Pregnancy Complications - 5

Gestational Diabetes

It is a glucose intolerance that is first recognized in pregnancy.

Clinical Findings

• Polyuria
• Polydipsia
• Polyphagia
• Fatigue
• Blurred vision
• Glucosuria
• Recurrent yeast infections
• Slow healing wounds
• Abnormal glucose results
• 1-hour glucose 140 mg/dL
• Abnormal 3-hour glucose tolerance test: 2 out of 4 values elevated
• FBS 95mg/dL
• 1-hour 180mg/dL
• 2-hour 155mg/dL
• 3-hour 140mg/dL

Outpatient Management

1. Dietician consult for ADA diet instructions
2. Discuss pathophysiology of gestational diabetes with patient
3. Demonstrate home glucose monitoring
4. Review range for glycemic control
5. Demonstrate logging of glucose results
6. Discuss role of exercise in glycemic control
7. Demonstrate urine ketone testing
8. Demonstrate insulin administration
9. Teach patient to count fetal movements
• Find comfortable position in quiet place and concentrate on fetal movement
• Document time of first fetal movement and time required for 10 movements (should not take more than 2 hours)
• If pattern of movement decreased, REPORT immediately

Pregnancy Complications - 4

Preeclampsia

Preeclampsia is a hypertensive disorder of pregnancy with multi system involvement

Clinical Findings

• Blurred or altered vision
• Epigastric pain
• Headache
• Edema
• Proteinuria
• Hyperreflexia
• Hypertension

Nursing Care

1. Closely monitor vital signs
2. Assess deep tendon reflexes
3. Dipstick urine for protein
4. Record presence of edema
5. Palpate tone of fundus
6. Auscultate fetal heart rate and apply EFM
7. Monitor patient comfort
8. Collect 24-hour urine
9. Place patient in side-lying position
10. Keep environment quiet and dim
11. Institute seizure precautions:
• Side rails up and padded
• Bed in low position
• Suction equipment available at bedside
• Oxygen available at bedsideInitiate IV fluids as ordered
12. Monitor intake and output
13. Initiate medications as ordered

Eclampsia

Clinical Findings

• Worsening of symptoms of preeclampsia
• Seizure activity

HELLP Syndrome

Clinical Findings

• Worsening symptoms of preeclampsia
• Malaise
• Epigastric pain
• Nausea/vomiting
• Laboratory findings:
• Hemolysis
• Elevated Liver enzymes
• Low Platelets

Pregnancy Complications - 3

Hyperemesis Gravidarum

It is an intractable vomiting in pregnancy with resultant weight loss and dehydration

Nursing Care

• Assess vital signs
• Observe for signs of dehydration
• Review electrolytes
• Access IV site as ordered
• Record fetal heart tones
• Record intake and output
• Record daily weight
• Check urine for ketones
• Administer antiemetics as orderedPreterm Labor

Preterm Labor

It is an onset of regular labor before the 37th completed week of gestation.

Clinical Findings

• Rhythmic lower abdominal cramping
• Complaints of backache
• Increased vaginal discharge
• Downward pelvic pressure
• Leaking of amniotic fluid
• Vaginal spotting
• Cervical effacement/dilation
• Shortening cervical length

Nursing Care

1. Determine gestational age
2. Assess uterine tone
3. Auscultate fetal heart tones and apply EFM
4. Obtain vaginal/urine cultures
5. Assess for leaking amniotic fluid: Ferning - Microscopically, amniotic fluid will resemble the leaves of a fern plant, and Nitrazine paper - Due to the alkaline nature of amniotic.
6. fluid, the nitrazine paper will change from yellow to blue
7. Perform vaginal exam to determine dilation and effacement of the cervix
8. Position side-lying
9. Initiate IV fluids as ordered
10. Administer corticosteroid to mother:  Accelerates maturity of fetal lungs AND Most benefit 24 hours after administered
11. Initiate tocolytic therapy

Pregnancy Complications - 2

Vaginal Bleeding (after 20 weeks’ gestation)

The complications may be related to placenta previa or abruptio placentae.

