o Wet cotton ball for distraction

Bleeding Complications of Pregnancy o Too much KCl will stop the heart
o Administer vitamin B6- nerves
Hyperemesis Gravidarum  Administer total parenteral nutrition as needed
Etiology o Maintains adequate nutrition
 Increased level of HCG o Should be consumed within 24 hours, regulate
o Weight decreases the TPN
 Transient hyperthyroidism
 Hypofunction of the anterior pituitary gland and adrenal Gestational Trophoblastic Disease (Hydatidiform)
cortex  Occurs at 16th week of gestation (2nd trimester)
o Undiagnosed problem of the neurologic system o No heartbeat of baby, but only proliferated cells
 Abnormalities of the corpus luteum  At 12 weeks fundic height is at pubic area, by 20 weeks of
 Helicobacter pylori infection gestation- umbilicus level. But for this woman, it is already
o GI bacteria at 30weeks gestation level
o Higher episodes of vomiting  Abnormal proliferation then degeneration of trophoblastic
Manifestations villi
 Persistent N/V beyond 16 weeks o Develops into placenta
 Weight loss of 5% minimum  Cells become fluid filled= fluid filled, grapelike cluster
 Dehydration  Proliferation= Large FH
 Electrolyte and acid-base imbalance  Persistence GTD may undergo malignant change
 Unusual stress (choriocarcinoma) and metastasize
o Accepting the pregnancy 2 Types of GTD
Nursing Responsibilities 1. Complete
 Exclude gestational trophoblastic disease  No fetus; “empty egg” fertilized by sperm
o No heartbeat upon ultrasound but positive on  Associated with choriocarcinoma- cancer
pregnancy test and abdomen enlarges  Chromosomal analysis
 IV fluids (Lactated Ringer’s Sol’n- D5LR) o Sperm 23 + Ovum 0 + duplication= 46
o Provides nutrition to client  Hydatiform mole
o Correct acid-base imbalance  If not treated:
 Monitor intake and output o Vaginal bleeding (16 wks)- anemia; 2nd trimester
o Measure vomit using kidney basin calibration bleeding
 NPO x 1st 24 hours then small frequent feeding if no o Increased uterus size, cramps
vomiting o No FHT’s
o Every 2-3 hours, dry toast/ crackers o Increased N/V because each mole is producing
o Bland taste to minimize triggering factors for HCG level
vomiting o Early PIH rather than 20-24 weeks because of
 Minimize food odors abnormal proliferation and uterus expansion
 Provide oral hygiene  Management: Vacuum aspiration and curettage
o Allow client to gargle every time she vomits 2. Partial
 Monitor weight  Only part of the placenta has vesicles
o If drastic weight loss, total parental nutrition will  Has chorionic villi but the rest are cells
be ordered by physician  Chromosomal analysis
Goal of treatment o Ovum 23 + 2 sperm (dispermy)= triploid
 Correct electrolyte imbalances and acid-base imbalances karyotype (69 chromosomes) OR
with oral or IV fluids o Ovum 23 + sperm 46= triploid karyotype (69
 Minimize vomiting by antiemetic drugs chromosomes)
Drug therapy Etiology
 Metoclopramide (Reglan)- Cat.B; Pre-op  36 above
o If not PO, then give direct parenteral  Asian
 Promethazine, Diphenhydramine  Previous molar pregnancy
 Famotidine, Ranitidine (Pre-op) Treatment of Hydatiform mole
 Ondansetron  Suction curettage
Nursing Care  Baseline level of hCG is tested every 2 wks
 Avoid foods that trigger N/V  Once normal, every 4 weeks for 6-12 months, to rule out
o Spicy, oily, aromatic, texture malignancy
 Small frequent feeding  hCG plateu or increase = malignancy
 Women advised to delay conception until follow-up care
 Increase K and Na rich food complete
o Replacement of electrolytes  If conceived hCG will increase and cannot be
 Provide support to the mother distinguishable whether pregnancy or malignancy induced
o Encourage verbalizations of feeling and thoughts  6 months hCG (-)- malignancy risk
Management  12 months hCG free- pregnancy is now allowed
