection of endometrium
O Fetal sequelae: „espiratory distress, sepsis,
prolapsed cord
O iagnoses; nitrazine paper, microscopic test of
amniotic fluid
O No digital examination!!!
   !   

* 

&* ! 
x contractions
x cramps
x backache
x diarrhea
x Vaginal discharge
x „OM
   !   


O ] 

x Tocolytics
x IV hydration
x bedrest
x steroids, if needed

)
%



O Assess fetal well-being, gestational age


O Administer antibiotics
O < 37 weeks gestation, minimal options
O > 3i weeks, assess lung maturity of fetus
O Monitor for signs and prevent premature labor
O ÷rovide psychological support for mother and
family
 --  

O Onset of Labor from 20-37 weeks
O „arely due to a single cause
O Common problem-11.6% of all births are
premature
 --  


O  !   
x Maternal renal, CV, M, ÷IH, placental
problems, trauma, ÷„OM
O    
x Maturational deficiencies- no body fat
x „espiratory istress
x ÷oor glucose, heat regulation

)
%

. 

O Assessment
x Thorough hx
x check bleeding
x check „OM
x B÷
O ] 

x Infection Control
x „eport any leaking
   


* 

&* ! 
Wt loss  
O  fetal mortalit
x  uterine size O cord compression
x Meconium in AF O mec asp
O LGA  shoulder
dystocia  C
O episiotomy/laceration
O depression
 -  

] 

fetal surveillance
¦ N T, q wk
¦ mom monitors fetal movement
)
& 

¦ ÷itocin (10-20/L) @ 1-2 m/min


every 20-60 min
" & 
 # &
" & 
 # &
  & 


* 

&* ! 
O uterine distention
O yspnea ]


O edema of lower extr Ë 
Ë 
   
isorders of Amniotic Fluid
'  & 


 
O cord compression
O musculoskeletal
deformities ]


O pulmonary hypoplasia Ë 
   
Y ! 
 
"
 

O Y ! 
 
"
 


x High blood pressure in pregnancy (÷IH)
x ÷reeclampsia
¦ ÷IH + proteinuria
x Eclampsia
¦ ÷IH + proteinuria + convulsions/seizures
x Toxemia ² old terminology
x Cause unknown
x Birth only definitive cure
x sually develops after 20th week, but
research has shown that it is determined at
implantation
x Vasospasm is main characteristic
x May increase risks of further complications
x  # )Y

¦ 1st pregnancy
¦ Obesity
¦ Family history of ÷IH
¦ >i0 years or <1Ñ years
¦ Multifetal pregnancy
¦ Chronic hypertension
¦ Chronic renal disease
¦ iabetes mellitus
¦ Treated/Monitored with diet modification,
daily weights, activity restriction, B÷ monitoring,
fetal kick counts, frequent monitoring for
proteinuria
x Medication is started if B÷ exceeds
moderate range

"
¦Methyldopa (Aldomet)
¦Labetalol
¦  & !
+ & ,
x 
  
)Y

¦ 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
¦ ÷roteinuria
¦ evelops as reduced blood flow damages kidneys
¦ Other Manifestations of ÷reeclampsia
¦CN ² HA
¦Eyes ² Visual disturbances
¦rinary Tract ² ecrease O
¦„espiratory ² ÷ulmonary Edema
¦GI and Liver ² Epigastric pain and N/V,
elevated liver enzymes
¦Blood ² HELL÷ ² hemolysis, elevated liver
enzymes, low platelets
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O   O   



O    O @
x !    
O  
   
  x @ 
O      
  
O ð
¦   !

¦ Woman has one or more generalized seizures


¦ Facial muscles twitch, then contraction of all
muscles
¦  
# 
¦ ecreased oxygen availability which may result
in fetal hypoxia
¦ Meconium
¦ IG„
¦ Fetal eath
x ] 
)Y
¦ ÷revention
¦ Management ² as discussed previously
¦ rug Therapy
¦Magnesium ulfate (anticonvulsant and
antihypertensive)
¦Antihypertensive rug Therapy if B÷
> 160/100 mg Hg
x 
 

¦ Assist to obtain ÷NC


¦ Help cope with therapy
¦ ÷rovide care/Monitor
¦ Administer meds
¦ ÷ostpartum Care
B&)
!  
O 
&B')
!  

x „h blood factor = „h+


x No „h blood factor in erythrocytes = „h-
x „h+ person can receive „h- blood if all other
factors compatible because factor is not
present
x „h incompatibility only occurs if the mother is
„h- and fetus is „h+
x „h- is autosomal recessive trait ² both parents
must pass on this gene to the fetus
x „h+ is dominate gene
x „h+ person can inherit two „h+ genes or one
„h+ and one „h-
x „h- 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
B&)
!  
x 
  

