Chapter 7

Conception and Development of the Embryo and Fetus

Basic Concepts of InheritanceHuman Genome Project (1990)Chromosomes

• 23 matched pairsDNAGenes

Cellular Division• Gametes

• Ova—female gamete• Sperm—male gamete

• Gametogenesis• Meiosis• Mitosis

Inheritance of DiseaseMultifactorial

• Genetic and environmental factors• Examples: cleft lip, neural tube defects

Unifactorial• Single gene inheritance• Examples: autosomal dominant, autosomal

recessive, X-linked disorders

Mendelian Inheritance

• Autosomal Dominant• Affected person has

affected parent• 50% chance of

passing the trait• Males & females

equally affected--dad can pass to son

• Autosomal Recessive• Can have clinically

normal parents, but both parents must be carriers

• 25% chance of affected child

• 50% chance child is carrier

• Males & females affected equally

X Linked InheritanceX-Linked Recessive• No male to male

transmission• 50% chance carrier mom

passes to son who will be affected

• 50% chance carrier mom passes to daughters who become carriers

• Affected dads cannot pass to sons, but all daughters are carriers

X-Linked Dominant (Extremely rare)

• Fragile X syndrome• Heterozygous females

may be affected• No male to male

transmission• Affected fathers will

have affected daughters, but no affected sons

Nursing Responsibilities Assess for signs and

symptoms of genetic disorders

Offer support Assist in value

clarification Educate on procedures

and tests

Assessing for Genetic Disorders

• Chorionic villi sampling (CVS)• Biopsy & chromosomal analysis of chorionic villi

of placenta (transvaginal or abdominally)• 8-12 weeks (earlier than amnio)• Risks

• Limb reduction syndrome• Excessive bleeding & pregnancy loss• Infection• Rh-Negative mom needs RhoGAM

• Advantages: 1st trimester,highly accurate, quicker results than amnio

Assessing for Genetic Disorders

Ultrasound--best between 16-20 weeks• Detect head and craniospinal defects: anencephaly,

microcephaly, hydrocephalus • GI malformations: omphalocele, gastroschisis• Renal malformations: dysplasia or obstruction• Skeletal malformations: caudal regression, conjoined

twins• Fetal nuchal translucency: 10-13 weeks

Assessing for Genetic Disorders• Amniocentesis: 15 - 20 wks

• Risks: miscarriage, bleeding, infection• Maternal age ≥ 35• Hx of child with chromosomal abnormality• Parent carrying chromosomal abnormality• Mother carrying x-linked disease• Parent with in-born error of metabolism• Both parents carrying autosomal recessive

disease• Family hx of neural tube defects

Process of Fertilization• Oocyte and sperm meet in fallopian tube

• Ovulation—cervical mucus changes

• 200 sperm reach fertilization site• Capacitation• Penetrates zona pellucida—prevents fertilization by other

sperm

Implantation• Zygote propelled by

• Cilia• Peristalsis

• Reaches uterine cavity in 3 to 4 days

Nidation• Occurs by 10th day after fertilization• Implantation bleeding• Blastocyst is buried beneath the endometrial

surface

Placenta• Develops from trophoblast cells

• Lacunae• Chorionic villi• Intervillous spaces

• Provides oxygenation, nutrition, waste elimination, and hormones

• Protects fetus

Placenta

Embryonic and Fetal Structures • Placenta

• Serves as the fetal lungs, kidneys and GI tract and as a separate endocrine organ throughout the pregnancy

• Placental circulation established as early as 3rd week of pregnancy

• Grows to 15-20 separate “lobes” called cotyledons• By wk 20, covers approx. 1/2 surface of internal uterus • No direct exchange of blood between the embryo and

the mother during pregnancy--exchange is through selective osmosis

Placental Circulation• Maternal blood from spiral arteries enters

intervillous space of endometrium

• Fetal chorionic villi reach into endometrium

• Membrane of chorionic villi is 1 cell thick

• Exchange of nutrients/substances

Placenta

Placenta

Substance Transport Across Placenta

• Diffusion• Active transport• Pinocytosis• Bulk flow and solvent drag • Accidental capillary breaks • Independent movement

Placental Hormones• Human chorionic gonadotrophin (hCG)• Human placental lactogen (hPL)• Progesterone• Estrogen

Development of the Embryo and Fetus

Yolk Sac• Develops 8 to 9 days after conception• Essential for transfer of nutrients during

second and third weeks of gestation• Hematopoiesis• Atrophies and is incorporated into umbilical

cord

Umbilical Cord• Usual location—center of placenta• 55 cm long (21 in); 1 to 2 cm diameter• Vessels: one vein, two arteries• Wharton’s Jelly: protects umbilical cord from

compression

Fetal Circulation• Heart begins to beat and circulate blood by

end of third week• Umbilical vein: blood from placenta to fetus • Low Po2 important to maintain fetal

circulation

Fetal Circulation Fetus derives oxygen and excretes carbon

dioxide from oxygen exchange in the placenta, NOT lungs

Specialized structures in fetus shunt blood flow away from non-functioning lungs to supply important organs of the body, especially the brain

Foramen ovale (right to left atrium) Ductus arteriosus (pulmonary artery to aorta) Ductus venosus (umbilical vein to inferior vena cava,

bypassing liver)

Critical Thinking• During a prenatal examination, an adolescent client

asks, "How does my baby get air?" The nurse would give correct information by saying: A) "The fetus is able to obtain sufficient oxygen due to the fact that your hemoglobin concentration is 50% greater during pregnancy."

•B) "The lungs of the fetus carry out respiratory gas exchange in utero similar to what an adult experiences."

•C) "The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream."

Fetal Membranes and Amniotic Fluid

Embryonic Membranes• Early protective structures• Two separate membranes

• Amnion—inner membrane, contains amniotic fluid

• Chorion—outer membrane, forms fetal portion of placenta

• Slightly adherent, form amniotic sac

Purposes of Amniotic Fluid• Protects and cushions fetus• Maintains normal body temperature • Symmetrical fetal growth• Freedom of movement• Essential for normal fetal lung development

Amniotic Fluid• Amount: 800 mL at 24 weeks• Fetal urine and lung secretions primary

contributors• Slightly alkaline• Contains antibacterial, other protective

substances

Human Growth and Development

Pre-Embryonic Period• First 2 weeks after conception• Rapid cellular multiplication and

differentiation• Establishment of embryonic membranes and

primary germ layers

Embryonic Period• Begins third week after fertilization through end of

eighth week• Organogenetic period: formation, differentiation of

all organs • Germ layers: ectoderm, endoderm, mesoderm• Vulnerable to environmental insults

