chapter 68 High-Risk Pregnancy and Childbirth

Amniocentesis: -the insertion of needle through the maternal abdominal wall into the amniotic sac to withdraw amniotic fluid * invasive test can be performed in the examiner's office or on an outpatients basis

*an ultrasound scan should always precede amniocentesis to determine the location of the placenta and the fetal parts * examiner confirms the fetal position by palpation, cleanses the area, and anesthetizes the skin site * a long sterile needle in inserted through the woman's abdominal and uterine walls into the amniotic sac * approx 20ml of fluid is removed * the needle is then removed and the insertion site is covered with a bandage

potential problems: *fetal death *macrosomia (pversized fetus) *fetus with respiratory disorder *difficult labor *preeclampsia or eclampsia * polyhydramnios * congenital malformations

*diabetes is usually more difficult to control during pregnancy * may become hyperglycemic, with resulting acidosis or diabetic coma * may become hypoglycemic with resulting fetal hypoxia * depending on the condition of the woman and fetus, diabetic women may deliver early (36-38 weeks) by induction or cesarean delivery

* follow -up after delivery of a hydatidiform mole is essential * human chorionic gonadotropin (hCG) titer must be done, the titer ratio should fall after delivery * titer that remains high or rises often indicates a situation known as choriocarcinoma which can be fatal and is treated with chemotherapy

*woman should avoid pregnancy for at lest 1 yr until a series of negative hCG levels are found and chemotherapy treatment is finished * any contraceptive method other than an intrauterine device is acceptable * if the woman is Rh negative admin of an anti-D gamma globulin (e.g. RHoGAM) is required to prevent Rh sensitization

INEVITABLE ABORTION *the loss of the roducts of conception cannot be prevented *increased cramping and blood loss with progressive cervical dilation characterize this type of abortion

INCOMPLETE ABORTION *occurs when the uterus expels some products of conception but retains others *extensive bleeding may occur * physician may perform a dilation and curettage (D&C) *also called dilation and evacuation * the surgeon dilates the cervix and then inserts instruments into the uterus * the uterine walls are scraped to remove any products of conception

DISORDERS AFFECTING THE FETUS infection Rh sensitization

INFECTIONS * respiratory disease such as viral pneumonia can cause fetal anoxia * if the woman contracts rubella early in preg fetal malformation is a strong possibility * a woman how's titer is low (<1:10) does not have the antibodies to fight rubella

placental growth or functioning, intrauterine infection, or pregnancy-induced hypertension

Nursing Considerations:(amniocentesis) instruct the client to empty her bladder before the test (to prevent bladder rupture) * monitor the woman's vital sighns during the test and for at least 1 hr afterward * monitor feta heart tones (FHT's) to ensure that the fetus is not in distress *the external fetal monitor is most often used * instruct the woman to notify the birth attendant if she has any dificulties after returning home, including any bleeding or cramping

SEPTIC ABORTION *when contents of the uterus become infected before or during an abortion, or when the uterus becones infected later * septic (endotoxic)shock may occur and may cause maternal death

RECURRENT SPONTANEOUS ABORTION *habitual abortion * a woman has lost three or more successive pregnancies * often caused by an incompetent cervix that dilates prematurely * birth attendant usually makes every possible efort to save the pregnancy * attempts are made ot determine the cause of the recurrent abortions and to correct the situation of possible * sometimes surgery may correct a problem causing the loss

maternal STI's are often transmitted to to the feus * maternal/fetal circulation transmits syphilis, gonorrhea, herpes virus 2, and human immunodeficiency virus or acquired immunodeficiency syndrome (HIV/AIDS)

RH SENSITIZATION * preventable in most cases * newborn in this situation is known as erythroblastosis fetalis * usually occurs at or near the delivery

MILD PREECLAMPSIA * may be treated at home with sedation or tranquilizers and a regular diet * most cases salt is omitted * resting in a lateral position (particularly the left side ) aids in placental circulation * encouraged to rest most of the time and avoid climbing

SEVERE PREECLAMPSIA *must be admitted to a healthcare facility * the eclampsia that may follow is one of the three leadong causes of maternal death in NA

