REIMBURSEMENT ISSUES

1

Chapter 28 Care of the High-Risk Mother,
Newborn, and Family with Special Needs
2
Complications of Pregnancy

• A high-risk pregnancy is one in which the life or
  health of the mother or infant is jeopardized by
  a disorder coincidental with or unique to
  pregnancy.
• A better understanding of human reproduction has
  greatly reduced morbidity and mortality.
• Understanding the high-risk patient will allow
  the nurse to provide individualized therapeutic
  nursing interventions.

3
Complications of Pregnancy

• Hyperemesis Gravidarum
• Etiology
• Vomiting during pregnancy that becomes excessive
  to cause electrolyte, metabolic, and nutritional
  imbalances
• Exact cause unknown possibly hormones (HCA) or
  psychogenic factors
• Clinical Manifestations
• Vomiting and retching that far exceed those seen
  with the usual morning sickness

4
Complications of Pregnancy

• Hyperemesis Gravidarum (continued)
• Assessment
• Frequency, amount, and character of emesis
• Fluid intake and output (IO)
• Skin turgor and mucous membranes
• Psychosocial assessment
• Fetal status

5
Complications of Pregnancy

• Hyperemesis Gravidarum (continued)
• Medical Management
• Intravenous feeding is instituted.
• Solid intake is restricted until vomiting stops.
• Bland solids such as toast and crackers are
  introduced slowly.
• In severe cases, TPN may be required.

6
Complications of Pregnancy

• Hyperemesis Gravidarum (continued)
• Nursing Interventions and Patient Teaching
• Oral hygiene
• Emotional support
• Patient teaching
• Provide dietary consult.
• Educate patient regarding condition.
• Teach patient how to assist with her treatment.
• Provide referrals for follow-up treatment.

7
Complications of Pregnancy

• Multifetal Pregnancy
• Etiology
• Twins are classified as monozygotic (originate
  from one fertilized ovum) or diazygotic (two
  separate ova fertilized at the same time).
• Pathophysiology
• Maternal and fetal risks are increased during
  multiple pregnancy.
• Because of overdistention of the uterus, twins
  usually are delivered before term and may have
  extended hospital stays.

8
Figure 28-1
(From Hamilton, P.M. 1989. Basic maternity
nursing. 6th ed.. St. Louis Mosby.)
Multiple pregnancies. A, Identical twins. B,
Fraternal twins.
9
Complications of Pregnancy

• Multifetal Pregnancy (continued)
• Clinical Manifestations
• Uterine enlargement exceeds the norm.
• Abdominal palpation is done using Leopolds
  maneuvers.
• There is auscultation of two distinct heart
  tones.
• Ultrasonography will reveal the presence of
  multiple fetuses.

10
Complications of Pregnancy

• Hydatidiform Mole (Molar Pregnancy)
• A gestational trophoblastic disease
• May be complete mole or partial mole
• Etiology
• Unknown, although an ovular defect possible
• Women at higher risk are those who have undergone
  ovulation stimulation with clomiphene and those
  who are in their early teens or older than 40
  years.

11
Complications of Pregnancy

• Hydatidiform Mole (Molar Pregnancy) (continued)
• Pathophysiology
• This is fertilization of an egg whose nucleus has
  been lost of inactivated.
• The fluid-filled vesicles grow rapidly, causing
  the uterus to be larger than expected.
• Usually there is no fetus, placenta, amniotic
  membranes, or fluid.

12
Complications of Pregnancy

• Hydatidiform Mole (Molar Pregnancy) (continued)
• Clinical Manifestations
• Early stage cannot be distinguished from normal
  pregnancy.
• Later, vaginal bleeding occurs.
• Uterus may be significantly larger than expected.
• Passages of vesicles may occur around 16 weeks of
  gestation.
• There is no fetal movement, fetal heart rate, or
  palpable fetal parts.

