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BACHELOR OF SCIENCE IN NURSING:
CARE OF MOTHER AND CHILD AT RISK OR
WITH PROBLEMS (ACUTE AND CHRONIC):
OBSTETRIC NURSING
COURSE MODULE COURSE UNIT WEEK
High-Risk Pregnant Client
Read course and unit objectives
Read study guide prior to class attendance
Read required learning resources; refer to unit
terminologies for jargons
Proactively participate in online discussions
Participate in weekly discussion board (Canvas)
Answer and submit course unit tasks
At the end of this unit, the students are expected to: Cognitive:
1. Define high-risk pregnancy, including pre-existing factors that contribute to its development.
2. Determine assessment methods and care for continuing prenatal visit.
- Assess a woman with an illness during pregnancy for changes occurring in the illness because of the pregnancy or the pregnancy because of the illness. Affective:
- Listen attentively during class discussions
- Demonstrate tact and respect of other students’ opinions and ideas.
- Accept comments and reactions of classmates openly. Psychomotor:
- Participate actively during class discussions.
- Follow Class rule and apply Netiquettes.
- Integrate knowledge of high-risk pregnancy and nursing process to achieve quality maternal and child health nursing care Adele Pilliteri, JoAnne Silbert-Flagg. (2018). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. (8 th Ed.). Ricci, Susan Scott Essentials of Maternity, Newborn, and Women's Health Nursing (4th Ed.) RA 9262: the Anti-Violence Against Women and their Children Act of 2004 | Philippine Commission on Women (pcw.gov.ph) Republic Act 9262: Anti-Violence Against Women and their Children This law refers to any act or a series of acts committed by an intimate partner (husband, ex-husband, live-in partner, boyfriend/girlfriend, fiance, who the woman had sexual/dating relationship):
- against a woman who is his wife, former wife.
- against a woman with whom the person has or had a sexual or dating relationship,
- against a woman with whom he has a common child.
- against her child whether legitimate or illegitimate within or without the family abode, Of which results in or is likely to result in physical, sexual, psychological arm or suffering or economic abuse including threats of such acts, battery, assault, coercion, harassment or arbitrary deprivation of liberty.
- Physical Violence – acts that include bodily or physical harm to a woman or her child (battery) o Causing/ threatening/ attempting to cause physical harm to the woman or her child. o Placing the woman or her child in fear of imminent physical harm
- Sexual Violence – the acts which are sexual in nature committed against a woman or her child. It includes, but is not limited to: o Rape, sexual harassment, acts of lasciviousness, treating a woman or her child as a sex object, making demeaning and sexually suggestive remarks, physically attacking the sexual parts of the victim’s body, forcing him or her to watch obscene publications and indecent shows or forcing the woman or her child to do indecent acts and/ or make films thereof, forcing the wife and mistress/ lover to live in the conjugal home or sleep together in the same room with the abuser. o Causing or attempting to make the woman or her child to perform sexual acts (that do not constitute
3. Permanent Protection Order (PPO) refers to the protection order issued by the court after notice and
hearing. The court shall not deny the issuance of protection order based on the lapse of time between the act of violence and the filing of the application. PPO shall be effective until revoked by the court upon
application of the person in whose favor it was issued.
High Risk Pregnancies When a woman enters pregnancy with a chronic condition such as vascular disease of kidney disease, both she and the fetus can be at risk for complications because either the pregnancy can complicate the disease or the disease can complicate the pregnancy, affecting the baby or leaving a woman less equipped to function in the future or undergo a future pregnancy. High-risk pregnancy is one in which a concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the mother, the fetus, or both. Remembering the term “high-risk” rarely refers to just one causative factor helps in the planning of holistic and ultimately effective nursing care growth was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. Risk Factors Any findings that suggest the pregnancy may have a negative outcome, for either the woman or her unborn child.
