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Perioperative Care of the Pregnant Surgical Patient
AUGUST 1994, VOL 60, NO 2
Home Study Program PERlOPERATlVE CARE OF THE PREGNANT SURGICAL PATIENT
he article “Perioperative care of the pregnant surgical patient” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Janet S. West, RN, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS(N), education coordinator, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn two contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Jan 3 1, 1995. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
BEHAVIORAL OBJECTIVES
After reading and studying the article on penoperative care of the pregnant surgical patient, the nurse will be able to (1) discuss the anatomic and physiologic changes in the pregnant surgical patient, ( 2 ) discuss the implications of these changes on the multidisciplinary approach to nursing care of the pregnant surgical patient, ( 3 ) describe general considerations in the penoperative care of the pregnant surgical patient, and (4) identify the penoperative nurse’s role when caring for the pregnant surgical patient.
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Perioperative Care of the Pregnant Surgical Patient culation. Red blood cell (RBC) mass only increases by 20%, contributing to the hemodilution or physiologic anemia associated with pregnancy. Due to this hemodilution, the woman's hematocrit decreases, but it should not fall below the 35% ratio of RBCs to plasma (normal range is 35% to 45% RBCs). The white blood cell (WBC) count increases from 6,000 to 12,000 (normal range is 4,000 to 10,000 WBCs) without underlying pathology. Clotting factors such as fibrinogen and factor VIII increase, resulting in a hypercoagulable state. Because of this, coagulopathy problems develop insidiously during pregnancy. Cardiac output increases 20% to 40% by the second trimester of pregnancy. The pregnant woman's heart rate increases by 15 to 20 beats per minute (BPM). Peripheral vascular resistance decreases to accommodate the increased plasma volume. Blood pressure decreases during the second ANATOMIC AND PHYSIOLOGIC trimester but approaches its prepregnant level by ALTERATIONS DURING PREGNANCY Perioperative management of the pregnant surgi- term.5 In the second and third trimesters of pregnancal patient requires a basic understanding of the nor- cy, the enlarging uterus compresses the vena cava when the patient is supine. ma1 physiologic and anatomic These normal hematologic changes that occur in the woman and cardiovascular changes of during pregnancy. Without this A B S T R A C T knowledge, pathologic conditions Successful perioperative pregnancy have profound implicacannot be distinguished from nor- management of the pregnant tions in the perioperative care of mal conditions. Alterations in each surgical patient requires a multi- the pregnant surgical patient. Due body system and their implications disciplinary nursing approach to to the increase in plasma volume, for the pregnant surgical patient decrease perinatal morbidity the pregnant patient may lose 30% are discussed separately and are and mortality. A comprehensive to 35% of her circulating volume summarized in Table 1. perioperative patient care plan before exhibiting signs and sympHematologic and cardiovas- and coordination with obstetric toms of shock. In addition, the decreased cular systems. During pregnancy, and neonatal team members the woman's plasma volume enhance the surgical outcome peripheral vascular resistance preincreases 30% to 50% above nor- for both the mother and her vents the development of cool, mal to accommodate the expand- child. A O R N J 60 (August clammy skin usually associated with shock. When compensatory ing uterine, placental, and fetal cir- 1 994) 205-2 16. he incidence of surgery during pregnancy ranges from 0.2% to 2.2%.' This percentage translates to 50,000 pregnant women undergoing surgery with anesthesia annually in the United States.2 Perinatal morbidity and mortality is higher in pregnancies in which maternal surgery occurs (eg, infant birth weights are lower at gestation, neonatal death is higher).3 The risk of preterm delivery also increases in women who undergo surgery during pregnan~y.~ When surgery during pregnancy is necessary, all health care providers must remember that there are two patients involved-the mother and the baby, whose survival is dependent on the mother's well-being. Special nursing interventions for the pregnant woman and her unborn child must be planned to ensure optimum maternal and fetal outcomes.
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Pon,ers
Table 1 PERIOPERATIVE NURSING CONSIDERATIONS FOR THE PREGNANT SURGICAL PATIENT
Affected body systems
Anatomic and physiologic alterations
Perioperative considerations
Cardiovascular
Physiologic anemia Increased cardiac output Increased heart rate Decreased peripheral vascular resistance
Maintain left lateral tilt in second and third trimesters. Monitor fetal heart rate continuously. Do not expect cool, clammy skin to develop in shock.
Respiratory
Increased tidal volume, respiratory rate Chronic compensated respiratory alkalosis Capillary engorgement of nasopharynx Diaphragm displaced upward as uterus grows
Administer supplemental oxygen. Suction and intubate gently to prevent epistaxis. Insert chest tubes1 to 2 interspaces above normal. Maintain pulse oximeter readings at 94% or greater.
Gastrointestinal
Decreased gastric motility Decreased gastroesophageal sphincter tone Increased gastric acid
Place nasogastric tube to prevent aspiration Administer antacids preoperatively to increase gastric pH and decrease gastric acid output. Expect displacement of appendix upward as gestation progresses.
Genitourinary
Urinary stasis, asymptomatic bacteriuria Increased uterine irritability from bladder distention and cystitis Bladder displaced out of pelvis by growing uterus Increased glomerular filtration rate
Avoid urinary catheterizationto prevent urinary tract infections. Assess bladder distention frequently. Be aware that bladder trauma is common in pregnant multitrauma victims. Maintain patient in a left lateral position to enhance urinary output.
Musculoskeletal
Stretched abdominal muscles Compressed, displaced abdominal organs
Use peritoneal lavage to diagnose intraabdominaltrauma. Place lavage calheter above the umbilicus in late pregnancy.
mechanisms are activated in acute blood loss, blood is shunted away from the uterus. Maintenance of maternal hemodynamic stability occurs at the expense of the fetus. Maternal shock cames an 80% fetal mortality rate.h Although the fetus has compensatory responses similar to an adult, the responses are brief, and hypoxia quickly ensues. Electronic fetal monitoring (EFM) allows continuous assessment and early detection of fetal compromise. Fetal monitoring also benefits the mother because it may detect ensuing maternal compromise before symptoms are apparent. The supine position in the second and third trimesters causes maternal hypotension in 30% of the pregnant p ~ p u l a t i o n Placing .~ a wedge under the woman’s right hip to displace the gravid uterus later-
ally is a simple and effective maneuver to prevent vena caval compression. The surgical team can accommodate this left lateral uterine displacement in Imost procedures without interfering with the surgery. Respiratory system. Pregnancy increases the woman’s metabolism, thus increasing her body’s oxygen demands. To compensate, the woman’s respiratory rate increases up to 15% greater than normal, and her pulmonary tidal volume increases 30% to 40%.RAs a result, the pregnant woman lives in a state of chronic, compensated respiratory alkalosis that changes her blood buffering system. Blood hydrogen ion concentration (pH) remains essentially unchanged even though the arterial partial pressure of oxygen (PO,) increases to 104 to 108 mm Hg, arterial partial pressure of carbon dioxide decreases 206
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Intraoperative placement of a nasogastric tube reduces
the pregnant patient’s risk of aspiration pneumonitis.
to 2 7 to 3 2 mm Hg, and plasma buffer bases decrease by an average of 5 I ~ E ~ / Pulmonary L.~ functional reserve capacity decreases because the gravid uterus elevates the diaphragm. Anatomic changes of pregnancy include capillary engorgement and swelling of the nasophaqnx. Epistaxis may occur with nasal airway placement or nasotracheal intubation.“’ The diaphragm becomes progressively elevated as the uterus grows and may be displaced upward as much as 4 cm. Chest tubes, when needed, should be inserted one to two interspaces above normal placement.” Increased oxygen demands and the higher metabolic rate associated with pregnancy combine to lower maternal oxygen reserve. Because the fetus possesses even less oxygen reserve than the mother, both individuals are extremely susceptible to hypoxia even during brief periods of apnea (eg, during suctioning, intubation). With an increased metabolism, the mother is vulnerable to hypoxic tissue damage. Fetal heart rate (FHR) changes are usually the first indicator of maternal hypoxia. It is imperative for the well-being of both the mother and fetus to keep the mother well oxygenated at all times. Maternal pulse oximeter readings should be maintained at levels greater than an oxygen saturation reading of 94%. Gastrointestinal system. Gastric motility decreases as a result of the body‘s increased progesterone secretion. The surgical team should approach the pregnant patient as having a full stomach regardless of when her last meal was reported to have been consumed. Nasogastric tubes should be placed promptly in the treatment of pregnant trauma patients to decrease the risk of aspiration. Gastroesophageal sphincter tone also is decreased in pregnancy, resulting in gastric acid reflux. In the third trimester, gastric acid secretion increases as intestinal motility decreases.’?
