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OB 8 - High risk pregnancy
Bsc nursing (blaw 213)
Kerala University of Health Sciences
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Unit 8 Assessment and Management Learning Objectives reading this unit, the learner will be able to: Describe screening and assessment in case of high risk pregnancy. Define hyperemesis gravidarum, its causes, signs and symptoms. Explain the nursing management of patient with hyperemesis gravidarum. Define antepartum hemorrhage. Explain its types in detail. Define ectopic pregnancy, sites of implementation of ectopic pregnancy, its causes and management of tubal ectopic pregnancy. Define preeclampsia, its causes, signs and symptoms. Explain the management of patient. Define the meaning of eclampsia, stages of convulsion, and complications of eclampsia. Define hydatidiform mole, its clinical manifestations, complication of H. mole and obstetrical management of H. mole. Enlist uterine abnormalities and displacements. Enumerate the diseases complicating pregnancy. Discuss the gynecological diseases complicating pregnancy. Explain gestational diabetes mellitus in detail. Define hydramnios. Explain the types of hydramnios, its causes, signs and symptoms. Explain the nursing management of patent with hyperemesis gravidarum. Explain Rh Incompatibility. Discuss in detail the mental disorder that occurs during pregnancy. Explain adolescent pregnancy. Describe elderly primigravida. Explain grand multipara in detail. Define multiple pregnancy. Explain the types of twins, its causes, signs and symptoms. Explain the management of twin delivery. Describe the abnormalities of placenta and cord. Discuss intrauterine growth retardation in detail. Unit 8 Assessment and Management Learning Objectives reading this unit, the learner will be able to: Describe screening and assessment in case of high risk pregnancy. Define hyperemesis gravidarum, its causes, signs and symptoms. Explain the nursing management of patient with hyperemesis gravidarum. Define antepartum hemorrhage. Explain its types in detail. Define ectopic pregnancy, sites of implementation of ectopic pregnancy, its causes and management of tubal ectopic pregnancy. Define preeclampsia, its causes, signs and symptoms. Explain the management of patient. Define the meaning of eclampsia, stages of convulsion, and complications of eclampsia. Define hydatidiform mole, its clinical manifestations, complication of H. mole and obstetrical management of H. mole. Enlist uterine abnormalities and displacements. Enumerate the diseases complicating pregnancy. Discuss the gynecological diseases complicating pregnancy. Explain gestational diabetes mellitus in detail. Define hydramnios. Explain the types of hydramnios, its causes, signs and symptoms. Explain the nursing management of patent with hyperemesis gravidarum. Explain Rh Incompatibility. Discuss in detail the mental disorder that occurs during pregnancy. Explain adolescent pregnancy. Describe elderly primigravida. Explain grand multipara in detail. Define multiple pregnancy. Explain the types of twins, its causes, signs and symptoms. Explain the management of twin delivery. Describe the abnormalities of placenta and cord. Discuss intrauterine growth retardation in detail. Textbook of Obstetric and Gynecological Nursing for KUHS Unit Outline Pelvic Inflammatory Disease Levels of Care (Primary, Secondary, Tertiary Pelvic Tuberculosis Level) TORCH (Toxoplasmosis, Rubella Disorders of Pregnancy Cytomegalovirus, Herpes Simplex) and Hyperemesis Gravidarum Sexually Transmitted Diseases (STDs) Abortion Medical Termination of Pregnancy (MTP) Urinary Tract Infection (UTI) Gynecological Disorders Complicating Ectopic Pregnancy Hydatidiform Trophoblastic Pregnancy Benign and Malignant Tumors of the Disease Reproductive Tract Antepartum Hemorrhage Pregnancy Induced Hypertension Uterine Abnormalities Preeclampsia Uterine Displacements Diseases Complicating Pregnancy Eclampsia Medical Illness During Pregnancy Gestational Diabetes Mellitus (GDM) Anemia Hydramnios Viral Infections in Pregnancy Rh Incompatibility Acquired Immunodeficiency Syndrome Multiple Pregnancy HIV Infection in Pregnancy Mental Disorders in Pregnancy Jaundice in Pregnancy Adolescent Pregnancy (Teenage Pregnancy) Heart Diseases in Pregnancy Elderly Primigravida Gestational Diabetes Mellitus (GDM) Grand Multipara Parasitic and Protozoal Infestations in Abnormalities of Placenta and Cord Pregnancy Intrauterine Growth Thyroid Dysfunction and Pregnancy Growth Restriction (IUGR) Surgical Illness during Pregnancy Coagulation Failure in Pregnancy Infections of the Genital Tract Immunology in Pregnancy Pelvic Abscess LEVELS OF CARE (PRIMARY, SECONDARY, TERTIARY LEVEL) Levels of maternal care: Modified from American College of Obstetriciaus and gyneocologists 2015. Level Definition, capabilities and example of patients Birth center (level 0) Definition: Care for low risk, uncomplicated, singleton, vertex presentation, term pregnancy. Capabilities: Ready to initiate emergency procedure immediately. Indication: Term, singleton, head presentation. Basic Care (level 1) Definition: Possible to detect, stabilize, begin a management of unexpected be maternal and fetal complications in uncomplicated pregnancy until patient can transferred. available Capabilities: Well organized system to operate emergency cesarean section, of lab test, blood bank supply, obstetric ultrasonographic evaluation at all the times, possible for massive transfusion, emergency release of blood products. Indication: Twin term pregnancy, uncomplicated cesarean section, try to expect labor in previous cesarean section history, preeclampsia without any severe symptom in term. Contd... Textbook of Obstetric and Gynecological Nursing for KUHS Unit Outline Pelvic Inflammatory Disease Levels of Care (Primary, Secondary, Tertiary Pelvic Tuberculosis Level) TORCH (Toxoplasmosis, Rubella Disorders of Pregnancy Cytomegalovirus, Herpes Simplex) and Hyperemesis Gravidarum Sexually Transmitted Diseases (STDs) Abortion Medical Termination of Pregnancy (MTP) Urinary Tract Infection (UTI) Gynecological Disorders Complicating Ectopic Pregnancy Hydatidiform Trophoblastic Pregnancy Benign and Malignant Tumors of the Disease Reproductive Tract Antepartum Hemorrhage Pregnancy Induced Hypertension Uterine Abnormalities Preeclampsia Uterine Displacements Diseases Complicating Pregnancy Eclampsia Medical Illness During Pregnancy Gestational Diabetes Mellitus (GDM) Anemia Hydramnios Viral Infections in Pregnancy Rh Incompatibility Acquired Immunodeficiency Syndrome Multiple Pregnancy HIV Infection in Pregnancy Mental Disorders in Pregnancy Jaundice in Pregnancy Adolescent Pregnancy (Teenage Pregnancy) Heart Diseases in Pregnancy Elderly Primigravida Gestational Diabetes Mellitus (GDM) Grand Multipara Parasitic and Protozoal Infestations in Abnormalities of Placenta and Cord Pregnancy Intrauterine Growth Thyroid Dysfunction and Pregnancy Growth Restriction (IUGR) Surgical Illness during Pregnancy Coagulation Failure in Pregnancy Infections of the Genital Tract Immunology in Pregnancy Pelvic Abscess LEVELS OF CARE (PRIMARY, SECONDARY, TERTIARY LEVEL) Levels of maternal care: Modified from American College of Obstetriciaus and gyneocologists 2015. Level Definition, capabilities and example of patients Birth