UNIT I: NURSING CARE OF THE FAMILY HAVING DIFFICULTY CONCEIVING A CHILD

NUCLEUS
OUTLINE  The heart of the egg cell;
I Overview of the Structure of the Ovum and Sperm Cell  It contains most of the genetic material in the form of
A Structure and Function of the Ovum chromosomes.
B Structure and Function of the Sperm Cell  This is where the genes are situated.
i Motility
II Infertility  An egg, like a sperm, contains half the number of
A Subfertility chromosomes as a normal cell,
i Primary Subfertility o i.e. 23 each.
ii Secondary Subfertility
B Sterility CYTOPLASM
i Tubal Ligation
ii Vasectomy  A gel-like substance that holds all the cell’s other internal
III Nursing Process Overview for a Couple with Subfertility structures, called organelles.
IV Causes of Female Infertility  It is in the cytoplasm that all the cell’s activities take place
A Pelvic Inflammatory Disease (PID) to keep it alive and functioning properly.
B Polycystic Ovary Syndrome (PCOS)  Amongst the more important organelles are structures
C Endometriosis called mitochondria, which supply most of the energy for the
D Ovary Problems
E Immune System Problems
cell.
F Luteal Phase Defect
G Fibroids ZONA PELLUCIDA
H Surgical Complications  An outer membrane of the egg.
I Poor Quality Cervical Mucous
J Premature Menopause
 This structure helps the sperm to enter the egg through
V Causes of Male Infertility its hard-outer layers.
A Underdeveloped Testes
B Swollen Veins in the Scrotum CORONA RADIATA
C Undescended Testes (Cryptorchidism)
D Infections such as Gonorrhea or Tuberculosis
 Surrounds an egg
E Exposure to Metals  Consists of two or three layers of cells from the follicle.
F Certain Medications  They are attached to the zona pellucida
G Injury to Testicles  Main purpose: to supply vital proteins to the cell
H Chronic Prostate Infections
I Autoimmunity
STRUCTURE AND FUNCTIONS OF A SPERM
J Retrograde Ejaculation
K Varicocele or Varicosity  A normal sperm will have the following characteristics:
VI Diagnostic Tests for Infertility o A smooth oval head The head of the sperm
A Male measures 2.5 to 3.5 um in diameter and 4.0 to 5.5
B Female um in length (um=micrometers).
VII Unexplained Subfertility o They have a well-developed acrosome that covers
VIII Alternatives to Childbirth 40 to 70 percent of the oval shaped head.
o A slim middle section (body) that is approximately
OVERVIEW OF THE STRUCTURE OF THE OVUM the same length as the head.
AND SPERM CELL o A thinner tail section that is about 45mcm in length.

STRUCTURE AND FUNCTIONS OF AN OVUM

Figure No. 2 Structure of a Sperm Cell

SPERM HEAD
 NUCLEUS
o contains 23 chromosomes
 ACROMOSOME
o involved in the recognition of the oocyte
Figure No. 1 Structure of an Ovum o Contains:
 Hyaluronidase – corona penetrating enzyme
 Acrosin – digests the zona pellucida

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 NURSING CARE OF THE FAMILY HAVING DIFFICULTY CONCEIVING A CHILD
MIDPIECE
 Contains tightly packed mitochondria that provide the
energy requires for swimming.
 TUBAL LIGATION
CENTRIOLE
 Located between the head and the midpiece. Essential for
movement of the pronuclear for union with the female
genome
TAIL (FLAGELLUM)
 It is divided into several parts that include:
o Connecting Piece – this is the part that connects
the flagellum to the sperm head
o Midpiece – contains mitochondria and provides
energy required for movement
o Principal Piece (Axial filament)
o End piece
MOTILITY
 Two types of Physiological Motility:
o ACTIVATED MOTILITY
 The type observed in the early stages of motility
(in the epididymis as well as freshly ejaculated
sperm).
 Gentle movement of the sperm's flagella from
one side to another as the cell moves along what
may appear to be a straight path.
o HYPERACTIVATED MOTILITY
(HYPERACTIVATION)
 This type of motility occurs is in the female
reproductive tract (site of fertilization).
 Movement is more erratic and more energy is
used for movement.
 Serves to prevent the sperm cell from getting
trapped, propelling through the reproductive tract
(of the female) as well as enhancing sperm
penetration into the egg (oocyte).
INFERTILITY
 A term used to describe the inability to conceive a child
or sustain a pregnancy to birth.
 A couple is said to be infertile if they have not become
pregnant after at least 1 year of unprotected coitus.
SUBFERTILITY
 Term used rather than “infertility” because it denotes that
couple has a potential to conceive.
 Affects 8% to 12% of couples desiring children
 A lessened ability to conceive
PRIMARY SUBFERTILITY
 There have been no previous conceptions
SECONDARY SUBFERTILITY
 There has been a previous viable pregnancy but the couple
is unable to conceive at present because of a known
condition
STERILITY
 Inability to conceive due to known cause such as absence
of a uterus.
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 The inability to create offspring (children) as a result of a
procedure such as tubal ligation, hysterectomy, or
vasectomy.
 Also known as “getting your tubes tied,” is a procedure in
which a woman’s fallopian tubes are blocked or partially
removed, preventing the chance for sperm and eggs to
meet.
VASECTOMY
 Similar to a tubal ligation, but for males the tube that allows
sperm to travel out from the testicle is partially removed.
PREDISPOSING FACTORS: SUBFERTILITY
 Age often increases the risk of infertility.
 Infertility can be caused by poor sexual or lifestyle habits
that are easily remedied.
o For example: The couple may be using a sexual
lubricant that interferes with the survival of the man's
sperm.
PREDISPOSING FACTORS: INFERTILITY
 Infertility can be caused by poor sexual or lifestyle habits
that are easily remedied.
o They may not be having sex often enough.
o Heavy use of alcohol, tobacco or drugs.
o Starvation diets or anorexia in the woman.
o Tight underwear or pants in men.
 Stress:
o In a woman, this may cause her periods to be
irregular.
o In a man, stress may reduce his sperm count.
IMPACTS OF STRESS ON THE BODY
 DIGESTIVE SYSTEM
o Disturbed eating habits acid reflux
o Diarrhea or constipation
o Obesity which is linked to a host of other health
problems.
o Extreme stress can also be associated with
diabetes.
o This is because excessive cortisol can affect the
activity of insulin.
o The body can also become resistant to insulin. This
can lead to diabetes.
 CIRCULATORY PROBLEM
o Cardiovascular diseases due to stress-induced
mechanisms are mediated primarily through
increased adrenergic stimulation.
o Both adrenaline and cortisol (increased during
stress) affect heart and blood pressure.
o Too much adrenaline makes blood pressure to go up
which in turn affects the functioning of the heart since
the heart has to pump harder and faster.
o Cortisol also alters bone mineral density thus
affecting the development of new bones in the body.
 SUPPRESSION OF IMMUNE SYSTEM
o The high levels of stress hormones suppress the
release of cytokines chemicals secreted by Th cells
(T helper cells- a type of T lymphocytes).
o Cytokines regulate both cell-mediated and humoral
immune response in the body.
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 NURSING CARE OF THE FAMILY HAVING DIFFICULTY CONCEIVING A CHILD
 REPRODUCTIVE SYSTEM (MEN AND WOMEN)
o Chronic stress may decrease libido and may even
cause erectile dysfunction or impotence in man.
o Testosterone levels can drop to an extent that
can interfere spermatogenesis (sperm
production).
o In women stress can affect menstrual cycle.
 It can lead to irregular, heavier or more painful
periods.
NURSING PROCESS OVERVIEW FOR A COUPLE
WITH SUBFERTILITY
ASSESSMENT
 Require many months and many tests, all of which had the
potential to interfere with a couple’s self-image, self-
esteem, and lifestyle.
 Today, a subfertility investigation is usually limited to
only three assessments:
o Semen Analysis
o Ovulation Monitoring
o Tubal Patency
 Even with this more directed approach to evaluation, a
nursing assessment often reveals that one or both partners
feel inadequate or angry and frustrated by what has
happened to them and their need to undergo testing.
NURSING DIAGNOSIS
 Focus on psychosocial issues associated with the inability
to conceive and the potentially nerve-wracking process of
fertility testing and management.
o Fear related to possible outcome of subfertility
studies
o Situational low self-esteem related to the apparent
inability to conceive
o Anxiety related to what the process of fertility testing
will entail
o Deficient knowledge related to measures to promote
fertility
o Anticipatory grieving related to failure to conceive or
sustain a pregnancy
o Powerlessness related to repeated unsuccessful
attempts at achieving conception
o Hopelessness related to perception of no viable
alternatives to usual conception
o If required tests interfere with a couple’s relationship
(including sexual patterns), “sexual dysfunction
related to command performance of subfertility
therapy” might be applicable.
EXPECTED OUTCOMES AND PLANNING
 In establishing expected outcomes with a couple
undergoing fertility testing and counseling, be certain the
couple realizes even after the reason for their subfertility is
identified, fertility may not be instantaneous.
 In some instances, a couple may need to change or modify
their goals if tests begin to show what they first wanted—to
have a child without medical intervention—is impossible.
 Participation in a support group may allow a couple to work
through the stress fertility testing places on their lives.
IMPLEMENTATION
 Fertility testing can be costly for a couple because not all
health insurance programs provide reimbursement for
these procedures.
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o Be certain couples are informed beforehand of
specific estimates of the cost of testing or therapy so
they can budget and plan their resources and the
next steps they want taken.
 It also may help provide them with time for sharing
experiences and increasing intimacy, helping to
compensate for any decreased enjoyment that comes from
“scheduled” sexual relations.
 Throughout testing, couples need thorough education
about the various procedures being done.
 Make sure to review any specific instructions about pre-
procedural and post-procedural care.
o Depending on their motivations, a couple’s reaction
to study results may vary from relief, to stoic
acceptance, to grief for children never to be born.
o Each partner may wonder whether the other will be
able to continue the relationship if he or she turns out
to be the subfertile one.
OUTCOME EVALUATION
 Examples of expected outcomes in this area include:
o The patient rearranges work plans to manage the
schedule of fertility testing by 1month’s time.
o The couple verbalizes they understand their
individual subfertility problem after preliminary
testing.
o The couple demonstrates a high level of self-esteem
after fertility studies, even in the face of disappointing
study outcomes.
o For a couple with the problem of subfertility, an
evaluation is best if it is ongoing because, as
circumstances around them change, so may their
goals and desires.
o Until they can accept an alternative method of having
children—adoption or an assisted reproductive
technique such as alternative insemination
(deposition of sperm into a woman’s cervix or uterus)
or in vitro fertilization (IVF; the union of sperm and
ovum under laboratory conditions)—former plans to
have children have been crushed.
o Continuing or future evaluations are also important
because a couple who decides at age 20 years to
choose child-free living may change their minds at a
later date.
o In the same way, a couple who chooses an assisted
reproductive technique may decide after a number of
unsuccessful attempts that they are no longer
interested in this method of conception.
o Keeping the evaluation as an ongoing process
allows such plans to be modified as necessary.
CAUSES OF FEMALE INFERTILITY
PELVIC INFLAMMATORY DISEASE (PID)
 May also develop from bacteria that reach the reproductive
organs through abortion, hysterectomy, childbirth, sexual
intercourse, use of an intrauterine (IUD) contraceptive
device or a ruptured appendix.
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POLYCYSTIC OVARY SYNDROME (PCOS) Table No. 1 Production of Hormones per Phase
 Symptoms: Phase FSH (IU/L) LH (IU/L)
o Excessive facial hair Early Follicular 3-10 2-8
o Thinning hair Mid-cycle Peak 4-25 10-75
o Acne Phase Estradiol (pmol/L)
o Depression Early Follicular 300 picomole/liter
o Unexplained weight gain Ovulatory Stage 500-3000
o Irregular or no periods Luteal Surge 100-1400
o High insulin or cholesterol readings Progesterone (nanomole/liter)
 The exact cause of PCOS isn't known.
0-6 nmol/L Ovulation unlikely
FACTORS THAT MIGHT PLAY A ROLE INCLUDE: 7-25 nmol/L Ovulation possible
 In PCOS, the ovaries produce high amounts of male > 25 nmol/L Ovulation likely
hormones, especially testosterone resulting in hirsutism
and acne.  Problems within the ovaries may inhibit reproduction as
 LH levels also remain abnormally high while FSH levels well. Instead of releasing an egg, the ovarian follicle
are abnormally low; Thus, the follicles do not produce remains empty, fails to rupture or traps the egg. •
eggs. Instead they form fluid-filled cysts that eventually  TURNER’S SYNDROME (HYPOGONADISM)
cover the ovaries. o No ovaries to produce ova.
 Excess Insulin o It results from a hormonal imbalance caused by a
o Insulin is the hormone produced in the pancreas that condition such as hypothyroidism, which interferes
allows cells to use sugar, your body's primary energy with hypothalamus-pituitary-ovarian interaction.
supply.  Ovarian tumors
o If your cells become resistant to the action of insulin,  Excessive exposure to X-rays or radioactive substances
then your blood sugar levels can rise and your body
might produce more insulin. IMMUNE SYSTEM PROBLEMS
o Excess insulin might increase androgen production,  Women may develop antibodies or immune cells that attack
causing difficulty with ovulation. the man's sperm, mistaking it for a toxic invader.
 Low-grade inflammation  Certain autoimmune diseases, in which the woman's
o This term is used to describe white blood cells' immune cells attack normal cells in her own body, may also
production of substances to fight infection. Research contribute to ovarian problems.
has shown that women with PCOS have a type of
low-grade inflammation that stimulates polycystic LUTEAL PHASE DEFECT
ovaries to produce androgens, which can lead to  In a luteal phase defect, a woman's corpus luteum (the
heart and blood vessel problems. mound of yellow tissue produced from the egg follicle) may
 Heredity fail to produce enough progesterone to thicken the uterine
o Research suggests that certain genes might be lining.
linked to PCOS.  Then the fertilized egg may be unable to implant.
ENDOMETRIOSIS FIBROIDS
 Refers to a condition in which sections of the uterine  Fibroids, or benign growths, may form in the uterus near the
lining implant in the vagina, ovaries, fallopian tubes or fallopian tubes or cervix.
pelvis.
 As a result, the sperm or fertilized egg cannot reach the
 These implants eventually form cysts that grow with each uterus or implant there.
menstrual cycle, and may eventually turn into blisters and  Fibroids in the uterus are very common in women over age
scars. 30.
o The scars can then block the passage of the egg.

