GESTATIONAL DIABETES MELLITUS (GDM)

P.311
Any degree of glucose intolerance that has its onset or it is
first diagnosed during pregnancy
Risk factors: Obesity, women w/ prior GDM, glycosuria,
strong family history of DM, over 30 yrs
Symptoms may disappear a few weeks following delivery
50% of women develop DM within 5 yrs
Risks to the fetus: spontaneous abortion, infection,
hydramnios, ketoacidosis, hypoglycemia, hyperglycemia
(can cause macrosomia), hydramnios (can cause
overdistention of uterus, premature rupture of
membranes, preterm labor, hemorrhage),
preeclampsia/eclampsia, polycythemia,
hyperbilirubinemia, respiratory distress syndrome,
neural tube effects (spina bifida)

NANDAs
Altered nutrition < body requirements
Risk for fetal/mother injury
Risk for noncompliance w/ diabetic diet
Risk for infection

Treatment includes:
Restricting dietary intake of calories & carbohydrates
Educating pt on monitoring blood glucose & diet & exercise
management
Educating pt on s/s of hypoglycemia & hyperglycemia w/
careful monitoring of fetus for macrosomia
3 meals & 3 snacks (one at bedtime)
Administering insulin to the client for glucose control as
prescribed if needed
Client instruction on self-administration of insulin
Oral hypoglycemic are contraindicated due to possible
teratogenic effects
Instruct pt to perform daily kick counts to assure fetal wellbeing
Keep 2 IV lines, one with 5% dextrose solution & one with a
saline solution
Notes:
Maternal insulin requirements decrease dramatically during
labor
Calorie needs increase during lactation to 500-800 kcal above
prepregnant requirements & insulin must be adjusted
accordingly
Women should be reassessed 6 wks postpartum to determine
whether her glucose levels are normal

BLEEDING DISORDERS: SPONTANEOUS ABORTION (MISCARRIAGE)

P.339
1st & 2nd trimesters major cause of bleeding: abortion
Abortion: expulsion of fetus prior to viability (before 20
weeks gestation, weight < 500g)> Can be spontaneous
(often called miscarriage) or induced
1st half of pregnancy causes of bleeding: ectopic
pregnancy & gestational trophoblastic disease
2nd half of pregnancy causes of bleeding: placenta previa &
abruption placenta

Spontaneous abortions categories:

- Threatened: Unexplained bleeding, cramping &

backache. Cervix closed. Bleeding may persist for days.
May be followed by partial or complete expulsion of
embryo or fetus, placenta & membranes. products of

conception.

- Imminent/Inevitable: Bleeding & cramping increase.

Internal cervical os dilates. Membranes may rupture.

- Complete: All the products of conception are expelled.

Cervix closed.

- Incomplete: Placenta is retained. Internal cervical os

dilated.

- Missed: Fetus dies is uterus but is not expelled. No

bleeding or cramping occurs. Uterine growth ceases,

breast changes regress, & woman may report brown

vaginal discharge. Cervix closed.

Note: Spotting is relatively common during pregnancy &

usually occurs following sexual intercourse or exercise
because of trauma to the highly vascular cervix. However,
women are advised to report any spotting or bleeding that
occurs during pregnancy so that it can be evaluated
Initial Assessment of bleeding:
Monitor BP frequently
Observe pt for behaviors indicative of shock (pallor, clammy
skin, perspiration, dyspnea, restlessness)
Count & weigh pads to assess amount of bleeding over a
given time period; save clots/tissues expelled
Assess fetal heart tones w/ Doppler if > 12 wks
Prepare for IV therapy
Have O2 available
Collect & organize data, including antepartal history, onset of
bleeding episode, laboratory studies
Notify physician or nurse-midwife
Obtain order to type & crossmatch for blood
Assess coping mechanisms of the woman in crisis. She may
feel quilty
Give emotional support, explain clearly procedures, and
communicate her status to family. Prepare woman for

- Recurrent/Habitual: Occurs consecutively in 3 or more

pregnancies
- Septic: Infection is present. Malodorous discharge.

possible fetal loss.

