Care of the Client Experiencing Dysfunctional Childbirth, Endocrine, Metabolic and Cardiac Dysfunctions in Pregnancy, Maternal Hemorrhage, and Perinatal Infection.

Lecture Thirteen: Care of the Client Experiencing Dysfunctional Childbirth, Endocrine, Metabolic and Cardiac Dysfunctions in Pregnancy, Maternal Hemorrhage, and Perinatal Infection.
NURS 2208
T. Dennis RNC, MSN
Objectives

1. Identify stressors related to dysfunctions in the maternity client.
2. Utilize knowledge of pathophysiology of disease processes to care for maternity clients with dysfunctions.
3. Utilize the nursing process to meet the needs of maternity clients with dysfunctions.
4. Assess comfort, physical safety, fluid and electrolyte, nutrition, emotional safety and security, love and belonging needs of maternity clients.
5. Apply principles of teaching /learning in the promotion and restoration  of optimal health in maternity clients.
6. Identify the purposes, actions, side effects of medication utilized in the care of maternity clients with dysfunctions.
7. Incorporate therapeutic nutrition in the care of the maternity client with dysfunctions.

Dysfunctional Childbirth

1. Rh Sensitization
2. ABO Incompatibility
3. Surgery During Pregnancy
4. Trauma
5. The Battered Pregnant Woman
6. Precipitous Birth
7. Dystocia
8. Anxiety and Fear
9. Dysfunctional Uterine Contractions
10. Precipitate Labor and Birth
11. Postterm Pregnancy
12. Fetal Malposition

1. Fetal Malpresentation
2. Developmental Abnormalities
3. Multiple Pregnancy
4. Fetal Distress
5. Intrauterine Fetal Death
6. Placental Problems
7. Cephalopelvic Disproportion
8. Umbilical Cord Problems
9. Amniotic Fluid Related Complications
10. Lacerations
11. Placenta Accreta

Rh Sensitization (pg. 419-423)

1. An antigen-antibody immunologic reaction within the body.
2. Occurs when an event allows Rh positive fetal cells to enter the circulation of an Rh negative woman (Rh positive blood transfusion, amniocentesis, tubal pregnancy).
3. Known antigens are controlled by three pairs of genes: Cc, Dd and Ee.
4. An Rh negative mother whose fetus is Rh positive may develop anti D antibodies in response to the small amount of blood that may cross the placenta even in a normal pregnancy (< 0.5 ml).
5. Exposure causes the development of gamma M immunoglobulin (IgM).
6. IgM antibodies are large and do not cross the placenta.
7. Once a woman is isoimmunized, she is immunized for life.

Rh Sensitization

1. The secondary response is development of immune globulin G (IgG) anti-D antibody.
2. IgG crosses the placenta coating the Rh positive cells and causing hemolysis.
3. The hemolysis creates fetal anemia.
4. The fetus responds by increasing red cell production of nucleated RBCs causing erythroblastosis fetalis.
5. Erythroblastosis fetalis is a hemolytic disease of the newborn characterized by anemia, jaundice, enlargement of the liver and spleen, and generalized edema. Caused by isoimmunization from Rh incompatibility or ABO incompatibility.

Rh Sensitization
Fetal-Neonatal Risks:

1. Infant death due to hemolytic disease secondary to Rh incompatibility.
2. RBC destruction leads to hyperbilirubinemia and anemia which leads to severe fetal edema called hydrops fetalis.
3. Congestive heart failure may occur as well as icterus gravis leading to kernicterus.
4. Rh sensitization is seen less due to the use of Rhogam ( Rh immune globulin.
5. Given at 28 weeks gestation, after amniocentesis or an episode of bleeding and 72 hours post delivery.

Screening for Rh incompatibility and Sensitization

1. First prenatal visit includes information concerning previous pregnancies.
2. Maternal blood type (ABO) Rh factor and antibody screen
3. An antibody screen (indirect Coomb’s test).
4. Fetal assessment includes: percutaneous umbilical cord blood sampling (PUBS), amniocentesis, amniotic fluid analysis, and ultrasound.
5. Fetal acites and subcutaneous edema may be seen on ultrasound.
6. A sinusoidal pattern on fetal monitoring.

