Chapter 20 Nursing Care of a Family Experiencing a Pregnancy Complication

from a Preexisting or Newly Acquired Illness

Nursing Process for care of a woman with a preexisting or newly acquired illness, the nurse must:

 Have a thorough understanding of the signs and symptoms of the illness in addition to an
understanding of the course of a normal pregnancy. It’s also important to teach a woman how
to assess her own health in relation to objective parameters.
 Nursing diagnoses developed for a woman with a high-risk pregnancy address her specific,
disease-related condition as well as any therapeutic restrictions her condition might require.
 Be certain that expected outcomes are realistic in light of a woman’s pregnancy and the
restrictions placed on her by her health. Remember that one family member with illness affects
all family members; therefore, outcomes should relate to the entire family’s health.
 Nursing interventions for a pregnant woman with a chronic illness may focus on teaching her
new or additional measures to maintain health during the pregnancy. Imaginative solutions to
problems may need to be created because, otherwise, a woman may be unable to adjust to the
extent of changes she must make.
 If an evaluation of outcomes at healthcare visits reveals that an expected outcome is not being
met, a new assessment, analysis, and planning need to be done. Make evaluation ongoing to
ensure that you know throughout the pregnancy whether interventions are successful.

KEY POINTS FOR REVIEW

 When women with a preexisting disease become pregnant, it is crucial to obtain a thorough
history and physical examination at the first prenatal visit to establish a baseline of information
on the condition. Documentation by a medication reconciliation form of any medication being
taken is important to protect against adverse drug interactions and the possibility of teratogenic
effects on the fetus.
 Teaching is an important nursing intervention because a woman with a preexisting illness must
modify her usual therapy to adjust to pregnancy. Health teaching and how it affects women’s
overall health helps in planning nursing care that not only meets QSEN competencies but also
best meets the family’s total needs.
 Because blood volume increases by as much as 50% during pregnancy, cardiac function may
become inadequate if cardiovascular disease is present. Cardiac illnesses that cause difficulty
can be either acquired disorders such as Kawasaki disease and rheumatic fever or congenital
disorders such as mitral valve stenosis and coarctation of the aorta.
 Iron-deficiency anemia, sickle-cell anemia, and folic acid–deficiency anemia are examples of
various forms of anemia that can also cause complications of pregnancy. Such anemias can
result in fetal distress because of inadequate oxygen transport.
 Urinary tract disorders can lead to pregnancy complications because pregnancy increases the
workload of the kidneys. UTIs and chronic renal disease are two disorders that may lead to early
pregnancy loss.
 Acute nasopharyngitis, asthma, pneumonia, influenza, and tuberculosis are common respiratory
disorders seen in pregnancy. The incidence of tuberculosis is on the increase and special
assessments and care are needed for these women.
  Juvenile rheumatoid arthritis and systemic lupus erythematosus are examples of rheumatic
disorders seen in pregnancy. These disorders generally require large doses of NSAIDs for
therapy. Women taking salicylates are advised to decrease use 2 weeks before birth to avoid
bleeding disorders in the newborn and premature closure of the ductus arteriosus.
 Some gastrointestinal illnesses that occur with pregnancy are hiatal hernia, cholecystitis, viral
hepatitis, inflammatory bowel disease, and appendicitis. If surgery is necessary for conditions
such as cholecystitis or appendicitis, it can be performed by laparoscopic technique during
pregnancy, but this may result in preterm labor.
 Recurrent seizures are the most frequently seen neurologic condition during pregnancy. Many
drugs used to control seizures are teratogenic. Women need to have their medical regimen
evaluated before pregnancy to be certain they are regulated on the fewest medications and the
lowest dosages possible.
 The major endocrine disorder seen during pregnancy is diabetes mellitus. Gestational diabetes is
diabetes that occurs only during pregnancy.

