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Repro > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

6 Factors of labor process

A

Passenger
Passageway
Position
Powers
Psyche
Participants

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2
Q

Labor: When to go to birthing facility? (6)

A
  • when contractions 5 minutes apart, last 60 seconds, and regular for an hour
  • Membrane ruptures, water breaks
  • Intense pain
  • Bloody show increases or frank bleeding
  • Decrease in fetal movement
  • Severe headache, blurred vision, epigastric pain
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3
Q

Rupture of Membranes (SROM or AROM)

  • Timing
  • Confirmation (3)
A

Timing: labor within 24-48 hrs of rupture

Confirmation
* Speculum exam: assess amniotic fluid in vaginal vault (pooling); ask pt. to cough to enhance flow
* Ferning: Amniotic fluid dries in fern pattern when placed on slide
* Nitrazine paper: turns blue in contact with amniotic fluid; use Q-tip or dip in vaginal fluid (uncommon b-c unreliable)

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4
Q

Rupture of Membranes (SROM or AROM)

  • Risks (5)
  • Nursing care (3)
A

Risks
- umbilical cord prolapse if presenting part not engaged in true pelvis
- infection if ruptured more than 24 hrs OR if foul smelling
- fetal compromise if meconium stained
- bleeding (vasa previa)
- severe variable decels if AROM

Nursing care
- assess FHR and maternal temp
- Assess color (clear and cloudy), amount, and odor (ocean/forest smell) of amniotic fluid
- document date and time of ROM

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5
Q

Stages of Labor

A

First (latent until 5 cm; active 6 cm; transition 8-10 cm)

Second (10 cm- birth of baby)

Third ( placenta delivery)

Fourth (postpartum

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6
Q

First stage of labor: Maternal and Fetal Assessments

Maternal - 4
Fetal - 2

A

Maternal
- vitals and pain q2h until ROM then q1h
- cervical exam
- review prenatal records and assess risk factors
- wellbeing q30min (focus more inward as contractions progress)- latent stage = good for pt education

Fetal
- FHR monitoring and maternal wellbeing q30 minutes
- leopold’s maneuvers for fetal position

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7
Q

First stage of labor: Nursing Care (3)

A
  • comfort measures (no supine position; clear liquids; frequent position changes)
  • GPS prophylaxis
  • encourage voiding q2h (more room for baby)
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8
Q

Second stage of labor: Maternal and fetal assessments (4)

A
  • assess FHR and maternal wellbeing q5-15 minutes
  • assess vitals q1h
  • sterile vaginal exam as needed (limit to prevent infection)
  • perineum flattens and bulges when pushing
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9
Q

Third stage of labor: Assessments (3)

A
  • Placenta to be out in 15 minutes ( prolonged if > 30 minutes)
  • vitals q15min
  • 1 and 5 min APGAR for infant
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10
Q

Third stage of labor: Nursing Care (3)

A
  • give uterotonics for placental delivery
  • check placenta for completeness
  • Complete documentation of delivery (labor summary, delivery summary, infant info, Apgar, infant resuscitation, documentation of personnel in attendance)
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11
Q

Hormonal Changes of Labor

Maternal - 3
Fetal - 1

A

Maternal
- decreased progesterone
- increased prostaglandins and oxytocin
- Estrogen and relaxin (soften cartilage and increase elasticity of ligaments so joints and tissue stretch for fetal passage)

Fetal
- increased cortisol and prostaglandins

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12
Q

Premonitory signs of labor (7)

A
  • Lightening (2 weeks prior to labor; fetal descent into true pelvis; easier to breathe; more urinating)
  • Braxton-hicks contractions (irregular and do not change cervix)
  • Cervical movement (Ripens, softens, moves posterior to anterior, partially effaced, thinned, dilates)
  • Increased discharge then loss of mucus plug (bloody show w/ pink/red discharge)
  • Nesting
  • NVD, indigestion
  • 1-2 lb weight loss
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13
Q

Signs of true labor (4)

A
  • progressive cervical dilation and effacement (effacement 0-100%; dilation 0-10 cm)
  • lower back discomfort radiates to abdomen
  • regular contractions (short intervals, increased duration and intensity)
  • contractions do not respond to hydration, rest, bath
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14
Q

Signs of false labor (4)

A
  • irregular contractions (braxton-hicks)
  • abdominal discomfort
  • no change in cervical dilation or effacement
  • contractions respond to hydration and rest
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15
Q

Passenger of Labor

Fetal Attitude (3)
Fetal Lie (2)

A

Attitude
- Flexed: back convex, head flexes to chest, thighs flexed over abdomen; easier passage through birth canal
- Deflexed (straight)
- Extended: concave back; larger diameter of head moves through birth canal

Lie
- Longitudinal: long axes/spine of fetus = parallel to woman’s; usual case
- Transverse: long axis of fetus = perpendicular to woman); need c-section

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16
Q

Passenger of Labor

Fetal Presentation (4)

A

Presentation (part of fetus that enters pelvic inlet first)
- Cephalic (occiput/flexed (preferred); frontum (brow); mentum/chin (face))
- Breech (pelvis, butt, feet)- reference: sacrum
- Transverse (shoulder) – reference: acromion
- Compound (extremity prolapses w/ presenting part i.e arm and head)

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17
Q

Passenger of Labor

Fetal Position (3)

A

Position (in relation to maternal pelvis)- want OA; OP will be causes back pain
- 1st letter: location of presenting part to woman’s pelvis (Left or Right)
- 2nd letter: specific fetal part presenting: occiput (O), sacrum (S), mentum (M), shoulder (A)
- 3rd letter: relationship of fetal presenting part to pelvis: anterior (A), posterior (P), Transverse (T)

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18
Q

Passageway of Labor

Pelvic type (5)
Fetal Station (3)

A

Pelvic types
- proven pelvis (prior vaginal delivery proves ability to deliver vaginally)
- Gynecoid (typical and optimal; rounded))
- Android (typical male; heart shape)
- Arthropod (narrow oval; okay for birth)
- Platypelloid (wide and flat; short AP; difficult for birth)

Fetal station
- 0 = head even w/ ischial spine; narrowest diameter fetus must pass through
- +3 when out of vagina
- best way to assess labor progress

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19
Q

Power of labor: Secondary (3)

A
  • urge to push in 2nd stage (push w/ open glottis during contractions)
  • ferguson reflex (stretch receptors in pelvis cause increased oxytocin release)
  • push while upright
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20
Q

Power of Labor: Contractions

Frequency (3)
Duration

A

Frequency
- minutes b/w beginning of 1 contraction to the next
- expected q2-3min (< 5 in 10 min)
- tachysystole if > 5 in 10 minutes (prevents reoxygenation of baby r/t oxytocin, dehydration, violence, preeclampsia, placental abruption, meth)

Duration
- seconds b/w beginning of contraction to end of contraction

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21
Q

Power of Labor: Contractions

Intensity (2)
Resting tone (2)

