Biologic Crisis

Davao Doctors College, Inc.
Gen. Malvar St., Davao City
WELCOME TO NCM 104
MADELINE N. GERZON, RN, MM

Clinical Instructor
MNGerzon, BSN 4L, Sept 2008

Nursing Care
Management 104
Care of the Patient with Acute

Objectives
• Identify the different conditions that
disturb pregnancy
• Identify the signs and symptoms of
problems during pregnancy
• Identify and discuss management of
conditions during pregnancy

Objectives
• Identify and plan nursing actions for

patients with problems during delivery
• Identify needs for unborn baby…
possible care
• Identify needs for high risk newborn
• Formulate nursing diagnoses

Normal Pregnancy
• 38 weeks
• Should have immunization required
• Should have ideal weight gain for
duration of pregnancy
• Should maintain healthy lifestyle
• Able to identify signs of possible
problems during pregnancy
What are we going to talk
about?

Adolescent Pregnancy Multiple Pregnancy
Delayed Pregnancy Hydramnios
Bleeding during Pregnancy Post-term Pregnancy
Abortion Isoimmunization, (Rh)
Ectopic Pregnancy Fetal Death
Hydatidiform Mole Uterine Hypofunction
Placenta Previa
Abruptio Placenta
Incompetent Cervix
PTL/PROM

Pre-existing or Newly Acquired Illness
•STD •Cardiovascular disorder

•Hematologic disorder •Endocrine disorder
•Respiratory disorder •Cancer
•Rheumatic disorder •Mental Illness
•Gastrointestinal disorder •Trauma
•Neurologic disorder
•Musculoskeletal disorder
•Cardiovascular disorder

What age are we
talking about?

Contributing Factors
• Peer pressure
∀ ↓ Self-esteem
• Lack of role models
• Gain attention
• Media
• Poverty
• Rite of passage
What to assess?
Risks (nutrition, body structure)

Fundal Height (concealment)
# of sexual partners

What to assess?
Knowledge on infant care/needs

Family unit/support system
Baseline VS/weight (PIH, etc)

Socioeconomic
•Reliance on welfare
•Cycle repeats itself
•Low knowledge how to take care
of the newborn

Maternal health
•CPD
•PIH
•Anemia
•Nutritional
∀↑ mortality
•Others
Fetal Health
•LBW, SGA, LGA
•Prematurity
•Resp complications (RDS, others)
•Cognitive deficits (bec of nut deficits
•Death

What nursing diagnosis can
you draw out?

Nursing Management
• Health Education
– Prenatal, immunization, etc
– Contraception, baby care
– Nutrition
• Maternal assessment
– LMP/EDC, anemia, fundal height
– Weight gain, LM

Nursing Management
• Fetal assessment
– FHT, LM, weight monitoring
• Referral to support unit (if necessary)
• Therapeutic communication
• Assist in physical preparation for
delivery (lamaze, exercise, etc)

• Pre-existing conditions
• Preterm labor SGA/LBW
• IUGR
• PIH Abruption
• C-section
• Uterine fibroids PP hemorrhage
• Chromosomal abnormalities – Why?

What to assess?
• Pre-existing conditions
• Fundal height
• Anxiety
• Psychosocial issues (career vs baby)

Delayed Pregnancy
What nursing diagnosis can

you formulate out of this
situation?

Nursing Management
– Delivery process, proper diet & exercise
– Discuss possible complications
– Pre-existing conditions
– Weight gain

Nursing Management
• Fetal assessment
• Referral to support unit (if necessary)
• Therapeutic communication
• Assist in physical preparation for
delivery

BLEEDING DURING
PREGNANCY

BLEEDING DURING PREGNANCY
Blood loss in excess of what is considered normal in the
Antepartum, Intrapartum and Postpartum periods
Normal blood loss

AMOUNT OF
TYPE PF DELIVERY EXPECTED BLOOD
LOSS
Vaginal Delivery 500 ml
Cesarean Section 1,000 ml
Cesarean + hysterectomy 1,500 ml

WHAT CONDITIONS
DO YOU KNOW
THAT BRING ABOUT
BLEEDING DURING
ANTEPARTUM?

ABORTION
• Naturally occurring
termination of pregnancy
before viability
• Usually before 20 wks
gestation or weight less
than 500 gm
• Danger - bleeding and
infection

ABORTION
Types
• THERAPEUTIC - purposely
terminating the pregnancy
• THREATENED - any vaginal
bleeding before 20 wks (slight
& dark brown-red in color)

ABORTION
Types
• INEVITABLE - occurs with gross
ROM, moderate bleeding,
cramping, open cervical OS, no
tissue passage
• INCOMPLETE – expulsion of parts
of conceptus, with retention of
some parts, there is heavy uterine
bleeding, cervical OS close, severe
cramping
ABORTION
Types
• COMPLETE - the cessation of
pain and bleeding after the entire
conceptus has been passed
• MISSED - occurs when the
conceptus dies but is not
expelled
• Recurrent or habitual - three or
more consecutive 1st trimester
abortion
TYPES OF SPONTANEOUS ABORTIONS

Abortion
Signs and symptoms
• Bleeding, clots, tissue
• Abdominal pain or cramps
• Dizziness, paleness, cold
clammy skin
• Anxiety, depression

NURSING
DIAGNOSIS?

