219-REVIEWER-PRELIMS.pdf

OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle COURSE OUTLINE:...

OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle COURSE OUTLINE: PRELIMS A person’s genotype - his or her actual gene composition 1. Wk. 1 Genetic Assessment and Counseling A person’s phenotype - his or her outward 2. Wk. 1 High Risk Pregnant Client appearance or the expression of the genes. 3. Wk. 1 High Risk Pregnant Client (Bleeding A person’s genome - is the complete set of genes Disorder) present which is about 50,000 - 100,000 4. Wk. 1 Second and Third Trimester Bleeding Normal Genome: Disorders 46 XX – female with 46 total chromosomes 5. Wk. 2 Pregnancy Induced Hypertension 46 XY – male with 46 total chromosomes 6. (Gestational Hypertension) Genetic disorders 7. Wk. 2 Gravido Cardiovascular Disorder - a defect in the structure or number of genes or 8. Wk. 2 Gestational Diabetes Mellitus chromosomes 9. Wk. 2 Anemia Pregnancy - Inherited or genetic disorders can be passed from REFERENCE one generation to the next. - Genetic disorders occur when an ovum and sperm PPT fuse in the meiotic division (ovum and sperm) - Other genetic disorders do not affect life in utero, result of the disorder becomes apparent only at the Genetic Assessment and Counseling - time of fetal testing or after birth Some genetic abnormalities are so severe that LEARNING OBJECTIVES: normal fetal growth cannot continue past that point. 1. Describe the nature of inheritance, patterns of recessive - In-vitro fertilization (IVF) can examined for genetic and dominant mendelian inheritance, and common disorders of single gene or chromosome concerns chromosomal aberrations that cause physical or cognitive before implantation. (egg and sperm) MENDELIAN INHERITANCE: DOMINANT AND disorders. RECESSIVE PATTERNS 2. Integrate knowledge of genetic inheritance with nursing Homozygous - a person has two healthy genes (one from process to achieve quality maternal and child health nursing the mother and one from the father) care. Heterozygous – a person with differ genes (a healthy gene 3. Use critical thinking to analyze ways that can make from the mother and an unhealthy gene from the father or genetic assessment or education more family centered vice versa) Inheritance of Disease GENETIC ASSESSMENT AND COUNSELLING 1. Autosomal Dominant Disorders Patients who are at risk of an inherited disorder should have - either has two unhealthy genes (homozygous an access to genetic counseling for advise, resources, and dominant) or heterozygous with gene causing the support. disease NATURE OF INHERITANCE - Autosomal dominant (Heterozygous) – free from the Genes traits,the chances are 50%, child would have the - are the basic units of hereditary that determine both disorder or would be disease and carrier free the physical and cognitive characteristics of people - Two heterozygous - 25% chance of a child’s being - Composed of DNA (Deoxyribonucleic acid) disease and carrier free, 50% chance would have Genetics the disorder, 25% child would have homozygous - the study of how and why chromosomal disorders dominant (incompatible with life) occur Dominantly Inherited pattern is present in the family: Cytogenetics a. One of the parents of a child with the disorder also will - is the study of chromosomes by light microscopy have the disorder. and the method by which chromosomal aberrations b. The sex of the affected individual is unimportant in terms are identified of inheritance. GENETIC DISORDERS c. There is usually a history of the disorder in other family 1. Nature of Inheritance members. 2. Mendelian Inheritance 2. Autosomal Recessive Inheritance 3. Dominant Patterns - diseases do not occur unless two genes for the 4. Recessive Patterns disease are present 5. Inheritance of Disease - 25% chance a child born will be disease and carrier NATURE OF INHERITANCE free (homozygous dominant for the healthy gene) In humans, each cell, contains 46 chromosomes - 50% chance a child will be like the parents free of (22 pair of autosomes and 1 pair of sex disease but carrying the gene (heterozygous) chromosomes). - 25% chance the child will have the disease Spermatozoa and ova each carry only half of the 23 (homozygous recessive) chromosomes. 1. Both parents of a child with the disorder are clinically free Each chromosome in the sperm cell, have similar of the disorder. size and shape and function (autosome, or 2. The sex of the affected individual is unimportant in terms homologous chromosome) in the ovum. of inheritance. 1 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle 3. The family history for the disorder is negative – that is no If a spermatozoa or ovum with 24 or 22 chromosomes fuses one can identify anyone else who had it (horizontal with a normal spermatozoa or ovum, the zygote will have transmission) either 47 or 45 chromosomes 4. A known common ancestor between the parents 45 chromosomes does not compatible with life, and the sometimes exists. embryo or fetus probably will be aborted 5. Both male and female came to possess a like gene for the 2. Deletion Abnormalities disorder. a chromosome disorder in which part of a chromosome breaks during cell division, causing to have the normal a. Cystic fibrosis number of chromosomes plus or minus an extra portion of a b. Adrenogenital Syndrome chromosome. c. Albinism 3. Translocation Abnormalities d. Tay-Sachs disease a child gains an additionalchromosome through another e. Galactosemia route f. Phenylketonuria e. g Down Syndrome g. Limb-girdle muscular dystrophy 4. Mosaicism down syndrome h. Rh Factor incompatibility an abnormal condition when the nondisjunction disorder 3. X-Linked Dominant Inheritance occurs after fertilization Characteristics: different cells in the body will have different chromosome 1. All individuals with the genes are affected (the gene is counts. dominant) The extent of the disorder depends on the proportion of 2. All female children of affected men are affected, all male tissue with normal chromosome structure to tissue with children of affected men are unaffected abnormal chromosome constitution. 3. It appears in every generation. 5. Isochromosomes 4. All children of homozygous affected women are affected. a chromosome accidentally divides by a horizontal one, a 50% of the children of heterozygous affected women are new chromosome with mismatched long and short arms can affected. result. 4. X-Linked Recessive Inheritance It has the same effect as a translocation abnormality - disorders are recessive, and inheritance of the gene when an entire extra chromosome exists from both parents is incompatible with life. GENETIC COUNSELING - the disease will be manifested by any male children 1. Provide concrete, accurate information about inherited who receive the affected gene from their mother. disorders. 1. Only males in the family will have the disorder. 2. Reassure that their child may inherit a particular disorder 2. A history of girls dying at birth for unknown reasons often that the disorder will not occur. exists (females who had the affected gene on both X 3. Allow people who are affected by inherited disordersto chromosomes) make informed choices about future reproduction. 3. Sons of an affected man are unaffected. 4. Educate about inherited disorders and the process of 4. The parents of affected children do not have the disorders. inheritance 5. Offer support by skilled health care professionals to 1. Hemophilia A (blood factor deficiencies) people who are affected by genetic disorders. 