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NSG-432 topic 5 content
Nursing Care of the Childbearing Family (NSG-432)
Grand Canyon University
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NSG-432 TOPIC 5
CHP 10
Assessment of high-risk pregnancy Assessment of risk factors
Biophysical factors o Genetic Inherited disorder, chromosomal anomalies, multiple gestations, large fetal size, ABO incompatibility o Nutrition Adolescents, three pregnancies in 2 years, tobacco/alcohol/drug use, dietary intake (illness, fads, bariatric surgery), inadequate or excessive wt gain, low hematocrit (less than 33%) o Medical and obstetric Complications (current or previous), pregnancy-related illness, previous loss Polydramnios (fetal GI issues) or oligohydramnios (possible fetal renal issues, PROM, IUGR, maternal hypertension or dehydration, uteroplacental insufficiency) IUGR- intrauterine growth restriction o Mother hx of HTN Chromosomal abnormalities o Maternal age o Parental chromosomal rearrangements or previous hx of this
Psychosocial factors o Smoking Risks include low birth weight infants, higher neonatal mortality rates, increased rates of miscarriage, and increased incidence of prelabor rupture of membranes o Caffeine Recommended no more than 12 oz per day o Alcohol/drugs o Psychological status History of abuse, social environment, unsafe practices, situational crisis
Sociodemographic factors o Low income/social o Determinants of health o Lack of prenatal care o Age o Adolescents- anemia, preeclampsia, CPD o Mature mothers- advanced age-ie over 35-increased risk for genetic issues, chronic disease
Environmental factors o Infections, chemical, pollutants (industrial, at home smoking) cat litter/gardening Biophysical profile
The biophysical profile (BPP) is a noninvasive dynamic assessment of a fetus that is based on acute and chronic markers of fetal disease
The BPP includes AFV, FBMs, fetal movements, and fetal tone determined by ultrasound and fetal heart rate (FHR) reactivity determined by means of the nonstress test
FHR reactivity, FBMs, fetal movement, and fetal tone reflect current CNS status, whereas the AFV demonstrates the adequacy of placental function over a longer period
Usually done late in second trimester or third- reliable predictor of fetal well-being
The lower the number the more concerns-may need to do an amniocentesis to check on lung development or may need to deliver the baby
Limitation- if fetus is sleepy, may require longer observations Biophysical Profile Management Score Interpretation Management 10 Normal; low risk for chronic asphyxia
Repeat testing at weekly to twice weekly intervals 8 Normal; low risk for chronic asphyxia
Repeat testing at weekly to twice weekly intervals 6 Suspect chronic asphyxia If ≥36–37 weeks of gestation or <36 weeks with positive testing for fetal pulmonary maturity, consider delivery; if < weeks and/or fetal pulmonary maturity testing negative, repeat biophysical profile in 4–6 h; deliver if oligohydramnios is present. 4 Suspect chronic asphyxia If ≥36 weeks of gestation, deliver; if <32 weeks of gestation, repeat score. 0-2 Strongly suspect chronic asphyxia
Extend testing time to 120 min; if persistent score ≤4, deliver, regardless of gestational age.