Nursing Care Management
• Nursing history
• Identify symptoms
• Provide comfort measures
• Evaluate blood loss (pads-
frequency of change)
• Recognize S/S of shock (paleness,
profuse sweating, tachycardia,
hypotension)

• Monitor I & O
• Replace fluids as ordered
• Prepare for D & C as
necessary
• Provide emotional support (no
false reassurance)
• Health education

Post Abortion Education
• Bleeding, cramping in the

next 1-2 wks
• Vaginal rest for 2 wks
• Check body temp BID
• Follow-up in 2 wks
• Nutrition

Ectopic Pregnancy
Ovum implants outside the uterus

Ectopic Pregnancy
Clinical Manifestations
• Missed menses, with signs of
pregnancy
• Sharp abdominal pain (stretching
of the tube)
• Vaginal spotting
• Low abdominal stabbing pain
(tube rupture)
• hCG levels fall
• No gestational sac on US

SITES OF ECTOPIC PREGNANCY

Surgical Management of Ectopic Pregnancy

Ectopic Pregnancy
• Assess for abdominal pain,
provide measures
• Monitor VS, observe for signs
of shock
• Maintain IV for plasma
administration, blood,
antibiotics and other required
medication

Ectopic Pregnancy
• Prepare for surgery
• Give emotional support, fetal
loss
• POST-OP: VS, I&O, promote
relaxation

Hydatidiform Mole
• Abnormal development of placenta
and proliferation of trophoblastic
tissue
• Complete - only placenta, no baby,
sperm fertilized empty egg
• Associated with choriocarcinoma
• Partial – two sperm fertilized an
egg

Risk factors
• Age > 40 yrs
• Previous miscarriages or ectopic pregnancy
• Mexico, Phillippines, Southeast Asia
Incidence
• 80% non-aggressive
• 15% aggressive
• 2% cancerous

Hydatidiform Mole
Signs and Symptoms
• 1st trime vaginal bleeding, anemia
• +/- passage of grapelike vesicles
(12 wks)
• Exagge pregnancy signs – hyperemesis,
inc uterine size, cramps
• No FHT
• Increased N/V
• Early PIH, Thyrotoxicosis

Hydatidiform Mole
Signs and symptoms
• Abnormally high Hcg levels
• Brownish vaginal discharge
• Uterine enlargement may be greater
than expected
• Diagnosed with transvaginal
ultrasound, Hcg (quantitative)
testing

“Molar” Pregnancy

Treatment of H. Mole
• D and C or D and E; microscopic
examination
• Serum Hcg and pelvic exam q 2 wks X 3
months, then q 1 months for up to 1 year
• Advised not to conceive for 1 year,
contraception provided

Treatment of H. Mole
• CXR q 4-6 weeks to r/o metastasis
• With no increased Hcg for 1 year, low risk of
recurrence or choriocarcinoma
• Persistent GTD 100% curable
• Methotrexate agent used for carcinoma

Hydatidiform Mole

• Assess for abdominal pain and

provide measures
• Maintain IV for plasma administration,
blood, antibiotics and other required
medication
• Give emotional support

EMPHASIZE
• Avoid pregnancy for 1 year
• Need for 1 year follow-up/monitoring
(HCG)
• Examination=detect choriocarcinoma
• Chemotherapy if indicated

Placenta Previa
• Placenta is implanted in the lower

uterine segment and located over
the internal os
• Complete, partial, marginal

Placenta Previa
Signs and Symptoms
•Painless bleeding during late
pregnancy (28th wks) and delivery
•Sudden and profuse bleeding
•Anemia
•Often high fetal presentation

High risk factors Placenta Previa
->35 y. o.
-multiparity
-prior CS delivery
-smoking Causes
-Scarred/poorly vascularized
endometrium
-Curettage, delivery, CS & infection
-Placental abnormality - Large
placenta (multiple pregnancy)
-Delayed development of trophoblast
Placenta Previa
• Low lying previa – implantation on lower
rather upper portion of uterus
• Total placenta previa - the internal cervical
os is covered completely by placenta
• Partial placenta previa - the internal os is
partially covered by placenta
• Marginal placenta previa - the edge of the
placenta is at the margin of the intenal os

classification

Medical Mgmt of Placenta Previa
Mom stable, Fetus > 36 wks S&S hypovol

in mom
fetus immature
•Bedrest •Amnio to  •delivery

•no sex act lung maturity
•report •delivery
bleeding
• Complete nursing history
• Take note duration of pregnancy,
when bleeding begun
• Ask patient estimate of blood loss, if
with pain, what she did for bleeding
• NO VAGINAL EXAMS!!!

