high risk pregnancy pdf notes | Summaries Nursing

Maternal & Child Health Nursing

NCM - 109

Judith Manuel

NCM 109(DME)

High Risk pregnancy

Goals of Prenatal Care

The major goal of prenatal care is to help ensure the birth

of a healthy baby while minimizing risk to the mother

The components involve in achieving this objective

1. Early, accurate determination of gestational age

2. 2 identification of pregnancies at increased risk for

maternal or fetal morbidity or mortality

3. Ongoing evaluation of matemal & fetal health status

4. 4 Anticipation of problems with intervention if

possible. to prevent or minimize morbidity

5. 5. Health promotion education support and shared

decision making

Risk Assessment during Pregnancy

Risk assessment is part of routine prenatal care

Risk factors are assessed systematically because each

risk factor present overall risk

High-risk pregnancies require close monitoring and

sometimes referral to perinatal center, especially if

women have complex-high risk conditions

These centers offer many specialty and subspecialty

services, provided by maternal, fetal and neonatal

specialists

High-Risk pregnancy

A high-risk pregnancy involves at least one of the

following:

1. the woman or baby is more likely to become ill

or die than usual

2. 2 Complications before and after delivery are

more likely to occur than usual

One in which the life or health of the mother or offspring

is jeopardized by a disorder coincidental with or

unique to pregnancy

For the mother, the high risk status extends (arbitrarily

through the Puerperium, that is, until 29 days after

delivery)

Post-delivery maternal complications are usually

resolved with a month of birth, but perinatal morbidity

may continue for months or years

When this happens, the support and skills of a

professional nurse are essential to a family who, in

addition to usual tasks of pregnancy, must take special

care to ensure the continuation of pregnancy and who

may be very concerned that the baby cannot be carried

to term

Categories of High-Risk Pregnancy(Assessment Tool)

1. Maternal Age and Parity factors

Age 16 years or under

Nullipara 35 or over - gestational age,pre-

eclampsia, PROM,

Multipara 40 or over -DM, anemia,

polyhydrmanios, PROM, preterm labor

Interval of 8 years or more since last pregnancy

High parity (5 or more)

Pregnancy occurring after 3 months or less after

last delivery

2. Non-marital pregnancy

3. Maternal disease

A. PIH, Hypertension, kidney disease

Pre-eclampsia with hospitalization before labor

Eclampsia

Kidney disease -pyelonephritis, nephritis

nephrosis etc.

Chronic hypertension, severe (160/100 mmHg or

over)

Blood pressure 140/90 mmHg or above on the

readings 30 minutes apart

4. Anemia or hemorrhage

Hematocrit 30% or below pregnancy

Hemorrhage (previous pregnancy) - severe

requinng transfusion

Hemorrhage (present pregnancy)

Anemia (hgb Below 10g which treatment other

than oral preparations is required

Sickle cell trait or diseases

History of bleeding or clotting disorder at any

time

5. Fetal factors

Two or more premature deliveries (twin=one

delivery)

Two or more consecutive spontaneous abortions

One or more still birth at term

One or more gross anomalies

Rh incompatibility or ABO immunization

problems

History of previous birth detects cerebral pals.

brain damage mental retardation metabole

disorders such as pnenyiketonuna (PKU)

History of large infant over 40320

6. Paternal age, other factors

7. Dystocia (history of or anticipated)

Contracted pelvis or cephalopelvic disproportion

(GPD)

Multiple pregnancies in curreht pregnancy

Two or more breech deliveries

Previous operative deliveries e.g. cesarean or

mid-forceps delivery

History of protonged labor (more than 18 hours

in nullipara, more than 12 hours in multipara)

Previous diagnosed genital tract anomalies

(incompetent cervix, cervical or uterine

malformation, solitary ovary or tube) or problems

such as ovarian mass, endometriosis

Short stature (91.5 m 60 in. or less)