Fetal Development

Fetal Period• Beginning ninth week until birth or

termination of pregnancy• Rapid body growth and differentiation of

tissues, organs, and systems • Less vulnerable stage

Weeks 17 to 20• Growth slows• Quickening• Vernix caseosa• Lanugo• By 20 weeks—fetus 300 g and 19 cm

(7.3 in)

Weeks 21 to 25• Gains weight• Skin pink• Rapid eye movements• Surfactant by 24 weeks

Weeks 26 to 29• If born, fetus may survive• Weeks 30 to 40

• Strong hand grasp reflex• Orientation to light• 38 to 40 weeks: 3000–3800 g and 45–50 cm (17.3–19.2 in)

Nurse’s Role in Prenatal Evaluation

• Initial prenatal visit• Assessment: cultural, emotional, physical,

and physiological factors• Education

• Genetic disorders• Prenatal tests

Nursing Responsibilities Assess for signs and

symptoms of genetic disorders

Offer support Assist in value

clarification Educate on procedures

and tests

Maternal Age and Chromosomes• Age 35 and above• Increased risk of chromosomal abnormalities

• Down syndrome• Deletion• Translocation

Multifetal PregnancyMonozygotic

• Develop from one zygote• Division occurs at end of first week

Dizygotic• Develop from two zygotes• Separate amnions and chorions

Fraternal Twins 2 Ova

Identical Twins 1 Ovum

Minimizing Threats to Embryo/Fetus

Nurse’s role• Assessment

• Environmental and lifestyle risks• Knowledge• Physical and psychosocial well-being

Preconception counseling

Chapter 8

Physiological and Psychosocial Changes During Pregnancy

Hormonal Influences• Pituitary hormones

• Influence ovarian follicular development• Prompt ovulation• Stimulate uterine lining

• Corpus luteum• Estrogen: growth• Progesterone: maintenance

Ovarian Hormones• Maintain endometrium• Provide nutrition• Aid in implantation• Decrease uterine contractility• Initiate breast ductal system development

Reproductive System

Uterus• Patterns of uterine growth• Estrogen, progesterone: hyperplasia,

hypertrophy allow uterus to enlarge, stretch• Weight increases from 70 g to 1100 g at term• Increased blood flow

Braxton-Hicks Contractions• Irregular, painless• Prepare uterine muscles• If irregular and last <60 seconds, reassure

woman• Regular pattern or associated with other

symptoms, seek medical attention

Cervix• Chadwick’s sign• Goodell sign• Softens• Forms mucus plug• Call if discharge bloody or yellow/green, foul

odor, itching, or pain

Vagina and Vulva• Thickening of vaginal mucosa• Rugae• Becomes edematous• More susceptible to yeast infections• pH: decreases from 6.0 to 3.5• Discuss vulvar hygiene

Other Reproductive Changes• Ovaries• Breasts

• Montgomery tubercles• Increased pigmentation (areolae)• Discuss bra size changes, options for infant

feeding, and strategies for successful breastfeeding

Integumentary System• Hyperpigmentation

• Chloasma• Linea nigra

• Cutaneous vascular changes • Striae gravidarum• Angiomas• Palmar erythema

Neurological System• Decreased attention span• Poor concentration• Memory lapses• Carpal tunnel syndrome• Syncope• Anticipatory guidance regarding changes

Cardiovascular System

Heart• Position: pushed upward, laterally to left• Cardiac hypertrophy due to increased blood volume,

cardiac output• Heart sounds: exaggerated first and third; systolic

murmurs

Blood Volume• Plasma and erythrocyte volume increase• Increased need for iron• Physiologic anemia• Teach regarding adequate hydration and diet

high in protein, iron• Increased fibrinogen volume

Cardiac Output• Blood pressure• Stasis of blood in lower extremities: risk for

varicose veins and venous thrombosis• Encourage daily walks to enhance circulation,

improve intestinal peristalsis

Supine Hypotension Syndrome• Pressure from enlarged uterus decreases

venous return from lower extremities• Hypotension, dizziness, diaphoresis, pallor

• Orthostatic hypotension• Stagnation of blood in lower extremities• Encourage to rise slowly; keep feet moving while

standing

MATERNAL POSITION & BLOOD FLOW

supine

side lying

Respiratory System• Increased tidal volume• Increased oxygen consumption• Diaphragm elevates• Increased chest circumference—dyspnea• Educate regarding normal changes and

symptoms

Eyes, Ears, Nose, Throat • Blurred vision—decreased intraocular

pressure and corneal thickening• Temporary condition

• Nasal stuffiness, congestion—increased mucus production• Epistaxis • Encourage increased fluid intake

Upper GI Tract• Mouth

• Gingivitis, ptyalism, hypertrophy of gums, epulis• Esophagus—pyrosis, reflux• Stomach and small intestine

• Morning sickness, absorption of nutrients

Lower GI Tract• Large Intestine—constipation• Liver and gallbladder

• Cholestasia, cholecystitis, cholelithiasis

Urinary System• Bladder

• Urinary frequency and urgency• Kidneys and ureters• Structural changes• Functional changes

• Glomerular filtration rate increases

Endocrine Glands• Thyroid gland

• Increased T4• Progressive increase in basal metabolic rate

• Pituitary gland• Prolactin• Oxytocin• Vasopressin

Musculoskeletal System• Postural changes

• Lumbar lordosis• “Waddle” gait

• Calcium storage• Decreased maternal serum calcium• Lower extremity cramps

Psychological Responses of Mother• Intendedness• Ambivalence: normal response• Acceptance: quickening (20 wks)--baby is “real”

Psychosocial Changes• Decreased ability to deal with stress and cope

with changes of pregnancy• Major developmental phases—ambivalence

and conflicting emotions• Nursing care tailored through each pregnancy

milestone

Developmental and Family Changes

• Duvall: stages of family development• Prepare for role as childcare providers• Reorganize home, family member duties, patterns

of money management• Reorient family relationships• Each pregnancy—adjust to transitions in

relationships with each other, children

Maternal Role Transition• Rubin—“tasks of pregnancy”

• Incorporate pregnancy into identity• Acceptance of the child• Reorder relationships

Maternal Tasks of Pregnancy• Seeking safe passage• Securing acceptance• Learning to give of self• Committing self to the unknown child

Pregnant Adolescent• Normal adolescent developmental tasks

conflict with tasks of pregnancy• May not seek prenatal care• Not future oriented—may not accept reality

of unborn child• Acceptance of pregnancy hindered

Nursing Assessment of Psychosocial Changes

• Thorough history: family background, past obstetrical events, status of current pregnancy

• Each visit—ask about pregnancy experience, address concerns, offer anticipatory guidance

Obstetrical History--G/P• Gravida: any pregnancy, including present

• Nulligravida: never been pregnant• Primigravida: in first pregnancy• Multigravida: 2nd or more pregnancy

• Para: birth after 20 wks gestation (before 20 wks: spontaneous abortion (SAB)• Nullipara: never given birth at > 20 wks• Primipara: has had 1 birth > 20 wks• Multipara: 2 or more births > 20 wks• Multiples such as twins are counted as ONE birth

G/P• Susie Smart is pregnant. • She has four sons at home:

twins born in 1996 at 34 weeks,then singletons born in 1998, and 2001. She had 1 miscarriage in 2000.

