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I.

Mother (HIGH RISK


CHILDBEARING-MATERNAL)

Female Reproductive
Anatomy & Physiology
I. External reproductive organs
A. Mons pubis / mons veneris pad of fat
w/c lies over the symphysis pubis
B. Labia majora 2 folds of skin w/ fat
underneath; contain bartholins glands
(believed to secrete a yellowish mucus)
C. Labia minora 2 thin folds of delicate
tissues

Glans clitoris small, erectile


structure at the anterior junction of
the labia minora
Vestibule narrow space seen when
the labia minora is separated
Urethral meatus external opening
of the urethra

Vaginal orifice external opening of


the vagina, covered by a thin
membrane
Perineum area from the lower
border of the vaginal orifice to the
anus

II. Internal reproductive


organs
A.Vagina 3-6 inch long dilatable
canal located between the bladder &
the rectum
B. Uterus hollow pear-shaped
fibromuscular organ 3 inches long, 2
inches wide, 1 inch thick, weighing
50gms in non-pregnant woman

C. Fallopian tubes 4 inches long from


each side of the fundus; widest part
(called ampulla) spreads into
fingerlike projections.
D. Ovaries almond-shaped, dull
white sex glands near the fimbriae,
kept in places by ligaments.

1. Assessment of risk factors of


pregnancy:
a. Lack of prenatal care
b. maternal age less than 18 or older
35
c. Conception w/in 2 mos of previous
delivery
d. Fifth or subsequent delivery
e. Pre-pregnant wt 20% more or less
than normal

f. Minimal or no wt gain
g. Fetal anomaly
h. Complications of labor & delivery
i. Drug or alcohol abuse

2. Screening procedures
Prenatal Screening Procedures
In an uncomplicated pregnancy,
expect about a dozen doctor visits

First Visit
Blood tests: To check the woman's
blood group and sometimes, to check
for presence of hepatitis B virus,
which might be transmitted to the
baby.
Cervical smear test: To test for an
early cancer of the cervix (if a test
has not been performed recently).
Also called a Pap smear.

First Visit and Throughout the


Pregnancy
Blood tests: To check for anemia in
the woman, and in women with Rhnegative blood groups, to look for
the presence of Rhesus antibodies.
Urine test: To check for proteinuria,
which could indicate a urinary tract
infection or preeclampsia.

Blood and urine test: To check for


diabetes mellitus.
Blood pressure check: To screen
for hypertension, which interferes
with blood supply to the placenta
and is a sign of preeclampsia.

First Visit and After ANY


Infection
Blood tests: To screen for rubella,
which can cause defects in the baby,
and for syphilis and HIV (the AIDS
virus) which can also be passed on.

First 12 Weeks
Chorionic villus sampling: May be
performed if there is a risk of certain
genetic (inherited) disorders being
passed on.

16 to 18 Weeks
Ultrasound scanning: Is carried
out to date the pregnancy accurately
and to detect any abnormalities
present in the fetus.
Amniocentesis: Carried out on
older women and those with spina
bifida or Down's syndrome to detect
possible abnormalities in the fetus.

Blood test: In some cases, the


amount of alpha-fetoprotein in the
blood is tested to determine whether
the baby has spina bifida.
Fetoscopy and fetal blood
sampling: In some cases, these are
carried out if there is doubt about
the normality of the baby.

High-risk or overdue pregnancies


Blood and urine tests: To assess
placental function and fetus health.
Electronic fetal monitoring: To
check on the fetal heart beat.
Ultrasound scanning: Extra scans
may be recommended to assess fetal
growth and development, location of
placenta, amount of amniotic fluid.

3. Diagnostic tests and laboratory


exams
a. Alpha-fetoprotein (AFP) enzyme
blood test
- elevated levels may identify the
pregnant woman carrying a baby
with neural tube defects (spina bifida
and anencephaly)

- if the AFP is elevated for two


samples, it is followed by
ultrasonography and amniocentesis
for further confirmation done at 14
to 16 weeks gestation

b. Ultrasonography
1. high-frequency sound wave testingdiscerns multiple pregnancy,
placental location and gestational
age by measurement of bi-parietal
diameters
nursing considerations:
1. encourage fluid and refrain from
voiding before the test

c. Chorionic villi sampling (CVS):

- a specialized alternative test to


amniocentesis.
It involves removing a small amount of
tissue called the chorionic villi, which
is located on the outside of the fetal
gestational sac and will later become
the placenta.

The most common reasons a CVS is


performed:
Maternal age of 35 years or more at
expected time of delivery
An abnormal first trimester screen
result
Ultrasound finding suggesting a
higher risk for a chromosome
abnormality

Previous pregnancy or family history


of certain chromosomal or genetic
disorders
Pregnancies at risk for certain
genetic conditions
A desire to obtain accurate test
results as early as possible in
pregnancy

The CVS may be performed


transabdominally by guiding a thin
needle through the abdominal wall to
the chorionic villi, then withdrawing a
small amount of this tissue (See
picture below, A)

Occasionally, particularly if the


thickest location of the villi is in the
lower portion of the uterus, the CVS
is performed transcervically by using
a thin flexible plastic catheter (hollow
tube) which is guided through the
cervical opening, somewhat like
having a Pap smear done. This
catheter is then used to remove a
small amount of the villi. (See
picture below, B).

