1. Fundal height; tenderness, masses, hernia.
2. Fetal heart rate (FHR).
3. Leopold's maneuver for presentation (after week 32).

1. Urinalysis—for protein, sugar, signs of asymptomatic infection; drug screen for high-risk groups.
2. Venous blood—Hgb, Hct; blood type and Rh factor; rapid plasma reagin (RPR); rubella titer, antibody titer, sickle cell. HIV and hepatitis antigen recommended for all pregnant clients.
3. Cultures (vaginal discharge; cervical scrapings, for Chlamydia trachomatis, Neisseria gonorrhoeae).
4. Tuberculosis (TB) screening in high-risk areas.
5. Multiple marker screen, 16 to 18 weeks optimum time.
6. Serum glucose screen, 24 to 28 weeks; 1-hour glucose tolerance test.

If TB positive during pregnancy, isoniazid (INH) and rifampin given daily. INH is associated with increase in fetal malformations, particularly neurotoxicity. Pyridoxine administered simultaneously to prevent their development.

1. Adolescent.
2. Primigravida, age 35 or older.
3. Multigravida, age 40 or older.

1. Habitual abortion.
2. Multiparity greater than 5.
3. Previous stillbirths.
4. Previous cesarean birth.
5. Previous preterm labor or delivery.

1. Enters health-care system late in pregnancy.
2. Irregular/episodic prenatal care visits.
3. Noncompliance with medical/nursing recommendations.

1. Cardiovascular: hypertension, heart disease.
2. Diabetes.
3. Other: renal, respiratory, infections, acquired immunodeficiency syndrome (AIDS).

1. Monitor status and progress of pregnancy.
2. Refer for medical management, as necessary.

1. Avoids factors predisposing to health problems.
2. Understands and implements therapeutic management of coexisting disorder/pregnancy.
3. Increases compliance with medical/nursing recommendations.

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.

1. Subjective symptoms
1. Palpitations; feeling that the heart is "racing."
2. Increasing fatigue or difficulty breathing, or both, with the usual activities.
3. Feeling of smothering and/or frequent cough.
4. Periorbital edema; edema of face, fingers (e.g., rings do not fit anymore), feet, legs.
2. Objective signs
1. Irregular weak, rapid pulse (≥100 beats/min).
2. Rapid respirations (≥25 breaths/min).
3. Progressive, generalized edema.
4. Crackles (rales) at base of lungs, after two inspirations and exhalations.
5. Orthopnea; increasing dyspnea on minimal physical activity.
6. Moist, frequent cough.
7. Cyanosis of lips and nailbeds.

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.

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-minute 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.

1. Well-balanced diet; adequate protein, fresh fruits and vegetables, water.
2. Avoid "junk food," stimulants (caffeine), excessive salt intake.

1. Goal: minimize physiological and psychological stress.
2. Medical management:
1. Reevaluation of cardiac status before EDD and labor.
2. Regional anesthesia for labor/birth.
3. Low-outlet forceps or vacuum extraction birth; episiotomy.
4. Continuous hemodynamic monitoring.
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 mother in labor.
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 (e.g., digitalis, diuretics, antibiotics).

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 volume.
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 woman who is postpartum (fundus, signs of infection, etc.).
3. Nursing care plan/implementation:

postpartum.

1. Goal: minimize stress on cardiopulmonary system.
1. Rest, dangle, ambulate with assistance.
2. Gradual increase in activity—as tolerated without symptoms.
3. Position: semi-Fowler's if needed.
4. Extra help with newborn care.

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.

1. Straw-colored fluid—mild disease.
2. Golden fluid—severe fetal disease.

Goal: prevent isoimmunization in women who are Coombs' negative

1. Postabortion—if no evidence of Rh sensitization (antibody formation) in the mother who is Rh negative, administer RhoGAM.
2. Prenatal—if no evidence of sensitization, administer RhoGAM at 28 weeks of gestation, as ordered, to all women who are Rh negative.
3. Postpartum—if no evidence of sensitization, administer RhoGAM within 72 hours of birth to women who are Rh negative and who gave birth to a baby who is Rh positive.
   Give RhoGAM to:
1. Mother who is Rh negative who gives birth to neonate who is Rh positive.
2. Mother who is Rh negative after spontaneous or induced abortion (>8 weeks).
3. Mother who is Rh negative after amniocentesis or chorionic villus sampling (CVS).
4. Mother who is Rh negative between 28 and 32 weeks of gestation.

