Exam 1 Flashcards
an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof
sentinel event
- leaving a foreign body in a client (sponge, 4x4, forceps)
- falls
- maternal death related to the birth process
- wrong milk to wrong baby
- birth injury
gestation
how long a woman is pregnant (40 weeks)
term
37 - 42 weeks
preterm
20 - 36.6 weeks
abortion (weeks)
less than 20 weeks
gravida
number of times a woman is pregnant
para
the number of times she has “emptied the uterus” delivered
GT
gravida & para
pregnancies and deliveries
GTPAL
Gravida (pregnancies) Term deliveries (37-42 weeks) Preterm deliveries (20-36.6 weeks) Abortions (less than 20 weeks) Living Children
GTPALM
Gravida (pregnancies) Term deliveries (37-42 weeks) Preterm deliveries (20-36.6 weeks) Abortions (less than 20 weeks) Living children Multiples (e.g., twins)
viability weeks
20 weeks
ability to live outside womb
organization that works closely with organizations to address sentinel events and to prevent these types of events from occurring in the first place
joint commission
common risks to women
Age
Adolescent (teen pregnancy)
Young/middle adulthood
Parenthood after age 35
Late reproductive age
Social, Cultural, Economic, & Genetic factors
- diseases among ethnic groups
Socioeconomic
- affects birth outcomes
- cycle
Substance abuse & Alcohol
Obesity
- BMI > 30
- risk for HTN, diabetes, post-term deliveries, IUGR, IFD
Eating Disorders
- anorexia nervosa
- bulimia
- binge-eating disorder
STDs
Lack of exercise, Stress, Depression, Anxiety/other mental health conditions, Sleep Disorders, Environmental/Workplace hazards, Sexual practices, Medical conditions, Female genital mutilation, Violence against women
common disease among ethnic groups
sickle cell - African Americans
Tay-Sachs - Jews
adult lactase deficiency - Chinese
beta thalassemia - Mediterranean
cystic fibrosis - Northern European
alcohol risks
low birth weight babies
fetal alcohol syndrome
intellectual disabilities
behavior problems
learning and physical problems
caffeine risks
coffee, tea, and soft drinks
Heart Dysrhythmias
prescription drug use risks
check to see if it crosses the placenta (most do)
illicit drug use risks
can cause birth defects
Check for drug use:
SROM
vaginal bleeding of unknown origin
FAS
fetal alcohol syndrome
severe facial deformity that can occur if fetus is exposed after 20 weeks
SROM
spontaneous rupture of membrane
IUGR
intrauterine growth restriction
IFD
intrauterine fetal demise/death
doxycycline and pregnancy (chlamydia)
pregnant women shouldn’t take doxycycline because it crosses the placenta and will make the baby’s teeth turn yellow when they are developed
genital warts (HPV)
pregnant women shouldn’t use podofilox because it can cause the lesions to proliferate and become friable (use cryotherapy to burn them off)
RPR (rapid plasma reagent)
performed on pregnant women to test for syphilis
PID
pelvic inflammatory disease
(infection that can be caused by gonorrhea, chlamydia, trachomatous)
increases risk for ectopic pregnancy, infertility, and/or chronic pelvic pain
if a mom is HIV positive
it does not mean the baby will have it
low blood levels of ovarian hormones stimulate the hypothalamus to secrete ______, which stimulates anterior pituitary secretions of FSH
GnRH (Gonadotropin-releasing hormone)
stimulates development of ovarian Graafian follicles and their production of estrogen
follicle stimulating hormone (FSH)
a marked _____ and a smaller peak of estrogen precede the expulsion of the ovum from the Graafian follicle by about 24-36 hours
luteinizing hormone (LH)
LH peaks about day __ or __ of a 28 day cycle
13 or 14
if fertilization has not occurred when LH peaks, regression of the _____ ______ follows
corpus luteum
then menstruation will occur
if there is no fertilization, estrogen levels begin to ______ and hypothalamic GnRH triggers the anterior pituitary to release LH
decrease
if fertilization occurs, no menstruation occurs and the corpus luteum continues to secrete _____ &____ for the first few months
progesterone & estrogen
produced by the ovarian corpus luteum and is necessary to mature and maintain the uterine lining
progesterone (pro-life)
a thin uterine lining is unable to nourish the implanted blastocyte
- Affect smooth muscle contractility
- Influences the production of progesterone and estrogen by the corpus luteum
prostaglandins
if they do not rise with LH, the ovum remains trapped in the graffin follicle
most common STD in the US
chlamydia
most prevalent in adolescents
- inflammation of cervix with mucopurulent discharge
- may be asymptomatic
- untreated may lead to urethritis, tubal occlusion, PID, and infertility
chlamydia clinical manifestations
screening/diagnosis of chlamydia
- screen 1st trimester or when enter healthcare
- by culture or DNA probe or enzyme immunoassay (CDC recommends nucleic acid amplification test [NAAT] or urinary, vaginal, or endocervical areas)
- retest 3rd trimester if multiple sex partners or under the age of 25
- test for gonorrhea
treatment/management of chlamydia
- azithromycin 1g PO single dose
or - doxycycline 100mg BID for 7 days
*pregnant women should not be given doxycycline because it will discolor baby’s teeth when they are developed - erythromycin ophthalmic ointment NBs conjunctival sac 1 hour after birth
chlamydia: pregnancy/fetal/neonatal effects
Pregnancy: increased incidence of PROM, PTL, PID, ectopic pregnancy
Newborn may be asymptomatic
conjunctivitis > scarring > blindness
respiratory problems may result in pneumonia
often asymptomatic
complaint of mucoid or mucopurulent vagina/endocervical discharge, dysuria, and swollen/reddened labia
pelvic, lower abdominal or rectal pain
vulvovaginal inflammation progresses to yellow-green vaginal discharge
may ascend to involve pelvic structures > PID
gonorrhea clinical manifestations
gonorrhea screening/diagnosis (aerobic gram-negative diplococcus)
gram stain culture of endocervical, vaginal, rectum, and possibly pharynx
chlamydia culture and serologic test for syphilis
screened at 1st prenatal visit (at risk clients screened again in 3rd trimester [36 weeks])
gonorrhea treatment/management
ceftriaxone (rocephin) 125 mg IM single dose
baby: erythromycin ophthalmic ointment within 1 hour of birth
gonorrhea: pregnancy/fetal/neonatal effects
Pregnancy: amnionitis, PTL, and postpartum salpingitis
Newborn: ophthalmia neoinatorum (gonococcal conjunctivitis)
- if untreated > blindness
because of the prevalence of chlamydia and gonorrhea, all states have a law requiring preventative treatment to newborns at birth
primary stage: ulcer (chancre) - condyloma - warts may be present on vulva, perineum, or anus (flatter than HPV genital warts)
secondary - maculopapular rash can be on hands and soles of the feet
this disease progresses to secondary and tertiary stages with varying characteristics
syphilis CM
syphilis screening/diagnosis
screened at first prenatal visit VDRL or RPR serology, again in 3rd trimester, and at time of birth if they are high risk
(if HIV or other STI, always check to see that RPR or VDRL was done too)
syphilis treatment/management
- penicillin G 2.4 million units single dose (if allergic to doxycycline or tetracycline - not to be used in pregnancy)
treatments by 18th gestation week prevents congenital syphilis in neonate (however, treat at time of diagnosis)
syphilis: pregnancy/fetal/neonatal effects
Pregnancy: may result in spontaneous abortion or PTL
- transmitted across placenta after approximately 18 weeks gestation
Newborn: congenital anomalies and/or congenital syphilis
- congenital syphilis: test on cord blood
- painful, red papules
- pustular vesicles that break and form wet ulcers that later crust
- low grade fever, chills, malaise, & severe dysuria
- dyspareunia (pain during intercourse)
herpes simplex virus type 2 (HSV)
medication is not a cure (acyclovir [zovirax] PO 7-10 days, suppressive treatment acyclovir/36 weeks decreases viral shedding during delivery, counseled cesarean birth may be indicated if active lesions present)
crosses placenta as well as acquired during direct contact during birth
screening by history and exam for lesions, new cases by culture from active lesions, multinucleate giant cells in microscopic exam of lesion exudates
condyloma acuminata (genital warts) that spread, enlarge during pregnancy (small, soft papillary swellings in the genital and anorectal regions)
human papilloma virus (HPV)
associated with cervical cancer later in life
speculum exam, Pap test (papanicolaou), history, SNS
trichloroacetic acid, laser treatment, cyocautery
vaginal discharge: thin, grayish with fish-like odor
intense pruritus
bacterial vaginosis (gardnerella)
wet-mount slide positive for clue cells
topical metronidazole (flagyl)
associated with PTL
thick, white, pruritic vaginal discharge
common in pregnancy r/t changes in vaginal with antibiotic tx and w DM or HIV infection
candidiasis (yeast infection)
wet-mount slide
monistat (antifungal) vaginal cream, diflucan (oral)
candida infection (oral thrush) if baby in direct contact with organism in birth canal
frothy, odorous vaginal discharge
trichomoniasis (protozoan)
flagellated trichomonads visible on microscopic exam of wet-mount slide
metronidazole (flagyl) for sexual partners is usual treatment (NO flagyl given to pregnant patients in 1st trimester)
