Nursing Care of a Family Experiencing a Sudden Pregnancy Complication PDF

Nursing Care of a Family Experiencing a Sudden Pregnancy Complication  The leading complications related directly to the pregnancy are thromboembolism, hemorrhage, infection, pregnancy-induced hypertension, and ectopic pregnancy BLEEDING DURING PREGNANCY  Hypovolemi...

Nursing Care of a Family Experiencing a Sudden Pregnancy Complication  The leading complications related directly to the pregnancy are thromboembolism, hemorrhage, infection, pregnancy-induced hypertension, and ectopic pregnancy BLEEDING DURING PREGNANCY  Hypovolemic shock occur when 10% of blood volume, or approximately 2 units of blood, have been lost; fetal distress occurs when 25% of blood volume is lost. – Important to know the baseline BP of patient Signs and Symptoms of Hypovolemic Shock Assessment Significance Increased Heart is attempting to circulate pulse rate decreased blood volume Decreased BP Less peripheral resistance because of decreased blood volume Cold clammy Vasoconstriction occurs to maintain skin blood volume in central body core Decreased Inadequate blood is entering kidneys urine output because of decreased blood volume Dizziness or Inadequate blood reaching cerebrum decreased because of decreased blood volume level of consciousness Decreased Decreased blood is returning to heart central venous because of reduced volume pressure SPONTANEOUS MISCARRIAGE Abortion is the medical term for any interruption of a pregnancy before a fetus is viable viable fetus is usually defined as a fetus of more than 20 to 24 weeks of gestation or one that weighs at least 500 g – A fetus born before this point is considered a miscarriage or premature or immature birth If interrupted spontaneously – miscarriage  Spontaneous miscarriage occurs in 15% to 30% of all pregnancies and arises from natural causes early miscarriage if it occurs before week 16 of pregnancy and a late miscarriage if it occurs between weeks 16 and 24 Causes of Spontaneous Miscarriage most frequent: abnormal fetal development (teratogenic or chromosomal) – Between 50% and 80% of fetuses aborted early have structural abnormalities rejection of the embryo through an immune response may occur implantation abnormalities, as up to 50% of zygotes probably never implant securely because of inadequate endometrial formation or from an inappropriate site of implantation  Miscarriage may also occur if the corpus luteum on the ovary fails to produce enough progesterone to maintain the decidua basalis Rubella, syphilis, poliomyelitis, cytomegalovirus, and toxoplasmosis infections cross the placenta and may also cause early miscarriage – Low production of estrogen and progesterone may cause endometrial lining to slough off, PG are released and contractions and cervical dilatation occur  Intake of Isotretinoin in first tri may cause miscarriage or fetal abnormality alcohol – may cause abnormal fetal growth and lead to miscarriage  Assessment: – Presence of vaginal spotting Treatment – Depends of symptoms  Threatened Abortion – HCG levels may be tested (should be doubled, if not, poor placental function may be suspected) – Avoid strenuous activities for the next 48 hrs – Coitus is restricted for two weeks  Imminent/inevitable Miscarriage – Threatened miscarriage occur with contractions and cervical dilatation – (-) FHT, (-) fetus on UTZ = Vacuum extraction or D&C – After D&C, woman should be monitored for bleeding (# of pads used)  Complete Miscarriage – the entire products of conception (fetus, membranes, and placenta) are expelled spontaneously without any assistance. – bleeding usually slows within 2 hours and then ceases within a few days after passage of the products of conception.  Incomplete Abortion – part of the conceptus (usually the fetus) is expelled, but the membrane or placenta is retained in the uterus – there is a danger of maternal hemorrhage as long as part of the conceptus is retained in the uterus because the uterus cannot contract effectively – D&C to evacuate other products of conception  Missed Miscarriage – AKA early pregnancy failure – fetus dies in the utero but not expelled – Fetus died 4-6 weeks before the onset of miscarriage (spontaneously occurs within two weeks – if pregnancy is at 14 weeks, PG or cytotec may be given to induce labor. Recurrent Pregnancy Loss Habitual Aborters – Possible causes: Defective spermatozoa or ova Endocrine factors such as lowered levels of protein-bound iodine (PBI), butanol-extractable iodine (BEI), and globulin-bound iodine (GBI); poor thyroid function; or luteal phase defect Deviations of the uterus, such as septate or bicornuate uterus Resistance to uterine artery blood flow Chorioamnionitis or uterine infection Autoimmune disorders such as those involving lupus anticoagulant and antiphospholipid antibodies Complications of Miscarriage Hemorrhage – Spontaneous complete – Hge is rare – Incomplete – major Hge if with coagulation D/O like DIC – WOF signs of Shock – Unusual odor or passing of large clots is abnormal – Bleeding – dark color to color serous fluid – Physician may give Methergin for uterine contraction  Infection – tends to develop in women who have lost appreciable amounts of blood – danger signs of infection: fever (>38˚C) , abdominal pain or tenderness, and a foul vaginal discharge – Usually caused by E. Coli – Caution a woman to wipe her perineal area from front to back after voiding and particularly after defecation