High Risk Pregnancy  Increased risk for hypovolemia, anemia, infection,

By: Alicia D. Barte, preterm labor, and preterm birth

RN, RM, MAN, EdD  Adversely affects oxygen delivery to fetus
 Fetal risks include blood loss or anemia, hypoxemia,
Healthy People 2020 hypoxia, anoxia, and preterm birth
Reduce maternal illness and complications due to
pregnancy; complications during hospitalized labor and Bleeding Disorders in Pregnancy
delivery Conditions Associated With Early Bleeding During
Reduce preterm births Pregnancy:
1. Spontaneous abortion
High-Risk Pregnancy 2. Ectopic pregnancy
 Condition that jeopardizes the mother, fetus, or both 3. Gestational trophoblastic disease
 Condition due to pregnancy or result of condition 4. Cervical insufficiency
present before pregnancy
 Higher risk of morbidity and mortality Conditions Associated With Late Bleeding During
 Risk assessment starts with first antepartal visit Pregnancy:
 Ongoing throughout the pregnancy 1. Placenta previa
2. Abruptio placentae
Introduction: 3. After 20th week of gestation
 Pregnancy including lbor d delivery itself a high risk
event Spontaneous Abortion
 The ain of risk assessment I to identify e factors that
may constitute greater than average risk to a  Cause unknown and highly variable
pregnancy  First trimester commonly due to fetal genetic
 This permits the prediction of potential adverse abnormalities
pregnancy outcomes and enables the process of  Second trimester more likely related to maternal
selecting women who may benefit from extra conditions
researches Nursing assessment
Maternal Death - (WHO) a death of a woman while  Vaginal bleeding
within 42 days termination of pregnancy irrespective of  Cramping or contractions
the duration and site o pregnancy, fro any course elated  Vital signs, pain level
to or aggravated by the pregnancy or in management  Client’s understanding
but in accidental or incidental causes.
Maternal Mortality: 10/100,000 pregnant women. Types of Spontaneous Abortion
Leading causes: hemorrhage, hypertension, infection, 1. Threatened
preeclampsia.

High Risk Pregnancy:

A. Maternal Age < 15 & > 35.
B. Parity Factors - 5 or more - great risk.
[PP hemorrhage] New preg. within 3 mos.
C. Medical-Surgical Hx - hx of previous uterine surgery
&/or uterine rupture, DM, cardiac dis, lupus, HTN, PIH,
HELLP, DIC etc. 2. Inevitable

HELLP
 A combination of the breakdown of red blood cells
(hemolysis; the H in the acronym), elevated liver
enzymes (EL), and low platelet count (LP) occurring in
pregnancy.
Pregnancy Complications
 Bleeding during pregnancy 3. Incomplete
 Hyperemesis gravidarum
 Gestational hypertension
 HELLP syndrome
 Gestational diabetes
 Pregnancy Complications
 Blood incompatibility
 Amniotic fluid imbalances
 Multiple gestation 4. Complete
 Premature rupture of membranes

Bleeding During Pregnancy

 Any bleeding in pregnancy is a medical emergency
 Maternal blood loss decreases oxygen-carrying
capacity
5. Missed
 Nursing assessment
 Clinical manifestations similar to spontaneous
abortion at 12 weeks
 Ultrasound visualization
 High HCG levels

6. Habitual Nursing management

 Preoperative preparation
Spontaneous Abortion:  Emotional support
Nursing Management  Education: treatment, serial hCG monitoring,
 Continued monitoring of vaginal bleeding prophylactic chemotherapy
 pad count; assess for passage of products of
conception Cervical Insufficiency
 pain level; medications  Premature dilation of cervix
 preparation for procedures  Cause unknown; possibly due to cervical damage
 Support: physical and emotional  Therapeutic management
 Stress that woman is not the cause of the loss  Bed rest, pelvic rest, avoidance of heavy lifting
 verbalization of feelings, grief support  Cervical cerclage
 referral to community support group
Nursing assessment
Ectopic Pregnancy  Risk factors
 Ovum implantation outside the uterus  Pink-tinged vaginal discharge or pelvic pressure
 Obstruction to or slowing passage of ovum through  Cervical shortening via transvaginal ultrasound
tube to uterus
Therapeutic management Nursing management
 Medical: drug therapy (methotrexate, prostaglandins,  Continuing surveillance; close monitoring for preterm
misoprostol, and actinomycin) labor
 Surgery if ruptured  Emotional support
 Rh immunoglobulin if woman Rh negative  Education

Nursing assessment Placenta Previa

 Hallmark sign: abdominal pain with spotting within 6 to
8 weeks after missed menses
 Laboratory and diagnostic testing: transvaginal
ultrasound, serum beta HCG; additional testing to
rule out other conditions
 Cause unknown; placenta implants over cervical os
 Classification
 Therapeutic management: dependent on bleeding,
amount of placenta over os, fetal development and
position, maternal parity, labor signs and symptoms

