Pregnancy At Risk Flashcards
The US is the _____th largest in maternal deaths.
Why?
5th
healthcare workers do not listen to their patients
NO abnormal VS are noticed when critical and at telling dangerous levels. They believe they are fine and send them home regardless
What are the different hemorrhagic conditions r/t pregnancy?
Abortion
Cervical Insufficiency
Ectopic Pregnancy
Gestational Trophoblastic Disease
Placenta Previa
Abruptio Placentae
Disseminated Intravascular Coagulation (DIC)
What is the general definition of an abortion?
pregnancy loss before fetus is viable or capable of living outside the uterus
before 20 weeks or <500 g
-Spontaneous or induced
Spontaneous abortion incidence % in pregnancy
18-31%
During what trimester do 75% of women lose their children to an abortion?
1st trimester
Spontaneous abortion incidence increases with
parental age
What is the most common cause of spontaneous abortions?
chromosomal abnormalities
What are the clinical manifestations of a spontaneous or induced abortion?
uterine cramping, backache, and pelvic pressure
passing of products of conception
bright red vaginal bleeding (spotting)
Abortion subgroups
Threatened
spotting w/o cervical changes (pregnancy threatened)
Abortion subgroups
inevitable
cannot stop
open cervical os
moderate to heavy bleeding
passing tissue
Abortion subgroups
incomplete
not all products of conception are expelled
Incomplete abortions require
D&C to prevent infection of the remaining products
Abortion subgroups
complete
all products of conception are expelled
Complete abortion requires what treatment
no tx required
Abortion subgroups
septic s/s
fever
abdominal pain
tenderness
foul-smelling discharge
scant-heavy bleeding
Abortion subgroups
missed
fetus passed away but remains in the uterus
cause Dead Fetus Syndrome
In a missed abortion, what can develop as a result? and what can it be divulged into?
Dead Fetus Syndrome
- possible develop DIC
DIC requires what procedure
D&C
Abortion subgroups
recurrent/habitual spontaneous abortion
defined as 3+ spontaneous abortions
Cervical os is
the opening in the cervix at the end of the endocervical canal
For missed or incomplete abortion, what treatment needs to occur if the abortion is <13 weeks?
D&C
For missed or incomplete abortion, what treatment needs to occur if the abortion is >13 weeks?
D&E
D&C
Dilation of the cervical os and Cuttrage - scrap out
D&E
Dilation and suction out the remainging
What could be used in a missed or incomplete abortion to induce contractions and expel the uterus?
Prostaglandin E2 or Cytotec
What are the 2 major complications of a missed abortion?
Infection
Disseminated Intravascular Coagulation (DIC)
If the woman has recurrent spontaneous abortions, what will the doctor follow up on?
examination of reproductive organs
refer for genetic counseling
identify hormone/endocrine problems
If a Rh-negative woman has any abortion, what needs to be given
Rh - immune globulin (Rhogam)
If the pregnancy is 18-19 weeks, the treatment would use what to induce the abortion?
prostaglandin
What is the psychological impact of an abortion?
frightening (wait and watch is difficult)
acute sense of grief, anger, disappointment, and sadness
Guilt and speculation they could have prevented the loss
How long can grief last after an abortion?
up to 18 months
- fantasies of unseen, unborn baby
What should nurses do after their patient has an abortion?
convey acceptance of expressed feelings
-provide information and simple brief explanations of what has occured
Induced abortions can be what types
Therapeutic (when the baby passes away inside the mother)
Elective (not wanted)
When asking a pregnant mother about her GTPALM, the nurse notices A1. What should the nurse ask when assessing the score?
Ask when the mother is alone as it could be a sensitive situation
Cervical Incompetence/Insufficiency is the
mechanical defect in the cervix which causes premature cervical ripening
What could cause cervical insufficiency?
previous trauma (D&C or cauterization)
Congenital structural defect
What is a cervical cerclage?
sutures reinforce the cervix
The cervical cerclage is removed when
near term in preparation of labor
Can a cervical cerclage be used for prophylactic reasons?
yes, 12-16 weeks
Why would a cervical cerclage be used for prophylactic reasons at 12-16 weeks of gestation?
hx of loss or cervical insufficiency
Is Rhogam given to a Rh-negative patient with a cervical cerclage procedure?
yes
What are the post-op instructions for a cervical cerclage patient?
monitor and home instructions
- antibiotics to prevent infections
- tocolytics to relax the uterus
- modify activity for 1-2 weeks
What should a patient post-op from a cervical cerclage monitor for and report if found?
uterine activity
leaking fluid
infection
The cervical cerclage post-op patient needs to watch their activity by
modifying activity (bedrest and activity to a minimum)
When is a cervical stitch removed?
at 36 weeks around the estimated labor
What is ectopic pregnancy?
implantation of fertilized ovum in sites other than the endometrial lining of the uterus
Ectopic pregnancy is a medical
emergency
An ectopic pregnancy is usually found where?
fallopian tube due to a tubular obstruction or blockage (scarring)
Ectopic Pregnancy S/S
Full feeling/tenderness in lower abdominal quadrants
+ pregnancy test
When does a pregnancy test become detectable?
6-8 weeks
What are the signs of acute rupture of an ectopic pregnancy?
vaginal bleeding
adnexal/abdominal mass (fetus)
referred shoulder pain
syncope/shock
Adnexal pain
lower abdomen on the tube or involved ovary
What are the vital signs while a patient is bleeding?
low BP
high pulse
The symptoms of a ectopic pregnancy occur around
6-8 weeks
What are the nursing interventions for an ectopic pregnancy?
1st assess VS STAT - low BP and high pulse
check for vaginal bleeding
start large bore IV to start fluids
notify provider immediately for removal
assess for abd masses or adnexal tenderness
Ectopic Pregnancy Tx IF STABLE
prepare for an abdominal US
medical mgmt with methotrexate
Ectopic Pregnancy Tx IF UNSTABLE
rapid surgical tx for ruptured ectopic
- explain the procedure and sign consent
- pre and post-op instructions
- T&C for 2 units of packed RBCs
- future pregnancy is desired and the tube is not ruptured - attempt to preserve the tube
- observe for shock
- Rhogam for Rh (-)
In a OR tx for a ruptured ectopic pregnancy, if a future pregnancy is desired, what happens?
if tge tube is not ruptured, they will attempt to preserve the tube
What is Methotrexate?
chemotherapeutic agent
What are the precautionary measures for nurses when handling Methotrexate?
- PPE with double-gloving
- verify name, medication, and dosage with another nurse
-air should not be expelled from the syringe so as not to aerosol the drug
T/F: You should expel the air in the syringe to prime the needle.
False, do not expel it as it could aerosolize the chemotherapeutic drug
What are the patient teachings for Methotrexate?
urine is considering toxic for 72 hours
avoid getting urine on the toilet seat, flush the toilet 2 times with the lid closing after voiding
- refrain from alcohol, vitamins with folic acid, NSAIDs, and avoid sunlight
What are the adverse effects of Methotrexate?
