Exam 2 - Ch. 21 Flashcards
Premature rupture of membranes (PROM)
Rupture of membranes prior to the start of contractions at or after 37 weeks
Risks associated with PROM
↑ risk of prolapsed cord, placental abruption, chorioamnionitis, cord compression, & neonatal ICU admissions
~ 90% of women with PROM go into labor within what time frame
Within 24 hours
Preterm premature rupture of membranes (PPROM)
Rupture of membranes prior to 37 weeks of gestation (≤36.6 weeks GA)
Risks of PPROM
↑ risk of infection (chorioamnionitis, endometritis, septicemia),
placental abruption
fetal malpresentation
cord prolapse, and precipitous labor
Risks that predispose a pregnant woman to PPROM
Most women with PPROM do not have identifiable risk factors, however, the incidence is higher in women who smoke, had a previous PPROM, and any vaginal bleeding during pregnancy.
PROM/PPROM Assessment
Sterile speculum exam
Nitrazine pH test
Arborization test (ferning)
Presence/absence of meconium-stained fluid
What percentage of women will go into labor w/in 24 hrs of PROM
90%
What percentage of women will go into labor within 24 hours of PPROM?
50%
**Active management of PPROM/PROM
Induction of labor w/in 24 hrs of ROM associated w/ ↓ chorioamnionitis and NICU admissions
**Expectant management of PPROM/PROM
Delay of induction >24 hrs of ROM (spontaneous labor w/in 72 hrs 95% of the time)
Considerations with PPROM or PROM
GBS + women treated with antibiotics
PPROM treatment
Corticosteroids in pregnancies under 34 weeks to promote fetal lung maturity
Prevent intraventricular hemorrhage
Necrotizing Enterocolitis and ↓ neonatal death by 30-60%.
Antibiotic therapy because PPROM may have been caused by infection OR result in infection (usually azithromycin, ampicillin, or amoxicillin)
Tocolytics used to prevent, suspend, or slow labor (off-label)
May be used for 48 hours to allow time for a full course of corticosteroids to be administered to the mother.
Use of tocolytics for PPROM is controversial
Magnesium sulfate between 24-34 weeks for fetal neuroprotection
(↓ cerebral palsy in neonate)
Bed rest – not found to improve outcomes, done anyway in many cases
Delivery – most women w/ PPROM will deliver w/in a week depending on risk/benefit assessment
Meds for PPROM
Antibiotic therapy because PPROM may have been caused by infection OR result in infection (usually azithromycin, ampicillin, or amoxicillin)
Tocolytics used to prevent, suspend, or slow labor (off-label). May be used for 48 hours to allow time for a full course of corticosteroids to be administered to the mother. Use of tocolytics for PPROM is controversial
Magnesium sulfate between 24-34 weeks for fetal neuroprotection
(↓ cerebral palsy in neonate)
Why are tocolytics used in PPROM?
Tocolytics used to prevent, suspend, or slow labor (off-label). May be used for 48 hours to allow time for a full course of corticosteroids to be administered to the mother. Use of tocolytics for PPROM is controversial
Preterm labor
Labor that causes cervical change at less than 37 weeks GA; may be spontaneous or induced
Is preterm labor spontaneous or induced?
Both
What is the leading cause of death for children under the age of 5?
Preterm birth
**Common reasons for preterm induction of labor
Placental problems
History of uterine scarring
Fetal growth restriction
Hypertension
Preclampsia
Poorly controlled gestational diabetes
Pregestational diabetes poorly controlled
PPROM
Preterm labor (PRL) four main causes
- HPA Axis (hypothalamic-pituitary-adrenal axis) - maternal stress)
- Inflammation – systemic, GU tract, chorioamnionitis
- Bleeding – hormonal cascade caused by the bleed, associated with inflammation
Uterine Overdistention – - Polyhydramnios, multiple gestation
PTL Symptoms
Irregular contractions, often mild
Report of “menstrual-like” cramping
Low back pain
Sensation of vaginal or pelvic pressure
Light bleeding, spotting, or bloody show
Diagnosis of PTL
Cervical dilation of 3 cm or more
Cervical shortening on ultrasound
Positive fetal fibronectin test (fFN): Evaluation of a protein concentrated between the placenta and the decidua of the uterus
Elevated levels associated with birth within 10 days (+ fFN: >50mg/mL)
Negative result is reassuring
Positive fetal fibronectin test (fFN)
Protein concentrated between the placenta and the decidua of the uterus
Elevated levels associated with birth within 10 days (+ fFN: >50mg/mL)
Negative result is reassuring
PTL interventions
- Suppression of Labor - Tocolytics – indomethacin, nifedipine, terbutaline, magnesium sulfate
Generally not used before 24 or after 34 weeks - Physical Activity Restriction - Common recommendation, lacks evidence base
