Nursing Care: Counseling about the procedures and alternatives Provide nonjudgmental care Allow the client to express her feelings Preparation for the procedures:

Surgery-D&C or hysterotomy (rarely used) Medications:

“Morning –after pill” –RU-482OxytocinProstaglandins-ProstinE2Misoprotol (Cytotec)

Post –procedure care Administer RhoGam if the client is Rh-negative Discharge Instructions

INCOMPETENT CERVIX is where there is painless effacement and dilation of the cervical os that is not associated with contractions

It often occurs in the second trimester Risk Factor:

Congenital uterine anomaliesDiethylstilbestrol (DES) exposureCervical operationsCervical TraumaCervical Inflammation

Clinical manifestations:Lower abdominal pain Urinary frequency in the second trimesterEffacement and Dilation of the cervixProtrusion of membranes through the cervix Rupture of the membranes in second

trimester

Treatment:Bedrest- Position client so there is pressure

off cervix Initially the Trendelenburg position may be used until after surgery

Serial cervical ultrasound assessmentNo vaginal examsAdminister tocolytic agentsSurgical intervention- Cerclage is a band of

nonabsorbable suture placed around the cervix.

Monitor for uterine contractions, fetal well being, and vital signs

Discharge planning:Teach the client the clinical manifestations

of preterm labor , rupture of membranes, and infection. And to report them to health care provider immediately.

Teach the client to return(to hospital) if uterine contraction begin , because the suture will need to be removed to prevent damage to cervix and allow birth

Keep follow up visits with the health care provider

Do Fetal Movement Counts

PLACENTA PREVIA is the improper implantation of the placenta in the lower uterine segment.

It is classified according to the degree to which the placenta covers the cervical os.:Low-layingMarginalPartialComplete or Total

Risk factors: Endometrial scarring Impede Endometrial vasculation related to:

Hypertension Diabetes mellitus Uterine tumor Drug abuse Smoking

Increase placenta mass Closely spaced pregnancies Multiple gestation Multiparity

Clinical Manifestations:Episodic painless vaginal bleeding after 20 weeks

gestationBright Red Bleeding without uterine contractionsUltrasound:

Reveals the malpositioned placenta

Complications of placenta previa:Preterm deliveryHypovolemiaAltered tissue perfusionDeterioration in fetal status

NURSING CARE: Perform a complete assessment on any pregnant client

that presents with painless bright red vaginal bleeding except:

NO VAGINAL EXAMS Insert large bore catheter(18 or greater) and maintain

IV infusion Monitor:

Vital signs Continuous Fetal monitoring I&O-pad count/weight them

Notify: Physician, charge nurse, ICN, and anesthesia personnel

Nurse Care:Obtain laboratory specimens:

CBC, Type & Rh, Type & CrossmatchBe prepared to deliver client:

Vaginally for the low-lying placenta-have Double set up in the Delivery room

Cesarean section for partial and complete placenta previa- have Hysterectomy tray in the delivery room

Provide emotional supportStrict Bedrest- Position client so pressure is not on

the placenta If client is stable and has diet order make sure it

is well balancePrenatal vitamins and iron will be continue

ABRUPTIO PLACENTA is a premature separation, either partial or total of a normally implanted placenta from the decidual lining of the uterus after 20 weeks’ gestation.

Classifications of Abruptio Placenta:Types: See next slide

Marginal-A Central/Concealed/Covert-B Complete-C

Degrees of placental separation: Grades-0-3

RISK FACTORS:PreeclampsiaEclampsiaChronic HypertensionMultipartyAbdominal Trauma Uterine AnomaliesSmokingCocaine AbusePremature Rupture Of Membranes-PROM

Complications of Abruptio Placenta:Risk of depleting clotting factorsDICHypovolemiaMultiorgan failureMaternal DeathUterine Placenta insuffiencyFetal HypoxiaFetal Death

Clinical manifestations:Sudden Dark Red Vaginal BleedingUnremitting painFirm-to boardlike uterineShock greater than blood lossUltrasound will show abruptionEFM:

Uterine irritability Nonreassuring Fetal Heart pattern- Loss of

variability and late decelerations

NURSING CARE:Assess and Monitor:

Amount of Vaginal Bleeding Vital Signs I&O Measure abdominal girth Uterine characteristics and activity EFM-Continuously For development of coagulation problemsReview lab values:

CBC, Coagulation studies, PT,PTT

Nursing Care: Insert large IV Catheter(18-gauge or

bigger) and maintain IV infusion Provide O@ at 8-12L/min Anticipate Transfusion Therapy:

RBC’sFFPPLT’sCrypopreciateAlbumin

Nursing Care:Anticipate Expedited Delivery:

Vaginally Cesarean section Have Hysterectomy Tray in room

Provide emotional support Instruct client and family on disease

process and procedures and possible surgery

Contact-Physician, Charge nurse, Anesthesia personnel, ICN unit

DISSEMINATED INTRAVASCULAR COAGULATION (DIC) is a complex coagulopathy condition which occurs secondary to another underlying disease process

Risk Factor: Preeclampsia/Eclampsia Sepsis Abruptio Placenta Prolonged IUFD Excessive Blood Uterine inversion or rupture Amniotic Fluid embolism (AFE)

Complications:HypovolemiaAlt. Tissue PerfusionMultiorgan failureMaternal deathFetal death

Clinical Manifestations: Shocklike state Overwhelming and diffuse hemorrhage:

Petechia, ecchymosis, hematomas Oozing of blood from puncture sites, IV sites, and

/or surgery incisions. Bleeding gums. Blood in urine Laboratory valves:

Decreased Hg and HctProlonged PTT and PTDecreased fibrinogenDecrease PLT’sD-Dimer

NURSING CARE:Care for this client is for the critically ill

client. Identify Risk factors predisposing to DIC.

Early detection is extremely importantMaintain IV site- Central line maybe placed.Anticipated Transfusion therapy:

Fresh Whole Blood Fresh Frozen plasma Cryoprecipate

Monitor VS, I&O, perfusion status*,bleeding, cardiopulmonary status

Nursing Care:Educate the client and family concerning

disease process, procedures.Provide support to the client and family.No Heparin is given to the client who has

DIC and who is pregnant or has been delivered

HYPEREMESIS GRAVIDARUM is a disorder with intractable vomiting associated with pregnancy with significant electrolyte imbalance and fluid deficit and possible starvation.

Etiology is unknown/PREGNANCY Risk Factors:

High levels of hCGGestational Trophoblastic DiseaseMultigestationPsychopathologic and emotional factorsStressOther pathophysiology