N/V with transient abdominal pain
Gestational Trophoblastic Disease aka
hydatidiform mole
molar pregnancy
Gestational Trophoblastic Disease Assessment
Hgh beta hCG than for gestational age
- Uterus larger than expected for gestational age
Hyperemesis- excess N/V
Vaginal bleeding(1st tri) varies from brown to profuse hemorrhage
absence of a fetal sac/heartbeat on US
Gestational Trophoblastic Disease can cause what in early development
preeclampsia before 24 weeks gestation
Gestational Trophoblastic Disease is characterized as what on a US?
snowstorm pattern with vesicles and absence of heartbeat and sac on US
gray-shaped nodules
Gestational Trophoblastic Disease malignant chnage leads to
choriocarcinoma and metastasis to the lung, vagina, liver, and brain
Gestational Trophoblastic Disease is
trophoblasts that attach the fertilized ovum to the uterine wall developing abnormally
In an anatomic view, what does a Gestational Trophoblastic Disease look like?
proliferation and edema of chorionic villi into a bunch of clear vesicles in grape-like clusters
- abnormal placenta
- embryo rare
- large enough to fill the uterus to advanced stages
- predispose to Choriocarcinoma
A patient comes in for a 20-week check-up and presents with their fundus at the xiphoid process. What do you suspect based on your findings?
The patient looks full-term when she is only half-term
- Gestational Trophoblastic Disease due to the advanced uterus compared to the actual gestation age
What are the tx for Gestational Trophoblastic Disease?
Evacuate the trophoblastic tissue (D&C)
Tx hyperemesis and preeclampsia
CBC, T&C, screen and coagulation status
Discharge instructions
Evacuate the trophoblastic tissue (D&C) for a molar pregnancy needs to avoid and get what test ran
Chext X-ray, CT, MRI for metastasis
avoid uterine stimulation (manual or chemical - Oxytocin)
What D/C instructions would you give a molar pregnancy after a D&C?
AVOID PREGNANCY FOR 1YEAR - birth control
obtain serum hCG monthly for 6 months then every 2 months for the next 6 months
If the hCG levels rise after the evacuation of the disease, what does this indicate?
malignancy
What do you treat the malignancy of Gestational Trophoblastic Disease with?
methotrexate
What s/s would you teach the patient to immediately report after the tx for Gestational Trophoblastic Disease?
bright red vaginal bleeding
temp >100.4
foul-smelling vaginal discharge
Placenta previa
implantation of the placenta in the lower uterus segment
Marginal/ Low-lying placenta classification
placenta implanted in the lower uterus but more than 3 cm from the internal cervical os
Partial placenta previa
lower placenta border is within 3 cm of the internal cervical os but does not completely cover the os
Total/Complete Previa
placenta completely covers the internal os
What are the s/s of placenta previa?
sudden onset of painless vaginal bleeding (bright red)
soft, relaxed uterus
no tenderness
When does the initial episode of placenta previa bleeding usually occur?
2-3rd trimester
- rarely life-threatening
How do you assess and dx placenta previa?
US to determine placental placement
The HCP orders a vaginal exam on a patient with sudden onset of vaginal bleeding but has no pain. What should the nurse do?
a) Continue with the exam
b) Question why the exam should be ordered and tell the charge nurse after performing the exam.
c) Tell the physician that a vaginal exam is contraindicated for a placenta previa suspected pt.
d) Tell the physician that a vaginal exam is contraindicated for an ectopic pregnancy suspected pt.
c) Tell the physician that a vaginal exam is contraindicated for a placenta previa suspected pt.
A vaginal exam on a placenta previa patient is ALWAYS
What could happen?
CONTRAINDICATED; can cause placental separation or tear placenta causing severe hemorrhage and death of the fetus
The management of a placenta previa patient is based on?
condition of the mother and fetus
- determine the amount of hemorrhage
- eval fetus using an electronic fetal monitor
- gestational age of the fetus
If the placenta previa patient is unstable or based on the fetal heart monitor the baby is not looking good. What would the doctor tell the patient?
Inpatient care in the Antepartum unit until delivery
monitored closely for compromise
immediate delivery
If the placenta previa patient is stable and based on the fetal heart monitor the baby has no fetal compromise. What would the doctor tell the patient?
Delay the birth to increase maturity and birth weight
Administer corticosteroids to speed up the maturation of fetal lungs
conservative mgmt may take place in the home or hospital
Why do you give a fetus corticosteroids?
speed up the maturation of fetal lungs
Why would you delay the birth of a stable placenta previa patient?
increase the maturation and birth weight
Placenta previa can be managed at home with the following criteria
- no evidence of active bleeding is present
- pt can maintain strict bed rest at home except for toileting and shower
- pt verbalizes understanding of risks and how to manage care
- can get to the hospital in a reasonable time if you start to bleed
- home is close to the hospital
- emergency systems available for immediate transport to the hospital
- perform daily kick counts and recognize uterine activity
What is the treatment for total or partial previa, heavy bleeding, or deterioration of the condition?
CESAREAN SECTION
- additional personnel (NICU fr baby)
18 g IV and consider a second line
blood on standby or immediately available
Abruptio Placentae is the
partial or complete premature detachment of the placenta from implantation in the uterus
Abruptio Placentae usually occur in what trimester?
3rd
Abruptio Placentae is considered an OB
emergency
- cause 15% of maternal deaths
Abruptio placentae can be caused by
Hypertensive disorders
High gravida (10+ pregnancies)
Abdominal trauma (car accidents, falls, IPV)
Cocaine, Meth, Marijuana, or Tobacco use
Short umbilical cord (can not reach out in descent)
PROM
Previous abruptio
How can Cocaine, Meth, Marijuana, or Tobacco use cause abruptio placentae?
vasoconstrictor leads to vessels of the placenta to pull loose
What are the s/s of abruptio placentae?
