Fetal Assessment 8/24/2015 11:32:00 AM

Explain the expected maternal physiologic adaptations to pregnancy.

Perform a comprehensive prenatal assessment.

Discuss the pathology, treatment, and nursing care of pregnant women with
anemia.

Antenatal Testing:
Ascertain fetal well-being, growth, and development
Indications:
 Performed if there is a reason to believe the fetus has a problem or
may develop one
 Maternal risk factors that indicate need antenatal testing:
o Medical conditions (DM, HTN, anemia)
o Demographic factors:
 Over age 35 or younger than 17
 Family history of genetic disorder
 Poverty
 Inadequate prenatal care
o Obstetric factors:
 Previous delivery of low birth weight infant, or large for
gestational age infant
 Multifetal gestation (twins)
 Previous unexplained fetal loss
 Hydramnios (too much amniotic fluid), oligohydramnios
(deficiency of amniotic fluid)
 Preterm labor or prolonged labor
o Maternal Factors
 Excessive weight gain
 Inadequate or poor pattern of weight gain
 Less than/greater than ideal weight at time of
conception
1st Trimester Testing:
 Ultrasound (any gestation)
o confirm pregnancy and location of pregnancy
 o determine gestational age
o confirm viability (ability to live)
o provide guidance in performing CVS and amniocentesis
 Chorionic Villi Sampling (9-12 weeks)
o Sampling the chorionic villi of placenta
o Recommended for those at high risk of delivering infants with
genetic anomalies
 Over 35, history of previous fetus w/ anomalies,
carriers of genetic defects
o Transabdominally or transcervically under ultrasound
guidance
o Risks:
 Fetal limb reduction if performed prior to 9 weeks
 PROM, SAB
 Rh sensitization (Rhogam given post-procedure)
 infection
o Advantages:
 Results available within 24 hrs
 Nuchal Translucency Testing (NTT) (11-13 weeks)
o Ultrasound to assess fluid accumulation between spine and
neck of fetus
o If nuchal folds greater than 3 mm, increased risk for
Down’s
o Screening, not Dx
2nd Trimester:
 Amniocentesis (15-20 weeks)
o Used for genetic diagnosis
o Used in 3rd (30-39 week) to assess fetal lung maturity
 LS ratio 2:1 is good
o Aspirate amniotic fluid
 MSAFP and Quadruple screens (14-22 weeks)
o 15-18 most accurate
 Doppler Flow Study (2nd trimester)
o Used to detect uteroplacental insufficiency
 Percutaneous Umbilical Blood Sampling (PUBS)/Cordocentesis
o Cord punctured close to placental insertion
 o used to obtain pure fetal blood from umbilical cord
 1-4 ml of blood
3rd Trimester:
 Biophysical profile
 Non Stress Test
 Contraction Stress Test
 Fetal movement counts (26-32 weeks)

Fetal Movement Counts: (3rd trimester)

“kick counts”
used mainly during 3rd trimester when movement peaks (26-32 weeks)
Advantages:
 economical
 noninvasive
 can be performed in client’s home
 can help to identify problems in absence of risk factors
Disadvantages:
 Time of day may affect movement
 Fetal sleep patterns decrease movement
o May occur for up to 40 minutes
 Maternal perception of movement can vary
 Maternal drug or medication use can affect fetal activity
Procedure:
 Woman lays on side and counts the number of times she feels the
fetus kick or move
 Ideal time frame and movements not established
o Record # of minutes it takes to feel 10 movements
Call Dr. If:
 They don’t feel prescribed number of movements within the
prescribed time
o If not 10 movements within 2 hours
 They don’t feel movement at least 4 times in any counting period
 Total number of movements for the day is less than 12
 Significant change in usual type and character of movement
Ultrasound: (all trimesters)
Uses sound waves that bounce off organs and fetus and reflect back
Can be performed transabdominally or transvaginally
 Transabdominal – performed with full bladder
 Transvaginal – more useful because it provides clearer image of
fetus
During 1st Trimester:
 Confirm pregnancy and viability
 Verify location of pregnancy
 Determine gestational age
 Provide guidance if performing chorionic vilii sampling and
amniocentesis
During 2nd or 3rd Trimester:
 Determine sex of fetus
 Confirm gestational age
 Placental evaluation localization
o If bleeding, rule out placenta previa
 Determine fetal number, presentation, and viability
 Determine amniotic fluid volume
 Evaluation of fetal well-being as part of BPP
Advantages:
 Client comfort and safety
 Clear visualization
 Noninvasive and painless and results are immediate
Disadvantages:
 Cost for those without insurance
Nurse Roles:
 Explain purpose of prescribed UT
 Reinforce teaching
 Encourage 1.5 quarts of fluid
 Apply transmission gel

Amniocentesis: (second and third trimester)

Invasive procedure used to aspirate the amniotic fluid from the amniotic sac
 Determines genetic analysis and fetal lung maturity
2nd Trimester:
 identify chromosomal abnormalities
 evaluate Rh-sensitized mother
 diagnose amnionitis
o infection of the uterus, amniotic sac
3 Trimester:
rd