Clinical Therapy (pg 421)

1. Goal is a mature fetus who has not developed severe hemolysis in utero.
2. Antepartum management includes early delivery and intrauterine transfusion (fetal distress, fetal hematoma, fetal-maternal hemorrhage, fetal death and chorioamnionitis.
3. Postpartal management: treat the unsensitized woman and isoimmune hemolytic disease in the newborn.
4. RhoGam is given to destroy fetal cells in the maternal circulation before sensitization occurs, blocking antibody production.
5. A Kliehauer-Betke test is performed to estimate the size of a fetomaternal bleed.

Nursing Care Management

1. Nursing assessment to determine client’s knowledge base on blood type.
2. Knowledge Deficit related to lack of understanding of the need for RhIgG and when it should be administered.
3. Ineffective Coping related to depression secondary to development of indications of the need for fetal exchange instruction.
4. Educate the client concerning times RhoGam is needed.
5. Provide emotional support to client and family.
6. Administer RhoGam as ordered.
7. Evaluation includes the client understanding of the need for administration of Rhogam.

Rh Immune Globulin

1. RhoGAM, Gamulin Rh, HyRho-D
2. Action: Suppression of the immune response in non-sensitized women with Rh-negative blood who receive Rh positive blood cells because of  fetomaternal hemorrhage, transfusion, or accident.
3. Indications: Suppress antibody formation in women with Rh-negative blood after birth, miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, amniocentesis, version, or chorionic villi sampling.
4. Dosage and route: Standard dose is 1 vial (300μg) IM gluteal or deltoid :microdose 1 vial (50μg) IM deltoid
5. Adverse Effects: myalgia, lethargy, localized tenderness or stiffness at the injection site.

Nursing Considerations

1. Give standard dose to mother within 72  hours of birth if baby is Rh positive, at 28 weeks gestation as prophylaxis, or after an incident or exposure risk that occurs after 28 weeks gestation (miscarriage, abortion, amniocentesis, after a version).
2. Give microdose for first trimester miscarriage or abortion, ectopic pregnancy, chorionic villi sampling.
3. Verify the client is Rh negative and has not been sensitized (that the Coombs test is negative) and that the baby is Rh positive.
4. Provide explanation to the client about the procedure, including the purpose, possible side effects, and effect on future pregnancies.
5. Have client sign a consent form per hospital/institution policy.
6. Verify correct dosage, confirm lot number, and patient identity prior to injection. Verify with another RN and document.

Question
A woman’s blood type is O negative. Following the birth of her Rh positive infant, she is to receive anti-Rh(D) gamma globulin (RhoGAM). Which of the following nursing actions is correct? Administer the medication:

1. subcutaneously.
2. within 72 hours after birth.
3. only if the indirect Coombs is positive.
4. only if the infant’s blood type is A or B.

ABO Incompatibility (pg. 423-424)

1. Is more common than Rh isoimmunization and causes less severe problems in the newborn.
2. Occurs when the fetal blood is A, B, or AB and the mother is O type blood. (O type clients already have anti-A and Anti-B antibodies which are transferred across the placenta to the fetus).
3. Occurs in 20 to 25% of the population.
4. Due to the maternal antibodies present in her serum and interaction between the antigen sites on the fetal red blood cells.
5. Infants display hyperbilirubinemia.
6. Treated with phototherapy, fewer than 1% of affected fetuses require exchange transfusion after birth.

Nursing Considerations

1. Nursing assessment to determine client’s knowledge base on blood type.
2. Knowledge Deficit related to lack of understanding of the need for administration of phototherapy for infant..
3. Ineffective Coping related to depression secondary to development of indications of the need for phototherapy or fetal exchange instruction.
4. Educate the client concerning possible need for phototherapy for newborn.
5. Provide emotional support to client and family.

Question
A 22 year old client is expecting her second baby in two weeks. Her blood type is O positive. The nurse might expect blood incompatibility problems if the fetus’ blood is:

1. Rh negative.
2. type A positive.
3. type O negative.
4. type O positive.

Surgery During Pregnancy (pg. 425-426)

1. Should be delayed if acceptable but may not be possible.
2. Some evidence of increased first trimester abortion and low birth weight infants.
3. Most common reason is appendicitis followed by cholecystectomy.
4. The pregnant client is at risk for vomiting and aspiration.
5. Urinary catheters prevent injury to the bladder.
6. Fetal heart tones should be monitored before, during and after surgery.
7. Left lateral position is optimal.

