MATERNAL

• Identifying client at risk begins with the first prenatal visit and continues through the puerperium; risk factors are anything that may be associated with a negative pregnancy outcome including physiological, psychological, sociodemographic, or environmental factors
• More frequent monitoring of high-risk clients important during pregnancy, labor, and birth, and the puerperium to help identify potential complications, ensure early treatment, and improve maternal-fetal outcomes
• Pregestational Conditions

  Fatigue, dyspnea, palpitation
• Congestive heart failure (CHF)

  • Most common complication of heart disease during pregnancy
  • Dyspnea on exertion, increasing fatigue, dyspnea at rest, moist cough, basilar rales
  • Cyanosis of nail beds, circumoral cyanosis
  • Tachycardia, irregular pulse, murmurs, chest pain
• New York Heart Association (NYHA) Classification of Heart Failure

  • Class I (Mild - Slight limitation but still comfortable with ordinary activity)
  • Class II (Moderate - Comfortable at rest, less than ordinary activity causes fatigue, dyspnea, palpitation)
  • Class III (Moderate-Marked limitation - Comfortable at rest, less than ordinary activity causes fatigue, dyspnea, palpitation)
  • Class IV (Severe - Unable to carry on any physical activity without discomfort, symptoms at rest)
• Gestational Diabetes


  Diabetes that results when the pancreas is unable to meet the increased demands for insulin production during pregnancy
• Effect of pregnancy on glucose metabolism

  1. During first trimester, insulin needs are low or decreased

  2. Late in first trimester, insulin requirements begin to rise as glucose use and glycogen storage by mother and fetus increase

  3. Human placental lactogen (hPL) from the placenta causes resistance to the action of maternal insulin, increasing circulating glucose for fetal use and increasing demand on maternal pancreas to produce more insulin

  4. Fetus produces its own insulin but obtains glucose from the mother across the placenta, amount of glucose available in maternal circulation stimulates fetal pancreas to produce insulin
• Effects of diabetes on pregnancy and the fetus

  • Maternal hydramnios
  • Preeclampsia, eclampsia, ketoacidosis, worsening retinopathy
  • Dystocia and stillbirth
  • Neonatal macrosomia, hypoglycemia, hyperbilirubinemia, delayed fetal lung maturity resulting in respiratory distress syndrome (RDS), increased incidence of congenital anomalies including defects of the heart or neural tube defect and sacral agenesis
• Type 2 Diabetes Mellitus

  Non-Insulin Dependent, Insulin-Resistant
• Risk factors for Type 2 Diabetes Mellitus


  • Family history of diabetes
  • Maternal obesity
  • Previous large-for-gestational-age (LGA) infants
  • Previous unexplained stillbirth
• Classic symptoms of Diabetes

  • Polyuria
  • Polydipsia
  • Polyphagia
• Diabetes screening during pregnancy

  Around 28 weeks gestation with a 50 gram oral GTT, if blood glucose is greater than 140mg/dL at 1 hour, a 3-hour 100 gram oral GTT is performed
• Priority nursing diagnoses for gestational diabetes

  • Risk for imbalanced nutrition, maternal and fetal: more than body requirements
  • Risk for injury maternal and fetal
  • Anxiety
• Implementation and collaborative care for gestational diabetes

  1. Teach client about the prescribed ADA diet regulation with no concentrated sweets

  2. Medications as prescribed

  3. Instruct client in frequent blood glucose, urine glucose, and ketone testing and keeping a diary of test results and activity levels

  4. Encourage regular non-strenuous exercise

  5. Monitor fetal well-being

  6. Monitor client for development of complications

  7. Prepare for possible induction of labor at 38 to 39 weeks with type 1 DM

  8. Insulin requirements drop dramatically after delivery of the placenta and removal of hormonal influences
• As many as 10% of pregnant women use tobacco, alcohol, or other drugs, often in combination; clients using illegal drugs may delay seeking care for fear of persecution; all pregnant women should be screened for substance abuse
• Assessment of substance abuse in pregnancy

  • Establish a trusting relationship with the client
  • Encourage client to describe all substance used, the amounts, times, and triggers to use, and any previous attempts to discontinue use
  • Evaluate client's motivation, support system, and personal strengths that may be elicited to change behaviors
• Priority nursing diagnoses for substance abuse in pregnancy

  • Ineffective health maintenance
  • Ineffective coping
  • Risk for impaired gas exchange
  • Risk for delayed growth and development
• Implementation and collaborative care for substance abuse in pregnancy