2. Color blindness COUPLES MOST APT TO BENEFIT FROM 3. Fragile X syndrome - a cognitive challenge syndrome GENETIC COUNSELING 4. Duchene muscular dystrophy ( Pseudohypertropic ) COUPLES WHO ARE MOST APT TO BENEFIT 5. Multifactorial (Polygenic) Inheritance - occur from multiple gene combinations combined FROM REFERRAL FOR GENETIC TESTING OR with environmental factors. COUNSELLING - Many childhood disorders tend to have higher than 1. A couple who has a child with a congenital disorder. usual incidence (heart disease, diabetes, cleft lip 2. A couple whose close relatives have a child with a genetic and palate, neural tube disorders) disorder - disorders is unpredictable 3. Any individual who is a known balanced translocation - Do not follow the Mendelian Laws carrier - No set patterns in family history 4. Any individual who has an inborn error of metabolism or 6. Imprinting chromosomal disorder. Imprinting - refers to the differential expression of genetic 5. A consanguineous(closely related) couple material and allows researchers to identify chromosomal 6. Any woman older than 35 years and any man older than material has come from the male or female parent. 55 years CHROMOSOMAL ABNORMALITIES 7. Couples of ethnic backgrounds in which specific illnesses (CYTOGENIC DISORDERS) are known to occur. 1. Nondisjunction Abnormalities Nursing Responsibilities: Chromosomal abnormalities occur if the division is uneven 1. Explain to a couple what proceduresthey can expect to (nondisjunction). undergo. The result may be that one new sperm cell or ovum has 24 2. Explain how different genetic screening tests are done and chromosomes and the other has only 22. when they are usually offered. 3. Supporting a couple during the wait for test results. 2 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle 4. Assisting couples in values clarifications, planning, and d. Amniocentesis - withdrawal of amniotic fluid through the decision making based on test results. abdominal wall for analysis. Genetic Disorders Assessment Done 14th- 16th wk. of pregnancy, fluid are karyotyped for 1. History chromosomal number and structure. a. Obtain information and document diseases in family e. Percutaneous Umbilical Blood Sampling or members for a minimum of three generations. Cordocentesis b. Document the mother’s age (disorders increase in Is the removal of blood from the fetal umbilical cord at about incidence with age). 17 wks. using an amniocentesistechnique. c. Document whether the parents are consanguineous or Allows analysis of blood components and more rapid related to each other. karyotyping than is possible d. Documenting the family’s ethnic background can reveal f. Fetal Imaging - used to assess a fetus for general size risks for certain disordersthat occur more commonly in some and structural disorders of the internal organs, spine and ethnic groupsthan others. limbs e. Extensive prenatal history of any affected person should a. Magnetic Resonance Imaging (MRI) be obtained to determine whether environmental conditions b. Ultrasound could account for the condition. g. Fetoscopy – the insertion of a fiberoptic fetoscope 2. Physical Assessment through a small incision in the abdomen into the uterus to a. Physical assessment of any family member with a visually inspect the fetus for gross abnormalities. disorder, child’s siblings, the couple seeking counseling is h. Preimplantation Diagnosis – possible for In-Vitro needed. Fertilization (IVF) b.During inspection, pay particular attention to certain body Provide genetic information extremely early in a pregnancy areas (space between the eyes; the height, contour,shape of A fertilized ovum removed from the uterus by lavage before ears,number of fingers and toes, presence of webbing) implantation and studied for DNA analysis Note: Abnormal fingerprints or palmar creases, abnormal The ovum would then be reinserted or not, depending hair whorls or coloring of hair on the findings and the parents’ wishes. c. Careful inspection of newborns to identify a child with a potential chromosomal disorder. Infants with multiple congenital anomalies, born less than 35 HIGH RISK PREGNANT CLIENT weeks’ gestation, and whose parents have other children LEARNING OBJECTIVES: with chromosomal disorders need extremely close 1. Define high-risk pregnancy including pre existing factors assessment. that contribute to its development. 3. Diagnostic Testing 2. Assess a woman with an illness during pregnancy for a. Karyotyping – a sample of peripheral venous blood or a changes occurring in the illness because of the pregnancy scraping of cells from the buccal membrane. 3. Determine assessment methods and care for continuing Cells are stained, placed under a microscope, photographed prenatal visit and chromosomes are identified size, shape, and stain, cut High Risk Pregnancies from the photograph, and arranged. Pregnancy with a chronic condition such as cardiovascular or b. Maternal Serum Screening Alpha-fetoprotein (AFP) - is kidney disease, unintentional injury or develops chronic a glycoprotein produced by the fetal liver and reaches a peak illness during pregnancy, both mother and the fetus can be at in maternal serum between the 13th and 32nd wk. of risk for complications. pregnancy. done routinely at the 15th wk. of pregnancy. Identifying a High - Risk Pregnancy 30% has false-positive rate if the date of conception is not High – risk pregnancy- is a concurrent disorder, pregnancy- well documented related complication, or external factors that jeopardizes the c. Chorionic Villi Sampling – a diagnostic technique that health of the woman, the fetus, or both. involves the retrieval and analysis of chorionic villi from the Risk Factors - findings that suggest pregnancy may have a placenta for chromosome or DNA analysis negative outcome, for either the woman or her unborn child. May be done as early as wk. 5 of pregnancy, more Assessments and Care for Continuing commonly done at 8 to 10 weeks. Prenatal Visits Instruct a woman to report chills or fever suggestive of infection or symptoms of threatened miscarriage (uterine 1. Health Interview contractions orvaginal bleeding). a. Interim history or new personal or family developments Women with an Rh-negative blood type need Rh immune since last visit globulin administration after the procedure to guard against b. Review danger signs of pregnancy isoimmunization in the fetus. c. Review symptoms of beginning labor The cells removed in CVS are karyotyped or for DNA 2. Physical examination analysis to reveal whether the fetus has a genetic disorder. a. Blood Pressure (every visit) If a twin or multiple pregnancy is present, with two or more b. Clean-catch urine for glucose, protein, and leukocytes separate placentas, cells should be removed separately from (every visit) each placenta. c. Blood serum level for Maternal serum Alpha- fetoprotein Because fraternal twins are derived from separate ova, one test (MSAFP) (16 weeks) twin could have a chromosomal abnormality while the other High AFP - neural tube defects (Spina bifida) does not. Low AFP – chromosomal anomaly (Trisomy 21) d. VDRL - test for syphilis if possibility of new exposure e. Glucose screen (28 weeks) 3 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle f. Glucose challenge test (24–28 weeks) Factors: g. Anti-Rh titer(28 weeks) 1. Maternal Age h. Group B streptococci (GBS) (35–37 weeks) Age: under 16 y/o 3. Fetal Health Maternal implications: Fetal heart rate Fundal height Poor Nutrition Quickening or fetal movement Poor Antenatal care Ultrasound dating of pregnancy Risk Pre