NUR3411C Maternal Newborn Study Guide: Test 1 Chapters 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 40-50 questions Question types: Multiple choice, select all that apply, dosage calculation, bowtie, matrix, trend, case study This study guide is intended to be a tool, not all-inclusive of the examination's content. Chapter 3 Assessment and Health Promotion Intimate Partner Violence o Can be inflicted by women o Physical or emotional abuse o Sexual assault o Isolation o Controlling all aspects of the woman’s life Money Shelter Time Food o Cycle of violence Phase 1: Tension building That her experiences increased tension, victim minimizes problems Tension becomes intolerable Phase 2: Abusive incident Batterer highly abusive, incident occurs Phase 3: Honeymoon period Loving, apologetic, promises change o Battering during pregnancy Rates range from 4% to 8% and may be as high as 20% in some populations Incidence of intimate partner violence may escalate May happen for the first time during pregnancy Risk to the fetus includes increased rate of miscarriage, preterm birth, and stillbirth o History Biographic data Reason for seeking care Present health or history of present illness Past health Family history Screen for abuse Review of systems Functional assessment o Physical examination General appearance Vital signs Objective data is recorded by body systems Findings are described in detail o Cultural considerations and communication variations Trust that woman is expert on her life, culture, and experiences If asked with respect and genuine desire to learn, woman will tell nurse how to care for her May be considered inappropriate for woman to disrobe completely for physical examination In many cultures a female examiner is preferred Menstrual Cycle o Menarche and puberty o Menstrual cycle o Endometrial cycle o Hypothalamic-pituitary cycle o Ovarian cycle Corpus luteum = where the egg came from o Other cyclic changes Cultural Competency Preconception Counseling and Risk factors o Social, cultural, genetic o Substance use and abuse Prescription drug use Illicit drug use Marijuana, cocaine, opiates, methamphetamine, phencyclidine Alcohol consumption Cigarette smoking Caffeine o Nutritional problems o Nutritional deficiencies Obesity Eating disorders Anorexia Bulimia nervosa Lack of exercise o Stress o Mental health conditions o Sleep disorders o Environmental and workplace hazards o Risky sexual practices o Risk for certain medical or gynecologic conditions o Female genital mutilation Chapter 4 Reproductive System Concerns Risk behaviors associated with STIs Signs, symptoms, causes and treatments of STIs (HPV, HSV, Gonorrhea, Chlamydia, Trichomonas, Syphilis, HIV/AIDS) as well as BV, and vulvovaginal candidiasis o Chlamydia Most frequently reported STI Infections often asymptomatic and highly destructive Screening and diagnosis Screening of asymptomatic and all pregnant women Management Drug therapy- doxycycline, azithromycin or amoxicillin o Gonorrhea—Neisseria gonorrhoeae Oldest communicable disease Aerobic and gram-negative diplococci Screening and diagnosis Women are often asymptomatic Management Treatment with antibiotic therapy- Ceftriaxone IM & azithromycin PO Drug-resistant strains on the rise o Syphilis—Treponema pallidum, a motile spirochete Transmission by entry in subcutaneous tissue through microscopic abrasions Transplacental transmission may occur at any time during pregnancy Infection manifests itself in distinct stages Primary - Chancre (painless papular lesion) at site of infection. Inguinal lymph node edema can indicate internal lesions Secondary - Maculopapular skin rash on the palmar surface of the hands and soles of the feet Tertiary - Damage to internal organs o Manifestations: eye infections leading to blindness, difficulty coordinating muscle movements, nervous system infections leading to headache, numbness, paralysis, dementia Screening and diagnosis Pregnant women- all screened in 1st trimester & repeated in third trimester if high risk Serologic tests- VDRL & RPR Management Penicillin G IM in a single dose Sexual abstinence during treatment o o o Pelvic inflammatory disease (PID) Results from ascending spread of microorganisms from vagina and endocervix to upper genital tract Caused by multiple organisms Most commonly involves: Uterine tubes (salpingitis) Uterus (endometriosis) At increased risk for: Ectopic pregnancy Infertility Chronic pelvic pain Human papillomavirus (HPV) Most prevalent viral STI seen in ambulatory health care settings Genital warts (Condyloma acuminata) Cervical cancer Signs & Symptoms Irritating vaginal discharge with itching Dyspareunia, postcoital bleeding Small warts- cauliflower- like appearance Abnormal changes to the cervix detected by a Pap test Screening and diagnosis Physical inspection Pap smear 21- 29 years old should have pap test every 3 years 30-65 years old should have pap test and HPV test every 5 years Management Vaccine- ages 9-26 years, preferred at 11-12 years No therapy has been shown to eradicate Medications Bichloroacetic acid (BCA), imiquimod Trichloroacetic acid (TCA) Podophyllin – can’t use during pregnancy Counseling and education Herpes simplex virus (HSV) Herpes simplex virus 1 (HSV-1) Transmitted nonsexually Herpes simplex virus 2 (HSV-2) Transmitted sexually HSV o Initial infection is characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria Maternal infection can have adverse effects on both the mother and fetus Increased miscarriage rates during the first trimester Association with cervical cancer has been observed o Prevention is critical! Viral hepatitis o Hepatitis B virus Most threatening to fetus and neonate Disease of liver; often a silent infection Transmitted parenterally, perinatally, orally (rarely), and through intimate contact Vaccination series o Hepatitis C virus Most common bloodborne infection in the United States Risk factor for pregnant women is history of injecting intravenous drugs Currently