BASIC CONCEPTS IN

MATERNAL NURSING
ppt2
Evelyn M. Balanquit, MAN
HIGH RISK PREGNANCY

What is high-risk pregnancy?

• It is when the life or well being of the woman or fetus has significantly
increased risk of disability (morbidity) or death (mortality) by a
disorder coincidental with or unique to pregnancy.
What is the importance of detecting high-risk pregnancy?
• There is better maternal-fetal/neonatal outcome when the factors
contributing to risk pregnancy are identified an acted upon with the
use of risk-appropriate care.
What is the maternal mortality rate in the Philippines?
• There is one (1) maternal death per 1000 livebirths.
What are the top causes of maternal mortality (1998)?
• Maternal mortality by main cause:
1. normal delivery and other complications related to pregnancy occurring in
the course of labor, delivery and puerperium
2. hypertension complicating pregnancy, childbirth, puerperium
3. postpartum hemorrhage
4. pregnancy with abortive outcome
5. hemorrhage related to pregnancy
What are the risk factors in pregnancy?
• Biophysical risks, originate from the woman or fetus
• Genetic
• Nutritional status: 20% under or overweight
What are the Medical history and current problems?

• Obstetrical history, current status

• Psychosocial risks, maternal behaviors and adverse lifestyle
• Smoking
• Caffeine: 3 or more cups of coffee
• Alcohol: no safe dose in pregnancy
• Drugs
• Abuse and violence
• Psychologic status (intrapsychic disturbances, family dissolution/disruption),
stress
• Working > 10 hours, heavy lifting, standing > 4 hours
What are the Sociodemographic risks?

• Low income
• Lack of prenatal care
• Age (<18 or >35), height < 145 cm (4'9")
• Parity > 5
• Marital status
• Residence
• Ethnicity
What are the Environmental Risks?

• Infection: viral, bacterial, fungal, protozoan

• Radiation
• Chemicals: pesticides, organic solvents, therapeutic drugs, illicit drugs,
industrial pollutants, cigarette smoke
• Physical: extreme heat >38.9 degrees, noise, vibration
STANDARDS ON PRENATAL CARE

What is the standard on prenatal care visits?

• Monthly prenatal visits until 28-30 weeks; every two weeks until 36
weeks and weekly from 37 weeks to delivery. If wis there are risk
factors, concurrent problems or disorders, prenatal visits will have
more frequency.
What are the common laboratory examinations in prenatal visits?
• In the DOH standards: CBC, Hgb, urinalysis, urine test for protein,
random blood sugar, blood typing.
What are the common prescriptions in prenatal visits?

• Supplementation of iron (60 mg elemental iron) with folic acid 2 tablets daily on the 5th
month until 2 months postpartum
• Low dose Vitamin A supplementation (10,000 IU in 2 weeks)
• In endemic areas, 1 iodized capsule to all pregnant women
• In areas with malaria, 2 tablets chloroquine phosphate (250 mg/tablet) every week for the
duration of pregnancy
• 0.5 ml of Tetanus Toxoid, (IM) in this schedule:
• TT1 - 1st contact
• TT2 - 1 month after TT1
• ТТ3 - 6 months after TT2
• TT4 - 1 year after TT3
• TT5 - 1 year after TT4
LOSS , GRIEF AND BEREAVEMENT IN PREGNANCY

When the pregnancy is at risk, the family is faced with the birth of a less than perfect child or
the death of a fetus or newborn. Sometimes, the woman also loses some aspect of the self, be it
structurally or psychologically.
 What are important nursing considerations in supporting the woman and her family?
• Provide psychological support by using caring behaviors
• Keep families together (answer questions truthfully)
• Provide opportunities to see and hold the newborn
• Provide photographs and other mementos
• Provide choices
• Assist parents in planning how to tell other family members
• Give them access to bereavement education and counseling
• Provide follow-up care
• Help them prepare for subsequent pregnancy
TESTS FOR FETAL WELL-BEING
• In the past, it was assumed that a good state of maternal health is equivalent to that
of the fetus. Current data shows that in order to enhance well-being and improve
perinatal outcome, there needs to be careful assessment of fetal status. The most
common parameter is fetal heart rate (FHR) with the use of a stethoscope, Doppler
and the electronic fetal monitor.

What are some pointers in auscultation of the fetal rate?

• Place the bell of the stethoscope over the area of maximum intensity of the FHR
• Place your finger on the maternal pulse to differentiate from FHR
• Count for 30-60 seconds
• If there is an elevation or a decrease of FHR from normal range of 120-160 bpm, do a
recounting to validate and associate with other factors, as needed
What are the common interventions to improve fetal heart rate patterns?