2 major categories of abortions 1. spontaneous (by natural cause or without medical intervention; "miscarriage 2. induced or therapeutic ( with medical intervention by way of mechanical assistance or medical agents)

SPONTANEOUS ABORTION * approx 10-20% of all pregnancies end in spontaneous abortion * fetal abnormalities or defects are the most frequent causes of spont abort * maternal alcohol use and cigarette smoking nay contribute * other causes include maternal disorders, trauma(e.g. motor vehicle accident) dietary factors, and abnormalities of pregnancy

efforts to save the fetus may include intrauterine transfusions (exchange of fetal blood in utero) if the pregnancy is less than 32 wks duration or early delivery at 34 to 38 wks

admin anti-D gamma globulin as known as Rh0(D) immune globulin (RH0 GHAM, Gamulin Rh) to the Rh negative woman can prevent erythroblastosis fetalis * this drug can be administered at 28 wks of gestation and again after 72 hrs * or after the birth of an Rh-positive baby, any abortion, or any invasive procedure such as an amniocentesis * RhoGAM prevents the woman's body from building up anti-Rh-positive antibodies * erythroblastosis fetalis is thus preventd even in Rh-positive fetuses

other conditions can be diagnosed including the congenital conditions of muscular dystrophy and cystic fibrosis as well as some fetal abnormalities such as spina bifida

*amniotic fluid analysis will also reveal a test for fetal lung maturity, called the LS ration *amniocentesis is frequently used to determine the status of an Rh-positive fetus in an Rh-negative woman

OXYTOCIN CHALLENGE TEST(OCT) *known as the contraction stress test *a way to evaluate the response of the fetal heart to contractions * nipple stimulation can initiate uterine contractions, but most often intravenous(IV) oxytocin is used

(OCT) * an IV administration of oxytocin by infusion pump is begun * an IV administration increases until three contractions occur within 10 minutes * the reaction of the fetal heart is determine using the fetal monitor * if toward the end of a contraction, the fetal heart rate decreased (late deceleration), uteroplacental insufficiency is indication, which may lead to fetal death

ULTRASONIC SCANNING: uses high-frequency sound waves to visualize intrauterine activity and structures * the graphic recording of this picture is called sonogram * from this image the examiner can learn much about the developing fetus

* a transducer placed on the skin of the abdomen, passes sound waves into the fetus * cause of various densities of body tissues (e.g. bone and muscle) the waves are echoed back to the transducer at different rates * a computer transforms the echo into an image on the monitor

signs and symptoms of hydatidiform * vaginal bleeding * uterus that is larger than expected for the weeks of pregnancy * anemia * excessive nausea and vomiting * signs of pregnancy-induced hypertension occuring before 24 wks of pregnancy *no fetal heart beat, fetal movement, or palpable fetal parts are detectable

* after diagnosis is certain, a physician usually performs a careful D&C * documentation following a client's D&C should include the amount and character of the expelled tissue, which should be saved and sent for pathologic exam * aseptic techniques should be used to avoid infection * the woman needs a great deal of emotional support because the experience is frightening

Make sure the client and the family understand the following precautions: * visiting is restricted *the room is kept quiet and fairly dark *sedatives are given * padded side rails are up at all times for safety * the woman is on bed rest * the woman should lie on her left side as much as possible (rationale: this helps to facilitate renal circuation in the woman and placental circulation for the fetus) * all intake and output are measured * vital signs are taken often; weight is taken often * blood is drawn periodically for testng * the fetus is monitored

* drug of choice in the treatment of severe preeclampsia (and prevention of eclampsia) is magnesium sulfate (MgSO4) given via IV or intramuscularly (IM) * this potent anticonvulsant drug slows neuromuscular conduction and depresses central nervous system irritability thus reducing muscular excitability and hyperreflexia

COMPLICATIONS OF ABORTION * when the placenta separates from the uterus, large blod vessels are exposed, which can lead to severe infection or hemorrhage

* during the time when most abortions were performed illegally and generally under unsanitary conditions, sepsis was a common concern

ECLAMPSIA * few women progress to this serious stage *most severe complications of pregnancy

