antepartdum Flashcards
high-risk pregnancy
Coincidental (had disease before pregnancy) or unique to pregnancy (unique to pregnancy). visit dr every 4 weeks during 1st and 2nd, and 3rd every 2 weeks. 0-13 - 1st, 14-26 - 2nd, 27-40 3rd trimester.*****
Risk Factors
Biophysical - mostly due to diseases. multiple birth, genetic abnormalities, nutritional deficiencies.
Psychosocial - depression, smoking, caffeine, alcohol, substance abuse. crisis w/ domestic violence.
Socio-demographic - poverty, lack of nutrition, prenatal care, less than 15 years of age, parody (# of deliveries greater than 20 wks) access to health care.
Environmental - a little bit of all of them, not clean or healthy place to live, more infections. radiation, air and water polution, and 2nd hand smoke, stress.
Antepartum Testing
To detect potential fetal compromise (usually a lack of 02)
32-34 weeks until delivery - fetal fibernectincan predict when person is going to deliver
Used primarily for women at risk for disrupted fetal oxygenation
BIOPHYSICAL ASSESSMENTS
VVP - vital physical profile. Daily Fetal Movement Count (AKA Kick Count) - daily movement counts - should be performed same time every day. lay on left side, hand on stomach, and lay for an hour and count. should be around 10 kicks an hour. best time is after meals.
Ultrasound - used for many things - wellbeing - usually look at movement, heartbeat, and RR, can see baby move, can see diaphragm
Biophysical Profile (BPP) - measures health of fetus. HR, muscle tone, breathing action, and how much amniotic fluid. also a non-stress test.
ultrasound
Abdominal or transvaginal. usually abdominal. if looking for anomalies, will do transvaginal.
when is Transvaginal used? (trans is first)
Transvaginal used mainly in in the first trimester - provides greater detail and can dx IUP (intrauterine pregnancy) and establish Gestational age earlier. can tell if cervix is thin.
Levels of ultrasonography:
Standard
Levels of ultrasonography:
Standard – GA, AFI’s etc.
Limited – e.g., check for vertex presentation, fetal HR
Specialized- suspected anatomical or physiological abnormal fetus
get to know your baby’s movements
if she doesn’t feel that movement, call the provider.
Indications For Use
Fetal Heart Activity
Gestational Age
Fetal Growth
Fetal Anatomy
Fetal Genetic
Fetal Position
Disorders and Physical Anomalies
Placental Position and Function
Adjunct to other tests
Fetal Well Being
Ultrasound to Determine Gestational Age
Fetal Growth
Recommended method of dating.
Most accurate between 14-22 weeks. most common one is from last mentstural period and nagal’s rule.
Gestational Sac dimensions (8 weeks)
Crown/Rump length (7-12 weeks)
BPD (biparatal diameter - just transverse section of skull) (12 weeks) and Femur Length (12 weeks)
Serial evaluations of BPD, Limb length and abdominal circumference can determine Fetal Growth
Biparietal Diameter (BPD) to determine (gest bpg at 12)
Gestational age
After 12 weeks
fetal well being
doppler flood flow analysis (not as common), amniotic fluid (through umbelical cord), NST, biophsical profile, modified biophycial profile.
biophysical profile scoring
fetal breathing movements - 2 ,gross body movement - 2, fetal tone - 2, reactive HR - 2, qualatative amniotic fluid - 2`
missing slide
14 - prob don’t need this
biophysical profile scoring
8 - 10 normal, 4-6 suspected chronic asphysxia, 2 strong suspicion of asphysxia
Amniotic Fluid Index (AFI)
Amniotic Fluid Volume (AVI) (same thing as amniotic fluid test) - what is the normal amount?
Measures the vertical depths of the largest pocket of amniotic fluid in all four quadrants surrounding the maternal umbilicus and totaled. 5 - 25 cm is normal fluid amount.
Biochemical Assessment
Procedures to obtain specimens:
Amniocentesis - take some anmiotic fluid.
Chorionic Villus Sampling (CVS) (placenta side towards infant)
Maternal Assays - blood draws - looking for downs, etc.
Percutaneous Umbilical Blood Sampling
AMNIOCENTESIS
Genetic and chromosomal abnormalities (15- 20 weks), Fetal Lung Maturity, Rh isoimmunization status and severity of hemolytic anemia, AFP (Alpha Feto Protein) levels which indicate anatomic abnormalities
2 Ways of Measuring the Infant’s Lung Maturity
- Lecithin to sphingomyelin (L/S) ratio: a mixture of lipids, proteins, and glycoproteins that make up surfactant:
2 or more indicated fetal lung maturity and low risk of infant respiratory distress syndrome
1.5 or less is associated w/high risk
- Phosphatidylglycerol: is a glycerophospholipid found in pulmonary surfactant and an indicator o fetal lung maturity
If a patient needs to be delivered, they should be delivered
If a patient needs to be delivered, they should be delivered regardless of fetal lung maturity. If a patient doesn’t need to be delivered, then we should wait.
if the pt needs to be delivered- BMZ <34 weeks
BMZ (betamethazone) <34 weeks with imminent delivery before 7 days and have not received it BMZ in the last 14 days.
