NURS 2410 Unit 1
Nancy Pares, RN, MSN
Metro Community College
Ethical decision making model
• Context
– Who is involved, what is the setting
– What other information is needed
– What personal beliefs of the nurse may impact the
situation
• Clarification of the issues
– What are the ethical issues
– Who should decide the issue
• Identification of alternatives and potential
outcomes
Decision making cont
• Ethical reasoning
– What ethical theories have bearing on the
situation
– Should some theories be given greater weight in
the decision making process
– What legal or social constraints are factors
– What obligations might be present in the role of
the nurse
Decision making model cont
• Resolution
– What is the best action in this situation
– What strategy should be used to carry out this
action
• Evaluation
– What were the outcomes
– Should this same action be used in the future for
similar dilemmas
Figure 1–1 Individualized education for childbearing couples is one of the prime responsibilities of the maternal-newborn nurse.
Maternal-Newborn
Nursing Roles
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Professional Nurse
Certified Registered Nurse
Nurse Practitioner
Clinical Nurse Specialist
Certified Nurse Midwife
Figure 1–4 A certified nurse-midwife confers with her client. SOURCE: Photographer, Jenny Thomas
Factors Contributing
to Family Values
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Religion and social beliefs
Presence and influence of the extended family
Socialization within the ethnic group
Communication patterns
Factors Contributing
to Family Values (cont’d)
• Beliefs and understanding about health and
illness
• Permissible physical contact with strangers
• Education
Legal Issues
• Standards of care:
– Minimum criteria for competent, proficient,
delivery of nursing care
• Institutional policies
• Ethical implications
Legal Issues (cont’d)
• Scope of practice:
– Defined by state’s Nurse Practice Act
– Identifies parameters within which nurses may
practice
• Laws
Negligence
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There was a duty to provide care.
The duty was breached.
Injury occurred.
The breach of duty caused the injury
(proximate cause).
Maternal-Child Issues
• Divergence between rights of mother and
rights of fetus:
– Mother may refuse fetal intervention.
– Fetal intervention may be forced on mother.
• Fetal research:
– Therapeutic vs. non-therapeutic
Figure 1–5 A collaborative relationship between nurse and physician contributes to excellent client care.
SOURCE: Photographer, Elena Dorfman
Maternal-Child Issues
• Intrauterine fetal surgery:
– Therapy for anomalies incompatible with life
– Health of the mother and fetus is at risk
– Surrogate, frozen embryo,
– Female circumcision
Maternal-Child Issues
• Abortion
– Can be performed until point of viability
– After viability, if mother’s health in jeopardy
• Nursing role
– Have right to refuse to assist
– Responsible for ensuring a qualified
replacement is available
Maternal-Child Issues
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Infertility
Human stem cells
Cord blood
Maternal refusal for c/del
Maternal refusal for fetal surgery
Standards of Care
• Womens’ health standards by Association of
Women’s Health, Obstetric and Neonatal
Nurses (AWHONN)
• State Boards
• Individual facilities policy
Practicing Safety
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A holistic interpersonal approach
Adequate documentation
Communication
Updated and realistic policies and procedures
Appropriate delegation
Question deviations from the standar
Follow chain of command
Benefits of
Evidence-Based Practice
• Transforms research findings into clinical
practice:
– Efficiency improvement
– Better outcomes
– Quality improvement
Cell Division
• Mitosis:
– Exact copies of original cell
• Meiosis:
– Production of new organism
• Deletion
Genetic terms
– Loss of chromosome material
• Translocation
– Misplacement
• Nondisjunction
– Chromosomes don’t separate correctly
• Karotype
– Chromosomal make up of an individual
Mosaicism
two or more genetically different cell populations
in an individual
Figure 11–2 Comparison of mitosis and meiosis.
Mitosis
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Interphase
Prophase
Metaphase
Anaphase
Telophase
Meiosis
• First division:
– Chromosomes replicate, pair, and exchange
information.
– Chromosome pairs separate, and cell divides.
• Second division:
– Chromatids separate and move to opposite poles.
– Cells divide, forming four daughter cells.
Oogenesis
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Ovary gives rise to oogonial cells.
Cells develop into oocytes.
Meiosis begins and stops before birth.
Cell division resumes at puberty.
Development of Graafian follicle.
Spermatogenesis
• Production of sperm
• First meiotic division:
– Primary spermatocyte replicates and divides.
• Second meiotic division:
– Secondary spermatocytes replicate and divide.
• Produce four spermatids.
Figure 11–3 Gametogenesis involves meiosis within the ovary and testis. A, During meiosis, each oogonium produces a single haploid ovum
once some cytoplasm moves into the polar bodies. B, Each spermatogonium, in contrast, produces four haploid spermatozoa.
