Assessing The Fetus & Intrapartum Complications Flashcards
PDD
Post due date
Optional Prenatal Screening
1st trimester
Cell free DNA
Maternal blood drawn.
Gender determined
Test for…
Trisomy 21, 18, 13
Fetal Rh
Optional Prenatal Screening
1st trimester
Integrated Screen (2 blood test & US)
TEST FOR…
Trisomy 21 & 28
Neural tube defects
Nuchal translucency
Is looking for….
Thickness of neck for Chromosomal abnormalities
US by trimester
Confirm pregnancy
Genetic disorder
Id multiple
Check fht
Estimate GA
RO Ectopic
Assist with invasive procedures
1st
US by trimester
Structure growth
Fetal growth
Id placenta abnormalities
Confirm fetal presentation
Id fht
BPP
assist invasive procedure
Measure amniotic fluid
2 & 3rd
US by trimester
RO retained placental parts (POC)
POSTPARTUM
Transvaginal US is used when
Early gestation
Late gestation to evaluate cervix (Effacement)
US in early gestation have patient empty bladder first
False
Early GA full bladder moves early uterus up from pelvis and visible
Always this type of ultrasound to confirm cephalic posistion at admission
This type of US is used to determine if Cleft plaete
4D?
2D (width & height)
3D + depth
W, D, H and time
Chorionic Villus Sampling CVS
Tissue is aspirated from placenta to detect genetic defects in fetus.
Fetal ______
Fetal karyotype
Rho-gam is used for CVS
This abnormal diagnostic test is preformed when…
1st trimester
10 - 13 weeks
US guides needle through ab and aspirates fluid from amniotic sac.
Amniocentesis
When?
Determines (4)
15 - 20 wks 2nd trimester
Fetal karyotype
Chromosomal abnormalities
Lung maturity / bilirubin level (3rd tri)
Nonstress test NST
Requirements for Reactive & Nonreactive
Reactive = Good 2 Accelerations within 20 - 40 minutes
Nonreactive = bad lack of the 2 Accelerations in 20 - 40 minutes
Accelerations give us an idea of what is happening with this body system of the baby
Neurological
Tips to promote Accelerations
Eating
Drink
Posistion NO SUPINE
Sounds baby can hear
Touching belly
Fetal Scalp stimulation- Only in Labor - Contradicted in FHR decelerations
Contraction Stress Test - AKA Oxytocin Stress Test
Determines well being of baby in response to….
Used to determine…
Contraindicated in…
3 contractions in 10 minute period
How well baby will handle labor
CS patient
Contraction Stress Test CST
Define
Negative
Positive
Equivocal
Negative = Good things
No late decelerations
Positive = Bad thing
Late decelerations present with 50% UC
Equivocal (3) types
Suspicious: Intermittent late decelerations or sig variable Decelerations
Late Decelerations in with contractions more frequent than every 2 minutes or last longer than 90 seconds
Insufficient Fewer than 3 UC in 10 minutes or FHR that cannot be interpreted
5 components of Biophysical profile
Fetal breathing movements US
Gross body movements US
Fetal Tone US
NST results EFM
Amniotic fluid volume US
Scoring Biophysical profile
NST result
Fetal breathing
Gross Body Movements
Fetal tone
Amniotic fluid volume
NST result: 2 reactive / 0 Nonreactive
Fetal breathing: (2) >1 episode >30 sec within 30 min / 0 Absent
Gross Body Movements: (2) >3 body/limb movements in 30 min / (0) <2 movements in 30 minutes
Fetal tone: (2) >1 extension and flexion / (0) Slow extension and partial flexion, no movement
Amniotic fluid volume: (2) >1 cm pocket, in 2 different areas / (0) Doesn’t meet other criteria
Normal score for Biophysical profile
8 or 10
Reasons to get a Biophysical profile
High Risk
Nonreactive Nonstress Test results
Shoulder dystocia
When the head delivers but shoulders are trapped by pubic bone.
