Chapter 7 Flashcards
what are some gestational complications?
- premature labor/birth
- premature rupture of membranes/ chorioamniotis
- cervical insufficiency
- multiple gestation
preterm labor can be described as __, __ or __
- extremely preterm: <28 weeks
- very preterm: 28-32 weeks
- moderate-late preterm: 32-37 weeks
major factors that affect/cause preterm labor
- uterine stretching
- decidual activation
- intrauterine infection
- maternal or fetal stress
- hx of preterm labor/birth
preterm birth: viability
more than likely, the fetus will survive outside the womb
preterm birth: peri variability
more than likely, the fetus will not survive outside the womb
risk factors of preterm birth
- prior preterm birth
- multiple gestation (not enough room for 2+)
- uterine/cervical abnormalities
management of PTL/PTB
- prediction: transvaginal ultrasound, fetal fibronectin
- medical: non-pharmacological, pharmacological
common medications for PTL
- calcium channel blocker: Nifedipine
- NSAID: indomethacin
- magnesium sulfate
- beta-adrengic receptor agonist: terbutaline
Nifedipine
calcium channel blocker used to treat PTL/PTB
- BP med
- 30 mg loading dose q4-6 hours
- <100 systolic BP: do not give
Terbutaline
beta-adrengic recepetor agonist used to treat PTL/PTB
smooth muscle relaxer; asthmatic drug
- causes maternal & fetal tachycardia
- monitor strict I&O, listen to lung sounds regularly
- risk for pulmonary edema, crackles in lungs, respiratory distress- cardiac arrest
- 0.5 mg dose
Indomethacin
NSAID used to treat PTL/PTB
- blocks the inflammatory response that triggers labor
- 100 mg rectally loading dose q1-2 hours if contractions persist
- 25 mg orally for next 24 hours
Magnesium Sulfate
used to treat
- PTL/PTB
- preeclampsia
- smooth muscle relaxant; use for fetal neural protection and to prevent seizures for mom
- causes lethargy, N/V, HA, resp. depression
- 4-8 mg is the therapeutic dose
maternal risk of PTL/PTB
- cardiac arrhythmias
- pulmonary edema
- CHF
fetus-newborn risk of PTL/PTB
premature
contraindications to preventing/treating PTL/PTB
- intrauterine fetal demise
- lethal fetal anomaly
- severe preeclampsia
- non-reassuring fetal status
- chorioamnionitis
- premature rupture of membranes
- maternal contraindications to tocolytics
nurse actions for patient at risk for PTL/PTB
-prenatal
- s/sx of PTL
- assess FHR
- cultures
- change position
- administer medication
- I&O
- FFN
- cervical status
- lung assessment
- notify provider
- emotional support
- education: fever, backache, water breaks, bleeding, more than 5-6 contractions in 1 hr, increased vaginal d/c- call doctor
- labs
what are the two types of premature ruptures?
- premature rupture of membranes (PROM); membranes rupture is anytime after 37 weeks (but before labor/not associated with labor)
- preterm premature rupture of membranes (PPROM): membranes rupture before 37 weeks
risk factors for PROM/PPROM
- STI
- multiple gestation
- hydramnios
- short cervical length
- bleeding
- previous PPROM or preterm birth
management of PROM/PPROM before 32 weeks:
neuroprotection: mag-sulfate
management of PROM/PPROM before 34 weeks:
- reduce risk for infection
- administer corticosteroids: betamethasone- stimulates the production of surfactant in fetal lungs; 12 mg IM q24 hours x2: give 1 shot, wait 24 hours then give 2nd shot. (can give “rescue dose” if mom comes back at least 7 days later and still experiencing symptoms)
management of PROM/PPROM after 34 weeks:
- induce labor
nursing actions for PROM/PPROM
- assess FHR and contractions
- assess for signs of infection
- monitor for labor signs: NST, BPP
cervical insufficiency
- want cervix to be 30-50 mm thick
- <25 mm is insufficient/ shortened cervix
- painless cervical dilation: after 1st trimester
- expulsion of pregnancy: in 2nd trimester
causes of cervical insufficiency
- previous cervical trauma
- D & C (abortion)
- cervical lacerations, LEEP
- abnormal cervical development
risks of cervical insufficiency
- hx of 2nd and early 3rd trimester births
- complications of cerclage: ROM, chorioamnionitis, cervical lacerations
- fetal risks: preterm birth
management of cervical insufficiency
- nonsurgical: activity rest, pessary, cervical cultures, antibiotics/tocolytics, serial transvaginal ultrasound
- surgical: cerclage, removal
nursing actions: post-cerclage
- monitor uterine activity
- monitor for vaginal bleeding/leaking of fluids
- monitor for infections
- discharge teaching: infection s/sx: fever, ROM, bleeding
multiple gestation: meaning
carrying multiple fetus’
- monozygotic twins
- dizygotic twins
monochorionic/monoamniotic twins
monozygotic twins that share a chorionic sac and placenta
monochorionic/diamniotic twins
monozygotic twins that have one chorionic sac but separate placentas fused together
dichorionic/diamniotic twins