Fertilization
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Uniting sperm and ovum form a zygote
Ova are fertile for 12 to 24 hours
Sperm are fertile for 72 hours
Takes place in the ampulla of fallopian tube
Changes in Sperm
• Capacitation:
– Removal of plasma membrane and glycoprotein
coat
– Loss of seminal plasma proteins
• Acrosomal reaction:
– Release of enzymes
– Allows entry through corona radiata
Figure 11–4 Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a sperm are depicted moving from top to
bottom. B, Scanning electron micrograph of human sperm surrounding a human oocyte (750ﾗ). The smaller spherical cells are granulosa cells
of the corona radiata. SOURCE: Used with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing.
After Sperm Entry
• Zone pellucida blocks additional sperm from
entering
• Secondary oocyte completes second meiotic
division
– Forms nucleus of ovum
• Nuclei of ovum and sperm unite
• Membranes disappear
• Chromosomes pair up
Twins
• Fraternal: two ova and two sperm
• Identical: single fertilized ovum
- Originate at different stages
Pre-embryonic
• Cleavage
• Blastomeres form morula
• Blastocyst:
- develops into embryonic disc and amnion
• Trophoblast:
- develops into chorion
Implantation
• Occurs 7 to 10 days after fertilization
• Blastocyst burrows into endometrium
• Endometrium is now called decidua
Embryonic Development
• Primary germ layers:
– Ectoderm
– Mesoderm
– Endoderm
Placenta
• Metabolic and nutrient exchange
• Maternal portion:
– Decidua
• Fetal portion:
– Chorionic villi
• Fetal surface covered by amnion
Placental Development
• Chorionic villi form spaces in decidua basalis
• Spaces fill with maternal blood.
• Chorionic villi differentiate:
– Syncytium: outer layer
– Cytotrophoblast: inner layer
• Anchoring villi form septa
Figure 11–13 Longitudinal section of placental villus. Spaces formed in the maternal decidua are filled with
maternal blood; chorionic villi proliferate into these maternal blood-filled spaces and differentiate into a syncytium
layer and a cytotrophoblast layer.
Umbilical Cord
• Body stalk fuses with embryonic portion of
the placenta
• Provides circulatory pathway from chorionic
villi to embryo:
– One vein
• Delivers oxygenated blood to fetus:
– Two arteries
Figure 11–14 Vascular arrangement of the placenta. Arrows indicate the direction of blood flow. Maternal blood flows through the uterine
arteries to the intervillous spaces of the placenta and returns through the uterine veins to maternal circulation. Fetal blood flows through the
umbilical arteries into the villous capillaries of the placenta and returns through the umbilical vein to the fetal circulation.
Placental Functions
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Nutrition
Excretion
Fetal respiration
Production of fetal nutrients
Production of hormones
Fetal Development: Week 4
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Beginning development of GI tract
Heart is developing
Somites develop—beginning vertebrae
Heart is beating and circulating blood
Eyes and nose begin to form
Arm and leg buds are present
Fetal Development: Week 6
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Trachea is developed
Liver produces blood cells
Trunk is straighter
Digits develop
Tail begins to recede
Fetal Development: Week 12
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Eyelids are closed
Tooth buds appear
Fetal heart tones can be heard
Genitals are well-differentiated
Urine is produced
Spontaneous movement occurs
Fetal Development: Week 16
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Lanugo begins to develop
Blood vessels are clearly developed
Active movements are present
Fetus makes sucking motions
Swallows amniotic fluid
Produces meconium
Fetal Development: Week 20
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Subcutaneous brown fat appears
Quickening is felt by mother
Nipples appear over mammary glands
Fetal heartbeat is heard by fetoscope
Fetal Development: Week 24
• Eyes are structurally complete
• Vernix caseosa covers skin
• Alveoli are beginning to form
Fetal Development: Week 28
• Testes begin to descend
• Lungs are structurally mature
Fetal Development: Week 32
• Rhythmic breathing movements
• Ability to partially control temperature
• Bones are fully developed but soft and flexible
Fetal Development: Week 36
• Increase in subcutaneous fat
• Lanugo begins to disappear
Fetal Development: Week 38
• Skin appears polished
• Lanugo has disappeared except in upper arms
and shoulders
• Hair is now coarse and approximately 1 inch in
length
• Fetus is flexed
Factors Influencing
Development
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Quality of sperm or ovum
Genetic code
Adequacy of intrauterine environment
Teratogens
Essential Components
of Fertility: Female
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Favorable cervical mucus
Clear passage between cervix and tubes
Patent tubes with normal motility
Ovulation and release of ova
Essential Components
of Fertility: Female (cont’d)
• No obstruction between ovary and tubes
• Endometrial preparation
• Adequate reproductive hormones
Essential Components
of Fertility: Male
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Normal semen analysis
Unobstructed genital tract
Normal genital tract secretions
Ejaculated spermatozoa deposited at the
cervix
Preliminary Investigation
of Infertility
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Ovulation
Cervix
Uterine structures
Tubal patency
Semen analysis
Figure 12–2 Sequence of events in a normal reproductive cycle showing the relationship of hormone levels to events in the ovarian and
endometrial cycles.
