1 Mother (High Risk Childbearing-maternal)

8/10/2019 1 Mother (High Risk Childbearing-maternal)

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I. Mother (HIGH RISKCHILDBEARING-MATERNAL)


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Female ReproductiveAnatomy & Physiology

I. External reproductive organs

A. Mons pubis / mons veneris pad of fatw/c lies over the symphysis pubis

B. Labia majora 2 folds of skin w/ fatunderneath; contain bartholins glands(believed to secrete a yellowish mucus)

C. Labia minora 2 thin folds of delicatetissues


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Glans clitoris small, erectilestructure at the anterior junction of

the labia minora

Vestibule narrow space seen when

the labia minora is separated

Urethral meatus external opening

of the urethra


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Vaginal orifice external opening ofthe vagina, covered by a thinmembrane

Perineum area from the lowerborder of the vaginal orifice to theanus


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II. Internal reproductiveorgans

A.Vagina 3-6 inch long dilatablecanal located between the bladder &the rectum

B. Uterus hollow pear-shapedfibromuscular organ 3 inches long, 2inches wide, 1 inch thick, weighing50gms in non-pregnant woman


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C. Fallopian tubes 4 inches long fromeach side of the fundus; widest part

(called ampulla) spreads intofingerlike projections.

D. Ovaries almond-shaped, dullwhite sex glands near the fimbriae,kept in places by ligaments.


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1. Assessment of risk factors ofpregnancy:

a. Lack of prenatal careb. maternal age less than 18 or older

35

c. Conception w/in 2 mos of previousdelivery

d. Fifth or subsequent delivery

e. Pre-pregnant wt 20% more or lessthan normal


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f. Minimal or no wt gain

g. Fetal anomaly

h. Complications of labor & deliveryi. Drug or alcohol abuse


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2. Screening procedures

Prenatal Screening Procedures

In an uncomplicated pregnancy,

expect about a dozen doctor visits


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First Visit

Blood tests:To check the woman'sblood group and sometimes, to checkfor presence of hepatitis B virus,

which might be transmitted to thebaby.

Cervical smear test:To test for an

early cancer of the cervix (if a testhas not been performed recently).Also called a Pap smear.


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First Visit and Throughout thePregnancy

Blood tests:To check for anemia inthe woman, and in women with Rh-negative blood groups, to look for

the presence of Rhesus antibodies.

Urine test:To check for proteinuria,which could indicate a urinary tractinfection or preeclampsia.


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Blood and urine test:To check fordiabetes mellitus.

Blood pressure check:To screenfor hypertension, which interfereswith blood supply to the placentaand is a sign of preeclampsia.


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First Visit and After ANYInfection

Blood tests:To screen for rubella,which can cause defects in the baby,and for syphilis and HIV (the AIDS

virus) which can also be passed on.


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First 12 Weeks

Chorionic villus sampling:May beperformed if there is a risk of certaingenetic (inherited) disorders being

passed on.


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16 to 18 Weeks

Ultrasound scanning:Is carriedout to date the pregnancy accuratelyand to detect any abnormalities

present in the fetus.

Amniocentesis:Carried out onolder women and those with spinabifida or Down's syndrome to detectpossible abnormalities in the fetus.


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Blood test:In some cases, theamount of alpha-fetoprotein in theblood is tested to determine whether

the baby has spina bifida.

Fetoscopy and fetal bloodsampling:In some cases, these arecarried out if there is doubt aboutthe normality of the baby.


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High-risk or overdue pregnancies

Blood and urine tests:To assessplacental function and fetus health.

Electronic fetal monitoring:Tocheck on the fetal heart beat.

Ultrasound scanning:Extra scansmay be recommended to assess fetalgrowth and development, location ofplacenta, amount of amniotic fluid.

3 Di ti t t d l b t


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3. Diagnostic tests and laboratoryexams

a. Alpha-fetoprotein (AFP) enzymeblood test

- elevated levels may identify thepregnant woman carrying a babywith neural tube defects (spina bifidaand anencephaly)


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- if the AFP is elevated for twosamples, it is followed byultrasonography and amniocentesis

for further confirmation done at 14to 16 weeks gestation


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b. Ultrasonography

1. high-frequency sound wave testing-

discerns multiple pregnancy,placental location and gestationalage by measurement of bi-parietal

diameters

nursing considerations:

1. encourage fluid and refrain fromvoiding before the test


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c. Chorionic villi sampling (CVS):

- a specialized alternative test toamniocentesis.

It involves removing a small amount oftissue called the chorionic villi, which

is located on the outside of the fetalgestational sac and will later becomethe placenta.


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The most common reasons a CVS isperformed:

Maternal age of 35 years or more atexpected time of delivery

An abnormal first trimester screenresult

Ultrasound finding suggesting a

higher risk for a chromosomeabnormality


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Previous pregnancy or family historyof certain chromosomal or genetic

disorders

Pregnancies at risk for certain

genetic conditions

A desire to obtain accurate testresults as early as possible inpregnancy


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The CVS may be performedtransabdominally by guiding a thinneedle through the abdominal wall to

the chorionic villi, then withdrawing asmall amount of this tissue (Seepicture below, A)


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Occasionally, particularly if thethickest location of the villi is in the

lower portion of the uterus, the CVSis performed transcervically by usinga thin flexible plastic catheter (hollow

tube) which is guided through thecervical opening, somewhat likehaving a Pap smear done. Thiscatheter is then used to remove asmall amount of the villi. (Seepicture below, B).