13
Complications of Pregnancy

• Hydatidiform Mole (Molar Pregnancy) (continued)
• Diagnostic Measures
• Ultrasonography, amniography, and measurement of
  HCA level
• Medical Management
• Most moles abort spontaneously.
• Suction curettage
• Induction of labor
• Nursing Interventions
• Provide information and support.

14
Complications of Pregnancy

• Ectopic Pregnancy
• Etiology
• Implantation occurs somewhere other than within
  the uterus.
• Most common site is within the fallopian tube
  other possible sites are the abdominal cavity,
  ovary, ligaments, and cervix.
• The progress of the fertilized ovum through the
  fallopian tube is slowed or obstructed.

15
Figure 28-2
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
Sites of implantation of ectopic pregnancies in
order of frequency of occurrence.
16
Figure 28-3
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
Ectopic pregnancy, abdominal.
17
Complications of Pregnancy

• Ectopic Pregnancy (continued)
• Pathophysiology
• Rupture of the fallopian tube and bleeding into
  the abdominal cavity
• Clinical Manifestations
• Slight vaginal bleeding
• Signs of peritoneal irritation sharp, localized,
  one-sided pain or pain referred to the shoulder
• Abdomen may be rigid and tender.

18
Complications of Pregnancy

• Ectopic Pregnancy (continued)
• Medical Management
• Rapid surgical treatment salpingectomy or
  salpingostomy
• Blood replacement
• Methotrexate administration for unruptured
  ectopic pregnancy

19
Complications of Pregnancy

• Spontaneous Abortion
• Etiology
• Termination of pregnancy before the age of
  viability
• May be caused by abnormal embryonic development,
  chromosomal defects, inheritable disorders,
  advancing maternal age and parity, chronic
  infections, chronic debilitating diseases, poor
  nutrition, and recreational drug use
• Pathophysiology
• Depends on the specific cause

20
Complications of Pregnancy

• Spontaneous Abortion (continued)
• Clinical Manifestations
• Threatened bleeding and cramping
• Inevitable bleeding increases and cervix dilates
• Complete all products of conception expelled
• Incomplete some, but not all, products of
  conception are expelled
• Missed fetus dies and growth ceases, but fetus
  remains in utero
• Septic malodorous bleeding, fever, and cramping
• Habitual spontaneously aborted in three or more
  consecutive pregnancies

21
Complications of Pregnancy

• Spontaneous Abortion (continued)
• Medical Management
• IV fluids may be administered.
• Replacement of blood loss
• Dilation and curettage (DC)
• Dilation and evacuation (DE)
• Patient Teaching
• Need for rest
• Iron supplementation, if blood loss occurred

22
Complications of Pregnancy

• Incompetent Cervix
• Passive and painless dilation of the cervix
  during the second trimester
• Etiology
• History of previous cervical lacerations during
  childbirth
• Excessive dilation for curettage or biopsy
• Patients mothers ingestion of
  diethylstilbestrol during pregnancy
• Congenitally short cervix or cervical or uterine
  anomalies

23
Complications of Pregnancy

• Incompetent Cervix (continued)
• Medical Management
• Prophylactic cerclage at 10 to 14 weeks of
  gestation
• Refrain from intercourse, prolonged standing, and
  heavy lifting.
• After cerclage, monitor for contractions,
  symptoms of rupture of membranes, and infection.
• Provide support.

24
Figure 28-4
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
A, Cerclage correction, recurrent premature
dilation of cervix. B, Cross section, closed
internal os.
25
Bleeding Disorders

• Placenta Previa
• Etiology
• Placenta implants in the lower uterine segment.
• Described by the degree to which the placenta
  covers the internal cervical os.
• Complete with total coverage
• Partial with incomplete coverage
• Marginal when only an edge approaches the
  internal os
• Cause is unknown.

