Care of Mother and Child At-Risk or with

Problems (Acute and Chronic)- Lecture

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR
Session # 9

Materials:
LESSON TITLE: CARE OF THE HIGH-RISK Book, pen, SAS and notebook
PREGNANT CLIENT (GESTATIONAL CONDITIONS-
SPONTANEOUS MISCARRIAGE) References:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
LEARNING OUTCOMES: th
Maternal and Child Health Nursing, 8 Edition.
At the end of the lesson, the student nurse can: USA: Lippincott Williams and Wilkins

1. Define Spontaneous Miscarriage its relation to pregnancy,
including pre-existing factors that contribute to its development.
2. Integrate knowledge of Spontaneous Miscarriage in relation
to pregnancy and nursing process to achieve quality maternal
and child health nursing care.
Perry, Shannon, Hockenberry, Marilyn J.,
Lowdermilk Deitra Leonard and Wilson, David
th
(2015) Maternal and Child Nursing Care,6
Edition. USA: Elsevier
Hockenberry, Marilyn and Wilson, David (2013)
Wong’s Essential of Pediatric Nursing,9th
Edition. USA: Elsevier

LESSON PREVIEW/REVIEW (5 minutes)

MAIN LESSON (50 minutes)

SPONTANEOUS MISCARRIAGE.
(Please refer to Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication-Bleeding During
Pregnancy Spontaneous Miscarriage p. 529)
ABORTION- any interruption of a pregnancy before a
fetus is viable (> 20 to 24 weeks & weighs at least 500 g)
 ELECTIVE ABORTION – medical termination of a
pregnancy
 MISCARRIAGE- spontaneous interruption of a
pregnancy
 Early miscarriage occurs before week 16 & late
miscarriage between weeks 16 & 24
Classifications of Spontaneous Abortions/Miscarriages
1. Threatened Miscarriage
Symptoms:
 vaginal bleeding- scant, usually bright red
 Slight cramping or backache
 No cervical dilatation
Causes of Spontaneous Miscarriage
 Abnormal fetal formation
 Immunologic factors: Rh/ABO incompatibility
 Implantation abnormalities
 Corpus luteum fails to produce enough P to
maintain the d. basalis (P therapy may be
attempted)
 Infection (rubella, syphilis, poliomyelitis, CMV,
toxoplasmosis, UTI)- fetus fails to grow, P & E
decline causing sloughing off of the endometrium
 Trauma
 Incompetent cervix
 Maternal systemic diseases: DM, thyroid
problems, severe anemia
Management:
 Assess fetal viability via UTZ; FHT
 Assess amount of bleeding
 Monitor VS; assess for impending shock
 Provide emotional support
 hCG titer at start of bleeding & after 24h (if viable,
hCG doubles)

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2. Imminent or Inevitable Miscarriage
Symptoms:
 + cramping or uterine contractions
 + Vaginal bleeding
 Cervix dilates & membranes rupture
3. Complete Miscarriage
Symptoms:
 the entire products of conception (fetus, placenta,
membranes) are expelled
 Bleeding, cramping & expulsion of conceptus
 Bleeding slows within 2 hours then stops within a
few days after passage of conceptus
 The cervix is closed & the uterus contracts
4. Incomplete Miscarriage
Symptoms:
 Bleeding, cramping & part of the conceptus
(usually the fetus) is expelled but the rest are
retained; cervix is dilated
 danger of hemorrhage because the uterus cannot
contract effectively
5. Missed Miscarriage/ Early Pregnancy Failure
Symptoms:
 the fetus dies in utero but is not expelled & the client
experiences decreasing signs of pregnancy
 Cervix is closed
 Dark brown vaginal discharge
 Pregnancy test (-)
 Fundal height does not increase in size
6. Recurrent Pregnancy Loss/Habitual Abortion
 Three Spontaneous miscarriage that occurred at the same gestational age
Causes
 Defective spermatozoa or ova
 Poor Thyroid Function
 Septate or Bicornuate Uterus
 Resistance to uterine artery blood flow
 Chorioamnionitis or uterine infection
 Autoimmune disorders such as Lupus Anticoagulant and Anti Phospholipid Antibodies
Complications of Miscarriage
1. Hemorrhage
 complete spontaneous miscarriage-
serious or fatal hemorrhage is rare.
 incomplete miscarriage or in a woman
who develops an accompanying
coagulation defect (usually DIC)- major
hemorrhage becomes a possibility
2. Infection
 fever higher than 100.4°F (38.0°C)
 Avoid strenuous activity, CBR for 24 to 48 h
 Avoid stress
 coitus is restricted for 2 weeks after bleeding to
avoid bleeding & infection
Management:
 assess bleeding;
 save any tissue fragments passed
 initiate IVT with an 18-gauge needle
 If (-) FHT & UTZ reveals empty uterus or
nonviable fetus, D&E
 after D & E monitor bleeding (saturating > 1
pad/hour is heavy bleeding)
 RhOGAM as necessary
 Provide psychological support
Management:
 Advise the woman to report heavy bleeding.
 No therapy needed since the process of is
complete due to spontaneous expulsion of the
entire products of conception.
Management:
 D & C or suction curettage
Management:
 UTZ to establish fetal death
 D&E
 If > 14 wks AOG, Prostaglandin suppository of
misoprostol (Cytotec) to dilate the cervix, followed
by oxytocin or
 mifepristone
 Miscarriage usually occurs spontaneously within 2
weeks
 If conceptus remains in the uterus > 5 weeks, risk
for DIC and sepsis
Management
1. Hemorrhage
 Monitor VS
 Position flat on bed
 Blood replacement if necessary
 D&C
2. Infection
 Advise women to wipe their perineal area
from front to back after voiding and