to prevent the spread of bacteria from the rectal area. – Caution her not to use tampons to control vaginal discharge, because stasis of any body fluid increases the risk of infection – MC: Endometritis – infection of the uterine lining  Septic Abortion – an abortion that is complicated by infection – uterus is a warm, moist, dark cavity, infectious organisms, once introduced, grow rapidly in this environment, particularly if products of conception such as necrotic membranes are still present. – Symptoms: fever and crampy abdominal pain, and her uterus feels tender to palpation. – Infection, if not treated, can lead to toxic shock syndrome, septicemia, kidney failure, and death  complete blood count, serum electrolytes, serum creatinine, blood type and crossmatch, and cervical, vaginal, and urine cultures are obtained IFC to monitor urine output IVF to restore fluid volume high-dose, broad-spectrum antibiotic therapy (penicillin, gentamicin, clindamycin) CVP to monitor left atrial filling pressure and hemodynamic status.  TT or tetanus immune globulin as prophylaxis D & C/ D & E to remove infected and necrotic tissue Infection following a septic abortion can be so severe that a woman needs to be admitted to an intensive care setting for continuing care. Dopamine and digitalis may be necessary to maintain sufficient cardiac output. Oxygen and perhaps ventilatory support may be necessary to maintain respiratory function.  – uterine scarring or fibrotic scarring of the fallopian tubes may cause infertility Isoimmunization – the production of antibodies against Rh- positive blood – mother is Rh-negative and the fetus is Rh-positive – After a miscarriage, because the blood type of the conceptus is unknown, all women with Rh-negative blood should receive Rh (D antigen) immune globulin (RhIG) to prevent the build up of antibodies in the event the conceptus was Rh-positive  Powerlessness or Anxiety – Assess a woman’s adjustment to a spontaneous miscarriage. Sadness and grief over the loss or a feeling that a woman has lost control of her life is to be expected. – Do not forget to assess a partner’s feelings as well, or that person’s grief over the pregnancy loss can be missed. Ectopic Pregnancy implantation occurs outside the uterine cavity 2nd most frequent cause of bleeding in first trimester MC in fallopian tube (95%), but may also occur in the ovary or cervix 80% occur in the ampullar portion, 12% occur in the isthmus, and 8% are interstitial or fimbrial  Risk factors: PID, smoking, IUD use, Hx of ectopic pregnancy Assessment: UTZ or MRI will reveal an ectopic pregnancy At 6-8 weeks, zygote grows large enough cause rupture of the FT. If implantation is in the interstitial portion of the tube, rupture can cause severe intraperitoneal bleeding a ruptured ectopic pregnancy is serious regardless of the site of implantation  S/S: sharp, stabbing pain in one of her lower abdominal quadrants at the time of rupture, followed by scant vaginal spotting With placental dislodgment, progesterone secretion stops and the uterine decidua begins to slough, causing additional bleeding Acute Hge may lead to shock Leukocytosis due to trauma Cullen’s Sign (umbilicus may develop a bluish tinge) may also be present  Chandelier’s Sign – cervical motion tenderness/pain pain in her shoulders from blood in the peritoneal cavity causing irritation to the phrenic nerve. A tender mass is usually palpable in Douglas’ cul-de-sac on vaginal examination  Tx: oral – methotrexate, then leucovorin; mifepritone (abortifacient) – Methotrexate – a folic acid antagonist chemotherapeutic agent Oral meds until hCG titer becomes negative If ruptured, surgical intervention is done (removal or ligation of the affected tube) Isoimmunization may occur Abdominal Pregnancy Fetus grows in pelvic cavity The danger of abdominal pregnancy is that the placenta will infiltrate and erode a major blood vessel in the abdomen, leading to hemorrhage If implanted on the intestine, it may erode so deeply that it causes bowel perforation and peritonitis.  Fetus is also at high risk because without a good uterine blood supply, nutrients may not reach the fetus in adequate amounts. The survival rate in an abdominal pregnancy is only approximately 60% because of poor nutrient supply Increased threat of fetal deformity growth restriction if infant survives Laparotomy as birth procedure Placenta may be difficult to remove, it may be left in place and be absorbed in 2 – 3 months  Gestational Trophoblastic Disease(Hydatidiform Mole) abnormal proliferation and then degeneration of the trophoblastic villi As the cells degenerate, they become filled with fluid and appear as clear fluid- filled, grape-sized vesicles embryo fails to develop Abnormal trophoblast cells must be identified because they are associated with choriocarcinoma, a rapidly metastasizing malignancy  Risk Factors: tends to occur most often in women who have a low protein intake, in women older than age 35 years, in women of Asian heritage, and in blood group A women who marry blood group O men Complete mole – all trophoblastic villi swell and become cystic Partial mole – some of the villi form normally; a macerated embryo of approximately 9 weeks’ gestation may be present and fetal blood may be present in the villi  A partial mole has 69 chromosomes (a triploid formation in which there are three chromosomes instead of two for every pair, one set supplied by an ovum that apparently was fertilized by two sperm or an ovum fertilized by one sperm in which meiosis or reduction division did not occur)  Assessment: uterus expand faster than normal Serum hCG: 1 to 2 million IU compared with a normal pregnancy level of 400,000 IU Symptoms of pregnancy- induced hypertension such as hypertension, edema, and proteinuria may appear At approximately week 16 of pregnancy, it will identify itself with vaginal bleeding.  