- monozygotic twins that have two chorion and separate placentas fused together
- dizygotic twins that have two chorion and separate placentas
twin type: morula splits
dichorionic diamniotic twins
- two separate placentas
- identical/monozygotic
twin type: split at hatching
monochorionic diamniotic
- fused placenta
- identical/monozygotic
twin type: blastocyst splits up to 1 week after implantation
monochorionic monoamniotic
- one placenta
- identical/monozygotic
twin type: two eggs/fertilzations
dichorionic diamniotic
- separate placentas
- fraternal/dizygotic
risks for women with multiple gestation
- hypertensive disorders
- gestational diabetes
- maternal hemorrhage
- anemia
- cholestasis
- acute fatty liver
- cesarean birth
risks for fetus-newborns of multiple gestation
- increase fetal morbidity and morality
- preterm birth
- increased risk of LBW
- monochorionic twins
- IUGR
- increased risk of congenital, chromosomal, genetic defects
maternal physiological changes for multiple gestation
- physiological changes are greater in twin pregnancies
- HCG levels increased
- fundal height is greater than dates
- increased cardiac output
- maternal blood volume is > 50-60%
- increased plasma volume
- increased dermatosis
- increased iron deficiency anemia
multiple gestation: ultrasound assessment shows __
- gestational age
- growth restriction
- chronioncity/amnionicity
management of multiple gestation
- ultrasound
- genetic testings
- monitor signs of PTB (*high risk for PTB)
- monitor for maternal anemia
- NST/BPP
- monitor for hypertension/preeclampsia
- monitor for hydramnios
- consult with perinatologist (NICU providers) when needed
nursing actions for multiple gestation
- assess for complications
- NST/BPP
- education
- nutrition
- emotional support
- adaptation of the couple
- referrals as needed
Hyperemesis Gravidarum is __
N/V
- peaks at 9 weeks gestation
- subsides around 20 weeks
hyperemesis gravidarum leads to __
- dehydration
- electrolyte and acid-base imbalance
- starvation ketosis
- weight loss
management of hyperemesis gravidarum
- treatment of N/V
- hydration (IV- banana bag- vit B, vitamins, minerals)
- labs
- correction of ketosis and vitamin deficiency
nursing actions for hyperemesis gravidarum
- assess N/V
- treatment of N/V
- emotional support
- oral hygiene
- daily weight
- I&O
- labs
- education
- complimentary therapy
intrahepatic cholestasis (ICP)
- pruritis (itchy) of the palms and soles of the feet
- hormonal
- develops late in pregnancy
- people are genetically predisposed
intrahepatic cholestasis is associated with what?
- increased preterm delivery
- meconium passage
- FHR abnormalities
- fetal death (IUFD)
intrahepatic cholestasis: risks to fetus
- serum bile acid levels
- transaminase levels
management of intrahepatic cholestasis
- UCDA: ursodeoxycholic acid
- antihistamines, corticosteroids, cholesytrmine
- risks to fetus
- NST/BPP
- delivery at 36 weeks
nursing actions for intrahepatic cholestasis
- monitor labs
- aquenous cream
- administer medications
- education
deiabetes mellitus: types
- pregestational: type 1 or type 2
- in pregnancy: gestational
normal changes in pregnancy when mom has diabetes
- insulin resistance
- hormonal shifts
goals for diabetic mom during pregnancy
- maintain euglycemia (normal glucose) control
- minimize complications
- prevent prematurity
pregestational diabetes: risks to mom
- DKA: diabetic ketoacidosis (very high blood sugar)
- hypertension/preeclampsia
- preterm labor
- spontaneous abortion
- poly/oligohydramnios
- cesarean section
- infection
- postpartum hemorrhage
pregestational diabetes: risks to fetus/newborn
- congenital defects
- macrosomia: abn large for gest. age
- hypoglycemia
- IUGR: abn. small for gest. age
- respiratory distress
- polycythemia
- prematurity
- cardiomyopathy
- stillbirth
medical managment of pregestational diabetes
- preconception care is the key in decreasing risks to both mom and baby
- HbA1C: may require more insulin than usual near end of pregnancy to maintain (3x as much sometimes)
- screening of kidney, thyroid, heart, eyes
- ultrasound, prenatal care, and antenatal testing
- medical nutrition therapy
risks during delivery: pregestational diabetes
- TTN: transient tachypnea: delay in clearance of fetal lung fluid following delivery
- respiratory distress: follows TTN
- hypoglycemia: follows resp. distress
nursing actions: pregestational diabetes
- educate
- nutrition: adjust meals/timing
- record keeping
- NST/BPP
gestational diabetes (GDM) testing
- screening from 24-28 weeks
- 1 hr glucose tolerance test (50g)
- 3 hr glucose tolerance test (100g)
risks for women with gestational diabetes
- hypoglycemia and DKA
- preeclampsia
- cesarean birth
- development of non-gestational diabetes
gestational diabetes: risks to fetus/newborn
- macrosomia
- IUGR
- hypoglycemia
- hyperbilirubinemia
- shoulder dystocia
