Signs and Symptoms of Pregnancy Part 3

Chapter 16 P. 323 Care of the Woman with Bleeding Disorder  Vaginal bleeding in the 1st trimester may result from a spontaneous abortion (miscarriage)  Vaginal bleeding in the 2nd or 3rd trimester may indicate an abnormal location of the placenta - Abortion is the expulsion of the fetus prior to viability; 20 weeks’ gestation or less than 500 g - know - Abortions are either: Spontaneous or miscarriage (occurring naturally) or Induced (occurring as a result of medical or surgical intervention) - Other complications that can cause bleeding in the first half of pregnancy are ectopic pregnancies and gestational throphoblastic disease. - In the second half of the pregnancy, particularly in the third trimester, the two major causes of bleeding are placenta previa and abruptio placentae. General Principles of Nursing Intervention  Spotting is relatively common during pregnancy and usually occurs following sexual intercourse or exercise because of trauma to the highly vascular cervix.  It is the nurse’s responsibility to make the initial assessment of bleeding: • Monitor blood pressure and pulse frequently • Observe the woman for signs of shock (Pallor, clammy skin, perspiration, dyspnea, restlessness) • Count and weigh pads to assess amount of bleeding (Save any clots or tissue expelled) • If pregnancy is 12 or >, assess FTH with Doppler • Prepare for IV therapy (dehydration = preterm labor) • Collect all data and lab studies • Obtain order for type and crossmatch blood (Remember she said we have to assess mom for RH Neg.) • Assess coping mechanism • Assess family’s response to situation Spontaneous Abortions(Miscarriage) Causes: • Chromosomal abnormalities - It’s the body’s natural way to get rid of an abnormal fetus • Maternal infections - Ex. UTI • Placental abnormalities – Implanted in an abnormal location? Umbilical cord too short? • Faulty implantation – Ectopic pregnancy? • Teratogenic drugs – Cocaine? Alcohol? • Weakened cervix – How many abortions have they had previously? • Trauma – Falls? Abuse? Classifications: Threatened abortion  Fetus is jeopardized  Unexplained bleeding or spotting  Cramping and backache  Physician will 1st check if the cervix is closed (if the cervix is closed they can save the baby)  If the cervix is closed you can put her on bedrest, reduce her activity, and she can go to term. Imminent Abortion  Bleeding and cramping increase, the internal cervical os dilates, membranes may rupture  Also called inevitable abortion Complete abortion  All the products of conception are expelled; cervix opened  May need a d&c Incomplete abortion • Some of the products of conception are retained, most often the placenta • Internal OS dilated slightly • Needs D & C Missed abortion Fetus dies in utero, but is not expelled Uterine growth ceases, breasts changes regress and woman will report brownish vaginal • • discharge Cervix is closed If the fetus is retained beyond 6 weeks, the breakdown of fetal tissue results in the release of thromboplastin, and disseminated Intravascular Coagulation (DIC) may develop. • Diagnosed by ultrasound • No bleeding or cramping • Can lead to infection Recurrent/ Habitual abortion • Abortion occurs consecutively in three or more pregnancies • Common in people who have an incompetent cervix Septic abortion • Infection present • Mat occur with prolonged rupture of membranes, pregnancy with an IUD, or by failed attempts to end a pregnancy by unqualified individuals • • Clinical Therapy  Pelvic cramping and chronic backache are reliable indicators of potential spontaneous abortions.  Speculum examination, and/or ultrasound for gestational aging of fetus, lab determination of hCG to confirm pregnancy, hemoglobin and hematocrit to assess blood loss. • Bed rest • Abstinence from coitus • Emotional support • If bleeding persists and abortion is imminent or incomplete, Sometimes hospitalization is needed • IV therapy/blood transfusions • If she is having contractions, they will give a tocolytic • Dilatation and curettage (D&C) – to clean out the uterus or suction to remove the remains of the fetus. • RhoGAM administered within 72 hours if woman RH negative mother delivers a RH positive baby! Usually given to RH negative women Nursing Management for the Woman Experiencing Spontaneous Abortions • Assess vital signs • Amount and appearance of bleeding • Level of comfort • General physical health • Check for contractions • Determine FHR with Doppler if pregnancy is 10-12 weeks