OB EXAM 1 (review the quiz material as well)

ANS: D Feedback A Incorrect: This procedure is known as in vitro fertilization (IVF). B Incorrect: This procedure is known as artificial insemination (AI). C Incorrect: This is the description for the procedure known as gamete intrafallopian transfer (GIFT). D Correct: A fertilized egg that is placed into the fallopian tube is known as ZIFT.

A nurse is providing instruction to a couple undergoing zygote intrafallopian transfer (ZIFT). The nurse is aware that instruction has been effective when the woman states: A. "My egg will be fertilized and then placed into my uterus." B. "My husband's sperm will be inserted into my uterus." C. "My husband's sperm and my egg will be placed into my fallopian tube." D. "A fertilized egg will be placed into my fallopian tube."

assessment of risk factors

A comprehensive approach to high risk pregnancy is used now. The factors associated with high risk childbearing are grouped into broad categories based on threats to health and pregnancy outcomes. Anyone that has a maternal complications or fetal complication is a high risk pregnancy They pose threats to the health of the mom and the baby Mom and baby are the two kids we take care of After the 20 weeks the baby is viable and we as health care providers can substain their life better

key points

A high-risk pregnancy is one in which the life or well-being of the mother or infant is jeopardized by a biophysical or psychosocial disorder coincidental with or unique to pregnancy. Biophysical, sociodemographic, psychosocial, and environmental factors place the pregnancy and fetus or neonate at risk.

key point

Because pregnant women may have a history of mental disorder or substance abuse, careful assessment is extremely important at the first and each subsequent prenatal and postpartum visit. Mood disorders account for most mental health disorders in the postpartum period. Psychotherapy is the first-line treatment option for women with mild to moderate peripartum depression.

Care management

Assessment and nursing diagnoses Accurate measurement of BP Assessment of edema, although the presence of edema is no longer included in the definition of preeclampsia Deep tendon reflexes (DTRs) Assess for hyperactive reflexes (clonus) Proteinuria: ideally determined by evaluation of a 24-hour urine collection Evaluate for signs and symptoms of severe preeclampsia: Headaches Epigastric pain Right upper quadrant abdominal pain Visual disturbances Go back to the tedious health assessment, make sure that the blood pressure is the right size Assesment of edemia- protein in the urine Check for deep tendon reflexes can determin if they have hyperflexia or clonus

Care Management: Pregestational Diabetes Mellitus

Antepartum Diet Exercise Insulin therapy Monitoring blood glucose levels Urine testing Complications requiring hospitalization Fetal surveillance Determination of birth date and mode If mom has an insuin pump need to indiacte during antepartum -before deliver They need to incorporate snacks and how many carbs If they exercise before then they need to exercise the same amount Need to add more fluids because If dehyrdated they can be at higher risk for hyperglycemia Baseline is going to be differnet for the patients Prior to meals glucose is 65-95 and post grandial or after meals 130-140 It is really important for patients to have tight control of their diabetes, if they do not have tight control then the babies can be big and they can can have IUGR Test urine for keytones Fetal survallience- need for increase in ultra sound, if the baby is growing bigger than the mom may need to have to induce labor or c- section For stress test should have 15 beats for minutes, in 15 seconds and 3 times in 20 minute window knowing that the non stress test for the gestational diabetic

Infertility Care Management

Assessment of male infertility Semen analysis Ultrasonography Other tests Male in reguards to reproduction Can be male or female that can have problems Male analysiss they explore the fetus, the can have transport and suvival rate of the sperm It is the easist and the earliest, the first line in the female infertility Undesended testes

key points

Blood loss during pregnancy should always be regarded as a warning sign until the cause is determined. Some miscarriages occur for unknown reasons, but fetal or placental maldevelopment and maternal factors account for many others. The type of miscarriage and signs and symptoms direct care management.

Anxiety Disorders (Cont.)

Care management Cognitive therapy Medications Benzodiazepines Associated with abuse and physical dependence in some women Increases the risk of oral cleft and floppy infant syndrome Most of the antianxiety medications are Food and Drug Administration (FDA) Category D or Category X Selective serotonin reuptake inhibitors (SSRIs): first-line therapy for this disorder If mom is taking benzo it does have impact on babies X- means should never be taken while pregant D - shows that there these can cause birth defects

Chapter 14

Chapter 14

chapter 26

Chapter 26

Chapter 27

Chapter 27

chronic hypertension

Chronic hypertension Affects 4% to 5% of pregnant women Ideally the management of chronic hypertension in pregnancy begins before conception Associated with increased incidence of the following: Abruptio placentae Superimposed preeclampsia Increased perinatal mortality IUGR Preterm birth

Classification of Hypertensive Disorders (Cont.)

Chronic hypertension Hypertension present before pregnancy or diagnosed before week 20 of gestation Chronic hypertension with superimposed preeclampsia Women with chronic hypertension may acquire preeclampsia or eclampsia Can be difficult to diagnose

interventions

Chronic hypertension (Cont.) Postpartum complications Pulmonary edema Renal failure Heart failure Encephalopathy Chronic hypertension: Diagnosis prior to pregnancy- up until 20 weeks gestation SBP>140, DBP>90 May aquire preclamspia- eclamspia <difficult to diagnosis> Hypetension that is chronic last longer than 6 months This patient has been diagnosis previously or last up into 20 weeks If patient has protien in the urine, they can aquire super imposed preeclampsia Often difficult to diagnosis The difference might be protein in the urine Think about the proteinuria signifies an advancement in the condition These are more of the baseline hypertension

significant and incident

Common medical complication of pregnancy Hypertensive disorders are a major cause of perinatal morbidity and mortality worldwide due to the following: Uteroplacental insufficiency Premature birth Of maternal deaths worldwide, 10% to 15% can be attributed to preeclampsia and eclampsia. Preeclampsia accounts for more than 50,000 maternal deaths each year. We see them commonly in complication of pregnancy The biggest thing we see is the uteral placental insufficancy- can be a fluid issue, a vascular issue When the uterus does not have adequet blood flow, and placenta doesn't have adequet blood flow the umbilical cord can be effected We have mom and baby, so we need to assess a complication with mom and if it is effecting the baby Premature birth- the perfusion may not be there and can cause complications and premature birth See 10-15% can be attributed to pre-clampsia

Variations in Prenatal Care

Cultural influences Many cultural variations are found in prenatal care Cultural barriers to prenatal care: lack of money, lack of transportation, language barriers, modesty Cultural prescriptions vs. cultural proscriptions Emotional response Physical activity and rest Clothing Sexual activity Diet Knowing what the preferences and beliefs are of the patient They may want same sex providers, need to accompany the needs, They need to know the diets that they eat, are they high in salt Need to make sure they are comfortable so they keep coming to their prenatal visits

Antepartum Testing: Biophysical Assessment

Daily fetal movement count (DFMC) Used to monitor fetus in pregnancies complicated by conditions that may affect oxygenation Also called kick counts Several different protocols are used for counting A count of fewer than three kicks in 1 hour warrants further evaluation by a nonstress test (NST). Fetal alarm signal Mom can do at home, it is cost effective, the biggest thing to recongize is the intra uterine growth restriction Kick counts- the baby needs to kick more than 3 times an hour Have to asses is the baby sleeping, how do we determine if the baby is awake, have the mom due exercise If there is not 3 kicks then do nonstress test Fetal alarm- can use caffine, little amount to wake it up

Diabetes Mellitus Introduction

Diabetes mellitus (DM) Affects 4% to 14% of pregnant women Pregnancy complicated by diabetes is considered high risk Pathogenesis Group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both Body compensates for its inability to convert glucose into energy by burning muscle and fats Key to an optimal outcome is strict glycemic control These patients are consider to be high risk population Talk about maternal complication The most important thing is if a mom is coming in to a pregnancy with prior diabetes They need to have good prenatal education but if going to pregnancy you can have an increase in stress and hormones and can cause her to be hyperglycemic Prior to education is a big factor

Anxiety Disorders (Cont.)

Diagnosis Panic attacks Panic disorder Generalized anxiety disorder PTSD

Estimating Date of Birth

Estimated date of birth (EDB) Older terms Estimated date of delivery (EDD) Estimated date of confinement (EDC) Ultrasound Standard procedure for determining the gestational age of the fetus Naegele's rule to calculate EDB Assumes that the woman has a 28-day cycle and that fertilization occurs on the 14th day After determining the first day of the LMP, subtract 3 calendar months and add 7 days The ultrasound is the most correct way of determine when the organ systems are developing The dates might be off if they see something that developed Negal's rule- this is assuming the mom has regular periods at 28-30 days The calculation is subtract 3 months and add 7 days Decemember 10 2011- 3 months and add 7 days= september 17th estimated date of delivery Start of the last period is when you calculate

Preeclampsia (Cont.)

Etiology A condition unique to human pregnancy Common risk factors Primigravidity in woman <19 or >40 years of age First pregnancy with a new partner History of preeclampsia Pregnancy-onset snoring The cause of preeclampsia is unknown. Many theories

Hyperemesis Gravidarum (Cont.)

Etiology Clinical manifestations Management Assessment Assess severity Weight, V/S, presence of ketonuria Psychosocial assessment: role of anxiety Due to increase in hormones Gestation of multiples, this can happen in a mom having one baby Assess the severity is the weight loss, how much weight did she lose Deitary log Proteinuria If the patient has anxiety then they can also have weight loss

Nursing Interventions: Education for Self-Management

Expected maternal and fetal changes Nutrition Personal hygiene Prevention of urinary tract infections Kegel exercises Preparation for breastfeeding Dental health Physical activity Mom presents with newly diagnosed pregnancy, has leukorea this is normal should be white, yellow or green is not normal Mom that comes in at 18 weeks with bleeding is abnormal Need to take prenatal vitamin that has nutrients for mom and baby If someone has chronic UTI they may need nutrion tips, they can be at risk for preterm labor Keegle excercises, pelvic floor excercises, need to do them multiple times through out the day, can do these keegles in the line at the grocery store Mom needs to do this so that they can strength so they don't have leaking If it is second time mom then they want to make sure they don't have incontience with bowel and bladder Asses early like the week 8, ask what the feeding plan is, formula or breast feeding Dental health- poor dental health can be assossiated with cardio vacular disease, need to encourage them to go to the dentist Physical activity- keep same rate of physical activity as before the pregnancy, not the time to do strenous activities if you havent done it before

Factors Associated with Infertility

Female infertility causes Hormonal and ovulatory factors Tubal and peritoneal factors Uterine factors Developmental anomalies Endometritis Vaginal-cervical factors See structural issues, tubal and periteneal factors See uterine factors, congential uterine abnormalites are not known until they try to have children and cannot The conception process not able to take place There can be vaginal enviroment problems, with all of these causes, takes a lot of time to discover because there are many problems that take place

care management

Follow-up visits Interview Physical examination Fetal assessment Gestational age Fetal heart tones Health status Fundal height Laboratory/other tests Follow up visits, the moms need to be reexamed They need a through physical exam, gestation age is determined by imaging and ultra sound The actual osculation of the heart sounds, Are they having issues with blood pressure or spotting or bleeding Hematological issues

Refer to powerpoint

Gammate interfallopian- reflective of the gamate, have 2 different types A and B This is where the gamete is put into the ovian The folican is removed and then transplanted back into the uterus, they place it into the tube and ready for fertilization B. thye are impllaced sperately, and placed into the fallopian tube, put them into tube and hope they get fertiziled, this can increase atopic pregnacy Take the product and place it into the destination, it is already ready to go, this can be a transport problem, they are already fertiziled, very beginning , this is blastocyst Is a union problem, the second is already a zygote GIFT- requires women to have 1 normal tube oocytes are aspirated from follicles laprascopically semen is collected laprascopically and the ova and the sperm are transferred to one uterine tube permitting natural fertilization ZILF- similar to GIFT but fertilization occurs in vitro and the zygote is placed in the uterine tube, about 1% use this method

Classification of Hypertensive Disorders

Gestational hypertension Onset of hypertension without proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of pregnancy Systolic BP >140, diastolic BP >90 Gestational hypertension SBP>140, DBP>90 After 20 weeks gestation* No proteinuria or systemic changes*

Perinatal Education

Goal is to help individuals and family members to make informed and safe decisions about pregnancy, birth, infant care, and early parenthood Classes for expectant parents Education programs consist of a menu of class series and activities from preconception through the early months of parenting. prepare for the antipartium, the partitum and after birth Offer the classes with relaxation and deep breathing See who they want the other role to be taken by, the dad, the spouce the sibbling

Early Pregnancy Bleeding (Cont.)

