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Complications of Pregnancy Module B. NUR 106 Spring, 2005. Assessment of Fetal Well-being. Detect physical abnormalities Monitor fetal condition Fetal movement Complex diagnostic testing Risks and benefits. Amniocentesis. Aspiration of amniotic fluid Determine genetic disorders

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assessment of fetal well being
Assessment of Fetal Well-being
  • Detect physical abnormalities
  • Monitor fetal condition
  • Fetal movement
  • Complex diagnostic testing
  • Risks and benefits
amniocentesis
Amniocentesis
  • Aspiration of amniotic fluid
  • Determine genetic disorders
  • Sex of fetus
  • Fetal lung maturity
  • Risks
  • Nursing management
chorionic villus sampling
Chorionic Villus Sampling
  • Aspiration of small sample of chorionic villus tissue
  • 8 to 12 weeks gestation
  • Detects genetic abnormalities
  • Risks and benefits
  • Nursing management
hormone levels
Hormone Levels
  • Estriol
  • Human chorionic gonadotropin
  • Maternal serum—alpha fetoprotein
alfa fetoprotein screening
Alfa-Fetoprotein Screening
  • MSAFP
  • AFAFP
  • Time sensitive
  • Low MSAFP levels associated with Down syndrome
  • High MSAFP levels associated with neural tube defects
triple marker screening
Triple Marker Screening
  • Alpha-fetoprotein
  • Human chorionic gonadotropin
  • Unconjugated estriol
high risk assessment
High Risk Assessment
  • Daily fetal movement count
  • Nonstress test
  • Biophysical profile
  • Contraction stress test
daily fetal movement count
Daily Fetal Movement Count
  • Begin at 27th week
  • Consider
    • Fetal sleep-wake cycles
    • Maternal food intake
    • Drug-nicotine use
    • Environmental stimuli
    • Maternal position
  • Procedure
fetal monitoring
Fetal Monitoring
  • Normal fetal heart rate
  • Baseline
baseline fhr
Baseline FHR
  • Rate
  • Variability
  • Assesses average rate for at least 2 minutes within a 10 minute window
  • Normal: 110 to 160 bpm
  • Bradycardia: < 110 bpm for 10 minutes
  • Tachycardia: > 160 bpm for 10 minutes
variability
Variability
  • Normal irregularity of fetal cardiac rhythm
  • Short-term
    • Beat-to-beat changes
    • Need fetal scalp electrode
  • Long-term
    • Rhythmic changes (waves) from the baseline value
    • Usually 3 to 5 beats
nonstress test
Nonstress Test
  • Assess response of FHR to periods of fetal movement
  • After 27th to 30th week
  • Frequency depends on condition of maternal-fetal unit
  • Indications
procedure
Procedure
  • Perform test during a time of activity
  • Maternal preparation
  • Maternal vital signs
  • Attach monitor
  • Monitor fetal movement
interpretation
Interpretation
  • Reactive result
  • Nonreactive result
  • Unsatisfactory result
contraction stress test
Contraction Stress Test
  • Assess ability of fetus to withstand the stress of uterine contractions
  • Assesses placental oxygenation and function
  • Determines fetal well being
  • Performed if NST is abnormal
interpretation1
Interpretation
  • Negative CST
  • Positive CST
  • Equivocal
  • Unsatisfactory
biophysical profile
Biophysical Profile
  • Assess fetal status
  • NST
  • Fetal breathing movements
  • Fetal body movements
  • Fetal muscle tone
  • Amniotic fluid volume
  • Placental grading
lung maturity testing
Lung Maturity Testing
  • Lecithin to sphingomyelin ratio
  • Phosphatidylglycerol
fibronectin
Fibronectin
  • Test for preterm delivery
  • Negative test result highly reliable
  • Reassures that risk of preterm delivery is low
  • Presence of fFN in symptomatic women during weeks 22 – 34 of gestation = increased risk of preterm delivery
hyperemesis gravidarum
Hyperemesis Gravidarum

Intractable nausea and vomiting that persists beyond the first trimester and causes disturbances in nutrition, electrolytes, and fluid balance

assessment
Assessment
  • Nausea most pronounced on arising
  • Persistent vomiting
  • Weight loss
  • Signs of dehydration
  • Electrolyte imbalances
  • Ketonuria
  • Increased hematocrit levels
nursing interventions
Nursing Interventions
  • Monitor vital signs
  • Monitor FHR, fetal activity and fetal growth
  • Monitor for dehydration and electrolyte imbalance
  • Daily weight, I&O, calorie count
  • Monitor urine for ketones
  • Administer IV fluids, antiemetics
bleeding disorders of early pregnancy
Bleeding Disorders of Early Pregnancy
  • Spontaneous abortion
  • Ectopic pregnancy
  • Hydatidiform mole
abortion
Abortion
  • Threatened
  • Imminent
  • Complete
  • Incomplete
  • Missed
  • Habitual
  • Elective
slide41
A 22 year old gravida i, para 0, is 11 weeks pregnant. She was admitted to the hospital with moderate vaginal bleeding and some abdominal cramping. Vaginal examination reveals that the cervix is dilated 2 cm. She is diagnosed as having an imminent abortion. What nursing interventions are indicated when caring for this patient?
