🤰🏾- Exam 2 Flashcards
Placenta previa
Abnormal implantation of the placenta in the lower uterus at or very near the cervical os
Indications for limited ultrasound scan
(Done quickly for a specific reason)
- determine placental location
- detect presence or absence of fetal ❤️ rate
- assess volume of amniotic fluid
- guide delivery of 2nd twin in a vag birth
- assist with amniocentesis
Doppler ultrasound blood flow assessment
Performed on pregnancies complicated by hypertension or fetal growth restrictions
To identify abnormalities in the diastolic flow
Low vs high levels of MSAFP are associated with what
Low levels associated with chromosomal abnormalities
Ex: Down syndrome, trisomy 21
High levels are associated with open NTD and body wall defects
Ex: anencephaly, spina bifida, hydronephrosis
Alpha-Fetoprotein screening
Done between 16 and 18 weeks
** maternal weight can misconstrue results **
Screening test , not diagnostic
Done to detect possible open body defects and congenital anomalies
Chorionic villus sampling
The villi are fetal tissues
Done between 10 and 12 weeks to diagnose fetal chromosomal, metabolic or DNA abnormalities
Can cause limb reduction defects (LRD)
Give RhoGAM to 🤰🏾that is Rh-negative
Amniocentesis
Done at 15 to 20weeks
Can cause foot deformations
May resume normal activities 24hrs after procedure
Aspirate 20mL of amniotic fluid for testing
Give RhoGAM
Amniocentesis in 2nd vs 3rd trimester
2nd - done to identify chromosome abnormalities
3rd - done to determine fetal lung maturity and test for fetal hemolytic disease (anemic , jaundice and hydrops fetalis)
Percutaneous umbilical blood sampling
Aka cordocentesis
Aspiration of fetal blood from the umbilical cord for prenatal diagnosis and management rH disease, abnormal blood clotting and determination of the acid-base stays of the fetus
can deliver therapeutic drugs/blood trans that can’t be delivered to the fetus in another way
Umbilical VEIN is used because it’s larger
3 goals and types of antepartum fetal surveillance
Goals
- Determine fetal health or compromise as accurately as possible
- Reduce perinatal morbidity and mortality
- Guide intervention by the obstetric team
Types: nonstress test, contraction stress and biophysical profile
Non-Stress Test
Used to determine reactive/reassuring fetal movement = At least 2 fetal heart accelerations with or without movement occur within a 20min period .
before the NST, the woman should void
Fetal acceleration is classified as
An increase of heart rate at least 15 beats lasting at least 15 secs
Preterm acceleration in a NST
In a fetus younger than 32wks two accelerations that peak 10 beats and lasts for 10 secs - within a 20min window
What is the concern with FHR accelerations without fetal movement
Fetal hypoxemia and acidosis
Uteroplacental insufficiency
Inability of placenta to exchange oxygen, carbon dioxide, nutrients and waste products properly between maternal and fetal circulations
CST interpretation: negative, positive, equivocal or unsatisfactory
Negative- (reassuring) no late deceleration present
Positive- (abnormal) late decelerations are present
Equivocal- test must be redone
Unsatisfactory- fewer than 3 contractions in 10mins occurred; unable to test
What is used to induced contractions in a contraction stress test (CST)
Diluted oxytocin
Oligohydramnios
Decreased amniotic fluid
Which suggests prolonged fetal hypoxia
Biophysical profile (BPP)
Assess FHR, fetal breathing movements, gross fetal movements, fetal muscle tone and amniotic fluid volume
Gradual hypoxia concept
Fetal activity is effected in stages with how long hypoxemia lasts
- loss of FHR reactivity (occurs first)
- reduced, then absent, fetal breathing movements
- reduced, then absent, gross (large) fetal movements
- reduced fetal tone
- prolonged hypoxemia: reduced amniotic fluid volume (occurs last)
Absence of fetal tone indicates what
Advanced asphyxia and acidosis
BPP score interpretation
Less than 4= deliver baby now
6= equivocal
8-10= normal
Maternal assessment of fetal movement
Assess the kick counts within a time period
Fetal circulation umbilical vein vs arteries
Vein- carries oxygenated blood TOWARD the fetus
Arteries- dexoxygenated blood AWAY from the fetus to the placenta
