Study guide exam 3
Chapter 9
Risk factors for IPV
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Risk Factors Associated with men COMMITTING IPV can be divide into 4 categories:
o (1) Individual Factors:
 Young age
 Heavy drinking
 Personality disorders
 Depression
 Low academic achievement
 Witnessing violence as a child
 Low income and/or unemployment
 Desire for Power and control in all relationships
 Anger and Hostility
o (2) Relationship Factors:
 Marital conflict
 Economic Stress
 Dysfunctional Family
 Martial instability
 Male dominance in family
 Cohabitation
 Having outside sexual partners
 Taking aggression out on others while growing up
o (3) Community Factors:
 Weak sanctions against IPV
 Poverty
 Low social capital
o (4) Societal Factors:
 Traditional gender norms
 Social norms supportive of violence
Assessment findings and nursing interventions when dealing with victims of abuse
Assessment
 Routine Screening for IPV is the First Way to Detect Abuse:
o Build rapport by listening, showing an interest in woman’s concerns, and creating an
atmosphere of openness
o Communicate support through a nonjudgmental attitude and tell the woman that no
deserves to be abused
o SCREEN FOR ABUSE DURING EVERY HEALTHCARE VISIT
o Ask Direct and/or Indirect Questions about Abuse
 Direct: “Does your partner hit you?” “Have you ever been or are you now in an
abusive relationship?”
 Indirect: “We see many women with injuries or complaints like yours and
often they are being abused. Is that what is happening to you?” “Many
women in our community experience abuse from their partners. Is anything
like that happening in your life?”
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Some Clues:
o Injuries: bruises on the chest and abdomen, scars from blunt trauma, minor
lacerations, weapon wounds on the face, head, and neck
 Bruises to the upper arm, neck, face, abdomen, or breasts
 Delay in seeking medical attention and patterns of repeated injury
o Injury Sequelae: Has, hearing loss from ruptured eardrums, joint pain, sinus infections,
teeth marks, clumps of hair missing, dental trauma, pelvic pain, breast/genital injuries
 Reported h/o of injury not consistent with the actual presenting problem
 STIs or pelvic inflammatory disease
 Frequent healthcare visits for chronic, stress-related disorders such as chest
pain, Has, back or pelvic pain, insomnia, injuries, anxiety, and GI disturbances
o Mental Health Problems: Depression, anxiety, substance abuse, eating disorders,
suicidal ideation, suicide attempts anger toward healthcare provider, PTSD
 Frequent tranquilizer or sedative use
 Comments about emotional or physical abuse of “a friend”
 Appearing nervous, ashamed, or evasive when asked questions
o Partner’s Behavior at Visit: Appearing overly solicitous or overprotective, is unwilling
to leave the client alone with the provider, answers questions for her, and attempts to
control the situation
Isolate the Woman Immediately: to
provide privacy and prevent potential
retaliation
Enhance the Nurse-Client Relationship:
o Educate the woman about the
connection between violence and
her sx
o Help the woman acknowledge
what has happened to her and
begin to deal with the situation
o Offer the woman referrals so she
can get the help that will allow
her to begin to heal
Assess Immediate Safety: Speak to the
woman alone and ask her:
o Does she feel safe going home
after her meeting with you?
o Does she need an immediate
place of safety for herself or her
children?
o Does she have a plan of escape if
she becomes at risk for her
safety?
o Does she need to consider an alternative exit from this building?
o Who are the people she could contact for help or support?
The Danger Assessment Tool: Assesses for the potential for homicidal behavior in an ongoing
abusive relationship based on risk factors for abuse-related murder:
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o Increased frequency or severity of abuse
o Presence of firearms
o Sexual abuse
o Substance abuse
o Precipitated by arguments and conflicts
o Generally violent behavior outside of the home
o Control issues e.g. daily chores, friends, job, money
o Physical abuse during pregnancy
o Suicide threats or attempts (victim or abuser)
o Child abuse
Document and Report Findings: Must include details about the frequency and severity of the
abuse, the location, extent, ad outcomes of injuries, and any txs or interventions
o Use direct quotes and be specific
o Describe any visible injuries, use a body map to show the location of the injuries
o Obtain photos (with informed consent) or document her refusal if woman declines
photos
o Laws in many states require healthcare providers to alert police to any injuries that
involve knives, firearms, or other deadly weapons, or that present life-threatening
emergencies – explain to the woman if you are required by law to report it
Interventions
 Communication Techniques: Listening, communicating belief, Validating the decision to
disclose, Emphasizing the unacceptability of this violence
o Provide sensitive, predictable care in an accepting setting
o Offer step-by-step explanations of procedures
o Provide educational
materials about
violence
o Allow the victim to
actively participate
in her care and have
control over all
healthcare
decisions
o Pace nursing
interventions and
allow the woman to
take the lead
 The ABCDES Tool: Provides
a framework for providing
sensitive nursing
interventions to abused
women – educating her
about community services,
providing emotional
support, and offering a
safety plan
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o A = Assurance – that she is not alone
o B = Belief that violence against women isn’t acceptable and believing her
o C = Confidentiality
o D = Documentation
o E = Education about the cycle of violence and that it will escalate
o S = Safety
Providing Emotional Support:
o Strengthen Sense of Control: Teaching coping strategies for stress management,
assisting with ADLs to improve her lifestyle, allowing her to make as many decisions as
she can, educating her about sx of PTSD and their basis
o Encourage Her to Establish Realistic Goals for Herself: Teaching problem-solving skills,
encouraging social activities to connect with other people
o Support/Allow Woman to Grieve her Losses: Listening to and clarifying her reactions
to the traumatic event, discussing shock, disbelief, anger, depression, and acceptance
o Explain to the Woman That: Abuse is NEVER okay, she didn’t ask for it and she doesn’t
deserve it, she is not alone, help is available, abuse is a crime and she is a victim, etoh,
drugs, money problems, depression, and jealous don’t cause violence, but all these
give the abuser an excuse for losing control and abusing her, the actions of the abuser
are not her fault, her history of abuse is believed, making a decision to leave an
abusive relationship can be hard and dangerous, and takes time
Offer a Safety Plan: See Below
Phases of domestic or IPV
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The Cycle of Violence: 3 distinct phases (1) The Tension-Building Phase (2) The Physically
Abusive Phase (3) The Honeymoon/Reconciliation Phase
o The cyclical behavior increases in frequency and severity as it is repeated over and
over again
o Can cover long or short periods of time; the honeymoon phase gradually shortens and
eventually disappears altogether
o Abuse in relationships typically becomes accelerated and this more dangerous over
time
o The abuser no longer feels the need to apologize and indulge in a honeymoon phase
as the woman becomes increasingly disempowered in the relationship
Phase 1 Tension-Building: Usually the longest phase of the cycle, tension escalates between
the partners
o Excessive drinking, jealous, or other factors → name-calling, hostility, friction
o Woman might sense that her partner is reacting to her more negatively; they are on
edge and react heatedly to any trivial frustration
o Woman often accepts partner’s building anger as legitimately directed toward her;
internalizes what she perceives as her responsibility to keep the situation from
exploding
o In her mind, if she does her job well, they remain calm; but if she fails, the resulting
violence is her fault
Phase 2 Physical Abuse: The explosion of violence
o The abuser loses control both physically and emotionally
o This is when the victim may be assaulted or murdered
o
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After a physically violent episode, most victims consider themselves lucky that the
abuse was not worse, no matter how severe their injuries
o They often deny the seriousness of their injuries and may refuse to seek medical tx
Phase 3 Honeymoon/Reconciliation: A period of calm, loving, and contrite behavior on the
part of the abuser
o Abuser may be genuinely sorry for the pain caused to the partner; they attempt to
make up for the brutal behavior and believe they can control the violence and will
never hurt the woman again
o The victim wants to believe that her partner can really change; she feels responsible,
at least in part, for causing the incidence and she feels responsible for her partner’s
wellbeing
Nursing goals when working with IPV victims
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Although it is important that the woman in an abusive situation is safe, it is MOST
IMPORTANT for a woman to regain a sense of control in her life
o A lack of control is what can prevent a woman from escaping an abusive situation
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Depending on when in the cycle of violence, the nurse encounters the abused woman, goals
may fall into 3 groups:
o (1) Primary Prevention: Aimed at breaking the abuse cycle through community
educational initiatives by nurses, physicians, law enforcement, teachers, and clergy
o (2) Secondary Prevention: Focuses on screening high-risk individuals and dealing with
victims and abusers in early stages with the goal of preventing progression of abuse
o (3) Tertiary Prevention: Geared toward helping severely abused women and children
recover and become productive members of society; and rehabilitating abusers to
stop the cycle of violence; these activities are typically long-term and expensive
What factors would the nurse incorporate in a safety plan?
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The choice to leave MUST belong to the victim; nurses cannot choose a life for the victim; they
can only offer choices
o Nurse’s role is that of a GUIDE NOT A SAVIOR
Leaving is a process, not an event
o Victims may try to leave their abuses as many as 7 – 8 times before succeeding
o Frequently, the final attempt to leave results in the death of the victim
o Women planning to leave an abuse relationship should have a safety plan
Safety Plan for Leaving an Abusive Relationship:
o When leaving, take the following items:
 Driver’s license or photo ID
 SSN or green card/work permit
 Birth certificates for you and any children
 Phone numbers for social services or woman’s shelter
 The deed or lease to your home or apartment
 Any court papers or orders
 Prescription medications
 A change of clothing for you and your children
 Pay stubs, checkbook, credit cards, and cash
 Health insurance cards
o If you need to leave a domestic violence situation immediately, turn to authorities for
assistance in gathering these materials
o Develop a plan for leaving and rehearse it
o Don’t use phone cards – they leave a trail to follow
Chapter 19
Definition of HELLP syndrome
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HELLP Syndrome: Hemolysis, Elevated Liver Enzymes, Low Platelet Count
o A Variant of Preeclampsia/Eclampsia Syndrome: occurs in up to 20% of clients with
preeclampsia with severe features
o Essential phenomenon in HELLP’s development (similar to preeclampsia) is an
abnormal trophoblastic invasion due to inadequate maternal immune tolerance
Complications: Increased risk for cerebral hemorrhage, retinal detachment, hematoma/liver
rupture, DIC, placental abruption, eclampsia, acute renal failure, pulmonary edema, and
maternal death
o Increased risk of stroke, cardiac arrest, seizure, subendocardial hemorrhage, adult
respiratory distress syndrome, sepsis, hypoxic encephalopathy
o Maternal or Fetal Death
LIFE-THREATENING OBSTETRIC COMPLICATION
o Considered by many to be a severe form of preeclampsia
o Hemolysis (Microangiopathic Hemolytic Anemia)
o Thrombocytopenia (Low platelet count)
o Liver dysfunction (Elevated liver enzymes)
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 RUQ tenderness
 N/V
 Jaundice
o Other S/Sx: HA, nausea (with or without vomiting), malaise, epigastric or RUQ pain,
changes in vision
Occurs in later stages of pregnancy and sometimes after childbirth
o If the condition presents prenatally, morbidity and mortality can affect both mom and
baby
Characterized by:
o Abnormal Vascular tone
o Vasospasm
o Coagulation defects
A clinically progressive condition – early dx is critical to prevent liver distention, rupture, and
hemorrhage, and the onset of DIC
o Misdiagnosis and delayed recognition are common due to vague and varying
presentation – A laboratory value-specific diagnosis
o Low Hct unexplained by any blood loss
o Elevated LDH (liver impairment)
o Elevated AST/ALT (liver impairment)
o Elevated BUN (renal impairment)
o Elevated bilirubin level (liver impairment)
o Elevated uric acid and Cr levels (renal involvement)
o Low platelet count < 100,000
Management: Focuses on stabilization of blood pressure and assessment of fetal wellbeing to
determine the optimal time for birth
o Tx dependent on severity, gestational age of fetus, and the condition of mother and
fetus
o Rapid action antihypertensive agents e.g. hydralazine or labetalol
o Magnesium sulfate (for prevention of seizures)
o Steroids prn for fetal lung maturity, and birth e.g. betamethasone or dexamethasone
o Blood component therapy e.g. FFP, PRBCs, or Platelets transfused
Assessments and frequency, with patient receiving magnesium
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Magnesium Sulfate: Used in the prevention and treatment of eclamptic seizures
o Blocks neuromuscular transmission and promotes vasodilation
Admin:
o Loading dose of 4 – 6 grams IV in 100 mL of fluid over 15 – 30 mins
o Followed by a maintenance dose of 1 – 3 grams as a continuous IV infusion to
maintain a serum Mg level of 4 – 7 mEq/L
Nursing Implications:
o Vital signs at least every 4 hours continuing through to postpartum for at least 24
hours; expect to administer magnesium sulfate infusion for 24 hrs. postpartum to
prevent seizure activity
o Monitor serum Mg closely (4 – 7 mEq/L)
o Assess DTRs – The Patellar Reflex
 Diminished or absent reflexes occur with magnesium toxicity (hyporeflexia)
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 0 to 4+ (2+/3+ are normal)
Assess for Ankle Clonus bilaterally – indicates CNS irritability and risk of seizures
 Hyperreflexia
Monitor for S/Sx of toxicity e.g. flushing, sweating, hypotension, cardiac and CNS
depression
Ensure Calcium Gluconate is available in case of toxicity
Signs and symptoms of magnesium toxicity and care
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Magnesium Toxicity: Therapeutic Range is 4 – 7 mEq/L, Toxic > 8 mEq/L
o 10 mEq/L: Possible loss of DTRs
o 15 mEq/L: Possible respiratory depression
o 25 mEq/L: Possible cardiac arrest
S/Sx:
o Respiratory Depression – RR < 12
o Absent Reflexes – graded 0
o Decreased urinary output < 30 mL/hr.
o Lethargy
o Slurred Speech
o Loss of Consciousness
Tx: Calcium Gluconate is the antidote
Signs & Symptoms, risk factors for mild and severe preeclampsia
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Preeclampsia: New-onset HTN accompanied by Proteinuria and/or maternal organ
dysfunction that targets the cardiovascular, hepatic, renal, and CNS
o Can be present with severe features or not
Risk Factors:
o Primigravida status
o Chromosomal abnormalities
o Structural congenital abnormalities
o Multiple gestation
o H/O preeclampsia in a previous pregnancy; family H/O of preeclampsia (mother or
sister)
o Excessive placental tissue e.g. women with Gestational trophoblastic disease (GTD) –
tumor develops in uterus after conception
o Chronic stress
o In vitro fertilization
o Lupus (autoimmune disease)
o Lower socioeconomic status
o H/O DM, HTN, or renal disease
o Poor nutrition; obesity
o African American ethnicity
o Maternal age < 20 y/o or > 35 y/o
S/Sx:
o HTN; HA; N/V
o Proteinuria; decreased urine output
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 Elevated serum sodium, BUN, uric acid, Cr
 Generalized edema and pulmonary edema
o Hemoconcentration; elevated Hct; unusual bruising or bleeding
o Visual disturbances: Blurred vision
o Hyperreflexia (of DTRs)/Clonus due to hypoperfusion
Preeclampsia Without Severe Features:
o BP > 140/90 after 20 weeks gestation
o No seizures/coma
o No Hyperreflexia
Preeclampsia with Severe Features:
o BP ≥ 160/110 on 2 occasions at least 6 hrs. apart while on bed rest
o No seizures/coma
o Yes Hyperreflexia
o HA, Oliguria, Blurred vision, Scotomata (Blind Spots)
o Pulmonary edema
o Thrombocytopenia (platelets <100,000)
o Cerebral disturbances
o Persistent epigastric or RUQ pain
o HELLP
o Progressive renal insufficiency
Eclampsia: The onset of seizure activity
o BP > 160/110
o Yes seizures/coma – The convulsive activity begins with facial twitching followed by
generalized muscle rigidity
 Woman’s face initially may become distorted with protrusion of the eyes
 Foaming at the mouth
 Respirations cease for the duration of the seizure from muscle spasms,
compromising fetal oxygenation
 Seizure complications can include tongue biting, head trauma, broke bones,
and aspiration
 Coma usually follows the seizure, with respirations resuming
o Yes hyperreflexia
o Severe HA, generalized edema, RUQ or epigastric pain, visual disturbances, cerebral
hemorrhage, renal failure, HELLP
Nursing care for Mild and severe preeclamptic patient
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Management for Preeclampsia Without Severe Features:
o Mild elevation in BP may be placed on bed rest at home; encouraged to rest as much
as possible in the lateral recumbent position to improve uteroplacental blood flow,
reduce BP, and promote diuresis
o Increased frequency of prenatal visits (weekly) and CBC, clotting studies, liver
enzymes, and platelet levels
o Woman monitors her BP daily q4 – 6 w/a, and reports any increased readings
o Monitors daily kick counts, and reports any decrease in fetal movements
o Balanced, nutritional diet with NO sodium restriction; encouraged to drink 6 – 8
glasses of water daily
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Contact Provider if: Increase in BP, burning or frequency when urinating, decreased
fetal activity/movement, HA (forehead or posterior neck region), dizziness or visual
disturbances, stomach pain, excessive heartburn, epigastric pain, decreased or
infrequent urinary, contractions or low back pain, easy or excessive bruising, sudden
onset of abdominal pain
o In the hospital: BP monitoring, fetal surveillance, nonstress testing, serial ultrasounds
to evaluate fetal growth and amniotic fluid volume
 Watchful waiting until pregnancy reaches at least 37 weeks gestation, fetal
lung maturity is documented, or complications that warrant immediate birth
 Monitor serum mag if getting, assess DTRs/ankle clonus
o During Labor: BP monitoring, quiet environment to decrease stimulation and promote
rest, close monitoring of neurologic status to detect any s/sx of hypoxemia, impending
seizure activity, or increased intracranial pressure
 Routine magnesium sulfate is NOT recommended for all women without
severe features
 Indwelling urinary catheter inserted to allow for accurate measurement of
urine output
Management of Preeclampsia with Severe Features:
o Perinatal BP control and monitoring, Prenatal aspirin therapy, Betamethasone for
women prior to 34 weeks gestation, parenteral magnesium sulfate prophylaxis, and
follow-up of postpartum BPs
o If a sudden onset: Controlling HTN, treated aggressively; preventing seizures
o During Labor: Oxytocin to stimulate uterine contractions, Antihypertensives to control
BP, Magnesium sulfate to prevent seizures; PGE2 gel may be used to ripen the cervix,
or a C-section may be performed if the pt is seriously ill
Management of Eclampsia: Eclampsia is the hallmark neurologic complication of
preeclampsia, the onset of seizure activity – Eclamptic seizures are a medical emergency and
require immediate tx to prevent maternal and fetal mortality
o ABCs for management – clear the airway, admin O2, position woman on left side,
protect her from injury during the seizure
o Suction equipment readily available for end of seizure
o IV fluids, IV magnesium sulfate for at least 24 hrs. after last seizure
o Antihypertensive meds
o After seizures are controlled, birth either via induction or C-section
Signs of Abruption placenta
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Placental Abruption: The early separation of a normally implanted placenta after the 20th
week of gestation prior to birth (Peaks 24-26 weeks), which leads to hemorrhage
o Results from bleeding between the decidua and placenta
o Occurs when the maternal vessels tear away from the placenta and bleeding occurs
between the uterine lining and the maternal side of the placenta
 As the blood accumulates, it pushes the uterine wall and placenta apart
o A significant cause of 2nd and 3d trimester bleeding with a high mortality rate
o Risk is 20x higher in subsequent pregnancy
Maternal Complications: Obstetric hemorrhage, need for blood transfusions, emergency
hysterectomy, DIC, Sheehan Syndrome or postpartum gland necrosis, and renal failure
o Maternal mortality rate is 5%
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Fetal/Newborn Complications: Fetal blood supply is compromised, and fetal distress develops
in proportion to the degree of placental separation; Low birth weight, preterm birth, asphyxia,
stillbirth, and perinatal death
o Fetal mortality rate is up to 40% depending on the extent of the abruption
Placental Abruption Classifications: Classified according to the extent of separation and the
amount of blood loss from the maternal circulation
o Grade 0: Clinically unrecognized before birth, diagnosis is made retrospectively after
birth
o Mild (Grade 1): No sign of vaginal bleeding, or minimal bleeding < 500mL; marginal
separation 10-20%, tender uterus, no coagulopathy, no signs of shock, no fetal distress
o Moderate (Grade 2): No sign of bleeding or moderate bleeding 1,000-1,500mL;
moderate separation 20-50%, continuous abdominal pain, mild shock, normal
maternal blood pressure, maternal tachycardia, evidence of fetal distress
o Severe (Grade 3): Absent to moderate bleeding > 1,500 mL, severe separation > 50%,
profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased maternal
blood pressure, significant maternal tachycardia, and the development of DIC
o Classification of 0 or 1: Typically associated with partial or marginal separation
o Classification of 2 or 3: Associated with a complete or central separation
o Can also be classified as either Partial or Complete depending on degree of separation
o Or classified as Concealed or Apparent by the type of bleeding
S/Sx: Variable depending on the extent of placental separation and the amount of maternal
blood loss
o Hemorrhage: always ensues, but can be apparent (as vaginal bleeding, in ~80%) or
concealed (~20%, absence of vaginal bleeding)
o Vitals: Can be within normal range, even with significant blood loss, because a
pregnant woman can lose up to 40% of her total blood volume without showing signs
of shock – monitor LOC
 Take vitals as frequently as q15-30 mins
o
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o
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Classic S/Sx: Painful, Dark red vaginal bleeding (port-wine color) because the blood
comes from the clot that formed behind the placenta; knife-like abdominal pain;
uterine tenderness; contractions; decreased fetal movement
Fundal Height: Increase in fundal high would indicate bleeding
Uterus: Any increased uterine tenseness or rigidity
 Contractions: Tetanic uterine contractions or changes in fetal heart rate
patterns suggesting the fetus has been compromised
S/Sx of DIC: Bleeding gums, tachycardia, oozing from IV insertion site, petechiae
 Decreased fibrinogen and platelets
 Prolonged PT and aPTT
 Positive D-dimer and fibrin degradation products
Signs and symptoms of placenta previa and nursing care
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Placenta Previa: “Afterbirth First”; When the placenta is inserted wholly or partly into the
lower uterine segment of the uterus, partially or completely covering the internal cervical
opening
o A bleeding condition that occurs during the last 2 trimesters of pregnancy
o Poses a high risk of prenatal and postpartum hemorrhage and perinatal morality
o Thought to be due to uterine endometrial scarring or damage in the upper segment,
or uteroplacental underperfusion
o The Cervical Os May become covered by the developing placenta
o Placental vascularization is defective, allowing the placenta to attach directly to the
myometrium (Accreta), deeply attach to the myometrium (Increta), or infiltrate the
myometrium (Percreta)
Classifications: Both need follow-up ultrasounds at 36 weeks gestation if the woman is
asymptomatic without bleeding
o “Placenta Previa”: If the placental edge covers the internal os
o “Low-Lying Placenta”: If the placental edge is less than 2cm from the internal os, but
does not cover it
Classical Clinical Presentation: Painless, bright red vaginal bleeding occurring during the 2nd
and 3rd trimester
o Initial bleeding usually isn’t profuse and ceases spontaneously, only to recur
o First episode of bleeding avg. occurs 27-32 weeks gestation
o
o
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Contractions may or may not occur with bleeding
Fetal distress is usually absent, but may occur when cord problems arise e.g. cord
prolapse or cord compression; or when blood loss is to the extent of maternal shock
or placental abruption has occurred
o Uterus is soft and tender upon examination
Labs and Dx Testing: To validate the position of the placenta, a transvaginal ultrasound is done
o In preparation for birth, an MRI may be done to allow for identification of Placenta
Accreta (placenta abnormally adherent to the myometrium), Placenta Increta
(placental penetration of the myometrium), or Placenta Percreta (placental invasion
of the myometrium to the peritoneal covering, causing rupture of the uterus)
Nursing Management: Focuses on monitoring the maternal-fetal status, including assessing
for s/sx of vaginal bleeding, fetal distress, and providing support and education, and info. On
diagnostic studies and procedures being performed
o Assess degree of vaginal bleeding, inspect the perineal area for pooled blood,
estimate and document amount
o Perform a peripad count on an ongoing basis
o With active bleeding, prepare for blood typing and cross-matching in case transfusion
is needed
o AVOID vaginal exams – may disrupt the placenta and cause hemorrhage
o Monitor maternal vital signs and uterine contractility, assess pain levels
o Assess fetal heart rates to monitor for fetal distress
o Monitor mom’s cardiopulmonary status – report any difficulty in respirations, change
in skin color, have O2 readily available
o Encourage mom to lie on her side to enhance placental perfusion
o Inspect IV site regularly or anticipate insertion of intermittent IV access
o Obtain lab tests as ordered e.g. CBC, coagulation studies, and Rh status
o Give Rh immunoglobulin if the pt is Rh-negative at 28 weeks gestation
Risk factors for abortion
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Abortion: The loss of an early pregnancy, usually before 20-21 weeks gestation; can be
spontaneous or induced
o Spontaneous Abortion: The loss of a fetus resulting from natural causes, meaning not
elective or therapeutically induced – layman terms = “Miscarriage” before 21 weeks,
“Stillbirth” after 21 weeks
Risk Factors:
o 50% are attributed to chromosomal abnormalities
o Frequency of spontaneous abortion increases with advanced maternal age
o Maternal Conditions:
 Cervical insufficiency
 Congenital or acquired anomy of the uterine cavity (uterine septum or
fibroids); polycystic ovary syndrome
 Hypothyroidism
 Diabetes, Chronic Nephritis, severe HTN
 Inherited or acquired thrombophilia, Lupus
 Acute infection e.g. Rubella, HSV, bacterial vaginosis, toxoplasmosis
Nursing care of woman experiencing abortion, medical management and care after
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When a pregnant woman calls and reports vaginal bleeding, she must be seen ASAP to
determine etiology
o Varying degrees of vaginal bleeding, low back pain, abdominal cramping, and passage
of products of conception tissue may be reported
RNs – Ask About:
o The color of vaginal bleeding – bright red is significant
o Amount of vaginal bleeding – the frequency with which she is changing her peripads
(saturation hourly is significant and the passage of any clots or tissue)
 Instruct her to save any tissue or clots passed and bring them with her
o A description of other s/sx she’s experiencing and their severity and duration
At the Office:
o Assess her vitals; assess current pain levels – evaluate the amt and intensity of
abdominal cramping or contractions
o Observe the amt, color, and characteristics of the bleeding
o Assess woman’s level of understanding about what is happening to her
Determining the Type of Spontaneous Abortion: 6 different types
o Threatened Abortion: Vaginal bleeding (often slight) early in a pregnancy, no cervical
dilation or change in cervical consistency, mild abdominal cramping, closed cervical os,
no passage of fetal tissue
 Dx: vaginal ultrasound to confirm is sac is empty; declining maternal serum
hCG and progesterone levels
 Tx: Conservative supportive tx, possible reduction in activity in conjunction
with nutritious diet and adequate hydration
o Inevitable Abortion: Vaginal bleeding (greater than associated with threatened
abortion), rupture of membranes, cervical dilation, strong abdominal cramping,
possible passage of products of conception
 Dx: Ultrasound and hCG levels to indicate pregnancy loss
 Tx: Vacuum curettage if products of conception aren’t passed to reduce risk of
excessive bleeding and infection; prostaglandin analogs e.g. misoprostol to
empty uterus of remained tissue (only used if fragments aren’t completely
passed)
o Incomplete Abortion: Passage of some of the production of conception – intense
abdominal cramping, heavy vaginal bleeding, cervical dilation
 Dx: ultrasound confirmation that products of conception are still in the uterus
 Tx: Client stabilization, evacuation of the uterus via dilation and curettage
(D&C) or prostaglandin analog
o Complete Abortion: Passage of all products of conception – H/O vaginal bleeding and
abdominal pain, passage of tissue with subsequent decrease in pain and significant
decrease in vaginal bleeding
 Dx: Ultrasound shows empty uterus
 Tx: No medical or surgical intervention necessary; follow-up apt. to discuss
family planning
o Missed Abortion: Nonviable embryo retained in utero for at least 6 weeks – Absent
uterine contractions, irregular spotting, possible progression to inevitable abortion
 Dx: ultrasound to identify products of conception in uterus