* generalized tonic-clone seizures, very rapid pulse, and very high blood pressure characterize eclampsia which develops in 1 of every 200 women with preclampsia

diagnosis is most often obtained by ultrasonography (Doppler ultrasound) which can usually identify the exact placental location * some situations , X-rays, may be used (including placentography) to visualize the placenta

* if fetus is under 36 weeks gestation the mother is put on strict bed rest * if no bleeding occurs ultrasound scanning may be done every 2 to 3 wks along with nonstress testing and biophysical profile * if bleeding is found, a cesarean delivery is anticipated

* the treatment for eclampsia is basically the same as that for severe preeclampsia, with delivery performed as soon as possible

* if seizures continue, the coma deepens * slushy respirations characteristic of lung edema are audible * prognosis is poor * primary causes of maternal death caused by hypertension are circulatory collapse, cerebral hemorrhage, and renal failure * major complication is abruptio placentae with maternal hemorrhage

* predisposing factors or placenta previa are numerous and include closely spaced pregnancies, abnormalities in uterine structure, late fertilization, and old cesarean scars * painless vaginal bleeding during the later months of pregnancy * primary symptoms caused by the placenta separating from the uterine wall

* if undetected before labor begins, placenta previa will result in hemorrhage because the cervical dilation causes increased tearing of the placental tissue * total placenta previa cesarean delivery *

when treating the woman with preeclampsia, check intake and output and body weight daily * output must be at least 30 ml per hr * may have an indwelling catheder * take vitals signs at least q2hrs * use fetal monitor to assess fetal status *

* low-fat, high-proteindiet may be necessary * may be npo and have an IV such as Ringers solution * check urine for albumin at least twice daily * reduce external stimuli as much as possible

therapeutic abortion may be recommended for a woman whose life is in jeopardy due to the stress of pregnancy

* medical reasons for therapeutic abortion include ---severe maternal cardiac disease ---severe renal or hypertensive disorder ---fetus with a high probability of congential anormaly ---in some maternal psychiatric disorders or family crises may be performed as an elective procedure

ABO INCOmPATIBILITY *type of hemolytic disease of the newborn * can arise of the woman's blood type is A and the fetus's is B or AB * if the mother is B and the fetus is A or AB * if the mother is O and the fetus is A,B, or AB

* not detectable before birth clinically milder than Rh sensitization * problem indicated by jaundice in the newborn within the first 24 to 36 hrs * phototherapy treatment for jaundice

Cause of hyperemesis gravidarum is unknown but vauous theories include * toxins in the bloodstream * possible hormonal imbalances * emotional conditions related to digestive disturbances

women whose established reaction to stress involves gastrointestinal disturbances often react the same way to pregnancy

ABRUPTIO PLACENTAE * the abrupt premature separation of the normally implanted placenta from the uterine wall * grave complication of late pregnancy * usually develops after the 20th wk of gestation and it often occurs without labor

some predisposing factors of abruptio placentae: *hypertension * preeclampsia * poor placental circulation * substance abuse * grand multiparity *numerous abortions of stillbirths

THE PREGNANT WOMAN WITH DIABETES *client and family education --method for self-testing blood for glucose several times a day --insulin and diet adjustments based on glucose level --method for insulin injections if the woman has not used insulin previously --signs of hyperglycemia or hypoglycemia occurs --signs and symptoms of beginning preeclampsia

CARDIAC DISORDERS *pregnancy places additional strain on the heart * cause of the increased blood flow the greatest dangers are during the last trimester, labor and delivery * with history of cardiac problems should be asses for dyspnea,chest pain, pulmonary edema

some habitual and spontaneous abortions are the result of premature cervical dilation during the second or early third trimester of pregnancy *this situation is called incompetent cervix * premature cervical dilation means that the cervix is unable to support a pregnancy * the weight of the fetus is sufficient to force the cervix to dilate, causing a spontaneous abortion

CAUSES: *cervical infections (e.g. chlamydia) * cervical or vaginal cancer * previous cervical biopsies or conization * prior multiple dilation and curettage procedures *

