Unit 1-Antepartum

Effects of Sedative on pregnancy

-CNS depression -Newborn withdrawal -Maternal seizure in labor -Newborn abstinence syndrome -Delayed lung maturity

Nursing Role in Genetic Counseling

-Detailed family and personal history and focused heath assessment -Active listening to identify concerns -Early referrals for further information -Safeguarding privacy and confidentiality -Ethical, legal and social issues -To assist individual/couple to make informed choices -To educate individual/couple about the effects of genetic disorders -Monitor emotional reactions after receiving info -Providing emotional support and accurate information -Culturally competent care

Nutrition Promotion

-Direct effect of nutritional intake on fetal well-being, growth, infant weight at birth and birth outcome -Client education (weight gain, take vitamin supplements, avoid dieting or meal skipping, limit soda and caffeine, avoid use of diuretics, physical activity daily) -Special considerations oCultural variations oPica oLactose intolerance-Lactose free milk or Ca+ fortified OJ pOther sources such as almonds, seeds, broccoli, kale

Medications R/T Ectopic Pregnancy

-Methotrexate -Prostaglandins -Misoprostol -Actinomycin

Diagnosis of Ectopic Pregnancy

-Beta HCG -US (typically transvaginal)

Nursing Assessment of Placenta Previa

-Risk factors -Presence of pain or uterine contractions -Amount of vaginal bleeding, is often spontaneous cessation then recurrence)

Neonatal Hypoglycemia

1. Mother' blood brings extra glucose to the fetus 2. Fetus makes more insulin to handle extra glucose 3. Extra glucose gets stored as fat and fetus becomes larger than normal

Task of learning to give of oneself

1st: Identifies what must be given up to assume new role 2nd: Identifies with infant, learns how to delay own desires 3rd: Questions her ability to become a good mother to infant

Task of Seeking acceptance of self in maternal role to infant ("binding in")

1st: Mother accepts idea of pregnancy but not of infant 2nd: wiht quickening, mother acknowledges fetus as a separate entity w/i her 3rd: Mother longs to hold infant and becomes tired of being pregnant

Pregnancy Associated Plasma Protein A (PAPP-A)

Similar to quad •Maternal serum blood test (done 11-13 weeks) •Protein secreted by the placenta •Low levels are associated with fetal chromosomal anomalies and Trisomies 13, 18, and 21, stillbirth, infant death, preterm birth and preeclampsia. •Small-for-Gestational-Age (SGA) •High level may predict a Large-for-Gestational-Age (LGA) baby.

Task of seeking acceptance of infant by others

1st: Acceptance of pregnancy by herself and others 2nd: family needs to relate to the fetus as member 3rd: unconditional acceptance w/o rejection

Goodell's Sign

Softening of the cervix

Hegar's Sign

Softening of the lower uterine segment or isthmus

Grades of DTR

4+ Very brisk, hyperactive with clonus 3+ Brisker than average, slightly hyperreflexic 2+ Average, expected response; normal 1+ Somewhat diminished, low normal 0 No response, absent

Therapeutic Range of Magnesium Sulfate in a Pregnant Woman

4.0-7.0 >8 is considered toxic 15-20 respiratory depression >20 cardiac arrest Assess: •2 hrs after Loading dose •Every 6 hrs for Maintenance Therapy

TORCH

Toxoplasmosis Other Rubella Cytomegalovirus (CMV) Herpes

Sickle Cell Anemia

Defect in hemoglobin molecule (hemoglobin S)

Preeclampsia

HTN that occurs after 20 weeks gestation and resolves by 12 wks postpartum -BP >140/90 w/o proteinuria

Examples of Dominant X-linked Inheritance

Vitamin D resistant rickets and Fragile X

Caloric Intake for pregnant women

regnant-add 300 (2500) Breastfeeding-add 500 (2700)

Advantages of Nonstress Test

•Quick to perform •Permits easy interpretation •Inexpensive •Can be done in an office or clinic setting •No known side effects

PGE2/dinosprostone (cervidil/prepidil)

•Stimulates cervix to soften and open and stimulate uterine ctx. Placed vaginally. Lay flat after insertion

Ectopic Pregnancy

•Ovum implantation outside the uterus (Fallopian tube) •Etiology: Obstruction to or slowing passage of ovum through tube to uterus (PID, d/o Chlamydia/gonorrhea) MOST Common cause is tubal scarring secondary to PID

Therapeutic Management of Heart Disease

-Risk assessment, functional capacity (mother needs to know S/Sx of cardiac decomposition) -Medication needs (dig, diuretics, beta-blockers) -Cardiac workup -Prenatal counseling -Increased frequency of prenatal visits

Patho of Heart Disease in Pregnant Patient

-Hemodynamic changes of pregnancy can overstress the woman's cardiovascular system •Therapeutic management

Examples of Autosomal Recessive Disorders

-Sickle cell anemia -Tay-Sachs Disease -Cystic Fibrosis -Phenylketonuria (PKU) -Early onset Alzheimer's

1 Hour Glucose Challenge Test

24 to 28 weeks unless high risk -75g glucose load (drink) -Serum glucose checked at 1 hour without regard for previous meal (no fasting necessary) -Follow up if > 140

Weight gain during pregnancy

25-35 lbs total First trimester: 3.5-5 Second and Third trimesters 1 lb/wk

Patho of Preeclampsia

3 Key Terms" -Vasospasm occurs causing more turbulent blood flow and increased resistance secondary to damage of cells in the vascular space -Hypoperfusion occurs to other organs (specifically the renal system) -Endothelial damage occurs as well as platelet aggregation and decreased vascular volume

Consequences of Iron Deficient Anemia

nLow birth weight nPreterm delivery nRisk of hemorrhage nRisk of infection

Teaching to Prevent Hep B Virus Progression

Abstain from alcohol and potentially hepatotoxic medications. • Avoid IV drug exposure or sharing of needles. • Encourage all household contacts and sexual partners to be vaccinated. • Receive immediate treatment for any STI. • Know that your newborn will receive the hepatitis B vaccine soon after birth. • Use good hand hygiene techniques at all times. • Avoid contact with blood or body fluids. • Use barrier methods such as condoms during sexual intercourse. • Avoid sharing any personal items, such as razors, toothbrushes, or eating utensils. • Inform all health care providers of your HBV status.

Medications R/T abortions

Misoprostol Mifepristone PGE2, dinoprostone

S/Sx of Placenta Previa

Painless, bright red vaginal bleeding in 2nd and 3rd trimester -Bleeding can occur spontaneously and repeatedly

Gestational DM Effects on Fetus

pCongenital anomalies (heart, skeleton) due to hyperglycemia pMacrosomia (large size) due to fetal hyperglycemia pFetal bilirubinemia pRespiratory distress due to poor or delayed lung maturity pBirth trauma due to fetal size/shoulder dystocia pNeonatal hypoglycemia

Magnesium Sulfate

•Standard treatment for anticonvulsive therapy •Depresses CNS, blocks peripheral neuromuscular transmission, produces anticonvulsant effects; decreases amount of acetylcholine released at end-plate by motor nerve impulse •Always administered via an infusion pump and along side a primary fluid, such as LR at KVO •Loading dose given initially at 4-6 grams over 15-20 minutes, and then a continuous rate of 1-2 grams/hour per physician order. •Short term therapy

Cytomeglovirus (CMV)

•Transmitted via body fluids •Most common congenital/perinatal infection (most common in daycare workers) •Present in >50% population •Maternal: "mono" like illness •The earlier the exposure the more severe the effect •Effect on newborn: hearing loss, intrauterine growth restriction, microcephaly, jaundice and intellectual disabilities •Exposure in day care setting •ED: Handwashing w/ soap and water, don't share eating utensils, safe sex

Assessment of Fetal Well Being

•Ultrasonography •Doppler Flow Studies •Alpha-fetoprotein analysis (AFP) •Triple and quad screening tests •Nuchal Translucency Screening •Amniocentesis •Chorionic Villus Sampling (CVS) •Percutaneous umbilical blood sampling (PUBS) •Nonstress Test (NST) •Biophysical Profile (BPP) Nursing Responsibilities: -Accurate pregnancy dating -Education -Pre and post procedure care -Risk/benefit profile

Examples of Positive S/Sx of Pregnancy

•Ultrasound verification of pregnancy (4-6 weeks) •Fetal movement felt by experienced clinician (20 weeks) •Auscultation of fetal heartbeat via doppler (10-12 weeks)

Physiological Changes of the GU system during pregnancy

•Urinary frequency - 1st and 3rd trimesters •Kidneys must compensate and they work harder •Changes to maternal renal system due to increased blood flow to kidneys due to hormones, enlarging uterus and increase in maternal blood volume •Increase in GFR: increased urine flow and volume •Ureters relax in response to progesterone •Glycosuria

