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OB Exam 1 Study Guide (The Bible)

Concepts Of Maternal-Child Nursing And Families (Nova Southeastern University)

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Exam 1 OB
Signs of Pregnancy pg. 363

Subjective (Presumptive) Changes

 The subjective changes of pregnancy are the symptoms the woman experiences and reports. Because they
can be caused by other conditions, they cannot be considered proof of pregnancy
 Amenorrhea, absence of menses, is the earliest symptom of pregnancy (with regular periods). It is not a
reliable sign of pregnancy by itself, but if it were accompanied by consistent nausea, fatigue, breast
tenderness, and urinary frequency, pregnancy would be very likely.
 Morning sickness - Nausea and vomiting that occurs early in the day (1 st Trimester)
- Women who experience NVP often have a more favorable pregnancy outcome than those who do
not.
 Excessive fatigue (1st & 3rd trimester)
 Urinary frequency as the enlarging uterus presses on the bladder (1 st and 3rd trimester)
 Breast changes (tenderness)
 Quickening (feels like gas pains and is the moment in pregnancy when the women starts to feel/perceive fetal
movements in the uterus), occurs 16-20 weeks after the LMP

Objective (Probable) Changes

 An examiner can perceive the objective changes that occur in pregnancy. Because these changes can have
other causes, they do not confirm pregnancy.
 Changes noted in the uterus and vagina during pregnancy within the first three months of pregnancy
– Softening of the cervix (Goodell’s sign)
– Dark violet coloration of cervix, vagina, and vulva (Chadwick’s sign)
– Softening of lower part of uterus, the isthmus (Hegar’s sign)
– An ease in flexing of the body of the uterus against the cervix (McDonald’s Sign)
– Progressive uterine enlargement - Know
o The fundus of the uterus is palpable just above the symphysis pubis at about 10-12 weeks’
gestation
o At the level of the umbilicus at 20 to 22 weeks’ gestation
o Between 24-34 weeks the height of the fundus correlates with the weeks of gestation
o Note: Woman can have other things growing here that aren’t a baby such as fibroids
- Enlargement of the abdomen (2nd Trimester she said this is when the uterus becomes an abdominal
organ)

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o Braxton-Hicks contractions can be palpated most commonly after the 28th week. Also
termed false labor.
o Uterine Souffle may be heard when the examiner auscultates the abdomen over the uterus.
Soft blowing sound at the same time as the maternal pulse.
– Funic soufflé is the soft blowing sound of the blood pulsating through the umbilical
cord which occurs at the same time as the fetus’s heart rate.
 Changes in Pigmentation (linea nigra, chloasma and striae)
 Fetal outline may be identified by palpation in many pregnant women after 24 weeks’
gestation
- Ballottement is the passive fetal movement elicited when the examiner inserts two
gloved fingers into the vagina and pushes against the cervix. This action pushes the
fetal body up and as it falls back the examiner feels a rebound.
 Pregnancy test
- A positive hCG test is not necessarily and indicator of pregnancy because it can
indicate molar masses and/or cancer, while low levels are associated with an
ectopic pregnancy

Diagnostic (Positive) Changes

 The positive signs of pregnancy are completely objective, cannot be confused with a pathologic state, and
offer conclusive proof of pregnancy
 Fetal heartbeat: detectable by Doppler ultrasound as early as 10-12 weeks of pregnancy
 Fetal movement: detected by echocardiography or transvaginal sonography but palpable after about 20
weeks of pregnancy
 Visualization of the fetus by ultrasound examination confirms a pregnancy. The gestational sac can be
observed by 4-5 weeks of gestation. Transvaginal ultrasound has been used to detect a gestational sac as
early as 10 days after implantation. Fetal heart activity by 6-7 weeks.

Reproductive System pg. 365

Uterus
 The change is primarily the result of the enlargement (hypertrophy) of the preexisting myometrial cells in
response to the stimulating influence of estrogen and the distention caused by the growing fetus.
 Shows progressive growth; moves from an oval shape to a globular shape and it starts looking like a light
bulb.
 Hegar’s sign: softening of the lower uterine segment
 Braxton-Hicks contractions: irregular uterine contractions (false contractions) that begin around the 4 th
month of pregnancy and can be mistaken for true labor contractions. These contractions have no effect on
the cervix.
 Leopold’s maneuvers: feeling and palpating the abdomen to evaluate the position and presentation of the
fetus
 By 20 weeks gestation, the fundus, or top of the uterus, is at the level of the umbilicus and measures 20 cm.
 The fundus reaches its highest level, at approximately 36 weeks, when it reaches the xiphoid process.
Because it pushes against the diaphragm, many women experience shortness of breath.
 Manipulating the uterus to determine the position of the baby
- Fundus: the top of the uterus
- Isthmus: Middle of the uterus
- Cervix: lover uterus
 Without a tape measure:
- At the pelvis = 12 cm
- Between the pelvis and the umbilicus = 16 cm
- At the umbilicus = 20 cm

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Cervix
 Chadwick’s Sign: bluish discoloration/dark violet in color
 Goodell’s sign: softening of the cervix due to estrogen and progesterone - probable sign of pregnancy
 The endocervical glands secrete a thick, sticky mucus that accumulates and forms the mucous plug, which
seals the endocervical canal and prevents the ascent of organisms into the uterus.
 These signs occur due to hormonal changes in the woman
Ovaries
 Ovulation stops
 Amenorrhea- suppression or absence of menstruation
 Fraternal twins develop from two eggs that are released and fertilized at the same time by two different
sperm
 Identical twins develop from one egg that splits into two
Vagina
 Vaginal epithelium undergoes changes due to circulating estrogen
 Chadwick’s sign: violet bluish, purplish discoloration of the vagina, cervix, vulva and mucus membrane (as
early as 4 weeks)
 Vaginal secretions- the ph changes from alkaline to acidic in order to protect the baby from any outside
bacteria.
 Vaginal secretions are called leukorrhea (Thick, white and acidic)
- This happens so that the acid can kill any sperm or bacteria that try to enter but makes the woman
more susceptible to candida (yeast) infections, which will show signs and symptoms of itching and
irritation.
Breast
 Increase in size, tingling, tender, sebaceous glands (Montgomery Tubercles) enlarge, striae (reddish stretch
marks that turn silver after childbirth)
 Appearance- fullness, areolae darkens
 There is an increase in sebaceous glands to help keep the breast moist
 Colostrum production (first milk): antibody-rich yellowish milk. Milk full of protein and it is very important for
the nurse to educate this to the patient.

Physiologic Changes in Pregnancy pg. 367

Gastrointestinal pg. 367

 Morning sickness - common in first trimester

– Instruct the patient to have small meals throughout the day
 Nausea and vomiting are common during the first trimester and may result from several factors, including
elevated human chorionic gonadotropin (hCG) levels, relaxation of the smooth muscle of the stomach, and
changed carbohydrate metabolism.
 The gums become hyperemic, swollen, and friable and tend to bleed easily. This changed is influenced by
estrogen and increased proliferation of blood vessels and circulation to the mouth.
 The secretion of saliva may increase and even become excessive (ptyalism).
 Dental plaque, calculus, and debris deposits increase during pregnancy and are all associated with gingivitis.
 Elevated progesterone levels cause smooth muscle relaxation, resulting in delayed gastric emptying and
decreased peristalsis. As a result the pregnant woman may complain of bloating and constipation
– High fiber, increase fluids, drink something warm in the morning to stimulate the bowels, try to
move around
 These symptoms are aggravated as the enlarging uterus displaces the stomach upward and the intestines are
moved laterally and posteriorly. The cardiac sphincter also relaxes, and heartburn (pyrosis) may occur
because of reflux of acidic secretions into the lower esophagus.
– Remain sited upright after eating, avoid spicy foods, eat in small portions
 Hemorrhoids frequently develop in late pregnancy from constipation and from pressure on vessels below the
level of the uterus.
– High fiber diet and increase fluids to prevent this

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 The emptying time of the gallbladder is prolonged during pregnancy as a result of smooth muscle relaxation
from progesterone. This, coupled with the elevated levels of cholesterol in the bile, can predispose the
woman to gallstone formation.
 If n/v persists past the first trimester = hyperemesis gravidarum

Hyperemesis Gravidarum

 Persistent and severe nausea and vomiting

 Can be fatal
 Can cause weight loss (which is malnutrition for the fetus and may cause IUGR), fluid and electrolyte
imbalance and dehydration. Dehydration causes uterine contraction, hence is risking placing the mother in
preterm labor. Would place on IV on this mom and load her with fluids.

Cardiovascular

 Heart position - shifts upward in transverse position

 Heart increases in size because its working harder
 Blood volume increases, as it is needed to provide adequate hydration to fetal and maternal tissues, to supply
blood flow to perfuse the enlarging uterus, and to provide a reserve to compensate for blood loos at birth
and during postpartum.
– Anemia includes hemoglobin of less than 10, 3.5 million RBCs or a normal morphology with central
pallor.
 Cardiac output increases & Stroke volume increases
 The pulse may increase by as many as 10 to 15 beats per minute between 14 to 20 weeks of gestation and
persists to term
 The blood pressure decreases slightly, reaching its lowest point during the second trimester. It gradually
increases to near pre-pregnant levels by the end of the third trimester.
 The enlarging uterus puts pressure on pelvic and femoral vessels, interfering/impeding with returning blood
flow and causing stasis of blood in the lower extremities. This condition may lead to dependent edema and
varicosity of the veins in the legs, vulva, and rectum (hemorrhoids) in late pregnancy. This increased blood
volume in the lower legs may also make the pregnant woman prone to postural hypotension.
 When the pregnant woman lies supine, the enlarging uterus may press on the vena cava, thus reducing blood
flow to the right atrium, lowering blood pressure, and causing dizziness, pallor, palpitations, and clamminess.
The enlarging uterus may also press on the aorta and its collateral circulation. This condition is called supine
hypotensive syndrome/ vena caval syndrome/ aortocaval compression.
– It can be corrected by having the woman lie on her left side or by placing a pillow or wedge under
her right hip.
 Your BP should not increase in pregnancy *abnormal* -> can be indicative of pre-eclampsia or PIH

Hematologic

 Plasma volume increases & RBC volume increases

 Because the plasma volume increase (50%) is greater than the erythrocyte increase (30%), the hematocrit,
which measures the concentration of red blood cells in the plasma, decreases slightly. This decrease is
referred to as the physiologic anemia of pregnancy (pseudoanemia).
– Vitamins and supplements help to prevent this
 Hemoglobin decreases (take supplements such as iron)
 Leukocytosis during pregnancy has no known cause but it is a normal finding. 5,600 to 12,200/mm3. Which
can increase up to 25,000/mm3 or higher.
 Both fibrin and plasma fibrinogen levels increase during pregnancy. Although the blood-clotting time of the
pregnant woman does not differ significantly from that of the non-pregnant woman, clotting factors VII, VIII,
IX, and X increase; thus, pregnancy is a somewhat hypercoagulable state. These changes, coupled with
venous stasis in late pregnancy, increase the pregnant woman’s risk of developing venous thrombosis.

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Respiratory

 Enlarging uterus presses upward on diaphragm causing difficulty in breathing, elevating the diaphragm
 Lung expansion may decrease
 Some hyperventilation and difficulty in breathing may occur (Fatigue, SOB, dyspnea)
 Nasal stuffiness and epistaxis (nosebleeds) may also occur because of estrogen-induced edema,
hypersecretion of mucus, and vascular congestion of the nasal mucosa.
 Increase maternal oxygen requirements
 10 to 12L oxygen can be given without a doctor’s order – not only does the mom need oxygen but the fetus
does too

Urinary

 During the first trimester, the enlarging uterus is still a pelvic organ and presses against the bladder,
producing urinary frequency. This symptom decreases during the second trimester, when the uterus becomes
an abdominal organ and pressure against the bladder lessens. Frequency reappears during the third
trimester, when the presenting part descends into the pelvis and again presses on the bladder, reducing
bladder capacity, contributing to hyperemia, and irritating the bladder.
 Infections
 R/t sluggishness of the urine
 Make sure is drinking a lot of fluids to prevent infections
 Glomerular filtration rate increases to meet the increase need of the circulatory system. Glycosuria may be
normal or may indicate gestational diabetes, so it always warrants further testing.
 1st and 3rd trimester is when women usually have urinary frequency

Skin and Hair (Integumentary)

 Stimulated by increased estrogen, progesterone, and α-melanocytic-stimulating hormone levels.
Pigmentation of the skin increases primarily in areas that are already hyper pigmented: the areolae, the
nipples, the vulva, and the perianal area.
 The skin in the middle of the abdomen may develop a pigmented line, the linea nigra, which usually extends
from the pubic area to the umbilicus or higher
 Facial chloasma (melasma gravidarum), also known as the “mask of pregnancy,” a darkening of the skin over
the forehead and around the eyes, may develop. Melasma is more prominent in dark-haired women and is
aggravated by exposure to the sun. Fortunately, it fades or becomes less prominent soon after childbirth
when the hormonal influence of pregnancy subsides.
 Striae (striae gravidarum when they result from pregnancy), or stretch marks, may appear on the abdomen,
thighs, buttocks, and breasts. They result from reduced connective tissue strength because of elevated
adrenal steroid levels.
 Vascular spider nevi, small, bright-red elevations of the skin radiating from a central body, may develop on
the chest, neck, face, arms, and legs. They may be caused by increased subcutaneous blood flow in response
to elevated estrogen levels. To avoid this:
- Elevate both legs when sitting or lying down
- Avoid prolonged standing or sitting
- Resting in the left lateral position
- Walking daily for exercise

Musculoskeletal

 Calcium: needs increase

 Magnesium: needs increase
 Pelvic joints: more pliable The joints of the pelvis relax somewhat because of hormonal influences. The result
is often a waddling gait.