Tx: suction curettage hCG to be monitored every 2 weeks until normal then every 4 weeks for 6-12 months Gradual declining hCG- no complication 3 times increase may suggest a malignant transformation occurring Woman should use contraceptive for 1 year to prevent pregnancy Premature Cervical Dilatation Incompetent Cervix/ Tracheloplasty/ Cervical Stitch – a cervix that dilates prematurely and therefore cannot hold a fetus until term – painless – first symptom is show (a pink-stained vaginal discharge) or increased pelvic pressure, which may be followed by rupture of the membranes and discharge of the amniotic fluid – occurs at approximately week 20 of pregnancy  Tx – Cervical cerclage – done at 12 – 14 weeks – Mc Donald or Shirodkar Tie – After cerclage surgery, women remain on bed rest (perhaps in a slight or modified Trendelenburg position) for a few days to decrease pressure on the new sutures.  Placenta Previa placenta is implanted abnormally in the uterus MC cause of painless bleeding in the third trimester four degrees – implantation in the lower rather than in the upper portion of the uterus (low-lying placenta) – Marginal implantation (the placenta edge approaches that of the cervical os) – implantation that occludes a portion of the cervical os(partial placenta previa); – implantation that totally obstructs the cervical os (total placenta previa)  Risk Factors: Increased parity, advanced maternal age, past cesarean births, past uterine curettage, multiple gestation, and a male fetus are all associated with placenta previa increase in congenital fetal anomalies may occur if the low implantation does not allow optimal fetal nutrition or oxygenation  Assessment: abrupt painless bright red vaginal bleeding Complications: maternal hge, because placenta is loosened, fetal oxygen supply may be compromised, preterm labor  Immediate care measures: – Be sure to assess: Duration of the pregnancy Time the bleeding began Woman’s estimation of the amount of blood— ask her to estimate in terms of cups or tablespoons (a cup is 240 mL; a tablespoon is 15 mL) Whether there was accompanying pain Color of the blood (red blood indicates bleeding is fresh or is continuing) What she has done for the bleeding (if she inserted a tampon to halt the bleeding, there may be hidden bleeding) Whether there were prior episodes of bleeding during the pregnancy Whether she had prior cervical surgery for premature cervical dilatation  Assess VS every 5 – 15 minutes Kleihauer-Betke Test IV therapy with large-gauge catheter Monitor urine output every hour Assess FHT Hemoglobin, hematocrit, prothrombin time, partial thromboplastin time, fibrinogen, platelet count, type and cross-match, and antibody screen will be assessed to establish baselines, detect a possible clotting disorder  Continuing Care Measures – If bleeding continues, fetus is compromised and labor has begun, birth must be accomplished regardless of the AOG – If bleeding stopped, maternal VS stable, fetus is not compromised, AOG is less than 36 weeks, birth may be delayed Abruptio Placenta premature separation of the placenta Occurs in about 10% of pregnancies Most frequent cause of perinatal death Predisposing factors: high parity, advanced maternal age, a short umbilical cord, chronic hypertensive disease, pregnancy-induced hypertension, direct trauma (as from an automobile accident or intimate partner abuse), vasoconstriction from cocaine or cigarette use, and thrombophilitic conditions that lead to thrombosis such as autoimmune antibodies, protein C, and factor V Leiden (a common inherited thrombophilia that occurs in 5% of whites and 1% of blacks May be caused by chrorioamnionitis  Assessment – sharp, stabbing pain high in the uterine fundus as the initial separation occurs – Uterine tenderness – Couvelaire Uterus – hard or board like uterus – May lead to DIC  Tx / Management – Large-gauge IV catheter for fluid replacement – oxygen to limit fetal anoxia. – Monitor FHT – Monitor maternal VS – Fibrinogen determination – Keep woman in lateral position – No abdominal, vaginal and pelvic exam – DIC – bleeding may occur (CS); fibrinogen or cryoprecipitate with fibrinogen to elevate woman’s fibrinogen level – Hysterectomy – to prevent exsanguination Disseminated Intravascular Coagulation an acquired disorder of blood clotting in which the fibrinogen level falls to below effective limit S/S: easy bruising or bleeding from an intravenous site Risk Factors: premature separation of the placenta, pregnancy-induced hypertension, amniotic fluid embolism, placental retention, septic abortion, and retention of a dead fetus  currently thought to be initiated by tissue factor or thromboplastin, which is released from trophoblastic or fetal tissue, or maternal decidua or endothelium Abnormal D-dimer result (fibrin) – occurs in 90% of patients with DIC To stop the process of DIC, the underlying insult that began the phenomenon must be halted Heparin to halt clotting cascade Platelet transfusion to restore platelets lost PRETERM LABOR labor that occurs before the end