Interventions
SHOULDER
SHOULDER
S = Surgery for risk factors & turtle sign
Risk factors: LGA, DM, Obesity, AMA, Operative Delivery.
MOST COMMON = NO RISK FACTORS
TURTLE SIGN = head delivers all the way but gets sucked back in.
H = Help called
Minimum in Delivery Room:
Labor nurse, Dr / Midwife, Baby Nurse at warmer
O = Over to Hands & Knees.
(Gaskin Maneuver)
Flipping movements/ gravity Will dislodge impacted shoulder. Difficulty for epidural)
U = Use McRoberts & Suprapubic Pressure.
Flex moms legs to abdomen/ Lower HOB / Apply Suprapubic pressure NOT FUNDAL (Downward Lateral “CPR-like”)
L = Leave extra space for delivery
(Empty bladder / Episiotomy- Allows more room for invasive Maneuver)
D = delivery provider procedures
(Delivery of posterior arm / rotational Maneuver (Woods & Rubin) Pressure is put on anterior or posterior side of babies shoulder to rotate and release shoulder.
Maneuver of Last Resort
Deliberate Clavicle Fracture
Zavanellis Maneuver: Head pushed back into uterus and C/S.
E = Ensure good communication
SBAR, CHECK BACK (closed communication), CUS, 2 Challenge rule (Assert your concern atleast 2x then move up chain of command)
R = Rigorous Documentation
Delivery time Head, shoulder, Interventions, Personelle
Shoulder dystocia is when Head delivers but shoulder get stuck on pelvis.
Risk factors…
Turtle sign…
Risk factors: LGA, DM, Obesity, AMA, Operative Delivery ( forceps )
MOST COMMON = NO RISK FACTORS
TURTLE SIGN = head delivers all the way but gets sucked back in.
Shoulder dystocia When the head delivers but shoulders are trapped by pubic bone
What does the “H “ stand for…
= Help called
Minimum in Delivery Room:
Labor nurse, Dr / Midwife, Baby Nurse at warmer
Shoulder dystocia When the head delivers but shoulders are trapped by pubic bone
Describe gaskins Maneuver…
Possible contraindicated with…..
On all 4s, running Maneuver
Epidural
Flex moms legs to abdomen
Lower HOB
Apply Suprapubic pressure NOT FUNDAL (Downward Lateral “CPR-like” small quick pumps)
Name of Maneuver…
Use McRoberts & Suprapubic Pressure.
Shoulder dystocia When the head delivers but shoulders are trapped by pubic bone
Do this with the bladder…
Episiotomy?
Catheter/ empty bladder
Episiotomy YES
You will get Vacation & Sick days in nursing
😀
Name good communication Teachniques (4)
How many times do you Assert your concern before moving up the chain of command
SBAR, CHECK BACK (closed communication), CUS, 2 Challenge rule (Assert your concern atleast 2x then move up chain of command)
What is documented in shoulder dystocia
Delivery time Head, shoulder, Interventions, Personelle
Assessment after Shoulder dystocia
Brachial Plexus nerve
Broken Clavicle/ Humerus
Bruising
Skin inspection/ TCB
Assess Moro
Palpate for crepitus & asymmetry
Hypoxia brain damage
Assess cord blood gas
Low pulse ox fetus how long do we give them outside the uterus to increase pulse ox
10 minutes
Airway posistion
Sniffing posistion
Nose slightly upwards
Suction mouth or nose firsr
Mouth
Low pulse ox infant after
Drying, warming, stimulation
Neutral Sniffing breathing posistion
Suction
What is the next intervention
Positive pressure ventilation
Ambu bag / NeoPuff
&
SPO² monitoring
4 Ps of dysfunctional labor
Problems with
POWER
PASSENGER
PASSAGE
PSYCHE
Birth occurs within 3 hrs…
Preciptious birth
Complications with Preciptious birth
Transient newborn tachypnea
Hypoxia
Bruising
Hematoma
Laceration
Prolonged labor
Look at - Reasons why
Epidural?
