FOUNDATIONAL NURSING KNOWLEDGE

Minor Disorders In Pregnancy

Objectives
At the end of this session, student should be able to;

 identify common disorders.  discuss the pathophysiology of the

disorders.  discuss the diagnosis of the above conditions.  Outline clinical nursing management for the above conditions.

Hyperemises Gravidarum Def: persistent uncomfortable vomiting that

begins in the first week of pregnancy and may continue throughout pregnancy.

Signs & symptoms  weight loss  dehydration  acidosis + alkalosis  urine ketones

Causes

 unknown  possible allergy to fetal proteins  elevated levels of pregnancy

hormones.  maternal thyroid dysfunction  cholecystitis or peptic ulcer disease

       

Nursing Management Correct electrolyte imbalance Encourage small frequent feeds Reduce nausea and vomiting Give prescribed anti-emetics + antihistamines Get out of bed slowly Avoid alcohol, caffeine, spicy or fatty foods Provide emotional support Maintain nutrition and fluid balance

Non Pharmacologic measures

   

mouth care positioning and relaxation technique music therapy quiet environment

Ante Partum Hemorrhage

Bleeding from the genital tract in late pregnancy, after 28 wks of gestation and before the onset of labour.

Types of APH

1. 2.

Placenta Abuptio Placenta praevia

Placenta Abruptio Def: Separation of a normally implanted placenta before the fetus is born- occurs when there is bleeding and formation of a hematoma on the maternal side of the placenta. Etiology: abdominal trauma, smoking, maternal hypertension, short umbilical cord, coagulopathies.

Concealed Bleeding

Signs and Symptoms

      

vaginal bleeding abdominal and low back pain low intensity contractions uterine tenderness hypovolaemic shock non reassuring CTG evidence of separation by u/scan

Nursing Intervention

 Admission at once  Evaluate maternal and fetal condition  Delay contractions with tocolytic

agents if mother contracting.  Provide emotional support  Explain to mother about possible caesarian section. Usual pre-op care.  Stay with mother.

Placenta Praevia Def: is an implantation of the placenta in the lower uterus. Classification:  Marginal- placenta implanted in lower uterus.  Partial- lower border of placenta is within 3cm of cervical os but does not fully cover it.  Complete- completely covers internal os.

 Grade 1

 Grade 2

 Grade 3

Grade 4

Signs and Symptoms

 sudden onset of painless uterine

bleeding. Bleeding may be mild, moderate or severe.  non-reassuring CTG

Conservative Management

Admission at once. NO DIGITAL examination. Avoid oxytocin infusion Bed rest. Avoid sex. Delay the birth..to increase weight and maturity.  Assess perineal pads.  Monitor fetal kick chart.
    

Active

Management

 Severe bleeding warrants immediate

c/ section.  Attempt to alleviate pain  In case of hypovoleamia, prepare to transfuse or use plasma expanders.  Remain with mother

Vasa Praevia A situation where the blood vessels in the umbilical cord develop a route away from the cord and the placenta. Blood vessels are between baby and cervical opening.

Uterine Rupture A full thickness separation of the uterine wall and the overlying serosa. Un-common but very serious situation that places the mother and fetus in a life threatening situation.  trauma  previous caesarian scar  obstructed labor/ instrumental del

Abortions Def: the loss of pregnancy before the fetus is viable. Fetus of less than 20 wks or weighing less than 500 grms. Etiology: Chromosomal abnormalities, maternal infections, maternal endocrine disorders, anatomic uterine disorders.

Six Groups
1.

Threatened abortion

2. 3. 4. 5. 6. 7.

Inevitable abortion Incomplete abortion Complete abortion Missed abortion Recurrent abortion Septic abortion

Symptoms
   

vaginal bleeding uterine cramping persistent backache fever/ uterine tenderness infection

Nursing Management
       

Follow up all investigations done. Rest Assess vital signs obstetrician to see. IV therapy to replace lost fluids Blood transfusion if Hb levels low Administer sedatives/ antibiotics Show mother empathy

Hydatidiform Mole Def: is a form of gestational trophoblastic disease that occurs when the trophoblastic develop abnormally. As a result of the abnormal growth, the placenta (not the fetus) develops. The fluid- filled villi form grapelike vesicles that may grow large enough to fill the uterus to the size of an advanced pregnancy.

