Antepartum Flashcards
At risk –> prenatal testing
7
Maternal age > 35 years
Birth of previous infant with chromosomal abnormalities or neural tube defect
Chromosomal abnormality in family member
Gender if mom is carrier of X-linked disorder
Pregnancy after 3 or more spontaneous abortions
Maternal Rh sensitization
Elevated levels of maternal serum AFP
Genetic Counseling
Availability
Facilities with maternal-fetal medicine services
State agencies
Agencies focus on a specific birth defect
(i.e., March of Dimes)
Process of genetic counseling
Diagnosis may never be established
Supplemental services
Environmental Influences
Causative agents - 6
Teratogens
Agents that cause birth defects
Multifactorial
Causative agents Maternal infectious agents Drugs, Rubella & Vaccine Pollutants Ionizing radiation Maternal hyperthermia Maternal co-morbidities
Multifactorial Disorders
An interaction of genetic tendency and environmental factors.
Affected close relatives
Gender
Geography
Cardiac anomalies
Cleft lip and palate
Neural tube defects
Prevention and Treatment for genetic, multifactorial conditions
Ideally before conception
Appropriate medical therapy for diseases
Identification of risks
Preventive treatment tailored to identified risks
400 mcg of folic acid daily before conception
Evaluation of the Fetus
Diagnostic (3) and Assessment (2)
Diagnostic Testing Ultrasound Amniocentesis CVS PUBS
Assessment of Fetal Well-Being
Nonstress Test
Biophysical Profile
Amniocentesis
Invasive test to identify chromosomal or biochemical abnormalities
Between 15 and 20 weeks
Risk of spontaneous abortion infection, ruptured membranes
In 3rd trimester to assess:
Fetal lung maturity
Detects fetal hydrops; erythroblastosis fetalis
PUBS – Percutaneous umbilical blood sampling
PUBS Invasive
after 16 wks
Blood gas, CBC, coag, Rh
Results in hrs
Cord laceration, thromboemboli, infection, spontaneous ab, PROM
Chronic villus sampling
CVS Invasive
10-13 wks
Karyotyping to identify chromosomal abnormalities
Results in 48 hrs
0.5% to 2.0% chance of spontaneous abortion & limb abnormalities
Non Stress Test
Accelerations indicate…
Reactive NST…
Assess fetal well-being – uteroplacental function
Noninvasive
After 28 wks
Accelerations in FHR indicative of
Adequate O2 of CNS
Healthy neural pathway from fetal CNS to FH
Ability of FH to respond to stimuli
Reactive NST
At least 2 FHR acceleration within 20 minute period
At least 15 beats above baseline
Lasting at least 15 seconds
Biophysical Profile (BPP)
Ultrasound evaluation of 5 parameters in fetus Breathing movement Movement of limbs or body Tone – extension/flexion of extremities Amniotic fluid index (AFI) Reactive FHR with activity (NST)
2 points for each
(8 to 10 normal, 4 to 6 possible compromise 0 to 2 high perinatal mortality)
Usually in 3rd trimester but may be done after 24 wks
Indications for BPP (10)
Maternal diabetes mellitus Maternal heart disease Maternal chronic hypertension Maternal sickle cell anemia Maternal renal disease Hx previous stillbirths Rh sensitization Maternal preeclampsia or eclampsia Suspected post maturity Intrauterine growth restriction
Maternal Co-Morbidities
Acute and chronic illnesses present before pregnancy, develop during pregnancy affect fetal health and outcome
Assess for symptoms Neurologic Respiratory Cardiovascular GI GU Musculo-skeletal Integumentary Psychosocial
Maternal co-morbidities can affect fetal health and outcome Respiratory CV Hemoglobinopathies Endocrine Autoimmune disorders Developmental disabilities
Respiratory
Asthma; Cystic Fibrosis
Cardiovascular Anomalies or Disease
Anomalies;
Hemoglobinopathies
Sickle cell disease; Thalassemia
Endocrine
Diabetes; Thyroid Conditions
Autoimmune Disorders
Multiple Sclerosis, Systemic Lupus, Erythematosis
Developmental Disabilities
Physical Disabilities
Cancer
Psychosocial Distress (9)
Increasing Anxiety Inability to establish communication Inappropriate responses or actions Denial of pregnancy Inability to cope with stress Intense preoccupation with the sex of the baby Failure to acknowledge quickening Failure to plan and prepare for the baby (e.g. living arrangements, clothing, feeding supplies Indications of substance abuse
Behavioral Health Disorders – Nursing Interventions
Provide strategies to…
Help decrease anxiety
Keep her oriented to reality
Promote optimal functioning during pregnancy and while in labor.