there is no vaccine Human immunodeficiency virus (HIV) o Heterosexual transmission now most common means of transmission in women o Estimated that 23% of new infections occur in women o Transmission of HIV occurs primarily through exchange of body fluids o Severe depression of cellular immune system associated with HIV infection characterizes AIDS o Symptoms include fever, headache, night sweats, malaise, generalized lymphadenopathy, myalgias, anemia, nausea, diarrhea, weight loss, sore throat, and rash o Screening and diagnosis Antibody screening enzyme immunoassay (EIA), confirmation with western blot or immunofluorescence assay All pregnant women in early pregnancy, repeat in third trimester if high risk o Counseling for HIV testing Perinatal transmission has decreased Discuss safe sex practices including barrier protection Nurses must consider confidentiality and documentation o Pregnancy and HIV Transmission to infant may occur at any time Definitive diagnosis of children less than 18 months is done based on lab evidence of HIV presence Proper treatment leads to <1% transmission to baby Antiretroviral therapy- given throughout pregnancy Triple-drug antiviral therapy or Highly active antiretroviral therapy (HAART) may be given Lab monitoring- STIs, viral load, CD4 counts Vaccinations- hepatitis B, pneumococcal infection, influenza Cesarean versus vaginal birth depends on viral load Vaginal infections o Bacterial Vaginosis Caused by alteration in normal vaginal bacterial flora Common vaginal infection Signs and symptoms Thin, watery white or gray vaginal discharge Vaginal discharge has a "fishy" smell "Clue" cells are seen on wet-mount preparation Treatment Metronidazole (Flagyl), Tinidazole, Clindamycin Some available as vaginal creams and/or orally o Candidiasis—Candida albicans Vulvovaginal candidiasis, or yeast infection, is second most common type of vaginal infection Predisposition Antibiotic therapy Diabetes Pregnancy Obesity Diets high in refined sugars Use of corticosteroids Immunosuppressed states Common signs & symptoms Vulvar & Vaginal pruritus Vulvar and vaginal erythema and inflammation Thick, creamy, white, cottage- cheese-like discharge Management Fluconazole o Over-the-counter agents Prevention o Trichomoniasis—Trichomonas vaginalis Common Symptoms Yellow-green, frothy, malodorous discharge and vaginal itching May have dysuria and dyspareunia Cervix bleeds easily (friable) and has tiny petechiae Can be asymptomatic Screening and diagnosis Specular examination Pap smear Management Metronidazole or tinidazole orally in a single dose Sexual transmission must be communicated to infected woman o Group B streptococci Associated with poor pregnancy outcomes An important factor in neonatal morbidity and mortality Screening at 35 to 37 weeks of gestation GBS + or unknown: Treated with IV antibiotics in labor Penicillin G or Ampicillin What STI are curable and what STIs are incurable TORCH infections- can cause birth defects/death to the baby o Toxoplasmosis Contracted via raw meat or handling of cat feces Manifestations- asymptomatic, fever, tender lymph nodes, malaise, muscle aches o Other (Hepatitis A, hepatitis B, syphilis, mumps, parvovirus b19, varicellazoster) o Rubella (German measles) Contracted through children with the rashes or neonates exposed in utero Manifestations- rash, mild lymphedema, fever, joint and muscle pain o Cytomegalovirus Transmitted via droplet or bodily fluids Manifestations: asymptomatic or mononucleosis- like manifestations o Herpes Simplex Virus Transmission to fetus is greatest during vaginal birth (when active lesions present) STI Prevention o Safer sex practices Knowledge of partner, reducing partners Low risk sex Condom use Vaccination Chapter 5 Infertility, Contraception and Abortion Types of contraceptives (IUD, Implants, Depo Provera, Sterilization, etc.) Coitus interruptus (withdrawal) Fertility awareness methods (FAMs) o Rely on avoidance of intercourse during fertile periods o FAMs combine charting menstrual cycle with abstinence or other contraceptive methods o Natural family planning (period abstinence) o Calendar rhythm method o Woman monitors fertile window o Most fertile 5 days before ovulation until 1 day post-ovulation, so intercourse is avoided or barrier protection is used cycle days 8-19 (for a regular length cycle) o Natural family planning (NFP), standard days method, cycle beads or software program o Calendar rhythm method (CRM) is based on premise that ovulation occurs at day 14 of cycle (plus or minus 2 days) o Billings method – spinnbarkeit (cervical mucous) o Advantages Natural, noninvasive and inexpensive o Disadvantages Requires extensive initial counseling Does not protect against STIs o Effectiveness Couples must practice abstinence Low reliability Barrier methods o Spermicides Chemical barrier, causes the vaginal flora to be more acidic, which is not favorable for sperm survival o Condoms, male & female (STI protection) Prevent spread of most STIs Use only water soluble lubricants with latex condoms o Diaphragm Must be fitted by a provider Use with spermicide to increase effectiveness Insert up to 6 hr prior to intercourse and leave in place for at least 6 hr after intercourse (no longer than 24 hours at a time) o Cervical cap Insert up to 6 hr prior to intercourse and leave in place for at least 6 hr after intercourse (no longer than 48 hours at a time) Use with spermicide to increase effectiveness o Contraceptive sponge Polyurethane sponge that contains spermicide that fits over the cervix Should be left in place for 6 hr after intercourse and provides protection up to 24 hours Hormonal methods o Combined estrogen-progestin contraceptives (COCs) Oral contraceptives and side effects Transdermal contraceptive system Vaginal ring Progestin-only contraceptives o Oral progestins (mini pill) Orally, daily Continuous, no “pill free” week Considered safe to take while breastfeeding o Injectable progestins Injected every 11 – 13 weeks