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I. Mother (HIGH RISKCHILDBEARING-MATERNAL)
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Female ReproductiveAnatomy & Physiology
I. External reproductive organs
A. Mons pubis / mons veneris pad of fatw/c lies over the symphysis pubis
B. Labia majora 2 folds of skin w/ fatunderneath; contain bartholins glands(believed to secrete a yellowish mucus)
C. Labia minora 2 thin folds of delicatetissues
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Glans clitoris small, erectilestructure at the anterior junction of
the labia minora
Vestibule narrow space seen when
the labia minora is separated
Urethral meatus external opening
of the urethra
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Vaginal orifice external opening ofthe vagina, covered by a thinmembrane
Perineum area from the lowerborder of the vaginal orifice to theanus
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II. Internal reproductiveorgans
A.Vagina 3-6 inch long dilatablecanal located between the bladder &the rectum
B. Uterus hollow pear-shapedfibromuscular organ 3 inches long, 2inches wide, 1 inch thick, weighing50gms in non-pregnant woman
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C. Fallopian tubes 4 inches long fromeach side of the fundus; widest part
(called ampulla) spreads intofingerlike projections.
D. Ovaries almond-shaped, dullwhite sex glands near the fimbriae,kept in places by ligaments.
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1. Assessment of risk factors ofpregnancy:
a. Lack of prenatal careb. maternal age less than 18 or older
35
c. Conception w/in 2 mos of previousdelivery
d. Fifth or subsequent delivery
e. Pre-pregnant wt 20% more or lessthan normal
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f. Minimal or no wt gain
g. Fetal anomaly
h. Complications of labor & deliveryi. Drug or alcohol abuse
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2. Screening procedures
Prenatal Screening Procedures
In an uncomplicated pregnancy,
expect about a dozen doctor visits
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First Visit
Blood tests:To check the woman'sblood group and sometimes, to checkfor presence of hepatitis B virus,
which might be transmitted to thebaby.
Cervical smear test:To test for an
early cancer of the cervix (if a testhas not been performed recently).Also called a Pap smear.
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First Visit and Throughout thePregnancy
Blood tests:To check for anemia inthe woman, and in women with Rh-negative blood groups, to look for
the presence of Rhesus antibodies.
Urine test:To check for proteinuria,which could indicate a urinary tractinfection or preeclampsia.
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Blood and urine test:To check fordiabetes mellitus.
Blood pressure check:To screenfor hypertension, which interfereswith blood supply to the placentaand is a sign of preeclampsia.
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First Visit and After ANYInfection
Blood tests:To screen for rubella,which can cause defects in the baby,and for syphilis and HIV (the AIDS
virus) which can also be passed on.
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First 12 Weeks
Chorionic villus sampling:May beperformed if there is a risk of certaingenetic (inherited) disorders being
passed on.
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16 to 18 Weeks
Ultrasound scanning:Is carriedout to date the pregnancy accuratelyand to detect any abnormalities
present in the fetus.
Amniocentesis:Carried out onolder women and those with spinabifida or Down's syndrome to detectpossible abnormalities in the fetus.
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Blood test:In some cases, theamount of alpha-fetoprotein in theblood is tested to determine whether
the baby has spina bifida.
Fetoscopy and fetal bloodsampling:In some cases, these arecarried out if there is doubt aboutthe normality of the baby.
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High-risk or overdue pregnancies
Blood and urine tests:To assessplacental function and fetus health.
Electronic fetal monitoring:Tocheck on the fetal heart beat.
Ultrasound scanning:Extra scansmay be recommended to assess fetalgrowth and development, location ofplacenta, amount of amniotic fluid.
3 Di ti t t d l b t
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3. Diagnostic tests and laboratoryexams
a. Alpha-fetoprotein (AFP) enzymeblood test
- elevated levels may identify thepregnant woman carrying a babywith neural tube defects (spina bifidaand anencephaly)
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- if the AFP is elevated for twosamples, it is followed byultrasonography and amniocentesis
for further confirmation done at 14to 16 weeks gestation
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b. Ultrasonography
1. high-frequency sound wave testing-
discerns multiple pregnancy,placental location and gestationalage by measurement of bi-parietal
diameters
nursing considerations:
1. encourage fluid and refrain fromvoiding before the test
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c. Chorionic villi sampling (CVS):
- a specialized alternative test toamniocentesis.
It involves removing a small amount oftissue called the chorionic villi, which
is located on the outside of the fetalgestational sac and will later becomethe placenta.
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The most common reasons a CVS isperformed:
Maternal age of 35 years or more atexpected time of delivery
An abnormal first trimester screenresult
Ultrasound finding suggesting a
higher risk for a chromosomeabnormality
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Previous pregnancy or family historyof certain chromosomal or genetic
disorders
Pregnancies at risk for certain
genetic conditions
A desire to obtain accurate testresults as early as possible inpregnancy
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The CVS may be performedtransabdominally by guiding a thinneedle through the abdominal wall to
the chorionic villi, then withdrawing asmall amount of this tissue (Seepicture below, A)
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Occasionally, particularly if thethickest location of the villi is in the
lower portion of the uterus, the CVSis performed transcervically by usinga thin flexible plastic catheter (hollow
tube) which is guided through thecervical opening, somewhat likehaving a Pap smear done. Thiscatheter is then used to remove asmall amount of the villi. (Seepicture below, B).
