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Nursing Maternal Exam 3
Key Points
Emotional Aspects of Pregnancy Psychological Responses Latent phase: mom feels anxious, talkative, excited Active phase: mom focused on self Transition phase: mom irritable, feels urge to push
- Ambivalence: unsure about pregnancy
- Acceptance
- Introversion: how will this affect me?
- Mood swings
- Changes in body image Reva Rubin’s Maternal Tasks
- Safe passage
- Seeking acceptance
- Binding in to the child
- Giving of oneself Expectant father
- First trimester: confused, baby seems “unreal”
- Second trimester: proud, increased acceptance and attachment, financial concerns
- Third trimester: anticipating the birth, some fears about labor process, baby’s health
- Couvade: unintentional development of physical symptoms!! Ex: nausea, aches and pains, etc. Mimics mom Fathering steps
- Accepting the pregnancy
- Identify with father role
- Reordering personal relationships
- Establishing relationship with fetus Nursing Care in Pregnancy Initial prenatal visit
- Generally recommended after 2 nd^ missed period (7-8 weeks)
- Begin with thorough history: chronic illnesses, social history, psychological needs.
- Determine Estimated Due Date (EDD) or Estimated Date of Confinement (EDC)
- Present pregnancy – LMP, presumptive signs (what signs has she been experiencing?), GTPAL
- Complete physical examination: assess pelvis for diagonal conjugate, and adequacy of pelvis for vaginal delivery of average-sized baby
- Draw all prenatal labs
- Begin all prenatal education: books, videos, etc. Nagele’s Rule for EDC (to determine estimated day to have baby)
- Begin with LMP (Last menstrual period and subtract 3 months and add 7 days) GTPAL vs Gravida – Para
- Gravida: number of pregnancies; Term deliveries: number of term deliveries > or = 37 weeks-42 weeks; Preterm deliveries: < 37 weeks; Abortions: < 20 weeks; Living children; Gravida/para: pregnancy/delivery – number of deliveries after 20 weeks gestation.
- Gravida = any pregnancy regardless of duration
- Para: birth after 20 weeks’ gestation (viability), regardless of whether the infant is born alive or dead. Lab Tests:
- UA and culture; blood (CBC and Type/Rh); VDRL/RPR/Serology; toxoplasmosis; rubella; hep B; HIV; antibody screening
- 10-12 weeks: Chorionic Villi Sampling
- 14-16 weeks: Amniocentesis
- 15-20 weeks: MSAFP – screening for NTD, Trisomy 21 (Down’s), and trisomy 18
- 24-28 weeks: Blood sugar 3 hour GTT
- 36 weeks +: Beta strep vaginal culture – can cause sepsis; post partum endometriosis. PERICARE!
- Hgb and Hct repeated as needed throughout pregnancy
- Urine: check glucose and protein at every prenatal visit. Should be 1 st^ morning specimen collected and refrigerated, but can also be fresh sample upon arrival at office.
- Ultrasound for dates/anomalies. Educational needs: begins at 1 st^ prenatal visit but continues throughout pregnancy; rest and sleep, exercise, employment, recreation, travel, use of drugs and alcohol, immunizations (can get flu shot and anything not a live virus), skin and breast care, clothing, dental health, nutrition. Prenatal Exercises and Sexual Activity during Pregancy
- Refer to page 375-377 for exercises
- Be open to discussion during prenatal visits about sexual activity
o Changes in desire r/t nausea, fatigue in first trimester, increased desire in 2 nd^ trimester,
decreased desire in 3 rd^ trimester r/t backache, size of baby
o Suggest alternative methods to express intimacy and stress importance of open
communication between partners. Warning Signs assessed at each prenatal visit!