H Mole

Etiology

During fertilization the sperm duplicates its own chromosomes while the ovum does not. Maternal contribution is present but the paternal contribution is doubled.

Sign and Symptoms

vaginal bleeding uterus larger than expected excessive nausea and vomiting early development pre-eclampsia B-hCG is high u/scan reveals vesicles but no fetal gestational sac  no fetal tone, heart beat, movement
     

Nursing Intervention  Evacuation of mole  Full Blood investigation to be done  Explain information about tests & procedures.  Teach measures to prevent infection  Provide dietary information  Teach signs of infection to report  Emphasize follow up care.

Sexually Transmitted Infections

Def: diseases that are transmitted through sexual intercourse. In pregnancy, the mother may pass the disease to her fetus via placenta.
   

Syphilis Gonorrhoea Chlamydia HIV

Syphilis Def: is a infection caused by Treponema pallidum, one of three spirochaetes associated with human disease. Symptoms:  fever, rash, swollen lymph nodes, genital lesions, fatigue, headache, weight loss, hair loss, sore throat, mouth ulcers.

Stages of Syphilis Infection

 Primary Infection  Secondary Infection  Tertiary Infection

Treatment & Management of Syphilis

 Prevent by abstinence  Counsel to prevent re-infection  Benzathine Penicillin is the primary

treatment/ doxycillin/ erythromycin for early syphilis < 1 year  Erythromycin is given if allergic to penicillin.  Trace and treat partner  Benz Pen x 3 doses. Procaine Pen x 15 days.

Complications of Syphilis

Maternal  enlarged liver, spleen, pneumonia, hepatitis. Fetal  spontaneous abortion, stillborn, premature labor.

PIH (Pregnancy Induced Hypertension)

Def: Pregnancy Induced Hypertension. Condition is peculiar to pregnancy. Blood pressure should normalize after delivery. Characterized by Hypertension,

generalized odema, proteinuria. Onset is usually before 20 wks gestation.

Pathophysiology

 Actual etiology unknown  In normal pregnancy, significant

increase in vascular and cardiac output.  Some women develop resistance to angiostenin II (vasoconstrictors).  Vasocontriction decreases the diameter of blood vessels, which results in endothelial cell damage. As a result, circulation to all organs is decreased.

Clinical Manifestation
 Elevated blood pressure: systolic > 130

mmHg and diastolic > 90 mmHg.  Proteinuria +  Odema may be present

Nursing Intervention
 Admit for rest  Monitor blood pressure until stable  Administer prescribed

antihypertensives  Monitor albumin rack/ proteinuria  Offer counselling/ reassurances to ally anxiety

Cardiac

Diseases

Cardiovascular function changes during pregnancy to meet additional maternal metabolic demands and the needs of the patient.  Rheumatic Heart Disease  Congenital Heart Disease

Classification of Cardiac Disease

Asymptomatic with all activity. Uncompromised. 2. Asymptomatic at rest, symptomatic with heavy physical activity. Slightly compromised. 3. Symptomatic at rest. Activity markedly compromised. 4. Symptomatic at rest. Severely compromised.

1.

Rheumatic Heart Disease

Def: is a complication that sometimes follows a streptoccol pharyngitis infection (strep throat). Even one bout of rheumatic fever may cause scarring of the heart valves, resulting in stenosis of the opening between the chambers of the heart.

Pathophysiology Mitral valve is the most common site of stenosis. Mitral valve obstructs free flow of blood from the atrium to left ventricle. The left ventricle becomes dilated. As a result pressure in the left atrium, pulmonary veins and pulmonary capillaries is chronically elevated. This elevation may lead to pulmonary hypertension, pulmonary edema or congestive heart failure.

Rheumatic Heart Disease

 mitral & aortic valve incompetence  mitral stenosis

Congenital Heart Disease  atrial septal defect  patent ductus arteriosis  ventricular septal defect

Signs and Symptoms



    

rales persist dyspnea on exertion cough heamoptysis progressive edema tachycardia

Nursing
   

Intervention

limit physical activity. avoid excessive weight gain prevent anemia. prevent upper respiratory tract infection.  carry out careful assessment for development congestive heart failure, pulmonary edema or cardiac dysrhythmias.

 administer medications  anticoagulants  antidysrhythmisa  antibiotics  anti-heart failures

1st Stage care

    

notify cardiologist/ obsterician. prophylactic antibiotics ECG as required X-match blood oxygen + resuscitation should be at hand

Induction
 oxytocin pessaries  oxytocin infusion avoided.