Previous SVD
How big is baby?
Things to do
Min invasive procedure
Monitor temp & EFM
Promote rest in early labor and labor down
Break Fear, tension, pain cycle
Advocate more time for labor/ avoid CS
Complications……
Both infection
Maternal exhaustion
Anxiety & fear
Arrest Dilation & Decent
Prevent CS how
Early labor: Walking move birthing ball
Promote change in posistion
Pitocin when ripe
Avoid AROM
Delay epidural to promote movement
Time
Bishop score measures…
Cervical ripeness 8 or higher
Most common reasons for CS sections
- Labor arrest
- Bad FHT
- Malposistions
Normal labor progression
4-5 cm…
5-6 cm…
4 - 5cm = 6 hrs
5 - 6 cm = 3 hrs
PROM <37 wks is called
Goal intervention….
Preterm Premature Rupture Membranes
Keep mom pregnant in the hospital until baby is deliverable
PPROM <37 WKS
Risks
Infection
Cord compression Oligohydramnios
Respiratory Distress Syndrome in preterm
PROM TX
TERM…
PRETERM… (meds)
Term: Induced after SROM, Monitor Temps, avoid invasive procedure (INFECTION RISK)
Preterm: Temp, avoid invasive procedure, antibiotics, tocolytics, steroids
RO ROM
(3) Procedures
Pooling (+ is pool of fluid noted near cervix)
Nitrazine - blue is ROM
Ferning = positive
Amniotic fluid Starts slow and increases and decreases around 32 weeks.
Give value and associated problems
Oligohydramnios / Polyhydramnios
Oligohydramnios <5
ROM, fetal hypoxia, fetal kidney dysfunction
Polyhydramnios >25
DM, Esophageal atresia, fetal anomalies, kidney issues
Preterm dates (3) Subcategories
Term (3) Subcategories
Postterm
Preterm 20 - 36.6
Extreme Viability- 27.6
Very 28 -31.6
Late 32 - 36.6
Term 37 - 41.6
Early 37 - 38.6
Full 39 - 40.6
Late 41 - 41.6
Posterm 42
Preterm labor: Cervical changes at 20 - 36.3 weeks
Risk for preterm baby….
Risk for mom….
Baby: Cerebral Palsy, Development delay, vision &, hearing problems
Mom: same as term
ID preterm labor
Cervical length…
Incomptent cervix..
Fetal fibronectin Test….
Infection… watch for…
<25 mm
Cerclage procedure - Stitch Cervix closed early GA
Test amniotic membrane protein associated. More accurate for negative results: FALSE POSITIVE FROM SVE, Intercourse, VB
Uti
Preterm treatment
Promote this posistion…
Side laying relaxation
NOT COMPLETE BEDREST
Drugs used for preterm labor
Betamethasone
Dose/Route/Frequency
Function:…..
Used in which patients (Time Frame)
Greatest benefit
SE
12 mg IM ×2 Doses 24 hours apart
Promotes surfactant production & fetal lung maturity
Used 23- 36 GA w/ risk of delivery in 7 days
Greatest benefits when birthing within 24 hrs of 1st dose
SE elevated BS for 7 - 10 days
Magnesium Sulfate (Preterm use)
Dose / Route / time
Function….
4 - 6 mg loading dose over 30 minutes follow by 2 gm / hr
Function: Neurological protection
Reduces Cerebral Palsy
Smooth muscle relaxants
Preterm Drugs
Nifedipine (Procardia)
Indomethacin (Indocin)
Terbutaline (Brethine)
Prostaglandin synthesis inhibitor, NSAID (48 hr max due to closure of ductus Arteriosus) Treats PDA after birth
Beta-adrenergic bronchodilator. USE: SLOWS DOWN CONTRACTIONS
SE Tachycardia, palpation, Dysrhthmias, chest pain, Dyspnea. / Propranolol a BETABLOCKER Will reverse severe side effects
CCB (Calcium Antagonist) Treats PTL & HTN
What do they all have in common?
