The College of Nursing

Nisi Dominus Frustra

College of Nursing
Maasin City, Souterhn Leyte

Supplemental Review
HIGH RISK PREGNANCY
(Prepared by: Rhenier S.Ilado R.N)

I. IDENTIFYING AND/OR MONITORING HIGH RISK PREGNANCY

a. Alpha-fetoprotein (AFP) enzyme blood test
- elevated levels may identify the pregnant woman carrying a baby with
neural tube defects (spina bifida and anencephaly)
- if the AFP is elevated for two samples, it is followed by ultrasonography
and amniocentesis for further confirmation done at 14 to 16 weeks gestation

b. Ultrasonography
1. high-frequency sound wave testing
- discerns multiple pregnancy, placental location and gestational age
by measurement of bi-parietal diameters
a. visualization during first 20 weeks of gestation is improved if the
bladder is full; a full bladder is not necessary after 20 weeks gestation
b. a level II sonogram may be performed to assess formation of
organs
c. nursing considerations:
1. encourage fluid and refrain from voiding before the test

c. Chorionic villi sampling (CVS):

- supplies some data as amniocentesis but can be done after 10 weeks
1. aspiration of villi done during the eighth to twelfth week of pregnancy
2. nursing considerations:
a. instruct to drink fluid so that bladder is full
b. after test, monitor for uterine cont5ractions, vaginal discharge
and teach to observe for signs of infection

d. Amniocentesis
- aspiration of amniotic fluid used to detect sex, chromosomal or biochemical
defects, fetal age, L/S ratio (2/1 ratio indicates lung maturity), increased bilirubin level
associated with Rh disease, and phosphatidylglycerol (PG), which appears in amniotic fluid
after thirty-fifth week, indicating fetal lung maturity.
1. test done with sonogram; usually after 12 to 15 weeks of gestation
2. nursing considerations:
a. have client void
b. after test monitor for uterine contractions, vaginal discharge
c. teach to observe for signs of infection
d. encourage rest

e. Non-tress test (NST)

- done to observe for accelerations of FHR in response to fetal movement
over a 30 to 40 minute period
1. Classification of results:
a. a test is negative or reactive if:
(1) baseline FHR is 120 to 160
(2) there are two accelerations in 10 minutes, each increasing
the FHR by 15 and lasting 15 seconds
 (3) the tracing shows variability of 10 or more beats per
minute

b. test is positive or non-reactive if the three criteria are not met

2. Nursing considerations:
a. fasting is not necessary
b. observe the fetal monitor
c. explain test to decreased anxiety
d. evaluate response to procedure

f. Contraction stress test (CST):

- to demonstrate whether a healthy fetus can withstand a decreased oxygen
supply during the stress of a contraction produced by exogenous oxytocin (pitocin) or
stimulation of nipples manually or by moist heat; if late decelerations appear, the fetus may
be compromised because of uteroplacental insufficiency
1. Classification of results
a. negative: no late decelerations with a minimum of three
contractions in 10 minutes; indicates that the fetus has good chance of surviving labor
b. positive: persistent and late decelerations occurring with more
than half the contractions; indicates need for considering premature intervention

c. suspicious: late decelerations occurring in less than half

of uterine contractions; test should be repeated in 24 hours

2. Nursing considerations:
a. void before test
b. monitor fetal heart rate for 30 minutes before test
c. monitor ,mother after test to observe for possible initiation of
labor
d. evaluate response to procedure

g. Biophysical profile (BPP):

- assess breathing movements, body movements, tone, amniotic fluid volume
and FHR reactivity (NST)
- a score of 2 is assigned to each finding, with a score of 8 to 10 indicating a
healthy fetus
1. used for fetus that may have intrauterine compromise
2. nursing considerations:
a. provide emotional support
b. evaluate response to procedure

h. Maternal assessment of fetal activity:

- need to contact physician or nurse midwife when there are fewer than 10
fetal movements in a 12 hour period.
- fewer than three fetal movements in an 8 hour period, or no fetal
movements in he morning
1. used to determine viability of fetus
2. nursing considerations:
a. teach how to record and report movements

