Maternal Newborn Nursing Study Notes

Essential Manifestations and Findings in Pregnancy

CNS:
- Headache - Often severe and persistent, not relieved by acetaminophen, a sign of cerebral edema or vasospasm.
- Dizziness - May indicate hypovolemia or orthostatic changes.
- Visual disturbances - Blurred vision, photophobia, scotoma (seeing spots or flashing lights), indicative of retinal arterial spasm.
Edema:
- Swelling in face and hands - Especially pitting edema, non-dependent edema, can be a sign of preeclampsia.
Gastrointestinal (GI) Tract:
- Any kind of abdominal pain - Epigastric or right upper quadrant pain, potentially indicative of liver distention in preeclampsia or HELLP syndrome, or uterine cramping/contractions.
Vital Signs:
- Increase in blood pressure (BP) - Hypertension, especially with values equal to or greater than $140/90$ mmHg.
- Increase in respiratory rate (RR) - May indicate respiratory distress or compensatory mechanism.
- Increase in pulse rate (PR) - Often a sign of hypovolemia, pain, or infection.
- Decrease in oxygen saturation (O2 sat) - Below $95\%$ requires immediate investigation and intervention.
- Increase in temperature (T) - Suggestion of infection.
- Excessive weight gain - More than $2$ kg (4.4 lbs) in a week, often due to fluid retention.
Abnormal Deep Tendon Reflexes (DTRs):
- Normal DTR: $+2$ (scale)
- Hyporeflexia: $0$ to $+1$
- Hyperreflexia: $+3$ (brisk, exaggerated, often indicative of preeclampsia), $+4$ (hyperactive with clonus, very concerning for severe preeclampsia/eclampsia).
Monitoring of Bleeding:
- Determine the amount and characteristics of bleeding - Quantify blood loss (e.g., weigh pads), note color (bright red vs. dark red) and presence of clots or tissue.

Nursing Priority for Bleeding in Pregnancy

Airway:
- Provide oxygen if needed - Maintain saturation >95\% using a non-rebreather mask.
Circulation:
- Administer fluids or blood transfusions if needed - Establish two large-bore IVs ( $18$ gauge or larger) for rapid fluid resuscitation with crystalloids (e.g., Normal Saline or Lactated Ringer's) and prepare for blood products (packed red blood cells).
- Correct hypovolemia by providing IV bolus of fluids and then a blood transfusion as necessary - Rapid infusion to restore intravascular volume.

Early Pregnancy Complications

Abortion Types:
- Threatened:
- Symptoms: Vaginal bleeding, mild cramping, closed cervix.
- Treatment: bed rest, pelvic rest (no intercourse), monitor hCG and progesterone levels.
- Inevitable:
- Symptoms: Vaginal bleeding, moderate cramping, cervical dilation, possible rupture of membranes.
- Can lead to complete or incomplete abortion
- Induced:
- Types include therapeutic (medical necessity) or elective (patient choice) abortion
- Missed:
- Symptoms: Fetus dies in utero but is not expelled; may have no symptoms or brown discharge.
- Determined by lack of heartbeat on ultrasound
- Ectopic Pregnancy:
- Symptoms: bleeding with unilateral pelvic pain or referred shoulder pain (diaphragmatic irritation from internal bleeding).
- Treatment:
  - Surgery if ruptured (laparoscopy for salpingectomy or salpingostomy in unstable patients or large/ruptured ectopic).
  - Methotrexate if not ruptured and the patient is stable - Systemic chemotherapy agent that inhibits cell division, used for unruptured ectopic pregnancies less than $3.5$ cm, with no fetal cardiac activity, and patient compliance for follow-up.
Hydatidiform Mole (Molar Pregnancy):
- Symptoms: bleeding (often dark brown, prune juice-like), hyperemesis gravidarum, and uterine enlargement (fundal height greater than expected for gestational age).
- Laboratory findings: hCG levels are higher than in normal pregnancy
- Ultrasound: shows snowstorm pattern (characteristic vesicular tissue)
- Treatment: Dilation and evacuation (suction curettage) - To remove molar tissue and prevent choriocarcinoma.
- Follow-up care: check hCG levels periodically for 6 months to 1 year until normal - To detect persistent trophoblastic disease; contraception is crucial during this period.
- Annual pelvic exams recommended

