Care of the Client Experiencing Reproductive Dysfunctions

Lecture Sixteen: Care of the Client Experiencing Reproductive Dysfunctions
NURS 2208
Fall 2002
T. Dennis RNC, MSN
Reproductive Dysfunctions

1. Discuss the female menstrual and reproductive cycles.
2. Identify common terms associated with reproductive dysfunctions.
3. Discuss the clinical manifestations and therapeutic management of reproductive dysfunctions.
4. Identify data to be included in the assessment of a client with reproductive disorders.
5. Formulate appropriate nursing diagnoses.
6. Select appropriate nursing interventions for a woman with reproductive dysfunction.

Education

1. Nurses should provide girls and women with clear information about menstrual issues, such as use of pads and tampons (including warnings regarding deodorant and absorbency); vaginal spray and douching practices; self-care comfort measures during menstruation, such as maintaining good nutrition, exercising, and applying heat and massage.

Menstruation (pg.40)

1. Menarche: Beginning of menstrual and reproductive function in the female. Average age 12 years.
2. Menstrual cycle: cyclic buildup of the uterine lining, ovulation, and sloughing of the lining occurring approximately every 28 days in non-pregnant females.
3. Menorrhagia: Excessive or profuse menstrual flow.
4. Hygiene: Tampons (change frequently regardless of blood flow), pads (change frequently), vaginal sprays (unnecessary and may cause irritation) and douching (sometimes used to treat vaginal infections but contraindicated for hygiene purposes, may contribute to endometriosis).

Amenorrhea (pg. 42)

1. Suppression or absence of menstruation.
2. Primary : 1) occurs when menstruation has not been established by age 18.        2) may be caused by congenital anomalies, or absence or imbalance of hormones.
3. Secondary: 1) occurs when an established menses of 3 months ceases. 2) common causes pregnancy, lactation, hormonal imbalances, poor nutrition, stressful life events, etc.
4. Treatment is dictated by causative factors. Once the underlying factors have been addressed, menses returns to the normal pattern.

Dysmenorrhea

1. Usually begins at or a day before, the onset of menses and disappears by the end.
2. Treatment: Hormone therapy (eg., oral contraceptives), nonsteroidal anti-inflammatory drugs, or prostaglandin inhibitors (ibuprofen, aspirin, naproxen) can alleviate dysmenorrhea.
3. Primary: cramps without underlying disease process.
4. Secondary: associated with pathology of the reproductive tract and usually appears after menstruation has been established. Includes: endometriosis, pelvic inflammatory disease (PID),
5. Self-care measures include: improving nutrition, exercising, applying heat, and getting extra rest. Avoid salt intake during menstruation, use a heating pad on the abdomen, daily exercise such as walking.

Premenstrual Syndrome (PMS) (pg. 43)

1. Occurs most often in women over thirty.
2. Symptoms include: irritability, depression, migraines, vertigo, rhinitis, nausea, vomiting, abdominal bloating, urinary retention, acne, weight gain, and mammary swelling and tenderness.
3. Symptoms occur 2 to 3 days before the onset of menstruation and subside as menstruation starts, with or without treatment.
4. Medical management usually includes progesterone agonists and prostaglandin inhibitors.
5. Self-care measures include: improving nutrition (taking vitamin B complex  (especially B6) and E supplements), and avoiding methylxanthines, found in chocolate and caffeine, undertaking a program of aerobic exercise, and participating in self-care support groups.

Menopause (pg. 58-60)

1. The time when menses cease.
2. Current median age is 51.3 years but may occur between ages 45 to 52.
3. Perimenopause: a normal life transition that begins with the first signs of change in the menstrual cycles and ends 6 to 12 months after menopause.
4. Perimenopause is marked by irregular menstrual cycles and hot flashes, shorter and lighter menses, occasional missed periods, abnormal FSH levels, increased vaginal dryness, and night sweats.
5. Menopause is the single day that marks the last naturally occurring menstrual period. The date is determined in retrospect one year from the last period. So contraception must be used for that year.

Menopause (pg. 58-60)
Psychological aspects:

1. Menopause in the past has had a negative connotation.
2. New research and treatments have diminished some negative aspects.

Physical aspects:

1. Age of onset may be influenced by overall health, nutritional, cultural, lifestyle and genetic factors.
2. Onset occurs when estrogen levels become so low menstruation stops.
3. Generally ovulation stops 1 to 2 years before menopause.
4. 2 to 4 years prior to menopause changes in cycles may occur.
5. Uterine endometrium, myometrium, cervical glands, fallopian tubes and ovaries atrophy.
6. A vasomotor disturbance known as hot flashes occurs.

Menopause (pg. 58-60)

1. Long range physical changes include Osteoporosis.
2. Osteoporosis is a decrease in bony skeletal mass.
3. Associated with decreased estrogen levels causing imbalances in bone formation and resorption.
4. Weight gain
5. Increased risks for coronary artery disease, hypertension, and strokes.

Menopause (pg. 58-60)
Medical Therapy may include Hormone replacement therapy (HRT): administration of hormones, usually estrogen and progestin, to alleviate the symptoms of menopause.
Benefits:

1. Stops hot flashes and night sweats
2. ↓ incidence of coronary artery disease
3. Prevention and treatment of bone loss
4. Improved bladder and vaginal tone
5. May improve memory

Risks:

1. ↑ risk of gallbladder disease, venous thrombosis, endometrial cancer, breast cancer and systemic Lupus

Dosage:

1. Estrogen  is given the first 25 days of the month then progestin is added duacring the last twelve days.

Menopause (pg. 58-60)
Prevention and treatment of osteoporosis:

1. Prevention is the primary goal of care.
2. Calcium intake of 1200 to 1500 mg per day for clients > 50 years of age.
3. Calcium supplements are most efficient when taken with a meal and when single doses do not exceed 500mg.
4. Participation in regular exercise program.
5. Fosamax (alendronate) inhibits bone resorption and increases bone mass. Recommended for women who cannot take estrogen. Must be taken on an empty stomach with water at least 30 minutes before any other fluid, food or medicine.

Menopause (pg. 58-60)
Alternative and Complementary Therapies:

1. Diet rich in calcium and vitamins, E, D, and B complex.
2. Phytoestrogens include carrots, yams and soy products.
3. Avoid caffeine, alcohol and spicy foods.
4. Begin weight bearing exercise: walking, jogging, running.
5. Practice relaxation techniques
6. Herbal remedies may include ginseng to relieve symptoms of hot flashes, headaches and fatigue.
7. Keeping a cool environment and drinking cool fluids may alleviate hot flashes.
8. Kegel exercises are important in maintaining vaginal and bladder tone.
9. Vaginal lubricants may alleviate vaginal dryness (decreased libido may occur).

