Ante Natal care - applern.com

Ante Natal care

Anila Simon PhD-c, RN, CVRN, CMSRNAppleRN Classes

Physiological Maternal Changes

- Cardiovascular system• Pulse may increase 10 beats/min• Blood pressure may decrease in second

trimester

– Respiratory system:Oxygen consumption increases by 15% to 20%


trimester



trimester



trimester


– Gastrointestinal system• Nausea and vomiting may occur from

first through third months• Constipation may occur• Hemorrhoids may develop

– Renal system: Frequency of urinationincreases in first and third trimesters

– Endocrine system: Basal metabolic rate rises





Physiological Maternal Changes









Physiological Maternal Changes– Reproductive system

• Uterus enlarges with increase in numberand size of blood vessels

• Cervix becomes shorter, more elastic, andlarger in diameter

– Skeletal system: Center of gravity changes– Metabolism

• Metabolic function increases• Body weight increases

– Reproductive system• Uterus enlarges with increase in number

and size of blood vessels• Cervix becomes shorter, more elastic, and

larger in diameter– Skeletal system: Center of gravity changes– Metabolism










Integumentary system (skin)

• Increased pigmentation• Appearance of linea nigra• Chloasma may appear• Striae may appear• Vascular spider nevi may appear




Laboratory Tests– Blood type and Rh factor

• Mother is Rh-negative and has negative antibody screen– Will need to repeat antibody screens– Should be given Rho(D) immune globulin (RhoGAM)

within 72 hours of birth of first baby when detected– With every other pregnancy, should be given

RhoGAM at twenty-eighth week of gestation andwithin 72 hours of birth of baby

– Tuberculin skin test• Positive test indicates need for chest x-ray to rule out

active disease– In pregnant client, x-ray cannot be performed until

after twentieth week of gestation

– Blood type and Rh factor• Mother is Rh-negative and has negative antibody screen

– Will need to repeat antibody screens– Should be given Rho(D) immune globulin (RhoGAM)




















Laboratory Tests

• Urine– Glucose – Diabetes– Protein – Pre Eclampsia– Nitrates and WBC – Infection– pH may be decreased and specific gravity may be

increased (vomiting)

• Blood : HCG levels (human chorionicgonadotropin )










Diagnostic Tests

– Ultrasonography• Outlines, identifies fetal and maternal structures• Assists in confirming gestational age and estimated

date of confinement– Chorionic villus sampling (High Risk)

• Assessment of a portion of the developing placenta(chorionic villi), which is aspirated through a thin sterilecatheter or syringe.

• Detects genetic abnormalities by sampling chorionicvillus tissue at eighth to twelfth week of gestation.

– Kick counts (fetal movement counting)
















Amniocentesis• Aspiration of amniotic fluid may be done from

thirteenth to fourteenth week of gestation• Used to determine genetic disorders,

metabolic defects, fetal lung maturity• Risks include maternal hemorrhage, infection,

abruptio placentae, premature rupture ofmembranes

• Alpha-fetoprotein (AFP) can be measuredfrom the amniotic fluid

• Aspiration of amniotic fluid may be done fromthirteenth to fourteenth week of gestation

• Used to determine genetic disorders,metabolic defects, fetal lung maturity

• Risks include maternal hemorrhage, infection,abruptio placentae, premature rupture ofmembranes










Diagnostic Test : AFP

• High levels of AFP are associated with neural tubedefects, such as anencephaly (incompletedevelopment of fetal skull and brain), spina bifida(open spine), or omphalocele (abdominal walldefect).

• High AFP levels also may be present with normalmultifetal pregnancies.

• Low levels of AFP are associated with chromosomaldisorders (Down syndrome) or gestationaltrophoblastic disease (hydatidiform mole).










Amniocentesis

• Fetal lung tests– Lecithin/sphingomyelin (L/S) ratio – a 2:1

ratio indicating fetal lung maturity (2.5:1 or3:1 for a client who has diabetes mellitus).

– Presence of phosphatidylglycerol (PG) –absence of PG is associated with respiratorydistress










After Amniocentesis

• Administer RhO(D) immune globulin (RhOGAM)to the client if she is Rh-negative

• Advise the client to report to her provider ifshe experiences fever, chills, leakage of fluid,or bleeding from the insertion site, decreasedfetal movement, vaginal bleeding, or uterinecontractions after the procedure.

• Encourage the client to drink plenty of liquidsand rest for the 24 hr post procedure.










Diagnostic Tests– Fern test

• Microscopic slide test to determinepresence of amniotic fluid leakage

– Nitrazine test• Determines presence of amniotic fluid in

vaginal secretions; shades of blue indicatethat membranes probably ruptured

– Fern test• Microscopic slide test to determine

presence of amniotic fluid leakage– Nitrazine test

• Determines presence of amniotic fluid invaginal secretions; shades of blue indicatethat membranes probably ruptured







NST/ CST• Nonstress test (Positive –reactive - is normal)

• Performed to assess placental function and oxygenation• Assesses fetal well-being – FHR vs Fetal movement• Normal- Increased FHR with FM• Outpatient clinic, external monitor

• Contraction stress test (positive is abnormal)• Performed to assess placental function, oxygenation and

baby tolerate labor?• FHR vs Contractions – gives oxytocin• Normal - No late deceleration, no variable deceleration

– Early deceleration is ok- due to head compression• Assesses fetal ability to tolerate labor, fetal well-being

• Nonstress test (Positive –reactive - is normal)• Performed to assess placental function and oxygenation• Assesses fetal well-being – FHR vs Fetal movement• Normal- Increased FHR with FM• Outpatient clinic, external monitor












Fetal Monitoring• External fetal monitoring

– Noninvasive; performed using transducer or Doppler– Transducer, fastened with belt, should be placed on

side of mother where fetal back is located (find usingLeopold’s maneuvers)

