Antepartum Complications Essential concepts Although most pregnancies progress to successful delivery without complications, various factors can

n alter the physiologic processes of pregnancy &compromise the wellbeing of the mother or the developing fetus. complications may occur at any time during pregnancy & can result an pre-existing maternal medical problems or from the pregnancy itself. Significant complications of pregnancy include: 1. Spontaneous abortion 2. Gestational trophoblastic disease (h-mole) 3. Ectopic pregnancy 4. Incompetent cervix 5. Hyperemesis gravidarum 6. Anemia 7. Placenta preyia 8. Abruptio placentae 9. Preeclampsia and eclampsia 10. Gestational diabetes 11. Hemolytic disease of the fetus and newborn 12. Infections Maternal conditions that can significantly affect the fetus or the progress of pregnancy include: DM cardiac disease hypertensive disease, Other disorders : Infections sexually transmitted disease smoking substance abuse Goals of prenatal nursing are: screening for, and preventing complications developing therapeutic interventions Early and consistent prenatal care results in: improved fetal and maternal outcome, regardless of complications that may occur. Evaluation of each pregnancy to identify at-risk clients as early as possible. Remember that risk assessments must :be updated throughout the pregnancy because a gestation categorized as low initially may become high risk later. A. Assessment 1. Health history a. Elicit a description of symptoms, including: onset, duration,. location, and precipitating factors, if known. Cardinal signs and symptoms of antepartum complications may include (Client and Family Teaching 12-1) (1) Dizziness (2) Nausea and vomiting (3) Headache (4) Fatigue (5) Abdominal pain or cramping

hemato-(anemia /hemoglobinopathies)

(6) Uterine labor contractions before the estimated date of delivery b. Explore personal and family history for risk factors for ante partum complications. 2. Physical examination a. Vital signs (1) Measure wt for excessive loss and gain. (2) Measure for increased BP. (3) Measure for rapid pulse. (4) Measure for increased temperature b. Inspection (1) Assess for vaginal bleeding. (2) Inspect for premature rupture of the membranes (PROM). (3) Assess the skin for rash, pale, dry skin, or edema. (4) Inspect the oral cavity for overall dental health and signs of poor nutrition rough tender tongue fissures at the corners of the mouth pale mucous membrane swollen or inflamed gingival c. Palpation (1) Palpate the uterus to determine whether: it is abnormally soft or hard, and it is larger or smaller than expected for gestational age (2) Palpate cervix - preterm cervical dilation d. Auscultate the FHR to detect abnormally fast or slow rate 3. Laboratory studies and diagnostic tests a. complete blood count (CBC) is the most routinely performed test In the laboratory. It provides information about the number, type, and health of red blood cells (RBCs) and white blood cells, and the hematocrit and hemoglobin value, b. pregnancy test (ie, human chorionic gonadotropin [hCG]) may be performed on maternal urine or serum. (+) test indicates pregnancy probably exists. other factors that can yield a (+) test result: medications tumors, premature menopause blood in the urine c. Serum atpha-fetoprotein measurement. Alpha-fetoprotein dominant protein in fetal plasma. A small amount crosses the placenta into the maternal serum, and some is excreted into the amniotic fluid. Therefore, it can be measured in maternal serum or in amniotic fluid. An abnormal, concentration of alphafetoprotein in either amniotic fluid or maternal serum is associated with such fetal anomalies as open neural tube defects anencephaly

 spina bifida d. Ultrasound refers to the use of high-frequency sound waves passed through the maternal abdomen. These sound waves are deflected by fetal structures and allow visualization of: fetal movement, fetal heart movement respiratory effort. used throughout pregnancy to determine: fetal age visualize the placenta locate pockets of amniotic fluid for amniocentesis e. Blood glucose and glycosolated hemoglobin. A blood glucose test indicates the concentration of glucose in the blood, represented in milligrams of glucose per deciliter of blood. Glycosolated hemoglobin measures the amt of glucose attached to hgb reflects the average blood glucose level over the past 4 - 6 wks and is usually reported as a single digit. f. The indirect Coombs test, used in the search for agglutination of Rh-positive RBCs to determine whether antibodies are present in maternal blood. It is used to anticipate hemolytic disease of the newborn. g. Amniocentesis aspiration of a sample of amniotic fluid for examination of fetal cells. May be used to determine chromosomal abnormalities or fetal lung maturity, or to diagnose fetal hemolytic disease, h. Serologic tests used to determine the presence & type of STDs i. Cultures disease and site specific,& are used to determine the type of infectious agent present & to identify medications to w/c these agents are susceptible B. Nursing diagnoses. (Both general and complication specific are listed. 1. General diagnoses a. Pain f. Altered family processes b. Anxiety g. Powerlessness c. Fear h. Knowledge deficit d. Ineffective individual coping i. Noncompliance e. Ineffective family coping: compromised 2. Complication-specific diagnoses a. Fluid volume deficit b. Anticipatory grieving c. Dysfunctional grieving d. Risk for infection | e. Situational low self-esteem f. Altered nutrition: less than body requirements g. Altered nutrition: more than body requirements h. Constipation i. Activity intolerance j. decreased cardiac output k. Altered tissue perfusion: uteroplacental C. Planning and outcome identification 1. The client and fetus (if applicable) will make a full recovery and will nd develop additional complications.

