Antepartum Flashcards
Placenta Previa
exists when the placenta is inserted wholly or partly into the lower uterine segment of the uterus, partially or completely covering the internal cervical opening. Occurs during the last 2 trimesters of pregnancy.
Placenta Previa- Pathophysiology
Cause unknown. It is initiated by implantation of the embryo in the lower uterus, perhaps due to uterine endometrial scarring or damage in the upper segment, which may incite placental growth in the unscarred lower uterine segment.
Placenta Previa- risk factors
Previous cesarean birth
Multiparity
Uterine insult or injury
Cocaine use
Previous D&C
Endometrial ablation
Prior placenta previa
Infertility treatment
Multiple gestations
Previous induced surgical abortion
Smoking
Previous myomectomy to remove fibroids
Short interval between pregnancies
Hypertension or diabetes
Placenta Previa- H&P
- Any bleeding now or in the past? (clinically presents as painless, bright red vaginal bleeding, occurs spontaneously during the 2nd or 3rd trimester)
- Assess for uterine contractions
- Palpate uterus (typically soft and non-tender)
Placenta Previa- Lab and Diagnostics
- Transvaginal ultrasound is done
- MRI
Placenta Previa- Nursing Mgmt
- Monitoring the maternal–fetal status, including assessing for signs and symptoms of vaginal bleeding and fetal distress and providing support and education to the client and her family
- VS and pain assessment
- Encourage her to lie on side
- Cesarean most likely
*avoid vaginal exam b/c it may disrupt the placenta and cause hemorrhage
Placental abruption
The early separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage
- 2nd or 3rd trimester bleeding, high mortality rate
Placental abruption- risk to mother and baby
- Maternal risks include obstetric hemorrhage, need for blood transfusions, emergency hysterectomy, disseminated intravascular coagulopathy (DIC), Sheehan syndrome or postpartum gland necrosis, and renal failure
- Perinatal consequences include low birth weight, preterm birth, asphyxia, stillbirth, and perinatal death.
Placental abruption- Pathophysiology
occurs when the maternal vessels tear away from the placenta and bleeding occurs between the uterine lining and the maternal side of the placenta. As the blood accumulates, it pushes the uterine wall and placenta apart
- Results in fetal hypoxia and possibly fetal death
- Etiology of this condition is unknown; however, it has been proposed that abruption starts with degenerative changes in the small maternal blood vessels, resulting in blood clotting, degeneration of the decidua (uterine lining), and possible rupture of a vessel
Placental abruption- Classification
Classified according to the extent of separation and the amount of blood loss from the maternal circulation
Grade 0: Clinically unrecognized before birth, diagnosis is made retrospectively after birth
- Mild (grade 1): No/minimal vaginal bleeding (<500 mL), marginal separation (10% to 20%), tender uterus, no coagulopathy, no signs of shock, no fetal distress
- Moderate (grade 2): No/moderate bleeding (1,000 to 1,500 mL), moderate separation (20% to 50%), continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia, evidence of fetal distress
- Severe (grade 3): Absent/moderate bleeding (>1,500 mL), severe separation (more than 50%), profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased maternal blood pressure, significant maternal tachycardia and the development of DIC
Placental abruption- Nursing Assessment
- Focus on maternal hemodynamic status and fetal well-being
- Assess for bleeding (can be concealed)
- Monitor LOC and S/S of shock (Vital signs can be within normal range, even with significant blood loss, because a pregnant woman can lose up to 40% of her total blood volume without showing signs of shock)
- Pain assessment
- Palpate abd for contractions, tenderness, tenseness, or rigidity
- Assess fetal HR
Placental abruption- Risk factors
Maternal age over 35 years old, poor nutrition, multiple gestation, excessive intrauterine pressure caused by hydramnios, multifetal pregnancy, recent trauma to the abdomen, chronic hypertension, fetal growth restriction, cigarette smoking, severe trauma (e.g., auto accident, intimate partner violence), history of abruption in a previous pregnancy, placental abnormalities, cocaine or methamphetamine abuse, thrombophilia, alcohol ingestion, and multiparity
Placental abruption- S/S
painful, dark red vaginal bleeding (port-wine color) because the bleeding comes from the clot that was formed behind the placenta; “knife-like” abdominal pain; uterine tenderness; contractions; and decreased fetal movement.