center (level 0) Definition: Care for low risk, uncomplicated, singleton, vertex presentation, term pregnancy. Capabilities: Ready to initiate emergency procedure immediately. Indication: Term, singleton, head presentation. Basic Care (level 1) Definition: Possible to detect, stabilize, begin a management of unexpected be maternal and fetal complications in uncomplicated pregnancy until patient can transferred. available Capabilities: Well organized system to operate emergency cesarean section, of lab test, blood bank supply, obstetric ultrasonographic evaluation at all the times, possible for massive transfusion, emergency release of blood products. Indication: Twin term pregnancy, uncomplicated cesarean section, try to expect labor in previous cesarean section history, preeclampsia without any severe symptom in term. Contd... Textbook of Obstetric and Gynecological Nursing for KUHS Alkalosis resulting from loss of HCI in vomitus. Jaundice develops in severe cases. Low urine output. Rapid pulse and low blood pressure. Hemoconcentration with rising blood urea nitrogen and falling serum levels of sodium, potassium chloride. The condition is said to be mild when there is loss of weight, but no dehydration. Moderate cases characterized dehydration and circulatory changes. Severe cases have biochemical changes with are complications (metabolic acidosis). Investigation Urinalysis: Quantity small. Dark color. High specific gravity with acid reaction. Presence of acetone, protein or bile pigments. Diminish absence of chloride. changes: Changes in the levels of serum electrolyte (sodium, potassium and chloride). Serum TSH, T3 and free T4. Ophthalmoscopic examination in severe cases to detect retinal hemorrhage or detachment of retina. ECG in case of abnormal serum potassium level. Complications Circulatory changes. Jaundice due to liver involvement. Retinal hemorrhage. encephalopathy. syndrome (disorientation and loss of memory). Renal insufficiency and renal failure. Polyneuritis. Delirium, coma, death. Management Women with hyperemesis gravidarum are admitted to hospital. Initially nothing is given mouth (at least 24 hours after the cessation of vomiting). Hypovolemia L of fluid and electrolyte imbalances are corrected administering intravenous fluid. Approximately, 3 of is to be infused in 24 hours, out of which half is dextrose and half is ringer solution. Extra Enteral amount crystalloids equal to the amount of vomitus and urine in 24 is to be added. nutrition through nasogastric tube is also helpful to manage the hours, condition. Some Mother should be encouraged to rest and should be cared in a single room. women are prescribed a mild sedative, if they are agitated. Supportive psychotherapy and counseling may help. regain her appetite. Gradually, full diet is restored. biscuits, toast are given. Small palatable meals at regular interval may help the mother to Before the bread intravenous and fluid is omitted, the foods are given orally. At first, dry carbohydrate foods items. Instruct the mother for Dietary recommendations, e., avoid taking fatty, spicy and preserved food Textbook of Obstetric and Gynecological Nursing for KUHS Alkalosis resulting from loss of HCI in vomitus. Jaundice develops in severe cases. Low urine output. Rapid pulse and low blood pressure. Hemoconcentration with rising blood urea nitrogen and falling serum levels of sodium, potassium chloride. The condition is said to be mild when there is loss of weight, but no dehydration. Moderate cases characterized dehydration and circulatory changes. Severe cases have biochemical changes with are complications (metabolic acidosis). Investigation Urinalysis: Quantity small. Dark color. High specific gravity with acid reaction. Presence of acetone, protein or bile pigments. Diminish absence of chloride. changes: Changes in the levels of serum electrolyte (sodium, potassium and chloride). Serum TSH, T3 and free T4. Ophthalmoscopic examination in severe cases to detect retinal hemorrhage or detachment of retina. ECG in case of abnormal serum potassium level. Complications Circulatory changes. Jaundice due to liver involvement. Retinal hemorrhage. encephalopathy. syndrome (disorientation and loss of memory). Renal insufficiency and renal failure. Polyneuritis. Delirium, coma, death. Management Women with hyperemesis gravidarum are admitted to hospital. Initially nothing is given mouth (at least 24 hours after the cessation of vomiting). Hypovolemia L of fluid and electrolyte imbalances are corrected administering intravenous fluid. Approximately, 3 of is to be infused in 24 hours, out of which half is dextrose and half is ringer solution. Extra Enteral amount crystalloids equal to the amount of vomitus and urine in 24 is to be added. nutrition through nasogastric tube is also helpful to manage the hours, condition. Some Mother should be encouraged to rest and should be cared in a single room. women are prescribed a mild sedative, if they are agitated. Supportive psychotherapy and counseling may help. regain her appetite. Gradually, full diet is restored. biscuits, toast are given. Small palatable meals at regular interval may help the mother to Before the bread intravenous and fluid is omitted, the foods are given orally. At first, dry carbohydrate foods items. Instruct the mother for Dietary recommendations, e., avoid taking fatty, spicy and preserved food Unit 8 and Management Antiemetic (phenergan 25 mg, stemetil 5 mg twice daily) is helpful to treat nausea and vomiting. Hydrocortisone 100mg IV in the drip is given in case with hypotension or in intractable vomiting. Oral prednisolone is also used in severe cases, Nutritional supplements (Vitamin B1, B6, B12 and vitamin C) are helpful to treat this condition. To monitor the recovery, check and record temperature, pulse, blood pressure at least twice daily. Maintain chart. Note the presence of acetone, protein and bile in the urine. Monitor blood biochemistry level and ECG report, if serum potassium level is abnormal. Termination of pregnancy is recommended in severe cases with jaundice, persistent albuminuria, poly neuritis to reverse the condition and to prevent maternal mortality. Nursing Process for Client with Hyperemesis Gravidarum Assessment Intractable vomiting. Weight loss. Ketosis, ketonuria. Dehydration. Epigastric pain. Drowsiness and confusion. Uncoordinated movements, jerking. Urine output and total intake. Goals and Objectives Ensure that the woman: Is Has normal electrolyte values. Verbalizes feelings and ability to cope with the pregnancy. Verbalizes knowledge of need for fluids. Nursing Diagnosis Risk for fetal injury. Risk for infection. Ineffective airway clearance. Risk for aspiration. Anxiety related to pregnancy outcome. Anticipatory grieving. Altered family coping. Planning Provide fluids to fluid and electrolyte balance. Create opportunities for the woman to explore out the feelings about pregnancy and her coping abilities. Provide teaching related to need for fluids and the dietary changes. Implementation Administer parenteral fluids, vitamins and sedatives as prescribed. Monitor intake, output and daily weight. Assess state of hydration. 