High Risk Prenatal Client

8/10/2019 High Risk Prenatal Client

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High Risk Prenatal Client

High risk pregnancy- When life or wellbeing of woman or fetus has significantly increased risk of harm, damage, injury, or disability (morbidity) or loss of life or death (mortality)by disorder coincidental w/ or unique to pregnancy

RISK FACTORS

A. DEMOGRAPHIC FACTORI. Age- 20-30 optimal age for bearing- below 16 / 35 up

II. Weight- overweight- underweight

III. Height- Less than 5ft (high risk because of pelvic shape)

B. SOCIO-ECONOMIC FACTOR1. Inadequate finances2. Overcrowding3. Poor standards of housing4. Poor hygiene5. Unplanned and prepared pregnancy esp. among adolescent6. Poverty and low educational status

C. OBSTETRIC HISTORY1. History of infertility or multiple gestation2. Grandmultiparity3. Previous abortion or ectopic pregnancy4. Previous loses : fetal death, stillbirth, neonatal or perinatal death5. Previous operative OB, CS, and midforceps delivery6. Previous uterine or cervical abnormality7. Previous abnormal labor : Premature labor or postmature labor, prolonged labor8. Previous high-risk infant : low birth wt (LBW), macrosomic (LGA) w/ neurologic deficit, birth injury or malformation

9. Previous hydatidiform mole (H-mole)

D. CURRENT OB STATUS1. Late or No prenatal care2. Maternal anemia3. Rh sensitization4. Antepartal bleeding, placenta previa and abruption placenta5. Pregnancy-induced hypertension6. Multiple gestation7. Premature or post-mature labor8. Polyhydramios9. PROM10. Fetus inappropriately large or small; abnormality in tests for fetal well being; abnormality in presentation

E. MATERNAL HISTORY STATUS1. Cardiac or pulmonary disease2. Metabolic disease : DM, thyroid disease3. Endocrine disorder : pituitary, adrenal4. Chronic renal disease : repeated UTI, bacteriuria5. Chronic hypertension6. Venereal and other infectious disease7. Major congenital anomalies of reproductive tract8. Hemoglobinopathies : sickle cell anemia, thalassemia9. Seizure disorder10. Malignancy11. Major emotional distress, mental retardation


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F. HABITS/HABITUATION1. Smoking2. Regular alcohol intake3. Drug abuse/use

DIAGNOSTIC TESTS in high risk-pregnancy

1. ULTRASONOGRAPHY/UTZ/ULTRASOUND

- A non-invasive diagnosis procedure utilizing a high-frequency sound waves to detect intrabody structures.

Purposes:1. In an early pregnancy : to confirm pregnancy2. To detect :fetuss

- viability, growth -FHT- number (multiple pregnancy) - AOG- position, presentation- abnormalities

3. Detects placental location or placental abnormality4. An important aid in high-risk procedures like amniocentesis

Preparation:1. Advices mother to drink 1 quarter of water 2 hrs before procedure.2.Instruct not to void (Ultrasound)In amniocentesis w/ ultrasound to offer visualization, the mother should void to prevent injuring the distended bladder w/ needle insertion.

3. Transmission gel is spread over maternal abdomen4. Psychological support is given to the mother/father-confinement is not needed-no need for dye and there is no x-ray radiation-takes about 30 min. to accomplish

2. NON-STRESS TEST (NST)- Observation of FHR related to movement- Test of fetal well-being

Preparation:1. Position semi- fowlers or left lateral 2. Check BP3. Explain :- Procedure takes : 30-60 min.- Mother needs to activate mark button w/ each fetal movement- Does not need hospitalization ambulatory basis4. Requires external electronic monitoring of FHT w/ ultrasound transducer and tocodynamometer to trace fetal activity and o r uterine activity

Interpretation:1. Normal : Reactive- Increased FHR (acceleration)- 15 bpm above baseline

- lasting 15 sec or more in a 10-20 min period w/ fetal movement

2. Abnormal : Non reactive-No FHR acceleration w/ fetal movement

Implication of Results:1. Normal : High risk pregnancy continues2. Abnormal : Mother needs another test, may be BPP

3. OXYTOCIN CHALLENGE TEST (OCT) OR CONTRACTION STRESS TEST (CST)

Purposes :1. Observation of response of the fetus to individual uterine contractions


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2. A test of feto-placental wellbeing

Preparation:1. Semi-fowlers or left lateral 2. BP is checked priorly and every 15 min. during test3. Explain-Procedure takes 1-3 hr to finish-Mother receives Oxytocin of increasing dosage-Soluset to the mainline and Aimed to cause 3 uterine contractions in 10 min.-May be done on outpatient basis

4. Require external electronic FHT monitoring w/ ultrasound transducer and tocodynamometer to detect uterine activity

Interpretation:1. Normal : Negative-No late deceleration of FHR w/ each of 3 contractions during a 10 min. interval2. Abnormal : Positive- w/ late decelerations of FHR w/ 3 contractions in 10 min.