¦ If mother produces anti-„h anitbodies no
outward manifestation
¦ Labs reveal increased antibody titers
¦ When maternal anti-„h antibodies cross the
placenta fetal erythrocytes are destroyed
(erythroblastocis fetalis)
x 
 
¦ ÷revent antibody production
¦ „hogam at 28 weeks and w/in 72 hours of
delivery
if mother „h- and baby „h+
¦ May also be given after amniocentesis as a
precaution
¦ Not effective if sensitization has already
occurred
¦ If antibody production occurs fetus is monitored
carefully
¦ Coomb·s test
¦ Amniocentesis
¦ ÷ercutaneous umbilical sampling test
¦ Intrauterine transfusion if severely anemic
ABO INCOM÷ATIBILITY
O More common than „h incompatibility
O Causes less severe problems
O Mom·s blood is O, fetus blood is A, B, or
AB
O Naturally occurring anti-A and anti-B
antibodies transfer across placenta to
fetus.
O Baby may show weak positive Coombs
test result
O May result to hyperbilirubinemia that can
be treated with phototherapy.
O „arely does this incompatibility lead to
the severe anemia of „h incompatibility.
O First time infant will have the most issues
that other children.
÷regnancy Complicated by Medical
Conditions

O"    

x ÷reexisting (Type I or Type II with


onset before pregnancy)
IABETE MELLIT
O iabetes mellitus that
occurs during
pregnancy(G M)
O Women who have
diabetes mellitus prior
to pregnancy are
referred to as
!   

&  +$",
 !   "
¦ ÷ancreas produces insufficient insulin or cells
resist effect of insulin
¦ Cells cannot receive glucose
¦ Body metabolizes protein and fat for energy
¦ ëetones and acid accumulate
¦ ÷erson loses weight
¦ ÷erson 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)
x   


$    
¦ Increased resistance of cells to insulin
¦ Increased speed of insulin breakdown

x $  
"    
¦ Maternal Links to G M
¦ Maternal Obesity (>1Ñ8 lbs.)
¦ ÷revious macrosomic infant
¦ Maternal age > 25 years
¦ ÷revious unexplained stillbirth or infant with
congenital anomalies.
¦ Family history of M
¦ Fasting glucose > 135 mg/dl or postmeal > 200
mg/dl
x ] 
"  "
 

¦ Identification
¦ iet Modification
¦ Monitoring
¦ ëetone Monitoring
¦ ÷O antidiabetic agents
¦ Insulin
¦ Exercise
¦ Fetal monitoring
¦ May indicate early delivery
Glucose Tolerance Test
áa º () (*  [a º
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!a % !0" (a % !1+ &a % !+
x 
  "  "

 

¦ elf-care/Management
¦ Emotional upport
¦ Encourage Breastfeeding
O Y  "  

x Affects small percentage of pregnant women

x Manifestations
¦ Increased clotting causes predisposition to
thrombosis
¦ If cannot meet demand leads to CHF
¦ ÷riority of care is limiting demands on heart
throughout pregnancy, labor, delivery and
postpartum period
O    
/
O  ) -
!    

O  )) -     
!   %
- '&
  %     
! ! 
& !



O  ))) - &     &  

!   % 0  
&
 
%    
O  )( -
    

 % 
   1! 

&  

O 
 /  )2))3
 ! 

2
&  % 
O   )))2)(3 !
& & 
x 
  Y  "  

¦ Teach self-management to patient


¦ Teach / of CHF
¦ iet modification
¦ Teach about eliminated stress



x Y % 45-.&
! 

x  ! 
! 

¦ Iron-deficiency
¦ „BCs small and pale
¦ ÷revention ² iron supplements
¦ Treatment ² elemental iron supplements
¦ #  &-& 

¦Large, immature „BCs


¦Iron-deficiency anemia may also be
present

¦÷revention ² folic acid supplement


¦Treatment ² 1mg/day supplement over
the amount of preventative supplement
O*   &  

x Abnormal Hgb that causes erythrocytes to


become sickle-shaped during hypoxia or acidosis
x Autosommal recessive trait
x Approx 1/12 African Americans has the trait
x ÷regnancy may cause crisis
x „isk to fetus ² occlusion of vessels leading to
preterm birth, IG„, fetal death
]   

¦Genetic trait that causes


abnormality in one of two
chains of Hgb ,alpha or beta

  
 "

 

¦ Nutrition education
¦ Education about changes in stool
pattern and characteristics
¦ avoid dehydration
)
 


x ]'Y- " % 

 
 