329 Unit 8 and Management Antiemetic (phenergan 25 mg, stemetil 5 mg twice daily) is helpful to treat nausea and vomiting. Hydrocortisone 100mg IV in the drip is given in case with hypotension or in intractable vomiting. Oral prednisolone is also used in severe cases, Nutritional supplements (Vitamin B1, B6, B12 and vitamin C) are helpful to treat this condition. To monitor the recovery, check and record temperature, pulse, blood pressure at least twice daily. Maintain chart. Note the presence of acetone, protein and bile in the urine. Monitor blood biochemistry level and ECG report, if serum potassium level is abnormal. Termination of pregnancy is recommended in severe cases with jaundice, persistent albuminuria, poly neuritis to reverse the condition and to prevent maternal mortality. Nursing Process for Client with Hyperemesis Gravidarum Assessment Intractable vomiting. Weight loss. Ketosis, ketonuria. Dehydration. Epigastric pain. Drowsiness and confusion. Uncoordinated movements, jerking. Urine output and total intake. Goals and Objectives Ensure that the woman: Is Has normal electrolyte values. Verbalizes feelings and ability to cope with the pregnancy. Verbalizes knowledge of need for fluids. Nursing Diagnosis Risk for fetal injury. Risk for infection. Ineffective airway clearance. Risk for aspiration. Anxiety related to pregnancy outcome. Anticipatory grieving. Altered family coping. Planning Provide fluids to fluid and electrolyte balance. Create opportunities for the woman to explore out the feelings about pregnancy and her coping abilities. Provide teaching related to need for fluids and the dietary changes. Implementation Administer parenteral fluids, vitamins and sedatives as prescribed. Monitor intake, output and daily weight. Assess state of hydration. 329 Unit 8 and Management Premature rupture of membranes: Inevitably leads to abortion. Inherited thrombophilia and protein C resistance cause both early and late miscarriages. Environmental factors: Smoking Alcohol Contraceptive agents Drugs, chemicals, noxious agents Unexplained: of abortion cause is unknown. Threatened Abortion Definition: It means that the process of miscarriage has started but has not progressed to stage from where recovery is impossible. Signs and Symptoms Bleeding per vagina: Slight bleeding that may be brownish or bright red in color. Bleeding usually stops spontaneously. Pain: Bleeding is painless. There may be mild backache or dull pain in lower abdomen, usually following hemorrhage. Investigations Blood test: For hemoglobin, hematocrit, ABO and Rh grouping. Urine test: For immunological test of pregnancy. Ultrasonography (TVS). Serum progesterone, serum hCG values are helpful to assess fetal Management Rest: Patient should be on bed until bleeding stops. Drugs: Diazepam 5 mg tablet twice daily for relief of pain. Advise patient to avoid heavy work load. Avoid intercourse. Advise patient for with repeated ultrasonography at weeks time. Inevitable Abortion Definition: It is the state of abortion from where continuation of pregnancy is impossible. Signs and Symptoms Increased vaginal bleeding. Lower abdominal in nature. Dilated internal OS. Management Administration of methergine 0 mg to control bleeding. If Start intravenous (IV) fluid therapy or in severe cases blood transfusion is required. gestation is weeks, dilatation and evacuation is followed curettage of the uterine cavity under general anesthesia. Suction evacuation followed curettage is done. 331 Unit 8 and Management Premature rupture of membranes: Inevitably leads to abortion. Inherited thrombophilia and protein C resistance cause both early and late miscarriages. Environmental factors: Smoking Alcohol Contraceptive agents Drugs, chemicals, noxious agents Unexplained: of abortion cause is unknown. Threatened Abortion Definition: It means that the process of miscarriage has started but has not progressed to stage from where recovery is impossible. Signs and Symptoms Bleeding per vagina: Slight bleeding that may be brownish or bright red in color. Bleeding usually stops spontaneously. Pain: Bleeding is painless. There may be mild backache or dull pain in lower abdomen, usually following hemorrhage. Investigations Blood test: For hemoglobin, hematocrit, ABO and Rh grouping. Urine test: For immunological test of pregnancy. Ultrasonography (TVS). Serum progesterone, serum hCG values are helpful to assess fetal Management Rest: Patient should be on bed until bleeding stops. Drugs: Diazepam 5 mg tablet twice daily for relief of pain. Advise patient to avoid heavy work load. Avoid intercourse. Advise patient for with repeated ultrasonography at weeks time. Inevitable Abortion Definition: It is the state of abortion from where continuation of pregnancy is impossible. Signs and Symptoms Increased vaginal bleeding. Lower abdominal in nature. Dilated internal OS. Management Administration of methergine 0 mg to control bleeding. If Start intravenous (IV) fluid therapy or in severe cases blood transfusion is required. gestation is weeks, dilatation and evacuation is followed curettage of the uterine cavity under general anesthesia. Suction evacuation followed curettage is done. 331 Textbook Obstetric and Gynecological Nursing for KUHS oxytocin drip (10 units is expelled but placenta is retained If gestation is saline separated, then digital separation normal at separated). not of removed ovum forceps, lying evacuation is done under general anesthesia. Complete Miscarriage Definition: When whole product of conception is expelled out it is called complete abortion. Signs and Symptoms History of expulsion of fleshy mass per vagina. Subsidence of abdominal pain followed expulsion. Vaginal bleeding becomes trace or absent. Uterus is smaller than period of amenorrhea. On vaginal examination, cervical os is found to be closed. On examination, the expelled fleshy mass is found intact. Management If there is doubt about complete expulsion of the products, transvaginal sonography is helpful, or uterine curettage should be done. The woman with gestation more than 12 weeks, gamma globulin 50 microgram or 100 microgram within 72 hours of abortion. Incomplete Abortion Definition: When the whole product of conception is not expelled out instead some parts remain inside the uterine cavity this situation is called incomplete abortion. Signs and Symptoms Continuous, colicky lower abdominal pain. Persistant vaginal bleeding. Uterus is smaller than the period of amenorrhea. Patulous cervical os admit tip of the finger. Expelled mass found to be incomplete abortion on examination. Management If the undertaken. In case patient of is in shock due should be resuscitated before any active treatment is In done. late abortion early abortion (before 12 dilatation and evacuation under general anasthesia is to be examination. removed (after 12 is evacuated under general anesthesia and the products are products Missed are Abortion subjected to a histological (Silent Definition: Miscarriage) the is abortion. 