Exam 3 Flashcards
Antepartal hemorrhagic disorders effect
Blood loss = decreased oxygen carrying capacity = increased risk for complications
What risks are increased with antepartal hemorrhagic disorders
Hypovolemia
Anemia
Infection
Preterm labor
Impaired oxygen delivery to the fetus
What risks are increased with maternal hemorrhage for fetus
Blood loss, anemia
Hypoxemia
Hypoxia
Anoxia
Preterm birth
What gestational age is considered abortion
Less than 20 weeks
What percent of pregnancies end in miscarriage
25%
50% of miscarriages are due to what
Chromosomal anomalies
Types of miscarriages
Threatened
Inevitable
Incomplete
Complete
Missed
Recurrent/habitual
What gestational age is considered miscarriage
Before 20 weeks
Habitual/recurrent miscarriage
3 or more before 20 weeks
Or less than 500g
Threatened miscarriage
Vaginal bleeding/cramping - not profuse
Cervix remains closed
Interventions for threatened miscarriage
Ultrasound to check fetus
Beta HCG levels (increase throughout pregnancy)
Bedrest
No sex until bleeding stops
Inevitable miscarriage
Cervical dilation that cannot be prevented
Procedure performed after incomplete miscarriage
Dilation and curettage
Incomplete miscarriage
More bleeding than normal
Tx: Pitocin, D&C
Complete miscarriage
No retained tissue
Missed miscarriage
Fetal demise without leaving uterus
Tx for missed miscarriage
Depends on gestation
4-6 wks: D&C
12+ weeks: Cytotec
Effacement
Thinning of cervix
How to monitor bleeding
Weigh pads
Cervical cerclage
Passive and painless dilation of cervix during 2nd/3rd trimester
Premature dilation of cervix tx
Cervical cerclage: Surgical procedure that involves placing stitches to tighten the cervix to prevent preterm birth
Done if had previous preterm birth
When else is cervical cerclage used
16-23 weeks and dilated to 1cm or greater, cerclage can salvage pregnancy and prevent preterm labor
What finding indicates need for cervical cerclage
Cervical length of 25 mm or less
Ectopic pregnancy
Fertilized ovum is implanted outside the uterine cavity; also called “tubal pregnancies”
- Early pregnancy bleeding
Complication of ectopic pregnancy
Rupture of fallopian tubes
Ectopic pregnancy s/sx
Abd pain - refers to shoulder
Delayed menses
Abnormal vaginal bleeding
Ectopic pregnancy dx
Beta HCG levels
What finding indicates ectopic pregancy
1500 milliunits or greater means products of conception should be seen in uterus on ultrasound
Ectopic pregnancy tx
Methotrexate - destroys rapidly dividing cells and body absorbs it
Surgery - salpingectomy (tube removal)
- salpingostomy: hole in tube to remove blastocyst (embryo); no suture used
What does scar tissue from salpingostomy cause risk of
(Another) ectopic pregnancy
Molar Pregnancy (Hydatidiform Mole)
Type of gestational trophoblastic neoplasia (GTN)
Non-cancerous growth in the uterus that looks like grape-like clusters
Can interfere with pregnancy
Partial molar pregnancy
Two sperm fertilize an egg, resulting in an extra set of paternal chromosomes
Molar pregnancy (Hydratidiform mole) s/sx
Anemia
N/V
Molar pregnancy (Hydratidiform mole) dx
Placenta previa s/sx
Bright red, painless blood during 2nd or 3rd trimester
Placenta abruption patho and s/sx
Placenta covers cervix
Placenta is separating from uterine wall
Painful bleeding
Placenta previa
Placenta implanted in lower uterine segment near or over internal cervical os
Placenta previa s/sx
Bright red, painless blood, 2nd or 3rd trimester
Placenta previa risk factors
Previous C section (scar tissue), AMA, multip, D&C, smoking, maternal cocaine use
Complications of placenta previa
Hemorrhage, preterm birth, IUGR, placenta accreta
Placenta accreta
Placenta grows into uterus and into other organs
How to dx placenta previa
Ultrasound (transabdominal initially then transvaginal)
Management of placenta previa
Bedrest, pelvic rest, no cervical checks
When to discharge pt after placenta previa
After 24 hours of no bleeding
Risk factors for placental abruption
HTN - chronic, gestational
Cocaine use, amphetamine use - increases BP
Cigarette smoking
Previous abruption
S/sx of placenta abruption
Vaginal bleeding - can but not always
Sudden, intense localized abd pain, tender uterus
Board-like uterus (blood)