eclampsia Risk Cephalopelvic disproportion Assessments that might categorize a Fetal or Neonatal Implications: “ Pregnancy at Risk ” Low Birth Weight 1. Obstetrical History Fetal demise 2. Medical History Factors: 3. Psychosocial Factors 4. Demographic Factors (Lifestyle) 1. Maternal age Age: above 35 y/o 1. Obstetric History Maternal implications: History of subfertility Risk Preeclampsia Previous premature cervical dilatation Risk Cesarean birth Existing uterine or cervical anomaly Fetal or Neonatal Implications: Previous preterm labor, preterm birth or CS Congenital anomalies Previous macrosomia infant Chromosomal aberrations Two or more spontaneous miscarriages or Factors: therapeutic abortions Previous hydatidiform Mole 2. Pre-pregnant Weight Previous ectopic pregnancy or stillborn/neonatal Underweight death Weight Previous multiple gestation - < 45.5 kg (100 lbs.) Previous prolonged labor - Less than 18.5 kg. Previous low-birth-weight infant Normal weight gain Previous mid forceps birth - 18.5 – 24.9 kg. Last pregnancy less than 1 year Maternal implications: Previous infant with neurologic deficit, birth injury, or Preterm or post term birth congenital anomaly Iron-deficiency anemia 2. Medical History Poor nutrition Cardiac or pulmonary disease, chronic hypertension Cephalopelvic disproportion Metabolic disease such as diabetes mellitus Prolonged labor Renal disease, recent urinary tract infection, or Fetal or Neonatal Implications: bacteriuria Low-birth weight Gastrointestinal disorders Preterm birth Seizure disorders IUGR Family history of severe inherited disorders Hypoxia associated with difficult labor and birth Surgery during pregnancy Factors: 3. Psychosocial Factors Pre-pregnant Weight Inadequate finances Overweight: Lack of support person - Weight > 91 kg (200 lbs.) Adolescent Maternal implications: Poor nutrition More than two children at home; no help Hypertension Lack of acceptance of pregnancy Gestational or Type 2 diabetes Attempt or ideation of suicide Cephalopelvic disproportion Inadequate or poor housing Risk for Cesarean birth Father of baby uninvolved Thrombophlebitis Dangerous occupation Difficulty hearing FHT, palpating fetal position Dysfunctional grieving Fetal or Neonatal Implications: Psychiatric history Postmature infants 4. Demographic Factors(Lifestyle) Macrosomia Maternal age under 16 or over 35 Factors Family History: Education less than 11 years Severe inherited disorders Cigarette smoking greater than 10 cigarettes a day Maternal implications: or living with a person who smokes Heavy lifting or long periods of standing Risk for miscarriage Unusual Stress Preterm birth No in-home smoke detectors Fetal or Neonatal Implications: Prenatal High-Risk Factors Genetic disorders 4 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle Fetal death Maternal implications: Chromosomal abnormalities Poor antenatal care Maternal Habits: Poor nutrition Smoking one pack per day or more Risk for Preeclampsia Maternal implications: Fetal Neonatal Implications: Risk for Hypertension Low birth weight Risk for Cancer Intrauterine growth restriction Fetal Neonatal Implications: Social and Personal factors: Low birth weight Poor diet IUGR Preterm birth Maternal implications: Stillbirth Inadequate nutrition ↓ Placental perfusion Risk for anemia ↓ Oxygen and nutrients available Risk for preeclampsia Maternal Habits: Fetal Neonatal Implications: Excessive Alcohol consumption Fetal malnutrition Maternal implications: Prematurity Poor nutrition Factors: Possible hepatic effects with long term consumption Multiparity > 3 Fetal Neonatal Implications: Maternal implications: Risk for Fetal alcohol Risk for antepartum or Postpartum hemorrhage Syndrome Fetal Neonatal Implications: Maternal Habits: Anemia Use of addicting Drugs Fetal death Maternal implications: Factors: Poor nutrition Living at high altitude Risk for Hepatitis C or HIV The amount of hemoglobin in blood increases at Abruptio placenta high altitude STI Maternal implications: Preterm labor Increased BP, tachycardia ↑ Hemoglobin Vasoconstriction Fetal Neonatal Implications: Fetal Neonatal Implications: Prematurity Congenital anomalies IUGR IUGR Hemoglobin (Polycythemia) Preterm birth Decreased fetal heart rate Screening Procedure Fetal death 1. Ultrasonography Risk low birth weight - measures the response of sound waves against Neonatal withdrawal solid objects. Maternal Habits: a. Diagnose pregnancy as early as 6 weeks’ gestation Food fads b. Confirm the presence, size, and location of the placenta and amniotic fluid Maternal implications: c. Establish that a fetus is growing and has no gross Premature birth anomalies (Hydrocephalus, Anencephaly, or spinal cord, Uterine contractions heart, kidney, and bladder defects Miscarriage d. Establish sex if a penis is revealed Fetal Neonatal Implications: e. Establish the presentation and position of the fetus Fetal abnormalities Ultrasounds may be used to detect: Prematurity a. Biparietal Diameter – to predict fetal maturity Maternal Habits: by measuring the biparietal diameter of the fetal head. Herbs and botanical medicine b. Doppler Umbilical Velocimetry (Doppler ultrasonography) Maternal implications: c. Placental Grading d. Amniotic Fluid Volume Assessment Premature birth 2. Electrocardiography Uterine contractions 3. Magnetic Resonance Imaging Miscarriage 4. Maternal Serum Alpha-fetoprotein Fetal Neonatal Implications: 5. Triple Screening Fetal abnormalities - MSAFP, estriol, hCG Prematurity 6. Chorionic Villi Sampling Social and Personal factors: 7. Amniocentesis Low Income level and Low educational level 8. Percutaneous Umbilical Blood Sampling 5 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle 9. Amnioscopy 1. Spontaneous Miscarriage - is visual inspection of the amniotic fluid with amnio - without medical or mechanical intervention scope 2. Induced abortion 10. Fetoscopy - with medical or mechanical intervention 11. Biophysical Profile Legal Aspects: - with five parameters (fetal reactivity, fetal breathing a. Only allowed for medical indications movements, fetal body movements, fetal tone and b. If continuation of pregnancy is risk to life of the woman amniotic fluid) c. At least two medical doctors should reach the decision and sign HIGK RISK PREGNANCY (BLEEDING d. Elective abortion is unlawful and considered a criminal act. Complications: DISORDER) a. Perforation of uterus, intestines, urinary bladder LEARNING OBJECTIVES: b. Severe hemorrhage which may lead to hypovolemic shock 1. Describe sudden complications of pregnancy that place a c. Sepsis and its associated complications, pregnant woman and her fetus at high risk. Spontaneous Miscarriage 2. Assess a woman who is experiencing a complication of Abortion pregnancy - termination of pregnancy before the age of viability 3. Identify expected outcomes to minimize the risks to a Viable fetus pregnant woman and her fetus when sudden complications - a fetus before 20-24 wks. of gestation, and weighs of pregnancy occur. at least 500 grams 4. Implement nursing care specific to a woman who has Types of Spontaneous Miscarriage: developed a sudden complication of pregnancy. 1. Threatened spontaneous Miscarriage Bleeding Disorders 2. Imminent (inevitable) Miscarriage - Vaginal bleeding during pregnancy is a deviation from the 3. Missed Miscarriage normal, may occur at any point during pregnancy, and is 4. Incomplete spontaneous Miscarriage always frightening. 