Care of the Woman at

Risk Because of Bleeding

During Pregnancy
Done by : Mohammad felfel
Care of the Woman at Risk Because of
Bleeding During Pregnancy

• During the first and second trimesters of pregnancy the major cause of
bleeding is abortion.
• Abortion is often defined as "pregnancy termination prior to 20
• Abortions are either spontaneous, occurring naturally, or weeks'
gestation or with a fetus weighing less than 500 g".induced, occurring as
a result of medical or surgical interruption.
• Miscarriage is a lay term applied to spontaneous abortion.
• Other complications that can cause bleeding in the first half of pregnancy
are ectopic pregnancy and gestational trophoblasticdisease.
• In the second half of pregnancy, particularly in the third trimester,the two
major causes of bleeding are placenta previa and abrupplacentae.
General Principlesof Nursing Intervention

• Vaginal bleeding is relatively common during pregnancy.

• Bleeding can arise following sexual intercourse or exercise as a result
of trauma to the highly vascular cervix, from cervical or vaginal
lesions, implantation of the pregnancy, or threatened or impending
miscarriage
• the woman is advised to report any spotting or bleeding that occurs
during pregnancy so that it can be evaluated
• the nurse’s responsibility to make the initial as- sessment of bleeding.
the following nursing measures should be implemented for
pregnant women being evaluated for bleeding during
pregnancy:

• Monitor blood pressure and pulse frequently.

• Observe the woman for indications of shock, such as pallor, clammy skin,
perspiration, dyspnea, or restlessness.
• Count and weigh pads to assess amount of bleeding over a given time
period; save any tissue or clots expelled.
• If pregnancy is of 12 weeks’ gestation or beyond, assess fetal heart tones
with a Doppler.
• Prepare for intravenous (IV) therapy. There may be standing orders to start
IV therapy on bleeding patients
• Prepare equipment for examination
• Have oxygen therapy available
 Cont..

• Collect and organize all data, including antepartum history,

onset of bleeding episode, any associated pain, laboratory
studies (hemoglobin, hematocrit, Rh status, and hormonal
assays).
• Obtain an order to type and cross-match for blood if there is
evidence of significant blood loss
• Assess coping mechanisms and support system of the woman
in crisis.
• Assess her expressions of anger, denial, guilt, depression, or
selfblame.
• Assess the family’s response to the situation.
 Spontaneous Abortion (Miscarriage)

• Pregnancy loss during the early weeks of ges- tation, when the
pregnancy may not yet be recognized, may be seen as a heavy
menstrual period
• Maternal age is the most significant risk factor for
spontaneousas a heavy menstrual period.
• The incidence is at least 15%.miscarriage.
• Over 50% of first trimester spontaneous abortions are
related tochromosomal abnormalities.
• Other causes include teratogenic drugs, faulty
implantation, a weakened cervix, placental
abnormalities, chronic maternal who use hot tubs or
jacuzzis are twice as likely to have diseases, endocrine
imbalances, and maternal infections.
• Fever may increase the risk of miscarriage.
• The major malformations most commonly associated with febrile
illnesses in women are neural tube defects
• The pathophysiology of spontaneous abortion differs according to the
cause.
• Chromosomal defects are generally seen as spontaneous abortionsduring
weeks 4 to 8.
• Insufficient or excessive hormonal levels usually will result in lossby 10 weeks'
gestation.
• Infectious and environmental factors may also be seen in firsttrimester
pregnancy loss.
• In late spontaneous abortion, the cause is usually a maternal [Link]
example, cervical insufficiency or maternal disease, and fetaldeath may not
precede the onset of abortion.
• Chances of successful pregnancy decrease with each succeedingabortion.
Following two to three consecutive losses, a woman andher partner should be
evaluated and are candidates for geneticcounseling.
 Classification