A

Intensity
- measured by palpation OR IUPC
- Mild (nose); moderate (chin), strong (forehead)

Resting tone (2)
- pressure in uterus b/w contractions
- Palpated (hard or soft)

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22
Q

Psyche of Labor (4)

A
  • mental and physical preparation (birth plans help)
  • previous experiences
  • emotional status (anxiety and stress slow labor)
  • social support (calm, direct, confident, gentle voices)
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23
Q

Pain management in Labor

Analgesia (ex. Fentanyl, morphine, butorphanol, nalbuphine, remifentanil, Nitrous oxide)
* Pros (2)
* Cons (3)

A

Pros
- short acting
- no IV access needed for nitrous oxide

Cons
- not continuous, not given close enough to birth
- respiratory depression (less w/ butorphanol; decreased FHR) for opioids
- dizziness or drowsiness for nitrous oxide

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24
Q

Pain management in Labor

Anesthesia (ex. local, regional (pudendal, epidural, spinal), general)
* Pros
* Cons (4)

A

Pros
- long lasting, can be given at anytime

Cons (informed consent required
- rids to bed and prolongs labor
- numbing
- risk for hypotension and spinal headache
- Other risks: hematoma, infection, urinary retention, pruritus, respiratory depression, hyperthermia, NV

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25
Q

Pain management in Labor

Nonpharmacological (8)

A
  • Position changes (birth ball, ambulation, chair sitting)
  • Massage (firm on legs and back)
  • Hydrotherapy (shower or tub)
  • Aromatherapy (lavender to distract)
  • Acupressure
  • breathing techniques (deep or hyperventilation into bag to prevent respiratory alkalosis)
  • Distraction
  • hot and cold (do not use w/ epidural)
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26
Q

Contraindications to labor induction (6)

A
  • Vasa previa (vessels not in placenta) or complete placenta previa
  • Transverse fetal lie
  • Umbilical cord prolapse
  • Previous classical cesarean birth
  • Active genital herpes infection
  • Previous myomectomy entering the endometrial cavity
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27
Q

Oxytocin

Purpose (3)
Indications (4)

A

Use: labor induction for 1cm/hr, labor augmentation, PP hemorrhage prevention

Indications
- gestational age (after 41 weeks)
- maternal (abruptio placentae, chorioamnionitis, preeclampsia, PROM, chronic conditions)
- fetal (multifetal, IUGR, isoimmunization, demise, oligohydramnios)
- control PP bleeding after placental expulsion

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28
Q

Oxytocin

Dose
Risks (4)

A

Dose: start at 0.5 mU/min and increase dose by 1 to 2 mU/min every 30 to 60 minutes until labor progresses to 1 cm/hr (more for PP)

Risks
- tachysystole (also r/t dehydration, violence, preeclampsia, placental abruption, meth)
- FHR decelerations
- Water intoxication (w/ high concentrations w/ hypotonic solutions (s/s of fluid overload: decreased urine output, edema, hypertension, pulmonary edema)-due to ADH effect
- PP use: coma, seizures

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29
Q

Fetal Heart Rate: Category 1

What it includes? (5)
What it means?

A

What it includes? (all of the following)
- Baseline rate 110 to 160 bpm
- Baseline variability moderate
- Late or variable deceleration absent
- Early decelerations absent or present
- Accelerations absent or present

What it means? favorable so routine management-

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30
Q

Fetal Heart Rate: Category 2 Indeterminate

What it includes? (7)
What it means?

A

What it includes? (any of the following)
- Bradycardia OR Tachycardia
- Minimal OR Marked baseline variability
- Absent baseline variability w/o recurrent decelerations, bradycardia, or tachycardia
- Absence of induced accelerations after fetal stimulation
- Recurrent variable or late decelerations w/ minimal or moderate baseline variability
- Prolonged decelerations b/w 2-10 minutes
- Variable decelerations w/ other characteristics, such as slow return to baseline “overshoot accelerations” or “shoulders”

What it means? surveillance and interventions needed

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31
Q

Fetal Heart Rate: Category 3

What it includes?
What it means?

A

What it includes?
- smooth sine wave in FHR baseline with a cycle frequency of 3 to 5 mins that persists for 20 mins or more (r/t opioid admin)
- Absent variability w/ Recurrent late decels, recurrent variable decelerations, or bradycardia

What it means?
- imminent delivery or intrauterine resuscitative measures needed

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32
Q

Oxytocin: Nursing Care (6)

A
  • high alert med (use IV pump on piggyback,
  • stop if tachysystole (recontinue if FHR reassuring after 10-30 minutes) OR when active labor starts
  • Monitor EFM continuously or q15 or 5 mins in low risk
  • Monitor UCs for strength, frequency, duration, resting tone, maternal pain q30 minutes
  • Assess vitals q2h
  • Assess I&O q8 hrs
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33
Q

FHR Monitoring: baseline (Normal range: 110-160 bpm)

Characteristics (3)
Changes (4)

A

Characteristics
- rounded to increments of 5 bpm during 10-minute window.
- at least 2 minutes of identifiable baseline segments (not necessarily contiguous).
- does not include accelerations or decelerations or periods of marked variability (amplitude greater than 25 bpm).

Changes
- Periodic: occur in relation to UCs.
- Episodic: occur independent of UCs
- Recurrent: occur in greater than or equal to 50% of the contractions in a 20-­minute period.
- Intermittent: occur in less than 50% of the contractions in a 20-minute period.

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34
Q

FHR Monitoring: Variability

Notes (3)

A
  • irregular fluctuations in fetal HR
  • Most important predictor of fetal oxygenation regardless of accels or decels
  • Develops around 28-30 weeks’ gestation
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35
Q

FHR Monitoring: Variability

Types
- Absent
- Mild
- Moderate
- Marked

A
  • Absent: Amplitude range is undetectable.
  • Minimal: Amplitude range is visually detectable at 5 bpm or less
  • Moderate: Amplitude from peak to trough is 6-25 bpm
  • Marked: Amplitude range greater than 25 bpm.
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36
Q

FHR Monitoring: Accelerations

  • What is it?
  • Cause?
A

After 32 weeks; 15 bpm above baseline (10 bpm above baseline if < 32 weeks)

Cause: fetal movement

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37
Q

FHR Monitoring: Decelerations

Early Decelerations
- What is it?
- Cause?

A

gradual periodic decrease in FHR from baseline to nadir lasting more than 30 seconds

Cause: head compression

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38
Q

FHR Monitoring: Decelerations

Variable Decelerations
- What is it?
- Cause?
- Key interventions (4)

A

abrupt periodic or intermittent decrease in FHR (15 bpm or more) from baseline to nadir lasting b/w 30 seconds and 2 minutes

Cause: umbilical cord compression (fetal HTN, acidemia)

Key interventions
- amnioinfusion if less than 60 bpm depth (contraindicated w/ vaginal bleeding, uterine anomalies, active infections, polyhydramnios)
- tocolytics (terbutaline)
- SVE for cord, labor progression, and fetal scalp stimulation
- IURM (change position, oxygen, discontinue oxytocin)

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39
Q

FHR Monitoring: Decelerations

Late Decelerations
- What is it?
- Cause?

