THE HIGH-RISK MOTHER

Introduction
 Pregnancy poses a risk to the life of every woman. Some
pregnancies are riskier than the others. Woman who have co-
existing health problems as diabetes ,anemia, malaria etc. are
more likely to develop complications. Healthy women can
also suffer from complications.
 It also poses a risk to babies. Complication and other health
problems of the woman can harm babies too.
 Introduction
 Death and disabilities from pregnancy can be
prevented or treated. These can be achieved by a
combination of interventions.
 Family Planning can help avoid and prevent
unplanned too early, too late, too close, too sickly
and too many pregnancies particularly among very
high risk women.
 Introduction
 Quality prenatal, delivery and postpartum
services can prevent complications, detect
problems early and allow prompt treatment
and management, mobilizing communities and
local government will help improve the status
of women who needed care.
 GOAL
 Improve the survival, health and well
being of mothers and the unborn
through a package of services for the:
 pre-pregnancy
 prenatal
 natal
 postnatal stages
 2a.2
Where are we now?

Population of over 80 million will double in 30

years at current growth rate of 2.36%

Rice production in 2002 grew by an average of

only 1.9% -- more hungry people competing for a
decreasing volume of rice
2a.3
Where are we now?
The lack of family planning  It is the poorest Filipinos
places a disproportionate (57.1%) who are not using
burden on the poor. family planning because of
poor access and ineffective
outreach
 20.5% of married women say
they need family planning but
are not using any method
Situationer
 The Philippine Situation
 3.1 million pregnancies occur each year. Half of these pregnancies are
unintended and one third ends in abortion
 About 473,000 abortions annually with induced abortion as 4th

leading cause of maternal deaths

 10 mothers die everyday due to childbirth and pregnancy related

complications

 Every mom who dies leaves 3 orphans. In effect, 30 children are orphaned
every day
 The Philippine Situation
 Only 25.1% of births in poorest quintile were delivered
by a professional attendant compared to 92.4% of the
richest quintile (2003 NDHS)
 Poor women are not consistently able to access
services. Only 1.7% have delivered by caesarean section.
 TFR is highest among the poor
 TFR is highest among the poor …

Wealth status
Fertility Rate

Low Second Middle Fourth High Total

(In percent)

Total fertility rate

(Average number of
children) 5.9 4.6 3.5 2.8 2.0 3.5

Wanted fertility rate

(Preferred number of
children) 3.8 3.1 2.6 2.2 1.7 2.5
Source: NSO and ORC Macro, 2003 NDHS, 2003
 SITUATIONER
 Population - 86 M
 Annual Growth Rate - 2.36%
 Fertility Rate - 3.6% urban; 4% rural
 Maternal Mortality Rate
- 162 / 100,000 live births
 Infant Mortality Rate
- 29/1,000 live births
 Maternal
Maternal Mortality
Mortality Rate
Ratio
250

225

200 209
175
172 162
150
139.6
MMR

125

100

75

50 52.2
25

1993 1998 2006 2015

Year
MDG Goal Actual Trend
Note: To show progress of MMR based on MDG, UNFPA estimated MMR based on the
average rate of progress in 2003.
 Health Indicators
Selected Asian Countries
Japan So.Korea Malaysia Thailand Philippine
s
Life 81 75 73 70 70
Expectancy
Infant Mort. 3 5 8 24 29
Rate
Underfivemort 5 5 8 28 40
ality

Maternal 8 20 41 44 160
Mortality

Population 0.3 0.8 2.2 1.4 2.3

Growth
 Situationer.. Cont.
 Contraceptive Prevalence Rate- 49.3 %
 The top 5 most commonly used FP Methods:
 Pills
 BTL
 Calendar
 Withdrawal
 IUD
 Basic Data
 Poor women have 3x more children
 Poor women are more likely to start sexual activity, get
married and have children the earliest
 Closely- spaced pregnancies higher among young mothers.
 Less educated, poor rural males are more likely to become
fathers early
 Husbands prefer more children than their wives.
 On the average, women want 3 children
 How are our mothers?
 360,000 pregnancies experienced obstetrical complications that
require hospitalization.
 Roughly, 10 women die every 24 hrs. from causes related to
pregnancy and childbirth
 3,650 maternal deaths / year…. most are in the rural areas.
 7 out of 10 deaths occur during labor or within 1 day after delivery.
 473,000 unsafe abortions take place every year
In Central Visayas, only four in 10 births occurs in a health
facility. The national average is less than four in every 10
births, which is also very low by WHO standards.

Percent 69.6

49.4
44.8 45.8

39.8 41.0
37.9
33.4
29.1 28.9
25.7 26.1
21.9 20.7 23.1

15.7 15.6
10.7

Phil NCR CAR R1 R2 R3 R4A R4B R5 R6 R7 R8 R9 R10 R11 R12 Caraga ARMM

Births Delivered in a Health Facility, by Region: 2003

 70 % of births were delivered
in the home

Hospital
27%

Home
Others
70%
3%
Central Visayas is among the regions with higher
percentage in terms of birth delivery assistance by
health professionals.

