NURSING CARE

OF THE HIGH-
RISK PRENATAL
CLIENT
NCM 109A

HARLENE ROSE R. CAYAT, RN

 OBJECTIVES:
❑At the end of the lecture, the students will be
able to:
 Describe the development and management of
hemorrhagic conditions of early pregnancy,
including spontaneous abortion, ectopic
pregnancy, and gestational trophoblastic
disease.
 Explain physiology and management of
placenta previa and placental abruption.

 Explain nursing considerations for each

complication of pregnancy.
 HEMORRHAGE
➢ rapid loss of blood equivalent to more than
1% of body weight
 Hypovolemic Shock
a. Signs and Symptoms:
✓ pallor ✓ tachypnea
✓ tachycardia ✓ cold clammy
✓ hypotension extremities
✓ confusion ✓ decreased
urine output
b. fetal distress occurs when blood loss
amounts to 25% of blood volume
 PERINATAL HEMORRHAGE
➢ occurs during pregnancy, labor and delivery
1. Antepartum hemorrhage
 Early antepartum hemorrhage
 Late antepartum hemorrhage
2. Intrapartum hemorrhage
✓ placental abruption ✓ abnormal
adhesion of the
✓ uterine rupture placenta
✓ uterine inversion
✓ CS complications
3. Postpartum hemorrhage
 Vaginal delivery: >500ml
 CS: 1000ml

 Early postpartum hemorrhage

 Most common cause:
✓ uterine atony ✓ lacerations
 Late postpartum hemorrhage
 Due to:
✓ retained placental fragments
✓ subinvolution of the uterus
 CAUSES OF BLEEDING DURING
PREGNANCY
 First Trimester Bleeding
✓ abortion ✓ ectopic pregnancy
 Second Trimester Bleeding
✓ hydatidiform mole ✓ incompetent cervix
 Third Trimester Bleeding

✓ placenta previa ✓ preterm labor

✓ abruptio placenta
 ASSESSMENT OF BLEEDING DURING
PREGNANCY
1. Vaginal Bleeding
a. Ask the woman:
✓ When was your last period?
✓ When did bleeding start?
✓ Are you still bleeding?
✓ Is the bleeding increasing or
decreasing?
✓ Could you be pregnant?
✓ Have you had recent abortion?
 ✓ Did you or anyone else do anything
to induce?
✓ Have you fainted recently?
✓ Do you have abdominal pain?
✓ Do you have any other concerns to
discuss?
b. Assess for:
✓ Amount of bleeding
 light bleeding
 takes 5 minutes or longer
for a clean pad or cloth to be
soaked
  heavy bleeding
 takes <5minutes for a clean
pad or cloth to be soaked
✓ Character of vaginal discharge
✓ Feel for lower abdominal pain
✓ Feel for fever
✓ Look for pallor
✓ Ask for presence of clots
✓ Ask for passage of tissue
✓ Vital signs
  Signs of shock:
 fast, weak pulse: 110/min or >
 fast breathing: 30/min or >
 low BP: systolic- <90mmHg
 pallor
 sweaty/cold clammy skin
 anxious, confused or
unconscious

c. Causes of vaginal bleeding in early pregnancy:

✓ threatened abortion
 ✓ ectopic pregnancy
✓ complete abortion
✓ inevitable abortion
✓ incomplete abortion
✓ molar pregnancy

2. Abdominal Pain
a. Ask the patient when the pain started and
stopped, if it did.
b. Ask location of pain
3. Abdominal Examination
a. During examination of the abdomen,
assess:
✓ Presence or absence of bowel sounds
✓ Abdominal tenderness or rigidity
✓ If in pain, note the location and severity
✓ For presence of any masses
✓ Signs of peritoneal inflammation such
as guarding and rebound tenderness
✓ Height of fundus
b. It is important for the nurse or midwife,
to be aware that:
 In a complete abortion, there is:
✓ no distention
✓ no rebound tenderness
✓ normal bowel sounds
✓ no hepatosplenomegaly
✓ only mild suprapubic tenderness
✓ usually, the uterus is either not
palpable abdominally or is just
slightly above the pubic symphysis
 In incomplete abortion:
✓ there are rebound tenderness
and/or a distended uterus

 Expect an order for:

✓ ultrasound
✓ IVF
✓ preparation of patient for
laparoscopy
✓ or an emergency exploratory
laparotomy
4. Bimanual Pelvic Examination

