NCM 101 Antepartum

ANTEPARTUM Signs of Pregnancy Presumptive Signs Probable Signs Positive Signs Presumptive SIGNS Breast changes feeling of tenderness, fullness, or tingling; enlargement and darkening of areola. Nausea and Vomiting Amenorrhea Frequent urination Fatigue Uterine enlargement uterus can be palpated over symphysis pubis Quickening Linea nigra line of dark pigment on the abdomen. Melasma dark pigment on face Striae gravidarum red streaks on abdomen. Probable Signs Chadwicks sign discoloration of the vagina. Goodells sign softening of the cervix. Hegars sign softening of the isthmus of the uterus. Ballottement passive fetal movement elicited by pushing up against the cervix with 2 finger. Braxton Hicks contractions periodic uterine tightening. Positive SIGNS Fetal heart beat ( 17-20 wks). Fetal heart rate is between 120 -160 bpm. Fetal movement actively palpable by a trained examiner after about 20 weeks gestation (19-22 weeks). Visualization of the fetus by ultrasound (5-6 weeks). Psychological Tasks of Pregnancy 1st Trimester: Pregnancy Validation - ambivalence, or feeling both pleased and not pleased about the pregnancy. Fetal Embodiment the mother feels that the fetus is a part of her. 2nd Trimester: Fetal Distinction she daydreams about what the baby will be like and think about the kind of mother she wants to be. Role Transition exploring the meaning of mothering and parenting skills. 3rd Trimester: Nesting 0r energy surge as due date approaches. Desire to get to the end of the pregnancy. Focus on the baby, delivery. Factors Affecting Psychological Response Body image some women feel fat and ugly, and others feel so good and beautiful when they are pregnant. Financial Situation a poor financial situation may be the cause of anxiety about infant care. Cultural Expectations conflicts may occur if the cultural expectations of the mother are different form that of the father or partner. Emotional Security a planned or long anticipated pregnancy will be received with joy and excitement, an unexpected or unwanted pregnancy may be met with fear, dread, or uncertainty. Support from Significant Others father/partner may feel left out, siblings see the new baby as a threat to their relationship with the parents, grandparents feel they are too young to become grandparents. Couvade is the development of physical symptoms by the expectant father such as fatigue, depression, headache, and nausea. Physiological Changes of Pregnancy Reproductive System Cardiovascular System Respiratory System Musculoskeletal System Gastrointestinal System Urinary System Integumentary System Endocrine System Reproductive System Uterus enlarges by hypertrophy of the muscle cells stimulated by estrogen and the growing fetus expanding evenly in all directions during pregnancy. Cervix - secretes a thick, sticky mucus that forms a plug in the cervix which prevents microorganisms from entering through the vagina. Ovaries follicles do not mature and ovulation does not occur during pregnancy. Vagina the acidic secretions prevent bacterial infections. Breast the nipples become more erect, the areolas darken, and the breast enlarge from hormonal influence. Cardiovascular System Dependent edema and varicose veins - Stasis of the blood in the lower extremities, caused by the enlarged uterus interfering with return blood flow. Supine hypotensive (vena caval)syndrome occurs when the mothers lies supine. Physiologic anemia of pregnancy - in plasma causing hemodilution as manifested by a lower hematocrit. Musculoskeletal System Gastrointestinal System Nausea and vomiting. Constipation this is caused by delayed gastric emptying, decreased peristalsis, and enlarging uterus that displaces the stomach and intestines. Heartburn - results from relaxation of cardiac sphincter allowing acidic gastric contents reflux. Urinary System Integumentary System Linea nigra pigmented line on the abdomen from umbilicus to symphysis pubis. Chloasma mask of pregnancy it is the darkening of the skin of the forehead and around the eyes. Striae gravidarum stretch marks are reddish streaks found in the abdomen, thighs, buttocks, and breasts. Endocrine System Thyroid disorders which occur during pregnancy are autoimmune in nature. Body develops antibodies against thyroid cells, which affect thyroid gland functions. Antibodies damage the thyroid cells result in lymphocytic thyroiditis (inflammation of the thyroid), known as Hashimoto's disease. Metabolism The metabolic rate of the mother increases during pregnancy as the demands of the growing fetus increase. The mother must meet her own and the fetuss nutritional needs. Metabolically speaking, pregnant women live in a state of "accelerated starvation."

