Pediatric Nursing

Introduction to Maternity and Pediatric Nursing, Fourth Edition Chapter 5

Nursing Care of Women with Complications During Pregnancy

High Risk Pregnancy Causes Relate to the pregnancy itself Occurs because the woman has a medical condition Results from environmental hazards Arise from maternal behavior or lifestyle

Assessment of Fetal Health Nurses responsibility Preparing patient properly for test Explaining reason for test Clarifying and interpreting results in collaboration with other HCPs Providing support to patient

Doppler Ultrasound Blood Flow Assessment

Danger Signs in Pregnancy Sudden gush of fluid from vagina Vaginal bleeding Abdominal pain Persistent vomiting Epigastric pain Swelling of face and hands Severe, persistent headache

Danger Signs in Pregnancy – Cont’d Blurred vision or dizziness Chills with fever > 100.4 degrees Painful urination or reduced urine output

Pregnancy-Related Complications Hyperemesis Gravidarum Manifestations Persisitent N/V Significant weight loss Dehydration: dry tongue and mucous membranes, decreased turgor, scant concentrated urine, high hematocrit Electrolyte and acid-base imbalance Unusual stress, emotional immaturity, passivity, ambivalence

Treatment Correct electrolyte imbalances and acid-base imbalances with oral or IV fluids Antiemetic drugs Possibly parenteral nutrition Pregnancy-Related Complications

Nursing Care Focus is on teaching Avoid foods that trigger N/V Eat small, frequent meals Teach about intake and output Provide support to the mother Pregnancy-Related Complications

Bleeding Disorders of Early Pregnancy Abortion Specific care depends on whether abortion induced or spontaneous Treatment Cervical cerclage Suturing of cervix – to help maintain threatened pregnancy Counseling Administration of oxytocin to help control blood loss Rhogam given if mother Rh negative

Bleeding Disorders of Early Pregnancy Nursing Care for Abortion Physical care Documents amount of bleeding Pad count Vital signs Instruct pt. To remain NPO if actively bleeding Instructions Report increased bleeding Monitor temp every 8 hours x 3 days Take iron supplement Resume sex as prescribed by HCP Appointment with HCP at assigned date and time

Bleeding Disorders of Early Pregnancy Emotional Care for Abortion Acknowledge grief Provide for spiritual support

Bleeding Disorders of Early Pregnancy Ectopic Pregnancy Occurs when fertilized egg is implanted outside uterine cavity 95% in fallopian tube May result from Hormonal abnormalities Inflammation Infection Adhesions Congenital defects Endometriosis Use of intrauterine contraception – due to inflammation Failed tubal ligation

Bleeding Disorders of Early Pregnancy Zygote cannot survive for long May die and be reabsorbed May rupture tube creating a surgical emergency Manifestations Lower abdominal pain Light vaginal bleeding If rupture occurs Sudden, severe abdominal pain, vaginal bleeding and hypovolemic shock Referred shoulder pain

Bleeding Disorders of Early Pregnancy Treatment for Ectopic Pregnancy Test for hCG Transvaginal US Laparoscopic exam Medical treatment No action if being reabsorbed Methotrexate (if tube not ruptured) – inhibits cell division Sugery to remove pregnancy from tube or entire tube if damage is severe

Bleeding Disorders of Early Pregnancy Nursing Care for Ectopic Pregnancy Vital signs Assessment of lung and bowel sounds IV fluids Blood replacement as necessary Antibiotics Pain management NPO Indwelling catheter Bed rest Emotional support

Bleeding Disorders of Early Pregnancy Hydatidiform Mole Molar pregnancy Occurs when the chorionic villi abnormally increase and form vesicles May be complete (no fetus) or partial (only part of the placenta has vesicles) May cause Hemorrhage Clotting abnormalities Hypertension Later development of choriocarcinoma

Bleeding Disorders of Early Pregnancy Chromosome abnormalities are common May occur in women at ages of extreme reproductive life Manifestations Bleeding Rapid uterine growth Failure to detect FHR activity Signs of hyperemesis gravidarum Unusually early PIH Snowstorm pattern on US with no evidence of fetus

Bleeding Disorders of Early Pregnancy Treatment for Hydatidaform Mole Vacuum aspiration and D&C Level of hCG is tested until undetectable and levels followed for at least 1 year Women advised to delay conception until follow-up care complete Rhogam given if mother Rh negative

Bleeding Disorders of Early Pregnancy Nursing Care for Hydatididaform Mole Observe for bleeding and shock Emotional support Education on reasons to delay pregnancy Contraception education

Bleeding Disorders of Late Pregnancy Placenta Previa Placenta develops in the lower part of the uterus versus the upper part There are 3 degrees of previa Marginal – reaches within 2-3 cm of cervical opening Partial – placenta partially covers the cervical opening Complete or Total – completely covers the opening