332 Textbook Obstetric and Gynecological Nursing for KUHS oxytocin drip (10 units is expelled but placenta is retained If gestation is saline separated, then digital separation normal at separated). not of removed ovum forceps, lying evacuation is done under general anesthesia. Complete Miscarriage Definition: When whole product of conception is expelled out it is called complete abortion. Signs and Symptoms History of expulsion of fleshy mass per vagina. Subsidence of abdominal pain followed expulsion. Vaginal bleeding becomes trace or absent. Uterus is smaller than period of amenorrhea. On vaginal examination, cervical os is found to be closed. On examination, the expelled fleshy mass is found intact. Management If there is doubt about complete expulsion of the products, transvaginal sonography is helpful, or uterine curettage should be done. The woman with gestation more than 12 weeks, gamma globulin 50 microgram or 100 microgram within 72 hours of abortion. Incomplete Abortion Definition: When the whole product of conception is not expelled out instead some parts remain inside the uterine cavity this situation is called incomplete abortion. Signs and Symptoms Continuous, colicky lower abdominal pain. Persistant vaginal bleeding. Uterus is smaller than the period of amenorrhea. Patulous cervical os admit tip of the finger. Expelled mass found to be incomplete abortion on examination. Management If the undertaken. In case patient of is in shock due should be resuscitated before any active treatment is In done. late abortion early abortion (before 12 dilatation and evacuation under general anasthesia is to be examination. removed (after 12 is evacuated under general anesthesia and the products are products Missed are Abortion subjected to a histological (Silent Definition: Miscarriage) the is abortion. 332 Obstetric Textbook the parametrium, tubes Grade endotoxic shock, jaundice or acute Grade Investigations high swab for or sensitivity Cervical or Urine analysis Blood test for hemoglobin, total and differential count of white cells, ABO and Rh Kidney and liver function test. Coagulation profile. Upright of abdomen and pelvis to detect uterine and gut perforation and peritonitis. Pelvic imaging studies include pelvic ultrasound for retained products of uterus, pelvic abscess peritonitis with pyoperitoneum, CT scan and MRI are also helpful. foreign body Complications Immediate Hemorrhage due to abortion or injury. Injury to uterus or adjacent structures, e., bowel or bladder. Spread of infection leads to: Generalized peritonitis Endotoxic shock Acute renal failure Thrombophlebitis Remote Chronic debility Chronic pelvic pain and backache Dyspareunia Ectopic pregnancy Depression Secondary infertility due to tubal blockage Management The treatment of shock, Large i., doses acute circulatory septic abortion failure depends with sepsis. on grade The of infection. The most serious complication is septic of broad spectrum antibiotics management calls for the Early Monitoring and correcting septic foci. blood volume and control electrolyte infection. imbalance. following: removal of Antibiotics If infection is are given and If the symptoms tissue remain in the evacuation advice uterus, oral antibiotics to rest. Moderate to should tender, dilatation and curettage or suction parenterally in use of antibiotics. Selected antibiotic for organisms. Antibiotic should be given hours. Obstetric Textbook the parametrium, tubes Grade endotoxic shock, jaundice or acute Grade Investigations high swab for or sensitivity Cervical or Urine analysis Blood test for hemoglobin, total and differential count of white cells, ABO and Rh Kidney and liver function test. Coagulation profile. Upright of abdomen and pelvis to detect uterine and gut perforation and peritonitis. Pelvic imaging studies include pelvic ultrasound for retained products of uterus, pelvic abscess peritonitis with pyoperitoneum, CT scan and MRI are also helpful. foreign body Complications Immediate Hemorrhage due to abortion or injury. Injury to uterus or adjacent structures, e., bowel or bladder. Spread of infection leads to: Generalized peritonitis Endotoxic shock Acute renal failure Thrombophlebitis Remote Chronic debility Chronic pelvic pain and backache Dyspareunia Ectopic pregnancy Depression Secondary infertility due to tubal blockage Management The treatment of shock, Large i., doses acute circulatory septic abortion failure depends with sepsis. on grade The of infection. The most serious complication is septic of broad spectrum antibiotics management calls for the Early Monitoring and correcting septic foci. blood volume and control electrolyte infection. imbalance. following: removal of Antibiotics If infection is are given and If the symptoms tissue remain in the evacuation advice uterus, oral antibiotics to rest. Moderate to should tender, dilatation and curettage or suction parenterally in use of antibiotics. Selected antibiotic for organisms. Antibiotic should be given hours. and Management medicines are: Commonly Gentamycin dose) gas gangrene serum units should be given. immunized for tetanus, serum units IU IM may be also of Blood Loss may occur due to: Abortion or delivery process. tissue. Retained Trauma to cervix, vagina and uterus, Secondary hemorrhage may persist after weeks. It is irregular and often heavier than normal menses. Hemorrhage may be caused disruption of clotting mechanism. DIC can occur with severe sepsis, curettage for missed abortion or removal of dead fetus from the uterus. Surgical Therapy (Removal of Septic Foci) Retained products of conception are common after illegal abortion due to septic technique. As abortion is often incomplete, evacuation should be performed at a convenient time within 24 hours following antibiotic therapy. Excessive bleeding is, of course, an urgent indication for evacuation. Early emptying not only minimizes the risk of hemorrhage but also removes the nidus of infection. But if infection is not localized and spreads to other organs, evacuation should be withheld for at least 48 hours after antibiotic therapy. Posterior colpotomy is to be done, if the infection is localized in the pouch of abscess is formed. Role of Nurse in Prevention of Sepsis Provide women with basic health education on human reproduction Socioeconomic conditions need to be improved and steps are taken to correct malnutrition and anemia Provide essential obstetric care to all pregnant women Nurse should guide women for safe legal abortion especially in peripheral and rural areas The traditional dais and midwives are trained for aseptic precautions Nurse should diagnose early, a case of septic abortion and sent them to appropriate centers for prompt Nurse management can provide intensive, multi disciplinary medical care to patients suffering from septic shock and Nurse should boost up family planning acceptance in order to curb the unwanted pregnancies its complications Recurrent Abortion Definition: It is defined as a sequence of three or more spontaneous consecutive abortions. Causes Genetic factors. Endocrine and metabolic disorders: Diabetic mother Thyroid disorder Luteal Phase Defect (LPD) Polycystic Ovary Syndrome (PCOs) 335 and Management medicines are: Commonly Gentamycin dose) gas gangrene serum units should be given. immunized for tetanus, serum units IU IM may be also of Blood Loss may occur due to: Abortion or delivery process. tissue. Retained Trauma to cervix, vagina and uterus, Secondary hemorrhage may persist after weeks. It is irregular and often heavier than normal menses. Hemorrhage may be caused disruption of clotting mechanism. DIC can occur with severe sepsis, curettage for missed abortion or removal of dead fetus from the uterus. Surgical Therapy (Removal of Septic Foci) Retained products of conception are common after illegal abortion due to septic technique. As abortion is often incomplete, evacuation