• Internal fetal monitoring– Invasive; requires rupturing of membranes;– Attachment of electrode to presenting part of fetus;

mother must be dilated 2 to 3 cm to perform thisprocedure

– Contra indication- Closed cervix, Placenta previa, STD,Breach, AIDS, Hep B

• External fetal monitoring– Noninvasive; performed using transducer or Doppler– Transducer, fastened with belt, should be placed on















Assessment

• Nägele’s rule : To estimate date ofconfinement, delivery date:• subtract 3 months from the first day of the last

menstrual period, add 7 days, and adjust the year

• McDonald’s Method – Fundal height –correlate with GA until third trimester.Consistency ( same person, samemeasurement) is important










Fundal Height

GTPAL acronym

• Gravidity – number of pregnancies.– Nulligravida – a woman who has never been

pregnant– Primigravida – a woman in her first pregnancy– Multigravida – a woman who has had two or more

pregnancies• Term births (38 weeks or more)• Preterm births (from viability up to 37 weeks)• Abortions/miscarriages (prior to viability)• Living children










Assessment

• TORCH• Toxoplasmosis,• Other infection (usually Hepatitis),• Rubella,• Cytomegalovirus,• Herpes Simplex

– Serious fetal problems







Assessment• Presumptive signs (subjective) : changes that the

woman experiences that make her think that she maybe pregnant.

• Amenorrhea• Fatigue• Nausea and vomiting• Urinary frequency• Breast changes – darkened areolae, Montgomery’s

glands• Quickening – slight fluttering movements of the fetus

felt by a woman, usually between 16 to 20 weeks ofgestation

• Uterine enlargement

• Presumptive signs (subjective) : changes that thewoman experiences that make her think that she maybe pregnant.















Pregnancy Signs

• Probable signs (objective) : changes that make theexaminer suspect a woman is pregnant (primarilyrelated to physical changes of the uterus).

• Abdominal enlargement related to changes in uterinesize, shape, and position

• Braxton Hicks contractions – false contractions;painless, irregular, and usually relieved by walking

• Positive pregnancy test• Fetal outline felt by examiner













Probable signs• Hegar’s sign: Softening and thinning of lower

uterine segment at about sixth week ofgestation

• Goodell’s sign: Softening of cervix, beginning atsecond month of gestation

• Chadwick’s sign: Bluish coloration of mucousmembranes of cervix, vagina, vulva at aboutsixth week of gestation

• Ballottement: Rebounding of fetus againstexaminer’s fingers on palpation

• Hegar’s sign: Softening and thinning of loweruterine segment at about sixth week ofgestation












Pregnancy Signs

–Positive Sign• Fetal heart rate : 120 to 160 per mt.• Active fetal movement• Outline of fetus on x-ray or

ultrasonogram


ultrasonogram


ultrasonogram


ultrasonogram

Common Discomforts of Pregnancy

• Nausea and vomiting– Eat crackers or dry toast 30 min to 1 hr before

rising in the morning to relieve discomfort.– Instruct the client to avoid having an empty

stomach and ingesting spicy, greasy, or gas-forming foods.

– Encourage the client to drink fluids betweenmeals.














• Urinary Frequency• UTI

– Encourage the client to wipe the perineal areafrom front to back after voiding;

– Avoid bubble baths– Wear cotton underpants; avoid tight-fitting pants;– Consume plenty of water (8 glasses per day).– Avoid urinary stasis











• Fatigue may occur during the first and thirdtrimesters – frequent rest periods

• Heartburn:– Eat small frequent meals– Not allow the stomach to get too empty or too

full,– sit up for 30 min after meals,– check with her provider prior to using any over-

the-counter antacids.













Common Discomforts of Pregnancy• Backaches

– Eexercise regularly, perform pelvic tilt exercises(alternately arching and straightening the back)

– Use proper body mechanics by using the legs to liftrather than the back, and use the side-lying position.

• Constipation– The client is encouraged to drink plenty of fluids, eat a

diet high in fiber, and exercise regularly.• Hemorrhoids

– A warm sitz bath and application of topical ointmentswill help relieve discomfort.

• Backaches– Eexercise regularly, perform pelvic tilt exercises

(alternately arching and straightening the back)– Use proper body mechanics by using the legs to lift

rather than the back, and use the side-lying position.• Constipation

– The client is encouraged to drink plenty of fluids, eat adiet high in fiber, and exercise regularly.

• Hemorrhoids– A warm sitz bath and application of topical ointments

will help relieve discomfort.













Warning Signs of pregnancy• Gush of fluid from the vagina (rupture of amniotic

fluid) prior to 37 weeks of gestation• Vaginal bleeding (placental problems such as abruption

or previa)• Abdominal pain (premature labor, abruptio placentae,

or ectopic pregnancy)• Changes in fetal activity (decreased fetal movement

may indicate fetal distress)• Persistent vomiting (hyperemesis gravidarum)• Severe headaches (gestational hypertension)• Elevated temperature (infection)

• Gush of fluid from the vagina (rupture of amnioticfluid) prior to 37 weeks of gestation

• Vaginal bleeding (placental problems such as abruptionor previa)

• Abdominal pain (premature labor, abruptio placentae,or ectopic pregnancy)

• Changes in fetal activity (decreased fetal movementmay indicate fetal distress)

• Persistent vomiting (hyperemesis gravidarum)• Severe headaches (gestational hypertension)• Elevated temperature (infection)











Warning Signs of pregnancy

• Dysuria (urinary tract infection)• Blurred vision (gestational hypertension)• Edema of face and hands (gestational hypertension)• Epigastric pain (gestational hypertension)• Concurrent occurrence of flushed dry skin, fruity

breath, rapid breathing, increased thirst and urination,and headache (hyperglycemia)

• Concurrent occurrence of clammy pale skin, weakness,tremors, irritability, and lightheadedness(hypoglycemia)










Warning signs

• warning signs of pregnancy

Adolescent pregnancy

• Major concerns– Poor nutritional status– Emotional and behavioral difficulties– Lack of social support systems– Increased risk of stillbirth– Low–birth-weight infants– Fetal mortality




• A nurse is teaching a group of women who arepregnant about measures to relieve backacheduring pregnancy. The nurse should teach thewomen which of the following? (Select all thatapply.)

