Saunders Chapter 22 Risk Conditions Related to pregnancy

a. Antepartum: Orally beginning after 12 weeks of gestation, maternal HAART is given to reduce the viral load to undetectable. b. Intrapartum: Intravenously during labor, zidovudine is given 1 hour before a vaginal birth and 3 hours before a cesarean section if the HIV RNA is greater than or equal to 400 copies/mL or unknown. c. Postpartum: In the form of syrup to the newborn 2 hours after birth and every 12 hours for 6 weeks; depending on agency procedures, the newborn may need to be placed in the newborn intensive care unit (NICU) to begin initial therapy.

1.Three-drug combination HAART (highly active antiretroviral therapy) treatment, which is monitored by an infectious disease specialist, is recommended to reduce mother-to-child transmission (MTCT). 2.Zidovudine is recommended for the prevention of MTCT and is administered based on the following recommendations:

If the viral load is less than 1000 copies/mL; otherwise, a cesarean section is recommended.

A vaginal birth is acceptable

A pregnancy that ends before 20 weeks gestation, spontaneously or electively

Abortion

1.Spontaneous vaginal bleeding 2.Low uterine cramping or contractions 3.Blood clots or tissue through the vagina 4.Hemorrhage or shock can result if bleeding is excessive

Abortion assessment

1.Maintain bed rest as orescribed 2.Monitor vital signs 3.Monitor for cramping and bleeding 4.Count perineal pads to evaluate blood loss and save expelled tissues and clots 5.Maintain IV fluids as prescribed; montior for hemorrhage or shock 6.Prepare client for D/C as prescribed for incomplete abortion 7.Adminster Rh D for Rh negative woman 8.Provide psychological help

Abortion interventions

1.Advanced maternal age 2.Those who previous miscarried 3.Previous elective abortion 4.Uterine abnormalities (adhensions or fibroids) 5.Prolonged time to achueve pregnancy 6.Low serum progesterone 7.Celiac disease 8.Thyroid dysfunction or Cushing's syndrome 9.Lupus 10.Infection, fever, trauma 11.Low BMI < 18.5 12.Smoking, alcohol, cocaine us, certain medications, high caffeine intake

Abortion risk factors

Premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered

Abruptio Placentae

1. Dark red vaginal bleeding. If the bleeding is high in the uterus or is minimal, there can be an absence of visible blood. 2. Uterine pain or tenderness or both 3. Uterine rigidity 4. Severe abdominal pain 5. Signs of fetal distress 6. Signs of maternal shock if bleeding is excessive C.

Abruptio Placentae assessment

1. Monitor maternal vital signs and fetal heart rate. 2. Assess for excessive vaginal bleeding, abdominal pain, and an increase in fundal height. 3. Maintain bed rest; administer oxygen, IV fluids, and blood products as prescribed. 4. Place the client in Trendelenburg's position if indicated to decrease the pressure of the fetus on the placenta, or place in the lateral position with the head of the bed flat if hypovolemic shock occurs. 5. Monitor and report any uterine activity. 6. Prepare for delivery of the fetus as quickly as possible, with vaginal delivery preferable if the fetus is healthy 7. Monitor for signs of disseminated intravascular coagulation in postpartum period

Abruptio Placentae interventions

1. Excessive thirst 2. Hunger 3. Weight loss 4. Frequent urination 5. Blurred vision 6. Recurrent urinary tract infections and vaginal yeast infections 7. Glycosuria and ketonuria 8. Signs of gestational hypertension and preeclampsia 9. Polyhydramnios 10. Large for gestational age fetus

Assessment gestational diabetes mellitus

1. Uncontrolled bleeding 2. Bruising, purpura, petechiae, and ecchymosis 3. Presence of occult blood in excretions such as stool 4. Hematuria, hematemesis, or vaginal bleeding 5. Signs of shock 6. Decreased fibrinogen level, platelet count, and hematocrit level 7. Increased prothrombin time and partial thromboplastin time, clotting time, and fibrin degradation products

Assessment of DIC

a. Caused by Haemophilus vaginalis (Gardnerella vaginalis) and transmitted via sexual contact b. Associated with premature labor and birth

Bacterial vaginosis

a. Metronidazole may be prescribed. b. Sexual partner may need to be treated

Bacterial vaginosis interventions

a. Client complains of "fishy odor" to vaginal secretions and increased odor after intercourse. b. Microscopic examination of vaginal secretions identifies the infection.

Bacterial vaginosisa assessment

1.Position thumb over client's biceps tendon, supporting client's elbow with the palm of the hand. 2.Strike a downward blow over the thumb with percussion hammer. 3.Normal response: Flexion of the arm at the elbow

Biceps assessment of reflexes

There is dark red vaginal bleeding, uterine pain or tenderness or both, and uterine rigidity.

Bleeding abruptio placentae

There is painless, bright red vaginal bleeding, and the uterus is soft, relaxed, and nontender.

Bleeding placenta previa

1.Montior for vital signs, FHR, and conditions of the fetus 2.Limit physical activities, and stress the need for rest 3.Monitir signs of cardiac stress and decompression 4.Encourage adequate nutrition to prevent anemia (which will worsen teh cardiac status) 5.Low sodium diet 6.Avoid excessive weight gain

Cardiac diease interventions

1.Montior vital signs frequently 2.Place the client on a cardiac monitor and EFM 3.Maintain bedrest with client lying on side with head and shoulders elevated 4.Adminsteroxygen if prescribed 5.Manage pain early in labor 6. Use controlled pusing methods to decrease cardiac stress

Cardiac diease patient during labor

1.Signs and symptoms of cardiac decompression A.Cough and respiratory congestion B.Dyspnea and fatigue C.Palpitations and tachycardia D.Peripheral edema E.Chest pain 2.Signs of respiratory infection 3.Signs of HF and PE

Cardiac disease assessment

a. Sexually transmitted pathogen associated with an increased risk for premature birth, stillbirth, neonatal conjunctivitis, and newborn chlamydial pneumonia b. Can cause salpingitis, pelvic abscesses, ectopic pregnancy, chronic pelvic pain, and infertility c. Diagnostic test is culture for Chlamydia trachomatis.

