Pregnancy Flashcards
Explain Fetal Circulation
Unlike in normal circulation, the vein carries oxygenated blood to the fetus from the placenta (the respiratory organ of the fetus) and the arteries carry de-oxygenated blood away from the fetus, through the cord to the placental chorionic villi, where the wastes are given back to the maternal circulation for excretion.
Possible effect of smoking while pregnant
Smoking can interefere with the fetus getting adequate nourishment and oxygen, resulting in newborn problems like being Small for Gestational Age (SGA)
What can cause aging of the placenta?
diabetes
How to cope with nausea/vomiting
- Eat five or six small meals
* Avoid fried foods or foods with odors
* Eat dry toast or crackers without liquids
How to cope with increased urinary frequency
- Wear a pad if leakage
* Do the Kegel exercise (Teach her how this is done)
How to cope with increased vaginal discharge
- Cleanliness – daily bathing
* Absorbent cotton underpants
* No douching
* If foul odor contact health provider
How long do pregnancies usually last?
40 weeks or 10 lunar months
How to obtain EDC or EDD?
First day of her last menstrual period
- 3 months
+ 7 days
What are some landmarks used to estimate EDD?
*Fundal heights
*When fetal heart is heard
–Normal is 120 - 160 beats per minute.
–Heard as early as 16 weeks, always by 19-20 weeks with a fetoscope. Can be heard as early as 8 weeks with a doppler, always by 10-12 weeks
*When the mother feels the baby move called “Quickening” - usually felt by 18 - 20 weeks
*Ultrasonography - gestational sac can be seen 5-6
weeks after Last Menstrual Period (LMP)
Primary Prevention during pregnancy?
Consists of education the client about healthy behaviors, screening test and monitoring for risk. (nutrition, exercises, sexual activities, discomfort, preparation)
Secondary Prevention during pregnancy?
The main focus is on providing the client with information about pregnancy and answering questions.
Tertiary Prevention during pregnancy?
During pregnancy the main focus of tertiary prevention is referring the client to existing systems for support. Examples would be WIC, Social Services, La Leche League, Healthy Start, and childbirth classes.
During pregnancy, a client should be assessed for the following risk factors:
- Age less then 16 years or over 35
- Anemia
- Poor physical state (e.g., obesity, low weight for height)
- Any sexually transmitted disease
- Use of tobacco, alcohol, or street drugs
- Poverty
- Lack of social support
- Poor medical conditions that pregnancy may complicate
(e. g., diabetes, epilepsy, asthma)
Which medication given for morning sickness caused limb deformities on the fetus?
Thalidomide
Clinical applications of ultrasounds..
- Early identification of pregnancy (5 to 6 wks following LMP)
- Identify ectopic pregnancies
- Measure biparietal diameter of the fetal head or the fetal femur length - confirm gestational age and
identify Inter Uterine Growth Retardation (IUGR) - Identify or confirm nonviable pregnancies
- Detection of fetal anomalies especially Anecephaly & Hydrocephalus (neural tube defects)
- Detect hydramnios or oligohydramnios
- Identify anmiotic fluid pockets - pocket less than 1
cm or absence of pocket are associated with perinatal
death - Locate the placenta prior to amniocentesis, guide
for Chorionic Villus Sampling, and for fetal therapy - Observe FRH beat and respirations
- Placental grading - measure calcification of placenta – grade III is correlated with fetal lung maturity (good if amniocentesis can’t be done)
- Detect fetal position and presentation; number of infants
How should a client prepare for a fetal ultrasound?
- -Must have full bladder except with location of placenta during amniocentesis
- -Drink 1 qt of water 2 hrs before; If NPO, catheterize and fill bladder with fluid
- If placenta previa do both with full and empty bladder
Risks of ultrasound?
Use only if necessary. Avoid during 1st trimester. No harmful effects on humans, but in animals-retarded fetal growth, cell damage, processing in brain changed & impaired immune system
Fetal Activity Records– how its done?
- Count the number of fetal movements within a selected period of time.
