Infertility, Pregnancy Termination and Loss
Chapter 9: Induced abortion (pp 228-232).
1. What is an induced abortion? What other terms are used to describe this interruption of pregnancy?

The purposeful interruption of a pregnancy before 20 weeks. Spontaneous abortion, miscarriage, elective or therapeutic abortion.
2. When do most induced abortions occur?

More than 90% are performed in the 1 st
trimester or by 16 weeks, with 60% in the first 8 weeks..
3. What are two reasons that the nurse could choose to not provide care for this patient?
 Religious, moral, ethical, or personal reasons you don’t have to participate.
4. What kind of counseling needs to be provided for patients seeking an induced abortion?

Identifying how she perceives the pregnancy, information about the choices available, and information about the types of abortion procedures.
5. How pregnant should a patient be to safely have a vacuum aspiration abortion?

8-12 weeks since LMP, preferably less than 9 weeks.
6. What three medications are used in combination for medical abortions (and why do they all have to start with M and have so many syllables!)
 Methotrexate (cytotoxic drug that blocks folic acid in fetal cells so they can’t divide), misoprostol (Cytotec is a prostaglandin analog that softens and dilates the cervix and causes ctxs), and mifepristone (blocks the progesterone receptors so progesterone can’t bind and maintain pregnancy).

Misoprostol has many side effects: N/V/D, HA, dizziness, fever, and chills.
7. In general, who are the "best" candidates for medical abortions (this is an opinion question based on the info you have just read!)?

8. When is a D&E performed?

Partial birth abortion is not a medical term, it is a legal term. Something has to die before removed from womb. Usually d/t congenital anomalies

D&E: Dilation and Evacuation is a 2 nd
treimester abortion.

Performed at any point up to 20 weeks gestation, most commonly between 13-16 weeks.
Chapter 10 Infertility
1. How common is infertility?

It effects 10-15% of reproductive age couples.
2. What percentage of time is infertility due to female factors, male factors and unexplained factors?

Unexplained: 20%

Of the explained-Female: 40%, Male: 40%
3. You are the charge nurse at an infertility clinic. It is your responsibility to schedule various infertility tests. Look at Table 10-1 on p. 240. A woman calls to schedule these tests. Her LMP is November 1st and she always has a 28 day cycle (fat chance!). When would you schedule these various tests?


Hysterosalpingogram: 7-10 menstrual cycle days (2-5 days after menstruation)

Postcoital test: 1-2 days before ovulation (within several hours after intercourse)

Sperm immobilization antigen-antibody reaction: Variable, at ovulation

Assessment of cervical mucus: variable, at ovulation

US diagnosis of follicular collapse: Ovaulation

Serum assay of plasma prpgesterone: 20-25 menstrual cycle days

BBT Basal body temperature: chart entire cycle

Endometrial biopsy: 21-27 menstrual cycle days (2-3 days before mestruation)

Sperm penetration assay: after 2 days, cut no more than 1 week of abstinence.
Chapter 10: Adoption
1. A married couple is considering adoption after five years of infertility treatments.
They had one SAB 1 ½ years ago. The woman is 42 and the man is 55. She would like to try one more shot at IVF (they have had three previous attempts without success) and he is ready to adopt. How would you assist them with the five emotional stages that contemplating adoptive parents may use to assist in their decisions?
Juno-adoption is losing a baby. There is a lot of grief around that.
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1: initial consideration of adoption

2: forming a decision as a couple
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3: soul searching and questioning personal values, beliefs, needs, and fears
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4: grieving over the unborn biological child

5: gathering information

Nurses listen, educate, inform, refer, evaluate effectiveness of treatments all with empathetic and considerate attitudes.
Chapter 31 pp. 804-815
1. What are some causes of spontaneous abortions (SAB)?

Endocrine imbalance, immunologic factors, infections, systemic disorders, genetic factors, advanced maternal age or parity, premature dilation of the cervix, inadequate futrition, drug use, and trauma.
2. Look at table 31-1 p. 807. What are the differences among threatened, inevitable and incomplete, complete, missed and septic SABs?

Threatened: slight spotting, mild cramping, no tissue or dilation, hasn’t happened yet.

Inevitable: moderate bleeding, nild to severe cramping, no tissue, cervical dilation, sometimes with ROM, miscarriage will occur.

Incomplete: heavy bleeding, severe cramping, passage of tissue with dilation, expulsion of fetus with retention of the placenta.

Complete: slight bleeding, mild cramping, passage of tissue with no dilation, all fetal tissue is passed.

Missed: None to spotting, no cramping, tissue, or dilation, the fetus is dead but the products of conception remain in utero for several weeks.

Septic: bleeding varies and is usually malodorous, cramping and tissue passage also vary, there is usually dilation, sever and abdominal tenderness are indicators and surgical evacuation is required.


Recurrent: Habitual, 3+ in a row.
3. How are the symptoms different among threatened, inevitable and incomplete SABs?
Why would it be important that we accurately gather information from the patient about her symptoms?

Risk factors such as hemorrhage and infection.

Stop if threatened: rest, medication, folic acid.

Binge drinkers greater risk!

Treatment may differe depending on the type of miscarriage.
4. What do HcG levels do at the start of a pregnancy?

Double every couple of days until about day 60-70.
5. So what’s an incompetent cervix (could they have named it anything more degrading to a woman’s concept of her ability to carry a child)?