BMZ 34 to 36.6 weeks
BMZ (betamethazone) 34 to 36.6 weeks at risk of preterm birth within 7 days and have not received BMZ or prior course was > 14 days
Complications
Less than 1%. -mom
Infection
Hemorrhage
damage to bladder or intestines.
Miscarriage
PTL
leakage of AF
Rh Sensitization
Complications
Less than 1% - baby
Death
Hemorrhage
Infection
nursing care
Report leaking fluid
Abdominal pain
Bleeding
Decreased Fetal movement
Fever
Rhogham to RH- women
educate
informed consent
fetal monitoring
chorionic villus sampling (chronic for 10 weeks)
10-12 weeks. ultrasound guided.
Fetal Assessment via Electronic Fetal Monitoring
non-stress test (NST), contraction stress test (OST)
Fetal Assessment via Electronic Fetal Monitoring
To determine the the timing of childbirth for women at risk for uteroplacental insufficiency (UPI), 32-34 weeks in high-risk patients, 1-2 times a week. main thing is to ensure baby has good O2 supply.
NON-STRESS TEST
evaluate FHR during movement.
Reactive/Nonreactive
Reactive = 2 Accelerations in 20 minutes. (if they are greater than 32 weeks) (less than 32 weeks, could be 15 and 10)
Accelerations are FHR equal or greater than 15 BPM over baseline lasting 15 seconds or more.
CONTRACTION STRESS TEST (we don’t want positive contractions with the stress test!)
Endogenous or Exogenous Oxytocin, Evaluate FHT with contractions, Negative: No decelerations with 3 UC’s lasting 40-60 seconds in 10 minutes, Positive: Decelerations with 50% or more of UC’s (we don’t want a positive) (we want negative)
contractions start where?
at the top, the fundus, and then they move down.
Contraindications to contraction stress test
placenta previa (over cervix), PTL, cervical insufficiency, multiple gestations, previous C/S
slides 30-34
minimal variability
<5 bpm variation around baseline
moderate variability
6-25 bpm variation
absent variability
no detectable variation around baseline
marked variability
> 25 bpm
SPONTANEOUS ABORTION (I was spontaneous before 20)
on testLoss of a fetus before 20 weeks, threatened, inevitable, incompomplete, complete, missed, recurrent (habitual), sepsis. 15% of pregnancies will have spontaneous abortion) . these are due to abnormalities of the fetus.
SPONTANEOUS ABORTION Signs and Symptoms
Dependent on duration of pregnancy.
Vaginal bleeding*
Abdominal pain*
Cramping
Pelvic Pressure
Low back pain
almost impossible to stop once it starts
SPONTANEOUS ABORTION Risk Factors:
Congenital malformations (1st Trimester. 60-70%), maternal infection, maternal endocrine problems, AMA (advanced maternal age), previous loss, UTI, thyroid issues, diabetes, spontaneous abortions in the past.
SPONTANEOUS ABORTION Management
Bedrest, Fluids (threatened)
D & C or suction curettage
D & E (evacuation - used with suction) (2nd Trimester)
Antibiotics (missed, septic)
Misoprostol
Pain medications
RhoGAM (RH-)
abortion after 20 weeks called
still birth or intrauterinie demise.
if a pregnant woman has bleeding,
she needs to be seen by the provider.
Induced Therapeutic Abortion
EAB (elective abortion) - Purposeful interruption of a pre-viable pregnancy. TAB (theraputic abortion) – Abortion for maternal/fetal disorder.
A 2012 study of more than 9,000 women found that
when women got no-cost birth control, the number ofunplanned pregnancies and abortions fellby between 62 and 78 percent.
H&P
Assess for co-morbidities and possible contraindications to any procedure
Confirm IUP (Intrauterine pregnancy)
Confirm gestational age (LMP - last menstrual period)
Rh status (Rhogam prophylaxis within 72 hours if needed)
LARC
long-acting reversible contraception
Medical Abortions
Available in the US up to nine weeks after the last menstrual period
Methotrexate and miso (up to 7 weeks after LMP)
Methotrexate – Blocks folic acid needed for cell reproduction
Misoprostol – empties the uterus (up to 10 weeks after LMP)
mifepristone (RU – 486) blocks progesterone (up to 10 weeks after LMP)
Least amount of complications
Surgical Abortions : Dilation and Curettage (D&C)
used up to 14-16 weeks
side effects - abortion
N/V (call dr. bc it could be infection), bleeding, cramping
Cervical insufficiency or Recurrent Premature Dilation of the Cervix
Recurrent passive and painless dilation of the cervix during the 2nd Trimester. dx based on history.