First Trimester Discomforts

•Urinary frequency/ incontinence (pelvic floor exercises, empty bladder when first feel sensation, avoid caffeine, reduce fluid intake after dinner) •Fatigue (get full night's sleep, eat a healthy balanced diet, schedule a nap in early afternoon, rest if tired) •Nausea/vomiting/heartburn (avoid empty stomach, eat dry crackers/toast, eat small frequent meals, avoid brushing teeth after eating, acupressure wristbands, drink fluids between meals, avoid greasy fried foods) •Breast tenderness •Constipation (increase high fier foods, drink 8x 8 oz water/day, prunes, warm liquids on rising , exercise each day, reduce cheese consumption) •Nasal stuffiness/epistaxis •Bleeding gums •Leukorrhea

Teaching For Iron Deficiency Anemia

•Daily prenatal vitamin •Oral iron supplementation & importance -Take iron supplements with OJ (Vit C) -Don't take w/ milk -dietary instruction on foods rich in iron -Meats, green/leafy veg, legumes, peanut butter, whole grains

Therapeutic Management of Placenta Previa

•Dependent on bleeding, amount of placenta over os, fetal development and position, maternal parity, labor signs and symptoms •Hospitalization may be necessary

Diagnosis of DIC

•Diagnosed based on lab tests such as fibrinogen, platelets, PT, PTT, D-dimer and FSP

Effects of Marijuana on pregnancy

-Anemia -Inadequate weight gain -Amotivational syndrome -Hyperactive startle reflex -Newborn tremors -Prematurity -IUGR (a baby who isn't growing as quickly as he should be inside the womb)

Screening for DM in pregnancy

-Assess risk at first visit Low risk—screen at 24 to 28 weeks High risk—screen as early as possible oHbA1c and serum glucose

Nursing Care of Patient with GDM

-3 meals and 3 snacks daily -40% quality CHO/ 35% protein/ 25% unsat fats -Some women can be managed with dietary changes only •Monitor glucose levels/tight glucose control •Management of low and high blood sugars—How do we treat episodes of hypoglycemia? •Prevention of complications

Autosomal Dominant

-Affects female/male family members equally -A single abnormal gene can produce the phenotype -Follows vertical pattern of inheritance (multiple generation) -The affected child usually has one affected parent -Carried on one chromosome of a pair -Offspring 50% chance mutation/normal Variable expression

Goal of nurse when managing a high risk pregnancy

-Always be assessing and asking good pointed questions to help prevent complications -Strongly encourage prenatal care -Create an environment where the mother feels safe and heard so that she will continue to follow up

Psychosocial Adaptations during pregnancy

-Ambivalence (mixed feelings or emotions) -Introversion -Acceptance -Mood Swings -Change in Body Image

Birth and Labor management for a GDM mother

-Assessment of fetal and maternal status for timing of delivery -Fetal lung maturity - is delayed in a diabetic mother - delays synthesis of phosphatidylglycerol PG Ratio for surfactant level. -Vaginal birth is preferred with possible labor induction. -IV saline or LR in labor -Maternal insulin requirements decrease dramatically during labor -Assessment of serum glucose- hourly for insulin needs (prevent neonatal hypoglycemia) -Monitor Fetal heart rate -Assessment of maternal vital signs, symptoms of hypoglycemia, urine output (I&O)

Nursing Management for GDM postpartum

-Assessment of glucose every 2-4 hours -Maternal insulin requirements drop significantly, generally reduced by ½ -Monitor newborn (birth weight, newborn glucose levels, bilirubin levels, vital signs) -Diabetic control and bonding -Breastfeeding encouraged -Family planning information

Management of Mild Preeclampsia

-Bed rest -Daily BP monitoring, and fetal movement counts -DTR eval -Use of antihypertensives, nutrition and protein -Daily weights -Hospitalization; IV magnesium sulfate during labor -Freq office visits -Change/worsening of symptoms such as headache, weight gain or decrease in fetal movement.

Cardiovascular Disorders in Pregnant Patient

-Blood volume and cardiac output increase up to 50% during pregnancy (peaks at 28 to 32 weeks), which places stress on a compromised heart. -Classic sx of heart disease can mimic those of late pregnancy including SOB, palpitations, edema and occas chest pain

Nursing Management of Cardiac Diseases

-Diuretics (furosemide) -Digitalis (digoxin) -Betablockers (labetolol) -Calcium channel blockers (nifedipine) -Anti-coagulants (heparin) -Rest periods -Nutrition-cardiac diet, Na+ restriction, fluid restriction -Preparation for diagnostic testing such as ECHO, EKG -Tests for fetal well being (US, NST, BPP) -Education and emotional support

Examples of Recessive X-linked Inheritance

-Duchenne Muscular Dystrophy -Hemophilia A and B -color blindness

Therapeutic Management of Iron Deficiency Anemia

-Eliminate symptoms -Correct deficiency -Replenish iron stores

Visit Schedule for pregnant mothers

-Every 4 weeks up to 28 weeks -Every 2 weeks from 29 to 36 weeks -Every week from 37 weeks to birth -If a pregnancy is high risk or becomes high risk during the pregnancy, visits will be more often specific to the pregnancy situation.

Pelvic Examination

-Examination of external and internal genitalia -Bimanual examination -Pelvic shape: gynecoid, android, anthropoid, platypelloid -Pelvic measurements: diagonal conjugate, true (obstetric) conjugate, and ischial tuberosity

s/sx of iron deficiency anemia

-Fatigue, weakness, malaise, anorexia, susceptibility to infection (frequent colds), pale mucous membranes, tachycardia, pallor, headache, restless leg syndrome, pica

Obstetric History

-G (gravida): the current pregnancy -T (term births): the number of pregnancies ending >37 weeks' gestation, at term -P (preterm births): the number of preterm pregnancies ending >20 weeks or viability but before completion of 37 weeks -A (abortions): the number of pregnancies ending before 20 weeks or viability -L (living children): number of children currently living

Lab Assessment of Long Term Glucose Control

-HbA1c (glycosylated hemoglobin levels) -Looks at glucose control over previous 100-120d -<7%--indicates good control, >8% poor control

Nursing Assessment of Iron Deficiency Anemia

-Hemoglobin and hematocrit, CBC, RBC, ferritin, TIBC, B12, folate -Diet -History

Assessing for Genetic Disorders

-History -Physical Assessment -Level 2 Ultrasound -Nuchal Translucency screening -Karyotyping -Chronic Vill Sampling -Amniocentesis -Maternal Serum Screening MSAFP -Triple and Quad Screening -Percutaneous Umbilical Sampling

Management of Severe Preeclampsia

-Hospitalization -Quiet environment -Complete bedrest with left lateral positioning -Monitoring vital signs -IV access -Lab work -Antihypertensives -O2 and suction equipment readily available -Monitor for changes in labs/symptoms -Seizure precautions -Magnesium sulfate -Preparation for birth

Management of Eclampsia

-Hospitalization (Mom maybe given dexamethasone/betamethasone to accelerate fetal lung maturity in preparation for an early delivery Maternal administration of magnesium sulfate IV during labor) -Seizure management -Magnesium sulfate -Antihypertensive agents and use of magnesium sulfate -Fetal and uterine monitoring; birth once seizures controlled

Examples of Autosomal Dominant Disorders

-Huntington's disease -Achondroplasia -Polycystic Kidney Disease -Hereditary breast/ovarian cancer -Marfan syndrome -Familial hypercholesterolemia=Hereditary non-polyp colorectal cancer

Medications R/T Gestational HTN

-Hydralazine (Apresoline) -Labetalol (Normodyne) -Nifedipine (Procardia) -Furoesemide (Lasix) -Magnesium Sulfate

Gestational DM

-In first trimester insulin demands are reduced b'c of increased metabolism (baby's needs are greatest in 1st trimester b'c baby is developing) -In 2nd and 3rd trimester it evens out -HPL released by placenta antagonizes insulin (pancreas is still working but mother can't compensate for the changes) -Impaired fasting glucose and impaired glucose tolerance

Common Cognitive and Behavioral Problems assoc with FASD

-Inability to forsee consequences -Inability to learn from previous experience -Lack of organization -Intellectual disability or low IQ -Difficulty in school, especially iwth math -Learning difficulties -Poor abstract thinking -Poor reasoning and judgment skills -Poor memory -Poor impulse control -Speech and language delays -Poor judgment

Cardiac Changes of the Pregnant Patient

-Increased cardiac workload & myocardial O2 demand -Increased uterine blood flow—50% more plasma volume in pregnancy -Pregnancy: Increased CO 30-50% -Increased HR 30% (10-20bpm) -Decreased vascular and pulmonary resistance—lowers BP -Hypercoagulable state-Increased clotting factors and platelets

Insulin for Management of DM antepartum

-Insulin doses are reduced in the first trimester to prevent hypoglycemia resulting from increased insulin sensitivity as well as from nausea and vomiting. (Usually Type I and II diabetics) -Insulins recommended in pregnancy do not cross the placenta -Newer short-acting insulins - lispro (Humalog) and aspart (NovoLog) help reduce episodes of hypoglycemia between meals (1 hour peak time) -Short-acting insulin (Regular) combined with Intermediate type (NPH) (Many prefer the split-dose therapy; 2/3 of the daily dose in the morning and the remaining 1/3 in the evening) -Some prefer the insulin pump to deliver a continuous insulin infusion. -Goals of Insulin - keep fasting blood glucose values of 60-90 mg/dL and 1 hr. postprandial value less than 120 mg/dL Maintain good glycemic control & good pregnancy outcomes

facial characteristics of FAS

-Low nose bridge -Short palpebral fissures -Short nose -Flat midface -Epicanthal folds -Minor ear abnormalities -Thin upper lip -Receding jaw