Treatment of Infertility
Problems
• Ovulatory:
– Pharmacologic treatment
– Donor oocytes
• Cervical:
– THI, IVF, GIFT
Treatment of Infertility
Problems (cont’d)
• Uterine/Tubal:
– IVF, GIFT
– Donor oocytes or gestational carrier
• Sperm:
– THI, IVF, GIFT
– Micromanipulation
Figure 12–8 Assisted reproductive techniques.
Physiologic and Psychological
Effects
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Marriage may be stressed
Relationship affected by intrusiveness
Guilt
Frustration
Anger
Shame
Physiologic and Psychological
Effects (cont’d)
• Loss of control
• Feelings of reduced competency and
defectiveness
• Loss of status and ambiguity as a couple
• A sense of social stigma
• Stress on the personal and sexual relationship
• A strained relationship with healthcare
providers
Nursing Management
of Infertility
• Counselor
• Educator
• Advocate
Indications for Preconceptual Genetic
Testing
• Maternal age 35 or over
• Family history:
– Known or suspected Mendelian genetic disorder
– Birth defects and/or mental retardation
Indications for Preconceptual Genetic
Testing (cont’d)
• Previous pregnancies:
– Previous child with chromosomal anomaly
– Previous child with metabolic disorder
– Two or more first trimester spontaneous abortions
Indications for Preconceptual Genetic
Testing (cont’d)
• Parental genetics:
– Couples with a balanced translocation
– Couples who are carriers for a metabolic disorder
• Abnormal MSAFP
• Women with teratogenic risk
Autosomal Dominant Disorders
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Multigenerational
50% chance of passing on the gene
Males and females equally affected
Varying degrees of presentation
Diseases
– Achondroplasia
– Marfans
– Neurofibromotosis
• Achondroplasia
– Most common dwarfism, lifespan and IQ WNL
• Marfans
– Connective tissue disorder, triad of ocular, skeletal
and CV alterations
• Neurofibromotosis (Von Recklinhausen)
– Soft tumor development of peripheral nerves
Figure 12–19 Autosomal dominant pedigree. One parent is affected. Statistically, 50% of offspring will be affected, regardless of sex.
Autosomal Recessive Disorders
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Carrier parents
25% chance of passing on abnormal gene
25% chance of an affected child
If child is clinically normal, 50% chance child is
carrier
• Males and females equally affected
• Diseases: CF, Sickle Cell, PKU, Tay Sachs
Figure 12–20 Autosomal recessive pedigree. Both parents are carriers. Statistically, 25% of offspring will be affected, regardless of sex.
X-linked Recessive
Disorders
• No male-to-male transmission
• 50% chance carrier mother will pass the
abnormal gene to sons (affected)
• 50% chance carrier mother will pass the
abnormal gene to daughters (carrier)
• Diseases: Hemophilia A, Duchennes MD,
Trisomies, Klinefelters, Turner’s Cri du chat,
Fragile X
Figure 12–21 X-linked recessive pedigree. The mother is the carrier. Statistically, 50% of male offspring will be affected, and 50% of female
offspring will be carriers.
Genetic Testing
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Genetic ultrasound
Genetic amniocentesis
Chorionic villus sampling
Percutaneous umbilical blood sampling
MSAFP
Figure 12–22 A, Genetic amniocentesis for prenatal diagnosis is done at 14 to 16 weeks’ gestation. B, Chorionic villus sampling is done at 8 to
10 weeks, and the cells are karyotyped within 48 to 72 hours.
Nurse’s Role
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Educate about tests
Provide support
Refer for counseling
Resource during and after counseling
Alcohol Use in Pregnancy
• Maternal effects:
– Malnutrition
– Bone-marrow suppression
– Increased incidence of infections
– Liver disease
• Neonatal effects:
– Fetal alcohol spectrum disorders (FASD)
Figure 19–2 Percentages of pregnant females ages 15 to 44 reporting past month alcohol use, by trimester, 2003–2004. SOURCE: Substance
Abuse and Mental Health Services Administration (SAMHSA). (2005).
Results from the 2004 National Survey on Drug Use and Health: National Findings. Office of Applied Studies, NSDUH Series H-28 DHHS
Publication No. SMA 05-4062. Rockville, MD: Author.
