NCP Prenatal Hemorrhage

Hemorrhage may occur early or late in pregnancy, owing to certain physiological problems, each with its own signs and symptoms, which help in establishing a differential diagnosis and in creating the plan of care. This general guide for care is meant to treat hemorrhage in the antepartal client. Where appropriate, interventions specific to each physiological problem are identified.

CLIENT ASSESSMENT DATA BASE: GENERAL FINDINGS

Circulation

Hypertension or hypotension may be present.
Pallor.
Dizziness.

Ego Integrity

Anxious, fearful, apprehensive

Food/Fluid

Nausea/vomiting

Safety

Pelvic inflammatory disease; repeated episodes of gonorrhea

Sexuality

Multiparity and advanced maternal age (>35).
Previous cesarean sections.
Repeated second- or third-trimester abortions.
Cervical scarring from lacerations, cervical conization, elective abortions, or dilation and curettage (D & C).
Specific conditions with appropriate signs and symptoms are listed in the prenatal time sequence in which they might appear.

Ectopic Pregnancy

Timing of rupture depends on location of fetus; i.e., isthmus of fallopian tube may rupture after 4–5 wk; an interstitial implantation may not rupture until the beginning of the second trimester. (Note: Enhanced diagnostic techniques are helping to identify the anomaly prior to tubal rupture.)

Circulation

Hypotension
Tachycardia
Delayed capillary refill
Cold, clammy skin
Faintness, syncope

Food/Fluid

Abdomen may be tender.

Pain/Discomfort

Colicky abdominal pain.
Referred shoulder pain may be noted as abdomen fills with blood.
Severe one-sided pain may occur in presence of tubal rupture.

Safety

Normal or subnormal temperature

Sexuality

Abdominal tenderness.
Uterine enlargement may be noted.
Adnexal mass is palpable on pelvic examination.
History of infertility/assisted reproductive techniques; use of progestin as only contraceptive/intrauterine device; prior tubal surgery.
Abortion: can occur at any time prior to 20 weeks’ gestation. (Refer to CP: Spontaneous Termination.)
Hydatidiform Mole (Gestational Trophoblastic Disease)
May occur as early as the 4th week or as late as the second trimester

Circulation

Hypertensive symptoms and/or edema may have developed before 20 weeks’ gestation (PIH).

Food/Fluid

Severe nausea/vomiting (hyperemesis gravidarum).
Urine may be positive for protein.

Sexuality

Uterus may be enlarged out of proportion to gestation or may be smaller than anticipated; bilateral ovarian enlargement.
No FHTs or fetal outline palpable; no fetal activity noted.
Clear, grapelike vesicles passed vaginally.
Decrease in breast tissue.

Placenta Previa

Generally occurs after 20 weeks’ gestation, usually third trimester; commonly the 8th mo (34 wk).

Circulation

Painless vaginal bleeding (amount dependent on whether previa is marginal, partial, or total); profuse bleeding may occur during labor.

Sexuality

Fundal height 28 cm or greater.
FHT within normal limits (WNL).
Fetus may be in transverse lie or unengaged.
Uterus soft.
Multiple gestation; increasing parity.
History of prior placenta previa, uterine surgery.

Abruptio Placentae

Premature separation of placenta usually occurs during third trimester, often during labor.

Circulation

Hypertension (predisposing factor).
Bleeding may be dark or bright; may be concealed.

Food/Fluid

Abdomen hard, boardlike; uterus tense with symmetric or asymmetric enlargement
Pain/Discomfort
May have pain with retroplacental hemorrhage; usually sudden onset, constant, marked tenderness to severe general or localized pain; low back pain

Sexuality

Rising uterine fundus, and tender to palpation.
Uterine tone may be increased; progressive decrease of relaxation between contractions.
Hyperactive fetus.
FHT may be WNL or may demonstrate bradycardia or tachycardia.

DIAGNOSTIC STUDIES

Culdocentesis: Positive for free blood.
Complete Blood Count (CBC): May reveal elevated WBC count, lowered Hb and Hct.
Human Chorionic Gonadotropin (HCG) Titers: Lowered with ectopic pregnancy, elevated with hydatidiform mole.
Activated Partial Thromboplastin Time (APTT), Partial Thromboplastin Time (PTT), Prothrombin Time (PT), and Platelet Count: May reveal prolonged coagulation, developing DIC.
Fibrinogen Levels: Decreased.
Fibrin Split Products and Fibrin Degradation Products: Present if DIC develops.
Estrogen and Progesterone Levels: Decline in spontaneous abortion.
Ultrasonography: Verifies the presence of a fetus, localizes the placenta, and reveals degree of separation; determines fetal age (based on measurement of biparietal diameter, length of femur, crown to rump).
Amniocentesis: Determines L/S ratio in cases of placenta previa.
Kleihauer-Betke Test on Maternal Serum, Vaginal Fluids, Amniotic Fluid, Gastric Lavage; or APT Test of Amniotic Fluid: Determines maternal versus fetal blood in amniotic fluid; estimates fetal blood loss.

NURSING PRIORITIES

1. Determine client/fetal status.
2. Maintain circulating fluid volume.
3. Assist with efforts to sustain the pregnancy, if possible.
4. Prevent complications.
5. Provide emotional support to the client/couple.
6. Provide information about possible short- and long-term implications of the hemorrhage.

DISCHARGE GOALS

1. Homeostasis achieved
2. Pregnancy maintained
3. Free of complications
4. Client/couple dealing constructively with situation
5. Condition, prognosis, and treatment needs understood