87.9
85.8

Percent 74.2 74.7

68.3

59.8 59.6
53.2
47.4 47.6
41.0 42.5
36.0 37.2

29.3 31.0

21.9 21.7

Phil NCR CAR R1 R2 R3 R4A R4B R5 R6 R7 R8 R9 R10 R11 R12 Caraga ARMM

Births Delivered with Assistance from Health Professionals*, by

*Health Professionals (Doctors,
Region: 2003 Midwives and Nurses)
 Only 60 % of births were attended by a
health care professional

Nurse
1%

Doctor
33% Midwife
26%

Traditional Birth
Attendant
others
39%
1%

Source: MCHS-PNSO, Philippines 2002

 Why do women die?
 Complications related to pregnancy occurring in the course
of labor, delivery and puerperium.( obstructed labor,
infection)
 Hypertension complicating pregnancy, childbirth, and
puerperium( eclampsia etc.)
 Postpartum Hemorrhage due to uterine atony, placental
retention
 Pregnancy with abortive outcome
 Hemorrhage related to pregnancy ( ectopic pregnancy,
placenta previa etc.)
 High Risk Pregnancy
 Is one in which a concurrent disorder, pregnancy-related
complication, or external factor jeopardizes the health of the
mother, the fetus, or both
 Some women enter pregnancy with a chronic illness that,
when superimposed on the pregnancy, makes it high risk
 Other women enter pregnancy in good health but then develop
a complication of pregnancy that causes it to become high
risk.
 Factors associated with increased risk

 lack of prenatal care

 age less than 18 or older than 35
 conception within two months of previous
delivery
 fifth or subsequent delivery
 prepregnant weight 20% more or less than
normal and/or minimal or no weight gain
 fetal anomaly
 Adolescence
 there may be interference with normal
physical growth and maturation
 lack of family acceptance or support

 isolation from peers

 delayed/ no prenatal care

 increased medical and obstetrical risks

*requires support for feelings, assistance with

decision-making, regular monitoring of
health status, instruction in nutrition
 Substance use/abuse
 Drugs (including alcohol) – may be increased
risk of maternal nutritional deficits, sexually
transmitted diseases (STDs), AIDS, delayed/no
prenatal care, withdrawal symptoms, and fetal
intrauterine growth retardation (IUGR),
anomalies, spontaneous abortions, death, signs
and symptoms of withdrawal or addiction in
neonate; educate, reinforce, counsel, and/or refer
as necessary; emphasize that a safe level of
alcohol has not been identified
 Cigarettes
 increased incidence of intrauterine growth
retardation (IURG), preterm births, low
Apgar scores, spontaneous abortions,
SIDS; as with drugs
 INFECTIONS
 Urinary tract infections (UTI's) – characterized
by urinary frequency and urgency, dysuria, and
sometimes hematuria and manifested in upper
tract by fever, malaise, anorexia, nausea,
abdominal/back pain; confirmed by >100,000/ml
bacterial colony count by clean catch urine;
sometimes asymptomatic
 treated with sulfa-based medications and
ampicillin
 Factors that Categorize a Pregnancy as High Risk
A. Pre-Pregnancy
Psychological Social Physical
a. history of drug dependence a. Occupation handling of a. Visual or hearing
b. History of mental illness toxic substances challenges
c. History of poor coping b. Environmental b. Pelvic inadequacy (CPD)
mechanism contaminants at home c. Secondary major illness
c. Isolated (heart disease, DM, kidney
d. Lower economic level disease, hypertension etc.)
e. Poor access to d. Poor gynecologic or
transportation for care obstetric history
f. Poor housing
g. Lack of support people
Psychological Social Physical

e. History of previous poor

pregnancy
outcome(miscarriage,
stillbirth, intrauterine fetal
death)
f. Pelvic inflammatory
disease
g. Obesity
h. Small stature
i. Younger than age 18
years or older than 35 years
j. Cigarette smoker
k. Substance abuse
B. Pregnancy
Psychological Social Physical

a. Loss of support a. Refusal of or neglected a. Intake of teratogen

b. Illness of a family prenatal care b. Multiple gestation
member b. Exposure to c. Poor placental formation
c. Decrease self-esteem environmental teratogens or position
d. Poor acceptance of c. Decreased economic d. Gestational diabetes
pregnancy support e. Nutritional deficiency
d. Conception less than 1 f. Poor weight gain
year after last pregnancy or g. PIH
pregnancy within 12 h. Infection
months of the first i. Amniotic fluid
pregnancy abnormality
j. post maturity
 C. Labor and Delivery
Psychological Social Physical

a. Severely frightened by a. Lack of support person a. Hemorrhage

labor and delivery b. Unplanned CS b. Infection
experience c. Lack of access to c. Dystocia
b. Inability to participate continued health care d. Precipitate birth
due to anesthesia d. Lack of access to e. Lacerations of cervix or
c. Lack of preparation for emergency personnel or vagina
labor equipment f. CPD
d. Birth of infant who is h. Retained placenta
disappointing in some
way
HIGH RISK PREGNANCY: The Woman who
develops a Complication of pregnancy

 A. Bleeding during Pregnancy:

 - vaginal bleeding is a deviation from the normal that
may occur at any time during pregnancy
 - a woman with any degree of bleeding needs to be
evaluated for the possibility of blood loss and hypovolemic
shock.
 - signs of hypovolemic shock occurs when 10% of
blood volume or approximately two units of blood, have been
lost; fetal distress occurs when 25% of blood volume is lost
  
 Signs and symptoms of Hypovolemic Shock
1. increased pulse rate
2. decreased blood pressure
3. increased respiratory rate
4. cold, clammy skin
5. decreased urine output
6. dizziness or decreased level of consciousness
7. decreased central venous pressure
 The Process of SHOCK due to blood loss (hypovolemia):

 BLOOD LOSS

Decreased intravascular volume

 Decreased venous return, decreased cardiac output, and lowered blood

pressure

 Body compensating by increasing heart rate to circulate the decreased

volume faster;

 Vasoconstriction of peripheral vessels

Increased respiratory rate and a feeling of apprehension at body changes

also occur
 Cold, clammy skin, decreased uterine perfusion. In the face of
continued blood loss, although the body shifts from interstitial
spaces into intravascular spaces, blood pressure will continue
to fall


Reduced renal, uterine and brain perfusion



 Lethargy, coma, decreased renal output



Renal failure


 Maternal and fetal death

Nursing Care of Women with
Complications During
Pregnancy
 High Risk Pregnancy Causes
 Relate to the pregnancy itself
 Occurs because the woman has a medical
condition
 Results from environmental hazards
 Arise from maternal behavior or
lifestyle
 Assessment of Fetal Health
 Nurses responsibility
 Preparing patient properly for test
 Explaining reason for test
 Clarifying and interpreting results in
collaboration with other HCPs
 Providing support to patient
DETERMINATION OF FETAL
STATUS & RISK FACTOR
 SCREENING TEST