Effects of Opiate and Narcotics on pregnancy

-Maternal and fetal withdrawal -Abroptio placentae -Preterm labor -Premature rupture of membranes -Perinatal asphyxia -Newborn sepsis and death -Intellectual impairment -Malnutrition

X-linked Inheritance

-May be recessive or dominant -Gene located only on the X chromosome -Inherited recessive variant seen in all males who have the gene -Characteristic of an X-linked variant is that fathers can't pass it to their sons, but their daughters can be carriers -Females with one affected gene are carriers (recessive) ›50% chance of passing disorder to sons ›50% chance of daughter being a carrier

Iron Deficiency Anemia

-Occurs during pregnancy due to increased maternal iron needs, fetal demands and large blood volume -Attributed to poor nutrition At risk Patients: -Meal skippers -Not good nutrition -Adolescent mothers

Autosomal Recessive

-Pattern is more horizontal than vertical -Two copies of the abnormal gene must be present to produce the phenotype (both parents affected) -Relatives of a single generation tend to have the condition (multiple sibling) Ethnic groups -Children of blood-related parents -Carriers and carrier testing -IF both parents are carriers: 25% of offspring may have the condition, 25% will be un-affected, 50% will be a carrier

Reasons for early testing

-Predict outcome of pregnancy -Manage remaining weeks of pregnancy -Plan for possible complications at birth -Plan for problems that may occur in newborn -Decide whether to continue pregnancy -Find conditions that may affect future pregnancies

Task of Ensuring safe passage throughout pregnancy and birth

-Primary focus of woman's attention 1st: Woman focuses on self; not fetus 2nd: Woman develops attachment of to fetus 3rd: Woman has concern for both herself and fetus Participation in positive self-care activities related to diet, exercise, and overall well-being

Fetal Management in Cardiac Disease

-Serial Ultrasounds for fetal growth and Nonstress Tests (NST) after 30 to 32 weeks -Determines fetal health and focuses on possible poor placental perfusion and delivery of the baby early if necessary (baby may develop slower due to poor perfusion and mom may deliver a low weight baby) -If mother's cardiac health deteriorates, may also have to deliver the baby early.

Nursing Assessment of Sickle Cell Anemia

-Signs and symptoms -Evidence of crisis

Physiological Changes of the musculoskeletal system during pregnancy

-Softening and stretching of ligaments holding sacroiliac joints and pubis symphysis -Postural change: increased swayback and upper spine extension -Forward shifting of center of gravity -Increase in lumbosacral curve (lordosis); compensatory curve in cervicodorsal area -Waddle gait

Effects of ETOH on pregnancy

-Spontaneous abortion -Inadequate weight gain -IUGR (a baby who isn't growing as quickly as he should be inside the womb) -Fetal ETOH spectrum disorder -Leading cause of intellectual disability

Nursing Management of Sickle Cell Anemia

-Support, education, follow-up -Labor: rest, pain management , oxygen and IV fluids, close FHR monitoring -Postpartum: antiembolism stockings, family planning options

Fetal surveillance in GDM

-Ultrasound -Alpha-fetoprotein levels -Non-stress testing -Biophysical profile -Amniocentesis.

Maternal Surveillance for Gestational Diabetes

-Urine for protein, ketones, nitrates, and leukocyte esterase -Evaluation of renal function/trimester -Eye exam in first trimester -HbA1c q4-6 weeks

Effects of Cocaine on pregnancy

-Vasoconstriction -Gestational HTN -abroptioa placentae -Abortion -"snow baby syndrome" -CNS defects -IUGR (a baby who isn't growing as quickly as he should be inside the womb)

Effects of Nicotine on pregnancy

-Vasoconstriction -Reduced uteroplacental blood flow -Decreased birth weight -Abortion -Pre term delivery -abruptio placentae -Fetal demise

Effects of Caffeine on pregnancy

-Vasoconstriction and mild diuresis in mother -Fetal stimulation but tetratogenic effects no documented

Assessment Preformed at Each Visit

-Weight and BP compared to baseline values -Urine testing for protein, glucose, ketones, and nitrites -Fundal height measurement to assess fetal growth -Quickening/fetal movement (15-20w) -Fetal heart rate (FHR) 110 to 160 bpm -Anticipatory guidance/teachiing: Immunization, safe use of medications, sex, job, travel, birth plans, problems to discuss and emergencies to report

S/Sx of Ectopic Pregnancy

Similar to S/Sx of miscarriage Triad: 1. abdominal pain 2. amenorrhea 3. vaginal bleed 6-8 wks s/p LMP ´Sharp, one-sided pain (stabbing; located where pregnancy is) ´Syncope ´Referred right shoulder pain ´Lower abdominal pain (Adnexal tenderness. Abdominal rigidity and tenderness) ´Decreased hemoglobin and hematocrit ´Increased leukocytes

Treatment and Management of Ectopic Pregnancy

Treatment: Options depend on size and whether a FHR is detected -Drug therapy (more likely option if early in pregnancy) -Surgical management (more likely option if further in pregnancy) -Monitor HCG levels -Monitor for tubal rupture!!!! Greatest concern! Teach pt s/sx also! -Analgesics for pain -Rhogam for Rh - mother

Triple and Quad Screening testing

Triple and Quad screening includes -Alpha-fetoprotein (AFP) -Human chorionic gonadotropin (chg.) -Unconjugated estriol (UE3) -Dimeric inhibin-A Indication: To identify rx for Down syndrome, neural tube defects, adn other chromosomal disorders Time: 15-18 weeks

Pyridoxine/Doxylamine

Delayed-release medication containing a combination of an antihistamine and vitamin B6 Symptomatic relief of nausea and vomiting during pregnancy Nursing Implications: -Be alert for drowsiness, dizziness, headache, irritability. -Do not administer with any central nervous system depressants or sleeping medications. -It must be taken daily, not as needed. -It should be taken on an empty stomach with a full glass of water.

Therapeutic Management of Sickle Cell Anemia

Dependent on status -Supportive therapy -Blood transfusions for severe anemia -Analgesics for pain -Antibiotics for infection

Amniocentesis

Diagnostic Amniotic fluid aspirated from amniotic sac Indication: To perform chromosome analysis, alpha-fetoprotein, DNA markers, viral studies, karyotyping and identify inborn errors of metabolism -Genetic testing for fetal abnormalities -Can tell gender -Determine fetal lung maturity in third trimester. Measures LS/PG (surfactant) Time: 15-20 wks want to allow for adequate amniotic fluid volume Concerns: Infection, pregnancy loss, fetal needle injuries

Promethazine

Diminishes vestibular stimulation and acts on the chemoreceptor trigger zone (CTZ) Symptomatic relief of nausea, vomiting, and motion sickness Nursing Indications: -Be alert for urinary retention, dizziness, hypotension, and involuntary movements. -Institute safety measures to prevent injury secondary to sedative effects. -Offer hard candy and frequent rinsing of mouth for dryness.

Alpha-fetoprotein

A sample of the woman's blood is drawn to evaluate plasma protein that is produced by the fetal liver, yolk sac, and GI tract adn crosses from the amniotic fluid into the maternal blood. Indication: Increased levels may indicate a nerual tube defect, Turner syndrome, tetralogy of Fallot, multiple gestation, omphalocele gastroschisis, or hydrocephaly. Time: 15-18 wks

Para

A woman who has produced one or more viable offsping carrying a pregnancy 20 weeks or more Primipara-one birth Multipara-two or more pregnancies Nullipara-No viable offspring

3 hour glucose tolerance test

Administered following a 3 day high carb diet and 6-8 hour overnight fast -Baseline fasting glucose level drawn -Patient drinks 100g oral glucose -Blood glucose drawn at 1, 2, and 3 hours. If one or more values are elevated then diagnosis of GD happens.

