NCM 109: Maternal & Child Nursing Week 2 PDF

NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY OUTLINE: I. Identifying a High-Risk Pregnancy A. Factors that Categorize a...

NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY OUTLINE: I. Identifying a High-Risk Pregnancy A. Factors that Categorize a Pregnancy as High-Risk II. Non-Bleeding Pregnancy-Related Complications A. Hyperemesis Gravidarum III. Bleeding During Pregnancy A. Vaginal Bleeding IV. First Trimester Bleeding Disorder A. Spontaneous Miscarriage i. Threatened Miscarriage ii. Imminent (Inevitable) Miscarriage iii. Complete Miscarriage iv. Incomplete Miscarriage v. Missed Miscarriage vi. Recurrent Pregnancy Loss B. Ectopic Pregnancy V. Second Trimester Bleeding Disorder A. Gestational Trophoblastic Disease (Hydatidiform Mole) B. Premature Cervical Dilation VI. Third Trimester Bleeding Disorder A. Placenta Previa B. Premature Separation of the Placenta (Abruptio Placentae) C. Preterm Labor NON-BLEEDING PREGNANCY-RELATED COMPLICATIONS IDENTIFING A HIGH-RISK PREGNANCY High-risk pregnancy – is one which a concurrent HYPEREMESIS GRAVIDARUM disorder, pregnancy-related complication, or external - Excessive nausea and vomiting that results in factor jeopardizes the health of the woman, the fetus, or dehydration and electrolyte imbalance both. - Interferes with the client’s food intake FACTORS THAT CATEGORIZE A PREGNANCY Assessment AS HIGH RISK - Risk factor – unknown - Diagnostics – by symptoms Clinical manifestations: Persistent nausea and vomiting, often with complete inability to retain food and fluids Significant eeight loss Dehydration Electrolyte and acid-base imbalances Treatment Medical - Replacement of parenteral fluids, electrolytes and vitamins Dietary - NPO for first 48bhours - After condition improves, six small feedings alternated with liquid nourishment in small amounts every one to two hours - If vomiting reoccurs, NPO and IV fluids are restarted - May require placement of central line for extended nutritional use of TPN or lipids. Herald & Mary Reviewer │Page 1 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY Nursing Care - woman with any degree of bleeding, needs to be - Goal: to assist with the medical and dietary evaluated for the possibility that she is management experiencing a significant blood loss or is developing hypovolemic shock. BLEEDING DURING PREGNANCY VAGINAL BLEEDING - Is always a deviation from the normal - May occur at any point during pregnancy - Always frightening - It must always be investigated: it can impair both the outcome of pregnancy and a woman’s life or health. Summary of Primary Causes of Bleeding During Pregnancy - 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. - Inform women of their blood pressure at prenatal visit. Signs and Symptoms of Hypovolemic Shock Herald & Mary Reviewer │Page 2 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY Emergency Interventions for Bleeding in Pregnancy - Alert health care team of emergency situation. - Place woman in bed on her side. - Begin IV such lactated Ringer’s with a 16- or 18- gauge angiocath. - Administer oxygen as necessary at 6-10 L/min by face mask. - Monitor uterine contractions and fetal heart rate by external monitor. - Omit vaginal examination. - Withhold oral fluid. - Order type and cross-match of 2 units whole blood. SPONTANEOUS MISCARRIAGE - Measure intake and output. - Occurs in 15% to 30% of all pregnancies and - Assess vital signs (pulse, respirations, and blood arises from natural causes. pressure or pulmonary artery catheter and blood - Early miscarriage: occurs before week 16 of determinations. pregnancy - Measure maternal blood loss by weighing - Late miscarriage: occurs between weeks 16 and perineal pads; save any tissue passed. 20. - Set aside 5 mL of blood drawn intravenously in a - Degree of placental attachment: clean test tube; observe in 5 min for clot First 6 weeks: developing placenta is formation. tentatively to the decidua of the uterus; - Assist with ultrasound examination. Weeks 6 to 12: a moderate degree of - Maintain a positive attitude about fetal outcome. attachment to the myometrium is present. - Support woman’s self-esteem; provide emotional After week 12, the attachment is support to woman and her support person. penetrating and deep. Degree of Bleeding Before 6 weeks: rarely severe After week 12: can be profuse because the placenta is implanted so deeply. (fortunately, at this time, with such deep placental implantation, the fetus tends to be expelled as in natural childbirth before the placenta separated. Bleeding is controlled due to postpartal contractions. Between 6 and 12 weeks: can lead to the most severe, even life-threatening, bleeding. Causes of Spontaneous Miscarriage - Abnormal fetal development – most common, teratogenic factor, chromosomal aberration, FIRST TRIMESTER BLEEDING DISORDER immunologic factor Abortion – the medical term for any interruption of a - Implantation abnormalities – inadequate pregnancy before a fetus is viable. endometrial formation or inappropriate site of implantation. Viable fetus – a fetus more than 20 to 24 weeks of - Corpus luteum on the ovary fails to produce gestation or one who weighs at least 500 g. enough progesterone to maintain decidua A fetus before this point is considered a miscarriage or basalis. (progesterone therapy for prevention) premature or immature birth. - Systemic infection – rubella, syphillis, poliomyelitis, cytomegalovirus, and Elective abortion – is the planned medical termination toxoplasmosis, urinary tract infections. of a pregnancy. - Ingestion of teratogenic drug example: isotretinoin (Accutane) for adolescent acne Miscarriage – when the interruption occurs - Ingestion of alcohol spontaneously Assessment - Vaginal spotting: presenting symptom - Confirmation of pregnancy: pregnancy test? - Pregnancy length in weeks - Duration of bleeding Herald & Mary Reviewer │Page 3 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY - Intensity: how much bleeding occurred? conception have been removed - Frequency: steady spotting? A single episode? form the uterus. - Associated symptom: cramping? Sharp pain? - Discharge instruction: assess and Dull pain? Has she ever had surgical surgery? record number of pads used to - Action: what was happening when the bleeding assess for heavy bleeding ( more started? What has she done to control the than 1 pad/hour is abnormally heavy bleeding? bleeding) - Blood type Complete Miscarriage Therapeutic management - The entire products of conception (fetus, - Depending on the symptoms and the description membrane, and placenta} are expelled