 During first visit, screening tests are

performed
 Determine the mother’s health
 Baseline data
 DIAGNOSTICS
 Fetal Diagnostic – used to :
1. Identify or confirm the existence of risk factors
2. Validate pregnancy
3. Identify optimum time for induction of labor if
indicated
4. Identify genetic abnormalities
 Ultrasound

 Use of sound and returning echo pattern,

to identify intra-body structure
 To assist for pregnancy dating
 Assessment of fetal viability, growth patterns,
anomalies, fluid volume
 Uterine anomalies
 Adnexal masses
 Used as adjunct to amniocentesis
 Safe for fetus
Ultrasound Images
4D Ultrasound Images
Chorionic Villus Sampling (CVS)

 Transcervical aspiration of chorionic villi tissues

at 8-12 weeks’ gestation.
 Purpose : diagnosing of genetic disorders
comparable to amniocentesis (except for NTD);
 Obtain informed consent
 Instruct to drink water to fill bladder before
procedure to aid in positioning the uterus for
catheter insertion.
 Report bleeding, infection or leakage of fluid

51
Chorionic Villus Sampling (CVS)
Amniotic Fluid Index
 Kick Count ( Fetal Movement Counting)

 Mother sits quietly/ lies down to left side

 Count fetal kicks for period of time
 Normal : at least 10 kicks/ 12 H
 Sudden violent mov’t followed by reduced
mov’t
 Fetal Movement
 Fetal movement that can be felt by the mother :
QUICKENING begins at approximately 18 –
20 weeks of pregnancy; peaks at 28-38 weeks
 Primigravid- quickening:20 weeks
 Multigravid- 16 weeks
 Ask the mother to observe fetal movement.
 A healthy fetus moves at least 10x a day.

55
 Sandovsky Method
- mother is in a left lateral recumbent position;
fetus normally moves a minimum of twice every
10 minutes or an average of 10 -12x an hour

 Cardiff Method – Count to ten

- records the time it takes for her to feel 10 fetal
movements; usually within 60 minutes

56
 Kick Count Assessment Tool

                                                                                                                                                                              
Doppler Ultrasound Blood Flow
Assessment
Lecithin/ Sphingomyelin Ratio
(2:1)
– important components of surfactant, a
phosphoprotein that lowers surface
tension of the lungs that facilitates
extrauterine expiration

59
 ALFA-fetoprotein
 Test done between 15-18 weeks
 Assess quantity of fetal serum protein
 Increase : open neural tube defect
abdominal wall defects
renal anomalies
Decrease/low : chromosomal trisomies
Alpha Feto Protein

                                                             
 AMNIOCENTESIS
 Aspiration of amniotic fluid
 Done from 13-14 weeks of pregnancy
 Empty bladder before procedure
 Prepare for UTZ to locate placenta
 PURPOSE :To determine genetic disorder, metabolic defect
and fetal lung maturity
 RISKS
1.Maternal hemorrhage
2.Infection
3. Rh iso-immunization
4. Abruptio placentae
5. Amniotic fluid emboli
6. Premature rupture of membrane
Amniocentesis
 Biophysical profile (BPS)
 Identify the risk for asphyxia
 Assesses 4 to 6 parameters (fetal breathing
movement, fetal movement, fetal tone, amniotic
fluid volume, placental grading, and fetal heart
reactivity/ reactive NST)
 Each item has a potential for scoring a 2; 12
highest possible score
 BPS 8 – 10: fetus is doing well
 BPS 4 – 6: fetus is in jeopardy

64
SCORING THE BIOPHYSICAL PROFILE
OBSERVATION NORMAL (2 points) ABNORMAL (0 points)

Non-Stress Test Reactive Non-reactive

Fetal Breathing Movement One breathing period lasting at least Breathing period less than 60 seconds
during 30 Minute Observation Period 60 seconds or no breathing observed

Fetal Body Movement 3 discrete and definite movements of Less than 3 discrete movements of
during 30 Minute Observation Period the arms, legs or body arms/legs or body

Arms and legs are usually flexed with

Fetal Muscle Tone Arms and legs are usually flexed with
head on chest. One definite extension
during 30 Minute Observation Period head on chest - No flexion
and retuen to flexion

Largest Pocket of fluid is greater Largest pocket is less than 1 cm in

Amniotic Fluid Volume than 1 cm in vertical diameter without vertical diameter without loops of
containing loops of cord cord
 ELECTRONIC
MONITORING
 Non-Stress Test (NST)
 Non-invasive
 Test performed in pregnancies over 28 weeks gestation.
 Acceleration in HR accompany normal fetal mov’t

 Contraction Stress Test (CST)

 Principle : healthy fetus can withstand decreased O2
during contraction but compromised fetus cannot.
 How is a NST Performed?
 Position mother in semi-fowler’s or side- lying
position or left lateral position to avoid vena cava
compression.
 The test involves attaching one belt to the mother’s
abdomen to measure fetal heart rate
 Another belt to measure contractions.
 Movement, heart rate and “reactivity” of heart rate
to movement is measured for 20-30 minutes.
 If the baby does not move, it does not necessarily
indicate that there is a problem; the baby could just
be asleep.
 A nurse may use a small “buzzer” to wake the baby
for the remainder of the test.
 Non-Stress Test
 Measures the response of fetal
heart rate to fetal movement
 Determines fetal well-being
 Performed to assess placental
function and oxygenation
 A NST may be performed if:
 Baby is not moving as frequently
as usual
 Post-term
 Suspect that the placenta is not
functioning adequately
 High-risk