Hydralizine

Apresoline Vascular smooth muscle relaxant, lowers BP. -Dose: 5-10mg IVP. -Can be given q 20 minutes until desired BP. -SE: Tachycardia, palpitations, headache, N/V/D

Biophysical Profile (BPP)

Assessment of 5 variables •Four variables assessed by ultrasound: -Fetal breathing movement -Fetal movements of body or limbs -Fetal tone (extremity extension and flexion) -Amniotic fluid volume (pockets of fluid around the fetus) One or more pockets of fluid measuring 2 cm •One variable assessed by NST -Reactive fetal heart rate (FHR) with activity (reactive nonstress test [NST])

Risks for Obese women

BMI >30 pGestational Diabetes pHypertension pThromboembolism pPreterm Labor and Birth pCongenital Anomalies pLarge Baby (macrosomia) at birth weight > 4000 grams pDepression pTends to remain overweight between babies. pProlongs pregnancy - post-term pIncreased stillbirth pHigher rate of cesarean births pHigher risk for postpartum hemorrhage

Umbilical Velocimetry

Doppler Blood Flow Study •Noninvasive ultrasound test •Measures blood flow changes that occur in maternal and fetal circulation to assess placental function •Creates "picture" (waveform) that looks like a series of waves •Helpful in assessing and managing pregnancies with suspected utero-placental insufficiency before asphyxia occurs

Trimesters of Pregnancy

Each last about 13 weeks 1st-1-12 2nd-12-28/29 3rd-Remaining

Education for Gestational DM

Be sure to keep your appointments for frequent prenatal visits and tests for fetal well-being. • Perform blood glucose self-monitoring as directed, usually before each meal and at bedtime. Keep a record of your results and call your health care provider with any levels outside the established range. Bring your results to each prenatal visit. • Perform daily fetal kick counts. Document them, and report any decrease in activity. • Drink eight to 10 8-oz glasses of water each day to prevent bladder infections and maintain hydration. • Wear proper, well-fitted footwear when walking to prevent injury. • Engage in a regular exercise program such as walking to aid in glucose control, but avoid exercising in temperature extremes. • Consider breastfeeding your infant to lower your blood glucose levels. • If you are taking insulin: • Administer the correct dose of insulin at the correct time every day. • Eat breakfast within 30 minutes after injecting regular insulin to prevent a reaction. • Plan meals at a fixed time and snacks to prevent extremes in glucose levels. • Avoid simple sugars (cake, candy, cookies), which raise blood glucose levels. • Know the signs and symptoms of hypoglycemia and treatment needed: • Sweating, tremors, cold, clammy skin, headache • Feeling hungry, blurred vision, disorientation, irritability • Treatment: Drink 8 oz of milk and eat two crackers or take two glucose tablets. • Treatment: Carry "glucose boosters" (such as hard candies) to treat hypoglycemia. • Know the signs and symptoms of hyperglycemia and treatment needed: • Dry mouth, frequent urination, excessive thirst, rapid breathing • Feeling tired, flushed, hot skin, headache, drowsiness • Treatment: Notify health care provider, because hospitalization may be needed. • Wear a diabetic identification bracelet at all times. • Wash your hands frequently to prevent infections. • Report any signs and symptoms of illness, infection, and dehydration to your health care provider, because these can affect blood glucose control.

Factors that put a woman at risk for a high risk pregnancy

Biophysical Factors • Genetic conditions • Chromosomal abnormalities • Multiple pregnancy • Defective genes • Inherited disorders • ABO incompatibility • Large fetal size • Medical and obstetric conditions • Preterm labor and birth • Cardiovascular disease • Chronic hypertension • Cervical insufficiency • Placental abnormalities • Infection • Diabetes • Maternal collagen diseases • Thyroid disease • Asthma • Post-term pregnancy • Hemoglobinopathies • Nutritional status • Inadequate dietary intake • Food fads • Excessive food intake • Underweight or overweight status • Hematocrit value less than 33% • Eating disorder Psychosocial Factors • Smoking • Caffeine • Alcohol and substance abuse • Maternal obesity • Inadequate support system • Situational crisis • History of violence • Emotional distress • Unsafe cultural practices Sociodemographic Factors • Poverty status • Lack of prenatal care • Age younger than 15 years or older than 35 years • Parity—All first pregnancies and more than five pregnancies • Marital status—Increased risk for unmarried women • Accessibility to health care • Ethnicity—Increased risk in non-White women Environmental Factors • Infections • Radiation • Pesticides • Illicit drugs • Industrial pollutants • Second-hand cigarette smoke • Personal stress

Ondansetron

Blocks serotonin release, which stimulates the vagal afferent nerves, thus stimulating the vomiting reflex Nursing Implications: -Monitor for possible side effects such as diarrhea, constipation, abdominal pain, headache, dizziness, drowsiness, and fatigue. -Monitor liver function studies as ordered.

Chadwick's Sign

Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion.

CRAFTT Questionnaire

C: Have you ever ridden in a car driven by someone (including yourself) who was high or drunk? • R: Do you drink or take drugs to relax, improve your self-image, or fit in? • A: Do you ever drink or take drugs while alone? • F: Do you have any close friends who drink or take drugs? • F: Does a close family member have a problem with alcohol or drugs? • T: Have you ever gotten in trouble from drinking or taking drugs?

Antidote of Magnesium Sulfate

Calcium Gluconate Ø1 gm IV over 5 mins Ø Use a 10% solution: 1 gm/ 10 mL of solution Ø Each milliliter contains 0.1 gm of calcium gluconate Ø Can repeat every hour X 8 per 24hr period Ø Calcium gluconate should be available

Effects of Pregnancy on Carbohydrate Metabolism

Early pregnancy: nPeripheral resistance to insulin—body compensates and makes more nincreased insulin production and tissue sensitivity nFetal demands (essential nutrients for fetus) Second half of pregnancy: nincreased peripheral resistance to insulin ndecreased glucose intolerance nPlacenta secretions of human placental lactogen (hPL) and growth hormone (somatotropin) Increases in in direct correlation with the growth of placental tissue rising throughout the last 20 weeks of pregnancy and causing INSULIN RESISTANCE!!! p

Abnormal Values for 3 hour glucose tolerance test

Fasting blood glucose level: <92 mg/dL At 1 hour: < 180 mg/dL At 2 hour: < 153mg/dL At 3 hour: < 140 mg/dL

Fluid and Vitamins per day

Fluid: 8 glasses Vitamin A 770-1300 mcg Vitamin C 85-120 mg Vitamin D 5 mcg Folate 500-600 mcg Calcium 1,000 mg Iron 9-27 mg

My Plate Nutrition in Pregnancy

Fruits: 2 cups/day Vegetables: 2.5-3 cups/day Grains: 6-7 oz/day Protein: 6-8 oz/day or 80 g Dairy: 3 cups/day

Nursing Assessment for woman with substance abuse

Have you ever used recreational drugs? If so, when and what? • Have you ever taken a prescription drug other than as intended? • What are your feelings about drug use during pregnancy? • How often do you smoke cigarettes? How many per day? • How often do you drink alcohol? • Have you ever felt guilty about drinking or drug use? If the assessment reveals substance use, obtain additional information by using the CRAFFT questionnaire, which is a sensitive screening instrument for identifying substance abuse

HELLP

Hemolysis, elevated liver enzymes, low platelets •Severe form of preeclampsia/eclampsia •Occur in later stages of pregnancy •Prevalence: 10-20% •Patho: Endothelial damage, damaged RBC, vascular damage, fibrin deposits and hypoperfusion to liver and kidneys •Increased risk of complications such as cerebral hemorrhage, liver injury, acute kidney injury, placental abruption and DIC

Placenta Previa

Implantation of the placenta over the cervical opening or in the lower region of the uterus -Classified by coverage/proximity to cervical os -Cause unknown; theory is that it occurs in subsequent pregnancies because placenta searches for fresh tissue rich in nutrients etc.

Level 2 US

Indication: Enables evaluation of structural changes Time: 18 week

Class 1 Heart Disease

Individuals w/ cardiac disease but w/ no resulting limitation of physical activity and no symptoms of cardiac insufficiency. -Ordinary physical activity causes no undue fatigue, dyspnea, or palpations; anginal pain is not present

Class 3 heart disease

Individuals w/ cardiac disease that results in marked limitation of physical activity. -They are comfortable at rest but less than ordinary physical activity results in fatigue, dyspnea, palpitation, or anginal pain

Class 2 heart disease

Individuals w/ cardiac disease that results in slight limitations of physical activity -They are comfortable at rest but ordinary physical activities causes fatigues, dyspnea, palpitation, or anginal pain

Class 4 heart disease

Individuals with cardiac disease that results in the inability to carry on any physical activity without experiencing discomfort. -Even at rest, they may experience symptoms of cardiac insufficiency or anginal pain; discomfort increases with any physical pain

Percutaneous umbilical blood sampling

Insertion of a needle directly into a fetal umbilical vessel under US guidance Indication: Used for prenatal dx of inherited blood disorders (hemophilia A), karyotyping, detection of fetal infection, determination of acid-base status, and assessment and tx of isoimmunization Time: after 16 wks Concerns: Fetal hemorrhage and risk of infection

Fetal nuchal translucency

Screening test An intravaginal US that measures fluid collection in the subcu space between the skin and the cervical spine of the fetus (the neck fold) Indication: To identify fetal anomalies. Abnormal fluid collection can be associated with genetic disorders (trisomies 13,18, 21), Turner syndrome, cardiac deformities, adn/or physical anomalies Time: 10-14 weeks First trimester Concerns: None

Diagnosis of Placenta Previa

It is usually found by US prior to any S/Sx

Furosemide

Lasix -Diuretic action. Lowers BP and pulls edema back to intravascular. -10-40mg IVP over 1-2 minutes. -Monitor urine output. -SE: dizziness, hypotension, electrolyte imbalances, muscle cramps/spasms, palpitations

Hyperemesis Gravidarum

Severe form of N/V -Main concern is F&E! -Symptoms usually resolve by week 20 -Usually requires hospitalization •Weight loss >5% of pre-pregnancy body weight •Dehydration, metabolic acidosis, alkalosis, and hypokalemia, Hypovolemia, hypotension, tachycardia, increased hematocrit, blood urea nitrogen, decreased urine output, low thiamine levels and fetal IUGR (a baby who isn't growing as quickly as he should be inside the womb)

Nutrition for the Pregnant Adolescent

Needs vary widely, depending upon: vWhether growth has been completed. vPhysical activity level. ØOften irregular ØSkipping breakfast ØFrequent snacking ØDay-to-day intake often varies drastically. vYoung adolescent (14 and under)—increase of 50 kcal/kg if physically active vIron needs for adolescents—30 mg to 60 mg per day of iron is indicated. Most important!