- One part of the BPP o Daily fetal movement counts Kick count o Decreased fetal activity is noted in response to hypoxemia o Other common recommendations are that mothers count fetal activity two or three times daily (e., after meals or before bedtime) for 2 hours or until 10 movements are counted, or all fetal movements in a 12-hour period each day until a minimum of 10 movements are counted Modified biophysical profile
- The modified BPP (mBPP) is being used increasingly as a way to shorten the testing time required for the complete BPP by assessing the components that are most predictive of perinatal outcome
- The mBPP combines the nonstress test, which assesses the current fetal condition, with measurement of the quantity of amniotic fluid, an indicator of placental function over a longer period of time
Fetal growth - Conditions that require ultrasound assessment of fetal growth include poor maternal weight gain or pattern of weight gain, previous pregnancy with intrauterine growth restriction (IUGR), chronic infections, substance use (e., tobacco, alcohol), maternal diabetes, hypertension, multifetal pregnancy, and other medical or surgical complications Biochemical assessment Amniocentesis - At or after 14-15 weeks to obtain amniotic fluid, which contains fetal cells - Under direct ultrasonographic visualization, a needle is inserted transabdominally into the uterus and amniotic fluid is withdrawn into a syringe - Looking for FETAL ANOMALIES - It should be avoided before 13 to 14 weeks of pregnancy because amniocentesis performed at an earlier gestational age has a higher risk for pregnancy loss, amniotic fluid leakage, and fetal talipes equinovarus (clubfoot) - Not performed unless true concerns as it is invasive and creates increased risk for complications (maternal hemorrhage, amniotic fluid embolism, fetal hemorrhage, fetal infection and fetal death) o Complications in the mother and fetus occur only rarely and include the following: Maternal: leakage of amniotic fluid, hemorrhage, fetomaternal hemorrhage with possible maternal Rh isoimmunization, infection, labor, placental abruption, inadvertent damage to the intestines or bladder, and amniotic fluid embolism (anaphylactoid syndrome of pregnancy) Fetal: death, hemorrhage, infection (amnionitis), and direct injury from the needle - Measures AFP- maternal serum blood test-high levels help to confirm neural tube defects such as spina bifida or anencephaly or an abdominal wall defect such as omphalocele - Fetal lung maturity o Late in pregnancy, accurate assessment of fetal lung maturity is possible by examining amniotic fluid to determine the L/S ratio or for the presence of PG o LS ratio and LBC – to identify fetal lung maturity - - should be 2:1 for maturity (lecithin/sphingomyelin ) Amnio indications - Older maternal age (35 years of age or older) - Older paternal age (there is no consensus, but usually considered to be 40- years of age) - Parents who are affected by or are carriers of genetic disorder, including sick cell anemia, Tay Sachs disease and cystic fibrosis - Women with a prior child with structural birth defects or with structural fetal defects identified by US during current pregnancy - Women with a prior child with a chromosomal abnormality SAFETY ALERT - Because of the possibility of fetomaternal hemorrhage, administering RhoD immunoglobulin to the woman who is Rh negative is standard practice after an amniocentesis Percutaneous Umbilical Blood Sampling (PUBS)
- Direct access to the fetal circulation during the second and third trimesters is possible through percutaneous umbilical blood sampling (PUBS) (also called cordocentesis)
- However, PUBS has been replaced in many centers by placental biopsy because it is a safer, easier, and faster alternative
- PUBS involves the insertion of a needle directly into a fetal umbilical vessel, preferably the vein, under ultrasound guidance
- Often used for evaluation of amnio or CVS results o Determines specific mutation
- May also be used to assess for fetal anemia, infection, or thrombocytopenia
- Risks o Transient fetal bradycardia o Bleeding from puncture site Maternal assays
- Alpha fetoprotein o Detects fetal anomalies High levels help to confirm neural tube defects such as spina bifida or anencephaly or an abdominal wall defect such as omphalocele o Assessment of lung maturity Should be 2:1 for adequate maturity
- Multiple marker screen o Detects chromosomal abnormalities o Available at 11-14 weeks
- Combs test o Screen for Rh alloisoimmunization o Screens for other antibodies o Elevated titer may require amnio to test for fetal hemolytic anemia
