Care of Mother and Child At-Risk or with

Problems (Acute and Chronic)- Lecture

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR
Session # 7

LESSON TITLE: CARE OF THE HIGH-RISK Materials:

PREGNANT CLIENT (GESTATIONAL CONDITIONS- Book, pen, SAS and notebook
SPONTANEOUS MISCARRIAGE)
LEARNING OUTCOMES:
Reference:
At the end of the lesson, the student nurse can:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
1. Define Spontaneous Miscarriage its relation to pregnancy, Maternal and Child Health Nursing, 8th Edition.
including pre-existing factors that contribute to its development. USA: Lippincott Williams and Wilkins

2. Integrate knowledge of Spontaneous Miscarriage in relation

to pregnancy and nursing process to achieve quality maternal
and child health nursing care.

LESSON PREVIEW/REVIEW (5 minutes)

MAIN LESSON (50 minutes)

SPONTANEOUS MISCARRIAGE.
(Please refer to Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication-Bleeding During
Pregnancy Spontaneous Miscarriage p. 529)
ABORTION- any interruption of a pregnancy before a Causes of Spontaneous Miscarriage
fetus is viable (> 20 to 24 weeks & weighs at least 500 g)  Abnormal fetal formation
 Immunologic factors: Rh/ABO incompatibility
 ELECTIVE ABORTION – medical termination of a  Implantation abnormalities
pregnancy  Corpus luteum fails to produce enough P to
 MISCARRIAGE- spontaneous interruption of a maintain the d. basalis (P therapy may be
pregnancy attempted)
 Early miscarriage occurs before week 16 & late  Infection (rubella, syphilis, poliomyelitis, CMV,
miscarriage between weeks 16 & 24 toxoplasmosis, UTI)- fetus fails to grow, P & E
Early miscarriage- before 16 weeks of pregnancy decline causing sloughing off of the endometrium
Late miscarriage- between 16-20 weeks of pregnancy  Trauma
 Incompetent cervix
 Maternal systemic diseases: DM, thyroid
problems, severe anemia
Classifications of Spontaneous Abortions/Miscarriages
1. Threatened Miscarriage Management:
Symptoms:  Assess fetal viability via UTZ; FHT
 vaginal bleeding- scant, usually bright red  Assess amount of bleeding
 Slight cramping or backache  Monitor VS; assess for impending shock
 No cervical dilatation  Provide emotional support
 hCG titer at start of bleeding & after 24h (if viable,
hCG doubles)
 Avoid strenuous activity, CBR for 24 to 48 h
 Avoid stress
 coitus is restricted for 2 weeks after bleeding to
avoid bleeding & infection

