ENGLISH NEW MIDWIFERY GNM TY UNIT 8 Management of Complications During Pregnancy

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ENGLISH NEW MIDWIFERY GNM TY UNIT 8 Management of Complications During Pregnancy

Unit : 8 Management of Complications During Pregnancy

Bleeding in pregnancy

Ectopic pregnancy:

Definition

When a fertilized ovum implants and develops in the endometrial cavity of a normal uterus (outside), it is called an ectopic pregnancy.

Anatomical site of implantation of ectopic pregnancy:

Tubal pregnancy is more common. Normally the right fallopian tube is more common than the left fallopian tube. The ampulla of the fallopian tube is the most common site of implantation of an ectopic pregnancy.

If an ectopic pregnancy occurs at the isthmus of the fallopian tube, it is considered a dangerous site that can also lead to tubal rupture.

etiology

Due to certain factors, the migration of fertilized ovum into the uterine cavity is delayed.

Due to factors that provide a favorable environment for fertilized ovum to implant in the tubal mucosa.

Due to hormonal factors,
Due to birth defect,
Due to a medical condition.

Risk factors

Due to prior ectopic pregnancy,
Due to previous surgery in the uterine tube,
Due to tubal reconstructive surgery,
Intra uterine contraceptive device no use due to failure,
Due to some type of infection like,
Pelvic Inflammatory Diseases,
chlamydia infection,
Gonorrhea etc.
Having a history of infertility,
Due to Assisted Reproductive Techniques (ART),
Due to infertility treatment like,
In Vitro Fertilization (IVF),
As the mother’s age is more than 35 years,
Due to inducing prior abortion,
Having a history of endometriosis.

Signs and Symptoms:

Symptoms and signs of ectopic pregnancy are classified into two types:

1) Acute type
2) Chronic type

1) Acute type
An acute type of ectopic pregnancy presents with a triad of symptoms such as:

amenorrhea,
Sharp colicky abdominal pain,
Vaginal bleeding
Nausea and vomiting
Palency usually depends on the amount of hemorrhage.
To see signs and symptoms of mourning,
such as,
Rapid and Fable Pulse,
Falling blood pressure,
Extremities are cold and clammy.
On abdominal examination, the abdomen feels tense, tense, and tender.
Abdominal tenderness.
Bowel is distended.
Massive intraperitoneal hemorrhage occurs with tubal rupture and tubal abortion.

Cullen sign positivity: dark bluish peri-umbilical ecchymosis due to hemoperitoneum.
Vaginal area pale during pelvic examination.
The uterus appears to float in the water.

2) Chronic type

Tubal mole is common in the chronic type
It is not known at first.
Its signs include anemia, bladder irritability, tachycardia and increased temperature.
amenorrhea,
abdominal pain,
Vaginal bleeding that appears dark in color shortly after abdominal pain.
Bladder irritation such as dysuria, frequency of urination, retention of urination.
Increase in body temperature.
Examination reveals that the patient is ill,
to see the pallor,
An increase in pulse rate even at rest.
Abdominal tenderness on the affected side.
Filling of mass like structure on lower abdominal site which is irregular.
Extreme tenderness of the cervix.

Diagnostic Evaluation:

History Collection,
Physical Examination,
blood examination,
Caldosynthesis (Tapping of Pouch of Douglas),
sonography,
Assessment of hcg level,
laparoscopy,
laparotomy,
Dilatation and Curettage,
Trans vaginal ultrasonography (USG)

Management of Ectopic Pregnancy

Management of ectopic pregnancy is divided into two types,
such as,

1) Acute ectopic pregnancy management,

2) Management of chronic ectopic pregnancy

Principles of Management

To prevent complications to the mother.

In case of ectopic pregnancy, laparotomy should be performed immediately because the fertilized ovum cannot survive outside the uterine cavity so the tissues are removed to prevent serious complications.

1) Management of acute ectopic pregnancy:

Provide anti-shock treatment to patient and prepare for urgent laparotomy.

Advise the patient to lie down flat on the bed.

Provide patient with inj.morphine 15 mg (IM).
If needed, start a 5% dexrose drip.

Arrangement of blood for blood transfusion.

Even if blood is not available or arranged and the patient is in a state of shock, performing a laparotomy is imperative.

The fallopian tube containing the gestational sac is removed through a laparotomy and a partially surgical procedure.

Performing a salpingectomy. In whose step,

Referring the patient to the hospital,

Advise the patient to lie down on a flat bed.

If the patient is collapsed, raise the bed towards the foot end.

Assessing the patient’s hemoglobin level.

If the patient needs blood transfusion, keep the blood ready.

Administer adequate intravenous fluids to the patient until blood is available.
Ex:=Ringer lactate,
Dexran.

Perform a quick laparotomy under general anesthesia on the patient for salpingectomy.

Then placing the incision on the line of intra umbacus.

After that recognize the uterus and shake out the blood continuously.

Both uterine sites should then be assessed to identify gestational shock in the fallopian tubes.

After that the affected tube and ogre are observed.
Clamps are then applied.

Then the gestational sac wadi affected fallopian tubes with and without ovaries are removed.

The clamps are replaced by chromic catgut ligatures which should not be tightened.

Proper hemostasis is then ensured.

A tubectomy or salpingectomy for hydrosalpinal fluid is performed for the other fallopian tube when the patient wants sterilization.

When a blood clot is free present in the peritoneal cavity, it should be aspirated as much as possible.

Then wash the pelvic cavity properly with normal saline and quickly close the abdomen.

In case of interstitial tubal pregnancy, only the gestational scar should be removed but sometimes for the purpose of better hemostasis, quick subtotal hysterectomy is required.

2)Management of chronic ectopic pregnancy:

All cases with chronic ectopic pregnancy should be admitted to emergency.

Keeping the patient properly under observation.

To carry out all investigations of the patient properly.

Control bleeding quickly and effectively.

Keeping blood transfusion available.

Provide intravenous infusion to the patient as prescribed.

Advise the patient to perform laparotomy as early as possible.

Preparing the patient for laparoscopy or laparotomy.

Then advise to perform salpingectomy.

With medical management in ectopic pregnancy, the ectopic pregnancy is removed by making an incision on the fallopian tube or removing a section of the tube.

If the patient has suppurative pelvic hematocele, provide appropriate antibiotics and drain the pus.

Removal of tubal mole by laparotomy and partial incision on the fallopian tube.

Provide proper management of patients after surgery.

