Exam 2 Flashcards
What monitor is used for Uterine Activity? “Internal and External”
Tocotransducer “toco”- placed on top of fundus (use gel)
Intrauterine Pressure Catheter (IUPC)- internal (inserted thru vagina)
What three things do you need to assess during a contraction?
○ Frequency
■ Start of one contraction to the start of another
■ Adequate active labor contractions are q2-5 minutes
■ Generally become more frequent in active labor q2-3 minutes
○ Duration
■ Start to finish of one contraction (last at least 40 seconds)
○ Strength
■ Depends on type of contraction monitoring
■ Can be palpated externally by placing a hand on the fundus during a contraction
● Classified as mild, moderate, or strong
■ Can only be measured with an internal contraction monitor (IUPC) (mmHg)
When would you use an IUPC (intrauterine pressure catheter)?
- Used with larger BMI
- Contraindicated in HIV Pos Patients
Fetal Heart Rate Monitoring Frequency Types
CONTINUOUS: remains on laboring person for the duration of labor
-External Monitor or Internal (more invasive)
INTERMITTENT: monitor every 15-60 minutes over one contraction
Where on the fetus are heart tones easiest to assess for a better fetal monitoring reading?
On the BACK of the fetus
What general quadrant on the maternal abdomen do you find fetal heart tones of a baby that is vertex? Breech?
Vertex: Lower Quadrant
Breech: Upper Quadrant
Internal Fetal ECG (rhythm vs just rate)Monitoring Types
Internal Fetal Electrode (IFE)
Fetal Scalp/spiral electrode (FSE)
Why would you do a fetal (ECG) internal monitor?
- Patient is moving a-lot and hard to get a tracing
- Fetal Intolerance requiring closer observation of the fetal heart pattern
- Maternal Habitus (extra fat)
- Contraindicated for HIV Positive Patients
What two steps in the labor process must be completed before any
internal monitors can be placed by a provider?
- Need to know baby is head down (vertex)
- ONLY if water is broken
Do contractions monitors need gel applied?
NO
Intermittent Auscultation
- One Benefit
- When to Assess Heart Rate
- When to NOT use
- Performed how frequently? (early labor, active labor, second stage)
- Benefit:
Freedom of movement for the laboring person
- When to Assess Heart Rate
Assess fetal heart rate BEFORE, DURING, and especially AFTER a contraction
- When to NOT use
Change to continuous monitoring if abnormalities detected
NOT option for high-risk pregnancies or patients receiving Pitocin
- Frequency:
EARLY- q30-60 minutes ACTIVE: q15-30 minutes SECOND STAGE: q5 minutes
Evidence shows that intermittent auscultation for low-risk labors is JUST AS effective as continuous monitoring and decreases risk of interventions (operative delivery/cesarean) (T/F)
True
Heart Rate Pattern Terminology: Used to describe frequency of accelerations/decelerations
● Intermittent (occasional)
● Recurrent (occurs with >50% of contractions)
● Periodic: (occurs as part of a pattern)
Definition of resting tone and nadir:
Characteristics of a fetal heart tracing…
● Resting tone: period of rest between contractions
● Nadir: lowest point of a fetal heart rate deceleration
Fetal Compromise-
Definition of Hypoxemia, Hypoxia, Acidemia
● Hypoxemia: decreased oxygen in fetal blood
● Hypoxia: decreased oxygen in fetal tissues
● Acidemia: severe enough oxygen deprivation leading to a drop in pH
What should be done if the nurse notices a client is contracting every 2 minutes?
- Decrease Oxytocin if on medication
- Give IV bolus (if super dehydrated contractions can become worse)
Baseline Fetal Heart Rate: Definition, Normal Rate
Definition:
● Average heart rate (beats per minute) OVER 10 MINUTES
Rate:
● Normal: 110-160
*NOTE: This is the first assessment that should be determined on a heart rate monitor
Fetal Tachycardia: rate and causes
Rate: (>160 bpm)
Causes:
○ Infection, maternal fever, early hypoxemia, illicit
drugs/some medications or maternal conditions
Fetal Bradycardia: rate and causes
Rate: (<110 bpm)
Causes:
○Medications like Narcotics and Magnesium Sulfate,
cardiac anomalies, maternal hyPOthermia
What should be the nurse’s first intervention if a monitor is placed
and the fetal heart rate detected in the 90’s?
Compare to mother’s pulse
What is variability?
What is the difference in rate between: Marked, Moderate, Minimal, and Absent:
It the average fluctuations of the heart rate (beats to beat)
- Marked (> 25bpm) SELDOM SEEN,
- Moderate (6-25bpm) IDEAL
Minimal (1-5bpm) Potential sign of fetal distress
- Absent (flat line)- Very concerning- NEED to deliver
- *Note: variability is the best indicator of fetal oxygenation status*
What situations/medications might cause a decrease in heart rate?
