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Maternal & Child Nursing Care Second Edition Marcia L. London Patricia W. Ladewig Jane W. Ball Ruth C.

Bindler Lecture Notes Chapter 15 Pregnancy at Risk: Gestational Onset Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Causes of Bleeding During the First and Second Trimester Abortion: Expulsion of the fetus before 20 weeks gestation Expulsion of fetus less than 500g Spontaneous: Occur naturally Induced: Caused b y medical or surgical means Medical therapy: Bed rest and abstinence from sex Persistent bleeding: Hospitalization IV therapy or blood transfusions Dilatation and curettage (D&C) or suction evacuation 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Miscarriage Related to chromosomal abnormalities Classification Threatened abortion Imminent abortion Complete abortion Incomplete abortion Miss ed abortion Recurrent abortion Septic abortion Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

A FIGURE 151 Types of spontaneous abortion. A, Threatened. The cervix is not dilate d, and the placenta is still attached to the uterine wall, but some bleeding occ urs. B, Imminent. The placenta has separated from the uterine wall, the cervix h as dilated, and the amount of bleeding has increased. C, Incomplete. The embryo or fetus has passed out of the uterus, but the placenta remains. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

B FIGURE 151 (continued) Types of spontaneous abortion. A, Threatened. The cervix i s not dilated, and the placenta is still attached to the uterine wall, but some bleeding occurs. B, Imminent. The placenta has separated from the uterine wall, the cervix has dilated, and the amount of bleeding has increased. C, Incomplete. The embryo or fetus has passed out of the uterus, but the placenta remains. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

C FIGURE 151 (continued) Types of spontaneous abortion. A, Threatened. The cervix i s not dilated, and the placenta is still attached to the uterine wall, but some bleeding occurs. B, Imminent. The placenta has separated from the uterine wall, the cervix has dilated, and the amount of bleeding has increased. C, Incomplete. The embryo or fetus has passed out of the uterus, but the placenta remains. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Spontaneous Abortion: Treatment Bed rest Abstinence from coitus D&C or suction evacuation Rh immune globulin Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Spontaneous Abortion: Nursing Care Assess the amount and appearance of any vaginal bleeding Monitor the womans vital signs and degree of discomfort Assess need for Rh immune globulin Assess fetal heart rate Assess the responses and coping of the woman and her family Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Ectopic Pregnancy: Risk Factors Tubal damage Previous pelvic or tubal surgery Endometriosis Previous ectopic pre gnancy Presence of an IUD High levels of progesterone Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Ectopic Pregnancy: Risk Factors (contd) Congenital anomalies of the tube Use of ovulation-inducing drugs Primary inferti lity Smoking Advanced maternal age Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Causes of Bleeding During First Half of Pregnancy Ectopic pregnancy

Implantation of fertilized ovum in site other than uterus Mortality rates declin ed almost 90% Initially symptoms of pregnancy Positive hCG present in blood and urine Chorionic villi grow into tube wall or implantation site Rupture and bleed ing into the abdominal cavity occurs 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Causes of Bleeding During First Half of Pregnancy (contd) Ectopic pregnancy Result is sharp unilateral pain and syncope Referred shoulder pain Lower abdomin al pain Vaginal bleeding Medical therapy: Intramuscular methotrexate if future pregnancy desired Surgical therapy: Salpingostomy or salpingectomy Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

PATHOPHYSIOLOGY ILLUSTRATED: ECTOPIC PREGNANCY Various implantation sites in ect opic pregnancy. The most common site is within the fallopian tube, hence the nam e tubal pregnancy. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Ectopic Pregnancy: Nursing Care Assess the appearance and amount of vaginal bleeding Monitor vital signs Assess the womans emotional status and coping abilities Evaluate the couples informationa l needs Provide post-operative care Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Gestational trophoblastic disease Gestational trophoblastic disease Pathologic proliferation of trophoblastic cells Includes: hydatidiform mole Invasive mole (chorioadenoma destruens) Choriocarcinoma, a for m of cancer

Initially, clinical picture similar to pregnancy Classic signs: Uterine enlargem ent greater than gestational age, vaginal bleeding 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Gestational Trophoblastic Disease: Symptoms Vaginal bleeding Anemia Passing of hydropic vesicles Uterine enlargement greater than expected for gestational age Absence of fetal heart sounds Elevated hCG Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Gestational Trophoblastic Disease: Symptoms Low levels of MSAFP Hyperemesis gravidarum Preeclampsia Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Causes of Bleeding During First Half of Pregnancy (contd) Therapy: Suction evacuation of the mole Uterine curettage for removal of placental fragments Hysterectomy for excessive bleeding Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