or more • Assess coping mechanisms • Infection • Main nursing diagnosis: Fluid Volume Deficit related to excessive bleeding secondary to spontaneous abortion. Form of miscarriage that is associated with a serious uterine High Risk Pregnancy  Is one in which the health of the fetus or the mother is in jeopardy - May be related to the mother - May be related to a pre-existing condition - May result from an environmental hazard - May be due to maternal behaviors Ectopic Pregnancy  Implantation of the fertilized ovum in the site other than the endometrial lining of the uterus  Could be in the ampulla of the fallopian tube (most common), intestines, outside of the uterus  Pregnancy outside of the uterus Causes • Tubal damage from PID (pelvic inflammation disease –> Gonorrhea infection which causes scarring of the lining of the tubes) • Previous tubal surgery (Scar tissue) • Congenital anomalies of the tube • Endometriosis (foreign tissue in the uterus) • Previous ectopic pregnancy • Presence of IUD • Utero exposure to Diethylstilbestrol (DES) is a manmade estrogen that was given to women way back when. Signs and symptoms • Amennorrhea, Breast tenderness, and nausea • Sharp unilateral pain and syncope and referred right shoulder pain all due to tubal rupture • Lower abdominal pain • Vaginal bleeding because of fluctuation of hormonal levels • KNOW physical assessment shows adnexal tenderness: the area over each fallopian tube is palpated, if pain is elicited, then the test is positive. Medical / surgical therapy: • Careful assessment of LMP • Pelvic exam to identify any abnormal pelvic mass • Transvaginal ultrasound • Serum hCG (Ectopic pregnancies have a slower increase of hCG levels than normal pregnancies) • Laproscopic interventions of necessary • Single shot of Methotrexate injection to treat un-ruptured ectopic pregnancy • Salpingostomy to remove the ectopic pregnancy and save the tube • Salpingectomy - removal of fallopian tube • Tuboplasty may be done to repair the fallopian tube afterwards Nursing assessment • Monitor the amount of vaginal bleeding • Monitor vital signs for developing shock • Assess pain level • Assess emotional state and coping ability • If surgical intervention, complete the appropriate ongoing assessment postoperatively Gestational Trophoblastic Disease (Hydatidiform Mole)  Proliferation of the trophoblastic cells. The throphoblast is the outermost layer of the embryonic cells. (Cells of the placenta)  Also called molar pregnancy  Hydatidiform mole is a condition which a proliferation of throphoblastic cells results in the formation of a placenta characterized by hydropic (fluid filled) grape-like clusters.  The disease results in a loss of pregnancy and the possibility of developing choriocarcinoma.  A molar pregnancy happens when tissue that normally becomes a fetus instead becomes an abnormal growth in your uterus. Even though it isn't an embryo, this growth triggers symptoms of pregnancy. Classified as two types: • Complete: develops from anuclear ovum that contains no maternal genetic material (Empty egg) Choriocarcinoma is directly associated with the complete mole • Partial: two sperms fertilizing an apparently normal ovum; the two sperms cause a genetic mutation that cause this. There may be a fetal sac and even a fetus.  Produces a very high hCG which is why the pregnancy test is positive   Even though the abdomen is growing there is no baby SHOULD NOT GET PREGNANT FOR A YEAR! This can become choriocarinoma so hCG levels need to be monitored for an entire year to make sure that the levels decrease and it is safe for her to get pregnant again - KNOW  Results in loss of pregnancy Clinical Manifestations:  Brownish vaginal bleeding occurs universally – like prune juice KNOW  Anemia because of the blood loss  Uterine enlargement - greater than expected for gestational age (Classic sign of complete mole)  No FHR  Elevated serum hCG markedly elevated  Gestational hypertension before 24 weeks Diagnostic & Treatment  Diagnosed by transvaginal ultrasound  Suction evacuation of the mole and curettage of the uterus  Possible hysterectomy (surgery to remove a woman's uterus)  Follow up to monitor hCG levels for about one year  Increase levels may indicate choriocarinoma (cancer)! Treatment  Chemotherapeutic agent  methotrexate if hCG levels never go down and the patient is diagnosed with Cancer. Nursing Care  Monitor vital signs  Monitor for bleeding signs of hemorrhage  Assess for abdominal pain  Assess coping ability  Have typed and cross-matched blood available for surgery  Administer oxytocin as ordered to keep uterus contracted to prevent hemorrhage  Stress the importance of follow-up visits Care of the Woman with Hyperemesis Gravidarum  Etiology unknown  Excessive projectile vomiting past the 1st trimester  Increased levels of hCG may play a role  May also be caused by misplacement of the GI tract or hypofunction of the aanterior pituitary gland and the adrenal cortex  In severe cases, hyperemesis causes dehydration, which leads to fluid and electrolyte imbalances and alkalosis from loss of hydrochloric acid.  