- Less than three fetal movements within an hour – further assessment needed
- No movements for 12 hours or very active (thrashing) may indicate a problem.
–Good for assessment with high risk pregnancies
Nonstress test
Mother is placed on a fetal heart monitor and assessed for response of the fetal heart rate when the fetus moves. *Start when 30 - 32 weeks; 1 to 2 times a week
- Reactive test— 2 or more fetal movements in 20 minutes ..FHR increase of 15 beats above baseline lasting at least 15 seconds from beginning of acceleration to end Long-term variability of 10 or more
- Nonreactive— No accelerations or less that 15 beats/min or lasting less than 15 sec. associated with movement in 20 minutes (some say 40 min)
- If reactive, repeat in 1 week
- If nonreactive – Contraction Stress Test (CST) same day (or repeat in 24 hours)
- If unsatisfactory - eat and return or CST
Indications for Nonstress test
Diabetic
Toxemia (PIH)
Decrease in fetal activity
Postmature
Nursing Interventions for Nonstress test
- May have to feed mom to get infant moving
- May have to use sound and/or vibration to make fetus wake up
Stress Test/Contraction Test
*Can be by nipple stimulation or oxytocin
*Around 32 - 34 weeks; 1 X week
*Results
—Negative test - no late or variable decelerations during 3 contractions, lasting 40 - 60 seconds, in 10 minutes
—Positive test - late decelerations in 50% of uterine
contractions
—Equivocal/Suspicious - more information needed
Amniocentesis
a procedure recommended to detect genetic abnormalities in early pregnancy, and fetal lung maturity in later pregnancy.
–Amniotic fluid is withdrawn from needle inserted through abdominal wall, into uterus. Patient is under local anesthesia, guided by ultrasound to prevent injury to mother or fetus. Must be more than 14 weeks to have enough fluid.
Implications for Amniocentesis
–Prenatal diagnosis of congenital disorders - need for
genetic counseling
–Evaluate Rh sensitized pregnancies - breakdown
products of RBC destruction especially concentrations of
bilirubin in amniotic fluid. Indicate condition of
infant and if interventions like intrauterine
transfusion is needed.
–Evaluate fetal maturity
*Lung = Lecithin/Sphingomyelin ratio
maturity 2:1
**With stress conditions like diabetes would need a 3:1 level
–Identification of meconium - color of fluid. If found,
assess further for hypoxia
–Sex of infant - sex linked disorders
–Infection
–Relief of polyhydramnios
–Fetal transfusion or other therapy
–Second trimester abortions
Nursing Interventions for Amniocentesis
- -Empty bladder
- -Observe after 30 min - vitals
- -Review complication with client: bleeding, fluid leaking, pain, contractions, fever, change in fetal activity
- -Give RhoGam if Rh-
- -Length of time for results (2 to 6 weeks) if negative may need counseling
PIH (Pregnancy Induced Hypertension)
aka Toxemia
- *Preeclampsia
* *Eclampsia-if convulsions occur
When do manifestations usually start to occur for PIH
- -Primips, both young and old
- -When diets are deficient in protein
- -Multiple pregnancies
- -Polyhydramnios
- -Diabetes
- -Can occur after delivery during postpartum
S/S of PIH (pre/eclampsia or toxemia)
- -Edema - mild to severe swelling of hands, face, and pitting of legs
- -Proteinurea - from 1gm in 24 hrs to 5gms or more in 24 hrs
- -Hypertension - increase of 30/15 above base or increase of 50 in systolic above base
- -Decrease in urinary output
- -Weight gain from edema
- -Headaches, visual disturbances, vasospasms
- -Hemoconcentration
- -Epigastric pain - most serious
Medical Management for Mild Preeclampsia
- Bed rest
- Adequate fluid intake
- Increased protein in the diet
- Regular sodium in diet with no added salt
- Check for deep tendon reflexes and clonus
- Monitor the patients progress closely, seeing patient twice a week if she is not hospitalized
- Twice a week nonstress test or contraction stress
- Ultrasound test for fetal growth
- Monitor coagulation studies
- Monitor weight gain
What to do with Administration of Magnesium Sulfate for severe preeclampsia
-Administration of magnesium sulfate (check reflexes before giving, have Calcium gluconate at bedside (must be given slowly).
