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Nursing Care of the Client During Labor and Delivery

• This is the second topic being reviewed for NCM109MCP, care of mothers, children, family and at risk population groups.
• This topic covers nursing care of the family experiencing complications pre, during, and post partum.

Bleeding During Pregnancy

• Occurs due to various causes, ranging from minor to serious.
• Heavy or persistent bleeding should be promptly addressed by a healthcare professional.

First Trimester

• Abortion is a medical term for any interruption of pregnancy before a fetus is viable.
• Viability is considered when the fetus is able to survive outside the uterus, usually around 20 weeks or 5 months.
• Abortion can be a surgical or medical procedure to end a pregnancy by removing the fetus and placenta from the uterus.
• A fetus born before viability is considered a miscarriage or a premature or immature birth.

Types of spontaneous abortion (miscarriage)

• Early miscarriage occurs before week 16 of pregnancy.
• Late miscarriage occurs between weeks 16 and 20.

Signs and Symptoms of Miscarriage

• Low back pain or abdominal pain that is dull, sharp, or cramping
• Vaginal bleeding with or without abdominal cramps.
• Tissue or clot-like material passing from the vagina.
• During weeks 6 to 12 the developing placenta is moderately attached.
• After week 12, the attachment is penetrating and deep.
• Bleeding before week 6 is rarely severe.
• Bleeding after week 12 can be profuse because the placenta is implanted so deeply.

Common Causes of Spontaneous Abortion

• Abnormal fetal development due to teratogenic factor or chromosomal aberration
• Immunologic factors
• Implantation abnormalities
• Failure of the corpus luteum on the ovary to produce enough progesterone to maintain the decidua basalis
• Alcoholic beverages ingestion
• UTI
• Systemic Infections like rubella, syphilis, poliomyelitis, CMV, and toxoplasmosis

Signs and Tests

• A pelvic exam includes assessment for thinning of the cervix (effacement), increased cervical dilatation, and evidence of rupture of membranes.
• HCG (Human Chorionic Gonadotropin) tests include qualitative and quantitative urine and blood tests.
• Urine HCG tests are a common method of determining if someone is pregnant.
• HCG can be detected in the blood or urine 1 to 2 days after implantation of the fertilized egg, or about 10 days after ovulation.
• Treatment and management requires tissue passing from the vagina to be examined to determine the source (fetal vs H-Mole).
• If remaining tissue is present a surgery or D&C may be performed.

Threatened Abortion

• Vaginal bleeding before 20 weeks AOG with a close cervix without evidence of fetal demise
• Signs and symptoms include:
  • Vaginal spotting that is scant and bright red
  • Slight abdominal cramping
  • No cervical dilatation
• Treatment & management includes assessing fetal heart beat (FHB), ultrasound testing (UTZ) and blood tests for the presence of HCG.
• Complete bed rest (CBR) or pelvic rest is ordered for 24-48 hours, with avoidance of strenuous activity.
• Abstain from intercourse and avoid douching and using tampons
• an impending miscarriage indicated by bleeding and pain, symptoms can not me stopped.
  • Signs and symptoms include Abdominal-pelvic cramps, Purulent cervical or vaginal discharges, Tachycardia, and Hypotension.
• Management save any tissue fragments, assess for FHB, D&C or D&E to ensure removal of all products of conception, and UTZ.

Complete Abortion

• It includes cases where all products of conception are removed from the uterus; expelled spontaneously without any assistance.
• Bleeding slows within 2 hours and then ceases within a few days after passage of the products.
  • Emotional support is important in these cases.

Incomplete Abortion

• This is when part of the conceptus (usually the fetus) is expelled, but the membranes or placenta are retained in the uterus.
  • Maternal hemorrhage is likely.
  • Signs and symptoms include: Vaginal bleeding, Low back pain or abdominal pain that may be dull sharp or cramping, and Tissue or clot passing from the vagina.
• Treatment for this is D & C or Suction Curettage.

Missed Abortion

• It commonly referred to as early pregnancy failure, when the fetus dies in utero but is not expelled.
  • Signs and symptoms include Absence of FHT, Abdominal Cramps/pain, Vaginal discharges or fluid or tissue, and Vaginal Bleeding.
  • Management usually consists of D&C, Prostaglandin suppository or misoprostol (Cytotec) to induce labor to cause dilatation, and Administration of oxytocin (for contraction of the uterus to start labor and to stop bleeding).

Recurrent Pregnancy Loss

• This is referring to 3 spontaneous miscarriages at the same gestational age, previously called habitual aborters.
  • Possible causes or factors can include: Abnormal spermatozoa or ova, Endocrine factors, Deviations of the uterus, Chorioamnionitis or uterine infection, and Autoimmune disorders.
• The diagnosis would include a UTZ of the uterus or Transvaginal UTZ, Blood test of thyroid function, Karyogram, CBC, and WBC.
  • Surgery for habitual abortion will be performed if the cause is incompetent cervix, with temporary management including a McDonald Procedure, Temporary Cerclage or delivery via normal delivery.
    • Permanent management involves Shirodkar Procedure, Delivery via Cesarean Section and Nursing Management including checking for signs of infection, signs of labor and normal bleeding.