clotrimazole (gyne-trimin) topical antifungal
group B streptococcus
asymptomatic, UTI
screening at 35-38 weeks gestation is recommended for all pregnant women
penicillin (ampicillin) broad spectrum
intra-amniotic infection
jaundice, fever, painful joints
transmitted through blood, saliva, vaginal secretions, semen, and breast milk
hep B
- HBsAG test (acute and chronic)
- IgM antibody (acute or recent)
- identify carriers at prenatal screening
- screened again 3rd trimester to allow tx during delivery and neonate at birth
- HB vaccine for unvaccinated pregnant clients
- series of HBsAG recommended for all newborns (1st injected given within 24hr/birth)
- infants of mothers positive for HBsAg need hep B immune globulin and vaccine at birth
maternal: prematurity, LBW
all pregnant women should be screened for
HIV Hep B Syphilis Chlamydia Gonorrhea (1st trimester)
women at risk screening
(multiple sex partners, drug abuse)
prescreened 3rd trimester
Hep C
anemia in pregnancy
iron deficiency
folic acid
sickle cell
total iron requirement for a pregnancy
1000 mg
(diet rarely meets pregnancy needs)
2nd & 3rd trimesters:
hgb = < 11 mg/dL
hct = <33
iron deficiency anemia maternal symptoms
pallor fatigue lethargy HA pica for various substances microcytic, hypochromic rbc's
iron deficiency anemia fetal effects
receives adequate iron at cost to mother
- in presences of severe maternal anemia, reduced hgb and O2 > compromised baby
iron deficiency anemia therapeutic management
elemental iron 200 mg (at least 3 months after correction of anemia)
- absorption decreased with milk, tea, and coffee
- absorption increased in presence of vitamin c (melon, strawberries)
adult female: 15 mg
pregnancy: 30 mg
parenteral: z track method
folic acid
essential for formation of rbc cell duplication and placental/fetal growth
maternal needs 2x during pregnancy r/t need for more erythrocytes, plus placental and fetal growth
folic acid deficiency anemia
caused by nutritional deficiencies (folate), hemolytic anemias, malabsorption, and specific medications
folic acid deficiency maternal symptoms
presence of megaloblasts (large, immature erythrocytes)
increased risk of spontaneous abortion, abruptio placentae, and fetal anomalies
folic acid anemia fetal effects
neural tube defects
folic acid anemia therapeutic management
folate supplement
adult female: 180
pregnancy: 400
lactation: 280
dietary
sickle cell anemia
autosomal recessive disorder
causes erythrocytes to assume an S shape
- they tend to clump together and occlude small by’s
characterized by chronic anemia, susceptibility to infection, and recurring episodes of sickle cell crisis
sickle cell anemia maternal symptoms
pregnancy may precipitate sickle crisis
sickle crisis associated with:
- jaundice r/t decreased bone marrow function and massive erythrocyte destruction
- pain r/t major infarcts in joints and all major organs
sickle cell fetal effects
prematurity
IUGR
fetal death during a sickle crisis
sickle cell therapeutic management
adequate hydration adequate nutrition folate supplement rest periods prompt tx of illness/infection
TORCH infections
a group of congenital infections that are passed from mother to child at some point during pregnancy, during delivery, or after birth
Toxoplasma gondii Other agents Rubella Cytomegalovirus (CMV) Herpes simplex virus (HSV)
Toxoplasmosis (protozoan) transmission
- raw meat
- infected animal (cat) feces
- transplacental
toxoplasmosis maternal effects
- influenza-like aching
- lymphadenopathy
- spontaneous abortion
toxoplasmosis fetal/neonatal effects
- congenital toxoplasmosis, LBW
- hepatosplenomegaly with jaundice, anemia
toxoplasmosis management
Avoid: eating uncooked meat, exposure to litter used by infected cats.
Titer checks during pregnancy
Elective ab may be discussed if titer is high during early pregnancy
varicella zoster (chicken pox) transmission
usually included as “other”, but could be many others
- direct contact
2. respiratory droplets
varicella zoster (chicken pox) maternal effects
preterm labor
encephalitis
varicella pneumonia
varicella zoster (chicken pox) fetal/neonatal effects
congenital varicella syndrome with limb hypoplasia, cataracts, microcephaly, and symmetric IUGR during 1st trimester
varicella zoster (chicken pox) management
varicella immune globulin for susceptible clients exposed during pregnancy
neonate born to mother with an active infection is given immune globulin within 72 hours
strict isolation for both mother and neonate
rubella (German measles) transmission
- transplacental
- direct contact
- respiratory droplets
rubella (German measles) maternal effects
rash
fever
malaise
spontaneous abortion during 1st trimester of pregnancy
rubella (German measles) fetal/neonatal effects
deafness MR IUGR cardiac defects microcephaly
rubella (German measles) management
prevent by rubella vaccinations in childhood
rubella titer is 1:8 is evidence of immunity
if vaccinated in adulthood, document understanding of pregnancy prevention for 3 months post vaccination
a herpes virus that becomes latent after primary infection
periodic reactivation and shedding
cytomegalovirus (CMV)
cytomegalovirus (CMV) transmission
- transplacental
2. body fluids
cytomegalovirus (CMV) maternal effects
flu-like symptoms
cervical discharge
cytomegalovirus (CMV) fetal/neonatal effects
fetal or neonatal death; severe generalized disease with hemolytic anemia, jaundice, hydrocephaly, or microcephaly
cytomegalovirus (CMV) management
no effective tx.
therapeutic ab considered if a primary infection occurs in 1st 20 weeks of pregnancy
hepatitis B transmission
- transplacental
- body fluids (blood, saliva, vaginal secretions, semen, breast milk)
- contaminated needles or blood transfusion
hepatitis B maternal effects
fever rash arthralgia abdominal pain enlarged and tender liver
hepatitis B fetal/neonatal effects
prematurity
LBW
development of acute infection at birth
possible neonatal death
hepatitis B management
all pregnant women are screened for HbsAG
at risk clients prescreened in 3rd trimester
newborn given immune globulin at birth to prevent infection from skin surface contamination
- repeated at 1 and 6 months of age
caused by retrovirus HIV
- depletes the body’s immune system (overwhelmed with opportunistic infections)
AIDS
AIDS transmission
- sexual exposure
- parenteral
- perinatal exposure of an infant to an infected mother
AIDS maternal effects
Antepartum: an increased incidence of other STDs
- offered the option of ZDV
Intrapartum: external EFM preferred
- avoid use of fetal scalp electrodes or blood sampling
Postpartum: breastfeeding contraindicated
- universal precautions for mom and baby
AIDS fetal/neonatal effects
if mother is HIV+, the newborn is given ELISA test for presence of HIV antibodies
- if positive but asymptomatic at birth, s/s usually become evident during 1st year of life
FTT, liver, and spleen involvement (bacterial infections most common)
AIDS management
prevention
safe sex practices, barrier contraceptives, Zidovudine (ZDV)
group B streptococcus (GBS) transmission
gram+ bacteria
- colonizes in the rectum, vagina, cervix, and urethra of women
- ascends after ROM or during birth
group B streptococcus (GBS) fetal/neonatal effects
- sepsis
- pneumonia or meningitis within 7 days of birth
(meningitis most common clinical symptom)
early (1st week of life) or late onset - may have permanent neurological deficits
group B streptococcus (GBS) management
IV antibiotics to mother in labor and/or to infant after birth
most common medical complication in pregnancy
hypertension
rate of hypertensive disorders has risen steadily since 1990 for all ages, races, and ethnic groups
significant contributor to maternal and perinatal morbidity and mortality
pre-eclampsia
potentially lethal complications during pregnancy
pre-eclampsi -> eclampsia
abruptio placentae
disseminated intravascular coagulation (DIC)
acute renal failure
adult respiratory distress syndrome (ARDS)
cerebral hemorrhage
HELLP syndrome
common types/classifications of hypertension
gestational
pre-eclampsia
eclampsia
chronic
preeclampsia superimposed on chronic hypertension
hypertension
a SBP >140 and a DBP >90 recorder on at least 2 separate occasions 4-6 hours apart within a maximum of 1 week
mean arterial pressure (MAP) > 105 mmHg
(sitting, right size cuff, no tobacco or caffeine 30 min prior)
onset of hypertension without proteinuria after 20 weeks gestation
gestational hypertension
recorded at least 2 separate occasions at least 4-6 hours apart but within 1 week
more frequent in multifetal pregnancies
usually develops at or after 37 weeks with no preexisting HTN
BPs return to normal within 1-12 weeks aft delivery
only 1 pressure has to be elevated
usually occurs 20 weeks after gestation in a previously normotensive pt AND has proteinuria
(may be mild or severe)
preeclampsia
- proteinuria at or above 30 mg (>/_ 1+ on a dipstick) or more in 2 random specimens at least 6 hours apart or >/_ 300 mg in 24 hours
mild: 140/90 x2 >4-6hrs apart (MAP >105, 24hr urine > 0.3g)
severe: >160/110 (MAP >105, 24hr urine >2g)
preeclampsia (2)
HTN and proteinuria developed after 2 weeks
elevated BP - often 1st sign
pathological edema
risk factors for preeclampsia
chronic renal disease chronic hon family hx of preeclampsia multiple gestation primigravidity or new partner maternal age diabetes rh incompatibility obesity
