Care of Mother and Child At-Risk or with

Problems (Acute and Chronic)-Lecture

INSTRUCTOR’S GUIDE BS NURSING / SECOND YEAR
Session # 4

LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT

CLIENT (PRE-GESTATIONAL CONDITIONS- RH Materials: Book, pen and notebook, index
SENSITIZATION AND HIV/AIDS) card/class list, speaker and LCD projector

LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:

1. Define Rh sensitization in relation to pregnancy,

including pre-existing factors that contribute to its
development. Reference:
2. Integrate knowledge of Rh Sensitization in relation to
pregnancy and nursing process to achieve quality Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
maternal and child health nursing care. Maternal and Child Health Nursing, 8th Edition.
3. Identify the difference HIV/AIDS and its effect to USA: Lippincott Williams and Wilkins
pregnancy, including preexisting factors that contribute
to its development.
4. Integrate knowledge of HIV/AIDS to nursing process to
achieve quality maternal and child health nursing care.

LESSON REVIEW/PREVIEW (5 minutes)

To the students: Identify what are the inherited diseases that can be pass on to their children.

MAIN LESSON (50 minutes)

(Chapter 21: Nursing Care of A Family Experiencing a Sudden Pregnancy Complication-Isoimmunization, p.558.Chapter
26: Nursing Care of Family with a High Risk Newborn-Illnesses that Occur in Newborns. P. 704)

HEMOLYTIC DISEASE OF THE NEWBORN

- is caused by either Rh or ABO incompatibility

*Mother produces antibodies that destroy RBCs of the fetus; hemolysis results in fetal anemia and hyperbilirubinemia

 occurs when fetal red blood cells (RBCs) which possess an antigen that the mother lacks
 cross the placenta into the maternal circulation, where they stimulate antibody production.
 The antibodies return to the fetal circulation and result in RBC destruction.

DIFFERENTIAL DIAGNOSIS of hemolytic anemia in a newborn infant:

 Isoimmunization
 RBC enzyme disorders (e.g., G6PD, pyruvate kinase deficiency)
 Hemoglobin synthesis disorders (e.g., alpha-thalassemias)
 RBC membrane abnormalities (e.g., hereditary spherocytosis, elliptocytosis)
 Hemangiomas (Kasabach Merritt syndrome)
 Acquired conditions, such as sepsis, infections with TORCH or Parvovirus B19 (anemia due to RBC aplasia)
and hemolysis secondary to drugs.

ISOIMMUNIZATION
1. ABO Incompatibility 2. RH INCOMPATIBILITY
Occurs when maternal blood type is O and fetus is Rh (D) factor is a protein antigen present on the
a. Type A- most common surface of some people’s RBC (Rh+)
b. Type B- most serious
c. Type AB- rare 1. Antibodies vs Rh antigen are not naturally-occurring but

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 1 of 7
 are produced when Rh+ blood enters the bloodstream of
1. The mother has inborn antibodies vs blood type A and B an Rh- person.
in her bloodstream. If fetus has type A or B blood and if 2. The Rh + gene is a dominant and therefore if either the
maternal and fetal blood mix, maternal antibodies will mother or the father or both parents are Rh+, the baby will
perceive the fetal RBC as an antigen and will destroy it be Rh+

2. Uncommon during pregnancy since antibodies is the Rh Sensitization/Rh Isoimmunization- It is the exposure
large IgM type & cannot cross placental barrier of Rh- blood to Rh+ blood resulting to production anti-Rh
abs
3. During delivery when placenta separates from the
decidua, the barrier is broken allowing maternal blood to It can occur through:
enter the fetal bloodstream.  Sensitization from previous pregnancy (Rh- mom
with Rh+ baby)
4. Maternal antibodies will then destroy fetal RBCs after  Inadequate response to prophylaxis
birth  Incompatible blood transfusion
5. Thus, signs of hemolytic disease will manifest several
hours after delivery -Insignificant amount of antibodies are formed
during pregnancy thus, 1 st baby is not greatly affected.
CLINICAL PRESENTATION -Greatest exposure occurs during placental
 generally less severe than with Rh disease. separation which causes massive production of anti Rh
abs during 1st 72 hrs postpartum
LABORATORY FINDINGS -Rh+ fetuses in future pregnancies will be affected
 Smear: microspherocytosis -Fetal anemia results & to compensate, fetal bone
 Mean Corpuscular Volume (MCV) <95, microcytic marrow produces immature RBCs(erythroblasts) causing
for a newborn (normal for adult) Erythroblastosis Fetalis
 Direct Coombs test is often weakly +.
ERYTHROBLASTOSIS FETALIS
MANAGEMENT -Fetal anemia may be so profound that it kills the
A. Preparation prior to delivery should include: fetus
 Blood: type O Rh negative packed RBCs, cross- -RBC destruction causes massive production &
matched against the mother. accumulation of bilirubin as the immature liver is unable to
 For severe HDN, have blood in the Resuscitation clear them from the body leading to
Room to correct severe anemia immediately after HYPERBILIRUBINEMIA & KERNICTERUS
birth by partial exchange transfusion (ExTx).
 Anticipate need for later ExTx for Fetal Complications of Erythroblastosis Fetalis
hyperbilirubinemia and have additional blood for 1. Anemia
these. 2. Splenomegaly & hepatomegaly
 Surfactant, if infant is preterm. 3. Hyperbilirubinemia
4. Hydrops fetalis- as organs are not perfused
 Catheters (e.g., angiocaths) for immediate
drainage of hydropic fluid. properly, the heart will eventually decompensate; fluid
builds up resulting to edema
5. Stillbirth
B. Resuscitation
 Obtain cord blood for bilirubin (total & direct),
albumin, blood type & Rh, Direct Coombs test,
CBC, platelets, reticulocyte count and nucleated
RBCs.
 assisted ventilation with oxygen. If ventilation is
difficult, drain pleural and ascitic fluid; during
paracentesis, take care to avoid puncturing the
enlarged liver and spleen.
 Insert umbilical arterial (UAC) and venous
catheters (UVC) and immediately measure blood
pressures, arterial pH and blood gas tensions,
hematocrit (Hct) and blood sugar.
 Correct metabolic acidosis with alkali, but only if
giving assisted ventilation
 Correct anemia, which is essential for effective
resuscitation.
 Do not infuse packed RBCs or blood through UAC

