Exam 2 Flashcards
What is gestational trophoblastic disease?
Hydatidiform mole, where trophoblasts develop abnormally. Placenta does not develop normally and if fetus is present, there will be fatal chromosomal defect
Medical management for hydatidiform mole
- Evacuation of trophoblastic tissue of the mole (usually by vacuum aspiration followed by curettage, then oxytocin)
- Continuous follow up to detect malignancies (choriocarcinoma may occur)
Difference between marginal placenta previa and partial placenta previa
Marginal: placenta’s border >3 cm from cervical os
Partial: placenta’s border <3 cm from cervical os, not completely covering it
What is abruptio placentae?
Separation of normally implanted placenta before fetus is born
S/S of placenta previa
Sudden onset of painless uterine bleeding in last half of pregnancy
S/S of abruptio placentae
Bleeding (may be concealed behind placenta)
Uterine tenderness
Frequent, low-intensity contractions
Abdomen/low back pain
High uterine resting tone, board like abdomen
Port wine colored amniotic fluid
Nonreassuring FHR patterns or fetal death
Signs of hypovolemic shock
Risk factors for placenta previa
Older women
Multiparty
Previous c/s
Prior uterine surgery
Asian ethnicity
Cocaine/cigarette use
Male fetus
Risk factors for abruptio placentae
Abdominal trauma
Cocaine/cigarette use
HTN
Multigravida status
Short umbilical cord
Premature rupture of membranes
Previous abruptio placentae
Symptoms of pre-eclampsia
HTN (>140/90) after 20 weeks. May be accompanied by Proteinuria
Risk factors for pre-eclampsia
Obesity
Pre-pregnancy diabetes
Treatment for preeclampsia
- Bedrest, monitor BP at home, daily weight, urinalysis, increased fetal assessments, high protein/high calorie diet
- Antihypertensive meds if BP >160/110
- 37 weeks or more: delivery
- 34-37 weeks: steroids and delay birth for 48 hrs
Meds given for severe preeclampsia
Lebatalol, Hydralazine, or Nifedipine
Magnesium sulfate
How does magnesium sulfate work?
CNS depressant, decreases amount of acetylcholine
Antidote for magnesium sulfate
Calcium gluconate
Therapeutic serum level of magnesium sulfate and toxic level
5-8 mg/dL
Toxic = >8 mg/dL
Significant adverse reactions of magnesium sulfate
CNS depression, respiratory depression, loss of DTR
Risks for mother with eclampsia
Ruptured membranes from seizure
Pulmonary edema
Heart failure
Reduced renal blood flow = Oliguria
What does HELLP stand for?
Hemolysis
Elevated liver enzymes
Low platelets
Risk factors for HELLP
Eclampsia
Chronic HTN
Diagnosis of gestational diabetes
During 1 hr GCT, if glucose > 140 mg/dL, need 3 hr
If 3 hr GTT glucose is >140 mg/dL = diabetes
Risks for fetus is mom has gestational diabetes
Congenital malformation
Small or large for gestational age
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia
Respiratory distress syndrome
Classification of cardiac disease
Acquired heart disease:
- Rheumatic
- Valvular stenosis
- MI
- Cardiomyopathy
Congenital heart disease:
- Left-to-right shunt
- Right-to-left shunt
- other congenital lesions
Cause of rheumatic heart disease
Sometimes following streptococcal pharyngitis that causes scarring of heart valves (mitral valve most common)
What can rheumatic heart disease lead to?
Pulmonary HTN
Pulmonary edema
Congestive heart failure
What is valvular stenosis caused by?
Infection or blockage of the heart (can sometimes be surgically repaired)
When is a pregnant pt most at risk for an MI?
Third trimester
What is cardiomyopathy?
Rare and often fatal disorder of heart muscle structure
What are examples of a left-to-right shunt?
Atrial septal defect (hole between atria)
Ventricular septal defect (hole between ventricles)
Patent ductus arteriosus (opening between two blood vessels leaving the heart)
What are examples of right-to-left shunts?
