OB High risk conditions in the Antepartum Period

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aclift
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OB High risk conditions in the Antepartum Period
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2013-12-01 22:40:24
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  1. Cardiac Disease
    Hemodynamic changes of pregnancy increase the workload of the heart; cardiac output increases 30-50% by mid-pregnancy

    A compromised heart may not be able to adapt to the added requirements of pregnancy
  2. What are the New York Heart Association's Classification of Heart Disease?
    • Class I: No limitation of activity
    • Class II: Slight limitation of activity
    • Class III: Considerable limitation of activity
    • Class IV: Symptoms present even at rest
  3. What is part of the assessment of a cardiac pregnant patient?
    • Edema
    • Anemia
    • Hypertension
    • Murmers/Palpitation
    • Diaphoresis
    • Chest pain
    •       Rest vs Exertion
    • Cough --> best indicator heart is in trouble!!!
    • Pallor
    • Syncope
    • SOB
    • Stress/Anxiety
    • Family Obligations
    • Support Systems
  4. What are the signs of cardiac decompensation
    • Progressive generalized edema
    • Crackles at the bases of lungs
    • Pulse irregularity
  5. What is the most common complication of heart disease during pregnancy?
    Congestive heart failure (CHF)
  6. What is the nursing care associated with a cardiac patient in L&D?
    EKG and FHR monitoring

    Oxygen by mask; pulse oximetry

    Pain management to reduce stress/decrease HR

    No intense pushing to prevent a vagal response

    No stirrups. Why?

    Forceps/vacuum usually required

    C/S only in OB emergency

    Avoid fluid overload

    No ergot meds such as methergine as it increases blood pressure

    Prevent endocarditis

    Cardiac monitoring X 48 hours
  7. What must a patient get before they are able to have an epidural?
    IV fluid bolus --> 1-2 L
  8. Does a pregnant cardiac patient continue her nitro and digoxin?
    YES
  9. What is used during pregnancy to reduce the risk of thrombus?
    Anticoagulants
  10. For mothers taking coumadin, what is usually perscribed and why?
    Heparin.

    Heparin doesn't cross the placenta
  11. What is given prophylactically to prevent endocarditis?
    Antibiotics
  12. Older clients are at greater risk of developing what cardiac conditions?
    ischemic cardiac disease and myocardial infarction
  13. What may influence how well a cardiac patient takes care of themselves at home?
    Cultural background affects the amount of support

    Role expectations
  14. Describe gestational diabetes and how it develops
    • Pregnancy created resistance to insulin in maternal cells
    • Why? --> to ensure fetus has enough glucose for growth and development
    • If pancreas cannot produce enough insulin to compensate, then maternal hyperglycemia or gestational diabetes occurs
  15. Why is there a potential for hypoglycemia in the infant of a diabetic mother (IOD)?
    Glucose crosses placenta to fetus

    High levels of maternal glucose stimulate fetal insulin production

    @ Birth, glucose supply from mom ends suddenly.. but baby is still producing high levels of own insulin

    High levels of fetal insulin and low levels of glucose CAN cause hypoglycemia in the neonate at birth
  16. What are the risk factors for Gestational Diabetes?
    • Family history of diabetes mellitus
    • Glucosuria on two successive occasions
    • Obesity (>200 lbs)
    • Multiparity
    • Hypertension
  17. When are women screened for gestational diabetes?
    • AT risk --> 1st visit
    • All women --> 24-28 wks

    Urine screen for sugar and ketosis at every prenatal visit

    Urine screen is not as reliable as blood
  18. Describe the 1 hour glucose tolerance test
    Patient drinks 50 g oral glucose (glucola)

    Blood glucose level drawn one hour later

    Fasting not required

    If result is >140 mg/dL this constitutes positive screen

    Pt. then must have a 3-Hour Glucose Tolerance Test
  19. Describe the 3 hour glucose tolerance test
    Administered following a 3-day high carb diet and an 8-hour overnight fast