of week 37 of gestation occurs in approximately 9% to 11% of all pregnancies responsible for almost two-thirds of all infant deaths in the neonatal period Preterm labor is always serious because if it results in the infant’s birth, the infant will be immature  associated with dehydration, urinary tract infection, periodontal disease, and chorioamnionitis Other Risk Factors: those who receive inadequate prenatal care, those who continue to work at strenuous jobs during pregnancy or perform shift work that leads to extreme fatigue, intimate partner abuse, small born women (mother) with overweight partner  S/S: persistent, dull, low backache; vaginal spotting; a feeling of pelvic pressure or abdominal tightening; menstrual- like cramping; increased vaginal discharge; uterine contractions; and intestinal cramping Tx/Management: – Presence of shortened cervix and fibronectin, a protein produced by trophoblast cells, in vaginal mucus predicts preterm contractions are ready to occur  Bed rest to relieve pressure on the cervix IVF to maintain hydration DHN may lead to release of ADH and oxytocin vaginal and cervical culture to rule out infection Tocolytic agent (terbutaline, ritodrine) to halt labor limit strenuous activities adequate nutrition Corticosteroid for lung surfactant formation  Betamethasone is preferred as it leads to lower rates of respiratory distress syndrome or bronchopulmonary dysplasia in newborns Terbutaline should not be given to patients with GDM Oral tocolytics until 37 weeks or until fetal lung maturity is achieved  ASSIGNMENT Examples of tocolytic agents Effects/ Side effects of tocolytic agents Examples of tocolytics which are stopped due to the side effects; What are those side effects? Routes of administration Nursing considerations in administering tocolytic agents. To be submitted on FEBRUARY 24, 2023. Handwritten. Long bond paper.  Fetal Assessment – Daily fetal movement count – FHT Labor that cannot be halted – ruptured membranes – > 50% effaced cervix, 3-4 cm dilated – NSD with Episiotomy or CS to reduce pressure on the fetal head and reduce the possibility of subdural or intra-ventricular hemorrhage from a vaginal birth – Increased risk of cord prolapse with AROM – Epidural for pain relief – Immediate cord clamping to prevent additional blood in circulation Preterm Rupture of Membranes rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks associated with infection of the membranes (chorioamnionitis) occurs in 5% to 10% of pregnancies Increased risk of uterine and fetal infection and cord prolapse (could also interfere with fetal circulation)  Potter-like syndrome or distorted facial features and pulmonary hypoplasia from pressure may occur with loss of amniotic fluid Preterm labor may follow rupture of the membranes and end the pregnancy  Assessment: – sudden gush of clear fluid from her vagina, with continued minimal leakage – Nitrazine paper test to test the fluid Yellow to blue – amniotic fluid Yellow to yellow – urine – Fern Test amniotic fluid – positive ferning on microscopic exam – High levels of AFP in vagina confirms PROM – cultures for Neisseria gonorrhoeae, Streptococcus B, and Chlamydia are usually taken  WBC and C-reactive protein increase with membrane rupture Avoid routine vaginal exam to decrease the risk for infection If labor dos not occur within 24 hours, it is induced (Oxytocin IV) as long as fetus is mature enough to survive  Tx/ Management – Bed rest if fetus is not viable – Corticosteroid – Prophylactic antibiotics – Tocolytics if labor begins – membranes can be resealed by use of a fibrin-based commercial sealant so they are again intact Pregnancy-Induced Hypertension a condition in which vasospasm occurs during pregnancy in both small and large arteries S/S: HPN, proteinuria, edema unique to pregnancy and occurs in 5% to 7% of pregnancies highly correlated with the antiphospholipid syndrome or the presence of antiphospholipid antibodies  Previously called Toxemia occur most frequently in: – Multiple pregnancy – primiparas younger than 20 years or older than 40 years – women from low socioeconomic backgrounds (perhaps because of poor nutrition) – those who have had five or more pregnancies – those who have hydramnios – those who have an underlying disease such as heart disease, diabetes with vessel or renal involvement, and essential hypertension  There is reduced blood supply to organs, most markedly the kidney, pancreas, liver, brain, and placenta. – Poor placental perfusion Ischemia in the pancreas may result in epigastric pain and an elevated amylase–creatinine ratio Spasm of the arteries in the retina leads to vision changes Vasospasm in the kidney increases blood flow resistance  Extreme edema can lead to cerebral and pulmonary edema and seizures (eclampsia) Thrombocytopenia occurs as platelets rush to sites of endothelial damage  Assessment – Classic signs of PIH: vision changes, typically hypertension, proteinuria, and edema – classified as gestational hypertension, mild pre- eclampsia, severe pre- eclampsia, and eclampsia  Gestational Hypertension – elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema  Mild Pre-eclampsia – has proteinuria (1+ or 2+) and blood pressure rises to 140/90 mm Hg, taken on two occasions at least6 hours apart – A second criterion for evaluating blood pressure is a systolic blood pressure greater than 30 mm Hg and a diastolic pressure greater than 15 mm Hg above prepregnancy values – Orthostatic