Nursing management Nursing assessment

 Preparation for treatment  Risk factors
 Analgesics for pain  Vaginal bleeding (painless, bright red in second or
 Medications for medical treatment third trimester, spontaneous cessation then
 Teaching about signs and symptoms of rupture recurrence)
 Surgery
 Emotional support
 Education

Gestational Trophoblastic Disease

 Two types:
1. Hydatidiform mole
2. Choriocarcinoma
 Exact cause unknown
 Therapeutic management
 Immediate evacuation of uterine contents (D&C)
 Long-term follow-up and monitoring of serial hCG Nursing management
levels  Monitoring of maternal–fetal status
 Vaginal bleeding; pad count Chronic Hypertension
 Avoidance of vaginal exams  Present prior to pregnancy or before 20 weeks
 FHR Gestational Hypertension
 Support and education: fetal movement counts,  Hypertension without proteinuria after 20 weeks
effects of prolonged bed rest (if necessary); signs and  BP returns to normal within 12 weeks postpartum
symptoms to report Preeclampsia
 Preparation for possible cesarean birth  Most common hypertensive disorder in pregnancy
 Mild or severe
Abruptio Placentae  Proteinuria after 20 weeks; Vasospasms,
 Separation of placenta leading to compromised fetal hypoperfusion, leading to the proteinuria and
blood supply edema
 Etiology unknown Eclampsia
 Classification  Onset of seizure activity in woman with preeclampsia
 Therapeutic management: assessment, control, and
restoration of blood loss; positive outcome; Nursing Management
prevention of DIC Mild preeclampsia
 Bed rest with daily BP monitoring and fetal movement
Nursing assessment counts
 Risk factors  Monitor urine for protein; daily weights
 Bleeding (dark red)  Hospitalization if home management ineffective
 Pain (knife like), uterine tenderness, contractions  IV magnesium sulfate during labor
 Fetal movement and activity (decreased) Severe preeclampsia
 FHR  May develop suddenly; BP >160/110
 Laboratory and diagnostic testing: CBC, fibrinogen  Hospitalization to stabilize, prevent seizures
levels,, type and cross-match, nonstress test,  Aggressive treatment due to threat to mother and
biophysical profile baby
 In labor, is given oxytocin and magnesium sulfate to
Nursing management prepare for birth
 Tissue perfusion: left lateral position, strict bed rest, Eclampsia
oxygen therapy, vital signs, fundal height,  Seizure management
continuous fetal monitoring  Magnesium sulfate; antihypertensive agents
 Support and education: empathy, understanding,  Delivery once seizures are controlled
explanations, possible loss of fetus, reduction of
recurrence Test Yourself Question
A woman hospitalized with severe preeclampsia is being
Question treated with hydralazine to control blood pressure.
Which of the following would the nurse expect to Which of the following would the lead the nurse to
assess in a woman with placenta previa? suspect that the client is having an adverse effect
a. Dark red vaginal bleeding associated with this drug?
b. Uterine tenderness Gastrointestinal bleeding
c. Fetal distress Blurred vision
d. Relaxed uterus Tachycardia
Sweating
Hyperemesis Gravidarum
 Severe form of nausea and vomiting HELLP (Hemolysis, Elevated Liver enzymes, Low
 Continuing past week 20 Platelet count)
 Weight loss >5% of pre-pregnancy body weight  A type of severe preeclampsia
 Dehydration, metabolic acidosis, alkalosis, and  Nursing assessment: similar to that for severe
hypokalemia preeclampsia; laboratory test results
 Therapeutic management  Nursing management: same as for severe
 Conservative (diet and lifestyle changes) preeclampsia
 Hospitalization with parenteral therapy
 (see Drug Guide 19-2) Blood Incompatibility

