Nursing Care of a

Family
Experiencing a
Sudden Pregnancy
Complication
Chapter 21
Bleeding During Pregnancy
Bleeding During Pregnancy
Bleeding During Pregnancy
 Bleeding During Pregnancy

• Vaginal bleeding may be innocent, but any degree of this during

pregnancy is potentially serious because it may mean that the
placenta has lossened, cutting off nourishment to the fetus.

• Any degree of bleeding must be evaluated for the possibility of

significant blood loss or developing hypovolemic shock.
 Process of shock due to blood loss

• Always potentially serious

• Potential emergency
▪ Placenta – Cut off
nourishment to the
fetus
▪ Amount of blood may
be in question
• Uterus is a “nonessential
organ”
▪ Blood diverted to
essential organs
• Assess for signs of
hypovolemic shock
 Assessment of
Pregnant Woman
with Hypovolemic
Shock
 Signs and Symptoms of Hypovolemic Shock

• Signs of hypovolemic shock occur when 10% of blood volume, or approximately 2 units of blood, have
been lost.
• Fetal distress occurs when 25% of blood volume is lost.
Emergency Interventions for Bleeding in Pregnancy
 HESI - Types and Treatment of Miscarriage
A. Threatened
i. Description: spotting without cervical changes
ii. Treatment: bed rest for 24 to 48 hours; no sexual intercourse for 2 weeks
B. Inevitable or incomplete
i. Description: moderate to heavy bleeding with tissue and products of conception present; open
cervical os
ii. Treatment: hospitalization; D&C (dilatation and curettage)
C. Complete
i. Description: all products of conception passed; cervix closed
ii. Treatment: no need for treatment
D. Septic
i. Description: fever, abdominal pain and tenderness; foul-smelling vaginal discharge; bleeding from
scant to heavy
ii. Treatment: termination of pregnancy; antibiotic therapy; monitoring for septic shock
E. Missed
i. Description: fetus dead; placenta atrophied but passage of products of conception has not
occurred; cervix closed
ii. Treatment: watchful waiting; check clotting factors and possibly terminate pregnancy to lessen the
chances of developing disseminated intravascular coagulation (DIC)
F. Recurrent/habitual
i. Description: loss of three or more previable pregnancies
ii. Treatment: varies based on cause; if premature cervical dilatation (incompetent cervix) is cause,
prophylactic cerclage may be done.
 Miscarriage

