Gynecological Nursing
Subtopic:
Abortion
Defining Abortion: Key Terms
Abortion refers to the premature ending of a pregnancy, specifically the expulsion of the products of conception before the fetus has reached viability. This is generally understood to be before the pregnancy reaches its 28th week.
Alternatively, abortion can be described as the termination of a pregnancy occurring before the 28th week of gestation. This is also indicated when a fetus is delivered weighing under 500 grams, signifying its non-viability outside the womb.
Early vs. Late Abortion Stages
Abortions are further categorized by the gestational age at which they occur, differentiating between early and late stages.
An early abortion is classified as the termination of pregnancy that takes place prior to the completion of the first trimester, specifically before the end of the 12th week of gestation.
Conversely, a late abortion is defined as the termination of pregnancy occurring during the second trimester, between the 12th and 24th weeks of gestation.
Causes of Abortion
Abortion can be broadly classified based on the origin of the underlying issues into several categories: those originating from the fetus itself, the mother, the uterus, and localized factors.
Fetal Factors:
Zygote Malformations due to Chromosomal Issues: Developmental problems arising from an abnormal chromosomal makeup in the zygote are significant contributors to abortion. Conditions like trisomy 21 (Down syndrome) or monosomy X (Turner syndrome), which involve an incorrect number of chromosomes, are examples that can lead to structural defects incompatible with continued development.
Abnormal Uterine Implantation: Issues with how the fertilized egg implants in the uterine wall can disrupt pregnancy. Conditions such as placenta previa, where the placenta is positioned low in the uterus near or covering the cervix, can interfere with the normal progression of fetal development. Improper implantation can compromise the essential supply of nutrients and oxygen to the developing embryo, potentially leading to pregnancy loss.
Diseases of the Fertilized Egg: Various disorders affecting the fertilized ovum itself can jeopardize the pregnancy. These can include genetic or metabolic conditions that hinder the embryo’s ability to thrive. Such problems can impede the fundamental processes required for embryonic growth and survival in the early stages of pregnancy.
Fetal Chromosomal Anomalies (30% – 40%): Irregularities in the fetus’s chromosome structure are a major factor in spontaneous abortions. These genetic errors, encompassing both numerical and structural abnormalities in chromosomes, are estimated to account for a significant proportion of pregnancy losses. Such anomalies can severely disrupt normal fetal development pathways, increasing the likelihood of abortion.
Maternal Factors:
Acute Infections with Elevated Body Temperature: Sudden illnesses that cause a high fever, like malaria, typhoid fever, or rubella, can increase the risk of abortion. The elevated body temperature and systemic effects of these infections can negatively impact the pregnancy.
Chronic Health Conditions: Long-term maternal health problems can create an environment unfavorable for pregnancy maintenance. Examples include conditions like anaemia, chronic kidney disease (nephritis), diabetes mellitus (DM), and syphilis. These pre-existing conditions can affect maternal and fetal health, increasing the risk of pregnancy loss.
Cervical Incompetence: Weakness or dysfunction of the cervix, known as cervical incompetence, can lead to an inability to maintain a pregnancy to term. A compromised cervix may prematurely dilate, particularly in the second trimester, resulting in pregnancy loss.
Severe Nutritional Deficiencies: Inadequate nutrition in the mother can have detrimental effects on both maternal health and fetal development. Severe malnutrition can compromise the conditions necessary for a healthy pregnancy, increasing the risk of abortion.
Oxytocic Medications: Certain medications designed to stimulate uterine contractions, known as oxytocic drugs, can inadvertently trigger abortion if used inappropriately or during pregnancy.
Hormonal Insufficiency: Insufficient hormone production in the mother can disrupt the pregnancy. For instance, inadequate progesterone production before the placenta is fully formed can impair the development of the decidua (uterine lining necessary for implantation). Thyroid disorders, both hypothyroidism (deficiency) and hyperthyroidism (overactivity), are also linked to an increased risk of abortion.
Effects of Drug Exposure: Exposure to certain substances can negatively impact pregnancy. This includes cytotoxic drugs (medications toxic to cells, often used in chemotherapy), radiation therapy, and overdoses of certain medications, such as antimalarial drugs. These exposures can be harmful to the developing fetus and increase the risk of abortion.