Can decrease bone density, need adequate intake of calcium and vitamin D Weight gain, depression, and irregular bleeding are more common side effects Return to fertility can be delayed greater than one year after discontinuation Not recommended for use for more than 2 years unless other methods are not suitable o Implantable progestins (Norplant) Implant inserted subdermally in woman’s upper underarm Impregnated with etonogestrel, a progestin Prevents ovulation; effective for 3 years Side effects: spotting, irregular bleeding, ovarian cysts, weight gain, acne, hair loss, headaches, mood changes, depression Sterilization o Female Tubal occlusion Tubal reconstruction o Male (vasectomy) Tubal reconstruction (reanastomosis) What contraceptive method is acceptable for breastfeeding women o Progestin-only pill (minipill) – oral Emergency contraceptives- types and timing of administration o Inhibits ovulation and the transport of sperm o Used within 72 hours of unprotected intercourse o Methods available in the United States High doses of estrogen or COCs Two days of levonorgestrel Insertion of the copper intrauterine device (IUD) Small, T-shaped device wrapped in copper inserted into the uterine cavity Medicated intrauterine system loaded with progestational agent (Mirena) IUD offers no protection against STIs or HIV Advantages: Long acting & reversible; effective for up to 10 years (device dependent). High efficacy, next best to permanent sterilization. Available hormone-free, and with progestin. Disadvantages: May cause cramping and irregular bleeding for first 3 to 6 months Woman must check for proper placement after each menses (string check) Risks include perforation, PID, expulsion, discomforts and increased bleeding Combined hormonal contraceptives (also called combined oral contraceptives) o Hormonal contraceptives, combined Contraindicated in pregnant clients, clients with cardiovascular disorders, previous history of thromboembolic disease, acute or chronic liver disease with abnormal function, presence of an estrogen-dependent carcinoma, undiagnosed uterine bleeding, heavy smoking, gall bladder disease, hypertension, diabetes and hyperlipidemia. Smokers over 35 years of age should not use Caution for decreased effectiveness when using with anticonvulsants and some antibiotics Does not protect from STIs Very effective when used correctly Noncontraceptive benefits include relief of menstrual symptoms, lessened cramps, decreased flow, improved cycle regularity (predictable menstruation) Reduction in incidence of some cancers Educate regarding warning signs during use o Warning signs (ACHES) A- abdominal pain- may indicate a liver or gall bladder problem C- chest pain or SOB- may indicate a clot in the heart or lungs H- Headaches (sudden or persistent)- may be caused by cerebrovascular accident or hypertension E- Eye problems- may indicate vascular accident or hypertension S- Severe leg pain- may indicate a thromboembolic process Assessment of female infertility o Test or examination Evaluation of the anatomy (pelvic examination) Hormone analysis- prolactin, FSH, LH, estradiol, progesterone, thyroid hormones Ultrasonography- visualize the reproductive organs Hysterosalpingography- radiologic procedure that uses dye to assess for tubal patency Hysteroscopy- radiographic procedure to examine the uterus for defect, distortion, or scar tissue Laparoscopy- procedure to visualize the internal organs Assessment of male infertility o Semen analysis o Scrotal ultrasound- visualize the testes and abnormalities in the scrotum Assisted reproductive therapies o Intrauterine insemination Sperm is placed in the uterus at time of ovulation o In vitro fertilization-embryo transfer (IVF-ET) Client’s eggs are collected, fertilized in the laboratory, then the embryo is transferred into the uterus o Ovum transfer (oocyte donation) Eggs are collected from a donor, fertilized and the embryo is transferred into the client’s uterus o Therapeutic donor insemination (TDI) Donor sperm is used to inseminate a person o Embryo hosting/ Gestational carrier A person carries the pregnancy, has no genetic connection to the embryo Chapter 6 Genetics, Conception, and Fetal Development Embryonic Stage o Primary germ layers Ectoderm, Mesoderm & Endoderm o Development of the embryo Day 15- 8 weeks is the embryonic stage At the end of the eight week all organ systems and external structures are present Critical time in the development of the organ systems and main external features Teratogens o Teratogens – Remember TORCH Drugs Chemicals Infection Exposure to radiation Maternal conditions (Diabetes, PKU) o Maternal nutrition Malnutrition Genetics terms (Genotype, Phenotype, Karyotype, etc.) o Genotype The genotype of a person is her or his genetic makeup. It can also refer to the alleles that a person has for a specific gene o Phenotype Phenotype is how a person looks (on the outside and inside the body) due to his or her genes and the environment (for example, having a certain eye color, being a specific blood type, or being a certain height). Phenotype also can refer to how a person’s body functions, for example, whether he or she has a certain disease. o Karyotype A karyotype is an individual’s complete set of chromosomes. The term also refers to a laboratory-produced image of a person’s chromosomes isolated from an individual cell and arranged in numerical order. A karyotype may be used to look for abnormalities in chromosome number or structure. Placental function and hormone production o Structure Maternal-placental-embryonic circulation by Day 17 o Function Endocrine gland- produces hormones such as hCG, hPL, progesterone Metabolic function and waste Nutrient storage- carbohydrates, calcium, protein, iron Chapter 7 Anatomy and Physiology of Pregnancy Definitions- gravidity, parity, term, preterm o Gravidity Gravida: Woman who is pregnant Gravidity: Pregnancy Nulligravida: Woman who has never been pregnant Primigravida: Woman pregnant