should be performed at a convenient time within 24 hours following antibiotic therapy. Excessive bleeding is, of course, an urgent indication for evacuation. Early emptying not only minimizes the risk of hemorrhage but also removes the nidus of infection. But if infection is not localized and spreads to other organs, evacuation should be withheld for at least 48 hours after antibiotic therapy. Posterior colpotomy is to be done, if the infection is localized in the pouch of abscess is formed. Role of Nurse in Prevention of Sepsis Provide women with basic health education on human reproduction Socioeconomic conditions need to be improved and steps are taken to correct malnutrition and anemia Provide essential obstetric care to all pregnant women Nurse should guide women for safe legal abortion especially in peripheral and rural areas The traditional dais and midwives are trained for aseptic precautions Nurse should diagnose early, a case of septic abortion and sent them to appropriate centers for prompt Nurse management can provide intensive, multi disciplinary medical care to patients suffering from septic shock and Nurse should boost up family planning acceptance in order to curb the unwanted pregnancies its complications Recurrent Abortion Definition: It is defined as a sequence of three or more spontaneous consecutive abortions. Causes Genetic factors. Endocrine and metabolic disorders: Diabetic mother Thyroid disorder Luteal Phase Defect (LPD) Polycystic Ovary Syndrome (PCOs) 335 Unit 8 and Management pushed up to expose the level of internal OS. A vertical incision is given posteriorly on junction. The nonabsorbable suture 4 braided nylon is passed submucously with the help of aneurysm needle to bring suture ends through the posterior incision. The anterior and posterior incisions are repaired interrupted stitches using chromic catgut. McDonald operation: In this, the nonabsorbable suture material is placed as a purse string high as possible at the junction of rugose vaginal epithelium and the smooth vaginal part of cervix below bladder level. The suture starts at the anterior wall and taking successive bites, it is carried around the lateral and posterior walls back to the anterior wall where the two ends of suture are tied. Postoperative patient should be on bed rest for days Natural progesterone and isoxsuprine injection and tablets are given The stitches are removed at 38th week or earlier, if pains start Contraindications of circlage operation: Intrauterine infection Ruptured membranes History of vaginal bleeding Severe uterine irritability Complications of circlage operation: Chorioamnionitis Rupture of membrane labor Nursing Responsibilities in Abortion Check vital signs, blood test, bleeding and vaginal secretion (character, color and volume). Maintain strict aseptic technique. Strengthen the perineal care and maintain the vulval cleanliness. Psychological care: Sympathizing, understanding and caring. To check ultrasound result. Empty the bladder. Comfort the bladder. Postoperative Care after Abortion Monitor vital signs to identify any internal bleeding or infection especially blood pressure and pulse. Assess the conscious level, the presence of malaise, cold clammy skin, pale or dizziness to rule out possibility of hypovolemic shock. Assess for severity of pain and provide analgesic as required. Check vaginal bleeding weighing perineal pads. (Vaginal bleeding stops normally within days). Assess the IV line and drip to make sure no kinking, obstruction and inaccurate rate flow. Encourage fluid intake to prevent dehydration due to blood loss during abortion. Maintain strict aseptic technique while providing care to the patient to prevent cross infection. Strictly monitor intake and output. Maintain healthy diet to provide the body with enough nutrition for fast recovery. Provide emotional support, encourage family support due to pregnancy loss. Allow grieving and expression of her concerns over the loss of pregnancy. Refer the client to social support groups. 337 Unit 8 and Management pushed up to expose the level of internal OS. A vertical incision is given posteriorly on junction. The nonabsorbable suture 4 braided nylon is passed submucously with the help of aneurysm needle to bring suture ends through the posterior incision. The anterior and posterior incisions are repaired interrupted stitches using chromic catgut. McDonald operation: In this, the nonabsorbable suture material is placed as a purse string high as possible at the junction of rugose vaginal epithelium and the smooth vaginal part of cervix below bladder level. The suture starts at the anterior wall and taking successive bites, it is carried around the lateral and posterior walls back to the anterior wall where the two ends of suture are tied. Postoperative patient should be on bed rest for days Natural progesterone and isoxsuprine injection and tablets are given The stitches are removed at 38th week or earlier, if pains start Contraindications of circlage operation: Intrauterine infection Ruptured membranes History of vaginal bleeding Severe uterine irritability Complications of circlage operation: Chorioamnionitis Rupture of membrane labor Nursing Responsibilities in Abortion Check vital signs, blood test, bleeding and vaginal secretion (character, color and volume). Maintain strict aseptic technique. Strengthen the perineal care and maintain the vulval cleanliness. Psychological care: Sympathizing, understanding and caring. To check ultrasound result. Empty the bladder. Comfort the bladder. Postoperative Care after Abortion Monitor vital signs to identify any internal bleeding or infection especially blood pressure and pulse. Assess the conscious level, the presence of malaise, cold clammy skin, pale or dizziness to rule out possibility of hypovolemic shock. Assess for severity of pain and provide analgesic as required. Check vaginal bleeding weighing perineal pads. (Vaginal bleeding stops normally within days). Assess the IV line and drip to make sure no kinking, obstruction and inaccurate rate flow. Encourage fluid intake to prevent dehydration due to blood loss during abortion. Maintain strict aseptic technique while providing care to the patient to prevent cross infection. Strictly monitor intake and output. Maintain healthy diet to provide the body with enough nutrition for fast recovery. Provide emotional support, encourage family support due to pregnancy loss. Allow grieving and expression of her concerns over the loss of pregnancy. Refer the client to social support groups. 