• Strict bedrest and monitor closely
• Ask whether there were prior
episodes of bleeding during
pregnancy
• Assess for hemorrhage and infection
• Ask if patient had cervical surgery

Abruption Placenta
 Premature
separation of the
placenta from the
uterine wall
 Total Abruption –
fetal death is
inevitable
 Partial Abruption –
fetus has a chance
of survival
Abruption Placenta
S/S
•Vaginal bleeding
(unless concealed)
•Abdominal pain
∀↑ U-activity
•Hemorrhage
-boardlike abd
-late deceleration
-S/S of shock
Med Mgmt of Placental Abruption
Mom stable,
↑ bleeding,
fetus immature
fetal distress
bedrest
tocolytics Emergency CS

 Maintain bed rest
 Monitor FHR and maternal VS
 Assess blood loss and abdominal
pain
 Administer blood replacement as
ordered

 Monitor I & O
 Nursing measures for shock
 Emotional support
 Prepare for emergency delivery

INTRAPARTUM PERIOD
BLEEDING

Uterine Rupture
•Separation of uterine wall
•Site of previous surgery
•With or without expulsion of the fetus

UTERINE RUPTURE
Signs and Symptoms

•Changes in FHR
•Sharp abdominal pain @ height of
contractions
•“Something tore”
•Profuse vaginal bleeding

UTERINE RUPTURE
Signs and Symptoms

•Profuse vaginal bleeding
•Sudden cessation of contractions (not
always)
•Loss of fetal station and FHR tracing
•Ease in fetal palpation
•Maternal shock

Uterine Rupture
Medical Management
•Immediate cesarean delivery with
preparation for massive hemorrhage
•Uterine repair vs hysterectomy

Uterine Rupture
Nursing Interventions
• Allay fear and anxiety
• Monitor vital signs closely (shock)
• Pre-op/post-op care
• Emotional support for family

Uterine Atony
•Failure of the uterus to contract after

delivery of the placenta
•Common cause of postpartum hemorrhage

Uterine Atony
Signs and Symptoms

•Bleeding following delivery of placenta
•“Boggy” fundus
•Missing placental parts

Uterine Atony
• Monitor vital signs

• Monitor bleeding
• Palpate character of fundus
• Icepack over fundal area

LABOR DISORDERS
•Incompetent Cervix
•PTL and PROM
•Postterm pregnancy

Incompetent Cervix
• Begins to dilate @ 2nd or 3rd trime

without uterine contractions
• Progressive cervical effacement &
dilation

Incompetent Cervix
Predisposing Factors
• When 2 or more spontaneous abortions occur
in the 2nd trimester
• Usually a result of weak, torn, or absent
sphincter muscle at cervical os

Incompetent Cervix
Causes
• Cervical trauma
• Infection
• Multiple gestation
• LEEP procedure/cone biopsy
• Late term abortion

Incompetent Cervix
Signs and Symptoms
•Cervical dilation (painless)
•Low abd pressure
•Contraction
•Bloody show, bleeding
•Urinary frequency

Incompetent Cervix
Treatment
• Bedrest
• Possible cerclage

Cerclage
Surgical suture around internal os around

week 13-15
Suture must be opened for delivery,
usually around 37 weeks
Mom must notify if SROM occurs
Risks to fetus; not 100% effective

Cerclage

• Tell client to report signs of labor

• Monitor fetal growth to term
• Continue prenatal assessment and care
• Observe for signs of labor, infection and
PROM

Premature Rupture of Membranes
• Many risk factors
• Maternal Sequelae: Abruption, amniotic
infection, post-partum infection of
endometrium
• Fetal sequelae: Respiratory distress, sepsis,
prolapsed cord
• Diagnoses; nitrazine paper, microscopic test
of amniotic fluid
• No digital examination!!!

Signs and Symptoms
– contractions
– cramps
– backache
– diarrhea
– Vaginal discharge
– ROM

• Treatment
– Tocolytics
– IV hydration
– bedrest
– steroids, if needed

• Assess fetal well-being, gestational age
• Administer antibiotics
• < 37 weeks gestation, minimal options
• > 34 weeks, assess lung maturity of fetus
• Monitor for signs and prevent premature
labor
• Provide psychological support for mother and
family

Pre-term Labor
• Onset of Labor from 20-37 weeks

• Rarely due to a single cause
• Common problem-11.6% of all births are
premature

Pre-term Labor
• Multiple causes
– Maternal renal, CV, DM, PIH, placental
problems, trauma, PROM
• Effects to fetus
– Maturational deficiencies- no body fat
– Respiratory Distress
– Poor glucose, heat regulation

Nursing Interventions/Care
• Assessment
– Thorough hx
– check bleeding
– check ROM
– BP
• Teaching
– Infection Control
– Report any leaking

Postterm Pregnancy
Signs and Symptoms
Risks
Wt loss ∀ ↑ fetal mortalit
↓ uterine size • cord compression
– Meconium in AF • mec asp
• LGA → shoulder
dystocia → CS
• episiotomy/laceration
• depression

Postterm Pregnancy
Treatment
fetal surveillance
• NST, q wk
• mom monitors fetal movement
Induction
• Pitocin (10-20U/L) @ 1-2 mU/min
every 20-60 min

Disorders of Amniotic Fluid

Polyhydramnios
Signs and Symptoms

• uterine distention
• Dyspnea Treatment
• edema of lower extr • Therapeutic
• amniocentesis

