Maternal Chap 21-22

• High-Risk Pregnancy:

  • Jeopardy to mother, fetus, or both
  • Condition due to pregnancy or result of condition present before pregnancy
  • Higher morbidity and mortality
  • Risk assessment with first Antepartal visit and each subsequent visit
• Conditions Complicating Pregnancy:

  • Perinatal Loss
  • Bleeding
  • Hyperemesis gravidarum
  • Gestational hypertension
  • HELLP syndrome
  • Gestational diabetes
• Perinatal Loss:

  • Death of a fetus or newborn is devastating to the mother and family
  • Nurses need to understand their own personal feelings to provide support and compassionate care
  • What to say: "I understand, I am here to listen, Does your baby have a name"
• Fetal Demise:

  • True stories can be found at https://www.nytimes.com/interactive/2015/health/stillbirth-reader-stories.html#megan-scott and https://www.cdc.gov/ncbddd/stillbirth/family-stories/adrian.html
• Causes of Bleeding:

  • Spontaneous abortion
  • Ectopic pregnancy
  • GTD/Hydatidiform mole
  • Cervical insufficiency
  • Placenta Previa
  • Abruptio placenta
• Spontaneous Abortion:

  • Termination of pregnancy before viability prior to 20 weeks; less than 500g
  • Presentation: Vaginal bleeding and cramping
  • Management: Bed rest, serial hCG’s & H&H, Dilation and curettage may be necessary to remove products of conception
  • Occurs in 15-30% of cases
  • Early miscarriage - before 16th week
  • Late miscarriage - between weeks 16 and 20
• Causes of Spontaneous Abortion:

  • Abnormal fetal development
  • Incompetent cervix
  • Anomaly of the uterine cavity
  • Hypothyroidism
  • Diabetes mellitus
  • Drug use
  • Infection
• Categories of Abortions:

  • Complete–all products of conception expelled
  • Incomplete–a portion of the products of conception retained in the uterus
  • Threatened–bleeding and cramping but no cervical dilatation
  • Imminent - if there are uterine contractions and cervical dilatation
  • Missed–nonviable embryo retained in uterus for at least 6 weeks; fetus dies in utero but is not expelled
  • Habitual–three or more successive abortions
  • Inevitable–cannot be stopped
• Spontaneous Abortion Nursing care:

  • Assess bleeding and signs of shock
  • Assess pain level
  • Assess for infection
  • Provide emotional support
• Ectopic Pregnancy:

  • Fertilized ovum implanted outside the uterine cavity usually due to an obstruction of the fallopian tube
  • Contributing Factors: Previous ectopic, STD’s, Endometriosis, Tubal or pelvic surgery, Uterine fibroids, IUD, Progesterone only BC pills (slows ovum transport)
• Ectopic Pregnancy Manifestations:

  • Missed menses
  • Vaginal bleeding & pelvic pain 6-8 wks after missed menses
  • Diagnosis: Lab test & Ultrasound
• Ectopic Pregnancy Management:

  • Administer Methotrexate
  • Nursing Care: Monitor for shock, prepare for surgery & provide emotional support
  • Surgical: Salpingectomy
• Gestational Trophoblastic Disease (GTD):

  • Characterized by abnormal placental development resulting in the production of fluid-filled grape-like clusters and vast proliferation of Trophoblastic tissues
  • Diagnosis: transvaginal U.S. showing vesicular molar pattern (grape clusters) high hCG levels
• GTD Clinical manifestations:

  • Bleeding grape-like tissue
  • Severe Hyperemesis
  • Uterine size larger than dates
  • Extremely high hCG levels
  • Early development preeclampsia
• GTD Management:

  • Immediate evacuation of uterine content by Dilatation & suction curettage
  • Tissue evaluate for Choriocarcinoma
  • Follow up for one year
• Nursing Assessment for GTD:

  • Assess for expulsion of grape-like vesicles
  • Severe morning sickness due to the high hCG levels
  • Unable to detect heart rate after 10-12 wks.
  • Early development of preeclampsia (prior to 24 wks.)
• Cervical Insufficiency:

  • Premature cervical dilatation due to a weak structurally defective cervix that spontaneously dilates in the absence of contractions in the 2nd trimester
  • Possible causes: Trauma to the cervix, Structure of cervix- less collagen and more smooth muscle
• Cervical Insufficiency Management:

  • Bed rest
  • Pelvic rest
  • Avoid heavy lifting
  • Cervical cerclage placed 2nd trimester if no infection present
• Cervical Insufficiency Nursing Assessment:

  • Monitor for preterm labor
  • Backache
  • Increased vaginal discharge
  • Rupture of membranes
  • Contractions
• Placenta Previa:

  • Occurs when the placenta implants near or over internal cervical os
  • Symptoms: Painless vaginal bleeding that occurs during the last two months of pregnancy
• Placenta Previa Therapeutic Management:

  • Based on bleeding, location of Previa and fetal development
  • "Wait and see" approach if fetus stable and no active bleeding may go home on bed rest
  • Bleeding present admitted to hospital monitoring bleeding, FHR, and avoid vaginal exams
• Placenta Previa Nursing Management:

  • Monitor vaginal bleeding
  • Monitor for fetal distress
  • Provide emotional support
  • Education
• Abruptio Placenta:

  • Premature separation of placenta from the uterine wall after 20 weeks of gestation leading to compromised fetal blood supply
  • Clinical manifestations: Knife-like pain, Port wine vaginal bleeding, Prolonged contraction, Rigid abdomen - couvelaire uterus, Uterine tenderness, Decreased FHR
• Abruptio Placenta Classification systems:

  • Grades 1, 2, 3
  • Diagnostic Testing: CBC, Fibrinogen levels, Prothrombin time and partial thromboplastin time (PT/PTT), Type and Cross-match, Kleihauer-Betke test, NST, Biophysical Profile
• Abruptio Placenta Causes:

  • Primary cause is unknown
  • Predisposing factors: high parity, advanced age at conception, short umbilical cord, chronic hypertension, direct trauma, vasoconstriction from cocaine or cigarette use, chorioamnionitis
• Abruptio Placenta Management Goal:

  • Assess, control and restore blood loss
  • Positive outcome for mother and baby
  • Prevent coagulation disorder
• Abruptio Placenta Nursing Management:

  • O2 therapy
  • Monitor FHR tracing
  • Monitor fundal height
  • Bed rest- left lateral position
  • Monitor V.S. for shock
  • Monitor for DIC
  • Emotional support
• Disseminated Intravascular Coagulation (DIC):

  • Characterized by abnormal blood clotting and bleeding throughout the body
  • Causes: abruptio placenta, hypertension, amniotic fluid embolism, placental retention, septic abortion, retention of dead fetus
• DIC Symptoms:

  • Widespread external/internal bleeding
  • Lab results: Decrease fibrinogen/platelets, Prolonged PT/PTT, Positive D-dimer test
• DIC Management:

  • Administer fluids to restore volume until blood is available
  • Monitor VS and output
  • Administer blood and needed blood components
• Hyperemesis:

  • "Morning sickness" normal nausea and vomiting experienced by 80% of pregnant women
  • Symptoms are mild and usually resolve at the end of the first trimester
• Hyperemesis Gravidarum:

  • Excessive vomiting accompanied by dehydration, electrolyte imbalance, ketosis, acetonuria and weight loss
  • Continues past the 20th wks.
  • Experiences N&V for the first time after 9 wks.
  • These mothers require hospitalization
• Hyperemesis Gravidarum Possible causes:

  • Etiology unknown could be due to high hormone levels, low blood glucose levels, Vit B complex and protein deficiency, metabolic stress, depression, elevated thyroid hormone levels
• Hyperemesis Gravidarum Diagnostic Test:

  • Liver enzymes
  • CBC
  • Urine
  • BUN
  • Urine specific gravity
  • Electrolytes
  • US (ultrasonography)
• Hyperemesis Gravidarum Management:

  • NPO for 24-36 hr.
  • IV therapy
  • Medications: Reglan, Phenergan, Zofran, Compazine, B6
  • Comfort
  • Emotional support
• Preterm Labor:

  • Regular uterine contractions with cervical change between 20 to 37 weeks gestation
  • Most common complication
  • Cause is not always known
  • Usually due to infection or over distended uterus
• Preterm Labor Common symptoms:

  • Persistent, dull low backache
  • Vaginal spotting
  • Abdominal tightening
  • Cramping
• Preterm Labor:

  • Common symptoms include persistent, dull low backache, vaginal spotting, abdominal tightening, cramping, increased vaginal discharge, and uterine contractions
  • Signs of labor include lightening (fetus dropped into pelvic cavity), bloody show, and rupture of membranes
  • Management goal is to inhibit or reduce contraction strength and frequency, and optimize fetal status by prolonging pregnancy
  • Attempt to stop labor if membranes have not ruptured, fetal distress is absent, no evidence of bleeding, cervix is not dilated more than 4 or 5 cm, and effacement is not more than 50%
• • Terbutaline is used as a tocolytic agent, tocolytic therapy, IV fluids, Betamethasone (a corticosteroid), and Amniocentesis
• Premature Rupture of Membranes:

  • Rupture of membranes prior to the onset of labor and is beyond 37 weeks gestation
  • PPROM is the preterm premature rupture of membranes prior to the onset of labor before the 37th week gestation
  • Assessment includes determining if ruptured with Positive Nitrazine and fern pattern, transvaginal ultrasound, and vaginal & cervical culture
  • Management involves delivering the patient for PROM, and for PPROM if no signs of labor in 48hrs may be discharged to home, with the goal to prevent infection, monitor for signs of labor, and promote fetal lung maturity