• A. Avoid any lifting.• B. Perform Kegel exercises twice a day.• C. Perform the pelvic rock exercise every day.• D. Use proper body mechanics.• E. Avoid constrictive clothing

• A nurse is teaching a group of women who arepregnant about measures to relieve backacheduring pregnancy. The nurse should teach thewomen which of the following? (Select all thatapply.)

• A. Avoid any lifting.• B. Perform Kegel exercises twice a day.• C. Perform the pelvic rock exercise every day.• D. Use proper body mechanics.• E. Avoid constrictive clothing

• A. INCORRECT: Lifting may be done by using the legs, ratherthan the back.

• B. INCORRECT: Kegel exercises are done to strengthen theperineal muscles and do not relieve backache.

• C. CORRECT: The pelvic rock or tilt exercise stretches themuscles of the lower back and helps relieve lower-backpain.

• D. CORRECT: The use of proper body mechanics preventsback injury due to the incorrect use of muscles when lifting.

• E. INCORRECT: Avoiding constrictive clothing helps preventurinary tract infections, vaginal infections, varicosities, andedema of the lower extremities.

• A. INCORRECT: Lifting may be done by using the legs, ratherthan the back.

• B. INCORRECT: Kegel exercises are done to strengthen theperineal muscles and do not relieve backache.

• C. CORRECT: The pelvic rock or tilt exercise stretches themuscles of the lower back and helps relieve lower-backpain.

• D. CORRECT: The use of proper body mechanics preventsback injury due to the incorrect use of muscles when lifting.

• E. INCORRECT: Avoiding constrictive clothing helps preventurinary tract infections, vaginal infections, varicosities, andedema of the lower extremities.

• A nurse is caring for a client who is pregnantand reviewing signs of complications thatshould be promptly reported to the provider.Which of the following should be included?

• A. Vaginal bleeding• B. Swelling of the ankles• C. Heartburn after eating• D. Lightheadedness when lying on back

• A nurse is caring for a client who is pregnantand reviewing signs of complications thatshould be promptly reported to the provider.Which of the following should be included?

• A. Vaginal bleeding• B. Swelling of the ankles• C. Heartburn after eating• D. Lightheadedness when lying on back

• A client who is at 7 weeks of gestation isexperiencing nausea and vomiting in themorning. The nurse in the prenatal clinic providesteaching that should include which of thefollowing?

• A. Eat crackers or plain toast before getting out ofbed.

• B. Awaken during the night to eat a snack.• C. Skip breakfast, and eat lunch after nausea has

subsided.• D. Eat a large evening meal.

• A client who is at 7 weeks of gestation isexperiencing nausea and vomiting in themorning. The nurse in the prenatal clinic providesteaching that should include which of thefollowing?

• A. Eat crackers or plain toast before getting out ofbed.

• B. Awaken during the night to eat a snack.• C. Skip breakfast, and eat lunch after nausea has

subsided.• D. Eat a large evening meal.

High Risk Antenatal

Anila Simon MS, RN, CVRN, CMSRNApple RN Coaching

Learn Nursing International

Bleeding During Pregnancy

• Vaginal bleeding during pregnancy is alwaysabnormal.

• Spontaneous Abortion: when a pregnancy isterminated before 20 weeks of gestation (thepoint of fetal viability) or a fetal weight lessthan 500 g.

• Vaginal bleeding during pregnancy is alwaysabnormal.

• Spontaneous Abortion: when a pregnancy isterminated before 20 weeks of gestation (thepoint of fetal viability) or a fetal weight lessthan 500 g.

Abortion– Description• Pregnancy that ends before twentieth week of gestation,

spontaneously or electively– Types• Spontaneous: Pregnancy ends because of natural causes• Induced: Therapeutic or elective reasons for terminating

pregnancy• Threatened: Developing spontaneous abortion• Inevitable: Threatened loss that cannot be prevented• Incomplete: Loss of some products of conception and

retention of others




retention of others




retention of others




retention of others

Slide 3

Abortion (continued)Types (continued)

• Complete: Loss of all products of conception• Missed: Retention of products of conception in utero

after fetal death• Habitual: Spontaneous abortions in three or more

successive pregnancies– Assessment

• Spontaneous vaginal bleeding; passage of clots ortissue through vagina; low uterine cramping orcontractions

– Interventions• Count perineal pads to evaluate blood loss and save

expelled tissues and clots• Educate client, family regarding dilation and curettage

(D&C) as prescribed








(D&C) as prescribed








(D&C) as prescribed








(D&C) as prescribed

Diagnostic and Therapeutic Procedures

• Ultrasound – to determine the presence of a viable ordead fetus, or partial or complete products ofconception within the uterine cavity.

• Dilation and curettage (D&C) – to dilate and scrape theuterine walls to remove uterine contents for inevitableand incomplete abortions.

• Dilation and evacuation (D&E) – to dilate and evacuateuterine contents after 16 weeks of gestation.

• Prostaglandins and oxytocin (Pitocin) – to augment orinduce uterine contractions and expulse the productsof conception













Ectopic Pregnancy• Abnormal implantation of a fertilized ovum outside of

the uterine cavity.• Usually in the fallopian tube, which can result in a tubal

rupture causing a fatal hemorrhage.• Unilateral stabbing pain and tenderness in the lower-

abdominal quadrant.• Referred shoulder pain due to blood in the peritoneal

cavity irritating the diaphragm or phrenic nerve aftertubal rupture.