Providing systemic methotrexate 50 mg IM to patients under medical treatment.

Rh antigen is not sensitized in positive Rh women. Anti-D gamma globulin-50 micrograms should be provided to the patient immediately after operation to prevent isoimmunization.

Providing care to resuscitate the patient in acute rupture of the fallopian tube.

Properly maintain vital sign intake output chart of patient.

Providing antibiotic medication to the patient.

Anchoring the patient to early movement.

Advising the patient for proper follow-up.

Abortion:

Definition of Abortion:

Abortion is a process in which pregnancy is terminated. In abortion, the product of conception is partially and completely separated and expelled from the uterine wall before the age of viability (28 weeks). This condition is called “abortion”. Abortion if it occurs spontaneously is called “miscarriage” and if induced abortion is called “induced abortion”.

Majority abortions or miscarriages occur during the first trimester of pregnancy i.e. during the first 12 weeks of pregnancy, then it is called “early miscarriage”. And the miscarriage that occurs after 13 weeks of pregnancy is called “late miscarriage”.

Etiology of Abortion:

The etiology of abortion is often complex and unclear but may include:

Ovular or fetal factor
Maternal environment
Paternal factor
4.Unknown (25%).

Ovular or fetal factor: An autosomal trisomy in which there are three homologous chromosomes instead of two autosomes. Any chromosome other than the sex chromosome (common).

Monosomy is the condition without one missing chromosome from a pair of homologous chromosomes.

Gross congenital malformation.

Blighted ovum (ovum without embryo).

Due to hydropic degeneration of villi.

A knot, twist, or interference with the circulation of the umbilical cord may cause the death of the fitus and its expulsion.

Due to placental formation.

Twins or hydroamnios.

Maternal Environment:

Maternal Illness: Like,

Infection:
Viral infection – rubella, cytomegalovirus, hepatitis parvovirus, influenza virus etc.
Parasitic – Malaria
Protozoal – Toxoplasmosis.

Maternal hypoxia and shock: It can be caused by the following conditions due to production of anoxic conditions.
Acute Prescription Disease,
Chronic Prescription Disease,
heart failure,
pernicious anemia,
Due to anesthesia complications,
Severe gastroenteritis,
Cholera.

Chronic Illness:
Hypertension
Chronic nephritis
Chronic wasting disease.

Endocrine factor:
hypothyroidism,
hyperthyroidism,
Diabetes mellitus.

Trauma:
Due to direct trauma to the abdominal wall,
Psychic: Emotional upset or changes in environment can lead to abortion.

c In a susceptible individual, even minor trauma, e.g.
Rough Road.
Internal Examination in Early Month.
Eliciting the Hager sign.
Sexual intercourse in the early months.

Toxic Agents: Toxic agents involve:
Environmental toxins such as:
a. Lead
b.Arsenic
c. Anesthetic gases
d. tobacco
e. Caffeine
f .Alcohol
g. Radiation in excess amount.

Cervico Uterine Factor:
Cervical incompetence,
Congenital malformation of uterus,
Uterine tumors (fibroids),
retroverted uterus,
Immunological Factors:

Lupus anticoagulant.
Antiphospholipid antibodies.
Alloimmune factors.

6.Blood group incompatibility: It involves Rh incompatibility.

Premature rupture of the membrane can lead to the condition of abortion.
Diabetic factor: Due to deficiency of folic acid and vitamin C.

Paternal Factor:

Due to defective sperm.
Due to the contribution of half the number of chromosomes of the ovum.

Common Non-Causes of Abortion:

First Trimester:

Defective germ plasma,
hormonal deficiency,
trauma,
Acute infection.

Mid Trimester:
Cervical incompetence,
Due to uterine malformations,
Uterine Fibroids,
Loimplantation of placenta,
Twins and Hydroamnios

Abortion condition can arise due to causes like etc.

Types of Abortion:

The types of abortion are as follows.

1) Spontaneous abortion

A) Threatened abortion,
B) Inevitable abortion,
C) Complete abortion,
D) Incomplete abortion,
E) Silent or missed abortion,
D) Septic abortion,
E) Recurrent abortion or habitual abortion,

2) Induced abortion

1)Spontaneous Abortion:
When abortion occurs naturally without any medical or surgical intervention, it is called spontaneous abortion. Its cause can be any genetic abnormality and maternal condition.

A) Threatened Abortion:

In threatened abortion, the process of abortion starts but the abortion does not reach the point where recovery is impossible, i.e. recovery can take place if proper care is taken.

B) Inevitable Abortion:

Inevitable abortion is a type of abortion in which the expulsion of the conceptus progresses with cervical dilatation. In this case, the pregnancy cannot be saved because most of the portion of the placenta is detached (from the uterine wall). This is a clinical type. is an abortion in which the changes in the abortion have progressed to the point where continuation of the pregnancy becomes impossible.

C) Complete Abortion:

Complete Abortion A type of abortion in which the product of conception is expelled in the form of mass is called complete abortion.

D) Incomplete Abortion:

Incomplete abortion is a type of abortion in which the entire product of the conceptus does not exit the uterine cavity but a small part of it remains in the uterine cavity, then this abortion is called incomplete abortion.

E) Silent or Missed Abortion:

Silent or missed abortion is said when the fetus has died in the uterine cavity and is retained in it for more than 4 weeks, then this abortion is called silent or missed abortion.

D) Septic abortion:

When the abortion is accompanied by evidence of infection of the uterus and its contents, i.e. the abortion is due to any infection, the abortion is called a septic abortion.

E) Recurrent Abortion or Habitual Abortion:

When three or more spontaneous abortions occur in sequence before 20 weeks, it is called recurrent abortion.

Other causes include immunoglobulin G, hormonal deficiency, and cervical incompetence.
genetic factor,
infection,
Also caused by endocrine and anatomical abnormalities.

2)Induced Abortion:
Induced Abortion means any medical or surgical procedure to terminate a pregnancy at will is called induced abortion.

Medical Abortion:

A medical abortion involves the use of medication to terminate a pregnancy and
Medical abortion is effective up to 10 weeks of pregnancy.

Ex:= combination of Mifeprostone and misoprostol.

Surgical Abortion:

It involves performing a surgical procedure by health care personnel and terminating the pregnancy. It is called surgical abortion Ex: vacuume Aspiration.

Threatened Abortion:

In threatened abortion, the process of abortion is started but the abortion does not reach the condition where recovery is impossible, i.e. recovery can take place if proper care is taken. And the pregnancy can continue.

