2nd and 3rd Trimester Bleeding Flashcards
1
Q
Second Trimester Bleeding
A
- premature cervical dilatation
2
Q
Premature Cervical Dilatation
A
- also known as “incompetent cervix” or “habitual aborters”
- cervix dilates prematurely and cannot hold the fetus until term
- painless cervical effacement and dilation in early mid-trimester resulting in expulsion of products of conception
3
Q
Premature Cervical Dilatation Risk Factors
A
- increased maternal age
- congenital structural defects (could be genetic)
- trauma to cervix (some surgical procedures such as pap smear)
- repeated d&c (from previous labor and delivery could cause cervical tear)
4
Q
Premature Cervical Dilatation Assessment
A
- pink-stained vaginal discharge
- increased pelvic pressure
- premature rupture of membrane
- contractions mid-trimester
- presence of painless cervical dilation
5
Q
Premature Cervical Dilatation Therapeutic Management
A
CERVICAL CERCLAGE:
1. Shirodkar technique
2. McDonald technique
6
Q
Cervical Cerclage
A
- 14-16 weeks AOG
- purse-string sutures are placed in the cervix by the vaginal route under regional anesthesia
- strengthen cervix and prevent it from dilating
- similar to drawstring
7
Q
Premature Cervical Dilatation (Shirodkar Technique)
A
sterile tape is threaded in a purse-string manner under the submucus layer of the cervix and sutures in place to achieve a closed cervix
8
Q
Premature Cervical Dilatation (McDonald Technique)
A
- temporary
- nylon sutures are placed horizontally and vertically across the cervix and pulled tight to reduce the cervical canam to a few millimeters in
9
Q
Premature Cervical Dilatation Nursing Management
A
- bed rest for 24 hours
- observe for bleeding, uterine contractions, and rupture of BOW
- ruptured BOW = remove suture to facilitate labor
- uterine contractions = ritodrine
- post op: restrict activities (including coitus) for 2 weeks
- place in slight or modified Tredelenburg position (prevent pressure to cervix)
- goal is to complete term
10
Q
Ritodrine
A
- tocolytic drug
- help or stop labor or uterine contractions
11
Q
Third Trimester Bleeding
A
- placenta previa
- abruptio placenta
12
Q
Normal Placenta
A
- 500 g
- 15-20 cm in diameter
- 1.5-3.0 cm thick
- weight is app. 1/6 of fetus
- normal number of cotyledons = 15-28
13
Q
Placenta Previa
A
abnormal implantation of placenta in the lower uterine segment, partially or completely covering the internal cervical OS
14
Q
Top Placenta Previa (Complete)
A
- placenta completely covers cervix
- NSD not possible
- placenta comes out first = oxygen suppy is cut off = hypoxia
15
Q
Partial Placenta Previa
A
- placenta is partially over the cervix
- NSD not possible since part of placenta still blocks cervix
16
Q
Marginal Placenta Previa
A
- placenta is near the edge of cervix
- may be subjected to double setup (NSD then ready CS setup)
- needs close monitoring for bleeding
17
Q
Placenta Previa Nursing Diagnoses
A
- altered tissue perfusion related to excessive bleeding causing fetal compromise
- fluid volume deficit related to excessive bleeding
- risk for infection related to excessive blood loss
- anxiety related to excessive bleeding
- fear related to outcome of pregnancy after episodes of bleeding
18
Q
PP DX: Altered Tissue Perfusion Related to Excessive Bleeding causing Fetal Compromise
A
PRIORITY: position on the side to promote placental perfusion (expand diaphragm and lungs)
- frequently monitor mother and fetus
- administer oxygen as facemask as indicated (8-10/ min)
- administer IV fluid as prescribed
19
Q
PP DX: Fluid Volume Deficit Related to Excessive Bleeding
A
PRIORITY: position in sitting position to allow weight of fetus to compress placenta and decrease bleeding
- maintain strict bed rest during a bleeding episode
- administer blood or blood products protocol per institutional policy
- establish and maintain a large- bore IV line as prescribed and draw blood for type and screen for blood replacement
- prepare mother for CS
20
Q
PP DX: Risk for Infection Related to Excessive Blood Loss
A
PRIORITY: assess odor of vaginal bleeding or lochia
- teach perineal care and handwashing
- use aseptic technique in providing care
- evaluate temp every 4 hours unless elevated (2 hours)
- evaluate WBC and differential count
21
Q
PP DX: Anxiety Related to Excessive Bleeding
A
PRIORITY: encourage verbalization of feelings by px and family
- ANXIETY due to px having no idea of the results of her condition
- explain all treatments and procedure
- provide information on CS delivery
- discuss the effects of long-term hospitalization or prolonged bed rest
22
Q
PP DX: Fear Related to Outcome of Pregnancy After Episodes of Bleeding
A
PRIORITY: encourage verbalization of feelings by px and family
- FEAR due to px having an idea of the possible outcomes of her condition (e.g. death)
- explain all treatments and procedures
- provide information on CS
23
Q
Placenta Previa Complications
A
- placenta accreta
- immediate hemorrhage (possible shock and maternal death)
