nursing care r/t pregnancy termination

Specialties Ob/Gyn

Published

staff note:please, answer the op's questions about how to provide proper care for patients following the loss of a pregnancy (for whatever reason) and the other things she wanted to know. do not post about the inadequacy of her instructor/program in this thread. do not turn this into a thread about the morality or immorality of abortion. thank you.

i don't wish to start a flame war, but i have some honest questions.

i am just weeks from graduation from a public college, to become a rn. my program director admits to keeping anything remotely relating to abortion completely off-limits. her values are very conservative, so the curriculum seems to reflect it (birth control was also left out). the textbooks they chose don't mention the nurse's role when a pregnancy ends without a live birth. when i did maternity/peds rotation, it was never mentioned. as we got to the part about molar pregnancies and eclampsia, all i was told was that the "resolve the pregnancy". i still know nothing about it, other than it makes some people angry enough to picket planned parenthood and it saves the lives of other people. :confused: the internet is even worse -- everyone shouting at each other and very little medical-focused info.

nursing care: i am guessing it might be to monitor for hemorrhage and infection. but there has got to be more to it than that? is care any different depending on trimester? on miscarriage ("natural") vs pharmaceutical vs surgical terminations?

if conditions are incompatible with life later in the pregnancy, is it considered an "abortion" to use surgical intervention to remove an already deceased fetus?

do nurses get training in how to handle the psych aspect for a post-abortion patient? not all women who have abortions want to terminate. is a psych or post-partum type screening typical done?

do nurses interested in a obgyn/reproductive health type specialty get any additional education? or do you just pick it up on the job as you go? and can you ask colleagues about it and be sure to get an accurate answer? or is talk relating to it greatly discouraged in the workplace, too?

does anyone here regularly give nursing care to women following pregnancy termination (intentional or miscarriage)? forgive what might be a naive question: but if you work in a clinic setting, is it true you have to be scared of terrorists and harassment? or has television really exaggerated that?

what is the nurse's role as patient advocate, when a dr's personal/religious beliefs cause permanent harm to a patient? eg. when a mother's life is in danger and a provider doesn't want to consider terminating the pregnancy or doesn't want to treat a recent post-termination pt who is having a complication.

thanks for giving me your professional advice, as i graduate and head into practice. i apologize in advance if i've offended anyone by asking about this topic. i know how strongly some people belief for/against this issue, and i do respect everyone's' beliefs on this issue. i just need some factual information. thank you.

Specializes in ER.
I don't mean to be offensive, but I'm a little tired of attitudes like this. I don't like the idea of abortion at all, but I realize it's probably not going away and I'm sensitive enough to not argue about it (normally) but then I see people all the time, trying to say that the people who are AGAINST abortion are somehow horrible monsters with no morals. What?! :crying2:
You are in this job (or should be) to care for others. It has nothing to do with YOU. There are and will be many aspects in nursing that we either like or dislike, but whatever the case may be, a person DESERVES to have the best possible nurse. The only way that can happen is if that nurse is given the best opportunity for learning, which is to ensure our instructors are giving accurate and complete information on each topic and not censoring based on opinion or personal preference/biases.

Being able to take care of whatever might walk in the door, as is my case working in an ER, is what is paramount. Not to be completely comfortable, but as least AWARE of what might happen is key.

Specializes in Med/Surg, Academics.
If conditions are incompatible with life later in the pregnancy, is it considered an "abortion" to use surgical intervention to remove an already deceased fetus?

I can help answer that one because I took care of a patient in this scenario. It was a D&C under sedation, and like a previous poster said, you watch for hemorrhage and other post-anesthesia issues. As for the psychosocial aspect, I asked her if she was ok with everything and followed her lead. I was in an acute care setting that did a lot of different procedures, so there were no psychosocial follow-up processes in place.

Although a miscarriage (depending on the timing) is technically a spontaneous abortion, I personally would not use the term "abortion" in the presence of a woman undergoing a procedure to have a dead fetus removed. Laypeople often associate abortion with elective pregnancy termination, and, regardless of their POV on elective abortion, I wouldn't say it. The surgical procedure was a D&C, and that's what I referred to it as. Other people might have a different opinion on terminology, but that is how I approached it.

Specializes in Med/Surg, Academics.

To the OP: out of curiosity, did you cover D&C's in your coursework? From what I've read, suction or D&C's are used for early elective abortions, so you might have covered what you need to know for a vast majority of elective abortions and not even realized it.

Maybe a poster who is familiar with early elective abortion procedures could confirm my understanding?

Later term abortions are a bit rarer, and I would suspect that the information you need to know concerning later term abortions would be on-the-job in a specialized setting. At any rate, not every medical condition I've run across on the floors was covered in class, but I wouldn't consider my program negligent because they didn't teach me everything.

Specializes in Med/Surg, Ortho, ASC.