Signs and Symptoms:

Vaginal erection,
Mild abdominal pain and cramping,
Bleeding to be slight,
Seeing blood no color bride red,
Mild abdominal pain,
Bleeding is painless,
mild back unite,
Dull pain in the lower abdominal area,
No fresh lump or expulsion of any kind,
having a closed cervix,
Seeing the discharge.

Sign:

Abdominally: A gravid uterus becomes soft filled and enlarged similar to a menorrhoea period.
Speculum examination or vaginal palpation: The os of the cervix is closed and a stained discharge is present.

Investigation:

Blood investigations including,
HB, ABO and Rh grouping.
urine test,
bimanual palpation,
Pelvic ultrasonography,
Transvaginal ultrasonography.

Management of threatened eruptions

Proper assessment and monitoring of pregnant women in nursing management of threatened abortion. To provide proper supportive care to women.

1) Assessment

Vital sign
To continuously monitor the mother’s vital signs. such as,
pulse,
blood pressure,
temperature,
Respiration etc.

Bleeding assessment
Assess the color, amount, intensity and consistency of vaginal bleeding.

History Collection
Collect proper history of mother including complete history about previous pregnancy and abortion.

2) Monitoring and Observation
Continuously observe the mother to assess whether she has any signs and symptoms of shock (hypotension, tachycardia, pallor).

Conduct proper investigations of mother including hemoglobin, hematocrit, ultrasonography, ABO & Rh grouping routinely.

3) Bed rest and physical activity
Advise the mother to take complete bed rest.
Advising the mother to do limited physical activity.
Advising mother not to do household work for one month.

4) Emotional support
To provide emotional support and reassurance to the mother and her family.
To properly clear the doubts and queries of the mother and her family members.
Do not give false reasons to mother and her family members.

5) Education
Providing education to the mother about the signs and symptoms of abortion such as increased bleeding, severe pain, etc. and advising her to seek immediate medical treatment if any such signs and symptoms are observed.
Provide education to mother to take proper follow up.

6) Hydration and nutrition
Advise the mother to have adequate fluid intake.
Continuously monitor mother’s intake output chart.
Advising the mother to take a properly balanced diet.
Advise the mother to consume a high fiber diet to prevent constipation.
Providing supplements to the mother with good fitting.
Ex:= Ferrous Sulphate 200 mg( BD. ),
Folic acid 5 mg/day (TDS).
Provide mother with high protein and vitamin E diet.

7) Medication administration
Providing prescribed meditation to the mother.
Provide medication to control bleeding and relieve pain.
Provide education to the mother about medication dosage, direction and side effects.
To relieve the mother if she has problem of slip and anxiety
Tab. Diazepam, (5-10 mg before night meal),
Or
Tab.Calmpose, (5-10 mg before night meal),
Or
Tab.valium (5-10 mg before night meal), should be provided.

Provide mild amount of laxative to mother at bed time for good bowel activity.
Ex:= Milk of Magnesia.

Do not provide enema to the mother as enema is responsible for stimulating uterine contractions in the mother.
Provide purgative or suppository in mild amount after 48 hours of signs and symptoms of threatened abortion to the mother to relieve constipation if present.

8) Consultancy and referral
Collaborating properly with other health care personnel for care.
To provide timely referral services to the mother if required.

9) Documentation
Timely documentation of mother’s assessment findings, interventions provided, and whether there are any changes in mother’s condition.

10) Follow up
Giving advice to take regular follow up for mother’s progress and reassessment.

Nursing management of threatened abortion is usually provided to provide properly comprehensive care to the mother and to bring about improvement in the mother’s condition.

Inevitable Abortion:

Inevitable abortion is a type of abortion in which the expulsion of the conceptus product progresses with cervical dilatation. In this abortion, the pregnancy cannot be saved/continuated because most of the portion of the placenta is detached (from the uterine wall). .This is a clinical type of abortion in which the abortive changes have progressed to the point where continuation of the pregnancy becomes impossible. It is called “inevitable abortion”.

Signs and Symbols:

Symptoms:
Increased vaginal bleeding,
This bleeding occurs due to detachment of the placenta from the uterine wall,
Severe colicky lower abdominal pain,
No exfoliation of tissues of any kind,
Dizziness due to heavy blood loss.
Sign
Vital signs are normal in majority of cases but in some cases signs of shock are seen due to excessive bleeding.
Skin is cold and clammy,
A uterus felt firm (contracted),
Cervix is seen dilating. The product of the concepts admitting the index finger is felt through the finger.

Management:

Assess the patient’s proper general condition.

Properly assess loss of product of conception.

If there is excessive amount of blood loss, properly administer intravenous (I.v.) fluids.

If the patient has lost excessive amount of blood, then proper blood transfusion should be done.

Blood Hb, ABO Rh group and random blood glucose level test if abortion has occurred.

Intramuscularly (I.m.) injection morphine to provide 15 mg.

In the case of inevitable abortion, if the cervix is fully dilated and the size of the uterus is less than 12 weeks, administer injection methargine 0.2 mg to control excessive bleeding.

If the patient is in shock condition, treat the shock condition properly by providing intravenous fluid (I.v.) or blood transfusion.

If the abortion procedure is before 12 weeks then curettage is done after providing GA (General Anesthesia) followed by dilatation and evacuation. Alternatively, suction and evacuation can be used.

If the abortion procedure is more than 12 weeks, an oxytocin drip (10 units in 500 ml of 5% dextrose) at a rate of 40-60 drops per minute enhances uterine contractions.

If the placenta is expelled and the placenta is retained, the ovum is removed with forceps.

If the placenta is not separated, GA is provided and digital separation is performed.

If bleeding is profuse due to a closed cervix (suggesting low implantation of the placenta), an abdominal hysterotomy may be required to empty the uterus.

If a condition of shock has arisen due to excessive blood loss, treat it properly.

Complete Abortion:

A complete abortion is a type of abortion in which the product of conception is expelled as a mass in which the fetus and placenta are usually completely expelled. The product of conception is not retained in the uterine cavity, i.e. the uterus is emptied. Called complete abortion.

Symptoms and signs:

A history of expulsion of flaccid mass-like structures,
Decreased abdominal pain,
Vaginal bleeding is minimal or absent,
Uterus appears smaller than during periods of amenorrhea,
Transvaginal ultrasonography showing empty ureteric VT.

