Chapter 5: Complications During Pregnancy: Nursing Care

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Welcome back to the Deep Dive.

Great to be here.

So today we're opening up the textbooks again.

We are looking at Leifers introduction to maternity and pediatric nursing in Canada.

Specifically,

chapter five, and this is this is a big one.

If you're a nursing student, you definitely know this chapter.

Oh, absolutely.

Yeah, this is where we we kind of leave the happy path of pregnancy, so to speak.

Exactly.

We've been talking a lot about the normal physiological changes, the, you know, the excitement, all of that glow, the nesting.

Yeah, all the wonderful things.

But chapter five, it's titled nursing care of women with complications during pregnancy.

And that title says it all.

It really does.

This is where the rubber meets the road.

I mean, the text is good to point out that most pregnancies are totally uncomplicated.

Right.

But this chapter is dedicated to those high risk situations where, you know, the health of the mother or the fetus is in jeopardy.

And the stakes are just, they're incredibly high.

They are.

And it can be because of the pregnancy itself or maybe a medical condition the mother already has, environmental things, lifestyle.

So it's a huge range of possibilities.

A huge range.

And the text makes a really important point right at the start for the family.

This is a crisis.

It's not just a medical issue.

It completely disrupts their lives.

That's such a crucial point.

It's not just a patient in a bed.

It's a family in crisis.

Precisely.

So our mission today, then, is to walk through this chapter.

We're going to go through it just as it's written.

We want to all these, you know, heavy clinical concepts into knowledge that's really clear, really actionable for nursing students.

And we're not just listing diseases.

We're digging into the assessments, the interventions, and this is so important, that family -centered care piece.

Right.

Because like you said, the psychological impact is just as heavy as the medical one.

And we're keeping it in the Canadian context, which this textbook is all about.

Yes, that's key.

So the guidelines, the specific drug names you might see, the screening protocols, this is all geared towards Canadian nursing practice.

Okay, so let's start where the chapter starts.

Right at the top, there's this bright box, patient teaching, danger signs in pregnancy.

These are the red flags.

These are the absolute must -know, non -negotiable red flags.

As a nurse, this is what you are drilling into your patient.

These are the things where you say, you don't wait, you call immediately.

So what's number one on the list?

A sudden gush of fluid from the vagina,

specifically before 37 weeks.

Okay, so let's break that down.

If your full term, say 40 weeks, a gush of fluid is, well, it's your water breaking, that's labor starting.

Correct, that's the expected event.

But before 37 weeks, we call that premature rupture of membranes, or POM.

And why is that so dangerous?

Because that amniotic sac is a sterile environment.

It's like a sealed bubble protecting the baby.

Right.

When it breaks, that seal is gone.

So infection.

Infection is the huge risk, choreomanianitis.

And there's another risk too.

If the baby's head isn't well down in the pelvis, the umbilical cord can actually wash out with the fluid, a prolapsed cord.

Which is a massive emergency.

A five alarm fire.

It cuts off the baby's oxygen supply.

So that gush isn't just a minor leak, it's a potential cascade of very bad things.

Got it.

What's next on the danger list?

Vaginal bleeding.

Always a concern, I imagine.

Always.

The text is very clear.

Vaginal bleeding is never, ever considered normal during pregnancy.

Full stop.

What could it mean in, say, the first trimester?

It could be a threatened miscarriage or an ectopic pregnancy.

Later on, in the second or third trimester, you have to think about the placenta.

Is it placenta previa?

Is it placental abruption?

We'll get into those, I'm sure.

We will.

But the bottom line for the patient is, any bleeding you call.

Okay, then the list has abdominal pain and persistent vomiting.

And this isn't just regular morning sickness, is it?

No, not at all.

We're talking about vomiting that is so severe you can't keep anything down.

It leads to dehydration, electrolyte imbalances.

We'll talk about hyperemesis later.

And the abdominal pain.

It's a huge question mark.

Is it premature labor?

Is it an abruption where the placenta is tearing away?

Is it a ruptured ectopic pregnancy?

You can't know at home, so you have to get it checked out.

What about the baby's movement?

This is one of the most important ones.

Decreased or absent fetal movements.

And the text gives a time frame for this, right?

It does.

It says this is especially critical after 26 to 28 weeks, once the movements are well established.

So why does a baby start moving?

A baby that stops moving might be a baby in distress.

They could be hypoxic, meaning they're not getting enough oxygen.

So they're conserving energy.

Exactly.

It's like they're powering down to protect the most vital organs like the brain and the heart.

It is a massive distress signal from the fetus.

That's terrifying.

Okay, then we get into a cluster of symptoms that to me sound like blood pressure issues.

You're spot on.

The text lists.

A severe persistent headache.

Not just a regular headache.

No, one that doesn't go away with Tylenol or rest.

Then blurred vision or dizziness seeing spots.

And then significant edema swelling of the face and hands.

And the text is specific here, right?

It's not about the ankles.

Very specific.

Almost everyone gets swollen ankles in late pregnancy.

That's just gravity and fluid.

But when you see it in the face, around the eyes, or in the hands where rings get tight,

that's different.

What is that a sign of?

These are the classic warning signs of preeclampsia.

It means the vascular system is under so much pressure that fluid is leaking out into the tissues everywhere.

The headache and blurred vision, that's from cerebral edema.

The brain itself is swelling.

Wow.

It's a true medical emergency.

What are the last few signs on that list?

Chills with a fever over 38 degrees Celsius.

That points to a serious infection.

Okay.

Painful urination.

That suggests the UPI, a urinary tract infection.

And we'll talk later about why even a simple UTI can be so dangerous in pregnancy.

And the last one is interesting.

It is.

It says a feeling that something is just not right.

I love that they include that.

It gives so much credit to maternal intuition.

It really does.

And it's so valid.

Mothers live in their bodies.

They are connected to that fetus 247.

They often detect very subtle changes long before our monitors do.

The text is basically telling nurses, listen to the mother.

