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Topics 5 & 6 - Important information for Final Exam highlighted & bolded within material
Nursing Care of the Childbearing Family (NSG-432)
Grand Canyon University
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Assessment of High-Risk Pregnancy: - Assessment of Risk Factors: o Biophysical Factors: those that originate within mother/fetus Genetic: inherited disorders, chromosomal anomalies, multiple gestation, large fetal size, ABO incompatibility Nutrition: adolescents, three pregnancies in 2 years, tobacco/alcohol/drug use, dietary intake (illness, fads, bariatric surgery), inadequate or excessive weight gain, low hematocrit (<33%) Medical & Obstetric: Complications (current or previous), pregnancy- related illness, previous loss Polyhydramnios (fetal GI issues) or oligohydramnios (possible fetal renal issues, PROM, IUGR, maternal hypertension/dehydration, uteroplacental insufficiency) IUGR- Intrauterine growth restriction o Mother- hx of HTN, diabetes, cardiac or autoimmune issues, pulmonary disease Chromosomal abnormalities: o Advanced maternal age o Parental chromosomal rearrangements or previous hx of this o Psychosocial factors: behaviors/adverse life events Smoking, caffeine (recommended no more than 12 oz/day) Alcohol/drugs Emotional distress, depression/mental health problems Psychological status: History of abuse, social environment, unsafe practice, situational crises o Sociodemographic Factors: Low income/Social Determinants of Health (SDOH) Lack of prenatal care Age: adolescents – anemia, preeclampsia, CPD Mature mothers (“advanced age” i. over 35) increased risk of genetic issues, chronic disease o Environmental factors: Infections, chemicals, pollutants (industrial, at home smoking), cat litter, gardening - Antepartum Testing: o Purpose: to identify those at risk for injury due to interrupted acute or chronic oxygenation Diabetes, hypertension, preeclampsia, renal or heart issue, IUGR, previous stillbirth, poly or oligohydramnios, etc
o Methods: Biophysical profile (BPP): noninvasive dynamic assessment of a fetus that is based on acute and chronic markers of fetal disease Usually done late in second trimester or third trimester- reliable predictor of fetal well-being (8-10 = normal) Lower the number, more the 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 observation 5 components o NST: to determine fetal heart rate reactivity o Fetal breathing movements (FBMs) o Fetal movements: daily fetal movement count (DFMC) “kick count” o Fetal tone o Amniotic fluid Scoring: normal = 2 in each category o NST: reactive pattern o Fetal breathing movements: ≥1 episode lasting ≥ seconds o Gross body movements: ≥3 discrete body/limb movement o Fetal muscle tone: ≥1 episode of extension (limb or trunk) with return of flexion o Amniotic fluid: ≥1 pocket measuring 2cm in two perpendicular planes Ultrasound: Detection of FHR, gestational age, growth, anatomy, genetic disorders, anomalies, position of fetus, position of placenta Levels of US: o Standard (“basic”) Diagnostic tool throughout pregnancy o Limited: To determine a specific piece of info about the pregnancy o Specialized (“detailed”) May be referred to as “targeted” Comprehensive exam for abnormal hx or lab findings Performed by highly trained professionals Nursing role: counsel and educate about the procedure
Women with a prior child with a structural birth defect or with a structural fetal defect identified by ultrasound during their current pregnancy Women with prior child with a chromosomal abnormality Chronic Villus Sampling: “placental biopsy” o 10-13 weeks o Small specimen from placenta o Allows for earlier diagnosis & rapid genetic results (reflects genetic makeup of fetus) Percutaneous Umbilical Blood Sampling (PUBS): o Direct access to fetal circulation o 2 nd and 3rd trimesters o Can be used for sampling or transfusion o Insertion of needle into umbilical vessel (vein preferred) o Often used for evaluation of amnio or CVS results: Determines specific mutation o May also be used to assess for fetal anemia, infection, or thrombocytopenia o Risks: Transient fetal bradycardia Bleeding from puncture site; fetomaternal bleeding Occasional fetal loss Maternal Assays: o Alpha fetoprotein: (AFP) Normal values correlate with gestational age and multiple maternal factors Screen for fetal anomalies High levels help to confirm neural tube defects such as spina bifida or anencephaly or an abdominal wall defect (omphalocele) o Lung maturity: LS ratio & LBC 2:1 for adequate fetal lung maturity o Multiple marker screen: Detects chromosomal abnormalities (trisomy 21- Down syndrome) Available at 11-14 weeks o Coombs test: Screen for Rh alloisoimmunization (incompatibility) Screens for other antibodies that may place fetus at risk for incompatibility with maternal antigens Elevated titer may require amnio to test for fetal hemolytic anemia