What is her Gravida/Para?

G = 5P = 3

Obstetrical History--G/PP =TPAL

• G = gravida, # of pregnancies• P is further broken down & multiples are counted:

• T = # of term infants born (37 wks+)• P = # of preterm births (> 20, < 37 wks)• A = # pregnancies ending in spontaneous or therapeutic

abortion (SAB/TAB)• L = # of currently living children

G/P vs GTPALSusie Smart is pregnant. She has four sons at home: twins born in 1996 at 34 wks, then singletons born in

1998, and 2001. She had 1 miscarriage in 2000.

• What is her G/P? • What is her GTPAL?

G = 5P = 3

Reflection:Reflection:

G = 5T (term) = 2P (preterm) = 1A (abortions) = 1L (living) = 4

Example

• Nancy Tam is seeing the MD for her first PN visit. She has 4 kids at home, two of whom are twins and were born at 33 wks. She has had 1 miscarriage and 1 abortion.

What is her gravida/para?G6 P3 AB 2 (SAB 1 & TAB 1)

What is her GTPAL?G6 T2 P1 A2 L4 or (G 6 P 2124)

????• Tracy H. is pregnant. She has one son at home born

at 38 wks. Her 2nd pregnancy ended at 10 wks gestation. She then had twins at 30 wks. One twin died soon after birth. • What is her G/P?

• G 4 P 2 AB 1• What is her GTPAL?

• G 4 P 1112

Estimated Birth Date (EDC/EDD/EDB)

• Use LMP (last menstrual period)

Assessment and Health Education

• Comprehensive history and physical exam• Ongoing education focusing on current

trimester and physical changes

First Prenatal Visit• Complete Physical Exam

• Pelvic exam: external genitals, vagina, cervix • Signs of pregnancy (Goodells, Hegars, Chadwicks)• Pelvic measurements: diagonal conjugate, obstetric

conjugate, ischial tuberosity diameter

• Sterile speculum, pap smear (infection, discharge, growths?)GC, Clamydia cultures

Laboratory Work• CBC• ABO & Rh type• Antibody screen• Rubella titer• VDRL or RPR (syphillis)• Hepatitis B surface antigen• Gonorrhea culture• Chlamydia culture• Alpha-fetoprotein @ 14wks**

• HIV screen • Urine: glucose, protein &

ketones by dipstick. • Urinalysis: RBCs,

leukocytes, bacteria• Hereditary disease

screening • Sickle cell• Tay-sachs• Cystic fibrosis

Assessment of Growth & Development(Confirm dating of pregnancy)

• Estimating fetal growth:• Fundal height: symphysis to top of fundus• McDonald’s Rule: Between wks 22-34 fundal height in

cms should match no. of weeks gestation (± 2 cm)• Milestones:

• 12 weeks: fundus clears symphysis• 20 weeks: fundus at umbilicus• 36 weeks, fundus at xyphoid

Assessing Fetal Development Fetal Movement/Heartbeat/Ultrasound

• Quickening: fetal movement felt by mom between 18-20 weeks (fetal movement record)

Fetal heart tones by doppler (intermittent) or ultrasound transducer (continuous) Can be heard as early as 10th or 11th week of pregnancy

by Doppler Normal: 110-160 BPM

Ultrasound: gestational sac by 5-6 wks Crown-to-rump, biparietal measurements

Chapter 10

Promoting a Healthy Pregnancy

Planning for Pregnancy• Preconception• Periconception• Interconception• Preconception counseling

• Identify conditions that could adversely affect pregnancy

The Healthy BodyMenstrual and medical history

• Exposure to childhood illnesses • Exposure to STIs• Exposures related to lifestyle choices

Physical examination• Laboratory evaluation• Genetic testing

Dental Care

The Healthy Mind• Readiness for motherhood• Psychological changes during pregnancy• The healthy relationship• Readiness for fatherhood• Support for life changes

Recommended Weight Gain

• 1st Trimester: 1 lb/month (3 lbs)• 2nd Trimester: ½ - 1 lb/ wk• 3rd trimester: 1 lb/week , esp last month; ↑ fetal wt gain• Total:

• 25-35 lbs--normal wt.• 30-40 lbs--underweight• 15-20 lbs--overweight

• Multiple gestation: 1 lb per week throughout pregnancy (40-45 lbs total)

Where does weight come from?

Maternal Nutrition

• Caloric Intake: 300 calories/day additional 2000-2500/daily• Protein increases to 60 g/day• Fat: need linoleic acid (not manufactured in body) - need more vegetable oils• Prenatal vitamins (contain folic acid)• Folic Acid: prevents neural tube defects• Minerals: calcium, phosphorus, iodine, iron, fluoride,

sodium, zinc

Maternal Nutrition (Continued)

• Fluid Needs• Two glasses of fluid daily over and above a daily quart

(a total of 6-8 glasses)

Promoting Nutritional Health

Nutritional Outcomes & Planning Nursing diagnosis Outcome identification and planning Outcome evaluation

• Family considerations• Financial considerations• Cultural considerations

Assessment: Nutritional HealthRisk Factors

Assessing Nutritional Health

• Typical day, 24-hour recall Nausea/vomiting?, cravings?, pica? Lab results: H&H for anemia, urinalysis for specific

gravity Physical findings:

Hair, mouth, eyes, neck, extremities, finger/toe nails, over/under weight (BMI), poor weight gain

Factors That Affect Nutrition• Eating disorders

• PICAabnormal craving for nonfood substances• Includes cravings for clay, ice cubes, dirt, cornstarch • Iron deficiency anemia can result

• Anorexia nervosa, bulimia nervosa• Cultural factors• Vegetarian diets• Food cravings and food aversions

Common Nutritional Problems• Nausea and Vomiting (Morning Sickness)

• Associated with a high level of chorionic gonadotropin, estrogen and/or progesterone levels

• Lowered maternal blood sugar levels• Lack of vitamin B6• Diminished gastric motility• Affects 50% of pregnant women

Common Nutritional Problems• Nausea and Vomiting Teaching:

• Crackers, pretzels, sourballs, delay breakfast• Frozen yogurt, fruit popsicles• Make up missed meals later in day• Do not go > 6 hours without food• **small, frequent meals keep Blood Sugar levels up**• Snack at bedtime & delay eating in AM if nauseous• Call MD if can’t keep anything down ≥ 24 hours

(hyperemesis gravidarium?)