Assessments and Care for Continuing Prenatal Visits
Health Interview • Interim history or new personal or family
developments since last visit
- Review danger signs of pregnancy
- Review symptoms of beginning labor
Physical examination • Blood pressure (every visit)
- Clean-catch urine for glucose, protein, and
leukocytes (every visit)
- Blood serum level for alpha-fetoprotein (MSAFP)
(16 weeks)
- VDRL test for syphilis if possibility of new exposure
- Glucose screen (28 weeks)
- Glucose challenge (24–28 weeks) if warranted
- Anti-Rh titer (28 weeks)
- Group B streptococci (GBS) (35–37 weeks)
Fetal Health • Fetal heart rate
Assessments That Might Categorize a Pregnancy as “at Risk”
1. Obstetric History
- History of subfertility
- Previous premature cervical dilatation
- Existing uterine or cervical anomaly
- Previous preterm labor or preterm birth or cesarean birth
- Previous macrosomic infant
- Two or more spontaneous miscarriages or therapeutic abortions
- Previous hydatidiform mole
- Previous ectopic pregnancy or stillborn/neonatal death
- Previous multiple gestation
- Previous prolonged labor
- Previous low-birth-weight infant
- Previous midforceps birth
- Last pregnancy less than 1 year
- Previous infant with neurologic deficit, birth injury, or congenital anomaly
2. Medical History
- Cardiac or pulmonary disease, chronic hypertension
- Metabolic disease such as diabetes mellitus
- Renal disease, recent urinary tract infection, or bacteriuria
- Gastrointestinal disorders
- Seizure disorders
- Family history of severe inherited disorders
- Surgery during pregnancy
- Emotional disorder or cognitive challenge
- Previous surgeries, particularly
- involving reproductive organs
- Endocrine disorders such as hypothyroidism
- Hemoglobinopathies
- Sexually transmitted infections
- Reproductive tract anomalies, history of abnormal Pap smear, malignancy
3. Psychosocial Factors
- Inadequate finances
- Lack of support person
- Adolescent
- Poor nutrition
- Fundal height
- Quickening or fetal movement
- Ultrasound dating of pregnancy
Screening Procedures :
- Ultrasonography Ultrasonography, which measures the response of sound waves against solid objects. During an ultrasound, intermittent sound waves of high frequency (above the audible range) are projected toward the uterus by a transducer placed on the abdomen or in the vagina. The sound frequencies that bounce back can be displayed on an oscilloscope screen as a visual image. The frequencies returning from tissues of various thicknesses and properties present distinct appearances. A permanent record, such as a video or photograph, can be made of the scan. It can be used to:
- Diagnose pregnancy as early as 6 weeks’ gestation
- Confirm the presence, size, and location of the placenta and amniotic fluid
- Establish that a fetus is growing and has no gross anomalies, such as hydrocephalus, anencephaly, or spinal cord, heart, kidney, and bladder defects
- Establish sex if a penis is revealed
- Establish the presentation and position of the fetus
- Predict maturity by measurement of the biparietal diameter of the head Ultrasonography can also be used to discover complications of pregnancy, such as the presence of an intrauterine device, hydramnios or oligohydramnios, ectopic pregnancy, missed miscarriage, abdominal pregnancy, placenta previa, premature separation of the placenta, coexisting uterine tumors, multiple pregnancy, or genetic disorders such as Down syndrome. Fetal anomalies such as neural tube disorders, diaphragmatic hernia, or urethral stenosis also can be diagnosed. Fetal death can be revealed by a lack of heartbeat and respiratory movement. After birth, an ultrasound may be used to detect a retained placenta or poor uterine involution in the new mother.
- Biparietal Diameter – used to predict fetal maturity by measuring the biparietal diameter of the fetal head.
- Doppler Umbilical Velocimetry (Doppler ultrasonography) – measures the velocity at which RBCs in the uterine and fetal vessels travel. Assessment of the blood flow through uterine blood vessels
Age < 16 Poor nutrition
Poor antenatal care
risk preeclampsia
risk cephalopelvic
disproportion
Low birth weight
fetal demise
Age > 35 risk preeclampsia
risk cesarean birth
congenital anomalies
chromosomal aberrations
Smoking one pack/day or
more
risk hypertension
risk cancer
↓ placental perfusion → ↓O
and nutrients available low
birth weight
IUGR
Preterm birth
Use of addicting drugs risk poor nutrition
risk of infection with IV drugs
risk HIV, hepatitis C
risk congenital anomalies
risk low birth weight
neonatal withdrawal
lower serum bilirubin
Excessive alcohol
consumption
poor nutrition
Possible hepatic effects with
long term consumption
risk fetal alcohol syndrome
is helpful to determine the vascular resistance present in women with diabetes or hypertension of pregnancy and whether resultant placental insufficiency is occurring. Because it will limit the number of nutrients that can reach the fetus, decreased velocity is an important predictor of poor neonatal outcome.
- Placental Grading - Based particularly on the amount of calcium deposits in the base of the placenta, placentas can be graded by ultrasound as 0 (a placenta 12–24 weeks), 1 (30–32 weeks), 2 (36 weeks), and 3 (38 weeks). Because fetal lungs are apt to be mature at 38 weeks, a grade 3 placenta suggests that the fetus is mature.
- Amniotic Fluid Volume Assessment - The amount of amniotic fluid present is yet another way to estimate fetal health because a portion of the fluid is formed by fetal kidney output. If a fetus is becoming stressed in utero so that circulatory and kidney functions are failing, urine output and, consequently, the volume of amniotic fluid also will decrease. A decrease in amniotic fluid volume puts the fetus at risk for compression of the umbilical cord and interference with nutrition.
