NURSING 3SS3 Care Scenario 2 Part 2 Readings,100% CORRECT

NURSING 3SS3 Care Scenario 2 Part 2 Readings Chapter 19 580 – 583 High risk pregnancy: one in which a condition exists that jeopardizes the health of the mother, her fetus or both – can result from the pregnancy or a condition that was present before the woman became pregnant 10% in Canada considered high risk High risk if there is a higher than avg chance of complications developing High risk conditions: gestational diabetes and ectopic pregnancy Early identification of the woman at risk is essential to ensure appropriate interventions are instituted promptly to increase the opportunity for a positive outcome Ultimate goal: the best possible outcome for the woman, her fetus and family Risk assessment: begins at the first antepartal visit and continues with each visit Categories of risk: biophysical, psychosocial, sociodemographic, environmental Major conditions that can complicate a pregnancy: bleeding during pregnancy (spontaneous abortion, ectopic pregnancy, gestational trophoblastic disease, cervical insufficiency, placenta previa, abruptio placentae), hyperemesis gravidarum, gestational hypertension, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, gestational diabtes, blood incompatibility, amniotic fluid imbalances (hydramnios and oligohydramnios), multiple gestation, premature rupture of membranes Bleeding during pregnancy: Can occur early or late and can be a result of numerous conitions Spontaneous abortion: - Abortion: loss of an early pregnancy, usually before 20 weeks of gestation - Spontaneous: loss resulting from natural causes – not elective or therapeutic - Miscarriage: term used by nonmedical ppl to denote a spontaneous abortion - About 80% of these occur within first trimester - 8% of recognized pregnancies is the overall rate but with the development of highly sensitive assays for hCG levels that detect pregnancies prior to the expected next menses, the incidence of pregnancy loss increases to 22-57% - Patho: o Most common cause is fetal genetic abnormalities usually unrelated to the mother o Maternal fetal infection (rubella, cytomegalovirus, HSV, bacterial vaginosis, toxoplasmosis), obstetric complications (placental abruption and hemorrhage), maternal medical conditions (diabetes, hypertension, hypothyroidism, chronic nephritis) - Nursing assessment: when a pregnant woman reports vaginal bleeding, she must be seen ASAP o Ask about colour of bleeding (bright red is significant),amount (how often she is saturating pad – every hour is significant), passage of clots or tissue o Tell her to save clots or tissue and bring it with her to the health care facility o Describe other signs and symptoms o Assess VS and observe amount colour and characteristics of bleeding o Rate current pain level o Intensity of cramping or contractions o Assessment helps to determine the type – threatened, inevitable, incomplete, complete, missed and habitual - Nursing management: provide monitoring and psychological support o Reassure that these usually result from abnormality and her actions didn’t cause it o Provide continued monitoring: amount of bleeding and passage of products o Assess pain and give pain management o Prepare for procedures and treatments like surgery to evacuate the uterus or meds like misoprostol or prostaglandin E2 o If woman is Rh negative and not sensitized, expect to admin Rh immune globulin within 72 hours after abortion is complete o Provide support: emotional support and physical support o Explain some causes of spontaneous abortion so woman understands what is happening o Sensitive listening, counselling, anticipatory guidance to woman and her family o Grieving period may last up to 2 years o Encourage support from friends and family o Referral to community support group for parents experiencing a miscarriage See page 98 for factors that put a woman at risk in pregnancy See page 99 for table on categories of spontaneous abortion and treatments - Threatened: slight vaginal bleeding early in pregnancy, mild cramping, no passage of fetal tissue o Vaginal ultrasound confirms whether sac is empty and declinghCG and progesterone levels to provide additional info about viability of pregnancy - Inevitable abortion: more vaginal bleeding, rupture of membranes, cervical dilation, strong cramping, possible passage of products of conception o Ultrasound and hCG levels to indicate pregnancy loss - Incomplete: passage of some products; intense cramping; heavy bleeding; ultrasound confirmation to see if products are still in uterus - Complete: passage of all products; vaginal bleeding and abdo pain; passage of tisse with subsequent decrease