Summary OB 204 – FINAL REVIEW OF NEWBORN AND HIGH RISK NEWBORN

Chapter 28 Care of the High-Risk Mother, Newborn, and Family With Special Needs Objectives  1. List conditions that increase maternal and fetal risk.  2. Compare and contrast abruptio placentae and placenta previa, noting signs and symptoms, complications, and nursing and medical management.  3. Identify diagnostic tests used to determine high-risk situations.  4. Compare and contrast hypertensive disorders experienced during pregnancy.  5. Identify preexisting maternal health conditions that influence pregnancy.  6. List the infectious diseases most likely to cause serious complications.  7. Discuss the care of the pregnant adolescent.  8. Discuss the problems created by alcohol and drug abuse.  9. Identify concerns related to preterm infants.  10. Explain the hemolytic diseases of the newborn.  11. Discuss nursing diagnoses related to high-risk conditions of the mother and the newborn.  12. Identify nursing interventions for the pregnant woman with a cardiac disorder.  13. Explain the care of a pregnant woman with a pulmonary disorder. Key Terms anasarca (ăn-ă-SĂR-kă, p. 890) atony (ĂT-ŏ-nē, p. 887) brown fat (p. 908) cerclage (sĕr-KLĂHZH, p. 883) direct Coombs test (p. 912) dizygotic (dī-zī-GŎT-ĭk, p. 879) eclampsia (ĕ-KLĂMP-sē-ă, p. 889) erythroblastosis fetalis (ĕ-rĭth-rō-blăs-TŌ-sĭs fĕ-TĂL-ĭs, p. 912) gestational diabetes mellitus (GDM) (jĕs-TĀ-shŭn-ăl dī-ă-BĒ-tēz MĔL-ĭ-tŭs, p. 898) gestational hypertension (GH) (jĕs-TĀ-shŭn-ăl hī-pĕr-TĔN-shŭn, p. 889) glycosylated hemoglobin (glī-KŌ-sĭ-lāt-ĕd HĒ-mō-glō-bĭn, p. 898) high-risk pregnancy (p. 877) hydramnios (hī-DRĂM-nē-ŏs, p. 887) hyperbilirubinemia (hī-pĕr-bĭl-ĭ-rū-bĭ-NĒ-mē-ă, p. 912) incompetent cervix (p. 882) indirect Coombs test (p. 912) infant mortality (p. 875) kernicterus (kĕr-NĬK-tĕr-ŭs, p. 912) kick count (p. 891) monozygotic (mŏn-ō-zī-GŎT-ĭk, p. 879) morbidity (p. 877) mortality (p. 877) phototherapy (p. 913) placental barrier (plă-SĔN-tăl, p. 912) preeclampsia (prē-ĕ-KLĂMP-sē-ă, p. 889) severe preeclampsia (p. 890) TORCH (p. 894) One of the indicators considered in the health of the nation is the rate of infant mortality (the number of infants who die within the first year of life, expressed as the number per thousand live births). The infant mortality rate is higher in the United States than in many other countries in the world. The last available ranking for this statistic placed the country 30th in line for this statistic (Centers for Disease Control [CDC], 2009). This number is troubling in a nation largely considered a super power. Approximately 4 million babies are born in the United States each year. The mortality rate is 6.9 per 1000 live births. Factors primarily associated with mortality rates are prematurity and low birth weight. Nearly 12% of babies are born 1 prematurely. The rate of low-birth-weight babies is 8.1%. Prevention of morbidity and mortality among mothers and infants depends on identification of the risk, along with appropriate and timely intervention during the perinatal period. With the changing demographics in the United States, more women and families are at risk for complications because of nonphysiologic factors. For example, increasing numbers of homeless, single, and uninsured pregnant women have no access to prenatal care during any stage of pregnancy. Behaviors and lifestyles that pose a risk to the health of the mother and fetus also contribute to the problem (Box 28-1). Box 28-1 Classification of High-Risk Factors of Pregnancy Biophysical  • Genetic considerations: Genetic factors may interfere with normal fetal or neonatal development, result in congenital anomalies, or create difficulties for the mother.  • Nutritional status: Adequate nutrition, without which fetal growth and development cannot proceed normally, is one of the most important determinants of pregnancy outcome.  • Medical and obstetric disorders: Complications of current and past pregnancies, obstetric-related illnesses, and pregnancy losses put the patient at risk. Psychosocial  • Smoking: A strong, consistent, causal relationship has been established between maternal smoking and reduced birth weight.  • Caffeine: Birth defects in humans have not been related to caffeine consumption. High intake (three or more cups of coffee per day) has been related to a slight decrease in birth weight.  • Alcohol: Alcohol exerts adverse effects on the fetus, resulting in fetal alcohol syndrome, fetal alcohol effects, learning disabilities, and hyperactivity.  • Drugs: The developing fetus may be adversely affected by drugs through several mechanisms. Drugs can cause metabolic disturbances, produce chemical effects, or depress or alter central nervous system function. This category includes medications prescribed by a health care provider or bought over the counter, and commonly abused drugs such as heroin, cocaine, and marijuana.  • Psychological status: Childbearing triggers profound and complex physiologic, psychological, and social changes, with evidence to suggest a relationship between emotional distress and birth complications. This risk factor includes conditions such as specific intrapsychic disturbances and addictive lifestyles. Sociodemographic  • Low income: Poverty underlies many other risk factors and leads to inadequate financial resources for food and prenatal care, poor general health, increased risk of medical complications of pregnancy, and greater prevalence of adverse environmental influences.  • Lack of prenatal care: Failure to diagnose and treat complications early is a major risk factor that arises from financial barriers or lack of access to care; cultural beliefs that do not support this need; and fear of the health care system and its providers. 2  • Age: Women at both ends of the childbearing age spectrum have a higher incidence of poor outcomes; however, age may not be a risk factor in all cases. o • Adolescents: More complications are seen in young mothers (less than 15 years old), who have a 60% higher mortality rate than those over age 20 years, and in pregnancies that occur less than 3 years after menarche. Complications include anemia, gestational hypertension (GH), prolonged labor, and contracted pelvis and cephalopelvic disproportion. Long-term social implications of early motherhood are lower educational status, lower income, increased dependence on government support programs, higher divorce rates, and higher parity. o • Mature mothers: The risks to mothers over 35 years old are not from age alone but from other considerations, such as number and spacing of previous pregnancies, genetic disposition of the parents, medical history, lifestyle, nutrition, and prenatal care. Medical conditions more likely to be experienced by mature women include hypertension and GH, diabetes, extended labor, cesarean birth, placenta previa, abruptio placentae, and death. Her fetus is at greater risk for low birth weight.  • Parity: The number of previous pregnancies is a risk factor that is associated with age and includes all first pregnancies, especially a first pregnancy at either end of the childbearing age spectrum. The incidence of GH and dystocia is higher with a first birth.  • Marital status: The increased mortality and morbidity rates for unmarried women, including a greater risk for GH, are often related to inadequate prenatal care and a younger childbearing age.  • Residence: The availability and quality of prenatal care varies widely with geographic residence. Women in metropolitan areas have more prenatal visits than those in rural areas, who have fewer opportunities for specialized care and consequently a higher incidence of maternal mortality.  • Ethnicity: Although ethnicity itself is not a major risk factor, race is an indicator of other sociodemographic risk factors. Nonwhite women are more than three times as likely as white women to die of pregnancy-related causes. Black babies have the highest rates of prematurity and low birth weight, with an infant mortality rate more than double that for whites. Environmental  • Various environmental substances can affect fertility and fetal development, the chance of a live birth, and the child's subsequent mental and physical development. Environmental influences include infections; radiation; chemicals such as pesticides, therapeutic drugs, illicit drugs, industrial pollutants, and cigarette smoke; stress; and diet.  • Paternal exposure to mutagenic agents in the workplace has been associated with an increased risk of spontaneous abortion. Although most pregnancies proceed normally, complications and high-risk situations can occur at any stage of the childbearing process. The nurse must be aware of these so that appropriate, timely actions can be taken (see Cultural Considerations box on high-risk pregnancies). The care provided must offer concern and protection for the welfare of both the mother and the child. Complications of Pregnancy All members of the obstetric team and other medical personnel collaborate closely to care for the patient at high risk. A high-risk pregnancy is one in which the life or health of the mother or the infant is jeopardized by a health concern. The condition may be preexisting, or it may be the result of pregnancy. For the mother, the high-risk status extends (based on medical judgment) through the puerperium (6 weeks after delivery). Postdelivery maternal complications are usually resolved within a month, but perinatal morbidity (state of having dis