 determine lung maturity when delivery is being considered prior to

38 weeks
o maturity indicated with ratio or 2:1
 diagnose fetal hemolytic disease
 reduce amniotic fluid in presence of polyhydromios
Risks:
 Injury to fetus, umbilical cord, or placenta
 Infection
 Preterm labor
Advantages:
 Brief procedure that is relatively simple to perform
 Fairly painless to client
 Complications are rare
Disadvantages:
 Performed later in the pregnancy
Procedure:
 Get informed consent
 Make sure bladder is empty
 Cleanse abdomen with betadine and drape
 Sterile technique and UT guidance to locate placenta
 Insert 22 gauge spinal needle 3-4 inches into uterine cavity
 Aspirate approx. 20 mL for analysis
 Withdraw and assess site for bleeding
 Assess VS, fetal status, and uterine activity
Nursing Role:
 Assist health care provider during procedure
 Clarify info and answer questions
 Monitor fetal and maternal status post-procedure
 Provide emotional support
 RhoGAM if mother – and father +
Quadruple Check: 2nd trimester
Uses AFP, hCG levels, diameric inhibin-A, and estriol to screen pregnancies
for NTD, trisomy 21 (Down’s), and trisomy 18
 Performed between 14-22 weeks gestation
o Most accurate btw 15-18 weeks (15-16)
Maternal Serum Alpha-Fetoprotein (MSAFP)
 Alpha-fetoprotein (AFP) is fetal protein excreted in fetal yolk sac
during the first 6 weeks of pregnancy
o AFP production taken over by fetal liver as pregnancy
progresses
 Elevated AFP indicates NTD (neural tube defect)
o Can range from Spina bifida to anencephalopathy (absence of
a portion of the fetal brain)
o 2-2.5 MoM = abnormally high
o > 3.5 MoM = outside norm, high risk for NTD
Advantages:
 Simple, cheap, minimally invasive
Disadvantages:
 Only screening tools
 Require further testing to confirm diagnosis
 If they seek prenatal care later in pregnancy, may miss testing
opportunity (after 22 weeks)
 Inaccurate calculation of gestational age or increased maternal
weight may result in inaccurate interpretation
Nursing Role:
 Explain purpose of these screening tools
 Stress that these test are strictly for screening, not Dx
 Emotional support for unexpected outcomes

Biophysical Profile (BPP) (3rd Trimester)

Uses electronic fetal monitoring and ultrasound to evaluate several
components to assess fetal well-being
Assesses asphyxia and hypoxia!
Indications:
 Management of IUGR
 Decreased fetal movement
 Pregnancies affected by DM, preeclampsia, preterm labor,
premature rupture of membranes (PROM), and postterm
pregnancies
Components Being Assessed:
 Fetal tone – last to go
 Fetal movements
Fetal breathing
Fetal heart rate reactivity – first to go
Amniotic fluid volume
o Red-flag is less than 5
o Induce birth
Advantages:
 Immediate results
 Noninvasive
 Allows high risk mothers to be treated conservatively since fetal
well-being can be established
Disadvantages:
 Labor intensive and expensive
 Requires trained UTonographer to perform the procedure
Findings:
 Each component given score of 2 if present and 0 if absent
o Total best = 10
 Fetal tone is first to develop, so during asphyxia, it will be the last
to go
 Fetal heart rate reactivity is last biophysical marker to develop, so
loss of it is the first sign of hypoxia

Non-stress Test (NST) (3rd Trimester)

Assesses fetal well-being through fetal heart rate reactivity using electronic
fetal monitoring
 Part of BPP
Advantages:
 Noninvasive
  Easy to administer
 Can be repeated as necessary
Disadvantages:
 There can be false positive nonreactive tracings (most likely due to
fetal sleep patterns)
Procedure:
 Woman placed on external fetal monitoring (EFM) in semi-Fowlers
or side-lying
 Given an event marker (button) and told to push the marker
whenever she feels fetal movement
 Takes 20-40 minutes
Nurse Roles:
 Administer and interpret NST
 Documenting and reporting findings
 Client education
Findings:
 Reactive NST – adequate oxygenation and an intact CNS
o Fetal heart tracing that shows at least two accelerations
within 20-40 minutes that is 15 beats above the baseline, and
lasts 15 seconds
 Nonreactive NST – shows that fetal heart rate is nonreactive to
movement
o Requires repeat testing
o If still non-reactive, BPP or CST are preformed
o May be caused by:
 Fetal sleep patterns
 Fetal hypoxia or asphyxia
 Maternal illicit drug use or medications
 Congenital heart anomalies

Contraction Stress Testing (CST) (3rd Trimester)

Used to observe the fetal response to the stress of uterine contractions
 Identifies fetuses with decreased oxygen reserves
 Demonstrated by presence of late decelerations
Indications:
 Follow-up on nonreactive NST (replacing BPP)
 Abnormal BPP
Any other condition that could result in placental insufficiency (DM,
IUGR, postdated pregnancy)
Contradicted in: (those who cannot handle contractions)
 Preterm pregnancies
 Third trimester bleeding
 Previous C-section birth with classic uterine incision
 Multiple gestation (twins)
Advantages:
Negative test result reassures adequate uteroplacental functioning
for at least another week
 Allows health care providers to analyze options for delivery
Disadvantages:
 Testing cannot be done if the contractions are contradicted
 Testing is time consuming and expensive
 Must be done in hospital
 Potential for errors in test interpretation
Procedure:
 Woman is placed on external fetal monitor (EFM) prior to testing in
a semi-fowler position
 Goal is to elicit three contractions within a 10 minute period while
observing the fetal heart response
o Done through oxytocin infusion or nipple stimulation
 Once desired contraction pattern is elicited, test is interpreted as
negative (desired result), positive (late decelerations), equivocal-
suspicious, equivocal-hyperstimulatory, or unsatisfactory
Findings:
 Negatve – no decelerations
 Positive – late decelerations occur symmetrically after each
contraction
 Equivocal (suspicious) – late decelerations are present, but not in
normal pattern
o Follow-up testing
 Equivocal (hyperstimulatory) – late decelerations occurred, but may
be due to contractions that occur more frequently than every 2
minutes or lasting longer than 90 seconds
 o Repeat test
 Unsatisfactory – CST cannot be interpreted that may be due to
unusual contractions
o Fewer than 3 contractions lasting 40-60 seconds in 10 min.

Dosage Calculation
Complications Prior to Pregnancy 8/24/2015 11:32:00 AM

Pregnancy with DM:

Type 1, type 2, other, and gestational diabetes
 Gestational DM = carb intolerance with onset or first recognition
during pregnancy
o Cause: (3)
 Unidentified preexisting DM
 Unmasking of metabolic abnormality with added stress
 Direct consequence of altered maternal metabolism
stemming from maternal hormone changes
o Early Dx is important because even mild DM can increase
mortality and morbidity
Patho:
 Early Pregnancy
o carb metabolism minimally affected
o If N/V or anorexia occur, may have hypoglycemic episodes
 Second Trimester
o fetal growth uses more glucose
o hPL hormone (human placental lactogen) creates insulin
resistance in maternal tissues so the baby can have enough
 normal pregnant woman produces more insulin
 if woman cannot maintain homeostasis, DM can develop
Risk Factors:
 Obesity
 Chronic HTN
 Family history
 Maternal age over 25
 Previous infant birth weight over 4000 gram
 GDM in a previous pregnancy
Complications:
 Maternal Risks:
o Hydramnios - increase in amniotic fluid
 Due to excessive fetal urination due to hyperglycemia
o Preeclampsia/Eclampsia
 Due to pre-existing dm related vascular changes
o Ketoacidosis – increase of ketone bodies in blood
 Released when fatty acids are metabolized
  Develops more rapidly in pregnant woman
 Can lead to coma and death of both if not treated
o Dystocia – difficult labor
 due to fetopelvic disproportion if fetal macrosomia
exists
o UTIs
 Due to increased glycosuria
 Can lead to pyelonephritis
o Worsening retinopathy
 Those with pre-existing DM should go to ophthalmologis
for evaluation during pregnancy
 Fetal Risks
o Most result directly from high maternal glucose levels
o IUGR – due to perfusion issues
o Congenital anomalies:
 Major cause of death for infants of DM mothers
 Often involve heart, CNS, and skeletal system
 Sacral agenesis – appears only in infants of mothers
with DM
Sacrum and lumbar spine fail to develop and

lower extremities are incomplete
o Macrosomia – excessive growth
 Due to sustained fetal hyperinsulinism and
hyperglycemia
 If born vaginally  at risk for injury due to dystocia
 C section indicated
o Postpartum Hypoglycemia
 Umbilical cord severes blood glucose supply from
mother but
 2-4 hours after
o Respiratory Distress Sydrome
 Inhibition of fetal enzymes that are necessary for
surfacant production due to high insulin levels
o Polycythemia – increased production of total RBCs in blood
 Mother’s blood contained glycosated hemoglobin
(Diminshed ability to release 02)
 o Hyperbilirubinemia – due to polycythemia
 Increased blood concentration strains liver
Diagnosis:
 Comprehensive prenatal assessment
o All woman get 75 g oral glucose tolerance test at 24-28
weeks
o Used to think DM specific screening not necessary for “low
risk women”
 Must meet ALL of the following:
 Less than 25 BMI; Normal weight prior to
pregnancy; Caucasian; No history of abnormal
glucose levels; No known DM in first-degree
relative
 Glycosylated hemoglobin (HbA1c)
o Not effective or recommended for gestational DM
o Pregestational DM – positive correlation between abnormal
values and SAB and fetal congenital anomalies
 Those with pre-existing that want to get pregnant need
to keep HbA1c at less than 6% without significant
hypoglycemia
 75 g OGTT (oral glucose tolerance test)
o involves fasting glucose, 1-, 2-, and 3-hour glucose challenge
test (GCT)
 Usually diagnosed between 24-28 weeks gestation
 Positive GDM diagnosis:
 Fasting =or> than 95
 1 hour =or> than 180
 2 hour =or> than 155
 3 hour =or> than 140
Management:
 Goals – control glucose levels, avoid vascular and organ damage
 Antepartum:
o Dietary regulation:
 300 kcal increase per day (divided among 3 meals and
3 snacks)
 40-50% from complex carbs
  20-30% from fats
 15-20% from protein
 may increase calorie intake if woman has ketonuria or
complains of hunger
o Glucose Monitoring:
 Essential for determining need for insulin and assesing
glucose control
 Fasting glucose levels
 One or two post-prandial levels
o Insulin Administration
 How much depends on ability to control glucose just
using diet
 Use human insulin
 Administered SubQ 4Xdaily
 Multiple injections (most common)
 Continuous infusion port
o Assess fetal well-being
 Quadruple screen at 16-20 weeks
 Ultrasound at 18 weeks and 28 weeks
 nonstress tests, biophysical profile in 3rd trimester
 Daily fetal movement counts at 3rd trimester
 Doppler flow analysis of placental blood flow
 Amniocentesis for lung maturity
 Intrapartum:
o Timing of birth
 Depends on lung maturity
 Most allowed to go to term (decrease risk of resp.
distress)
Some Dr induce labor at term to avoid problems rt
decreased perfusion
 C-section if nonreassuring fetal status exists
 Preterm birth if vascular changes or worsening HTN
o Labor Management:
 Maintain normal glucose levels – prevents neonatal
hypoglycemia
 Assess for S/S of hypoglycemia and act accordingly
  diaphoresis, disorientation, clammy skin,
headache, hunger, decreased urination, and
blurred vision
 Measure glucose levels hourly to detemine insulin need
 May not be needed
 DC or reduce long-acting insulins
 2 IV lines – one with 5% dextrose (for hypoglycemia),
one with NS
 NS for bolus insulin
 Flush tubing with insulin before prescribed
amount is added
 Postpartum:
o Insulin requirements fall significantly
 Reestablish after 24 hours based on need
o Women with GDM who did not require insulin during
pregnancy do not need it postpartum
 Monitor glucose levels
 If elevation in glucose occurs, oral antihyperglycemic
agents may be tried if woman IS NOT breastfeeding
Reassess 6 weeks
 If normal levels – minimum 3 year interval
reassessments
o Encourage mother/infant interaction
 breastfeeding

Pregnancy and HIV/AIDS:

HIV can be transmitted across the placenta, and infect the fetus
 Transmitted through contaminated blood and through breast milk
Management:
 Prenatal (Antepartum):
o All women are screened at first prenatal assessment, those at
high risk receive repeat screening
 Testing is voluntary with informed consent
o Ongoing observation for signs and symptoms of infections
  Fever, diarrhea, cough, skin lesions, behavior changes,
weight loss, fatigue, persistent candidiasis
o Monitoring for complications:
 Weight loss in late pregnancy, fever, check mouth for
thrush, ascultate lungs, assess lymph nodes, liver,
spleen for enlargement; visual checks to detect
toxoplasmosis
o Antiretroviral therapy for HIV+
o Avoid invasive newborn assessment methods
 Intrapartum
o IV AZT or ZVD during labor (post-exposure prophylaxis)
 Bolus, followed by continuous maintenaince IV infusion
until delivery of fetus
o Controversy on vaginal or cesearean birth
 If vaginal is allowed, invasive procedures are avoided
 Postpartum:
o Continue with ART or HAART
o Newborn will begin PO AZT syrup within 8-12 hours
o Newborns may test positive for HIV up to 18 months because
of maternal antibodies passed through passive immunity
o DON’T breastfeed
Nursing Process:
 Assessment:
o Assess woman’s knowledge of infection and transmission and
the implications for her pregnancy, delivery, and newborn
o Assess for S/S of worsening disease or infection
 Night sweats, weight loss, fever, lymphanopathy
 Diagnosis:
o Risk for infection, knowledge deficit, ineffective family coping
 Implementation:
o Health promotion education – infection prevention,
surveillance of fetal growth, psychosocial support
o Intrapartum – avoid or minimize exposure of infant to
maternal blood
 Bathe infant as soon as possible postdelivery
 Delay heel sticks until after bath
  Bottle feeding over breast feeding

