Care of Mother and Child at Risk or with

Problems (Acute and Chronic)

Module #1

Lesson Title: CARE OF THE HIGH-RISK PREGNANT CLIENT Materials:

(PRE-GESTATIONAL CONDITIONS-CARDIOVASCULAR
DISORDERS AND PREGNANCY) Pen, paper, index card, book, and class List

Learning Targets:
At the end of the module, students will be able to: References:
1. Define types and effects of cardiovascular disorders to
pregnancy, including preexisting factors that contribute to its Pilliteri, Adele and Silbert-Flagg, JoAnne
development such as cardiovascular disease; and, (2018) Maternal and Child Health Nursing, 8th
2. Integrate knowledge of cardiovascular disorders to nursing Edition. USA: Lippincott Williams and Wilkins
process to achieve quality maternal and child health nursing
care.

A. LESSON PREVIEW/REVIEW

The instructor will be starting to introduce himself/herself to the class and the assigned subject, Care of Mother
and Child At-Risk or with Problems (Acute and Chronic). The course outline will be distributed and discussed
accordingly. Listed below are the additional information vital in orientation:

B. MAIN LESSON
The instructor should discuss the following topics. Instruct students to take down notes.

HIGH-RISK PREGNANCY- is one in which a concurrent RISK FACTORS

disorder, pregnancy-related complication, or external
factor jeopardizes the health of the woman, the fetus, or A. DEMOGRAPHIC FACTORS
both.  Age: <16 or over 35 (optimal age: 20-30yo)
 Weight: overweight or underweight
 Mother or fetus has a significant increased chance  Height: <5 feet
of harm, damage, injury, or disability(morbidity),
and loss of life or death(mortality) B. SOCIOECONOMIC STATUS
 Inadequate finances
 Overcrowding, poor standards of housing
 Nutritional deprivation
 Severe social problems
 Unplanned & unprepared pregnancy, especially
adolescents
C. OBSTETRIC HISTORY D. CURRENT OBSTETRICAL STATUS
 History of infertility or multiple gestation  Late or no prenatal care
 Grand multiparity  Maternal anemia
 Previous abortion or ectopic pregnancy  Rh sensitization
 Previous losses: fetal death, stillbirth, neonatal  Antepartal bleeding; placenta previa, Abruptio
deaths Placenta
 Previous operative OB: Cesarean Section,  Pregnancy Induced Hypertension
forceps delivery  Multiple gestation
 Previous uterine/cervical abnormality  Premature or postmature labor
 Previous high-risk infant: Low Birth Weight, Large  Polyhydramnios
for Gestational Age, birth injury or malformation  Premature Rupture of Membranes
 Previous hydatidiform mole

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #1
 Small for Gestational Age, Large for Gestational
Age, abnormality in tests and presentation
E. MATERNAL MEDICAL HISTORY/STATUS  Hemoglobinopathies
 Cardiac/pulmonary disease  Seizure disorder
 Metabolic disease: Diabetes Mellitus, thyroid  Malignancy
disease  Major emotional disorders, mental retardation
 Endocrine disorders: pituitary, adrenal
 Chronic renal disease: repeated Urinary Tract F. HABITS/LIFESTYLE
Infection, bacteriuria  Smoking during pregnancy
 Chronic hypertension  Regular alcohol intake
 Sexually Transmitted Infections and other  Drug use/abuse
infections
 Major congenital anomalies of the reproductive
tract
IDENTIFYING CLIENT AT RISK
 It begins with the 1st prenatal visit & continues throughout the pregnancy

 It involves subjective as well as objective assessment techniques such as screening procedures, laboratory
and diagnostic examinations
Standard Examinations Done in a Prenatal Visit  Leopold’s Maneuver
 Complete Blood Count- screens for anemia  Pelvic adequacy examination
 Edema Check-normally in Lower extremities (if  Urinalysis and Culture-screening for
found on leg; in arms & feet, may indicate pre- asymptomatic bacteriuria as early as 1st prenatal
eclampsia) visit; if (+), culture is done
 Fetal heart Rate (N= 120-160 bpm)  Vital Signs
 Fundic Height- measured from 22-34 weeks &  Weight- pattern of weight gain/loss is recorded
correlates with gestational age with normal  Non-Stress Test
pregnancy  Oxytocin Contraction Test/Contraction Stress
 Height- during initial visit Test
 Biophysical Profile

Cardiovascular Disorders and Pregnancy

Effects of Pregnancy on Heart Disease

Blood Volume & Cardiac output

 Blood Volume peaks at 24-28 weeks
 Cardiac output increases 50%
 Heart must contract harder& faster
 Postpartum-blood circulating in the uterus & placenta returns to maternal circulation