- Electrocardiography Fetal ECGs may be recorded as early as the 11th week of pregnancy. The ECG is inaccurate before the 20th week, however, because until this time fetal electrical conduction is so weak that it is easily masked by the mother’s ECG tracing. It is rarely used unless a specific heart anomaly is suspected.
- Magnetic Resonance Imaging Magnetic resonance imaging (MRI) also may be used to assess the fetus. Because the technique apparently causes no harmful effects to the fetus or woman, MRI has the potential to replace or complement ultrasonography as a fetal assessment technique. It may be most helpful in diagnosing complications such as ectopic pregnancy or trophoblastic disease, because later in a pregnancy fetal
movement (unless the fetus is sedated) can obscure the findings.
- Maternal Serum Alpha-Fetoprotein AFP is a substance produced by the fetal liver that is present in both amniotic fluid and maternal serum. The level is abnormally high in maternal serum (MSAFP) if the fetus has an open spinal or abdominal defect such as spina bifida or omphalocele, because the open defect allows more AFP to enter the mother’s circulation. MSAFP levels begin to rise at 11 weeks’ gestation and then steadily increase until term. Traditionally assessed at the 15th week of pregnancy, between 85% and 90% of neural tube defects and 80% of Down syndrome babies can be detected by this method.
- Triple Screening Triple screening, or analysis of three indicators (MSAFP, unconjugated estriol, and hCG), may be performed in place of simple AFP testing to yield even more reliable results. As with the measurement of MSAFP, it requires only a simple venipuncture of the mother.
- Chorionic Villi Sampling Chorionic villi sampling (CVS) is a biopsy and chromosomal analysis of chorionic villi that is done at 10 – 12 weeks of pregnancy. Coelocentesis (transvaginal aspiration of fluid from the extraembryonic cavity) is an alternative method to remove cells for fetal analysis.
- Amniocentesis Amniocentesis (from the Greek amnion for “sac” and kentesis for “puncture”) is the aspiration of amniotic fluid from the pregnant uterus for examination. The procedure can be done in a physician’s office or in an ambulatory clinic. It is typically scheduled between the 14th and 16th weeks of pregnancy to allow for a generous amount of amniotic fluid to be present. The technique can be used again near term to test for fetal maturity.
- Percutaneous Umbilical Blood Sampling PUBS (also called cordocentesis or funicentesis) is the aspiration of blood from the umbilical vein for analysis. After the umbilical cord is located by ultrasound, a thin needle is inserted by amniocentesis technique into the uterus and is guided by ultrasound until it pierces the umbilical vein.
degree of attachment to the myometrium is present. After week 12, the attachment is penetrating and deep. Because of the degrees of attachment achieved at different weeks of pregnancy, it is important to attempt to establish the week of the pregnancy at which bleeding has become apparent. Bleeding before week 6 is rarely severe; bleeding 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 separates. Uterine contractions then help to control placental bleeding as it does postpartally. For some women, then, the stage of attachment between weeks 6 and 12 can lead to the most severe, even life- threatening, bleeding. Causes of Spontaneous Abortion:
- Abnormal fetal formation (teratogenic factor/ chromosomal aberration)
- Immunologic factors
- Implantation abnormalities
- Failure of the corpus luteum to produce progesterone
- Systemic infection
- Ingestion of teratogenic drug
- Ingestion of alcohol at time of conception Assessment
- Vaginal spotting/ bleeding
- Description of the bleeding
- History of bleeding episode
- Actions taken by the pregnant woman before and during the episode of bleeding Types of Abortion
- Threatened abortion
- Symptoms begin as vaginal bleeding, initially only scant and usually bright red. A woman may notice slight cramping, but no cervical dilatation is present on vaginal examination.
- A woman with an apparent threatened miscarriage may be asked to come to the clinic or office to have fetal heart sounds assessed or an ultrasound performed to evaluate the viability of the fetus.
- Blood for human chorionic gonadotropin hormone (hCG) may be drawn at the start of bleeding and again in 48 hours.
- If it does not double, poor placental function is suspected. Avoidance of strenuous activity for 24 to 48 hours is the key intervention, assuming the threatened miscarriage involves a live fetus and presumed placental bleeding.
- Women are apt to be extremely worried at the sight of bleeding. They need to talk with a sympathetic, supportive person about how distressed they feel. Be certain to convey concerned assurance that miscarriages happen spontaneously, not because of anything a woman did.
- If the spotting with threatened miscarriage is going to stop, it usually does so within 24 to 48 hours after a woman reduces her activity. Once bleeding stops, she can gradually resume normal activities.
- Coitus is usually restricted for 2 weeks after the bleeding episode to prevent infection and to avoid inducing further bleeding.
- As many as 50% of women with a threatened miscarriage continue the pregnancy; for the other 50%, unfortunately, the threatened miscarriage changes to imminent or inevitable miscarriage.