- Cell free DNA screening o Uses maternal blood o Chromosomal screening: looks for (trisomy 13,18 and 21) o Also provides a definitive diagnosis noninvasively for fetal Rh statues, fetal sex, and certain paternally transmitted single gene disorders Nonstress test
- A reliable screening of fetal well being
- The nonstress test (NST) is the most widely applied technique for antepartum evaluation of the fetus
- Done to determine whether the intrauterine environment continues to support the fetus
- However, some medications (i., opioids and propranolol [Inderal]) and chronic smoking can adversely affect the test
- The NST can be performed easily and quickly in an outpatient setting because it is noninvasive, easy to perform and interpret, relatively inexpensive, and has no known contraindications
- Procedure o Placed on monitor-given a button to press when movement is felt o May have to stimulate/wake the baby- vibracoustic tool or orange juice
o Class A 2 or more abnormal values Fasting postprandial glucose are diet controlled o Class B, C,D,F,R,T Pregestational diabetes status B: Onset of disease occurs after 20 years of age, and duration of illness is <10 years. C: Onset of disease occurs between 10 and 19 years of age, duration of illness is 10–19 years, or both D: Onset of disease occurs before 10 years of age, duration of illness is >20 years, or both F: women has developed diabetic nephropathy R: women has developed retinitis poriferans T: women has had a renal transplant Metabolic changes associated with pregnancy
- 1 st trimester o Influenced by rise of estrogen and progesterone
- 2 nd and 3rd trimesters o Diabetogenic effect Decreased tolerance to glucose Increased insulin resistance Deceased hepatic glycogen stores
- After birth and placental delivered o Abrupt drop in placental hormones o Maternal tissues quickly regain pre-pregnancy insulin sensitivity
- Although glucose crosses the placenta, insulin does not
- Maternal insulin requirements gradually increase from approximately 18 to 24 weeks of gestation to approximately 36 weeks of gestation
- For the nonbreastfeeding mother, the prepregnancy insulin-carbohydrate balance usually returns in approximately 7 to 10 days
- Lactation uses maternal glucose; therefore, the breastfeeding mother’s insulin requirements remain lower during lactation Pregestational diabetes mellitus
- Preconception counseling for pregestational (preexisting) o 1 st trimester Requires less insulin-may need to reduce dose to prevent hypoglycemia N/V and cravings may cause dietary fluctuation in glucose Hyperglycemia in first trimester may cause congenital anomalies o 2 nd and 3rd trimester Insulin needs may increase
- Maternal risk and complications o Recommend reliable contraception until glycemic control is optimal o Poor blood glucose control Increased risk for macrosomia- LGA (birth weight more than 4000- or more than 90th percentile) Increased risk for shoulder dystocia Related to disproportionate increase in shoulder, trunk, and chest size Increased risk for:
Preeclampsia Polyhydramnios DKA- especially during stress, infection or illness o Can occur with blood glucose levels barely exceeding 200 mg/dL compared with 300-350 mg/dL in the nonpregnant state
- Fetal and neonatal risks and complications o Hyperglycemia in 1st trimester Main cause of diabetes-related anomalies Cardiovascular system CNS
- Breast feeding should not have significant impact on insulin levels- golden hour very important because baby is at risk for hypoglycemia
- Assessment o Acute and chronic complications Retinopathy Nephropathy Cardiac involvement Antepartum
- Diet o Adjustment of insulin needs o Dietary management during diabetic pregnancy must be based on blood (not urine) glucose levels o The average diet includes 2200 calories (first trimester) to 2500 calories (second and third trimesters)
- Exercise o Encouraged with careful monitoring of blood glucose
- Insulin therapy o May need adjustment o In the first trimester, from weeks 6 to 10 of gestation, the insulin dose should be reduced by 10% to 25% to avoid hypoglycemia o The commonly prescribed insulin dose is 0 units/kg in the first trimester for women with type 1 diabetes
- Self monitoring of blood glucose o Continuous glucose monitoring (CGM) measures the glucose content of interstitial fluid through a needle sensor inserted into subcutaneous tissue
- Urine testing o Specifically for ketones o Monitoring for urine ketones may detect inadequate caloric or carbohydrate intake or skipped meals or snacks
- Complications requiring hospitalization o Dehydration and infection may lead to hyperglycemia and DKA