- Vaginal bleeding
- Edema of face and in fingers – hypertension or preeclampsia
- Severe continuous headache – hypertension or preeclampsia
- Dim or blurred vision/spots/flashes
- Abdominal pain/persistent vomiting
- Fever and chills
- Gush of fluid from vagina
- Dysuria, backache, flank pain Subsequent prenatal visits
- Generally recommend monthly visits for low-risk mothers through 32 weeks gestation
o Assess weight, BP, urine, sxs of complications, FHR, McDonald’s Rule – if 22 weeks
pregnant should be 22 cm from symphysis pubis to top of fundus
- 32-36 weeks – bi-monthly appointments
- 36 weeks – delivery – weekly visits Maternal and Fetal Nutrition Greater need for nutrients: uterine-placental-fetal unit; maternal blood volume increases; mammary changes; RDA = 300kcal more/day than pre-pregnant dietary needs Recommended Weight gain throughout pregnancy: 1 st^ trimester = 3.5-5lbs (1.6-2.3kg); 2 nd^ and 3rd trimester – 1lb/week (0.5 kg/wk) Protein: 60g/day; fetal growth, placental growth, amniotic fluid production, uterine muscle growth, blood production; fish, meat, eggs Iron: 27mg/day
- facilitates blood cell production
- if mom is anemic, there is an increased risk of lethargy in mom, preterm births, intolerance to blood loss at delivery
- guidelines for taking iron (ex ferrous sulfate, FerroSequels, Ferrous Fumarate) Weight gain over pregnancy: underweight 28-40lbs; normal weight 25-35lbs; overweight 15- 25lbs; obese 15lbs.
Factors affecting nutrition: eating disorders, Lactase deficiency (lactose intolerance) and pica – the practice of eating non-edible substances (clay, dirt, laundry starch, etc) Cultural spiritual influences
- Many cultures have hot/cold theories on nutrition and pregnancy is often viewed as a “hot” time that requires foods that fall under the “cold” categories. These foods generally include dairy foods. Be sure to assess carefully
- Vegetarians still need adequate proteins and need to be taught of good resources
o Lacto-ovovegetarians – mild, dairy products and eggs
o Lactovegetarians – include dairy, but no eggs
o Vegans – strict vegetarians who eat no food from any animal sources. These persons
need to plan how to get adequate complete proteins and sufficient calories
▪ Complete proteins: beans and rice, peanut butter on whole grain bread, whole
grain cereal with soy milk Psychosocial factors – role of food and serving food as a maternal role
- Socioeconomic factors
- Education – it is essential for nurses to integrate teaching on healthy eating in pregnancy from the first prenatal visit.
- Psychological factors – food may be used as a substitute for emotions or may be avoided if patient is depressed Feeling nauseated?
- Eat dry foods like carbs; eat cold foods, small amounts frequently, don’t get hungry; fresh air; limited fried/fatty foods; foods with little or no smell; don’t brush teeth right after eating Feeling constipated?
- Eat high fiber; increase fluids; increase exercise to increase bowel motility; avoid laxatives Heartburn?
- Small frequent meals; avoid spicy foods; no tight clothes across stomach; don’t lie down after meals; may need to sleep in recliner in last weeks WIC (Women, Infants and Children – federally funded program provided by Health Department)
- Supplemental nutrition program for moms and babies
- Income eligible
- Food coupons for pregnant and lactating women
- Formula available for bottle fed babies
- Must go to nutrition class taught by dietician
- Children have regular developmental assessments by nurses Blood Type and Rh
- Blood types – two parts the ABO part and the Rh part
o A, B, O specify the types of proteins found on RBCs
o Rh factor is most important factor in Rh disease
▪ Rh factor group of proteins that occur only on the surface of RBCs
▪ Rh factor present on RBCs then you are Rh positive
▪ Rh factor absent on RBCs then you are Rh negative
- Rh isoimmunization occurs when an Rh negative mother has an Rh positive child
o Causes the destruction of the infant’s red blood cells (anemia) during pregnancy and after
birth.
- Rh disease: the immune system recognizes foreign cells (rh positive cells that have transferred from fetus to mother through the placenta) and sets out to destroy the invading cells by forming antibodies to recognize future foreign cells to fight off invasion
o Antibodies are produced after the first delivery so the first baby is unaffected
o Future pregnancies are at risk because the body recognizes a fetus with positive
blood type as a foreign invasion and the immune response will destroy fetal blood cells causing fetal anemia and increase risk for fetal death.
