Focus on high-risk pregnancies, defined as conditions that pose a jeopardy to the mother, fetus, or both.
Conditions may arise due to pregnancy or preexisting conditions.
Presence of higher morbidity and mortality rates necessitates comprehensive risk assessment starting from the first antepartal visit and continuing throughout the pregnancy.
High-Risk Pregnancy
Definition: Pregnancy that has a risk to the mother, fetus, or both.
Causes: Can be due to complications arising during pregnancy or existing conditions prior to pregnancy.
Assessment: Initial risk evaluation during the first antepartal visit and continual assessment.
Pregnancy Complications
Common complications that can arise during pregnancy include:
Bleeding during pregnancy
Hyperemesis gravidarum
Gestational hypertension
HELLP syndrome
Gestational diabetes
Amniotic fluid imbalances
Multiple gestation
Premature rupture of membranes (PROM)
Early Bleeding During Pregnancy
Conditions Associated with Early Bleeding
Spontaneous abortion: A common cause of bleeding in early pregnancy.
Ectopic pregnancy: Implantation of the embryo outside the uterine cavity, often in a fallopian tube.
Cervical insufficiency: Premature dilation of the cervix leading to bleeding.
Spontaneous Abortion
Causes: Generally unknown, but often linked to fetal genetic abnormalities in the first trimester and maternal conditions in the second trimester.
Nursing Assessment: Important assessments include:
Monitoring for vaginal bleeding
Cramping or contractions
Vital signs
Pain level
Understanding of the situation by the client.
Types of Spontaneous Abortion
Threatened abortion: Presence of bleeding without cervical dilation.
Inevitable abortion: Bleeding with cervical dilation.
Incomplete abortion: Some but not all products of conception have been expelled.
Complete abortion: All products of conception expelled.
Missed abortion: Fetus has died but has not been expelled.
Provide emotional and physical support to the mother, assure her the loss is not her fault, and facilitate the verbalization of feelings and grief support, including referrals for community support groups.
Ectopic Pregnancy
Definition: Implantation of an ovum outside the uterus, commonly in a fallopian tube.
Pathophysiology: Often due to obstruction or delayed passage of the ovum through the tube.
Therapeutic Management
Medical Treatment:
Drug therapy includes:
methotrexate
prostaglandins
misoprostol
actinomycin.
Surgery: Required if the ectopic pregnancy ruptures.
Rh immunoglobulin: Administered if the woman is Rh-negative.
Nursing Assessment for Ectopic Pregnancy
Hallmark sign: Abdominal pain with spotting occurring 6 to 8 weeks after a missed menstrual period.
Contributing factors: Various factors may contribute, including prior ectopic pregnancies.
Laboratory and Diagnostic Testing:
Transvaginal ultrasound
Serum beta hCG levels for diagnosis.
Nursing Management for Ectopic Pregnancy
Preparation for Treatment: Including administering analgesics for pain.
Emotional Support: Providing education about signs of rupture and emotional support is essential.
Cervical Insufficiency
Definition: The premature dilation of the cervix; the cause is often unknown but may involve cervical damage.
Therapeutic Management
Interventions include:
Bed rest
Pelvic rest
Avoiding heavy lifting
Cervical cerclage: a stitch placed in the cervix to help carry the pregnancy to term.
Nursing Assessment & Management for Cervical Insufficiency
Assessment:
Identify risk factors
Monitor for pink-tinged vaginal discharge or pelvic pressure.
Assess cervical shortening with transvaginal ultrasound.
Management:
Continuous surveillance and monitoring for preterm labor.
Provide emotional support and education to the patient.
Placenta Previa
Definition: Condition where the placenta implants over the cervical os. The cause is often unknown.
Classification of Placenta Previa
Classified based on the degree to which the placenta covers the cervical os.
Therapeutic Management
Dependent upon:
Degree of bleeding
Amount of placenta over the os
Fetal development and position
Maternal parity and labor signs.
Nursing Assessment for Placenta Previa
Identify risk factors and monitor for:
Painless vaginal bleeding in the second or third trimester
History of spontaneous cessation followed by recurrence.
Nursing Management for Placenta Previa
Monitor maternal-fetal status through regular assessments:
Vaginal bleeding and pad count
Avoid vaginal exams
Fetal heart rate (FHR) monitoring.
Provide support and education focusing on:
Fetal movement counts
Effects of prolonged bed rest (if necessary)
Signs and symptoms the patient should report.
Prepare for potential cesarean delivery if necessary.
Placental Abruption
Definition: Premature separation of the placenta from the uterus, leading to compromised blood supply to the fetus.
Etiology: Often unknown.
Therapeutic Management for Placental Abruption
Focuses on assessment, control, and restoration of blood loss as well as prevention of disseminated intravascular coagulation (DIC).
Nursing Assessment for Placental Abruption
Risk factors may include prior history.
Clinical assessment may reveal:
Dark red bleeding, sharp pain, uterine tenderness, and contractions.