68
 ELECTRONIC

MONITORING
Non-Stress Test (NST)
 Non-Invasive

Result Interpretation Significance

Reactive 2 or more increase Fetus has adequate
in HR 15bpm/15s or oxygenation and an
>20-mins period intact CNS
Each fetal mov’t
Non-Reactive No FHR acceleration Fetus asleep or with
<15bpm/min or problems
<15s thru fetal
mov’t
Unsatisfactory FHR pattern not able Repeat NST or do
to be interpreted CST
Inadequate fetal
activity
Non-Stress Test
ELECTRONIC MONITORING

 Contraction Stress Test

(CST)
 Evaluates the respiratory
function of the placenta
 Not done unless willing
to deliver the fetus
 2 types
1. Nipple stimulated CST
2. Oxytocin challenge test
CST

 External fetal monitor is applied to the mother,

and a 20 to 30 minute baseline strip is recorded.
 The uterus is stimulated to contract by the
administration of a dilute dose of oxytocin or by
having the mother use nipple stimulation until 3
palpable contractions with a duration of 40
seconds or more in a 10 minute period have been
achieved.
 Frequent maternal BP readings are done, and the
mother is monitored closely while increasing72

doses of oxytocin are given.

 ELECTRONIC
MONITORING
 Contraction Stress Test (CST)

Result Interpretation Significance

Negative 3 contractions, 40- Fetus should tolerate
60s long/ within 10- labor if it occurs
min period. No late within 1 week
deceleration.
Positive Persistent/consistent Fetus at increased
late deceleration risk
with >50% of
contraction
Suspicious Late deceleration in Repeat CST in 24H
less than 50% of
contraction
Unsatisfactory Poor tracing Same for suspicious
 Interpretation

1. Baseline Rate – is an average FHR

during 10-min period. Normal rate 110-
160bpm
2. Baseline Variability- beat to beat change
in FHR. Occur 3-5x/min
3. Acceleration – are short term increase in
FHR usually caused by Fetal movement
Early deceleration- due to head compression,
no intervention

Late deceleration – dec. HR that begin at the

peak of contractions inc. FHR due to
utero-placental insufficiency give O2 to
mother.
 Variable deceleration – reduction of
FHR that have no relationship to
contractions of the uterus. Compression
in umbilical cord reduces blood flow
between fetus & placenta
Percutaneous Umbilical Blood Sampling
(PUBS)

– second- and third-trimester method to

aspirate cord blood (location identified by
ultrasound)
to test for genetic conditions
chromosomal abnormalities
fetal infections
hemolytic or hematological disorders

77
Percutaneous Umbilical Blood
Sampling
Percutaneous Blood Sampling
 Danger Signs in Pregnancy
 Sudden gush of fluid from vagina
 Vaginal bleeding
 Abdominal pain
 Persistent vomiting
 Epigastric pain
 Swelling of face and hands
 Severe, persistent headache
Danger Signs in Pregnancy –
Cont’d
 Blurred vision or dizziness
 Chills with fever > 100.4 degrees
 Painful urination or reduced urine
output
 Pregnancy-Related
Complications
 Hyperemesis Gravidarum
 Manifestations
 Persisitent N/V
 Significant weight loss
 Dehydration: dry tongue and mucous membranes,
decreased turgor, scant concentrated urine, high
hematocrit
 Electrolyte and acid-base imbalance
 Unusual stress, emotional immaturity,
passivity, ambivalence
 Pregnancy-Related
Complications
 Treatment
 Correct electrolyte imbalances and
acid-base imbalances with oral or IV
fluids
 Antiemetic drugs
 Possibly parenteral nutrition
 Pregnancy-Related
Complications
 Nursing Care
 Focus is on teaching
 Avoid foods that trigger N/V
 Eat small, frequent meals
 Teach about intake and output
 Provide support to the mother
 HYPERTENSION DISORDERS
 Preexisting hypertension (HTN) – diagnosed
and treated before pregnancy; requires strict
medical and obstetrical management
 Pregnancy-induced hypertension (PIH) – no
prior incidence, develops during pregnancy
and resolves during postpartum period
 PRE-ECLAMPSIA
 Vasospasm occurs during pregnancy
 (synonymous with PIH)
 may progress from mild to severe
 TRIAD of symptomatology:
 Hypertension (vascular effect)
 Edema (interstitial effect)
 Proteinuria (kidney effect)
 MILD PRE-ECLAMPSIA
 Elevated BP : 140/90 or
 Increase of +30/ +15 mmHg on two consecutive
occasions at least 6 hours apart as compared to
first-trimester BPs
 Edema: generalized edema that does not clear
overnight, or more significantly, facial; sudden
weight gain >2 lbs/wk (2nd trimester); >1 lb/wk
(3rd trimester)
 Proteinuria 1+ - 2+ in two consecutive tests at
least 6 hours apart or 300 mg/L in a 24-h
specimen
 May be managed at home
SEVERE PRE-ECLAMPSIA
 BP 150-160/100-110, increased edema 3+ - 4+
proteinuria
 Oliguria (Urine output <500 ml/ 24 hours)
 Complaints of headache, visual changes,
epigastric pain, extreme irritability
 Hyperreflexia
 HELLP – hemolysis (significantly decreased
Hct), elevated liver enzymes (Hepatic
dysfunction- SGOT, SGPT), low platelet count
 Managed in the hospital
 ECLAMPSIA