of the bleeding a woman gives. spontaneously without assistance - The bleeding usually slows within 2 hours TYPES OF SPONTANEOUS MISCARRAIGE and then ceases within a few days after Threatened Miscarriage passage of the product of conception. ▪ Symptoms: - Vaginal bleeding, initially scant and Incomplete Miscarriage usually bright red - Part of the conceptus (usually the fetus) is - Slight cramping, no cervical expelled, but the membrane or placenta is dilatation retained in the uterus. - Danger: maternal hemorrhage ▪ Intervention: - Management: Dilation and curettage or - Assessment of FHT: to evaluate the suction curettage viability of the fetus - HCG extraction: to evaluate placental Missed Miscarriage function - Commonly referred to as early pregnancy - Avoidance of strenuous activity for 24 failure to 48 hrs: key intervention - The fetus dies in utero but is not expelled. - Bed rest not usually necessary: blood will only pool vaginally ▪ Sign: ▪ Emotional support: - No increase in fundic height - Convey support and assurance. during prenatal examination - Do not be judgmental - No fetal heart sounds ▪ As many as 50% of women with a ▪ Symptom: threatened miscarriage continue the - Painless, vaginal bleeding pregnancy. - Or no prior clinical symptom at all Imminent (Inevitable) Miscarriage ▪ Symptom: ▪ Management: - uterine contractions - Ultrasound to confirm death - cervical dilatation – loss of the of fetus. products of conception cannot be - D&E halted - Over 4 weeks of pregnancy: labor is induced by a ▪ Management: prostaglandin suppository or - Report to health care facility: uterine misoprostol (Cytotec) to dilate camping and uterine contraction the cervix, followed by - Save any tissue fragments she has oxytocin stimulation or passed for examination. administration of mifepristone - D&E is performed: if no heart techniques used for elective sounds detected and ultrasound termination of pregnancy. reveals an empty uterus or - If pregnancy is not actively nonviable fetus, to ensure that all terminated, miscarriage products of conception are usually occurs spontaneously removed. within 2 weeks. DANGER: - Be sure to inform the woman that disseminated intravascular pregnancy was already lost before coagulation (DIC), a procedure is performed. coagulation defect, may - Save tissue fragment from D&E to develop if the dead (and be examined for Hmole and possibly toxic) fetus remains assurance that all products of too long in utero. Herald & Mary Reviewer │Page 4 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY Recurrent Pregnancy Loss Septic abortion - Three spontaneous miscarriages - An abortion that is complicated by - Occurs in about 1% of women who wants infection. to be pregnant. - Common in women who have tried to self- - Possible causes: abort or were aborted illegally using a Defective spermatozoa or ova nonsterile instrument such as knitting Endocrine factors such as lowered needle. levels of protein-bound iodine (PBI), butanol-extractable iodine (BEI), ▪ Symptoms and globulin-bound iodine (GBI), - Fever poor thyroid function or luteal phase - Crampy abdominal pain defect - Tender uterus upon palpation Deviation of the uterus, such as septate or bicornuate uterus ▪ Left untreated, can lead to: Resistance to uterine artery blood - Toxic shock syndrome flow - Septicemia Chorioamnionitis or uterine infection - Kidney failure Autoimmune disorders such as - Death those involving lupus anticoagulant and antiphospholipid antibodies. ▪ Management: - Immediate, intensive Complications of Miscarriage assessment and treatment Hemorrhage - CBC, serum electrolytes, - Monitor vital signs to detect hypovolemic serum creatinine, blood type shock and crossmatch, and cervical, - If excessive vaginal bleeding is occurring, vaginal, and urine cultures immediately position a woman flat and are obtained. massage the uterine fundus to try to aid - Indwelling urinary catheter contraction. may be inserted to monitor - D&C or suction curettage urine output hourly. - Blood transfusion may be necessary. - IV to restore fluid volume and - Direct replacement of fibrinogen or another to provide route of antibiotics. clotting factor may be used to increase - CVP or pulmonary artery coagulation ability. catheter (left atrial filling - After self-limiting complete miscarriage, pressure and hemodynamic instruct the woman clearly to observe the status) following: - D&C or D&E More than 1 pad per hour is - Admission to intensive care excessive unit Changes of color Unusual odor - If a woman recovers through an intensive Passing of blood clots episode, septic abortion may lead to To take medication (Methergine) as infertility because of fibrotic scarring of the prescribed fallopian tube. Counselling for a woman who tried to Infection self-abort to assist her to learn better - Tends to develop if a woman have lost problem-solving methods for the appreciable amounts of blood. future. - Teach the danger signs of infection: Fever Isoimmunization Abdominal pain or tenderness Foul vaginal discharge Dislodge placenta (spontaneous birth or by D&C) - E. coli – most common cause of infection - blood from placental villi (fetal blood) may after miscarriage enter the maternal circulation. After defecation, teach the woman - if fetus was Rh-positive and mother is Rh to wipe anal area from front to back. negative = isoimmunization. - After a miscarriage, because the blood - no tampons, as this causes stasis of any type of the conception is unknown, all body fluid and increases risk of infection. women with Rh-negative blood should receive Rh (D antigen) immune globulin (RhIG) to prevent the buildup of antibodies in the event the conceptus was Rh + Herald & Mary Reviewer │Page 5 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY Powerless or Anxiety - As with pregnancy loss for any reason, assess a woman’s adjustment to a spontaneous miscarriage. - Sadness and grief over the loss or a feeling that a woman has lost control of her life is to be expected. - Do not forget to assess a partner’s feelings as well, or that person’s grief over the pregnancy loss can be missed. - Spontaneous miscarriage can be particularly heartbreaking for an older woman, because she realizes that her window of childbearing is limited. ECTOPOC PREGNANCY - Is one which implantation occurs outside of the uterine cavity. - The implantation may occur on the surface of the ovary or in the cervix. - The most common site (app 95% of such pregnancies) is in a fallopian tube. - 80% occur in the ampullar portion, 12% occur in the isthmus, and 8% are the interstitial or fimbrial. - The second most frequent