Contractions
Vasa previa
Rare condition in which fetal vessels lie over the cervical os, and the vessels are implanted into the fetal membranes rather than into the placenta
Types of vasa previa
Velamentous insertion
Succenturiate placenta
Battledore (marginal) insertion
Velamentous insertion
Cord vessels branch at membranes and then onto placenta
Succenturiate placenta
Placenta has divided into two or more lobes
Battledore (marginal) insertion (consideration)
Increases risk of fetal hemorrhage
Complications r/t clotting
Disseminated intravascular coagulation (DIC)
Disseminated intravascular coagulation (DIC)
AKA consumptive coagulopathy or defibrination syndrome
Acquired syndrome characterized by intravascular activation of coagulation which is widespread, rather than localized, and results in excessive clot formation and hemorrhage
DIC cause
Triggered by release of large amount of tissue factor as a result of placental abruption
HTN complication during pregnancy
Major cause of maternal and perinatal morbidity and mortality
Gestational hypertension
HTN after wk 20 (previously normal BP)
140+/90+
Resolves after birth (6-12 months)
What can gestational HTN develop into
50% end up with preeclampsia
Preeclampsia
HTN after 20 wks + protein in urine
- OR Thrombocytopenia , impaired liver function, pulmonary edema, renal insufficiency
Can develop in postpartum
Eclampsia
Seizures develop from preeclampsia
Antepartum, during labor, or postpartum
Chronic HTN
Dx before 20 wks gestation
Chronic HTN with superimposed preeclampsia
Started pregnancy with HTN
AND either BP increases after being well controlled OR new onset of proteinuria
Risk factors for preeclampsia
Mutifetal gestation (twins, triplets)
Hx of preeclampsia
Chronic HTN
Preexisting DM
Nulliparity - first pregnancy
Same father for subsequent pregnancies, risk decreases (diff. women = risk increases)
Cause of preeclampsia
Unknown
HELLP syndrome
H - hemolysis
EL - elevated liver enzymes
LP - low platelets
Complication of HELLP
Bleeding risk
How to dx or prevent preeclampsia
No reliable test or tool
What to assess in preeclampsia
BP - positioned on left side
LE edema - face/hands edema is concerning
DTR’s - increased = preeclampsia
24 hour urine
Gestational HTN and preeclampsia severe features
RUQ pain - liver
Severe headache
Vision changes
Photosensitive
Postpartum care for gestational HTN and preeclampsia
Going home with BP medications
Nursing managements for gestational HTN and preeclampsia
Dark, quiet environment
Monitor fetal HR
Assess for s/sx of placenta abruption
Limit activity, bed rest
Administer antihypertensives
Magnesium sulfate
Med of choice for preventing and treating seizures (eclampsia)
Magnesium sulfate route
IVPB
Magnesium sulfate administration timing
Initial loading dose
Then continuous maintenance dose
Magnesium sulfate SE
Dizziness
N/V
Sweating
Blurred vision
Headache
Magnesium sulfate nursing management
Strict I/O’s with catheter - limit intake to 125mL/hour
Continuous EFM (Electronic Fetal Monitoring) and toco
DTR’s
Antidote for magnesium sulfate
Calcium gluconate
Early eclampsia s/sx
Altered mental status
Severe headache
N/V
Blurred vision, seeing double
Abd pain RUQ pain
Decreased UOP
Proteinurea
Nursing consideration if seizure occurs
Safety
Patent airway - position on side
No restraint
Call for help, do not leave pt bedside
Call light available
What population is at higher risk for chronic HTN
African Americans
Factors that affect the process of labor and birth - the 5 P’s
Passenger: Fetus and Placenta
Passageway: Birth canal
Powers: Contractions
Position (of mother)
Psychologic Response
Frank breach
Legs folded ankles to head
Single footling breach
One foot sticking out
Complete breach
Legs crossed, butt first
Shoulder presentation
Type of breach
Shoulder coming out first
Fetal lie
How spine of fetus and mother line up
Longitudinal fetal lie
Most common
Fetus aligned with mother
Transverse fetal lie
Fetus positioned across mother’s pelvis
Most common early in pregnancy
Oblique fetal lie
Baby turned sideways
Spine facing laterally
Vertex presentation
Chin tucked
Type of fetal attitude
Sinciput presentation
Chin neutral position
Type of fetal attitude
Brow presentation
Chin up