- respiratory distress
- birth trauma (because they are so big)
medical management: gestational diabetes
- controlled with diet and exercise
- 40% controlled by insulin
- cesarean section for fetus >4500g
- monitor for type 2 diabetes following pregnancy
nursing actions: gestational diabetes
- education
- diet management
- reinforce self-care/self-management
preeclampsia
- a disease involving the development or worsening of high blood pressure; typically during 2nd trimester
- systolic is 140 or higher
- unknown etiology
- HTN after 20 weeks gestation
- proteinuria
- treatment is symptomatic
risk factors that cause preeclampsia
- nulliparity
- <20 years old
- > 35 years old
- multiple gestation
- previous family hx
- chronic HTN
- gestational diabetes
preeclampsia: risks to women
- cerebral edema/hemorrhage, stroke
- pulmonary edema
- DIC: decimated intravascular coagulation
- CHF: congestive heart failure
- HELLP
- abruption
- risk of developing heart disease
eclampsia
- a severe form of preeclampsia
- same s/sx as preeclampsia, & seizures
HELLP syndrome
Hemolysis
Elevated
Liver enzymes
Low
Platelets
- considered to be a variant of preeclampsia/ complication of preeclampsia
** only treatment is to deliver infant and placenta
preeclampsia: risks to fetus
- IUGR
- premature
- stillbirth
- intolerance to labor
preeclampsia s/sx
- elevated BP
- proteinuria
- elevated liver function tests
- headache
- visual changes
- epigastric pain
s/sx of (mild) preeclampsia
- elevated BP
- protein in urine
- water retention and swelling
- weight gain exceeding 2lbs/week
s/sx of severe preeclampsia
- headaches
- changes in vision
- pain in abdomen and back
- nausea/vomiting
medical management of preeclampsia
- magnesium sulfate
- antihypertensive medications
- induction of labor
warning signs of eclampsia
- severe HA
- epigastric pain
- hyperreflexia with clonus (tremors)
- restlessness
eclampsia: during seizure care
- remain with patient
- call for assistance
- prevent injury
- document
eclampsia: post seizure care
- assess maternal fetal status
- assess airway
- administer oxygen
- IV access
- administer magnesium
nursing actions: eclampsia/preeclampsia
- assess for signs of preeclampsia
- monitor labs
- administer medications
- test urine (looking for protein in urine)
hemolysis
red blood cells are broken down too quickly
- can lead to anemia
elevated liver enzymes
- taken as a sign that liver function is compromised
low platelet count
at risk for excessive bleeding because platelets are responsible for clotting blood
- low platelet because they are gathering at site of damage
hypertensive disorders of pregnancy
- chronic hypertension
- preeclampsia
- eclampsia
- gestational hypertension
4 R’s of quality improvement AIM patient safety bundle: severe hypertension
Readiness
- every unit: preparations, education, simulations
Recognition & Prevention
- every patient: screening, dx and classification, prevention approaches
Response
- every event/case: management and treatment, patient education
Reporting & Systems Learning
- every unit: debriefs & multidisciplinary review, QI measures, documentation and coding
placenta previa: risk factors
- endometrial scarring and increased placental mass
- maternal: shock, blood loss, Rh sensitization, maternal death
- feus/newborn: fetal compromise, hypoxia, fetal anemia, prematurity
placenta previa: s/sx
- painless vaginal bleeding (bright red)
- hemodynamic changes related to blood loss
- FHR changes due to maternal blood loss
management of placenta previa
- ultrasound placenta location
- cesarean section
- monitor bleeding
nursing actions: placenta previa
- monitor labs
- assessment: color and amount of blood
- notify provider
- assess for pain, contractions
- IV insertion/maintenance
- administer medication
placenta abruption
- bleeding at the decidual-placenta interface which can result in partial or complete detachment of the placenta before delivery
- bleeding is always maternal
placenta abruption: s/sx
- vaginal bleeding
- abdominal pain
- hypertonic contractions
- uterine tenderness
- non-reassuring FHR
placenta abruption: risk factors
- previous abruption
- hypertensive disorders
- trauma
- maternal: blood loss, hysterectomy, renal failure, maternal death
- fetus/newborn: premature, asphyxia, stillbirth, perinatal death
medical management of placenta abruption
- hospitalization
- steroids: betamethasone sodium phosphate
nursing actions: placenta abruption
- FHR monitoring
- s/sx of abruption
- palpate uterus (tender- not good)
- monitor for hypotension
- insertion of IV
- oxygen
- document blood loss
placenta accreta: risks
- maternal: hemorrhage, shock, excessive blood loss, infection, thromboembolism, surgical complication
- fetus/newborn: premature
placenta increta
placenta attaches itself deep into the myometrium of the uterus muscle wall.
