COURSE NO: Nursing Care Management 107

Care of Mother, Child @ Risk of with Problems (

Acute and Chronic Lec)

Rolita Grace Valdez- Garcia, RN, RM, MSN

Nursing Care for mothers with
gestational complications
Nursing Care for mothers with gestational
complications
1. Hyperemesis Gravidarum
- Also called as pernicious or persistent vomiting
Is nausea and vomiting of pregnancy that is prolonged
past 12 week of pregnancy that is so severe which
causes dehydration, ketonuria & significant wt loss
Causes:
Unknown
Elevated HCG
Thyroid Dysfunction
S/Sx:P
- Excessive nausea & vomiting
- Signs of dehydration
- Elevated hematocrit
Complicatiom:
DEHYDRATION
Management:
1. Hospitalization for about 24 hrs
- IV fluids
- NPO for 24 hrs
- metoclopramide
- Management ( no dehydration)
- Have dry, Conservative low, high carbohydrate &
bland diet
- Take dry crackers
- Small frequent feeding
- Avoid pressure around the stomach
- Temporary cessation of iron supplement
- Avoid highly seasoned and spicy foods
- Take vitamin supplement to correct nutritional
deficiencies
- Have enough relaxation and rest
2. Gestational Trophoblastic Dse( Hydatidiform Mole)
is an abnormal proliferation and degeneration of the
trophoblastic villi, they become filled with fluid and
appear as graped like vesicles
- Incidence is1 for every 1,500 pregnacy
Risk factors
1. Women older that 35 yrs old
2. Woman with low intake of protein
3. Hx of H mole
Types:
1. Complete
- All trophoblastic villi swell and becomes cystic
- If embryo forms it dies immediately
- Chromosomes was only contributed by the father
or an empty ovum
2. Partial
- Some villi normally grow
- Fetal may grow about 9 weeks then macerates
- mother’s chromosomes remain but there are 2 sets
from the father, placenta and fetus are formed but
failed to develop
- Rarely leads to chorio carcinoma
S/Sx:
- Excessive nausea and vomiting
-Uterus tends to expand faster than normally
- ( -) FHT
- HCG 1-2 million iu more than 400,000 iu
- HCG still present after 100 days
- Spotting of dark blood or profuse fresh blood with
fluid filled vesicles
- Signs of Gestational Hypertension before 20th week
- UTZ reveals mass of a fluid filled vesicles instead of
a developing fetus
Tx:
- Suction curettage
Test for HCG=
- Analyzed every 2 wks until level are normal, then
every 4 wks for 6-12 mos ( some have still (+) @ 3
weeks/ ¼ @ 40 days)
- Declining result suggest no complication
- 3x increase suggest malignancy
- Woman should use oral contraceptive for 12 mos
-after 6 months and HCG is negative , the woman is
free of malignancy
- METHOTREXATE is given as prophylactic
- Early screening for next pregnancy
3. Abortion- a medical term for any interruption
o of pregnancy before the fetus is viable
- May also be termed as MISCARRIAGE
*Spontaneous Miscariage- involuntary loss of
the products of conception prior to 24 wks
- Fetus is below 20-24 weeks
- Wt less than 500 gms
• Early miscarriage- before 16th week
• Late miscarriage- - 16th- 20th week
Etiology:
- Genetic
-Structural abnormalities
- Teratogens
- Abnormal implantation
- Alcohol
- UTI
- Infections
TYPES OF Spontaneous Miscarriage
a. Threatened Miscarriage- manifest by scant
vaginal bleeding, usually bright red, slight cramping
, (-) cervical dilatation
- Bleeding occurs within 28-48 hrs
Management:
-evaluate FHT and viability of fetus through UTZ
- Instruct client to save all pads
- Bed rest/ limit strenuous activity
- Advise the pt not to engage in sexual intercourse
- Can gradually go back after bleeding stops
- Evaluate HCG
b. Imminent ( Inevitable) Miscarriage- loss of
the products of conception that cannot be
prevented
- + uterine contraction and cervical dilatation
- + Rupture of membranes
Tx:
- D&C
- Tissue fragments should be saved for further
analysis
- - inform the woman that pregnancy was
already lost
- Records number of pads used
c. Complete Miscarriage
- entire product of conception are expelled
spontaneously
- Bleeding slows within 2 hrs until few days
S/Sx:
- abdominal pain
- passage of tissue