in pain and significant decrease in vaginal bleeding; ultrasound demonstrates empty uterus - Missed abortion: non viable embryo retained in utero for at least 6 weeks; absent uterine contractions; irregular spotting; possible progression to inevitable abortion; ultrasound identifies products of conception in uterus - Habitual abortion: history of 3 or more consecutive spontaneous abortions; not carrying pregnancy to viability or term See page 100 for table on the drug guid for medications used for spontaneous abortions 589 – 596 Cervical Insufficiency: premature dilation of the cervix; a weak, structurally defective cervix that spontaneously dilates in the absence of contractions in the second trimester, resulting in loss of the pregnancy – less than 1% - Patho: exact mechanism is unknown; some have linked it with having less collagen and more smooth muscle than normal on the cervix but others have disproven this link o Likely to be the clinical end point of many pathologic processes like congenital cercvical disorders, deep cervical laceration secondary to prior vaginal or caesarean birth, infection, trauma to servix o Cervical length has been associated with this; short cervix and risk for preterm birth - Therapeutic management: bed rest, pelvic rest, avoid heavy lifting, surgeray (cervical cerclage in the second trimester using a suture to secure and reinforce the internal os) o Cervical cerclage should be considered for asymptomatic pregnant women with a history of preterm birth and cervical measurement less than 25mm prior to 24 weeks gestation - Nursing assessment: obtain a history to determine if there are risk factors (previous cervical trauma, preterm labour, fetal loss in second trimester, previous surgeries or procedures involving cervix) o Be alert for complains of vaginal discharge or pelvic pressure (pink tinged discharge or increase in pelvic pressure) o Cervical dilation also occurs and if this continues, rupture of membranes, release of fluid and uterine contractions occur, resulting in delivery of fetus often before its viable o Transvaginal ultrasound: around 20 weeks gestation to determine cervical length and evaluate for shortening o Shortening occurs from the internal os outward and can be viewed on ultrasound as funnelling o Amount of funnelling can be determined by dividing funnel length by cervical length o Most common time a short cervix develops I 18-22 weeks o A cervical length less than 25mm is abnormal between 14 and 24 weeks and may increase chance of preterm labour - Nursing management: monitor the woman closely for signs of preterm labour: backache, increased vaginal discharge, rupture of membranes, uterine contractions o Provide preop care and teaching if the woman will have a cerclage o Teach about signs and symptoms of preterm labour the need to report any changes immediately o Activity restrictions Placenta previa: bleeding condition that occurs during the last two trimesters – the placenta implants over the cervical os which can cause serious morbidity and mortality to the fetus and mother and is associate with serious consequences from hemorrhage, abruption (separation) of the placenta, preterm birth or emergency c section - Patho: unknown; initiated by implantation of embryo in lower uterus and with placental attachment and growth, the cervical os becomes covered o Placental vascularization is defective, allowing placenta to attach directly to myometrium, invade the myometrium or penetrate it o Complete: internal cervical os is completely covered o Partial: internal os Is partially covered o Marginal: placenta is at the margin or edge of the internal os o Low lying placenta previa: implanted in lower uterine segment near internal os but doesn’t reach it - Therapeutic management: o If mother and fetus are stable, you may just wait and see – at home or on an anepartal unit o If no active bleeding and client has readily available access to reliable transportation, can maintain bedrest at home and can comprehend instruction, expectant care at home is appropriate o If client requires continuous care and monitoring and can’t meet the home care requirements, antepartal unit is the best environment - Nursing assessment: o Risk factors: advancing maternal age (more than 35 years), previous caesarean birth, multiparity, uterine insult or injury, prior placenta previa, multiple gestations, previous induced surgical abortion, smoking o Health history and physical exam: ask about previous problems with bleeding or problems now  Classic clinical presentation: painless, bright red vaginal bleeding occurring in 2nd or 3rd trimester  Initial bleeding usually not profuse and it ceases