THREATENED ABORTION exist any time bleeding or cramping occurs in the first 20 wks of pregnancy without major cervical dilation * many birth attendants will not take extreme measures to save such a pregnancy because a spontaneous abortion is often nature's way of disposing of a malformed fetus * if bleeding is slight, hormones or muscle relaxer's are given * client is put in bed with feet elevated for 48 to 72 hrs * if bleeding stops she may resume linited activities * if true uterine contractions occur the prognosis is more guarded

COMPLETE ABORTION occurs when the woman spontaneously expels all the products of conception (e.g. the placenta and fetus) * uterus then contracts toward normal size, and normal delivery is given to the woman * observe the client closely for signs of hemorrhage * check ger b/p to see that it remains stable * note and report any changes in skin color, especially pallor or cyanosis * check for pulse( weak rapid pulse is a sign of shock) * birth attendant checks to make sure the uterus is contracted * document the number of perineal pads the client uses and the amount of bleeding

certain congenital disorders which amniocentesis can determine at about the 14th wk of gestation are an indication for abortion to avoid birth of a severely impaired child * if a woman has rubella (German measles) during pregnancy, especially during the first trimester the likelihood of fetal defects is strong and an abortion may be performed *chapter 74

CRIMINAL OR ILLEGAL ABORTION * an intervention in pregnancy without medical or legal justification * because illegal abortions are in unsterile environments the risks to the pregnant woman are great * major risks include hemorrhage and infections

Potential complications of placenta previa: *loss of uterine muscle tone (atony) *uterine rupture *retention of placental tissue *air embolism- serious complication caused by exposure of uterine sinuses and blood vessels to the air *** the fetus is at considerable risk and fetal shock and maternal or fetal death are possible

DIAGNOSIS MANAGEMENT *if vaginal bleeding occurs the client should be hospitalized immediately and placed on bed rest *fetal monitoring, IV and blood admin, possible cesarean delivery,vaginal packing and emergency infant resuscitation should be anticipated

EXISTING DISORDERS COMPLICATION PREGNANCY *diabetes mellitus * cardiac disorders * chemical dependency

DIABETES MELLITUS * endocrine disorder in which the pancreas fails to produce sufficient insulin for proper use of glucose

physical trauma can cause immediate placental separation * the extent of the separation determines the amount of danger to the fetus * common cause of stillbirth

DIAGNOSIS AND MANAGEMENT * can occur at any time in pregnancy before birth, giving rise to fetal distress * bleeding may be apparent of hidden * if bleeding is externally visible it is often dark * uterus becomes tender and rigid and symptoms of maternal shock, may occur * fetal movement may increase or decrease * if the woman feels pain or the uterine fundus rises it may indicate bleeding and pooling behind the placenta (retroplacental hemorrhage)

*Untreated postabortion sepsis can be fatal *sterility (the inability to conceive) is another common result * therefore maintaining surgical asepsis (sterile conditions) and removing all the products of conception from the uterus are vitally important

therapeutic abortions involve complex and difficult decisions * regardless of the decision, depression, guilt, and anger are not uncommon psychological concerns

a woman's blood pressure that spontaneously and rapidly drops may indicate maternal hemorrhage

ECTOPIC PREGNANCY * pregnancy is one that implants outside the uterus * ectopic means outside

NURSING CONSIDERATIONS ( NST) *explain the steps of the testing and assisting the client physically and emotionally during the procedure * woman needs an empty bladder * should be positioned in an semi-fowler's position * after testing, the nurse assists the wonan off the table and allows her to void * fluids may be encourages at this time * if serial NST's are scheduled discuss the date and tine of the next test with the woman * healthcare provider will generally discuss the results of the testing

FETAL BIOPHYSICAL PROFILE * combines and NST with ultrasonic etal assessment to check for fetal well-being * using ultrasound, the examiner evaluates fetal breathing, fetal movement, fetal tone, amniotic fluid volume, and placental grade * these components including the NST are scored between 0(abnormal) to 12 (normal) * with a score of 8 to 12 the fetus is considered to be doing well

common questions may include situations that need immediate nursing actions such as with ectopic pregnancy

GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE) * embryo dies in utero * the chorionic villi degenerate, forming grape-like clusters of vesicles * at first the pregnancy seems normal but then the uterus enlarges more rapidly than usual * the woman has episodes of spotting and bleeding with brownish-red discharge of tapiocalike vesicles\ * the mole can become very large

any bleeding in pregnancy or labor is serious sign and must be reported immediately to the healthcare provider