If she says something feels wrong, believe her.

That's a powerful message.

Okay.

So now that we have these red flags, the chapter moves into how we actually investigate them.

It goes into the assessment of fetal health.

Right.

This is where the technology comes in.

And the nurse's role here is so critical.

You're the bridge between all this high tech equipment and a very anxious patient.

Because these tests, they're not routine for most people.

They're scary.

If you're having an amniocentesis, you're not there for fun.

Not at all.

You're there because there's a concern.

So the text emphasizes the nurse's role in preparing the patient, explaining why a test is being done, what it's going to feel like.

And then helping to clarify the results.

Exactly.

In collaboration with the physician or midwife.

You're the translator, the emotional support person.

You're there to reduce that anxiety.

The text also brings up a really Canadian point here, talking about telemedicine.

Yes.

And this is so relevant for our geography.

If you live in a rural or northern community, you might be hours away from a specialist.

Or flight away.

A flight away.

Exactly.

Telemedicine allows a local clinic to

transmit ultrasound images or fetal heart rate tracings to a perinatologist in a major urban center.

So the woman can get expert advice without having to leave her community and her family for weeks on end.

It's a game changer for equitable access to care.

Definitely.

Okay, let's look at figure 5 .1 in the text.

It's a diagram of an amniocentesis.

If you're a student looking at this, what are the key takeaways?

Okay, so the first thing you'll see is the pregnant abdomen.

Then there's an ultrasound transducer placed on the skin.

So the ultrasound is happening at the same time.

It is absolutely crucial.

The ultrasound is the guide.

It shows the operator exactly where the fegus is, where the umbilical cord is, and where the placenta is.

The goal is to find a safe pocket of amniotic fluid.

So you don't poke the baby.

You do not poke the baby.

Or the placenta.

You can see the long thin needle being inserted through the abdominal wall, then the uterine wall, and into that amniotic cavity to draw out a sample of the fluid.

And why are we doing this?

What's in that fluid?

Well, it depends on when in the pregnancy we do it.

Early on, say around 15 to 17 weeks, it's almost always for genetic analysis.

The fluid contains fetal cells that we can test for chromosomal abnormalities like Down syndrome.

And later in pregnancy.

Later on, it's often to check for fetal lung maturity.

If we think we need to deliver a baby preterm, we can test the fluid to see if the lungs are producing enough surfactant to breathe on their own.

Ah, okay.

Makes sense.

It can also be used to check for infection or issues with blood incompatibility.

Got it.

And now the chapter moves into table 5 .1, which is this huge comprehensive list of fetal diagnostic tests.

Students really need to know the differences here.

Let's try to go through them.

First up, the most common one, ultrasound.

The absolute workhorse of obstetrics.

In early pregnancy, it does a few key things.

Confirms that the pregnancy is in the uterus.

Not ectopic.

Exactly.

It verifies viability.

It's their heartbeat.

And it helps establish a really accurate gestational age by measuring the fetus.

The text points out a specific nursing instruction here that always seems to catch students by surprise.

About the bladder.

Yes.

For an abdominal ultrasound in early pregnancy, the woman needs a full bladder.

She has to drink one to two liters of water before the appointment.

That seems counterintuitive.

Usually you're asked to empty your bladder for procedures.

So why full?

In early pregnancy, the uterus is still a pelvic organ.

It's tucked down behind the pubic bone.

A full bladder acts like an acoustic window.

It lifts the uterus up and out of the pelvis and pushes the bowel out of the way so the sound waves can get a clear shot and create a good image.

But that changes later, right?

It does.

Later in pregnancy, the uterus is so big it's an abdominal organ so a full bladder isn't needed.

And another key distinction, if it's a transvaginal ultrasound where the probe goes inside the vagina, the bladder must be empty.

Why empty for that one?

Because you want the probe to be as close to the uterus and ovaries as possible.

An empty bladder allows for that.

Okay, that's a great clinical pearl.

Next on the list on the table,

kick counts.

This is so important.

It's low tech, but it's incredibly valuable because it empowers the mother to monitor her own baby.

So what's the protocol?

For women in high risk pregnancies, starting around 26 to 28 weeks, the teaching is to lie on their side.

Why on their side?

To maximize blood flow to the placenta.

It's best to do it about an hour after a meal because the glucose spike from the food usually makes the baby more active.

And she just counts the movements.

She counts every movement.

A kick, a roll, a flutter.

The guideline in the text says the minimum she should feel is six movements in a two hour period.

And if she doesn't get six movements in two hours?

She needs to call her provider and go in for further assessment immediately.

No waiting.

Because as you said before, a decrease in movement can be a sign of fetal acidosis or that the placenta isn't working well.

Exactly.

The baby is powering down to conserve resources.

It's a try for help.

Okay, Doppler ultrasound blood flow assessment.

What's that?

This is a specialized ultrasound that looks at the blood flow through the umbilical artery.

What does that tell us?

It tells us how well the placenta is working.

In a healthy pregnancy, there's good continuous forward blood flow to the baby.

If the placenta is failing, there's increased resistance and the blood flow can become sluggish or even reverse between heartbeats.

A very bad sign.

A very, very bad sign.

It means the baby is being starved of oxygen and nutrients and will likely need to be delivered soon.

Okay.

The table also lists a bunch of screening tests.

First trimester screening, CVS, cell -free DNA.

Right.

So these are all ways to screen for genetic abnormalities early on.

First trimester screening combines an ultrasound looking at the neutral translucency, a fluid collection at the back of the baby's neck with a maternal blood test.

And chorionic villus sampling or CVS?

That's a diagnostic test, more invasive than a screen.

It takes a tiny sample of the placenta, usually between 10 and 13 weeks for genetic testing.

It gives a definitive answer much earlier than an amnio.

And cell -free DNA.

That's a maternal blood test.

It analyzes fragments of fetal DNA that is circulating in the mother's blood.

