1	Circulation
2	Altered Circulatory Status Of The Pregnant Woman Inc. need for blood and Oxygen for mom and baby. Inc. blood volume by 30%-50% or (1500cc) Inc. blood flow: cardiac output 30%-50% Inc. heart rate 10-15 bpm with occasional palpitations; symptoms at end of second trimester Slight cardiac enlargement & repositioned higher and to the left
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4	If volume Increases dramatically, then the blood vessels must change to accommodate Slight drop in B/P until the end of the second trimester. Progesterone relaxes smooth muscle in the cardiovascular system Estrogen promotes proliferation of circulation; accelerates the production of RBC’s (4.0-5.5). Serum, however, increases at a faster rate than the RBC’s.
5	Normal Physiologic Anemia Of Pregnancy Hemodilution Change in Hct & Hgb Corrects itself eventually at some time during the third trimester` Must take in 30mg-60mg more Iron to keep up with need. Unlikely that dietary intake will be sufficient.
6	Other Circulatory Changes Varicosities & hemorrhoids Inc. RBC’s = Inc. Iron requirement Postural Hypotension-Supine Hypotensive Syndrome; Best position to improve circulation is left lateral recumbent. WBC’s =25,ooo/mm3
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8	Increased Ability To Clot Inc. fibrin, fibrinogen and adhesiveness of platelets Inc. anti-fibrin lysis factors Inc. clotting factors in general Lower extremity edema: Increased hydrostatic pressure; decreased colloid osmotic pressure. Lower venous stasis
9	Conditions Of Risk During Pregnancy A healthy heart can handle the changes of pregnancy. The woman with heart disease may have to compensate.
10	Cardiac Compensation Ventricular dilatation: Stretch myocardial fibers to inc. strength of the hearts contraction. Ventricular hypertrophy: Inc. size of the heart to inc. its effectiveness. Tachycardia: Heart attempts to pump oxygenated blood more quickly to the tissues allowing for greater oxygen exposure.
11	Decompensation Cough dyspnea edema palpitations moist rales murmurs
12	Cardiac Classifications Class I: Asymptomatic. No limitation of physical activity. ClassII: Slight limitation of physical activity. Asymptomatic at rest; symptoms occur with heavy physical activity ClassIII: Moderate to marked limitation of physical activity. Symptomatic during less than normal physical activity. Class IV: Inability to carry on any physical activity without experiencing discomfort. Angina & insufficiency at rest.
13	Who is at greatest risk? Women in classes I and II usually experience a normal pregnancy and have few complications, whereas those in classes III and IV are at risk for more severe complications. Must consider termination or total hospitalization for saving the life of the mother.
14	Conditions of Risk Rheumatic Heart Disease Mitral Valve Prolapse Congenital Defects Peripartum Cardiomyopathy: Last month of pregnancy or 1st 5 months postpartum
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16	Antepartum Education for Compensating Cardiac Clients Diet- Iron supplementation, potassium, low sodium, increased protein, fluids and fiber. Rest- 8-10 hours / night Avoid infection- URIs may tax heart See PCP Q2wks. until 20 weeks; Then < 1 week
17	Intrapartum Management of Cardiac Clients V.S.- q15-30 minutes: Call PCP if HR > 100, RR > 25, signs of pulmonary edema, pulse ox < 95% Position- left side, semi fowlers or higher Subacute endocarditis (SBE) or infective endocarditis, prophylaxis with antinbiotics with antibiotics May require hemodynamic monitoring Evaluate effects of pain, anxiety and intravascular volume shifting Oxygen administration.
18	Intrapartum Continued Control volume carefully: Strict I&O Monitor effects of epidural anesthesia: gives better pain relief and causes fewer alterations in hemodynamics Continuous fetal monitoring Meds: anticoags,digoxin, lasix, B-adrenergics Valsalva must be avoided in second stage: forceps or vacuum./ Soft pushing or open glottal pushing
19	Postpartum First 48 hours watch for decompensation Critical period during 3^rd Stage of Labor as Cardiac Output increases by 65%. Placental blood is transfused back into maternal curculation. Not out of danger for 1 week Class 1&2 can breastfeed. Class 3& 4 cannot.