Exam 2 Flashcards
How do you know when baby is done feeding
Breast is soft
Breast produces right amount for growth state infant is in
How to tell if newborn has been sufficiently fed
Might nod off, calm, not irritable, will stop crying
How big is newborn’s stomach on day 1
5-7 ml
Newborn stomach size on day 3
23-27ml
Positive signs of labor
Fetal movement by examiner
Fetal heart sounds
Visualization of Fetus by US
Probable signs of labor
Fetal outline by examiner Breast changes Positive test Abdominal and uterine enlargement Chadwick’s sign - blueish cervix Goodell’s sign Ballotement Braxton Hicks Skin pigmentation Hagor’s sign
Presumptive signs of labor (from mom’s perspective)
N/V (morning sickness) Fatigue Amenorrhea (absence of period) Urinary frequency Quickening (flutter feeling - could be gas) Breast changes
Chadwick’s sign
Blue cervix
Goodell’s sign
Softening of the cervix
Hegor sign
Softening of the uterus
Ballottement
Tap and fetus gets bumped to top of cervix and comes back down
how much weight do newborn’s lose after birth?
5-10%
when do newborns regain their weight ?
10-14 days after birth
when can babies start having solids
6 mons to avoid food allergies
T/F: length is a better measure of growth
True - grow 2.5 cm per month in the first 6 months
what does skin to skin do for breastfeeding?
mom releases oxytocin faster
promotes milk production
promotes uterine involution
more demand, the more mom supplies
when should breastfeeding start?
w/i 30 mins of birth to take advantage of alert stage
LATCH Assessment
L - latch - too sleepy, repeated attempts, lips flared/rhythmic sucking
A- audible swallowing - non, a few, spontaneous/intermittent/frequent
T - type of nipple.- inverted, flat, everts after stimulation
C - comfort - engorged/severe pain, filling/red, soft/non tender
H- hold - full assist, minimal assist, no assist
how often should moms feed
every 2-3 hours during the day and every 4 hours at night
15-20 mins on each breast
must empty breast to avoid plugged ducts
stages of human milk
colostrum = days 1-2
transitional milk - day 3
mature milk by day 14
engorgement
when breast is too full - want to make sure breast is emptying to avoid
T/F: preemie milk is fattier
True
immunologic advantages of breastmilk
IgA antibodies
non allergenic
colonizes infant gut with proper bacteria
nutritional advantages of breastmilk
whey high concentration of cholesterol and balance of amino acids promote myelination and neuro dev minerals iron - more readily absobred self regulated eating less ear infections
psychosocial advantages of breastfeeding
provides more frequent direct skin contact b/w mother and infant
maternal benefits of breastfeeding
lowers risk of breast and ovarian cancer
less osteoporosis
faster involution of uterus and pre pregnancy weight
other newborn benefits of breastfeeding
increases o2 saturation
maintains temp regulation
decreases SIDs
reduction in cancer, asthma, dermatitis, type 1 and 2 diabetes
contraindications of breastfeeding
fetal galactosemia
mastectomy/breast enlargement
HIV
cytomegalovirus, active TB, varicella, human T cell lymphotropic virus type I and II
maternal medications (chemo, illegal drugs, radiation therapies, antiretrovirals)
common breast feeding positions
cradle hold
cross cradle
football hold
side lying hold
steps in breastfeeding
massage breast
tap lower lip of baby to open mouth
scoop mouth over nipple
problems in breastfeeding
nipple soreness - check latch/position cracked nipples - check latch flat or inverted nipples - address latch engorgement - pain control, emptying inadequate/excessive let down plugged dugs - patience/feeding mastitis - medical intervention
how to prevent breast milk from coming in
ice packs, cabbage leaves, avoid stimulation (tight fitting bra and no hot water)
how to know if newborn baby has had enough
weight loss should not exceed 10%
birthweight should return in a few weeks
fontanelles should be flat, skin should not be dry
stools shouldn’t be hard
T/F: you should wake an infant up to feed
true
how to store fresh breastmilk
4-6 hours at room temp
8 days in the fridge
3-4 months in the freezer
if thawed, good for 24 hrs in the fridge
how to store formula
24-48 hours in the fridge
do not freeze
T/F: if the milk is in contact with the baby during the feed, you can reuse
False! Finish feed within 1 hour and discard
recommended weight gain for BMI 18.5 - 24.9
25-35 pounds
2.2-4.4 in first trimester
1 pound per week in the last trimester
recommended weight gain for BMI less than 18.5
28-40 lbs
recommended weight gain for BMI 25-29.9
15-25 pounds
recommended weight gain for BMI 30 and above
11-20 lbs
calorie requirements during pregnancy
no change during first trimester
300 cals extra during 2nd and 3rd trimester
carb requirements for pregnancy
increase during 2nd and 3rd timester
protein requirements for pregnancy
71 g compared to 46 g for nonpregnant women
how many servings of Ca a day in pregnancy?