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 As the pregnant woman’s center of gravity gradually changes, the lumbar spinal curve becomes accentuated
(lordosis), and her posture changes. This posture change compensates for the increased weight of the uterus
anteriorly and frequently results in low backache

Central Nervous System

 Pregnant women frequently describe decreased attention, concentration, and memory during and shortly
after pregnancy, but few studies have explored this phenomenon.

Endocrine

Thyroid

 The thyroid gland often enlarges slightly during pregnancy because of increased vascularity and hyperplasia
of glandular tissue. Women with low thyroid levels (thyroid insufficiency) may compromise fetal neurologic
development.

Pituitary

 Pregnancy is made possible by the hypothalamic stimulation of the anterior pituitary gland.
 Follicle-stimulating hormone (FSH), which stimulates ovum growth, and luteinizing hormone (LH), which
brings about ovulation. Stimulation of the pituitary also prolongs the ovary’s corpus luteal phase. This
maintains the endometrium in case conception occurs.
 Prolactin, another anterior pituitary hormone, is responsible for initial lactation.
 The posterior pituitary secretes vasopressin (antidiuretic hormone) and oxytocin. Vasopressin causes
vasoconstriction, which results in increased blood pressure; it also helps regulate water balance.
 Oxytocin promotes uterine contractility and stimulates ejection of milk from the breasts (the letdown reflex)
in the postpartum period.

Pancreas

 The pregnant woman has increased insulin needs, and the pancreatic islets of Langerhans, which secrete
insulin, are stressed to meet this increased demand. Any marginal pancreatic function quickly becomes
apparent, and the woman may show signs of gestational diabetes mellitus (GDM).

Hormones in pregnancy:

Human Chorionic Gonadotropin (hCG)

 This hormone stimulates progesterone and estrogen production by the corpus luteum to maintain the
pregnancy until the placenta is developed sufficiently to assume that function.
Human Placental Lactogen (hPL)
 Also called human chorionic somatomammotropin, human placental lactogen (hPL) is produced by the
syncytiotrophoblast.Human placental lactogen is an antagonist of insulin; it increases the amount of
circulating free fatty acids for maternal metabolic needs and decreases maternal metabolism of glucose to
favor fetal growth.
Estrogen
 Estrogen stimulates uterine development to provide a suitable environment for the fetus. It also helps
develop the ductal system of the breasts in preparation for lactation.
Progesterone
 Progesterone plays the greatest role in maintaining pregnancy. It maintains the endometrium and inhibits
spontaneous uterine contractility, thus preventing early spontaneous abortion. Progesterone also helps
develop the acini and lobules of the breasts in preparation for lactation.
Relaxin
 Relaxin inhibits uterine activity, diminishes the strength of uterine contractions, aids in the softening of the

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cervix, and has the long-term effect of remodeling connective tissue, which is necessary for the uterus to
accommodate pregnancy

Prostaglandins

 Prostaglandins are lipid substances that can arise from most body tissues but occur in high concentrations in
the female reproductive tract and are present in the decidua (endometrium) during pregnancy.
 They are responsible for maintaining reduced placental vascular resistance. Decreased prostaglandin levels
may contribute to hypertension and preeclampsia. Prostaglandins may also play a role in the complex
biochemistry that initiates labor.
 At the beginning of pregnancy, the synthesis of estrogen and progesterone is ensured by the corpus luteum
that is maintained by hCG. The activity of the corpus luteum decreases with the beginning of the 8 th week in
order to be entirely replaced by the placenta at the end of the 1 st trimester.
 The corpus luteum is what produces the hormones before the placenta takes over.

Metabolism

 Taking iron supplements is essential for fetal growth and brain development and in prevention of maternal
anemia. It is needed to form new blood cells for the expanded maternal blood volume. 27 mg of ferrous iron
per day is recommended.
 An increase in folic acid is essential before pregnancy and in the early weeks of pregnancy to prevent neural
tube defects in the fetus. 400 to 800 mcg of folic acid per day are recommended.
 Protein in diet should be increased from 60 to 80/g day, while calories should be increased by 300/day from
the daily-recommended intake of 1800 to 2200.

Weight

 The recommended total weight gain during pregnancy for a woman of normal weight before pregnancy is
11.5 to 16 kg (25 to 35 lb)
 For women who were overweight before becoming pregnant, the recommended gain is 6.8 to 11.5 kg (15 to
25 lb).
 Women with obesity are advised to limit weight gain to 5 to 9 kg (11 to 20 lb).
 Underweight women are advised to gain 12.7 to 18.1 kg (28 to 40 lb)
 During the first trimester, women whose pre-pregnancy weight is within the normal weight range, weight
gain of about 3.5 to 5 lb is considered normal. For underweight women, weight gain should be at least 5 lb.
For over-weight women, weight gain should be 2 lb. During the second and third trimesters, for women
whose pre-pregnancy weight is within the normal weight range, weight gain should be about 1 pound per
week, for those underweight then over 1 pound per week and for those over-weight a weight gain of less
than 1 pound a week.

Water Metabolism

 The increased level of steroid sex hormones affects sodium and fluid retention.
 The extra water is needed for the fetus, the placenta, amniotic fluid, and the mother’s increased blood
volume, interstitial fluids, and enlarged organs.

Nutrient Metabolism

 Low sodium, adequate calories, increased protein

 The fetus makes its greatest protein and fat demands during the second half of pregnancy, doubling in weight
during the last 6 to 8 weeks.

Psychological Response to Pregnancy

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The Mother
 The way each woman meets the stresses of pregnancy is influenced by her emotional makeup, her sociologic
and cultural background, and her acceptance or rejection of the pregnancy.
 However, many women manifest similar psychologic and emotional responses during pregnancy, including
ambivalence, acceptance, introversion, mood swings, and changes in body image.
 Many women commonly experience feelings of ambivalence (doubt) during early pregnancy. This
ambivalence may be related to feelings that the timing is somehow wrong; worries about the need to modify
existing relationships or career plans; fears about assuming a new role; unresolved emotional conflicts with
the woman’s own mother; and fears about pregnancy, labor, and birth.
 These feelings may be more pronounced if the pregnancy is unplanned or unwanted. Indirect expressions of
ambivalence include complaints about considerable physical discomfort, prolonged or frequent depression,
significant dissatisfaction with changing body shape, excessive mood swings, and difficulty accepting the life
changes resulting from the pregnancy.
 Lower acceptance of the pregnancy tends to be related to unplanned pregnancy and greater evidence of fear
and conflict. When a pregnancy is well accepted, the woman demonstrates feelings of happiness and
pleasure in the pregnancy
First Trimester
- During the first trimester, feelings of disbelief and ambivalence are paramount. The woman’s baby
does not seem real, and she focuses on herself and her pregnancy
- Remember this is because there are yet no physical changes. Her uterus is still a pelvic organ. If she
is an adolescent she may be “day dreaming” that she might have had an abortion
Second Trimester
- During the second trimester, quickening occurs. This perception of fetal movement helps the woman
think of her baby as a separate person, and she generally becomes excited about the pregnancy
even if earlier she was not.
- As pregnancy becomes more noticeable, the woman’s body image changes. She may feel great
pride, embarrassment, or concern
Third Trimester
- In the third trimester, the woman feels pride about her pregnancy and anxiety about labor and birth.
Physical discomforts increase, and the woman is eager for the pregnancy to end
- The woman tends to be concerned about the health and safety of her unborn child and may worry
that she will not cope well during childbirth. Toward the end of this period, there is often a surge of
energy as the woman prepares a “nest” for the infant. Many women report bursts of energy, during
which they vigorously clean and organize their homes

Psychologic Tasks of the Mother

Four major tasks that the pregnant woman undertakes to maintain her intactness and that of her family and to
incorporate her new child into the family system
1. Ensuring safe passage through pregnancy, labor, and birth. The pregnant woman feels concern for both her
unborn child and herself. She looks for competent maternity care to provide a sense of control. She may seek
information from literature, observation of other pregnant women and new mothers, and discussion with
others
2. Seeking acceptance of this child by others. In this adjustment the woman’s partner is the most important
figure.
3. Seeking commitment and acceptance of herself as mother to the infant (binding-in). The child begins to
become a real person, and the mother begins to develop bonds of attachment. The mother experiences
movement of the child within her in an intimate, exclusive way, and bonds of love form. The mother develops
a fantasy image of her ideal child.
4. Learning to give of oneself on behalf of one’s child. Childbirth involves many acts of giving. The man “gives” a
child to the woman; she in turn “gives” a child to him. Life is given to an infant; a sibling is given to older
children of the family. The woman begins to develop a capacity for self-denial and learns to delay immediate
personal gratification to meet the needs of another.

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The Father
 Initially, expectant fathers may feel pride in their virility, which pregnancy confirms, but also have many of
the same ambivalent feelings as expectant mothers. The extent of ambivalence depends on many factors,
including the father’s relationship with his partner, his previous experience with pregnancy, his age, his
economic stability, and whether the pregnancy was planned.
 They also share the experiences of pregnancy and birth with their partners
First Trimester
- After the initial excitement attending the announcement of the pregnancy, an expectant father may
begin to feel left out. He may be confused by his partner’s mood changes. He might resent the
attention she receives and her need to modify their relationship as she experiences fatigue and
possibly a decreased interest in sex. He might also be concerned about what kind of father he will
be.
Second Trimester
- The father’s role in the pregnancy is still vague, but his involvement may increase as he watches and
feels fetal movement and listens to the fetal heartbeat during a prenatal visit. For many men, seeing
their infant on ultrasound is an important experience in accepting the reality of pregnancy
- The father-to-be’s anxiety is lessened if both parents agree on the paternal role the man is to
assume
Third Trimester
- If the couple’s relationship has grown through effective communication of their concerns and
feelings, the third trimester is often a rewarding time
- If the father has developed a detached attitude about the pregnancy, however, it is unlikely he will
become a willing participant, even though his role becomes more obvious. Concerns and fears may
recur. The father may worry about hurting the unborn baby during intercourse or become
concerned about labor and birth. He may also wonder what kind of parents he and his partner will
be.
Couvade
 Couvade has traditionally referred to the observance of certain rituals and taboos by the male to signify the
transition to fatherhood. This observance affirms his psychosocial and biophysical relationship to the woman
and child. More recently the term has been used to describe the unintentional development of physical
symptoms such as fatigue, increased appetite, difficulty sleeping, depression, headache, or backache by the
partner of a pregnant woman. Men who demonstrate couvade syndrome tend to have a higher degree of
paternal role preparation and be involved in more activities related to this preparation.
Siblings
 Bringing a new baby home often marks the beginning of sibling rivalry. The siblings view the baby as a threat
to the security of their relationships with their parents
 Because they do not have a clear concept of time, young children should not be told too early about the
pregnancy
 The mother may let the child feel the baby moving in her uterus, explaining that the uterus is “a special place
where babies grow.” The child can help the parents put the baby clothes in drawers or prepare the baby’s
room.
 Consistency is important in dealing with young children. They need reassurance that certain people, special
things, and familiar places will continue to exist after the new baby arrives
Grandparents
 Younger grandparents leading active lives may not demonstrate as much interest as the young couple would
like.
 In other cases, expectant grandparents may give advice and gifts unsparingly. For grandparents, conflict may
be related to the expectant couple’s need to feel in control of their lives, or it may stem from events signaling
changing roles in the grandparents’ own lives (e.g., retirement, financial concerns, menopause, or death of a
friend).
 Some parents of expectant couples may already be grandparents with a developed style of grand parenting.
 Clarifying the role of the helping grandparent ensures a comfortable situation for all.