Management:

Assess the patient’s proper general condition.

Properly assess loss of product of conception.

Continuously monitoring the mother’s condition.

Properly assess the amount of blood loss the patient has.

If there is excessive amount of blood loss, properly administer intravenous (I.v.) fluids.

If the patient has lost excessive amount of blood, then proper blood transfusion should be done.

Blood Hb, ABO Rh group and random blood glucose level test if abortion has occurred.

If the patient is in shock condition, treat the shock condition properly by providing intravenous fluid (I.v.) or blood transfusion.

If a condition of shock has arisen due to excessive blood loss, treat it properly.

Advise the patient to undergo uterine curettage if expulsion of the product of completely conceptus is suspected.

Advise patients for transvaginal sonography to prevent unnecessary surgical procedures.

An Rh negative patient without antibodies in her system should be protected by anti-D gamma globulin 100 micrograms I/M respectively in case of early abortion within 72 hours.

Incomplete Abortion:

Incomplete abortion is a type of abortion in which the entire (complete) product of the conceptus is not expelled from the uterine cavity but a small part of it remains in the uterine cavity, then this abortion is called incomplete abortion.

Symptoms and signs:
History of expulsion of small amount of mass like structure from vaginal area,
Colic pain in lower abdominal area,
During the internal examination.
Uterus appears smaller than during periods of amenorrhea,
Vaginal bleeding is observed,
Expulsion of incomplete mass like structure is seen during examination.

Management:

Assess the patient’s proper general condition.

Properly assess loss of product of conception.

If there is excessive amount of blood loss, properly administer intravenous (I.v.) fluids.

If the patient has lost excessive amount of blood, then proper blood transfusion should be done.

Blood Hb, ABO Rh group and random blood glucose level test if abortion has occurred.

Intramuscularly (I.m.) injection morphine to provide 15 mg.

In the case of inevitable abortion, if the cervix is fully dilated and the size of the uterus is less than 12 weeks, administer injection methargine 0.2 mg to control excessive bleeding.

If the patient is in shock condition, treat the shock condition properly by providing intravenous fluid (I.v.) or blood transfusion.

If the abortion procedure is before 12 weeks then curettage is done after providing GA (General Anesthesia) followed by dilatation and evacuation. Alternatively, suction and evacuation can be used.

If the abortion procedure is more than 12 weeks, an oxytocin drip (10 units in 500 ml of 5% dextrose) at a rate of 40-60 drops per minute enhances uterine contractions.

If the placenta is expelled and the placenta is retained, the ovum is removed with forceps.

If the placenta is not separated, GA is provided and digital separation (dilatation and evacuation) is performed.

If bleeding is profuse due to a closed cervix (suggesting low implantation of the placenta), an abdominal hysterotomy may be required to empty the uterus.

If a condition of shock has arisen due to excessive blood loss, treat it properly.

Proper removal of the product of conceptus by ovum forceps or blunt curettage in condition of incomplete abortion.

In late cases (dilatation + curettage) the tissue left behind is operated to remove bits of tissue, and the removed material is sent for histological examination.

Silent or missed abortion:

Silent or missed abortion is said when the fetus has died in the uterine cavity and is retained in the uterine cavity for more than 4 weeks, then this abortion is called silent or missed abortion.

Symptoms and signs: Persistent brownish vaginal discharge,
Subsidence of pregnancy related symptoms,
Uterine growth arrest,
Absence of fetal heart sound,
Cervix becomes firm,
Fetal skeletal collapse in radiology,
Absent fetal movement.

Investigation:

Blood investigations including,
HB, ABO and Rh grouping.
urine test,
bimanual palpation,
Pelvic ultrasonography,
Transvaginal ultrasonography.

Management:

When the uterus is less than 12 weeks:

Vaginal evacuation is done without delay.

Slow dilatation of cervix by suction and evacuation or Laminaria tent and emptying of uterus under GA.

Keep in mind the risk of hemorrhage during the operation.

Uterus more than 12 wk: For this, induction is done by following methods:

Oxytocin:
Initially start with: 10-20 units of oxytocin in 500 ml dextrose saline 5% given as a drip with 30 drops/min.

If the above regimen fails, increase the dose of oxytocin to 100 units in a pint of 5% dextrose saline at a drip rate of 30 drops/min.

Use the above method with caution.

Prostaglandins:

It is more effective than oxytocin.

Inj. 15 Methyl PG F 2α (Carboprostromethamine) 250 µg I/M every 3 hours. Such is provided at intervals for a maximum of 10

A prostaglandin E₁ analog (gemiprost pessary) is inserted into the posterior vaginal fornix up to a maximum of 5 times every 3 hours.

Proper assessment and monitoring of pregnant women in the management of abortion. To provide properly supportive care to women.

Assessment:

Vital sign
To continuously monitor the mother’s vital signs. such as,
pulse,
blood pressure,
temperature,
Respiration etc.

Bleeding assessment
Assess the color, amount, intensity and consistency of vaginal bleeding.

History Collection
Collect proper history of mother including complete history about previous pregnancy and abortion.

Monitoring and Observation
Continuously observe the mother to assess whether she has any signs and symptoms of shock (hypotension, tachycardia, pallor).

Conduct proper investigations of mother including hemoglobin, hematocrit, ultrasonography, ABO & Rh grouping routinely.

Bedrest and physical activity
Advise the mother to take complete bed rest.
Advising the mother to do limited physical activity.
Advising mother not to do household work for one month.

Emotional support
To provide emotional support and reassurance to the mother and her family.
To properly clear the doubts and queries of the mother and her family members.
Do not give false reasons to mother and her family members.

Education
Providing education to the mother about the signs and symptoms of abortion such as increased bleeding, severe pain, etc. and advising her to seek immediate medical treatment if any such signs and symptoms are observed.

Hydration and nutrition
Advise the mother to have adequate fluid intake.
Continuously monitor mother’s intake output chart.
Advising the mother to take a properly balanced diet.
Advise the mother to consume a high fiber diet to prevent constipation.
Providing supplements to the mother with good fitting.

Medication Administration
Providing prescribed medication to the mother.
Provide medication to control bleeding and relieve pain.
Provide education to the mother about the dosage, duration and side effects of the medication.

Provide mild amount of laxative to mother at bed time for good bowel activity.
Ex:= Milk of Magnesia.

Consultancy and referral
Properly collaborating for care with other health care personnel.
To provide timely referral services to the mother if required.

