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  1. COMPLICATIONS AFFECTING COMFORT, REST, MOBILITY: INCOMPETENT CERVIX
    1. Pathophysiology—inability of cervix to support growing weight of pregnancy; associated with repeated spontaneous second trimester abortion.
    2. Etiology:
      1. Unknown.
      2. Congenital defect in cervical musculature (exposure to diethylstilbestrol [DES]).
      3. Cervical trauma during previous birth, abortion; aggressive, deep, or repeated dilation and curettage.
    3. Assessment:
      1. History of habitual, second-trimester abortions.
      2. Painless, progressive cervical effacement and dilation during second trimester.
      3. Signs of threatened abortion or (early thirdtrimester) preterm labor.
    4. Analysis/nursing diagnosis:
      1. Pain related to early dilation.
      2. Fear related to possible pregnancy loss.
    5. Nursing care plan/implementation:
      1. Medical management
        1. Cerclage surgical procedure ( Shirodkar, McDonald ).
      2. Preoperative nursing management
        1. Goal: reduce physical stress on incompetent cervix. Bedrest, supportive care.
        2. Goal: emotional support. Encourage verbalization of anxiety, fear, concerns.
        3. Goal: health (preoperative) teaching. Explain procedure—purse-string suture encircles cervix and reinforces musculature.
        4. Goal: preparation for surgery.
      3. Postoperative nursing management
        1. Goal: maximize surgical result. Bedrest, supportive care.
        2. Goal: health teaching.
          1. Avoid: strenuous physical activity; straining, infection.
          2. Report promptly: signs of labor (vaginal bleeding, cramping).
          3. Need for continued, close health surveillance.
    6. Evaluation/outcome criterion: woman carries pregnancy to successful termination.
  2. COMPLICATIONS AFFECTING SENSORY/PERCEPTUAL FUNCTIONS: PREGNANCYINDUCED HYPERTENSION (PIH); PREECLAMPSIA/ECLAMPSIA
    1. Pathophysiology:
      1. Generalized arteriospasm → increased peripheral resistance, decreased tissue perfusion, and hypertension.
      2. Kidney:
        1. Reduced renal perfusion and vasospasm → glomerular lesions.
        2. Damage to membrane → loss of serum protein (albuminuria). Note: Reduced serum albumin/globulin (A/G) ratio alters blood osmolarity → edema.
        3. Increased tubular reabsorption of sodium → increased water retention (edema).
        4. Release of angiotensin contributes to vasospasm and hypertension.
      3. Brain: decreased oxygenation, cerebral edema, and vasospasm → visual disturbances and hyperirritability, convulsions, and coma.
      4. Uterus: decreased placental perfusion → increased risk of SGA baby, abruptio placentae, oligohydramnios.
    2. Etiology: unknown. Risk factors:
      1. Pregnancy—occurs only when a functioning trophoblast is present; more common in first pregnancies. Onset: develops after week 20 of gestation, through labor, and up to 48 hours postpartum.
      2. Coexisting conditions—diabetes, multifetal gestation, polyhydramnios, renal disease.
      3. Angiotensin gene T235.
    3. Assessment—types:
      1. Preeclampsia—mild
        1. Hypertension—systolic increase of 30 mm Hg or more over baseline; diastolic rise of 15 mm Hg or more.
        2. Proteinuria—1 gm/day.
        3. Edema—digital and periorbital; weight gain over 0.45 kg (1 lb)/wk.
      2. Preeclampsia—severe
        1. Increasing hypertension—systolic at or above 160 mm Hg or more than 50 mm Hg over baseline; diastolic, 110 mm Hg or more.
        2. Urine: proteinuria (5 gm or more in 24 hours); oliguria (400 mL or less in 24 hours).
        3. Hemoconcentration, hypoproteinemia, hypernatremia, hypovolemic condition.
        4. Nausea and vomiting.
        5. Epigastric pain—due to edema of liver capsule.
        6. Cerebral or visual disturbances (before convulsive state):
          1. Disorientation and somnolence.
          2. Severe frontal headache.
          3. Increased irritability; hyperreflexia.
          4. Visual disturbance: blurred vision, halo vision, dimness, blind spots.
        7. bulbImageHELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets).
      3. Eclampsia
        1. Tonic and clonic convulsions; coma.
        2. Renal shutdown—oliguria, anuria.
    4. Assessment—woman who is hospitalized:
      1. Vital signs (blood pressure in side-lying position, pulse, respirations)—q2–4h, while awake (if mild to moderate preeclampsia) or as necessary. Note: Record, report persistent hypertension.