❖ The PHYSICIAN performs pelvic

examination when there is bleeding in the
FIRST TRIMESTER
 MIDWIVES/NURSES are NOT ALLOWED
by law to conduct IE or PE when there is
vaginal bleeding.
 The physician may perform bimanual
examination for the following purposes:
✓ Confirm pregnancy
✓ Assess the size and position of the
 uterus as to knowledge of the
position of the uterus; and direction
of the cervical canal will enable the
health worker to consider these
factors so as to avoid perforating the
uterus or injuring the cervix when
inserting instruments

✓ Determine the degree of cervical

dilation

✓ Assess pelvic pain/tenderness

✓ Assess tenderness around the fallopian
tubes and ovaries that may be associated
with ectopic pregnancy and/or infection
✓ Assess for masses or anomalies
 Prepare woman for pelvic examination:
✓ Gather and prepare all supplies
✓ Explain the procedure and the need for it
to the woman and obtain consent
✓ Place the patient in a position appropriate
for the procedure being performed
✓ Drape woman properly

 Note that:
 In complete abortion, PE may show:
✓ some blood on the perineum or
vagina but limited active bleeding
 ✓ cervix is non-tender to minimally tender
✓ cervical canal is closed for complete and
threatened abortion
✓ uterus is smaller than what is expected
for dates, and it is non-tender to mildly
tender
 In incomplete abortion, IE will reveal:
✓ cervix is dilated in incomplete and
inevitable abortion
✓ active bleeding is present from
internal os
 ✓ clots and tissues may also be present in
the vagina or cervical canal
✓ if cervical motion tenderness is present,
suspect ectopic pregnancy

 Speculum Examination
 Purpose:
✓ Determine the stage of abortion by noting
the amount of bleeding and whether the
cervix is open or closed
✓ Detect signs of infection by
noting foul smelling discharge
✓ Note any cervical/vaginal injury
✓ Remove any visible products of conception
from vaginal canal or cervical os
✓ Determine presence of pus/foreign matter
that indicates infection
 Laboratory Studies

✓ CBC

✓ Blood typing and crossmatching

✓ Rh Testing
 Management:
✓ D&C for incomplete abortion
✓ hysterectomy for uncontrollable
bleeding
✓ transfusing the patient with
platelets, coagulation factors—
usually administered in the form of
FFP or cryoprecipitate
 ✓ fibrinogen in addition to PRBC;
whole blood may be transfused as
another alternatives
 Beta-HCG: helps distinguish a complete
abortion from a threatened abortion or
ectopic pregnancy
✓ HCG level: above 1500-2000 mIU/ml,
then a transvaginal UTS should
detect a viable intrauterine pregnancy
✓ HCG level: over 3000 mIU/ml, should
enable one to visualize a viable
intrauterine pregnancy by transabdominal
UTS
 Urinalysis

 Transvaginal Ultrasound

✓ to rule out an ectopic pregnancy,

retained products of conception, or
other etiologies

Sources:
Pillitteri, A. & Silbert-Flagg, J. (2018). Maternal and
Child Health Nursing: Care of the Childbearing &
Childbearing Family (8th edition). Lippincott Williams
& Wilkins.

Evangelista-Sia, M. (2011). Outline In Obstetric for

Nurses and Midwives (4th edition). MESIA Publishing.
 DEFINITION OF TERMS
1. ABORTION
➢ most common bleeding disorder of
early pregnancy

 Types of Abortion
a. Induced Abortion
✓ the deliberate termination of a
pregnancy
Elective abortion
 Therapeutic abortion
b. Spontaneous abortion
✓ loss of a fetus during
pregnancy due to natural causes
 Threatened abortion
involves vaginal bleeding

 Inevitable abortion involves

vaginal bleeding, abdominal
cramping and progressive
dilation of the cervix, with or
without rupture of the
membranes
 Complete abortion is the
expulsion from the uterus of
all the products of conception,
which is more likely to occur
before the 8th week of
pregnancy

 Incomplete abortion is the

partial expulsion of the
products of conception
➢ Usually occurs in
the 2nd trimester
  Missed abortion occurs when
the fetus dies and is retained
in the uterus
2. UNSAFE ABORTION
➢ termination of pregnancy by persons
lacking the necessary skills or in an
environment lacking the minimal standards
of care or both
3. ILLEGAL ABORTION
➢ any abortion which is performed by any
person who is not permitted under the
relevant law of the country to carry out
such a procedure
4. EARLY ABORTION
5. LATE ABORTION
6. POST ABORTION CARE
➢ composed of the following components:
✓ emergency treatment of
complications from a spontaneous
or unsafe induced abortion
✓ family planning counseling and
services
✓ access to comprehensive
reproductive health care
 ✓ community education

