Care for Mother and Child at Risk or with 4.

Hemorrhage and shock can result if bleeding

Problems is excessive.
RLE Learning Material 3
TOPIC I: Care of At-Risk/High-Risk and Mother D. Interventions
1. Maintain bed rest as prescribed.
A pregnant mother can be at-risk or high risk at 2. Monitor vital signs.
any stage, beginning with fertilization, and through 3. Monitor for cramping and bleeding.
birth. Early diagnosis of a risk factor for a 4. Count perineal pads to evaluate blood loss
complication or the early onset of the complication and save expelled tissues and clots.
can lead to early treatment and prevention of 5. Maintain intravenous (IV) fluids as
damage to the mother or fetus. prescribed; monitor for signs of hemorrhage
Often the cause of the complication is not known, or shock.
but many associated conditions can provide an 6. Prepare the client for dilation and curettage
opportunity to anticipate the condition and prevent as prescribed for incomplete abortion.
or minimize the negative consequences. 7. Administer Rho(D) immune globulin, as
prescribed, for a Rh-negative woman.
I. ABORTION 8. Provide psychological support.
A. Definition:
▪ A pregnancy that ends before 20 weeks’ II. ANEMIA
gestation, spontaneously or electively A. Definition
1. Iron deficiency anemia is a condition that
B. Types of Abortion develops as a result of an inadequate amount
Types of Definition of serum iron.
Abortion 2. Anemia predisposes the client to postpartum
Spontaneous Pregnancy ends because of infection.
natural causes.
Induced Therapeutic or elective reasons B. Assessment
exist for terminating pregnancy. 1. Fatigue
Threatened Spotting and cramping occur 2. Headache
without cervical change. 3. Pallor
Inevitable Spotting and cramping occur, 4. Tachycardia
and cervix begins to dilate and 5. Hemoglobin value is usually less than 10
efface. g/dL (100 mmol/L); hematocrit value is
Incomplete Loss of some of the products of usually less than 30%.
conception occurs, with part of
the products retained (most often C. Interventions
placenta is retained). 1. Monitor hemoglobin and hematocrit levels
Complete Loss of all products of every 2 weeks.
conception. 2. Administer and instruct the client about iron
Missed Products of conception are and folic acid supplements.
retained in utero after fetal 3. Instruct the client to take iron with a source
death. of vitamin C to increase its absorption and to
Habitual Spontaneous abortions occur in avoid taking iron with tea, milk products, or
3 or more successive caffeine. Iron is absorbed best if taken
pregnancies. between meals.
4. Instruct the client to eat foods high in iron,
C. Assessment folic acid, and protein.
1. Spontaneous vaginal bleeding 5. Teach the client to monitor for signs and
2. Low uterine cramping or contractions symptoms of infection.
3. Blood clots or tissue through the vagina
 6. Prepare to administer parenteral iron or blood
transfusions; this may be prescribed for
severe anemia.
7. Prepare for the administration of oxytocic
medications in the postpartum period if
excessive bleeding is a concern.
III. CARDIAC DISEASE
A. Definition
A pregnant client with cardiac disease may be
unable physiologically to cope with the added
plasma volume and increased cardiac output that
occur during pregnancy; blood volume peaks at
weeks 32 to 34 and then declines slightly to week 40.

B. Maternal Cardiac Disease Risk Groups

Group I (Mortality Rate, Group II Group III (Mortality Rate, 25%
1%) (Mortality Rate, 5% to 15%) to 50%)
• Corrected tetralogy of Fallot • Mitral stenosis with atrial • Aortic coarctation
• Pulmonic or tricuspid disease fibrillation (complicated)
• Mitral stenosis (classes I and • Artificial heart valves • Myocardial infarction
II) • Mitral stenosis (classes III and IV) • Marfan syndrome
• Patent ductus arteriosus • Uncorrected tetralogy • True cardiomyopathy
• Ventricular septal defect • Aortic coarctation (uncomplicated) • Pulmonary
• Atrial septal defect • Aortic stenosis hypertension
• Porcine valve