- Inevitable (Imminent) Abortion
- A threatened miscarriage becomes an imminent (inevitable) miscarriage if uterine contractions and cervical dilation occur. With cervical dilation, the loss of the products of conception cannot be halted.
- A woman who reports cramping or uterine contractions is usually asked to come to the hospital.
- She should save any tissue fragments she has passed and bring them with her so they can be examined.
- If no fetal heart sounds are detected and an ultrasound reveals an empty uterus or nonviable fetus, a
physician may perform a vacuum extraction D&E to ensure that all the products of conception are removed.
- Be certain the woman has been told that the pregnancy was already lost and that all procedures are to clean the uterus and prevent further complications such as infection, not to end the pregnancy.
- Save any tissue fragments passed in the labor room, along with any brought from home, so they can be examined for an abnormality such as gestational trophoblastic disease or for assurance that all the products of conception have been removed from the uterus.
- A woman should assess vaginal bleeding by recording the number of pads she uses. Saturating more than one pad per hour is abnormally heavy bleeding.
- Complete Abortion
- In a complete miscarriage, the entire products of conception (fetus, membranes, and placenta) are expelled spontaneously without any assistance.
- The bleeding usually slows within 2 hours and then ceases within a few days after passage of the products of conception.
- Incomplete Abortion
- Part of the conceptus (usually the fetus) is expelled, but the membrane or placenta is retained in the uterus. The term “incomplete” can be confusing for women. They may interpret it to mean that because the miscarriage is incomplete, the pregnancy will continue.
- Be careful not to encourage false hopes by also misinterpreting this term.
- There is a danger of maternal hemorrhage as long as part of the conceptus is retained in the uterus because the uterus cannot contract effectively under this condition.
- The physician will usually perform a dilation and curettage (D&C) or suction curettage to evacuate the remainder of the pregnancy from the uterus.
- Missed Abortion
- Also commonly referred to as early pregnancy failure, the fetus dies in utero but is not expelled.
- A missed miscarriage is usually discovered at a prenatal examination when the fundal height is measured and no increase in size can be demonstrated or when previously heard fetal heart sounds cannot be heard.
- An ultrasound can establish the fetus has died. Often the embryo died 4 to 6 weeks before the onset of miscarriage symptoms or failure of growth was noted.
- After the ultrasound, most commonly a D&E will be done. If the pregnancy is over 14 weeks, labor may be induced by a prostaglandin suppository or misoprostol (Cytotec) to dilate the cervix, followed by oxytocin stimulation or administration of mifepristone techniques used for elective termination of pregnancy
- If the pregnancy is not actively terminated, miscarriage usually occurs spontaneously within 2 weeks.
- There is a danger of allowing this normal course to happen, however, because disseminated intravascular coagulation (DIC), a coagulation defect, may develop if the dead (and possibly toxic) fetus remains too long in utero.
- Recurrent Pregnancy Loss (Habitual Abortion)
- In the past, women who had three spontaneous miscarriages that occurred at the same gestational age were called “habitual aborters.”
- They were advised they were apparently too “nervous” or that something was so wrong with their hormones that childbearing was not for them.
- Today, the term recurrent pregnancy loss is used to describe this miscarriage pattern, and a thorough investigation is done to discover the cause of the loss and help ensure the outcome of a future pregnancy.
- Recurrent pregnancy loss occurs in about 1% of women who want to be pregnant.
- Although many losses occur for unknown reasons, possible causes include:
Approximately 2% of pregnancies are ectopic; it is the second most frequent cause of bleeding early in pregnancy. The incidence is increasing because of the increasing rate of pelvic inflammatory disease, which leads to tubal scarring. It occurs more frequently in women who smoke compared with those who do not. There is some evidence that intrauterine devices (IUDs) used for contraception may slow the transport of the zygote and lead to an increased incidence of tubal or ovarian implantation. The incidence also increases following in vitro fertilization. Women who have one ectopic pregnancy have a 10% to 20% chance that a subsequent pregnancy will also be ectopic. This is because salpingitis that leaves scarring is usually bilateral. Congenital anomalies such as webbing (fibrous bands) that block a fallopian tube may also be bilateral. For unknown reasons, oral contraceptives used before pregnancy reduce the incidence of ectopic pregnancy. There are no unusual symptoms at the time of implantation. The corpus luteum of the ovary continues to function as if the implantation were in the uterus. No menstrual flow occurs. A woman may experience the nausea and vomiting of early pregnancy, and a pregnancy test for hCG will be positive. Many ectopic pregnancies are diagnosed by an early pregnancy ultrasound. Magnetic resonance imaging (MRI) is also effective to use for this. If not revealed by an ultrasound, at weeks 6 to 12 of pregnancy (2 to 8 weeks after a missed menstrual period), the zygote grows large enough to rupture the slender fallopian tube or the trophoblast cells break through the narrow base. Tearing and