Introduction

Pregnancy is a natural state of women. With the onset of pregnancy, a series of physiological changes occurs in a woman's body. Complications of pregnancy arise during gestation or birth. They can occur during pregnancy, childbirth or in the postpartum period and represent a significant danger to the mother and child.

Complications can lead to premature termination of pregnancy, uterine bleeding, fetal developmental delay, and even the death of the baby. When a woman knows what complications can occur during pregnancy, it is necessary to do everything possible to avoid them by any means possible. In most cases, the risk of complications is significantly reduced due to the medical monitoring of pregnancy. Placenta previa, abruption placentae, preterm labor and prolapsed umbilical cord sometimes occur even among healthy pregnant women. Although, frequency of their occurrence is rather low, they present a serious danger to women’s and baby’s life. This paper will examine priority nursing interventions required when handling these complications during pregnancy, as well as an importance of a nurse’s role while managing such cases.

Placenta Previa

Frequency of Occurrence

In normal pregnancy, the placenta is usually located at the bottom of the uterus body or on the back wall with the transition to the side walls, i.e. in those areas where the blood supply to the uterine wall is the best. The placenta is less frequently located on the front wall since the front wall of the uterus is subjected to much greater changes than the back wall. In addition, the location of the placenta on the rear wall protects it from an accidental injury.

Placenta previa is a pathology, in which the placenta is situated in the lower uterine segment on any wall, blocking the area of the internal os partially or completely. The frequency of occurrence of placenta previa is an average of 0.1% to 1% of all births. Cases, when the placenta overlaps the region of the internal os only partially, are marked with a frequency of 70-80% of the total number of placenta previa cases. The variant when the placenta covers the area of the internal os completely occurs with a frequency of 20-30%. Also, 0.2 - 3.0% of cases occurs at around 37 - 40 weeks of gestation. In the earlier stages of pregnancy, placenta previa is noted more frequently (up to 5 - 10% of cases). However, the uterus is stretched with the growth of the fetus, and there is a high probability of migration (movement) of the placenta above to the normal location.

High infant mortality rate, which ranges from 7 to 25%, depending on the technical equipment of the maternity hospital is fixed with placenta previa. A high rate of infant mortality with placenta previa is determined by a relatively high frequency of premature birth, fetoplacental insufficiency, and malposition in the uterus. In addition to the high infant mortality, placenta previa can cause severe complications such as bleeding in women, which is the cause of about 3% of deaths of pregnant women. Placenta previa is referred to the pregnancy pathology because of the risk of infant and maternal mortality.

Risk Factors

The reasons that cause placenta previa may be related both to the condition of the mother's body, and the peculiarities of a fetal egg. The primary cause of complications is the degenerative processes in the endometrium. In this case, the fertilized egg is not able to penetrate (be implanted) in the endometrium of the bottom and / or the body of the uterus; therefore, it is forcing it to go down below. Predisposing factors can be:

  1. chronic inflammation of the uterus;
  2. multiple births;
  3. abortion and curettage of the uterus;
  4. childbirth and abortion, complicated by septic diseases;
  5. tumors of the uterus;
  6. scars on the uterus (surgical delivery, removal of fibroids); congenital malformations of the uterus;
  7. internal endometriosis;
  8. sexual infantilism;
  9. smoking;
  10. drug use;
  11. the first births in the 30 years or more;
  12. the disturbance in ovarian hormonal function;
  13. multiple pregnancy.

Priority Nursing Interventions

The main symptom of placenta previa is painless recurrent bleeding from the genital tract. The diagnosis of placenta previa can be based on characteristic clinical manifestations or the results of objective research (ultrasonography and bimanual pelvic examination). Currently, ultrasonography diagnosis is the most informative and safe method of detecting placenta previa. If placenta previa is found, ultrasonography should be performed periodically, at intervals of 1 - 3 weeks, in order to determine its rate of migration. In 24 weeks, if bleeding is not abundant or completely stops, the woman should receive conservative treatment aimed at the preservation of pregnancy up to 37 - 38 weeks. The treatment of placenta previa is the application of the following drugs: tocolytic and antispasmodic drugs that improve the elongation of the lower segment of the uterus; preparations for the treatment of iron deficiency and anemia; preparations for the improvement of blood supply to the fetus. The Role of Canadian Registered Nurse During Interventions

While handling the placenta praevia complication, the main role of Canadian registered nurse is to make sure of the physiological well-being of the patient and the fetus. The nurse should take and record important features; assess bleeding; monitor the shock pulse, cold moist skin and fall in blood pressure; monitor FHR; provide strict bed rest to minimize the risk to the fetus; observe further bleeding.