Implication of Results:

1. Normal: Pregnancy continues, normal result of OCT may require weekly tests2. Abnormal result: may indicate a need to terminate pregnancy

4. NIPPLE STIMULATION CONTRACTION TEST

Purposes:1. Determine feto-placental function/well-being2. Breasts are stimulated w/ rolling of nipples or warm-towel applicaition3. The baseline data are obtained through monitoring as in OCT procedure4. Interpretation: as in OCT : the absence of late decelerations in 3 contractions in 10 min is the desired result

5. BIOPHYSICAL PROFILE (BPP)- a scoring combining ultrasound assessment of :1. Fetal breathing2. Fetal movement3. Fetal muscle tone4. Reactivity of heart rate

5. Amniotic fluid volume

Scores:8-10 : Normal, low risk for chronic asphyxia4-6 : Suspected chronic asphyxia0-2 : Strong suspicion of chronic asphyxia

6. AMNIOCENTESIS- Entering the amniotic sac to aspirate amniotic fluid for a variety of diagnostic exams to detect fetal wellbeing

Major risks:1. Trauma : fetus, placenta, umbilical cord2. Infection3. Abortion4. Preterm labor

Preparation:1. Secure an informed consent2. Prepare for ultrasound : to locate placenta and to provide visualization to a blind procedure-ultrasound in amniocentesis : client needs to void-pelvic ultrasound only: clients should not void3. Increase oral fluids: Take 1 quarts water 2 hrs before4. Prepare needle , gauge : 20- 22 , 3 -6 5. Prepare for administration of local anesthesia of abdomen6. Provide psychological support

-Amt. of amniotic fluid to be aspirated up to 30ml at 15 to 18 weeks gestation


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Implications:1. Decreased L/S ratio2. Fetal blood false high levels of AFP

Aftercare:1. Monitor 30-60 min2. Observe for side effects such as :-vaginal discharge

-increase uterine/fetal activity- fever and chills

Analysis of amniotic fluid1. TO determine fetal lung maturityL/S ratio: 2:1 means mature lungs

2. Determination of AOG-Creatinine levels : 2.0 mg 36 wks AOG more than 2.0 mg greater than 36 wks-Nile blue stain (lipid cells) when 20 % of cells are stained w/ orange means fetal weight is at least 2500 g

3. Alpha-fetoprotein levels :High levels : presence of neural defects such as :-aspina bifida-tracheoesophageal atresia

4. Genetic disorder5. Rh incompatibility : Increased levels of bilirubin identified isoimmunization; evaluated for intrauterine transfusion or deliver6. Inborn errors metabolism : biochemical analysis of fetal cell enzymes*Rh- rhesus7. Fetal distress: passage of meconium in cephalic presentation (not significant in breech presentation)8. Sex-linked disorders : sex chromosome determination

7. X-RAY LATERAL PELVIMETRY-Indications for radiography to determine pelvic size and shape- suspected cephalopelvic disproportion-history of injury/disease of pelvis and spine

-previous difficult delivery- cases of maternal deformity or limp

8. SERIAL ESTRIOL DETERMINATION-Measures feto-placental wellbeing-specimens: serum/ 24 hr urine

Results:1. Normal : gradual increase in serial estriol w/c is 12-50 mg/day at term2. Abnormal : sudden drop of less than 50% of level means fetal distress3. Persistent low levels means fetal wellbeing is compromised

9. CHORIONIC VILLI SAMPLING (CVS)- Earliest test possible on fetal cells- Sample obtained by slender catheter passed through cervix to implantation site

10. PUBS- Used in 2 nd and 3 rd tri.-Uses ultrasound to locate umbilical cord-Cord blood aspirated and tested


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IDENTIFYING A HIGH RISK PREGNANCY

High risk pregnancy- One in w/c a concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the woman, fetus, or both.