Oligohydramnios
Risks
• cord compression
• musculoskeletal
deformities Treatment
• pulmonary hypoplasia • amnioinfusion

Pregnancy Induced
Hypertension
•Pre-eclampsia
•HELLP
•Eclampsia

Pregnancy Induced Hypertension
Pre-eclampsia
•BP > 140 mmHg sys or 90 mmHg dias

•with proteinuria (> 300mg/24 h) after 20
wks gestation
•Can progress to eclampsia (seizures)

Pregnancy Induced Hypertension
Signs and Symptoms of Pre-eclampsia

•Rapid wt gain
•Edema of hands and face
•Proteinuria
•Hyperreflexic DTRs
•Headache, visual disturbances
•Epigastric pain

Treatment of Pre-eclampsia
Mild: diastolic < 100, Severe: diastolic > 110, 3+
1+ proteinuria, no H/A proteinuria, ↓ U/O, H/A, visual
disturbances
 Bedrest  Bedrest, ↓ stimuli
 ↑protein diet  Meds
 Apresoline for severe
 document fetal HTN
activity  MgSO4
 weekly NST (anticonvulsant &
antihypertensive)
 Delivery

ECLAMPSIA
Pre-eclampsia + seizures
•80% seizures prior to delivery

•Others postpartum (23 days post delivery)
•Intrapartum and postpartum seizures
Management
•Ante/intra - MgSO4 & delivery
•Postpartum - MgSO4
•MgSO4 + antihypertensive to control BP
Eclampsia
Signs and Symptoms

 facial twitching
 tonic-clonic seizures
 pulmonary edema
 circ/renal failure

Eclampsia – Complications
•Placental abruption
•Perinatal asphyxia
•Maternal hemorrhage
•CV damage
•Severe respi insufficiency
•DIC
•Perinatal death
•Maternal death
HELLP
•Variant of severe pre-eclampsia
•Characterized by:
•Hemolysis
•Elevated liver enzymes
•Low Platelet
•May not meet BP criteria for severe pre-eclampsia
•“Great masquerader”

HELLP Syndrome
Signs and Symptoms

 RUQ pain
 n/v
 edema
 ↓ plts
 ↑ liver enzymes

HELLP – Signs and Symptoms
•BP mildly elevated

•Proteinuria +/-
•Malaise almost 100%
•GI symptoms
•Frequently referred
•Frequently misdiagnosed

HELLP – Complications
•Abruption 7-20%
•Acute renal failure
•Hepatic hematoma
•Liver rupture
•Hemorrhage
•Fetal death
•Maternal death

Tx of Eclampsia/HELLP Syndrome
•Bed rest
•Meds
•MgSO4
•Valium/Phenobarb
•Hydralazine
•Steroids
•Delivery

Risk Control Strategies for PIH
 Seizure precautions
 monitor for s/s Mg toxicity (RR<12,
absent DTR’s, sweating, flushing,
confusion, ↓ B/P)
 Ca gluconate @ BS
  Mg levels

Risk Control Strategies for PIH
 IV MgSO4 (should be “Y” connected to

another primary bag)
 D/C MgSO4 for RR < 12 or absent DTR’s
  renal function (30 mL/hr)

PEGNANCY AND
CARDIOVASCULAR
DISORDERS

Heart Disease
 Affects small percentage of pregnant
women
 Manifestations
 Increasedclotting causes predisposition to
thrombosis
 If cannot meet demand leads to CHF
 Priority of care is limiting demands on heart
throughout pregnancy, labor, delivery and
postpartum period

Heart Disease
 Nursing Care for Heart Disease
 Teach self-management to patient
 Teach S/S of CHF
 Diet modification
 Teach about eliminated stress

Cardiovascular Disorders
Anemia
 Hgb levels < 10.5-11.0 g/dl in pregnancy
Signs and Symptoms

Paleness, conjunctiva
Body malaise
Easy fatigability
Less ROM

 Anemia
 Iron-deficiency
 RBCs small and pale
 Prevention – iron supplements
 Treatment – elemental iron
supplements

 Anemia
 Folic acid-deficiency
 Large, immature RBCs
 Iron-deficiency anemia may also be
present
 Prevention – folic acid supplement
 Treatment – 1mg/day supplement
over the amount of preventative
supplement
 Sickle cell disease
 Abnormal Hgb that causes erythrocytes to
become sickle-shaped during hypoxia or
acidosis
 Autosommal recessive trait
 Pregnancy may cause crisis
 Risk to fetus – occlusion of vessels leading

to preterm birth, IUGR, fetal death

Sickle Cell Disease
 Maternal Effects  Fetal Effects
 pain  IUGR/SGA
 jaundice  skeletal changes
 Pyelonephritis
 PIH/preeclampsia
 leg ulcers
 CHF

Thalasemia
 Genetictrait that causes
abnormality in one of two chains
of Hgb ,alpha or beta

 Nursing
Care for Anemias during
pregnancy
 Nutritioneducation
 Education about changes in stool
pattern and characteristics
 Taught to avoid dehydration

Thromboembolic disease
• Pulmonary embolism is one of the

leading causes of maternal death
• Thrombus-collection of platelets on
the wall of a blood vessel