337 Textbook of Obstetric and Gynecological Nursing for KUHS MEDICAL TERMINATION OF PREGNANCY (MTP) abortion is the deliberate induction of abortion prior to 20 weeks gestation a registered medical Legal practitioner in the interest of health and life. Provision for MTP under MTP Act Continuation of pregnancy would involve serious risk of life or grave injury to the physical and mental health of the pregnant woman. There is substantial risk of the child being born with serious physical and mental abnormalities to handicapped in life. Pregnancy as a result of rape. Pregnancy is caused as a result of failure of contraceptive method (tubectomy or vasectomy). Where there are actual or reasonably foreseeable environments (social or economic) which could lead risk of injury to the health of the mother. Indications for MTP Therapeutic Deteriorating health due to pulmonary tuberculosis. Cardiac diseases grade and IV with history of decompensation. Chronic glomerulonephritis. Malignant hypertension. Intractable hyperemesis gravidarum. malignancy. Diabetes mellitus with retinopathy. Psychiatric illness. Social Pregnancy caused rape. Parous woman having unplanned pregnancy with low status. Pregnancy due to failure of contraceptive. Eugenic Risk Inherited of ba being chromosomal born with and various physical and mental abnormalities and include: Rubella infection in first trimester. Exposure to teratogenicity drugs or disorders. gene disorders, Congenital malformations of siblings. One or both parents mentally defective. Prerequisites for MTP Only a registered perform medical abortion practitioner the having the opinion of experience of The registered medical pregnancy gynecology and obstetrics procedure is required to approved the can government only be for MTP. is established necessary. maintained weeks. If pregnancy government is or weeks, places 338 Textbook of Obstetric and Gynecological Nursing for KUHS MEDICAL TERMINATION OF PREGNANCY (MTP) abortion is the deliberate induction of abortion prior to 20 weeks gestation a registered medical Legal practitioner in the interest of health and life. Provision for MTP under MTP Act Continuation of pregnancy would involve serious risk of life or grave injury to the physical and mental health of the pregnant woman. There is substantial risk of the child being born with serious physical and mental abnormalities to handicapped in life. Pregnancy as a result of rape. Pregnancy is caused as a result of failure of contraceptive method (tubectomy or vasectomy). Where there are actual or reasonably foreseeable environments (social or economic) which could lead risk of injury to the health of the mother. Indications for MTP Therapeutic Deteriorating health due to pulmonary tuberculosis. Cardiac diseases grade and IV with history of decompensation. Chronic glomerulonephritis. Malignant hypertension. Intractable hyperemesis gravidarum. malignancy. Diabetes mellitus with retinopathy. Psychiatric illness. Social Pregnancy caused rape. Parous woman having unplanned pregnancy with low status. Pregnancy due to failure of contraceptive. Eugenic Risk Inherited of ba being chromosomal born with and various physical and mental abnormalities and include: Rubella infection in first trimester. Exposure to teratogenicity drugs or disorders. gene disorders, Congenital malformations of siblings. One or both parents mentally defective. Prerequisites for MTP Only a registered perform medical abortion practitioner the having the opinion of experience of The registered medical pregnancy gynecology and obstetrics procedure is required to approved the can government only be for MTP. is established necessary. maintained weeks. If pregnancy government is or weeks, places 338 Textbook of Obstetric and Gynecological Nursing for KUHS Tubal Pregnancy tubes, it is called tubal pregnancy. in the fallopian Definition: When the pregnancy Causes and Pelvic Inflammatory Disease (PID): cause. It increases the risk of ectopic pregnancy, Salpingitis trachomatis infection is the most common Chlamydia Contraceptive failure: There are less chances of ectopic with the use of contraceptive devices but following is relative increase in tubal pregnancy (7 times more) if pregnancy occurs with JUD contraceptions increase the incidence of ectopic pregnancy. IUD: in situ. There CUT 380 A and levonorgestrel devices have the lowest rate of ectopic pregnancies whereas progestasert has got the highest one. Sterilization operation: There is highest incidence of being ectopic following laparoscopie bipolar coagulation. Use of progestin only pill or postcoital estrogen pills cause impaired tubal motility hence causes ectopic. Here are other reasons for tubal pregnancy: Tubal surgery: Tubal reconstructive surgery, tubal pathology, kinking of the tube or terminal stricture causes ectopic pregnancy. Intrapelvic adhesion: Following pelvic surgery the chances of being ectopic increases. Assisted reproductive techniques: Like IVF, embryo transfer increases the risk of ectopic pregnancy Developmental defect of the tube: Such as hypoplasia, undue tortuosity and tubal diverticula. Prior induced abortion: Increases the risk. Previous ectopic pregnancy: Increases the chances of ectopic Clinical Presentation of Ectopic Pregnancy Symptoms The classical triad of symptoms of ectopic pregnancy are: Amenorrhea: Short period of weeks there may be delayed period or history of vaginal spotting, amenorrhea may be absent even. Abdominal Pain pain: It is the most constant feature. It is acute, agonizing or colicky. Shoulder is located at lower abdomen: Unilateral, bilateral or may be generalized. be tip pain (referred pain due to diaphragmatic irritation from hemoperitoneum) may present. Vaginal Vomiting, bleeding may be slight and continuous. Expulsion of decidual cast be there. from hemoperitoneum. syncopal attack is due to reflex vasomotor disturbances following may peritoneal irritation Signs General Feature of shock: proportionate to the amount of Pallor: Severe look: The and patient looks quiet and conscious, perspires and looks blanched. and feeble, hypotension, internal cold hemorrhage. clammy extremities. 340 Textbook of Obstetric and Gynecological Nursing for KUHS Tubal Pregnancy tubes, it is called tubal pregnancy. in the fallopian Definition: When the pregnancy Causes and Pelvic Inflammatory Disease (PID): cause. It increases the risk of ectopic pregnancy, Salpingitis trachomatis infection is the most common Chlamydia Contraceptive failure: There are less chances of ectopic with the use of contraceptive devices but following is relative increase in tubal pregnancy (7 times more) if pregnancy occurs with JUD contraceptions increase the incidence of ectopic pregnancy. IUD: in situ. There CUT 380 A and levonorgestrel devices have the lowest rate of ectopic pregnancies whereas progestasert has got the highest one. Sterilization operation: There is highest incidence of being ectopic following laparoscopie bipolar coagulation. Use of progestin only pill or postcoital estrogen pills cause impaired tubal motility hence causes ectopic. Here are other reasons for tubal pregnancy: Tubal surgery: Tubal reconstructive surgery, tubal pathology, kinking of the tube or terminal stricture causes ectopic pregnancy. Intrapelvic adhesion: Following pelvic surgery the chances of being ectopic increases. Assisted reproductive techniques: Like IVF, embryo transfer increases the risk of ectopic pregnancy Developmental defect of the tube: Such as hypoplasia, undue tortuosity and tubal diverticula. Prior induced abortion: Increases the risk. Previous ectopic pregnancy: Increases the chances of ectopic Clinical Presentation of Ectopic Pregnancy Symptoms The classical triad of symptoms of ectopic pregnancy are: Amenorrhea: Short period of weeks there may be delayed period or history of vaginal spotting, amenorrhea may be absent even. Abdominal Pain pain: It is the most constant feature. It is acute, agonizing or colicky. Shoulder is located at lower abdomen: Unilateral, bilateral or may be generalized. be tip pain (referred pain due to diaphragmatic irritation from hemoperitoneum) may present. Vaginal Vomiting, bleeding may be slight and continuous. Expulsion of decidual cast be there. from hemoperitoneum. syncopal attack is due to reflex vasomotor disturbances following may peritoneal irritation Signs General Feature of shock: proportionate to the amount of Pallor: Severe look: The and patient looks quiet and conscious, perspires and looks blanched. and feeble, hypotension, internal cold hemorrhage. clammy extremities. 