It's a highly accurate screen for things like Down syndrome.

Okay.

Now let's get to the ones that always trip students up.

Yeah.

The stress tests.

The non -stress test, NST, and the contraction stress test, CST.

Let's simplify them.

The non -stress test, or NST, is the most common one.

We're just monitoring the baby's heart rate to see how it responds to its own movements.

There's no stress being applied.

So what are we looking for?

What's a good result?

A good result is reactive.

We want to see the baby's heart rate go up when it moves.

And acceleration.

Exactly.

Think about it.

When you get up and walk across the room, your heart rate increases.

That's a sign of a healthy, intact nervous system.

So we want to see the fetal heart rate accelerate by at least 15 beats per minute, for at least 15 seconds, two times in a 20 -minute window.

And that tells you the baby is getting enough oxygen and is doing well at that moment.

It does.

It's a snapshot of fetal well -being.

Okay.

So then what's the contraction stress test, the CST?

The CST is asking a different question.

It's asking,

can this fetus tolerate the stress of labor?

And the stress of labor is the contractions?

Precisely.

During a contraction, blood flow to the placenta is temporarily squeezed off.

A healthy baby has enough reserve to handle that just fine.

A compromised baby doesn't.

So how do you do the test?

You induce contractions?

You induce mild, infrequent contractions.

You can do that with a very low dose of oxytocin IV,

or sometimes by having the woman stimulate her own nipples, which releases natural oxytocin.

And what are you watching for on the monitor?

We are watching for decelerations.

If the baby's heart rate drops after a contraction, that's a positive or abnormal test.

It's a major red flag that the baby will not tolerate a vaginal birth.

That makes a lot of sense.

Finally, from this table, the biophysical profile or BPP.

I like to call the BPP the fetal report card.

It's much more comprehensive than an NST alone.

Why is that?

What does it include?

It combines an NST with an ultrasound assessment of four other markers.

Okay.

What are they?

Fetal breathing movements.

We're looking for practice breathing.

Fetal body movements, big movements like stretching.

Fetal tone small movements like opening and closing a hand.

And finally,

amniotic fluid volume.

Amniotic fluid volume.

That seems different from the others.

Why is that on the report card?

It's a marker of long -term placental function.

Most of the amniotic fluid in the second half of pregnancy is fetal urine.

Okay.

So if a baby is under chronic stress from a poorly functioning placenta, its body shunts blood flow away from organs like the kidneys to protect the brain and heart.

Less blood to the kidneys means less urine.

Which means low amniotic fluid or oligohydramnios.

It's a sign that the baby has been struggling for a while.

So each of those five components gets a score and you add it up.

Exactly.

A score of eight or 10 of the 10 is great.

A score of four or less usually means the baby needs to be delivered right away.

Wow.

That is a really thorough assessment.

Okay.

Let's move from assessment into the first major complication the chapter covers.

Hyperemesis Gravidarum.

Right.

And it's so important to differentiate this from morning sickness.

They are not the same thing.

How is it different?

The text is very clear.

Hyperemesis is excessive.

It's pathological.

It's nausea and vomiting that's so persistent it actually interferes with their food and fluid intake.

So what are the clinical signs, the manifestations we'd see?

Significant weight loss.

The book says more than 5 % of her pre -pregnancy weight and severe dehydration.

What does that look like?

Dry mouth, dry mucous membranes, poor skin turgor.

If you pinch the skin at tense,

the urine becomes very dark and concentrated.

And the text mentions ketoneuria.

What's that?

That means there are ketones in the urine.

It's a sign of starvation.

The body has run out of available glucose for energy so it starts breaking down its own fat stores.

Ketones are the byproduct of that fat breakdown.

It sounds miserable.

It's absolutely debilitating and it can lead to serious electrolyte and acid base imbalances that can affect the heart and brain.

The text mentions that for a while people thought it was purely psychological.

Yes.

It explicitly says that while stress was once blamed as the cause, we now understand it's much more complex.

The emotional distress women experience is often a result of the condition, not the cause.

Of course.

I mean, imagine feeling like you have a horrible stomach flu, 247, for months.

It impacts your ability to work, to care for your other children, to function at all.

It's incredibly isolating.

So what's the treatment?

First, you have to rule out other causes like gastroenteritis or maybe gallbladder or liver problems.

Once you've confirmed its hyperemesis, the priority is correcting the dehydration and electrolyte imbalance.

That means IV fluids.

And medications.

Yes.

The first line drug in Canada is often D -Clectin, which is a combination of an antihistamine and vitamin B6.

If that's not enough, they might move to other antimedics like Ondansetron, which you might know as Zofran.

What about the nursing care?

A lot of this will be managed at home.

A huge part of it is patient teaching.

You work with her to identify and avoid triggers.

Odors are a huge one.

Right.

So, you know, maybe her partner needs to stop cooking bacon in the house for a few months.

Simple, but effective.

What about diet?

Small, frequent meals.

The key is to never let the stomach get completely empty because that can trigger nausea, but also to never overfill it.

So nibbling all day.

Pretty much.

Yeah.

And focusing on easily digested carbohydrates.

Crackers, dry toast, baked potatoes, plain rice, things that are bland and won't upset the stomach.

The text also suggests sitting upright for a while after meals to reduce any reflux.

And the emotional support piece.

It's vital.

You have to listen to her.

The text notes that women often feel isolated and afraid to even leave the house because they might vomit in public.

That sounds awful.

So the nurse needs to validate that experience.

Acknowledge how difficult it is.

Don't just wave it off as, oh, that's just being pregnant.

It's not.

This is a serious medical condition.

A really important distinction.

Okay.

Let's shift gears now into a really big topic.

Bleeding disorders of early pregnancy.

The text groups these into three main culprits in the first half of pregnancy.

Abortion, ectopic pregnancy, and hide into the form mole.

Let's start with abortion.

And we need to be clear about the terminology here.

We do.

In medical terms, abortion simply means the termination of a pregnancy before 20 weeks of gestation.