Assess familys response to situation

NANDAs
Acute pain r/t abdominal cramping secondary to
threatened abortion
Anticipatory grieving r/t expected loss of unborn child

Nursing Interventions for bleeding/spontaneous abortion:

Perform a pregnancy test
Assist with an ultrasound
Bed rest, abstinence from sex & sedation
Administering analgesics is cramping is severe
Administering antibiotics is septic abortion
IV therapy or blood transfusions to replace fluids, & dilation &
curettage (D&C) or suction evacuation (D&E) is performed
to remove remainder of the products of conception.
If woman is Rh- & not sensitized, RhoGAM is given within 72
hrs
Give oxytocin (Pitocin) as prescribed to expulse products of
conception

ECTOPIC PREGNANCY
P.340
Implantation of fertilized ovum in a site other than
endometrial lining of the uterus
Occurs when the fertilized ovum is prevented or slowed in
its passage through the tube & thus implants before it
reaches the uterus, usually in the fallopian tube, which
can result in a tubal rupture causing a fatal hemorrhage
Risk factors: PID, contraceptive IUD, congenital anomalies
of tube, endometriosis, previous tubal surgery
Initially symptoms of pregnancy
hCG present in blood & urine
Chorionic villi grow into the tube wall or implantation site
Rupture & bleeding into abdominal wall occurs
S/S: sharp unilateral pain, syncope, referred shoulder pain,
lower abdominal pain, vaginal bleeding, adnexal
tenderness.
NANDAs
Acute pain
Anticipatory grieving

Nursing Interventions:
Take VS, check skin color & urine output
Determine level of pain
Monitor for signs of shock
Methotrexate injection IM to inhibit cell division &
enlargement of the embryo. Prevents rupture of fallopian
tube in order to preserve it if future pregnancy is desired
Replacement of fluid loss & maintenance of electrolyte
imbalances
Provide pt education & psychological support
Prepare client for surgery & postoperative nursing care
Salpingostomy: via laparoscope. Incision made lengthwise
& the products of conception are gently removed. Surgical
incision is left open & allowed to close naturally. Possible
before rupture.
Salpingectomy (removal of the tube): via laparoscope. If the
tube is ruptured or if future childbearing is not an issue.
Note: Rh- women nonsensitized women are given Rhimmune globulin to prevent sensitization

GESTATIONAL TROPHOBLASTIC DISEASE / HYDATIDIFORM MOLE

P. 342
Pathologic proliferation of the trophoblastic cells
It includes hydatidiform mole, invasive mole
(chorioadenmoma destruens) & choriocarcinoma (form
of cancer)

Procedures:
Ultrasound
Suction curettage to aspirate & evacuate the mole
Follow up hCG for 1 year (^hCG may indicate
choriocarcinoma)
Chemotherapy if choriocarcinoma (Methotrexate)

Hydatidiform mole (molar pregnancy) is a disease in

which:
- Abnormal developments of the placenta occurs resulting in Nursing Interventions:
hydropic vesicles (fluid-filled, grapelike cluster)
Monitor for s/s of trophoblastic disease: rapid uterine growth,
- Trophoblastic tissue proliferates
vaginal bleeding accompanied by discharge, excessive
Molar pregnancies are classified in:

- Complete: develops from an ovum containing no maternal

genetic material, an empty egg, which is fertilized by a
normal sperm
- Partial: A normal ovum w/ 23 chromosomes is fertilized by
two sperm or by a sperm that failed to undergo under
the first meiotic division & therefore contains 46
chromosomes
S/S: vaginal bleeding, elevated serum hCG, anemia, no
fetal heart tones & no fetal movement, gestational HTN
before 24 wks, uterine enlargement

vomiting (hyperemesis gravidarum) due to excessive hCG

levels, symptoms of pregnancy-induced hypertension (HTN,
edema, proteinuria)
Measurement of fundal height
Check VS
Type cross & match
Administer oxytocin as ordered to keep uterus contracted &
prevent hemorrhage
Advise pt to avoid pregnancy for 1 year
Give immune globulin (RhoGAM) to any Rh- woman
Give emotional support, explain procedures

NANDAs
Fear r/t possible development of choriocarcinoma
Anticipatory grieving r/t loss of the pregnancy