Pregnancy and Cardiac Disorders

Cardiac disease is number 4 cause of maternal mortality
Those with pre-existing CV conditions cannot compensate for changes
 May result in CHF
Caused By:
 Congenital heart defects
o Complete surgical repair = good pregnancy prognosis
 Take ABX prophylactically to prevent endocarditis
o Increased risk of heredity
 Rheumatic heart disease
o Mitral valve stenosis in most common and serious lesion
o Aortic valve involvement is second most common
o Increased risk for CHF
 Marfan
o Autosomal dominant
o 5 fold increase in morbity with pregnancy
 Cardiomyopathy
o Pregnancy-induced - Occurs in last month of pregnancy or
first 5 months postpartum
o Rare but serious
 Eisenmenger Syndrome
o 50% mortality rate in pregnancy
 Mitral Valve Prolapse
o Asymptomatic, mitral click and systolic murmur
o Tolerate pregnancy well
o Give BB, Inderal
Classifications:
 Based on tolerance for physical activity
 Class 1:
o No activity limitation, no S/S of cardiac insufficiency
 Class 2:
o Slight activity limitations
 o May experience fatigue, dyspnea, palpitations, or angina with
normal activity
o Comfortable at rest
 Class 3:
o Marked intolerance to less than ordinary activities
o Fatigue, dyspnea, palpitations, or angina
o Comfortable at rest
 Class 4:
o Unable to do any activity without experiencing cardiac
symptoms
o Even at rest, pt may experiency signs of cardiac insufficiency
Effects on Pregnancy:
 Pts in classes 1 or 2 usually have little to no complications during
pregnancy
 Classes 3 and 4 are at risk for severe complications
o Require counseling prior to pregnancy regarding course of
treatment and optimum outcomes
Possible Complications:
 Infection – increases heart workload
o Monthly screening for bacteriuria
o ABX as needed
 Anemia – increases heart workload
o Diagnose and treat early
Diagnosis:
 History and physical
 ECC (echocardiogram)
 ECG (electrocardiogram)
 Chest X-ray
 Auscultation of heart sounds
Treatment:
 Heart Defects (surgically corrected or not)
o ABX prophylaxis during labor
 Prevent subacute bacterial endocarditis
 Peripartum Cardiomyopathy (not heart defects)
o Digoxin, diuretics, vasodilators, anticoagulants, sodium
restriction, and strict bedrest
  If complications - treat with antibiotics, diuretics, anticoagulants,
antiarrhythmics, and digitalis throughout pregnancy
 Vaginal delivery with epidural can be accomplished in all classes
o 1 and 2, spontaneous with adequate pain relief as long as
signs of decompensation are recognized and addressed
o 3 and 4 may be hospitalized prior to labor for stabilization
 may require invasive monitoring
o May use vacuum extraction or forceps to decrease use of
Valsalva’s maneuver during second stage
 C-section only used if fetal or maternal indications exist
Nursing Process:
 Assessment:
o Maternal VS and fetal status
o Signs of decompensation and activity intolerance according to
classification
 Cough; edema; SOB; murmurs; palpitations; rales
o Assess woman’s understanding of treatment regimen and
ability to adhere to it
 Nursing Dx:
o Decreased CO; Impaired gas exchange; Anxiety
 Implementation:
o Monitor for S/S of worsening disease
o Monitor for postpartum adaptation for S/S of cardiac
decompensation
o Pt education:
 Ways to conserve energy
 Importance of healthy weight and nutrition
 Effects of stress, smoking, and illicit drugs on CV
system
 Prescribed treatment
o Allow mother and family to express concerns

Pregnancy and Substance Abuse

  15-17 year olds have highest rate of illicit subtance abuse with
pregnancy
 High risk:
o Effects substances can have on a fetus
o May not seek help until delivery
 Can’t monitor for complications
 Even if they do get prenatal care, they may not admit
to substance abuse
 Using these substances during the first trimester is most dangerous
Most common effects on pregnancy and newborn:
 Premature labor and delivery
 Spontaneous abortion
 Placental abruption
 Stillbirth
 Newborn:
o can have physical abnormalities or delays
o IUGR
o Fetal alcohol syndrome
 Check chart on 2.6 page 5!!
Nursing Process:
 Assessment:
o Develop a trusting relationship and assess general health and
nutritional status
o Ask about past use, type abused, amount, and length of time
it was abused
o Assess mom’s understanding of the impact of illicit
substances on pregnancy and newborn
 Nursing Dx:
o Risk for fetal injury; risk for infection; ineffective health
maintenance; ineffective coping
 Implementation:
o Establish nonjudgemental, trusting relationship
o Monitor for potential complications
 Preterm labor, placental abruption, inadequate
nutrition, and infection
o Fetal surveillance for well-being
 o Client education:
 Impact of substance abuse
 Proper nutrition
 S/S of preterm labor or other complications
o Psychosocial support
Complications of Alcohol Abuse:
 Maternal – SAB, PTL, nutritional deficiencies
o Postpartum – seizures, delirium
 Breastfeeding can cause decreased maternal milk
letdown reflex (no alcohol exposure through feeding)
 Fetus – birth defects (neural), delayed nerve cell growth, mental
retardation, FAS, developmental delays
Cocaine/Crack:
 Causes vasocontriction, tachycardia, and HTN
o Decreases blood flow to placenta
 Maternal – seizures, hallucinations, pulm. Edema, resp. failure,
cardiac problems
 Fetal – SAB, abruptio placentae, IUGR, preterm, stillbirth

Pregnancy and Anemia:

Diagnosis:
 Anemia - HgB < 12 in nonpregnant woman
 Pregnant – HgB < 11

Iron-Deficiency:
Most common medical complication of pregnancy
Iron needed to synthesize HgB
 Defiency of iron will result in less HgB and O2 transportation
Patho:
 Expansion of plasma volume without normal expansion of maternal
HgB mass
 Pregnant woman needs 1000 mg iron intake during the pregnancy
o Body only retains 200mg through amenorrhea
Complications:
  Maternal – may be asymptomatic
o More susceptible to infection
o Increased chance of preeclampsia and postpartal hemorrhage
o Intolerance of minimal blood loss during birth
o Cardiac failure (if HgB < 6)
 Fetal
o Low birth weight
o Prematurity
o Stillbirth
o Neonatal death in severe cases
o Not deficient at birth, but may have lower iron stores and are
at increased risk for iron deficiency anemia during infancy
Treatment:
 Prevention – 27 mg daily
 Treatment – 60-120mg daily (larger dose for twins)
 Iron-rich diet
 Stool softeners to prevent constipation
Nursing Roles:
 Client teaching:
o Take iron with Vit C to increase absorption
o Absorption decreased if taken with meals
 But, GI upset is more likely if taken on empty stomach
 So eat
o Stool will turn black
o Keep out of reach of children (fatal)

Folic Acid Decificiency:

Most common cause of megaloblastic anemia during pregnancy
Patho:
 Folic Acid needed for DNA and RNA synthesis
 In defiency, immature RBCs fail to divide, become enlarged, and
are fewer in number
Complications:
 Neural tube defects (spina bifida)
Manifestations:
 Not detected until late in pregnancy
  True folic acid deficiency anemia
o N/V, anorexia; HgB may be as low as 3-5
Treatment:
 Prevention – 0.4 mg of folate daily
o Recommended pre-pregnancy also
 Treatment – 1 mg folic acid supplement daily
 Increased dietary intake
o Fresh leafy green veggies, orange juice, citrus fruits and
juices, red meat, fish, poultry, and legumes
o Can be lost in cooking (don’t microwave)

Sickle Cell Disease Anemia

Recessive autosomal disorder that results in malformation of HgB
 Those with the disease are homozygous
 Those with the trait are heterozygous (normally asymptomatic)
Patho:
 Abnormal HgB S causes RBCs to be sickle or crescent shaped
 Anemia occurs when RBcells break down
Manifestations:
 Acute, recurrent episodes of tissue, abdominal, and joint pain
Maternal Risks:
 Woman with trait have good prognosis
o At risk for nephritis, bacturia, and hematuria
o Tend to become anemic
 Woman with disease have more risk
o Low O2 pressure (caused by dehydration, infection, high T, or
acidosis) causes vaso-occlusive crisis
 Causes sudden attacks of pain due to ischemia
 Occur more often in second half of pregnancy
 Mortality is rare
 Anemia (need transfusion)
 Infections
 Emergency C-sections
Fetal Risks:
 Preterm and IUGR
 Fetal death is associated with vaso-occulsive attacks in placenta
Treatment:
 Folic acid supplements of 4 mg/day to maintain HgB by intense
erythropoiesis
 Treat infections promptly
o Dehydration and fever can trigger an attack
 Rehydrate with IV fluids
 O2
 Antibiotics
 Analgesics
 Monitor fetal heart rate
 If attack during labor:
o Position on left lateral side
o Oxytocin may be used to promote labor
o Episiotomy and outlet forceps to shorten second stage of
labor
 Antiembolism stockings used postpartum
Nursing Implications:
 Client Teaching:
o Hydration
o Hygeine, avoid ppl with infections
o Folic acid supplements

Thalassemia Anemia
Autosomal recessive disorder characterized by defect in alpha or beta chain
of HgB molecule
Patho:
 Defect causes shortened RBC life
 ^ Results in extreme erythropoiesis in liver, spleen, and bones
o hepatosplenomegaly and bony malformations
Heterozygous = Thalassemia minor
 Mild anemia only symptom
Homozygous = Thalassemia major
 No symptoms present for first few months of life
 Once infants start producing adult-type HgB:
o They develop severe anemia
o Dependent on transfusions
  Eventually develop iron overload
 Must get iron chelation therapy to avoid damage to liver
and heart
 Without chelation therapy, they don’t live past 20 or 30
Maternal Complications:
 Minor = mild anemia
o Must be distinguished from iron deficiency because they
should not receive iron supplements unless she is iron
deficient
o Iron-deficiency = low serum iron and ferritin levels
o Thalassemia minor = normal iron and ferritin levels
 Major = pregnancy is rare
o If pregnant  severe anemia, needs transfusion, and at risk
for CHF
Treatment:
 Folic Acid supplements (NOT IRON)
 Transfusion and chelation therapy
 Avoid exposure to infections and seek treatment promptly if
infected
 Keep hydrated, oxygenated, and free of infection
Complications Due to Pregnancy 8/24/2015 11:32:00 AM

Hypertensive Disorders:
Account for 17% of maternal deaths in US
Chronic HTN – HTN diagnosed before pregnancy or prior to 20 weeks
gestation
4 types of HTN disorders:
 Preeclampsia/Eclampsia
 Gestational HTN
 Transient Gestational HTN
 Chronic HTN with superimposed preeclampsia