Endometriosis (pg. 63)

1. Condition characterized by the presence of endometrial tissue outside the uterine cavity.
2. Can be found in the vagina, lungs, cervix, central nervous system and GI tract.
3. Most common location is the pelvis.
4. Tissue responds to the hormonal changes of the menstrual cycle and bleeds in a cyclic fashion.
5. Results in inflammation, scarring of the peritoneum, and formation of adhesions.
6. Most common symptom of endometriosis is pelvic pain.

Endometriosis (pg. 63)
Treatment:

1. Medical, surgical intervention or both.
2. Laser vaporization under laparoscopic examination.
3. Hysterectomy with bilateral salpingo-oophorectomy.
4. Mild disease: NSAIDS and analgesics.
5. Other medications include: oral contraceptives, progestins, antiprogestins, and gonadotrophin-releasing hormones (GnRH).
6. Danazol is an antiprogesterone treatment  that is frequently used: suppresses GnRH which suppresses ovulation and causes amenorrhea. Side effects include: hirsutism, acne, weight gain and vaginal bleeding.

Danazol

1. Danacrine: 400 mg po bid
2. Therapeutic classification: Hormones
3. Pregnancy category: X
4. Indication: Treatment of moderate endometriosis that is unresponsive to conventional therapy.
5. Adverse reactions: amenorrhea, weight gain, voice changes, decreased breast size.
6. Caution: Pregnancy should be avoided while on this medication.

Endometriosis (pg. 63)
Nursing Assessment:

1. Thorough history
2. Understanding of condition

Diagnosis:

1. Pain related to peritoneal irritation secondary to endometriosis
2. Ineffective Individual Coping related to depression secondary to infertility.

Nursing Plan:

1. Explain condition, symptoms, treatment alternatives, and prognosis.
2. Review medication knowledge.
3. Review need to make choices considering not postponing pregnancy.
4. Support the client by being nonjudgmental.

Toxic Shock Syndrome (pg. 64)

1. Associated with the use of super-absorbent  tampons.
2. Causative organism is staphylococcus aureus.
3. Common signs: fever, desquamation of skin (especially the palms of hands and soles of feet), rash, hypotension, dizziness, vomiting, diarrhea, and disorders of the central nervous system.
4. Treatment includes: hospitalization with supportive therapy including intravenous therapy to maintain blood pressure. Severe cases may require renal dialysis, administration of vasopressors, and intubation.
5. Education: Change tampons every 3 to 6 hours and avoid use of super-absorbent tampons. Alternate tampons and pads and use only pads overnight.

Pelvic Inflammatory Disease (PID) (pg. 72)

1. An infection of the fallopian tubes (salpingitis) that may or may not be accompanied by a pelvic abscess;  may cause infertility secondary to tubal damage.
2. Disease is more common in women who have had multiple sexual partners, a history of PID, early onset of sexual activity, a recent gynecologic procedure, or an intrauterine device.
3. Causative organisms include: Chlamydia trachomatis and neisseria gonorrhoeae.
4. Symptoms include: bilateral sharp cramping pain in the lower quadrants, fever, chills, purulent vaginal discharge, irregular bleeding, malaise, nausea, and vomiting.
5. Possible to be asymptomatic and have normal lab values.

Pelvic Inflammatory Disease (PID) (pg. 72)
Clinical therapy:

1. Diagnosis consists of a clinical examination to define symptoms, blood tests, and culture for Chlamydia and GC.
2. Direst abdominal tenderness with palpation, adnexal tenderness, and cervical and uterine tenderness with movement.
3. Laparoscopy may be used to obtain cultures and confirm diagnosis.
4. Hospitalization with intravenous administration of antibiotics.
5. Sexual partner should also be treated.

Pelvic Inflammatory Disease (PID) (pg. 72)
Nursing Assessment:

1. Thorough history (IUD)
2. Alert to risk factors for condition
3. Symptoms of lower abdominal pain, malaise, foul smelling discharge

Diagnosis:

1. Pain related to peritoneal irritation
2. Knowledge deficit related to lack of information about possible infertility

Nursing Plan:

1. Explain condition, symptoms, treatment alternatives, and prognosis.
2. Review medication knowledge.
3. Discuss signs and symptoms of PID and stresses the importance of early detection.
4. Support the client by being nonjudgmental.

Abnormal Uterine Bleeding (pg.74)

1. Dysfunctional uterine bleeding (DUB): characterized by anovulatory cycles with abnormal uterine bleeding that does not have an identifiable cause.
2. Oligomenorrhea: scanty or infrequent menstrual flow
3. Polymenorrhea: occurring with abnormal frequency
4. Menorrhagia: excessive bleeding
5. Metrorrhagia: spotting or breakthrough bleeding
6. Menometrorrhagia: irregular and excessive menstrual flow
7. Intermenstrual bleeding: bleeding between menses

Abnormal Uterine Bleeding (pg.74)

1. Diagnosis is made by excluding organic causes
2. Lab tests: Pap smear, thyroid function studies, pregnancy test and possible endometrial biopsy.
3. Goals of treatment: control bleeding, prevent or treat anemia, prevent endometrial hyperplasia or cancer, and restore quality of life.
4. Pharmacologic treatment for women desiring pregnancy includes clomiphene citrate or gonadotrophins to induce ovulation.
5. Reproductive tract diseases that cause bleeding problems include: Abnormal pregnancy (threatened, missed or incomplete abortion, ectopic pregnancy), 2) Endometrial, cervical , or ovarian cancer, 3) Uterine lesions (fibroids, polyps, adenomyosis), 4) Cervical lesions (polyps, cervicitis, herpes, or chlamydia.

Ovarian Masses (pg. 74)

1. Between 70 to 80% of ovarian masses are benign.
2. No relationship exists between ovarian masses and ovarian cancer.
3. Symptoms: sensation of fullness or cramping in the lower abdomen, dyspareunia (painful sexual intercourse), irregular bleeding, or delayed menstruation. May be asymptomatic and mass noted on routine pelvic exam.
4. Diagnosis: made on the basis of a palpable mass with or without tenderness and other related symptoms.
5. Clinical management: observation for a month or two (most cysts will resolve and are harmless), oral contraceptives may be prescribed to suppress ovarian function, A repeat pelvic exam is done to determine effectiveness of treatment.
6. Surgery is not always necessary.