8. History of concurrent conditions

Diabetes mellitus, gestational diabetes

Hyperemesis gravidarum

Thyroid disease (hypothyroidism and

hyperthyroidism)

Malnutrition or extreme obesity (20% over ideal

weight for height; 15 % under ideal weight for

height)

Organic heart disease

Syphilis and FORCH infections

Tuberculosis or other serious pulmonary

pathologic conditions Malignant or premalignant

tumors including hydatidiform mole

Psychiatric disease or epilepsy

Mental retardation

9. Those with previous history of

Late registration

Poor clinic attendance

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NCM - 109 Judith Manuel High Risk pregnancy Goals of Prenatal Care  The^ major^ goal^ of^ prenatal^ care^ is^ to^ help^ ensure^ the^ birth of a healthy baby while minimizing risk to the mother  The^ components^ involve^ in^ achieving^ this^ objective

Early, accurate determination of gestational age
2 identification of pregnancies at increased risk for maternal or fetal morbidity or mortality
Ongoing evaluation of matemal & fetal health status
4 Anticipation of problems with intervention if possible. to prevent or minimize morbidity
1. Health promotion education support and shared decision making Risk Assessment during Pregnancy  Risk assessment is part of routine prenatal care  Risk factors are assessed systematically because each risk factor present overall risk  High-risk pregnancies require close monitoring and sometimes referral to perinatal center, especially if women have complex-high risk conditions  These centers offer many specialty and subspecialty services, provided by maternal, fetal and neonatal specialists High-Risk pregnancy  (^) A high-risk pregnancy involves at least one of the following:
the woman or baby is more likely to become ill or die than usual
2 Complications before and after delivery are more likely to occur than usual  (^) One in which the life or health of the mother or offspring is jeopardized by a disorder coincidental with or unique to pregnancy  For^ the^ mother,^ the^ high^ risk^ status^ extends^ (arbitrarily through the Puerperium, that is, until 29 days after delivery)  Post-delivery maternal complications are usually resolved with a month of birth, but perinatal morbidity may continue for months or years  When^ this^ happens,^ the^ support^ and^ skills^ of^ a professional nurse are essential to a family who, in addition to usual tasks of pregnancy, must take special care to ensure the continuation of pregnancy and who may be very concerned that the baby cannot be carried to term Categories of High-Risk Pregnancy( Assessment Tool) 1. Maternal Age and Parity factors  Age 16 years or under  Nullipara^35 or^ over^ -^ gestational^ age,pre- eclampsia, PROM,  Multipara^40 or^ over^ -DM,^ anemia, polyhydrmanios, PROM, preterm labor  Interval^ of^8 years^ or^ more^ since^ last^ pregnancy  High parity (5 or more)  Pregnancy^ occurring^ after^3 months^ or^ less^ after last delivery **2. Non-marital pregnancy
Maternal disease** A. PIH, Hypertension, kidney disease  (^) Pre-eclampsia with hospitalization before labor  (^) Eclampsia  (^) Kidney disease -pyelonephritis, nephritis nephrosis etc.  (^) Chronic hypertension, severe (160/100 mmHg or over)  (^) Blood pressure 140/90 mmHg or above on the readings 30 minutes apart 4. Anemia or hemorrhage  Hematocrit^ 30%^ or^ below^ pregnancy  Hemorrhage^ (previous^ pregnancy)^ -^ severe requinng transfusion  Hemorrhage^ (present^ pregnancy)  Anemia^ (hgb^ Below^ 10g^ which^ treatment^ other than oral preparations is required  Sickle^ cell^ trait^ or^ diseases  History^ of^ bleeding^ or^ clotting^ disorder^ at^ any time 5. Fetal factors  Two^ or^ more^ premature^ deliveries^ (twin=one delivery)  Two^ or^ more^ consecutive^ spontaneous^ abortions  One^ or^ more^ still^ birth^ at^ term  One^ or^ more^ gross^ anomalies  Rh^ incompatibility^ or^ ABO^ immunization problems  History^ of^ previous^ birth^ detects^ cerebral^ pals. brain damage mental retardation metabole disorders such as pnenyiketonuna (PKU)  History^ of^ large^ infant^ over^40320 **6. Paternal age, other factors
Dystocia (history of or anticipated)**  Contracted^ pelvis^ or^ cephalopelvic^ disproportion (GPD)  Multiple^ pregnancies^ in^ curreht^ pregnancy  Two^ or^ more^ breech^ deliveries  Previous^ operative^ deliveries^ e.g.^ cesarean^ or mid-forceps delivery  History^ of^ protonged^ labor^ (more^ than^18 hours in nullipara, more than 12 hours in multipara)  Previous^ diagnosed^ genital^ tract^ anomalies (incompetent cervix, cervical or uterine malformation, solitary ovary or tube) or problems such as ovarian mass, endometriosis  Short^ stature^ (91.5^ m^60 in.^ or^ less)
History of concurrent conditions  Diabetes^ mellitus,^ gestational^ diabetes  Hyperemesis^ gravidarum  Thyroid^ disease^ (hypothyroidism^ and hyperthyroidism)  Malnutrition^ or^ extreme^ obesity^ (20%^ over^ ideal weight for height; 15 % under ideal weight for height)  Organic^ heart^ disease  Syphilis^ and^ FORCH^ infections  Tuberculosis^ or^ other^ serious^ pulmonary pathologic conditions Malignant or premalignant tumors including hydatidiform mole  Psychiatric^ disease^ or^ epilepsy  Mental^ retardation 9. Those with previous history of  (^) Late registration  (^) Poor clinic attendance

