NURSING DIAGNOSIS RELATED TO OBSTETRICAL SITUATIONS

Prepared by Richard Benedict S. Roxas, RN, MD

FIRST TRIMESTER OF PREGNANCY

MEDICAL APPROACH GOALS: 1st Trimester 1. Health status of the Mother and Fetus

2. Determine the accurate AOG via LMP/UTZ

3. Initiation of Plans for Obstetrical Care

4. Identify Risk for Complication and reduce as possible

NURSING GOALS: 1ST TRIMESTER

GOAL TARGET: NORMAL FETAL GROWTH & WELL BEING (PILITERI)1. Health seeking behaviors r/t to knowledge of fetal

growth

2. Anxiety related to lack of fetal movement

3. Deficient knowledge r/t good parental care for fetal well being

DR ROXAS: Important that the MD is already confirmed the patient is Pregnant! 1st thing you must know!! Before Doing Nursing Actions.

Psychological Nursing Diagnoses• 1. Anxiety r/t unexpected pregnancy• 2. Altered Breathing Pattern r/t respiratory changes in pregnancy

• 3. Disturbed Body Image r/t weight gain with pregnancy

• 4. Deficient Knowledge r/t normal pregnancy

• 5. Imbalanced Nutrition r/t less than body requirements r/t early nausea & vomiting.

• 6. Risk for injury to the fetus r/t current lifestyle behaviors

• 7. Deficient knowledge r/t exposure to teratogens during pregnancy.

• 8. Decisional conflict r/t to desire to become pregnant

• 9. Imbalanced nutrition r/t increased demands (Dr. Roxas)

Common Psychological Changes GOALS

• 1. Accepting Pregnancy : 1st Trimester• - Cultural and Norms• 2. Accepting the Baby : 2nd Trimester

- (Quickening)

- Thinking the sex of the fetus • 3. Preparing for the baby and end of pregnancy: 3rd Trimester• - Role Playing & Fantasizing

Common Psychological Responses with Negativity Aspect• 1. Grief (Loss of previous Responsibility)• 2. Narcissism (Self Centeredness, a Change in Activity)• 3. Introversion vs. Extroversion• 4. Body Image and Boundary• 5. Stress• 6. Couvade Syndrome (Male partner affected)• 7. Emotional Lability (Mood Changes)• 8. Changes in Sexual Desire ( Depende)• 9. Changes in Expectant Family (Sibling rivalry)

PLAN TARGET: Health Teachings & Life Style Modification

1. Teratogenic Effects of Pollution, Viruses & Drugs Avoidance

2. Important Diagnostic Procedures such as Amniocentesis & UTZ studies, Karyotyping and Genetic Counseling

3. Nutritional supplementation such as Vitamin B complex, folic acid & Fe+

4. Immunizations such as Tetanus Toxoid, Measles, Chicken Pox

5. Health Related status of Maternal concerns such as Fe+ deficiency, DM, Heart Disease, Alcoholism, HIV, STD’s, Size of the Uterus and uterine surface characteristics.

6. Importance of Baseline Collection of Diagnostic Labs such as CBC, RBC, Hgb, Hgb1ac, and Pap Smear

7. Routine Prenatal Visit Schedules

Terminology Important Assessment1. Nagele’s Rule (LMP – 3 months +7 days) = EDC/EDB

2. Assessment for FETAL WELL BEING:

- Fetal Movement (Quickening) = 18-20 wks AOG to 28-

38 wks AOG

Sandovsky Method = L recumbent position after a meal

then count fetal movements 10-12

times/hour is expected result

Important: Inform if less than 10 movements/hr

1. Baby is sleeping?

2. Respiratory Depression Nutritional, Drugs etc

3. Fetal Death

• Cardiff Method: Count 1 to 10 intervals from the last fetal movement

• - Fundal Height Measurement• - This can be evident as early as 12th week after LMP• 16 WEEKS HALF WAY UMBILICUS & SYMPHYSIS• 20 WEEKS LEVEL OF THE UMBILICUS• 36 WEEKS BELOW THE ENSIFORM CARTILAGE

• - Fetal Heart Rate (Stethoscope/Doppler UTZ) – 120 to 160 beats/hr (10-11th week AOG via UTZ)

Possible Reasons for Reduced HR/Bradycardia

1. Baby is sleeping Stimulate Bell/Music

(Vibroacaustic Stimulation)

2. Drug induced Oxitocic Agents, Anesthesia etc

- Oxytocin, Methergine, Misoprostol (PGE1)

Contracts the uterus

3. Cord Compression/ Fetal Head Compression (Type 1)

4. Fetal Compromise/Death

5. Uteroplacental Insufficiency (Type2)

What are the effects of Uterine Contraction by Dr. Roxas

• 1. Smooth muscle uterus contracts compression of the collateral arteries that supplies the uterus. (MATERNAL SIDE) NET EFFECT: Reduction in the PLACENTAL BLOOD FLOW (Uteroplacental Insufficiency)

• 2. Reduce uterine blood flow Damage uterus, it can cause ischemia in the myometrium PLACENTAL SEPARATION

• 3. POSITIVE ATTRIBUTES: During Labor & Delivery (Prevents Postpartum Bleeding, Uterine Atony, Uterine Prolapse, Removal of Fetal Fecundities)

FETAL EFFECTS Decrease Uterine Space Compresses the Fetus & Cord

• 1. Reduction in the Placental Blood Flow• 2. Decrease Heart Rate (Variation or Deceleration) • a. Compression of the Fetal Head Vagal • Stimulation Vagus nerve stimulates the • Muscarinic Receptor of L side of the heart • BRADYCARDIA (AcH release)• b. Compression of the Umbilical Cord (Variation)

BIOPHYSICAL SCORING: Most Accurate for FETAL WELL BEING Assessment

• 1. Non-stress Test• 2. Placental Grading• 3. Fetal Movement (Least Reliable)• 4. Fetal Heart Tone• 5. Fetal Breathing• 6. Amniotic Fluid Determination

Ultrasonographic Importance• 1. Very critical for identification of intrauterine/extrauterine

pregnancy.