 Provide IV fluids  Malignancy
 Restore electrolyte balance o Methotrexate
o Add potassium chloride to IV fluids o Dactinomycin
Kristen Azusano
Nursing Care 2. Inevitable abortion- membranes rupture and cervix
 Observe for bleeding and shock dilates/opened, pregnancy cannot be saved
 Emotional support  Uterus contracts, internal cervical os dilates, ruptured
 Education on reasons to delay pregnancy membrane
 Contraception education  Save tissue fragments she has passed for analysis
o Condom o Fetus is brought to the hospital for
o Pills  Pad counting after dilatation and curettage
 Administer oxytocin Management
o Contraction of uterus to prevent bleeding  Prevention of bleeding and infection
 Assess for anemia  Curettage- ensures all products of conception are
o High risk for profuse bleeding removed after miscarriage
o Inspection: Pallor o Dilatation and evacuation
o Lab: CBC, Hemoglobin, HCT count o Dilatation and curettage
o *Inform the woman that the pregnancy is los prior
Miscarriage to procedure
 Expulsion of the fetus prior to viability (20 weeks AOG or 3. Missed miscarriage
<500 gms)  Early pregnancy failure
o Age of viability=20 weeks (potential of fetus to  Fetus die in utero but is not expelled
survive outside uterus)  May or may not have bleeding
o 500gms> can be considered as early preterm  No increase fundic height, no FHT
 Also called abortion  ULTRASOUND confirms no FHT
 Spontaneous or Induced o 10-12 weeks via doppler then ultrasound for
 Early miscarriage= before 16 wks confirmation
o Dilatation and curettage  Intrauterine fetal death stages
 Late miscarriage= 16-20 wks o Fetal maceration- 1-2 wks missed IUFD
o Given a medication to contract uterus and expel o Fetal mummification- 2-4 wks missed IUFD
the fetus o Lithopedion/ Womb stone- 4 wks and above
o Delivery of immature placenta IUFD
o Dilatation and curettage if incomplete Management
Etiology  Pregnancy before 14 weeks
 Chromosomal abnormalities o Dilatation and evacuation
 Teratogenic drugs o Dilatation and curettage
 Faulty implantation  Pregnancy over 14 weeks
 Immunologic factor o Induction of labor
o Blood incompatibility o Misoprostol (Cytotec) is introduced into the
 Weakened cervix posterior fornix of vagina to cause dilatation
o Cervix should be closed until 37th week o Oxytocin causes uterine contraction
 Not enough production of progesterone  No management = spontaneous miscarriage within 2 weeks
o Progesterone thickens endometrium, maintain  Danger in no management
placental function and it is the pregnancy o Disseminated Intravascular Coagulation (DIC)
hormone may develop if the new toxic dead fetus remains
o Developing embryo will not be able to attach too long in the utero
onto the endometrium/ uterus o Underlying disorder- systemic activation of
 Maternal conditions coagulation to A or B
o Chronic disease (nutritional deficiency, o A-Widespread fibrin deposition- microvascular
teratogenic medications) thrombotic obstruction- organ failure
o Endocrine imbalances (progesterone hormone) o B-Consumption of platelets and clotting factors-
o Infections (perineal area- urinary tract, thrombocytopenia coagulation factor deficiency-
Subcategories bleeding in eyes, gums, ears etc. (most common)
1. Threatened abortion- vaginal bleeding occurs, but pregnancy 4. Recurrent pregnancy loses
can still be saved  Habitual, consecutively in three or more pregnancy usually
 Cervix closed due to
 + bright red bleeding o Incompetent cervix
 Blood hCG within 48-hour period = placenta and o Bicornate uterus
amniotic sac is still intact o Defective sperm or ovum
Management o Endocrine problems
 Assess vaginal d/c, NPO if severe bleeding o Resistance to uterine artery blood flow
 Assess accompanying symptoms o Autoimmune
