NCM 109- Maternal and Child Health Nursing focusing on at-risk, high-risk and sick clients

PRELIMS – Nursing Care of the Pregnant Client

4P’s:
• Passenger
• Passageway
• Psyche
• Powers
th
5 is the Presentation
Normal Duration of Pregnancy:
• 9 months
• 37 to 42 weeks
• 266-280 days
• 10 lunar months has a period of 4 weeks
• Before 37 weeks – preterm
• After 42 weeks – post term or post mature Between 37-42 weeks – full term
• 120-160 BPM – normal fetal heart rate 30- 40% ‒ increase in blood volume
Signs of fetal distress:
• Bradycardia – heart rate below 120 (above 160 tachycardia)
• Meconium-stained amniotic fluid – clear normal (green – meconium stained)
• Hyperactivity of the fetus – 40 or more movements perceived per hour for at least 14
days shortly before delivery. 
A. Nursing Care of the Pregnant Client
High-risk Pregnancy
is one in which a concurrent disorder, pregnancy-related complication, or external factor
jeopardizes the health of the woman, the fetus, or both.
Rarely refers to just one causative factor but includes psychological and social as well as physical
aspects helps in the planning of holistic, and ultimately effective, nursing care
Pre-pregnancy
Factors that categorize a pregnancy as high risk:

A. Psychological
• History of drug dependence
• History of intimate partner abuse
• History of mental illness
• History of poor coping mechanism
• Survivor of childhood sexual abuse
• Cognitively challenged
Pre-pregnancy
Factors that categorize a pregnancy as high risk:
B. Social
• Occupation involving handling of toxic substances (including radiation and anesthesia)
• Environmental contaminants at home
• Isolated
• Lower economic level
 • Poor access to transportation of care
• High altitude
• Highly mobile lifestyle
• Poor housing
• Lack of support people
C. Physical
• Visual or hearing challenges
• Pelvic inadequacy of misshape
• Uterine incompetency, position or structures
• Secondary major illnesses
• Poor gynecologic or obstetric history
• History of previous poor pregnancy outcom (miscarriage, stillbirth)
• History of child with congenital anomalies
• Obesity
• Pelvic inflammatory disease
• History of inherited disorder
• Small stature
• Potential of blood incompatibility
• Younger than 18 years or older than 35 years
• Cigarette smoker
• Substance abuse
ASSESSMENT
Always ask women at prenatal visits about any symptoms that might indicate a complication
such as pain or vaginal symptoms or other medical history
Discharge Color During Pregnancy
NURSING DIAGNOSIS
Nursing diagnoses pertaining to a woman with a pregnancy complication should reflect both the
physical problem and the woman’s or family’s concern. Some examples include:
1. Anxiety related to guarded pregnancy outcome
2. Fear of preterm labor ending the pregnancy
3. Anticipatory grieving related to uncertain pregnancy outcome
4. Deficient knowledge related to signs and symptoms of possible complications Risk for
infection related to incomplete miscarriage
5. Deficient fluid volume related to third-trimester bleeding
6. Risk for ineffective tissue perfusion related to gestational hypertension
OUTCOME IDENTIFICATION AND PLANNING
Treatment protocols should be regularly updated and maintained so they are current.
Be certain they reflect a current nursing management level, so nurses can act swiftly and
independently as needed with lifesaving measures.
Once a woman’s condition stabilizes, outcome identification can then focus on long-term
objectives.
IMPLEMENTATION
Continued both healthy maternal and fetal physical growth A woman’s and family’s
psychological health
Continuation of the pregnancy for as long as possible
Maintaining an optimistic attitude of fetal progress is important so a woman does not begin
anticipatory grieving for her fetus, which could halt the growth of bonding.
OUTCOME EVALUATION
Evaluate the woman and her family’s attitude and the woman’s physical status at each
healthcare visit to be certain she and her family are coping with the situation and adjusting
psychosocially.
Evaluation will then include the ability of the family to care for an ill infant or grieve if a
newborn dies.
Examples of expected outcomes include:

Patient’s blood pressure is maintained within acceptable parameters for remainder of

pregnancy.
Couple states they feel able to cope with anxiety associated with the pregnancy complication.
Patient’s signs and symptoms of hypertension of pregnancy do not progress to eclampsia.
Patient accurately verbalizes crucial signs and symptoms she should immediately report to her
primary healthcare provider.
Couple expresses feelings of sadness over pregnancy loss.
Patient is able to adhere to the medical treatment regimen and experiences no adverse effects
from the treatment.