Bleeding Disorders of Late Pregnancy A low-lying placenta is near the cervix Not a true placenta previa May or may not be accompanied by bleeding May be discovered during a routine exam

Bleeding Disorders of Late Pregnancy Manifestations of Placenta Previa Bright red, painless vaginal bleeding Risk of hemorrhage increases with nearing of labor Fetus often in abnormal presentation Fetus may have anemia Mother may be more at risk postpartum for infection and hemorrhage Vaginal organisms can easily reach placenta site Lower portion of uterus has fewer muscles resulting in weaker contractions

Bleeding Disorders of Late Pregnancy Treatment Depends on length of gestation and amount bleeding Goal is to maintain pregnancy as long as safely possible Mother encouraged to lie on side or with pelvic tilt to avoid supine hypotension Delivery by C-section if total or partial May deliver vaginally if low-lying or marginal

Bleeding Disorders of Late Pregnancy Nursing Care Observe for vaginal blood loss Observe for S/S of shock Vital signs q 15 minutes if actively bleeding and oxygen administered NO VAGINAL EXAMS Continuos fetal monitoring Prepare for Cesarean if indicated Supportive Care

Bleeding Disorders of Late Pregnancy Abruptio Placentae Permanent separation of placenta from implantation site Predisposing factors include Hypertension Cocaine or Alcohol Use Smoking Poor Nutrition Abdominal Trauma Prior History of Abruption Placentae Folate deficiency

Hypertension During Pregnancy Manifestations of Abruptio Placentae Bleeding with abdominal or low back pain Bleeding may be concealed at first Dark red vaginal bleeding when blood leaks past placenta Uterine tenderness and firm May have cramp-like contractions Fetus may or may not be in distress Fetus/Neonate may have anemia or hypovolemic shock

Hypertension During Pregnancy 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 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

Hypertension During Pregnancy Treatment 1 st Choice – Immediate Cesarean Blood and clotting factor replacement if necessary After delivery problem quickly resolves 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

Hypertension During Pregnancy Hypertension During Pregnancy High blood pressure in pregnancy (PIH) Preeclampsia PIH + proteinuria Eclampsia PIH + proteinuria + convulsions/seizures Toxemia – old terminology

Hypertension During Pregnancy Cause unknown Birth only definitive cure Usually develops after 20 th week, but research has shown that it is determined at implantation Vasospasm is main characteristic May increase risks of further complications

Hypertension During Pregnancy Risk Factors for PIH 1 st pregnancy Obesity Family history of PIH >40 years or <19 years Multifetal pregnancy Chronic hypertension Chronic renal disease Diabetes mellitus

Hypertension During Pregnancy If mild to moderate BP readings (systolic <160mm Hg and diastolic <110 mmHg) identified medications typically not used to treat Treated/Monitored with diet modification, daily weights, activity restriction, BP monitoring, fetal kick counts, frequent monitoring for proteinuria

Hypertension During Pregnancy Medication is started if BP exceeds moderate range Drugs of Choice Methyldopa (Aldomet) Labetalol Nifedipine (Procardia)

Hypertension During Pregnancy Manifestations of PIH Vasospasm impede blood flow to mother and placenta resulting in: Hypertension Typically should not occur in pregnancy due to hormonal changes which decrease resistance to blood flow Edema Occurs when fluid leaves blood vessels and enters tissues Proteinuria Develops as reduced blood flow damages kidneys

Hypertension During Pregnancy Other Manifestations of Preeclampsia CNS – HA Eyes – Visual disturbances Urinary Tract – Decrease UOP Respi9ratory – Pulmonary Edema GI and Liver – Epigastric pain and N/V, elevated liver enzymes Blood – HELLP – hemolysis, elevated liver enzymes, low platelets

Hypertension During Pregnancy Eclampsia Woman has one or more generalized seizures Facial muscles twitch, then contraction of all muscles Effects on Fetus Decreased oxygen availability which may result in fetal hypoxia Meconium IUGR Fetal Death

Hypertension During Pregnancy Treatment of PIH Prevention Management – as discussed previously Drug Therapy Magnesium Sulfate (anticonvulsant and antihypertensive) Antihypertensive Drug Therapy if BP > 160/100 mg Hg

Hypertension During Pregnancy Nursing Care Assist to obtain PNC Help cope with therapy Provide care/Monitor Administer meds Postpartum Care

Blood Incompatibility Rh and ABO 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+

Blood Incompatibility Rh- is autosomal recessive triat – both parents must pass on this gene to the fetus Rh+ is dominate 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

