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
Danger signs – First Trimester (6)
Vaginal bleeding, Abdominal pain
Severe, persistent vomiting
Indicators of infection, hypoxia
Ectopic Hydatiform mole Spontaneous abortion Hyperemesis gravidarum Perinatal infections Hypoxia (maternal chronic or acute)
Hydatiform Molar Pregnancy
Symptoms and risks
Gestational Trophoblastic Disease
Proliferation and degeneration of trophoblastic villi
Symptoms
Vaginal bleeding, size/date discrepancy
excessive nausea/vomiting, abdominal pain
Risks – choriocarcinoma – repeat mole
Tx: remove uterine contents (D+C)
Ectopic Pregnancy
Symptoms
Treatment in Fallopian tubes
Symptoms Missed period Positive pregnancy test (though low hCG) Abdominal pain Vaginal spotting
Treatment in Fallopian Tubes
Medical
If tube not ruptured, Methotrexate IM to dissolve embryo
Surgical
If tube not ruptured, laparoscopic salpingostomy to remove products of conception and salvage the tube
If tube is ruptured, laparoscopic salpingectomy
Counseling
Spontaneous Abortion
Before 20 weeks of gestation
bleeding, cramping, abdominal pain, decreased symptoms of pregnancy
D+C if necessary
Emotional support
Incompetent Cervix aka Cervical Insufficiency
Painless dilation and cervical effacement Before second trimester Bedrest Cerclage McDonald Shirodkar
Severe Morning Sickness
Hyperemesis Gravidarum
Symptoms (5)
Excessive vomiting
Unable to retain fluids
Dehydration Electrolyte imbalance Acid-Base imbalance Starvation Ketosis Weight Loss
Severe morning sickness
Dx and Interventions
1. NPO + IVF
Emotional Support
2. Slowly add food
Monitor weight
Continue supportDanger signs – 2nd trimester
9
Vaginal bleeding, Abdominal pain; Leaking amniotic fluid; Fundal height; Glycosuria; HTN/Proteinuria; Absence of fetal movement
Spontaneous abortion
Hyperemesis Gravidarum
Perinatal infections
Hypoxia
Fetal compromise PROM Preterm Labor Preeclampsia HELLP Syndrome
rH incompatibility
Rh- mom plus Rh+ dad
AKA
Rh Isoimmunization = antibodies (which can cross the placenta destroy the baby’s RBCs resulting in massive hemolysis
RhoGAM 28 -34 wks (prenatal dose)
RhoGAM 24 to 72 hours post partum if baby is Rh+
Coombs Test
Indirect vs. Direct
Negative vs. Positive
Indirect = antibody screen – measures number of Rh+ antibodies in mother’s blood
Direct = detects antibodies coated Rh+ cells in infant’s blood
Done after delivery
Negative indirect coombs
Mother given RhoGAM
Positive indirect coombs “sensitized”
Fetus monitored for hemolytic disease of the newborn (erythroblastosis fetalis)
ABO incompatibility
Mother type O
Previous exposure to a protein (antigen)
Anti-antigen antibodies present in mom
Fetus A, B, or AB
A, B, AB all contain the protein antigen not present in O
Hemolysis of fetal RBCs
PROM
Premature rupture of membranes
Cause: Multifactorial
The earlier the gestation, the more likely infection and inflammation may be causative factors
Symptom: gush / trickle / leaking of fluid from vagina
Confirmation of amniotic fluid??
Nitrazine or ferning
PROM
Criteria influencing the treatment plan:
Establish gestational age
Ultrasound to assess fetus
In labor? Sxs of Infection?