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Cultural Values and Pregnancy

 Cultures have a universal tendency to create ceremonial rituals or rites around important life events. The
rituals and customs of a group are a reflection of the group’s values.
 In many developed countries, such as the United States, Canada, England, and Germany, populations are
becoming more and more ethnically diverse as the number of immigrants continues to grow.
 It is not realistic or appropriate to assume that people who are new to a country or area will automatically
abandon their ways and adopt the practices of the dominant culture
 Consequently, the identification of cultural values is useful in planning and providing culturally sensitive care
 For this reason, the nurse needs to supplement a general knowledge of cultural values and practices with a
complete assessment of the individual’s values and practices
 Cultural assessment is an important aspect of prenatal care.
 The nurse needs to identify the prospective parents’ main beliefs, values, and behaviors about pregnancy and
childbearing. This includes information about ethnic background, amount of affiliation with the ethnic group,
patterns of decision making, religious preference, language, communication style, and common etiquette
practices.
 Once this information is gathered, the nurse can then plan and provide care that is appropriate and
responsive to family needs

Antepartum Nursing Assessment

 1st trimester: 0-12 weeks

 2nd trimester: 13-28 weeks
 3rd trimester: 29-40 weeks
 Duration of pregnancy:
- 9 Calendar Months
- 10 Lunar Months
- 280 days
- (266 days from time of ovulation)
- 40 weeks
 At 12 weeks’ gestation the fundus can be palpated at the symphysis pubis. At 16 weeks’ gestation the fundus
is midway between the symphysis and the umbilicus. At 20 weeks the fundus can be palpated at the
umbilicus and measures approximately 20 cm from the symphysis pubis. By 36 weeks, the fundus I just below
the xiphoid process and measures approximately 36 cm.
 Baby goes up to the xiphoid process at 36 weeks. After 36 weeks it is difficult to measure the baby's size by
measurement because when the head drops the baby goes back down towards the pelvis.
 Nagele’s rule states that in order to get the estimated delivery date (EDD), you count back 3 months from the
first day of the last menstrual period and add 7 days to that date.

Common Discomforts of Pregnancy in 1st Trimester

1. Urinary frequency
 Cause
- Pressure of growing uterus on bladder
 Management
- Decrease fluid intake at night
- Maintain fluid intake during day
- Void when feel urge
- Most common during 1st & 3rd trimester
2. Breast enlargement and sensitivity
 Cause
- Effects of hormones, especially estrogen and progesterone

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 Management
- Wear a good supporting bra with wide shoulder straps a cup size bigger
3. Nasal stuffiness and epistaxis
 Cause
- Elevated estrogen levels
 Management
- Avoid decongestants!
- Use humidifiers, cool mist vaporizers, and normal saline drops
4. Ptyalism (the excessive spitting in pregnancy)
 Cause
- Unknown
 Management
- Perform frequent mouth care
- Chew gum or suck hard candy
5. Nausea and vomiting
 Cause
- Unknown; although some books say its because of the hormones
 Management
- Avoid foods or smell that exacerbate condition
- Eat dry crackers or toast before arising in the morning
- Eat small, frequent meals

Common Discomforts of Pregnancy in 2nd Trimester:

1. Shortness of breath
• Cause
- Growing fetus puts pressure on the diaphragm
• Management
- Use extra pillows at night to keep more upright
- Limit activity during the day to what they are comfortable with or less
2. Heartburn – Pyrosis
 Cause
- Displacement of the stomach & intestines by growing fetus
• Management
- Eat small, more frequent meals
- Use antacids
- Avoid overeating and use of spicy foods
3. Varicosities
• Cause
- Weight of the uterus, which causes pooling and engorgement of veins in lower extremities
- Heredity, age, obesity
- Increased vascularity
• Management
- Rest in sims’ position
- Elevate legs regularly
- Avoid crossing legs
- Avoid tight stockings
- Avoid long periods of standing
4. Leukorrhea (white vaginal discharge): If it is offensive: greenish/pink/odor = get medical tx
• Cause
- Increased estrogen levels

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• Management
- Take daily bath or shower
- HOT GIRL PANTIES HAVE TO GO! Wear cotton underwear (to absorb extra moisture)
- Do not douche!!! (you’ll wash away natural bacteria)
5. Backache
• Cause
- Lumber lordosis that develops to maintain balance on later pregnancy
• Management
- Wear shoes with low heals
- Walk with pelvis tilted forward
- Use firmer mattress
- Perform pelvic rocking or tilting
- Mild discomfort = OKAY … severe discomfort may indicate premature labor
6. Flatulence
• Cause
- Decreased gastric motility
- Pressure of growing uterus on large intestine
• Management
- Avoid gas-forming foods (beans, broccoli, oatmeal)
- Chew food thoroughly
- Engage in regular daily exercises
- Maintain regular bowel routine
7. Leg cramps
• Cause
- Decrease serum calcium levels
- Increase serum phosphate
- Interference with circulation
• Management
- Extend affected leg and dorsiflex the foot
- Elevated lower legs frequently
- Apply heat to muscles
- Evaluate diet and make sure she is getting enough electrolytes
8. Carpal Tunnel Syndrome
• Cause
- Compression of the medial nerve of the wrist
- Weight gain and edema may also contribute
• Management
- Avoid aggravating hand movements
- Elevate affected arm
- Wear splints
9. Faintness
• Cause
- Pooling of blood in lower extremities
- Anemia
- Supine orthostatic hypotension
• Management
- Rise slowly from sitting to standing / avoid lying on her back
- Evaluate H&H
- Avoid hot and stuffy environments

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10. Mood swings

• Cause
- Hormonal
 Management
- Inform client and partner mood swings are normal

Subsequent Prenatal Assessment – Know

The recommended frequency of antepartum visits in an uncomplicated pregnancy is as follows:

 Every 4 weeks for the first 28 weeks’ gestation

 Every 2 weeks until 36 weeks’ gestation
 After week 36, every week until childbirth

Maternity is divided into three sections (Phases of Pregnancy)

 Antepartum- time between conception and the onset of labor. (This is what will be on exam 1)
 Intrapartum-period from the onset of true labor until the birth of the baby and placenta.
 Postpartum- time from birth until the woman’s body returns to pre-pregnant state.

Obstetric terms (GTPAL)

 Gravida: The total number of pregnancies including the current one regardless duration
 Term: The number of infants born at term - 38 weeks or more gestation
 Preterm: The number of infants born after 20 weeks’ gestation but before completion of 37 weeks’ gestation
 Abortion /miscarriage: The number of pregnancies that ended in either therapeutic or spontaneous abortion
- before 20 weeks
 Living: The number of children currently living
 Note: If you have twins, it is considered ONE pregnancy during calculation

Pregnancy Terminology

 Gravid – The state of being pregnant

 Gestation – number of weeks from the first day of the last menstrual period.
 Term – normal duration of pregnancy - 38-42 weeks’ gestation
 Para – birth after 20 weeks’ gestation regardless of whether the infant is born alive or dead
 Primipara – woman who has had one birth at more than 20 weeks’ gestation
 Multipara – woman who has had two or more births at more than 20 weeks’ gestation
 Nullipara – woman who has had no births at more than 20 weeks’ gestation
 Stillbirth – infant born dead after 20 weeks’ gestation
 Multigravida – Woman pregnant for at least the third time or more
 Nulligravida – Woman who has never been pregnant
 Primigravida – woman who is pregnant for the first time
 Secundigravida – woman pregnant for the second time

Patient Profile
The history is essentially a screening tool to identify factors that may place the mother or fetus at risk during the
pregnancy.
1. Current pregnancy
 First day of normal menstrual period (LMP)
 Presence of complications (High BP, diabetes, asthma, etc)
 Attitude towards pregnancy (she can be depressed about it)
 Results of pregnancy test
2. History of previous pregnancies

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 Number of pregnancies and number of living children

 Number of abortions
 Length of pregnancy (to help determine the length of the next one; if you had babies at 28 weeks
you may deliver the next one early)
 Type of birth (C-sections, vaginal)
- Once a section is not always a C-section. It is safer to have a natural birth 2 years after
having a C-section.
 Type of anesthesia used, if any
 Complications associated with childbirth, if any
 Neonatal complications
 Blood type and Rh factor
- RH factor affects a mother who is negative. It affects mom when she becomes pregnant
from a positive man. When the RH negative mother becomes pregnant, if the baby is
positive and the blood gets into her blood stream her body will see that as a foreign body,
and her body will build immunity and fight that blood. The first baby will be fine. It affects
the next baby because they will be seen as a foreign body so she will keep aborting the rest
of her babies.
- (RhoGAM shot is given at 28 weeks to protect her against any Rh-positive red blood cells
from the fetus.)
 Prenatal education classes and resources
3. Gynecologic history
 Date of last Pap smear; results?
 Previous infections
 Previous surgery
 Age at menarche – regularity, frequency, and duration of menstrual flow
 History of dysmenorrhea
 History of infertility
 Sexual history
 Contraceptive history
4. Current medical history
 General health, including nutrition
 Weight – pre-pregnant and current.
 Medications and use of herbal medications - interactions can occur
 Previous or presence use of alcohol, tobacco, or caffeine (these things are teratogenic and can have
bad effects on the baby; a baby born to an alcoholic can have fetal alcohol syndrome or come out
with seizures/ withdrawal symptoms because the baby wants drug; A baby born to a diabetic may
experience hypoglycemia.)
 Illicit drug use and drug allergies and other allergies
- Ex: Thalidomide was given for n/v in pregnancy in the 60's; babies were born without limbs
because of the effects of the drug.
 Potential teratogenic insults to this pregnancy – viral, medications, X-rays, cats at home, surgery
- Teratogen= Any biological, physical, chemical, or radioactive agent that causes structural or
functioning damage to the fetus
 Presence of chronic disease conditions such as diabetes, hypertension, cardiovascular, renal, cancer,
thyroid disorder
 Record of Immunizations - Ask about immunization history. For example: screening for rubella is
done but not treated until after delivery. Reasons being are because these vaccinations are live
viruses. If given during pregnancy, the baby will be born death.
 With some vaccines the benefit outweighs the risk.
 Advise pregnant women to avoid live virus vaccines (MMR and varicella) and to
avoid becoming pregnant within 1 month of having received one of these vaccines
because of the theoretical risk of transmission to the fetus.
5. Past medical history

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 Childhood diseases
 Past treatment for any disease condition
 Surgical procedures
 Presence of bleeding disorders or tendencies (Blood transfusions)
6. Family medical history
 Presence of chronic diseases
 Multiple births- twins?
 History of congenital disease or deformities
 Cesarean births and cause, if known
7. Genetic history (patient, father of child)
 Birth defects
 Recurrent pregnancy loss
 Stillbirth
 Down syndrome, any disability
 Ethnic background
 Genetic disorder
8. Religious beliefs related to health care and birth
 Does the woman wish to specify a religious preference on the chart?
 What practices are important for her spiritual well-being?
 Might some of these practices affect the child?
9. Occupational history
 Occupation
 Physical demands on job (you have standing jobs like retail; educate them and tell them to take
short breaks and put their legs up when they can)
 Exposure to chemicals or harmful substances
 Do you have opportunities fro regular meals and breaks for snack?
10. Partner’s history
 Age
 Significant health problems
 Previous or present alcohol intake, drug use, tobacco use
 Blood type and Rh factor
 Occupation
 Educational level
 How does he feel about the pregnancy?
11. Personal history
 Age
 Relationship status
 Educational level
 Ethnic background (sickle cell disease is common in blacks; Thalassemia is common in asians)
 Socioeconomic status
 How does she feel about being pregnant?
 Any history of emotional or physical deprivation or abuse of herself or children or any abuse in her
current relationship?
 History of mental health problems
 Support systems – important!