1. Explain, discuss that RhoGAM suppresses antibody formation in susceptible woman who is Rh negative carrying fetus that is Rh positive. Note: Cannot reverse sensitization if already present.
2. Required during and after each pregnancy with fetus who is Rh positive.

Goal: prevent spread of disease.

1. Initial treatment regimen: isoniazid (INH), rifampin (RIF), and ethambutol (EMB).
2. Pyridoxine (vitamin B₆) recommended for women who are pregnant and taking INH.
3. Routine use of pyrazinamide (PZA) should be avoided because of inadequate teratogenicity data.
4. Avoid: streptomycin (which interferes with development of the ear; may cause congenital deafness).

1. Explain, discuss transmission of disease, importance of completion of medication regimen.
2. Because small concentration of antituberculosis drugs in breast milk do not produce toxicity in the newborn who is nursing, breastfeeding should not be discouraged for a woman who is HIV seronegative and is planning to take (or is taking) INH or other anti-TB medications.

1. If have a positive M. tuberculosis culture or suspected TB disease, treat without delay.
2. Rifamycin.
3. Although routine use of pyrazinamide not recommended if pregnant (due to inadequate teratogenicity data), benefits for women who are HIV infected and pregnant outweigh potential pyrazinamide-related risks to fetus.

Goal: prevent spread of disease.

1. Hepatitis B immune globulin (HBIG) to infant at birth.
2. Hepatitis B vaccine at 1 week, 1 month, 6 months after birth.

1. Explain, discuss transmission of disease, importance of completion of vaccination regimen.
2. Centers for Disease Control and Prevention (CDC) has recommended that all newborn infants be vaccinated for hepatitis B.
3. The risk of HBV infection in children is not only from perinatal transmission from mothers who are HBV infected, but also from close contact with household members and caregivers who have acute or chronic HBV infection.
4. Ensure that all infants born to mothers who are HBsAg positive receive timely and appropriate immunoprophylaxis with HBIG and hepatitis B vaccine.
5. Discontinue interferon therapy during pregnancy (effect on fetus is unknown).

1. Human placental lactogen (HPL).
2. Progesterone.
3. Estrogen.
4. Cortisol.

1. Decreased glucose tolerance.
2. Increased metabolic rate.
3. Increased production of adrenocortical and pituitary hormones.
4. Decreased effectiveness of insulin (increased resistance to insulin by peripheral tissues).
5. Increased gluconeogenesis.
6. Increased size and number of islets of Langerhans to meet increased maternal needs.
7. Increased mobilization of free fatty acids.
8. Decreased renal threshold, increased glomerular filtration rate; glycosuria common.
9. Decreased CO₂-combining power of blood; higher metabolic rate increases tendency to acidosis.

1. Nausea and vomiting—predispose to ketoacidosis.
2. Insulin requirements—relatively stable or may decrease in first trimester; rapid increase during second and third trimesters; rapid decrease after birth to prepregnant level.
3. Pathophysiological progression (nephropathy, retinopathy, and arteriosclerotic changes) may appear; existing pathology may worsen.

1. Family history.
2. Previous infant 9 lb or more.
3. Unexplained fetal wastage—abortion, stillbirth, or early neonatal death.
4. Obesity with very rapid weight gain.
5. Polyhydramnios (excessive amniotic fluid).
6. Previous infant with congenital anomalies.
7. Increased tendency for intense vaginal or urinary tract infections.
8. Previous history of gestational diabetes.

Symptoms: "3 Ps"—polydipsia, polyphagia, polyuria—and weight loss.

1. Fetal heart rate.
2. Excessive fundal height.
1. Polyhydramnios.
2. Large-for-gestational-age (LGA) fetus.
   Note: With vascular pathology, small-for-gestational-age (SGA) fetus.

1. 50-gm oral glucose tolerance test (GTT): woman ingests 50 gm oral glucose solution; 1 hour later plasma glucose obtained. If 140 mg/dL, 3-hour oral GTT ordered.
2. Abnormal 3-hour GTT: two or more of the following findings are diagnostic of gestational diabetes:
1. Fasting blood sugar (FBS) ≥95 mg/dL.
2. One hour ≥180 mg/dL.
3. Two hours ≥155 mg/dL.
4. Three hours ≥140 mg/dL.
3. Diabetic classification criteria:
1. Type 1—autoimmune disease in which the body's immune system destroys pancreatic beta cells; ↓ production of insulin; need additional insulin. About 10% with diabetes are type 1.
2. Type 2— ↑ insulin resistance despite adequate insulin production; treatment may include: diet, exercise, weight loss, oral drugs to stimulate release of insulin; or insulin injections. About 90% with diabetes are type 2.
3. Gestational—occurs in about 3% of all pregnancies. GTT administered at 24 to 28 weeks' gestation; two abnormal values indicate diagnosis of gestational diabetes. About 40% of women with gestational diabetes will develop type 2 diabetes within 5 years.