Surgery During Pregnancy (pg. 425-426)
Nursing assessment and diagnosis:

1. Altered tissue perfusion (fetal) related to the effects of general anesthesia on fetal oxygenation
2. Anxiety related to lack of knowledge of preoperative and postoperative procedures.
3. Fear related to the possible effect of surgery on fetal outcome.

Nursing Plan and Implementation:

1. Education to review pre and post operative considerations.
2. Monitoring two patients as opposed to one.
3. Monitor vital signs every 4 hrs.
4. Maintain a side-lying position.

Question
A woman in her third trimester of pregnancy is scheduled for an open reduction of her fractured radius and ulna. Her postoperative nursing care will include:

1. maintaining her in a side lying position.
2. using minimal narcotics to reduce teratogenic effects.
3. administering oxygen for 24 hours following surgery.
4. providing a bedpan in order to help her maintain bedrest.

Trauma (pg. 426-428)

1. Accidents and injury are the leading causes of death in women of reproductive age.
2. Domestic abuse may be the etiology of trauma.
3. Early pregnancy fainting and fatigue may increase the chance of injury.
4. Late in pregnancy poor coordination, may fall.
5. Maternal mortality most often occurs from head trauma and hemorrhage.
6. Uterine rupture and abruption results from strong deceleration in automobile accidents.
7. Complications caused by trauma are more common after assault than after MVAs.

Trauma (pg. 426-428)
Clinical Therapy:

1. Stabilize the injury and promote well-being for both mother and fetus.
2. Ensuring airway adequacy, maintaining ventilation and adequate circulatory volume, controlling acute bleeding, and splinting fractures to prevent vascular or tissue injury.
3. Once the mother is stabilized, fetal status is assessed.
4. Monitor for 4 hours if no contractions, bleeding or leaking of amniotic fluid. If any of the above a 24 to 48 hr stay is required.
5. Fetomaternal hemorrhage occurs 4 to 5 times more often in women who have experienced trauma.
6. A Kleihauer-Betke test is used to detect fetal cells.
7. Perimortem birth by c-section is indicated after 4 minutes of CPR.

Trauma (pg. 426-428)
Nursing assessment and diagnosis:

1. Pain related to the effects of the trauma experienced
2. Constipation related to immobility secondary to the effects of the accident.
3. Fear related to the effects of the trauma experienced.

Nursing Plan and Implementation:

1. Education to explain need for monitoring and bedrest.
2. Monitoring two patients as opposed to one.

Question
A woman at 34 weeks gestation is admitted to the Emergency department accompanied by her husband. The husband tells the physician that his wife fell down the porch stairs. The client is having no vaginal bleeding, uterine contractions, or leaking of amniotic fluid. In addition to monitoring the client’s vital signs, the nurse should also:

1. monitor the fetal heart rate and uterine activity for 4 hours.
2. perform a nitrazine test.
3. check her deep tendon reflexes.
4. check for cervical dilatation.

The Battered Pregnant Woman (pg 428)

1. Abuse often begins or increases with pregnancy.
2. Affects one in six women.
3. May result in loss of pregnancy, preterm labor, low birth weight infants, fetal injury and fetal death.
4. Indicators of abuse: chronic psychosomatic symptoms, nonspecific or vague complaints, old scars or bruising around the head, chest, arms, abdomen and genitalia.
5. Decrease in eye contact, silence when the partner is in the room, history of nervousness, insomnia, drug overdose or alcohol problems are also sign of battery.
6. Goals of treatment are to identify the woman at risk, increase her decision making abilities, to decrease the potential for further abuse, and provide a safe environment for mother and child.

Care of the Client with TORCH Infection (pg. 429)

1. Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes simplex virus.
2. Exposure of the pregnant client during the first 12 weeks of pregnancy may cause developmental anomalies.
3. Toxoplasmosis: protozoa, miscarriage likely, Use good handwashing, do not eat raw meat or exposure to cat litter.
4. Rubella: virus (three day measles), congenital anomalies, vaccination at least three months prior to pregnancy.
5. Cytomegalovirus: virus, fetal death or severe generalized diseases, respiratory or sexually transmitted maternally, no immunity develops and may recur in subsequent pregnancies.
6. Herpes Simplex: virus, skin lesions, mental retardation, and microcephaly.