Alkalosis at first and then if untreated Metabolic acidosis (complication)  Decrease urinary output, hypovolemia, hypotension, tachycardia, increased hematocrit and BUN also occur.  Severe potassium loss may interfere with the ability of the kidneys to concentrate urine and may disrupt cardiac functioning.  Starvation = muscle wasting  Severe protein and vitamin deficiency = may lead to fetal death Clinical Treatment  Correction of fluid and electrolyte imbalances  Intravenous Fluids/ TPN (Potassium is usually added to prevent hypokalemia)  NPO for 48 hours typically  Anti-emetics  Stress reduction  Small, frequent meals  Improve nutritional status  Vitamin supplements  pyridoxine (Vitamin B6) Nursing Care       Assess emesis Supportive and directed at Maintained a relax environment and away from strong food smells Food needs to be attractively served with no strong spices/seasoning or offensive smells Good oral hygiene- she may have cuts in her mouth due to all the vomiting Monitor weight Monitor for signs of complications Care of the Woman with Hypertensive Disorder  Most common medical complication in pregnancies. Classification  Preeclampsia  eclampsia  Chronic hypertension  Chronic hypertension with superimposed preeclampsia or eclampsia  Gestational (or transient) hypertension, classified after 20 weeks of pregnancy Preeclampsia  Preeclampsia is defined as gestational hypertension after 20 weeks gestation with a blood pressure of 140/90 or higher X 2 at least 6 hours apart accompanied by proteinuria in a previously normotensive woman  Sudden onset of severe edema  Most often preeclampsia occurs in the last 10 weeks of gestation, during labor or in the first 48 hours after childbirth  Although birth of the fetus and removal of the placent, are the only cure for preeclampsia, it can be controlled with early diagnosis and careful management.  Often seen in teenagers or in women over 35, escecially if they are primigravida  Cause of preeclampsia is unknown but it affects all systems of the body  Blood pressure begins to rise Maternal Risk  CNS changes:  Hyperreflexia (Due to high doses of Magnesium Sulfate)  Headache  Seizures  Thrombocytopenia  Cause is unknown, but birth is the cure  Known risk factors include:  1st pregnancy  Obesity  Age  Family hx, pt. hx  Multifetal pregnancy  Chronic renal disease  DM Others  Renal failure  Abruption placentae  DIC  Ruptured liver  Pulmonary embolism HELLP syndrome (Hemolysis, Elevated Liver enzymes, and low platelet count)  Women who experience this multiple organ failure syndrome have high morbidity and motrality rates as do their offspring.  The hemolysis that occurs = microangiopathic hemolytic anemia  Elevated liver enzymes occur due to blood flow that is obstructed by fibrin deposits  Hyperbilirubinemia and Jaundice may be seen.  Liver disention causes epigastric pain  Thrombocytopenia platelet count less than 100,000 (S/s: N/V, flu-like symptoms)  Women with true HELLP syndrome should give birth regardless of gestational age Fetal–Neonatal Risk  Small for gestational age (SGA) cause is related specifically to vasospasm and hypovolemia which resulted in fetal hypoxia and malnutrition  Premature because of necessity of early birth  Hypermagnesemia (due to administration of magnesium sulfate to mother)  Increased morbidity and mortality Clinical Manifestations and Diagnosis  Mild preeclampsia o BP 140/90 mm hg or higher o +1 proteinuria may occur o Liver enzymes may be elevated minimally o Edema may be present  Severe preeclampsia o May develop suddenly o BP 160/110mm hg or higher on two separate readings while on bedrest 6 hours apart o Proteinuria 5 g or higher in a 24-hour urine collection o Dipstick urine protein 3+ - 4+ on 2 random samples at least 4 hours apart o Oliguria present of less than 500 mL in 24 hours o Samples must be obtained at least 4 hours apart o Visual or cerebral disturbances (Frontal headaches, blurred vision, scotomata- spots before the eyes) o Cyanosis or pulmonary edema o Epigastric or right upper gastric pain (Sign of impending convulsion due to engorgement of the liver) o Impaired liver function o Thrombocytopenia or evidence of hemolysis (IUGR) o n/V, irritability, hyperreflexia, retinal edema  Eclampsia o Grand-mal convulsions or coma o May occur anytime: antepartum, intrapartum, or postpartum o Some women have only one seizure, others have a lot Clinical Manangment  Prevention of cerebral hemorrhage, convulsion, hematologic complications, renal and hepatic disease and birth of an uncompromised newborn (as close to term as possible) Antepartum Management  Depends on the severity of the disease Home care (mild preeclampsia) • Client monitor BP • Daily weights and test protein in urine daily (Weight gain of 3lbs in 24 hours or in a 3-day period are generally a cause for concern) • Remote NST’s done daily or BPPs are bi-weekly • Instructed to report a worsening in condition Hospital care (mild preeclampsia) • Bed rest primarily on left side for promotion of circulation. • Daily weights • Urine dipstick for protein daily • BP check 4 times a day • Diet moderate to high protein, 80 to 100 g a day to replace protein loss in urine. • Sodium intake should be moderate no more than 6 g a day, but sodium restriction and diuretics are no longer used • To achieve a safe outcome of the fetus, Fetal movement records, NSTs and ultrasonography are performed every 3- 4 weeks and BPP, amniocentesis to determine fetal lung maturity and Doppler Velocimetry at 30 to 32 weeks. • Walk to reduce edema • Fetal evaluation • Management cont. Hospital Care of Severe preeclampsia • Birth • Complete Bedrest • Diet high protein and moderate sodium as long as the woman is alert • Anti-convulsants (Magnesium Sulfate) • Fluids and electrolyte replacement • Corticosteroids (Bethamethasone or dexamethasone for women whose baby’s need help for their lungs to mature or moms with HELLP Syndrome) • Anti-hypertensive (CCBs for sustained systolic of 160 labetalol (nonselective) or hydralazine(vasodilator)Methadopa • Also 24 hour urine collection Hospital Care of Eclampsia • Anticonvulsants: Bolus of 4-6gms of magnesium sulfate (should also have calcium gluconate in case of magnesium toxicity) • • Loading dose: 4-6 g magnesium sulfate administered over a 15-20 minute period • Maintenance dose: 2-3 g/hr via infusion pump • Adjunct anticonvulsants: Dilantin • Diuretics – Lasix • Digitalis • Strict I&O’s an foley • Ongoing Nursing Care • Keep patient away from simulation • Monitor • There are at risk up to 48 hour after birth. • Never leave woman by themselves after birth. Assess the following  Vital signs, FHR  Urinary output, urine protein, urine specific gravity  Pulmonary edema  Deep tendon reflexes  Placental separation  Headache  Visual disturbances  Epigastric pain (HELLP syndrome means its getting worse)  Laboratory blood test  LOC  Emotional response and level of understanding  Magnesium sulfate if drug of choice to prevent convulsions should be continued postpartum  Antidote- calcium gluconate Deep Tendon Reflexes  0: absent reflex  1+: trace, or seen only with reinforcement  2+: normal  3+: brisk  4+: Hyperactive; very brisk jerky or clonic response ABNORMAL (i.e., repetitive vibratory movements) HEELP Syndrome When the patient has right upper abdominal pain, hemolysis of the liver. Increased risk for  Placental abruption, acute renal failure, pulmonary edema, hepatic hematoma, ruptured liver, fetal/maternal death  Hemolysis, elevated liver enzyme and low platelet count Management  Bp measurements  Assess for edema (dependant or pitting)  Assess DTR’s CBC, clotting studies, blood chemistry, Type and screen Surgery During Pregnancy o Surgery complicates about 1 in every 500 pregnancies o First trimester surgeries increase the incidence of abortion o Increased incidence of fetal mortality o And low birth weight infants (less than 2500g) o Increase incidence of preterm labor o Increase incidence of intrauterine growth restrictions o Inability to perform some diagnostic procedures may hinder diagnosing of the disease Trauma During Pregnancy Types of trauma  Blunt  Penetrating injuries  Gunshot wounds  MVA most common Causes  Maternal shock  Premature labor or spontaneous abortion  Maternal mortality  head trauma or hemorrhage  Placental abruption  Traumatic separation of placenta  Fetal mortality  Premature birth and ROM Battered Pregnant Woman  