2. Correct and accurate AOG and EDB• 3. Demonstration of size, shape of fetus, placental • attachment, maturity of fetus/placenta and position.• 4. Femoral Length, Abdominal Circumference, Fetal Head • critical for IUGR• 5. Determine Hydramnios or Oligohydramnios• 6. Assisting invasive procedures, identification of clots, • foreign bodies, parasites etc.

Amniocentesis• Uses:• 1. Done 16 wks AOG for fetal cell culture• 2. Identifies cytogenetic constitution of the fetus and its

abnormalities ( TRISOMY, Erythroblastosis Fetalis example)• 3. Confirming Fetal Sex as early 15th wks AOG • 4. Lecithin/Sphingomyelin Ratio• 5. Inborn Errors of Metabolism• 6. Bilirubin Determination• 7. Alpha Fetoprotein (AFP)

• Complication:• 1. Risk for trauma & cord damage• 2. Infection• 3. Abortion or Premature Labor

Terminology Commonly used in PRENATAL CARENulligravida NEVER has been pregnant (Doesn’t mean she has no sex experience)

Virgin No sexual contact (Physical/Psychological)

Gravida + HCG test or confirmed Pregnant (Doesn’t mean the pregnancy is terminated/aborted or progress)

Nullipara Gravid mother never completed beyond abortion (never reached variability age)

Primipara Gravid mother delivered that has reached variability

Parturient Labor mother

Peurpera Postpartum Mother

Maternal Assessments• 1. Pelvic Examination (Vaginal Speculum for • Inspection)• - Cervical Characteristics• - Pap Smear Cytology• - Gonococcal Identification • - Vaginal Secretion Characteristics • (Candida/Triconomonas)

• 2. Abdominal Examination:• Leopolds Maneuver (Presenting Part)• RN: Check for any carious teeth (Dental), varicosities • (Elastic Stockings)

NURSE MONITORS THE FOLLOWING

• 1. Maternal Blood Pressure• 2. Maternal Body Weight and Percent Increase• 3. Fundal Height• 4. Vaginal Examination• 5. Urine Output• 6. Diet & Activity• 7. Sexual Intercourse • 8. Psychological Acceptance• 9. Ventilation Pattern of Breathing

Common Discomforts in PREGNANCY

• 1. Nausea & Vomiting 1st trimester• 2. Backache 2nd to 3rd Trimester• 3. Varicosities 2nd to 3rd Trimester• 4. Hemmorrhoids 3rd Trimester• 5. Heart Burn/ GERD 2nd- 3rd Trimester• 6. Pica 1st Trimester• 7. Ptyalism 1st Trimester• 8. Fatigue Any Trimester but must r/o Anemia• 9. Headache 1st- 2nd Trimester (Short Lived not continous)• 10. Leukorrhea 2nd to 3rd and Postpartum• 11. Constipation 1st trimester• 12. Breast Tenderness• 13. Palmar Erythema• 14. Muscle cramps• 15. Frequent Urination

NURSING DIAGNOSIS to Discomforts• 1. Health seeking behaviors r/t interest in • maintaining optimal health in pregnancy• 2. Anxiety r/t minor discomforts of pregnancy• 3. Risk for fluid volume deficit r/t nausea and • vomiting• 4. Risk for altered sexuality patterns r/t fear in • harming the fetus during pregnancy

5. Disturbed sleep pattern r/t frequent need to

empty bladder during at night.

Maternal Laboratory Test: For Baseline Determination• 1. Blood: CBC, Hgb, RBC indices, WBC, BLOOD

• TYPING, Antibodies for rubella, hepatitis A/B

Physiologic Anemia vs. Pathologic Anemia • 2. URINALYSIS: Glucose, Protein/Albumin, Bacteria • (Asymptomatic Bacteriuria)• Hint: Compression of the Urinary Tracts may mimic

stasis of urine.

DANGER SIGNS OF PREGNANCYDR. ROXAS: Its important that nurse recognize the following salient features to promote safety and well being of both the passenger and mother.

1. Profuse Vaginal Bleeding is different from Vaginal Spotting

2. Swelling of Face & Fingers/ EDEMA

3. Severe continuous Headache

4. Blurring of Vision

5. Abdominal Pains

6. Persistent Vomiting

7. Chills/Fever

8. Escape of Fluid in the Vagina

9. Marked changes in FETAL MOVEMENTS (Absent)

Scheduling Prenatal Check-Ups• 1st Week to 32nd Weeks AOG Every Month• 32 Weeks to 36 Weeks AOG Every 2 Weeks• 36 Weeks to Delivery Every Week• Beyond 38 weeks or Postmaturity NOW NA

Health Promotion Strategies• 1. Bathing (Avoid Bath tub and hot water ?)• 2. Dental Care (Gingival Hypertrophy is common) • 3. Perineal Hygene • 4. Breast Care• 5. Clothing (loose fitting garments)• 6. Sexual Activity• 7. Diet & Exercise• 8. Sleep• 9. Travel •