    A baseline fasting blood glucose level drawn

    Patient drinks 100 g oral glucose

    Blood glucose levels then drawn at 1,2, and 3 hours

    If two or more values are elevated, the patient is diagnosed with gestational diabetes
  20. What are the intervals and the abnormal readings for the 3 hour glucose tolerance test?
    Fasting --> 95 mg/dL or higher

    1 hours --> 180 mg/dL or higher

    2 hours --> 155 mg/dL or higher

    3 hours --> 140 mg/dL or higher
  21. What is the optium fasting glucose level for a gestational diabetic during labor?

    Why??
    60-90 mg/dL

    prevent hypoglycemia later for infant
  22. What are some complications of gestational diabetes?
    Infection

    Spontaneous abortion

    Preterm or early labor

    Macrosomia/newborn shoulder dystocia

    Neonatal hypoglycemia

    Fetal congential abnormalities

    C-Section, forceps, vaccum assisted delivery
  23. What is important to remember about oral hypoglycemics and pregnant women?
    Most oral hypoglycemics are teratogenic in nature

    Insulin does not cross the placenta --> will prescribe if needed

    In most cases, diet and exercise will control gestational diabetes
  24. LGA or Macrosomic
    Large for Gestational Age

    • Over 9lbs
    • >4000 g
  25. SGA or Microsomic baby
    Small for gestational age

    • Less than 5 lbs
    • <2500 g
  26. What babies are at risk for hypoglycemia after birth?
    • LGA
    • SGA
    • Infant of Diabetic Mom
    • Symptomatic
    • Preemies
  27. How do insulin needs change during the 1st trimester?
    Insulin need is reduced because of increased insulin production by pancreas
  28. How do insulin needs change during the second trimester?
    Insulin need increases as placental hormones such as hPL act as insulin antagonists, decreasing insulin’s effectiveness

    Changing insulin needs during pregnancy
  29. How do insulin needs change during the 3rd trimester?
    Insulin needs may double or even quadruple but usually level off at 36 weeks gestation
  30. How do insulin needs change at the day of birth?
    Insulin requirements drastically decrease
  31. How do insulin requirements change in postpartum?
    Mothers use glucose for breastfeeding; maintain lower insulin requirements

    Insulin needs of non-breastfeeding mothers return to pre-pregnancy levels in 7-10 days

    • Weaning of breastfeeding infant causes mother’s insulin needs to return to
    • pre-pregnancy levels
  32. Interventions for Infants of Diabetics
    Accu-checks: usually 3 performed in the immediate transitional period

    Why? Performed to rule out hypoglycemia in the neonate

    Normal level: 40-80 mg/dL

    • If <40 mg/dL; infant is fed immediately. If rechecked and still <40, IV glucose initiated
    • with a doctor’s order
  33. What cultural/age aspects are associated with an increased risk in gestational diabetes?
    Older moms

    Occurs more commonly among hispanic, Native american, Asian, and African American populations
  34. Mothers are at increased risk of what if they have gestational diabetes (within 5 years)
    developing diabetes mellitus
  35. PIH
    Pregnancy-induced hypertension
  36. Preeclampsia
    Hypertension in pregnancy with proteinuria or edema or both
  37. Eclampsia
    Convulsion in a person with preeclampsia
  38. HELLP
    Severe PIH involving

    • Hemolysis
    • Elevated liver enzymes
    • Low Platlets
  39. What are the 3 cardinal symptoms of preeclampsia?
    1) Hypertension

    2) Proteinuria

    3) Generalized edema

    Note: New evidence/literature suggests that edema should no longer be considered a cardinal symptom of preeclampsia since edema is so common in the pregnant patient
  40. What is the pathophysiology of preeclampsia?
    Factors affecting the peripheral resistance that do not allow normal vasodialation