Uterine Masses (pg. 75)

1. Fibroid tumors (leiomyomas) are among the most common benign disease entities affecting women.
2. Develop when smooth muscle cells  are present in whorls and arise from uterine muscle and connective tissue.
3. Size varies from 1 to 2 cms to size of a ten week fetus.
4. Client is frequently asymptomatic.
5. Symptoms include: lower abdominal pain, fullness or pressure, menorrhagia, metrorrhagia, or increased dysmenorrhea. May be palpated on pelvic exam.
6. Ultrasound can assist and confirm diagnosis.
7. Initial treatment: increase the frequency of pelvic exams to every 3 to 6 months.
8. Treatment if mass is increasing in size or symptoms: surgery (myomectomy, D&C, hysterectomy). Majority of these masses require no treatment and will shrink after menopause.

Endometrial Cancer (pg. 75)

1. Most commonly a disease of the postmenopausal client.
2. Hallmark sign: vaginal bleeding in postmenopausal women not treated with hormone replacement therapy.
3. Diagnosis: made by endometrial biopsy or post-hysterectomy pathologic examination of the uterus.
4. Treatment: Total Abdominal Hysterectomy (TAH) and bilateral salpingo-oophorectomy. Radiation therapy may be indicated, depending on the staging of the cancer.
5. TAH or TVH: Discharge teaching should include 1) no menstruation will occur, 2) Intercourse should be avoided for 4 to 6 weeks, 3) may be temporary loss of vaginal sensation if TVH, 4) heavy lifting should be avoided for 2 months.

Ovarian Cancer (pg. 1543)

1. Causes more deaths than any other cancer of the female reproductive system due to advanced disease process at diagnosis.
2. Occurs more frequently in women between 55 and 65 years old.
3. Risk factors: family history, increasing age and high fat diet.
4. Risk reducing factors: Breast feeding, multiple pregnancies, oral contraceptive use,  and early age at first birth.
5. Clinical manifestations: usually asymptomatic in early stages, increased abdominal girth, bowel and bladder dysfunction, pain, menstrual irregularities, and ascites. Classified as Stage I, II, and III.
6. Treatment: total abdominal hysterectomy, chemotherapy, and radiation.

Cervical Cancer (pg. 1540)

1. An increased risk of cervical cancer is associated with low economic status, early sexual activity (before 17), multiple sexual partners, infection with HPV (human papilloma virus), and smoking.
2. Widespread use of the Pap test is attributed with the decrease in cervical cancer over the past 40 years.
3. Progression from normal cervical cells to dysplasia and on to cervical cancer appears to be related to repeated injuries to the cervix.
4. Clinical manifestations: may be asymptomatic, leukorrhea, intermenstrual bleeding. Classified as Class I,II, III, IV, and V.
5. Diagnosis: pap test, colposcopy, and biopsy.
6. Treatment: repeat Pap test, laser, cautery, cryosurgery, surgery, radiation. (Pap smears and pelvic exams should be preformed annually beginning at age 18 or when sexually active.)

Pelvic Relaxation (pg. 77)

1. Cystocele: the downward displacement of the bladder, which appears as a bulge in the anterior vaginal wall. Classified as mild to severe. Corrected surgically with an anterior colporrhaphy.
2. Rectocele: weakening between the rectum and vagina. Corrected surgically with a posterior colporrhaphy.
3. Contributing factors include: childbearing, obesity, genetic predisposition and increased age.
4. Symptoms: stress incontinence, loss of urine when coughing, sneezing, laughing or sudden exertion. Vaginal fullness, a bulging out of the vaginal wall, and/or a dragging sensation. May have to push upward vaginally to be able to urinate completely.
5. Treatment: Kegel exercises, estrogen improves condition of vaginal mucous membrane, vaginal pessary may be used if surgery is no indicated.
6. Pessary: a device inserted into the vagina to function as a supportive structure for the uterus.

Uterine Prolapse (pg. 1548)

1. The downward displacement of the uterus into the vaginal canal.
2. Rated by degrees: 1) First degree; cervix rests in the lower part of the vagina, 2) Second degree; cervix is at the vaginal opening, 3) Third Degree; uterus protrudes through the introitus.
3. Symptoms: a feeling of something coming down, dyspareunia, backache, bowel or bladder problems, stress incontinence and tissue irritation to the protruding cervix.
4. Therapy: Kegel exercises, pessary, surgery (vaginal hysterectomy with an anterior and posterior repair).

Questions?

Care of the Newborn of a Substance Abusing Mother

Lecture Fifteen: Care of the Newborn of a Substance Abusing Mother
NURS 2208
Fall 2002
T. Dennis RNC, MSN
Substances Commonly Abused During Pregnancy

1. Tobacco
2. Alcohol
3. Cocaine/Crack
4. Marijuana
5. Phencyclidine (PCP)
6. Heroin
7. Methadone

Fetal Alcohol Syndrome (pg. 832)

1. (FAS) A syndrome caused by maternal alcohol ingestion and characterized by microcephaly, intrauterine growth retardation, short palpebral fissures, and maxillary hypoplasia.
2. FAS rates are higher among Native Americans and Alaskans.
3. Fetal alcohol effects (FAE): alcohol related birth defects.
4. Ethanol freely crosses the placenta to the fetus.
5. Contributing factors may include drug abuse, caffeine, and poor diet.
6. Long term complications: 1) failure to thrive associated with weak suck development, persistent vomiting until 6 to 7 months of age. 2) hypotonicity, placidity, decreased ability to habituate repetitive stimuli. 3) normal or below normal IQ (environmental support does not typically increase IQ).

Nursing Assessment and Diagnosis (pg. 833)

1. Abnormal structural development and CNS dysfunction: 1)microcephaly,            2) hyperactivity and 3) mental retardation.
2. Growth deficiencies: 1) weight, length and head circumference are initially growth restricted, 2) growth  deficiences related primarily to head circumference and linear growth.
3. Distinctive facial abnormalities: 1) broad nasal ridge, 2) flattened midfacies, short upturned or beaklike nose, micrognathia (abnormally small lower jaw).
4. Associated anomalies: 1) septal and valvular defects of the heart, 2) eyes, 3) kidneys, 4) congenital dislocated hips (skeletal anomalies).

Nursing Diagnosis (pg. 833)

1. Altered Nutrition: Less than Body Requirements related to decreased food intake and hyperirritability.
2. Alteration in Neurodevelopmental Status related to central nervous system involvement secondary to maternal alcohol use.
3. Ineffective Family Coping related to dysfunctional family dynamics and substance-dependent mother.

Nursing Plan and Implementation (pg. 833)

1. Nursing plan includes recognizing signs characteristics of the FAS newborn and planning care aimed at avoiding heat loss, providing adequate nutrition, reducing environmental stimuli, and education for the family.
2. Interventions include: provide a quiet, dimly lighted environment, allow extra time for feedings, keep personnel and visitors to a minimum, monitor vital signs frequently and observe for seizure activity and respiratory distress.