Tx:
-no further medical or surgical treatment
-Instruct pt to rest
Advise the mother to report heavy bleeding
d. Incomplete Miscarriage
- expulsion of some parts and retention of other
parts of conception in the utero

S/Sx:
-heavy vaginal bleeding
- Severe uterine cramping
- Open cervix
- Passage of tissue
- UTZ reveals some products of conception are
still in the uterus
 Management:
1. D&C (Dilatation and Curettage)
2. Monitor blood loss
- inspect perineal pads
- monitor V/.S
- Monitor blood studies
- monitor I & O
3. Emotional Support
e. Missed Miscarriage ( early pregnancy failure)
- retention of all products of conception after the
death of the fetus in the uterus
S/Sx : absence of FHT
- Uterus fails to enlarge
- Decreases HCG
Tx:
- D&C if fetus is less than 14 wks
- If more then 14 wks , deliver the fetus ( induce
labor) using misoprostol followed by oxytocin
Complications:
-Hemorrhage, Infection and DIC
f. Recurrent pregnancy loss or Habitual abortion
- Miscarriages occur in 3 or more successive
pregnancies
- Occurs in 1% of women
Causes: Defective spermatozoa/ova
- Endocrine factors:
- Deviations of the uterus
- Resistance to uterine artery blood flow
- Chorioamnionitis/ uterine infection
- Autoimmune disorder
Tx: Identify and treat the cause
 COMPLICATIONS OF MISCARRIAGE
1. Hemorrhage
2. Infection
- most often develop in women who have
lost a significant amount of blood
- Cause by E. Coli or group A streptococcus
S/Sx:
- High fever
- Abdominal pain or tenderness
- Foul smelling vaginal discharge
 3. Septic Abortion- is an abortion complicated
by infection
- Usually occurred in women who have tried to
self abort or pregnancy was aborted illegally
- More common in areas where abortion is
illegal
- There is use of unsterile instrumen
S/Sx
- Fever
- Crampy abdominal pain
- Tender uterus
Complication:
-Toxic shcok syndrome
-Septicemia
-Kidney failure
-Death
Tx/ Mgt:
-Broad spectrum of antibiotics
-D-& C
-IVF
-Dopamine and Digitalis are given
-Counselling
 4. Isoimmunization
5. Powerlessness or Anxiety
- Sadness and grief over the loss and feeling
that the woman has loss control of her life
- Lack of support for the woman
- pregnancy loss is a heartbreaking for older
woman
ECTOPIC PREGNANCY- implantation occurs
outside the uterus
Site:
Causes:
- PID
- Smoking

S/Sx
-Sharp stabbing pain in the lower abd quadrant
-Scant vaginal spotting
-leukocytosis
- Movement of the cervix causes excruciating
pain
- Abdomen becomes rigid
- Cullens sign
- Hemorrhage /Shock: rapid & thready pulse,
rapid RR & decrease BP
Dx
1. Culdoscopy/laparoscopy
2. UTZ
3. CBC- dec Hct, WBC increase