- Rh isoimmunization prevention: mother given anti Rh gamma globulin (RhoGAM) at 28 weeks gestation and within 72 hours after delivery, miscarriage, ectopic and for abortions. in miscarriages and ectopic pregnancy there is a risk for hemorrhage.
o Prevents the formation of antibodies that might affect future infants.
▪ RhoGAM only affective if mother has not already developed antibodies to rh-
positive blood type.
▪ RhoGAM attacks baby’s HGB
- Care plan for hemolytic disease
o Zone 1: mild; management: amino for delta-OD 450 every 4-5 weeks; delivery: at term
o Zone 2: moderate: management: amino for delta-OD 450 every 1-2 weeks; delivery in 37
weeks.
o Upper zone 2: moderate to severe; management: amino for delta-OD 450 every 1-
weeks; delivery: 34-36 weeks if fetal lungs are mature
o Zone 3: severe; management: fetal blood transfusion; delivery: deliver at once if
fetal lungs are mature. Complications of Pregnancy
- 4 categories approved by the NIH and Nat’ I High Blood Pressure Education Program (NHBPEP)
o Chronic Hypertension: hypertension that was either present before conception or
detected before the 20 th^ week of gestation and did not resolve in the early postpartum.
o Chronic hypertension with superimposed preeclampsia – the disorder most often
associated with severe maternal and fetal complications. It is seen in women who…
▪ Were hypertensive before the 20 th^ week gestation but have new onset proteinuria.
▪ Have both hypertension and proteinuria before 20 weeks gestation
▪ Have previously controlled hypertension who have a sudden increase in blood
pressure
▪ exhibit thrombocytopenia (<100,000 cells/mm3) and increased liver enzymes
o Gestational Hypertension
▪ Tansient – increase blood pressure that occurs without proteinuria late in
pregnancy or in the early postpartum period, but returns to normal by 12 weeks postpartum.
▪ Chronic – increased blood pressure that occurs without proteinuria late in
pregnancy or in the early postpartum period but remains high after 12 weeks postpartum.
o Pre-eclampsia-eclampsia – this is a pregnancy-specific, multi-system syndrome
▪ Diagnosis is determined by presence of hypertension, occurring after the
20 th^ week gestation, accompanied by proteinuria.
▪ Other symptoms that may occur with increased blood pressure; visual
changes, headache, abdominal pain, or abnormal lab values
▪ Eclampsia is the convulsive phase of preeclampsia, when the seizures cannot be
attributed to other causes.
- Preeclampsia vs eclampsia = if never have a seizure, not in eclampsia… you are in preeclampsia
- Preeclampsia - Page 461 BUN and CREATININE
o Definition: increased blood pressure (generally defined as 140/90 or an increase in
systolic of 30 and diastolic of 15) occurring after 20th^ week gestation accompanied by proteinuria (spilled protein). Edema is no longer used in the definition because is it so common in pregnancy, however, sudden weight gain does warrant close observation.
o Symptoms: HEADACHE, visual disturbances.
o HTN leads to cardiac or renal problems
o Increase of 30mmHg systolic or 15 mmHg diastolic above baseline
o The “gold standard” is a 24 hour urine specimen with excretion of >300mg of protein in
24 hours
o This correlates with a dipstick of 1+(30mg/dL) or greater if specific gravity is
<1.030 or 2+ if the specific gravity is higher.
o Void and disguard first void, keep bucket of pee in ice
o Weight gain of:
▪ > 1.5kg/month (3.3lbs) in the second trimester
▪ or > 0.5kg/week (1.1lb) in the third trimester.
o Puffiness of face and hands rather than dependent edema manifested as swollen ankles
and feet – in legs and feet at end of day and disappears in morning is not significant. Face and hands is more indicative in shift of fluids in cells!