Chlamydia

a. Usually asymptomatic—may have dysuria or dyspareunia b. Bleeding between periods or after coitus c. Mucoid or purulent cervical discharge d. Dysuria and pelvic pain

Chlamydia assessment

a. Screen the client to determine whether she is high risk; this is indicated for all pregnant clients if the client is in a high- risk group or if infants from previous pregnancies have developed neonatal conjunctivitis or pneumonia. b. Instruct the client in the importance of rescreening, because reinfection can occur as the client nears term. c. Ensure that the sexual partner is treated for the infection. d. Treatment for both gonorrhea and chlamydia should be done, which includes antibiotics. e. Complications in pregnancy may include septic spontaneous abortion or miscarriage, preterm delivery, premature rupture of the membranes (PROM), chorioamnionitis, disseminated gonococcal infection, ophthalmia neonatorum, postpartum metritis

Chlamydia interventions

a. Screen the client to determine whether she is high risk; this is indicated for all pregnant clients if the client is in a high- risk group or if infants from previous pregnancies have developed neonatal conjunctivitis or pneumonia. b. Instruct the client in the importance of rescreening, because reinfection can occur as the client nears term. c. Ensure that the sexual partner is treated for the infection. d. Treatment for both gonorrhea and chlamydia should be done, which includes antibiotics. e. Complications in pregnancy may include septic spontaneous abortion or miscarriage, preterm delivery, premature rupture of the membranes (PROM), chorioamnionitis, disseminated gonococcal infection, ophthalmia neonatorum, postpartum metritis.

Chlamydia inteventions

Bacterial infection of the amniotic cavity; can happen because of premature or prolonged ROM, vaginitis, aminocentesis, or IU procedures *May result in neonatal sepsis and postpartnum endometritis

Chorioamnionitis

1.Uterine tenderness and contractions 2.Elevated body temperature 3.Maternal or fetal tachcardia 4.Foul odor to amniotic fluid 5.Leukocytosis

Chorioamnionitis assessment

1.Monitor maternal vital signs and FH 2.Monitor for uterine tenderness, contractions, and fetal activity 3.Monitor results of blood clutures 4.Prepare for amniocentesis to obtain amniotic fluid for gram stain and leukocyte count other testing as prescribed 5.Adminster antibotics after cultures are obtained 6.Adminster oxytocic medications as prescribed to increase uterine tone 7.Prepare to obtain neonatal cultures after birth

Chorioamnionitis interventions

1.Position client with her legs dangling over the edge of examining table. 2.Support the leg with 1 hand and sharply dorsiflex client's foot with the other hand. Maintain the dorsiflexed position for a few seconds and then release foot. 3.Normal response (negative clonus response): -Foot remains steady in dorsiflexed position. -No rhythmic oscillations or jerking of foot is felt. -When released, foot drops to plantar-flexed position with no oscillations. 4.Abnormal response (positive clonus response): -Rhythmic oscillations occur when foot is dorsiflexed. -Similar oscillations are noted when foot drops to plantar-flexed position.

Clonus assessment of reflexes

1. Abruptio placentae 2. Disseminated intravascular coagulopathy 3. Fetal growth restriction 4. Preeclampsia and eclampsia 5. Intracranial hemorrhage; maternal cerebral hemorrhage or infarction 6. Subcapsular hepatic hematoma 7. HELLP (hemolysis, elevated liver enzyme levels, low platelet count) syndrome 8. Oligohydramnios 9. Placental insufficiency 10. The need for preterm delivery or cesarean delivery 11. Maternal and/or fetal death

Complications of hypertension and gestational hypertension disorders

a. is caused by human papillomavirus. b. Infection affects the cervix, urethra, anus, penis, and scrotum. c. Human papillomavirus is transmitted through sexual contact. .

Condyloma acuminatum

a. Infection produces small to large wart-like growths on the genitals. b. Cervical cell changes may be noted because human papillomavirus is associated with cervical malignancies

Condyloma acuminatum assessment

a. Lesions are removed by the use of cytotoxic agents, cryotherapy,electrocautery, and laser, but this is done for symptomatic relief only and is usually delayed until after birth. The genital warts often regress after delivery, and treatment outcomes may be poor until after delivery. b. Encourage annual Papanicolaou test. c. Sexual contact should be avoided until lesions are healed (condoms reduce transmission). d. Cesarean delivery is indicated only if genital warts are obstructing the pelvic outlet or if vaginal delivery would result in excessive bleeding

Condyloma acuminatum interventions

1. Organism is transmitted through close personal contact; it is transmitted across the placenta to the fetus, or the fetus may be infected through the birth canal. 2. The mother may be asymptomatic; most infants are asymptomatic at birth. 3. Cytomegalovirus causes low birth weight, intrauterine growth restriction, enlarged liver and spleen, jaundice, blindness, hearing loss, and seizures. 4. Antiviral medications may need to be prescribed for severe infections in the mother, but these medications are toxic and may only temporarily suppress shedding of the virus; risk versus benefit will be considered by the PHCP. 5. Maintain contact precautions.