● Temporary decreases in variability can be normal: S_leep Cycles_ of ~10
minutes, Narcotics and Magnesium Sulfate
Acceleration
● Transient increase in heart rate of 15 beats per minute (bpm) above the baseline
lasting at least 15 seconds
Deceleration and Types
● Transient decreases in heart rate from the baseline
● Can be associated with a contraction or unrelated
Types:
● Early deceleration
● Variable deceleration
● Late deceleration
● Prolonged deceleration
Early Decelerations
● U-shaped curved decelerations
● Always occur with contractions
● Occur due to fetal head compression
● Benign
● No interventions necessary
Variable Decelerations (DIFFERENT THAN VARIABILITY)
● V-shaped decelerations that take <30 seconds to get to the nadir (lowest part)
● Abrupt drop in heart rate from baseline
● Occurs due to umbilical cord compression
● Benign if small and transient, abnormal if repetitive and large
● Can be related or unrelated to contractions
What intervention would likely be most helpful for variable decelerations?
Change maternal position: hopefully relieves pressure off of umbilical cord
Late Decelerations
● Decelerations that take >30 seconds to get to the nadir
● Decrease in heart rate where the nadir occurs AFTER the peak of a contraction
● Sign of fetal hypoxemia due to placental insufficiency
● More concerning
Would we offer food or liquids to a client with repetitive late decelerations?
No: potential c-section
Reasons for decelerations: VEALCHOP
Variable———————–Cord Compression
Early—————————-Head Compression
Accelerations—————-Okay or Good
Late—————————–Placental Insufficiency
Prolonged Deceleration Length
● Drop in heart rate that lasts longer than 2 minutes
● Suggests poor fetal reserve
Prolonged Deceleration Nursing Interventions:
● First! Start performing intrauterine resuscitation
● If no improvement within 1-2 minutes, must elicit help
How long can a fetus maintain perfusion if deprived of oxygen
before suffering long-term consequences?
Around 12 min
Intrauterine Resuscitation: Interventions
● First intervention on the NCLEX is to turn off any IV Pitocin
● Reposition
● Start IV fluid bolus
● Assess maternal blood pressure
● Assess uterine contraction pattern
● Call for assistance
● Consider cervical exam
● Potentially prepare for urgent/emergent delivery
NICHD Categories of Fetal Heart Rate Monitoring
● Category 1-Good
○ Defined as: Normal baseline, moderate variability, +/- accelerations, - decelerations
(except early decelerations are okay)
● Category 2: ALL OTHERS (majority of tracings)
○ Defined as: All tracings that do not fall into category 1 or 3
○ Outcome: Continue to perform intrauterine resuscitation if needed and monitor
● Category 3-Bad
○ Defined as: absent variability with recurrent late or early decelerations AND/OR
bradycardia
For both Contraction Stress Test (CST) & Vibroacoustic stimulation (VAS) Pos vs. Neg test
Positive test: Not reassuring (decelerations with contractions/sound)
Negative test: reassuring (no decelerations)
Contraction stress test (CST)
-Create contractions by administering Oxytocin
○ Requires 3 contractions lasting at least 40 seconds to occur in a 10 minute period to offer accurate results
What do you do with a positive CST or VAS
result?
Assess further and do an ultra sound called a (BPP)
What is a Vibroacoustic stimulation (VAS)
Assesses fetal response to a loud noise
BPP (Biophysical Profile) Ultrasound
● Detailed ultrasound assessment to assess fetal well-being
● Gives more information than a non-stress test alone and helps determine fetal
well-being
● May help in determining if a fetus should be delivered or not
● Assesses fetal movement, fetal breathing, fetal tone & amniotic fluid volume
● Score is out of 10
○ 8 points from ultrasound
○ 2 points from nonstress test
● No odd points are awarded
○ Score is either 0 or 2 for each criteria
Nonstress Test (NST)
● Most common form of fetal surveillance; easy and noninvasive
● 20 minute fetal heart tracing
● Good predictor of fetal well-being if reassuring
● High risk pregnancies may have monthly, weekly, or even daily NSTs scheduled
Criteria for Nonstress Test (NST): Reactive vs Non-reactive
● Must have at least 2 accelerations and no decelerations in 20 minute period (except
early decelerations are okay)○ Reactive = reassuring (criteria met)
● If have not met criteria after 20 minutes:○ Continue to watch for another 40 minutes
● If have not met criteria after 1 hour:○ Non-reactive = non-reassuring (criteria not met)
○ Would then need more information → send for Biophysical profile ultrasound (BPP)
Cesarean Births: categorization for one or more C-sections
What type of incision allows for potential vaginal delivery later?