5. Complete spontaneous Miscarriage 6. Habitual 3 or more consecutive Any degree of bleeding, needs to be evaluated; 7. Septic a. Significant blood loss b. Hypovolemic shock Miscarriage c. Danger to the fetal blood supply - is a premature or immature birth Spontaneous Miscarriage Blood Loss - occurs in 15% - 30% of all pregnancies and arises ↓ from natural causes. Decreased intravascular volume a. Early miscarriage – occurs before week 16 of pregnancy ↓ b. Late miscarriage – occurs between week 16 and 20 of Decreased venous return, decreased cardiac output, and pregnancy lowered BP Common Causes of Spontaneous Miscarriage: Body compensating by: 1. Abnormal Fetal Development a. increasing HR to circulate the decreased volume faster - a. Teratogenic factors b. Vasoconstriction of peripheral vessels (to save blood to - b. Chromosomal aberration vital organs) 2. Immunologic factors or rejection of the embryo through c. Increased RR and a feeling of apprehension at body immune response changes 3. Implantation abnormalities - 50% Zygote never implant securely Blood Loss Causes: ↓ - a. Inadequate endometrial formation Cold clammy skin, decreased uterine perfusion - b. Inappropriate site of implantation ↓ - c. Failure of the corpus luteum to produce enough In the of continued blood loss, although the body shifts fluid progesterone from interstitial spaces into intravascular spaces, BP will 4. Ingestion of alcohol at the time of conception continue to fall 5. Urinary tract infection - associated with preterm birth. ↓ 6. Systemic infection Reduced renal, uterine, and brain perfusion Cause: ↓ Rubella, Syphilis, Poliomyelitis Cytomegalovirus, Lethargy, coma, decreased renal output Toxoplasmosis ↓ Assessment: Renal failure 1. Vaginal spotting / bleeding ↓ 2. Description of the bleeding Maternal and Fetal death 3. Associated symptoms - cramping, sharp or dull pain 4. History of bleeding episode Bleeding Disorders 5. Actions taken by the pregnant woman before and during Types: the episode of bleeding 6 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle Types of Miscarriage D&E (Dilatation and evacuation (D&E) – the dilatation of the 1. Threatened Miscarriage cervix and surgical evacuation of the uterus to remove all Early under 16 wks. pregnancy tissue Late -16-24 wks. Health Teaching: 50% - continue the pregnancy, 50% changes from After discharge threatened to immanent or inevitable miscarriage 1. Instruct client to assess their vaginal bleeding by recording Cervical os is closed and the product of conception the number of pads used have not been expelled Note: Symptoms: Saturating more than one pad per hour is abnormally heavy a. Vaginal bleeding – initially scant and bright red bleeding b. Slight uterine cramping Complete Miscarriage c. No cervical dilatation on vaginal examination 3. Complete Miscarriage (Close cervix) the entire products of conception are expelled d. Product of conception have not been expelled spontaneously without any assistance (Fetus, Cause: membranes, and placenta) Unknown – possibly Cause: a. Chromosomal abnormalities 1. Unknown b. Uterine abnormalities 2. Chromosomal abnormalities Diagnosis Test: 3. Uterine abnormalities a. Blood exam – test for HCG hormones at the start of Symptoms: bleeding and again in 48 hrs. if the placenta is still intact, the 1. Vaginalspotting level of HCG in the bloodstream should double in this time 2. Cramping b. Ultrasound – to evaluate the viability of the fetus 3. Cervical dilatation c. Assess fetal heart sounds 4. Complete expulsion of uterine contents Management: - Bleeding usually slows within 2 hours and ceases a. Avoidance of strenuous activity for 24-48 hrs. within a few days after passage of the products of b. Complete bed rest conception c. Coitus must be restricted for 2 wks. to prevent infection Management: and to avoid inducing further bleeding 1. No Therapy (process is complete) d. Once bleeding stops, can gradually resume normal 2. Advice the client to report heavy bleeding activities Incomplete Miscarriage 4. Incomplete Miscarriage 2. Imminent (Inevitable) Miscarriage - the part of the fetus is expelled but the membranes If uterine contraction and cervical dilatation occur, or placenta are retained in the uterus the loss of the product of conception cannot be Cause: halted. 1. Unknown Cause: 2. Possible chromosomal or uterine abnormalities 1. Unknown reasons High Risk: 2. Possible Poor placental attachment Hemorrhage and Uterine infection Symptoms: Symptoms: a. Cervical dilatation (Cervical os open) 1. Vaginal spotting b. Uterine contractions 2. Cramping c. Cramping 3. Cervical dilatation (Open cervix) d. Vaginal spotting to heavy bleeding 4. Incomplete expulsion of uterine contents Danger: Maternal Hemorrhage Management: Diagnosis Test: 1. Dilatation & Curettage 1. Assessment of fetal heart sounds 2. Suction curettage 2. Ultrasound Missed Miscarriage Management: 5. Missed Miscarriage 1. Assessment The fetus dies in utero but is not expelled. (Early 2. Save any tissue fragments – to established that all pregnancy failure) products of conception have been removed and to analyze Cause: abnormalities(H-mole) and recording the number of pads used. Unknown If no fetal heart sounds detected and Ultrasound reveals 1. Possible chromosomal abnormalities empty uterus or nonviable fetus reveal 2. Uterine abnormalities 3. D&C or D & E Diagnosis Test: D & C (Dilation and curettage) – the dilatation of the cervix a. Fundal height measurement - no increase in size during and surgical removal of part of the lining of the uterus and prenatal exam the contents by scraping and scooping b. Ultrasound – establish embryo died 4 to 6 wks. before onset of miscarriage symptoms or failure of growth was noted 7 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle c. Absence of fetal heart sounds 4. Obtaining hemoglobin and hematocrit levels and securing Symptoms: blood sample for blood typing or cross-matching 1. Vaginalspotting 5. Administer oxygen by mask and monitor oxygen saturation 2. Slight cramping levels by pulse oximetry for rapid respiration Management: 6. Urge the client to rest in a left side-lying position to help prevent vena cava compression 1. D & C (Dilatation and Curettage) 7. Continue to provide information about care and emotional 2. D & E (Dilatation and Evacuation) support 3. Pregnancy over 14 wks. may induced labor Complications of Miscarriage a. Prostaglandin suppository or Misoprostol (Cytotec) - introduced into the cervix to cause dilatation 1. Hemorrhage b. Administration of Mifepristone - an oxytocin stimulation Nursing Intervention: which cause uterine contractions and birth. a. Monitor vital signs – to detect Hypovolemic shock If pregnancy is not actively terminated, miscarriage b. Excessive vaginal bleeding - position flat and massage occurs spontaneously within 2 wks. uterine fundus to aid contraction Danger: c. Apply Pneumatic Antishock garments – to maintain blood Disseminated Intravascular Coagulation (DIC) – may pressure develop if the dead (and possibly toxic) fetus remains too d. D & C or suction curettage long in utero e. Oral medication of methylergonovine maleate Recurrent Pregnancy Loss (Habitual Aborters) (Methergine) to aid uterine contraction 6. Recurrent Pregnancy Loss ( “habitual aborters” f. Blood Transfusion to replace blood loss woman who had three spontaneous miscarriages g. Direct replacement of fibrinogen or another clotting factor that occurred at the same gestational age. may be used to increase coagulation ability Possible Causes: h. Monitor vaginal bleeding (amount, color, odor, or passing of large clots) 1. Defective spermatozoa or ova 2. Endocrine factors 2. Infection a. Lowered levels of protein-bound iodine (PBI) Escherichia coli – organisms responsible for infection after b. Butanol-extractable iodine (BEI) miscarriage c. Globulin-bound iodine (GBI) spread from the rectum forward into the vagina d. Poor thyroid function (Luteal phase defect) Caution: 3. Deviations of the uterus(Bicornuate uterus) 4. Resistance to uterine artery blood flow client to always wipe their perineal area from front to back 5. Chorioamnionitis or uterine infection (E-coli) after voiding and after defecation to prevent spread of 6. Autoimmune disorder bacteria Endometritis - inner lining of the uterus Immediate Assessment of Vaginal e Parametritis Peritonitis bleeding during Pregnancy Thrombophlebitis 1. Confirmation of Pregnancy - (+) Pregnancy test Septicemia 2. Pregnancy length – Age of Gestations Nursing Intervention: 3. Duration – how long did the bleeding episode last? 4. Intensity – how much bleeding occurred 1. Observe closely for fatal complication 5. Description – blood mixed with amniotic fluid or mucus? 