If advanced labor or infection, deliver fetus if viable
-> induction or c/s depending upon gestational age, distress
Assessment: Twins
Ultrasound findings
Ultrasound:
closed cervix
normal growth for both fetus A & fetus B
excessive amniotic fluid (polyhydramnios)
Discordant twins
Twin to Twin transfusion
Identical twins born at 28 weeks
Drastic Different weights
Multiple Gestation
Nursing Dx
Risk of Preterm Labor
Risk of Premature Rupture of Membranes
Warning signs of preterm labor (7)
Abdominal pain Contractions Pelvic Pressure Vaginal Discharge that is heavy Low dull backache Menstrual-like cramps Bleeding and spotting
Higher risk for preterm labor (6)
Smoke/drugs Carrying more than one baby Poor nutrition Underweight before pregnancy Previous preterm deliveries Infection
Preterm Labor characteristics (4)
Gestation 20-37 wks Persistent uterine contractions (4 every 20 mins or 8 per hour) Cervical effacement at least 80% Cervical dilation of more than 1 cm
Tocolysis
Inhibit labor
Treatment PTL…
If fetus is viable
If labor is progressing
Careful maternal monitoring & FHR monitoring
Identify and report symptoms of fetal hypoxia
If fetus viable:
hydrate, home on bedrest, no work, no sex, no distress, stress reduction
If labor is progressing:
- > hydration
- > tocolysis = Nifedipine, MgSO4, Propranolol
- > corticosteroids = Dexamethasone, Betamethasone
Hypertensive Disorders
Chronic hypertension
Present before pregnancy (therefore, in first trimester also)
Possibly undiagnosed before prenatal visits
Gestational/Transient [aka Pregnancy-induced hypertension]
Develops in 2nd trimester
Hypertension with no other symptoms
Preeclampsia –> eclampsia
Hypertension
Proteinuria
Chronic hypertension with superimposed preeclampsia
Gestational Vs. Preeclampsia
High BP but no proteinuria
High BP and proteinuria
Preeclampsia
Maternal Characteristics
Other 3 factors
Disease of placenta – 7-10% of pregnancies
Vasospasms Endothelial tissue damage
-> Delivery of fetus is the only cure
Second leading cause of maternal death - about 1/10-15 pregnancies
Maternal Characteristics
Age 35
Race – higher in African Americans
Socioeconomic status – lower asso. W/poor diets, increase in smoking
Primagravida 6-8 times more likely to develop PIH
Genetic predisposition , oxidative stress, and the release of immune factors cause placental dysfunction
Preeclampsia
Symptoms
Medical Management
Symptoms
B/P > 140/90 @ 20 wks or more
Proteinuria
Sometimes: pitting pedal edema, facial edema
Medical Management
- > stabilize blood pressure - > prevent eclampsia
nifedipine, hydralazine, labetolol
increased monitoring
Eclampsia
Seizures and coma
Eclampsia is grand mal seizures as a result of the progression of preeclampsia
Eclampsia does not have a B/P correlation, or proteinuria, etc.
Mild pre can cause eclampsia
Preeclampsia Maternal Complications CNS -- 4 Hepatic -- 2 Renal --3 Pulmonary --1
Maternal CNS Seizures Cerebral Edema Cerebral Hemorrhage Stroke (thrombosis)
Hepatic
Liver rupture or Failure
Subcapsular Hemorrhage
Renal
Renal Failure
Oliguria
Glomerulopathy
Pulmonary
Pulmonary Edema
Preeclampsia Fetal Complications
5
Preterm Labor Fetal Demise Hypoxia IUGR Oligohydramnios
Preeclampsia Severity
Mild
Systolic 140-160
Diastolic 90-110
Protein 3-5gm in 24
Severe
Systolic >160
Diastolic >110
Protein >5 gm in 24
Medical Management – prevent eclampsia
Uncontrolled or high HTN
Bedrest EFM IVF (NPO in case of c/s) Antihypertensive therapy -- labetalol, hydralazine Magnesium Sulfate -- To prevent seizures Fetal gestation >34 wks –> deliver Corticosteroids
MgSO4 protocol = prevent overdose from resp failure and cardiac arrest
Nursing Interventions
What is the focused assessment for a pt being tx with MgSO4?