- Fetal surveillance o Baseline EDB o Nonstress testing if the preferred primary method to evaluate th4e fetal well being 1-2x/week after 32 weeks o Because the fetus of a woman with diabetes is at increased risk for neural tube defects (NTDs) (e., spina bifida, anencephaly, microcephaly), measurement of maternal serum alpha-fetoprotein is performed
Early pregnancy screening - Screening with history, risk factors, blood glucose Screening at 24-28 weeks of gestations - 50 g oral glucose and 1 hour measurement o 130-140 mg/dL or above is positive o If positive 3 hour 100 g oral glucose tolerance test An initial positive screening result is followed by step 2, a 3-hour (100- g) oral glucose tolerance test (OGTT) on another day The OGTT is administered after an overnight fast and at least 3 days of unrestricted diet (at least 150 g of carbohydrate) and physical activity Antepartum - Similar medication as with pregestational diabetes o Strict blood glucose control - Diet o Standard diet (usually 2000-2500) - Exercise o Moderate exercise o Build lean muscle mass (improves sensitivity to insulin) - Self monitoring of blood glucose o Usually done at home o Reviewed at prenatal visits - Pharmacologic therapy o 1/3 GDB require insulin or oral hypoglycemia o If fasting plasma glucose levels are persistently greater than 95 mg/dL, 1- hour postmeal levels are persistently greater than 140 mg/dL, or 2-hour postmeal levels are persistently greater than 120 mg/dL, pharmacologic therapy is initiated o Women who are unable or unwilling to take insulin by injection or are cognitively impaired may be candidates for oral hypoglycemic medication - Fetal surveillance o Routine unless concerns o If medication is sued 2x/week testing starting at 32 weeks Intrapartum - Blood glucose monitored to maintain 80-110 mg/dL o Insulin given if necessary o Avoid IV fluids with dextrose - Possible c/s if preeclampsia or macrosomia Postpartum - Generally return to normal glucose after birth - Will need screening with subsequent pregnancies o 75g, 2 hour OGTT or a false plasma glucose levels at 4-12 weeks postpartum Other medical disorders in pregnancy Anemia - Common in pregnancy - Increased risk at delivery due to blood loss - Iron deficiency anemia o Most common type of anemia
o Preventable o Easily treated with iron supplements Teach cleint to eat iron rich foods, take with vitamin C, avoid taking with calcium (decrease absorption)
- Folic acid deficiency o Found in dark leafy green vegetables, citrus fruits, eggs, legumes, and whole grains o Also in supplements
- Sickle cell hemoglobinopathy o Most people with sickle cell trait are asymptomatic o Approx. 1 in 12 black adults in the US have sickle cell trait o Women with sickle cell trait require genetic counseling and partner testing to determine the risk of their children having sickle cell trait or disease o Encouraged to labor in side lying position o May require supplemental O o Maintain adequate hydration
- Thalassemia o Common anemia in which an insufficient amount of hemoglobin is produced to fill the RBCs o Managed similarly as sickle cell Pulmonary disorders Asthma
- Unpredictable with pregnancy
- Goal is preventing asthma exacerbations
- Education o Avoiding triggers o Use of prophylactic medications o Management of acute episodes
- Poorly controlled asthma may need additional monitoring and testing Cystic fibrosis
- Common autosomal, recessive genetic disorder o Production of excessive viscous secretions
- Pregnancy generally well-tolerated o May need closely followed pulmonary function testing o Fetal assessment essential
- During labor o Monitor cardiac output closely Integumentary disorders Skin disorders
- Normal changes with pregnancy Pruritus gravidarum (severe itching)
- Usually disappear shortly after birth
- Can reoccur in 50% future pregnancy Polymorphic eruption of pregnancy
- Usually does NOT recur in other pregnancies
- PEP classically appears in primigravidas during the mid to late third trimester and occurs slightly more often in women carrying male fetuses
- The lesions usually appear first on the abdomen but can spread to the arms, thighs, back, and buttock
o It consists of five questions and takes less than 1 minute to complete o Because women frequently deny or greatly underreport usage when asked about drug or alcohol consumption during pregnancy, asking about substance use before pregnancy is often an effective screening method
- CRAFFT is a substance abuse screening tool designed specifically for use with individuals aged 12 to 21 o It consists of six questions o A “yes” answer to two or more questions suggests a serious problem and indicates a need for further assessment Assessment
- Comprehensive med history and complete physical exam