2. Be certain that the client is familiar with danger signs of 6. Frequency – Steady spotting? A single episode? infection 7. Associated Symptoms – Cramping? Sharp pain? Dull a. Fever higher than 100.4 ◦ F (38.0 ◦ C) pain? Has she ever had cervical surgery? b. Abdominal pain or tenderness 8. Action – what was she done to control the bleeding c. Foul smelling vaginal discharge 9. Blood Type – Rh (-) patient need Rh Immunoglobulin to 3. Advise the client not to use tampons prevent Isoimmunization Bleeding During Pregnancy 3. Septic Abortion an abortion that is complicated by infection after a Signs and symptoms of Hypovolemic shocks spontaneous miscarriage more frequently in women Signs and symptoms of Hypovolemic shocks: who have tried to self-abort or were aborted illegally 1. Increase Pulse Rate using a non sterile instrument 2. Decreased Blood Pressure Symptoms: 3. Increased Respiratory Rate 1. Fever, crampy abdominal pain 4. Cold clammy skin 2. Uterine tenderness upon palpation 5. Decreased urine output 3. If left untreated, infection can lead to: 6. Dizziness or decreased level of consciousness (Toxic shock syndrome, Septicemia, Kidney failure, Death) 7. Decreased central venous pressure Assessment and Treatment: Management of Hypovolemic Shocks: 1. CBC, serum electrolytes, serum creatinine 1. Assessment of vital signs and fetal and continuous fetal 2. Blood type and crossmatch monitoring 3. Cervical, vaginal, and urine cultures 2. Intravenous fluid replacement (Ringer’s lactate) 4. Insertion of indwelling urinary catheter to monitor urine 3. Use large-gauge angiocath (16 or 18 for rapid fluid output hourly to assess kidney function expansion and blood transfusion) 8 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle 5. Provide a route for high-dose, broad- spectrum antibiotics 1. Pregnancy test – HCG (+) (Combination of Penicillin, Gentamicin and Clindamycin) 2. Ultrasound – 6 -12 wks. of pregnancy 6. Dilatation and Curettage or Dilatation and evacuation to (Transvaginal ultrasound) demonstrate ruptured remove all infected or necrotic tissue from the uterus tube and blood collecting in the peritoneum 7. Tetanus toxoid subcutaneously or tetanus immune globulin 3. Magnetic Resonance Imaging (MRI) -if not given intramuscularly revealed by an Ultrasound Side Effects: Clinical Manifestations: 1. Infertility because of uterine scarring or fibrotic scarring of 1. Sharp, stabbing pain in one of the lower abdominal the fallopian tubes quadrants at the time of rupture (Unilateral) 2. Infection by trying to Self abort – needs follow-up 2. Dark red or brown vaginal bleeding counseling to assist the client to learn better problem-solving 3. Blood loss – hypotension, lightheadedness, signs of methods for the future severe shock 4. Leukocytosis 4. Isoimmunization 5. Rigid abdomen from peritoneal irritation (Rh incompatibility) is a condition that happens 6. Cullen sign – bluish-tinged discoloration around the when a pregnant woman’s blood protein is umbilicus due to hemoperitoneum incompatible with the baby’s, causing her immune 7. Pain in the shoulder caused by irritation of the phrenic system to react and destroy the baby’s blood cells nerve 8. Dull vaginal and abdominal pain 5. Powerlessness or Anxiety 9. Tender mass palpable in cul-de-sac on vaginal Management: examinations 1. Assess a woman’s adjustment to a spontaneous Therapeutic Management: miscarriage. 1. Oral administration of methotrexate followed by leucovorin a. Sadness and grief over the loss - unruptured ectopic pregnancy b. Feeling that a woman has lost control of her life is to be Methotrexate – is a folic acid antagonist, expected. chemotherapeutic agent, that attacks and destroys 2. Assess a partner’s feelings or that person’s grief over the fast-growing cells. pregnancy loss Treated until a Negative hCG titer is achieved Primary causes of Bleeding during Pregnancy 2. Hysterosalpingogram or Ultrasound - performed after the First and Second Trimester chemotherapy to assess whether the tube is fully patent. 1. Miscarriage 3. Mifepristone - an effective causing sloughing of 2. Ectopic Pregnancy the tubal implantation site implantation occurred outside the uterine cavity 4. Blood sample for hemoglobin level test Common Site of Implantation: 5. Blood typing and cross-matching 6. Intravenous fluid using a large-gauge catheter to restore 1. Fallopian tube – 95% intravascular volume a. Ampulla – 80% 7. Culdoscopy - is a procedure to closely examine cervix, b. Isthmus – 12% vagina and vulva for signs of disease. c. Interstitial or fimbria – 8% 8. Laparoscopy - a surgical procedure using fiber-optic 2. Cervix instrument is inserted through the abdominal wall to view the 3. Ovary organs in the abdomen or to permit a surgical procedure 4. Abdomen Purpose: Causes: 1. To ligate the bleeding vessels 1. Adhesion of the fallopian tube 2. To remove or repair the damaged fallopian tube. a. Previous infection (Chronic salpingitis or Pelvic Surgical Management: inflammatory disease) 9. Laparotomy – Salpingectomy – is a surgical incision into b. Congenital malformations the abdominal cavity to remove one (unilateral) or both c. Scar from tubal surgery (bilateral) fallopian tubes d. Uterine tumor 10. Antibiotic 2. Congenital anomalies Therapeutic Management: a. Webbing (fibrous bands) Predisposing factors: 10. Administration of (RhIG) RhoGAM to Rh (-) negative mothers 1. Cigarette Smoking Nursing Care: 2. Intrauterine devices (IUDs) - may slow the transport of the 1. Vital signs zygote 2. Administer IV fluids 3. Previous ectopic pregnancy (10% to 20% because of 3. Monitor for vaginal bleeding Salpingitis leaves scarring usually bilateral). 4. Monitor I & O Assessment: 1. No unusual symptoms at the time of implantation 2. No menstrual flow occurs. 3. Nausea and vomiting of early pregnancy 4. Pregnancy test positive for hCG (+) Diagnosis Test: 9 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle SECOND AND THIRD TRIMESTER - some of the trophoblastic villi form normally. a. Syncytio trophoblastic layer appears swollen and BLEEDING DISORDERS misshapen. b. Embryo may grow for about 9 wks. LEARNING OBJECTIVES: c. Partial mole rarely lead to Choriocarcinoma 1. Assess a woman who is experiencing a complication of d. Partial mole has 69 Chromosomes (69 XX or 69 XY) pregnancy. Paternal and Maternal 2. Implement nursing care specific to a woman who has There are three chromosomes instead oftwo for developed a sudden complication of pregnancy. every pair Primary causes of Bleeding during Pregnancy One set supplied by an ovum fertilized by two sperm. Second Trimester Third Trimester An ovum fertilized by one sperm in which meiosis did not occur. 