Complications during the antepartum

  1. 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 hours sleep each night; 30 minutes 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).
      6. 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
      7. Evaluation/outcome criteria:
        1. Successfully carries uneventful pregnancy to term.
        2. Experiences no cardiopulmonary decompensation during labor, birth, or postpartum.
  2. Disorders affecting fluid-gas transport in fetus: Rh incompatibility
    1. Pathophysiology - in an Rh-negative mother: Rh-positive fetal red blood cells enter the maternal circulation —» maternal antibody formation —» antibodies cross placenta and enter fetal bloodstream —» attack fetal red blood cells —» hemolysis —» anemia, hypoxia.
      1. The pregnant Rh-positive mother carries her infant (Rh negative or positive) without incident.
      2. The pregnant Rh-negative mother carries an Rh-negative infant without incident.
      3. The pregnant Rh-negative mother usually carries her first Rh-positive child without problems unless she has been sensitized by inadvertent transfusion with Rh-positive blood. Note: Fetal cells do not usually enter the maternal bloodstream until placental separation (at abortion, abruptio placentae, amniocentesis, or birth).
    2. Etiology:
      1. The Rh factor is an antigen on the red blood cells of some people (these people are Rh positive); the Rh factor is dominant; a person may be homozygous or heterozygous for Rh factor.
      2. An Rh-negative person is homozygous for this recessive trait - does not carry the antigen; develops antibodies when exposed to Rh-positive red blood cells (isoimmunization) through transplacental (or other) transfusion.
      3. Following birth of an Rh-positive infant, if fetal cells enter the mother’s bloodstream, maternal antibody formation begins; antibodies remain in the maternal circulation.
      4. At time of next pregnancy with Rh-positive fetus, antibodies cross placenta —> hemolysis. Note: Degree of hemolysis depends on amount (titer) of maternal antibodies present.
    3. Possible serious complication (fetal) - rare today. Hydrops fetalis - most severe hemolytic reaction: severe anemia, cardiac decompensation, hypoxia, edema, ascites, hydrothorax; may be stillborn.
    4. Assessment:
      1. Prenatal - diagnostic procedures:
        1. Maternal blood type and Rh factor.
        2. Indirect Coombs test - to determine presence of Rh sensitization (titer indicates amount of maternal antibodies).
        3. Amniocentesis - as early as 26 weeks of gestation - amount of bilirubin by-products indicates severity of hemolytic activity.
        4. RhoGAM between 28-32 weeks to prevent antibody formation.
      2. Intrapartal observation of amniotic fluid (after membrane rupture).
        1. Straw-colored fluid - mild disease
        2. Golden fluid - severe fetal disease
      3. Postnatal -
    5. Nursing care plan/implementation:
      1. Goal: prevent isoimmunization in Coombsnegative women
        1. Postabortion - if no evidence of Rh sensitization (antibody formation) in the Rh-negative mother, administer RhoGAM.
        2. Prenatal - if no evidence of sensitization, administer RhoGAM at 28 weeks of gestation, as ordered, to all Rh-negative women.
        3. Postpartum - if no evidence of sensitization, administer RhoGAM within 72 hours of birth to Rh-negative women who gave birth to Rh-positive baby.
            Give RhoGAM to:
          1. Rh-negative mother who gives birth to Rh-positive neonatal
          2. Rh-negative mother after spontaneous or induced abortion (>8 weeks).
          3. Rh-negative mother after amniocentesis or chorionic villus sampling (CVS).
          4. Rh-negative mother between 28 and 32 weeks of gestation.
      2. Goal: health teaching.
        1. Explain, discuss that RhoGAM suppresses antibody formation in susceptible Rh-negative women carrying Rh-positive fetus. Note: Cannot reverse sensitization if already present.
        2. Required during and after each pregnancy with Rh-positive fetus.
    6. Evaluation/outcome criteria:
      1. Successfully carries pregnancy to term.
      2. No evidence of Rh isoimmunization.
      3. Birth of viable infant.