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 2. Imminent or Inevitable Miscarriage Management:
Symptoms:  assess bleeding;
 + cramping or uterine contractions  save any tissue fragments passed
 + Vaginal bleeding  initiate IVT with an 18-gauge needle
 Cervix dilates & membranes rupture  If (-) FHT & UTZ reveals empty uterus or
nonviable fetus, D&E
 after D & E monitor bleeding (saturating > 1
pad/hour is heavy bleeding)
 RhOGAM as necessary
 Provide psychological support
3. Complete Miscarriage Management:
Symptoms:  Advise the woman to report heavy bleeding.
 the entire products of conception (fetus, placenta,  No therapy needed since the process of is
membranes) are expelled complete due to spontaneous expulsion of the
 Bleeding, cramping & expulsion of conceptus entire products of conception.
 Bleeding slows within 2 hours then stops within a
few days after passage of conceptus
 The cervix is closed & the uterus contracts
4. Incomplete Miscarriage Management:
Symptoms:  D & C or suction curettage
 Bleeding, cramping & part of the conceptus
(usually the fetus) is expelled but the rest are
retained; cervix is dilated
 danger of hemorrhage because the uterus cannot
contract effectively
5. Missed Miscarriage/ Early Pregnancy Failure Management:
Symptoms:  UTZ to establish fetal death
 the fetus dies in utero but is not expelled & the client  D&E
experiences decreasing signs of pregnancy  If > 14 wks AOG, Prostaglandin suppository of
 Cervix is closed misoprostol (Cytotec) to dilate the cervix, followed
 Dark brown vaginal discharge by oxytocin or
 Pregnancy test (-)  mifepristone
 Fundal height does not increase in size  Miscarriage usually occurs spontaneously within 2
weeks
 If conceptus remains in the uterus > 5 weeks, risk
for DIC and sepsis
6. Recurrent Pregnancy Loss/Habitual Abortion
 Three Spontaneous miscarriage that occurred at the same gestational age
Causes
 Defective spermatozoa or ova
 Poor Thyroid Function
 Septate or Bicornuate Uterus
 Resistance to uterine artery blood flow
 Chorioamnionitis or uterine infection
 Autoimmune disorders such as Lupus Anticoagulant and Anti Phospholipid Antibodies
Complications of Miscarriage
1. Hemorrhage Management
 complete spontaneous miscarriage- 1. Hemorrhage
serious or fatal hemorrhage is rare.  Monitor VS
 incomplete miscarriage or in a woman  Position flat on bed
who develops an accompanying  Blood replacement if necessary
coagulation defect (usually DIC)- major  D&C
hemorrhage becomes a possibility 2. Infection
2. Infection  Advise women to wipe their perineal area
 fever higher than 100.4°F (38.0°C) from front to back after voiding and
 abdominal pain or tenderness particularly after defecation to prevent the
 foul-smelling vaginal discharge spread of bacteria that could cause
3. Septic Abortion- an abortion complicated by infection.
infection  Advise the woman not to use tampons

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  occurs in women who have tried to self-abort or (stasis of any body fluid increases the risk
whose pregnancy was aborted illegally using a of infection).
nonsterile instrument such as a knitting needle 3. Septic Abortion
 fever and crampy abdominal pain; her uterus will  CBC, serum electrolytes and CREA;
feel tender to palpation. blood type and cross-match; and cervical,
 Left untreated, such an infection can lead to toxic vaginal, and urine cultures are obtained
shock syndrome, septicemia, kidney failure, and  Combination of penicillin (gram-positive
death coverage), gentamicin (gram-negative
4. Isoimmunization- whenever the placenta is aerobic coverage), and clindamycin
dislodged some blood from the placental villi may (gram-negative anaerobic coverage) is
enter the maternal circulation. If the fetus is Rh (+) commonly prescribed to combat the
infection.
& the woman is Rh (-), the mother may produce
 D&C or D&E
antibodies against Rh (+) blood & would attempt 4. Isoimmunization
to destroy RBC of the next infant while it is in  Administer RhOGAM or RhIg to all
utero. women with Rh (-) blood to prevent
5. Powerlessness or Anxiety buildup of antibodies in case the fetus is
Rh (+)
5. Powerlessness or Anxiety
 assess a partner’s or the extended
family’s feelings as well, or the potential
impact of their grief and possible lack of
support for the woman over the
pregnancy loss can be missed.
CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.