1. PREGNANCY-INDUCED HYPERTENSION
(GESTATIONAL HYPERTENSION, PREECLAMPSIA, ECLAMPSIA, HELLP SYNDROME)
Data Base:
 A. characterized by a triad of symptoms; edema, hypertension and proteinuria
occurring after the twentieth to twenty-fourth week of gestation and disappearing
6 weeks after birth
B. occurs primarily in primiparas below 17 years of age and above 35 years of age
and women with numerous pregnancies, chronic hypertension, diabetes mellitus
severe nutritional deficiencies, multiple pregnancy or trophoblastic disease
C. clinical findings:
1. Gestational hypertension
a. increased blood pressure during pregnancy that resolves within 6 weeks
after birth
b. no edema or proteinuria is present; blood changes rarely occur in
uncomplicated gestational hypertension

2. Preeclampsia
a. mild: systolic pressure increased 30 mm hg or more above normal; diastolic
pressure increased 15 mm hg or more above normal; protenuria +1; edema
manifested by exccesive weekly weight gain and upper-body edema
b. severe: BP is 160/110 or above on two readings taken 6 hours apart
after bed rest; protenuria 3+ to 4+; extensive edema (puffiness of hands and face);
hyperreflexia

3. Eclampsia: seizures and/or coma associated with hypertension,

protenuria and edema

4. HELLP syndrome (H, hemolysis; EL, elevated liver enzymes; LP, low platelet
count)
a. occurs with little warning and often with no previous signs of PIH
b. right upper quadrant pain occurs in 90% of affected women; protenuria
may occur
c. liver enzymes are elevated, platelets and RBC’s are low
d. blood smear reveals broken red blood cells
e. occurs after 28 weeks gestation or 48 to 72 hours after birth

5. Blood chemistry:
- rise in hematocrit, uric acid, liver enzymes and blood urea nitrogen
concentrations and decrease in RBC’s, platelets and CO2 combining power indicate worsening
preeclampsia

D. Guidelines for prevention of pregnancy-induced hypertension

1. sound nutrition counseling during pregnancy and lactation
2. increase protein to 60 g daily in the second and third trimesters
3. caloric intake should be increased 10% during pregnancy; severe caloric
restriction is harmful during pregnancy
4. restriction of sodium is harmful during pregnancy and cam result in electrolyte
imbalance and elimination of essential nutritional components; may contribute to reduced
circulation volume
5. diuretics are contraindicated during pregnancy because they cause hypovolemia
and deplete essential nutrients for mother and fetus

E. Therapeutic interventions
1. Gestational hypertension
a. frequent rest periods
b. dietary management with increased fluid intake
2. Mild preeclampsia
a. high protein diet
b. ambulatory care; frequent visits to obstetrician
 c. frequent rest periods with feet elevated; side lying position to enhance
renal and placental perfusion
3. Severe preeclmpsia or eclampsia
a. hospitalization and complete bed rest
b. magnesium sulfate given IV by infusion pump to prevent or limit seizures
c. albumin concentrate to increase renal flow and correct the hypovolemia
d. antihypertensive:
1. hydralazine (apresoline)
2. labetalol hydrochloride (adalat)
3. methyldopa (aldomet)
e. foley catheter
f. labor induction or cesarean birth once symptoms are under control
g. calcium gluconate for the mother and levallorphan (lorfan) for the
newborn if respiratory depression occurs from magnesium sulfate
h. if fetus is less than 34 weeks gestation, stimulation of surfactant
production with betamethasone is attempted
4. HELLP syndrome
a. same as severe preeclapmsia or eclampsia
b. blood pr blood products may be administered if necessary

Nursing care of clients with pregancy-induced hypertension

(Preeclampsia, Eclampsia, HELLP Syndrome)

A. Assessment
1. blood pressure elevation
2. presence of edema; excessive weight gain, puffiness of hands, feet or face
3. albumin in urine; oliguria
4. hyperreflexia; persistent headache; blurred vision
5. epigastric pain

B. Analysis/ Nursing Diagnosis

1. anxiety related to course of pregnancy and possible death of fetus
2. deficient fluid volume related to fluid shift out of intravascular compartment
3. risk for injury to mother related to sedation, seizures, magnesiul toxicity
4. risk for injury to fetus related to hypoxic episodes during maternal seizures