• Nursing Actions– Replace fluids, and maintain electrolyte balance.– Provide client education and psychological support.

• Abnormal implantation of a fertilized ovum outside ofthe uterine cavity.

• Usually in the fallopian tube, which can result in a tubalrupture causing a fatal hemorrhage.

• Unilateral stabbing pain and tenderness in the lower-abdominal quadrant.

• Referred shoulder pain due to blood in the peritonealcavity irritating the diaphragm or phrenic nerve aftertubal rupture.












HYPEREMESIS GRAVIDARUM

• Excessive nausea and vomiting past 12 weeks andresults in a 5% weight loss, electrolyte imbalance,and ketosis

• Nursing Care– Monitor the client’s I&O. Give the client IV fluids.– Assess the client’s skin turgor and mucous

membranes.– Monitor the client’s vital signs.– Monitor the client’s weight.– Have the client remain NPO for 24 to 48 hr.










Diabetes Mellitus• Screen all pregnant women between 24 th- 28th week of gestation• Can be treated by diet alone; some may need insulin• During second and third trimesters, maternal insulin needs increase

(hormones – insulin resistance)• Fetus produces own insulin and pulls glucose from mother,

predisposing mother to hypoglycemia• Risk for polyhydramnions, eclampsia, dystocia, infections (yeast)• Newborn infant of diabetic mother at risk for

– hypoglycemia, hyperbilirubinemia, respiratory distresssyndrome, hypocalcemia, congenital anomalies

• Assessment– Signs similar to those of diabetes mellitus in nonpregnant

women (polyuria, polydipsia, polyphagia)

• Screen all pregnant women between 24 th- 28th week of gestation• Can be treated by diet alone; some may need insulin• During second and third trimesters, maternal insulin needs increase


















Gestational Diabetes Mellitus• Monitor the client’s blood glucose.• Monitor the fetus.• Administer insulin• Client education

– Instruct the client to perform daily kick counts.– Educate the client about diet and exercise.– Instruct the client about self-administration of insulin

• Signs : Hypoglycemia (nervousness, headache, weakness,irritability, hunger, blurred vision, tingling of mouth orextremities)

• Hyperglycemia (thirst, nausea, abdominal pain, frequenturination, flushed dry skin, fruity breath)

• Monitor the client’s blood glucose.• Monitor the fetus.• Administer insulin• Client education












Diabetes Mellitus (continued)– Interventions

• Include diet, insulin, exercise, monitoring blood glucoselevels.

• Instruct the client to perform daily kick counts.• Oral hypoglycemics are not advised (Glyburide used

rarely)• Monitor for signs of hyperglycemia, glycosuria,

ketonuria, hypoglycemia• Keep a journal with test results and meds

– Interventions during labor• Monitor fetal status continuously for signs of distress

– Interventions during postpartum period• Monitor mother for hypoglycemic reaction, signs of

postpartum hemorrhage

























Gestational Trophoblastic Disease• Hydatidiform Mole, Choriocarcinoma, and Molar Pregnancy• swollen, fluid-filled, and takes on the appearance of grape-like

clusters.• Excessive vomiting (hyperemesis gravidarum) due to elevated hCG

levels may be present• Rapid uterine growth more than expected for the duration of the

pregnancy due to the over proliferation of cells• An ultrasound reveals a dense growth with characteristic vesicles,

but no fetus in utero.• Nursing Actions

• Measure fundal height.• Symptoms of preeclampsia may be present• Assess vaginal bleeding and discharge.• RhO(D) immune globulin (RhoGAM) to the client who is Rh-

negative

• Hydatidiform Mole, Choriocarcinoma, and Molar Pregnancy• swollen, fluid-filled, and takes on the appearance of grape-like






negative







negative







negative

Preterm Labor

• Occurs after 20 th week, but before 37th week ofgestation.

• Contractions occur more frequently than every 10minutes, last 30 seconds or longer, persist

• Assessment : Rupture of amniotic membranes• Interventions

• Maintain left lateral position, Monitor fetal status.• Betamethasone to hasten surfactant production.• Administer tocolytics (to stop contractions)













Preterm Labor• Client Education• Immediate Actions for pt experiencing suspected

premature labor (at home)• 1. Empty Bladder• 2. Left Lying Position• 3. Drink 3-4 cups of water• 4.Palpate abdomen to assess contraction, 10 mts apart

or closer- contact doc• 5. rest for 30 mts and slowly resume activity if

symptoms disappear. If symptoms persist upto 1 hr,contact doc

• Client Education• Immediate Actions for pt experiencing suspected












Tocolytics– Contraindications for tocolytics

• Active vaginal bleeding, dilation of the cervix greater than 6cm, chorioamnionitis, greater than 34 weeks of gestation,and acute fetal distress.

– Ritodrine, Turbutaline, Mag sulphate, Nefidipine,Indomethacin

– Betamethasone : pulmonary edema & hyperglycemia– Indomethacin : PP hemorrhage, blood-tinged sputum– Magnesium sulfate toxicity: -loss of deep tendon

reflexes, urinary output less than 30 mL/hr, respiratorydepression less than 12/min, pulmonary edema,and/or chest pain

– Contraindications for tocolytics• Active vaginal bleeding, dilation of the cervix greater than 6

cm, chorioamnionitis, greater than 34 weeks of gestation,and acute fetal distress.