NCM - 109 Judith Manuel  Home situation making clinic attendance and hospitalization difficult  Mothers including minors, without farmily resources (includes desertions, adoptions, injuries, separations, family withdrawal and sole support) Nursing Diagnosis of High Risk  Anxiety^ related^ to^ guarded^ pregnancy^ outcome  Deficient fluid volume related to third trimester bleeding  Risk^ for^ infection^ related^ to^ incomplete^ miscarriage.^ Risk for ineffective tissue perfusion related to pregnancy induced hypertension  Deficient^ knowledge^ related^ to^ signs^ and^ symptoms^ of possible complications Outcome and Planning  Outcome usually focus on a short term frame  Outcomes^ should^ address^ both^ fetal^ and^ maternal^ welfare and often reflect total family welfare  Once^ a^ woman^ s^ condition^ stabilizes.^ outcome identification can then focus on long term objective  (^) Women with pregnancy complications spend a few days in the hospital for therapy and monitoring  Outcome^ Evaluation  Evaluate^ women's^ attitude^ and^ physical^ status^ at^ each health care visit to be certain she is coping with the situation and the fear and the strain she lives under until the child is born  Evaluate the ability of the family to care for an ill Infant  Examples:  (^) Client's BP is maintained with acceptable parameters  (^) Couple states they feel able to cope with anxiety associated with the pregnancy complication  (^) Client remains free of signs & symptoms (s/s) of pregnancy induced hypertension  (^) Client accurately verbalizes crucial s/s to report to the health care provider immediately Implementation  Maintaining an optimistic attitude of fetal progress is important so a woman does not begin anticipatory grieving  If pregnancy cannot be continued, be available to offer support to the family who grieves for the loss of an unborn child or loss of childbearing potential  Be certain she spends enough time with her child to see that although perhaps born before term, her infant is well or healthy  If an infant is ill at birth, be certain a mother spends time with the child as well, perhaps visiting in an intensive care BLEEDING DISORDERS OF PREGNANCY  Hemorrhage^ is^ defined^ as^ the^ rapid^ loss^ of^ more^ than 1% of body weight in blood. Rapid blood loss results in:  Inadequate^ tissue^ perfusion  Deprivation^ of^ glucose^ &^ oxygen^ in^ the^ tissues  Build^ up^ of^ waste^ products  (^) Hypovolemic shock occurs when bleeding results in blood loss amounting to 10% of blood volume or approximately 2liters of blood have been lost.  (^) Perinatal hemorrhage is hemorrhage that occurs during pregnancy, labor and delivery.  (^) Antepartum hemorrhage : refers to hemorrhage that occurs anytime during pregnancy  (^) Early antepartum hemorrhage (before 20 weeks gestalion) may be caused by abortion, ectopic pregnancy and molar pregnancy  (^) Late antepartum hemorrhage (after 20 weeks gestation) may result from placental abruption and placenta previa  (^) Intrapartum hemorrhage hemorrhage that occurs during labor and is almost commonly due to:  (^) Placental abruption  (^) Uterine rupture  (^) Uterine inversion  (^) Abnormal adhesions of the placenta  (^) CS complications  (^) Postpartum hemorrhage : is defined as blood loss greater than 500 ml, in a vaginal delivery or 1000 ml in a cesarean birth.  (^) Early postpartum hemorrhage occurs during the first 24 hours after delivery. The most common cause is uterine atony and lacerations  (^) Late postpartum hemorrhage occurs after 24 hours after delivery and most often due to retained placental fragment and subinvolution of the uterus Different Bleeding Disorders of Pregnancy  First^ trimester^ bleeding:^ Abortion^ and^ Ectopic Pregnancy  Second^ trimester^ bleeding:^ Hydalidiform^ mole^ and Incompetent Cervix  Third^ trimester^ bleeding:^ Placenta^ previa^ and^ Abruptio placenta Definition of Terms  Abortion:^ any^ interruption^ of^ pregnancy^ before^ a^ fetus^ is viable (i.e. able to survive outside of the uterus if bom at this time), that is before 20 weeks gestation or before the fetus weighs 500 gms. It is also termed as miscarriage or a premature or immature birth. Spontaneous abortion occurs in 15% to 30% of all pregnancies and arises from natural causes.  Early^ miscarriage:^ occurs^ before^16 weeks.  Late^ miscarriage :^ occurs^ between^16 weeks^ and^ 20.^ A distinction is made between early and late miscarriage because more difficulties are encountered in late miscarriage. After 12 weeks, the placental attachment is penetrating and deep so bleeding is more likely and can be profuse. With deep placental implantation, the fetus tends to be expelled as in natural childbirth before the placenta separates and uterine contractions will help to control placental bleeding as they do postpartally. Bleeding before week 6 is rarely severe  Abortus:^ a^ fetus^ that^ is^ aborted^ weighing^ less^ than^500 gms.  Occult^ Pregnancy:^ refers^ to^ those^ zygotes^ that^ were aborted before pregnancy is diagnosed or recognized  Clinical^ Pregnancy^ refers^ to^ those^ pregnancies^ that were diagnosed. Of 1000 ovulatory cycles, only 673 will result in clinical pregnancy, Approximately 15 % of all recognized pregnancies end in spontaneous abortion

