Chapter 7
Conception and Development of the
Embryo and Fetus
Basic Concepts of Inheritance
Human Genome Project (1990)
Chromosomes
• 23 matched pairs
DNA
Genes
Cellular Division
• Gametes
• Ova—female gamete
• Sperm—male gamete
• Gametogenesis
• Meiosis
• Mitosis
Inheritance of Disease
Multifactorial
• Genetic and environmental factors
• Examples: cleft lip, neural tube defects
Unifactorial
• Single gene inheritance
• Examples: autosomal dominant, autosomal
recessive, X-linked disorders
Mendelian Inheritance
• Autosomal Dominant
• Affected person has
affected parent
• 50% chance of
passing the trait
• Males & females
equally affected--dad
can pass to son
• Autosomal Recessive
• Can have clinically
normal parents, but both
parents must be carriers
• 25% chance of affected
child
• 50% chance child is
carrier
• Males & females affected
equally
X Linked Inheritance
X-Linked Recessive
• No male to male
transmission
• 50% chance carrier mom
passes to son who will be
affected
• 50% chance carrier mom
passes to daughters who
become carriers
• Affected dads cannot pass
to sons, but all daughters
are carriers
X-Linked Dominant
(Extremely rare)
• Fragile X syndrome
• Heterozygous females
may be affected
• No male to male
transmission
• Affected fathers will
have affected
daughters, but no
affected sons
Nursing Responsibilities
 Assess for signs and
symptoms of genetic
disorders
 Offer support
 Assist in value
clarification
 Educate on procedures
and tests
Assessing for Genetic Disorders
• Chorionic villi sampling (CVS)
• Biopsy & chromosomal analysis of chorionic villi
of placenta (transvaginal or abdominally)
• 8-12 weeks (earlier than amnio)
• Risks
•
•
•
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Limb reduction syndrome
Excessive bleeding & pregnancy loss
Infection
Rh-Negative mom needs RhoGAM
• Advantages: 1st trimester,highly accurate, quicker results
than amnio
Assessing for Genetic Disorders
Ultrasound--best between 16-20 weeks
• Detect head and craniospinal defects: anencephaly,
microcephaly, hydrocephalus
• GI malformations: omphalocele, gastroschisis
• Renal malformations: dysplasia or obstruction
• Skeletal malformations: caudal regression, conjoined
twins
• Fetal nuchal translucency: 10-13 weeks
Assessing for Genetic Disorders
• Amniocentesis: 15 - 20 wks
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Risks: miscarriage, bleeding, infection
Maternal age ≥ 35
Hx of child with chromosomal abnormality
Parent carrying chromosomal abnormality
Mother carrying x-linked disease
Parent with in-born error of metabolism
Both parents carrying autosomal recessive
disease
• Family hx of neural tube defects
Process of Fertilization
• Oocyte and sperm meet in fallopian tube
• Ovulation—cervical mucus changes
• 200 sperm reach fertilization site
• Capacitation
• Penetrates zona pellucida—prevents fertilization by other
sperm
Implantation
• Zygote propelled by
• Cilia
• Peristalsis
• Reaches uterine cavity in 3 to 4 days
Nidation
• Occurs by 10th day after fertilization
• Implantation bleeding
• Blastocyst is buried beneath the endometrial
surface
Placenta
• Develops from trophoblast cells
• Lacunae
• Chorionic villi
• Intervillous spaces
• Provides oxygenation, nutrition, waste
elimination, and hormones
• Protects fetus
Placenta
Embryonic and Fetal Structures
• Placenta
• Serves as the fetal lungs, kidneys and GI tract and as a
separate endocrine organ throughout the pregnancy
• Placental circulation established as early as 3rd week of
pregnancy
• Grows to 15-20 separate “lobes” called cotyledons
• By wk 20, covers approx. 1/2 surface of internal uterus
• No direct exchange of blood between the embryo and
the mother during pregnancy--exchange is through
selective osmosis
Placental Circulation
• Maternal blood from spiral arteries enters
intervillous space of endometrium
• Fetal chorionic villi reach into endometrium
• Membrane of chorionic villi is 1 cell thick
• Exchange of nutrients/substances
Placenta
Placenta
Substance Transport
Across Placenta
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Diffusion
Active transport
Pinocytosis
Bulk flow and solvent drag
Accidental capillary breaks
Independent movement
Placental Hormones
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Human chorionic gonadotrophin (hCG)
Human placental lactogen (hPL)
Progesterone
Estrogen
Development of the
Embryo and Fetus
Yolk Sac
• Develops 8 to 9 days after conception
• Essential for transfer of nutrients during
second and third weeks of gestation
• Hematopoiesis
• Atrophies and is incorporated into umbilical
cord
Umbilical Cord
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Usual location—center of placenta
55 cm long (21 in); 1 to 2 cm diameter
Vessels: one vein, two arteries
Wharton’s Jelly: protects umbilical cord from
compression
Fetal Circulation
• Heart begins to beat and circulate blood by
end of third week
• Umbilical vein: blood from placenta to fetus
• Low Po2 important to maintain fetal
circulation
Fetal Circulation

Fetus derives oxygen and excretes carbon
dioxide from oxygen exchange in the placenta,
NOT lungs
Specialized structures in fetus shunt blood flow
away from non-functioning lungs to supply
important organs of the body, especially the
brain
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Foramen ovale (right to left atrium)
Ductus arteriosus (pulmonary artery to aorta)
Ductus venosus (umbilical vein to inferior vena cava,
bypassing liver)
Critical Thinking
• During a prenatal examination, an adolescent client
asks, "How does my baby get air?" The nurse would
give correct information by saying:
A) "The fetus is able to obtain sufficient oxygen due to the
fact that your hemoglobin concentration is 50% greater
during pregnancy."
•
B) "The lungs of the fetus carry out respiratory gas exchange
in utero similar to what an adult experiences."
•
C) "The placenta assumes the function of the fetal lungs by
supplying oxygen and allowing the excretion of carbon
dioxide into your bloodstream."
