Nursing Care of a Family Experiencing a
A feeling of pelvic pressure or abdominal
Sudden Pregnancy Complication
PRETERM LABOR and
PREGNANCY INDUCED HYPERTENSION (PIH)
PRETERM LABOR
• Occurs before the end of week 37 of gestation.
• Because of this, it is responsible for almost two
thirds of all infant deaths in the neonatal period
(American College of Obstetricians and
Gynecologists [ACOG], 2016a).
• A woman is documented as being in actual labor
rather than having false labor contractions if
contractions have caused cervical effacement over
80% or dilation over
1 cm.
• Maintaining general health during pregnancy is
the best preventive measure to avoid preterm birth.
• Educate woman about the signs of labor:
o Knowing the signs of labor can help women
identify if preterm birth is beginning because
some women wait before they seek help for
preterm labor because they diagnose back
pain or contractions as nothing more than
extremely hard Braxton Hicks contractions.
• It is associated with:
o Dehydration
o Urinary tract infection
o Periodontal disease
o Chorioamnionitis
o Large fetal size.
o Women who continue to work at strenuous
jobs during pregnancy or perform shift work
that leads to extreme fatigue.
o Intimate partner violence and the trauma this
causes may be yet another cause (Alhusen,
Ray, Sharps, et al.,
2015).
• Common symptoms of early preterm labor:
1. Persistent, dull, and low backache
2. Vaginal spotting
3.
tightening.
4. Menstrual like cramping
5. Increased vaginal discharge
6. Uterine contractions
7. Intestinal cramping.
THERAPEUTIC MANAGEMENT
1. A woman who is in preterm labor is usually first
admitted to the hospital and placed on bed rest to
relieve the pressure of the fetus on the cervix.
2. External fetal and uterine contraction monitors
are attached to monitor FHR and the intensity of
contractions.
3. Intravenous fluid therapy to keep her well
hydrated is begun because although not well
documented, hydration may help stop contractions.
o This is thought to be effective because if a
woman is dehydrated, the pituitary gland will
be activated to secrete antidiuretic hormone,
which might cause the pituitary gland to
release oxytocin as well, strengthening
uterine contractions.
4. Vaginal and cervical cultures and a clean catch
urine sample are prescribed to rule out infection.
o If a urinary tract infection is present, the
woman will be prescribed an antibiotic that is
especially effective for group B streptococcus
as this infection can be fatal in a newborn.
DRUG ADMINISTRATION
1. Terbutaline
o is a drug approved to prevent and treat
bronchospasm but may be used as a
tocolytic agent (i.e., an agent to halt labor).
o should not be used for over 48 to 72 hours
of therapy because of a potential for serious
maternal heart problems and death.
o It should not be used in an outpatient or
home setting because its administration
requires constant professional assessment
(Roman, 2013).
2. Magnesium sulfate
o For fetal neuroprotection is used prior to 32
weeks to help prevent cerebral palsy in
premature infants (Nijman, van Vliet, Koullali,
et al., 2016).
3. Corticosteroid (betamethasone)
o The formation of lung surfactant appears to
accelerate, thus reducing the possibility of
respiratory distress syndrome or
bronchopulmonary dysplasia (Msan, Usta,
Mirza, et al., 2015).
o If the pregnancy is under 34 weeks, a
woman may be given
 Two doses of 12 mg
betamethasone I.M. 24 hours
apart, or
 Four doses of 6 mg
dexamethasone I.M. 12 hours
apart.
PREGNANCY-INDUCED HYPERTENSION
 A condition in which vasospasm occurs during
pregnancy in both small and large arteries.
 With gestational hypertension, this reduced
responsiveness to blood pressure changes
appears to be lost because of the prostaglandin
release.
 Vasoconstriction occurs
 Blood pressure increases dramatically.
 Beginning about the 20th week of pregnancy,
almost all body systems begin to be affected.
 The cardiac system, for example, can easily
become overwhelmed because the heart is
forced to pump against rising peripheral
resistance.
 Causes a reduced blood supply to organs,
most markedly the kidney, pancreas, liver,
brain, and placenta.
 Poor placental perfusion reduces the fetal
nutrient and oxygen supply.
  Ischemia in the pancreas
 Can result in epigastric pain and an
elevated amylase creatinine ratio.
 If spasm occurs in the arteries of the retina,
 Vision changes can occur.
