NURSING CARE

MANAGEMENT 109
Care for the Mother and Child at risk
(Acute and Chronic)

Andro S. Larong, RN
Classroom Instructor
MODULE1
LESSON 1 WEEK 1
 BIBLE VERSE: Philippians 4:6-8

Do not be anxious about anything, but in every situation, by prayer

and petition with thanksgiving, present your requests to God. And the
Peace of God, which transcends all understanding, will guard your
Hearts and your minds in Jesus Christ.

LEARNING OUTCOMES:

1. Performs assessment on high-risk prenatal client.

2. Discuss pre-gestational conditions.
3. Design a nursing care plan for high-risk prenatal client.
INTRODUCTION

Pregnancy is a normal physiological function of all living species. Couples

(or, in more recent times, single individuals) who have chosen to become
parents look forward to having a healthy, happy, and bright newborn
enter their lives. They anticipate the arrival of a baby who they will be able
to love and nurture over the years to grow into a happy, healthy and
productive adult. However, pregnancies do not always progress smoothly
and the pregnant woman and her family or significant other may
experience a complication at some point during the childbearing year.
Complications that arise during this time are often challenging and
demand the perinatal nurse’s skills, knowledge, and expertise combined
with the nursing process to first identify the pregnant patient at risk and
then formulate, implement, and evaluate an appropriate, holistic plan of
care. Identification and activation of appropriate community resources is
also an essential component of the care plan. Throughout the entire
process, the nurse must remain cognizant of the unique individuality of
the patient and her family and deliver care that is respectful of their
diversity and culture

LEARNING
CONTENT
Childbearing at Risk
Nursing Management of Pregnancy
at Risk
Pregnancy Related Complications
This lesson describes the major conditions related
directly to the pregnancy that can complicate a
pregnancy, possibly affecting maternal and fetal
outcomes:

these include bleeding during pregnancy (spontaneous

abortion, ectopic pregnancy, gestational trophoblastic disease)
cervical insufficiency, placenta previa, abruptio placenta),
hyperemesis gravidarum, gestational hypertension, HELLP
syndrome, gestational diabetes, blood incompatibility,
hydramnios and oligohydramnios, multiple gestation,
prematurerupture of membranes (PROM),
 Ectopic
Pregnanc
y
An ectopic pregnancy is one
that implants outside of the
 uterine cavity. Implantation
may occur in the fallopian
tube (99%), on the ovary,
the cervix, on the outside of
the fallopian tube, the
abdominal wall, or on the
bowel.
Patients who
present with vaginal
bleeding, a missed
period, and
abdominal
tenderness or pain
should always be
evaluated for an
ectopic pregnancy.
Pain increases after
rupture of the ectopic pregnancy and the woman may
experience referred shoulder pain from diaphragmatic
 irritation caused by blood in the peritoneal cavity.

RISK FACTORS :
History of sexually transmitted infections or pelvic inflammatory
disease
Prior ectopic pregnancy
Previous tubal, pelvic, or abdominal surgery
Endometriosis
Current use of exogenous hormones (i.e., estrogen, progesterone)
In vitro fertilization or other method of assisted reproduction In
utero diethylstilbestrol (DES) exposure with abnormalities of the
reproductive organs
Use of an intrauterine device

Assessment and Diagnosis

ASSESS FOR:
unilateral, bilateral or diffuse abdominal pain
missed period
 palpable mass is present on bimanual examination in
approximately 50% of women
Active bleeding is associated with rupture
hypotension, tachycardia, vertigo and shoulder pain

DIAGNOSIS:
Increased WBC
TVS (transvaginal ultrasound)

Management
SURGICAL
Salpingectomy (removal of the ruptured fallopian tube) by
laparotomy (surgical procedure in which the abdomen is opened to
visualize the abdominal organs) has long offered an almost 100% cure
for the treatment of an ectopic pregnancy. However, current clinical
emphasis is aimed not only on prevention of maternal death but also
on the prompt restoration of health through a rapid recovery with
preservation of fertility. To achieve this goal, laparoscopic
(visualization of the reproductive organs using a laparoscope
inserted into the pelvic cavity through a small incision in the
abdomen), salpingostomy (incision into the fallopian tube to remove
the pregnancy) and partial salpingectomy are replacing laparotomy
as the treatment mode of choice. At present, laparotomy is
performed only when a laparoscopic approach is too difficult, the
surgeon is not trained in operative laparoscopy, or the patient is
hemodynamically unstable
NON – SURGICAL