Cytomegalovirus ("C")

1. Pregnancy places demands on carbohydrate metabolism and causes insulin requirements to change. 2. Insulin resistance and hyperinsulinemia may predispose some women to diabetes. 3. Maternal glucose crosses the placenta, but insulin does not. 4. The fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to hypoglycemic reactions. 5. The newborn of a diabetic mother may be large in size but has functions related to gestational age rather than size. 6. The newborn of a diabetic mother is at risk for hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, hypocalcemia, and congenital anomalies.

Diabetes Mellitus

1. Tests used to determine the presence of antibodies to HIV include enzyme-linked immunosorbent assay (ELISA), Western blot, and immunofluorescence assay (IFA). 2. A single reactive ELISA test by itself cannot be used to diagnose HIV, and the test should be repeated with the same blood sample; if the result is again reactive, follow- up tests using Western blot or IFA should be done. 3. A positive Western blot or IFA is considered confirmatory for HIV. 4. A positive ELISA that fails to be confirmed by Western blot or IFA should not be considered negative, and repeat testing should be done in 3 to 6 months.

Diagnosis HIV and AIDS

DIC is a maternal condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation

Disseminated Intravascular Coagulation (DIC)

1. Seizure typically begins with twitching around the mouth. 2. Body then becomes rigid in a state of tonic muscular contractions that last 15 to 20 seconds. 3. Facial muscles and then all body muscles alternately contract and relax in rapid succession (clonic phase may last about 1 minute). 4. Respiration ceases during seizure because diaphragm tends to remain fixed (breathing resumes shortly after the seizure). 5. Postictal sleep occurs.

Eclampsia

1. Remain with the client and call for help. 2. Ensure an open airway, turn the client on her side, and administer oxygen by face mask at 8 to 10 L/minute. 3. Monitor fetal heart rate patterns. 4. Administer medications to control the seizures as prescribed. 5. After the seizure has ended, insert an oral airway and suction the client's mouth as needed. 6. Prepare for delivery of the fetus after stabilization of the client, if warranted. 7. Document occurrence, client's response, and outcome.

Eclampsia event

1. Implantation of the fertilized ovum outside of the uterine cavity 2. Most common location is the ampulla of the fallopian

Ectopic Pregnancy

1. Missed menstrual period 2. Abdominal pain 3. Vaginal spotting to bleeding that is dark red or brown 4. Rupture: Increased pain, referred shoulder pain, signs of shock

Ectopic Pregnancy assessment

1. Obtain assessment data and vital signs. 2. Monitor bleeding and initiate measures to prevent rupture and shock. 3. Methotrexate, a folic acid antagonist, may be prescribed to inhibit cell division in the developing embryo. 4. Prepare the client for laparotomy and removal of the pregnancy and tube, if necessary, or repair of the tube. 5. Administer antibiotics; Rho(D) immune globulin is prescribed for Rh-negative women.

Ectopic Pregnancy interventions

1. the death of a fetus after the twentieth week of gestation and before birth. 2. The client can develop DIC if the dead fetus is retained in the uterus for 3 to 4 weeks or longer.

Fetal death in utero

1. Absence of fetal movement 2. Absence of fetal heart tones 3. Maternal weight loss 4. Lack of fetal growth or decrease in fundal height 5. No evidence of fetal cardiac activity 6. Other characteristics suggestive of fetal death noted on ultrasound

Fetal death in utero assessment

1. Prepare for the birth of the fetus. 2. Support the client's decision about labor, birth, and the postpartum period. 3. Provide support and ask what can be helpful; provide assistance as appropriate and requested. 4. Accept behaviors such as sadness, anger, and hostility from the parents. 5. Refer the parents to an appropriate support group.

Fetal death in utero interventions

1. Gestational diabetes occurs in pregnancy (during the second or third trimester) in clients not previously diagnosed as diabetic and occurs when the pancreas cannot respond to the demand for more insulin. 2. Women may be diagnosed with overt diabetes while pregnant as well, and as a result of personal risk factors such as being overweight or obese, there is an increased likelihood of overt, unrecognized diabetes. An HbA1C level may be helpful in making this determination. 3. There is an increased incidence of gestational diabetes when a woman also has polycystic ovarian syndrome. 4. Gestational diabetes frequently can be treated by diet alone; however, some clients may need insulin (selected oral medications that are safe during pregnancy may be prescribed). 5. Most women with gestational diabetes return to a euglycemic state after birth; however, these individuals have an increased risk of developing diabetes mellitus in their lifetimes. 6. Early screening at an initial prenatal visit is done if the client has predisposing conditions as risk factors. 7. The need for cesarean section is more likely, and neonatal hypoglycemia and macrosomia may be evident

Gestational Diabetes

a. an infection caused by Neisseria gonorrhoeae, which causes inflammation of the mucous membranes of the genital and urinary tracts. b. Transmission of the organism is by sexual intercourse. c. Infection may be transmitted to the newborn's eyes during delivery, causing blindness (ophthalmia neonatorum).

Gonorrhea

Usually asymptomatic; vaginal discharge, urinary frequency, and lower abdominal pain possible

Gonorrhea assessment

a. Testing is done during the initial prenatal examination to screen for gonorrhea; the screening may be repeated during the third trimester in high-risk clients. b. Instruct the client that treatment of her partner is necessary if infection is present. c. Complications are similar to those of chlamydia.