destruction of the blood vessels in the tube result. The extent of the bleeding that occurs depends on the number and size of the ruptured vessels. If implantation is in the interstitial portion of the tube (where the tube joins the uterus), rupture can cause severe intraperitoneal bleeding. Fortunately, the incidence of tubal pregnancies is highest in the ampullar area (the distal third), where the blood vessels are smaller and profuse hemorrhage is less likely. However, continued bleeding from this area may, in time, result in a large amount of blood loss. Therefore, a ruptured ectopic pregnancy is serious regardless of the site of implantation. A woman usually experiences a sharp, stabbing pain in one of her lower abdominal quadrants at the time of rupture, followed by scant vaginal spotting. The amount of bleeding evident with a ruptured ectopic pregnancy often does not reveal the actual amount present, however, because the products of conception from the ruptured tube and the accompanying blood may be expelled into the pelvic cavity rather than into the uterus. With this type of rupture, blood does not reach the vagina to become evident. With placental dislodgment, progesterone secretion stops, and the uterine decidua begins to slough, causing additional bleeding. If internal bleeding progresses to acute hemorrhage, a woman may experience lightheadedness and rapid pulse, signs of shock. Any woman with sharp abdominal pain and vaginal spotting needs to be evaluated by her health care provider to rule out the possibility of ectopic pregnancy. When helping determine the possibility of an ectopic pregnancy, ask a woman whether she has pain or vaginal bleeding. Occasionally, a woman will move suddenly and pull one of her round ligaments, the anterior uterine supports. This can cause a sharp, but momentary and innocent, lower quadrant pain. However, it would be rare for this phenomenon to be reported in connection with vaginal spotting. By the time a woman with a ruptured ectopic pregnancy arrives at the hospital or physician’s office, she may already be in severe shock, as evidenced by a rapid, thready pulse, rapid respirations, and falling blood pressure. Leukocytosis may be present, not from infection but from the trauma. Temperature is usually normal. A transvaginal ultrasound will demonstrate the ruptured tube and blood collecting in the peritoneum. Either a falling hCG or serum progesterone level suggests that the pregnancy has ended. If the diagnosis of ectopic pregnancy is in doubt, a physician may insert a needle through the posterior vaginal fornix into the cul-de-sac under sterile conditions to see whether blood can be aspirated. A laparoscopy or culdoscopy can be used to visualize the fallopian tube if the symptoms alone do not reveal a clear picture of what has happened. However, ultrasonography alone usually reveals a clear-cut diagnostic picture. If a woman waits for a time before seeking help, gradually her abdomen becomes rigid from peritoneal irritation. Her umbilicus may develop a bluish tinge (Cullen’s sign). A woman may have continued extensive or dull vaginal and abdominal pain; movement of the cervix on pelvic examination may cause excruciating pain. There may be 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. An unruptured ectopic pregnancy can be treated medically by the oral administration of methotrexate followed by leucovorin. Methotrexate, a folic acid antagonist chemotherapeutic agent, attacks and destroys
fast-growing cells. Because trophoblast and zygote growth are so rapid, the drug is drawn to the site of the ectopic pregnancy. Women are treated until a negative hCG titer is achieved. A hysterosalpingogram or ultrasound is usually performed after the chemotherapy to assess whether the tube is fully patent. Mifepristone, an abortifacient, is also effective at causing sloughing of the tubal implantation site. The advantage of these therapies is that the tube is left intact, with no surgical scarring that could cause a second ectopic implantation. If an ectopic pregnancy ruptures, it is an emergency. Keep in mind the amount of blood evident is a poor estimate of the actual blood loss. A blood sample needs to be drawn immediately for hemoglobin level, typing and cross-matching, and possibly hCG level for immediate pregnancy testing, if pregnancy has not yet been confirmed. Intravenous fluid using a large-gauge catheter to restore intravascular volume is begun. Blood then can be administered through this same line when matched. The therapy for a ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. A rough suture line on a fallopian tube may lead to another tubal pregnancy, so either the tube will be removed or suturing on the tube is done with microsurgical technique. C. Gestational Trophoblastic Disease (Hydatidiform Mole) Gestational trophoblastic disease is 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 choriocarcinoma, a rapidly metastasizing malignancy. The incidence of gestational trophoblastic disease is approximately 1 in every 1500 pregnancies. The condition tends to occur most often in women who have a low protein intake, in women older than age 35 years, in women of Asian heritage, and in blood group A women who marry blood group O men. Types of Molar Growth:
- Complete Mole
- All trophoblastic villi swell and become cystic.
- If an embryo forms, it dies early at only 1 to 2 mm in size, with no fetal blood present in the villi.
- On chromosomal analysis, although the karyotype is a normal 46XX or 46XY, this chromosome component was contributed only by the father, or an “empty ovum” was fertilized and the chromosome material was duplicated.