7. ABORTUS
➢ aborted fetus weighing <500 grams
8. OCCULT PREGNANCY
➢ zygotes that were aborted before
pregnancy is diagnosed or recognized
9. CLINICAL PREGNANCY
10. BLIGHTED OVUM
➢ small macerated fetus, sometimes there is
no fetus, surrounded by a fluid inside an
open sac
11. CARNEOUS MOLE
➢ zygote that is surrounded by a capsule of
clotted blood

12. IMMATURE INFANT

➢ infant having a birth weigh between 500 to
1000 grams

13. FULL TERM INFANT

 CAUSES OF SPONTANEOUS
ABORTION
1. Fetal Factors
➢ most common cause
 About 80%-90% of early spontaneous
abortion is abnormal development of
the zygote, embryo or fetus.
2. Maternal Factors
➢ are congenital or acquired conditions of the
mother, including environmental factors
that can cause abortion
a. Abortion increases with advancing maternal
age, especially after 35 years of age

 below 35 y/o: 15% miscarriage rate

 between 35-39 y/o: 20-25%miscarriage

rate

 between 40-42 y/o: about 35%

miscarriage rate

 above 42 y/o: about 50% miscarriage

rate
b. Structural abnormalities of the reproductive
tract such as:
 congenital uterine defects

 fibroids

 cervical incompetence

c. Inadequate progesterone production by the

corpus luteum or placenta

d. Maternal infections such as rubella virus

 FREQUENCY
 The frequency of spontaneous abortion
increases further with maternal age.
 Late implantation, those occurring 8 to 10
days after fertilization, is also associated with
a higher incidence of abortion.
 More abortions, about 80% occur
within the 1st trimester.
 A woman who has a history of abortion has a
higher chance, about 5 to 20% of having
another abortion than a woman who has not
had abortion.
 COMPLICATIONS OF ABORTION
1. Hemorrhage
➢ more common with late abortions

2. Infection or Septic Abortion

3. Disseminated Intravascular Coagulation

(DIC)

4. Isoimmunization
TYPES OF SPONTANEOUS ABORTION
A. THREATENED ABORTION
 Signs and Symptoms
✓ light vaginal bleeding
✓ none to mild uterine cramping

 Instruct client to save all pads for

examination.
TYPES OF SPONTANEOUS ABORTION
(Threatened Abortion)

 Management
a. Conservative Management
➢ no other medical therapy is needed

❖ In any MILD BLEEDING episode that occurs

during the 1st trimester:
 If a pregnant woman with light
vaginal bleeding only comes to the
health center or clinic for check-up:
✓ Ask woman to change perineal
pad
TYPES OF SPONTANEOUS ABORTION
(Threatened Abortion)

 Management

✓ Observe bleeding for 4-6 hours

✓ Advice the woman to return

immediately if bleeding
increases, tissue is passed and
the cramps worsen for further
evaluation and treatment
✓ Follow up in 2 days
TYPES OF SPONTANEOUS ABORTION
(Threatened Abortion)

 Management
 Instruct client to rest until 3days
after bleeding has stopped
 Advise the couple not to engage in
coitus for up to 2 weeks after
bleeding has stopped
TYPES OF SPONTANEOUS ABORTION
(Threatened Abortion)

 Management

b. HCG testing at onset of bleeding and after 48

hours may be performed

c. Parents usually worry that they might have

lost the baby or may lose the baby anytime
soon after a bleeding episode
TYPES OF SPONTANEOUS ABORTION

B. INEVITABLE or IMMINENT ABORTION

 Signs and Symptoms
✓ moderate to profuse bleeding
✓ moderate to severe uterine cramping
✓ open cervix or dilation of cervix
✓ no tissue passed yet
✓ rupture of membranes
TYPES OF SPONTANEOUS ABORTION
(Inevitable or Imminent Abortion)

 Management
a. Hospitalization is necessary
b. Prepare for evacuation of uterine contents—
less than 16 weeks gestation
 Monitor the client for
signs/symptoms of internal bleeding
 Oxytocin after D&C
TYPES OF SPONTANEOUS ABORTION
(Inevitable or Imminent Abortion)

 Management
c. The physician may choose to initially wait for
spontaneous expulsion of products of
conception and then evacuate the uterus—
more than 16 weeks of gestation
 Infusion of Oxytocin 40 units in 1L IV
fluids at 40 drops per minute
d. Provide clarification, sympathetic
understanding and emotional support
TYPES OF SPONTANEOUS ABORTION
(Inevitable or Imminent Abortion)