Gonorrhea interventions

0 Reflex absent 1 + Reflex present but hypoactive 2 + Normal reflex 3 + Hyperactive reflex 4 + Hyperactive reflex with clonus present

Grading Response reflexes

1. is a leading cause of life-threatening perinatal infections. 2. The gram-positive bacterium colonizes the rectum, vagina, cervix, and urethra of pregnant and nonpregnant women. 3. Meningitis, fasciitis, and intra-abdominal abscess can occur in the pregnant client if she is infected at the time of birth. 4. Transmission occurs during vaginal delivery. 5. Early-onset newborn GBS occurs within the first week after birth, usually within 48 hours, and can include infections such as sepsis, pneumonia, or meningitis; permanent neurological disability can result. 6. Diagnosis of the mother is done via vaginal and rectal cultures at 35 to 37 weeks of gestation. 7. Antibiotics may be prescribed for the mother during labor and birth; IV antibiotics may be prescribed for infected infants. 8. Maintain contact precautions.

Group B Streptococcus (GBS) (may be included as an "O" under TORCH complex)

1. HIV is the causative agent of AIDS. 2. Women infected with HIV may first show signs and symptoms at the time of pregnancy or possibly develop life-threatening infections because normal pregnancy involves some suppression of the maternal immune system. 3. Repeated exposure to the virus during pregnancy through unsafe sex practices or intravenous (IV) drug use can increase the risk of transmission to the fetus.

HIV and AIDS

1. occurs following the escape of blood into the maternal tissue after birth. 2.Predisposing conditions include operative delivery with forceps or injury to a blood vessel.

Hematoma

1.Abnormal severe pain 2.Pressure in perineal area (client feels like she need a bowel movement) 3.Palpable, senstive swelling in perineal area with discolored skin 4.Inability to void 5.Decreased hemoglobin and hematocrit levels 6.Signs of shock, such as pallor, tachycardia, and hypotension, if significant blood loss has occurred

Hematoma assessment findings

1. Monitor vital signs. 2. Monitor client for abnormal pain, especially when forceps delivery has been performed. 3. Apply ice to the hematoma site. 4. Administer analgesics as prescribed. 5. Monitor intake and output. 6. Encourage fluids and voiding; prepare for urinary catheterization if the client is unable to void. 7. Administer blood replacements as prescribed. 8. Monitor for signs of infection, such as increased temperature, pulse rate, and white blood cell count. 9. Administer antibiotics as prescribed; infection is common after hematoma formation. 10. Prepare for incision and evacuation of the hematoma if

Hematoma interventions

1. The risks of prematurity, low birth weight, and neonatal death increase if the mother has hepatitis B infection. 2. Hepatitis is transmitted through blood, saliva, vaginal secretions, semen, and breast milk and across the placental barrier.

Hepatitis B

1.Minimize the risk for intrapartum ascending infections (limit the number of vaginal examinations). 2.Remove maternal blood from the neonate immediately after birth. 3.Suction the fluids from the neonate immediately after birth. 4.Bathe the neonate before any invasive procedures including injections. 5.Clean and dry the face and eyes of the neonate before instilling eye prophylaxis. 6.Infection of the neonate can be prevented by the administration of hepatitis B immune globulin and hepatitis B vaccine soon after birth but after the newborn is bathed. 7.Discourage the mother from kissing the neonate until the neonate has received the vaccine. 8.Inform the mother that the hepatitis B vaccine will be administered to the neonate and that a second dose should be administered at 1 month after birth and a third dose at 6 months after birth.

Hepatitis B interventions

1. Herpes simplex virus affects the external genitalia, vagina, and cervix and causes draining, painful vesicles. 2. Acyclovir may be prescribed to treat recurrent outbreaks during pregnancy or used as suppressive therapy late in pregnancy to prevent an outbreak during labor and birth. 3. Virus usually is transmitted to the fetus during birth through the infected vagina or via an ascending infection after rupture of the membranes. 4. No vaginal examinations are done in the presence of active vaginal herpetic lesions. 5. Herpes can cause death or severe neurological impairment in the newborn. 6. Delivery of the fetus is usually by cesarean section if active lesions are present in the vagina; delivery may be performed vaginally if the lesions are in the anal, perineal, or inner thigh area (strict precautions are necessary to protect the fetus during delivery). 7. Maintain contact precautions.

Herpes simplex virus ("H")

1. Hydatidiform mole is a form of gestational trophoblastic disease that occurs when the trophoblasts, which are the peripheral cells that attach the fertilized ovum to the uterine wall, develop abnormally. 2. The mole manifests as an edematous grape-like cluster that may be nonmalignant or may develop into choriocarcinoma.

Hydatidiform Mole

1. Fetal heart rate not detectable 2. Vaginal bleeding, which may occur by the fourth week or not until the second trimester; may be bright red or dark brown in color and may be slight, profuse, or intermittent 3. Signs of preeclampsia (progressive blood pressure elevations) before the 20th week of gestation; note that preeclampsia usually occurs after 20 weeks of pregnancy, typically in the third trimester. 4. Fundal height greater than expected for gestational date 5. Elevated human chorionic gonadotropin levels 6. Characteristic snowstorm pattern shown on ultrasound

Hydatidiform Mole assessment

1. Prepare the client for uterine evacuation (before evacuation, diagnostic tests are done to detect metastatic disease). 2. Evacuation of the mole is done by vacuum aspiration; oxytocin may be administered after evacuation to contract the uterus. 3. Monitor for postprocedure hemorrhage and infection. 4. Tissue is sent to the laboratory for evaluation, and follow-up is important to detect changes suggestive of malignancy. 5. Human chorionic gonadotropin levels are monitored every 1 to 2 weeks until normal prepregnancy levels are attained; levels are checked every 1 to 2 months for 1 year. 6. Instruct the client and her partner about birth control measures so that pregnancy can be prevented during the 1-year follow-up period.

