antepartal tests and complications of pregnancy

birth equity

- Focus on redressing structural racism and social determinants through systems-level initiatives to improve maternal and infant health.

- Toxic stress exists among black community.

- Suggestions of strategies as first steps in reversing historical patterns of poor sexual and reproductive health outcomes are ideal among black women.

responses to high risk pregnancy

•Stress and anxiety exist about the maternal illness and its effect on the fetus, and the disruption to their home- and work-related activities.

•Threats to self-esteem; the woman may feel she has somehow failed as a woman and/or is failing as a mother. Self-blaming commonly occurs for real or imagined wrongdoing.

•Disappointment and frustration often occur when goals of having a healthy pregnancy, a normal birth, and a healthy baby are impeded by a pregnancy complication.

•Conflict can occur when competing and opposing goals are present during high-risk pregnancy.

•Crisis occurs when the woman and her family are threatened by a pregnancy complication and an uncertain outcome.

nursing actions for gestational comp

•Provide time for the woman and family to express their concerns and feelings. Practice active listening.

•Provide information repeatedly with the patient and significant other(s) to facilitate a realistic appraisal of events.

•Facilitate referrals related to the condition.

•Encourage the woman and her family to participate in decision-making and express preferences to enhance autonomy and patient-centered care.

•Consistently noted nurses play an invaluable role in leading and supporting efforts to increase access to care for all women.

•Nurses should be aware of barriers that affect health-care access and strive to reduce disparities through advocacy work with organizations.

•Nurses can also provide support, information, and referrals to women from underserved communities.

•Make efforts to meet their needs and desires. Communication and shared decision-making improve outcomes.

•If patient is hospitalized, have flexible guidelines for the family to minimize separation.

•Be a skilled communicator.

•Be a witness to events.

pre term labor

•Regular contractions of the uterus resulting in changes in the cervix before 37 weeks gestations

pre term birth

•birth between 20 0/7 and 37 0/7 weeks of gestation

- high risk for comp of neonate

- medically indicated vs non medically indicated

four major causes leading to ptl

1.Excessive uterine stretch or distention

2.Decidual hemorrhage (abruption)

3.Intrauterine infection

4.Maternal or fetal stress - placental insufficiency, cervical insufficiency, cervical remodeling

managing ptl: suppresing uterine activity (tocolytics)

- magnesium sulfate

- terbutaline

- indomethacin: nsaids

- nifedipine

- its not my time

magnesium dose

• 4-6 gm loading dose over 20 min, then 1-4gm/hr

• can cause flushing, hot flashes, n/v

• adverse: flash pulmonary edema

what is reversal agent for magnesium toxicity

calcium gluconate

terbutaline dose

0.25mg SQ q 3 hrs

indomethacin dose

NSAIDs 100 mg PR, then PO q 6-8 hrs

nifedipine dose

• 30 mg loading dose, 10-30 mg q 4-6 hr

• prevents calcium from entering muscle (prevents contraction)

promoting fetal lung maturity

• Betamethasone (Celestone): Antenatal glucocorticoids → given to mom

- 12.5mg IM, repeat x1 in 24 hours

- Administered between 24 -34 weeks gestation

predicting spontaneous preterm labor

•History of PTL

•Fetal fibronectin (fFN): test cervical secretions, if present-> potential for PROM, PTL → placenta starting to detach

•Cervical Length - <30 increases risk

premature rupture of membranes

•Rupture of amniotic sac and leakage of fluid at least 1 hour before onset of labor

- confirm: ferning, pooling, amniosure

- obtain sample of fluid for lung maturity testing

comp prom

chorioamnionitis (infection in placenta), prolapsed cord

prolonged rom

- ruptured over 24 hrs

preterm rupture of memebranes (pprom)

•Membranes rupture before 37 weeks gestation

risk pprom

•Infection is major risk factor

•History of conization or cerclage (weak cervix)

•Low socioeconomic status, low body mass index, nutritional deficiencies, smoking

causes pprom

•Pathologic weakening of amniotic membranes

•Inflammation

•Stress from uterine contraction

comp pprom**

-Chorioamnionitis* most common complication

managing prom/pprom

• Based on gestational age:

• Late Preterm (34 0/7 to 36 6/7): induction or c section, single course steroids, looks for s/s infection