Labetolol

Normodyne •Beta blocker, lowers BP. -Dose: 20-40mgIVP. -SE: GI disturbances, dizziness, vertigo

Nursing Assessment and Management for the Woman over 35

Nursing assessment ØPre-existing medical issues ØPreconception counseling; lifestyle changes; beginning pregnancy in optimal state of health ØLaboratory and diagnostic testing for baseline; Nuchal translucency, quadruple blood test screen amniocentesis/chorionic villi sampling Nursing management ØPromotion of healthy pregnancy; education; early and regular prenatal care; dietary teaching; continued surveillance

Procedure of Amniocentesis

Preformed sterilely by physician after obtaining informed consent.

Signs & Symptoms of Pregnancy

Presumptive: Subjective Probable: Objective-signs a health care provider can detect on physical examination Positive: Diagnostic

Nifedipine

Procardia -Dilates arteries and arterioles, lowers BP and stops uterine contractions (Calcium channel blocker). -10-20 mg PO every 4-8 hours. -SE: dizziness, angina, cough

Drugs R/T Hyperemesis Gravidarum

Promethazine (Phenergan) Pyridoxine/doxylamine Ondansetron (Zofran)

Pharmacologic Management of Gestational DM

Put on oral meds or insulin if: not achieve a -FBG <92 - 1-hr. postprandial (pp) < 180 -2 hr pp < 153 Recommended use of diet and meds to achieve a 1 hr pp of 130 •Woman manage oral medications better during pregnancy than insulin - move to oral route if appropriate. •Glyburide (glibenclamide) and Glucophage (metformin) used in pregnancy •These meds do not cross the placenta and do not cause fetal/neonatal hypoglycemia.

Mifepristone

R/T abortion Progesterone antagonist- allows prostaglandins to stimulate uterine ctx, may be given in several doses. Monitor: headache, amount of vaginal bleed, N/V, acetaminophen for pain

Misoprostol (Cytotec)

R/T abortion •Placed vaginally. Stimulates the uterine muscle to contract to expel content. Monitor for: pain level, diarrhea, assess amount of vaginal bleeding and monitor for sx of shock (tachycardia, hypotensive)

Chorionic villus sampling

Removal of small tissue specimen from the fetal portion of the placenta (reflects fetal genetic makeup) Indication: To detect fetal karyotype, sickle cell anemia, phenylketonuria, down syndrome, Duchene muscular dystrophy, and numerous other genetic disorders Time: 10-12 week Concerns: Severe transverse limb defects and spontaneous pregnancy loss

Teaching Guidelines of Woman with Mild Preeclampsia

Rest in a quiet environment to prevent cerebral disturbances. • Drink eight to 10 glasses of water daily. • Consume a balanced, high-protein diet including high-fiber foods. • Obtain intermittent bed rest to improve circulation to the heart and uterus. • Limit your physical activity to promote urination and subsequent decrease in blood pressure. • Enlist the aid of your family so that you can obtain adequate rest time. • Perform self-monitoring as instructed, including: • Taking your own blood pressure twice daily • Recording the number of fetal kicks daily • Contact the home health nurse if any of the following occurs: • Increase in blood pressure • Burning or frequency when urinating • Decrease in fetal activity or movement • Headache (forehead or posterior neck region) • Dizziness or visual disturbances • Stomach pain, excessive heartburn, or epigastric pain • Decreased or infrequent urination • Contractions or low back pain • Easy or excessive bruising • Sudden onset of abdominal pain • Nausea and vomiting

McDononald's Method for Measuring fundal height

Tape measurement from the notch of the symphysis pubis to the top of the uterine fundus as a woman lies supine. Is equal to the week of gestation in centimeters between the 20th and 31st week of pregnancy. •Over the symphysis pubis at 12 weeks •At the umbilicus at 20 weeks - 18-20 weeks mother feels the fetus (Quickening) •At the Xiphoid Process at 36 weeks •After 36 weeks, the fundal height drops due to the baby dropping (lightening) and is no longer a reliable method •What happens if measurement is too big or too little compared to gestational age? If greater than 4 cm difference then further evaluation is required

Gravida

Total # of pregnancies (regardless of outcome) Nulligravida-never been pregnant Primigravida-First pregnancy Secudigravida-second pregnancy

Nursing Assessment and Management for Spontaneous Abortion

Treat mother similar to any other patient at risk or with active hemorrhage §Vaginal bleeding/passage of products of conception—Risk for hemorrhage, risk for infection §Vital signs §Pain §Maternal blood type and Rh- If negative, will need Rhogam IM §Continued monitoring (very important b'c it can help determine treatment plan): vaginal bleeding, pad count, passage of products of conception, pain level, preparation for procedures, medications §Mom can bleed w/o losing pregnancy §Mom can just be monitored in some cases but may need a procedure §Emotional support and grieving the loss

Nursing Management of Cardiac Disease Postpartum

Usually when mother begins decompensating pAssess vital signs and signs of cardiac decompensation frequently pEncourage side-lying or semi-Fowlers position pAs needed—oxygen, diuretics, sedatives, analgesics, prophylactic antibiotics, digitalis pIf needed anticoagulant therapy (NO warfarin) pAnti embolic stockings or Intermittent pneumatic compression (IPC) Boots pActivity gradually increased, Out of bed ASAP when able to tolerate it. pAppropriate diet and stool softeners (prevent straining) pDischarge instructions include signs of cardiac problems.

Risk Factors for gestational DM

nObesity/weight gain in pregnancy nprior history of GDM nGlycosuria/proteinuria nfamily history of diabetes nAge 35 years or older nHistory of large babies (9lb or more) nHistory of unexplained fetal or perinatal loss nPrevious infant w/ congenital anomaly or unexplained fetal death nHigher risk in Native American, Hispanic and Asian Cultures.

Nursing Management of Cardiac Disease Intrapartum (L&D)

pAssess vital signs and lung sounds frequently, signs and symptoms of cardiac decompensation. pEncourage side-lying and semi-Fowlers position pContinuous electronic fetal monitoring pAs needed—oxygen, diuretics, sedatives, analgesics, prophylactic antibiotics, digitalis pEpidural anesthesia if appropriate pPushing—shorter, moderate pushes with periods of relaxation between pushes. pMay not push when fully dilated but use low forceps or a vacuum suction may be used to prevent fatigue if there is cardiac decompensation (congestive heart failure)

Gestational DM Effects on Mother

pHydramnios (too much amniotic fluid) due to fetal diuresis caused by hyperglycemia pKetoacidosis due to elevated glucose levels pIncreased risk of urinary tract infections and vaginal yeast infections pGestational hypertension pStillbirth due to poorly controlled diabetes and ketoacidosis

Antepartum Nursing Management of Cardiac Disease

pMonitor cardiac functional capacity, vital signs, and signs of cardiac decompensation at each antepartum visit (Cough, dyspnea, edema, murmur, palpitations, rales, weight gain and jugular vein distension. Note if signs and symptoms are progressive) pAssess factors that increase stress on the heart (anemia, infection, lack of support, home and career demands) pDiet—high iron, high protein, low sodium, adequate calories pActivity—restricted activities, 8 to 10 hours of sleep, rest periods, avoid sources of infection - After recovery exercise is encouraged. pFrequency of visits—every 2 weeks during the first half of the pregnancy, then every week

Management of the Obese Pregnant Mother

pPreconception assessment and counseling are needed. pPre- pregnancy weight reduction. pNeeds promotion of dealing with weight, diet and exercise. pSpecial dietary interventions - must have adequate nutrition during pregnancy. pCare must be done with honesty and respect. pMay need to be seen more often during pregnancy to intervene early in any pregnancy complications. pMonitor weight gain

Nursing Management of the Woman with Substance Abuse

pPreconception assessment and counseling are needed. pPre- pregnancy weight reduction. pNeeds promotion of dealing with weight, diet and exercise. pSpecial dietary interventions - must have adequate nutrition during pregnancy. pCare must be done with honesty and respect. pMay need to be seen more often during pregnancy to intervene early in any pregnancy complications. pMonitor weight gain

Changes in Partner's reaction to pregnancy

qCouvade syndrome (pregnancy pains with SO) qAmbivalence qAcceptance of roles (second semester) qPreparation for reality of new role (third semester)

Folic Acid during pregnancy

vRequired for normal growth, reproduction, and lactation. vRed blood cell formation. VDecrease risks for neural tube defects (NTD) spina-bifida, meningomyelocele, and anencephaly by 50-70%. vChild bearing women should take 0.4mg (400mcg) prior to conception (Most pregnancies are unplanned!!) NTD occurs 3-4 weeks after conception (before a woman realizes she is even pregnant

Iron during pregnancy

vRequirements increase because of the growth of fetus, placenta, and an increased maternal blood volume. vMaintaining iron levels in the mother is vital, because fetal iron levels are always low at birth and minimal from milk. vIron Deficiency Anemia is related to an increased risk for preterm delivery and low birth weight vRDA for iron during pregnancy is 27 mg/day. vTake iron with orange juice to increase absorption. vNo dairy 1 hour before or after iron consumption..