spontaneously, only to recur  First episode of bleeding usually 27-32 weeks gestation  Bleeding usually due to the thinning of the lower uterine segment in prep for the onset of labour  If bleeding occurs at implantation site in lower uterus, uterus can’t contract adequately and stop the flow of blood from open vessels  Usually with normal placental implantation in upper uterus, minor disruptive placental attachment’ isn’t a problem bc there is a larger volume of myometrial tissue able to contract and constrict bleeding vessels  Assess for uterine contractions  Palpate the uterus – usually soft and nontender  Auscultate fetal heart rate – usually normal  Fetal distress usually absent but can occur with cord problems like prolapse or compression o Lab and diagnostic testing: transvaginal ultrasound done to validate position of placenta  MRI may be ordered when preparing for delivery to allow identification of placenta accreta (abnormal adherence to myometrium), increta (accreta with penetration of myometrium) or percreta (placental accreta with invasion of myometrium to the peritoneal covering, causing rupture of uterus)  These abnormalities are rare but can cause high morbidity and mortality, possibly necessitating a hysterectomy at delivery - Nursing management: monitor maternal-fetal status, including assessing for signs and symptoms of vaginal bleeding and fetal distress o Provide education and support o For many women, a caesarean will be planned o Monitoring maternal fetal status:  Assess degree of bleeding, assess perineal area for pooled blood, estimate and document amount of bleeing  Perform a pad count  Report changes in amount or frequency  If active bleeding, prepare for blood typing and matching in case blood transfusion is needed  Monitor vitals and uterine contractility  Have client rate pain  Asses FHR  Monitor moms cardiopulmonary status  Oxygen equipment ready  Obtain lab tests (CBC, coag studies, Rh status)  Avoid vaginal exams – they may disrupt placenta and cause hemorrhage o Providing support and education:  Determine moms understanding of placenta previa and associated procedures and treatments  Provide info about the condition  Explain assessments and treatments  Teach woman how to perform and record fetal movement daily  Asses physical and emotional impact bedrest may have on mom  Evaluate coping mechanisms to see how she will cooperate and adjust to the treatment plan  Let mom verbalize feelings and fears  Assess skin to prevent skin breakdown when bedrest is needed  Encourage balanced diet and adequate fluid intake to prevent complications with urinary and bowel elimination secondary to berest  Teach signs and symptoms that should be reported immediately  Prepare for possible caesarean birth See page 104 for care plan for placenta previa Abruptio placentae: separation of a normally located placenta after the 20th week of gestation and prior to birth that leads to hemorrhage - High mortality rate - 1% of preganncies worldwide - Fetal mortality is 20-40% - Maternal mortality 6% - Patho: etiology is unknown but some say abruption starts with degenerative changes in the small maternal arterioles, resulting in thrombosis, degeneration of the decidua and possible rupture of the vessel o Bleeding from vessel forms a retroplacental clot o Bleeding causes increased pressure behind placenta and results in separation o Fetal blood supply is compromised and fetal distress develops o Classified according to extent of separation and amount of blood loss  Mild: grade 1: minimal bleeding (less than 500mL), marginal separation (10-20%), tender uterus, no coagulopathy, no shock signs, no fetal distress  Moderate: grade 2: moderate bleeding (), moderate separation (20-50%), continuous abdo pain, mild shock  Severe: grade 3: absent to moderate bleeding (more than 1500mL), severe separation (over 50%), profound shock, agonizing abdo pain, development of disseminated intravascular coagulopathy (DIC) - Therapeutic management: assess control and restore amount of blood lost and prevent coagulation disorders like DIC o Start two large bore IV lines with NS or LR solution to combat hypovolemia o Obtain blood specimens for hemodynamic status values and typing and cross matching o Monitor fetal and maternal wellbeing o C section done immediately if there is fetal distress after severity of abruption os determined and appropriate blood and fluids are given o If no fetal distress, close monitoring with delivery planned at earliest sign of fetal distress o Newborn should be treated for shock, blood loss and hypoxia bc of the possibility of fetal blood loss thru the placenta o If mom gets DIC, treatment focuses on determining