FIGURE 152 Hydatidiform mole. A common sign is vaginal bleeding, often brownish ( the characteristic prune juice appearance) but sometimes bright red. In this figur e, some of the hydropic vessels are being passed. This occurrence is diagnostic for hydatidiform mole. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Incompetent Cervix Associated with repeated second trimester abortions Possible causes Cervical trauma Infection Congenital cervical or uterine anomalies Increased ute rine volume (as with a multiple gestation) Diagnosis: Positive history of repeated second trimester abortions Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Treatment: Surgical Procedures Shirodkar procedure (cerclage) Modification of it by McDonald Reinforces the wea kened cervix Purse-string suture is placed in cervix Done in first trimester or early in second trimester Cesarean birth may be planned Suture may be cut at ter m and vaginal birth permitted Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

FIGURE 153 A cerclage or purse-string suture is inserted in the cervix to prevent preterm cervical dilatation and pregnancy loss. After placement the string is t ightened and secured anteriorly. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Nursing Interventions Monitor women for premature labor Monitor for premature rupture of membranes Tea ch client Signs of premature labor Signs of premature rupture of membranes Tell client to contact healthcare provider if membranes rupture or labor begins Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Hyperemesis Gravidarum Exact cause of hyperemesis is unclear Increased levels of hCG may play a role Se vere cases: Causes dehydration Fluid-electrolyte imbalance Alkalosis Metabolic acidosis Decreased urinary outpu t 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Aim of Treatment Control vomiting: Antiemetics Correct fluid and electrolyte imbalance potassium chloride Correct dehydration: Intravenous (IV) fluids Improve nutritional statat us Vitamin supplements Total parenteral nutrition 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Nursing Care Supportive Directed at maintaining a relaxed environment Maintaining oral hygien e Monitoring weight Monitoring for signs of complications Once oral feedings res ume, food needs to be attractively served Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Premature Rupture of Membranes Spontaneous rupture of membranes before labor Preterm PROM (PPROM): Rupture of m embranes before term Maternal risk of infection increases Risk of abruptio place ntae Fetal-newborn: Risk of respiratory distress syndrome Fetal sepsis, malprese ntation and prolapse of umbilical cord Increased perinatal morbidity and mortali ty Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Premature Rupture of Membranes (contd) Prevention of infection Use sterile speculum to detect amniotic fluid Limit digital vaginal examinations If maternal signs of infection evident, antibiotic therapy started immediately U pon admission to nursery: Infant assessed for sepsis, placed on antibiotic Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Premature Rupture of Membranes (contd) Absence of infection and gestation age less than 37 Hospitalization and bed rest Complete blood cell count (CBC) C-reactive protein and urinalysis Continuous or intermittent fetal monitoring Regular nonstress tes ts (NSTs) or biophysical profiles Maternal vital signs assessed every 4 hours Re gular laboratory evaluations 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Premature Rupture of Membranes (contd) Absence of infection /gestation age less than 37weeks Fetal lung maturity studies Maternal corticosteroid administration Bed rest with bathroom privileges Monitor temperature and pulse every 4 hours Keep fetal move ment chart and have weekly NST Call healthcare provider for signs of complicatio ns 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 If sent home: Discharge instructions Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Preterm Labor Labor that occurs between 20 and 37 weeks gestation Documented uterine contracti ons (4 in 20 minutes or 8 in 1 hour) Documented cervical change Cervical dilatat ion of greater than 1 cm Cervical effacement of 80% or more Chart page 347 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

TABLE 151 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler Risk Factors for Spontaneous Preterm Labor. 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

TABLE 152 Self-Care Measures to Prevent Preterm Labor. 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Preterm Labor (contd) Management Assessment of cervicovaginal fibronectin Assessment of cervical length via ultra sound Obtaining history of previous preterm birth Assess for the presence of inf ections Educating clients about preterm labor Assessing for early signs and symp toms Maternal laboratory studies 2007 by Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Preterm Labor (contd) Management IV infusion: Promotes maternal hydration Tocolysis: Medications used to stop lab or -adrenergic agonists and magnesium sulfate Prostaglandin synthetase inhi itor s Calcium channel lockers 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Tocolytics