C. Interventions
1. monitor blood pressure; every 15 minutes during critical phase; every 1 to 4 hours
as condition improves
2. insert foley catheter; monitor urine output and albumin
3. assess edema; daily weights, intake and output
4. maintain high protein diet with normal salt intake
5. monitor hyperreflexia
6. administer magnesium sulfate as ordered (check for sufficient urinary output
before starting)
7. monitor for magnesium toxicity
a. assess for depressed patellar reflexes
b. assess for depressed respirations, below 12 to 14 breaths per minute
c. magnesium blood levels every 6 hours; therapeutic range is 4 to 8 mg/dl
d. have calcium gluconate available; if magnesium sulfate toxicity is present
8. observe for indications of a seizure; maintain seizure precautions; monitor vital
signs and fetal heart rate following a seizure
9. maintain on bed rest in left side-lying position; maintain quiet environment; limit
visitors
10 monitor FHR
11. observe for signs of labor and bleeding
 12. monitor hematologic studies related to HELLP syndrome
13. assess anxieties and concerns
14. be prepared for an induced or emergency cesareans birth
15. continue to monitor for related complications for 48 hours after birth

D. Evaluation
1. maintains (mother and fetus) vital signs with acceptable range
2. remains free from seizures
3. maintains fluid balance

2. ABORTION
Data Base:
A. Definition
1. a spontaneous or planned interruption of pregnancy in which there is complete
expulsion or partial expulsion (incomplete) of the products of conception before the period
of viability
2. period of gestation is 20 weeks or less, the conceptus will weigh below 500 g and
will be less than 16.5 cm long
3. may be caused by the presende of embryonic defects, external mechanical force
or trauma

B. Types/Clinical Findings
1. threatened abortion:
- cervix is closed,. But bleeding, cramping and backache occur; pregnancy
may continue uninterrupted

2. Imminent of Inevitable abortion:

- bleeding and cramping become more severe, cervix dilates and membranes
may rupture

3. Incomplete abortion:
- all the products of conception are not expelledinsti within 24 to 48 hours

4. Complete abortion:
- all products of conception expelled within 24 to 48 hours

5. Missed abortion:
- fetus dies in utero but not expelled; client must be monitored for
disseminated intravascular coagulopathy (DIC)

6. Habitual abortions:
- three consecutive pregnancies that end in abortion

D. Therapeutic interventions
1. complete bed rest
2. diagnostic/Therapeutic blood studies
a. blood cell count
b. blood typing
c. Rh incompatibility
d. Cross-matching with availability of blood
3. dilation and curettage or vacuum aspiration performed if the products of
conception are retained

Nursing care of Clients Experiencing Abortion:

A. Assessment
 1. vital signs; amount of bleeding
2. pain
3. emotional response to loss

B. Analysis/Nursing Diagnosis
1. anticipatory grieving related to loss of expected infant
2. pain related to uterine contractions
3. situational low self-esteem related to inability to carry pregnancy to term

C. Planning/Implementation
1. institute measures to alleviate fear and anxiety; assist with grieving process
2. point out physiologic, reality, but encourage client to work through feelings;
grieving may last up to 24 months
3. monitor amount and type of bleeding; save and count number of pads, distinguish
between dark clotted blood and frank bleeding, which is bright red; monitor fundus for
firmness after products of conception are expelled
4. monitor vital signs for signs of hypovolemia, shock, and infection; monitor CBC,
hemoglobin and hematocrit; prepare for administration of blood; administer oxygen if
necessary
5. maintain fluid and electrolyte balance
6. administer RhoGAM to Rh-negative client after abortion
7. educate about necessity for follow up care and support groups

D. Evaluation/Outcomes
1. remains free from complication such as hemorrhage and infection
2. express feelings

3. ECTOPIC PREGNANCY
Data base:
A. Pregnancy in which implementation occurs outside the uterus (most frequent site is
middle portion of fallopian tube, other sites are abdomen, ovaries or cervix)
B. Early signs and symptoms are usually concealed, may be diagnosed by
ultrasonography and radioimmunoassay
C. Pattern in tubal pregnancy; spotting after one or two missed menstrual periods,
sudden, sharp. Knife-like lower right or left abdominal pain radiating to shoulder;
concealed bleeding from side of rupture leads to sudden shock
D. Clients who have had pelvic inflammation disease (PID)
E. Therapeutic interventions
1. diagnosis confirmed by ultrasound examination, laparoscopy or culdocentesis
2. immediate blood replacement if blood loss is severe
3. surgical repair or removal of ruptured fallopian tube. (e.g. methotrexate) or
therapies to inhibit cell division if fetus is less than 4 cm by ultrasound