 If retinal hemorrhage occurs
 Blindness can result.
 Vasospasm in the kidney
 Increased blood flow resistance leads to
degenerative changes of the kidney
glomeruli because of back pressure.
 This leads to increased permeability of the
glomerular membrane
 A condition in which vasospasm occurs during
pregnancy in both small and large arteries.
 With gestational hypertension, this reduced
responsiveness to blood pressure changes
appears to be lost because of the prostaglandin
release.
 Vasoconstriction occurs
 Blood pressure increases dramatically
 Beginning about the 20th week of pregnancy,
almost all body systems begin to be affected.
 The cardiac system, for example, can easily
become overwhelmed because the heart is
forced to pump against rising peripheral
resistance.
 Causes a reduced blood supply to organs,
most markedly the kidney, pancreas, liver,
brain, and placenta.
 Poor placental perfusion reduces the fetal
nutrient and oxygen supply.
 Ischemia in the pancreas
 Can result in epigastric pain and an
elevated amylase creatinine ratio.
 If spasm occurs in the arteries of the retina,
 Vision changes can occur.
 If retinal hemorrhage occurs
 Blindness can result.
 Vasospasm in the kidney
 Increased blood flow resistance leads to
degenerative changes of the kidney
glomeruli because of back pressure.
 This leads to increased permeability of the
glomerular membrane
 allowing the serum proteins
albumin and globulin to escape
into the urine (i.e., proteinuria).
 Decreased glomerular filtration
 Lowered urine output and
clearance of creatinine.
 If increased kidney tubular reabsorption occurs,
retention of sodium begins.
 Sodium retains fluid, edema results.
 Edema is further increased because, as
more protein is lost, the osmotic pressure
of the circulating blood falls and fluid
diffuses from the circulatory system into the
denser interstitial spaces to equalize the
pressure
RISK FACTORS:
1. Multiple pregnancy
2. Primiparas younger than 20 years or older
than 40 years old.
3. Women who have polyhydramnios
4. Low socioeconomic background
5. Women with underlying disease
a. Heart disease
b. Diabetes
c. Essential hypertension
SIGNS & SYMPTOMS:
1. Hypertension
2. Edema
3. Proteinuria
4. Gestational Hypertension
o Bp 140/90 mmHg, or
o Systolic Bp >30 mmHg; Diastolic > 15
mmHg above pregnancy level
o No proteinuria nor edema
o Bp returns to normal after birth.
5. Mild Preeclampsia
o Bp 140/90 mmHg
o Systolic Bp >30 mmHg; Diastolic > 15
mmHg above pregnancy level
o Proteinuria +1 to +2
o Weight gain 2 lbs. /wk. in 2nd trimester; 1
lb./wk. in 3rd trimester.
o Mild edema in upper extremities or face.
6. Severe Preeclampsia
o Bp 160/110 mmHg
o Proteinuria: 3+ to 4+ on a random sample
o Oliguria: 500 ml or less in 24 hrs.
o Pulmonary involvement: shortness of
breath
o Hepatic dysfunction
o Epigastric pain due to ischemia in the
pancreas and liver.
 Cerebral Edema
 Visual disturbances such as blurred
vision or seeing spots before the
eyes may be reported.
  Severe headache
 Marked Hyperreflexia
 Ankle Clonus (i.e., a pulsed motion of
the foot after flexion).
 Rating the Ankle Clonus:
 Mild = 2 movements
 Moderate = 3-5 movements
 Severe = Over 6 movements
 Extreme Edema
 is most readily palpated over bony
surfaces, such as over the tibia on the
anterior leg, the ulnar surface of the
forearm, and the cheekbones, where
the sponginess of fluid filled tissue can
be palpated against bone.
 If there is swelling or puffiness at these
points to a palpating finger but the
swelling cannot be indented with finger
pressure, the edema is described as
nonpitting.
- 1+ = If the tissue can be
indented slightly, this is pitting
edema;
- 2+ = moderate indentation;
- 3+ = deep indentation;
- 4+ = indentation so deep it
remains after removal of the
finger is pitting edema.
o This accumulating edema will reduce a
woman’s urine output to approximately 400 to
600 ml per 24 hours.
7. Eclampsia
 Seizure or coma occurs.