It doesn't imply cause.

So it can be spontaneous, which is what most people call a miscarriage.

Correct.

Or it can be induced, which is a therapeutic or elective termination.

The chapter focuses on spontaneous abortion here.

Okay.

And table 5 .2 in the book breaks down spontaneous abortion into several types.

This is classic exam material for nursing students.

Let's go through them.

First, threatened versus inevitable.

Okay.

In a threatened abortion, you have some cramping and vaginal spotting, but, and this is the key, the cervix is closed.

The pregnancy is still viable.

So it's threatened, but it might not be lost.

Exactly.

The treatment is usually an ultrasound to confirm there's still a heartbeat and then limited activity.

Basically we wait and see.

And an inevitable abortion.

The name really says it all.

The bleeding and cramping are worse.

And crucially, the cervix has started to dilate.

The membranes might even rupture.

At that point, the pregnancy cannot be saved.

It's going to proceed.

That's heartbreaking.

Okay.

Then the table has incomplete versus missed.

An incomplete abortion is when some of the pregnancy tissue has passed, but some of it, usually placental tissue, is retained in the uterus.

And that's dangerous.

Very dangerous.

That retained tissue prevents the uterus from clamping down and contracting effectively, which can lead to severe hemorrhage.

It's also a breeding ground for infection.

So what's the treatment for that?

It usually requires a procedure called a D &E dilation and evacuation to gently remove the remaining tissue and ensure the uterus is empty.

Okay.

And a missed abortion.

A missed abortion is when the fetus has died in utero, but the body doesn't expel it.

The signs of pregnancy, like nausea, might disappear and the uterus stops growing.

But there's no bleeding or cramping initially.

Right.

It's often discovered at a routine appointment when they can't find a heartbeat.

This also requires medical or surgical evacuation of the uterus.

The nursing care here has two major components,

the physical and the emotional.

Physically, you're on high alert for shock.

Hypovolemic shock from blood loss.

Box 5 .1 in the text lists the signs.

The very first sign is usually tachycardia, a rising pulse rate.

Before the blood pressure drops.

Yes.

The heart starts beating faster to try to compensate for the decreased blood volume.

Then as it gets worse, you'll see the blood pressure start to fall.

The skin becomes pale, cool, and clammy.

So as the nurse, you're monitoring vital signs constantly.

And you're tracking the bleeding.

Absolutely.

You're counting the perineal pads.

For the most accurate measurement, you're actually weighing them.

The rule of thumb is that one gram of weight equals about one milliliter of blood loss.

And emotionally, the text has a whole care plan 5 .1 dedicated to this.

And this is so, so important.

The care plan contrasts effective communication with ineffective communication.

What's an example of effective communication?

Just being present, saying simple, honest things like, I'm so sorry for your loss, or this must be so difficult.

Sometimes the most powerful thing you can do is just sit with them in silence and listen.

And what's on the ineffective list?

The what not to say.

Oh, all the cliches that people say when they're uncomfortable.

You're young, you can have another baby.

That's a terrible one.

It is.

Or, it was probably for the best.

Maybe something was wrong with it.

These statements just completely invalidate the person's grief.

The text really emphasizes that you have to validate the loss, no matter how early the pregnancy was.

Yes, it doesn't matter if it was six weeks or 16 weeks.

To those parents, that was their baby.

That was a future, a whole set of dreams.

The grief is real, and our job is to acknowledge and support it.

So important.

Okay, let's move to the second cause of early bleeding.

Ectopic pregnancy.

An ectopic pregnancy is any pregnancy that implants outside of the uterine cavity.

And the text says 95 % of the time, that implantation happens in the fallopian tube.

Which is not designed to hold a pregnancy.

Not at all.

The text describes it as a disaster waiting to happen.

The fallopian tube is narrow and it can't stretch like the uterus can.

As the embryo grows, it will eventually rupture the tube.

And that's a medical emergency.

A life -threatening emergency, because it causes massive internal bleeding.

So what are the symptoms a woman might experience?

At first, it might just seem like a normal pregnancy.

A missed period, maybe some lower abdominal pain on one side, some light vaginal bleeding or spotting.

But there's one crucial red flag symptom the text points out that indicates a rupture.

Yes, and it's a weird one.

Shoulder pain.

Shoulder pain?

That seems completely unrelated to the pelvis.

Why shoulder pain?

It's referred pain.

When the tube ruptures, blood pours into the abdominal cavity.

That pool of blood irritates the diaphragm and the phrenic nerve.

The brain interprets that nerve irritation as pain in the shoulder.

Wow.

So if a woman comes in with abdominal pain and says her shoulder hurts, you have to think ruptured ectopic.

It's a classic sign of significant internal bleeding.

How is it treated?

It depends on whether the tube is ruptured.

If it's caught early and the tube is still intact, they can sometimes use a medication called methotrexate.

Isn't that a chemotherapy drug?

It is.

It works by stopping cells from dividing.

So it stops the pregnancy from growing and the body can then reabsorb it.

The huge benefit is that it can save the fallopian tube.

And if the tube has already ruptured?

Then it's straight to the operating room for emergency surgery.

They have to remove the damaged tube, a self -injectomy, and stop the hemorrhage.

Okay.

The third bleeding disorder of early pregnancy is a strange one.

Hidatidiform mole.

It is a strange one.

It's also known as gestational trophoblastic disease.

The text has a very memorable visual description for it.

It does.

It says the uterus is filled with grape -like vesicles.

What happens is the chorionic villi, which are the little finger -like projections that form the placenta, they grow abnormally.

They become these swollen fluid -filled sacs.

And there's no viable fetus?

Usually not.

It's just this abnormal placental tissue.

What are the signs and symptoms?

There are a few classic ones.

First, the uterus grows much faster than expected.

A woman might be 10 weeks pregnant, but measure like she's 20 weeks.

Okay.