and correcting the underlying cause – replacement of coagulation factors by transfusing fresh frozen plasma and cryoprecipitate to maintain circulating volume and give oxygen to cells of body; anticoagualnts, packed red cells, platelet concentrates, antithrombin, non clotting protein containing volume expanders also used o Side note: DIC – bleeding disorder characterize by an abnormal reduction in the elements involved in blood cloting resulting from the widespread intravascular clotting – lab shows decreased fibrinogen and platelets, prolonged PTT - Nursing assessment: this is a medical emergency – rapid assessment needed o Health history and physical exam: assess for risk factors like smoking, advanced age, poor nutrition, multiple gestation, excessive intrauterine pressure caused by hydramnios, hypertension, severe trauma, cocaine use, alcohol ingestion, multiparity  Ask about prior pregnancies or abruptions  Be aware of male fetal gender, chorioamnionitis, prolonged ruptured membranes, pre-eclampsia and low socioeconomic status  Assess for bleeding – present in 80% of women  The other 20% are concealed hemorrhage and the absence of vaginal bleeding  Remember vitals can be within normal ranges bc pregnant women can lose up to 40% of blood volume without showing signs of shock  Assess for pain – type, onset, location  Ask if shes had contractions  Palpate abdomen and note contractions, uterine tenderness, tenseness or rigidity  Decreased fetal movement may be the presenting complaint resulting from fetal jeopardy or fetal death – assess FHR  Classic manifestations of this; dark red vaginal bleeding, knife like abdo pain, uterine tenderness, contractions, decreased fetal movement o See page 107 for chart on placenta previa vs abruptio placentae o Lab and diagnostic testing: CBC for current hemodynamic status; fibrinogen levels (a moderate dip may indicate DIC); PTT; type and cross match  Kleihauerbetke test (detects fetal RBCs in maternal circulation, determines degree of fetal hemorrhage and helps calculate appropriate dosage of Rhogam shot to Rh negative moms)  Nonstress test: demonstrates findings of fetal jeopardy manifested by late decelerations or bradycardia  Biophysical profile: evaluates clients with chronic abruption and a score lower than 6 may indicate fetal compromise - Nursing management: immediate care o Ensure adequate tissue perfusion: bed rest in left lateral position to prevent pressure on vena cava o Administer oxygen via nasal canula o Monitor O2 sat o Vitals frequently like Q15mins o Observe changes in VS that may indicate hypovolemic shock o Expect to insert an indwelling catheter to assess hourly urine output o Initiate an IV infusion for fluid replacement using large bore catheter o Assess fundal height for hcanges o Monitor characteristics of any vaginal bleeding o Signs and symptoms of DIC like bleeding gums, tachycardia, oozing from IV site, petechiae o FHR monitoring electronically o Assess uterine contractions and report increased tenseness or rigidity - Providing support and education: o Empathy and understanding o Acknowledge emotions and fears o Answer questions openly and explain indicators of fetal wellbeing o Assist family to deal with loss or with birth of newborn in the NICU o Education to reduce risks of this: stop smoking or using drugs in pregnancy 600 – 609 Gestational Hypertension: - Hypertension without proteinuria after 20 weeks gestation and return of the BP to normal postpartum - BP of 140/90 or more on two occasions at least 6 hours apart - Chronic hypertension appears before the 20th week of gestatin or before current pregnancy and continues after woman gives birth - Common manifestations of preeclampsia: hypertension and proteinuria - In women with pre-existing hypertension, preeclampsia should be defined as resistant hypertension, new or worsening proteinuria, or one or more of the other adverse conditions (headache, visual disturbances, persistent abdo pain, severe nausea or vomiting, chest pain) - Patho: o Results in pulmonary edema, oliguria, seizures, thrombocytopenia, coagulation, abnormal liver function, abnormal liver enzymes o Not much as proven to prevent this o Only low dose aspirin and calcium have shown minimal protective effects o Mechanism involved are vasospasm and hypoperfusion o Endothelial injury occurs, leading to platelete adherence, fibrin deposition and schistocytes o Generalized vasospasm results in elevation of BP and reduced blood flow to brain, liver, kidneys, placenta and lungs o Decreased liver perfusion leads to impaired liver function and subcapsular hemorrhage o Decreased brain perfusion leads to small cerebral hemorrhages and