Tetralogy of Fallot (combo of 4 heart defect, causes oxygen poor blood to flow from heart into body)
Eisenmenger syndrome (irregular blood flow in heart and lungs, causes blood vessels in lungs to become stiff and narrow)
S/S of heart disease
Dyspnea with exertion
Syncope with exertion
Hemoptysis
Paroxysmal nocturnal dyspnea
Chest pain with exertion
Which classes of heart disease are safe to get pregnant, and which aren’t?
Class I or II, high risk, but ok to get pregnant
Class III or IV, should not get pregnant (risk for MI if cardiomyopathy)
Drug therapy for pts with cardiac disease
Anticoagulants
Antirrhythmics
Ant-infectives
Drugs for heart failure
Recommendations for delivery for a pt with cardiac disease
Vaginal delivery (less blood)
Minimize pushing and use of Valsalva maneuver
Limit prolonged labor
Postpartum management for pts with cardiac disease
- Possible cardiac decomposition during postpartum period
- Observe for signs of infection, hemorrhage, thromboembolism (conditions can act together to cause heart failure in cardiac pts)
- Watch for S/S of congestive heart failure
Recommended weight gain for obese women (BMI 30 or >)
11 to 20 lbs
Recommended weight gain for overweight women (BMI 25-29.9)
15 - 25 lbs
What is a normal/safe contraction pattern?
< or equal to 5 contractions in 10 mins
What should you do if tachysystole or nonreassuring FHR during induction/augmentation of labor?
1 - reduce or stop infusion
2 - side lying position
3 - oxygen by face mask at 10L/min
4 - notify provider (anticipate order for terbutaline)
5 - oxytocin may be administered again if tachysystole resolves and FHR returns to normal
Nursing actions for pt undergoing induction/augmentation of labor
Assess for excessive uterine activity
Assess BP and pulse every 30 min & with each oxytocin increase
Record intake and output
Observe for signs of water intoxication
Assess for uterine antony in pp period (soft uterus, excess lochia)
What causes contractions?
Stimulated by oxytocin
Coordinated process between uterus and fluctuations of estrogen and progesterone
Frequency of contractions
How often
Measured from the beginning of one contraction to the beginning of the next (in minutes)
Duration of contractions
How long the contraction lasts
Measured from the beginning of one contraction to the end of it (in seconds)
Intensity of contractions
Measured by pain scale, palpation
Three phases of each contraction
Increment (period of increasing strength)
Peak (most intense period)
Decrement (period of decreasing intensity)
Interval (period of time between contractions)
What are you checking during a cervical exam?
Effacement (thinning of cervix)
Dilation (cervix opening)
Station
Presenting part of baby
(And if membranes are still intact)
What happens to maternal blood flow during labor?
- Decreased blood flow to uterus during contraction = decreased placental blood flow
- increase in blood volume
- increased BP and slowed pulse
- supine hypotension more likely (encourage other positions)
What happens to respirations during labor?
Increased depth and rate
Hyperventilation (rapid and deep breathing), respiratory alkalosis (too much CO2), tingling
What happens to hematopoietic system during labor?
- Normal blood loss: 500mL vaginal, 1000mL c/s
- Clotting factors elevated (fibrinogen) during pregnancy, labor, and after delivery
What are the four Ps of childbirth?
Powers - contractions and maternal pushing
Passage - parts of the pelvis
Passenger - fetus, membranes, placenta
Psyche - anxiety, culture, expectations, experience, support
Fetal anatomical and positional variables that influence the course of labor
- Fetal head (want cephalic presentation)
- Fetal lie (orientation of the long axis of the fetus to the long axis of the woman. Want it to be longitudinal and parallel to the long axis of the woman)
- Attitude (Relation of fetal body parts to one another. Want flexion)
- Presentation (fetal part that first enters the pelvis. Want cephalic vertex)
- Position (location of presenting part in relation to four quads of pelvis)
Cardinal movements of the head in normal labor
Engagement
Descent
Flexion
Internal rotation
Crowing
Extension
Restitution
External rotation
First stage of labor
From start of labor until full dilation
3 phases
3 phases of the first stage of labor
Latent phase (0-3 cm)
Active phase (4-6 cm)
Transition (7-10 cm)
Second stage of labor
Complete dilation to delivery of baby
Third stage of labor
Delivery of baby to after placenta is delivered
Fourth stage of labor
1-4 hours after delivery
What should be done if a pt has an epidural and maternal hypotension occurs?