(>1:8 to 1:32) o Cell-free DNA screening: Looks for chromosomal anomalies (trisomy 13, 18, & 21)- extra/missing chromosomes Uses maternal blood Also provides a definitive diagnosis noninvasively for fetal Rh status, sex, and certain paternally transmitted single gene disorders Nonstress Test: a reliable screening of fetal well-being Done to determine whether the intrauterine environment continues to support the fetus Procedure: o Placed on a monitor- given a button to press when movement is felt o May have to stimulate/wake up the baby- vibracoustic tool Sound & vibration stimulation o Repeated 1-2x weekly for remainder of pregnancy Interpretation: o “reaction” is positive = NORMAL o Two accelerations in a 20 min period, each lasting at least 15 secs and peaking at least 15 bpm above baseline o RELIABLE SCREENING OF FETAL WELL-BEING o “non reactive” is negative Does not demonstrate at least two qualifying accelerations w/in a 20 min period Doesn’t always mean baby is compromised Will do further testing- monitor mom and baby Contraction Stress test: Provides an earlier warning of fetal compromise than the NST and produces fewer false-positive results Procedure: o Nipple stimulation- stimulation of nipples with warm washcloths or through clothes for 5-10 mins to start contractions o Oxytocin- three uterine contractions of moderate intensity, each lasting 40-60 secs, observed w/in a 10-minute period Interpretation: o Negative is GOOD- no signs of fetal issues o Positive is NOT GOOD- appear to be issues with fetal well- being (late decels w/ contraction = fetal hypoxia)
Preconception counseling: for pregestational (preexisting) 1 st trimester: requires less insulin- may need to reduce dose to prevent hypoglycemia o Nausea, vomiting, and cravings may cause dietary fluctuations in glucose o Hyperglycemia in first trimester may cause congenital anomalies 2 nd & 3rd trimester: Insulin needs may increase Maternal risks: Recommend reliable contraception until glycemic control is optimal Poor blood glucose control: o Increased risk of macrosomia- LGA (100-4500g or more than 90th percentile) o Increased risk for should 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, compared with 300-350 in nonpregnant state Fetal & Neonatal Risk: Hyperglycemia in 1st trimester o Main cause of diabetes related anomalies CV system, CNS Breastfeeding should not have significant impact on insulin levels o Gold hour very important because baby is at risk for hypoglycemia Assessment: Acute and chronic complications: o Retinopathy, nephropathy, cardiac involvement Antepartum: Diet: adjustment of insulin needs Exercise: encouraged with careful monitoring of blood glucose Insulin Therapy: may need adjustment Self-monitoring of blood glucose Urine testing: specifically for ketones Complications requiring hospitalization: o Dehydration & infection may lead to hyperglycemia and DKA Fetal surveillance: o Baseline EDB o Nonstress testing: 1-2x/week after 32 weeks
Determination of birthday and mode of birth o Optimal time 39 weeks May be earlier delivery with maternal or fetal complications Intrapartum: Compilations r/t dehydration, hypoglycemia, hyperglycemia Care: o 1 st stage: IV fluids, monitoring of blood glucose, continuous fetal monitoring o 2 nd stage: risks for should dystocia and other CPD risks (cephalopelvic dystocia) Postpartum: Insulin requirements: decrease substantially after birth and placenta delivered o Gestational Diabetes mellitus: Increased incidence r/t overweight/obesity Likely to reoccur for future pregnancies Maternal risks: Less risk than pregestational diabetes Preeclampsia & cesarean birth Development of type II diabetes later in life Fetal risks: Less risk that pregestational diabetes o Critical development period is prior to development of GDM Greater risk of macrosomia and birth trauma Risk for neonatal hypoglycemia Screening for gestational diabetes mellitus: Early pregnancy screening: o Screened with history, risk factors, blood glucose Screening at 24-28 weeks of gestation o 50g oral glucose & 1 hour measurement o 130-140 or above = positive o If positive; 3 hours 100g oral glucose tolerance test (OGTT) Antepartum: Similar modification as with pregestational DM o Strict blood glucose control Diet: standard diabetic diet (usually 2000-2500 kcal/day) Exercise: moderate exercise o Build lean muscle mass (improves sensitivity to insulin) Self-monitoring of blood glucose o Usually done at home, reviewed at prenatal visits