Thromboembolic disease
• Embolus-thrombus that has detached
from the vessel and is flowing in the
blood
• Thrombophlebitis-a thrombus that
causes inflammation of a blood vessel
wall

Risk factors for
thromboembolic disease
• Venous stasis
• Increased blood volume
• Increased clotting times

thromboembolic disease
Assessment
• Positive Homan’s sign
• Warmth and redness of the calf
• Dyspnea, chest pain, hemoptysis and
tachycardia (pulmonary embolism)
Treatment
– IV heparin, Coumadin, bed rest

Hyperemesis gravidarum
• Excessive vomiting during pregnancy
• Can lead to dehydration, starvation,
weight loss and IUGR
• Occurs more frequently with
– Multifetal pregnancy’s
– First pregnancy’s
– Hydatiform mole

hyperemesis gravidarum
Management
• Hospitalization may be required
• IV fluids
• Vitamin & mineral supplements are given
• Strict I&O
• NPO-then gradual increase of diet & fluids

hyperemesis gravidarm
Nursing Responsibilities
• VS, I & O cc/cc
• IV fluids
• Small frequent feedings (crackers)
• Bedrest
• Emotional support

DIABETES MELLITUS
• Diabetes mellitus that
occurs during
pregnancy(GDM)
• Women who have
diabetes mellitus prior
to pregnancy are
referred to as
pregestational
diabetics (PGDM)

Diabetes mellitus
• DM is an endocrine
disorder of carbohydrate
metabolism
• Blood sugar rises
(glucose)because the
pancreas cannot produce
enough or ineffective
insulin
• Insulin is needed to draw
glucose out of the blood
and allow it to enter the
body’s cells
Diabetes mellitus
• Pancreas produce
insufficient insulin or cells
resist effect of insulin
• Cells cannot receive
glucose

DIABETES MELLITUS
• Body metabolizes protein and fat for energy
– Ketones and acid accumulate
– Person loses weight
– Person experiences fatigue and lethargy
– Fluid moves to tissues to dilute excess
glucose leading to increased thirst
resulting in tissue dehydration and
glycosuria (glucose-bearing urine)

Effect of Pregnancy on Glucose
Metabolism
• Increased resistance of cells to insulin

• Increased speed of insulin breakdown

Pregestational diabetes
• Type I (IDDM)-insulin dependant diabetes
mellitus
• Type II (NIDDM)-non insulin dependant
diabetes mellitus
• Pregnancy will affect blood sugar control
in both types

Pregestational diabetes
• Oral hypoglycemics cannot be taken
during pregnancy because of the
potential adverse effects on the fetus
• Insulin will need to be taken in both types
through out pregnancy

RISKS IN PGDM
• Spontaneous abortion
• Infections-urinary and vaginal
• Hydramnios
• PIH
• Ketoacidosis
• Hypoglycemia
• Macrosomia-increased fetal size

Effects of Gestational Diabetes
• Maternal Effects • Fetal Effects
– UTI – macrosomia
– hydramnios – hypoglycemia at
– PTL/PROM birth
– shoulder dystocia – RDS
– epis/lac
– CS
– HPN

Treatment of Pre-existing DM
• Team approach
• Monitor glycosylated Hgb A
• Diet: 50% carb, 20% prot, 30% fat
• Insulin TID
• Hourly glucoses during labor
• NST’s weekly (starting at 28-30 wks)
• Amnio ( lung maturity)

Predisposing factors to
GDM
• Obesity
• Chronic hypertension
• Maternal age over 25 years
• Family history of diabetes
• Previous birth of large infant
• Unexplained fetal anomaly or loss of previous
pregnancy

Signs & symptoms of GDM
• The three “P”’s
– Polyuria- excessive urination
– Polyphagia- excessive hunger
– Polydypsia- excessive thirst
– weight loss, dizziness, feeling lightheaded
when a meal is skipped
– Other signs may be rapid growth of the fetus-
LGA- large for gestational age

– PTL/PROM birth
– epis/lac
– CS
– HPN

Diagnoses of GDM
• All pregnant women
are screened for
GDM
• A glucose tolerance
test is done between
24 and 30 weeks
gestation
• Routine testing of
urine for glucose is
done at every
prenatal visit MNGerzon, BSN 4L, Sept 2008
Glucose Tolerance Test
1° GTT (24 - 28 wks) 3° GTT
drink 50g glucose, •hi carb diet X 2
if 1° BS > 140 days, then NPO after
MN
•FBS, then drink
100g glucose,
 1°, 2°, 3° BS
Gestational Diabetes is diagnosed with FBS > 105 or with 2 of the
following BS results:
1° > 190, 2° > 165, 3° > 145

– PTL/PROM birth
– epis/lac
– CS
– HPN

Management of GDM
• Diet-2200 –2400 calories
per day with 50% fiber
carbohydrates, 10-20%
protein and 20-30% fat
divided in 3 meals
• Exercise adequate
exercise enables body to
burn excess glucose

