Clinical aspects of Maternal and Child Nursing

Complications During Complications During PregnancyPregnancy

Lectur 6Lectur 6

Othman Ta’aniOthman Ta’aniRN-MSNRN-MSN

Characteristic Causes of Characteristic Causes of High-Risk PregnanciesHigh-Risk Pregnancies

Can relate to the pregnancy itselfCan relate to the pregnancy itself Or the woman has a medical Or the woman has a medical

condition or injurycondition or injury Or from environmental hazards Or from environmental hazards

that affect the mother or her that affect the mother or her fetusfetus

Or from maternal behaviors or Or from maternal behaviors or lifestyles that have a negative lifestyles that have a negative effect on the mother or fetuseffect on the mother or fetus

Assessment of Fetal Assessment of Fetal HealthHealth

The Goal of fetal assessmentThe Goal of fetal assessment Positive outcomesPositive outcomes

Nursing responsibilitiesNursing responsibilities Preparing the patientPreparing the patient Explaining procedures/testsExplaining procedures/tests Clarifying and interpreting resultsClarifying and interpreting results Collaboration with other healthcare Collaboration with other healthcare

providersproviders Psychosocial supportPsychosocial support

Danger Signs in Danger Signs in PregnancyPregnancy

Sudden gush of fluid from the vaginaSudden gush of fluid from the vagina Vaginal bleedingVaginal bleeding Abdominal painAbdominal pain Persistent vomitingPersistent vomiting Epigastric painEpigastric pain Edema of face and handsEdema of face and hands Severe, persistent headacheSevere, persistent headache Blurred vision or dizzinessBlurred vision or dizziness Chills with fever over 38.0Chills with fever over 38.0° ° C (100.4C (100.4° ° F)F) Painful urination or reduced urine outputPainful urination or reduced urine output

Pregnancy-Related Pregnancy-Related ComplicationsComplications

Hyperemesis GravidarumHyperemesis Gravidarum Excessive Nausea and vomitingExcessive Nausea and vomiting

Electrolyte/acid base imbalanceElectrolyte/acid base imbalance Significant weight lossSignificant weight loss Decreased urine outputDecreased urine output High hematocritHigh hematocrit

TreatmentTreatment Correct dehydration and inadequate nutritionCorrect dehydration and inadequate nutrition

Nursing Care for Nursing Care for HyperemesisHyperemesis

Patient EducationPatient Education Reduce factors that trigger nausea Reduce factors that trigger nausea

and vomitingand vomiting Keep accurate I&OKeep accurate I&O Frequent, small mealsFrequent, small meals

Easley digested carbohydratesEasley digested carbohydrates Drinking liquids between mealsDrinking liquids between meals Reduce stressReduce stress

Pregnancy-Related Pregnancy-Related ComplicationsComplications

Bleeding Disorders of Early PregnancyBleeding Disorders of Early Pregnancy AbortionAbortion Ectopic PregnancyEctopic Pregnancy

Bleeding Disorders of Late PregnancyBleeding Disorders of Late Pregnancy Placenta previaPlacenta previa Abruptio placentaeAbruptio placentae

Bleeding Disorders of Early Bleeding Disorders of Early Pregnancy Pregnancy

Abortion Abortion Spontaneous AbortionSpontaneous Abortion

The involuntary loss of the products of The involuntary loss of the products of conception prior to 24 weeks’ gestationconception prior to 24 weeks’ gestation

Threatened AbortionThreatened Abortion Cervix is closed & no tissue is passedCervix is closed & no tissue is passed

Inevitable AbortionInevitable Abortion Increased bleeding & cervix dilatesIncreased bleeding & cervix dilates

Incomplete AbortionIncomplete Abortion Bleeding dilation of cervix & passage Bleeding dilation of cervix & passage

of tissueof tissue

AbortionAbortion

Bleeding Disorders of Early Bleeding Disorders of Early Pregnancy (continued)Pregnancy (continued)

AbortionAbortion CompleteComplete

Passage of all products of conception, Passage of all products of conception, cervix closes and bleeding stopscervix closes and bleeding stops

Missed Missed Fetus dies in uterus but is not expelled, Fetus dies in uterus but is not expelled,

uterine growth stops and sepsis is uterine growth stops and sepsis is possiblepossible

Recurrent Recurrent 2 or more consecutive spontaneous 2 or more consecutive spontaneous

abortions abortions

Induced AbortionsInduced Abortions

Therapeutic AbortionTherapeutic Abortion Intentional termination of Intentional termination of

pregnancy before age of viability to pregnancy before age of viability to preserve the health of the motherpreserve the health of the mother

Elective AbortionElective Abortion Intentional termination of Intentional termination of

pregnancy for reasons unrelated to pregnancy for reasons unrelated to mothers healthmothers health

Document amount and character of Document amount and character of bleedingbleeding