Precipitous Birth (pg. 576-579)

1. DO not leave the client alone.
2. Auxiliary personnel should call the CNM or physician, bring equipment needed, open packs, and set up the warmer.
3. Provide a sterile field.
4. Apply gentle pressure to the fetal head and supports the perineum with the other hand.
5. After delivery of the head, check for cord.
6. Suction mouth then nose.
7. Very slippery. Clamp cord. Cut cord.
8. Place infant on mother’s abdomen.
9. Obtain blood for cord gases.
10. Observe for signs of placental separation.
11. Documentation.

Dystocia (pg. 606-634)

1. Difficult labor due to mechanical factors produced by the fetus or maternal pelvis, or due to inadequate uterine or other muscular activity. 
2. Delivery requires the harmonious functioning of four components: psychosocial factors, contractile forces, fetus, and maternal pelvis or birth passage.

Dystocia (pg. 606-634)
Risk Due to Anxiety and Fear:

1. Anxiety and fear may exacerbate pain, producing more pain and producing more anxiety and fear. ↑catecholamines = ↓myometrial function = ineffectual labor.
2. Anxiety may be displayed as quiet, uninterested, denial like characteristics. Some families have used all emotional reserve in the pregnancy so they may be more vocal.
3. The goal of clinical therapy is to provide therapies that will decrease the client’s anxiety.

Risk Due to Anxiety and Fear
Nursing assessment and diagnosis:

1. Sensory/Perceptual  Alteration related to reactivation of traumatic memories.
2. Anxiety related to lack of knowledge of preoperative and postoperative procedures.
3. Fear related to the possible effect of surgery on fetal outcome.
4. Ineffective Individual Coping related to increased anxiety and stress associated with labor and birth process.
5. Ineffective Family Coping related to anxiety associated with labor and birth.

Nursing Plan and Implementation:

1. Supporting the laboring client and her family.
2. Education, comfort measures, remain calm, outcomes positive..

Dystocia Related to Dysfunctional Uterine Contractions (pg. 610-612)

1. The most common type of dystocia is related to dysfunctional (or uncoordinated) uterine contractions that result in a prolongation of labor.
2. Dysfunctional contractions are irregular, of low amplitude, and slow progress which causes arrest of cervical dilatation. (Hypotonic contractrions)
3. Cause unknown. May be familial.
4. Protracted labor: ctx’s irregular with low amplitude, and cervical dilatation is< 1cm/hr.
5. Arrest of Progress: No change of cervical dilatation for 2 hours.
6. The indication for Pitocin is evaluated.

Dystocia Related to Dysfunctional Uterine Contractions (pg. 610-612)

1. Hypotonic contractions and soft tissue dystocia add to poor labor progress.
2. Cephalopelvic disproportion (CPD): A condition in which the fetal head is of such a shape or size, or in such a position, that it cannot pass through the maternal pelvis.
3. If CPD exists, oxytocin (Pitocin) should not be used.
4. If CPD is ruled out, Amniotomy may be performed and oxytocin augmentation is begun.
5. Amniotomy : artificial rupture of membranes requires the temperature to be monitored more frequently (monitor every 2 hours).

Oxytocin
Oxytocin:

1. hormone normally produced by the posterior pituitary, responsible for stimulation of uterine contractions and the release of milk into the lactiferous ducts.
2. Infused at a prescribed individualized dosage rate, and this rate is increased, decreased, or maintained at fixed intervals based on client vital signs, uterine response, and FHR.
3. Objective is to establish an adequate contraction pattern that promotes labor progress, generally represented by contractions every 2 to 3 minutes that last 50 to 60 seconds with moderate intensification.

Oxytocin
Recommendations:

1. Oxytocin infusion is mixed 20 units in 1000cc D5LR or 9 units in 150 cc D5W.
2. Infusion rate is 1mu/min per infusion pump (originally dripped by microdrip, nasal spray, buccal tablets).
3. Dose may be increased to 2 mu/min then by 2mu/min every 15 minutes as needed to produce adequate labor pattern.
4. Electronic fetal monitoring (EFM) is used to monitor the fetal heart rate and contraction pattern to provide ongoing information concerning the fetal response to the augmentation.
5. Scalp pH may be done to determine fetal well being.
6. Contractions are evaluated as hypotonic, adequate, hyperstimulated or tetanic.

Dystocia Related to Dysfunctional Uterine Contractions (pg. 610-612)
Nursing assessment and diagnosis:

1. Assess maternal vital signs, contractions, cervical dilatation, fetal descent, and fetal heart rate characteristics.
2. Assess for caput
3. Assess stress and coping mechanisms.
4. Assess for loss of control from client and family.
5. Pain related to difficulty in relaxing secondary to uterine contractions.
6. Anxiety related to lack of knowledge of preoperative and postoperative procedures.
7. Fear related to the possible effect of surgery on fetal outcome.
8. Ineffective Individual Coping related to increased anxiety and stress associated with labor and birth process.