Late Pregnancy Complications

Placenta Previa (Abnormal Location of the Placenta):
- Types:
- Marginal (placenta is within $2.5$ cm of the internal os)
- Partial (placenta partially covers the internal os)
- Complete (placenta completely covers the internal os)
- Delivery method for partial and complete: C-section
- Symptoms: Painless, bright red bleeding - Occurs as the cervix dilates or effaces.
- Importance of ultrasound to locate placental location - Confirmatory diagnostic tool.
- Contraindication: No pelvic exam should be done if previa is suspected - Digital examination can stimulate contractions or cause further placental separation and hemorrhage.
- Treatment: Prepare for C-section if a term pregnant patient presents with profuse bright red vaginal bleeding - Management depends on bleeding severity, gestational age, and fetal status; may involve bed rest, IV fluids, and corticosteroid administration for fetal lung maturity if preterm.
- Monitoring: Signs of hypovolemic shock and postpartum infection
Placenta Abruptio (Premature Separation of the Placenta):
- Predisposing factors:
- Hypertension (most common)
- Gestational diabetes
- Multifetal pregnancy
- Early rupture of the bag of water
- Substance abuse (especially cocaine)
- Abdominal trauma (e.g., motor vehicle accident, domestic violence)
- Folate and iron deficiency
- Past history of abruption
- Symptoms: Painful dark red bleeding and a firm, board-like uterus (hypertonus).
- Additional symptoms: Back pain (if placenta implanted in posterior uterine wall)
- Treatment: C-section is often required - Immediate delivery is usually indicated due to fetal distress or maternal hemorrhage; may involve rapid IV fluid and blood product administration.
- Risks: Disseminated intravascular coagulation (DIC) - Due to widespread activation of clotting cascade and consumption of clotting factors.
- Monitoring: Internal and external bleeding, signs of hypovolemic shock, fetal heart rate monitoring for distress.

Pregnancy-Related Complications

Hypertension in Pregnancy:
- Chronic Hypertension:
- Pre-existing hypertension in pregnant women (diagnosed before pregnancy or before $20$ weeks gestation).
- Gestational Hypertension:
- Elevated blood pressure (equal to or greater than $140/90$ mmHg) during pregnancy without proteinuria and/or edema (diagnosed after $20$ weeks gestation, resolving by $12$ weeks postpartum).
- Additional Monitoring:
- Non-Stress Test (NST) or Biophysical Study for fetal well-being starting at 28 weeks for high-risk pregnancies.
Preeclampsia (Toxemia of Pregnancy):
- Key symptoms:
- Increased blood pressure (equal to or greater than $140/90$ mmHg) and proteinuria (equal to or greater than $+1$ on dipstick or $300$ mg in a $24$ -hour urine collection) occurring typically after $20$ weeks.
- Edema in face and hands (non-dependent, pitting edema).
- Headache (persistent, severe, fronto-occipital).
- Visual disturbances (blurred vision, scotoma, photophobia).
- Abdominal or epigastric pain (right upper quadrant pain, indicative of liver capsule distention).
- Nausea and vomiting.
- Hemolysis (part of HELLP syndrome).
- Laboratory findings:
- Decreased platelets (less than $100,000$ /mm $^3$ ).
- Elevated liver enzymes (ALT and AST greater than twice the upper limit of normal).
- Abnormal kidney function (elevated creatinine and uric acid).
- DTRs: $+3$ (Hyperreflexia) or $+4$ (with clonus).
- HELLP Syndrome:
- Acronym: Hemolysis (microangiopathic hemolytic anemia), Elevated liver enzymes (due to hepatocellular dysfunction), Low platelet (due to platelet consumption and vasoactivated endothelium). A severe variant of preeclampsia.
- Treatment options:
- Medications:
  - Labetalol - Beta-blocker, used to manage severe hypertension by reducing peripheral vascular resistance without significantly altering heart rate.
  - Magnesium sulfate (to prevent seizure/eclampsia) - A CNS depressant and vasodilator that reduces neuromuscular irritability and relaxes smooth muscle. Administered often as an IV loading dose followed by continuous infusion.
  - Therapeutic level: $4$ to $8$ mg/L
  - Monitoring: BURP (Blood pressure, Urine output, Respiratory rate, Patellar reflex or DTRs). Assess for signs of magnesium toxicity such as decreased DTRs, respiratory depression (<12 breaths/min), decreased urine output (<30 mL/hr), and hypotension.
  - Calcium gluconate as antidote for toxicity (administer $10$ mL of $10\%$ solution IV push over $3$ minutes).
  - Caution: Magnesium sulfate can cause uterine relaxation, leading to postpartum uterine atony and hemorrhage - Closely monitor for uterine tone and bleeding after delivery.
- Delivery of the fetus - Only definitive cure for preeclampsia.
- Nursing Care for Preeclampsia:
- Instruct the patient to monitor CNS (headache, visual changes) and GI (epigastric/RUQ pain) manifestations.
- Instruct the patient to monitor fetal movements (fetal kick counts).
- Maintain a quiet, dark environment, limit visitors, implement seizure precautions.