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 2 of 7
 because of risk of damage to spinal cord from
emboli.

Complications of Exchange Transfusion (ExTx):

 Hypocalcemia due to Ca++ binding by citrate.
Give Ca-gluconate 100 mg after every 100 mL of blood
exchanged.
 Hypoglycemia particularly after the ExTx, due to
dextrose load from anticoagulant of donor blood
and hyperinsulinism in HDN.
Thrombocytopenia and granulocytopenia due to washout
with the ExTx.
 Hyperkalemia, especially with older units of
blood.
 Hypothermia, associated with inadequate
warming of blood.
Prevention
1. Prenatal Screening
History: past pregnancies, BT, abortion, invasive diagnostic procedures during pregnancy
Blood typing & Rh typing
Coomb’s test (titer >1:16 indicates sensitization); indirect Coomb’s Test (maternal serum), direct Coomb’s Test
(cord blood); if negative, test at 16 to 20 wks and at 26-27 wks
Give RhIg aka anti Rho(D) gamma globulin(RhoGAM) at 28 wks and within 72h after delivery

2. RHOGAM should be given to all Rh- women who:

Have delivered Rh+ babies
Have had untypeable pregnancies such as ectopic pregnancies, stillbirth & abortion
Have received ABO compatible Rh+ blood
Have had invasive dx procedures like amniocentesis or Chorionic Villi Sampling

Management
1. Amniocentesis q 2wks beginning at 26 wks to monitor bilirubin
2. Percutaneous umbilical blood sampling at 18-20 wks if bilirubin levels are high
3. Intrauterine Blood fetal transfusions (IUFT) at 10-day to 2-week intervals until 34-36 wks
HIV/AIDS

 HIV infection and AIDS can be caused by placental transfer or direct contact with maternal blood during birth.
 HIV is a slowly replicating retrovirus and has at least two main divisions, HIV-1 and HIV-2, followed by a variety of
further subtypes.
 The virus acts by attacking the lymphoreticular system, in particular CD4-bearing helper T lymphocytes.
 The virus enters the cell, substitutes its own RNA and DNA for the cell’s DNA, and begins to replicate, destroying
the lymphocytes in the process as well as their ability to initiate an effective B-lymphocyte response.
(Chapter 42: Nursing Care of A Family with an Immune Disorder, p.1174)

ETIOLOGIC AGENT:

1. retrovirus that targets helper T lymphocytes (T4 cells) that contain the CD4 antigen (which regulates normal immune
response) making the patient susceptible to opportunistic infections
2. Present in infected person’s blood, semen, and other body fluids

Risk factors: Assessment

1. Multiple sexual partners of the individual or Early Symptoms:
sexual partner 1. Fatigue
2. Bisexual partner, MSM 2. Anemia
3. IV drug use by the individual or partner 3. Diarrhea
4. Others: BT, tattoo, etc 4. Weight loss
5. Lymphadenopathy
6. Night sweats

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 3 of 7
Stages:

1. Initial invasion of virus with mild, flulike symptoms

2. Seroconversion- production of antibodies vs HIV; happens in 6 weeks to 1 year
3. Asymptomatic period for 3 to 11 years
4. Symptomatic period with opportunistic infections & possibly malignancies (CD4 cell count < 200cells/mm3)
5. Toxoplasmosis, tuberculosis
6. Oral & vaginal candidiasis
7. GIT illnesses
8. Kaposi sarcoma
9. P. carinii pneumonia (PCP)- most common opportunistic infection
10. Herpes simplex
11. HIV-associated dementia

KAPOSI SARCOMA-is a cancer that causes patches of PCP (Pneumocystis Carinii Pneumonia)- a life-
abnormal tissue to grow under the skin, in the lining of threatening lung infection that can affect people with
the mouth, nose, and throat, in lymph nodes, or in other weakened immune systems, such as those infected with
organs. These patches, or lesions, are usually red or HIV, the virus that causes AIDS.
purple.