Save anything that looks like clots or Save anything that looks like clots or tissue for evaluation by a pathologisttissue for evaluation by a pathologist

Monitor vital signsMonitor vital signs If actively bleeding, woman should be If actively bleeding, woman should be

kept NPO in case surgical intervention kept NPO in case surgical intervention is neededis needed

Nursing Care of Early Nursing Care of Early Pregnancy Bleeding DisordersPregnancy Bleeding Disorders

Post-Abortion TeachingPost-Abortion Teaching

Report increased bleedingReport increased bleeding Take temperature every 8 hours for 3 daysTake temperature every 8 hours for 3 days Take an oral iron supplement if prescribedTake an oral iron supplement if prescribed Resume sexual activity as recommended by Resume sexual activity as recommended by

the health care providerthe health care provider Return to health care provider at the Return to health care provider at the

recommended time for a checkup and recommended time for a checkup and contraception informationcontraception information

Pregnancy can occur before the first Pregnancy can occur before the first menstrual period returns after the abortion menstrual period returns after the abortion procedureprocedure

Emotional CareEmotional Care

Spiritual supportSpiritual support from someone from someone of the family’s choice and of the family’s choice and community support groups may community support groups may help the family work through the help the family work through the grief of any pregnancy lossgrief of any pregnancy loss

Review effective and ineffective Review effective and ineffective communicationcommunication techniques techniques

Effective CommunicationEffective Communication

Ectopic PregnancyEctopic Pregnancy

95% occur in fallopian tube95% occur in fallopian tube

Scarring or tubal deformity may result from:Scarring or tubal deformity may result from: Hormonal abnormalitiesHormonal abnormalities InflammationInflammation InfectionInfection Congenital defectsCongenital defects

Ectopic Pregnancies Ectopic Pregnancies (Continued)(Continued)

ManifestationsManifestations Lower abdominal pain, may have Lower abdominal pain, may have

light vaginal bleedinglight vaginal bleeding If tube ruptures:If tube ruptures:

May have sudden severe lower May have sudden severe lower abdominal painabdominal pain

Vaginal bleedingVaginal bleeding Signs of hypovolemic shockSigns of hypovolemic shock

Ectopic Pregnancies Ectopic Pregnancies (Continued)(Continued)

TreatmentTreatment Pregnancy testPregnancy test Transvaginal ultrasoundTransvaginal ultrasound Laparoscopic examinationLaparoscopic examination Priority is to control bleedingPriority is to control bleeding Actions can be taken:Actions can be taken:

Using medicationsUsing medications Or by surgery to remove pregnancy Or by surgery to remove pregnancy

from the tubefrom the tube

Signs and Symptoms of Signs and Symptoms of Hypovolemic ShockHypovolemic Shock

Changes in fetal Changes in fetal heart rateheart rate

Rising pulse Rising pulse (tachycardia)(tachycardia)

Rising respiratory Rising respiratory rate (tachypnea)rate (tachypnea)

Shallow, irregular Shallow, irregular respirations; air respirations; air hungerhunger

Falling blood Falling blood pressure pressure (hypotension)(hypotension)

Decreased or absent Decreased or absent urinary output urinary output (usually less than 30 (usually less than 30 ml/hr)ml/hr)

Pale skin or pale Pale skin or pale mucous membranesmucous membranes

Cold, clammy skinCold, clammy skin FaintnessFaintness ThirstThirst

Urinary Tract InfectionsUrinary Tract Infections

Pregnancy alters Pregnancy alters self-cleaning self-cleaning action due to action due to pressure on pressure on urinary urinary structuresstructures

Prevents bladder Prevents bladder from emptying from emptying completelycompletely

May develop cystitisMay develop cystitis Burning with urinationBurning with urination Increased frequency Increased frequency

and urgency of and urgency of urinationurination

Normal or slightly Normal or slightly elevated temperatureelevated temperature

PyelonephritisPyelonephritis High feverHigh fever ChillsChills Flank pain or Flank pain or

tendernesstenderness Nausea and vomitingNausea and vomiting

Effects of a High-Risk Effects of a High-Risk Pregnancy on the FamilyPregnancy on the Family

Disruption of usual rolesDisruption of usual roles Financial difficultiesFinancial difficulties Delay attachment to the infantDelay attachment to the infant Loss of expected birth Loss of expected birth

experienceexperience

Postpartum complication

Postpartum complications

Preexisting maternal health problems contribute to many postpartum complications.

Overall nursing objectives for high risk post partum clients include:

a-Promote diagnosis and treatment of post partum complications to minimize risk morbidity and mortality.

b- Promote comfort . c- Explore emotional aspects. d- Minimize separation of the mother and

infant. e- assist the client and family to deal with

anger, anxiety and fear.

Nursing Process for women with postpartum

complications 1- Assessment a- Health history Cardinal signs and symptoms. b- Physical examination -vital signs. -inspection. -palpation. c- laboratory and diagnostic

studies.