Infected/ Septic Abortion

• Abortion complicated by an infection.
• When the woman tried try to self-abort or the pregnancy was aborted illegally using a nonsterile instrument.
• Signs and Symptoms include Fever, Abdominal pain/cramps, and Tenderness of the uterus.
• Danger Signs of Infection include: Fever, Abdominal pain or tenderness , Prolonged or heavy vaginal bleeding, Foul Smelling Vaginal discharges ,and Backache.
• It can lead to toxic shock syndrome, septicemia, kidney failure and death if left untreated.
  • The Management would include assessment for CBC, Blood typing, Serum Electrolytes, Creatinine, Cervical, Vaginal, and Urine Cultures, with treatment including Indwelling Catheter, IVF, D&C, Tetanus Toxoid injection, UTZ, and a Combination of Antibiotic Regimen.

Ectopic Pregnancy

• Occurs when the implantation occurred outside the uterine cavity, most commonly in the the fallopian tube.
  • Causes can include Surgery, Endometriosis, Smoking, Previous ectopic pregnancy, PID, Fertility Drugs that increase egg production, Pelvic or abdominal Surgery, and Fallopian tube damage from infection.
• Signs and Symptoms include normal pregnancy signs, accompanied by pain which is the first red flag sign.
• Other Signs and Symptoms: Vaginal spotting or bleeding Dizziness or fainting Low blood pressure and Lower back pain
• Unruptured Ectopic Pregnancy will include Missed period, Abdominal pain within 3-5 weeks, Scant, dark brown vaginal bleeding, and Vague discomfort.
• Ruptured Ectopic Pregnancy will include Sudden sharp severe pain, Shoulder pain and (+) Cullen's Sign showing a bluish-tinged umbilicus.
  • Diagnostic Tests include: Urine pregnancy test, (+) pregnancy test to determine the fetal age, Pelvic Exam, UTZ, and Culdocentesis.
    • Treatment: surgery or Laparoscopy.
• Nursing care considerations : Vitals signs, Monitor I&O, Administer IVF, Monitor Vaginal bleeding, and Prepare for Culdocentesis.

High-Risk women.

• Are between the ages of 35 and 44 years of age. These women may have a history of PID, Previous Ectopic pregnancy or Surgery on the fallopian tube, Infertility problems, and have needed medication to stimulate ovulation.

Bleeding During Pregnancy: Second Trimester

Gestational Trophoblastic Disease (Hydatidiform Mole)

• This involves abnormal proliferation and then degeneration of the trophoblastic villi.
• It can appear as clear fluid filled grape-sized vesicle.
• Hydatid is the drop of water and mole means spot
• There are two types including Partial and complete.

Partial Molar

• It is a pregnancy that includes an abnormal embryo (a fertilized egg that has begun to grow) but does not survive.

Complete Molar

• It is a pregnancy in which there is small cluster of clear blisters or pouches that don't contain an embryo

Etiology

• It is unknown but can be caused by the following:
  • Problems with the chromosome.
  • Problem with the nutrition - Problems with the ovaries and uterus
  • The molar can sometimes develop from a placental tissue that is left behind in the uterus after a miscarriage or childbirth.
  • Signs and Symptoms include:
    • (+) Pregnancy test, symptoms for the 1st 3-4 months, where the uterus grows abnormally fast and women experience vaginal bleeding ranging from and scant spotting to excessive bleeding by end of moth 3.
    • That the presence of hyperthyroidism, that leads to weight loss, increased appetite, and intolerance to heat.
    • That grapelike cluster of cells itself will be shed with the blood during is time - Nausea and vomiting due to increased HCG and progesterone. -(-) fetal Movement and fetal heart rate The early signs: Vesicles passed thru the vagina, Hyperemesis gravidarum, Fundal height that increases, vaginal bleeding that can be scant or profuse, and pre-eclampsia at about 12 weeks -Late Signs: HPN before 20th week, Vesicles look like a “snowstorm” on sonogram, Anemia, and Abdominal cramping.
  • Serious Late Complications: Hyperthyroidism, Pulmonary embolism

Diagnosis

• It should be suspected until the 3rd month where a fetal heartbeat is present with bleeding and severe nausea and vomiting, especially when their physician will examine the woman's abdomen feeling for any strange humps or abnormalities in the uterus
  • Tubal pregnancy will ruled out with the patient showing abnormally increased HCG level with vaginal bleeding even with (-)FHB where and unusually large uterus will indicate a molar pregnancy with no finding on UTZ.
    • Therapeutic Management suction curettage to evacuate the abnormal trophoblast cells.

Cervical Insufficiency (Premature Cervical Dilatation)

• This is when a previous incompetent cervix that commonly occurs at week 20 of pregnancy, where the fetus is still too immature to survive.
  • Signs and symptoms:Painless dilatation and show (a pink-stained vaginal discharge) - often the first symptom to to rupture of the membranes and discharge of the amniotic fluid
    • Can be caused by increased age at conception, congenital structural structural defects, or trauma to the cervix
  • Management is cervical Cerclage, where patient remains on bed rest in slight trendelenberg to protect the new sutures.