CARDIOVASCULAR DISORDERS1. Valve damage Caused by rheumatic fever or Kawasaki disease2. Congenital anomalies e.g., Atrial septal defect or uncorrected coarctation of the aorta

3. Aortic dilatation Caused by Marfans syndrome 4. Coronary artery disease and varicosities As the number of women delaying their first pregnancy until later in life

Blood volume and cardiac output increase during pregnancy

1. Functional heart murmurs Because of increased blood flow past valves2. Heart palpitations also normal

Valvular and aortic artery constrictions- Women who had Kawasaki disease as a child may have this and it can lead to true valve dysfunction and organic murmurs

1. The danger of pregnancy in a woman w/ cardiac disease is primarily because of Increase in circulatory volume2. The most dangerous time for a woman is in weeks 28-32 just after the blood volume peaks3. A womans heart may become so overwhelmed by the increase in blood volume toward the end of pregnancy that her cardiac out put falls to the point that vitalorgans including the placenta are no longer perfused adequately. Then , neither oxygen nor nutritional requirements of her cells or those of the fetus can be met.4. There are 4 categories of heart disease

CARDIAC DISEASE- Caused by inability to cope w/ added volume and increase cardiac output that occurs during pregnancy.

Class I- Uncompromised- No symptoms of insufficiency- No limits on physical activity

Class II Slightly compromised- Slight limitation of activity- Dyspnea, fatigue, palpitation, chest pain or angina pain- W/ ordinary activity

*Recommendation (I & II)- Sleep for 10 hrs- Rest 30 min. every after meal*Good prognosis for vaginal delivery

Class III- Markedly compromised- Considerable limitation of activity

- Less than normal activity procedures- Excessive symptoms of fatigue, palpitations, chest pain, dyspnea, comfortable only a t rest

*Recommendation- Early hospitalization for 7-8 mos. of pregnancy

Class IV- Severely compromised- Inability to perform any physical activity- Symptoms of insufficiency present at rest

*Recommendation- Therapeutic abortion


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*Poor prognosis for vaginal delivery; no lithotomy and valsalva maneuver w/c can trigger cardiac arrest ; no rectal suppository w/c can trigger valsalva maneuver

CONGENITAL ANOMALIES- Atrial septal disease- Ventricular septal defect- Occur from congenital or rheumatic heart disease- Pulmonary stenosis- Coarction of Aorta

1. RHEUMATIC HEART DISEASE (rheumatic endocarditis)- Endocarditis w/ scar tissue formation on the mitral, aortic, tricuspid valves w/ resulting stenosis or insufficiency- Patient w/ mitral valve prolapsed may require prophylactic therapy during laborPathophysio :valve stenosis Decrease blood flow , work on the heart chambers increase regurgitation occurs through incomplete closed valve , workload on heart increases

Assessment1. Tachycardia2. Dyspnea3. Diastolic murmur4. Crackles at lung bases5. Hemoptysis6. Orthopnea

Management1. Activity limitation2. Close medical supervision3. Rest4. Limited sodium intake5. Prophylactic antibiotics6. Serial ultrasound, non stress test, and BPP

Nursing intervention1. Assess maternal V/S and cardiopulmonary status2. Monitor weight gain3. Prescribed medication4. Frequent prenatal visit

5. Report danger signs and symptoms6. Assess nutritional pattern7. Frequent rest8. Report any signs and symptoms of infection9. Advise rest in lateral recumbent position10. Anticipate use of epidural anesthesia labor11. Close observation for changes during labor12. Monitor V/S13. W/ severe heart failure used anticoagulant and cardiac glycoside therapy14. Encourage ambulation15. Administer of a prophylactic antibiotic16. Instruct to avoid high altitude, smoking area, crowded areas, drinking alcohol, and food w/ caffeine and smoking is prohibited

Remember*should avoid- infection- excessive weight- edema- anemia

2. DIABETES MELLITUS- Metabolic disorder characterized by hyperglycemia resulting from lack of insulin- Endocrine disorder of carbohydrate, proteins and fat metabolism

Gestational DM (GDM)Pregestational DM (PGDM) prior to pregnancy


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Classification:1. Type I (IDDM) Insulin dependent DM2. Type II (NIDDM) Non insulin dependent DM

Factors :1. Hereditary2. Environment3. Lifestyle

Susceptible for type I:1. Production of autoantibodies against beta cells of pancreas2. Restriction of beta cells3. Decline or lack of insulin4. Hyperglycemia5. Lipolysis6. Protein catabolism

Assessment:1. Hyperglycemia2. Glycosuria3. Polyuria4. Polydipsia5. Weight loss6. Increased incidence of candidal infections7. Hydramnios8. S/S of macrovascular and microvascular changes9. Peripheral vascular disease10, Retinopathy11. Nephropathy12. Neuropathy

Diagnostic test1. Screening w/ an oral glucose challenge test2. 100 g glucose load used at 24-28 wks gestation

Management

1. Blood glucose monitoring2. Target glucose level of FBS3. Diet, exercise and insulin administration

Type 11. Monitoring of glucose level2. Evaluation of glycosylated hgb (HbA1c) level every 3-4 mos.

