Canadian Maternity, Newborn, and Women’s Health Nursing Chapter 13: High-Risk Pregnancy

1. Canadian Maternity, Newborn, and Women’s Health NursingChapter 13: High-Risk Pregnancy

2. Pregnancy Risk Assessment • Psychosocial • Economic • Nutrition-related • Family-related considerations

3. Health Complications in Pregnancy • Asthma • Labour: assess vital signs; shortness of breath, increased respiratory rate, inspiratory and expiratory effort, oxygen saturation • Asthma medicine; avoid Demerol or morphine • Aim for adequate respiratory function; ability to cope with labour and birth; verbalize understanding of and fetal well-being; consistency of care

4. Health Complications in Pregnancy (cont.) • Cystic fibrosis • Observe for signs of malabsorption; monitor maternal weight and pancreatic enzymes, fluid and electrolyte balance; assess results of laboratory testing; adequate oxygenation • Oral supplements, pulse oximetry, oxygen if required; breastfeeding permitted once sodium content has been determined

5. Health Complications in Pregnancy (cont.) • Cardiovascular disease • Types • Class I: angina during strenuous or prolonged activity • Class II: angina during vigorous activity • Class III: symptoms with daily activities • Class IV: symptomatic when resting

6. Health Complications in Pregnancy (cont.) • Cardiovascular disease (cont.) • Mitral stenosis • Mitral valve prolapse • Peripartum cardiomyopathy • Atrial septal defects

7. Health Complications in Pregnancy(cont.) • Cardiovascular disease (cont.) • Collaborative management: pregnancy • Physical examination, chest x-ray, ECG, blood gas analysis, echocardiogram • Activity restriction, rest, iron supplementation; monitoring of mother and fetus • Aim for adequate ventilation, tissue perfusion, hydration

8. Health Complications in Pregnancy(cont.) • Cardiovascular disease (cont.) • Collaborative management: labour and birth • Vital signs; fatigue, difficulty breathing or shortness of breath, palpitations, swollen feet • Reduce cardiac workload; goal is vaginal birth after 36 weeks’ gestation; hemodynamic monitoring, urine output, fetal monitoring

9. Health Complications in Pregnancy (cont.) • Anemia • Iron-deficiency anemia • Assess hemoglobin, hematocrit, serum ferritin, free erythrocyte protoporphyrin • Dietary review; prenatal vitamins, adequate iron; financial discussion regarding affordable diet

10. Health Complications in Pregnancy (cont.) • Anemia (cont.) • Sickle cell anemia • Health history, blood count, reticulocyte count, blood urea nitrogen, glucose, direct bilirubin, urinalysis • Folic acid supplementation • Sickle cell crisis: acute episode of vascular occlusion

11. Health Complications in Pregnancy (cont.) • Autoimmune diseases • Systemic lupus erythematosus • Frequent prenatal visits; monitor renal function, blood pressure, fetal health • Corticosteroid therapy • Labour: blood pressure, edema, proteinuria, urine output, cardiac monitoring, lung sounds, blood counts, fetal monitoring • May need cesarean delivery

12. Health Complications in Pregnancy (cont.) • Autoimmune diseases (cont.) • Antiphospholipid syndrome • Recurrent spontaneous abortions, unexplained pregnancy loss in second or third trimester, venous thrombosis, arterial thrombosis, stroke, SLE, autoimmune thrombocytopenia, prolonged clotting assay • Treatment: prednisone with low-dose aspirin; low-molecular-weight heparin

13. Health Complications in Pregnancy (cont.) • Infections • HIV: test during pregnancy for early diagnosis and treatment of newborn • Teach risks and benefits of care; determine level of knowledge about disease; plan for the newborn • Assess emotional state and ability to cope • Goal is to reduce maternal viral load before delivery; might have cesarean birth

14. Health Complications in Pregnancy (cont.) • Infections (cont.) • HIV (cont.) • Therapy: start antiretroviral drug during pregnancy; give intravenously during labour and birth • Test for HIV in newborn; ongoing medical treatment will be an extension of the care started during pregnancy

15. Health Complications in Pregnancy (cont.) • Infections (cont.) • Sexually transmitted infections (STIs) • Prenatal care: inquire about sexual activity, previous STIs, risk factors • Physical examination • Screening, treatment, and follow-up throughout pregnancy

16. Health Complications in Pregnancy (cont.) • Infections (cont.) • Group B streptococcus • Prenatal: swab at 35 to 37 weeks; if positive, need antibiotics at least 4 hours before birth • Rubella • Screen for rubella immunity at first prenatal visit; if no immunity, counsel to avoid contact with children who have not been immunized

17. Question • A client develops a rash on her face, and rubella is suspected. Which transmission-based precautions would the nurse use when caring for this client? • Contact precautions • Droplet precautions • Airborne precautions

18. Answer b) Droplet precautions • Transmission of rubella is by droplet. Symptoms of rubella infection include a rash that may or may not be itchy that begins on the face and progresses to the trunk.