The risk of aspiration pneumonitis is higher during pregnancy, thus warranting aggressive medical management of gastric acid output preoperatively. The administration of 15 to 30 mL of sodium citrate approximately 30 minutes before surgery increases gastric pH. Some anesthesia care providers administer hydrogen ion receptor antagonists (eg, cimetidine, ranitidine) in combination with sodium citrate to raise the gastric pH even more.13 Genitourinary system. Urinary tract changes in pregnancy include dilation of the renal calices, pelves, and ureters.IS This dilation results in urinary stasis and asymptomatic bacteriuria; therefore, the pregnant patient is predisposed to pyelonephritis. Unnecessary urinary catheterization should be avoided to prevent the introduction of bacteria in the bladder that may result in a urinary tract infection. Bladder distention as well as cystitis cause uterine irritability, so the patient’s bladder should be kept empty. In addition, the bladder is displaced by the enlarged uterus out of the protection of the pelvis, causing the mother to be predisposed to traumatic bladder injury. Glomerular filtration rates increase up to 50% during pregnancy, causing medications to be excreted more rapidly.” Supine positioning in later pregnancy decreases urine output and glomerular filtration rates. Maintaining a lateral position in the pregnant patient enhances the patient’s kidney function. Musculoskeletal system. As pregnancy progresses, the woman’s abdominal muscles become stretched by the enlarging uterus. Compression and displacement of abdominal organs by the gravid uterus make diagnosing pathology or injury a challenge. In abdominal trauma, visceral responses to intraperitoneal stimuli make abdominal examination unreliable, so peritoneal lavage becomes necessary in diagnosing abdominal trauma.I6 In late pregnancy, the peritoneal lavage catheter should be placed above the umbilicus to avoid inadvertent trauma to the displaced bladder. PREOPERATIVE PATIENT CONSIDERATIONS
The type of surgery, the available equipment and staffing, the gestational age, and the maternal/fetal condition should be considered when deciding where the patient should have surgery. Most labor and delivery (L&D) suites are not equipped for general surgery procedures. In most situations, the operating room will best meet the surgical needs of the pregnant patient. Regardless of where the surgical procedure takes place, a multidisciplinary team approach is 208
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blood flow to the fetus. The pregnant patient facing surgery not only fears for herself, but also for her unborn child. Reassurance that the fetus will be monitored throughout the procedure allays some of her anxiety. If the patient is given regional anesthesia, the fetal monitor volume can be adjusted so she can hear the fetal heart beat. This nursing intervention has a calming effect on the patient. Judicious use of antianxiety medications is advocated during pregnancy, but in some instances, the benefits far outweigh any risks. Increased rates of congenital anomalies are not found in babies Figure 1 Left lateral tilt to displace the gravid uterus is accomplished born to mothers who undergo by placing a towel pack under the patienis right hip. surgery during pregnancy. This lack of anomalies indicates that essential. In viable gestations, OR and L&D staff medications administered to the pregnant surgical members must collaborate to prepare for possible patient during the perioperative period are not strong cesarean delivery. In addition, a neonatal team should teratogens (ie, agents that cause embryonic maldevelbe notified and available for neonatal emergencies. If opment in the first trimester of pregnancy).I7 the likelihood of a cesarean birth is high, the OR temPreoperative and postoperative pain medication perature should be raised preoperatively to prevent should be administered as needed; however, the perineonatal hypothermia. A source of radiant heat and operative nurse should be aware that there are a variresuscitation supplies must be readily available for ety of factors that affect maternal and fetal absorption the neonate before surgery on the woman begins. of narcotics or antianxiety agents. The amount of Electronic fetal monitoring is a valuable tool for medication, the administration site, the drug distribuassessing intrauterine fetal well-being during surgi- tion to maternal tissues, metabolism, and renal excrecal procedures. An L&D nurse who is adept at EFM tion of the narcotic affect the concentration of the drug interpretation should be i n attendance with the in the fetus. Any condition that diminishes uterine patient throughout the entire perioperative period. blood flow will alter the transfer of drugs to the fetus Not only will the L&D nurse interpret the fetal mon- and, conversely, from the fetus to the mother. itor strip, he or she also will suggest appropriate The immature fetal liver is poorly equipped to patient interventions and interpret fetal responses to metabolize pain medication, The maternal renal and those interventions. hepatic systems assist the fetus in metabolizing and Pregnant surgical patients, regardless of gesta- excreting pain medications if the mother does not tional age, are at increased risk for preterm labor; have a condition such as hypertension or diabetes that therefore, baseline information regarding uterine alters placental and uterine perfusion. The FHR variactivity should be obtained preoperatively. Preopera- ability decreases during the peak action of pain medtive pharmacological interventions (eg, tocolytic ications but returns to normal with maternal excretion agents) to arrest preterm labor can be instituted to of the analgesic agent.@ decrease the risk these patients have for preterm The perioperative nurse should evaluate the delivery. patient’s clinical picture continually to rule out Preoperative patient anxiety should be mini- underlying pathology when reduced FHR variability mized. Sympathetic nerve fiber discharge in the anx- occurs. If delivery is to occur soon after administraious pregnant patient results in decreased uterine tion of pain medication, short-acting narcotics 210 AORN JOURNAL
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should be used instead of long-acting analgesics. The IV route is preferred over the intramuscular route so that medication absorption rates and peak actions are predictable. INTRAOPERATIVEPATIENT CONSIDERATIONS
Intraoperative priorities are determined by the surgeon and are dependent on the condition of the mother and the gestational age of the fetus. In emergent surgery situations, the maternal condition overrides consideration for the fetus, because fetal survival is assured only through maternal survival. In nonemergent surgery situations, the fetus is afforded overriding consideration to promote optimum fetal outcome. The surgeon explains these intraoperative priorities to the patient and her family members before surgery. The simple maneuver of laterally tilting the uterus off the vena cava is probably one of the most important intraoperative nursing interventions. This maneuver not only prevents supine maternal hypotension but enhances uterine perfusion. Lateral tilting becomes crucial in second and third trimester gestations; however, in some cases, gestational age may not be known. If the uterus is at the level of the umbilicus, lateral displacement of the uterus is indicated. Figure 1 shows the proper positioning of a wedge under the right maternal hip for displacing the uterus to the left. Electronic fetal monitoring should be employed in gestations of 20 weeks or longer. Uterine activity as well as FHR should be monitored continuously. Monitoring during abdominal surgery may be accomplished by placing a sterile sleeve over the fetal monitor ultrasonic transducer. Sterile gel is needed for conduction (Figure 2). An L&D nurse must don surgical attire and manually hold the ultrasonic transducer in place to maintain a readout on the fetal monitor. If contractions cannot be monitored electronically, the L&D nurse may manually palpate the uterus for contractions (Figure 3). Uterine activity increases when bladder distention develops. If the surgery is expected to last longer than one hour, a Foley catheter should be inserted preoperatively to prevent bladder distention. If a Foley catheter is not inserted, the circulating nurse should palpate the bladder for distention every 30 minutes when fluids are being infused rapidly (ie, greater than 250 mL/hour). If uterine activity is detected and the bladder is distended in a patient without a Foley catheter, surgery is interrupted, and a Foley catheter is inserted under sterile conditions.
Figure 2 Asepsis is maintained and intraoperative fetal monitoring is accomplished by covering the ultrasonic transducer with a sterile sleeve and using sterile conductive gel. Anesthetic exposure during pregnancy can be minimized by prepping and draping the patient before induction of general anesthesia. We conducted a national survey of hospitals that had more than 2,000 annual births and found that only 4 1 % prepped and draped the pregnant surgical patient before the induction of anesthesia.19 The practice of giving general anesthesia to the pregnant surgical patient before prepping and draping adds 10 to 50 minutes of unnecessary, additional anesthetic exposure to the fetus. The circulating nurse should shield the uterus when intraoperative x-rays are taken. A sterile sheet wrapped around a lead apron and placed across the uterus provides adequate shielding while maintaining asepsis. If fluoroscopy is necessary, the circulating nurse can place an apron underneath the patient preoperatively to minimize radiation exposure to the fetus. The pregnant patient who requires extracorporeal circulation (ECC) needs several intraoperative interventions for optimum fetal outcome. The use of ECC during pregnancy carries a reported fetal death rate of 21.8%.20 The perfusionist should increase the pump volume by 40 mL/kg of maternal weight to mimic the volume expansion of the pregnancy. Higher pump pressures also should be employed to maintain adequate uterine blood flow. Anticoagulation, if indicated, should be achieved by using heparin because, unlike warfarin derivatives, heparin does not cross the placenta. Extracorporeal circulation should be conducted at normal
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t e m p e r a t u r e s in p r e g n a n t patients. Poor placental perfusion during maternal hypothermia c a n cause fetal bradycardia. Maternal hypothermia also may obscure differentiation of fetal bradycardia from fetal hypoxia. In addition, hypothermia has been associated with ventricular fibrillation in the mother and possible ventricular fibrillation in the fetus.?' Preterm labor also has been associated with rewarming the hypothermic pregnant patient. A s a result, every effort should be made to keep the pregnant surgical patient normothermic during surgery. The OR temperature should be set at a minimum 75" F (24" C ) . Only warm irrigation, IV, and prep Figure 3 During abdominal surgery, an L&D nurse holds an ultrasonic solutions should be used, Warm transducer to detect fetal heart rate in the pregnant Surgical patient. blankets should be provided before prepping. and minimal exposure of the patient should help maintain maternal patient's obstetric (OB) care provider. Because the normal PO, is higher during pregnormothermia. Thermal drapes, blankets, and head covers can be u5ed on the patient if hypothermia nancy (ie, 104 to 108 mm Hg), supplemental oxygen should be given early to maintain 94% or greater develops. patient oxygen saturation. Continuous pulse oximetry should be employed to assess the recovering patient's PosTOPERATlVE CARE If fetal stress or uterine contractions are detected oxygen saturation status. Magnesium sulfate. Postanesthesia care unit on the intraoperative fetal monitor strip, the patient should recover in the L&D unit. If this is not possible, nurses must be aware of the side effects of tocolytic a well-coordinated team approach that includes a peri- drugs that the patient may receive. Magnesium sulfate natal team member is crucial. Electronic fetal moni- is a commonly used tocolytic agent that blocks the toring should continue postoperatively for two hours uptake of acetylcholine at the myoneural junction. The if there are no surgical complications. With complica- therapeutic level of magnesium sulfate is 5 to 7 tions, fetal monitoring should continue for at least 24 mddL. Levels greater than 5 to 7 mg/dL are considhours. All trauma surgical patients should have 24- ered toxic and may result in severe respiratory depreshour fetal monitoring whether there are surgical com- sion and death. Nursing care of the patient who plications or not because of an increased risk for pla- receives magnesium sulfate includes hourly monitoring and recording of fluid intake cental abruption. and output, Nurses should administer pain medications as assessment of deep tendon reflexes every one to needed. Analgesia pumps provide the patient consistwo hours, and tent pain relief with minimal medication. Intrathecal patient sensorium checks. morphine as well as epidural analgesics successfully Urinary output should be at least 25 mL/hour to and safely treat postoperative pain during pregnancy. Frequent nursing assessment for bladder distention is ensure excretion of the drug, and respirations should a priority to decrease uterine irritability in the postop be at least 16 breaths per minute. Deep tendon reflexerative period. In addition, the nurses should quantify es diminish or cease before respiratory compromise and report any vaginal spotting or bleeding to the develops. I f magnesium sulfate is administered in 212 AORN JOURNAL
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conjunction with general anesthesia, extubation may not be accomplished immediately after surgery because the patient's protective gag reflex may be diminished and the patient may exhibit some degree of respiratory depression. Terbutaline. Terbutaline, a beta-sympathomimetic preparation that is usually given to relax uterine muscle, is another widely used tocolytic agent. If bleeding is present, regardless of its origin, this drug should not be used because it may increase the maternal pulse rate and thus mask a cardinal sign of hypovolemia. In addition, terbutaline counteracts the body's own compensatory mechanisms in blood loss.22Cardiac disease, diabetes, and thyroid disorders are medical conditions in which terbutaline is contraindicated or should be used with extreme caution. Oral and written discharge instructions specific to the pregnant surgical patient should include signs and symptoms of labor: backache and cramping, change in vaginal discharge and spotting, and leakage of fluid from the vagina. If symptoms of labor are present, the patient should notify her obstetrician immediately. Patients also should be instructed in the technique of uterine palpation for contractions. In addition, if the patient is on terbutaline as a tocolytic, she should understand the importance of taking the medication as prescribed and checking her pulse prior to dosing. If her pulse is greater than 120 BPM, the patient should be instructed to omit the terbutaline dose and call her obstetrician for further instructions regarding this medication. CASE STUDY
Ms R, a 19-year-old primigravida with a 36-week pregnancy, presented to our obstetrical triage complaining of abdominal pain, fever, and anorexia. An initial physical examination revealed a 5-ft 6-inch, 183-lb, dehydrated female with an irritable uterus; a right flank and lower abdomen with rebound, referred tenderness; and positive bowel sounds. Vital signs were normal except for a temperature elevation of 101" F (38.5" C). Pelvic examination by the obstetrician revealed cervical dilation of 1 cm with 50% effacement and a presenting part that was unengaged. Initial external fetal monitoring revealed reactive FHR and an active fetus. The patient's perception of pain and uterine activity were unchanged after an observation period of four hours, during which laboratory work was obtained and
Terbutaline is not recommended for patients with diabetes, cardiac disease, or thyroid disorders.