ABRUPTIO PLACENTAE
P. 513
Premature separation of a normally implanted placenta
from the uterine wall
Considered catastrophic event because of the severity of
the resulting hemorrhage
Marginal: placenta separates at its edges, the blood
passes between the fetal membranes & the uterine wall,
blood escapes vaginally
Central: placenta separates centrally, blood trapped
between placenta & uterine wall. Concealed bleeding
Complete: Total separation of placenta. Massive vaginal
bleeding

Management:
Place client on bed rest
Refrain from vaginal exams (may exacerbate bleeding)
Assess cardiovascular status of mother frequently - VS every
15 min, skin color & pulse quality hourly, measure CVP
hourly as ordered
Monitor fetus & uterine activity electronically resting tone&
fetal status every 15 min
Develop a plan for the birth of the fetus (prepare for cesarean
as needed) if fetus is at term, vaginal delivery is preferred.
Monitor for signs of DIC
Maintain 2 large bore IV sites fluids & blood products as
ordered
S/S: sudden onset of intense localized uterine pain, vaginal
bleeding, board-like abdomen that is tender, fetal distress Monitor I & O & urine Specific Gravity
Measure abdominal girth as ordered
Maternal Implications: intrapartum hemorrhage, DIC,
hypofibrinogenemia (coagulation factors decreased), fatal Review & evaluate diagnostic tests Hgb, Hct, coagulation
status
hemorrhagic shock, renal failure, vascular spasm,
Neonatal resuscitation as ordered
intravascular clotting
Provide information & emotional support
Fetal-Neonatal Implications: sequelae of prematurity,
hypoxia, anemia, brain damage, fetal demise

PLACENTA PREVIA
P. 516
Placenta is abnormally implanted in the lower uterine
segment rather than the upper portion of the uterus.
This implantation may be on a portion of the lower
segment or over the internal cervical os
Total internal os completely covered
Partial internal os is partially covered
Marginal edge of os is covered
Low-lying placenta implanted in lower segment in
proximity to os
Major complications: maternal hemorrhage, fetal
prematurity, death
S/S: painless, bright-red vaginal bleeding

Interventions:
Bed rest with bathroom privileges as long as the woman is
not bleeding
NO VAGINAL EXAMINATIONS
Monitor blood loss, pain, uterine contractility
Evaluating FHR with an external fetal monitor
Monitoring maternal vital signs every 5 min during active
hemorrhage & every 15 min in the absence of hemorrhage
Give O2 as ordered/needed
Complete laboratory evaluation Hgb, Hct, Rh factor,
urinalysis
Maintain large bore IV access for blood transfusion
IV fluids (lactated Ringers solution)

NANDAs
Fluid volume deficit
Anxiety
Impaired gas exchange

2 U of crossmatched blood available for transfusion

Provide information & emotional support
Verify familys ability to cope with anxiety of unknown
outcome

INCOMPETENT CERVIX
P. 343
Nursing Interventions:
Bed rest, hydration (to promote relaxed uterus & inhibit
uterine contractions), antibiotics, anti-inflammatory,
progesterone supplement
Monitor/Teach for premature labor & premature rupture of
membranes& to notify healthcare provider
VS
Measure of s/s of incompetent cervix
Pelvic pressure
Assess vaginal discharge pink stained bleeding
Surgical Procedures:
Shirodkar procedure (cerclage) or a modification of it by Uterine contractions, ROM, infection
McDonald: reinforces the weakened cervix by encircling Educate client to refrain from sex, heavy lifting & prolonged
standing
it at the level of the internal os w/ suture material. Purse Administer tocolytics prophylactically to inhibit uterine
string suture placed in cervix. Once suture is placed, a
contractions
cesarean birth may be planned (to prevent repeating
procedure in future pregnancies) or the suture may be
cut at term & vaginal birth permitted
Premature dilatation of the cervix, usually in the 4th or 5th
month
Associated w/ repeated 2nd trimester abortions
Causes: cervical trauma, infection, congenital
cervical/uterine anomalies, ^uterine volume (as in
multiple gestation)
Diagnosis: based on positive history of repeated
painless/bloodless 2nd trimester abortions