Blood Incompatibility Manifestations If mother produces anti-Rh anitbodies no outward manifestation Labs reveal increased antibody titers When maternal anti-Rh antibodies cross the placenta fetal erythrocytes are destroyed (erythroblastocis fetalis)

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

Pregnancy Complicated by Medical Conditions Diabetes Mellitus Preexisting (Type I or Type II with onset before pregnancy) Gestational (GDM occurs only during pregnancy)

Pregnancy Complicated by Medical Conditions Pathophysiology of DM Pancreas produces insufficient insulin or cells resist effect of insulin Cells cannot receive glucose Body metabolizes proteina 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)

Pregnancy Complicated by Medical Conditions Effect of Pregnancy on Glucose Metabolism Increased resistance of cells to insulin Increased speed of insulin breakdown Gestational Diabetes Mellitus Maternal Links to GDM Maternal Obesity (>198 lbs.) Previous macrosomic infant Maternal age > 25 years Previous unexplained stillbirth or infant with congenital anomalies] Family history of DM Fasting glucose > 135 mg/dl or postmeal > 200 mg/dl

Pregnancy Complicated by Medical Conditions Treatment of Diabetes During Pregnancy Identification Diet Modification Monitoring Ketone Monitoring PO antidiabetic agents Insulin Exercise Fetal monitoring May indicate early delivery

Pregnancy Complicated by Medical Conditions Nursing Care for Diabetes During Pregnancy Self-care/Management Emotional Support Encourage Breastfeeding

Pregnancy Complicated by Medical Conditions Heart Disease Affects small percentage of pregnant women Manifestations Increased clotting 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

Pregnancy Complicated by Medical Conditions Nursing Care for Heart Disease Teach self-management to patient Teach S/S of CHF Diet modification Teach about eliminated stress

Pregnancy Complicated by Medical Conditions Anemia Hgb levels < 10.5-11.0 g/dl in pregnancy 4 types in pregnancy Iron-deficiency RBCs small and pale Prevention – iron supplements Treatment – elemental iron supplements 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

Pregnancy Complicated by Medical Conditions Sickle cell disease Abnormal Hgb that causes erythrocytes to become sickle-shaped during hypoxia or acidosis Autosommal recessive trait Approx 1/12 African Americans has the trait Pregnancy may cause crisis Risk to fetus – occulsion of vessels leading to preterm birth, IUGR, fetal death Thalasemia Genetic trait that causes abnormality in one of two chains of Hgb ,alpha or beta

Pregnancy Complicated by Medical Conditions Nursing Care for Anemias During Pregnancy Nutrition education Education about changes in stool pattern and characteristics Taught to avoid dehydration

Pregnancy Complicated by Medical Conditions Infections TORCH - Devestating infections for fetus T – toxoplasmosis O – other infections R – rubella C – cytomegalovirus H – herpes simplex virus

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

Pregnancy Complicated by Medical Conditions Herpes virus – type 1 and type 2 – type 2 affects pregnancy Infection in infant can be localized or widespread, may cause death or neurological complications Treatment and Care – Avoid contact with lesions, if active outbreak Cesarean delivery

Pregnancy Complicated by Medical 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

Pregnancy Complicated by Medical Conditions HIV – causitive 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 Perinatal exposure (20% - 40% chance of infecting infant) Transplacentally Contact with infected maternal secretions at birth Breastmilk

Pregnancy Complicated by 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 Possible S/S in newborn Low birth weight Enlagred liver and spleen Jaundice Anemia Inflammation of eye structures Neurological damage

Pregnancy Complicated by Medical 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 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. 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

Pregnancy Complicated by Medical Conditions TB S/S fatigue weakness loss of appetite and weight Fever Night sweats Treatment and Nursing Care Isoniazid and Rifampin to mother for 9 months Infant may have preventative therapy for 3 months

Pregnancy Complicated by Medical Conditions Sexually Transmitted Diseases Prevention is by safe sex with protection of condom Herpes HIV Syphilis Gonorrhea Chamydia Trichomoniasis Genital Warts

Pregnancy Complicated by Medical Conditions Urinary Tract Infections More common in pregnancy due to pressure on urinary structures keeps bladder from emptying completely and because ureters dilate and lose motility under influence of relaxing effects of progesterone and relaxin Cystitis – infection of bladder S/S Burning with urination Increased frequency and urgency May have slightly elevated temp

Pregnancy Complicated by Medical Conditions Pyelonephritis – infection of kidney(s) S/S High fever Chills Flank pian N/V Treatment for UTIs Antibiotic therapy Nursing Care Teach to wipe front to back Intake adequate fluid Urinate before and after intercourse Teach S/S

Pregnancy Complicated by 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

Pregnancy Complicated by 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

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

Pediatric Nursing

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