1. Gestational 1. Placenta Previa Assessment: Trophoblastic Disease 2. Abruptio Placenta 1. Overgrowth of uterus 2. Premature Cervical 3. Preterm labor 12th wk. AOG - fundus is over the symphysis brim 20-24 wk. Dilatation AOG - at the umbilicus 2. Serum and Urine test of hCG (+) 1-2 million IU compared Gestational Trophoblastic Disease (H- mole) with normal pregnancy level of 400,000 IU Trophoblast – are cells forming the outer layer of a 3. Nausea and vomiting (High hCG level) blastocyst 4. Vaginal spotting of dark brown discharges with clear fluid-filled vesicles. Function: 5. Ultrasound - no Fetal growth no Fetal heart sounds. Provide nutrients to the embryo and develop into a Therapeutic Management: large part of the placenta. 1. Suction curettage – to evacuate the abnormal Trophoblast play an important role in embryonic implantation cells. and interaction with the decidualized maternal Following mole extraction: uterus. 1. Pelvic examination Fertilization 2. Serum test – HCG level analyzed Blastocyst – an embryo that is developed after fertilization every 2 wks. until levels are normal Abnormal proliferation and degeneration of the every 4 wks. for 6 - 12 months trophoblastic villi, as the cells degenerate they 3. Prophylactic Methotrexate – drug of choice for become filled and appear as clear fluid-filled, grape- choriocarcinoma sized vesicles 4. Oral estrogen/progesterone contraceptives The incidence of Gestational Trophoblastic disease 5. Dactinomycin – can be added if metastasis occur is approximately 1 in every 1500 pregnancies Cervical Insufficiency The embryo fails to develop due to abnormal (Premature Cervical Dilatation) Trophoblast cells produced. Incompetent Cervix - Associated with Choriocarcinoma - a cervix that dilates prematurely and cannot retain a High Risk: fetus until term. 1. Low protein intake occur at approximately week 20 of pregnancy. 2. Older than 35 y/o associated with 3. Asian 1. Increased maternal age 4. Blood Group A women who marry Blood Group O 2. Congenital structural defects 5. Incidence of GTD have increase risk of 2nd h-mole 3. Cervical trauma pregnancy Diagnosis Test: Diagnosis Test: Early Ultrasound before sign and symptoms occur 1. Ultrasound - show dense growth (snowflake pattern) Sign and Symptoms: 2. Chromosomes Analysis 1. Painless cervical dilatation a. Maternal Serum Screening 2. Bloody show (Pink-stained vaginal discharge) b. Chorionic Villi Sampling 3. Increased pelvic pressure Types of Gestational Trophoblastic disease 4. Premature rupture of the membrane and discharge of 1. Complete Mole amniotic fluid. - all trophoblastic villi swell and become cystic. Management: if embryo forms: 1. Cervical Cerclage - a purse-string sutures are placed in Dies early at 1-2 mm. in size with no fetal blood present in the cervix by vaginal route under regional anesthesia. the villi 80% - 90% success rate if embryo forms: Types: Chromosomal Analysis: Paternal origin a. Mc Donald procedure - a nylon sutures are placed a. Contributed only by the Father horizontally and vertically across the cervix. (12-14 wks.) b. Empty ovum was fertilized b. Shirodkar - sterile tape is threaded in a purse- string c. Chromosome was duplicated manner under the subcutaneous layer of the cervix 2. Partial mole Note: 10 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle Suture are removed 37th to 38th wks. of pregnancy 8. Administer IVF as prescribed, with large-gauge catheter to After cerclage surgery: allow for blood replacement. 1. Bed rest in a slight or modified Trendelenburg position. 9. Attach external monitoring equipment to record FHS and 2. Avoid coitus and limit activities uterine contractions. Contradictions: 10. Betamethasone - (stimulate fetal lungs maturity) fetus 1. Active labor less than 34 wks. Gestation 2. Premature rupture of membrane 11. Cesarean birth 3. Abruptio placenta Abruptio Previa 4. Active vaginal bleeding Premature separation of a normally implanted 5. Chorioamnionitis – inflammation of fetal membrane due to placenta either partial, marginal or complete that bacterial infection. can lead to extensive bleeding. Primary causes of Bleeding most frequent cause of perinatal death. during Third Trimester of Pregnancy separation occurs late in pregnancy, even as late as Placenta Previa during the 1st and 2nd stage of labor. Is a condition of pregnancy in which placenta Causes: Unknown implanted abnormally in the uterus Predisposing factors: assessed through routine Sonograms 1. High parity Causes: 2. Advanced maternal age 1. Increased Parity 3. Short umbilical cord 2. Advanced maternal age 4. Chronic Hypertensive disease 3. Past cesarean births 5. Hypertension of pregnancy (PIH) 4. Past uterine curettage 6. Direct trauma 5. Multiple gestation 7. Cocaine or cigarette use (Vasoconstriction) 6. Male fetus are all associated with Placenta Previa 8. Thrombosis formation 9. Infection (Chorioamnionitis) – infection of the fetal Diagnosis Test: membrane Ultrasound Sign and Symptoms: Sign and Symptoms: 1. Sharp,stabbing abdominal pain 1. Sudden onset of painless uterine bleeding, (bright-red 2. Uterine tenderness during palpation. discharges) – begins when the lower uterine segment starts 3. Heavy vaginal bleeding accompanies premature to differentiate from the upper segment late in pregnancy separation of the placenta (wk. 30) 4. Signs of hypovolemic shock 2. Bleeding may be profuse or scanty and spotting Hypovolemic shock continuous. the circulatory dysfunction due to bleeding. Fetal Implications: reduction of intravascular blood volume that could a. Congenital fetal anomalies lead to tissue anoxia. b. Fetal restricted growth a. Tachycardia Four Degrees of Placenta Previa b. Hypotension 1. Low-lying placenta c. Shallow respiration 2. Partial Placenta Previa d. Cyanosis 3. Total Placenta Previa 5. Couvelaire uterus – the uterus is purplish in color, 4. Marginal Implantation board-like and rigid as bleeding progresses. Types of Abruptio Placenta: 1. Low-lying Placenta 1. Concealed (Central, Convert) implantation in the lower rather than in the upper 2. Marginal bleeding type portion. 3. Total bleeding type 2. Partial Placenta Previa implantation that occludes a portion of the cervical 1. Concealed (Central, Convert) os. The placenta detaches from the center and blood 3. Total Placenta Previa accumulates behind the placenta. implantation that totally obstructed the cervical os. 2. Marginal bleeding type 4. Marginal Implantation the type that manifests with external hemorrhage. placenta edge approaches the cervical os Vaginal bleeding is dark red “old” blood Management: 3. Total bleeding type 1. Bed rest, side-lying position with no bathroom privileges denotes the degree of placental detachment 2. Monitor blood loss. Do a perineal pad count. Severe hemorrhage, external or internal that fetal 3. Kleihauer- Betke test – a test strip procedure to detect outlook is poor. fetal RBC in the maternal circulation for Rh (-) mother. Degree of Separation Grade Criteria: 4. Obtain baseline vital signs – to detect symptoms of 1. Grade 0 Hypovolemic shock. Assess BP every 5-15 mins. - no symptoms of separation, placenta is examined 5. Never attempt a pelvic or rectal examination – it may after birth and shows recent clot on maternal initiate massive hemorrhage. surface. 6. Laboratory exam – to detect possible clotting disorders. 