etiology of preeclampsia
disruption in placental perfusions and endothelial cell dysfunction
cause of preeclampsia is unknown - however, it is a condition unique to pregnancy and the only cure is delivery of the infant
why we look for blurred vision, headaches, liver functions, epigastric pain/RUQ pain, blood work
low platelets can be a precursor to HELLP, proteinuria
the major pathological factor in preeclampsia
poor perfusions as a result of vasospasm
- vasoconstriction results from sensitivity to vasopressors (like angiotensin II)
- arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and increases BP
- endothelial cell dysfunction as a result of vasospasm
effects of preeclampsia
placental: impaired perfusion leads to early aging of the placenta and IUGR of the fetus
renal: decreased GFR results in oliguria, increased excretion of protein (mainly albumin), decreased uric acid clearance, sodium and water retention
hepatic: decreased perfusion can result in hepatic edema and subcapsular hemorrhage as evidenced by the complaint of epigastric pain or RUQ pain (a sign of impending eclampsia)
- liver enzymes become elevated (AST, ALT, and LDH)
neurological: vasospasms and decreased perfusion can result in:
- cerebral edema (change in emotion, mood, and LOC)
- CNS irritability (H/A, hyperreflexia, +ankle clonus, and occasionally eclampsia)
- visual disturbances (scotomata and blurring)
lab values:
- decreased serum albumin (results in decreased plasma colloid osmotic pressure - fluid moves out of the intravascular resulting in hemoconcentration, increased viscosity, and tissue edema)
- increased Hit as a result of hemoconcentration
- increased BUN, serum creatinine, and serum uric acid as a result of degenerative glomerular change
the occurrence of seizures or coma in a woman with preeclampsia
eclampsia
HTN that occurs before pregnancy or dx before 20th week gestation
(also if it persists more than 6-12 weeks postpartum)
chronic hypertension
women with chronic HTN with new proteinuria or an exacerbation of HTN or proteinuria, thrombocytopenia, or increased hepatocellular enzymes
preeclampsia superimposed on chronic hypertension
proteinuria
- concentration at or above 30 mg/dL (>/_ 1+ on dipstick)
- in at least 2 urine specimens
- at least 6 hours apart
OR
- 24 hour specimen
- concentration at or above 300 mg/24hrs
- both in absence of UTI
eclampsia priorities
- keep the patient safe
- turn onto side
- suction
- oxygen
- IV mag sulfate
- monitor fetus
- uterine & cervical assessment
- document
following a seizure, a decision must be made regarding delivery
(may try to postpone delivery until antenatal gluticorticoids can be given and benefit received)
*document: time, duration, and any urinary or fecal incontinence
(seizure activity or coma in a woman with preeclampsia with no history of preexisting pathology that can result in seizure activity)
preeclampsia/hypertension assessment
History & S/S:
- the nurse should take a thorough history at the 1st prenatal visit to identify risk factors for the development of preeclampsia
- assess for s/s of preeclampsia at each subsequent prenatal visit
Blood Pressure:
- BP measured in a standardized manner
Edema:
- assess for distribution, degree, and pitting
- breath sounds are auscultated to assess crackles, which may indicate pulmonary edema (pulmonary edema is associated with severe preeclampsia)
*diuretics (lassie) are only used in preeclampsia when there is evidence of CHF or pulmonary edema
(diuretic therapy further reduces intervillous blood flow (placental perfusion), which may lead to serious fetal jeopardy) *daily weights
DTRs/Clonus:
- assess biceps & patellar reflexes as well as ankle clonus
- clonus: no rhythmic oscillations [negative beats of clonus]
+ clonus: presence of rhythmic oscillations [positive # of beats of clonus]
- hyperreflexia is a sign of CNS irritability (sign of impending eclampsia)
- absence of reflexes when a patient is being treated with magnesium sulfate is a sign of toxicity (Mg level >9mg/dL)
mild preeclampsia management
Home Bedrest:
- if proteinuria <0.3mg/24hr urine specimen
- without subjective complaints
- home situation and support system conductive
- some health agencies (alert, materia, etc.) have a home program fro HTN in pregnancy
Daily Monitoring of BP & Weight:
- perform in a consistent manner
- report abnormal weight gain and elevations in BP
Fetal Surveillance:
- home: fetal kick counts daily and (if available) home NST 1-2x weekly
- hospital: NSTs, biophysical profiles as indicated
- ultrasound for fetal growth at diagnosis and every 3 weeks
Monitor Urine Protein:
- dip urine daily and report any increase in value
S/S to report:
- ^BP - >140/90
- decreased fetal movement
- headache
- visual disturbances
- epigastric or URQ pain
- ^ proteinuria
- decreased urinary output
- N/V
- malaise
- any sign of labor, vaginal bleeding, or abdominal tenderness
Diet:
- same as a normal healthy pregnant woman
- do not limit salt, except possibly in chronic hypertensive, because they already have a low plasma level and they need salt to maintain blood volume and perfuse the placenta
Emotional Support:
- both patient and family
- address concerns and fears
- assist with adjustment to bed rest
severe preeclampsia management
Hospital Bedrest:
- management of severe preeclampsia is best achieved in a tertiary care center (availability of perinatology, neontology, and a NICU)
- management ranges from conservative to to immediate delivery depending on maternal and fetal status, as well as the gestation age
Maternal & Fetal Surveillance:
- may require an ICU setting and/or hemodynamic monitoring (invasive monitoring should be considered for women with severe cardiac disease and/or renal failure (in some instances pulmonary edema)
- maternal assessment for disease progression - physical and lab data
- close fetal surveillance is warranted - observing for signs of uteroplacental insufficient (daily NST, biophysical profile, umbilical artery doppler flow studies)
- baseline labs and frequent laboratory monitoring observing for an increase in liver enzymes, decrease in platelets, changes in coagulation studies and electrolytes (assess for HELLP and DIC)
- daily weights, I&O, Foley catheter placement to assess for renal function
Pharmacological Interventions:
- Mg sulfate - quiet the CNS (have Ca gluconate available for Mg toxicity)
- oral antihypertensive (given if SBP >160 - 180, DBP 100 - 110) [give with caution - if DBP below 90, could reduce uteroplacental perfusion]
Environment:
- environment should be quiet and non stimulating due to CNS irritability
- emergency medications and equipment close by and readily available (suction and oxygen)
Delivery:
- if immediate delivery is indicated then C section would most likely be the delivery mode of choice, especially if the cervix is unfavorable (a prolonged labor could increase risk of maternal morbidity)
nonstress test (NST)
baseline variability decelerations accelerations uterine activity
biophysical profiles with doppler flow
fetal movement/tone fetal breathing amniotic fluid index heart rate reactive or nonreactive NST
preeclampsia postpartum
frequent BP & vital signs (q 4hr/48 hrs)
Mg sulfate (12-24 hrs post delivery to prevent development of eclampsia) - analgesics are given with caution due to mg sulfate potentiating their effect
uterine tone and lochia (Mg sulfate can interfere with the uterus clamping down, thus causing a boggy uterus and heavy lochia flow, placing the woman at risk for postpartum hemorrhage)
- oxytocin should be administered to treat the boggy uterus and control bleeding
- methergine and ergot rat are contraindicated because they cause an increase in blood pressure
family support & bonding
- promote bonding and interaction with fetus
- educate patient and family on care and prognosis
- encourage breastfeeding (breastfeeding is the best form of nutrition for the premature infant - *mg sulfate is NOT a contraindicated for breastfeeding)
*one-third of all cases of preeclampsia occurred after delivery in a recent study and the risk remains for up to 28 days post partum
HELLP syndrome
(H) hemolysis - breakdown of RBC as they pass through the small vessels with endothelial cell damage and fibrin deposit
(EL) elevated liver enzyme - a result of impaired hepatic blood flow and fibrin deposits
(LP) low platelets
- a lab diagnosis, NOT clinical diagnosis
- variant of severe preeclampsia (affects ~1 in a 1000 pregnancies)
- cause unknown - thought to be a result of changes that occur with severe preeclampsia (arteriole vasospasm, endothelial cell damage, and platelet aggregation resulting in tissue hypoxia; possibly an immunologic component as well)
HELLP syndrome s/s
range from asymptomatic of preeclampsia to N/V, epigastric pain or RUQ, general malaise
HELLP syndrome complications
renal failure pulmonary edema ruptured liver hematoma DIC placental abruption
HELLP syndrome nursing responsibilities
- assess and observe for signs of bleeding (petechia or bruising from bp cuff, IV site, gums)
- jaundice
- monitor lab values and report to physician
- fetal status (at risk for abruption)
triangular helmet shaped cells found in blood - usually indicative of disorders of small blood vessels
burr cell
pathological form of diffuse clotting that consumes large amounts clotting factors causing widespread external and/or internal bleeding