¦ T ² toxoplasmosis
¦ O ² other infections
¦ „ ² rubella
¦ C ² cytomegalovirus
¦ H ² herpes simplex virus
(  )
 


x    %  ² May be asymptomatic in


mother, but serious problem in infant

¦ Mental retardation
¦ eizures
¦ Blindness
¦ eafness
¦ ental abnormalities
¦ ÷etechiae (blueberry muffin rash)
¦ No effective treatment, therapeutic abortion
may be offered if early in pregnancy
 
mild virus with low fever and rash, but effects on
fetus can be devastating
¦ Microcephaly
¦ M„
¦ Congenital cataracts
¦ eafness
¦ Cardiac defects
¦ IG„
¦ Treatment ² Immunization prior to pregnancy
Y ! % 3 ! 
& ! 6 3
! 6affects pregnancy

¦ Infection in infant can be localized or


widespread, may cause death or
neurological complications

¦ Treatment and Care ² Avoid contact


with lesions, if active outbreak Cesarean
delivery
Y ! B

>transmitted by blood and body fluids, can also


cross placenta

U ] 

&  ² screen during
pregnancy, infants born to women who are
Hepatitis B+ should be given Hepatitis B
immune globulin (HbIG), followed by Hep B
vaccine
x Y)(
U causative organism of AI , cripples immune system

 7  &
   

¦ exual contact with infected person


¦ ÷arenteral or mucous membrane exposure to infected
body fluids
¦ ÷erinatal exposure (20% - i0% chance of infecting
infant)
¦ Transplacentally
¦ Contact with infected maternal secretions at birth
¦ Breastmilk
O 
%  )
 


]1!  
U caused by Toxoplasma gondii, a parasite that may be in
cat feces in raw meat and transmitted through the
placenta
¦ ÷ossible / in newborn
¦ Low birth weight
¦ Enlarged liver and spleen
¦ Jaundice
¦ Anemia
¦ Inflammation of eye structures
¦ Neurological damage
] 

&
 

¦Cook all meats thoroughly


¦Wash hands after handling raw
meat
¦Avoid litter boxes , soil and sand
boxes
¦Wash fresh fruits and veggies well
$!B  !   
² leading cause of perinatal infections. Organism found in
woman·s rectum, vagina, cervix, throat or skin. Woman
usually asymptomatic, but can be transmitted to baby at
delivery.

¦ " 
 
¦ + culture of woman·s vagina or rectum at 35-37 weeks
gestation

¦ ] 

¦ Antibiotics to mother prior to delivery


¦ Antibiotic therapy to infant after delivery
]B'*)*
*.*
¦ fatigue
¦ weakness
¦ loss of appetite and weight
¦ Fever
¦ Night sweats
] 

&
 

¦ Isoniazid and „ifampin to mother for Ñ months


¦ Infant may have preventative therapy for 3 months
* 1  ]
 &"   
÷revention is by safe sex with protection of
condom

x Herpes
x HIV
x yphilis
x Gonorrhea
x Chamydia
x Trichomoniasis
x Genital Warts
O 
 ] )
 


x 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
x   ² infection of bladder
¦ /
¦ Burning with urination
¦ Increased frequency and urgency
¦ May have slightly elevated temp
x  
!  ² infection of kidney(s)
*.*
¦ High fever
¦ Chills
¦ Flank pian
¦ N/V

x ] 
])
¦ Antibiotic therapy

x 
 
¦ Teach to wipe front to back
¦ Intake adequate fluid
¦ rinate before and after intercourse
¦ Teach /
*
 
> theuse of illicit or recreational drugs
during pregnancy .

] 

&
 

¦ Identify substance abused


¦ Educate on potential effects of drug
¦ se nonjudgmental approach
 

Alcohol, no safe level


O isplaces other nutritional food intake
O Fetus may show signs of:
IG„
CN dysfunction
Craniofacial abnormalities (FA )
ùCocaine

O Causes vasoconstriction, elevated B÷,


tachycardia
O May cause seizures
O May cause spontaneous abortion, fetal
malformation, neural tube defects
O Newborn: irritability, hypertonicity, poor
feeding patterns, increased risk of I
Opiates

O ÷roduces analgesia, euphoria, respiratory


depression
O Newborns experience withdrawal within
2i-72 hours after delivery
O High-pitched cry, restlessness, poor
feeding seen in the newborn
Nursing care:
O ÷rovide quiet environment
O Wrap infant and hold snuggly
O Observe for seizures
O Administer anticonvulsants, sedatives as
ordered
]  "
 



  
B 

¦ May enter late to prenatal care
¦ May make up excuses
] 

&
 

¦ ÷rovide for privacy


¦ Be nonjudgmental
¦ Offer resources
¦ Assessment of maternal and fetal
well-being
  Y -
- 
 


  #  
O isruption of „oles
O Financial ifficulties
O elayed Attachment
O Loss of Expected Birth Experience
„eferences
O Introduction to Maternity  ÷ediatric Nursing; Fourth Edition, 2003;
Gloria Leifer, Ma, „N; Associate ÷rofessor Obstetrics, ÷ediatrics, and
Trauma Nursing; „iverside Community
College; „iverside, California; aunders
The EN !!!