symptoms of arterial vasospasm like headaches, visual disturbances, blurred vision, hyperactive deep tendon reflexes o Decreased kidney perfusion reduces GFR, resulting in decreased urine output and increased sodium, BUN, uric acid and creatinine – furthering edema o Increased cap permeability in the kidneys allows albumin to escape which reduces plasma colloid osmotic pressure and moves more fluid into extracellular spaces – pulmonary and generalized edema - Therapeutic management for mild preeclampsia: o No signs of renal or hepatic ysufnction or coagulopathy o Milk elevations in BP may be placed on bed rest at home recumbent position to improve uteroplacental blood flow, reduce BP and promote diuresis o CBC, clotting studies, liver enzymes and platelet levels will be tested more frequently o Monitor BP daily every 4-6 hours while awake o Measure protein in urine using dipstick o Weight to detect gains o Fetal movement counts daily o Balanced nutritional diet with no sodium restriction o 6-8 glasses of water daily o If home management doesn’t help, may be admitted to hospital – monitor BP, weight, fetal surveillance o BP monitored frequently during labour and magnesium sulphate is used to prevent seizure activity with antihypertensives if BP begins to rise o Catheter used to measure urine output - Management of severe preeclampsia: o BP more than 160/110 and proteinuria more than 5g in 24 hours; oliguria of less than 400mL in 24 hours, cerebral and visual symptoms, rapid weight gain o Immediate hospitalization needed o Birth of baby is the only cure o Treated aggressively o Control hypertension, prevent seizures, prevent long term morbidity, and prevent death o In labour with preeclampsia: oxytocin to stimulate uterine contractions and magnesium sulphate to prevent seizureactivity o Vaginal delivery is preferable if possible – PGE2gel can ripen the cervix o Newborn whose mother received magnesium sulphate needs to be monitored for resp depression, hypotension and hypotonia - Management of eclampsia: o Convulsive activity usually begins with facial twitching, followed by generalized muscle rigidity o Respirations cease for the duration of the seizure – this compromises fetal oxygenation o Coma usually follows seizure activity with respiration resuming o Initial management: clear the airway – position woman on left size and protect her from injury o Suctioning to remove secretions from mouth when seizure is over o IV lfuidsusedto replace urine output and insensible losses o FHR monitored closely o Magnesium sulphate given to prevent any more seizures - Nursing assessment: o Accurate measure of client’s BP o Assess for complaints of progression of disease like visual changes, severe headaches, unusual bleeding or bruising, RUQ pain, sudden weight gain, nausea and vomiting o (side note: proteinuria is 0.3g or more of urinary protein per 24 hours or more than 1+ protein by chemical reagent strip or dipstick of at least two random urine samples collected at least 6 hours apart with no evidence of UTI) o Health history and physical exam:  Risk factors: primigravida status, multifetal pregnancy, history of preeclampsia in previous pregnancy, fam history of preeclampsia, lower socioeconomic group, history of diabetes, hypertension or renal disease, black race, age extremes, obesity  Complete nutritional assessment – protein, calcium, calories, fluids  Obtain BP mreasurements with the woman in the same position (BP highest in sitting position and lowest in side lying position) and by using same technique (automated or manual)  Obtain clients weight and assess for amount of location of edema  Ask if rings still fit, if her face is puffy  Weights are important to identify sudden gains in a short time span  Dependent edema: present on lower half of body if the client is ambulatory, where hydrostatic pressure is greatest – usually in feet and ankles or in the sacral area if client is on bedrest  Pitting edema: leaves small depression or pit after finger pressure is applied to a swollen area – record depth of pitting  1+ means 2mm depression and disappearing rapidly; 2+ is 4 mm depression; disappearing in 10-15 seconds; etc until 4+ where its 8mm depression lasting 2-3 minutes o Lab and diagnostic tests: CBC, serum electrolytes, BUN, creatinine, hepatic enzyme levels; urine specimens checked for protein – if levels are 1+ or 2+ or greater, a 24 hour urine collection is completes - Nursing management: close monitoring of BP and ongoing assessment for disease progression - Teaching for woman with mild preeclampsia: o Rest in a quiet environment to prevent cerebral disturbances o Drink 8-10 glasses of water daily o Consume balanced