Dissemination Intravascular Coagulation (DIC)
*always a secondary diagnosis
risk factors for DIC in obstetric population
placental abruption gram-neg sepsis HELLP syndrome intrauterine death with retained fetus severe preeclampsia retained placenta amniotic fluid embolism (usually not able to be determined until autopsy) hemorrhagic shock transfusion reaction
Disseminated Intravascular Coagulation (DIC)
activation of coagulation sequence: thrombi throughout microcirculation
consumption of platelets and coagulation factors to sub-hemostatic levels
activation fibrinolysis
tissue hypoxia: microinfarcts
hemorrhage from (minor) trauma due to consumption/depletion of clotting factors and fibrinolysis destroying clots
DIC nursing responsibilities
monitor for bleeding (petechiae, oozing form injection sites, hematuria, and reposition frequently to assess for bleeding in dependent tissues)
monitor urinary output with with foley (usually rimester bag attached)
if still pregnant, place patient in side-lying position
oxygen if ordered 10-12 L/min
administer blood and blood products as ordered
patient and family education and emotional support
Blood Products:
fresh frozen plasma is used to replace low levels of coagulation factors caused by DIC
- platelets may also be given to restore low levels
- cryoprecipitate may also be used to correct low levels of fibrinogen
a phospholipid-protein extract of tissue (usually lung, brain, or placenta) that contains both the tissue factor and phospholipid necessary to promote activation of factor X by factor VII
thromboplastin
absolute insulin insufficiency
requires admin of exogenous insulin
T1 DM
an insulin resistance with varying degrees of insulin deficiency
T2 DM
risk factors: obesity aging sedentary lifestyle hypertension prior gestational diabetes
any degree of glucose intolerance with onset or recognition during pregnancy
gestational diabetes
White’s classification of GDM
based on age at diagnosis, duration of illness and presence of vascular disease
Gestational Diabetes:
- A1
- A2
Pregestational Diabetes:
- B
- C
Vascular Complications:
- D
- F
- R
- T
A-C = Generally GOOD pregnancy outcomes D-T = already have vascular damage of long-standing diabetes
effect of pregnancy on insulin requirements in 1st trimester
insulin production increased -> increased peripheral use of insulin -> results in decreased BG (hypoglycemia)
fetus siphons glucose from mother across placenta
N/V may-> drop in maternal blood glucose
human placental lactose (HPL) is secreted (this is an insulin antagonist)
insulin requirements in 2nd and 3rd trimesters
by the end of pregnancy, insulin requirements increase as much as 4x the usual amount of insulin
with expulsion of placenta -> abrupt drop of hormones and return to prepregnant state (insulin needs decrease)
maternal risks and complications
*more common with T1DM
worsening of pre-existing disease -> vascular problems -> retinopathy
hypoglycemia 1st half of pregnancy
hyperglycemia -> ketoacidosis 2-3rd trimester (high blood values)
preeclampsia and eclampsia
polyhydramnios in 10-20% od diabetic
(too much amniotic fluid = amniotic fluid index [AFI] > 24cm in all pools or more than 8cm in deepest vertical pool)
dystocia (shoulder)
baby pancreas produces own insulin by
10 weeks gestation
the fetal pancreas is secreting enough insulin to use the glucose from mom by about 10 weeks gestation
GDM effects on baby
macrosomia: poor glucose control r/t excess glucose from mom
- can cause baby to be large for gestational age (LGA) - baby greater than 4000 grams
IUGR r/t maternal vascular involvement - mom has poor control of glucose… up and down
delayed lung maturity -> RDS (respiratory distress syndrome)
hypoglycemia after birth
congenital anomalies
- neural tube defects
- skeletal defects (sacral agenesis)
screening and testing to r/o GDM
50 gram oral glucose tolerance test
3 hour oral glucose tolerance test
target blood glucose levels during pregnancy (not at testing)
FBS or fasting - 60-105 mg/dl
1 hr post meal - < 140 mg/dl
2 hr post meal - 60 mg/dl
3 hour 100 gram OGTT is more definitive than simple GTT
values of OGTT
FBS <95 mg/dl
1hr <180 mg/dl
2hr <155 mg/dl
3hr <140 mg/dl
management of DM during pregnancy
monitor glucose
diet
exercise
insulin therapy
Glycosylated hemoglobin
measure of control over previous 6 weeks
dietary management (GDM)
based on BG levels
goal is to minimize wide fluctuations of glucose levels in order to avoid hypo/hyperglycemia
euglycemia
- Normal Glucose
plasma glucose 60-105 (before meal) <140 (1hr after meal)
diet management: calories
2200 cal 1st trimester
2500 cal 2nd & 3rd trimester
- based on BMI
- 35 cal/kg/IBW/day (non-obese)
25/kg/IDW/day (obese) - 3 meals/day w/2-3 snacks
- CHO: no more than 55%
- regular meals: no skipping
- night snack with protein to prevent drop in blood glucose in the night
exercise (GDM)
monitored very closely
15-30 minutes walking 4-6x/week
snack of protein or complex CHO before exercise
monitor glucose before, during, and after exercise
insulin therapy (GDM)
2/3 days of insulin dose given at breakfast -> combination of intermediate or long-acting & short-acting insulin
1/3 of days insulin is given in the evening -> combination of long and short-acting insulin
less insulin needed in the 1st trimester
- more in the 2nd and 3rd
oral hypoglycemics seldom used during pregnancy
*significantly less insulin need after delivery -> precipitous drop after delivery of placental hormones
risk factors for hypoglycemia
too little food
too large insulin dose
stress
illness/V/D
exercise
symptoms of hypoglycemia
nervousness
HA
shaking irritable
hunger
blurred vision
diaphoresis
treatment of hypoglycemia
check blood glucose
< 70 mg/dL = eat or drink 15g simple CHO (hard candy or SL glucose paste/tabs)
rest x15min -> recheck glucose
if >70 mg/dL, eat a meal with protein to stabilize glucose level
notify caregiver if continues < 70 mg/dL
hyperglycemia
BG >130 mg/dL
ketones in urine (ketones cross placenta)
skin: dry and flushed
thirst with frequent urination
kussmaul respirations with fruity odor to breath (r/t ketones and acetonuria
- treatment = regular insulin as ordered
- evaluation = BG 80-120 mg/dL
DKA = medical emergency*
- excessive BG and ketone bodies result in osmotic diuresis with loss of fluids and electrolytes, volume depletion, and cellular dehydration
- can lead to fetal death
fetal surveillance (GDM)
MSAFP at 15-20 weeks gestation
US for anomalies, AF volume, fetal size
fetal ECG at 20-22 weeks (esp if poor control in early pregnancy)
biophysical profile
NST 1-2x weekly from 34 weeks gestation
FM (kick) daily from 28 weeks
Goal: prevent IUFD and max opportunity for van delivery
timing of delivery (metabolic/endocrine disorders)
optimal time = 38.5-40 weeks gestation
elective induction between 39-40 weeks
reasons for earlier delivery:
- poor metabolic control
- hypertensive disorder getting worse
- macrosomia
- IUGR
management of diabetes during labor and birth
- regular insulin infusing IVPB
- fluids and insulin titrated to maintain glucose <140 mg/dL
- hourly glucose checks
Second stage of labor:
- voluntary pushing requires energy -> glucose checks performed more frequently
- monitor for failure to progress (shoulder dystocia, CPD)
management of GDM postpartum
Insulin requirement decrease is dramatic with removal of placenta and insulin antagonists
Poor metabolic control can delay lactogenesis and milk production
Breast feeding helps stabilize diabetes
Maintain integrity of nipples and areola -> prevent risk of infection
(DM more prone to infection [mastitis/yeast infection] especially if poor glucose control)
DM: family planning
oral contraceptives are controversial r/t effect on carbohydrate metabolism and risk of thrombus
appropriate contraceptives:
- barrier methods
- IUD
IUD recommended without risk of infection
risk factors for GDM
family hx ethnic group maternal obesity previous LGA infant previous unexplained stillbirth
IDM
infant of diabetic mother
IDM hypoglycemia symptoms
jittery
tremors
hypotonia
unstable temperature
treatment for infant hypoglycemia
normal serum glucose = 40-60 mg/dL
routine heel sticks for glucose checks
early and frequent feeding of breast milk, formula, or D5W
NGT if poor feeding or RR is increased
concerned about neurologic injury as a result of severe or prolonged hypoglycemia
feed within 1hr of birth
- feed every 2-3 hours during 1st 24hrs
hyperemesis
severe vomiting of pregnancy that causes weight loss of at least 5% of pre pregnancy weight
accompanied by dehydration, electrolyte imbalance, nutritional deficiencies, and ketonuria
usually begins at 4 weeks and can last until 20 weeks of pregnancy
could be cause by increasing levels of estrogen, progesterone, & human chorionic gonatrophins (hCG)
hyperemesis etiology
possible causes:
- high levels of hCG or estrogen
- may be associated with hyperthyroidism during pregnancy
- esophageal reflux, reduces gastric motility, and decreased secretion of free hydrochloric acid
> Psychosocial Factors:
- ambivalence towards pregnancy
- increased stress
- conflicting feelings regarding motherhood
- body changes
- lifestyle alterations
hyperemesis clinical symptoms
- inability to retain even clear liquids
- significant weight loss >5%