proteinuria – on long periods of standing, they excrete protein; at bed rest, they do not Ask for as morning urine sample to confirm what causes proteinuria  Edema because of the protein loss, sodium retention, and lowered glomerular filtration rate weight gain of more than 2 lb/wk in the second trimester or 1 lb/wk in the third trimester usually indicates abnormal tissue fluid retention  Severe Preeclampsia – blood pressure rises to 160 mm Hg systolic and 110 mmHg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mm Hg above her prepregnancy level – Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are also present. – extreme edema (pitting edema)  Some women have severe epigastric pain and nausea and vomiting, possibly because of abdominal edema or ischemia to the pancreas and liver Shortness of breath if pulmonary edema develops visual disturbances such as blurred vision or seeing spots before the eyes, severe headache and marked hyperreflexia and perhaps ankle clonus (a continued motion of the foot) if cerebral edema develops  Eclampsia – most severe classification of PIH – cerebral edema is so acute that a grand-mal seizure (tonic-clonic) or coma occurs – maternal mortality rate is as high as 20% from causes such as cerebral hemorrhage, circulatory collapse, or renal failure – Hypoxia and fetal acidosis – Poor fetal prognosis – Vasospasm may cause premature separation of placenta  Nursing Interventions for a Woman With Mild PIH – Monitor Antiplatelet Therapy – Promote Bed Rest – Promote Good Nutrition – Provide Emotional Support  Nursing Interventions for a Woman With Severe PIH – Support Bed Rest – Monitor Maternal Well-being VS q 4 Lab test Daily Hct (to monitor edema) Plasma Estriol levels to test placenta function Daily weight same time each day IFC to monitor urine output – Monitor fetal well being  Support a Nutritious Diet – high in protein and moderate in sodium Administer Medications to Prevent Eclampsia – hydralazine (Apresoline), labetalol (Normodyne), or nifedipine – can cause maternal tachycardia. Therefore, assess pulse and blood pressure before and after administration – MgSO4 a cathartic, reduces edema by causing a shift in fluid from the extracellular spaces into the intestine Reduces blood pressure a central nervous system depressant (blocks peripheral neuromuscular transmission) -- lessens the possibility of seizures  Magnesium Sulfate overdose – decreased urine output, depressed respirations, reduced consciousness, and decreased deep tendon reflexes – If oliguria (less than 100 mL in 4 hours) results, excessively high serum levels of magnesium can result – Antidote: Calcium gluconate – Before administration: urine output above 25 to 30 mL/hr, specific gravity of 1.010 or lower. Respirations above 12 per minute, a woman should be able to answer questions asked of her such as her name or address, ankle clonus (a continued motion of the foot) should be minimal, deep tendon reflexes should be present  Deep Tendon Reflexes – Pattelar reflex or knee jerk – Biceps or triceps reflex if with epidural anesthesia Oliguria – intravenous infusion of salt-poor albumin – high-colloid solution will call fluid into the bloodstream from interstitial tissue by osmotic pressure; the kidneys will then excrete the extra fluid along with magnesium sulfate levels  MgSO4 IV – crosses placenta and may cause respiratory depression – Monitor FHT, WOF late decelerations – UTZ to show fetal breathing movements – Continued after delivery then tapered down – Delay BF until drug is discontinued – May cause osteoporosis Ca supplements  Nursing Interventions for a Woman With Eclampsia – eclampsia occurs when cerebral irritation from increasing cerebral edema becomes so acute that a seizure occurs – happens late in pregnancy but can happen up to 48 hours after childbirth – Immediately before a seizure: blood pressure rises suddenly from additional vasospasm. temperature rises sharply to 103° to 104° F (39.4° to 40° C) from increased cerebral pressure blurring of vision or severe headache (from the increased cerebral edema) reflexes become hyperactive may experience a premonition that “something is happening”  Vascular congestion of the liver or pancreas can lead to severe epigastric pain and nausea Urinary output may decrease abruptly to less than 30 mL/hour  Tonic-Clonic Seizures – Tonic phase – After the preliminary signal or aura that something is happening, all the muscles of the woman’s body contract Respirations stop – cyanosis Might bite her tongue from rapid closing of jaw Lasts approx. 20 secs  Clonic (second) phase – the woman’s bladder and bowel muscles contract and relax; incontinence of urine and feces may occur – Breathing begins but ineffective, pt may remain cyanotic – Lasts up to 1 minute  Postictal stage – woman is semicomatose and cannot be roused except by painful stimuli for 1 to 4 hours – If placental separation occurs, labor may begin – painful stimulus of contractions may initiate another seizure – Keep NPO – Continuously assess fetal heart sounds and uterine contractions  Birth – There is some evidence that a fetus does not continue to grow after eclampsia occurs, so terminating the pregnancy at this point is appropriate for both mother and child. – For an unexplained reason, fetal lung maturity appears to advance rapidly with PIH (possibly from the intrauterine stress), so even though the fetus is younger than 36 weeks, the lecithin–sphingomyelin ratio may indicate fetal