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Preterm La or (contd) Nursing management Identify woman at risk Assess the progress of la or Administration of medication s Teach how to recognize onset of la or Provide information a out community reso urces Assess impact of la or on mother and fetus Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Signs and Symptoms of Preterm La or Uterine contractions occurring every 10 minutes or less Mild menstrual-like cram ps felt low in the ad omen Constant or intermittent feeling of pelvic pressure R upture of mem ranes Low, dull ackache, which may e constant or intermittent Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Signs and Symptoms of Preterm La or (contd) A change in vaginal discharge A dominal cramping with or without diarrhea Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Classification and Pathophysiology Classification Gestational (or transient) hypertension Preeclampsia-eclampsia Chronic hypertens ion Chronic hypertension with superimposed preeclampsia or eclampsia Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Preeclampsia-eclampsia Definition

Blood pressure of 140/90 or higher on two occasions at least 6 hours apart accom panied y proteinuria Signs of impending eclampsia include: Scotomata, lurred vision, epigastric pain, vomiting, persistent or severe heada che, neurologic hyperactivity, pulmonary edema, or cyanosis 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Characteristics of Preeclampsia Maternal vasospasm Decreased perfusion to virtually all organs Decrease in plasm a volume Activation of the coagulation cascade Alterations in glomerular capilla ry endothelium Edema Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

PATHOPHYSIOLOGY ILLUSTRATED: PRECLAMPSIA A, In a normal pregnancy, the passive q uality of the spiral arteries permits increased lood flow to the placenta. B, I n preclampsia vasoconstriction of the myometrial se ment of the spiral arteries occurs. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Maternal Risks Hyperreflexia and headache Seizures, renal failure and a ruptio placentae Dissem inated intravascular coagulation (DIC) Ruptured liver and pulmonary em olism HEL LP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Fetal-Neonatal Risks Small for gestational age (SGA) Premature Hypermagnesemia (Magnesium sulfate adm inistration to mother) Increased mor idity and mortality Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Clinical Manifestations and Diagnosis Mild preeclampsia BP 140/90 mm Hg or higher 1+ proteinuria may occur Liver enzymes may e elevated minimally Edema may e present BP 160/110 mm Hg or higher measurements, 6 hours apart 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Severe preeclampsia Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Clinical Manifestations and Diagnosis Severe preeclampsia Proteinuria 5 g in a 24-hour urine collection Dipstick urine protein 31 to 41 on 2 random samples Samples must e o tained at least 4 hours apart Visual or cere ral distur ances Grand mal convulsion May occur antepartum, intrapartum, or pos tpartum Eclampsia Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Management Home care of mild preeclampsia Client monitors her lood pressure Measures weight and tests urine protein daily Remote NSTs performed daily or i-weekly Advised to report signs of worsening p reeclampsia Bed rest and moderate to high protein diet Fetal evaluation 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Hospital care of mild preeclampsia Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Management (contd) Severe preeclampsia Bed rest Diet: High-protein, moderate-sodium Anticonvulsants: Magnesium sulfate Fluid and electrolyte replacement Corticosteroids and antihypertensive drugs Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Management (contd) Eclampsia Anticonvulsants: Bolus of magnesium sulfate Sedation and other anticonvulsants: Dilantin Diuretics to treat pulmonary edema Furosemide (Lasix) Digitalis: For ci rculatory failure Strict monitoring of intake and output Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Management (contd) Nursing care

Monitor vital signs and auscultate lungs Evaluate fetal heart rate patterns Moni tor urinary output and urine protein hourly Check specific gravity of the urine hourly Weigh the woman daily at the same time Assess deep tendon reflexes and cl onus 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

TABLE 153 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler Deep Tendon Reflex Rating Scale 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

FIGURE 154 To elicit clonus, with the knee flexed and the leg supported, sharply dorsiflex the foot, hold it momentarily, and then release it. Normally the foot returns to its usual position of plantar flexion. Clonus is present if the foot j erks or taps against the examiners hand. If so, the num er of taps or eats of clo nus is recorded. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

HELLP Hemolysis, elevated liver enzymes, and low platelet Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Chronic Hypertensive Disease Chronic hypertension exists when the lood pressure is 140/90mm Hg or higher ef ore pregnancy or efore the 20th week of gestation, or when hypertension persist s 42 days following child irth. Gestational hypertenison- occurs midpregnancy wi thout proteinuria Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Exposure of lood to procoagulants Formation of fi rin in the circulation Fi rin olysis Depletion of clotting factors End-organ damage 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

DIC Definition Disseminated intravascular coagulation (DIC) is a systemic process producing h throm osis an hemorrhage. It involves