Incidence – 4% to 8%  May result in loss of pregnancy  Preterm labor  Low birth weight infant  Fetal death  Abused women have higher rates of complications  Anemia, infection, low weight gain, bleeding in the 1 st and 2nd trimester Management Early detection  Ask about abuse at several prenatal visits  May not disclose until she becomes familiar with caregivers  Assess old scars  Be alert for signs of bruising Target areas  Breast  Abdomen  Genitalia  How to Help o o o o Accepting, nonjudgmental environment Listen and allow her to express her concerns Provide list with community resources and emergency numbers Client has to make decision to seek help Perinatal Infections affecting the Fetus:  Toxoplasmosis  Rubella  STD’s  Cytomegalovirus (CMV)  Hepatitis B virus (HBV)  Group Beta Streptococcus (GBS)  HIV  Perinatal Infections affecting the Fetus  Toxoplasma gondii – a protozoan parasite  Contracted by ingestion or handling undercooked meat or handling cat feces  Early maternal infection results in congenital toxoplasmosis, leading to spontaneous abortion  Caution about cooking meat thoroughly  Avoid handling cat feces  Use gloves while gardening  Treatment with spiramycin as soon as possible  Education for woman and family Rubella-virus  Transmission- Across the placenta to fetus  Congenital rubella syndrome (CRS) may result  Treatment: Prevention  Vaccination  1st trimester greatest risk for heart damage, cataracts, mental retardation  2nd trimester- permanent hearing impairment, microcephaly, retardation  Neonate – clinical signs- CHD, IUGR, cataracts  Nursing care- focused on prevention STD’S Herpes, Syphilis, Gonorrhea, Chlamydia  STD’s are most common in the reproductive years  Viral STI’s are hard to treat; may have the virus for life  Client should be asked about risk factors, previous STI’s and sexual activity  Physical examination  Treatment of bacterial infections should be tailored to situation  Education regarding safety Cytomegalovirus (CMV)- herpes  Most common cause of congenital neurologic impairment  Acquired during gestation can result in:  Stillbirth or miscarriage  IUGR- condition in which the baby doesn’t grow normal weight during birth  Congenital anomalies or other infections  Infants appear asymptomatic at birth but develop sensorineural problems Risk  Contact with infected children in daycare centers Prevention  Proper handwashing  No treatment exist, provide supportive counseling Hepatitis B  Transmitted sexually, IV drug use  Infection can occur during birth  Symptoms – fever, rash, decreased appetite abdominal pain, aching, malaise, weakness, jaundice, enlarged liver  Prevention/treatment – hepatitis B vaccine Group B Streptococcus (GBS)  Incidence 1.8 per 1000 live births  Major cause of neonatal morbidity and mortality  Usually asymptomatic  Newborn infections results from vertical transmissions  Risk- preterm labor, previous hx, ROM longer than 18 hours  Prenatal care – vaginal/rectal swab at 35 – 37 weeks gestation  Treatment – intrapartal antibiotics at least 4 hours before birth, until after birth  Infant monitoring- risk of transmission higher in the 1 st 24 hours, However, education should be give to monitor infant for up to seven days. Rh Alloimmunization  Rh-negative woman carries Rh + fetus  Fetal red blood cells cross into maternal circulation  Antigen-antibody response occurs  1st child not affected  Affects subsequent pregnancies  Rh antibodies enter the fetal circulation  Hemolysis of fetal red blood cells and fetal anemia Fetal and Neonatal Risk: Clinical Presentation (varies with disease severity)  Anemia  Jaundice  Hepatosplenomegaly  Fetal hemolytic anemia  Hydrops fetalis (severe fetal edema)  Stillbirth Rh Alloimmunization Prevention  Screening  History  Identification  Antibody screen ( indirect Coomb’s test)  Identify if woman is sensitized  Administer 300mcg Rh immune globulin (RhoGAM)  Give RhoGAM in the following cases: - Pregnant Rh- woman who have no antibody titer - At 18 weeks’ gestation - Baby father is Rh + or unknown - With in 72 hours after each abortion - Amniocentesis and placenta previa - Invasive procedures that may cause bleeding ABO Incompatibility  Mother has type o blood and the infant has A, B, or AB  Maternal antibodies cross placenta    Hemolysis of fetal RBC’s Unlike Rh incompatibility, the 1st infant is involved No relationship between the appearance of the disease and repeated sensitization from one pregnancy to the next  No antepartal treatment required  Hyperbilirubinemia in the infant  Hyperbilirubinemia treated with phototherapy After birth:  Assess newborn carefully  Assess for Hyperbilirubinemia Percutaneous Umbilical Blood Sampling (PUBS) or Cordocentesis  It’s a technique used for obtaining blood that allows for rapid chromosome diagnosis, genetic studies, or transfusion for Rh isoimmunization or hydrops fetalis  Similar to amniocentesis  Direct access to fetal circulation  Insertion of needle directly into a fetal umbilical vessel under ultrasound guidance  Blood is pulled out from the fetus’ umbilical cord.  