lung maturity – a woman with eclampsia is not a good candidate for surgery – Vaginal birth is preferred  Nursing Interventions During the Postpartum Period – Postpartum hypertension may occur up to 10 to 14 days after birth, although it usually occurs no more than 48 hours after birth – Advise woman to return for postpartum check up  Management of Seizure – Maintain patent airway – O2 via face mask to protect the fetus – Turn to side to allow drainage of secretions – MgSO4 or Diazepam (Valium) – Assess O2 sat – Fertal monitor to asses fetal status – Check for vaginal bleeding (abruptio) Evidence of placental separation appears first in fetal status, then vaginal bleeding HELLP SYNDROME a variation of PIH named for the common symptoms that occur: hemolysis that leads to anemia,elevated liver enzymes that lead to epigastric pain, and low platelets that lead to abnormal bleeding/clotting and petechia occurs in 4% to 12% of patients with PIH  May result in maternal mortality rate as high as 24% and an infant mortality rate as high as 35% occurs in both primigravidas and multigravidas may be associated with an- tiphospholipid syndrome or the presence of antiphospholipid antibodies  S/S: proteinuria, edema and increased blood pressure, additional symptoms of nausea, epigastric pain, general malaise, and right upper quadrant tenderness from liver inflammation hemolysis of red blood cells; thrombocytopenia; elevated liver enzyme levels (alanine aminotransferase [ALT]and serum aspartate aminotransferase [AST]  close observation for bleeding Complications: subcapsular liver hematoma, hyponatremia, renal failure, and hypoglycemia from poor liver function. Mothers are at risk for cerebral hemorrhages, aspiration pneumonia, and hypoxic encephalopathy Fetal complications: growth restriction and preterm birth  Tx/Management – FFP or platelets – If hypoglycemic – glucose infusion – Birth of baby as soon as feasible – No epidural anesthesia due to clotting problem, bleeding at the site may occur Multiple Pregnancy Multiple gestation is considered a complication of pregnancy because a woman’s body must adjust to the effects of more than one fetus. occurs in 2% to 3% of all births Identical (monozygotic) twins begin with a single ovum and spermatozoon – Single-ovum twins usually have one placenta, one chorion, two amnions, and two umbilical cords – Always same sex  Two thirds of twins are fraternal(dizygotic, nonidentical), the result of the fertilization of two separate ova by two separate spermatozoa (possibly not from the same sexual partner) – Double-ova twins have two placentas, two chorions, two amnions, and two umbilical cords – The twins may be of the same or different sex  Assessment – uterus begins to increase in size at a rate faster than usual – Alpha-fetoprotein levels are elevated – multiple sets of fetal heart sounds are heard – ultrasound can reveal multiple gestation sacs early in pregnancy – In some instances, early ultrasound examinations reveal multiple amniotic sacs but then later in pregnancy, in as many as 30% of women, only one fetus remains vanishing twin syndrome  Therapeutic Management – susceptible to complications of pregnancy such as PIH, hydramnios, placenta previa, preterm labor, and anemia than are women carrying one fetus – more prone to postpartum bleeding because of the additional uterine stretching that must occur – 25% of low-birth-weight babies are from multiple pregnancies – higher risk of congenital anomalies in twins, such as spinal cord defect, than with single births – higher incidence of velamentous cord insertion (the cord inserted into the fetal membranes) with twins than with single births  With monozygotic twins, the fetuses can share vascular communication, possibly leading to overgrowth of one fetus and undergrowth of the second (a twin-to-twin transfusion), resulting in discordant infants If a single amnion is present, there can be knotting and twisting of umbilical cords, causing fetal distress or difficulty with birth Early and close observation of the pregnant woman  Hydramnios Amniotic fluid is formed by a combination of the cells of the amniotic membrane and from fetal urine amniotic fluid volume during pregnancy is 500 to 1000 mL at term Occurs with hyperglycemia Excess fluid more than 2000 mL or an amniotic fluid index above 24 cm is considered hydramnios can cause fetal malpresentation (transverse) can lead to premature rupture of the membranes from the increased pressure with possible prostaglandin release  Assessment: – unusually rapid enlargement of the uterus – Palpation of parts of the fetus and FHT auscultation is difficult – extreme shortness of breath as the overly distended uterus pushes up against her diaphragm – may develop lower extremity varicosities and hemorrhoids because of poor venous return from the extensive uterine pressure – Increased weight gain – UTZ to document presence of hydramnios  Management – maintaining bed rest helps to increase uteroplacental circulation and reduces pressure on the cervix, which may help prevent preterm labor – report any sign of ruptured membranes or uterine contractions – Assess VS and edema – Amniocentesis daily to remove extra AF – Avoid constipation High fiber diet Stool softeners if diet is not enough  PROM and preterm birth may occur because of excessive pressure, After birth, the infant must be assessed carefully for factors that may have interfered with the ability to swallow in utero  