high protein diet including high fibre o Intermittent bed rest to improve circulation to heart and uterus o Limit physical activity o Enlist aid of family so you can have enough rest o Take your own BP twice daily o Check and record weight daily o Urine dipstick twice daily o Record fetal kicks daily o Contact nurse if incresase in BP, protein in urine, gain of more than 1lb in 1 weeks, burning or frequency when urinating, decrease in fetal activity or movement, headache, dizzy, increased edema, stomach pain, excessive heartburn, decreased or infrequent urination, contractions or lower back pain, easy or excessive bruising, nausea and vomiting - See page 113 for medications with preeclampsia and eclampsia - Intervening with preeclampsia: o Frequent monitoring to detect changes bc preeclampsia can progress rapidly o Usually they can be managed at home if they have a good understanding of the disease process, are stable, and have no abnormal lab test results and demonstrate good fetal movement o Home care nurse makes frequent visits and follow up phone calls o Early detection and management is associated with the greatest success in reduction and progression of the condition o Side note: preeclampsia increases the risk for placental abruption, preterm birth, IUGR and fetal distress during childbirth - Intervening with severe preeclampsia: o Hospitalization, bed rest in left lateral lying position o Dark and quiet room o Sedatives as ordered to encourage bedrest o Seizure precautions like padding side rails, have oxygen, suction equipment and call light readily available to protect client from injury o Closely monitor BP and administer antihypertensives as ordered o Assess vision and consciousness o Monitor intake and output every hour o Assess for pulmonary edema like crackles and wheezes upon auscultation, dyspnea, decreased O2 sats o Prepare woman for possible tests like nonstress test, serial ultrasounds, amniocentesis, biophysical profile o Other lab tests: liver enzymes like LDH, ALT, AST; chemistry panel like creatinine, BUN, uric acid, glucose; CBC, coagulation studies like PTT and bleeding time, 24 hour urine collection o Administer parenteral magnesium sulphate as ordered o Magnesium toxicity: diminished or absent reflexes because the afferent and efferent nerve pathways don’t relay messages properly o Sustained clonus: CNS involvement – presence of rhythmic involuntary contractions most often at the foot or ankle o Signs of magnesium toxicity: RR less than 12 breaths per minute, absence of deep tendon reflexes, decrease in urinary output (below 30mL an hour)  Monitor serum magnesium levels – 4-7 are therapeutic but higher than 8 is toxic  As levels increase, risk for respiratory paralysis and hypothermia, pulmonary edema, depressed reflexes, hypotension, flushing, drowsiness, depressed cardiac function, diaphoresis, hypocalcaemia, hypophosphatemia, hyperkalemia, visual changes o See page 115 for how to assess reflexes and clonus o Administer calcium gluconate as the antidote o Closely monitor for signs and symptoms of labour o Perform continuous electronic fetal monitoring and assess for fetal wellbeing o Administer glucocorticoid treatment to enhance fetal lung maturity and prepare for labour induction in condition warrants o Provide emotional support o Offer praise for small accomplishments - Intervening with eclampsia: o Onset of seizure activity identifies eclampsia o Start with facial twitching, then body becomes rigid, then clonic phase involves altering contraction and relaxation of all body muscles o Respirations stop during seizue activity and resume shortly after it ends o Dim lights and keep room quiet o Document time and sequence of events o As soon as seizure stops, suction nasopharynx and administer oxygen o Assess for uterine contractions o Prepare for birth as soon as possible to reduce risk of perinatal mortality - Providing followup care: continue to monitor signs for 48 hours at least and continue to admin magnesium sulphate for 24 hours to prevent seizure activity and monitor magnesium levels o Assess vitals at least every 4 hours and assess fundus, lochia, breasts, bladder, bowels, emotional state HELLP: hemolysis, elevated liver enzymes, low platelets - Occurs in about 20% of pregnant women diagnosed with severe preeclampsia - Usually develops in third trimester but can develop earlier in pregnancy or up to 48 hours postpartum - Leads to increased risk of liver hematoma or rupture, placental abruption, DIC, stroke, pulmonary edema, cerebral edema, renal damage, sepsis, death - Patho: the hemolysis is microangiopathic hemolytic anemia when RBCs become fragmented as they pass thru