Placental abruption- Lab and Diagnostics
- CBC
- Fibrinogen levels
- Prothrombin time (PT) and activated partial thromboplastin time (aPTT)
- Type and cross-match
- NST
- Biophysical profile
Placental abruption- Nursing Mgmt
immediate care
- strict bed rest, in L lateral position
- Nasal cannula and monitor tissue perfusion
- maternal VS every 15 minutes
- insert Foley catheter to assess I/O
- IV access with large-bore catheter
- Assess fundal height (increase in size would indicate bleeding)
- continuous fetal monitoring
- provide support and education
Chadwick’a sign
bluish discoloration of the cervix, vagina, and vulva
Hegars sign
softening of the lower uterine segment, 6 wks
Goodells sign
softening of the cervix
Lordosis
Curve inward of the lower spine (how Brent says I stand-chest up, butt out)
PARA
the # of births over 20 wks gestation, living or not
Gravida
the # of confirmed pregnancies a women has had
GTPAL
Gravida, Term births, Preterm births (>20 wks), Abortions and miscarriages (<20 wks), Living children
Gestation terms
Late preterm: 34-36 6/7 weeks
Early term: 37-38 6/7 weeks
Full term: 39-40 6/7 weeks
Late term: 41-41 6/7 weeks
Post term: 42+
Signs of Pregnancy
Presumptive: amenorrhea, enlarged breasts, N/V, quickening, fatigue, urinary frequency
Probable: Goodell sign (softening of the cervix), Chadwicks sign (bluish discoloration of the cervix), positive preg. test, Braxton hicks, ballottement (feeling for a fetus in the uterus), enlarged uterus
Positive: Visualize the fetus, fetal heart tones, palpate the fetus
Estrogen
-secreted by corpus luteum until placenta takes over
-inhibits secretion go FSH and LH, suppressing ovulation
- stim. growth of maternal tissue (uterus, breast, genitalia)
-relaxes joints and ligaments
-increases vascularity
Progesterone
-secreted by the corpus luteum until placenta takes over
-inhibits secretion of FSH and LH, suppressing ovulation
-relaxes smooth muscle decreasing uterine contractility
Pregnancy hormones
Prolactin: prepares breasts for lactation
Oxytocin: stim. contraction and milk ejection
Human Chorionic Somatomammotropin: (human placental lactogen) acts as growth hormone, decreases maternal metabolism of glucose, increases fatty acids for metabolic needs
Hemodilution- anemia values
Values of hemoglobin less than 11g/dl in the first or third trimester or less than 10.5 in the 2nd semester are considered anemic. Hct. 32% or less is also considered anemic
Supine Hypotension
lying on back blocs blood flow to the brain from the vena cava; have pt lie on L side
Diet for the pregnant women
increased dietary intake of 300 calories/day
Prenatal visit schedule
1st: within first trimester (12 weeks)
-monthly visits wks 16-28
-every 2 wks from 29-36 wks
-weekly or bi-wkly from 36-birth
*baby considered viable @ 24wks
Nagele’s Rule
Date of your last menstrual period + 7 days - 3 months = Estimated due date
Calcium (foods)
dairy, almonds, canned fish, dried beans/lentils
* support bone/teeth growth
Iron (foods)
animal meats, leafy greens, eggs, tofu, tempeh, fortified foods
*Vit C aids in absorption
Folic Acid (foods)
leafy greens, black-eyed peas, citrus, peanuts, liver, legumes
*Aids in RBC formation; deficiency risk of NTD
Psychological Adaptation to Pregnancy: stages
1st trimester
-Ambivalence (indifference) and Introversion (self focused); baby isnt real, change in body image
Psychological Adaptation to Pregnancy: stages
2nd trimester
establishes relationship w/ fetus; fetus as separate being; pregnancy/fetus main focus; more outward focus on other mothers and those pregnant
Psychological Adaptation to Pregnancy: stages
3rd trimester
Tired of being pregnant; realistically prepares for birth and parenting; reordering relationships
Trimester months
1st 0-13
2nd 14-26
3rd 27-40
High risk pregnancies can be coincidental or unique
Coincidental: preexisting condition ex. diabetes, HTN
Unique: that which is new to the pregnancy
Risk factors of pregnancy
Biophysical: genetics, diabetes, asthma, thyroid disease, obese or underweight, HTN, chromosomal abnormalities
Psychosocial: smoking, caffeine, substance abuse, domestic violence, emotional distress
Socio-demographic: poverty, lack of prenatal care, young or old age, ethnicity, access to care
Environmental: pollutants, second hand smoke, infection, radiation, etc.
Biophysical assessment
daily fetal movement (kick counts), ultrasound, and biophysical profile (BPP)