**Reflexes
4+ hyper
3+ brisker than normal
2+ average
1+ diminished
0 no response
clonus-like homans-hold foot forward and let go. spasms in both positions
Medical Management for severe Preeclampsia
(delivery is indicated)
-Administration of magnesium sulfate
-Administration of hydralazine 5 to 10 mg IV slowly for
diastolic pressure of 110 mg or greater
-Insert a central venous pressure line or Swan-Ganz
catheter for hemodynamic monitoring
-Induction of labor if cervix is favorable - C. Section?
-Continued administration of magnesium sulfate 24 to
48 hours postpartum
-Use of epidural is controversial
Medical Management for Eclampsia
- Protect patient form injury
- Stop seizures with meds
- Deliver once stable
Nursing Interventions for Eclampsia
-Assess for signs of worsening PIH or impending seizure -Provide a calm, nonstimulating environment
-Institute seizure precautions (side rails up, tongue
depressor, oxygen, and suction)
-Administer medications as ordered
-Monitor deep tendon reflexes and for the presence of
clonus
-Watch for delivery and abruptio placenta. Medications can make mother unaware of labor
The client experiences excessive vomiting and may require hospitalization.
Hyperemesis Gravidarum
This vomiting may be due to hormonal changes or because of psychological problems. It many happen with every pregnancy or only with one.
Treatments/Nursing Interventions for Hyperemesis Gravidarum
- IV therapy to maintain normal fluid balance
- Assess for metabolic acidosis - breath odor
- Patient will be on I&O
- Medications to control vomiting
- Introduce foods slowly
- Decrease stress, may need psychiatric assessment
slight bleeding, cramping, interventions may prevent abortion from happening
Threatened
bleeding, contractions, without intervention women will abort
Imminent
bleeding, ROM, cervical dilation, contractions, abortion cannot be avoided
Inevitable
When abortion occurs all products of conception are expelled
Complete
when abortion occurs parts are retained. may need oxytoxic or D&C
Incomplete
fetal death, but products are retained, may develop infection of DIC
Missed
aborts three or more pregnancies in a row
Habitual
can be with either spontaneous or induced, often after criminal
Septic
Nursing Interventions for spontaneous abortions (miscarriage)
- -Save all pads and any tissues passed
- -Observe for shock, infection, DIC, & Thrombophlebitis
- -Administer RhoGam if mother is Rh-
- -Give emotional support, this is a very difficult time for the parents.
- -Do not give false encouragement
- -Parents need to know it is not uncommon for grieving to last from 6 to 24 months
- -The date the infant was due is another emotional time.
- -Often the parents feel they did something wrong that caused the miscarriage
Pregnancy that occurs outside the uterus, usually in the tube. The main cause is a blockage in the tube because of malformations, tumors, adhesions or diseases like gonorrhea.
Ectopic pregnancy
Symptoms of Ectopic pregnancy
–Sharp abdominal pain on one sided/rupture of tube
causing referred shoulder pain
–Bleeding into the abdominal cavity resulting in shock
–Usually is sudden and very painful, but some women have mild symptoms like spotting first
Nursing Interventions for Ectopic Pregnancy
- -Watch for shock
- -Usual post op. care following removal of tube (may need a blood transfusion)
- -Emotional support - fear of happening again and concern about being able to become pregnant with only one tube
Abnormal degeneration of the products of conception thought to be due to an abnormal ova or protein deficiency.