Adequate fetal oxygenation needs what 5 related factors
1 normal maternal blood flow and volume to the placenta
2 normal oxygen saturation in maternal blood
3 adequate exchange of oxygen and carbon dioxide in the placenta
4 an open circulatory path between the placenta and the fetus through vessels in the umbilical cord
5 normal fetal circulatory and oxygen-carrying functions
5 factors of fetal ❤️ rate regulation
1 autonomic nervous system
2 baroreceptors
3 chemoreceptors
4 CNS
5 adrenal glands
FHR and parasympathetic vs sympathetic nervous system
Sympathetic- increases ❤️ rate through release of epinephrine and norepinephrine
Parasympathetic- reduces ❤️ rate and maintains variability through stimulation of the vagus nerve / exerts greater influence as the fetus matures between 28 and 32wks gestation
fhr in the term fetus is lower than in the preterm fetus
Compromise of fetal oxygenation may occur because of what 5 factors
1 maternal cardiopulmonary alterations
2 hypertonic uterine contractions
3 placental disruptions
4 umbilical blood flow interruptions
5 fetal alterations
Doppler transducer
Produces a two-part muffled sound that resembles the sound of a galloping 🐴.
Represent closure of the heart valves during systole (mitral / tricuspid) and diastole (aortic / pulmonic)
Tocotransducer
Detects changes in abdominal contour to measure uterine activity “assess contractions”
Classification of variability
Absent - undetectable
Minimal - undetectable to 5 bpm
Moderate - 6 to 25 bpm
Marked - greater than 25 bpm
Early decelerations
Fetal head compression increases ICP causing the vagus nerve to slow the ❤️ rate - not associated with fetal compromise and require no intervention
Mirror contractions
Late decelerations
Deficient exchange of oxygen and waste products in the placenta (uteroplacental insufficiency)
Intervention: reposition to Left side, give oxygen, increase fluids, decrease pitocin
Variable decelerations
Conditions that reduce flow through the umbilical cord
Interventions: reposition, decrease pitocin, give amnioinfusion
Aminoinfusion
Infusion of a sterile isotonic solution into the uterine cavity during labor to reduce umbilical cord compression
May also be done to dilute meconium in amniotic fluid and reduce the risk that the infant will aspirate thick meconium at birth
Contraction frequency
Beginning of one contraction to beginning of the next
Contraction duration
Beginning to end of each contraction
How long contraction lasts
Cord blood gases and pH
Umbilical cord blood analysis is used to asses the infants oxygenation and acid-base balance immediately after birth
What is the physiologic retraction ring
The division between the upper and lower segments of the uterus
Upper- contracts actively and during labor becomes thicker
Lower- and cervix contracts passively , during labor both become thinner and are pulled upward
Effacement vs dilation
Effacement is thinning and shortening of uterus
Dilation is opening of uterus
During labor which cervix remains thickest a multipara or nullipara
Multipara’a cervix remains thicker that the nullipara’s cervix
Increment, acme, decrement
3 phases of a contraction:
Increment- period of increasing strength
Acme- aka peak period during which the contraction is most intense
Decrement- period of decreasing intensity
Physiological effects of the birth process:
Maternal response
5 systems
Cardiovascular - increase in maternal blood volume, increasing BP decrease ❤️ rate
Respiratory - increased respirations , can lead to respiratory alkalosis
GI - decreased motility can cause nausea and vomiting
Urinary - decreased sensation of a full bladder
Hematopoietic -
Respiratory alkalosis
Result of hyperventilation when she exhales too much carbon dioxide
Presentation:
Tingling of hands and feet, numbness and dizziness
Intervention:
Help mom slow her breathing and breathe into a paper bag to restore normal carbon dioxide levels
Physiological effects of the birth process:
Fetal response
3 systems
Placental circulation-
Cardiovascular- alterations in ❤️ rate
Pulmonary-
What are the 4 components of the birth process
Powers- uterine contractions (1st stage) and pushing efforts (2nd stage)
Passage- maternal pelvis and soft tissues