26
Figure 28-5
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
Types of placenta previa. A, Complete (total). B,
Incomplete (partial). C, Marginal (low lying).
27
Bleeding Disorders

• Placenta Previa (continued)
• Pathophysiology
• In the last trimester of pregnancy, uterine size
  increases and the cervix begins to dilate and
  efface.
• As the placenta separates from the cervix,
  sinuses at the site begin to bleed.
• Clinical Manifestations
• Painless, bright-red, vaginal bleeding occurs.
• Bleeding may be intermittent or occurs in gushes.

28
Bleeding Disorders

• Placenta Previa (continued)
• Medical Management
• Cesarean birth is usually the treatment of
  choice.
• Following the diagnosis, the patient should
  remain in the hospital under close supervision.
• Blood, typed and cross-matched, is usually
  available for emergency use.

29
Bleeding Disorders

• Abruptio Placentae
• Etiology
• This is premature separation of the normally
  implanted placenta fro the uterine wall.
• It generally occurs late in pregnancy, frequently
  during labor.
• Cause is unknown.
• Predisposing factors include trauma, chronic
  hypertension, and pregnancy-induced hypertension.
• Blunt external abdominal trauma may also be a
  cause.

30
Bleeding Disorders

• Abruptio Placentae (continued)
• Pathophysiology
• When the placenta separates from the uterine
  wall, bleeding occurs from the uterine sinuses.
• The most common classification of placental
  abruption is according to type and severity.
• Grade I, grade II, or grade III
• Clinical Manifestations
• Sudden, severe pain is accompanied by uterine
  rigidity.

31
Bleeding Disorders

• Abruptio Placentae (continued)
• Assessment
• When vaginal bleeding occurs during pregnancy,
  the nurse should observe the following
• Duration, amount, color, and characteristics of
  the bleeding
• Vital signs
• Pain
• Fetal heart rate
• Emotional response

32
Bleeding Disorders

• Abruptio Placentae (continued)
• Diagnostic Tests
• Hemoglobin and hematocrit
• Blood typing and cross-matching
• Hormone studies
• Ultrasound scans
• Medical Management
• Cesarean delivery
• Hysterectomy may be necessary to control bleeding

33
Bleeding Disorders

• Abruptio Placentae (continued)
• Nursing Interventions
• Oxygen should be available.
• IV or blood replacement may be required.
• Support patient and family.
• Remain with the woman as much as possible.
• Prepare her for possible loss.

34
Bleeding Disorders

• Disseminated Intravascular Coagulation
• Etiology
• This is a potentially life-threatening disorder
  that results from alterations in the normal
  clotting mechanism.
• It may be seen with abruptio placentae,
  incomplete abortion, hypertensive disease, or
  infectious process.

35
Bleeding Disorders

• Disseminated Intravascular Coagulation
  (continued)
• Pathophysiology
• As a result of stressing the coagulation
  processes in an attempt to prevent excessive
  blood loss, the body produces excessive amounts
  of thrombin, stimulating the conversion of
  fibrinogen to fibrin.
• Elevated fibrin levels result in multiple small
  clots forming in small blood vessels, which may
  lead to obstruction of vessels, ischemia, and
  damage to vital organs.
• This clot formation also traps platelets and can
  result in generalized hemorrhage.

36
Bleeding Disorders

• Disseminated Intravascular Coagulation
  (continued)
• Assessment
• All women with complications that may result in
  DIC should be observed closely for signs of
  bleeding.
• Diagnostic Tests
• Hemoglobin and hematocrit
• Clotting factor studies

37
Bleeding Disorders

• Disseminated Intravascular Coagulation
  (continued)
• Medical Management
• IV administration of fibrinogen, blood, and other
  substances that will help restore normal clotting
  mechanisms
• May include heparin via continuous infusion pump
  and oxygen therapy
• Delivery of the fetus should occur quickly.
• Nursing Interventions
• Support medical treatment report signs and
  symptoms promptly.