o Nausea, palpitations, tachycardia for hypovolemia Management
 Transvaginal ultrasound to verify fetal status  Assess maternal reproductive system
o Placenta is still intact and BOW, fetus heartbeat o Incompetent cervix= cerclage
 Limit activities (limit sexual activities x2wks)  Genetic screening
 Pad counting  Screening for maternal factors
o Monitor increased vaginal bleeding 5. Complete miscarriage
 All products of conception expelled
Kristen Azusano
  Bleeding slows within 2 hours Management
 No procedure required o Rhogam administration to mother
 Verified through ultrasound o After birth of first child, within 72 hours-
6. Incomplete abortion- Some products of conception have been Rhogam is administered to prevent developing
expelled, but some remain antigen
 Part of coneptus remains inuterus
 Risk for infection Ectopic Pregnancy
 DNC is done  Occurs when fertilized egg is implanted outside uterine
Management cavity
 Stabilize CV state (Vital signs monitoring) o 95% in fallopian tube- 80% ampulla, 12%
 Removal of retained tissues isthmus, 8% interstitial or fibrial
 D&C (<14 wks) Risk factors
 D&E (>14 wks) ff. by curettage  Previous tubal damage or tubal surgery
 Uterotonics may be administered  Congenital abnormalities
Post miscarriage education  Endometriosis
 Bleeding should be subsiding  Presence of an IUD
 Cramping X 1-2 wks  Uterine exposure to diethylstilbestrol (DES)
 Vaginal rest x 1 wk May result from
 Monitor temp BID  Hormonal abnormalities
 Follow up in 2 wks  Congenial defects
Complications of miscarriage  Vasconstrictive effects of smoking
 Hemorrhage  Obstruction
o Fully soaking more than 1 pad per hour o Inflammation from infection
o Passing large blood clots o Scarring from fallopian surgeries
o Might case or an effect of DIC Assessment
Management  Probable and presumptive signs of pregnancy
o Monitor VS closely (signs of hypovolemia) o hCG hormone is elevated
o Uterine massage over symphysis pubis (<20 wks)  Localized sharp stabbing abdominal pain (R or L lower
o D&C quadrant)
o Methylergonovine maleate (methergine)  Spotting
administration (contract uterus and elevate BP)  No gestational sac on transvaginal ultrasound
 Infection may rupture fallopian tube at 6-12th AOG
o Common if instruments used are not sterile Fallopian rupture
o Retained products of conception can cause both  Interstitial implantation- severe intraperitoneal bleeding
infection and bleeding o May experience shoulder pain
o Monitor for fever >38 C, foul smelling vaginal  Initial scanty vaginal bleeding bec. Blood is in the pelvic
and heavy vaginal discharge and abdominal pain cavity
o Instruct proper pericare to avoid E.coli spread to  Rigid abdomen from peritoneal irritation
vagina (front to back)  Cullen sign
 Septic abortion  Palpable mass on Cul de sac
o Usually occurs when on sterile instruments used  Additional vaginal bleeding as placenta dislodge and
for abortion decidua sloughs off
o Needs immediate intensive assessment and  (+) signs of hypovolemia: Increase RR and HR, pulses
therapy thready, lower BP
o High dose broad spectrum antibiotic is prescribed Treatment
o Hemodynamic monitoring done  Medical treatment
o D&C and tetanus toxoid administration done  No action if reabsorbed
o Infertility may be a complication o Methotrexate (if tube not ruptured)
 Folic acid antagonist and inhibits scell
 Isoimmunization
divison
o Occurs when
 Given until (-) hCG titer
 Mother is Rh -ve and father is Rh +ve
o Hysterosalpingogram to check if pregnancy is
 Baby is Rh +ve
still present
 Fetomaternal haemorrhage occurs
o 1st baby has no problem, but succeeding
 Surgery to remove pregnancy from tube or entire tube if
pregnancy is in danger if not managed
damage is severe
o During birth, separation of placenta from mother,