Bleeding concealed or overt
uterine tenderness/pain locally over the abruption site
persistent abdominal pain - contraction never goes away
rigid, board -like abdomen
FHR abnormalities - Late decelerations
Shock s/s low BP and high pulse
IUPC reveals high resting tone
If the bleeding from the abruptio placentae is dark red, what does that mean?
overt bleeding
Abruptio Placentae Nursing Interventions
bed rest (no vaginal or rectal manipulation)
notify immediately AND prep for immediate C-section
Left lateral for placenta perfusion
EFM for contractions and FHR
IV infusion with large bore catheter
STAT CBC, clotting, Rh factor, and T&C
constant surveillance (signs of DIC)
assess for IPV ASKING WHEN ALONE
Quantify blood loss
emotional support, teach regarding mgmt and expected outcomes
Conservative mgmt of the Abruptio Placentae if
mild and the fetus is <34 weeks
- no signs of distress
What are the conservative mgmt for a mild abruptio placenta?
bed rest
tocolytic to reduce uterine activity
corticosteroids (accelerate fetal lung maturity)
Rhogam to Rh (-) women
If the abruptio placentae patient has fetal compromise or maternal deterioration in status, what needs to happen next?
immediate delivery with the NICU team at the delivery
DIC means
Disseminated Intravascular Coagulation
Consumptive Coagulopathy
DIC is a
defect in coagulation where the mother can not clot her excessive bleeding
- anticoagulation with excessive bleeding
- micro-circulation of inappropriate coagulation concurrently
DIC causes ischemia by
Formation of tiny clots in tiny blood vessels that block blood flow to organs
- excessive bleeding
Diseases that cause DIC
placental abruption
prolonged retention of a dead fetus
endothelial damage (severe preeclampsia and HELLP Syndrome)
maternal sepsis
amniotic fluid embolism
Anemia
decrease in the O2-carrying capacity of the blood
Anemia is caused by
iron deficiency
reduced dietary intake
Anemia is associated with increases of what complications?
miscarriage, preterm labor, preeclampsia, infection, PP hemorrhage, and IUGR
IUGR means
Intrauterine growth restriction
Pregnant women are considered anemic if their hemoglobin and hematocrit are what in the different trimesters?
Hgb <11g/dL, Hct <37% in first trimester
Hgb < 10.5g/dL, Hct < 35% in second trimester
Hgb < 10g/dL, Hct <32% in third trimester
Iron deficiency anemia s/s
pallor
fatigue
pronounced lethargy
HA
inflammation of the lips and tongue
What is the total iron requirement for a single fetus pregnancy in one day?
1000 mg/day
What are good sources of iron in food?
meat
fish
chicken
liver
green leafy veggies
What are the different infections possible in pregnancy?
UTI
Vaginal (Candiasis, bacterial vaginosis)
Viral (Rubella, COVID-19, Hep B, Cytomegalovirus, Varicella - Zoster)
Non-viral (Toxoplasmosis, Group B Strep)
STIs
Intrauterine Infection
UTIs in pregnancy can result in
pyelonephritis if untreated
- stay in the hospital
UTIs increase the risk of
preterm labor and premature delivery
Maternal complications from a UTI include
high fever
flank pain
septic shock
ARDs
Candidiasis in pregnancy can develop into
thrush in newborns (yeast infection)
Bacterial vaginosis can lead to
PROM, preterm labor and birth, intraamniotic infection, PP endometritis, neonatal sepsis and death
What is one of the first signs of pyelonephritis or a UTI?
pain with urination
What is the only protection for the fetus from Rubella?
prevention
If the mother has Rubella, what can result in the fetus?
fetal congenital heart defects
IUGR
congenital cataracts
hearing and vision problems
If a woman gets COVID-19 during pregnancy, the preliminary studies show that she is at an increased risk of?
preeclampsia
stillbirth
maternal death
Hepatitis B causes an increased risk for what in OB patients?
prematurity
LBW
neonatal death
If a mother is Hep B +, what should be given to the newborn?
- clean thoroughly and carefully bathed before injections
- receives Hep B immune globulin FOLLOWED by Hep B vaccine
Cytomegalovirus Tx
none for the mother or fetus
What can result if a mother gets infected with the cytomegalovirus?
stillbirth
congenital CMV
microcephaly
IUGR
cerebral palsy
mental retardation
rash
jaundice
hepatosplenomegaly
What precautions are taken for a mother infected with the Varicella-Zoster virus?
Airborne/Contact
Standard
What type of staff should take care of the Varicella-Zoster virus patient?
immune only staff
If the pregnant mother is infectedwith Chickpox at 13-20 weeks gestational age, what could occur to the fetus?
limb hypoplasia, cutaneous scars, chorioretinitis
cataracts
microcephaly
IUGR
If the pregnant woman gets infected 2-5 days before birth, what could happen to the fetus?
life-threatening varicella infection
- congenital varicella syndrome
Toxoplasmosis caused by
protozoa in raw uncooked meat
cat feces in the litter box
Toxoplasmosis can cause what in pregnancy
congenital toxoplasmosis
stillbirth
microcephaly
hydrocephalus
blindness
deafness
Group B Strep infection is the leading cause of
life-threatening perinatal infections
Group B Strep is tested with cultures at what weeks
35-37
If the mother is positive for Group B Strep, what will the nurses need to do?
administer PCN, cephalosporin, or clindamycin
for 2 minimum doses before delivery at least 4 hours to get to the baby
What STIs could infect the fetus in a pregnancy?
Syphilis
Gonorrhea
Chlamydia
Trichomoniasis
Human papillomavirus
Herpes Simplex Virus
Human Immunodeficiency Virus
Chorioamnionitis is
infection of the amnion/chorion/amniotic fluid
S/S of chorioamniotitis
maternal fever
fetal tachycardia >160 baseline for 10 minutes
maternal WBCs >15000 (w/o corticosteroids)
purulent fluid from the cervical os
Chorioamnionitis interventions
wash hands before and after touching pt
- Temp q2 hours after ROM and - q hour for a fever
keep pads under dry and limit vaginal exams - aseptic
inform neonatal staff if infection signs
Antibiotic therapy starts when identified
Assess maternal pulse, respiration, and BP hourly if fever is present
Chorioamnionitis can lead to what if untreated
sepsis
- high pulse and respirations
- low BP
high lactic acid
What do you give as an antipyretic for a maternal fever?
acetaminophen
- assess maternal fever, pulse, respirations, and BP hourly
PROM is the
Rupture of membranes before the onset of true labor regardless of gestational age
PPROM is the
rupture of membranes before 37 weeks gestation
- Associated with preterm labor and birth
When a baby is born with PPROM, the infection risk increases if not delivered within
24 hours
A newborn born before ___ -___ weeks is at the greatest risk of PPROM.
32-34 weeks
Conditions associated with PPROM
Infection of the vagina or cervix
Weak structure of the amniotic sac
Previous preterm birth, especially if preceded by PPROM
Fetal abnormalities or malpresentation
Incompetent or short cervix
Over distention of the uterus
Maternal hormonal changes
Maternal stress or low socioeconomic status
Maternal nutritional deficiencies and diabetes
PROM management depends on gestational age. What order should the nurse intervene and verify?
1st - verify ROM with nitrazine/fern/amnisure testing
2nd - If nearterm - induce labor if not
3rd - If preterm less than 36 weeks
= weight risks and benefits of fetal infection and risk of prematurity
PROM management if short-term
tocolytics to delay delivery and administer corticosteroids
What should be considered for management of PROM?
fetal age
lung maturity
amount of amniotic fluid
signs of fetal compromise
If there is no signs of infection of fetal lung immaturity after PROM,
admit and observe for infection or labor
- daily non-stress tests
- biophysical profile with amniotic fluid
- fetal lung maturity testing
- maternal antibiotics for 7 days
With a PROM patient what patient teachings does the nurse need to verify understanding completely?