KEY TERMS

deep vein thrombosis (DVT) - formation of a blood clot in the veins of the lower extremities

glucose challenge test - also called the one-hour glucose tolerance test, measures your
body's response to sugar (glucose).

glycosuria - minimal presence of abnormal amounts of glucose in urine

glycosylated hemoglobin (HbA1c) - a measure of the amount of glucose attached to hemoglobin,

is used to detect the degree of hyperglycemia present.

high-risk pregnancy - is one in which a concurrent disorder, pregnancy-related

complication, or external factor jeopardizes the health of the
woman, the fetus, or both.

hyperglycemia - increased serum glucose levels

hypoglycemia - lowered serum glucose levels

megaloblastic anemia - enlarged red blood cells

orthopnea - a woman cannot sleep in any position except with her chest
and head elevated

paroxysmal nocturnal dyspnea - suddenly waking at night with shortness of breath

peripartal cardiomyopathy - is a weakness of the heart muscle that by definition begins

sometime during the final month of pregnancy through about
five months after delivery, without any other known cause.
Most commonly, it occurs right after delivery.
Chapter 21 Nursing Care of a Family Experiencing a Sudden Pregnancy
Complication
Nursing Process for a woman who develops a complication of pregnancy, the nurse must:

 Always ask women at prenatal visits about any symptoms that might indicate a complication
such as pain or vaginal symptoms (e.g., leaking of fluid or bleeding). Provide enough time for a
thorough health history so more subtle problems such as headache, blurred vision, or back pains
can be discovered and investigated thoroughly. In addition, review the danger signs of
pregnancy with women and, if appropriate, significant family members or other support people
so potential problems can be recognized early and a healthcare provider can be contacted.
Assure women they are free to call whenever they are concerned. Otherwise, they may wait
until symptoms become acute rather than call when a symptom is first noticed.
 Nursing diagnoses pertaining to a woman with a pregnancy complication should reflect both the
physical problem and the woman’s or family’s concern.
 Be sure outcomes address both fetal and maternal welfare and often total family welfare.
Treatment protocols should be regularly updated and maintained so they are current. Be certain
they reflect a current nursing management level, so nurses can act swiftly and independently as
needed with lifesaving measures. Once a woman’s condition stabilizes, outcome identification
can then focus on long-term objectives.
 Interventions for a woman experiencing a complication of pregnancy require an
interprofessional approach that speaks to several different areas: Continued both healthy
maternal and fetal physical growth; A woman’s and family’s psychological health; Continuation
of the pregnancy for as long as possible.
 Be aware that after a complication of early pregnancy, a woman cannot help but worry for the
remainder of the pregnancy the complication will recur or the original insult to the fetus was
severe enough to cause long-term effects. Evaluate the woman and her family’s attitude and the
woman’s physical status at each healthcare visit to be certain she and her family are coping with
the situation and adjusting psychosocially.