Pain Relief
 epidural block  nitrous oxide + O2

narcotics (consult Dr.)  TPR/ ECG/ BP  Semi fowlers position  Lithotomy position not recommended


2nd Stage Care  labor should be short without undue exertion on the part of mother.  Prolong pushing with held breath is undesireable  Encourage mother to push with natural urges.  Forceps delivery is optional

rd 3

stage care

 syntometrine  oxytocin  frusemide / lasix

Anemia Def: is a condition in which a decline in circulating red blood cell mass reduces the capacity to carry oxygen to the vital organs of mother or fetus. Hemoglobin is less than 10.5 or 11.5 g d/L. Anemia is the most common problem in pregnancy.

Causes Iron Deficiency Anemia poor dietary intake poo gastrointestinal absorption excess demand blood loss

Effects of Anemia  Mother fatique reduced resistance to infection predispose to PPH potentially life threatening  Fetus intra-uterine hopxia growth retardation/ infant death

Management
 Lecture on diet  Iron supplements (iron/ folic acid

tabs/ ascorbic acid/ vitamins. Fortification of foods.  Imferon injection/ IV therapy  blood transfusion

Maternal Complications
   

bacteria endocarditis thrombo-embolism heart failure fibrilation/ cyanosis

Signs and Symptoms

 pallor  Fatique  lethargy  headache

Nursing Intervention

 Routine supplemental iron therapy.  ferrous sulphate  Diet: high protein + iron+ fortified flour  imferon therapy  blood transfusion

Gestational Diabetes Mellitus

Def: a complex disorder of carbohydrate metabolism caused primarily by partial or complete lack of insulin secretion by beta cells of the pancreas. Classification: Type 1 Type 2 Gestational Maternal Effects:  Ketoacidosis  urinary tract infection  shoulder dystocia

Pathophysiology
Caused partial or complete lack of insulin secreted by beta cells of the pancreas. Without insulin, glucose accumulates in the blood resulting in hyperglycemia.  Early Pregnancy (1- 20 wks).  Late Pregnancy (20- until birth)

Risk Factors

      

Obesity. Weight > 85 kg Maternal > 30 years Previous GDM History of impaired sugar tests Previous unexplained stillbirth Previous large babies Hypertension

      

Fetal Effects congenital malformation variation in fetal size Neonatal Effects cardiac dysfunction hypoglycemia hypocalcaemia hyperbilirubinemia respiratory distress syndrome

Nursing Intervention
       

Aim to normalize sugars Dietician to counsel Close monitoring of glucose levels Monitor fetal well being Administer insulin Teach to self medicate (Insulin therapy) Plan for delivery (mode and time) Exercise

Pre-Term Premature of MembranesPPROM

Pre-term is defined as the birth of an infant before 37 wks of gestation. Pre-term labour is defined as uterine contractions prior to 37 wks gestation. Therefore PPROM is the rupture of membranes prior to 37 wks gestation.

Possible causes of PPROM



     

UTI coital and digital examinations STI infections abusive spouse heavy home chores history of cough history of trauma

Nursing Intervention PPROM

Take careful history of leak Assess maternal and fetal condition Assist with speculum examination Dexacortine protocol if pregnancy < 34 weeks.  Antibiotics as prescribed  Watch for Maternal pyrexia NO DIGITAL EXAMINATION
   

Reference
 McKinney. E., Ashwill. J., James. S. (2005). Maternal

child nursing (2nd ed). St. Louis. Elsevier saunders.  Noval. J. & Bromm. B. (1999). Maternal and Child Health Nursing (9th ed). St. Louis. Mosby Elsevier.  Bennett. V., Brown. L. (1996). Myles textbook for midwives (12th ed). Edinburgh. Churchill Livingstone.  World Health organization (WHO). (1996). Maternal health and safe motherhood progam. Publisher.