for first time Multigravida: Woman who has had two or more pregnancies o Parity Parity: Number of pregnancies in which fetus or fetuses have reached viability, not number of fetuses (e.g., twins) born. Whether the fetus is born alive or is stillborn (fetus who shows no signs of life at birth) after viability is reached does not affect parity Nullipara: Woman who has not completed a pregnancy with fetus or fetuses who have reached stage of fetal viability Primipara: Woman who has completed one pregnancy with fetus or fetuses who have reached stage of fetal viability Multipara: Woman who has completed two or more pregnancies to stage of fetal viability o Term Preterm: Pregnancy that has reached 20 weeks of gestation but before completion of 37 weeks of gestation Late preterm: Pregnancy that has reached between 34 weeks 0 days and 36 weeks 6 days gestation Early term: Pregnancy that has reached between 37 weeks 0 days and 38 weeks 6 days gestation Full term: Pregnancy that has reached between 39 weeks 0 days and 40 weeks 6 days Late term: Pregnancy that has reached between 41 weeks 0 days and 41 weeks 6 days Postterm: Pregnancy that has reached 42 weeks 0 days and beyond gestation Viability: Capacity to live outside the uterus; about 22 to 25 weeks gestation are on the threshold of viability These very premature infants are vulnerable to brain injury GTPAL- know what each letter stands for and how to write out GTPAL based on a client’s history o Two digits G—Gravida P—Para o Five digits GTPAL Gravidity, term, preterm, abortions, living children o G- 1 o P- 2 o G3P2002 PREGNANT NOW, 2 TERM, 0 PRETERM, 0ABORTONS, 2 LIVING Presumptive, probable, positive changes of pregnancy o Signs of pregnancy Presumptive Those changes felt by the woman Probable Those changes observed by an examiner o Positive pregnancy test o Chadwick sign (blue cervix) Positive Those signs are attributed only to the presence of the fetus o Hear fetal heart sounds o Fetus on ultrasound o Fetal movement Changes in the following systems- respiratory, cardiovascular, integumentary o General body systems Cardiovascular system Blood volume increases – 30-45% Cardiac output increases – 30-50% Blood pressure Supine hypotensive syndrome Circulation and coagulation times Increases in various clotting factors Increased risk of clots 5-7 fold Respiratory system Maternal oxygen demands increase Maternal oxygen consumption increases 20-40% above pre-pregnancy levels Size of the chest may enlarge to allow for lung expansion Respiratory rate is unchanged or slightly increased Renal system GFR increases by 50% due to pregnancy hormones, increase in blood volume and metabolic demands Urinary output (volume) remains unchanged Urinary frequency, urgency, nocturia, and bladder irritability are common in pregnancy Integumentary system Chloasma or melasma (mask of pregnancy) Linea nigra Striae gravidarum Musculoskeletal system Changes in posture- lordosis Pelvic joints relax Diastasis recti abdominus Risk of falls due to change in center of gravity Neurologic system Carpal tunnel syndrome Headaches Lightheadedness, faintness and syncope (common in early pregnancy) Gastrointestinal system Nausea and vomiting- due to increasing hCG levels PICA- nonfood cravings Constipation Pyrosis (heartburn) Endocrine system The placenta becomes an endocrine organ that produces large amounts of hCG, progesterone, estrogen, hPL and prostaglandins Hormones function to maintain the pregnancy and prepare the body for delivery Chapter 8 Nursing Care of the Family During Pregnancy Nagele’s Rule o Determine first day of last menstrual period (LMP), subtract 3 months, add 7 days (plus 1 year if needed) o Most women give birth from 7 days before to 7 days after EDB Maternal Serum Alpha- fetoprotein- what does it test for? When is it tested? o Multiple-marker or triple-screen blood test (alpha fetal protein) o Follow up visit o Fetal Assessment o What is an Alpha-fetoprotein (AFP) Test? An AFP test is a test that is mainly used to measure the level of alpha-fetoprotein (AFP) in the blood of a pregnant person. The test checks the baby's risk for having certain genetic problems and birth defects. An AFP test is usually done between 15 and 20 weeks of pregnancy Common discomforts of pregnancy and interventions o Nausea and vomiting- eat crackers or dry toast before rising in the morning; avoid having an empty stomach, avoid spicy, greasy or gas- forming foods. Drink fluids between meals o Breast tenderness- wear a supportive bra o Urinary frequency- empty the bladder frequently, decrease fluid intake before bed, perform kegel exercises o UTIs- wipe front to back, avoid bubble baths, wear cotton underwear, avoid tightfitting pants, consume plenty of water, urinate before and after intercourse, void once you feel the urge, notify the provider if the urine is foul-smelling, bloody or cloudy o Fatigue- engage in frequent rest periods o Heartburn- eat, small frequent meals, do not lie down immediately after eating o Constipation- drink plenty of fluids, eat a high fiber diet, exercise regularly o Hemorrhoids- a warm sitz bath, witch hazel pads, and application of topical ointments o Backaches- exercise regularly, perform pelvic tilt exercises, use proper body mechanics, use the side-lying position o Shortness of breath- maintain good posture, sleep with extra pillows, contact the provider is manifestations worsen o Leg cramps- Extend the affected leg with the knee straight and dorsiflex the foot. Heat and massage may help o Varicose veins and lower extremity edema- rest with legs and hips elevated, avoid constricting clothing, wear supportive hose, avoid sitting and standing for long time periods, not sit with the legs crossed. Sleep in the left lateral position, and exercise moderately with frequent walking o Gingivitis, nasal stuffiness, epistaxis- gently brush the teeth, follow good dental hygiene, use a humidifier, use normal saline nose drops or spray o Braxton Hicks contractions- position