• Abortion
• Spontaneous Miscarriage
☻ Threatened Miscarriage
☻ Imminent (Inevitable)
Miscarriage
☻ Complete Miscarriage
☻ Incomplete Miscarriage
☻ Missed Miscarriage
• Recurrent Pregnancy Loss
 Abortion
Abortion
• 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
✔ more than 20 to 24 weeks of gestation
✔ weighs at least 500 g.
• A fetus born before this point is considered a miscarriage or premature or immature birth
 Spontaneous Miscarriage
Spontaneous Miscarriage
• is an early miscarriage if it occurs before week 16 of pregnancy and a late miscarriage if it occurs
between weeks 16 and 24.
• May occur at different times of the pregnancy
• Based on the time this occurs, the placenta’s depth of attachment determines the amount of
bleeding
• 6th week
• Developing placenta is tentatively attached to the decidua of the uterus
• 6-12 week
• Moderate degree of attachment to the myometrium is present
• After week 12
• the attachment is penetrating and deep
• bleeding after week 12 can be profuse because the placenta is implanted so deeply
• HESI Hint - Spontaneous abortion may be the result of intimate partner violence. Intimate partner
violence often begins or occurs more frequently during pregnancy.
 Causes of Spontaneous Miscarriage
• First trimester- abnormal fetal development (due either to a
teratogenic factor or a chromosomal aberration).
• Immunologic factors
• Rejection of the embryo through an immune response
• Implantation abnormalities
• Corpus luteum fails to produce enough progesterone to maintain
decidua basalis
• Systemic infection
• Rubella, syphilis, poliomyelitis, cytomegalovirus, and
toxoplasmosis infections readily cross the placenta.
• Urinary tract infections
• Endometrial sloughing due to an infection which slows down the
estrogen and progesterone production, this will result to release of
prostaglandin, leading to uterine contaction and cervical dilation
along with expulsion of the products of the pregnancy.
• Ingestion of a teratogenic drug
• Ingestion of alcohol
 Spontaneous Miscarriage
Threatened Miscarriage
• Vague bleeding, scant, bright red
• Slight cramping
• No cervical dilation
• May be asked to come to the clinic or office to have fetal heart sounds assessed or an ultrasound
performed to evaluate the viability of the fetus.
• hCG is checked (level doubles in 48 hrs, if it does not double, poor placental function is suspected.)
• Avoid strenuous activity for 24-48 hrs, no coitus for 2 wks
 Spontaneous Miscarriage
Imminent (Inevitable) Miscarriage
• Uterine contractions and cervical dilation occur
• She should save any tissue fragments she has passed and bring them with her so they can be
examined.
• If no fetal heart sounds and ultrasound reveals an empty uterus, a physician may perform a vacuum
extraction (dilation and evacuation [D&E]) to ensure that all products of conception re removed.
• After D&E, woman should assess vaginal bleeding by recording number of pads.
• >1 pad/hr = abnormally heavy bleeding
 Spontaneous Miscarriage
Complete Miscarriage
• entire products of conception (fetus, membranes, and placenta) are expelled spontaneously.
• Bleeding slows within 2h and ceases within few days after passage of products
 Spontaneous Miscarriage
Incomplete Miscarriage
• Part of the conceptus (usually the fetus) is expelled, but the membrane or placenta is retained in the
uterus.
• Pregnancy is already lost
• Danger for maternal hemorrhage as long as part of the conceptus is retained in the uterus because the
uterus cannot contract effectively under this condition.
• D&C (Dilation and curettage) or suction curettage to prevent hemorrage and infection
 Spontaneous Miscarriage
Missed Miscarriage
• Commonly referred to as early pregnancy failure
• The fetus dies in utero but is not expelled
• usually discovered at a prenatal examination when the fundal height is measured and no increase in
size can be demonstrated or when previously heard fetal heart sounds cannot be heard.
• If the embryo actually died 4-6 weeks before onset of miscarriage
• Dilation and curettage
• If the pregnancy is over 14 weeks
• Labor via prostaglandin suppository or misoprostol (Cytotec) to dilate the cervix
• Oxytocin stimulation or administration of mifepristone techniques for elective termination
• If pregnancy is not actively terminated
• Miscarriage occurs spontaneously within 2 weeks
• Coagulation defect may develop if the dead fetus (toxic) remains too long in the utero.
 Miscarriage
Recurrent Pregnancy Loss
• Defective spermatozoa or ova
• Endocrine factors such as lowered levels of protein-bound iodine (PBI), butanol-extractable iodine
(BEI), and globulin-bound iodine (GBI); poor thyroid function; or luteal phase defect
• Deviations of the uterus, such as septate or bicornuate uterus
• Resistance to uterine artery blood flow
• Chorioamnionitis or uterine infection
• Autoimmune disorders such as those involving lupus anticoagulant and antiphospholipid antibodies
 Complications of Miscarriage
Hemorrhage
• DIC (Disseminated intravascular coagulation)
• D&C (Dilation and curettage) if hemorrhage is not stopped
• Count pads
• > 1 sanitary pad/hr is excessive
• Methergen to aid contraction
Infections
• Fever (>100.4° F or 38.0° C)
• Abdominal pain or tenderness
• Foul vaginal discharge
Septic Aborrtion
• Abortion that is complicated by infection
• May lead to toxic shock syndrome, septicemia, kidney failure, and death.
• May also lead to infertility due to uterine scarring or fibrotic scarring of the fallopian tube after woman
recovers.
Isoimmunization
• production of antibodies against Rh-positive blood.
• If the woman’s next child should have Rh-positive blood, these antibodies would attempt to destroy
the red blood cells of this infant during the months that infant is in utero.
Powerlessness or Anxiety
 Ectopic Pregnancy
• It is one in which implantation occurs outside the
uterine cavity. The implantation may occur on the
surface of the ovary or in the cervix.
• Most common site is in a fallopian tube. Usually in
the ampullar tube, distal 3rd of tube. (approx. 80%
in the ampullar portion, 12% in the isthmus, and
8% are interstitial or fimbrial)

• May be due to adhesions, previous infection

(chronic salphingitis or pelvic inflammatory
disease), congenital malformations, tubal surgery
scars, uterine tumor pressing on the proximal end
of the tube, the zygote cannot travel the length of
the tube. Considered a medical emergency.