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INITIAL PRE-NATAL CARE VISIT Maternal History History of Current Pregnancy Last menstrual period Bleeding or spotting Cramping or pain Pregnancy test Quickening Feelings about the pregnancy (Both parents) History Of Previous Pregnancies # of previous pregnancies # of living children Hx of miscarriages Hx of abortions Complications, fetal and maternal # of premature deliveries Condition of babies at birth Breast-feeding Gynecologic History Age of menarche. Duration and interval of periods Use of birth control pills. Hx of use of pills to become pregnant. Hx of use of any other form of birth control. Dysmenorhea,Vaginal infections Pelvic surgery. Abnormal Pap smear results. STD Medical History Allergies, Medications Viral infections, Recent x-rays Diseases of the lungs, heart, nervous system, stomach, intestines, kidneys, thyroid gland, or pancreas Surgery Bleeding problems or blood transfusions Serious accidents Blood clot in legs or lungs Social History Alcoholic beverages Use of over-the-counter drugs Smoking hx Use of illegal drugs Exercise Living conditions Financial problems Nature of work do you do Exposure to chemicals or radiation. Family history Hx of hypertension, diabetes, or blood problems in the family Twins, triplets Birth defects Mental retardation Mothers intake of DES when pregnant High blood pressure in any of mothers pregnancies Dietary History # of meals each day? Special diets Vitamins Special diet in a previous pregnancy Unusual cravings The Nurse Should Obtain the Following Lab Results: Rubella Blood type Rh factor Optional: HIV status Toxoplasma Hepatitis B screen Tuberculosis Gonorrhea Chlamydia One-hour glucose tolerance test 24-28 weeks Maternal serum fetoprotein 15-18 weeks Estimating Duration of Pregnancy Naegeles Rule: Take the date of the first day of the LMP, subtract 3 months, and add & days.(J,F,M dont add) Gestation Calculator: In the shape of either a wheel or a chart which provides other information such as fetal weight and body length for each week. Fundal Height: Fairly accurate in indicating gestational age, between 18 to 30 weeks gestation. The fundus is measured in centimeters from the top of the pubic symphysis to the top of the uterine fundus. A sudden increase may indicate twins or hydramnios. A smaller increase may indicate growth retardation. Other Indicators: Ultrasound an ultrasound can detect a gestational sac 5 to 6 weeks after LMP. Fetal heartbeat generally heard by 10 to 12 weeks with the Doppler device. Fetoscope can hear the FHB at 18 to 20 weeks. Quickening fetal movement is usually felt by the mother at about 20 weeks gestation. Stages of Fetal Development Pre-embryonic Stage Day 10 - the pre-embryo is in the form of a bilaminar disk, with two layers of somewhat differentiated cells. Day 12 - a trilaminar disc has formed, with three layers of cells, each of which contains cells that are the ancestors of certain body systems: Endoderm (the innermost layer, next to the amnion): digestive tract, respiratory tract Mesoderm (the middle layer): muscle, bone, connective tissue, reproductive tract, circulatory system Ectoderm (the outermost layer, next to the yolk sac): nervous system, skin and its derivatives (lens of eye). Neural tube forms - It will develop into the nervous system (Brain, spinal cord, hair, and skin), the foundation for thought, senses, feeling, and more. Heart and primitive circulatory system - rapidly forming while still in its beginning stages, the very life support system that will carry the fetus throughout his life.