A

gradual periodic decrease in FHR (15 bpm or more) from baseline to nadir lasting more than 30 seconds; occurs after contraction (prolonged if > 2 minutes)

Cause: uteroplacental insufficiency

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40
Q

Leopold’s Maneuver (4 steps)

A
  • Determine part of fetus located in fundus of uterus
  • Determine location of fetal back
  • Determine presenting part
  • Determine location of cephalic prominence
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41
Q

Intrauterine Resuscitation Measures for Category II or III

Assessments (3)
Interventions (7)

A

Assessments
- vital and uterine activity for fever, hypotension, tachysystole
- cervix for umbilical cord prolapse, rapid dilation, rapid descent of fetal head
- fetal acid-base status w/ scalp or vibroacoustic stimulation

Interventions
- Maternal position (left or right)
- IV bolus 500 mL LR
- Ephedrine for hypotension
- Give 10 L/min O2 via nonrebreather
- Reduce uterine activity (stop oxytocin, Remove cervical ripening agent, give Terbutaline)
- Amnioinfusion (contraindicated w/ active infection, vaginal bleeding, polyhydraminos)
- Alter pushing efforts (q3 UCs instead of every UC)
- Decrease pt. anxiety (support)

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42
Q

Cervical Ripening: Methods

Mechanical (2)
Pharmacological (2)

A

Mechanical
- Hygroscopic dilator (dried seaweed promotes dilation by water absorption which leads to local prostaglandin release)
- Transcervical balloon catheters (placed in extra-amniotic space and inflated w/ sterile water above internal os to put direct pressure on cervix); falls out once cervical dilation happens usually 6-12 hrs

Pharmacological
- Prostaglandin E2 (PGE2) (dinoprostone, e.g., Prepidil gel or Cervidil insert)
- Prostaglandin E1 (PGE1) (misoprostol, e.g., Cytotec)

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43
Q

Cervical ripening

Contraindications (7)

A
  • Ruptured membranes (relative)
  • regular contractions or tachysystole
  • unexplained vaginal bleeding
  • Active herpes
  • Fetal distress (malpresentation, nonreassuring FHR)
  • hx of prior traumatic delivery, uterine myomectomy w/ the endometrial cavity or cesarean delivery esp transverse scar (no prostaglandins in TOLAC)
  • Vasa or Placenta previa
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44
Q

Cervical ripening

Indication (2)
Nursing Care (4)

A

Indication
- little to no cervical effacement
- bishop score (< 6)- r/t fetal station, dilation, effacement, position and consistency of cervix)

Nursing care
- Ensure HCP gets informed consent
- Continuous FHR and UC monitoring (4 hrs after intravaginal misoprostol, 2 hrs after oral misoprostol, 15 mins after insert removal)
- Delay oxytocin for 30-60 mins after removal of insert (4 hrs after last misoprostol dose)
- for insert, pt in supine or lateral for 2 hrs after insert

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45
Q

Preterm Labor

What is it?
Signs and symptoms (4)

A

Uterine contractions and progressive cervical change between 20 and 37 weeks gestation due to decidua and fetal membrane activation, stress, uterine distention,

Signs and symptoms
- Contractions > q10 min for more than 1 hour (may be painful or painless)
- Discomfort (Abdominal cramping, low back pain, menstrual-like cramps, suprapubic/pelvic pressure)
- Vaginal discharge (ROM, increased amount)
- cervical change (80% effacement, dilation 2cm or more)

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46
Q

Preterm labor

Neonatal consequences (5)

A

o Cerebral palsy
o Hearing and vision impairment
o Chronic lung disease
o Sepsis
o Poor growth

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47
Q

Preterm Labor

Risk Factors (10)

A
  • hx PTB (most important)
  • IVF
  • Behaviors: smoking, substance abuse, multiple sexual partners, hx of DES exposure
  • poor health (low/high BMI, low SES, anemia, infection, inflammation)
  • pregnancies < one yr apart
  • Extreme ages (very young, very old)
  • uterine or cervical abnormalities (short cervix, distention due to multiple fetus; Hydramnios or oligohydramnios)
  • Inadequate support (IPV, late Prenatal care, unmarried)
  • Stress
  • Chronic health conditions (HTN, DM, clotting disorders, abnormal lipid metabolism)
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48
Q

Preterm Labor

Prevention (7)

A
  • education is key (bedrest
  • Teach pt about timing/palpation of contractions, may be painless
  • Document FHR baseline and note any patterns b-c
    FHR lower in preterm since CNS less developed
  • Identify and treat infections - UTI/STDs
  • Encourage Hydration
  • care for in antenatal unit (bedrest, tocolytics, stopping sexual stimulation no longer recommended routinely)
  • may use progesterone or tocolytics to prevent PTL w/ observation
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49
Q

Tocolytics

Goal
Types (4)

A

Goal: prolong labor 48-72 hours to give steroids time to increase lung maturity

Types
- Magnesium sulfate:
- Beta-adrenergic drugs – Terbutaline, Ritodrine
- Calcium channel blockers – Nifedipine
- Prostaglandin synthesis inhibitors – Indomethacin

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50
Q

Contraindications for tocolysis (7)

A
  • dilated > 6cm
  • preeclampsia with severe features or eclampsia
  • maternal bleeding w/ hemodynamic instability
  • infection (chorioamnionitis)
  • cardiac disease
  • fetal distress or demise (IUFD, lethal anomaly, nonreassuring fetal status)
  • PROM
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51
Q

Magnesium Sulfate

Side effects (10)

A
  • hot flashes, sweating, flushing
  • burning at IV site
  • NV
  • dry mouth
  • drowsiness, lethargy
  • blurred vision
  • hypocalcemia -> muscle weakness and loss of DTRs
  • SOB and respiratory depression
  • transient hypotension
  • headache
  • pulmonary edema and chest pain - Cardiac arrest
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52
Q

Magnesium Sulfate

Antidote
Contraindication
Care (5)

A

Antidote: calcium gluconate

Contraindication: myasthenia gravis

Care
- give for 12-24 hrs after contractions cease (do not give > 5-7 days)
- maintain therapeutic level of 4-7 mEq/L
- 1-hr checks (DTRs, respiratory rate) - stop if <95% O2sat, <12 RR
- strict I&O
- do not give w/ CCBs

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53
Q

Magnesium Sulfate

Use (3)
Dose (3)

A

Use
- seizure prophylaxis w/ preeclampsia via relaxation of smooth muscle
- slow or stop premature labor
- protect brains of premature babies

Dose
- 40g in 1000 mL IV
- Loading dose: 4 – 6 g over 20 – 30 min
- Maintenance dose: 1 - 4 g/hr