nursing interventions1
Nursing Interventions
  • Save perineal pads / tissue
  • Emotional support
  • Observe for shock
  • Bed rest / diversional activity
  • RhoGAM
  • Possible surgery
  • Medication / Blood
slide43
Ectopic pregnancy is often difficult to diagnose because its symptoms are similar to those of abdominal conditions. Identify at least five signs or symptoms of ectopic pregnancy and briefly explain why each occurs.
ectopic pregnancy
Ectopic Pregnancy
  • Fertilized ovum implants outside the uterus
  • Symptoms at 6 to 12 weeks of gestation
  • Severe unilateral pelvic-abdominal pain
  • Pain may refer to shoulder
  • Tender abdominal mass
  • Nausea, faintness
  • Bleeding – frank or occult
nursing interventions2
Nursing Interventions
  • Monitor vital signs
  • Administer intravenous fluids
  • Provide oxygen when needed
  • Medicate for pain
  • Assess lab results
  • Prepare for possible surgery
  • Provide emotional support
incompetent cervix
Incompetent Cervix
  • Premature dilation of cervix
  • Occurs in 4th or 5th month of pregnancy
  • Associated with cervical trauma
  • Vaginal bleeding at 18 to 28 weeks
  • Fetal membranes visible through cervix
  • Treatment is surgical
hydatidiform mole
Hydatidiform Mole
  • Gestational trophoblastic disease
  • Developmental anomaly of placenta
  • Changes chorionic villi into a mass of clear vesicles
  • Edematous grapelike cluster
  • May develop into choriocarcionoma
assessment1
Assessment
  • FHR not detectable
  • Vaginal bleeding
  • Symptoms of PIH
  • Fundal height > expected for date
  • Elevated hCG
  • Ultrasound shows characteristic snowstorm pattern
bleeding disorders of late pregnancy
Bleeding Disorders of Late Pregnancy
  • Placenta previa
  • Abruption placenta
placenta previa
Placenta Previa
  • Painless
  • Spotting or heavy bleeding
  • Bright-red bleeding
  • Soft, non-tender, relaxed uterus with normal tone
  • Shock in proportion to observed blood loss
  • Signs of fetal distress usually not present
assessment2
Assessment
  • Episodic painless vaginal bleeding after 20th week of pregnancy without contractions
  • Each successive bleeding episode heavier than the last
  • Profuse hemorrhage
  • Ultrasound shows location of placenta
nursing interventions3
Nursing Interventions
  • No vaginal exams
  • Bedrest
  • Monitor vital signs and fetal well-being
  • Assess blood loss
  • IV access
  • Provide adequate nutrition
  • Provide emotional support
abruptio placenta
Abruptio Placenta
  • Severely painful
  • Heavy bleeding may be partially or completely hidden
  • Usually dark-brown bleeding
  • Rigid, board-like, tender uterus possibly with contractions
  • Shock seeming to be out of proportion to blood loss
  • Signs of fetal distress
assessment3
Assessment
  • Painful, rigid, board-like abdomen with vaginal bleeding
  • Central abruption
  • Marginal abruption
  • Fetal outcome
nursing interventions4
Nursing Interventions
  • Monitor vital signs
  • Continuous EFM
  • Assess for bleeding, uterine activity, abdominal pain
  • Measure abdominal girth
  • Review lab values
  • IV access
  • Provide oxygen
hypertensive disorders
Hypertensive Disorders
  • Pregnancy induced hypertension
  • Preeclampsia and eclampsia
  • Chronic hypertension
  • Superimposed preeclampsia
  • Transient hypertension
pathophysiology
Pathophysiology
  • Vasospasm reduces blood flow to mother’s organs and placenta
