A woman who develops a

complication of
pregnancy
 OBJECTIVES:
 1. Describe complications of pregnancy that place a pregnant woman and her
fetus at high risk.
 2. Identify National Health Goals related to complications of pregnancy and
specific measures nurses can take to help the nation achieve these goals.
 3. Use critical thinking to analyze ways that nurses can help prevent
complications of pregnancy while keeping care family centered.
 4. Assess a woman who is experiencing a complication of pregnancy.
 5. Formulate nursing diagnoses that address the needs of a woman and her
family experiencing a complication of pregnancy.
 6. Identify expected outcomes to minimize the risks to a pregnant woman and
her fetus when a complication of pregnancy occurs.
 7. Plan nursing interventions to meet the needs and promote optimal
outcomes for a woman and her family during a complication of pregnancy.
 8. Implement nursing care specific to a woman who has developed a
complication of pregnancy such as teaching her how to recognize the
symptoms of preterm labor.
 9. Evaluate expected outcomes for effectiveness and achievement of care.
 10. Identify areas of nursing care related to high-risk pregnancy that could
benefit from additional nursing research or the application of evidence-
based practice.
 11. Integrate knowledge of complications of pregnancy with nursing process
to achieve quality maternal and child health nursing care
Nursing Process Overview
 Assessment
Always ask women at such visits about any symptoms that might indicate a
complication such as pain or bleeding. Provide enough time for a thorough health
history so more subtle problems such as headache, blurred vision, or vaginal spotting
can be discovered and investigated thoroughly.
 Nursing Diagnosis
Nursing diagnoses pertaining to a woman with a pregnancy complication should
reflect both the physical problem and the family’s concern.
 Outcome Identification and Planning
Be sure that outcomes address both fetal and maternal welfare and often total family
welfare. Treatment protocols, such as those related to bleeding, preterm labor, and
pregnancy induced hypertension, should be regularly updated and maintained so they
remain current. Be certain that they reflect a current nursing management level so
nurses can act swiftly and independently as needed with life-saving measures.
 Implementation
Interventions for a woman experiencing a complication of pregnancy include measures to maintain
several different areas:
 Continued healthy fetal growth
 Continued maternal physical health
 A woman’s and family’s psychological health
 Continuation of the pregnancy as long as possible
 Outcome Evaluation
Although the success or failure of some nursing interventions cannot be fully evaluated until a child is
born or even into the postnatal period, outcomes should be evaluated throughout the pregnancy if
possible.
A. Bleeding during Pregnancy
Vaginal bleeding during pregnancy is always a deviation from the normal, may occur at any point
during pregnancy, and is always frightening.
FIRST TRIMESTER:
1. SPONTANEOUS MISCARRIAGE
Abortion is the medical term for any interruption of a pregnancy before a fetus is viable (able
to survive outside the uterus if born at that time). A viable fetus is usually defined as a fetus of more
than 20 to 24 weeks of gestation or one that weighs at least 500 g.
a. Threatened Miscarriage (early: under 16 weeks; late—16 to 24 weeks)
-Cause: Unknown; possibly
chromosomal, uterine abnormalities -
Assessment: Vaginal spotting, perhaps slight cramping, but no
cervical dilatation is present on vaginal examination.
b. Imminent (inevitable) miscarriage A threatened miscarriage becomes an imminent
(inevitable) miscarriage if uterine
contractions and cervical
dilation occur.
-Assessment: Vaginal spotting, cramping,
c. Complete Miscarriage -In a complete miscarriage, the entire products of conception
(fetus, membranes, and placenta) are expelled spontaneously without
any assistance.
-Assessment: Vaginal spotting, cramping, cervical dilatation, and
complete expulsion of uterine contents.
d. Incomplete Miscarriage -In an incomplete miscarriage, part of the conceptus (usually
the fetus) is expelled, but the membrane or placenta is retained in the
uterus.
-Assessment: Vaginal spotting, cramping, cervical dilatation, but
incomplete expulsion of uterine contents.
e. Missed Miscarriage -In a missed miscarriage, also commonly referred to as early
pregnancy failure, the fetus dies in utero but is not expelled.
-Assessment: Vaginal spotting, perhaps slight cramping; no apparent loss
of pregnancy.
-Cautions: Disseminated intravascular coagulation associated with
missed miscarriage.
COMPLICATIONS OF MISCARRIAGE:
 Hemorrhage
 Infection
 Septic Abortion
 Isoimmunization
 Powerlessness or Anxiety
2. Ectopic Pregnancy -An ectopic pregnancy is one in which implantation occurs
outside the uterine cavity. The implantation may occur on the
surface of the ovary or in the cervix.
The most common site is in a
fallopian tube.
Cause: Implantation of zygote at site other than in uterus; tubal
constricture, adhesions associated.
Assessment: Sudden unilateral lower abdominal quadrant pain; minimal
vaginal bleeding, possible signs of shock or
haemorrhage.
SECOND TRIMESTER:
3. Gestational Trophoblastic Disease (Hydatidiform Mole)
Cause: is abnormal proliferation and then degeneration of the
trophoblastic villi, fertilization or division defect.
Assessment: Overgrowth of uterus; highly positive human chorionic
gonadotropin (hCG) test; no fetus present on ultrasound;
bleeding from
vagina of old or fresh blood accompanied by cyst formation.
Cautions: Retained trophoblast tissue may become malignant
(choriocarcinoma); follow for 6 months to 1 year with
hCG testing.
4. Premature Cervical Dilatation- previously termed an incompetent cervix, refers to a cervix that dilates
prematurely and therefore cannot hold a fetus until term.
Cause: Cervix begins to dilate and pregnancy is lost at about 20 weeks; unknown cause, but cervical
trauma from dilatation and curettage (D&C) may be associated.
Assessment: Painless bleeding leading to expulsion of fetus.
Cautions: Can have cervical sutures placed to ensure a second pregnancy.