- avoid sex, orgasm, or inserting anything into the vagina
- avoid breast stimulation with preterm gestation
- Temp a least 4x/day minimum
- Report 37.8C or 100F
- Maintain activity restrictions (bedrest unless bath/toilet)
- Note/report uterine contractions or foul odor or discharge
Preterm Labor begins
after the 20th gestational week but before 37 weeks
(21-36 weeks)
Preterm labor infants are not equipped for extrauterine life and may develop
cerebral palsy
developmental delay
vision or hearing impairment
significant emotional/financial burdens for the families
T/F: Racial disparities exist in preterm birth rates.
True - AA and Hispanics then caucasian
Risk factors for preterm labor
Uterine over-distention
Decidual (endometrium) activation
Premature activation of normal physiological initiation of labor
Inflammation and infection in decidua, fetal membranes, and amniotic fluid
What is the goal of preterm labor?
delay birth and promote fetal maturation
How can you predict preterm labor?
cervical length
infections
PPROM previously
Fetal fibronectin (fFN) test
Fetal fibronectin test
high negative predictive and low positive predictive value
Fetal fibronectin test - NEGATIVE
< 1% chance of delivering in the next 2 weeks
Fetal fibronectin test - POSITIVE
12-17% chance of delivering in the next 2 weeks
Fetal fibronectin test steps
- collect specimens before any manipulation to avoid contamination
- rotate the swab across the posterior fornix for 10 seconds to absorb cervicovaginal secretions
- remove and immerse in buffer
- secure and label
How do you stop preterm labor initially?
- identify and tx infections and causes
- limit activity - left lateral or semi-sitting positions
- Hydrate: Oral and IV fluids
- Tocolytics
Oral fluids can do what in stopping preterm labor?
reduce uterine irritability and risk of UTIs
High IV infusion volumes of preterm labor can cause
maternal respiratory distress - PE
Tocolytics can successfully
delay birth to provide time
- does not decrease the rate of preterm birth
T/F: Tocolytics decrease the rate of preterm birth.
False, does not demonstrate a decrease in preterm birth
Tocolytics can provide time for
Maternal corticosteroids
Antibiotics to prevent neonatal infection with GBS
Transfer to a tertiary facility
Give magnesium sulfate for neuroprotection
What drugs can be given in preterm labor?
Magnesium Sulfate
Mg Sulfate is used to
depress myometrium contractility
CNS depressant
PIH and suppress labor
Mg Sulfate dosage and effectiveness
Load: 4g in 20-30 mins
THEN IV 2g/hr
Mg Sulfate Therapeutic level
5/7-8
Mg Sulfate antidote for toxicity
Calcium Gluconate
Mg Sulfate maternal effects
Flushing, dry mouth, lethargy, headache, muscle weakness, pulmonary edema, cardiac arrest
Mg Sulfate fetal effects
Lethargy, hypotonia, respiratory depression
- resuscitate possible and ready
May reduce risk of cerebral palsy in neonate; Shown to offer neuro-protection in preterm infant
Mg Sulfate nursing interventions
Monitor lung sounds and FHR, contractions, and MgSO4 levels
Stop immediately and give an antidote for toxicity
Mg Sulfate S/S Toxicity
Absent DTRs <12
Resp < 12
Severe hypotension
Decreased LOC
Pulmonary edema
Chest pain
Urine output <30ml/hr
Prostaglandin Synthesis Inhibitors medication names
Indomethacin sodium; Naproxen sodium;
Fenoprofen
Prostaglandin Synthesis Inhibitors are used to
stop the production of prostaglandin
Prostaglandin Synthesis Inhibitors are effective in
delaying delivery 48+ hours
- used short-term due to fetal side effects
- used in < 32 week gestations
NSAID
Indomethacin sodium dosage
50mg PO loading
25-50 mg PO every 6 hours
Indomethacin sodium should not be used longer than
48 hours
Indomethacin sodium maternal effects
Nausea, heartburn, GI upset; pulmonary edema, blurred vision, headache, nausea, post partum hemorrhage
Indomethacin sodium fetal effects
Constriction of ductus arteriosus – not late, pulmonary hypertension, reversible decrease in renal function, with oligohydramnios, intra-ventricular hemorrhage,
hyper-bilirubinemia, NEC
Indomethacin sodium nursing mgmt
Monitor FHR and uterine contractions;
Listen to lung sounds
Treat nausea and heartburn;
Monitor for manifestations of pulmonary edema; monitor for postpartum hemorrhage
Nifedapine
Nicardipine
(procardia, adalat)
SHOULD NOT BE ADMINISTERED CONCURRENTLY WITH
Mg Sulfate
Pts with Nifedapine or Nicardipine (Procardia, Adalat) should not be used with
terbutaline
Nifedipine or Nicardipine (Procardia, Adalat)
is used for
block Calcium availability for muscle contraction
Nifedipine or Nicardipine (Procardia, Adalat) is effective in delaying delivery for
49-72 hours
- Give corticosteroids for baby lungs now
Nifedapine or Nicardipine (Procardia, Adalat)
maternal effects
Flushing, headache, dizziness, nausea, transient hypotension, pulmonary edema
Nifedapine or Nicardipine (Procardia, Adalat)
fetal effects
May decrease utero-placental blood flow
Nifedapine or Nicardipine (Procardia, Adalat)
nursing interventions
Monitor FHR and UCs
Monitor maternal blood pressure and heart rate
Nifedipine or Nicardipine (Procardia, Adalat) should be cautioned in which patients
renal disease
hypotension
Nifedipine or Nicardipine (Procardia, Adalat) should be HELD
for BP < 90/50 or HR >120
Terbutaline / Ritodrine
are used to
Suppress uterine activity
Delay delivery by 3 days
Terbutaline dosage
IV/ - max 0.08mg/min
SQ 0.25 mg q 3-4 hours
Ritodrine dosage
max dose .35 mg/min IV
Terbutaline / Ritodrine
maternal effects
Cardiac or cardio-pulmonary arrhythmias, pulmonary edema, myocardial ischemia, hypotension, tachycardia,
Elevation in maternal glucose, hypokalemia
Terbutaline / Ritodrine
fetal effects
Fetal tachycardia,
Hyper-insulinemia, hyper-glycemia,
Myocardial and septal hypertrophy,
Myocardial ischemia
Terbutaline / Ritodrine
nursing mgmt
Monitor FHR and UCs
Monitor I & O for overload
Auscultate lungs for pulmonary edema
Monitor maternal HR and may hold dose for heart rate >120
Monitor blood glucose
Antenatal Corticosteroids medication types
Betamethasone or Dexamethasone
Antenatal Corticosteroids are recommended to administer between
24-34 weeks
- risk for preterm birth within 7 days
Antenatal Corticosteroids is used for
reducing Respiratory Distress Syndrome and intraventricular hemorrhage in preterm infants
- 2 doses 12-24 hours apart (Beta)
- 4 doses 12 hours apart (Dexta)
What is contraindicated for the administering of Antenatal Corticosteroids?