Expected Date of Delivery (EDD, EDB,EDC) can be determined by:

 Doppler ultrasound contraindicated during first trimester

 Fundal height: measurement of uterine size
 Naegele’s rule:
 Unreliable in irregular periods
 To calculate: ADD 7 days to the last period and subtract that month by 3.
 11/20 --> 11/27 --> EDD: 8/27

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 12/20/2015 --> 12/27/15 --> EDD: 9/27/16

 5/5/2015 --> 5/12/2015 --> EDD: 2/12/2016

Antepartum: Goals For Care

 Ensure safe birth for mother and child

 Teach necessary health habits
 Educate in self care for pregnancy
 Provide physical care
 Prepare parents for responsibilities of parenthood
 Identify risk that can be changed or controlled
 Prenatal care begins at the knowledge of conception
 Mother/family history is essential
 Expected date of delivery
 Recommended prenatal visits

Antepartum: Routine Care

 Review of risk
 Vital signs
 Weight
 Urinalysis (to see if she is spilling any sugar/ketones)
 Fundal height
 FHR (fetal hr)
 Nutrition
 Any Problems

Laboratory Evaluation and Disease Screening

 CBC
o Hemoglobin 12-14
o Hematocrit 42-47
o RBC 4.2-5.4
o WBC 5-10
o Platelet 150-450
 hCG - helps you check for pregnancy and helps you lose weight.
 ABO blood type and RH status, Rh negative mother would likely receive RhoGAM at 28 weeks gestation and
again within 72 hours after childbirth
 Rubella titer, MMR (if mom gets measles while pregnant she can have an abortion
 Hemoglobin (needs enough iron for the baby)
 Calcium (is important because the baby can pull from her reserves --> teeth falling out)
 Urinalysis because protein in the urine is indicate of preeclampsia
 Glucose
 Hepatitis B by detecting presence of hepatitis antibody surface antigen (HbsAg) in blood
 STI with venereal disease research laboratory (VDRL) to detect STIs including syphilis, herpes, HPV, and
gonorrhea
 HIV (only if consent granted)
 Illicit drug screen
 Sickle-cell screen
 Pap smear to detect cervical cancer, gonorrhea, chlamydia, or group B streptococcus

Subsequent Prenatal Assessment and Labs

 Vital signs

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 Weight gain
 FHR (normal is 110-160)
 Labs (Hemoglobin, MSAFP, GTT)
- Maternal Serum Alpha-Fetoprotein (looks for things like down syndrome, spina bifida)
o Glucose tolerance test (helps diagnose gestational diabetes)
- Group Beta Streptococci (GBS)

Assessment of Fetal Activity and Well-Being

 Some test is for screening purposes while others are diagnostic

- Screening: they indicate the fetus may be at risk for a certain disorder or abnormality. For example,
all women get screened for gestational diabetes but not all women have the OGTT unless for
diagnostic purposes.
- Diagnostic: they can diagnose the abnormality
 Factors that indicate a pregnancy is at risk include:
- Maternal age <16 or >35
- Chronic maternal HTN, preeclampsia, DM, or heart disease
- Presence of Rh alloimmunization
- A maternal history of unexplained stillbirth
- Pregnancy prolonged past 42 weeks’ gestation
- Multiple gestation (triplets?)
- Previous cervical incompetence

Maternal Assessment of Fetal Activity

 Fetal well being is typically used to monitor fetal well being beginning at approximately 28 gestational weeks
 One study of mothers with perceived decreased fetal movement identified 80% of those fetuses with
intrauterine growth restriction.
 A reduction of fetal movement has been associated with fetal hypoxia, fetal growth restriction, and fetal
death
 Although more research is needed to determine if fetal activity assessment improves neonatal outcomes, the
literature does suggest that maternal monitoring does result in a decrease in perinatal mortality and
decreases maternal anxiety

Fetal movements count methods

 They focus on having the woman keep a fetal movement record (FMR) using a technique such as the Cardiff
Count-To-Ten method
 Its noninvasive and lets the pregnant woman monitor and record movements easily and without expense

Teaching highlights – what to tell the pregnant woman bout assessing fetal activity

 Explain that movements are first felt around 18 weeks

 Slowing or stopping of fetal movements may indicate further evaluation by HCP
 Daily Fetal Movement Count (DFMC) or “Kick Counts”
- Keep a daily record of fetal movement, beginning at about 27 weeks’ gestation
- Begin counting at the same time each day about 1 hour after meals if possible
- When assessing fetal activity lay in a side-lying position quietly
 Movements vary but most women feel the fetal movement at least 10 times in 2 hours.

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 Using the DFM record, have the woman count 3 times a day for 20-30 minutes each session. If there are
fewer than 3 movements in a session, have the woman count for 1 hour or more.
 Explain when to contact the HCP:
- If there are fewer than 10 movements in 2 hours
- If overall the fetus’s movements are slowing, and it takes much linger each day to note 10
movements
- If there are no movements in the morning
- If there are fewer than 3 movements in 8 hours
 Describe the procedure and demonstrate how to assess fetal movements. Sit beside the woman and show
her how to place her hand on the fundus to feel the fetal movement.
 Frequently used in conditions that may affect fetal oxygenation
 Fewer than 5 fetal movements within 1 hour warrants further evaluation; call HCP- she said in class KNOW
 Women should take the Cardiff Count-to-ten score card to each parental visit for evaluation
 IN WOMEN WITH MULTIPLE GESTATION, DAILY FETAL MOVEMENTS ARE MUCH HIGHER

Ultrasonography/Sonogram

 Use of intermittent high frequency waves to create an image of the fetus

 It is noninvasive, is painless for both the woman and the fetus, and has no known harmful effects to either
 Ultrasound is limited by fetal position and technician skills
 An ultrasound may seem “normal” but abnormalities may at times go unrecognized
• Primary reason of this is to reassure the parents and healthcare provider

Indications for use:

- Early identification of pregnancy – as early as 5-6 weeks

- Fetal heart activity by as early as 6 weeks and fetal breathing movements by as early as 11 weeks’
gestation
- Identification of more than one embryo or fetus
- Measurement of the biparietal diameter of the fetal head or the fetal femur length to assess growth
patterns- helps determine gestational age of fetus and detect if IUGR
- Clinical estimations of birth weight- helps detect macrosomia (not within weight limits)
- Detection of fetal anomalies such as facial anomalies, anencephaly, and hydrocephalus
- Examination of nuchal translucency in the first trimester to assess for trisomy 21 (down syndrome)
and other fetal structural anomalies
- Length of fetal nasal bone- risk factor for syndrome
- Identification of amniotic fluid volume (AFV) and amniotic fluid index. If the AFI > 24cm or AFV >8
then the mother is at risk for hydramnios. Woman with an AFI <5cm and AFV <2 are at risk for
oligohydramnios. At 39 weeks the amniotic fluids begin to decline. Before that if any of the above
happen, then it is placing the fetus at risk for unknown status, IUGR, meconium-stained amniotic
fluid, and increased risk for the admission into NICU
- Soft-tissue masses (tumors) can be differentiated
- Location of the placenta. The placenta is located before amniocentesis to avoid puncturing the
placenta.
- Placenta grading. As the fetus matures, the placenta calcifies. It is the lifeline of the baby; If the
placenta is not functioning or aging, the baby needs to come out; if the placenta is in the wrong
place and blocking the cervix the lady may not be able to deliver vaginally; the placenta CANNOT
come out before the baby.
- Determination of fetal position and presentation
- Detection of fetal death

Trans abdominal Ultrasound

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 A transducer is moved across the woman’s abdomen

 The woman is often scanned with a full bladder
 The woman is advised to drink 1 – 1.5 quarts of water approximately 2 hours before the examination, and she
is asked to refrain from emptying her bladder
 When the bladder is full, the examiner can assess other structures, especially the vagina and cervix, in
relation to the bladder.
 The ability to see the lower portion of the uterus and cervix is particularly important when vaginal bleeding is
noted and placenta previa is the suspected cause

Transvaginal Ultrasound

 Improved images that have enabled sonographers the ability to identify structures and fetal characteristics
earlier in pregnancy
 Internal visualization can also be used as a predictor for preterm birth in high-risk cases (example shortening
of the cervix or funneling cervix)
 Place the woman in lithotomy position, with appropriate drapes to provide privacy and a female attendant in
the room.
 It is important for her buttocks to be at the end of table so that, once inserted, the probe can be moved in
various directions
 It may be performed on an empty bladder and most woman do not feel discomfort during the exam

Danger signs in pregnancy

 



Any type of bleeding during pregnancy is not normal

 Possible causes:
- Placenta abruption [complication in which the placenta detaches from the womb (uterus)] painful
bleeding
- Placenta previa [when the placenta covers the opening in the mother's cervix.] painless bleeding
- Preterm labor; Miscarriage/abortion
 Usually labor starts with a back pain.

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 Any fluid gushing from vagina can be a sign of ruptured membranes; it could be a leaky bladder but we need
to make sure that it is not premature labor.
 Swollen hands/fingers --> check for development of gestational hypertension if swelling does not go away
after lying down
 A lady who has high BP during pregnancy accompanied by epigastric pain/ burns, blurred vision seeing stars,
or protein in urine (pre-eclampsia) or edema in the ankles.
 Eclampsia = seizures in pregnancy, coma
 We give magnesium sulfate to the patient that has preeclampsia to prevent the seizures (eclampsia)
 If she is having regular contractions before 37 weeks she is in preterm labor and we want to stop the labor
(ex: albuterol -- relaxes uterine muscles; given as a tocolytic which stops contractions).
 Excessive OR no movement: SEEK HELP
 Embryo = 8 weeks // Fetus = 12 weeks

Sexual Concerns:

 Sexual intercourse is O.K during pregnancy. However, contraindicated in cases:

- Of known placenta previa
- Ruptured membranes
- Multiple pregnancy
- Threatened abortion
- Incompetent cervix
- Sexually transmitted infections
- If at risk for having miscarriages
 Women predisposed to pre-term labor should avoid:
- Nipple stimulation –stimulates contractions
o Causes the release of oxytocin which can lead to contractions. For some women it can
cause a funny feeling in the abdomen that
- Vaginal penetration
- Orgasms - uterine contractions can occur during orgasms
- Sperm can trigger contractions and induce labor; hormone in sperm also helps with the softening of
the cervix which makes labor easier
o Use alternative positions
o Sexual desire may change during pregnancy
o Partners need to communicate feelings and needs

First-Trimester Combined Screening

Amniocentesis

 Amniocentesis is a procedure used to obtain amniotic fluid Insertion of a needle trans-abdominally into the
uterus to obtain amniotic tissue via ultrasound guidance
o If this test is being performed at 30 weeks then it is to check lung maturity of the fetus
 It is performed early in the pregnancy or between 15-16 weeks of pregnancy (she said 14 weeks in class and
to KNOW that)
 A sterile procedure! A 22-guage needle is inserted into the intrauterine cavity to withdraw amniotic fluid
(Usually 15-20mL of fluid is removed for testing)
 Once the needle is retracted, the practitioner looks for streaming (Indication of intrauterine bleeding) and
Rhogam is given to the mom to prevent Rh alloimmunization.
 Testing of the amniotic fluid can provide information about fetal health, fetal lung maturity, and genetic
disorder.

Indications for use

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 Genetic concerns
 Congenital anomalies - Neural Tube Defect
 Fetal maturity
 Fetal hemolytic disease

Maternal risk

 Hemorrhage
 Fetomaternal hemorrhage
 Infection
 Labor- Know that this is the main complication
 She said: question the mother: do you have any sensation of pressure on your abdomen? Any
tightening? Foul smelling vaginal discharge?
 Abruption placentae
 Damage to intestines or bladder
 Amniotic fluid embolism – when fluid enters central circulation. This is an emergent event!

Fetal risk

 Death
 Hemorrhage
 Infection (amnionitis)
 Injury from needle – if so, the baby can loose a limb
 Miscarriage or preterm labor
 Leakage of amniotic fluid

Nursing Management

 Encourage patient to empty bladder prior to amniocentesis to avoid the risk of bladder puncture
 Following the procedure, administer RhoGAM IM if the woman is Rh negative.
 Asses vital signs and fetal hear rate every 15 minutes for an hour after the procedure
 Observe the puncture site for bleeding or drainage
 Instruct the client to rest after returning home and remind her to report fever, leaking amniotic fluid, vaginal
bleeding, or uterine contractions or any chances in fetal activity (increased or decreased) to the health care
provider.

Chorionic Villus Sampling (CVS)

 Removal of small tissue specimen from fetal portion of placenta

 Chorionic villi originate in zygote
 Tissue reflects genetic makeup of fetus
 Used for diagnosis of genetic, metabolic and DNA studies
 It cannot detect neural tube defects because it’s done so early in pregnancy
 Advantage: Earlier diagnosis and rapid results. Performed between 10 and 12 weeks of gestation (done
earlier in pregnancy than amniocentesis)
 Not recommended to do before 10 weeks because can cause birth defects or loss of a limb

Nursing Management

 Nurse assist the woman throughout procedure

 MD does the CVS
 If a transabdominal CVS is done, inform the patient that the bladder must be filled by drinking water.
 Nurse can further clarify the physician’s instructions

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 Nurse monitors the woman for short period after CVS:

- Observes contractions or uterine activity
- Amniotic fluid leakage
- Bleeding or pain
 Complications post procedure: amniotic fluid leakage from the puncture site or vaginal spotting or infection

Non-stress Test

 Widely used method to evaluate fetal status. May be used alone or along with other diagnostic test (BPP)
 It’s two belts; one with the tocodynamometer which detects uterine or fetal movement and the other belt
which holds the ultrasound transducer to detect FHR
 Demonstrates fetus’s ability to respond to its environment by acceleration of FHR with movement
 Labor and delivery is a very stressful time for the mother and the baby. So if, for example, the mother has a
heart condition we need to be monitoring her extra carefully, hence high risk
 Typically initiated after 30-32 weeks’ gestation, the non-stress test is usually done to assess FHR reactivity and
well being. Usually done for post-term or high-risk pregnancies
 Basically they are checking to see how this baby is reacting during a stressful moment, contraction.
Results
- Reactive test: accelerations (at least 2) of 15 bpm above the baseline, lasting 15 seconds or more in
a 20-minute window. This indicates the fetus is doing good. KNOW
- Nonreactive test: accelerations are not present or do not meet the above criteria, indicating the
fetus is at risk or asleep.
 If the FHR remains nonreactive for longer than 30 minutes (after extending the time) then the test is repeated
after the woman eats or the fetus is stimulated via vibroacoustic stimulation or palpation (this should wake
the fetus up)
 If reactive test is still not obtained, additional testing such as BPP or immediate birth is considered
 The baby’s heart rate should increase by 10 beats. When they put the baby under stress and the heart rate
starts going down -Deceleration’s, the doctor realizes that the baby will not survive labor

Biophysical Profile – BPP

 Real-time sonography coupled with external fetal heart rate and uterine contraction monitoring.
 A biophysical profile (BPP) test measures the health of the baby (fetus) during pregnancy
 A BPP test may include a non-stress test with electronic fetal heart monitoring and a fetal ultrasound.
Assessment of 5 biophysical profile to assess fetus risks: KNOW
1. Fetal breathing movement (with ultrasound)
2. Fetal movements of body or limbs (with ultrasound)
3. Muscle tone (extension and flexion of extremities) (with ultrasound
4. Amniotic fluid volume (with ultrasound)
5. Reactive fetal heart rate (FHR) (with activity (reactive non-stress test [NST])
 By combining these five assessments, the BBP helps to either identify the compromised fetus or confirm the
healthy fetus

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 Also provides an assessment of placental functioning

 Each variable is given a score of 0 or 2. (0 for abnormal and 2 normal findings)
- Total range 0-10.
- A score of 10/10 or 8/10 with normal amniotic fluid is considered normal and reassuring-KNOW
 Useful in women with risk of placental insufficiency or fetal compromise because of the following:
o Decreased fetal movements, IUGR, DM, PROM, post term, chronic HTN, preeclampsia or eclampsia,
hyperthyroidism, sickle cell disease, suspected fetal prematurity, history of previous stillbirths, Rh
sensitization, abnormal estriol excretion, hyperthyroidism, renal disease, nonreactive NST

Pregnancy ar Risk: Pregestational Problems

Chapter 15 P. 293
Gestational Diabetes
 Carbohydrate intolerance is developed or recognized for the first time during pregnancy
 4% is women experience GD
 The placenta is producing hPL, an insulin antagonist. It makes the insulin less sufficient because it is insulin
resistant.