 Obstetrical emergency
 Hypertension
 Proteinuria
 Convulsions
 Coma

 Death is from cerebral hemorrhage,

circulatory collapse, or renal failure
 RISK FACTORS
 African Americans
 >35-y-old or <17-y-old primigravida
 multiple fetuses
 history of diabetes and renal disease
 family history of PIH
 prenatal screening at each visit for
symptomatology
 MANAGEMENT OF MILD PRE
ECLAMPSIA (HOME)
 bedrest side-lying
 increased protein, moderate sodium diet
 discontinue smoking, weigh daily
 instruct patient/family member to look for and
report immediately any of above signs of worsening
 record FM; NST 1-2 times/wk
 monitor lab work, uric acid (indicative of
worsening), and BUN (monitor kidney functioning)
 MANAGEMENT OF MODERATE TO
SEVERE PRE ECLAMPSIA (HOSPITAL)
 absolute bedrest
 seizure precautions
 strictly controlled diet,
 anti-hypertensives and anticonvulsants
 strict I and O and daily serum electrolytes to
maintain hypovolemia and fluid and
electrolyte balance
 maternal and fetal status must be monitored
frequently and routinely
 emotional support/counseling for unexpected
course/ outcomes
MANAGEMENT FOR ECLAMPSIA
 May be maternal recurrence, cerebral hemorrhage,
DIC, and fetal hypoxia
 ensure patent airway (suction and O2 as necessary)
 monitor mother for signs and symptoms of cerebral
hemorrhage, placenta abruptio, pulmonary edema
 may require invasive hemodynamic monitoring
 IV with large-bore needle, type and cross-match
blood available for emergency transfusion
 monitor fetal status
 MgSO4 IV
 immediate delivery if signs and symptoms do not
subside
Management of Hypertension
During Pregnancy
 Treatment
 1st Choice – Immediate Cesarean
 Blood and clotting factor replacement if necessary
 After delivery problem quickly resolves
 Nursing Care
 Prepare for C-section
 Close, continuous monitoring of mother and baby
 Observe for S/S shock
 Prepare for compromised infant
 Prepare for grieving if infant dies
 Magnesium Sulfate
 Drug of choice for the prevention and treatment of
convulsion
 Therapeutic level is 4 – 7 mg/ 100 ml
 Given slowly piggy back IV but may be irritating to vein
or IM given Z tract method
 Monitor RR closely as respiration may be depressed
 Poor urinary excretion may lead to toxicity. Accurate I
and O (catheterization)
 Monitor deep tendon reflex (DTR), absence means
increase in magnesium level
 Monitoring of maternal and fetal vital signs
 Antidote is CALCIUM GLUCONATE
 MANAGEMENT
 Labor induction with IV oxytocin (administered
simultaneously with MgSO4), or in severe cases,
cesarean delivery may be indicated
 In cases of severe hypertension, seizures may still
occur 24-48 h postpartum; monitor MgSO4 or
hydralazine may be continued postpartum
 PHARMACOLOGICAL MANAGEMENT OF PREGNANCY-INDUCED
HYPERTENSION
Medications Side Effects Nursing Considerations
Magnesium sulfate Flushing, sweating CNS depressant, anticonvulsant
Symptoms of toxicity: Monitor BP, P, R, FHR at least every
sudden drop in BP, 15 min; MgSO4 levels and DTR
respirations <12/min, prior to administration, mental
urinary output <25-30 status frequently; have
ml/hr, resuscitation equipment and
decreased/absent calcium gluconate/ chloride
DTRs, (antidote) in room
toxic serum levels
Hydralazine Tachycardia, Vasodilator
(Apresoline) palpitations Maintain diastolic BP
Headache 90-100 mm Hg for adequate
Nausea and vomiting uteroplacental flow;
Orthostatic monitor FHT and neonatal status
hypotension
Diazepam Risk of neonatal Sedative, anticonvulsant
(Valium) depression if given Monitor FHT and neonatal status
within 24 h of delivery
Methyldopa May masks symptoms Used for chronic HTN
(Aldomet) of preeclampsia; Monitor maternal, fetal, and
risk of maternal neonatal vital signs
orthostatic Monitor maternal mental status
hypotension and
decreased pulse and
BP in neonate for 2-3
d
Hemolytic anemia
Propranolol Decreased heart rate, Take apical rate before giving
(Inderal) depression, Monitor BP, EKG
hypoglycemia
Hypertension During Pregnancy
 Hypertension During Pregnancy
 High blood pressure in pregnancy (PIH)
 Preeclampsia
 PIH + proteinuria
 Eclampsia
 PIH + proteinuria + convulsions/seizures
 Toxemia – old terminology
Hypertension During Pregnancy
 Cause unknown
 Birth only definitive cure
 Usually develops after 20th week, but research
has shown that it is determined
at implantation
 Vasospasm is main characteristic
 May increase risks of further complications
Hypertension During Pregnancy
 Risk Factors for PIH
 1st pregnancy
 Obesity
 Family history of PIH
 >40 years or <19 years
 Multifetal pregnancy
 Chronic hypertension
 Chronic renal disease
 Diabetes mellitus
Hypertension During Pregnancy
 If mild to moderate BP readings (systolic <160mm Hg
and diastolic <110 mmHg) identified medications
typically not used to treat
 Treated/Monitored with diet modification,
daily weights, activity restriction, BP monitoring,
fetal kick counts, frequent monitoring for
proteinuria
Hypertension During Pregnancy
 Medication is started if BP exceeds moderate range
 Drugs of Choice
 Methyldopa (Aldomet)
 Labetalol
 Nifedipine (Procardia)
Hypertension During Pregnancy
 Manifestations of PIH
 Vasospasm impede blood flow to mother and placenta resulting in:
 Hypertension
 Typically should not occur in pregnancy due to hormonal

changes which decrease resistance to

blood flow
 Edema
 Occurs when fluid leaves blood vessels and enters tissues

 Proteinuria
 Develops as reduced blood flow damages kidneys
Hypertension During Pregnancy
 Other Manifestations of Preeclampsia
 CNS – HA
 Eyes – Visual disturbances
 Urinary Tract – Decrease UOP
 Respi9ratory – Pulmonary Edema
 GI and Liver – Epigastric pain and N/V, elevated
liver enzymes
 Blood – HELLP – hemolysis, elevated liver
enzymes, low platelets
Hypertension During Pregnancy
 Eclampsia
 Woman has one or more generalized seizures
 Facial muscles twitch, then contraction of all muscles