Other Causes: Uterine & Trauma
Uterine Abnormalities:
Uterine Structural Issues: Physical abnormalities of the uterus can interfere with pregnancy. This includes conditions like a retroverted uterus (tilted backwards), a divided uterus (bicornuate uterus with two horns), or the presence of fibroids, particularly submucosal fibroids (noncancerous growths located within the uterine cavity). These structural issues can impact implantation and fetal development.
Trauma:
Physical Injury to the Uterus: Significant physical trauma to the uterus can induce abortion. This can result from direct impact injuries, falls, or procedures involving the insertion of instruments or foreign objects into the cervix or uterus. Surgical procedures like myomectomy (removal of fibroids from the uterus) can also, in certain circumstances, increase the risk.
Immunological Factors:
Immune System Incompatibility: Certain immunological incompatibilities between the mother and the fetus can lead to abortion. For example, in rhesus (Rh) incompatibility, maternal antibodies can cross the placenta and attack fetal red blood cells, potentially causing pregnancy loss.
Acute Emotional Distress:
Sudden and Severe Emotional Shock: Extreme emotional disturbances, such as severe fright or sudden bereavement (loss of a loved one), can, in some cases, trigger uterine contractions and potentially lead to abortion. While less common, extreme emotional stress is considered a potential contributing factor in certain circumstances.
Predisposing Factors to Abortion
Pregnancy Circumstances:
Adolescent Pregnancies: Pregnancies occurring during adolescence are often unintended and may unfortunately lead to abortion due to limited access to necessary resources, inadequate social support systems, and insufficient knowledge about reproductive health and parenting.
Closely Spaced Pregnancies: Pregnancies that occur with very short intervals may place excessive strain on a woman’s physical health and emotional well-being, potentially elevating the likelihood of abortion.
Advanced Maternal Age Pregnancies: Pregnancies in women of older reproductive age can be associated with increased medical risks, which may lead some individuals to consider abortion as an option.
Challenges Related to Teenage Sexuality and Pregnancy:
Inadequate Sex Education and Contraceptive Access: Insufficient or absent sex education and limited availability of contraception are major factors contributing to high rates of unintended teenage pregnancies and subsequent abortions.
Sociocultural Influences: Societal norms and cultural beliefs can significantly shape adolescent sexual behaviors and increase the risk of unplanned pregnancies and their terminations.
Suboptimal Family Planning Practices:
Inconsistent or Incorrect Contraceptive Use: Failure to use family planning methods correctly or consistently can result in contraceptive failure and unwanted pregnancies.
Limited Access to Family Planning Services: Barriers to accessing affordable and effective contraception contribute to unintended pregnancies and abortions.
Pregnancy Resulting from Coercion or Violence:
Sexual Coercion or Rape-Related Pregnancies: Pregnancies originating from non-consensual sexual acts like coercion or rape may result in abortion, particularly as the individual did not consent to the pregnancy.
Relationship Instability:
Unstable or Abusive Partner Relationships: Relationships characterized by instability or abuse can contribute to unplanned pregnancies and abortion considerations, especially if the pregnant individual feels unsafe or lacks support within the relationship.
Financial Hardship:
Economic Constraints: Financial difficulties can make it challenging to manage the expenses associated with raising a child, potentially leading individuals to consider abortion as a response to economic pressures.
Educational or Professional Commitments:
Career or Education Priorities: Some individuals may opt for abortion to prioritize their educational pursuits or maintain their employment, particularly when they lack sufficient resources or support to manage both pregnancy and these responsibilities.
Relationship Betrayal:
Infidelity in Partnership: In certain situations, the discovery of infidelity by a partner may lead to abortion decisions, especially if trust within the relationship has been severely compromised and the pregnant individual is unwilling to raise a child in that circumstance.
Preventions of Abortion
Public Health Education: Educate communities regarding the serious risks associated with unsafe abortion procedures.
Promote Family Planning Awareness: Emphasize the importance of family planning within community education programs to enable informed reproductive choices.
Expand Family Planning Services for Adolescents: Provide accessible family planning services specifically tailored for school-aged girls and adolescents.