Fetal Membranes and
Amniotic Fluid
Embryonic Membranes
• Early protective structures
• Two separate membranes
• Amnion—inner membrane, contains amniotic
fluid
• Chorion—outer membrane, forms fetal portion of
placenta
• Slightly adherent, form amniotic sac
Purposes of Amniotic Fluid
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Protects and cushions fetus
Maintains normal body temperature
Symmetrical fetal growth
Freedom of movement
Essential for normal fetal lung development
Amniotic Fluid
• Amount: 800 mL at 24 weeks
• Fetal urine and lung secretions primary
contributors
• Slightly alkaline
• Contains antibacterial, other protective
substances
Human Growth and Development
Pre-Embryonic Period
• First 2 weeks after conception
• Rapid cellular multiplication and
differentiation
• Establishment of embryonic membranes and
primary germ layers
Embryonic Period
• Begins third week after fertilization through end of
eighth week
• Organogenetic period: formation, differentiation of
all organs
• Germ layers: ectoderm, endoderm, mesoderm
• Vulnerable to environmental insults
Fetal Development
Fetal Period
• Beginning ninth week until birth or
termination of pregnancy
• Rapid body growth and differentiation of
tissues, organs, and systems
• Less vulnerable stage
Weeks 17 to 20
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Growth slows
Quickening
Vernix caseosa
Lanugo
By 20 weeks—fetus 300 g and 19 cm
(7.3 in)
Weeks 21 to 25
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Gains weight
Skin pink
Rapid eye movements
Surfactant by 24 weeks
Weeks 26 to 29
• If born, fetus may survive
• Weeks 30 to 40
• Strong hand grasp reflex
• Orientation to light
• 38 to 40 weeks: 3000–3800 g and
45–50 cm (17.3–19.2 in)
Nurse’s Role in
Prenatal Evaluation
• Initial prenatal visit
• Assessment: cultural, emotional, physical,
and physiological factors
• Education
• Genetic disorders
• Prenatal tests
Nursing Responsibilities
 Assess for signs and
symptoms of genetic
disorders
 Offer support
 Assist in value
clarification
 Educate on procedures
and tests
Maternal Age and Chromosomes
• Age 35 and above
• Increased risk of chromosomal abnormalities
• Down syndrome
• Deletion
• Translocation
Multifetal Pregnancy
Monozygotic
• Develop from one zygote
• Division occurs at end of first week
Dizygotic
• Develop from two zygotes
• Separate amnions and chorions
Identical Twins
1 Ovum
Fraternal Twins
2 Ova
Minimizing Threats to
Embryo/Fetus
Nurse’s role
• Assessment
• Environmental and lifestyle risks
• Knowledge
• Physical and psychosocial well-being
Preconception counseling
Chapter 8
Physiological and Psychosocial
Changes During Pregnancy
Hormonal Influences
• Pituitary hormones
• Influence ovarian follicular development
• Prompt ovulation
• Stimulate uterine lining
• Corpus luteum
• Estrogen: growth
• Progesterone: maintenance
Ovarian Hormones
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Maintain endometrium
Provide nutrition
Aid in implantation
Decrease uterine contractility
Initiate breast ductal system development
Reproductive System
Uterus
• Patterns of uterine growth
• Estrogen, progesterone: hyperplasia,
hypertrophy allow uterus to enlarge, stretch
• Weight increases from 70 g to 1100 g at term
• Increased blood flow
Braxton-Hicks Contractions
• Irregular, painless
• Prepare uterine muscles
• If irregular and last <60 seconds, reassure
woman
• Regular pattern or associated with other
symptoms, seek medical attention
Cervix
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Chadwick’s sign
Goodell sign
Softens
Forms mucus plug
Call if discharge bloody or yellow/green, foul
odor, itching, or pain
Vagina and Vulva
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Thickening of vaginal mucosa
Rugae
Becomes edematous
More susceptible to yeast infections
pH: decreases from 6.0 to 3.5
Discuss vulvar hygiene
Other Reproductive Changes
• Ovaries
• Breasts
• Montgomery tubercles
• Increased pigmentation (areolae)
• Discuss bra size changes, options for infant
feeding, and strategies for successful
breastfeeding
Integumentary System
• Hyperpigmentation
• Chloasma
• Linea nigra
• Cutaneous vascular changes
• Striae gravidarum
• Angiomas
• Palmar erythema
Neurological System
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Decreased attention span
Poor concentration
Memory lapses
Carpal tunnel syndrome
Syncope
Anticipatory guidance regarding changes
Cardiovascular System
Heart
• Position: pushed upward, laterally to left
• Cardiac hypertrophy due to increased blood volume,
cardiac output
• Heart sounds: exaggerated first and third; systolic
murmurs
Blood Volume
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Plasma and erythrocyte volume increase
Increased need for iron
Physiologic anemia
Teach regarding adequate hydration and diet
high in protein, iron
• Increased fibrinogen volume
Cardiac Output
• Blood pressure
• Stasis of blood in lower extremities: risk for
varicose veins and venous thrombosis
• Encourage daily walks to enhance circulation,
improve intestinal peristalsis
Supine Hypotension Syndrome
• Pressure from enlarged uterus decreases
venous return from lower extremities
• Hypotension, dizziness, diaphoresis, pallor
• Orthostatic hypotension
• Stagnation of blood in lower extremities
• Encourage to rise slowly; keep feet moving while
standing
MATERNAL POSITION
& BLOOD FLOW
side lying
supine
Respiratory System
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Increased tidal volume
Increased oxygen consumption
Diaphragm elevates
Increased chest circumference—dyspnea
Educate regarding normal changes and
symptoms
Eyes, Ears, Nose, Throat
• Blurred vision—decreased intraocular
pressure and corneal thickening
• Temporary condition
• Nasal stuffiness, congestion—increased
mucus production
• Epistaxis
• Encourage increased fluid intake
Upper GI Tract
• Mouth
• Gingivitis, ptyalism, hypertrophy of gums, epulis
• Esophagus—pyrosis, reflux
• Stomach and small intestine
• Morning sickness, absorption of nutrients
Lower GI Tract
• Large Intestine—constipation
• Liver and gallbladder
• Cholestasia, cholecystitis, cholelithiasis
Urinary System
• Bladder
• Urinary frequency and urgency
• Kidneys and ureters
• Structural changes
• Functional changes
• Glomerular filtration rate increases
Endocrine Glands
• Thyroid gland
• Increased T4
• Progressive increase in basal metabolic rate
• Pituitary gland
• Prolactin
• Oxytocin
• Vasopressin
Musculoskeletal System
• Postural changes
• Lumbar lordosis
• “Waddle” gait
• Calcium storage
• Decreased maternal serum calcium
• Lower extremity cramps
Psychological Responses of Mother
• Intendedness
• Ambivalence: normal response
• Acceptance: quickening (20 wks)--baby is “real”
Psychosocial Changes
• Decreased ability to deal with stress and cope
with changes of pregnancy
• Major developmental phases—ambivalence
and conflicting emotions
• Nursing care tailored through each pregnancy
milestone
Developmental and
Family Changes
• Duvall: stages of family development
• Prepare for role as childcare providers
• Reorganize home, family member duties, patterns
of money management
• Reorient family relationships
• Each pregnancy—adjust to transitions in
relationships with each other, children
Maternal Role Transition
• Rubin—“tasks of pregnancy”
• Incorporate pregnancy into identity
• Acceptance of the child
• Reorder relationships
Maternal Tasks of Pregnancy
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Seeking safe passage
Securing acceptance
Learning to give of self
Committing self to the unknown child
Pregnant Adolescent
• Normal adolescent developmental tasks
conflict with tasks of pregnancy
• May not seek prenatal care
• Not future oriented—may not accept reality of
unborn child
• Acceptance of pregnancy hindered
Nursing Assessment
of Psychosocial Changes
• Thorough history: family background, past
obstetrical events, status of current pregnancy
• Each visit—ask about pregnancy experience,
address concerns, offer anticipatory guidance
Obstetrical History--G/P
• Gravida: any pregnancy, including present
• Nulligravida: never been pregnant
• Primigravida: in first pregnancy
• Multigravida: 2nd or more pregnancy
• Para: birth after 20 wks gestation (before 20 wks:
spontaneous abortion (SAB)
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Nullipara: never given birth at > 20 wks
Primipara: has had 1 birth > 20 wks
Multipara: 2 or more births > 20 wks
Multiples such as twins are counted as ONE birth
G/P
• Susie Smart is pregnant.