Premature Rupture of Membranes– Description

• Rupture of the amniotic sac before onset of true labor,regardless of length of gestation

– Assessment• Nitrazine test positive• Fern test positive• Presence of pool of fluid near cervix

– Interventions• Depending on gestational week, may remain in hospital or at

home on bed rest or with activity limitations• NO PV (unless absolute necessary, sterile technique) , check

temp Q 2hrs, hydration• If home

– Educate to avoid sexual intercourse, insertion of anything intovagina

– Avoid breast stimulation if gestation is preterm– Monitor temperature; report temperature of 100° F immediately– Administer antibiotics to mother as prescribed

– Description• Rupture of the amniotic sac before onset of true labor,

regardless of length of gestation– Assessment

• Nitrazine test positive• Fern test positive• Presence of pool of fluid near cervix






















Placenta Previa

– Description• Improperly implanted placenta in the lower uterine

segment, near or over the internal cervical os• May be total, partial, marginal, or low-lying, depending

on how much of os is covered– Assessment

• Sudden onset of painless, bright red vaginal bleeding– Meds

• Corticosteroids, such as betamethasone (Celestone),promote fetal lung maturation if delivery is anticipated(cesarean birth).

• Have oxygen equipment available in case of fetaldistress.



















Placenta Previa

– Interventions• Monitor maternal and fetal status• Assess for bleeding, leakage, or contractions• Maintain mother in side-lying position as prescribed• Monitor amounts of bleeding; assess for development

of shock• Refrain from performing vaginal exams (may exacerbate

bleeding).• Administer IV fluids, blood products, and medications

as prescribed




as prescribed




as prescribed




as prescribed

Abruptio Placentae– Description

• Premature separation of the placenta from the uterinewall after twentieth week of gestation, before fetus isdelivered

– Assessment• Dark red, painful vaginal bleeding• Uterine rigidity

– Interventions• Monitor maternal and fetal status• Maintain bed rest; administer oxygen• Prepare for delivery of fetus as quickly as possible;

vaginal delivery preferred but, because of emergency,cesarean section may be done

– Description• Premature separation of the placenta from the uterine

wall after twentieth week of gestation, before fetus isdelivered














Abruptio Placentae– Interventions

• Monitor maternal and fetal status• Maintain bed rest; administer oxygen• Palpate the uterus for tenderness and tone.• Assess FHR pattern.• Administer IV fluids, blood products, and medications• Corticosteroids to promote fetal lung maturity• Administer oxygen 8 to 10 L/min via face mask.• Assess urinary output and monitor fluid balance.• Prepare for delivery of fetus as quickly as possible;

vaginal delivery preferred but, because of emergency,cesarean section may be done.

– Interventions• Monitor maternal and fetal status• Maintain bed rest; administer oxygen• Palpate the uterus for tenderness and tone.• Assess FHR pattern.• Administer IV fluids, blood products, and medications• Corticosteroids to promote fetal lung maturity• Administer oxygen 8 to 10 L/min via face mask.• Assess urinary output and monitor fluid balance.• Prepare for delivery of fetus as quickly as possible;






Supine Hypotensive Syndrome

(Vena Cava Syndrome)– Description

• Occurs when venous return to heart is impaired byweight of uterus; results in partial occlusion of venacava and descending aorta and in reduced cardiacreturn, cardiac output, blood pressure

– Assessment• Faintness, lightheadedness, vertigo, hypotension, fetal

distress– Interventions

• Position client in lateral recumbent position to shiftweight of fetus off inferior vena cava

• Monitor maternal and fetal vital signs



















Anemia– Description

• Predisposes client to postpartum infection– Assessment

• Fatigue, headache, pallor, tachycardia,hemoglobin level lower than 10 mg/dL,hematocrit level lower than 30 g/dL

– Interventions• Monitor hemoglobin and hematocrit levels

every 2 weeks• Instruct client to take iron and folic acid

supplements






supplements






supplements






supplements

Medications - Anemia

• Ferrous sulfate (325 mg) iron supplements twice daily– Instruct the client to take the supplement on an empty

stomach.– Encourage a diet rich in vitamin C-containing foods to

increase absorption.– Suggest that the client increase roughage and fluid intake

in diet to assist with discomforts of constipation.• Iron dextran (Imferon)

– Used in the treatment of iron-deficiency anemia when oraliron supplements cannot be tolerated by the client who ispregnant.
















HIV/AIDS• Routine laboratory testing in the early prenatal period.• Procedures, such as amniocentesis and an episiotomy, should be

avoided due to the risk of maternal blood exposure.• Avoid internal fetal monitors, vacuum extraction, and forceps

during labor.• Administration of injections and blood testing should not take place

until the first bath is given to the newborn.• Instruct the client not to breastfeed• Postpartum period: If mother immunocompromised, place in

protective isolation• Antiviral prophylaxis (retrovir -Zidovudine) may be given to mother

– Administer retrovir at 14 weeks of gestation, throughout thepregnancy, and before the onset of labor or cesarean birth.

– Administer retrovir to the infant at delivery and for 6 weeks followingbirth.

• Routine laboratory testing in the early prenatal period.• Procedures, such as amniocentesis and an episiotomy, should be





















Group B, Streptococcus ß-Hemolytic

• GBS is a bacterial infection that can be passedto a fetus during labor and delivery.

• Positive GBS may have maternal and fetaleffects, including premature rupture ofmembranes, preterm labor and delivery,chorioamnionitis, infections of the urinarytract, and maternal sepsis.

• Vaginal and rectal cultures are performed at36 to 37 weeks of gestation.










GBS• Administer intrapartum antibiotic prophylaxis (IAP).

(Penicillin)• ■■ Client who delivered previous infant with GBS infection• ■■ Client who has GBS bacteriuria during current

pregnancy• ■■ Client who has a GBS-positive screening during current

pregnancy• ■■ Client who has unknown GBS status who is delivering at

less than 37 weeks of gestation• ■■ Client who has maternal fever of 38° C (100.4° F)• ■■ Client who has rupture of membranes for 18 hr or

longer

• Administer intrapartum antibiotic prophylaxis (IAP).(Penicillin)

• ■■ Client who delivered previous infant with GBS infection• ■■ Client who has GBS bacteriuria during current




longer






longer






longer

XV. Gestational Hypertension (GH)– Description and types

• Acute hypertensive state that develops after twentieth week ofgestation

• hypertensive disorders of pregnancy whereby the woman has anelevated blood pressure at 140/90 mm Hg or greater recorded atleast twice, 4 to 6 hr apart, and within a 1-week period, after the20th week of pregnancy

• Condition can be mild or severe; can progress to eclampsia,characterized by presence of seizures

• associated with placental abruption, kidney failure, hepatic rupture,preterm birth, and fetal and maternal death.