IV hydration was administered. Laboratory values consisted of a normal urinalysis and a complete blood count that was normal except for a WBC of 13,100. In view of these findings, Ms R was admitted to the inpatient OB floor for continued observation and evaluation. Intravenous fluid therapy continued at 125 mL/hour. Acetaminophen was administered to reduce her fever. Because Ms R ' s condition remained unchanged and she continued to have an elevation in body temperature, a general surgeon was consulted the next morning to rule out appendicitis or cholelithiasis. After examining Ms R, the surgeon consulted with the obstetrician and scheduled an exploratory laparotomy. A laparoscopic approach could not be considered because the advanced gestation had caused an upward displacement of the abdominal viscera, and trocar placement and abdominal insufflation would be dangerous in this situation. Ms R remained NPO in preparation for surgery with IV fluids to maintain hydration. Intravenous cefotaxime and clindamycin antibiotic therapy was instituted before surgery. Preoperative teaching was provided by both the L&D and OR nursing staff members to the patient and her family members. Preoperative teaching included a discussion on the multidisciplinary team approach to patient care, possibility of a cesarean birth, need for tocolytic medication administration to treat preterm labor, relief of postoperative pain, and need for 24-hour hospitalization after surgery for observation and EFM. The patient signed a surgical consent for an exploratory laparotomy and possible cesarean delivery. The neonatologist and intensive care nursery staff members were notified of the impending surgery and the possibility of an emergency cesarean birth. The
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neonatal team was available during the surgery. An experienced L&D nurse joined the perioperative team to provide continuous fetal and uterine monitoring. Before surgery, a staff anesthesia care provider evaluated Ms R and discussed the risks of anesthesia, including preterm labor. Ms R agreed to general endotracheal anesthesia for surgery. The circulating nurse performed a preoperative patient assessment that included obtaining an obstetrical history on the surgical patient’s hepatitis and HIV status, known allergies, exposure to tuberculosis, bleeding and coagulopathy problems, antibody screening for Rh-immune status, and previous pregnancies and preterm deliveries. Approximately 17 hours after admission, Ms R was transported to the operating room. The circulating nurse positioned Ms R on the OR bed in a supine position with a left lateral tilt attained by placing a towel pack under Ms R’s right hip. The L&D nurse monitored the fetus continuously using an EFM unit. An anesthesia care provider placed electrocardiogram (ECG), blood pressure, end-tidal carbon dioxide, and neuromuscular blockade monitors on the patient. The circulating nurse placed an electrosurgical unit dispersive pad on Ms R’s left thigh. The general surgeon, assisted by the OB resident, prepped and draped the patient’s abdomen in a sterile manner. After adequate patient preoxygenation, a rapid-sequence general anesthesia was administered to the patient. The circulating nurse maintained cricoid pressure until the endotracheal intubation was secure to prevent aspiration of gastric contents. The obstetrician was present in the operating room throughout the procedure. At this time, the L&D nurse scrubbed, donned sterile attire, and draped the external ultrasonic transducer to the fetal monitor in a sterile plastic sleeve. The L&D nurse held the transducer approximately 1 112 inches from the incision site to monitor the FHR. She also periodically palpated the uterus for contractions. Sterile ultrasonic gel was used on the transducer for conduction. A right paramedian surgical incision revealed congenital bands around the appendix and ileum laterally and retroperitoneally. The appendix appeared initated and was mobilized, ligated, dissected, and sent to pathology. Postoperative histological examination revealed a vermifoiin appendix with nonspecific, follicular, lymphoid hyperplasia. Abdominal findings
were normal for this stage of pregnancy, and no inflammatory processes were noted. Sponge, instrument, and needle counts were correct, and the surgical incision was closed. During the surgical procedure, the fetus exhibited a lowering of baseline FHR by approximately 20 BPM (ie, from 160 to 140 BPM) but returned to the original baseline FHR within 30 minutes after surgery. There were no decelerations of the FHR, but the variability of the FHR decreased dramatically during surgery. Contractions were palpable during the last 10 minutes of the procedure. The circulating nurse, the surgeon, and the anesthesia care provider transferred Ms R directly to the OB recovery area on the L&D unit when she was awake, alert, and oriented. She was placed in a left lateral position with 40% oxygen delivered via face mask to maintain adequate maternal and fetal oxygenation. The ECG, pulse oximetry, blood pressure, and continuous EFM monitoring were resumed. Pulse oximetry readings were maintained between 95% and 100% oxygen saturation, and vital signs remained stable. The FHR was 140 BPM and nonreactive with no evidence of fetal distress. Uterine contractions were noted every one to two minutes with uterine irritability. The L&D nurses administered IV magnesium sulfate for tocolysis and gave IV meperidine for pain, intramuscular promethazine for nausea, and IV cefazolin every six hours for prophylaxis against infection. Ms R continued to receive IV tocolytic agents in the postoperative OB care unit until her contractions ceased. She was transferred to the antenatal unit on postoperative day one. She tolerated fluids and required little pain medication. On postoperative day two, she was transferred back to the L&D unit when her uterine contractions resumed, although she had no cervical change. Subcutaneous and oral administration of tocolytic agents successfully arrested the uterine contractions, and Ms R was returned to the antenatal unit on postoperative day three. She was discharged on postoperative day four, and the remainder of her pregnancy was uneventful. Ms R was admitted to the hospital for induction of labor five weeks after her surgery and one week past her due date. After 13 hours, she spontaneously delivered a 7-lb 9-oz healthy male under epidural anesthesia. The baby’s Apgar scores were 8 and 9 at one and five minutes, respectively. The postpartum course was uneventful. Both mother and child continue to do well at the time of this writing.