Glucose Monitoring
• Glucose monitoring- blood

sugar levels should be
under 105mg/dl fasting
and below 120mg/dl after
meals
• blood sugar should be
tested up to 4 times daily
• Urine should be tested
daily upon arising for
ketones MNGerzon, BSN 4L, Sept 2008
Medications
• Insulin is given to
women who have
pregestational
diabetes to control
blood sugar
• Some women
diagnosed with GDM
can be controlled with
diet alone

Fetal surveillance
• Prenatal fetal assessment is essential
• Tests preformed include
– Biophysical profile
– Serum alpha-fetoprotein (AFP)
– Amniocentesis
– NST- non stress test
– Frequent kick counts

Nursing diagnoses r/t GDM
• Knowledge deficit r/t metabolic disorder,

self testing, and meaning of results
• Nutritional, altered les than body
requirements r/t potential glucose
intolerance
• Injury risk for to fetus and women r/t
hyperglycemia

Nursing diagnoses r/t GDM
• Injury risk for fetus r/t uteroplacental
functioning
• Family coping ineffective, r/t woman’s
need to be hospitalized during pregnancy
• Noncompliance related to need for close
monitoring and additional prenatal visits

Diabetes: Patient Education
• Glucose monitoring
• insulin administration
– type, onset, peak, duration, times, sites,
injection technique
• diet
• s/s hypoglycemia
– tremors, pallor, cold/clammy skin
– give milk & crackers or glucagon inj
• s/s hyperglycemia
– fatigue, flushed skin, thirst, dry mouth,
– check glu, call MD for insulin order
Disseminated Intravascular
Coagulation (DIC)
• May complicate abruptio placentae
• Large clot behind placenta consumes
clotting factors which leaves mother
deficient
• Clot formation and destruction occurs at
the same time

DIC
• Mother may bleed from all orifices due to
depletion of clotting factors
• Postpartum hemorrhage may occur
• Infection likely due to damaged tissue being
susceptible to bacteria

DIC
Treatment
• 1st Choice – Immediate Cesarean
• Blood and clotting factor replacement if
necessary
• After delivery problem quickly resolves

DIC
Nursing Care
• Prepare for C-section
• Close, continuous monitoring of mother
and baby
• Observe for S/S shock
• Prepare for compromised infant
• Prepare for grieving if infant dies

MULTIFETAL GESTATION
Monozygotic (identical)
•Dyzygotic (fraternal)
Assessment
•History
•Wt gain
•Abnormal palpation
•Fundal height greater than expected
•Asynchronous FHT
Risks of Multifetal Gestation
• PIH
• GDM
• PPH
• Anemia
• UTI
• PTL
• Placenta previa
• CS

Multifetal Gestation
• Nursing Management
– Complete history
– Health education
– Compliance to prenatal check-up
– Daily activities
– Family support

RH Incompatibility
•Rh factor antigens on fetal RBC differ
from Mom’s RBC
•Mom is Rh- and fetus is Rh+
•Not problem in first pregnancy unless
exposed

RH Incompatibility
•Other pregnancies: placenta tears,

fetal blood enters mom’s circulation
•Antigen-antibody reaction in fetus
destroys fetal RBC
•Coomb’s test
•Passive immunity

Rh Incompatibility
• Rh Incompatibility
– Rh blood factor = Rh+
– No Rh blood factor in erythrocytes = Rh-
– Rh+ person can receive Rh- blood if all other
factors compatible because factor is not
present
– Rh incompatibility only occurs if the mother is
Rh- and fetus is Rh+

Rh Incompatibility
– Rh- is autosomal recessive trait – both parents
must pass on this gene to the fetus
– Rh+ is dominant gene
– Rh+ person can inherit two Rh+ genes or one
Rh+ and one Rh-
– Rh- mother does not have the factor and
therefore if her fetus does her body may respond
with antibody production as a defense
mechanism (isoimmunization)
• Typically occurs at delivery and would
therefore affect subsequent pregnancies
Rh Incompatibility
– Manifestations
• If mother produces anti-Rh antibodies no
outward manifestation
• Labs reveal increased antibody titers
• When maternal anti-Rh antibodies cross
the placenta fetal erythrocytes are
destroyed (erythroblastocis fetalis)

Rh Incompatibility
– Nursing Care
• Prevent antibody production
– Rhogam at 28 weeks and w/in 72
hours of delivery if mother Rh- and
baby Rh+
» May also be given after
amniocentesis as a precaution
» Not effective if sensitization has
already occurred

Blood Incompatibility
– Nursing Care
• If antibody production occurs fetus
is monitored carefully
– Coomb’s test
– Amniocentesis
– Percutaneous umbilical sampling test
– Intrauterine transfusion if severely
anemic

Amniocentesis

Percutaneous Blood Sampling

(Fetal) S&S Rh Incompatibility
• Hyperbilirubinemia
– jaundice
– Kernicterus (severe neuro d.o. r/t ↑ bili)
• anemia
• hepatosplenomegaly
• Hydrops fetalis