o Pitting edema of lower extremities while on bedrest
o Nulliparas – never given birth
o Multigetational pregnancies
o History of previous pregnancy with preeclampsia
o Maternal age <19 or >
o African American ethnicity
o Family history of preeclampsia
o Presence of pre-existing disease: chronic hypertension, renal disease, diabetes mellitus
- Changes in normal pregnancy
o Increased cardiac output by 50%
o Increased blood volume by 1500ml
o Decreased peripheral vascular resistance
o Decreased blood pressure
o Increased renin
o Increased GFR
o Increased ECF
o Aldosterone effects blocked
o Generalized vasospasm (fundamental cause of preeclampsia)
▪ Hypertension
▪ Decreased intravascular volume decreased placental perfusion IUGR
(intrauterine growth retardation) of fetus, fetal distress
▪ Decreased renal perfusion decreased GFR urine output (oliguria)
▪ Increased BUN and Creatinine and uric acid
▪ Increased proteinuria decreased serum albumin
▪ Increased extravascular fluid (edema) pulmonary, retinal and cerebral edema
dyspnea, scotomata, CNS irritability/hyperreflexia, HA, N and vomiting, convulsions
▪ Decreased hepatic perfusion increased liver function tests and epigastric pain
(RUQ) – this is a serious problem if complain of epigastric pain!
o Signs and symptoms: BP >140/90; periorbital edema; 1+ to 2+ proteinuria by dipstick;
mild edema of face and hands; platelet count > 120,
o Home care of mild preeclampsia:
▪ Monitor daily weight for gain
▪ Monitor blood pressure daily
▪ Monitor urine for protein daily (dipstick)
▪ Remote NST’s are performed
▪ Daily fetal movement counts
▪ Lab tests: BUN, liver enzymes, 24-hour urine for protein, creatinine clearance
▪ Encourage rest in Left Lateral position
▪ Go to hospital with any worsening symptoms
- Hospital care of mild preeclampsia
o Bedrest, left lateral recumbent position to increase renal perfusion which promotes
diuresis and lowers blood pressure
o Diet – well balanced, nutritious, moderate sodium (not > 6g/day), moderate
increase protein to replenish what is spilled by kidneys
o Assessment of fetal well-being
▪ DFMC, BPP, NST, Amniocentesis
o Assessment of material well-being
▪ BP assessed four time a day or every 4 hours
▪ Daily weight and assessment of worsening edema
▪ Assessment of HA, visual changes, epigastric pain, hyperreflexia
▪ Lab tests: daily urine dipstick for protein, 24 hour protein, CBC with platelet
count every 2 days, serum creatinine, uric acid, and liver function tests (AST, ALT, LDH, Bili)
- Sever Preeclampsia signs and symptoms
o BP of 180/110 or higher on 2 occasions at least 6 hours apart while on bedrest
o Proteinuria > or = 5g/L in 24 hours or 3+ or > on 2 random urine samples 4 hours apart
o Oliguria: urine output < 500 ml/24 hr
o Cerebral or visual disturbances – HA, scotomata or blurred vision
o Pulmonary edema or cyanosis
o Epigastric or RUQ pain!!!
o Imipaired liver function (increased AST, APT)
o Thrombocytopenia
o IUGR
o Hyperreflexia, irritability, emotional tension, N/V
- Treatment of Severe Preeclampsia – DELIVERY IS the CURE
o Absolute bedrest
o Queit environment to reduce stimuli
o High protein, moderate sodium diet
o Anticonvulsant – magnesium sulfate is drug of choice because of its CNS depressant
action
o Corticosteroids – betamethasone or dexamethasone is given to mother to promote lung
development in fetus. ONLY GIVEN TO HELP BABY, not mom. They stimulate production of surfactant in fetus lungs
o Fluid and electrolyte replacement – need to keep balance
o Antihypertensives – if diastolic > 105- 110
- Medications used in treatment of Preeclampsia
o Magnesium Sulfate: a 4-6 g bolus is given IV over 20 minutes, then a continuous infusion
of 2g/hr is generally advocated – major side effect is patient has an out of body experience feels like body is on fire and heart is racing.