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Continued maturation and refinement of body systems. Wk 912: external sex characteristics differentiate, urine production begins. Wk 1316: face is developed, quickening is felt Wk 1720: vernix caseosa covers skin protecting it from amniotic fluid, lanugo present. Wk 2124: surfactant present, L/S ratio 1.2:1 indicating immaturity Wk 25-28: may assume head first position Wk 29-32: skin becomes pigmented, subcutaneous fat Wk 33-38: testes descend into scrotum,L/S ratio 2:1 indicating maturity. ANTEPARTUM DIAGNOSTIC TESTS Blood type Rh, erythroblastosis fetalis. Immunologic test to detect presence of rubella, untreated syphilis, HepB, HIV. Urine test to confirm pregnancy (HCG). Hematologic studies Genital cultures Fetoscopy Triple screen (15-20wks) Downs syndrome. Alpha-fetoprotein high level indicates NTD like Spina Bifida and Anencephaly. Glucose (Normal = Negative or + 1)- High levels of glucose may be one indicator of high blood sugar, gestational diabetes or diabetes mellitus. Urine Tests pH - Measures acidity/alkalinity High Ph indicate high fluid intake Low pH indicate inadequate fluids & dehydration. Protein (Normal = Negative) Small amounts may be in urine from vaginal secretions & dehydration. Amounts of 2+ to 4+ may indicate possible UTI, Kidney Infection or PIH. Ketones (Normal = Negative) Ketones are products of the breakdown of fatty acids caused by fasting. The body breaks down fats because there are not enough carbohydrates and proteins available. Ketones may be deleterious to fetus. Amniocentesis after 14th wks to diagnose and determine: Gestational age by way of lecithin-sphingomyelin ratio. Diagnosed chromosomal aberrations Sex-linked disorders. Blood type incompatibility. Rh-negative mother must receive Rh0 (D) immune globulin ; RhoGAM to prevent fetal isoimmunization. Chorionic Villi Sampling 10th Week Heart is almost completely developed and resembles that of a newborn baby. An opening the atrium of the heart and the presence of a bypass valve divert much of the blood away from the lungs, as the child's blood is oxygenated through the placenta. Twenty tiny baby teeth are forming in the gums. 12th Week FETAL PERIOD From 9th week to termination of pregnancy (38-40 wk). Other Diagnostic Tests NST (32-34 wks) nonreactive indicates fetal hypoxia, fetal sleep cycle, or the effects of the drugs. Not to be used to patients who are obese. OCT (oxytocin challenge test) evaluate fetal ability to withstand oxytocin-induced contraction. Given after nonreactive NST. Not indicated for previous CS or 3rd trimester Nipple stimulation stress test activate se4nsory receptors in the areola. Same reactive pattern as the NST.

Embryonic Stage 4th week - The embryo produces hormones which stop the mother's menstrual cycle. 5th Week Embryo is the size of a raisin. By day twenty-one, the embryo's tiny heart has begun beating. Blood is now pumping and all four heart chambers are now functioning. The neural tube enlarges into three parts, soon to become a very complex brain. Umbilical cord develops. The spine and spinal cord grows faster than the rest of the body at this stage and give the appearance of a tail. Lungs start to appear, along with brain. Arm and leg buds appear. The placenta begins functioning. 6th Week The arms and legs continue to develop - These limbs are stretching out more and more. Brain is growing well. Lenses of the eyes appear. Nostrils are formed. Intestines grow - Initially these are actually located outside the baby's body within the umbilical cord. Pancreas the fetus is now equipped to deal with digestive enzymes and take on processing the insulin and glucagons the body needs to function. 7th Week Facial features are visible, including a mouth and tongue. The major muscle system is developed. The child has its own blood type, distinct from the mother's. These blood cells are produced by the liver now instead of the yolk sac. Intestines start to form in the umbilical cord. Teeth begin to develop under the gums. Elbows form. The eyes have a retina and lens. 8th Week The embryo is about half an inch long protected by the amniotic sac, filled with fluid. The arms and legs have lengthened, and fingers can be seen. The toes will develop in the next few days. Brain waves can be measured. Cartilage and bones begin to form. The basic structure of the eye is well underway. The tongue begins to develop Intestines move out of the umbilical cord into the abdomen. Body grows and makes room. The fingers and toes have appeared but are webbed and short. Baby's length (crown to rump) is 0.61 inch (1.6cm) and weight is 0.04 ounce (1gm). 9th Week