Placenta Previa

It is a low-lying position of placenta in the uterus that partially or completely covers the cervical os. Clinical Findings:

• Painless bright red vaginal bleeding
• Bleeding may be reported after intercourse
• Uterine tone soft upon palpation
• Interventions dependent on amount of bleeding and labor status
• If partial placenta previa is noted in early gestation, then repeat ultrasound later in pregnancy (may demonstrate absence of previa as uterus grows)
• If labor active and os is covered, then cesarean birth necessary
• If bleeding controlled and labor absent, then conservative management is applied

Patient Teaching (Conservative Management)

• No tampon use
• No sexual intercourse
• Monitor and report bleeding
• Patient instructed to report placenta placement when admitted to hospital
• Cesarean preparation class
• Count fetal movements

Abrupto Placentae

Clinical Findings

• Abdominal pain (sudden onset, intense and localized)
• Fundus firm, boardlike, with little relaxation
• Vaginal bleeding
• Bleeding may be concealed within the uterine cavity
• Fetal heart tones may be non-reassuring

Nursing Care (vaginal bleeding/late pregnancy)

1. Monitor amount of bleeding
2. Check vital signs
3. Observe for signs of shock
4. Evaluate fetal heart tones
5. Palpate uterine tone
6. Apply electronic fetal monitor (EFM)
7. REPORT alterations in fetal heart rate pattern
8. REPORT hypertonic contractions with poor resting tone
9. Do not attempt vaginal exam until placenta placement verified
10. Initiate IV fluids
11. Report laboratory and ultrasound findings
12. Prepare staff for possible cesarean birth
13. Attend to patient’s emotional needs

Pregnancy Complications - 1

Vaginal Bleeding (before 20 weeks’ gestation)
It may be related to spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease.

Spontaneous Abortion
It is a loss of pregnancy before viability, clinical Findings:

• Vaginal spotting (may pass clots)
• Abdominal cramping
• Cervical changes
• Fetal heartbeat may be present or absent

Ectopic Pregnancy
It is a product of conception implant outside the uterus, clinical findings:

• Vaginal spotting
• hCG lower than expected for dates
• Lower abdominal pain
• Ultrasound findings: absence of intrauterine gestational sac
• If rupture occurs, it would be: Positive Cullen’s sign (periumbilical bluish hue), Shoulder pain, and Signs of shock

Gestational Trophoblastic Disease
It is an abnormal proliferation of trophoblastic cells without viable fetus, Clinical Findings:

• Vaginal spotting (dark brown)
• Fundal height greater than expected for dates
• hCG greater than expected for dates
• Excessive nausea and vomiting
• Absence of fetal heart tones
• Ultrasound findings: Snowflake-like clusters, absence of fetus

Nursing Care (vaginal bleeding/early pregnancy)

1. Monitor amount of bleeding
2. Assess vital signs
3. Observe for signs of shock
4. Auscultate for fetal heart tones (FHTs)
5. Collect passed tissue/clots
6. Monitor patient comfort
7. Check blood type and Rh factor
8. Administer Rh(D) immunoglobulin if indicated
9. Initiate IV fluids as ordered
10. Report lab/ultrasound findings
11. Attend to patient’s emotional needs

Forceps Birth

Forceps birth is an assisted birth, sometimes called an instrumental or operative vaginal birth, uses instruments that are attached to baby’s head so that baby can be pulled out. Forceps are described as stainless steel that come in two intersecting parts and have curved end to cradle baby’s head. It can be used as low or outlet forceps or for mid-forceps procedures.
This procedure is done to provide traction or to assist in rotation of the fetus.

Advantages:

• Provide assistance when laboring women is exhausted
• May decrease need for cesarean birth

Disadvantages:

• Maternal complication such as vaginal and perineal lacerations and postpartal hemorrhage
• Neonatal complication such as facial bruising, edema and cerebral trauma.

Nursing care:

• Explain the procedure to woman
• Encourage her to relax perineum and breathe during forceps application
• Advice physician when contraction is present
• Assess newborn for facial bruising or edema.

Induction

Induction labor is a procedure to stimulate uterine contraction during pregnancy before labor begins spontaneously. It is done for various reason, especially for mother and baby health reason. Elective induction may be accomplished by oxytocin infusion.

Advantages:

• IV oxytocin induction is usually successful when labor readiness has been established, fetal maturity is established and Bishop score is 9 or more.
• Maternal and fetal status can be monitored closely.

Disadvantages:
Induction is an invasive procedure.
Hypertonic labor, fetal distress, alterations in blood pressure, ruptured uterus.

Indications:

• Postmaturity
• Premature rupture of membranes
• PIH
• Presence of maternal disease such as diabetes mellitus
• Fetal demise.

Contraindications:

• Grand multiparity
• Placental abdominalities
• Previous uterine surgery
• Fetal distress
• Preterm fetus
• Positive CST
• Abnormal fetal presentation
• Presenting part above inlet
• Cephalopelvic disproportion (CPD).

Nursing Intervention:

• Obtain baseline tracing of uterine contractions
• Follow established protocols
• Increase IV dosage only after assessing contractions, FHR, and maternal blood pressure and pulse.
• Do not increase rate once desired contraction pattern is obtained.
• Discontinue oxytocin if contraction frequency is less than 2 minutes of duration is more than 90 seconds, or if fetal distress is noted.