7
Vital signs -> blood pressure, temperature, FHR
Neuro -> level of consciousness (A&Ox4), confusion, deep tendon reflexes, visual disturbances
Pain -> headache, epigastric pain
Respiratory -> respirations & sPO2, coughing, SOB, dyspnea, rales/rhonchi
Uterus/Placenta -> uterine rigidity, vaginal bleeding
Urine -> output, protein, specific gravity
Weight (daily), pedal edema
Labs
P/S -> emotional state, knowledge -> teaching
For Magnesium Sulfate induced
Respiratory Depression or Respiratory Arrest,
institute Emergency Treatment:
TOXICITY
STOP Magnesium Sulfate infusion immediately.
Oxygen at 10LPM via face mask
GIVE Calcium Gluconate 1 Gram slow IVP
(in Pre-eclampsia tray or Crash cart)
Continuous Pulse Oximetry and ECG monitors
Contact anesthesia for airway management (Rapid Response)
HELLP Syndrome
Symptoms (3)
What does it lead to?
Treatment?
Delivery?
Hemolysis, Elevated Liver enzymes and Low Platelets
Variant or Complication of Preeclampsia
Flu-like symptoms
Epigastric pain from distended liver
Jaundice
Multiple system organ failure
FFP or platelet transfusion
Delivery ASAP
HELLP Syndrome
Hemolysis, Elevated Liver enzymes and Low Platelets
Platelet Count
Platelets 100,000
AST > 70
ALT > 50
Danger signs – third trimester
Vaginal bleeding; Abdominal pain Fundal height; Leaking amniotic fluid; Absence of fetal movement; Glycosuria; HTN/Proteinuria; Abnormal fetal heart rate
Perinatal infection Hypoxia Fetal compromise PROM PTL Preeclampsia HELLP Placenta Abruptio Placenta previa
Thrombophlebitis
Deep Vein Thrombus
Thromboembolism
Pulmonary Emboli
Increased risk during pregnancy -- 4Increased blood volume
Venous stasis in legs
Hypercoagulation
Compression of inferior vena cava in 3rd trimester
Teaching: encourage walking discourage sedentary activities
Chronic Infections
GBS
“GBS+ (Group Beta Strep) is the leading infectious cause of neonatal morbidity and mortality in the US” (CDC2010)
All pregnant women are screened between
35-37 wks gestation via vaginal swab
If culture is positive, IV antibiotics are
administered at delivery
Chronic Infections
HIV
HIV
Compliance with antiretroviral regimen
Retesting at 34-36 wks
Nursing Diagnoses Ineffective Health Maintenance Interrupted Family Processes Risk for Infection Nursing Interventions? Prenatal Intrapartum
Acute Infections
Respiratory URI, Tb UTI Chorioamnionitis -> Septicemia
Hemorrhagic Disorders: Placenta Previa
Dx
Symptoms
Medical management
Implantation of placenta near or obstructing the cervical os
Dx – prenatal ultrasound
Painless bright red vaginal bleeding in third trimester
Presenting part – not engaged
Possibly transverse lie
Medical Management
No vaginal examinations!
-> c/s
-> NSVD possible for high partial
Hemorrhagic Disorders: Abruptio Placenta
Dx
Symptoms
Medical Management
Separation of the placenta from the uterine wall
Dx – ultrasound, clinical presentation
Severe pain and dark vaginal bleeding in third trimester
Not in labor or
Labor could be progressing normally
Medical Management -> c/s EMERGENCY -> NSVD possible If in labor If minimal bleeding If hemodynamically stable No uterine tenderness No fetal distress
Hemorrhagic Disorders: Complications
Hemorrhage
Disseminated Intravascular Coagulation (DIC)
clotting disorder: low fibrinogen –> bleeding from every orifice
Fetal hypoxia, Fetal demise
Postpartum risk:
lack of contractions in lower uterus -> postpartum hemorrhage