change and walking should relieve the pain. If contractions increase in intensity and frequency with regularity, the client should notify the provider (Braxton Hicks contractions are a tightening in your abdomen that comes and goes. They are contractions of your uterus in preparation for giving birth. They tone the muscles in your uterus and may also help prepare the cervix for birth.) o Supine hypotension- Lie in a side- lying position or semi- sitting position with the knees slightly flexed Danger signs of pregnancy o First Trimester Burning on urination Severe vomiting Diarrhea Fever or chills Abdominal cramping or vaginal bleeding Miscarriage/etopic o Second and Third Trimester Gush of fluid from the vagina prior to 37 weeks Vaginal bleeding – placenta privia/abruta Abdominal Pain Changes in fetal activity Persistent vomiting Severe headaches – gestational hypertension Elevated temperature – infection Dysuria – UTI Blurred vision – gestational hypertension Edema of the face and hands – gestational hypertension Epigastric pain – gestational hypertension Concurrent flushed dry skin, fruity breath, rapid breathing, increased thirst and urination, headache – hyperglycemia Concurrent clammy, pale skin, weakness, tremors, irritability, lightheadedness – hypoglycemia Self-Care actions for health promotion- employment, exercise, travel, dental care, activity, rest, sexual activity Chapter 9 Maternal and Fetal Nutrition BMI ranges and weight gain recommendations in pregnancy o Energy needs Weight gain Body mass index (BMI) = weight/height2 Underweight woman Body Mass Index (BMI) less than 18.5 Recommended gain 28–40 lb (12.5–18 kg) Normal-weight woman Body Mass Index (BMI) 18.5–24.9 Recommended gain 25–35 lb (11.5–16 kg) Overweight woman Body Mass Index (BMI) 25–29.9 Recommended gain 15–25 lb (7–11.5 kg) Obese woman Body Mass Index (BMI) over 30 Recommended gain 11–20 lb (5–9.1kg) o Expected Weight Gain Normal weight Gain of 2.2–4.4 lb (1 to 2 kg) during the first trimester Average gain of 1 lb (0.5 kg) per week during the last two trimesters Caloric needs in pregnancy and breastfeeding o Calories First trimester- same as the non-pregnant state Second trimester- an additional 340 calories Third trimester- an additional 452 calories o Protein Essential to basic growth Additional 25g in the second and third trimesters o Omega 3 fatty acids LCPUFAs- DHA & AA Essential to fetal brain development and neurologic function o Fluids Recommended daily intake 8-10 glasses (2.3L) of fluid o Minerals and vitamins Iron Increased RBC mass & adequate iron transfer to fetus Patient Teaching Iron Supplementation p 222 Calcium Bone and teeth formation Daily recommendation: 1000mg/day for 19-50 years of age & 1300 mg/day for those under 19 years Folic acid Neurologic development and prevention of neural tube defects Prior to pregnancy women of childbearing age should take 400 mcg of folic acid daily During pregnancy, women should take 600 mcg of folic acid daily o Nutrition needs during lactation similar to those during pregnancy (450-500 cal/day) o Needs for energy (calories), protein, calcium, iodine, zinc, the B vitamins, and vitamin C remain greater than nonpregnant needs Foods to avoid in pregnancy o Alcohol contraindicated in pregnancy o Caffeine Limit intake to 200mg daily Can cause IUGR, SAB, infertility o Artificial sweeteners Have not been found to have adverse effects on the mother and fetus o No soft cheeses or foods that are unpasteurized o No swordfish, shark, tilefish, or king mackerel o Tuna to 6oz a week o Do not restrict calorie intake to lose weight during pregnancy o Avoid megadoses of vitamins Maternal and fetal risks associated with abnormal weight gain Chapter 10 Assessment of High-Risk Pregnancy Fetal Movement Counts o Daily fetal movement count (DFMC) Simple yet valuable method to evaluate the condition of the fetus Several methods can be used to count Once a day for 60 minutes 2 to 3 times daily –ATI (2hrs after meals or before bedtime) (less than 3per/hr = concern) 10 movements in a 12-hour period o Non-stress test o Widely used method of evaluating fetal status [alone or as part of biophysical profile (BPP)] o Adequately oxygenated fetus with intact fetal central nervous system should demonstrate accelerated fetal heart rate (FHR) in response to fetal movement o Requires electronic monitor to observe and record fetal heart rate accelerations o Advantages Quick to perform Permits easy interpretation Inexpensive Can be done in an office or clinic setting No known side effects o Disadvantages Sometimes difficult to obtain a suitable tracing Woman must remain relatively still for at least 20 minutes High false-positive rate o Positioning options Reclining chair or in bed Left-tilted, semi-Fowler or side-lying position o Avoid supine position Less fetal movement Maternal back pain Maternal shortness of breath o Electronic fetal monitor to obtain data Fetal heart rate (FHR) tracing Fetal movement (FM) o Monitor placed beneath woman's clothing o Provide woman with privacy o Results Shows at least two accelerations of FHR with fetal movements of 15 beats/min, lasting 15 seconds or more, over 20 minutes = reactive NST 15x15 rule over 20 min In preterm fetuses (prior to 32 weeks), rate is 10 beats above baseline for 10 seconds in a 20 minute window 10x10 rule over 20 min If reactive criteria are not met, than it is nonreactive For example, the accelerations do not meet the requirements (15 x 15 or 10 x 10) If data cannot be interpreted, or there was inadequate fetal activity, than it is unsatisfactory Biophysical Profile o o o o o Purpose is to either to identify the compromised fetus or to confirm the healthy fetus Provides an assessment of placental functioning Biophysical risks Genetic disorders ABO Multiple births Nutritional and general health status Young Multiple pregnancies Tobacco, drugs, alcohol Weight gain Medical or obstetric-related illness Poorly controlled diabetes mellitus Hypertensive