Maternal Child Nursing Chapter 5- Nursing Care of Women with Complications During Pregnancy

High risk pregnancy - - One in which the health of the mother or fetus is in jeopardy Causes of high risk pregnancies include what characteristics? - - They relate to the pregnancy itself - They occur b/c the woman has a medical condition/injury that complicates the pregnancy - They result from environmental hazards that affect mother or fetus - They arise from maternal behaviours or lifestyles that have a negative effect on the mother or fetus What signs should the nurse teach a pregnant women to report and seek treatment immediately? - - Sudden gush of fluid from the vagina prior to 37 wks gestation - Vaginal bleeding - Abdominal pain - Decreased/absent fetal movements, "kick count" (after 26-28wks) - Persistent vomiting - Epigastric pain - Significant edema of face and hands - Severe, persistent headache - Blurred vision or dizziness - Chills with fever greater than 38.0C (100.4F) - Painful urination or reduced urine output - Feeling something is "just not right" hyperemesis gravidarum - - Severe nausea and vomiting that can interfere with food intake and fluid balance as well as work, family and every aspect of women's life - Fetal growth may be restricted resulting a low birth weight infant - Dehydration impairs perfusion of the placenta, reducing the delivery of blood oxygen and nutrients to the fetus - Present in 0.5-2% of women and usually between 10-20wks - Most cases resolve by 20wks of pregnancy but in more severe cases, affected women continue to have severe nausea and vomiting until giving birth Manifestations of hyperemesis gravidarum - - Persistent nausea and vomiting, often with complete inability to retain food and fluids - Significant weight loss (more than 5% of prepregnant weight) - Dehydration as evidenced by a dry tongue and mucous membranes, decreased turgor of the skin, decreased urinary volume with increased concentration and a high serum hematocrit level - Electrolyte and acid base imbalances - Ketonuria - Psychological factors such as unusual stress, emotional immaturity, passivity or ambivalence about pregnancy Ketonuria - ketones in the urine Treatment of hyperemesis gravidarum - - Correct dehydration and electrolyte/acidbase imbalances with orator IV fluids - Antiemetic medications such as Diclectin - When antiemetics don't work other medications such as metoclopramide and zofran may be prescribed - Severe cases may necessitate hospitalization and total parenteral nutrition Nursing care for hyperemesis gravidarum - - Woman should be taught how to reduce factors that trigger nausea and vomiting such as avoiding food odours - Accurate I/Os and daily weight records to assess fluid balance - Frequent, small amounts of food and fluid keep the stomach from becoming too full which can trigger vomiting and decreases gastric distention - Easily digested carbohydrates such as crackers or baked potatoes are tolerated best - Sit upright after meals to reduce gastric reflux into esophagus Abortion - - Spontaneous (miscarriage) or intentional termination or interruption of a pregnancy before 20wks gestation Types of spontaneous abortions - 1. Threatened 2. Inevitable 3. Incomplete 4. Complete 5. Missed 6. Recurrent Threatened abortions - - Cramping and backache with light spotting; cervix is closed and no tissue is passed - US is used to determine if fetus is living, limited activity prescribed. Inevitable abortions - - Increased bleeding, cramping, cervix dilates - Pt placed on limited activity and monitored, awaits natural evacuation of uterus. Incomplete abortion - - Bleeding, cramping, dilation of cervix, passage of tissue - Uterus may be emptied of remaining tissue by dilation and evacuation (D&E) or vacuum extraction Complete abortion - - Passage of all productions of conception, cervix closes, bleeding stops - Pt is monitored and emotional support is given. Give Rh0(D) immune globulin if indicated Missed abortion - - Fetus dies in utero but is not expelled, uterine growth stops, sepsis can occur - If fetus is not expelled, uterus is evacuated by D&E Recurrent abortion - - 2+ consecutive spontaneous abortions usually caused by incompetent cervix or progesterone levels inadequate to maintain pregnancy - incompetent cervix may be treated with cerclage, a reinforcement of the cervix with a surgical suture; pt is then monitored for early signs of labour and the cerclage removed to prevent injury Treatment of abortion - - When a threatened abortion