cause of bleeding early in pregnancy. Causes - Previous infection (salpingitis or PID) - Congenital malformations - Scars from tubal surgery - A uterine tumor pressing on the proximal end of the tube. - Occurs most frequently in women who smoke - IUD - Previous ectopic pregnancy (10-20% chance) - Use of fertility drug - In Vitro Fertilization Assessment - Diagnosed by an early pregnancy ultrasound. - Light vaginal bleeding - Nausea and vomiting - Lower abdominal pain - Sharp abdominal cramps - Pain on one side of your body - Dizziness or weakness: if internal hemorrhage progresses - Pain in your shoulder, neck, or rectum - If the fallopian tube ruptures, the pain and bleeding could be severe enough to cause fainting. - If a woman waits for a time before seeking help: Gradually her abdomen becomes rigid from peritoneal irritation. - Umbilicus may develop a bluish tinge (Cullen’s sign) - Herald & Mary Reviewer │Page 6 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY - Continuing extensive or dull vaginal and abdominal pain - Movement of the cervix on pelvic examination may cause excruciating pain. - Pain in her shoulders from blood in the peritoneal cavity causing irritation to the phrenic nerve. - A tender mass is usually palpable in Douglas’ cul- de-sac on vaginal examination. Therapeutic Management - Methotrexate followed by leucovorin – for unruptured ectopic pregnancy - Mifepristone (abortifacient) – cause sloughing of Signs and Symptoms the tubal implantation site - Fetal outline is easily palpable through the - Laparoscopy – for ruptured ectopic pregnancy. abdomen. Ligate the bleeding vessels and to remove or - A woman may not be as aware of movements as repair damage fallopian tube. she would be normally - May experience painful fetal movements and ABDOMINAL PREGNANCY abdominal cramping with fetal movements. - Rare - Sudden lower quadrant pain earlier in pregnancy. - Occurs when after an ectopic pregnancy - An ultrasound or MRI will reveal the fetus outside ruptures, the products of conception are expelled the uterus. into the pelvic cavity with a minimum of bleeding. - Placenta continues to grow in the fallopian tube, Danger spreading perhaps into the uterus for a better - Placenta will infiltrate and erode a major blood blood supply vessel in the abdomen, leading to hemorrhage. - Or it may escape into the pelvic cavity and - If implanted on the intestine, it may erode so implant on an organ such as an intestine. deeply that it causes bowel perforation and - The fetus will grow in the pelvic cavity (abdominal peritonitis. pregnancy). - High risk fetus because of inadequate uterine - This can also occur if a uterus ruptures because supply. an old uterine scar ruptures during pregnancy. - 60% survival rate of fetus - For infants who do survive, there is an increased threat of fetal deformity or growth restriction from an inadequate nutrient supply. - Infant must be born through laparotomy. - Placenta may be left in place especially if it has been implanted in the intestine. - Placenta is allowed to be absorbed spontaneously in 2 or 3 months. - A follow-up ultrasound can be used to detect whether this has occurred, or a woman can be treated with methotrexate to help the placenta absorb Herald & Mary Reviewer │Page 7 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY SECOND TRIMESTER BLEEDING DISORDER GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE) - Abnormal proliferation and then degeneration of the trophoblastic villi. As the cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized vesicles The embryo fails to develop beyond a primitive start. - Abnormal trophoblast cells must be identified because they are associated with Assessment choriocarcinoma, a rapidly metastasizing Symptoms malignancy. - Abnormal growth of the womb (uterus) - Risk Factors: Excessive growth in about half of Incidence: 1 in every 1500 pregnancies cases tends to occur most often in women who Smaller-than-expected growth in have a low protein intake about a third of cases in women older that age 35 years in women of Asian heritage - Nausea and vomiting that may be severe in blood group A women who marry blood enough to require a hospital stay group O men - Vaginal bleeding in pregnancy during the first 3 months of pregnancy 2 TYPES OF H-MOLE - Symptoms of hyperthyroidism 1. Complete Mole Heat intolerance - There is an abnormal placenta but no fetus Loose stools - All trophoblastic villi swell and become Rapid heart rate cystic Restlessness, nervousness - If embryo forms, it dies early at only 1 to 2 Skin warmer and more moist than mm in size, with no fetal blood present in usual the villi Trembling hands - On chromosomal analysis, although the Unexplained weight loss karyotype is a normal 46XX 46XY, this chromosome component was contributed - Symptoms similar to preeclampsia that only by the father or an “empty ovum” was occur in the 1st trimester or early 2nd fertilized and the chromosome material trimester -- this is almost always a sign of was duplicated a hydatidiform mole, because preeclampsia is extremely rare this early in a normal pregnancy High blood pressure Swelling in feet, ankles, legs Exams and Tests - A pelvic examination may show signs similar to a normal pregnancy, but the size of the womb may be abnormal and the baby's heart sounds are absent. There may be some vaginal bleeding - A pregnancy ultrasound will show an abnormal placenta with or without some development of a baby 2. Partial Mole - Tests may include: - There is an abnormal placenta and some HCG blood test fetal development Chest x-ray - Some of the villi form normally CT or MRI of the abdomen - The syncytiotrophoblastic layer, however, Complete blood count is swollen and misshapen Blood clotting tests - A macerated embryo of approximately 9 Kidney and liver function tests weeks gestation may be present and fetal blood may be present in the villi. - 69 Karyotype Herald & Mary Reviewer │Page 8 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY Therapeutic Management - Sutures are then removed at 37 weeks to 38 - If your doctor suspects a molar pregnancy, a weeks of pregnancy. suction curettage (D and C) may be performed. - A hysterectomy may be an option for older THIRD TRIMESTER BLEEDING DISORDER women who do not wish to become pregnant in PLACENTA PREVIA the future. - A condition in pregnancy in which the placenta is - After treatment, serum HCG level will be implanted abnormally in the uterus followed. It is important to avoid pregnancy and - It is the most common cause of painless bleeding to use a reliable contraceptive for 6 - 12 months in the third trimester