Multiple Choice

1. A 16th week pregnant client had undergone Dilatation and Curettage related to her vaginal bleeding and was
diagnose to have Spontaneous Miscarriage. She asked you what are the possible causes of her Condition. The
following are causes of Spontaneous Miscarriage, EXCEPT:
A. Abnormal fetal formation
B. Immunologic factors: Rh/ABO incompatibility
C. Abruptio Placenta
D. Incompetent cervix
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. A patient who is 17 weeks pregnant is passing pieces of body tissue along with blood clots and dark red blood
from the vagina. What should the nurse direct the patient to do at this time?
A. Begin immediate bed rest.
B. Count the number of perineal pads that are saturated with blood.
C. Continue with the normal daily activity and monitor pulse rate every hour.
D. Seek immediate medical attention and bring the expressed vaginal material.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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3. A 16-week pregnant client was diagnosed to have Threatened Miscarriage. You know that this type of
miscarriage presents which of the following sign and symptoms?
A. Her vaginal bleeding is scant, usually bright red there is slight cramping or backache but there is no cervical dilatation.
B. The entire products of conception (fetus, placenta, membranes) are expelled there is bleeding, cramping & expulsion of
conceptus
C. Bleeding, cramping & part of the conceptus (usually the fetus) is expelled but the rest are retained and her cervix is
dilated
D. The fetus dies in utero but is not expelled & the client experiences decreasing signs of pregnancy.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. An 18-week pregnant client was diagnosed with Incomplete Miscarriage. Which of the following is the best
definition of the patient’s diagnosis?
A. Her vaginal bleeding is scant, usually bright red there is slight cramping or backache but there is no cervical dilatation.
B. The entire products of conception (fetus, placenta, membranes) are expelled there is bleeding, cramping & expulsion of
conceptus
C. Bleeding, cramping & part of the conceptus (usually the fetus) is expelled but the rest are retained and her cervix is
dilated
D. The fetus dies in utero but is not expelled & the client experiences decreasing signs of pregnancy.
ANSWER: ________
RATIO:_____________________________________________________________________ ______________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. A 20-week pregnant client was diagnosed with Missed Miscarriage/ Early Pregnancy Failure. Which of the
following is the best description for the patient’s diagnosis?
A. Her vaginal bleeding is scant, usually bright red there is slight cramping or backache but there is no cervical dilatation.
B. The entire products of conception (fetus, placenta, membranes) are expelled there is bleeding, cramping & expulsion of
conceptus
C. Bleeding, cramping & part of the conceptus (usually the fetus) is expelled but the rest are retained and her cervix is
dilated
D. The fetus dies in utero but is not expelled & the client experiences decreasing signs of pregnancy.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. A 19-week pregnant client was referred to the hospital and was diagnosed with Complete Miscarriage. Which
of the following is the best description for the patient’s diagnosis?
A. Her vaginal bleeding is scant, usually bright red there is slight cramping or backache but there is no cervical dilatation.
B. The entire products of conception (fetus, placenta, membranes) are expelled there is bleeding, cramping & expulsion of
conceptus
C. Bleeding, cramping & part of the conceptus (usually the fetus) is expelled but the rest are retained and her cervix is
dilated
D. The fetus dies in utero but is not expelled & the client experiences decreasing signs of pregnancy.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. A 16-week pregnant client was diagnosed to have Threatened Miscarriage. The following are management of
Threatened Miscarriage, EXCEPT:
A. Assess fetal viability via Ultrasound and Fetal Heart Tone
B. Complete bed rest for 24 to 48 hours
C. Coitus is restricted for 2 weeks after bleeding
D. Save any tissue fragments passed
ANSWER: ________

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RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. A patient came to the hospital with fever, abdominal pain and foul-smelling discharge. Which of the following
complications of Miscarriage is the patient experiencing?
A. Septic Abortion
B. Isoimmunization
C. Infection
D. Hemorrhage
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. A patient came to the hospital for check-up and she told you that she try to self-abort with a knitting needle.
Which of the following complications of Miscarriage is the patient experiencing?
A. Septic Abortion
B. Isoimmunization
C. Infection
D. Hemorrhage
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. A pregnant patient came to the hospital and told you that she is dizzy, pale in appearance and she is having
“heavy bleeding” and soaked 10 maternal pads in a period of 4 hours per day. Which of the complication of
Miscarriage is the patient experiencing?
A. Septic Abortion
B. Isoimmunization
C. Infection
D. Hemorrhage
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
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4. ANSWER: ________
RATIO:_______________________________________________________________________________________
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5. ANSWER: ________

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 RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________
RATIO:_______________________________________________________________________________________
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LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.
PERIOD 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
PERIOD 2
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
PERIOD 3
32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

AL STRATEGY: Minute Paper

1. Your student will ask you to use index cards or half-sheets of paper to provide written feedback to the following
questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. After writing the instructor will collect the responses before you leave.

(For next session, review Chapter 21: Nursing Care of A Family Experiencing a Sudden Pregnancy Complication-
Bleeding During Pregnancy p. 537-541)

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