Nursing Care of Clients with an Ectopic Pregnancy:

A. Assessment
1. vital signs; signs of shock
2. bleeding; right tender abdomen
3. character and location of pain
4. level of anxiety

B. Analysis/ Nursing Diagnosis

1. ineffective cardiopulmonary tissue perfusion related to hemorrhage
2. fear related to potential disturbance in future childbearing ability
3. anticipatory grieving related to loss of expected infant
4. pain related to tubal rupture
C. Planning/ Implementation
1. assess continuously for signs of shock; administer blood transfusion if ordered
for excessive blood loss
2. administer analgesics as ordered for pain
3. provide emotional support
4. provide preoperative and postoperative care
5. administer RhoGAM to Rh-negative client

D. Evaluation/Outcomes
1. maintain hemostasis
2. states implications for future childbearing
3. express feelings

4. TROPHOBLASTIC DISEASE
Data base:
A. Definition
1. a group of disorders in which there is an abnormal proliferation of tissues and
high hCG levels
2. these disorders include hydatidiform mole, and choriocarcinoma

B. Clinical findings
1. molar pregnancy – no fetus or amnion
2. chriocarcinoma – may occur years after a hydatidiform mole
3. uterus is generally larger for period of gestation and fetal parts are not palpable;
4. symptoms of pregnancy-induced hypertension and hyperemesis are common
5. potential for uterine perforation, hemorrhage, passing of grapelike substance and
infection
6. confirmation by ultrsonography

C. Therapeutic interventions
1. if spontaneous evacuation does not occur, evacuation by dilation and curettage or
hysterectomy is performed
2. continued follow up of serum gonadotropin levels is imperative for 1 year to rule
out metastasis from chorionic carcinoma (increased gonadotropin levels require
chemotherapy); metastasis to lungs is common
3. preventing a new pregnancy is essential for 1 year
4. chemotherapy when malignant

Nursing Care of Clients with Hydatidiform Mole of Trophoblastic Disease:

A. Assessment
1. vaginal bleeding (brownish prune juice) containing grapelike tissue
2. uterine enlargement; fundal height greater than expected for length of
pregnancy
3. vomiting
4. elevated blood pressure earlier than 24 weeks gestation
5. absence of fetal heart tones or activity

B Analysis/Nursing Diagnosis
1. ineffective coping related to loss of expected infant, uncertainty of continuing a
future pregnancy
2. fear related to possible development of cancer
3. situation low self-esteem related to carrying of an abnormal pregnancy

C. Planning /implementation
 1. same for client experiencing abortion
2. teach importance of follow up care

D. Evaluation/Outcomes
1. continues follow up care
2. uses measures to prevent pregnancy for 1 year

5. INCOMPETENT CERVIX
Data Base:
A. Definition
1. cervical effacement and dilation in early second trimester resulting in expulsion of
products of conception
2. usually results from previous forceful dilation and curettage, difficult birth or
congenitally short cervix

B. Clinical findings
1. painless contraction in mid-trimester
2. birth of dead or non-viable fetus

C. Therapeutic interventions
1. cerclage procedure during 14th to 16th week of gestation; suture or ribbon placed
beneath cervical mucosa to close cervix
2. at end of pregnancy, cesarean birth or cutting of suture for vaginal birth
3. bed rest

Nursing Care of Clients with an Incompetent Cervix:

A. Assessment
1. weeks of gestation
2. obstetric history
3. knowledge of the cerclage procedure

B. Analysis/Nursing Diagnosis
1. anticipatory grieving related to potential loss of expected infant
2. situational low self-esteem related to inability to complete pregnancy without
intervention
3. risk for infection related to invasive procedure

C. Planning/Implementation
1. maintain bed rest for 24 hours after cerclage
2. monitor for rupture of membranes or bleeding
3. monitor FHR