    Thomboxane: powerful vasoconstrictor that stimulates platelet affregation

    Prostacyclin: Powerful vasodialator & inhibitor of platelet aggregation

    • When there is an imbalance:
    •        Progressive vasoconstriction --> thomboxane
    •        Leads to hypertension, reduced circulation
    •        to placenta and cardiovascular system
  41. Mild Preelcampsia

    s/s
    • B/P >140/90
    • Protien
    •      Trace to 2+ or 300 mg/24 hrs
    • Mild edema
    • Mild hypertension
  42. Severe Preeclampsia
    • B/P > 160/110
    • Protien
    •      3-4+ or > 500mg/24 hrs

    • HAVisual changes
    • Increased liver enzymes
    • Oliguria
    • Decreased uteroplacental perfusion
  43. Preeclampsia: Signs & Symptoms

    Frontal Headache
    Cerebral Edema, cerebral vasospasm
  44. Preeclampsia: Signs & Symptoms

    Visual Disturbances
    Retinal ateriolar spasm
  45. Preeclampsia: Signs & Symptoms

    Epigastric Pain
    Hepatic congestion
  46. Preeclampsia: Signs & Symptoms

    Hypertension
    Generalized vasoconstriction
  47. Preeclampsia: Signs & Symptoms

    Nausea and Vomiting
    Hepatic congestion
  48. Preeclampsia: Signs & Symptoms

    Proteinuria/oliguria
    Glomerular damage
  49. Preeclampsia: Signs & Symptoms

    Hyperrelexia of DTRs
    Cortical brain spasms; cerebral edema
  50. Preeclampsia: Signs & Symptoms

    Clonus
    Cortical brain spasms; cerebral edema
  51. How do you assess clonus? What is the purpose? How is it charted? and what does it indicate?
    Assesses for hyperreflexia at the ankle joint

    • Examiner sharply dorsiflexes the foot, maintains the position for a moment and then
    • releases the foot

    Normal response (negative clonus) is elicited when no rhythmic jerks are felt

    Abnormal response (positive clonus) is the rhythmic oscillations of one or more “beats”

    Charted as 1, 2, or 3 beats of clonus

    3 beats of clonus can suggest impending seizure
  52. How do you document DTR's?
    • Reflexes are graded on a scale of 0 to
    • 4+ as follows:

    4+  Hyperactive; very brisk, jerky, or clonic response; abnormal

    3+  Brisker than average

    2+  Average response; normal

    1+  Diminished response; low normal

    0  No response; no movement
  53. What is eclampsia?

    What are the complications?
    Seizures (grand mal) or coma

    • Complications:
    •       Fetus not being perfused
    •    
    •       Increased risk of maternal death related to
    •                Pulmonary embolism
    •                Organ failure
    •                Cardiac failure
    •                Cerebral Hemorrhage
  54. What are the diagnostic tests and labs order for a mom with suspected preeclampsia?
    • H & H
    • Liver enzymes --> liver damage??
    • Platelets --> going into HELLP?
    • DIC profile, clotting studies
    • Chemistry panel including: BUN, creatinine, uric acid
  55. Labetalol
    Maintenance therapy for HTN

    usually 100-200 mg PO BID
  56. Apresoline (hydralazine)
    IV bolus for acute episodes of HTN

    5-10 mg IV bolus Q 5 min X 3
  57. Anticonvulsant therapy

    Magnesium sulfate
    Loading dose of 4-6 grams IV given over 20-30 min

    Followed by 1-2 grams IV maintenance dose

    • Critical drip --> always on a pump!!
    • Never leave the room during the bolus!!!
  58. Theraputic Serum Mag levels
    4-7 mEq/L    or      5-8   mg/dL