OVARY PROBLEMS
 Decreased production of any one of the five hormones
that regulate a woman's reproductive cycle may result in
infertility.
o GnRH or LHRH
o FSH
o LH
o Estrogen
o Progesterone

SURGICAL COMPLICATIONS
 Scar tissue (adhesions) left after abdominal surgery can
cause problems in the movement of the ovaries, fallopian
tubes, and uterus, resulting in infertility.

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 NURSING CARE OF THE FAMILY HAVING DIFFICULTY CONCEIVING A CHILD

 Frequent abortions may also produce infertility by RETROGRADE EJACULATION

weakening the cervix or by leaving scar tissue that obstructs
the uterus.
POOR QUALITY CERVICAL MUCOUS
 Sometimes a woman's mucous fails to thin around the time
of ovulation, and consequently it prevents the sperm from
traveling through it.
 A cervical infection may also be the cause.
 In retrograde ejaculation the muscles of the urethra do not
force the sperm out.
 Instead, the sperm travel backward into the bladder.
 Causes of retrograde ejaculation include:
o Drugs such as tranquilizers or high blood pressure
medicines.
o Diseases such as diabetes or multiple sclerosis.
o Neck, bladder or prostate surgery.
o Spinal cord injury.

PREMATURE MENOPAUSE VARICOCELE OR VARICOSITY

 Some women may experience premature menopause,
 Enlargement of the internal spermatic vein
when their ovaries stop producing eggs.
 Can also increase temperature and congestion within the
 Cause:
testes, which may slow and disrupt spermatogenesis.
o Excessive exercise or anorexia

CAUSES FOR MALE INFERTILITY

 The most common cause for male infertility is a problem
with the sperm-either low sperm count or sperm with poor
quality.
 Some conditions that may contribute to sperm problems
include:

UNDER-DEVELOPED TESTES
 Usually arising after a mumps infection, a hernia surgery,
an injury or birth defect.

SWOLLEN VEINS IN RGE SCROTUM

UNDESCENDED TESTES (CRYPTORCHIDISM)

 A problem often presents from birth in which the testes
remain in the body cavity. Normally they descend into the DIAGNOSIS
scrotum before birth.
DIAGNOSTIC TESTS: MALE
INFECTIONS SUCH AS GONORRHEA OR
TUBERCULOSIS SEMEN ANALYSIS
 Block the ducts through which the sperm travel.  To determine sperm count & motility
 Must have 2 – 4 days of sexual abstinence prior to the test.
EXPOSURE TO METALS  Average ejaculation: 2.5 – 5 ml
 Average normal sperm count: 50 – 200 million/ml
 Such as leads, or chemicals such as pesticides.
 The minimum sperm count considered normal has:
o 33 - 46 million sperm/ml of seminal fluid, or 50 million
CERTAIN MEDICATIONS per ejaculation
 Tagamet (cimetidine), o Fifty percent (50%) of sperm that are motile
 Dilantin (phenytoin), o Thirty percent (30%) that are normal in shape and
 Folex (methotrexate), form
 Axulfidine (sulfasalazine),
 Corticosteroids TIPS FOR ENSURING AN ACCURATE SEMEN
 Chemotherapy drugs ANALYSIS
o Cytoxan  Abstain from intercourse or masturbation for about 2 – 4
o Neosar (cyclophosphamide). days.
 Use a clean, dry plastic or glass container with a secure lid
INJURY TO TESTICLES to collect the sample.
 Avoid using any lubricants before you collect the specimen.
CHRONIC PROSTATE INFECTIONS  After you’ve collected the specimen in the container, close
it securely and write down the time you collected it.
AUTOIMMUNITY  Take the specimen to the laboratory or healthcare
provider’s office immediately so it can be analyzed within 1
 In which antibodies or cells of the man's immune system
hour of collection.
attack sperm cells, mistaking them for toxic invaders.
 Keep the specimen at body temperature while transporting
 The antibodies attach themselves to the sperm and may
it. Carrying it next to your chest is one way to do this.
cause them to stick together, or may stop them from
penetrating the cervical mucous or the egg.
ADDITIONAL TESTING FOR MEN, IF WARRANTED:

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 Urinalysis  You're most fertile about two days before

 A complete blood count your basal body temperature rises, but sperm
 Blood typing, including Rh factor can live up to five days in your reproductive tract.
 Serologic test for syphilis  If you're hoping to get pregnant, this is the time to
o a test for the presence of HIV have sex.
 Erythrocyte sedimentation
o An increased rate indicates inflammation
 Protein-bound iodine
o A test for thyroid function
o Hypothyroidism can cause poor semen quality, low
sperm count, reduced testicular function, erectile
dysfunction, and drop in libido.
 Cholesterol level
o Arterial plaques could interfere with pelvic blood flow
 Follicle-stimulating Hormone (FSH), Luteinizing Hormone
(LH), and testosterone levels (Niederberger, 2016)

DIAGNOSTIC TESTS: FEMALE

BASAL BODY TEMPERATURE (BBT)

 A fertility awareness-based method.
 A type of natural family planning.
 By tracking your basal body temperature each day, you
may be able to predict when you'll ovulate.
 In turn, this may help you determine when you're most likely
to conceive.
 If you're hoping to get pregnant, you can use the basal body
temperature method to determine the best days to have
sex.
 HOW TO USE THE BASAL BODY TEMPERATURE
(BBT) METHOD
o Take your basal body temperature every morning
before getting out of bed
 Use a digital oral thermometer or one specifically
designed to measure basal body temperature.
 Make sure you get at least three hours of
uninterrupted sleep each night to ensure an
accurate reading.
 Always take your temperature using the same
method.
o Plot your temperature readings on graph paper.
 Record your daily basal body temperature and
look for a pattern to emerge.
 Your basal body temperature may increase
slightly— typically less than a 1/2 degree F (0.3
C) — when you ovulate.
 You can assume ovulation has occurred when
the slightly higher temperature remains steady
for three days or more.
o Plan sex carefully during fertile days.

CERVICAL MUCUS EXAM PELVIC EXAM AND ULTRASONOGRAPHY

 To determine elasticity for sperm motility.
CERVICAL MUCUS (SPINNBARKEIT)
 Once you notice that your CM has the consistency of raw
egg whites, you know you're in your fertile period.
 If you hold it between two fingers, it can stretch an inch or
two without breaking in the middle.
 This type of CM allows the sperm to swim easily into the
cervix.
 To identify obvious reproductive problems.
 BLOOD HORMONE LEVELS & THYROID FUNCTION
TEST
o To measure levels of estrogen & progesterone, and
influence of thyroid hormones.
 SIMS-HUHNER TEST (Post-coital Cervical Mucus Test)
o To determine pH of cervical mucus, effects of
hormones.