HYPEREMESIS GRAVIDARUM
P. 344

Excessive nausea & vomiting during pregnancy

Rare, cause unclear

^ levels of hCG may play a role

Severe cases cause dehydration, F & E imbalances,

alkalosis, metabolic acidosis if untreated, severe K+ loss,

decreased urinary output, hypovolemia, hypotension,

tachycardia, ^ Hct & BUN, liver dysfunction (enzymes

elevated)
S/S: excessive vomiting for prolonged periods,
dehydration, weight loss, decreased BP, increased pulse,

poor skin turgor

Interventions:
NPO until dehydration corrected (48 hrs)
IV fluids to correct dehydration & F & E imbalance (KCl)
Administer antiemetics as prescribed
Improve nutritional status: Vitamin B6 & B12 & TPN (if no
improvement)
Advance to clear liquids when vomiting stops
Advance diet as tolerated with frequent, small meals, avoid
greasy & highly seasoned foods, increase intake of K & Mg
Stress-reduction techniques, relaxed environment
Maintain oral hygiene
Monitoring weight

NANDAS
Imbalanced nutrition < body requirements
Fear

PREMATURE RUPTURE OF MEMBRANES (PROM)

P.345
PROM Spontaneous rupture of the membranes prior to the Interventions:
Start antibiotic therapy immediately if maternal signs of
onset of labor
PPROM (Preterm premature rupture of membranes: is the
infection are evident
rupture of membranes occurring after 20 wks but before On admission to nursery, newborn is assessed for sepsis &
37 wks of gestation
placed on antibiotics

Infection is the major risk of PROM & PPROM for

both the client & fetus because once the amniotic
membranes have ruptured, micro-organisms can
ascend from the vagina into the amniotic sac
Associated with: infection, previous history of PROM,
hydramnios, multiple pregnancy, UTI, amniocentesis,
placenta previa, abruption placentae, trauma,
incompetent cervix, bleeding during pregnancy,
anomalies
Risk for abruption placenta
Maternal risk of infection ^
Fetal-Newborn risk: respiratory distress syndrome, fetal
sepsis, malpresentation & prolapsed of umbilical cord
Diagnosis
Sterile speculum to detect amniotic fluid in vagina
Nitrazine paper turns blue
Microscopic examination Ferning Test
DONT DO Digital vaginal examination - increases risk of
infection

Management of PROM in the absence of infection & gestation

< 37 wks is usually conservative: hospitalization, bed rest,
CBC, C-reactive protein & urinalysis, continuous electronic
fetal monitoring, regular NST or biophysical profiles, VS
every 4 hrs, regular laboratory evaluations, vaginal
examination avoided, fetal lung maturity studies,
administration of surfactant, administration of maternal
corticosteroids
Note: maternal corticosteroid administration to promote fetal
lung maturity & prevent respiratory distress syndrome
remains controversial
If patient discharged, give instructions: To continue bed rest
w/bathroom privileges, monitor temperature & pulse every
4 hrs, keep fetal movement chart, have weekly NST, abstain
from intercourse; & to call physician & return to hospital if
she has fever/uterine tenderness or contractions/ increased
leakage of fluids/decreased fetal movement/foul-smelling
vaginal discharge

PRETERM LABOR (PTL)

P.347
Labor that occurs 20-37 wks gestation
Risk factors: UTI or vaginal infections, previous preterm
birth, multifetal pregnancy, hydramnios (excessive
amniotic fluid), age <17 or >35, low socioeconomic
status, smoking, substance abuse, domestic violence,
history of multiple miscarriages/abortions, DM, HTN,
incompetent cervix, placenta previa, abruption
placentae, uterine abnormalities, etc..
Indications of PTL:
Documented uterine contractions: 4 in 20 min or 8 in 1 hr
Documented cervical change: dilatation > 1cm
Cervical effacement of 80% or more
Fetal-neonatal implications:
Morbidity & mortality (Respiratory distress syndrome)
Increased risk of trauma during birth
Maturational deficiencies

Selfcare Measures to prevent PTL: rest 2-3 times a

day on left side, drink water & juice fruit, avoid
caffeine drinks, avoid lifting, contact healthcare
provider if s/s of PTL, sexual activity may need to
be modified/ avoided.

