Nursing Care of Women with Complications during the Prenatal Period
3. Encourage client and family to express feelings
4. Refer to health care providers, agencies, and clergy as
needed
Evaluation/Outcomes
1. Maintains emotional and physiologic well being
2. Verbalizes concerns
3. Arrives at decisions through problem solving
4. Uses support systems
NURSING CARE OF WOMEN WITH
COMPLICATIONS DURING
THE PRENATAL PERIOD
HYPERTENSIVE DISORDERS OF PREGNANCY
Data Base
A. Classification of hypertensive states
1. Gestational hypertension
a. Hypertension during pregnancy beginning in second
trimester (20 to 24 weeks); disappears 6 weeks after
birth
b. May have edema or proteinuria; blood changes
rarely occur in uncomplicated gestational
hypertension
2. Transient hypertension
a. Gestational hypertension without preeclampsia
b. Resolves by 12 weeks’ postpartum
3. Preeclampsia
a. Mild: blood pressure (BP) 140/90 mm Hg on two
readings taken 6 hours apart; systolic BP increase of
30 mm Hg or diastolic BP increase of 15 mm Hg;
proteinuria +1 (30 mg/dL) or more
b. Severe:
(1) Objective: BP 160/110 mm Hg or higher on
two readings taken 6 hours apart after bed rest;
proteinuria +3 to +4; hyperreflexia; oliguria;
hemoconcentration
(2) Subjective: blurred vision; epigastric pain;
irritability; persistent headache
c. Blood chemistry: elevated hematocrit and
hemoglobin; increased uric acid, liver enzymes, and
blood urea nitrogen (BUN); decreased carbon
dioxide combining power (may indicate worsening
preeclampsia)
d. Qualitative urinalysis: increased albumin output
(proteinuria) and/or decreased urinary output
indicates worsening preeclampsia
4. Eclampsia
a. Seizure and/or coma; seizure may be preceded by
rolling of eyes to one side while staring
b. Occurs after intractable, severe preeclampsia
5. Chronic hypertension: preexisting
6. Preeclampsia superimposed on chronic hypertension
a. Previously controlled BP becomes elevated;
proteinuria
b. Blood chemistry: thrombocytopenia, elevated
creatinine; other clinical manifestations of severe
preeclampsia
555
B. Risk factors: first pregnancy at younger than 17 years of
age; over 35 years of age; obesity; numerous pregnancies;
chronic hypertension; diabetes mellitus; severe nutritional
deficiencies; multifetal pregnancy; trophoblastic disease
C. HELLP syndrome (Hemolysis, Elevated Liver enzymes,
Low Platelet count); preeclampsia with hepatic dysfunction
1. Sudden onset; may not have previous signs of
preeclampsia; 2% to 12% incidence in women with
severe preeclampsia; occurs after 24 weeks’ gestation or
after birth
2. Right upper quadrant pain in 90% of affected women;
may have proteinuria
3. Blood smear reveals broken RBCs (schistocytes or burr
cells)
4. Increased uric acid, liver enzymes, and BUN
D. Guidelines for prevention of hypertensive disorders of
pregnancy
1. Reduction of risk factors if possible
2. Adherence to prenatal recommendations (e.g., diet,
exercise, rest, regular prenatal examinations)
3. Prophylactic treatment is not available
4. Sodium restriction and diuretics are contraindicated
E. Therapeutic interventions
1. Gestational hypertension
a. Frequent rest periods
b. Dietary management with increased fluid intake
c. Treated symptomatically
2. Mild preeclampsia
a. High-protein diet
b. Ambulatory care; frequent visits to health care provider
c. Frequent rest periods with feet elevated; side-lying
position to enhance renal and placental perfusion
3. Severe preeclampsia or eclampsia
a. Hospitalization and complete bed rest
b. Magnesium sulfate administered intravenously via
infusion pump; if respiratory depression caused by
magnesium sulfate occurs, calcium gluconate for
mother and levallorphan (Lorfan) for newborn
c. Antihypertensives: hydrALAZINE, NIFEdipine
(Procardia), methyldopa (Aldomet), labetalol
d. Indwelling catheter for output assessment
e. Labor induction or cesarean birth
f. Betamethasone for preterm birth less than 34 weeks’
gestation (stimulates fetal surfactant production)
4. HELLP syndrome
a. Same as severe preeclampsia or eclampsia
b. Blood or blood product replacement if necessary
Nursing Care of Women with Hypertensive
Disorders of Pregnancy
Assessment/Analysis
1. Clinical indications of cerebral involvement (e.g., persistent
headache, visual disturbances, irritability, confusion)
2. Vital signs for hypertension
3. Urinary status for proteinuria, oliguria
4. Extremities for edema, increasing daily weight
5. Epigastric pain
556 CHAPTER 26 Nursing Care of Women at Risk during Pregnancy, Labor, Childbirth, and the Postpartum Period