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  abdominal pain or tenderness
 foul-smelling vaginal discharge
3. Septic Abortion- an abortion complicated by
infection
 occurs in women who have tried to self-abort or
whose pregnancy was aborted illegally using a
nonsterile instrument such as a knitting needle
 fever and crampy abdominal pain; her uterus will
feel tender to palpation.
 Left untreated, such an infection can lead to toxic
shock syndrome, septicemia, kidney failure, and
death
4. Isoimmunization- whenever the placenta is
dislodged some blood from the placental villi may
enter the maternal circulation. If the fetus is Rh (+)
& the woman is Rh (-), the mother may produce
antibodies against Rh (+) blood & would attempt
to destroy RBC of the next infant while it is in
utero.
5. Powerlessness or Anxiety
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
particularly after defecation to prevent the
spread of bacteria that could cause
infection.
 Advise the woman not to use tampons
(stasis of any body fluid increases the risk
of infection).
3. Septic Abortion
 CBC, serum electrolytes and CREA;
blood type and cross-match; and cervical,
vaginal, and urine cultures are obtained
 Combination of penicillin (gram-positive
coverage), gentamicin (gram-negative
aerobic coverage), and clindamycin
(gram-negative anaerobic coverage) is
commonly prescribed to combat the
infection.
 D&C or D&E
4. Isoimmunization
 Administer RhOGAM or RhIg to all
women with Rh (-) blood to prevent
buildup of antibodies in case the fetus is
Rh (+)
5. Powerlessness or Anxiety
 assess a partner’s or the extended
family’s feelings as well, or the potential
impact of their grief and possible lack of
support for the woman over the
pregnancy loss can be missed.

Multiple Choice

1. Naiza is in the first trimester of pregnancy arrives at a health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding
management of care. Which statement, if made by the client, indicates a need for further education?
A. “I will maintain strict bedrest throughout the remainder of pregnancy.”
B. “I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of
bleeding.”
C. “I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the
pad.”
D. “I will watch for the evidence of the passage of tissue.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. It is a type of miscarriage wherein there is bleeding and cramping occur with the cervix closed and membranes
intact.
A. complete
B. inevitable
C. habitual
D. missed
E. threatened
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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3. It is a type of miscarriage wherein some of the products are expelled, but the placenta remains attached. Heavy
bleeding and cramping do not subside until entire placenta is removed.
A. habitual
B. missed
C. incomplete
D. complete
E. threatened
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. What type of miscarriage that occurs with 3 consecutive pregnancies?

A. habitual
B. missed
C. incomplete
D. complete
E. threatened
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. It is a type of miscarriage when the embryo or fetus dies but isn’t expelled. It’s often discovered by the
physician when no FHT is present. Fetus must be expelled within 6wks or DIC and/or infections can occur.
A. habitual
B. missed
C. incomplete
D. inevitable
E. threatened
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. It is a type of miscarriage wherein all of the products of conception are expelled.

A. inevitable
B. complete
C. threatened
D. habitual
E. missed
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. During a prenatal screening of a client with diabetes, the nurse should keep in mind that the client is at
increased risk for which complications? SELECT ALL THAT APPLY
A. Still Birth
B. Rh incompatibility
C. Gestational hypertension
D. Placenta previa
E. Spontaneous abortion
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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8. The following are causes of Spontaneous Miscarriage, SELECT ALL THAT APPLY:
A. Abnormal fetal formation
B. Immunologic factors: Rh/ABO incompatibility
C. Implantation abnormalities
D. Toxoplasmosis
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

9. An abortion complicated by infection that occurs in women who have tried to self-abort or whose pregnancy
was aborted illegally using a nonsterile instrument such as a knitting needle.
A. Spontaneous
B. Complete
C. Habitual
D. Septic
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. The following are types of abortion, SELECT ALL THAT APPLY.
A. Threatened
B. Incomplete
C. Complete
D. Habitual
E. Early Pregnancy Loss
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
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4. ANSWER: ________
RATIO:_______________________________________________________________________________________
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5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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6. ANSWER: ________

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 RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________
RATIO:_______________________________________________________________________________________
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LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.
PERIOD 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
PERIOD 2
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
PERIOD 3
41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

AL STRATEGY: Minute Paper

1. Your student will ask you to use index cards or half-sheets of paper to provide written feedback to the following
questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. After writing the instructor will collect the responses before you leave.

(For next session, review Chapter 21: Nursing Care of A Family Experiencing a Sudden Pregnancy Complication-
Bleeding During Pregnancy p. 537-541)

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