disorders Advanced maternal age Biophysical Profile (BPP) Indications Client presentation Vaginal bleeding evaluation Size- dates discrepancy Decreased fetal movement Preterm labor Possible ROM (ruptured membranes) Nonreactive NST (stress test) Scoring Criteria Score of 2 assigned to each variable with normal finding Score of 0 assigned to each variable with abnormal finding Maximum score of 10 Scores of 8 (with normal amniotic fluid) and 10 considered normal Reflect least chance of being associated with compromised fetus unless decreased amount of amniotic fluid noted 4-6 abnormal risk of asphyxia <4 asphyxia Amniocentesis o Studies can be performed on amniotic fluid, can be performed after 14 weeks, but depending on indication, may be performed in later pregnancy o US guidance used to identify fetal and placental positions, and pockets of amniotic fluid o Provide information on Fetal health Genetic disorders Fetal health Fetal lung maturity (third trimester) o Amniocentesis Fetal complications Death Hemorrhage Infection (amnionitis) Injury from needle Risks may be minimized by using ultrasound to direct the procedure Fetal lung maturity is determined by The lecithin/sphingomyelin (L/S) ratio o A ratio of 2:1 indicates fetal lung maturity (2.5:1 or 3:1 if client is diabetic) Presence of phosphatidylglycerol (PG) o Absence of PG is associated with respiratory distress o o o Chorionic villus sampling (CVS) Earlier diagnosis and rapid results Performed between 10 and 13 weeks of gestation Removal of small tissue specimen from fetal portion of placenta o Chorionic villi originate in zygote o Tissue reflects genetic makeup of fetus Risks of CVS include: o Failure to obtain tissue o Rupture of membranes o Leakage of amniotic fluid o Bleeding o Intrauterine infection o Maternal tissue contamination of specimen o Rh alloimmunization – cross contamination of – and + o Spontaneous abortion Percutaneous umbilical blood sampling (PUBS) Direct access to fetal circulation Insertion of needle directly into a fetal umbilical vessel under ultrasound guidance In many centers has been replaced by placental biopsy Can be performed after 18 weeks gestation Detects certain genetic disorders, blood conditions, and infections Can also be used to deliver blood transfusions or medication to a baby via the umbilical cord. Maternal assays Alpha-fetoprotein (AFP) – just a screening test Maternal serum levels screened for neural tube defects (NTDs) 80% to 85% of open NTDs and abdominal wall defects can be detected early Recommended for all pregnant women between 16- 18 weeks gestation High levels can indicate a neural tube defect or open abdominal defect Low levels can indicate Down Syndrome Chapter 11 High- Risk Prenatal Care: Preexisting Conditions Diabetes mellitus/ GDM o Diabetes mellitus The most common endocrine disorder associated with pregnancy Pregnancy complicated by diabetes considered high risk Diabetes can be successfully managed with a multidisciplinary approach Key to an optimal outcome is strict maternal glucose control 10% of pregnancies Insulin dependent o Classification of diabetes type 1 diabetes type 2 diabetes Gestational diabetes mellitus (GDM) is any degree of glucose intolerance with onset or recognition during pregnancy o Diabetes mellitus Maternal risks and complications Macrosomia – big baby Hydramnios – fluid levels increased Ketoacidosis Hyperglycemia Hypoglycemia o Fetal and neonatal risks and complications Perinatal mortality risk increased – r/o cord event Congenital malformations Respiratory distress syndrome (RDS) – affects lung development Prematurity IUFD (intrauterine fetal demise) o Assessment and nursing diagnosis Interview Physical examination Assess acute and chronic complications of diabetes Laboratory tests Baseline renal function UA and culture Glycosylated hemoglobin A Patient needs much more frequent monitoring o Review self-monitoring Ideal blood glucose levels in pregnancy 60-105 mg/dL before meals or fasting Less than or equal to 120 mg/dL 2hours after meals o Antepartum care Diet and exercise Insulin therapy Self-monitoring blood glucose levels Urine testing Complications requiring hospitalization Fetal surveillance Daily kick counts o Intrapartum care Glucose monitoring hourly Insulin infusion Avoid dextrose solutions May require a cesarean birth o After birth care Insulin requirements decrease substantially Encourage breastfeeding GDM o Care management Screening for gestational diabetes mellitus Early pregnancy screening Screening at 24 to 28 weeks o Women at average risk 50-g, 1-hour OGTT at 24‒28 weeks' gestation (step 1) Oral glucose given at any time of the day No requirement for fasting If glucose level less than 140 mg/dL, they pass screening test (no step 2 needed) If glucose level equal to or greater than 140 mg/dL, than step 2 required, 3-hour glucose test o High Risk Factors Nonwhite women Prior history of GDM Prior birth of large-for-gestational-age LGA infant Marked obesity Diagnosis of polycystic ovarian syndrome Hypertension Glycosuria Strong family history of type 2 DM Stillborn Gestational age over 25 Iron deficiency anemia o Most common medical complication of pregnancy o Hemoglobin (Hb) levels below 11 g/dL o Iron intake recommended in pregnancy is 27 mg/day o Prevention o Supplemental iron or folic acid during pregnancy o Take iron supplements with vit C source and not with calcium source o Iron-rich diet (legumes, fruit, green leafy vegetables, meat) o Easily tired o More susceptible to infection o Increased chance of preeclampsia-eclampsia and postpartum hemorrhage o Cannot tolerate even minimal blood loss during birth o Possible delayed healing of episiotomy or incision Substance abuse o The continued use of substances despite related problems in physical, social, or interpersonal areas o Dual diagnosis Substance abuse plus another psychiatric disorder o Damaging effects on the fetus are well documented o Barriers to treatment Women fear losing custody of