Bleeding During Pregnancy: Third Trimester

Preterm Labor

• Occurs before the end of week 37 of gestation, which is potentially serious to the infant's immature birth at 37 weeks. - The primary sign is a persistent dull and low backache, vaginal spotting , a feeling of pelvic pressure or abdominal tightening like menstrual-like cramping and increased vaginal discharge with uterine or intestinal cramping. - Associated with: Previous preterm birth, Short intervals between pregnancies, Short cervical length, Smoking and illicit drug use, Perinatal infection, Placenta previa, Polyhydramnios, Uterine anomalies, and Fetal birth defects. - Management would be admitting patient to the hospital placing them on bed rest to relieve the pressure of the fetus on the cervix where they ill b attached to CTG to monitor FHR and the intensity of contractions along with IV fluid therapy stopping to elp stopcontractions and to test vaginal and cervical cultures for infection. - Drug Administration includes. Terbutaline, a tocolytic agent that is approved to prevent and treat bronchospasm that should used over longer that 48 to 72 hours due to potential heart problems for mom but given along with magnesium sulfate to prevents preeclampsia and help protect the fetal’s brain under 32 weeks. - Fetal Assessment to assess fetal activity. if contractions have ceased the patient can be safely cared for at home.

Preterm Rupture of Membranes (PROM)

• This is a rupture of fetal membranes with loss of amniotic fluid before 37 weeks that poses a major threat to the fetus that can be assessed via ultrasound the patient also receives laboratory testing for infections and they avoid vaginal exams with medication antibiotics an corticosteroid if there are no signs of infection.

HELLP Syndrome

• It is a variation of the gestational hypertensive process named for its common symptoms.
  • HELLP stands for: Hemolysis leading to anemia; Elevated Liver enzymes lead to epigastric pain; Low platelets lead to abnormal bleeding/clotting - This occurs for primis and multigravida, associated with APS or the presence of antiphospholipid antibodies.
    • Symptoms include Proteinuria, Edema, increased blood pressure, Nausea ,epigastric pain, ,and a general right upper quadrant tenderness from inflammation of the liver.
      • Diagnostic testing will show Hemolysis of red blood cells, Thrombocytopenia and Elevated liver enzyme levels (ALT/AST).
  • Complications are most associated with the subcapsular liver hematoma, Hyponatremia, Renal failure Hypoglycemia from poor liver function.
    • Birthing Parents run the risk of cerebral hemorrhages, aspiration pneumonia and hypoxic encephalopathy. - The Fetal complications include growth restriction and preterm birth.

Treatment options

• A transfusion of fresh frozen plasma or platelets, hypoglycemia correction thru IV glucose and vaginal or cesarean birth performed as soon the infant is viable with mom being monitored for hemorrhage no epidural is administered..

Multiple Pregnancy

• Considered a pregnancy complication needing multiple adjustments to different body aspects involving more than one of the following complications.

Assessment

• Uterus increases in size at a rate faster than usual
• Elevated alpha-fetoprotein (AFP) levels in the blood
• Different portions of their abdor report flurries at the time of quickening
• Multiple sets of fetal heart sounds or multiple gestation sacs early in ultrasound exams.
• More Susceptible To Complications Of gestation Including Hyperemesis Gestational Hypertension Polyhydramnios Placenta Previa Preterm Labor Anemia - more susceptible to the need for Cesarean Birth.

Identical Twins

• result when monozygotic, formed rom a single ovum and single spermatozoon that divides to form two identical individuals with one placenta, one and two umbilical cords.

Fraternal twins - result when dizygote, formed from two eggs and two sperms, create a two non-identical twins with separate placentae, chorions, amnions, and 2 umbilical cords and the resulting baby are have the same with different sex.

More Susceptible to pregnancy complications including

 Hyperemesis
Gestational Hypertension

Polyhydramnios Placenta Previa Preterm Labor anemia with postpartum that include low birth rate babies, discordant infants that need monochroniotic twins and those that need Amniotic fluid

ISOIMMUNIZATION (Rh Incompatibility)

• Occurs in a Rh-negative pregnant women when their first Rh-positive baby cause them to build antibodies to their second Rh-positive causing a multitude of issues with the new baby since their body will attack their D antigen with the Rh factor resulting in a hemolytic fetal state known as erythroblastosis fetalis

Assessment

• Antibody titer testing with results of 0 in the first testing with a low number on on repeat testing means that there their current fetus in danger so the infant will be delivered early if not the effort wil go into reducing number antibodies in the mother

treatment

• RhIG a passive form of (D) antibodies will be given to Rh-negative in addition a Rhogam injection is given again after 72 after birth so that more natural antibodies are not formed the infants blood type should be determines

FETAL DEATH

Main causes

• Chromosomal abnormalities
• Infections like hepatitis B
• Immunologic Causes – - If it occurs quickening, that means mom will not be aware due to movements .A check is also assessed a routine check up and at that time they not able hear heard .If Fetus died at 20 weess the woman will began spotting where the fetus is non life form will born will look are macerated .if quickening no longer fetal hearbeat will able to heard.