Team approach to care during pregnancy (internist, OB and nurse). Most dangerous period is in weeks 28 to 32, just after
the BV peaks, earlier in more severe cases

Most Commonly Cause Difficulty During Pregnancy Risk Factors

1. Valve Damage due to Kawasaki Disease or 1. Rheumatic fever- 90% of all 5. Pulmonary disease
Rheumatic Fever cases 6. Renal diseases
2. Congenital Anomalies such as ASD or Uncorrected 2. Congenital heart defects 7. Heart surgery
Coarctation of Aorta 3. Arteriosclerosis
3. Aortic Dilatation 4. Myocardial Infarction:
4. Marfan Syndrome pregnancy is generally
contraindicated with
previous MI and who have
severe left ventricular
damage & heart failure

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #1
Classification of Heart Disease

Class Description
I Uncompromised. Ordinary physical activity causes no discomfort. No symptoms of cardiac insufficiency and no
anginal pain.

II Slightly compromised. Ordinary physical activity causes excessive fatigue, palpitation, and dyspnea or anginal
pain.

III Markedly compromised. During less than ordinary activity, woman experiences excessive fatigue, palpitations,
dyspnea, or anginal pain.

IV Severely compromised. Woman is unable to carry out any physical activity without experiencing discomfort.
Even at rest, symptoms of cardiac insufficiency or anginal pain are present.

From Criteria Committee of the New York Heart Association. (1994). Nomenclature and criteria for diagnosis of diseases
of the heart and great vessels (9th ed.). Boston, MA: Little, Brown & Co.

Prognosis & Management

1. Woman with Artificial valve Prosthesis

a. Pregnant women in the past were not advised to get pregnant to the increase blood volume and increase
workload of the heart.
b. To watch out for SUBCLINICAL BLEEDING/HEMOLYSIS

Observe the following:

 Petechia
 Premature separation of placenta

2. Women with Chronic Hypertensive Vascular Disorder

 Women with chronic hypertensive vascular disease before pregnancy is usually associated with atherosclerosis or
renal disease and usually puts the mother and the fetus at risk.

3. Women with Venous Thromboembolic Disease (DVT)

 Increases with a combination of the following:
1. Stasis of blood in the lower extremities from uterine pressure
2. Hypercoagulability (effect of elevated estrogen levels)
3. Vessel damage

AT RISK of DEVELOPING Deep Vein Thrombosis (DVT)

a. Spontaneous Miscarriage
b. Fetal death
c. Hypertension of Pregnancy
d. Antiphospholipid antibodies(aPLA)/antiphospholipid syndrome

Complications
Pulmonary Emboli Congestive heart failure (LSCHF)
Signs and Symptoms: Maternal dysrhythmias
Chest pain Spontaneous abortion
Sudden onset of dyspnea Premature labor
Hemoptysis Intrauterine growth retardation
Tachycardia/Missed Beats
Dizziness and Fainting

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #1

Assessment
Diagnostic Test Criteria for establishing Signs of Cardiac Other Signs
diagnosis of Heart Disease Decompensation
 ECG  Persistent murmurs  moist cough  Syncope w/ exertion
 Echocardiography  Permanent cardiomegaly  Pedal edema: signs of  Cyanosis
 Echocardiogram  Severe dysrhythmias pulmonary edema  Clubbing of fingers
(ultrasound of the  Severe dyspnea  Dyspnea, increasing with  Neck vein distention
heart) activity  Cardiomegaly
 Tachycardia  Pulmonary
 Tachypnea hypertension
 Chest pains on exertion
 Cyanosis
 Persistent heart murmurs
Safety alert: presence of severe dyspnea, syncope with exertion, hemoptysis, nocturnal tachycardia and angina require
prompt evaluation

A pregnant woman w/ heart disease should avoid infection, excessive weight gain, edema and anemia because these
conditions increase the workload of the heart

Treatment/Management: Individualized
1. Frequent prenatal visits 7. Iron supplement- prevent/treat anemia
2. Rest, physical and mental: 8. Oxygen as necessary
 Sleep at least 8-10 hours at night & 2 rest periods 9. Anticoagulant-Heparin/Enoxaparin to prevent clot
during the day formation with DVT and Pulmonary Emboli as
 Instruct client to lie down for 30 mins after meals complication
 Allow only light work, no stair climbing, no 10. Nitroglycerin- relieves angina by vasodilation
exhaustion  take: 5 min before effort
 Activity limitation especially for Class 3 & 4  how often: q 5 mins up to 3 tabs, if the chest pain
3. Severely affected clients may need to be admitted as is not relieved after 15 mins, go to ER
early as mid-2nd trimester  take tablet while sitting down
4. Digitalis. Withhold if PR <60bpm or >100bpm  storage: covered, replace every 3 months
5. Diuretics. If Potassium-excreting (e.g., Furosemide  Side Effects: hypotension, Headache, flushing,
(Lasix)) burning & stinging sensation under the tongue
SIDE EFFECTS: hypokalemia increases the risk for  Types: tablet, patch, cream, sublingual
digitalis toxicity; report signs like bradycardia, N/V, 11. Corticosteroid- help to reduce the formation of
diarrhea, colored vision deficiency (xanthopsia) additional antibodies in aPLA
6. Antibiotics-before any invasive procedure; prophylaxis
vs. Rheumatic Fever; treatment of bacterial infection

CHECK FOR UNDERSTANDING

The instructor will prepare 10 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.