o
Tx: Evacuation of uterus (if inevitable abortion does not occur): suction
curettage during 1st trimester, D&C during 2nd trimester; Induction of labor
with intravaginal PGE2 suppository to empty uterus without surgical
intervention
Recurrent Abortion: H/O 3 or more consecutive spontaneous abortions; not carrying
the pregnancy to viability or term
 Dx: validation via client’s hx, no diagnostic ultrasound findings
 Tx: Identification and tx of underlying cause (e.g. genetic or chromosomal
abnormalities, reproductive tract abnormalities, chronic diseases or
immunologic problems); Cervical cerclage (sewing cervix closed to prevent
miscarriage/preterm delivery) in 2nd trimester if incompetent cervix is the
cause
Nursing Management
 Focuses on providing continued monitoring and psychological support for acute loss and grief;
reassurance that spontaneous abortion usually results from an abnormality and her actions
did not cause the abortion
 Monitoring and Ongoing Assessments: amt. of vaginal bleeding through pad counts, observe
for passage of products of conception tissue, assess pain and provide appropriate pain
management to address cramping discomfort
o Assist in preparing the woman for procedures and txs such as surgery to evacuate the
uterus or meds such as misoprostol or prostaglandin E2 (PGE2)
o If the woman is Rh-negative and not sensitized, expect to administer RhoGAM within
72 hrs. after the abortion is complete
 Providing Support: Emotional reaction may vary depending on the desire for the pregnancy
and available support network
o Prepare woman and family for the assessment process and answer their questions
o Explaining some of the causes of spontaneous abortion can help understanding, and
may allay her fears and guilt that she did something to cause the pregnancy loss
o Woman may experience acute sense of loss and go through grieving process
o Sensitive listening, counseling, anticipatory guidance, allow verbalization of feelings
and asking questions about future pregnancies
o Grieving period may last years and is highly individualized
o Encourage friends and family to be supportive, but give the family space and time to
work through their loss
o Referral to a community support group can be helpful
Signs and symptoms of ectopic pregnancy, med mtg and nursing interventions

