1. NCM 102.1 – MCN
Hyperemesis Gravidarum
•Unremitting nausea and vomiting that persists after the first trimester.
•Usually occurs with the first pregnancy and commonly affects pregnant women with conditions, such as hydatidiform
mole or multiple pregnancy, that produce a high level of human chorionic gonadotropin.
•This disorder occurs among Blacks in about 7 in 1,000 pregnancies and among Whites in about 16 in 1,000 pregnancies.
Assessment Findings
• Unremitting nausea and vomiting (cardinal s/sx)
• Vomitus contains:
– initially: undigested food, mucus, and small amounts of bile
– later: bile and mucus
– finally: blood and material that resembles coffee grounds
• Substantial wt loss and eventual emaciation caused by persistent vomiting, thirst, hiccups, oliguria, vertigo, and
headache.
• Evaluate 24-hr dietary recall.
• Determine for pica.
• Inspection may reveal:
– pale, dry, waxy, and possibly jaundiced skin, with decreased skin turgor
– dry, coated tongue
– subnormal or elevated temperature
– rapid pulse
– fetid, fruity breath odor from acidosis.
• May appear confused and delirious. Lassitude, stupor and, possibly, coma may occur.
Medical Management
Diagnostic Test
•Serum analysis shows decreased protein, chloride, sodium, and potassium levels and an increased blood urea nitrogen
level.
•Other laboratory tests reveal ketonuria, slight proteinuria, an elevated hemoglobin level, and an elevated white blood cell
count.
• May require hospitalization to correct electrolyte imbalance and prevent starvation.
• I.V. infusions-to maintain nutrition until she can tolerate oral feedings.
• Progresses slowly to clear liquid diet, then to full liquid diet, finally, to small, frequent meals of high-protein solid foods.
• Midnight snack helps stabilize blood glucose level.
• Parenteral vitamin supplements and potassium replacement help correct deficiencies.
• Jeopardized health due to persistent vomiting- antiemetic is administered.
• Meclizine (Antivert) and Diphenhydramine -low risk for teratogenicity.
• Total parenteral nutrition- rarely needed.
• If vomiting stops and electrolyte balance has been restored- pregnancy usually continues without recurrence of
hyperemesis gravidarum.
• Most pts feel better as they begin to regain normal wt, but some continue to vomit throughout pregnancy, requiring
extended treatment.
• If appropriate, some patients may benefit from consultations with clinical nurse specialists, psychologists, or
psychiatrists.
Priority Nursing Diagnoses with Interventions
1. Risk for deficient fluid volume may be r/t excessive gastric losses and reduced intake, possibly evidenced by dry
mucous membranes, decreased/concentrated urine, decreased pulse volume and pressure, thirst, and
hemoconcentration.
•Maintain I.V. fluids, as ordered, until the patient can tolerate oral feedings.
•Maintain NPO status until vomiting stopped. Ice chips may be given.
•Monitor fluid intake and output, vital signs, weight, serum electrolyte levels, and urine for ketones.
•Medicate with antiemetics as prescribed.
2. Imbalanced nutrition: less than body requirements may be r/t inability to ingest/digest/absorb nutrients (prolonged
vomiting), possibly evidenced by reported inadequate food intake, lack of interest in food/aversion to eating, and weight
loss.
•Suggest decreased liquid intake during meals.
•Advise woman that oral intake can be restarted when emesis has stopped.
•Company and diversionary conversation at mealtime may be beneficial.
•Instruct the patient to remain upright for 45 minutes after eating to decrease reflux.

2. •Suggest that the patient eat two or three dry crackers on awakening in the morning, before getting out of bed, to alleviate
nausea.
3. Fatigue may be r/t muscle weakness 2° emaciation
•Teach the patient protective measures to conserve energy and promote rest.
•Teach relaxation techniques; fresh air and moderate exercise, if tolerated.
•Schedule activities to prevent fatigue.
4. Risk for ineffective coping may be r/t stress of pregnancy and illness: risk factors may include situational/maturational
crisis (pregnancy, change in health status, projected role changes, concern about outcome).
•Provide reassurance and a calm, restful atmosphere.
•Encourage the patient to discuss her feelings about her pregnancy and the disorder.
•Help the patient develop effective coping strategies.
•Refer her to the social service department for help in caring for other children at home, if appropriate.
5. Fear may be r/t concerns for fetal well-being
 Praise mother for attempts of following therapeutic regimen.
 Explain the effects of all medications and procedures on maternal as well as fetal health.
 Accentuate the positive signs of fetal well-being.
Premature Labor
•Premature labor (preterm labor) is the onset of rhythmic uterine contractions that produce cervical changes after fetal
viability but before fetal maturity.
•It usually occurs between the 20th and 37th week of gestation.
•Between 5% and 10% of pregnancies end prematurely; 75% to 85% of neonatal deaths as well as many birth defects
result from this disorder.
•Fetal prognosis depends on birth weight and length of gestation:
 Neonate’s wt <1 lb 10 oz (737 g) and of <26 weeks' gestation have a survival rate of 40-50%;
 Wt= 1 lb 10 oz to 2 lb 3 oz (737 to 992 g) and of 27 to 28 weeks' gestation have a survival rate of 70% to 80%;
 Wt= 2 lb 3 oz to 2 lb 11 oz (992 to 1,219 g) and of >28 weeks' gestation have an 85% to 97% survival rate.