Documentation
Timely documentation of mother’s assessment findings, interventions provided, and whether there are any changes in mother’s condition.

Follow up
Advising the mother to follow up regularly for progress and reassessment. Management of abortion is generally provided to provide properly comprehensive care to the mother and to bring about improvement in the condition of the mother.

Septic abortion:

When the abortion is accompanied by evidence of infection of the uterus and its contents, i.e. the abortion is due to any infection, the abortion is called a septic abortion.

Etiology:

1.It is involved in sepsis caused by microorganisms that are normally present in the vagina (endogenous).

2.Microorganisms are:
such as,
a Anaerobic:
Bacteroides Group (Fragilis)
Anaerobic streptococci
Clostridium welchii
Tetanus bacilli
b Aerobic:
E. coli
Klebsiella
Staphylococcus
Pseudomonas
Haemolytic Streptococcus.

The increased association of sepsis with illegal induced abortion is due to the fact that:

Proper antiseptic and asepsis are not taken.
Incomplete evacuation
Due to inadvertent injury to the genital organs and adjacent structures, especially the (gut) intestine.

Symptoms and signs

Signs of septic abortion, infection such as,
fever,
feeling cold,
Riggers coming,
Foul smelling vaginal discharge and purulent vaginal discharge.
Infection is likely to be transmitted in the blood stream.
Abdominal pain and tenderness,
Tachycardia,
An increase in the pulse rate to more than 100-120 beats per minute indicates that the infection has spread to the uterine cavity.
Vaginal bleeding is observed,
Having a history of septic shock,
A history of jaundice, oligouria and anuria should be found.
A gravid uterus feels same, small in size, firm, and tender with movement.
Foul purulent discharge from uterus.

Diagnostic Evaluation:

The main two investigations of septic abortion are:

routine investigation,
Special Investigation

Routine Investigation:
Cervical and high vaginal swabs are taken before internal examination (to find out the dominant micro-organism).
Blood test to estimate Hb.
WBC – Total and Differential Count.
Culture and urinalysis.
ABO and Rh grouping.

Special Investigation:

Pelvis and Abdomen Ultrasonography,
Pelvis and Abdomen X ray,
Blood studies: culture, serum electrolyte, and coagulation profile.

Grading:

Septic abortion is generally divided into three grades.

1) Grade 1: Infection is usually localized in the uterus and is usually associated with spontaneous abortion.

2) Grade 2: In this the infection usually spreads to the pelvic structure.

3) Grade 3: In this the infection is usually generalized peritoneum i.e. spread to the peritoneum or sometimes a condition of septic shock may also arise.

Management:

Management of the condition of a patient with septic abortion generally depends on the patient’s severity.

Obtain mother’s hi-vaginal or cervical swab culture, medication sensitivity test, and Gram stain.

Examination of the vagina is done to note the condition of abortion. If the product of conception is found loosely in the cervix, it should be removed by sponge-holding forceps.

An overall assessment of the case and grading for further treatment is done.

Conduct all investigations of the patient properly.

Provide proper treatment to the patient to remove sources of infection and sepsis.

Provide proper supportive therapy to the patient.

Administer sports therapy to the mother to restore normal homeostatic and cellular metabolism.

Grade I or mild septic abortion: Drug of choice or antibiotic used is capsule.

Ampicillin/Amoxicillin (Mox, Coymox)
500 mg TDS × 7 days
cap. Cephadroxil (Cephodar) 500 mg BD × 7 days
cap. Chloromycetin 500 mg 6 hourly.x 7 days.

While giving Cap.Chloromycetin. Blood test is done for Hb, TLC, DLC and platelets.

In grade 1 prophylactically anti-gas gangrene serum 8000 units and antitetanus serum 3000 units I/M are given.

Analgesic and sedative medications are given as per the doctor’s prescription.

To minimize oliguria, anemia or shock, blood transfusion is done.

Incomplete evacuation within 24 hours after providing antibiotics after grade 1 abortion.

Gentleness should be maintained while doing curettage, which can prevent injury.

Medicines given in Grade II are according to the type of organism, i.e. gram positive and gram negative. For gram positive:

inj. Aqueous penicillin G 5 million units every 6 hours.
Inj. Ampicillin 0.5-1 g IV every 6 hours.

For gram negative:
Inj. Gentamicin 1.5 mg/kg IV every 8 hours.
Inj. Ceftriaxone 1.5 IG, IV every 12 hours.

For anaerobes:
Inj. Metronidazole 500 mg IV every 8 hours.
Inj. Clindamycin 600 mg IV every 6 hours.

To monitor the mother’s vital signs properly.

The uterus is emptied by suction evacuation with antibiotic treatment within 6 hours.

If uterus and intestine are injured then laparotomy is done.

If the uterus is injured or infected, a hysterectomy is performed.

When the infection is localized to the pouch of Douglas, a posterior colpotomy is performed.

In grade III, it is referred to as severe septic abortion with antibiotic therapy. The mother is resuscitated and fluid and electrolyte balance is maintained.

When laparotomy is performed by a surgeon experienced, simple drainage of pus is also effective.

Recurrent Abortion or Habitual Abortion:

When a sequence of three or more spontaneous abortions occurs before 20 weeks of pregnancy, it is called recurrent abortion. Other causes include immunoglobulin G, hormonal deficiency, and cervical incompetence.
genetic factor,
infection,
Also caused by endocrine and anatomical abnormalities.

Etiology:

Due to genetic chromosomal error,
Due to anatomical defect,
Like, cervical incompetence and uterine anomalies,
Uterine infection,
endocrine disorders,
immunological factor,
idiopathic

Signs and Symtones:
Absence of fetal heart sound,
Multiple spontaneous abortions (recurrent).

Diagnostic evaluation:

History Collection,
Physical Examination,
VDRL test,
thyroid function test,
ABO & RH Grouping,
Topzoplasma IgG and IgM,
ultrasonography,
hysterosalpingography,
hysteroscopy,
laparoscopy,
endocervicals swab,
Simmons Analysis.

Management:

In nonpregnant state of the patient, complete history should be collected and properly recorded.

Assess the general health status of the patient.

Perform a pelvic examination to assess for cervical incompetence.

Laboratory tests like blood test, urine test, cervical culture,
Perform hysteroscopy, ultrasonography, and dilatation and curettage (D&C) to look for uterine KVT abnormalities.

Proper treatment of any infection during post conception.