small, damaged blod vessels o Elevated liver enzymes bc of reduced blood flow to liver secondary to obstruction from fibrin deposits o Hyperbilirubinemia and jaundice from liver impairment o Low platelet levels bc of vascular damage, resulting form vasospasm and platelets aggregates at sites of damage, resulting in thrombocytopenia - Therapeutic management: based on severity, gestational age, contiion of mom and baby o Admitted to tertiary centre with a NICU o Other treatments: magnesium sulphate, antihypertensives, correction of coagulopathies o After this is diagnosed and woman is stable, birth of infant is indicated o Blood component therapy: fresh frozen plasma, packed red cells, platelets – address the microangiopathic hemolytic anemia o Birth may be delayed up to 96 hours to give betamethasone or dexamethasone to stimulate lung maturation in the preterm fetus - Nursing assessment: similar to preeclampsia o Alert to nausea, malaise, epigastric or right upper quadrant pain, demonstrable edema o Diagnosis made on the following:  Low hematocrit not explained by blood loss  Elevate LDH, AST, ALT (liver impairment)  Elevaeted BUN  Elevated bili  Elevated uric acid and creatinine levels (renal involvement)  Low platelet count - Nursing management: same for severe preeclampsia – closely monoor for changes Gestational diabetes: glucose intolerance during pregnancy Blood incompatibility: - Blood type of Rh factor - Blood type incompatibility: ABO incompatibility – not as severe as Rh incompatibility - ABO rarely causes significant hemolysis and antepartum treatment isn’t needed - Approx. 15% of white Canadian women are Rh negative - Maternal alloimmunization occurs in 1-2% of Rh negative women in Canada - Patho: o Hemolysis associated with ABO incompatibility is limited to mothers with type O whose fetuses have type A or B o If mothers with type A and B blood, antibodies are of the IgM class which don’t cross the placenta but in type O mothers, the antibodies are IgG in nature o Since A and B antigens are widely expressed in a lot of tissues besides RBCs, only a small portion of antibodies crossing the placenta are available to bind to fetal red cells and fetal red cells appear to have less surface expression of A or B antigen, resulting in fewer reactive sites o With ABO incompatibility, usually mom is type O with anti A and anti B antibodies and the infant is A, B or AB – when an interaction of antibodies present in the maternal serum hits the antigen sites on the fetal red cells, the incompatibility arises o Rh incompatibility happens when woman with Rh negative blood is exposed to Rh positive blood cells and then develops Rh antibodies o Most commonly arises when exposure of Rh negative mother happens with an Rh positive fetus during pregnancy or birth when RBCs from fetal circulation leak into maternal circulation – then alloimmunization or sensitization occurs and maternal antibodies are produced against the foreign Rh antigen o Theoretically, blood doesn’t mix but in reality, small placental accidents, abortions, ectopic pregnancy, abdo trauma, amniocentesis, placental previa and abruptio placentae allow fetal blood to enter maternal circulation o Once sensitized, it takes about a month for Rh antibodies in maternal circulation to cross over into fetal circulation but in most cases, sensitization happens during delivery so firstborn infants with Rh positive blood are not affected o Risk of alloimmune response increases with each subsequent pregnancy involving a fetus with Rh positive blood - Nursing assessment of blood incompatibilities: o Determine woman’s blood type and Rh status at first prenatal visit o When client is Rh, prepare her for antibody screen (indirect Coombs test) to determine if she has developed isoimmunity to Rh antigen - Nursing management: o If the indirect Coombs test is negative (meaning there are no antibodies), the woman is a candidate for WinRho o But if woman is positive, WinRho is no help because isoimmunization has occurred and then the fetus is monitored carefully for hemolytic disease o Incidence of isoimmunization has declined bc of WinRho o Rh immunoglobulin helps destroy any fetal cells in maternal circulation before sensitization occurs, thus inhibiting maternal antibody production o Recommended that every Rh negative nonimmunized woman gets WinRho at 28 weeks gestation and again within 72 hours after giving birth; also if there was ectopic pregnancy, chorionic villus sampling, amniocentisis, prenatal hemorrhage, maternal trauma, abortion, fetal surgery Amniotic fluid imbalances: amniotic fluid is from maternal and fetal structures like amnion, chorion, maternal blood, fetal