Cocaine Use in Pregnancy:
Maternal Effects
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Seizures and hallucinations
Pulmonary edema
Respiratory failure
Cardiac problems
Spontaneous first trimester abortion, abruptio
placentae, intrauterine growth restriction
(IUGR), preterm birth, and stillbirth
Cocaine Use in Pregnancy:
Fetal Effects
• Decreased birth weight and head
circumference
• Feeding difficulties
• Neonatal effects from breast milk:
– Extreme irritability
– Vomiting and diarrhea
– Dilated pupils and apnea
Heroin Use in Pregnancy
• Maternal effects:
– Poor nutrition and iron-deficiency anemia
– Preeclampsia-eclampsia
– Breech position
– Abnormal placental implantation
– Abruptio placentae
– Preterm labor
Heroin Use in Pregnancy
(cont’d)
• Maternal effects:
– Premature rupture of the membranes (PROM)
– Meconium staining
– Higher incidence of STIs and HIV
• Fetal effects:
– IUGR
– Withdrawal symptoms after birth
Substance Use in Pregnancy:
Maternal Effects
• Marijuana: difficult to evaluate, no known
teratogenic effects
• PCP - maternal overdose or a psychotic
response
• MDMA (Ecstasy) - long-term impaired memory
and learning
Figure 19–1 Percentages of females ages 15 to 44 reporting past month use of any illicit drugs, by pregnancy status and age, 2003–2004.
SOURCE: Substance Abuse and Mental Health Services Administration (SAMHSA). (2005). Results from the 2004 National Survey on Drug Use
and Health: National Findings. Office of Applied Studies, NSDUH Series H-28 DHHS Publication No. SMA 05-4062. Rockville, MD: Author.
Pathology of Diabetes
Mellitus (DM)
• Endocrine disorder of carbohydrate
metabolism
• Results from inadequate production or
utilization of insulin
• Cellular and extracellular dehydration
• Breakdown of fats and proteins for energy
Gestational Diabetes (GDM)
• Carbohydrate intolerance of variable severity
• Causes:
– An unidentified preexistent disease
– The effect of pregnancy on a compensated
metabolic abnormality
– A consequence of altered metabolism from
changing hormonal levels
Effect of Pregnancy on
Carbohydrate Metabolism
• Early pregnancy:
– Increased insulin production and tissue sensitivity
• Second half of pregnancy:
– Increased peripheral resistance to insulin
Maternal Risks with DM
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Hydramnios
Preeclampsia-eclampsia
Ketoacidosis
Dystocia
Increased susceptibility to infections
Fetal and Neonatal Risks
with DM
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Perinatal mortality
Congenital anomalies
Macrosomia
IUGR
RDS
Polycythemia
Fetal and Neonatal Risks
with DM (cont’d)
• Hyperbilirubinemia
• Hypocalcemia
Screening for DM
in Pregnancy
• Assess risk at first visit:
– Low risk - screen at 24 to 28 weeks
– High risk - screen as early as feasible
Risk Factors
• Age over 40
• Family history of diabetes in a first-degree
relative
• Prior macrosomic, malformed, or stillborn
infant
• Obesity
• Hypertension
• Glucosuria
Screening Tests
• One-hour glucose tolerance test:
– Level greater than 130-140 mg/dl requires further
testing
• 3-hour glucose tolerance test:
– GDM diagnosed if 2 levels are exceeded
Treatment Goals
• Maintain a physiologic equilibrium of insulin
availability and glucose utilization
• Ensure an optimally healthy mother and
newborn
• Treatment:
– Diet therapy and exercise
– Glucose monitoring
– Insulin therapy
Figure 19–4 The nurse teaches the pregnant woman with gestational diabetes mellitus how to do home glucose monitoring. SOURCE:
Photographer, Jenny Thomas.
Fetal Assessment
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AFP
Fetal activity monitoring
NST
Biophysical profile
Ultrasound
Nursing Management
• Assessment of glucose
• Nutrition counseling
• Education about the disease process and
management
• Education about glucose monitoring and
insulin administration
• Assessment of the fetus
• Support
Iron-deficiency Anemia
• Maternal complications:
– Susceptible to infection
– May tire easily
– Increased chance of preeclampsia and postpartal
hemorrhage
– Tolerates poorly even minimal blood loss during
birth
Iron-deficiency Anemia
(cont’d)
• Fetal complications:
– Low birth weight
– Prematurity
– Stillbirth
– Neonatal death
Iron Deficiency Anemia
(cont’d)
• Prevention and treatment:
– Prevention - at least 27 mg of iron daily
– Treatment - 60-120 mg of iron daily
Folate Deficiency
• Maternal complications:
– Nausea, vomiting, and anorexia
• Fetal complications:
– Neural tube defects
• Prevention - 4 mg folic acid daily
• Treatment - 1 mg folic acid daily plus iron
supplements
Sickle Cell Anemia
• Maternal complications:
– Vaso-occlusive crisis
– Infections
– Congestive heart failure
– Renal failure
Sickle Cell Anemia
(cont’d)
• Fetal complications include fetal death,
prematurity, and IUGR.