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2. nursing considerations:

a. instruct to drink fluid so thatbladder is full

b. after test, monitor for uterinecontractions, vaginal discharge andteach to observe for signs ofinfection


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Most women do not report the CVSprocedure to be very painful. It

usually takes a minute or two toperform, and is commonly describedas feeling similar to a blood draw.

Some women experience mildcramping afterwards or light spottingthat usually goes away within a day

or two.


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d. Amniocentesis study of amnioticfluid

Preparation:

Explain to the patient the procedure

Have consent form signed

Empty the bladder


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Ultrasound to locate the placenta

Leopolds maneuvers are done

Position patient on supine, but elevatehead and shoulders to one side

The abdomen is prepped with anantiseptic, draped and the site exposedand infiltrated with local anesthetic


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An 18-20 gauge spinal needle isintroduced either behind the fetal neck

10-20 ml of amniotic fluid is withdrawn

and placed in an opaque container

Most important nursing action: Check

the FHR before immediately after and2 hours later


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B. Risks involved:

Hemorrhage from penetration of theplacenta

Infection

Fetus can be punctured

Uterine irritation

Cli i l U


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Clinical Uses:

Genetic diagnosis

Spectrophotometer studies

Fetal maturity tests

Sex determination


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e. Non-stress test (NST) based on theprinciple that FHR accelerates in

response to fetal movement.

Advantages over OCT:

Does not require administration ofoxytocin

Can be done in matter of 20-40 minutes


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Procedure:

Done concomitantly with external FHRmonitoring

Patient presses a button whenever shesenses fetal movement


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f. Contraction stress test (CST):

- to demonstrate whether a healthyfetus can withstand a decreasedoxygen supply during the stress of acontraction produced by exogenous

oxytocin (pitocin) or stimulation ofnipples manually or by moist heat; iflate decelerations appear, the fetus

maybe compromised because ofuteroplacental insufficiency


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1. Classification of results

a. negative: no late decelerations with

a minimum of three contractions in10 minutes; indicates that the fetushas good chance of surviving labor

b. positive: persistent and latedecelerations occurring with more

than half the contractions; indicatesneed for considering prematureintervention


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c. suspicious: late decelerationsoccurring in less than half of uterinecontractions; test should be repeated

in 24 hours


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2. Nursing considerations:

a. void before test

b. monitor fetal heart rate for 30minutes before test

c. monitor ,mother after test toobserve for possible initiation oflabor

d. evaluate response to procedure


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g. Biophysical profile (BPP):

- assess breathing movements, bodymovements, tone, amniotic fluidvolume and FHR reactivity (NST)- ascore of 2 is assigned to each

finding, with a score of 8 to 10indicating a healthy fetus

1. used for fetus that may haveintrauterine compromise


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a. provide emotional supportb. evaluate response to procedure


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h. Maternal assessment of fetalactivity:- need to contact physician

or nurse midwife when there arefewer than 10fetal movements in a12 hour period.- fewer than three

fetal movements in an 8 hour period,or no fetal movements in themorning

1. used to determine viability of fetus


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a. teach how to record and reportmovements


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Laboratory Examination:


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NORMAL HEMATOLOGIC VALUES

Nonpregnant Pregnant

Hemoglobin (HGB) 1216 g/dl 11.515 g/dl

Hematocrit (HCT) 3648 3236.5

Red blood cells (RBC) 45.36 no change

White blood cells(WBC)

410.6 620

NORMAL VALUES FOR RENAL


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FUNCTION

Nonpregnant PregnantSerum creatinine 0.61.2 mg/dl 0.530.9 mg/dl

Serum BUN 9-11 mg/dl 8-10 mg/dl

Serum uric acid 4.55.8 mg/dl 25.8 mg/dl

Urine Cr clearance 90130 mL/min 150200 mL/min

Urine uric acid 250750 mg/24 hr Increases

Urine glucose 60115 mg/dl Increases


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NORMAL HEPATIC VALUESLiver Enzymes Nonpregnant Pregnant

Alanine transaminase(ALT)

378 U/L Unchanged

Aspartateaminotransferase(AST)

370 U/L Unchanged

Alkaline phosphatase(ALP)

20145 ImU/ml > up to 24 times

Lactatedihydrogenase (LDH)

300650 U/L Upper end of normalto 700 U/L

I COMPLICATIONS OF


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I. COMPLICATIONS OFPREGNANCY

C Di f t D i


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Common Discomforts DuringPregnancy

Morning Sickness

Fatigue

Urinary Frequency

Heartburn

Constipation

Hemorrhoids Varicosities

B k h


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Backache

Insomnia

Leg cramps

Supine Hypotensive Syndrome

Vaginal discharge

Skin changes


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Danger Signals of Pregnancy

any bleeding from vagina

gush of fluid from vagina

regular contractions

severe headaches


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epigastric pain

vomiting that persists

change in fetal activity pattern

temperature elevation

swelling in upper body


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II. GENERAL NURSINGRESPONSIBILITIES

Teach danger signals of pregnancyearly in prenatal period

Early teaching allows the client toparticipate in the identification andreporting of symptoms


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Early recognition and reporting ofdanger signals

Interventions are specific for theindividual risks.

N si Di sis:


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Nursing Diagnosis: Anxiety

Fluid volume deficit

Risk for infection

Ineffective tissue perfusion

Knowledge deficit


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1 Mother (High Risk Childbearing-maternal)

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