• Fertilization occurs as normal

⮚ Obstruction in the fallopian tube prevents the
zygote from reaching the uterus
 Ectopic Pregnancy Assessment

1. May be diagnosed with Magnetic Resonance Imaging (MRI) or

and ultrasound early in pregnancy (6-12 weeks).
2. In ruptured ectopic pregnancy, a woman experiences;
⮚ sharp, stabbing pain in the lower abdominal quadrants
⮚ scant vaginal spotting
⮚ If internal bleeding progresses to acute hemorrhage,
woman may feel lightheadedness and rapid pulse →
shock.
⮚ Falling HCG
3. Physician may insert a needle through the posterior vaginal
fornix into the cul-de-sac to see whether blood can be
aspirated to determine ectopic pregnancy.
4. Laparoscopy to visualize fallopian tube
5. Cullen’s sign (bluish tinge umbilicus) may develop, if signs are
ignored.
 Ectopic Pregnancy Therapeutic Management
1. Methotrexate
⮚ Folic acid antagonist chemotherapeutic agent
⮚ Attacks and destroys fast-growing cells
⮚ Treated with this drug until negative HCG titer is achieved
⮚ Hysterosalpingogram or ultrasound is used to assess
fallopian tube patency.
2. Mifepristone
⮚ an abortifacient
⮚ effective at causing sloughing of the tubal implantation
site.
⮚ the tube is left intact, with no surgical scarring that could
cause a second ectopic implantation.
3. Laparoscopy
⮚ to ligate the bleeding vessels and to remove or repair the
damaged fallopian tube.
4. Rh (D) immune globulin (RhIG)
⮚ for isoimmunization protection in future childbearing.
 Abdominal Pregnancy
• Placenta escapte into the pelvic cavity and implant
on an organ such as an intestine, where the fetus
will grow in the pelvic cavity.
• Occurs due to ruptured uterus.
• May be revealed by;
⮚ Ultrasound
⮚ MRI
• May report;
⮚ sudden lower quadrant pain
• Danger
⮚ the placenta will infiltrate and erode a major
blood vessel in the abdomen, leading to
hemorrhage.
⮚ if implanted in the intestine, it may erode so
deeply and may cause bowel perforation
and peritonitis.
⮚ Fetus is in a high risk due to lack of nutrients
• Infant must be born via laparotomy
Gestational Trophoblastic Disease
(Hydatidiform Mole)
• Abnormal proliferation then degeneration of trophoblastic villi
• Abnormal trophoblast cells must be identified because they are associated
with choriocarcinoma, a rapidly metastasizing malignancy
• Cells degenerate then fill with fluid
⮚ Clear, fluid-filled grape-sized vesicles
Gestational Trophoblastic Disease
(Hydatidiform Mole)
Risk Factors
• Low protein intake
• >35 years old
• Asian descent
• Blood group A women who marry blood group O men
Gestational Trophoblastic Disease
(Hydatidiform Mole) TWO TYPES
A. Complete Mole
⮚ ALL trophoblastic villi swell and become cystic
⮚ Embryo forms and dies early at 1-2 mm, with no fetal blood present in the villi.
⮚ Chromosome component was contributed only by the father or an “empty ovum”
was fertilized and duplicated.

B. Partial Mole
⮚ Syncytiotrophoblastic layer of villi is
swollen and misshapen.
⮚ Embryo may grow of approx. 9 wks then
macerates, with fetal blood present in the
villi.
⮚ Has 69 chromosomes (triploid formation)
 Gestational Trophoblastic Disease
(Hydatidiform Mole) Assessment and Management

Assessment
• Rapid uterine growth
• Very positive hCG
• No fetal heart tones
• Vaginal bleeding (resembling prune juice)