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Rh Alloimmunization: Causes Rh-negative woman carries an Rh-positive fetus Fetal red lood cells cross into maternal circulation Response: Production of Rh anti odies Transfer of RBCs usua lly occurs at irth The first child is not affected Su sequent pregnancy Rh anti odies enter the fetal circulation Result: Hemolysis of fetal red lood c ells and fetal anemia 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

A FIGURE 155 Rh alloimmunization sequence. A, Rh-positive father and Rh-negative mo ther. B, Pregnancy with Rh-positive fetus. Some Rh-positive lood enters the mot hers loodstream. C, As the placenta separates, the mother is further exposed to the Rh-positive lood. D, Anti-Rh-positive anti odies (triangles) are formed. E, In su sequent pregnancies with an Rh-positive fetus, Rh-positive red lood cell s are attacked y the anti-Rh-positive maternal anti odies, causing hemolysis of the red lood cells in the fetus. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

B FIGURE 155 (continued) Rh alloimmunization sequence. A, Rh-positive father and Rh negative mother. B, Pregnancy with Rh-positive fetus. Some Rh-positive lood ent ers the mothers loodstream. C, As the placenta separates, the mother is further exposed to the Rhpositive lood. D, Anti-Rh-positive anti odies (triangles) are formed. E, In su sequent pregnancies with an Rh-positive fetus, Rh-positive red lood cells are attacked y the anti-Rhpositive maternal anti odies, causing hem olysis of the red lood cells in the fetus. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

C FIGURE 155 (continued) Rh alloimmunization sequence. A, Rh-positive father and Rh negative mother. B, Pregnancy with Rh-positive fetus. Some Rh-positive lood ent ers the mothers loodstream. C, As the placenta separates, the mother is further exposed to the Rhpositive lood. D, Anti-Rh-positive anti odies (triangles) are formed. E, In su sequent pregnancies with an Rh-positive fetus, Rh-positive red lood cells are attacked y the anti-Rhpositive maternal anti odies, causing hem olysis of the red lood cells in the fetus. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

D FIGURE 155 (continued) Rh alloimmunization sequence. A, Rh-positive father and Rh negative mother. B, Pregnancy with Rh-positive fetus. Some Rh-positive lood ent ers the mothers loodstream. C, As the placenta separates, the mother is further exposed to the Rhpositive lood. D, Anti-Rh-positive anti odies (triangles) are formed. E, In su sequent pregnancies with an Rh-positive fetus, Rh-positive red lood cells are attacked y the anti-Rhpositive maternal anti odies, causing hem olysis of the red lood cells in the fetus. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

E FIGURE 155 (continued) Rh alloimmunization sequence. A, Rh-positive father and Rh negative mother. B, Pregnancy with Rh-positive fetus. Some Rh-positive lood ent ers the mothers loodstream. C, As the placenta separates, the mother is further exposed to the Rhpositive lood. D, Anti-Rh-positive anti odies (triangles) are formed. E, In su sequent pregnancies with an Rh-positive fetus, Rh-positive red lood cells are attacked y the anti-Rhpositive maternal anti odies, causing hem olysis of the red lood cells in the fetus. Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Rh Alloimmunization: Fetal and Neonatal Risks Anemia Hemolytic syndrome Erythro lastosis fetalis Marked fetal edema, called hydrops fetalis Congestive heart failure Marked jaund ice Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Rh Alloimmunization: Prevention Screen for Rh incompati ility and sensitization Take a history Identify Rh-negative woman Anti ody screen (indirect Coom s test) Identifies if woman is sensitized Give injection of 300 mcg Rh immune glo ulin Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Rh Alloimmunization: Prevention (contd) Give Rh immune glo ulin in the following cases Pregnant Rh-women who have no anti ody titer At 28 weeks gestational age Mother w hose a ys father is Rh positive or unknown After each a ortion and within 72 hou rs postpartum Amniocentesis and placenta previa Invasive procedures that may cau se leeding Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

TABLE 154 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler Rh Alloimmunization 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

ABO Incompati ility Cause: Mother has type O lood and infant has A, B, or AB

Anti-A and anti-B anti odies occur naturally During pregnancy maternal anti odie s cross placenta Cause hemolysis of the fetal red lood cells Unlike Rh incompat i ility, first infant is often involved, no evidence of repeated sensitization, no antepartal treatment 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

