Pregnancy Complications - 2

Vaginal Bleeding (after 20 weeks’ gestation)

The complications may be related to placenta previa or abruptio placentae.

Placenta Previa

It is a low-lying position of placenta in the uterus that partially or completely covers the cervical os. Clinical Findings:

• Painless bright red vaginal bleeding
• Bleeding may be reported after intercourse
• Uterine tone soft upon palpation
• Interventions dependent on amount of bleeding and labor status
• If partial placenta previa is noted in early gestation, then repeat ultrasound later in pregnancy (may demonstrate absence of previa as uterus grows)
• If labor active and os is covered, then cesarean birth necessary
• If bleeding controlled and labor absent, then conservative management is applied

Patient Teaching (Conservative Management)

• No tampon use
• No sexual intercourse
• Monitor and report bleeding
• Patient instructed to report placenta placement when admitted to hospital
• Cesarean preparation class
• Count fetal movements

Abrupto Placentae

Clinical Findings

• Abdominal pain (sudden onset, intense and localized)
• Fundus firm, boardlike, with little relaxation
• Vaginal bleeding
• Bleeding may be concealed within the uterine cavity
• Fetal heart tones may be non-reassuring

Nursing Care (vaginal bleeding/late pregnancy)

1. Monitor amount of bleeding
2. Check vital signs
3. Observe for signs of shock
4. Evaluate fetal heart tones
5. Palpate uterine tone
6. Apply electronic fetal monitor (EFM)
7. REPORT alterations in fetal heart rate pattern
8. REPORT hypertonic contractions with poor resting tone
9. Do not attempt vaginal exam until placenta placement verified
10. Initiate IV fluids
11. Report laboratory and ultrasound findings
12. Prepare staff for possible cesarean birth
13. Attend to patient’s emotional needs

Pregnancy Complications - 1

Vaginal Bleeding (before 20 weeks’ gestation)
It may be related to spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease.

Spontaneous Abortion
It is a loss of pregnancy before viability, clinical Findings:

• Vaginal spotting (may pass clots)
• Abdominal cramping
• Cervical changes
• Fetal heartbeat may be present or absent

Ectopic Pregnancy
It is a product of conception implant outside the uterus, clinical findings:

• Vaginal spotting
• hCG lower than expected for dates
• Lower abdominal pain
• Ultrasound findings: absence of intrauterine gestational sac
• If rupture occurs, it would be: Positive Cullen’s sign (periumbilical bluish hue), Shoulder pain, and Signs of shock

Gestational Trophoblastic Disease
It is an abnormal proliferation of trophoblastic cells without viable fetus, Clinical Findings:

• Vaginal spotting (dark brown)
• Fundal height greater than expected for dates
• hCG greater than expected for dates
• Excessive nausea and vomiting
• Absence of fetal heart tones
• Ultrasound findings: Snowflake-like clusters, absence of fetus

Nursing Care (vaginal bleeding/early pregnancy)

1. Monitor amount of bleeding
2. Assess vital signs
3. Observe for signs of shock
4. Auscultate for fetal heart tones (FHTs)
5. Collect passed tissue/clots
6. Monitor patient comfort
7. Check blood type and Rh factor
8. Administer Rh(D) immunoglobulin if indicated
9. Initiate IV fluids as ordered
10. Report lab/ultrasound findings
11. Attend to patient’s emotional needs

Forceps Birth

Forceps birth is an assisted birth, sometimes called an instrumental or operative vaginal birth, uses instruments that are attached to baby’s head so that baby can be pulled out. Forceps are described as stainless steel that come in two intersecting parts and have curved end to cradle baby’s head. It can be used as low or outlet forceps or for mid-forceps procedures.
This procedure is done to provide traction or to assist in rotation of the fetus.

Advantages:

• Provide assistance when laboring women is exhausted
• May decrease need for cesarean birth

Disadvantages:

• Maternal complication such as vaginal and perineal lacerations and postpartal hemorrhage
• Neonatal complication such as facial bruising, edema and cerebral trauma.

Nursing care:

• Explain the procedure to woman
• Encourage her to relax perineum and breathe during forceps application
• Advice physician when contraction is present
• Assess newborn for facial bruising or edema.

Induction

Induction labor is a procedure to stimulate uterine contraction during pregnancy before labor begins spontaneously. It is done for various reason, especially for mother and baby health reason. Elective induction may be accomplished by oxytocin infusion.

Advantages:

• IV oxytocin induction is usually successful when labor readiness has been established, fetal maturity is established and Bishop score is 9 or more.
• Maternal and fetal status can be monitored closely.

Disadvantages:
Induction is an invasive procedure.
Hypertonic labor, fetal distress, alterations in blood pressure, ruptured uterus.