Emphasis on health promotion in proper prenatal care of the patient.

See the patient if there is cervical in computer C then perform cerclage operation, Sirodkar or Mc Donald operation. Then remove stitches after 38th wick or before.

If the mother has a condition of bleeding then report immediately.

Provide education to patients for regular antenatal checkup and hospital delivery.

Management of abortion involves comprehensive care and support for women undergoing termination of pregnancy, whether spontaneous (miscarriage) or induced (therapeutic) abortion.

History Collection
Completing a complete history of a woman’s medical, obstetrical and gynecological conditions.

Assessing gestational age of pregnancy, identifying reasons for abortion.

Complete vital sign monitoring of the mother including,
blood pressure,
pulse,
Properly and continuously monitoring respiration and temperature etc.

Assess the client for any signs of haemorrhage eg excessive bleeding pallor etc.

Perform an abdominal examination to assess the tenderness of the uterine cavity.

Then perform a pelvic examination to assess whether cervical dilatation and products of conception are present in the uterine cavity.

Providing proper emotional support and counseling to mother and family members.

Advising the patient to explain his feelings.

Providing education about available resources for psychological support such as support groups and counseling services.

Provide prescribed analgesic medication such as NSAID or Acetaminophen to relieve the patient’s pain.

Advise the patient to use non-pharmacological measures such as heating pads and relaxation techniques to relieve the patient’s pain.

Assess the patient for signs of excessive building.
Properly assessing the amount of blood loss to the mother Preparing for blood transfusion if the patient needs it

Assess the patient for signs and symptoms of infection such as,
fever,
foul smelling,
Properly assess for symptoms like discharge and lower abdominal pain.

Provide adequate antibiotic medication to the patient as prescribed.

Properly monitor the patient for signs of incomplete abortion such as continuous heavy bleeding and camping pain.

Preparing the patient for possible surgical intervention such as dilatation and curettage (D & C).

Provide patient education about signs and symptoms requiring immediate medical care such as heavy bleeding, pain, and fever.

Provide instruction to maintain perineal hygiene to prevent infection.

Advise the patient to make a follow-up appointment one to two weeks after the abortion so that complete recovery can be properly ascertained.

Provide complete patient education about the importance of follow up visits.

Provide information to the patient about available contraceptive options to prevent unintended pregnancy.

Also provide patient education about the timing of using contraceptives after abortion.

Discharge planning involves ensuring that the patient is able to go home and that the patient can receive adequate support and a safe environment at home.

Then provide written instructions on meditation use, activity restrictions, and signs of complications. Provide information about support services and resources available in the community.

Properly and accurately document all assessments, interventions, patient responses and education provided.

Recording the emotional states of patients and providing counseling and psychological support to them.

The nurse plays a critical role in the comprehensive management of women who have had an abortion, which involves providing compassionate care, ensuring the patient’s physical and emotional well-being, and providing patient education about post-abortion care and contraceptive options. is

Proper assessment, monitoring and providing proper intervention of the patient can prevent complications and facilitate the recovery process.

Proper management of abortion plays an important role in improving the mother’s well-being.

Induced Abortion:

Induced Abortion means any medical or surgical procedure to terminate a pregnancy at will is called induced abortion.

Medical Termination of Pregnancy (MTP)

Medical termination of pregnancy is a medical procedure in which a woman can undergo termination of pregnancy to maintain her health or well-being by considering certain criteria.

Termination of pregnancy by medical or surgical method before the stage of viability of the fetus is called induction of abortion, legal or illegal. Abortion was legalized in India as medical termination of pregnancy in August 1971 and came into effect from April 1972 and revised by Happened in 1975.

indication

When a woman’s life is in danger and her physical and mental health is severely damaged.

Child may have physical and mental abnormalities.

In the condition that the child has any congenital anomaly.

Being pregnant due to rape.

Due to social or economic reasons, mother’s health is damaged and contraceptive measures have failed.

According to Indian law, abortion is allowed up to 20 weeks, the opinion of one registered medical practitioner is required for pregnancies up to 12 weeks and two registered medical practitioners for 12 to 20 weeks.

Returned (written) consent of the patient and consent of the guardian is required in cases where the patient is under 18 years or mentally handicapped.

Contraindications

Have uncontrolled blood pressure greater than 160/100,
Having Cardio Vascular Diseases,
Women are above 35 years of age,
Have severe renal failure, liver disease or respiratory disease,
Using systemic corticosteroids,
coagulopathy or women receiving anticoagulant therapy,
Mother is anemic,
Have an uncontrolled seizure disorder.

Who can perform medical termination of pregnancy?:

The Chief Medical Officer or Civil Surgeon authorizes the following doctors for medical termination of pregnancy:

Holder of Post Graduate Degree or Diploma in Obstetrics and Gynaecology.

Six months training as a resident in obstetrics and gynaecology.

One year experience in Obstetrics and Gynecology Department.

Registered Medical Practitioner assisted in 25 cases of Medical Termination of Pregnancy (MTP).

Place for MTP (Medical Termination of Pregnancy):

A hospital established or maintained by the Government or a place approved by the Chief Medical Officer or Civil Surgeon.

Records:

Recording medical termination of pregnancy in the form. Maintain confidentiality and report to Director of Health Services.

Penalty:
A person who does not comply with this act can be punished with imprisonment of 2 to 7 years.

Methods of Medical Termination of Pregnancy (MTP):

First Trimester (up to 12 weeks):

Medical
This involves terminating the pregnancy using medication such as,
Mifepristone,
Mifepristone and Misoprostol,
Mithotrexate and Misoprostol,
Tamoxifen and misoprostol.

surgical
A pregnancy is terminated using a surgical procedure.
such as,
Menstrual Regulation, Vacuum Aspiration,
Saxan Evacuation and Curettage,
Dilatation and evacuation.

Second Trimester (13-20 wks):

prostaglandins,
Dilation and evacuation,
Intra uterine instillation of hyperosmotic solutions,
oxytocin infusion,
Hysterotomy.

Complications:

Complications usually depend on the method by which Medical Termination of Pregnancy (MTP) is performed.

Immediate complications
Cervical lacerations,
uterine perforation,
hemorrhage,
grief,
thrombosis,
embolism,
The post-abortal triad may include pain, bleeding, and low-grade fever, depending on the method used for medical termination of pregnancy.

remote
Gynecological complications,
Obstetric complications,
Failed Abortion,
Ectopic pregnancy etc.

