Editing Maternal and Newborn Nursing (section)

== Antepartum Complications ==

=== Hypertensive disorders ===

* '''Chronic hypertension''': present before pregnancy or before 20 weeks.
* '''Gestational hypertension''': new hypertension after 20 weeks without proteinuria or severe features.
* '''Preeclampsia''': after 20 weeks, blood pressure of 140/90 mm Hg or higher on two occasions at least 4 hours apart, ''plus'' proteinuria (300 mg or more per 24 hours, protein to creatinine ratio of 0.3 or more, or 2+ dipstick when other methods are unavailable). Preeclampsia can also be diagnosed '''without proteinuria''' if new hypertension is accompanied by thrombocytopenia, elevated liver enzymes, renal insufficiency, pulmonary edema, or new cerebral or visual symptoms. The underlying problem is abnormal placental development with widespread endothelial dysfunction and vasospasm, which is why it affects the brain, liver, kidneys, lungs, platelets, and placenta all at once.
* '''Severe features''' include systolic 160 mm Hg or higher or diastolic 110 mm Hg or higher, platelets below 100,000/mm3, transaminases roughly twice normal or severe persistent right upper quadrant pain, creatinine above 1.1 mg/dL or doubled, pulmonary edema, and new cerebral or visual disturbance.
* '''Eclampsia''': generalized seizure in a patient with preeclampsia, not explained by another cause.
* '''HELLP syndrome''': '''H'''emolysis, '''E'''levated '''L'''iver enzymes, '''L'''ow '''P'''latelets. It may present with malaise and right upper quadrant pain and can occur with only mildly elevated blood pressure, so it is missed if the nurse anchors on blood pressure alone.

'''Nursing care.''' Definitive treatment is birth. Until then: quiet low-stimulation environment, seizure precautions with suction and oxygen at the bedside, strict intake and output, deep tendon reflexes and clonus, serial blood pressures, daily weights, fetal surveillance, and teaching the patient to report headache, visual change, and epigastric pain.

'''Magnesium sulfate''' is given for '''seizure prophylaxis''', not to lower blood pressure. It is a central nervous system depressant and a smooth muscle relaxant, typically a loading dose followed by a continuous infusion on a pump. Monitor '''deep tendon reflexes, respiratory rate, level of consciousness, urine output, and fetal heart rate'''.
* Earliest reliable sign of toxicity: '''loss of deep tendon reflexes'''. Then respiratory depression (respirations below 12 per minute), then decreased level of consciousness, then cardiac arrest.
* Urine output below 30 mL/hour is a red flag because magnesium is cleared renally and will accumulate.
* '''Antidote: calcium gluconate IV''', kept immediately available whenever magnesium is infusing.
* Expect flushing, warmth, and sedation; these are effects, not toxicity. Newborns of mothers on magnesium may be hypotonic and sleepy with respiratory depression.

Acute severe hypertension is treated with '''IV labetalol, IV hydralazine, or oral immediate-release nifedipine'''. '''ACE inhibitors and ARBs are contraindicated in pregnancy''' because of fetal renal injury and death.

=== Bleeding disorders ===

{| class="wikitable"
! !! Placenta previa !! Placental abruption
|-
| Bleeding || Painless, bright red, sudden onset || Painful, often dark red; may be '''concealed''' with little visible blood
|-
| Uterus || Soft, nontender, relaxed || Rigid, board-like, tender; frequent low-amplitude contractions
|-
| Key risk factors || Prior cesarean or uterine surgery, prior previa, multiparity, multiple gestation, advanced age, smoking || Hypertension and preeclampsia, cocaine use, abdominal trauma, smoking, prior abruption, PPROM
|-
| Critical nursing rule || '''No vaginal or digital cervical exam''' || Monitor for DIC and hypovolemic shock; prepare for possible emergency birth
|}

Other first-trimester bleeding causes include spontaneous abortion, '''ectopic pregnancy''' (unilateral pelvic pain, missed period, positive hCG, possible referred shoulder pain and syncope from hemoperitoneum; a surgical emergency if ruptured), and '''gestational trophoblastic disease''' (molar pregnancy: markedly elevated hCG, uterus larger than dates, grape-like vesicles, hyperemesis, early-onset hypertension; requires hCG follow-up and strict contraception because of choriocarcinoma risk).

=== Preterm labor and PPROM ===

'''Preterm labor''' is regular contractions with cervical change between 20 0/7 and 36 6/7 weeks. Teach patients that preterm labor can feel like low dull backache, pelvic pressure, menstrual-like cramping, increased or changed vaginal discharge, and vague abdominal tightening, not necessarily classic painful contractions.

* '''Tocolytics''' (nifedipine, indomethacin before 32 weeks, terbutaline for short-term use only) buy roughly 48 hours, and that time is the point.
* '''Antenatal corticosteroids''' (betamethasone 12 mg IM in two doses 24 hours apart, or dexamethasone) accelerate fetal lung maturity and reduce respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. Benefit is greatest 24 hours to 7 days after the first dose.
* '''Magnesium sulfate before about 32 weeks''' is given for '''fetal neuroprotection''' (reduced cerebral palsy), a different indication from seizure prophylaxis.

'''PPROM''' (preterm premature rupture of membranes) is rupture before 37 weeks and before labor. Priorities are avoiding infection (limit vaginal exams, monitor temperature, pulse, and uterine tenderness for chorioamnionitis) and watching for '''cord prolapse'''. Confirm rupture by pooling on sterile speculum exam, nitrazine paper turning blue (alkaline amniotic fluid), and ferning on microscopy. Blood, semen, and vaginal infection cause false-positive nitrazine results.

=== Other antepartum conditions ===

* '''Hyperemesis gravidarum''': intractable vomiting with weight loss above about 5 percent, dehydration, ketonuria, and electrolyte imbalance. Care is IV fluids, electrolyte correction, antiemetics, and thiamine before glucose-containing fluids in prolonged vomiting.
* '''Gestational diabetes''': target values commonly taught are fasting below 95 mg/dL, 1 hour postprandial below 140 mg/dL, and 2 hours postprandial below 120 mg/dL. Insulin is the traditional first-line pharmacologic agent because it does not cross the placenta. Insulin requirements ''rise'' through pregnancy as placental hormones create insulin resistance, then '''drop sharply immediately after the placenta is delivered''', which is when postpartum hypoglycemia occurs. Fetal and neonatal risks include macrosomia, shoulder dystocia, birth injury, neonatal hypoglycemia, hyperbilirubinemia, and respiratory distress syndrome.
* '''Anemia, infection, cardiac disease, and substance use''' all raise risk. TORCH infections (toxoplasmosis, other such as syphilis and parvovirus B19, rubella, cytomegalovirus, herpes simplex) cause congenital injury. Active genital herpes lesions at the onset of labor are an indication for cesarean birth.