1/3 pregnant patients deliver via cesarean
Primary: first cesarean
Repeat: more than one first cesarean
Ideally you want horizontal incision
What type of incision will force you to ALWAYS deliver via c-section?
VERTICAL incision on abdomen or uterus (NEVER labor again)!!!!!!!!!!
Indications for Cesarean Births
- History of any uterine surgery
- Placental abnormality
- Active Herpes Lesions
- Fetal Malposition (BREECH)
- Multiple Gestations
- Maternal Medication Condition
Types of monitoring for high-risk pregnancies
-Diagnostic Genetic Testing:
*Amniocentesis or Chorionic Villus Sampling (CVS)
-Nonstress Test (NST), Contraction Stress Test (CST), Vibroacoustic Stimulation Test (VAS)
-Additional Ultrasounds:
*Biophysical Profile (BPP)
What risk do Cesarean Sections have on babies?
Respiratory Distress
What is external Cephalic Version (ECV)? What are the risks?
Turns a baby from a breech or transverse to a vertex position
-Externally rotated on abdomen (epidural recommended)
Performed by 1-2 doctors at the same time and ultrasound assess
Risks: Fetal distress or Placental abruptions
At what gestational age do we think it would be best to try to rotate a breech baby?
37 weeks
What is Amniocentesis (“Amnio”)?
Indications?
● Amniotic fluid (contains fetal cells) drawn up in a syringe via needle into the uterus after 14 weeks
● Indications: diagnosis of aneuploidy or anomalies, assess fetal lung maturity, fetal blood typing
What is Chorionic Villus Sampling (CVS)?
● Transcervical or transabdominal biopsy of the fetal part of the placenta after 10 weeks
● Similar indications as amnio
Nursing interventions for External Cephalic Version (ECV)
- Administer tocolytic Terbutaline BEFORE procedure to relax uterus
- Trace fetal heart rate before and after procedure, education, documentation
*DO NOT ATTEMPT until uterus is relaxed: how do you know? heart rate increases from terbutaline
VTOL/TOLAC vs VBAC
- *ATTEMPT** to deliver vaginal after Cesarean (VTOL OR TOLAC)
- -Vaginal trial of labor (VTOL)*
- -Trial of labor after Cesarean (TOLAC)*
- *SUCCESS**: (VBAC)
- -vaginal birth after cesarean (VBAC)*
Contraindication for VTOL OR TOLAC
- Vertical incisions
- Abnormal fetal presentation (breech)
- Multiples
What is a complication for a vaginal delivery after cesarean?
Uterine Rupture but RARE
Two types of pain in labor?
Visceral Pain and Somatic Pain
Visceral Pain
● Pain from uterine and cervical nerves, stretching og of
cervical tissue, distension of uterine muscle, pressure on
nearby organs and nerves, ischemia from disruption in
uterine blood flow with contractions ○ Includes referred pain
○ 1st stage of labor
Somatic Pain
● Pain from pressure on perineum and against nearby
bladder and rectum; lacerations
○ Often note a decrease in pain intensity
○ “Ring of fire” is not always reported
Why don’t we want to give narcotics close to delivery?
Can pass to baby
What is Nitrous? What does it do? How is it administered?
● 50% oxygen, 50% nitrous
● Self-administered via facemask
● Short half-life so rare side effects to patient or baby
● Does not reduce pain intensity but reduces pain perception
Local Anesthesia: used for what?
Provides coverage for a specific area: mostly used for laceration repairs or doesn’t want to feel crowning
Difference between regional epidural vs General anesthesia
Regional does not effect cognitive- mother still awake
General anesthesia is used for emergencies- baby is at risk for respiratory depression cause additional meds are given to mom: goal is deliver FAST so baby is exposed least amount of time
Side Effects of Epidural
- Hypotension (#1 side effect and expect it)
- itching
- back soreness
rare-spinal headache
Nursing intervention for Epidural side effect: Hypotension
- GIVE a fluid bolus in anticipation
- Assess vitals VERY often 2-5 min
What is a bishop’s score done by provider? Above and below 8 indications:
If score is below 8 then cervical ripening is needed
* have to use chemical methods (both prostaglandins that cause mild contractions)
*mechanical methods just force cervix to dilate (balloon or laminara)
If score is above 8- then you can go straight to inductions and start oxytocin
Augmentation (used to speed up labor)
-Chemical : oxytocin
- Mechanical or physical:
- sex or nipple stimulation
- membrane stripping
- artificial rupture of membranes
Nurses Role with Synthetic oxytocin
- Monitor fetal heart rate
- manage oxytocin titration based on uterine activity
- document
- educate
When is synthetic oxytocin contraindicated?