• Preterm (24 0/7 to 33 6/7): day course antibiotics, steroids, gbs swab, mg sulfate infusion for neuro protection for baby

• Periviable (Less than 23 to 24 weeks): patient counseling, antibiotics as early as 20 weeks, steroids and tocolytics

nursing actions managing prom/pprom

- assess fhr

- contractions

- s/s infection

- fetal and labor comp

- vag bleeding

- antenatal testing

s/s chorio

- fetal tachycardia

- fundal tenderness

etiology cervical insuf

•Impaired cervical strength

• short cervical length

dx cervical insuf

•OB history of preterm births or late miscarriages

managing cervical insuf

cerclage

f/u care cervical insuf

•Close monitoring of pregnancy

•Report sign/symptoms of preterm labor

tx for incompetent cervix

•Cervical cerclage: stitching cervix shut to prev from opening too early during preg

•Prophylactic cerclage placed at 13-14 wks

•Rescue cerclage at 16-24 wks

•Removed at 36-37 wks

key fx multiple gestation

Multiple gestations are considered high-risk pregnancies because of the increased risk of complications the mother and/or fetuses can experience

twin to twin transfusion syndrome

• A complication of monochorionoic twins (share same placenta)

• Vascular connections in the placenta (artery to artery, vein to vein, artery to vein)

  • Imbalance of blood flow

  • One twin receives more blood flow, and the other twin receives less blood flow

• without intervention fetal death occurs 90% of the time in one or both fetuses

nursing implications multiple gestation

•Hospitalization may be needed during the pregnancy

•Label monitor with letters to indicate which fetus "A, B, C, D...."

multiple gestations moms are at increased risk for

•Pulmonary edema

•Hyperemesis gravidarum

•Additional testing and fetal surveillance

•Preterm labor

- gestational DM

s/s Hyperemesis gravidarum

prolonged vomiting, weight loss, dehydration, electrolyte imbalances, ketosis, malaise, low BP

risk Hyperemesis gravidarum

• young age,

• nulliparity,

• BMI <18.5 or >25,

• low socioeconomic status,

• multiple gestation,

• deficiency in thiamine and vitamin B1,

• fetus with chromosomal abnormality

tx Hyperemesis gravidarum

- IVF for fluid or electrolyte imbalance

- antiemetics

- Vit B6 with doxylamine (Unisom),

- small freq meals, high protein

what is intrahepatic cholestasis of preg

liver is stressed -> increases bile acid production -> bile acid enters bloodstream

Intrahepatic cholestasis of pregnancy s/s

•pruritus (palms & soles)

•dark urine, light colored stools

•elevated serum bile acids (LFTS)

- jaundice

tx Intrahepatic cholestasis of pregnancy

• Ursodeoxycholic Acid,

• Benadryl,

• Monitor liver function (LFTs),

• Cool oatmeal baths,

• baking soda,

• delivery

comp Intrahepatic cholestasis

Birth Asphyxia - meconium delivery, stillbirths and preterm birth bc increased levels of fetal serum bile acids

key fx diabetes

•The most common endocrine disorder associated with pregnancy

•Pregnancy complicated by diabetes considered high risk

•Diabetes can be successfully managed with a multidisciplinary approach

key to optimal outcome diabetes

strict glucose control*

pregestational dm

•Occurs in women who have preexisting disease (TYPE I or TYPE II)

•Sometimes complicated by vascular disease, retinopathy, or nephropathy

•Almost all of these patients are insulin-dependent

gestational dm

•any degree of glucose intolerance with onset or recognition during pregnancy

acute comp dm

- Hypoglycemia (insulin shock): Rapid onset

- Diabetic ketoacidosis (DKA): slow onset

- Preeclampsia

birth comp dm

- Preterm Delivery

- Preeclampsia (Eclampsia, HELLP)