7. Monitor urine output every hour 11 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle 2. Grade 1 3. Cervical dilatation – greater than 1 cm - minimal separation, cause vaginal bleeding, Risk factors: Maternal factors changes in maternal VS, no occurrence of fetal 1. Excessive fatigue distress and hemorrhagic shock. 2. Maternal infections (UTI, Chorioamnionitis) 3. Grade 2 3. Dehydration - moderate separation, there is evidence of fetal 4. Large fetal size distress, uterus is tense and painful on palpation. 6. Chronic illness or disease (cardiovascular, diabetes, renal) 4. Grade 3 7. Extreme emotional stress - extreme separation, without immediate 8. Intimate partner violence and trauma. interventions, maternal hypovolemic shock and fetal Sign and Symptoms: death will result. 1. Persistent, dull, and low backache. Management: 2. Vaginal spotting 1. Keep the client in left lateral position, reposition at interval. 3. Feeling of pelvic pressure or abdominal tightening 2. Monitor fetal heart sound and record maternal VS every 4. Menstrual-like cramping 5-15 mins. 5. Increased vaginal discharge, uterine contractions, and 3. IVF replacement and Oxygen therapy (to limit fetal anoxia) Intestinal cramping. 4. Baseline fibrinogen (if bleeding is extensive) 6. Pain, discomfort or pressure in the vulva or thighs 5. No abdominal, vaginal or pelvic examination Therapeutic Management: 6. Assess amount and nature of bleeding 1. Hospitalization Preterm Rupture of Membrane 2. Bed rest – left lateral is rupture of fetal membrane with loss of amniotic 3. Monitor FHR and uterine contractions. fluid before 37 wks. of pregnancy. 4. Vaginal, cervical cultures, and clean-catch urine samples. Causes: Unknown 5. Adequate Hydration: Oral and Parenteral Associated with infection of the membranes 6. Drug tocolytics and corticosteroids (Chorioamnionitis) 1. Tocolytic agent - administered to arrest labor by Complications: relaxation of the uterus. 1. Uterine and fetal infection a. Terbutaline – given initially IV, oral, subcutaneous 2. Increased pressure on the umbilical cord Side effects: 3. Cord prolapse – extension of the cord out Cardiorespiratory (fetal tachycardia, ↓BP, chest pain, of the uterine cavity into the vagina. dizziness) 4. Potter - like syndrome – distorted facial features Antidote: Propranolol (Inderal) 5. Pulmonary Hypoplasia – incomplete development of the b. Magnesium sulfate – inhibits labor by stopping premature lungs resulting in abnormally low number or size of alveoli contractions. Sign and Symptoms: Side effects: 1. Sudden gush of clear fluid from the vagina Respiratory depression, and reflexes 2. Differentiated by Nitrazine paper (Acid-Alkaline) Antidote: calcium gluconate Amniotic fluid – alkaline reaction on the paper 2. Corticosteroids - given to enhance maturation of fetal (appear blue) lungs. Urine – causes an acidic reaction (remain yellow) e.g. betamethasone, dexamethasone 3. Positive Ferming – swabbing and drying on a slide and Ordered between 24-34 wks. of gestation, before 34 viewing it in the microscope. wks. if birth is inevitable appearance of a high- estrogen fluid on microscopic Labor that cannot be Halted: (Inevitable) Criteria: examination (Amniotic-fluid) Cervical dilatation 3-4 cm dilated, 50% effacement 4. Presence of high level of (AFP- alpha-fetoprotein) in the ruptured fetal membrane vagina. Method of delivery: Cesarean Section 5. Ultrasound – assess the amniotic fluid index a. To reduce pressure on fetal head 6. Cultures for Neisseria gonorrhea, Group B streptococcus b. To reduce subdural or intraventricular hemorrhage chlamydia. Gestational Conditions 7. Blood test for WBC count, C- reactive protein (increase Hyperemesis gravidarum (Pernicious or Persistent level result (+) rupture of membrane) vomiting) is nausea and vomiting of pregnancy that Note: is prolonged past wk. 12 of pregnancy Avoid vaginal exam due to risk of infections occurs at an incidence of 1 in 200 to 300 women Management: Causes: 1. Strict bed rest 1. Unknown 2. Administration of Corticosteroid – to hasten fetal lung 2. Increase thyroid function maturity. 3. Associated by Helicobacter pylori 3. Prophylactic administration of broad-spectrum antibiotics Sign and Symptoms: 4. Administration of Tocolytic agent if labor begins. Preterm Labor: a. Vomiting b. Fatigue Criteria of Preterm Labor: c. Dehydration 1. Contractions - 4 in 20 mins or 8 in 60 mins and d. Ketonuria progressive change in cervix. e. Weight loss 2. Cervical effacement - 80% or greater 12 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle f. Elevated hematocrit concentration Management: Implications: Hospitalization for 24 hrs. 1. Kidney 1. NPO for 24 hrs. vasoconstriction leads to ↓ blood flow leading to ↑ 2. IVF (3000 ml. RL with added vit. B) Renin, Angiotensin and Aldosterone secretion 3. Antiemetic (metoclopramide (Reglan) substances that increases vasoconstriction and 4. Measure I & O blood volume, further ↑ blood pressure causes 5. If no vomiting for 24 hrs. clear fluid damage to the arterial walls 6. Dry toast, crackers, or cereal every 2-3 hrs., gradually to ↓ blood supply lead to : soft diet then normal diet a. Decreased urine output and Proteinuria 7. TPN if vomiting returns b. Sodium retention (Edema) 2. Pancreas PREGNANCY INDUCED ischemia in the pancreas result in: a. Epigastric pain HYPERTENSION (GESTATIONAL 3. Retina b. Elevated amylase HYPERTENSION) spasm of the arteries in the retina leads to vision changes Three factors that influence Blood pressure: a. Retinal hemorrhage 1. Cardiac Output b. Blindness the amount of blood the heart pumps through the 4. Placenta – poor perfusion reduces fetal nutrients and circulatory system in a minute. oxygen supply. 2. Blood volume Pathophysiologic Events the total amount of circulatory blood in the body. 1. Vasoconstriction and arteriolar vasospasm. 3. Resistance 2. Decrease in circulating volume anything that works against the blood flow to the 3. Activation of the coagulation system artery. a. Flexibility b. Diameter Predisposing factors: c. Blood viscosity 1. Multiple pregnancy 2. Primipara younger than 20 y/o or older than 40 y/o Pregnancy InducedHypertension (PIH) 3. Low socioeconomic backgrounds Is a condition in which vasospasm occursin both 4. Five or more pregnancies small and large arteries. 5. Client with Polyhydramnios – over production of amniotic develops during pregnancy and regresses in the fluid postpartum period. 6. Diseases (heart disease, diabetes with vessel or renal occursin 5% to 7% of pregnancies involvement, hypertension ) Beginning about 20th wk. of pregnancy Maternal Implication: “Toxemia of Pregnancy” produced “Toxin” in response to the foreign protein 1. Increase blood pressure of the growing fetus and the toxin lead to the typical 2. Decrease perfusion symptoms. 3. Ischemia of various organs(kidney, pancreas, liver, brain Cause: Unknown and Placenta) Fetal Implication: correlated with Antiphospholipid antibodies in maternal blood 1. Intrauterine growth restriction occurs when the immune system mistakenly attacks 2. Low birth weight the normal protein in the blood causes blood clots 3. Prematurity formation 4. IUFD Types of Pregnancy Induced Hypertension Vascular Spasm – occur due to increased cardiac output 1. Gestational Hypertension required by pregnancy 2. Mild Preeclampsia ↓ 3. Severe Preeclampsia Injuries to the endothelial cells of the arteries 4. Eclampsia ↓ Gestational Hypertension Vasoconstriction and Increase Blood Pressure 1. Gestational Hypertension ↓ Blood pressure is 140/90 mmhg. Reduces blood supply to organs No proteinuria or edema ↓ Blood pressure returns to normal after birth. (Kidney, pancreas, liver, brain, Placenta) Nursing Intervention: ↓ 1. BP monitoring Result in signs and symptoms 2. Low salt diet 3. No drug therapy Pathophysiologic Events Mild Preeclampsia Reduces Blood supply to organs 2. Mild Preeclampsia Hypertension, Proteinuria and Edema. 