Ectopic Pregnancy: Any pregnancy in which the fertilized ovum implants outside the uterine
cavity, including the fallopian tubes (most common 96%), cervix, ovary, and the abdominal
cavity
o Abnormally implanted embryo grows and draws it blood supply from the site of
abnormal implantation – creating potential for organ rupture as it grows because only
the uterine cavity is designed to expand and accommodate fetal development
o Can lead to massive hemorrhage, infertility, or death
o The primary cause of death during the 1st trimester of pregnancy in the US
 A ruptured ectopic pregnancy is a MEDICAL EMERGENCY



Risk Factors: Conditions that obstruct or slow the passage of the fertilized ovum through the
fallopian tube to the uterus
o Can be a physical blockage in the tube or failure of the tubal epithelium to move the
zygote down the tube
o Most cases: Tubal Scarring – Secondary to Pelvic Inflammatory Disease (PID)
o Gonorrhea and chlamydia silently attack fallopian tubes
o Previous tubal surgery, infertility, previous pregnancy loss (induced or spontaneous),
sterility, previous ectopic pregnancy
o Use of an IUD, h/o multiple sexual partners, use of progestin-only oral contraceptives,
douching, exposure to diethylstilbestrol (DES)
o Uterine fibroids, endometriosis
o Smoking – alters tubal motility
o Maternal age > 35
S/Sx: Challenging because many women are asymptomatic before tubal rupture
o Classic Clinical Triad: Abdominal Pain, Amenorrhea, and Vaginal Bleeding
 Tender abdomen
 Painful vaginal exam
 Cervical motion tenderness
 Possible adnexal mass
o HALLMARK OF ECTOPIC PREGNANCY: ABDOMINAL PAIN WITH SPOTTING WITHIN 6 – 8
WEEKS AFTER A MISSED MENSTRUAL PERIOD – many women also have sx typical of
early pregnancy e.g. breast tenderness, nausea, fatigue, shoulder and low back pain
o Ruptured: severe, sudden, sharp lower abdominal pain, faintness, referred shoulder
pain, hypotension, tachycardia, abdominal distention, hypovolemic shock
Management of Ectopic Pregnancy: Regardless of approach, beta-hCG is monitored until it is
undetectable to ensure that any residual trophoblastic tissue that forms the placenta is gone;
and all Rh-negative unsensitized pts are given Rh immunoglobulin to prevent isoimmunization
in future pregnancies
o Hemodynamically Stable/Non-ruptured Ectopic Pregnancies: Laparoscopic surgery or
IM methotrexate – Prostaglandins, Misoprostol, and Actinomycin have also been used
in nonsurgical management of ectopic pregnancy with ~ 90% success
 To get methotrexate must be hemodynamically stable, no signs of active
bleeding in the peritoneal cavity, low beta-hCG levels (< 5,000 mIU/mL), and
the mass must be less than 4cm (determined by ultrasound) and must be
unruptured
 Woman must follow up weekly for next several weeks until beta-hCG titers
decrease (beta-hCG level changes between days 0 and 4 after methotrexate
therapy have clinical significance and predictive value; decreasing = highly
predictive of tx success)
 Contraindications to Methotrexate: Unstable, Severe persistent abdominal
pain, Renal or Liver disease, Immunodeficiency, Active pulmonary disease,
Peptic Ulcer, Suspected intrauterine pregnancy, and Poor client compliance
o Surgical Intervention:
 For unruptured fallopian tube/methotrexate isn’t suitable – linear
salpingostomy to preserve the tube (important for preservation of future
fertility)


For ruptured ectopic pregnancy, surgery necessary due to uncontrolled
hemorrhage – Salpingectomy – laparotomy with a removal of the tube may be
necessary
Nursing Management: focuses on preparing the woman for tx, providing support, and
education about prevention measures
o Preparing for Tx: administer analgesics, educate about meds and procedures/what to
expect, review s/sx of adverse effects, s/sx of rupture, close monitoring of vitals,
bleeding (peritoneal or vaginal), and pain status to ID hypovolemic shock
 Stress need for weekly follow-up hCG titers
o Emotional Support: Reaction is unpredictable, but important to recognize that she has
experienced a pregnancy loss in addition to undergoing tx for a potentially lifethreatening condition
 Help her make the experience more “real” by encouraging expression of
feelings and concerns openly and validating that this is a loss of pregnancy and
it’s okay for her to grieve over the loss – acknowledge the pregnancy and
allow her to discuss her feelings about what the pregnancy means
 Ask about her feelings and concerns about future fertility
 Provide education on the need to use contraceptives for at least 3 menstrual
cycles to allow her reproductive tract to heal and the tissue to be repaired
 Spiritual care, information about community support groups
o Prevention Education: Reduce risk factors such as multiple partners, intercourse
without a condom – contracting STIs that lead to PID, early dx and tx of STIs, if an IUD
– describe s/sx of PID to reduce risk of repeat ascending infections causing tubal
scarring, don’t smoke, seek prenatal care early to confirm location of pregnancy
Diagnosis of incompetent cervix and medical treatment and nursing care




Incompetent Cervix/Cervical Insufficiency: also called Premature dilation of the cervix
o Describes a weak, structurally defective cervix that spontaneously dilates in the
absence of uterine contractions in the 2nd trimester or early 3rd trimester, resulting in
the loss of the pregnancy
o Typically occurs in the 4th or 5th month of gestation before the point of fetal liability →
the fetus dies unless the dilation can be arrested
o The cervical dilation is typically rapid, relatively painless, and accompanied by minimal
bleeding
Risk Factors: Previous cervical trauma, preterm labor, fetal loss in the 2nd trimester, previous
surgeries/procedures involving the cervix, previous loss of pregnancy around 20 weeks
o DIAGNOSIS: REMAINS DIFFICULT, CORNERSTONE IS A H/O OF A PREGNANCY LOSS
DURING THE 2ND OR EARLY 3RD TRIMESTER ASSOCIATE WITH PAINLESS CERVICAL
DILATION WITHOUT EVIDENCE OF UTERINE ACTIVITY
 Serial Transvaginal ultrasound 16-24 weeks to determine cervical length,
evaluate for shortening, and attempt to predict an early preterm birth
 Cervical shortening viewed on the ultrasound as Funneling – A CERVICAL
LENGTH < 25 mm 16-24 WEEKS IS ABNORMAL
S/Sx: Complaints of vaginal discharge or pelvic pressure – often woman reports a pink-tinged
vaginal discharge or an increase in low pelvic pressure, cramping with vaginal bleeding, and
loss of amniotic fluid
Management:
o
o
o
o

Bed rest, pelvic rest, avoidance of heavy lifting
Progesterone supplementation in women at risk for preterm birth
Placement of a Cervical Pessary (a round, silicone device at the mouth of the cervix)
Cervical Cerclage in 2nd trimester – up to 28 weeks gestation – (surgical transvaginally
or transabdominally– sewing cervix shut with 1 stitch to reinforce the internal os)
 Typically only used if a short cervix is identified at or after 20 weeks and no
infection (cautious decision)
 H/O 2nd trimester pregnancy loss with painless dilation, prior cerclage for
cervical insufficiency, H/O spontaneous preterm birth prior to 34 weeks
 Cervical dilation on physical exam in 2nd trimester
 Complications: Suture displacement, ROM, chorioamnionitis
Nursing Management: Focuses on monitoring closely for signs of preterm labor: backache,
increase in vaginal discharge, ROM, uterine contractions
o Provide emotional support and education
o Teach s/sx of preterm labor and need to report any changes immediately
o Reinforce the need for activity restrictions if appropriate and continued regular
follow-up
GTD disease and assessment findings and patient teaching



Gestational Trophoblastic Disease (GTD): (AKA Molar Pregnancy) A group of disorders of
placental development including:
o Hydatidiform Mole: A benign neoplasm of the chorion in which the chorionic villi
degenerate and become transparent vesicles containing clear, viscid fluid; classified as
complete or partial
 Complete: contains no fetal tissue and develops from an “empty egg”; embryo
is not viable and dies, no circulation is established, and no embryonic tissue is
found – associated with the development of choriocarcinoma – surgery can
remove most complete moles
 Presentation: Vaginal bleeding, anemia, excessively enlarged uterus
for gestational date, preeclampsia, and hyperemesis
 Partial: has a triploid karyotype (69 chromosomes) because 2 sperm have
fertilized the ovum
 Presentation: Missed or incomplete abortion e.g. vaginal bleeding,
small or normal sized for gestational date uterus
o Choriocarcinoma: Neoplasms of the trophoblast – A chorionic malignancy from the
trophoblastic tissue
 Presentation: Asymptomatic at first; Early sx are SOB, indicative of metastasis
to the lungs (most common site of metastases)
Common Features of all Trophoblastic Lesions: They produce hCG, which serves as a clinical
marker for the presence of persistent or progressive trophoblastic disease
o There is an abnormal hyperproliferation of trophoblastic cells that would normally
develop into the placenta during pregnancy
o Gestational tissue is present, but the pregnancy is not viable
o Maternal tumor that arises from gestational tissue, not maternal tissue
Assessment Findings: similar to those of spontaneous abortion at ~ 12 weeks of pregnancy
o Reports of early sx of pregnancy e.g. amenorrhea, breast tenderness, fatigue


o Brownish vaginal bleeding/spotting
o Anemia
o Inability to detect a fetal rate after 10-12 weeks gestation
o Fetal parts not evidence with palpation
o Bilateral ovarian enlargement caused by cysts and elevated levels of hCG
o Persistent, often severe nausea and vomiting due to high levels of hCG
o Fluid retention and swelling
o Uterine size larger than expected for pregnancy dates
o Extremely high hCG levels present (no dx value)
o Early development of preeclampsia prior to 24 weeks gestation
o Absence of fetal heart rate or fetal activity
o Expulsion of grape-like vesicles (possible in some women)
Dx: made by high hCG levels and the characteristic appearance of the vesicular molar pattern
in the uterus via transvaginal ultrasound
Nursing Management:
o Preparing the Client: Upon dx, they need an immediate evacuation of the uterus via
D&C
o Education: about the risk that cancer may develop after a molar pregnancy and the
strict adherence needed with the follow-up regimen
 Close clinical surveillance for ~ 1 year
 Serial serum beta-hCG levels used to detect residual trophoblastic tissue
(continued high or increasing hCG titers are abnormal ad nee further
evaluation)
 The possible use of chemotherapy e.g. methotrexate may be started
prophylactically
 Strongly urge the pt to use a reliable contraceptive to prevent pregnancy for 1
year because a pregnancy would interfere with tracking serial hCG levels used
to identify a malignancy
Hyperemesis Gravidarum treatment and risks