      2. Fetal heart tones at time of vital signs.
      3. Deep tendon reflexes (DTRs) and clonus—to identify/monitor CNS hyperirritability.
      4. I&O—to identify diuresis. (Note: Oliguria indicates pathologic progression.)
      5. Urinalysis (clean-catch specimen) for protein, daily or after each voiding, as necessary.
      6. Signs of pathologic progression (see II. C. Assessment—types).
      7. Signs of labor, abruptio placentae (Note: high blood pressure, or a rapid drop, may initiate abruptio), DIC.
      8. Emotional status.
      9. Daily weight, amount/distribution of edema (pitting; pedal, digital, periorbital)—to identify signs of mobilization of tissue fluid, diuresis.
    5. Analysis/nursing diagnosis:
      1. Fluid volume excess: hemoconcentration, edema related to altered blood osmolarity and sodium/water retention.
      2. Altered nutrition, less than body requirements: protein deficiency related to loss through damaged renal membrane.
      3. Altered tissue perfusion related to increased peripheral resistance and vasospasm in renal, cardiovascular system.
      4. Altered urinary elimination: oliguria, anuria related to hypovolemia, vasospasm.
      5. Sensory/perceptual alterations: visual disturbances, hyperirritability related to cerebral edema, decreased oxygenation to brain.
      6. Anxiety related to symptoms, implications of pathophysiology.
      7. Diversional activity deficit related to need for reduced environmental stimuli, bedrest.
      8. Risk for injury related to seizure.
    6. Prognosis:
      1. Good—symptoms mild, respond to treatment.
      2. Poor—convulsions (number and duration); persistent coma; hyperthermia, tachycardia (≥120 beats/min); cyanosis, and liver damage.
      3. Terminal—pulmonary edema, congestive heart failure (CHF), acute renal failure, cerebral hemorrhage. The earlier the symptoms appear, the poorer the outcome for the pregnancy.
    7. Nursing care plan/implementation: Goal: health teaching.
      1. infoImageRest—frequent naps in lateral Sims' position.
      2. Immediate report of danger signs:
        1. Digital and periorbital edema.
        2. Severe headache, irritability.
        3. Visual disturbances.
        4. Epigastric pain.
      3. Do roll-over test (blood pressure while on back and lateral positions).
      4. Importance of regular prenatal visits.
      5. Monitoring own blood pressure between prenatal visits.
    8. Nursing care plan/implementation—woman who is hospitalized:
      1. Goal: reduce environmental stimuli, to minimize stimulation of hyperirritable CNS. Limit visitors and phone calls.
      2. Goal: emotional support.
        1. Encourage verbalization of anxiety, fears, concerns.
        2. Explain all procedures, seizure precautions.
      3. Goal: supportive care.
        1. Encourage bedrest—to increase tissue perfusion, promote diuresis.
        2. infoImagePosition: lateral Sims'—to reduce risk of supine hypotensive syndrome.
      4. Goal: health teaching. Rest with reduced stimuli.
      5. pillImageGoal: monitor and administer drugs as ordered.
        1. Anticonvulsants (especially magnesium sulfate).
        2. Antihypertensives.
        3. Diuretics (used rarely, and only in presence of CHF).
        4. Blood volume expanders.
      6. Goal: seizure precautions. To safeguard maternal/fetal status:
        1. Observe for signs and symptoms of impending convulsion:
          1. Frontal headache.
          2. Epigastric pain.
          3. Sharp cry.
          4. Eyes: fixed, unresponsive.
          5. Facial twitching.
        2. Emergency items (suction equipment, airway, drugs, IV fluids) immediately available.
      7. Goal: convulsion care (woman with eclampsia).
        1. Maintain patent airway; administer oxygen.
        2. Safety—padded bed rails.
        3. Reduce environmental stimuli: dim lights, quiet.
        4. Observe, report, and record:
          1. Onset and progression of convulsion.
          2. If followed by coma or incontinence.
        5. Prepare for immediate cesarean delivery; check FHR. Close observation for 48 hours postpartum, even if no further convulsions.
    9. Evaluation/outcome criteria:
      1. Woman complies with medical/nursing plan of care.
      2. Woman's symptoms respond to treatment; progression halted.
      3. Woman carries uneventful pregnancy to successful termination.