1. Knowledge and acceptance of disease and its management:
1. Signs and symptoms of hyperglycemia/hypoglycemia (see Table 6-28. Comparison of Diabetic Complications ).
2. Appropriate behaviors (e.g., skim milk for symptoms of hypoglycemia).
2. Skill and accuracy in monitoring serum glucose (dextrometer use).
3. Skill and accuracy in preparing and administering insulin dosage; site rotation; subcutaneous injection in abdomen.
4. Close monitoring—prenatal status assessment every 2 weeks until 30 weeks, then weekly until birth. Alert to signs of emerging problems (need for insulin adjustment, polyhydramnios, macrosomia).
5. Other—as for any woman who is pregnant.

1. Pathophysiology of diabetes, as necessary; effect of pregnancy on management.
2. Signs and symptoms of hyperglycemia, hypoglycemia; appropriate management of symptoms.
3. Hygiene—to reduce probability of infection.
4. Exercise—needed to control serum glucose levels, to regulate weight gain, and for feeling of well-being.
5. Need for close monitoring during pregnancy.
6. Insulin regulation:
1. Requirements vary through pregnancy: first trimester—may decrease with some periods of hypoglycemia due to fetal drain; second trimester—increased need for insulin; third trimester—needs may be triple prepregnant dose; acidosis more common in late pregnancy (precipitated by emotional stress, infection).
2. Serum glucose testing—dextrometer, blood glucose, or other.
3. Preparation and self-administration of insulin injection, as necessary.
4. Prompt reporting of fluctuating serum glucose levels.
7. Diagnostic testing/hospitalization:
1. Nonstress test.
2. Sonography.
3. Amniocentesis.

Goal: dietary counseling

1. Optimal weight gain—about 24 lb.
2. Needs 25 to 35 calories/kg of ideal body weight (1800–2600 calories).
3. Protein—18% to 25% (2 gm/kg, or about 70 gm daily).
4. Carbohydrates: 50% to 60% in complex form (milk, bread).
5. Fats—25% to 30% unsaturated.
6. No fruit juice; no cold cereal; carbohydrates limited.

1. Regulation of insulin (oral hypoglycemics contraindicated in early pregnancy, due to teratogenicity; cross placental barrier).
2. Control of infection.
3. Determination of fetal jeopardy or indications for early termination of pregnancy.

1. Monitors serum glucose levels accurately (dextrometer, blood glucose).
2. Prepares and self-administers insulin appropriately.
3. Complies with dietary regimen.

1. Medical evaluation—procedures:
1. Serum glucose levels (↓ 120 mg/dL).
2. Sonography for fetal growth: biophysical profile (BPP) evaluates fetal physical well-being and volume of amniotic fluid.
3. Nonstress testing/contraction stress testing.
4. Amniocentesis for fetal maturity. Note: Lecithin/sphingomyelin (L/S) ratio may be elevated in women who are diabetic; phosphatidylglycerol [PG] more accurate for women who are diabetic.
2. Nursing assessment:
1. Daily weight, vital signs, FHR q4h, I&O.
2. Fundal height and Leopold's maneuver on admission.

1. Explain all procedures.
2. Assist with tests for fetal status.
3. Prepare for possibility of preterm or cesarean birth.

1. Signs and symptoms of hyperglycemia, hypoglycemia (see Table 6-28. Comparison of Diabetic Complications ). Hourly blood sugar measurements.
2. Electronic fetal monitoring—to identify signs of fetal distress.
3. Other—as for any woman in labor.