• Maternal position changes: avoid supine to prevent compression of

vena cava thereby causing hypotension; use knee-chest when there is
suspected cord compression; side-lying to promote placental
circulation and increase renal blood flow.
• Reduction in uterine activity: best done by reducing oxytocin
administration; maternal side-lying position; administration of
tocolytics
• Administration of IV fluids to improve maternal intravascular volume
and protect from decreased placental perfusion
• Oxygen administration can improve fetal oxygenation
What are the tests done in high-risk pregnancy which use fetal heart rate?

• Nonstress test interprets fetal heart rate reactivity as a response to fetal

movements. When the fetal heart rate peaks at least 15 bpm above the
baseline lasting for 15 seconds or more on two accelerations, this is highly
predictive of intrauterine survival for 7 days; when the fetus is unable to
meet that criteria, there is acidosis due to suboptimal oxygenation.
• Contraction Stress Test interprets the fetal heart rate in response to
hypoxia during uterine contraction induced either by intermittent nipple
stimulation or IV infusion of oxytocin; a negative CST is highly predictive of
intrauterine survival for 7 days; positive CST may be due to fetal hypoxia.
• Vibrocoustic Stimulation evaluates FHR accelerations following the use of
an vibratory sound (ex. Electrolarynx) applied over fetal head.
What is the significance of mothers doing a fetal
movement count after 24 weeks of pregnancy?
• Fetal movement is reduced in hypoxic states due to decreased oxygen
consumption and need to conserve energy.
 < 3-4/hour is an indication for referral.
Cardiff count of 10' means that having less than 10 counts in 10 hours
calls for further evaluation
Note: fetal movements are not usually present in sleep; reduced in
maternal intake of depressant drugs, alcohol and smoking
What is the significance of doing amniocentesis (transabdominal needle
aspiration of 10-20 ml of amnio fluid for laboratory analysis)?

• At 12-14 weeks: detects genetic abnormalities but carries the

maternal risks of infection and Rh isoimmunization (in a Rh negative
mother) and 0.3-0.5% risk of fetal loss.
• At 3rd trimester: detects pulmonary maturity by testing the lecithin
sphingomyelin (2:1) ratio indicates adequate surfactant and mature
fetal lungs), phosphatidyl glycerol (PG) and phosphatidylinositol (PI)
• tests for hemolytic disease using bilirubin concentralis
What are the important nursing
responsibilities in amniocentesis?
• Informed consent
• Position: supine with a rolled towel or pillow on right buttock to
decrease pressure on vena cava and aorta
• Abdominal preparation
• Vital signs: Maternal BP and FHR before and after
• Rest and avoldance of strenuous activities before like jogging and
aerobic exercises for 1-2 days
What is the value of doing amniotic fluid volume studies by ultrasound scanning?

• The measurement of 4 quadrants of amniotic fluid pockets detects

abnormalities in volume which is associated with fetal disorders. A
total of 5-19 cm is normal, > 20 cm is polyhydramnios, < 5 cm
oligohydramnios.
What is the biophysical profile (BPP)?
• The BPP is the use of 5 fetal well-being parameters that are CNS
controlled and sensitive to hypoxia. These are:
- Fetal tone
- Movement
- Breathing
- Reactive FHR (done by NST) and
- Amniotic fluid studies.
With each having a score of 2, a score of 8-10 is very reassuring.
How does maternal urinary (at term the value is 10-30 mg/
day) or plasma (9-22 ug/dI) estriol level evaluate fetal status?

• The production of estriol by the placenta is dependent on the

function of the fetal adrenal gland and liver. A reduction in 50-60% of
the previous value of estriol or progressive decrease in serial values is
suggestive of fetal jeopardy.
What is the significance of performing alpha-fetoprotein
plus screening on maternal serum at 16-18 weeks of AOG?

• It is 60-70% accurate in detecting Down's syndrome (low serum level

of AFP, unconjugated estriol, higher level of HCG), 85% accurate in
detecting open neural tube defects.
COMPLICATIONS IN PREGNANCY

EARLY PREGNANCY LOSS

• Pregnancy with an abortive outcome is the 4th cause of maternal
mortality in the Philippines
• What is early pregnancy loss? It is the loss of the products of
conception before the of viability (before 20 weeks AOG, fetus
weighing < 350 grams). It is commonly called abortion.
What are the causes of pregnancy loss?

• Loss before 12 weeks are usually due to:

blighted ovum (no fetal structures develop) and do not require
further work-up. Late abortions where the fetus is cytogenetically
normal require further work-up to determine the cause the demise
(hormonal abnormality, infection, uterine abnormalities, cervical
incompetence, defective placenta, immunologic fetal rejection,
antiphospholipid antibody syndrome, uncontrolled systemic diseases).
ECTOPIC PREGNANCY

What is/are the common signs?