Nifedipine (Procardia)
CCB (Calcium Antagonist) Treats PTL & HTN
Indomethacin (Indocin)
Prostaglandin synthesis inhibitor, NSAID (48 hr max due to closure of ductus Arteriosus) Treats PDA after birth
Terbutaline (Brethine)
Beta-adrenergic bronchodilator. SE Tachycardia, palpation, Dysrhthmias, chest pain, Dyspnea. / Propranolol a BETABLOCKER Will reverse severe side effects
BISHOP SCORE
Value that vag birth is most likely
Para 0: Value associated with successful IOL
Para 1: Value associated with successful IOL
Score that needs cervical ripening agents
8+
7+
5+
4 or less
Misoprostol
Dose route….
Hold…
25 - 50 mcg PO or Intravaginal Q4hrs
Hold if >3 UC in 10 minutes
Prostaglandin E1 used to treat gastric ulcers
Off lable use…(2)
Contradictions…
Risk….
Cervical ripener / PPH
Contradicted previous uterine surgery (rupture risk)
Risk: Tachysystole, Cat 2 or 3 tones, uterine rupture
Dinoprostone (Cervidill)
Describe
Risk
Cervical ripener
Time released prostaglandin gel on a string left next to cervix for 12 hrs.
Risk: Tachycardia, Cat 2 or 3 FHT, Uterine rupture
Can oxytocin be used to ripen cervix…
Yes
Mechanical forms of induction
AROM
Membrane Sweep
Uterine Foley bulb
Lamonaria sticks
Marginal cord insertion is when the umbilical cord implants with in 3 cm of edge of placenta.
Risk….
SGA Baby
Detachment from the placenta
Velamentous Cord insertion…
Risk for…(this condition)
When cord embeds into amniotic sac
Risk for: Vasa Previa
Prolapse cord after ROM
Risk Factors…
Baby is most likely in this station…
Interventions…
Small fetus, breech position, transverse lie, Polyhydramnios
+2, +1
Lift baby’s head off cord.
Treatment: maternal posistion (Knee to chest / Trendelenberg, elevated hips)
CS unless vag birth is faster
Avoid touching cord!
Uterine Rupture
What happens to contractions?
What happens to the station?
Worst case scenario
Contractions STOP
Station REDUCES
Baby Dies
Uterine Inversion
Uterus complete or part way turned inside out.
Cause…
Pulling on cord after birth
Fundal pressure during or after birth
Weak uterus
Interventions for uterine Inversion
Push it back in place.
Give Pitocin after back in place
May require hysterectomy
Anaphylactoid Syndrome aka Amniotic fluid embolism
Mom blood stream is exposed to babies components
Cascade of things going wrong.
List maternal problems…
Treatments….(FLUIDS)
DIC, Left Ventricle failure, organ failure, hemostatic instability.
F FOLLOW CPR guidelines
L liters of oxygen
U Utilize mech vent
I IV fluids
D Donated blood
S Survival of Fetus/ CS for cardiac arrest for mom
When is the fetus more vurnable to trauma forces
1st or 3rd
3rd more vulnerable
1st it’s protected by pelvis
Any type of Trauma Requires hospital observation to RO abruption. With continuous monitoring
T or F
T
Trauma
Fetal effects
Hypoxia, acidosis, neurological defects, fractures, hemorrhage
Trauma management does follow the ABC but this..
Avoid Supine / Use wedge
Abruption risk. Monitor baby
Give this medication….
CAB
Rho-gam
Gaskins Maneuver
Describe/ Use
4 on the floor / Running Start posistion
Used to allow room for baby stuck in shoulder dystocia
Rubins Maneuver
Pressure to the back of the baby’s front shoulder to rotate it inward, narrowing the shoulder width to help it pass through the birth canal.
Woods screw
Pressure to the front of the baby’s back shoulder, rotating it in a corkscrew motion to help release the shoulder.
