Nursing 353
Maternal Risk Factors
Fetal Assessment
February 3rd, 2005
High Risk Pregnancy
The life or health of the mother or fetus is
jeopardized
 Examples include:

– GDM
– Previous loss
– AMA
– HTN
– Abnormalities with the neonate
Perinatal Mortality
Overall maternal deaths are small
 Many deaths a preventable
 Education and prenatal care are very
important

Antepartum Testing


FKCs BID
UTZ
–
–
–
–
–
–
–
–
–
–
FHR
Gestation age
Abnormalities
IUGR
Placental location and quality
AFI
Position
BPP
Doppler flow
Fetal growth
Ultrasound
Can be done abdominally or transvaginally
 1st trimester done to detect viability,
calculate EDC
 2nd trimester done to detect anomalies,
calculate EDC
 3rd trimester done to do BPP, fetal growth
and well-being, AFI

Doppler Flow Analysis via UTZ
Study blood blow in the fetus and placenta
 Done on high risk mothers:

– IUGR
– HTN
– DM
– Multiple gestation
AFI

Polyhydramnios – too much amniotic fluid

Oligohydramnios – too little amniotic fluid
Biophysical Profile

Includes 5 components:
– Fetal breathing movements
– Gross body movements
– Fetal tone
– AFI
– NST - reactive
Amniocentesis
Used with direct ultrasound
 Less than 1% result in complications

– Complications include:
 Fetal death, miscarriage
 Maternal hemorrhage
 Infection to fetus
 Preterm labor
 Leakage of amniotic fluid
Meconium
Visual inspection of amniotic fluid
 Meconium is defined as thin and thick and
particulate
 Associated with fetal stress: hypoxia,
umbilical cord compression

CVS
Done between 9 -12 weeks
 Genetic studies
 Removal of small amount of tissue from
the fetal portion of the placenta
 Complications: vaginal spotting,
miscarriage, ROM, chorioamnionitis
 If done prior to 10 weeks, increased risk
of limb anomalies

AFP
Genetic test
 Done with mothers blood
 16-20 weeks gestation
 Mandated by state of California

EFM
Third trimester goal is to continue to
observe the fetus within the intrauterine
environment
 Goal: dx uteroplacental insufficiency
 NST vs. CST

NST
90% of gross fetal body movements are
associated with accelerations of the FHR
 Can be performed outpatient
 Not as sensitive
 User friendly but must interpret strip
 Fetus may be in a sleep state or affected
by maternal medications, glucose etc.

NST
To be reactive must meet criteria
 Must be at least 20 minutes in length
 Must have 2 or more accelerations that
meet the ’15 X 15’ criteria
 Must have a normal baseline
 Must have LTV

NST

To stimulate a fetus that is not meeting
criteria:
– Change positions of the mother – LS, RS
– Increase fluids
– Acoustic stimulator
CST
Done in the inpatient setting only!
 Has contraindications
 May be expensive if meds/IV needed
 Monitored for 10 minutes first
 Then may use nipple stimulation or
oxytocin stimulation
 No late decelerations than negative CST

CST
Endocrine and Metabolic Disorders
#1 Diabetes Mellitus
 Disorders of the thyroid
 Hyperemesis

Diabetes
Hyperglycemia
 May be due to inadequate insulin action or
due to impaired insulin secretion
 Type 1 – insulin deficiency
 Type 2 – insulin resistance
 GDM – glucose intolerance during
pregnancy

DM
10th week fetus produces it own insulin
 Insulin does not cross the placental barrier
 Glucose levels in the fetus and directly
proportional to the mother
 2nd and 3rd trimesters – decreased
tolerance to glucose, increased insulin
resistance, increased hepatic function of
glucose

Diabetic Nephropathy

Increased risks for:
– Preeclampsia
– IUGR
– PTL
– Fetal distress
– IUFD
– Neonatal death
DM
Poor glycemic control is associated with
increased risks of miscarriage at time of
conception
 Poor glycemic control in later part of
pregnancy is assoc. with fetal macrosomia
and polyhydramnios

Polyhydramnios

May compress on the vena cava and aorta
causing hypotension, PROM, PP
hemorrhage, maternal dyspnea
Macrosomia
Disproportionate increase in shoulder and
trunk size
 4000-4500gms or greater
 Fetus will have excess stores of glycogen
 Increased risks of

– Shoulder dystocia
– C/S
– Assisted deliveries
IUGR
Compromised uteroplacental insufficiency
 02 available to the fetus is decreased

RDS
Increased RDS due to high glucose levels
 Delays pulmonary maturity

Neonatal Hypoglycemia
Usually 30-60 minutes after birth
 Due to high glucose levels during
pregnancy and rapid use of glucose after
birth
 Related to mothers level of glucose control

Labs with DM
HBA1c
 1 hour PP
 FBS

Diet
Sweet success diet
 Well balanced diet
 6 small meals / day
 Have snack at HS
 Never skip meals
 Avoid simple sugars