• Missed period, vaginal spotting of dark red or brown, abdominal pain (dull,
unilateral lower quadrant due to tubal stretching followed bu sharp colicky
pain) that happens 6-8 weeks after the last menstrual period.
• After rupture, generalized, unilateral or deep lower quadrant acute
abdominal pain, referred shoulder (below the scapula) in case of rupture of
proximal end of the fallopian tube (this is due to blood irritating the
peritoneal cavity), fainting and dizziness.
• In intra-abdominal ectopic pregnancy Cullen's sign (ecchymotic blueness of
umbilicus due to hemaperitoneum) can be seen. The woman usually
undergoes transvaginal ultrasound and serial hCG levels.
What are the common nursing diagnoses and expected outcomes of care?

Nursing diagnoses Expected outcomes

Potential complications Vital signs are stable
Altered comfort pain Verbalize pain relief
Grieving Able to grieve over pregnancy loss
HYDATIDIFORM MOLE (MOLAR
PREGNANCY)
What is/are the common signs?
• Vaginal bleeding (brown or bright red) by 12 weeks
• Uterus larger than gestational age
• Bilateral ovarian enlargement
• Absence of FHR
• Other signs include hyperemesis, passage of vesicles, anemia.
What are the common nursing diagnoses and
expected outcomes of care?
Nursing diagnoses Expected outcomes
High-risk for fluid volume deficit Vital signs within normal limits.
Absent or minimal vaginal bleeding.
Grief Verbalize feelings of grief.
Abortion

• The termination of pregnancy before fetus is viable.

• . "Fetus is viable" is defined as fetus of 20 weeks AOG, weighing < 350
grams.
• May be elective (planned, medical termination of pregnancy) or
reproductive problem.
Predisposing/precipitating factors are:
1. Chromosomal defect
2. Teratogenic factor
3. Immunologic ( anti phospholipid antibody )
4. Faulty placental development
5. Infection
6. Hyperemesis
7. Trauma
8. Severe stress
9. Disease
10. Incompetent cervical os
Types of Abortion:
1. Spontaneous = pregnancy ends of natural cause.
2. Induced = therapeutic or elective reasons for terminating pregnancy.
3. Inevitable = threatened loss that cannot be prevented
4. Incomplete = loss of some products of conception and retention of
others
5. Complete – loss of all products of conception in utero after fetal death.
6. Missed = retention of products of conception in utero after fetal death.
7. Habitual = spontaneous abortions in three or more successive
pregnancies.
8. Septic = abortion due to infection.
BLEEDING DISORDERS IN PREGNANCY
Abruptio Placenta
• Premature separation of placenta from the uterine wall. :
• Common in older gravidas, hypertensives, with previous history, of experienced direct
trauma, and with fibrin defects
• Classic manifestation in third trimester is painful, dark red, non- clotting vaginal
bleeding. Also, abdominal or low back pain, hypertonic to tetanic uterus, enlarged
uterus with tenderness, and fetal distress.
• In concealed bleeding, signs of hypovolemia beyond observed blood loss, increase in
abdominal girth and fundic height.
• Ultrasound reveals normal result; but with decreased hematocrit and hemoglobin and
increased clot retraction.
• Complications include shock and coagulopathy (DIC).
What are the common nursing diagnoses and
expected outcomes of care?
Nursing diagnoses Expected outcomes
Alteration in maternal tissue perfusion Improved vital signs
Improved or stable clotting; no anemia
Decreased blood loss; no hypovolemia
Improved comfort level
Alteration in fetal oxygenation Normal fetal heart rate and variability
Anxiety Express fears and concerns
PLACENTA PREVIA
What is/are the common signs?
• Painless, bright red vaginal bleeding and fetal malpresentation
diagnosed through ultrasound.
What are the common nursing diagnoses and
expected outcomes of care?
Nursing diagnoses Expected outcomes
Alteration in tissue perfusion Vital signs stable
Clotting studies within normal limits
Few uterine contractions
Minimal blood loss
Normal FHT, improved variability
Maternal anxiety Reports decreased anxiety
INTRAVASCULAR COAGULATION
What is/are the common signs?
• bleeding in the urine, IV sites, uterus, nose, etc,
• signs of shock (pallor, lamming skin, pulse is rapid, irregular and
thready, falling BP, change in level of consciousness)
• abnormal clotting results (low fibrinogen, decreased platelet,
abnormal prothrombin and thromboplastin time, increased fibrin and
fibrin split products)
• fetal distress.
What are the common nursing diagnoses and
expected outcomes of care?
Nursing diagnoses Expected outcomes
Alteration in maternal perfusion Decreased blood loss
Clotting studies within normal limits
Vital signs stable
Respiration is normal
Alteration in fetal perfusion FHT is normal
Maternal anxiety Able to verbalize feelings regarding threat to self and
fetus
High risk for altered consciousness LOC remains normal