of pregnancy after treatment for a molar pregnancy. This allows for accurate testing to be sure that the abnormal 4 Levels of Implantation tissue does not grow back. Women who get Low-lying placenta pregnant too soon after a molar pregnancy have Marginal implantation – the placenta edge a high risk of having another molar pregnancy. approaches that of the cervical os Partial placenta previa – implantation that Prognosis occludes a portion of the cervical os - More than 80% of hydatidiform moles are benign Total placenta previa – implantation that totally (noncancerous). Treatment is usually successful. obstructs the cervical os Close follow-up by a doctor is important. After treatment, use effective contraception for at least Estimation of the degree the placenta covers the 6- 12 months to avoid pregnancy internal cervical os: - In some cases, hydatidiform moles develop into - 100% invasive moles. These can grow deep into the - 75% uterine wall and cause bleeding or other - 30% and so forth complications - In a few cases, a hydatidiform mole develops into a choriocarcinoma. This is a fast-growing cancerous form of gestational trophoblastic disease. PREMATURE CERVICAL DILATATION - Previously termed as incompetent cervix - Refers to a cervix that dilates prematurely and therefore cannot hold a fetus until term. - It occurs about 1% of women. - Painless - 1st symptom: show increased pelvic pressure rupture of membranes discharge of amniotic fluid - Commonly occurs at approximately 20 weeks of pregnancy Causes - Increased maternal age Etiology - Congenital structural defects - Increased parity - Trauma to the cervix (e.g. D&C) - Advanced maternal age - Premature cervical dilatation is diagnosed only - Past cesarean births after the pregnancy is lost - Past uterine curettage - Multiple gestation Therapeutic Management - Male fetus - Cervical cerclage (McDonald or Shirodkar procedure) Assessment McDonald procedure: nylons are placed - Ultrasound – placenta are diagnosed early before horizontally and vertically across the cervix and pulled tight to reduce the cervical any symptoms occur canal to a few millimeters in diameter - Vaginal bleeding – begins when the lower uterine Shirodkar procedure: sterile tape is segment starts to differentiate from the upper threaded in a purse-string manner under segment late in pregnancy (approximately week the submucous layer of the cervix and 30) and the cervix begins to dilate sutured in place to achieve a closed cervix - Bleeding is due the inability of the placenta to stretch to accommodate the differing shape of the Herald & Mary Reviewer │Page 9 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY lower uterine segment or the cervix Continuing Care Measures - Bleeding is usually abrupt, painless, bright red, - If labor has begun, bleeding is continuing, and sudden enough to frighten a woman. or the fetus is compromised – birth must be - Bleeding may stop abruptly, or it may slow after accomplished regardless of gestational the initial hemorrhage but continue as continuous age. spotting - If the bleeding has stopped, the fetal heart - Low-lying placentas migrate upward to a sounds are of good quality, maternal vital noncervical position, the condition is explained to signs are good, and the fetus is not yet 36 a woman, and she is cautioned to avoid coitus, to weeks of age – managed by expectant get adequate rest, and to call her health care waiting provider at any sign of vaginal bleeding - A woman remains in the hospital on bed rest for close observation for 48 hours Therapeutic Management - Betamethasone, a steroid that hastens Emergency situation fetal lung maturity, may be prescribed for - risk of hemorrhage, fetal oxygen is the mother to encourage the maturity of compromised and preterm labor fetal lungs is the fetus is less than 34 weeks gestation. Immediate Care Measures - Place woman immediately on bed rest in a PREMATURE SEPARATION OF THE PLACENTA side-lying position. Be sure to assess: (ABRUPTIO PLACENTAE) Duration of pregnancy - Problem in which the placenta separates too Time the bleeding began early from the wall of the uterus. Woman’s estimation of the amount - In a normal pregnancy, the placenta stays firmly of blood-ask her to estimate in terms attached to the inside wall of the uterus until after of cups or tablespoons (a cup is 240 the baby is born. ml; a tablespoon is 15 mL) - In placenta abruptio, the placenta breaks away Whether there was accompanying (abrupts) from the wall of the uterus too early, pain before the baby is born Color of the blood (red blood indicates bleeding is fresh or is continuing) What she has done for the bleeding (if she inserted a tampon to halt the bleeding, there may be hidden bleeding) Whether there were prior episodes of bleeding during the pregnancy Whether she had prior cervical surgery for premature cervical dilatation Inspect perineum for bleeding. Estimate the present rate of blood Symptoms loss Call your doctor right away if: Weigh perineal pads before and after use - Have light to moderate bleeding from the and calculate the difference vagina Never attempt a pelvic or rectal - Have a painful or sore uterus. It might also examination with painless bleeding late in feel hard or rigid pregnancy (may initiate massive - Couvelaire uterus – hard, boardlike uterus hemorrhage) with no apparent or minimally apparent Obtain baseline vital sign bleeding Continue to assess blood pressure every 5 - Have signs of early labor. These include to 15 minutes regular contractions and aches or pains in Intravenous infusion using a large-gauge the lower back or belly catheter - Notice that that the baby is moving less Monitor input and output, as often as every than usual hour - You can't really tell how serious placenta Monitor fetus and uterine contractions abruptio is by the amount of vaginal Blood exam bleeding. Sometimes the blood gets If the previa is under 30% by ultrasound, trapped between the placenta and the wall vaginal birth is feasible of the uterus. So, there might be a serious If over 30%, and the fetus is mature, problem even if there is only a little cesarean birth is the choice. bleeding. Herald & Mary Reviewer │Page 10 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 27, 2025 COMPLICATIONS OF PREGNANCY Call 911 or emergency services right away if Risk Factors there is: - Dehydration - Sudden or severe pain in the abdomen. - Urinary tract infection - Severe vaginal bleeding, such as a gush of - Periodontal disease blood or passing a clot. - Chorioamnionitis - Any symptoms of shock. These include - African American women feeling lightheaded or like