How It is done, they will band the cervix or suture the cervix

key points

Hydatidiform mole is a gestational trophoblastic disease (GTD). GTD refers to a group of pregnancy-related trophoblastic proliferative disorders without a viable fetus that are caused by abnormal fertilization. Placenta previa and placental abruption are differentiated by type of bleeding, uterine tonicity, and presence or absence of pain.

Care Management

Identifying and preventing preeclampsia No reliable test or screening tool has been developed Low-dose aspirin (60 to 80 mg) may help certain high risk women Potential biomarkers being investigated Tyrosine kinase (sFLt) and serum placental growth factor Abnormal uterine artery Doppler velocimetry in the first or second trimester of pregnancy Low dose asprin can decrease the risk of preeclampsia Might determain arterial blood flow

key points

In pregnant women with pregestational diabetes, lack of glycemic control before conception and in the first trimester of pregnancy may be responsible for fetal congenital malformations. For pregnant women who have diabetes and are insulin dependent, insulin requirements increase as the pregnancy progresses and may quadruple by term as a result of insulin resistance created by placental hormones, insulinase, and cortisol. After birth, levels decrease dramatically; breastfeeding affects insulin needs. Poor glycemic control before and during pregnancy in women who have diabetes can lead to maternal complications such as miscarriage, infection, and dystocia (difficult labor) caused by fetal macrosomia.

key points

In the United States, about 20% of infertility cases are unexplained; of that 80% in which causative factors are known, about 40% are related to female causes, 40% are related to male causes, and 20% are attributable to both male and female causes. Common etiologic factors of infertility include decreased sperm production, ovulation disorders, tubal occlusion, and endometriosis. Obesity or smoking in either partner is receiving increasing attention as a cause of infertility.

Antepartum Assessment Using Electronic Fetal Monitoring

Indications Does the intrauterine environment continue to support the fetus? Nonstress test Procedure Interpretation: reactive or nonreactive Vibroacoustic stimulation Why would someone need fetal monitoring- any mom that has diabetes, is going to be at risk Need to have non stress test preformed more requently If on ultrasound, if something does not seem right then the baby needs to be evaluated A non stress test see if the baby is able to respond or react One is a Toco and the heart rate monitior TOCO assess for contactions And heart rate looks at the heart rate of the baby The mom lays in semi fowlers and put the monitor on

key points

Infertility is the inability to conceive and carry a child to term gestation when the couple has chosen to do so. Infertility affects approximately 15% of otherwise healthy adults. Infertility increases as the woman ages, especially after age 40 years.

Hyperemesis Gravidarum (Cont.)

Initial care Intravenous (IV) therapy for correction of fluid and electrolyte imbalances Medications Enteral or parenteral nutrition as a last resort Nursing interventions Follow-up care Pre term labor is with dehydration, she is at increase risk for preterm labor Need to prevent this from happening Zolfran is a good thing to help prevent patient from throwing up Zantac- is an anti-reflux Do not put patient on enterial nutition unless lass resort Want to make sure that we check up on baby, check the non stress chest

care management

Initial visit Prenatal interview Reason for seeking care Current pregnancy Childbearing and female reproductive history Health history Nutritional history History of drug and herbal preparation use Family history Social, experiential, occupational history Education is very important- can talk about obtaining initial assessment What is the reason they came in, the missed period or the they took a pregnancy test Why are they here Current pregnacy- need to know how they are coping with it, we have some people who are over the moon with it or they may have not expected It Asking family childbearing history, were they using contraceptives or was this plans For example if she was on birth control and was using antibiotics and got pregnant Have they had miscarriages in the past, the GTPAL What dietary recall, what are the food groups they avoid They may not be able to take diary The prenatal period need to be on folic acid and prenatal vitamins The 8 week exposure is the most crutial- the baby can be effective If it is a class C it can effect the child, it could be for cardiac or diabetes but harmful to the baby Family history and inherited, have families gone through invetro, have anyone been pregnant with twins, test for STI's

Psychologic Considerations Related to High-Risk Pregnancy

Label of high risk often increases the patient's sense of vulnerability May exhibit anxiety, low self-esteem, guilt, frustration, and inability to function May affect parental attachment, accomplishment of the tasks of pregnancy, and family adaptation to the pregnancy Asses their financial strengths, they may have guilt because they may have done something before they knew they were pregnant If they have axiety

key points

Most infertility cases are treated with conventional medical and surgical therapies. Reproductive alternatives for family building include ovarian stimulation, followed by IUI, IVF-ET, GIFT, or ZIFT, oocyte donation, embryo donation, TDI, gestational or surrogate motherhood, and adoption.

Variations in Prenatal Care (Cont.)

Multifetal pregnancy Puts the mother and fetuses at increased risk for adverse outcomes Multifetal pregnancies are more likely to end in prematurity. Spontaneous rupture of membranes before term is more common. Congenital malformations twice as common in monozygotic twins as in singletons Multifetal- more than one baby at the pregnacy What happens if they have 2 separate cords and 2 separate placenta We can see fetal death of one twin, as long as one of the fetus is thriving, she may go the full gestation and have a still born of the one twin Need to inform the mom and prepare her Congential malformation Monozygotic- share the sac and the placenta, one might be more successful Prepare them for preterm labor

Anxiety Disorders (Cont.)

Nursing interventions Special considerations for medications during pregnancy

Pregestational Diabetes Mellitus

Pregestational diabetes mellitus About 10% of pregnancies have preexisting DM Preconceptional counseling Maternal risks and complications Hydramnios/polyhydramnios Ketoacidosis Hypoglycemia/hyperglycemia Fetal and neonatal risks and complications IUFD Congenital malformations Hypoglycemia at birth 10% OF pregnancies for the type 1 and type 2 coming in Gestational diabetics or pregestration have an increase in fluid volume (polydyramnio), and the babies can be bigger because they have larger fluid volume Uterus is bigger in side Can be at risk for DKA because of imbalance control of the insulin Fluxations between the hypo and hyper Much better to manage someone with hyper than hypo IUFD- intrauterine growth restriction- fetal demise is the death This puts them at risk if the babies are much larger Hypoglycemia at birth If they have poor glucose control, they will not have great thermoregulation

Perinatal Mood Disorders (PMDs) (Cont.)

Prevalence Between 14% and 23% of pregnant women will experience depression symptoms during pregnancy An estimated 5% to 25% of women will have PPD Diagnosis Edinburgh Postnatal Depression Scale Ex. AHN chrissy teigan talks about her feels of depression

Maternal Phenylketonuria (Cont.)

Prevention Identification of women in reproductive years who have disorder Screening at the first prenatal visit if status unknown Infants born to women with this disorder are either homozygous or heterozygous for the trait.

interventions

Severe gestational hypertension and preeclampsia with severe features Goals of care are to ensure maternal safety and formulate a plan for delivery. Intrapartum care Bed rest with siderails up Darkened environment Magnesium sulfate therapy Antihypertensive medications

interventions continued

Severe gestational hypertension and preeclampsia with severe features (Cont.) Postpartum care Vital signs, DTRs, level of consciousness 30% of cases of eclampsia and HELLP syndrome occur postpartum. Unable to tolerate excessive blood loss Future health care Seven-fold risk of developing preeclampsia or eclampsia in a future pregnancy Increased risk of adverse perinatal outcomes Eclampsia can happen during pregnacy or immediately post partum Once the placenta is deliver the incidents of effects decreases, essential your body is going from abnormal to normal Vital signs, deep tendon reflexes, if they are unable to tolerate excessive blood loss

Diagnosis of pregnancy

Signs and symptoms Presumptive indicators Reported by woman Amenorrhea, nausea and vomiting, breast tenderness, urinary frequency, fatigue Quickening Vaginal exam to determin the softening The bluish tip is a propable 14 weeks is when the uterus will arise out of the adbomen, will see uterine contraction Braxtion hicks- are not true contractions, can feel that by second trimester and all the way through The postive pregnancy test

Diagnosis of Pregnancy (Cont.)

Signs and symptoms (Cont.) Positive indicators Attributed to the fetus Fetal heartbeat distinct from mother's Fetal movement felt by someone other than mother Visualization of the fetus Hearing fetal heart sounds, can hear the heart beat and see the fetus The fetal heart beat- can sound like a swishing sound We may be listening to mom instead of baby by the rate, the mom is slower around 60, The fetal is faster May hit femeral artery of mom Ultrasound confirms

Assessment of Risk Factors (Cont.)

Sociodemographic Arise from mother and her family Lack of prenatal care, low income, marital status, and ethnicity Environmental Hazards in workplace and woman's general environment May include chemicals, anesthetic gases, and radiation If they are somone who did not have good health care, these are patients that we worry about for high risk pregnancy Financies and insurance Enviorment- it is good to understand what the patients occupation is and what hazards they are exposed to For example if they are an x-ray tech can be at increased risk for harms Lead and mercury are worry in pregnancy Need to avoid consumption of certain fish such as tuna, swordfish, shark, tilefish

Late Pregnancy Bleeding (Cont.)

The cord it attached more medial and this cord is attached at the end look at powerpoint

key points

The intent of emergency interventions for eclampsia is to prevent self-injury, enhance oxygenation, reduce aspiration risk, and establish control with magnesium sulfate.

key points

The investigation of infertility is conducted systematically and simultaneously for male and female partners. The couple's relationship dynamics, sexuality, and ability to cope with the psychologic and emotional effects of diagnostic procedures and treatment of infertility must be considered in the plan of care. Ongoing support is recommended.

Antepartum Testing: Biochemical Assessment (Cont.)

The level of what they are assesing, the chorion and the ambion. Ambioncentisis-is going into the pocket of fluid, the ambonic The chorionic test- is assesing the tissue

Antepartum Testing: Biochemical Assessment (Cont.)