Evaluation (pg. 833)

1. The FAS newborn is able to tolerate feedings and gain weight.
2. The FAS infant’s hyperirritability is controlled, and the newborn has suffered no physical injuries.
3. The parents are able to identify and meet the special needs of their newborn and accept outside assistance as needed.

Drug Dependence (pg. 833)

1. Almost all drugs cross the placenta and enter into the fetal circulation.
2. Intrauterine asphyxia
3. Intrauterine infection
4. Alterations in birth weight
5. Low apgar scores

1. Respiratory distress
2. Jaundice
3. Congenital anomalies and growth retardation
4. Behavioral abnormalities
5. Withdrawal

Long Term Effects (pg. 834)

1. Inability to express emotions
2. High risk for motor development problems, language skills, and feeding difficulties due to swallowing disorders
3. Increased risk of Sudden Infant Death Syndrome
4. Higher incidence of respiratory illness, gastrointestinal illness (May be related to the mother’s drug abuse problem which results in a lack of education regarding proper infant care, feeding and hygiene.
5. Subject to abuse, neglect or both.

Clinical Therapy (pg. 835)

1. The goal of clinical therapy is to prevent complications through prenatal management and pharmacologic management of newborn narcotic withdrawal.
2. The client should be placed on a methadone reduction program.
3. It is not recommended that the client be withdrawn completely from narcotics while pregnant.
4. Newborn treatment may include: 1) management of complications, 2) serologic tests for syphilis, HIV, and hepatitis B, 3) urine drug screen and meconium analysis, 4) and social service referral.
5. Pharmacologic treatment is based on drug exposure and symptoms. Drugs may include: phenobarbital, paregoric, oral morphine sulfate solution, Donnatal elixir, and simrthicone  (Mylicon) drops.
6. Nutritional support is important.

Nursing Assessment and Diagnosis (pg. 835)

1. Early identification of the newborn needing clinical or pharmacologic interventions decreases the incidence of mortality and morbidity.
2. Note mother’s last drug intake and dosage level.
3. Prepare for complications associated with substance abuse during pregnancy.
4. Identify symptoms of newborn withdrawal: Hyperirritability (incessant shrill cry), tremors, seizures, short unquiet sleep, tachypnea (>60 breadths per minute), poor feeding, disorganized suck, flushing, facial scratches.
5. Lab values are WNL with these infants.

Nursing Assessment and Diagnosis (pg. 835)

1. The fetus of a heroin addicted mother is likely to have meconium aspiration.
2. When caring for the client who abuses opiate narcotics, the nurse encourages regular attendance at prenatal classes, assesses for poor weight gain or for weight loss, and gives positive reinforcement for desired behaviors.
3. Do not encourage the client who abuses opiate narcotics to immediately stop using all narcotics.

Nursing Diagnosis (pg. 836)

1. Altered Nutrition: Less than Body Requirements related to vomiting and diarrhea, uncoordinated suck, swallow reflex, hypertonia secondary to withdrawal.
2. Impaired Skin Integrity related to constant activity.
3. Altered Parenting related to hyperirritable behavior
4. Ineffective Family Coping: Disabling related to drug abuse, poverty, and lack of education
5. Sleep Pattern Disturbance related to CNS excitability secondary to drug withdrawal

Nursing Plan and Implementation (pg. 836)
Care is based on reducing the withdrawal symptoms and promoting adequate respiration, temperature, and nutrition.

1. Temperature regulation
2. Monitor vital signs
3. Stimulation if apnea occurs
4. Small, frequent feedings
5. IV therapy as needed
6. Medications as ordered (paregoric, phenobarbital)
7. Proper positioning on the right side
8. Weigh the infant every 8 hours during withdrawal
9. Swaddling with hands near mouth
10. Place in a quiet, dimly lighted area of the nursery

Nursing Plan and Implementation (pg. 836)

1. The client’s educational plan should focus on the relationship of substance abuse to her health and the health of her baby.
2. Do not tell the patient you will report her to the authorities if she fails to comply with treatment.
3. The client she may be able to have medication for pain during labor depending on her current drug status.
4. Plan care for the infant who may be experiencing neonatal abstinence syndrome (withdrawal) to include a quiet area in the nursery, frequent, small feedings and close swaddling and/or mittens to prevent facial scratches.

Evaluation (pg. 836-840)

1. The newborn tolerates feedings, gains weight, and has a decreased number of stools.
2. The parents learn ways to comfort their newborn.
3. The parents are able to cope with their frustrations and begin to use outside resources as needed.

Care of The High Risk Neonate

Lecture Fourteen: Care of The High Risk Neonate
NURS 2208
T. Dennis RNC, MSN
At Risk Newborns (pg. 805)

1. SGA newborn
2. LGA newborn
3. Infant of a diabetic mother
4. Postterm newborn
5. Preterm newborn
6. Newborn exposed to HIV/AIDS
7. Newborn with congenital anomalies
8. Newborn with congenital heart defect
9. Care of the family of at risk newborns and nurses caring for them

Legal and Ethical Considerations (pg. )

1. Increased levels of nursery care have evolved with increased knowledge about the newborn.
2. High-touch / High-tech environment.
3. When is enough, enough?
4. Caring for the caretaker.

Identification of the High Risk Newborn (pg. 805)

1. An at-risk infant is one who is susceptible to illness (morbidity) or even death (mortality) because of dysmaturity, immaturity, physical disorders, or complications during or after birth.
2. Predictable risk factors include: 1) Low socioeconomic level of the mother with limited access to health care, 2) Exposure to environmental dangers such as toxic chemicals or illicit drugs, 3) Preexisting maternal conditions,  4) Maternal age or parity, and medical complications related to the pregnancy.
3. Risks may be anticipated and the appropriate facility can be notified for transport or preparation.
4. Birth related risks may be evaluated by electronic fetal monitoring and Apgar score.

Identification of the High Risk Newborn (pg. 805)

1. Birth weight and gestational age together are the criteria used to assess neonatal maturity and mortality risk.
2. Preterm, Term, and Postterm.
3. LGA, AGA, and SGA are plotted on the newborn classification and mortality risk chart.
4. Neonatal mortality risk (chance of death within the first 28 days of life) decreases as both gestational age and birth weight increase.
5. Neonatal morbidity rating assists in determining the needs of particular infants for special observation and care.
6. Minute to minute observations may mean the difference between survival and non-survival.