NCM 101 Antepartum

Vibroacoustic stimulation over the fetals head for 1 to 5 seconds. Noninvasive and convenient. Fetal movement count - < than 10 movements in 2 hours indicates compromise. TERMS USED IN DESCRIBING A PREGNANT CLIENT Abortion loss ofpregnancy before the age of viability (usually 20 to 24 weeks gestation). Gravida pregnancy, regardless of duration, includes present pregnancy. Para delivery (birth) after 24 weeks gestation, wether infant born alive or dead or number of infants born. Preterm delivery after 24 weeks gestation but before 38 weeks (full term). Term a pregnancy between 38 to 42 weeks gestation. Nulligravida never been pregnant. Primigravida pregnant for first time. Multigravida pregnant two or more times. Nullipara never having delivered an infant after 24 weeks gestation. Primipara has delivered once after 24 weeks gestation. Multipara has delivered twice or more after 24 weeks gestation. Posterm delivery after 42 weeks gestation. GP/TPAL Gravida, Para / Term, Preterm, Abortions, Living. Examples: a. Mary Jo is G2 P1/T2 P0 A0 L2 2nd pregnancy, one delivery/two infants at term(twins), both living. b. Susan is G4 P2/T1 P1 A1 L2 4th pregnancy, two deliveries/one term infant, one preterm infant, one abortion, two living children. Complications of Pregnancy Discomforts of Pregnancy Antepartum Complications Other Antepartum Complications Abnormal fetoprotein values Rh isoimmunization problems AIDS Adolescent Pregnancy Gestational Diabetes Multifetal Pregnancy Antepartum Danger Signs Gestational Diabetes An abnormal glucose tolerance due to the decreased effectiveness of insulin during the second and third trimesters. Untreated diabetes in pregnancy may lead to polyhydramnios Dystocia Preeclampsia, stillbirth, neonatal hypoglycemia, respiratory distress syndrome, and premature delivery. Risk Factors Family history of diabetes in first-degree relatives Poor obstetric history Previous macrosomic infant Previous newborn with congenital abnormalities High parity Assessment Positive 1-hour glucose tolerance test confirmed by 3-hour glucose challenge test Observe for signs of hyper- and hypoglycemia. Observe for signs of preeclampsia, polyhydramnios, and macrosomia. Nursing Considerations Continually monitor fetal well-being. Strict monitoring to maintain glucose in normal range. Frequent antepartum visits for adequate supervision. Educate client on blood glucose monitoring and diet guidelines, and about the effects of high blood sugar on the mother and the fetus. Measure urine protein and ketones.

Bleeding Complications Abortion loss of pregnancy before fetus is viable (>20 wks). a. Threatened vaginal bleeding, cervix closed, fetus not expelled. b. Inevitable vaginal bleeding heavy, + contractions, cervix dilated. c. d. e. Interventions: Peripad count Save all tissue passed Prepare patient for D&C. Provide emotional support. Incomplete fetus expelled, placenta retained. Complete all products of conception expelled. Missed fetus dies in utero and is retained.

Ectopic Pregnancy The fertilized ovum is implanted outside the uterine cavity. In 95% of all ectopic pregnancies, the egg is implanted in one of the fallopian tubes so rupture of the site usually occurs. Alternative names are abdominal, cervical, or tubal pregnancy. If left untreated, an ectopic pregnancy can lead to severe internal bleeding, which is life-threatening. Prevalent in blocked fallopian tubes or damaged due to endometriosis, scarring after tubal surgery, pelvic inflammatory disease (PID), or a previous ectopic pregnancy. Risk factors include infertility, exposure to several STDs, smoking, and having an IUD in place during conception.

Symptoms: Significant cramping or tenderness, usually on one side of the lower abdomen. If a tubal rupture occurs, the pain becomes very sharp and steady before spreading throughout the entire pelvic region. Brown vaginal spotting or light bleeding. Heavy bleeding if the tube ruptures. Nausea and vomiting (might be difficult to distinguish from morning sickness). Dizziness or weakness. (If the tube ruptures, a weak pulse, clammy skin, and fainting are common.)

NCM 101 Antepartum

Shoulder or neck pain (caused by the buildup of blood under the diaphragm when the tube ruptures). Nursing Considerations Assist in correction of underlying cause of D.I.C. (delivery of fetus, removal of abruptio placenta, treatments of preeclampsia). Replace blood and blood products as ordered. Administer heparin as ordered to prevent clot formation Provide emotional support. Hyperemesis Gravidarum Extreme, persistent nausea and vomiting during pregnancy that may lead to: Dehydration Weight loss Lightheadedness or fainting Ketones in urine Increased hematocrit Increased pulse rate Decreased blood pressure Assessment Monitor frequency of vomiting. Measure weight loss. Monitor urine for ketones. Monitor pulse. Evaluate fluids and electrolyte balance Assess for signs of metabolic acidosis (headache, stupor, disorientation). Nursing Considerations Intravenous hydration isotonic solutions will be ordered. Fluid replacement Antiemetic administration as ordered Small, frequent meals starting with liquids and progressing to solids Encourage weight gain. Monitor fundal height and the patients weight. Provide emotional support. Cervical Cerclage Treatment for cervical incompetence, the cervix is sewn closed during pregnancy, helps prevent miscarriage or premature labor. Used if cervix is at risk of opening under the pressure of the growing pregnancy. A weak cervix is a result of: History of second-trimester miscarriages. A previous cone biospy Damaged cervix by pregnancy termination. The best time for the cervical cerclage procedure is in the third month (12-14 weeks) of pregnancy. Incompetent Cervix Hydatidiform Mole A rare mass or an abnormal growth that may form inside the uterus at the beginning of a pregnancy.