38
Bleeding Disorders

• Postpartum Hemorrhage
• Etiology
• Early postpartum hemorrhage is blood loss greater
  than 500 ml in the first 24 hours after delivery.
• Late postpartum hemorrhage occurs after the first
  24 hours.
• The most common causes of early hemorrhage are
  uterine atony, retained placenta or fragments of
  the placenta, and lacerations of the perineum.

39
Bleeding Disorders

• Postpartum Hemorrhage (continued)
• Pathophysiology
• The major action that prevents hemorrhage is
  contraction of the uterus, which seals off the
  uterine sinuses.
• Hemorrhage results when loss of tone or tissue
  remaining in the cavity prevents adequate
  contraction of the uterus.
• Assessment
• Uterine contraction and lochia bleeding, color,
  amount and source vital signs

40
Bleeding Disorders

• Postpartum Hemorrhage (continued)
• Medical Management
• Retained placental fragments dilation and
  curettage (DC)
• Perineal lacerations repair of lacerations
• Uterine atony fundal massage keep bladder
  empty and administer oxytocics
• Failure to control bleeding may necessitate a
  hysterectomy.

41
Bleeding Disorders

• Postpartum Hemorrhage (continued)
• Nursing Interventions
• Fundal massage
• Monitor vital signs.
• Prepare for surgery if indicated.
• Administer oxytocin or other drugs, as ordered.
• Patient Teaching
• Teach patient how to perform the postpartum
  checks of the fundus and lochia.
• Call physician if bleeding is excessive.

42
Bleeding Disorders

• Pregnancy-Induced Hypertension
• Etiology
• A disease encountered during pregnancy or early
  in the puerperium, characterized by increasing
  hypertension, albuminaria, and generalized edema
• Includes preeclampsia and eclampsia
• Cause unknown
• Increased risk for multiple pregnancy, diabetes
  mellitus, or family history of PIH

43
Bleeding Disorders

• Pregnancy-Induced Hypertension (continued)
• Pathophysiology
• Complex hormonal and vascular changes occur.
• These lead to increased blood pressure, decreased
  placental perfusion, decreased renal perfusion,
  altered glomerular filtration rate, and fluid and
  electrolyte imbalance.
• Clinical Manifestations
• Edema, hypertension, and proteinuria

44
Bleeding Disorders

• Pregnancy-Induced Hypertension (continued)
• Assessment
• Blood pressure
• Weight
• Edema scale of 1 to 4
• Urine tested for albumin
• Diagnostic Tests
• Hematocrit BUN, CBD, clotting studies, liver
  enzymes, type and screen, urine for specific
  gravity and protein, electrolyte panels

45
Bleeding Disorders

• Pregnancy-Induced Hypertension (continued)
• Medical Management
• May or may not need to be hospitalized
• Bedrest lateral recumbent position
• Well-balanced diet with adequate protein
• IV therapy for emergency situations
• Magnesium sulfate to prevent seizures
• Sedatives and antihypertensives

46
Bleeding Disorders

• Pregnancy-Induced Hypertension (continued)
• Nursing Interventions
• Assess for headache, edema, and blurred vision.
• Monitor IO indwelling catheter may be
  necessary.
• Monitor fetal heart rate fetal monitor may be
  needed.
• Perform kick count
• Monitor daily weight.
• Enforce bedrest.
• Provide emotional support.

47
Bleeding Disorders

• Pregnancy-Induced Hypertension (continued)
• Patient Teaching
• Educate on danger signs of complications of
  pregnancy.
• Stress the importance of regular medical
  supervision.
• Encourage high-quality protein, vitamin, and
  mineral intake.

48
Bleeding Disorders

• HELLP Syndrome
• H hemolysis
• EL elevated liver enzymes
• LP low platelet count
• This represents an extension of the pathology of
  severe preeclampsia and eclampsia.
• Symptoms usually appear early in the third
  trimester.