Management
• Suction curettage
• Follow up with pelvic exam, scheduled serum hCG (every 4 weeks for the next 6-
12 months) → Declined hCG titers suggests no complication.
• Must delay childbearing plans for a year
• Dactinomycin is taken if metastasis occurs.
 Premature Cervical Dilatation
• termed as an incompetent cervix
• refers to a cervix that dilates prematurely and therefore
cannot hold a fetus until term
• Symptoms;
1. Dilatation is usually painless
2. Show (a pink-stained vaginal discharge) or increased
pelvic pressure
3. Rupture of membranes and discharge of amniotic fluid
4. Contractions
5. Fetal birth
• Usually occurs at 20 weeks
• Cervical cerclage may be performed to prevent premature
cervical dilatation from happening in a second pregnancy.
⮚ Performed when 2nd pregnancy is healthy (12-14
weeks)
⮚ Purse-string sutures are placed in the cervix via
vaginal route under regional anesthesia.
⮚ McDonald or a Shirodkar procedure
✔ Sutures serve to strengthen the cervix and
prevent it from dilating.
 Placenta Previa
• Placenta is planted in the lower part of the uterus
• Common cause of painless bleeding in the third trimester of pregnancy.
• Various degrees of implantation
1. Lower portion (low-lying placenta)
2. Marginal implantation (the placenta edge approaches that of the cervical os)
3. Partial placenta previa (occludes a portion of the cervical os)
4. Total placenta previa (total obstruction of cervical os) Associated with placenta
previa:
1. Increased parity
2. Advanced maternal age
3. Past cesarean births
4. Past uterine curettage
5. Multiple gestation
6. Male fetus
 Placenta Previa Assessment
❖ Detected via sonogram
❖ Abrupt, painless, bright red, vaginal bleeding ( approx. week 30; 3rd trimester)
❖ May stop abruptly
❖ May also be slow, continuous spotting The bleeding of placenta
❖ Soft uterus previa, is an emergency
❖ Possible signs of shock situation. It places the mother
❖ Placenta in lower uterine segment at risk for hemorrhage.
❖ Fetal Heart Rate is usually normal
The fetal oxygen supply
maalso be compromised,
because the placenta is
lossened. This may cause
preterm labor (labor before
end of week 37)
 Placenta Previa Therapeutic Management
Immediate Care Measures
• Ensure adequate blood supply to
a woman and fetus → bed rest in
side-lying position.
• Inspect bleeding and blood loss
• Apt or Kleihauer-Betke test (test
strip procedures)
• Vital signs
• No pelvic or rectal exams
• Assess and record fetal heart
sounds or uterine contractions.
• Blood count
• Abdominal examination to reveal
engagement of fetal head
• Vaginal examination to investigate
dilatation
• Have oxygen equipment available
Continuing Care Measures
• Bed rest for 48 hours
• Obtained fetal heart sounds and
laboratory tests.
• Betamethasone
- a steroid that hastens fetal lung
maturity
- prescribed for mother to
encourage the maturity of fetal lungs
if fetus is less than 34 weeks’
gestation.
 Birth

• 37 weeks gestation, fetus may be 2500g

• Amniocentesis analysis for lung maturity will show positive
result of lecithin-sphingomyelin ratio
• Bleeding occurs
• Labor begins
• Fetus shows distress and needs to be born

CESAREAN BIRTH OF WOMAN WITH PLACENTA PREVIA

• Skin incision is transverse (bikini)
• Uterine cut must be high, vertically above the low
implantation site of placenta
• More prone to postpartum hemorrhage
• More likely to develop endometritis
 Abruptio Placentae
• Premature separation of the placenta
• Sudden separation of the placenta from the uterus.
• Extensive bleeding → perinatal death
⮚ Most frequent cause of perinatal death
• Occurs late in pregnancy Predisposing factors
• Primary cause is unknown 1. High parity
⮚ Several predisposing factors 2. Advance maternal age
• The separation generally occurs late in pregnancy; it 3. Short umbilical cord
may occur as late as during the first or second stage of 4. Chronic hypertensive
labor. disease
5. Pregnancy-induced
hypertension
6. Direct trauma
7. Vasoconstriction from
cocaine or cigarette use
8. Thrombophilitic
conditions
9. Chorioamnionitis
(infection of fetal
membranes and fluid)
 Abruptio Placentae Assessment