Nursing assessment ABO incompatibility

 Onset, duration, diet history; risk factors, weight,
associated symptoms, perception of situation
 Liver enzymes, CBC, BUN, electrolytes
 Nursing management
 Comfort and nutrition (NPO, IV fluids, hygiene, oral
care, I&O)
 Support and education: reassurance; home care
follow-up (see Teaching Guidelines 19-1)
Hypertensive Disorders in Pregnancy
 Type O mothers & fetuses with type A or B blood (less
severe than Rh incompatibility)
Rh incompatibility
 Exposure of Rh-negative mother to Rh-positive fetal
blood; sensitization & antibody production
 Risk increases with each subsequent pregnancy and
fetus with Rh-positive blood
Nursing assessment:
 Maternal blood type and Rh status; indirect Coombs
Nursing management tolerance
 RhoGAM at 28-32 weeks, and again within 72 hours 4. Gestational diabetes
PP  Classification during pregnancy
1. Pregestational diabetes
Polyhydramnios 2. Gestational
 Amniotic fluid >2,000 mL  Pathophysiology and pregnancy
 Therapeutic management and close monitoring  Fetal demands
 Removal of fluid  Role of placental hormones
 Indomethacin (decreases fluid by decreasing fetal  Changes in insulin resistance
urinary output)  Effects on mother
Nursing assessment  Effects on fetus (see Table 20-1)
 Risk factors
 Fundal height, c/o abdominal discomfort and dyspnea, Therapeutic management
difficulty palpating fetal parts or obtaining FHR  Preconception counseling
Nursing management  Blood glucose level control (HbA1C <7%)
 Ongoing assessment and monitoring; assisting with  Glycemic control
therapeutic amniocentesis  Nutritional management
 Hypoglycemic agents
Oligohydramnios  Close maternal and fetal surveillance
 Amniotic fluid <500 mL  Management during labor and birth
 Therapeutic management
 Serial monitoring; amnioinfusion and birth for fetal Test Yourself
compromise The nurse is teaching a pregnant woman with type 1
Nursing assessment diabetes about her diet during pregnancy. Which client
 Risk factors, fluid leaking from vagina statement indicates that the nurse's teaching was
Nursing management successful?
 Continuous fetal surveillance “I'll basically follow the same diet that I was following
 Assistance with amnioinfusion and monitoring of fluid before I became pregnant.”
I&O “Because I need extra protein, I'll have to increase my
 Comfort measures, position changes intake of milk and meat.”
“Pregnancy affects insulin production, so I'll need to
Multiple Gestation make adjustments in my diet.”
 Therapeutic management: serial ultrasounds, close “I'll adjust my diet and insulin based on the results of my
monitoring during labor, operative delivery (common) urine tests for glucose.”
Nursing assessment:
 Uterus larger than expected for EDB; ultrasound Diabetes Mellitus
confirmation Assessment
Nursing management:  Health history; physical examination; risk factors
 Education and support antepartally;  Screening at first prenatal visit; additional screening at
 Labor management with perinatal team on standby 24 to 28 weeks for women considered at risk
 Postpartum assessment for possible hemorrhage  Maternal surveillance: urine for protein, ketones,
nitrates, and leukocyte esterase; evaluation of renal
Premature Rupture of Membranes (PROM) — women function/trimester; eye exam in 1st trimester; HbA1c
beyond 37 weeks’ gestation q 4-6 weeks
Preterm premature rupture of the membranes (PPROM)  Fetal surveillance: ultrasound; alpha-fetoprotein
--- women less than 37 weeks’ gestation levels; biophysical profile; nonstress testing;
Treatment: dependent on gestational age; no unsterile amniocentesis
digital cervical exams until woman is in active labor;
expectant management if fetal lungs immature Nursing management (see Nursing Care Plan 20-1)
Nursing assessment: risk factors, s/s of labor, s/s of  Optimal glucose control
infection; electronic FHR monitoring, amniotic fluid  Blood glucose levels; medication therapy
characteristics (see Box 19-3); Nitrazine test, fern test,  Nutritional therapy
ultrasound  Measures during labor and birth; postpartum
 Prevention of complications
Nursing management  Client education and counseling (see Teaching
 Infection prevention Guidelines 20-1)
 Identification of uterine contractions
 Education and support Congenital and Acquired Heart Disease
 Discharge home (PPROM) if no labor within 48 hours  Congenital usually due to structural defects at birth
(see Teaching Guidelines 19-3) (see Table 20-2)
 Acquired primarily rheumatic in origin
Diabetes Mellitus  Functional classification system
 Typical classification Class I: asymptomatic; no limitation of physical activity
1. Type 1 Class II: symptomatic (dyspnea, chest pain) with
2. Type 2 increased activity
3. Impaired fasting glucose and impaired glucose Class III: symptomatic (fatigue, palpitation) with normal
activity
Class IV: symptomatic at rest or with any physical Question
activity When assessing a pregnant woman with iron deficiency
anemia, which of the following would the nurse expect to
Nursing Management find?
 Stabilization of hemodynamic status Pink mucous membranes
 Risk reduction measures: education, counseling, Increased appetite
support Fatigue
 Cardiac medications if prescribed Bradycardia
 Energy conservation; nutrition
 Fetal activity monitoring
 Signs and symptoms of cardiac decompensation Question
 Monitoring during labor After teaching a pregnant woman with iron deficiency
anemia about her prescribed iron supplement, which
Chronic Hypertension statement indicates successful teaching?
 Hypertension before pregnancy or before 20th week “I should take my iron with milk.”
of gestation or persistence >12 weeks postpartum “ I should avoid drinking orange juice.”
 Therapeutic management: preconception counseling, “I need to eat foods high in fiber.”
lifestyle changes, antihypertensive agents for “I'll call the doctor if my stool is black and tarry.”
severe hypertension; fetal movement monitoring;
serial ultrasounds Thalassemia
Nursing assessment  Two forms: alpha (minor); beta (major)
Nursing management: lifestyle changes (DASH diet);  Women with minor form: little effect on pregnancy
frequent antepartal visits; monitoring for abruptio except for mild persistent anemia
placentae, preeclampsia; daily rest periods; home BP  Women with major form: usually no pregnancy due
monitoring; close monitoring during labor and birth and to lifelong, severe hemolysis, anemia, and premature
postpartum follow-up death
 Management dependent on severity of disease
Respiratory Disorders:  Supportive care and expectant management
Sickle Cell Anemia
Asthma  Defect in hemoglobin molecule (hemoglobin S)
 Pathophysiology  Therapeutic management: dependent on status;
 Effect of normal physiologic changes of pregnancy on supportive therapy; blood transfusions for severe
respiratory system anemia, analgesics for pain, antibiotics for infection
 Therapeutic management Nursing assessment:
 Drug therapy (budesonide, albuterol, salmeterol)  signs and symptoms;
Nursing assessment  evidence of crisis
 Asthma triggers; lung auscultation Nursing management
Nursing management  Support, education, follow-up
 Client education (see Teaching Guidelines 20-2)  Labor: rest; pain management ; oxygen and IV fluids;
 Oxygen saturation monitoring during labor close FHR monitoring
 Postpartum: antiembolism stockings; family planning
Tuberculosis options
 Therapeutic management
 Medications: combination of isoniazid, rifampin, Infections
ethambutol  Cytomegalovirus
Nursing assessment  Rubella
 Risk factors; signs and symptoms of TB  Herpes simplex virus
 Screening  Hepatitis B virus
Nursing management  Varicella zoster virus
 Compliance with drug therapy  Parvovirus B19
 Education; health promotion activities  Group B streptococcus
 Transmission prevention  Toxoplasmosis (see Table 20-3)