THIRD TRIMESTER:
6. Placenta Previa Is a condition of pregnancy in which the placenta is implanted abnormally in the uterus.
Cause: Low implantation of placenta possibly because of uterine abnormality.
Assessment: Painless bleeding at beginning of cervical dilatation
Cautions: No vaginal examinations to minimize placental trauma.
7. Premature Separation of the Placenta (Abruptio Placentae)
Cause: Unknown cause; associated with hypertension; placenta separates from uterus
Assessment: Sharp abdominal pain followed by uterine tenderness; vaginal bleeding;
signs of maternal shock, fetal distress
Cautions: Disseminated intravascular coagulation associated with condition

B. Preterm Labor
is labor that occurs before the end of week 37 of gestation.
Assessment: Show (pink-stained vaginal discharge) accompanied by uterine
contractions becoming regular and effective
Cautions: Preterm labor may be halted if the cervix is less than 4 cm dilated and the
membranes are intact. Corticosteroids are administered to aid fetal lung maturity.
C. Preterm rupture of membranes
is rupture of fetal membranes with loss of amniotic fluid during pregnancy
before 37 weeks.The cause of preterm rupture is unknown, but it is associated with
infection of the membranes (chorioamnionitis).
A woman usually describes a sudden gush of clear fluid from her vagina, with
continued minimal leakage. Occasionally, a woman mistakes urinary incontinence
caused by exertion for rupture of membranes. Amniotic fluid cannot be differentiated
from urine by appearance, so a sterile vaginal speculum examination is done to
observe for vaginal pooling of fluid.
If labor does not begin and the fetus is not at a point of viability, a woman is
placed on bed rest either in the hospital or at home and administered a corticosteroid
to hasten fetal lung maturity. Prophylactic administration of broad-spectrum
antibiotics during this period may both delay the onset of labor and reduce the risk of
infection in the newborn sufficiently to allow the corticosteroid to have its effect.
D. Pregnancy-induced hypertension (PIH)
is a condition in which vasospasm occurs during pregnancy in both small and large arteries.
Signs: proteinuria, and edema develop.
CLASSIFICATION OF PIH
a. Gestational Hypertension- A woman is said to have gestational hypertension when she
develops an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema.
blood pressure returns to normal after birth.
b. . Mild Pre-eclampsia- A woman is said to be mildly pre-eclamptic when she has proteinuria
and blood pressure rises to 140/90 mm Hg, taken on two occasions at least 6 hours apart.
proteinuria of 1–2on a random sample
Edema develops, as mentioned, because of the protein loss, sodium retention, and lowered
glomerular filtration rate. The edema is not just the typical ankle edema of pregnancy
but begins to accumulate in the upper part of the body.
 c. Severe Pre-eclampsia- Blood pressure of 160/110; proteinuria 3–4 on a random sample
and 5 g on a 24-hour sample; oliguria (500 mL or less in 24 hours or altered renal function
tests; elevated serum creatinine more than 1.2 mg/dL); cerebral or visual disturbances
(headache, blurred vision); pulmonary or cardiac involvement.