Avoid triggers, use prophylactic medications, management of acute episodes Poorly controlled asthma may need additional monitoring and testing o Cystic Fibrosis: Common autosomal recessive genetic disorder Production of excessive viscous secretions Pregnancy generally well-tolerated May need closely followed pulmonary function testing Fetal assessment essential During labor: monitor cardiac output closely
- Skin Disorders: normal changes with pregnancy o Pruritus gravidarum (severe itching): Usually disappears shortly after birth Can reoccur in 50% future pregnancies o Polymorphic eruption of pregnancy (PEP): Usually does NOT recur in other pregnancies Itchy bumpy rash on stretch marks o Treatment: Both symptomatic tx with: Skin lubrication, topical antipruritic, and oral antihistamines Ultraviolet light and careful exposure to sunlight decrease itching
- Substance Use Disorders: o Prescription or illicit drugs, tobacco, alcohol, marijuana, cocaine, meth o Prevalence: Continues to grow in the US Usage is usually higher in 1st & 2nd trimester o Maternal and Fetal Effects of Selected Drugs: Most associated with low birth weight and preterm birth IUGR o Barriers to Treatment r/t: Social stigma, labeling, and guilt are significant barriers to receiving necessary care Fear losing other children or criminal prosecution Lack of treatment options o Legal Considerations: Defined as child abuse in 23 states Should be aware of current laws in your practicing state o Screening: Recommend screening everyone at first prenatal visit Discussion of past and present use of tobacco, alcohol, & other drugs o Prescription medications and OTC o Herbal remedies
Requires lots of education on risks of use 4 Ps Plus: parents, partners, past, and pregnancy, depression/domestic violence CRAFFT substance abuse screen for adolescents & young adults o Assessment: Comprehensive med history and complete physical exam Lab for syphilis, hep B & C, and HIV CBC & TB Gonorrhea & chlamydia o Interventions: Education on risks, treatment, referrals o Follow-up care: With known SUD Home assessment Social services interview Family or support identified Home nurse visit
o Identifying and Preventing Preeclampsia: BP should be monitored and urine should be checked for protein at each prenatal visit No specific test; diagnosis relies on identification of S/S Women at risk of developing preeclampsia may receive low-dose aspirin daily between 12-28 weeks gestation o Assessment: BP should be taken with a manual BP cuff Edema, DTR, presence (or absence) of clonus, proteinuria (at least 1+ on dipstick or >300mg) Examination should include assessment for severe features including: Headache, epigastric pain, RUQ pain, and visual disturbances o Interventions: Gestational hypertension and preeclampsia without severe features: Close monitoring of the mother and fetus May be appropriate for home care Woman should be hospitalized if severe features develop Maternal assessment includes: o Monitoring of BP, labs, maternal weight & careful monitoring for severe features Fetal assessment includes; o Daily kick counts, serial nonstress tests, serial ultrasound, and monitoring of amniotic fluid levels Complete/partial bed rest recommended Gestational hypertension and preeclampsia with severe features: Increased risks of maternal and fetal mortality/morbidity Requires IMMEDIATE HOSPITALIZATION Mag sulfate used to prevent seizure activity (decreases CNS excitability) Serial labs are necessary Fetal assessment = essential o Frequent monitoring to identify and respond to s/s of magnesium toxicity Calcium gluconate: antidote to mag sulfate o Should be readily available in case of toxicity o Mag crosses placenta and can impact fetus (EFM strip) Hydralazine, labetalol, nifedipine to control BP
- Eclampsia: o Immediate care: Time the seizure, protect patient safety- side rails up & padded After seizure- lower HOB and turn to left side; ensure airway (ABC) Call code if needed; IV line should be placed If mag is running, increase mag; recurrent seizures lorazepam
After woman stabilized, assess fetal well-being; membranes may have ruptured (CHECK MEMBRANES) Determine best route for delivery (vaginal vs c-section)