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54
Q

Terbutaline (Beta2 agonist)

Maternal side effects (8)

A
  • Tachycardia
  • hypokalemia -> chest discomfort (palpitations, dysrhythmias, SOB)
  • Tremors
  • CNS (Headache, dizziness, nervousness)
  • nasal congestion
  • N&V
  • hyperglycemia
  • hypotension
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55
Q

Terbutaline (Beta2 agonist)

Fetal Side effects (3)
When to notify HCP (4)

A

Fetal Side effects
- tachycardia
- hyperinsulinemia
- hyperglycemia

When to notify provider
- HR > 130 – need ECG monitoring
- BP <90/60
- Pulmonary edema
- FHR > 180 bpm

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56
Q

Terbutaline (beta2 agonist)

Action
Dose
Contraindications (5)

A

Action: relax smooth muscle and cause bronchodilation

Dose: 0.25 mg q4h SubQ for no more than 24 hrs

Contraindications (anything that relaxes smooth muscles)
- cardiac disease sensitive to tachycardia
- GDM
- hyperthyroidism
- hemorrhage
- seizure disorders

57
Q

Nifedipine (CCB)

Action
Dose
Side effects (5)

A

Action: relax smooth muscle for tocolysis or maternal hypertension

Dose: 10-20 mg q3-6h PO (no more than 24 hrs)

Side effects
- hypotension (maternal and fetal)
- headache
- flushing
- maternal tachycardia
- dizziness and nausea

58
Q

Nifedipine (CCB)

Contraindications (2)
Nursing Care (3)

A

Contraindications
- hypotension
- aortic insufficiency (any preload-dependent cardiac lesions)

Nursing care
- help ambulate
- do not give w/ terbutaline or mag sulfate
- monitor hepatic enzymes

59
Q

Indomethacin (NSAID)

Action
Maternal Side effects (2)
Fetal side effects (4)
Contraindications (4)

A

Action: prostaglandin inhibitor for tocolysis

Maternal Side effects
- gastritis (NV)
- esophageal reflux

Fetal side effects
- Premature closure of fetal ductus arteriosus
- intraventricular hemorrhage
- oligohydramnios
- necrotizing enterocolitis in preterm newborns

Contraindications
- Platelet dysfunction of bleeding disorder
- hepatic or renal dysfunction (hepatitis)
- gastrointestinal ulcerative disease
- asthma (in women with hypersensitivity to aspirin)

60
Q

Corticosteroids (ex. Betamethasone, Dexamethasone)

Indication
Action
Dose (2)
Maternal Side effects (3)

A

Indication: Prevent/reduce severity of neonatal respiratory distress syndrome b/w 24- and 34-weeks gestation if risk for PTB in 7 days

Action: Stimulates fetal lung maturity and helps w/ neuroprotection

Dosage and Route:
Betamethasone – 12mg IM, two doses 24 hours apart
Dexamethasone – 6mg IM, four doses 12 hours apart

Maternal and fetal effects
- increase in WBC count
- hyperglycemia (lasts 72 hrs)
- decrease in fetal breathing in body movements (lasts 72 hrs)

61
Q

Inevitable preterm birth

Assessment (3)
Care (2)

A

Assessment
- malpresentation
- fetal and/or early neonatal loss
- dilation 4 cm or more

Care
- neonatal resuscitation
- mag sulfate to prevent/reduce neonatal neurologic sequelae

62
Q

Cesarean Delivery

Incision Types (2)

A
  • transverse (horizontal) - best prognosis
  • Classical (vertical) - unable to TOLAC; used for PTL
63
Q

Cesarean Delivery: Nursing Care

Preoperative (7)

A
  • Establish IV and foley catheter access
  • Labs: CBC, Type & Cross
  • Uterine assessment and abdominal prep
  • Assist w/ anesthesia: Epidural (if was laboring), Spinal (if planned c-section), CSE
  • Pre-op meds: Reglan (metoclopramide), Bicitra (sodium citrate- lowers acidity of stomach contents), antibiotics
  • Transfer to OR suite and call neonatologist/NICU (if needed),
  • Circulating nurse duties (Intraoperative nursing care; surgical tool count)
64
Q

Cesarean Delivery: Postoperative care

Prevention of complications (4)

A
  • Avoid infection / sepsis (Hand-washing, keep incision dry, check lochia for odor)
  • Avoid respiratory stasis (Deep breathing, coughing, incentive spirometer)
  • Prevent DVT thrombosis r/t hypercoagulability (SCDs, Leg rollers, leg exercises, ambulation ASAP)
  • Prevent GI effects (gas, constipation, ileus) via monitor for abd distention, bowel sounds, flatulence, Stool softener (Colace), laxatives (Ducolax), rocking chair, ambulation
65
Q

Cesarean Delivery: GI education

Diet (2)
Education (3)

A

Diet
- clear liquids (no solids until peristalsis returns)
- avoid straws and carbonated beverages b/c cause gas pain

Education
- rocking chair to relieve gas pain
- prevent constipation (enema if no BM by day 3)
- may have NV

66
Q

Cesarean Delivery: Postoperative Care

General (5)

A

General care
- Recovery assessments – fundus q15min (same as for SVD)
- Monitor incisional bandage for bleeding and intactness
- Splinting with pillow or binder to assist w/ coughing, ambulation and prevent undue pressure
- foley for 12-24 hrs
- clean incision w/ mild soap (no lotions)

67
Q

TOLAC and VBAC

Indications (4)

A
  • One lower uterine transverse incision
  • more than one, twin pregnancy, or induction of labor WITH appropriate counseling
  • facility must be able to do emergency c/s
  • low risk (normal BMI, term pregnancy, normal birth weight, avg. maternal age, spontaneous labor)
68
Q

TOLAC and VBAC

Benefits (4)
Risks (3)

A

Benefits
- shorter hospital stay
- fewer complications (hemorrhage, thromboembolism, infection)
- fewer neonatal breathing problems
- Reduced consequences of multiple c-sections (hysterectomy, bowel or bladder injury, transfusion, infection, placenta previa or placenta accreta)

RIsks
- rupture of the uterus and associated sequelae (hemorrhage, hypovolemic shock, bladder/bowel injury, hysterectomy; HIE for baby)
- hypovolemia and need for blood transfusions
- maternal bladder or bowel lacerations

69
Q

Meconium-stained Fluid

Risk (and 4 effects)
Risk factor

A

Risk
- Aspiration (4 effects: hypoxia by airway obstruction, surfactant dysfunction, chemical pneumonitis, pulmonary hypertension)

Risk Factor: post-term (> 41 weeks)

70
Q

Meconium-stained Fluid

Cause (2)
Management (3)

A

Cause
- Neural stimulation of GI tract (fetal hypoxic stress)
- Vagal stimulation of head or spinal cord compression = peristalsis and rectal sphincter relaxation