49
Complications Related to Infection

• Etiology
• The infectious diseases that may cause
  complications are numerous.
• Some are airborne or ingested, most are spread
  via direct contact, usually through sexual
  transmission others are spread by use of
  contaminated needles or via blood transfusions.

50
Complications Related to Infection

• Nursing Interventions
• Use gloves, masks, gowns, and glasses when
  performing procedures that involve splashing of
  body fluids.
• Gloves should be worn when cleaning or assessing
  the breasts or perineal area and when giving the
  initial newborn bath and changing diapers.
• Perform a thorough handwashing.
• Decrease the neonates exposure to maternal blood
  and secretions.
• The membranes should be left intact until birth.

51
Complications Related to Infection

• Patient Teaching
• Education on prevention of infection should start
  long before pregnancy.
• Immunization for rubella before childbearing
  years is essential.
• Importance of having children immunized should be
  stressed to the mother.
• Hygiene practices and proper storage and
  preparation of meats should be reviewed.
• Safe sex practices should be discussed.

52
Complications Related to Existing Medical
Conditions

• Diabetes Mellitus
• Etiology
• This is an endocrine disorder that affects
  metabolism and the utilization of glucose.
• It is not curable and is often difficult to
  control in the nonpregnant patient.
• In pregnancy, hormonal changes and stresses
  placed on the maternal body systems result in
  even more complex medical and nursing management.

53
Complications Related to Existing Medical
Conditions

• Diabetes Mellitus (continued)
• Pathophysiology
• The pancreas does not produce an adequate amount
  of insulin to metabolize glucose normally.
• Because glucose does not enter the cells without
  adequate insulin, blood glucose levels remain
  high.
• The cells release stored fat and protein for
  energy, leading to ketosis and a negative
  nitrogen balance.

54
Complications Related to Existing Medical
Conditions

• Diabetes Mellitus (continued)
• Pathophysiology (continued)
• Gestational diabetes mellitus is characterized by
  an inability to produce sufficient insulin to
  maintain normal glucose levels during pregnancy.
• Clinical Manifestations
• Alteration in blood glucose levels above 120
  mg/dl significantly increases the risk of
  complications
• Polyuria, polydipsia, and polyphagia

55
Complications Related to Existing Medical
Conditions

• Diabetes Mellitus (continued)
• Assessment
• Urine testing should be done at all prenatal
  visits.
• Presence of glucose indicates need for further
  testing.
• Stress diet, activity, and medication compliance.
• Assess for vascular system complications.
• Diagnostic Tests
• Blood glucose levels glucose tolerance tests
• Glycosylated hemoglobin
• Tests to evaluate fetal well-being

56
Complications Related to Existing Medical
Conditions

• Diabetes Mellitus (continued)
• Nursing Interventions
• Assess the patient carefully at each visit.
• Complete all blood glucose level evaluations.
• Report any abnormalities to the physician.
• Patient Teaching
• Diet, medication, and health practices
• Necessity of good control of the disease

57
Complications Related to the Cardiovascular System

• Pregnancy increases demands on the cardiovascular
  system.
• The normal, healthy heart is able to adapt to the
  increased demands.
• Women who have preexisting cardiac disease face
  increased risk when cardiac function is
  challenged by pregnancy.

58
Complications Related to the Cardiovascular System

• Etiology
• Most common problems result from rheumatic heart
  disease, congenital heart defects, or mitral
  valve prolapse.
• Peripartum cardiomyopathy is occasionally
  observed in patients who have no history of
  cardiac problems.

59
Complications Related to the Cardiovascular System

• Pathophysiology
• Increased blood volume, heart rate, and cardiac
  output overstress the cardiac muscle, valves, and
  vessels.
• Symptoms of the underlying pathologic condition
  are exacerbated, resulting in cardiac
  decompensation, congestive heart failure, and
  other medical problems.