Preeclampsia
Proteinuria and HTN that occurs after 20 weeks gestation
Cause is unknown
 May be abnormal prostaglandin action, dietary deficiencies (Ca and
Zn), or genetic predisposition
Risk Factors:
 Mother over 40 or under 17
 Primigravidas (1st child)
 DM
 Chronic HTN
 Close family with history
Complications:
 Placental abruption
 Premature
 IUGR
 Fetal hypoxia
 CVA
Patho:
 KNOW CHART ON 2.7 Page 2
 Vasospasms causes endothelial cell damage
 Vasospasms and cell damage cause poor organ perfusion
o Affects uteroplacental unit, brain, liver, and kidneys
 Goes from mild preeclampsia, to severe preclampsia to either
eclampsia or HELLP syndrome
 o Eclampsia
 seizure activity (or coma) in woman diagnosed with
preeclampsia with no medical history of seizures
 Can be focal, multifocal, or generalized
o HELLP syndrome
 Severe preeclampsia with:
 Hemolysis (low Hct)
 Elevated Liver enzymes
 Low Platelets (less than 100,000)
 Give birth regardless of fetal age if maternal/fetal
condition worsens
Manifestations:
 High BP and proteinuria
 Neuro symptoms
o Headache, scotomata (spots in vision), increased blurred
vision, hyperreflexia
 Edema (periorbital)
 Epigastric or right upper quadrant pain (liver distention)
 Abnormal labs (elevated BUN, creatinine, liver enzymes, and clots)
 If liver fails:
o Jaundice,
o Increased AST, ALT
 If Kidneys fail:
o Elevated BUN/creatinine
o Extreme proteinuria
 Worsening Preeclampsia:
o Increasing edema in hands/face – gain of 3 lbs (1.4 kg) in 24
hrs or 4 lbs (1.8 kg) in 3 days
o Worsening headache, visual disturbances, disorientation
o Epigastric pain
o Decreased urinary output - <500 ml/day
o N/V
o Bleeding gums
Diagnosis:
 Mild Preeclampsia
o Two BP readings between 140/90 – 159/109 six hours apart
 o Proteinuria of 300mg/per day or +1 urine dip
 Severe preeclampsia
o Two BP readings at or above 160/110 six hours apart
o Proteinuria of 500mg/per day or +3 urine dip
o Can also have pulmonary edema, cyanosis, epigastric pain,
impaired liver function, thrombocytopenia, and IUGR
Management:
 Traditionally  delivery regardless of gestational age
o Disease process reverses after birth
o Getting the baby in the NICU is better than the unhealthy
environment of severe preeclampsia
 Those at high risk  aspirin
 Mild:
o At home monitoring of BP and daily weights
o Maintain high protein diet (prevents high edema)
o Fetal movement counts
o Bed rest may be recommended
o Periodic lab testing (platelet counts, uric acid and BUN, liver
enzymes, and 24hr urine for creatinine clearance and total
protein)
o Testing for fetal well-being
 Severe:
o Inpatient
o After 34 weeks, may be at home management depending on
maternal and fetal status
o Complete bed rest and dietary restrictions
 Left lateral recumbent position
 High-protein, moderate sodium (<6g/day)
o Usually have catheter – strict I&O
o BP medicines – hydralazine or labetalol (avoid in asthma &
CHF)
o Seizure prevention meds – mg sulfate
o Meds to promote fetal lung maturity in those mothers who
must deliver preterm – corticosteroids
o Fetal surveillance (non-stress tests and biophysical profile)
o Low stimulation environment
Nursing Process for Preeclampsia:
 Antepartum/Intrapartum
o Assessment:
 Assess symptoms and VS (differentiate btw mild and
severe)
 deep tendon reflexes
 lab values
 Neuro status (headaches, visual disturbances, seizure
activity)
 I/O, edema, and daily weights
 Continuous fetal monitoring
o Nursing Dx:
 FVE; Risk for injury; Impaired Tissue Perfusion; Anxiety
o Implementation:
 Client education
 Provide guidance for potential need for and method of
delivery
 Emotional support
 Administer antihypertensives for acute hypertensive
crisis
 Mag Sulfate to prevent eclampsia or seizures
 Therapeutic range is 4-8mg
 At 4mg – DTR decreases back to normal
levels, 1st indication that it’s working
 Have Ca gluconate at bedside
 Monitor for toxicity:
 Over 9 mg
 Check for extreme decreased reflexes
 Loss of patellar reflex is right before loss of
respiratory reflex and pulm. paralysis
 May occur with decreased urinary output
 Corticosteriods to promote fetal lung maturity
 Calm, quiet environment
 Postpartum:
o Vigilant monitoring of VS, deep tendon reflexes, and neuro
status
 o Mag sulfate infusion for 24 hours
 Calcium gluconate at bedside
 Seizures can occur during 1st 48hrs postpartum
o Monitor I/O, weight, and edema
 Diuresis should return
o Monitor lab values
o Client teaching:
 Recognized S/S of worsening condition (neuro, visual)
 Follow-up appointments
o Promote mother/infant bonding
Nursing Process for Eclampsia:
 Assess for signs of impending seizure:
o Change in mental status
o Hyperreflexia (reflexes greater than 2+) and/or clonus
(hyperactive nerves)
o Right upper quadrant or epigastric pain
o Signs of cerebral irritability (severe headache, scotomata)
 Nursing Dx:
o Risk for maternal and fetal injury
 Implementation (if seizure occurs):
o Maintain airway
o Maintain safety – stay at bedside and call for help
o Monitor duration of seizure and body movement
o Administer Mag Sulfate per protocol
o Once seizure is over:
 Put pt on her side
 Assess fetal status
 Prepare for delivery (C-section)
 Support family

Early Pregnancy Bleeding Disorders:

Occur during first half of pregnancy (up to 20 weeks)

Spontaneous Abortion
Pregnancy loss prior to fetal viability (under 20 weeks or under 500g)
 No action taken by mother
 “miscarriage”
most common cause of bleeding
Caused By:
 Result of chromosomal abnormalities (most often)
 Teratogen exposure
 Chronic medical conditions (DM, SLE)
6 Subsets:
 1 GRAM IS ONE ML OF BLOOD LOSS
o peripad
 Backache and cramping with bleeding are main indicators of
abortion
o Other less harmful things can cause bleeding
 Threatened:
o Manifestations:
 Vaginal spotting, light bleeding, uterine cramping,
backache, NO cervical dilation or rupture of membranes
o Treatment:
 More symptoms persist  more likely the pregnancy
will be lost
 Bed rest, pelvic rest
 Client education (signs of infection and passage of
tissue)
 Inevitable:
o Manifestations:
 Vaginal bleeding, uterine cramping, cervical dilation,
rupture of membranes
o Treatment:
 Delivery is imminent
 Allow natural expulsion
 Dilatation and curettage
 Incomplete:
o Manifestations:
 Heavy vaginal bleeding, severe cramping, cervical
dilation, rupture of membranes, passage of some tissue
 o Treatment:
 Avoid hypovolemia and shock
 Can lead to DIC – disseminated intravascular
coagulation
 Overactive clotting
 Blood transfusion if necessary
 D&C or suction evacuation
 Complete:
o Manifestations:
 All products are expelled
 Cervix is beginning to close
 Bleeding starts to subside
o Treatment:
 Teach client to watch for excessive bleeding and S/S of
infection
 Pelvic rest
 Follow-up care
 Missed:
o Manifestations:
Fetus dies but is retained in uterus
Uterus stops growing and early symptoms of pregnancy
disappear
o Treatment:
 Ultrasound to confirm fetal death
 D&C, suction evacuation if less than 12 weeks gestation
 Administration of prostaglandins or oxytocin to induce
labor if older than 12 weeks gestation
 Can have DIC
 Recurrent:
o Manifestations:
 Three or more consecutive SABs
o Treatment:
 Genetic counseling and thorough exam of reproductive
system
 Treat infections or other medical conditions
 A cerclage for incompetent cervix
  Septic:
o Presence of infection due to not fully passing particles
o May occur after prolonged, unrecognized rupture of
membranes
o May occur if pregnant with IUD in utero
o Common in self-abortion or botched abortion