13 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle a. Blood Pressure - is 140/90 mmhg 5. Administer drugs: Systolic BP – elevates to 30 mmhg a. Hypotensive (Hydralazine(Apresoline), Labetalol Diastolic BP – elevates to 15 mmhg above pre (Normodyne), Nifedipine pregnancy level - ↓ Hypertension BP is taken on two occasions at least 6 hrs. apart. it lower blood pressure by peripheral dilatation and b. Mild edema in upper extremities or face – due to thus do not interfere with placental circulation sodium retention lowered glomerular filtration rate Monitor PR, BP before and after administration – c. Weight gain over 2 lb./ wk. in second trimester causes maternal and 1 lb./ wk. in 3rd trimester tachycardia – administered slowly to avoid sudden d. Proteinuria of 1+ to 2+ on a random sample. drop of BP Nursing Intervention: Diastolic pressure should not be lowered below 80 1. Monitor Antiplatelet Therapy - low- dose aspirin may – 90 mmhg – cause inadequate placental perfusion prevent or delay the development of Preeclampsia (Aspirin b. Magnesium Sulfate – (anticonvulsant) drug of choice to 81 mg.) prevent eclampsia 2. Provide emotional support (potential serious of symptoms) IV in a loading dose, act immediately but the effect Eclampsia lasts for 30-60 mins, administration must be 3. Severe Preeclampsia continuous risk for Eclampsia Dose: initial - 2-6 grams IV in 250ml solution over 20 min followed by individually calculated IV Sign and Symptoms: infusion 1. Blood pressure is 160/110 mmHg. Symptoms of overdose from Magnesium sulfate: Systolic increase greater than 30 mm hg Diastolic pressure greater than 15 mm hg. 1. Decrease urine output 2. Proteinuria 3+ to 4+ on a random urine sample. 2. Depressed respiration 3. Cerebral or visual disturbances (Headache, blurred vision) 3. Reduced consciousness 4. Nausea or vomiting 4. Decreased deep tendon reflex 5. Pulmonary edema (shortness of breath) Adverse Effects: 6. Extensive peripheral edema Flushing, thirst, with toxicity, absence of DTR, Assessment: EDEMA respiratory depression, cardiac arrhythmias, cardiac 0 + - No pitting edema arrest, decreased urine output 1 + - if the tissue can be indented slightly and 1. Monitored urine output disappear rapidly Severe oliguria – less than 100 ml. in 4 hrs. 2 + - moderate indentation Urine output should be over 30 ml/hr.,sp. Gravity 3 + - moderately severe edema - deep indentation 1.010 or lower 4 + - severe pitting edema 2. Maintain Serum magnesium level should remain below 75 7. Epigastric pain meq/l 8. Oliguria- 500 ml. or less in 24 hrs. 3. RR 12 bpm altered renal function test 4. Minimal ankle clonus, DTR present elevated serum creatinine more than 1.2 mg,/dl 5. Observe for CNS depression and hypotonia in infant at 9. Hepatic dysfunction birth and calcium deficit in mother 10. Thrombocytopenia 6. Calcium gluconate – antidote for Mag SO4 toxicity –available at bedside Nursing Intervention: Dose: 1 gram IV (10 ml. of 10% solution) 1. Support bed rest - left recumbent position greater blood 7. Monitor FHR and observe fetal effects (late deceleration of flow to the uterus uterine contractions) Place the client in a private room. Eliciting A Patellar Reflex And Ankle Clonus a. Darken the room – bright light can trigger seizures Patellar Reflex b. Visitors are restricted 1. Place the woman in a supine position, ask her to bend her c. Raise side rails to prevent injury if seizure occur knee slightly. 2. Support a nutritious intake – moderate to high protein diet, 2. Place your hand under her knee to support the leg. moderate in sodium 3. Locate the patellar tendon in the midline just below the 3. Monitor Maternal Well- being: kneecap. a. Monitor Blood Pressure every 4 hrs. to detect for any 4. Strike it firmly and quickly with a reflex hammer or theside increase of your hand. b. Obtain blood studies (CBC, platelet, liver function, BUN, If the leg and foot move, a patellar reflex is present. creatinine and fibrin) – to assess renal and liver function and The reflex is scored as: DIC often accompanies severe vasospasm c. Blood typing and cross matching – at risk for abruptio 0 - No response; hypoactive; abnormal placenta (Bleeding) 1+ - Somewhat diminished response but not abnormal 4. Monitor Fetal Well- being: 2+ - Average response a. Doppler auscultations every 4 hrs. intervals 3+ - Brisker than average but not abnormal b. Nonstresstest or biophysical profile – to assess 4+ - Hyperactive; very brisk; abnormal uteroplacental insufficiency. c. Oxygen administration to the mother – to maintain Ankle Clonus - an involuntary and rhythmic muscle adequate fetal oxygenation contraction caused by permanent lesion in descending motor neurons. 14 I Jebby  OUR LADY OF FATIMA UNIVERSITY - QUEZON CITY BACHELOR OF SCIENCE IN NURSING SUBJECT: NCMA 219 CARE OF MOTHER, CHILD AT RISK OR PROBLEMS (ACUTE & CHRONIC) Transes by: Jebsen B. Sacanle Clonus may be found at the ankle, patella, triceps, Primary care for Tonic - Clonic Seizures wrist, biceps Nursing Responsibilities: 1. To Elicit ankle clonus, dorsiflex the woman's foot three 1. Maintain patent airway to prevent aspiration times in rapid succession. Turn onto the side to allow secretions to drain in As you take your hand away, observe the foot. If no their mouth. further motion is present, no ankle clonus is 2. MagSo4 or diazepam may be administered by IV as present. emergency measures 2. if the foot continues to move involuntarily, clonus is 3. Assess O2 saturation via pulse oximeter present, rated as present or absent 4. Administer O2 by face mask as needed to protect fetal Mild - (2 movements) oxygenation Moderate - (3–5 movements) 5. Apply external fetal monitor to assess FHR Severe - (over 6 movements) 6. Assess uterine contractions and check for vaginal Nursing Intervention: bleeding to detect placental separation If pregnancy is greater than 34 wks. Labor should be induced or a Cesarean birth Stage II Clonic Stage performed - lasts up to 1 min. If pregnancy is less than 34 wks. – intervention to 1. Bladder, bowel muscles contract and relax - incontinence alleviate symptoms and allow to continue of urine and feces pregnancy 2. Remain cyanotic - breathing is not entirely effective Eclampsia 4. Eclampsia Stage III Postictal Stage either seizure or coma accompanied by signs and - unconscious and cannot be roused except for symptoms of preeclampsia. painful stimuli for 1 - 4 hrs. happens late in pregnancy but can happen up to 48 Nursing Responsibilities: hrs. after childbirth 1. Extremely closed observation and assess for uterine Ineffective tissue perfusion (vasoconstriction of contraction blood vessel) 2. Keep the client on her side to drain secretion from their Deficient fluid volume related to fluid loss to mouth subcutaneous tissue Head tilted to keep the airway open Risk of fetal injury ( reduced placental perfusion) Knee stops the body from rolling onto stomach Social isolation (prescribed bed rest) Hand supports head and mouth is toward the Symptoms: ground 1. BP ↑, temperature ↑(103◦F- 104◦F (39◦C- 40◦C) 3. NPO 2. Blurring of vision or severe headache (increase cerebral 4. Be certain conversation Is limited edema) 5. Continue to check for vaginal bleeding every 15 mins. 3. Severe epigast