Nursing Process for women with postpartum complications

2- Nursing diagnosis. a- general diagnosis. b- complication related diagnosis. 3- Planning. 4- Implementation a- promote a full physical recovery. b- assist client and family to deal with

physical and emotional stresses of postpartum complication.

c-encourage parent- newborn bonding. d- provide client and family teaching.

5- outcome evaluation.

1-Postpartum hemorrhage

-Postpartum hemorrhage is blood loss of more than 500 ml following the birth of a newborn.

-Early post partum hemorrhage which is usually due to uterine atony, laceration or retained placenta fragments, occurs in the first 24 hours after delivery.

-Late postpartum hemorrhage occurs after 24 hours after delivery and is generally caused by retained placental fragments or bleeding disorder.

-Delayed uterine atony or placental fragments prevent the uterus from contracting effectively. The uterus is unable to form an effective clot structure and bleeding continues.

-Nursing management includes

-prevent excessive blood loss and resulting complications.

-assist the client and family to deal with physical emotional stress of postpartum complications.

2- subinvolution

-It is delayed return of the enlarged uterus to normal size and function.

-It results from retained placental fragments and membranes, endometritis, or uterine fibroid tumor.

-Uterine atony or placental fragments prevent the contracting effectively.

-Clinical manifestations – prolonged lochial discharges.

-irregular or excessive bleeding. -larger than normal uterus.

-Nursing management

1-prevent excessive blood loss, infection, and other complications.

2-assist the client and family to deal with physical and emotional stresses of postpartum complications.

3-Puerperal infection

-It is an infection developing in the birth structures after delivery.

-It is a major cause of maternal morbidity and mortality.

-The most common site of post partum infection is the pelvic cavity.

-It can be caused by poor sterile technique, cesarean birth.

-clinical manifestations: -Fever. -pain, redness, tenderness and firmness.

4- Mastitis

-It is inflammation of the breast tissue that is usually caused by infection or by stasis of milk in the ducts.

5-Thrombophlebitis and thrombosis

-Thrombophlebitis is an inflammation of the vascular endothelium with clot formation on the vessels wall.

-A thrombus forms when blood components (platelets and fibrin) combine to form an aggregate body (clot).

-Pulmonary embolism occurs when a clot traveling through the venous system lodges within the pulmonary circulation system, causing occlusion or infarction.

-Predisposing factors

-Hx of thrombophlebitis.-obesity.-Hx of cesarean delivery.-Maternal age older than 35 years.-Varicosities.-Anemia .

-Pathophysiology

-The three major causes of thrombus formation and inflammation are-venous stasis, hypercoagulable blood, and injury to innermost layer of blood vessel.

The level of most coagulation factors are increased during pregnancy.

A-Clinical manifestations -superficial thrombophlebitis within the

saphenous vein system manifests as pain, tenderness, and warmth along the vein.

-Pathophysiology

-DVT symptoms include muscle pain.

-Femoral thrombophlebitis generally occurring 10-14 days after delivery, produces chills, fever, stiffness, and pain.

-Pulmonary embolism is heralded by sudden intense chest pain with severe dyspnea followed by tachypnea, pleuratic pain cough, tachycardia, hemoptysis, and temperature above 38 C.

B-Lab. Findings. -Venography. -Doppler ultrasound.

Nursing Management

1- promote resolution of symptoms and prevent the development of embolus.

-Anticoagulant therapy. -It is important not to administer

estrogen for lactation suppression .because it may encourage clot formation.

2- Provide client and family teaching.

3- Assist the client and family to deal with physical and emotional stresses of postpartum complications.

6- Urinary tract infection

-It is indicated by more than 100 thousands bacterial colonies /ml of urine in two consecutive clean, voided, midstream specimens.

-Two common types of UTIs are cystitis, inflammation of the urinary bladder, and pyelonephritis, inflammation of the renal pelvis.

-Another cause of UTIs is retention and residual urine due to over distention and incomplete emptying of the bladder.

- E-coli, (the most common causative organism).

-Clinical manifestation

-cystitis manifestations include frequency ,urgency, dysuria,

hematuria, temperature elevation, and suprapubic pain.

-Pyelonephritis manifestations include high fever, chills, flank pain, nausea and vomiting.

-Nursing management – -recognize signs of infection and prevent

the development of further complications.

7-Postartum mood disorder

-The disorders are- 1 -Postpartum blues.-include fatigue, anxiety,

mood instability, with onset 1 to 10 days postpartum and lasting 2 weeks or less.

2 -Postpartum depression without psychotic

features. includes confusion, fatigue, feeling of

hopelessness and shame, and alteration in mood.

3 -Postpartum depression with psychotic features (postpartum psychosis)-includes symptoms of postpartum depression plus delusion, auditory hallucinations, and hyperactivity.