o Salpingostomy via laparascope- another risk for
fetal blood mixes with mother’s blood and the
ectopic PG
mother develops antibody against the negative
o Salpingectomy- removal of affected fallopian
blood
o Next pregnancy, baby is Rh +ve, but since tube
Nursing care for EP
antigen is now present, it will attack the baby’s
blood as something that is foreign=  Vital signs
erythroblastosis fetalis  IV fluids
o  Blood replacement as necessary
o Pregnancy is terminated <20wk)  Antibiotics

Kristen Azusano
  Pain management  No pelvic or rectal exam
 NPO Treatment
 Indwelling catheter  Depends on length of gestation and amount bleeding
 Bed rest  Goal: maintain pregnancy as long as safely possible (at
 Emotional support least 36 weeks)
 Mother encouraged to lie on side of with pelvic tilt to avoid
Bleeding disorder of late pregnancy (Third trimester) supine hypotension
Cervical insufficiency  C-section if total or partial
 Incompetent cervix  Deliver vaginally if low-lying or marginal under 30%
 Dilates and cannot retain fetus until term previa
 Cervical dilatation is painless  With no active bleeding
Risk factors o Expectant management
 Increased maternal age o No intercrouse, digial exams
 Uterine congenital defects  With late pregnancy bleeding
 Cervix trauma o Assess status, circulatory stability
 Repeated history of D&C o May need corticosteriouds, tocolysis,
Assessment amniocentesis
 Pinkish vaginal discharge
 Pelvic pressure
 Watery vaginal discharge
 Uterine contractions
 Very short labor then delivery of fetus
Treatment
 Cerclage
o Cervical stitching at 12-14 weeks upon
confirmation of viable pregnancy
o Preventive measure most of the time
 McDonald
o Vertical and horizontal suturing is done
 Shirodkar
o Sterile tape is secured in a purse-string manner
Nursing responsibility
 Post cerclage
o Inform woman that she must remain on a bed rest Expectant management
for a few days  May be discharged if stable after 72 hours of inpatient
 Ideal position Trendelenburg observation
 Sexual activites may resume after bed rest period  No increase in
Birth post cerclage o Hemorrhage
 Vaginal birth- sutures removed o Need for transfusion
 Abdominal approach- sutures remain Tocolysis in placenta previa
 Relax the uterus
Placenta Previa  Greatest morbidity and mortality related to prematurity
 Placenta develops in the lower part of the tuers  Tocolysis can add an additional 11 days to pregnancy
 4 degrees of previa o Allows for administration of corticosteroids
o Low lying placenta o Increase in maternal or fetal complications
o Marginal- lower placental border > 3cm from o Increase birth weights average of 320 grams
internal os, almost touching cervical os  Relax uterus prolongs pregnancy and gives more time for
o Partial- within 3cm of cervical opening lung maturity
o Complete or total- completely covers the opening Double set-up exam
Manifestations  Evaluation of previa by digital exam in operating room set
 Bright red, painless vaginal bleeding not associated with for immediate cesarean delivery
activities  Appropriate only in less than 30% previa with vertex
 Fetus often in abnormal presentation presentation
 Fetus may have anemia  Carefully palpate placental edge and fetal head
 Risk of hemorrhage increases with nearing labor  Perform cesarean delivery for:
approximately 30 wks o Complete previa
 Mother may be more at risk postpartum for infection and o Fetal head not engaged
hemorrhage o Non-reassuring tracing
o Vaginal organisms can easily reach placental site o Brisk or persistent bleeding
o Lower portion of uterus has fewer muscles Home care criteria
resulting in lower contractions  No active bleeding
 Diagnosis: Ultrasound to confirm  Bed rest is possible
 Full bladder can create false appearance of anterior previa  Home is near hosp.