tachysystole, non-reassuring fetal heart tracing
Amniotomy:
process of breaking water by a provider
○ Must be at least a little dilated
○ Use of an amnihook to snag bag of water
often used to speed up labor process
Nurse Role with Amniotomy
- Assess fetal heart rate before and after,
- Assist with linen change
- check temperature q1 hour afterwards (risk of infection)
- education
- document
What is the risk of performing an amniotomy when the fetus has a high station and is
ballotable?
cord prolapse
Chorioamnionitis (infection): SYMPTOMS
● Maternal symptoms:
○ Tachycardia
○ Fever over 100.4F
○ Tender abdomen
○ Odorous amniotic fluid
● Fetal symptoms:
○ Tachycardia
Nursing interventions for chorioamnionitis
- Monitor temperatures
- Administer medications
- Educate
- Follow postpartum
protocols for newborn
Labor Dystocia (dysfunctional labor): Nursing roles
- Reposition as much as possible
- Increase oxytocin
- Advocate for more time to labor if patient desires, reassure client
Shoulder dystocia maneuvers (2)
- Super pubic pressure (climb on bed and put fist by lower pubic bone where should is stuck)
- McRobert’s maneuver (patient legs back)
Forceps-Assisted Vaginal Delivery (FAVD): Nursing Role
- Gather team
- education
- empty bladder
- continue to support and coach with pushing
- palpate for contractions
- document
OB Emergency: Cord Prolapse: Nursing Role
Nursing role:
● Call for help
● Work with team
● Vaginal exam to alleviate pressure of presenting part on cord
● Reposition patient to hands and knees
● “Ride the bed”-do not remove hand until delivery
● Others can begin intrauterine resuscitation
● Educate and anticipatory guidance
Cord Prolapse: What is it?
● Cord seen or felt below presenting part, often accompanied by fetal distress
Forceps Description
- risks (maternal and fetal)
- Used when?
● Maternal Risks: larger laceration, more perineal pain postpartum, hematoma
● Fetal Risks: bruising, abrasions, facial palsy, subdural hematoma
● Can be used when the fetus is in a higher station
● Requires more anesthesia
Disseminated Intravascular Coagulopathy: Signs/Diagnosis/Treatment
● Hallmark signs: bleeding from IV sites, nose bleeds, petechiae
● Diagnosis: Bloodwork (CBC to assess platelets and coags to assess clotting factors)
● Treatment: rapid fluid resuscitation and replacement of volume, blood, and clotting
factors
Disseminated Intravascular Coagulopathy: Nursing Role
- Call for help
- follow protocols
- assist team members
- draw and send stat labs
- assist with fluid resuscitation
- blood transfusions
- I&Os
- education
- document
Amniotic Fluid Embolism
● Presenting symptoms: restlessness, impending sense of doom, dyspnea,
respiratory distress, shock, cardiac arrest, DIC-associated symptoms :
Amniotic Fluid Embolism: Nursing Role
Nursing role:
● Prepare for CPR, follow protocols, assist
team members, draw and send stat labs,
assist with fluid resuscitation and blood
transfusions, I&Os, education, document
Vacuum-Assisted Vaginal Delivery (VAVD): Nursing Role
- Gather team, education
- empty bladder
- continue to support and coach with pushing
- palpate for contractions
- document
Vacuum-Assisted Vaginal Delivery (VAVD): Description
● Maternal Risks: larger laceration, more perineal pain postpartum, hematoma
● Fetal Risks: cephalohematoma, scalp lacerations, subdural hematoma
● Fetus has to be a lower station
● Less training is involved
● Less anesthesia required
What is Uterine Rupture?
Separation of uterine layers
Uterine Rupture: Nursing Role
- Call for help/ communication
- work with team
- assist with transport to operating room
- education
- document
Emergency Cesarean Indications: (Maternal and Fetal)
Maternal indications:
● Amniotic fluid embolism
● Emergency in the pregnant patient (Cardiac, respiratory, or stroke emergency)
● Post-mortem cesarean
Fetal indications:
● Prolonged deceleration leading to terminal bradycardia
● Cord prolapse
● Uterine rupture
Emergency Cesarean: Nursing Role
● Call for help
● Work with team
● Patient education
● Facilitate transport
● Communicate priority considerations using SBAR
Why might an early epidural be recommended for a patient who is expected to have a high risk delivery?
Increased risks can make for a faster transfer to the operational room if needed if complications occur.
What conditions warrant increased fetal surveillance?
- Diabetes
- Chronic hypertension
- Preeclampsia
- Intrauterine growth restriction (IUGR)
- Multiple gestation
- Oligohydramnios
- Preterm premature rupture of membranes
- Postdates or postterm gestation
- Previous stillbirth
- Decreased fetal movement
- Renal disease
- Cholestasis of pregnancy
What does increased fetal surveillance entail again?