4 servings
what do you have increased need for when it comes to nutrition
Mg, Zn, Selenium
Vit A and C
Thimaine, riboflavin, niacin, folate, B6, B12
iron
risk factors associated with iron deficiency anemia
low birth weight, increases risk of preterm birth, inadequate fetal brain development, maternal and infant mortality
daily supplement of iron 30 mg
why is folate important during preg
associated with neural tube defects 3-4 weeks after conception
fresh green veggies, liver, peanuts and fortified foods
400 mcg should be taken daily
how much water should a pregnant woman drink per day
at least 8-12 glasses of fluid a day
4-6 should be water
what should a pregnant woman not consume
energy drinks mercury raw or undercooked eggs soft cheeses alcohol
complications of pregnancy
nausea
constipation (can come from iron)
PICA
PKU
what to avoid to avoid nausea
caffeine, fats, spices, triggers
avoid fluid with meals
PICA
craving/consumption of non food substances
associated with iron deficiency, poor or excessive weight gain, fecal impaction, lead poisoning, decreased infant head circumference, low birth weight
impacts 11-16% of women
PKU
genetic disease
linked to developmental delays and behavioral problems
should resume PKU diet (low in protein) at least 3 months before pregnancy and continue through
PP nutrition recommendations
weight loss of 10-12 pounds
high fluid intake
PP nutrition for breastfeeding moms
adequate caloric intake (330 for first 6 mos, 400 for second 6 months)
no caffeine or alcohol
increased protein
calcium
hormones of the repro cycle
GnRH FSH LH estrogen progesterone
when does ovulation occur
just after decline of estrogen
how long is the follicular phase
varies in women
1-14 days
how long is the luteal phase
always 14 days - fixed
days 15-28
ovulation to menses
where does fertilization occur
outer third of the fallopian tube = ampulla
what happens to the egg if it is fertilized (what does it secrete first)
secretes hCG - maintains progesterone levels until the placenta takes over
OTC pregnancy tests detect…
hCG
99% accurate
what can high levels of hCG indicate
multifetal pregnancy
ectopic pregnancy
hydatidiform mole
genetic abnormality (like Down’s)
what can low levels of hCG indicate
miscarriage
stages of lacerations
first degree - small tear
second degree - involves underlying muscles
third degree - involves anal sphincter
fourth degree - extends to rectum
t/f: episiotomy is evidenced based
false
disadvantages of episitomy
blood loss, infection, pain, discomfort, major perineal trauma, sexual dysfunction
does the vagina go back to pre pregnancy state
not necessarily
do vaginal secretions increase or decrease during pregnancy
increase
what is covered in the first antepartum appt
current pregnancy - how? past pregnancies gyno history - abnormal paps, issues/ovaries current and past medical history pertinent histories - birth father's maternal assessment fetal assessment education job/occupation
nagele’s rule
add 7 days to LMP and subtract 3 months
is fundal height measurement a good indication of how far along
no but b/w 18-32 weeks can be + or - 2 cm
abortion
before 20 weeks
stillbirth
demise/loss after 20 weeks
preterm
after 20 weeks, before 36.6
early term
37.0 to 38.6 weeks
full term
39.0 to 40.6 weeks
late term
41.0 weeks to 41.6
post term
more than 42.0 weeks
GTPAL
gravidity = all pregnancies including current term = births beyond 37.0 weeks preterm = births b/w 20.0 and 36.6 weeks abortion = before 20.0 weeks living = number of living children
gyno history questions
pap smear history previous infections? surgery? infertility or dysmenorrhea? contraceptives
current medical history questions
immunizations all medications/drugs infections/illnesses/chronic diseases weight and nutrition activity eye and dental exams
past and family medical history
hospitalizations, accidents
blood transfusion history
presence of chronic illness or diseases in immediate family
history of multiple births, congenital diseases
mental illness
c-sections
pertinent history
genetic religious/cultural occupational birth father social history
prenatal visit frequency
monthly for 7 months
every 2 weeks during 8th month
every week during last month
education during pregnancy
avoid all OTC meds and supplements avoid alcohol, tobacco, substance use, raw fish, soft cheeses flu vaccine genetic testing exposure to hazardous materials exercise avoid hot tubs or saunas 2-3L of water every day
common discomforts of 1st trimester
N/V breast tenderness nose bleeds urinary frequency UTIs fatigue ptylaism - increased saliva increased vaginal discharge
what labs should you have done during first trimester
rubella, CBC, hep B titer, blood type
common discomforts during 2nd trimester
UTIs heartburn constipation/hemorrhoids backaches varicosities, edema braxton hicks supine hypotension
education during 2nd trimester
breastfeeding lifestyle - sex, rest, relaxation, can lose balance complications fetal growth and dev birth methods/birth plan
3rd trimester education
childbirth prep
use back pillows to prop to side
common discomforts of 3rd trimester
UTIs, urinary frequency fatigue heartburn constipation/hemorrhoids backaches SOB leg cramps, edema, varicosities braxton hicks supine hypotension
t/f: pregnant women and close friends/family should get the tdap vaccine
true
will reduce cases by 33%, hospitalizations by 38%, deaths by 49%
Antepartum danger signs
Abdominal pain
High fever above 38.3 (101F)
Vaginal bleeding
Decreased or absent fetal movement
Epigastric pain (RUQ) —> associated with preeclampsia, associated with liver
Sudden gush of fluid
Persistent vomiting
Blurred vision/dizziness (any visual changes) - sign of HBP/preeclampsia
Painful urination - dysuria
Swelling of hands and face
Severe/persistent headache that doesn’t go away with tylenol
Prenatal Head Assessment
- headache, dizziness, visual changes
- rhinitis/nose bleeds (d/t increased estrogen)
- hypertrophy of gingival tissue (d/t increased estrogen)
- neck nodes (d/t increased estrogen)
- slight hyperplasia of thyroid by third month (d/t increased estrogen)
- nutrition
- increased fluids —> decreased dehydration can cause contractions
- N/V
Prenatal Psychosocial Assessment
Desire for pregnancy Fear r/t anticipation of pain Body image changes Social support Sleeping/rest Mobility/balance - center of balance has changed
Prenatal skin assessment
Consistent with racial/ethnic background Edema of lower extremities Spider nevi = common 2nd trimester = striae gravidarum (can be based on heredity), hyperpigmentation (cholasma, Linea Nigra) Acne
Prenatal chest/lungs assessment
- lungs clear bilaterally
- heart sounds are regular
- palpitations d/t to SNS
- short systolic murmurs
- breasts: darker pigmentation of nipple and areola, increased in first 20 weeks, nodular, heavy
Prenatal CV assessment
- pulse increases 10-50/min around 20.0 week
- cardiac hypertrophy
- respirations increase 1-2/min
- BP range w/ in pre-pregnancy range during 1st trimester
- BP decreases 5-10 mm Hg during 2nd trimester
- BP returns to pre-pregnancy after 20.0 week
- supine hypotensive syndrome
Pernatal abdomen assessment
- no upper right quadrant pain
- linea nigra; purple striae
- decreased gastric mobility
- N/V from hormonal changes; increased pressure
- diastasis of rectus muscles
- fundal measurement
- fetal HR
- fetal movement
Prenatal perineum assessment
- odorless discharge; non irritating
- Goodell’s sign
- hegar sign
- Chadwick sign
- posterior cervix
- pelvic exam
- urinary frequency and output stays the same
- increased filtration rate
- assess for ketones/proteinuria/UTI
Prenatal extremities assessment
- swelling of feet (and should assess for swelling of hands)
- pulses, temp, ROM, varicosities, palmar erythema
- reflexes
- carpal tunnel syndrome b/c of fluid retention
Muscular skeletal prenatal assessment
- backache: lumbar spinal curve accentuated
- pelvic joints relax
- weight increases causes body alteration
Prenatal endocrine assessment
Large amounts of hCG, progesterone, estrogen, lactogen, prostaglandins from placenta
Prenatal Lab Tests
Blood type, rh factor CBC with diff Hgb electrophoresis Rubella titer hep B screen GBS (35-37 weeks) Urinalysis One hour glucose tolerance (24-28 weeks) Pap test Vaginal/cervical culture PPD screen VDRL (sphyllis)/HIV screen TORCH screening MSAFP
Clincial pelvimetry
Pelvic type is assessed externally or via sterile vaginal exam
Most common pelvic type?