60
Complications Related to the Cardiovascular System

• Clinical Manifestations
• Edema
• Cyanosis
• Tachycardia
• Palpitations
• Dysrhythmias and chest pain
• Dyspnea and fatigue
• Physical exertion may increase the symptoms
• Decreased cardiac output
• Pulmonary edema
• Pleural effusion

61
Complications Related to the Cardiovascular System

• Assessment
• Take vital signs.
• Evaluate unusual fatigue with activity.
• Monitor for edema, weight gain, murmurs, cough,
  dyspnea, and abnormal lung sounds.
• Diagnostic Tests
• Chest x-ray
• Electrocardiogram
• Echocardiogram
• Auscultation
• Blood gas analysis

62
Complications Related to the Cardiovascular System

• Nursing Interventions
• Teach the importance of diet, medications, pacing
  activity, and adequate rest.
• Iron intake must be adequate to prevent anemia.
• Sodium may be restricted.
• Stool softeners may be administered.
• Semi-Fowlers or side-lying position with the
  head elevated during labor is used.
• Cardiotonics, diuretics, prophylactic
  antibiotics, sedatives, and analgesics may be
  required.
• Conservation of energy during delivery is
  important.

63
Complications Related to Age

• Adolescents
• Growth and Development
• Developmental tasks of adolescence must be
  accomplished before the child can become a mature
  adult.
• Pregnancy interrupts work on identity formation
  and developmental tasks.
• There several physiological concerns with the
  pregnant adolescent
• Increased risk for PIH, cephalopelvic
  disproportion, abruptio plancentae, low birth
  weight, IUGR, anemia, infection, preterm
  delivery, and perinatal death

64
Complications Related to Age

• Adolescents (continued)
• Assessment
• Encourage early and continued prenatal care.
• Refer the adolescent for appropriate social
  support services.
• Nursing Interventions
• Labor and birth
• Support of a knowledgeable coach is necessary.
• Teach about relaxation, ambulation, side-lying,
  and comfort measures.

65
Complications Related to Age

• Nursing Interventions
• Postpartum Care
• Explicit directions for self-care and infant care
  are required.
• Assess new mothers parenting abilities.
• Postpartum contraception is a high priority.
• Provide emotional support if contemplating
  adoption.
• Adolescent Father
• Needs support to discuss emotional responses
• May have feelings of guilt, powerlessness, or
  bravado

66
Complications Related to Age

• Older Pregnant Woman
• Women who have their first child after they are
  35 years old have an increased risk of maternal
  and fetal complications.
• As women maintain better overall health and
  fitness, increased age appears to be less of an
  impediment to a normal pregnancy.
• Psychosocial adjustment to parenthood at this
  time of life depends greatly on the individual
  and her particular situation.

67
Complications Related to the Newborn

• Newborns at Risk
• It is important to identify any maternal risk
  factors as soon as possible to decrease the risk
  to the fetus/newborn.
• The newborn is assessed at the time of delivery
  Apgar score gives important information about the
  newborns status at 1 and 5 minutes after
  delivery.
• It is important to distinguish between infants
  who are preterm and those who are small for
  gestational age.

68
Complications Related to the Newborn

• Gestational Age
• Preterm 0 to 37 weeks of pregnancy
• Term 38 to 41 weeks of pregnancy
• Postterm 42 or more weeks of pregnancy
• Dubowitz and Dubowitz method of determining
  gestational age
• Ideally, tests performed between 2 and 8 hours of
  age

69
Complications Related to the Newborn

• Preterm Infant
• Etiology/Pathophysiology
• Exact causes are unknown.
• Some cases may be related to maternal or
  placental problems.
• Infant is developmentally immature.
• Lungs are not producing sufficient amounts of
  surfactant to allow adequate oxygenation.
• Circulation may not have adapted from fetal to
  neonatal as it usually does in a term infant.