active infection
What is precautionary for the administering of Antenatal Corticosteroids?
complicated with diabetes
If an infant is born sooner than 24 hours, is it okay to still give antenatal corticosteroids?
yes, still some benefits
Post-term pregnancy lasts
longer than 42 weeks
- prolonged pregnancy can be due to miscalculation of EDD
Risks to the fetus if a post-term pregnancy
Placental insufficiency - increases the risk for stillbirth longer the pregnancy lasts
Meconium aspiration syndrome
Large Baby
Fetus may continue to grow - complications dysfunctional labor, lacerations, or infections
Mgmt for a Post-term Pregnancy
Accurate determination of due date – US in early pregnancy and ensure the gestation age at 20 weeks
Induction of labor at 39 weeks (earlier for HTN)
Labor Dystocia
difficult birth resulting from any cause
Labor Dystocia can result from one or all of
P’s
Power
Passage
Passenger
Position
Psyche
Labor Dystocia
r/t Powers
ineffective uterine contractions and secondary bearing-down efforts
Labor Dystocia
r/t Passage
- maternal pelvis, uterus, cervix, vagina, perineum
Labor Dystocia
r/t Passenger
fetal size, fetal position, placenta
Labor Dystocia
r/t Position
position of the laboring woman – TURN (osteoposterior)
Labor Dystocia
r/t Psyche
response to labor-anxiety
Shoulder Dystocia is
shoulder becomes impacted above the maternal symphysis
OB emergency
Shoulder Dystocia is usually due to a
large infant (IDM)
What makes shoulder dystocia an emergency?
cord compression between the fetal body and maternal pelvis
Initial s/s of the shoulder dystocia is
“turtle sign”
- the baby comes out and goes back in due to the shoulder stuck on the maternal pelvis
Shoulder Dystocia Tx
- prepare for STAT surgical delivery
- call for help
- McRoberts Maneuver
- keep time
-suprapubic pressure was applied to move the impacted shoulder past the symphysis - After delivery check the infant clavicle for fx
What is the priority nursing action in Shoulder Dystocia?
McRoberts maneuver
McRoberts Maneuver
pulls the legs as far as possible toward the chest
suprapubic pressure
The McRoberts Maneuver opens up the pelvis to
15-30 degrees supine
What is the abnormal presentation/position?
fetal occiput posterior
occiput transverse position
Brow, miliary, or face presentation
breech
What are the initial sign of persistent OP?
low back pain
give counterpressure
What maternal position changes will help abnormal presentation or positions from the fetus?
TURN side to side q 1-2 hours
Hands and Knees
Side-lying especially far side-lying with the use of peanut ball
Squatting (for the second stage)
Sitting, kneeling, or standing while leaning forward
The physician may assist with rotation using forceps
Brow, military, or face presentation may require _________ delivery
Cesarean
What breech presentations are dangerous?
frank
full
single footling
In a breech presentation, the greatest fetal risk is
the head is the last to be born
- head can be entrapped if sevix clamps around the neck
- umbilical cord compressed
What would the FHM show for a possible breach?
late decelerations to variables due to compressed umbilical cor
- low perfusion to the baby
With prolonged labor, the infection rate for fetal and maternal are more likely with
prolonged ROM
What is the “normal” length of labor?
Nullipara 1.2 cm/hr
Parous 1.5 cm/hr
Both = 6 hr to progress 4-5 hrs and 3 hrs from 5-6cm
After 6 cm, multiparas progress
faster the nulliparas
Nullipara 2nd stage labor
without epidural
with labor
w/o epidural 2.8 hours
with labor 3.6 hours
Precipitous labor occurs within
3 hours on onset
Precipitous labor can cause trauma to
genital tract of the mother, bruising, intracranial hemorrhage, or nerve damage
hyperbiliruibinemia
Precipitous labor priority nursing care
promotion of fetal O2
maternal comfort
Precipitous labor associated with
placental abruption, fetal meconium, infection, maternal cocaine use, postpartum hemorrhage, and low APGAR scores
In a precipitous labor, staff should be
alerted to rapid labor progression and be prepared for delivery of the fetus
- mother supported
What is the leading cause of maternal morbidity and mortality in pregnancy?
HTN disorders of pregnancy
- subsets
- progressive
What is the only way for a road to recovery of the HTN in pregnancy?
delivery of the fetus
What is the underlying mechanism of pregnancy HTN?
vasospasm leads to poor perfusion
- simultaneously with chronic HTN
HTN in pregnancy is associated with
placental abruption, kidney failure, hepatic rupture, preterm birth, and fetal and maternal death
Gestational HTN begins after
20th-week gestation
For Gestational HTN let the HCP know if the BP
Elevated B/P ≥ 140/90 recorded on two different occasions at least 4 hours apart
Gestational HTN proteinuria
NONE
Preeclampsia S/S
GH with the addition of ≥ 1+ proteinuria
Possible transient headaches along with episodes of irritability
Edema may be present in finger and face (not in feet = normal)
Reflexes may be normal
If HTN is before the 20th week, think
molar pregnancy
Severe Preeclampsia S/S
B/P ≥ 160/110
Proteinuria > 2+ or 3+ = increase in edema
Oliguria (< 100 ml in 4 hours)
CNS symptoms: severe headache, visual disturbances - Black floaty spots
Extensive peripheral edema; Pulmonary edema or cyanosis
Impaired liver function
Hyperreflexia (3+) with possible ankle clonus
Thrombocytopenia, elevated serum creatinine, marked liver enzyme elevations
Epigastric and right upper quadrant pain (think it is indigestion)
If the patient has severe preeclampsia, the rapid response should be ready to be called. Why?
seizure due to CNS irritation
black floaty spots - scotoma
Clonus means
nervous system is affected
blood work elevated
Normal DTR
2
HELLP Syndrome stands for
Hemolysis = low iron and perfusion
Elevated Liver Enzymes (AST/ALT) = edema and no ciruclation
Low Platelets - PP Hemorrhage
HELLP Syndrome
s/s subset for severe preeclampsia
Epigastric or RUQ pain, malaise, lower right chest or mid-epigastric area, nausea and vomiting
HELLP Syndrome
If the patients are normotensive and with no proteinuria do you still give them Mg Sulfate?
yes
HELLP Syndrome can cause
Hepatic rupture, renal failure, and preterm birth can lead to fetal and maternal death
Eclampsia can cause what in pregnant women with preeclampsia or new onset 48-72 hours postpartum?