C. Assessment a. Monitor vital signs frequently.

1. Signs and symptoms of cardiac
decompensation
a. Cough and respiratory congestion
b. Dyspnea and fatigue
c. Palpitations and tachycardia
d. Peripheral edema
e. Chest pain
2. Signs of respiratory infection
3. Signs of heart failure and pulmonary
edema
D. Interventions
1. Monitor vital signs, fetal heart rate, and
condition of the fetus.
2. Limit physical activities and stress the need
for sufficient rest.
3. Monitor for signs of cardiac stress and
decompensation, such as cough, fatigue,
dyspnea, chest pain, and tachycardia; also
monitor for signs of heart failure and
pulmonary edema.
4. Encourage adequate nutrition to prevent
anemia, which would worsen the cardiac
status; in addition, a low-sodium diet may
be prescribed to prevent fluid retention and
heart failure.
5. Avoid excessive weight gain.
6. During labor, prepare to do the following:
b. Place the client on a cardiac monitor
and on an external fetal monitor.
c. Maintain bed rest, with the client lying
on her side with her head and shoulders
elevated.
d. Administer oxygen as prescribed.
e. Manage pain early in labor.
f. Use controlled pushing efforts to
decrease cardiac stress.
Excessive weight gains places stress on
the heart. In addition, obesity places the
client at increased risk for complications
during pregnancy.
IV. DIABETES MELLITUS
A. Definition
1. Pregnancy places demands on
carbohydrate metabolism and causes
insulin requirements to change.
2. Maternal glucose crosses the placenta, but
insulin does not.
3. The fetus produces its own insulin and
pulls glucose from the mother, which
predisposes the mother to hypoglycemic
reactions.
 4. The newborn of a diabetic mother may be
large in size, but has functions related to
gestational age rather than size.
5. The newborn of a diabetic mother is at risk
for hypoglycemia, hyperbilirubinemia,
respiratory distress syndrome,
hypocalcemia, and congenital anomalies.
During the first trimester, maternal insulin
needs decrease. During the second and third
trimesters, increases in placental hormones
cause an insulin-resistant state, requiring an
increase in the client’s insulin dose. After
placental delivery, placental hormone levels
abruptly decrease, and insulin requirements
decrease.
B. Gestational diabetes mellitus
1. Gestational diabetes occurs in pregnancy
(during the second or third trimester) in
clients not previously diagnosed as diabetic
and occurs when the pancreas cannot
respond to the demand for more insulin.
2. Pregnant women should be screened for
gestational diabetes between 24 and 28
weeks of gestation.
3. A 3-hour oral glucose tolerance test is
performed to confirm gestational diabetes
mellitus.
4. Gestational diabetes frequently can be
treated by diet alone; however, some
clients may need insulin.
5. Most women with gestational diabetes
return to a euglycemic state after birth;
however, these individuals have an
increased risk of developing diabetes
mellitus in their lifetimes.
C. Predisposing conditions to gestational
diabetes
1. Older than 35 years
2. Obesity
3. Multiple gestation
4. Family history of diabetes mellitus
5. Large for gestational age fetus
D. Assessment
1. Excessive thirst
2. Hunger
3. Weight loss
4. Frequent urination
5. Blurred vision
6. Recurrent urinary tract infections and
vaginal yeast infections
7. Glycosuria and ketonuria
8. Signs of gestational hypertension
9. Polyhydramnios
10. Large for gestational age fetus
E. Interventions
1. Employ diet, medications (if diet cannot
control blood glucose levels), exercise, and
blood glucose determinations to maintain
blood glucose levels between 65 mg/dL
(3.7 mmol/L) and 130 mg/dL (7.4 mmol/L)
as prescribed.
2. Observe for signs of hyperglycemia,
glycosuria and ketonuria, and
hypoglycemia.
3. Monitor weight.
4. Increase calorie intake as prescribed, with
adequate insulin therapy so that glucose
moves into the cells.
5. Assess for signs of maternal complications
such as preeclampsia (hypertension and
proteinuria).
6. Monitor for signs of infection.
7. Instruct the client to report burning and
pain on urination, vaginal discharge or
itching, or any other signs of infection to
the health care provider (HCP).
8. Assess fetal status and monitor for signs of
fetal compromise.
F. Interventions during labor
1. Monitor fetal status continuously for signs
of distress and, if noted, prepare the client
for immediate cesarean section.
2. Carefully regulate insulin and provide
glucose intravenously as prescribed
because labor depletes glycogen.
G. Interventions during the postpartum period
1. Observe the mother closely for a
hypoglycemic reaction because a
precipitous decline in insulin requirements
normally occurs (the mother may not
require insulin for the first 24 hours).
 2. Reregulate insulin needs as prescribed after B. Predisposing conditions
the first day, according to blood glucose Predisposing Conditions for DIC
testing. ▪ Abruptio placentae
3. Assess dietary needs, based on blood ▪ Amniotic fluid embolism
glucose testing and insulin requirements. ▪ Gestational hypertension
4. Monitor for signs of infection or ▪ HELLP syndrome
postpartum hemorrhage. ▪ Intrauterine fetal death
▪ Liver disease
V. DISSEMINATED INTRAVASCULAR ▪ Sepsis
COAGULATION (DIC)
C. Assessment
A. Definition 1. Uncontrolled bleeding
DIC is a maternal condition in which the 2. Bruising, purpura, petechiae, and
clotting cascade is activated, resulting in the ecchymosis
formation of clots in the microcirculation. 3. Presence of occult blood in excretions such
as stool
Pathophysiology if DIC 4. Hematuria, hematemesis, or vaginal
bleeding
5. Signs of shock
6. Decreased fibrinogen level, platelet count,
and hematocrit level
7. Increased prothrombin time and partial
thromboplastin time, clotting time, and
fibrin degradation products