▪ Hemolysis – cell breakdown
▪ Elevated Liver Enzymes
▪ Low Platelet (<100,000/mm3)
- Sometimes associated with severe preeclampsia
- Symptoms: N/V, malaise, flu-like symptoms, or epigastric pain (Liver problems) with or without hypertension
- Persons presenting with these symptoms should have CBC with platelets and liver enzymes drawn
- These patients should be managed at tertiary care centers
- Corticosteroids: while usually given to foster fetal maturity, they have been found to stabilize platelet counts and hepatic enzymes and LDH levels. Dexamthasone is often chosen for HELLP syndrome. Diabetes in Pregnancy
- Did it exist BEFORE pregnancy?
o Pregestational Diabetes Mellitus
▪ Type 1
▪ Type 2
▪ 1/2000 pregnancies
o Gestational Diabetes
▪ Any degree of glucose intolerance with the onset or first recognition
occurring during pregnancy
▪ 2-5% of all pregnancies
- 90% of all cases of diabetes in pregnancy
- 25% of these women will develop Type 2 diabetes later in life
- Normal CHO Metabolism in Pregnancy
o Goal of changes is to provide adequate glucose to fetus for growth
o Maternal glucose crosses the placenta
o Maternal insulin does NOT
o Key concept to understand!!!!!
- CHO Metabolism – 1 st^ trimester
o Increase in E and P stimulate Beta cells of Pancreas to increase Insulin production
o Equal increase use of glucose decrease in serum glucose levels (FBS decreases)
o Increase in tissue glycogen stores
o Decrease in liver glycogen production
o Equal Pregestational Diabetics hypoglycemia
- CHO Metabolism – 2 nd^ and 3 rd^ trimester
o Pregancy is a “diabetogenic” state
o Hormones levels lead to decrease tolerance to glucose
o Increase insulin resistance
▪ HPL- Human Placental Lactogen
- Insulin antagonist – won’t let insulin work
▪ Placental insulinases
- Breakdown insulin at placental site
- Net Result = Change in Insulin. Needs for Mother during Pregnancy – pre-gestational diabetics (diabetics before pregnant)
o 1 st^ trimester = decrease need for insulin
▪ increased insulin production, N/V, decreased food intake, increased transfer to
fetus
o 2 nd^ trimester = gradual increase
o 3 rd^ trimester = 2-4 times higher need for insulin by 36 week, then levels off til labor
o After delivery = decreases; glucose/insulin balance OK by 7-10 days
o Pregestational diabetes
▪ If poor control very early in pregnancy miscarriage
▪ Macrosomic baby C/S
▪ Pre-eclampsia
▪ PTL – pre-term labor
▪ Infections (UTIs, Vag)
▪ Polyhydramnios
▪ Ketoacidosis/hypoglycemia
o Gestational – onset
▪ 2x likely to have pre-eclampsia
▪ Macrosomic baby – C/S
o Pregestational
▪ Congenital defects – heart, skeletal, CNS
o Same as Gestational
o Macrosomia birth trauma
o Hypoglycemia
o RDS
o Hypocalcemia
o Hyperbilirubinemia
o Thrombocytopenia
o Polycythemia
- Management of Pre-gestational diabetes
o Pre-conceptual counseling
▪ Establish glycemic control BEFORE pregnancy
▪ Understand the VERY close monitoring
- Blood glucose levels 4-8 times a day
- Frequent dr visits
▪ If type 2 – some oral hypoglycemic agents are teratogenic insulin subq during
pregnancy
o Hgb A1c
▪ Good control = 2.5% to 5.9%
▪ Fair control = 6% to 8%
▪ Poor control = > 8%
o Diet very carefully balanced
▪ Should be followed by registered dietician
o Exercise
▪ Not vigorous, best time is after meals
- Management of Pre-gestational diabetes – INSULIN
o Multiple daily injections needed
o Blood glucose monitoring
▪ Frequent done in doctor office or at home
o Delivery
▪ Frequent NST/BPP in last 2 months of pregnancy
▪ Deliver by 40 weeks
o Excellent resource link from the National Diabetes Education Program with handouts in
various languages and lots of resources
o Another great resource with tables from Merck Manual
o Group – B Hemolytic Streptococcus
▪ Major cause of perinatal infections
▪ Found in Vagina and Urine
▪ Increase fetal mortality and morbidity
▪ Screen 35-37 weeks
- If positive – treat in labor
o Penicillin: 5 million units IV 1; 2.5 million units every 4 hours
o Ampicillin: 2 GMs IV x 1; 1 GM every 4 hours
o Clindamycin 900mg IV q 8 hours OR Erythromycin 500mg IV
q 6hr till delivery if allergic to penicillin!