Oligohydramnios refers to a pregnancy with less than the average amount of amniotic fluid usually caused by a bladder or renal disorder in the fetus that interferes with voiding can occur from severe growth restriction Because the fetus is so cramped for space, muscles are left weak at birth, lungs fail to develop (hypoplastic lungs), leading to severe difficulty breathing after birth, and features of the face become distorted (termed Potter’s syndrome) Potter’s Syndrome  Assessment/ Management – Slow growth of uterus – Revealed by UTZ – Amniotransfusion or instillation of fluid into the uterus by amniocentesis procedure can help relieve this concern – Infants need careful inspection at birth to rule out kidney disease and compromised lung development. Post Term Pregnancy A pregnancy that exceeds 38-42 weeks is prolonged (post term pregnancy, postmature, or postdate) occurs in 3% to 12% of all pregnancies Prolonged pregnancy can occur in a woman receiving a high dose of salicylates, because it interferes with the synthesis of prostaglandins also associated with myometrial quiescence, or a uterus that does not respond to normal labor stimulation  Fetal complications: – meconium aspiration – Macrosomia and/or Lack of growth – Decreased blood perfusion due to decreased placental function Lack of oxygen, fluid and nutrients supply to the fetus – Oligohydramnios – variable decelerations – If labor has not begun by 41 weeks, a maternal vaginal fibronectin level, a nonstress test, and/or a biophysical profile may be ordered to document the state of placental perfusion and the amount of amniotic fluid present  If lab exams are normal – miscalculation of due date If lab exams are abnormal – labor is induced by PG or misoprostol, oxytocin – CS if oxytocin is ineffective  Pseudocyesis or false pregnancy, nausea and vomiting, amenorrhea, and enlargement of the abdomen occur in either a nonpregnant woman or a man several theories regarding why the phenomenon occurs: – wish-fulfillment theory suggests a woman’s desire to be pregnant actually causes physiologic changes to occur; – conflict theory suggests a desire for and fear of pregnancy create an internal conflict leading to physiologic changes; – and depression theory attributes the cause to major depression  (+) Breast and abdominal enlargement but UTZ reveals (-) pregnancy Counseling of patient to help them better handle their needs Isoimmunization (Rh Incompatibility) occurs when an Rh-negative mother (one negative for a D antigen or one with a dd genotype) carries a fetus with an Rhpositive blood type (DD or Dd genotype) the father of the child must either be homozygous (DD) or heterozygous (Dd ) Rh-positive people who have Rh-positive blood have a protein factor (the D antigen) that Rh-negative people do not have  After sensitization, mother forms antibodies against D antigen Antibodies cross placenta and cause hemolysis of RBCs – hemolytic disease of the newborn or erythroblastosis fetalis amniocentesis or percutaneous umbilical blood sampling may cause fetal blood to enter maternal circulation  Assessment/Management: – All mothers with Rh negative blood should have anti-D antibody titer during first prenatal visit If the results are normal or the titer is minimal (normal is 0; a ratio below 1:8 is minimal), the test will be repeated at week 28 of pregnancy, if this is also normal, no therapy is needed If a woman’s anti-D antibody titer is elevated at a first assessment (1:16 or greater), the well-being of the fetus in this potentially toxic environment will be monitored every 2 weeks (or more often) by Doppler velocity of the fetal middle cerebral artery, a technique that can predict when anemia is present or fetal red cells are being destroyed  If the artery velocity remains high, a fetus is not developing anemia and most likely is an Rh-negative fetus If the reading is low, it means a fetus is in danger Rh (D) immune globulin (RhIG), a commercial preparation of passive Rh (D) antibodies against the Rh factor, is administered to women who are Rh-negative at 28 weeks of pregnancy  RhIG cannot cross placenta RhIG is injected to a mother with Rh positive baby within 72 hours to prevent formation of normal antibodies RhIG is a passive antibody protection and is destroyed in 2 weeks to 2 months Coomb’s Test – Direct – detects antibodies that are stucked in the RBC surface – Indirect – detects antibodies that are floating freely in blood  Intrauterine Transfusion – done by injecting red blood cells, by amniocentesis technique, directly into a vessel in the fetal cord or depositing them in the fetal abdomen where they migrate into the fetal circulation – 75 to 150 mL of washed red cells are used, depending on fetal age – Mother to rest for 30 mins with fetal and uterine activity monitoring – Transfusion is sometimes done only once during pregnancy, or it may be repeated as often as every 2 weeks  Risks (Transfusion): – cord blood vessel could be lacerated by the needle – uterus may be so irritated that labor contractions begin After Birth – exchange transfusion to remove hemolyzed red blood cells and replace them with healthy blood cells  Fetal death most severe complications of pregnancy most likely causes include chromosomal abnormalities, congenital malformations, infections such as hepatitis B, immunologic causes, and complications of maternal disease Key Points for Review Vaginal bleeding during pregnancy is always serious until ruled otherwise because it has the potential to diminish the blood supply of both the mother and fetus. The amount of bleeding which is evident may not be truly indicative of the amount of bleeding occurring as hidden, internal bleeding may also be happening. As a rule, women with bleeding during pregnancy should be positioned on their side to improve placental circulation. Spontaneous miscarriage is the loss of a pregnancy before viability of the fetus (20 to 24 weeks). The majority of these early pregnancy losses are attributed to chromosomal abnormalities. Miscarriages are classified as threatened, imminent, complete, incomplete, missed, or recurrent pregnancy loss. Women who have a spontaneous miscarriage at home should bring any tissue passed to the hospital for an analysis for gestational trophoblastic disease.  