HYPEREMESIS GRAVIDARUM * pernicious vomiting * more severe than normal morning sickness

NONSTRESS TEST (NST): * provides information on the fetal heart rate in response to fetal activity * gives the healthcare provider an indirect measurement of uteroplacental function * healthy fetus is active in utero and the fetal heart rate normally increases as the fetus moves in the uterus * monitoring process is carried out for approx 40 minutes * procedure is usually performed after 28 wks generally performed in a location that is close to place where the woman can deliver the baby if necessary

INFORMATION PROVIDED (NST) * reactive -when at least two episodes of fetal heart rate accelerations of 15 beats per min (bpm) period within a continuous 10-minute per * reactive test shows that the fetal heart rate increases with every fetal movement and that the fetus is doing well * nonreactive test- -shows that the fetal heart rate did not increase with activity * fetus may be experiencing lack of oxygen * fetus may not be active during the course of the test *fetus is then stimulated by other methods ( palpating or shaking the uterus, making loud noises, or stimulating the woman's nipples

Maternal serum a-fetoprotein (MSAFP) levels are increasingly used as a screening tool to detect the presence of fetal neural tube defects and open abdominal wall defects early in pregnancy

INTERRUPTED PREGNANCY * may be due to abortion, premature cervical dilation, ectopic pregnancy or hydatidiform mole

birth attendant may order an amniocentesis when he or she suspects intrauterine growth restriction (IUGR) which generally results in an infant who is small for gestational age (SGA)

IUGR can begin at any time during pregnancy and is lnked to inadequate amounts of oxygen and nutrients necessary for fetal growth * causes related to maternal conditions include diabetes (gestational or long-standing)

* because the drug's effects on the central nervous system assess the woman's respirations and deep-tendon reflexes frequently * observe and report any changes * also monitor urinary output because oliguria can result from excessively high levels of MgSO4 * calcium gluconate (Kalcinate) is the specific antidote for MgSO4 * kept by the bedside in case of toxicity

If MgSO4 does not control seizures, diazepam (Valium) may be used * furosemide (Lasix) may be needed to stimulate urine output *K+ often is given with Lasix *other medications ---hydralazine HCL (Apresoline) is the antihypertensive agent of choice ---labetalol HCL (Normodyne) methyldopa (Aldomet,Dopamet,(Canada)) and nifedipine (Adalat, Procardia) are sometimes used

*amniocentesis involves some risk *placental and fetal damage, premature labor, or abortion may result, although the use of ultrasound minimizes the risks

Information Provides: testing of amniotic fluid can reveal a number of abnormalities * it can diagnose some disorders causing fetal intellectual impairment, such as Down syndrome or the genetic condition known as Tay-Sachs disease

damage to the fetus may include anemia, anoia and death

NURSING CONSIDERATIONS * DIAGNOSIS OF ABRUPTIO PLACENTAE IS BASED ON THE CLIENT'S history, physical exam, and lab studies * sonogrmas are used to rule out placenta previa but they are not diagnostic for placental abruption * amount of vaginal bleeding seen can be misleading because blood may be trapped behind the placenta * nurse must be aware of changes in vital signs and indicators such as sudden extreme pain or aberrations in uterine shape

surgical methods and the use of blood transfusion have greatly reduced maternal mortality * prognosis of the fetus depends on the effect of maternal hemorrhage on fetal circulation and oxygenation

NURSING CONSIDERATIONS * observe the mother closely for hemorrhage following a placenta previa delivery * if bleeding continues to be severe and attempts at control are unsuccessful and emergency hysterectomy may be performed

INFORMATION PROVIDED(OCT) *provides information on how well the placenta is supplying oxygen to the fetus *particularly useful in detecting fetuses that are beginning to experience difficulty because of inadequate placental circulation * classified as a positive when there are persistent late decelerations with more than 50% of the contractions * a decision is made about continuing the pregnancy or preforming a cesarean delivery

NURSING CONSIDERATIONS (OCT) * although it is not dangerous it may stimulate labor * generally performed in the labor and delivery area of the healthcare facility-after the fetus is viable (after 20 wks)