70
Complications Related to the Newborn

• Preterm Infant (continued)
• Etiology/Pathophysiology (continued)
• Lack of subcutaneous fat, large surface area
  relative to body weight, and poor reserves of
  glucose and brown fat all contribute to problems
  with heat conservation.
• Fluid and acid-base imbalance is frequently
  observed.
• Problems with absorption of nutrients are common.
• Neurologically immature gag, suck, and swallow
  reflexes may be weak or absent.

71
Complications Related to the Newborn

• Preterm Infant (continued)
• Clinical Manifestations (continued)
• Posture is froglike or flaccid.
• Color is usually ruddy, and cyanosis is common.
• The head appears very large in proportion to the
  body, and the bones of the skull are pliable with
  large, flat fontanels.
• The skin is very thin and translucent with
  obvious blood vessels and little subcutaneous
  fat.
• Genitals are small.
• Cry is weak, and reflexes are immature or absent.

72
Complications Related to the Newborn

• Preterm Infant (continued)
• Assessment
• All systems of the preterm newborn must be
  assessed carefully and continuously.
• Greatest potential problem is respiratory
  distress syndrome grunting on expiration, nasal
  flaring, circumoral cyanosis, substernal
  retractions, and tachypnea.
• An accurate assessment of gestational age is a
  good indicator of the problems the preterm
  newborn is likely to experience.

73
Complications Related to the Newborn

• Preterm Infant (continued)
• Nursing Interventions
• Major goals include maintaining and stabilizing
  preterm newborns until they mature adequately.
• Respiratory regulation
• Thermal regulation
• Fluid and electrolyte regulation
• Sensory stimulation
• Promotion of bonding with the parents

74
Complications Related to the Newborn

• Postterm Infant (continued)
• May show signs of placental insufficiency because
  the aging placenta is not fully functioning.
• There may be an increase in risk for perinatal
  mortality resulting from intrauterine hypoxia
  during labor and birth.
• Infant is at risk for asphyxia, respiratory
  distress, and hypoglycemia.

75
Complications Related to the Newborn

• Gestational Size
• Small for Gestational Age (SGA)
• Weight is below the 10th percentile for age.
• Appropriate for Gestational Age (AGA)
• Weight is between the 10th and 90th percentiles.
• Large for Gestational Age (LGA)
• Weight is above the 90th percentile.
• Low Birth Weight (LBW)
• Weight is 2500 g or less at birth.

76
Complications Related to the Newborn

• Infant of a Diabetic Mother
• Frequently exhibits macrosomia, hypoglycemia,
  perinatal asphyxia, hypocalcemia, respiratory
  difficulties, and hyperbilirubinemia
• May also have congenital anomalies as a result of
  the uncontrolled maternal blood glucose levels in
  early pregnancy

77
Complications Related to the Newborn

• Hemolytic Diseases
• Etiology
• Hemolysis may result from basic incompatibility
  of blood groups, such as ABO incompatibility, or
  from a transfer of antibodies through the
  placenta.

78
Complications Related to the Newborn

• Hemolytic Diseases (continued)
• Pathophysiology
• Rh incompatibility occurs only when the mother is
  Rh negative and the fetus is Rh positive.
• If the woman is sensitized, antibodies are
  produced.
• Exposure can occur during pregnancy when some
  fetal blood cells enter the maternal circulation.
• Maternal antibodies may cross the placental
  barrier in a subsequent pregnancy if the fetal
  RBCs contain the Rh antigen, the maternal Rh
  antibodies cause hemolysis.

79
Figure 28-11, A B
(From Novak, J.C., Broom, B.L. 1995. Ingalls
Salernos maternal and child health nursing. 8th
ed.. St. Louis Mosby.)
A, Rh-positive fetus carried by Rh-negative
mother. B, Rh protein crosses placental barrier.
80
Figure 28-11, C D
(From Novak, J.C., Broom, B.L. 1995. Ingalls
Salernos maternal and child health nursing. 8th
ed.. St. Louis Mosby.)
C, Mothers system manufactures antibodies. D,
Antibodies cross back over placenta.
81
Complications Related to the Newborn

• Hemolytic Diseases (continued)
• Clinical Manifestations
• The mother shows no clinical symptoms.
• Jaundice present at birth or observed during the
  first 24 hours of life is considered an indicator
  of a pathologic condition.
• Kernicterus may result in neurologic damage or
  death.
• Anemia resulting from RBC destruction is also
  possible.