Ectopic Pregnancy
Implantation of fertilized ovum in any area other than the uterine
endometrium
 Responsible for 6% of maternal death due to hemorrhage
 Can decrease the chance of subsequent pregnancy due to damage
or destruction of fallopian tubes
Risk Factors:
 History of previous ectopic pregnancy
o (increases risk by 10%, 25% in those with multiple previous
ectopic pregnancy)
 History of STIs (Chlymidia is common cause)
 Pelvic Inflammatory Disease (PID)
 Failed tubal ligation or previous tubal surgery (tubes tied)
 Presence of IUD
 In utero exposure to diethylstilbestrol (DES)
 Advanced maternal age
 Smoking
 Ovulation-inducing medications
 Endometriosis
Manifestations:
 Missed period
 Unusually slow rising hCG levels (n/v)
 Lower Abdominal or pelvic pain
o One-sided or diffuse
 Vaginal spotting or bleeding
 PE reveals adnexal tenderness
 Dizziness
 Internal hemorrhage
 o More commonly slow bleeding and abd becomes rigid and
tender
 If rupture occurs:
o Sudden severe lower quadrant abdominal pain
o Profuse hemorrhage
o Hypovolemic shock (even without external bleeding)
Management:
 If not ruptured – administer Methotrexate IM
o Folic acid antagonist
o Inhibits embryo cell division and causes regression of tissue
o Decreases hCG levels
 Surgical management
o Linear salpigostomy (not ruptured) – incision in tube,
removal of conceptus, leave tube to heal without suturing
o Salpingectomy (ruptured) – removal of tube to control
bleeding and prevent shock
o If woman is in shock, they will make abdominal incision
instead of a laproscopy

Gestational Trophoblastic Disease

“molar pregnancy”
abnormal proliferation and edema of chorionic villi that leads to a placenta
that resembles a cluster of grapes, but no embryo or fetus
Risk Factors:
 Advanced maternal age
 History increases chance of reoccurence
Categories:
 Complete mole – results from ovum without a nucleus fertilized by
sperm (or two sperms) that duplicates its own genetic material
resulting in no embryo
 Partial mole – normal ovum that is fertilized by two sperm, may
have some embryo/fetal parts
o May be recognized after spontaneous abortion or may go
unnoticed
Complications:
 Anemia – frequent bleeding
  Infection
 DIC
 Hyperthyroidism
 Pulmonary embolism or edema
 Choriocarcinoma (causes elevated hCG levels)
Manifestations:
 Elevated hCG levels (hyperemesis gravidarum)
o Excessive N/V
o Rule out choriocarcinoma
 Dark vaginal bleeding – prune juice
 Uterine larger than expected for gestational age
 No fetal heart beat
 Passage of hydropic vessels
o Anemia if loss of blood
 Associated with early onset of preeclampsia
 Greiving loss of possible pregnancy
Diagnosis:
 UT usually after 6-8 weeks
Management:
 Control breathing
 If older woman with no intentions of more children or excessive
bleeding  hysterectomy
 Uterine Contractions are AVOIDED (don’t want them to throw the
clots or vesicles in the sinusoids of the uterus)
o Given oxytocin after evacuation
 Immediate evacuation of mole via vacuum aspiration followed by
curettage
o D&C
 RhoGAM!!!! Post-op for Rh negative women (unsensitized)
o RhD antigen is contained in trophoblast
 Post evacuation follow-up requires elevation of serum hCG levels
every 1-2 weeks until normal pre-pregnancy levels return
o Then every 1-2 months for 1 year
o Choriocarcinoma occurs in 20% of women
 Pregnancy must be avoided for at least one year
 o So choriocarcinoma can be detected through elevated hCG
levels not associated with pregnancy

Nursing Process for Early Pregnancy Bleeding Disorders

Assessment:
 VS and comfort (BP and HR 1st!!!)
 If fetal HR present on ultrasound  good sign!
 Vaginal bleeding and signs of shock
o Count and weigh peripads
 1 GRAM IS ONE ML OF BLOOD LOSS
o Observe for pallor, clammy skin
 Emotional status and coping abilities
 Understanding of treatment
Nursing Dx:
 FVD; Acute pain; Risk for infection; Grieving
Implementation:
 Client education:
o Pre and post op care
o Post discharge self-care and follow-up
o S/S of infection
 If incomplete or imminent abortion:
o If bleeding persists – hospitalize
o If severe bleeding – transfusion and fluid replacements
 Emotional support
 Referrals for community resources
 Give RhoGAM within 72 hours if mother is Rh- and not sensitized