Assessment Management

1. ELISA test- if (+) 2x then 1. Monitor CD4+ T cell counts.

2. Western Blot Test- confirmatory test 2. Goal: maintain CD4 cell count > 500 cells/ mm3.
3. In late infection, CD4+ T cell count <200cells/ul 3. Antiretroviral therapy: oral Zidovudine during
4. Presence of opportunistic infections pregnancy & IV during labor & delivery) plus1 or
5. 20-50% of infants born to untreated HIV +
women will contract the virus & develop AIDS in more protease inhibitors like ritonavir (Norvir) or
the 1st year of life indinavir (Crivixan) in conjunction with a nucleoside
reverse transcriptase inhibitor drug.
4. Neonate is also given zidovudine
5. Breastfeeding is not recommended
6. Educate client on safe sex practices, testing of sex
partners
7. Monitor client for signs of opportunistic infection:
fever, weight loss, fatigue, candidiasis, cough, skin
lesions
8. CS delivery-performed before rupture of
membranes
9. If vaginal delivery is unavoidable, no episiotomy!

CHECK FOR UNDERSTANDING (30 minutes)

The instructor will prepare 10-15 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 4 of 7
Multiple Choice

(For 1-10 items, please refer to the questions in the Rationalization Activity)

RATIONALIZATION ACTIVITY (DURING THE FACE TO FACE INTERACTION WITH THE STUDENTS)
The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss
among their classmates.

1. A 26-week pregnant client was diagnosed with ABO incompatibility. She asked you what her diagnosis means.
Which of the following is incorrect regarding ABO incompatibility?
A. The mother has inborn antibodies vs blood type A and B in her bloodstream.
B. Uncommon during pregnancy since antibodies is the large IgM type & cannot cross placental barrier
C. During delivery when placenta separates from the decidua, the barrier is broken allowing maternal blood to enter the
fetal bloodstream.
D. Antibodies vs Rh antigen are not naturally-occurring but are produced when Rh+ blood enters the bloodstream of an
Rh- person.
ANSWER: D
RATIONALE: Antibodies vs Rh antigen are not naturally-occurring but are produced when Rh+ blood enters the
bloodstream of an Rh- person refers to Rh incompatibility.

2. An 18-week pregnant client ask you what is Rh incompatibility. Which of the following is correct regarding Rh
Incompatibility? EXCEPT:
A. Rh (D) factor is a protein antigen present on the surface of some people’s RBC (Rh+)
B. Antibodies vs Rh antigen are not naturally-occurring but are produced when Rh+ blood enters the bloodstream of an
Rh- person.
C. The mother has inborn antibodies vs blood type A and B in her bloodstream.
D. The Rh + gene is a dominant and therefore if either the mother or the father or both parents are Rh+, the baby will be
Rh+
ANSWER: C
RATIONALE: The mother has inborn antibodies vs blood type A and B in her bloodstream refers to ABO incompatibility
not with Rh incompatibility.

3. Kyra a client who gave birth to a female newborn and was diagnosed as having ABO incompatibility. Which of
the following is incorrect for the laboratory findings of a newborn with ABO incompatibility?
A. Blood Smear result is microspherocytosis
B. <95, microcytic for a newborn
C. Direct Coombs test is often weakly +
D. Direct Coombs test is often weakly –
ANSWER: D
RATIONALE: A negative Coombs test indicates that the fetus is not presently in danger from problems relating to Rh
incompatibility. An abnormal (positive) result means that the mother has developed antibodies to the fetal red blood cells
and is sensitized.

4. Kyra’s child was ordered to have Exchange Transfusion. She asked you what are the possible complications of
the procedure. The following are complications of Exchange Transfusion, EXCEPT:
A. Hypothermia
B. Hypocalcemia
C. Hyperkalemia
D. Hypoglycemia
E. Hypernatremia
ANSWER: E
RATIONALE: The potential complications of exchange transfusion are: infection, rebound hypoglycemia, hypocalcemia
(due to citrate anticoagulant in the transfused blood), hyperkalemia (if older red cells are used), late onset alkalosis,
volume overload, hemolysis, thrombocytopenia, neutropenia, coagulopathy, Graft versus host disease (GvHD) and
hypothermia. These complications can be avoided or minimized by careful technique and good general patient care,
although because many of these patients are quite ill and unstable, exchange transfusion can be a risky procedure.