McRoberts Maneuver
Flexing the mother’s thighs sharply up toward her abdomen, which flattens the spine and tilts the pelvis, helping to widen the birth canal
Zavanellis Maneuver….
Head pushed back into uterus and C/S.
Absolute last resort
Name and describe 3 tocolytics
Nifedipine, a calcium channel blocker, is used as a tocolytic by relaxing the smooth muscles of the uterus to reduce contractions in cases of preterm labor.
Indomethacin, a nonsteroidal anti-inflammatory drug (NSAID), also acts as a tocolytic by inhibiting prostaglandin synthesis, which helps decrease uterine activity and delay labor.
Terbutaline, a beta-adrenergic agonist, is used to temporarily halt uterine contractions by relaxing uterine muscle, often administered in acute settings to manage preterm labor.
Incomplete abortion
Interventions (5)
Interventions for…
TS
IV Fluids
DC
IV Oxytocin
Hemorrhage medication (3)
Misoprostol (Cytotec), Methylergonovine (Methergine)
Carboprost (Hemabate)
Symptoms include:
Membranes ruptured
Cervix dilated
Contractions
Bleeding
Describes….
Inevitable Abortion
When should you US labor and induction patients to confirm cephalic posistion at admission
Always
Tissue is aspirated to detect presence of genetic defects in fetus (Fetal Karyotype)…
Chorionic Villus Sampling
Results time frame for CVS
Preliminary 2 - 3hrs
Full 5 - 7 days
Most accurate diagnostic test
Amniocentesis
Definition of Accelerations
> 32 wks
<32wks
15 × 15 >32 weeks
10 × 10 <32 weeks
What type of result is a healthy result in NST
Reactive = 2 Accelerations within 20 - 40 mins Good Oxygenation
Shoulder dystocia Risk Factors
High birth weight
GDM
Operative vag delivery
Previous shoulder dystocia
Maternal obesity
AMA
Do you debrief with patient and their family after SHOULDER Dystocia
Yes. But seperate
Preciptious labor =
Preciptious birth =
Preciptious labor = <3 hrs
Preciptious birth = Fast delivery (could be any length of time)
What date does the placenta become No Good.
> 42 weeks
When is the latest we would induce labor
41 wks
To avoid reaching 42 wks when the Placenta is No Good
Oxytocin has the same Contradictions as…
SVD
Previa, breech, HSV lesions, uterine incision, prolapsed cord.
Fetal distress: Cat 2 & 3
Prolonged use of Pitocin may oversaturate the receptor sites and cause…
Increase risk of PPH
What is the Goal with Oxytocin
UC q ____ min, ____ sec, intensity ____ mmHg, resting tone < _____
UC q 2-3 min, 40 - 90 sex, 50- 80 mmHg, resting tone <20
Induction/ Aug Dose Oxytocin
Start ____ & increase Doseage by ____ every 30 minutes
Dose is increased by uterine response & absence of adverse effects
Start 0.5 - 1 mU/min & increase Doseage by 1- 2 mU/min every 30 minutes
Oxytocin
PPH Prevention Dose
10 - 40U titrate
Which is associated with Vada previa
Velamentous Cord insertion or Marginal Cord Insertion
Velamentous Cord insertion
SS
Hypovolemic shock
Pain ab chest scapula inspiratory
Contractions STOP
Station RECEDES
Palpation of fetus outside the uterus
Abnormal fetal HR
Fetal Deoxygenation / Death
From this problem….
Uterine Rupture
Uterine Rupture
Tx if unstable
Immediate CS
Down syndrome
Turner syndrome
Klinefelter syndrome
Trisomy 18
Trisomy 13
Cri du Chat syndrome
Fragile X syndrome
All this type of problem
Down syndrome (trisomy 21)
Turner syndrome (missing X chromosome)
Klinefelter syndrome (extra X chromosome in males)
Trisomy 18 (Edwards syndrome), Trisomy 13 (Patau syndrome), Cri du Chat syndrome (deletion on chromosome 5)
Fragile X syndrome
Chromosomal