Interventions:
Assessment of cervicovaginal fibronectin ( protein of
amniotic fluid found in vaginal secretions when fetal
membrane is lost)
Assessment of cervical length via ultrasound (if shorter than
expected, positive signs of PTL)
Assess signs of vaginal infection
Obtain history of previous preterm birth
Assess laboratory studies (CBC, C-reactive protein, vaginal
cultures, urine cultures)
Mother is asked to lie on her side to ^ profusion
IV infusion to promote maternal hydration
Tocolysis: medications used in an attempt to stop labor (Badrenergic agonists, Mg Sulfate, prostaglandin synthetase
inhibitors, Ca channel blockers
Identify woman at risk
Assess progress of labor
Teach mother to recognize onset of labor (low backache,
pressure in pelvis & cramping; increase/change/or blood
vaginal discharge; regular uterine contractions with a
frequency of every 10 min lasting 1 hr or longer, GI
cramping sometimes w/ diarrhea, premature rupture of
membranes)
Management of a client who is in preterm labor
includes focusing on stopping uterine contractions by
restricting activity, ensuring hydration, identifying &
treating an infection, administering tocolytic
medications, & assuring fetal well-being by
accelerating fetal lung maturity with glucocorticoids

HYPERTENSION IN PREGNANCY, PREECLAMPSIA & ECLAMPSIA

P. 352
Management:
BP begins to rise after 20 weeks of gestation
Decreased level of vasodilators & increase level of
Home care of Mild preeclampsia: Woman monitors her BP,
vasoconstrictors
weight, urine protein daily. Remote NSTs performed daily or
Preeclampsia is the most common hypertensive disorder
biweekly. Advise to report any changes.
Hospital care of mild preeclampsia: Bed rest primarily on
in pregnancy. It is defined as gestational hypertension
with a BP of 140/90 (mild) or 160/110 (severe) or higher
left side to decrease pressure on vena cava, moderate-high
on 2 occasions at least 6 hrs apart accompanied by
protein diet.
proteinuria (5g in a 24 hr urine collection) & edema.
Tests to evaluate fetus status:
Dipstick urine protein 31-41 in 2 random samples
Fetal movement record
Nonstress test
obtained 4 hrs apart. It most often occurs in the last 10
Ultrasonography every 3-4 wks for serial
wks of gestation, during labor, or in the first 48 hrs after
determination of growth
childbirth. Most common in women < 17 yrs or > 35.
Biophysical profile
Eclampsia is the most severe form of preeclampsia,
Serum Creatinine
characterized by generalized seizures or coma. May
Amniocentesis to determine fetal lung maturity
occur antepartum, intrapartum or postpartum
Severe preeclampsia: Birth may be treatment of choice for
both mother & fetus, even if fetus is immature. Other
Maternal Risks: Hyperreflexia, headache, seizures, renal
include: bed rest, diet (high protein, moderate Na+),
failure, abruption placentae, DIC, ruptured liver, PE, HELLP
anticonvulsants (Mg Sulfate treatment of choice), F & E
syndrome
replacement, corticosteroids, antihypertensives
Fetal-Neonatal Risks: Small for gestational age, premature, Eclampsia: An eclamptic seizure requires immediate,
Hypermagnesemia (Mg Sulfate administration to mother),
effective treatment. Bolus of 4-6 g Mg Sulfate is given IV
increased morbidity & mortality
over 5 min. Sedatives (Diazepam), Dilantin (for prevention),
Diuretics (Lasix) for pulmonary edema, Digitalis (for
Assessment:
circulatory failure). I & O monitored hourly. Woman is
BP every 1-4 hrs, Temperature every 4 hrs, pulse &
observed for signs of labor & vaginal bleeding & abdominal
respirations
rigidity which may indicate abruption placentae. While she
Fetal heart rate
is comatose, she is positioned on her left side / the side rails
Urinary output: 700 mL or greater in 24 hrs, or at least 30
up.
mL/hr
Intrapartal Management: Labor inducement with IV
Urine protein: 3+ or 4+ indicates loss of 5g or more of
oxytocin if evidence of fetal maturity & cervical readiness.
protein in 24 hrs
Assessment for signs of worsening preeclampsia. Analgesics
Urine specific gravity hourly
may be used for discomfort or epidural block. O2 is
Weight: weigh the woman daily at the same time, she
administered.
should be wearing the same robe or gown & slippers
Postpartal Management: Woman with preeclampsia
Pulmonary edema: observe for coughing, auscultate lungs
usually improves rapidly after giving birth, although seizures
for moist respirations
can still occur during first 48 hrs postpartum. If hypertension
Deep tendon reflexes & clonus: for signs of hyperreflexia
is severe, woman may continue to receive antihypertensives
Placental separation: for vaginal bleeding & uterine rigidity
or Mg sulfate.
Headache
Visual disturbances: blurring or any changes
Extra interventions:
Epigastric pain