I have minimal experience with this. My facility does not perform abortions except when the outcome is already clearly defined. Even then, because it is such a rare occurrence, the pre-op, OR and post-op nurses are allowed to volunteer to care for the patient or conversely, may bow out of caring for the patient. My only real addition to the conversation is that post-AB education and information is crucial. Depending upon the length of the pregnancy, various options are available. Burial or cremation of the POC are sometimes utilized and/or required. My facility offers a grief service every 6 months for all involved. Customarily, the participation of the parents is not required. But parents need to have the information upon which to make the decision and so that is an important part of post-op teaching.

STAFF NOTE #2:

There are two big topics fighting for space in this thread. One is the OP's request for the information she needs regarding the care of patients who lose a pregnancy (for whatever reason).

The other is the response people are having to the idea that this information was not included in her education in the first place.

Please, keep this thread focused on the facts pertaining to patient care.

No amount of indignation or flaming of her instructors or program will help to get her where she needs to be now.

Further posts discussing the inadequacy of her training will be subject to moderation.

Thank you.

Specializes in ER.

there are also plenty of ob/gyn books out there to educate yourself.

Did you read all the info provided in your nursing books? Start there and try and take a little extra time studying it. You could also pick up additional books if need be if this field interests you.

Specializes in Family NP, OB Nursing.
Nursing care: I am guessing it might be to monitor for hemorrhage and infection. But there has got to be more to it than that? Is care any different depending on trimester? On miscarriage ("natural") vs pharmaceutical vs surgical terminations?

The basics are exactly what you brought up. Monitor VS, bleeding and for s/s of infection and I would include pain management as well. Most of the care is very similar to what the woman would receive after delivery of a viable fetus, so think along the lines of post-partum care.

The other part, and the most important part, is providing emotional support. A pregnancy loss, whether because of an induced abortion or a spontaneous abortion can be/usually is very emotional. Some people want to talk, some don't. So listen, take your clue from the patient and do what you can.

If conditions are incompatible with life later in the pregnancy, is it considered an "abortion" to use surgical intervention to remove an already deceased fetus?

Usually if there is a fetus that is deceased, labor is induced and delivered lady partslly. Sometimes a procedure called, dilation and evacuation, can be done. This is similar to a D&C, but requires a few different steps that I won't discuss in depth, but the end result is the pregnancy is ended.

The same things can be done for a pregnancy that is found to be incompatible with life such as anacephaly, but sometimes the parents choose to wait until labor starts on its own. Again, it depends on how far advanced the pregnancy is.

Do nurses get training in how to handle the psych aspect for a post-abortion patient? Not all women who have abortions want to terminate. Is a psych or post-partum type screening typical done?

Most specialized training occurs on the job, and sometimes inservices are done for things like this. My first fetal loss patients taught me a lot and I asked the other nurses, but each woman deals differently, so you adjust how you treat them and the family. If they want to talk, listen, don't assign blame and offer resources as indicated. Usually, there are a list of resources on the unit to provide to the patient.

Do nurses interested in a obgyn/reproductive health type specialty get any additional education? Or do you just pick it up on the job as you go? And can you ask colleagues about it and be sure to get an accurate answer? Or is talk relating to it greatly discouraged in the workplace, too?

Again, you get trained to do the job you take. It's part of orientation and yes, you pick it up as you care for the patients. I ALWAYS talked with my co-workers. I learned so much from them. Also, remember if you are working in situations where abortions/terminations are done the other nurses are dealing with the same issues.

LOL, I can't think of any unit I've ever worked on where talking about work issues was ever discouraged, though at times I think maybe NOT having to hear some of my co-workers talk would have been good. ;)

Does anyone here regularly give nursing care to women following pregnancy termination (intentional or miscarriage)? Forgive what might be a naive question: but if you work in a clinic setting, is it true you have to be scared of terrorists and harassment? Or has television really exaggerated that?

I worked in a hospital setting, so I can't answer the question about that type of harassment personally, but I've had friends who have on occasion dealt with this type of situation. I'm not sure to what extent it was however.

Most of my patients had either spontaneous abortions (miscarriages) or were undergoing terminations for fetal demise and we did also deliver those fetuses with issues that were incompatible with life. So, most of my patients weren't terminating by choice. Most induced abortions were done on an outpatient basis, in the OR and we didn't get them to our floor unless there were complications, but sometimes that did happen.

What is the nurse's role as patient advocate, when a dr's personal/religious beliefs cause permanent harm to a patient? eg. when a mother's life is in danger and a provider doesn't want to consider terminating the pregnancy or doesn't want to treat a recent post-termination pt who is having a complication.

Always advocate for your patient, no matter what your beliefs are. Personally, I lean pro-life with exceptions for rape/incest and life of mother, BUT I don't judge women who have them. I'm not living their lives. I'm not in their situation. If they are my patient, they are treated the exact same way as all my other patients.