Nutritional Health-Special Needs

• Pregnant adolescents need at least 2500 calories/day• Good nutrition a problem• More apt to eat junk food

• Help them ID nutritious food within their food preferences

• Inadequate iron & calcium intake common

Critical Thinking•

A pregnant client who is a lacto-vegetarian asks the nurse for assistance with her diet. What instruction should the nurse give the client about protein intake?

A) "Protein is important; therefore, the addition of one serving of meat a day is necessary."

B) "Eggs are important to add to your diet. Eat six eggs per

week."

C) "A daily supplement of 4 mg vitamin B12 is important."

D) "Milk products contain protein, but they are very low in iron."

Exercise, Work, and Rest

Exercise• Muscle strengthening• No rigorous aerobic activity

Work• Impact on pregnancy• Maternity leave

Rest

Medications• Safe versus teratogenic • Over-the-counter• Herbal and homeopathic preparations• Prescription• FDA pregnancy categories

Teratogens• Medications: FDA Classification/Category A-D, X• Cigarettes: Low birth weight, IUGR, SAB, SIDS• Alcohol: Fetal alcohol syndrome: SGA, cognitive

deficits, characteristic craniofacial deformity• Caffeine: hi doses: SAB, IUGR. Limit to 300

mg/day• Cocaine: abruption, PT birth, IUGR, cognitive

deficits• Environmental: chemicals, metals, radiation, etc.

Fetal alcohol syndrome

Advanced Maternal Age• Increased risk if mom > 35:

• maternal death (chronic medical conditions)• SAB, low birth wt & preterm birth• cesarean section• gestational DM, PIH, HTN, placenta previa, difficult

labor, newborn complications• Down syndrome

• Advanced paternal age: ↑genetic problems and late fetal death

Adolescent Pregnancy Developmental Tasks:

• Early ( ≤14 ): impulsive, self-centered, concrete thinker

• Middle (15-17): rebellious, peer group, moving to formal operational thought, does not see long-term consequences

• Late (18-19): better decision-making ability, concrete operation thought, abstract thought, understands consequences 0f behavior

Adolescent Pregnancy• Increased risks:

• Late prenatal care & often do not follow recommendations (smoking, wt. gain)

• Preterm birth, low birth wt, preeclampsia, iron-deficiency anemia, Alcohol, drug, tobacco use, STI

• ↑ cephalopelvic disproportion (CPD Undeveloped pelvis

Common Discomforts• Nausea and vomiting Fatigue • Nasal congestion Backache• Dental problems Leukorrhea• Constipation/hemorrhoids Dyspepsia • Leg cramps Flatulence• Dependent edema Insomnia• Varicosities Dyspareunia• Round ligament pain Nocturia• Hyperventilation, shortness of breath• Numbness/tingling in fingers• Supine Hypotensive Syndrome

Signs and Symptoms of Danger

First Trimester• Severe, persistent vomiting• Abdominal pain and vaginal bleeding• Indicators of infection

Second Trimester• Maternal complications

• Preeclampsia• Premature rupture of the membranes• Preterm labor

• Fetal complications• Decreased fundal height• Absence of fetal movement after quickening

Third Trimester• Maternal complications

• Gestational diabetes• Placenta previa• Abruptio placentae

• Fetal complications• Hypoxia

Pregnancy Map• Prenatal care map• Timetable

Childbirth EducationPrimary goal

• To promote a positive childbearing experience• Empowerment• Dispelling myths• Alleviate fear

Topics• Anatomy and physiology• Comfort measures• Labor and birth process• Relaxation and pain management

Childbirth Education—Methods• Lamaze

• Empowerment• Dispelling myths• Controlled breathing, position, massage, relaxation

• Bradley• Inward relaxation• Normal breathing

Other Methods• Dick-Read• HypnoBirthing• LeBoyer method• Odent method• Birthing from within

Finding Information on Childbirth Education

• Primary source—health care provider• Online and at-home programs• Parents need to ask questions about the class

to determine if it fits their needs• Factors related to personal values and beliefs• Decrease fear through knowledge

The Birth Plan• Written information that identifies labor and

birth preferences• The choices• Choosing a provider• Choosing a location• Discussion with healthcare provider

Chapter 11

Caring for the Woman Experiencing Complications

During Pregnancy

Early Pregnancy Complications• Perinatal loss• Ectopic pregnancy• Gestational trophoblastic disease

• Signs/symptoms: vaginal bleeding, excessive nausea/vomiting, abdominal pain, size/date discrepancy

• Management: remove uterine contents

Gestational Trophoblastic DiseaseHydatiform Mole

• Abnormal proliferation & degeneration of throphoblastic cells (which give rise to the chorion)

• Molar pregnancy: Embryo fails to develop, cells proliferate, then become clear, fluid-filled vesicles (grape-size)

• S/S ↑fundal height for dates, ↑hCG levels, brownish vaginal bleeding & discharge of vesicles

• TX: suction evacuation & f/u for possible choriocarcinoma, hCG testing, delay new pregnancy for 12 months

Spontaneous Abortion• Before 20 weeks of gestation• Signs/symptoms: bleeding, cramping,

abdominal pain, decreased symptoms of pregnancy

• Management: D & C

Premature Cervical Dilatation (incompetent cervix)

• Painless dilation of cervix without contractions due to structural or functional defect of cervix

• S/S: pinkish show, ↑pelvic pressure, followed by ROM, UC’s & birth.

• Associated with: adv maternal age, congenital structural defects, trauma to cervix

• Treatment • Cerclage -with next pregnancy

Hyperemesis Gravidarum• 0.5-2% of pregnancies• Severe nausea and vomiting

• Dehydration, ketonuria, significant weight loss in first trimester, or

• Continues after 12 weeks• Carbohydrate depletion/ketonuria

• Unable to maintain usual nutrition• Dehydration/electrolyte imbalances

• Low sodium, potassium, chloride

Hyperemesis Gravidarum• Therapeutic management

• Hospitalization• NPO• IV hydration (KCl if hypokalemic)• Vitamin replacement• Parental nutrition• Medication (Reglan, Zofran)• Gradual reintroduction of food

Chapter 19 Pregestational Problems Diabetes

• PATHOPHYSIOLOGY:• In 2nd half of pregnancy, hPL & other hormones

cause ↑ maternal peripheral resistance to insulin to ensure sufficient circulating glucose for fetus. Due to this, existing diabetes is augmented and diabetic potential may result in gestational DM.