2. The client and family will express their fears and anxieties, and will exhibit functional grieving. 3. The client and family will understand the complication and treatment regimen, 4. The client and family will comply with the treatment regimen. D. Implementation 1. Ensure that appropriate physical needs are addressed and monitor for additional complications. a. Assist the woman to plan for adequate rest, activity, and nutrition, b. Assist the couple to set realistic goals based on the mother's health and the restrictions required by the complication. 2. Address emotional and psychosocial needs. a. Assess the client's feeling about herself and the pregnancy and assist the woman to maintain her self-esteem. b. Encourage verbalization of any grief, loss, and potential guilt feelings c. Offer emotional support to the client and her family as they go through a normal grieving process due to a crisis to their pregnancy, or a loss of their pregnancy. d. Evaluate client & her family's support system e. Assess for an appropriate coping response. 3. Provide client and family teaching. a. Provide information about the actual complication & expected outcome if possible. b. Instruct couple about specific s/s to report c. Provide printed instructions on various selfcare measures (use of medications, dietary and activity restrictions, and rest) to manage the existing problem& prevent additional complication d. Explain the need, purpose, & procedure for various diagnostic tests. E. Outcome evaluation 1. client &fetus (if applicable) recover fully and do not develop additional complications. 2. client& family express their fears & anxieties, & exhibit functional grieving. 3. client & family understand the complications & treatment regimen. 4. client & family comply w/ the tx regimen II N !' AND FAMILY TEACHING 12-1 >report the ff s/s to her health care provider immediately: SIGN/SYMPTOM Sudden gush of fluid from the vagina spotting or bleeding from the vagina Headache with visual disturbance, epigastric pain, swelling of hands and face, or sudden weight gain Uterine pain fever, rash, malaise, or other flulike symptoms Unusual, foul-smelling, or purulent discharge from the vagina I'.nn on urination, frequency of urination, and backache i.imily history of diabetes, dizziness, confusion, thirst glycosuria, or polyuria l.xposure to a communicable disease Sudden lower abdominal pain, minimal

vaginal bleeding, confusion, pale, pulse, or severe shoulder pain

2.
3. 4. 5. 6.

Abortion (spontaneous) Ectopic pregnancies Preterm labor and delivery Intrauterine growth retardation Congenital malformation a. Result of genetic disorder 7. Cesarean birth 8. Previous fetal lost 9. Pregnancy-induced hypertension

POSSIBLE INDICATION Rupture of membranes, impending labor, or route for infection Labor, placenta previa, abruptio placentae, ectopic pregnancy, or hydatidiform mole Pregnancy induced hypertension, preeclampsia, or eclampsia Labor, abruptio placentae, and urinary tract infection Infection by an organism Infection by an organism Urinary tract infection Diabetes mellitus Possible infection by an organism Possible ectopic pregnancy

10. Diabetes 11. Vaginal bleeding in pregnancy 12. Isoimmunization 13. Multiple gestation 14.Large infants E. Current obstetrical history a. PIH (21% of maternal deaths) b. Infection(18% of maternal deaths) STD TORCH syndrome (Toxoplasmosis, Othyer Rubella, Cytomegaloviru, iInfection, Herpes) Other viral diseases *hepatitis or AIDS c. Hemorrhage (14% of maternal deaths) d. Exposure to toxic environmental agents e. Use of drug f. Multiple gestation g. Abnormal presentation h. Premature rupture of membranes i. Chronic health problems eg. diabetes, cardiac diseses, anemia j. Coexisting medical problem k. Abnormal antenatal lab results F. Socio-economic status A. low economic status- often associated with; 1. Inadequate nutrition 2. lack of general knowledge about health care needs B. Incidence of SGA babies C. Malnutrition or deprivation less than 4 kg weight gain by 30 weeks gestation related to eating disorders D. Drug or alcohol addiction- associated with congenetal anomalies, intrauterine growth retardation, etc E. Smoking associated with low BW infants Diagnostic tests Tests, biophysical & biochemical tests to evaluate fetal, placental function / fetalmaturity critical in high-risk pregnancy Fetal movement or fetal kick count Nonstress testing (NST) Contraction stress test (CST( Nipple stimulation-contraction stress test

2.