• She has four sons at home:
twins born in 1996 at 34 weeks,
then singletons born in 1998, and 2001.
She had 1 miscarriage in 2000.
What is her Gravida/Para?
G=5
P=3
Obstetrical History--G/P
P =TPAL
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G = gravida, # of pregnancies
P is further broken down & multiples are counted:
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T = # of term infants born (37 wks+)
P = # of preterm births (> 20, < 37 wks)
A = # pregnancies ending in spontaneous or therapeutic
abortion (SAB/TAB)
L = # of currently living children
Reflection:
G/P vs GTPAL
Susie Smart is pregnant. She has four sons at home:
twins born in 1996 at 34 wks, then singletons born in
1998, and 2001. She had 1 miscarriage in 2000.
• What is her G/P?
G=5
P=3
• What is her GTPAL?
G=5
T (term) = 2
P (preterm) = 1
A (abortions) = 1
L (living) = 4
Example
• Nancy Tam is seeing the MD for her first PN
visit. She has 4 kids at home, two of whom
are twins and were born at 33 wks. She has
had 1 miscarriage and 1 abortion.
 What is her gravida/para?
G6 P3 AB 2 (SAB 1 & TAB 1)
 What is her GTPAL?
G6 T2 P1 A2 L4 or (G 6 P 2124)
????
• Tracy H. is pregnant. She has one son at home born
at 38 wks. Her 2nd pregnancy ended at 10 wks
gestation. She then had twins at 30 wks. One twin
died soon after birth.
• What is her G/P?
• G 4 P 2 AB 1
• What is her GTPAL?
• G 4 P 1112
Estimated Birth Date
(EDC/EDD/EDB)
• Use LMP (last menstrual period)
Assessment and Health Education
• Comprehensive history and physical exam
• Ongoing education focusing on current
trimester and physical changes
First Prenatal Visit
• Complete Physical Exam
• Pelvic exam: external genitals, vagina, cervix
• Signs of pregnancy (Goodells, Hegars, Chadwicks)
• Pelvic measurements: diagonal conjugate, obstetric
conjugate, ischial tuberosity diameter
• Sterile speculum, pap smear
(infection, discharge, growths?)
GC, Clamydia cultures
Laboratory Work
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CBC
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ABO & Rh type
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Antibody screen
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Rubella titer
VDRL or RPR (syphillis)
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Hepatitis B surface antigen
Gonorrhea culture
Chlamydia culture
Alpha-fetoprotein @ 14wks**
HIV screen
Urine: glucose, protein &
ketones by dipstick.
Urinalysis: RBCs,
leukocytes, bacteria
Hereditary disease
screening
• Sickle cell
• Tay-sachs
• Cystic fibrosis
Assessment of Growth & Development
(Confirm dating of pregnancy)
• Estimating fetal growth:
• Fundal height: symphysis to top of fundus
• McDonald’s Rule: Between wks 22-34 fundal height in
cms should match no. of weeks gestation (± 2 cm)
• Milestones:
• 12 weeks: fundus clears symphysis
• 20 weeks: fundus at umbilicus
• 36 weeks, fundus at xyphoid
Assessing Fetal Development
Fetal Movement/Heartbeat/Ultrasound
• Quickening: fetal movement felt by mom between 18-20
weeks (fetal movement record)
 Fetal heart tones by doppler (intermittent) or ultrasound
transducer (continuous)
 Can be heard as early as 10th or 11th week of pregnancy
by Doppler
 Normal: 110-160 BPM
 Ultrasound: gestational sac by 5-6 wks
 Crown-to-rump, biparietal measurements
Chapter 10
Promoting a Healthy Pregnancy
Planning for Pregnancy
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Preconception
Periconception
Interconception
Preconception counseling
• Identify conditions that could adversely affect
pregnancy
The Healthy Body
Menstrual and medical history
• Exposure to childhood illnesses
• Exposure to STIs
• Exposures related to lifestyle choices
Physical examination
• Laboratory evaluation
• Genetic testing
Dental Care
The Healthy Mind
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Readiness for motherhood
Psychological changes during pregnancy
The healthy relationship
Readiness for fatherhood
Support for life changes
Recommended Weight Gain
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1st Trimester: 1 lb/month (3 lbs)
2nd Trimester: ½ - 1 lb/ wk
3rd trimester: 1 lb/week , esp last month; ↑ fetal wt gain
Total:
• 25-35 lbs--normal wt.
• 30-40 lbs--underweight
• 15-20 lbs--overweight
• Multiple gestation: 1 lb per week throughout pregnancy (4045 lbs total)
Where does
weight
come from?
Maternal Nutrition
• Caloric Intake: 300 calories/day additional
2000-2500/daily
• Protein increases to 60 g/day
• Fat: need linoleic acid (not manufactured in body)
- need more vegetable oils
• Prenatal vitamins (contain folic acid)
• Folic Acid: prevents neural tube defects
• Minerals: calcium, phosphorus, iodine, iron, fluoride,
sodium, zinc
Maternal Nutrition
(Continued)
• Fluid Needs
• Two glasses of fluid daily over and above a daily quart
(a total of 6-8 glasses)
Promoting Nutritional Health
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Nutritional Outcomes & Planning
Nursing diagnosis
Outcome identification and planning
Outcome evaluation
• Family considerations
• Financial considerations
• Cultural considerations
Assessment: Nutritional Health
Risk Factors
Assessing Nutritional Health
• Typical day, 24-hour recall
 Nausea/vomiting?, cravings?, pica?
 Lab results: H&H for anemia, urinalysis for specific
gravity
 Physical findings:
 Hair, mouth, eyes, neck, extremities, finger/toe
nails, over/under weight (BMI), poor weight gain
Factors That Affect Nutrition
• Eating disorders
• PICAabnormal craving for nonfood substances
• Includes cravings for clay, ice cubes, dirt, cornstarch
• Iron deficiency anemia can result
• Anorexia nervosa, bulimia nervosa
• Cultural factors
• Vegetarian diets
• Food cravings and food aversions
Common Nutritional Problems
• Nausea and Vomiting (Morning Sickness)
• Associated with a high level of chorionic gonadotropin,
estrogen and/or progesterone levels
• Lowered maternal blood sugar levels
• Lack of vitamin B6
• Diminished gastric motility
• Affects 50% of pregnant women
Common Nutritional Problems
• Nausea and Vomiting Teaching:
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Crackers, pretzels, sourballs, delay breakfast
Frozen yogurt, fruit popsicles
Make up missed meals later in day
Do not go > 6 hours without food
**small, frequent meals keep Blood Sugar levels up**
Snack at bedtime & delay eating in AM if nauseous
Call MD if can’t keep anything down ≥ 24 hours
(hyperemesis gravidarium?)