Strengthen Legal Frameworks on Unsafe Abortion: Governments should reinforce and implement regulations and laws aimed at controlling and reducing unsafe abortion practices.
Promote Positive Child Upbringing: Parents should focus on providing children with a strong upbringing that includes values and responsible decision-making.
Enhance Youth-Friendly Health Services: Improve and strengthen healthcare services at all facilities to be more accessible and sensitive to the needs of young people.
Empower Community-Based Organizations: Support community-based groups in their efforts to educate communities about the dangers of unsafe abortions and promote safe reproductive health practices.
Types of Abortion
Abortions are generally categorized into two main types: spontaneous and induced.
Spontaneous Abortion
Spontaneous abortion, commonly known as miscarriage, refers to the unintended loss of a pregnancy occurring naturally before the fetus reaches a gestational age of 20 weeks. This type of pregnancy loss is quite prevalent.
It is the most frequent complication of pregnancy, estimated to occur in approximately 10% to 20% of all recognized pregnancies.
Subtypes of Spontaneous Abortion:
Threatened Abortion: Characterized by bleeding during the early stages of pregnancy. Critically, in a threatened abortion, the cervix remains closed, and there has been no expulsion of the products of conception (POC). In many cases, threatened abortions resolve without medical intervention, and the pregnancy can continue.
Inevitable Abortion: In this type, the cervix has dilated (opened), and the products of conception may be visible at the cervical opening. This indicates that pregnancy termination is unavoidable. An inevitable abortion will progress to either an incomplete or a complete abortion, and the pregnancy cannot be sustained.
Incomplete Abortion: Occurs when only a portion of the products of conception are expelled from the uterus. Some tissue remains inside the uterus.
Complete Abortion: Indicates that all products of conception have been fully expelled from the uterus. The uterus is empty of pregnancy-related tissue.
Recurrent Abortion (Habitual Abortion): Defined as the occurrence of three or more consecutive spontaneous abortions. This indicates a recurring issue in maintaining pregnancy.
Induced Abortion
Induced abortion is the deliberate termination of a pregnancy before the fetus is capable of surviving outside the uterus on its own (fetal viability). This is a medical procedure that is legally permitted in many nations, although its legality varies globally.
Subtypes of Induced Abortion:
Legal or Therapeutic Abortion: This form of induced abortion is performed under legal conditions and often to protect the life or physical or mental health of the pregnant person. It can also be indicated in specific circumstances like pregnancies resulting from rape or incest.
Illegal or Criminal Abortion: This type of abortion is conducted outside the bounds of the law, making it a criminal act in many jurisdictions. Illegal abortions pose significant health hazards to the individual undergoing the procedure due to the lack of qualified medical professionals and adherence to safe medical practices, drastically increasing the risk of complications like septic abortion (severe infection).
Nursing Care After Abortion
Supporting Patient Through Anxiety and Providing Emotional Support
Assess and Facilitate Emotional Expression: Evaluate the patient’s level of anxiety and actively encourage them to express their feelings openly. Recognize that both the patient and their partner may experience guilt. Facilitate grieving and acknowledge that the grieving process is unique to each person.
Consider Cultural Perspectives: Understand and consider the patient’s and their partner’s cultural beliefs and values regarding abortion and pregnancy loss.
Establish Therapeutic Relationship: Build a trusting nurse-patient relationship by demonstrating empathy, understanding, and a non-judgmental attitude (unconditional positive regard). Provide compassionate care, acknowledging the significance of the pregnancy to the patient.
Provide Psychological Comfort and Support: Offer mental and emotional support to both the patient and their partner throughout the process. Utilize comfort techniques such as relaxation exercises and controlled breathing to help manage anxiety. Clearly explain all procedures and ensure the patient is well-informed to participate in decision-making. Remain present with the patient to provide reassurance and support.
Support Person and Spiritual Support: Facilitate the presence of a chosen support person, especially during second-trimester abortion procedures, as this can provide emotional stability. If desired, explore spiritual support options as a coping mechanism. Encourage the patient to ask questions and openly express any fears or concerns they may have.