Hyperemesis Gravidarum
Persistent, uncontrollable vomiting that begins in the 1st weeks and may
continue throughout pregnancy
Can Result In:
 Weight loss, dehydration
 Electrolyte imbalance (low K due to dehydration)
 Starvation
Caused By:
  Unknown
 Elevated estrogen or hCG levels
 Hyperthyroidism
 Vit. B deficiency
 Psychological issues (family stressors or ambivalence)
Diagnosis:
 Through client report of intractable vomiting
 Health care provider findings of dehydration, ketonuria, and five
percent weight loss of pre-pregnancy weight
o Ketonuria – using protein as a fuel source because they are
throwing up all their carbs that can be used for energy
 Body starts breaking down fat and glucose in cells
 Ultrasound to rule out trophoblastic pregnancy
Management:
 Ruling out other causes (ultrasound to rule out molar)
 Methods of controlling morning sickness
o Crackers by bedside, avoid triggers
 Antiemetics and Pyridoxine (Vit. B6) for 1st line pharm therapy for
n/v
 Hospitilize if treatment isn’t working and pt shows signs of
dehydration, electrolyte imbalance, and hemoconcentration
 Inpatient:
o Initially: NPO, IVF for dehydration
 KCl added to prevent hypokalemia
 Replacement of thiamine (vit. B1) and pyridoxine (vit.
B6) important to correct deficiencies to prevent
peripheral neuropathy
 Desired urine output is a minimum of 1000 ml/day
o TPN or tube feeding (if non-responsive to IV fluids)
o Stabilize weight loss
Nursing Process:
 Assessment:
o Maternal VS
o I/O, daily weights
o Skin turgor, mucous membranes
o Fetal growth/development
 Implementation:
o Avoid smells that trigger N/V and heat/humidity
o 5-6 smaller high-carb, low-fat meals instead of three larger
meals
 carbonated beverages between meals in small amounts
 high-protein snacks
 After stabilization  progressive diet
 low fat soft diet and complex carbs with limited
liquids
o administer antiemetics
o client education
o emotional support
o avoid fatty foods and temperature extremes
o rest with feet up and head elevated
High Risk Pregnancies 8/24/2015 11:32:00 AM

Trauma During Pregnancy

Accidents and injury leading cause of death in women of reproductive years
 Normal physical changes increase risk for injury
 Maternal mortality from head trauma or hemorrhage
Complications:
 Psychological distress
 Poor weight gain
 Infection
 Anemia
 Second or third trimester bleeding
 May also experience sexual abuse (high risk of contracting STIs)
Can Lead To:
 Loss of pregnancy
 Preterm labor
 Low-birth-weight
 Injury to fetus
 Fetal death
Nursing Process:
 Identify signs of abuse:
o Frequently starts or increases with pregnancy
o Chronic psychosomatic symptoms
o Old scars or bruises
o Decreased eye contact or nervousness
o History of abuse
o Husband will want to stay with woman at all times
(overbearing)
 Implementation:
o Identify and increase decision-making abilites
o Provide a safe environment
o Screen in a private setting
o Ask direct settings
o Try to get man away from woman
o Determine immediate safety of woman

Describe the effects of infections and interventions to lesson/prevent

complications on the pregnant women and her unborn child
Pregnancy and Infections:
Fetal infection can occur any time during pregnancy
 Most likely to cause harm in first trimester
o Organ development
 Infections later in pregnancy
o Growth restriction
o Neuro disturbances
Toxoplasmosis:
 Caused by protozon Toxoplasma gondii
o Transmission through poorly or undercooked meat, dirty
vegetables (wear gloves if gardening), and cat litter and feces
 Complications:
o Infection during 1st trimester has lowest incidence of fetal
infection
 But has highest rate of fetal damage
 Diagnosis:
o Serologic testing for antibodies
 Treatment:
o Treat promptly
o Spiramycin – decreases fetal transmission
 It does not cross placenta
 Tx only for mother
o Pyrimethamine/ Sulfadiazine/ Folinic Acid only after 18 weeks
gestation
 Tx for fetus
Rubella:
 Mild in children and adults
 Fetal-neonatal risks
 Best treatment is PREVENTION
o Therapeutic abortion if infected in first trimester
o MMR vaccine not given to pregnant woman (live)
 Should not try to get pregnant for at least 1 month
after receiving vaccine
o Test all pregnant woman for immunity
o MMR vaccine postpartum
Cytomegalovirus:
 Belongs to herpes simplex virus group
 Found in urine, saliva, cervical mucus, semen, and breast milk
o Transmission common in day-care facilities
o Chronic condition and may shed virus continually for years
 No treatment for maternal CMV
 Fetal-neonatal risks
Herpes Simplex Virus:
 1 in 6 infected between ages 14 and 49
 fetal-neonatal risks
 test mothers early if at risk
 infected infant
 Treatment:
o Antivirals after 36 weeks
 Acyclovir, famiciclovir, valacyclovir
 Acyclovir near term can reduce need for C-section
Group B Strep:
 Lower GI, urogenital tracts
 Maternal morbidity
 Fetal-Neonatal risks
o Unexpected intrapartum stillbirth
 Treatment:
o Screening and prophylaxis
o Can still have vaginal birth
Human B19 Parvovirus:
 Causes erythema infectiosum – AKA 5th disease
 Fetal risks:
o Fetal death usually occurs 4-12 weeks postinfection
o Spontaneous abortion
o Stillbirth
o Fetal hydrops
 Weekly measures of peak systolic velocity of middle cerebral artery
(MCA)
o To Dx fetal edema
UTIs
Pyelonephritis
Vaginal Infections (yeast, bacterial, trich)

Rh Incompatibility:
Rh blood group present on surface of erythrocytes
 If Rh- person is exposed to Rh+ blood:
o Antibody-antigen response – sensitized
 Maternal IgG antibodies produced 
hemolysis/destruction of fetal RBCs
Patho
 Small amount of fetal blood crosses placenta
 Rh- mother, Rh+ fetus
 Maternal IgG antibodies produced
o Results in positive Coombs tests
 Hemolysis of fetal red blood cells
 Rapid production of erythroblasts
 Hyperbilirubinemia
 RhD alloimmunization
o Rh incompatibility
Screening:
 First prenatal visit
o Maternal blood type; Rh factor antibody screen
 Sensitization may occur antepartally
 Rh immune globulin (Rhogam given @28 weeks and within 72
hours of birth - if positive fetus/newborn)
Treatment:
 Administration of Rh immune globulin RhoGam
o When there is any chance of maternal and fetal blood
exposure/mixing
o At 28 weeks if father is Rh+ (if mother is not already
sensitized)
 If she already has antibodies, there is no point
 If mother is positive for antibodies:
o Early birth
 Ideally, wait until fully developed
 If severe, may deliver earlier
o Intrauterine transfusion