Usually due to colonization of cells, precancer or cancer, that weakens cervix so it opens or scars it so it won’t open.

Can be a cause of late miscarriage.

Passive and painless dilation of the cervix during the 2 nd
trimester.

All or nothing: cervix is either competent or incompetent.
6. What are the signs of an ectopic pregnancy? What are the major risks? What other conditions can this life threatening pregnancy look like?
 Pg 812

Look at our case study #3.

Signs: missed period, adnexal fullness, tenderness to pain, N/V, temperature, dark red or brown bleeding, referred shoulder pain, cullen’s sign (ecchymotic blueness around the umbilicus).

Pain, can look like appendicitis, GI problems, UTI, salpingitis, tortion of the ovaries,

Risks are not mutually exclusive, they can have different things at the same time.

10% maternal mortality r/t hemorrhage.
 Talk about getting them to a provider asap, don’t be alone.
7. What is the major physical risk with a hydatidiform mole?
We already discussed previas and abruptions. Just remember to be aware these can occur anytime, but are most likely to occur in the third trimester

Really rare.

Major risk factor is choriocarcinoma (complete especially).

Complete and partial. Complete when sperm and empty ovum, no placental tissue, embryonic tissue. Partial is normal ovum but 2 sperm.

Perform D&C, treat for cancer if tissue shows symptoms, metastasizes to lungs.

Serial HcG levels, postpone pg for at least 1 year.

Uterus is really larger than expected at duration of pregnancy, present with HTN and dark bleeding. Any symptoms of gestational HTN before 24 weeks may suggest hydatidiform mole.

Maternal blood has no placenta to receive it, therefore hemorrhage into the uterine cavity and vagina occurs (anemia, N/V, cramping, distention, preeclampsia).
8. What are dermoid cysts? p. 282

Germ cell tumors usually occurring in childhood.

Contain hair, teeth, sebaceous secretions, and bones.


Usually asymptomatic unless large enough to pressure other organs.
Chapter 41
1. How can having a miscarriage affect a mother and a father? Look at Box 41-1 p. 1092 as an overview.

They may grieve differently, it is a loss of a baby and the loss of identities of parents.
2. What is the technical difference between miscarriage, fetal death, stillbirth, and newborn death?

A baby younger than 20 weeks is considered a product of conception, whereas embryos, uterine tubes removed with an ectopic pregnancy, and tissue from a pregnancy obtained during a dilation and curettage are all considered tissue.

Miscarriage: spontaneous abortion, referring to the loss of the fetus before 20 weeks.

Fetal death: death of a fetus after 20 weeks of gestation and before birth, with absence of any signs of life after birth.

Stillbirth: birth of a baby after 20 weeks and 1 day of gestation or weighing 350 gms that does not show any signs of life.

Newborn death: neonatal death: death of a newborn within the first 28 days after birth.
3. Name three phases of grief and list at least 2 characteristics of each phase.

Parental grief: acute distress, intense grief, reorganization.

Acute: shock numbness, intense crying, depression, accepting reality of loss, loss of identity as mother and father and as parents.

Intense: loneliness, guilt, anger, emptiness, yearning, anxiety, fear, disorganization, sadness and depression, difficulties with cognitive processing and decision making, physical symptoms such as headaches, back aches, and fatigue.

Reorganization: Asking why, search for meaning, reduction of distress, reentering normal life activities with less guilt and more enthusiasm, making
 future palns, including possible pregnancies.
4. Name 4 important assessments when working with a family which has experienced a perinatal loss.

The nature of parental attachments to the pregnancy or infant, the meaning of the pregnancy and the related losses they are experiencing.
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The circumstances surrounding the loss, including level of preparation, understanding, and unresolved issues.
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The immediate response of mother and father to the loss, behavioral and cultural backgrounds, congruency of emotions and reactions.

The social support network for the parents and the extent to which it has been activated.
5. Name 5 nursing interventions when working with a family which has experienced a perinatal loss.

Help the mother, father, and other family members actualize the loss

Help the parents with decision making


Help the bereaved to acknowledge and express their feelings

Normalize the grief process and facilitate positive coping

Meet the physical needs of the postpartum bereaved mother

Assist with the bereaved in communicating with, supporting, and getting support from family
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Create memories for parents to take home
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Communicate using a caring framework (pg. 1104)

Be concerned about cultural and spiritual needs of parents
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Provide sensitive care at and after discharge

Provide postmortem care
6. What are the pros and cons of autopsy?
 Pros: It can answer the “why” question and help in processing grief, may perhaps prevent another miscarriage or death in the future with the knowledge they obtain.

Cons: It is highly expensive and not covered by insurance, can be against religious doctrines, parents may feel their baby has already been through enough.
7. How would you use the Perinatal Grief Scale on page 1095?

I would make sure to tell the patient to be as honest as they can be, and to let them know that the information is confidential and will only be used to help them.

I would determine their score and use it to assess future interventions such as a psych consult or referrals to community groups.

It can also be used to empower them, to see that others have had these thoughts and feelings and that what they are experiencing was common enough to put on paper.
8. Putting a baby up for adoption doesn’t seem to be in our text so I am including it here because it is also a loss of a newborn for the woman and her family who is choosing to relinquish her child. Look back through this chapter from the perspective of assisting this patient with her loss. What might her (their) grief response be?

Just because she made the choice to give her child up for a better life does not mean she will not worry, wonder, and experience the grief and loss of identity and relationship with that child.