These test are very complex To the mom it is invasive and into the cavity and pull the ambonic fluid out

key points

The prenatal period is a preparatory one both physically, in terms of fetal growth and parental adaptations, and psychologically, in terms of anticipation of parenthood. Pregnancy affects parent-child, sibling-child, and grandparent-child relationships. Discomforts and changes of pregnancy can cause anxiety for the woman and her family and require sensitive attention and a plan for teaching self-management measures.

key points

The woman with hyperemesis gravidarum may have significant weight loss and dehydration. Management focuses on restoring fluid and electrolyte balance and preventing recurrence of nausea and vomiting. Thyroid dysfunction, hyperthyroidism, or hypothyroidism during pregnancy requires close monitoring of thyroid hormone levels to regulate therapy and prevent fetal insult. High levels of phenylalanine in the maternal bloodstream cross the placenta and are teratogenic to the developing fetus. Damage can be prevented or minimized by dietary restriction of phenylalanine before and during pregnancy.

key points

Weight gain: BMI Height and weight ratio, they can go into normal, underweight and overweight Normal BMI is recommended 25-35 pounds through out pregnacy If mom is underweight than 28-40 pounds If mom is overeright then 15-25 pounds The biggest cause of maternal weight gain- may gain a little more weight on the mom and the baby They are patient specific, they start to accumulate weight after the second trimester The third trimester is biggest fetus weight It is a lot of fluid volume and actual weight Diabetic patient, Need to follow carb counting diet to make sure that they have a strict carb counting control Monitor weight gain, mom with diabetes needs to see nutritionalist Tightly monitor

chapter 15

chapter 15

chapter 30

chapter 30

Chapter 9

chapter 9

nutritional needs during pregnancy

• Dietary Reference Intakes (See textbook) • Weight gain will should increase gradually, picking up after the 14th week • Increased energy needs o Pre-Pregnancy BMI (height to weight ratio)- to determine amount of desired weight gain. (Normal BMI 25-35lbs, Underweight BMI 28-40lbs, Overweight 15-25lbs) * Know BMI ranges* BMI Weight Status Below 18.5 Underweight 18.5—24.9 Normal 25.0—29.9 Overweight 30.0 and Above Obese • Increase Fiber and Fluids to promote GI Motility- Preventing/managing waste elimination and constipation. • Increase Fluids- to prevent dehydration • Minerals and Vitamins o Iron (Physiologic Anemia)- May need supplemented based on maternal lab values and dietary intake. o Calcium, Magnesium, Sodium, Potassium, Zinc- Recommend a Prenatal Vitamin prior to conception or as soon as pregnancy is achieved to decrease developmental risk factors. o Fat Soluable- Vitamins ADEK- All play an essential role in maternal health and fetal development. o Water Soluable- Vitamins Folate, Pyroxidine and C- All play an essential role in maternal health and fetal development. • Medical based nutrition management if the maternal patient has a diabetes prior to or during pregnancy. • PICA-craving of non-food items, signifies a mineral need-worrisome o Clay, cornstarch and ice- leads to major constipation, decreased appetite • Increased educational need for Adolescent population focusing on: o Nutrient Knowledge- High risk for decreased nutrients in their diet o Meal Planning- My Plate Recommendations o Food Preparation- Safe food and handling o Access to Prenatal Care WIC o Educational Programs • Avoid Alcohol- No safe amounts, Decrease or eliminate Caffeine- No more than 200mg per day, Provide smoking cessation- avoid nicotine or other drugs. • Physical Activity During Pregnancy o Maintain same exercise routine as prenatal, not an ideal time to increase activity o Increased risk for dehydration- increase fluid intake before physical activity o Dehydration increases maternal risk for preterm labor o Need for slight increase in calories • Nutritional related discomforts of pregnancy- Nausea/vomiting, Constipation and Heartburn (pyrosis) o N/V- Reaction to increased HCG levels during pregnancy- typically resolves by the end of the first trimester. Needs education about maintaining adequate nutrition and fluid intake. o Constipation- Increase fluids, fiber and activity o Pyrosis- Encourage small frequent meals, avoid laying down after meals, limit fluid intake during meal time. o Ginger- appropriate non-pharmacological measure for GI symptoms. • Cultural Influences- be culturally aware of preferences and specialty dietary practices o Think about what these diets may be lacking in regards to essential nutrients (Vegan, Vegetarian, ect.) o If no eggs/milk or animal proteins- increased risk for B12 deficency

nutritional needs during lactation (breast feeding) post partum

• Need a little more calories and a lot more fluids • Avoid Alcohol- No safe amounts, Decrease or eliminate Caffeine- No more than 200mg per day, Provide smoking cessation- avoid nicotine or other drugs. • Weight loss goals- Promote/attain a healthy weight o Lactating (Breast feeding women)- 1 Kg per month ♣ Breast feeding increases maternal metabolism- need for increased caloric intake to maintain healthy body weight. o Non- Lactating- 0.5 to 0.9kg per week

nutritional needs before pregnancy

• Review Nutritional Intake (Calcium Ch 14.6, Folate Ch 15.1, B12) • Ensure a healthy diet, with adequate nutrients- Key in the first trimester for embryonic and fetal development. • Preconception Counciling- Prior to pregnancy to encourage healthy lifestyles to get the woman in the best state of health for a pregnancy. • Folic Acid- Essential for Neural Tube Development, 400mcg/day for Prenatal and increase to 600mcg/day for Pregnancy o What are some appropriate food choices to increase Folic Acid? o (Think fortified food sources)-leafy greens, citrus fruit , bread, cereals , pasta, rice

Antepartum Testing: Biochemical Assessment (Cont.)

Biochemical assessment involves biologic examination and chemical determinations Procedures used to obtain the needed specimens include amniocentesis, percutaneous umbilical blood sampling, chorionic villus sampling, and maternal sampling Amniocentesis: obtains amniotic fluid Performed after 14 weeks of gestation Potential complications Indications for use Genetic concerns Fetal maturity Fetal hemolytic disease Biochemical assessment- can asses ambionic fluid the corionic fluid Assesed through ambiocentesis, Amniocentesis Preformed after 13 weeks, If inserting something sharp into the abdomen can get infection, fetus can get infection secondary to the procedure If we insert the sharp needle, we can see ambionic fluid leak out Can see hemorage The benefit is looking for AFP- alpha fetal protein If there is any abnormalties the AFP level will be increased Fetal maturity, the surfaction productions, dependent on the lung We asses for L/S ration 2:1. Fetal lungs are mature at full development- 35-40 weeks We determine maturity with testing If the water broke and the baby is not full term that we can do the antepartum testing If the liver produces the AFP it can be a humatoloical or genetic disorder If they have an amniocentesis- they do not have to asses for genetic concerns, fetal maturity and fetal hemolytic disease amniocentesis can be done 14 weeks after pregnancy when the organ is in abdomen high levels of AFP help confirm for spina bifida and ancephalopthy can assess for prenatal genetic disorders, pulmonary disorders and fetal hemolytic diseases

assessment of risk factors (cont)

Biophysical Originates with the mother or the fetus May affect development and functioning of both Genetic disorders, nutritional and general health status, and medical or obstetric-related illnesses It may effect the development and functioning of both Uteral placenta insufficancy- if the mom doesnt have the ability to purfuse the placenta then the baby can have a complication It is serious risk because of the oxygen and the nutrients, can make the baby very small Illness results in or from the pregnancy The utilization of alcohol, street drugs that can have side effects

Key Points (Cont.)

Biophysical assessment techniques include DFMCs, ultrasonography, and MRI. Biochemical monitoring techniques include amniocentesis, PUBS, CVS, MSAFP, multiple marker screens, and cell-free DNA screening in maternal blood.

Antepartal Hemorrhagic Disorders

Bleeding in pregnancy jeopardizes maternal and fetal well-being. Maternal blood loss decreases oxygen-carrying capacity and increases risk for the following conditions: Hypovolemia Anemia Infection Preterm labor Impaired oxygen delivery to the fetus If the mom is at least 20 weeks gestation need to provide care for 2 patients If the baby is viable- which is at 20 Abortion can occur up til 19 6/7 Focus is on mom til 20 weeks Bleeding-is not normal Braxton hicks- is normal false contracations Leukoria- is white discharge Bleeding or spottting may be normal but is also a red flag If mom is hypovolemic- she can be at risk for falls If she has a spontanous abortion she can have hypovolemia Anemia can occur and need to take iron supplements The biggest risk is the hypovolemia Some bleeding if you are a multigestational then bleeding is more common The cervix may not be completely closed- so can cause an increase in bleeding

Antepartum Assessment Using Electronic Fetal Monitoring (Cont.)

Can see if mom has contraction, the baby's heart rate should decellerate, there is a decrease in blood flow, Mom does not have to be actively contracting The biggest thing is that maybe the baby's heart rate is 150, and we want to see that if the baby's heart beat will go 15 beats above for 15 seconds, 3 times with in 20 minutes Ex. 165 for 15 seconds and then goes back down This is baby's tolerance to intrauterine life, if baby is sleeping, the vibratory device will wake the baby up and they do the test again If it does not do this, this is a non reactive stress test The person may need to go to labor and develivery suit Will look at printed out strip- the N.P, PA or doctor will look at stress test If they have diabetes they will go out 2-3 days a week once you get passed 36 weeks

Perinatal Substance Abuse (Cont.)

Care management Screening Assessment Interventions Medical management Nursing interventions Follow-up care Cannot breast feed on drugs except methadone Mom should recongize that smoking will interfere with the let down of the milk, so she needs to stop smoking 2 hours before breast feeding Education piece is so important, social services are a safe place and our care ends at post partum, can relapse into same old patterns, Exam is 50 questions, if we talked about it in class then it is on exam Things that were really stressed, used the white board a lot more on the last class, pay attention on the highlights Brush self up on the stufff got tested on Do not focus on it, focus on the new material Look at nutriton -when is it important, folic acid consumed first trimester, can cause nural tube -dehydration can put at preterm labor, Nutritional needs increase if breast feeding, needs to be the same that it was in pregnancy Will increase hydration and nutrition (slightly aboved) If mom didn't work out before pregnancy- then they can do slight pregnancy weight Mom will mutiple pregnancy because the cervix has more pressure so they may be at risk for preterm labor if they do strengious exercise Depends on mom previous ostretric history Leukoria- white discharge Breast tenderness, braxton hicks are only in the abdomen they are normal Bleeding is never normal! Always need to check, if it is new the mom needs to come in

Perinatal Mood Disorders (PMDs) (Cont.)

Care management Usually a combination of antidepressants and cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) Antidepressant medications We do not want to jump to medications right away

key points

Careful glucose monitoring, insulin administration when necessary, and dietary counseling are used to create a normal intrauterine environment for fetal growth and development in the pregnancy complicated by diabetes mellitus. Because GDM is asymptomatic in most cases, all women who are not known to have pregestational diabetes undergo routine screening by history, clinical risk factors, or laboratory assessment of blood glucose levels during pregnancy. Two different methods for diagnosing GDM are currently used.

early pregnancy bleeding

Cervical insufficiency Etiology Passive and painless dilation of the cervix during the second trimester May be either acquired or congenital Diagnosis Speculum/digital pelvic exams; transvaginal U/S Cervical funneling Patient that has cervix that is closed and long This cervix is unable to stay fully closed, They can clamp or cervix- there is an opening called the cervical ozz- this is when they can suture the cervix and should be removed around 36-37 weeks

early pregnancy bleeding

Cervical insufficiency (Cont.) Care management Cerclage: may be placed either prophylactically or as a therapeutic or rescue procedure after cervical change has been identified Removed by 36 weeks of gestation Follow-up care Bed rest for a few days following cerclage Watch for and report signs of preterm labor, rupture of membranes, and infection. Follow up care is important, watch a report for signs and symptoms

key points

Cervical insufficiency may be treated with a cervical or abdominal cerclage; the woman is instructed on recognizing the warning signs of preterm labor, preterm premature rupture of membranes, and infection. Ectopic pregnancy is a significant cause of maternal morbidity and mortality.

Chapter 28

Chapter 28

chapter 29

Chapter 29

key points

Childbirth education teaches tuning in to the body's inner wisdom and coping strategies that enhance women's ability to cope effectively with labor and birth. Perinatal education strives to promote healthier pregnancies and family lifestyles. Nurses can help pregnant women and their families to make informed decisions about care providers, birth settings, and labor support.

Antepartum Testing: Biochemical Assessment (Cont.)

Chorionic villus sampling (CVS) Technique for genetic studies Earlier diagnosis, rapid results Performed between 10 and 13 weeks of gestation Involves removal of small tissue specimen from fetal portion of placenta Transcervically or transabdominally Done transcervixally or transabdomenlly It is linked to genetic testing and genetic screening This is preformed in the first trimester go into chorion and remove a piece of the placenta

Diabetes Mellitus Introduction (Cont.)