you are going - Adolescents faint; feeling confused, restless, or weak; - Inadequate prenatal care feeling sick to your stomach or vomiting; - Strenuous jobs and having fast, shallow breathing. - Shift work that causes fatigue - In rare cases, symptoms of shock are the - Women of small stature and the husband is only signs of a serious problem. overweight - Intimate partner abuse Symptoms - Persistent, dull, low backache - Vaginal spotting - A feeling of pelvic pressure or abdominal tightening - Menstrual-like cramping - Increased vaginal discharge - Uterine contractions - Intestinal cramping Therapeutic Management Therapeutic Management - Assess presence of fetal fibronectin, a protein - Intravenous fluid replacement with a large-gauge produced by trophoblast cell. catheter If present in vaginal mucus, preterm - Oxygen by mask to prevent fetal anoxia contractions are ready to occur - Monitor fetal heart sounds and maternal vital Absence of the protein predicts the labor signs every 5 to 15 minutes will not occur for at least 14 days. - Lateral or side-lying position - Do not perform any abdominal, vaginal, or pelvic - Intravenous fluid therapy to keep the woman examination hydrated - Vaginal and cervical cultures and a clean-catch urine sample are obtained to rule out infection. - Antibiotic is started if there is an infection. - Tocolytic agent, an agent to halt labor, such as terbutaline may be prescribed. - Drug Administration: If the pregnancy is under 34 weeks, a woman may be given a steroid to attempt to hasten fetal lung maturity: ▪ Betamethasone 1.2 mg IM every 24 hrs x 2 doses (preferred as it leads to lower rates of respiratory distress syndrome or bronchopulmonary dysplasia in newborns PRETERM LABOR ▪ Dexamethasone 6 mg IM every 12 - Labor that occurs before the end of week 37 of hrs x 4 doses gestation. it takes about 24 hours for betamethasone - Occurs approximately 9% to11% of all to have an effect, so it is important labor be pregnancies. halted for at least this long - It is responsible for almost two-thirds of all infant The effect lasts approximately 7 days deaths in the neonatal period. - Any woman having persistent uterine contractions (four every 20 minutes) or 80% ────── END ────── cervical effacement or 1 cm dilated should be considered to be in labor - Preterm labor is always serious because it results in the infant’s birth, the infant will be immature Herald & Mary Reviewer │Page 11 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 28, 2025 EMERGENCIES DURING LABOR OUTLINE: Hydramnios (excess amniotic fluid) I. Prolapse Umbilical Cord Medical Treatment II. Uterine Rupture - First action is to displace the fetus upward to stop A. Complete Rupture compression against the pelvis B. Incomplete Rupture Maternal positions such as knee-chest, C. Dehiscence Trendelenburg can accomplish the III. Uterine Inversion displacement IV. Amniotic Fluid Embolism Side-lying with hips elevated on pillows The experienced physician may push the PROLAPSE UMBILICAL CORD fetus upward from the vagina - The umbilical cord prolapses if it slips downward - Oxygen and a tocolytic drug such as terbutaline after the membranes have ruptured may be indicated - In this position it can be compressed between the fetal head and the woman’s pelvis, interrupting blood supply to and from the placenta - The primary focus is to deliver the fetus by the quickest possible means, usually cesarean delivery Classification Nursing Care - Monitor FHT regularly - Position client to promote relief of compression - In addition to prompt corrective actions and assisting with emergency procedures, the nurse should remain calm to avoid the woman's anxiety - After birth, help the woman understand the experience UTERINE RUPTURE - A tear in the uterine wall occurs if the muscle cannot withstand the pressure inside the organ Risk Factors - It is more likely if the fetus does not fill completely the space in the pelvis or if fluid pressure is great when the membranes rupture like: Fetus is high in the pelvis when the membranes rupture (presenting part is not engaged) COMPLETE RUPTURE Very small fetus, as in prematurity - There is a hole through the uterine wall, from the Abnormal presentations, such as uterine cavity to the abdominal cavity footling breech or transverse lie Herald & Mary Reviewer │Page 12 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 28, 2025 EMERGENCIES DURING LABOR Low transverse uterine incision is least likely to rupture - Grand multiparity - Intense labor contractions, oxytocin stimulation - Blunt abdominal trauma Characteristics - The woman may have no symptoms, or she may have sudden onset of severe signs and symptoms, such as: Shocked caused by bleeding into the abdomen (vaginal bleeding may be INCOMPLETE RUPTURE minimal) - The uterus tears into a nearby structure, such as Abdominal pain, pain in the chest, between a ligament, but not all the way into the abdominal the scapula or with inspiration cavity Cessation of contractions Abnormal or absent fetal heart tones Palpitations of the fetus outside the uterus Medical Management - Surgery - Hysterectomy for extensive tear while small tears can be surgically repaired Nursing Care - Monitor closely clients receiving oxytocin or in trial labor for VBAC - Monitor client’s vital signs - Place in Trendelenburg if in shock (rising pulse rate and falling blood pressure - Notify physician immediately UTERINE INVERSION - Occurs if the uterus turns inside out after the infant is born - May be partial or complete - A small depression in the top of the uterus is not in the abdomen and protrudes from the vagina with its inner surface showing is a common manifestation - Rapid onset of shock is common DEHISCENCE - An old uterine scar, usually from a cesarean birth, separates Risk Factors - Women with previous surgery on the uterus Classical incision prone to rupture Herald & Mary Reviewer │Page 13 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 28, 2025 EMERGENCIES DURING LABOR Causes - Uterus is not firmly contracted, and health care Treatment Includes provider pulls the cord to deliver the placenta - Providing respiratory support with intubation and - Vigorous fundal massage when the uterus is not mechanical ventilation as necessary firm and is pushed downward toward the pelvis - Treating shock with electrolytes and volume expanders - Replacing coagulation factors such as platelets and fibrinogen - Packed RBC are sometimes given intravenously Nursing Care - Assist in the above treatment - Monitor intake and output - Monitor oxygen saturation Medical Management - Physician will try to replace the inverted