- Lab for syphilis, hep B&C, and HIV
- CBC & TB
- Gonorrhea and chlamydia Interventions
- Education on. Risk, tx, and referrals Follow-up care
- With know SUD o Home assessment o Social service interview o Family support identified o Home nurse visit CHP 12 high-risk perinatal care Hypertension in pregnancy
- Hypertensive disorder occur in 5-10% of pregnancies o Major cause of maternal and perinatal mortality/morbidity Type Description Gestational HTN disorders Gestational HTN Development of HTN after 20 weeks of gestation in a woman with a previously normal BP Preeclampsia Development of HTN and proteinuria in a woman after 20 weeks of gestations who previously had neither condition In the absence of proteinuria, the development of new-onset HTN with a new onset of any of the following: thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema or cerebral or visual symptoms Eclampsia Development of seizures or coma in a woman with preeclampsia who has no hx of preexisting pathology that can result in seizure activity Chronic HTN disorders Chronic HTN HTN that is present before the pregnancy or diagnosed before 20 weeks gestation Superimposed preeclampsia Chronic HTN is association with preeclampsia
- Classification
o Gestational HTN: BP grater than 140/90 on 2 separate occasions at least 4 hours apart after 20 week gestations in a women who previously had normal BP BP will return normal within 12 months of delivery Half of the women diagnosed with gestational HTN will develop preeclampsia o Preeclampsia: HTN with proteinuria develop after 20 weeks in a woman who previously did not have these conditions May also develop in the PP period o Eclampsia: onset of seizure activity or coma in a woman with preeclampsia Can occur anytime before, during or after birth Many cases occur more than 48 hours after birth o Chronic HTN disorder: HTN that is [present before pregnancy or develops before 20 weeks gestations Preeclampsia Etiology
Risk factor include first pregnancy, multifetal gestation, chronic hypertension, history of preeclampsia in prior pregnancy, pregestational diabetes mellitus, preexisting thrombophilias, obesity, lupus, maternal age 35 or older, ART treatment Pathophysiology
The placenta is the primary issue, and the cure involves delivery of the placenta
The exact pathophysiology is not fully understood; however we know that there are some characteristics changes in placental perfusion and endothelial cell dysfunction
Reduced kidney perfusion result in oliguria
Fluid shift occur resulting in hemoconcentration, increased blood viscosity, and tissue edema
Cerebral edema and hemorrhage may occur which can lead to CNS irritability resulting in HA, clonus, and seizures
Visual disturbance may also develop in relation to changes in blood flow to the retina HELLP syndrome o A variant of preeclampsia characterized by hemolysis, elevated liver enzymes and low platelets o Diagnosed by laboratory criteria o Occur more frequently in white women than other races o A diagnosis of HELLP syndrome is associated with an increased risk for maternal death and adverse perinatal outcomes, including pulmonary edema, acute renal failure, disseminated intravascular coagulation (DIC), placental abruption, liver hemorrhage or failure, acute respiratory distress syndrome (ARDS), sepsis, and stroke Identifying and preventing preeclampsia o Blood pressure should be monitored and urine should be checked for protein at each prenatal visit o There is no specific test for preeclampsia; diagnosis relies on identification of S/S o Women at risk od developing preeclampsia may receive low dose aspirin daily between 12-28 weeks gestations Assessment
Administration o Verify health care provider’s order. o Position woman in side-lying position. o Prepare solution and administer with an infusion control device (pump). o Piggyback solution of 40 g of magnesium sulfate in 1000 mL lactated Ringer’s solution with infusion-control device at the ordered rate: loading dose—initial bolus of 4–6 g over 15–30 min; maintenance dose—2 g/h, according to unit protocol or health care provider’s specific order.
Maternal and fetal assessment o VS and assessment are performed as ordered by the health care provider and per hospital protocol o Monitor blood pressure, pulse, respiratory rate every 15–30 min, depending on woman’s condition o Monitor FHR and contractions continuously. o Monitor level of consciousness, intake and output, proteinuria, DTRs, headache, visual disturbances, and epigastric pain at least hourly o Restrict hourly fluid intake to a total of no more than 125 mL/h; urinary output should be at least 25–30 mL/h.