  • Vascular endothelial damage
  • Hypertension
  • Edema
  • Proteinuria
pih assessment
PIH - Assessment
  • Mild preeclampsia
  • Severe preeclampsia
  • Systemic responses
  • Lab values
nursing interventions5
Nursing Interventions
  • Bedrest -- left lateral position
  • Monitor B/P and weight
  • Monitor neurological status
  • Monitor DTRs
  • Provide adequate fluids
  • Monitor I & O
  • Increase dietary protein
  • Administer medications as prescribed
magnesium sulfate mg so 4
Magnesium Sulfate ( Mg SO4 )
  • Mg++ causes vasodilation
  • Therapeutic levels = 4 to 8 mg/dL
mg so 4 therapy
Mg SO4 Therapy
  • Monitor blood pressure closely
  • Monitor maternal serum Mg SO4 levels every 6 - 8 hours
  • Monitor respirations closely
  • Assess patellar tendon reflex
  • Determine urinary output
  • Monitor FHR continuously
  • Continue Mg SO4 infusion for approximately 24 hours after birth
maternal side effects
Maternal Side Effects

Vasodilation

  • Flushing
  • Headaches
  • “Hot Flashes”
  • Blurred vision
  • Nasal Congestion
  • Decreased peripheral vascular resistance
maternal side effects1
Maternal Side Effects
  • Neuromuscular depression
  • Respiratory depression
  • Myocardial depression
  • Gastrointestinal system
    • nausea
    • vomiting
neonatal side effects
Neonatal Side Effects
  • Hypocalcemia
  • Hypermagnesemia
  • Respiratory depression
chronic hypertension
Chronic Hypertension
  • Occurs before pregnancy
  • Diagnosed before 20th week of gestation
  • Diagnosed during pregnancy and persists beyond the 42 day postpartum
assessment4
Assessment
  • Headaches
  • Visual changes
  • Blood pressure 140/90 mm Hg or >
  • Delayed fetal growth
  • Oligohydramnios
antihypertensives
Antihypertensives
  • Given for diastolic blood pressure of 105 to 110 or above
  • Methyldopa
  • Hydralazine
  • Labetalol
  • Nifedipine
diabetes
Diabetes
  • Pregnancy places demands on carbohydrate metabolism
  • Insulin requirements increase in 2nd and 3rd trimester
    • Insulin-dependent diabetes
    • Diabetes in pregnancy
assessment5
Assessment
  • Risk factors
  • Classic symptoms
  • Frequent UTIs and yeast infections
  • Screening at 24-28 weeks gestation
nursing interventions6
Nursing Interventions
  • Prenatal visits bimonthly for 6 months than weekly
  • Maintain blood glucose between 65-130 mg/dL
  • Monitor for hypoglycemia / hyperglycemia
  • Glucose control
  • Monitor for infection, PIH, ketoacidosis
  • Reinforce diet instructions
gestational diabetes
Gestational Diabetes
  • Occurs during 2nd and 3rd trimesters
  • No prior diagnosis
  • Screened during 26th week
  • Glucose = 105 mg/dL
  • Diet
  • Medications
  • “Normal” after delivery
cardiac disease
Cardiac Disease
  • Rheumatic fever
  • Congenital heart disease
assessment6
Assessment
  • Dyspnea and fatigue
  • Cough
  • Peripheral edema
  • Anginal-type pain
  • Palpitations and tachycardia
  • Signs of pulmonary edema
  • Signs of respiratory infection
nursing interventions7
Nursing Interventions
  • Monitor VS, FHR, condition of fetus
  • Activity and rest
  • Encourage adequate nutrition
  • Maintain bed rest as ordered
  • Monitor for signs of respiratory infection
  • Encourage adequate nutrition
  • Administer cardiac medications
anemia
Anemia
  • Decrease in RBCs
  • Types
    • Iron deficiency
    • Folic acid
    • Hemoglobinopathies