Ectopic pregnancy is pregnancy implantation outside the uterus, usually in a fallopian tube. If discovered before the tube ruptures, methotrexate or mifepristone can be administered to cause the conceptus to be reabsorbed. If not discovered early, sharp lower quadrant pain occurs at about 6 to 12 weeks as the tube ruptures. Surgery is done to remove the conceptus and repair the tube to halt bleeding. Gestational trophoblastic disease is abnormal overgrowth of trophoblast cells. If not discovered by an ultrasound early in pregnancy, bleeding and expulsion of the abnormal growth occur at about the 16th week of pregnancy. Women need close follow-up after this because it can lead to choriocarcinoma, a malignancy.  Premature cervical dilatation occurs when the cervix dilates early in pregnancy, before viability of the fetus. Sutures (cervical cerclage) can be placed to prevent the cervix from dilating prematurely this way again in a second pregnancy. Placenta previa is low implantation of the placenta so that it crosses the cervical os. If this is not discovered before labor, cervical dilatation may cause the placenta to tear, causing severe blood loss. Women who have symptoms of placenta previa (painless vaginal bleeding in the third trimester) should not have vaginal examinations done to prevent disruption of the low-implanted placenta.  Premature separation of the placenta (abruptio placentae), placental separation from the uterus before the fetus is born, usually occurs late in pregnancy. This separation immediately cuts off blood supply to the fetus. Women with increased parity, those with previous uterine surgery, and those who use cocaine are at highest risk for this. Often it is manifested by sudden, sharp fundal pain, then a continuing dull pain and vaginal bleeding. Disseminated intravascular coagulation is a blood disorder that may occur with any trauma, so it can accompany such conditions as premature separation of the placenta and pregnancy-induced hypertension. Blood coagulation is so extreme at one point in the circulatory system that clotting factors are used up, resulting in their absence in the remainder of the system. Beginning symptoms of this include easy bruising, petechiae, and oozing from intravenous sites. Heparin is used to stop the local coagulation and free up clotting factors for systemic use. Preterm labor is labor that occurs after 20 weeks and before the end of the 37th week of pregnancy. A woman is said to be in preterm labor when she has had uterine contractions every 10 minutes for 1 hour and cervical dilatation begins. Common tocolytics, drugs that can halt labor, are betasympathomimetic agents such as terbutaline (Brethine). Preterm rupture of the membranes is tearing of the fetal membranes with loss of amniotic fluid before the pregnancy is at term. After rupture, there is a high risk of fetal and uterine infection (chorioamnionitis) and preterm birth. Pregnancy-induced hypertension is a unique disorder that occurs with pregnancy with three classic symptoms: hypertension, edema, and proteinuria. It is categorized as pre- eclampsia or eclampsia. If mild (blood pressure not over 140/90), treatment is bed rest and perhaps low-dose aspirin. If severe (blood pressure over 160/110), bed rest plus administration of magnesium sulfate is necessary. If a seizure occurs, the condition becomes eclampsia. Helping prevent the disease from progressing to this stage is an important nursing responsibility.  The HELLP syndrome is a unique form of pregnancyinduced hypertension marked by hemolysis of red blood cells, elevated liver enzymes, and a low platelet count. Multiple gestation puts an additional strain on a woman’s physical resources and may lead to preterm birth with immaturity of her infants. Helping a woman plan adequate nutrition and rest during pregnancy are nursing responsibilities. Post term pregnancy is pregnancy that extends beyond 42 weeks. As the placenta deteriorates at this time, it can cause a fetus to receive decreased nutrients. Hydramnios is overproduction of amniotic fluid (above 2000 mL), a condition that can lead to ruptured membranes and premature birth because of increased intrauterine pressure. Oligohydramnios is the lessened amount of fluid and suggests a renal disorder exists in the fetus. Isoimmunization (Rh incompatibility) is a possibility when a woman who is Rh negative is sensitized and carries a fetus who is Rh positive. Maternal antibodies form and destroy fetal red blood cells, leading to anemia, edema, and jaundice in the newborn. Being certain women are screened for blood type and antibody titer early in pregnancy is a nursing responsibility