INFORMATION PROVIDED : ultrasound scan determine gestational age, fetal head size, location of the placenta, and some fetal abnormalities *identify multiple pregnancies and in some cases, it can also determine the sex of the fetus * also used in conjunction with tests such as amniocentesis * women are often allowed to watch the fetus move and listen to the heartbeat * she is usually given a print or videotape of the ultrasound to take home

NURSING CONSIDERATIONS: (ultrasonic scan) *explain to the woman that a full bladder is necessary for the test so that the fetal parts wll move up into the abdomen allowing for better visualization of the fetus, * ask the women to drink large amounts of liquids * tell her she will not be allowed to empty her bladder * the test takes 20 minutes with no known harmful effects * noninvasive

PLACENTAL AND AMNIOTIC DISORDERS * placenta previa -the placenta implants into the wrong place within the woman's uterus * abruptio placentae-the placenta tears abruptly and prematurely from the uterus * both can be life-threatening to the woman and the fetus *polyhydramnios or excessive amniotic fluid presents serious dangers t the fetus

PLACENTA PREVIA * when the placenta implants in the lower segment of the uterus rather than in the upper wall * low implantation is placental attachment at the opening or border of the cervical os but not covering it *partial placenta previa- partially obliterates the cervical os * total placenta previa-when the placenta totally covers the cervical os

in some cases of hyperemesis gravidarum an abortion may be necessary

PREGNANCY-INDUCED HYPERTENSION (PIH) *hypertension, edema, and proteinuria are conditions that characterize PIH

OTHER TESTS * Percutaneous umbilical blood sampling (PUBS) and chorionic villus sampling (CVS) -- diagnose fetal defects early in pregnancy --invasive --serious risk for fetus and women --usually done if considering abortion because of serious genetic defect

PUBS has also become the preferred method of intrauterine blood transfusion for Rh-sensitized fetuses because it can be done early in the pregnancy

* not all of these parameters must be present for the diagnosis of PIH * edema is more indicative of advancing disease and multiorgan involvement *PIH may occur antepartally, intrapartally or postpartally * it is a major contrubutor to maternal and fetal morbidity and mortality

symptoms of PIH result from vasoconstriction and vasospasm of blood vessels throughout the body * central nervous system, kidneys, and liver may be affected * decreased blood flow to the placenta and uterus may endanger the fetus

PREeCLAMPSIA * woman who previously was experiencing normal progression of pregnancy but who develops PIH with edema, proteinuria, or both (usually after the 20th wk of gestation)

preeclampsia develops in approx 5% of pregnancies * most often in primigravidas and in women with a history of high blood pressure or vascular disorders * although the symptoms most often allow the obstetrician to intercept preeclampsia and treat it early, it can occur explosively, perhaps the day after an exam * should report symptons immediately

INDUCED ABORTION * therapeutic abortion * criminal or illegal abortion

THERAPEUTIC ABORTION * legal termination of pregnancy under a physician;s direction * induced abortion before 16th to 20th wk of gestation is legal in the U.S. and in may other countries although an abortion may be difficult to in some areas * it may be done or medical or personal reasons

high risk pregnancy (at-risk pregnancy) used physiologic or psychological factors could significantly increase the chances of mortality or morbidity of the woman or fetus

Tests to asses fetal status: (most common) *amniocentesis *ultrasonic scanning *oxytocin challenge test * nonstress test

PIH is divided into preeclampsia and eclampsia depending on symptoms

The HELLP syndrome indicates a potentially life-threatening complication of pregnancy-induced hypertension Hemolysis(destruction of red blood cells (RBC's) Elevated Liver enzymes Low Platelet count

blood glucose testing, dietary adjustments and danger signs that must e reported are necessary teaching for the diabetic woman and her family

gestational diabetes * develop diabetes for the first time during pregnancy *women who have delivered a baby weighing more than 9lbs are known to develop type 1 or 2 diabetes later

symptoms of an ectopic pregnancy *spotting or bleeding 2 to 4 weeks after a mused menstrual period * often pain accompanies the bleeding, which may be quite severe