82
Complications Related to the Newborn

• Hemolytic Diseases (continued)
• Assessment
• Know maternal blood type and Rh factor.
• If the mother is Rh negative, it is necessary to
  know the blood type of the father if he is also
  Rh negative, no Rh-based problem will occur.
• If the father is Rh positive, the possibility of
  problems occurring is present.
• Assess the womans history for any occurrences
  that may have caused sensitization.

83
Complications Related to the Newborn

• Hemolytic Diseases (continued)
• Diagnostic Tests
• Indirect Coombs test
• Amniocentesis
• Optical density studies
• After delivery, direct Coombs test on the
  infants blood

84
Complications Related to the Newborn

• Hemolytic Diseases (continued)
• Nursing Interventions
• Maternal
• Anti-Rh gamma globulin (RhoGAM)
• Given at 28 weeks of pregnancy and again within
  72 hours of delivery
• Newborn
• Assess for jaundice and anemia.
• Monitor bilirubin, hemoglobin, and hematocrit.
• Phototherapy is given for bilirubin levels of 12
  to 15 mg/dl.

85
Complications Related to the Newborn

• Drug and Alcohol Abuse Syndromes
• Etiology
• Most drugs, including common substances such as
  alcohol and nicotine, are able to cross the
  placental barrier and affect the fetus.
• A wide range of fetal and maternal complications
  may occur.
• Pathophysiology
• This varies with the drug involved.

86
Complications Related to the Newborn

• Drug and Alcohol Abuse Syndromes (continued)
• Clinical Manifestations and Assessment
• Alcohol dependency
• Fetal alcohol syndrome multiple anomalies
• Drug dependency
• A wide range of problems are manifest.
• The symptoms depend on the particular drug used.
• Diagnostic Tests
• Drug screening

87
Complications Related to the Newborn

• Drug and Alcohol Abuse Syndromes (continued)
• Nursing Interventions
• Observation of the newborn is essential to detect
  increasing instability.
• Physical care includes temperature regulation and
  monitoring of vital signs.
• Small feedings are given and the infant is
  observed for diarrhea, regurgitation, and
  vomiting.
• IV therapy may be required.
• Medications may be administered to prevent
  serious withdrawal symptoms.

88
Complications Related to Postpartum Mental Health
Disorders

• Mood Disorders
• They typically occur within 4 weeks of
  childbirth.
• Mild depression or baby blues some may have
  postpartum depression (PPD).
• Prominent feature of PPD is rejection of the
  infant.
• Attitudes toward the infant may include
  disinterest, annoyance with care demands, and
  blame because of mothers lack of maternal
  feeling.
• Obsessive thoughts about harming the child may
  occur.

89
Complications Related to Postpartum Mental Health
Disorders

• Mood Disorders (continued)
• Medical Management
• The natural course is gradual improvement over
  the 6 months after birth.
• Support treatment alone is not effective for
  major PPD.
• Pharmacologic interventions are needed in most
  instances antidepressants, anxiolytic agents,
  and electroconvulsive therapy.
• Psychotherapy focuses on the mothers fears and
  concerns and monitoring for suicidal thoughts.

90
Nursing Process

• Nursing Diagnoses
• Nutrition less than body requirements
• Fear
• Cardiac output, decreased
• Grieving, anticipatory
• Knowledge, deficient
• Fluid volume, deficient
• Diversional activity, deficient
• Injury, risk for
• Thermoregulation, ineffective
• Anxiety