• Treatment:
– Folic acid
– Prompt treatment of infections
– Prompt treatment of vaso-occlusive crisis
Thalassemia
• Treatment:
– Folic acid
– Transfusion
– Chelation
HIV in Pregnancy
• Asymptomatic women - pregnancy has no
effect
• Symptomatic with low CD4 count - pregnancy
accelerates the disease
• Zidovudine (ZDV) therapy diminishes risk of
transmission to fetus
• Transmitted through breast milk
• Half of all neonatal infections occurs during
labor and birth
HIV in Pregnancy:
Maternal Risks
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Intrapartal or postpartal hemorrhage
Postpartal infection
Poor wound healing
Infections of the genitourinary tract
HIV Effects on Fetus
• Infants will often have a positive antibody titer
• Infected infants are usually asymptomatic but
are likely to be:
– Premature
– Low birth weight
– Small for gestational age (SGA)
Treatment During
Pregnancy
• Counsel about implications of diagnosis on
pregnancy:
– Antiretroviral therapy
– Fetal testing
– Cesarean birth
Cardiac Disorders
in Pregnancy
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Congenital heart disease
Marfan syndrome
Peripartum cardiomyopathy
Eisenmenger syndrome
Mitral valve prolapse
Less Common Medical
Conditions in Pregnancy
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Rheumatoid arthritis
Epilepsy
Hepatitis B
Hyperthyroidism
Hypothyroidism
Maternal phenylketonuria
Less Common Medical
Conditions in Pregnancy (cont’d)
• Multiple sclerosis
• Systemic lupus erythematosus
• Tuberculosis
Chapter 20
Pregnancy at Risk:
Gestational Onset
Spontaneous Abortion
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Threatened abortion
Imminent abortion
Incomplete abortion
Complete abortion
Figure 20–1 Types of spontaneous abortion. A, Threatened. The cervix is not dilated, and the placenta is still attached to the uterine wall, but
some bleeding occurs. B, Imminent. The placenta has separated from the uterine wall, the cervix has dilated, and the amount of bleeding has
increased. C, Incomplete. The embryo/fetus has passed out of the uterus; however, the placenta remains.
Figure 20–1 (continued) Types of spontaneous abortion. A, Threatened. The cervix is not dilated, and the placenta is still attached to the
uterine wall, but some bleeding occurs. B, Imminent. The placenta has separated from the uterine wall, the cervix has dilated, and the amount
of bleeding has increased. C, Incomplete. The embryo/fetus has passed out of the uterus; however, the placenta remains.
Figure 20–1 (continued) Types of spontaneous abortion. A, Threatened. The cervix is not dilated, and the placenta is still attached to the
uterine wall, but some bleeding occurs. B, Imminent. The placenta has separated from the uterine wall, the cervix has dilated, and the amount
of bleeding has increased. C, Incomplete. The embryo/fetus has passed out of the uterus; however, the placenta remains.
Spontaneous Abortion
(cont’d)
• Missed abortion
• Recurrent pregnancy loss
• Septic abortion
Spontaneous Abortion:
Treatment
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Bed rest
Abstinence from coitus
D&C or suction evacuation
Rh immune globulin
Spontaneous Abortion:
Nursing Care
• Assess the amount and appearance of any
vaginal bleeding
• Monitor the woman’s vital signs and degree of
discomfort
• Assess need for Rh immune globulin.
• Assess fetal heart rate
• Assess the responses and coping of the
woman and her family
Ectopic Pregnancy:
Risk Factors
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Tubal damage
Previous pelvic or tubal surgery
Endometriosis
Previous ectopic pregnancy
Presence of an IUD
High levels of progesterone
Ectopic Pregnancy:
Risk Factors (cont’d)
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Congenital anomalies of the tube
Use of ovulation-inducing drugs
Primary infertility
Smoking
Advanced maternal age
Ectopic Pregnancy:
Treatment
• Methotrexate
• Surgery
Figure 20–2 Various implantation sites in ectopic pregnancy. The most common site is within the fallopian tube, hence the name “tubal
pregnancy.”
Ectopic Pregnancy:
Nursing Care
• Assess the appearance and amount of vaginal
bleeding
• Monitors vital signs
• Assess the woman’s emotional status and
coping abilities
• Evaluate the couple’s informational needs.
• Provide post-operative care
Gestational Trophoblastic
Disease: Symptoms
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Vaginal bleeding
Anemia
Passing of hydropic vesicles
Uterine enlargement greater than expected
for gestational age
• Absence of fetal heart sounds
• Elevated hCG
Gestational Trophoblastic
Disease: Symptoms
• Low levels of MSAFP
• Hyperemesis gravidarum
• Preeclampsia
Gestational Trophoblastic
Disease: Treatment
• D&C
• Possible hysterectomy
• Careful follow-up
Figure 20–3 Hydatidiform mole. A common sign is vaginal bleeding, often brownish (the characteristic “prune juice” appearance) but
sometimes bright red. In this figure, some of the hydropic vessels are being passed. This occurrence is diagnostic for hydatidiform mole.