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 NURSING CARE OF THE FAMILY HAVING DIFFICULTY CONCEIVING A CHILD

TUBAL PATENCY TEST DRUGS THAT AFFECT GONODAL FUNCTION &

 Hysterosalpingogram (X-ray) FERTILITY
 Laparoscopic exam (direct visualization)
o To determine condition and patency of fallopian ANDROGENS
tubes.
 To replace deficient male hormones
 ESTROGENS
ENDOMETRIAL BIOPSY
 To replace deficient hormones to control hormonal balance.
 To determine condition of endometrium
CONCEPTION ENHANCERS
HYSTEROSCOPY
 Visual inspection of the uterus through insertion of
hysteroscope through the vagina, cervix, and into the Table No. 2 Ovulatory Stimulants
uterus. CLOMIPHENE CITRATE (CLOMID)
NURSING IMPLICAIONS  A follicle-maturing agent used during the 5th – 10th day
 Take careful lifestyle and sexual history of both partners, of menstrual cycle
chronic health problems, medications, smoking, drug use, ACTION An estrogen agonist commonly used to
exposure to chemicals, radiation. stimulate the ovary.
 Provide detailed explanation of all tests to couple. DOSAGE  Initially, 50 mg/day orally for 5
 Know that process of assessment of fertility and days (started anytime if no
subsequent interventions may be lengthy menstrual flow has occurred
recently or about the fifth day of
INTERVENTIONS the cycle if menstrual flow is
occurring).
 Therapy for Anovulation
 If ovulation does not occur with
 Important for adequate ova production:
this initial therapy, the drug can be
o Nutrition
followed by a prescription of 100
o Body Weight
mg/day for 5 days started as early
o Exercise
as 30 days after the initial course
 Are all important for adequate ova production
of therapy.
because they all influence the blood
glucose/insulin balance (Best & Bhattacharya,  This second course may be
repeated one more time.
2015)
POSSIBLE  Abdominal discomfort
NUTRITION
ADVSERSE  Distention
 High glucose or Insulin Levels
EFFECT  Bloating
o Can disrupt the production of FSH and LH, leading  Nausea & vomiting
to ovulation failure.  Breast tenderness
 Vitamin D  Vasomotor flushing
o May also be instrumental in maintaining pituitary  Ovarian enlargement
hormone levels (Shahrokhi, • Ghaffari & Kazerouni,  Ovarian overstimulation Multiple
2016). births
 Visual disturbances
BODY WEIGHT NURSING  Ensure women have had a pelvic
 Maintain a BMI of 18.5 to 24.9. IMPLICATIONS examination and baseline
 Eat slowly digested carbohydrate foods (e.g., brown rice, hormonal studies before therapy.
pasta, dark bread, beans) and fiber-rich vegetables (e.g.,  Review medication scheduling.
asparagus, broccoli)  Urge women to use a calendar or
o can not only increase fertility by keeping insulin some other system to mark their
levels balanced but also may prevent gestational treatment schedule and also to
diabetes when a woman becomes pregnant determine and plot ovulation.
(Sanabria-Martínez, García-Hermoso, Poyatos-  Remind patients that timing
León, et al., 2015). intercourse with ovulation is
important for achieving
EXERCISE pregnancy.
 Exercising 30 minutes per day by walking or doing mild  Advice patient 24-hour urine
aerobics also helps to regulate blood glucose levels and samples may be periodically
increase fertility, necessary.
o Stress may play a role in limiting ovulation as this  Caution patients to report any
may lower hypothalamic secretion of the bloating, stomach pain, blurred
gonadotropin-releasing hormone (GnRH), which vision, unusual bleeding, bruising,
then lowers the production of LH and FSH, which or visual changes.
leads to anovulation.  Inform patients that therapy can
be repeated for a total of three
courses; if no results are obtained,
therapy will be discontinued at that
point.

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BROMOCRIPTINE Inhibits release of prolactin which can o the response can be reduced by abstinence or
(Parlodel) cause unovulation condom use for about 6 months
o The administration of corticosteroids to a woman
HUMAN Acts similarly to FSH or LH to stimulate may have some effect in decreasing sperm
MENOPAUSAL growth and maturation of ovarian immobilization because it reduces her immune
GONADTROPIN follicles. response and antibody production.
(PERGONAL)
THERAPY FOR EJACULATION CONCERNS
Gonadotropin- Used when clomiphene is ineffective  Psychological or sexual counseling
releasing  Use of a phosphodiesterase inhibitor, such as sildenafil
hormone (GnRH) (Viagra) or tadalafil (Cialis)
 Dapoxetine, a short-acting selective serotonin reuptake
Table No. 3 For Hyperplasia Defects inhibitor, is a drug that has been developed especially for
Danazol  Reduces endometrial hyperplasia the treatment of premature ejaculation and shows good
(Cyclomen)  Inhibits estrogen defects. results when taken about 1 hour before planned coitus
Prednisone  Reduces adrenal hyperplasia (Yue, Dong, Hu, et al., 2015).

THERAPY FOR LACK OF TUBAL PATENCY THERAPY FOR UTERINE CONCERNS

 Diathermy or steroid administration may be helpful to
reduce adhesions. LUTEAL PHASE DEFECT
 Hysterosalpingography (instillation of a contrast dye  This can be corrected by progesterone vaginal
under X-ray monitoring) can be attempted to see if the force suppositories begun on the third day of a woman’s
of the dye insertion will break adhesions. temperature rise and continued for the next 6 weeks (if
 Canalization of the fallopian tubes and plastic surgical pregnancy occurs) or until a menstrual flow begins.
repair (microsurgery) are other possible treatments.
 Laparoscopy or Laser Surgery MYOMA (FIBROID TUMOR) OR INTRAUTERINE
o To remove peritoneal adhesions or nodules of ADHESIONS)
endometriosis that are holding the tubes fixed and
away from the ovaries (Magos, 2012).  A myomectomy, or surgical removal of the tumor and
adhesions, can be scheduled (Bailey, Jaslow, & Kutteh,
 IVF is more commonly used today and more apt to
2015).
result in a viable pregnancy.
 If the growth is small, this can be done by a hysteroscopic
ambulatory procedure.
ASSISTED REPRODUCTIVE TECHNIQUES
 the woman may be prescribed estrogen for 3 months as
 If ovulation, sperm production, or sperm motility problems
another method to prevent adhesion formation
cannot be corrected, assisted reproductive strategies are
 an intrauterine device (IUD) may be inserted to prevent the
the next step.
uterus from touching and forming new adhesions – Be
 Therapeutic insemination
certain she has a good explanation of the IUD’s purpose
o Alternative or IUI is the instillation of sperm from a
and that it can be easily removed in about 1 month’s time.
masturbatory sample into the female reproductive
tract by means of a cannula to aid conception at the
time of ovulation
ABNORMAL UTERINE FORMATION (SEPTATE
UTERUS)
THERAPY FOR INCREASING SPERM COUNT AND  Surgery is also available. However, these defects are
MOTILITY usually related to early pregnancy loss, not initial
 Abstain from coitus for 7 to 10 days at a time to increase subfertility.
the count.
 Ligation of a varicocele (if present) ENDOMETRIOSIS
 Avoid recreational marijuana use  Can be treated both medically and surgically
 Wear looser clothing  TREATMENT
 Avoid long periods of sitting, and o PAIN MEDICATION
 Avoid prolonged hot baths  Nonsteroidal anti-inflammatory drugs (NSAIDs)
ibuprofen (Advil, Motrin IB, others) or naproxen
THERAPY FOR SPERM TRANSPORT DISORDERS sodium (Aleve) to help ease painful menstrual
 If sperm are not able to pass through the vas deferens cramps.
because of obstruction, surgery to relieve the obstruction is o HORMONE THERAPY HORMONAL
extensive, costly, and may not have a positive outcome. CONTRACEPTIVES
o A better solution can be extracting sperm from a  Birth control pills, patches and vaginal rings help
point above the blockage and injecting it into the control the hormones responsible for the buildup
vagina or uterus of the man’s partner by intrauterine of endometrial tissue each month.
insemination (IUI)  Using hormonal contraceptives — especially
o Today, sperm can be cryopreserved (frozen) in a continuous-cycle regimens — may reduce or
sperm bank before radiation or chemotherapy and eliminate pain in some cases.
then used for alternative insemination afterward  GONADOTROPIN-RELEASING HORMONE
 If the problem appears to be that sperm are immobilized by (Gn-RH) AGONISTS AND ANTAGONISTS
vaginal secretions due to an immunologic factor

VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H 8

 NURSING CARE OF THE FAMILY HAVING DIFFICULTY CONCEIVING A CHILD
- These drugs block the production of
ovarian-stimulating hormones, lowering
estrogen levels and preventing
menstruation.
- This causes endometrial tissue to shrink.
- Because these drugs create an artificial
menopause, taking a low dose of estrogen
or progestin along with Gn-RH agonists
and antagonists may decrease
menopausal side effects, such as hot
flashes, vaginal dryness and bone loss.
- Menstrual periods and the ability to get
pregnant return when you stop taking the
medication.
THERAPY FOR VAGINAL AND CERVICALL
CONCERNS
IF SPERM DO NOT APPEAR TO SURVIVE IN VAGINAL
SECRETIONS BECAUSE SECRETIONS ARE TOO
SCANT OR TENACIOUS
 A woman may be prescribed low-dose estrogen therapy to
increase mucus production during days 5 to 10 of her cycle.
 Conjugated estrogen (Premarin) is a type of estrogen
prescribed for this purpose.
IF A VAGINAL INFECTION IS PRESENT
 The infection will be treated according to the causative
organism based on culture reports.
 Vaginal infections such as trichomoniasis and moniliasis
tend to recur, requiring close supervision and follow-up.
 If the woman’s sexual partner is the source of infection, and
is therefore reinfecting her, the partner needs antibiotic
therapy as well.
 Caution women who are prescribed metronidazole (Flagyl)
for a Trichomonas infection;
o Although no studies have shown fetal malformations
after its use, it may be teratogenic early in pregnancy
and therefore should not be continued if the woman
suspects she has become pregnant.
UNEXPLAINED SUBFERTILITY
 In a small percentage of couples, no known cause for
subfertility can be discovered.
 It may be that the problem of one partner alone is not
significant, but when combined with a small problem in the
other partner, together, these become sufficient to create
subfertility.
 It is obviously discouraging for couples to complete a fertility
evaluation and be told their inability to conceive cannot be
explained.
 Offer active support to help the couple find alternative
solutions at this point, such as continuing to try to conceive,
using an assisted reproductive technique, choosing to
adopt, or agreeing to a child-free life.
ASSISTED REPRODUCTION TECHNIQUES
 If ovulation, sperm production, or sperm mobility problems
cannot be corrected, assisted reproductive strategies are
the next step for a couple to consider.
BEFORE BEGINNING ANY OF THESE PROCEDURES:
 Urge a woman to be in excellent health by discontinuing
smoking or recreational drug behaviors
 Ingesting a diet high in protein
VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H
 A BMI within a normal range of 18.5 to 24.9.
 Tests for HIV and hepatitis C
 A hormone profile including levels of FSH, LH, estrogen,
and progesterone to test for ovarian reserves (whether
ovaries have the capacity to produce multiple oocytes)
 Intravaginal sonogram to visual usual structures.
 Consider the budget
 Availability of health insurance because the couple may not
be able to afford these therapies
 Consider their religion or cultural beliefs because they may
find these unacceptable procedures. LGBT couples may
also feel uncomfortable seeking reproductive advice.
 In all instances, culturally sensitive care is required by the
nurse
INTRAUTERINE INSEMINATION (IUI)
 The instillation of sperm from a masturbatory sample into
the female
 Reproductive tract by means of a cannula to aid conception
at the time of ovulation (Kop, van Wely, Mol, et al., 2015).
 The sperm can either be instilled into the cervix
(intracervical insemination) or directly into the uterus (IUI)
at the time of predicted ovulation.
o BBT charting, mucus analysis, or
 Urinary test kits for LH can be used to detect the day of
ovulation • (Hamilton, 2012).
 Either the male partner’s sperm (alternative insemination by
male partner) or donor
 Sperm (alternative insemination by donor) can be used.
INDICATIONS:
 The male partner has no sperm or an inadequate sperm
count
 A woman has a vaginal or cervical factor that interferes with
sperm motility
 A woman has hormonal issues affecting fertility.
 Donor insemination can be used if the man has a known
genetic disorder he does not want to be transmitted to
children
 A woman does not have a male partner.
 It is also a useful procedure for men who underwent a
vasectomy but now wish to have children
o Today, sperm can be cryopreserved (frozen) in a
sperm bank before radiation or chemotherapy and
then used for alternative insemination afterward
PREPARATION
 A woman receives an injection of clomiphene (Clomid) or
FSH 1 month prior to the insemination
o So follicle growth of ova is stimulated
o Ovulation can be predicted.
PROCEDURE
 On the selected day of insemination (confirmed by a serum
analysis of progesterone), the sperm sample is instilled next
to her cervix using a device similar to a cervical cap or
diaphragm, or sperm are injected directly into the uterus
using a flexible catheter.
 Donors for alternative insemination are volunteers who
have no history of disease and no family history of possible
inheritable disorders.
 The blood type, or at least the Rh factor, can be matched
with the woman’s to prevent incompatibility.
 Sperm can be selected according to desired physical or
mental characteristics if desired.
9
 NURSING CARE OF THE FAMILY HAVING DIFFICULTY CONCEIVING A CHILD
 If FSH was used to stimulate follicle growth, caution women
that the chance for a multiple birth (twins or triplets)
increases so she can be prepared for this (Trew & Lavery,
2012).
IN VITRO FERTILIZATION (IVF)
 Overall Live Birth Rate by IVF:
o 41% to 43% per treatment cycle for women under 35
years
o It is as low as 13% to 18% for woman age 40 years
(American Pregnancy Association, 2015).
o About 25% of pregnancies end in spontaneous
miscarriage (the same rate as for natural
pregnancies).
o COST: $12,000 to $17,000 per cycle
INDICATIONS:
 Woman has obstructed or damaged fallopian tubes
 Man has oligospermia or a very low sperm count.
 Absence of cervical mucus prevents sperm from entering
the cervix or antisperm antibodies cause immobilization of
sperm
 Couples with unexplained subfertility of long duration
PREPARATION
 1 month before the procedure, the woman is given FSH to
stimulate oocyte growth.
 Beginning about the 10th day of the menstrual cycle, the
ovaries are examined daily by sonography to assess the
number and size of developing ovarian follicles.
 When a follicle appears to be mature, a woman is given an
injection of hCG, which causes ovulation in 38 to 42 hours.
PROCEDURE
 One or more mature oocytes are removed from a woman’s
ovary by laparoscopy and fertilized by exposure to sperm in
a laboratory.
 The oocytes chosen are incubated for at least 8 hours to
ensure viability.
 The male partner or donor supplies a fresh or frozen semen
specimen.
 A donor ovum, rather than the woman’s own ovum, can be
used for a woman who does not ovulate or who carries a
sex- linked disease she does not want to pass on to her
children.
 Young women who had extensive ovarian radiation or
ovaries removed before surgery for ovarian cancer can
have oocytes cryopreserved before surgery and used for
IVF (Brezina, Ding, Ke, et al., 2015).
 The sperm cells and oocytes are mixed and allowed to
incubate in a growth medium.
 About 40 hours after fertilization, the laboratory-grown
fertilized ova (now zygotes) are inserted into a woman’s
uterus, where, ideally, one or more of them will implant and
grow.
 Genetic analysis to reveal chromosomal abnormalities or
the potential sex can be completed at this point.
 Progesterone or LH may be prescribed to a woman
following IVF
 A routine serum pregnancy test as early as 11 days after
transfer will be done
o Proof that zygote has implanted
GAMETE INTRAFALLOPIAN TRANSFER
 In gamete intrafallopian transfer (GIFT) procedures, ova are
obtained from ovaries exactly as in IVF.
VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H
 Instead of waiting for fertilization to occur in the laboratory,
however, both ova and sperm are instilled, within a matter
of hours, using a laparoscopic technique, into the open end
of a patent fallopian tube.
 Fertilization then occurs in the tube, and the zygote moves
to the uterus for implantation.
ZYGOTE INTRAFALLOPIAN TRANSFER
 Zygote intrafallopian transfer (ZIFT) is similar to IVF in that
the egg is fertilized in the laboratory,
 The fertilized egg is transferred by laparoscopic technique
into the end of a waiting fallopian tube.
SURROGATE EMBRYO TRANSFER
 Surrogate embryo transfer is an assisted reproductive
technique for a woman who does not produce ova.
PROCEDURE:
 The oocyte is donated by a friend, relative, or an
anonymous donor (Check, Wilson, Levine, et al., 2015).
 The menstrual cycles of the donor and recipient are
synchronized by administration of gonadotropic hormones.
 At the time of ovulation, the donor’s ovum is removed by a
transvaginal, ultrasound-guided procedure.
 The oocyte is then fertilized in the laboratory by the recipient
woman’s partner’s sperm (or donor sperm) and placed in
the recipient woman’s uterus by embryonic transfer.
 Once pregnancy occurs, it progresses the same as an
unassisted pregnancy.
ALTERNATIVES TO CHILDBIRTH
SURROGATE MOTHERS
 A surrogate mother is a woman who agrees to carry a
pregnancy to term for a subfertile couple or an LGBT couple
(Dar, Lazer, Swanson, et al., 2015).
 The surrogate may provide the ova, which is then
impregnated by the man’s sperm in the laboratory.
 In other instances, the ova and sperm both may be donated
by the subfertile couple; in a third technique, both donor ova
and sperm are used.
 Surrogate mothers are often friends or family members who
assume the role out of friendship or compassion, or they
can be referred to the couple through an agency or attorney
and receive monetary reimbursement for their expenses.
 The subfertile couple can enjoy the pregnancy as they
watch it progress in the surrogate.
 A number of ethical and legal problems arise if the
surrogate mother decides at the end of pregnancy that she
has formed an attachment to the fetus and wants to keep
the baby despite the pre-pregnancy agreement she signed.
 Court decisions have been split on whether the surrogate
or the subfertile couple has the right to the child.
 Another potential problem occurs if the child is born
imperfect and the subfertile couple then no longer wants the
child.
 Who should have responsibility in this instance?
 For these reasons, the couple and the surrogate mother
must be certain they have given adequate thought to the
process and to what will be the outcome should these
problems occur before they attempt surrogate mothering.
10
 NURSING CARE OF THE FAMILY HAVING DIFFICULTY CONCEIVING A CHILD

ADOPTION
 Adoption is an alternative for subfertile and LGBT couples,
those individuals who have genetic-related health
conditions or health conditions that would make pregnancy
high risk.

CHILD-FREELIVING
 Child-free living is another option available to both fertile
and subfertile couples.
 A couple in the midst of fertility testing may begin to
reexamine their motives for pursuing pregnancy and may
decide pregnancy and parenting are not worth the
emotional or financial cost of future treatments.
 They may decide the additional stress of going through an
adoption is not for them either, or they may simply decide
children are not necessary for them to complete their family
unit.
 Child-free living can be as fulfilling as having children
because it allows a couple more time to help other people
and contribute to society through personal
accomplishments.
 It has advantages for a couple in that it also allows time for
both members to pursue careers.
 They can travel more or have more time and money to
pursue hobbies or continue their education.
 If a couple still wishes to include children in their lives in
some way, many opportunities are available to do this
through family connections (most parents welcome offers
from siblings or other family members to share in
childrearing), through volunteer organizations (such as Big
Brother or Big Sister programs), or through local schools
and town recreational programs.
 Many couples who believe overpopulation is a major
concern choose child-free living even if subfertility is not
present
 Parents who choose child-free living typically rate their
marriage as happier than for those with children probably
because of the decreased expense involved and the
availability of more free time, which allow them greater
freedom in life (Avison & Furnham, 2015)

REFERENCES

Silbert-Flagg, J. A. (2022). Nursing Care of the Family Having

Difficulty Conceiving a Child. In Maternal & Child Health
Nursing: Care of the childbearing and Childrearing family (9th
ed., Vol. 1) Wolters Kluwer.