Hydatidiform Mole interventions

Intractable nausea and vomiting during the first trimester that causes disturbances in nutrition and fluid and electrolyte balance

Hyperemesis Gravidarum

1. Nausea most pronounced on arising; may occur at other times during the day 2. Persistent vomiting 3. Weight loss 4. Signs of dehydration 5. Fluid and electrolyte imbalances

Hyperemesis Gravidarum assessment

1. Initiate measures to alleviate nausea, including medication therapy; if unsuccessful, and weight loss and fluid and electrolyte imbalances occur, intravenously administered fluid and electrolyte replacement or parenteral nutrition may be necessary. 2. Monitor vital signs, intake and output, weight, and calorie count. 3. Monitor laboratory data and for signs of dehydration and electrolyte imbalances. 4. Monitor urine for ketones. 5. Monitor fetal heart rate, activity, and growth. 6. Encourage intake of small portions of food (low-fat, easily digestible carbohydrates, such as cereals, rice, and pasta). 7. Encourage the intake of liquids between meals to avoid distending the stomach and triggering vomiting. 8. Encourage the client to sit upright after meals.

Hyperemesis Gravidarum interventions

A. Description and types: Four major categories include preeclampsia, chronic/preexisting hypertension, chronic hypertension with superimposed preeclampsia, and gestational hypertension. B. Blood pressure elevations can lead to preeclampsia and then eclampsia (seizures) C. Women who have had preeclampsia, especially those who delivered preterm, have an increased risk later in life of cardiovascular disease and kidney disease, including heart attack, stroke, and high blood pressure. D. Having preeclampsia once increases the risk of having it again in a future pregnancy. E. Preeclampsia also can lead to eclampsia (seizures). F. HELLP syndrome can result. HELLP stands for hemolysis, elevated liver enzymes, and low platelet count. In this condition, red blood cells are damaged or destroyed, blood clotting is impaired, and the liver can bleed internally, causing chest or abdominal pain. HELLP syndrome is a medical emergency; the woman can die from HELLP syndrome or have lifelong health problems as a result.

Hypertensive Disorders of Pregnancy

1. Persistent hypertension 2. Swelling of the face or hands 3. Headache 4. Changes in eyesight 5. Pain in the upper abdomen or shoulder 6. Nausea and vomiting (in the second half of pregnancy) 7. Sudden weight gain 8. Difficulty breathing

Hypertensive Disorders of Pregnancy assessment

1. Previous preeclampsia or gestational hypertension, previous placental abruption, or fetal demise 2. Primigravida 3. Family history or first-degree relative with preeclampsia 4. Women who are 40 years or older 5. African American ethnicity 6. Women who are carrying more than one fetus 7. History of chronic hypertension, kidney disease, or both 8. Women who have medical conditions such as chronic hypertension, renal disease, connective tissue disease, diabetes mellitus, thrombophilia, or lupus erythematosus 9. BMI greater than 26 10. Metabolic syndrome 11. Multifetal pregnancy 12. Hydatidiform mole, hydrops fetalis, unexplained intrauterine growth retardation (IUGR) 13. Mother had IUGR as a newborn 14. Women who had in vitro fertilization

Hypertensive disorders of Pregnancy risk factors

1.Bleeding that occurs 10 to 14 days after conception 2.Lasts 1-2 days and light

Implantation Bleeding

1. Incompetent cervix refers to premature dilation of the cervix, which occurs most often in the fourth or fifth month of pregnancy and is associated with structural or functional defects of the cervix. 2. Treatment involves surgical placement of a cervical cerclage

Incompetent Cervix

1. Vaginal bleeding 2. Fetal membranes visible through the cervix

Incompetent Cervix assessment

1. Provide bed rest, hydration, and tocolysis, as prescribed, to inhibit uterine contractions. 2. Prepare for cervical cerclage (at 10 to 14 weeks of gestation as prescribed), in which a band of fascia or nonabsorbable ribbon is placed around the cervix beneath the mucosa to constrict the internal os. 3. After cervical cerclage, the client is told to refrain from intercourse and to avoid prolonged standing and heavy lifting. 4. The cervical cerclage is removed at 37 weeks of gestation or left in place and a cesarean birth is performed; if removed, cerclage needs to be repeated with each successive pregnancy. 5. After placement of the cervical cerclage, monitor for contractions, rupture of the membranes, and signs of infection. 6. Instruct the client to report to the PHCP immediately any postprocedure vaginal bleeding or increased uterine contractions

Incompetent Cervix interventions

a. Administration of isoniazid, pyrazinamide, and rifampin daily for 9 months (as prescribed); ethambuto is added if medication resistance is likely. b. Pyridoxine should be administered with isoniazid to the pregnant client to prevent fetal neurotoxicity caused by isoniazid. c. Promote breast-feeding only if the client is noninfectious.

Interventions Pregnant client

1. Institute measures to prevent opportunistic infections. 2. Avoid procedures that increase the risk of perinatal transmission, such as amniocentesis and fetal scalp sampling.

Interventions Prenatal period HIV/AIDS

1. Monitor fetal status continuously for signs of distress and, if noted, prepare the client for immediate cesarean section. 2. Carefully regulate insulin and provide glucose intravenously as prescribed because labor depletes glycogen.

Interventions during labor gestational diabetes

1. Observe the mother closely for a hypoglycemic reaction because a precipitous decline in insulin requirements normally occurs (the mother may not require insulin for the first 24 hours). 2. Reregulate insulin needs as prescribed after the first day, according to blood glucose testing. 3. Assess dietary needs, based on blood glucose testing and insulin requirements. 4. Monitor for signs of infection or postpartum hemorrhage.

Interventions during the postpartum period gestational diabetes

1. Remove underlying cause. 2. Monitor vital signs; assess for bleeding and signs of shock. 3. Prepare for oxygen therapy, volume replacement, blood component therapy, and possibly heparin therapy. 4. Monitor for complications associated with fluid and blood replacement and heparin therapy. 5. Monitor urine output and maintain at least 30 mL/hr (renal failure is a complication of DIC).