Hydatidiform Mole/Molar Pregnancy
Symptoms of Hydatidiform Mole/Molar Pregnancy
- -Severe nausea and vomiting, might think she has hyperemesis gravidarum at first
- -Uterus enlarges at a rapid rate, often misinterpreted as twins or that her due date is wrong
- -Increased levels of HCG
- -Signs of toxemia before the 24th week
- -Bleeding (spotting to profuse)
- -Passage of grape like clusters
- -Sonogram will revel the problem. This is followed by a D&C to remove the products of conception.
- -Client must be closely followed for possible cancer and discourage from becoming pregnant until cancer is ruled out
Which gestational problem must the patient be tested for cancer after having?
Hydatidiform Mole/Molar Pregnancy
Nursing Interventions for Hydatidiform Mole/Molar Pregnancy
- -Usual post op, watch for hemorrhage
- -Must have close follow up for cancer
when the placenta separates from the normal implantation site in upper segment of the uterus before birth.
Abruptio Placenta
Types of Abruptio Placenta
–Central (Also called concealed) – blood is retained in uterine cavity; trapped between placenta and uterine wall
–Marginal (also called partial separation) –some bleeding vaginally
–Complete separation – placenta becomes completely detached from
the uterine wall - massive bleeding vaginally
Etiology of Abruptio Placenta
Trauma
Chronic Vascular Disease
High parity
Toxemia
Clinical Manifestations of Abruptio Placenta
Central
- -Intense, cramp like, acute uterine pain
- -Uterine tenderness and rigidity
- -Lack of alternate contraction–relaxation of uterus
- -Fetal heart tones – bradycardia or absent
- -No bleeding from vagina
- -Decrease in BP
Marginal
- -Dark red vaginal bleeding
- -Non-rigid abdomen
- -Tenderness over uterus
- -Decrease in BP
Complete
- -Massive vaginal bleeding
- -Rigid abdomen
- -Acute pain in abdominal area
- -Profound shock
Treatment for Abruptio Placenta
depends upon severity and extent of labor
Mild – rupture membranes to hasten delivery
and help control bleeding
Mod to Severe – immediate C. Section
Treatment for blood loss and shock
Blood drawn for coagulation studies (DIC)
Nursing Management for Hemorrhage (could be from Abruptio Placenta)
- -Keep patient on bed rest
- -Do abdominal girths or measure from symphysis to top of fundus.
- -Observe for shock
- -Carefully monitor contractions, fetal heart tones, and vital signs
- -CVP line (10cm H2O is goal)
- -Give packed cells or whole blood if ordered
when the ovum implants low in the uterus toward the cervix and the placenta develops so that it partially or completely covers the internal os. Occurs once in every 150 deliveries.
Placenta Previa
Types of Placenta Previa’s
–Total (also called complete) – os is entirely covered
–Partial – only part of os is covered
–Low lying (also called marginal) – marginally overlaps os
Etiology of Placenta Previa
- -Multiparas
- -Increased age of mother
- -Placenta Accreta
- -Defective development of blood vessels in decidua
- -Large placenta
Clinical Manifestations of Placenta Previa
- -Painless vaginal bleeding after the seventh month with no precipitating cause.