Toxoplasmosis

§Cats are the hosts and the parasite is shed in the feces §Other sources: contaminated soil /water, undercooked meat §Exposure in pregnancy poses a high risk to the fetus §The earlier the exposure, the more severe the impact §Low birth weight, enlarged liver, intrauterine growth restriction, microcephaly, neurological damage §Teaching: Don't clean litter box, proper cleaning of cutting boards/work surfaces, wash all vegetables/fruits, gardening gloves, avoid undercooked meats

Spontaneous Abortion

§Pregnancy loss prior to 20 weeks §Most common complication of early pregnancy §Common cause for 1st trimester abortions is fetal genetic abnormalities

Clinical Manifestation of Severe Preeclampsia

´Blood pressure of 160/110mmHg or higher on 2 occasions 6 hrs. apart at bedrest ´Diastolic pressure 30mmHg above pre-pregnancy level ´Marked Proteinuria of 5 g or higher in 24 hours (3+ to 4+) ´Oliguria (less than or equal to 400 mL/24 hours) ´Cerebral or visual symptoms ´Extensive edema - rapid weight gain

High risk pregnancy

´Jeopardy to mother, fetus, or both ´Condition due to pregnancy or result of condition present before pregnancy ´Higher morbidity and mortality ´Risk assessment with first antepartum visit; ongoing

Nursing Management of DIC

´May first notice with easy bruising or bleeding from an IV site. ´Platelet Count - Decreased to ≤ 100,000/ul ´Stop the process of DIC - delivery of the baby and placenta. ´Administer Heparin to halt the clotting cascade ´Replacement Therapy - Blood or platelet transfusion to replace loss after the heparin therapy. To be sure the new blood factors are not consumed by the coagulation process. ´Fresh frozen plasma or platelets or cryoprecipitate (contains fibrinogen) ´Blood coagulation studies return to Normal

Vegetarian Diet during pregnancy

ØA plant-based diet is suitable during pregnancy & lactation, if it is well planned. ØPay special attention to intake of protein, iron, calcium, Vitamin D and Vitamin B12 ØIf no soy milk, may need calcium and vitamin D supplements. ØProtein sources: soy, beans, lentils, nuts, grains, seeds ØB12: pay attention to fortified soy foods and a B12 supplement ØCalcium needs via soy, fortified OJ and tofu ØIron needs: eat a variety of meat alternatives along with vitamin C rich foods ØThe more restrictive the higher the risk for nutritional deficiencies

Substances and Food to Avoid

ØAlcohol ØCaffeine ØRaw eggs (Salmonella) ØRaw milk ØSoft cheeses - Brie, feta, blue cheese (unpasteurized) ØDeli meats, hotdogs (heat first to prevent Listeriosis) ØLarge fish (mercury) shark, swordfish, king mackerel, orange roughie, ahi tuna and tilefish ØEat small amounts of fish low in mercury such as shrimp, canned light tuna, salmon, pollock, and catfish ØSushi (Raw Seafood) ØUnpasteurized items (Listeria) ØListeriosis in found in hot dogs, luncheon meats, or deli meats unless they are reheated until steaming hot. ØTobacco ØIllicit drugs/Cocaine- Affects mental development, increase risk for placental abruption ØArtificial sweeteners-Controversial, but best to avoid

Dietary Protein during pregnancy

ØDevelopment of fetal tissue ØContribute to energy metabolism ØFetus has greatest demand in the last half of pregnancy ØProtein intake during pregnancy should be 80 g/day. (complete proteins - have all 9 essential amino acids). ØPrimary source meat, poultry, fish, eggs, yogurt and dairy products. ØFortified soy milk, tofu, and soybean curd.

Peripartum cardiomyopathy

ØDysfunction of the Left Ventricle. Heart size increases- cardiomegaly ØOccurs in the last month of pregnancy or the first 5 months postpartum. ØHappens in a woman with no previous HX of heart disease. Cause unknown but association with gestational hypertension. ØSymptoms - Congestive heart failure (CHF) dyspnea, orthopnea, fatigue, cough, chest pain, palpitations, and edema of face, hands and feet.

Maternal Role Tasks

üEnsuring safe passage throughout pregnancy and birth üSeeking acceptance of infant by others üSeeking acceptance of self in maternal role to infant ("binding in") üLearning to give of oneself

Rubella

•"German measles" •Spread through droplets or direct contact •The earlier the exposure the worse the effect •Newborn: Triad of congenital cataracts, cardiac defects, microcephaly/ intellectual disabilities •All women screened at first prenatal visit •Cannot vaccinate in pregnancy (Live virus!) •Titer >1:8 indicates immunity •Immunize postpartum

Physiological Changes of the pituitary system during pregnancy

•1st Trimester: Decrease circulating insulin and glucose creates a hypoglycemia state. Insulin doesn't cross placenta, so fetus must make own insulin •2nd Trimester: Human placental lactogen hPL, secreted by the placenta, acts as an antagonist to glucose, so insulin production increases

Bottle-Feeding

•Many different formulations of formula to suit needs •Partner or other family members can help with feedings, especially at night •Promotes bonding •Disadvantages: Cost of formula, bottles and nipples, formula use increases newborn risk of certain problems such as ear infections, asthma, colic, respiratory infection and others, preparation of formula

Physiological Changes of the Cervix during pregnancy

•6-8 weeks cervix begins to soften (Goodell's sign) •Production of cervical mucus and mucus plug due to presence of progesterone •Leukorrhea (a mild, odorless discharge from the vagina; protects from infection) •Increase in vascularization causes a bluish-purple coloration to cervix (Chadwick's sign) •As labor begins, other changes mediated by prostaglandins, inflammation, cervical stretch by the fetal head and release of oxytocin

S/Sx of DIC

•: Hypotension, bleeding •: Formation of petechiae •: Blood clots •: Decreased LOC •: Decreased urine output

Teaching Guidelines for Hyperemesis Gravidarum

•Avoid noxious stimuli, such as strong flavors, perfumes, or strong odors like frying bacon, that might trigger nausea and vomiting. • Avoid tight waistbands to minimize pressure on abdomen. • Eat small, frequent meals throughout the day. • Separate fluids from solids by consuming fluids in between meals. • Avoid lying down or reclining for at least 2 hours after eating. • Use high-protein supplement drinks. • Avoid foods high in fat. • Increase your intake of carbonated beverages. • Increase your exposure to fresh air to improve symptoms. • Eat when you are hungry, regardless of normal mealtimes. • Drink herbal teas containing peppermint or ginger. • Avoid fatigue, and learn how to manage stress in life. • Schedule daily rest periods to avoid becoming overtired. • Eat foods that settle the stomach, such as dry crackers, toast, or soda.

Second Trimester Discomforts

•Backache (avoid sitting/standing for long periods, apply heating pad, support lower back with pillows, avoid excessive bending/lifting/walking w/o rest, wear supportive low heeled shoes) •Leg cramps (Elevate legs above heart, ask PCP about calcium supplements) •Hemorrhoids (have regular time for daily BM, avoid straining, use warm sitz baths and cool witch hazel compresses for comfort)

Clinical Manifestations of Preeclampsia

•Blood pressure of 140/90mmHg or higher on 2 occasions 6 hrs. apart at bedrest •300mg/24 hours or greater than a 1+ protein on a random dipstick urine sample •Mild facial or hand edema •Mild weight gain •No CNS complaint such as headache, visual changes or epigastric pain •No hyperreflexia •No seizures

Labs and Diagnostic Tests for Abortion

•Blood work -Type and screen -Check hemodynamic status •Serum quantitative Beta HCG -Drawn to monitor pregnancy progress or trend during a miscarriage (Normal values should double about every 2 days) -In cases of miscarriage, will be drawn frequently to trend down to "0" to ensure that all of uterine contents have been expelled •Ultrasound -Fetal measurement -Presence or absence of a fetal heart rate

Breastfeeding

•Bonding between mom and child •Economical/ readily available •Provides immunity to newborn •Babies less likely to develop ear infections, atopic dermatitis, diabetes and many others •Newborn less likely to develop food allergies/sensitivities •Less prone to vomiting or GERD •Breast milk is perfectly formulated for newborn nutrition •Disadvantages: Partner can't help, requires practice and dedication.