child and criminal prosecution Less than 10% of pregnant women receive treatment Substance abuse treatment programs do not address issues affecting pregnant women Long waiting lists and lack of health insurance present further barriers to treatment o Legal considerations Some states consider in-utero exposure to be abuse or neglect Healthcare practitioners possibly required to report positive results Legal mandating may impact provider-patient relationship o Screening First prenatal visit Past and present use Include prescription and herbal substances Nonjudgmental approach Toxicology testing Urine Meconium hair Assessment Additional assessment related to conditions more likely in women with substance abuse issues Infections HIV Hepatitis Syphilis Common STIs Ultrasounds Gestational age Interventions Medical management Education Consequences of drug use Monitoring Treatment programs Nursing interventions Low threshold for pain requires additional approaches to management Decreased involvement with infant requires advice and education Considerations for breastfeeding related to infant exposure Follow-up care Assess safety of home environment Social services involved Availability of friends/family support systems Home care visits If infant’s well-being is questionable, case will be referred to child protective services agency o o o o Chapter 12 High- Risk Prenatal Care: Gestational Conditions Spontaneous abortiono Classifications Threatened – unexplained bleeding, cramping, backache; cervix closed Inevitable – bleeding & cramping increase; cervical os dilates, may SROM(spontaneous rupture of membranes) Complete – all products of conception are expelled Incomplete – some products of conception (usually placenta) are retained Missed – fetus dies in utero but is not expelled Recurrent pregnancy loss – occurs consecutively in 3 or more pregnancies Septic abortion – infection is present o Risk Factors Chromosomal abnormalities Advanced maternal age Premature cervical dilation Chronic maternal diseases (ex. DM) Maternal malnutrition Trauma or injury Substance use Chronic Maternal infections Anomalies in the fetus or placenta o Nursing Care Perform a pregnancy test Observe color and amount of bleeding Avoid vaginal exams Assist with Ultrasound Administer medications and blood products as prescribed Retain passed tissue for examination Provide client education and support Refer to pregnancy loss support groups Labs o Hgb & Hct o Clotting Factors o WBC o Serum hCG levels (body will adjust levels if baby is viable or not) Vaginal bleeding- nursing interventions o Hemorrhagic disorders in pregnancy are medical emergencies o Maternal blood loss decreases oxygen-carrying capacity Increased risk for hypovolemia, anemia, infection, preterm labor, and preterm birth Adversely affects oxygen delivery to fetus Fetal risks include blood loss or anemia, hypoxemia, hypoxia, anoxia, and preterm birth o Cervical Insufficency Risk Factors o o OB history of preterm births, late miscarriages, cervical trauma, congenital structural defects of the uterus or cervix Diagnosis Ultrasound showing a short cervix (<25mm)m presence of cervical funneling or effacement of the cervix Management cerclage Follow-up care Close monitoring of pregnancy Report sign/symptoms of preterm labor Ectopic Pregnancy Incidence and etiology Fertilized ovum implanted outside uterine cavity Tubal rupture and hemorrhage Leading cause of infertility 95% occur in uterine (fallopian) tube o Most located on ampulla Clinical manifestations o Abdominal pain o Delayed menses o Abnormal vaginal bleeding (spotting) Diagnosis o Quantitative hCG levels o Transvaginal ultrasound Medical management o Medical Methotrexate- dissolves the pregnancy by destroying rapidly dividing cells o Surgical Salpingectomy- removal of the fallopian tube (performed when tube has ruptured) Salpigostomy- remove the products of conception and conserve the tube Hydatidiform Mole Proliferation of trophoblastic cells creates placenta characterized by hydropic (fluid-filled) grapelike clusters Types o Complete – no maternal genetic tissue is present o Partial – usually has triploid number of chromosomes (69) Consequences o Loss of pregnancy o Remote possibility of developing choriocarcinoma Signs and Symptoms o Vaginal bleeding o Often brownish (like prune juice) but it may be bright red o Uterine enlargement greater than expected for gestational age o Passage of hydropic vesicles (grapelike clusters) o Serum hCG levels are markedly elevated o Hyperemesis gravidarum o Anemia due to blood loss o Symptoms of preeclampsia before 24 weeks' gestation o Absent fetal heart tones o Low levels of AFP Diagnosis and Treatment o o o o o Ultrasound Primary diagnostic tool Therapy Suction curettage is most often successful for evacuation of the mole Rh immune globulin administered to Rh-negative women Hysterectomy may be treatment of choice to reduce risk of choriocarcinoma when no further pregnancies are desired Follow-up Care Serum hCG weekly until the level decreases to normal for three weeks, then monthly for 6- 12 months to detect GTD Placenta previa Placenta implanted in lower uterine segment near or over internal cervical os Classification based on degree the internal cervical os is covered by placenta Complete placenta previa Marginal placenta previa Low-lying placenta previa Incidence and etiology Clinical manifestations Maternal and fetal outcomes Abnormal placental attachment Excessive bleeding Fetal risks include malpresentation, preterm birth, fetal anemia, and congenital anomalies Risk Factors Prior cesarean birth High gravidity High parity Advanced maternal age Women of African and Asian descent Previous miscarriage Previous induced abortion Cigarette smoking Male fetus Nursing Assessment/Managaement Maternal assessment for painless, bright-red vaginal bleeding o Most accurate diagnostic sign of placenta previa o If this sign develops during the last 3 months of pregnancy, placenta previa should