Management
- wipe mouth and face; no rigorous suctioning (use bulb)
- No intrapartum suctioning OR routine intubation regardless of severity
- Alert NICU team so full resuscitation skills (endotracheal intubation) available

71
Q

Chorioamnionitis

What is it?
Cause
Risks (5)

A

infection of placenta and membranes

Cause: bacteria from vagina moves into uterus

Risks
- neonatal infection
- PTL
- HIE (Hypoxic-ischemic encephalopathy)
- cerebral palsy
- periventricular leukomalacia

72
Q

Chorioamnionitis

Risk factors (5)

A
  • Low parity
  • Invasive procedures (excess vaginal digital exams and intrauterine monitors)
  • meconium-stained fluid
  • infection (GBS, STIs)
  • amniocentesis
73
Q

Chorioamnionitis

S/s (5)
Treatment (2)

A
  • fever
  • fetal tachycardia (bradycardia possible),
  • WBC (>15,000)
  • purulent or foul smelling discharge from cervical os
  • low glucose or positive amniotic fluid culture

Treatment
- antipyretics
- antibiotics

74
Q

Obstetrical emergencies (6)

A
  • Shoulder dystocia
  • Prolapse of umbilical cord
  • Vasa previa/ruptured vasa previa
  • Rupture of the uterus
  • Anaphylactic syndrome/amniotic fluid embolism
  • Disseminated intravascular coagulation (DIC)
75
Q

Prolapsed Cord

Appearance (2)
Risks
Risk Factors (3)

A

Appearance
- Cord below presenting part through the introitus or into vagina
- May be occult and palpable through membranes

Risks: hypoxia

Risk factors
- polyhydramnios
- multiple gestation
- ROM or PROM when presenting part not engaged

76
Q

Prolapsed Cord

Care (7)

A
  • Check FHR after ROM
  • Elevate the presenting part off of cord
  • Position (knee-chest, Trendelenburg)
  • O2
  • IV fluid
  • discontinue Pitocin, consider tocolytic (terbutaline to stop contractions)
  • Must expedite delivery, usually by c/section
77
Q

Shoulder Dystocia

Causes (3)
Risk Factors (5)

A

Causes:
- anterior shoulder unable to pass under pubic arch
- Fetopelvic disproportion (FPD)
- Maternal pelvic abnormalities

Risk Factors:
- Maternal diabetes
- previous history of shoulder dystocia
- prolonged 2nd stage of labor
- fetal macrosomia (>4.5 kg)
- excessive weight gain

78
Q

Shoulder Dystocia: complications

Neonatal (4)
Maternal (4)

A

Neonatal Complications
- Birth injury -brachial plexus injury, fracture of clavicle/humerus
- asphyxia r/t neck compression
- hyperbilirubinemia
- neonatal encephalopathy if > 5 min delay b/w head and body delivery

Maternal complications
- Hemorrhage
- vaginal/rectal injury (symphyseal separation, 4th degree lacerations)
- infection
- peripheral neuropathy

79
Q

Shoulder Dystocia

S/s (3)

A
  • Slowing of descent into the pelvis
  • Development of caput on baby’s head (swelling)
  • Turtle sign (head sucks back in after delivery of head)
80
Q

Shoulder Dystocia: Management

Preferred (4)

A
  • call for assistance
  • instruct patient not to push unless directed
  • McRoberts maneuver (legs hyperflexed against the abdomen; opens the pelvic outlet and straightens the sacrum)- 2 people
  • suprapubic pressure w/ palm or fist (NO FUNDAL PRESSURE to prevent uterine rupture)
81
Q

Shoulder Dystocia: Management

Non-preferred (4)

A
  • Gaskin all-fours for woman
  • Woods corkscrew maneuver (rotate posterior shoulder out then anterior)
  • episiotomy extension (not preferred b-c bone issue not tissue issue)
  • Zavanelli maneuver (rare; head replacement then c-section)
82
Q

Amniotic Fluid Embolism

Pathophysiology
Manifestations (5)

A

Pathophysiology: disruption of maternal-fetal interface exposes vascular system and allows amniotic fluid into maternal blood stream leading to cardiopulmonary collapse/arrest

S/s
- change in LOC
- negative inotropism (decreased cardiac output and shock)
- pulmonary edema and vasospasm
- severe sudden hypoxia and ARDS (dyspnea)
- massive fibrinolysis

83
Q

Disseminated Intravascular coagulation (DIC)

Pathophysiology (2)
Labs (3)

A

Pathophysiology
- impaired coagulation and bleeding/hemorrhage r/t platelet and clotting factor consumption AND fibrinolysis
- multi-organ ischemia r/t mucrovascular thrombosis from endothelial damage

Labs
- decreased platelets
- increased aPTT and PT
- increased D-dimer

84
Q

Disseminated Intravascular Coagulation

Triggers

A
  • placental abruption
  • Amniotic Fluid Embolism
  • sepsis
  • acute fatty liver of pregnancy
  • dead fetus syndrome (prolonged retention of fetus/stillbirth)
  • severe preeclampsia
  • HELLP
  • hemorrhage
85
Q

Vital Signs Red Trigger Warnings

Temp
SBP
DBP
HR
RR
O2 sat
LOC Changes
Output

A

Temperature: < 35 or > 38
SBP: < 90 or > 160
DBP: >100
HR: <40 or > 120
RR: <10 or >30
O2 sat: < 95%
LOC Changes: Agitation, confusion, unresponsive
Output: <35 mL/hr for 2 hrs or more

86
Q

PP Reproductive System: Involution of Uterus

Patho
Fundal Height (6)

A

Patho: uterus returns to prepregnancy size, shape and location through uterine contractions, atrophy of the uterine muscle, and a decrease in size of uterine cells.

Fundal height
- Immediate after birth = midway b/w umbilicus and symphysis pubis
- 12 Hours PP: @ umbilicus or 1 cm above
- 24 hours PP: 1 cm below umbilicus
- After Day 1: Uterus decreases by 1 cm/day (1 finger)
- 14 days: Below symphysis pubis, no longer palpable
- 6-8 weeks: Pre-pregnant size.

