Dr/ Nawal Kamal

Dr/ Nawal Kamal

Lecturer of Obstetrics and Gynecology Faculty of Nursing South Valley University

Dr/ Nawal Kamal

Outlines:

• Introduction

• Classification of heart disease

• Homodynamic changes during pregnancy

• Effects of pregnancy on heart disease

• Effects of heart disease on pregnant women

• Effects of pregnancy on heart disease

• Nursing management

• Nursing management for patient with class 111 or IV heart disease

Dr/ Nawal Kamal

Introduction

• The incidence of heart disease with pregnancy

world is between 0.2 and 3.7 % Rheumatic heart

disease accounts for about half of the cases while

congenital heart defects are responsible for most

of the remaining half. Maternal mortality in

pregnant cardiac patients is 10% world wide and

12.8 % in Egypt.

Dr/ Nawal Kamal

Dr/ Nawal Kamal

Classification of Heart Disease

Classification of heart disease:

• The classification of heart disease is based on

function not diagnosis different individuals

with the same diagnosis may be in different

functional classification, and individual with

various diagnoses will be in each functional

classification:

Dr/ Nawal Kamal

Classification of heart disease:

• Class 1: no limitation of physical activity.

• Class 2: slight limitation of physical activity, fatigue, dyspnea, palpitation occurring with ordinary activity.

• Class3: moderate to marked limitation of physical activity. Excessive fatigue, dyspnea, palpitation or anginal pain occurring with less than ordinary activity.

• Class4: in ability to carry on physical activity .Dyspnea at rest.

Dr/ Nawal Kamal

Dr/ Nawal Kamal

Homodynamic Changes During Pregnancy

Homodynamic changes during pregnancy:

• Cardiac output increase by as much as 40%.

• Blood volume increase by as much as 50%.

• Heart work increase by about 30 to 40

• Peripheral resistance decrease.

• Blood pressure decrease in the first half of pregnancy followed by arise to pregnant state or higher.

Dr/ Nawal Kamal

Dr/ Nawal Kamal

Effects of Pregnancy on Heart Disease

Effects of pregnancy on heart disease:

1. Pregnancy deteriorate patient one clinical grade, but acute heart failure may occur:

– between 28-32 weeks maximum increase blood volume and cardiac output and hem dilution).

– During labor ( contraction increase load on the heart ) usually second stage more than first stage.

Dr/ Nawal Kamal

Effects of pregnancy on heart disease: cont

– During third stage and immediately post partum because following placenta delivery 500-900 ml blood pass to right ventricle + ↓IVC compression →double cardiac output and volume overload on the heart Acute heart failure may be sudden →acute pulmonary edema with maternal mortality rate 70%.

Dr/ Nawal Kamal

Effects of pregnancy on heart disease: cont

2.Arrhythmias as arterial as fibrillation

(pregnancy ↓threshold for arrhythmias).

3.Bacterial endocarditis in pregnancy

4.Thrombembolic complication commonest

vascular complication of pregnancy.

5.Rheumatic activation and chorea.

Dr/ Nawal Kamal

Dr/ Nawal Kamal

Effects of Heart Disease on Pregnancy

Effects of heart disease on pregnant women:

1- Maternal complication:

polyhydromnious

preterm labor

post partum hemorrhage

abortion increase the incidence of maternal

mortality.

Dr/ Nawal Kamal

Effects of heart disease on pregnant women: cont.

2- Fetal complication: cyanotic heart disease abortion 70%.

Congenital heart disease → increase congenital fetal malformation.

IUGR up to IUFD due to chronic hypoxia and low cardiac output.

Preterm labor

Early neonatal death.

Dr/ Nawal Kamal

Nursing management :

I- Nursing assessment: History:

• History of dyspnea, palpitation and easy fatigue ability.

• Identify other factors that would increase strain on heart e.g. anemia infection and anxiety.

• Family history of heart disease. • Determine the women activity level including rest. • Examination: determine the functional capacity of the

heart in each antenatal visit by taking the women pulse, respiration and blood pressure .

Dr/ Nawal Kamal

Dr/ Nawal Kamal

Nursing care during antenatal period:

1- Promotion of adequate nutrition: diet should be rich in iron ,protein and essential

nutrients. Low in sodium

2- Promotion of rest: rest is necessary to reduce the workload of the heart 8 to10 hours of sleep are essential with daily rest

period. The patient should be instructed to rest on the left

side. Lateral recumpant position to facilitate blood flow to

the fetus.

Dr/ Nawal Kamal

3- Promotion from infection:

women must be informed about the importance of protecting herself from infection, especially upper respiratory infection and stress on the heart.

Teach the patient to report signs and symptoms of infection.

Dr/ Nawal Kamal

4- Promotion of client acceptance of the need to restrict activity:

decrease exertion reduces fatigue and

promotes adequate ventilation and

preservation of cardiac reserves.