      • Sickle cell disease
      • Thalassemia
assessment7
Assessment
  • Fatigue
  • Headache
  • Pallor
  • Tachycardia
  • Diagnostic test: H & H
  • Treatment: Iron and folic acid
nursing interventions8
Nursing Interventions
  • Monitor H & H every 2 weeks
  • Iron and folic acid supplements
  • Take iron with vitamin C
  • Foods high in iron, folic acid and protein
  • Monitor for infection
  • May use parenteral iron / transfusions
infection in pregnancy
Infection in Pregnancy
  • Immunological system suppressed
  • Genitourinary adaptations to pregnancy
  • Risk factors increase severity
  • Fever
  • Pneumonia
  • Direct infection of fetus
  • Systemic infection
torch infections
TORCH Infections
  • T = Toxoplasmosis
  • O = Other infections
  • R = Rubella
  • C = Cytomegalovirus
  • H = Herpes
group b streptococcus
Group B Streptococcus
  • Bacterial infection found in the lower GI and urogenital tracts
  • Screening cultures at 35-37 weeks
  • Leading infectious cause of neonatal sepsis and mortality
  • Carriers often asymptomatic
  • Intrapartum prophylaxis
sexually transmitted diseases
Sexually Transmitted Diseases
  • Syphilis
  • Gonorrhea
  • Chlamydia
  • Trichomoniasis
  • HPV
  • HIV
vaginal infections
Vaginal Infections
  • Candidiasis
  • Bacterial vaginosis
urinary tract infections
Urinary Tract Infections
  • Cause preterm labor
  • Untreated may cause pyelonephritis
rh incompatibility and sensitization
Rh Incompatibility and Sensitization
  • Determine maternal blood type and Rh factor
  • Antibody screen (indirect Coombs’ test)
  • RhoGAM administration
  • Serial ultrasounds
  • Amniotic fluid analysis
  • Erythroblastosis fetalis
nursing interventions9
Nursing Interventions
  • Client education
  • RhoGAM protocol
  • Kleihauer-Betke test
  • Ultrasound
  • EFM, BPP
  • Intrauterine exchange transfusion
multifetal pregnancy
Multifetal Pregnancy
  • Monozygotic or dizygotic
  • Assisted reproductive techniques
  • Diagnosis
  • Interventions
  • Complications
nursing interventions10
Nursing Interventions
  • Monitor vital signs
  • Monitor FHR, fetal activity, fetal growth
  • Monitor cervical changes
  • Ultrasound
  • Monitor for anemia
  • Monitor and treat preterm labor
  • Prepare for possible cesarean section
substance abuse
Substance Abuse
  • Tobacco
  • Alcohol
  • Marijuana
  • Cocaine
  • Heroin
preterm labor
Preterm Labor
  • Occurs after the 20th week and before the 37th week of gestation
  • Contractions every 10 minutes lasting 30 seconds or longer
  • Documented cervical change
  • Effacement of 80%
  • Dilation of 2 cm
risk factors
Risk Factors
  • Previous history of preterm labor or birth
  • Demographic factors
  • Lifestyle factors
  • Health problems
  • Uterine factors
assessment8
Assessment
  • Increased or bloody discharge
  • Leaking amniotic fluid
  • Backache
  • Pressure and cramping
  • Palpable uterine contractions
  • Diarrhea
nursing interventions11
Nursing Interventions
  • Maintain bedrest
  • Tocolytic agents
  • Betamethasone
  • Magnesium sulfate
  • Monitor fetal status
trauma
Trauma
  • MVAs
  • Homicide
  • Abuse
  • Domestic violence
adolescent pregnancy
Adolescent Pregnancy
  • Developmental tasks
    • Adolescence
    • Pregnancy
  • Special needs
    • Physical
    • Support
    • Role changes
medications
Medications
  • Review drugs discussed
  • Dosage
  • Route
  • Nursing implications