- Partial Mole
- Some of the villi form normally.
- The syncytio-trophoblastic layer of villi, however, is swollen and misshapen. A macerated embryo of approximately 9 weeks’ gestation may be present and fetal blood may be present in the villi.
- Has 69 chromosomes (a triploid formation in which there are three chromosomes instead of two for every pair, one set supplied by an ovum that apparently was fertilized by two sperm or an ovum fertilized by one sperm in which meiosis or reduction division did not occur). This could also occur if one set of 23 chromosomes was supplied by one sperm and an ovum that did not undergo reduction division supplied 46.
- Rarely lead to choriocarcinoma.
- hCG titers are lower in partial than in complete moles; titers also return to normal faster after
technique. The sutures serve to strengthen the cervix and prevent it from dilating. In a McDonald procedure, nylon sutures are placed horizontally and vertically across the cervix and pulled tight to reduce the cervical canal to a few millimeters in diameter. With a Shirodkar technique, sterile tape is threaded in a purse string manner under the submucous layer of the cervix and sutured in place to achieve a closed cervix. Although routinely accomplished by a vaginal route, sutures may be placed by a transabdominal route. With these procedures, the sutures are then removed at weeks 37 to 38 of pregnancy so the fetus can be born vaginally. When a transabdominal approach is used, the sutures may be left in place and a cesarean birth performed. Be certain to ask women who are reporting painless bleeding (the symptoms of spontaneous miscarriage also) whether they have had past cervical operations, to remind them they may have sutures in place. After cerclage surgery, women remain on bed rest (perhaps in a slight or modified Trendelenburg position) for a few days to decrease pressure on the new sutures. Usual activity and sexual relations can be resumed in most instances after this rest period. E. Abruptio Placenta The placenta appears to have been implanted correctly. Suddenly, however, it begins to separate and bleeding results. Premature separation of the placenta occurs in about 10% of pregnancies and is the most frequent cause of perinatal death. The separation generally occurs late in pregnancy; it may occur as late as during the first or second stage of labor. Because premature separation of the placenta may occur during an otherwise normal labor, it is important always to be alert to the amount and kind of vaginal bleeding a woman is having in labor. Listen to her description of the kind of pain she is experiencing to help detect this grave complication. The primary cause of premature separation is unknown, but certain predisposing factors have been identified, including:
- High parity
- Advanced maternal age
- A short umbilical cord
- Chronic hypertensive disease, pregnancy-induced hypertension
- Direct trauma (as from an automobile accident or intimate partner abuse)
- Vasoconstriction from cocaine or cigarette use
- Thrombophilitic conditions that lead to thrombosis such as autoimmune antibodies, protein C, and factor V Leiden (a common inherited thrombophilia that occurs in 5% of whites and 1% of blacks). Premature separation of the placenta may also follow a rapid decrease in uterine volume, such as occurs with sudden release of amniotic fluid. A woman experiences a sharp, stabbing pain high in the uterine fundus as the initial separation occurs. If labor begins with the separation, each contraction will be accompanied by pain over and above the pain of the contraction. In some women, additional pain is not evident with contractions, but tenderness can be felt on uterine palpation. Heavy bleeding usually accompanies premature separation of the placenta, like placenta previa, although it may not be readily apparent. There will be external bleeding only if the placenta separates first at the edges and blood escapes freely from the cervix. If the center of the placenta separates first, blood can pool under the placenta, and although bleeding is intense, it is hidden from view. The uterus becomes tense and feels rigid to the touch. If blood infiltrates the uterine musculature, Couvelaire uterus or uteroplacental apoplexy, forming a hard, board like uterus with no apparent, or minimally apparent, bleeding present occurs. As bleeding progresses, a woman’s reserve of blood fibrinogen may be used up in her body’s attempt to
accomplish effective clot formation and disseminated intravascular coagulation (DIC syndrome) can occur. Separation of the placenta is an emergency. A woman needs a large gauge intravenous catheter inserted for fluid replacement and oxygen by mask to limit fetal anoxia. Monitor fetal heart sounds externally and record maternal vital signs every 5 to 15 minutes to establish baselines and observe progress. The baseline fibrinogen determination is followed by additional determinations up to the time of birth. Keep a woman in a lateral, not supine, position to prevent pressure on the vena cava and additional interference with fetal circulation. For better prediction of fetal and maternal outcome, the degrees of placental separation can be graded. Unless the separation is minimal (grades 0 and 1), the pregnancy must be terminated because the fetus cannot obtain. adequate oxygen and nutrients. If vaginal birth does not seem imminent, cesarean birth is the birth method of choice. If DIC has developed, cesarean surgery may pose a grave risk because of the possibility of hemorrhage during the surgery and later from the surgical incision. Intravenous