Smoking during pregnancy has serious health risks including…
8
Alcohol and other drugs easily pass from mother to baby through placenta
Bleeding complications Miscarriage Stillbirth Prematurity Placenta previa Placental abruption Low birth weight (LBW) Sudden infant death syndrome
Substance Abuse
Legal Considerations
Legal considerations
Some women who abuse substances may face criminal charges
Nurses who encourage prenatal care, counseling, and treatment are of greater benefit to mother and child than prosecution
The role of the nurse is to support the patient in her efforts to achieve a healthy outcome of her pregnancy
Perinatal Infections
STIs TORCH
STIs
Chlamydia, Gonorrhea, Syphilis, HPV, HIV + AIDS
TORCH Toxoplasmosis Other: Varicella, Hepatitis B Rubella Cytomegalovirus Herpes Simplex
How perinatal infections affect the fetus
Nursing Dx? (4)
Outcome?
Interventions?
Nursing Diagnoses? Ineffective Health Maintenance Grieving Readiness for Enhanced Knowledge Ineffective Coping
Outcome?
Interventions?
Diabetes Mellitus
Classifications
Classification
Pregestational - Diabetes Mellitus existing before pregnancy
Type 1 diabetes
Type 2 diabetes
Gestational diabetes mellitus (GDM) is any degree of glucose intolerance with onset or recognition during pregnancy (2nd or 3rd trim)
Prediabetes: impaired fasting glucose (IFG)
Pregnancy and Insulin Production
Steps to increased blood glucose
Placenta produces hormones (estrogen, cortisol and human placental lactogen
These hormones inhibit the functioning of insulin
Blood glucose is increased
Changing Insulin Needs during pregnancy
First trimester: Insulin need is reduced
Second trimester: Insulin need increases
Third trimester: Insulin requirement gradually increase to 36 weeks
Delivery: Maternal insulin requirement drops drastically to pre-pregnancy level - intervention: frequent BS during labor
Breastfeeding mother maintains lower insulin requirement
Weaning breastfeeding mother returns to prepregnancy level
ADA Guidelines: Preconception Care
Maintain A1C levels
Gestational Diabetes and Pregnancy
Screening
Glucose/Carbohydrate intolerance with onset during pregnancy
7% of all pregnancies – as high as 15% in some populations
Screening: patient history, or clinical risk factors, or glucose challenge test
Symptoms warranting OGTT (6)
Persistent glycosuria on 2 visits Proteinuria Urinary frequency after 1˚ trimester Excessive thirst or hunger Recurrent monilial infections Polyhydramnios, suspected large fetal size, or increased fundal height for date
Low Risk for gestational Diabetes (4)
High risk for gestational diabetes (4)
Low Risk Normal weight before pregnancy Under age 25 No hx unexplained stillbirth No diabetes in immediate family
High Risk Ethnicity: Af Am, Hisp, Native Am HTN Hypercholesterolemia GD or LGA in previous pregnancy
Tx for prenatal clinical development for different types of DM
Treatment for Mom
Diet
If not managed well on diet, add meds
Drugs
Type 1
Insulin - may be admitted during 2nd trimester to regulate
Type 2 and GDM
Oral hypoglycemic (Glyburide & Metformin) may be effective; Prescribed, though not approved by FDA (Category B / C)
Insulin, if diet and oral hypoglycemics not effective
Treatment for Baby - After delivery
