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  1. COMPLICATIONS AFFECTING FLUID-GAS TRANSPORT
    1. Placenta previa—abnormal implantation; near or over internal cervical os. Increased incidence with multiparas, multiple gestation, previous uterine surgery.
      1. Assessment:
        1. Painless, bright red vaginal bleeding (may be intermittent); absence of contractions, abdomen soft.
        2. If in labor, contractions usually normal.
        3. Boggy lower uterine segment—palpated on vaginal examination. ( Note: If placenta previa is suspected, internal examinations are contraindicated.)
        4. Medical diagnosis—procedure: sonography—to determine placental site.
      2. Analysis/nursing diagnosis:
        1. Anxiety related to bleeding, outcome.
        2. Fluid volume deficit related to excessive blood loss.
        3. Altered tissue perfusion related to blood loss.
        4. Altered urinary elimination related to hypovolemia.
        5. Fear related to fetal injury or loss.
      3. Nursing care plan/implementation:
        1. Medical management
          1. Sterile vaginal examination under double setup.
          2. Vaginal birth possible if bleeding minimal, marginal implantation; if fetal vertex is presenting so that presenting part acts as tamponade.
          3. Cesarean birth for complete previa.
        2. Nursing management. Goal: safeguard status.
      4. Evaluation/outcome criteria: (Table 4-9. Comparison of Placenta Previa and Abruptio Placenta ) (see following section on abruptio placentae).
    2. Abruptio placentae—premature separation of normally implanted placenta from uterine wall.
      1. Assessment:
        1. Sudden-onset, severe abdominal pain.
        2. Increased uterine tone—may contract unevenly, fails to relax between contractions; very tender.
        3. Shock usually more profound than expected on basis of external bleeding or internal bleeding.
        4. Medical evaluation—procedures: DIC screening (bleeding time, platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen); sonogram to see placental hemoseparation.
      2. Analysis/nursing diagnosis:
        1. Fluid volume deficit related to bleeding.
        2. Potential for fetal injury related to uteroplacental insufficiency.
        3. Fear related to unknown outcome.
      3. Potential complications:
        1. Afibrinogenemia and DIC.
        2. Couvelaire uterus—bleeding into uterine muscle.
        3. Amniotic fluid embolus.
        4. Hypovolemic shock.
        5. Renal failure.
        6. Uterine atony, hemorrhage, infection in postpartum.
      4. Nursing care plan/implementation:
        1. Medical management
          1. Control: hemorrhage, hypovolemic shock; replace blood loss.
          2. pillImage  Cesarean birth.
          3. Fibrinogen, crystalloids, blood replacement.
          4. pillImageIV heparin—by infusion pump—to reduce coagulation and fibrinolysis.
        2. Nursing management. Goal: safeguard status.
      5. Evaluation/outcome criteria:
        1. Experiences successful termination of pregnancy.
          1. Woman gives birth to viable newborn (by vaginal or cesarean method).
          2. Woman has minimal blood loss.
          3. Woman's assessment findings within normal limits.
          4. Woman retains capacity for further childbearing.
        2. No evidence of complications (anemia, hypotonia, DIC) during postpartum period.
  2. COMPLICATIONS AFFECTING COMFORT, REST, MOBILITY
    1. Polyhydramnios—amniotic fluid over 2000 mL (normal volume: 500–1200 mL).
      1. Etiology: unknown. Risk factors:
        1. Maternal diabetes.
        2. Multifetal gestation.
        3. Erythroblastosis fetalis.
        4. Preeclampsia/eclampsia.
        5. Congenital anomalies (e.g., anencephaly, upper-GI anomalies, such as esophageal atresia).
      2. Assessment:
        1. Fundal height: excessive for gestational estimate.
        2. Fetal parts: difficult to palpate, small in proportion to uterine size.
        3. Increased discomfort—due to large, heavy uterus.
        4. Increased edema in vulva and legs.
        5. Shortness of breath.
        6. GI discomfort—heartburn, constipation.
        7. Susceptibility to supine hypotensive syndrome—due to compression of inferior vena cava and descending aorta while in supine position.
        8. Medical diagnosis—procedures:
          1. Sonography—to diagnose multifetal pregnancy, gross fetal anomaly, locate placental site.
          2. Amniocentesis—to diagnose anomalies, erythroblastosis.
      3. Potential complications:
        1. Maternal respiratory impairment.
        2. Premature rupture of membranes (PROM) with prolapsed cord or amnionitis.
        3. Preterm labor.
        4. Postpartum hemorrhage—due to overdistention and uterine atony.
      4. Analysis/nursing diagnosis:
        1. Pain related to excessive size of uterus impinging on diaphragm, stomach, bladder.
        2. Impaired physical mobility related to increased lordotic curvature of back, increased weight on legs.
        3. Altered tissue perfusion related to decreased venous return from lower extremities, compression of body structures by overdistended uterus.
        4. Potential fluid volume deficit related to potential uterine atony in immediate postpartum, secondary to loss of contractility due to overdistention.
        5. Sleep pattern disturbance related to respiratory impairment and discomfort in side-lying position.
        6. Anxiety related to discomfort, potential for complications associated with congenital anomalies.
        7. Altered urinary elimination (frequency) related to pressure of overdistended uterus on bladder.
      5. Nursing care plan/implementation:
        1. Medical management
          1. Amniocentesis—remove excess fluid very slowly, to prevent abruptio placentae.
          2. Termination of pregnancy—if fetal abnormality present and woman desires.
        2. Nursing management
          1. Goal: health teaching.
            1. infoImageNeed for lateral Sims' position during resting; semi-Fowler's may alleviate respiratory embarrassment.