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2. nursing considerations:
a. instruct to drink fluid so thatbladder is full
b. after test, monitor for uterinecontractions, vaginal discharge andteach to observe for signs ofinfection
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Most women do not report the CVSprocedure to be very painful. It
usually takes a minute or two toperform, and is commonly describedas feeling similar to a blood draw.
Some women experience mildcramping afterwards or light spottingthat usually goes away within a day
or two.
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d. Amniocentesis study of amnioticfluid
Preparation:
Explain to the patient the procedure
Have consent form signed
Empty the bladder
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Ultrasound to locate the placenta
Leopolds maneuvers are done
Position patient on supine, but elevatehead and shoulders to one side
The abdomen is prepped with anantiseptic, draped and the site exposedand infiltrated with local anesthetic
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An 18-20 gauge spinal needle isintroduced either behind the fetal neck
10-20 ml of amniotic fluid is withdrawn
and placed in an opaque container
Most important nursing action: Check
the FHR before immediately after and2 hours later
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B. Risks involved:
Hemorrhage from penetration of theplacenta
Infection
Fetus can be punctured
Uterine irritation
Cli i l U
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Clinical Uses:
Genetic diagnosis
Spectrophotometer studies
Fetal maturity tests
Sex determination
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e. Non-stress test (NST) based on theprinciple that FHR accelerates in
response to fetal movement.
Advantages over OCT:
Does not require administration ofoxytocin
Can be done in matter of 20-40 minutes
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Procedure:
Done concomitantly with external FHRmonitoring
Patient presses a button whenever shesenses fetal movement
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f. Contraction stress test (CST):
- to demonstrate whether a healthyfetus can withstand a decreasedoxygen supply during the stress of acontraction produced by exogenous
oxytocin (pitocin) or stimulation ofnipples manually or by moist heat; iflate decelerations appear, the fetus
maybe compromised because ofuteroplacental insufficiency
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1. Classification of results
a. negative: no late decelerations with
a minimum of three contractions in10 minutes; indicates that the fetushas good chance of surviving labor
b. positive: persistent and latedecelerations occurring with more
than half the contractions; indicatesneed for considering prematureintervention
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c. suspicious: late decelerationsoccurring in less than half of uterinecontractions; test should be repeated
in 24 hours
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2. Nursing considerations:
a. void before test
b. monitor fetal heart rate for 30minutes before test
c. monitor ,mother after test toobserve for possible initiation oflabor
d. evaluate response to procedure
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g. Biophysical profile (BPP):
- assess breathing movements, bodymovements, tone, amniotic fluidvolume and FHR reactivity (NST)- ascore of 2 is assigned to each
finding, with a score of 8 to 10indicating a healthy fetus
1. used for fetus that may haveintrauterine compromise
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2. nursing considerations:
a. provide emotional supportb. evaluate response to procedure
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h. Maternal assessment of fetalactivity:- need to contact physician
or nurse midwife when there arefewer than 10fetal movements in a12 hour period.- fewer than three
fetal movements in an 8 hour period,or no fetal movements in themorning
1. used to determine viability of fetus
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2. nursing considerations:
a. teach how to record and reportmovements
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Laboratory Examination:
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NORMAL HEMATOLOGIC VALUES
Nonpregnant Pregnant
Hemoglobin (HGB) 1216 g/dl 11.515 g/dl
Hematocrit (HCT) 3648 3236.5
Red blood cells (RBC) 45.36 no change
White blood cells(WBC)
410.6 620
NORMAL VALUES FOR RENAL
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FUNCTION
Nonpregnant PregnantSerum creatinine 0.61.2 mg/dl 0.530.9 mg/dl
Serum BUN 9-11 mg/dl 8-10 mg/dl
Serum uric acid 4.55.8 mg/dl 25.8 mg/dl
Urine Cr clearance 90130 mL/min 150200 mL/min
Urine uric acid 250750 mg/24 hr Increases
Urine glucose 60115 mg/dl Increases
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NORMAL HEPATIC VALUESLiver Enzymes Nonpregnant Pregnant
Alanine transaminase(ALT)
378 U/L Unchanged
Aspartateaminotransferase(AST)
370 U/L Unchanged
Alkaline phosphatase(ALP)
20145 ImU/ml > up to 24 times
Lactatedihydrogenase (LDH)
300650 U/L Upper end of normalto 700 U/L
I COMPLICATIONS OF
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I. COMPLICATIONS OFPREGNANCY
C Di f t D i
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Common Discomforts DuringPregnancy
Morning Sickness
Fatigue
Urinary Frequency
Heartburn
Constipation
Hemorrhoids Varicosities
B k h
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Backache
Insomnia
Leg cramps
Supine Hypotensive Syndrome
Vaginal discharge
Skin changes
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Danger Signals of Pregnancy
any bleeding from vagina
gush of fluid from vagina
regular contractions
severe headaches
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epigastric pain
vomiting that persists
change in fetal activity pattern
temperature elevation
swelling in upper body
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II. GENERAL NURSINGRESPONSIBILITIES
Teach danger signals of pregnancyearly in prenatal period
Early teaching allows the client toparticipate in the identification andreporting of symptoms
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Early recognition and reporting ofdanger signals
Interventions are specific for theindividual risks.
N si Di sis:
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Nursing Diagnosis: Anxiety
Fluid volume deficit
Risk for infection
Ineffective tissue perfusion
Knowledge deficit
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