19. Health Complications in Pregnancy (cont.) • Infections (cont.) • Toxoplasmosis: thorough cooking of meat; avoid cat feces; use gloves when gardening; treat with spiramycin • Cytomegalovirus: avoid contact with children in daycare or health care settings; encourage frequent hand washing • Parvovirus: transmission by inhaled particles, hand-to-mouth contact, contaminated blood

20. Health Complications in Pregnancy (cont.) • Renal and urinary problems • UTIs and pyelonephritis • Recognize difference between UTI and normal pregnancy changes • Pyelonephritis: costovertebral angle tenderness, high fever, chills, myalgia, nausea, vomiting • Antibiotics and antimicrobial agents • Hygiene: wipe from front to back after urination and intercourse; extra fluid intake; cotton underwear

21. Health Complications in Pregnancy (cont.) • Renal and urinary problems (cont.) • Acute renal failure • Sudden decrease in renal function • Thorough health history and physical examination; vital signs; blood count, electrolytes, coagulation profile • Fetal monitoring

22. Health Complications in Pregnancy (cont.) • Diabetes mellitus • May be pre-existing or gestational • Potential nursing diagnosis • Anxiety • Deficient knowledge • Risk for ineffective health maintenance • Imbalanced nutrition • Ineffective coping

23. Health Complications in Pregnancy (cont.) • Diabetes mellitus (cont.) • Review or teach blood glucose self-monitoring • Promote diet management • Encourage activity and exercise • Administer insulin • Monitor the fetus • Provide care during labour and birth

24. Psychosocial Disorders and Problems • Depression • Changes in mood, sleep patterns, appetite, weight; feelings of helplessness • Counselling, medications • Bipolar disorder • Cyclic patterns of depression and mania • Medications may be teratogenic

25. Psychosocial Disorders and Problems (cont.) • Intimate-partner violence • May begin or increase during pregnancy • Screen for suggestive indicators • Nonthreatening, nonjudgemental approach • SOS: Screen, Offer options, Safety

26. Psychosocial Disorders and Problems (cont.) • Intimate-partner violence (cont.) • Potential nursing diagnoses: • Fear • Anxiety • Chronic pain • Deficient knowledge • Pain • Impaired parenting

27. Psychosocial Disorders and Problems (cont.) • Intimate-partner violence (cont.) • Emergency safety plan; treat with respect and dignity; one-to-one nursing care • Provide encouragement and support; information about community resources and shelters; ensure safety and well-being of mother and fetus

28. Psychosocial Disorders and Problems (cont.) • Substance use • Tobacco, alcohol, marijuana, cocaine, alcohol, opioids • Methadone treatment in perinatal period • Eating disorders • Anorexia, bulimia

29. Obesity and Pregnancy • Obesity • Increased risk of hypertension, vascular disease, diabetes, cesarean birth • Increased risk for fetal anomalies

30. Gestational Complications • Hyperemesis gravidarum • Severe nausea and vomiting • Many theories regarding etiology • Assess history, weight; complete blood count, electrolytes, liver enzymes, thyroid and bilirubin levels, urine for ketones and protein • Monitor intake and output; nutritional counselling

31. Gestational Complications (cont.) • Hypertensive problems • Diastolic higher than 90 mm Hg • Pre-existing hypertension • Gestational hypertension • With comorbid conditions (diabetes, renal disease) • With preeclampsia (after 20 weeks, with proteinuria)

32. Collaborative Care: The Pregnant Client With Hypertension • Monitor blood pressure, urine output, protein in urine, neurologic signs, renal function, edema, headaches, blood counts, liver function tests • Fetal assessment: movement counts, nonstress tests, biophysical profile, Doppler studies • Potential nursing diagnoses: anxiety, ineffective health maintenance, pain, risk for compromised family coping, social isolation • Risk for seizures • Pharmacologic treatments

33. HELLP Syndrome • Hemolysis, elevated liver enzymes, low platelet count • Epigastric pain, nausea and vomiting • Hemolytic anemia, hepatic dysfunction • Critically ill

34. HELLP Syndrome (cont.) • Management depends on gestational age, maternal health, fetal status • Ongoing monitoring of reflexes, intake and output, BP, fetal heart rate • Antihypertensive therapy • Magnesium sulfate to prevent seizures

35. Question • A pregnant client is showing severe signs of gestational hypertension. What would the nurse expect when testing the client’s reflexes? • Hyperreflexia • Normal reflexes • Absence of reflexes

36. Answer a) Hyperreflexia • Neurological signs are very important to monitor when caring for a client with gestational hypertension. A client may present with brisk reflexes or hyperreflexia.