KEY POINTS FOR REVIEW

 Vaginal bleeding during pregnancy is always serious until ruled otherwise because it has the
potential to diminish the blood supply to both the mother and fetus.
 The amount of bleeding that is evident may not be truly indicative of the amount of bleeding
occurring because hidden, internal bleeding may also be happening. As a rule, position women
with bleeding during pregnancy on their side to improve placental circulation and prevent
supine hypotension syndrome.
 Spontaneous miscarriage is the loss of a pregnancy before viability of the fetus (20 to 24 weeks).
The majority of these early pregnancy losses are attributed to chromosomal abnormalities. They
are classified as threatened, imminent, complete, incomplete, missed, or recurrent pregnancy
loss. Women who have a spontaneous miscarriage at home should bring any tissue passed to
the hospital for an analysis for gestational trophoblastic disease. APS is an autoimmune disease
that may contribute to recurrent miscarriages; therapy is SQ heparin and low-dose aspirin.
 Ectopic pregnancy is implantation outside the uterus, usually in a fallopian tube. If discovered
before the tube ruptures, methotrexate can be administered to cause the conceptus to be
reabsorbed. If not discovered early, sharp lower quadrant pain occurs at about 6 to 12 weeks as
the tube ruptures. A laparoscopy is necessary to remove the conceptus and repair the tube to
halt bleeding.
 Gestational trophoblastic disease is abnormal overgrowth of trophoblast cells. If not discovered
by an ultrasound early in pregnancy, bleeding and expulsion of the abnormal growth occur at
about the 16th week of pregnancy. Women need close follow-up after this because it can lead
to choriocarcinoma, a malignancy.
 Premature cervical dilatation occurs when the cervix dilates early in pregnancy before viability
of the fetus. Sutures (cervical cerclage) can be placed to prevent the cervix from dilating
prematurely this way again in a second pregnancy.
 Placenta previa is low implantation of the placenta so that it crosses the cervical os. If this is not
discovered before labor, cervical dilatation may cause the placenta to tear, causing severe blood
loss. Women who have symptoms of placenta previa (i.e., painless vaginal bleeding in the third
trimester) should not have vaginal examinations done to prevent disruption of the low-
implanted placenta.
 Premature separation of the placenta (i.e., abruptio placentae) or placental separation from the
uterus before the fetus is born usually occurs late in pregnancy and cuts off blood supply to the
fetus. Women with increased parity, those with previous uterine surgery, and those who are
cocaine dependent are at highest risk for this. Often, it is manifested by sudden, sharp fundal
pain and then a continuing dull pain and vaginal bleeding.
 DIC is a blood disorder that may occur with any trauma, so it can accompany such conditions as
premature separation of the placenta and hypertension of pregnancy. Blood coagulation is so
extreme at one point in the circulatory system that clotting factors become diminished, resulting
in their absence in the remainder of the system. Beginning symptoms of this include easy
bruising, petechiae, and oozing from intravenous sites. Heparin is used to stop the local
coagulation and free up clotting factors for systemic use.
 Preterm labor is labor that occurs after 20 weeks and before the end of the 37th week of
pregnancy. A woman is said to be in preterm labor when she has had uterine contractions every
10 minutes for 1 hour and cervical dilatation begins. Magnesium sulfate, parentally
administered, is the drug of choice to halt preterm labor.
 A corticosteroid is also used in preterm labor management because it appears to accelerate the
formation of lung surfactant in the fetus.
 Preterm rupture of the membranes is tearing of the fetal membranes with loss of amniotic fluid
before the pregnancy is at term. After rupture, there is a high risk of fetal and uterine infection
(i.e., chorioamnionitis) and preterm birth.
 Preeclampsia is a unique disorder that occurs with three classic symptoms: hypertension,
edema, and proteinuria. It is categorized as preeclampsia or eclampsia. If mild (blood pressure
not over 140/90 mmHg), treatment is bed rest and perhaps low-dose aspirin. If severe (blood
pressure over 160/110 mmHg), bed rest plus administration of magnesium sulfate will be
prescribed. If a seizure occurs, the condition becomes eclampsia. Helping prevent the disease
from progressing to this stage not only meets QSEN competencies but also can best meet the
family’s total needs.
  The HELLP syndrome is a unique form of gestational hypertension marked by hemolysis of red
blood cells, elevated liver enzymes, and a low platelet count.
 Multiple gestation puts an additional strain on a woman’s physical resources and may lead to
preterm birth with immaturity of her infants. Helping a woman plan adequate nutrition and rest
during pregnancy are nursing responsibilities.
 Postterm pregnancy is pregnancy that extends beyond 42 weeks. Because the placenta
deteriorates at this time, it can cause a fetus to receive decreased nutrients.
 Polyhydramnios is overproduction of amniotic fluid (above 2,000 ml) and is a condition that can
lead to ruptured membranes and premature birth because of increased intrauterine pressure.
Oligohydramnios is characterized by too little amniotic fluid and suggests a renal disorder may
exist in the fetus.
 Isoimmunization (Rh incompatibility) is a possibility when a woman who is Rh negative is
sensitized and carries a fetus who is Rh positive. Maternal antibodies form and destroy fetal red
blood cells, leading to anemia, edema, and jaundice in the newborn. Being certain that women
are screened for blood type and antibody titer early in pregnancy is a nursing responsibility.