I've never run into a doc not treating a patient post procedure. Some nurses I worked with refused these patients, but then there was always someone to take them. We did have a doc who wouldn't prescribe birth control. In fact she wouldn't discuss it with the patient since her religion forbid it. When I cared for her patients I would discuss birth control with them, let them know what their options were and if they wanted it called one of her partners to discuss/prescribe it for the patient. Of course, the doc who didn't prescribe was informed that her patient wanted birth control and that I had discussed it with her Sr. partner who would prescribe it. This worked well enough for everyone involved.

Hope this info helps! Good luck and check with the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), http://www.awhonn.org/awhonn/ for accurate nursing info.

Post #19 is an excellent example of information helpful to someone with the OP's questions. Thank you NPinWCH.

STAFF NOTE: Some of you will notice that one or more of your post(s) was edited or deleted. Posts that diverged from the primary topic (what the OP wanted to learn to provide proper care for patients experiencing the loss of a pregnancy) were edited or deleted, as were posts that quoted or addressed them.

If you feel that a post is objectionable, use the red triangle report button in the lower left corner rather than engage another member in the thread. Thanks to those members who did make reports.

Once again, if this thread is to remain open, please, stick to the subject of helping the OP obtain the education she seeks.

Thank you.

OP, did you learn about giving Methotrexate IM for an ectopic pregnancy?

At my hospital we admit pt's to the med-surg ward if we expect any loss of pregnancy.

If a pt is hemorrhaging, you need to get them to OR, and get them ready before they go. Big IV's, fluids running, labs, blood ready, consents, etc.

Just be sensitive to the fact that your pt experienced a loss. Consider social work or a chaplain if you need it. Our chaplain sometimes gives people baby blankets, which has not been helpful in my opinion. I just try to listen and make sure the pt doesn't feel she did anything wrong, guilty, or otherwise.

Realize that some physical symptoms of your pt might be attributed to the great psychosocial stress, or due to the methotrexate. Make sure you're medicating for pain/nausea, etc, but realize the medication may not relieve the pain.

For discharge, make sure you teach your pt the s/s of infection, hygiene, what is normal/abnormal blood flow, when to call the doc, when to follow up, incision care, and if there is follow up blood work. Sometimes Hcg levels have to be monitored for several months.

Use your judgment and be compassionate. No one is ever excited about terminating a pregnancy, whether it occurred through 'natural' or artificial means. Often these women are in yucky situations and need lots of support.

I have only been an L&D nurse for a year and a half but it's long enough to have seen some fetal losses.

In our L&D, we only admit patients who are over 20 weeks, otherwise they are sent to emerg. We do not do D&Cs on our floor, but we do induce if the fetus (over 20 weeks) is deceased. We also work with women who present in labour and the fetus is not yet old enough to survive outside the womb. We also have infants that pass during the labour itself or shortly after. In terms of terminology, I believe Ontario's definitions are different from the States (and maybe from other provinces too). Where I work, if the infant/fetus is over 20 weeks and 500 grams, it is not considered an abortion whether it is spontaneous or induced, it is considered a preterm delivery. If the infant is born alive and dies, it is considered a neonatal death. If the infant is born still, it is a preterm stillbirth. Before 20 weeks, it is considered a "therapeutic abortion" if the pregnancy is terminated, for medical or social reasons (including ectopic pregnancies, ancephaly, etc.).

Most of our patients, if they are stable, choose to go home as soon as possible. We do not do any standard psych eval, but we certainly look for clues that may be apparent while the patient is in hospital. They are provided with contact info from social work and chaplaincy, and they have a follow-up with their Obstetrician at 6 weeks. Our postpartum care for patients is similar to a live birth- vital signs, fundal height, lochia, LOC, perineal care, etc. I would say the medical care does not depend on trimester, but more on the complications surrounding the loss- whether there was an abruption, infection, comorbidities, etc.

We learn a lot on the job, and I am lucky to work in an environment with LOTS of support from coworkers. One thing I highly recommend, if you will be working in the field, is to take a perinatal bereavement course. Here in Ontario, we have many courses offered by PBSO (Perinatal Bereavement Services of Ontario) and they are amazing. One of the most important things I learned from the course is that the amount of grief a mother/father/family feels does NOT depend on the gestational age of the baby but from their attachment to it. Some individuals may become very attached as soon as they learn they are pregnant and may have much difficulty coping with an early loss. Others may not become as attached and may not grieve as strongly even with a later loss. Also, silence and presence are very powerful. You don't always have to be saying or doing something.

In Ontario, nurses can study for their Perinatal Nursing certificate, which is a post-graduate certificate. It is not ob/gyn specific, but covers maternal and fetal health during the whole perinatal period, and I assume it includes a bereavement course.

Hope those answers help you, and good luck in your nursing career!

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