Gynecoid (50%)
Prior to tests, what should you teach?
- assess whether the woman knows the reason for the test
- provide an opportunity for questions
- explain the test procedure
- validate the woman’s understanding of the prep
- answer any questions
Ultrasound scanning
Use of high frequency sound waves
Takes 20 minutes
What does an ultrasound show?
allows the observation of fetal movements including breathing, cardiac action, and vessel pulsation
If GBS +, when do you give antibiotics
During active labor or ROM
When to give rubella vaccine if non-immune?
Vaccine prior to hospital discharge
no pregnancy for 3 months after vaccine
If Rh -, when do you give Rhogam?
28 weeks, or after any trauma or exams that could cause mixing of blood
Within 72 hours of birth
If infant direct Coombs is positive why dont we give rhogam?
Mom is already alloimmunized so rhogam won’t prevent anything, she is alloimmunized for life
How can you tell if a newborn was born by c section?
No conehead/molding
Benefits of spontaneous labor
Provides natural pain relief
Helps calm woman
Facilitates normal detachment of placenta
Enhance breastfeeding
Warm the mother’s skin
Clear fetal lung fluid
Ensure transfer of maternal antibodies to the fetus
Vaginal seeding
Babies born through vaginal canal have stronger immune system to bacteria they encounter after
May be d/t traveling vaginal canal and exposure to flora in canal
Seeding = swab canal/flora and swab infant’s mouth if baby is born by C-section
Why 39 weeks for bishop scoring?
Estimated Date of birth - someone at 39 weeks is going to be b/w 38-40 weeks.
How can pitocin be delivered?
IV or IM
Interventions or medications for blood loss postpartum
- fundal massage, IV fluids, empty bladder, balkri balloon
- methergine, hemabate, pitocin, cytotec
When is methergine contraindicated?
Hypertension
external abdominal ultrasound - when is it useful?
noninvasive
more useful after first trimester
internal transvaginal US
first trimester
invasive
detects ectopic pregnancy
establishes gestational age
doppler ultrasound blood flow analysis
noninvasive
IUGR evaluation
Level I US characteristics
assess number of fetuses, presentations, lie, viability, location of placental site, and amniotic fluid volume
Level II US characteristics
more comprehensive
evaluates fetal anatomy along with level I parameters
when can a US show the gestational sac?
4-5 weeks
when can US show fetal heart mvmts?
7 weeks
when can US show fetal breathing mvmts?
11 weeks
when can US measure crown rump length?
before 12 weeks
what can a US do in the second trimester?
measure fetal biparietal diameter, femur length, abdominal and head circumferences to estimate gestational age and weight
Quadruple check
- MSAFP
- uE3 conjugated estriol
- hCG
- inhibin A
**screening not diagnostic
indications of Downs from MSAFP
MSAFP = low
uE3 = low
hCG = high
inhibin A = high
AFP
alpha fetoprotein - produced by fetus and can be detected in maternal serum by 7th week
most accurate b/w weeks 16-18
what can impact MSAFP levels that is not abnormalities?
diabetes, smoking and multiples
what does amniocentesis measure?
Chromosomal and biochemical determinations
-measures AFP for neural tube defects and L/S ratio for fetal lung maturity (later in pregnancy), blood typing
Can validate abnormalities detected by US
how and when is amniocentesis performed?
aspiration though a needle of amniotic fluid (through abdominal wall or intravaginally)
15-16 weeks gestation
what does a pregnant women have to do before amniocentesis?
empty bladder
sign consent form
post amniocentesis and CVS responsibilities
monitor UCs at start and then 1-2 hours post procedure
how and when is chorionic villi sampling performed
aspiration through a thin catheter or syringe of chorionic villi (through abdominal wall or intravaginally)
9-12 weeks gestation
what does the mom need to do before CVS?
drink plenty of fluid to fill bladder so fetus can’t move around as much
provide consent
risks of CVS
spontaneous abortion
infection of amniotic fluid
break amniotic fluid
PUBS (percutaneous umbilical blood sampling)
most common method to sample fetal blood during amniocentesis.. can use that blood for:
- Kleihauer Betke test (fetal blood)
- CBC count with diff
- indirect coombs
- visualization of chromosomes
- blood gases
risks of PUBS
- cord laceration
- cord infection
- hemorrhage
fetal movement assessment low tech intervention
kick count
helps woman become aware of fetal activity
what is normal for a fetal movement assessment
3 or more mvmts in 1 hour
when should you call your HCP regarding fetal movement
no fetal movement in 8 hours
less than 10 fetal movements in 12 hours (really 2)
violent fetal movement followed by decreased activity
when should fetal movement assessments happen
when you can feel the fetus
same time every day that the fetus is active
count kicks and document once you reach 10
can drink water to wake baby up
When do you do the non stress test?
3rd trimester
How do you conduct a non stress test
Place on EFM for 20 minutes
What does a reactive stress test mean?
2 or more accelerations of at least 15bpm, each lasting at least 15 seconds, during the 20 mins
No decels
Moderate variability
What does a non reactive stress test mean?
Criteria wasn’t met
What do you do for non reactive stress test result?
Give baby more time
Snack for mom
More detailed test
How often do AMA get non stress test?
Weekly in third trimester
How often do diabetics and high BP patients get a non stress test?
1-2x per week during last trimester
How to perform contraction stress test?
Nipple stimulation (for 2 minutes, rest 5 minutes and repeat)
Pitocin stimulation
Terbutaline to stop contractions
What is a normal result for a contraction stress test
Negative = normal, no fetal heart rate decels 3 contractions (40 seconds) within 10 minute periods
What does a positive contraction stress test mean?