Nurse’s Role as an Educator

Unfortunately, the specific treatment capable of changing the place of attachment and the location of the placenta in the uterus does not currently exist. Therefore, the therapy in case of placenta previa is aimed at relieving the bleeding and preserving the pregnancy as long as possible - ideally before the date of birth. Thus, it is extremely important for the nurse to be an educator of the pregnant women with such complications. A nurse should ensure women’s knowledge about the safe behavior. Also, the nurse should inform the patient about the rules she should follow and explain their necessity and the reasons. With placenta previa during pregnancy, a woman must necessarily abide the protective regime aimed at the elimination of various factors that can provoke bleeding. It means that a woman should limit physical activity, do not jump and ride on a bumpy road, do not fly a plane, do not have sex, avoid stress, do not lift weights, etc. During the free time, she should lie on the back, lifting up her legs, for example, on the wall, a desk, a couch, etc.

Abruption Placentae

Frequency of Occurrence

Abruption placentae is a premature detachment of the placenta, which is situated normally. It is a complication that appears untimely in the detachment of the placenta, which takes place not after the birth of the fetus, as it should be, but during pregnancy or the birth process. This complication occurs with a frequency of 0.5 - 1.5% of cases. A third case of abruption placentae is accompanied by profuse bleeding and the development of relevant complications such as hemorrhagic shock and DIC syndrome (disseminated intravascular coagulation).

Risk Factors

There are a number of predisposing factors that increase the risk of such complications. Abruption placentae are considered to be a manifestation of the system, sometimes latent pathology. The risk increases in cases of arterial hypertension, glomerulonephritis, diabetes, antiphospholipid syndrome, the development of nephropathy and burdened anamnesis, if such has happened before. In addition, the physical effects (hit or fall) may also provoke detachment. Also, abruption placentae may be a manifestation of an allergic reaction to medication, especially the introduction of protein solutions and transfusions of donated blood.

Priority Nursing Interventions

It is not difficult to make a diagnosis of abruption placentae of a normally situated placenta with the unfolded classical symptomatology. When symptoms of premature placental abruption are not obvious (no pain factor, external bleeding, or fetal hypoxia), the diagnosis is made by excluding other diseases. Ultrasonography helps to diagnose the problem since it can determine the size of the exfoliated area of the placenta, sizes of retroplacental hematoma and others.

A therapy of abruption placentae is based on the choice of methods for the most rapid and gentle birth. In addition, the nurse must carry out the activities aimed at combating hemorrhage, shock, and to fill the factors that increase blood coagulation at the same in a timely manner. The nurse determines obstetric tactics when choosing a method of birth due to three following parameters: 1. Time of detachment (whether it occurred during pregnancy or already during delivery). 2. The intensity of bleeding and blood loss. 3. The general condition of the mother and fetus. The Role of Canadian Registered Nurse During Interventions

The major guidelines for Canadian registered nurse’s actions are the following - Estimate the vital signs of bleeding and conduct the electronic monitoring of maternal and fetal signs of shock.

  1. Never perform vagina or rectum examination or take any action that would stimulate uterine activity.
  2. Evaluate the necessity of immediate delivery; indicate the need for emergency cesarean delivery.
  3. Ensure proper management. Place a woman in a lateral position to prevent pressure on the vena cava.
  4. Insert a large caliber intravenous catheter into a large vein to replace fluids. Get a blood sample for the level of fibrinogen. Monitor FHR externally and measuring maternal vital signs every 5 to 15 minutes.
 

Nurse’s Role as an Educator

The nurse must carefully monitor the condition of the placenta and fetus. For this purpose, the nurse needs to conduct an ultrasonography and cardiotocography regularly. It is also necessary to monitor the state of the blood coagulation system of women by means of laboratory tests. The patient is assigned to bed rest. In addition, for the treatment of placental abruption, the following drugs should be used: medicines relax the uterus (tocolytic therapy); spasmolytic (papaverine, no-spa, magnesium sulfate, metacin, etc.); hemostatic agents (ascorbic acid, menadione, detsinon); therapy aimed at combating anemia (iron supplements).