Nutritional Health-Special Needs
• Pregnant adolescents need at least 2500
calories/day
• Good nutrition a problem
• More apt to eat junk food
• Help them ID nutritious food within their food
preferences
• Inadequate iron & calcium intake common
Critical Thinking
•
A pregnant client who is a lacto-vegetarian asks the
nurse for assistance with her diet. What instruction
should the nurse give the client about protein intake?
A) "Protein is important; therefore, the addition of one serving
of meat a day is necessary."
B) "Eggs are important to add to your diet. Eat six eggs per
week."
C) "A daily supplement of 4 mg vitamin B12 is important."
D) "Milk products contain protein, but they are very low in
iron."
Exercise, Work, and Rest
Exercise
• Muscle strengthening
• No rigorous aerobic activity
Work
• Impact on pregnancy
• Maternity leave
Rest
Medications
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Safe versus teratogenic
Over-the-counter
Herbal and homeopathic preparations
Prescription
FDA pregnancy categories
Teratogens
• Medications: FDA Classification/Category A-D, X
• Cigarettes: Low birth weight, IUGR, SAB, SIDS
• Alcohol: Fetal alcohol syndrome: SGA, cognitive
deficits, characteristic craniofacial deformity
• Caffeine: hi doses: SAB, IUGR. Limit to 300
mg/day
• Cocaine: abruption, PT birth, IUGR, cognitive
deficits
• Environmental: chemicals, metals, radiation, etc.
Fetal alcohol syndrome
Advanced Maternal Age
• Increased risk if mom > 35:
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•
•
•
maternal death (chronic medical conditions)
SAB, low birth wt & preterm birth
cesarean section
gestational DM, PIH, HTN, placenta previa, difficult
labor, newborn complications
• Down syndrome
• Advanced paternal age: ↑genetic problems and late
fetal death
Adolescent Pregnancy
Developmental Tasks:
• Early ( ≤14 ): impulsive, self-centered, concrete
thinker
• Middle (15-17): rebellious, peer group, moving to
formal operational thought, does not see long-term
consequences
• Late (18-19): better decision-making ability,
concrete operation thought, abstract thought,
understands consequences 0f behavior
Adolescent Pregnancy
• Increased risks:
• Late prenatal care & often do not follow
recommendations (smoking, wt. gain)
• Preterm birth, low birth wt, preeclampsia, irondeficiency anemia, Alcohol, drug, tobacco use,
STI
• ↑ cephalopelvic disproportion (CPD
Undeveloped pelvis
Common Discomforts
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Nausea and vomiting
Nasal congestion
Dental problems
Constipation/hemorrhoids
Leg cramps
Dependent edema
Varicosities
Round ligament pain
Hyperventilation, shortness of breath
Numbness/tingling in fingers
Supine Hypotensive Syndrome
Fatigue
Backache
Leukorrhea
Dyspepsia
Flatulence
Insomnia
Dyspareunia
Nocturia
Signs and Symptoms
of Danger
First Trimester
• Severe, persistent vomiting
• Abdominal pain and vaginal bleeding
• Indicators of infection
Second Trimester
• Maternal complications
• Preeclampsia
• Premature rupture of the membranes
• Preterm labor
• Fetal complications
• Decreased fundal height
• Absence of fetal movement after quickening
Third Trimester
• Maternal complications
• Gestational diabetes
• Placenta previa
• Abruptio placentae
• Fetal complications
• Hypoxia
Pregnancy Map
• Prenatal care map
• Timetable
Childbirth Education
Primary goal
•
•
•
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To promote a positive childbearing experience
Empowerment
Dispelling myths
Alleviate fear
 Topics
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Anatomy and physiology
Comfort measures
Labor and birth process
Relaxation and pain management
Childbirth Education—Methods
• Lamaze
• Empowerment
• Dispelling myths
• Controlled breathing, position, massage, relaxation
• Bradley
• Inward relaxation
• Normal breathing
Other Methods
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Dick-Read
HypnoBirthing
LeBoyer method
Odent method
Birthing from within
Finding Information on Childbirth
Education
• Primary source—health care provider
• Online and at-home programs
• Parents need to ask questions about the class to
determine if it fits their needs
• Factors related to personal values and beliefs
• Decrease fear through knowledge
The Birth Plan
• Written information that identifies labor and
birth preferences
• The choices
• Choosing a provider
• Choosing a location
• Discussion with healthcare provider
Chapter 11
Caring for the Woman
Experiencing Complications
During Pregnancy
Early Pregnancy Complications
• Perinatal loss
• Ectopic pregnancy
• Gestational trophoblastic disease
• Signs/symptoms: vaginal bleeding, excessive
nausea/vomiting, abdominal pain, size/date
discrepancy
• Management: remove uterine contents
Gestational Trophoblastic Disease
Hydatiform Mole
• Abnormal proliferation & degeneration of
throphoblastic cells (which give rise to the chorion)
• Molar pregnancy: Embryo fails to develop, cells
proliferate, then become clear, fluid-filled vesicles
(grape-size)
• S/S ↑fundal height for dates, ↑hCG levels, brownish
vaginal bleeding & discharge of vesicles
• TX: suction evacuation & f/u for possible
choriocarcinoma, hCG testing, delay new pregnancy
for 12 months
Spontaneous Abortion
• Before 20 weeks of gestation
• Signs/symptoms: bleeding, cramping,
abdominal pain, decreased symptoms of
pregnancy
• Management: D & C
Premature Cervical Dilatation
(incompetent cervix)
• Painless dilation of cervix without contractions due to
•
•
•
•
structural or functional defect of cervix
S/S: pinkish show, ↑pelvic pressure, followed by ROM, UC’s
& birth.
Associated with: adv maternal age, congenital structural
defects, trauma to cervix
Treatment
Cerclage -with next pregnancy
Hyperemesis Gravidarum
• 0.5-2% of pregnancies
• Severe nausea and vomiting
• Dehydration, ketonuria, significant weight loss in first
trimester, or
• Continues after 12 weeks
• Carbohydrate depletion/ketonuria
• Unable to maintain usual nutrition
• Dehydration/electrolyte imbalances
• Low sodium, potassium, chloride
Hyperemesis Gravidarum
• Therapeutic management
• Hospitalization
•
•
•
•
•
•
NPO
IV hydration (KCl if hypokalemic)
Vitamin replacement
Parental nutrition
Medication (Reglan, Zofran)
Gradual reintroduction of food
Chapter 19 Pregestational Problems
Diabetes
• PATHOPHYSIOLOGY:
• In 2nd half of pregnancy, hPL & other hormones
cause ↑ maternal peripheral resistance to insulin
to ensure sufficient circulating glucose for fetus.