D. Interventions
1. Remove underlying cause.
2. Monitor vital signs; assess for bleeding and
signs of shock.
3. Prepare for oxygen therapy, volume
replacement, blood component therapy,
and possibly heparin therapy.
4. Monitor for complications associated with
fluid and blood replacement and heparin
The rapid and extensive formation of therapy.
clots that occurs in DIC causes the 5. Monitor urine output and maintain at least
platelets and clotting factors to be depleted; 30 mL/ hour (renal failure is a
this results in bleeding and the potential complication of DIC).
vascular occlusion of organs from
thromboembolus formation. VI. ECTOPIC PREGNANCY

A. Definition
1. Implantation of the fertilized ovum outside
of the uterine cavity
2. Most common location is the ampulla of
the fallopian tube.
Sites of tubal ectopic pregnancy. Numbers
indicate the order of prevalence.
B. Assessment
1. Missed menstrual period
2. Abdominal pain
3. Vaginal spotting to bleeding that is dark red
or brown
4. Rupture: Increased pain, referred shoulder
pain, signs of shock
C. Interventions
1. Obtain assessment data and vital signs.
2. Monitor bleeding and initiate measures to
prevent rupture and shock.
3. Methotrexate, a folic acid antagonist, may be
prescribed to inhibit cell division in the
developing embryo.
4. Prepare the client for laparotomy and
removal of the pregnancy and tube, if
necessary, or repair of the tube.
5. Administer antibiotics; Rho(D) immune
globulin is prescribed for Rh-negative
women.
VII. FETAL DEATH IN UTERO
A. Definition
1. Fetal death in utero refers to the death of a
fetus after the twentieth week of gestation
and before birth.
2. The client can develop DIC if the dead fetus
is retained in the uterus for 3 to 4 weeks or
longer.
B. Assessment
1. Absence of fetal movement
2. Absence of fetal heart tones
3. Maternal weight loss
4. Lack of fetal growth or decrease in fundal
height
5. No evidence of fetal cardiac activity
6. Other characteristics suggestive of fetal
death noted on ultrasound
C. Interventions
1. Prepare for the birth of the fetus.
2. Support the client’s decision about labor,
birth, and the postpartum period.
3. Accept behaviors such as anger and hostility
from the parents.
4. Refer the parents to an appropriate support
group.
Cultural, spiritual, and religious practices and
beliefs are important to consider when caring
for the parents of a fetus who has died. Be
aware of the cultural, spiritual, and religious
practices and beliefs of the client.
VIII. HEMATOMA
A. Description
1. Hematoma occurs following the escape of
blood into the maternal tissue after birth.
2. Predisposing conditions include operative
delivery with forceps or injury to a blood
vessel.
B. Assessment
Hematoma: Assessment Findings
Abnormal, severe pain
• Pressure in perineal area (client states that she
feels like she has to have a bowel movement)
• Palpable, sensitive swelling in the perineal
area, with discolored skin
• Inability to void
• Decreased hemoglobin and hematocrit levels
• Signs of shock, such as pallor, tachycardia,
and hypotension, if significant blood has
occurred
C. Interventions
1. Monitor vital signs.
2. Monitor client for abnormal pain, especially
when forceps delivery has been performed.
3. Apply ice to the hematoma site.
4. Administer analgesics as prescribed.
5. Monitor intake and output.
 6. Encourage fluids and voiding; prepare for
urinary catheterization if the client is unable
to void.
7. Administer blood replacements as prescribed.
8. Monitor for signs of infection, such as
increased temperature, pulse rate, and white
blood cell count.
9. Administer antibiotics as prescribed because
infection is common after hematoma
formation.
10. Prepare for incision and evacuation of the
hematoma if necessary.
IX. HYDATIDIFORM MOLE (H-mole)
A. Definition
1. Hydatidiform mole is a form of gestational
trophoblastic disease that occurs when the
trophoblasts, which are the peripheral cells
that attach the fertilized ovum to the uterine
wall, develop abnormally.
2. The mole manifests as an edematous