87
Q

Postpartum Hemorrhage: Subinvolution of uterus

Factors (3)
Manifestations (3)

A

Factors
- retained placental fragments
- infection (endometritis)
- fibroids

Manifestations
- Soft and larger than normal uterus
- Lochia returns to rubra and is heavy.
- Back pain

88
Q

PP Reproductive System: Uterine Changes

3 changes

A
  • contractions (for PP hemostasis r/t release of oxytocin)- prevent PP hemorrhage)
  • afterpains (moderate to severe cramping; more noticeable in multipara; decreased after 3rd PP day)
  • Lochia: bloody discharge from uterus (RBC, sloughed off endometrial tissue, epithelial cells, bacteria)
89
Q

PP Endocrine changes (5)

A
  • Decreased Placental hormones (estrogen, progesterone) by 3 weeks
  • Lactating women-prolactin levels increase by 3 weeks (suppresses menses)
  • lactating women- oxytocin released causing let-down reflex when infant nurses
  • Menses returns 7-9 wks PP if not breastfeeding, 4 months if breastfeeding
  • anovulatory until 4th menses cycle
90
Q

PP Urinary changes (4)

A
  • bladder distention can lead to uterine atony (displaced fundus)
  • Postpartum Fluid Loss via extreme diuresis (3000 mL; 150 mL q2-4 hrs) and diaphoresis r/t decreased estrogen (resolves 12 hr s PP)
  • decreased sensation to void and incomplete emptying r/t increased bladder capacity, pushing, epidural effects
  • transient stress incontinence (resolves in 6wk-3m PP
91
Q

PP Breast Changes

  • General (4)
  • Breastfeeding (3)
A

General
- Immediately after birth till 14 hr. PP = full, soft, nontender
- 2nd day PP = slightly firm nontender
- 3rd day PP = Larger, firm, warm, tender, throbbing pain due to increase in vascular and lymphatic system.
- Engorgement ends in 24-48 hrs.

Breastfeeding
- Before lactation - colostrum ( high protein and antibodies)
- mature Milk will come in 72 – 96 hours after birth
- engorgement can recur in breastfeeding who miss feedings, have inadequate removal of milk.

92
Q

PP Breast Care

  • Breastfeeding (4)
  • non-breastfeeding (3)
A

Breastfeeding care
- feed on demand and q2-3 hrs to prevent milk stasis
- stimulate milk flow w/ breast massage or warm compresses
- increase calories 500-1000 per day
- watch for s/s of mastitis or plugged milk ducts (tender, pea-sized lumps)

Non-breastfeeding care
- good support bra 24 hrs/day
- cold compresses
- avoid stimulation (no heat or pumping)

93
Q

PP Cardiovascular Changes (7)

A
  • Blood loss (Vaginal-200-500 mls AND cesarean-500-1000 mls)
  • Physiologic edema
  • Stroke volume and Cardiac output increases for 24-48 hours ( pre-pg levels w/n 10 days)
  • transient anemia that resolves by 8 weeks (hct < 32, Hgb <11) r/t plasma volume increase from extracellular to intravascular
  • Risk for thromboembolism r/t pregnancy being a hypercoagulable state (clotting factors return to normal in 2 weeks)
  • PP chills right after birth r/t vascular instability.
  • Risk for orthostatic hypotension (normal after 1 week)
94
Q

PP Cardiovascular Changes

Why is typical blood loss not a concern? (3)

A
  • due to elimination of uteroplacental circulation (decrease in uterine blood flow and shift of nearly 500 ml from uteroplacental bed)
  • due to loss of placental endocrine function
  • due to mobilization of extravascular water into intravascular space (Plasma loss > RBC loss, reverses hemodilution of pregnancy)
95
Q

PP Vital Sign Changes

Temp (2)
BP (2)
Respirations
HR

A

Temperature
- 38°C is common in 1st 24 hours r/t exertion of L&D, dehydration, hormones
- Temp of > 38° C(100.4 F) after 1st 24 hours = infection

Blood Pressure
- Usually normal (decrease = hypovolemia, increase = PP preeclampsia)
- may have transient 5% increase in systolic and diastolic BP

Respirations
- normal

Pulse
- Bradycardia (>100 = hemorrhage, hypovolemia or infection

96
Q

PP Assessments

BUBBLEHE
Timing

A

Breasts (breastfeeding)
Uterus/Fundus
Bladder elimination
Bowel elimination
Lochia
Episiotomy (perineum)
Homan’s Sign/Lower extremities (calf pain w/ dorsiflexion = DVT)
Emotional state (comfort, pain, attachment)

Timing
- done q15 min for 1st hr, then q30 min for 2nd hr, q4 for 22hr, every shift after 24 hrs

97
Q

PP Labs (4)

A
  • Hgb/Hct increases
  • WBC increases (12,000-25,000) (leukocytosis of puerperium may mask acute postpartum infections, thrombophlebitis) - Pre-pregs level by 7 days PP
  • If rubella nonimmune, need to be immunized for rubella prior to discharge.
  • If Maternal Rh (neg) blood type with neg direct Coombs, Rh pos newborn: mother needs Rhogam within 72 hours (no rhogam for rh- infant)
98
Q

PP Hemorrhage: Risk factors (9)

A
  • multiparity
  • rapid or prolonged labor
  • assistive birth (forceps, vacuum, c-section, large episiotomy, tocolytics or halogenated anesthetics)
  • ROM > 24hrs r/t infection risk
  • conditions (preeclampsia, Chorioamnionitis or intra-amniotic infection)
  • previous PPH or uterine surgery
  • Uterine overdistention (macrosomia, multiple gestation, polyhydramnios)
  • Placental abnormality (succenturiate lobe, placenta previa, placenta accreta, abruptio placentae, hydatidiform mole)
  • fetal demise
99
Q

Postpartum hemorrhage: Tone (uterine atony)
most common

Factors (5)
Interventions (2)

A

Factors
- Overdistended uterus (macrosomia, hydramnios, multiples)
- Anesthesia
- High parity (> 5)
- Rapid, Prolonged, dysfunctional(induced) labor
- fibroids

Interventions
- maintain uterine tone (fundal massage)
- prevent bladder distention (s/s fundus displaced from midline; empty bladder)

100
Q

Postpartum hemorrhage: Tissue (retained or abnormal placenta)

Factors (3)
S/s (3)
Intervention

A

Factors
- retained placental fragments esp if manual removal
- Acreta, increta, percreta (unusual placental adherence-doesn’t easily separate)
- placenta Abruption or Previa

Signs and symptoms
- Subinvolution of uterus (remains larger than normal)
- Profuse bleeding after 1st week PP
- Pale skin or blue discoloration

Interventions
- may need D& C by provider

101
Q

Postpartum hemorrhage: Trauma

Factors - 4
Manifestations - 3
Intervention - 1

A

Factors
- operative (forceps, vacuum)
- Vaginal/cervical lacerations r/t macrosomia, multifetal, precipitous labor
- Hematomas (Swelling, discoloration, tenderness and bulging area just under the skin)
- Ruptured uterus

Manifestations
- Slow, steady flow of blood of unclotted blood
- Lochia rubra that continues into the fourth day following birth
- firm uterus

Intervention
- surgical removal of hematoma if > 3cm

102
Q

Postpartum hemorrhage: Thrombin Disorders

Factors (3)
Manifestations (3)

A

Factors
- Preeclampsia
- Stillbirths
- Coagulation disorders (DIC)

Manifestations
- Oozing from IV sites
- abnormal clotting (Nosebleeds, Petechiae, Bleeding gums)
- Hypotension (shock)

103
Q

Early vs late PP hemorrhage

Timing
Manifestation
Cause

A

Early PP Hemorrhage
Timing: 1st 24 hr (esp. 1st hr)
Manifestation: soak 1 pad q15 mins
Cause: Uterine atony, Distended bladder, high or unrepaired laceration or vaginal hematoma