Type of fetal attitude
Types of fetal positions
ROA
ROT
ROP
LOP
LOT
LOA
Right/Left
Occipito
Anterior/Posterior/Transverse
Best fetal positions
ROA and LOA
Facedown
Fetal station
Measures the decent of the baby
In relation to ischial spine
x/x/x
dilation/effacement/station
ex. 8/100/0
Types of bony pelvis’
Gynecoid
Android
Anthropoid
Platypelloid
Gynecoid
Optimal pelvis type
Round, wide bone structure
Android
Wedge- or cone-like shape, with a wider top and narrower bottom
Anthropoid
Narrow, oval-shaped pelvis that’s deeper than it is wide
Platypelloid
Flat, wide, and shallow pelvis that’s the least common type. It’s more bean-shaped than heart-shaped
Lower uterine segment
Where contraction occur
Pushes baby down, putting pressure on cervix
Type of soft tissue
Introitus
Vaginal opening
Primary powers
Contractions
Secondary powers
Bearing down
What to measure during contractions
Frequency, duration, intensity
Where to measure contraction on strip
From beginning of one to the beginning of the next
How much time is between the dark lines of the fetal monitoring strip
1 minute
Each box is 10 seconds
Phases of contractions
Increment: Increasing
Acne: Peak
Decrement: Decreasing
Signs preceding labor
Lightening - fetal head drops into pelvis
Bloody show
Losing mucus plug
Persistent low back pain
Braxton Hick’s contractions - no cervical change
Wt loss - 1-3lbs, fluid/electrolyte shifting
Nesting - surge to prepare for baby
Phases in first stage of labor
Latent: 0-3cm
Active: 4-7cm
Transition: 8-10cm
First stage of labor
Events preceding full dilation
Second stage of labor
Time from fully dilated to baby coming out
Third stage of labor
Pushing stage
Fourth stage of labor
Delivery of placenta until mom is stable
Things that initiate the onset of labor
Sex
Nipple stimulation - releases oxytocin
7 Cardinal movements of mechanisms of labor
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation (also called Restitution)
Expulsion
Normal fetal HR
Monitor during labor
110-160
What factors affect fetal HR
Reduction of blood flow d/t HTN (gestational or chronic), hemorrhage, hypotension, anemia
Factors that alter fetal circulation
Compressed of umblilical cord
Fetal head compression
Reduction in blood flow to intervillous space of placenta
Ways to monitor fetal HR
Intermittent auscultation - Usually Q30mins, with doppler, fetoscope, fetal monitor ultrasound
- Does not detect patterns
Electronic fetal monitoring (EFM)
- External or internal
What must happen before internal EFM is used
Water broken
Dilated 1-2cm
Monitors uterine contractions
IUPC - Intrauterine pressure catheter
FSE - Fetal scalp electrode
Sinusoidal pattern
Sawtooth FHR pattern
Not good
When can you determine FHR is brachy or tachy
After 10 minutes
Periodic changes in FHR
Occur in reaction to uterine contractions
Episodic changes in FHR
Not related to uterine contractions
Normal acel for 32+ wk
15x15 acels
For at least 15 seconds
1 box up and over
Cause of early decels
Good thing, indicates progression of labor
Head compression d/t contractions
Peak of contraction should mirror decel (Periodic)
More than 30 seconds
Cause of late decels
Poor oxygenation
Uterine tachysystole, hypertonus
Hypotension
Postterm date
Maternal diabetes
IUGR - small baby
Occurs right after contraction (Periodic)
More than 30 seconds
Nursing interventions for late decels
Turn patient
Oxygen - nonrebreather at 10L
Fluid bolus
Turn off Pitocin
Administer Terbutaline - slow contractions
Cause of variables/variablity
Cord compression
Abrupt onset
For less than 30 seconds
Nursing intervention for variability
Turn pt
Fluids
Turn of Pitocin
Amnioinfusion: Fluid into uterus, more cushioning
Notify HCP
Prolonged decel
Gradual or abrupt
At least 15 beats below baseline, more than 2 mins but less than 10 (after 10 min is considered baseline change)
FHR category 1
HR WNL
Moderate variability
Absent late or variables
Early decels present or absent
Acels present or absent
FHR category 2
Anything between 1 and 3
No acels after stimulation
FHR category 3
Absent baseline variability
Recurrent late decels
Recurrent variable decels
Bradycardia
Sinusoidal pattern
How often to document assessment of pt with epidural vs not
Q15mins
Q30mins