Diabetes Mellitus• Preexisting DM during pregnancy:

• Regulation of glucose & insulin more difficult• Insulin needs ↓ in 1st trimester BUT ↑ in 2nd & 3rd

trimester--may be 2 to 4 x greater by end• Glucose levels can become out of control-balance is upset• GOAL: close control of glucose levels (fasting glucose <

95 mg/dL & 2 hour postprandial < 120 mg/dL)• Glycosylated hemoglobin (HbA1c) measures control:

normal: 4.8-7.8%. > 10% associated with 20-25% rate of fetal anomaly

Gestational DM• 1-14% of pregnancies• Manifests at midpoint of pregnancy, when insulin resistance

increases• Risk of type 2 later as high as 50%• Risk factors:

• Obesity, age, hx of large babies, unexplained fetal loss, congenital anomalies, family hx, Native Americans, Hispanics, Asians

• May or may not need insulin

Effects of DM

• MOTHER• Hydramnios• Preeclampsia• Ketoacidosis• Difficult labor

(dystocia)• Retinopathy

• BABY• Congenital anomalies

• Heart, CNS, skeletal• Stillbirth• Macrosomia • Hypoglycemia• Respiratory distress syndrome

(RDS)• Polycythemia/hyper-

bilirubinemia

Diabetes Mellitus Screening in pregnancy:

• 1 hour, 50 g oral glucose challenge at 24-28 wks (at 1st PN visit if hi-risk)• If 1 hour value ≥ 130 - 140, do 3 hour test.

• 3 hour, 100 g oral glucose tolerance test• Diagnosis of gestational DM if 2 or more of the following

values are met or exceeded:

• Fasting95 mg/dL• 1 hour 180 mg/dL• 2 hours155 mg/dL• 3 hours140 mg/dL

Patient TeachingDiet ExerciseGlucose monitoring Insulin pump therapyInsulin administration Signs of hypo/hyper-glycemia

Placental functioning & fetal well-being testingNST, AFI Assessment of fetal size andFetal kick counts maturation

Delivery at term or possibly 38 weeks, c-section if macrosomia/ CPD suspected

Management

Abruptio Placentae• Premature separation of placenta from uterine wall• S/S: sharp, stabbing pain high in fundus, heavy

bleeding (may be occult), hard, board-like uterus, tense, painful uterus, signs of shock due to blood loss, Port-Wine aminotic fluid if ROM.

• Predisposing fx: ↑parity, adv. maternal age, short umbilical cord, chronic HTN, PIH, direct trauma, vasoconstriction from cocaine or cigarette use

• Fetal distress on monitor. Can progress to DIC.

Abruptio Placentae

Abruptio Placentae

• Management: • Emergency. Immediate c-section if

birth not imminent.• Lg. gauge IV • O2 via mask, fetal monitoring,

maternal VS, lateral positioning, labs, blood transfusion (have 2 units avail)

• CBC (H&H), Fibrinogen levels, platelet count, PT/PTT, fibrin degradation products ( sx of DIC)

Placenta Previa

Low implantation of placenta (1 in 200)• abrupt, painless, bright red bleeding• Associated with ↑parity, adv. maternal age,

previous c-section or uterine curettage, multiple gestation

• Dx: ultrasound. May resolve as pregnancy progresses.

• Bleeding common around 30 wks: Bedrest, VS, IV fluids, type & cross-match, observe for bleeding

• Emergency: assess bleeding, hx, uc’s/labor• NEVER do vaginal exam !!!

Low-lying Marginal

Partial Complete

Placenta Previas

Prolapsed Cord

• Loop of umbilical cord slips down in front of the presenting part

• S/S: deceleration of FHT: bradycardia, persistent variable decels, cord palpatedor seen in vagina

• Associated with:• Premature rupture of membranes• Transverse or breech presentation• Multiple gestation• Placenta previa• Hydramnios• CPD (non-engagement of fetal head)

Prolapsed Cord

• Management: Hold fetal head off cord, Trendelenburg or knee/chest position, immediate emergency c-section

• Prevention• Watch fetal heart tones after rupture of

membranes (SROM or AROM). Do VE if any sign of fetal distress.

• If head not engaged, women with ruptured membranes should not ambulate.

Preterm Labor (PTL)• Occurs before 37 weeks

gestation

• 11-12% of pregnancies

• 75% of neonatal morbidity & mortality where congenital anomalies do not exist

Preterm Labor• S/S: low backache, vaginal spotting, pelvic

pressure, abdominal tightening, cramping• Associated with: dehydration, UTI,

chorioamnionitis

• UC > every 10 minutes

• Can attempt to stop if effacement < 50% and dilatation < 4-5 cm

• DX: clinical presentation, vaginal exam, UA, CBC, vaginal culture, test for ROM

• Fetal Fibronection screen**

Drugs Used in Treating Preterm Labor

• Antibiotics (ampicillin, erythromycin)• Group B streptococcus prophylaxis, chorioamnionitis

• Corticosteroids (Betamethasone or Dexamethasone)• 24 to 34 weeks gestation• Accelerate the formation of lung surfactant (Betamethasone)

• TOCOLYTICS: ( = stop contractions)• Terbutaline 1st line agent (subcutaneous injection or PO)

• Works on Beta-2 receptor sites in uterus• Side effects: tachycardia, arrhythmia, palpitations,

hyperglycemia• FDA now disallows use for PTL

Drugs Used in Treating Preterm Labor

TOCOLYTICS, cont.• Magnesium Sulfate (IV) (pg 500)

• Central nervous system depressant• 4-6 g loading dose, 2 g maintenance

• Procardia (nifedipine) (PO)• Calcium channel blocker, relaxes smooth muscle• Side effects: hypotension, tachycardia, facial flushing,

headache• *Becoming drug of choice ---evidence based practice

PTL: Self Care Teaching• Signs of PTL: May be subtle • UCs q 10 mins or closer, cramping, pelvic pressure, ROM, low dull

backache, change in vaginal discharge• Evaluation of UCs (uterine contractions)• Pelvic rest/activity level• What to do if experiencing symptoms:

• Empty bladder, lie on side, drink H20, palpate for UC’s & time, rest, call MD if symptoms persist

Preterm Premature Rupture of Membranes

• Loss of amniotic fluid before 37 weeks of pregnancy (5-10% of pregnancies)

• Usually associated with chorioamnionitis, vaginal infection (chlamydia, gonorrhea) or UTI