Due to this, existing diabetes is augmented and
diabetic potential may result in gestational DM.
Diabetes Mellitus
• Preexisting DM during pregnancy:
• Regulation of glucose & insulin more difficult
• Insulin needs ↓ in 1st trimester BUT ↑ in 2nd & 3rd
trimester--may be 2 to 4 x greater by end
• Glucose levels can become out of control-balance is upset
• GOAL: close control of glucose levels (fasting glucose <
95 mg/dL & 2 hour postprandial < 120 mg/dL)
• Glycosylated hemoglobin (HbA1c) measures control:
normal: 4.8-7.8%. > 10% associated with 20-25% rate of
fetal anomaly
Gestational DM
• 1-14% of pregnancies
• Manifests at midpoint of pregnancy, when insulin resistance
increases
• Risk of type 2 later as high as 50%
• Risk factors:
• Obesity, age, hx of large babies, unexplained fetal loss,
congenital anomalies, family hx, Native Americans,
Hispanics, Asians
• May or may not need insulin
Effects of DM
• MOTHER
•
•
•
•
Hydramnios
Preeclampsia
Ketoacidosis
Difficult labor
(dystocia)
• Retinopathy
• BABY
• Congenital anomalies
• Heart, CNS, skeletal
•
•
•
•
Stillbirth
Macrosomia
Hypoglycemia
Respiratory distress syndrome
(RDS)
• Polycythemia/hyper-bilirubinemia
Diabetes Mellitus
Screening in pregnancy:
• 1 hour, 50 g oral glucose challenge at 24-28 wks (at 1st PN visit
if hi-risk)
• If 1 hour value ≥ 130 - 140, do 3 hour test.
• 3 hour, 100 g oral glucose tolerance test
• Diagnosis of gestational DM if 2 or more of the following
values
are met or exceeded:
• Fasting
95 mg/dL
• 1 hour
180 mg/dL
• 2 hours
155 mg/dL
• 3 hours
140 mg/dL
Management

Patient Teaching
Diet
Glucose monitoring
Insulin administration

Placental functioning & fetal well-being testing
NST, AFI
Fetal kick counts

Exercise
Insulin pump therapy
Signs of hypo/hyper-glycemia
Assessment of fetal size and
maturation
Delivery at term or possibly 38 weeks,
c-section if macrosomia/ CPD suspected
Abruptio Placen
• Premature separation of placenta from uterine wall
• S/S: sharp, stabbing pain high in fundus, heavy
bleeding (may be occult), hard, board-like uterus,
tense, painful uterus, signs of shock due to blood
loss, Port-Wine aminotic fluid if ROM.
• Predisposing fx: ↑parity, adv. maternal age, short umbilical
cord, chronic HTN, PIH, direct trauma, vasoconstriction from
cocaine or cigarette use
• Fetal distress on monitor. Can progress to DIC.
Abruptio Placentae
Abruptio
Placentae
• Management:
• Emergency. Immediate c-section if birth
not imminent.
• Lg. gauge IV
• O2 via mask, fetal monitoring, maternal
VS, lateral positioning, labs, blood
transfusion (have 2 units avail)
• CBC (H&H), Fibrinogen levels, platelet
count, PT/PTT, fibrin degradation
products ( sx of DIC)
Placenta Previa
Low implantation of placenta (1 in 200)
• abrupt, painless, bright red bleeding
• Associated with ↑parity, adv. maternal age, previous
c-section or uterine curettage, multiple gestation
• Dx: ultrasound. May resolve as pregnancy
progresses.
• Bleeding common around 30 wks: Bedrest, VS, IV
fluids, type & cross-match, observe for bleeding
• Emergency: assess bleeding, hx, uc’s/labor
•NEVER do vaginal exam !!!
Placenta
Previas
Low-lying
Marginal
Partial
Complete
Prolapsed Cord
• Loop of umbilical cord slips down in front of the presenting
part
• S/S: deceleration of FHT: bradycardia, persistent
variable decels, cord palpatedor seen in vagina
• Associated with:
•
•
•
•
•
•
Premature rupture of membranes
Transverse or breech presentation
Multiple gestation
Placenta previa
Hydramnios
CPD (non-engagement of fetal head)
Prolapsed Cord
• Management: Hold fetal head off cord,
Trendelenburg or knee/chest position, immediate
emergency c-section
• Prevention
• Watch fetal heart tones after rupture of
membranes (SROM or AROM). Do VE if any
sign of fetal distress.
• If head not engaged, women with ruptured
membranes should not ambulate.
Preterm Labor (PTL)
• Occurs before 37 weeks
gestation
• 11-12% of pregnancies
• 75% of neonatal
morbidity & mortality
where congenital
anomalies do not exist
Preterm Labor
• S/S: low backache, vaginal spotting, pelvic
pressure, abdominal tightening, cramping
• Associated with: dehydration, UTI,
chorioamnionitis
• UC > every 10 minutes
• Can attempt to stop if effacement < 50% and
dilatation < 4-5 cm
• DX: clinical presentation, vaginal exam, UA,
CBC, vaginal culture, test for ROM
• Fetal Fibronection screen**
Drugs Used in Treating Preterm Labor
• Antibiotics (ampicillin, erythromycin)
• Group B streptococcus prophylaxis, chorioamnionitis
• Corticosteroids (Betamethasone or Dexamethasone)
• 24 to 34 weeks gestation
• Accelerate the formation of lung surfactant (Betamethasone)
• TOCOLYTICS: ( = stop contractions)
• Terbutaline 1st line agent (subcutaneous injection or PO)
• Works on Beta-2 receptor sites in uterus
• Side effects: tachycardia, arrhythmia, palpitations,
hyperglycemia
• FDA now disallows use for PTL
Drugs Used in Treating Preterm Labor
TOCOLYTICS, cont.
• Magnesium Sulfate (IV) (pg 500)
• Central nervous system depressant
• 4-6 g loading dose, 2 g maintenance
• Procardia (nifedipine) (PO)
• Calcium channel blocker, relaxes smooth muscle
• Side effects: hypotension, tachycardia, facial flushing,
headache
• *Becoming drug of choice ---evidence based practice
PTL: Self Care Teaching
• Signs of PTL: May be subtle
• UCs q 10 mins or closer, cramping, pelvic pressure, ROM, low dull
backache, change in vaginal discharge
• Evaluation of UCs (uterine contractions)
• Pelvic rest/activity level
• What to do if experiencing symptoms:
• Empty bladder, lie on side, drink H20, palpate for UC’s &
time, rest, call MD if symptoms persist
Preterm Premature Rupture of
Membranes
• Loss of amniotic fluid before 37 weeks of pregnancy
(5-10% of pregnancies)
• Usually associated with chorioamnionitis, vaginal
infection (chlamydia, gonorrhea) or UTI
• **Increased risk of cord prolapse
• DX: Observe for vaginal leaking (sterile speculum
exam for pooling), nitrizine paper, ferning test, fetal
distress, sx infection
Ferning pattern seen on slide with amniotic fluid
Premature Rupture of Membranes
• Management
• If less than 37 wks: hospitalization,
• Bedrest
 fetal monitoring/NST
• steroids (24-34 wks)  CBC
• broad-spectrum antibiotics
• VS monitoring (temp q 4 hours)
• Betamethasone
• Accelerate lung maturity by ↑surfactant production
• Usual course: 12 mg, IM, q 24 hours for 2 doses Side
effects: maternal hyperglycemia--DM may require more
insulin
Hyperemesis Gravidarum
• Criteria: persistent vomiting, measure of acute
starvation, and weight loss
• Management
• Rest
• Small frequent meals (dry, bland foods)
• High-protein snacks
Critical Thinking
• A woman is experiencing preterm labor. The client
asks why she is on betamethasone (Celestone). The
best response by the nurse would be, "This
medication:
A) Will halt the labor process, until the baby is more mature.”