Planning/Implementation 4. Complete abortion: all products of conception expelled

1. Monitor BP every 15 minutes during critical phase; every 1 within 24 to 48 hours
to 4 hours as condition improves 5. Missed abortion: fetus dies in utero but not expelled;
2. Insert indwelling catheter; monitor urine for output and risk for developing disseminated intravascular
proteinuria coagulopathy (DIC)
3. Monitor edema, daily weights, I&O 6. Habitual abortions: three consecutive pregnancies that
4. Administer magnesium sulfate as prescribed (check for terminate spontaneously
sufficient urinary output before starting); assess for E. Therapeutic interventions
therapeutic response (e.g., +2 deep tendon reflexes, 1. Maintenance of complete bed rest
increased urinary output, absence of seizures) 2. Diagnostic/therapeutic blood studies: complete blood
5. Monitor for magnesium toxicity count (CBC), blood typing, and Rh factor;
a. Assess for depressed or absent deep tendon reflexes (e.g., crossmatching if blood is available; serum progesterone
patellar, brachial) or serial beta human chorionic gonadotropin (β-hCG)
b. Observe for depressed respirations (fewer than 12 to 14 3. Dilation and curettage or vacuum aspiration to remove
breaths/min), flushed face retained products of conception
c. Assess magnesium blood levels every 6 hours; therapeutic
range is 4 to 8 mg/dL
d. Have calcium gluconate available for magnesium sulfate Nursing Care of Women Experiencing
toxicity Spontaneous Abortion
6. Observe for indications of seizure activity (e.g., may be Assessment/Analysis
preceded by rolling of eyes to one side with a stare); 1. Vital signs; amount of bleeding
maintain seizure precautions; monitor vital signs and FHR 2. Level of pain
after seizure 3. Emotional response to loss
7. Monitor FHR Planning/Implementation
8. Monitor hematologic studies 1. Institute measures to alleviate fear and anxiety
9. Maintain on bed rest in side-lying position; maintain quiet, 2. Monitor and document amount and type bleeding
dark environment; limit visitors a. Save and count number of perineal pads
10. Offer high-protein diet with adequate sodium intake b. Distinguish between dark clotted blood and frank
11. Explore anxieties and concerns bleeding (bright red)
12. Observe for signs of bleeding and labor 3. Monitor vital signs for hypovolemia, shock, and infection
13. Be prepared for induced birth or emergency cesarean birth 4. Monitor fundus for firmness after products of conception
14. Continue to monitor for 48 hours after birth during are expelled
diuresis (seizures [eclampsia] may occur several weeks 5. Check laboratory reports (e.g., CBC, hemoglobin,
postpartum) hematocrit) in preparation for blood transfusion
Evaluation/Outcomes 6. Administer oxygen if necessary
1. Maintains (mother and fetus) vital signs within acceptable 7. Maintain fluid and electrolyte balance
range 8. Administer RhoGAM if prescribed
2. Remains free from seizures 9. Assist with grieving process
3. Maintains fluid balance a. Discuss physiologic reality, but encourage to work
through feelings
SPONTANEOUS ABORTION b. Expect that grieving may continue for 24 months
c. Encourage participation with thanatology services and
Data Base bereavement/support groups when appropriate
A. Complete or partial expulsion (incomplete) of products of 10. Educate about necessity for follow-up care
conception before viability; gestational age 20 weeks or less; Evaluation/Outcomes
weight less than 500 grams; length less than 16.5 cm 1. Remains free from complications (e.g., hemorrhage,
B. Incidence: 10% to 20% of confirmed pregnancies infection)
C. Risk factors: embryonic defects, maternal hormone 2. Expresses feelings
imbalances, immunological factors, infections, genetic
factors, systemic disorders, external mechanical force, ECTOPIC PREGNANCY (TUBAL PREGNANCY)
trauma
D. Types/clinical findings Data Base
1. Threatened abortion: cervix closed, bleeding, cramping, A. Implantation of fertilized ovum outside uterus; most
backache; pregnancy may continue uninterrupted frequently (95%) in middle portion of fallopian tube; other
2. Imminent or inevitable abortion: cervix dilates, sites in abdomen, ovaries, and cervix
bleeding, severe cramping, membranes may rupture B. Incidence; rising; 20 in 1000 pregnancies
3. Incomplete abortion: all products of conception not C. Risk factors: Pelvic inflammatory disease (PID), tubal
expelled after cervical os has dilated surgery, endometriosis