Non Stress Test, Biophysical profile, Amniocentesis
Antepartum Unit
Not 1:1 care, but meant for high-risk pregnant patients stay short or long-term
Why are multiples high-risk?
Less room. They like to share things alot: bigger uterus can give body misleading information so uterus things it can go into labor early; or create complications postpartum such as hemorrhage, unequal sharing of nutrients,
Multiple Gestation: Baby A vs B
● Patient choice to deliver via cesarean depending on position of baby A
○ Baby A is the lowest/presenting baby
○ Risk of baby B needing a breech extraction
(T/F Different types of twins dictate how high-risk the pregnancy is
True
What type of twins do you think has the biggest risk of complications?
mono/mono
Types of Twin Pregnancies (how baby are sharing things)
Types:
● Mono/mono (monochorionic/monoamniotic)
● Mono/di (monochorionic/diamniotic)
● Di/Di (dichorionic/diamniotic)
Twin sharing types definition of Chorion
● -chorion-related to the placenta
Twin sharing types definition of Amnion
● -amnion-related to the amniotic sac:
What is PROM?
First sign of when water breaks before the onset of contractions
What is PPROM?
Same as PROM but occurs BEFORE 37 weeks
Why is breaking of the bag of water an automatic ticket to the hospital?
High Risk of Infection
Preterm Premature Rupture of Membranes Risk Factors:
Risk factors: prior preterm labor/birth****, infections, large uterus, low BMI, low
socioeconomic status, smoking
Preterm labor is before what week?
37
Preterm Labor Risk Factors:
Risk factors: Previous preterm labor/delivery*****, short cervix, infection (like UTI,
STI, vaginitis)
One Preterm Labor Cause
Multifactorial; infection is a known cause
What type of medications are used to slow down pre term labor?
Tocolytic medications
Terbutaline
Relaxes smooth muscle, warn client that they may feel like their heart is racing
(also uses to give baby a break fetal destress cause it relaxes the smooth muscle and slows contractions so baby’s heart rate can increase due to decelerations.
Goal: Goal is to at least slow contractions enough until betamethasone has had time to mature lungs
Is Terbutaline a short term of long term medicine?
SHORT-term
Nefidipine:
Calcium channel blocker (also used as an antihypertensive)
○ Don’t give if maternal hypotension
Tocolytics: slow or stop preterm contractions: 2 TYPES
Examples: Terbutaline, Nifedipine
Medication that is a neuroprotection for preterm fetus (decreases risk of cerebral palsy)
Magnesium Sulfate
Medication that is a steroid to boost lung maturity
Betamethasone
For preterm labor, does the postpartum patient need to remain on
Magnesium Sulfate after delivery?
no
Magnesium Sulfate (a CNS depressant) for Preterm Labor used soley for what?
** Neuroprotective decreasing the risk
of cerebral palsy
- ● Used to be used as a tocolytic but no longer the primary indication*
- ○ Acts as a smooth muscle relaxant so a side effect is slightly relaxing the uterus*
Magnesium Sulfate Nursing Indications:
*Get a base line
*Makes patients fell off (warn them) (complains of hot flashes, nausea/vomiting during initial administration)
*Remain at bedside during first 20-30 min
*2 nurse sign off
*Hourly assessments during duration of administration
*Strict bedrest to decrease risk of falls
(could plan with position changes, make sure bladder is being emptied regularly) - used bedpan first as least invasive, call light within reach due to fall risk, bed low , *strict I/O!!!!!!!
Mag Check: What do you include:EVERY HOUR
- symptom assessment
- vitals
- strict I&Os
- lung sounds
- edema
- deep tendon reflexes (DTRs)
- clonus
Edema normal in patients?
Pitting 1 in lower extremities normal but NOT normal in hands or face or plus 2 on extremities
Mag Sulfate Toxicity (Hypermagnesemia) Symptoms
*Lethargy, difficult to arouse (lower Glascow coma scale), decreased
deep tendon reflexes, pulmonary edema, abnormal vital signs
● Severe toxicity: respiratory depression, coma
What is the first nursing intervention to choose on the NCLEX if you find your
patient on Magnesium Sulfate is in respiratory depression?