PUBS is perfomed if the fetus is suspected of being anemic. It is done to determine fetal hematocrit. If fetal hematocrit is <30%, then the fetus is given intrauterine blood transfusion either intravenously through PUBS or intraperitoneally. This is due to not knowing whether the infant is Rh negative or positive. But now we have other ways of knowing.  This test can also be performed to assess the acid/base level of the fetus. She said: if the mom has PIH and the baby is having deceleration, then you want this test to be performed to check and see if the baby is acidic. Childbirth at risk: Prelabor Complications Chapter 21 p. 441 Care of The Woman With Premature Rupture of Membranes (PROM)  Spontaneous rupture of the membranes prior to the onset of labor  Preterm premature rupture of membranes (PROM) is the rupture of membranes before the 37 weeks of pregnancy. (AKA when your water breaks)  Anytime the membranes rupture that means that there is now open area for infection to enter so the baby is now at risk. She must deliver quickly if this occurs. Causes  Infection – KNOW  Previous history  Amniocentesis (removal of fluid to be tested for abnormalities)  Placenta previa  Abruption placentae  Trauma  Incompetent cervix Clinical Therapy  Nitrazine paper test* (positive if blue  blue means that it is amniotic fluid)  Fern test* (positive if amniotic fluid shows a fern-like pattern under a microscope)  No digital exams- if membrane is ruptured then you are placing the fetus and mother are high risk for infection  FHR  BPP  If infection suspected, IV antibiotics  Prophylactic antibiotics for 48 hours while awaiting cultures Clinical Therapy Absences of Infection  If less than 37 weeks  Hospitalized on bedrest  CBC, CRP, U/A  FHR  Regular NST, BPP  Assess maternal temperature and FHR every 4 hours  Regular laboratory evaluations  Fetal lung maturity studies  Maternal corticosteroid administration Clinical Therapy  At home  Bedrest with bathroom privileges  Monitor T & P 4 times a day  Fetal movement journal  NST weekly  Call HCP for signs of complications  Return to hospital for fever, uterine tenderness or contractions, increased leakage of fluids, decrease fetal movement or foul-smelling vaginal discharge Nursing Care  Report signs of infection  Evaluate uterine activity  Encourage woman to rest on left side  Use comfort measures  Ensure hydration, if temperature present  Educate on implications of PROM and treatment  Physiologic support  Listen, give information, provide explanations  Prepare couple for outcome  No vaginal exam when there is a premature rupture of membrane. IF you need to do a vaginal exam then you must use a sterile procedure, sterile glove because the protection layer around the baby is gone once premature rupture of membrane has occur. Preterm Labor p. 449  Labor that occurs between 20 and 36 completed weeks of pregnancy  Document uterine contractions (4 in 20 minutes or 8 in one hour)  Document cervical change (if cervix is still closed send her home with tocolytics) • Also note that if she is 38 weeks and having contractions, but the cervix is closed, send her home on tocolytics as well  Cervical dilation of greater than 1 cm  Cervical effacement of 80% or more means you are in labor  it’s the thinning of the cervix. Normally it is thick feeling like your nose and thinning feeling like the inside skin on the side of your mouth. Risk factors (chart on page 445) she said know risk factors  Stress – lack of social support?  Age - Adolescent pregnancy is high risk for PTL  Multiple pregnancies – high risk for PTL because of the volume and the pressure starts to open the cervix  Placenta previa  Abdominal surgery during 2 trimester  Cervical insufficiency/ incompetent – high risk for PTL  Dilated cervix 1cm at 32 weeks’ gestation  Bleeding after 12 weeks  Inadequate or no prenatal care  Mother with chronic disease; HTN, DM, obesity  History or current Infection – febrile? STD’s?  