Interventions for DIC

1. Employ diet, medications 2. Encourage moderate physical activity. 3. Facilitate referral to a diabetic educator and nutritionist. 4. Observe for signs of hyperglycemia, glycosuria and ketonuria, and hypoglycemia. 5. Monitor weight. 6. Maintain calorie intake as prescribed, with adequate oral medication or insulin therapy so that glucose moves into the cells. 7. Assess for signs of maternal complications such as preeclampsia, a serious blood pressure disorder that can affect all organs in the body (hypertension is characteristic of the condition). 8. Monitor for signs of infection. 9. Instruct the client to report burning and pain on urination, vaginal discharge or itching, or any other signs of infection to the primary health care provider (PHCP). 10. Assess fetal status and monitor for signs of fetal compromise. 11. Schedule visits every 2 weeks until 36 weeks, and then every week from 36 weeks and

Interventions for gestational diabetes mellitus

1. Close blood pressure and weight monitoring throughout the pregnancy; the client may need to be taught how to take her blood pressure at home. 2. Weekly or twice weekly health care visits may be necessary; delivery may be recommended at 37 weeks of gestation (earlier if there is evidence of fetal distress). 3. Monitor fetal activity (teach the client how to perform Kick counts) and fetal growth (ultrasounds will be prescribed). 4. Encourage frequent rest periods, instructing the client to lie in the lateral position; for preeclampsia with severe features, the client may be hospitalized and bed rest may be prescribed (client should be placed in the lateral position). 5. Administer medications as prescribed to reduce blood pressure; blood pressure should not be reduced rapidly, because placental perfusion can be compromised. 6. Provide adequate fluids. 7. Monitor intake and output; a urinary output of 30 mL/hr indicates adequate renal perfusion. 8. Monitor neurological status, because changes can indicate cerebral hypoxia or impending seizure. 9. Monitor deep tendon reflexes and for the presence of hyperreflexia or clonus, because hyperreflexia indicates increased central nervous system irritability (Box 22-5). 10. Monitor for HELLP syndrome. 11. Evaluate renal function through prescribed studies such as blood urea nitrogen, serum creatinine, and 24-hour urine levels for creatinine clearance and protein. 12. Magnesium sulfate (use a controlled infusion device) may be prescribed to prevent seizures; magnesium sulfate may be continued for 24 to 48 hours postpartum. 13. Monitor for signs of magnesium toxicity with the administration of magnesium sulfate, including flushing, sweating, hypotension, depressed deep tendon reflexes, decreased urine output, and central nervous system depression including respiratory depression; keep antidote (calcium gluconate) available for immediate use, if necessary. 14. Corticosteroids may be prescribed to promote fetal lung maturity. 15. Prepare the client for delivery as prescribed.

Interventions for hypertension and preeclampsia

a. Management focuses on preventing disease and treating early infection. b. Skin testing is performed on the newborn at birth, and the newborn may be placed on isoniazid therapy; the skin test is repeated in 3 to 4 months, and isoniazid may be stopped if the skin test results remain negative. c. If the skin test result is positive, the newborn should receive isoniazid for at least 6 months (as prescribed). d. If the mother's sputum is free of organisms, the newborn does not need to be isolated from the mother while in the hospital.

Interventions newborn

Intrapartum period a. If the fetus has not been exposed to HIV in utero, the highest risk exists during delivery through the birth canal. b. Avoid the use of internal scalp electrodes for monitoring of the fetus. c. Avoid episiotomy to decrease the amount of maternal blood in and around the birth canal. d. Avoid the administration of oxytocin, because contractions induced by oxytocin can be strong, causing vaginal tears or necessitating an episiotomy. e. Place heavy absorbent pads under the mother's hips to absorb amniotic fluid and maternal blood. f. Minimize the neonate's exposure to maternal blood and body fluids; promptly remove the neonate from the mother's blood after delivery. g. Suction fluids from the neonate promptly. h. Prepare to administer zidovudine as prescribed to the mother during labor and delivery.

Intrapartum period HIV/AIDS

1. results from fertilization of 2 ova (fraternal or dizygotic) or a splitting of 1 fertilized ovum (identical or monozygotic). 2. Complications include miscarriage, anemia, congenital anomalies, hyperemesis gravidarum, intrauterine growth restriction, gestational hypertension, polyhydramnios, postpartum hemorrhage, premature rupture of membranes, and preterm labor and delivery.

Multiple gestation

1. Excessive fetal activity 2. Uterus large for gestational age 3. Palpation of 3 or 4 large parts in the uterus 4. Auscultation of more than 1 fetal heart rate 5. Excessive weight gain

Multiple gestation assessment

1. Monitor vital signs. 2. Monitor fetal heart rates, activity, and growth. 3. Monitor for cervical changes. 4. Prepare the client for ultrasound as prescribed. 5. Monitor for anemia; administer supplemental vitamins as prescribed. 6. Monitor for preterm labor, and treat preterm labor promptly. 7. Prepare for cesarean delivery for abnormal presentations. 8. Prepare to administer oxytocic medications as prescribed after delivery to prevent postpartum hemorrhage from uterine overdistention.

Multiple gestation interventions

These women have lower prolactin response to suckling in the first week postpartum, contributing to high rates of breast-feeding failure in this population.

Obese women

Places the client at risk for several complications during pregnancy, including gestational diabetes, gestational hypertension, preeclampsia, venous thromboembolism, and increased need for cesarean birth.

Obesity in Pregnancy

Can result from difficulty obtaining IV access, epidural access, intubation, and decreased oxygen consumption with associated increased cardiac output, stressing the heart.