NCM - 109 Judith Manuel Signs & Symptoms:  Moderate^ to^ profuse^ bleeding  Moderate^ to^ severe^ uterine^ cramping  Open^ cervix^ or^ dilatation^ of^ cervix  Rupture^ of^ membranes .^ No^ tissue^ has^ passed^ yet Management  Hospitalization  %^ D&C  Oxytocin^ after^ D&C  Sympathetic^ understanding^ and^ emotional^ support COMPLETE MISCARRIAGE  Refers^ to^ the^ spontaneous^ expulsion^ of^ the^ products^ of conception (fetus, membrane, and placenta) Signs & Symptoms:  Typically,^ the^ patient^ gives^ a^ history^ of^ vaginal bleeding, abdominal pain and passage of tissue. After the passage of tissue, the patient observed that the pain and vaginal bleeding significantly diminished  On^ examination^ on^ the^ clinic^ or^ hospital,^ the^ following is noted:  Light^ bleeding^ or^ some^ blood^ in^ the^ vaginal^ vault  No^ tenderness^ in^ the^ cervix,^ uterus^ or^ abdomen  None^ to^ mild^ uterine^ cramping  Closed^ cervix  Empty^ uterus^ on^ ultrasound Management:  Because^ the^ process^ is^ complete,^ no^ therapy^ other^ than advising the woman to report heavy bleeding INCOMPLETE MISCARRIAGE  Expulsion^ of^ the^ part^ of^ the^ conceptus^ (usually^ the^ fetus), but the membranes or placenta are retaine din the uterus. Signs & Symptoms:  Heavy^ vaginal^ bleeding  Severe^ uterine^ cramping  Open^ cervix,  Passage^ of^ tissue  UTZ^ shows^ that^ some^ products^ of^ conception^ are^ still inside the uterus Management:  The^ goal^ of^ intervention^ is^ prompt^ evacuation^ of^ the uterus to prevent hemorrhage or infection