Insulin
Regular/Lispro and NPH
 2/3 dose in am and 1/3 dose in pm

Monitoring Glucose Levels
FBS
 1 hour PP
 HS
 5 checks / day

Fetal Surveillance

NSTs done around 26 weeks, weekly

At 32 weeks done biweekly with NST/BPP
Infections and DM

Infections are increased:
– Candidiasis
– UTIs
– PP infections
DM
Increased risk of IUFD after 36 weeks
 Increased congenital anomalies

– Cardiac defects
– CNS defects
 Spina bifida
 anencephaly
– Skeletal defects
DM and labor
Continuous fetal monitoring
 Blood glucose levels in tight control
 Be prepared for CPD

GDM
Women with GDM at risk of developing
DM later on in life
 NSTs around 28 weeks

Hyperthyroidism
Typically caused by Grave’s disease
 S/S:

– Fatigue
– Heat intolerance
– Warm skin
– Diaphoresis
– Weight loss
Should be treated in pregnancy
 Tx with PTU
 Beta blockers
 May lead to thyroid storm if untreated

Hypothyroidism
Usually caused by Hashimoto’s
 S/S:

– Weight gain
– Cold intolerance
– Fatigue
– Hair loss
– Constipation
– Dry skin
Tx with thyroid hormones such as
synthroid or levothyroxine
 Maintain TSH wnl
 Checked periodically throughout the
pregnancy

Cardiovascular Disorders
The heart must compensate for the
increased workload
 If the cardiac changes are not well
tolerated than cardiac failure can develop
 1% of pregnancies are complicated by
heart disease

NY Heart Association Classes
Class
 Class
 Class
 Class

I
II
III
IV
Cardiac output is increased
 Peak of the increase 20-24 weeks
gestation
 Cardiac problems should be managed with
cardiologist
 Mortality with pulmonary hypertension and
pregnancy is more than 50%
 Diet: low sodium

Nursing Care
Avoiding anemia
 Avoid strenuous activity
 Monitor for: cardiac failure and pulmonary
congestion

During Labor
Side lying position
 Prophylactic antibiotic
 Epidural
 Attempt vaginal delivery
 If anticoagulant therapy is needed:

– Heparin
– Lovenox
MVP
Common and usually benign
 May experience syncope, palpitations and
dyspnea
 Prophylactic antibiotics given before
invasive procedure or birth

Anemia
Most common iron deficiency
 Hgb falls below 12 (most labs)
 Typically seen in the end of 2nd trimester
 Iron supplementation

Folic Acid Deficiency Anemia
Increases risk of NTD, cleft lip
 Recommended dose 400 mcg/day
 Supplemented in cereal and many other
foods

Sickle Cell Anemia
Abnormal hemoglobin SS types in the
blood
 People have recurrent attacks of fever and
pain in the abdomen and extremities
 Caused from tissue hypoxia, edema
 African-Americans

Sickle Cell Trait
Typically asymptomatic
 Sickling of the RBCs but with a normal
RBC life span

Thalassemia
Common anemia
 Insufficient amount of Hgb is produced to
fill the RBCs
 Mediterranean region
 Genetic disorder
 May be associated with LBW babies and
increased fetal death

Asthma
Common with FH
 1-4% of pregnant women have Asthma
 Possible adverse events associated with
asthma:

– LBW
– Perinatal mortality
– Preeclampsia
– Complicated labor
– Hyperemesis
Asthma Continued
Goal is to relieve the attack, prevent the
asthma attack, and maintain 02
 Should be managed with OB and ENT
 May require tx: albuterol, steroids, O2

Epilepsy
Seizure disorder
 May result from developmental
abnormalities or injury
 20% have an increase in seizure activity
during pregnancy
 Risks: more seizures, risk of vaginal
bleeding, abruptio placentae, fetus may
experience seizures

Epilepsy Continued
Use of antiepeleptic meds during
pregnancy has been linked to risks for the
fetus
 Smallest therapeutic dose to be given
 Daily folic acid supplementation
 Managed with OB and neurologist

RA
Chronic arthritis
 Pain upon movement and swelling in joint
spaces
 More often in women
 2/3 of women with RA find the severity of
symptoms decrease during pregnancy
 Typically give baby ASA

SLE
Inflammatory disease, autoimmune
antibody production
 Advised to wait until in remission for 6
months to become pregnant
 15-60% of women will develop
exacerbation of SLE during pregnancy or
postpartum
 Tx: ASA and steroids

Cholelithiasis
More often in women
 Pregnancy makes women more vulnerable
 Surgery often delayed until after delivery

Appendicitis
Dx may take more time to find
 Sxs: abdominal pain, nausea, vomiting,
loss of appetite
 Increases incidence of PTL or SAB

Maternal Infections
TORCH
Toxoplasmosis – protozoan infection,
neonatal effects – jaundice,
hydrocephalus, microcephaly
 Other- Heb A or B, Group B, Varicella, HIV
 Rubella (German measles) – if contracted
in 1st Trimester fetus may have congenital
deformities