Assessment findings
• Activity: Works outside home, job heavy/stressful; Unusual fatigue
• Circulation: HPN, pathological edema (signs of PIH); Preexisting CV disease
• Ego Integrity: Moderate anxiety apparent
• Elimination: Dark amber urine, dec frequency/amount
• Food/Fluid: Inadequate or excessive wt gain; Inadequate fluid intake; Dry mucous membranes
• Pain/Discomfort: Intermittent to regular contractions (may not be painful) <10min apart and lasting @ least 30 sec
for 30–60 min
• Respiratory: May be heavy smoker (7–10 cigarettes/d)
• Safety: Infection may be present (i.e., UTI and/or vaginal infection).
• Sexuality: Cervical os softening/dilated/effacing; Bloody show; PROM; 3rd trimester bleeding; Previous abortions,
preterm labor/delivery, hx of cone biopsy, <1 yr since last birth; Uterus may be overdistended, owing to
polyhydramnios, macrosomia, or multiple gestation.
• Social Interaction: May be low socioeconomic status
Medical and Surgical Managements
Diagnostic Test
•Premature labor is confirmed by the combined results of prenatal history, physical examination, and presenting signs and
symptoms.
•Ultrasonography is used to identify the position of the fetus in relation to the mother's pelvis, document gestational age,
and estimate fetal weight.
•Vaginal examination is used to confirm progressive cervical effacement and dilation.
•Electronic fetal monitoring confirms rhythmic uterine contractions and is used to monitor fetal well-being.
•Differential diagnosis excludes Braxton Hicks contractions and urinary tract infection.
 Nitrazine Test or “Ferning” Slide: Determines PROM.
 WBC Count: Elevation indicates presence of infection.
 Urinalysis and Culture: Rule out UTI.
 Amniocentesis: L/S ratio detects phosphatidyl glycerol (PG) for fetal lung maturity; or amniotic infection.

3. • Focuses on suppressing premature labor when tests show immature fetal pulmonary development, cervical
dilation of less than 4 cm, and factors that warrant continuation of pregnancy.
• Bed rest and hydration
• If pt doesn't respond, tocolytic therapy is instituted.
• Beta-adrenergic stimulants stimulate the beta2 receptors, inhibiting the contractility of uterine smooth muscle.
– Terbutaline (Brethine)
– Isoxsuprine
– Ritodrine (Yutopar)
• Magnesium sulfate - to relax the myometrium.
• After successful tocolysis, oral therapy is maintained until 36 weeks' gestation.
• Some pts successfully deliver at term after this treatment.
• Glucocorticoid administration to the mother at <33 weeks gestation enhances fetal pulmonary maturation and reduces
incidence of respiratory distress syndrome.
• Continuous fetal monitoring
• Avoidance of amniotomy - to prevent cord prolapse or damage to the fetus' soft skull
• Maintenance of adequate hydration through I.V. fluids
• Avoidance of sedatives and opioids that might harm the fetus.
• Morphine or meperidine - to minimize maternal pain, have little effect on uterine contractions, but because they depress
CNS, may cause fetal respiratory depression.
• They should be given in the smallest dose possible and only when needed.
• Cesarean birth may be planned to reduce pressure on the fetal head and reduce the possibility of subdural or
intraventricular hemorrhage from a vaginal birth.
Priority Nursing Diagnoses and Interventions
1. Risk for fetal injury may be r/t preterm birth: risk factors may include delivery of premature/immature infant.
•Maintain bed rest and administer medications as ordered.
•Minimize adverse effects by keeping the patient in a lateral recumbent position as much as possible.
•Maintain adequate hydration by drinking 8-10 glasses of water daily.
•If necessary, give oxygen to the patient through a nasal cannula.
2. Risk for poisoning: risk factors may include dose-related toxic/side effects of tocolytics.
•Help the patient get through labor with as little analgesic and anesthetic as possible. To minimize fetal CNS depression,
avoid administering an analgesic when delivery seems imminent. Monitor fetal and maternal response to local and
regional anesthetics.
•When giving a beta-adrenergic stimulant, a sedative, or an opioid, monitor blood pressure, pulse rate, respirations, fetal
heart rate, and uterine contraction pattern.
•When giving magnesium sulfate, monitor neurologic reflexes and be alert for maternal adverse reactions, such as
tachycardia and hypotension. Keep calcium gluconate at the bedside.
3. Acute pain may be r/t labor contractions
•Give analgesics sparingly, mindful of their potentially harmful effect on the fetus.
•Teach relaxation techniques and breathing exercises.
•Promote diversional activities such as watching TV, listening to calm music.
4. Activity intolerance may be related to muscle/cellular hypersensitivity, possibly evidenced by continued uterine
contractions/irritability.
 Pace activities to promote frequent rest periods.
 Monitor vital signs and compare with baseline to assess for tolerance to activity.
 Encourage SO’s to assist pt with ADL’s.
5. Anxiety may be related to situational crisis, perceived or actual threats to self/fetus, and inadequate time to prepare for
labor, possibly evidenced by increased tension, restlessness, expressions of concern, and autonomic responses
(changes in vital signs).
•Encourage the patient and her family to discuss their feelings and concerns. Offer emotional support, and help them to
develop effective coping strategies.
•If possible, arrange for the parents to see and hold the infant soon after delivery to promote bonding.
•Provide pt and family teaching regarding s/sx and management of premature labor.
Prepared By:
Ma. Louredes Balucan
Reynel Dan Galicinao
Angelia Galinato
Geraldine Ridad