Gestational Trophoblastic
Disease: Nursing Care
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Monitor vital signs
Monitor vaginal bleeding
Assess abdominal pain
Assess the woman’s emotional state and
coping ability
Bleeding Disorders
• Placenta previa - placenta is improperly
implanted in the lower uterine segment
• Abruptio placentae - premature separation of
a normally implanted placenta from the
uterine wall
Cervical Incompetence:
Treatment
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Serial cervical ultrasound assessments
Bed rest
Progesterone supplementation
Antibiotics
Anti-inflammatory drugs
Cerclage procedures
Figure 20–4 A cerclage or purse-string suture is inserted in the cervix to prevent preterm cervical dilatation and pregnancy loss. After
placement, the string is tightened and secured anteriorly.
Hyperemesis Gravidarum:
Treatment
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Control vomiting
Correct dehydration
Restore electrolyte balance
Maintain adequate nutrition
Hyperemesis Gravidarum:
Nursing Care
• Assess the amount and character of further
emesis
• Assess intake and output and weight.
• Assess fetal heart rate
• Assess maternal vital signs
• Observe for evidence of jaundice or bleeding
• Assess the woman’s emotional state
Nursing Care of Clients
with PROM
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Determine duration of PROM
Assess gestational age
Observe for signs and symptoms of infection
Assess hydration status
Assess fetal status
Assess childbirth preparation and coping
Nursing Clients
with PROM (cont’d)
• Encourage resting on left side
• Provide comfort measures
• Provide education
Nursing Care of Clients
with Preterm Labor
• Identify risk for preterm labor
• Assess change in risk status for preterm labor
• Assess educational needs of the woman and
her loved ones
• Assess the woman’s responses to medical and
nursing intervention
• Teach about the importance of recognizing the
onset of labor
Signs and Symptoms of
Preterm Labor
• Uterine contractions occurring every 10
minutes or less
• Mild menstrual like cramps felt low in the
adbomen
• Constant or intermittent feeling of pelvic
pressure
• Rupture of membranes
• Low, dull backache, which may be constant or
intermittent
Signs and Symptoms of
Preterm Labor (cont’d)
• A change in vaginal discharge
• Abdominal cramping with or without diarrhea
Classification of
Hypertension in Pregnancy
• Preeclampsia-eclampsia
• Chronic hypertension
• Chronic hypertension with superimposed
preeclampsia
• Gestational hypertension
Characteristics of
Preeclampsia
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Maternal vasospasm
Decreased perfusion to virtually all organs
Decrease in plasma volume
Activation of the coagulation cascade
Alterations in glomerular capillary
endothelium
• Edema
Characteristics of
Preeclampsia (cont’d)
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Increased viscosity of the blood
Hyperreflexia
Headache
Subcapsular hematoma of the liver
Figure 20–7 A, In a normal pregnancy, the passive quality of the spiral arteries permits increased blood flow to the placenta. B, In
preeclampsia, vasoconstriction of the myometrial segment of the spiral arteries occurs.
Figure 20–7 (continued) A, In a normal pregnancy, the passive quality of the spiral arteries permits increased blood flow to the placenta. B, In
preeclampsia, vasoconstriction of the myometrial segment of the spiral arteries occurs.
Hypertensive Effects
on Fetus
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Small for gestational age
Fetal hypoxia
Death related to abruption
Prematurity
Home Management
• Monitoring for signs and symptoms of
worsening condition
• Fetal movement counts
• Frequent rest in the left lateral position
• Monitoring of blood pressure, weight, and
urine protein daily
• NST
• Laboratory testing
Management of Severe
Preeclampsia
•
•
•
•
•
•
Bed rest
High-protein, moderate-sodium diet
Treatment with magnesium sulfate
Corticosteroids
Fluid and electrolyte replacement
Antihypertensive therapy
Signs and Symptoms
of Eclampsia
•
•
•
•
•
•
Scotomata
Blurred vision
Epigastric pain
Vomiting
Persistent or severe headache
Neurologic hyperactivity
Signs and Symptoms
of Eclampsia (cont’d)
• Pulmonary edema
• Cyanosis
Management of Eclampsia
•
•
•
•
•
•
Assess characteristics of seizure
Assess status of the fetus
Assess for signs of placental abruption
Maintain airway and oxygenation
Position on side to avoid aspiration
Suction to keep the airway clear
Management of Eclampsia
(cont’d)
• To prevent injury, raise padded side rails
• Administer magnesium sulfate
Rh Incompatibility
•
•
•
•
•
Rh – mother, Rh + fetus
Maternal IgG antibodies produced
Hemolysis of fetal red blood cells
Rapid production of erythroblasts
Hyperbilirubinemia
Figure 20–10 Rh alloimmunization sequence. A, Rh-positive father and Rh-negative mother. B, Pregnancy with Rh-positive fetus. Some Rhpositive blood enters the mother’s blood. C, As the placenta separates, the mother is further exposed to the Rh-positive blood. D, The mother is
sensitized to the Rh-positive blood; anti-Rh-positive antibodies (triangles) are formed. E, In subsequent pregnancies with an Rh-positive fetus,
Rh-positive red blood cells are attacked by the anti-Rh-positive maternal antibodies, causing hemolysis of red blood cells in the fetus.