D. Evaluation/Outcomes
1. describes signs of labor and to seek immediate medical care when labor begins
2. continues pregnancy to term

6. PLACENTA PREVIA
Data Base:
A. Definition
1. an abnormal implantation of the placenta in the lower uterine segment

B. Types:
1. type I – Low-lying:
 - placenta is at lower uterine segment next to os; uterus stretches with
gestation, placenta moves away from os
2. Type II – Marginal:
- placental edge is at the os, but does not cover it
3. Types III – partial:
- placental edge partially covers the os
4. type IV – complete:
- placenta is centered over the cervical os

C. Clinical findings
1. painless, bright red bleeding: hemorrhage in the third trimester
2. soft uterus in the latter part of pregnancy
3. signs of infection may be present

D. Therapeutic interventions
1. ultrasonography to confirm the presence of placenta previa
2. depends on location of placenta, amount of bleeding and status of the fetus
3. home monitoring with repeated ultrasounds may be possible with type I-low lying
4. control bleeding
5. replace blood loss if excessive
6. cesarean birth, if necessary
7. betamethasone is indicated to increase fetal lung maturity

Nursing Care of Clients with Placenta Previa:

A. Assessment
1. presence of bright-red blond with absence of pain
2. vital signs indicating shock (hypovolemic)
3. changes in or absence of FHR
4. level of anxiety (usually increases)

B. Analysis/Nursing Diagnosis
1. ineffective cardiopulmonary tissue perfusion in mother and fetus related to
hemorrhage and interruption of placental oxygen supply
2. fear related to acuteness of physical status and possible death of fetus and/or
mother
3. anticipatory grieving related to outcome of pregnancy and threat of termination
of child bearing ability

C. Planning/Interventions
1. no admission vaginal examination; if vaginal examination is to be performed, double
setups (vaginal and cesarean) must be provided
2. maintain bed rest in semi-fowlers position
3. monitor FHR continuously; will be normal if placenta is functioning
4. monitor maternal vital signs continuously; assess color for pallor or cyanosis;
administer oxygen
5. assess perineal pads to determine blood loss; monitor hgb and Hct; prepare for
cesarean birth if bleeding persist
6. administer intravenous therapy and .or blood replacement

D. Evaluation/Outcomes
1. delivers viable, stable newborn
2. demonstrates hemodynamic stability

7. ABRUPTIO PLACENTA
Data base:
A. Definition
1. partial, marginal or complete premature separation of a normally implanted
placenta

B. Clinical Findings
1. painful dark-red bleeding
2. board-like abdomen
3. persistent uterine contractions/tenderness (couvelaire’s uterus)
4. signs of fetal distress – hyperactivity and increased in FHR
5. bleeding and hemorrhage

C. Nursing Diagnosis
1. ineffective tissue perfusion in both mother and fetus related to hemorrhage and
interruption of placental oxygen supply

D. Implementation
1. maintain bed rest in left lateral recumbent position
2. monitor FHR
3. monitor maternal vital signs
4. assess the mother for pallor or cyanosis; administer oxygen
5. secure blood typing and cross-matching, coagulation studies, hemoglobin and
hematocrit
6. perform Kleihauer- Betke test (test strip procedure)
- this is used to detect whether the blood is of fetal or maternal origin
7. never attempt pelvic and vaginal exam (agitation of the cervix may lead to severe
hemorrhage)
8. administer IV therapy
9. monitor for signs of DIC, i.e seepage of blood from IV site or incision areas

COMPLICATONS OF LABOR AND BIRTH:

1. PREMATURE RUPTURE OF MEMBRANES (PROM)
Data Base:
A. Definition
1. spontaneous rupture of membranes before onset of labor
B. Maternal implication: ascending infection

C. Fetal implications
1. prolapsed cord
2. FHR decelerations caused by cord compression from lack of amniotic fluid
3. sepsis from ascending infection

D. Therapeutic interventions
1. hospitalization with bed rest after 37 weeks of gestation
2. amnioinfusion of isotonic saline in some cases to allow for fetal movement and
lessen danger of cord compression
3. prophylactic antibiotics

Nursing Care of clients with Premature Rupture of Membranes:

A. Assessment
1. time of rupture of membranes
2. fetal heart rate and maternal vital signs
3. perineum for prolapsed cord
4. confirmation of rupture of membranes by fern test; microscopic examination
reveals fernlike crystals of sodium chloride
 5. confirmation of presence of amniotic fluid by nitrazine test; paper turns blue
when touched by alkaline solution (7.0 to 7.5) rather than acidic vaginal secretions

B. Ananlysis/Nursing diagnosis
1. anxiety related to outcome of pregnancy
2. risk for ineffective fetal tissue perfusion related to prolapsed cord
3. risk for infection related to premature rupture of membranes

C. Planning/ Implementation
1. monitor FHR and maternal cital signs; temperature and pulse every 2 hours
2. monitor uterine activity
3. avoid unnecessary vaginal examinations
4. ensure adequate hydration
5. educate parents; amniotic fluid is still being produced
6. provide perineal care
7. administer antibiotics as ordered

D. Evaluation/Outcomes
1. remains free from infection
2. progress through labor to safe delivery of newborn

2. PRETERM LABOR
Data base:
A. contraction begin after the twentieth week but before the thirty-eight week of
gestation, causing effacement and dilation of the cervix
1. a fetus of 20 or more weeks gestation who dies before or during delivery is
classified as stillbirth
2. preterm births account for 75% to 38% of neonatal morbidity and mortality

B. contributing factors include history, risky lifestyle, multiple gestations, maternal

illness with fever, heroin and opiate use, bacterial vaginitis, multiple abortions, and
pyelonephritis

C. diagnostic studies
1. transvaginal cervical sonography

D. therapeutic interventions
1. bed rest; sidelying position, preferably left side
2. tocolytic therapy directed toward postponing labor
a. betasymppathomimetics such as ritifrine (yutopar) and terbutaline sulfate
(brethine)
b. magnesium sulfate
c. prostaglandin inhibitors
d. calcium channel blockers such as nifedipine
3. glucocorticoid theraphy
a. betamethasone (celestone)
b. administered 24 to 48 hours before birth if birth appears inevitable
c. reduce incidence and severity of respiratory distress syndrome (RDS) in
preterm infants; enhances formation of surfactant
4. home uterine monitoring

Nursing Care of Clients During Preterm Labor:

A. Assessment
1. number of weeks of gestation
2. presence of live and viable fetus
 3. presence of labor; two contractions lasting 30 seconds within 15 minutes; cervical
dilation less than 4 cm; effacement 50%less
4. no signs of hemorrhage or infections
5. presence of severe pregnancy induced hypertension
6. prolonged rupture of membranes
7. emotional status of mother

B. Analysis/Nursing Diagnosis
1. situational low self-esteem related to failure to carry pregnancy to full term
2. fear related to acute status of infant and potential for death

C. Planning/Implementation
1. prevention by decreasing risk factors when possible
a. teach regarding drug use and lifestyle risks
b. teach the importance of early reporting of temperature elevations
c. monitor for urinary tract infection; asymptomatic bacteriuria (ASB) shows
a positive culture above 100,000/mm3
2. monitor vital signs, FHR, contractions and progression of labor
3. maintain bed rest
4. inform client about medication; obtain consent; explain that the use of pain
medications will be limited to avoid their depressive effects on the fetus
5. provide emotional support; reduce anxiety and prepare for possible loss of infant
6. provide special care related to the administration of tocolytic medications
a. obtain baseline blood data and electrocardiographic (ECG) readings
b. monitor vital signs; hypotension can occur with all tocolytics; tachycardia
can occur with terbutaline and ritodrine
c. maintain hydration but monitor for pulmonary edema
d. monitor for signs of hypokalemia and hyperglycemia
e. monitor intake and output and neurologic reflexes
7. prepare for use of glucocorticoid therapy for fetus
8. prepare for preterm birth if labor continues
9. provide home instructions for halting pre-term labor
a. assessment by home health nurse should include vital signs, FHR, breath
sounds, fetal activity, cervical status, blood and urine glucose levels, fundal height,
maternal weight, uterine evaluation, presence of edema
b. rest periods in lateral position; avoidance of vigorous activity
c. increased fluid intake
d. no sexual intercourse or sexual activity that leads to orgasm
e. no nipple stimulation
f. avoidance of stressful events