TORCH
CMV- transmitted person to person, may
cause CNS damage to fetus
 Herpes Simplex (HSV 2) – if initial
infection occurs in pregnancy, higher
incidence of perinatal loss. Fetus may pick
up virus if present in the vagina during
labor

Mental Health Disorders
Anxiety Disorders
Most common mental disorders
 Include: phobias, panic disorders, OCD,
PTSD
 Tx: relaxation techniques, breathing
exercises, imagery

Depression in Pregnancy
6% of women develop depression for the
1st time during pregnancy
 Tx: counseling and tx with SSRIs
 Wellbutrin only med named as Category B
 Many women opt to DC meds during
pregnancy

Substance Abuse in
Pregnancy
Substance Abuse
Damaging effects well documented in
research to fetus
 Any use of ETOH or illicit drugs during
pregnancy is considered abuse
 31% of women had used one or more
substances during pregnancy (as
compared to 62% during prepregnancy)

Smoking

Risks of any amount of smoking include:
– SAB
– SGA
– Bleeding
– IUFD
– Prematurity
– SIDS
Alcohol
Many women reluctant to tell health care
provider
 Risks:

– LBW
– Mental retardation
– Learning and physical deficits
– With FAS – severe facial deformities
Alcohol during Pregnancy

Risks to mother:
– HTN
– Anemia
– Nutritional deficits
– Pancreatitis
– Cirrhosis
– Alcoholic hepatitis
Marijuana
Crosses the placenta and causes increased
carbon monoxide levels in mother’s blood
 May cause fetal abnormalities

Cocaine
In the US, 10-15% of all pregnant women
use cocaine
 Problems associated with use: polydrug
use, poor health, poor nutrition, STIs,
infections, HIV
 Poverty big issue

Cocaine in Pregnancy

Maternal effects:
–
–
–
–
–
–
–
–
–
Cardiovascular stress
Tachycardia
HTN
Dysrhythmias
MI
Liver damage
Sz
Pulmonary disease
Death

Fetal Complications:
–
–
–
–
Abruptio placentae
PTL
Precipitous labor
Risks for abdominal
pregnancy
– Fetal complications
after delivery
Opiates in Pregnancy
Drugs include: heroin, Demerol, morphine,
codeine, methadone
 Methadone is used to treat addiction to
other opiates
 Possible effects on pregnancy and heroin
use are: Preeclampsia, PROM, infections,
PTL
 Tx: Methadone and psychotherapy
 Goal: prevent withdrawal symptoms

Methamphetamine
CNS stimulant
 Most common use n the 18-30 yr old
range
 Neonatal complications include:

– IUGR
– PRL/PTB
Postpartum Psychologic
Complications
Baby Blues
Usually within 4 weeks of childbirth
 Many experience this

PPD
Intense sadness, crying all the time, mood
swings, fears, anger, anxiety, irritability
 Incidence of PPD at 8 weeks – 12% and
8% at 12 weeks
 Many women feel guilty
 May need tx but usually resolves on own

Postpartum Psychosis
Delusions, hurting self or the infant,
emotional lability, insomnia,
suspiciousness, confusion, obsessive
concerns regarding the baby
 1-2/1000 births
 35-60% recurrence with each subsequent
birth
 Usually symptoms appear within 8 weeks
of birth

Medical Management
Supportive family
 Intense psychotherapy
 Emergency
 Tx: SSRIs
 SSRIs contraindicated while breastfeeding


1. A client asks the nurse to again explain
the purpose of the amniocentesis test.
The nurse responds that one purpose of
this test is to indicate the:
– A.
– B.
– C.
– D.
– E.
Accurate age of the fetus
Presence of certain congenital anomalies
Biparietal diameter of the skull
Hormone content of the amniotic fluid
Mainly the presence of Down’s syndrome

2. The nurse explains to a new mother
that the condition of SGA is caused by:
– A.
– B.
– C.
– D.
Placental insufficiency
Maternal obesity
Primipara
Genetic predisposition

3. A pregnant client with diabetes is controlled
by insulin. When she asks the nurse what will
happen to her insulin requirements during
pregnancy, the correct response is:
– A. “Because your case is so mild, you are likely not to
need much insulin during your pregnancy”
– B. “It’s likely that as the pregnancy progresses you
will need increased insulin”
– C. “Every case is individual so there is really no way
to know”
– D. “If you follow the diet closely and don’t gain too
much weight, your insulin needs should stay the
same”

4. The nurse in the newborn nursery
understands that assessing a newborn
with a diabetic mother, initially the insulin
level would be:
– A.
– B.
– C.
– D.
Higher than in normal infants
Lower than in normal infants
The same as in normal infants
Varied from baby to baby

5. A client is admitted to L&D, at 38
weeks gestation. She is there for
evaluation because she is experiencing
polyhydramnios. The nurse understands
that this diagnosis means that:
– A. There is the normal amount of amniotic
fluid, thinner in volume
– B. A less-than-normal amount of amniotic
fluid is present
– C. An excessive amount of amniotic fluid is
present
– D. A leak is causing the fluid to accumulate
outside the amniotic sac