Antidote: Calcium Gluconate
Intrauterine Growth Restriction (IUGR): Correlation/%/ Diagnosed by
When baby is measuring under the 10th percentile
Correlated with high-risk pregnancies, drug/alcohol use/ malnutrition
Diagnosed by ultrasound
Post-Term Pregnancy: Week/Risk factors/ risks to (maternal or fetal)
● Pregnancy beyond 42 weeks
● Risk factors: nulliparity, prior post-term pregnancy, male fetus, obesity, genetics
● Maternal risks: dysfunctional labor, operative delivery, cesarean birth,
postpartum hemorrhage
● Fetal risks: post maturity syndrome, oligohydramnios, abnormal fetal growth,
shoulder dystocia, meconium aspiration syndrome, fetal distress
Post- Term Pregnancy Monitoring
Monitoring:
- weekly or biweekly NST and/or BPP,
- daily fetal movement counts
Hyperemesis Gravidarum (HEG): complications
Rare but debilitating nausea and vomiting of pregnancy lasting all 3 trimesters
● Complications: weight loss, electrolyte/nutritional imbalances, dehydration,
mental health disorders, babies that are small for gestational age (SGA) or
intrauterine growth restricted (IUGR)
● Often requires multiple hospitalizations for IV therapy and/or
pharmacologic/nutrition management
Bethamethasone:
● Glucocorticosteroid
● Given to any pregnant patient with a possible risk of preterm delivery within 48
hours (boost lung maturation)
● Given deep IM injection x 24 hours x 2 doses
○ Each injection take 24 hours to fully work
■ So patient considered “beta complete” or “BMZ complete” 48 hours after first dose
● Expected outcomes: increased lung maturity, decreased risk of respiratory
distress
● Side effects: hyperglycemia
Cardiac Conditions Affecting Pregnancy
● Diseased hearts may have difficulty keeping up with the physiologic changes
before, during, and after birth
○ Occasionally patients with cardiac conditions require scheduled cesareans to
avoid putting extra stress on the heart in labor
Intrahepatic Cholestasis of Pregnancy (ICP)
● Liver abnormality
● Characterized by severe itching without rash (usually of palms of hands and soles
of feet)
● Diagnosed by ↑ bile acids and ↑ liver enzymes
● Induction and/or increased fetal monitoring necessary to reduce risk of
complications and/or stillbirth
HIV Positive
● Antiretroviral therapy (ART) recommended in pregnancy and labor
● Low viral load and ART use correlated with decreased risk of transmission to fetus
● In labor, no internal monitoring
● Vaginal deliveries are recommended
● Breastfeeding contraindicated in developed countries
● Newborn bath performed after delivery instead of immediate skin-to-skin contact
● Newborn monitored closely and often put on prophylactic medications
Substance Abuse in Pregnancy
● 5.4% of pregnant patients admitted to using illicit drugs in the past month
○ Includes cigarettes (most common), marijuana, alcohol, opioids, hard drugs
○ Often concurrent with mental health and/or gynecologic infections
● Opioid epidemic is a real, national health crisis ( dont’ give opioid to every mother cause it can develop a potential of substance abuse)
● Risk factors: scant or delayed prenatal care, missed appointments, treatment
noncompliance, significant social history, poor weight gain
Substance Abuse Barriers and Screening
● Barriers to treatment: stigma, guilt, fear of losing custody and/or facing charges,
treatment not tailored to pregnant women, long wait lists, inadequate insurance
coverage
● Screening is performed at the 1st prenatal appointment and upon hospital
admission
○ Common screening tool: 4 P’s Plus
● Occasionally a toxicology test is used at the hospital on patient and/or baby
Substance Abuse Nursing Role:
Education, ensure proper resources, assess safety of relationships, escalate if
suspicions of pain medication abuse
4 P tool:
Screen for Substance Abuse:
Partner Use
Patient Use
Pregnancy Use
Past Use
A nurse is caring for a client during a non stress test (NST). At the end of a 30 min period of observation, the nurse notes the following findings : the fetal HR baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15/min in the fetal HR during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make?
A nonreactive test
Rationale: an NST that does not produce two more qualifying accelerations within a 20 minute period is interpreted as nonreactive. Qualifying accelerations peak at least 15/min above the FHR baseline and last at least 15 seconds.
A nurse in the L&D unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
Place the client in the lateral position
Rationale: this is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.
Placenta Abruption
Placenta Abruption:Most delivery vaginally; acute/severe may deliver via cesarrean
Not always an emergency
Which 3 placental abnormalities are automatic cesareans
● Placenta Previa
● Placenta accreta/percreta/increta
● Vasa previa
Placental Abnormalities Nursing Interventions
Recognize and assess complaints of bleeding, pain, or rupture of membranes,
notify provider, work with team if plan is to deliver, follow protocols
Placenta Abruption
● Premature separation of the placenta from the uterine wall
● Majority of deliveries still occur vaginally
● Marginal or complete; acute or chronic
● Risk factors: uncontrolled hypertension, trauma, drug use (cocaine)
● Moderate-severe separation can lead to shock, DIC, and emergency cesarean
Placenta Previa
● Low-lying placenta that covers or is in close proximity to the cervical os
● Always requires a cesarean birth
● Only clinically important if a patient has symptoms and/or signs of labor
● Cause: incidental finding
● Risk factors: Prior cesarean births, advanced maternal age, multiparity, prior
previa, smoking, placenta accreta/increta/percreta
** WE DO NOT WANT THEM LABORING
Coagulopathies
Most commonn types:
● Idiopathic/immune thrombocytopenia purpura (ITP)○ Autoimmune condition that increases risk of postpartum hemorrhage
● Von Willebrand disease: form of hemophilia○ Most common congenital bleeding disorder
● Disseminated intravascular coagulopathy (DIC) (rare abnormal blood clotting thruout vessels)
● All require close monitoring of labs
● May require platelet or plasma transfusion
● 1 of the 4T’s discussed later as a cause of postpartum hemorrhage (Thrombin!)