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 5 of 7
5. A patient was diagnosed with Habitual Abortion due to Rh incompatibility and had a fetal complication of
Erythroblastosis Fetalis. She asked you what will be the complication if she will get pregnant again. The
following are complications of Rh Incompatibility, EXCEPT:
A. Anemia
B. Splenomegaly & hepatomegaly
C. Hyperbilirubinemia
D. Wilms Tumor
E. Hydrops fetalis
ANSWER: D
RATIONALE: Wilms Tumor is a form of kidney cancer that primarily develops in children. Nearly all cases of Wilms tumor
are diagnosed before the age of 10, with two-thirds being found before age 5. Wilms tumor is often first noticed because
of abdominal swelling or a mass in the kidney that can be felt upon physical examination.

6. The following are true regarding HIV/AIDS, EXCEPT:

A. HIV infection and AIDS can be caused by placental transfer or direct contact with maternal blood during birth.
B. HIV is a slowly replicating retrovirus and has at least two main divisions, HIV-1 and HIV-2, followed by a variety of
further subtypes.
C. The virus acts by attacking the lymphoreticular system, in particular CD4-bearing helper T lymphocytes.
D. HIV/AIDS is spread through saliva.
ANSWER: D
RATIONALE: Contact between broken skin, wounds, or mucous membranes and HIV/AIDS infected blood or blood-
contaminated body fluids. Deep, open-mouth kissing if both partners have sores or bleeding gums and blood from the
HIV-positive partner gets into the bloodstream of the HIV/AIDS negative partner. HIV/AIDS is not spread through saliva.

7. Reme a pregnant client asked you what are the risk factors for having HIV/AIDS. The following are risk factors
of HIV/AIDS, EXCEPT:
A. Multiple sexual partners of the individual or sexual partner
B. Bisexual partner
C. IV drug use by the individual or partner
D. Deep, open-mouth kissing without mouth sores
ANSWER: D
RATIONALE: Deep, open-mouth kissing if both partners don’t have sores or bleeding gums. HIV/AIDS is not spread
through saliva.

8. A patient asked you regarding HIV/AIDS on what is Seroconversion. You know that Seroconversion is:
A. Seroconversion is the production of antibodies versus HIV that happens in 5 weeks to a year.
B. Seroconversion is the production of antibodies versus HIV that happens in 6 weeks to a year.
C. Seroconversion is the production of antibodies versus HIV that happens in 7 weeks to a year.
D. Seroconversion is the production of antibodies versus HIV that happens in 4 weeks to a year.
ANSWER: B
RATIONALE: Seroconversion is the production of antibodies versus HIV that happens in 6 weeks to a year.
Seroconversion is a sign that the immune system is reacting to the presence of the virus in the body. It's also the point at
which the body produces antibodies to HIV. Once seroconversion has happened, an HIV test will detect antibodies and
give a positive result.

9. A pregnant client was admitted with a lung infection that can affect people with weakened immune systems,
such as those infected with HIV, the virus that causes AIDS. Which of the following condition pertains to the
client’s condition?
A. Hospital Acquired Pneumonia
B. Community Acquired Pneumonia
C. Pneumocystis Carinii Pneumonia
D. Fungal Pneumonia
ANSWER: C
RATIONALE: PCP (Pneumocystis Carinii Pneumonia)- a life-threatening lung infection that can affect people with
weakened immune systems, such as those infected with HIV, the virus that causes AIDS.

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 6 of 7
10. You were conducting a physical examination to a pregnant client. Upon examining the skin of the patient you
saw red to purplish skin patches and was told that she is taking Zidovudine. You know that the patient is having:
A. Angiosarcoma
B. Fibroblastic Sarcoma
C. Kaposi’s Sarcoma
D. Leiomyosarcoma
ANSWER: C
RATIONALE: Kaposi’s Sarcoma is a cancer that causes patches of abnormal tissue to grow under the skin, in the lining
of the mouth, nose, and throat, in lymph nodes, or in other organs. These patches, or lesions, are usually red or purple.

LESSON WRAP-UP (5 minutes)

Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track
how much work they have accomplished and how much work there is left to do. This tracker will be part of the student
activity sheet.

You are done with the session! Let’s track your progress.
PERIOD 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
PERIOD 2
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
PERIOD 3
32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

AL STRATEGY: Minute Paper

1. Towards the end of the class, students are asked to use index cards or half-sheets of paper to provide written
feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. Collect the responses as or before the students leave. One way is to station yourself at the door and collecting
“minute papers” as student file out.
3. Respond to students’ feedback during the next class meeting or as soon as possible

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 7 of 7