 Management
e. The woman should be encouraged to delay
the next pregnancy until she is completely
recovered

f. Instruct woman to continue taking iron

supplements for the next 3 months
g. Advise woman on self-care:
 Rest for a few days, especially if
feeling tired and avoid strenuous
activity
TYPES OF SPONTANEOUS ABORTION
(Inevitable or Imminent Abortion)

 Management
 Advise on hygiene
 Advise woman to return immediately if
she has any of the following danger
signs:
✓ increased bleeding
✓ continued bleeding for 2 days
✓ foul-smelling vaginal discharge
✓ abdominal pain
TYPES OF SPONTANEOUS ABORTION
(Inevitable or Imminent Abortion)

 Management
✓ fever, feeling ill, weakness
✓ dizziness or fainting

 Advise woman to return in if delay(6

weeks or more) in resuming
menstrual periods
TYPES OF SPONTANEOUS ABORTION

C. COMPLETE ABORTION

 Signs and Symptoms

✓ vaginal bleeding
✓ abdominal pain
✓ passage of tissue
TYPES OF SPONTANEOUS ABORTION
(Complete Abortion)

❖ On examination in the clinic or hospital, the

following is noted:
✓ light bleeding or some blood in
the vaginal vault
✓ no tenderness in the cervix,
uterus or abdomen
✓ none to mild uterine cramping
✓ closed cervix
✓ empty uterus on ultrasound
TYPES OF SPONTANEOUS ABORTION
(Complete Abortion)

 Management

a. Usually needs no further medical or

surgical treatment
b. The patient must still be observed closely for
continued bleeding or signs of infection
c. Advise to eat high iron foods
d. Instruct patient to rest for a few days to 2
weeks; refrain from intercourse
TYPES OF SPONTANEOUS ABORTION
(Complete Abortion)

 Management

e. Tell patient that she may experience

intermittent menstrual-like flow and cramps
during the following week
f. It is important that the expelled products of
conception are evaluated by a physician and
confirmed to be intact and truly products of
conception
TYPES OF SPONTANEOUS ABORTION
(Complete Abortion)

 Management

g. Reassure patient that her next pregnancy is

likely to last to term if she is young and has
no other risk factors
❖ Pregnancy is discouraged for the next
3 months after abortion
h. Advise the patient on:
✓ self care ✓ family planning
✓ to continue taking iron supplements
TYPES OF SPONTANEOUS ABORTION
(Complete Abortion)

 Management

i. Advise the patient to return if any of the

following symptoms occur:

✓ bleeding does not stop in 2 days

✓ severe pelvic or abdominal pain
✓ temperature > 100°F
✓ menses has not returned after 6
weeks
TYPES OF SPONTANEOUS ABORTION

D. INCOMPLETE ABORTION
 Signs and Symptoms
✓ heavy vaginal bleeding
✓ severe uterine cramping
✓ open cervix
✓ passage of tissue
✓ ultrasound shows that some of the
products of conception are still inside
the uterus
TYPES OF SPONTANEOUS ABORTION
(Incomplete Abortion)

 Management

❖ The GOAL OF INTERVENTION is prompt

evacuation of the uterus to prevent
hemorrhage and infection.

a. Dilation & Curettage

 Inspect the fundus frequently to make
sure it is well contracted
 The uterus must be kept contracted
TYPES OF SPONTANEOUS ABORTION
(Incomplete Abortion)

 Management
 If the patient is BLEEDING—1st action is
to place patient flat and massage the
uterus.
 Oxytocin is administered as ordered

 DANGER of D&C: uterine perforation

✓ complains of shoulder pain and
abdominal pain
TYPES OF SPONTANEOUS ABORTION
(Incomplete Abortion)

 Management
✓ tachycardia & hypotension—
internal bleeding
 Examination of the products of conception
❖ Normal findings:
✓ villi: white branching projections
of placental tissue

✓ gestational sac: transparent

membrane attached to the villi
TYPES OF SPONTANEOUS ABORTION
(Incomplete Abortion)

 Management
✓ decidua: maternal endometrial
tissue that is firm, with coarse
shaggy borders
✓ fetal fragments may be seen at
gestations >10 weeks

❖ Abnormal Findings:
✓ presence of decidua without villi
✓ grape-like clusters
TYPES OF SPONTANEOUS ABORTION
(Incomplete Abortion)

 Management
✓ old blood clots, pus, or foul-
smelling material
b. Keep uterus contracted after evacuation
 Measures to contract uterus:
✓ administer oxytocic drugs
✓ external bimanual compression
✓ internal bimanual compression
✓ aortic compression
TYPES OF SPONTANEOUS ABORTION
(Incomplete Abortion)