– Predisposing conditions• Chronic conditions, such as renal disease, hypertension, diabetes

mellitus• Primigravida, especially women younger than 19 years or older than

40 years of age








40 years of age








40 years of age








40 years of age

XV. Gestational Hypertension (GH)– Assessment

• Mild: Elevated blood pressure, usually 15 to 30 mm Hgabove baseline;

• weight gain of 1 lb/week or more in last trimester;• mild, generalized edema;• proteinuria of 1+ to 2+

• Severe: Severe hypertension, systolic blood pressure atleast 160 mm Hg or diastolic at least 110 mm Hg;massive, generalized edema; weight gain; proteinuria 3+to 4+; oliguria; visual disturbances; headache; HELLPsyndrome of laboratory findings—hemolysis, elevatedliver enzymes, low platelets

• Eclampsia: Characterized by generalized seizures
















HELLP syndrome• Severe preeclampsia involving hepatic

dysfunction.• HELLP syndrome is diagnosed by laboratory tests.

– H – hemolysis resulting in anemia and jaundice– EL – elevated liver enzymes resulting in elevated

alanine aminotransferase (ALT) or aspartatetransaminase (AST), epigastric pain, and nausea andvomiting

– LP – low platelets (less than 100,000/mm3), resultingin thrombocytopenia, abnormal bleeding and clottingtime, bleeding gums, petechiae, and possiblydisseminated intravascular coagulopathy (DIC)

• Severe preeclampsia involving hepaticdysfunction.

• HELLP syndrome is diagnosed by laboratory tests.– H – hemolysis resulting in anemia and jaundice– EL – elevated liver enzymes resulting in elevated











Magnesium sulfate.• Medication of choice for prophylaxis or treatment to lower

blood pressure and depress the CNS.• Nursing Considerations

– Use an infusion control device to maintain a regular flow rate.– Inform the client that she may initially feel flushed, hot, and

sedated with the magnesium sulfate bolus.– Monitor the client’s blood pressure, pulse, respiratory rate,

deep-tendon reflexes,– Monitor level of consciousness, urinary output (indwelling

urinary catheter for accuracy),– Monitor for presence of headache, visual disturbances,

epigastric pain– Monitor uterine contractions, and FHR and activity.

• Place the client on fluid restriction of 100 to 125 mL/hr, andmaintain a urinary output of 30 mL/hr or greater.

• Medication of choice for prophylaxis or treatment to lowerblood pressure and depress the CNS.

• Nursing Considerations– Use an infusion control device to maintain a regular flow rate.– Inform the client that she may initially feel flushed, hot, and




















Magnesium sulfate.• Monitor the client for signs of magnesium sulfate

toxicity.– BLURP: decreased blood pressure; decreased level of

consciousness decreased urinary output; respiratorydepression; depressed or absent patellar reflex

– Cardiac dysrhythmias

• If magnesium toxicity is suspected:– Immediately discontinue infusion.– Administer antidote calcium gluconate.– Prepare for actions to prevent respiratory or cardiac

arrest.

• Monitor the client for signs of magnesium sulfatetoxicity.– BLURP: decreased blood pressure; decreased level of




arrest.





arrest.





arrest.

XV. Gestational Hypertension (GH)(continued)– Complications of GH

• Hematological conditions, such as disseminatedintravascular coagulation, thrombocytopenia

• Placental conditions, such as abruptio placentae,placental insufficiency

• Intrauterine growth restriction, intrauterine fetal death– Interventions for mild hypertension

• Close monitoring of blood pressure• Frequent rest periods• Administer antihypertensives as prescribed• Monitor renal function, especially for proteinuria, intake

and output






and output






and output






and output

XV. Gestational Hypertension (GH)(continued)– Interventions for mild preeclampsia

• Implement interventions as noted for mild hypertension• Monitor neurological status, especially for signs of

impending seizure• Monitor for deep tendon reflexes, presence of clonus• Monitor for HELLP: Laboratory diagnosis for severe

preeclampsia characterized by hemolysis, elevated liverenzyme levels, low platelet count

• No added salt diet, with increase in dietary protein andcarbohydrates
















XV. Gestational Hypertension (GH)(continued)

– Interventions for severe preeclampsia• Implement interventions for mild hypertension and mild preeclampsia• Administer magnesium sulfate as prescribed• Monitor for signs of magnesium toxicity, including BURP: decreasedblood pressure; decreased urinary output; respiratory depression;depressed or absent patellar reflex

• Keep calcium gluconate antidote at bedside at all times– Eclampsia

• Diagnosed when seizures occur• Provide care as with any seizure; monitor fetal heart rate and

contractions• Administer magnesium sulfate as prescribed• Prepare for delivery of fetus
















Discharge instructions• Maintain the client on bed rest, and encourage side-lying

position.• Promote diversional activities.• Have the client avoid foods that are high in sodium (may

not completely restrict sodium – possibility of Hypovolemiaand fetal distress)

• Have high protein diet.• Have the client avoid alcohol and limit caffeine.• Instruct the client to be adequately hydrated.• Maintain a dark quiet environment to avoid stimuli that

may precipitate a seizure.• Maintain a patent airway in the event of a seizure.• Administer antihypertensive medications as prescribed.

• Maintain the client on bed rest, and encourage side-lyingposition.