Her HCG levels, the pregnancy hormone, will be extremely high, much higher than in a normal pregnancy.

And on an ultrasound, you don't see a fetus.

You see what's described as a snowstorm pattern.

And the bleeding.

It's often a brownish, prune -juice -colored discharge, sometimes with those grape -like vesicles passing.

Also, preeclampsia can develop very early, which is rare before 20 weeks in a normal pregnancy.

The follow -up care for a molar pregnancy is really unique and absolutely critical.

It is non -negotiable.

After the uterus is evacuated, the woman must be taught to use reliable contraception and avoid getting pregnant for at least one year.

One full year.

Why?

Because in a small percentage of cases, this abnormal tissue can persist and turn into a type of cancer called choreocarcinoma.

Wow.

We monitor the woman's HCG levels regularly after the mole is removed.

They should fall to zero and stay there.

If they start to rise again, it could signal that cancerous tissue is growing.

And a new pregnancy would also make HCG levels rise, so you wouldn't be able to tell the difference.

Exactly.

It would completely mask the detection of a potential cancer.

So that one year of follow -up is a critical safety measure.

That is such a tough conversation to have with someone who has just lost a pregnancy.

It is.

You're telling them they've lost this pregnancy and now they can't even try again for a year.

It's a double blow and requires a tremendous amount of psychosocial support from the nurse.

Let's shift now to bleeding disorders of late pregnancy.

We're past 20 weeks and now we're talking about the placenta again.

And table 5 .3 gives us the classic comparison that every nursing student must know inside and out.

Placenta previa versus placental abruption.

Let's start with placenta previa.

What does presia mean?

It means in the way.

The placenta has implanted in the lower part of the uterus over or very close to the cervix.

It's blocking the exit.

The book says it can be total, partial, or marginal.

Right.

Total previa means the placenta completely covers the cervical opening.

Partial means it covers part of it.

And marginal means it's just at the edge.

And what is the hallmark sign of placenta previa?

This is the key differentiator.

The bleeding is painless and it's bright red.

Why is it painless?

Because the bleeding is caused by the lower part of the uterus starting to thin out and stretch in late pregnancy.

As it does, it can tear some of the placental attachments, causing bleeding.

But there's no pain associated with that.

And the uterus itself stays soft and relaxed.

And there is a huge, bolded, all -cap safety alert in the book about this.

The biggest safety alert, no vaginal exams, ever.

If a woman comes in with bright red, painless bleeding, you do not perform a vaginal exam.

Why not?

Because if the placenta is covering the cervix and you insert your fingers to check for dilation, you can literally poke a hole right through the placenta.

And cause a massive hemorrhage.

A catastrophic, life -threatening hemorrhage for both mom and baby.

Diagnosis is made by ultrasound only.

Okay, now let's contrast that completely with placental abruption.

Abruption is the premature separation of a normally implanted placenta.

So the placenta is in the right spot, high up in the uterus, but it starts to peel away from the uterine wall before the baby is born.

This sounds incredibly dangerous.

It is.

It cuts off the oxygen and nutrient supply to the fetus and it causes bleeding for the mother.

What are the symptoms of an abruption?

Think the opposite of previa.

The bleeding is often dark red and it is associated with intense constant pain.

And the uterus.

It becomes board -like, rigid,

hard as a rock.

It's because blood is leaking behind the placenta, irritating the uterine muscle and causing it to go into a sustained titanic contraction.

The book also says the bleeding can be concealed.

Yes, that's what makes it so insidious.

If the separation happens in the middle of the placenta, the blood can be trapped behind it.

So you might not see any visible vaginal bleeding, but the woman is in excruciating pain, her abdomen is rigid and the baby's heart rate is plummeting.

What are the main causes of abruption?

The text links it strongly to hypertension.

The high pressure damages the delicate blood vessels behind the placenta.

Also, cocaine use is a major risk factor because it causes intense vasoconstriction and any kind of abdominal trauma, a car accident, a fall or intimate partner violence With abruption, the book mentions a terrifying complication called DIC.

What is that?

DIC stands for Disseminated Intravascular Coagulation.

It's a clotting catastrophe.

What happens?

Basically, the body sends all of its clotting factors and platelets to the site of the abruption to try and form a massive clot.

It uses them all up.

So you run out of clotting factors for the rest of your body.

Exactly.

You start bleeding from everywhere, your IV sites, your gums, your nose, from any little scrape.

You are simultaneously clotting and bleeding to death.

It's an absolute emergency that requires immediate delivery of the baby and massive transfusion of blood products.

That is just heavy stuff.

Very heavy.

It makes sense then that the next major section is on hypertensive disorders during pregnancy or HDP, since you said that's a big risk factor for abruption.

Yes, they are very closely linked and HDP is a whole spectrum of conditions.

So let's get the definition straight.

What's pre -existing hypertension?

That's high blood pressure that the woman had before she got pregnant or that's diagnosed before 20 weeks of gestation.

Okay.

And gestational hypertension?

Gestational hypertension, or GH, is high blood pressure that develops after 20 weeks of pregnancy.

But,

and this is the key distinction, there is no protein in the urine.

And as soon as you add protein in the urine, it becomes?

Preeclampsia.

That's the defining feature.

Preeclampsia is a blood pressure over 42090 on two occasions, plus proteinuria.

Why is the protein in the urine so significant?

It's a sign of kidney damage.

Preeclampsia isn't just about high blood pressure.

It's a multi -system disease where the blood vessels all over the body become leaky and damaged.

The kidneys are one of the first organs to show that damage by leaking protein.

The text then goes into the symptoms of severe preeclampsia.

Let's break down the why behind them.

Why the severe headache?

Cerebral edema.

The blood vessels in the brain become leaky, and fluid seeps into the brain tissue, increasing the pressure inside the skull.

That's what causes the relentless headache.

It's also what makes the nervous system so irritable, leading to hyperactive deep tendon reflexes.

A sign a seizure could be coming.

A major warning sign.