D. Evaluation/Outcomes
1. mother demonstrates cessation of labor
2. fetus remains in utero with acceptable fetal heart rate and fetal movements
3. mother and partner state recurring signs of preterm labor

3. POSTTERM LABOR
A. extends beyond the forty-first week of gestation or 2 weeks beyond expected date
of birth; 38 to 42 weeks gestation is considered full term

B. fetal risk
1. decreased amniotic fluid may lead to cord compression during labor
2. decreased placental function because placental aging lowers oxygen and
nutritional transport; fetus becomes compromised during labor (may become asphyxic or
hypoglycemic)
 3. increasing size (mainly length) and hardening of skull may contribute to
cephalopelvic disproportion

C. maternal risk present only if infant is excessively large

D. therapeutic intervention; induction of labor

Nursing Care of Clients During Post term Labor:

A. Assessment
1. number of weeks of gestation; date of last menstrual period; EDB
2. biophysical profile, particularly amount of amniotic fluid
3. fetal heart rate; results of stress and nonstress tests
4. presence of meconium
5. level of anxiety related to delayed date of birth
6. newborn will have little vernix, long nails and hair, peeling wrinkled skin, reduced
subcutaneous fat, meconium staining

B. Analysis/ Nursing Diagnosis

1. fear related to fetal well-being because of aging placenta and decreased amniotic
fluid
2. risk for injury to mother and neonate related to large size of neonate

4. PRECIPITATE LABOR
Data base:
A. rapid labor of less than 3 hour duration
B. Hazards to mother are perineal laceration and postpartum hemorrhage
C. hazards to infant are anoxia and intracranial hemorrhage

Nursing Care of Clients During Precipitate Labor:

A. Assessment
1. rapid cervical dilation
2. accelerated fetal descent
3. history of rapid labor
4. rapid uterine contractions with decreased periods of relaxation between
contractions

B. Analysis/Nursing Diagnosis
1. Risk for maternal injury related to rapid expulsion of fetus resulting in lacerations
and hemorrhage

C. Planning/Implementation
1. remain with mother and monitor closely
2. keep emergency birth pack at bedside
3. keep mother and partner informed through-out process of labor and birth
4. support and guide fetal head through birth canal when birth occurs

D. Evaluation/ Outcomes
1. mother remains injury free
2. neonate remains injury free

PREEXISTING HEALTH PROBLEMS THAT AFFECT PREGANCY:

1. HEART DISEASE
Data base:
A. origin: 90% rheumatic (incidence expected to decrease as incidence of rheumatic
fever decreases), 10% congenital lesions or syphilis

B. normal hemodynamics of pregnancy that adversely affect the client with heart
disease
1. oxygen consumption increased 10% to 20% related to needs of growing fetus
2. plasma level and blood volume increase; RBC’s remain the same (physiologic
anemia)

C. functional or therapeutic classification of heart disease during pregnancy

1. Class I: no limitation of physical activity; no symptoms of cardiac
insufficiency or angina
2. Class II: slight limitation of physical activity; may experience excessive
fatigue, palpitation, angina or dyspnea; slight limitations as indicated
3. Class III: moderate to marked limitation of physical activity; dyspnea, angina
and fatigue occur with slight activity and bed rest is indicated during most of pregnancy
4. Class IV: marked limitation of physical activity; angina, dyspnea and
discomfort occur at rest; pregnancy should be avoided; indication for termination of
pregnancy

Nursing care of Pregnant Clients with Heart Disease:

A. Assessment
1. prenatal period: vital signs, weight gain, dietary patterns, emotional outlook,
knowledge about self-care, sign of heart failure, stress factors such as work, household
duties
2. intra-partal period: vital signs (heart rate will increase), respiratory changes
(dyspnea, coughing, crackles); FHR patterns
3. Post-partal period: signs of heart failure or hemorrhage related to fluid shifts;
intake and output

B. Nursing Diagnosis
1. activity intolerance related to increased cardiac workload
2. anxiety related to unknown course of pregnancy, possible loss of fetus and
inability to perform role responsibilities