Dr/ Nawal Kamal

5- Monitoring of cardiac status:

during the first half of pregnancy the women is seen every 2 weeks . during the second half she is seen every week especially between weeks 28-30 in order to:

assess cardiac status

assess of symptoms of cardiac decomposition occur.

Teeth signs and symptoms of deteriorating cardiac status such as dyspnea, orthopenea, cough and hemoptasis and how to report them. Education for self care.

Dr/ Nawal Kamal

The women should understand her condition:

signs and decomposition

any medication she is taking and how to use it .

reasons for the need to decrease activity if symptoms occur.

Dr/ Nawal Kamal

6- When therapy is being initiated , the nurse should assist the patient by:

providing oxygenation

providing skin care.

Ensuring that constipation is avoided.

Promoting good nutrition.

Dr/ Nawal Kamal

NURSING MANAGEMENT

Dr/ Nawal Kamal

Nursing management for patient with class 111 or IV heart disease:

• Patient with grade 111 heart disease should

not leave the hospital until they reached grade

• Grade IV patients should not leave hospital at

any time until after delivery.

• The patient may need to be hospitalized for

digitalis therapy.

Dr/ Nawal Kamal

Nursing management for patient with class 111 or IV heart disease: cont.

• The nurse should take apical pulse for a full

minute before administration of digitalis and

with hold dose if pulse is < 60.

• Check cardiac monitor for arrhythmias.

• Observe for hypokalemia.

• Provide foods high in potassium.

Dr/ Nawal Kamal

Nursing Care During The Intrapartum period :

1- Monitoring of maternal and fetal well-being :

• Assess maternal pulse, respiration, and bp.

• Pulse rate greater than 100 b/m or respiration greater than 25/min ,requires careful evaluation to detect early signs of decomposition.

• Electronic fetal monitoring.

• Monitoring maternal contraction.

Dr/ Nawal Kamal

2- Promotion of optimum cardiac function through proper position:

side-lying and semi fowlers position help in assuring cardiac emptying and proper oxygenation, and maximum utero placental blood flow.

3- Monitoring pulmonary function:

carefully assess the patient for the presence of cough or dyspnea.

Dr/ Nawal Kamal

4- Implementation of supportive therapy:

• use of prophylactic antibiotics on doctors orders.

• Oxygen by mask if dyspnea occur.

• Administration of:

• diuretics to decrease the venous return to the heart and therapy decrease the pulmonary and left arterial blood pressure so reducing pulmonary cognitions.

• Sedative: help to alleviate anxiety and decrease the voluntary muscle activity during the second stage of labor.

Dr/ Nawal Kamal

5- Reduction of physical exertion during labor and delivery:

• Encourage relaxation and sleep between contraction.

• Support the women emotionally to be less anxious.

• The nurse guards the women against over exertion during pushing by coaching her to use shorter more moderate , open glottis pushes with complete relaxation between pushes.

• Monitor vital signs closely every 10 minutes during the second stages.

Dr/ Nawal Kamal

• Oxytocin is contraindicated for heart disease in first and second stage.

• Blood loss during 3rd and 4th stage of labor is kept to minimum by promote delivery of the placenta and oxytocin administration and bimanual compression. -Nursing care during post partum period.

Dr/ Nawal Kamal

Nursing Care During The Postpartum period :

• Promoting of recovery:

– monitoring vital signs regularly.

– Maintain the women in semi fowlers positions

– The women resumes activity gradual and progressively

– Facilitate Powel elimination.

Dr/ Nawal Kamal

• Provision of psychological support:

• Give the women opportunities to discuss her birth experience.

• Encourage maternal / fetal attachment .

• Continue to closely monitor maternal status after delivery since cardiac workload is great.

Dr/ Nawal Kamal

• Postpartum hemorrhage, infection and thrembo-embolism can all precipitate crises and must be prevented or immediately treated.

• Education and assistance in newborn care:

• A woman with grad I and II heart disease can breastfeed her infant.

• The nurse can assist the woman to a comfortable side-lying position with her head moderately elevated or to a semi-Fowler’s position.

Dr/ Nawal Kamal

• Preparation for the discharge

• Realistic home care plans should be communicated with patients.

• Plan with the woman an activity schedule that is gradual, progressive, and appropriate to her needs and home environment.

• Give appropriate information and counseling regarding sexual relations and contraception.

Dr/ Nawal Kamal

• Evaluative outcome criteria

• Anticipated outcome of nursing care include the following:

• the woman participate in developing an appropriate health care regimen and follows it throughout her pregnancy.

• The woman clearly understands her condition and its possible impact on pregnancy, labor and delivery, and postnatal period.

Dr/ Nawal Kamal

• The woman successfully delivers a healthy

infant.

• The woman avoids congestive heart failure.

• The woman is comfortable caring for her

newborn infant.

Dr/ Nawal Kamal

Dr/ Nawal Kamal