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healthy mother and full-term baby in a pregnant patient who underwent an exploratory laparotomy and appendectomy at 36 weeks’ gestation. A
CONCLUSION
Management of the pregnant surgical patient poses a challenge for perioperative nurses. To provide optimal care, nurses need to understand the normal anatomic and physiologic changes of pregnancy. Collaborating with L&D nurses and formalizing a perioperative plan of care enhance the outcome for both the mother and the fetus. Without this multidisciplinary approach to the pregnant surgical patient. perinatal morbidity and mortality cannot be improved. The multidisciplinary nursing approach used in this case resulted in a
Jo M. Kendrick, RN. M S N , C , is an obstetrical nui‘se practitioner at the Uiiil.ei.si& of Tennessee Medical Centei‘. Ki i oni l l e . Pallas Harnrnond Powers, RN, is a iuscular special@ nurse in the O R at the U i i i n ~ s i t yojTenizessee Medical Cerirei..Kiio.t-viIle
7. Roberts. Chestnut. “Anesthesia for the obstetric patient with cardiac disease.“ 601-609. 8. L E Oakley. J D Johnson. “Traumatic injury in pregnancy,” Crit691. ical Cuiv Nzrrse 11 (June 1991) 64-73. 9. V Sorenson et al. “Manage2. G Levinson, S Shnider. “Anesthesia for surgery during pregnancy.” ment of general surgical emergencies in Aiiestlir.siufi~i~ 0b.wri.ics. ed S in pregnancy.” The Aniei.icriri SurShnider. G Levinson (Baltimore: gpoii 56 (April 1990) 245-250. 10. Ihid. 248. William & Wilkins. 1Y87) 188-205. 1 I. L Pimentel, ”Mother and child: 3. R I Mazze. B Kallen. ‘.ReproTrauma in pregnancy.” Eniei~geiicy ductive outcome after anesthesia and operation during pregnancy: A regMediciiie Clinics ofNor-rli America 9 istry study of 5.405 cases.“ Anir~ic~uii (August 1991) 549-563. Jorrriiul of’Ob.stetrir~.si i i i d C y c c o l o 12. C Bremer. L Cassata. ”Trauma gy 161 (November 1989) 1178-1185. in pregnancy.” Niii-siii,gC1iiiie.s of North Aniericci 2 1 (December 1986) 4. B Duncan et al, “Fetal risk of 705-7 16. anesthesia and surgery during preg13. L Reisner, “Anesthesia for nancy,“ Aiirsthesiolog~64 (June cesarean delivery.” Clinical Obsrer1986) 790-794. 5. S Roberts. D Chestnut. ”Anesi k s & Gyiiec~oI~ 30~ (September q~ thesia for the obstetric patient with 1987) 539-55 1. cardiac disease,” Clinical Olistr~tr.ic~s 14. J Johnson. L Oakley, “Managing minor trauma during pregnancy,” & Gyiwcology 30 (September 1987) Jorri~rialof Obstc,ti.ic~.Gynecologic & 60 1-6 10. Neoiiutul N i i / ~ s i i i g20 (September/ 6. S Clark. “Shock in the pregOctober 1991) 379-384. nant patient.” Seniiiiul-s in Pri.iiiaro115. Ibitl. 383. o * y 14 ~ (February 1990) 52-58.
NOTES 1. W Barron, “The pregnant surgical patient: Medical evaluation and management.” Ainials oflirte/md Medic,ine 101 (November 1984) 683-
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16. Pimentel, “Mother and child: Trauma in pregnancy,” 549.563. 17. Mazze, Kallen, “Reproductive outcome after anesthesia and operation during pregnancy: A registry study of 5,405 cases,” 1178-1185. 18. F Spielman, “Systemic analgesics during labor,” Clinical Obsteti.irs & Gynecology 30 (September 1987) 495-504. 19. J M Kendrick, C Woodard, S
Cross, “Fetal and uterine surveillance during maternal surgery in the USA: A mail survey,” AORN Journal (in press). 20. J Conroy et al, “Anesthesia for open heart surgery in the pregnant patient,” Southern Medical Journal 82 (April 1989) 492-495. 2 1. R G Sutton, J P Dearing, “Cardiopulmonary bypass during pregnancy: A case report,” Journal of E.ma-t.oipor-r~a1 Techiio/ogy20 no 2 (Summer 1988) 67-71. 22. B Nuwayhid, M Rajabi, “Betasympathomimetic agents: Use in perinatal obstetrics,” Clinics in Perk nutology 14 (December 1987) 757782.
education by the Konsos State Board of Nursing This course offering IS opproved for two contact hours The Kansas Stote Board of Nursing opproved provider number is L TO 1 14-03 16 Professional nurses ore invited to submit monuscripts for the Home Study Progrom Manuscripts or queries should be sent to the Editor, AORN Journal, 2 170 S Parker Rd, Suite 300, Denver, CO 80231-571 1 As with all monuscripk sent to the Journal, papers submitted for Home Study Programs should not hove been previously published or submitted simultoneously to ony other publication
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Examination PERIOPERATIVE CARE OF THE PREGNANT SURGICAL PATIENT
7. Increased rates of congenital anomalies are found in babies born to mothers who undergo surgery during pregnancy. a. true b. false
1.During pregnancy, the woman’s hematologic values change in the following way to accommodate the expanding uterus, placenta, and fetal circulation. a. hematocrit increases b. white blood cells decrease c. clotting factors decrease d. plasma volume increases
8.Intraoperative priorities are determined by the surgeon dependent on a. equipment needs, available staffing b. signed surgical consent, family’s wishes c. laboratory values, HIV status of mother d. mother’s condition, gestational age of fetus
2. Cardiovascular changes in the pregnant surgical patient include all of the following except a. decreased cardiac output in a supine position from uterine compression on the vena cava b. increased peripheral circulation c. mild tachycardia and a decreased mean arterial pressure d. hypertension in the third trimester
9.According to the authors, what is one of the most important intraoperative nursing interventions? a. applying cricoid pressure to prevent aspiration b. placing a fetal heart monitor on patient c. inserting Foley catheter into patient d. placing patient in lateral tilt position
3.The maternal patient can sustain an acute blood loss of 30% to 35% before exhibiting signs and symptoms of shock because of a. elevated blood pressure b. decreased perfusion needs during pregnancy c. increased plasma volume d. placental compensation
1 a I t is beneficial to the fetus to prep and drape the maternal patient before induction of general anesthesia. a. true b. false
4. What is the best position for a pregnant surgical patient in her second or third trimester undergoing an exploratory laparotomy? a. left lateral decubitus b. supine c. high Fowler’s to facilitate breathing d. low lithotomy with wedge under right hip 5.The pregnant woman lives in a state of chronic, compensated a. metabolic acidosis b. metabolic alkalosis c. respiratory alkalosis, d. respiratory acidosis
11.What intraoperative nursing interventions should the nurses initiate to ensure maternal normothermia during surgery? a. Place compression stockings on patient. b. Insert Foley catheter into patient. c. Increase IV pump volume and pressure. d. Use warm irrigation, IV, and prep solutions. 12.Postoperative use of morphine and epidural analgesics increases the risk of congenital anomalies. a. true b. false
I t Postoperative nursing care of the pregnant trauma 6. According to the authors, fetal heart rate changes are usually the first indicator of maternal hypoxia. a. true b. false
surgical patient includes a. reporting vaginal bleeding promptly b. the use of prescribed, supplemental oxygen and continuous pulse oximetry
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the placental blood barrier c. gastric bleeding from delayed gastric emptying and increased gastric acid output d. signs of preterm labor due to manipulation of reproductive organs
c. electronic fetal monitoring for 24 hours after surgery d. all of the above IQTerbutaline is a tocolytic agent that is used with extreme caution in what medical conditions associated with the maternal surgical patient? a. appendicitis, cholelithiasis b. pancreatitis, peptic ulcer disease c. diabetes, cardiac disease, and thyroid disorders d. hypertension, urinary tract infections ISPreoperative teaching for the maternal patient includes a discussion on which of the following? 1. possibility of cesarean birth 2. need for 24-hour hospitalization after surgery 3. multidisciplinary team approach to patient care 4. need for tocolytic medication administration to treat preterm labor a. 1 and 2 b. 2 a n d 3 c. 1, 2,and3 d. all of the above
16.Preoperative nursing measures include 1. administering antacids and oxygen to patient 2. decreasing patient anxiety, monitoring fetal heart rate continuously 3. placing nasogastric tube in patient 4. administering magnesium sulfate, terbutaline nebulizer treatment a. 1 and2 b. 2 a n d 3 c. I , 2 , and 3 d. all of the above 17.According to this article, the most common cause of fetal death in utero is a. placental separation b. maternal shock c. head injury d. uterine rupture l a w h a t should the perioperative nurse consider when caring for the pregnant surgical patient after surgery? a. a prolonged recovery time because pregnant surgical patients require larger amounts of anesthetic agents b. fetal distress from anesthetic agents crossing
19.Where is blood shunted when a pregnant surgical patient is in shock? a. away from the uterus b. to the uterus for fetal protection c. to the maternal kidneys for homeostasis d. to the central nervous systems of both patients =Toxic levels of magnesium sulfate in the maternal patient may result in a. severe hemorrhage and shock b. elevated blood pressure and epistaxis c. severe respiratory depression and death d. decreased potassium levels and arrhythmias =.Nursing care of the pregnant patient who receives magnesium sulfate includes a. ventilatory care b. hourly fluid intake and output monitoring c. rotating intramuscular injection sites d. frequent range of motion exercises =.Placement of a nasogastric tube in the pregnant surgical patient decreases her risk of aspiration pneumonitis during a surgical procedure. a. true b. false =A
preoperative obstetrical history assessment should include a. anesthetic preference of patient b. name of insurance company c. religious preference d. patient’s hepatitis and HIV statuses
-Poor placental perfusion during maternal hypothermia can cause fetal tachycardia. a. true b. false #Electronic fetal monitoring should be employed in gestations of 16 weeks or less. a. true b. false
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Answer Sheet PERlOPERATlVECARE
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lease fill out the application and answer form below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
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Learner Evaluation PERIOPERATWE CARE OF THE PREGNANT SURGICAL PATIENT The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. OBJECTIVES
To what extent were the following objectives of this home study program achieved? ( I ) Discuss the anatomic and physiologic changes in the pregnant surgical patient. (2) Discuss the implications of these changes on the multidisciplinary approach to nursing care of the pregnant surgical patient. (3) Describe general considerations in the perioperative care of the pregnant surgical patient. (4) Identify the perioperative nurse's role when caring for the pregnant surgical patient. CONTENT
(1) Did this article increase your knowledge of the subject matter? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individual objectives met? (5) Was the content of the article relevant to the objectives? TEST wLsIIoNs/ANswuIs
(1) Were they reflective of the content? (2) Were they easy to understand? (3) Did they address important points'?