And why the visual changes, like seeing spots or blurred vision.

For the same reason.

It's caused by arterial spasm and edema in and around the retina.

The blood supply to the eye is being affected.

Okay, and then there's epigastric pain.

Pain in the upper abdomen.

This is a very ominous sign.

It's caused by liver edema.

The liver is swelling up inside its capsule, which is incredibly painful.

It indicates severe organ damage and often precedes a seizure or a stroke.

The text also mentions a variant called H -A -L -L -L -P syndrome.

Yes, H -E -L -P is an acronym for a particularly severe form of preeclampsia.

It stands for hemolysis, which is the breakdown of red blood cells.

Okay.

Elevated liver enzymes, which concerns the liver damage we just talked about.

And LP for low platelets, which means the clotting system is starting to fail.

A patient with H -E -L -L -P syndrome is critically ill.

Critically ill.

And if preeclampsia progresses all the way to a seizure, it gets a new name.

It's then called eclampsia.

That's the end point.

A tonic -clonic grand mal seizure.

It's a disaster because it cuts off oxygen to the baby and can cause a placental abruption.

The only cure for preeclampsia and eclampsia is delivery of the baby in placenta.

So how do we manage this and try to prevent the seizures?

The book calls magnesium sulfate the gold standard.

It is.

Magnesium sulfate is given intravenously.

It's a CNS depressant.

It works by calming down that hyper excitable nervous system to prevent seizures.

It's important to note it's not actually a blood pressure medication.

That's a common misconception.

While it might lower the blood pressure slightly, that's not its primary purpose.

We give other medications like libetalol or hydrolazine for the blood pressure itself.

Magnesium is purely a brain protector.

But it's also a very dangerous drug.

You have to monitor for toxicity.

Constantly.

It's usually a one -to -one nursing situation.

Because it's a depressant, if the levels get too high, it will depress everything.

So what's the first sign of toxicity?

The first thing you'll see is the loss of deep tendon reflexes.

That's why the nurse has to check them hourly with a reflex hammer.

If the reflexes become sluggish or absent, you have to stop the infusion.

And if it progresses?

The next thing to go is the respiratory drive.

Her breathing will become slow and shallow and she can go into respiratory rest.

You also watch urine output because the kidneys excrete magnesium.

If urine output drops below 30 millimellars per hour, the levels can bill up to toxic range very quickly.

And if you see signs of toxicity, there's an antidote, right?

Yes.

And it must be at the bedside at all times.

The antidote is calcium gluconate.

Okay.

Let's switch gears to a different kind of complication.

Blood incompatibility.

We're talking about RH factor.

Figure 5 .6 in the book has a great diagram of this.

Right.

So this is all about the RH factor, which is the little positive or negative sign on your blood type.

The problem arises when the mother is RH negative and the fetus is RH positive.

Exactly.

The baby inherits the RH positive factor from the father.

So you have a mismatch.

But the text is clear that the first baby is usually unaffected by this.

Why is that?

Because maternal and fetal blood don't normally mix during the pregnancy.

The placenta keeps them separate.

The problem happens at delivery.

When the placenta separates.

Right.

When the placenta detaches, there's almost always a small bleed where some of the baby's RH positive blood cells get into the mother's RH negative circulation.

And her body sees those cells as foreign.

Like a virus or bacteria.

Her immune system says this doesn't belong here.

And it creates antibodies to destroy those RH positive cells.

This process is called isoimmunization or sensitization.

So once she has those antibodies, she has them for life.

And the problem is the next pregnancy.

Exactly.

If she gets pregnant again with another RH positive baby, those antibodies she made are now primed and ready.

They're small enough to cross the placenta and they will attack the new fetus's red blood cells.

What does that do to the fetus?

It causes severe anemia, which can lead to heart failure, massive swelling, a condition called Hydrops fetalis, and death.

It's devastating.

But it's also almost entirely preventable now.

It is.

With a medication called Rho -D, immune globulin.

The brand name in Canada is often WinRho.

How does it work?

You can think of it like a cloaking device.

It's an injection of passive antibodies.

We give it to the RH negative mother at 28 weeks gestation.

And again, within 72 hours after she gives birth, if the baby is RH positive.

And what does it do?

It finds and destroys any of those stray fetal RH positive cells in her bloodstream before her own immune system has a chance to notice them and make its own permanent antibodies.

So it prevents her from ever becoming sensitized.

Exactly.

And the text also notes it needs to be given after any event where blood might mix after a miscarriage, an abortion, an amniocentesis, or any abdominal trauma.

A true triumph of preventative medicine.

It really is.

Okay, let's move into the next major section.

Pregnancy complicated by medical conditions.

The first and biggest one discussed is diabetes mellitus.

This is a huge topic.

The physiology of pregnancy and diabetes is fascinating.

So what's the connection?

Pregnancy itself is a diabetogenic state.

It naturally creates a state of insulin resistance.

Why would the body do that?

The placenta produces hormones like human placental lactogen that actively block the mother's insulin.

The purpose is to keep more glucose circulating in the mother's bloodstream.

So there's plenty available to be transported across the placenta to the growing fetus.

So the fetus gets a steady supply of fuel,

but that means the mother's pancreas has to work harder.

Way harder.

It has to pump out two to three times the normal amount of insulin to overcome that resistance and keep her own blood sugar in a normal range.

And if her pancreas can't keep up with that demand?

That's when she develops gestational diabetes mellitus, or GDM.

So what are the risks of having high blood sugar during pregnancy?

What does it do to the baby?

This is the key concept.

Glucose crosses the placenta freely, but the mother's insulin does not.

Okay.

So the baby is essentially swimming in a high sugar environment.

In response, the baby's own pancreas starts working over time, producing massive amounts of its own insulin.

And what does all that fetal insulin do?

In a fetus, insulin acts like a growth hormone.

It tells the body to store all that extra sugar as fat.

So you get a condition called macrosomia, a very, very large baby.