uterus while the woman is under general anesthesia - After the uterus is replaced, oxytocin is given to contract the uterus and control bleeding - If replacement is unsuccessful, hysterectomy is indicated Nursing Care - Assess client’s uterus at least every 15 minutes for firmness, height and deviations (the lower uterus is supported every assessment) - Monitor vital signs and signs of bleeding - An indwelling catheter may be used to keep bladder empty so that the uterus will contract well Assess patency - Provide emotional support AMNIOTIC FLUID EMBOLISM ────── END ────── - Occurs when amniotic fluid, with its particles such as vernix, fetal hair and sometimes meconium, enters the woman’s circulation and obstructs small blood vessels in the lungs - Likely to occur during a very strong labor because the fluid is “pushed” into small blood vessels that rupture as the cervix dilates. - Characterized by abrupt onset of hypotension, respiratory distress, and coagulation abnormalities triggered by the thromboplastin contained in the amniotic fluid Herald & Mary Reviewer │Page 14 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 28, 2025 POSTPARTUM COMPLICATIONS OUTLINE: - Certain medicines that significantly reduce heart I. Shock function or blood pressure. II. Hemorrhage A. Hypovolemic Shock HEMORRHAGE B. Anemia - Traditionally defined as blood loss greater than C. Early Postpartum Hemorrhage 500 ml after vaginal birth or 1000ml after i. Uterine Atony cesarean delivery - Early postpartum hemorrhage – occurs within 4 ii. Genital Trauma hrs after delivery iii. Hematomas of the - Late postpartum hemorrhage – occurs after 24 Reproductive Tract hrs up to 6 weeks after delivery D. Late Postpartum Hemorrhage - Major risk is hypovolemic shock III. Other Complications A. Thromboembolic Disorder HYPOVOLEMIC SHOCK B. Heart Disease - Occurs when the volume of blood is depleted C. Anemia and cannot fill the circulatory system D. Blood Incompatibility Between the - The woman can die if blood loss does not stop Pregnant Woman and Fetus and the blood volume is not corrected i. ABO Incompatibility - Body’s response to hypovolemia ii. RH (RHESUS) Incompatibility Initially, increased heart rate and IV. Effects Of High-Risk Pregnancy on the respiratory rate – increases the oxygen Family content and more quickly circulate the V. Noninvasive Technologies in the Future remaining blood (compensatory of Prenatal Care mechanism) The first blood pressure change is narrow SHOCK pulse pressure (a falling systolic pressure - Is a condition in which the cardiovascular and a rising diastolic pressure) – the BP system fails to provide essential oxygen and continues falling and eventually cannot be nutrients to the cells. Many organs can be detected damaged as a result. - Shock is a life-threatening condition that occurs - Blood flow to essential organs gradually stops when the body is not getting enough blood flow. to make more blood available for vital organs (heart and brain) – causing skin and mucous Main Types of Shock membrane to become pale, cold and clammy Cardiogenic shock - As blood loss continues, flow to the brain - caused by pulmonary embolism, anemia, decreases, resulting in mental changes, such as hypertension or cardiac disorders anxiety, confusion, restlessness and lethargy - As blood flow to kidney decreases, they respond Hypovolemic shock by conserving fluid – urine output decreases - caused by postpartum hemorrhage or and eventually stops blood clotting disorders Medical Management Anaphylactic shock - Stopping the blood loss - caused by allergic responses to drugs - IV fluids to maintain the circulating volume and administered replace fluids - Giving blood transfusions to replace lost RBC Septic shock - Giving oxygen to increase the saturation of - caused by puerperal infection remaining blood cells - Placing an indwelling catheter to assess urine Neurogenic shock output, which reflects kidney function - caused by damage to the nervous system. Medical Management - Assess VS every 15 mins until stable Causes - Routine frequent assessment of lochia in the - Heart problems such as heart attack or heart fourth stage of labor helps to identify early failure postpartum hemorrhage - Low blood volume as with heavy bleeding or When the amount of lochia is normal and dehydration the uterus in firm but signs of - Changes in blood vessels as with infection or hypovolemia is evident, the cause may be severe allergic reactions a large hematoma Herald & Mary Reviewer │Page 15 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 28, 2025 POSTPARTUM COMPLICATIONS Excessive bright red bleeding despite a Blood loss is usually bright red than lochia firm fundus may indicate a cervical or and flows in a continuous trickle vaginal laceration Uterus is firm Occurrence of petechiae, bleeding from venipuncture sites or oliguria may Treatment indicate a blood clotting problem - Notify physician for suturing - In the first hour postpartum the perineal pad Nursing Care should be weighed to determine the output - Report s/s of bleeding amount (1g=1ml) - Keep client on NPO - I and O should be recorded and IV therapy monitored HEMATOMAS OF THE REPRODUCTIVE TRACT - Careful explanation to the mother and provide - Collection of blood within the tissues emotional support - Usually on the vulva or inside the vagina - Seen as a bluish or purplish mass ANEMIA - Severe discomfort that analgesics do not relieve - Occurs after hemorrhage because of the lost RBC Treatment - The woman may feel dizzy or light-headed and - Small hematomas usually resolve without is likely to faint, especially in charging position treatment quickly - Larger ones may require incision and drainage - Difficulty in meeting needs due to less tissue of the clots perfusion - Bleeding vessel is ligated or the area is packed - Iron supplements are prescribed to provide with a hemostatic material to stop the bleeding adequate amounts of this mineral for manufacturer of RBC Nursing Care - Ice pack is sufficient for small hematomas EARLY POSTPARTUM HEMORRHAGE - Keep on NPO until the physician has examined Results from one of the following: the client Uterine Atony LATE POSTPARTUM HEMORRHAGE - Lack of normal muscle tone of the uterus - Usually occurs after discharge from the hospital - Caused by uterine overdistention, retained and usually results from: placental fragments, prolonged labor, full Retention of placental fragments bladder, or use of drugs during labor that relaxes Subinvolution of the uterus the uterus - Characteristics: Treatment Uterus is difficult to feel or boggy - Administration of oxytocin, methergine or