1. D&C or Suction Curettage  (^) The uterus must be kept contracted after D&C to prevent bleeding. If bleeding occurs, first action is place patient flat and massage the uterus. Oxytocin is administered as ordered to maintain uterine contraction  (^) Inspect the fundus frequently to make sure it is well contracted  A^ danger^ of^ D&C^ is^ uterine^ perforation.^ Suspect perforation when patient complains of unusual symptoms such as shoulder pain and significant abdominal pain. Internal bleeding aybe the cause of tachycardia and hypotension in the absence of excessive vaginal bleeding

Inspect the patient's perineal pad to estimate the blood loss. A saturated perineal pad can absorb approximately 60 to 100 ml. of blood. It is more accurate to monitor blood loss by weighing perineal pad before and after use  (^) Monitor BP and pulse rate  (^) Monitor the blood studies of the patient's clotting factors. If the patient's vital signs show symptoms of shock but the bleeding per vagina is minimal and the uterus is well contracted, bleeding maybe occurring by DIC  Monitor^ I^ &^ O.^ oliguria^ is^ a^ sign^ of^ decreased^ renal perfusion which occurs with shock
Sympathetic understanding and emotional support MISSED MISCARRIAGE  Retention^ of^ all^ products^ of^ conception^ after^ the^ death^ of fetus in the uterus Signs & symptoms:  Absence^ of^ FHT  Signs^ of^ pregnancy^ disappear-^ Uterus^ fails^ to^ enlarge  .A^ serum^ or^ urine^ test^ for^ subunit^ of^ HCG^ becomes negative earlier than expected or does not double within 48-72 hours  UTZ^ showing^ no^ cardiac^ activity Management:
Depending on the age of gestation or size of condeptus, the products of conception has to be removed from the uterus to prevent DIC (Disseminated Intravascular Coagulation)
Up to 28 week gestation, missed abortion is frequently managed by inserting a 20mg dinoprostone (prostaglandin E2) suppository into the vagina q 3 to 4 h as necessary to produce contractions. The drug is not approved for use after 28 weeks. Laminaria are inserted into the cervix to cause softening and dilatation
Late missed abortion maybe completed with a 'dilute IV infusion of oxytocin which causes contraction of the uterus and delivery of the products of conception. After delivery, curettage maybe needed to remove fragments of placenta. RECURRENT PREGNANCY LOSS, (HABITUAL ABORTION)  Miscarriage/abortion^ occurring^ in^3 or^ more^ successive pregnancies Possible causes:
Defective spermatozoa or ova
Endocrine factors such as lowered levels of protein- bound iodine (PBI), butanol-extractable iodine (BEI), and globulin-bound iodine, (GBI); poor thyroid function; or luteal phase defect
Deviations of the uterus, such as septate or bicornuate uterus
Resistance to uterine artery blood flow
Chorioamnonitis or uterine infection
Autoimmune disorders such as those involving lupus anticoagulant and antiphospholipid antibodies Management:
Treating the cause
Specific treatment according to the cause of abortion include: a. Cervical cerclage: suturing of the cervix or application of cervical cerclage is performed if the cause of repeated abortion is a mechanical defect in the cervix (incompetent cervix) b. Fertility drugs: stimulate estrogen & progesterone production to create a better-nourished uterine lining which is more suitable for implantation of an embryo.