Examples of Probable S/Sx of Pregnancy

•Braxton Hicks contractions 16-28wks •Positive pregnancy test (urine/blood) 4-12wks •Abdomen enlargement 14wks •Goodell's sign- 5wks: Softening of the cervix •Chadwick's sign-6-8wks:Bluish-purple coloration of the vaginal mucosa and cervix •Hegar's sign-6-12wks: Softening of the lower uterine segment or isthmus

Physiological Changes of the Breast during pregnancy

•Breasts become fuller and more tender •Nipples and areola darken in response to hormones •Stretch marks may appear with sudden growth •Colostrum can be expressed by the 3rd trimester

In event of Eclampsia a nurse would

•Call for help, maintain airway, administer oxygen via face mask •Position client to side •Client safety •Documentation of events •IV access for IV fluids •Administration of medications (anti-hypertensives, magnesium sulfate IV) •Monitor fetal heart rate •Delivery once seizures controlled

What are Woman over 35 at risk for

•Chromosomal Assessment and Genetic Counseling •Gestational Hypertension (Chronic Hypertension) •Labor Complications of Failure to Progress FTP: Cesarean Birth, Post Term Birth and Preterm Birth •Difficulty accepting pregnancy •Post Partum Hemorrhage

Nursing Management of Hyperemesis Gravidarum

•Comfort and nutrition (NPO, IV fluids, hygiene, oral care, I&O) •IVF-Normal saline, electrolytes (K+), Vitamin B1 •Clear liquids then advance diet slowly •Antiemetics-Given IV Zofran/Compazine •If not able to tolerate oral intake or sx worsen, may need total parenteral nutrition (TPN) •Support and education: reassurance; home care follow-up

Therapeutic Management of Hyperemesis Gravidarum

•Conservative (reassurance, meal planning and lifestyle changes) •Lab work to evaluate electrolyte imbalance and hydration status. •Gut rest (NPO) •Antiemetics (Zofran) •IV fluids with replacement of B1 (Thiamine) and potassium •Hospitalization with parenteral therapy for intractable cases (may place a central line)

Examples of those who may benefit from Genetic Counseling

•Couples with previous children with congenital disorders or inborn errors of metabolism •Congenital anomaly diagnosed prenatally or at birth •Couples with close relatives who have genetic disorders •Two or more pregnancy losses or stillborn •Individuals with a chromosomal disorder or inborn error of metabolism •Consanguineous couples (closely related couple) •Women older than 35 and men older than 50 years of age •Abnormal pregnancy screening or newborn screening •Exposure to drugs, medications, radiation, chemicals or infection. •Couples of ethnic backgrounds where genetic diseases are known to occur

Disseminated Intravascular Coagulation

•DIC is a bleeding disorder •Abnormal reduction in the elements involved in blood clotting resulting from widespread intravascular clotting üPrecipitating Factors for DIC: Toxic, Inflammatory, Hypoxic, and/or Immune Responses üVascular Disorders & Hemorrhage • placental abruption, shock, hypertension, retained deceased fetus •High morbidity and mortality

Magnesium Sulfate Assessment

•DTR - Patellar Reflexes •Respirations - 12/min/normal Depth •Hourly Urine Output - 30 mL/hr •Creatinine Levels •LOC (talk to pt. make sure they are answering questions appropriately etc.)

Chromosomal Abnormalities

•Differences in the number or structure of chromosomes are a major cause of birth defects •Most chromosomal abnormalities occur in the egg or sperm •50% of all spontaneous first-trimester losses •Always associated with some degree of mental or physical disability •1/150 live born infants .During meiosis nondisjunction results in Aneuploidy which is an extra or missing chromosome. •Trisomy 21(Downs syndrome) mothers age 35 or older are at greater risk (three copies of chromosome 21)

Assessment and Management for the Pregnant Adolescent

•Encourage regular prenatal visits & monitor for problems •Vision of self in future in the parenting role •Realistic role models; emotional support •Support system and community resources •Level of child development education •Financial and resource management; work and educational experience •Anger and conflict resolution skills •Knowledge of health and nutrition for self and child •Future planning (return to school; career or job counseling); options for pregnancy •Frequent evaluation of physical and emotional well-being •Stress management; self-care

Physiological Changes of the Ovaries during pregnancy

•Enlarge initially •Ovulation ceases due to change in hormone levels •The ovaries (corpus luteum) support the pregnancy until the placenta takes over, generally 6-7 weeks •Placenta becomes major producer of progesterone

Examples of Presumptive S/Sx of Pregnancy

•Fatigue 12wks •Nausea and vomiting 4-14wks •Breast tenderness 3-4wks •Urinary frequency 6-12wks •Amenorrhea (missed period) •Fetal movements (quickening 16-20 weeks) •Uterine enlargement 7-12wks •Breast enlargement 6wks •Hyperpigmentation of skin 16wks

Physiological Changes of the Uterus during pregnancy

•Grows at a steady rate in response to estrogen •80-90% uterine blood flow goes to placenta (largest amount of blood flow to nourish baby) •Presses on adjacent organs (bladder, lungs) •Vena cava compression/orthostatic hypotension (don't lay supine) •Fundal height correlates w/ gestational age •Braxton-Hicks contractions

Physiological Changes of the GI system during pregnancy

•Gums may bleed/ increase in gingivitis in response to estrogen •Ptyalism—excessive salivation •Risk for constipation •Risk for hemorrhoids •Heartburn due to relation of pyloric sphincter and delayed gastric emptying •Nausea and vomiting

Nursing Assessment of Gestational DM

•Health history; physical examination; risk factors •Vital signs, blood pressure, weight •Fundal height and fetal movement •Screening at first prenatal visit; additional screening at 24 to 28 weeks for women considered at risk (1 hour glucose challenge test and 3 hr glucose tolerance test)

Fetal HR Assessment

•Heard on external Doppler from the 10th to 12th week of pregnancy. •Normal Fetal Heart Rate (FHR) 110-160 bpm. •If mother is obese it may be a week or two later. •Can see fetal heart beating on ultrasound using a vaginal probe at 5-6 weeks.

Other Infections

•Hepatitis B virus (tested for in pregnancy) •Varicella zoster virus •Parvovirus B19 •Group B streptococcus •Human immunodeficiency virus (HIV)

Nursing Assessment for Ectopic Pregnancy

•History and physical--missed period, abnormal bleeding, pelvic pain •Review of history for risk factors such as history of ectopic preg, h/o PID or STI, History of IUD use, uterine abnormalities such as fibroids, smoker

Nursing Assessment of Cardiac Diseases

•History and physical-4 key risk factors -Race/ethnicity -Age -Obesity -HTN/Pre-eclampsia •Lab work and diagnostic testing •Vital signs, heart sounds, EKG and pulse ox, weight •Inspection for edema •Presence of fetal movement/teaching fetal kick counts •Assessment of fetal heart rate (FHR) •Recognition of cardiac decompensation (mimic CHF)- SOB, dyspnea, cyanosis, edema, abnormal heartbeat/rate, chest pain, syncope, increasing fatigue, cough

Physiological Changes of the integumentary system during pregnancy

•Hyperpigmentation; mask of pregnancy (facial melasma) •Linea nigra (brownish linear discoloration of center abdomen) •Striae gravidarum (stretch marks) •Varicosities •Vascular spiders •Palmar erythema •Decline in hair growth; increase in nail growth

What are Pregnant Adolescents at Risk for

•Hypertension •Premature Labor •Cephalopelvic Disproportion (CPD) •Hemorrhoids •Low birth weight infants •Iron—deficiency anemia •Poor eating habits •Post Partum Hemorrhage •Lack of Knowledge, lack of support, depression

Preconception Care

•Immunization status •Underlying medical conditions •Reproductive health care practices •Sexuality and sexual practices •Nutrition/Intake of folic acid to prevent neural tube defects •Lifestyle practices •Psychosocial issues •Medication and drug use •Support system

Physiological Changes of the Cardiovascular System during pregnancy

•Increase in cardiac output •Pulse may increase •Blood pressure declines slightly •Stasis in lower extremities (edema) •Vena cava syndrome •Increase in blood volume (50% above pre-pregnant levels) and erythrocytes •Physiologic anemia of pregnancy (more circulatory volume same amount of HMG) •Leukocytes, fibrin, and plasma fibrin increase (puts pt at risk for clots) •Iron demands increase

Physiological Changes of the respiratory system during pregnancy

•Increased oxygen consumption •Change in diaphragmatic excursion—growing uterus pushes everything up, lungs can't fully inflate •Increased respiratory rate, hyperventilation and hypocapnia •Monitor pregnant clients with chronic lung issues •Nasal congestion/rhinitis •Epistaxis (nosebleed)

Risks for adverse pregnancy outcomes

•Isotretinoins (Accutane) •Alcohol misuse •Antiepileptic drugs •Diabetes (preconception) •Folic acid deficiency (desired is 400-800mcg/d) •Hepatitis B •HIV/AIDS •Illicit drug abuse •Hypothyroidism •Maternal phenylketonuria •Rubella sero-negativity •Obesity •Oral anticoagulants •Sexually transmitted infections (STI) •Smoking (pre-term birth and low birth weight)

Lab levels of Iron Deficiency Anemia

•Low Hgb <11g/dl •Low Hct < 35% •Low Serum iron (fe) <30mcg/dl •Low Serum Ferritin <100mg/dl •Microcytic and hypochromic RBC

Nursing Management of Placenta Previa

•Monitoring of maternal-fetal status •Bedrest/monitor maternal vital signs •Vaginal bleeding; monitor blood loss; pad count •Avoidance of vaginal exams!!!!! •Presence of uterine contractions •FHR and fetal well being (US, BPP, NST) •Quality IV access •Lab work: CBC, coag studies, Blood, PT, PTT, fibrongen, platelet count, type and screen, type/Rh--?RhoGAM -Support and education: fetal movement counts, effects of prolonged bed rest (if necessary); signs and symptoms to report, emotional support -Teaching (no intercourse) -Preparation for possible cesarean birth (oVaginal birth - if previa is less than 30% (by ultrasound) oCesarean Section if over 30% or continued heavy bleeding) -Strict Intake & Output -IV fluids -Ultrasound to locate placenta - Maybe amniocentesis for fetal lung maturity if less than 36 weeks. -Betamethasone (Celestone) - steroid given IM to mother if under 36 weeks to mature fetal lungs -Post delivery - prone to post partum hemorrhage

Maternal Assessment of Fetal Activity

•Monitors fetal well-being •Begins at approximately 28 gestational weeks •Reduction in movement may indicate fetal hypoxia, growth restriction, or fetal death.