Classification Type 1 diabetes Absolute insulin deficiency Type 2 diabetes Relative insulin deficiency Pregestational diabetes mellitus Label given to type 1 or 2 diabetes that existed prior to pregnancy Gestational diabetes mellitus (GDM) They should have both their PCP and their gyno Pregestation- lebal given to tpe 1 or type 2 existed prior to pregnancy Diagnosed type 1 or type 2 mom These moms can come in with oral glucose control, type 1 if they have a pump they are more intune They may have more diligence Gestational- Hormone increase can cause glucose intolerance, the placenta is full of hormones, it is going to be the driver for the glucose, if we have the glucose elevating, the placenta will act as a agonist, it will not allow the body to have enough insulin to develop or produce Metabolic changes, is due to metabolic changes

clotting disorder in pregnancy continued

Clotting problems Disseminated intravascular coagulation (DIC) Pathologic form of diffuse clotting that consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both DIC is never a primary diagnosis: result of other acute or traumatic event Care management and nursing interventions Correction of the underlying causes DIC is never primary diagnosis Cause because of acute or chronic event Disrupted clotting factors can cause patient to hemorrage If they have a tramatic event or on anti-coagulation they need to be alarted how to stop hemorrage

Perinatal Substance Abuse (Cont.)

Commonly abused drugs Tobacco Alcohol Marijuana Cocaine Methamphetamine Opioids Prescription drugs Tobacco- decrease placenta profussion and have a lower birth weight Alcohol- neurological defects are effected, espically the first 8 weeks, first trimester Weed- it retains Co2 in the mom, we have decrease of o2 in the mom and decrease in o2 in the baby Cocaine- emergency condition with placetena, (detaction of the placenta, see severe pain, dark red) increases the risk of placenta detatcement Methamphetamine- intrauterine growth restriction, restriction on o2, Opiods- heroin, codenien, and methadone, none of them are really safe but methadone is safer, "if mom is using heroin, mom she be converted to methadone, the big difference is, the heroin can use needles, (can have increase HIV, hep b and hep c), the mom will be given methadone that is taking a pill, depending on their tolerance"- the baby will still have dependence Screening- do historical data anayalisis, have the mom ever used drug, has she started because she is stressed Mom could of used substances because of stress Baby is on morphine to get off withdrawel Mom is on methadone Need to taper drug If the mom wishes to get off of the drug, recongize what is the safest for the mom Baby can receive tylenol Or oxycodon, during labor it is painful, prgenacy is painful and they may need more in opiods, need to assess baby for neurologic

Gestational Diabetes Mellitus (GDM)

Complicates 3% to 9% of all pregnancies Fetal risks Women who are obese prior to conception and develop GDM are at an increased risk of giving birth to infants with central nervous system (CNS) defects Screening for gestational diabetes Two Step-Step 1: 50g oral glucose screen, if positive move to step 2 100g oral glucose tolerance test (OGTT) One Step- 75g oral glucose tolerance test (OGTT) Pregestration- had type1-type 2 before and gesttation is they aquired diabetes while pregnant Pregnancy aquired diabetes It does increase fetal risk This baby is going to be at risk for being large and at the time of delivery The diabgostic is a screening- if the mom has aquired diabetes, they do 1 step- oral glucose, mom fast for 12 hours and required to drink this very sugary drink, they draw blood work and they draw the glucose, want to see if mom's body can compensate for the sugar, if the insulin demand is not enough then they ned a two stop method They draw after a 50 g oral soulton and the second is the 100g they measure it at 28 weeks Based on normal production, between 20 weeks and 40 the surge of glucose can go up Mom A is able to compensate with insulin Mom B cannot compensate with insulin 20-30 weeks is the highest surge of insulin Mom needs tight control of her weight gain If the mom is gaining too much they can have increase to gesatational diabetes The biggest risk is hormonal The placenta is different every time

Late Pregnancy Bleeding (Cont.)

Cord insertion and placental variations Vasa previa: fetal vessels lie over the cervical os, and the vessels are implanted into the fetal membranes rather than into the placenta Velamentous insertion of the cord: cord vessels branch at membranes and then onto placenta Succenturiate placenta: placenta has divided into two or more lobes Battledore (marginal) insertion of the cord: increases risk of fetal hemorrhage

Detecting fetal heart tones

Different methods, it is gone through the adomen The fetal Y- pinpoint through the adomen and listen with stethoscope

percutaneous umbilical blood sampling (PUBS)

Directly into the cord or fluid pouch can asses anemia, infection and thrombocytopenia

Perinatal Substance Abuse

Dual diagnosis, which is common, is the coexistence of substance abuse and another psychiatric disorder. Prevalence: approximately 15% of all pregnant women Risk factors Barriers to treatment Legal considerations Some states consider in utero drug exposure to be a form of child abuse or neglect under civil child-welfare statutes. Legally mandated testing and reporting can potentially place the provider in an adversarial relationship with the client. Neural tube can be effect no alchol during pregnancy, passes easily through mom to fetus Can cause fetal alcohol syndrome Patietns that are victums of abuse, patients that live under the poverty level Doesn't want to admit that she is shamed, have to imbrace the fact that the mom is trying to help herself and that we are their to help Test it for drugs, can refer to child protective services

early pregnancy bleeding

*refer to powerpoint picture* A- threatened miscarriage, s/s: spotting, mild cramping and when the cervix is completley closed but blood leaks out B and C- the cervix is open, an evidable and a complete, will see an increase in blood flow, it is actively happening or will happen in a window of time These patients may also have tissue that comes out of the uterus B and C in incomplete, the fetus will be expelled but placenta will be remained D- is an example of what has been expelled, it is complete, it is the baby and the placenta Risk is higher than someone who has never had an aborition before E- a missed miscarriage- the fetus does not have intrauterine life, no longer living inside of the women This can be diangosised at any point of the pregnancy DNC- cotterize and debred out the uterus, they suction and pull out the rest A, B, C, and E will require debrement They all before 20 weeks and there is no specific week For test: all contents of uterus need to have contents expelled, see blood loss (hypovolemia), this mom is at increased risk for infection Outcome for baby is all the same

late pregnancy bleeding

*refer to powerpoint picture* slide 21 Parial, can still cause pain Partial with hemmorage, that will cause pain Completely detach, the patient is highest risk for hemmorgae (bottom picture)

ANS: D Feedback A Incorrect: A urine sample should be obtained to determine if there is protein and albumin spillover as a result of reduced kidney perfusion. This can be done after the BP has been evaluated. B Incorrect: Decreased placental perfusion is a complication of hypertensive disorders in pregnancy. The first action of the nurse should be to obtain the client's BP. The client should then be placed on the fetal monitor in order to evaluate the fetus. C Incorrect: Central nervous system irritability associated with preeclampsia often manifests itself as a headache. Once an accurate BP has been obtained, the health care provider should be notified. D Correct: Accurate measurement of BP is essential to detect hypertensive disorders including preeclampsia. Personnel caring for pregnant women need to be consistent in taking and recording BP measurements in a standardized manner. BP readings are easily altered by the cuff size and position of the client.

A client at 36 weeks of gestation presents to labor and delivery complaining of a constant headache for the past 2 days. She also states that her face "seems more swollen than usual." What should be the nurse's first action? A. Obtain a urine sample. B. Place the client on a fetal heart monitor. C. Notify the physician of the client's concerns. D. Take the client's blood pressure.

Diagnostic Tests: Female Infertility

Additional testing may be warrented, a hysteroscopy augrophy is first picture It is going into the opening of the uterus all the way up to the fallopian structures Administer die during this testing, if the die can travel up to the fallopian tubes then it is not a structure problem flexible scope through the cervix to uterine cavity done 2-5 days after menstruation just in case flushed out fertilized ovum most expensive and invasive and not first line of assessment Laparoscopy exploration One will have a camera and one will have a tool, look for pollups or abnormalities The tubes in the ovaries can be twisted- ovarian contorsion and this means the ovariery cannot release the egg its indicated for a women who is having sign of endometriosis preformed early in the menstrual cycle a needle and co2 is inserted into the uterus to elevate abdomen wall from organs and create empty space for visulization if patency is assessed then dye is inserted

infertility

Affects about 15% of reproductive-age couples Subfertility: prolonged time to conceive Sterility: inability to conceive Increases with age, particularly women older than 35 years Diagnosis and treatment of infertility require physical, emotional, and financial investment. There may be due to how long they have taken birth control pills Can be timely and very costly to the family Be very cautious because this may cost a lot of money Want to promote fertility if this is the goal of the patient

Variations in Prenatal Care (Cont.)

Age differences Adolescents Less likely than older women to receive adequate prenatal care Women older than 35 years Multiparous women Primiparous women Adolescents need the most education of all prenatal pregnancies, they have this cant happen to me mentality They just need to be well educated early on Women over than 35, If they are multiple kids then they may not want more educaton If this is their first kid then they may want a lot of education and to know the risk

key points

Alcohol abuse during pregnancy is the leading cause of cognitive disability in the United States, and it is entirely preventable. Treatment programs must start with an understanding that substance abuse in women is a complex problem surrounded by multiple individual, familial, and social issues that require many levels of intervention and treatment.

Nursing Interventions: Education for Self-Management (Cont.)

Alcohol, cigarette smoking, caffeine, drugs Normal discomforts Recognizing potential complications Recognizing preterm labor Sexual counseling Using the history Countering misinformation Safety and comfort during sexual activity Psychosocial support The first trimester is the first cruital time Abortion can occur up to the 20 week window Bleeding is not normal Constipation is big- the decrease in parastalisis, and GI motility Need to increase fluid, fiber and exercise If they are nausae they may need IV fluid because they cannot intake fluid and don't want to get dehyration Gush of fluid and blood is not normal

GDM Care Management

Antepartum Diet Exercise Self-monitoring of blood glucose Pharmacologic therapy Fetal surveillance Diet, exercise, need to carb count for snacks and meals If they did the fluid before and they can do it now then they just need to increase fluids and make sure they are testing blood glucose This is a newly diagnosised diabetic Need to check blood sugar before meals and at night And they need to check an hour after meals 130-140 It is safe to give a mom insulin Can give regular insulin (IV most common), metformin and glodulide Non stress chest and fetal ultra sound for 38 weeks

key points

Antidepressant medications are the usual treatment for PPD; however, specific precautions are needed for breastfeeding women. Treatment of peripartum onset of anxiety disorders requires a combination of medication, education, supportive measures, and psychotherapy. Treatment of both depression and anxiety is critical to improving mental health.

Infertility Care Management

Assessment of female infertility Diagnostic tests Detection of ovulation Hormone analysis Ultrasonography Hysterosalpingography Hysteroscopy Laparoscopy First line is exploring the males reproductive system Dtection with ovulation, the first sign to see is the hormone levels, we draw the levels of the hormones prolactin level FSH and LH go together Estrodial Progesteron- necessary to substain pregnancy Higher incidents Thyroid can play a factor in infertlity and hormones They use transvaginal altra sound, to determain the overaries It is minimally invasive because it is trans vagenal Explore invasively, can go from having ultrasound to determin the tubes or ovaries If they have abnormal mesnstrual then look at endocrine levels

Infertility Care Management (Cont.)

Assisted reproductive therapies Zygote intrafallopian transfer (ZIFT) Oocyte donation Embryo donation Surrogate mothers/embryo hosts Therapeutic donor insemination (TDI) Adoption Success rates and costs of ART Risks of ART Cryopreservation ZIFT- already fertiziled and going into the embryo phase In the zygot phase Care and management: oocyte (an egg) Is the donated egg This is embryo donation, already fertizled from day 15-8 weeks Sugot- implanted into another mom so that they can develop the child Depends on when things are retrieved, there is a higher incident with multiple gestation Cryopreservation- ovumn or sperm is froze, for example if someone is young and gets cancer and the chemo can cause harm to eggs, they can free eggs and want to become pregnant later in life During Cryopreservation, the antomy and the function may not be returned back to her so they may use a surgot detending on the age of the mom so she can have a child

Infertility Care Management (Cont.)