Abnormal
Late decels
When would you recommend a biophysical profile
Negative non stress test = non reactive
Positive contraction test
How do you score BPP
Score of 10 with 2 points for each:
- FHR reactivity
- fetal breathing movements
- fetal body movements
- fetal tone
- amniotic fluid volume
Fetal asphyxia = 0
7/10 or below = induce
Hyperemesis gravidarum
N/V post first trimester
Women at risk for weight loss, dehydration, electrolyte imbalances, ketonuria, acidosis
Can cause IUGR
Cause of hyperemesis gravidarum
High hCG/estradiol
H. Pylori infection
History of migraines or asthma
How to diagnoses hyperemesis gravidarum
Weight loss > 5% pre pregnancy weight
Dehydration
Ketonuria
History of intractable vomiting
How to treat hyperemesis gravidarum
Avoid odors Frequent small meals Vitamin b6 Phenergan / reglan / Zofran Ginger Acupressure/ acupuncture IV fluids
If rh- mom is exposed to rh+ fetus…
Mom Will create IgG antibodies against RBC of fetus = alloimmunization
Will impact second rh + baby that mom has
If an indirect Coombs test is negative…
Mom is not alloimmunized
Give rhogam at 28 weeks, after any trauma or procedure, and within 72 hours after birth (after another negative indirect Coombs at birth)
If indirect Coombs is positive at birth…
Run Coombs on infant , run KB test
If positive = no rhogam —> mom is already alloimmunized. Need to frequently monitor and observe
Oligohydramnios
Too little amniotic fluid, a 5cm or less pocket of amniotic fluid
Seen with post maturity, IUGR, renal malformations
How to treat oligohydraminos
Amnioinfusion
Polyhydramnios
Too much fluid
>20 cm pocket
Seen with congenital anomalies
How to treat polyhydramnios
Indocin (indomethacin)
PROM
Premature rupture of membranes anytime after 37 weeks before onset of labor
PPROM
Preterm premature rupture of membranes anytime before 37 weeks
Prolonged rupture
More than 24 hours before birth
How to manage PROM
Birth within 24-48 hours (unless PPROM - birth can be delayed with close mgmt)
Treat for infection (chorioamnionitis)
Risk for decels and cord prolapse
How to treat prolapse cord
priority: get pressure off of cord
Keep hand in vagina and push presenting part away from cord but don’t push cord in!
-Place mom in trendelenburg or chest prone down/kneeling position, buttocks up
-Type and cross match blood, large bore IV
-monitor FHR
-Prepare for emergency c section
-cover with gauze and saline
Placenta previa
Placenta abnormally implants in lower segment of uterus near or over cervical os (2% incidence)
Can result in bleeding in first trimester
Placenta previa grade 1 or 2
Low lying placenta
Grade 3 partial previa
Partial previa
Usually cannot have vaginal birth
Grade 4 placenta previa
Total
Most complicated - c section
Can’t efface or dilate
Factors that may contribute to previa
Precious hx of placenta previa Uterine scarring Maternal age greater than 35-40 years Multifetal gestation Smoking and/or cocaine use Large placenta Placenta accreta
Previa assessment
- painless bright red vaginal bleeding in 2nd or 3rd trimester
- fetus position
- reassuring FHR
- normal VS
- h/h, CBC, blood type and rh, coag profile, kleihauer-betke
- transabdominal or transvaginal US
- refrain from SVE to avoid bleeding
- BRP (bed rest) if no bleeding
Placenta accreta
Abnormally deep attachment into uterine wall
1 in 2000 pregnancies
Accreta
Attach to myometrium (75% of cases)
Increta
Invades myometrium (17%)
Percreta
Penetrates myometrium (5-7%)
How do estrogen and progesterone impact insulin?
Stimulate insulin production
Increase tissue response to insulin to make insulin more easily stored
T/f: Insulin needs during first trimester are decreased
True
Can insulin cross the placenta?
No
Can glucose cross the placenta?
Yes
Do insulin requirements increase or decrease at birth?
Decrease because placenta separation causes decrease in hormones which causes decrease in insulin requirements at the tissue level
What happens to insulin requirements post partum
Decrease
Decrease further with breastfeeding
What causes hypoglycemia in neonates
Lack of glucose supply, but production of excessive insulin
Blood sugar drops when cord is clamped
Glucose comes from food/milk in 2-4 hours- babies also get sleepy
Gestational diabetes mellitus
Glucose intolerance
Gestational is controlled with diet and education
Risks associated with diabetes
Hydraminos Preeclampsia (treat w/ low dose aspirin) Ketoadidosis Fetal macrosomia and IUGR UTI/vaginitis Retinopathies Congenital abnormalities Sacral agenesis Respiratory distress syndrome
What should you watch for during 1st prenatal visit r/t diabetes
HbAic >= 6.5%
Fasting glucose >= 126
2 hour glucose >= 200
How do you monitor glucose during l&d and postpartum
Glucose levels every 1-2 hours during active labor
Discontinue insulin at end of 3rd stage of labor
Monitor s/s postpartum
Reassess 4-12 weeks postpartum
What is the hemoglobin level considered anemic?
Less than 11 g/dl
Risk factors for anemia
Race Altitude Smoking Nutrition Medications
When is the greatest need for iron?
Second half of pregnancy
Nursing interventions for anemia
- education on iron supplementation
- monitor h/h every 2 weeks
- take vitamin c but avoid with caffeine or milk
- recognize signs and symptoms - fatigue, headache, pallor, tachycardia, hgb < 11
- advocate for pain month in cases of sickle cell anemia
Impact of marijuana during pregnancy
Lower birth weight
Impact of cocaine/crack during pregnancy
Placental vasoconstriction
SAB, abruption, IUGR, preterm birth, stillbirth
Microcephaly, anomalies, SIDS
No breastfeeding!
Impact of opioids during pregnancy
Abnormal placental implantation, abruption, PTL, PROM, meconium
IUGR, LBw, preterm birth, fetal distress
Impact of heroin
Anemia
Preeclampsia/eclampsia
STI
preterm birth, IUGR
Can psych drugs cross the placenta
Yes
No psychotropic drugs are approved by FDA
Need to balance risk associated with parental exposure
What congenital heart defects, if repaired, can proceed as normal?