ABO Incompati ility (contd) Creates hyper iliru inemia in the infant Hyper iliru inemia is treated with phot otherapy Assess for potential for ABO incompati ility - type O mother and type A or B father Following irth New orn assessed carefully Asses for development of hyper iliru inemia Unlike Rh incompati ility, it cannot e prevented Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Effects of Surgical Procedures First trimester surgery: Increase incidence of a ortion Increased incidence of f etal mortality Low- irth-weight (less than 2500 g) infants Increased incidence o f preterm la or Increased incidence of intrauterine growth restriction Ina ility to perform some diagnostic procedures (x-ray) - may hinder diagnosis of disease during pregnancy Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Special Considerations Surgery during early second trimester decreases risk of complication During surg ery, wedge placed under mothers hip prevents uterine compression of major lood v essels Insertion of nasogastric tu e to decrease vomiting An indwelling catheter Prevents ladder distension Facilitates monitoring of output 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Special Considerations (contd) Fetal heart rate must e monitored electronically during and after surgery Posto peratively Encourage to turn, reathe deeply, and cough Encourage use of ventilation therap y Early am ulation to prevent complications Discharge teaching is very important Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Impact of Trauma During Pregnancy Types of trauma Blunt trauma Penetrating injuries Gunshot wounds Falls Direct assaults Maternal shock Premature la or or spontaneous a ortion 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Causes: Motor vehicle accident - most common Impact Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Impact of Trauma During Pregnancy (contd) Maternal mortality: From head trauma or hemorrhage Uterine rupture is rare Placental a ruption High rate of fetal mortality Prematu re irth Traumatic separation of the placenta Early rupture of mem ranes Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Treatment Major injuries

Life-saving measures for woman Esta lishing an airway Control external leeding Administer IV fluid to alleviate shock Kept on her left side to prevent further hypotension Oxygen is administered at 100% Exploratory surgery may e necessary 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Treatment (contd) Fetus near term and uterus damaged: Cesarean section Fetus immature Uterus can

Evaluation of fetal heart rate and movement Minor injuries

Fetal monitoring for minimum of 4 hours Signs of o stetric complications such as uterine leeding Monitoring for 24 hours is recommended 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

e repaired Pregnancy continue to term

Physical A use During Pregnancy Incidence: 4% to 8% May result in loss of pregnancy Preterm la or, low- irth-wei ght infants, and fetal death A used women have higher rates of complications Anemia, infection, and low weight gain First- and second-trimester leeding 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Be alert for non-specific signs Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Physical A use During Pregnancy (contd) Management: Early detection Ask a out a use at several prenatal visits Client ma y only disclose a use after knowing her caregivers Assess old scars on parts of the ody Be alert for signs of ruising: Target areas of violence during pregnan cy Clients reasts A domen or genitalia 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Treatment Create an accepting, nonjudgmental environment Allow client to express her conce rns She needs to e aware of community resources Emergency shelters Police, legal, and social services Counseling Client has to make decision to seek assistance Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Prenatal Infections Toxoplasmosis: Protozoan toxoplasma gondii Transmission Eating raw or undercooked meat Contact with the feces of infected cats Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Prenatal Infections (contd) Fetal-neonatal risks Fetal infection Severe fetal disease or death Severe neonatal disorders Treatment Sulfadiazine and pyrimethamine Given after the first trimester Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458

Prenatal Infections (contd) Ru ella: Virus Transmission: Across placenta to fetus Fetal neonatal infection Infant should e isolated Ru ella syndrome Vaccination of all children Vaccination of women of reproductive age 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Treatment: Prevention Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Prenatal Infections (contd) Cytomegalovirus: Virus Transmission Across placenta to fetus Cervical route during

Fetal infection Fetal death Neonatal disorders Treatment: Currently none exist Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

irth

Prenatal Infections (contd) Herpes simplex virus: HSV-1 or HSV-2 Transmission: Ascending infection during i rth After mem ranes rupture Transplacental: Rare Neonatal infection Treatment: Antiviral therapy (acyclovir) Active herpes lesion : Cesarean section No evidence of genital infection exists, vaginal irth is pre ferred Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58

Prenatal Infections (contd) Group B streptococcal infection (GBS) - acterial infection Transmission: Vertic al from mother during irth From colonized nursing personnel From colonized infants Neonatal infection treated with anti iotics Prevention Early identification Anti iotic prophylaxis 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Je rsey 07458 Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler

Prenatal Infections (contd) Other Infections Urinary tract infections Vaginal infections Sexually transmitted infections Maternal infections may cause spontaneous a ortions. Some evidence links infecti on and prematurity Risk of maternal and fetal mor idity and mortality Early diag nosis and treatment is necessary Maternal & Child Nursing Care, 2/e By London / Ladewig / Ball / Bindler 2007 y Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, New Jersey 074 58