 Effects on Fetus
 Decreased oxygen availability which may

result in fetal hypoxia

 Meconium

 IUGR

 Fetal Death
Hypertension During Pregnancy
 Treatment of PIH
 Prevention
 Management – as discussed previously
 Drug Therapy
 Magnesium Sulfate (anticonvulsant and antihypertensive)
 Antihypertensive Drug Therapy if BP
> 160/100 mg Hg
Hypertension During Pregnancy
 Nursing Care
 Assist to obtain PNC
 Help cope with therapy
 Provide care/Monitor
 Administer meds
 Postpartum Care
 Blood Incompatibility
 Rh and ABO Incompatibility
 Rh blood factor = Rh+
 No Rh blood factor in erythrocytes = Rh-
 Rh+ person can receive Rh- blood if all other factors
compatible because factor is not
present
 Rh incompatibility only occurs if the mother is
Rh- and fetus is Rh+
 Blood Incompatibility

 Rh- is autosomal recessive triat – both parents must pass on

this gene to the fetus
 Rh+ is dominate gene
 Rh+ person can inherit two Rh+ genes or one Rh+
and one Rh-
 Rh- mother does not have the factor and therefore if her
fetus does her body may respond with antibody production
as a defense mechanism (isoimmunization)
 Typically occurs at delivery and would therefore affect

subsequent pregnancies
 Blood Incompatibility
 Manifestations
 If mother produces anti-Rh anitbodies no outward
manifestation
 Labs reveal increased antibody titers
 When maternal anti-Rh antibodies cross the placenta
fetal erythrocytes are destroyed (erythroblastocis fetalis)
 Blood Incompatibility
 Nursing Care
 Prevent antibody production
 Rhogam at 28 weeks and w/in 72 hours of delivery
if mother Rh- and baby Rh+
 May also be given after amniocentesis as a precaution

 Not effective if sensitization has already occurred

 If antibody production occurs fetus is monitored

carefully
 Coomb’s test
 Amniocentesis
 Percutaneous umbilical sampling test
 Intrauterine transfusion if severely anemic
 Pregnancy Complicated
by Medical Conditions
 Diabetes Mellitus
 Preexisting (Type I or Type II with
onset before pregnancy)
 Gestational (GDM occurs only during
pregnancy)
 DM CLASSIFICATION
 Type I – insulin-dependent (IDDM)
 Type II – non insulin-dependent (NIDDM)
 Gestational diabetes (GDM)
 Impaired glucose tolerance (IGT)
 Diabetes – interaction of diabetes and
pregnancy may cause serious problems for
mother and fetus/newborn
 Pregnancy Complicated
by Medical Conditions
 Pathophysiology of DM
 Pancreas produces insufficient insulin or cells resist
effect of insulin
 Cells cannot receive glucose
 Body metabolizes proteina and fat for energy
 Ketones and acid accumulate
 Person loses weight
 Person experiences fatigue and lethargy
 Fluid moves to tissues to dilute excess glucose leading to
increased thirst resulting in tissue dehydration and
glycosuria (glucose-bearing urine)
 EFFECTS OF DIABETES ON
PREGNANCY
 Maternal
 long-standing diabetes and/or poor control before
conception can increase risk of maternal
infections – monilial vaginitis, pyelonephritis,
UTI
 Polyhydramnios (>2,000 ml amniotic fluid)
 pregnancy-induced hypertension (PIH), and
consequent preterm labor
 Instrumental or cesarean delivery
 Postpartum bleeding
 Pregnancy Complicated
by Medical Conditions
 Effect of Pregnancy on Glucose Metabolism
 Increased resistance of cells to insulin
 Increased speed of insulin breakdown
 Gestational Diabetes Mellitus
 Maternal Links to GDM
 Maternal Obesity (>198 lbs.)
 Previous macrosomic infant
 Maternal age > 25 years
 Previous unexplained stillbirth or infant with congenital
anomalies]
 Family history of DM
 Fasting glucose > 135 mg/dl or postmeal > 200 mg/dl
FETAL AND NEONATAL EFFECTS
 Due to hyperglycemia – in more severe cases,
congenital anomalies- neural tube defect,
cardiac, GI and renal defects
 macrosomia (large for gestational age but may
have immature organ systems) and
 IUGR < prematurity
 Delayed lung maturity - respiratory distress
syndrome (RDS) in neonate
 Neonatal hypoglycemia
 Neonatal hyperbilirubinemia
 Neonatal polycythemia
 untreated ketoacidosis can cause coma and death
of mother and fetus
GESTATIONAL DIABETES
 Women who do not begin in pregnancy with diabetes
become diabetic during pregnancy (approximately 2 –
3%)
 usually normal response to glucose load before and
after pregnancy
 abnormal response is usually noted after 20 weeks,
when insulin need accelerates, bringing about
symptoms; some gravidas will need exogenous insulin
but majority are controlled by diet; oral hypoglycemics
must not be used because they maybe teratogenic and
increase the risk of neonatal hypoglycemia
 60 -70 % chance of GDM in the next pregnancy
 40% of those with GDM may develop DM
 Risk Factors (GDM)
 obesity, family history of diabetes; patient
history of gestational diabetes,
hypertension/PIH, recurrent UTI's, monilial
vaginitis, polyhydramnios; previously large
infant (9 lb/4,000 g or more), previously
unexplained death/anomaly or stillbirths;
glycosuria, proteinuria on two or more
occasions
 ASSESSMENT
 Diabetes – at 24-28 wk for all gravidas
 Screen blood glucose level 1 hour after 50 g
concentrated glucose solution
 Three-hour glucose tolerance test
 OGTT 100 mg glucose
 normal findings:
 FBS: 80-100 mg/dL
 1 h: <190 mg/dL
 2 h: <165 mg/dL
 3 h: <145 mg/dL
 ASSESSMENT
 If two or more abnormal findings, significant
for diabetes
 Glycosylated hemoglobin (HbA1c) – measures
control over the past 3 mo; elevations (>68%)
in first trimester are associated with increased
risk of congenital anomaly and spontaneous
abortion; in the last trimester with macrosomia
RKSteoxon
 MANAGEMENT
 Diet: 20% calories from protein; 50% from
carbohydrates; 30% from fats; increased dietary fibers;
not less than 1800 calories per day
 Exercise: to lower blood glucose
 Stress Management
 Try diet first; then Insulin: usually short acting
(regular) insulin combined with immediate acting
 NO ORAL HYPOGLYCEMIC AGENT! –passes
through the placenta and can be teratogenic
 Pregnancy Complicated
by Medical Conditions
 Treatment of Diabetes During Pregnancy
 Identification
 Diet Modification
 Monitoring
 Ketone Monitoring
 PO antidiabetic agents
 Insulin
 Exercise
 Fetal monitoring
 May indicate early delivery
 Pregnancy Complicated
by Medical Conditions
 Nursing Care for Diabetes During Pregnancy
 Self-care/Management
 Emotional Support
 Encourage Breastfeeding
 CARDIAC DISEASE
Assessment
 Monitor vital signs and do EKG as heart lesion