 Signs & symptoms of preeclampsia
NURSING DIAGNOSIS:
1. Ineffective tissue perfusion r/t
vasoconstriction of blood vessels.
2. Deficient fluid volume r/t fluid loss to
subcutaneous tissue.
3. Risk for fetal injury r/t reduced placental
perfusion 2 to vasospasm.
4. Social isolation r/t prescribed bed rest.
NURSING INTERVENTION:
1. Mild Preeclampsia
a. Monitor Antiplatelet Therapy
i. Because of the increased tendency for
platelets to cluster along arterial walls, a
mild antiplatelet agent, such as low dose
aspirin, may prevent or delay the
development of preeclampsia (Leaf &
Connors, 2015).
ii. Be certain they purchase low dose aspirin
(81 mg, sold as baby aspirin) as excessive
salicylic levels can cause maternal bleeding
at the time of birth.
b. Promote Bed Rest
i. When the body is in a recumbent position,
sodium tends to be excreted at a faster rate
than during activity.
ii. Bed rest, therefore, is the best method of
aiding increased evacuation of sodium and
encouraging diuresis of edema fluid.
iii. Be certain women know to rest in a lateral
recumbent position to avoid uterine
pressure on the vena cava and prevent
supine hypotension syndrome.
c. Promote Good Nutrition
i. Assess if a woman has someone to help
her prepare food, or either bed rest or
nutrition may be compromised.
d. Provide Emotional Support
2. Severe Preeclampsia
a. Support bed rest.
i. Needs hospitalization so bed rest can be
enforced and woman can be observed
closely.
ii. Restrict visitors to support people (e.g.,
husband)
iii. Raise side rails (padded) to prevent
injury
iv. Room needs to be dimly lit.
b. Monitor maternal well being
i. Monitor Bp
ii. Obtain blood studies as ordered.
1. Obtain daily hematocrit levels as
ordered. This level will rise (>40%) if
increased fluid is leaving the
bloodstream for interstitial tissue
[edema].
iii. Assess weight: same time, daily.
iv. Indwelling catheter may be inserted.
c. Monitor fetal well being
i. External fetal monitor is ttached.
ii. O2 administration may be necessary to
maintain adequate fetal oxygenation.
d. Support a nutritious diet
i. Moderate to high protein diet
ii. Moderate sodium in the diet
iii. IVF line should be initiated and maintained
to serve as an emergency route for drug
administration.
e. Administer medications to prevent eclampsia.
i. Hydralazine (Apresoline) to reduce
hypertension (5 10 mg/IV)
1. Lowers Bp by peripheral dilatation
2. Can cause tachycardia.
• Assess pulse & Bp before & after
administration.
• Diastolic should not be lowered below 80-90
mmHg or inadequate placental perfusion
could occur.
ii. Magnesium Sulfate (Loading dose 4 6 g
Maintenance dose 12 g/hr. IV)
1. Muscle relaxant
2. Prevent seizures
• Has CNS depressant action by blocking
peripheral neuromuscular transmission.
3. Reduces edema by causing a shift in
fluid from extracellular spaces into the
intestine.
4. Symptoms of overdose:
a. Decreased urine output
 b. Depressed RR
c. Reduced consciousness
d. Decreased tendon reflexes
iv. Calcium gluconate
3. Eclampsia
a. Preliminary signs before seizure:
b. Tonic Clonic seizures
The Patellar Reflex is scored as:
0 = No response; hypoactive; abnormal
1+ = Somewhat diminished response but not
abnormal
2+ = Average response
3+ = Brisker than average but not abnormal
4+ = Hyperactive; very brisk; abnormal
iii. Diazepam (Valium)
1. Halt seizures
2. 5 - 10 mg IV, administer slowly.
3. Dose may be repeated q 5 10 minutes
(up to 30mg/ hr.).
4. Observe for respiratory depression or
hypotension in mother and respiratory
depression and hypotonia decreased
muscle tone) in infant at birth.
1. Antidote for MgSO4 intoxication.
2. 10 ml of a 10% calcium gluconate (1 g I.V.)
must be prepared at bedside when
administering MgSO4.