• **Increased risk of cord prolapse• DX: Observe for vaginal leaking (sterile speculum

exam for pooling), nitrizine paper, ferning test, fetal distress, sx infection

Ferning pattern seen on slide with amniotic fluid

Premature Rupture of Membranes• Management

• If less than 37 wks: hospitalization, • Bedrest fetal monitoring/NST• steroids (24-34 wks) CBC• broad-spectrum antibiotics • VS monitoring (temp q 4 hours)• Betamethasone

• Accelerate lung maturity by ↑surfactant production• Usual course: 12 mg, IM, q 24 hours for 2 doses Side

effects: maternal hyperglycemia--DM may require more insulin

Hyperemesis Gravidarum• Criteria: persistent vomiting, measure of acute

starvation, and weight loss• Management

• Rest• Small frequent meals (dry, bland foods)• High-protein snacks

Critical Thinking• A woman is experiencing preterm labor. The client

asks why she is on betamethasone (Celestone). The best response by the nurse would be, "This medication:

A) Will halt the labor process, until the baby is more mature.” B) Will relax the smooth muscles in the infant's lungs so the baby

can breathe."

C) Is effective in stimulating lung development in the preterm infant."

D) Is an antibiotic that will treat your urinary tract infection, which caused preterm labor."

Hypertensive Disorders• Classifications:

• Chronic• Preeclampsia-eclampsia• Chronic hypertension with superimposed

preeclampsia• Gestational/transient

Preeclampsia• Multisystem, vasopressive• Disease of placenta• SPASMS• Morbidity and mortality• Management

• Delivery of fetus only cure

Nursing Assessments—Preeclampsia

• Identify hypertension• Proteinuria• Edema• CNS alterations

• Eclampsia: seizures

Pregnancy Induced Hypertension

• Cause unknown. 5-7% of pregnancies in US. Manifests in 2nd half of pregnancy

• Vasospasm of small & large arteries• Dx: ↑BPs (140/90), proteinuria (>1+)

• Non-diagnostic findings: edema (truncal/facial), headache, visual disturbance, epigastric pain, hyperreflexia

• ↑Risk: ethnicity, multiple gestation, primigravid < 20 or > 40 y.o., ↓socio-economic, grand multiparity, underlying disease (heart, HNT, DM, kidney), previous history

Pathology of Pregnancy Induced Hypertension

• As a result of increased vasoconstriction, GFR is greatly compromised

• Organ perfusion is poor and fluid diffuses from blood stream into interstitial tissue → edema

• Decreased urine output and proteinuria.• Edema occurs as result of protein loss, and lowered

GFR.

Concept Map of PIH Symptoms

EDEMAPROTEINURIA

Anti-angiosin from placenta → Fibrin Deposits& Vasospasm

Renal damage → Liver Damage → Renin-Angiotensin System ↑Liver Panel ↓Platelets

DIC

Glomerular Damage

↓osmotic pressure → Intravascular Volume

↑ Hct Oligouria

Strict I&O

24 hr UrineRenal labs

AntihypertensivesMannitolDecadron

HYPERTENSION

Monitor sx Bleeding

MgSo4 Hyperreflexia

Headache

Cerebral Edema Blurred Vision

Diagnosis of pregnancy induced hypertension

• 24 hour urine is the most definite diagnosisProtein 2+ or higher

• Metabolic Panel (Comprehensive or Basic)• Elevated BUN, uric acid and creatinine• Elevated liver function tests (AST, ALT)• Low Albumin

• Complete Blood Count• Low Platelet Count--level determines the severity

of hypertension• Hemoconcentration increased (↑ Hct/Hgb)

Pregnancy Induced Hypertension

• S/S: edema, visual changes, epigastric pain, severe headache, hyperreflexia, clonus, oliguria

• Management: bedrest, maternal/fetal monitoring, quiet, darkened room, seizure precautions, delivery

• Medications:• IV magnesium sulfate to prevent seizure• IV hydralazine or labetalol to ↓BP

Magnesium Sulfate

• Purpose: Prevents seizure (eclampsia)• Dosage: 4 gram loading dose over 20-30 mins, then

2 gram/hr maintenance dose• Nursing considerations:

• Limit total IV intake to 125 cc/hr• Foley catheter & strict I&O• Serum magnesium levels q 6 hrs

• Normal: 1.8-2.5• Therapeutic: 5-7• Hyporeflexia, slurred speech, N, somnolence: 9-12• Respiratory distress: >12• Cardiac arrest: >15

MgSO4 Nsg Considerations, cont.

• Assess deep tendon reflexes, BP, RR, lung sounds, urine output, level of consciousness. Stop infusion if s/s of toxicity occur.

• Pt. Teaching:• Normal side effects with MgSO4:

• Warmth over body/flushing• Burning at IV site• Mild SOB, mild chest pain• Congestion, headache, dizziness

• Antidote: 10% Calcium Gluconate, 10 ml, IVP over 2-3 mins.

Pregnancy Induced Hypertension

• Eclampsia: seizure - tonic-clonic type• Maintain airway, position to side, O2, pulse ox,

suction as needed • Continuous fetal monitoring, monitor for possible

abruption (vaginal bleeding, non-reassuring FHT)• Delivery after stabilization• Seizure may cause precipitous birth

Pregnancy Induced Hypertension

• HELLP Syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)• Complication of preeclampsia (4-12% of women with

preeclampsia)• S/S: nausea, epigastric pain, general malaise, RUQ

tenderness, visual changes • Lab: hemolysis of RBC’s, platelets < 100,000, elevated

liver enzymes (ALT/AST)• TX: platelet transfusion, delivery of baby, monitor for

hemorrhage & DIC, steroids to ↑ renal function

Disseminated Intravascular Coagulopathy (DIC)

• External or internal bleeding• Nursing care

• Meticulous maternal and fetal assessment• Place indwelling catheter with strict I&O• Oxygen—rebreathing mask• Blood and blood products• Emotional support

• DIC Is A Disorder Of The "Clotting Cascade."

• It Results In Depletion Of Clotting Factors In The Blood.

Causes of DIC • DIC is when your body's blood

clotting mechanisms are activated throughout the body.

• Micro Blood clots form

throughout the body, and eventually using up the blood clotting factors. These are then not available to form clots at the local sites of real tissue injury. (microthrombi)

• Clot dissolving mechanisms are also increased-fibrinolysis

Possible Precursors To DIC • Hemorrhagic shock • Transfusion reaction• Sepsis• Severe pre-eclampsia or HELLP syndrome• Retained fetal demise• Premature separation of the placenta • Retained placenta • Amniotic fluid embolism (usually not able to be

determined until autopsy)

(Human Labor and Birth, Oxorn and Foote)

Critical Thinking• The nurse identifies the following assessment findings on a

client with preeclampsia: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+ on dipstick; and edema of the hands, ankles, and feet. On the next hourly assessment, which of the following new assessment findings would be an indication of worsening of the preeclampsia?