* There is a higher chance of Ectopic Preg in

succeeding preg.
4. Culdocentesis- aspiration of bloody fluid from
the cul-de-sac of douglas
5. HCG
Tx:
Unruptured:
A. Methotrexate- given to appropriate patients
based on AOG, HCG level, size
Ruptured:
Salphingectomy
- No Tx needed for spontaneously EP that ends
and do not rupture
5. Pre mature Cervical dilatation or Incompetent
Cervix- cervix that dilates prematurely & cannot
hold a fetus until term, occurs approximately 2
20 wks
S/Sx- show
- Increase pelvic pressure
- Rupture of membrane
- + uterine contraction
Cause:
- maternal age
- Congenital structural defect
- Trauma to the cervix
Tx:
Cervical Cerclage
Mc Donald- temporary nylon suture is place
horizontally & vertically across the cervix and
pulled tight to reduce cervical canal
- Remove at 37 wks
Shirodkar Technique- sterile tape is threaded in
a purse string manner
 Complication during the third trimester
Placenta previa- a condition of pregnancy in
which the placenta is abnormally implanted
Types:
Predisposing Factors:
-Multiparity - abnormal placenta
-Multiple preg -Advance maternal age
-Short umbilical cord
S/Sx:
Painless Bleeding ( 24-30 wks)
Dx: UTZ
Tx:
- Place woman immediately on Bed Rest
- Assess the ff:
a. Duration of pregnancy
b. Time of bleeding began
c. Womans estimation of blood loss
d. If accompanied by pain
e. What she has done
f. Prior episode of bleeding
g. Previous cervical surgery
h. Color of the blood
- Inspect the perineum for bleeding and
estimate the present of blood loss
- Assess blood pressure every 5-15 minutes
- Monitor FHT
- Monitor urine output
- Administer IVF
- Type of placenta previa and AOG dictates the
final management
6. Pre-mature separation of the Placenta (Abruptio
Placenta)
- pre mature separation of the placenta after 20
wks or before delivery and even before the 1st and
2nd stage of labor
Cause:
- Unknown
Predisposing Factors: Maternal Hpn
- Advance maternal age
- Grand multiparity
- Trauma
- Short umbilical cord
- Smoking
Classification:
1. Covert/central
2. Overt/marginal
S/sx:
Vaginal bleeding
Abdominal pain
Couvelaire Uterus-hard, boardlike abdomen
Signs of fetal distress
Tx:
-Monitor V/S and FHT every 15 mins
-Do not perform abdominal , vaginal & Pelvic exam
-CS is the birth method of choice
7. Disseminated Intravascular Coagulation (DIC)
- Is an acquired disorder of blood clotting in which
the fibrinogen level falls to below effective limits
- May develop due to the following conditions:
Abruptio placenta, hypertension of pregnancy,
amniotic fluid embolism, placental retention, septic
abortion and missed abortion
S/SX
- easy bruising or bleeding from the intravenous site
Tx:
-Stop the cause
- Hep[ari is given IV then SQ
8. Hypertensive Disorders in Pregnancy
- is a condition which vasospasm occurs during
pregnancy in both small and large arteries
Pre Eclampsia – a pregnancy related disease process
evidence by hpn and proteinuria
- Also termed asToxemia of pregnancy
CAUSE:
- Unknown
- Common in women younger than 20 and above
40y/o
- Underlying diseases DM, heart disease
TYPES
a. Gestational Hypertension
- elevated blood pressure of 140/90 but has no
proteinuria or edema
-BP returns to normal after birth
No drug therapy is necessary
b. Pre eclampsia without severe features
- blood pressure of 140/90 taken on 2 occasion
with 6 hrs apart or systolic elevated 30mmhg or
diastolic pressure elevated 15 mmhg above pre
pregnancy level, proteinuria of 1-2+, wt gain
over 2 lbs per week in the 2nd tri and 1 lb per
week in 3rd tri & mild edema on the upper
extremities or face

Management: usually manage at home

1. Promote bed rest
2. Monitor anti platelet therapy
3. Promote good nutrition
4. Provide emotional support
c. Pre eclampsia with severe features
- blood pressure of 160/110; proteinuria 3-
4+, on a random sample and 5g on a 24 hr
sample, oliguria, altered creatinine, cerebral
and visual disturbances, epigastric pain,
extensive peripheral edema
Management:
- Bed rest
- Monitor maternal and fetal well being
- Provide nutritious diet
- Administer Medication to prevent eclampsia
- *Magnesium Sulfate
Action: prevent convulsion
Intervention before the administration:
- + deep tendon reflex
- RR= above 12bpm
- Urine output of 30 ml per hr
- Therapeutic range: 5-8 mg/ml
- Antidote : Calcium Gluconate
- Induced labor/CS if pregnancy is 36 wks and there
is evidence of fetal lung maturity
 d. Eclampsia
- seizure accompanied by S/Sx of pre eclampsia
- Usually happens at late pregnancy up to 48 hrs after
childbirth