 Management

c. Monitor blood loss

d. Management of shock:
 Provide universal measures for shock:
✓ ensure patent airway
✓ keep on NPO
✓ keep the woman warm
✓ elevate the legs
TYPES OF SPONTANEOUS ABORTION
(Incomplete Abortion)

 Management

 Administer oxygen by mask or nasal

cannula at 6-8 lpm
 Start intravenous fluids rapidly (16-18G) in
preparation for blood transfusion
✓ blood transfusion is required if hgb is
5g/100ml or less or hct is 15% or less
 If SHOCK IS SEVERE, BT is instituted or if
safe blood is not available, plasma
expanders is given
TYPES OF SPONTANEOUS ABORTION
(Incomplete Abortion)

 Management
✓ Normal saline should be given prior to
plasma expanders or blood transfusion
 Prophylactic antibiotic therapy

e. Provide sympathetic understanding and

emotional support
TYPES OF SPONTANEOUS ABORTION

E. MISSED ABORTION
 Signs and Symptoms
✓ s/sx appear 4 weeks after the death of
the embryo
✓ absence of FHT after it has been
initially auscultated
✓ abdominal pain and bleeding will stop—
brown vaginal discharge
✓ signs of pregnancy disappear
TYPES OF SPONTANEOUS ABORTION
(Missed Abortion)

 Missed abortion should be suspected when

the:
✓ uterus fails to enlarge
✓ fetal heart sounds are not heard at the
appropriate time or disappears after it
has been initially heard
✓ serum or urine test for the subunit HCG
becomes negative earlier than expected
or does not double within 48-72 hours
TYPES OF SPONTANEOUS ABORTION
(Missed Abortion)

✓ UTS showing no cardiac activity

provides the earliest diagnosis

 Management

 If the dead tissue is retained in the

uterus for >6-8 weeks, there is a risk of
the woman developing coagulation
disorders which will result in serious
bleeding.
TYPES OF SPONTANEOUS ABORTION
(Missed Abortion)

 Management

 Depending on the age of gestation or size

of conceptus, the products of conception
has to be removed from the uterus to
prevent DIC.
TYPES OF SPONTANEOUS ABORTION
F. HABITUAL ABORTION or RECURRENT
PREGNANCY LOSS
➢ refers to abortion occurring in 3 or more
successive pregnancies

 Causes

✓ abnormal sperm cells and egg cells

✓ chromosomal abnormalities
✓ uterine anomalies
TYPES OF SPONTANEOUS ABORTION
(Habitual Abortion or Recurrent Pregnancy Loss)

 Causes
✓ infection such as gonorrhea
✓ hormonal factors due to thyroid disease, etc
✓ age related infertility
✓ abnormal blood clotting
✓ autoimmune disorders
 Management
 Requires extensive diagnostic
investigation, including genetic
and chromosomal studies
TYPES OF SPONTANEOUS ABORTION

G. INFECTED/COMPLICATED ABORTION
➢ infection that involves the products of
conception and the maternal reproductive
organs

 Signs and Symptoms

✓ vaginal bleeding
✓ temperature >38°C
✓ abdominal pain and tenderness
TYPES OF SPONTANEOUS ABORTION
(Infected/Complicated Abortion)

 Signs and Symptoms

✓ foul smelling vaginal discharge
✓ history of attempt to induce abortion with
uterine manipulation

 Management
 Insert an IV line and give fluids
 Give paracetamol
 Give appropriate IM/IV antibiotics
 Refer urgently to hospital
TYPES OF SPONTANEOUS ABORTION
H. SEPTIC ABORTION
➢ dissemination of bacteria(and/or their
toxins) into the maternal circulatory and
organ system

 Signs and Symptoms

✓ foul smelling vaginal discharge
✓ uterine cramping
✓ fever, chills and peritonitis
TYPES OF SPONTANEOUS ABORTION
(Septic Abortion)

 Signs and Symptoms

✓ Leukocytosis ✓ patient is acutely ill

 Management
 Insert IV fluids
 Start IV antibiotic therapy
 Refer to hospital
 D&C if accompanied by incomplete abortion
❖ Infertility may occur after recovery.
Care of Mother, Child & Adolescent
At-Risk/High Risk Client
(NCM109A)

Thank you for

listening!
Sources:
Pillitteri, A. & Silbert-Flagg, J. (2018). Maternal and Child Health Nursing: Care
of the Childbearing & Childbearing Family (8th edition). Lippincott Williams &
Wilkins.

Evangelista-Sia, M. (2011). Outline In Obstetric for Nurses and Midwives (4th

edition). MESIA Publishing.