 Presenting part may overshadow posterior previa  Immediate transport available
 Transvaginal scan can locate placental edge and internal os
Kristen Azusano
  Woman understands risks

Abruptio Placentae
 Permanent separation of placenta from implantation site
 Compromise fetus wellbeing- oxygen and nutrients
Predisposing factors
 Hypertension
 High parity
 Smoking/ drug use
 Age
 Abdominal trauma
 Prior history of abruption placentae
 Short umbilical cord
 Chorioamionitis
Manifestations
 Bleeding with sharp, stabbing pain, painful
 Bleeding may be concealed at first DIC- Disseminated Intravascular Coagulation
 Dark red vaginal bleeding when blood leaks placenta  Complication of bleeding
 Uterine tenderness and firm
 May have cramp-link contractions Preterm Labor
 Fetus may or may not be in distress  Labor that occurs before end of 37 weeks
 Fetus/ neonate may have anemia or hypovolemic shock  Uterine contractiosn are persistent however mild
 Complications is the birth of an immature infant
Signs and symptoms  True labor
 Vaginal bleeding (unless concealed) o Cervic effaces over 80%
 Abdominal pain o Cervix dilates more than 1cm
 Uterine activity increased Risk factor
 Hemorrhage  Dehydration -> oxytocin
o Boardlike abdominal (Couvelaire uterus)-  UTI
Sustained contraction  Periodontal disease
o Late decelerations  Chiromantic
o S/sx shock and DIC  LGA fetus
Diagnosis: Ultransound- abruption  Adolescent pregnancy
 Strenuous nature of work
Manifestation
 Persistent, dull, low back pain
 Vaginal spotting
 Pelvic pressure
 Abdominal tightening
 Increased vaginal discharge
Management
 Labor can be halted if
o Intact BOW
o (-) fetal distress
o (-) bleeding
o Cervix is <4cm dilated and not more than 90%
effaced
 Bed rest
 Cardio tocogram monitoring
Treatment
 Hydration thru IV
 1st choice- immediate cesarean
 Assess for presence of infection
 Blood and clotting factor replacement prevent DIC
 Medication
Nursing care
o Terbutaline- treatment of asthma by relaxing
 Prepare for C-section
smooth muscles
 Lateral position
 SE: Tachycardia, not used more than 72
 Close, continuous monitoring of mother and baby hrs
 Observe for S/S shock o Magnesium sulfate- prevention of eclamptic
 Prepare for compromised infant seizure by relaxing smooth muscles
 Prepare for grieving if infant dies o Betamethasone 12mg/IM q24hrs x 2 doses for
fetual lung surfactant
o Dexamethasone 5 mg/IM q12hrs x 4 doses to aid
in production of fetal lung surfactant if at <34
weeks AOG
 Discharge if pretmerm labor is aresred and fetal well being
is evident
Kristen Azusano
  Health teachings
o Adequate hydration
o Proper nutrition
o Refrain from smoking
o Kick counting

Preterm rupture of membraines

 BOW ruptures before 37 weeks AOG
 Risk factor: infection
 Complications
o Infection
o Cord prolapses
o Potter like syndrome (face distortion, pulmonary
hypoplasia)
Assessment
 Sudden gush of fluid from vagina with continuous leaking
 Nitrazine paper turns blue upon testing
 (+) Ferning test
 Amniotic fluid index in ultrasound
Management
 If fetus is mature enough, labor contractions may be
induced
 Mother on bed rest until fetus is mature
 Medications: tocolytics, corticosteroids (lung maturity),
prophylactic antibiotics

Anemia
 Decline in circulating RBC
 Less than 10.5 or 11g/dL
 May lead to preterm birth or low birth weight
Iron Deficiency Anemia
 Total iron requirement: 1000mg/fetus
 Maternal effects: pallor, fatigue, lethargy and headache
 Pica- eating things that are not usually edible
 Microcytic and hypochromic RBC
Management
 Ferrous sulfate OD to TID
 Vit. C increases absorption
 Hgb < 8.5 mg/dL= Parenteral Fe
Folic Acid Deficiency (Megaloblastic Anemia)
 Folic acid functions as coenzyme int eh synthesis of DNA
 Essential for cell duplication and fetal growth
 RBC formation
Risk factors
 Multiple pregnancies
 Hemolytic Anemias
 Anticonvulsant
 Malabsorption problems
Fetal/neonatal effects
 Spontaneous abortion Abruptio placenta
 Fetal anomalies (NTD)
Management
 Daily allowance: doubled during pregnancy (.6mg
supplementation)
 If with Hx of child NTD:
o Additional .4mg supplementation 1 mo. prior to
pregnancy
o Best sources: fortified beans, fresh dark green
leafy vegetables
o **Follic acid is destroyed during cooking

Kristen Azusano