Assessment: Symptoms of early pregnancy. Abdominal pain, localized on one side. Rigid, tender abdomen; abnormal pelvic mass. Bleeding; if severe may lead to shock. Positive Cullens sign (bluish discoloration around the umbilicus). Diagnostic Exams: Ultrasound exams are used to determine whether pregnancy is developing in the right place. Culdocentesis a needle is inserted into the space at the top of the vagina, behind the uterus. A sample of fluid is extracted. If the sample contains blood, bleeding from a ruptured fallopian tube has occurred. Laparoscopic surgery - the surgeon inserts a small camera beneath the umbilicus and looks at the tubes and ovaries to see if there is an ectopic pregnancy. Interventions: Prepare client for surgery. Institute measures to control/treat shock. If hemorrhage severe continue to monitor postoperatively. Allow client to express feelings about loss of pregnancy and concerns about future pregnancies. Disseminated Intravascular Coagulation Pathological clotting disorder that is diffuse and causes injury rather than protecting sites of coagulation. The consumption of clotting factors such as platelets and fibrinogen resulting in widespread external or internal bleeding. Uncontrolled uterine hemorrhage, bleeding from laceration sites, placental abruption, abortion, or shock. Prothrombin and platelets Widespread formation of intravascular clots Clotting factor expended Severe generalized hemorrhaging Life threatening! Etiologies Septic shock Placental/uterine hemmorhage IUFD Amniotic fluid embolism Thrombi secondary to preeclampsia Thrombi secondary to thrombophlebitis Early signs of DIC Protime Fibrinogen Thrombocytopenia Bleeding from gums Bleeding from puncture sites Ecchymosis Treatment complex, packed cells, fibrinogen, whole blood, plasma Assessment Spontaneous or uncontrolled bleeding Monitor labs for decreasing platelets, fibrinogen, and increasing prothrombin time. Observe for signs of shock (tachycardia, anxiety, restlessness).

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Intermittent or continuous bright red or brownish vaginal bleeding by the 12th week of gestation. Absence of fetal heart tone. HCG levels are much higher than normal. No fetal skeleton in the ultrasound. Interventions: Therapeutic abortion. Monitor weekly HCG levels until stabilized for 3 consecutive weeks. Periodic follow-up for 1-2 years because of increased risk of neoplasm. Multifetal Pregnancy More than one set of FHT. Uterine size > expected. Alpha-fetoprotein levels. Interventions: Bed rest if dilatation occurs at 24-28 wks. 2x weekly NST to document fetal growth. intake of calories, iron & folate. Monitor cardiovascular and pulmonary status of the patient. Health Beliefs and Practices Wearing a necklace can cause the umbilical cord to wrap around the babys neck. Eating dark colored foods can cause the baby to have dark skin. Admiring flowers is not advisable because the petals resemble cleft lip and palate. Eating twin bananas can result in having twins. Eating spicy foods can cause a hot-tempered baby. Dont sit on the stairs because it can cause a long labor. The pregnant woman should not pick fruits from the tree, the baby can steal the tree's spirit and cause it to die. Dont hang underwear outside, the evil spirit will cause deformities to baby. Dont sit in the dark, the evil spirit will take away the baby through miscarriage. High-Risk Pregnancy A pregnancy that has maternal or fetal complications requiring special medical attention or bed rest. Complications - the risk of illness or death before or after delivery is greater than normal for the mother or baby. Risk Factors: Risk factors do not threaten pregnancy to the same extent. Smoking - SIDS Poor nutritional habits Pre-pregnancy maternal health status Domestic violence Psychosocial factors infections The presence of chronic medical problems in the mother. Past history of repeated preterm delivery. Abnormalities of the fetus or placenta. Prior health care Multiple gestation Drugs that interferes with folic acid: Lithium Streptomycin Tetracycline Thalidomide Warfarin (Coumadin) Isotretinoin (Accutane) Alcohol abuse - Fetal alcohol syndrome. Diagnosis: A risk-scoring sheet is utilized by many healthcare agencies during the prenatal assessment to establish if a woman may be at risk for complications during her pregnancy. Lab data and ultrasound are also utilized to determine high-risk pregnancies by specific blood tests and imaging of the baby.