3. Administer at 5 ml/min.
i. Bp rises suddenly from additional spasm.
ii. Temperature rises (39.4 40 C) from
increased cerebral pressure.
iii. Blurring of vision or severe headache from
increased cerebral edema.
iv. Hyperactive reflexes.
v. Epigastric pain & nausea from vascular
congestion of the liver or pancreas.
i. Tonic seizures:
1. Back arches
2. Arms & legs stiffen
3. Jaw closes abruptly
4. Respirations stop
5. Lasts for approx. 20 sec.
6. Maintain patent airway
7. Adm. O2 by mask
8. Assess O2 saturation via pulse
oximeter.
9. Apply an external fetal monitor.
10. Turn woman on her side to allow
secretions to drain from her mouth.
ii. Clonic Seizures
1. Body muscles contract & relax
repeatedly.
2. Inhales & exhales irregularly.
3. Incontinence of urine
& feces may occur.
4. Lasts up to 1 min.
5. O2 therapy continued.
6. MgSO4 or diazepam (Valium) may be
administered IV as an emergency
measure.
iii. Postictal state:
1. Semi-comatose
2. Extremely close observation is
necessary because seizure may cause
premature separation of the placenta
(abruption placenta) and labor may begin.
3. Painful stimulus of contraction may
initiate another seizure.
4. Keep woman on side lying position.
5. Keep NPO
6. Continue monitoring FHR and uterine
contractions.
7. Check for vaginal bleeding every 15 min
• Birth:
o Labor may be induced as soon as the woman’s
condition stabilizes, usually 12 24 hrs. after
seizure.
o Preferred method of delivery for eclamptic
patient is vaginal delivery.
o Cesarean birth is always more hazardous for
the fetus than vaginal birth because of the
association of retained lung fluid.
o C/S is preferred if fetus is in imminent danger.
NURSING INTERVENTIONS DURING THE
POSTPARTUM PERIOD
o Postpartum preeclampsia may occur up to 10 to
14 days after birth, although it usually occurs within
48 hours after birth.
- Therefore, monitoring blood pressure in the
postpartum period and at healthcare visits
and being alert for preeclampsia, which can
occur as late as 2 weeks post birth, are
essential to detect this residual
hypertension (Takaoka, Ishii, Taguchi, et
al., 2016).
 HELLP SYNDROME
• HELLP Syndrome is a variation of the gestational
hypertensive process named for the common
symptoms that occur:
 Hemolysis (rapid destruction of RBC)
leads to anemia.
 Elevated Liver enzymes lead to epigastric
pain.
 Low Platelets lead to abnormal
bleeding/clotting (Pourrat, Coudroy, &
Pierre, 2015).
 Results in a maternal mortality rate
as high as 24% and an infant
mortality rate as high as 35%.
 It occurs in both primigravida and
multigravidas and is associated with
APS or the presence of
antiphospholipid antibodies (Tufano,
Coppola, Maruotti, et al., 2015).
SIGNS & SYMPTOMS:
 Proteinuria
 Edema
 Increased Blood Pressure
 Nausea
 Epigastric Pain
 General Malaise
 Right upper quadrant tenderness (if liver
inflammation occurs).
Laboratory Studies Reveal:
 Hemolysis of red blood cells (they appear
fragmented on a peripheral blood smear).
 Thrombocytopenia (a platelet count
<100,000/mm3), and
 Elevated liver enzyme levels (effects of
hemorrhage and necrosis of the liver).
 Alanine aminotransferase [ALT] or SGPT.
• 7 to 56 units per liter of serum.
 Serum aspartateaminotransferase [AST])
• 5 to 40 units per liter of serum.
 Because of the low platelet count, women
with the HELLP syndrome need extremely
close observation for bleeding, in addition
to the observations necessary for
preeclampsia.
Complications:
• Subcapsular Liver Hematoma
• Hyponatremia
• Renal failure
• Hypoglycemia from poor liver function.
Maternal Complications:
• Cerebral Hemorrhages
• Aspiration Pneumonia
• Hypoxic Encephalopathy
Fetal complications:
• Growth restriction
• Preterm birth (Barnhart, 2015)
Therapy
 Transfusion of fresh frozen plasma or
platelets.
• To improve the platelet count.
 Intravenous Glucose Infusion
• If hypoglycemia is present
 The infant is born as soon as feasible by
either vaginal or cesarean birth.
• Be alert that maternal hemorrhage
may occur at birth because of poor
clotting ability.
• Epidural anesthesia may not be
possible because of the low platelet
count and the high possibility of
bleeding at the epidural site.