Ø Threatened abortion: Unexplained bleeding, cramping, or

backache indicate that the fetus may be in [Link]
may persist for days.
• The cervix is closed.
• It may be followed by partialor complete expulsion of pregnancy,
or it may resolve withoutthreatening the fetus.
Ø Imminent abortion: Bleeding and cramping increase.
Theinternal cervical os dilates. Membranes may rupture. The
terminevitable abortion also applies
Ø Incomplete abortion: Part of the products of conception
areretained, most often the placenta.
• The internal cervical os is dilated
Ø Complete abortion: All the products of conception are expelled.
• The uterus is contracted and the cervical os may be closed.
Ø Missed abortion: The fetus dies in utero but is not expelled.
• Uterine growth ceases, breast changes regress, and the woman may
report a brownish vaginal discharge.
• The cervix is closed.
• Diagnosis is made based on history, pelvic examination, and a drop
in hG levels or a negative pregnancy test and may be confirmed by
ultrasound if necessary.
• If the fetus is retained beyond 4 weeks,fetal autolysis (breakdown of
cells or tissue) results in the release of thromboplastin, and (DIC)
may develop.
• Recurrent pregnancy loss, called habitual abortion: Abortion
occurs consecutively in three or more pregnancies.
Ø Septic abortion: There is presence of infection; occur with
prolonged,unrecognized rupture of the membranes, pregnancy
with intrauterine device(IUD) in utero, or attempts by
inadequately prepared individuals to terminate pregnancy.
• Septic abortion is less common since the availability of legal
abortion.
Types of spontaneous abortion.
A. Threatened. The cervix is not dilated, and the placenta is still attached to the uterine
wall, but some bleeding occurs.
B. Imminent. The placenta has separated from the uterine wall, the cervix has dilated, and
the amount of bleeding has in- creased.
C. Incomplete. The embryo/fetus has passed out of the uterus; however, the placenta
remains.
Clinical Therapy
• One of the more reliable indicators of potential spontaneous abortion isusually
absent in bleeding caused by polyps, ruptured cervical bloodthe presence of
pelvic cramping and backache. These symptoms are vessels, or cervical
erosion.
• Vaginal bleeding occurs in 20% to 25% of first trimester pregnancies.
• speculum examination to determine the presence of cervical polyps
orEvaluations to help determine the cause of vaginal bleeding includeactivity and
a gestational sac, or crown-rump length that is small forcervical erosion,
ultrasound scanning for the presence of cardiacgestational age.
• Presence of a fetal heartbeat on ultrasound provides a high likelihoodof the
pregnancy.
• Laboratory determination of hCG level can confirm a pregnancy, but it
cannot confirm a live embryo/fetus.
• Blood is typed and cross-matched for possible replacement
[Link] and hematocrit levels to assess blood loss.
• Pregnant woman with bleeding often includes bed rest, abstinence
fromcoitus and sedation.
• If bleeding persists and abortion is imminent or incomplete, the
womanreplace fluid, and dilation and curettage (D&C) or suction
evacuationmay be hospitalized, IV therapy or blood transfusions may be
started tois performed to remove the remainder of the products of
conception.
• If the woman is Rh negative and not sensitized, and there has been
priorultrasound documentation of fetal cardiac activity, Rh immune
globulin(RhoGAM) is given within 72 hours.
• In missed abortions, the products of conception eventually are expelled
spontaneously.
• if this does not occur within 1 monthto 6 weeks after fetal death,
hospitalization is necessary.
• Suction evacuation, or D&C, is done if the pregnancy is in the first
trimester. Beyond 12 weeks' gestation, induction of labor
NURSING CARE MANAGEMENT

• If a woman in her first trimester of pregnancy begins cramping bleeding is not heavy
or spotting
she may be evaluated on an outpatient basis if the bleeding is not heavy.
• Providing emotional support is an important task for nursescaring for women
who have spontaneously aborted.
• Couples who approached the pregnancy with feelings of joy and a sense of
expectancy now feel grief, sadness, and possibly anger.
• Because many women, even with planned pregnancies, feelsome
ambivalence initially, guilt is a common emotion.
• The woman may harbor negative feelings about herself , ranging from lowered self-
esteem resulting from a belief that she is lacking or abnormal in some way, to a
notion that the abortion may be a punishment for some wrongdoing