Methotrexate, a chemotherapeutic drug and folic acid

inhibitor that stops cell production and destroys remaining
trophoblastic tissue, is used in the management of
uncomplicated, non–life-threatening ectopic pregnancies.
Patients are considered to be eligible for methotrexate
therapy if the ectopic mass is unruptured and measures 1.6
inch (4 cm) or less on ultrasound examination. Patients with
larger ectopic masses, embryonic cardiac activity, or clinical
evidence of acute intra-abdominal bleeding (acute tender
abdomen, hypotension, or falling hematocrit) are not eligible
for this mode of treatment (Murray et al., 2005).

Gestational
Trophoblastic
Disease Gestational trophoblastic disease (GTD) is
a clinical diagnosis that includes the
histologic diagnoses of hydatidiformmole
(“molar pregnancy”), locally invasive
mole, metastatic mole, and
choriocarcinoma.
It is a disease characterized by an
abnormal placental development that
results in the production of fluid-filled
grapelike clusters (instead of normal
 placental tissue) and a vast proliferation
of trophoblastic tissue. It is associated
with loss of the pregnancy and rarely, the
development of cancer. GTD occurs in 1 in
1200 pregnancies (Berman, DiSaia, &
Tewari, 2004).
CAUSE:
The cause of molar pregnancy is unknown, but it is thought that
complete moles result from the fertilization of an empty ovum (one
whose nucleus is missing or nonfunctional) by a normal sperm. Since
the ovum contains no maternal genetic material, all chromosomes in a
molar pregnancy are paternally derived.

2 TYPES

Complete mole- characterized by trophoblastic proliferation and the

absence of fetal parts.
Incomplete - often appear with a coexistent fetus that has a triploid
genotype (69 chromosomes) and multiple anomalies. Most fetuses
associated with incomplete moles survive only several weeks in utero
before being spontaneously aborted.
 SIGNS AND SYMPTOMS
-vaginal bleeding which may be scant or profuse and ranges in color from
dark brown to bright red; Anemia
-discrepancy between uterine size and dates.
-Severe nausea and vomiting
-abdominal pain
-pre-eclampsia
-absence of FHT
-elevated hCG and low maternal serum alpha-fetoprotein (MSAFP)

RISK FACTORS :
✔ Women of higher age

✔ History of previous molar pregnancy

✔ maternal diet is low in betacarotene, animal fats, and folic acid and
also in women with blood type A whose partners are of blood type
O
✔ prior miscarriages
 ✔ Women who had undergone ovulation stimulation with clomiphene
(Clomid).

Diagnosis and management

Diagnosis:
Ultrasound: The placental tissue appears in a “snowstorm” pattern due to
the profuse swelling of the chorionic villi.
Management:
Clinical management involves removal of the uterine contents with
meticulous follow-up that includes serial beta-hCG levels. The hCG levels
should be assessed every 1 to 2 weeks until hCG is undetectable on two
consecutive determinations. Thereafter, hCG should be measured every 1 to
2 months for at least a year (Cunningham et al., 2005).
Nursing Management:
Effective contraception is needed during this time to prevent pregnancy and
the resulting confusion about the cause of changes in the hCG levels. In
addition, pregnancy could mask an hCG rise associated with malignant GTD.
The perinatal nurse should carefully counsel the patient about different
methods of contraception and stress the importance of avoiding pregnancy
for a year.

Spontaneous
Abortion
A spontaneous abortion (SAB) or miscarriage is a pregnancy that
ends before 20 weeks gestation. The type of SAB that occurs is
defined by whether any or all of the products of conception (POC)
have been passed and whether or not the cervix is dilated.