Rh Incompatibility

Implication for Rh-negative mothers - If the mother is Rh-negative and the fetus is Rh-positive, fetal RBCs can enter maternal circulation, stimulating antibody production in the mother. These antibodies can then attack future Rh-positive fetal RBCs, leading to erythroblastosis fetalis or hydrops fetalis.
Testing:
- Indirect Coombs’ test checks for isoimmunization or presence of anti-Rh antibodies in the mother. If positive, it indicates sensitization and further monitoring is needed; if negative, Rhogam is indicated.
Rhogam Administration:
- Given at $28$ weeks of pregnancy as prophylaxis.
- Within $72$ hours post-delivery if the newborn is Rh-positive.
- Also administered after amniocentesis, chorionic villus sampling (CVS), external cephalic version, abdominal trauma, or if there is bleeding during pregnancy before $28$ weeks - Any event that might allow fetal blood cells to enter maternal circulation.
- Prevents the formation of Rh antibodies in Rh-negative mothers by binding to fetal Rh-positive cells in maternal circulation, thereby blocking the mother's immune response.

Gestational Diabetes

Screening:
- Conducted between $24$ to $28$ weeks of pregnancy with a $1$ -hour (non-fasting) glucose challenge test, followed by a $3$ -hour oral glucose tolerance test (OGTT) if the $1$ -hour result is elevated.
- Earlier screening for higher-risk women (e.g., obesity, history of GDM, family history of diabetes).
Monitoring:
- Postprandial glucose goal: $140$ mg/dL or less 1 hour postprandial, or $120$ mg/dL or less 2 hours postprandial. Fasting glucose target: $95$ mg/dL or less.
- Treatment: If uncontrolled by diet and exercise, initiate insulin therapy - Insulin does not cross the placenta; oral hypoglycemics like glyburide or metformin may be used in some cases.
- Importance of diet and exercise - Medical Nutrition Therapy (MNT) is the cornerstone of GDM management; focus on complex carbohydrates, adequate protein, and healthy fats. Moderate exercise ( $30$ minutes most days of the week) helps improve glucose utilization.
- NST or Biophysical study for fetal well-being starts at $28$ weeks - To monitor for macrosomia, polyhydramnios, or fetal distress.
Risk Post-Gestational Diabetes:
- $15\%$ to $50\%$ risk of developing Type 2 diabetes later in life - Encourage lifelong healthy lifestyle and regular screening for Type 2 diabetes.
Newborn Monitoring:
- Watch for hypoglycemia immediately after birth, especially if the mother's blood glucose was poorly controlled. Additional risks for the newborn include macrosomia, hyperbilirubinemia, respiratory distress syndrome, and hypocalcemia.