37. Preterm Premature Rupture of Membranes • Premature rupture of membranes (PROM) • Preterm premature rupture of membranes (pPROM): before 37 weeks • Risk factors: nutritional deficiencies, substance use, multifetal pregnancy, infections, trauma • Risk for chorioamnionitis, preterm birth, intrauterine death, amniotic band syndrome

38. Collaborative Care: Preterm Premature Rupture of Membranes • Potential nursing diagnoses: constipation, anxiety, fatigue; risk for infection, maternal/fetal injury, deficient fluid volume; • Maternal vital signs, fetal heart rate, abdominal palpation, inspection of perineal area, Nitrazine and fern tests • Bed rest; assess for fever, chills, change in amniotic fluid; uterine contractions and fetal heart rate; assess amniotic fluid for lecithin/sphingomyelin ratio

39. Cervical Insufficiency/Incompetence • Cervical insufficiency (painless cervical dilation) can progress to pPROM and preterm birth • Risk factors: history of excessive cervical dilation for curettage or biopsy; previous cervical lacerations during childbirth; cervical or uterine anomalies • Cerclage: suturing early in second trimester helps prevent cervical relaxation and dilation

40. Disseminated Intravascular Coagulopathy • Complex coagulation disorder • Complete blood count, prothrombin time, activated partial prothrombin time, fibrinogen, fibrin degradation products, d-dimer • Monitor vital signs, oxygen saturation, blood pressure, pulse; replace blood volume; blood products, coagulation components; cardiovascular and respiratory support

41. Placental Alterations • Placenta previa • Placenta implants in lower uterine segment • Risk factors: previous cesarean, previous placenta previa, uterine anomalies • Complications: coagulopathy, postpartum hemorrhage • Anticipate cesarean birth; blood administration

42. Placental Alterations (cont.) • Invasive placenta • Placenta implants into myometrium; doesn’t separate after birth • Complications: hemorrhage • Anticipate cesarean birth; blood administration • Circumvallate placenta

43. Question • A pregnant client has an ultrasound indicating the placenta extends up to the internal os but is not covering it. As the client’s nurse, you would classify this as which type of placenta previa? • Type I • Type II • Type III • Type IV

44. Answer b) Type II • As her nurse, you should classify the condition as Type II placenta previa. Type II placenta previa is marginal implantation and includes the lower edge of the placenta extending to but not covering the internal os.

45. Placental Alterations (cont.) • Placental abruption: placenta separates from uterus; bleeding may be visible or concealed • Risk factors: hypertension; cocaine, alcohol, tobacco use; abdominal trauma • Vaginal bleeding, pain in abdomen or back, uterine tenderness and rigidity • Goal is stabilization; delivery method depends on risk for hemorrhage and risk for fetus

46. Collaborative Care: The Pregnant Adolescent • Assess teen’s social support system • Potential nursing diagnoses: fatigue, deficient knowledge, situational low self-esteem; risk for ineffective health maintenance, imbalanced nutrition, delayed growth and development

47. Collaborative Care: The Pregnant Adolescent (cont.) • Provide information about options • Educate about procedures, processes, risks, benefits; refer to community nursing, social services for psychosocial support • Collaborate with health care providers to determine care plan

48. Multiple Pregnancy • Increased potential for abnormalities, prematurity • Assess by ultrasound: gestation, fetal growth, amniotic fluid volume • Nutritional considerations; activity may need to be restricted

49. Multiple Pregnancy (cont.) • Potential nursing diagnoses: anxiety, fear, constipation, imbalanced nutrition, ineffective health maintenance, deficient knowledge, compromised family coping • Teach symptoms of preterm labour; prepare for emotional, financial, practical stresses • Movement counts, Doppler studies, biophysical profiles, NST

50. Perinatal Loss • Early pregnancy loss • Ectopic pregnancy: implantation outside the uterus • Gestational trophoblastic disease: proliferation and degeneration of trophoblastic villi • Late pregnancy loss • Stillbirth: fetal death at >20 weeks, >500 g