What other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s):
Author names and addresses:
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Home Study Program PERlOPERATlVE CARE OF THE PREGNANT SURGICAL PATIENT
he article “Perioperative care of the pregnant surgical patient” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Janet S. West, RN, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS(N), education coordinator, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn two contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Jan 3 1, 1995. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
BEHAVIORAL OBJECTIVES
After reading and studying the article on penoperative care of the pregnant surgical patient, the nurse will be able to (1) discuss the anatomic and physiologic changes in the pregnant surgical patient, ( 2 ) discuss the implications of these changes on the multidisciplinary approach to nursing care of the pregnant surgical patient, ( 3 ) describe general considerations in the penoperative care of the pregnant surgical patient, and (4) identify the penoperative nurse’s role when caring for the pregnant surgical patient.
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Perioperative Care of the Pregnant Surgical Patient culation. Red blood cell (RBC) mass only increases by 20%, contributing to the hemodilution or physiologic anemia associated with pregnancy. Due to this hemodilution, the woman's hematocrit decreases, but it should not fall below the 35% ratio of RBCs to plasma (normal range is 35% to 45% RBCs). The white blood cell (WBC) count increases from 6,000 to 12,000 (normal range is 4,000 to 10,000 WBCs) without underlying pathology. Clotting factors such as fibrinogen and factor VIII increase, resulting in a hypercoagulable state. Because of this, coagulopathy problems develop insidiously during pregnancy. Cardiac output increases 20% to 40% by the second trimester of pregnancy. The pregnant woman's heart rate increases by 15 to 20 beats per minute (BPM). Peripheral vascular resistance decreases to accommodate the increased plasma volume. Blood pressure decreases during the second ANATOMIC AND PHYSIOLOGIC trimester but approaches its prepregnant level by ALTERATIONS DURING PREGNANCY Perioperative management of the pregnant surgi- term.5 In the second and third trimesters of pregnancal patient requires a basic understanding of the nor- cy, the enlarging uterus compresses the vena cava when the patient is supine. ma1 physiologic and anatomic These normal hematologic changes that occur in the woman and cardiovascular changes of during pregnancy. Without this A B S T R A C T knowledge, pathologic conditions Successful perioperative pregnancy have profound implicacannot be distinguished from nor- management of the pregnant tions in the perioperative care of mal conditions. Alterations in each surgical patient requires a multi- the pregnant surgical patient. Due body system and their implications disciplinary nursing approach to to the increase in plasma volume, for the pregnant surgical patient decrease perinatal morbidity the pregnant patient may lose 30% are discussed separately and are and mortality. A comprehensive to 35% of her circulating volume summarized in Table 1. perioperative patient care plan before exhibiting signs and sympHematologic and cardiovas- and coordination with obstetric toms of shock. In addition, the decreased cular systems. During pregnancy, and neonatal team members the woman's plasma volume enhance the surgical outcome peripheral vascular resistance preincreases 30% to 50% above nor- for both the mother and her vents the development of cool, mal to accommodate the expand- child. A O R N J 60 (August clammy skin usually associated with shock. When compensatory ing uterine, placental, and fetal cir- 1 994) 205-2 16. he incidence of surgery during pregnancy ranges from 0.2% to 2.2%.' This percentage translates to 50,000 pregnant women undergoing surgery with anesthesia annually in the United States.2 Perinatal morbidity and mortality is higher in pregnancies in which maternal surgery occurs (eg, infant birth weights are lower at gestation, neonatal death is higher).3 The risk of preterm delivery also increases in women who undergo surgery during pregnan~y.~ When surgery during pregnancy is necessary, all health care providers must remember that there are two patients involved-the mother and the baby, whose survival is dependent on the mother's well-being. Special nursing interventions for the pregnant woman and her unborn child must be planned to ensure optimum maternal and fetal outcomes.
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Pon,ers
Table 1 PERIOPERATIVE NURSING CONSIDERATIONS FOR THE PREGNANT SURGICAL PATIENT
Affected body systems
Anatomic and physiologic alterations
Perioperative considerations
Cardiovascular
Physiologic anemia Increased cardiac output Increased heart rate Decreased peripheral vascular resistance
Maintain left lateral tilt in second and third trimesters. Monitor fetal heart rate continuously. Do not expect cool, clammy skin to develop in shock.
Respiratory
Increased tidal volume, respiratory rate Chronic compensated respiratory alkalosis Capillary engorgement of nasopharynx Diaphragm displaced upward as uterus grows
Administer supplemental oxygen. Suction and intubate gently to prevent epistaxis. Insert chest tubes1 to 2 interspaces above normal. Maintain pulse oximeter readings at 94% or greater.
Gastrointestinal
Decreased gastric motility Decreased gastroesophageal sphincter tone Increased gastric acid
Place nasogastric tube to prevent aspiration Administer antacids preoperatively to increase gastric pH and decrease gastric acid output. Expect displacement of appendix upward as gestation progresses.
Genitourinary
Urinary stasis, asymptomatic bacteriuria Increased uterine irritability from bladder distention and cystitis Bladder displaced out of pelvis by growing uterus Increased glomerular filtration rate
Avoid urinary catheterizationto prevent urinary tract infections. Assess bladder distention frequently. Be aware that bladder trauma is common in pregnant multitrauma victims. Maintain patient in a left lateral position to enhance urinary output.
Musculoskeletal
Stretched abdominal muscles Compressed, displaced abdominal organs
Use peritoneal lavage to diagnose intraabdominaltrauma. Place lavage calheter above the umbilicus in late pregnancy.
mechanisms are activated in acute blood loss, blood is shunted away from the uterus. Maintenance of maternal hemodynamic stability occurs at the expense of the fetus. Maternal shock cames an 80% fetal mortality rate.h Although the fetus has compensatory responses similar to an adult, the responses are brief, and hypoxia quickly ensues. Electronic fetal monitoring (EFM) allows continuous assessment and early detection of fetal compromise. Fetal monitoring also benefits the mother because it may detect ensuing maternal compromise before symptoms are apparent. The supine position in the second and third trimesters causes maternal hypotension in 30% of the pregnant p ~ p u l a t i o n Placing .~ a wedge under the woman’s right hip to displace the gravid uterus later-
ally is a simple and effective maneuver to prevent vena caval compression. The surgical team can accommodate this left lateral uterine displacement in Imost procedures without interfering with the surgery. Respiratory system. Pregnancy increases the woman’s metabolism, thus increasing her body’s oxygen demands. To compensate, the woman’s respiratory rate increases up to 15% greater than normal, and her pulmonary tidal volume increases 30% to 40%.RAs a result, the pregnant woman lives in a state of chronic, compensated respiratory alkalosis that changes her blood buffering system. Blood hydrogen ion concentration (pH) remains essentially unchanged even though the arterial partial pressure of oxygen (PO,) increases to 104 to 108 mm Hg, arterial partial pressure of carbon dioxide decreases 206
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Intraoperative placement of a nasogastric tube reduces
the pregnant patient’s risk of aspiration pneumonitis.
to 2 7 to 3 2 mm Hg, and plasma buffer bases decrease by an average of 5 I ~ E ~ / Pulmonary L.~ functional reserve capacity decreases because the gravid uterus elevates the diaphragm. Anatomic changes of pregnancy include capillary engorgement and swelling of the nasophaqnx. Epistaxis may occur with nasal airway placement or nasotracheal intubation.“’ The diaphragm becomes progressively elevated as the uterus grows and may be displaced upward as much as 4 cm. Chest tubes, when needed, should be inserted one to two interspaces above normal placement.” Increased oxygen demands and the higher metabolic rate associated with pregnancy combine to lower maternal oxygen reserve. Because the fetus possesses even less oxygen reserve than the mother, both individuals are extremely susceptible to hypoxia even during brief periods of apnea (eg, during suctioning, intubation). With an increased metabolism, the mother is vulnerable to hypoxic tissue damage. Fetal heart rate (FHR) changes are usually the first indicator of maternal hypoxia. It is imperative for the well-being of both the mother and fetus to keep the mother well oxygenated at all times. Maternal pulse oximeter readings should be maintained at levels greater than an oxygen saturation reading of 94%. Gastrointestinal system. Gastric motility decreases as a result of the body‘s increased progesterone secretion. The surgical team should approach the pregnant patient as having a full stomach regardless of when her last meal was reported to have been consumed. Nasogastric tubes should be placed promptly in the treatment of pregnant trauma patients to decrease the risk of aspiration. Gastroesophageal sphincter tone also is decreased in pregnancy, resulting in gastric acid reflux. In the third trimester, gastric acid secretion increases as intestinal motility decreases.’?