Passenger- fetus, membranes and placenta
Psyche- psychological response to labor is influenced by anxiety, culture, expectations, life experiences and support
Fetal lie
The orientation of the long axis of the fetus to the long axis of the woman
Longitudinal- in 99% of pregnancies parallel to the long axis of woman. Head or feet enter pelvis first
Transverse- long axis of fetus is at right angle to long axis of mom
Fetal attitude
The relation of fetal body parts to one another
Flexion- (normal) head flexed toward chest and arms and legs flexed over thorax
Extension- (abnormal) head and right arm are extended
Fetal presentation or presenting part
The fetal part that first enters the pelvis:
1 cephalic
2 breech
3 shoulder
cephalic presentation with fetal head flexed most common
4 variations of Cephalic presentation
Vertex- or occiput presentation. Most common. Fetal head is fully flexed
Military- head in neutral position. Neither flexed or extended. Occipitofrontal presenting
Brow- fetal head partly extended. Supraoccipitomental presenting
Face- head is extended. Occiput near fetal spine. Submentobregmatic presenting
Which fontanel can be felt in the vertex presentation vs military presentation
Vertex- posterior
Military- anterior
Breech presentation is more common in term or preterm fetus
More common in preterm births and when a fetal abnormality like hydrocephalus prevents the head from entering the pelvis
Abnormalities of maternal uterus and pelvis or with placenta previa
3 variations of Breech presentation
Frank- most common. Fetal legs are extended across the abdomen towards the shoulders
Full (complete)- reversal of cephalic presentation. Head, knees and hips are flexed but butt is presenting
Footling- occurs when one or both feet are presenting
Lightening
Descent of the fetus toward the pelvic inlet before labor
What are the 7 cardinal movements
Descent
Engagement
Flexion
Internal rotation
Extension
External rotation
Expulsion
Descent
Descent of the fetal presenting part through the true pelvis
Engagement
The Fetal presenting part as its widest diameter reaches the level of the ischial spines of the mothers pelvis (0 station)
Flexion
Of the fetal head allows the smallest head diameters to align with the smaller diameters of the midpelvis as the fetus descends
Internal rotation
Allows the largest fetal head diameters to align with the largest maternal pelvic diameters
Extension
Of the fetal head as the neck pivots on the inner margin of the symphysis pubis, allows the head to align with the curves of the pelvic outlet
the head is born
External rotation
Of the fetal head aligns the head with the shoulders during expulsion
Expulsion
Of the fetal shoulders and fetal body
What are the 4 stages of labor
Stage 1- cervical effacement and dilation occur longest stage
Stage 2- (expulsion) begins with complete dilation and full effacement and ends with birth of the 👶🏾
Stage 3- (placental) begins with the birth of the baby and ends with the expulsion of the placenta shortest stage, average length 6 mins
Stage 4- physical recovery and bonding may experience chills
Schultze mechanism vs Duncan mechanism
Schultze- placenta expelled with the SHINNY fetal side presenting first more common
Duncan- ROUGH maternal side presents first
Latent phase of the first stage of labor
Lasts through the first 3cm of dilation
Lasts 7.3-8.6hrs in nulliparas and 4.1-5.3hrs in multiparas
Contractions every 5mins lasting 30-40secs
Active phase of the first stage of labor
Cervix dilates from 4 to 7cm , effacement is completed
Fetus descends in the pelvis and internal rotation begins
Contractions are 2-5 mins apart lasting 40-60secs
Transition phase of the first stage of labor
Cervix dilates from 8 to 10cm
bloody show increases with completion of dilation
Contractions 1.5-2mins apart lasting 60-90secs
Leg tremors, nausea and vomiting are common
When should 🤰🏾go to the hospital
-contractions:
nullipara 5mins apart for 1 hour
multipara 10mins apart for 1 hour
- ROM
- Bleeding/increased bloody show
- Decreased fetal movement
How does a nurse establish a therapeutic relationship with mom and their significant other