o If GBS status unknown – Prophylactic treatment is indicated if:
▪ Previous infant with GBS
▪ GBS bacteria during this pregnancy
▪ Pre-term labor
▪ Temp in labor > 100.4 F
▪ Membranes ruptured > 18 hours
- Other Perinatal infections
o Syphyllis –VDRL RPR
o Gonorrhea
o Chlamydia
o TORCH
▪ Toxoplasmosis – only screen for people who have cats in the house
▪ Rubella – causes congenital heart defects
▪ Cytomegalovirus
▪ Herpes
- Hemorrhagic Complications
o Abortion = loss of pregnancy BEFORE 20 weeks gestation
o Spontaneous (miscarriage) or induced
o 10% of all pregnancies end in a miscarriage
o most in 1 st^ trimester
o Types of Abortions
▪ Threatened – cervix closed, may be stopped
▪ Imminent – cervix open, certain to occur
▪ Incomplete – all or part of conceptus retained, bleeding continues
▪ Missed – fetus dies in utero, but not expelled until months later
▪ Habitual – three or more consecutive abortions
o Ectopic Pregnancy
▪ Egg implants outside of uterus
▪ Lost of pain and internal bleeding (hypovolemic shock)– manifested by
symptoms of shock(shoulder pain) – life-threatening
▪ Surgical intervention needed (remove tube)
o Hydatidiform Mole
▪ No fetus, fluid filled vesicle
▪ N/V, no FHT’s, 2 nd^ trimester bleeding—prune-juice
▪ D&C
▪ Not get pregnant for 1 year
▪ Choriocarcinoma, if HCG is elevated – elevated MORE than normal just pregnant
woman
▪ 20% have malignancies following
o Incompetent Cervix
▪ Cerclage – McDonald’s or Shirodkar procedure
- 10-14 weeks gestation
- NO intercourse, Prolonged standing, heavy lifting
- On bedrest as much as possible
- Teach signs of Preterm Labor
- Take tocolytics as ordered
- Home uterine monitoring
▪ Remove suture at 37 weeks vaginal
▪ Leave suture in C-section
- Other complications of pregnancy: Hyperemesis Gravidarum
o Intractable vomiting in pregnancy
o 5% loss of body weight, dehydration, ketosis, metabolic alkalosis
o Rule out Gestational Trophoblastic Dz by ultrasound
o Medical Management/Nursing care
▪ If doesn’t respond to small, frequent meals, then needs hospitalization: NPO,
IV fluids with KCL to prevent hypokalemia, B-vitamin replacement (B1 and B especially)
▪ If still unable to eat, may need TPN
temporarily Pain Relief Measure Used in Labor -decreased variability with narcotics IV to mom with babies! -gate control theory efflourage – interruption of pain pathways by stimulating peripheral nerve endings. -vasodilation with epideral hypotension -give bolus of 1000cc of fluid before epideral to decrease chance of hypo during epideral
o Gate control theory
▪ Pain can be controlled by tactile stimulation and modified by activities
controlled by CNS (backrub, effleurage, suggestion, distraction, and conditioning)
o Endorphins – released when you feel pain
▪ Endogenous morphine – if endorphins are released pain will be decreased –
relaxed environment and positive thoughts. Endorphin levels act on central and peripheral system to decrease pain
o First stage – cervical dilation causes visceral pain – contractions
o Second stage – perineal pressure on structures, stretching, burning (somatic pain)
o Factors affecting response to pain
o Barbituates
▪ Seconal, pentobarbital – used to promote relaxation and sleep in early or false
labor.