C. Implementation
1. Prenatal period:
a. teach importance of rest and avoidance of stress
b. instruct regarding use of elastic stockings and periodic elevation of legs
c. teach appropriate dietary intake: adequate calories to ensure appropriate,
but not excessive, weight gain, limited, not restricted, salt intake
d. administer medications as ordered: heparin, furosemide (Lasix), digitalis,
betablockers (inderal)
e. monitor for signs of heart failure, such as respiratory distress and
tachycardia
2. Intra-partal period:
a. encourage mother to remain in semi-fowlers or left lateral position
position
b. provide continuous cardiac and fetal monitoring
c. assist with forceps birth in second stage of labor to avoid work of pushing
3. Post-partal period: most critical time because of increased circulating blood
volume after birth of placenta
a. institute early ambulation schedule; apply elastic stockings
b. monitor for signs of heart failure such as respiratory distress and
tachycardia
 c. monitor for heart rate: accelerated heart rate of mother in latter half of
pregnancy puts extra workload on her heart
d. provide for adequate rest; the increase in oxygen consumption with
contractions during labor makes length of labor a significant factor
e. provide close supervision: sudden tachycardia during birth or sudden
bradycardia and normal increase in cardiac output following birth may cause cardiac arrest

D. Evaluation
1. delivers healthy infant
2. maintains cardiac status within acceptable limits

2. DIABETES MELLITUS
Data base:
A. normal physiology of pregnancy that affects woman with diabetes
1. vomiting during pregnancy, especially in the first trimester, decreases
carbohydrate intake with resulting acidosis and insulin dosage adjustment
2. human placental lactogen decreases insulin response in pregnant diabetics and
maternal sparing of glucose: this leads to a greater need for insulin, although insulin
increases, resistance to insulin also increases because of the presence of placental lactogen.
Thus more exogenous insulin is required to maintain normal blood glucose, especially in latter
part of pregnancy
3. normal lowered renal threshold for glucose can result in glusosuria
4. muscular activity during labor depletes glycogen; therefore carbohydrate intake
must be increased

B. Diabetes mellitus during pregnancy may be:

1. pre-gestational
a. type 1 diabetes
- complications include retinopathy, neuropathy and coronary artery disease
b. type II diabetes
- complications include retinopathy, neuropathy and coronary artery disease

2. gestational
a. diet controlled

C. hazards of diabetes during pregnancy

1. often there is history of anomalies, still births and fetal deaths
2. babies are excessively large, weighing over 4000 g (macrosomia)
3. neonatal deaths occur as a result of hypoxia, hypoglycemia, congenital anomalies
and preterm labor
4. pregnancy induced hypertension and hydramnios are common
5. cesarean birth may be necessary

Nursing Care of Pregnant Clients with Diabetes Mellitus:

A. Assessment
1. length of time client has had diabetes mellitus
2. dietary patterns
3. blood glucose level
4. presence of support persons

B. Nursing Diagnosis
1. fear related to health of newborn
2. deficient fluid volume related to osmotic diuresis

C. Implementation
 1. care of mother
a. teach and encourage adherence to dietary and insulin regimens
b. reach signs and symptoms of hyperglycemia (acidosis) and hypoglycemia (insulin
reaction)
c. teach serum glucose testing, insulin administration and record keeping
d. reinforce need for various tests for fetal well-being, such as ultrasound, stress
and non stress test, amniocentesis and L/S ratio
e. prepare client for induction of labor or CS birth if indicated
f. continue monitoring for fluid and electrolyte balance and ketoacidosis
g.
2. care of neonate
a. admit infant to neonatal intensive care unit necessary
b. keep the infant warm because of poor temperature control mechanisms
c. observe respiration (stomach aspiration performed at the time of birth, because
hydramnios inflates stomach, which pushes up and interferes with diaphragm
d. observe for signs of hypoglycemia and hypocalcemia such as lethargy, poor sucking
reflex, cyanosis, decreased blood glucose (30-45mg/dl)
e. provide glucose water feeding to prevent acidosis (with poor sucking reflx,
glucose should be given parentally)
f. obersrev for congenital anomalies; there is increased incidence in babies of
diabetic mothers

D. Evaluation
1. maintains serum glucose levels within acceptable limits
2. delivers a healthy newborn