Treatment/ Management: Physical Examination: A woman with severe high-risk factors in pregnancy should be referred to a perinatal center to obtain the highest level of care for herself and her baby. Antepartum Testing Amniocentesis Fetal transfusions Fetal surgery Chorionic Villi Sampling Aging placenta post term pregnancy 3x more likely to cause death of the baby. The treatment is to induce labor before problems start to occur. Hemolytic disease of the newborn (destruction of the red blood cells) can occur when Rh incompatibility exists between child and mother. Rhogham [Rh0(D)immune globulin], which can be given to the mother in the first 72 hours after delivery and at the twenty-eighth week of pregnancy Blighted Ovum Known as anembryonic pregnancy happens when a fertilized egg attaches itself to the uterine wall, but the embryo does not develop. Cells develop to form the pregnancy sac, but not the embryo itself. A blighted ovum usually occurs within the first trimester before a woman knows she is pregnant. A high level of chromosome abnormalities usually causes a womans body to naturally miscarry. Teratology of Drugs and other Substances Artificial Sweetener - Aspartame Caffeine Aspirin Smoking Antihistamines Antibiotics Recreational Drugs (marijuana, cocaine) Antidepressant Drugs Antiepileptic Drugs Acne Drugs - accutane Cardiovascular Drugs TORCH: Teratogenic Maternal Infections Cytomegalovirus Member of herpes family MOT: transmitted by droplet infection, transplacental Mother: asymptomatic Fetus: Severe brain damage (hydrocephalus, microcephaly, spasticity), eye damage, deafness, or chronic liver disease The child may have Blueberry muffin lesions (large petechiaes) Rubella (German Measles) Caused by rubella virus usually causes only mild systemic illness in the mother Fetus: deafness, mental and motor retardation, PDA and Pulmonary artery stenosis, SGA, thrombocytopenic purpura, cleft lip and palate. Do not administer rubella vaccine during pregnancy or if the woman is planning to conceive Upon administration of rubella vaccine, woman is not advised to become pregnant for three months Herpes Simplex Virus (Genital Herpes Infection) If happens in the first trimester = Spontaneous abortion

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Syphillis If happens in the 2nd and 3rd trimester = premature birth, IUGR, continuing infection of the newborn birth If vaginal lesions are present, cesarean section is performed Caused by Treponema pallidum Fetus: deafness, mental retardation, fetal death. Newborn: extreme rhinitis, syphilic rash. Caused by Borrelia burgdorferi. Spread by the bite of a deer tick. Highest incidence occurs in the summer and early fall. The woman falls deeply unconscious, breathing noisily. This can last only a few minutes or may persist for hours. The following may develop: Epilepsy Subarachnoid/cerebral hemorrhage Preexisting brain tumors may fulminate Uremia Liver failure Placental necrosis Glomerular (kidney) and tubal necrosis. Interventions: CBR in a lateral position. I&O Restriction of salty foods. IVF administration restriction during labor. Seizure precautions. Medications: Magnesium Sulfate (IV/IM) Apresoline Furosemide if pulmonary develops. Delivery should take place: As soon as the womans condition has stabilized. Regardless of the gestational age. Should occur within 24 hours of the onset of symptoms. Should occur within 12 hours of the onset of convulsions in eclampsia. Delaying delivery to increase fetal maturity is unsafe for both the woman and the fetus. If vaginal delivery is not anticipated within 12-24 hrs deliver by CS. Control BP by : Hydralazine 5 mg IV slowly q 15 until BP. Repeat hourly as needed or give hydralazine 12.5 mg IM q2 prn. Magnesium Sulfate: Reduce the amount of acetylcholine produced by motor nerves preventing seizure. Promotes maternal vasodilation tissue perfusion. Anticonvulsant effect. Side effects: BP, reflexes, respirations, UO Antidote: Calcium glucanate Cardiac Disease Classification: Class1: no limitation on activity. Class2: minimal limitation on activity. Class3: marked limitations on activity. Class4: discomfort even at rest. Interventions: Left-side position w/ head elevated & O2 during labor. Class 1 & 2 Sodium restriction Antibiotics Class 3 & 4 Anti-coagulants Anti-arrhythmics Betablockers Diuretics Emergency Birth Emergency delivery of the fetus may become necessary when the well-being of the mother or fetus is in jeopardy. Causes:

Lyme Disease

Symptoms:a typical skin rash, erythema chronicum migrans (large, macular lesions with a clear center), joint pains, bells palsy. Fetus: spontaneous abortion. Prevention: Wear long sleeves when hiking. Use tick repellant. Remove the tick within 24 hours. Treatment: Administration of tetracycline and doxycycline. Hypertension During Pregnancy PIH A condition unique to pregnancy where HTN is accompanied by proteinuria, edema usually appears after the 20th week. Mild: a. Edema of hands & face b. HTN +30/+15mmHg over baseline. c. Proteinuria +1. Severe: Headache Epigastric pain (impending seizure) Visual disturbance Eclampsia (all of the above) plus: Tonic clonic seizure Altered mental status coma. Labor may begin. Eclampsia Fatal condition can develop in the 2nd half of pregnancy, no known etiology, believed it results from poor nutrition. Pre-eclampsia signs include high blood pressure, protein in the urine, and excessive edema. Stages of Eclamptic Seizure: 1. Premonitory stage 2. Tonic stage 3. Clonic stage 4. Comatose stage Premonitory stage Usually missed; the woman rolls her eyes, facial and hand muscles twitch slightly. Tonic stage - The twitching turns into clenching. The woman may bite her tongue as she clenches her teeth, while the arms and legs go rigid. The respiratory muscles spasm, causing the woman to stop breathing. This stage continues for around 30 seconds. Clonic stage Spasm stops but the muscles start to jerk violently. Frothy, slightly bloodied saliva appears on the lips and can sometimes be inhaled. The convulsions stop, leading into a temporary unconscious stage. Comatose stage

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Prolapsed umbilical cord Uterine rupture Amniotic embolism Prolapsed Umbilical Cord Etiology: Fetus at high fetal station. Hydramnios Multifetal pregnancy Small fetus or breech presentation Transverse lie S/S: Cord palpable during vaginal exam Cord visible at the vaginal opening. Variable deceleration or bradycardia noted. Uterine Rupture Etiology: Blunt abdominal trauma High parity with thin uterine wall Intense uterine contractions S/S: Abdominal pain and tenderness at the peak of contraction. Feeling that something ripped. Chest pain on inspiration. Amniotic Fluid Embolism Etiology: Fetal particulate matter (skin, hair, vernix, cells, mecomium) in the fluid that obstructs the maternal pulmonary vessels. S/S: Coughing w/ pink, frothy sputum Cyanosis and hemorrhage Shock disproportionate to blood loss Sudden dyspnea and tachypnea Interventions: Monitor maternal VS, I&O, O2 sat, FHR. Administer O2 8-10L/minute Initiate and maintain IVF to replace volume loss. Provide emotional support and reassurance to the patient to reduce anxiety. Prepare the patient and her family for the possibility of CS. Placenta Abruption Vaginal bleeding may be caused by the placenta detaching from the uterine wall before or during labor. Usually occurs after the 20th week or during the last 12 weeks of pregnancy. Signs of Placental Abruption: Vaginal bleeding depends on how much of the placenta has detached. Sharp, sudden abdominal pain Boardlike, tense abdomen. S/S shock. Fetal distress, bradycardia. High risks factor: Multipara. Are age 35 or older. Hx of abruption before. Have sickle cell anemia. High blood pressure. Trauma or injuries to the stomach. Cocaine use. Interventions: VS q 15, FHR q 15. Left side lying position w/ O2. Prepare patient for delivery. Prepare fibrinogen / fibrin products (DIC). Assess for bleeding / clotting problems. Nursing Considerations Bed rest in wedge position to prevent supine hypotension. Continually monitor fetal well-being. Treat signs of shock and hemorrhage. Provide emotional support Type and cross match blood. Placenta Previa Occurs when the placenta lies low in the uterus partly or completely covering the cervix. It is serious and requires immediate care. Vaginal bleeding after 7th month usually occurs w/o pain. High Risks Factor: Multipara Previous cesarean birth. Other surgery on the uterus. Carrying twins or triplets. Uterine Abnormalities. Interventions: CBR Sterile speculum for vaginal exams. Peripad count. Assess fetal response, movement, FHR. Prepare patient for cesarean birth. Monitor Hct & Hgb. Breech Presentations The feet or buttock present first as opposed to the head. Occurs in about 1:40 births. Complications include: intracranial bleeding Neck, hip, shoulder dislocation clavicle fracture internal organ disruption genital edema premature placental rupture prolapsed cord uterine rupture Types of Breech Presentation Complete or full breech -flexion of the fetus legs, fetus is sitting in a tailor fashion. The buttocks and feet appear at the vaginal opening almost simultaneously. Frank and single breech - fetus thighs are flexed on his abdomen, legs are against his trunk and feet are in his face (foot-in-mouth posture). This is the most common and easiest breech presentation to deliver. Incomplete breech. The fetus feet or knees will appear first. His feet are labeled single or double footing, depending on whether 1 or 2 feet appear first. Preterm Labor Vaginal bleeding may be a sign of labor. Up to a few weeks before labor begins, the mucus plug may pass. This is normally made up of a small amount of mucus and blood. If it occurs earlier, you could be entering preterm labor and should see your physician immediately. Signs of Preterm Labor symptoms that occur before the 37th week of pregnancy: Vaginal discharge (watery, mucus, or bloody).