always be considered until ruled out by ultrasound examination Bleeding usually begins as scant and becomes more profuse Uterus is usually soft, relaxed and non-tender Bed rest if active bleeding, BR privileges allowed if no active bleeding IV fluids I&O Labs (CBC, Blood type & Rh, coagulation profile) Consider unengaged fetal presenting part (obstruction) Transverse lie is common Assessment of fetal status FHR: continuous external fetal monitoring Anticipate need for blood transfusion Assess maternal vital signs Every 15 minutes if no hemorrhage Every 5 minutes with active hemorrhage External tocodynamometer (contraction monitor) NO vaginal exams Premature separation of placenta (Abruptio placentae) Grades o Grade 1 o Mild separation Grade 2 o Moderate separation Grade 3 o Severe separation Expected findings Sudden onset of intense uterine pain Bleeding, usually dark red Hypovolemia Hypertonic contractions Fetal distress Risk Factors Previous placental abruption Increased maternal age Increased parity Cigarette smoking Cocaine abuse Trauma Maternal hypertension Multifetal gestation PPROM or PROM Cord insertion and placental variations Vasa previa Velamentous insertion of the cord Cord vessels begin in the branch at the membranes and then course to the placenta Succenturiate placenta The placenta is divided into two or more lobes and not one mass Hyperemesis gravidarum Definition: Excessive vomiting accompanied by dehydration, electrolyte imbalance, weight loss, nutritional deficiencies and ketonuria Increased risk for intrauterine growth restriction, small for gestational age, or preterm birth if the condition persists o Risk factors Age < 30 years Multifetal gestation Diabetes Gastrointestinal disorders Family history of hyperemesis Clinical hyperthyroid disorders Psychosocial issues/ high stress levels o Findings Weight loss Dehydration Dry mucus membranes Poor skin turgor Increased pulse rate Decreased blood pressure o Labs Urinalysis Chemistry profile Thyroid test Complete Blood count o Nursing Care Determine severity of the problem Monitor I&O Assess skin turgor, mucus membranes Monitor VS Monitor weight Nothing by mouth (NPO) IV fluid administration Pyridoxine (vitamin B6) alone or in combination with and doxylamine as initial treatment Corticosteroids treat refractory hyperemesis gravidarum Preeclampsia/ Eclampsia o Preeclampsia Pregnancy-specific syndrome Hypertension develops after 20 weeks of gestation in previously normotensive women A vasospastic systemic disorder categorized as mild or severe Etiology Signs and symptoms develop only during pregnancy and disappear after birth Associated high risk factors Family history of preeclampsia Multifetal pregnancy African-American race Obesity Before 19 and after 40 years old First pregnancy Preexisting medical or genetic conditions (DM, RA, SLE, Chronic HTN, Chronic renal disease) Pathophysiology Progresses along a continuum from mild to severe Caused by disruptions in placental perfusion and endothelial cell dysfunction Hypertension and vasospasm Decreased renal perfusion and glomerular filtration rate (GFR decrease) Decreased output and retention of sodium Increased serum levels of creatinine, BUN, uric acid Hyperreflexia Decreased placental perfusion Increased viscosity of blood Proteinuria greater than or equal to 1+ Mild Few if any symptoms Diagnostic criteria o Blood pressure elevated to ≥140/90 mmHg or higher o Proteinuria is 1+ to 2+ on dipstick, or 300 mg in a 24 hr specimen Edema no longer considered diagnostic criterion Generalized edema may be present Severe May develop suddenly Epigastric pain RUQ Diagnostic criteria o Blood pressure ≥160/110 mmHg on two occasions at least 6 hours apart during bed rest o Dipstick urine protein measurement 3+ or greater on two random samples at least 4 hours apart o Oliguria with urine output ≤500 mL in 24 hours o Eclampsia Seizure activity or coma in woman diagnosed with preeclampsia No history of preexisting pathology Eclamptic seizures can occur before, during, or after birth Severe preeclampsia plus seizure activity Characterized by grand mal convulsion or coma May occur before onset of labor, during labor, or early in postpartum period Women may have one or more seizures Severe headache and epigastric pain Severe gestational hypertension and severe preeclampsia Greater risk for pregnancy complications Expectant management Perinatologist services Antihypertensives Corticosteroids Intrapartum care Magnesium sulfate Control of blood pressure Nursing Care Nurses should assess: VS (BP, pulse, respirations and temperature) Pulse oximetry FHR Urine output Urine for protein & specific gravity Daily weight Pulmonary edema DTRs Headache, visual disturbance, epigastric pain Abdominal rigidity (placental separation) LOC Monitor I&O Laboratory blood tests Emotional response and level of understanding Nursing Care Maintain a quiet, low-stimulus environment in hospital; private room; limit visitors Woman should be in left lateral recumbent position Limit phone calls, bright lights, sudden loud noises Pad side rails of the bed Monitor effectiveness of medications Provide care during seizures Eclampsia Immediate care Maintain patient airway and safety during seizure Stabilize mother after seizure Magnesium sulfate Fetal status Prevention Prenatal care for assessment and early interventions o o o HELLP syndrome o Laboratory diagnostic variant of severe preeclampsia involves hepatic dysfunction, characterized by: Hemolysis (H) Elevated liver enzymes (EL) Low platelets (LP) o Nonspecific symptoms reported N/V, flu- like symptoms, epigastric pain Worsen at night and improve during day AST&ALT increase Platelets <1000 Can lead to DIC o Associated with increased risk for: Pulmonary edema Acute renal failure Liver hemorrhage or failure Disseminated intravascular coagulation (DIC) Placental abruption Acute respiratory distress syndrome Sepsis Stroke Fetal and maternal death Placenta previa vs. abruption (abruptio placentae)