grapelike cluster that may be nonmalignant
or may develop into choriocarcinoma.
B. Assessment
1. Fetal heart rate not detectable
2. Vaginal bleeding, which may occur by the
fourth week or not until the second trimester;
may be bright red or dark brown in color and
may be slight, profuse, or intermittent
3. Signs of preeclampsia (elevated blood
pressure and proteinuria) before the
twentieth week of gestation
4. Fundal height greater than expected for
gestational date
5. Elevated human chorionic gonadotropin
levels
6. Characteristic snowstorm pattern shown on
ultrasound
C. Interventions
1. Prepare the client for uterine evacuation
(before evacuation, diagnostic tests are done
to detect metastatic disease).
2. Evacuation of the mole is done by vacuum
aspiration; oxytocin is administered after
evacuation to contract the uterus.
3. Monitor for postprocedure hemorrhage and
infection.
4. Tissue is sent to the laboratory for
evaluation, and follow-up is important to
detect changes suggestive of malignancy.
5. Human chorionic gonadotropin levels are
monitored every 1 to 2 weeks until normal
prepregnancy levels are attained; levels are
checked every 1 to 2 months for 1 year.
6. Instruct the client and her partner about birth
control measures so that pregnancy can be
prevented during the 1-year follow-up
period.
X. HYPEREMESIS GRAVIDARUM
A. Definition
Intractable nausea and vomiting during
the first trimester that causes disturbances in
nutrition and fluid and electrolyte balance
B. Assessment
1. Nausea most pronounced on arising; may
occur
2. at other times during the day
3. Persistent vomiting
4. Weight loss
5. Signs of dehydration
6. Fluid and electrolyte imbalances
C. Interventions
1. Initiate measures to alleviate nausea,
including medication therapy; if
unsuccessful, and weight loss and fluid and
electrolyte imbalances occur, intravenously
administered fluid and electrolyte
replacement or parenteral nutrition may be
necessary.
2. Monitor vital signs, intake and output,
weight, and calorie count.
3. Monitor laboratory data and for signs of
dehydration and electrolyte imbalances.
4. Monitor urine for ketones.
5. Monitor fetal heart rate, activity, and growth.
6. Encourage intake of small portions of food
(low-fat, easily digestible carbohydrates,
such as cereals, rice, and pasta).
7. Encourage the intake of liquids between
meals to avoid distending the stomach and
triggering vomiting.
8. Encourage the client to sit upright after
meals.
XI. Gestational Hypertension E. Interventions for mild hypertension
A. Definition and types 1. Monitor blood pressure.
- Hypertension can be mild or severe, leading 2. Monitor fetal activity and fetal growth.
to preeclampsia and then eclampsia 3. Encourage frequent rest periods, instructing
(seizures) the client to lie in the lateral position.
Signs of preeclampsia are hypertension and 4. Administer antihypertensive medications as
proteinuria. prescribed; teach client about the importance
of the medications.
B. Assessment 5. Monitor intake and output.
C. Predisposing conditions 6. Evaluate renal function through prescribed
1. Primigravida studies such as blood urea nitrogen, serum
2. Women younger than 19 years or older than creatinine, and 24-hour urine levels for
40 years creatinine clearance and protein.
3. Chronic renal disease
4. Chronic hypertension F. Interventions for mild preeclampsia
5. Diabetes mellitus 1. Provide bed rest and place the client in the
6. Rh incompatibility lateral position.
7. History of or family history of gestational 2. Monitor blood pressure and weight.
hypertension 3. Monitor neurological status because changes
can indicate cerebral hypoxia or impending
D. Complications of gestational hypertension seizure.
1. Abruption placentae
2. Disseminated intravascular coagulation
3. Thrombocytopenia
4. Placental insufficiency
5. Intrauterine growth restriction
6. Intrauterine fetal death
7. HELLP syndrome (a laboratory diagnosis
for severe preeclampsia characterized by
hemolysis, elevated liver enzyme levels, and
low platelet count)