Reportable conditions o Blood pressure: systolic ≥160 mm Hg or diastolic ≥110 mm Hg o Respiratory rate: <12 breaths/min o Urinary output: <25–30 mL/h o Presence of headache, visual disturbances, decrease in level of consciousness, or epigastric pain o Increasing severity or loss of DTRs, increasing edema, proteinuria o Any abnormal laboratory values (magnesium level, platelet count, creatinine clearance, protein/creatinine ratio, levels of uric acid, AST, ALT, prothrombin time, partial thromboplastin time, fibrinogen, fibrin split products) o Any other significant change in maternal or fetal status
Emergency measures o Keep emergency drugs and intubation equipment immediately available. o Keep side rails up. o Keep lights dimmed, and maintain a quiet environment. SAFETY ALERT
If magnesium toxicity is suspected, prompt actions are needed to prevent respiratory or cardiac arrest.
The magnesium infusion should be discontinued immediately
Calcium gluconate (antidote for magnesium sulfate) can be given intravenously SAFETY ALERT
Understanding regarding the effect of magnesium sulfate on FHR baseline variability is controversial.
Because fetal levels of magnesium approximate those of the mother, fetal sedation is possible.
However, absent or minimal baseline variability should not be assumed to be the result of magnesium sulfate therapy until other causes of fetal hypoxemia have been ruled out Eclampsia
Immediate care o Time the seizure
o Protect the pt safety- side rails up and padded o After seizure, lower head of the bed and turn to left side o Ensure patent airway o Call code if needed o IV line should be placed o If magnesium running, increase magnesium o If recurrent seizures, lorazepam should be administered o After women stabilized, assess fetal well being Membranes may have ruptured o Determine best route for delivery, vaginal vs c-section
Hyperemesis gravidarum Etiology
- Nausea develops between 4-8 weeks of gestation
- HG= severe N/V that results in weight loss, electrolyte imbalance, nutritional deficiencies and ketonuria Clinical manifestations
- Significant weight loss and dehydration
- May also have low BP and increase pulse, dry mucous membranes, poor skin turgor, and electrolyte imbalances Assessment
- Frequency/severity, Duration of episodes of N/V and description of vomitus
- Any diarrhea or other GI disturbances, precipitating/alleviating factors, pharmacological/nonpharm measure used, complete physical exam, pre-pregnancy wight Interventions
- Initial care o IV therapy for fluid and electrolyte replacement; may be in pt or out pt o May also need antiemetic medication. Corticosteroids, antacids and gerd medication may also be used o Once vomiting controlled, small frequent meals should be started o Need plenty of rest o Follow up care- small frequent meals, notify provider if vomiting returns In the beginning, limited amounts of oral fluids and bland foods such as crackers, toast, or baked chicken are offered Avoid an empty stomach Drink liquids from a cup with a lid Try warm ginger ale (with sugar, not artificial sweetener) or water with a slice of lemon Early pregnancy bleeding Spontaneous abortion
- Miscarriage is a pregnancy that end due to natural causes before the age of viability (before 20 weeks)
- 10-15% of all pregnancies end in miscarriage
- 80% of miscarriage occur before 12 weeks
- Different types of miscarriage require different care
- When speaking with family, miscarriage term should be used
- Types o The types of miscarriage include threatened, inevitable, incomplete, complete, and missed
o Indications for cerclage placement are a poor obstetric history, which should include at least 1 previous early preterm birth, a short (<25 mm) cervical length identified on transvaginal ultrasound, and an open cervix found on digital or speculum examination o Placement may occur sometime between 12 and 23 weeks and must be removed before the woman labors o Progesterone therapy may be needed and would continue until the woman reaches 36 weeks gestation o Bed rest is no longer advised o The cerclage is removed at 36 weeks gestation Ectopic pregnancy
- Pregnancy in which the egg implants outside the uterus, most often in the fallopian tube
- Most diagnosed before rupture