Cervical insufficiency or Recurrent Premature Dilation of the Cervix
Risk Factors:
Congenital (presence of bicornuate uterus; exposure to DES (birth control bill from the 70s), short cervix)
Acquired (multiple gestation, infection, trauma )
Hormonal (relaxin)
Cervical insufficiency or Recurrent Premature Dilation of the Cervix - management
medical:
Bedrest
Pelvic Rest
anti inflammatory meds
Progesterone
Surgical:
Cerclage (36 weeks)
Prophylactic (11-15 weeks)
Risks
PTL (preterm labor)
PPROM (preterm, premature rupture of membranes)
Chorioamnionitis
Cervical insufficiency or Recurrent Premature Dilation of the Cervix - management - Nursing Care:
Observe for CTX, PPROM, S&S of infection.
Education:
activity restrictions
Tocolytics (slows contractions down)
S&S to report
ECTOPIC PREGNANCY Risk Factors:
History of STI or Pelvic Inflammatory Disease, previous ectopic preg, endometrosis, IUDs, assisted reproductions.
ECTOPIC PREGNANCY Symptoms:
Missed Period
Tenderness
Pain
Shoulder Pain (internal bleeding)
Vaginal Bleeding
Shock
GESTATIONAL TROPHOBLASTIC DISEASE
tumors that grow in the uterus. an egg w/ no dna in it.
A group of rare cancers including:
Hydatidiform Mole
Invasive mole
Choriocarcinoma
Placental Site Trophoblastic Tumor
Overgrowth of the trophoblast or outer layer of the embryonic cells.
ECTOPIC PREGNANCY Management:
Methotrexate
Emergency Surgery (Salpingectomy)
Attempt to preserve tube
Serial hCG levels (3-6 weeks) (to check if they’re still pregnant)
6% of maternal deaths due to
ectopic pregnancies - education is key.
main STDS
gonn and chlyamdia
silent killer
ectopic pregnancy
Hydatidiform Mole (the mole is empty)
Complete: An egg with no genetic information is fertilized by a sperm. Partial: An egg is fertilized by two sperm and the placenta becomes the molar growth
Hydatidiform Mole (the mole is dark red)
SYMPTOMS:
Second Trimester Vaginal Bleeding (dark brown or red). Uterus larger than dates. Elevated HCG levels hyperemisis. cramping and preeclampsia.
Hydatidiform Mole
CARE:
Most- SAB if not- D&C, D&E
Risk- Choriocarcinoma
Follow-up monthly
Serial hCG every 1-2 week until hCG is undetectable on two separate blood levels
Then hCG every 1-2 months for at least a year
NO PREGNANCY.
usually short of breath bc the tumor can move to the lungs.
HYPEREMESIS GRAVIDARUM
70% of women will experience n/v
3% will develop severe n/v
1-5% n/v will be so severe they will require hospitalization
Etiology unclear. May be related to high levels of estrogen, progesterone and hcg
HYPEREMESIS GRAVIDARUM
Is a dx of exclusion. Persistent vomiting not related to other causes
A measure of acute starvation (ketonuria)
Excessive n/v and weight loss (>5% of pre-pregnant weight)
HYPEREMESIS GRAVIDARUM Risk Factors:
Hyperthyroid disorders
Molar pregnancy
Multiple gestation
DM
GI disorders
Previous Pregnancy
HYPEREMESIS GRAVIDARUM Initial Assessment:
R/O other causes (especially when presenting with N&V for the 1st time after nine weeks)
Gastroenteritis
Pyelonephritis (uterus pushes on uteter)
Pancreatitis
Cholecystitis
Hepatitis
Thyroid
HYPEREMESIS GRAVIDARUM Initial Assessment: Assess for dehydration
Hypotension
Intake and Output
U/A (specific gravity)
Skin turgor, mucous membranes
Electrolyte imbalance (labs, S&S of hypokalemia)
Vit. B1, B6 and B12 deficiencies (Wernicke-Korsakoff syndrome)
IV Fluids: electrolyte replacement.
NPO
HYPEREMESIS GRAVIDARUM Nursing Care: Anti-emetics:
(usually on multiple meds before it is under control)
Pyridoxine (B6)/Doxylamine*
Phenergan
Reglan
Compazine
Zofran
Chlorpromazine
Steroids
Small frequent meals
HYPERTENSIVE DISORDERS IN PREGNANCY
Occurs in 5-10% of all pregnancies
Is a leading cause of maternal death.