Late PP Hemorrhage
Timing: >24H after the birth, but < 6 weeks
Manifestation: soak 1 pad q1 hr
Cause: subinvolution r/t Retained products of conception, Endometriosis

104
Q

PP Hemorrhage: hypovolemic shock

S/s (9)

A
  • Tachycardia
  • Tachypnea
  • Skin- cool, pale, clammy
  • Dizziness, nausea
  • Anxiety, “air hunger” r/t hemorrhage
  • Urine output decreases
  • Hypotension (late sign)
  • blood loss (> 500 mL in vaginal, > 1000 mL in cesarean)
  • decreased Hct by 10% since admission or 2% in first 48 hrs pp
105
Q

PP Hemorrhage: Discharge education (3)

A
  • more fatigued than the usual pp woman
  • discharged w/ iron supplements OR increase iron foods((leafy green vegetables, beans, red meat, poultry, iron-fortified cereal, breads, pasta, dried fruits (raisins))
  • increase fluids
106
Q

Fundal massage

Do’s (3)

A
  • support lower uterine segment above symphysis pubis (prevents uterine inversion)
  • use circular motion
  • reassess after 5-10 minutes of massage
107
Q

PP Physical Assessment: Lochia Rubra

Timing
Consistency (4)

A

Timing: day 1-3

Consistency
- bright red bleeding that diminishes in amount and pales in color (scant in C-section)
- May have fleshy odor (similar to menstrual blood)
- small clots
- increased amount w/ standing or breastfeeding

108
Q

PP Physical Assessment: Lochia Serosa

Timing
Consistency (3)

A

Timing: Day 4-10

Consistency
- pink-brown
- scant amount and fleshy odor
- increased amount w/ physical activity

109
Q

PP Physical Assessment: Lochia Alba

Timing
Consistency (2)

A

Timing: Day 10-14

Consistency
- creamy white or yellow discharge of mucus and leukocytes
- scant amount and fleshy odor

110
Q

PP Physical Assessment: Lochia

Amounts (5)

A

Scant: < 1 inch or only on tissue when whipped
Light: < 4 inches
Moderate: < 6 inches
Heavy: saturated within 1 hour
Excessively heavy: soaked in 15 minutes

111
Q

PP Bladder Emptying: Patient education (8)

A
  • void 300 mL q2- 4 hours
  • use bathroom/bedpan (Foley catheter may be needed if suspect retention (< 100cc/hr. or < 300cc/void)
  • Administer analgesics if dysuria
  • Use peppermint oil b-c vapors relax urinary sphincter
  • Drink minimum of 10 glasses per day (2L of water/day)
  • Do pelvic floor muscle training to improve continence, sexual function and prevent prolapse.
  • Cotton underwear
  • Nutrition (increase urine acidity w/ cranberry juice, apricots, plums)
112
Q

PP Bowel Function

Causes of delay (3)
Other GI changes (5)

A

Delayed due to: (for 2 weeks PP)
- Fluid losses and dehydration
- Decreased GI motility r/t pain meds, decreased physical activity
- Perineal discomfort r/t hemorrhoids, lacerations, episiotomy

GI changes
- constipation
- NV r/t labor
- No BM expected for 2-3 days
- increased appetite is normal
- weight loss (11-12 lb immediately, 5-8 lb r/t diuresis)

113
Q

PP Bowel Function

Patient education (4)

A
  • Administer stool softeners or Dulcolax (stimulant if needed)
  • Ambulate to increase GI motility and decrease risk of gas pains.
  • Drink 10 glasses (3000 mL) of fluid per day esp. water and prune juice
  • Increase fiber and roughage in diet (fruits, vegetables, whole grains, legumes)
114
Q

PP Hemorrhoids: Care (4)

A
  • Position patient laterally and lift buttock to expose anal area (note # and size of hemorrhoids, thrombosis)
  • Topical anesthetics for discomfort
  • Topical steroids, sitz baths, cold compresses to reduce edema
  • Stool softeners (Colace)
115
Q

PP Episiotomy/Laceration: Care (8)

A
  • Wash hands
  • Cleanse front to back with peri-bottle lavage, blot dry
  • Change peri pads when soiled- monitor for odor as a sign of infection
  • Vulvar ice packs and cold sitz bath (1st 24 hrs) for edema
  • Warm sitz bath after 24hrs to promote circulation and healing.
  • analgesics (ibuprofen and acetaminophen) prn for discomfort
  • Topical anesthetics (Anesthetic creams/sprays, Witch hazel compresses, Hemorrhoidal creams) for discomfort
  • Tighten gluteal muscles as pt sits then relax them after she sits to cushion perineum and increase comfort.
116
Q

PP Episiotomy/Laceration: Assessments

REEDA
Levels of episiotomy/lacerations (4)
Types of episiotomy (2)

A

Redness, Edema, Ecchymosis, Drainage, Approximation of edges of episiotomy or laceration

Levels
1st Degree: Vaginal Membranes
2nd Degree: Vaginal Membranes + Fascia
3rd Degree: Vaginal Membranes + Fascia + Anal Sphincter
4th Degree: Vaginal Membranes + Fascia + Anal Sphincter + Anal Canal

Types of epistiomies
- Midline = heals quicker and less pain than mediolateral
- Mediolateral = incision at 45-degree angle to perineum

117
Q

Factors that impact maternal role attainment (7)

A
  • teenage mothers
  • social support
  • experienced mothers vs new mother
  • pregnancy readiness
  • pregnancy and birth experience (baby in NICU, pain, CNS depressantS)
  • cultural beliefs
  • infant characteristics (appearance, temperament)
118
Q

Mercer’s 4 stages of becoming a mother

A
  • Commitment, attachment, and preparation for infant during pregnancy
  • Acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the early weeks after birth.
  • Moving toward a new normal during the first 4 months
  • Achievement of a maternal identity around 4 months
119
Q

Rubin’s Maternal Role Attainment: Taking-in (4)

A
  • Last 24-48 hrs
  • Focused on self (not infant)- personal comfort, rest, food important
  • Decision making difficult so dependent on others for help in care
  • Re-lives delivery experience
120
Q

Rubin’s Maternal Role Attainment: Taking-hold (6)

A
  • Lasts from 2 days-1 wk
  • Dependence -> independence (decision making)
  • shift from pregnancy role to maternal role
  • Increased energy level
  • need reassurance about ability to meet infant needs
  • great time for teaching
121
Q

Rubin’s Maternal Role Attainment: Letting-go (5)

A
  • From 1 week onward
  • See self as separate from infant
  • Give up fantasy delivery and baby
  • may have feelings of grief, guilt, Depression
  • Readjustment – giving up previous role
122
Q

PP blues

Timing (2)
S/s (5)
Management (2)

A

Timing
- first few days – 2 weeks due to hormones, fatigue, role stress for most women
- peak day 5-10

