Lecture Thirteen: Care of the Client Experiencing Dysfunctional Childbirth, Endocrine, Metabolic and Cardiac Dysfunction

1. Lecture Thirteen: Care of the Client Experiencing Dysfunctional Childbirth, Endocrine, Metabolic and Cardiac Dysfunctions in Pregnancy, Maternal Hemorrhage, and Perinatal Infection. NURS 2208 T. Dennis RNC, MSN

2. Objectives Identify stressors related to dysfunctions in the maternity client. Utilize knowledge of pathophysiology of disease processes to care for maternity clients with dysfunctions. Utilize the nursing process to meet the needs of maternity clients with dysfunctions. Assess comfort, physical safety, fluid and electrolyte, nutrition, emotional safety and security, love and belonging needs of maternity clients. Apply principles of teaching /learning in the promotion and restoration of optimal health in maternity clients. Identify the purposes, actions, side effects of medication utilized in the care of maternity clients with dysfunctions. Incorporate therapeutic nutrition in the care of the maternity client with dysfunctions.

3. Dysfunctional Childbirth Rh Sensitization ABO Incompatibility Surgery During Pregnancy Trauma The Battered Pregnant Woman Precipitous Birth Dystocia Anxiety and Fear Dysfunctional Uterine Contractions Precipitate Labor and Birth Postterm Pregnancy Fetal Malposition Fetal Malpresentation Developmental Abnormalities Multiple Pregnancy Fetal Distress Intrauterine Fetal Death Placental Problems Cephalopelvic Disproportion Umbilical Cord Problems Amniotic Fluid Related Complications Lacerations Placenta Accreta

4. Rh Sensitization (pg. 419-423) An antigen-antibody immunologic reaction within the body. Occurs when an event allows Rh positive fetal cells to enter the circulation of an Rh negative woman (Rh positive blood transfusion, amniocentesis, tubal pregnancy). Known antigens are controlled by three pairs of genes: Cc, Dd and Ee. An Rh negative mother whose fetus is Rh positive may develop anti D antibodies in response to the small amount of blood that may cross the placenta even in a normal pregnancy (< 0.5 ml). Exposure causes the development of gamma M immunoglobulin (IgM). IgM antibodies are large and do not cross the placenta. Once a woman is isoimmunized, she is immunized for life.

5. Rh Sensitization The secondary response is development of immune globulin G (IgG) anti-D antibody. IgG crosses the placenta coating the Rh positive cells and causing hemolysis. The hemolysis creates fetal anemia. The fetus responds by increasing red cell production of nucleated RBCs causing erythroblastosis fetalis. Erythroblastosis fetalis is a hemolytic disease of the newborn characterized by anemia, jaundice, enlargement of the liver and spleen, and generalized edema. Caused by isoimmunization from Rh incompatibility or ABO incompatibility.

6. Rh Sensitization Fetal-Neonatal Risks: Infant death due to hemolytic disease secondary to Rh incompatibility. RBC destruction leads to hyperbilirubinemia and anemia which leads to severe fetal edema called hydrops fetalis. Congestive heart failure may occur as well as icterus gravis leading to kernicterus. Rh sensitization is seen less due to the use of Rhogam ( Rh immune globulin. Given at 28 weeks gestation, after amniocentesis or an episode of bleeding and 72 hours post delivery.

7. Screening for Rh incompatibility and Sensitization First prenatal visit includes information concerning previous pregnancies. Maternal blood type (ABO) Rh factor and antibody screen An antibody screen (indirect Coomb�s test). Fetal assessment includes: percutaneous umbilical cord blood sampling (PUBS), amniocentesis, amniotic fluid analysis, and ultrasound. Fetal acites and subcutaneous edema may be seen on ultrasound. A sinusoidal pattern on fetal monitoring.

8. Clinical Therapy (pg 421) Goal is a mature fetus who has not developed severe hemolysis in utero. Antepartum management includes early delivery and intrauterine transfusion (fetal distress, fetal hematoma, fetal-maternal hemorrhage, fetal death and chorioamnionitis. Postpartal management: treat the unsensitized woman and isoimmune hemolytic disease in the newborn. RhoGam is given to destroy fetal cells in the maternal circulation before sensitization occurs, blocking antibody production. A Kliehauer-Betke test is performed to estimate the size of a fetomaternal bleed.

9. Nursing Care Management Nursing assessment to determine client�s knowledge base on blood type. Knowledge Deficit related to lack of understanding of the need for RhIgG and when it should be administered. Ineffective Coping related to depression secondary to development of indications of the need for fetal exchange instruction. Educate the client concerning times RhoGam is needed. Provide emotional support to client and family. Administer RhoGam as ordered. Evaluation includes the client understanding of the need for administration of Rhogam.

10. Rh Immune Globulin RhoGAM, Gamulin Rh, HyRho-D Action: Suppression of the immune response in non-sensitized women with Rh-negative blood who receive Rh positive blood cells because of fetomaternal hemorrhage, transfusion, or accident. Indications: Suppress antibody formation in women with Rh-negative blood after birth, miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, amniocentesis, version, or chorionic villi sampling. Dosage and route: Standard dose is 1 vial (300�g) IM gluteal or deltoid :microdose 1 vial (50�g) IM deltoid Adverse Effects: myalgia, lethargy, localized tenderness or stiffness at the injection site.

11. Nursing Considerations Give standard dose to mother within 72 hours of birth if baby is Rh positive, at 28 weeks gestation as prophylaxis, or after an incident or exposure risk that occurs after 28 weeks gestation (miscarriage, abortion, amniocentesis, after a version). Give microdose for first trimester miscarriage or abortion, ectopic pregnancy, chorionic villi sampling. Verify the client is Rh negative and has not been sensitized (that the Coombs test is negative) and that the baby is Rh positive. Provide explanation to the client about the procedure, including the purpose, possible side effects, and effect on future pregnancies. Have client sign a consent form per hospital/institution policy. Verify correct dosage, confirm lot number, and patient identity prior to injection. Verify with another RN and document.