Dystocia Related to Dysfunctional Uterine Contractions (pg. 610-612)
Nursing Plan and Implementation:

1. Supporting the laboring client and her family.
2. Suggest change of position, rocking in a chair, sitting up, walking.
3. Provide warm shower, whirlpool, quiet environment, music, back-rub, therapeutic touch and visualization.
4. Comfort measures including: mouth care, linen changes, effleurage and relaxation exercises.
5. One to one nursing is optimal.
6. Address the client’s questions with clear, accurate information to keep her and family up to date on treatment and progress.
7. Address hyperstimulation: Oxygen, stop pitocin, left side, fluid bolus, call the physician.

Precipitate Labor and Birth (pg 612-614)

1. Extremely rapid labor and birth within 3 hours.
2. Cervical dilatation is 5 cms in the primigravida or more per hour or 10 cms in an hour for the multipara.
3. Labor may be associated with cocaine abuse, abruptio placenta, meconium stained fluid and low apgar scores in the newborn.
4. Extensive lacerations of the cervix, vagina, and perineum may occur.
5. Intracranial trauma may occur due to rapid descent and resistance of the birth canal.
6. Terbutaline or magnesium sulfate may be used to slow the labor process.

Postterm Pregnancy (pg. 614-615)

1. Pregnancy that extends more than 294 days or 42 completed weeks past the first day of the last menstrual period.
2. Postterm pregnancy occurs more frequently in primigravidas and clients over 35.
3. Cause unknown,
4. LGA or macrosomic babies resulting in induction, forcep or vacuum assisted vaginal birth or c-section.
5. Placental changes cause decreased uteroplacental circulation, decreased amniotic fluid which increases risk of umbilical cord compression.
6. Babies SGA due to decreased nutrition.
7. Meconium staining leading to distress

Postterm Pregnancy (pg. 614-615)
Clinical Therapy:

1. After 40th week, begin NST, BPP, and doppler flow studies.
2. Tests may be done 2 to 3 times a week.
3. If problems noted, induction is scheduled.
4. During labor –ongoing assessment of FHR by electronic fetal monitoring (EFM).
5. Ongoing assessment of labor progress to determine clues associated with macrosomic infant, meconium staining, and or resuscitation needs.
6. Provide education and support to the client.

Fetal Malposition (pg. 615-617)
Persistent Occiput-Posterior (OP) :

1. Occurs in 25% of pregnancies at term.
2. May cease labor progress or be delivered in a posterior position.
3. Client experiences intense back pain throughout labor unless the baby rotates.
4. May result in a 3rd or 4th degree laceration or extension of the midline episiotomy or fractured coccyx.

Fetal Malpresentation (pg. 617-624)

1. Three vertex attitudes are classified as abnormal presentations: 1) Military (scinciput), 2) brow and 3) face.
2. Brow: fetal neck and cerebral injuries can occur.
3. Face: risks of CPD and prolonged labor are increased. Occurs most frequently in multiparas, preterm birth and anencephaly. Infant may have facial edema, bruising and petechiae.
4. Breech: Breech presentation is the most common malpresentation. Frank, Complete and Footling.
5. Head trauma more likely in breech delivery, entrapment may occur, cord compression risk.
6. External version is attempted at 37 to 38 weeks ( carries risk of placental problems and preterm labor).

Version (pg 652)

1. External and Internal
2. “turning of the fetus”
3. Usually done at 37 weeks
4. Criteria: single fetus, breech is not engaged, adequate amniotic fluid, a reactive NST, and 37 or more weeks gestation.
5. Procedure: Explain that the procedure is painful, may result in cesarean section, requires a fetal monitor tracing, frequent vital signs and may need terbutaline to stop labor.
6. Aftercare includes: Monitoring for contractions, kick count of fetus and monitoring for fetal movement.

Developmental Abnormalities (pg624-625)

1. Fetal macrosomia is defined as weight of more than 4000gms (8lbs, 14 oz) at birth.
2. A client who is obese is 3 to 4 times more likely to have a macrosomic infant.
3. Increased risk for prolonged labor, uterine rupture, CPD, fetal cerebral trauma, shoulder dystocia, brachial plexus injury and fractured clavicles.
4. Shoulder dystocia is an obstetrical emergency. McRoberts maneuver is performed  ( thighs flexed up to widen perineum and supra-pubic pressure is applied.
5. Support and educate client and family.