            2. Explain diagnostic or treatment procedures.
            3. Signs and symptoms to be reported immediately: bleeding, loss of fluid through vagina, cramping.
          2. Goal: prepare for diagnostic and/or treatment procedures.
            1. Permission for amniocentesis.
          3. Goal: emotional support for loss of pregnancy (if applicable).
            1. Encourage verbalization of feelings.
            2. Facilitate grieving: permit parents to see, hold infant; if desired, take photograph, footprints for them.
      6. Evaluation/outcome criteria:
        1. Woman complies with medical/nursing management.
        2. Woman's symptoms of respiratory impairment, etc., reduced; comfort promoted.
        3. Woman experiences normal, uncomplicated pregnancy, labor, birth, and postpartum.
  3. DIAGNOSTIC TESTS TO EVALUATE FETAL GROWTH AND WELL-BEING
    1. Daily fetal movement count (DFMC)
      1. Assesses fetal activity.
      2. Noninvasive test done by woman who is pregnant.
      3. Five to 10 movements per hour: normal activity.
      4. Five movements or less per hour may indicate fetal jeopardy or sudden change in movement pattern.
      5. Assess for fetal sleep patterns.
    2. Nonstress test (NST)
      1. Correlates fetal movement with FHR. Requires electronic monitoring.
      2. Reactive test—three accelerations of FHR to 15 beats/min above baseline FHR, lasting for 15 seconds or more, over 20-minute time period.
      3. Nonreactive test—no accelerations or acceleration less than 15 beats/min above baseline FHR. May indicate fetal jeopardy. Vibroacoustic simulator (VAS) to differentiate hypoxia from fetal sleep.
      4. Unsatisfactory test—data that cannot be interpreted or inadequate fetal activity; repeat.
    3. Contraction stress test (CST); oxytocin challenge test (OCT)
      1. Correlates fetal heart rate response to spontaneous or induced uterine contractions.
      2. Requires electronic monitoring.
      3. Indicator of uteroplacental sufficiency.
      4. Identifies pregnancies at risk for fetal compromise from uteroplacental insufficiency.
      5. Increasing doses of oxytocin are administered to stimulate uterine contractions until three in 10-minute period.
      6. Interpretation: negative results indicate absence of late decelerations with all contractions.
      7. Positive results indicate late FHR decelerations with contractions.
      8. Nipple stimulation (breast self-stimulation test) may also release enough systemic oxytocin to contract uterus to obtain CST. Instruct not to do at home.
    4. Biophysical profile (BPP)
      1. Observation by ultrasound of four variables for 30 minutes and results of nonstress testing:
        1. Fetal body movements.
        2. Fetal tone.
        3. Amniotic fluid volume.
        4. Fetal breathing movements.
      2. Variables are scored at 2 for each variable if present, score of 0 if not present; score of less than 6 is associated with perinatal mortality.
    5. Ultrasound
      1. Noninvasive procedure involving passage of high-frequency sound waves through uterus to obtain data regarding fetal growth, placental positioning, and the uterine cavity.
      2. Purpose may include:
        1. Pregnancy confirmation.
        2. Fetal viability.
        3. Estimation of fetal age.
        4. Biparietal diameter (BPD) measurement.
        5. Placenta location.
        6. Detection of fetal abnormalities.
        7. Confirmation of fetal death.
        8. Identification of multifetal gestations.
        9. Amniotic fluid index.
      3. No risk to mother with infrequent use. Fetal risk not determined on long-term basis.
    6. Amniocentesis (see Figure 4-5. Amniocentesis)
      1. Invasive procedure for amniotic fluid analysis to assess fetal lung maturity or disease; done after 14 weeks of gestation.
      2. Needle placed through abdominal-uterine wall; designated amount of fluid is withdrawn for examination.
      3. Empty bladder if gestation greater than 20 weeks.
      4. Risk of complications less than 1%. Ultrasound always precedes this procedure.
      5. Possible complications: onset of contractions; infections (probably amnionitis); placental punctures; cord puncture; bladder or fetal puncture.
      6. Advise women to observe and report the following to physician: fetal hypoactivity or hyperactivity, vaginal bleeding, vaginal discharge (clear or colored), signs of labor, signs of infection.
    7. Analysis of amniotic fluid
      1. Chromosomal studies to detect genetic aberrations.
      2. Biochemical analysis of fetal cells to detect inborn errors of metabolism.
      3. Determination of fetal lung maturity by assessing lecithin/sphingomyelin ratio.
      4. Evaluation of phospholipids; aids in determining lung maturity.
      5. Determination of creatinine levels; aids in determining fetal age. (Greater than 1.8 mg/dL indicates fetal maturity and the fetal age.)
      6. Assesses isoimmune disease.
      7. Presence of meconium may indicate fetal hypoxia.
    8. Chorionic villus sampling (CVS)
      1. Cervically invasive procedure.
      2. Advantage—results can be obtained after 10 weeks of gestation due to fast-growing fetal cells.
      3. Procedure—removal of small piece of tissue (chorionic villus) from fetal portion of placenta. Tissue reflects genetic makeup of fetus.
      4. Determines some genetic aberrations and allows for earlier decision for induced abortion (if desired) from abnormal results. Does not diagnose neural tube defects; clients who have CVS need further diagnoses with ultrasound.
      5. Protects "pregnancy privacy" because results can be obtained before the pregnancy is apparent and decisions can be made regarding abortion or continuation of gestation.
      6. Risks involve: spontaneous abortion, infection, hematoma, intrauterine death, Rh isoimmunization, and fetal limb defects, if done before 9 weeks of gestation.