❖ Sharp, stabbing pain high in the uterine fundus as initial

separation occurs.
❖ Bleeding; concealed or overt (if overt, dark red)
❖ Uterine tenderness
❖ Pain with each contraction
❖ FHR abnormalities
❖ Signs of hypovolemic shock (Internal or external bleeding)
❖ Couvelaire uterus – Hard, boardlike uterus, bleeding into the
uterine musculature.
❖ Potential for DIC (disseminated intravascular coaguation)
syndrome
❖ Laboratories (hemoglobin level, typing and cross-matching,
fibrinogen level, and fibrin breakdown products)
❖ For quick assessment of DIC
⮚ draw 5ml of blood
⮚ place it in a clean, dry test tube
⮚ rest it for 5 minutes
⮚ if no clot = interference with blood coagulation
 Abruptio Placentae Therapeutic Management
❖ Institute bed rest with no vaginal or rectal
manipulation, and notify health care provider
immediately.
❖ Large-gauge intravenous catheter inserted for
fluid replacement (16- to 18- gauge catheter)
❖ Closely monitor contractions and FHR.
❖ Oxygen by mask to limit fetal anoxia
❖ Monitor fetal heart sounds and record maternal
vital signs every 5-15 mins.
❖ Lateral position, not supine, to prevent pressure
on vena cava. • Pregnancy must
❖ NO abdominal, vaginal, or pelvic exams be terminated
❖ Obtain degree of placental separation. due to lack of
❖ IV fibrinogen or cryoprecipitate fetal nutrients and
❖ Possible hysterectomy to prevent oxygen.
• Cesarean birth
exsanguination
❖ Potential for infection, DIC (bleeding gums or
nose, reduced laboratory values for platelets,
fibrinogen, and prothrombin) bleeding from
injection sites, ecchymosis)
 Abruptio Placentae Vs. Placenta Previa

Clients with abruptio placentae or placenta previa (actual

or suspected) should undergo no abdominal or vaginal
manipulation.
• No Leopold maneuvers
• No vaginal examination
• No rectal examinations, enemas, or suppositories
• No internal monitoring
 Disseminated Intravascular Coagulation
• Acquired disorder of blood clotting in which the fibrinogen level falls to below effective limits.
• occurs when there is such extreme bleeding and so many platelets and fibrin from the general
circulation rush to the site that not enough are left in the rest of the body.
• Symptoms
• Easy bleeding
• East bruising
• Emergency that can reuslt in extreme blood loss
LABORATORIES
• Platelets (≤ 100,000/ µL)
• Low prothrombin
• Elevated thrombin time
• Decreased fibrinogen (<150mg/dL)
• Fibrin split products (>40µg/mL)
 Disseminated Intravascular Coagulation
Management
• Stop the cause of coagulation
• Administer heparin
• Restore coagulation
• Heparin (IV initially, then SQ)
• Blood or Platelet transfusion
• Antithrombin III factor
• Fibrinogen
• Cryoprecipitate
• FFP (Fresh frozen plasma)
 Preterm Labor
• Labor that occurs before end of week 37 of gestation.
• Preterm labor is always serious because if it results in the infant’s birth, the infant will be immature.
• Precursors:
⮚ Dehydration
⮚ Urinary Tract Infection
⮚ Periodontal disease
⮚ Chorioamnionitis
⮚ Adolescent
⮚ African American descent
⮚ Lack of prenatal care
⮚ Women who work at strenous jobs during pregnancy
⮚ Women who were born small but the father of their child is overweight
• Symptoms:
⮚ Persistent, dull, low backache
⮚ Vaginal spotting
⮚ Feeling of pelvic pressure or abdominal tightening
⮚ Menstrual-like cramping
⮚ Increased vaginal discharge
⮚ Uterine contractions
⮚ Intestinal cramping
 Preterm Labor
MANAGEMENT
• Bedrest to relieve pressure
• Intravenous therapy to keep hydrated
• External monitoring to assess FHR, IVFs, vaginal and cervical cultures,
clean-catch urine sample to rule out infection.