Multiple Pregnancy (pg. 626-630)

1. Twinning occurs in 2% of all pregnancies in the United States.
2. The “vanishing” twin syndrome in first trimester.
3. Second trimester loss is associated with congenital anomalies, growth restriction, and chromosomal abnormalities.
4. Twin to twin transfusion may occur with blood being drained from one twin to the other.
5. Cervical incompetence is increased, preterm labor is increased.
6. Perinatal mortality decreases at 38 weeks, optimal delivery time.
7. Clients with multiple gestations are more likely to develop spontaneous abortions, Hypertension, maternal anemia, hydramnios, and complications during labor and delivery.
8. May be delivered vaginally or by cesarean section.
9. During labor both twins are monitored.

Ectopic Pregnancy



























Fetal Distress (pg. 630-631)

1. Evidence that the fetus is in jeopardy (oxygen supply is insufficient to meet the physiologic demands of the fetus), such as a change in the fetal heart rate pattern or fetal activity.
2. The most common initial signs of fetal distress are meconium stained fluid (in a vertex presentation) and changes in the fetal heart rate.
3. For FHR changes, treatment centers on relieving the hypoxia (position change, administering O2 at 10 to 12 l/min, dc the pitocin, ↑fluid, and call the physician.

Intrauterine Fetal Death (pg. 632-634)

1. Intrauterine fetal demise (IUFD) accounts for ½ perinatal mortality after 20 weeks gestation.
2. Cause may be unknown or related to PIH, abruptio placentae, placenta previa, diabetes, infection, congenital anomalies, and isoimmune disease.
3. Prolonged retention of the demise may lead to development of disseminated intravascular coagulation (DIC).
4. Determined by ultrasound with absence of heart action (may also see overlapping of cranial bones “Spaldings sign”).
5. Cessation of movement is frequently first indication of fetal death. Delivery is accomplished by induction or surgery depending on gestational age.

Placental Problems (pg. 634-642)

1. Abruptio placentae: premature separation of a normally implanted placenta from the uterine wall. May be: marginal, central or complete. Usually accompanied by complaints of uterine pain and vaginal bleeding . Client complains of mod to severe abdominal pain. Abdomen may be rigid on palpation.
2. Placenta previa: the placenta is improperly implanted in the lower uterine segment. Usually diagnosed by painless bright red bleeding.
3. Other placental problems are classified as developmental or degenerative ( velamentous insertion of the umbilical cord versus calcifications and infarcts.

Abruptio Placenta





















Placenta Previa



















Umbilical Cord Problems (pg.643-645)

1. Prolapsed cord: umbilical cord that becomes trapped in the vagina before the fetus is born.
2. Pressure is placed on the umbilical cord as it is trapped between the presenting part and the maternal pelvis.
3. Prevention is the optimal medical approach.
4. Knee chest position is recommended as well as delivery by cesarean section.
5. FHR status must be assessed immediately following rupture of membranes.
6. On SVE, if cord is found the nurse gently places pressure on the fetal head to relieve pressure on the cord until delivery occurs.

Amniotic Fluid Related Complications (pg. 645-646)
Amniotic Fluid Embolism: occurs when a bolus of amniotic fluid enters the maternal circulation and then the maternal lungs.

1. Cause is unknown (possible immune response similar to anaphylactic shock).

Hydramnios (Polyhydramnios): occurs when there is over 2000 mL of amniotic fluid.

1. Cause unknown but associated with major congenital anomalies.

Oligohydramnios: less than normal amount of amniotic fluid (500 ml is considered normal).

1. Cause unknown but associated with postmaturity, aaaiugr secondary to placental insufficiency, and fetal renal anomalies.

Cephalopelvic Disproportion (pg. 647-648)

1. Cephalopelvic Disproportion occurs when there is a narrowed diameter in the maternal pelvis.
2.  The narrowed diameter is called a contracture, and it may occur in the pelvic inlet, midpelvis, or outlet.
3.  If pelvic measurement are borderline, a trial of labor may be attempted.
4. Failure of cervical dilatation or fetal descent would then necessitate a cesarean birth.