Hyperemesis Gravidarum: A severe form of nausea and vomiting of pregnancy, associated
with significant costs and psychosocial impact
o Results in dehydration, nutritional deficiencies, weight loss of > 5% of pre-pregnancy
body weight, electrolyte imbalance, ketosis, and the need for hospitalization
o Characterized by persistent, uncontrollable nausea and vomiting that begins before 9
weeks gestation and/or extends beyond the first trimester
 Peak incidence is at 8-12 weeks of pregnancy; sx usually resolve by 20 weeks
 Every pregnant woman needs to be instructed to report any episodes of
severe nausea and vomiting, or episodes that extend beyond the first
trimester
Risk Factors: Previous pregnancy complicated by hyperemesis, molar pregnancies, h/o H.
pylori infection, multiple gestation, pre-pregnancy h/o of genitourinary disorders,
hyperthyroidism, and pre-pregnancy psychiatric diagnosis
o Young age, h/o intolerance of oral contraceptives, nulliparity, trophoblastic disease,
emotional or psychological stress, GERD, primigravida status, obesity, H. pylori
seropositivity



Complications of Hyperemesis Gravidarum: Results in dehydration, nutritional deficiencies,
weight loss of > 5% of pre-pregnancy body weight, electrolyte imbalance, ketosis, and the
need for hospitalization
o Dehydration can lead to preterm labor
o Extreme discomfort, loss of work productivity and sleep, damaged family relationships
o Neurologic disturbances, Renal damage, Ketosis, Alkalosis from loss of HCl,
hypokalemia, retinal hemorrhage, death
Treatment: IV FLUIDS MAY BE REQUIRED FOR REHYDRATION, BUT THE PRIORITY IS TO STOP
ALL INTAKE OF FOOD AND FLUID FOR A PERIOD OF TIME (THE FIRST 24-36 HRS.) UNTIL
VOMITING HAS STOPPED – to allow GI tract to rest
o Initially: Dietary and lifestyle changes
o Hospitalization: IV fluids ad drugs to rehydrate and reduce sx – NS (prevention of
hyponatremia) with vitamin B6 (pyridoxine), and electrolytes
 Antiemetics: rectally or IV/IM (IV/IM = second pillar of tx)
 Diclegis (Pyridoxine/Doxylamine) + Vitamin B6 + Doxylamine = First
line tx
 Dimenhydrinate (Dramamine), Diphenhydramine (Benadryl), and
Promethazine (Phenergan) = Second line tx
 Ondansetron (Zofran) = Third line tx (b/c its newer, effects not as
known)
 Diclegis Nursing Implications: Be alert for drowsiness, dizziness, HA, irritability;
do not administer with any CNS depressants, must be taken daily, not PRN,
should be taken on an empty stomach with a full glass of water (if not NPO)
 Promethazine Nursing Implications: Urinary retention, dizziness, hypotension,
dyskinesias, institute safety measures to prevent injury secondary to sedative
effects, offer hard candy and frequent rinsing of mouth for xerostomia
 Ondansetron Nursing Implications: Diarrhea, constipation, abdominal pain,
HA, dizziness, drowsiness, fatigue, monitor LFTs as ordered
o CATs: Acupressure, hypnosis, massage, therapeutic touch, ginger, Sea-Bands
Patient Teaching to Minimize Nausea/Vomiting:
o Avoid noxious stimuli e.g. strong flavors, perfumes, strong odors like frying bacon that
might trigger n/v
o Avoid tight waistbands to minimize pressure on abdomen
o Eat small, frequent meals throughout the day
o Separate fluids from solids by consuming fluids in between meals
o Avoid lying down or reclining for at least 2 hrs. after eating
o Us high-protein supplement drinks
o Avoid foods high in fat
o Increase intake of carbonated beverages
o Increase exposure to fresh air to improve sx
o Eat when you are hungry, regardless of normal mealtimes
o Drink herbal teas containing peppermint or ginger
o Avoid fatigue, and learn how to manage stress in life
o Schedule daily rest periods to avoid becoming overtired
o Eat foods that settle the stomach e.g. dry crackers, toast, or soda
Define PROM and nursing assessments
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Prelabor Rupture of Membranes (PROM): The spontaneous rupture of the amniotic sac (aka
bag of waters) before the onset of true labor – used when referring to a woman who is
beyond 37 weeks gestation
o Preterm Prelabor Rupture of Membranes (PPROM): the rupture of membranes prior
to the onset of labor in a woman who is less than 37 weeks gestation
o Latent Period: The time interval from PROM to the onset of regular contractions
Complications: Infection, cord prolapse, placental abruption, preterm labor
o If prolonged > 24 hrs., risk for infection (chorioamnionitis, endometritis, sepsis, and
neonatal infections) increases and continues to increase the longer the time since the
amniotic sac ruptured
Risk Factors: Low socioeconomic status, multiple gestation, low BMI, tobacco use, h/o
preterm labor, placenta previa, placental abruption, UTI (frequency, urgency, dysuria, flank
pain), vaginal bleeding at any time in pregnancy, illicit drug use, cerclage, amniocentesis,
maternal infection, increased uterine size (potential polyhydramnios, macrosomia, multiple
gestation), uterine and fetal anomalies, STIs, cervical insufficiency, cigarette smoking during
pregnancy, pelvic infection
S/Sx: Leakage of fluid, vaginal discharge, vaginal bleeding, pelvic pressure without
contractions
Nursing Assessments: Focus on obtaining a complete health history and performing a physical
exam to determine fetal and maternal status, accurate assessment of gestational age,
knowledge of maternal, fetal, and neonatal risks
o Assess for S/Sx of Labor: cramping, pelvic pressure, back pain
o Vitals/Labs: signs indicative of infection e.g. fever, elevated WBCs
o
o

FHR Monitoring: continuous evaluation of fetal wellbeing; fetal tachycardia = infection
Vaginal Exam: to determine cervical status in PROM (in PPROM – sterile! And cervix is
not palpated)
o Amniotic Fluid Characteristics: amt. (decreased amt. reduces cushioning effect and can
lead to cord compression), color, odor (foul can indicate infection), time ruptured,
evidence of meconium (typically indicates fetal distress related to hypoxia – stains
fluid yellow/green/brown)
Patient Education for PPROM: monitor daily fetal kick counts, check temp daily, watch for
signs r/t beginning of labor, report any tightening of abdomen or contractions, avoid
touching/manipulation breasts – could stimulate labor, don’t insert anything into the vagina,
do not swim in pools/sit in hot tub, take showers not baths, maintain specific activity
restrictions as recommended, wash hands thoroughly after bathroom, wipe front to back,
keep perianal area clean and dry, take abx as directed, call provider with changes included
fever, uterine tenderness, racing heart, and foul-smelling vaginal discharge
Amnioinfusion Indications, Poly/Oligohydramnios



Polyhydramnios (Hydramnios): Too much amniotic fluid > 2000 mL, between 32-36 weeks
gestation
o Associated with maternal DM (18% of women with DM will develop)
o Associated with fetal anomalies of development e.g. upper GI obstruction or atresia
(e.g. anus non-patent), neural tube defects, and abdominal wall defects
 In fetuses with chromosomal abnormalities e.g. trisomy 13 or 18 – impaired
swallowing, anencephaly (baby born without parts of brain and skull, a type of
neural tube defect)
o Fetal labor intolerance, low 5-min APGAR scores, increased neonatal birth weight,
congenital abnormalities, and NICU admissions
RNs – Suspect Hydramnios When:
o Uterine enlargement, maternal abdominal girth, and fundal height are larger than
expected for fetal gestational age
o Rapid uterine growth
o Maternal abdominal discomfort/tightness/sensations of being severely stretched
o Uterine contractions (from over stretching of uterus)
o SOB, lower extremity edema
Oligohydramnios: Decreased amt. of amniotic fluid < 500 mL, between 32-36 weeks gestation
o May result from conditions that block the fetus from making urine or blocks the urine
from going into the amniotic sac
o Most commonly in 3rd trimester (and 2 weeks past the due date – amniotic fluid levels
naturally decline)
o Reduces ability of fetus to move freely without risk of cord compression, increases risk
for fetal death and intrapartum hypoxia
Chapter 20
What is the effect of antivirals on HIV positive women?

Women who are HIV + should be treated with ART regardless of their CD4 count or viral load

Antiretroviral Therapy: for both mom and newborn – goal is to reduce the viral load as much
as possible to reduce risk of transmission to the fetus, core goal is to bring viral load to an
undetectable level
o PO daily until given birth, IV admin during labor, and oral zidovudine (AZT) for the
newborn within 6-12 hrs. after birth
o Medications are complicated, expensive, and associated with numerous adverse
effects and possible toxic reactions
o Reduce likelihood of mother-to-infant transmission and provide optimal suppression
of viral load in the mother
Assessments and education recommended for HIV+ women in pregnancy





Women with HIV need comprehensive prenatal care – STARTS WITH PRETEST AND POST-TEST
COUNSELING
o Pretest counseling – pt completes a risk assessment survey, RN explains meaning of
positive vs. negative test results, obtains informed consent for HIV testing, and
educates about how to prevent HIV infection by changing lifestyle behaviors if needed
o Post-test counseling – informing pt of the test results, reviewing the meaning of the
results again, and reinforcing safer sex guidelines
o All should be documented in pt’s chart
Recommendation that all pregnant women be offered HIV antibody testing, regardless of their
risk of infection, and that testing be done during the initial prenatal evaluation – to tx and
decreased risk of transmission and maintain woman’s health
ELISA (Enzyme-Linked Immunosorbent Assay): detects HIV antibodies, which develop within 612 weeks after exposure
o Prepare the woman with a reactive ELISA screening test for an additional test e.g.
Western Blot test or Immunofluorescence Assay
o Western Blot Test: Confirms ELISA test
o Additional STI testing may be necessary – women infected with HIV have high rates of
STIs, esp. HPV, vulvovaginal candidiasis, bacterial vaginosis, syphilis, HSV, chancroid
CMV, gonorrhea, chlamydia, and hep B
Health History and Physical Exam: Hx for risk factors (unsafe sex practices, multiple sex
partners, injectable drug use)
o Flu-Like Sx: low fever, fatigue, sore throat, night sweats, diarrhea, cough, skin lesions,
muscle pain
o Factors that Increase Perinatal Transmission: high maternal viral load, low maternal
CD4 count, maternal genital tract infections, nutritional deficiencies, drug abuse,
cigarette smoking, unprotected sexual intercourse, other opportunistic and coexisting
infections e.g. TB, malaria; prolonged ruptured membranes, and breastfeeding
o Height, weight, determine if she’s lost weight recently
o S/Sx of STIs e.g. vulvovaginal candidiasis, bacterial vaginosis, HSV, chancroid CMV, or
chlamydia
WOMEN WHO REQUEST HIV TESTS, DESPITE REPORTING NO INDIVIDUAL RISK FACTORS
SHOULD BE CONSIDERED AT RISK, SINCE MANY ARE LIKELY NOT TO DISCLOSE THEIR HIGH-RISK
BEHAVIORS
o Screening ONLY women who are identified as high risk based on their hx is
INADEQUATE due to the prolonged latency period that can exist after exposure

WHEN PROVIDING DIRECT CARE, ALWAYS FOLLOW STANDARD PRECAUTIONS

Preparing for Labor, Birth, and PP:
o C-section before onset of labor and before the rupture of membranes significantly
reduces the rate of perinatal transmission
o HIV + women should be offered elective c-section birth to reduce transmission rate
beyond that capable of ART
o Operative births should be performed at 38 weeks
o Amniocentesis should be avoided to prevent contamination of the amniotic fluid with
maternal blood
o Decisions are based on viral load, duration of ruptured membranes, progress of labor,
and other pertinent clinical factors
o After birth, motivation for ART may be lower, affected adherence, encourage therapy
continuation for her own sake and the newborn’s
o Reinforce family planning methods, incorporating a realistic view of the mother’s
disease status
 Hormonal contraceptives aren’t protective against HIV infection, and dual
protection with condoms should be the goal
o Breastfeeding isn’t recommended
o Instruct in self-care methods included proper method for disposing of perineal pads to
reduce risk of exposing others to infected body fluids
Pt Education: Determine pt’s readiness for the discussion, identify the pt’s individual needs for
teaching, emotional support, and physical care, counsel in a caring, sensitive manner; Address
the following info:
o Infection control issues at home
o Safe sex precautions
o Stages of HIV disease process and tx for each stage
o Sx of opportunistic infections
 S/Sx of newborn/infant infections and to report these ASAP
o Preventive drug therapies for the unborn infant
o Avoidance of breastfeeding
o Referrals to community support, counseling, and financial aid
o Pt’s support system and potential caregiver

o
o
o
Importance of continual prenatal care
Need for well-balanced diet
Measures to reduce exposure to infections
When (in the antepartal) is the highest risk for woman with heart disease, how often are her PN visits