S/s
- Able to care for baby
- mild mood swings (emotional lability, feeling sad, anxious, or overwhelmed)
- crying spells
- insomnia and anorexia
- fatigue or restlessness

Management
- assess at 1-2 week check up
- encourage rest

123
Q

PP Depression

S/s (6)

A
  • Sleep/appetite disturbances (insomnia, hypersomnia, weight gain, weight loss)
  • emotional distress (Anxiety, fear, panic, guilt)
  • inability to concentrate
  • Despondent (feeling down/depressed or hopeless; loneliness, isolation)
  • Thoughts of harming baby or self
  • unable to safely care for infant
124
Q

PP Depression

Timing
Management (4)

A

Timing
- Lasts longer than 2 weeks within 12 months PP

Management
- assess in pediatric setting or at 2-week PP visit
- for mild PPD, Psychotherapy
- for moderate PPD, Psychotherapy AND antidepressants
- for severe PPD or suicidal ideation, Psychotherapy, Antidepressants, Intense psychiatric care, ECT

125
Q

PP Depression: risk factors (9)

A
  • LGB > heterosexual
  • Hx of depression or anxiety during or prior to pregnancy
  • Inadequate social support (poor quality relationship w/ partner OR mother; life stressors)
  • young age
  • unintended pregnancy (ambivalent about having a baby)
  • family history
  • birth or pregnancy different from plan (cesarean, emergency w/ mother or newborn, NICU baby)
  • Abuse: IPV, history of childhood sexual abuse
  • Low SES
126
Q

PP Sexual Activity: Patient Education (5)

A
  • may resume sexual activity at 2-4 weeks
  • 3 criteria for resuming: Bleeding is slowed/stopped; No discomfort experienced; Pt is ready psychologically
  • Episiotomy/lacerations typically healed after 2 weeks
  • Hormonal contraception safely initiated after 3 weeks (LARCs can be placed in immediate PP)
  • Use of lubricant advised due to vaginal dryness
127
Q

PP Danger Signs (8)

A
  • Soaking a pad/hr, presence of egg sized clots; return of rubra
  • Fever: Temp > 100.4 lasting 24hrs or longer in first 10 days
  • Mastitis: Redness, swelling, lump in breast
  • Cystitis: dysuria, frequency, urgency
  • Thrombophlebitis: Pain in calf; PE if SOB or chest pain
  • Endometritis: Foul smelling vaginal D/C, pelvic pain
  • Postpartum Depression: thoughts of hurting yourself or someone else
  • Preeclampsia: severe headache, seizures, blurry vision, epigastric or abdominal pain, facial swelling
128
Q

5 leading causes of maternal mortality

A
  • Maternal suicide
  • Hemorrhage (most common after suicide)
  • infection
  • hypertensive disorders
  • VTE
129
Q

Maternal mortality

Definition
Statistics (3)

A

Definition: death of a woman during pregnancy or within one year of pregnancy (CDC) not related to accidental or incidental causes.

Statistics
- more likely in AA women due to discrimination and bias
- 50% preventable
- 50 % after discharge

130
Q

SDOH: Nursing Interventions (3)

A
  • Nonjudgmental care
  • Resource management (transportation)
  • Patient-centered care (tailor to patient’s lifestyle)
131
Q

Methylergonovine (Methergine)

Use
Side effects (3)
Contraindication

A

Use: uterotonic for PP hemorrhage prevention or treatment

Side effects: hypertension, NV, headache

Contraindications: BP > 140/90

132
Q

Carboprost (Hemabate)

Use
Side effects (4)
Contraindication

A

Use: uterotonic for PP hemorrhage (prostaglandin)

Side effects: NVD, fever, increased BP, headache

Contraindications: asthma

133
Q

Hemorrhage/Hypovolemic Shock: Nursing Care (9)

A
  • Call for help
  • Massage uterus (if firm, find source)
  • Empty bladder (foley)
  • IV access (increase rate of maintenance fluids and maintain blood products)
  • Add Uterotonic Medications: oxytocin, methergine, hemabate to IV (given in 4 hrs PP)
  • O2 (10-12 L via nonrebreather)
  • lateral position. elevate extremities for venous return
  • notify provider (bimanual compression, balloon tamponade, pack w/ gauze)
  • Weigh blood-soaked peripad (1g = 1mL)
134
Q

PP Infection: Uterus (Endometritis)
most common

-S/s (6)
-management

A

S/s
- fever, malaise
- Tachycardia
- subinvolution
- excessive fundal tenderness
- return of lochia rubra
- foul-smelling lochia

Management
- clindamycin and gentamicin OR ampicillin until afebrile for 24-48 (IV if severe)

135
Q

PP Infection: Bladder, Urinary tract, kidneys (Pyelonephritis)

-S/s (6)

A
  • Cloudy urine
  • labs: hematuria, bacteriuria
  • frequency, urgency
  • dysuria and suprapubic pain
  • costovertebral angle tenderness with Pyelo
  • Small, frequent voiding of <150 mL per voiding
136
Q

PP infection: risk factors (9)

A
  • History of c/s
  • PROM
  • Invasive procedures (Frequent cervical exams, Internal fetal monitoring, amnioinfusion, episiotomy/lacerations,)
  • Preexisting pelvic infection (bacterial vaginosis, UTI, cervicitis
  • Poor nutrition (obesity, malnutrition)
  • DM
  • Epidural (urinary retention)
  • Anemia ( < 11)
  • prolonged labor
137
Q

PP infection: Management (5)

A
  • prevention with hand washing and aseptic technique
  • Monitor vitals and temperature (tachycardia, fever) q4h or q2h if elevated temp
  • Increase fluids and promote nutrition (2L fluids; 1800-2000 calories if lactating, 1500 cal if nonlactating)
  • Administer antibiotics and analgesics
  • Monitor for worsening of signs and symptoms: Bleeding, drainage, pain
138
Q

PP infection: Mastitis

What is it?
Cause
S/s (4)
Complication

A

inflammation/infection of breast which locally obstructs flow of milk usually at 3-4 weeks OR 3-6 months of breastfeeding

Cause: due to bacteria entering nipple cracks r/t improper infant latch

S/s
- Red, warm lump in breast with radiating erythema
- cracked, blistered, reddened nipples
- Fever, malaise, chills
- body and headache

Complication: abscess formation

139
Q

PP infection: Mastitis

Management (3)
Prevention (6)

A

Management
- continue to breastfeed b-c infection in breast tissue not milk
- Nipple care (moist heat for circulation)
- antibiotics (cephalexin, dicloxacillin) for 10-14 days

Prevention
- Fully empty both breasts during breastfeeding
- Massage breast during breastfeeding esp. tender areas and under armpit
- Wear larger bra.
- Use correct latch-on and removal, air-dry nipples, and multiple breastfeeding positions to decrease nipple irritation and tissue breakdown.
- Hand hygiene prior to feeding
- Avoid missing feedings.

Repro (4 decks)

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