B) Will relax the smooth muscles in the infant's lungs so the baby
can breathe."
C) Is effective in stimulating lung development in the preterm
infant."
D) Is an antibiotic that will treat your urinary tract infection,
which caused preterm labor."
•
Hypertensive Disorders
• Classifications:
• Chronic
• Preeclampsia-eclampsia
• Chronic hypertension with superimposed
preeclampsia
• Gestational/transient
Preeclampsia
•
•
•
•
•
Multisystem, vasopressive
Disease of placenta
SPASMS
Morbidity and mortality
Management
• Delivery of fetus only cure
Nursing Assessments—
Preeclampsia
•
•
•
•
Identify hypertension
Proteinuria
Edema
CNS alterations
• Eclampsia: seizures
Pregnancy Induced Hypertension
• Cause unknown. 5-7% of pregnancies in US.
Manifests in 2nd half of pregnancy
• Vasospasm of small & large arteries
• Dx: ↑BPs (140/90), proteinuria (>1+)
• Non-diagnostic findings: edema (truncal/facial),
headache, visual disturbance, epigastric pain,
hyperreflexia
• ↑Risk: ethnicity, multiple gestation, primigravid < 20
or > 40 y.o., ↓socio-economic, grand multiparity,
underlying disease (heart, HNT, DM, kidney),
previous history
Pathology of Pregnancy Induced
Hypertension
• As a result of increased vasoconstriction, GFR is
greatly compromised
• Organ perfusion is poor and fluid diffuses from
blood stream into interstitial tissue → edema
• Decreased urine output and proteinuria.
• Edema occurs as result of protein loss, and lowered
GFR.
Concept Map of PIH Symptoms
Anti-angiosin from placenta → Fibrin Deposits
& Vasospasm
Renal damage →
Liver Damage →
Renin-Angiotensin System
↑Liver Panel
↓Platelets
DIC
Monitor sx
Bleeding
Strict I&O
Oligouria
↓osmotic pressure →
Intravascular Volume
PROTEINURIA
Mannitol
Decadron
24 hr Urine
Renal labs
MgSo4
↑ Hct
Diagnosis of pregnancy induced
hypertension
• 24 hour urine is the most definite diagnosis
Protein 2+ or higher
• Metabolic Panel (Comprehensive or Basic)
• Elevated BUN, uric acid and creatinine
• Elevated liver function tests (AST, ALT)
• Low Albumin
• Complete Blood Count
•
Low Platelet Count--level determines the severity of
hypertension
• Hemoconcentration increased (↑ Hct/Hgb)
Pregnancy Induced Hypertension
• S/S: edema, visual changes, epigastric pain, severe
headache, hyperreflexia, clonus, oliguria
• Management: bedrest, maternal/fetal monitoring,
quiet, darkened room, seizure precautions, delivery
• Medications:
• IV magnesium sulfate to prevent seizure
• IV hydralazine or labetalol to ↓BP
Magnesium Sulfate
• Purpose: Prevents seizure (eclampsia)
• Dosage: 4 gram loading dose over 20-30 mins, then
2 gram/hr maintenance dose
• Nursing considerations:
• Limit total IV intake to 125 cc/hr
• Foley catheter & strict I&O
• Serum magnesium levels q 6 hrs
• Normal: 1.8-2.5
• Therapeutic: 5-7
• Hyporeflexia, slurred speech, N, somnolence: 9-12
• Respiratory distress: >12
• Cardiac arrest: >15
MgSO4 Nsg Considerations, cont.
• Assess deep tendon reflexes, BP, RR, lung sounds,
urine output, level of consciousness. Stop infusion if
s/s of toxicity occur.
• Pt. Teaching:
• Normal side effects with MgSO4:
• Warmth over body/flushing
• Burning at IV site
• Mild SOB, mild chest pain
• Congestion, headache, dizziness
• Antidote: 10% Calcium Gluconate, 10 ml, IVP over
2-3 mins.
Pregnancy Induced Hypertension
• Eclampsia: seizure - tonic-clonic type
• Maintain airway, position to side, O2, pulse ox,
suction as needed
• Continuous fetal monitoring, monitor for possible
abruption (vaginal bleeding, non-reassuring FHT)
• Delivery after stabilization
• Seizure may cause precipitous birth
Pregnancy Induced Hypertension
• HELLP Syndrome (Hemolysis, Elevated Liver
enzymes, Low Platelets)
• Complication of preeclampsia (4-12% of women with
preeclampsia)
• S/S: nausea, epigastric pain, general malaise, RUQ
tenderness, visual changes
• Lab: hemolysis of RBC’s, platelets < 100,000, elevated
liver enzymes (ALT/AST)
• TX: platelet transfusion, delivery of baby, monitor for
hemorrhage & DIC, steroids to ↑ renal function
Disseminated Intravascular
Coagulopathy (DIC)
• External or internal bleeding
• Nursing care
•
•
•
•
•
Meticulous maternal and fetal assessment
Place indwelling catheter with strict I&O
Oxygen—rebreathing mask
Blood and blood products
Emotional support
• DIC Is A Disorder Of The
"Clotting Cascade."
• It Results In Depletion Of
Clotting Factors In The
Blood.
Causes of DIC
• DIC is when your body's blood
clotting mechanisms are
activated throughout the body.
• Micro Blood clots form
throughout the body, and
eventually using up the blood
clotting factors. These are then
not available to form clots at
the local sites of real tissue
injury. (microthrombi)
• Clot dissolving mechanisms
are also increased-fibrinolysis
Possible Precursors To DIC
•
•
•
•
•
•
•
•
Hemorrhagic shock
Transfusion reaction
Sepsis
Severe pre-eclampsia or HELLP syndrome
Retained fetal demise
Premature separation of the placenta
Retained placenta
Amniotic fluid embolism (usually not able to be
determined until autopsy)
(Human Labor and Birth, Oxorn and Foote)
Critical Thinking
• The nurse identifies the following assessment findings on a
client with preeclampsia: blood pressure 158/100; urinary
output 50 mL/hour; lungs clear to auscultation; urine protein
1+ on dipstick; and edema of the hands, ankles, and feet. On
the next hourly assessment, which of the following new
assessment findings would be an indication of worsening of
the preeclampsia?