Few women die during pregnancy with heart disease, but they are at risk for other
complications e.g. heart failure, arrhythmias, and stroke – infants at risk for premature birth,
low birth weight, resp. distress syndrome, intraventricular hemorrhage, and death
Women with cardiac disease may benefit from preconception counseling so they know the
risks before deciding to become pregnant
A woman’s ability to function during pregnancy often more important than the actual dx of
the cardiac condition; classifications of maternal cardiovascular risk in 4 categories based on
how much they are limited during physical activity, normal breathing, and varying degrees of
SOB and/or chest pain:
o Risk Class I: No detectable increased risk of maternal mortality, and no or mild
increase in morbidity e.g. Pulmonary stenosis, patent ductus arteriosus, and mitral
prolapse
o Risk Class II: Small increased risk of maternal mortality or moderate increase in
morbidity e.g. atrial or ventricular septal defect, repaired tetralogy of Fallot, most
arrhythmias
 Cardiac consult every trimester
o Risk Classes II and III: Intermediate increased risk of maternal mortality or moderate
to severe increase in morbidity e.g. mild left ventricular impairment or hypertrophic
cardiomyopathy
 Cardiac consult every trimester and delivery at appropriate level hospital
o Risk Class III: Significantly increased risk of maternal mortality or severe morbidity e.g.
moderate left ventricular impairment, mechanical valve, moderate mitral stenosis,
and ventricular tachycardia
 Cardiac consult every other month and prenatal care/delivery at appropriate
level hospital
o Risk Class IV: Pregnancy contraindicated; extremely high risk of maternal mortality or
severe morbidity e.g. pulmonary arterial HTN, severe ventricular dysfunction, severe
mitral stenosis, and severe aortic dilation
 Cardiac consult and follow-up monthly
o Classification may change as pregnancy progresses and woman’s body must cope with
increasing cardiovascular system stress from physiological changes
First Trimester Hemodynamic Changes: increase risk for problems due to increased cardiac
workload and greater myocardial O2 demand
o PEAK CARDIAC OUTPUT AT 20-24 WEEKS, CONTINUES TO INCREASE UNTIL IT
PLATEAUS AT 28-24 WEEKS
o CHANGES START AS EARLY AS THE 2ND MONTH OF GESTATION
Prenatal Visits: Every 2 weeks until the last month (28 weeks gestation), and then weekly!!!
Infections in pregnancy- risk factors, education, and transmission to fetus and when

GBS, CMV, and Toxoplasmosis see below


STIs Affecting Pregnancy:
o Syphilis: Maternal infection ↑ risk of premature labor and birth, newborn may be
born with congenital syphilis causing jaundice, rhinitis, anemia, IUGR, and CNS
involvement
 All pregnant women screened and tx with Benzathine penicillin G 2.4 million
units IM to prevent placental transmission
o Gonorrhea: Majority of women are asymptomatic; causes ophthalmia neonatorum in
the newborn from birth through infected birth canal
 All women screened at first prenatal visit with repeat screening in 3rd
trimester
o Chlamydia: Majority of women are asymptomatic; associated with infertility, ectopic
pregnancy, spontaneous abortion, low birth weight, stillbirth, neonatal mortality;
transmitted to newborn through vaginal birth; newborn may develop conjunctivitis or
pneumonia
 All women screened at first prenatal visit and txed with erythromycin
o HPV: Causes warts in genital area (condylomata acuminata) that may grow large
enough to block a vaginal birth; fetal exposure during birth is associated with
laryngeal papillomas
 Vaccines for women and girls 9-26 y/o are 100% effective
o Trichomonas: Infection produces itching, burning, dysuria, strawberry patches on
cervix, and vaginal discharge; infection associate with PROM and preterm birth
 Tx is a single 2g dose of metronidazole (Flagyl)
o HSV: Infection by direct contact of the skin or MMs with an active lesion through such
activities as kissing, sexual contact (vaginal, oral, anal), or routine skin-to-skin
contract; primary infection lasts ~ 3 seeks, recurrent episodes are less severe;
associated with infections of the genital tract can result in significant mother and fetal
mortality and morbidity; spontaneous abortion, birth anomalies, IUGR, or preterm
labor; infant severe neurologic impairment or death
 Greatest risk of transmission when mom develops a primary infection near
term and it’s not recognized
 Most neonatal infections acquired after membrane rupture or at birth with
direct contact
 Without active lesions, vaginal birth is acceptable, but if active lesions within 6
weeks of term, a c-section is preferred – all invasive procedures that might
cause a break in infant’s skin should be avoided e.g. AROM, fetal scalp
electrode, forceps/vacuum extraction
 Some providers start antivirals prophylactically to prevent an active outbreak
at time of birth
Rubella: German Measles; spread by droplets or through direct contact with a contaminated
object; increased risk of mom to fetal transmission with earlier exposure to virus (1 month:
50% chance, 2 months: 25%, 3 months: 10%)
o Newborn: congenital cataracts, glaucoma, cardiac defects, microcephaly, HEARING
IMPAIRMENT = most common, and intellectual disability
 All women screened at first prenatal visit, a rubella antibody titer of 1:8 means
immune
 Women should get the flu vaccine if planning pregnancy during flu season
 All women screened prior to discharge after birth of the newborn
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Hepatitis B Virus (HBV): Bloodborne through contaminated blood, illicit drug use, and sexual
contact; can cause life-threatening liver disease (cirrhosis, liver failure, hepatocellular
carcinoma); acutely infected women only transmit to fetus at 10% in first trimester, and 8090% in 3rd trimester; 60% of infants born to hep B + women have chronic hepatitis B by 6
months old; infection in pregnancy associated with increased risk of preterm birth, fetal
distress during labor, meconium peritonitis, low birth weight, and neonatal death – fetus at
particular risk during birth b/c of possible blood contact
o All women should be tested for hep B surface antigen (HBsAg) regardless of previous
HBV vaccine or screening – all women screened at the first prenatal visit; expect to
repeat screening later in pregnancy for women in high-risk groups
o Infants born to hep B + moms should receive single-antigen HBV vaccine and hepatitis
B immunoglobin within 12 hrs. after birth; vaccines recommended at 1 month and 6
months
o Risk Factors: H/O STIs, household contacts with HBV-infected person, employment as
a healthcare provider, abuse of IV drugs, prostitution, foreign born, multiple sexual
partners, Chinese, Southeast Asian, or African heritage, and Sexual partners who are
HBV infected
o Pt Education to Prevent Hep B Progression:
 Abstain from etoh and potentially hepatotoxic medications, avoid IV drug
exposure or sharing of needles
 Encourage all household contacts and sexual partners to be vaccinated
 Receive immediate tx for any STI
 Know that your newborn will receive the hep B vaccine soon after birth
 Use good HH at all times
 Avoid contact with blood or body fluids
 Use barrier methods e.g. condoms during sex
 Avoid sharing any person items e.g. razors, toothbrushes, utensils
 Inform all providers of you HBV status
Varicella Zoster Virus (VZV): a herpes family virus that causes chickenpox (varicella) and
shingles (herpes zoster); pregnant women at risk when they come in close contact with
children that have active infections; highly contagious, higher incidence in winter and spring;
transmitted to the fetus via the placenta in the first half of pregnancy or at birth via direct
contact; varicella vaccine is contraindicated for pregnant women b/c fetal effects are
unknown; low birth weight, skin lesions in a dermatomal distribution, spontaneous abortion,
chorioretinitis, cataracts, pneumonia, IUGR, delayed milestones, cutaneous scarring, limb
hypoplasia, microcephaly, ocular abnormalities, intellectual disability, and early death
o Vaccine in all women age 13+
o Education to women who work in high-risk occupations e.g. daycare, teachers
Parvovirus B19 (Fifth Disease): transmitted by respiratory secretions; most infected people are
asymptomatic; maternal infection transmitted to fetus may be associated with a normal
outcome, but fetal death may also occur without ultrasound evidence of infection sequelae
(spontaneous abortion, severe fetal anemia), but majority have no adverse pregnancy
outcomes
o Risk Factors: teachers, daycare workers, women living with school-age children
o Screening: in early pregnancy
o Education: HH after handling children, cleaning toys and surfaces children have been
in contact with, avoiding sharing food and drinks
Group B Strept: when are woman tested, what happens if positive-prenatally and during labor


Group B Streptococcus (GBS): Naturally occurring bacterium found in ~ 50% of healthy adults;
gram-positive, colonizes GI and GU tracts; women who test positive for GBS are considered
carriers – Rarely serious in adults, but can be life-threatening in newborns
o Carrier Status: Is transient and does not indicate illness; ~50% of pregnant women
carry GBS in the rectum or vagina, thus introducing the risk of colonization of the fetus
during birth
o Newborns: GBS is the most common cause of sepsis (early onset within a week after
birth) and meningitis (late onset after the first week), frequent cause of newborn
pneumonia (early onset)
 Genital tract colonization poses the most serious threat to the newborn
because of exposure during birth and to the mother due to ascending infection
after membranes rupture – thought to cause chorioamnionitis, endometritis,
and PP wound infection
ALL PREGNANT WOMEN SHOULD BE SCREENED FOR GBS AT 35-37 WEEKS GESTATION (36-37
weeks) AND TREATED
o Vaginal and rectal specimens are cultured
o If Positive: Abx prophylaxis to the mother during childbirth
 PREGNANT WOMEN AND WOMEN IN LABOR WHO HAVE POSITIVE CULTURES
ARE TXED WITH A PENICILLIN-BASED ABX
o Penicillin G = tx of choice; PO prophylactically in prenatal period; in labor usually
admin IV at least 4 hours before birth so it can reach adequate levels in the serum and
amniotic fluid to reduce the risk of newborn colonization
o If allergic: alternative abx
Assessment findings for CMV, risks to fetus
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Cytomegalovirus (CMV): A member of the herpesvirus family (HSV 1/2, Varicella zoster virus,
and Epstein – Barr virus) – transmitted via body fluids – THE MOST COMMON CONGENITAL
AND PERINATAL VIRAL INFECTION IN THE WORLD
o MOM IS USUALLY ASYMPTOMATIC!
Risk of Serious Fetal Injury is the greatest when maternal infection develops in 1st trimester or
early 2nd trimester – there is no proven in utero tx for infected fetuses
o But!!! Not easily transmitted from host to recipient; transmitted by direct contact with
urine, saliva, blood, tears, semen, ad breast milk
Complications: Can transmit (1) In Utero – only one associated with permanent disability (2)
During birth (3) After birth; CMV infection during pregnancy may result in:
o Abortion
o Stillbirth
o Low birth weight
o IUGR
o Microcephaly
o Deafness/Blindness
o Intellectual disability
o Jaundice
o Congenital or Neonatal Infection
o

Newborn Clinical Appearance: petechial rash, microcephaly, jaundice, and abnormal
posture of extremities secondary to CNS damage
 CMV Inclusion Disease: CMV in the fetus and newborn – hepatomegaly,
thrombocytopenia, IUGR, jaundice, microcephaly, hearing loss, chorioretinitis,
intellectual disability
Pt Teaching: Wash hands frequently with soap and water, wear gloves, esp. after diaper
changes, feeding, wiping nose or drool, and handling children’s toys; do not share cups, plates,
utensils, food, toothbrushes, towels, or washcloths; do not put a child’s pacifier in your
mouth; clean toys, countertops, and other surfaces that come in contact with children’s urine
or saliva; practice safe sex, limiting sexual partners, using condoms consistently
Risk factors for toxoplasmosis, patient teaching- what should they avoid?
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Toxoplasmosis: Relatively widespread parasitic infection caused by a one-celled organism,
Toxoplasma gondii
Pregnancy Infection: transplacental transfer from mother to fetus; high risk of fetal damage,
preterm labor, and stillbirth, low birth weight, newborn enlarge liver and spleen, visual
problems, CP, hearing loss, seizures, chorioretinitis, jaundice, IUGR, hydrocephalus,
microcephaly, neurologic damage, and anemia
o Severity varies with gestational age – earlier infection = more severe effects
Cats!!!! The definitive hosts of this parasite and shed it in their feces; transferred hand to
mouth after touching cat feces while changing the cat litter box or through gardening in
contaminated soil
Contaminated Food/Drink: undercooked infected meat e.g. pork, lamb, venison; drinking
contaminated water, eating unwashed fruits and vegetables
Treatment: during pregnancy to reduce risk of congenital infect is a combination of
pyrimethamine and sulfadiazine (Sulfonamides)
PATIENT EDUCATION:
o Avoid eating raw or undercooked meat, esp. lamb or pork; cook all meat to an internal
temp of 160 F throughout
o Clean cutting boards, work surfaces, and utensils with hot, soapy water after contact
with raw meat or unwashed fruits and vegetables
o Peel or thoroughly wash all raw fruits and vegetables before eating them
o Wash hands thoroughly with warm, soapy water after handling raw meat, fruits, and
vegetables
o Avoid feeding the cat raw or undercooked meats
o Avoid emptying or cleaning the cat’s litter box – have someone else do it daily
o Keep outdoor sandboxes covered to prevent cat feces contamination; Avoid contact
with children’s sandboxes because cats can use them as litter boxes
o Keep the cat indoors to prevent it from hunting and eating birds or rodents
o Avoid uncooked eggs and unpasteurized milk
o Wear gardening gloves when in contact with outdoor soil
Risk factors for adolescent pregnancy- who is at risk, what tasks are affected?