Obesity in Pregnancy delivery complications

Effects on the newborn, including stillbirth, premature birth, congenital anomalies, future obesity, heart disease, and difficulty with breast-feeding.

Obesity in Pregnancy effects on newborn

"O" includes HIV—discussed earlier, syphilis— discussed under Sexually Transmitted Infections, parvovirus, hepatitis B virus [HBV], West Nile, etc.

Other Infections "O"

1.Abortion 2.Malignancy 3.Polyps 4.Molar pregnancy 5.Ectopic pregnancy 6.Idiopathic 7.Infection 8.Subchornic hemorrhage 9.UTI 10.Placenta previa 11.Abruptio placenta 12.Cervicitis

Other causes of bleeding while pregnant

1.Position client with her legs dangling over the edge of the examining table or lying on her back with her legs slightly flexed. 2.Strike patellar tendon just below kneecap with percussion hammer. 3.Normal response: Extension or kicking out of the leg

Patellar assessment of reflexes

an improperly implanted placenta in the lower uterine segment near or over the internal cervical os

Placenta Previa

The placenta is implanted in the lower uterus, but its lower border is more than 3 cm from the internal cervical os.

Placenta Previa Marginal (low-lying)

The lower border of the placenta is within 3 cm of the internal cervical os but does not fully cover it.

Placenta Previa Partial

The internal cervical os is covered entirely by the placenta when the cervix is dilated fully.

Placenta Previa Toatal (complete)

1. Sudden onset of painless, bright red vaginal bleeding occurs in the last half of pregnancy. 2. Uterus is soft, relaxed, and nontender. 3. Fundal height may be more than expected for gestational age.

Placenta Previa assessment

1. Monitor maternal vital signs, fetal heart rate, and fetal activity. 2. Prepare for ultrasound to confirm the diagnosis. 3. Vaginal examinations or any other actions that would stimulate uterine activity are avoided. 4. Maintain bed rest in a side-lying position as prescribed. 5. Monitor amount of bleeding (treat signs of shock). 6. Administer intravenous (IV) fluids, blood products, or tocolytic medications as prescribed; Rho(D) immune globulin may be prescribed. 7. If bleeding is heavy, a cesarean delivery may be performed.

Placenta Previa interventions

Placenta accreta is an abnormally adherent placenta; placenta increta occurs when the placenta penetrates the uterine muscle itself; placenta percreta occurs when the placenta goes all the way through the uterus.

Placental Abnormalities

May cause hemorrhage immediately after birth because the placenta does not separate easily

Placental Abnormalities assessment

1. Monitor for hemorrhage and shock. 2. Prepare the client for a hysterectomy if a large portion of the placenta is abnormally adherent.

Placental Abnormalities intervention

a. Monitor for signs of infection. b. Place the mother in protective isolation if she is immunosuppressed. c. Breast-feeding is likely to be restricted; follow PHCPs recommendations regarding breast-feeding. d. Instruct the mother to monitor for signs of infection and report any signs if they occur. e. The newborn can room with the mother; however, depending on agency procedures, the newborn may be placed in NICU for the first 24 hours of life to complete baseline laboratory studies and receive the initial treatment.

Postpartum period HIV/AIDS

1. Thromboembolism formation is a concern; as prescribed, thromboembolism stockings, sequential compression devices (SCDs), and pharmacological venous thromboembolism prophylaxis may be necessary postdelivery. 2. Postpartum hemorrhage is more common, as well as difficulty locating the fundus, predisposing further to this problem. 3. Endometritis is common in this population. 4. Early ambulation is encouraged to prevent venous thromboembolism formation. 5. Frequent monitoring and cleaning of surgical incisions (episiotomy or cesarean incision) is needed to prevent infection or dehiscence due to excess abdominal fat

Potential postdelivery complications and associated interventions with obesity

1. Thromboembolism formation is a concern; as prescribed, thromboembolism stockings, sequential compression devices (SCDs), and pharmacological venous thromboembolism prophylaxis may be necessary postdelivery. 2. Postpartum hemorrhage is more common, as well as difficulty locating the fundus, predisposing further to this problem. 3. Endometritis is common in this population. 4. Early ambulation is encouraged to prevent venous thromboembolism formation. 5. Frequent monitoring and cleaning of surgical incisions (episiotomy or cesarean incision) is needed to prevent infection or dehiscence due to excess abdominal fat

Potential postdelivery complications due to obesity

1. Older than 35 years 2. Obesity—BMI greater than 30 3. Nonwhite race 4. Previous unexplained perinatal loss 5. Previous child born with congenital anomalies 6. Polycystic ovarian syndrome 7. Multiple gestation 8. First-degree relative with diabetes mellitus or gestational diabetes 9. Previous delivery of a fetus weighing greater than 9 lb 10. Maternal birth weight less than 6 lb or greater than 9 lb 11. Previous pregnancy with gestational diabetes 12. Glycosuria 13. Essential or pregnancy-related hypertension 14. Use of glucocorticoids

Predisposing conditions/risk factors to gestational diabetes

Unable physiologically to cope with the added plasma volume and increased cardiac output that occur during pregnancy; blood volume peaks at weeks 32 to 34 and declines at week 40

Pregnant with cardiac disease

Not a reliable indicator of preeclampsia. Evidence demonstrates that kidney or liver dysfunction can occur without signs of protein, and that the amount of protein in the urine does not predict how severely the disease will progress.

Proteinuria

1. Results from bacterial infections that extend upward from the bladder through the blood vessels and lymphatics 2. Frequently follows untreated urinary tract infections and is associated with increased incidence of anemia, low birth weight, gestational hypertension, premature labor and delivery, and premature rupture of the membranes

Pyelonephritis

Is managed as high risk because she is vulnerable to infections.