- increased risk for anemia secondary to increased blood loss and infection secondary to invasive procedure to resolve bleeding
- intrauterine growth restriction
- congenital anomalies
- fetal mortality resulting from hypoxia in utero and prematurity
24
Q
Placenta Previa Medical and Surgical Management
A
- Medical Management
○ IV access
○ Laboratory examinations
○ Blood typing and cross matching
○ Administration of Betamethasone (Celestone) - Surgical Management
○ Amniocentesis
○ CS section
25
Abruptio Placenta
- premature separation of the implanted placenta before the birth of the fetus
- hemorrhage can be occult or apparent
- placenta begins to detach during pregnancy = bleeding from vessels
- the larger the area detaches, the greater the amount of bleeding
26
Occult Hemorrhage
placenta usually separates centrally and a large amount of blood is accumulated under the placenta
27
Apparent Hemorrhage
presenting part is along the placental margin and blood flows under the membranes and through the cervix
28
Abruptio Placenta Assessment
- determine amount and type of bleeding and presence or absence of pain
- monitor maternal and fetal vs (maternal BP, pulse, FHR, FHR variability)
- palpate abdomen
○ note the presence of contractions and relaxations between contractions (if contractions are present)
○ if contractions are not present, assess the abdomen for firmness (board-like abdomen= super firm)
- measure and record fundal height to evaluate the presence of concealed bleeding
- prepare for possible delivery
29
Abruptio Placenta Nursing Diagnoses
1. ineffective tissue perfusion (placental) related to excessive bleeding/ hypotension/ decreased cardiac output causing fetal compromise
2. acute pain related to increase urine activity
3. fluid volume deficit related to excessive bleeding
4. risk for infection related to excessive blood loss
5. fear related to excessive bleeding procedures and unknown outcome
30
AP DX: Ineffective Tissue Perfusion (Placental) Related to Excessive Bleeding/ Hypotension/ Decreased Cardiac Output causing Fetal Compromise
PRIORITY: position in left lateral position with head elevated to enhance placental perfusion
- evaluate fetal status with continuous external fetal monitoring
- evaluate amount of bleeding by weighing all pads
- monitor CBC results and vs
- administer oxygen through a snug face mask at 8-12L/ min (or as prescribed)
- prepare for possible CS if maternal fetal compromise is evident
31
AP DX: Acute Pain Related to Increase Uterine Activity
- instruct/ encourage use of relaxation techniques to augment analgesics
- instruct px on cause of pain to decrease anxiety
- administer pain medication as needed and as prescribed
32
AP DX: Fluid Volume Deficit Related to Excessive Bleeding
PRIORITY: establish and maintain a large-bore IV line as prescribed and draw blood for type and screen for blood replacement
- evaluate coagulation studies
- monitor maternal vital signs and contractions
- monitor vaginal bleeding
- evaluate fundal height to detect an increase in bleeding
33
AP DX: Risk for Infection Related to Excessive Blood Loss
- use aseptic technique when providing care
- evaluate temp q4 (q2 if elevated)
- evaluate WBC and differential count
- teach perineal care and handwashing
- assess odor of vaginal bleeding or lochia
34
AP DX: Fear Related to Excessive Bleeding, Procedures, and Unknown Outcome
- inform mother and family about status of herself and fetus
- explain all procedure in advance
- answer questions calmly and in simple terms
- encourage presence of support system
35
Abruptio Placenta Complications
1. maternal shock
2. anaphylactoid syndrome of pregnancy
3. postpartum hemorrhage
4. acute respiratory distress syndrome
5. Sheehan's syndrome
6. renal tubular necrosis
7. rapid labor and delivery
8. maternal and fetal death
9. prematurity
36
Abruptio Placenta Medical and Surgical Management
- Medical Management
○ IV administration of fibrinogen or cryoprecipitate
○ Laboratory examinations
- Surgical Management
○ CS section
37
Placenta Previa (Bleeding)
- mostly external
- small to produse in amount
- bright red
38
Placenta Previa (Pain and Uterine Tenderness)
- usually absent
- uterus is soft
39
Placenta Previa (Fetal Heart Tone)
usually normal
40
Placenta Previa (Presenting Part)
usually not engaged
41
Placenta Previa (Shock)
usually not present unless bleeding is excessive
42
Placenta Previa (Delivery)
may be delayed depending on size of the fetus and amount of bleeding
43
Abruptio Placenta (Bleeding)
- may be concealed
- external dark hemorrhage or bloody amniotic fluid
44
Abruptio Placenta (Pain and Uterine Tenderness)
- usually present
- irritable uterus, progresses to board-like consistency
45
Abruptio Placenta (Fetal Heart Tone)
maybe irregular or absent
46
Abruptio Placenta (Presenting Part)
may be engaged
47
Abruptio Placenta (Shock)
moderate to severe depending on the extent of concealed and external hemorrhage
48
Abruptio Placenta (Delivery)
- immediate delivery
- usually by CS section