Nursing Care Management (pg. 806)

1. Decreasing physiologically stressful situations.
2. Constantly observing for subtle signs of change in clinical condition.
3. Interpreting laboratory data and coordinating interventions.
4. Conserving the infant’s energy for healing and growth.
5. Providing for developmental stimulation and maintenance of sleep cycles.
6. Assisting the family in developing attachment behaviors.
7. Involving the family in the planning and providing care.

Small for Gestational Age (pg. 806-812)

1. SGA: any newborn who at birth is at or below the 10th percentile for weight on the newborn classification chart.
2. Newborn may be preterm, term, or postterm.
3. Intrauterine growth restriction (IUGR): Fetal undergrowth due to any etiology, such as intrauterine infection, deficient nutrient supply, or congenital anomalies (used interchangeably with SGA).
4. SGA infants have an increased risk for asphyxia, perinatal mortality, polycythemia, and hypoglycemia.

Small for Gestational Age (pg. 806-812)

1. Contributing factors: maternal factors, maternal disease, environmental factors, placental factors, and fetal factors.
2. Symmetric (proportional) IUGR.
3. Asymmetric (disproportional) IUGR.
4. Complications: perinatal asphyxia, aspiration syndrome, heat loss, hypoglycemia, and polycythemia.
5. Significant IUGR is associate with: congenital malformations, intrauterine infection, continued growth difficulties, and learning difficulties.

LGA Newborn  (pg. 812-813)

1. Large for Gestational Age: a neonate whose birth weight is at or above the 90th percentile on the intrauterine growth curve (at any week of gestation) is considered LGA.
2. Best known condition associated with excessive growth of the newborn is maternal diabetes.
3. Contributing factors: genetic polycythemia, and hyperviscosity.
4. predisposition, multiparous clients, male newborns, and newborns with erythroblastosis fetalis, Wiedemann syndrome, or transposition of the great vessels.
5. Complications: birth trauma due to CPD, increased incidence of cesarean births/labor inductions, and hypoglycemia,

Infant of a Diabetic Mother
(pg.813-814)

1. Excessive fetal growth is caused by:          1) exposure to high levels of maternal glucose, 2) fetal response of increased insulin production, and 3) insulin has a “growth hormone effect” that results in greater linear growth.
2. Complications include: hypoglycemia, hypocalcemia, hyperbilirubinemia, birth trauma, polycythemia, respiratory distress syndrome, and congenital anomalies.

Postterm Newborn (pg. 815)

1. Any newborn born after 42 weeks gestation.
2. Cause unknown but associated factors include: primiparity, high multiparity, and a history of prolonged pregnancies.
3. Complications of post maturity syndrome: hypoglycemia, meconium aspiration, polycythemia, congenital anomalies, seizures due to hypoxic insult, and cold stress.
4. Characteristics are caused primarily by a combination of an aging placenta, subsequent insufficiency and continued exposure to amniotic fluid.

Care of the Preterm (Premature) Newborn    (pg 817-832)

1. An infant born before the completion of 37 weeks gestation.
2. Cause of preterm labor are poorly understood.
3. Major problem is variable immaturity of all systems.
4. The degree of immaturity depends on the length of gestation.
5. Common complications of the cardiopulmonary system include: respiratory distress syndrome, patent ductus arteriosis, and pulmonary air leaks.
6. Heat loss is a major problem due to : high ratio of body surface to body weight, decreased subcutaneous fat, thinner, more permeable skin, extended posture, and decreased ability conserve heat in body core.

Care of the Preterm (Premature) Newborn
GI immaturity leads to:

1. an increased danger of aspiration
2.  inability to meet caloric needs due to small stomach
3. Limited ability to convert essential amino acids
4. Inability to handle the increased osmolarity of formula protein
5. Difficulty with lactose digestion
6. Deficiency of calcium and phosphorus
7. Increased basal metabolic rate and increased oxygen consumption due to fatigue of sucking.
8. Feeding intolerance and NEC due to ↓intestinal perfusion.

Care of the Preterm (Premature) Newborn

1. At risk due to decreased glycogen stores for hypoglycemia, low iron stores, and high bilirubin levels and any blood loss is highly significant.
2. Brain growth is most rapid in the third trimester, so the closer to term the better the neurological prognosis.
3. A common interruption of neurological development in the preterm infant is caused by intraventricular hemorrhage (IVH) and intracranial hemorrhage (ICH).
4. Periods of reactivity may not be observed at all, more disorganized in their sleep-wake cycles, unable to focus on human face and environmental objects as well as term infants, and their neurological responses (sucking, muscle tone) are weaker.

Care of the Preterm (Premature) Newborn
Nutrition:

1. Early feeding is helpful in maintaining metabolism and lowering the possibility of complications but increases risk for complications related to maturity of the digestive system.
2. Feeding regimens are based on the infant’s weight and estimated stomach capacity.
3. Total parenteral nutrition (TPN) is given to newborns who cannot tolerate any oral feedings.
4. Nutritional intake is considered adequate when there is weight gain of 20 to 30 grams per day.
5. Methods of feeding include: bottle feeding, breast feeding, gavage feeding, transpyloric feeding and TPN.

Care of the Preterm (Premature) Newborn
Complications:

1. Patent ductus arteriosis
2. Apnea
3. Intraventricular hemorrhage (IVH)
4. Respiratory distress syndrome (RDS)
5. Sepsis
6. Retinopathy of pre-maturity (ROP)
7. Bronchopulmonary dysplasia (BPD)
8. Pulmonary interstital emphysema (PIE)
9. Posthemorrhagic hydrocephalus

Nursing Assessment (pg. 826)

1. Color
2. Skin
3. Lanugo
4. Head size
5. Skull

1. Ears
2. Nails
3. Genitals
4. Resting position
5. Cry
6. Reflexes/Activity

Nursing Diagnosis (pg. 836)

1. Impaired Gas Exchange
2. Ineffective Breathing Pattern
3. Alteration In Cardiovascular Status
4. Ineffective Thermoregulation
5. Potential Hyperbilirubinemia

1. Altered Nutrition: Less Than Body Requirements
2. Fluid Volume Deficit
3. High Risk For Intraventricular Hemorrhage
4. Ineffective Family Coping
5. Dysfunctional Grieving

Nursing Plan and Implementation (pg. 827)

1. Maintenance of respiratory function
2. Maintenance of neutral thermal environment
3. Maintenance of fluid and electrolyte status
4. Provision of adequate nutrition and prevention of fatigue during feeding.
5. Prevention of infection
6. Promotion of Parent-infant attachment
7. Promotion of developmentally supportive care
8. Preparation for home care

Evaluation (pg. 827-832)

1. The preterm newborn is free of respiratory distress and establishes effective respiratory function.
2. The preterm newborn gains weight and shows no signs of fatigue or aspiration during feedings.
3. The parents are able to verbalize their anger, anxiety, and guilt feelings about birth of a preterm baby and show attachment behavior such as frequent visits and growing confidence in their participatory care activities.
4. The preterm newborn demonstrates a serial head circumference growth rate of 1 cm/week.