1. A 26-year-old pregnant client has a history of heart disease and she told the doctor that ordinary physical activity
causes no discomfort and has no symptoms of cardiac insufficiency and no anginal pain. Which of the following class of
heart disease does the client has?
A. Compromised
B. Slightly compromised
C. Markedly compromised
D. Severely compromised
E. Uncompromised

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #1
2. A 28-year-old pregnant client has Uncorrected Coarctation of Aorta, and she told the doctor that when she do ordinary
physical activity it causes excessive fatigue, palpitation, and dyspnea or anginal pain. Which of the following class of heart
disease does the client has?
A. Compromised
B. Slightly compromised
C. Markedly compromised
D. Severely compromised
E. Uncompromised

3. A pregnant patient was diagnosed when she was a child with Atrial Septal Defect and now pregnant, she went to the
hospital due to extreme fatigue, dyspneic and palpitations every time she takes the stairs or walk a couple of meters.
According to the Classification of Heart Disease which class does the patient belongs to?
A. Class 1
B. Class 2
C. Class 3
D. Class 4

4. A pregnant client is experiencing chest pain and was diagnosed with Chronic Hypertensive Vascular Disorder; her
doctor ordered a medication called Nitroglycerin. The following are correct statement regarding Nitroglycerin, EXCEPT:
A. Nitroglycerin works by relaxing the smooth muscle and blood vessels in the body.
B. A vasodilator drug used for the treatment of chest pain and high blood pressure.
C. Nitroglycerin sublingual tablets should not be chewed, crushed, or swallowed.
D. It is taken within 5 mins up to 3 tablets and if the chest pain is not relieved after 15 minutes the patient will take a rest.

5. A 28-week pregnant woman came to the Outpatient Department for her prenatal check-up and was requested to do
Ultrasound of her heart. Which of the following diagnostic test is called Ultrasound of the Heart?
A. Electrocardiogram
B. Electrocardiography
C. Echocardiogram
D. Electroencephalogram

6. A pregnant client ask you what the common causes of heart disorder in pregnancy are. The following are most common
cause of cardiovascular disorder during pregnancy, EXCEPT:
A. Atrial Septal Defect
B. Uncorrected Coarctation of Aorta
C. Marfan Syndrome
D. Pulmonary Embolism

7. A 29 weeks pregnant came to the emergency room department due to severe dyspnea, hemoptysis, nocturnal
tachycardia, and angina. What makes the client prompt actions means?
A. requires no intervention.
B. requires referral to her doctor.
C. requires immediate intervention.

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #1
D. requires rest and oxygen therapy

8. Althea, an 18-week pregnant client with an Aortic Dilatation was advised to decrease the workload of the heart. The
following conditions increases the workload of the heart.
A. Infection
B. Eupnea
C. Weight Loss
D. Vasodilation

9. A pregnant client is taking Furosemide for the treatment of her edema, and she asked you what the side effects of
Potassium-wasting diuretics are. The following are side effects of potassium-wasting diuretics, EXCEPT:
A. Hyperkalemia
B. Hypokalemia
C. Bradycardia
D. Xanthopsia

10. A 28-year-old pregnant client has Marfan Syndrome, and she told the doctor that during less than ordinary activity,
woman experiences excessive fatigue, palpitations, dyspnea, or anginal pain. Which of the following class of heart
disease does the client has?
A. Compromised
B. Slightly compromised
C. Markedly compromised
D. Severely compromised
E. Uncompromised
.

C. LESSON WRAP-UP

AL Activity: CAT: 3-2-1 This strategy provides a structure for students to record their own comprehension and
summarize their learning. It also gives the teacher an opportunity to identify areas that need re-teaching, and areas of
student interest

Instructions:

1. As an exit ticket at the end of the class period

2. After the lesson, have each student record three things he or she learned from the lesson.
3. Next, have them record two things that they found interesting and that they’d like to learn more about.
4. Then, have students record one question they still have about the material.
5. Review the students’ responses. You can use this information to help develop future lessons and determine if some
of the material needs to be taught again.

Three things you learned:

1.

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #1
2

3.

Two things that you’d like to learn more about:

1.

2.

One question you still have:

1.

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