d. Eclampsia- This is the most severe classification of PIH. A woman has passed into this
stage when cerebral edema is so acute that a grand-mal seizure (tonic-clonic) or coma occurs.
The fetal prognosis with eclampsia is also poor because of hypoxia and consequent fetal
acidosis.
Nursing Interventions for a Woman With Mild PIH
 Monitor Antiplatelet Therapy
 Promote Bed Rest.
 Promote Good Nutrition
 Provide Emotional Support.
Nursing Interventions for a Woman With Severe PIH
 Support Bed Rest
 Monitor Maternal Well-being
 Monitor Fetal Well-being
 Support a Nutritious Diet.
 Administer Medications to Prevent Eclampsia
E. HELLP SYNDROME
 HELLP syndrome is a variation of PIH named for the common symptoms that
occur: hemolysis that leads to anemia, elevated liver enzymes that lead to
epigastric pain, and low platelets that lead to abnormal bleeding/clotting and
petechial.
 Because of the low platelet count, women with the HELLP syndrome need close
observation for bleeding, in addition to the observations necessary for pre-
eclampsia. Complications associated with the syndrome are subcapsular liver
hematoma, hyponatremia, renal failure, and hypoglycemia from poor liver
function. Mothers are at risk for cerebral hemorrhages, aspiration pneumonia, and
hypoxic encephalopathy. Fetal complications can include growth restriction and
preterm birth.
F. Multiple Pregnancy
 Multiple gestation is considered a complication of pregnancy because a woman’s body
must adjust to the effects of more than one fetus.
 Women with a multiple gestation are more susceptible to complications of pregnancy
such as PIH, hydramnios, placenta previa, preterm labor, and anemia than are women
carrying one fetus. They also are more prone to postpartum bleeding because of the
additional uterine stretching that must occur.

G. Hydramnios
 Excess fluid more than 2000 mL or an amniotic fluid index above 24 cm is considered
hydramnios.
 Too much amniotic fluid can cause fetal malpresentation because the additional uterine
space can allow the fetus to turn to a transverse lie. It also can lead to premature
rupture of the membranes from the increased pressure with possible prostaglandin
release. Amniocentesis can be performed to remove some of the extra amniotic fluid.
H. Oliguhydramnios
 refers to a pregnancy with less than the average amount of amniotic fluid.
 As part of the volume of amniotic fluid is formed by the addition of fetal urine, this is
usually caused by a bladder or renal disorder in the fetus that interferes with voiding.
Amniotransfusion or instillation of fluid into the uterus by amniocentesis procedure
can help relieve this concern.

I. Post Term Pregnancy

 A term pregnancy is 38 to 42 weeks long. A pregnancy that exceeds these limits is
prolonged (post term pregnancy, postmature, or postdate).
 Remaining in utero for longer than 2 weeks beyond term creates a danger to a fetus for
several reasons. Meconium aspiration is more apt to occur as fetal intestinal contents
are more likely to reach the rectum. If the fetus continues to grow, macrosomia could
create a birth problem.
J. Pseudocyesis
 In pseudocyesis (false pregnancy), nausea and vomiting, amenorrhea, and enlargement of the abdomen occur in
either a nonpregnant woman or a man
 There are several theories regarding why the phenomenon occurs: wish-fulfillment theory suggests a woman’s
desire to be pregnant actually causes physiologic changes to occur; conflict theory suggests a desire for and fear
of pregnancy create an internal conflict leading to physiologic changes; and depression theory attributes the
cause to major depression.

K. Isoimmunization
 Rh incompatibility occurs when an Rh-negative mother (one negative for a D antigen or one with a dd genotype)
carries a fetus with an Rhpositive blood type (DD or Dd genotype)
 The Rh factor exists as a portion of the red blood cell, so these maternal antibodies cross the placenta and cause
red blood cell destruction (hemolysis) of fetal red blood cells (Fig. 21.10). A fetus can become so deficient in red
blood cells that sufficient oxygen transport to body cells cannot be maintained. This condition is termed
hemolytic disease of the newborn or erythroblastosis fetalis.
 To reduce the number of maternal Rh (D) antibodies being formed, Rh (D) immune globulin (RhIG), a
commercial preparation of passive Rh (D) antibodies against the Rh factor, is administered to women who are
Rh-negative at 28 weeks of pregnancy.
L. Fetal Death
 one of the most severe complications of pregnancy
 The most likely causes include chromosomal abnormalities, congenital
malformations, infections such as hepatitis B, immunologic causes, and
complications of maternal disease.
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