The placenta’s role is very important. It is responsible for the biological process by which the baby is developing normally. The child's life depends on the placenta. Deviations and related pathologies may lead to the baby’s death since it performs gas exchange, nutritional and excretory, hormonal, and protective functions. The placenta should not depart during pregnancy. This process is dangerous for the baby because it can deprive it of oxygen and nutrients. However, it can happen almost to every woman. Therefore, the nurse’s role is extremely important. First of all, a nurse should inform the patient about the symptoms of placental abruption, which may be bleeding, stress and pain of the uterus with placental abruption, and heart disorder in a child. The nurse should make sure that in the event of such symptoms, women would seek medical help immediately. Also, the nurse must educate pregnant women about rules, following which can prevent abruption placentae. The nurse should make the patient aware of the necessity to compulsorily attend scheduled scans, periodically undergo ultrasound examination, through which the nurse can detect even small hematoma abruption. Definitely, there are some things that the nurse cannot control; however, she/he should try to convince the pregnant women to observe a healthy lifestyle, give up alcoholic beverages, tobacco products, drugs, harmful food, protect herself from the injuries, and to be fastened in the car. In case of an exacerbation of chronic diseases or occurrence of inflammatory processes and allergic reactions, she should not ignore these symptoms but start the treatment immediately. This knowledge, being timely provided by the nurse can save the child’s and mother’s lives.

Preterm Labor

Frequency of Occurrence

Childbirth is a natural end of pregnancy. Normally, a baby is born at a term of 38-42 weeks. The fetus has developed completely in this period, and its internal organs are ready to function in the outside world. The birth process begins when the pregnant women’s body feels ready for the child to be born. However, there are cases when labor begins early. It is an indication of the presence of some problems in the mother or child. A premature baby is not yet ready for independent living, and such situations are avoided by doctors to prolong pregnancy to a normal term. However, 6-8% of all births are premature.

Only 5-7% of this number happens in periods ranging from 22 to 27 weeks. A little more than 30% of premature babies are born in the period from 27 to 33 weeks. Over 50% of all premature births occur in 34-37 weeks.

Risk Factors

The reasons for preterm labor are Preterm early onset of labor, premature rupture of membranes, complications of the uterus or the fetus. The Risk Factors are the following:

  1. drug abuse;
  2. consumption of any alcoholic beverage; inadequate or improper diet;
  3. excessive weight gain by the pregnant;
  4. hormonal imbalance;
  5. heavy physical work;
  6. sexual life;
  7. infection;
  8. the excessive sensitivity of the uterus;
  9. functional failure of the pressure of the cervix;
  10. placenta previa;
  11. abnormal structure of the uterus;
  12. abnormal development of the fetus;
  13. multiple pregnancy;
  14. stressful situations;
  15. age of 17 years and more than 35 years.

Priority Nursing Interventions

Primarily, in case of the premature beginning of contractions, tocolysis are administered. These medications are taken before 37 weeks of gestation. Magnesia sulfate, 10% ethyl alcohol, and some other preparations can be also used as a means of reducing the tone of the uterus.

At the second stage of the treatment, physicians are trying to eliminate the cause of premature births. When identifying the infection, antibiotics are administered, as well as sedation drugs.

With the development of cervical incompetence in a term up to 28 weeks of pregnancy, the tightening seams are imposed on the cervix, which prevents an ovum from falling out of the uterus. For more than 28 weeks, in the case when the pregnant has the defective cervix, a special supporting Golgi ring is introduced into the vagina. It holds the fetus and does not allow it to put pressure on the cervix. The treatment complex always includes a hormonal drug dexamethasone. Its action is aimed at the stimulation of the development of the child’s lungs. The Role of Canadian Registered Nurse During Interventions

If  the preterm labor is suspected, but there are no signs or symptoms of impending delivery, a Canadian registered nurse should act as follows:

  1. Do not perform a digital vaginal examination;
  2. Perform sterile mirror examination;
  3. Try to exclude the premature rupture of membrane;
  4. Obtain a swab for fetal fibronectin;
  5. Perform initial assessment;
  6. Confirm the exact time;
  7. Palpate contractions;
  8. Start electronic fetal monitoring to assess fetal response to fight;
  9. Initiate access to antibiotics, hydration and other drugs.

Nurse’s Role as an Educator

Preterm labor is dangerous both for a child and the mother. The nurse should identify the patient with a risk factor of preterm labor and ensure that she knows and complies with the recommendations that can prevent a dangerous situation. Also, the nurse should inform the patient about harbingers of preterm birth: pain, tightness in the lower back, the changing nature of painful ailments in the body, cramps, indigestion, a feeling of squeezing pelvis, and changes in vaginal discharge. The nurse should explain the necessity to go immediately to the hospital with the appearance of these symptoms. For pregnant women who experienced premature labor, it is often fraught with psychological problems, when the mother may blame herself for what had happened. Because of this, many suffer from the postpartum depression.