- Sexual activity can stimulate contractions
- Progesterone Supplementation-Shortened cervix (PRE-labor) - progesterone to extend pregnancy, Not indicated when +fFN test result
- Medication Management - Corticosteroids from ~23 to 34 weeks, Antibiotics, Magnesium sulfate for fetal indications (as well as tocolytic indication)
What is chrioamnionitis
Infection of the amnion, chorion, or both
Common cause of chrioamnionitis
Commonly caused by the ascent of bacteria through the cervix
Risk factors for chorioamnionitis
PPROM, PROM, multiple digital vaginal exams, prolonged labor, preterm birth, HIV, invasive fetal/ctx monitoring, genital tract infx
Maternal Complications of chrioamnionitis:
Maternal: prolonged labor, postpartum hemorrhage, wound infection, endometritis, venous thrombus, sepsis
Neonatal Complications of chrioamnionitis:
Neonatal: sepsis/septic shock, perinatal death, asphyxia, CP, pneumonia, meningitis, IVH, neurodevelopmental delay, prematurity-related problems
Diagnostic criteria for chrioamnionitis
maternal fever greater than 38˚C (100.4° F) plus at least two of the following:
fetal tachycardia
maternal tachycardia
uterine tenderness
foul-smelling discharge
elevated white blood cell count (over 15,000 cells/mm3)
Treatment for chorioamnionitis
broad spectrum antibiotics – usually ampicillin and gentamicin
Postterm pregnancy is defined as what?
≥ 42 weeks gestation
Risks of postterm pregnancy:
Fetal macrosomia, cord compression, prolonged labor, dystocia, birth injury, infection, operative delivery, postpartum hemorrhage
Post-term newborn characteristics with postterm labor
Peeling skin starting on palms/soles, decreased vernix, sparse lanugo, ↑ scalp hair, longer nails
What is dysmaturity
intrauterine malnutrition d/t aging of placenta
What are the risks of dysmaturity
↑ risk of perinatal mortality – 2x greater than at term GA
Characterized by long, thin body, SGA, & may have loose skin w/ prominent creases; oligohydramnios
**Treatment for postterm pregnancy
Treatment: expectant management or induction of labor
**Induction of labor assessment for postterm pregnancy
Bishop score to assess cervical ripeness (distensible, soft, partly dilated)
Bishop score evaluates cervical 1) dilation, 2) effacement, 3) station, 4) consistency, and 5) position (2 points each)
Score of 8 or higher is considered favorable for a greater chance of a successful vaginal delivery
Score of 6 or less = unfavorable → requires cervical ripening
**Cervical ripening requires a Bishop score of what?
6 or less
Two ways to ripen a cervix
Pharmaceutical or mechanical
Pharmaceutical ways of ripening a cervix
Prostaglandins often used prior to oxytocin
Misoprostol PO or PV – higher doses associated with uterine tachysystole
Dinoprostone (Cervidil, Prepidil)
Contraindicated for women with previous cesarean birth or uterine surgery → risk of uterine rupture
RN monitoring
Mechanical ripening of a cervix
Mechanical ripening:
Insertion of a balloon catheter into the cervix
Increased risk for infection; decreased risk of uterine tachysystole
induction of labor done how?
After cervical ripening; administer IV Oxytocin (Pitocin) – synthetic form
Common dilution: 30 units oxytocin in 500 mL of NSS or LR. At this dilution, 1 mU/min is 1 mL/hour.
Initial dosing of oxytocin: 0.5 to 6 mU/min and increased in doses of 1 to 2 mU/min until regular contraction pattern established
Goal: 5 contractions in 10 min lasting 40-90 seconds in duration –OR- 200-250 Montevideo units
Side effects of labor induction
GI distress, water retention, tachycardia, hypotension, and uterine tachysystole
When do you stop pitocin in a labor induction?
Stop infusion & notify OB provider if uterine tachysystole or nonreassuring FHR → intrauterine resuscitation measures & possible administration of tocolytic (terbutaline)
What is an amniotomy?
Artificial rupture of membranes (AROM)
Fetus must be vertex & engaged for what procedure?
Amniotomy
**Risk for what with amniotomy
Risk for cord prolapse & infection
What is this indicative of?
Uterine tachysystole
A nursing student accurately explains induction of labor by stating which of the following:
A. Pitocin is used with a favorable Bishop score to mimic natural labor contractions.
B. Pitocin is used to cause uterine tachysystole and therefore the birth of the baby.
C. Cervical ripening is indicated when a Bishop score is 8 or higher.
D. Pitocin is most effective when the cervix is firm, posterior, and closed.
A. Pitocin is used with a favorable Bishop score to mimic natural labor contractions.
Pitocin is used when the patient has a favorable Bishop score of what?