S/Sx before seizure

- Increase in BP
- Increase in Temp
- Blurring of vision
- Decrease urinary output
- Severe epigastric pain
During Seizure:
-Cyanosis
- Incontinence of urine and feces
Tx/Mgt:
Tonic -Clonic seizure
-Maintain airway
- Prevent aspiration
- Monitor FHT
- Administer MgSO4 or Valium
- Monitor for Vaginal bleeding and uterine contraction
- Pt is NPO
BIRTH
- Decision about birth will be made soon after seizure (
12hrs-24 hrs)
- Vaginal birth with minimum anesthesia is ideal
- CS if fetal distress is imminent
HELLP Syndrome
- Is a variation of the gestational hypertensive
process named for symptoms that occur:
a. Hemolysis that leads to anemia
b. Elevated liver enzymes that lead to epigastric pain
c. Low platelets lead to abnormal bleeding
- Occurs 4%-12% of patients who have elevated
blood pressure during pregnancy
- Occurs primigravida and multi
Cause:
- unknown
S/Sx
- Proteinuria
- Edema
- Hypertension
- Nausea
- Epigastric pain
- Right upper quadrant pain and tenderness
- Bleeding
Complications:
- hyponatremia, renal failure , hypoglycemia, renal
failure, cerebral hemorrhage
FETUS: IUGR & Preterm Labor
Treatment:
- Transfusion of Fresh plasma or Platelets
- Intravenous glucose
- Mother delivers either vaginal or CS
MULTIPLE PREGNANCY
- 2 or more fetuses are conceived
TYPES
1. Identical or monozygotic
- Begins with single ovum and spermatozoons
- Have a single placenta, 1 chorion, 2 umbilical
cords, 2 amnions
- Usually of same sex
2. Fraternal or Dizygotic
- 2 separate ova, 2 separate sperm, 2 placenta, 2
chorions, 2 amnions
- Maybe different or of same sex
Assessment:
-Increase in size of uterus is faster
-Multiple FHT
-Multiple gestational sac UTZ
Complications:
- PIH
- Pre term labor
- Anemia
- Post partum bleeding
Management:
- Bed rest
- Provide emotional support
- Close prenatal supervision
Oligohydramnios
- -Amniotic fluid of less than the average amniotic
fluid
Causes:
- fetal renal anomalies
- PROM
- Post term pregnancy
S/Sx
Decrease amount of amniotic fluid by UTZ
Management:
Frequent monitoring of maternal and fetal well being
Pre term Labor
- -A labor that occurs before the end of 37 week of
gestation

Predisposing Factors:
-UTI
- Chorioamnionitis
- Adolescent w/ poor pre natal
- Dehydration
- Strenuous job
- Intimate partner abuse
S/Sx :
- Persistent full back ache
- Vaginal spotting
- Feeling of pelvic pressure
- (+) uterine contraction

Management:
- Bed rest
- IVF
- TOCOLYTIC ( TETRABUTALINE)

- Limit strenuous activity

POSTTERM PREGNANCY
- A pregnancy that exceeds 42 weeks
- Also called as post mature, postdate
Causes:
Long menstrual cycle
Women receiving salicylate
Complications:
Meconium stain
Birth problem
Decrease blood perfusion, O2, & nutrients
Oligohydramnios
Management:
NST
Biophysical Profile
If biophysical profile is abnormal, labor will be
induce
- Misoprostol is applied to the vagina
followed by oxytocin
- CS is dine if induce labor fails
Polydramnios- excess of amniotic fluid more than
2,000 ml or amniotic fluid index of 24 cm
Causes:
- Fetal abnormalities
- Maternal factors
S/Sx:
-Excessive uterine size – lower varicosities
-Shortness of breath
Complications
Pre mature labor
Abruptio placenta
Post partum hemorrhage
Cord porlapse
Malpresentation
Therapeutic Management:
- Bed rest
- Instruct the woman to report any signs of
ruptured membrane
- Assess V/S
- Assess edema
- Avoid constipation
Oligohydramnios
- Amniotic fluid of less than 300 ml or amniotic
index of less than 5 cm

Causes:
- fetal renal anomalies
- PROM
- Post term pregnancy
S/Sx
Decrease amount of amniotic fluid by UTZ
Management:
Frequent monitoring of maternal and fetal well being
PSEUDOCYESIS ( false pregnancy)
- A condition wherein the woman believe that she is
pregnant
S/Sx:
Nausea and vomiting
Fatigue
Amenorrhea
Fullness of the breast