CLASSIFICATION OF HYPERTENSIVE STAGES OF PREGNANCY

TYPE DESCRIPTION
Gestational Hypertensive Disorders
Gestational hypertension Blood pressure elevation detected first time after mid-pregnancy
without proteinuria
Preeclampsia Pregnancy-specific syndrome that usually occurs after 20 week of
gestation and is determined by gestational hypertension plus
proteinuria
Eclampsia Occurrence of seizures in a preeclamptic woman
Chronic Hypertensive Disorders
Chronic hypertension Hypertension that is present and observable before pregnancy or that
is diagnosed before week 20 of gestation
Preeclampsia superimposed on Chronic hypertension with new proteinuria or exacerbation of
chronic hypertension hypertension (previously well controlled) or proteinuria,
thrombocytopenia, or increases in hepatocellular enzymes
MILD VERSUS SEVERE PREECLAMPSIA
Parameter Evaluated Mild Severe Severe
Systolic blood pressure ≥140 but < 160 mm Hg ≥ 160 mm Hg (two readings, 6 hr apart,
while on bed rest)
Diastolic blood pressure ≥90 but < 110 mm Hg ≥110 mm Hg
Proteinuria (24-hr specimen is ≥ 0.3 but < 2 g in 24-hr ≥ 5 g in 24-hr specimen (≥3+ on
preferred to eliminate hour-to-hour specimen (1+ on random random dipstick sample)
variations) dipstick)
Creatinine, serum (renal function) Normal Elevated (> 1.0 mg/ dL [> 76.3 mcmol/
L])
Platelets Normal Decreased (< 100,000 mm3 [< 100 x
109/L])

Liver enzymes (alanine Normal or minimal Elevated levels

aminotransferase or aspartate increase in levels
aminotransferase)
Urine output Normal Oliguria common, often < 500 mL/ day
Severe, unrelenting headache not Absent Often present
attributable to other cause;
mental confusion (cerebral
edema)

Persistent right upper quadrant or Absent May be present and often precedes
epigastric pain or pain penetrating seizure
to back (distention of liver
capsule); nausea and vomiting
Visual disturbances (spots or Absent to minimal Common
“sparkles”; temporary blindness;
photophobia)
Pulmonary edema; heart Absent May be present
failure; cyanosis
Fetal growth restriction Normal growth Growth restriction; reduced amniotic
fluid volume
Modified from Lowdermilk D, Cashion MC, Perry S, Alden K: Maternity & women’s health care, ed 10,
St. Louis, 2012, Mosby.