- S/Sx o Abdominal pain, missed menses, abnormal vaginal bleeding o If rupture occurs, lower abdominal pain, bluish bruising around umbilicus, may show signs of shock, abdomen may fill with blood o The majority of women with an ectopic pregnancy report a period that is delayed 1 to 2 weeks or lighter than usual or an irregular period o If the ectopic pregnancy is not diagnosed until after rupture has occurred, referred shoulder pain may be present in addition to generalized, one-sided, or deep lower quadrant acute abdominal pain
- Quantitative HCG test and ultrasound should be performed
- If unruptured, can be treated with methotrexate
- If ruptured, surgery is required
- HCG levels should be measured weekly after ectopic pregnancy
- Should avoid pregnancy for 3 months after the ectopic pregnancy Molar pregnancy (hydatidiform mole)
- Excessive growth of placental trophoblast that forms grapelike clusters and fill the uterine cavity
- Results from fertilized egg but a fetus does not form
- Can develop into a cancerous condition
- The woman will experience bright red to dark brown vaginal bleeding, anemia from blood loss, N/V, and may experience hyperthyroidism related to the molar pregnancy
- Hyperthyroidism is reversed with treatment of the molar pregnancy
- Diagnosis o Is done by US and serum HCG levels o HCG levels will be high and continually rise o Suction and curettage may be needed Dilation and curettage refers to the dilation of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping
- Weekly serum HCG should be done until the level is normal and remain normal for 3 consecutive weeks
- Follow up assessment usually continues for a year
- The woman should avoid pregnancy during this time
- The woman is at increased risk of developing GTN (gestational trophoblastic neoplasia)
Late pregnancy bleeding Placenta previa
- The placenta partially or completely cover the internal cervical os
- This can lead to bleeding as the cervix begins to dilate
- This is diagnosed on US
- Characterized as painless, bright red vaginal bleeding during 2nd or 3rd trimester
- All women with painless vaginal bleeding after 20 weeks of gestation should be assumed to have a placenta previa until proven otherwise
- May need to be hospitalized for assessment of condition
- Should have large bore IV
- May require blood replacement if bleeding is significant
- May be able to discharge home
- After 26 weeks, cesarean delivery is performed
- The woman may experience more bleeding than normal after delivery Abruptio placentae
- Premature separation of the placenta from the uterine wall
- Characterized by painful, dark bleeding and ridged or board like abdomen
- Can be partial or complete
- Management depends on the severity
- If mother and fetus are stable, Expectant management is indicated
- If near term, immediate birth is management of choice
- Vaginal or cesarean delivery depend on severity/grade/amount of separation and how much bleeding is occurring
- Mother may require blood replacement depending on amount of blood loss and clinical manifestations
- Active management o An indwelling catheter is inserted for continuous assessment of urine output, an excellent indirect measure of maternal organ perfusion Clotting disorder in pregnancy
- Normal clotting o Preserves homeostasis by building a clot in response to an injury excessive bleeding o The clotting cascade and the fibrinolytic system work together
- Clotting problems (DIC) o Often related to preeclampsia and results in both bleeding and clotting at the same time o Clotting factors are used up leaving the pt at risk of excessive bleeding o Treatment is correction of underlying cause o The nurse must monitor for s/s of bleeding o May require replacement of blood products o In-dwelling catheter should be placed and renal function needs to be monitored closely CHP 17 labor and birth complications Preterm birth vs low birth weight
- Preterm refers to the gestational age
- Preterm infants are smaller than average due to their immature gestational age
- Low birth weight may occur for different reasons such as IUGR-something preventing the fetus from growing as expected Spontaneous vs indicated preterm birth
- Preterm birth can be a natural, spontaneous event or it may occur to resolve maternal or fetal risk factors such as severe preeclampsia which can affect the mother and the fetus Causes of spontaneous preterm labor and birth
NSG-432 topic 5 content
Course: Nursing Care of the Childbearing Family (NSG-432)
University: Grand Canyon University
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