Fundal height is often high (above prostaglandins umbilicus) - Dilation and curettage Lochia is increased and may contain large clots Nursing care - Watch for s/s of shock Medical and Nursing Management - Instruct client to report the following: Massage a boggy uterus Persistent bright red bleeding For bladder distention: let client void or Return of red bleeding after it has catheterization changed to pinkish or white. Let infant suck breast to stimulate contraction OTHER COMPLICATIONS Oxytocin or methergine are often indicated Correct the cause of bleeding THROMBOEMBOLIC DISORDER Hysterectomy, through rare, is needed if - A venous thrombosis is a blood clot within the other measures do not correct it vein Should be kept in NPO until bleeding stops - The size of clot increases as more blood passes it and deposits more platelets, fibrin and cells General Trauma - Often causes inflammation in the blood vessel walls - Lacerations of the reproductive tract (perineum, - A pregnant client is at risk because of the vagina, cervix or area around the urethra) compression of the blood vessels by the heavy Likely to occur if there is rapid labor, uterus by pressure behind the knees when the forceps or vacuum delivery legs are placed in the stirrup, or by blood vessel Herald & Mary Reviewer │Page 16 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 28, 2025 POSTPARTUM COMPLICATIONS injury during cesarean section HEART DISEASE - Normally, the levels of fibrinogen and other - Affects a small percentage of pregnant women clotting factors, increase during pregnancy, - During a normal pregnancy, the increase in heart whereas levels of clot-dissolving factors rate, blood volume and cardiac output places a decrease -> causing a state of physiological strain on the heart that may not be hypercoagulability tolerated in a woman with preexisting heart - If the woman has varicose veins or remains in disease bed rest her state of hypercoagulability places - Cardiac failure can occur prenatally, during labor her at an increased risk for thrombus formation or in the postpartum period Types Classifications Superficial Vein Thrombosis (SVT) Class I - involves the saphenous vein of the lower - no limitation of physical activity leg and is characterized by a painful, hard, reddened, warm vein that is easily seen Class II - slight limitation of physical activity; Deep Vein Thrombosis (DVT) ordinary activity causes fatigue, - can involve veins from the feet to the palpitation, dyspnea or angina femoral area and is characterized by pain, calf, tenderness, leg edema, color Class III changes, pain when walking, and - moderate to marked limitation of physical sometimes a positive Homan’s sign activity; less than ordinary causes fatigue, etc. Pulmonary Embolism (PE) - occurs when the pulmonary artery is Class IV obstructed by a blood clot that breaks off - unable to carry on any activity without (embolism) and lodges in the lungs experiencing discomfort. - It may have a dramatic s/s such as sudden chest pain, cough, dyspnea, Assessment decreased level of consciousness and - Clinical manifestation: signs of heart failure Thrombosis- due to increased clotting factor Treatment Due to the increased demands of - SVT is treated with analgesics, local application pregnancy, the woman’s heart may not of heat, and elevation of the legs to promote meet theses and s/s of congestive heart venous drainage failure may occur. - DVT is treated similarly with the addition of SQ ▪ Persistent cough, often with or IV anticoagulants expectoration of mucus that may - Clients PE is transferred to the ICU for be blood-tinged observation ▪ Moist lung sounds because of fluids in the lungs Nursing Care ▪ Fatigue or fainting on exertion - Prevention of thrombi is important: ▪ Orthopnea Pregnant woman should not cross their ▪ Severe pitting edema of the lower legs because it impedes blood flow extremities or generalized edema If elevated, no pressure or sharp flexion of ▪ Palpitations legs so as not to impede blood flow ▪ Changes in FHT indicating hypoxia Encourage early ambulation or ROM or growth restriction if placental during postpartum period blood flow is reduced Antiembolic stockings are indicated if varicose veins are present - During labor, each contraction temporarily shifts Place padding in stirrups during delivery 300-500 ml of blood from the uterus and placenta to the woman’s circulation, possibly - If in anticoagulant therapy: overloading her weakened heart Teach s/s of excess anticoagulation such - Excess interstitial fluid rapidly returns to the as prolonged bleeding from minor injuries, circulation after birth, predisposing the woman bleeding gums, nosebleeds and to circulatory overload during the postpartum unexplained bruising period Use a soft toothbrush and avoid minor traumas Herald & Mary Reviewer │Page 17 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 28, 2025 POSTPARTUM COMPLICATIONS Treatment not used due to fetal complications - Usually under the care of an obstetrician and a ▪ Beta adrenergic - causes cardiologist fetal bradycardia, respiratory - More prenatal visits are recommended depression, and 1. DIET - Should gain enough but excessive hypoglycemia weight gain is avoided because it adds to ▪ Thiazide diuretics - has the demands of the heart harmful effects on the fetus 2. BED REST – especially after the 30th week ▪ Angiotensin-converting of gestation to ensure that pregnancy is enzyme (ACE) inhibitors – carried to term or at least 36 weeks. are contraindicated during 3. MEDICATIONS: pregnancy a) DIGITALIS b) IRON PREPARATIONS 10.Vaginal birth is preferred over cesarean ▪ Fer-in-sol/Feosol – anemia delivery because it carries less risk for should be prevented because infection or respiratory complications that the body compensates by further tax the impaired heart increasing cardiac output, 11.Forceps or vacuum extraction deliveries thus further increasing may be used to decrease the need for cardiac workload. maternal pushing 4. Classes III and IV are not put on lithotomy Nursing Care position during delivery to avoid Goal: client education on heparin therapy increasing venous return. The semi-sitting - Explain why the change of treatment if she is on position is preferred to facilitate easy warfarin therapy before the pregnancy respirations. - Teach how to administer medication 5. Anesthetic of choice is caudal anesthesia - Advise on the importance of laboratory tests, for effortless pushless and painless which include delivery. Partial thromboplastin time (PTT) Activated partial thromboplastin time REMEMBER: Gravidocardiac are not (aPTT) allowed to push with