Decreased fetal movement and activity.
Laboratory and Diagnostic Testing:
Complete blood count (CBC)
Fibrinogen levels
Prothrombin time (PT)/activated partial thromboplastin time (aPTT)
Type and cross-match for blood transfusion if needed.
Nursing Management for Placental Abruption
Ensure tissue perfusion by:
Positioning the patient in the left lateral position
Maintaining strict bed rest
Monitoring vital signs
Continuous fetal monitoring.
Education and emotional support are key, providing empathy and understanding, and preparing for possible loss of the fetus.
Additional Conditions During Pregnancy
Hyperemesis Gravidarum
Definition: A severe form of nausea and vomiting during pregnancy.
Symptoms: Symptoms usually resolve around week 20 but may include:
Weight loss >5% of prepregnancy weight
Dehydration
Metabolic acidosis and alkalosis
Hypokalemia.
Therapeutic Management for Hyperemesis Gravidarum
Conservative management includes dietary and lifestyle modifications.
Hospitalization may be necessary for parenteral therapy if severe.
Nursing Assessment & Management for Hyperemesis Gravidarum
Assess:
Onset, duration, and course of nausea/vomiting
Dietary habits and history
Weight and associated symptoms.
Laboratory tests may include liver enzymes, CBC, BUN, electrolytes, and ultrasound.
Nursing management includes maintaining comfort and nutrition through IV fluids, hygiene, and oral care while reassuring the patient and following up in a home care plan.
Hypertensive Disorders of Pregnancy
Types include:
Gestational hypertension
Preeclampsia
Eclampsia
Chronic hypertension
Chronic hypertension with superimposed preeclampsia.
Nursing Assessment & Management for Gestational Hypertension
Assess risk factors, monitor blood pressure, nutritional intake, weight, and evaluate urine for protein.
Management:
Home management for mild cases.
Hospitalization for severe preeclampsia, implementing a quiet environment, using sedatives, seizure precautions, and antihypertensives.
Monitor deep tendon reflexes (DTR) and watch for signs of magnesium toxicity during labor.
Prepare for birth if necessary.
Management for Mild-Severe Pre-eclampsia & Eclampsia
For mild preeclampsia:
Implement bed rest, daily monitoring of BP and fetal movements.
For severe preeclampsia:
Hospitalization with IV magnesium sulfate during labor.
For eclampsia:
Manage seizures with magnesium sulfate and antihypertensive agents before planning for delivery once seizures are controlled.
HELLP Syndrome
Definition: A severe form of preeclampsia characterized by:
Hemolysis
Elevated liver enzymes
Low platelet count.
Nursing Assessment: Similar to severe preeclampsia.
Nursing Management: Same as for severe preeclampsia.
Blood Incompatibility
ABO Incompatibility: Occurs when type O mothers have fetuses with type A or B blood.
Rh Incompatibility: Exposure of an Rh-negative mother to Rh-positive fetal blood can lead to sensitization and antibody production, increasing risks with subsequent pregnancies.
Nursing Assessment: Determine maternal blood type and Rh status.
Nursing Management: Administer RhoGAM at 28 weeks to prevent sensitization.
Amniotic Fluid Imbalances
Hydramnios
Definition: Amniotic fluid level >2,000 mL.
Therapeutic Management: Close monitoring, fluid removal, or indomethacin to decrease fetal urinary output.
Nursing Assessment: Monitor risk factors, fundal height, abdominal discomfort, and difficulty in palpating fetal parts.
Nursing Management: Continuous assessment and monitoring; assist with therapeutic amniocentesis.
Oligohydramnios
Definition: Amniotic fluid level <500 mL.
Therapeutic Management: Serial monitoring, amnioinfusion, and planning for birth in cases of fetal compromise.
Nursing Assessment: Check for risk factors and fluid leaking.
Nursing Management: Maintain continuous fetal surveillance and assist with amnioinfusion, providing comfort measures and position changes.
Multiple Gestation
Therapeutic Management: Requires serial ultrasounds, close monitoring during labor, and possible operative delivery.
Nursing Assessment: Uterus may feel larger than expected for the estimated date of birth (EDB); confirmation via ultrasound.
Nursing Management: Education and support during antepartum care, management of labor with a perinatal team, and assessment postpartum for potential hemorrhage.
Premature Rupture of Membranes (PROM & PPROM)
PROM: Occurs in women beyond 37 weeks gestation.
PPROM: Occurs in women less than 37 weeks gestation.
Treatment: Depends on gestational age; avoid unsterile digital cervical exams until active labor; expectant management if fetal lungs are immature.
Nursing Assessment: Monitor risk factors, signs of labor, electronic FHR monitoring, amniotic fluid characteristics, nitrazine test, fern test, and ultrasound as needed.
Nursing Management for Premature Rupture of Membranes
Focus on:
Prevention of infection.
Identification of uterine contractions.
Patient education and support.
Discharge home (if PPROM) if no labor develops within 48 hours.