Make the family feel welcome, determine family expectations about birth, convey confidence, assign a primary nurse, use touch for comfort, respect cultural values
Maternal vital signs are assessed to identify signs of
Hypertension and infection
A temperature of 38’C (100.4’F) or higher suggests infection
What are the signs of impending birth
Grunting sounds, bearing down, sitting on one butt cheek and saying “the baby’s coming”
Database assessment during admission
- obtain basic info (LMP, Due date, GTPAL, etc)
- fetal assessment presentation and position assessed using vaginal exam and leopold
- labor status
- physical examination
no vag exam if active bleeding or preterm , do speculum exam instead
What are the 4 Leopold’s maneuvers
1- distinguishes between cephalic or breech presentation
2- determines which side the fetal back is facing
3- determines if presenting part is engaged
4- determines if head is flexed or extended not done if in breech position
What does yellow or green amniotic fluid color mean
Amniotic fluid should be clear and may contain bits of vernix
Yellow- cloudy, yellow and foul-smelling suggests infection
Green- indicates that the fetus passed meconium before birth
Intact / bulging / ruptured membranes
Intact- feel slippery , no leakage of amniotic fluid can be detected
Bulging- feel like a slippery, fluid-filled balloon
Ruptured- show drainage of fluid from the vagina
What is 0 station
When the presenting part is at the ischial spine
Negative numbers- no fetal descent
Positive numbers- head descent through pelvis
Conditions associated with fetal compromise
- FHR outside the normal range or loss of variability
- meconium stained amniotic fluid
- cloudy, yellowish or foul-smelling amniotic fluid
- Hypertonic contractions (reduces placental blood flow)
- maternal hypotension or hypertension
- maternal fever (100.4’F)
What does laboring down mean
The technique of delaying pushing until the reflex urge to push occurs
What is valsalva maneuver
“Purple pushing”
Sustained pushing while holding a breath
Nursing interventions to elevate discomfort during birth
Comfort measures
Teaching
Encouragement
Giving of self (spend time with patient)
Pharmacologic measures
Caring for the birth partner
Evaluation
List examples of comfort measures during child birth the nurse should do
Dim lights Mouth care (ice chips) Adjust temperature Damp washcloths Maintain dry chux Change position Assist bladder emptying Provide cleanliness
Maternal positions during first stage vs second stage
First- sitting leaning forward with support, semi sitting, side lying, kneeling leaning forward with support
Second- hands and knees, semi sitting and side lying
Back labor
When the back of the fetal head puts pressure on the woman’s sacral promontory (occiput posterior position)
Hands-and-knees position enhance the internal rotation mechanism of labor
Pushing before stage 1 is complete causes
Cervical edema
Block labor
Lacerations
Nurse’s responsibilities during birth
- preparation of delivery table
- perineal cleansing preparation
- support with final pushing efforts
- administer medications (oxytocin to contract uterus and control blood loss)
Nursing care during the fourth stage of labor
Care of the infant- cardiopulmonary , thermoregulatory and identifying the infant
the mother- assess VS q15mins, assess fundus firmness and position, a full bladder interferes with contraction of the uterus and assess lochia
the family unit- first hour after birth ideal for parent and infant attachment
Early nipple stimulation from the baby attempting to latch helps what
Initiate milk production and contract the uterus
What are the three risks associated with amniotomy
Prolapse cord
Infection
Abruptio placentae
Chorioamnionitis
Inflammation of the amniotic sac, usually caused by bacterial and viral infections
Hydramnios vs oligohydramnios
Hydramnios- excessive volume of amniotic fluid associated with some fetal abnormalities
Oligohydramnios- abnormally small quantity of amniotic fluid maybe associated with placental insufficiency or fetal urinary tract abnormalities
What are the criteria for an amniotomy
Active labor (4cm)
Term (37wks)
Engaged (0 station)
Induction vs augmentation
Induction- to cause/initiate labor
Augmentation- stimulate effective contractions after labor has begun