The risk of aspiration pneumonitis is higher during pregnancy, thus warranting aggressive medical management of gastric acid output preoperatively. The administration of 15 to 30 mL of sodium citrate approximately 30 minutes before surgery increases gastric pH. Some anesthesia care providers administer hydrogen ion receptor antagonists (eg, cimetidine, ranitidine) in combination with sodium citrate to raise the gastric pH even more.13 Genitourinary system. Urinary tract changes in pregnancy include dilation of the renal calices, pelves, and ureters.IS This dilation results in urinary stasis and asymptomatic bacteriuria; therefore, the pregnant patient is predisposed to pyelonephritis. Unnecessary urinary catheterization should be avoided to prevent the introduction of bacteria in the bladder that may result in a urinary tract infection. Bladder distention as well as cystitis cause uterine irritability, so the patient’s bladder should be kept empty. In addition, the bladder is displaced by the enlarged uterus out of the protection of the pelvis, causing the mother to be predisposed to traumatic bladder injury. Glomerular filtration rates increase up to 50% during pregnancy, causing medications to be excreted more rapidly.” Supine positioning in later pregnancy decreases urine output and glomerular filtration rates. Maintaining a lateral position in the pregnant patient enhances the patient’s kidney function. Musculoskeletal system. As pregnancy progresses, the woman’s abdominal muscles become stretched by the enlarging uterus. Compression and displacement of abdominal organs by the gravid uterus make diagnosing pathology or injury a challenge. In abdominal trauma, visceral responses to intraperitoneal stimuli make abdominal examination unreliable, so peritoneal lavage becomes necessary in diagnosing abdominal trauma.I6 In late pregnancy, the peritoneal lavage catheter should be placed above the umbilicus to avoid inadvertent trauma to the displaced bladder. PREOPERATIVE PATIENT CONSIDERATIONS
The type of surgery, the available equipment and staffing, the gestational age, and the maternal/fetal condition should be considered when deciding where the patient should have surgery. Most labor and delivery (L&D) suites are not equipped for general surgery procedures. In most situations, the operating room will best meet the surgical needs of the pregnant patient. Regardless of where the surgical procedure takes place, a multidisciplinary team approach is 208
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blood flow to the fetus. The pregnant patient facing surgery not only fears for herself, but also for her unborn child. Reassurance that the fetus will be monitored throughout the procedure allays some of her anxiety. If the patient is given regional anesthesia, the fetal monitor volume can be adjusted so she can hear the fetal heart beat. This nursing intervention has a calming effect on the patient. Judicious use of antianxiety medications is advocated during pregnancy, but in some instances, the benefits far outweigh any risks. Increased rates of congenital anomalies are not found in babies Figure 1 Left lateral tilt to displace the gravid uterus is accomplished born to mothers who undergo by placing a towel pack under the patienis right hip. surgery during pregnancy. This lack of anomalies indicates that essential. In viable gestations, OR and L&D staff medications administered to the pregnant surgical members must collaborate to prepare for possible patient during the perioperative period are not strong cesarean delivery. In addition, a neonatal team should teratogens (ie, agents that cause embryonic maldevelbe notified and available for neonatal emergencies. If opment in the first trimester of pregnancy).I7 the likelihood of a cesarean birth is high, the OR temPreoperative and postoperative pain medication perature should be raised preoperatively to prevent should be administered as needed; however, the perineonatal hypothermia. A source of radiant heat and operative nurse should be aware that there are a variresuscitation supplies must be readily available for ety of factors that affect maternal and fetal absorption the neonate before surgery on the woman begins. of narcotics or antianxiety agents. The amount of Electronic fetal monitoring is a valuable tool for medication, the administration site, the drug distribuassessing intrauterine fetal well-being during surgi- tion to maternal tissues, metabolism, and renal excrecal procedures. An L&D nurse who is adept at EFM tion of the narcotic affect the concentration of the drug interpretation should be i n attendance with the in the fetus. Any condition that diminishes uterine patient throughout the entire perioperative period. blood flow will alter the transfer of drugs to the fetus Not only will the L&D nurse interpret the fetal mon- and, conversely, from the fetus to the mother. itor strip, he or she also will suggest appropriate The immature fetal liver is poorly equipped to patient interventions and interpret fetal responses to metabolize pain medication, The maternal renal and those interventions. hepatic systems assist the fetus in metabolizing and Pregnant surgical patients, regardless of gesta- excreting pain medications if the mother does not tional age, are at increased risk for preterm labor; have a condition such as hypertension or diabetes that therefore, baseline information regarding uterine alters placental and uterine perfusion. The FHR variactivity should be obtained preoperatively. Preopera- ability decreases during the peak action of pain medtive pharmacological interventions (eg, tocolytic ications but returns to normal with maternal excretion agents) to arrest preterm labor can be instituted to of the analgesic agent.@ decrease the risk these patients have for preterm The perioperative nurse should evaluate the delivery. patient’s clinical picture continually to rule out Preoperative patient anxiety should be mini- underlying pathology when reduced FHR variability mized. Sympathetic nerve fiber discharge in the anx- occurs. If delivery is to occur soon after administraious pregnant patient results in decreased uterine tion of pain medication, short-acting narcotics 210 AORN JOURNAL
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should be used instead of long-acting analgesics. The IV route is preferred over the intramuscular route so that medication absorption rates and peak actions are predictable. INTRAOPERATIVEPATIENT CONSIDERATIONS
Intraoperative priorities are determined by the surgeon and are dependent on the condition of the mother and the gestational age of the fetus. In emergent surgery situations, the maternal condition overrides consideration for the fetus, because fetal survival is assured only through maternal survival. In nonemergent surgery situations, the fetus is afforded overriding consideration to promote optimum fetal outcome. The surgeon explains these intraoperative priorities to the patient and her family members before surgery. The simple maneuver of laterally tilting the uterus off the vena cava is probably one of the most important intraoperative nursing interventions. This maneuver not only prevents supine maternal hypotension but enhances uterine perfusion. Lateral tilting becomes crucial in second and third trimester gestations; however, in some cases, gestational age may not be known. If the uterus is at the level of the umbilicus, lateral displacement of the uterus is indicated. Figure 1 shows the proper positioning of a wedge under the right maternal hip for displacing the uterus to the left. Electronic fetal monitoring should be employed in gestations of 20 weeks or longer. Uterine activity as well as FHR should be monitored continuously. Monitoring during abdominal surgery may be accomplished by placing a sterile sleeve over the fetal monitor ultrasonic transducer. Sterile gel is needed for conduction (Figure 2). An L&D nurse must don surgical attire and manually hold the ultrasonic transducer in place to maintain a readout on the fetal monitor. If contractions cannot be monitored electronically, the L&D nurse may manually palpate the uterus for contractions (Figure 3). Uterine activity increases when bladder distention develops. If the surgery is expected to last longer than one hour, a Foley catheter should be inserted preoperatively to prevent bladder distention. If a Foley catheter is not inserted, the circulating nurse should palpate the bladder for distention every 30 minutes when fluids are being infused rapidly (ie, greater than 250 mL/hour). If uterine activity is detected and the bladder is distended in a patient without a Foley catheter, surgery is interrupted, and a Foley catheter is inserted under sterile conditions.
Figure 2 Asepsis is maintained and intraoperative fetal monitoring is accomplished by covering the ultrasonic transducer with a sterile sleeve and using sterile conductive gel. Anesthetic exposure during pregnancy can be minimized by prepping and draping the patient before induction of general anesthesia. We conducted a national survey of hospitals that had more than 2,000 annual births and found that only 4 1 % prepped and draped the pregnant surgical patient before the induction of anesthesia.19 The practice of giving general anesthesia to the pregnant surgical patient before prepping and draping adds 10 to 50 minutes of unnecessary, additional anesthetic exposure to the fetus. The circulating nurse should shield the uterus when intraoperative x-rays are taken. A sterile sheet wrapped around a lead apron and placed across the uterus provides adequate shielding while maintaining asepsis. If fluoroscopy is necessary, the circulating nurse can place an apron underneath the patient preoperatively to minimize radiation exposure to the fetus. The pregnant patient who requires extracorporeal circulation (ECC) needs several intraoperative interventions for optimum fetal outcome. The use of ECC during pregnancy carries a reported fetal death rate of 21.8%.20 The perfusionist should increase the pump volume by 40 mL/kg of maternal weight to mimic the volume expansion of the pregnancy. Higher pump pressures also should be employed to maintain adequate uterine blood flow. Anticoagulation, if indicated, should be achieved by using heparin because, unlike warfarin derivatives, heparin does not cross the placenta. Extracorporeal circulation should be conducted at normal
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t e m p e r a t u r e s in p r e g n a n t patients. Poor placental perfusion during maternal hypothermia c a n cause fetal bradycardia. Maternal hypothermia also may obscure differentiation of fetal bradycardia from fetal hypoxia. In addition, hypothermia has been associated with ventricular fibrillation in the mother and possible ventricular fibrillation in the fetus.?' Preterm labor also has been associated with rewarming the hypothermic pregnant patient. A s a result, every effort should be made to keep the pregnant surgical patient normothermic during surgery. The OR temperature should be set at a minimum 75" F (24" C ) . Only warm irrigation, IV, and prep Figure 3 During abdominal surgery, an L&D nurse holds an ultrasonic solutions should be used, Warm transducer to detect fetal heart rate in the pregnant Surgical patient. blankets should be provided before prepping. and minimal exposure of the patient should help maintain maternal patient's obstetric (OB) care provider. Because the normal PO, is higher during pregnormothermia. Thermal drapes, blankets, and head covers can be u5ed on the patient if hypothermia nancy (ie, 104 to 108 mm Hg), supplemental oxygen should be given early to maintain 94% or greater develops. patient oxygen saturation. Continuous pulse oximetry should be employed to assess the recovering patient's PosTOPERATlVE CARE If fetal stress or uterine contractions are detected oxygen saturation status. Magnesium sulfate. Postanesthesia care unit on the intraoperative fetal monitor strip, the patient should recover in the L&D unit. If this is not possible, nurses must be aware of the side effects of tocolytic a well-coordinated team approach that includes a peri- drugs that the patient may receive. Magnesium sulfate natal team member is crucial. Electronic fetal moni- is a commonly used tocolytic agent that blocks the toring should continue postoperatively for two hours uptake of acetylcholine at the myoneural junction. The if there are no surgical complications. With complica- therapeutic level of magnesium sulfate is 5 to 7 tions, fetal monitoring should continue for at least 24 mddL. Levels greater than 5 to 7 mg/dL are considhours. All trauma surgical patients should have 24- ered toxic and may result in severe respiratory depreshour fetal monitoring whether there are surgical com- sion and death. Nursing care of the patient who plications or not because of an increased risk for pla- receives magnesium sulfate includes hourly monitoring and recording of fluid intake cental abruption. and output, Nurses should administer pain medications as assessment of deep tendon reflexes every one to needed. Analgesia pumps provide the patient consistwo hours, and tent pain relief with minimal medication. Intrathecal patient sensorium checks. morphine as well as epidural analgesics successfully Urinary output should be at least 25 mL/hour to and safely treat postoperative pain during pregnancy. Frequent nursing assessment for bladder distention is ensure excretion of the drug, and respirations should a priority to decrease uterine irritability in the postop be at least 16 breaths per minute. Deep tendon reflexerative period. In addition, the nurses should quantify es diminish or cease before respiratory compromise and report any vaginal spotting or bleeding to the develops. I f magnesium sulfate is administered in 212 AORN JOURNAL
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conjunction with general anesthesia, extubation may not be accomplished immediately after surgery because the patient's protective gag reflex may be diminished and the patient may exhibit some degree of respiratory depression. Terbutaline. Terbutaline, a beta-sympathomimetic preparation that is usually given to relax uterine muscle, is another widely used tocolytic agent. If bleeding is present, regardless of its origin, this drug should not be used because it may increase the maternal pulse rate and thus mask a cardinal sign of hypovolemia. In addition, terbutaline counteracts the body's own compensatory mechanisms in blood loss.22Cardiac disease, diabetes, and thyroid disorders are medical conditions in which terbutaline is contraindicated or should be used with extreme caution. Oral and written discharge instructions specific to the pregnant surgical patient should include signs and symptoms of labor: backache and cramping, change in vaginal discharge and spotting, and leakage of fluid from the vagina. If symptoms of labor are present, the patient should notify her obstetrician immediately. Patients also should be instructed in the technique of uterine palpation for contractions. In addition, if the patient is on terbutaline as a tocolytic, she should understand the importance of taking the medication as prescribed and checking her pulse prior to dosing. If her pulse is greater than 120 BPM, the patient should be instructed to omit the terbutaline dose and call her obstetrician for further instructions regarding this medication. CASE STUDY
Ms R, a 19-year-old primigravida with a 36-week pregnancy, presented to our obstetrical triage complaining of abdominal pain, fever, and anorexia. An initial physical examination revealed a 5-ft 6-inch, 183-lb, dehydrated female with an irritable uterus; a right flank and lower abdomen with rebound, referred tenderness; and positive bowel sounds. Vital signs were normal except for a temperature elevation of 101" F (38.5" C). Pelvic examination by the obstetrician revealed cervical dilation of 1 cm with 50% effacement and a presenting part that was unengaged. Initial external fetal monitoring revealed reactive FHR and an active fetus. The patient's perception of pain and uterine activity were unchanged after an observation period of four hours, during which laboratory work was obtained and
Terbutaline is not recommended for patients with diabetes, cardiac disease, or thyroid disorders.