occurs, efforts are made to keep the fetus in utero until the age of viability - In recurrent pregnancy loss, causes are investigated that could include genetic, immunological, anatomical, endocrine or infection factors. - Cerclage; suturing of an incompetent cervix that opens when the growing fetus presses against it, it is successful in many cases - Low hCG level by 8wks may be an ominous sign about the health of the pregnancy - While bleeding is a significant predictor of loss, the absence of nausea and vomiting associated with the pregnancy could indicate miscarriage - Termination of pregnancy after 20wks of gestation may be done, usually in cases of fetal abnormalities that are incompatible with life or severe health risk to the mother. - In all cases of loss, counselling of the parents is essential. - Even when the woman elects to terminate pregnancy, there are emotional responses that need to be recognized and addressed - Termination/interruption of pregnancy can be done surgically with a dilatation and evacuation (D&E) procedure or medically with a combination of 2 medications; mifepristone and misoprostol, they are given 24hrs apart and depending on gestational age, may be dispensed after seeing a HCP or the woman may be hospitalized. - Oxytocin controls blood loss before and after curettage, much as the medications do after term birth, - Rh0(D) immune globulin (300mcg) is given to Rh- women after any abortion to prevent development of antibodies that might harm a fetus during a subsequent pregnancy Physical nursing care for abortions - - Documents amount and character of bleeding and saves anything that looks like clots/tissues for evaluation by a pathologist during a spontaneous abortion - Pad count with an estimate saturation of weighing pads is the most accurate method to determine blood loss - Woman with threatened abortion who remains at home is taught to report increased bleeding or passage of tissue - Check the hospitalized women's bleeding and VS to identify excessive blood loss that may result in hypovolemic shock if the blood loss continues - Should remain NPO if she has active bleeding to prevent aspiration is anesthesia is required for D&E; lab tests such as hemoglobin level and hematocrit will be ordered - After vacuum aspiration or curettage, the amount of vaginal bleeding is observed; BP, pulse and resps are checked every 15mins for 1hr, then every 30mins until discharge from PACU. Woman's temp is checked on admission to recovery and every 4hrs until discharge to monitor for infection Hypovolemic shock - Shock caused by fluid or blood loss. S&S of hypovolemic shock - - Rising, weak pulse (tachycardia) - Rising respiratory rate (tachypnea) - Shallow, irregular respirations; air hunger (O2 saturation less than 95%) - Decreasing BP (hypotension) - Decreased or absent urine output (usually less than 30mL/hr) - Pale skin or mucous membranes - Cold, clammy skin - Faintness - Thirst Self care at home following an abortion - - Assess ongoing bleeding and report if it increases - Don't use tampons, can cause infection - Take temp. every 8hrs for 3 days, report signs of infection (temp. of 38C or higher, foul odour, brownish vaginal discharge) - Take oral iron supplement if prescribed - Sexual activity can be resumed as recommended by HCP (usually after bleeding has stopped) - Return to HCP at recommended time for checkup and contraception enforcement. Seek help sooner if challenged with sleeping, eating or depressed mood. - Pregnancy can occur before first menstruation period returns after abortion procedure Emotional nursing care for abortions - - Listen to woman and acknowledge the grief she and her partner feel - Offer resources to community bereavement groups, spiritual support of family's choice Ecotopic pregnancy - - When fertilized ovum is implanted outside the uterine cavity - 95% occur in fallopian tube (tubal pregnancy) - Obstruction or other abnormality of the tube prevents zygote from being transported into the uterus - Scarring from a previous pelvic infection or abnormality of the fallopian tubes or inhibition of normal tubal motion to propel the zygote into the uterus may result from the following; *Hormonal abnormalities *Inflammation *Infection *Adhesions *Congenital defects *Endometriosis - Women who have had a previous tubal pregnancy or failed tubal ligation is also more likely to have an ectopic pregnancy - Zygote that is implanted in Fallopian tube cannot survive for long b/c the blood supply and size of tube are