Assisted reproductive therapy (ART): fertility treatments in which both eggs and sperm are handled Intrauterine insemination (IUI) In vitro fertilization-embryo transfer (IVF-ET) Preimplantation genetic diagnosis Gamete intrafallopian transfer (GIFT) ART- exterinal source Is where the fertility is achieved IUI- sperm can be introduced directly into the uterus this is preferred technique for introducing sperm donor or sperm that needs to be washed IVF- ovarian stimulation, to develop and to mature their ovumn, their egg This is the best way for them to concieve The collection occurs through the transvagional region to capture the mature ovumn They are fertilized externally and then put back into the uterus to implant into uterine wall Capturing the ovumn and then reimplanting into uterus Risk: the patient can be at patient for miscarriage If they fertizile multiple ovumn they put it into the uterus and if all the mature eggs divide then can see the mom having multiple children

Interventions (Cont.)

Eclampsia Immediate care Premonitory signs: persistent headache and blurred vision Epigastric or right upper quadrant pain Altered mental status Convulsions appearing without warning Ensuring a patent airway and client safety Maternal stabilization Eclampsia- immediate care Notice the epigastric pain Make sure patient has suction and o2 Typically seizures can be grand mal Maternal stabilzation

Classification of Hypertensive Disorders (Cont.)

Eclampsia Onset of seizure activity or coma in a woman with preeclampsia No history of preexisting pathology 50% of eclamptic women develop the condition while pregnant Women can develop eclampsia in the immediate postpartum period Eclampsia Pre-eclampsia findings Will see protein in urine Neuro changes Visual changes PT assessment C/O "worst headache, persistant" "blurry vision, floaters" *can get seizures- saftey of mom and baby any patient that has seizure need oxygen, need to put bed in lowest position, turn to left side, make sure pillows are around the sides Do not put anything in their mouth and do not restrain them Put them on oxygen- as soon as she is having a seizure *the biggest difference from preeclampsia and eclampsia is the big neuro change, such as headache, and floaters If their physiological condition is the same as preeclampsia to neuro changes in eclamspia, need to still be on magensum sulfate Interventions Stabalized BOTH Vital signs of mom and baby, RFM, neuro signs will see hyper-reflexia And need to give mag sulfate and neuro protection Pre clampsia occurs after 20 weeks, the fetal lung maturity does not occur til 35 weeks So the baby may not have full lung development If it is something we can do such as o2, change in position if its stuff we cant do then call the doctor

Early Pregnancy Bleeding (Cont.)

Ectopic pregnancy (Cont.) Diagnosis Difficult differential diagnosis: numerous disorders share similar signs and symptoms Quantitative β-hCG levels and transvaginal ultrasound examination; progesterone level Tubal pregnancy management Medical management: methotrexate Surgical management Follow-up care the atopic pregnacy is the signs and symptoms is the extreme abdominal pain, they have ridget stomach Need to asses Look at progesterone level to maintian pregnancy For a tubal pregnancy- use methotrexate to help with the passage, it reasborbes down to the reproductive tract Have a salfinotomy- the fallopian tubes, they remove the atopic pregnancy through the fallopian tubes and then suture it back up

Early Pregnancy Bleeding (Cont.)

Ectopic pregnancy: the fertilized ovum is implanted outside the uterine cavity; also called "tubal pregnancies" Incidence and etiology Clinical manifestations Typically s/s occur 6 to 8 weeks after the last normal menstrual period The three most classic symptoms are the following: Abdominal pain Delayed menses Abnormal vaginal bleeding (spotting) Need to explore complications which is not true pregnancy Tubal pregnancy can be in the fallopian tubes, this is an atopic pregnacy and can cause a problem for the mom The tubes are very small and not used for baby's to grow Recongize this in 6-8 weeks after menstrual period, but they can get rupture of reproductive system They will get abdomen pain

key points

Education about safety during activity and exercise is essential, given maternal anatomic and physiologic responses to pregnancy. Important components of the initial prenatal visit include detailed and carefully documented findings from the interview, a comprehensive physical examination, and selected laboratory tests. Follow-up visits are shorter than the initial visit and are important for monitoring the health of the mother and fetus and providing anticipatory guidance as needed.

key points

Even in normal pregnancy the nurse must remain alert to hazards such as supine hypotension, signs and symptoms of potential complications, and signs of family maladaptations. Blood pressure is evaluated on the basis of absolute values and length of gestation and is interpreted in light of modifying factors. Each pregnant woman needs to know how to recognize and report signs of potential complications such as preterm labor.

Key Points (Cont.)

Fetal care centers have evolved in response to the need to provide diagnostic and therapeutic options as well as care coordination and other support services for families with a fetal anomaly diagnosis. Reactive NSTs and negative CSTs suggest fetal well-being.

Fetal Care Centers

Fetal care centers have evolved in response to the need to provide diagnostic and therapeutic options as well as support services for families with a fetal anomaly diagnosis. Access to support services such as genetic counseling, social work, chaplain services, a palliative care team, and ethics consultation because of the complex emotional stressors they face Can see this at clinics, these are imvasive based procedures, the mom recieves some local anestetic Controled OBGYN center Might explore decisions Likely have some surgery If she is a single mom, If she is someone who doesn't have employment Antipartium follow up testing

Antepartal Hemorrhagic Disorders (Cont.)

Fetal risks from maternal hemorrhage Blood loss, anemia Hypoxemia Hypoxia Anoxia Preterm birth Hemorrhagic disorders in pregnancy are medical emergencies. The incidence and type of bleeding vary by trimester. If the mom is bleeding it is a medical emergency up til 20 weeks

key points for nutrition powerpoint

Folic acid is super important, can result in neural tube defects Recommended folic acid for those who are not pregant are 400mg and if pregnant will increase to 600 mg The B12 intake, dietary restrictions, B12 is from animal products or protein, need to supplement the B12 with vitamins Caloric intake- the caloric needs are patient specific, based on prepregnancy BMI If they were normal weight, underweight or over weight They need to get the most bang for their buck, the caloric intake might not increase but they need to get a lot more nutrients If a patient is pregnant they should be taking a prenatal viamin If they are on a calorie restriction or if they are increasing calories then they need to take the prenatal vitamin that has calcium, zinc, iron, potassium They can end up with iron deficancy, so if they do not have enough hemoglobin or maternal hemoglobin then they can have problem, make sure mom has everything she needs Nutrition and hydration Generally at risk for becoming dehyrated, there is a higher risk for preterm labor, if the mom doesn't have enough ambonic fluid than can cause preterm labor Maintain the activity they are used to because if they try to increase exercise can become dehydrated Need to make sure they know the signs of dehyration Can get cramping in the legs from dehyration, they are going to have cramping of the uterus They can see increase in baxton hicks because they do not have enough fluid- can feel these after 16 weeks

Preeclampsia (Cont.)

HELLP syndrome Laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction Hemolysis (H) Elevated liver enzymes (EL) Low platelets (LP) HELLP syndrome occurs in 0.5% to 0.9% of all pregnancies. 10% to 20% of women who have preeclampsia with severe features develop it. HELLP Hemolysis - complete blood count Elevated liver enzymes, the right upper quadrent pain, it can be liver pain and that's why preeclamspia is assossiated with liver pain Low platelets - if they have low coagulation times, we need to alert the doctor Increase incident with pre-eclampisa *assessment: monitor lab values of the liver and blood count Liver has coagulation patterns and filtration so that why it effects the blood count Hemolysis Occurs in less than 1 percent but more common in preeclamptic patients

Preeclampsia (Cont.)

HELLP syndrome (Cont.) Result of arteriolar vasospasm, endothelial cell dysfunction with fibrin deposits, and adherence of platelets in blood vessels The clinical presentation is often nonspecific; most women with the disorder report the following: History of malaise Influenza-like symptoms Epigastric or right upper quadrant abdominal pain Symptoms worsen at night and improve during the daytime. May complain of flu like sysmptoms *the right upper gastric pain is the biggest thing they complain about

Antepartum Testing: Biophysical Assessment (Cont.)

Have 3 and 4D imaging

birth Setting choices

Hospital Labor, delivery, recovery rooms (LDRs) Labor, delivery, recovery, postpartum rooms (LDRPs) Birth centers Home birth Remains a controversial topic in American health care Magee goes to triag and if you are in active birthing or if you have time If at any point the patient has emergency, then they will go to a steralized operating room and will not do C-section at the bedside The birthing center down town has different ways to birth, the whirlpool for water birth, birthing balls and beds for the birth Homebirths done but not as done because of the contreversial They need to know they have a veriaty of birthing option Need to educate patient about prenatal vitamins even before they become pregnant in birthing centers- these patients are at low risk pregnancy they are stocked with drugs just in case and they are located near a hospital for safety measures -hospital- the mother is taken to the labor and delivery room first and after the birth stays in the recovery unit for 1-2 hours, she is then transferred to postpartum where they stay the rest of their stay

early pregnancy bleeding

Hydatidiform mole (molar pregnancy) Type of gestational trophoblastic disease Benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grapelike cluster Incidence and etiology Occurs in 1 in 1000 pregnancies in the United States Cause is unknown Types Complete: no embryonic or fetal parts Partial: often have embryonic or fetal parts and an amniotic sac Assess the mom because she may have wanted this pregnacy Trophoblastic disease- this develops insufficantly, can look grape like, it is a cluster of disorganized cells Have two different types, Compete molar is composed of 0 parts of embryo or fetus, it is just disorganized growth Partial- can have parts of the fetus such as buds of teeth and hair, it is not an organized pregnancy

early pregnancy bleeding

Hydatidiform mole (molar pregnancy) (Cont.) Clinical manifestations Anemia from blood loss, excessive nausea and vomiting (hyperemesis gravidarum), and abdominal cramps Diagnosis Transvaginal ultrasound and serum hCG levels Care management: suction curettage Nursing interventions Follow-up care These moms are going to bleed more than atopic pregancy Hyperemisis graivadiarum- this causes increase nausual vomititng Will have excessive amounts of hCG in molar pregnancy because hCG can cause morning sickness in pregnancy Need to educate mom to avoid to become pregnant for a year because the hCG is elevated for a year after amolar pregnancy and can cause problems with the second pregnancy

key points

Hypertensive disorders during pregnancy are a leading cause of maternal and perinatal morbidity and mortality worldwide. The cause of preeclampsia is unknown, and there are no known reliable tests for predicting women at risk for developing preeclampsia.

thyroid disorders

Hyperthyroidism Rare in pregnancy 90% to 95% cases in pregnancy are caused by Graves' disease Clinical manifestations Heat intolerance, diaphoresis, fatigue, anxiety, emotional lability, and tachycardia May include weight loss, goiter, and a pulse rate greater than 100 beats/minute Primary treatment during pregnancy is drug therapy. Over active thyroid- graves diseases, see this in 90 to 95 percent of cases Clinical manifesation, fatigue anxiety, know the mom has an increase cardiac output, Drug therapy is the first primary treatment First trimester: Beta blockers- manage the symptoms, they help with tachy cardia, they are safe during pregnancy Methimazole- MMI 2nd trimester- propythiourial (PTU)

Thyroid Disorders (Cont.)

Hypothyroidism (Cont.) Severe hypothyroidism is often associated with infertility and an increased risk of miscarriage. Occurs in 2 to 3 in 1000 pregnancies Symptoms: weight gain, lethargy, decrease in exercise capacity, and cold intolerance Nursing care Education Medication regimen: levothyroxine (e.g., T4 [Synthroid]) If a patient diabetes and hypothyroid and ovarian cyst Moms can have a hypertension issues, the mom can develop pre-exclampsia They have an increase risk of miscarriage Will experience weight gain, can have lethargy and cold intolerance Need to be monitor closely, need to monitor if they have had too much synthroid in their system, they can go into graves disease If they have too little synthroid they can go into mix edema coma

Antepartum Testing: Biophysical Assessment (Cont.)