• A) Blood pressure 158/104 • B) Reflexes 2+ • C) Platelet count 150,000 • D) Urinary output 20 mL/hour

Special Conditions and Circumstances that may Complicate Pregnancy

Multiple Gestation• High-risk pregnancy• Morbidity and mortality• Management

• Delivery at Level III facility

Hemoglobinopathies• Sickle cell disease• Thalassemia

• Close maternal and fetal surveillance• Rh0(D) isoimmunization

• Admininster RhoGAM to prevent• ABO

• Coombs test

Isoimmunization-Rh Incompatibility• Rh Negative mom• If fetus is Rh positive,

--MOM may make antibodies against fetal blood

• Causes hemolysis of fetal RBC--extreme anemia (erythroblastosis fetalis)

• Indirect Coombs tests whether MOM has been sensitized. If negative (no sensitization has occurred), Rhogam will be given to prevent sensitization.

Isoimmunization-Rh Incompatibility

Isoimmunization, cont.• To prevent maternal antibody formation:

• Rh immune globulin (RhIG or Rhogam) is given:• At 28 wks• After any incident that might cause mixing of

maternal/fetal blood like abortion, miscarriage, ectopic pgncy, amniocentesis, CVS sampling, evacuation of mole, external version

• Baby’s cord blood tested--if Rh + or DIRECT Coombs positive, Rhogam given to MOM in 1st 72 hours.

• Treatment for BABY• Positive DIRECT coombs indicates hemolytic disease of

newborn. Baby’s RBC have been sensitized which causes lysis of RBCs (will cause hyperbillirubenemia).

Cardiovascular Disorders

• Most common problems• Valvular damage---prophylactic antibiotics• Congenital heart defects• ↑ Maternal age--more chronic disease

• Coronary artery disease, varicosities• Pregnancy taxes circulatory system

• ↑ volume and cardiac output--danger of CHF• Class I & II, no problem • Class III & IV have risk of severe complications--

pregestational counseling advised.

Heart DiseaseInterventions during labor & birth

• Epidural for pain control• Limit/eliminate pushing--

forceps/ vacuum delivery• Sidelying positions to ↑

perfusion to baby

• Class III & IV may need invasive cardiac monitoring

• Danger: (S/S CHF)• ↑ HR or RR in

mom• Crackles or SOB• Edema• Cough

Other Cardiovascular Disorders• Peripartum cardiomyopathy

• No history of cardiac disease• Signs/symptoms: dyspnea, fatigue,

peripheral/pulmonary edema

Trauma• Preventing accidents

• 6-7% of pregnancies• Most commonly in 3rd trimester

• Physiologic changes affecting trauma care• Psychosocial considerations

• Fear for fetus, anxiety, guilt• Assessment

Pregnancy history Bleeding? Cramping?Fetal movement? Physical exam Carefully document accidentConsider abuse or self-inflicted injury

Trauma

• Open wounds Lacerations Puncture wounds Animal or snake bites

• Blunt abdominal trauma/MVA**Placental abruption**• Kleihauer-Betke test• Rh Neg: Need

Rhogam• Choking: chest thrusts

Venous Thrombosis and Pulmonary Embolism

• Symptoms• Diagnosis

• Doppler ultrasound• Ventilation-perfusion (VQ) scan

Respiratory Complications• Pneumonia

• Aggressive management• Asthma• Cystic Fibrosis

Inflammatory Disease & Pregnancy

• Systemic lupus erythematosus (SLE)• Increased risk of pregnancy complications• Management

• Immunosuppression of SLE flare• Careful fetal surveillance• If flare-up during pregnancy, rapid implementation of

treatment

Psychiatric Complications• Depression• Schizophrenia• Bipolar disorder• Anxiety disorders• Eating disorders• Substance addiction

Antepartum Fetal Assessment• Chorionic villus sampling• PUBS• Amniocentesis• Amnioscopy or fetoscopy• Ultrasonography• Fetal kick counts

Assessment of Fetal Well-Being (cont.)

• Doppler ultrasound • Fetal biophysical profile• Non-stress test• Vibroacoustic stimulation• Contraction stress test• Electronic fetal heart rate monitoring

Antenatal Bedrest • Regular community health nurse home visits• Involve various community resources• Support groups • Provide emotional support

Ultrasonography*

• 2 Types: transabdominal and transvaginal

• Purposes- ?

• Transvaginal helpful for imaging cervix to look for shortening and funneling, signs of incompetent cervix

Common Uses of Ultrasound in Pregnancy (pg 545 for AGOC indications)

• Diagnose pregnancy & multiple gestation• Confirm EDC, predict maturity by measurement:

• Estimate fetal weight/estimated gestational age (EDC)• 1st trimester: crown-rump length (6-10 wks) (± 3-5

days)• After 1st trimester: femur length, abdominal

circumference & biparietal diameter (± 7-21 days)• Confirm presence, size & location of placenta & amniotic

fluid (AFI)• Determine growth, sex & presentation of fetus• Diagnose fetal death

Measuring femur length

Measuring the head

Assessing Fetal Well-Being: Fetal Movement

• Fetal Movement: felt between 18-20 weeks (quickening)• Fetal Kick Count: should feel 10 movements in 1 hour

(assess at same time of day)*• Associated with accelerations on non-stress test (NST)*• Decreased fetal movement is a DANGER sign

Biophysical Profile*

• Measures 5 parameters (score max. of 2 for ea.)• Fetal breathing• Fetal movement• Fetal tone• AFI• NST

• Score: 8-10, baby is well; 6, suspect problems; 4, fetus in jeopardy

Modified Biophysical Profile• NST & AFI: Normal if NST is reactive & AFI > 5

cm

Amniotic fluid index (AFI)• Assessment of amniotic fluid.

• Rationale: ↓uteroplacental perfusion may lead to ↓fetal renal blood flow, ↓urination & oligohydramnios (fetal swallowing & urine output determine amniotic fluid volume)

• Pockets of fluid visualized by US are measured • From 28-40 wks:

• AFI should be 12-15 cm.• Above 20-24 cm: polyhydramnios• Below 6 cm: oligohydramnios

Assessing fetal well-beingFetal Heart Sounds

Fetal heart tones by doppler or ultrasound transducer (continuous) Can be heard as early as 10th or 11th week of pregnancy

by Doppler Normal: 110-160. Slows with advancing gestational age Monitored for non-stress test (NST)-- primary test

for fetal well-being

Assessing FHT: Baseline

• Normal: 110-160, The “flat part” between accelerations (accels) or decelerations (decels). Look at at least 10 min. strip.