Indications for induction of labor
- gestational and chronic hypertension
- PROM
- chorioamnionitis
- postterm (over 42 weeks)
- intrauterine growth restriction
- positive contract test
- isoimmunization (maternal fetal blood incompatibility)
- fetal death
Contraindications of induction of labor
- disproportion between fetal head and maternal pelvis
- unfavorable fetal presentation (transverse or breech)
- placenta previa/abruptio placentae
- multifetal gestation or multiparity (6 or more)
- prior classical uterine incision
- active genital herpes
- prolapse cord
Dinoprostone
(Prepidil) prostaglandin gel
0.5mg applied to cervix, maximum recommended dose 1.5mg applied to cervix and 2.5mg vaginally
Actions for HC: side lying, 8-10L oxygen, administer tocolytic (terbutaline of mag sulfate)
When to start oxytocin: delay 6-12hrs recommended
Comments: remain still for 15-30mins after application, increases effects of ephedra , use caution in women with asthma/hypertension/glaucoma/Renal, liver or heart disease
Vaginal insert dinoprostone
Cervidil
10mg in a time release vaginal insert left in place for up to 12hrs. Remove with onset of active labor, ROM, uterine hyperstimulation
Actions for HC: side lying, 8-10L oxygen, administer tocolytic (terbutaline of mag sulfate), remove insert
When to start oxytocin: 30-60mins after removal of insert
Misoprostol
Cytotec
25mcg of 100mcg tablet vaginally
Actions for HC: side lying, 8-10L oxygen, administer tocolytic (terbutaline of mag sulfate)
When to start oxytocin: atleast 4 hours after last dose
Comments: only approved for peptic ulcers but used for cervical ripening
contraindicated in previous cesarean or other uterine surgery
Bishop score
Estimates whether the cervix is favorable for induction
Cervical dilation, effacement, fetal station, cervical consistency, position
Vaginal birth more likely to result if score is higher than 8
Serial induction of labor
May be performed when the cervix is not favorable and she has an indication for induction but same-day birth is not imperative
Postdate pregnancy
Version
Change fetal presentation
Contraindications: abnormal uterus shape, baby over 4000g, engagement of fetal head, nuchal cord
Risks: fetal hypoxia, abruptio placentae and immediate c-section if compromised
perform NST or BPP, after 37wks, administer tocolytic or RhoGAM if needed
Version
Change fetal presentation
Contraindications: abnormal uterus shape, baby over 4000g, engagement of fetal head, nuchal cord
Risks: fetal hypoxia, abruptio placentae and immediate c-section if compromised
perform NST or BPP, after 37wks, administer tocolytic or RhoGAM if needed
Serial induction of labor
May be performed when the cervix is not favorable and she has an indication for induction but same-day birth is not imperative
Postdate pregnancy
Bishop score
Estimates whether the cervix is favorable for induction
Cervical dilation, effacement, fetal station, cervical consistency, position
Vaginal birth more likely to result if score is higher than 8
Misoprostol
Cytotec
25mcg of 100mcg tablet vaginally
Actions for HC: side lying, 8-10L oxygen, administer tocolytic (terbutaline of mag sulfate)
When to start oxytocin: atleast 4 hours after last dose
Comments: only approved for peptic ulcers but used for cervical ripening
contraindicated in previous cesarean or other uterine surgery
Vaginal insert dinoprostone
Cervidil
10mg in a time release vaginal insert left in place for up to 12hrs. Remove with onset of active labor, ROM, uterine hyperstimulation
Actions for HC: side lying, 8-10L oxygen, administer tocolytic (terbutaline of mag sulfate), remove insert
When to start oxytocin: 30-60mins after removal of insert
Dinoprostone
(Prepidil) prostaglandin gel
0.5mg applied to cervix, maximum recommended dose 1.5mg applied to cervix and 2.5mg vaginally
Actions for HC: side lying, 8-10L oxygen, administer tocolytic (terbutaline of mag sulfate)
When to start oxytocin: delay 6-12hrs recommended
Comments: remain still for 15-30mins after application, increases effects of ephedra , use caution in women with asthma/hypertension/glaucoma/Renal, liver or heart disease
Operative vaginal birth
Forceps or vacuum extraction