(especially those of the mitral valve) may become

aggravated by pregnancy
 Chest pain

 Dyspnea

 Treatment of heart disease in pregnancy is

determined by the functional capacity of the heart,

and type of delivery will be influenced by the
mother’s status and the condition of fetus
 CLASSIFICATION
 CLASS I – no limitation, no discomfort with
ordinary physical activity.
 CLASS II – slight limitation, ordinary activity
causes dyspnea, fatigue, chest pain &
palpitations.
 CLASS III – Marked limitation, less than ordinary
activity cause excessive fatigue; palpitations,
chest pain & dyspnea.
 CLASS IV – Severe limitation; patient experiences
symptoms even at rest; unable to perform any
physical activity without discomfort
 SIGNS & SYMPTOMS
 1.Difficulty of breathing – dyspnea, orthopnea,
nocturnal dyspnea
 2. Hemoptysis
 3. Syncope with exertion
 4. Chestpain
 5. Cyanosis
 7. Clubbing of fingers
 8. Neck vein distention
 9. Systolic & diastolic murmurs
CARE OF PREGNANT WOMEN WITH
CARDIAC DISEASE
 Reduce cardiac workload – promote rest, infection
prophylaxis, prevention of anemia, provision of
adequate calories/ fiber/ nutrients and no added salt (2.5
g/day); reduce stress and anxiety; delivery without
bearing down (eg, forceps assisted, pain relief)
 Strengthen cardiac function –administer medication (eg,
digoxin)
 Prevent volume overload
 Monitor fetal well-being
 Pregnancy Complicated by
Medical Conditions
 Nursing Care for Heart Disease
 Teach self-management to patient
 Teach S/S of CHF
 Diet modification
 Teach about eliminated stress
 Nursing Management
 Encourage rest
 Encourage moderation in physical activity
 Explain importance of avoidance of upper
respiratory infections
 Be alert for signs of heart failure: increase of
dyspnea; tachycardia
 Monitor activity level
 Pregnancy Complicated
by Medical Conditions
 Anemia
 Hgb levels < 10.5-11.0 g/dl in pregnancy
 4 types in pregnancy
 Iron-deficiency
 RBCs small and pale
 Prevention – iron supplements

 Treatment – elemental iron supplements

 Folic acid-deficiency
 Large, immature RBCs
 Iron-deficiency anemia may also be present
 Prevention – folic acid supplement

 Treatment – 1mg/day supplement over the amount

of preventative supplement
 Pregnancy Complicated
by Medical Conditions
 Sickle cell disease
 Abnormal Hgb that causes erythrocytes to become sickle-
shaped during hypoxia or acidosis
 Autosommal recessive trait
 Approx 1/12 African Americans has the trait
 Pregnancy may cause crisis
 Risk to fetus – occulsion of vessels leading to preterm
birth, IUGR, fetal death
 Thalasemia
 Genetic trait that causes abnormality in one of two chains
of Hgb ,alpha or beta
 Pregnancy Complicated
by Medical Conditions
 Nursing Care for Anemias During Pregnancy
 Nutrition education
 Education about changes in stool pattern and
characteristics
 Taught to avoid dehydration
 TORCH test series
 group of maternal systemic infections that can be
transmitted across the placenta or by ascending
infection to the fetus;
 infection early in pregnancy may produce significant
and devastating fetal deformities,
 later in pregnancy infection may result in
overwhelming active systemic disease and/or CNS
involvement, causing severe neurological
impairment or death of newborn
 Pregnancy Complicated
by Medical Conditions
 Infections
 TORCH - Devestating infections for fetus
 T – toxoplasmosis

 O – other infections

 R – rubella

 C – cytomegalovirus

 H – herpes simplex virus

 Toxoplasmosis
 caused by protozoan Toxoplasma gondii
 Caused by eating raw or poorly coked meat or by contact with
the feces of infected animals
 Asymptomatic or myalgia, malaise, rash, splenomegaly, and
posterior cervical lymphadenopathy
 Damage to the fetus is worse if acquired early in the pregnancy
 Dx: Sabin-Feldman dye test
 discourage eating undercooked meat and handling cat litter
box
 Tx: Sulfadiazine & Pyrimethamine
 Incidence of abortion, stillbirths, neonatal death & severe
congenital anomalies is high
 Rubella (transplacental)
– prenatal testing required by law; caution susceptible woman
about contact; vaccine is not given during pregnancy
 Period of greatest risk for teratogenic effect:

 during the 1st trimester; between 3rd – 7th weeks of

pregnancy – damage usually results in death, (deafness,

psychomotor problems, microcephaly)
 2nd trimester – hearing impairment

 Leukemia in childhood noted

 Best Tx: PREVENTION!