KEY TERMS

Abortion - is a medical term for any interruption of a pregnancy before a fetus is viable

ankle clonus - a pulsed motion of the foot after flexion

cervical cerclage - After the loss of one child because of premature cervical dilatation, a surgical
operation termed cervical cerclage can be performed to prevent this from
happening in a second pregnancy

chorioamnionitis - infection of the fetal membranes and fluid

Couvelaire uterus - If blood infiltrates the uterine musculature, Couvelaire uterus or

uteroplacental apoplexy, forming a hard, boardlike uterus occurs.

early pregnancy failure - the fetus dies in utero but is not expelled

eclampsia - a is the most severe classification of pregnancy-related hypertensive disorders.

ectopic pregnancy - one in which implantation occurred outside the uterine cavity.

erythroblastosis fetalis - hemolytic disease of the newborn

gestational trophoblastic disease - is abnormal proliferation and then degeneration of the

trophoblastic villi

HELLP syndrome - is a variation of the gestational hypertensive process named for the common
symptoms that occur: Hemolysis leads to anemia; Elevated liver enzymes lead to
epigastric pain; Low platelets lead to abnormal bleeding/clotting.

hemolytic disease of the newborn - (or erythroblastosis fetalis) A fetus can become so deficient in
red blood cells from this that a sufficient oxygen transport to
body cells cannot be maintained.
Polyhydramnios - occurs when there is excess fluid of more than 2,000 ml or an amniotic fluid
index above 24 cm

isoimmunization - the production of antibodies against Rh-positive blood

miscarriage - termed a premature or immature birth

oligohydramnios - refers to a pregnancy with less than the average amount of amniotic fluid

placenta previa - a condition of pregnancy in which the placenta is implanted abnormally in the
lower part of the uterus, is the most common cause of painless bleeding in the
third trimester of pregnancy

postterm pregnancy - occurs in 3% to 12% of all pregnancies

preeclampsia - is a pregnancy-related disease process evidenced by increased blood pressure

and proteinuria. An older term for preeclampsia was toxemia of pregnancy

premature cervical dilatation - previously termed an incompetent cervix, refers to a cervix

that dilates prematurely and therefore cannot retain a fetus
until term

premature separation of the placenta - also called abruptio placentae, the placenta appears to
have been implanted correctly.

preterm labor - is labor that occurs before the end of week 37 of gestation. It occurs in
approximately 9% to 11% of all pregnancies.

preterm rupture of membranes - is rupture of fetal membranes with loss of amniotic fluid
before 37 weeks of pregnancy

recurrent pregnancy loss - used to describe this miscarriage pattern (women who had three
spontaneous miscarriages that occurred at the same gestational age
were called “habitual aborters.”)

Rh incompatibility - occurs when an Rh-negative mother (one negative for a D antigen or one with
a dd genotype) carries a fetus with an Rh-positive blood type (DD or Dd
genotype).

tocolytic agent - an agent to halt labor

Chapter 22 Nursing Care of a Pregnant Family with Special Needs
Nursing Process for care of a pregnant woman with special needs, the nurse must:

 When caring for a woman who is physically challenged, keep in mind physical disabilities occur
in degrees; therefore, first establish the impact of the disability on a woman’s lifestyle before
beginning to offer guidance for care measures during pregnancy. Be certain to assess physical
strengths as well as limitations and psychosocial strengths as well as challenges
 Nursing diagnoses established for pregnant women with special needs differ in degree, but not
in substance, from the nursing diagnoses established for all pregnant women. For example, if a
pregnant adolescent is still growing, sound nutrition is an extremely important issue for both her
and her fetus.
 Be especially careful to establish realistic outcomes given a woman’s particular condition or
situation. Planning for a pregnant woman with special needs, therefore, often involves
identifying support people to help with this added stress. This support can come from family,
friends, a professional organization, or healthcare providers
 Interventions for the high-risk pregnant woman include promoting a healthy pregnancy and
preventing pregnancy complications. Care focuses on teaching and encouraging a woman with
any special needs to determine how best to manage her pregnancy according to her particular
situation.
 An evaluation of nursing interventions for the care of a pregnant woman with special needs
often focuses on a woman’s physical and emotional readiness for childbearing, maintenance of
fetal health, and a woman’s ability to provide a safe and healthy environment for her newborn.

KEY POINTS FOR REVIEW

 Adolescent pregnancy is a major concern because although it is decreasing in incidence, it still

occurs at a high rate and can interfere with the development of both an adolescent and fetus.
Nursing care needs to be individualized to meet the prepartal, intrapartal, and postpartum
needs of this age group. Planning nursing care that helps adolescents view a pregnancy as a
growth experience not only meets QSEN competencies but can also best help a girl mature to be
an effective parent.
 Women who delay childbearing until age 40 years may need additional discussion time at
prenatal visits to help them incorporate a pregnancy into their lifestyle. They may need
reminders to save time during the day for rest, particularly if at risk for gestational hypertension
or varicosities.
 Women who are physically, cognitively, visually, mobility, or hearing challenged are apt to have
special needs during pregnancy that must be addressed by healthcare providers so adjustments
to ensure a safe outcome can be made during pregnancy. Providing time for discussion early in
pregnancy so these needs can be identified and anticipated is an important role for nurses.
 Women who are physically or cognitively challenged may need help adjusting their usual
regimen to pregnancy. Be certain they are aware of how to contact help in an emergency.
Ensure all medications they are taking for their primary disorder are safe for use during
pregnancy.
  A woman who is substance dependent presents a unique challenge for healthcare providers
during pregnancy. Encouraging her to decrease or halt her substance intake to safeguard the
health of a fetus is a short-term goal. Addressing her need to decrease her substance intake for
the remainder of her life so she can be a quality parent is a long-term goal.
 The fetus of a woman who is substance dependent is at high risk because of the direct effects of
the substance and the indirect effects of an unhealthy lifestyle. Women should be encouraged
to join substance reduction/maintenance programs, if possible, to reduce fetal risk.
 Trauma in pregnancy results from sources such as violence, automobile accidents, and falls.
Women with traumatic injuries need to be carefully assessed to be certain their fetus is unhurt
and to determine if intimate partner violence could have been the cause of the trauma.

KEY TERMS

Adolescence - is a period of growth and change that can be stressful for both the teenager
and her family.

advanced maternal age - is the label for pregnant women 35 years and older at delivery.

autonomic dysreflexia - a syndrome in which there is a sudden onset of excessively high blood
pressure.

culdocentesis - or needle aspiration through the posterior vaginal fornix into the peritoneal
cavity

emancipated minor - or a mature minor—a person capable of making healthcare decisions

generativity - a sense of moving away from themselves and becoming involved with the
world or community

paracentesis - needle aspiration

peritoneal lavage - the process of inserting a peritoneal dialysis catheter into the abdominal
cavity, adding a quantity of an isotonic solution, aspirating it again, and
analyzing it for blood or urine

substance abuse - is defined as the inability to meet major role obligations, an increase in legal
problems or risk-taking behavior, or exposure to hazardous situations because
of an addicting substance

substance dependent - A person is substance dependent when he or she has withdrawal symptoms
following discontinuation of the substance, combined with abandonment of
important activities, spending increased time in activities related to the
substance use, using substances for a longer time than planned, or continued
use despite worsening problems because of substance use.