Nursing Assessment of Hyperemesis Gravidarum

•Onset, duration, course of N/V; diet history; aggravating or alleviating factors • Risk factors, weight and weight loss, associated symptoms, perception of situation •Physical examination (MM, VS) •Liver enzymes, CBC, BUN, electrolytes, urine specific gravity •Ultrasound

Nursing Management to Promote Self-Care

•Personal hygiene •Avoidance of saunas and hot tubs •Dental care •Breast care •Exercise (see Teaching Guidelines 12.2) •Sleep and rest •Sexual activity and sexuality •Employment (see Teaching Guidelines 12.3) •Travel (see Teaching Guidelines 12.4) •Immunizations and medications (see Box 12.5) -Live flu vaccine, MMR, Varicella, BCG CONTRAINDICATED

Goals of preconception care

•Promote the health and well-being of a woman and her partner before pregnancy • •The goal of preconception care is to identify any areas such as pre-existing health problems, lifestyle habits, or social/personal concerns that might unfavorably affect pregnancy. •Period of greatest consequence risk to a developing embryo is 17 to 56 days after conception • •During the first trimester, the fetus is most susceptible to damage from substances, like alcohol, drugs and certain medicines, and illnesses, like rubella (German measles).

First Prenatal Visit

•Reason for seeking care -Suspicion of pregnancy and date of last menstrual period (LMP) -Signs and symptoms of pregnancy -Positive pregnancy test •Menstrual cycle history/last menstrual period (LMP)/use of contraception •Current pregnancy •Advanced maternal age •Reproductive history/past pregnancy history •Gynecological history •Medical/surgical-Establish a baseline of current health •Establish a trusting relationship •Physical examination •Lab testing

S/Sx of Magnesium Toxicity

•Respiratory Rate < 12 breaths per minute (Some hospitals < 14 bpm) •Maternal pulse oximeter reading < 95% •Absence of Deep Tendon Reflexes •Sweating, flushing •Altered sensorium (confused, lethargic, slurred speech drowsy, disoriented) •Hypotension •Serum magnesium value above therapeutic rage of 4 to 7 mEq/L (4.8-9.6 mEq/L)

Third Trimester Discomforts

•Return of first-trimester discomforts •Shortness of breath •Heartburn and indigestion (Avoid spicy or greasy food, sleep on several pillows, stop smoking and avoid caffeine, avoid lying down for at least 3 ours after meals, avoid foods that trigger sympotms, take antacids sparingly) •Dependent edema •Braxton Hicks contractions (changes position or light exercise, increase fluids)

Nursing Assessment of Gestational HTN

•Risk factors, BP, nutritional intake, weight, edema; urine for protein; other laboratory tests if indicated History and physical exam, VS, weight •Lab work: CBC, electrolytes, liver enzymes, BUN, creatinine, urine for protein, 24- hour urine collection for protein/creatinine clearance •Ask about swelling of face, fingers and ankles. Assess client for edema •Assess deep tendon reflexes (DTR)—Patellar reflex •Hyperreflexia present due to CNS irritation, clonus may be present (p. 689)

Nursing Care Post Amniocentesis

•Risks of Hemorrhage, Infection, Puncture (amniotic fluid leakage) and miscarriage •Pillow/towel under right hip to prevent maternal hypotension •Place mother on FHR and contraction monitor for 30 to 60 minutes for uterine irritability. •Monitor for bleeding, assess maternal VS, monitor for contractions •Rh- Negative mother receives RhoGAM •Rest and light activity for 24 hours.

BPP Scoring Criteria

•Score of 2 assigned to each normal finding •Score of 0 assigned to each abnormal finding •Maximum score of 10 •Scores of 8 (with normal amniotic fluid) and 10 considered normal -Reflect least chance of being associated with compromised fetus unless decreased amount of amniotic fluid noted

Clinical Manifestations of Eclampsia

•Seizure activity of pregnancy •Life threatening to mom and baby •Complications include: respiratory depression, compromised fetal oxygenation, head trauma, aspiration •Once seizure is controlled and mom is stable, delivery may be imminent •These clients may be monitored in a high risk obstetrical unit or in the ICU •BP >160/110 •Marked proteinuria •Generalized edema, severe headache, epigastric pain, visual disturbances, renal failure, HELLP, SEIZURE

Management of HELLP

•Seizure precautions and ensure O2 and suction equipment •Monitor VS, edema, DTR •Bedrest and strict I & O •Fetal monitoring •Treatment based on severity, gestation age and health of mom and similar to that of a woman with pre-eclampsia •Goal is to lower BP, protect the developing fetus and prevent seizure •IV access •Administration of rapid acting antihypertensives or magnesium sulfate •Administration of betamethasone to speed up lung maturity so delivery can take place •May give fresh frozen plasma, packed RBC or platelets in cases of anemia or thrombocytopenia

Prenatal laboratory tests

•Serum pregnancy test- Quantitative Beta HCG •Urinalysis •Complete blood count (CBC) •Blood typing and Rh factor •Rubella titer 1:8 or less - Nonimmune 1:10 or above is immunity •Hepatitis B surface antigen •HIV • VDRL/ RPR testing (done for syphilis) • Pap Smear/Gonorrhea & Chlamydia cultures

Herpes

•Sexually transmitted infection (STI •Perinatal transmission is assoc with pregnancy loss, intrauterine growth restriction, preterm labor •Greatest risk of transmission is a primary infection near delivery that goes untreated •Vaginal birth verses C-section? •Reported history of HSV... -Prophylactic antiviral medications given (acyclovir) PO daily -Started around 32 weeks -Prevents an active outbreak near delivery

Interpreting a Nonstress Test

•Shows at least two accelerations of FHR with fetal movements of 15 beats/min, lasting 15 seconds or more, over 20 minutes •In preterm fetuses, rate is 10 beats above baseline for 10 seconds in a 20-minute window. •Up to 50% of 28- to 32-week gestational age fetuses have a nonreactive NST. •Reactive criteria are not met. -For example, the accelerations do not meet the requirements of 15 beats/min or do not last 15 seconds...Non-reactive

S/Sx of HELLP

•Similar to symptoms reported by clients with Pre-eclampsia •Nausea •Right upper quadrant pain •Headache •Visual changes, scotoma •General malaise

Disadvantages of Nonstress Test

•Sometimes difficult to obtain a suitable tracing •Woman must remain relatively still for at least 20 minutes. •High false-positive rate

Danger Signs in Pregnancy

•Spotting or bleeding •Sudden gush of fluid or bleeding from vagina •Abdominal pain •Chest pain •Fever/chills •Dizziness, blurred vision, double vision, spots •Persistent vomiting •Severe headache •Edema •Muscular irritability •Epigastric pain •Oliguria/Dysuria •No fetal movement •Regular uterus contractions before 37 weeks

Labs during Pregnancy

•Urine (Glucose, protein, WBC) •CBC (Initial visit and 28 wks.) •Screening for chromosomal anomalies -Quad Marker Screen (AFP, hCG, UE, inhibin) -Performed @ 15-22weeks ideal 16-18 weeks •Indirect Coombs (Rh negative women @ 28weeks. Rhogam if indicated) •Glucose Tolerance Test (Between 24-28weeks) •Group B Strep (GBS) (Performed @ 35-37weeks. Rectal and vaginal swabs: Test for carrier. ALL women are tested for it. Not a STI)

Estimated Due Date (Nagele rule)

•Use first day of LNMP 11/21/19 •Subtract 3 months 8/21/19 •Add 7 days 8/28/19 •Add 1 year 8/28/20 = EDD -Early US can be used if LMP not known

Prenatal Physical Exam

•Vital signs, weight •Head-to-toe assessment -Cardiovascular and respiratory -Head and neck -Chest -Abdomen, including fundal height -Extremities -Pelvic exam

Nonstress Test

•Widely used method of evaluating fetal status [alone or as part of biophysical profile (BPP)] •Adequately oxygenated fetus with intact fetal central nervous system should demonstrate accelerated fetal heart rate (FHR) in response to fetal movement. •Requires electronic monitor to observe and record fetal heart rate accelerations