High risk child bearing Any existing / developing condition / factor that prevents / impedes the normal progress of pregnancy to the delivery of a viable, healthy, term infant. Assessment of risk factors A. Age Under or over 35 (greater risk over 40) years old Pregnant adolescents have higher incidence of Prematurity Pregnancy induced hypertension Cephalopelvic disproportion, poor nutrition Inadequate antepartal care Women over 35 are at increased risk for 3. chromosomal disorders in infants Down syndrome Pregnancy-induced hypertension Cesarean delivery B. Parity a) multiparity 2 / more pregnancies (may not be significant) b) Grand parity 6 or more pregnancies c) Interval between pregnancies C. Past health history Diabetes Heart disease Renal condition Essential hypertension Anemia Thyroid disorder Physical D. past obstetrical history 1. Lack or antepartal care a.Poor compliance with visit schedule(may be a factor in late detection of health problems) b.Contributes to high infant mortality rate

 Ultrasonography Chronic villi sampling Amniocentesis Laboratory studies Assessment of risk factors 1. fetal movement or fetal kick count A. Definition daily recording of fetal movements to assess active and passive fetal states in normal pregnancies and those with complications B. Procedure a noninvasive test that may be done directly by pregnant mothers C. interpretation; - (optimal number of fetal movement varies with source) A. Normally 3 or more movements are felt in an hour, fetal states normally vary (cycling periods of rest and activity) B. Marked decreased in fetal movement (unrelated to sleep) of 2 or less movements / hour should be reported and a nonstress test(NST) may be scheduled D. Reassure client that there are fetal rest and sleep states with minimal or no fetal movement Diagnostic Tests, biophysical and biochemical tests to evaluate fetal, placental function or fetal-maturity critical in high-risk pregnancy 1. Fetal movement or fetal kick count

A. daily recording of fetal movements

to assess active & passive fetal states in normal pregnancies & those w/ complications Procedure: a noninvasive test that may be done directly by pregnant mothers Interpretation; (optimal number of fetal movement varies with source) A. Normally 3 or more movements are felt in an hour, fetal states normally vary (cycling periods of rest & activity) B. Marked decreased in fetal movement (unrelated to sleep) of 2 or less movements / hour should be reported & a NST may be scheduled Reassure client that there are fetal rest and sleep states with minimal or no fetal movement 2. Nonstress test (NST) - observation of fetal heart rate (FHR) related to fetal movement (accelerations suggest fetal well being with good prognosis) INDICATION For fetal evaluation, especially in post term pregnancies, uteroplacental insufficiencies, poor fetal history Procedure:

o Performed in an ambulatory setting or in the hospital obstetrical unit by nurse trained in test administration. o Requires external electronic monitoring (indirect) using ultrsound transducer to measure FHR and tocodynamometer to trace activity or spontaneous uterine activity o Positioned in semi-fowlers / left lateral position o Maternal BP recorded initially o Requires 30-50 minutes to administer test (10-12 mins tracing obtained) o Client must activate mark button w/ every fetal movement NST Interpretation Reactive (Normal) 2 FHR accelerations (>than 15 bpm) above baseline lasting 15 seconds or more occur with fetal movement I 10 or 20 minute period Nonreactive (abnormal) failure to meet the reactive criteria indicates the need for additional evaluation, perhaps using contraction stress test(CST) or oxytocin challenge test (OCT) Unsatisfactory result; uninterpretable FHR or fetal activity recording; additional testing performed in 24 hours or OCT done 3. CONTRACTION STRESS TEST (CST) or OXYTOCIN CHALLENGE TEST (OCT) The Response Of The Fetus (FHR Pattern) to induce contraction is observed as an indicator of uteroplacental and fetal physiologic integrity. Indications: - Pregnancy at risk for placental insufficiency or fetal compromise OCT/CST Procedure: A. performed on an out patient basis in or near labor and delivery unit. - Requires external electronic monitoring (indirect) using UTZ to measure FHR & tokodynamometer to trace uterine activity. Positioned on semi-fowlers / left lateral position Initial bp taken & intervals during the procedure Requires 1 - 3 hours to complete test. Increasing doses of oxytocin are administered as a dilute intravenous infusion according to hospital protocol / physicians order until uterine contraction occurs CST/OCT interpretation: 1. Negative(normal): the absence of late deceleration of FHR with each 3 contractions during a 10 minute interval; known as negative window 2. Positive (abnormal): the presence of late deceleration of FHR with each 3 contractions during a 10 minute interval; known as negative window 3. Equivocal or suspicious: the absence of positive or negative window (i.e. criterion of 3 contractions during a 10 minute interval is not achieved)

High risk pregnancies are usually allowed to continue if a negative Oct is obtained; test is repeated weekly 4. NIPPLE STIMULATION-CONTRACTION TEST: a) Baseline data obtained through monitoring as in CST procedure b) Breast stimulated by warm towel application or nipple rolling, causing release of oxytocin and producing uterine contractions c) Interpretation: as with cst. Uterine contraction with absence of late decelerations is the desired outcome 5. ultrasound

4.