Nursing Role with the Patient Undergoing MTP:

The nurse should provide comfort and support to the mother and her family members and provide proper reassurance by clearing all their queries.

If the mother decides to have an abortion, her husband and the patient’s own consent should be obtained along with their written permission.

Continuous monitoring and providing support to the patient before medical termination of pregnancy, during the procedure and even after the procedure is completed.

Providing proper education to the mother about the complications that may arise after abortion such as,
Continuous vaginal bleeding with clots up to three weeks after abortion,
Providing education to women about fever, continuous pain, and burning micturition etc.

First menses start 2 to 8 weeks after a woman is advised to have an abortion.

Advise women that if lactase is started, it is in mild amounts and lasts for 48 hours if the breast is not stimulated.

Provide them with education or follow-up visits two to eight weeks after medical termination of pregnancy (MTP) to ensure that the reproductive organs have returned to their prepregnancy state.

Thus, termination of pregnancy is done in medical termination of pregnancy.

APH (Ante Partum Haemorrhage):

Bleeding from the genital tract after the 28th week of pregnancy but before the birth of the child is called APH (Ante Partum Haemorrhage).
Or
“Antepartum Haemorrhage (APH) is bleeding from or in the genital tract that starts at 24 weeks of pregnancy and precedes the birth of the child” This condition is called Antepartum Haemorrhage (APH).

It is placenta previa (where the placenta is implanted abnormally low in the uterine cavity). Or it can be caused by different conditions like placental abruption (where the placenta prematurely separates from the wall of the uterine cavity).

Placenta Privia:

When the placenta partially or completely implants near or above the internal os of the lower segment of the uterus it is called “placenta previa”. 1/3 cases of antepartum hemorrhage are due to placenta previa.

Etiology:

The exact cause of placenta implantation in the lower uterine segment is unknown.

Some theories are given below:

Dropping Down Theory:

According to this theory, the fertilized ovum drops down in the lower uterine segment and implants in the same setting.

Persistence of chorionic activity

It explains the formation of the capsular placenta from the chorion coming in contact with the decidua vera of the lower segment of the uterus.

Defective decidua

In this the chorionic villi are spread over a large area of the uterine wall to receive nourishment.
During this process, not only does the placenta become membranous but implantation in the lower part of the uterus may occur.

Large Surface Area of Placenta:

Because of the big surface area like twins, the placenta implants in the lower segment.

High Risk Factors:
Multipara.
Increase maternal age
( > 35).

Having a history of privy lower segment caesarean section (L.S.C.S).
If any other scar is present in the uterus due to it.
Big Placental Size and Abnormalities,
Placental hypertrophy due to smoking,
Privy curettage.

Types of placenta previa:
There are four types of placenta previa depending on the degree of extension of the placenta into the lower segment of the uterine cavity.

1) Type I (lateral placenta previa),
2) Type II (Marginal placenta previa),
3) Type III (Incomplete placenta previa),
4) Type IV (Complete placenta previa)

1) Type I (Lateral placenta previa):
In this type no major part of the placenta is attached to the upper segment but only the lower margin enters the lower segment but does not reach the os.

2) Type II (Marginal placenta previa):

In this type, the placenta only reaches the margin of the internal os but does not cover it. If the placenta is anterior, vaginal birth is possible, blood loss is average, and the risk of fetal hypoxia is higher than maternal shock.

3) Type III (Incomplete placenta previa): Placenta does not cover the internal os centrally but partially when the cervix begins to efface and dilate in late pregnancy, bleeding occurs due to lower stretch.

4) Type IV (Complete placenta previa): In this the placenta covers the internal os even when it is fully dilated. Severe haemorrhage occurs and caesarean section is required to save the life of mother and baby.

Sign and Symbols

symptoms
vaginal bleeding,
Bleeding is sudden.
Bleeding is painless.
Bleeding is causeless.
Bleeding is recurrent.
Bleeding is unrelated to activity and often occurs during sleep and the patient is alarmed upon waking to find himself in a pool of blood.

In placenta previa, the blood is bright red because of bleeding from a separated ytero-placental sinus. Sign
Patient has evidence of late pregnancy.
Evidence of blood loss is also seen such as shock, anemia depending on the degree of hemorrhage.
Abdomen
In this, the size of the uterus is according to the gestational period.
Uters feel soft, relaxed, and elastic.
A breech, transverse, unstable lie shows malpresentation.
The head is floating.
A fetal heart sound is often present.
Bright red blood is seen in placenta previa.

Diagnostic evaluation:

Diagnostic evaluation is done by two methods:

1) Placentography,
2) Clinically

1) Placentography: a) Sonography: Trans abdominal ultra sound
(TAS).
Trans vaginal ultra sound
(TVS).
Transperineal ultrasound.
Magnetic Resonance Imaging (MRI),
radiography,
radioactive isotope,

2) Clinically:
By Internal Examination (Double Setup Examination),
Direct visualization daring cesarean section,

Management of placenta previa:

Principles of management of placenta previa

To prevent injury to the fitus,
To reduce the risk of infection,
To control vaginal bleeding,
To promote health and reduce anxiety.

Management:

Provide adequate amount of antenatal care to the patient to improve the health status of the mother.

Perform an ultrasound at 20 weeks followed by a repeat ultrasound at 34 weeks to confirm the type of placenta previa.

Instruct the pregnant woman to rest in bed and then gently palpate the uterus for tenderness and tone.

To properly assess the amount of blood loss.
Color of bleeding and complete blood count (CBC) test.

Inj to patient as per hospital policy and prescription. Provide Morphine 15 mg IM.

Properly assess the amount of blood loss the client has suffered.

To properly note the client’s vital signs like,
temperature,
pulse,
respiration,
Blood pressure.

To properly assess the client for anemic condition or not.

To check the fetal heart sound regularly and frequently.

Abdominal examination of the pregnant woman followed by note of fetal heart sound and proper note of any tenderness present in the uterus.

Do not perform vaginal examination in the condition of placenta previa as it may increase bleeding.

Properly monitoring pregnant women for continuous or intermittent bleeding.

Arrangements should be made to shift the pregnant woman to another well equipped hospital having blood transfusion facility, caesarean section facility and neonatal care unit if required.

If the client has a hemorrhagic condition, start intravenous dextrose normal saline drips.

Advise the client to avoid stress and advise to take complete bed rest.

When the client is admitted to the hospital follow the following treatment viz.