Eclampsia
1. Seizure typically begins with twitching around the mouth.
2. Body then becomes rigid in a state of tonic muscular contractions that last 15 to 20 seconds.
3. Facial muscles and then all body muscles alternately contract and relax in rapid succession (clonic phase
may last about 1 minute).
4. Respiration ceases during seizure because diaphragm tends to remain fixed (breathing resumes shortly
after the seizure).
5. Postictal sleep occurs.
 4. Monitor deep tendon reflexes and for the
presence of hyperreflexia or clonus, because
hyperreflexia indicates increased central
nervous system irritability.
5. Provide adequate fluids.
6. Monitor intake and output; a urinary output
of 30 m L/hour indicates adequate renal
perfusion.
7. Increase dietary protein and carbohydrates
with no added salt.
8. Administer medications as prescribed to
reduce blood pressure; blood pressure
should not be reduced drastically because
placental perfusion can be compromised.
9. Monitor for HELLP syndrome.
G. Interventions for severe preeclampsia
1. Maintain bed rest.
2. Administer magnesium sulfate (use a
controlled infusion device) as prescribed to
prevent seizures; magnesium sulfate may be
continued for 24 to 48 hours postpartum.
3. Monitor for signs of magnesium toxicity,
including flushing, sweating, hypotension,
depressed deep tendon reflexes, urine output,
and central nervous system depression
including respiratory depression; keep
antidote (calcium gluconate) available for
immediate use, if necessary.
4. Administer antihypertensives as prescribed.
5. Prepare for the induction of labor.
H. Eclampsia
1 Assessment: Characterized by
generalized seizures (Box 26-6)
2 Interventions (see Priority
Nursing Actions)
PRIORITY NURSING ACTIONS
Eclampsia Event
1. Remain with the client and call for help.
2. Ensure an open airway, turn the client on
her side, and administer oxygen by face
mask at 8 to 10 L/ minute.
3. Monitor fetal heart rate patterns.
4. Administer medications to control the
seizures as prescribed.
5. After the seizure has ended, insert an oral
airway, and suction the client’s mouth as
needed.
6. Prepare for delivery of the fetus after
stabilization of the client, if warranted.
7. Document occurrence, client’s response,
and outcome.
Eclampsia refers to the occurrence of a seizure.
It is a potentially preventable extension of severe
preeclampsia; early identification of preeclampsia
in a pregnant client allows intervention before the
condition reaches the seizure state. If eclampsia
occurs, the nurse remains with the client and calls
for help. The nurse ensures an open air way. If the
client is not on her side already, the nurse attempts
to turn the client on her side. The side-lying
position permits greater circulation through the
placenta and may help to prevent aspiration. The
nurse administers oxy gen by face mask at 8 to 10
L/ minute to ensure adequate placental
oxygenation. The nurse also notes the time the
seizure began and the duration of the seizure and
protects the client from injury during the event.
The nurse monitors fetal heart rate patterns closely
and administers medications as prescribed
(magnesium sulfate may be prescribed). After the
seizure has ended, the nurse inserts an oral airway
to maintain airway patency and suctions the
client’s mouth as needed. If warranted, the nurse
prepares for the delivery of the fetus after
stabilization of the client. The nurse documents the
occurrence, the client’s response, and the outcome.
Reference
Lowdermilk et al. (2016), p. 667.
Assessment of Reflexes
Body Part How to assess? Normal Response
Biceps ▪ Position thumb over client’s biceps tendon, Flexion of the arm at the elbow
supporting client’s elbow with the palm of
the hand.
▪ Strike a downward blow over the thumb with
percussion hammer.
Patellar ▪ Position client with her legs dangling over Extension or kicking out of the leg
the edge of the examining table or lying on
her back with her legs slightly flexed.
▪ Strike patellar tendon just below kneecap
with percussion hammer.
Clonus ▪ Position client with her legs dangling over Normal response (negative clonus response):
the edge of examining table. ▪ Foot remains steady in dorsiflexed
▪ Support the leg with 1 hand and sharply position. No rhythmic oscillations or
dorsiflex client’s foot with the other hand. jerking of foot is felt.
Maintain the dorsiflexed position for a few ▪ When released, foot drops to plantar-flexed
seconds and then release foot. position with no oscillations.
Abnormal response (positive clonus response):
▪ Rhythmic oscillations occur when foot is
dorsiflexed.
▪ Similar oscillations are noted when foot
drops to plantarflexed position.