placenta percreta
placenta attaches itself and grows through uterine wall and extends into other organs, i.e. bladder
- need to deliver baby
medical management: placenta accreta
- timing of delivery
- potential need for hysterectomy
nursing actions: placenta accreta
- assess
- education
- emotional support
- monitor labs: CBC, clotting factors
ectopic pregnancy
- implantation outside of uterus, in fallopian tube
- 95% occur in fallopian tube
ectopic pregnancy: s/sx
- pelvic pain: sharp, sudden onset, lower
- light to heavy bleeding
- weakness, dizziness
management of ectopic pregnancy
- early dx: HCG levels, transvaginal ultrasound, progesterone levels
- medication if tube not ruptured (not a viable pregnancy)- Methotrexate
gestational trophoblastic disease
- abnormal trophoblast cells grow inside the uterus
- non-viable pregnancy
- will have hCG, will feel like pregnancy but ultrasound will show abnormal cells and not a fetus
- molar: hydatiform mole; 3rd haploid genome is paternally derived
- non-molar: gestational trophoblastic neoplasia; 3rd haploid genome is maternally derived
TORCH infections: define
Toxoplasmosis
Other- Hep B
Rubella
Cytomegalovirus
Herpes simplex
substance abuse affects on fetus/newborn
- LBW
- developmental disabilities
- preterm birth
- infant mortality
what is substance abuse?
- alcohol
- smoking
- illicit drugs: cocaine, opioid use, marijuana
facial characteristics associated with fetal alcohol exposure
- low nasal bridge
- minor ear abnormalities
- indinstint philtrum
- micrognathia
- thin upper lip
- flat midface and short nose
- short palpebral fissures
- epicanthal folds
decidual activation
the cells talk to each other and all decide to go into labor
fetal fibronectin
in lining of the uterus and amniotic sac normally
- swab the vaginal canal (present)- increased risk of delivering in the next 7 days
- swab the vaginal canal (not present)- likely you won’t go into labor soon
calcium gluconate
- used to reverse magnesium toxicity
cerclage
stitch in the cervix closing the opening of the cervix, and putting a rubber band called a pessary to keep it closed
- take out around 36-37 weeks
ICP maternal s/sx
- dark urine
- pale stools
diabetes: timing
after 20 weeks- gestational
before 20 weeks- diabetic, not gestational diabetic
what percent of women with GDM develop Type 2 DM?
50%
preeclampsia vs. chronic hypertension
preeclampsia: HTN that develops after 20 weeks gestation
chronic HTN: HTN that woman has had all along
magnesium sulfate doses
- loading dose 4-8g diluted in 100 mL, over 15-20 minutes (1x)
- maintenance dose 1-2g q1hr
placenta previa is ___
when the blood vessels of the placenta are right over the cervix and fetus is resting on top of it
placenta accreta is __
when the placenta grows into the uterine wall during pregnancy; placenta remains attached after birth of child
nursing actions: gestational trophoblastic disease
- D&C
- monitor hCG levels: want normal for 6 months before tries to get pregnant again
management of hypertensive disorders in pregnancy (HDP): 5 key elements
- recognize sx and dx HDP
- blood pressure control
- seizure prevention
- delivery
- 34 weeks: preeclampsia with severe features
- 37 weeks: preeclampsia without severe features or gestational hypertension - postpartum surveillance