•
•
•
•
•
A) Blood pressure 158/104
B) Reflexes 2+
C) Platelet count 150,000
D) Urinary output 20 mL/hour
Special Conditions and
Circumstances that may
Complicate Pregnancy
Multiple Gestation
• High-risk pregnancy
• Morbidity and mortality
• Management
• Delivery at Level III facility
Hemoglobinopathies
• Sickle cell disease
• Thalassemia
• Close maternal and fetal surveillance
• Rh0(D) isoimmunization
• Admininster RhoGAM to prevent
• ABO
• Coombs test
Isoimmunization-Rh Incompatibility
• Rh Negative mom
• If fetus is Rh positive,
--MOM may make antibodies against fetal blood
• Causes hemolysis of fetal RBC--extreme anemia
(erythroblastosis fetalis)
• Indirect Coombs tests whether MOM has been
sensitized. If negative (no sensitization has
occurred), Rhogam will be given to prevent
sensitization.
Isoimmunization-Rh Incompatibility
Isoimmunization, cont.
• To prevent maternal antibody formation:
• Rh immune globulin (RhIG or Rhogam) is given:
• At 28 wks
• After any incident that might cause mixing of
maternal/fetal blood like abortion, miscarriage, ectopic
pgncy, amniocentesis, CVS sampling, evacuation of
mole, external version
• Baby’s cord blood tested--if Rh + or DIRECT Coombs
positive, Rhogam given to MOM in 1st 72 hours.
• Treatment for BABY
• Positive DIRECT coombs indicates hemolytic disease of
newborn. Baby’s RBC have been sensitized which causes
lysis of RBCs (will cause hyperbillirubenemia).
Cardiovascular Disorders
• Most common problems
• Valvular damage---prophylactic antibiotics
• Congenital heart defects
• ↑ Maternal age--more chronic disease
• Coronary artery disease, varicosities
• Pregnancy taxes circulatory system
• ↑ volume and cardiac output--danger of CHF
• Class I & II, no problem
• Class III & IV have risk of severe complications-pregestational counseling advised.
Heart Disease
Interventions during labor & birth
• Epidural for pain control
• Limit/eliminate pushing-forceps/ vacuum delivery
• Sidelying positions to ↑
perfusion to baby
• Class III & IV may
need invasive cardiac
monitoring
• Danger: (S/S CHF)
•
•
•
•
↑ HR or RR in mom
Crackles or SOB
Edema
Cough
Other Cardiovascular Disorders
• Peripartum cardiomyopathy
• No history of cardiac disease
• Signs/symptoms: dyspnea, fatigue,
peripheral/pulmonary edema
Trauma
• Preventing accidents
• 6-7% of pregnancies
• Most commonly in 3rd trimester
• Physiologic changes affecting trauma care
• Psychosocial considerations
• Fear for fetus, anxiety, guilt
• Assessment
Pregnancy history Bleeding? Cramping?
Fetal movement? Physical exam
Carefully document accident
Consider abuse or self-inflicted injury
Trauma
• Open wounds
 Lacerations
 Puncture wounds
 Animal or snake bites
• Blunt abdominal
trauma/MVA
**Placental abruption**
• Kleihauer-Betke test
• Rh Neg: Need Rhogam
• Choking: chest thrusts
Venous Thrombosis
and Pulmonary Embolism
• Symptoms
• Diagnosis
• Doppler ultrasound
• Ventilation-perfusion (VQ) scan
Respiratory Complications
• Pneumonia
• Aggressive management
• Asthma
• Cystic Fibrosis
Inflammatory Disease
& Pregnancy
• Systemic lupus erythematosus (SLE)
• Increased risk of pregnancy complications
• Management
• Immunosuppression of SLE flare
• Careful fetal surveillance
• If flare-up during pregnancy, rapid implementation of
treatment
Psychiatric Complications
•
•
•
•
•
•
Depression
Schizophrenia
Bipolar disorder
Anxiety disorders
Eating disorders
Substance addiction
Antepartum Fetal Assessment
•
•
•
•
•
•
Chorionic villus sampling
PUBS
Amniocentesis
Amnioscopy or fetoscopy
Ultrasonography
Fetal kick counts
Assessment of Fetal
Well-Being (cont.)
•
•
•
•
•
•
Doppler ultrasound
Fetal biophysical profile
Non-stress test
Vibroacoustic stimulation
Contraction stress test
Electronic fetal heart rate monitoring
Antenatal Bedrest
•
•
•
•
Regular community health nurse home visits
Involve various community resources
Support groups
Provide emotional support
Ultrasonography*
• 2 Types: transabdominal and transvaginal
• Purposes- ?
• Transvaginal helpful for imaging cervix to look for
shortening and funneling, signs of incompetent
cervix
Common Uses of Ultrasound in Pregnancy
(pg 545 for AGOC indications)
• Diagnose pregnancy & multiple gestation
• Confirm EDC, predict maturity by measurement:
• Estimate fetal weight/estimated gestational age (EDC)
• 1st trimester: crown-rump length (6-10 wks) (± 3-5
days)
• After 1st trimester: femur length, abdominal
circumference & biparietal diameter (± 7-21 days)
• Confirm presence, size & location of placenta & amniotic
fluid (AFI)
• Determine growth, sex & presentation of fetus
• Diagnose fetal death
Measuring femur length
Measuring the
head
Assessing Fetal Well-Being:
Fetal Movement
• Fetal Movement: felt between 18-20 weeks (quickening)
• Fetal Kick Count: should feel 10 movements in 1 hour
(assess at same time of day)*
• Associated with accelerations on non-stress test (NST)*
• Decreased fetal movement is a DANGER sign
Biophysical Profile*
• Measures 5 parameters (score max. of 2 for ea.)
• Fetal breathing
• Fetal movement
• Fetal tone
• AFI
• NST
• Score: 8-10, baby is well; 6, suspect problems; 4, fetus
in jeopardy
 Modified Biophysical Profile
• NST & AFI: Normal if NST is reactive & AFI > 5
cm
Amniotic fluid index (AFI)
• Assessment of amniotic fluid.
• Rationale: ↓uteroplacental perfusion may lead to
↓fetal renal blood flow, ↓urination &
oligohydramnios (fetal swallowing & urine output
determine amniotic fluid volume)
• Pockets of fluid visualized by US are measured
• From 28-40 wks:
• AFI should be 12-15 cm.
• Above 20-24 cm: polyhydramnios
• Below 6 cm: oligohydramnios
Assessing fetal well-being
Fetal Heart Sounds
 Fetal heart tones by doppler or ultrasound
transducer (continuous)
 Can be heard as early as 10th or 11th week of
pregnancy by Doppler
 Normal: 110-160.
 Slows with advancing gestational age
 Monitored for non-stress test (NST)-- primary test
for fetal well-being
Assessing FHT: Baseline
• Normal: 110-160, The “flat part” between
accelerations (accels) or decelerations
(decels). Look at at least 10 min. strip.