Lacerations (pg. 648-649)
Lacerations of the cervix or vagina may be indicated by bright red bleeding in the presence of a well contracted uterus. Vaginal and perineal lacerations are categorized in terms of degree:

1. 1) First degree: limited to fourchet, perineal skin, & vaginal mucous membrane.
2. 2) Second degree: involves the perineal skin, vaginal mucous membrane, underlying fascia, and muscles of the perineal body; may extend upward on one or both sides of the vagina.
3. 3) Third degree: extends through the perineal skin, vaginal mucous membranes, and perineal body and involves the anal sphincter: it may extend up the anterior wall of the rectum.
4. 4) Fourth degree: Extends through the rectal mucosa to the lumen of the mucosa.

Placenta Accreta (pg. 649)

1. The chorionic villi attach directly to the myometrium of the uterus.
2. Accreta, increta (myometrium invaded) and percreta (myometrium penetrated).
3. Occurrence is one in 2500 births.
4. Primary complication is maternal hemorrhage and failure of the placenta to separate after birth.
5. Hysterectomy may be necessary treatment depending on involvement.

Pregnancy Induced Hypertension (pg. 405-419)
Hypertension is the most common medical disorder in pregnancy.

1. Classifications: Preeclampsia-eclampsia, chronic hypertension, chronic hypertension with superimposed preeclampsia, and late or transient hypertension.
2. Preeclampsia and eclampsia are two categories of pregnancy induced hypertension (PIH).
3. Preeclampsia: progressive disease process unless there is intervention to control it.
4. Eclampsia: “convulsion”
5. Cause remains unknown.

Preeclampsia- eclampsia (pg. 405-419)

1. A multisytemic disorder characterized by reduced perfusion to maternal organs.
2. Characterized by the development of hypertension, proteinuria, and edema.
3. Hypertension alone may be present in early disease process and is the basis for diagnosis.
4. Definition of preeclampsia is an increase in systolic pressure of 30mm Hg or an increase of diastolic pressure of 15mm Hg over baseline.
5. In the absence of baseline values, 140/90 has been accepted as hypertension.
6. HELLP Syndrome (hemolysis, elevated liver enzymes, low platelet count) is associated with severe preeclampsia.

Preeclampsia – Eclampsia (pg. 405-419)

1. May impact most organ systems.
2. CNS changes are reflected by hyperreflexia, headache, blurred vision, and seizure resulting from cerebral edema.
3. Intracerebral hemorrhage is the most common cause of death, retinal detachment may occur but has spontaneous reattachment with reduction in blood pressure and diuresis. Pulmonary edema may occur as well as abruptio placenta and DIC.
4. Infants may be SGA because of intrauterine growth retardation or preterm necessitated by delivery.
5. Other signs: edema, nausea and vomiting, epigatric pain, irritability and emotional tension.
6. Eclampsia: characterized by convulsion or coma. May occur prior to labor or 48 hrs post partum.

Preeclampsia – Eclampsia (pg. 405-419)

1. Only known cure for PIH is birth of the infant.
2. Low dose aspirin is experimental.
3. Monitor blood pressure, weight gain, urine protein, platelet count, fetal growth, and vaginal bleeding.
4. Bedrest in left lateral recumbent position,diet balanced and high in protein, sodium intake moderate,  evaluate fetal status (kick count, NST, BPP), BP 4 x a day, weight qd, urine dipstick qd, platelet count q 2 days, liver panel 2 x a week. Monitor reflexes with vs or every hour when MgSO4 therapy.
5. Anticonvulsants: MgSO4
6. Corticosteroids: Betamethasone
7. Antihypertensive: Apresoline (hydralazine Hydrochloride)
8. Fluid and electrolyte replacement: KVO
9. Postpartum management includes MgSO4.

Diabetes Mellitis (pg. 356 – 366)

1. The key point in care of the pregnant client with diabetes is scrupulous maternal plasma glucose control.
2. Control is best achieved by home glucose monitoring, multiple daily insulin injections, and a careful diet.
3. To reduce the incident of congenital anomalies and other problems in the neonate, the woman should have a normal blood glucose throughout the pregnancy.
4. Diabetic clients need to be assessed more frequently than their low risk counterparts.
5. The client needs to be educated and involved in their plan of care from the very beginning of the pregnancy. Client needs to be educated that her baby may be Larger than other infants of the same gestational age..