Prolapsed Umbilical Cord

Frequency of Occurrence

Prolapsed umbilical cord is a rare complication, occurring in one out of 1,000 births, in which the appearance of the umbilical cord precedes the passage of the fetus through the birth canal. Prolapsed umbilical cord is a serious threat to life of the fetus, as pressing the part of umbilical cord to the wall of the pelvis by the fetal leads to poor circulation in the fetus, its asphyxia and death.

Risk Factors:

  1. preterm delivery (birth at term of 28-37 weeks);
  2. polyhydramnios (increased volume of amniotic fluid);
  3. malposition of the fetus (transverse, oblique);
  4. long umbilical cord (umbilical cord longer than 70 cm).

Priority Nursing Interventions

The main task here is to determine the loss of the umbilical cord loops and assess the presence of pulsation of blood vessels during the obstetric inspection. If the cord is pulsating, then circulation is not broken and the fetus is still alive. The inspection should be carried out in the intervals between contractions. Premature rupture of membranes should be prevented. Previa cord loops is a contraindication for the amniotomy - instrumental opening membranes. Management of delivery with prolapsed umbilical cord depends on the degree of maturity of the birth canal and the general condition of the fetus. With the full opening of the internal os and the absence of signs of hypoxia, birth by the vaginal route, with output forceps if necessary, can be possible. If umbilical cord prolapsed with incomplete cervical dilatation and further deterioration of the fetus, the doctor performs an emergency Caesarean section. The Role of Canadian Registered Nurse During Interventions- If the cord prolapse is suspected, perform vaginal examination;

  1. If the cord is palpated, determine if there is a pulsation;
  2. If the cord prolapse is confirmed, call for help and stay with a woman;
  3. Place the head of a woman down with hips raised;
  4. Put a gloved hand into the vagina and put pressure on the fetal presenting part to stop compression of the brain;
  5. Notify the attending physician and the necessary team members.

Nurse’s Role as an Educator

Due to modern technology, it is possible to determine the risk of prolapsed umbilical cord long before birth. For example, ultrasound during pregnancy can reveal not only the presentation of the umbilical cord but also determine its length and other features. Therefore, the educating role of the nurse involves informing those at risk about the measures which can save their and child’s life. Thus, the nurse should inform the patient in detail about her actions in case if prolapsed umbilical cord occurs. She should make the patient understand the alarming symptoms such as discharge of amniotic fluid, after which there is a feeling of a foreign body in the vagina. The nurse should consult the women on how to behave when such symptoms appear. To relieve compression of the umbilical cord during prenatal contractions, women must enter an arm into the vagina and to try to push the arm and fetal head up, hold it in this position before coming to the hospital.

Nurse’s Approach in Supporting Clients and Their Family Members

Dangerous complications during pregnancy listed above are often a severe shock to the patient and her family, so they should be treated with the utmost care and attention to provide them with the psychological support. In such cases, the duty nurse is to be honest and truthful to the patient. However, the talks about the diagnosis, the features of the complication cannot go beyond the designated physician. The same can be said about the conversations with the relatives of the patients. When people are suffering, they seek informal communication. The psychotherapeutic role of nurses is very important. At the same time, the nurse should always remember that the partnership with the patients does not have to go into familiarly. She sympathizes with the patient but does not identify herself with the patient’s feelings. The patient should always be sure that their conversations are confidential.

When the family experienced the death of a child, they pass all stages of grief. Many relatives feel guilt. The nurse should recommend books and brochures on these topics. It will help to consider the situation reasonably. If there is such a need, the parents are sent to the institution, where they receive the psychotherapeutic help. Since it is difficult to ask for help themselves, sometimes the nurse makes the first step in negotiating with a specialist about the time of admission. Also, the nurse tells the family members about the existence of support groups and asks whether they are interested in such groups. She tries to motivate them to attend.

Conclusion

Placenta previa, abruption placentae, preterm labor and prolapsed umbilical cord are dangerous complications that sometimes occur during pregnancy. However, in many cases, they can be prevented. The risk factors list shows that most frequently they occur in those women who do not care much about their health during pregnancy, neglect personal hygiene, do not comply with advice received from nurses. First and foremost, it impacts adversely on the state and development of the fetus. However, the frequency of their occurrence is rather low. The outcome of the pregnancy and delivery depends not only on the woman but also on the nurse that takes care of the patient during pregnancy. Thus, it is a direct responsibility of the nurse to be an educator to improve the patient’s knowledge of her condition and ensure that she knows how to behave in case of emergency.

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