Bleeding During Pregnancy

Vaginal bleeding during pregnancy is always a deviation from the normal, is always potentially
serious, may occur at any point during pregnancy, and is always frightening.
Process of Shock because of Blood loss
SPONTANEOUS MISCARRIAGE
Abortion - is a medical term for any interruption of a pregnancy before a fetus is viable.
Miscarriage - A fetus born before 20 to 24 weeks of gestation or one that weighs at less than
500 g. Premature or immature birth.
Early miscarriage - occurs before week 16 of pregnancy.
Late miscarriage - occurs between weeks 16 and 20.

Common Causes of Miscarriage

First trimester of pregnancy
Abnormal fetal development, due either to a teratogenic factor or to a chromosomal aberration.
In other miscarriages
Immunologic factors may be present or rejection of the embryo through an immune response
may occur.
Another common cause of early miscarriage involves implantation abnormalities, as up to 50%
of zygotes probably never implant securely because of inadequate endometrial formation or
from an inappropriate site of implantation.
Occur if the corpus luteum on the ovary fails to produce enough progesterone to maintain the
decidua basalis.
Ingestion of alcohol at the time of conception or during early pregnancy
Urinary tract infections
Systemic infections
Diagnosis
Threatened Miscarriage - vaginal bleeding, no cervical dilatation
Management
Assess fetal heart sounds
Blood may be drawn to test for human chorionic gonadotropin
Complete bed rest is usually not necessary
Coitus may be restricted for 2 weeks
Imminent (Inevitable) Miscarriage - an imminent miscarriage when uterine contractions and
cervical dilation occur as, with cervical dilation, the loss of the products of conception cannot
be halted.
Management
Save any tissue fragments
For no FHT, medical management or Dilatation and Curettage

Diagnosis
Complete Miscarriage - entire products of conception (fetus, membranes, and placenta) are
expelled spontaneously without any assistance.
Incomplete Miscarriage - part of the conceptus (usually the fetus) is expelled, but the
membranes or placenta are retained in the uterus.
Management
D&C or suction curettage
Missed Miscarriage - early pregnancy failure, the fetus dies in utero but is not expelled.
Management
D&C
Prostaglandin suppository or misoprostol
Oxytocin stimulation or administration of mifepristone techniques
Diagnosis
Recurrent Pregnancy Loss - three spontaneous miscarriages that occurred at the same
gestational age were called “habitual aborters.”
Possible causes include:
• Defective spermatozoa or ova
• Endocrine factors
• such as lowered levels of protein-bound iodine
• butanol- extractable iodine (BEI)
• globulin-bound iodine (GBI); poor thyroid function; or a luteal phase
defect
• Deviations of the uterus, such as septate or bicornuate uterus
• Resistance to uterine artery blood flow
• Chorioamnionitis or uterine infection
• Autoimmune disorders such as those involving lupus anticoagulant and
antiphospholipid antibodies (APAS) or Hughe’s Syndrome
Complications of Miscarriage
Hemorrhage
Coagulation defect
D&C
Blood transfusion
Methylergonovine Maleate
Infections - develop most often in women who have lost an appreciable amount of blood.
Organism
Escherichia coli
Complications of Miscarriage (INFECTION)
Septic Abortion - abortion complicated by infection. (toxic shock syndrome, septicemia, kidney
failure, and death
FC
Medical: penicillin (gram-positive coverage), gentamicin (gram-negative aerobic coverage), and
clindamycin (gram- negative anaerobic coverage)
Central Venous Pressure Or Pulmonary Artery Catheter
D&C or D&E
TT and Immunoglobulin
Dopamine and digitalis
Complications of Miscarriage (INFECTION)
Isoimmunization - the production of antibodies against Rh-positive blood.
Rh (D antigen) immune globulin (RhIG)
Powerlessness or Anxiety
ECTOPIC PREGNANCY
one in which implantation occurred outside the uterine cavity.
Therapeutic Management
Administration of methotrexate , until a negative hCG titer is achieved
Hysterosalpingogram or ultrasound
Laparoscopy
ABDOMINAL PREGNANCY
Rarely after ectopic pregnancy, products of conception are expelled into the pelvic cavity with a
minimum of bleeding
GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE)
Abnormal proliferation and then degeneration of the trophoblastic villi.
The condition tends to occur most often in women who have a low-protein intake, in women
older than 35 years of age, in women of Asian heritage, and in blood group A women who
marry blood group O men