- Hyperemesis Gravidarum (HG): o Etiology: Nausea develops between 4-8 weeks gestation (normal) HG = severe N/V that results in weight loss, electrolyte imbalance, nutritional deficiencies & ketonuria o Clinical manifestations: Significant weight loss & dehydration May also have low BP and increase pulse Dry mucous membranes, poor skin turgor, electrolyte imbalances o Assessment: Frequency/severity/duration of episodes of n/v and description of vomitus Any diarrhea or other GI disturbances Precipitating/alleviating factors Pharmacological/nonpharmacological measures used Complete physical exam & prepregnancy weight o Interventions: Initial care: IV therapy for fluid and electrolyte replacement o May be inpatient or outpatient May also need antiemetic medication, corticosteroids, antacids, and GERD medication Once vomiting controlled, small frequent meals should be started Need for plenty of rest Follow-up care: Small, frequent meals Notify provider if vomiting returns
- Early Pregnancy Bleeding: o Spontaneous abortion/miscarriage: A pregnancy that ends due to natural causes before the age of viability (before 20 weeks) 10-15% of all pregnancies end in miscarriage 80% of miscarriages occur before 12 weeks Different types of miscarriage require different care When speaking with the patient/family, term miscarriage should be used o Cervical Insufficiency: a.k. incompetent cervix One cause of late miscarriage May be cause of recurrent late miscarriage Can be diagnosed through obstetric history, speculum exam, or by visual inspection of the cervix on ultrasound
Diagnosed on ultrasound Characterized by: Painless, bright red vaginal bleeding during 2nd or 3rd trimester 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 be discharged home After 36 weeks, Cesarean delivery performed Woman may experience more bleeding than normal delivery o Abruptio Placentae/Placental abruption: Premature separation of the placenta from uterine wall Characterized by: Painful, DARK RED bleeding, and RIGID/BOARDLIKE ABD Management depends on severity Mother & fetus = stable; expectant management indicated If near term, immediate birth is management of choice Vaginal 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
- Clotting Disorders in Pregnancy: o Normal Clotting: Preserves homeostasis by building a clot in response to an injury to prevent excessive bleeding Clotting cascade and fibrinolytic system work together o Clotting Problems (DIC): Often related to preeclampsia and results in both bleeding and clotting at the same time Clotting factors are used up leaving patient at risk of excessive bleeding Treatment = correction of underlying cause Nurse must monitor for s/s of bleeding May require replacement of blood products In-dwelling catheter should be placed, and renal function needs to monitored closely
Preterm Labor & Birth: - Preterm Birth vs Low Birth Weight: Preterm refers to gestational age o Preterm infants are smaller than average due to their immature gestational age o Low birth weight may occur for different reasons such as IUGR- something preventing the fetus from growing as expected - Spontaneous vs Indicated preterm birth: o Preterm birth can be natural and spontaneous o Or may occur to resolve maternal/fetal risk factors (preeclampsia) o Causes: Infection, structural abnormalities of the uterus that affects the uterus or cervix, unexplained vaginal bleeding, genetic predisposition, maternal/fetal stress, uterine overdistention, fetal allergy, decreased/low levels of progesterone o Predicting Spontaneous Preterm Labor & Birth: Risk factors: History of a previous spontaneous preterm birth between 16 and 36 weeks of gestation History of genital tract colonization, infection, or instrumentation Black race Bleeding of uncertain origin in pregnancy Uterine anomaly Use of assisted reproductive technology Multifetal gestation Cigarette smoking, substance abuse Prepregnancy underweight (BMI <19) and prepregnancy obesity (BMI >30) Periodontal disease Limited education and low socioeconomic status Late entry into prenatal care High levels of personal stress in one or more domains of life Cervical length: Can be an indicator of preterm birth Length changes before uterine activity begins Fetal fibronectin- FFN: glycoprotein found in early and late pregnancy Presence in late 2nd and early 3rd trimester indicate placental inflammation preterm labor Better indicator of who will NOT go into labor Women with negative test have <1% chance of going into labor within 2 weeks following the test - Assessment = s/s of labor - Interventions: o Prevention: address known risk factors present in the pregnant client
Obstetric Procedures:
Version o External: used to turn fetus from breech to cephalic presentation Success rate is 65% & reduces risk of cesarean delivery by 50% Ultrasound to confirm presentation is performed followed by an NST Gentle constant pressure on the abdomen is used to turn the fetus Usually performed 36-37 weeks gestation o Internal: rarely used, most often with a twin delivery to turn the second twin Provider inserts hand into uterus to physically turn the fetus Cesarean is most often used for managing malpresentation in multifetal pregnancy
Induction of Labor: chemical or mechanical initiation of labor o Elective induction of labor: when labor is induced without a medical indication Not recommended before 39 completed weeks of gestation Success of induction is more likely when cervix is favorable The Bishop score should be assessed before induction; a score of 8 or more, there is a higher likelihood of vaginal birth o Cervical ripening methods: Chemical agents (prostaglandins or misoprostol) Balloon catheters (foley catheter balloon) inserted to canal then inflated Causes cervix to open in response to mechanical pressure applied by balloon Sweeping/stripping amniotic membranes not recommended due to side effects & little evidence that it’s effective Sexual intercourse, nipple stimulation, walking Amniotomy (artificial ROM) may be used to induce/augment labor o Oxytocin: Can be administered via IV infusion to stimulate uterine contractions High alert medication! Requires careful monitoring Should be given slowly in small increments Woman should be placed on continuous fetal monitoring when receiving Nurse will monitor for uterine tachysystole (>5 contractions in 10 mins)
Augmentation of Labor: assisting labor that has already started but is not progressing o Most common methods = amniotomy & oxytocin administration
Operative Vaginal Birth: o Forceps-assisted birth: curved blades (forceps) assist to deliver fetal head Indications: prolonged 2nd stage of labor, fetal compromise o Vacuum-assisted birth: vacuum cup is suctioned onto the fetal head to assist in delivery of the head
Cesarean Birth: o Indications: fetal, maternal, or fetal-maternal combined o Elective: c-section without a medical indication o Scheduled: labor/vaginal delivery are contraindicated as with active genital herpes infection, birth is necessary but cannot be induced as with some hypertensive states, repeat c-section o Unplanned: unplanned or emergency cesarean o Forced: legal requirement due to fetal jeopardy such as when the woman refuses and an ethical board must be called into place to advocate for fetal well-being o Surgical techniques: different types of incisions may be used Low-transverse uterine incision less risk of uterine rupture w/ subsequent pregnancies Provides the opportunity to attempt a trial of labor or a vaginal birth after cesarean w/ a late pregnancy Less blood loss with this incision o Complications & risks: Risks and complications are similar to other surgeries including bleeding, infection, etc. o Anesthesia: Cesarean may use spinal, epidural, or general anesthesia o Prenatal preparation: prenatal education classes should include discussion of cesarean birth & should emphasize the similarities & differences between different modes of birth
Trial of Labor: allowing the mother to labor for a “reasonable” period of time (usually 4- 6 hours) to determine if vaginal birth may be possible
Vaginal Birth After Cesarean (VBAC): reasons for primary/previous cesarean should be considered, many indications may not be recurring complications o Not all women are candidates but success rates = 60-80%
Obstetric Emergencies:
Meconium-Stained Amniotic Fluid: occurs when fetus passes meconium prior to delivery o May or may not be associated with fetal distress o Risk for meconium aspiration after delivery
Shoulder Dystocia: anterior shoulder gets “stuck” under the mother’s pubic arch o McRoberts maneuver combined w/ suprapubic pressure may free the shoulder o Increased risk with LGA fetus
Prolapsed Umbilical Cord: medical emergency & results in the need for immediate C- section o When presenting part is not well engage, cord may slip out ahead of the fetus when the membranes rupture o Pressure should be applied to presenting fetal part until delivery to relieve compression of the cord & restore fetal blood flow o Cord should not be touched or handled (may cause vessels to spasm)
Topics 5 & 6 - Important information for Final Exam highlighted & bolded within material
Course: Nursing Care of the Childbearing Family (NSG-432)
University: Grand Canyon University
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