Notes from the discussion by Ms. Rosalind Navarro, R.N.,

M.A.N

VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H 11

 NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION FROM A PREEXISTING OR NEWLY ACQUIRED ILLNESS

UNIT II: NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION

FROM A PREEXISTING OR NEWLY ACQUIRED ILLNESS

CARDIAC DISEASES
OUTLINE
IX Cardiovascular Disorders
A Cardiac Disease
LEFT-SIDED HEART FAILURE
i Left-Sided Heart Failure  Left-sided heart failure occurs in conditions such as mitral
ii Right Sided Heart Failure stenosis, mitral insufficiency, and aortic coarctation
iii Peripartum Heart Disease  The left ventricle cannot move the large volume of
iv Assessment of a Woman with Cardiac Disease blood forward that it has received by the left atrium from
v Fetal Assessment
B Nursing Diagnosis and Related Interventions the pulmonary circulation
C Nursing Interventions During Labor and Birth o This causes back pressure
D Postpartum Nursing Interventions o The left side of the heart becomes distended,
E Artificial Valve Prosthesis systemic blood pressure decreases in the face of
F Chronic Hypertensive Vascular Disease lowered cardiac output, and pulmonary
G Thromboembolic Disease hypertension occurs.
X Hematologic Disorders  When pressure in the pulmonary vein reaches a point of
A Anemia
i True Anemia
about 25 mmHg, fluid begins to pass from the pulmonary
ii Iron-Deficiency Anemia capillary membranes into the interstitial spaces surrounding
iii Folic Acid-Deficiency Anemia the lung alveoli and then into the alveoli themselves
XI Endocrine System Disorders (pulmonary edema)
A Diabetes Mellitus o Pulmonary edema produces profound shortness of
B Classification of Diabetes Mellitus breath as it interferes with oxygen– carbon dioxide
C Diabetes during Pregnancy exchange (Brushers, 2012)
i Monitoring a Woman with Diabetes o If pulmonary capillaries rupture under the pressure,
ii Therapeutic Management
D Timing for Birth
small amounts of blood leak into the alveoli and the
woman develops a productive cough with blood-
speckled sputum
CARDIOVASCULAR DISORDERS o Woman with severe pulmonary edema can sleep in
any position EXCEPT orthopnea (chest and head
 Cardiovascular disease (even with hypertension included),
elevated)
which was once a major threat to pregnancy, now
 Elevating her chest allows fluid to settle to the
complicates only approximately 1% of all pregnancies
bottom of her lungs and free space for gas
 It is responsible for 5% of maternal deaths during exchcange
pregnancy (Cunningham, Leveno, Bloom, et al., 2010). o She may also notice paroxysmal nocturnal
 The cardiovascular disorders that most commonly cause dyspnea
difficulty during pregnancy are valve damage concerns  Suddenly waking at night with shortness of
caused by rheumatic fever or Kawasaki disease and breath
congenital anomalies such as atrial septal defect or  Occurs when heart action is more effective when
uncorrected coarctation of the aorta (Kuo, Yang, Chang, et she is at rest
al., 2012).  If MITRAL STENOSIS is present, it is difficult for blood to
 The most dangerous time for her is in weeks 28 to 32, just leave the left atrium
after the blood volume peaks. o A secondary problem of thrombus formation can
occur from non-circulating blood
Table No. 4 Classification of Heart Disease  To prevent thrombus formation, a woman may be
CLASS DESCRIPTION prescribed an anticoagulant.
I Uncompromised. Ordinary physical activity  To decrease the strain on the aorta,
causes no discomfort. No symptoms of cardiac antihypertensives may be prescribed to control
insufficiency and no anginal pain. blood pressure, diuretics to reduce blood volume,
II Slightly compromised. Ordinary physical and -blockers to improve ventricular filling
activity causes excessive fatigue, palpitation,
and dyspnea or anginal pain. RIGHT-SIDED HEART FAILURE
III Markedly compromised. During less than  The right ventricle is overwhelmed by the amount of
ordinary activity, woman experiences blood received by the right atrium from the vena cava
excessive fatigue, palpitations, dyspnea, or  It can be caused by an unrepaired congenital heart defect
anginal pain. such as pulmonary valve stenosis
IV Severely compromised. Woman is unable to  Congestion of the systemic venous circulation and
carry out any physical activity without decreased cardiac output to the lungs occurs.
experiencing discomfort. Even at rest,  Blood pressure decreases in the aorta because less
symptoms of cardiac insufficiency or anginal blood is able to reach it;
pain are present.  Pressure is high in the vena cava from back pressure of
blood.
 Both jugular venous distention and increased portal
circulation are evident.
 The LIVER and SPLEEN both become distended

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 NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION FROM A PREEXISTING OR NEWLY ACQUIRED ILLNESS

o Extreme liver enlargement can cause dyspnea and

pain in a pregnant woman because the enlarged
liver, as it is pressed upward by the enlarged uterus,
puts extreme pressure on the diaphragm
 During labor, they may need a pulmonary artery catheter
inserted to monitor pulmonary pressure.
 Women with this condition also need extremely close
monitoring after epidural anesthesia to minimize the risk of
hypotension.

PERIPARTUM HEART DISEASE

 Peripartal Cardiomyopathy can originate in pregnancy in
women with no previous history of heart disease (Hess &
Weinland, 2012)
 Occurs because of the stress of the pregnancy on the
circulatory system
 The mortality rate can be as high as 50%.
o It occurs most often in African American multiparas
in conjunction with gestational hypertension
 Signs of myocardial failure:
o shortness of breath,
o chest pain, and
o nondependent edema.
o Her heart increases in size (i.e., cardiomegaly).
 Therapy:
o sharply reduce her physical activity;
o many women also need a diuretic, an arrhythmia
agent, and digitalis therapy to maintain heart
function.
 If the cardiomegaly persists past the postpartum period, it
is generally suggested a woman not attempt any further
pregnancies because the condition tends to recur or worsen
in additional pregnancies
ASSESSMENT OF A WOMAN WITH CARDIAC
DISEASE
 Document a woman’s level of exercise performance
o (i.e., what level she can do before growing short of
breath and what physical symptoms she
experiences, such as cyanosis of the lips or nail
beds).
 Ask if she normally has a cough or edema
o (it’s important that women with cardiac disease
always report coughing during pregnancy because
pulmonary edema from heart failure may first
manifest itself as a simple cough).
o Documenting edema is also important because the
usual innocent edema of pregnancy must be
distinguished from the beginning of edema from
heart failure (serious)
 Be certain to record a baseline blood pressure, pulse
rate, and respiratory rate in either a sitting or lying position
at the first prenatal visit; at future health visits, always obtain
these in the same position for the most accurate
comparison
 If a woman’s heart disease involves right-sided heart
failure, assess liver size at prenatal visits.
 For an additional cardiac status assessment, an
electrocardiogram (ECG) or an echocardiogram may be
done at periodic points in pregnancy.
o Assure the woman that an ECG merely measures
cardiac electrical discharge and so cannot harm her
fetus in any way. Echocardiography uses ultrasound
and, likewise, will not harm her fetus.
FETAL ASSESSMENT
 At the point that maternal blood pressure becomes
insufficient to provide an adequate supply of blood and
nutrients to the placenta, fetal health can be compromised.
 The infants of women with severe heart disease tend to
have low birth weights or be small for gestational age
because of acidosis, which develops due to poor
oxygen/carbon dioxide exchange or not being furnished
with enough nutrients
o This can result in preterm labor, which exposes the
newborn to the hazards of immaturity as well as low
birth weight.
 If the placenta is not filling well, a fetus may not respond
well to labor
o (evidenced by late deceleration patterns on a fetal
heart monitor),
 and a cesarean birth may be necessary
o (an increased risk for both the mother and fetus).
NURSING DIAGNOSIS AND RELATED
INTERVENTIONS
NURSING DIAGNOSIS
 Deficient knowledge regarding steps to take to reduce the
effects of maternal cardiovascular disease on the
pregnancy and fetus
OUTCOME EVALUATION
 Client identifies danger signs such as angina pain and
steps to take when they occur; maternal blood pressure
is maintained above 100/60 mmHg and fetal heart rate
at 110 to 160 beats/min.
 PROMOTE REST
o Women with cardiac disease need two rest periods
a day (fully resting, not getting up frequently) and a
full night’s sleep (not tossing and turning) to obtain
adequate rest
o Rest should be in the left lateral recumbent position
to prevent supine hypotension syndrome and
increased heart effort.
o Women should plan activities so they stop exercising
before the point when cardiac output becomes
insufficient to meet systemic body demands causing
peripheral and uterine/placental constriction.

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 NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION FROM A PREEXISTING OR NEWLY ACQUIRED ILLNESS
 PROMOTE HEALTHY NUTRITION
o A woman with cardiac disease may need closer
supervision of nutrition during pregnancy than the
average woman because she must gain enough
weight to ensure a healthy pregnancy and a healthy
baby, but she must not gain so much weight that her
heart and circulatory system become overburdened.
o Be certain she is remembering to take her prenatal
vitamins. These contain an iron supplement to help
prevent anemia
 EDUCATE REGARDING MEDICATION
o Women taking cardiac medication, such as digoxin,
before pregnancy may need to increase their
maintenance dose because of their expanded blood
volume during pregnancy
 A woman who was not digoxin dependent before
pregnancy may need such therapy prescribed as
pregnancy advances and her cardiac output has
to be increased or strengthened.
o Digoxin also has a unique use during pregnancy as
it can be administered to the woman to slow the
fetal heart if fetal tachycardia is present.
o Arrhythmia agents such as adenosine, B-blockers,
and angiotensin-converting enzyme (ACE) inhibitors
to reduce hypertension are safe to use during
pregnancy and are also frequently prescribed.
o Nitroglycerin, a compound often prescribed for
angina, although not well studied during pregnancy
(a category C drug), is also considered safe (Karch,
2013).
 EDUCATE REGARDING AVOIDANCE OF INFECTION
 BE PREPARED FOR EMERGENCY ACTIONS
NURSING INTERVENTIONS DURING LABOR AND
BIRTH
 Frequently assess a woman’s blood pressure, pulse,
and respirations and monitor fetal heart rate and
uterine contractions during labor
o To make sure circulatory system is not failing and the
placenta is filling adequately
 A rapidly increasing pulse rate (>100 beats/min) is an
indication a heart is pumping ineffectively and so has
increased its rate in an effort to compensate.
 It’s good to advise a woman to assume a side-lying position
during labor to reduce the possibility of supine hypotension
syndrome
 If a woman has some pulmonary edema, however, it may
be necessary for her to elevate her head and chest (a semi-
Fowler’s position) to ease the work of breathing.
 Epidural anesthesia the anesthetic of choice for women
with heart disease because this decreases the sensation of
pushing and can make both labor and birth less taxing.
o Because of the lack of pushing, low forceps or a
vacuum extractor may be used for birth
POSTPARTUM NURSING INTERVENTIONS
 The period immediately after birth is a critical time for a
woman with heart disease because, with delivery of the
placenta, the blood that supplied the placenta is released
into her general circulation, increasing her blood volume by
20% to 40%.
 During pregnancy, the increase in blood volume that
occurred did so over a 6-month period, so her heart had
time to gradually adjust to this change
 After birth, the increase in pressure takes place within 5
minutes, so the heart must make a rapid and major
adjustment
VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H
 A woman may need a program of decreased activity and
possibly anticoagulant and digoxin therapy until her
circulation stabilizes.
 Anti-embolic stockings or intermittent pneumatic
compression (IPC) boots may be prescribed to increase
venous return from the legs.
 A woman with heart disease is often interested in close
inspection of her baby immediately after birth because she
wants to know if her infant has a heart defect or was harmed
by any medication she took during pregnancy.
o Be certain to point out that acrocyanosis is
normal in newborns so she does not interpret
her baby’s peripheral cyanosis as cardiac
inadequacy.
 Kegel exercises are acceptable for perineal strengthening
immediately, but the woman should not begin postpartum
exercises to improve abdominal tone until her primary care
provider approves them
ARTIFICAL VALVE PROSTHESIS
 Women with heart valve prostheses were advised not to
become pregnant for fear the increased blood volume
gained during pregnancy would overwhelm the artificial
valve.
 Today, evidence shows women with a valve prosthesis can
complete a pregnancy safely (Suri, Keepanasseril,
Aggarwal, et al., 2011).
 The use of oral anticoagulants women take to prevent the
formation of blood clots at the valve site.
 The usual maintenance drug for this, sodium warfarin
(Coumadin), increases the risk of congenital anomalies in
infants (pregnancy risk category D)
CHRONIC HYPERTENSIVE VASCULAR DISEASE
 Women with chronic hypertensive disease enter pregnancy
with an elevated blood pressure (140/90 mmHg or above).
 Hypertension of this kind is usually associated with
arteriosclerosis or renal disease, making it a problem for the
older pregnant woman.
 Chronic hypertension can be serious because it places
both the woman and fetus at high risk because of poor
heart, kidney, and/or placental perfusion during the
pregnancy (Gelson, Curry, Gatzoulis, et al., 2011).
 Medical Management:
o A prescription of B-blockers and ACE inhibitors to
reduce blood pressure by peripheral dilation to a
safe level, but not to reduce it below the threshold
that allows for good placenta circulation.
o Methyldopa (Aldomet) is a typical drug that may be
prescribed.
VENOUS THROMBOEMBOLIC DISEASE
 A combination of stasis of blood in the lower extremities
from uterine pressure and hypercoagulability
 When the pressure of the fetal head at birth puts additional
pressure on lower extremity veins, damage can occur
to the walls of the veins
 With this triad of effects in place (stasis, vessel damage,
and hyper coagulation), the stage is set for thrombus
formation in the lower extremities
 The likelihood of deep vein thrombosis (DVT) leading to
pulmonary emboli is highest in women 30 years of age or
older because increased age is yet another risk factor for
thrombosis formation
 PREVENTION:
o avoiding the use of constrictive knee-high stockings,
o not sitting with legs crossed at the knee,
14
 NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION FROM A PREEXISTING OR NEWLY ACQUIRED ILLNESS