• Promote diversional activities.• Have the client avoid foods that are high in sodium (may














• A nurse in labor and delivery is providing care fora client who is in preterm labor at 32 weeks ofgestation. Which of the following medicationsshould the nurse anticipate the provider willprescribe to hasten fetal lung maturity?

• A. Calcium gluconate• B. Indomethacin (Indocin)• C. Nifedipine (Procardia)• D. Betamethasone (Celestone

• A nurse in labor and delivery is providing care fora client who is in preterm labor at 32 weeks ofgestation. Which of the following medicationsshould the nurse anticipate the provider willprescribe to hasten fetal lung maturity?

• A. Calcium gluconate• B. Indomethacin (Indocin)• C. Nifedipine (Procardia)• D. Betamethasone (Celestone

• A. INCORRECT: Calcium gluconate is administeredas an antidote for magnesium sulfate toxicity.

• B. INCORRECT: Indomethacin is an NSAID used tosuppress preterm labor by blocking prostaglandinproduction.

• C. INCORRECT: Nifedipine is a calcium channelblocker used to suppress uterine contractions.

• D. CORRECT: Betamethasone is a glucocorticoidthat is given to clients in preterm labor to hastensurfactant production.

• A. INCORRECT: Calcium gluconate is administeredas an antidote for magnesium sulfate toxicity.

• B. INCORRECT: Indomethacin is an NSAID used tosuppress preterm labor by blocking prostaglandinproduction.

• C. INCORRECT: Nifedipine is a calcium channelblocker used to suppress uterine contractions.

• D. CORRECT: Betamethasone is a glucocorticoidthat is given to clients in preterm labor to hastensurfactant production.

• A nurse in the emergency department is caringfor a client who reports abrupt, sharp, right-sidedlower quadrant abdominal pain and bright redvaginal bleeding. The client states she missed onemenstrual cycle and cannot be pregnant becauseshe has an intrauterine device. The nurse shouldsuspect which of the following?

• A. Missed abortion• B. Ectopic pregnancy• C. Severe preeclampsia• D. Hydatidiform mole

• A nurse in the emergency department is caringfor a client who reports abrupt, sharp, right-sidedlower quadrant abdominal pain and bright redvaginal bleeding. The client states she missed onemenstrual cycle and cannot be pregnant becauseshe has an intrauterine device. The nurse shouldsuspect which of the following?

• A. Missed abortion• B. Ectopic pregnancy• C. Severe preeclampsia• D. Hydatidiform mole

• A nurse at an antepartum clinic is caring for a clientwho is at 4 months of gestation. The client reportscontinued nausea and vomiting and scant, prune-colored discharge. She has experienced no weight lossand has a fundal height larger than expected. Which ofthe following complications should the nurse suspect?

• A. Hyperemesis gravidarum• B. Threatened abortion• C. Hydatidiform mole• D. Preterm labor

• A nurse at an antepartum clinic is caring for a clientwho is at 4 months of gestation. The client reportscontinued nausea and vomiting and scant, prune-colored discharge. She has experienced no weight lossand has a fundal height larger than expected. Which ofthe following complications should the nurse suspect?

• A. Hyperemesis gravidarum• B. Threatened abortion• C. Hydatidiform mole• D. Preterm labor

• A nurse on the obstetrical unit is admitting aclient who is in labor. The client has a positive HIVstatus. The nurse is aware that which of thefollowing is contraindicated for this client? (Selectall that apply.)

• A. Episiotomy• B. Vacuum extraction• C. Forceps• D. Cesarean birth• E. Internal fetal monitorin

• A nurse on the obstetrical unit is admitting aclient who is in labor. The client has a positive HIVstatus. The nurse is aware that which of thefollowing is contraindicated for this client? (Selectall that apply.)

• A. Episiotomy• B. Vacuum extraction• C. Forceps• D. Cesarean birth• E. Internal fetal monitorin

• A nurse is caring for a client who has aprescription for magnesium sulfate. The nurseshould recognize that which of the following arecontraindications for use of this medication.(Select all that apply.)

• A. Acute fetal distress• B. Preterm labor• C. Vaginal bleeding• D. Cervical dilation greater than 6 cm• E. Severe gestational hypertension



• A. CORRECT: Acute fetal distress is a complication thatis a contraindication for the use of magnesium sulfatetherapy.

• B. INCORRECT: Preterm labor is an indication for theuse of magnesium sulfate.

• C. CORRECT: Vaginal bleeding is a complication that is acontraindication for magnesium sulfate therapy.

• D. CORRECT: Cervical dilation greater than 6 cm is acomplication that is a contraindication for magnesiumsulfate therapy.

• E. INCORRECT: Severe gestational hypertension is anindiction for the use of magnesium sulfate.






L&D CareAnila Simon MS, RN, CVRN, CMSRN

Apple RN CoachingLearn Nursing International

Anila Simon MS, RN, CVRN, CMSRNApple RN Coaching

Learn Nursing International

Labor– Lightening: Fetus descends into pelvis about 2 weeks before

delivery– Leopold maneuvers – abdominal palpation of fetus– Braxton-Hicks contractions increase– True labor

• Contractions increase in duration and intensity• Cervical dilation, effacement are progressive

– False labor• Labor does not produce dilation, effacement, or descent• Contractions are irregular, without progression• Walking has no effect on contractions; often relieves false

labor

– Lightening: Fetus descends into pelvis about 2 weeks beforedelivery

– Leopold maneuvers – abdominal palpation of fetus– Braxton-Hicks contractions increase– True labor



labor





labor





labor

• Assessment during Labor (initial)– BP, PR, RR - q 1 hr, Temp – Q 2 hr– Contractions q 30 mts (q15 mts – high risk)

• Ice chips and clear liquids – prevent dehydration• Position comfortably• Relaxation Techniques• Asessment during Labor (later)