MEDICATIONS TO HALT LABOR

• Terbutaline
• Bronchospasm; Tocolytic agent
• frequently used
• Magnesium sulfate
• halt contractions
• is no longer recommended because of its many side effects
• Betamethasone
• Steroid; effective at 24h, to attempt to hasten fetal lung maturity
• leads to lower rates of respiratory distress syndrome or
bronchopulmonary dysplasia in newborns
• Nifedipine (Procardia)1, Indomethacine (Indocin)2
• Calcium channel blocker 1 and prostaglandin antagonist 2
• not drugs of choice because of their side effects.
 Preterm Labor

MEDICATIONS TO HALT LABOR

• Beta-sympathomimetic drugs
• act to halt contractions by coupling with adrenergic receptors on
the outer surface of the membrane of myometrial cells
• Ritodrine hydrochloride (Yutopar)
• beta-2 receptor that causes blood vessels and bronchi to relax
along with the uterine muscle. As a result, hypotension can occur.

FETAL ASSESSMENT
• Count to 10 test
• The typical fetus moves 10 times in an hour.
• a woman lies down on her left side and times the number of
minutes it takes for her to feel 10 fetal movements (about an hour)
or counts the number of fetal movements she feels in 1 hour (the
average is 10 to 12).
• If fetal movements is still under 10 per hour = report immediately
 Preterm Rupture of Membranes
• Rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks.
• Associated with infection of the membranes (chorioamnionitis)
• Dangers:
• Uterine and fetal infection
• Increased pressure on the umbilical cord from the loss of amniotic fluid → affect fetal circulation
• Cord prolapse
• Potter-like syndrome or distorted facial features and pulmonary hypoplasia from pressure
 Preterm Rupture of Membranes Assessment
ASSESSMENT
• sudden gush of clear fluid from vagina, with continued minimal leakage.
• Associated with vaginal infection, must obtain cultures.
• Neisseria gonorrhoeae
• Streptococcus B
• Chlamydia
• Blood drawn for white blood count and C-reactive protein
• No routine vaginal examination to prevent infection

THERAPEUTIC MANAGEMENT
• Bed rest
• Administer corticosteroid to hasten fetal lung maturity
• Prophylactic administration of broad-spectrum antibiotics to both delay labor and reduce risk of
infection in the newborn and to allow corticosteroid to effect.
• Administer Tocolytic agent if labor contractions begin
• Amnioinfusion to reduce pressure on the fetus or cord and allow a term birth
• Membranes can be resealed by use of a fibrin-based commercial sealant so they are again intact.
Pregnancy-Induced Hypertension
• is a condition in which vasospasm occurs during
pregnancy in both small and large arteries.
• Originally it was called toxemia because researchers
pictured a toxin of some kind being produced by a woman
in response to the foreign protein of the growing fetus, the
toxin leading to the typical symptoms.
• Occur most frequently in women of;
• Color
• Multiple pregnancy
• Primiparas younger than 20 years or older than 40
years
• Low socioeconomic backgrounds
• Five or more pregnancies
• Hydramnios (overproduction of amniotic fluid)
• Those who have an underlying disease
Pregnancy-Induced Hypertension Physiologic
Changes
Pregnancy-Induced Hypertension
CLASSIFICATION
• Mild Preeclampsia
• Severe Preeclampsia
• Eclampsia - Seizure

BIRTH
• Vaginal birth
 Pregnancy-Induced Hypertension Nursing
Interventions (MILD PIH)
MONITOR ANTIPLATELET THERAPY
• Low-dose aspirin (50-150mg)
⮚ may prevent or delay development of pre-eclampsia.
PROMOTE BED REST
• Best method of aiding increased evacuation of sodium and encouraging diuresis.
• Lateral recumbent position
⮚ to avoid uterine pressure on the vena cava and prevent supine hypotension
syndrome.