• Bradycardia: < 110 for > 10 minutes (otherwise, it is a deceleration)• Causes: hypoxia, hemorrhage, cord prolapse,

hypothyroidism, heart block• Tachycardia: >160 for > 10 minutes

• Causes: maternal fever/infection, dehydration, hypoxia, medication (terbutaline, amphetamines, cocaine), arrhythmias (SVT), hyperthyroidism

FHR Variability• The range of the “baseline” heart rate in

variation from the baseline.

-the “jitteriness” of the baseline• Absent: undetectable (looks like a straight line)• Minimal <6 bpm• Moderate: 6-25 bpm• Marked: > 25 bpm

• Moderate variability implies: intact CNS, normal cardiac responsiveness, fetus is well-oxygenated & doing well

FHR Variability, cont.• Decreased variability (look for cause)

• Fetal sleep cycle• Hypoglycemia• Hypoxia• Placental perfusion problems• Narcotic (Nubain, Stadol), Celestone, MgS04

• Increased variability• Fetal or maternal catecholamine release • Scalp stimulation• Concern if persistent & decreased variability

Fetal Heart Rate (FHR) Testing Nonstress Test (NST)

• Fetal movement produces accelerations (accels) of the FHR

• Accelerations: intact central & autonomic nervous system--baby is not hypoxic

• Criteria ??• Reactive (reassuring): 2 or more accels• Accel criteria: 15 BPM above baseline FHR & duration of 15

seconds or more (15 x 15)

• High-risk pregnancy: bi-weekly NSTs from 32-34 wks

Reactive (Reassuring) NST

Example of a reactive nonstress test (NST). Accelerations of 15 bpm lasting 15 seconds with each fetal movement (FM). Top of strip shows fetal heart rate (FHR); bottom of strip shows uterine activity tracing. FHR increases (above the baseline) at least 15 beats and remains at that rate for at least 15 seconds before returning to the former baseline.

Fetal Heart Monitor Strip

Does this NST show evidence of fetal well-being?

Fetal Heart Monitor Strip

Does this NST show evidence of fetal well-being?

Evaluating Contractions•Uterine Activity Assessment

• External monitor--tocodynamometer• Palpation for intensity• Pattern: Frequency, duration

• Internal--intrauterine pressure catheter (IUPC)• Intensity read on graph paper in mm/Hg

Periodic & Non-Periodic Changes

• Accelerations:• Abrupt increase of 15 bpm for a least 15

seconds (less than 2 minutes)• Indicate healthy, well-oxygenated fetus with

intact CNS. Basis of reactive NST.

• Decelerations:• Early• Variable• Late• Prolonged

Monitoring in Labor• Frequency: Count time from START of one

contractions to START of next.• Duration: Count time from START of one

contraction to END of same contraction• Intensity: PALPATION for external monitor:

mild (chin), moderate (nose), strong (forehead)

Intermittent Fetal Heart Rate Monitoring

• Low risk moms• Home births and birthing centers (low-risk

pregnancies, natural childbirth)• Allows for greater maternal freedom of

movement• Non Stress Tests usually 20 mins q 1-2 hrs

Indications forContinuous Fetal Monitoring

• Multiple gestation• Placenta Previa• Oxytocin infusion• Fetal bradycardia/non-reassuring

FHR• Maternal Complications (Gestational

Diabetes, PIH)• Intrauterine Growth Restriction

(IUGR)

Indications for Continuous Fetal Monitoring

• Post dates• Meconium-stained amniotic fluid• Abruption placenta- suspected or

actual• Abnormal non-stress test• Abnormal uterine contractions• Fetal distress• Provider preference and facility

protocol

Monitoring in Labor

• Fetal HR: external or internal monitor: fetal scalp electrode (FSE)

• Leopolds maneuvers• Locate fetal back

• 1st stage: FH q 30 mins• 2nd stage: FH q 5 mins• EFM Terms

• Baseline• Variability• Periodic changes• Non-periodic changes

Early Decelerations• occur with contractions

• Rounded in shape• Gradual: > 30 secs from onset to bottom

(nadir)• Start of decel is with start of UC• Nadir coincides with peak of UC (mirror image)• Benign: caused by head compression, more

common in primigravidas•Head compression→ ↓cerebral blood flow→ vagal response→ ↓ HR

Variable Decelerations• Independent of Contractions• hypertonic UCs, cord compression)

• V, W or U shaped, variable in size, shape & timing to UCs

• Abrupt: < 30 secs from onset to nadir• At least 15 bpm down and 15 secs long (less

than 2 minutes)• assoc. with oligoydramnios• Cord compression

• Total cord occlusion → fetal hypertension or hypoxemia → stimulation of fetal baroreceptors or chemoreceptors → central vagal stimulation → variable decel

Late Decelerations• occur with UC’s

• Rounded in shape• Gradual: > 30 secs from onset to nadir• Start is AFTER start of UC• Nadir is AFTER peak of UC (offset)• Need to be addressed--ominous if persistent

and occurring with more than 50% of UC’s. Consider expedited delivery.• Uteroplacental Deficiency: ↓

intervillous blood flow → fetal hypoxemia → anerobic metabolism → ↑ lactic acid → metabollic acidosis → myocardial & CNS depression

Decelerations• Prolonged-can be variable or late type

• Visually apparent ↓ in rate--at least 15 bpm below baseline

• Lasting 2 to 10 minutes ( > 10 = bradycardia)• Causes:

• Cord compression, maternal hypotension (epidural/spinal), tetanic (hypertonic) UCs, maternal seizure, narcotic overdose/respiratory depressions rapid fetal descent, uterine rupture, abruption

• Address immediately for cause and correct.• Consider expedited delivery if doesn’t correct

Intrauterine Fetal Resuscitation

• *Stop pitocin• Reposition to left lateral, Trendelenberg if needed• Oxygen via mask at 8-10 L/min• Increase IV fluids• SQ terbutaline (0.25 mg) if uterus not relaxing• Vaginal exam for possible cause: prolapse, fetal

descent, rupture, abruption• Amnioinfusion for variable decels• Notify MD/midwife

Which strip shows signs that immediateintervention is needed? Why? Whatwould you do?

A

B

Case Study• M.V. is a 17 year old in her first pregnancy. She

states she is 36 weeks pregnant and has not received any prenatal care. The following assessments are made by the RN:• Vital signs: 110/72, 82, 16, 98.4• Fundal height: 32 cm• Patient states she has not felt the baby moving today

• What is your assessment of baby’s well-being?• Does this client need any additional testing for fetal

well-being? If so, what?