Classifications
Abortus: Fetus lost before 20 weeks of gestation, less than 17.5 oz.
(500 g), or less than 9.8 inches (25 cm) in size
Complete abortion: Complete expulsion of all POC before 20
weeks of gestation

Incomplete abortion: Partial expulsion of some but not all POC

before 20 weeks of gestation
Classifications

Inevitable abortion: No expulsion of products, but bleeding and

dilation of the cervix such that a pregnancy is unlikely

Threatened abortion: Any intrauterine bleeding before 20 weeks

of gestation, without dilation of the cervix or expulsion of any POC

Missed abortion: Death of the embryo or fetus before 20 weeks of

gestation with complete retention of the POC; these often proceed to
a complete abortion within 1 to 3 weeks but occasionally they are
retained much longer.
 CAUSE:

• It is estimated that 60% to 80% of all SABs in the first trimester are
associated with chromosomal abnormalities (Griebel,Halvorsen,
Goleman, & Day, 2005).
• Infections (bacteriuria and Chlamydia trachomatis) •
maternal anatomical defects
• immunological and endocrine factors
• Second trimester spontaneous abortions (12 to 20 weeks) have
been linked to chronic infection, recreational drug use, maternal
uterine or cervical anatomical defects, maternal systemic disease,
exposure to fetotoxic agents, and trauma (Cunningham et al.,
2005).

Diagnosis and management

Diagnosis:
A woman who is experiencing a spontaneous abortion usually presents
with bleeding and may also complain of cramping, abdominal pain, and
decreased symptoms of pregnancy; cervical changes (dilation) may be
present on vaginal examination. An ultrasound is performed for placental
evaluation and to determine fetal viability (Cunningham et al., 2005).
Management:
• Dilatation and Curettage
• For the case of an incompetent cervix – cerclage (temporary suturing of
the cervix)
• RH negative women – RhoGAM to prevent antibody formation

Hyperemesis
Gravidarum
Nausea and vomiting is a common condition of pregnancy that
affects 70% to 85% of pregnant women and usually resolves by
the 16th week of gestation.
Hyperemesis gravidarum represents the extreme end of the
nausea/vomiting spectrum in terms of severity.

Hyperemesis gravidarum is the most common indication for

admission to the hospital during the first part of pregnancy and
is second only to preterm labor as the most common reason for
hospitalization during pregnancy (ACOG, 2004a; Hunter, Sullivan,
Young, & Weber, 2007).
RISK FACTORS : generally unknown but;
Hyperemesis gravidarum may be related to the elevated
levels of estrogen or hCG. Or, it may be associated with
the transient elevation of thyroid hormone during
pregnancy.
✔ increased placental mass associated with multiple gestation
and molar pregnancy;
✔ a history of hyperemesis gravidarum in a previous pregnancy;
✔ a history of motion sickness or migraine headaches; ✔
 pregnant with a female child is also considered to be at risk
(ACOG, 2004a).
Maternal Effects

Serious complications of hyperemesis gravidarum for the

woman and fetus arise in the group of women who cannot
maintain their weight despite antiemetic therapy. In addition to
increased hospital admissions, some women experience
psychosocial morbidity of such significance that they feel
compelled to terminate the pregnancy. Depression,
somatization (the conversion of mental experiences into
physical symptoms), and hypochondriasis can also be a
problem for some women (ACOG, 2004a)

Fetal Effects
❑ fetal intrauterine growth restriction (IUGR)

Diagnosis and management

 DIAGNOSIS
Criteria for the diagnosis of hyperemesis gravidarum include persistent
vomiting unrelated to other causes, a measure of acute starvation
(usually large ketonuria), and some discrete weight loss, most often 5%
of the pre-pregnancy weight.
MANAGEMENT
✔ Advised to regularly take multivitamins before the next conception ✔
Rest
✔ avoid foods and sensory stimuli that provoke symptoms ✔ eat small
frequent meals of dry, bland foods and include high-protein snacks in
their diet.
✔ Avoid spicy foods.

✔ Eating crackers before arising in the morning may be of benefi t and

ginger capsules have been shown to be effective.
Purposive Assignment
 By group:

Among the topics discussed choose one topic

and make a Nursing Care Plan.