 Why is there a decrease in the 1st trimester of insulin needs; meaning the mom not needing insulin? There is
N/V so the moms are not taking in adequate amounts of food
 Why does insulin need increase dramatically during 2nd trimester? Because the sugar is needed for the growth
of the fetus. These carbohydrates are going it then. So the more sugar ingested, the greater need for insulin.
 Intrapartum: During delivery, what sis the mother loosing? Energy. So those she need insulin? No. Because
while she is pushing, she’s sweating, burning energy and therefore at higher risk of being hypoglycemic. So
usually during labor, there will be an order to set up D5W (Dextrose 5%) IV fluids. This is the only time we
give it.
- Check glucose: do finger stick every 4 hours
 What happens to insulin needs while you are breast feeding? Insulin requirement decrease. So the nurse
should pre-snack the mother before breastfeeding.
 High glucose in the mother  high glucose in the baby
 This is when a mom was not diabetic and then became diabetic during pregnancy
Maternal risk
 Previous history
 Previous birth of LGA (large gestational age) infant – very indicative of diabetes >9lbs

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 Hx. of stillbirth or spontaneous abortion

 Family hx. of type 2 diabetes
 Obesity
 HTN
 Age – older woman are at higher isk
 Race: Caucasian
 Diet related
Fetal Risk
 Macrosomic (LGA) = very big baby. The mothers hyper insulin state causes the fetus to use the available
glucose, which leads to excessive growth and fat deposits. (think should dislocation)

 IUGR (intrauteral growth retardation)- vascular changes in the mother decrease the efficiency of placental
perfusion and the fetus is not as well sustained. Their body size is big, but internally their organs are smaller
than supposed to be. For example, by 16 weeks the fetus is supposed to be peeing already and these babies
don’t. May lead to mental retardation
 Congenital anomalies in diabetic pregnancies occur 6%-12% and is the major cause of death of infants born
to woman with diabetes. Usually due to high glucose levels early in the pregnancy. The common anomalies
being the heart, central nervous system, and skeletal system.
Infants
 Hypoglycemia; once the umbilical cord is cut after birth, the generous maternal blood glucose supply stops.
However, continued Islets cells hyperactivity leads to high insulin levels and depleted blood glucose in 2-4
hours. Must test infant for glucose. If hypoglycemia, saturate baby; meaning feed them right away.
 Polycythemia (excess number of RBC’s) in the newborn is mainly due to the diminished ability of glycosylated
hemoglobin in the mother’s blood to release oxygen
 Hyper-bilirubinemia – direct result from the inability of immature liver enzymes to metabolize the increased
bilirubin resulting from polycythemia  Jaundice or worse
 Respiratory distress syndrome (RDS) appears to results from high levels of fetal insulin, which inhibit some
fetal enzymes necessary for surfactant production
Complications
 Forceps delivery (insertion of blade and pull the baby down with pressure
 Shoulder dystocia- when the baby shoulder is too large and born vaginally usually seen in infants with
macrosomia
 Cesarean section
 Screening
 Hypoglycemia: how do we screen (meaning ALL women get checked for this: Books says 75 g oral but she
said 50 g
o 50g random glucose test at 24- 28 weeks- the oral glucose load can be given at any time of the
day with no requirements for fasting. One hour later, the plasma glucose is measured.
o Results: if elevated greater than 130 - 140 mg/dL, mother requires further testing
o Diagnostic Test: 100-g, 3 hour oral glucose test. The mom is placed on a high 3 day carbohydrate
test, and then the night before the test she goes NPO. That next morning they draw blood, then

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they give her the 100-g glucose and then 3 hours later re draw blood. If results are >140 , then
theyre diagnosed with GD
 To diagnose gestation diabetes, they do an oral glucose tolerance test for 3 days then NPO for the night
before. The day of test they are given 100 grams of oral glucose and then they draw samples, if glucose come
out greater than 140 you have gestational diabetes.
Management
 Diet (Nutritionist and Endocrinologist)
- Educate mother to eat a snack before bed which should be composed of complex carbohydrates and
protein to prevent hypoglycemia during the night
 Glucose monitoring!
 Insulin management- our goal is a tight glucose control
 Ultrasound is done at 18 weeks to confirm GD and then at 28 weeks to monitor fetal IUGR
 NST – to evaluate fetal well-being; beginning at 28 weeks and increased to twice weekly at 32 weeks’
gestation
 Education- s/s of hypoglycemia, hyperglycemia
 Obstetrician
 Endocrinologist
 Social worker
 Nursing diagnosis:
 Nutritional imbalance.
 Risk for infection
 Hypoglycemia
Nursing diagnosis
 Risk for infection related to increased levels of glucose in urine (UTI—Preterm Labor)
 Nutrition imbalance; Less than body requirements related to poor carbohydrate metabolism
 Injury Risk for Injury related to possible complications such as macrosomia

Questions
If around 18 weeks an ultrasound is done on a type 1 DM what would be the reason for the exam?
- To monitor the growth of the baby (ex: microsomia, IUGR)

True/False: Insulin requirement increase as pregnancy progresses?

- True

A type 1 DM is scheduled to deliver at 34 weeks. The nurse explains that the early delivery is necessary because
A. Anomalies of the fetus
B. Placental insufficiency (causes IUGR, SMG)
C. Fetal lung maturity
D. Placental maturity
She said: answer these questions by asking yourself, if we deliver the fetus at 34 weeks due to _answer_ then
what difference will this cause?

Human immunodeficiency virus (HIV)

 Because of improvements in treatments some HIV infected women are choosing to become pregnant
 Most pediatric transmissions are acquired perinatally
 Transmission rate without treatment is 25%
 HIV testing with consent
 Treatment should be started during pregnancy
 Minimized vaginal exams
 Prolonged ROM increase risk of HIV transmission
 Antibiotic therapy should be started at least 4 hours before birth
 Cesarean birth is the option to decrease perinatal transmission
 Provide emotional, nonjudgmental support
 Infant -HIV testing and administration of antiviral drugs

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Pregnancy at Risk: Gestational Onset

Chapter 16 P. 323
Care of the Woman with Bleeding Disorder
 Vaginal bleeding in the 1st trimester may result from a spontaneous abortion (miscarriage)
 Vaginal bleeding in the 2nd or 3rd trimester may indicate an abnormal location of the placenta
- Abortion is the expulsion of the fetus prior to viability; 20 weeks’ gestation or less than 500 g -
know
- Abortions are either: Spontaneous or miscarriage (occurring naturally) or Induced (occurring as a
result of medical or surgical intervention)
- Other complications that can cause bleeding in the first half of pregnancy are ectopic pregnancies
and gestational throphoblastic disease.
- In the second half of the pregnancy, particularly in the third trimester, the two major causes of
bleeding are placenta previa and abruptio placentae.
General Principles of Nursing Intervention
 Spotting is relatively common during pregnancy and usually occurs following sexual intercourse or
exercise because of trauma to the highly vascular cervix.
 It is the nurse’s responsibility to make the initial assessment of bleeding:
• Monitor blood pressure and pulse frequently
• Observe the woman for signs of shock (Pallor, clammy skin, perspiration, dyspnea, restlessness)
• Count and weigh pads to assess amount of bleeding (Save any clots or tissue expelled)
• If pregnancy is 12 or >, assess FTH with Doppler
• Prepare for IV therapy (dehydration = preterm labor)
• Collect all data and lab studies
• Obtain order for type and crossmatch blood (Remember she said we have to assess mom for RH
Neg.)
• Assess coping mechanism
• Assess family’s response to situation
Spontaneous Abortions(Miscarriage)
Causes:
• Chromosomal abnormalities - It’s the body’s natural way to get rid of an abnormal fetus
• Maternal infections - Ex. UTI
• Placental abnormalities – Implanted in an abnormal location? Umbilical cord too short?
• Faulty implantation – Ectopic pregnancy?
• Teratogenic drugs – Cocaine? Alcohol?
• Weakened cervix – How many abortions have they had previously?
• Trauma – Falls? Abuse?
Classifications:
Threatened abortion
 Fetus is jeopardized
 Unexplained bleeding or spotting
 Cramping and backache
 Physician will 1st check if the cervix is closed (if the cervix is closed they can save the baby)
 If the cervix is closed you can put her on bedrest, reduce her activity, and she can go to term.
Imminent Abortion
 Bleeding and cramping increase, the internal cervical os dilates, membranes may rupture
 Also called inevitable abortion
Complete abortion
 All the products of conception are expelled; cervix opened
 May need a d&c
Incomplete abortion
• Some of the products of conception are retained, most often the placenta
• Internal OS dilated slightly

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• Needs D & C
Missed abortion
• Fetus dies in utero, but is not expelled
• Uterine growth ceases, breasts changes regress and woman will report brownish vaginal
discharge
• Cervix is closed
• If the fetus is retained beyond 6 weeks, the breakdown of fetal tissue results in the release
of thromboplastin, and disseminated Intravascular Coagulation (DIC) may develop.
• Diagnosed by ultrasound
• No bleeding or cramping
• Can lead to infection
Recurrent/ Habitual abortion
• Abortion occurs consecutively in three or more pregnancies
• Common in people who have an incompetent cervix
Septic abortion
• Infection present
• Mat occur with prolonged rupture of membranes, pregnancy with an IUD, or by failed
attempts to end a pregnancy by unqualified individuals

Clinical Therapy
 Pelvic cramping and chronic backache are reliable indicators of potential spontaneous abortions.
 Speculum examination, and/or ultrasound for gestational aging of fetus, lab determination of hCG to confirm
pregnancy, hemoglobin and hematocrit to assess blood loss.
• Bed rest
• Abstinence from coitus
• Emotional support
• If bleeding persists and abortion is imminent or incomplete,
Sometimes hospitalization is needed
• IV therapy/blood transfusions
• If she is having contractions, they will give a tocolytic
• Dilatation and curettage (D&C) – to clean out the uterus or
suction to remove the remains of the fetus.
• RhoGAM administered within 72 hours if woman RH negative mother delivers a RH positive
baby! Usually given to RH negative women
Nursing Management for the Woman Experiencing Spontaneous Abortions
• Assess vital signs
• Amount and appearance of bleeding
• Level of comfort
• General physical health
• Check for contractions
• Determine FHR with Doppler if pregnancy is 10-12 weeks or more
• Assess coping mechanisms
• Infection
• Main nursing diagnosis: Fluid Volume Deficit related to excessive bleeding secondary to
spontaneous abortion.
Form of miscarriage that is associated with a serious uterine
High Risk Pregnancy
 Is one in which the health of the fetus or the mother is in jeopardy
- May be related to the mother
- May be related to a pre-existing condition
- May result from an environmental hazard
- May be due to maternal behaviors
Ectopic Pregnancy