Tetralogy of fallot, atrial septal defect, ventricular septal defect, patent ductus arteriosus
What congenital heart defects make pregnancy contraindicated
Eisenmenger syndrome Pulmonary HTN Uncorrected coarctation of the aorta Aortic stenosis Marfan syndrome All cause persistent cyanosis
What congenital heart defect tolerates pregnancy well
Mitral valve prolapse
What is peripartum cardiomyopathy and what are the s/s (cow dep)
serious dysfunction of left ventricle that occurs toward end of pregnancy or in first 5 months postpartum
No previous history
Chest pain, Dyspnea, orthopnea, palpitations, weakness, edema
WHO risk classes for CVD: no contraindications
Class I and II
WHO risk classes for CVD: contraindicated pregnancy
Schedule IV
Heart disease in pregnancy assessments
Frequent prenatal appts Assessment b/w 28-32 weeks Oxygen and diuretics during labor Pain mgmt to decrease pain Assisted birth to decrease pushing Critical period of 48 hours postpartum
T/f: bleeding during pregnancy is normal
False - abnormal. Always has to be investigated
Causes of bleeding in pregnancy: before 20 weeks
Abortion
Ectopic pregnancy
Gestational trophoblastic disease
Trauma
Causes of bleeding during pregnancy: second half of pregnancy
Trauma Placenta previa Abruptio placentae Labor Preterm labor
Nurses role in bleeding during pregnancy
- assess history
- monitor VS and bleeding ant
- assess gestational age and fetal heart tones
- insert IV, collect GTs, H&H
- prepare for US and/ or vaginal exam
- rh status
- psychological support
- assess signs of shock, phlebitis, ectopic pregnancy
Spontaneous abortion
Expulsion of products of conception before age of viability (20 weeks or 500g)
Causes of SAB
Chromosomal abnormalities Teratogenic drugs Structural abnormalities Placental abnormalities Maternal disease Cervical insufficiency Endocrine imbalances
SAB procedures
US
cervical exam
D&C
Dilation and evacuation - to evacuate uterine contents after 16 weeks
Prostaglandins into amniotic sac or as a vaginal suppository and oxytocin
Dilation and curettage
- empty bladder
- assist woman to relax
- watch for vasovagal reaction
- observe for signs of uterine perforation afterwards
- may be given prophylactic antibiotics
- monitor vital signs
- give rhogam if woman is Rh negative
SAB discharge instructions
contact provider if:
Heavy bright red bleeding
Elevated temp
Foul smelling discharge
Small amount of discharge normal for 1-2 weeks Pelvic rest for 2 weeks Avoid pregnancy for 2 months Antibiotics Support groups
Ectopic pregnancy
Implantation of a fertilized ovum in a site other than the endometrial lining of the uterus
Cause of ectopic pregnancy
PID, endometriosis, previous ectopic pregnancy IUD Pelvic or tubal surgery AMA Ovulation inducing drugs
S/s of ectopic pregnancy
One sided lower abdominal pain or diffuse lower abdominal pain
Fainting/dizziness
Referred right shoulder pain —> ask if appendix has been removed
Ectopic pregnancy interventions
IV access Labs Pelvic exam US Emotional support
treatment for ectopic pregnancy
methotrexate IM, saplingostomy/salpingectomy
Gestational trophoblastic disease (molar pregnancies)
- a group of rare tumors that develop during the early stages of pregnancy
- hydatidiform mole
hydatidiform mole
- growth of an abnormal fertilized egg or an overgrowth of tissue from the placenta and produce HcG
- will show a positive pregnancy test result
- complete (empty egg) and partial (69 chromosomes instead of 46)
- risk of choriocarcinoma (cancer)
symptoms of gestational trophoblastic disease
vaginal bleeding anemia N/V elevated HCG low levels of AFP hyperemesis HTN before 24th week (due to rapid growing, causing pressure vascularly) absent fetal heart tones uterus enlarges at a rapid rate
interventions of gestational trophoblastic disease
- baseline chest X ray
- serum HCG weekly until negative and then monthly
- avoid pregnancy for a year
trauma
- assessing for placental detachment, mixing of fetal and maternal blood
- EFM; vital signs, KB test, hemoglobin F
KB test
measures amount of fetal hemoglobin transferred to maternal bloodstream
diagnoses fetomaternal hemorrhage, quantification, risk for PTL
low sensitivity and tendency to over estimate volume of hemorrhage
hemoglobin F
quantification more reliable test for quantifying fetomaternal hemorrhage
placenta previa
placenta abnormally implants in lower segment of the uterus near or over the cervical os (2% incidence)
abruptio placentae (abruption)
premature separation of a normally implanted placenta (1% incidence)
factors that may contribute to abruption
- maternal HTN
- blunt external abdominal trauma
- cocacine use resulting in vasoconstriction
- hx of abruption
- smoking
- PROM
- multifetal pregnancy
assessment of abruption
- dark red bleeding, port wine amniotic fluid
- acute abdominal pain, sudden onset
- board like abdomen, increase in uterine size
- contractions with hypertonicity
- fetal distress
- woman is at risk DIC
- H/H, coag factors, KB test, clotting factors
- urine output less than 30 cc per hour
what values would you see in DIC
fibrinogen and platelet decreased
PT and PTT prolonged
risk factors for preterm labor
- infections
- hx of PTB, abortions
- multifetal pregnancy
- hydraminos
- age below 17 or above 35
- low SES
- smoking, substance abuse
- domestic violence
- diabetes or HTN
- lack of prenatal care
- placenta previa/abruption
- short pregnancy interval (short time b/w last and current birth)
- uterine abnormalities
- recurrent premature cervical dilation
assessment of PTL (mother’s perspective)
- persistent low backache
- pelvic pressure and cramping
- GI cramping, with or without diarrhea
- urinary urgency, frequency
- vaginal discharge
- cervical change, bleeding
- contractions, with or without pain
- PROM
what does a positive fetal fibronectin mean?
determines risk of preterm birth in the next 7 days
related to inflammation of placenta
swab of vaginal secretions b/w 24 and 34 weeks
what other assessments would you do for PTL?
- endocervical length measurement with US - if less than 30mm –> risk of PTL
- home uterine activity monitoring
- cervical culture
- BPP, NST
how to prevent PTL
hydration
cerclage
infection screening
how to treat PTL
focus is to stop uterine contractions
activity restriction
hydration
treat infections (tachycardia, elevated temp, fetal tachycardia)
medications for PTL
- progesterone (prophylactic)
- nifedipine (procardia, adalat)
- mag sulfate (prophylactic)
- indomethacin (indocin)
- betamethasone (celestone) - helps surfactant develop
- terbutaline (brethine)
when to use terbutaline?