340 Unit 8 and Management Abdominal examination: Lower tumid, tender. No mass is usually felt, shifting dullness present, bowels may be distended. Pelvic examination: The findings are: Vaginal white. Uterus seems normal in size or slightly bulky. Extreme tenderness on fornix palpation or on movement of the cervix. No mass is usually felt through the fornix. The uterus floats as in water. Diagnosis of Tubal Pregnancy Blood examination: It includes Hb, ABO and Rh grouping, total white cell count differential count, and ESR. Culdocentesis: It needle is simple is fitted and safe procedure to diagnose ectopic pregnancy. In this, an 18 lumbar puncture with a syringe, the posterior fornix is punctured to gauge pouch of douglas. Aspiration of blood with hematocrit greater than gain signifies access ruptured to the ectopic pregnancy. Estimation of The suspicious findings are: Lower concentration of compared to normal intrauterine pregnancy Doubling time in plasma fails to occur in 2 days and Sonography: sonography. Transvaginal sonography is more informative. Combination of quantitative values when Laparoscopy: the patient Offers is benefit in cases of confusion with other pelvic lesions. It should be employed only hemodynamically stable. Serum in normal saline as lacy fronds, are diagnostic of intrauterine Chorionic Dilatation villi and that curettage: float Identification of decidua without villi structure is very much suggestive. whereas progesterone: level Level greater than 25 is suggestive of viable intrauterine pregnancy. pregnancy Laparotomy: Offers benefits when in doubt. suggests an ectopic or abnormal intrauterine pregnancy. Management of Tubal Pregnancy Detailed history, evaluation of risk factors and examination. Serum early as weeks from the last menstrual period. gestational Ultrasound sac scan: as Transvaginal sonography provides visualization of a intrauterine Urine suggests an ectopic or abnormal intrauterine less than progesterone: 5 Level is suggestive of viable intrauterine pregnancy whereas level it reaches In normal pregnancy, the pregnancy. level doubles levels are In ectopic pregnancies, levels usually every increase hours until and is positive in of an ectopic pregnancy. Urine pregnancy is sensitive single serum level is diagnostic lower in ectopic pregnancies than in healthy pregnancies. No less. Mean Figure 3. of ectopic pregnancies. Management of Tubal Pregnancy has to been shown in Unit 8 and Management Abdominal examination: Lower tumid, tender. No mass is usually felt, shifting dullness present, bowels may be distended. Pelvic examination: The findings are: Vaginal white. Uterus seems normal in size or slightly bulky. Extreme tenderness on fornix palpation or on movement of the cervix. No mass is usually felt through the fornix. The uterus floats as in water. Diagnosis of Tubal Pregnancy Blood examination: It includes Hb, ABO and Rh grouping, total white cell count differential count, and ESR. Culdocentesis: It needle is simple is fitted and safe procedure to diagnose ectopic pregnancy. In this, an 18 lumbar puncture with a syringe, the posterior fornix is punctured to gauge pouch of douglas. Aspiration of blood with hematocrit greater than gain signifies access ruptured to the ectopic pregnancy. Estimation of The suspicious findings are: Lower concentration of compared to normal intrauterine pregnancy Doubling time in plasma fails to occur in 2 days and Sonography: sonography. Transvaginal sonography is more informative. Combination of quantitative values when Laparoscopy: the patient Offers is benefit in cases of confusion with other pelvic lesions. It should be employed only hemodynamically stable. Serum in normal saline as lacy fronds, are diagnostic of intrauterine Chorionic Dilatation villi and that curettage: float Identification of decidua without villi structure is very much suggestive. whereas progesterone: level Level greater than 25 is suggestive of viable intrauterine pregnancy. pregnancy Laparotomy: Offers benefits when in doubt. suggests an ectopic or abnormal intrauterine pregnancy. Management of Tubal Pregnancy Detailed history, evaluation of risk factors and examination. Serum early as weeks from the last menstrual period. gestational Ultrasound sac scan: as Transvaginal sonography provides visualization of a intrauterine Urine suggests an ectopic or abnormal intrauterine less than progesterone: 5 Level is suggestive of viable intrauterine pregnancy whereas level it reaches In normal pregnancy, the pregnancy. level doubles levels are In ectopic pregnancies, levels usually every increase hours until and is positive in of an ectopic pregnancy. Urine pregnancy is sensitive single serum level is diagnostic lower in ectopic pregnancies than in healthy pregnancies. No less. Mean Figure 3. of ectopic pregnancies. Management of Tubal Pregnancy has to been shown in Unit 8 I and Management Management of Ectopic Pregnancy Be ectopic minded Some clinical features Some clinical features B hCG positive negative positive Strong clinical features Patient in Repeat in 1 week USS TVS hemodynamically Resuscitation and Negative Discriminatory zone of on TVS 1500 laparotomy Pregnancy excluded Ruptured tubal ectopic pregnancy Intrauterine sac Empty uterine cavity with adnexal mass Salpingectomy Determine viability BhcG 1s es in 48 hours Laparoscopy Serum progesterone Repeated USG Unruptured tubal ectopic pregnancy Intrauterine pregnancy Expectant Medical Surgery Initial Falling hCG titer Ectopic mass diameter is cm Direct local Systemic Conservative No evidence of bleeding or rupture on TVS Methotrexate MTX Expectant Potassium chloride Actinomycine Conservative Exterpative Fimbrial expression Salpingostomy Salpingotomy Salpingectomy follow up to detect persistent trophoblastic disease (ectopic pregnancy) Segmental resection Fig. 3: Management of tubal pregnancy Abdominal Pregnancy Abdominal pregnancy is rare. A primary abdominal ectopic pregnancy is the result of implantation of the fertilized ovum on the peritoneal surface. A secondary abdominal pregnancy forms when an embryo extrudes through rupture or due to abortion of a tubal pregnancy. The embryo does not die because of its chorionic attachments to the uterine tube and grows forming attachments to the pelvic peritoneum, omentum, intestines, If etc. The fetus grows in the peritoneal cavity but the majority of these pregnancies do not survive. these pregnancies occur, the fetus dies early in pregnancy, it maybe reabsorbed or calcification occurs. 