– BP, PR, RR, FHR - q 5 -15mts.– Contraction - continuous– Uterine fundus tone

• Episiotomy : document degree (1,2,3,4)













Fetal Heart Rate Monitoring– Normal FHR 120 to 160 beats/min

• If change occurs, turn mother to left side, administeroxygen as prescribed

• Accelerations may occur with fetal movement orcontractions

• Early decelerations occur during contractions when fetalhead is pressed against woman’s pelvis; require nointervention

• Late decelerations usually associated with impairedplacental exchange or uteroplacental insufficiency;require interventions to improve placental blood flow andfetal oxygenation, including immediate delivery of fetus

• Variable decelerations usually caused by umbilical cordcompression; require change in maternal positioning

– Normal FHR 120 to 160 beats/min• If change occurs, turn mother to left side, administer

oxygen as prescribed• Accelerations may occur with fetal movement or

contractions• Early decelerations occur during contractions when fetal

head is pressed against woman’s pelvis; require nointervention















Early Decelerations

Late Decelerations

Variable Decelerations

Pain Management

• Nonpharmacological– Position changes– Hydrotherapy– Breathing techniques & Relaxation

• Pharmacological :- Should be minimal risk.- Lumbar Epidural block

- monitor urinary output (retention may occur)- Monitor BP( maternal hypotension)

• All systemic drugs cross placental barrier













Dystocia

– Description• Difficult labor that is prolonged or more painful• May occur because of problems caused by uterine

contractions, fetus, or bone and tissues of maternalpelvis

– Assessment• Fetal distress• Lack of progress in labor

– Interventions• Assess fetal heart rate (FHR); monitor for distress• Monitor uterine contractions• Assess for prolapse of cord after rupture of membranes













Prolapsed Cord– Description

• Umbilical cord displaced between presenting part and amnion orprotrudes through cervix, causing compression, compromising fetalcirculation

– Assessment• Visible umbilical cord• Irregular and slow FHR

– Interventions• Relieve cord pressure immediately, call for help.• Turn mother side to side or elevate her hips to shift fetal presenting

part toward her diaphragm• Elevate fetal presenting part lying on cord by applying finger pressure

with sterile gloved hand• Do not attempt to push cord into uterus• Monitor FHR and for signs of hypoxia• Administer oxygen to mother as prescribed• Prepare for emergency cesarean birth as prescribed

– Description• Umbilical cord displaced between presenting part and amnion or

protrudes through cervix, causing compression, compromising fetalcirculation

















Rupture of Uterus– Description

• Complete or incomplete separation of uterine tissue asresult of tear in wall of uterus from stress of labor

– Assessment• Fetus palpated outside uterus (complete rupture)

– Interventions• Monitor for and treat signs of shock; administer

oxygen, intravenous fluids, blood products asprescribed

• Prepare mother for cesarean section or hysterotomywith hysterectomy as prescribed

• Provide emotional support for client, partner, family

– Description• Complete or incomplete separation of uterine tissue as

result of tear in wall of uterus from stress of labor– Assessment

• Fetus palpated outside uterus (complete rupture)– Interventions

• Monitor for and treat signs of shock; administeroxygen, intravenous fluids, blood products asprescribed















Amniotic Fluid Embolism

– Description• Escape of amniotic fluid into maternal circulation; debris

containing amniotic fluid deposits in pulmonaryarterioles, usually fatal to mother

– Assessment• Abrupt onset of respiratory distress, chest pain;

cyanosis; seizures; heart failure, pulmonary edema; fetalbradycardia, distress

– Interventions• Institute emergency measures to maintain life• Administer oxygen 8 to 10 L/min; prepare for intubation,

mechanical ventilation



















Fetal Distress– Assessment

• FHR lower than 120 or more than 160 beats/min• Meconium-stained amniotic fluid• Fetal hyperactivity• Progressive decrease in baseline variability• Severe variable decelerations, late decelerations

– Interventions• Place mother in lateral position; elevate legs• Administer oxygen at 8 to 10 L/min via face mask as

prescribed• Discontinue oxytocin (Pitocin) if infusing as prescribed• Monitor maternal and fetal vital signs• Prepare for emergency cesarean section as prescribed

– Assessment• FHR lower than 120 or more than 160 beats/min• Meconium-stained amniotic fluid• Fetal hyperactivity• Progressive decrease in baseline variability• Severe variable decelerations, late decelerations









• A nurse is caring for a client who is receivingnifedipine (Procardia) for prevention ofpreterm labor. The nurse should monitor theclient for which of the following clinicalmanifestations?

• A. Blood-tinged sputum• B. Dizziness• C. Pallor• D. Somnolence

• A nurse is caring for a client who is receivingnifedipine (Procardia) for prevention ofpreterm labor. The nurse should monitor theclient for which of the following clinicalmanifestations?

• A. Blood-tinged sputum• B. Dizziness• C. Pallor• D. Somnolence

• A. INCORRECT: Blood-tinged sputum productionis an adverse affect associated with indomethacin(Indocin).

• B. CORRECT: Dizziness and lightheadedness areassociated with orthostatic hypotension, whichoccurs when taking nifedipine.

• C. INCORRECT: Facial flushing and heat sensationare adverse effects associated with nifedipine.

• D. INCORRECT: Nervousness, jitteriness, and sleepdisturbances are adverse effects associated withnifedipine.

• A. INCORRECT: Blood-tinged sputum productionis an adverse affect associated with indomethacin(Indocin).

• B. CORRECT: Dizziness and lightheadedness areassociated with orthostatic hypotension, whichoccurs when taking nifedipine.

• C. INCORRECT: Facial flushing and heat sensationare adverse effects associated with nifedipine.

• D. INCORRECT: Nervousness, jitteriness, and sleepdisturbances are adverse effects associated withnifedipine.















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