Providing Pain Relief and Comfort
Pain Assessment and Monitoring: Thoroughly assess the intensity, nature, and location of the patient’s pain, keeping in mind that pain perception varies between individuals. Regularly monitor and document both verbal reports of pain and any observable signs of discomfort every two hours.
Educate About Expected Discomfort: Prepare the patient for the type and level of discomfort they can expect during the abortion process. Provide clear information about the use of both prescription and over-the-counter pain relievers.
Administer Analgesics and Comfort Measures: Administer prescribed pain medications, which may include narcotic or non-narcotic analgesics, sedatives to reduce anxiety, and antiemetics to control nausea and vomiting. Offer non-pharmacological comfort measures, such as relaxation techniques, breathing exercises, and massage. Assist the patient in finding comfortable positions and encourage frequent position changes to alleviate discomfort.
Assist with Pain Management Procedures: Provide assistance during pain management procedures, such as the administration of a paracervical block (local anesthetic) before surgical abortion procedures to minimize pain. Support the patient in utilizing pain management strategies effectively throughout the termination process.
Promoting Maternal Safety and Preventing Injuries
Assess Abortion Method and Monitor for Complications: If the abortion is self-managed, inquire about the methods used to assess for potential risks or complications. Monitor for excessive nausea and vomiting, which can be indicative of complications, both before and after an elective abortion.
Evaluate for Respiratory Distress and Vital Signs: Carefully assess for signs of respiratory distress such as dyspnea (difficulty breathing), wheezing, or agitation, as these may suggest complications. Continuously monitor vital signs. Evaluate the patient’s level of general discomfort and specifically address any reports of abdominal pain or tenderness, which could indicate issues. Emphasize the critical importance of attending a follow-up medical examination to ensure complete recovery and address any potential late complications.
Ensure Proper Procedures and Administer Necessary Medications: Determine the status of the cervix prior to the procedure. Assist with procedures like the insertion of Laminaria tents (cervical dilators) or prostaglandin administration to prepare the cervix. Administer Rho(D) immune globulin (RhoGAM) to Rh-negative patients following the abortion to prevent Rh sensitization in future pregnancies. Be prepared to assist with additional treatments or procedures required to manage any complications that may arise.
Preventing Hypovolemic Shock
Monitor Vital Signs and Assess Blood Loss: Closely monitor vital signs, paying attention to an elevated pulse rate or other indicators of shock (e.g., low blood pressure, rapid breathing). Accurately monitor and assess the amount of blood loss by counting and weighing perineal pads to quantify blood loss.
Patient Education and Emergency Preparedness: Educate the patient on recognizing and reporting signs of excessive bleeding (haemorrhage) and ensure they understand and adhere to prescribed medications. Provide clear emergency contact information and instructions for seeking immediate medical help if needed.
Cervical Assessment and Medication Administration: Determine cervical status before the procedure. Assist with the insertion of Laminaria tents or prostaglandin administration as needed. Administer prescribed antiemetic medications to manage nausea and vomiting. Draw blood samples for blood typing and crossmatching in case blood transfusion becomes necessary due to blood loss.
Oxygen and Intravenous Fluid Administration: Administer supplemental oxygen to increase oxygen levels in the body if needed. Initiate intravenous fluid administration as prescribed by the medical provider to maintain hydration and blood volume. Be prepared to assist with surgical procedures, such as uterine aspiration or dilation and curettage (D&C), to control haemorrhage if it occurs.
Preventing Infection
Monitor for Infection Signs: Vigilantly monitor for signs and symptoms of infection, including fever, crampy abdominal pain, and uterine tenderness. Regularly assess vital signs, particularly body temperature, to detect early signs of infection.
Hand Hygiene and Perineal Care Education: Strictly adhere to hand hygiene protocols, washing hands thoroughly before and after each patient care activity to prevent cross-contamination. Educate the patient on proper perineal hygiene techniques to reduce the risk of bacterial spread and infection.
Promote STD Screening and Infection Reporting: Educate the patient about the importance of universal screening for sexually transmitted diseases (STDs) for all sexually active individuals. Instruct the patient to promptly report any signs or symptoms of infection (e.g., fever, unusual discharge, pain) to their healthcare provider for timely diagnosis and treatment.