Two types of Molar Growth

A 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.
Partial Mole - some of the villi form normally. The syncytiotrophoblastic layer of villi, however,
appears swollen and misshapen. The embryo may grow for about 9 weeks but then macerates;
some fetal blood may be present in the villi.
Assessment
Cells grow so rapidly, the uterus tends to expand faster than usual or the uterus reaches its
landmarks.
hCG is produced by the trophoblast cells that are overgrowing, a serum or urine test of hCG for
pregnancy will be strongly positive.
Therapeutic Management
Suction curettage to evacuate the abnormal trophoblast cells.
CERVICAL INSUFFICIENCY (PREMATURE CERVICAL DILATATION)
Premature cervical dilatation, previously termed an incompetent cervix, refers to a cervix that
dilates prematurely and therefore cannot retain a fetus until term.
Associated with:
Increased maternal age
Congenital structural defects
Trauma to the cervix
Cervical cerclage
McDonald or a Shirodkar
Approximately weeks 12 to 14, purse-string sutures are placed in the cervix by the vaginal route
under regional anesthesia.
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.
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.
PLACENTA PREVIA
A condition of pregnancy in which the placenta is implanted abnormally in the lower part of the
uterus, is the most common cause of painless bleeding in the third trimester of pregnancy
TYPES
Low-lying placenta- implantation in the lower rather than in the upper portion of the uterus.
Marginal implantation - the placenta edge approaches that of the cervical os.
Partial placenta previa - implantation that occludes a portion of the cervical os.
Total placenta previa - implantation that totally obstructs the cervical os.
Conditions Associated With Placenta Previa
Increased parity
Advanced maternal age
Past cesarean births
Past uterine curettage
Multiple gestation
Perhaps a male fetus a
Assessment
Routine sonogram done to date the pregnancy
Any sign of vaginal bleeding
Bleeding is usually abrupt, painless, bright red.
Therapeutic Management
Immediate Care Measures
Ensure an adequate blood supply to a woman and fetus, place the woman immediately on bed
rest in a side-lying position
Inspect the perineum for bleeding and estimate the present rate of blood loss.
Baseline vital signs
Never attempt a pelvic or rectal examination with painless bleeding late in pregnancy
Attach external monitoring equipment to record fetal heart sounds and uterine contractions.
Attach external monitoring equipment to record fetal heart sounds and uterine contractions (an
internal monitor for either fetal or uterine assessment is contraindicated).
CBC, UA, IVF

Birth
Past 37 weeks at the time of the initial bleeding
Amniocentesis analysis
CS
ABRUPTIO PLACENTAE
Premature separation of the placenta
Predisposing Factor
High parity
Advanced maternal age
A short umbilical cord
Chronic hypertensive disease
Hypertension of pregnancy
Direct trauma (as from an automobile accident or intimate partner violence)
Vasoconstriction from cocaine or cigarette use
Thrombophilic conditions that lead to thrombosis formation
It also may be caused by chorioamnionitis or infection of the fetal membranes and fluid
Assessment
A sharp, stabbing pain high in the uterine fundus as the initial separation occurs.
Couvelaire uterus or uteroplacental apoplexy, forming a hard, board like uterus occurs
Therapeutic Management
IVF
O2
FHT and VS monitoring
Fibrinogen Baseline
Keep a woman in a lateral, not supine, position to prevent pressure on the vena cava and
additional interference with fetal circulation
Do not perform any abdominal, vaginal, or pelvic examination
DISSEMINATED INTRAVASCULAR COAGULATION
An acquired disorder of blood clotting in which the fibrinogen level falls to below effective limits
Early symptoms
Easy bruising or bleeding from an intravenous site.
Blood Analysis
Platelet decreased to ≤100,000/μl
prothrombin will be low
thrombin time will be elevated
fibrinogen will be decreased to <150 mg/dl
fibrin split products will be >40 mcg/ml
D-dimer analysis is specific for fibrin
Mgt (termination of pregnancy, heparin, Whole Blood transfusion)
Thanks
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