measures during Pregnancy Discomfort Trimester Intervention Morning 1st Eat dry sickness(N & V) carbohydrate in AM, avoid fried, odorous, and greasy foods, small meals, bet. Meals eat crackers w/o fluid Discomfort Trimester Intervention
Fatigue 1st Rest frequently
as needed. Urinary 1st & 3rd Kegel exercise, frequency and perineal pad for urgency leakage. Void frequently, decrease fluids prior to bed time; avoid caffeinated or carbonated beverages Discomfort Trimester Intervention Heartburn 2nd & 3rd Small meals bland foods, antacids if ordered. Avoid fat and fried, spicy foods. Constipation 2nd & 3rd Increase fluid intake, eat foods high in roughage, exercise moderately, NO laxative unless ordered. Discomfort Trimester Intervention Hemorrhoids 3rd Avoid constipation,pro mote regular vowel habits, do not strain.Supposito ries as prescribe Varicosities 3rd Avoid crossing legs and long avoid elastic periods of garters and other sitting or standing, rest w/ Constrictive feet and hips clothing elevated, Discomfort Trimester Intervention Backache 3rd Correct posture, low heeled shoes,pelvic tilt exercise Insomnia 3rd Warm shower before retiring Leg cramps 3rd Warm packs,maintain adequate calcium Supine 3rd Left side-lying hypotensive position syndrome Discomfort Trimester Intervention
Faintness 2nd & 3rd Sit or lie down,
avoid sudden changes in position,avoid prolonged standing Vaginal 1st & 2nd Good hygiene, discharge cotton underwear, no douching unless prescribe. Discomfort Trimester Intervention
Shortness of 2nd & 3rd Good posture,
breath sleep with head elevated by several pillows Skin changes, All Interventions dryness, itching symptomatic; cool baths, lotions, oils as indicated. Causes of Bleeding in Pregnancy 1. Early Pregnancy(1st Trimester ) 1. Abortion 2. Ectopic Pregnancy 3. Hydatidiform Mole 2. Late Pregnancy (3rd Trimester ) 1. Placenta Previa 2. Abruptio Placenta (Abortion -termination of pregnancy before the age of viability. Types: 1. Spontaneous (Table) ± miscarriage w/o medical or mechanical intervention. 2. Induced 1. Therapeutic ± to safeguard maternal life/health 2. Criminal/Elective- performed in abortion clinics or hospitals Causes of Abortion 1. Defective ovum/congenital defects. 2. Unknown causes 3. Maternal factors 1. Chronic infection, fibroid tumors. 2. Malnutrition, severe anemia 3. Trauma 4. Endocrine disturbance: progesterone and thyroid hormone dysfunction. 5. Exposure to tetratogens. 6. Environmental hazards. Signs of Abortion (Assessment findings) 1. Vagina Bleeding ± observe carefully for accurate determination of amount saving all perineal pads. 2. Contractions, pelvic cramping, backache 3. Passage of tissues/fetus 4. Cervical dilatation 5. Lowered hemoglobin if blood loss is significant.(less than 10.5mg/dL) 6. Signs related to blood loss- pallor, tachycardia, tachypnea, cold clammy skin, restless, oliguria, hypotension, air hunger. Complications of Abortion 1. Hemorrhage 2. Infection 3. Infertility 4. Uterine perforation from curettage 5. PID (Pelvic Inflammatory disease. 6. Retained products of conception, may lead to H- mole 7. Anemia Clinical Classification of Spontaneous Abortion Type of Bleeding Abdomi Cervical Passage of Fever Abortion nal Dilatation tissue Cramps Threatened Slight Slight if none none None present Inevitable Moderat Moderat With Membrane none e to e to effacement s may severe severe rupture, loss of fetus Complete Small to none open Placenta none moderat w/ e fetus(com plete Type of Bleeding Abdomina Cervical Passage of Fever l cramps Dilatation tissue Abortion Incomplete Severe Severe Open w/ Fetal or None tissue in the placental cervix tissue; membranes of placenta retained Missed None to None none none none severe (no FHT) Habitual 3 May Of any or more represent of the signs above Septic Mild to severe Maybe W/ or w/o. yes severe close or foul open smelling dis TYPE NRSNG CONSIDERATIONS/TREATMENTS THREATEND :Ultrasound for uterine sac. :Decreased activity for 24-48 hrs, avoid stress :No sexual intercourse for 2 wks. After bleeding stops. :Monitor amount and character of bleeding Inevitable :Monitor for bleeding. :Emotional support :D & C :Fluid replacement, IV¶s, crossmatch for possible blood BT TYPE NRSNG CONSIDERATIONS/TREATMENTS Incomplete :Administer oxytocin/IV :D & C or suction evacuation Complete :Possible oxytocin PO; no other Tx if no evidence of hemorrhage or infection. Missed :D & C w/in 4-6 wks :After 12 wks, dilate cervix w/ several applications of prostaglandin gel or suppositories of laminaria (dried sterilized seaweed that expands w/ cervical secretions) Habitual :Cerclage (encircling cervix w/ suture) Ectopic Pregnancy ( Any gestation outside the uterine cavity ( Most frequent in the fallopian tubes, where the tissue is incapable of the growth needed to accommodate pregnancy. Predisposing factors 1. Fallopian Tube 1. Surgery 2. Congenital anomalies of the tube 3. Adhesions, spasm, tumors 4. Postabortion sepsis 5. PID 2. IUD Usage Types 1. Tubal ± the most common, 90 ± 95% of cases; tubal rupture occurs before 12 weeks 2. Ovarian 3. Abdominal 4. Cervical Signs/Assessment 1. History of missed periods and symptoms of early pregnancy 2. Positive pregnancy test only in about 50% of cases (hCG is low in ectopic pregnancy) 3. Vaginal bleeding 4. Cullen¶s sign ± Bluish navel due to internal bleeding 5. Abdominal pain ± unilateral radiating to the shoulders; 1st sign corresponding to the rupture of the tube. If tube is unruptured ± usually, chronic bleeding with the abdomen gradually becoming rigid and very tender. 