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Pelvic or lower abdominal pressure. Low, dull backache. Stomach cramps, with or without diarrhea. Regular contractions or uterine tightening. Fetal Prospective Survival Insufficient Power Sufficient power and coordinated contractions are essential for a smooth uncomplicated labor. Weak power of the contractions or the pattern of contractions disorganized, the mother is more likely to become exhausted. This can cause fetal distress resulting in fetal harm and/or c-section. Causes of insufficient power or improper contractions: Disordered uterine action Colicky uterus Constriction ring - bandl's ring Rigid cervix Edematous cervix Annular detachment Passage Way Obstructions (pelvic, uterine, cervix,) complicate birthing process. Tumors Cysts Fractures Subluxations Flat male-like pelvis (android) Physiological changes (degenerative joint disease, tuberculosis, rickets, osteomalacia) Incompetent Or Weakened Cervix? Previous surgery on the cervix Damage during a difficult birth Malformed cervix or uterus from a birth defect Previous trauma to the cervix, such as a D&C (dilation and curettage) from a termination or a miscarriage. DES (Diethylstilbestrol) exposure. Toxoplasmosis Contracted by eating infected, undercooked meat,contaminated fruit or vegetables. If had cats for some time, may have already been exposed to toxoplasmosis and developed immunity to it. Fatigue Fever Swollen lymph nodes Prevention: Avoid exposures to cat feces. Do not give your cat raw meat. Wash hands thoroughly after contact with cat or contact with raw meat. Keep counters clean and cook meat thoroughly. When eating out, order meat well done. Good hygienic measures prevent transmission. Diagnostic tests: Routinely screen for toxoplasmosis immunity before pregnancy or during the first prenatal visit. Blood test - determine if exposed. If present during pregnancy, treatment with antibiotics given for several months to reduce the risk of severe damage to the baby. Cordocentesis - test that determine whether an infection has occurred during pregnancy. Aging placenta Post term pregnancy 3x more likely to cause death of the baby. The treatment is to induce labor before problems start to occur. Fetal Danger Signs Maternal Danger Signs Fetal Danger Signs Meconium Staining Green color in the amniotic fluid Hypoxia Vagal Reflex Stimulation Increased Bowel Motility Loss of Sphincter Control Maternal Danger Signs Abnormal Pulse > 100 bpm indication of hemorrhage. Inadequate or Prolonged Contractions Exhaustion (inertia) Less Frequent Less Intense Shorter in duration Longer than 70 minutes may interfere with adequate uterine artery filling. Pathologic Retraction Ring Indentation across a womans abdomen. Upper and lower segment of the uterus join. Extreme uterine stress. Impending uterine rupture. Abnormal Lower Abdominal Contour Due to full bladder during labor. Bladder may be injured by the pressure of a fetal head. Pressure of a full bladder may not allow the fetal head to descend. Increasing Apprehension Warnings of psychological danger Needs to be investigated for physical reasons Oxygen deprivation Internal hemorrhage