- symptoms of dehydration (poor skin turgor, dry mucus membranes, decreased BP, increased pulse, concentrated urine, low output)
- symptoms of starvation (elevated BUN and ketonuria)
- electrolyte imbalance of Na, Cl, K+
hyperemesis fetal risk
- IUGR
- abnormal development (anomalies)
- death from lack of nutrition, hypoxia, or maternal ketoacidosis
ketoacidosis
accumulation of ketones in the blood from hyperglycemia that leads to metabolic acidosis
be very careful with Terbutaline & corticosteroids (can contribute to DKA)
assessment of client with hyperemesis
Subjective:
- intractable vomiting beyond 20 weeks
- weight loss
Signs of Dehydration:
- poor skin turgor
- dry mucosa
- concentrated urine
Signs of Electrolyte or Acid-Base Imbalance:
- fetid, fruity breath odor from metabolic acidosis
- ketones in urine
Signs of Starvation:
- muscle wasting
- jaundice
- bleeding gums (vitamin deficiency)
hyperemesis management
- IV fluid with glucose, electrolytes, and vitamins to replace fluids and imbalances
- NPO until dehydration resolved and vomiting has stopped for 48 hrs
- I&O (including emesis
- daily weights
- small, frequent meals (once 48hr/no emesis) [dry to wet, every 2-3hrs)
hyperemesis medications
Antiemetics (control N/V)
- vespirin or compazine
- phenergan
- zofran
- reglan
Nexium (purple pill) or Pepcid
Steroid Therapy
Enteral or parenteral nutrition
hyperemesis nutrition
NPO until vomiting subsides (48hrs)
slowly advance diet as tolerated
wet to dry diet
clear liquids, herbal teas, salty foods
avoid caffeine, carbonated beverages
avoid high fat, greasy, and highly seasoned foods
avoid liquids with meals
upright position x1-2 hours past eating
hyperemesis nursing interventions
- Emesis basin
- Provide oral hygiene
- Provide a quiet restful environment
- Cool, wet washcloths
maternal phenylketonuria
Inborn error of metabolism
absence impairs the body’s ability to metabolize phenylalanine found in all protein foods -> toxic accumulation of phenylalanine in the blood occurs which interferes with brain development and function
- Caused by deficiency in enzyme phenylalanine hydrolase
- Toxic accumulation of phenylalanine in blood interferes with brain development
- Dietary therapy for PKU is continues throughout life
- Lack of dietary compliance during pregnancy place infant as risk for microcephaly, mental retardation, and congenital heart defects
phenylketonuria (PKU) treatment during pregnancy
- Low protein diet (excludes meat, eggs, milk, and nuts)
- Maternal phenylalanine levels should remain between 2-6 mg/dL
- Breastfeeding discouraged r/t mild concentration of phenylalanine
Baby: phenylalanine-free formula
purposes of antenatal testing
- Determine fetal well-being
- Estimate growth and weeks gestation
- Predict outcome of pregnancy
high-risk pregnancy
pregnancy in which the life or health of the mother and/or fetus is jeopardized by a disorder coincidental with or unique to the pregnancy
- Discussing a high-risk pregnancy situation with a patient can be a very stressful time for the mother and her support system
Nurse needs to know about each antenatal test:
- Indications for the test
- Timing of the tests
- How the test is done
- Interpretation of test results
- Nursing care with each test
Daily Fetal Movement Count (Kick Count)
- Fetuses should be active unless asleep
- High risk mother: check fetal movements 2-3x/day for 30 min-1hr
- Low risk mothers: check fetal movements 1-2x/day for 30 min-1hr
- Should feel 5-6 fetal movements within each time frame (< 3 movements = do a NST, CST, &/or BPP)
- No fetal movement in 12hrs = fetal alarm signal
- Teach mother to call doctor if fetal movements get consistently decreased
- a reassuring sign for the mom
- 10 movements in 12 hours
- Great fetal wellbeing = fetal movement, well oxygenated fetus
Ultrasonography
ultrasound, sonogram
- Performed in clinic or hospital (special training)
- Safer than x-ray
Provides information:
- Gestational age
- Number of fetus
- Normal vs. abnormal fetal growth
- Fetal & placental anatomy/anomalies
- Fetal activity
- Uterine abnormalities
- Visual guide for some invasive processes
early ultrasounds = early diagnosis = allow parents to make decisions
therapy for the fetus, intrauterine surgery, termination of pregnancy, or preparation for the care of an infant with a disorder
Types of Ultrasound
Standard (Level 1) = fetal viability, gestational age, placental location, fetal anatomic structures for malformation, & AFV (amniotic fluid volume aka amniotic fluid index [AFI])
Limited (Level 2) = fetal presentation during labor, FHT when not able to obtain in other ways
Specialized (Level 3) = anatomically or physiologically abnormal fetus
methods of performing ultrasound
Abdominal:
- ultrasonic gel is placed on abdomen to transmit the sound waves as the transducer is moved across abdomen
- bladder must be full, especially in 1st and 2nd trimesters
- positioned sitting or reclining with wedge under hips
Transvaginal or Endovaginal:
- performed in lithotomy position
- also used to determine cervical length
- used frequently in the early weeks of pregnancy
> tilting the patient helps alleviate supine hypotension
due to placement of the uterus, the extra blood volume and the baby, she could have a supine hypotension reaction, such as dizziness, which can lead to fetal hypoxia
indications for ultrasound
Verify gestation age & due date (EDC)
- in 1st trimester, look at crown-rump length to determine age & fetal growth
- in 2nd trimester, look at biparietal diameter of fetal skull
- fetal length: from external condyle to trochanter of femur can indicate fetal age
- fetal growth
Locate position/placement of placenta
Check for ectopic pregnancy
Determine number of fetuses
Determine fetal status/viability/death
Determine fetal presentation
Amniotic fluid volume (AFV)
Measure cervical length in preterm labor
AFI (amniotic fluid index)
> 10 cm with normal in upper range 25 cm
< 5cm = oligo
>25 cm = poly
Non-Stress Test
Electronic Fetal Monitoring Tests
- Fetal Monitoring for 20-30 minutes
- Reactive or Nonreactive findings
> Reactive = normal FHR baseline with fetal movement (accelerations = fetal movement)
> Nonreactive = additional testing needed - Vibroacoustic stimulation = sound & vibration used to elicit a fetal response
AWHONN guidelines = 2 15x15 accelerations in 20 minutes in a 32-40wk gestation
1 10x10 accelerations in 1hr for 24-31.6wk gestation
Contraction Stress Test (CST)
or
Oxytocin Contraction Test (OCT)
FHR baseline for 10-20 minutes
Contractions started
- by nipple stimulation
- by IV Pitocin/Oxytocin
- 3 contractions in 10 minutes
- how fetus reacts to contractions
Findings are Negative, Positive, or Equivocal:
- No late decelerations = Negative CST/OCT
- Late decelerations = Positive CST/OCT
you want a negative test (baby not stressing from contractions)
Biophysical Profile
- Abdominal Ultraound
Measures:
Fetal breathing movements
- 1 movement that is 30 seconds in duration/30 minutes
Gross body movement
- at least 3 trunk/limb movements in 30 minutes
Fetal tone
- 1 episode of flexion & extension (includes hand)
Qualitative amniotic fluid volume
- AFI >5cm or at least 1 pocket >2cm
Reactive non-stress test (NST)
- 2 accelerations in 20 minutes
BPP: looking for a total score of 10
- Normal = score of 2/area
- Abnormal = 0
- Looking for 10:10 ratio
BATMAN: Breathing movements of the fetus Amniotic fluid volume Tone of the fetus And Nonstress test
Amniocentesis
- Ultrasound guided needle through abdomen into uterine cavity to obtain amniotic fluid for testing
- Done after 14 weeks gestation when uterus rises above the symphysis pubis and fluid amounts are adequate to get sample
Fluid shows:
Lecithin/syhingomyelin (L/S ratio) or shake test
- checks for fetal maturity
Alpha-fetoprotein
- used as screening tool for neural tube defects
Desquamated fecal cells
- allows for genetic testing
Timing of Amniocentesis
Early pregnancy - to detect chromosomal abnormalities
Late pregnancy - most often to determine fetal lung maturity with L/S ratio to detect the amount of surfactant production in fetal lungs
Ratio of 2:1 indicates fetal lung maturity
Surfactant is a substance that reduces the surface tension of pulmonary fluids to allow gas exchange in the alveoli
Complications of Amniocentesis
- Infection
- Injury to fetus
- Leakage of AF
- Pregnancy loss
- Maternal hemorrhage
- Rh Isoimmunization
- Amniotic fluid embolism
- Fetal death
RARE… prior to the test, families should be given info about indications for amnio, how the procedure is done, risks involved, and ramifications of the findings
- If the findings include something that may expedite delivery, then the pt has to deal with the decision to go along with the recommendations
- 0.1-0.3% change of miscarriage after amniocentesis
Amniocentesis nursing responsibilities
- Have mother empty bladder prior to procedure
- Monitor fetus before procedure and at least 1hr post
- Observe for vaginal bleeding, leakage of AF, severe cramping, or fever (teach)
- Mild physical discomfort; most women fear procedure
Chorionic Villus Sampling (CVS)
- Performed at 10-13 weeks of pregnancy
- Used to diagnose chromosomal and genetic defects
- Sample of blood and tissue is taken from the chorionic villi at edge of placenta
(the placenta can be accessed vaginally or abdominally [fetal portion of placenta]) - Cells from the villi have the same genetic make-up as the cells from the embryo