- -Bleeding may be intermittent
- -As internal os begins to dilate, the part of placenta that overlies the os separates and leaves gaping vessels, so bleeding occurs
- -Uterus usually remains soft and flaccid
Diagnosis of Placenta Previa
–History of painless bleeding in late pregnancy
–Localization of placenta by ultrasound
–Sterile vaginal or pelvic examinations are usually not
done as part of diagnosis
Treatment for Placenta Previa
–Hospitalized immediately
–Usually placed on bed rest
–Blood typed and crosshatched for possible transfusion
–Treatment depends upon type of placenta previa, condition of mother,
and viability of baby
–Mechanical pressure applied to placental site
by bringing down baby’s head and occluding blood vessels – usually accomplished by rupture of membranes
–Delivery by C. Section ( if baby is small and bleeding stops, delivery is usually postponed)
Nursing Management for Placenta Previa
- -Maintain patient on bed rest and provide quiet rest atmosphere
- -Count perineal pads
- -Observe for hemorrhage
- -Give emotional support, explain procedures, and help allay fears
- -Do not perform vaginal examinations
- -Have emergency setup for C. section or vaginal (Double setup)
- -Carefully monitor fetal heart tones
Onset of labor before the 38th week and after the 20th week
Preterm Labor
*Etiology (unknown in most cases) of Preterm Labor
Maternal factors
Premature Rupture of Membranes (PROM)
Incompetent cervix
Preeclampsia or eclampsia
Cardiovascular or renal diseases
Diabetes
Infection
Injury
Abdominal surgery
Uterine anomalies
History of previous preterm L&D
Drug use like cocaine
Fetal factors
Multiple gestation
Hydramnios
Fetal anomaly or infection
Fetal death
S/s of preterm labor
Contractions – at least q 10 min, lasting 30 sec for 1 hour
Bloody discharge
Diarrhea
Cervical dilatation and effacement
Possible rupture of membranes
Pain and pressure in lower back and abdomen
Treatment of preterm Labor
Bed rest
No coitus or enemas
IV for hydration
I&O
Medications
Ritodrine (Yutopar)
Terbutaline sulfate (Brethine)
Magnesium sulfatePrenatal concerns about Gestational Diabetes
- Rapid changes in maternal insulin needs during pregnancy
- Diabetic clients are followed closer than normal pregnant client
3 They are at higher risk for developing the following complications
*Polyhydramnious
*Toxemia (PIH)
*Hypo-hyperglycemia
Facts to remember regarding Insulin with Gestational Diabetes
Maternal insulin does not cross placenta, by 12 wks fetus makes insulin, but this does not lower blood sugar level (maternal control)
During the 1st trimester the fetus is growing rapidly so it draws large amounts of glucose from the mother. Also, maternal vomiting results in the maternal need for insulin going way down.
Hormones being produced during the 2nd trimester have anti-insulin effect so the maternal need for insulin may increase to as much as 100-200 units a day
Cardiac Problems during Pregnancy. Classifications:
I & II usually do fine with pregnancy
III& IV caution with pregnancy
Most common heart conditions:
Rheumatic heart disease
Congenital heart defects
Mitral valve prolapse (MVP)
Peripartum Cardiomyopathy
Which types of heart conditions should NOT become pregnant?
Cyanotic types
Mitral valve prolapse (MVP) and Pregnancy
- Usually do well. Symptoms may be less since increase in fluid volume makes the prolapse less, so feel better
- Inderal, limit caffeine, antibiotics
Peripartum Cardiomyopathy and Pregnancy
- -Dysfunction of left ventricle
- -Develops last month of pregnancy and first five months postpartum
- -Cause is unknown
- -Heart gradually returns to normal
- -Discourage subsequent pregnancies
Prenatal Care of Pregnant women with Heart Disease
- Pregnancy expands plasma, volume which increases
cardiac output and causes an increased work load on
the heart - can result in congestive heart failure or
death - Followed more closely by health care provider
- Assessment for congestive heart failure; cough, dyspnea, edema diastolic heart murmur, palpitations, moist rales
- Monitor for anemia, infection
- Teach client: Signs of Congestive Heart Failure (CHF)..Nutrition–>Diet high in protein, iron, low salt, (not no salt).. Don’t want extra weight gain
Avoid infections.
Fatigue, extra rest- smaller more freq meals - Medications
Antibiotics,
Anticoagulant therapy - Heparin, NOT Coumadin
it crosses the placenta
Diuretics (if CHF) - thiazide, Lasix
Digitalis (CHF)
Which anticoagulant crosses the placenta and should NOT be used
Coumadin
What Danger Signs should all clients report immediately to their health care provider?
- Sudden gush of fluid
- Bleeding
- Abdominal pain
- Temperature above 101 F
- Dizziness, blurring of vision, double vision
- Persistent vomiting
- Severe headaches
- Edema of hands, face, legs and feet
- Sudden weight gain
- Muscular irritability, convulsions
- Epigastric pain
- Oliguria
- Dysuria
- Absence of fetal movements