administration of fibrinogen or cryoprecipitate (which contains fibrinogen) may be used to elevate a woman’s fibrinogen level prior to and concurrently with surgery. Fetal prognosis depends on the extent of the placental separation and the degree of fetal hypoxia. Maternal prognosis depends on how promptly treatment can be instituted. Death can occur from massive hemorrhage leading to shock and circulatory collapse or renal failure from the circulatory collapse. F. Premature Labor Premature Labor occurs before the end of week 37 of gestation. It occurs in approximately 9% to 11% of all pregnancies. It is responsible for almost two-thirds of all infant deaths in the neonatal period. Any woman having persistent uterine contractions (four every 20 minutes) should be in labor. A woman is documented as being in actual labor rather than having false labor contractions if she is having uterine contractions that cause cervical effacement over 80% or dilation over 1 cm. Preterm labor is always serious because if it results in the infant’s birth, the infant will be immature. It can happen for unknown reasons, but it is associated with dehydration, urinary tract infection, periodontal disease, and chorioamnionitis. Women who continue to work at strenuous jobs during pregnancy or perform shift work that leads to extreme fatigue may have a higher incidence than others. It tends to occur in pregnancies of women who were born small, but the father of their child is overweight, as if the fetus growing faster than its mother can accommodate might trigger preterm birth. Intimate partner abuse may be yet another cause. Participating in mild leisure sports activities such as walking may help prevent preterm birth. Common symptoms of early preterm labor include a persistent, dull, low backache; vaginal spotting; a feeling of pelvic pressure or abdominal tightening; menstrual-like cramping; increased vaginal discharge; uterine contractions; and intestinal cramping. Medical attempts can be made to stop labor if the fetal membranes are intact, fetal distress is absent, there is no evidence that bleeding is occurring, the cervix is not dilated more than 4 to 5 cm, and effacement is not more than 50%. Intravenous fluid therapy to keep her well hydrated is begun because hydration may help stop contractions. If a woman is dehydrated, the pituitary gland is activated to secrete antidiuretic hormone, and this may cause it to release oxytocin as well. Oxytocin strengthens uterine contractions. By keeping a woman well hydrated, therefore, the release of oxytocin may be minimized. Vaginal and cervical cultures and a clean-catch urine sample are obtained to rule out infection. If a urinary tract infection is present
minimal leakage. Occasionally, a woman mistakes urinary incontinence caused by exertion for rupture of membranes. Amniotic fluid cannot be differentiated from urine by appearance, so a sterile vaginal speculum examination is done to observe for vaginal pooling of fluid. If the fluid is tested with Nitrazine paper, amniotic fluid causes an alkaline reaction on the paper (appears blue) and urine causes an acidic reaction (remains yellow). The fluid can also be tested for ferning, or the typical appearance of a high-estrogen fluid on microscopic examination (amniotic fluid shows this; urine does not). Because preterm rupture of membranes is associated with vaginal infection, cultures for Neisseria gonorrhoeae, Streptococcus B, and Chlamydia are usually taken. Blood is drawn for white blood count and C-reactive protein, which increase with membrane rupture. Avoid doing routine vaginal examinations because the risk of infection rises significantly when digital examinations are performed after preterm rupture of membranes. If a fetus is estimated to be mature enough to survive in an extrauterine environment at the time of rupture and labor does not begin within 24 hours, labor contractions are usually induced by intravenous administration of oxytocin so the infant is born before infection can occur. If labor does not begin and the fetus is not at a point of viability, a woman is placed on bed rest either in the hospital or at home and administered a corticosteroid to hasten fetal lung maturity. Prophylactic administration of broad-spectrum antibiotics during this period may both delay the onset of labor and reduce the risk of infection in the newborn sufficiently to allow the corticosteroid to have its effect. Women positive for Streptococcus B need intravenous administration of penicillin or ampicillin to reduce the possibility of this infection in the newborn. A woman with no signs of infection may be administered a tocolytic agent if labor contraction. GESTATIONAL CONDITIONS
- Hyperemesis gravidarum Hyperemesis gravidarum (sometimes called pernicious or persistent vomiting) is nausea and vomiting of pregnancy that is prolonged past week 12 of pregnancy or is so severe that dehydration, ketonuria, and significant weight loss occur within the first 12 weeks of pregnancy. It occurs at an incidence of 1 in 200 to 300 women. The cause is unknown, but women with the disorder may have increased thyroid function because of the thyroid stimulating properties of human chorionic gonadotropin. Some studies reveal that it is associated with Helicobacter pylori, the same bacteria that cause peptic ulcers. With hyperemesis gravidarum, a woman’s nausea and vomiting are so severe that she cannot maintain her usual nutrition. She may show an elevated hematocrit concentration at her monthly prenatal visit because her inability to retain fluid has resulted in hemoconcentration. Concentrations