a tubal pregnancy requires surgical removal of part or all of the affected tube to prevent rupture an untreated ectopic pregnancy can be rapidly fatal due to shock from blood loss after tubal rupture

treatment depends on the severity of maternal blood loss, determined by lab findings, fetal maturity and the biophysical condition of both the woman and the fetus

continuously monitor the fetus of a fetal fetal heart rate is present * identify the upper limit of the fundus and mark it on the woman's abdomen with a felt-tip pen * observe the fundus for changs in shape or movement upward * measure abdominal girth (the distance around) with a flexible tape measure * if the abdomen increases in firth or moves upward, blood may be collecting within the uterus; this dangerous situation usually calls for immediate cesarean delivery

possible maternal complications: * bleeding into the uterine muscles * precipitous labor ( fast and uncontrolled) * loss of uterine tone(atony) * oliguria leadin to acute renal failure

disseminated intravascular coagulation (DIC) and maternal death may occur

CHEMICAL DEPENDENCY *addicted pregnant woman may be malnourished * may result in failure to seek antepartal care

drug use may result in: *stillbirth *spontaneous abortion * abruptio placentae * numerous congenital defects

most common ectopic pregnancy is tubal pregnancy * rare for abdominal and ovarian pregnancies to be seen

factors predisposing to ectopic pregnancy *tubal occlusion *intrauterine contraceptive device * tumors * pelvic infection * endocrine imbalances * abnormal tubal development

*prompt treatment of PIH includes controlling symptoms as much as possible and allowing labor to start normally or initiating it when the safety of the woman and fetus best permits

following delivery the woman with PIH must continue to be monitored * if elevated blood pressure continues for more than 42 days after delivery she is diagnosed with chronic hypertension

MISSED ABORTION * occurs when the fetus has died but remains in the uterus * if the fetus is not expelled spntaneously withn 1 month the pregnancy will be terminated and a D&C will be performed

for inevitable, incomplete, and missed abortions, occurring between 16 and 20 wks dinoprostone (ProstinE2)may be administered to the mother * cause the uterus to expel the fetus

ABORTION(AB) * the natural or artificial (through medical intervention) termination o a pregnancy * occurs commonly in nature

if the aborting woman is Rh-negative a specific anti-D immune globulin such as Rh immune plobulin (Rho-GAM) should be given as a precautionary measure against Rh-sensitivity

few drugs can be used without potential harm to the fetus * may receive IV glucose and water with electrolytes, antiemetics, and sedatives

in the more advanced stages: *headache *mental aberrations *delirium *coma *jaundice *cyanosis

6 week check=up should nclude extensive evaluation of the woman's blood pressure, complete blood count, blood urea nitrogen, urinalysis, and creatinime level

magnesium sulfate the drug of choice for PIH is often continued for 24 hrs after delivery

cervical weakness may be congenital * one such cause is maternal exposure to diethylstillbestrol inutero

minor surgical procedures are often used for the pregnant woman with an incompetent cervix * a nonabsorbable suture called a cervical cerclage or cervical ring is placed around the cervix * it holds the cervix closed during the remainder of the pregnancy * when the woman begins labor the suture or the ring is removed * if the cerclage is permanent the woman requires a cesarean delivery

the loss or termination of a pregnancy has physical, psychological, and emotional consequences for the woman

nursing care focus on meeting the woman's immediate needs and providing support

predicting preeclampsia is also possible with a test in which the client's blood pressure is measured while she lies on her back and gain while she lies on her left side * referred to as the roll-over test

of diastolic bp is 20mmHg higher when she is lying on her back preeclampsia is likely * should lay on her left side as much as possible * seen every 2 days during pregnancy

woman's bp should not be reduced too much or too quickly, to avoid causing fetal anoxia * maintain bp in the range of 90 to 100 diastolic

oxytocin (pitocin) used to induce labor

morning sickness usually begins between the second and fourth week of gestation and ends at approximately the 12th week * it may continue throughout the pregnancy

persistent vomiting to the point of excessive weight loss, dehydration, severe loss of appetite and acetone in the urine are signs of hyperemesis gravidarum * may also have excessive salivation (ptyalism), epigastric and rib discomfort, constipation or diarrhea, nutritional, anemia, and electrolyte imbalances