IV hydration was administered. Laboratory values consisted of a normal urinalysis and a complete blood count that was normal except for a WBC of 13,100. In view of these findings, Ms R was admitted to the inpatient OB floor for continued observation and evaluation. Intravenous fluid therapy continued at 125 mL/hour. Acetaminophen was administered to reduce her fever. Because Ms R ' s condition remained unchanged and she continued to have an elevation in body temperature, a general surgeon was consulted the next morning to rule out appendicitis or cholelithiasis. After examining Ms R, the surgeon consulted with the obstetrician and scheduled an exploratory laparotomy. A laparoscopic approach could not be considered because the advanced gestation had caused an upward displacement of the abdominal viscera, and trocar placement and abdominal insufflation would be dangerous in this situation. Ms R remained NPO in preparation for surgery with IV fluids to maintain hydration. Intravenous cefotaxime and clindamycin antibiotic therapy was instituted before surgery. Preoperative teaching was provided by both the L&D and OR nursing staff members to the patient and her family members. Preoperative teaching included a discussion on the multidisciplinary team approach to patient care, possibility of a cesarean birth, need for tocolytic medication administration to treat preterm labor, relief of postoperative pain, and need for 24-hour hospitalization after surgery for observation and EFM. The patient signed a surgical consent for an exploratory laparotomy and possible cesarean delivery. The neonatologist and intensive care nursery staff members were notified of the impending surgery and the possibility of an emergency cesarean birth. The
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neonatal team was available during the surgery. An experienced L&D nurse joined the perioperative team to provide continuous fetal and uterine monitoring. Before surgery, a staff anesthesia care provider evaluated Ms R and discussed the risks of anesthesia, including preterm labor. Ms R agreed to general endotracheal anesthesia for surgery. The circulating nurse performed a preoperative patient assessment that included obtaining an obstetrical history on the surgical patient’s hepatitis and HIV status, known allergies, exposure to tuberculosis, bleeding and coagulopathy problems, antibody screening for Rh-immune status, and previous pregnancies and preterm deliveries. Approximately 17 hours after admission, Ms R was transported to the operating room. The circulating nurse positioned Ms R on the OR bed in a supine position with a left lateral tilt attained by placing a towel pack under Ms R’s right hip. The L&D nurse monitored the fetus continuously using an EFM unit. An anesthesia care provider placed electrocardiogram (ECG), blood pressure, end-tidal carbon dioxide, and neuromuscular blockade monitors on the patient. The circulating nurse placed an electrosurgical unit dispersive pad on Ms R’s left thigh. The general surgeon, assisted by the OB resident, prepped and draped the patient’s abdomen in a sterile manner. After adequate patient preoxygenation, a rapid-sequence general anesthesia was administered to the patient. The circulating nurse maintained cricoid pressure until the endotracheal intubation was secure to prevent aspiration of gastric contents. The obstetrician was present in the operating room throughout the procedure. At this time, the L&D nurse scrubbed, donned sterile attire, and draped the external ultrasonic transducer to the fetal monitor in a sterile plastic sleeve. The L&D nurse held the transducer approximately 1 112 inches from the incision site to monitor the FHR. She also periodically palpated the uterus for contractions. Sterile ultrasonic gel was used on the transducer for conduction. A right paramedian surgical incision revealed congenital bands around the appendix and ileum laterally and retroperitoneally. The appendix appeared initated and was mobilized, ligated, dissected, and sent to pathology. Postoperative histological examination revealed a vermifoiin appendix with nonspecific, follicular, lymphoid hyperplasia. Abdominal findings
were normal for this stage of pregnancy, and no inflammatory processes were noted. Sponge, instrument, and needle counts were correct, and the surgical incision was closed. During the surgical procedure, the fetus exhibited a lowering of baseline FHR by approximately 20 BPM (ie, from 160 to 140 BPM) but returned to the original baseline FHR within 30 minutes after surgery. There were no decelerations of the FHR, but the variability of the FHR decreased dramatically during surgery. Contractions were palpable during the last 10 minutes of the procedure. The circulating nurse, the surgeon, and the anesthesia care provider transferred Ms R directly to the OB recovery area on the L&D unit when she was awake, alert, and oriented. She was placed in a left lateral position with 40% oxygen delivered via face mask to maintain adequate maternal and fetal oxygenation. The ECG, pulse oximetry, blood pressure, and continuous EFM monitoring were resumed. Pulse oximetry readings were maintained between 95% and 100% oxygen saturation, and vital signs remained stable. The FHR was 140 BPM and nonreactive with no evidence of fetal distress. Uterine contractions were noted every one to two minutes with uterine irritability. The L&D nurses administered IV magnesium sulfate for tocolysis and gave IV meperidine for pain, intramuscular promethazine for nausea, and IV cefazolin every six hours for prophylaxis against infection. Ms R continued to receive IV tocolytic agents in the postoperative OB care unit until her contractions ceased. She was transferred to the antenatal unit on postoperative day one. She tolerated fluids and required little pain medication. On postoperative day two, she was transferred back to the L&D unit when her uterine contractions resumed, although she had no cervical change. Subcutaneous and oral administration of tocolytic agents successfully arrested the uterine contractions, and Ms R was returned to the antenatal unit on postoperative day three. She was discharged on postoperative day four, and the remainder of her pregnancy was uneventful. Ms R was admitted to the hospital for induction of labor five weeks after her surgery and one week past her due date. After 13 hours, she spontaneously delivered a 7-lb 9-oz healthy male under epidural anesthesia. The baby’s Apgar scores were 8 and 9 at one and five minutes, respectively. The postpartum course was uneventful. Both mother and child continue to do well at the time of this writing.
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healthy mother and full-term baby in a pregnant patient who underwent an exploratory laparotomy and appendectomy at 36 weeks’ gestation. A
CONCLUSION
Management of the pregnant surgical patient poses a challenge for perioperative nurses. To provide optimal care, nurses need to understand the normal anatomic and physiologic changes of pregnancy. Collaborating with L&D nurses and formalizing a perioperative plan of care enhance the outcome for both the mother and the fetus. Without this multidisciplinary approach to the pregnant surgical patient. perinatal morbidity and mortality cannot be improved. The multidisciplinary nursing approach used in this case resulted in a
Jo M. Kendrick, RN. M S N , C , is an obstetrical nui‘se practitioner at the Uiiil.ei.si& of Tennessee Medical Centei‘. Ki i oni l l e . Pallas Harnrnond Powers, RN, is a iuscular special@ nurse in the O R at the U i i i n ~ s i t yojTenizessee Medical Cerirei..Kiio.t-viIle
7. Roberts. Chestnut. “Anesthesia for the obstetric patient with cardiac disease.“ 601-609. 8. L E Oakley. J D Johnson. “Traumatic injury in pregnancy,” Crit691. ical Cuiv Nzrrse 11 (June 1991) 64-73. 9. V Sorenson et al. “Manage2. G Levinson, S Shnider. “Anesthesia for surgery during pregnancy.” ment of general surgical emergencies in Aiiestlir.siufi~i~ 0b.wri.ics. ed S in pregnancy.” The Aniei.icriri SurShnider. G Levinson (Baltimore: gpoii 56 (April 1990) 245-250. 10. Ihid. 248. William & Wilkins. 1Y87) 188-205. 1 I. L Pimentel, ”Mother and child: 3. R I Mazze. B Kallen. ‘.ReproTrauma in pregnancy.” Eniei~geiicy ductive outcome after anesthesia and operation during pregnancy: A regMediciiie Clinics ofNor-rli America 9 istry study of 5.405 cases.“ Anir~ic~uii (August 1991) 549-563. Jorrriiul of’Ob.stetrir~.si i i i d C y c c o l o 12. C Bremer. L Cassata. ”Trauma gy 161 (November 1989) 1178-1185. in pregnancy.” Niii-siii,gC1iiiie.s of North Aniericci 2 1 (December 1986) 4. B Duncan et al, “Fetal risk of 705-7 16. anesthesia and surgery during preg13. L Reisner, “Anesthesia for nancy,“ Aiirsthesiolog~64 (June cesarean delivery.” Clinical Obsrer1986) 790-794. 5. S Roberts. D Chestnut. ”Anesi k s & Gyiiec~oI~ 30~ (September q~ thesia for the obstetric patient with 1987) 539-55 1. cardiac disease,” Clinical Olistr~tr.ic~s 14. J Johnson. L Oakley, “Managing minor trauma during pregnancy,” & Gyiwcology 30 (September 1987) Jorri~rialof Obstc,ti.ic~.Gynecologic & 60 1-6 10. Neoiiutul N i i / ~ s i i i g20 (September/ 6. S Clark. “Shock in the pregOctober 1991) 379-384. nant patient.” Seniiiiul-s in Pri.iiiaro115. Ibitl. 383. o * y 14 ~ (February 1990) 52-58.