Administration of
Rh Immune Globulin
•
•
•
•
•
After birth of an Rh+ infant
After spontaneous or induced abortion
After ectopic pregnancy
After invasive procedures during pregnancy
After maternal trauma
ABO Incompatibility
• Mom is type O
• Infant is type A or B
• Maternal serum antibodies are present in
serum
• Hemolysis of fetal red blood cells
Surgery During Pregnancy
• Incidence of spontaneous abortion is increased in
first trimester
• Insert nasogastric tube prior to surgery
• Insert indwelling catheter
• Encourage patient to use support stockings
• Assess fetal heart tones
• Position to maximize utero-placental circulation
Trauma During Pregnancy
• Greater volume of blood loss before signs of
shock
• More susceptible to hypoxemia with apnea
• Increased risk of thrombosis
• DIC
• Traumatic separation of placenta
• Premature labor
Battering During Pregnancy
•
•
•
•
•
•
Psychological distress
Loss of pregnancy
Preterm labor
Low-birth-weight infants
Fetal death
Increased risk of STIs
Perinatal Infections
•
•
•
•
•
•
Toxoplasmosis
Rubella
Cytomegalovirus
Herpes simplex virus
Group B streptococcus
Human B-19 parvovirus
Fetal Risks: Toxoplasmosis
•
•
•
•
•
Retinochoroiditis
Convulsions
Coma
Microcephaly
Hydrocephalus
Fetal Risks: Rubella
• Congenital cataracts
• Sensorineural deafness
• Congenital heart defects
Fetal Risks: Chlamydia
•
•
•
•
•
•
Neurologic complications
Anemia
Hyperbilirubinemia
Thrombocytopenia
Hepatosplenomegaly
SGA
Fetal Risks: Herpes
• Preterm labor
• Intrauterine growth restriction
• Neonatal infection
Fetal Risks: GBS
•
•
•
•
•
Respiratory distress or pneumonia
Apnea
Shock
Meningitis
Long-term neurologic complications
Fetal Risks: Human
B-19 Parvovirus
• Spontaneous abortion
• Fetal hydrops
• Stillbirth
Resources
• HELLP Syndrome Society
This website offers information on HELLP syndrome
and patient support. It also promotes research to
assist prevention and treatment of this disease.
• Preeclampsia
The Preeclampsia Foundation is a nonprofit
organization dedicated to funding research, raising
public awareness, and providing support and
education to patients diagnosed with preeclampsia.
Resources
• Group B Streptococcal Infection
The CDC offers guidelines for providing care to
the patient with group B strep and
professional resources.
• Bleeding Disorders in Pregnancy
OBGYN.net provides an ultrasound image
collection of bleeding disorders in pregnancy.
Resources
• Herpes in Pregnancy
Herpes.com provides information about how
herpes affects pregnancy.
• Gestational Trophoblastic Disease
The American Cancer Society provides
information about gestational trophoblastic
disease including symptoms, detection, and
treatment.
Resources
• Hyperemesis Education and Research Organization
This site provides a wealth of information and
support to patients suffering with hyperemesis
gravidarum and healthcare professional information
as well. The site is well researched and offers
information written by medical professionals.
• Preterm Labor
Sidelines.org is a site provided to support those
experiencing a high-risk pregnancy.