The text defines it as over 4 ,000 grams, or about 8 pounds 13 ounces.

And that causes problems at birth.

Big problems.

Risk of shoulder dystocia, birth trauma, and a higher rate of c -sections.

And what happens to the baby right after it's born?

This is the other major risk.

As soon as the umbilical cord is cut, that high sugar supply from the mother is instantly gone.

But the baby's pancreas doesn't know that.

Exactly.

It's still in overdrive, pumping out huge amounts of insulin.

Result is a precipitous drop in the baby's blood sugar.

Severe hypoglycemia, which can cause jitteriness, poor feeding, and even seizures in the newborn.

So it's critical to monitor their blood sugar after birth.

Very critical.

The chapter includes table 5 .5, which compares the signs of hypoglycemia and hyperglycemia.

This is need to know for nurses.

The signs of hypoglycemia low blood sugar are tremors, sweating, hunger, weakness, irritability.

If a patient has these, you need to give them a fast -acting sugar immediately.

Juice, milk,

glucose tablets.

And hyperglycemia, high blood sugar.

That looks different.

Fatigue, flushed hot skin, dry mouth, excessive thirst, and a fruity odor to the breath.

Okay.

The next medical condition is heart disease.

This is a serious one.

The main issue here is the massive increase in blood volume during pregnancy.

How much does it increase?

By 40 to 50 percent.

That is a huge additional workload for the heart to pump.

A healthy heart can handle it, but if a woman has a pre -existing condition, like a congenital heart defect or a damaged valve, this strain can push her into congestive heart failure.

Box 5 .4 in the book lists the key signs of heart failure to watch for.

Right.

And there are things like a frequent moist cough, sometimes with blood -tinged sputum.

Chemoptysis.

Exactly.

Severe pitting edema, extreme fatigue, and orthopnea.

The inability to breathe while lying flat because fluid is backing up into the lungs.

Labor must put an incredible strain on the heart.

It's the most dangerous time.

The goal is to minimize her exertion.

Vaginal birth is actually preferred over a C -section because the fluid shifts with surgery are often harder on the heart.

So how do they minimize exertion during a vaginal birth?

They often provide excellent pain relief with an epidural.

And to shorten the second stage of labor, they will often use forceps or a vacuum to help deliver the baby so the woman doesn't have to do a lot of strenuous pushing, which can cause dangerous shifts in blood pressure.

And what about anticoagulants?

Some women with heart conditions are on them.

This is a key point.

If she needs an anticoagulant, the drug of choice during pregnancy is heparin.

Why heparin?

Because its molecules are too large to cross the placenta so it doesn't affect the fetus.

The other common one, warfarin or coumadin, is teratogenic.

It's known to cause birth defects so it's avoided.

Let's quickly touch on anemia.

Iron deficiency anemia is the most common type.

The big teaching point for the nurse here is about absorption.

You have to teach the patient to take her iron supplement with a source of vitamin C, like orange juice.

Why is that?

Vitamin C dramatically increases the absorption of iron.

And you also have to teach her what not to take it with.

Like what?

Milk, tea, coffee or antacids.

They all block iron absorption.

And you have to warn them about their stools.

You do.

You have to say, your bowel movements are going to turn black or dark green.

This is a normal and expected side effect of the iron.

It does not mean you are bleeding.

That's a very important piece of anticipatory guidance.

It prevents a lot of panic.

The chapter also brings up the topics of obesity and bariatric surgery.

Right.

And this is increasingly common.

Obesity is a risk factor for almost everything we've talked about so far.

Gestational diabetes, hypertension, preeclampsia.

For women who've had bariatric surgery, the concern is different.

It's about nutrient absorption.

They can't absorb vitamins and minerals as well.

Exactly.

And they are prone to something called dumping syndrome.

They need very close nutritional monitoring throughout the pregnancy to make sure both they and the baby are getting everything they need.

Okay.

That covers the major medical conditions.

Now let's dive into infections.

The book uses the classic acronym, TORCH.

It does.

TORCH stands for Toxoplasmosis, Other, Rubella, Cytomegalovirus, and Herpes.

It's a way to remember some of the key infections that are known to cause birth defects.

Let's pull out some of the most important nursing points for a few of these.

Rubella.

Rubella or German measles.

If a mother gets this during pregnancy, it can cause devastating defects like deafness, blindness,

heart defects, and microcephaly.

But there's a vaccine for it.

There is.

The MMR vaccine.

The key nursing point is that this is a live virus vaccine.

Therefore, it absolutely cannot be given during pregnancy.

So what do we do?

We screen all women for rubella immunity at their first prenatal visit.

If a woman is found to be nonimmune, we teach her to avoid anyone who might be sick, and then we give her the vaccine strictly postpartum after she delivers.

Okay.

What about herpes?

General herpes.

The main concern here is transmission to the baby during a vaginal birth.

Which can be catastrophic for the newborn.

It can cause neonatal herpes, which has a very high mortality rate and can cause severe brain damage.

So the rule is, if the mother has any active, visible herpetic lesions in the genital area at the time of labor,

a cesarean birth is mandatory.

To bypass the infected area.

Exactly.

Hepatitis B.

We screen every single pregnant woman for hepatitis B.

If the mother is positive, we can prevent transmission to the infant.

Within 12 hours of birth, the infant receives two injections.

One is hepatitis B immune globulin, which is a dose of ready -made antibodies, and the other is the first dose of the hepatitis B vaccine.

This combination is over 95 % effective at preventing the baby from becoming a chronic carrier.

Okay, let's talk about GBS.

Group B streptococcus.

This one can be confusing for parents because the mother isn't sick at all.

That's the key thing to explain.

GBS is a type of bacteria that lives normally and harmlessly in the vagina and rectum of about 25 % of healthy women.

It doesn't cause them any problems.

But it's a problem for the baby.

It can be a huge problem.

If the baby is exposed to and colonized by the bacteria during its passage through the birth canal, it can develop a very serious rapid onset infection in the first few days of life.