o Maternal status
▪ Check BP, watch for decreased respirations, encourage rest between contractions
o Fetal status
▪ Note a decrease in beat to beat variability
▪ Try to administer narcotic IV during the contraction over appropriate time
frame narcotics effect babys variability
o Labor status
▪ Relaxation fosters dilation
o A total loss of sensory capability, may be regional or centrally to brain (consciousness is
lost); usually implies that one or more vital organ functions are under partial or total control of anesthesia provider. ONLY USED AS LAST RESORT don’t want to depress mom because that depresses baby
o Regional Blocks – differentiate site of insertion in each type
o Epidural:
▪ Advantages: mom alert and cooperative, only partial paralysis, gastric emptying
delay, blood loss minimal, decrease effect on fetus
▪ Disadvantages: maternal hypotension, need for IV, numbness heaviness of legs,
may make labor longer and increase pushing.
▪ Needles doesn’t cross dura. Spinal = crosses dura into dura space
o Spinal block: with spinal, takes minutes before whole bottom half is numb
▪ Advantages: good pain control, alert and awake, no respiratory effects
▪ Disadvantages: Marked hypotension, decreased cardiac output, spinal H/A,
loss of motor function and sensory function
- Complications – spinal H/A – constant H/A when HOB elevated, sx alleviated when lying flat H/A = headache… doctors punctured spinal space and fluid (CSF) leaked out. When CSF leaks out, brain stem compresses. Treat with caffeine and blood patch to create a seal over spinal space – good hydration
- Extra on care with anesthesia
o Platelets < 100,000 = no epidural
▪ Anatomical problems as well
▪ Scoliosis
▪ Active inefection
▪ Allergies to meds
o Nursing care: mom BP: cath
o Baby HR: shivering = increased heat loss
o Spinal block: immediate action, short duration; hydrate 500ccs before
o Nursing care: IV infusion
- Nursing Care with Epidural Anesthesia
o Careful hemodynamic monitoring
▪ Assess BP q5 minutes at beginning of procedure and continue till 20 minutes
after insertion of catheter. Longer if BP is decreased.
▪ Bolus with 1000ml of fluid, commonly Lactated Ringers solution, prior to beginning
procedure.
o Positioning
▪ Client is asked to sit at the side of the bed. Have client relax, drop shoulders,
use relaxation breathing during contractions
▪ Help client stay still and push lower back out towards the anesthesiologist
o Pudendal Block numbs the nerves that run along vaginal canal
▪ Advantages: alert, motor control, complete perineal anesthesia, no maternal
hemodynamic changes
▪ Disadvantages: lack pushing sensation, increase change of forceps or vacuum.
o Local infiltration numbness of area for epis, used at time of delivery
▪ Advantages: rapid anesthesia 10 mins
▪ Disadvantages: none
o Use of epidural and intrathecal narcotics
▪ Short-acting
- Fentanyl or Sufenta-short term pain relief good for rapid laboring patients
▪ Long-acting
- Morhpine (Duramorph or Astromorph – long-acting)
- Risks to mother and common side effects – respiratory depression, decreased motor function, itching, dizziness.
- Essential nursing assessments – assess respiratory status and sensorimotor status q 1hour every 24 hours
- Interventions – Benadryl, Nubain for itching
o General Anesthesia – Emergencies only!