If there is any disruption with in the 24 hour period then they need to call the doctor because can be a problem If the baby was active and then not active Quickening- 17-18 weeks If multiple gestation quickening occurs around 16 weeks 14 weeks the mom can feel the baby in the abdomen Closer to 20 weeks you can feel 18-20 weeks is when you should start to count kick counts

Maternal Phenylketonuria

Inborn error of metabolism caused by an autosomal recessive trait that creates a deficiency in the enzyme phenylalanine hydrolase, which impairs the body's ability to metabolize foods with protein Is tested for routinely in the newborn screen If unrecognized, can cause cognitive impairment in the affected individual Prompt diagnosis and therapy with a phenylalanine-restricted diet significantly decreases the incidence of cognitive impairment in the individual High levels of phenylalanine in pregnancy associated with microcephaly, cognitive impairment, congenital heart defects in offspring Women with PKU should be advised against breastfeeding because their milk contains a high concentration of phenylalanine. Metabolic tereatogens, this means this baby is at risk for congential abnormlaities These babies are born from the mom and tested to see if the baby has the gene This baby is higher for developing PKU, so they need to avoid breast feeding because has higher risk of phenylalanine The mom can still passs it from mom and baby The PKU screening, know that it is an inherited disorder

care management

Initial visit (Cont.) Prenatal interview (Cont.) History or risk of intimate partner violence Review of systems Physical examination Supine hypotension Laboratory tests Urine, cervical, and blood samples Screening and diagnostic tests for infectious diseases and metabolic conditions Offering assistance and support, now is the time for us to start educating Needs to be educated as soon as she is pregant, there are different assistant programs If he mom has hypotention from maternal, as the mom is laying on back, the nerves may compress with the enlargening of the fetus and so we need to tell the mom to repostion herself Endocrine function should be test and STI

GDM Care Management (Cont.)

Intrapartum Blood glucose monitored hourly in labor Infusion of regular insulin Postpartum Will return to normal glucose levels after birth Likely to recur in future pregnancies Increased lifetime risk for development of T2D Increase the stress of labor will increase insulin Give Iv fluids and regular insulin The placenta is the major cause of increase hormones Need to monitor post partum levels Need to educate to mom that she can develop type 2 diabetes in 10-15 years and they need to be informed that they can get gestational again The complications and the risk factors are the same for pregestational and gestational

Care Management: Pregestational Diabetes Mellitus (Cont.)

Intrapartum Monitoring for dehydration Blood glucose levels carefully monitored Continuous EFM Intravenous infusion Possible cesarean birth for macrosomia During delivery the mom will need fluids and insulin EFM- electronic fetal monitoring This is the vital signs of the patient Take mom's vital signs Possible ceseran for macrosomia- big baby Can deliver very large babies to determine at term that they are big or small As long as the baby is full term If they induce induction do they want to do C-section or vag delievery

key points

Magnesium sulfate, the anticonvulsant of choice for preventing or controlling eclamptic seizures, requires careful monitoring of reflexes, respirations, and renal function. Women with preeclampsia (especially early-onset and preeclampsia with severe features) have an increased risk of developing chronic hypertension and cardiovascular disease later in life.

Antepartum Testing: Biophysical Assessment (Cont.)

Magnetic resonance imaging (MRI) Noninvasive radiologic technique Examiner can evaluate the following: Fetal structure, overall growth Placenta Quantity of amniotic fluid Maternal structures Biochemical status of tissues and organs Soft-tissue, metabolic, or functional anomalies MRI- safe, because does not have iondized radition that the CT has CT scan- not safe Thinking about maternal structure we may need more imaging The biggest thing is going to asses more about the placenta Sometimes pregnacy and growth of new tissues can become neoplastic or cancer Maternal structures can see cervix and uterus

Factors Associated with Infertility (Cont.)

Male infertility causes Can be caused by structural and hormonal disorders Undescended testes Hypospadias Varicocele (varicose vein of the scrotum) Low testosterone levels Azoospermia: no sperm cells produced Oligospermia: few sperm cells produced Substance abuse With congentital birth defects they can develop a vericose vein or vericose seal Can have hormonal balance, some medication taken in the past and substance abuse mumps especially after adolescence can cause permeant testes damage

key points

Management of late-pregnancy bleeding requires immediate evaluation; care is based on gestational age, amount of bleeding, and fetal condition. DIC is a pathologic form of clotting that causes widespread bleeding and clotting. It is never a primary diagnosis but always results from some event that triggered the clotting cascade.

Mental Health Disorders During Pregnancy

Management of mental health disorders takes place primarily in community settings. Women with mental illness who give birth have a higher risk of obstetric complications. Women are at the greatest risk for developing a psychiatric disorder between the ages of 18 and 45 years—the childbearing years. The biggest thing to recongize is the highest incident between 18-45 years old Women with mental health have obstretic complication When talking about mental health disorders may be engaging in risking behaviors, alcohol, drugs, unsafe sexual intercourse

Antepartum Testing: Biochemical Assessment (Cont.)

Maternal assays Maternal serum alpha-fetoprotein (MSAFP) Maternal serum levels used as screening tool for neural tube defects (NTDs) in pregnancy Detects 80% to 85% of all open NTDs and open abdominal wall defects early in pregnancy Screening recommended for all pregnant women Triple- and quad-screening to detect autosomal trisomies Do a maternal serum alpha protein, can see if baby has any neural tube defects Can be signficant that the baby has neural tube defects Spina bifida is a neural tube defect, there organs are on the external aspect Trible and quadruple Trisomy 13, 18 and 21 with the moms postive fetal protein Top 5 reasons Asses for downsyndrome and the mom older than 35 The generalized screening tool Detection of the alpha fetal protein and see if it normal If neural tube is fully developed, need to make sure they have folic acid Multiple marker testing for the trisomy

Antepartum Testing: Biochemical Assessment (Cont.)

Maternal assays (Cont.) Cell-free DNA screening in maternal blood Noninvasive prenatal genetic testing Provides definitive diagnosis noninvasively for fetal Rh status, fetal gender, and certain paternally transmitted single gene disorders Performed as early as 10 weeks of gestation Results are usually available in about 10 business days This is for the trisomy 21, 13, 18 If there are more DNA strands then it is suspected that there is some DNA that is suspected cell free DNA asses for RH status, gender and parentally transmitted single gene disorders amplifies cell-free DNA coombs test- screening tool for RH incompatibility, if the maternal titers are greater than 1:8 then this can mean severity of hemolytic anemia

Antepartum Testing: Biochemical Assessment (Cont.)

Maternal assays (Cont.) Multiple marker screens Coombs' test Screening tool for Rh incompatibility Detects other antibodies that may place fetus at risk for incompatibility with maternal antigens The Coombs test - is to test for Rh It is an antogen based on the blood We need to know if the mom has the same capatiability as the baby The father can have a different blood type than the mom Assessing the coombs test can see if the mom rh If the mom;s body sees something foreign then the mom's body can reject it, for example the fetus The mom neds to take injection 1-8 the mom has been cencitised Give rogan If the mom is positive and the baby is negative If the mom is positive and the dad is negative, can start to develop antibodies so they would give Rogan If the baby is the opposite of the mom, they can receive the Rogan during pregnancy Transfusion through the placenta, the moms blood through the cord can be transmitted to the baby Bigger problem for the second pregnancy After the first trimester, after 13-14

Diabetes Mellitus Introduction (Cont.)

Metabolic changes associated with pregnancy Normal pregnancy is characterized by alterations in maternal glucose metabolism, insulin production, and metabolic homeostasis Glucose is the primary fuel for the fetus Glucose crosses the placenta, insulin does not Insulin production increases during the first trimester Diabetogenic effect in second and third trimesters During this time the glucose is primary function of the brain So if the baby doesn't have the glucose, then then if can effect mom and baby insulin Baby can cover the insulin with the high glucose, where the mom does not. So the baby can have hypoglycemic episode If mom has hypoglycemia the baby will have hypoglycemia Neurological complications can occur if the baby has routine periods of hypoglycemia Will not be able to tolerate the surge in glucose

Interventions

Mild gestational hypertension and preeclampsia without severe features Goals of therapy are to ensure maternal safety and deliver a healthy newborn close to term. Home care Maternal and fetal assessment Activity restriction Diet Can be monitor at home, can restrict sodium or restrict other things they have Severe gestational hypertension, goal is to prevent eclampsia The preeclmaptic stage they may need to be admitted to the hospital If they are at home, then they need to be on bed rest because of the neuro changes Need dark enviroment, mag sulfate therapy Anti-hypertension- see labatolo used for anti-hypertensive

early pregnancy bleeding

Miscarriage (spontaneous abortion): a pregnancy that ends as a result of natural causes before 20 weeks of gestation Approximately 10% to 15% of pregnancies end in miscarriage. Types of miscarriages Threatened Inevitable Incomplete Complete Missed Recurrent Letter A- before 20 weeks This is a spontanious abortion There is a high number of pregnancy's that do not go the through the full misscarriages

early pregnancy bleeding

Miscarriage care management Assessment and nursing diagnoses Initial care Depends on the classification of the miscarriage and on signs and symptoms Expectant management Medical management: misoprostol (Cytotec) Surgical management: dilation and curettage (D&C) Follow-up care Follow-up phone calls; support groups Recongizing that no bleeding is normal Image A- will likely still end up with miscarriage Educate and council mom because this is a fragile time Medications that can be used to try to ebstain preganancy Follow up care is necessary because it is a medical surgery

morbidity and mortality

Morbidity Renal failure Coagulopathy Cardiac or liver failure Placental abruption Seizures Stroke Mortality Pregnancy-related hypertension accounts for 10% to 15% of maternal deaths worldwide. Morbidity is the risk for death Mortality is actual death The mom can result in renal failure, cardiac or liver complication Placenta abruption A lot of central nervous system disorders Hypertension: 140/90 is the lowest diagnosis for hypertension The vasular resistance will play part in the mom and baby

Key Points (Cont.)

Most assessment tests have some degree of risk for the mother and fetus and usually cause some anxiety for the woman and her family. The nurse's roles in assessment and management of the high-risk pregnancy are primarily those of educator and support person.

Variations in Prenatal Care (Cont.)

Multifetal pregnancy (Cont.) Counseling needs to be provided for Risk of preterm labor Modification of weight gain and nutritional intake Selective reproduction Lifestyle changes Can place a strain on finances, space, workload, and the woman's and family's coping capabilities Weight gain- what is the appropiate amount of weight to gain, they may gain a little more, Selective reproductive, if they only wanted one kid Life style changes- who will care for her other children if she has other kids,

clotting disorder in pregnancy

Normal clotting Normally, a delicate balance (homeostasis) exists between the opposing hemostatic and fibrinolytic systems Hemostatic system stops flow of blood from injured vessels Fibrinolytic system Process through which fibrin is split into fibrinolytic degradation products and circulation is restored Hypercoaguability Anything that can prevent clots should be eduated These patients volume replacements are necessary If they have a risk for clotting then they have elevated liver enzymes Patients may present with factor 5 clotting disorders, their increase risk for clotting may be higher If the mom is on lovenox- blood thinner, this thins the blood If the mom is at high risk because of placenta that is detatched but she also has high risk for DVT then she is at a increased risk for hemmorgae Recongize who is at highest risk for hemmorgae during pregancy If the mom is hemorraging in the hospital we need to give fresh frozen plasma or vitamin K

Hyperemesis Gravidarum

Normal nausea and vomiting complicates 50% to 80% of all pregnancies, typically beginning at 4 to 10 weeks of gestation, usually resolving by 20 weeks of gestation Hyperemesis gravidarum is excessive, prolonged vomiting accompanied by the following: Weight loss Electrolyte imbalance Nutritional deficiencies Ketonuria Increase in HcG People that are pregant with multiple babies such as twins If someone is experiences a molar pregnancy Morning sickness- at the end of the first trimester Not all women experience morning sickness The biggest thing with these patients lose a lot of weight, if they are nausaeated then they are not eating The nutrients are not eating, if they are not consuming nutrients then the baby can have IUGR because she does not have the nutrients Some vitamins can make the mom nauseated, can give mom zolfran(anti-vomit, emmetic) this allows the patient to eat or take medication Dailey weights, they can loose up 5 percent in total weight With proteinuria this can cause acidosis because it is breaking down muscle

Perinatal Mood Disorders (PMDs) (Cont.)