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 Implantation of the fertilized ovum in the site other than the endometrial lining of the uterus
 Could be in the ampulla of the fallopian tube (most common), intestines, outside of the uterus
 Pregnancy outside of the uterus
Causes
• Tubal damage from PID (pelvic inflammation disease –> Gonorrhea infection which causes
scarring of the lining of the tubes)
• Previous tubal surgery (Scar tissue)
• Congenital anomalies of the tube
• Endometriosis (foreign tissue in the uterus)
• Previous ectopic pregnancy
• Presence of IUD
• Utero exposure to Diethylstilbestrol (DES) is a manmade estrogen that was given to women
way back when.
Signs and symptoms
• Amennorrhea, Breast tenderness, and nausea
• Sharp unilateral pain and syncope and referred right shoulder pain all due to tubal rupture
• Lower abdominal pain
• Vaginal bleeding because of fluctuation of hormonal levels
• KNOW physical assessment shows adnexal tenderness: the area over each fallopian tube is
palpated, if pain is elicited, then the test is positive.
Medical / surgical therapy:
• Careful assessment of LMP
• Pelvic exam to identify any abnormal pelvic mass
• Transvaginal ultrasound
• Serum hCG (Ectopic pregnancies have a slower increase of hCG levels than normal
pregnancies)
• Laproscopic interventions of necessary
• Single shot of Methotrexate injection to treat un-ruptured ectopic pregnancy
• Salpingostomy to remove the ectopic pregnancy and save the tube
• Salpingectomy - removal of fallopian tube
• Tuboplasty may be done to repair the fallopian tube afterwards
Nursing assessment
• Monitor the amount of vaginal bleeding
• Monitor vital signs for developing shock
• Assess pain level
• Assess emotional state and coping ability
• If surgical intervention, complete the appropriate ongoing assessment postoperatively

Gestational Trophoblastic Disease (Hydatidiform Mole)

 Proliferation of the trophoblastic cells. The throphoblast is the outermost layer of the embryonic cells. (Cells
of the placenta)
 Also called molar pregnancy
 Hydatidiform mole is a condition which a proliferation of throphoblastic cells results in the formation of a
placenta characterized by hydropic (fluid filled) grape-like clusters.
 The disease results in a loss of pregnancy and the possibility of developing choriocarcinoma.
 A molar pregnancy happens when tissue that normally becomes a fetus instead becomes an abnormal growth
in your uterus. Even though it isn't an embryo, this growth triggers symptoms of pregnancy.
Classified as two types:
• Complete: develops from anuclear ovum that contains no maternal genetic material (Empty egg)
Choriocarcinoma is directly associated with the complete mole
• Partial: two sperms fertilizing an apparently normal ovum; the two sperms cause a genetic mutation
that cause this. There may be a fetal sac and even a fetus.
 Produces a very high hCG which is why the pregnancy test is positive
 Even though the abdomen is growing there is no baby

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 SHOULD NOT GET PREGNANT FOR A YEAR! This can become choriocarinoma so hCG levels need to be
monitored for an entire year to make sure that the levels decrease and it is safe for her to get pregnant
again - KNOW
 Results in loss of pregnancy
Clinical Manifestations:
 Brownish vaginal bleeding occurs universally – like prune juice KNOW
 Anemia because of the blood loss
 Uterine enlargement - greater than expected for gestational age (Classic sign of complete mole)
 No FHR
 Elevated serum hCG markedly elevated
 Gestational hypertension before 24 weeks
Diagnostic & Treatment
 Diagnosed by transvaginal ultrasound
 Suction evacuation of the mole and curettage of the uterus
 Possible hysterectomy (surgery to remove a woman's uterus)
 Follow up to monitor hCG levels for about one year
 Increase levels may indicate choriocarinoma (cancer)!
Treatment
 Chemotherapeutic agent  methotrexate if hCG levels never go down and the patient is diagnosed with
Cancer.
Nursing Care
 Monitor vital signs
 Monitor for bleeding signs of hemorrhage
 Assess for abdominal pain
 Assess coping ability
 Have typed and cross-matched blood available for surgery
 Administer oxytocin as ordered to keep uterus contracted to prevent hemorrhage
 Stress the importance of follow-up visits

Care of the Woman with Hyperemesis Gravidarum

 Etiology unknown
 Excessive projectile vomiting past the 1st trimester
 Increased levels of hCG may play a role
 May also be caused by misplacement of the GI tract or hypofunction of the aanterior pituitary gland and the
adrenal cortex
 In severe cases, hyperemesis causes dehydration, which leads to fluid and electrolyte imbalances and
alkalosis from loss of hydrochloric acid.
 Alkalosis at first and then if untreated Metabolic acidosis (complication)
 Decrease urinary output, hypovolemia, hypotension, tachycardia, increased hematocrit and BUN also occur.
 Severe potassium loss may interfere with the ability of the kidneys to concentrate urine and may disrupt
cardiac functioning.
 Starvation = muscle wasting
 Severe protein and vitamin deficiency = may lead to fetal death
Clinical Treatment
 Correction of fluid and electrolyte imbalances
 Intravenous Fluids/ TPN (Potassium is usually added to prevent hypokalemia)
 NPO for 48 hours typically
 Anti-emetics
 Stress reduction
 Small, frequent meals
 Improve nutritional status
 Vitamin supplements  pyridoxine (Vitamin B6)
Nursing Care
 Assess emesis

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 Supportive and directed at Maintained a relax environment and away from strong food smells
 Food needs to be attractively served with no strong spices/seasoning or offensive smells
 Good oral hygiene- she may have cuts in her mouth due to all the vomiting
 Monitor weight
 Monitor for signs of complications

Care of the Woman with Hypertensive Disorder

 Most common medical complication in pregnancies.
Classification
 Preeclampsia  eclampsia
 Chronic hypertension
 Chronic hypertension with superimposed preeclampsia or eclampsia
 Gestational (or transient) hypertension, classified after 20 weeks of pregnancy

Preeclampsia
 Preeclampsia is defined as gestational hypertension after 20 weeks gestation with a blood pressure of 140/90
or higher X 2 at least 6 hours apart accompanied by proteinuria in a previously normotensive woman
 Sudden onset of severe edema
 Most often preeclampsia occurs in the last 10 weeks of gestation, during labor or in the first 48 hours after
childbirth
 Although birth of the fetus and removal of the placent, are the only cure for preeclampsia, it can be
controlled with early diagnosis and careful management.
 Often seen in teenagers or in women over 35, escecially if they are primigravida
 Cause of preeclampsia is unknown but it affects all systems of the body
 Blood pressure begins to rise
Maternal Risk
 CNS changes:
 Hyperreflexia (Due to high doses of Magnesium Sulfate)
 Headache
 Seizures
 Thrombocytopenia
 Cause is unknown, but birth is the cure
 Known risk factors include:
 1st pregnancy
 Obesity
 Age
 Family hx, pt. hx
 Multifetal pregnancy
 Chronic renal disease
 DM
Others
 Renal failure
 Abruption placentae
 DIC
 Ruptured liver
 Pulmonary embolism
HELLP syndrome (Hemolysis, Elevated Liver enzymes, and low platelet count)
 Women who experience this multiple organ failure syndrome have high morbidity and motrality rates as do
their offspring.
 The hemolysis that occurs = microangiopathic hemolytic anemia
 Elevated liver enzymes occur due to blood flow that is obstructed by fibrin deposits
 Hyperbilirubinemia and Jaundice may be seen.
 Liver disention causes epigastric pain
 Thrombocytopenia platelet count less than 100,000 (S/s: N/V, flu-like symptoms)

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 Women with true HELLP syndrome should give birth regardless of gestational age
Fetal–Neonatal Risk
 Small for gestational age (SGA) cause is related specifically to vasospasm and hypovolemia which resulted in
fetal hypoxia and malnutrition
 Premature because of necessity of early birth
 Hypermagnesemia (due to administration of magnesium sulfate to mother)
 Increased morbidity and mortality
Clinical Manifestations and Diagnosis
 Mild preeclampsia
o BP 140/90 mm hg or higher
o +1 proteinuria may occur
o Liver enzymes may be elevated minimally
o Edema may be present
 Severe preeclampsia
o May develop suddenly
o BP 160/110mm hg or higher on two separate readings while on bedrest 6 hours apart
o Proteinuria 5 g or higher in a 24-hour urine collection
o Dipstick urine protein 3+ - 4+ on 2 random samples at least 4 hours apart
o Oliguria present of less than 500 mL in 24 hours
o Samples must be obtained at least 4 hours apart
o Visual or cerebral disturbances (Frontal headaches, blurred vision, scotomata- spots before the eyes)
o Cyanosis or pulmonary edema
o Epigastric or right upper gastric pain (Sign of impending convulsion due to engorgement of the liver)
o Impaired liver function
o Thrombocytopenia or evidence of hemolysis (IUGR)
o n/V, irritability, hyperreflexia, retinal edema
 Eclampsia
o Grand-mal convulsions or coma
o May occur anytime: antepartum, intrapartum, or postpartum
o Some women have only one seizure, others have a lot
Clinical Manangment
 Prevention of cerebral hemorrhage, convulsion, hematologic complications, renal and hepatic disease and
birth of an uncompromised newborn (as close to term as possible)
Antepartum Management
 Depends on the severity of the disease
Home care (mild preeclampsia)
• Client monitor BP
• Daily weights and test protein in urine daily (Weight gain of 3lbs in 24 hours or in a 3-day period are generally
a cause for concern)
• Remote NST’s done daily or BPPs are bi-weekly
• Instructed to report a worsening in condition
Hospital care (mild preeclampsia)
• Bed rest primarily on left side for promotion of circulation.
• Daily weights
• Urine dipstick for protein daily
• BP check 4 times a day
• Diet moderate to high protein, 80 to 100 g a day to replace protein loss in urine.
• Sodium intake should be moderate no more than 6 g a day, but sodium restriction and diuretics are no longer
used
• To achieve a safe outcome of the fetus, Fetal movement records, NSTs and ultrasonography are performed
every 3- 4 weeks and BPP, amniocentesis to determine fetal lung maturity and Doppler Velocimetry at 30 to
32 weeks.
• Walk to reduce edema

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• Fetal evaluation
• Management cont.
Hospital Care of Severe preeclampsia
• Birth
• Complete Bedrest
• Diet high protein and moderate sodium as long as the woman is alert
• Anti-convulsants (Magnesium Sulfate)
• Fluids and electrolyte replacement
• Corticosteroids (Bethamethasone or dexamethasone for women whose baby’s need help for their lungs to
mature or moms with HELLP Syndrome)
• Anti-hypertensive (CCBs for sustained systolic of 160 labetalol (nonselective) or
hydralazine(vasodilator)Methadopa
• Also 24 hour urine collection
Hospital Care of Eclampsia
• Anticonvulsants: Bolus of 4-6gms of magnesium sulfate (should also have calcium gluconate in case of
magnesium toxicity) •
• Loading dose: 4-6 g magnesium sulfate administered over a 15-20 minute period
• Maintenance dose: 2-3 g/hr via infusion pump
• Adjunct anticonvulsants: Dilantin
• Diuretics – Lasix
• Digitalis
• Strict I&O’s an foley
• Ongoing Nursing Care
• Keep patient away from simulation
• Monitor
• There are at risk up to 48 hour after birth.
• Never leave woman by themselves after birth.
Assess the following
 Vital signs, FHR
 Urinary output, urine protein, urine specific gravity
 Pulmonary edema
 Deep tendon reflexes
 Placental separation
 Headache
 Visual disturbances
 Epigastric pain (HELLP syndrome means its getting worse)
 Laboratory blood test
 LOC
 Emotional response and level of understanding
 Magnesium sulfate if drug of choice to prevent convulsions should be continued postpartum
 Antidote- calcium gluconate
Deep Tendon Reflexes
 0: absent reflex
 1+: trace, or seen only with reinforcement
 2+: normal
 3+: brisk
 4+: Hyperactive; very brisk jerky or clonic response ABNORMAL (i.e., repetitive vibratory movements)
HEELP Syndrome
When the patient has right upper abdominal pain, hemolysis of the liver.
Increased risk for
 Placental abruption, acute renal failure, pulmonary edema, hepatic hematoma, ruptured liver, fetal/maternal
death
 Hemolysis, elevated liver enzyme and low platelet count
Management

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 Bp measurements
 Assess for edema (dependant or pitting)
 Assess DTR’s CBC, clotting studies, blood chemistry, Type and screen

Surgery During Pregnancy

o Surgery complicates about 1 in every 500 pregnancies
o First trimester surgeries increase the incidence of abortion
o Increased incidence of fetal mortality
o And low birth weight infants (less than 2500g)
o Increase incidence of preterm labor
o Increase incidence of intrauterine growth restrictions
o Inability to perform some diagnostic procedures may hinder diagnosing of the disease

Trauma During Pregnancy

Types of trauma
 Blunt
 Penetrating injuries
 Gunshot wounds
 MVA most common
Causes
 Maternal shock
 Premature labor or spontaneous abortion
 Maternal mortality
 head trauma or hemorrhage
 Placental abruption
 Traumatic separation of placenta
 Fetal mortality
 Premature birth and ROM