new onset grand mal seizures
Eclampsia Warning signs of impending seizures
Severe headache, drowsiness or mental confusion
Severe epigastric pain is particularly ominous
Hyperreflexia or clonus
Nausea and vomiting
Decreased urinary output indicates poor renal perfusion
Visual disturbances such as blurred, double vision, or seeing spots
Hemoconcentration
Seizure Mgmt
Priority is prevention of injury and stabilization of the maternal airway
Monitor fetal heart rate and for contractions (bradycardia and decals)
Keep patient on her side
Suction equipment readily available
Side rails padded and up
Mgmt of Preeclampsia
do not restrict salt
ONLY CURE IS DELIVERY OF BABY AND PLACENTA
-based on severity and maturity
- 37 weeks gestation without severe fts
If < 34 weeks gestation and delivery can be delayed 48 hours to administer
corticosteroids to mature fetal lungs
Severe Preeclampsia Management
Requires inpatient hospitalization - Antepartum, OBICU, L&D
Bed rest and fetal monitoring
- no walking the halls
May be possible if the woman does not have severe preeclampsia and no evidence of worsening fetal or maternal status
home care
Patients should do what at-home care in HTN of pregnancy
Reduce activity (sedentary most of the day)
Home blood pressure monitoring
Follow-up with provider every 3-4 days
Fetal activity checks (kick counts)
Left Lateral position for perfusion
Intrapartum Care of HTN pregnancy
1/2 of eclamptic seizures occur during labor or the first 48 hours after birth
Fetus and mother should be monitored continuously
Mother should be kept in a lateral position
Decrease stimulation/agitation - limit visitors and control pain
Large bore IV access – INT minimum for C section emergency
Urine protein every hour
Hourly I & O
B/Ps q 15 to 30 min
Postpartum Care for HTN pregnancy
Careful assessment of blood loss and signs of shock are essential
V/S q 4 hours
Monitor for visual disturbances
Administration of magnesium for 24 hours after delivery or last seizure
Signs of recovery in PP HTN in pregnancy
Diuresis
Decreased protein in urine
Return of B/P to normal
Resolution of abnormal labs
Antihypertensive Medications indicated for
- only if severe HTN
Systolic > 160 mm/Hg
Dystolic > 110 mm/Hg
Decrease risk of stroke or congestion heart failure
1st line antihypertensive -
preservation of uteroplacental blood flow
1st Line Hypertensive medications for pregnancy
Labetalol
Hydralazine
Nifedipine
Labetalol
less maternal tachycardia and fewer adverse effects
Hydralazine
headaches, maternal hypotension, fetal distress
Nifedipine
- reflex tachycardia, headaches, and synergistic effect with magnesium sulfate may cause hypotension and neuromuscular blockade
Magnesium Sulfate is used to
anticonvulsant
prevent seizures
CNS depressant
Magnesium Sulfate as a CNS Depressant
depresses CNS irritability and relaxes smooth muscle
Prevents and controls seizures in severe preeclampsia
Prevents contractions in preterm labor
Offers neuroprotection of the preterm fetus
Magnesium Sulfate should be given as a IVPB over
15-20 minutes
Signs of Magnesium toxicity
Respiratory difficulty/depression RR <12
Chest pain
Mental confusion; Slurred speech
no deep tendon reflexes
Flushing, sweating, lethargy
Hypotension
Mg serum level >8
urine < 30 mL/HR
Response to signs and symptoms of Magnesium toxicity
STOP the magnesium !!!!!
Notify the provider – STAT Mag
Be prepared to administer calcium gluconate and resuscitation equipment – at bedside and readily available STAT
Calcium Gluconate can cause
fatal arrhythmia-cardiac monitoring advised
DTR occur at
jaw jerk
supinator
biceps
triceps
knee
ankle
Grading of DTR
0 - NONE
1 PRESENT
2 BRISK NORMAL
3 VERY BRISK
4 CLONUS
Maternal Risk of obesity
Gestational diabetes
Preeclampsia
Thromboembolism
Cesarean delivery
Preterm birth
Birth trauma
Postpartum hemorrhage
Postpartum anemia
Fetal Risk for obesity
Stillborn
NTDs
Hydrocephaly
Cardiovascular defects
Macrosomia
Hypoglycemia
Birth injury - shoulder dystocia
NICU admissions
Pregnancy after bariatric surgery
postpone 12-24 months after surgery
assess vitamins and nutritional deficiency
signs of intestinal obstruction
edu on health, complications, and psychological support
Cardiac Diseases that can occur in pregnancy
Rheumatic Heart Disease
Valvular Stenosis
Myocardial Infarction
Cardiomyopathy
Hemodynamic changes in pregnancy have a profound effect on patients with
cardiac disease; management related to the disorder present and impact on cardiac function
Assess for cardiac decompensation
Class I or II cardiac disease
mgmt
Limit physical activity
Avoid excessive weight gain
Prevent anemia
Prevent infection
Careful assessment for the development of CHF or pulmonary edema
Class III or IV cardiac disease
Primary goal - prevent cardiac decompensation and development of CHF
May need to rest most of the day
Cardiac decompensation is likely with little or no activity
Intrapartum mgmt for cardiac diseases
Prevent Valsalva maneuvers even during the second stage
Avoid the use of stirrups
Try to minimize the effects of labor on the cardiovascular system, may need operative assist
Manage IV fluid administration to prevent fluid overload
Position the woman on her side, with her head and shoulders elevated
Pulse oximetry to monitor O₂ saturation - use O₂ if saturation is < 95%
Administer pain medication/epidural earlier
Quiet and calm environment
Fetus monitored continuously
Signs of cardiac decompensation should be reported immediately
PP Mgmt for Cardiac Disease
Fourth stage of labor associated with risks - monitor closely
After placenta delivery, 500-1000 ml of blood returns to intravascular volume
80% increase in cardiac output in 10 to 15 min
Avoid abrupt position changes
No evidence of distress in intrapartum, there may be cardiac decompensation postpartum
Observe closely for signs of infection, hemorrhage, and thromboembolism
Breastfeeding imposes extra demands on the heart - advised on an individual basis not to breastfeed
Lactation consultant - which drugs are safe for breastfeeding
Hyperemesis Gravidarum
Persistent, uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout pregnancy
Hyperemesis Gravidarum can cause
Loss of 5% or more of pre-pregnancy weight
Dehydration - increased urine specific gravity and oliguria
Acidosis from starvation or alkalosis from loss of acid in gastric fluids
Elevated levels of blood and urine ketones
Fluid and electrolyte imbalance
Hypokalemia
Deficiency of vitamin thiamin, riboflavin, vitamin B₆, vitamin A, and retinol-binding proteins
Psychological stress
Hyperemesis Gravidarum mgmt
rule-out other causes of persistent N/V
H&H and electrolytes - report abnormalities
Control with crackers in the morning, vitamins, and Rx antiemetics
If the simpler methods of Hyperemesis Gravidarum are unsuccessful and wt loss, electrolyte imbalance persists then
Intene Antepartum unit
IV fluid and electrolytes replacement
TPN
Hyperemesis Gravidarum nursing interventions
Record of elimination and observe for signs of dehydration
Daily weight in hospital
Food should be attractively presented in small portions; low fat, easily digested
Soups and other liquids in between meals
Use ginger
Sit upright after meals
Provide emotional support
If the pregnant woman had T2 or T2DM before pregnancy, do you need to screen them
no need to screen
With gestational DM, glucose intolerance is present/not present before pregnancy.