Previa vs Abruption
- *Previa** is painless uterine bleeding and location of placenta
- *Abruption** is painful uterine bleeding and separation of uterine wall/ acute
Do we deliver the patient with placental previa or abruption conditions as soon as the patient complains of bleeding?
In both cases, bleeding does not always result in immediate delivery!
Placenta Accreta/Percreta/Increta: What is it? How is it diagnosed?
● Abnormal placental attachment beyond the endometrium○ Diagnosed via ultrasound in pregnancy
● Not clinically important until delivery → Plan for cesarean
birth○ Often counseled for hysterectomy and blood transfusions
Plecental (Accretta/Percreta/ Increta): Severity Order
● Accreta: placenta attached to myometrium (think Aattached)
● Increta: placenta attached into myometrium (IN further into myometrium)
● Percreta: placenta attached through myometrium and often (think PERFUSES TO other) to nearby organs such as bladder
Early Bleeding causes:
● Miscarriage
● Ectopic
● Incompetent Cervix
● Hydatiform Mole (molar
pregnancy)
Late Bleeding causes:
● Placenta Previa
● Placenta Abruption
Bleeding in Pregnancy/Hemorrhagic Disorders (Info based on trimester)
● Bleeding in the first trimester is normal 50% of the time
● 1st trimester: Assume all pain and bleeding is an ectopic until proven otherwise
● 2nd and 3rd trimester: Assume all bleeding is due to a placenta previa
****NO pelvic exams until identify placental location!
Vasa Previa:
● Fetal vessels on outer surface of placenta exposed
● Want to avoid spontaneous labor at all costs
○ Contractions/rupture of membranes can lead to fetal exsanguination since
vessels are exposed
● Early scheduled cesarean around 34 weeks
● Any signs of labor likely immediate cesarean
Hypertensive Disorders of Pregnancy
● Chronic Hypertension
● Gestational Hypertension
● Preeclampsia
● Eclampsia
● Superimposed preeclampsia (SIPE)
Chronic vs. Gestational Hypertension
Chronic hypertension related to pregnancy:
● Preexisting hypertension that is diagnosed before 20 weeks gestation
● Patients may or may not be on antihypertensive medications
Gestational hypertension:
● Hypertension that develops after 20 weeks gestation
● No change in lab values or symptoms other than high blood pressure
Preeclampsia Risk Factors
● Nulliparous
● Age > 40 years
● Assisted Reproductive Fertility treatments
● Obesity
● Diabetes
● Multiple pregnancy
● Hypertension, prior preeclampsia, or family history of preeclampsia
Gestational Hypertension vs. Preeclampsia
- All have elevated blood pressures but the difference comes down to lab values,*
- CNS symptoms, and pre-existing hypertension*
● Gestational hypertension (gHTN): normal labs and no symptoms
● Preeclampsia (preX or preE): abnormal labs & CNS symptoms, no preexisting
chronic hypertension
Superimposed preeclampsia (SIPE):
Same as preeclampsia above but develops in a
patient with chronic hypertension
Preeclampsia Signs & Symptoms:
● Elevated blood pressure >130/90
● Severe headache unrelieved by Tylenol (NEURO INVOLVEMENT)
● Blurry vision (NEURO INVOLVEMENT) can precede strokes
● Epigastric pain
● Sudden weight gain and/or swelling of face/hands (Kidney INVOLVEMENT)
○ Fluid retention and decreased urine output; can lead to overload and
pulmonary edema
● Liver involvement:
○ Signs of liver pain that is often accompanied by elevated liver enzymes
● Endothelial damage
○ Hypertension, fluid retention, can lead to low platelets
Preeclampsia: LAB VALUES
● Elevated protein in urine (large amount of urine (3+), protein > 0.4) (DECREASED RENAL FUNCTION)
● Elevated liver enzymes (↑ ALT, AST and uric acid)
● Decreased kidney function (↑ BUN)
● May have thrombocytopenia (↓ platelets
CBC, BMP, URINE
Preeclampsia Diagnosis : NURSING INTERVENTIONS
● Serial lab draws, symptom assessment, frequent blood pressure checks, fetal
monitoring, “Mag check” hourly assessments if on Magnesium Sulfate, likely foley
placement at some point in labor or postpartum
Preeclampsia Diagnosis: Mild vs. Severe: BP VALUES
Mild Preeclampsia:
● Blood pressure >130/90 and <160/110 plus abnormal lab(s)
Severe Preeclampsia:
● BP (SBP> 160 and/or DBP> 110)
….. and/or severe CNS symptoms and abnormal lab values