PROMOTE GOOD NUTRITION

• No restriction of sodium
PROVIDE EMOTIONAL SUPPORT
 Pregnancy-Induced Hypertension Nursing
Interventions (SEVERE PIH)
SUPPORT BED REST
• Visitors are usually restricted to prevent triggering seizure initiating eclampsia
• Raise side rails to help prevent injury if seizure occur.
• Darken the room if possible to prevent triggering seizures.
• Avoid stress
MONITOR MATERNAL WELL-BEING
• Monitor vital signs q4h
• Obtain blood studies (complete blood count, platelet count, liver function, blood urea nitrogen,
and creatine and fibrin function and the development of DIC, which often accompanies
severe vasospasm.)
• Daily hematocrit levels
• Plasma estriol levels (test for placenta function)
• Electrolyte levels
• Assess optic fundus for signs of arterial spasms, edema, or hemorrhage.
• Daily weight to assess fluid retention.
• Insert indwelling urinary catheter for accurate recording of I/O (should be >600mL/24hr)
 Pregnancy-Induced Hypertension Nursing
Interventions (SEVERE PIH)
MONITOR FETAL WELL-BEING
• Doppler auscultation q4h
• FHR may be assessed via external fetal monitor.
• Mother may have a nonstress test or biphysical profile for uteroplacental sufficiency.
• Oxygen administration
SUPPORT A NUTRITIOUS DIET
• Moderate to high in protein
• Moderate in sodium
• Intravenous fluid for emergency route for drug and fluid administration to reduce
hemoconcentration and hypovolemia.
Pregnancy-Induced Hypertension Medications
(SEVERE PIH)
 Pregnancy-Induced Hypertension Nursing
Interventions (ECLAMPSIA)
First Stage Second Stage
Third Stage (Semicomatose)
(Tonic Phase) (Clonic Phase)
20 seconds 1 minute • Cannot be roused except by
painful stimuli for 1 to 4 hours.
• All muscles contract • Bladder and bowel • Labor may begin during this period
• Back arches, arms and muscles contract and • Keep woman on her side so
legs stiffen, and her jaw relax secretion can drain from mouth.
closes abruptly. • Breathing begins but • NPO
• Halt respirations and not effective • Limit conversation (hearing is the
may become slightly last sence lost, and the first one
cyanotic. regained.
• Assess fetal heart sound and
uterine contractions.
• Check vaginal bleeding e 15 mins.
Pregnancy-Induced Hypertension Birth (ECLAMPSIA)
• Pregnancy more than 24 weeks
• Birth will be made as soon as a woman’s condition stabilizes (12 to
24h after seizure)
• Evidence shows fetus does not continue to grow after eclampsia
occurs
• Cesarean birth is not the choice
• Hazardous for the fetus
• Association of retained lung fluid
 HELLP Syndrome
Hemolysis → Anemia
Elevated Liver enzymes → epigastric pain
Low Platelets → abnormal bleeding/clotting and petechia
• Occurs in both primigravidas and multigravidas
• Choice of delivery is either vaginally or C/section
• Symptoms:
⮚ Proteinuria
⮚ Edema
⮚ Increased blood pressure
⮚ Nausea
⮚ Epigastric pain
⮚ General malaise
⮚ Right upper quadrant tenderness
⮚ Liver inflammation
 Multiple Pregnancy
• Considered a complication of pregnancy because a
woman’s body must adjust to the effects of more than one
fetus.
• Identical (monozygotic) twins (B)
• single ovum and spermatozoon
• zygote divides into two identical individuals
• one placenta, one chorion, two amnions, and two
umbilical cords.
• always the same sex
• Nonidentical (dizygotic) twins (A)
• two separate ova and two spermatozoa (possibly not
from the same sexual partner)
• two placentas, two chorions, two amnions, and two
umbilical cords.
• Same or different sex
• Difficult to determine by ultrasound because they may
sometimes fuse and appear as one large placenta.
 Multiple Pregnancy
ASSESSMENT
• Uterus increase in size at a rate faster than usual
• Alpha-fetoprotein levels are elevated
• During quickening, woman may report flurries of action at different portions of her
abdomen rathen than at one spot.
• Multiple sets of fetal heart sounds are heard
• Ultrasound may reveal multiple gestation sacs
 Hydramnios

• Excess fluid more than 2000mL (normal: 500-1000mL)

or an amniotic fluid index above 24 cm.
• Too much amniotic fluid can cause fetal malpresentation
because additional uterine space can allow fetus to turn
to a transverse lie.
• Can also lead to premature rupture of membranes which
can adds risk of infection, prolapse cord, and preterm
birth.
ASSESSMENT MANAGEMENT
• Rapid uterine enlargement (1st • Bed rest
sign) • Report contractions
• Difficulty auscultating FH tones • Avoid constipation
• Shortness of breath • Vital signs monitoring
• Varicosities • Amniocentesis
• Hemorrhages • Needled for controlled leakage
• Weight gain
 Oligohydramnios

• Fluid less than or equal to 500mL (normal: 500-1000mL)