• Bradycardia: < 110 for > 10 minutes
(otherwise, it is a deceleration)
• Causes: hypoxia, hemorrhage, cord prolapse,
hypothyroidism, heart block
• Tachycardia: >160 for > 10 minutes
• Causes: maternal fever/infection, dehydration,
hypoxia, medication (terbutaline,
amphetamines, cocaine), arrhythmias (SVT),
hyperthyroidism
FHR Variability
• The range of the “baseline” heart rate in
variation from the baseline.
-the “jitteriness” of the baseline
•
•
•
•
Absent: undetectable (looks like a straight line)
Minimal <6 bpm
Moderate: 6-25 bpm
Marked: > 25 bpm
• Moderate variability implies: intact CNS,
normal cardiac responsiveness, fetus is
well-oxygenated & doing well
FHR Variability, cont.
• Decreased variability (look for cause)
•
•
•
•
•
Fetal sleep cycle
Hypoglycemia
Hypoxia
Placental perfusion problems
Narcotic (Nubain, Stadol), Celestone, MgS04
• Increased variability
• Fetal or maternal catecholamine release
• Scalp stimulation
• Concern if persistent & decreased variability
Fetal Heart Rate (FHR) Testing
Nonstress Test (NST)
• Fetal movement produces accelerations (accels) of the
FHR
• Accelerations: intact central & autonomic nervous system-baby is not hypoxic
• Criteria ??
• Reactive (reassuring): 2 or more accels
• Accel criteria: 15 BPM above baseline FHR & duration of 15
seconds or more (15 x 15)
• High-risk pregnancy: bi-weekly NSTs from 32-34 wks
Reactive (Reassuring) NST
Example of a reactive nonstress test (NST). Accelerations of 15 bpm
lasting 15 seconds with each fetal movement (FM). Top of strip shows
fetal heart rate (FHR); bottom of strip shows uterine activity tracing. FHR
increases (above the baseline) at least 15 beats and remains at that rate
for at least 15 seconds before returning to the former baseline.
Fetal Heart Monitor Strip
Does this NST show evidence of fetal well-being?
Fetal Heart Monitor Strip
Does this NST show evidence of fetal well-being?
Evaluating Contractions
•Uterine Activity Assessment
•External monitor--tocodynamometer
•Palpation for intensity
•Pattern: Frequency, duration
•Internal--intrauterine pressure catheter (IUPC)
•Intensity read on graph paper in mm/Hg
Periodic & Non-Periodic Changes
• Accelerations:
• Abrupt increase of 15 bpm for a least 15
seconds (less than 2 minutes)
• Indicate healthy, well-oxygenated fetus with
intact CNS. Basis of reactive NST.
• Decelerations:
•
•
•
•
Early
Variable
Late
Prolonged
Monitoring in
Labor
• Frequency: Count time from START of one
contractions to START of next.
• Duration: Count time from START of one
contraction to END of same contraction
• Intensity: PALPATION for external monitor:
mild (chin), moderate (nose), strong (forehead)
Intermittent Fetal Heart Rate
Monitoring
• Low risk moms
• Home births and birthing centers (low-risk
pregnancies, natural childbirth)
• Allows for greater maternal freedom of
movement
• Non Stress Tests usually 20 mins q 1-2 hrs
Indications for
Continuous Fetal Monitoring
• Multiple gestation
• Placenta Previa
• Oxytocin infusion
• Fetal bradycardia/non-reassuring FHR
• Maternal Complications (Gestational
Diabetes, PIH)
• Intrauterine Growth Restriction (IUGR)
Indications for
Continuous Fetal Monitoring
• Post dates
• Meconium-stained amniotic fluid
• Abruption placenta- suspected or actual
• Abnormal non-stress test
• Abnormal uterine contractions
• Fetal distress
• Provider preference and facility protocol
Monitoring in Labor
• Fetal HR: external or internal monitor:
fetal scalp electrode (FSE)
• Leopolds maneuvers
• Locate fetal back
• 1st stage: FH q 30 mins
• 2nd stage: FH q 5 mins
• EFM Terms
• Baseline
• Variability
• Periodic changes
• Non-periodic changes
Early Decelerations
• occur with contractions
•
•
•
•
•
Rounded in shape
Gradual: > 30 secs from onset to bottom (nadir)
Start of decel is with start of UC
Nadir coincides with peak of UC (mirror image)
Benign: caused by head compression, more
common in primigravidas
•Head compression→ ↓cerebral blood
flow→ vagal response→ ↓ HR
Variable Decelerations
• Independent of Contractions
• hypertonic UCs, cord compression)
• V, W or U shaped, variable in size, shape & timing
to UCs
• Abrupt: < 30 secs from onset to nadir
• At least 15 bpm down and 15 secs long (less than
2 minutes)
• assoc. with oligoydramnios
•Cord compression
• Total cord occlusion → fetal hypertension or
hypoxemia → stimulation of fetal baroreceptors
or chemoreceptors → central vagal stimulation
→ variable decel
Late Decelerations
• occur with UC’s
•
•
•
•
•
Rounded in shape
Gradual: > 30 secs from onset to nadir
Start is AFTER start of UC
Nadir is AFTER peak of UC (offset)
Need to be addressed--ominous if persistent
and occurring with more than 50% of UC’s.
Consider expedited delivery.
•Uteroplacental Deficiency:
↓
intervillous blood flow → fetal hypoxemia →
anerobic metabolism → ↑ lactic acid →
metabollic acidosis → myocardial & CNS
depression
Decelerations
• Prolonged-can be variable or late type
• Visually apparent ↓ in rate--at least 15 bpm
below baseline
• Lasting 2 to 10 minutes ( > 10 = bradycardia)
• Causes:
• Cord compression, maternal hypotension
(epidural/spinal), tetanic (hypertonic) UCs, maternal
seizure, narcotic overdose/respiratory depressions
rapid fetal descent, uterine rupture, abruption
• Address immediately for cause and correct.
• Consider expedited delivery if doesn’t correct
Intrauterine Fetal Resuscitation
•
•
•
•
•
•
*Stop pitocin
Reposition to left lateral, Trendelenberg if needed
Oxygen via mask at 8-10 L/min
Increase IV fluids
SQ terbutaline (0.25 mg) if uterus not relaxing
Vaginal exam for possible cause: prolapse, fetal
descent, rupture, abruption
• Amnioinfusion for variable decels
• Notify MD/midwife
A
B
Which strip shows signs that immediate
intervention is needed? Why? What
would you do?
Case Study
• M.V. is a 17 year old in her first pregnancy. She
states she is 36 weeks pregnant and has not received
any prenatal care. The following assessments are
made by the RN:
• Vital signs: 110/72, 82, 16, 98.4
• Fundal height: 32 cm
• Patient states she has not felt the baby moving today
• What is your assessment of baby’s well-being?
• Does this client need any additional testing for fetal
well-being? If so, what?