contractions (to Platelet counts prevent Valsalva maneuver which increases venous return to already - Stress the importance of reporting immediately weak, damaged heart.) s/s of heparin overdose such as: ▪ Bruising without reason 6. Ergotrate and other oxytocics, ▪ Petechiae scopolamine, diethylstilbestrol and oral ▪ Bleeding of nose and gums contraceptives are contraindicated because they cause fluid retention and Goal: to prevent developmental of CHF promote, thromboembolisation. - Teach s/s of CHF 7. Most critical period – the period - Provide rest periods immediately following delivery because – - Advise to stop activity when dyspnea is the 30%-50% increase in blood volume experienced during pregnancy will be reabsorbed into - Need to plan her diet so that she has enough the mother’s circulation in a matter of 5- calories but without gaining too much weight 10 minutes and the weak heart must - Identify stressors (because stress increases the make rapid adjustment to this change. demands on the heart) and ways to avoid them 8. Limiting of physical activity to decrease heart demand (frequent rest periods to ANEMIA strict bed rest) - Is the reduced ability of the blood to carry 9. Drug therapy includes: oxygen to the cells a) Heparin- to prevent clot formation - Hemoglobin levels lower than 10.5g/dl in the 2nd ▪ Warfarin (Coumadin) – an trimester and below 11g/dl in the 1st and 3rd anticoagulant is not used trimester indicate anemia during pregnancy because it can cause birth defects (has teratogenic Assessment effects) - Clinical manifestation: Take note that an anemic woman has b) The usual drugs to treat vague symptoms to none hypertension and arrythmias are Some s/s include: Herald & Mary Reviewer │Page 18 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 28, 2025 POSTPARTUM COMPLICATIONS ▪ Fatigue easily and have little energy BLOOD INCOMPATIBILITY BETWEEN THE ▪ Skin and mucous membrane are PREGNANT WOMAN AND FETUS pale - The placenta allows maternal and fetal blood to ▪ Shortness of breath, a pounding be close enough to exchange oxygen and waste heart, and a rapid pulse may occur products without actually mixing with severe anemia - However, small leaks that allows fetal blood to enter the mother’s circulation may occur during The woman who develops anemia pregnancy or when the placenta detaches from gradually has fewer symptoms than the the uterus during the third stage of labor (1-2 woman who becomes anemic abruptly drops of fetal blood may initiate antibody production) Four Anemias Are Significant During Pregnancy - No problem occurs if maternal and fetal blood Nutritional anemia types are compatible - Iron-deficiency anemia - But if the maternal and fetal blood factors differ, - Folic acid-deficiency anemia the mother’s body will produce antibodies, process is called ISOIMMUNIZATION -> these Genetic anemia antibodies will cross the placenta and destroy - Sickle cell anemia (deficient of oxygen) the foreign fetal red blood cells, process called - Thalassemia (poor hemoglobin SENSITIZATION Formation) ABO Incompatibility Treatment - Results when the mother’s blood group is Nutritional anemia type O (contains anti-A and anti-B - Iron- Iron or folic supplements antibodies) and the fetus blood type is - either type A, B or AB Genetic anemia - Milder form of isoimmunization - Treatment is geared towards preventing - Can occur in the first pregnancy complications - Does not necessarily increase in severity - with each subsequent pregnancy Nursing Care Goal: to assist on the above treatment RH (RHESUS) Incompatibility - Teach woman what foods are rich in Iron and - Happens when Rh antigens enter the folic blood of a Rh-negative mother and she Iron - meats. Chicken, liver, green, leafy produces Rh antibodies (proteins) which vegetables, whole or enriched grain crosses the placenta and destroy the Rh products, nuts, tofu, eggs, dried fruits positive RBC’s Folic acid – green leafy vegetables, - Affects the second or subsequent asparagus, green beans, fruits, whole pregnancies, rarely the first pregnancy, grains, liver, legumes, yeast and severity of disorder progresses if treatment is not made - Teach also woman how to absorb iron more in the diet Assessment Although milk is beneficial in pregnancy, Diagnostic: it should not be taken at the same time Prenatal screening witH iron supplement because the iron ▪ Indirect Coomb’s test – performed on the will not be absorbed easily mother’s serum to measure the number Foods high in Vitamin C may enhance of Rh (+) antibodies (critical level is absorption usually defined as greater than titer of Do not take antacids with iron 1:8) - ANTIBODY rescreening is usually - Inform woman that iron makes the stool dark done at 24, 28 and 32 weeks AOG green to black in color and that mild to detect any developing gastrointestinal discomfort may occur sensitization during the pregnancy - For women with sickle cell anemia, they should prevent dehydration and activities that may ▪ Obtain prenatal history – check to see if cause hypoxia mother has had previous abortions, - For women with thalassemia, they are taught to pregnancies terminated beyond eight situations in which infections are more likely weeks or has received a blood transfusion and to report any s/s of infection immediately ▪ Post delivery detection Herald & Mary Reviewer │Page 19 of 21 C NCM 109: MATERNAL & CHILD NURSING WEEK 2 Ma’am Agnes Candelaria│January 28, 2025 POSTPARTUM COMPLICATIONS - Direct Coomb’s test - reveals Financial Difficulties presence of maternal antibodies - Women may stop from working attached to RBCs of an Rh(+) infant - Medical costs are rising o Umbilical cord blood is - Social service referrals may help the obtained family cope with their expenses o If titer is 1:64, indicates extreme degree of hemolytic Delayed Attachment to The Infant disease - Pregnancy normally involves gradual acceptance of and emotional attachment Other fetal tests include: to the fetus - Hemoglobin and hematocrit may be - The woman with high-risk pregnancy may decreased stop planning for the child and may - Increased reticulocyte count withdraw emotionally to protect herself - Elevated bilirubin from pain and loss if the outcome is poor. Clinical Manifestation Loss of Expected Birth Experience - The woman has no obvious effects - Couples rarely anticipate problems when - Increased levels of these antibodies are present they begin a pregnancy in antibody titers - Most have specific expectations about - Results to erythroblastosis fetalis (fetal how their pregnancy, particularly the birth, hemolysis) – depends of severity will proceed - At high-risk pre