- Birth Trauma

- Should Dystocia

- Fractured Clavicles

- Cesarean Deliveries

insulin requirements during trimesters

1: decreased insulin requirement bc of hormones

2: increased bc hormones start to increase

3: insulin double or triple requirement

- after : insulin needs drop significantly, breastfeeding helps

risk gdm

•No known risk factors are identified in 50% of cases

•History of fetal macrosomia

•Strong family history of diabetes

•Obesity

•Physical inactivity

•Previous Hx of GDM

•PCOS

•HTN

assesment findings gdm

•4 Ps

•Blurred vision

•Frequent UTIs

•Excessive fatigue and hunger

•Recurrent yeast infections

•Sudden weight loss

•Episodes of hypoglycemia

screening tool for gdm

- gold standard

- 1 hr (50 g) oral glucose tolerance test

- if negative (< 130-140)→ routine prenatal care

- if positive (> 130-140) → 3 hr (100g) test (fasting then drink and check bs q hr)

positives of 3hr glucose test ranges

- two or more values are met

- fasting: 95

- 1hr: 180

- 2hr: 155

- 3 hr: 140

gdm self management and education

•Self Glucose monitoring

•Diet & Exercise

•Oral Medications- 25-50 % of GDM will need medication

•May need Insulin Injections

•Determination of birth date and mode of birth

key fx gdm postpartum

- Encourage Breastfeeding: lactose in the milk requires glucose for synthesis

- Weight loss after delivery will reduce insulin resistance

- Most return to normal

- High risk for future GDM in pregnancy

- Increased risk of type 2 diabetes

- Reassess at 6-12 weeks

gestational htn

•Onset of hypertension without proteinuria after 20 wks gestation

preeclampsia

•Pregnancy-specific syndrome

•Hypertension develops after 20 wks gestation in previously normotensive women

•Vasospastic systemic disorder categorized as mild or severe

eclampsia

•Seizure activity or coma in woman diagnosed with preeclampsia

•No history of pre-existing pathology

•Eclamptic seizures can occur before, during, or after birth

chronic htn d/o

- chronic htn

- chronic htn w superimposed preeclampsia

chronic htn

•Hypertension in a pregnant woman present before pregnancy

chronic htn w superimposed preeclampsia

•Chronic hypertension (b4 pregnancy)in association with preeclampsia

risk fx preeclampsia

•Nulliparity

• Maternal age older than 35 years

• Prepregnancy obesity BMI greater than 30

• Multiple gestation

• Family history of preeclampsia

• Chronic hypertension, kidney disease, systemic lupus, thrombophilia, antiphospholipid syndrome, or diabetes before pregnancy

• Previous preeclampsia or eclampsia

• Gestational diabetes

• Assisted reproduction

risk to mom preeclampsia

•Cerebral edema, hemorrhage, or stroke

• Disseminated intravascular coagulation (DIC)

• Pulmonary edema

• Congestive heart failure

• Maternal sequelae resulting from organ damage include renal failure, HELLP syndrome, thrombocytopenia and disseminated intravascular coagulation, pulmonary edema, eclampsia (seizures), and hepatic failure

• Abruptio placenta

•Heart disease

risk to baby preeclampsia

- Consequences ofuteroplacental ischemia include fetal growth restriction, oligohydramnios, placental abruption, and nonreassuring fetal status. Therefore, fetuses of women with preeclampsia are at increased risk of spontaneous or indicated preterm delivery.

• Fetal intolerance to labor due to decreased placental perfusion

• Stillbirth

assessment findings preeclampsia

•Elevated BP

•Proteinuria may or may not be present (ACOG)

•Elevations in liver function tests, diminished kidney function, altered coagulopathies

•Edema

assessment tool for preeclampsia

SPASMS

- significant bp changes occur w out warning

- proteinuria is serious sign of renal involvement

- arterioles are affected by vasospasms that result in endothelial damage and leakage of intravascular fluid into interstitial space, edema results

- significant lab changes (most notable lfts and platelets) signal worsening of disease