48-72 hours use to gain time in order to administer 2 doses of betamethasone
long term use is questionable –> associated with maternal deaths
cervical insufficiency: assessment
- cervical length surveillance b/w 16 and 24 weeks
- assessment for funneling/thinning of cervix
- cerclage
- serial US of cervix throughout pregnancy to make sure its closed
- no sex until 34 weeks and then remove it before dilation
what are hypertensive disorders associated with
associated with abruption kidney failure hepatic rupture PTB fetal and maternal death
chronic hypertension
HTN before 20 weeks
140/90 prior to pregnancy
no proteinuria
gestational HTN
after 20th week of pregnancy
elevated BP (140/90) at least twice, 4-6 hours apart, within 1 week
no proteinuria
BP returns to baseline 6 weeks PP
what is the treatment for preeclampsia
birth
exclusively a disease of pregnancy
cause of preeclampsia/eclampsia
- immune response against pregnancy
- presence of widespread arteriolar vasospasm
- injury of endothelial lining of blood vessels
- intravascular fluid moves to extravascular space
mild preeclampsia
gestational HTN with proteinuria of greater than 1+
24 hour protein test > 300mg
may or may not have transient headaches and/or edema
severe preeclampsia
blood pressure 160/100 or greater proteinuria 2+ or more - greater than 500 mg in 24 hour test elevated serum creatinine (>1.2 mg/dL) oliguria visual disturbances hyperreflexia with possible clonus edema hands and face right upper quadrant epigastric pain thrombocytopenia
eclampsia
severe preeclampsia with onset of seizure activity or coma
-preceded by headache, severe epigastric pain, hyperreflexia, and hemo-concentrations (warning signs of probably convulsions)
HELLP syndrome
variant of gestational HTN in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction
H: hemolysis
EL: elevated liver enzymes, epigastric pain, N/V
LP: low platelets, abnormal bleeding and clotting time and possible DIC
cause of HELLP
- platelets accumulate at lesion sites (thrombocytopenia) and a fibrin network forms (elevated liver enzymes)
- RBCs are forced through fibrin network under high BP, resulting in hemolysis with damaged erythrocytes (hyperbilirubinemia; jaundice)
- maternal liver damage from microemboli in hepatic vasculature, which causes ischemia/tissue damage within liver
- obstruction of hepatic blood flow and continual deposit of fibrin causes hepatic distension (can palpate liver)
risk factors for HTN disorders
- younger than 20, older than 40
- morbid obesity
- chronic renal disease
- chronic HTN
- hx of preeclampsia, gestational HTN
- diabetes
- molar pregnancy
nursing care: preeclampsia
- assess LOC
- pulse oximetry
- daily weights
- vital signs
- NST, BPP, AFI
- assess for proteinuria
- s/s
- frequent rest
medications for mild preeclampsia
low dose aspirin methyldopa (aldomet) nifedipine (adalat, procardia) hydralazine (apresoline, neopresol) labetalol PO
medications for severe preeclampsia
mag sulfate –> to prevent seizures and keep BP normal
labetalol/hydralazine IV bolus
low dose aspirin
81mg daily after 12 weeks gestation
reduced premature birth by 14%
reduced IUGR by 20%
does not increase risk of excessive bleeding at birth
nursing care: severe preeclampsia
nursing care for preeclampsia hourly VS, urine output (>30 cc), reflexes, lung sounds, visual assessment, clonus, edema and epigastric pain eval continuous fetal monitoring strict I/O (IV fluid max 125) expect mag sulfate dim, quiet room
MgSO4 dose
loading dose of 4-6g - 20-30 min via pump, with maintenance of 2-3 g/hr via pump
continue for 24 hours postpartum
MgSO4 toxicity signs
absence of reflexes decreased urine output (less than 30/hr) decreased respirations (<12 / min) decreased LOC cardiac dysrhytmias
MgSO4 antidote
calcium gluconate (1 g of 10% solution IV push over 3 mins)
MgSO4 fetal effects
hypotonia
observe infant for delayed effect after birth
NICU
PP management
BP may rise 3-6 days postpartum
antihypertensive meds for 4-6 wks PP (potentially)
late PP eclampsia (more than 48 hours but less than 4 weeks PP)
past 4 weeks = chronic HTN
labor dystocia
interference in 5Ps psychosocial passenger power passageway position
hypertonic uterus (dystocia of power)
- frequent, intense, painful UCs
- tachysystole (terbuatline short term to space out contractions)
- rest with short term opioid/sedative
hypotonic uterus (dystocia of power)
contractions are infrequent or not strong enough to cause labor
either prolonged labor less than 1cm per hour or arrest of progress: no cervical change for 2 hours
how to treat hypotonic uterus
augment with pitocin
amniotomy to rupture membranes
amniotomy
artificial rupture of membranes with amniohook
form of augmentation of labor
should only happen when fetus is engaged
nurse should note TACO
chorioamnionitis
infection that can occur with rupture of membranes
risks associated with ROM
risk for variable decels d/t lack of fluid d/t cord compression
risk for cord prolapse
amnioinfusion
0.9% sodium chloride or LR through IUPC to supplement amniotic fluid amt
oligohydramnios
too little amniotic fluid
RN’s role in dystocia of power
manage pitocin position changes LOCK assist with amniotomy assist with IUPC
dystocia: position (4 things)
use or misuse of gravity
shoulder dystocia
inadequate maternal expulsion power from lying on back for too long
affected psychological response
what happens during a shoulder dystocia
inferior shoulder gets stuck by pelvic bone
can lead to brachial nerve injury
RN role during shoulder dystocia
subrapubic pressure stool timer --> need to know when it starts and for how long team - get team assembled - NICU McRobert's position
how to anticipate shoulder dystocia
leopold’s
turtling effect
read chart first - big baby, post date, diabetic mom, no previous birth or failed vaginal birth
how to avoid shoulder dystocia
w/ squatting
episiotomy
can be used in shoulder dystocia to create more space
happens at pelvic bone level
treatment for episiotomy
ice then heat
stitches dissolve on their own
no baths
dystocia: passenger
- persistent occiput posterior position
- brow, face, shoulder, compound presentation
- transverse
- breech
moxibustion complementary therapy
burn incense - thought to help turn baby
external cephalic version
an attempt to turn the fetus so that he or she is head down (from breech)
when can you perform ECV
after 37 weeks
risks w/ ECV
ROM
prolapse
uterus rupture
decels
RN role during ECV
IV assist with sonogram rhogam/KB if indicated tocolytics OR team NST
macrosomnia
> 4000 grams - can lead to fetus not being engaged and can lead to shoulder dystocia
what to expect with dystocia (passenger)
position changes pelvic rocking counterpressure on lower back for pain instrumental delivery C-section
cephalopelvic disproportion (CPD)
head doesn't fit could be d/t -contracture/narrowing of pelvis -fetus is too large for size of pelvis (doesn't mean fetus is too large) -android and platypelloid pelvis at risk
trial of labor
might try to see if vaginal birth can happen
why does sitting or squatting help with dystocia of passage
can increase outer diameters
when might you need cervical ripening
post dates
preeclampsia
water broke but no labor
gestational DM
what is the bishop scale used for
used to determine maternal readiness for labor by evaluating cervix
what is the bishop scale composed of
dilation effacement station consistency position
what score do you want for multiparous
> 8
what score do you want for nulliparous
> 10
what does cervical ripening do
-promotes cervical softening, dilating, effacement, and a more successful induction of labor
cervical ripening: mechanical and physical methods
foley bulb catheter (w/o urine bag) - pump up 50 cc --> puts pressure on cervix membrane stripping amniotomy laminaria lamicel
cervical ripening: chemical methods
misoprostol (cytotec tablets orally or vaginally)
dinoprostone (cervidil, prepidil)
what are the benefits of dinoprostone vs. misoprostol
dinoprostone can be removed - wrapped around cervix and dissolves to help efface and dilate. can remove string and stop
can’t take back misoprostol –> can cause labor
what do you do if there is fetal distress caused by cervical ripening, induction, augmentation?