Explain medical therapy & its purpose & offer honest

Laboratory blood tests
information
Level of consciousness, emotional response & level of
Maintain quiet, low-stimulus environment
understanding
Avoid unlimited phone calls
Assess for Mg sulfate toxicity: if suspected, immediately
Keep woman on left side as much as possible
discontinue infusion & administer calcium gluconate
Explain to family the reason of the seizures

HELLP SYNDROME
P. 352
H hemolysis (anemia & jaundice)

Management:

EL elevated liver enzymes (epigastric pain, nausea,

vomiting, flu-like symptoms))
LP low platelet count(thrombocytopenia, abnormal
bleeding or clotting time, bleeding gums, petechiae, DIC)

BP measurements
Platelet transfusions if <20,000/mm3.
Assess fetus using NST & biophysical profile
Observe for edema

Sometimes associated with severe preeclampsia

Variant of gestational hypertension in which hematologic
conditions coexist with severe preeclampsia involving
hepatic dysfunction
Increased risk for: placenta abruption, acute renal failure,
pulmonary edema, hepatic hematoma, ruptured liver,
DIC, PE, fetal/maternal death

Rh ALLOMMUNIZATION
P. 361
Sensitization
Most often occurs when an Rh- woman carries an Rh+
fetus either to term or to termination by miscarriage or
induced abortion
It can also occurs if an Rh- woman receives an Rh+ blood
transfusion
RBCs from fetus invade the maternal circulation, thereby
stimulating the production of Rh antibodies.
Because this transfer occurs at birth, first child is not
affected
In subsequent pregnancies, however, Rh antibodies cross
the placenta & enter the fetal circulation, causing severe
hemolysis
Destruction of fetal RBCs cause anemia in the fetus

Fetal-Neonatal risks: anemia, hemolytic syndrome

(erhythroblastosis fetalis), fetal edema (hydrops fetalis),
CHF, marked jaundice

Screening for Rh Incompatibiliy & Sensitization:

Take a history of previous sensitization, abortions, blood
transfusions, or children who developed jaundice or anemia
during the newborn period
Identify Rh- woman by asking if she knows her blood type &
Rh factor.
Ask if she had ever received Rh immune globulin, if she has
any previous pregnancies & their outcomes, & if she knows
her partners Rh factor
Identify other medical complications such as diabetes,
infections or hypertension
Antibody screen (Indirect Coombs test done on the mothers
Note: Rh immune globulin (RhoGAM) administration
blood to measure # of Rh+ antibodies & Direct Coombs
prevents maternal sensitization. It provides passive
test done on the infants blood to detect antibody-coated
antibody protection against Rh antigens. This tricks the
Rh+ RBCs)
body, which does not then produce antibodies of its own. Give injection of 300 mcg Rh immune globulin to pregnant
An Rh- mother who has no antibody titer (indirect Coombs
Rh- women who have no antibody titer, at 28wks
test negative, nonsensitized) & has given birth to an Rh+
gestational age, to mothers whose babys father is Rh+,
fetus (Direct Coombs test negative) is given an injection
after each abortion & within 72 hrs postpartum,
of Rh immune globulin within 72 hrs of childbirth so she
amniocentesis & placenta previa, before invasive
does not have time to produce antibodies to fetal cells that
procedures that may cause bleeding
entered her bloodstream when the placenta separated

ABO INCOMPATIBILITY
P.364
Management:
Type O mother incompatibility with a type A,B, or AB fetus
Anti-A & Anti-B antibodies occurs naturally because
Assess for potential for ABO incompatibility type O mother &
women are naturally exposed to the A & B antigens
type A or B father
Following birth, assess newborn carefully for development of
through the foods they eat & through exposure to
infection.
hyperbilirubinemia & treat it with phototherapy
Once they become pregnant, the maternal serum Anti-A &
Anti-B antibodies cross the placenta & produce
hemolysis of the fetal RBCs
Unlike Rh incompatibility, 1st infant is often involved

 Antepartal treatment is never warranted