of sodium, potassium, and chloride may be reduced because of her low intake, and hypokalemic alkalosis may result if vomiting is severe. In some women, polyneuritis, because of a deficiency of B vitamins, develops. Weight loss can be severe. Urine may test positive for ketones, evidence that a woman’s body is breaking down stored fat and protein for cell growth. If left untreated, the condition is associated with intrauterine growth restriction or preterm birth if a woman becomes dehydrated and can no longer provide a fetus with essential nutrients for growth. Always try to determine exactly how much nausea and vomiting women are having during pregnancy. Ask a woman to describe the events of the day before if she says it was a typical day. How late into the day did the nausea last? How many times did she vomit, and how much? What was the total amount of food she was able to eat? Women with hyperemesis gravidarum usually need to be hospitalized for about 24 hours to monitor intake, output, and blood chemistries and to restore hydration. All oral food and fluids are usually withheld. Intravenous fluid (3000 mL of Ringer’s lactate with added vitamin B, for example) may be administered to increase hydration. An antiemetic, such as metoclopramide (Reglan), may be prescribed to control vomiting. Throughout this period, carefully measure intake and output, including the amount of vomitus. If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid may be begun and the woman may be discharged home, usually with a referral for home care. If she can continue to
take clear fluid, small quantities of dry toast, crackers, or cereal may be added every 2 or 3 hours, then she can be gradually advanced to a soft diet, then to a normal diet. If vomiting returns at any point, enteral or total parenteral nutrition may be prescribed. Home care follow-up provides further information about the client’s status after hospital discharge.
- Pregnancy-Induced Hypertension Pregnancy Induced Hypertension Pregnancy-induced hypertension (PIH) is a condition in which vasospasm occurs during pregnancy in both small and large arteries. Signs of hypertension, proteinuria, and edema develop. It is unique to pregnancy and occurs in 5% to 7% of pregnancies. Originally it was called toxemia because researchers pictured a toxin of some kind being produced by a woman in response to the foreign protein of the growing fetus, the toxin leading to the typical symptoms. A condition separate from chronic hypertension, PIH tends to occur most frequently in women
- with a multiple pregnancy,
- primiparas younger than 20 years or older than 40 years,
- women from low socioeconomic backgrounds (perhaps because of poor nutrition),
- those who have had five or more pregnancies,
- those who have hydramnios (overproduction of amniotic fluid; refer to discussion later),
- those who have an underlying disease such as heart disease, diabetes with vessel or renal involvement, and essential hypertension. The symptoms of PIH affect almost all organs. The vascular spasm may be caused by the increased cardiac output that occurs with pregnancy and injures the endothelial cells of the arteries or the action of prostaglandins (notably decreased prostacyclin, a vasodilator, and excessive production of thromboxane, a vasoconstrictor and stimulant of platelet aggregation). Normally, blood vessels during pregnancy are resistant to the effects of pressor substances such as angiotensin and norepinephrine, so blood pressure remains normal during pregnancy. With PIH, this reduced responsiveness to blood pressure changes appears to be lost. Vasoconstriction occurs and blood pressure increases dramatically. With hypertension, the cardiac system can become overwhelmed because the heart is forced to pump against rising peripheral resistance. This reduces the blood supply to organs, most markedly the kidney, pancreas, liver, brain, and placenta. Poor placental perfusion may reduce the fetal nutrient and oxygen supply. Ischemia in the pancreas may result in epigastric pain and an elevated amylase–creatinine ratio. Spasm of the arteries in the retina leads to vision changes. If retinal hemorrhages occur, blindness can result. Typically hypertension, proteinuria, and edema are considered the classic signs of PIH. Of the three, hypertension and proteinuria are the most significant as extensive edema occurs only after the other two are present. Symptoms rarely occur before 20 weeks of pregnancy. PIH is classified as gestational hypertension, mild preeclampsia, severe pre-eclampsia, and eclampsia, depending on how far development of the syndrome has advanced.
- Gestational Hypertension A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema. Perinatal mortality is not increased with simple gestational hypertension, so no drug therapy is necessary. A woman is said to be mildly pre-eclamptic when she has proteinuria and blood pressure rises to 140/ mm Hg, taken on two occasions at least 6 hours apart. The diastolic value of blood pressure is extremely important to document because it is this pressure that best indicates the degree of peripheral arterial spasm present. A second criterion for evaluating blood pressure is a systolic blood pressure greater than 30 mm Hg and a diastolic pressure greater than 15 mm Hg above prepregnancy values. This rule is helpful, but the value of 140/90 mm Hg is a more useful cutoff point when there are no baseline data available, such as when a woman seeks prenatal care late in pregnancy.
- Mild pre-eclampsia In addition to the hypertension a woman has proteinuria (1+ or 2+ on a reagent test