Dehydration / Hydramnios  Low social economic status  Uterine anomalies  History of PTL- if it happened once, its more than likely going to happen again  Amniocenteses – high risk for PTL Clinical Therapy Assess cervicovaginal fibronectin (fFN) - This test similar to that of a Pap smear. fFN is a protein normally found in the fetal membranes and decidua. If fFN is found in the cervicalvaginal fluid then the woman is a high risk to give birth; labor  Assess cervical length via ultrasound- it the cervical cord short? Because if so if can cause opening of the cervix  Obtain history of previous preterm birth  Assess for the presence of infection- any UTI? Must address it because it may place her in PTL  Educate patient about preterm labor  Assess for early signs and symptoms of labor  Maternal laboratory studies- H&H, ketones in urine (this means Dehydrations; if so give IV fluids)  IV infusions for maternal hydration  Tocolytic: Medications used in the attempt to stop labor/ contractions. Examples are beta adrenergic agonist (magnesium Sulfate; loading dose 4-6 mg, Pitocin, dobutamin (orally), cyclooxygenase (prostaglandin synthetase- E and F to prevent labor) inhibitors, and calcium channel blockers nifedipine (Procardia-it relaxes smooth muscle therefore stopping contractions), endometacin she said know drugs Question If patient come into the ER complaining of UTI what should you do? - Assess for signs of labor, if the patient is having contraction, early rupture of membrane.  How do you know if a cervix is dilated without doing a vaginal exam? - By ultrasound Tocolytics  B – adrenergic agonist magnesium sulfate  Prostaglandin synthetase inhibitors  Calcium channel blockers  Medications used to stop labor Incompetent Cervix  Weak cervix  Premature dilatation of the cervix, usually in the 4th or 5th month of Pregnancy  Associated with repeated second trimester abortions Possible causes:  Cervical trauma  Infection  Congenital cervical or uterine anomalies  Multiple gestation  Diagnosis: Positive history of repeated second trimester abortions Treatment- Surgical procedure  Shirodkar procedure (cerclage  string that holds the cervix together)  Purse-string suture is placed in the cervix in the first trimester or early in the second trimester  Has to be put in early enough before the cervix starts opening  Suture cut at term and vaginal delivery permitted Placenta Previa  A low-lying placenta  Placenta implantation in the lower uterine segment  PAINLESS  Will definitely be a c-section Predisposing Factors  Prior hx of placenta previa  Multiple pregnancies  Hx. of multiple births  Prior uterine scars  Placenta is not going to attach to an area with scar tissue Symptoms  Quiet onset bright red bleeding  Abdomen soft, palpable  Painless bleeding Nursing Responsibilities  Bedrest  Monitor blood loss (pad count)  Perineal care  Education re: s/s of labor, condition  Monitor labs  Type and screen  Emotional support  Monitor the baby Placenta Abruption  Premature separation of the placenta  PAINFUL  C-section for sure Symptoms  Dark venous blood  Abdomen rigid, hard  Severe pain  Sudden onset Nursing Responsibilities  Prepare for emergency C-section (baby is not getting any oxygen and needs to come out) Unknown location for test 1 LOL Physiologic Changes of Pregnancy…  Pregnancy: Variation to…  Age-related perspectives  Adolescent pregnancy  Pregnancy after age 35 you are at high risk; you need more antenatal care  Between ages 23 and 34 are the best ages to have babies - Body is at its healthiest - Pelvic bone is more pliable and the baby can come out easier  Sociocultural variations  Ex: having a career first before having a baby or having a baby and then focusing on your education  Religious variations Maternal-Fetal Assessment and Care… General Survey  Nutrition  Grooming  Posture  Mood  Affect  General appearance Skin/ Breast; you want to look for any…  Scars (ex: previous c-section or abd sx; find out when? And how long ago?)  Tracks (to determine if pt is a drug user)  Bruising (where did you get that bruise?)  Variations in skin Heart/Lungs & Abdomen     We need to auscultate her breath sounds and her heart sounds (may be a cardiac patient who is pregnant; a lot of them won’t tell you unless you ask them) A soft, blowing systolic murmur from the increased cardiac volume is a normal finding; because the heart is putting out more blood. On the abdomen you may see: straie, linea nigra Check fundal height to estimate the gestation of the baby