20 weeks
Gestational Hypertension - comes into pregnancy w/ HTN
Pre-eclampsia
eclampsia (eclampsia means you’ve had a seizure)
cHTN with superimposed pre-eclampsia
cHTN with superimposed eclampsia
HELLP Syndrome (Hemolysis, Elevated Liver Enzymes, Low Platelets) - bleeding issues.
4 types - chronic - comes into pregnancy w/ HTN, gestational HTN , preeclamsia - liver enzymes and bp greater than 140/90, can be either diastolic or systolic.
NORMAL FINDINGS IN PREGNANCY
high Blood
high Plasma Volume (50%)
high Cardiac Output
low BP (until 3rd trimester)
low Total Peripheral resistance
FINDINGS IN PRE-ECLAMPSIA (Yolanda as high BP and her blood is the same)
Little or no change in Blood and Plasma Volume
Variable Cardiac Output
high - BP
high - Total Peripheral resistance
Risk Factors PRE-ECLAMPSIA
First pregnancy
Family history
Obesity
Multiple gestations
Hx of Pre-eclampsia
Hx of poor pregnancy outcome: IUGR, placental abruption or IUFD
Pre-existing diabetes, HTN, or renal disease
Gestational diabetes
diagnosis - PRE-ECLAMPSIA
32 Weeks Gestation with no previous hypertension documented.
Admission B/P – 142/94
Present B/P - 160/112 x 2
0.5 PCR Protein in urine
headache 8 out of 10
Rates URQ pain “6” out of 10
Patient is a G2/P1 with previous diagnosis of Pre-eclampsia
PRE-ECLAMPSIA - how to treat
have right sized BP for patient.
slide 84
abdominal pain, esp upper right quadrant (liver), SOB, oliguria. 1st bp is high. serial bp readings every 20 min. crackles, lung sounds.
good drugs for pre-eclampsia
lobetalol and hydrolazine
Nursing Care with Magnesium Sulfate
Duo check of dosing before administration.
Baseline, V.S., Severe features, & EFM
4-6 gms IV over 20 minutes (BMI >35 use 6 gms)
V.S. every 5 minutes
Magnesium Sulfate - maintanence infusion
Duo check of dosing before administration.
1 gm/hr. IV
V.S. every 1 hour for 8 hours.
DTR’s, clonus - holding and dropping foot, lung sounds, & LOC with V.S.
Magnesium Sulfate - other nursing care
Foley catheter for Strict I/O
Continuous EFM
Seizure precautions - pads on siderails
Strict Bedrest
Antidote for Mag toxicity - calcium gluconate
Quiet & dim environment
Cool wash cloth & emesis bag
Education
lab draws before magnesium
Magnesium level
Hepatic Panel
CBC
Magnesium level at 30 minutes
Magnesium level every 6 hours
CBC & Hepatic panel daily
lab will call and say levels are high, but you want the high levels.
magnesium
Hypotonia - If labor is being induced or if it started on its own, hypotonia from the magnesium will interfere with the ability of the uterine muscle to contract. Prepare for Pitocin infusion.
Flushing
Diarrhea
N/V
after mag is administered
The neonate will experience some side effects from the magnesium infusion. Magnesium does cross the placental barrier. The neonate will experience some respiratory depression and hypotonia, causing decreased APGAR scores also. These side effects subside within 24 hours.
preeclampsia w/out severe features (can take care of it at home)
Instruct in self monitoring: BP, urine dips, kick counts
Signs and symptoms of worsening disease
Importance of frequent visits and fetal assessments
Regular diet
Reinforce activity restrictions
HELLP SYNDROME
May or may not have pre-eclamptic symptoms or may have only mild pre-eclamptic symptoms. H – hemolysis. EL – elevated liver enzymes. LP – low platelets
Placenta Previa
One in 200 pregnancies will be affected.Chances with 1st pregnancy is one in 400. With each cesarean section a woman has her chance increase dramatically.
Placental Abruption
Early separation of a normally implanted placenta after 20 weeks gestation. occurs in 1%. 40% mortality rate for the fetus. 5% maternal mortality rate
Amniotic Fluid (1000ml normal) - Polyhydraminos (poly is 2000 years old)
> 2,000ml
32-36 weeks
2% of pregnancies
Associated with DM***
Fetal anomalies
Risk for Preterm labor, PPROM, PROM
Amniotic Fluid (1000ml normal) - Polyhydraminos - Oligohydraminos
<500ml
32-36 weeks
4% of pregnancies
Fetus unable to make urine or something blocks the urination
Poor pregnancy outcomes
PPROM
Preterm Premature Rupture of Membranes
PROM
Premature Rupture of Membranes