- Use has declined as noninvasive techniques have developed (maternal serum screens, ultrasound)
> Risks and benefits need to be discussed with patient and family prior to procedure (need informed consent)
advantages/disadvantages of CVS
Advantages:
- Can be done early in pregnancy 8-13 weeks
- Sample gives genetic makeup data
Disadvantages:
- Bleeding
- Rupture of amniotic membranes
- Intrauterine infection
- Spontaneous abortion
- Performed prior to 10 weeks gestation (has been associated with limb anomalies)
Percutaneous Umbilical Blood Sampling (PUBS)
Cordocentesis
- Direct access to fetal
circulation - Ultrasound guided withdrawal of blood (1-4mL) from a fetal umbilical blood vessel near its insertion into the placenta
- Blood tested for genetic information, fetal infection, acid-base status of fetus
- Kleihauer-Betke test = determines the presence of fetal to maternal bleeding (tests for fetal cells in maternal blood)
Treatment = transfuse the anemic or thrombocytopenia fetus in utero
PUBS complications
- Bleeding from puncture site
- Cord laceration
- Thromboembolism
- Preterm labor
- Premature ROM
- Infection
Follow-up: Continuous fetal monitoring and repeat ultrasound for bleeding or hematoma formation
Maternal Serum Alpha Fetoprotein (MSAFP)
- Maternal Serum Test
- Performed between 15-20 weeks
- Elevated levels are associated with open neural tube and abdominal wall defects
- US elevated levels to R/O fetal abnormalities or multiple gestation
Types of NTD = Spina Bifida & Anencephaly
Indirect Coomb’s Test
- Maternal Serum blood test used to screen for Rh incompatibility
- Titer > 1:8, other testing (like amniocentesis) is done to detect fetal hemolytic anemia
Pregnancy Test
Detect human chorionic gonadotropic (hCG)
- Urine (3-4 weeks) [accuracy depends on following instructions]
- Serum (8-10 days)
> Increase may indicate Down’s or multiples
Decrease may indicate ectopic or impending miscarriage
Presumptive
Probable
Positive
velvety appearance of cervix due to increased vascularity, hypertrophy, and hyperplasia of cervix
(softening of cervical tip in a normal, unscarred cervix)
around 6th week
Goodell Sign
violet-blue vaginal mucosa and cervix
Chadwick Sign
prenatal period
- Pregnancy lasts a little over 9 calendar months
- Lunar months (not calendar) used to determine fetal age
- Normal pregnancy lasts 10 lunar months (280 days, 40 weeks)
- 3 trimesters
physical changes associated with pregnancy
- Early changes are related to increase in estrogen and progesterone levels
- Mid-pregnancy changes (anatomical -> caused by pressure from the expanding uterus)
Physiological and anatomical changes develop in many organ systems during the course of pregnancy and delivery
uterine changes
uterus changes in:
- size
- shape
- position
Fundus height is an important measure of fetal wellbeing
- helps to estimate gestational age of fetus
- During 2nd & 3rd trimesters (18-30 wks) fundal height in cm approximately equals fetal age in weeks + 2cm
- 16 weeks halfway between symphysis pubis and umbilicus
- 20-22 weeks at approximately the umbilicus
Braxton Hick’s
Uterine contractions (UC) -> increase blood flow to uterus and strengthen muscles for birth process -> Braxton Hicks
- DO NOT cause cervical dilation
- Are often mistaken for early labor
- Sometimes perceived as painful, but usually are not
- May be felt as early as the 4th month (can cause urinary frequency)
softening and thinning of lower segment of uterus
about the 6th week - probable sign of pregnancy
Hegar’s Sign
fundal height decreases as fetus descends into the pelvis in preparation for delivery (38-40 weeks)
Lightening
passive movement of the fetus
Ballottement
- technique of palpating a floating structure by bouncing it gently and feeling it rebound
Examiner taps cervix gently and palpates fetal rebound in the amniotic fluid
examiner taps on cervix - fetus rises -> may feel abdomen… then sinks and examiner feels a gentle tap on the finger
- usually present about 16 weeks gestation
maternal observation of fetal movement
Quickening
18-20 weeks gestation = nulliparous
14-16 weeks = multiparous
seals endocervical canal -> prevents ascent of bacteria from vagina to the uterus
mucus plug (operculum)
- expulsion of plug may be first sign of labor
white or slightly gray mucoid vaginal discharge that occurs in response to cervical stimulation by estrogen & progesterone
leukorrhea
vaginal changes
pH of vaginal vault 3.5 -> acidic
Vaginal secretions increased (leukorrhea)
Screening - evaluate for pathology and presence of STDs
- Gonorrhea & Chlamydia -> risk of corneal scarring of infant during vaginal birth
- HSV -> organism may cross placenta and contaminate fetus or during vaginal delivery
(active HSV = always a C/S
most common cause of ophthalmia neonatorum
chlamydia
environmental substances or exposures that result in functional or structural disability
teratogenic
breast changes
- Colostrum - may leak from nipple (precursor to milk - yellow in color)
- this usually happens after delivery but can start before
- high in protein and immune properties (liquid gold)
- Breast size increases -> nipples and areola may darken
- glands increase in both size and number
- May have striae gravidarum (stretch marks)
- Superficial veins become prominent
what hormone causes production of milk
PROLACTIN
Estrogen & Prolactin have an INVERSE relationship
- when placenta delivered, prolactin becomes dominant
Oxytocin responsible for milk letdown
CV system changes: Blood Volume
- Expansion of vascular volume up to 45-50%
- Peaks 32-34th week
(Volume peaks in the 3rd trimester) - Increase in vascular volume (50%) -> increase in RBCs (30%) -> hemodilution -> pseuoanemia of pregnancy
- hgb below 11g/dL usually caused by iron deficiency anemia
- folic acid and iron supplements to meet demands of increased blood supply and fetus
- 32nd-34th weeks most vulnerable time for pregnant cardiac client
CV changes: Cardiac Output
- CO increases 30-50% (peaking at 25-30 weeks)
- Affected by maternal position -> Vena cava syndrome aka supine hypotensive syndrome
- More than 95% of pregnant women develop systolic murmurs: check left sternal border (may hear splitting s1, s2 then halfway through may hear s3 due to rapid diastolic filling)
murmurs caused by the increases in blood volume and cardiac output
CV changes: BP
- BP does NOT increase during pregnancy: progesterone, prostaglandins, & relaxin effect
- may even decrease during 2nd trimester
- BP 140/90 is a danger signal of pregnancy
- Absolute value determination of gestational hypertension
- Watch the MAP when HTN
Absolutes for Preeclampsia
140/90 mmHg OR
systolic elevated 30 mmHg over baseline and diastolic elevated 15 mmHg over baseline
if you see this, start looking for protein in the urine
- Preeclampsia is a progressive disease of pregnancy
- No one knows the exact cause
Clotting Factors Increased
- Fibrinogen
- Clotting Factors VII, VIII, IX, X
- Risk for blood clots
Pregnant women hypercoagulable state
Respiratory System Changes
- Oxygen consumption increased by 20-40%
- Diaphragm elevated by enlarging uterus -> thoracic cage widens to compensate so vital capacity same
- diaphragm excursions are greater during breathing in pregnancy
- Breathing changes from thoracic (abdominal) to diaphragmatic (chest)
- May complain of SOB or even dyspnea
- Pregnancy is a state of alkalosis
> hyperventilation -> decreased CO2 levels -> alkalosis - Increased chest circumference
- Respiratory rate unchanged or increased only slightly
Pulmonary Congestion
- Increased vascularity of upper respiratory tract -> engorgement and edema of mucosa (nose, oropharynx, larynx, and trachea)
- Symptomatic nasal congestion
- Epistaxis is common (nosebleeds)
- nose may widen at the base to allow for better O2 consumption and ventilation
Basal Metabolism and Acid-Base Balance
- Basal metabolism rate increases 10-20% by term
- Increase in O2 demand of the uterine-placental-fetal unit
- Acid-base balance = respiratory alkalosis compensated by mild metabolic acidosis
- Breathing pattern of hyperventilation blowing off CO2 -> alkalosis
Renal system changes
Urinary frequency in 1st trimester and again in 3rd trimester r/t lightening
High risk for UTI (symptomatic or asymptomatic)
- Dilated ureters and renal pelvis
- Relaxed tone -> increased capacity -> stasis of urine
UTI correlated to premature labor
(Symptoms of UTI: frequency with urgency, dysuria, hematuria)
Glycosuria (high sugar content) occurs at <160 mg/dL in pregnant clients (this is lower than non-pregnant clients)
- Perfect place for infections to occur (bacteria loves sugary, warm, dark, wet places - vagina and ureter)
*All pregnant clients are screened for GDM at 24-28 weeks gestation (high risk tested earlier)
Proteinuria
UA at each clinic visit
Cardinal Signs of Preeclampsia:
- Proteinuria
- Edema
- Elevated BP
- HA or dizziness
- Blurred vision
Renal Teaching
Report symptoms of UTI (especially urgency)
Importance of screening for GDM
Side-lying position improves urinary output and helps decrease edema
Supine position compromises renal, cardiac, and uterine flow
Skin changes
Linea nigra Striae gravidarum Chloasma r/t estrogen Palmar erythema Hypertrophy of gums
facial pigmentation
Chloasma
a darkly pigmented line from the umbilicus to the pubic area
linea nigra