- multiple organ systems can be involved: cv, hematology, hepatic, renal, cns

- s/s appear after 20 wks gestation

managing preeclampsia

- mg sulfate

- antihypertensives

- anticonvulsants

mg sulfate for preeclampsia

- contraindicationos: pulm edema, renal failure, myasthenia gravis

- prev eclampsia (seizures)

antihypertensives for preeclampsia

- for sbp >=160 or dbp >=110

- labetalol

- hydralazine

- nifedipine

anticonvulsants for preeclampsia

- for recurrent seizures or when mg is contraindicated

- lorazepam

- diazepam

assessments when on magnesium sulfate

•Continuous FHR and ctx monitoring

•q15-30 min: VS

•At least hr: LOC, I&O, urine output, proteinuria, DTR’s, s/s of h/a, visual disturbance, epigastric pain (UO must be >30/hr)

what needs to be available if giving mag sulfate

•Crash cart, resuscitative equipment at bedside, calcium gluconate available

pt education mag toxicity

•MgSo4 will cause initial flushing, feeling hot, sedated, nauseated. Notify if epigastric pain or trouble breathing

s/s mag toxicity

•DTRs- sluggish or absent, flaccidity/muscle weakness

•CNS depression

•Respirations <12/min

•Decreased urine output <25-30ml/hr

•Chest pain, EKG changes, Cardiac arrest, Pulmonary edema

labs mag sulfate toxicity (preeclampsia)

- Mag Level >8, Elevated liver enzymes (LFTs) and elevated renal function tests (BUN, Creatinine, albumin)

what do you do for mag toxicity

•Prepare to give Calcium Gluconate 10% 1G slow IVP (10ml over 3 minutes)

safety measures for preeclampsia

• Environment - Quiet, decrease stimulation, decrease lighting

• Seizure Precautions - Suction equipment, Oxygen equipment, Call button within reach, Crash cart nearby

• Emergency Medications

• Emergency Birth Pack

emergency meds preeclampsia

•Magnesium Sulfate

•Hydralazine, Labetalol, Nifedipine

•Calcium Gluconate

grading dtrs

-4+ very brisk, hyperactive, w clonus

-3+ brisker than avg, slightly hyperreflexic

- 2+ avg, expected response, normal

- 1+ somewhat diminished, low normal

- 0: no response, absent

what is eclampsia

• Seizure Activity in the presence of preeclampsia

• s/s: h/a, visual disturbances, DTR 4+

immediate care eclampsia

- Call for help, remain at bedside

- Maintain patient airway and safety during seizure

- Side rail up, protect pt, roll to side to prevent aspiration

post seizure care eclampsia

- Stabilize mother

- Suction as needed

- O2 non-rebreather 10 L/min

- VS, EFM

- Magnesium sulfate, diazepam, lorazepam

hellp syndrome

•H: Hemolysis

•EL: Elevated Liver enzymes

•LP: Low Platelets

- caused by preeclampsia

s/s hellp syndrome

•N&V, epigastric pain, RUQ pain, headache, blurred vision, malaise, increasing BP

cure for help

delivery of fetus**

placenta previa

•Previa or low-lying

s/s placenta previa

Abnormal placental attachment

Painless bright red bleeding in 2nd or 3rd trimester

dx placenta previs

abd us

managing placenta previa

- Observation

- No Vaginal Exams!

- Cesarean birth

nursing actions placenta previa

Performing assessment, monitor FHR, s/s of hemorrhage, IV access, anticipate C/S

placental abruption

•Premature separation of placenta from uterine wall (Abruptio placentae)

•Fetal mortality rate is 20%

s/s placental abruption

- Painful-board like abdomen

- Painful bleeding

- Uterine tenderness- feels like knife

- late decels

assessing placenta abruption

•Coagulation abnormalities (H&H, Platelets, D-Dimer,)

•Fetal blood can be found in maternal circulation or vaginal blood, check Kleihauer-Betke (KB)

•Ultrasound

managing placenta abruption

- Expectant: pad count, labs, IV, Foley

-Active: PREPARE FOR EMERGENCY C/S

what is placenta accrete spectrum

grows into layers of uterus

risk fx placenta accreta spectrum

•Women with myometrial damage caused by previous C/S, with placenta overlying the uterine scar

•Multigravida

•IVF

risk for mom placenta accrete spectrum

•Hemorrhagic and hypovolemic shock

•mortality

risk for baby pas

-ptb

assessment findings pas

•Diagnosed by ultrasound (placenta growing too deeply into uterine wall

•Postpartum hemorrhage

what is abortion

•Clinical Termination of pregnancy

classifications of abortion

- Induced: procedure or medication

- Elective: termination before viability at the request of the woman

- Therapeutic: termination for serious maternal medical indications or fetal anomalies

- Spontaneous

miscarriage

- loss of intrauterine pregnancy before viability