Rapid no dextrose IV fluid bolus
Maternal repositioning
O2 administration
If those are ineffective, IV phenylephrine or ephedrine administered to promote vasoconstriction to raise BP
What can happen if the epidural catheter moves?
Intravascular injection: an intense block or one that is too high, absence of anesthesia, or a unilateral block
If a pt has an epidural and it is found that she has a fever, what should be done?
Should look for other symptoms of infection like:
Fetal tachycardia or amniotic fluid with strong odor
Could not be infection and be resulting from epidural block instead
Adverse effects of epidural opioids
N/v
Pruritus
Shivering
Delayed respiratory depression (for 12 hrs after admin of epidural opioid)
Monitoring vitals after epidural placement
Should assess maternal BP and FHR every 5 min for first 15 min or after every increase of med
Repeat assessment of BP and FHR at 30 min and 1 hr after the procedure
Other types of spinal meds given besides epidural
Intrathecal opioids
CSE (combined Intrathecal opioids with epidural)
Spinal block
Types of parenteral analgesia
Neperidine (Demerol) - controversial
Fentanyl (Sublimaze)
Butorphanol (Stadol)
Nalbuphine (Nubian)
Which parenteral analgesics should a mother with opioid dependence issues not be given? and why?
Butorphanol and nalbuphine
Because they are mixed agonist-antagonist drugs and may cause withdrawal effects in herself and newborn
5 factors for adequate fetal oxygenation
1- Sufficient maternal blood flow and volume to placenta
2- Normal maternal oxygen saturation
3- Adequate exchange of oxygen and carbon dioxide
4- Open circulatory path from placenta to fetus through umbilical cord vessels
5- Normal fetal circulatory and oxygen-carrying functions
Instruments used for intermittent auscultation
Fetoscope
Picard stethoscope
Handheld Doppler ultrasound
What causes early decelerations?
Fetal head compression
Benign and not associated with interruption of fetal hypoxia, acidosis, or low APGAR scores
What causes late decelerations?
Decreased fetal blood flow, resulting in fetal hypoxia
(Will typically dissipate with repositioning, etc. Concerning when they are recurring)
What causes variable decelerations?
Interruption of oxygenation at the level of the umbilical cord, where cord vessels may be compressed
Corrective measures that may be done when nonreassuring FHR patterns are noted
Maternal repositioning
IV fluid blouses
Administer oxygen
Reduce UA
Correct maternal hypotension
Perform amnioinfusion
Modify second-stage pushing efforts
What does repositioning mother to lateral or hands and knees help with?
Variable or prolonged decelerations r/t cord compression
Lateral repositioning may also increase uterine blood flow
How does in IV bolus of fluid help with placental perfusion and fetal oxygenation?
Increases circulating blood volume and improves cardiac output
Nursing actions for a maternal hypotension
Lateral repositioning
IV hydration
If those actions are not sufficient, may need medication to increase BP (epi or phenylephrine)
What does veal shop stand for?
Variable - Cord compression
Early - Head compression (OK)
Accelerations - OK
Late - Placental insufficiency
What is a prolonged FHR pattern?
Can be periodic or episodic
Acceleration or deceleration that lasts >2 min - 10 min
After 10 min = Brady or tachycardia
4 categories needed to assess UA
Frequency
Duration
Intensity
Resting tone
Categories of fetal heart rate patterns
Category 1 = normal
Category 2 = indeterminate
Category 3 = abnormal and need to deliver baby
What do variable, late, or prolonged decelerations indicate? What should be done?
Interruption of oxygen transfer
Need to:
move pt to left side
IV fluids
Oxygen
Notify provider (last)
Slow contractions
What is the ABCD approach to FHR management?
Assess O2 pathway and identify etiology of FHR changes (both maternal and fetal)
Begin conservative measures
Clear obstacles to delivery
Determine delivery plan