8 or higher and should mimic natural labor contractions.
A favorable Bishop score (≥8) is calculated by assessing
Cervical dilation, effacement, station, softening, and anterior position.
What is an undesirable complication of labor induction.
Uterine tachysystole
What is premature detachment of the placenta
Detachment from the decidua of the uterus after 20 weeks GA
When does detachment of the decidua from the uterus occur?
After 20 weeks GA
**How is placental detachment classified?
Classified as mild/moderate/severe and either acute or chronic
**Possible causes of detachment of the placenta
Often unknown…
can be due to blunt force trauma, smoking, cocaine use, uterine structural abnormalities
**Risk factors of detachment of the uterus
History of previous placental abruption, smoking, HTN
**prognosis of detachment of the placenta from the uterus
Prognosis:
Mild abruption: typically self-limiting & may have little impact on mother/fetus
Severe abruption: may result in complete detachment of the placenta and risk the life of the mother and the fetus.
Abruption of ≥ half of the interface b/tw placenta & decidua assoc. w/ fetal death and DIC
**S/S of an acute placental abruption
Sudden onset of abdominal pain, vaginal bleeding (possible) & frequent hypertonic contractions. Uterus rigid on palpation & may be tender.
**S/S of Chronic placental abruption
Intermittent light vaginal bleeding may be only maternal sign
Fetus may be SGA, have IUGR &/or oligohydramnios
Treatment depends on GA and degree of abruption:
May need hospitalization – continuous fetal monitoring & ctx, IV access (for blood transfusion), maternal hemodynamic monitoring (UO, HR, BP, blood loss)
Corticosteroids for fetal lung development if less than 34 wks GA
What is Disseminated Intravascular Coagulopathy (DIC)
Pathologic activation of the clotting cascade that results simultaneously in blood clots, platelet and clotting factor depletion, and bleeding.
What can DIC lead to?
Can lead to thrombosis, hemorrhage, and multiple organ failure
True/False: DIC is DIC is always a complication of another pregnancy condition
True
**What is placenta previa?
Occurs when placental tissues overlie the internal cervical os.
**Major maternal complication of placenta previa
hemorrhage
**How does placenta previa present?
Painless vaginal bleeding
**How is placenta previa diagnosed?
Diagnosed by ultrasound
**Is it possible that placenta previa resolves?
May resolve as pregnancy progresses (lower uterine segment lengthens and grows toward fundus & placenta moves away from os)
**Digital vaginal examination is indicated or contraindicated with known or suspected placenta previa?
contraindicated
**Why is vagina exam contraindicated in placenta previa?
Palpation associated with acute bleeding
**What are the recommendations for placenta previa?
Women are often instructed to avoid exercise & vaginal intercourse after 20 weeks GA
Delivery in placenta previa is usually indicated at what GA and by what method?
36-37 weeks (c-section)
What is vasa previa?
Occurs when fetal blood vessels overlie the cervical os.
Is digital vaginal examination indicated/contraindicated in vasa previa?
Contraindicated.
A patient who has had no prenatal care presents to triage with vaginal bleeding. She reports that she is not contracting. After determining that the patient is likely around 34 weeks pregnancy, what should the nurse do next?
Evaluate her cervix with a sterile vaginal exam
Reassure the patient bloody show is normal in labor
Notify the obstetric provider
Draw prenatal lab work
Notify the obstetric provider
The nurse should notify the obstetric provider. The patient’s symptoms could indicate a placenta previa and require evaluation.
A sterile vaginal exam should not be conducted in a woman with a known or suspected placenta previa.
Bloody show is normal in labor but because the patient is not contracting, labor is not likely.
The provider may order prenatal labwork after evaluating the patient.
A nurse is assessing a newborn delivered at 42.1 weeks gestation. Which of the following findings would the nurse expect to see?
Excessive amounts of vernix
Short, pliable fingernails
Smooth plantar surfaces
Loose, peeling skin
ANSWER: loose, peeling skin – due to depletion of fat stores and dehydration related to advanced age of fetus
Smooth plantar surfaces would be seen in preterm newborns
Vernix decreases as fetus matures
Fingernails would be long from prolonged growth, and maybe stained green from meconium passage
A woman who is 29.3 weeks GA is admitted to the triage unit with vaginal bleeding. To differentiate between placenta previa and placental abruption, the nurse would assess for which of the following?
ANSWER: the most common difference between placenta previa and abruption is abdominal pain.
Leopold’s maneuver assesses for fetal positioning in utero
The amount of blood is does not differentiate between the two
Maternal BP is inconclusive in this case