Newborn exposed to HIV/AIDS (pg. 840)

1. Transmission during the perinatal and newborn periods can occur across the placenta or through breast milk or contaminated blood.
2. The majority of infants born to infected mothers ultimately remain uninfected (Vertical transmission decreased by AZT during gestation).
3. May show signs and symptoms within days of birth (enlarged spleen and liver, swollen glands, recurrent respiratory infection, weight loss, urinary tract infections and candidiasis infection.
4. Routine newborn care, standard precautions.
5. Hand washing is crucial.
6. All infants born to HIV positive mothers require regular clinical, immunologic, and virologic monitoring.
7. Routine immunizations except for the live polio vaccine.

Newborn with Congenital Anomalies (pg.841)

1. Congenital hydrocephalus
2. Anencephaly
3. Choanal atresia
4. Cleft lip
5. Cleft palate
6. Tracheoesophageal fistula
7. Diaphragmatic hernia
8. Myelomeningocele
9. Omphalocele
10. Gastroschisis

Newborn with Congenital Heart Defect (pg. 844)

1. Classified as acyanotic (without cyanosis) or cyanotic (with cyanosis).
2. The common cardiac defects seen in the first 6 days of life are left ventricular outflow obstructions (mitral stenosis, aortic stenosis, or atresia), hypoplastic left heart, coarctation of the aorta, patent ductus arteriosis, transposition of the great vessels, tetrology of Fallot, and large ventricular septal defect or atrial septal defects.
3. Many cardiac defects will not clearly manifest themselves until after discharge from the birthing unit.
4. Three most common manifestations are: cyanosis, detectable heart murmur, and signs of congestive heart failure (tachycardia, tachypnea, diaphoresis).

Newborn with Inborn Errors of Metabolism

1. Inborn errors of metabolism are a group of hereditary disorders that are transmitted by mutant genes: Phenylketonuria (PKU), Maple syrup urine disease (MSUD), Homocystinuria, Galactosemia, and congenital hypothyroidism.
2. PKU is the most common.
3. Phenylalanine is the essential amino acid used by the body for growth and excess is converted to Tyrosine.
4. The newborn with PKU lacks the ability to convert resulting in high levels of phenylalanine which results in a progressive mental retardation.
5. PKU is required by law in most states. The PKU must be drawn 24 to 72 hours after initiation of breast milk or formula feeding.

Birth Related Stressors (pg 863-902)

1. Newborn at risk due to asphyxia
2. Newborn with respiratory distress/Transient Tachypnea
3. Newborn with meconium aspiration syndrome
4. Newborn with persistent pulmonary hypertension
5. Newborn with complications due to respiratory therapy
6. Newborn with cold stress
7. Newborn with hypoglycemia
8. Newborn with jaundice
9. Newborn with polycythemia
10. Newborn with infection

Asphyxia (pg. 863)
Pathophysiology:

1. Results from cardiopulmonary, respiratory and biochemical factors.
2. Due to failure of lung expansion and hypoxia, fetal circulation reoccurs.
3. Biochemical: hypoxia causes anaerobic metabolism, rapidly using glycogen supplies.

Asphyxia (pg. 863)
Protective mechanisms:

1. Relatively immature brain
2. Lower resting metabolic rate than adults
3. Use energy more efficiently

Complications:

1. Severe, prolonged hypoxia may result in brain damage or death of the newborn.

Asphyxia (pg. 863)
Risk factors:

1. Non-reassuring fetal heart rate patterns
2. Difficult birth
3. Fetal Blood Loss
4. Apneic episode that is unresponsive to tactile stimulation
5. Inadequate ventilation
6. Prematurity
7. Structural Lung abnormality
8. Cardiac arrest

Asphyxia (pg. 863)

1. Requires immediate resuscitation of the newborn.
2. The goal of clinical therapy is to identify the fetus at risk for asphyxia and prepare for resuscitative efforts immediately at birth.
3. Monitor fetal well being during the prenatal and intrapartal periods.
4. Deliver the fetus immediately before major damage occurs and treat the asphyxiated infant.

Asphyxia (pg. 863)
Treatment:

1. Suction is always performed before resuscitation to prevent mucous, blood, and/or meconium being aspirated into the lungs.
2. Dry the baby off
3. If no respirations or gasping, provide Positive Pressure ventilation with 100% O2.
4. Endotracheal Intubation may be required
5. Position on a firm surface
6. Compressions with two-finger method or both thumbs
7. Medications as indicated

Nursing Assessment and Diagnosis (pg. 866)

1. Observe for the infant at risk.
2. Ineffective Breathing Pattern related to lack of spontaneous respirations at birth secondary to intrauterine asphyxia.
3. Decreased Cardiac Output related to impaired oxygenation.
4. Ineffective Family Coping: Compromised related to baby’s lack of spontaneous respirations at birth and fear pf losing their newborn.

Nursing Plan and Implementation (pg. 866)

1. Assemble the necessary equipment and insure proper functioning (LDR, DR, OR, Nursery, NICU).
2. Restock immediately after use.
3. Call for additional support- resuscitation is at least a two person effort.
4. Document, document, document.
5. Parent teaching: keep parents informed.

Evaluation (pg. 867)

1. The risk of asphyxia is promptly identified and intervention is started.
2. The newborn’s metabolic and physiological processes are stabilized and recovery proceeds without complications.
3. The parents can describe the reason for resuscitation and what was done to resuscitate their newborn.
4. Parents can verbalize their fears about the resuscitation process and potential implications for their infant’s future.

Respiratory Distress Syndrome (RDS) (pg. 867)

1. An inappropriate respiratory adaptation to extrauterine life.
2. Also referred to as Hyaline membrane Disease (HMD).
3. The result of a primary absence, deficiency, or alteration in the production of pulmonary surfactant.
4. Occurs more frequently in infant 30 weeks gestation or less.
5. Occurs more frequently in premature Caucasian infants than in infants of African descent and almost twice as often in males than in females.