▪ IV anesthesia – NaPenthothal
▪ Complications
- Fetal depression – fast delivery
- Uterine relaxation – increase bleeding due to relaxation
- Vomiting and aspiration – Bicitra 30 mins before
▪ Nursing Care
- Use of antacid (Bicitra)
- Positioning mother – assist intubation
▪ Types of Anesthetics
- Amides- Lidocaine, Mepivacaine, Bupivicaine (Marcaine): more powerful and longer acting, placental transfer and affect on fetus
- Esters – Procaine (novacaine), Nesacaine, Pontocaine: Metabolize quickly, placental transfer Diabetes in Pregnancy
- Background
o Prevalence of diabetes is increasing at a rapid rate
o As of 2006, 20.8 million Americans with diabetes; 90% type 2, 1/3 undiagnosed, 16%
children and teens with type 2 diabetes
o Pre-gestational diabetes: diabetes that is present prior to a pregnancy. Can be type 1 or
o Gestational diabetes (GDM): Carbohydrate intolerance of variable severity with the
onset or first recognition during pregnancy.
o Low risk women:
Pre-meal Glucose Less than or equal to 105 mg/dL 1 hour after eating Less than or equal to 155 mg/dL 2 hours after eating Less than or equal to 130 mg/dL Insulin Preparation Onset Peak Duration Rapid 5 – 15 min. 90 min. 4 - 6 hours Regular 30 min. 2 – 4 hrs 6 - 8 hours Intermediate (NPH) ~ 2 hours 4 – 10 hrs
hrs Long acting ~ 4 hours Flat peak Up to 24 hrs normal fetal growth and development.
o Avoid hyperglycemia
- General Nutritional Guidelines
- Meal Planning: diet should be individualized and culturally appropriate
- Nutritional goals: provide sufficient calories for
o Spread carbohydrates throughout the day: 3 meals, 3 small snacks
▪ Fewer carbs during periods of higher insulin resistance, ex: AM hours
▪ Avoid high glycemic index foods: sugary foods or fluids between meals
▪ Use of sugar substitutes is okay!
- Exercise is important: it reduces insulin resistance, walking is well tolerated. Intrapartal Complications – the five P’s! Power, passageway, passenger, placenta
- Complications of the powers
o Dystocia: Dysfunctional or uncoordinated uterine contractions that result in a prolongation
of labor. (mom’s contractions not normal)
- Dysfunctional Labor: Forces of Labor Dystocia Hypertonic – Contractions, no dilation, exhausted moms give ambien to help sleep Hypotonic Phase of Labor Latent (< 4 cm) Active (> 4 cm)
Symptoms ■ ↑freq & intensity of contractions,
pain
■ ↓ freq & intensity of contractions,
don’t
■ ↓effectiveness ■ No progress in labor
Risks Fetal Distress-early in labor process Infection, Exhaustion, Hemorrhage, Late fetal distress Treatment Rest Uterus Stimulate Uterus R/O CPD (rules out cephalopelvic disproportion, is pelvis too small?), Breech, etc. Medications Morphine, Stadol Pitocin
- Nursing Care: Hypertonic Dystocia
o Fluids
o Bedrest – exhausted
o Sedation to promote relaxation and reduce pain
o Careful monitoring of mother and fetus
o Relaxation techniques
o Pain management
o Lots of encouragement!
- Nursing Care: Hypotonic Dystocia
o Put them in the tub to help relaxation
o Careful monitoring of mother and fetus
o Offer warm shower
o Relaxation techniques
o Assist with AROM and careful monitoring of fetus
o Prepare to start Oxytocin infusion
o Lost of encouragement!
o < 3 hours; Rapid dilation and decent
o Risks:
▪ Mom: genital tract lacerations, abruption placentae, postpartum hemorrhage
▪ Fetus: meconium-stained fluid, bruising, cerebral trauma
o Treatment: safe passage of fetus through perineal support, calm atmosphere, careful
assessment postpartum of both mom and baby.
o Treatment, if history of precipitous labor
▪ Induce with SROM and BE READY
- Preterm Labor (PTL) = <37 weeks
o PTL is the #1 perinatal and neonatal problem in the US
o A major goal of healthy people 2020:
▪ Reduce PTL rate in US to 7.6%
▪ In 2011, 12.8% of all babies were born preterm (all-time high)
▪ Rate in increasing, not decreasing
o Maternal Causes:
▪ Race, SES, Age (< high school education and unmarried)
▪ Smoking
▪ Alcohol in excess
▪ Illicit drugs like Cocaine or heroine
▪ Poor nutrition
▪ Exposure to toxins