Nursing interventions Educate the woman about depression as an illness and the plan of care, including medications. Discuss alternative treatments, and respect her choice if she refuses medications. Maintain a caring, hopeful relationship. Being an illness as part of their care, need to discuss alternative treatments If mom is pregant and doesn't want to risk to baby, need to tell the patient If it is too harmful to the baby

Assessment of Risk Factors (cont.)

Oligohydramnios Renal agenesis (Potter syndrome) Premature rupture of membranes Prolonged pregnancy Uteroplacental insufficiency Maternal hypertensive disorders Oligohydramnios- decreased ambonic fluid, less than 300 ml If the baby has trouble producing urine then the volume will start to decrease in the ambonic sack Premature rupture of membrane, this is why mom's water breaks prior to term Prolonged pregnacy- is when the prgnancy gets beyond the 41 week The ambonic fluid is the nutition souce and extretion, the baby is consuming more than the mom can create Uteroplacental insufficiency Maternal hypertension- intake should equal output, if the mom is not profussing the baby the baby is not being profussed then they will have a decrease and th ambionic fluid will decrease The fetal heart output makes up part of the ambionic fluid

preeclampsia

Pathophysiology Placental ischemia → endothelial cell dysfunction Generalized vasospasm → poor tissue perfusion in all organ systems Increased peripheral resistance and blood pressure (BP) Increased endothelial cell permeability Reduced kidney perfusion Plasma colloid osmotic pressure decreases. Decreased liver perfusion Neurologic complications Reduces the kidney function Decrease neurological complications Different complications that can occur

Preeclampsia (Cont.)

Pathophysiology Progressive disorder with placenta as the root cause Begins to resolve after the placenta has been expelled Spiral arteries in the uterus normally become larger and thicker to handle increased blood volume. This vascular remodeling does not occur or only partially develops in women with preeclampsia and decreased placental perfusion and hypoxia result

Antepartum Testing: Biochemical Assessment (Cont.)

Percutaneous umbilical blood sampling (PUBS) (also called cordocentesis) Direct access to the fetal circulation during the second and third trimesters Most widely used method for fetal blood sampling and transfusion Insertion of needle directly into fetal umbilical vessel under ultrasound guidance Percantanious umbilical- not done until second trimester 13-14 weeks Done to determine if there is a fetal infection or inherited blood disorder Trans fusion reaction, infection, need to asses baby through umbilical cord Asses the vein- the baby could lose circulation if they take the blood from the artery Need to make sure accessing the venus circulation If they do have blood borne antibodies can do fetal trasnfusion via intrauterine

Perinatal Mood Disorders (PMDs)

Perinatal mood disorders (PMDs): a set of disorders that can occur any time during pregnancy as well as in the first year postpartum and can include depression (PPD), anxiety, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), and postpartum psychosis Of all women experiencing pregnancy the first symptom can be post partum or during pregnancy Screening is often difficult Utilize a screening tool, score from a 1-5 scale The second is a subjective communication tool

key points

Peripartum depression with suicidal or homicidal intent or plan as well as peripartum depression with psychotic features is a psychiatric emergency. Immediate evaluation by a mental health professional is warranted. Identification of women at greatest risk for substance abuse during pregnancy and depression in the postpartum period can be facilitated by use of various screening tools.

Perinatal Care Choices

Physicians Midwives Certified nurse-midwives (CNMs) Direct entry midwives or certified midwives (CMs) Traditional or lay midwives Doulas Birth plans Have midwifes, Have nurse practioners, physican assistant Traditional and la midwife CNM or CM the educated by trade midwife, they have prescriptive right for medications, they have admitting rights Midwifes can deliver at a hopsital Lay midwife, have some prescriptive right, they are not as certified as CM or CNM and they can only provide care outside of the hospital Asmish use lay midwifes for care Doulas- support person, can be family friend or hired help , families want doulas, they act as coach or support plan Birth plan- some women want water births, some women do not want epidural and no medications, we want to foster their goals unless they are not safe goals Make sure that we double check to see if they changed their goal

late pregnancy bleeding

Placenta previa Placenta implanted in lower uterine segment near or over internal cervical os Degree to which the internal cervical os is covered by placenta used to classify three types Complete placenta previa Marginal placenta previa Low-lying placenta Aprevia- is a preview to the baby Aprevia is the low lying placenta The placenta can shift upwards A complete previa- is when the placenta blocks the cervix Placenta previa- placenta is implanted lower, complete marginal and low lying Marginal placenta previal-Half cover the cervix Complete placenta previa- completely covering the cervix

Late Pregnancy Bleeding (Cont.)

Placenta previa (Cont.) Diagnosis Transabdominal ultrasound examination Care management Expectant management Home care Active management Transabdominal- is a regular pregnancy ultrasound done through the abdomen If the mom will result in a cerian delievery Need to prevent the delivery They can have a great risk of hemoorage so the mom needs to be hospitalized If the placenta is more than 2cm, it can still deliver it vaginaly, otherwise she needs to have C-section so that mom and baby are safe Blood is BRIGHT RED NO PAIN

late pregnancy bleeding

Placenta previa (Cont.) Incidence and etiology 1 in 200 pregnancies Clinical manifestations Painless bright red vaginal bleeding during second or third trimester Maternal and fetal outcomes Major complication is hemorrhage Fetal death (caused by preterm birth) Stillbirth, malpresentation, fetal anemia, intrauterine growth restriction (IUGR) Placenta previa is bright red blood and painless, the mom will not come in complaining of pain bleeding occurs in 2nd or 3rd trimester Outcomes: mom is at risk for hemorrhage Can get still birth

Infertility Care Management (Cont.)

Plan of care and interventions Psychosocial Major life stressor; can disrupt relationships Nonmedical Diet, habit changes; weight loss Complementary and alternative measures Medical Correcting pre-existing factors Ovarian stimulation Can be a major life stressor, this is not only something medically or psychosocially We know that stress can cause amenorrhea, can increase cortisol and changes in the menstrual cycle it is going to complicate the condition even more Make sure we talk to patient Caffine can cause infertility, overweight and underweight can have problems with infertility If it an hormonal imbalance a physican can prescribe hormones to increase fertility

Care Management: Pregestational Diabetes Mellitus (Cont.)

Postpartum First 24 hours, insulin requirements drop substantially Risk of hemorrhage due to uterine distention May be recieveing insulin with the baby, the placenta- is the root cause of the type 1 and type 2 diabetics Once the placenta is delivered then we need to monitor the glucose post partum because she is at higher risk for hypoglycemia Risk of hemorrgae- if the uterus that is blown up with the ambionic fluid and stretched behyond what it is stretched through, muscle may have a hard time contracting, post partum hemorage is due to the uterus not clamping down and contracting like it normally does

Postpartum Mood Disorders

Postpartum depression Experienced by 10% to 15% of postpartum women Cause can be biologic, psychologic, situational, or multifactorial Risk factors Poor nutrition Complications of pregnancy and birth increase the risk for PPD If we are treating one patient may go to baby

Postpartum Mood Disorders (Cont.)

Postpartum depression (Cont.) Care management To recognize symptoms of PPD as early as possible, the nurse should be an active listener and demonstrate a caring attitude. Nurses cannot depend on women to volunteer unsolicited information about their depression or ask for help. If the mom is depressed then the bonding between the mom an the baby are delayed Look for the mom's attachment to the baby Does the mom have attachment, or is mom withdrawn

Postpartum Mood Disorders (Cont.)

Postpartum depression (Cont.) Paternal postpartum depression Incidence is unclear, with reports varying from 10% to more than 50% The best predictor of paternal depression is having a partner with PPD.

Postpartum Mood Disorders (Cont.)

Postpartum depression (Cont.) Postpartum depression without psychotic features Symptoms Medical management Postpartum depression with psychotic features Rare, affecting approximately 0.1% to 0.2% of postpartum women Symptoms Medical management Miscarriage can cause post partum depression If baby is born with birth defect Poor nutrition can play an impact on post partum nutrition If they are breast feeding, mom needs to have essentials The incidences are unclear and vary patient to patient Paternial depression can have an increase of depression if the mom has depression Without psychosis- they can have sadness, guilt, inadequet for baby, occurs weeks after dilvery up until a year can be post partum depression The mood is the big majority With pyschosis- can experience hallucinations, paranoid thought, risk for self harm, high risk of population goes through sucicide Going through the branches of what post partum depression they have Care for these patients, is to recongize as soon as possible

Postpartum Mood Disorders (Cont.)

Postpartum depression (Cont.) Screening for postpartum depression Interventions Nursing care on the postpartum unit Nursing care in the home and community Referral Providing safety Psychiatric hospitalization Psychotropic medications Psychotropic medications and lactation Other treatments for PPD We need to ask the difficult questions What does the mom feel, are their red flags, the primary nurse, need to ask initial questions Going to be first minute they cry and then they are happy, it is the surge of hormones Post portum happens at the end of the 6 weeks post partum Who does the majority of the care Recongize that we need to provide safety, SSRI's are safe for pregnancy Need to know the half life of the drug, it is escrited druing the breast milk, "pump and dump" know what the peak of the med is, pump and discrete it and then you can feed the baby

Nursing Interventions: Education for Self-Management (Cont.)

Posture and body mechanics Rest and relaxation Employment Clothing Travel Medications and herbal preparations Immunizations Do not want mom to strain or pull a muscle They have destaci recti- so make sure the mom knows proper body mechanics, know the direct patient care, 50 pounds of lifting might be too much for her Can travel up to the third trimester Need to know if mom is traveler because can get DVT because have hypercoaguability They assess MMR titers, some things can be transmission to the placenta Need TDAP because can get transmission to baby if ill

Classification of Hypertensive Disorders (Cont.)

Preeclampsia Pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman In the absence of proteinuria, preeclampsia may be defined as hypertension along with the following: Thrombocytopenia Impaired liver function New development of renal insufficiency Pulmonary edema New-onset cerebral or visual disturbances All hypertension disorders increase risk to mom/baby: Increase risk of IUGR - interuterine group restriction, small baby And increase risk of PTL- preterm labor Pre-eclampsia- mom was normotensive (or had chronic hypertension) prior to pregnnacy prior to pregnancy Increae in BP after 20 weeks gestation sBP>140 and DBP>90 and proteinuria!!! If no protienuria -thrombocytopnia, impaired LFT, decreased renal function, pulmonary edema, neurological changes Assessment: Increase in BP, edema (wt gain) - if patient has vacular complication can result in backflow or over flow, increased cardiac output, the fluid is going to go somewhere Can determain patient has edema is the pluses and the weight gain, need to do daily weights If they have fluid in the interstitial space it will be pitting edema, may have vague headaches, visual disturbances, blurry vision that comes and goes Their reflexes, worry about not only head ache or vision changes, have a increase risk of having hyper reflexia, the patients can cause tentany, such as clonius Clonius is when you press on the foot, it countinues to tap Hyper-reflexia, HA Visual disturbances Proteinuria- urealysis -24 degree urine Interventions VS(maturnal) EFM (baby vital signs) Input and output - worry about how much urine is being put out, can put catheter in to monitor Neuro assessment- magnesum sulfate, change in neurologic conditions can switch from preeclampsia to eclamspia Magnesum sulfate- need to be started if they see neuro changes, it is going to relax the neuro reflexes, if she is hyperreflexive, an outcome would be a decreae in neurologic sysmtoms or decrease the hyperflexia If patient is hyperflexive and recieves mag sulfate and now they are hypoflexive, they can receive toxicitiy, they should have calcium gluconate Need to stop the the medication (magesium) and then give calcium gluconate Can see a decrease level of conciousness, always monitor vital signs, we need to asses what the baby's heart rate is Basic interventions for nurse can turn and reposition baby and give them oxygen- can give a little of 02 because the baby's o2 can be decreasing too Abdominal assessment Liver- want to see if mom has right upper quadrent pain that can relate to liver *key is to prevent eclampsia*

key points

Preeclampsia is a multisystem disease, and the pathologic changes are present long before clinical manifestations such as hypertension become evident. HELLP syndrome, which is usually diagnosed during the third trimester, is a variant of preeclampsia, not a separate illness.

endocrine and metabolic disorder

Pregnancy can be complicated by the following disorders: Diabetes mellitus Hyperemesis gravidarum Hyper- and hypothyroidism Phenylketonuria The primary objective of nursing care is to achieve optimal outcomes for both the pregnant woman and the fetus. Diabetes and thyroid are important Integrate, pregnancy talk about the diabetic condition Hyperemesis gravidarium- can be due to high levels of HcG, if they have multiple pregnancy, molar pregnancy, hyper and hypo active thryoid PKU is a condition that is from the mom that is inheretied The primary objective is to retrieve those optium outcome Type 1 or type 2 diabetes

Late Pregnancy Bleeding (Cont.)