Respiratory Distress Syndrome (RDS) (pg. 867)
Contributing factors:

1. Prematurity
2. Surfactant deficiency disease

Complications:

1. Hypoxia
2. Respiratory acidosis
3. Metabolic acidosis

Clinical Therapy:

1. The primary goal of prenatal management is to prevent preterm birth through aggressive treatment of preterm labor and administration of corticosteroids to enhance fetal lung development. Postnatally: 1) maintain adequate oxygenation and ventilation, 2) correct acid base abnormalities, and 3) provide supportive care to maintain homeostasis

Respiratory Distress Syndrome (RDS)
Medical management:

1. Oxygenation: oxyhood, Nasal cannula
2. Ventilatory support: ventilator, ECMO, nitrous oxide
3. Transcutaneous O2 and CO2 monitoring, pulse oximetry
4. Blood gas monitoring
5. Correction of acid-base imbalance
6. Environmental temperature regulation
7. Adequate nutrition: oral, gavage, and TPN
8. Protection from infection

Nursing Assessment and Diagnosis (pg. 866)
Assessment:

1. Increasing cyanosis
2. Tachypnea (60 or > breaths per minute)
3. Grunting respirations
4. Nasal flaring
5. Significant retractions, labored respirations
6. Apnea (episode of nonbreathing for more than 20 seconds)
7. Flaccid, hypotonic, unresponsive to stimuli
8. Seizures (indicative of deterioration and possible CNS damage.

Diagnosis:

1. Impaired Gas exchange
2. Altered Nutrition: Less than Body Requirements
3. Risk for infection

Nursing Plan and Implementation (pg. 866)

1. Admit directly to the special care nursery
2. Lab as ordered: blood type, Rh, Coombs, CBC
3. Administer antibiotics as ordered.
4. IV access for meds, hydration and nutritional support.
5. Assist MD/NP with placement of arterial catheter lines.
6. Attach servo probe to infant’s skin, radiant warmer on servo control.
7. Attach 3 lead EKG for continuous cardiac and respiratory monitoring.
8. Attach pulse ox to infant extremity.
9. Monitor oxygen administration.

Evaluation (pg. 867)

1. Prompt identification and early intervention occurred.
2. Newborn is free of respiratory distress and metabolic alterations.
3. Parents verbalize concerns, survival factors and understanding of treatment rationales.

Transient Tachypnea of the Newborn (pg. 870)

1. Occurs more frequently in AGA and near term infants.
2. Incident during the birth process which results in failure to clear the airway of lung fluid and or mucous.
3. An excess of fluid in the lungs due to aspiration of amniotic fluid.
4. Occurs more frequently in c-section newborns
5. Onset occurs shortly after birth with signs of: expiratory grunting, nasal flaring, and mild cyanosis.
6. Respiratory rates may be as high as 100 to 140 breaths per minute.

Transient Tachypnea of the Newborn (pg. 870)
Clinical Therapy:

1. Initial x-ray resembles RDS with minor differences.
2. Chest x-ray is clear in 48 to 72 hours
3. O2 at 30% to 50% usually under oxyhood correct hypoxemia.
4. IVF’s for fluid and electrolyte imbalances
5. Oral feedings are contraindicated due to high respiratory rate.
6. Infant usually begins to improve by 8 to 24 hours.
7. Duration of clinical course is 72 hours.
8. R/O pneumonia and persistent pulmonary hypertension.

Meconium Aspiration Syndrome (pg. 873)

1. Respiratory disease of the term, postterm, and SGA newborns cause by inhalation of meconium or meconium stained amniotic fluid into the lungs.
2. Characterized by mild to severe respiratory distress, hyper-expansion of the chest, hyper-inflated alveoli, and secondary atelectasis.
3. Syndrome primarily affects term, SGA, postterm and newborns who have experienced a long labor.
4. The severity of the clinical symptoms correlates with the extent of the aspiration.
5. The extreme hypoxia caused by cardiopulmonary shunting can lead to PPHN (Persistent Pulmonary Hypertension).

Normal Arterial Blood Gas Values for the Newborn

1. pH : 7.31 - 7.45
2. Arterial oxygen pressure (Pao2) :

   50–70 mm Hg

1. Carbon dioxide pressure (Paco2) :

    33-48 mm Hg

1. Bicarbonate :  16-24 mEq/L
2. Oxygen saturation : > 90%

Meconium Aspiration Syndrome (pg. 873)
Clinical Therapy:

1. Suctioning the nasopharynx and oropharynx before the delivery of the body.
2. Endotracheal intubations to visualize the cords: vigorous infant with thick meconium intubate and suction, thin meconium do not intubate, depressed infant suction.
3. Delivery of high oxygen concentrations and controlled ventilation.
4. Surfactant replacement.
5. Maintenance of systemic blood pressure by dopamine.
6. Extracorporeal membrane oxygenation (ECMO), a form of hear/lung machine may be needed.
7. Chest physiotherapy (Chest percussion, vibration, and drainage to remove the debris).

Meconium Aspiration Syndrome (pg. 873)
Nursing assessment and diagnosis:

1. Observe for signs of fetal hypoxia and meconium staining. After delivery, observe for hypoxia, convulsions, hematuria, oliguria, or anuria.
2. Ineffective Gas Exchange, Altered Nutrition: Less than Body Requirements, and Ineffective Family Coping: Compromised.

Nursing Plan and Implementation:

1. Prevention of meconium aspiration
2. Maintaining adequate oxygenation and ventilation.
3. Regulating temperature.
4. Observing intravenous fluids.
5. Providing caloric requirements.
6. Monitoring antibiotic treatment.

Evaluation:

1. The newborn is free of respiratory distress and metabolic complications
2. Parents can verbalize concern, understanding of treatment.

Persistent Pulmonary Hypertension (pg. 878)

1. Respiratory disease resulting from right to left shunting of blood away from the lungs and through the ductus arteriosis and patent foramen ovale.
2. May also be called persistent fetal circulation because the syndrome includes a return to fetal circulation.
3. Typically born at term or postterm and presents with tachycardia and cyanosis.
4. ECMO has improved chance of survival in these infants.
5. High frequency ventilation is another mode of treatment.

Complications Due to Respiratory Therapy (pg. 880)

1. Pulmonary Interstitial Emphysema: the accumulation of air in the lung tissues. Overdistention and rupture of the alveoli occur related to high ventilator pressures.
2. Pneumothorax: the accumulation of air into the thoracic cavity between the parietal and visceral pleura when alveoli are overdistended, rupture and air leaks into the thoracic cavity (pg.881)
3. Bronchiopulmonary Dysplasia (BPD): most commonly occurs in very compromised low-birth-weight infants who require oxygen therapy and assisted  mechanical ventilation for treatment of RDS.

Cold Stress (pg. 882)
Pathophysiology:

1. Excessive heat loss resulting in the use of compensatory mechanisms (increased respirations and non-shivering thermogenesis) to maintain core body temperature.
2. Occurs thought the mechanisms of evaporation, convection, conduction and radiation.
3. Metabolic consequences of cold stress can be devastating and potentially fatal to the infant.