Anemia in Pregnancy (pg. 366-370)

1. Anemia indicates inadequate levels of hemoglobin in the blood.
2. The common anemias of pregnancy are due either to insufficient hemoglobin production related to nutritional deficiency in iron or folic acid during pregnancy or to hemoglobin destruction in inherited disorders (sickle cell anemia and thalassemia).
3. Maternal risks are susceptibility to infection, fatigue, ↑ chance of PIH and hemorrhage, and poor healing of episiotomy or incision.
4. Neonatal risks include: LBW, prematurity, stillbirth and neonatal death as well as decreased iron stores.
5. Goal is prevention through diet and supplements, parenteral iron may be needed. (iron, folate)

AIDS in Pregnancy (pg. 370-376)

1. HIV infection, which is transmitted through blood and body fluids may also be transmitted transplacentally to the fetus.
2. Signs and symptoms include: fatigue, anemia, malaise, progressive weight loss, lymphadenopathy, diarrhea, fever, neurologic dysfunction, or Kaposi’s sarcoma.
3. Weekly Nonstress testing should begin at 32 weeks.
4. AZT treatments are implemented during labor and given to the neonate post delivery.
5. Nurses should employ blood and body fluid precautions (standard precautions) in caring for all women to avoid potential spread of infection.
6. CONFIDENTIALITY is key and education (no breastfeeding).
7. Support the stage of disease process.

Heart Disease in Pregnancy (pg. 376-379)

1. Cardiac disease during pregnancy requires careful assessment, limitation of activity, and knowing and reporting signs of impending cardiac decompensation by both the client and nurse.

1. Signs and symptoms of Decompensation: Frequent cough (wet), dyspnea (progressive), Edema (progressive to include face, eyes and extremities), Heart murmurs, palpitations and rales (progressiveness is the key to these symptoms because most occur in a mild degree in all pregnancies.

Bleeding Disorders in Pregnancy (pg 386)

1. Spontaneous abortion
2. Ectopic Pregnancy
3. Molar pregnancy

Perinatal Infection (pg 65)

1. Vulvovaginal Candidiasis: Yeast infection, thick curdy vaginal discharge, severe itching-male may experience rash. Treatment is 150 mg of Fluconazole or intravaginal insertion of miconazole or nystatin.
2. Bacterial Vaginosis: bacterial infection of the vagina (formally Gardinella vaginalis) characterized by foul-smelling, grayish vaginal discharge that has a fishy odor.Flagyl is contraindicated in pregnancy and Clindamycin is used instead.
3. Trichomoniasis: parasitic protozoan that causes inflammation of the vagina, characterized by itching, burning vulvar tissue and yellow-green, frothy, odorous discharge. Treatment is Flagyl.

Perinatal Infection (pg 65, 429-434)

1. Gonorrhea: infection caused by Neisseria gonorrhoeae. Majority of women asymptomatic but most common symptom is purulent, greenish yellow discharge, dysuria, and urinary frequency. Treatment for pregnant women is a cephalosporin and erythromycin.
2. Herpes Genitalis: Herpes simplex type 2 causes most cases of recurrent genital herpes. Primary episode is characterized by the development of single or multiple blister-like vesicles which usually occur in the genital area and affect the vaginal walls, cervix, urethra, and anus. Inflammation and pain secondary to the lesion may cause difficult urination and urinary retention. Treatment with Acyclovir is to prevent pain and secondary infection. Educate patient  that “active herpes” may be transmitted to the baby during vaginal birth.

Perinatal Infection (pg 65, 429-434)

1. Syphilis: chronic infection caused by a spirochete. Can be acquired congenitally through transplacental inoculation and can result form maternal exposure to infected exudate during sexual contact with open wounds or infected blood. Divided into early (chancre appears) and late stages (skin eruptions). Treatment is Penicillin to treat mother and fetus.

Postpartal Hemorrhage (pg. 981-988)
Early postpartal hemmorhage occurs in the first 24 hours post delivery.

1. Uterine atony (relaxation of the uterus) primary cause.
2. Other causes: lacerations, retained placental fragments, vulvar, vaginal, and pelvic hematomas, uterine rupture.
3. Prevented by good prenatal care, early recognition and management.
4. Oxytocin may be ordered to stimulate uterus to control bleeding.
5. Blood transfusion, hysterectomy may be needed.

Late postpartal hemmorrhage occurs from 24 hrs to 6 weeks postpartum.

1. Most oftendue to subinvolution which is due to retained placental fragments.

Questions?