Indications: exhaustion, inability to push effectively, non reassuring FHR patterns, failure of presenting part to rotate and descend
Contraindications: severe fetal compromise, maternal CHF and pulmonary edema, high fetal station and disproportionate fetus size to maternal pelvis
Chignon
Scalp edema that often forms under the suction cup of a vacuum extractor
3 Classifications for operative vaginal delivery
Outlet operative vaginal delivery- fetal head is at perineum, with the scalp visible at vaginal opening
Low operative vaginal delivery- fetal head between +2 and +3 (passed ischial spine)
Midpelvis operative vaginal delivery- fetal head between 0 and +2 station
Median or midline episiotomy
Advantages: minimal blood loss, neat healing with little scarring, less postpartum pain
Disadvantages: an added laceration may extend the median episiotomy into the anal sphincter, limited enlargement of the vaginal opening due to anal sphincter
Mediolateral episiotomy
Advantages: more enlargement of the vaginal opening (more room for the baby to come out), little risk that the episiotomy will extend to the anus
Disadvantages: more blood loss, increased postpartum pain, more scarring and irregularity in the healed scar, prolonged dyspareunia (painful intercourse)
Why is the rate of c-sections increasing
- women having their first baby more like to do c-section
- first baby induced greater risk for c-section
- repeat c-sections more common
- more common in older pregnant woman
- breech position
- higher maternal requests
Placenta accreta
Abnormal adherence of the placenta to the uterine wall, often along the previous incision area
Indications and risks of cesarean section
Indications- dystocia, cephalopelvic disproportion, hypertension, active genital herpes, previous uterine surgical procedures, prolapsed cord, breech, abruptio placentae
Risks- infection, hemorrhage, UTI, thromboembolism, paralytic ileus, atelectasis
Why is Bicitra administered before cesarean section
Given to reduce gastric acidity
Pfannenstiel skin incision
Transverse or “bikini” cut
Advantages: less visibility when healed and the pubic hair grows back, less chance of dehiscence or formation of a hernia
Disadvantages: less visualization of the uterus, can’t be done as quickly (emergency cesarean), can’t easily be extended to give greater operative exposure, re-entry at a subsequent cesarean may require more time
McRoberts maneuver
To relieve dystocia the woman flexes her thighs sharply against her abdomen , which straightens the pelvic curve somewhat
Gynecoid shaped pelvis
- most common
- round, cylindric shape throughout. Wide pubic arch (90 degrees or greater)
- prognosis for vaginal birth: good
Anthropoid shaped pelvis
- long, narrow oval. Anteroposterior diameter is longer than transverse diameter. Narrow pubic arch
- prognosis for vaginal birth: more favorable than android or platypelloid pelvic shape. Fetus may be born in occiput posterior position
Android shaped pelvis
- heart or triangular-shaped inlet. Narrow diameters throughout. Narrow pubic arch
- prognosis for vaginal birth: poor
Platypelloid shaped pelvis
- flattened wide, short oval. Transverse diameter wide, but anteroposterior diameter short. Wide pubic arch
- prognosis for vaginal birth: poor
- not ideal for vaginal delivery= cesarean
Precipitate labor vs precipitate birth
Labor- birth occurs within 3 hours of its onset
Birth- when a trained attendant is not present to assist
Medication used to accelerate fetal lung maturity
Betamethasone (celestone) - 12mg IM. Corticosteroid used to stimulate surfactant production BEFORE delivery.
Dexamethosone - 6mg IM q12h x 4 doses
Fetal fibronectin
A protein present in fetal tissue that correlates with presence of onset of labor
*positive fFN mid pregnancy could mean maternal or fetal infection
Prolapsed cord
Occult prolapse- cord compressed between fetus and pelvis and can’t be seen or felt during vaginal exam
Cord prolapsed infront of fetal head
Complete cord prolapse- cord can be seen protruding from the vagina
Interventions: reposition, give oxygen, don’t touch cord, keep presenting part elevated
First trimester ultrasound
Done at 5-6 weeks
Transvaginal
Done to confirm pregnancy and measure gestation with CRL (crown-rump length)