NCM - 109 Judith Manuel The drugs used include : Clomiphene, Pergonal or other injectable fertility drugs c. Aspirin or Mini-Heparin d. Luteal phase progesterone support e. Uterine abnormalities such as uterine septum, intrauterine polyps, tumors and adhesions maybe the cause of habitual abortion. Correction of these defects is done before pregnancy is attempted to ensure a normal uterine anatomy that is ideal for implantation and fetal development f. Treatment of medical illness such as SLE, DM, hypothyroidism, STD before and during pregnancy to ensure successful gestation INFECTED ABORTION  Infection^ involving^ the^ products^ of^ conception^ and^ the maternal reproductive organs

SEPTIC ABORTION  Dissemination^ of^ bacteria^ (and/or^ their^ toxins)^ into^ the maternal circulatory and organ system. The patient is acutely ill experiencing signs and symptoms of infection and of threatened or incomplete abortion. Septic abortions were often associated with induced abortions performed by untrained persons using nonsterile techniques or criminal abortions. Signs and symptoms:  Foul^ smelling^ vaginal^ discharge  Crampy,^ abdominal^ pain;^ uterus^ feels^ tender^ to^ palpation  Fever,^ chills^ and^ peritonitis  Leukocytosis^ -^^ WBC^ count  Critically^ ill^ patients^ may^ evidence^ septic^ or^ endotoxic shock with vasomotor collapse, hypothermia, hypotension, oliguria or anuria and respiratory distress Management:  Treat^ abortion  High^ dose^ of^ antibiotic^ therapy:^ penicillin^ for^ gram negative microorganisms. Clindamcin and tobramycin for gram positive microorganism  D&C^ if^ accompanied^ by^ incomplete^ abortion^ Infertility may occur after recovery due to scarring of uterus & fallopian tubes. Scarring can interfere with fertilization and proper implantation COMPLICATIONS OF ABORTION/MISCARRIAGE A. Hemorrhage : major hemorrhage is a possibility for incomplete abortion & in a woman who develops an accompanying coagulation defect (usually DIC) Management :
1. Monitor vital signs for any changes to detect possible hypovolemic shockfrom contracting
2. Flat on bed and massage uterine fundus to aid in contraction (if possible)
3. Applying pneumatic antishock garments to help maintain BP
4. D&C or suction curettage to empty uterus of materials that prevents it
5. Instruction on how much bleeding is abnormal (more than one sanitary pad per hour is excessive), color changes of blood (from dark color to color of serous fluid), unusual odor, passing of large clots
6. Explain the importance of taking oral medication (methylergonovine maleate) if prescribed, which aids in contraction B. Infection or septic abortion is often a complication of criminally induced abortion C. Disseminated intravascular coagulation (DIC) may occur if a missed abortion is retained beyond one month. This complication is common in late abortion D. Isoimmunization  Whenever^ a^ placenta^ is^ dislodged,^ either^ by^ spontaneous birth or by a D&C at any point in pregnancy, some blood from the placental villi (the fetal blood) may enter the maternal circulation. If the fetus was Rh positive and the woman is Rh negative, enough Rh- positive fetal blood may enter the maternal circulation to cause isoimmunization-the production of antibodies against  Rh-positive^ blood.^ If^ the^ woman's^ next^ child^ should^ have Rh-positive blood, these antibodies would attempt to destroy the red blood cells of this infant during the months that infant is in utero E. Powerlessness or anxiety

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