stretch marks on trunk and thighs r/t stretching of connective tissues
striae gravidarum
darker red palms r/t hyperemia
palmar erythema
Musculoskeletal Changes
Postural and Gait Changes:
- Lumbar lordosis as center of gravity shifted forward
- lumbar and dorsal curves accentuated -> results in low back pain
- Typical “waddling gait” as Relaxin hormone relaxes pelvic points
Pubic symphysis & sacroiliac joints loosen due to relaxin to allow passage of baby
Muscle cramps or tetany r/t hypocalcemia (or hypokalemia, hypomagnesia)
Teach client correct exercises for cramps
Neurologic Changes
Changes in sensorium (light-headed or dizzy)
- r/o postural hypotension/hypoglycemia
Carpal tunnel, edema, compression of median nerve in wrist
Lordosis (back sway) - can cause pain because of traction on the nerves and compression of nerve roots
Hypocalcemia can cause cramps and tetany
Pain - related to nerve compression
GI changes
Ptyalism (excessive salivation)
- check for starchy food consumption or nausea
N/V
- early subjective sign of pregnancy
- may be related to hormonal changes
- subsides past 1st trimester
R/O hyperemesis agravidarum if persists longer than 1st trimester
Pyrosis (heartburn) common -> increased progesterone causes decreased tone and motility of smooth muscles resulting in reflux, slower stomach emptying time, and reverse peristalsis (also can cause constipation)
Hemorrhoids r/t constipation and increased secretion of cholesterol may predispose to gallstones
Pica
Pulmonary aspiration of gastric contents can occur following vomiting or regurgitation
Human Chorionic Gonadotropin (hCG)
maintains corpus luteum production of estrogen and progesterone until placenta takes over
progesterone
- Decreases secretion of FSH/LH
- Maintains pregnancy by relaxing smooth muscle
- Decreases uterine contractility
- Increases fat deposits in subcutaneous tissue over the abdomen, back, and upper thighs
- Decreases ability to use insulin
estrogen
- Decreases secretion of FSH/LH
- Increases fat deposits in subcutaneous tissue over the abdomen, back, and upper thighs
- Increases size of genitals, uterus, and breasts
- Increases vascularity
- Relaxes pelvic ligaments and joints
- Interferes with folic acid metabolism
- Increases total body proteins
- Increases retention of sodium and water
- Decreases maternal use of insulin
Prolactin
prepares breasts for lactation
Oxytocin
- Stimulates uterine contractions
- Stimulates milk ejection from breasts
Human Chorionic Somatomammotropin (hCS)
- Acts as a growth hormone
- Contributes to breast development
- Decreases metabolism of glucose
- Increases fatty acids for metabolic needs
Insulin
- Increased production of insulin to compensate for insulin antagonists caused by placental hormones
(insulin antagonists decrease tissue sensitivity to insulin or ability to use it)
Cortisol
Increases production of insulin
Increases peripheral resistance to insulin
Maternal nutritional recommendations
Weight Gain (total = 25-35lbs)
- 2 to 4 lbs (1st trimester)
- 1 lb/week (2nd & 3rd trimester)
Adequate fluid intake (3L/day)
- 8-10 glasses/day
- 4-6 glasses should be water
Increase caloric intake by 300 calories per day
- Breastfeeding = 450-500 calories per day
Increase Vitamin A, C , & folate (0.4mg daily when pregnant)
Take prenatal vitamins & supplemental iron as prescribed.
Avoid constipation by eating raw fruits, vegetables, cereals, and bran
Avoid heartburn by eating small, frequent meals, avoiding fatty foods, avoid lying down after meals, & carbonated soda
Avoid alcohol/tobacco
Limit caffeine
Avoid certain foods
Maternal weight gain
Based on pre-pregnancy weight
Underweight:
- Preterm labor
- LBW
- IUGR
Overweight:
- Macrosomia & Cephalopelvic Disproportion (CPD)
- Operative Vaginal Birth & Emergency Cesarean Section
- Postpartum Hemorrhage
- Infection (wound, genital tract, urinary tract)
- Birth Trauma
- Late Fetal Death
- Preeclampsia
- Gestational Diabetes
the intentional prevention of pregnancy during sexual intercourse
contraception
the device or practice used to decrease risk of conceiving
Birth Control
*most birth control methods do NOT prevent STIs
general concepts of contraception
- dealing with an individual’s personal beliefs and values
- method must be suited to individual
- individuals must be motivated to succeed
Contraception: Nursing Role
- Education of client in available methods of contraception, their effectiveness, and side effects
- Help clients explore feelings as to what is acceptable and what is not
- Thorough explanation of how method works, any potential complications or SE
BRAIDED mnemonic for documentation of informed consent regarding education of the patient concerning contraception and sterilization
Benefits: information about the advantages and success rates
Risks: information about disadvantages and failure rates
Alternatives: information about other available methods
Inquires: opportunities to ask questions
Decisions: opportunity to decide or to change mind
Explanations: information about method and how it’s used
Documentation: information given and patient’s understanding
contraception: information to assist with decision making
- Medical and OB history
- Age
- Parity
- Religion
- Educational level
- Socioeconomic status
- Smoking habits
- Comfort with touching one’s body
- Frequency of sexual activity
- Number of partners
Non-pharmacological methods of contraception
- fertility awareness methods
- barrier methods
- diaphragm
- female and male sterilization by tubal ligation or vasectomy
Fertility Awareness (contraception)
- Based on understanding of menstrual cycle and ovulation
- Ovulation occurs 14 +/- 2 days before the onset of menses
- Egg (ova) life is approximately 16-24 hours
- Sperm life 48-72 hours, however the ability to fertilize ovum probably lasts longer than 24-48hrs
- No cost involved
- No side effects
Fertility Awareness Methods
Calendar (rhythm) method or Standard Days Method
- may use cyclebeads necklace to help determine days
- patient instructed to abstain from intercourse during the estimated fertility period (8-19 days, watching the white beads)
- must have regular cycles
- Count from 1st day of menses, number of days before next cycle
- Do for a minimum of 6 months
- Shortest cycle was 24 days less 18 equal the 6th day
- Longest cycle was 30 days less 11 equal the 19th day
- Couple would abstain from days 6-19 to prevent pregnancy
Cervical Mucus (billings) Method
Evaluate changes in cervical mucus changes in:
- Spinnbarkeit (stretch) and slippery
- Clearness
- Change in pH to alkaline (not available to patient)
- Ferning (on microscope slide - not available to patient)
Abstinence during fertile period when cervical mucus is wet, clear, and stretchable
Patient needs to be comfortable touching own body to be successful with this method
Cervical mucous changes throughout the menstrual cycle
Postmenstrual: scant
Preovulation: cloudy, yellow, or white and sticky
Ovulation: clear, wet, sticky, slippery
Post ovulation fertile mucus: thick, cloudy, sticky
Post ovulation, post fertile: scant
Spinnbarkeit: right before ovulation, the mucus is thin, clear, and thick and can be stretched 5+ cm between thumb and forefinger = maximum fertility
- sperm can survive in this setting
Basal Body Temperature (BBT)
- Measures body temp every am before ANY activity
- Record on graph
- Drop in temperature prior to ovulation and an increase in temperature after ovulation occurs
- Abstain from intercourse for several day before the expected time of ovulation and for 3 days afterward (remember viability of sperm)
Sympthothermal or Combination Method
Combines BBT and Cervical Mucous methods
Evaluates and records:
- cycle days
- cervical mucus changes
- increased libido
- Mittleschmerz (mid-cycle pain)
- basal body temp
Abstinence for several days before and 3 days after ovulation
Male and female condoms
- Used in conjunction with spermicidal foam to increase effectiveness
- Recommended to prevent STDs for couples not in long-standing, mutually monogamous relationships
Spermicides alone are not effective when a highly reliable contraceptive method is sought
(work by reducing sperm motility)
Diaphragm
Round, flexible device that covers the cervix
Must be fitted for size by HCP
Inserted into the vagina up to 6hrs before intercourse
Used with spermicidal jelly or cream
Must remain in place for 6-8hrs after intercourse
Increase risk for UTI
Return to HCP for size refitting if weight fluctuates up or down
Does NOT prevent STD
Must be washed after each use with mild soap and water then dried and kept away from heat in order to keep the integrity
Cervical cap is like a diaphragm, but smaller and can at time shift from cervical os
Contraceptive sponge, not used as much = contained N9 spermicide that destroys the sperm cell membrane
- moistened before insertion
- good for 24hr
- wearing >24-30hrs could cause TSS
Pharmacological Methods of Contraception
- Oral contraceptive pills
- Contraceptive Transdermal (skin) patch
- Vaginal ring
- Single rod implant
- Depo-Provera
- Intrauterine devide (IUD)
- Emergency contraception
Oral Contraceptive Pill
- Combination of estrogen and progestin
a. Monophasic - fixed doses
b. Multiphasic - alter the amount of progestin and sometimes the amount of estrogen within each cycle - Progestin only (mini-pill)