  59. What happens if there is not enough Mag Sulfate in a preeclampsia patient?
    • Preeclmpsia gets worse
    • Urinary output decreases, proteinuria
    • CNS remains overstimulated
    • Increases risk of seizure
    •        Clonus present
    •        Brisk DTRs
    •        N/V
    •        HA, visual problems
    •        Epigastric pain
  60. What happens if there is too much mag sulfate in a preeclampsea patient?
    • Patient becomes toxic
    • Urinary output decreases
    • Causes severe CNS depression
    • Increases risk of respirator/cardiac arrest
    •       DTRs absent
    •       RR <12
    •       Clonus absent
    •       Somulence
  61. What is the best indicator that a preeclamsia patient is getting better on Mag sulfate after having too much or too little?
    Increase in urinary output
  62. What is the antidote for Mag sulfate overdose?
    Calcium gluconate

    1 gram IV (10mL of 10% solution)

    ROA --> 2-3 min (can stop the heart)

    Some agencies dictate that only docs can administer
  63. What is the nursing management for a preeclamptic and eclamptic patient?
    • Frequent vital signs, especially B/P
    • Assess edema and chart as 1+, 2+, 3+, 4+
    • Record daily weight
    • Encourage a high-protein diet
    • Position client on left side
    • Test urine for protein every 8 hours
    • Measure and record urine intake/output
    • Assess deep tendon reflexes/clonus Q 1-4 hrs as deemed necessary
    • Insert Foley as ordered
    • Implement seizure precautions
    • Assemble oral airway, suction, and O2 @ bedside
    • Administer anticonvulsant, magnesium sulfate as per orders; continue 24-48 hours after delivery (thomboxane still in body, kidneys still not working as well.. takes a while!)
    • Assess fetal status by FHM
    • Ensure bed rest or restricted activity
    • Decrease environmental stimuli
    • If situation becomes critical, prepare for C-Section
    • Educate the client and family members
  64. Important intervention after a seizure for a preeclampsea patient
    O2 by mask 8-10L
  65. Diazepam (Valium)
    Halt seizures

    5-10 mg/IV

    • Administer slowly. Dose may be repeated Q 5-10 min (up to 30 mg/hr)
    • Observe for resp depression or hypotension in mother and resp depression and hypotonia in infant at birth
  66. HELLP syndrome
    • Hemolysis
    • Elevated Liver enzymes
    • Low Platelets <100,000

    • Secondary Symptoms:
    •        Jaundice
    •        GI bleeding
    •        Bleeding gums
    •        Epigastric pain --> hepatic congestion
  67. What client teaching is needed for a preeclampsia patient?
    Report any increase in B/P, proteinuria, weight gain, decreased fetal movement

    Rest/activity: bed rest may be necessary

    Diet and fluid recommendations are much the same as for the healthy pregnant woman

    Avoid alcohol and limit caffeine intake --> stimulant and vasoconstrict
  68. What are the lifespan and cultural variations associated with preeclampsia?
    Age extremes are most at risk

    Native American and African American women have the highest occurrence rates

    Asian and Pacific Islander women have the lowest rates

    • Some cultural groups view pregnancy as a normal/healthy state; prenatal care is
    • minimal. PIH may go undetected
  69. Hyperemesis Gravidarum
    Nausea/vomiting affects 70% of all pregnancies (morning sickness)

    Usually occurs in 1st trimester; benign

    • If vomiting is excessive resulting in dehydration, electrolyte imbalance or
    • ketosis, hyperemesis gravidarum results

    Remember: baby is getting everything it needs from the placenta (stores nutrients!!)
  70. What are the risk factors for Hyperemesis Gravidarum
    • Less than 20 years of age
    • Obese
    • Nonsmokers
  71. What are the nursing interventions for Hyperemesis Gravidarum?
    • NPO --> 24-48 hours (give the gut a rest)
    • IV therapy to hydrate and correct elect imbalances
    • Nutritional Supplements
    • Diet as tolerated
  72. S/S of Hyperemesis Gravidarum
    • Persistent, uncontrollable vomiting --> esp smells
    • Decreased urinary output --> not drinking
    • Rapid pulse --> from dehydration
    • Low-grade fever --> push fluids!
    • Weight loss --> vomiting
    • Electrolyte imbalances
  73. What are pharmacological management tools for hyperemesis gravidarum
    • Sedatives
    • Antiemetics --> zofran, phenergan, compazine
    • Correction of fluid and electrolyte imbalances
    • Vit B6 and ginger very effective
  74. What should a patient be taught about Hyperemesis Gravidarum?
    • Eat small amounts Q 2-3 hours
    • Eat low-protein food
    • Avoid greasy or fried foods
    • Sit upright after meals to reduce reflux
    • Snack before going to bed
    • Eat dry crackers before rising
    • Get out of bed slowly and avoid sudden movements Avoid brushing teeth immediately after eating
  75. Placenta Previa