Iron Deficiency Anemia Vulnerable Populations

 Usually due to inadequate dietary intake  Adolescents
 Therapeutic management: eliminate symptoms,  Pregnant woman over age 35
correct deficiency, replenish iron stores  Women who are positive for the human
Nursing assessment immunodeficiency virus (HIV)
 Fatigue, weakness, malaise, anorexia, susceptibility to  Women who are substance abusers
infection (frequent colds), pale mucous  Pregnant Adolescent
membranes, tachycardia, pallor Nursing assessment
 Abnormal lab results  Vision of self in future
 Low hemoglobin, low hematocrit, low serum iron,  Realistic role models; emotional support
microcytic and hypochromic cells, and low serum  Level of child development education
ferritin  Financial and resource management; work and
 educational experience  Nonjudgmental approach
 Anger and conflict resolution skills  State protection agency investigation for positive
 Knowledge of health and nutrition for self and child newborn drug screen
 Challenges of parenting role  Counseling
 Community resources  Education

Pregnant Adolescent
Nursing management
 Support
 Future planning (return to school; career or job
counseling); options for pregnancy
 Frequent evaluation of physical and emotional well-
being
 Stress management; self-care
 Education (see Box 20-4)

Woman Over Age 35

Nursing assessment
 Preconception counseling; lifestyle changes;
beginning pregnancy in optimal state of health
 Laboratory and diagnostic testing for baseline;
amniocentesis; quadruple blood test screen
Nursing management
 Promotion of healthy pregnancy; education; early and
regular prenatal care; dietary teaching; continued
surveillance

Women Who Are HIV Positive

 Impact of pregnancy and HIV: threats to self, fetus,
and newborn
 Therapeutic management: oral antiretroviral drugs
twice daily from 14 weeks until birth; IV
administration during labor; oral syrup for newborn
in 1st 6 weeks of life; decision for birthing method
Nursing assessment:
 history and physical examination;
 HIV antibody testing; testing for STIs

Nursing management
 Pretest and posttest counseling
 Education
 Support
 Preparation for labor, birth, and afterward
 Elective cesarean birth
 Compliance with antiretroviral therapy
 Family planning methods

Pregnant Woman with Substance Abuse

 Impact of pregnancy: fetal vulnerability; teratogenic
effect; addiction consequences
 Effect of common substances (see Table 20-4)
 Alcohol: FAS; FASD (see Box 20-5; Figure 20-5)
 Caffeine; nicotine
 Cocaine
 Marijuana
 Opiates and narcotics: neonatal abstinence syndrome
 Sedatives
 Methamphetamines and use of bath salts

Nursing assessment:
 history and physical examination (see Box 20-6);
 urine toxicology

Nursing management