Eclampsia:
● Preeclampsia that has progressed and resulted in a seizure, stroke, and/or coma
● Priority is safety during seizure
● Need magnesium sulfate on board (IV or IM) and potentially anti-seizure med
● Delivery ideally not immediate; depends on well-being of fetus
Eclampsia: NURSING INTERVENTIONS
- Protect the airway
- turn head
- raise and pad side rails
- call for help
- document seizure details, remain at bedside during and after, ensure adequate IV access
- assess vitals to determine need for medications
- assess fetal heart rate
- assist with transfer to imaging if needed
- work with team
Magnesium Sulfate for Preeclampsia/Eclampsia Patients
● CNS Depressant
● Indication for pregnant patient for labor and for 12 hours after delivery
● Neuroprotective for pregnant patient by preventing stroke and seizures
● Dosage: Loading dose and maintenance dose similar to preterm labor
● Seizure precautions needed for these patients
What symptoms might you expect if a patient’s preeclampsia is worsening and/or
may progress to eclampsia?
Meaning: Progression from mild to severe preeclampsia and/or severe preeclampsia to eclampsia
● More abnormal lab values
● Higher blood pressure
● Worsening of the CNS symptoms
● More abnormal “Mag checks”
○ Hyperreflexive (↑ deep tendon reflexes (DTRs)
○ Presence of clonus (“beats” from ankle reflex)
○ Increasing fluid retention (pulmonary edema, urine output <30cc/hour)
When is Anti-Hypertensive Medications in Pregnancy indicated?
● Indicated if two severe range blood pressures 15 minutes apart
● Severe range BP (SBP> 160 and/or DBP> 110)
Are patients with first baby more likely for preclampsia or patient with multiple pregnancies?
Patients with FIRST pregnancy and note * older pregnant mothers over 35
Can Preeclampsia still labor and have vaginal deliveries?
Yes, as long as preeclampsia isn’t increasing and baby is ok
HELLP Syndrome (in family of preeclampsia but different)
● Hemolysis (breakdown of redblood cells
● Elevated (liver enzymes)
● Liver enzymes
● Low (platelets)
● Platelets
● Can be life-threatening
● If platelets are too low, may not be able to administer an epidural
Two types of Gestational Diabetes
● Diet-Controlled (A1GDM)
● Insulin-Dependent (A2GDM)
Diabetes Assessment in Pregnancy
● All patients tested at 28 weeks
○ Unless already have preexisting diabetes
● Risk factors: family history of diabetes, obesity, previous gestational diabetes,
previous macrosomia, elevated HbA1C
○ These patients may perform GTT (glucose tolerance test) earlier than 28 weeks
Gestational Diabetes Testing : Lab value
● 1 hour (50g) GTT performed at 28 weeks (or earlier if high risk)
○ Abnormal: Blood sugar >130
If Gestational Diabetes 1 hour tests above 130?
Then requires 3 hours (100g) GTT test
○ 4 blood draws
○ Abnormal: 2 or more of the blood sugar values are elevated
What diagnoses Gestational Diabetes?
- 1st 1 hour test over 130
- 3 hour test (2 out of 4 numbers are abnormal
Possible Fetal Consequences of Diabetes
Can make bigger baby:
● Poor glycemic control before and during pregnancy increases the risk of:
-Congenital anomalies, macrosomia (growth beyond gestational age) and associated risk in labor & delivery (shoulder dystocia, labor dystocia, need for operative delivery/cesarean), neonatal HYPOglycemia
Nursing Interventions for Diabetes in Pregnancy
● Ensure access to medical supplies
● Teach how to use equipment for blood sugar monitoring and medication
administration
● Focus is not on weight loss
● Nutrition counseling: increase protein, vegetables, fiber, decreasing sugars, do
not skip meals, eat snacks or refer to nutritionist
● Importance of exercise
● Hypoglycemia signs and symptoms
● Blood sugar goals
Variables vs Variability
- *Variables:** type deceleration where heart rate goes down fast and back up fast (dont want decels)
- *Variability** is the beat to beat change in fetal heart rate (want variability)
Define Fetal Tachysystole While in Labor:
>5 contractions in 10 minutes (ctxs q 2 minutes or less)○ Averaged over 30 minutes (just know you don’t want more than every 2 min contractions)
○ If not corrected, fetus may become distressed if too many contractions