a. Cervical mucus remains thick and does not provide a suitable environment for sperm penetration
The body secretes follicle-stimulating (FSH) and LH in response to fluctuating levels of ovarian estrogen and progesterone. Ingesting suppresses the action of the hypothalamus and anterior pituitary that inhibits the production of FHS and LH, therefore follicles do not mature, suppressing ovulation. Yearly exams are needed in order to continue receiving prescriptions for oral contraceptives. Women should be aware that some over the counter meds and herbal supplements can sometimes affect oral contraceptives. There are also some prescribed medications that should not be taken at the same time with oral contraceptives (see pg. 155)
Oral contraception should be taken at the same time daily
SE of Hormonal Contraceptives
Contraindications
- Breakthrough bleeding
- H/A
- Nausea
- Breast tenderness
- Acne
- Depression
- Fatigue
- Weight gain
Serious:
- Stroke
- MI
- Thromboembolism
- Hypertension
- Gallbladder Disease
- Liver tumors
ACHES: serious SE
Abdominal pain = liver or gallbladder
Chest pain or SOB = possible clot in lungs or heart
Headache (severe) = HTN or CVA
Eye problems (loss, blurred, dizziness) = HTN or CVA
Severe leg pain or swelling = thromboembolic process
Contraceptive Transdermal Patch
- Contains a combination of estrogen and progestin
- Patch placed on abdomen, buttocks, upper outer arm, or torso (but NOT breast)
- Replaced each week for 3 weeks
- Not used for 1wk for menstruation
- 28 day cycle repeated
Vaginal Ring
- Small, flexible ring inserted deep into the vagina for 3 out of every 4 weeks
- A new ring is used for each 4week cycle
- Delivers continuous levels of progestin & ethinyl estradiol
Single Rod Implant
- Synthetic progestin is released to prevent ovulation for about 3 years (then must be removed)
- Can be inserted under the skin of the upper inner arm
Depo-Provera
- IM injection containing synthetic progesterone 150 mg
- Given every 11-13 weeks (must be given during the 1st 5 days of menstrual cycle)
- Suppresses ovulation and produces thick cervical mucus that decreases sperm motility
- Effective, convenient, inexpensive, compared to other methods
- Menstrual bleeding is diminished or absent
- May be a delay in fertility for up to 18 months when discontinued
Intrauterine Device (IUD)
- Contains copper or progesterone and is inserted into the uterus by HCP
- String protrudes from vagina
- Provides continuous protection, so compliance is not an issue
Side Effects:
- Irregular menstrual cycles
- Increased bleeding and cramping during menstruation
PAINS: serious SE
P = period late, abnormal, spotting, or bleeding
A = abdominal pain; pain during intercourse
I = infection exposure; STDs
N = not feeling well; fever and chills
S = string missing, shorter, or longer
Good for 3-5 years
Not recommended for women who have not had children
Not recommended for women with hx of PID
If pregnancy occurs with IUD in place, increased risk for miscarriage and premature labor
Emergency contraception after unprotected intercourse
Insertion of copper IUD
Ingestion of high-dose progesterone-only pills (Plan B)
- can be bought OTC
- take ASAP but within 72hrs
Ingestion of high dose combination or oral contraceptive pills
Vasectomy
- Male sterilization procedure
- Vas deferent cut or cauterized
- Sterility achieved after numerous ejaculations has cleared the ducts
- Sperm count needed to determine effectiveness
- Should be considered permanent (although sometimes successfully reversed)
Important to go for follow-up visit
Bilateral Tubal Ligation
Surgical procedure in which both fallopian tubes are ties, cut, or blocked in order to prevent conception
- May be done in the immediate postpartum period because of access to Fallopian tubes
- Does not affect hormonal levels or sexuality
Diagnosis of Pregnancy
Pregnancy suspected when client misses a menstrual period
Human chorionic gonadotropin (hCG) = earliest biochemical marker for pregnancy
- Pregnancy tests based on recognition of hCG
Psychological Adaptation to Pregnancy: Task 1
Accepting the fact of pregnancy
Ambivalence - normal response
Denial - especially adolescents
Seeks validation of pregnancy
Ambivalence usually resolved 1st trimester
- If it persists, may need intervention to help client deal with unresolved conflicts r/t motherhood
Psychological Adaptation to Pregnancy: Task 2 (Relationship with Fetus)
To incorporate baby into self-image
- Accept the pregnancy (quickening helps)
- Focused on self in 1st trimester (not baby)
- Reordering of personal relationships (especially mom)
Fetal Distinction
- Accepts baby as separate from self (usually 2nd trimester)
Preparation for birth and parenting roll
- “Nesting” behaviors
Pregnancy Initial Assessment
Reason for seeking care
Current pregnancy (signs)
Reproductive history
- Details of previous pregnancies
- Contraceptive history
- STD history
Review of systems
1st trimester
1-13 weeks
2nd trimester
14-26 weeks
3rd trimester
27-40 weeks
what pelvic shape do you want to see
gynecoid (can’t tell by appearance)
pelvic shape: well rounded inlet, wide pubic arch
Gynecoid
pelvic shape: narrow, especially lower dimensions
android
pelvic shape: narrow transverse diameter
anthropoid
pelvic shape: pelvis flattened, AP shallow
platypelloid
why are pelvic measurements important
to ensure adequacy for delivery
abdominal examination setup
bladder empty
small pillow to tilt to one side
measure height of funds
reasons for variation in fundal height
IUGR - funds < than expected r/t dates
Macrosomia > than expected
Multiple pregnancy
Tumor
Hydatidiform mole
Fetal anomaly or fetal demise
Transverse lie
Prenatal Visit Schedule
- 1st visit should be within the 1st 12 weeks or earlier
- 16-28 weeks = q4weeks
- 29-36 weeks = q2weeks
- 36 weeks until term = q1week
- post term - 2x/week with fetal monitoring
Supine Hypotension
As pregnancy advances, the weight of the uterus presses on abdominal vessels (vena cava & aorta) causing low blood pressure
Symptoms:
- Pallor
- Dizziness
- Increased HR
- Nausea
- Skin damp, cool, sweating
Interventions:
- Position on side until symptoms subside and VS stable
- left side to roll off vena cava (increase perfusion to uterus, placenta, & fetus)
Determination of Gestational Age
Dates -> size of uterus consistent with date
Auscultation of FHT
- US doppler at 10-12 weeks gestation
- Fetoscope (bone conduction) 18-20 weeks
Date of Quickening (fetal movement [butterflies])
- Leopold’s maneuvers for position
US exam -> measure BPD (size of head)
Warning signs during pregnancy
1st Trimester:
- Severe vomiting
- Chills, fever
- Dysuria
- Diarrhea
- Abdominal cramping
- Vaginal bleeding
2nd & 3rd Trimester:
- Persistent, severe vomiting
- Sudden discharge of fluid from vagina < 37wks
- Vaginal bleeding, severe abdominal pain
- Severe backache/flank pain
- Change in fetal movements
- Contractions; pressure; cramping < 37 wks.
- Visual disturbances: blurring/double vision/spots
- Face/fingers/sacrum swelling
- Headaches; severe/frequent or continuous
- Muscular irritability or convulsions
- Epigastric/Abd pain (heartburn/severe stomachache)
- Glycosuria, + GTT reaction
- UTI can cause preterm labor
- If she is having vaginal bleeding (vaginal previa – placenta) do NOT put fingers in vagina because the placenta is over laying or has pulled away from the wall and you can rupture the placenta
- Always do a history on your patient
- Epigastric pain = hypertension so long it caused liver failure
Danger Signals of Pregnancy
Normal fetal heartrate = 110-160
- Babies can have a heart attack in utero
Variable d cells – cord compression
signs of potential complications
Discharge of fluid from vagina before 37 w
Vaginal bleeding
Severe abdominal pain
Change in FM
UC…pressure and/or cramping
before 37 wks
Visual disturbances
Edema…swelling of face, fingers, sacrum
HA
Muscular Irritability
Epigastric or abdominal pain
Glycosuria
safe level of alcohol during pregnancy
NO safe level has been established (including social drinks)
true labor
regular UC and cervical dilation
Braxton Hicks
irregular UC and no cervical dilation
PTL instructions
If no regular contraction pattern is established and ROM has not occurred:
- Empty bladder (full bladder can cause contractions)
- Drink 2-3 glasses water or juice
- Rest on left side x1hr
- Palpate for UC (teach)
- If symptoms persist, call or go to doctor
Adolescent Pregnant Client
Growth & Development needs as well as support growth of fetus
Social needs override prenatal care
Denial and late entry into health care
Complications common (PIH, IUGR) - body is not developed enough to support birth
you do not let someone push until their cervix is 10 cm (before could cause cervical rupture, which can cause them to bleed to death)
- a child’s body is not ready to ever have a 10cm cervix
Aged Pregnant Client
Over 35 more likely to experience GDM
Vascular problems are more common (e.g., HTN)
Chromosomal changes
Increase risk for miscarriages, stillbirth, placenta prevue, placenta abruption, and c/section
Multifetal Pregnancy
Increased risk for mom and baby
Anemia r/t fetal demand for iron
More frequent prenatal visits and U/S
Nutritional demands
Placenta previa
Premature labor and birth
Ethical dilemmas
- selective reduction if more than 3 fetus
1 fetus = 50% more blood volume (increases with each fetus)
Lamaze
relaxation