• Usually cause by fetal bladder or renal disease
• Cramped uterine space
• Fetal weak muscles
• Hypoplastic lungs
• Potter syndrome
• Uterus fails to grow at the expected rate
• Confirmed via ultrasound
 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).
• Infant is postmature or dysmature
• Infant is more apt to meconium aspiration
• Infant may have macrosomia if it continues to grow
• Placenta’s ability is only 40-42 weeks, after that the placenta acquires calcium
deposits, which exposes fetus to decreased blood perfusion.
• Infant may suffer lack of oxygen, fluid, and nutrients
• Can occur in woman receiving high dose of salicylates, myometrial quiescence, or a
uterus that does not respond to normal labor stimulation.
 Post-Term Pregnancy
ASSESSMENT
• If labor has not begun 41 weeks, documentation of status of placental perfusion must be ordered.
• Maternal vaginal fibronectin level
• Nonstress test
• Biophysical profile
THERAPEUTIC MANAGEMENT
• Prostaglangin gel or misoprostol (Cytotec)
• to initiate ripening, or stripping of membranes
• Monitor the fetal heart rate closely during labor to be certain placental insufficiency is not occurring
from aging of the placenta
 Pseudocyesis
• False pregnancy
• Symptoms
• Nausea
• Vomiting
• Amenorrhea
• Breast tenderness
• Enlargemenr of the abdomen (appears
to be 7 or 8 months)
THEORIES
• Wish-fulfillment Theory
• a woman’s desire to be pregnant
actually causes physiologic changes to
occur.
• Confict Theory
• a desire for and fear of pregnancy
create an internal conflict leading to
physiologic changes
• Depression Theory
• Cause to major depression
Isoimmunization (RH Incompatibility)
 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 Rh positive blood type (DD or Dd genotype).
• African Americans are missing the Rh (D) factor in their blood
• When an Rh-positive fetus begins to grow inside an Rh-negative mother who is sensitized, it is as
though her body is being invaded by a foreign agent and forms antibodies against the invading
substance.
• The Rh factor exists as a portion of the red blood cell
• Rh antibodies cross the placenta and cause red blood cell destruction (hemolysis) of fetal red
blood cells
• Infant may get;
⮚ Hemolytic disease of the newborn or erythroblastosis fetalis
• May be a threat to a second pregnancy if incompatibility effect to first child is less.
 Isoimmunization (RH Incompatibility)
ASSESSMENT
• All women with Rh-negative blood
⮚ Anti-D antibody titer done at 1st pregnancy & repeated at 28 wks
⮚ No therapy if results are normal or minimal (normal: 0; a ration below 1:8 is minimal)
⮚ If elevated (1:16 or greater), fetus is already in toxic environment; continue fetal monitoring every
2 wks
⮚ Dopper velocity will monitor fetal middle cerebral artery to predict presence of anemia to fetal red
blood cells

• THERAPEUTIC MANAGEMENT
• RhIG - Rh (D) immune globulin
• a commercial preparation of passive Rh (D) antibodies against the Rh factor
• administered to women who are Rh-negative at 28 weeks of pregnancy and 72 hours after birth
of an Rh-positive child.
• These cannot cross the placenta and destroy fetal red blood cells
• After birth, baby’s blood type is determined
⮚ If Rh-positive: Coombs test negative = large number of antibodies not present in the
mother
✔ Mother receives RhIG
⮚ If Rh-negative: No maternal antibodies formed
✔ No RhoGAM
 Fetal Death
• One of the most severe complications of pregnancy
• Natural miscarriage
• Causes
⮚ Chromosomal abnormalities
⮚ Congenital malformations
⮚ Infections (hepB)
⮚ Immunologic causes
⮚ Complications of maternal disease
• A real-time ultrasound will reveal no fetal heartbeat is present.
• Symptoms
⮚ Painless spotting
⮚ Uterine contractions with cervical effacement and dilation
ASSESSMENT AND MANAGEMENT
• No fetal heartbeat can be heard by ultrasound
• Observe women who give birth to a dead fetus for excess bleeding because if fetus died in
utero for longer length = DIC (Disseminated Intravascular Coagulation)
• Women may be aware of the absence of movement if fetus died past the point of
quickening
• Misoprostol (Cytotec)
⮚ .to effect cervical ripening
• Oxytocin
THANK YOU!