stop medication
LOCK - position, oxygen, fluids, notification, possibly terbutaline
what is induction of labor
- initiation of uterine contractions to stimulate labor before spontaneous onset
- mechanical or chemical cervical ripening
pharmacological methods of induction
IV oxytocin, endogenous oxytocin (nipple stimulation)
nonpharm methods of induction
membrane stripping castor oil (GI irritation that can cause induction)
contraindications of induction of labor
vertical incision on uterus, placenta previa or suspected abruption, multiple gestation other than twins, abnormal fetal lie
when do you augment labor
stimulation of hypotonic contractions once labor has spontaneously begun but progress is inadequate
vacuum assisted birth
cuplike suction device attached to fetal head
traction applied DURING contraction to apply the pressure before the next contraction
when could you have a vacuum assisted birth
vertex (head down) presentation
no CPD
ruptured membranes
risks of vacuum assisted birth
lacerations
subdural hematoma
cephalohematoma (must monitor bump where suction was placed)
caput succedaneum
normal occurrence with vacuum
resolves within 24 hours
how many times can you try a vacuum assisted birth
can only pop off 3 times
nurse should record how many tries
forceps assisted birth
two curved spoon like blades applied during contraction
put on hard parts of cranium, turn head or help with traction
when can you use forceps
abnormal presentation
arrest of rotation
no CPD
ruptured
risks associated with forceps
lacerations
bladder or urethral injuries to mom
facial nerve palsy
bruising
when is C-section indicated
failed vaginal birth CPD failure to progress shoulder dystocia placenta previa transverse shouldn't be elective
factors influencing rate of c sections
changing philosophies regarding best method for delivering breech interpretation of EFM tracings changing practice related to VBACs increased use of epidural anesthesia convenience
RN role: c section preop
- bring support person in
- assessment data
- consents, identification, lab data, blood type, Rh
- anti embolism stockings and sequential compression device
- admin preop medications
- assist in epidural placement
- urine catheter placement
- positioning in PACU
- prepare surgical site
- bovie pad, straps
- warm blankets
- TIME OUT
- oversee sterility and OR conduct
- counts
what’s included in a time out
right patient, time, procedure and provider
RN role: c section post op
REEDA
fundal tenderness
lochia
post surgical assessments
what could indicate endometritis
foul smelling lochia
things for RN to note post c section
baby bonding / breast feeding may be impacted
increased risk of constipation
C/S limits number of children (no more than 3-4)
risk of adhesions (chronic pain, infertility, GI problems) which increase with each subsequent c section
when would VBACs not be possible
- evidence of uterine ruptures
- vertical incision from previous c section
- uterus shape changes
- non-reassuring fetal HR
- trial of labor
- myocmectomies - surgery to remove uterine fibroids
- active Herpes outbreak
- 3 or more cesareans
when do VBACs have the best outcome
1 C/S w/ horizontal incision and previous successful vaginal birth
complete uterine rupture
uterus splits open
incomplete uterine rupture
layers separate along previous incisions or surgery
risks for uterine rupture
congenital uterine anomaly uterine trauma LGA multiples polyhydramnios hyperstimulation versions multigravida
*would want to put in IUPC to know contraction pressure
signs of uterine rupture (assessment)
sensation of ripping or tearing sharp abdominal pain uterine tenderness contractions "that don't go away" nonreassuring FHR change in uterine shape cessation of contractions
recommendation for uterine rupture
alert provider while IV fluids
be ready for possible blood transfusion
stat C/S
precipitous labor
3 hours or less from onset of contractions to time of birth
risks with precipitous labor
tearing fetal distress (not enough time to transition) hemorrhage mom panicking placenta retention
RN role during precipitous labor
DO NOT leave unattended call for help globes do not breakdown bed stay calm pant with an open mouth light pressure on fetal head eye contact to buy time and stop pushing encourage her to stay calm
PP hemorrhage
cumulative blood loss >= 1000ml within 24 hour after birth process regardless of route of birth
*might be over 500 for vaginal births and over 1000 for CS
early (primary) hemorrhage
within 24 hours
late (secondary) hemorrhage
up to 12 weeks PP
what can cause early PP hemorrhage
- uterine atony (relaxation of the uterus)
- lacerations of the gential tract
- retained placenta
- vulvar, vaginal, pelvic hematomas
- uterine inversion
- coag disorders (DIC)
risk factors for uterine atony
macrosomia polydramnios multiple gestation prolonged or precipitous birth oxytocin augmentation/induction retained placenta placenta previa/accrete abruption magnesium
4 Ts of uterine atony
tone
trauma
tissue
thombin time
what can cause late PP hemorrhage
result of subinvolution (failure to return to normal size of uterus) or retention of placental tissue
signs of late PP hemorrhage
scant brown lochia
irregular heavy bleeding - bright red, more than 1 pad/ hour
boggy fundus that doesn’t respond to massage
abnormal clots
high temp
unusual pelvic discomfort or backache
persistent bleeding, firm fundus
rise in fundal height
increased pulse, decreased BP - sign of shock
hematoma formation
late PP hemorrhage: nursing assessment
monitor fundus, lochia, bladder
perineal pain
weighing of perineal pads (1 ml = 1g)
PP hemorrhage treatment (in order of less invasive to more)
- fundal or uterine massage
- elevate legs 20-30 degrees
- fluid replacement
- meds
- prepare for blood transfusion
- uterine tamponade - bakri balloon catheter
- uterine artery embolization
- laparoscopy: compression/ligation of arteries
- hysterectomy = last resort
meds for PP hemorrhage
pitocin
methergine
cytotec (800-1000 mg rectally)
hemabate
what can prevent a uterus from contracting
retained placenta
risk factors for retained placenta
excessive traction on cord
partial separation
abnormal adherence
preterm births (20-24 wks)
retained placenta assessment
monitor uterus (atony) monitor lochia monitor VS (increased temp) maintain or initiate IV fluids oxygen
retained placenta: recommendations
H & H
alert provider for manual separation or D&C
uterine inversion
turning inside out of uterus
emergency situation
risk factors for uterine inversion
retained placenta uterine atony excessive fundal pressure multiparity fundal implantation extreme traction on cord
uterine inversion assessment
pain in lower abdomen large red mass protrusion dizziness hypotension pallor assess introitus stop oxytocin
introitus
any type of entrance or opening
assess/visualize lochia
uterine inversion recommendations
alert provider stat
be ready with terbutaline, antibiotics
C-section for future births!