Battered Pregnant Woman

 Incidence – 4% to 8%
 May result in loss of pregnancy
 Preterm labor
 Low birth weight infant
 Fetal death
 Abused women have higher rates of complications
 Anemia, infection, low weight gain, bleeding in the 1 st and 2nd trimester
Management
Early detection
 Ask about abuse at several prenatal visits
 May not disclose until she becomes familiar with caregivers
 Assess old scars
 Be alert for signs of bruising
Target areas
 Breast
 Abdomen
 Genitalia
 How to Help
o Accepting, nonjudgmental environment
o Listen and allow her to express her concerns
o Provide list with community resources and emergency numbers
o Client has to make decision to seek help

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Perinatal Infections affecting the Fetus:

 Toxoplasmosis
 Rubella
 STD’s
 Cytomegalovirus (CMV)
 Hepatitis B virus (HBV)
 Group Beta Streptococcus (GBS)
 HIV
 Perinatal Infections affecting the Fetus
 Toxoplasma gondii – a protozoan parasite
 Contracted by ingestion or handling undercooked meat or handling cat feces
 Early maternal infection results in congenital toxoplasmosis, leading to spontaneous abortion
 Caution about cooking meat thoroughly
 Avoid handling cat feces
 Use gloves while gardening
 Treatment with spiramycin as soon as possible
 Education for woman and family

Rubella-virus
 Transmission- Across the placenta to fetus
 Congenital rubella syndrome (CRS) may result
 Treatment: Prevention
 Vaccination
 1st trimester greatest risk for heart damage, cataracts, mental retardation
 2nd trimester- permanent hearing impairment, microcephaly, retardation
 Neonate – clinical signs- CHD, IUGR, cataracts
 Nursing care- focused on prevention

STD’S
Herpes, Syphilis, Gonorrhea, Chlamydia
 STD’s are most common in the reproductive years
 Viral STI’s are hard to treat; may have the virus for life
 Client should be asked about risk factors, previous STI’s and sexual activity
 Physical examination
 Treatment of bacterial infections should be tailored to situation
 Education regarding safety

Cytomegalovirus (CMV)- herpes

 Most common cause of congenital neurologic impairment
 Acquired during gestation can result in:
 Stillbirth or miscarriage
 IUGR- condition in which the baby doesn’t grow normal weight during birth
 Congenital anomalies or other infections
 Infants appear asymptomatic at birth but develop sensorineural problems
Risk
 Contact with infected children in daycare centers
Prevention
 Proper handwashing
 No treatment exist, provide supportive counseling

Hepatitis B
 Transmitted sexually, IV drug use
 Infection can occur during birth

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 Symptoms – fever, rash, decreased appetite abdominal pain, aching, malaise, weakness, jaundice, enlarged
liver
 Prevention/treatment – hepatitis B vaccine

Group B Streptococcus (GBS)

 Incidence 1.8 per 1000 live births
 Major cause of neonatal morbidity and mortality
 Usually asymptomatic
 Newborn infections results from vertical transmissions
 Risk- preterm labor, previous hx, ROM longer than 18 hours
 Prenatal care – vaginal/rectal swab at 35 – 37 weeks gestation
 Treatment – intrapartal antibiotics at least 4 hours before birth, until after birth
 Infant monitoring- risk of transmission higher in the 1st 24 hours, However, education should be give to
monitor infant for up to seven days.

Rh Alloimmunization
 Rh-negative woman carries Rh + fetus
 Fetal red blood cells cross into maternal circulation
 Antigen-antibody response occurs
 1st child not affected
 Affects subsequent pregnancies
 Rh antibodies enter the fetal circulation
 Hemolysis of fetal red blood cells and fetal anemia
Fetal and Neonatal Risk:
Clinical Presentation (varies with disease severity)
 Anemia
 Jaundice
 Hepatosplenomegaly
 Fetal hemolytic anemia
 Hydrops fetalis (severe fetal edema)
 Stillbirth
Rh Alloimmunization Prevention
 Screening
 History
 Identification
 Antibody screen ( indirect Coomb’s test)
 Identify if woman is sensitized
 Administer 300mcg Rh immune globulin (RhoGAM)
 Give RhoGAM in the following cases:
- Pregnant Rh- woman who have no antibody titer
- At 18 weeks’ gestation
- Baby father is Rh + or unknown
- With in 72 hours after each abortion
- Amniocentesis and placenta previa
- Invasive procedures that may cause bleeding

ABO Incompatibility
 Mother has type o blood and the infant has A, B, or AB
 Maternal antibodies cross placenta
 Hemolysis of fetal RBC’s
 Unlike Rh incompatibility, the 1st infant is involved
 No relationship between the appearance of the disease and repeated sensitization from one pregnancy to the
next

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 No antepartal treatment required

 Hyperbilirubinemia in the infant
 Hyperbilirubinemia treated with phototherapy
After birth:
 Assess newborn carefully
 Assess for Hyperbilirubinemia

Percutaneous Umbilical Blood Sampling (PUBS) or Cordocentesis

 It’s a technique used for obtaining blood that allows for rapid chromosome diagnosis, genetic studies, or
transfusion for Rh isoimmunization or hydrops fetalis
 Similar to amniocentesis
 Direct access to fetal circulation
 Insertion of needle directly into a fetal umbilical vessel under ultrasound guidance
 Blood is pulled out from the fetus’ umbilical cord.
 PUBS is perfomed if the fetus is suspected of being anemic. It is done to determine fetal hematocrit. If fetal
hematocrit is <30%, then the fetus is given intrauterine blood transfusion either intravenously through PUBS
or intraperitoneally. This is due to not knowing whether the infant is Rh negative or positive. But now we
have other ways of knowing.
 This test can also be performed to assess the acid/base level of the fetus. She said: if the mom has PIH and
the baby is having deceleration, then you want this test to be performed to check and see if the baby is acidic.

Childbirth at risk: Prelabor Complications

Chapter 21 p. 441
Care of The Woman With Premature Rupture of Membranes (PROM)
 Spontaneous rupture of the membranes prior to the onset of labor
 Preterm premature rupture of membranes (PROM) is the rupture of membranes before the 37 weeks of
pregnancy. (AKA when your water breaks)
 Anytime the membranes rupture that means that there is now open area for infection to enter so the baby is
now at risk. She must deliver quickly if this occurs.
Causes
 Infection – KNOW
 Previous history
 Amniocentesis (removal of fluid to be tested for abnormalities)
 Placenta previa
 Abruption placentae
 Trauma
 Incompetent cervix
Clinical Therapy
 Nitrazine paper test* (positive if blue  blue means that it is amniotic fluid)
 Fern test* (positive if amniotic fluid shows a fern-like pattern under a microscope)
 No digital exams- if membrane is ruptured then you are placing the fetus and mother are high risk for
infection
 FHR
 BPP
 If infection suspected, IV antibiotics
 Prophylactic antibiotics for 48 hours while awaiting cultures
Clinical Therapy
Absences of Infection  If less than 37 weeks
 Hospitalized on bedrest
 CBC, CRP, U/A
 FHR
 Regular NST, BPP
 Assess maternal temperature and FHR every 4 hours
 Regular laboratory evaluations

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 Fetal lung maturity studies

 Maternal corticosteroid administration
Clinical Therapy  At home
 Bedrest with bathroom privileges
 Monitor T & P 4 times a day
 Fetal movement journal
 NST weekly
 Call HCP for signs of complications
 Return to hospital for fever, uterine tenderness or contractions, increased leakage of fluids, decrease fetal
movement or foul-smelling vaginal discharge
Nursing Care
 Report signs of infection
 Evaluate uterine activity
 Encourage woman to rest on left side
 Use comfort measures
 Ensure hydration, if temperature present
 Educate on implications of PROM and treatment
 Physiologic support
 Listen, give information, provide explanations
 Prepare couple for outcome
 No vaginal exam when there is a premature rupture of membrane. IF you need to do a vaginal exam then you
must use a sterile procedure, sterile glove because the protection layer around the baby is gone once
premature rupture of membrane has occur.

Preterm Labor p. 449

 Labor that occurs between 20 and 36 completed weeks of pregnancy
 Document uterine contractions (4 in 20 minutes or 8 in one hour)
 Document cervical change (if cervix is still closed send her home with tocolytics)
• Also note that if she is 38 weeks and having contractions, but the cervix is closed, send her
home on tocolytics as well
 Cervical dilation of greater than 1 cm
 Cervical effacement of 80% or more means you are in labor  it’s the thinning of the cervix. Normally it is
thick feeling like your nose and thinning feeling like the inside skin on the side of your mouth.
Risk factors (chart on page 445) she said know risk factors
 Stress – lack of social support?
 Age - Adolescent pregnancy is high risk for PTL
 Multiple pregnancies – high risk for PTL because of the volume and the pressure starts to open the cervix
 Placenta previa
 Abdominal surgery during 2 trimester
 Cervical insufficiency/ incompetent – high risk for PTL
 Dilated cervix 1cm at 32 weeks’ gestation
 Bleeding after 12 weeks
 Inadequate or no prenatal care
 Mother with chronic disease; HTN, DM, obesity
 History or current Infection – febrile? STD’s?
 Dehydration / Hydramnios  Low social economic status
 Uterine anomalies
 History of PTL- if it happened once, its more than likely going to happen again
 Amniocenteses – high risk for PTL
Clinical Therapy
 Assess cervicovaginal fibronectin (fFN) - This test similar to that of a Pap smear. fFN is a protein normally
found in the fetal membranes and decidua. If fFN is found in the cervicalvaginal fluid then the woman is a
high risk to give birth; labor

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 Assess cervical length via ultrasound- it the cervical cord short? Because if so if can cause opening of the
cervix
 Obtain history of previous preterm birth
 Assess for the presence of infection- any UTI? Must address it because it may place her in PTL
 Educate patient about preterm labor
 Assess for early signs and symptoms of labor
 Maternal laboratory studies- H&H, ketones in urine (this means Dehydrations; if so give IV fluids)
 IV infusions for maternal hydration
 Tocolytic: Medications used in the attempt to stop labor/ contractions. Examples are beta adrenergic agonist
(magnesium Sulfate; loading dose 4-6 mg, Pitocin, dobutamin (orally), cyclooxygenase (prostaglandin
synthetase- E and F to prevent labor) inhibitors, and calcium channel blockers nifedipine (Procardia-it relaxes
smooth muscle therefore stopping contractions), endometacin she said know drugs
Question
If patient come into the ER complaining of UTI what should you do?
- Assess for signs of labor, if the patient is having contraction, early rupture of membrane.

How do you know if a cervix is dilated without doing a vaginal exam?

- By ultrasound

Tocolytics
 B – adrenergic agonist magnesium sulfate
 Prostaglandin synthetase inhibitors
 Calcium channel blockers
 Medications used to stop labor
Incompetent Cervix
 Weak cervix
 Premature dilatation of the cervix, usually in the 4th or 5th month of Pregnancy
 Associated with repeated second trimester abortions
Possible causes:
 Cervical trauma
 Infection
 Congenital cervical or uterine anomalies
 Multiple gestation
 Diagnosis: Positive history of repeated second trimester abortions
Treatment- Surgical procedure
 Shirodkar procedure (cerclage  string that holds the cervix together)
 Purse-string suture is placed in the cervix in the first trimester or early in the second trimester
 Has to be put in early enough before the cervix starts opening
 Suture cut at term and vaginal delivery permitted

Placenta Previa
 A low-lying placenta
 Placenta implantation in the lower uterine segment
 PAINLESS
 Will definitely be a c-section
Predisposing Factors
 Prior hx of placenta previa
 Multiple pregnancies
 Hx. of multiple births
 Prior uterine scars
 Placenta is not going to attach to an area with scar tissue
Symptoms
 Quiet onset bright red bleeding
 Abdomen soft, palpable

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 Painless bleeding
Nursing Responsibilities
 Bedrest
 Monitor blood loss (pad count)
 Perineal care
 Education re: s/s of labor, condition
 Monitor labs
 Type and screen
 Emotional support
 Monitor the baby

Placenta Abruption
 Premature separation of the placenta
 PAINFUL
 C-section for sure
Symptoms
 Dark venous blood
 Abdomen rigid, hard
 Severe pain
 Sudden onset
Nursing Responsibilities
 Prepare for emergency C-section (baby is not getting any oxygen and needs to come out)

Unknown location for test 1 LOL

Physiologic Changes of Pregnancy…
 Pregnancy: Variation to…
 Age-related perspectives
 Adolescent pregnancy
 Pregnancy after age 35 you are at high risk; you need more antenatal care
 Between ages 23 and 34 are the best ages to have babies
- Body is at its healthiest
- Pelvic bone is more pliable and the baby can come out easier
 Sociocultural variations
 Ex: having a career first before having a baby or having a baby and then focusing on your education
 Religious variations

Maternal-Fetal Assessment and Care…

General Survey
 Nutrition
 Grooming
 Posture
 Mood
 Affect
 General appearance
Skin/ Breast; you want to look for any…
 Scars (ex: previous c-section or abd sx; find out when? And
how long ago?)
 Tracks (to determine if pt is a drug user)
 Bruising (where did you get that bruise?)
 Variations in skin
Heart/Lungs & Abdomen
 We need to auscultate her breath sounds and her heart sounds (may be a cardiac patient who is pregnant; a
lot of them won’t tell you unless you ask them)

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 A soft, blowing systolic murmur from the increased cardiac volume is a normal finding; because the heart is
putting out more blood.
 On the abdomen you may see: straie, linea nigra
 Check fundal height to estimate the gestation of the baby

Genitalia
 Assess for vaginal changes
 Chadwick’s sign
 Hegar’s sign
 Goodell’s sign
 Pap-smear and vaginal cultures (b/c we want to check for genital warts or abnormal vaginal secretions to
treat that first; if she still has this when its time to give birth she cannot deliver vaginally)
Pelvimetry
 The pelvic bones are assessed for size and shape to determine adequacy for vaginal birth
 If the pelvic bones are too narrow the baby won’t be able to navigate through the canal
 The two most important measurements are the diagonal conjugate and the bi-ischial diameter

Bony Pelvis
 The bony and ligamentous pelvic mechanism is designed to…
- Protect the pelvic viscera
- Support the vertebral column
- Facilitate locomotion
- The pelvic girdle is adapted for strength, support, and locomotion.