Sequence of Assessments for Rh
BloodSensitization
Test for Type & Rh Factor
Rh-positive
Rh-negative
No further testing
Indirect Coombs
- +
Repeat frequently Titer increasing
Give ↓
RhoGAM Titer not increasing
amniocentesis ( bilirubin)
↓
Elevated
continue to monitor No change
↓
↓ retest, U/S
retest prn ↓
MNGerzon, BSN 4L, Sept 2008 intrauterine transfusion or
early delivery
Management of Rh Incompatibility
Prenatal
•per algorithm
• Prevention • Postpartum
– RhoGAM at 28  direct Coomb’s
weeks – RhoGAM to mom if
(unsensitized baby is Rh+ (within
women only) 72 hrs of birth)
Infections in Pregnancy

Pregnancy with Pre-existing
Medical Conditions
• Infections
– TORCH - Devastating infections for fetus
• T – toxoplasmosis
• O – other infections
• R – rubella
• C – cytomegalovirus
• H – herpes simplex virus
Medical Conditions
• Viral Infections
– Cytomegalovirus – May be asymptomatic
in mother, but serious problem in infant
• Mental retardation
• Seizures
• Blindness
• Deafness
• Dental abnormalities
• Petechiae (blueberry muffin rash)
• No effective treatment, therapeutic abortion
may be offered if early in pregnancy

Pregnancy with Pre-existing Medical
Conditions
Rubella – mild virus with low fever and
rash, but effects on fetus can be
devastating
• Microcephaly
• Congenital cataracts
• Deafness
• Cardiac defects
• IUGR
• Treatment – Immunization prior to pregnancy

Conditions
Herpes virus (Type 1 and 2)
Type 2 affects pregnancy
• Infection in infant can be localized or
widespread, may cause death or
neurological complications

Conditions
Herpes virus (Type 1 and 2)
Type 2 affects pregnancy
• Treatment and Care – Avoid contact with
lesions, if active outbreak Cesarean
delivery

Medical Conditions
• Nonviral Infections
– Toxoplasmosis – caused by Toxoplasma

gondii, a parasite that may be in cat feces
in raw meat and transmitted through the
placenta

Medical Conditions
Toxoplasmosis
• Possible S/S in newborn
– Low birth weight
– Enlarged liver and spleen
– Jaundice
– Anemia
– Inflammation of eye structures
– Neurological damage

Conditions
• Treatment and Nursing Care
– Cook all meats thoroughly
– Wash hands after handling raw meat
– Avoid litter boxes , soil and sand
boxes
– Wash fresh fruits and veggies well

Conditions
Group B streptococcus
 leading cause of perinatal infections
 Organism found in woman’s rectum, vagina,
cervix, throat or skin
 Woman usually asymptomatic, but can be
transmitted to baby at delivery

Conditions
Group B streptococcus
• Diagnosis
– + culture of woman’s vagina or rectum at
35-37 weeks gestation
• Treatment
– Antibiotics to mother prior to delivery
– Antibiotic therapy to infant after delivery

Medical Conditions
Tuberculosis
S/S
– fatigue
– weakness
– loss of appetite and weight
– fever
– night sweats

Medical Conditions
Tuberculosis
• Treatment and Nursing Care
– Isoniazid and Rifampicin to mother for 9
months
– Infant may have preventative therapy
for 3 months

Medical Conditions
Sexually Transmitted Diseases
– Herpes
– HIV
– Syphilis
– Gonorrhea
– Chlamydia
– Trichomoniasis
– Genital Warts

Conditions
Hepatitis B
 transmitted by blood and body fluids,
can also cross placenta
• Treatment and Care – screen during
pregnancy, infants born to women who are
Hepatitis B+ should be given Hepatitis B
immune globulin (HbIG), followed by Hep B
vaccine

Medical Conditions
HIV – causative organism of AIDS,

cripples immune system
• Acquired one of three ways
– Sexual contact with infected person
– Parenteral or mucous membrane
exposure to infected body fluids

Conditions
HIV – causative organism of AIDS, cripples

immune system
• Perinatal exposure (20% - 40% chance of
infecting infant)
Transplacentally
Contact with infected maternal secretions at
birth
Breastmilk

Women at Risk for HIV/AIDS
Infection
• History of drug use, especially intravenous

• History of prostitution
• Frequent sexual intercourse with multiple
partners
• Sexual intercourse with men who have sex with
other men

Women at Risk for HIV/AIDS
Infection
• Residence in an area of the
country with high prevalence of
HIV and AIDS
• Received a blood transfusion or
blood products prior to 1985
• Having sex with someone with
any of the above risk factors

Signs of HIV Infection in Infants
• Opportunistic infections such as
PCP and interstitial lymphocytic
pneumonia
• Candida diaper rash, thrush, and
diarrhea
• Recurrent bacterial infections
• Growth failure, neurologic
problems, and developmental
delays
Antiretroviral Drug Therapy
• Nucleoside reverse transcriptase
inhibitors: zidovudine, didanosine,
salcitabine
• Nonnucleoside reverse
transcriptase inhibitors:
nevirapine, delavirdine, lovirdine
• Protease inhibitors: saquinavir,
indinivir, ritonavir, nelfinavir

AIDS
– Asymptomatic at birth
– vag candidiasis
– Candidal diaper rash
– PID
– thrush
– genital herpes
– diarrhea
– HPV
– recurrent bacterial
– PCP
infections
– FTT
Treatment:
– dev delay
ZDV (zidovudine) during PG, L&D
ZDV to neonate for 6 wks
Urinary Disorders in Pregnancy