NOTES 1. W Barron, “The pregnant surgical patient: Medical evaluation and management.” Ainials oflirte/md Medic,ine 101 (November 1984) 683-
AORN IS accredited 0s o provider of continuing education in nursing by the American Nurses CredentiolingCenter‘s Commission on Accreditohon AORN recognizes this octiviiy as continuing educotion for registered nurses This recognition does not imply thot AORN or the American Nurses Credentioling Center‘s Commission on Accreditotion approves or endorses any product included in the activity AORN mointains the following provider numbers Alabama ABNP0075, California BRN00667, Florida 27FOI 77, low0 103 AORN IS approved 0s a provider of continuing nursing
16. Pimentel, “Mother and child: Trauma in pregnancy,” 549.563. 17. Mazze, Kallen, “Reproductive outcome after anesthesia and operation during pregnancy: A registry study of 5,405 cases,” 1178-1185. 18. F Spielman, “Systemic analgesics during labor,” Clinical Obsteti.irs & Gynecology 30 (September 1987) 495-504. 19. J M Kendrick, C Woodard, S
Cross, “Fetal and uterine surveillance during maternal surgery in the USA: A mail survey,” AORN Journal (in press). 20. J Conroy et al, “Anesthesia for open heart surgery in the pregnant patient,” Southern Medical Journal 82 (April 1989) 492-495. 2 1. R G Sutton, J P Dearing, “Cardiopulmonary bypass during pregnancy: A case report,” Journal of E.ma-t.oipor-r~a1 Techiio/ogy20 no 2 (Summer 1988) 67-71. 22. B Nuwayhid, M Rajabi, “Betasympathomimetic agents: Use in perinatal obstetrics,” Clinics in Perk nutology 14 (December 1987) 757782.
education by the Konsos State Board of Nursing This course offering IS opproved for two contact hours The Kansas Stote Board of Nursing opproved provider number is L TO 1 14-03 16 Professional nurses ore invited to submit monuscripts for the Home Study Progrom Manuscripts or queries should be sent to the Editor, AORN Journal, 2 170 S Parker Rd, Suite 300, Denver, CO 80231-571 1 As with all monuscripk sent to the Journal, papers submitted for Home Study Programs should not hove been previously published or submitted simultoneously to ony other publication
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Examination PERIOPERATIVE CARE OF THE PREGNANT SURGICAL PATIENT
7. Increased rates of congenital anomalies are found in babies born to mothers who undergo surgery during pregnancy. a. true b. false
1.During pregnancy, the woman’s hematologic values change in the following way to accommodate the expanding uterus, placenta, and fetal circulation. a. hematocrit increases b. white blood cells decrease c. clotting factors decrease d. plasma volume increases
8.Intraoperative priorities are determined by the surgeon dependent on a. equipment needs, available staffing b. signed surgical consent, family’s wishes c. laboratory values, HIV status of mother d. mother’s condition, gestational age of fetus
2. Cardiovascular changes in the pregnant surgical patient include all of the following except a. decreased cardiac output in a supine position from uterine compression on the vena cava b. increased peripheral circulation c. mild tachycardia and a decreased mean arterial pressure d. hypertension in the third trimester
9.According to the authors, what is one of the most important intraoperative nursing interventions? a. applying cricoid pressure to prevent aspiration b. placing a fetal heart monitor on patient c. inserting Foley catheter into patient d. placing patient in lateral tilt position
3.The maternal patient can sustain an acute blood loss of 30% to 35% before exhibiting signs and symptoms of shock because of a. elevated blood pressure b. decreased perfusion needs during pregnancy c. increased plasma volume d. placental compensation
1 a I t is beneficial to the fetus to prep and drape the maternal patient before induction of general anesthesia. a. true b. false
4. What is the best position for a pregnant surgical patient in her second or third trimester undergoing an exploratory laparotomy? a. left lateral decubitus b. supine c. high Fowler’s to facilitate breathing d. low lithotomy with wedge under right hip 5.The pregnant woman lives in a state of chronic, compensated a. metabolic acidosis b. metabolic alkalosis c. respiratory alkalosis, d. respiratory acidosis
11.What intraoperative nursing interventions should the nurses initiate to ensure maternal normothermia during surgery? a. Place compression stockings on patient. b. Insert Foley catheter into patient. c. Increase IV pump volume and pressure. d. Use warm irrigation, IV, and prep solutions. 12.Postoperative use of morphine and epidural analgesics increases the risk of congenital anomalies. a. true b. false
I t Postoperative nursing care of the pregnant trauma 6. According to the authors, fetal heart rate changes are usually the first indicator of maternal hypoxia. a. true b. false
surgical patient includes a. reporting vaginal bleeding promptly b. the use of prescribed, supplemental oxygen and continuous pulse oximetry
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the placental blood barrier c. gastric bleeding from delayed gastric emptying and increased gastric acid output d. signs of preterm labor due to manipulation of reproductive organs
c. electronic fetal monitoring for 24 hours after surgery d. all of the above IQTerbutaline is a tocolytic agent that is used with extreme caution in what medical conditions associated with the maternal surgical patient? a. appendicitis, cholelithiasis b. pancreatitis, peptic ulcer disease c. diabetes, cardiac disease, and thyroid disorders d. hypertension, urinary tract infections ISPreoperative teaching for the maternal patient includes a discussion on which of the following? 1. possibility of cesarean birth 2. need for 24-hour hospitalization after surgery 3. multidisciplinary team approach to patient care 4. need for tocolytic medication administration to treat preterm labor a. 1 and 2 b. 2 a n d 3 c. 1, 2,and3 d. all of the above
16.Preoperative nursing measures include 1. administering antacids and oxygen to patient 2. decreasing patient anxiety, monitoring fetal heart rate continuously 3. placing nasogastric tube in patient 4. administering magnesium sulfate, terbutaline nebulizer treatment a. 1 and2 b. 2 a n d 3 c. I , 2 , and 3 d. all of the above 17.According to this article, the most common cause of fetal death in utero is a. placental separation b. maternal shock c. head injury d. uterine rupture l a w h a t should the perioperative nurse consider when caring for the pregnant surgical patient after surgery? a. a prolonged recovery time because pregnant surgical patients require larger amounts of anesthetic agents b. fetal distress from anesthetic agents crossing
19.Where is blood shunted when a pregnant surgical patient is in shock? a. away from the uterus b. to the uterus for fetal protection c. to the maternal kidneys for homeostasis d. to the central nervous systems of both patients =Toxic levels of magnesium sulfate in the maternal patient may result in a. severe hemorrhage and shock b. elevated blood pressure and epistaxis c. severe respiratory depression and death d. decreased potassium levels and arrhythmias =.Nursing care of the pregnant patient who receives magnesium sulfate includes a. ventilatory care b. hourly fluid intake and output monitoring c. rotating intramuscular injection sites d. frequent range of motion exercises =.Placement of a nasogastric tube in the pregnant surgical patient decreases her risk of aspiration pneumonitis during a surgical procedure. a. true b. false =A
preoperative obstetrical history assessment should include a. anesthetic preference of patient b. name of insurance company c. religious preference d. patient’s hepatitis and HIV statuses
-Poor placental perfusion during maternal hypothermia can cause fetal tachycardia. a. true b. false #Electronic fetal monitoring should be employed in gestations of 16 weeks or less. a. true b. false
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Answer Sheet PERlOPERATlVECARE
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Learner Evaluation PERIOPERATWE CARE OF THE PREGNANT SURGICAL PATIENT The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. OBJECTIVES
To what extent were the following objectives of this home study program achieved? ( I ) Discuss the anatomic and physiologic changes in the pregnant surgical patient. (2) Discuss the implications of these changes on the multidisciplinary approach to nursing care of the pregnant surgical patient. (3) Describe general considerations in the perioperative care of the pregnant surgical patient. (4) Identify the perioperative nurse's role when caring for the pregnant surgical patient. CONTENT
(1) Did this article increase your knowledge of the subject matter? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individual objectives met? (5) Was the content of the article relevant to the objectives? TEST wLsIIoNs/ANswuIs
(1) Were they reflective of the content? (2) Were they easy to understand? (3) Did they address important points'?
What other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s):
Author names and addresses:
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