Interventions1. Monitor patient status throughout the pregnancy2. Review result of fingerstick blood glucose monitoring3. Follow up lab results4. Encourage consistent exercise program5. Diabetic care management6. Assist w/ preparation for labor7. Assess possible complications and effects

Mother:1. Has 30% to 40% chance of developing DM in 1-25 yrs.2. Dystocia because of large infant3. Increased risk for postpartum hemorrhage due to over distention of uterus4. Polyhydramnios5. Gestational hypertension6. Maternal mortality7. Retinopathy and nephropathy8. Preterm delivery9. UTI


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10. Candidiasis , Moniliasis11. Spontaneous abortion

Infant:1. Sacral agenesis2. Congenital anomalies3. Macrosomia4. Prematurity5. Hypoglycemia and Hypocalcemia6. Birth injury

7. Respiratory distress8. Intrauterine fetal growth retardation9. Fetal death

3. SUBSTANCE ABUSE- Misuse or overuse of substance including alcohol, prescription, OTC, and illicit drugs

I. Caffeine- Coffee, tea, cola, chocolate, cold remedies, analgesics

Maternal effects:1. CNS and cardiac function stimulation2. Vasoconstriction3. Mild dieresis results

Fetal effect:1. Placental barrier is crossed

II. Tobacco- Decrease in O2 carrying capacity of hemoglobin- Carbon monoxide crosses the placenta- Nicotine causes decrease in uterine perfusion and vasoconstriction- Cadmium interferes w/ placental transfer and zinc

Maternal effects:1. Decrease in placental perfusion2. Anemia

3. PROM4. Preterm labor5. Spontaneous abortion

Fetal effects:1. Prematurity2. LBW3. Fetal demise4. Developmental delays5. Incidence of SIDS6. Pneumonia

III. Alcohol- Interferes w/ nutrient absorption- Neuronal differentiation- Facilitate free radical damage- Induces premature death of cells that develop into facial bone and cartilage

Maternal effects:1. Spontaneous abortion

Fetal effects:1. Fetal demise2. IUGR3. Fetal alcohol syndrome (facial and cranial)4. Fetal alcohol effects


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IV. Narcotics- heroin, methadone, morphine

Maternal effects:1. Spontaneous abortion2. ROM3. Preterm labor4. Increase incidence of STD5. HIV exposure6. Hepatitis

7. Malnutrition

Fetal effects1. IUGR2. Perinatal asphyxia3. Intellectual impairment3. Neonatal abstinence syndrome4. Neonatal infections5. Neonatal death (SIDS, child abuse and neglect)

V. Cocaine- cracked - Causes decrease in blood flow to the heart- Platelet aggregation- Brain (seizures)- Intestines- Uterus-Increase in fetal neurotransmitter causes teratogenic effects

Maternal effects:1. Hyperarousal state2. Generalized vasoconstriction3. HPN4. Spontaneous abortion5. Abruptio placenta6. Preterm labor

7. Cardiovascular complications8. Seizure9. STD

Fetal effects:1. Stillbirth2. Poor feeding reflexes3. N/V4. Diarrhea5. Decrease in intellectual development6. Prune-belly syndrome resulting from absence of abdominal muscle

VI. Amphetamine- speed in ice - When processed in crystals to smoke methampethetamines ecstasy

Maternal effects:1. Malnutrition2. Tachycardia3. Withdrawal symptoms

Fetal effects:1. Increase in risk for Cardiac anomalies2. Cleft palate3. IUGR4. Withdrawal syndrome5. Fetal death


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VII. Marijuana- pot , grass - Delta-9-tetrahydrocannabiral crosses placenta- Takes 30 days to be excreted- Increase in carbon monoxide 5x more than tobacco- Detrimental when used during 1 st tri. where fetal organs are being formed

Maternal effects:1. High incidence of anemia

2. Inadequate weight gain

Fetal effects:1. IUGR2. Neonatal tremors3. Sensitivity to light

Assessment:1. Malnutrition2. STD3. poor self image

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High Risk Prenatal Client