lungs, Gi tract, kidneys and skin - Polyhydramnios: too much amniotic fluid 612 – 616 Premature rupture of membranes (PROM): rupture of the bag of waters before the onset of true labour - Associated conditions: infection, prolapsed cord, abruptio placentae, preterm labour - Most common diagnosis associated with preterm births - If prolonged (over 24 hours), risk for infection increases - Time interval from rupture of membranes to onset of regular contractions is the latent period - Usually used when referring to a woman beyond 37 weeks gestation, has presented with spontaneous rupture of membranes and is not in labour Preterm PROM: rupture of membranes prior to onset of labour in a woman who is less than 37 weeks gestation - Risks associated may stem from immaturity like respiratory distress syndrome, intraventricular hemorrhage, patent ductus arteriosus and necrotizing enterocolitis Therapeutic management: - An unsterile digital cervical examination is not done until woman enters active labour - If fetal lungs are mature, induce labour - If fetal lungs are immature, expectant management is carried out with adequate hydration, decreased physical activity, pelvic rest and close observation for infection (frequent monitoring of vitals and lab tests (WBCs)) - Corticosteroids can be given to enhance fetal lung maturity Nursing Assessment: - Obtain a complete health history and perform a physical exam to determine maternal and fetal status - Health history and physical exam: o Determine date, time and duration of membrane rupture o Ascertain the gestational age based on date of mothers last menstrual period, fundal height and ultrasound dating o Review risk factors for infection like increased uterine size, uterine and fetal anomalies, lower socioeconomic status, STIs, cervical insufficiency, vaginal bleeding and cigarette smoking o Ask about history of UTIs or pelvic or vaginal infection o Assess for signs and symptoms of labour like cramping, pelvic pressure or back pain o Assess for signs of infection like fever and tachycardia, abdominal or uterine tenderness, fetal tachycardia (over 160), elevated WBCs and C reactive proteins, and cloudy foul smelling amniotic fluid o Continuous electronic fetal heart rate monitoring o Vaginal exam to ascertain the cervical status in PROM o If its preterm PROM, a sterile speculum exam is done because a digital exam may diminish latency (period of time from rupture of membranes to birth) and increase newborn morbidity o Observe the amniotic fluid for meconium or foul odor  If meconium is present, can indicate fetal distress related to hypoxia  Meconium stains the fluid yellow to greenish brown  Foul odour indicates infection  Observe amount of fluid (if there is less fluid, cord compression could be possible) - Lab and Diagnostic Testing: o Insert a sterile speculum and get a sample of the fluid in the vaginal area o Nitrazine test: the pH of the fluid is tested (amniotic fluid is more basic (7) than normal vaginal secretions (4.5)  The paper turns blue in the presence of amniotic fluid  False positives with blood, urine, semen or antiseptic chemicals are present o Fert test: get a sample of vaginal fluid on a slide and view it under a microscope  Amniotic fluid develops a fern like pattern o Other tests: urinalisis and urine culture; cervical test or culture for chlamydia or gonorrhea; vaginal culture for bacterial vaginosis and trichomoniasis; vaginal and rectal culture for GBS Nursing Management: - Prevent and identify uterine contractions - Great risk for infection bc of the break in the amniotic fluid and its close proximity to vaginal bacteria - Monitor vitals closely and be alert for increased temp or pulse - Report any fetal tachycardia (indicating maternal infection) or variable decelerations (indicating cord compression) - Evaluate the results of lab tests like the CBC - Encourage woman and partner to verbalize feeling and keep them informed - When appropriate, prepare the woman for induction if she is near term - If labour doesn’t start within 48 hours, the woman with preterm PROM may be discharged home on expectant management which can include antibiotics if cultures are positive, activity restrictions and education about signs and symptoms of infection Teaching for a woman with preterm PROM: - Monitor baby activity by performing fetal kick counts daily - Check temp daily and report increases - Watch for signs related to beginning of labour - Avoid touching breasts (could stimulate labour) - Don’t insert anything into vagina or vaginal area - Activity restrictions - Wash hands thoroughly after using bathroom and wipe from front to back - Keep perineal area clean and dry