Conditions
Urinary Tract Infections
 Common in pregnancy due to pressure
on urinary structures
 keeps bladder from emptying completely and
ureters dilate and lose motility under influence
of relaxing effects of progesterone and relaxin

Conditions
Urinary Tract Infections

 Cystitis – infection of bladder
• S/S
– Burning with urination
– Increased frequency and urgency
– May have slightly elevated temp

Medical Conditions
– Pyelonephritis – infection of kidney(s)

• S/S
– High fever
– Chills
– Flank pain
– N/V
– Treatment for UTIs
• Antibiotic therapy

Medical Conditions
– Nursing Care
• Teach to wipe front to back
• Intake adequate fluid
• Urinate before and after intercourse
• Teach S/S

Medical Conditions
• Substance Abuse – the use of illicit or

recreational drugs during pregnancy
– Treatment and Nursing Care
• Identify substance abused
• Educate on potential effects of drug
• Use nonjudgmental approach

Effects of Substances Taken
During Pregnancy
• Teratogens - a substance that produces

defects in a fetus
• Alcohol - may cause fetal alcohol syndrome
• Tobacco - retards growth and increases risk
of illness, disability, and death
• Other Substances - steroids, antibiotics,
excessive amounts of vitamins, caffeine

Medical Conditions
• Trauma During Pregnancy
– Manifestations of Battering
• May enter late to prenatal care
• May make up excuses
– Treatment and Nursing Care
• Provide for privacy
• Be nonjudgmental
• Offer resources
• Assessment of maternal and fetal well-being
Special Considerations
• Blunt Abdominal Trauma
• Penetrating Abdominal Trauma
– Stabbing injury
– Gunshot injury

Blunt Trauma
• Injuries
– Head injury most common
– Retroperitoneal hemorrhage
– Abruptio placenta
– DIC
– Uterine Rupture

Blunt Trauma
Seatbelts – 3 Points Restraints
 1/3 – ½ improperly or don’t use belts
 Unbelted is at 2.3X to give birth <48 hrs &
4.1X fetal death

Penetrating Injury
GSW’s
– Gravid uterus alter injury pattern to the mother
– If missile enter upper abdomen; increased
probability of harm (upto 100%).
– If enters below uterine fundus visceral injury
less likely (0%)

(1) Awwad JT et al: High-velocity penetrating wounds of the gravid uterus: Review of 16 years
of civil war, Obstet Gynecol 83:259, 1994.
Trauma in Pregnant Women
• Stabbing Injury
– Rare
– Morbidity 93 % - Mortality 50 %
– Many advocate exploratory laprotomy since
uterus laceration is devastating b/c of its
enlarged circulation.
MNGerzon,
(1) Meizner I, Potashnik G: Sharpnel BSN 4L,
penetration Sept 2008resulting in fetal death, Isr J
in pregnanc
Med Sci 24:431, 1988.
Pre-hospital Consideration
• Oxygen
• Shock should be anticipated
• ED should be notified early, GA >24 wks
• Transport in L lateral position (GA > 20
wks)

Effects of a High-Risk
Pregnancy on the Family
• Disruption of Roles
• Financial Difficulties
• Delayed Attachment
• Loss of Expected Birth Experience

References
• Introduction to Maternity & Pediatric Nursing; Fourth Edition,
2003; Gloria Leifer, Ma, RN; Associate Professor Obstetrics,
Pediatrics, and Trauma Nursing; Riverside Community
College; Riverside, California; Saunders

HEART DISEASE
• Pregnancy results in: increased cardiac
output, heart rate, and blood volume
• CONGENITAL HEART DISEASE
• RHEUMATIC HEART DISEASE
• these are the TWO MAJOR factors in
heart disease in pregnancy
• work load of the heart is increased

PERIODS OF DANGER
• DURING LABOR & DELIVERY-cardiac
output increases by 15%-20% and may
trigger CHF
• POSTPARTUM- decreased peripheral

resistance and pulmonary embolism are
two major problems

SIGNS OF WORSENING HEART
DISEASE
• FATIGUE
• SHORTNESS OF BREATH
• COUGHING
• WHEEZING
• WEIGHT GAIN
• EDEMA
• INABILITY TO SLEEP

IMPORTANT TEACHING
• Advise about: Activity ( get 9-10 hrs rest
daily) Diet- salt restriction, avoid
excessive wt gain
• Diuretics may be prescribed-Digoxin may
be used in severe cases
• L&D-position, pain control,pulse ox, IV
fluid control

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Davao Doctors College, Inc.

Gen. Malvar St., Davao City

WELCOME TO NCM 104

MADELINE N. GERZON, RN, MM

MNGerzon, BSN 4L, Sept 2008

Care of the Patient with Acute

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• Identify and plan nursing actions for

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•STD •Cardiovascular disorder

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Risks (nutrition, body structure)

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Knowledge on infant care/needs

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What nursing diagnosis can

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Normal blood loss

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• Bleeding, cramping in the

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• Assess for abdominal pain and

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• Placenta is implanted in the lower

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