Risks to the mother HIV and AIDS

1. Teratogenic in the first trimester 2. Organism is transmitted to the fetus across the placenta. 3. Causes congenital defects of the eyes, heart, ears, and brain 4. Blood titer studies will be done. If not immune (titer less than 1:8), the client should be vaccinated in the postpartum period; the client must wait 1 to 3 months (as specified by the PHCP) before becoming pregnant.

Rubella (German measles) ("R")

a. is a chronic infectious disease caused by the organism Treponema pallidum. b. Transmission is by physical contact with syphilitic lesions, which usually are found on the skin, mucous membranes of the mouth, or genitals. c. The infection may cause abortion or premature labor and is passed to the fetus after the fourth month of pregnancy as congenital syphilis.

Syphilis

a. A serum test (Venereal Disease Research Laboratory or rapid plasma reagin) for syphilis is done on the first prenatal visit; prepare to repeat the test at 36 weeks of gestation because the disease may be acquired after the initial visit. b. If the test result is positive, treatment with an antibiotic may be necessary. c. Sonographic evaluation is necessary to assess for signs of placental syphilis. d. Instruct the client that treatment of her partner is necessary if infection is present, and intercourse should be avoided until treatment is instituted. e. Complications include transmission to fetus (100% in primary and secondary stages), congenital anomalies, deafness, neurological impairment (mortality rate is 50%). f. Those with syphilis should also be tested for HIV.

Syphilis interventions

1. Highly communicable disease caused by Mycobacterium tuberculosis 2. Transmitted by the airborne route 3. Multidrug-resistant strains of tuberculosis can result from improper compliance, noncompliance with treatment programs, or development of mutations in tubercle bacillus.

TB

If a chest radiograph is required for the mother, it is done only after 20 weeks of gestation, and a lead shield for the abdomen is required.

TB Diagnosis

1. Transplacental transmission is rare. 2. Transmission can occur during birth through aspiration of infected amniotic fluid. 3. The newborn can become infected from contact with infected individuals.

TB Transmission

a. Possibly asymptomatic b. Fever and chills c. Night sweats d. Weight loss e. Fatigue f. Cough with hemoptysis or green or yellow sputum g. Dyspnea h. Pleural pain

TB assessment Mother

a. Fever b. Lethargy c. Poor feeding d. Failure to thrive e. Respiratory distress f. Hepatosplenomegaly g. Meningitis h. Disease may spread to all major organs

TB assessment to Newborn

Active disease during pregnancy has been associated with an increase in hypertensive disorders in pregnancy

TB risk to mother

1. Caused by infection with the intracellular protozoan parasite Toxoplasma gondii 2. Produces a rash and symptoms of acute, flu-like infection in the mother 3. Transmitted to the mother through ingestion of raw meat or handling of cat litter of infected cats 4. Organism is transmitted to the fetus across the placenta 5. Can cause miscarriage in the first trimester 6. Client education regarding preventing infection is critical

Toxoplasmosis "T"

1. Sexual exposure to genital secretions of an infected person 2. Parenteral exposure to infected blood and tissue 3. Perinatal exposure of an infant to infected maternal secretions through birth or breast-feeding

Transmission of HIV and AIDS

a. is caused by Trichomonas vaginalis and is transmitted via sexual contact. b. A normal saline wet smear of vaginal secretions indicates the presence of protozoa. c. Infection is associated with premature rupture of the membranes and postpartum endometritis.

Trichomoniasis

a. Yellowish to greenish, frothy, mucopurulent, copious, malodorous vaginal discharge b. Inflammation of vulva, vagina, or both may occur.

Trichomoniasis assessment

a. Metronidazole may be prescribed. b. Sexual partner may need to be treated

Trichomoniasis interventions

A. Description: A urinary tract infection can occur during pregnancy (pregnancy is a predisposing factor). A urinary tract infection can be either lower urinary tract (cystitis) or upper urinary tract (pyelonephritis). B. Women may also experience asymptomatic bacteriuria.

Urinary Tract Infection (Acute Cystitis and Acute Pyelonephritis)

1. History of urinary tract infections 2. Urinary tract anomalies 3. Low socioeconomic status 4. Sexual activity 5. Young age 6. Sickle cell trait 7. Poor hygiene 8. Anemia 9. Diabetes mellitus 10. Obesity 11. Catheterization

Urinary Tract Infection (Acute Cystitis and Acute Pyelonephritis) predisposing conditions

Is done at the first prenatal visit or at 12 to 16 weeks' gestation. Rescreening is done based on risk factors.

Urinary Tract Infection (Acute Cystitis and Acute Pyelonephritis) screening

a. Candida albicans is the most common causative organism. b. Predisposing factors include use of antibiotics, diabetes mellitus, and obesity. c. Vaginal candidiasis is diagnosed by identifying spores of Candida albicans

Vaginal candidiasis

a. Vulvar and vaginal pruritus b. White, lumpy, cottage cheese-like discharge from vagina

Vaginal candidiasis assessment

a. An antifungal vaginal preparation may be prescribed. Oral fluconazole should be avoided during pregnancy due to the risk of miscarriage. b. For extensive irritation and swelling, sitz baths may be helpful. c. Sexual partner may need to be treated

Vaginal candidiasis inteventions

Between 24 and 28 weeks of gestation via the 1- hour glucose challenge test. *If the 1-hour glucose challenge test is abnormal, a 3-hour oral glucose tolerance test is performed to confirm gestational diabetes mellitus

When should pregnant women should be screened for gestational diabetes

Is tuberculin skin testing is safe during pregnancy; however, the PHCP may want to delay testing until after delivery.

Yes