~ 11- 19 y/o; Most girls are unmarried, aren’t well prepared for emotional, psychological, and
financial responsibilities of parenthood
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Are the least likely of all maternal age groups to get early and regular prenatal care
Risk Factors:
o Culture/Ethnicity: Highest in African American and Hispanic teenagers; Higher in
southern states
o Early menarche
o Peer pressure to become sexually active
o Lack of accurate contraceptive information
o Fear of telling parents
about sexual activity
o Feelings of
invulnerability
o Unprotected sex
o Early dating without
supervision
o Poverty
o Lower self-esteem and
inability to negotiate
with potential sexual
partners
o Lack of appropriate role
models
o Strong need for
someone to love
o Drug use, truancy from
school, or other behavioral problems
o Wish to escape a bad home situation
Impacts – Especially on Psychosocial Development – Tasks include:
o Loss of self-esteem, societal discrimination, destruction of life projects, prolongation
of poverty
o Seeking economic and social stability
o Adjusting to sexually maturing bodies and feelings
o Developing a personal value system
o Building meaningful relationships with others
o Becoming comfortable with their changing bodies
o Working to become independent from their parents
o Understanding abstract ideas
o Learning to verbalize conceptually
Define chronic HTN and risk factors
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
Chronic HTN: Exists when the woman has high BP before pregnancy or before 20 weeks
gestation, or when HTN persists for more than 12 weeks postpartum
Risk Factors: Age, race, BMI – typically seen in older, obese women, with glucose intolerance
o Modifiable: Smoking, obesity, caffeine intake, excessive etoh, excessive salt intake,
use of NSAIDs, diet, inactivity
o Nonmodifiable: Increasing age, African American
Gestational diabetes: risks, diagnostics, maternal education, risk to fetus, what diet should you
recommend for gestational diabetes and education regarding their daily blood glucose monitoring

Gestational Diabetes: Glucose intolerance with its onset during pregnancy, usually dx in 2nd or
3rd trimester, that was not clearly overt prior to pregnancy
o Dx: 24-28 weeks; Fasting <95; OGTT 1 hr. > 180; and OGTT 2 hr. >153; OGTT 3 hr. done
if results are abnormal
 Goals: FBG < 95, 1 hr OGTT < 140, 2 hr OGTT <120, 3 hr OGTT < 95
o Screening done at first prenatal visit and for at-risk women again in 24-28 weeks
 Don’t Need First Prenatal Visit Screening: No h/o glucose intolerance, < 25 y/o,
normal body weight, no family h/o DM (first degree relatives), no h/o poor
obstetric outcomes, not from an ethnical/racial group with a high prevalence
of DM

Risk Factors:
o Previous infant with congenital anomaly (skeletal, renal, CNS, cardiac)
o H/O GDM or polyhydramnios
o Family h/o DM
o Meds – corticosteroids, antipsychotics
o > 35 y/o
o Polycystic ovary syndrome
o Multiple pregnancy (twins, triplets)
o Previous infant birth weight > 9 lbs.
o Previous unexplained fetal demise or neonatal death
o Maternal obesity, BMI > 30
o HTN before pregnancy or in early pregnancy
o Hispanic, Native American, Pacific Islander, African American
o Recurrent monilia infections that don’t respond to tx
o S/Sx of glucose intolerance (polyuria, polyphagia, polydipsia, fatigue)
o Presence of glycosuria or proteinuria
Glucose Monitoring: review glucose levels at each visit, reinforce glucose monitoring usually
4x/day, before meals and at bedtime and to keep a record of the results
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Nutritional Teaching: Gestational Diabetes Diet: plenty of whole fruits and non-starchy
vegetables, moderate amts. of lean proteins and healthy fats, moderate amounts of whole
grains, plus starchy vegetables, fewer foods that have a lot of sugar e.g. soft drinks, fruit
juices, pastries
o Avoid weight loss and dieting during pregnancy
o Ensure that food intake is adequate to prevent ketone formation and promote weight
gain
o Be physically active daily
o Eat 3 meals/day plus 3 snacks to promote glycemic control: 40% of kcal from complex
carbs, 35% of kcal from protein, 25% of kcal from unsaturated fats
o Small frequent feedings throughout day are recommended
o Bedtime snacks recommended
o Include protein and fat at each meal
Risk factors of the obese patient

Obesity during pregnancy is defined of a BMI of ≥ 30
o

Tend to gain excessive weight in pregnancy – strongly associated with PP weight
retention, which increases the risk of additional weight gain in subsequent pregnancy
and risk of childhood obesity in offspring
Complications: GDM, HTN, thromboembolism, preeclampsia, preterm labor and birth,
congenital anomalies, childhood and adolescent obesity, fetal macrosomia (birth weight >
4000g), difficulty fight PP infections, depression, tendency to remain overweight/obese
between pregnancies, prolongation of pregnancy/increased likelihood of post-term infant,
increased risk of stillbirth, low birth weight, higher rate of c-section, early pregnancy loss,
increased risk of maternal mortality, high risk for PP hemorrhage
Risk factors due to asthma
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Maternal asthma is linked to an increased risk of infant death, stillbirth, preeclampsia,
intrauterine growth restriction (IUGR), preterm birth, and low birth weight
o Risks linked to the severity of the asthma; more severe = higher risk
Maternal asthma linked to maternal HTN, placenta previa, uterine hemorrhage, and
oligohydramnios
Potential harm to mom and fetus by undertx or delay in seeking tx
Successful asthma management can reduce adverse perinatal outcomes: preeclampsia,
preterm birth, and low birth weight
Drug abuse and alcohol abuse: risk factors to fetus
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Fetus experiences substance use, abuse, and addition; fetal vulnerability to drugs is much
higher because fetus hasn’t developed the enzymatic system needed to metabolize drugs
Factors Associated with Substance Abuse During Pregnancy: Low self-esteem, inadequate
support systems, low self-expectations, high levels of anxiety, socioeconomic barriers,
involvement in abusive relationships, chaotic familial and social systems, h/o psychiatric
illness or depression
Risks to the Fetus: preterm labor, abortion, IUGR, placental abruption, low APGAR scores, 3rd
trimester bleeding, meconium staining at birth, fetal demise, low birth weight,
neurobehavioral abnormalities, long-term childhood developmental consequences
Etoh: Fetal Alcohol Spectrum Disorder (FASD) – brain, craniofacial, heart defects,
neurotoxicity, immune system dysfunction
o Intake increases risk of etoh-related birth defects, including growth deficiencies, facial
abnormalities, CNS impairment, behavioral disorders, and intellectual development
o
o
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No amt. of etoh consumption is considered safe during pregnancy
Damage to the fetus can occur at any stage of pregnancy, even before a woman knows
she’s pregnant
o Cognitive defects and behavioral problems resulting from prenatal exposure are
lifelong
o Etoh-related birth defects
are completely preventable
o Craniofacial Dysmorphia –
thin upper lip, small head
circumference, small eyes,
limb anomalies, low nasal
bridge, short palpebral
fissures, short nose, flat
midface, epicanthal folds,
minor ear abnormalities,
receding jaw
o Postnatal growth
restriction, attention
deficits, delayed reaction
time, poor scholastic
performance
Heroin/Opioids – Neonatal Abstinence Syndrome (NAS): irritability, hypertonicity, jitteriness,
fever, excessive and often high-pitched cry, vomiting, diarrhea, feeding disturbances,
respiratory distress, disturbed sleeping, excessive sneezing and yawning, nasal stuffiness,
diaphoresis, fever, poor sucking, tremors, seizures
o Withdrawal during pregnancy is extremely dangerous for the fetus, so a prescribe oral
methadone maintenance program combined with psychotherapy is recommended for
the pregnant woman
Marijuana: THC narrows the bronchi and bronchioles, and produces inflammation of the
MMS, causes tachycardia, reduced BP, orthostatic hypotension
Iron-Deficiency Anemia
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
Anemia: A reduction in RBC volume, measured by Hct or a decreased Hgb concentration in the
peripheral blood → decreased O2 carrying capacity to vital organs or mom and fetus
o In pregnancy, generally defined as Hgb < 11 in first and third trimesters, and < 10.5 in
second trimester
Iron-Deficiency Anemia: accounts for 75-95% of anemia in pregnant women (1 in 4
pregnancies), and is usually r/t iron-deficient diet, GI issues affecting absorption, or a short
pregnancy interval
o Maternal anemia in early pregnancy has a negative impact on fetal neurodevelopment
r/t iron deficiency in the developing brain
o Complications: preterm delivery, perinatal mortality, postpartum depression, low
birth weight, fetal/neonatal cardiovascular strain, and intellectual disability with poor
mental and psychomotor performance, increased risk of hemorrhage due to impaired
platelet function and infection during and after birth
o S/Sx & Assessments: Fatigue, malaise, weakness, anorexia, increased susceptibility to
infection e.g. frequent colds, inspect skin and MMs noting any pallor, obtain V/S and
report any tachycardia; diminished quality of life, impaired cognitive function,
increased risk for thromboembolic events, DM, HA, HTN, placental abruption, restless
legs syndrome, and pica behaviors
 Poor nutrition, hemolysis, multiple gestation, limited intervals b/t
pregnancies, blood loss
 Timing of ingestion of substances that interfere with iron absorption e.g. tea,
coffee, chocolate, and high-fiber foods
 Labs: Hgb < 11, Hct <35%, serum iron < 30, serum ferritin < 100; microcytic and
hypochromic cells
o Tx: Iron supplementation for all pregnant women with ferrous sulfate 325mg 1-3x/day
along with ascorbic acid 500mg to enhance iron absorption; SE: nausea, abdominal
pain, constipation, black stool
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Stress prenatal vitamins that contain 27 mg/day of iron, and an iron
supplement consistently
Encourage her to take with vitamin C containing fluids like orange juice; NOT
milk (decreases absorption)
Taking on empty stomach increases absorption, but many women can’t
tolerate GI discomfort (n/v/d/c, abdominal discomfort, anorexia, metallic
taste) – suggest she takes with meals and increases intake of fiber and fluids
to overcome SEs
Recommend foods high in iron (dried fruits, whole grains, green leafy
vegetables, lean meats, peanut butter, iron-fortified cereals)
Chapter 21
Bishop’s score and labor induction; Labor inductions – candidates, medications (uses, side effects);
Augmentation, meds used
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Labor Augmentation: Stimulating the uterus, typically with oxytocin – to enhance ineffective
contractions after labor has begun (also induce uterine contractions)
Labor Induction: The stimulation of uterine contractions by medical or surgical means before
the onset of spontaneous labor
o Significantly increases the risk of C-section, time spent in labor and birth,
instrumented delivery, use of epidural analgesia, and NICU admission, esp. for
nulliparous women
o Before labor induction is started, fetal maturity (dating, ultrasound, amniotic fluid
studies) and cervical readiness (vaginal examination, Bishop scoring) must be assessed
– both need to be favorable for a successful induction
Recommendations:
o Labor induction should be performed only for a clear medical indication
o
o
o
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Women being induced should not be left unattended
Oxytocin use for delay in labor in women with an epidural is not recommended
Labor induction should only be performed after cephalopelvic disproportion has been
ruled out
o Labor induction should not be applied to women with abnormal fetal presentations
o Close monitoring is needed of the FHR and uterine contraction patterns
Indications for Labor Induction: Generally indicated when the benefits of birth outweigh the
risks to the mother or fetus for continuing pregnancy
o Most Commonly – Prolonged gestation
o PPROM; Gestational HTN; Cardiac disease; renal disease; Chorioamnionitis; Dystocia;
Intrauterine fetal demise; Isoimmunization; DM
Contraindications to Labor Induction: Complete placenta previa; Placental abruption;
Transverse fetal lie; Prolapse umbilical cord; Prior classic uterine incision that entered the
uterine cavity; Pelvic structure abnormality; Previous myomectomy; Vaginal bleeding with
unknown cause; Invasive cervical cancer; Genital Herpes infection; Abnormal FHR patterns
Cervical Ripening: Induction of labor frequently involves cervical ripening with a variety of
methods – a process by which the cervix softens via the breakdown of collagen → elasticity
and distensibility preceding cervical dilation
o An important variable when labor induction is being considered
o A Ripe Cervix: Shortened, centered (anterior), softened, and partially dilated
o An Unripe Cervix: Long, closed, posterior, and firm
o Cervical ripening usually begins prior to the onset of labor contractions and is
necessary for cervical dilation and the passage of the fetus
The Bishop Score: Scoring system used to evaluate cervical ripeness; helps to identify women
who would be most likely to achieve a successful induction of labor
o The duration of labor is INVERSELY correlated with the Bishop score
o Score > 8 indicates a successful vaginal birth
o Score < 6 usually indicate that a cervical ripening method should be used prior to
induction
Medical Induction of Labor: 2 components
o Cervical Ripening – evaluated by pelvic exam and determination of Bishop Score
documented; achieved by either mechanical or pharmacological methods
o Induction of Contractions
Nonpharmacological Methods of Cervical Ripening: Less frequently use, but be aware
o Herbal agents: primrose oil, black haw, black and blue cohosh, red raspberry leaves;
Castor oil; Hot baths; Enemas; Not scientifically validated!! None recommended
regarding efficacy or safety
o
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Sexual Intercourse and breast stimulation: promotes release of oxytocin → uterine
contractions; Semen is a biologic source of prostaglandins → cervical ripening; Not
validated by research though
Mechanical Methods of Cervical Ripening: All have similar mechanism of action – application
of local pressure stimulates the release of prostaglandins to ripen the cervix
o Advantages: (compared to pharmacological methods) simplicity, preservation of the
cervical tissue or structure, lower costs, fewer side effects
o Risks: Infection (increased via mechanical methods vs. pharmacological methods),
bleeding, membrane rupture, placental disruption
o E.g. Indwelling catheter inserted into the endocervical canal to ripen and dilate the
cervix – catheter is placed in the uterus and balloon is filled; direct pressure is then
applied to the lower segment of the uterus and the cervix; causes stress in the lower
uterine segment and the local production of prostaglandins
o Hygroscopic Dilators: absorb fluids, a the expand they provide mechanical pressure
Surgical Methods of Cervical Ripening: Stripping of the membranes and performing an
amniotomy
o Stripping of the Membranes: inserting a finger through the internal cervical os and
moving in a circular direction causing the membranes to detach; manual separation of
the amniotic membranes from the cervix
o Amniotomy: inserting a cervical hook (Amniohook) through the cervical os to
deliberately rupture the membranes; promotes pressure of the presenting part on the
cervix and stimulates an increase in activity of local prostaglandins
o Risks: umbilical cord prolapse/compression, maternal/neonatal infection, FHR decels,
bleeding, discomfort
Pharmacologic Methods of Cervical Ripening:
o Prostaglandins: Can attain cervical ripening independent of uterine contractions– can
be beneficial or induce excessive contractions and increase maternal and perinatal
morbidity
o Prostaglandin Analogs: Dinoprostone Gel (Prepidil), Dinoprostone Inserts (Cervidil),
Misoprostol (Cytotec), synthetic PGE1 analog
 PGE1 Analog: Gastric cytoprotective agent in the tx and prevention of peptic
ulcers; admin intravaginally or orally to ripen cervix or induce labor; doses 2550 mcg typically used
 Dinoprostone: Only FDA-Approved drug as a cervical ripening agent

o
Misoprostol: Still recognized as such; Major ADRs: Hyperstimulation of the
uterus, which may progress to uterine tetany with marked impairment of
uteroplacental blood flow, uterine rupture (requiring surgical repair,
hysterectomy, and/or salpingo-ophorectomy – removal of one or both
ovaries/fallopian tubes), or anaphylactoid syndrome of pregnancy
(anaphylaxis-like rx when amniotic fluid enters maternal circulation);
Contraindicated: prior uterine scars e.g. NOT for women attempting vaginal
birth after C-section
Oxytocin: Potent endogenous uterotonic agent for both artificial induction and
augmentation of labor; stimulates uterine contractions
 Low Bishops scores, commonly used after cervical ripening has been initiated
 Once cervical ripening has begun, oxytocin is the most common pharmacologic
agent used for inducing or augmenting labor
 Response varies widely; some women = sensitive to small amt.
 Most Common ADR: Uterine hyperstimulation
 Side Effects: Antidiuretic effect → decreased urine flow → water intoxication
(S/Sx: HA, Vomiting); hypotension, uterine hypertonicity
 Admin: IVPB 10 units in 1 L of isotonic solution; titrated to achieve stable
contractions every 2-3 mins lasting 40-60 seconds