Premature separation of placenta (abruptio placentae) [placental abruption] Detachment of part or all of placenta from implantation site after 20 weeks of gestation Occurs in 1 in 75 to 1 in 226 pregnancies Maternal hypertension is a primary risk factor Classification systems Grades 1 (mild), 2 (moderate), 3 (severe) Dark red bleeding and pain The placenta is detacting from the uterus after 20 weeks If the plaenta is not attached to the uterus then it will not have nutrition, oxygen, blood The baby will not receive these and can have a still birth When we think about bleeding we look at large amounts If the mom is preeclamptic, they have an increased risk of this occuring DARK RED AND PAIN

late pregnancy bleeding

Premature separation of placenta (abruptio placentae) [placental abruption] (Cont.) Clinical manifestations Separation may be partial, complete, or only involve margin of placenta Vaginal bleeding, abdominal pain, and uterine tenderness and contractions Boardlike abdomen; Couvelaire uterus Maternal and fetal outcomes Diagnosis Management Expectant Active We need to recongize the differences with the cord Mom side is beefy red, dirty dunkin Baby is shiny side, shiney sholtz When you look at it, is is where the cord is attached, if you try to hold on something with the cord, it will lift from the surface but cause much more pressure

definitions

Prenatal period: A time of physical and psychologic preparation for birth and parenthood Duration of pregnancy: Gestation Spans 9 calendar months, 10 lunar months 40 weeks or 280 days Trimesters First: weeks 1-13 Second: weeks 14-26 Third: weeks 27-40 Prior to pregnancy- this is biological and physical change Gestation- pregnacy Most pregnancy can last up to 40 weeks, this is full term If thinking about full term- 20-36 6/7 Term baby 37 weeks and up 3 trimesters- 13-14 weeks a piece If we look at GTPAL- we can be In the second trimester and still have a mischarage -20 weeks Is viability The biggest thing is the presumptive vs predicitve Presumptive is amenorrhea- biggest thing, can see breast tenderness, quickening, first felt outside the wound Within the first Premagravity- the first time mom, she will feel the fluttering the quickening,17-18 The mutligravita mom anotmy has changed and adaptive, so they will feel it sooner

Nursing Role in Antepartal Assessment for Risk

Provide education Anticipatory planning Counseling for family adaptation Support person In many settings nurses perform the following: NSTs CSTs BPPs Our role Is education, we want to explain what the procedure is like, who is the support person Explain to them that that they can be in many settings ' Just look at the powerpoint and look at the stuff in the book that is on the powerpoint The way the hesi answers the question then we need to look at the HeSi tips for will be on the hesi

Assessment of Risk Factors (Cont.)

Psychosocial Maternal behaviors and adverse lifestyles that have a negative effect on health of mother or fetus May include emotional distress and disturbed interpersonal relationships Inadequate social support Unsafe cultural practices Need social support And unsafe cultural practices- need to understand what the patients beliefs are Can cause emotional stress, prior to pregnancy they may need to make adjustments

seat belt safety with pregnancy

Seat belt safety, will go across illiac crest, The seat belt needs to go below the fetus, on the belt line and right by the chest

Diagnosis of Pregnancy (Cont.)

Signs and symptoms (Cont.) Probable indicators Detected by examiner Uterine enlargement Braxton Hicks contractions Placental souffle Ballottement Positive pregnancy test

Assessment of Risk Factors (cont.)

Specific pregnancy-related problems and related risk factors Intrauterine growth restriction: fetoplacental Chromosomal abnormalities Congenital malformations Intrauterine infection Genetic syndromes (trisomy 13 and trisomy 18) Abnormal placental development Intra uterine growth restriction with in the baby Can be cause by chromosomal abnomrlaities, infection, trismony 13 and 18 The placenta may not be fully developed genetic disorders increase after the women is 35, the mom can have a higher risk of infertility and their child having a genetic disorder such as tay sachs, trisomy 18-21, hemophilia and thalamissas First is maternal cause and this powerpoint is fetus cause

Assessment of Risk Factors (cont.)

Specific pregnancy-related problems and related risk factors Intrauterine growth restriction: maternal causes Hypertensive disorders Diabetes Chronic renal disease Thrombophilia Cyanotic heart disease Poor weight gain Smoking, alcohol, illicit drug use Multiple gestation Cause and can lead to interuterine growth restriction IUGR - the decrease of oxygen to the baby causes restriction If the mom has diabetes it can cause a restriction of growth to the baby, type 1 type 2 gesattional Poor weight gain, poor matural nutrition Multiple gestation- if there is more than one fetus at the time growing, twins, triples

Assessment of Risk Factors (cont.)

Specific pregnancy-related problems and related risk factors Polyhydramnios Diabetes mellitus Fetal congenital anomalies Polyhydramnios- volumes up to 2 liters Normal is 700-1000 ml, anything greater than 1000 is poly If we have too much ambionic fluid It can be due to maternal diabetes And fetal congenital anomalities, in the GI tract The baby is producing too much urine and there is too much ambionic fluid If too much fluid can be caused for preterm birth because of too much pressure When the buffer is gone there is not enough profussion against the wall

key points

There is an increased incidence of physical, mental, and verbal abuse during pregnancy. Culture, age, parity, and multifetal pregnancy can have a significant effect on the course and outcome of the pregnancy. Nurses must ask pregnant women and their families about preferences, practices, and customs related to childbearing to provide culturally sensitive care.

Antepartum Testing: Biophysical Assessment (Cont.)

These are the sounds waves as the blood flow Educate patient

Anxiety Disorders

Twice as likely to be diagnosed in women compared with men Characterized by prominent symptoms of anxiety that impair functioning Examples include the following: Obsessive-compulsive disorder (OCD) PTSD Generalized anxiety disorder Panic disorder Agoraphobia and other phobias Twice as likely to be diagnsosied by women than men They have periods of fear, or they do not want to go out, they obessively check to make sure everything is okay PTSD is most commonly treated with Benzodiazapines Need to assess baby for the neuro status and respitory status Period of with drawel, the mom might not want to take medication

Antepartum Testing: Biophysical Assessment (Cont.)

Ultrasonography Levels of ultrasonography Abdominal Transvaginal Indications for use Fetal heart activity Gestational age Fetal growth Fetal anatomy Ultrasound- positive pregnancy indicator, can visuzal the fetus This is minimially invasive to non invasive Trasnvaginal is the first autrasound the mom recieves Use external for the abdomen Can use just abdomen ultrasound after the 13 weeks, Fetal heart activity can see it 6-7 weeks Gestational age- can be visulaized on an ultrasound If the kidneys are suppose to be at 5 weeks and we look at ultrasound and these arent developed then the baby may not be that far along Most reliable after 8 weeks to use ultrasound to determine justational age Ultrasound for fetal growth- if the mom has diabetes, If the moms not gaining enough weight, there are some maternal factors If she has had a previous pregnancy had intra uterine growth restriction If the mom uses alcohol or drugs Fetal anatomy- what we can visual with the baby, can see the head the neck and the spine Organ systems can visualise heart, the stomach and small bowel, bladder The liver and the kidney can be visulaized and all 4 arms legs Really important to asses growth early because can may be stilborn Macrosomia- is a very large baby, can see this in the diabetic mom Can approach term period- the baby can be 9-10 pounds, can induce the mom The baby can become strengulated if too big

Antepartum Testing: Biophysical Assessment (Cont.)

Ultrasonography (Cont.) Indications for use Fetal genetic disorders and physical anomalies Placental position and function Adjunct to other invasive tests Fetal well-being Doppler blood flow analysis Amniotic fluid volume Biophysical profile (BPP) Modified biophysical profile Asses the servical spine and neck- can detect abdnomality of this around 10-14 weeks, this is the problem with the neural tube Placental position and function, the placenta can be low lying, ideally the placenta is going to be imbedded into the uteruas on the side or the top of the uterus If the placenta is low lying, where the cervix is, if the placenta is covering the cervix then it may shift and It is okay, but if the placenta does not shift and grows over the exit then this is a complication, on ultrasound it may be low lying. They may experience bleeding If low lying placenta,can start to grow and navigate, placenta prevow- if the placenta doesn't move then may need C-section If we do not have great profussion then we may have decreae in fluid volume, the mom will be at risk for bleeding The fluid volume can determine how much fluid volume Should have 3 blood vessles- 2 artery and 1 vein if you a two vessel vein can have 2 arteries and no vein will get no o2, if 1 artery and 1 vein then get profussion by 50 percent Biophysical profile can be done, to visualize the ambionic fluid, the breathing patternsof baby and fetal movement, fetal tone, fetal heart rate and fetal reactivity They receive a score, should be 8-10, if its less than 8 then aditional testing would be needed APGAR score- 8-10 APGAR assessed the first 60 seconds after birth and then reassessed at 5 minutes. if difficulty then reassess at 10, 15, 20 minutes

Antepartum Testing: Biophysical Assessment (Cont.)

Ultrasonography (Cont.) Nursing role Nonmedical ultrasounds 3-D and 4-D increasingly popular with pregnant women and their families American Institute of Ultrasound in Medicine (AIUM) and the American College of Obstetricians and Gynecologists (ACOG) have published statements that strongly discourage this practice Exposure of the fetus to high-frequency soundwaves without a clear medical indication Performed by people who are not qualified health care professionals Educate patient that it is safe based on american college

Diabetes Mellitus Introduction (Cont.)

When mom first becomes pregnant and she becomes pregnant, it will go up one time before gestation insulin demand to be higher because glucose is higher If she is someone who is manage with a pump She may get into the hospital and be on regular insulin because the pump may not be enough Not everyone will have to go to the hopsital but they are at higher risk Mom can be at higher risk for hypertension due to diabetes Asses urine for protein, and ketones because can show some kind of renal impairment

future health care

Women with preeclampsia with severe features have a significantly increased risk of developing preeclampsia in a future pregnancy. These women have an increased risk of developing chronic hypertension and cardiovascular disease later in life. For now, women should be educated about lifestyle changes (maintaining a healthy weight, increasing physical activity, and avoiding smoking) that may decrease the risk for developing future health problems. See these patients more common but we have a lot more education Life style changes and the amount of adequet weight gain

Mental Health Disorders During Pregnancy (Cont.)

Women with serious mental disorders may be engaging in sexual activities that can result in pregnancy. Mental health disorders have implications for the following: Pregnant woman Fetus Newborn Entire family The new born and the entire family Paranatal mood disorders During the antipartum or post partum