not present
How do you test for glucose intolerance
24 weeks 1-hour test if abnormal then the 3 hour test is abnormal = gestation DM
Pregnancy does what to insulin
progressive insulin resistance
Glucose is transported across the placenta easily by
carrier-mediated facilitated diffusion
- maternal insulin does not cross the placenta
The glucose levels in the placenta are ___________ _______________ to the maternal levels.
directly proportional
At the 10th week of gestation, the fetus does what in gestational diabetes
begins secreting insulin at levels to use the maternal glucose
In the 2-3 trimesters, pregnancy excretes a diabetic effect on the maternal
metabolic status
Gestational DM Dx
1-hour glucose challenge > 140
3 hour Oral Glucose tolerance test
- fasting >95
- 1 hour > 180
- 2 hours > 155
- 3 hours > 140
When do you do the glucose intolerance test in pregnancy?
24-28 weeks
What is the gold standard for dx diabetes in gestation?
3 hour oral glucose tolerance test
3 hour Oral Glucose tolerance test
women must fast from
midnight to the test
What are the insulin requirements during the 1st trimester?
decreased need
What are the insulin requirements during the 2nd trimester?
Increased need for insulin; Glucose use increases
What are the insulin requirements during the 3rd trimester?
Increased need for insulin due to placental maturation and human Placental Lactogen (hPL) production
What are the insulin requirements during labor?
Usually decreased need for insulin - diabetic women will have glucose level checked hourly and continuous infusion of insulin and glucose is started if needed
What are the insulin requirements during the PP
Decreased need for insulin - Breastfeeding helps lower the amount of insulin needed
Fetal effects from maternal hyperglycemia?
Fetal death
Macrosomia-LGA (blood sugar
IUGR if mother Type 1 with vascular changes
Respiratory Distress Syndrome
Hyperbilirubinemia
Fetal effects of maternal hypoglycemia
Prematurity
Cardiomyopathy or cardiac anomaly
Congenital Defects
Psychiatric disorders
Maternal complications from DM
Infections
Preeclampsia
Hydramnios
Ketoacidosis
Hypoglycemia
Hyperglycemia
IUGR
baby is not growing inside the uterus = tiny
When the baby grows big so does the maternal heart. Why?
activity decreases due to the low perfusion of the heart
Self-mgmt of DM in gestation
Check blood glucose levels 4-8 times per day
Record blood glucose levels, food intake, activity, and insulin
Self-monitor of urine ketones
Provide an expected plan of prenatal care, tests, and fetal surveillance
Diet is individualized
Provide an expected plan for labor and delivery
Urine dipstick for glucose and protein each office visit
Exercise 3 times/week for at least 20 minutes unless contraindicated
Know symptoms of hypoglycemia: Always have fast-acting carbohydrate
Daily kick counts for 2nd trimester
In the 2nd trimester a gestational Diabetic mother needs to monitor
daily kick counts
Rh + antigen is
present
Rh - antigen is
absent
If a person with Rh (-) blood is exposed to Rh + blood, what happens?
antigen-antibody response occurs
If antibodies form and Rh (-) person is considered
sensitized (alloimmunized, isoimmunized)
Sensitization may occur in the antepartum via
small transplacental bleeds
The risk of fetal of blood incompatibility is primarily for
subsequent pregnancies after isoimmunization
What happens to the baby if the mother is not given Rhogam after/during her 1st baby?
hemolysis by maternal IgG antibodies attack the baby
= fetal anemia
Fetal anemia
Fetus increases RBC production; the presence of nucleated RBCs (erythroblasts) - erythroblastosis fetalis
RBC destruction can lead to hyperbilirubinemia (Kernicterus)
Untreated anemia causes fetal edema called hydrops fetalis
erythroblastosis fetalis
Fetus increases RBC production; the presence of nucleated RBCs (erythroblasts)
(Kernicterus)
RBC destruction can lead to hyperbilirubinemia
hydrops fetalis
Untreated anemia causes fetal edema
Maternal Screening for Rh incompatibility
1st prenatal visit
- blood type, Rh factor, antibody screening
What happens if the mother is Rh (-) with a negative antibody screening and no other complication arises?
Rhogam given at 28 weeks
If there is an amniocentesis, CVS, abruptio placentae, trauma, or ECV, what needs to be assessed and given?
risk of fetal/maternal blood mixing
- Rhogam
At delivery, the nurse needs to do a repeat antibody screening in Rh (-) women if the baby is Rh (+) within
72 hours
T/F: If a test requires a possibility of an Rh (-) mother to pass blood to a Rh (+) fetus, you should wait until 28 weeks even if the test is before 28 weeks.
False at the test if before 28 weeks
Indirect Coombs Test
detects antibodies against RBCs present unbound in the patient’s serum
Rh immune globulin products: prevent
production of the anti-Rh (D) antibdoies
When do you give the Rhogam in antepartum and PP?
Antepartum = 28 - 30 weeks gestation
PP = WITHIN 72 HOURS of delivery if the fetus is Rh +
given any risk of blood mixing (trauma, abortion)
Do you Rhogam to an alloimmunized pregnant pt?
no as it is already too late and the antibodies against the + fetus are made
What is done if they are sensitized and pregnant?
Anti-D antibody titers
Anti-D antibody titers are evaluated every
2-4 weeks starting 16-18 weeks gestation
If Anti-D antibody titers remain negative then the fetus is
not at risk
If the Anti-D antibody titers are positive, then the fetus is
at risk
Goal if the pregnant woman is sensitized
birth of a mature fetus who has not developed severe hemolysis/anemia in utero
ABO Incompatibility usually involves
type o mother and type A or B fetus
Anti A and Anti B antibides occur
naturally
Once pregnant, maternal anti-A and anti-B antibodies
cross the placenta and cause hemolysis of fetal RBCs
ABO incompatibility is not treated during
antepartum period
How does the ABO incompatibility affect the babies?
mild anemia
hyperbilirubinemia = bili lights
Placenta accreta
Invasion of the trophoblast is beyond the normal boundary (80%)
Placenta increta
Invasion of trophoblast extends into uterine myometrium (15%)
Placenta percreta
Invasion of trophoblast extends into uterine musculature; can adhere to other pelvic organs (5%)
In a placenta accreta, increta, or perceta, what is required?
hysterectomy
watch for profuse hemorrhage
Prolapsed umbilical cord is a
OB emergency
A prolapsed umbilical cord usually occurs
slips under the presenting part
after ROM
- presenting part descends onto the cord, reduces or eliminates blood flow
Prolapsed Umbilical Cord risk factors
Breech position
Polyhydramnios
High station (- stations) not engaged
Preterm Gestation
High Parity
What is the 1st thing you assess when a prolapsed cord is noticed?
fetal heart rate monitoring
What does the FHRM show with a prolapsed umbilical cord?
sustained bradycardia, variable decelerations, or prolonged decelerations
When a prolapsed cord is detected what needs to happen to keep the cord from collapsing?-
Vaginal Exam with gloved fingers push upward lifting the fetal presenting part off of the cord
- call for assistance and notify anesthesiology and NICU
- stop Oxytocin infusion
- O2 10 L/min by Non-Rebreather
- IV 18 g
- Give Terbutaline to decrease contractions
With a prolapsed cord, what can be done to keep the umbilical cord from being compressed?