GBS sepsis, pneumonia, or meningitis.

So how do we present that?

We do universal screening.

A vaginal and rectal swab is collected from every pregnant woman between 35 and 37 weeks.

And if she tests positive?

Then she is treated with intravenous antibiotics, usually penicillin, during labor.

The goal is to knock down the number of bacteria in the vagina right before the baby comes through, which dramatically reduces the risk of transmission.

Okay, let's move on to the next section, environmental hazards.

The first topic is teratogens.

A teratogen is any substance, a drug, a chemical, an infection, that can cause a birth defect.

And the text emphasizes that timing is everything.

What do you mean by that?

Exposure during the first eight weeks of pregnancy, the period of organogenesis when all the organs are forming, is most likely to cause a major structural defect, like a heart defect or a cleft palate.

And exposure later on.

Later exposure is more likely to cause problems with growth, like intrauterine growth restriction or functional problems like brain development.

The chapter then goes into specific substances.

Let's start with alcohol.

The text is unequivocal on this.

There's no known safe amount of alcohol to drink during pregnancy.

And the risk is fetal alcohol spectrum disorder, or FASD.

Right.

It's a range of effects, but the most severe form includes distinct facial features,

growth restriction, and most devastatingly permanent, irreversible brain damage that leads to lifelong learning and behavioral problems.

It is 100 % preventable.

What about opioids?

If a mother uses opioids during pregnancy, the baby will be born physically dependent on the drug.

This leads to a condition called neonatal opioid withdrawal syndrome,

or NOWS.

What does that look like in a newborn?

These babies are miserable.

They have a high -pitched, inconsolable cry.

They have tremors.

They can't eat or sleep well.

They have vomiting and diarrhea.

They're in withdrawal.

The nursing approach here is really important.

It emphasizes a non -judgmental harm reduction approach.

Yes.

The text talks about methadone maintenance therapy.

The goal is not to force a woman into a dangerous withdrawal during pregnancy, because that can harm the fetus.

The goal is to get her onto a stable, legal, prescribed dose of methadone.

Why is that better?

It prevents the highs and lows of illicit drug use.

It reduces her risk -taking behaviors.

And it brings her into the health care system so she can get consistent prenatal care.

It's about meeting her where she is and keeping her and the baby as safe as possible.

Okay.

Let's talk about trauma during pregnancy.

The book states that trauma is the leading non -obstetrical cause of death in pregnant women.

From what?

Things like motor vehicle accidents and falls.

But the chapter also makes a very strong point about screening for intimate partner violence, or IPV.

Because the risk goes up during pregnancy.

It often begins or escalates during pregnancy.

It is absolutely essential that the nurse screens every single woman for IPV and that it's done when she is alone in a private safe space.

The chapter has a specific box, box 5 .8, on CPR modifications for a pregnant woman.

This is critical, life -saving information.

It is.

If a pregnant woman goes into cardiac arrest, you cannot just lay her flat on her back and start chest compressions.

Why not?

Because in the second half of pregnancy, the heavy uterus will compress the inferior vena cava, the major vein that returns blood from the lower body to the heart.

This is called supine hypotension.

So no blood gets back to the heart.

And if no blood is returning to the heart, there's nothing for the heart to pump.

Your chest compressions will be completely ineffective.

So what's the modification?

You must manually displace the uterus to the left.

You can do that by putting a wedge or a rolled up blanket or even just someone's knee under her right hip to tilt her entire body about 15 to 30 degrees to the left.

And that gets the weight of the uterus off the vena cava.

And allows blood to return to the heart so your CPR can actually work.

It's a simple stick that can be the difference between life and death.

That is so important to know.

Okay, as we wrap up, the chapter ends by talking about the psychosocial impact of a high -risk pregnancy.

And this brings us full circle.

A high -risk diagnosis disrupts everything for a family.

Roles have to change.

If a mother is on bed rest, she can't work.

She can't care for her other children.

This creates immense financial and emotional stress.

And the book talks about something called delayed attachment.

Yes.

This is a really important concept.

It's a form of self -protection.

The parents might be so afraid that they're going to lose the baby that they emotionally withdraw from the pregnancy.

So they don't buy baby clothes or they don't want to talk about names.

Exactly.

They're afraid to bond.

Because they think the potential loss will hurt less if they haven't allowed themselves to get attached.

The nurse needs to recognize this isn't bad parenting.

It's a coping mechanism driven by profound fear.

And the nurse's role is to support them through that.

To listen.

To provide information.

To connect them with resources like social workers or support groups.

We have covered such a huge amount of ground today.

From the very first danger signs all the way through bleeding, hypertension,

diabetes, trauma.

It's a massive chapter.

But I think if you look for the common thread, it's always the nurse's role.

It's about astute assessment, knowing what to look for, what the signs mean.

And it's about education empowered the patient and her family with the knowledge they need to be partners in their care.

What really stands out to me is that constant balance between the high tech and the high touch.

You're managing a magnesium sulfate drip one minute, which is very technical.

And the next minute you're sitting with a family who has just lost their baby.

And your only job is to just be a compassionate human being.

That is the absolute essence of maternity nursing.

You have to be technically brilliant to catch the subtle signs of preeclampsia.

But you have to be emotionally present to support a mother through the terror of a high risk diagnosis.

I'd like to leave our listeners with a final thought on that.

We talked about delayed attachment.

That idea of parents holding back their love out of fear.

So as you're studying all these clinical facts, the lab values, the drug doses, the BKP scores, I want you to also consider the immense emotional weight these diagnoses carry.

How do you, as a future nurse, plan to balance your technical competence with that profound empathy that's required when what's supposed to be a happy event turns into a medical crisis?

That is the question.

And answering it well is what defines a great nurse.

Thank you so much for joining us for this deep dive into Chapter 5.

A warm thank you from the Last Minute Lecture Team.

Good luck with your studies.

Good luck, everyone.