hematomas assessment
250-500 ml of clotted blood within tissues
pain rather than noticeable bleeding
monitor size and note time
icepacks for first 24 hours
hematomas recommendation
notify provider
evacuation/ligation
venous thromboembolism
thrombopheblitis: thrombus associated with inflammation
pulmonary embolism
DVT
VTE assessment
leg pain and tenderness unilateral area of swelling warmth calf tenderness redness
how to prevent VTE
antiembolism stockings
early and frequent ambulation
avoid prolonged periods of immobility
fluid intake
VTE recommendation
- facilitate bedrest
- elevate extremity above heart avoiding pillow under knees
- intermittent or continuous warm moist compresses as prescribed
- do not massage affected area
- thigh high antiembolism stockings
- anticoags
- monitor aPTT, PT
- avoid pregnancy, aspirin, ibuprofen, alcohol
pulmonary embolism
fragments of entire clot dislodges and moves into circulation
complications of DVT
when fatalities occur within PE?
within 30-60 mins
PE assessments
apprehension pleuritic chest pain peripheral edema dyspnea tachypnea hypotension hypoxia
PE recommendations
scans and angiograms of lungs
embolectomy
meds - alteplase, streptokinase
amniotic fluid embolism
infiltration of amniotic fluid into maternal circulation
amniotic fluid can obstruct pulmonary vessels
can be d/t sac or veins rupturing d/t pressure
amniotic fluid embolism assessment
sudden chest pain resp. distress bleeding from incisions / IV sites uterine atony circulatory collapse
amniotic fluid embolism recommendation
alert provider oxygen IV fluids be ready to assist with ventilation and intubation position on side with tilted pelvis foley C/S
ITP (idiopathic thombocytopenic purpura)
autoimmune disorder
platelet life span is decreased resulting in severe hemorrhage following a C/S or lacerations
disseminated intravascular coag (DIC)
clotting and anticlotting mechanism occur at same time
risk factors for DIC
abruption, fetal demise, severe preeclampsia or eclampsia, hemorrhage, molar pregnancy, amniotic fluid embolism
ITP & DIC assessment
epistaxis petechiae ecchymoses excessive bleeding hypotension tachycardia oliguria
ITP & DIC recommendation
CBC with diff
clotting factors (platelets, fibrinogen, PT increased)
platelet transfusion
possible splenectomy
puerperal infection
- infection of repro tract associated w/ childbirth that occurs at any time up to 6 weeks following childbirth or abortion
- temp of 100.4 or higher for 2 consecutive days during first 10 days after birth
s/s of puerperal infection
- body aches
- chills
- fever
- malaise
- tachycardia
- sites includes uterus, wounds, bladder or breast
endometritis
infection of uterine lining
usually begins on 2-5th day PP
risk factors for endometritis
C/S retained placenta PROM/chrioamniotis multiple vaginal exams prolonged labor infections (i.e. chlamydia)
endometritis assessments
uterine tenderness and enlargement lower abdominal pain tachycardia chills fatigue loss of appetite dark profuse lochia that is malodorous
endometritis recommendations
notify provider for labs and medications (i.e. antibiotics)
What can lead to wounds from the birthing process
Cesarean, episiotomies, lacerations, trauma to birth canal
how to assess wounds
REEDA redness edema ecchymosis discharge approximation
UTI
can be secondary to bladder trauma during birth or a break in aseptic technique during foley placement
UTI assessments
urgency, frequency dysuria pelvic discomfort fever chills malaise
what should you encourage for UTI
voiding
sitz bath, warm water, running water, in and out cath
avoid bladder distension!
UTI recommendations: nursing
urinalysis
blood work
antibiotics
Is mastitis always bacterial and is it 1 or 2 breasts?
inflammation of breast with or without bacteria infection
usually cause by staph
usually unilateral
when does mastitis usually occur
usually 2-4 weeks in breastfeeding women
risk factors for mastitis (4)
milk stasis from blocked duct
nipple trauma
poor breastfeeding technique, including decreased frequency
poor hygiene
what can cause burning nipple pain
candida
mastitis assessments
painful or tender localized hard mass
reddened area
chills
fatigue
mastitis recommendations
continue breastfeeding at least every 2-4 hours
contact the provider for antibiotics to get rid of infection
What does high levels of AFP indicate
Open neural tube defects, spina bfida, anencephaly
OR could indicate incorrect gestational age, more than one fetus, gastroschisis (hole in abdominal wall) or fetal death
When can you perform quadruple check
Second trimester
*more accurate when combined with ultrasound
What is a quadruple check used to screen
NTD, trisomy 21, and trisomy 18
indications for amniocentesis
AMA
couples who already had a cild with a birth defect or family history of chromosomal birth defects
pregnant women with other abnormal screening or genetic test results
what does chorionic villi sampling test for
genetic, metabolic and DNA abnormalities
usually completed 10-12 weeks gestation
priority after amniocentesis
monitor fetus
bishop score: what is it used for?
a scale used by medical professionals to assess how ready your cervix is for labor
arrest of progress
no cervical change for 2 hours
prolonged labor
less than 1 cm per hour