 Live attenuated vaccine given to children (not given during

pregnancy)
 Cytomegalovirus (CMV)
– transmitted in body fluids; detected by
antibody/serological testing
 Virus found in urine, saliva, cervical mucus,

semen & breast milk

 Principal organs affected: blood, brain and liver

 Anemia, hyperbilirubinemia, thrombocytopenia,

(petecchiae, ecchymosis), hepatosplenomegaly

 Encephalitis (lethargy, convulsions)

 Cerebral palsy may develop

 Herpes type 2
 transplacental, ascending infection within 4-6 h
after ROM or contact during delivery if active
lesions
 cesarean delivery if there are active lesions
 S/S: genital irritation and itching, vaginal or
urethral discharge- may be copious, foul-smelling;
enlarged tender lymph nodes; dysuria begins as
reddish papules>> itchy pustular vesicles>> break
and form painful wet ulcers>> dry and develop
crusts
 Herpes type 2
 20 – 50% rate of spontaneous abortion if infection
occurs during the 1st trimester
 Infection after the 20th week leads to incidence of
premature birth and not to teratogenic effects
 Survivors have permanent visual damage & impaired
psychomotor & intellectual development
 Tx: relieve woman’s vulvar pain ; Sulfonamide
 Pregnancy considerations: Cesarean section- most
probable course for delivery; good handwashing;
cleaning of room using universal precautions
 HEALTH TEACHING

 NO sexual activity in the presence of lesions and 10-

14 days after lesions subsided
 keep vulva clean and dry in the presence of lesions
 sitz bath
 use foley catheter if retention persists
 povidone- iodine douche and acyclovir NOT used
during pregnancy
 Pregnancy Complicated
by Medical Conditions
 Viral Infections
 Cytomegalovirus – May be asymptomatic in mother,
but serious problem in infant
 Mental retardation
 Seizures
 Blindness
 Deafness
 Dental abnormalities
 Petechiae (blueberry muffin rash)

 No effective treatment, therapeutic abortion may be offered if

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

 Treatment – Immunization prior to pregnancy

 Pregnancy Complicated
by Medical Conditions
 Herpes virus – type 1 and type 2 – type 2
affects pregnancy
 Infection in infant can be localized or widespread,
may cause death or neurological complications

 Treatment and Care – Avoid contact with lesions, if

active outbreak Cesarean delivery
 Pregnancy Complicated
by Medical Conditions
 Hepatitis B – transmitted by blood and body fluids,
can also cross placenta
 Treatment and Care – screen during pregnancy, infants
born to women who are Hepatitis B+ should be given
Hepatitis B immune globulin (HbIG), followed by Hep
B vaccine
 Pregnancy Complicated
by Medical Conditions
 HIV – causitive organism of AIDS, cripples
immune system
 Acquired one of three ways
 Sexual contact with infected person
 Parenteral or mucous membrane exposure to infected
body fluids
 Perinatal exposure (20% - 40% chance of infecting infant)
 Transplacentally

 Contact with infected maternal secretions at birth

 Breastmilk
 Pregnancy Complicated
by Medical Conditions
 Non-viral Infections
 Toxoplasmosis – caused by Toxoplasma
gondii, a parasite that may be in cat feces in
raw meat and transmitted through the
placenta
 Possible S/S in newborn
 Low birth weight
 Enlagred liver and spleen
 Jaundice
 Anemia
 Inflammation of eye structures
 Neurological damage
 Pregnancy Complicated
by Medical Conditions
 Treatment and Nursing Care
 Cook all meats thoroughly
 Wash hands after handling raw meat
 Avoid litter boxes , soil and sand boxes
 Wash fresh fruits and veggies well
 Group B streptococcus – leading cause of perinatal infections.
Organism found in woman’s rectum, vagina, cervix, throat or skin.
Woman usually asymptomatic, but can be transmitted to baby at
delivery.
 Diagnosis
 + culture of woman’s vagina or rectum at 35-37 weeks gestation

 Treatment
 Antibiotics to mother prior to delivery

 Antibiotic therapy to infant after delivery

 Pregnancy Complicated
by Medical Conditions
 TB
 S/S
 fatigue
 weakness
 loss of appetite and weight
 Fever
 Night sweats
 Treatment and Nursing Care
 Isoniazid and Rifampin to mother for 9 months
 Infant may have preventative therapy for 3 months
 Pregnancy Complicated
by Medical Conditions
 Sexually Transmitted Diseases
 Prevention is by safe sex with protection of condom
 Herpes
 HIV
 Syphilis
 Gonorrhea
 Chamydia
 Trichomoniasis
 Genital Warts
 Pregnancy Complicated
by Medical Conditions
 Urinary Tract Infections
 More common in pregnancy due to pressure
on urinary structures keeps bladder from
emptying completely and because ureters
dilate and lose motility under influence of
relaxing effects of progesterone and relaxin
 Cystitis – infection of bladder
 S/S
 Burning with urination
 Increased frequency and urgency
 May have slightly elevated temp
 Pregnancy Complicated
by Medical Conditions
 Pyelonephritis – infection of kidney(s)
 S/S
 High fever
 Chills
 Flank pian
 N/V
 Treatment for UTIs
 Antibiotic therapy
 Nursing Care
 Teach to wipe front to back
 Intake adequate fluid
 Urinate before and after intercourse
 Teach S/S
 Pregnancy Complicated
by Medical Conditions
 Substance Abuse – the use of illicit or recreational
drugs during pregnancy .
 Treatment and Nursing Care
 Identify substance abused

 Educate on potential effects of drug

 Use nonjudgmental approach

 Pregnancy Complicated
by Medical Conditions
 Trauma During Pregnancy
 Manifestations of Battering
 May enter late to prenatal care
 May make up excuses
 Treatment and Nursing Care
 Provide for privacy
 Be nonjudgmental
 Offer resources
 Assessment of maternal and fetal
well-being
Effects of a High-Risk Pregnancy
on the Family
 Disruption of Roles
 Financial Difficulties
 Delayed Attachment
 Loss of Expected Birth Experience
 References
 Introduction to Maternity & Pediatric Nursing; Fourth Edition, 2003;
Gloria Leifer, Ma, RN; Associate Professor Obstetrics, Pediatrics, and
Trauma Nursing; Riverside Community
College; Riverside, California; Saunders
The END!!!