Providing immediate attention,

Then properly planning what type of treatment is required.

In the immediate assessment, the amount of blood loss the client has suffered, his general condition, his pallor, pulse rate and blood pressure should be properly noted.

Send blood samples immediately to the laboratory for cross-matching and assessment of hemoglobin levels.

Start an infusion of normal saline to the patient.

Keeping blood ready to hand for transfusion after cross matching of blood.

Perform gentle abdominal palpation to assess the presence of any active bleeding.

Formulation of line of treatment:
In this, proper treatment should be provided according to the condition.

The hemoglobin level should be properly estimated and should be 10 gm or more.

Expectant treatment should be provided till 37 weeks are completed.

Termination in any of the following conditions viz:
Recurring hemorrhage,
dead fits,
Fetus is a congenital malformation,
India If there is uterine growth retardation (IUGR), termination is performed in such conditions.

Specific treatment is started after admission to the hospital. As such, vaginal examination is performed in the operation theater to properly prepare for cesarean section.

After examination the membrane is artificially ruptured then oxytocin is started then delivery is conducted as per condition.

If the labor process is progressing satisfactorily without any bleeding, perform vaginal delivery.

If the bleeding is continuous, the pregnant woman should undergo caesarean section.

Assess presentation if baby is malformed or dead, ventous delivery if vertex presentation and breech delivery if breech.

Abruptio Placenta:

Definition:

Abruptio placenta is a form of antepartum hemorrhage (APH) in which the normally situated placenta prematurely separates from the uterine wall and causes bleeding called abruptio placenta.

Types of Abruptio Placenta:

There are mainly 3 types of placental abruption namely,
1) Revealed,
2) Concealed,
3) Mix.

1) Revealed or mild type: In this type blood comes downwards between the membrane and decidua after the separation of the placenta i.e. the blood is externally visible this type is a common type of abruptio placenta.

2) Concealed: In this concealed type of abruptio placenta, the blood collects behind the separated placenta or between the membrane and decidua i.e. the blood is not externally visible. This type is a rare type of abruptio placenta.

3) Mix: In this type, the blood is partially collected inwardly (concealed) and partially visible outwardly (revealed), i.e., there are both revealed and concealed types of placental abruption. It is called mix abruptio placenta.

Etiology:

The exact cause is unknown,
5 th is more common in gravida,
Due to mother’s advanced age,
Due to poor socioeconomic condition,
malnutrition,
smoking.
Other factors like,
preeclampsia,
Sudden uterine decompression,
short cord,
Supine hypotensive syndrome,
Folic acid deficiency,
Due to torsion of the uterus,
Due to direct trauma to toe, high parity or uterine over distension.

Risk Factors:

sort cord,
Due to premature rupture of membranes,
Due to uterine leiomyomas,
chorioamnionitis,
polyhydramnios,
Anticoagulant therapy,
No use of cocaine,
smoking,
Due to trauma to the abdomen,
hypertension,
Due to intra-uterine growth retardation (IUGR),

Diagnostic evaluation

History Collection,
Physical Examination,
Blood test A hematocrit, urea, electrolyte
, to assess fibrinogen level, thrombin time, blood group and cross match.
Urine Examination,
Placentography,
ultrasound,
Cardiotocography.

Symptoms and signs:

Painful vaginal erection,
Tender board like uterus (especially when concealing hemorrhage or vaginal bleeding),
Fit bradycardia and late deceleration,
Fetal Heart Rate (FHR) being Absent,
Signs of mourning being present.
Bleeding is caused by preeclampsia or trauma.
Bleeding can be a mix of visible and invisible bleeding.
Blood is of dark red color.
In this, the condition of anemia is seen more than the amount of visible blood loss.
Abruptions of the placenta are seen in 1/3 of cases of features of preeclampsia.
In abruptio placenta, the height of the uterus is enlarged more than the gestational age.
Abruption of placenta ma uterus can be tense, tender and rigid.
Abruptio placentae malpresentation is unrelated and may also involve the head.
Heart sounds are often absent in abruptio placenta.
The placenta is found in the upper segment of the uterus.

Management:

Prevention:

The objectives of the intervention are as follows, viz.
To eliminate the responsible causes of placental separation.
Early identification of preeclampsia and hypertensive disorders and providing effective treatment.
Properly correct the patient if he is anemic.
To start early treatment to prevent patient complications.
Avoid trauma, sudden decompression of uterus, supine hypotension.

To shift the patient immediately to the maternity hospital.

Complete assessment of the patient in the hospital.

Properly assess the amount of blood loss the patient has.

Properly assessing the maturity of fits.

Assess the general condition of the patient properly.

Perform a complete diagnostic evaluation of the patient. Like, blood hemoglobin level,
Hematocrit level,
coagulation profile,
ABO and RH grouping, doing urine analysis.

Providing Ringer’s Latest (RL) solution to the patient.

Prepare the patient for proper blood transfusion.

Close monitoring of maternal or fetal condition.

Prepare the patient for delivery.

If the patient has any complication, manage it properly.

Definitive Treatment: If the patient is in labour, perform low rupture of membranes, if necessary, start oxytocin drip followed by vaginal delivery.

Provide adequate amount of antenatal care to the patient to improve the health status of the mother.

Instruct the pregnant woman to rest in bed and then gently palpate the uterus for tenderness and tone.

To properly assess the amount of blood loss.
Color of bleeding and complete blood count (CBC) test should be done.

Properly assess the amount of blood loss the client has suffered.

To properly note the client’s vital signs like,
temperature,
pulse,
respiration,
Blood pressure.

To properly assess whether the client has an anemic condition or not.

To check the fetal heart sound regularly and frequently.

Abdominal examination of the pregnant woman followed by note of fetal heart sound and proper note of any tenderness present in the uterus.

Proper monitoring of pregnant women for continuous or intermittent bleeding.

Arrangements should be made to shift the pregnant woman to another well equipped hospital having blood transfusion facility, caesarean section facility and neonatal care unit if required.

If the client has a hemorrhagic condition, start intravenous dextrose normal saline drips.

Advise the client to avoid stress and advise to take complete bed rest.

When the client is admitted to the hospital, follow the following treatment such as, giving immediate attention,

Then properly planning what type of treatment is required.

In the immediate assessment, the amount of blood loss the client has suffered, his general condition, his pallor, pulse rate and blood pressure should be properly noted.

Send the blood samples immediately to the laboratory for cross-matching and assessment of hemoglobin levels.