Monitoring: uterus should relax b/t contractions, resting uterine tone > 20
indicates uteroplacental insufficiency → fetal hypoxia (continuous FHR
monitoring)
Dystocia, problems with powers, passenger, passageway, Psyche; Hypotonic; Hypertonic contractionsrisks and treatments


Dystocia: The abnormal progression of labor; influenced by a number a maternal and fetal
factors; characterized by a SLOW AND ABNORMAL PROGRESSION OF LABOR (Bear in mind
that labors are often longer today perhaps due to often higher BMI, rates of labor induction,
and increased use of epidural anesthesia)
o The leading indicator of C-section in the US – frequently requires medical or surgical
interventions which increases risk
o A fatiguing factor for both mom and fetus
o Associated with increase in postpartum infections and perineal lacerations
o Usually can’t be predicted or diagnosed with certainty – “Failure to Progress” –
includes lack of progressive cervical dilation, lack of descent of fetal head, or both
 Usually becomes apparent during the active phase of labor
Risk Factors: Epidural analgesia/excessive analgesia, multiple pregnancy, hydramnios,
maternal exhaustion, ineffective maternal pushing technique, occiput posterior position,
longer first stage of labor, nulliparity, short maternal stature < 5 ft. tall, fetal birth weight > 8.8
lbs., Shoulder dystocia, abnormal fetal presentation or position (breech), fetal anomalies
(hydrocephalus), maternal age > 34 y/o, high caffeine intake, gestation age > 41 weeks,
chorioamnionitis, ineffective uterine contractions, and high fetal station at complete cervical
dilation
o Occiput Posterior Position
o Fetal Birth Weight > 8.8 lbs.
o Shoulder Dystocia
o Abnormal Fetal Presentation or Position (Breech)
o Fetal Anomalies (Hydrocephalus)
o High Fetal Station at Complete Cervical Dilation

Dystocia can result from problems/abnormalities involving Powers (Expulsive Forces),
Presentation, Position, and Fetal Development (Passenger), maternal bony pelvis or birth
canal (Passageway), and maternal stress (Psyche)
o Better to characterize labor abnormalities as:
 Protracted Disorders – slower than normal progress/rate of cervical dilation –
may be the result of cephalopelvic disproportion; most women though benefit
from hydration, some nutrition, emotional reassurance, and position changes;
these women may go on and give birth vaginally
 Arrest Disorders – complete cessation of progress/cervical dilation in over 2
hrs.; arrest of descent (fetal head doesn’t descend for more than 1 hr. in
primiparas and more than 30 mins in multiparas); failure of descent (no
descent)
Problems with Powers: The expulsive forces of the uterus
 Hypertonic Uterine Dysfunction: The uterus may never fully relax between contractions
(hypertonic contractions) – puts the fetus in jeopardy
o Contractions are ineffective, erratic, and poorly coordinated because they only involve
a portion of the uterus and more than one uterine pacemaker is sending signals for
contraction
o Women have a prolonged laten phase, stay at 2-3 cm dilation, and don’t dilate as they
should
o Placental perfusion becomes compromised, decreasing O2 to the fetus
o Hypertonic contractions exhaust the mother – frequent, intense, and painful
contractions with little progression
o More Often: in early labor, nulliparous women
 Hypotonic Uterine Dysfunction: The uterus relaxes too much (hypotonic contractions) – causes
ineffective contractions
o Occurs during active labor (dilation > 5-6 cm) when contractions become poor in
quality and lack sufficient intensity to dilate and efface the cervix
o Associated Factors: Overstretching of the uterus, large fetus, multiple fetuses,
hydramnios, multiple parity, bowel/bladder distention preventing descent, excessive
analgesia
o S/Sx: Weak contractions that become milder, fundus easily indented with fingertip
pressure at the peak of each contraction, contractions that become more infrequent
and briefer
o Major Complication: Hemorrhage after giving birth because the uterus can’t contract
effectively to compress blood vessels
 Precipitate Labor: The uterus contracts so frequently and with such intensity that a very rapid
birth takes place; LABOR IS COMPLETED IN < 3 HRS. FROM THE START OF CONTRACTIONS TO
BIRTH
o Too rapid a labor → maternal injury and increased fetal risk of traumatic or asphyxia
insults
o Women typically have soft perineal tissues that stretch readily, permitting the fetus to
pass through the pelvis readily; or abnormally strong uterine contractions
o Maternal complications are rare if pelvis is adequate and fast fetal descent; but too
fast = cervix not dilated/effaced → cervical lacerations and potential uterine rupture
o
Fetal complications: head trauma (intracranial hemorrhage, nerve damage, hypoxia)
Problems with the Passenger: Presentation, Position, Fetal Development
 Any position other than occiput anterior or a slight variation of the fetal position or size
increases the risk of dystocia; Can affect the contractions or fetal descent through the
maternal pelvis
 Common problems: occiput posterior position, breech presentation, multifetal pregnancy,
excessive size (macrosomia) as it relates to cephalopelvic disproportion, structural anomalies
 Persistent Occiput Posterior: most common malposition; slightly larger diameter → slows fetal
descent (poorly flexed fetal head + poor uterine contractions)
 Anencephaly: Face and brow presentations; rare; associated with fetal abnormalities
 Pelvic contractures; Placenta Previa; Hydramnios; Low Birth Weight; Large Fetus
 By 35-36 weeks gestation; majority spontaneously settle into vertex position
 Breech: Associated with multifetal pregnancies, grand multiparity (> 5 births), maternal age >
35, placenta previa, hydramnios, preterm births, uterine malformations or fibroids, uterine
scarring, female infants, fetal anomalies e.g. hydrocephaly
o External Cephalic Version: A procedure in which the fetus is rotated from breech to
cephalic presentation by manipulation through the mother’s abdominal wall at or
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near term; b/t 36-38 weeks gestation; performed only under US guidance and
continuous fetal monitoring; only successful ~50%; current recommendation = surgical
birth without attempt
Shoulder Dystocia: The obstruction of fetal descent and birth b/c of the fetal shoulders after
the fetal head has been delivered; OBSTETRIC EMERGENCY – failure of the shoulders to deliver
spontaneously
o Complications: Permanent brachial plexus palsy; Transient Erb or Duchenne Brachial
plexus palsies; Clavicular or Humeral Fractures; Neonatal Asphyxia; postpartum
hemorrhage secondary to uterine atony, vaginal lacerations, anal tears, uterine
rupture
Multifetal/Multiple Gestation: Twins, triplets, or more infants within a single pregnancy; most
common maternal complication = postpartum hemorrhage due to uterine atony
Macrosomia: Excessive fetal size; newborn weighs 4,000-4,500 grams (8.13-9.15 lbs.) or more
at birth; associated with later in life obesity, DM, and CVD
o And Fetal Abnormalities: e.g. hydrocephalus, ascites, large mass on head or neck
o Complications: Increased risk of PP hemorrhage, shoulder dystocia, low APGAR scores,
dysfunctional labor, fetopelvic disproportion, soft tissue laceration during vaginal
birth, fetal injury/fracture, perinatal asphyxia
Problems with the Passageway: Pelvis and Birth canal
 Relate to a contraction of one or more of the 3 planes of the maternal pelvis: inlet, midpelvis,
and outlet
 4 Basic Pelvis’: Gynecoid, Anthropoid, Android, Platypelloid
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
Contraction of the midpelvis is more common than inlet contraction and typically causes an
arrest of fetal descent
Obstructions in the maternal birth canal e.g. selling of soft maternal tissue (Soft tissue
Dystocia) can also hamper fetal descent and impede labor progression outside the maternal
bony pelvis
Problems with the Psyche
 Fear, anxiety, helplessness, isolation, weariness
 Psychological distress can indirectly lead to dystocia
 Hormones released in response to anxiety can → dystocia
o Intense anxiety stimulates the SNS → Catecholamine release → Myometrial
dysfunction; Anxiety → increased fear/tension, reduced pain tolerance, decreased
uterine contractility
o Norepi and Epi → uncoordinated/increased uterine activity
VBAC, risks, candidates

Vaginal Birth After Cesarean (VBAC): Giving birth vaginally after having at least one c-section
birth
o
o
o
TOLAC (Trial of Labor After Cesarean): A planned attempt to give birth vaginally by a
woman who has had a previous surgical birth regardless of the outcome
Contraindications of VBAC: Prior uterine incision, prior transfundal uterine surgery
(myomectomy), uterine scar other than transverse cesarean scar, obesity, short
maternal stature, macrosomia, maternal age > 40, gestational DM, contracted pelvis,
inadequate staff/facility if an emergency c-section is needed in the event of uterine
rupture
Contraindicated IN VBAC: Cervical ripening agents (increases risk of uterine rupture)
Preterm labor: nursing assessment, meds and pt education

Preterm Labor: The occurrence of regular uterine contractions accompanied by cervical
effacement and dilation before the end of 37 weeks gestation; if not halted → preterm birth
o Infants: Possible respiratory distress syndrome, congenital heart defects,
thermoregulation problems, acidosis, weight loss, intraventricular hemorrhage,
jaundice, hypoglycemia, feeding difficulties from diminished stomach
capacity/underdeveloped suck reflex, neurologic disorders r/t hypoxia and trauma at
birth; CP, intellectual impairment, vision defects, and hearing loss

S/Sx of Preterm Labor:
o Change or increase in vaginal discharge with mucous, water, or blood in it
o Pelvic pressure (pushing down sensation), or feeling of pelvic fullness
o Low, dull backache; General sense of discomfort or unease
o Heaviness or aching in the thighs
o Menstrual-like cramps, intestinal cramping with or without diarrhea
o
o