6. Lab results: : Low Hgb and Hct : Low HCG (NV: 400,000 I.U. in 24 hrs) : Increased WBC Diagnosis 1. Ultrasound 2. Laparoscopy ± an procedure that provides visualization of the pelvic organs via small external incision on the abdomen 3. Culdocentesis ± assesses intraperitoneal bleeding by needle puncture of the cul-de-sac of Douglas. Treatment 1. Surgery ± Salpingectomy 2. Methotrexate Nursing Interventions 1. Monitor v/s, bleeding, I & O 2. Institute measures to control/treat shock 3. Physical and Psychological preparation of client for surgery 4. Allow client to express feelings about loss of pregnancy and concerns about future pregnancies. Hydatidiform mole (Gestational Trophoblastic Disease) ( A developmental anomaly of the chorion where it fails to develop and instead degenerate and become fluid filled vesicles. ( Common in Orient and in people of low socio- economic status ( Cause ; unknown Predisposing factors 1. Increase maternal age 2. Low socio-economic status 3. Low protein diet 4. Hx of abortion 5. Clomiphene therapy to induce ovulation Signs/Assessment 1. Dark red to brownish vaginal bleeding, intermittent or profuse bleeding by 12 weeks. 2. Size of uterus is disproportionate to the length of pregnancy; (bigger) 3. Excessive N & V due to high level of HCG. 4. Symptoms of preeclampsia under 20 weeks. 5. No fetal heart sounds or palpation of fetal parts. 6. Ultrasound shows no fetal skeleton. 7. Anemia Nursing Interventions 1. Monitor v/s, bleeding, I & O 2. Provide pre and postoperative care for evacuation of uterus 3. Provide emotional support for loss pregnancy of the client. 4. Prepare for discharge: 1. Emphasize the need for ff-up lad work to detect rising HCG levels indicative of carcinoma. 2. Teach contraceptive methods to avoid pregnancy for at least 1 year. Treatment 1. Surgical ± D & C 2. Medical- follow up supervision for 1 year. 1. Weekly serum HCG level, until they are negative, then every other week for 3-4 months; then monthly for a year 2. Pelvic exam may be required every 2 wks. During the early period after the D & C Placenta Previa ( Low implantation of the placenta so that it overlays some or all of the internal cervical os. Predisposing factors 1. Multiparity 2. Uterine factors: 1. Poor vascularity 2. Fibroid tumors 3. Increased age ± above 35 years old Types/stages/Degree 1. Marginal ± placenta lies over the margins of the internal os 2. Partial ± partially covers the internal os 3. Complete ± totally covers the internal os Signs/Assessment 1. Cardinal sign ± painless bright red vaginal bleeding. Bleeding may be intermittent,in gushes, or continuous. 2. Uterus remains soft. 3. FHR usually stable unless maternal shock present. Diagnosis 1. Ultrasound to locate placenta. Treatment 1. Hospitalization initially 2. Send home if bleeding ceases and pregnancy to be maintained Nursing Interventions 1. Bedrest side-lying or Trendelenburg position for at least 72 hrs. 2. No vaginal, rectal exam unless delivery would not be a problem. Maintain sterile conditions for any invasive procedures. 3. Monitor maternal/fetal v/s 4. Daily Hgh and Hct. 5. 2 units cross of cross-matched blood available 6. Monitor amount of blood loss 7. Amniocentesis for lung maturity of the fetus. 8. Make provision for double set-up procedure. 9. Provide Physical and psychological comfort Abruptio Placentae ( Separation of Placenta from part or all of normal implantation site. Predisposing Factors 1. Seen frequently in women with hypertension, previous abruptio placentae, late pregnancies, and multigravidas, but cause is essentially unknown. 2. Short umbilical cord 3. Trauma 4. Advance age 50% of cases results as a consequence of convulsion in eclampsia Types 1. Concealed/covert/central 1. Placenta separates at the center-causing blood the accumulate behind the placenta. 2. Bleeding not evident 3. Signs of shock not proportional to the amount of external bleeding 2. Marginal/overt/external bleeding type 1. Placental separates at the margins 2. Bleeding is external. Signs/Assessment 3. Painful vaginal bleeding 4. Abdomen (uterus) is tender boardlike, painful, tense 5. Usually occurs after the 20th week of pregnancy 6. Slow or absent FHT 5. Watch out for signs of shock 6. If in labor; absent alternating contraction and relaxation of the uterus. Diagnosis 1. Clinical Diagnosis is by means of the s/s 2. Ultrasound can detect the retroplacental clot. 3. Clotting studies: DIC ± disseminated intravascular coagulation. 1. Complications:CVA, Couvelaire uterus (segment of uterus may not contract well ± hysterectomy), hypofibrinogemia. Nursing Interventions 1. Ensure bedrest 2. Careful monitoring 1. Maternal v/s 2. FHR 3. Labor onset/progress 4. Uterine pain 5. Bleeding 6. I & O (oliguria/anuria) 3. Administer fluid, plasma, & blood replacement as ordered. 4. Prepare for emergency surgery as indicated 5. Provide psychological support; explain what is happening 6. Observe for associated problems after delivery. 1. Poorly contracting uterus (Couvelaire) 2. DIC 3. Neonatal distress