Care management:

1. Warm newborn slowly
2. Monitor skin temp
3. Initiate efforts to maintain neutral thermal environment

Hypoglycemia (pg. 884)

1. Occurs when the blood glucose level is less than 40 mg/dL.
2. Occurs more commonly in IDM, SGA, and preterm AGA newborns.

Clinical Therapy:  signs & symptoms

1. Lethargy, jitteriness   
2. Poor feeding
3. Vomiting
4. Pallor
5. Apnea, irregular respirations
6. Hypotonia
7. Tremors, jerkiness
8. High-pitched cry

Hypoglycemia (pg. 884)
Treatment:

1. Early breastfeeding or formula feeding is a major preventative approach.
2. Intravenous therapy with 10% dextrose may be indicated with rate based on weight.
3. Oral glucose may be used.
4. Repeat blood sugar in 30 minutes.
5. Use heelstick method to obtain blood sugar values.
6. Use left lateral heel site to avoid damage to the newborn’s heel (pg. 885- 886).

Hypoglycemia (pg. 884)
Nursing Assessment and Diagnosis

1. Identify the newborn at risk: jitteriness, tremors, periods of apnea.
2. Monitor blood glucose levels.
3. Altered Nutrition: Less than body Requirements
4. Ineffective Breathing pattern related to tachypnea and apnea.
5. Pain related to frequent heelsticks for glucose monitoring.

Nursing Plan and Implementation

1. Monitor blood glucose levels
2. Initiate early feedings.
3. Monitoring glucose intravenous infusions.
4. Maintaining a neutral thermal environment.
5. Encourage non-nutritive sucking to decrease crying behaviors.
6. Weigh daily

Jaundice (pg. 887)

1. The most common abnormal finding in the newborn is jaundice.
2. Physiologic jaundice is due to the newborn’s shorter red cell life span, slower uptake by the liver, lack of intestinal bacteria, and poorly established hydration.
3. Hypothermia, hypoglycemia, asphyxia and some neonatal medications increase the chances of a newborn becoming jaundiced.
4. Hyperbilirubinemia: Excessive amount of bilirubin in the blood; indicative of hemolytic processes due to blood incompatibility, intrauterine infection, septicemia, neonatal renal infection, and other disorders.

Jaundice (pg. 887)
Clinical Therapy:

1. Phototherapy: the treatment of jaundice by exposure to high intensity light.
2. Exposure to high intensity light decreases serum bilirubin levels in the skin by facilitating biliary excretion of unconjugated bilirubin.
3. Phototherapy does not alter the underlying cause of the jaundice.
4. Phototherapy can be provided through conventional banks of phototherapy lights, by a fiber optic blanket or a combination of both.
5. Exchange transfusion is the withdrawal and replacement  of the newborn’s blood with donor blood.

Jaundice (pg. 887)
Nursing Assessment and Diagnosis

1. Identify the newborn at risk: assess for jaundice.
2. Monitor bilirubin levels.
3. Risk for Altered Parenting related to parenting a newborn with jaundice.
4. Risk for Injury related to use of phototherapy.
5. Fluid Volume Deficit related to increased insensible water loss and frequent loose stools.

Nursing Plan and Implementation

1. Monitor temperature for hyperthermia or hypothermia.
2. Apply eye patches over newborns closed eyes.
3. Turn off lights when drawing blood for repeat bilirubin.
4. Maintaining a neutral thermal environment.
5. Observe for signs of dehydration and perineal excoriation.
6. Weigh daily

Polycythemia (pg. 895)

1. An abnormal increase in the number of total red blood cells in the newborn’s circulation.
2. Observed more commonly in SGA, full term newborns with delayed cord clamping, maternal-fetal and twin to twin transfusions, or chronic intrauterine hypoxia.
3. Hct levels of 65 to 70 are considered polycythemic.
4. Symptoms include: ruddy appearance, tachycardia, congestive heart failure, grunting, tachypnea, and cyanosis.
5. Partial exchange transfusions may be indicated in infants who are symptomatic but controversial in newborns who are asymptomatic.

Infection (pg. 896)

1. Most nosocomial infections in the NICU present as bacteremia/sepsis, urinary tract infections, meningitis, or pneumonia.
2. Maternal antepartal infections such as rubella, toxoplasmosis, cytomegalic inclusion disease, and herpes may cause congenital infection.
3. Prevention of infection is essential prenatally and intrapartally, Erythromycin ointment in the eyes post delivery for GC, antibiotic therapy for asymptomatic positive group B streptococcal  infection intrapartally.

Infection (pg. 896)
Clinical Therapy:

1. Two blood cultures from two peripheral sites.
2. Spinal fluid culture following spinal tap.
3. Urine specimen for culture typically done by supra-pubic bladder aspiration.
4. Skin cultures are taken if there are any lesions or drainage from lesions.
5. Nasopharyngeal, rectal, ear canal, and gastric aspirate cultures may be obtained.
6. CBC, chest x-ray, serology (WBC 30,000 normal first 24 hours.)
7. A low neutrophil count and high band (immature white cells) count indicate an infection is present.
8. Antibiotic therapy is initiated after cultures with Ampicillin and Gentamicin.
9. After cultures are evaluated, appropriate antibiotic therapy is instituted. Therapy may continue for 7 to 14 days or may be discontinued on the 3rd day.

Infection (pg. 896)
Nursing Assessment and Diagnosis

1. Identify the newborn at risk: assess for infection.
2. Assess for subtle behavioral changes, lethargy or irritability, color changes (pallor, duskiness, cyanosis).
3. Assess for feeding intolerance, temperature instability (hypothermia), and hyperbilirubinemia.
4. Risk for Infection related to immature immunologic system.
5. Fluid Volume Deficit related to feeding intolerance.

Nursing Plan and Implementation

1. Monitor temperature for hyperthermia or hypothermia.
2. Promote strict hand washing technique.
3. Scrupulous care of equipment (to include isolettes, warmers, soap dispensers stethoscopes).
4. Maintaining a neutral thermal environment.
5. Observe for signs of dehydration.
6. Provide respiratory support.
7. Provide adequate calories.
8. Weigh daily

TORCH (pg. 429)

1. Tests for : toxoplasmosis, rubella, cytomegalovirus, and herpes simplex virus.
2. Cytomegalovirus may be acquired transplacentally
3. Diagnosis is CMV in the urine of the pregnant client.
4. No treatment exist for the pregnant client or the newborn.
5. Infection in the fetus can result in extensive tissue damage and after birth microcephaly, hydrocephaly, cerebal palsy, and /or mental retardation.

Questions?

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?