Abortion Nursing Care Planning and Management

Bleeding in early pregnancy is one of the first calls you will field on a maternity unit, and how fast you assess and stabilize the patient sets the course. Your job is compassionate, nonjudgmental, patient-centered care: recognize the type of loss, protect the mother's circulating volume, and support her through a hard moment. Know the pathophysiology, the warning signs, and what you can start before the physician arrives.

What is Abortion?

Abortion is the disruption of a pregnancy before the fetus reaches its viable age of more than 20 to 24 weeks of gestation or weighs at least 500g.

Pathophysiology

The most common cause is abnormal fetal development, from either a chromosomal aberration or a teratogenic factor. The next most common is abnormal implantation of the zygote, where inadequate endometrial formation or an inappropriate implantation site leaves the placental circulation underdeveloped. Poor placental circulation starves the fetus of nutrition and ends in abortion.

Risk Factors

Congenital structural defect, from a chromosomal aberration or a serious physical defect. Low progesterone, because progesterone maintains the decidua basalis and a corpus luteum that fails to produce enough puts the fetus at risk. Rh incompatibility, where an incompatible Rh leads the mother's body to reject the fetus. Undernutrition, which starves both mother and fetus. Drugs contraindicated in pregnancy that compromise the fetus. Infection, in which the fetus fails to grow, estrogen and progesterone fall, the endometrium sloughs, and released prostaglandins drive uterine contractions, cervical dilatation, and expulsion of the products of conception.

Types

Classify the type after a thorough assessment of the cervix, bleeding, and whether the products of conception are intact.

• Threatened abortion. Embryo still viable, products of conception intact, cervix closed, but vaginal bleeding is present.
• Inevitable/Imminent abortion. Embryo dead, products of conception intact or expelled, cervix dilated, vaginal bleeding present.
• Complete abortion. All products of conception expelled, embryo dead, cervix dilated, mild bleeding.
• Incomplete abortion. Embryo dead but some products of conception remain, cervix dilated, severe vaginal bleeding.
• Missed abortion. Embryo dead inside the uterus, products of conception intact, cervix closed, brown vaginal discharge present.
• Recurrent/Habitual abortion. Recurrent once the woman has had 3 consecutive miscarriages at the same gestational age.

Signs and Symptoms

Identify these first, before ruling out other causes of bleeding.

• Vaginal spotting. Small brownish to reddish spots, usually when the cervix dilates slightly after lifting heavy objects or mild abdominal trauma.
• Vaginal bleeding. A serious sign that the cervix may have opened and the products of conception may be expelled.
• Cramping, sharp, or dull pain in the symphysis pubis. Can occur on both sides, from trauma or premature contractions that cause cervical dilation.
• Uterine contractions felt by the mother. False or true, either is alarming in early pregnancy because contractions can expel the uterine contents.

Diagnostic Tests

• Pregnancy test. Confirms the pregnancy when vaginal bleeding occurs. A negative result sends the woman for other tests to find the cause of the bleeding. A positive result means classifying the abortion by the presenting signs.
• Ultrasound. The safest confirmatory test. Confirms the pregnancy and whether the products of conception are still intact.

Medical Management

These are physician's orders the nurse anticipates and assists with.

• Intravenous fluids. Anticipate IV therapy such as Lactated Ringer's, plus oxygen at 6-10L/minute by face mask, to replace intravascular fluid loss and support fetal oxygenation.
• Avoid vaginal examinations. The physician avoids further vaginal exams that could disturb the products of conception or trigger cervical dilatation.
• Ultrasound. Ordered to assess fetal and maternal wellbeing.

You are the frontline. The first information lands with you, so initiate care and stabilize the patient before the physician arrives rather than waiting on orders.

Surgical Management

• Dilatation and evacuation. Removes all products of conception from the uterus. First confirm no fetal heart sounds and an empty uterus on ultrasound.
• Dilation and curettage. Most often performed for incomplete abortion to remove retained products of conception. A uterus that cannot contract effectively traps the contents, risking serious bleeding and infection.

Nursing Management

Nursing Assessment

• Vaginal spotting is the presenting symptom. Teach the woman to notify her provider the moment she notices it.
• Know the guidelines for assessing bleeding in pregnancy, since you receive the initial information first.
• Ask what she was doing before the spotting or bleeding started and what she did when she first noticed it.
• Ask about the duration and intensity of bleeding and pain. Identify her blood type for Rh incompatibility.

Nursing Diagnosis

• Risk for deficient fluid volume related to bleeding during pregnancy.

Nursing Interventions

• If bleeding is profuse, place the woman flat on her side and monitor uterine contractions and fetal heart rate by external monitor.
• Measure intake and output to gauge renal function, and assess vital signs for the maternal response to blood loss.
• Measure maternal blood loss by saving and weighing used pads.
• Save any tissue on the pads, since it may be part of the products of conception.

Evaluation

Restore maternal blood volume and stop the bleeding source. Keep blood pressure above 100/60 mmHg, pulse below 100 beats per minute, and fetal heart rate at a normal 120-160 beats per minute. Urine output should stay above 30 mL/hr, with only minimal bleeding for no more than 24 hours.