Grading Response
0 Reflex absent
1+ Reflex present but hypoactive
2+ Normal reflex
3+ Hyperactive reflex
4+ Hyperactive reflex with clonus present

XII. INCOMPETENT CERVIX C. Interventions

A. Definition 1. Provide bed rest, hydration, and tocolysis, as
1. Incompetent cervix refers to premature dilation prescribed, to inhibit uterine contractions.
of 2. Prepare for cervical cerclage (at 10 to 14 weeks
2. the cervix, which occurs most often in the of gestation), in which a band of fascia or
fourth nonabsorbable ribbon is placed around the
3. or fifth month of pregnancy and is associated cervix beneath the mucosa to constrict the
4. with structural or functional defects of the internal os.
cervix. 3. After cervical cerclage, the client is told to
5. Treatment involves surgical placement of a refrain from intercourse and to avoid prolonged
cervical cerclage. standing and heavy lifting.
4. The cervical cerclage is removed at 37 weeks
B. Assessment of gestation or left in place and a cesarean birth
1. Vaginal bleeding is performed; if removed, cerclage must be
2. Fetal membranes visible through the cervix repeated with each successive pregnancy.
 5. After placement of the cervical cerclage, B. Obesity in pregnancy can have negative effects on
monitor for contractions, rupture of the the newborn, including stillbirth, congenital
membranes, and signs of infection. anomalies, future obesity, and heart disease.
6. Instruct the client to report to the HCP
immediately any postprocedure vaginal C. Complications in nursing care
bleeding or increased uterine contractions. 1. Difficulty obtaining IV access, epidural access,
and intubation if needed
XIII. MULTIPLE GESTATION 2. Mobility and transfer difficulties
A. Definition 3. Bed size and equipment accommodations
1. Multiple gestation results from fertilization of
2 ova (fraternal or dizygotic) or a splitting of 1 D. Potential postoperative complications and
fertilized ovum (identical or monozygotic). associated interventions
2. Complications include spontaneous abortion, 1. Thromboembolism stockings (TEDs),
anemia, congenital anomalies, hyperemesis sequential compression devices (SCDs), and
gravidarum, intrauterine growth restriction, pharmacological venous thromboembolism
gestational hypertension, polyhydramnios, prophylaxis such as heparin are used
postpartum hemorrhage, premature rupture of postoperatively.
membranes, and preterm labor and delivery. 2. Early ambulation is encouraged to prevent
venous thromboembolism formation.
B. Assessment 3. Vigilant monitoring and cleaning of surgical
1. Excessive fetal activity incisions to prevent infection due to excess
2. Uterus large for gestational age abdominal fat.
3. Palpation of 3 or 4 large parts in the uterus
4. Auscultation of more than 1 fetal heart rate
5. Excessive weight gain

C. Interventions
1. Monitor vital signs.
2. Monitor fetal heart rates, activity, and growth.
3. Monitor for cervical changes.
4. Prepare the client for ultrasound as prescribed.
5. Monitor for anemia; administer supplemental
vitamins as prescribed.
6. Monitor for preterm labor and treat preterm
labor promptly.
7. Prepare for cesarean delivery for abnormal
presentations.
8. Prepare to administer oxytocic medications
after delivery to prevent postpartum
hemorrhage from uterine overdistention.

XIV. OBESITY IN PREGNANCY

A. Definition: Obesity in every population, including
adults and children, is a problem in the United
States. Obesity in pregnancy places the client at
risk for complications during pregnancy, including
venous thromboembolism and increased need for
cesarean birth.