inadequate; zygote or embryo may die and be resorbed by the woman's body or tube may rupture with bleeding into abdominal cavity, creating surgical emergency Manifestations of ectopic pregnancy - - Woman has a history of a missed menstrual period and often describes symptoms of lower abdominal pain, sometimes accompanied by light vaginal bleeding - If tube ruptures, she may have sudden severe lower abdominal pain, vaginal bleeding and signs of hypovolemic shock - Amount of vaginal leading may be minimal b/c most blood is lost into the abdomen rather than externally through vagina - Shoulder pain is a symptom that often accompanies bleeding into the abdomen (referred pain) Treatment for ectopic pregnancy - - Sensitive pregnancy test for hCG is done to determine if woman is pregnant - Transvaginal US exam determines whether the embryo is growing within the uterine cavity - Culdocentesis; puncture of upper posterior vaginal wall with removal of peritoneal fluid may occasionally be performed to identify blood in woman's pelvis which suggests tubal rupture - Laparoscopic exam may be done to view the damaged tube with an endoscope - Surgeon attempts to preserve the tube if woman wants other children but this is not always possible - Priority medical treatment is to control blood loss; blood transfusion may be needed for massive hemorrhage - Depending on gestation and amount of damage to Fallopian tube the following 3 treatments may be chosen; 1. No action is taken if woman's body is resorbing the pregnancy 2. Medical therapy with methotrexate (if tube is not ruptured) inhibits cell division in the embryo and allows it to be resorbed 3. Surgery to remove the products of conception (POC) from the tube is performed if minimal; severe damage requires removal of entire tube and occasionally, the uterus Nursing care for ectopic pregnancy - - Observing for hypovolemic shock - Vaginal bleeding is assessed although most lost blood may remain in the abdomen - Nurse should report increasing pain, particularly shoulder pain, to the HCP - If woman has surgery, preoperative and postop care is similar to that for other abdominal surgeries including; *VS to determine hypovolemic shock and temp to identify infection *Assessment of lungs and bowel sounds *IV fluid; blood replacement may be ordered if loss was substantial *Antibiotics as ordered *Pain assessment and options such as PCA *NPO status preop, oral intake usually resumes after surgery beginning with ice chips and then clear fluids or full diet may be resumed immediately depending on HCPs orders *Indwelling foley as ordered, urine output is a significant indicator of fluid balance and will fall/stop if woman hemorrhages; mimimum acceptable urine output is 30mL/hr *Bed rest before surgery; nurse should have adequate assistance when woman first ambulates b/c she is more likely to experience orthostatic hypotension if she has lost a lot of blood - Provide emotional support; loss of a Fallopian tube threatens future fertility and is another source of grief hydatidiform mole - - When chorionic villi (fringe like structures that form the placenta) increase abnormally and develop vesicles (small sacs) that resemble tiny grapes - Mole may be complete, with no fetus present, or partial in which only part of the placenta has the characteristic vesicles - May cause hemorrhage, clotting abnormalities, HTN, potentially later development of cancer (choriocarcinoma) - Chromosome abnormalities are found in many cases - More likely to occur in women at age extremes of reproductive life Manifestations of hydatidiform mole - - Bleeding which may range from spotting to profuse hemorrhage and may be of a brown colour; cramping may be present - Rapid uterine growth and a uterine size that is larger than expected for gestation - Failure to detect fetal heart activity - Signs of hyperemesis gravidarum - Unusually early development of gestational HTN - Higher than expected levels of hCG - Distinctive "snow storm" pattern on US but no evidence of a developing fetus Treatment for hydatidiform mole - - Transvaginal US verifies diagnosis - Uterus is evacuated by vacuum aspiration and D&E - Level of hCG is tested and rested until it is undetectable and the levels are followed for at least 1yr; persistent/rising levels suggest that vesicles remain or that malignant change has occurred - Woman should delay conceiving until follow up care is complete b/c new pregnancy would confuse tests for hCG - Rh0(D) immune globulin is prescribed for the Rh negative woman