Pelvis
 Four bones
- Two innominate (ilium, ischium, pubis)
 Sacrum
 Coccyx
- The pelvis resembles a basin and is formed anteriorly and laterally by the innominate bones and
posteriorly by the sacrum and coccyx
- Four pelvic joints
 Symphysis pubis
 Sacrococcygeal
 Two sacroiliac
- Over age 25 the symphysis pubis tends to fuse so it is harder
- and less elastic for the baby to come through
Determination of an Adequate Pelvis
Diagonal conjugate
 Distance from sacral promontory to symphysis pubis
 Approximate length of fingers introitus to sacrum
 Adequate diagonal conjugate > 11.5cm
 This is done by the obstetrician
Bi-Ischial Diameter
 Distance between Ischial tuberosities
 We are looking at the measurement from one
spine to the next to see how wide it is
 Approximately width of fist
 Adequate intertuberous diameter > 8 cm

Types of Bony Pelvis

Anthropoid = AP diameter > transverse diameter, oval shaped
 25% females

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Platypelloid – flat pelvis, outlet may be inadequate

 35%
Android = wide transverse diameter, heart shaped, not favorable for labor
 20% females
Gynecoid = most spacious obstetrically, inlet and outlet adequate for birth.
 50% females
 If other than gynecoid MAY require c-section. It depends on the babies’ size also
Types of Pelvis

Question
Insulin requirement increases as pregnancy progresses (true or false)?
- True

A type 1 DM is scheduled to deliver at 34 weeks the nurse explain that the early delivery is necessary because?
- Anomalies of the fetus
- Placental insufficiency
- Fetal lung maternity
- Placental maternity

A 20 year old primigravda is diagnosed with PIH she ask why this happened to her?
- Her prady.

OB- TERMINOLOGY/ VOCABULARY

Abortion Birth occurring before the end of 20 weeks gestation

Acrocyanosis A bluish discoloration of hands and feet and may be present in the first few
hours of birth but resolves with improve circulation
Ambivalence
Amenorrhea Absence of menses. May be primary or secondary
Amniocentesis Procedure whereby amniotic fluid is obtained for genetic disorders, fetal health
status and evaluation of fetal maturity
Antepartum Time between conception and onset of labor. Used interchangeably with
prenatal
Ballottement Rebound of the fetus or passive fetal movement felt by the examiner by pushing
the fetal body up against the cervix
Braxton Hicks Contractions Irregular, usually painless uterine contractions occurring intermittently
throughout pregnancy beginning around 4th month. Often called false labor
Chadwick’s Sign Bluish purple discoloration of cervix, vagina, vulva and mucus membrane (as
early as 4 weeks)

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Chloasma (Melasma) Facial darkening of skin around forehead and prominent in dark-haired women
worsened by exposure to the sun (mask of pregnancy)
Chorion
Colostrum Yelowish or creamy looking that is thicker than mature milk and contains more
protein, fat-soluble vitamins and minerals. It also contains high levels of
immunoglobulins (antibodies) IgA and provides passive immunity.
Couvade syndrome Development of physical symptoms such as fatigue, backache, depression etc by
the partner of the pregnant woman.
Diastasis recti Separation of the rectus abdominis muscle due to excess pressure of the
enlarged uterus resulting in pendulous abdomen.
Embryo
EDC
Estrogen
Fertilization
Fetus
Folicle Stimulated Hormone
Funic Souffle A soft blowing sound of blood pulsating through umbilicus-occurs at same rate
as the fetal heart rate.
Gestation Number of weeks of pregnancy since the first day of the last menstrual period
Goodell’s sign Softening of the cervix-due to estrogen and progesterone-probable sign of
pregnancy
Gravida Any pregnancy regardless of duration including present one
Hegar’s sign Softening of the isthmus of cervix-around 6-8 weeks
Hyperptyalism
Implantation
Leopold’s maneuvers
Leukorrhea
Lightening
Linea nigra Pigmented line extending from pubic area to umbilicus
Luteinizing hormone (LH
Multigravida Woman in second or any subsequent pregnancy

Multipara A woman who has had 2 or more births at more than 20 weeks gestation
Naegele’s rule
Nulligravida Woman who has never been pregnant
Nullipara Woman who has had no births at more than 20 weeks gestation
Operculum

Para (Parity) Birth after 20 weeks gestation regardless of whether infant is born alive or dead.
Pelvic landmarks
Pica Persistent eating of substances such as clay, soil, soap etc.
Placenta
Postpartum Time from birth until the body returns to prepregnancy state
Primigravida A woman who is present for the first time.
Primipara A woman who has had one birth at more than 20 weeks gestation, regardless of
whether the infant was born alive or dead.
Postterm labor Labor occurring after 42 weeks
Postpartum Time from delivery of the placenta and membranes until woman returns to pre-
pregnant condition.
Preterm labor Labor occurring after 20 weeks, but before 37 weeks gestation.
Progesterone
Prostaglandins

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Pseudoanemia Physiology anemia of pregnancy. Increase plasma volume 50%, is greater than
total erythrocyte (red blood cell) volume of 30%, the hematocrit-(red blood cells
in plasma) decrease.

Pyrosis
Quickening Is a fluttering sensation in the abdomen (woman’s perception of fetal
movement) Occurs about 18-20 wks in a primiparous but as early as 16 weeks
in a multiparous
Relaxin
Sibling rivalry
Stillbirth An infant born dead after 20 weeks of gestation
Striae gravidarium Stretch marks, reddish and wavy that appear on abdomen, thighs and buttocks.

Teratogens
Uterine Souffle A soft blowing sound heard during abdominal auscultation over the uterus at
same rate with maternal pulse-due to increased uterine blood flow.
Vena Cava Syndrome

Viability

Medications list

OB Medication List
This is a list of the most common drugs used in OB. For each drug you should know the generic
name, indications, route, safe dose, contraindications, compatibility etc.
Some are on page 446

1. Pitocin

2. Ropivicaine

3. Penicillin

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4. Cytotec

5. Cervidil

6. Clindamycin

7. Ampicillin

8. Nubain

9. Stadol

10. Fentanyl

11. Tylenol

12. Vistaril

13. Methergine

14. Hemabate

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15. Zofran

16. Regaln

17. Percocet

18. Ducoste

19. Nupercainal ointment

20. Tucks pads

21. Dermaplast spray

22. Lactated Ringers

23. Dextrose 5% and Lactated Ringers

24. Ibuprofen

25. Erythromycin Ointment

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26. Vitamin K

27. Sucrose Folic Acid

28. Magnesium Sulfate – p. 448

Class: beta adrenergic agonist; Tocolytic and anticonvulsant
MOA: acts as a CNS depressant by decreasing the quantity of acetylcholine released by
motor nerve impulses and thereby blocking neuromuscular transmission.
 This action reduces the possibility of convulsion, which is why magnesium sulfate is
used in the treatment of preeclampsia.
 Because magnesium sulfate secondarily relaxes smooth muscle, it may cause transient
blood pressure readings, although it is not an antihypertensive.
 Magnesium sulfate may also decrease the frequency and intensity of uterine
contraction; as a result, it is used as a tocolytic in the treatment of preterm labor.
Route, Dosage, Frequency
For treatment of Preterm Labor:
 Recommended loading dose: 4-8 g IV in 100 mL of Lactated Ringer’s solution using
infusion pump over 20-60 minutes, followed by a maintenance dose of 2-4 g/hr
titrated to response and side effects.
For treatment of Preeclampsia
 Loading dose: 4-6 g magnesium sulfate administered over a 20-30 minute period
 Maintenance dose: 2-3 g/hr via infusion pump
Side Effects with loading dose:
 Flushing; feeling warm
 Headache
 Nystagmus
 Nausea, vomiting
 Dizziness
 Lethargy; sluggishness
 Pulmonary edema
 Constipation
 Blurred vision
 Slurred speech
Toxicity Signs: KNOW
 Depression or absence of reflexes- hyperflexia FIRST SIGN
 Oliguria
 Confusion
 Respiratory depression LATE SIGN
 Circulatory collapse
 And respiratory paralysis
If any of these are suspected, STOP the drip and notify HCP immediately.

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Fetal side effects:

 Hypotonia
 Lethargy
 Respiratory distress
Nursing Considerations
 Monitor the blood pressure every 10-15 minutes during adm.
 Monitor maternal serum magnesium levels as ordered (usually every 6-8 hours)
o Therapeutic levels are in range of 4-8 mg/dl
o Reflexes often disappear at serum levels of 9-13 mg/dl
o Respiratory depression occurs at levels of 14 mg/dl
o Cardiac arrest occurs at levels of 30mg/l and above
 Monitor respirations closely. If respiratory rate is < 12 , toxicity may be occurring.
 Assess knee jerk or patellar tendon reflex for evidence of diminished or absent
reflexes
 Determine urinary output. If output < 30 mL/hr, then toxicity may occur
 If any of the above are no WNL, discontinue drip until they return to normal limits
 ANTIDOTE: Calcium gluconate. Should be available at the bedside. The usual dose is
1 g given IV over a period of about 3 minutes
 Monitor FHR continuously with IV administration
 Continue magnesium sulfate after birth for approximately 24 hours as prophylaxis
against post partum seizures if given for preeclampsia
 Therapy is continued for 12 hours after uterine contractions have stopped if given
for preterm labor
 If drug was given to mother close to birth, monitor infant for signs of toxicity
29. Betamethasone (Celestone Soluspan) p. 444
Class: Glucocorticoid
MOA: Unclear with its MOA but studies have shown that stimulation of enzyme activity are
how this drug can induce pulmonary maturation and decrease the incidence of respiratory
distress syndrome in preterm infants.
 The enzyme is required for biosynthesis of surfactant by the type II pneumocytes.
Surfactant is a major importance to the proper functioning of the lung in that it
decreases the surface tension of the alveoli. Glucocorticoids also increase the rate
of glycogen depletion, which leads to thinning of the inter-alveolar septa and
increases the size of the alveoli. The thinning of the epithelium brings the capillaries
into closer proximity with the air spaces and improves oxygen exchange.
Route, dosage, frequency
 Prenatal maternal IM injection of 12 mg of betamethasone are given once a day for
two days. Dexamethasone has also been given in doses of 6 mg every 12 hours for 4
doses. To obtain maximum results, birth should be delayed for at least 24 hours
after completing the first round treatment.
 Repeat courses of corticosteroids should not be used routinely. There is some
controversy with administering corticosteroids when membranes are ruptured,
fueled by concerns that this could mask infection.
Contraindications
 Inability to delay birth

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 Adequate L/S ratio

 Presence of a condition that necessitates immediate birth (example maternal
bleeding)
 Presence of maternal infection, DM
 Gestational age greater than 34 completed weeks
Effects on Fetus/Newborn
 Lowered cortisol levels at birth, but rebound occurs by 2 hours of age
 Hypoglycemia
 Increased risk of neonatal sepsis
Nursing Considerations
 Assess for presence of contraindications
 Provide education regarding possible side effects
 Administer betamethasone deep in gluteal muscle, avoid injection into deltoid
 If membranes are ruptured, temperature monitoring is warranted every 2 hours or
more frequently if temperature instability is concerning
 Periodically monitor BP, pulse, weight, and edema
 Assess lab for electrolytes and blood glucose
 Some people state that betamethasone and tocolytic drugs should not be given
together due to cause of pulmonary edema.

30. Dexamethasone- read above

31. Terbutaline

32. Hydralazine

33. Procardia (nifedipine)

 Calcium channel blocker: it decreases smooth muscle contractions by blocking the slow
calcium channels at the cell surface
 Side effects: arterial vasodilation and includes hypotension, tachycardia, facial flushing,
and headache
 Toxolytic (Do not use along with mag sulfate but yes with beta adrenergic

34. Methotrexare

35. Methyldopa

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36. Indomethacin (Indocin)

Class: Cyclooxygenase inhibitor - Prostaglandin synthetase

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