  1. Monitor clients for complications

  2. Monitor for fetal growth and well-being

  3. Teach client about potential negative effects of substance use in pregnancy and the fetus

  4. Assist with referrals as indicated

  5. Reinforce teaching about nutrition and the effects on fetal development

  6. Support client's efforts to change negative behaviors
• HIV/AIDS


  • The human immunodeficiency virus type (HIV-1) causes the condition known as acquired immunodeficiency syndrome (AIDS)
  • HIV is transmitted through contact with infected blood and body secretions, usually during sexual contact or intravenous drug use
  • Pregnancy doesn't appear to change the course of illness for the mother, the fetus may contract the virus transplacentally or through breast milk but generally fetal infection is considered to occur during vaginal birth
  • Current maternal treatment with antiretroviral drugs, including zidovudine (Retrovir) orally during pregnancy and intravenously during labor and delivery, has decreased neonatal transmission to <7% with vaginal birth and <1% with cesarean birth
  • Maternal HIV antibodies cross the placenta so all infants of HIV-positive mothers will test positive at birth and until maternal antibodies are depleted at between 15 to 18 months of age
• Assessment of HIV/AIDS in pregnancy

  1. Antibodies to HIV are detected with the enzyme-linked immunosorbent assay (ELISA) test and results confirmed by the Western blot test

  2. All pregnant women should be offered HIV testing because most clients are asymptomatic for an average of 10 years before signs of opportunistic infection occur
• Priority nursing diagnoses for HIV/AIDS in pregnancy

  • Risk for infection
  • Decisional conflict
  • Compromised family coping
  • Anticipatory grieving
• Implementation and collaborative care for HIV/AIDS in pregnancy


  1. Provide emotional support and reproductive counseling to client and family

  2. Evaluate client for other STIs and hepatitis B

  3. Review lab results

  4. Monitor clients for signs of opportunistic infections (Fever, unexplained weight loss, productive cough, skin infections)

  5. Administer prophylactic antiretroviral drugs

  6. Monitor fetal growth and well-being

  7. Use standard blood and body fluid precautions with all clients

  8. Protect fetus from maternal secretions
• Rh sensitization


  Rh-negative women who become pregnant with Rh-positive embryo/fetus (from an Rh-positive father) become sensitized to the Rh antigen when there is contact between maternal and fetal blood; other causes of Rh sensitization might be blood transfusion of Rh-positive blood to an Rh-negative woman, or fetomaternal blood contact during an amniocentesis or other invasive procedure
• Effects of Rh incompatibility and sensitization

  1. Sensitized Rh-negative women develop anti-Rh antibodies, which cross the placenta in subsequent Rh-positive pregnancies and destroy fetal RBCs

  2. Hemolysis of fetal RBCs leads to greatly increased immature RBC production, termed erythroblastosis fetalis

  3. Continued RBC destruction and anemia results in jaundice and marked failure

  4. Breakdown of RBCs releases bilirubin, causing jaundice; high levels of circulating bilirubin can cause kernicterus, a condition of yellow staining of the basal ganglia and brain from bilirubin deposits and may result in permanent neurological damage
• Assessment of Rh sensitization


  1. All pregnant women should be tested for blood group Rh factor and routine antibody screening; a history of previous miscarriage, blood transfusions, or infants experiencing jaundice should be noted

  2. If the client is Rh-negative, the father of the infant may be tested to determine his Rh status; an Rh-negative father and mother will only produce Rh-negative offspring who will not be affected by Rh incompatibility

  3. An indirect Coombs test on maternal blood determines whether the Rh-negative client has developed antibodies to the Rh antigen; serial antibody screening should continue throughout pregnancy to identify increasing antibody production; a direct Coombs test is done on the infant's blood after birth to identify maternal antibodies attached to fetal RBCs
• Priority nursing diagnoses for Rh sensitization

  • Risk for injury
  • Deficient knowledge
  • Anxiety
• Implementation and collaborative care for Rh sensitization

  1. Provide support and education to the client and family; the client should carry an Rh negative identification card and recognize that she may need the medication RhoGAM with future reproductive events

  2. Unsensitized Rh-negative client should be given 300mcg of Rh immune globulin (RhoGAM) IM at 28 weeks and also within 72 hours of delivery; the antibodies in the immune globulin bind with any Rh antigens in maternal circulation, providing passive immunity to the mother so she will not become sensitized to any Rh antigens and produce antibodies of her own

  3. RhoGAM is not given to mothers who are already sensitized and have antibodies (positive indirect Coombs' test)

  4. Rh immune globulin is also given after abortion, ectopic pregnancy, amniocentesis, chronic villi sampling, percutaneous umbilical cord sampling, external fetal version, or antepartum hemorrhage because of risk of maternal exposure to fetal Rh antigen

  5. The Kleihauer-Betke test estimates the amount of fetal blood in the maternal circulation; it is used to determine the dose of Rh immune globulin when a larger fetal-maternal bleed is suspected

  6. Evaluate the fetus for development of complications using serial ultrasound for amniotic fluid volume, fetal size, and the development of edema or an enlarged heart

  7. A sinusoidal electronic fetal monitoring pattern indicates severe fetal anemia; biophysical profile (BP) may be used to identify a compromised fetus

  8. Amniocentesis or percutaneous umbilical cord sampling (PUBS) may be used to determine fetal Rh; both procedures carry the risk of causing maternal exposure and sensitization, so RhoGAM should be given

  9. An early delivery with phototherapy and exchange transfusion may be planned if the fetus is developing anemia close to term

  10. Intrauterine exchange transfusion may be performed for the severely affected fetus until viability is reached