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GI upset: n/v/d; UTI symptoms
More than 6 contractions/hr.
 RNs: Assess the pattern of the contractions; the contractions must be
persistent such that 4 contractions occur every 20 mins, or 8 contractions
occur in 1 hr.
 Eval Cervical Dilation and Effacement: Cervical effacement is ≥ 80%, cervical
dilation > 1 cm
 Engagement – of fetal presenting part is noted
Labs/Dx Testing for Preterm Labor: CBC to detect infection (may be contributing factor),
Urinalysis to detect bacteria and nitrites (indicative of UTI), Amniotic fluid analysis (to
determine fetal lung maturity and presence of subclinical chorioamnionitis)
o BOTH TESTS HELP DECIDE WHO TO TX WITH CORTICOSTEROIDS AND POSSIBLY
TOCOLYTICS
o Fetal Fibronectin: Glycoprotein produced by the chorion, attaches the fetal sac to the
uterine lining; Normally present in cervicovaginal secretions up to 22 weeks and again
at end of pregnancy 1-3 weeks before labor; Not normally detected 24-34 weeks
unless there’s a disruption; Present in cervicovaginal fluid prior to delivery, regardless
of gestational age
 MARKER FOR IMPENDING MEMBRANE RUPTURE WITHIN 7-14 DAYS IF LEVEL
INCREASES > 0.05 mcg/mL
 A negative fetal fibronectin is a strong predictor that preterm labor in next 2
weeks is unlikely
o Cervical Length Measurement: via Transvaginal ultrasound obtained 16-24 weeks
gestation – looks at cervical length/width, funnel length/width, and percentage of
funneling
 THE MOST RELIABLE PREDICTOR OF PRETERM DELIVERY
 ≥ 3cm delivery within 14 days is unlikely
 Length of 2.5 cm during mid-trimester → substantially higher risk of preterm
birth before 35 weeks
Corticosteroids: A single course prenatally improves most neonate’s neurodevelopmental
outcomes if given before 34 weeks
o Given to the mother b/t 24-34 weeks, can help prevent/reduce frequency or severity
of resp. distress syndrome in premature infants
o Given to accelerate fetal lung maturity
o Require at least 24 hrs. to become effective, beneficial effects on fetal lung maturation
have been reported within 48 hrs. of initial admin
o Betamethasone: Promotes fetal lung maturity by stimulating surfactant production;
also reduces risk of neonatal intraventricular hemorrhage
 RN Considerations: Admin 2 doses IM 24 hrs. apart; Monitor for maternal
infection or pulmonary edema; Educate parents about potential benefits to
preterm infant; Assess maternal lung sounds and monitor for signs of infection
Tocolytic Therapy: Most likely ordered if preterm labor occurs before 34 weeks in an attempt
to delay birth and reduce resp. distress
o DOES NOT PREVENT PRETERM BIRTH, BUT MAY DELAY IT
o Contraindications: Placental abruption, acute fetal distress or death, oligohydramnios,
severe preeclampsia/eclampsia, active vaginal bleeding, dilation > 6cm,
chorioamnionitis, maternal hemodynamic instability
 Intrauterine infection
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Active hemorrhage, Prolonged premature rupture of the membranes
Fetal distress, fetus before viability, fetal abnormality incompatible with life,
intrauterine demise
o Magnesium Sulfate: Reduces muscle’s ability to contract to arrest preterm labor (and
seizure prophylaxis in pre/eclampsia
 RN Considerations: Admin IV loading dose 4-6g over 15-30 mins, then maintain
infusion at 1-4 g/hr.; Assess vitals, DTRs hourly, report any hypotension;
monitor LOC, report any HA, blurred vision, dizziness, continuous FHR
monitoring, Monitor I/Os; Report RR <12; auscultate for pulmonary edema,
monitor serum Mg levels, Have Calcium Gluconate available for possible
toxicity; Common maternal side effects – flushing nausea, vomiting, dry
mouth, lethargy, blurred vision, HA
o Indomethacin: A prostaglandin synthetase inhibitor, inhibits prostaglandins which
stimulate contractions
 Contraindications: > 32 weeks gestation; fetal growth restriction; h/o asthma,
urticaria, or allergic type rx to aspirin or NSAIDs
 Maternal ADRs: N/V, heartburn, rash, prolonged bleeding, oligohydramnios,
HTN
 Neonatal ADRs: Constriction of ductus arteriosus, premature ductus closure,
necrotizing enterocolitis, oligohydramnios, pulmonary HTN
 RN Considerations: continuously assess vitals, uterine activity, and FHR; admin
PO form to reduce GI irritation; do not give to women with peptic ulcer
disease; schedule ultrasound to assess amniotic fluid vol. and function of
ductus arteriosus before initiation; monitor for signs of maternal hemorrhage
 Admin loading dose 50-100mg PO or rectally, followed by 25-50 mg q6
hrs. for 8 doses
 Monitor maternal urine output, temp., and amniotic fluid index (AFI)
periodically
o Atosiban: An oxytocin receptor antagonist
o Nifedipine: A calcium channel blocker – calcium can’t move into muscle cells, and
inhibits uterine activity
 Contraindications: Women with cardiovascular disease or hemodynamic
instability
 Caution: When given in combination with magnesium sulfate because of
increased risk of hypotension
 Maternal ADRs: Flushing, HA, transient tachycardia, palpitations, postural
hypotension, peripheral edema
 Fetal ADRs: Transient fetal tachycardia, decreased uteroplacental blood flow
manifested as fetal bradycardia, which can lead to fetal hypoxia
 RN Considerations: Monitor BP hourly if giving with mag sulfate, report a
pulse rate > 110; admin PO or SL q4-8hrs. as ordered
Preterm Labor Guidelines:
o There are no clear first line Tocolytic Drugs (drugs that promote uterine relaxation by
interfering with uterine contractions) to manage preterm labor
 Tocolytic drugs may prolong pregnancy for 2-7 days, during this time, steroids
can be given to improve fetal lung maturity
 A single course of corticosteroids is recommended for all pregnant women 2434 weeks gestation who are risk of preterm birth within 7 days – prenatal

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
corticosteroids reduce the incidence and severity of neonatal respiratory
distress syndrome
o Deferring birth to the 39th week is not recommended if there is a medical or obstetric
indication for an earlier delivery
o Abx don’t prolong gestation and should be reserved for group B streptococcal
prophylaxis in women when birth is imminent
Teaching to Prevent Preterm Labor:
o Avoid traveling for long distances in cars, trains, plans, or buses
o Avoid lifting heavy objects e.g. laundry, groceries, young child; performing hard,
physical work; Mild to moderate levels of exercise are permitted e.g. walking daily
o Achieve an appropriate pre-pregnancy weight; achieve adequate iron stores through
balanced nutrition; Consume balance nutritional diet to gain appropriate weight
during pregnancy
o Wait at least 18 months between pregnancies
o Visit a dentist in early pregnancy to evaluate and tx any periodontal dz
o Enroll in a smoking cessation program if unable to quit on own; avoid substances e.g.
marijuana, cocaine, heroin
o Curtail sexual activity until after 37 weeks if experiencing preterm labor sx
o ID factors and areas of stress, use stress management techniques
o If experiencing IPV, seek resources to modify situation
Teaching to Recognize S/Sx: Report these
o Uterine contractions, cramping, or low back pain
o Feeling of pelvic pressure or fullness
o Increase in vaginal discharge, leaking of fluid from vagina
o N/V/D
Teaching what to do if Having S/Sx:
o Stop what you’re doing and rest for 1 hr.
o Empty your bladder
o Lie down on left side
o Drink 2-3 glasses of water
o Feel your abdomen and make note of the hardness of the contraction; call provider
and describe the contraction as:
 Mild – if it feels like the tip of the nose
 Moderate – if it feels like the tip of the chin
 Strong – if it feels like your forehead
Prolapsed cord-assessment and nursing interventions

Umbilical Cord Prolapse: OBSTETRIC EMERGENCY, when the cord precedes the fetus out; 50%
perinatal mortality rate
o Increased risk if the fetal presenting part doesn’t adequately fill the pelvis, or obstetric
interventions performed that dislodge the presenting part
o Prolapse usually leads to total or partial occlusion of the cord → fetal perfusion
deteriorates rapidly → fetus dies if unrelieved

Dx: by seeing or palpating the prolapsed cord outside or within the vagina and abnormal FHR
patterns – once dx, birth should be expedited

Prevention is Key – Risk Factors: Multiparity, non-cephalic presentations, long length of cord,
preterm labor, low birth weight, multifetal pregnancy, and placement of cervical ripening
balloon
o More Common in Pregnancies Involving: Malpresentation, Growth restriction,
Prematurity, Ruptured Membranes with Fetus at a High Station, Hydramnios, Grand
Multiparity, and Multiple Gestation
Nursing Management: Prompt recognition; FIRST SIGN OF CORD PROLAPSE IS SUDDEN FETAL
BRADYCARDIA OR RECURRENT VARIABLE DECELERATIONS THAT BECOME PROGRESSIVELY
MORE SEVERE
o Call for help ASAP and DO NOT leave the woman – tell her what’s happening and what
options she can discuss with provider
o When membranes are artificially ruptured, help verify the presenting part is well
applied to cervix and engaged in pelvis
o If cord compression occurs, examiner puts a sterile gloved hand into vagina and holds
the presenting part off the umbilical cord until delivery
o Positioning: Modified Sims, Trendelenburg, and knee-chest position helps relieve cord
pressure
o DO NOT TRY TO PUT CORD BACK IN UTERUS
o Monitor FHR, maintain bed rest, admin O2 as ordered, provide emotional support and
explanations
o If cervix isn’t fully dilated, prepare woman for emergency c-section

NST

Nonstress Test (NST): Common prenatal test to check baby’s health; FHR monitored for 20-30
mins to see how it responds to maternal movements – nothing is done to place stress on the
baby during the test
o Typically done > 28 weeks gestation
o E.g. done during labor too to see how baby responds to contractions

Biophysical Profile (BPP): Measures breathing movements of the fetus, fetal tone, fluid index
(amniotic fluid volume), and fetal HR via real-time ultrasound and nonstress test
o Total possible points that can be given is 10; each section is scored either a 0 or a 2
o Score of 8 – 10 is normal and indicates that the CNS is functioning and the fetus in not
hypoxic
o Score of 6 or below possibly indicates a compromised fetus
BPP
What are the effects of Fetopelvic disproportion?
Problems with the Passenger: Presentation, Position, Fetal Development
 Any position other than occiput anterior or a slight variation of the fetal position or size
increases the risk of dystocia; Can affect the contractions or fetal descent through the
maternal pelvis
 Macrosomia: Excessive fetal size; newborn weighs 4,000-4,500 grams (8.13-9.15 lbs.) or more
at birth; associated with later in life obesity, DM, and CVD
o And Fetal Abnormalities: e.g. hydrocephalus, ascites, large mass on head or neck
o Complications: Increased risk of PP hemorrhage, shoulder dystocia, low APGAR scores,
dysfunctional labor, fetopelvic disproportion, soft tissue laceration during vaginal
birth, fetal injury/fracture, perinatal asphyxia
Problems with the Passageway: Pelvis and Birth canal
 Relate to a contraction of one or more of the 3 planes of the maternal pelvis: inlet, midpelvis,
and outlet
 4 Basic Pelvis’: Gynecoid, Anthropoid, Android, Platypelloid
 Contraction of the midpelvis is more common than inlet contraction and typically causes an
arrest of fetal descent
 Obstructions in the maternal birth canal e.g. selling of soft maternal tissue (Soft tissue
Dystocia) can also hamper fetal descent and impede labor progression outside the maternal
bony pelvis
Post-dates- risks of, interventions

Post-Term Pregnancy: Continues past the end of 42 weeks or 294 days from the first day of
the last menstrual period
o Incorrect Dates: account for majority of these cases – may women have irregular
menses and thus, can’t ID the date of the last menstrual period accurately
o Risk Factors: Previous prolonged pregnancy
o Maternal Complications: Risk is r/t to the large size of the fetus at birth
 Increased chance of c-section needed, increased chance of forceps/vacuumassisted birth, increased chance of labor induction with oxytocin necessary
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Dystocia
Birth trauma
PP hemorrhage
Infection
Maternal exhaustion, feelings of despair, increased anxiety, reduced coping
ability, blaming self, negative feelings about self, strained relationships
o Fetal Complications:
 Macrosomia
 Shoulder dystocia and Brachial plexus injuries
 Low APGAR scores
 Postmaturity Syndrome: loss of subcutaneous fat and muscle, and meconium
staining
 Cephalopelvic disproportion
 Aging placenta → Decreased O2/nutrients to fetus
 Decreasing amniotic fluid volume after 38 weeks → possible oligohydramnios
→ fetal hypoxia → increased risk of cord compression due to less cushioning
effect → Predisposition to aspiration of meconium released in response to
hypoxic insult
Choosing Expectant Management: For Labor induction vs. post-term pregnancy Daily fetal kick
counts, nonstress tests with amniotic fluid assessments as part of the biophysical profile
twice/week, weekly cervical exams to evaluate for ripening
o Pt’s stress/anxiety concerning prolonged pregnancy
o Pt’s coping ability and support network
RN Care: Continuously assess and monitor FHR to ID potential fetal distress (late/variable
decels), monitor woman’s hydration status to ensure maximal placental perfusion, when
membranes rupture, assess amniotic fluid (color, amt., odor); monitor woman’s labor pattern
closely; encourage woman to verbalize feelings, concerns, and answer questions; provide
support, presence, information, and encouragement
Amniotic fluid embolism signs and symptoms

Amniotic Fluid Embolism/Anaphylactoid Syndrome of Pregnancy (ASP): an unforeseeable, lifethreatening complication; associated with maternal and newborn morbidity and mortality
o Amniotic fluid containing debris particles (hair, skin, vernix, meconium) enters
maternal circulation and obstructs the pulmonary vessels, causing respiratory distress
and circulatory collapse
o Characterized by: Sudden onset hypotension, cardiopulmonary collapse, hypoxia, and
coagulopathy
 4 Cardinal Signs: (1) Respiratory Failure (2) Altered Mental Status (3)
Hypotension (4) DIC
o S/Sx:
 Acute onset maternal dyspnea and cyanosis → Respiratory distress and
respiratory arrest
 Acute onset maternal hypotension and DIC
o Risk Factors: Placental abruption, uterine overdistention, fetal demise, eclampsia,
amniocentesis, uterine trauma, oxytocin-stimulated labor multiparity, advanced
maternal age, and ruptured membranes
o RN Interventions:
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Oxygenation 100% and Resuscitation; endotracheal intubation, mechanical
ventilation
IV fluids, inotropic agents (Vasopressors) to maintain cardiac output and BP
Control of hemorrhage and coagulopathy (oxytocin and prostaglandin analogs
to control uterine atony and bleeding)
Seizure precautions
Steroids to control inflammatory response
Vitals, pulse ox, skin color, temp
Monitor for signs of coagulopathy: vaginal bleeding, bleeding from IV site,
bleeding from gums – (Infusion of PRBCs or FFP as necessary)
Forceps delivery, complications




Forceps: stainless steel instruments, similar to tongs, with rounded edges that fit around the
fetus’s head – all forceps have a locking mechanism that prevents the blades from
compressing the fetal skull
o Outlet Forceps: Used when the fetal head is crowning
o Low Forceps: Used when the fetal head is at a +2 station or lower, but not yet
crowning
Indications: Prolonged 2nd stage of labor, distressed FHR pattern, failure of presenting part to
fully rotate and descend into pelvis, limited sensation, and inability to push effectively due to
regional anesthesia, presumed fetal jeopardy/fetal distress, maternal heart disease, acute
pulmonary edema, intrapartum infection, maternal fatigue, maternal infection
Complications: Maternal and fetal tissue trauma
o Cervical, vaginal, or perineal laceration, hematoma, extension of episiotomy incision
into the anus, hemorrhage, infection
o Newborns: ecchymoses, facial and scalp lacerations, facial nerve injury,
cephalohematoma, caput succedaneum
Requirements: Membranes ruptured, Cervix completely dilated, Fetus vertex and engaged,
Adequate maternal pelvis size