Complications during the antepartum

2. Disorders affecting fluid-gas transport: cardiac disease
1. Pathophysiology: cardiac overload —> cardiac decompensation —» right-sided failure pulmonary edema
2. Etiology:
   1. Congenital heart defects.
   2. Valvular damage - due to rheumatic fever (most common lesion is mitral stenosis, which can lead to pulmonary edema and emboli).
   3. Increased circulating-blood volume and cardiac output - exceeds cardiac reserve Greatest risk: after 28 weeks of gestation - reaches maximum (30-50%) volume increase; postpartum - due to diuresis.
   4. Secondary to treatment (tx) (e.g., tocolysis and B methasone)
   5. Pregnancy after valve replacement.
3. Normal physiological alterations during pregnancy that mimic cardiac disorders:
   1. Systolic murmurs, palpitations, tachycardia, and hyperventilation with some dyspnea on normal moderate exertion.
   2. Edema of lower extremities.
   3. Cardiac enlargement.
   4. Elevated sedimentation rate near term.
4. Assessment:
   1. Medical evaluation of cardiac status. Classification of severity of cardiac involvement.
      1. Class I - least affected; asymptomatic with ordinary activity.
      2. Class II - activities somewhat limited; ordinary activities cause fatigue, dyspnea, angina
      3. Class III - moderate/marked limitation of activity; common activities result in severe symptoms of fatigue, etc.
      4. Class IV - most affected; symptomatic (dyspnea, angina) at rest; should avoid pregnancy.
   2. Cardiac decompensation:
      1. Subjective symptoms

         Palpitations; feeling that the heart is “racing”

         Increasing fatigue or difficulty breathing, or both, with the usual activities

         Feeling of smothering and/or frequent cough

         Periorbital edema; edema of face, fingers (, rings do not fit anymore), feet, legs

      2. Objective signs

         Irregular weak, rapid pulse (>100 beats/min)

         Rapid respirations ( >25 breaths/ min)

         Progressive, generalized edema Crackles (rales) at base of lungs, after two inspirations and exhalations

         Orthopnea; increasing dyspnea on minimal physical activity

         Moist, frequent cough Cyanosis of lips and nailbeds

5. Analysis/nursing diagnosis:
   1. Fluid volume excess related to inability of compromised heart to handle increased workload (decreased cardiac reserve—» congestive heart failure).
   2. Impaired gas exchange related to pulmonary edema secondary to congestive heart failur
6. Nursing care plan/implementation:
   1. Medical management:
      1. Diuretics, electrolyte supplements.
      2. Digitalis (dose may need to be higher because of dilution in the increased blood volume of pregnancy).
      3. Antibiotics - prophylaxis against rheumatic fever; treatment of bacterial infections during pregnancy.
      4. Anticoagulants. Heparin is preferred because its large molecule cannot easily cross placenta. Occasionally, sequelae may include maternal hemorrhage, preterm birth, stillbirth.
      5. Oxygen, as needed
      6. Mitral valvotomy for mitral stenosis often brings dramatic relief
   2. Goal: health teaching
      1. Need for compliance with therapeutic regimen, medical/nursing recommendations.
      2. Drug actions, dosage, necessary actions (how to take own pulse, reportable signs/symptoms).
      3. Methods for decreasing work of heart:
         1. Adequate rest - minimum 10 hr sleep each night; 30 min nap after each meal.
         2. Avoid heavy physical activity (including housework), fatigue, excessive weight gain, emotional stress, infection.
         3. Avoid situations of reduced ambient O₂, such as smoking, exposure to pollutants, flight in unpressurized small planes.
   3. Goal: nutritional counselin
      1. Well-balanced diet; adequate protein, fresh fruits and vegetables, water.
      2. Avoid “junk food,” stimulants (caffeine), excessive salt intak
   4. Goal: anticipatory planning: management of labor.
      1. Goal: minimize physiological and psychological stress.
      2. Medical management:
         1. Reevaluation of cardiac status before EDB and labor.
         2. Regional anesthesia for labor/ birth
         3. Low-outlet forceps birth; episiotomy.
      3. Assessment: continuous.
         1. Physiological response to labor stimuli - frequent   vital signs (pulse rate most sensitive and reliable indicator of impending congestive heart failure).
         2. Color, respiratory effort, diaphoresis.
         3. Contractions, etc. - same as for any laboring mother.
      4. Nursing care plan/implementation: labor.
         1. Goal: safeguard status.
            1. Report promptly: pulse rate over 100; respirations more than 24 between contractions.
            2. Oxygen at 6 liters, as needed
         2. Goal: emotional support - to reduce anxiety, facilitate cooperation.
            1. Encourage verbalization of feelings, fears, concerns.
            2. Explain all procedures.
         3. Goal: promote cardiac function. Position - semirecumbent; support arms and legs.
         4. Goal: promote relaxation/control over labor discomfort. Encourage Lamaze (or other) breathing/relaxation techniques.
         5. Goal: reduce stress on cardiopulmonary system. Discourage bearing-down efforts.
         6. Goal: relieve stress of pain, eliminate bearing-down. Prepare for regional anesthesia
         7. Goal: maintain effective cardiac function. Administer medications, as ordered (, digitalis, diuretics, antibiotics).
   5. Goal: anticipatory planning: postpartal management.
   1. Factors increasing risk of cardiac decompensation:
      1. Delivery —> rapid, decreased intraabdominal pressure —» vasocongestion and rapid rise in cardiac output.
      2. Loss of placental circulation.
      3. Normal diuresis increases circulating blood volum
   2. Assessment:
      1. Observe for tachycardia or respiratory distress.
      2. Monitor blood loss, I&O - potential hypovolemic shock, cardiac overload due to diuresis.
      3. Pain level - potential neurogenic shock.
      4. Same as for any postpartum mother (fundus, signs of infection, etc).
   3. Nursing care plan/implementation: postpartum.
      1. Goal: minimize stress on cardiopulmonary system.
         1. Rest, dangle, ambulate with aid
         2. Gradual increase in activity - as tolerated without symptoms.
         3. Position: semi-Fowler’s if needed
         4. Extra help with newborn care
   6. Evaluation/outcome criteria:
   1. Successfully carries uneventful pregnancy to term.
   2. Experiences no cardiopulmonary decompensation during labor, birth, or postpartum.