Vaginal Exam with finger pressure until Cesarean birth
Insert catheter and fill with 500mL warmed, sterile normal saline
Left lateral, knee to chest, knee-chest, or Trendelenburg
With a prolapsed cord, the baby needs to be born within
30 minutes
What is essential for the nurse to do during the chaos of a prolapsed cord?
keep clam and keep the pt and family informed
What is the priority in a prolapsed cord?
prompt delivery
Trauma is the leading cause of
maternal death during pregnancy
due to abdominal injury from MVA
- uterine rupture
- penetrating trauma (GSW)
Following trauma, placental abruption is monitored for up to
24 hours
Unresolved bleeding can lead to
maternal exsanguination in 8-10 minutes
Uterine Rupture is
Tear - wall of the uterus because the uterus cannot withstand the pressure
Uterine Rupture is often associated with
previous uterine surgery, can occur on unscared uterus
- VBAC
Complete Uterine Ruptures
direct communication between uterine and peritoneal cavities
Incomplete Uterine Rupture
tear in the peritoneum lining of the uterus or broad ligament but not the peritoneal cavity
Dehiscence Uterine Rupture
partial separation of an old uterine scar
- Little or no bleeding occurs, often no signs or symptoms
S/S of uterine rupture
FHM - earliest signs - non-reassuring FHR, or absent FHR, and loss of contraction pattern
Constant abdominal pain or change in pain cessation of contractions
Loss of fetal station on abdominal palpation
Referred chest or shoulder pain
Hematuria
Hypovolemic shock
Mgmt of uterine rupture
Emergency C-section - immediate blood products
Neonatal resuscitation should be anticipated
Anaphylactoid Syndrome of Pregnancy/Amniotic Fluid Embolism is when
Amniotic fluid enters the maternal circulation and is carried to the lungs
Amniotic fluid embolism patho
Fetal particulate matter in fluid obstructs pulmonary vessels
Failure of the right ventricle occurs early and leads to hypoxemia
Left ventricular failure follows
S/S of amniotic fluid embolism
Abrupt respiratory distress, depressed cardiac function, and circulatory collapse occurs
DIC is likely
Amniotic fluid embolism is often fatal and survivors may have
neurological defects
Pregnant Substance Abuse can result in
poor pregnancy outcomes and early childhood behavioral and developmental problems
Substance Abuse can happen with
alcohol
cigarette
illicit drugs
When assessing the possibility of substance abuse, the nurse should
Ask directly about substance use with a nonjudgmental attitude
Alcohol is a CNS
DEPRESSANT - most common teratogen
Alcohol can cause what during pregnancy
cause physical and mental birth defects, preterm birth, and miscarriage
- Fetal Alcohol Syndrome Diseases
_____ alcohol during pregnancy; passes swiftly to the fetus through the placenta
ZERO
Smoking/Tobacco Use infants are more likely
preterm, wt 1/2 lb less
3x risk of SIDS
Nicotine reduces
uterine blood flow
Carbon monoxide binds to
hemoglobin, reducing oxygen-carrying capacity of blood
What is a risk in utero of maternal tobacco use?
abruptio placentae
What are the residual effects past the neonatal period?
Deficits in growth, intellectual and emotional development, and behavior
Increased risk for prematurity, bronchitis and pneumonia
Methamphetamines AND Cocaine are a CNS
STIMULANT
Meth from the mother can cause what effects in an OD
Seizures, heart attacks, strokes, and maternal deaths
When the mother has Meth the fetus is at risk for
IUGR, preterm birth, microcephaly, and abruptio placentae
What can happen to the mother when taking cocaine
vasoconstriction, seizures, abruptio placentae, hallucinations, pulmonary edema, cerebral hemorrhage, respiratory failure, and heart problems
What can happen to the fetus when the mother takes cocaine?
IUGR, microcephaly, cerebral infarctions, shorter body length, altered brain development, increased incidence of PROM, meconium staining, and premature birth
Marijuana maternal s/s
- tachycardia, low blood pressure which can result in orthostatic hypotension
Marijuana fetal s/s
crosses to placenta; increases carbon monoxide levels, reducing oxygen to fetus
Marijuana alters the response of the neonates by
- altered response to visual stimuli, increased tremulousness, high-pitched cry
Marijuana fetal long-term effects
- deficits in memory, attention, cognitive function or motor skills
Marijuana can cause what to gestation
shortened and higher incidence of IUGR
Heroin/opioid abuse is linked to
adverse consequences for the mother and fetus
Heroin/opioid abuse fetal risks
fetal physiological dependence and maternal lifestyle associated with heroin use
- NAS
What should be used for Heroin/opioid use when they are in labor?
Methadone
What should be avoided in pregnant Heroin/opioid abuse?
Naloxone
NAS
Neonatal Abstinence Syndrome
- withdrawal in NICU
Perinatal Loss can occur in
Previous pregnancy, early or late pregnancy loss
Concurrent death and survival in multifetal pregnancy
Perinatal palliative or hospice care services
Perinatal Loss Interventions
Allow expression of feelings
Acknowledging the infant (NAME IF HAVE ONE)
Presenting the infant to the parents – hold, See, pictures, and bond
Preparing a memory packet
Respect cultural practices
Assist with other needs – siblings
Provide follow-up care including referrals (counseling, support groups)
Swanson’s Theory of Caring
knowing
being with
doing for
enabiling
maintaining beliefs
Knowing -
understanding the event, avoiding prior assumptions about the meaning of the event, philosophy of personhood, willing to recognize others as a significant being
Being with -
emotionally present, conveying ongoing availability, sharing feelings, one small step beyond knowing
Doing for -
doing for one what they would do for themselves, comforting, anticipatory, protective of the other’s needs, preserving dignity
Enabling
facilitating the passage through life transitions and unfamiliar events, using expert knowledge for the betterment of the other, to facilitate the capacity to grow in the other
Maintaining belief
sustaining faith to get through the event, to face a future with meaning, believing in them and holding them in esteem, maintaining a hope-filled attitude while offering realistic optimism
If the patient has a c-section before 28 weeks, do you need to give the Rhogam before the c-section?
no, but give it within 72 hours after the baby is born