Indications:

• Postmaturity
• Premature rupture of membranes
• PIH
• Presence of maternal disease such as diabetes mellitus
• Fetal demise.

Contraindications:

• Grand multiparity
• Placental abdominalities
• Previous uterine surgery
• Fetal distress
• Preterm fetus
• Positive CST
• Abnormal fetal presentation
• Presenting part above inlet
• Cephalopelvic disproportion (CPD).

Nursing Intervention:

• Obtain baseline tracing of uterine contractions
• Follow established protocols
• Increase IV dosage only after assessing contractions, FHR, and maternal blood pressure and pulse.
• Do not increase rate once desired contraction pattern is obtained.
• Discontinue oxytocin if contraction frequency is less than 2 minutes of duration is more than 90 seconds, or if fetal distress is noted.

Amniotomy

Amniotomy is the artificial rupture of membranes, sometimes called as AROM. It is done to stimulate labor.

Advantages:

• Amniotomy can stimulate contractions
• Amniotomy can evaluate the amniotic fluid

Disadvantages:

• Birth must occur within 24 hour when amniotomy is done, and may be need cesarean birth.
• Increased risk of prolapsed cord
• Risk of Infection

Nursing Care:

• Auscultate Fetal Heart Rate before and after amniotomy
• Record the time of Amniotomy, Fetal Heart Rate, and characteristics of fluid (amount, color and odor).
• Instruct woman to remain in bed unless fetal presentation part is well engaged. It is done to prevent prolapsed of umbilical cord.

Risks for Mother:

• Increases the risk of infection.
• Labor may become more aggressive
• The mother increases her chances of having uneven dilation.

Risk for Baby:

• Increase of umbilical cord compression
• The pressure on the baby’s head causes swelling in some part.

Diabetes in Pregnancy

Client with diabetes and their infants are at risk for complication during pregnancy. Infants of diabetic mother tent to be large for gestational age. It is caused by glucose that crosses the placenta, whereas insulin does not, these infants tend to gain weight. The problem is that high glucose environment impedes lung development and although the infants are large for gestational age, they are often premature.

Complication of infants from maternal diabetes:

• Patent ductus arteriosus (PDA)
• Polyhydramnions
• Premature delivery
• Respiratory distress syndrome

Complications of mother with diabetes pregnancy:

• Hypertension
• Renal disease
• Ketoacidosis
• Vascular compromise
• Seizure activity related to hypoglycemia

Another problem in diabetes pregnancies is that the fluctuations in maternal blood sugar can result in fetal brain damage or sudden fetal death due to ketosis. That's why the client should be taught to check their blood glucose levels frequently during the day. Level over 120 mg/dL should be reported to the doctor for treatment.

Infants born to diabetic mothers might be delivered by cesarean section because of their large sizes and they should be assessed immediately after delivery for hypoglycemia by performing a dextrostix. The glucose level of 40 mg/dL or lower indicates hypoglycemia in the infant.

The blood is usually drawn from a heel stick and should be stuck on the lateral aspect of the heel. Blood test should be performed to detect hypocalcemia, hypokalemia and acidosis status.

Ectopic Pregnancy

Ectopic pregnancy is the condition in which the ovum implants in area other than the endometrial lining of the uterus. This pregnancy is not commonly successful since the areas outside of the uterus cannot sustain for a full-term pregnancy. It’s studied that it usually happens when there is a tubal blockage that prevents the fertilized ovum from passing through the fallopian tubes.

Ectopic pregnancy can be happened at abdominal, tubal, myometrial or cervical.

Ectopic pregnancy at abdomen:
The abdomen is usually unable to sustain for embryo growth

Ectopic pregnancy at tubal:
This is the most common site of ectopic pregnancy. It can causes mother at risk for tubal rupture that can be a life threatening condition.

Ectopic pregnancy at myometrial:
We cannot recognize it until delivery that usually requires a hysterectomy to stop bleeding. Sometime it is called as placenta accrete.

Ectopic pregnancy at cervical:
It has relation with placenta previa

Precipitating Factors:

1. Pelvic Inflammatory Disease
2. Previous tubal surgery or tubal pregnancy
3. Endometriosis, and
4. Congenital anomalies of the fallopian tubes

Sign and Symptoms:

1. Sharp one-sided pain
2. Tenderness of adnexal, area over ovary and tube
3. Vaginal bleeding (may or may not seen)
4. Hard and rigid abdomen and signs of circulatory collapse when tubal is ruptured.

How to care patient with ectopic pregnancy:

• Provide emotional support for whom undergoing surgical or medical treatment
• Provide emergency resuscitation and emergency surgery
• Teach mother about pre and post operative self care
• Consider to refer mother to a Fetal Demise Support Group