2. nursing considerations:
a. instruct to drink fluid so that
bladder is full
b. after test, monitor for uterine
contractions, vaginal discharge and
teach to observe for signs of
infection

Most women do not report the CVS


procedure to be very painful. It
usually takes a minute or two to
perform, and is commonly described
as feeling similar to a blood draw.
Some women experience mild
cramping afterwards or light spotting
that usually goes away within a day
or two.

d. Amniocentesis study of amniotic


fluid
Preparation:
Explain to the patient the procedure
Have consent form signed
Empty the bladder

Ultrasound to locate the placenta


Leopolds maneuvers are done
Position patient on supine, but elevate
head and shoulders to one side
The abdomen is prepped with an
antiseptic, draped and the site exposed
and infiltrated with local anesthetic

An 18-20 gauge spinal needle is


introduced either behind the fetal neck
10-20 ml of amniotic fluid is withdrawn
and placed in an opaque container
Most important nursing action: Check
the FHR before immediately after and
2 hours later

B. Risks involved:
Hemorrhage from penetration of the
placenta
Infection
Fetus can be punctured
Uterine irritation

Clinical Uses:
Genetic diagnosis

Spectrophotometer studies
Fetal maturity tests
Sex determination

e. Non-stress test (NST) based on the


principle that FHR accelerates in
response to fetal movement.
Advantages over OCT:
Does not require administration of
oxytocin
Can be done in matter of 20-40 minutes

Procedure:
Done concomitantly with external FHR
monitoring
Patient presses a button whenever she
senses fetal movement

f. Contraction stress test (CST):


- to demonstrate whether a healthy
fetus can withstand a decreased
oxygen supply during the stress of a
contraction produced by exogenous
oxytocin (pitocin) or stimulation of
nipples manually or by moist heat; if
late decelerations appear, the fetus
maybe compromised because of
uteroplacental insufficiency

1. Classification of results
a. negative: no late decelerations with
a minimum of three contractions in
10 minutes; indicates that the fetus
has good chance of surviving labor
b. positive: persistent and late
decelerations occurring with more
than half the contractions; indicates
need for considering premature
intervention

c. suspicious: late decelerations


occurring in less than half of uterine
contractions; test should be repeated
in 24 hours

2. Nursing considerations:
a. void before test
b. monitor fetal heart rate for 30
minutes before test
c. monitor ,mother after test to
observe for possible initiation of
labor
d. evaluate response to procedure

g. Biophysical profile (BPP):


- assess breathing movements, body
movements, tone, amniotic fluid
volume and FHR reactivity (NST)- a
score of 2 is assigned to each
finding, with a score of 8 to 10
indicating a healthy fetus
1. used for fetus that may have
intrauterine compromise

2. nursing considerations:
a. provide emotional support
b. evaluate response to procedure

h. Maternal assessment of fetal


activity:- need to contact physician
or nurse midwife when there are
fewer than 10fetal movements in a
12 hour period.- fewer than three
fetal movements in an 8 hour period,
or no fetal movements in the
morning
1. used to determine viability of fetus

2. nursing considerations:
a. teach how to record and report
movements

Laboratory Examination:

NORMAL HEMATOLOGIC VALUES


Nonpregnant

Pregnant

Hemoglobin (HGB)

1216 g/dl

11.515 g/dl

Hematocrit (HCT)

3648

3236.5

Red blood cells (RBC)

45.36

no change

White blood cells


(WBC)

410.6

620

NORMAL VALUES FOR RENAL


FUNCTION
Nonpregnant

Pregnant

Serum creatinine

0.61.2 mg/dl

0.530.9 mg/dl

Serum BUN

9-11 mg/dl

8-10 mg/dl

Serum uric acid

4.55.8 mg/dl

25.8 mg/dl

Urine Cr clearance

90130 mL/min

150200 mL/min

Urine uric acid

250750 mg/24 hr

Increases

Urine glucose

60115 mg/dl

Increases

NORMAL HEPATIC VALUES


Liver Enzymes

Nonpregnant

Pregnant

Alanine transaminase
(ALT)

378 U/L

Unchanged

Aspartate
aminotransferase
(AST)

370 U/L

Unchanged

Alkaline phosphatase
(ALP)

20145 ImU/ml

> up to 24 times

Lactate
dihydrogenase (LDH)

300650 U/L

Upper end of normal


to 700 U/L

I. COMPLICATIONS OF
PREGNANCY

Common Discomforts During


Pregnancy

Morning Sickness
Fatigue
Urinary Frequency
Heartburn
Constipation
Hemorrhoids
Varicosities

Backache
Insomnia
Leg cramps

Supine Hypotensive Syndrome


Vaginal discharge
Skin changes

Danger Signals of Pregnancy


any bleeding from vagina
gush of fluid from vagina
regular contractions
severe headaches

epigastric pain
vomiting that persists
change in fetal activity pattern
temperature elevation
swelling in upper body

II. GENERAL NURSING


RESPONSIBILITIES
Teach danger signals of pregnancy
early in prenatal period
Early teaching allows the client to
participate in the identification and
reporting of symptoms

Early recognition and reporting of


danger signals

Interventions are specific for the


individual risks.

Nursing Diagnosis:
Anxiety
Fluid volume deficit

Risk for infection


Ineffective tissue perfusion
Knowledge deficit

Assignment: Find the


meaning of the ff

Morning Sickness
Fatigue
Heartburn
Constipation
Hemorrhoids
Varicosities
Insomnia
Leg cramps
Supine Hypotensive Syndrome
epigastric pain