o avoiding standing in one position for a long period. o Vit. B12 deficiency
 MEGALOBLASTIC ANEMIA
HEMATOLOGIC DISORDERS o Enlarged RBC that do not work properly
o Anemia that develop
ANEMIA  Medical Management:
o Women expecting to become pregnant
TRUE ANEMIA  Supplement of 400 ug folic acid daily
 Eat folacin-rich foods
 Hemoglobin <11 g/dl (hematocrit <33%) in the 1st or 3rd o During pregnancy • Folic acid req is 600 ug/day
trimester of pregnancy
 Hemoglobin <10.5 g/dl (hematocrit <32%) in the 2nd ENDOCRINE SYSTEM DISORDERS
trimester
DIABETES MELLITUS
IRON-DEFICIENCY ANEMIA
 Is an endocrine disorder in which the pancreas cannot
 Causes: produce adequate insulin to regulate body glucose levels
o Diet low in iron
o Heavy menstrual periods Table No. 5 Classification of Heart Disease
o Unwise weight-reduction program CLASS DESCRIPTION
o Women who were pregnant in <2 yrs. before the TYPE 1 A state characterized by the destruction
current pregnancy of the beta cells in the pancreas that
o Low socio-economic levels who have not had iron- usually leads to absolute insulin
rich diets deficiency.
 Associated with: 1. Immune-mediated diabetes
o Low birth weight & preterm birth mellitus results from
o Extreme fatigue & poor exercise tolerance autoimmune destruction of the
 Characteristics of blood: beta cells.
o Microcytic (i.e., small red blood cell) 2. Idiopathic type 1 refers to forms
o Hypochromic (i.e., less hemoglobin than the that have no known cause
average red cell TYPE 2 A state that usually arises because of
 Medical Management: insulin resistance combined with a
o As prophylaxis: relative deficiency in the production of
 Iron supplement of 27 mg/day during pregnancy. insulin.
o Diet high in iron and vitamins (e.g., green leafy GESTATIONAL A condition of abnormal glucose
vegetables, meat, and legumes) DIABETES metabolism that arises during pregnancy.
o Will be prescribed with 120 – 200 mg elemental iron Possible signal of an increased risk for
(ferrous sulfate or ferrous gluconate type 2 diabetes later in life.
 Reminders: IMPAIRED A state between “normal” and “diabetes”
o Iron is absorbed best in an acid medium. GLUCOSE in which the body is no longer using
 Advise women, therefore, to take iron HOMEOSTASIS and/or secreting insulin properly.
supplements with orange juice or a vitamin C 1. Impaired fasting glucose: a state
supplement, which supplies ascorbic acid. when fasting plasma glucose is
o Some women report constipation or gastric irritation at least 110 but under 126 mg/dl
when taking oral iron supplements. 2. Impaired glucose tolerance: a
 Increasing roughage in the diet state when results of the oral
 Always taking the pills with food glucose tolerance test are at
o Ferrous sulfate turns stools black least 140 but under 200 mg/dl in
 If iron-deficiency anemia is severe and a woman the 1-hour sample
has difficulty with oral iron therapy, intravenous
iron can be prescribed

FOLIC ACID DEFICIENCY ANEMIA

 Folic acid, folate or folacin, one of the B vitamins (B9), is
necessary for:
o The normal formation of RBC in the mother
o Prevention of neural tube defects in the fetus and
abdominal wall defects.
o Full blown, it may be a contributory factor in
early miscarriage or premature separation of the
placenta
 It occurs most often in:
o Multiple pregnancies
o Women with secondary hemolytic illness
o Women who are taking hydantoin, an anticonvulsant
agent
o Women who have been taking oral contraceptives
o Women who have had gastric bypass for morbid
obesity

VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H 15

NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION FROM A PREEXISTING OR NEWLY ACQUIRED ILLNESS

Figure No. 3 Pathophysiology and clinical manifestations

VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H 16

 NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION FROM A PREEXISTING OR NEWLY ACQUIRED ILLNESS
DIABETES DURING PREGNANCY
CLINICAL MANIFESTATIONS
 Women with either type 1 or type 2 diabetes who have
successful regulation of glucose and insulin metabolism
before pregnancy are apt to develop less-than-optimal
control during pregnancy because all women
experience several changes in the glucose– insulin
regulatory system as pregnancy progresses.
 In all pregnancies, the glomerular filtration of glucose is
increased (the glomerular excretion threshold is lowered),
causing slight glycosuria.
 The rate of insulin secretion is increased, and the
fasting blood sugar level is lowered.
 Insulin resistance as pregnancy progresses or insulin does
not seem as effective during pregnancy
o Caused by the presence of the hormone human
placental lactogen
 (i.e., chorionic somatomammotropin)
o hHigh levels of cortisol, estrogen, progesterone, and
catecholamines.
 This resistance to or destruction of insulin is helpful in a
healthy pregnancy because it prevents the maternal
blood glucose from falling to dangerous limits.
 It causes difficulty for a pregnant woman with diabetes
because she must then increase her insulin dosage
beginning at about week 24 of pregnancy to prevent
hyperglycemia.
 If a woman has preexisting kidney disease (revealed by
proteinuria, decreased creatinine clearance, and
hypertension), the risk of hypertension of pregnancy
rises markedly (Au, RaynesGreenow, Turner, et al., 2016).
 Infants of women with poorly controlled diabetes tend to be
large (>10 lb)
 HYDRAMNIOS
o high glucose concentration causes extra fluid to shift
and enlarge the amount of amniotic fluid.
 MACROSOMIC INFANT
o may create birth problems at the end of the
pregnancy because of CPD.
 HIGH INCIDENCE OF CONGENITAL ANOMALY:
o Caudal regression syndrome (failure of the lower
extremities to develop)
o Spontaneous miscarriage
o Stillbirth in women with uncontrolled diabetes.
 At birth, neonates are more prone to hypoglycemia,
respiratory distress syndrome, hypocalcemia, and
hyperbilirubinemia.
MONITORING A WOMAN WITH DIABETES
 A woman with diabetes (type 1 or type 2) before pregnancy
should meet with her primary healthcare provider prior to
becoming pregnant; the tendency for congenital anomalies
in the fetus is highest in early weeks of pregnancy.
 A woman should use a home test kit to determine she is
pregnant so she knows this at the earliest possible time
 The measurement of glycosylated hemoglobin (HbA1c)
o A measure of the amount of glucose attached to
hemoglobin, is used to detect the degree of
hyperglycemia present.
o Measuring HbA1c reflects the average blood
glucose level over the past 4 to 6 weeks (i.e., the
time the hemoglobin in red blood cells were picking
up the glucose).
o The upper normal level of HbA1c is 6% of total
hemoglobin.
VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H
o A urine culture may be done each trimester to detect
asymptomatic UTIs as the increased glucose
concentration in urine may lead to increased
infection
 An ophthalmic examination should be done once during the
pregnancy for a woman with gestational diabetes and at
each trimester for women with known diabetes
RISK FACTORS FOR DEVELOPING GESTATIONAL
DIABETES:
 Obesity
 Age over 25 years
 History of large babies (10 lb or more)
 History of unexplained fetal or perinatal loss
 History of congenital anomalies in previous pregnancies
 History of polycystic ovary syndrome
 Family history of diabetes (one close relative or two distant
ones)
 Member of a population with a high risk for diabetes (Native
American, Hispanic, Asian)
ASSESSMENT
 FASTING PLASMA GLUCOSE (FBS)
o Greater than or equal to 126 mg/dl or a nonfasting
plasma glucose greater than or equal to 200 mg/dl
meets the threshold for the diagnosis of diabetes and
does not need confirmation.
 NPO for 8 hrs. before the test.
 50-G GLUCOSE CHALLENGE TEST
o Between 24 and 28 weeks’ gestation to determine if
they are at risk for gestational diabetes.
 ORAL GLUCOSE TOLERANCE TEST (OGTT)
o The woman drinks an oral 100-g glucose solution;
o A venous blood sample is then taken for glucose
determination at 1, 2, and 3 hours later.
o If two of the four blood samples collected for this test
are abnormal or the fasting value is above 95 mg/dl,
a diagnosis of diabetes is made
Table No. 6 oral glucose challenge test values (fasting
plasma Glucose values) for pregnancy following a 100-g
Glucose solution
TEST PREGNANT GLUCOSE LEVEL (mg/dl)
TYPE
Fasting 95
1 hr 180
2 hrs 155
3 hrs 140
NURSING DIAGNOSIS
 Risk for ineffective tissue perfusion related to reduced
vascular flow
 Imbalanced nutrition, less than body requirements, related
to inability to use glucose
 Risk for ineffective coping related to required change in
lifestyle
 Risk for infection related to impaired healing accompanying
condition
 Deficient fluid volume related to polyuria accompanying the
disorder
 Deficient knowledge related to complex health problem
 Health-seeking behaviors related to voiced need to learn
home glucose monitoring
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 NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION FROM A PREEXISTING OR NEWLY ACQUIRED ILLNESS
NURSING DIAGNOSIS AND RELATED
INTERVENTIONS
 One of the most important facets of the nurse’s role in
caring for the pregnant woman with diabetes: health
teaching.
 Important topics:
o Nutrition
o Exercise
o Insulin administration
o Blood glucose monitoring,
o Explanations of the various fetal assessment tests
that will be done.
 Deficient knowledge related to a therapeutic regimen
necessary during pregnancy
OUTCOME EVALUATION
 Patient states importance of careful attention to nutrition,
exercise, and home monitoring of glucose levels during
pregnancy;
o Describes nutrition and exercise program;
o States intention to keep nutrition and exercise
constant
EDUCATION REGARDING NUTRITION DURING
PREGNANCY
 Women with diabetes need to be aware of how much
carbohydrate they eat daily by estimating the total
carbohydrate each anticipated meal will contain and
then administer a number of units of insulin prior to that
based on a predetermined insulin-to-carbohydrate ratio.
 Dietary control, or maintaining an adequate glucose intake
so hypoglycemia does not occur, may be extremely difficult
early in pregnancy because of nausea and vomiting.
 A 1,800- to 2,400-calorie diet (or one calculated at 30
kcal/kg of ideal weight), divided into three meals and three
snacks is a typical nutrition regimen during pregnancy.
 60 kg body weight x 30 kcal/kg = 1,800 kcal/day ÷ 3 meals
o Breakfast = 200 kcal
o Lunch = 200 kcal
o Dinner = 200 kcal
 Ideally, 20% of dietary calories should be from protein, 40%
to 50% from carbohydrate, and up to 30% from fat
(Dornhorst & Williamson, 2012).
 Increased amount of dietary fiber (slows down absorption
of glucose).
 Women are extremely vulnerable to hypoglycemia at
night during pregnancy because of the continuous fetal
use of glucose during the time they sleep.
o Urge a woman to make her final snack of the day one
of protein and a complex carbohydrate (e.g., an egg
and whole grain toast) to allow slow digestion during
the night.
o If a woman cannot eat because of vomiting or
nausea early in pregnancy or heartburn in later
pregnancy, she should immediately notify her
healthcare provider as she may need temporary
intravenous fluid and glucose supplementation.
o keep her weight gain to a suitable amount
(approximately 25 to 30 lb) in the hope of limiting the
size of her infant and making a vaginal birth possible.
o Urge women, however, not to reduce their intake to
below 1,800 calories during pregnancy as an intake
this low in carbohydrates can lead to fat breakdown
and acidosis.
VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H
 With exercise, blood glucose levels decrease because the
muscles increase their need for glucose, an effect which
lasts for at least 12 hours after exercise.
 If the arm in which a woman injected insulin is actively
exercised, the insulin is released so quickly that it can cause
hypoglycemia.
o a woman should eat a snack consisting of a protein
or complex carbohydrate before exercise.
o In a woman with poor blood glucose control, extreme
exercise will cause hyperglycemia and ketoacidosis
as the liver both releases glucose and breaks down
fatty acids in an attempt to supply enough energy for
the exercise, yet the body cannot use them because
of inadequate insulin
THERAPEUTIC MANAGEMENT
BLOOD GLUCOSE MONITORING
 Completed four times a day by the patient. The patient
pricks her finger and uses a glucometer to determine her
blood glucose.
 The patient should obtain fasting and 1-hour
postprandial values.
 Fasting blood sugar (FBS) = 90 g/dl and below
 1 hr. Postprandial values = less than 140 g/dl.
 If the patient is hypoglycemic, she should have some
carbohydrate rich food, like crackers, and a protein, like
milk.
 Simple sugars can create hyperglycemia and rebound
hypoglycemia
INSULIN PUMP THERAPY
 An insulin pump is an automatic pump with thin tubing,
which is placed subcutaneously, most often on the woman’s
abdomen.
TEST FOR PLACENTAL FUNCTION AND FETA WELL-
BEING
 Serum α-fetoprotein level obtained at 15 to 17 weeks to
assess for a neural tube defect
 Ultrasound examination performed at approximately 18 to
20 weeks to detect gross abnormalities
CREATININE CLEARANCE TEST
 May be ordered each trimester.
 A normal creatinine clearance rate suggests a woman’s
vascular system is intact because kidney function is normal.
 By default, this also implies uterine perfusion is also
adequate.
 Normal level of serum creatinine for pregnant women: 0.4 –
0.8 mg/dl (Source: American Society of Nephrology)
PLACENTAL FUNCTIONING
 May also be assessed:
o Weekly non-stress test or biophysical profile during
the last trimester of pregnancy
o Daily non-stress test if her regulation is poor.
o A woman may be asked to self-monitor fetal well-
being by recording how many movements occur an
hour (usually about 10 fetal kicks)
o An ultrasound examination may be taken at week 28
and then again at weeks 36 to 38 to determine fetal
growth, amniotic fluid volume, placental location, and
biparietal diameter.
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 NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION FROM A PREEXISTING OR NEWLY ACQUIRED ILLNESS

 Oligohydramnios (i.e., a small amount of  Test women with GDM every 1-3 years if her 6- to 12-wk
amniotic fluid) may indicate fetal growth OGTT is normal
restriction or a fetal renal abnormality, whereas  Ongoing screening may be done with any glycemic test
 Polyhydramnios (i.e., an excessive amount of (A1C, fasting plasma glucose, OGTT)
amniotic fluid) may indicate gastrointestinal
malformation or poorly controlled disease.
o A lecithin/sphingomyelin ratio by amniocentesis REFERENCES
is usually performed by week 36 of pregnancy to
assess fetal lung maturity.
 The synthesis of phosphatidylglycerol, the Silbert-Flagg, J. A. (2022). Nursing Care Of A Family
compound that stabilizes surfactant, is delayed if Experiencing A Pregnancy Complication From A Preexisting
hyperglycemia is present. Or Newly Acquired Illness. In Maternal &amp; Child Health
 The presence of phosphatidylglycerol, is used Nursing: Care of the childbearing and Childrearing family (9th
to indicate lung maturity for these infants. ed., Vol. 1) Wolters Kluwer.
 Although it is known that administering
corticosteroids to the mother during the last week
Notes from the discussion by Ms. Rosalind Navarro, R.N.,
of pregnancy can hasten lung maturity,
corticosteroids may also impair fetal insulin M.A.N
release and perhaps fetal pancreatic islet
development
 Corticosteroid use to improve lung maturity is not
usually recommended.

TIMING FOR BIRTH

 The most hazardous times for a fetus during a diabetes-
involved pregnancy are weeks 36 to 40 of pregnancy.
o Because of his or her large size.
 In the past, many infants were birthed early by routine
cesarean birth at 37 weeks gestation to prevent fetal
loss from placental insufficiency during these final weeks;

CESAREAN BIRTH
 Was chosen because it is difficult to induce labor
prematurely because the cervix is not yet ripe or
responsive to labor contractions;
o Babies of women with diabetes are large, making
vaginal birth difficult;
 If at all possible, vaginal birth is preferred.
o Labor may be induced by rupture of the membranes
or an oxytocin infusion after measures to induce
cervical ripening
 Both labor contractions and fetal heart sounds need to be
conscientiously monitored during labor .
 A woman’s glucose level is regulated during labor to
prevent hypoglycemia.
 If a woman will be given an epidural anesthetic, use of an
intravenous glucose solution (D5NSS) as a plasma volume
expander should be avoided to prevent hyperglycemia from
developing; Ringer’s lactate or 0.9% saline is infused
instead.

POSTPARTUM ADJUSTMENT
 One- or 2-hour postprandial blood glucose determinations
help to regulate how much insulin she needs during this
adjustment period.
o A woman with gestational diabetes usually
demonstrates normal glucose values by 24 hours
after birth and then will need no further diet or insulin
therapy.
 IF polyhydramnios was present during pregnancy
o at risk of hemorrhage from poor uterine contraction.
 GDM is associated with increased maternal risk for type 2
diabetes o
o An oral glucose tolerance test (OGTT) is
recommended at the 6- to 12-week postpartum visit

VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H 19

 NURSING CARE OF A FAMILY EXPERIENCING A SUDDEN PREGNANCY COMPLICATION

UNIT III: NURSING CARE OF A FAMILY EXPERIENCING

A SUDDEN PREGNANCY COMPLICATION

OUTLINE o Reduced responsiveness to blood pressure changes

XII Pregnancy Induced Hypertension appears to be lost because of the prostaglandin
A Pathophysiologic Events release
B Assessment
i Risk Factors
o Vasoconstriction occurs and blood pressure
ii Signs and Symptoms increases dramatically
C Gestational Hypertension  Beginning in the 20th week
D Mild Preeclampsia o Almost all body systems begin to be affected
E Severe Preeclampsia o Cardiac system can easily become overwhelmed
F Eclampsia because the heart is forced to pump against rising
XIII Nursing Diagnosis peripheral resistance
XIV Nursing Intervention
 Causes a reduced blood supply to organs
A Mild Preeclampsia
B Severe Preeclampsia  Kidney, pancreas, liver, brain, and placenta
C Eclampsia  Poor placental perfusion reduces fetal nutrient
i Preliminary Signs Before Seizure and oxygen supply
ii Tonic-Clonic Seizures o Vasoconstriction occurs
XV Birth  Blood pressure increases dramatically
o Ischemia in pancreas
 can result to epigastric pain and elevated
PREGNANCY INDUCED HYPERTENSION amylase-creatinine ration
 A form of high blood pressure in pregnancy o Spasm occurs in the arteries of the retina,
 A condition in which vasospasm occurs in both small and  vision changes occur
large arteries during pregnancy o If retinal hemorrhage occurs,
 Also called as TOXEMIA or PREECLAMPSIA  blindness is the result
o Researchers pictured the symptoms as being o Vasospasm in the kidney
caused by women producing a toxin of some kind in  increases blood flow resistance leads to
response to the foreign protein of the growing fetus degenerative changes of the kidney glomeruli
 It occurs in about 5 to 7% of all pregnancies because of back pressure
 Cause of this disorder is unknown, but it is highly correlated - Increased permeability of the glomerular
with the antiphospholipid syndrome or the presence of membrane
antiphospholipid antibodies in maternal blood (Danza, Ruiz- - Decreased glomerular filtration; lowered
Irastorza, & Khamashta, 2012) urine output and clearance of creatinine
 Chronic Hypertension o If increased kidney tubular reabsorption occurs,
o High blood pressure that is present before retention of sodium begins
pregnancy begins  Sodium retains fluid
 Occurs in  Edema is further increased due to lost of proteins
o Women of color,  The osmotic pressure of the circulating blood falls
o Those with multiple pregnancies,  And fluid diffuses from the circulatory system into
o Primiparas younger than 20 years old or older the denser interstitial spaces to equalize
than 40 years of age, pressure
o Women with socioeconomic backgrounds, o Extreme edema
o Those who had five or more pregnancies,  can lead to maternal and pulmonary edema and
o Those who have Hydramnios eclampsia
 (i.e. overproduction of amniotic fluid) o Thrombocytopenia or a lowered platelet count
o Those who have an underlying disease such as  Occurs as platelets cluster at the sites of
heart disease, diabetes with vessel or renal endothelial damage
involvement, and essential hypertension

PATHOPHYSIOLOGIC EVENTS
 Symptoms affect almost all organs
 Vascular spasm that occurs may be caused by the
increased cardiac output required by the pregnancy
o Which injuries the endothelial cells of the arteries
o Reduced the action of prostacyclin—a prostaglandin
vasodilator
o Excess production of thromboxane—a prostaglandin
constrictor and stimulant of platelet aggregation
 DURING PREGNANCY:
o Blood vessels are resistant to the effects of pressor
substances such as angiotensin and
norepinephrine
 Even with the increase blood supply, blood
pressure remains normal during pregnancy

VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H 20

NURSING CARE OF A FAMILY EXPERIENCING A SUDDEN PREGNANCY COMPLICATION

Figure 4. Physiologic changes with PIH

VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H 21

 NURSING CARE OF A FAMILY EXPERIENCING A SUDDEN PREGNANCY COMPLICATION

ASSESSMENT

RISK FACTORS
 Women with underlying disease:
o Heart disease
o Diabetes
o Essential Hypertension

SIGNS AND SYMPTOMS

 Hypertension
 Edema
 Proteinuria

GESTATIONAL HYPERTENSION
 BP 140/90 mmHg or
 Systolic BP > 30 mmHg; Diastolic 15 mmHg above
pregnancy level
 No proteinuria nor edema
 BP returns to normal after birth

MILD PREECLAMPSIA
 BP 140/90 mmHg
 Systolic BP > 30 mmHg; Diastolic 15 mmHg above
pregnancy level
 Proteinuria +1 to +2
 Weight gain 2 lbs/wk in 2nd trimester; 1 ln/wk in 3rd
trimester
 Mild edema in upper extremities or face

SEVERE PREECLAMPSIA
 BP 160/110 mmHg
 Proteinuria: 3+ to 4+ on a random sample
 Oliguria: 500 ml or less in 24 hrs
 Pulmonary involvement: shortness of breath Figure 5. Assessing the Woman with
 Hepatic dysfunction Gestational Hypertension
 Epigastric pain due to ischemia in the pancreas
 Cerebral Edema ECLAMPSIA
o Visual disturbances: blurred vision due to spasm  Seizure or coma occurs
of arteries or seeing spots before the eyes may  Signs and symptoms of preeclampsia
be reported
o Severe headache NURSING DIAGNOSIS
o Marked hyperreflexia and perhaps ankle clonus  Ineffective tissue perfusion r/t vasoconstriction of blood
 (i.e. a pulsed motion of the foot after flexion) vessels
 Mild, moderate, severe  Deficient fluid volume r/t fluid loss to subcutaneous tissue
 Extreme edema  Risk for fetal injury r/t reduced placental perfusion 2° to
o Is most readily palpated over bony surfaces, such as vasospasm
over the tibia on the anterior leg, the ulnar surface of
 Social isolation r/t prescribed bed rest
the forearm, and the cheekbones, where the
sponginess of fluid-filled tissue can be palpated
against bone.
NURSING INTERVENTION
o If there is swelling or puffiness at these points to a
palpating finger but the swelling cannot be indented MILD PREECLAMPSIA
with finger pressure, the edema is described as  Monitor Antiplatelet Therapy
nonpitting. o Because of the increased tendency for platelets to
cluster along arterial walls, a mild antiplatelet agent,
Table No. 7 Assessment of Edema such as low-dose aspirin, may prevent or delay the
Score Description development of preeclampsia (Leaf & Connors,
1+ If the tissue can be indented slightly, this is pitting edema; 2015).
2+ Moderate indentation
3+ Deep indentation
o Be certain they purchase low-dose aspirin (81 mg,
4+ Indentation so deep it remains after removal of the finger is sold as baby aspirin) as excessive salicylic levels
pitting edema. can cause maternal bleeding at the time of birth.
 Promote bed rest
o This accumulating edema will reduce a woman’s o When the body is in a recumbent position, sodium
urine output to approximately 400 to 600 ml per 24 tends to be excreted at a faster rate than during
hours activity.

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 NURSING CARE OF A FAMILY EXPERIENCING A SUDDEN PREGNANCY COMPLICATION

o Bed rest, therefore, is the best method of aiding  Observe for respiratory depression or
increased evacuation of sodium and encouraging hypotension in mother and respiratory
diuresis of edema fluid. depression and hypotonia (decreased muscle
o Be certain women know to rest in a lateral recumbent tone) in infant at birth.
position to avoid uterine pressure on the vena cava
and prevent supine hypotension syndrome. Table No. 8 Patellar Reflex Scoring
 Promote good nutrition Score Description
o Assess if a woman has someone to help her prepare 0 No response; hypoactive; abnormal
food, or either bed rest or nutrition may be 1+ Somewhat diminished response but not
compromised abnormal
 Provide emotional support 2+ Average response
3+ Brisker than average but not abnormal
SEVERE PREECLAMPSIA 4+ Hyperactive; very brisk; abnormal
 Support bed rest
o Needs hospitalization so bed rest can be enforced
and woman can be observed closely
o Restrict visitors to support people
 (i.e. husband)
o Raise side rails to prevent injury
o Room needs to be dimly lit
 Monitor maternal well-being
o Monitor BP
o Obtain blood studies as ordered
o Obtain daily hematocrit levels as ordered
 this level will rise if increased fluid is leaving the
bloodstream for interstitial tissue [edema]
o Assess weight; same time, daily
o Indwelling catheter may be inserted
 Monitor fetal well-being
o External fetal monitor is attached
o O2 adm. may be necessary to maintain adequate
fetal oxygenation
 Support a nutritious diet
o Moderate to high protein diet
o Moderate sodium in the diet
o IVF line should be initiated and maintained to serve
as an emergency rout for drug adm.
 Administer medications to prevent eclampsia
o Hydralazine (Apresoline) to reduce hypertension (5-
10 mg/IV)
 Lowers BP by peripheral dilatation
 Can Cause tachycardia
- Assess pulse and BP before and after ECLAMPSIA
adm.
- Diastolic should not be lowered below 80- PRELIMINARY SIGNS BEFORE SEIZURE
90 mmHg or inadequate placental  BP suddenly rises from additional spasm
perfusion could occur  Temperature rises (39.4-40°C) from increased cerebral
o Magnesium sulfate (5-8 mg/100ml) pressure
 Muscle relaxant  Blurring of vision or severe headache from increased
 Prevent seizures cerebral edema
- Has CNS depressant action by blocking  Hyperactive reflexes
peripheral neuromuscular transmission  Epigastric pain and nausea from vascular congestion of the
 Symptoms of overdose: liver or pancreas
- Decreased urine output
- Depressed RR
TONIC-CLONIC SEIZURES
- Reduced consciousness
- Decreased tendon reflexes  Tonic Seizures:
o Calcium gluconate o Signs and Symptoms:
 Antidote for MgSO4 intoxication  Back arches
 10 ml of a 10% calcium gluconate must be  Arms and legs stiffen
prepared at bedside when administering MgSO4  Jaw closes abruptly
o Diazepam (Valium)  Respirations stop
 Halt seizures  Lasts for approx. 20 secs
 5-10 IV, administer slowly o Nursing Interventions:
- Dose may be repeated q 5 to 10 minutes  Maintain patient pathway
(up to 30 mg/hr)  Adm. O2 by mask
 Assess O2 saturation via pulse oximeter

VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H 23

 NURSING CARE OF A FAMILY EXPERIENCING A SUDDEN PREGNANCY COMPLICATION

 Apply an external fetal monitor

 Turn woman on her side to allow secretions to
drain from her mouth
 Clonic Seizures:
o Signs and Symptoms:
 Body muscles contract and relax repeatedly
 Inhales and exhales irregularly
 Incontinence of urine and feces may occur
 Lasts up to 1 min
 O2 therapy continued
 MgSO4 or diazepam (Valium) may be
administered via IV as an emergency measure
 Postictal State:
o Semi-comatose
o Extremely close observation is necessary because
seizure may cause premature separation of the
placenta and labor may begin
o Painful stimulus of contraction may initiate another
seizure
o Keep woman on side lying position
o Keep NPO
o Continue monitoring FHR and uterine contractions
o Check for vaginal bleeding every 15 mins

BIRTH
 Labor may be induced as soon as the woman’s condition
stabilizes
o Usually 12 to 24 hrs after seizure
 Preferred method of delivery for eclamptic patient is vagina
delivery
 C/S is preferred if fetus is in imminent danger

REFERENCES

Silbert-Flagg, J. A. (2022). Nursing Care Of A Family

Experiencing A Sudden Pregnancy Complication. In
Maternal &amp; Child Health Nursing: Care of the
childbearing and Childrearing family (9th ed., Vol. 1) Wolters
Kluwer.

Notes from the discussion by Ms. Rosalind Navarro, R.N.,

M.A.N

VILLAFLOR, KYLIE NICOLE | UNIVERSITY OF CEBU – BANILAD BSN 2H 24