Hyperemesis Gravidarum

Dietary Recommendations:
- Crackers (dry, bland foods), ginger (ginger ale, ginger candy), and vitamin B6 can alleviate symptoms. Avoid fatty, spicy, or strong-smelling foods.
Monitoring:
- Signs and symptoms of dehydration (decreased urine output, dry mucous membranes, poor skin turgor, orthostatic hypotension, electrolyte imbalance, ketonuria).
- Encourage small frequent meals and sips of fluid - Every 1-2 hours to prevent an empty stomach.
- Advise against getting full - Overeating can exacerbate nausea.
- May require IV hydration and antiemetics in severe cases.

Fetal Alcohol Spectrum Disorder (FASD)

Awareness of features of a newborn with FASD - Facial dysmorphology (small palpebral fissures, smooth philtrum, thin upper lip), growth restriction, CNS abnormalities (intellectual disability, developmental delays, behavioral problems).

Effects of Smoking During Pregnancy

Risks include autism, fetal growth retardation (IUGR), and abruptio placenta. Also increased risk of preterm birth, low birth weight, Sudden Infant Death Syndrome (SIDS), and respiratory problems for the child.

Iron Deficiency Anemia

Risks: Can cause preterm birth, intrauterine growth restriction (IUGR), low birth weight; instruct the patient to monitor for uterine contractions (sign of preterm labor).
Dietary Considerations:
- Know foods rich in iron (e.g., red meat, poultry, fish, fortified cereals, legumes, dark leafy greens).
- And those that enhance iron absorption (e.g., citrus fruits, tomatoes, strawberries, rich in Vitamin C). Avoid consuming iron with milk, tea, or coffee, as these inhibit absorption.
Lab Tests:
- Hemoglobin/hematocrit, ferritin (best indicator of iron stores), serum iron, total iron-binding capacity (TIBC).

Group B Streptococcus (GBS) Infection

Screening:
- Conducted at $36$ weeks via vaginal and rectal swab - To identify asymptomatic carriers.
Treatment:
- If positive, administer IV antibiotics (Penicillin or Ampicillin) during labor - At least $4$ hours before delivery for adequate prophylaxis to prevent early-onset GBS disease in the newborn.
Risks:
- Can cause maternal perinatal infection (chorioamnionitis, postpartum endometritis) and infection in the newborn (sepsis, pneumonia, meningitis).

Hepatitis B in Pregnant Women

If mother is positive:
- Newborn should receive Hepatitis B Immune Globulin (HBIG) and the first dose of the Hepatitis B vaccine within $12$ hours of birth - To provide immediate passive immunity and initiate active immunity, preventing vertical transmission.

Other Important Notes

Review nursing actions for each condition mentioned.
Amniocentesis Considerations (refer to ATI Book pages 33-34):
- Importance of providing factual statements to alleviate client anxiety. Example: "This procedure involves inserting a needle into the uterus to withdraw amniotic fluid for genetic testing."
- Avoiding non-therapeutic reassurances (e.g., "don't worry," "everything will be fine").
- Nurses should not predict outcomes before they happen.
Lecithin and Sphingomyelin (L/S) Ratio:
- Know the normal ratio relation to fetal lung maturity enhancement medication. An L/S ratio of $2:1$ or greater indicates fetal lung maturity. If the ratio is low, corticosteroids (e.g., betamethasone) may be administered to the mother to accelerate fetal lung development.
Maternal Alpha-Fetoprotein and L/S Ratio Interpretation (refer to ATI Book page 34).
Biophysical Profile:
- Focus on total score findings (refer to ATI Book pages 30-31). *A score of $8-10$ is normal, $6$ is equivocal, and $0-4$ is abnormal and