343 Unit 8 I and Management Management of Ectopic Pregnancy Be ectopic minded Some clinical features Some clinical features B hCG positive negative positive Strong clinical features Patient in Repeat in 1 week USS TVS hemodynamically Resuscitation and Negative Discriminatory zone of on TVS 1500 laparotomy Pregnancy excluded Ruptured tubal ectopic pregnancy Intrauterine sac Empty uterine cavity with adnexal mass Salpingectomy Determine viability BhcG 1s es in 48 hours Laparoscopy Serum progesterone Repeated USG Unruptured tubal ectopic pregnancy Intrauterine pregnancy Expectant Medical Surgery Initial Falling hCG titer Ectopic mass diameter is cm Direct local Systemic Conservative No evidence of bleeding or rupture on TVS Methotrexate MTX Expectant Potassium chloride Actinomycine Conservative Exterpative Fimbrial expression Salpingostomy Salpingotomy Salpingectomy follow up to detect persistent trophoblastic disease (ectopic pregnancy) Segmental resection Fig. 3: Management of tubal pregnancy Abdominal Pregnancy Abdominal pregnancy is rare. A primary abdominal ectopic pregnancy is the result of implantation of the fertilized ovum on the peritoneal surface. A secondary abdominal pregnancy forms when an embryo extrudes through rupture or due to abortion of a tubal pregnancy. The embryo does not die because of its chorionic attachments to the uterine tube and grows forming attachments to the pelvic peritoneum, omentum, intestines, If etc. The fetus grows in the peritoneal cavity but the majority of these pregnancies do not survive. these pregnancies occur, the fetus dies early in pregnancy, it maybe reabsorbed or calcification occurs. 343 Textbook of Obstetric and Gynecological Nursing for KUHS Signs and Symptoms continues, the woman complains of persistent lower frequency. abdominal There pain, be nausea, vomiting. or Fetal movements are painful. On abdominal Ultrasound confirms the and fetal parts constipation, If pregnancy diarrhea, abdominal distention and increased urinary examination, there is tenderness may vaginal spotting are hemorrhage. superficial. Abnormal fetal lie and loud fetal heart sounds. diagnosis. Management Delivery the intestines, it may be left in situ. When the placenta is inside, the risk of infection is is laparotomy. Separation of placenta may be followed major left hemorrhage. If the placenta is attached but is to considered as a safer option. Fetal mortality is very high. The growth is retarded and high, deformed in of cases due to oligohydramnios. The fetus usually dies when the membranes rupture or in immediate neonatal period from respiratory distress. Cervical Pregnancy Cervical pregnancy occurs due to implantation in the cervical canal. It may be due to rapid passage of the fertilized ovum or fertilization of the ovum after it reaches the cervical canal. It is rare and seldom lasts beyond the 20th week. Signs and Symptoms Painless bleeding soon after the time of implantation. Palpation of the cervical mass with distention and thinning of the cervical wall. Partial dilatation of the external os and a slightly enlarged uterine fundus. Management Removal of products of conception curettage and packing of the cervical canal or total abdominal hysterectomy. Nursing Responsibility in Ectopic Pregnancy Upon arrival at the emergency room, place the woman flat in bed. Assess the vital signs to establish baseline data and determine if the patient is under shock. A woman who has a ruptured ectopic pregnancy might present signs of shock such as rapid, thread pulse, rapid respirations, and decreased blood pressure. There would be decreased progesterone levels that would indicate that the pregnancy has ended. It is vital that midwives and nurses have an awareness of the emotional trauma of ectopic pregnancy when taking a history from a woman. Monitor maternal vital signs to determine the presence of hypotension and tachycardia caused rupture normal range. or hemorrhage. Vital signs, especially the blood pressure and pulse rate, should be stable and within the Monitor Patient must intake exhibit moist mucous membranes, good skin turgor, and adequate capillary refill. The and output. Maintain accurate intake and output to establish the renal function. patient at must maintain adequate fluid volume at a functional level as evidenced normal urine Monitor output for and a normal specific gravity between the of 1 and 1. hemorrhage. presence and amount of vaginal bleeding to further assess ranges the present situation indicating distention Monitor for indicate increase in pain and abdominal distention and rigidity since increased pain and abdominal rupture and possible hemorrhage. 14 Textbook of Obstetric and Gynecological Nursing for KUHS Signs and Symptoms continues, the woman complains of persistent lower frequency. abdominal There pain, be nausea, vomiting. or Fetal movements are painful. On abdominal Ultrasound confirms the and fetal parts constipation, If pregnancy diarrhea, abdominal distention and increased urinary examination, there is tenderness may vaginal spotting are hemorrhage. superficial. Abnormal fetal lie and loud fetal heart sounds. diagnosis. Management Delivery the intestines, it may be left in situ. When the placenta is inside, the risk of infection is is laparotomy. Separation of placenta may be followed major left hemorrhage. If the placenta is attached but is to considered as a safer option. Fetal mortality is very high. The growth is retarded and high, deformed in of cases due to oligohydramnios. The fetus usually dies when the membranes rupture or in immediate neonatal period from respiratory distress. Cervical Pregnancy Cervical pregnancy occurs due to implantation in the cervical canal. It may be due to rapid passage of the fertilized ovum or fertilization of the ovum after it reaches the cervical canal. It is rare and seldom lasts beyond the 20th week. Signs and Symptoms Painless bleeding soon after the time of implantation. Palpation of the cervical mass with distention and thinning of the cervical wall. Partial dilatation of the external os and a slightly enlarged uterine fundus. Management Removal of products of conception curettage and packing of the cervical canal or total abdominal hysterectomy. Nursing Responsibility in Ectopic Pregnancy Upon arrival at the emergency room, place the woman flat in bed. Assess the vital signs to establish baseline data and determine if the patient is under shock. A woman who has a ruptured ectopic pregnancy might present signs of shock such as rapid, thread pulse, rapid respirations, and decreased blood pressure. There would be decreased progesterone levels that would indicate that the pregnancy has ended. It is vital that midwives and nurses have an awareness of the emotional trauma of ectopic pregnancy when taking a history from a woman. Monitor maternal vital signs to determine the presence of hypotension and tachycardia caused rupture normal range. or hemorrhage. Vital signs, especially the blood pressure and pulse rate, should be stable and within the Monitor Patient must intake exhibit moist mucous membranes, good skin turgor, and adequate capillary refill. The and output. Maintain accurate intake and output to establish the renal function. patient at must maintain adequate fluid volume at a functional level as evidenced normal urine Monitor output for and a normal specific gravity between the of 1 and 1. hemorrhage. presence and amount of vaginal bleeding to further assess ranges the present situation indicating distention Monitor for indicate increase in pain and abdominal distention and rigidity since increased pain and abdominal rupture and possible hemorrhage. 14
OB 8 - High risk pregnancy
Course: Bsc nursing (blaw 213)
University: Kerala University of Health Sciences
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