1.   Position: lateral Sims'—to reduce compression of inferior vena cava and aorta due to polyhydramnios or LGA baby. (Supinehypotensive syndrome results from compression; reduced placental perfusion increases incidence of fetal hypoxia/anoxia.)
2. Medical management—varies widely.
1. Timing—amniocentesis to determine PG and phosphatidylinositol levels (estimate fetal pulmonary surfactant).
2. Insulin added to intravenous infusion of 0.9 NaCl and titrated to maintain serum glucose approximately 100 mg/dL. 5% to 10% D/W IV needed to prevent hypoglycemia that may lead to maternal ketoacidosis; hyperglycemia may result in newborn hypoglycemia.
3. Ultrasound to identify macrosomia >4050 gm.

1. Loss of placental hormones that degrade insulin.
2. Lower metabolic rate. Woman requiring large doses of insulin may need to triple caloric intake and decrease insulin by one-half.

1. Observe for:
1. Hypoglycemia.
2. Infection.
3. Preeclampsia/eclampsia (higher incidence in women who are diabetic).
4. Hemorrhage (associated with polyhydramnios, macrosomia, induction of labor, forceps birth, or cesarean birth).
2. Monitor healing of episiotomy/abdominal incision.

1. Medical management: insulin calibration—requirement may drop to one-half or twothirds pregnant dosage on first postpartum day if woman is on full diet (due to loss of human placental lactogen and conversion of serum glucose to lactose).
2. Nursing management
1. Goal: euglycemia. Blood glucose, insulin as ordered.
2. Goal: avoid trauma, reduce risk of UTI. Avoid catheterization, where possible.
3. Goal: health teaching. Nipple care—to prevent fissures and possible mastitis.
4. Goal: reduce serum glucose and insulin needs. Encourage/support breastfeeding → antidiabetogenic effect. Note: If acetonuria occurs, stop breastfeeding while physician readjusts diet/insulin balance; may pump breasts to maintain lactation. If hypoglycemic, adrenalin level rises → decreased milk supply and let-down reflex.

1. Risk of infant inheriting gene for diabetes is greater if mother has early-onset, insulin-dependent disease.
2. Increased risk of congenital disorders.

1. Oral contraceptives are controversial because they decrease carbohydrate tolerance; may be cautiously prescribed for women with no vascular disease and who are nonsmokers. Intrauterine device (IUD) contraindicated because of impaired response to infection. Barrier contraceptives (diaphragm or condoms with spermicides) recommended.
2. Tubal ligation: if mother has vascular involvement (i.e., retinopathy or nephropathy), increased risk with later pregnancies.

1. Self-care measures.
2. Importance of eating on time, even if infant must wait to breastfeed or bottle feed.
3. Importance of adequate rest and exercise to maintain insulin/glucose balance.
4. Organize schedule to care for infant, other children, and her diabetes. Allow time for self.

1. Successfully completes an uneventful pregnancy, labor, and birth of a newborn who is normal and healthy.
2. Makes informed judgments regarding parenting, family planning, management of her diabetes.

1. Infections: HIV-positive status, AIDS, STIs, hepatitis, cirrhosis, cellulitis, endocarditis, pancreatitis, pneumonia.
2. Psychiatric illness: depression, paranoia, irritability.
3. Trauma related to violence.

1. Spontaneous abortions.
2. History of abruptio placentae.
3. Preterm labor.
4. Preterm rupture of membranes.
5. Fetal death.
6. Low-birth-weight (LBW) infants.
7. Tremors/seizures.

1. Preterm labor contractions.
2. Hypoactivity or hyperactivity in fetus.
3. Poor or decreased weight gain.
4. STI.
5. Undiagnosed vaginal bleeding.
6. Drugs being used and methods of self-administration.

1. Attitudes re: pregnancy.
2. Current support system: lacking.
3. Current living arrangements; lifestyle.
4. History of psychiatric illness.
5. History of physical, sexual abuse.
6. Involvement with legal system.

1. Nicotine.
2. Alcohol (fetal alcohol syndrome [FAS] or fetal alcohol effects [FAE]).
3. Marijuana.
4. Stimulants—cocaine, crack, ice, methamphetamine.
5. Opiates—heroin, methadone, Darvon, codeine, Vicodin, OxyContin.
6. Sedatives, hypnotics.
7. Caffeine.
8. Ecstasy.

1. LBW, small heads.
2. Irritable, difficult to console.
3. Disorganized suck-swallow reflex.
4. Impaired motor development.
5. Congenital anomalies: genitourinary, gastrointestinal, limb anomalies.
6. Cerebral infarctions.
7. Breastfeeding allowed; thought to ease infant withdrawal.
8. Poor, slow weight gain; failure to thrive.