    Low Lying/Marginal -->  Placenta implanted near margin of internal os

    Partial --> Placenta partially covers the internal os

    Complete --> Placenta completely covers/obstructs the os
  76. What are the risk factors for placenta previa?
    • Increased maternal age
    • Multiple gestation
    • History of placenta previa
    • Uterine scarring
    • Uterine tumors
    • Closely-spaced pregnancies
  77. What are the S/S of Previa?
    Painless, bright red vaginal bleeding

    Progressively more severe bleeding as delivery nears

    Decreasing urinary output

    Anxiety and fear
  78. What is the nursing management for Previa?
    • Assess amount and character of bleeding
    • Monitor vital signs
    • Monitor urinary output
    • Monitor fetal heart rate and fetal activity
    • Avoid digital vaginal exams as this may cause a placental abruption
    • Instruct client to avoid enemas, douching, sexual intercourse
    • Monitor for continued bleeding/onset of labor
    • Administer intravenous fluid replacement
    • Administer steroids (betamethasone/dexamethasone) if delivery unavoidable
  79. What are the complications of previa?
    • Hemorrhage
    • Fetal distress/demise related to hypoxia in utero
    • Intrauterine growth restriction
    • Cesarean delivery
    • Preterm birth
    • Blood transfusion reactions
  80. What is the emergency management for previa?
    • O2 at 8-10L via mask
    • Frequent vital signs
    • Measure blood loss frequently
    • Prepare for C-Section
    • Continuous electronic fetal monitoring
    • CBC, type/match, clotting studies
    • #16 gauge IV x 2 with LR or NS
  81. What is a placental abruption?
    Premature separation (prior to birth) of the placenta from the uterine wall

  82. What are the two types of Placental Abruption?
    1) Apparent

    2) Concealed/Occult

  83. What are the risk factors for placental abruption?
    • History of previous abruption
    • Hypertension/PIH
    • Sudden uterine decompression such as AROM
    • Short umbilical cord
    • Drug use during pregnancy especially cocaine
    • Smoking
    • Folic acid deficiency
    • Abdominal trauma
  84. What are the S/S of placental abruption?
    • Dark red vaginal bleeding
    • Uterine rigidity; “boardlike” abdomen
    • Sudden onset of intense abdominal pain
    • Uterine contractions
    • Fetal distress
  85. What are the nursing interventions for placental abruption?
    • Assess amount and character of  bleeding; degree of abdominal rigidity; degree of pain
    • Assess fetal activity and heart tones
    • Measure fundal height if concealed bleeding is suspected
    • Monitor for shock
    • Provide emotional support
    • Prepare for possible C-section
    • Administer blood transfusions if ordered
  86. What are the maternal effects of placental abruption?
    • Anemia
    • Hemorrhage
    • Shock
    • DIC
    • Organ Ischemia
    • Hysterectomy
    • Death
  87. What are the fetal effects of placenta abruption?
    • Fetal Hypoxia
    • Prematurity
    • Small for gestational age
    • Neurologic deficits
  88. What crosses the placenta?
    • Glucose
    • Oral hypoglycemics
    • Coumadin
    • TORCH infections
  89. What does not cross the placenta?
    • Heparin
    • Insulin

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