Nurse’s Role in Pain Relief
• Support decision for pharmaceutical pain
relief
• Offer alternative therapies if pharmaceuticals
not desired
• Support changes in decision
• Educate about options
• Reassure that accepting medication for pain is
not failure
Systemic Analgesia
Common indications for medications
Systemic Analgesia
• Goal is to provide maximum pain relief with
minimal risk
• Alteration in maternal state affects fetus
Administration of
Systemic Analgesia
•
•
•
•
•
When woman is uncomfortable
Well-established labor pattern
Contractions occurring regularly
Significant duration of contractions
Moderate to strong intensity
Maternal Assessments
•
•
•
•
The woman is willing to receive medication
Vital signs are stable
Contraindications are not present
Knowledge of other medications being
administered
Fetal Assessments
•
•
•
•
Fetal heart rate between 110 and 160 bpm
Reactive nonstress test
Short-term variability is present
Long-term variability is average
Assessment of
Labor Progress
•
•
•
•
Contraction pattern
Cervical dilatation
Fetal presenting part
Station of the fetal presenting part
Nursing Considerations
• Record the drug name, dose, route, site on
EFM strip and chart
• Record the woman’s blood pressure and pulse
(before and after) on the EFM strip and chart
• Safety precautions
– Raising the side rails
– Assessment of the FHR
Sedatives
• Use: early latent phase
• Purpose: relaxation and sleep
• Common medications - Seconal and Ambien
H1-receptor antagonists
• Use - Early latent phase
• Purpose - Sedative, antiemetic
• Common medications - Phenergan, Vistaril,
Bendadryl
Narcotics
• Use: active phase
• Purpose - pain management
• Common medications - Stadol, Nubain,
Demerol
• Narcotic antagonist - Narcan
Regional Anesthesia
• Temporary and reversible loss of sensation
• Prevents initiation and transmission of nerve
impulses
• Types
– Epidural
– Spinal
– Combined epidural-spinal
Epidural: Advantages
• Produces good analgesia
• Woman is fully awake during labor and birth
• Continuous technique allows different
blocking for each stage of labor
• Dose of anesthetic agent can be adjusted
Epidural: Disadvantages
•
•
•
•
•
•
Maternal hypotension
Postdural puncture seizures
Meningitis
Cardiorespiratory arrest
Vertigo
Onset of analgesia may not occur for up to 30
minutes
Spinal Block: Advantages
•
•
•
•
Immediate onset of anesthesia
Relative ease of administration
Smaller drug volume
Maternal compartmentalization of the drug
Spinal Block: Disadvantages
• High incidence of hypotension
• Greater potential for fetal hypoxia
• Uterine tone is maintained, making
intrauterine manipulation difficult
• Short acting
Combined Spinal-Epidural:
Advantages
• Spinal agent has a faster onset
• Medication can be added to increase the
effectiveness
• Preserves motor functioning
• Most drugs are used in low dose
Combined Spinal-Epidural: Disadvantages
• Higher incidence of nausea and pruritus
Pudendal
• Perineal anesthesia for the second stage of
labor, birth, and episiotomy repair
• Advantages are ease of administration and
absence of maternal hypotension
• Urge to bear down may be decreased
Figure 25–7 A, Pudendal block by the transvaginal approach. B, Area of perineum affected by pudendal block.
Figure 25–7 (continued) A, Pudendal block by the transvaginal approach. B, Area of perineum affected by pudendal block.
Local
• Used for episiotomy repair
• Advantage is that it involves the least amount
of anesthetic agent
• The major disadvantage is that large amounts
of solution must be used
Nursing Management:
Prior to Administration
•
•
•
•
Assess maternal and fetal status
Assess labor progress
Start an IV and administer preload
Help woman into position
Nursing Management:
After Administration
•
•
•
•
•
•
Monitor maternal and fetal vital signs
Assess for hypotension
Tale corrective measures for hypotension
Administer antiemetics as needed
Monitor respiratory rate
Assess bladder and catheterize if unable to
void
Complications of
Epidural Anesthesia
• Toxic reactions
– Unintentional placement of the drug
– Excessive amount of the drug
– Accidental intravascular injection
• Spinal headaches
Complications of
Spinal Anesthesia
•
•
•
•
•
•
Hypotension
Drug reaction
Total spinal neurologic sequelae
Spinal headache
Nausea, shivering, and urinary retention
Ineffective anesthesia
Complications of
Pudendal Anesthesia
•
•
•
•
Systemic toxic reaction
Broad ligament hematoma
Perforation of the rectum
Trauma to the sciatic nerve
Methods of General
Anesthesia
• Intravenous injection
– Sodium thiopental (Pentothal)
– Ketamine
• Inhalation of anesthetic agents
– Nitrous Oxide
– Low-dose halogenated agents
Complications of
General Anesthesia
• Fetal depression
– Depth and duration
• Uterine relaxation
• Potential for chemical pneumonitis
– Decrease in gastrointestinal motility
– Acidic gastric secretions
Contraindications
• Preterm infant
– Avoid analgesia during labor
• Preeclampsia
– Regional anesthesia is preferred
– General anesthesia may aggravate hypertension
Contraindications
(continued)
• Diabetes
– Potential for decreased uteroplacental flow due to
hypotension
– Increased risk of cardiovascular depression with
regional
• Cardiac
– Continuous epidural avoids cardiovascular
changes with bearing down
Contraindications
(continued)
• Bleeding
– Regional blocks are contraindication due to
reduction in volume