Exam 3 Flashcards
most common reason for doing prenatal testing is
advanced maternal age (35 years or older)
advanced paternal age is more than
55 years
after that there is an increase in certain chromosomal abnormalities
Reasons for prenatal testing (7)
- Maternal age > 35 years
- Birth of previous infant with chromosomal abnormalities or neural tube defect
- Chromosomal abnormality in family member
- Gender if mom is carrier of X-linked disorder
- Pregnancy after 3 or more spontaneous abortions
- Maternal Rh sensitization
- Elevated levels of maternal serum AFP
the point of genetic counseling is to
help the family make some decisions and prepare them for the potential effects that may present in their baby
it’s quite common for down syndrome babies to also have
cardiac anomalies
multifactorial disorders
more than 1 gene is involved
also, environmental factors or sex of child may affect if it is expressed
Cardiac anomalies
Cleft lip and palate
Neural tube defects
Teratogens
any factor that adversely affects the fertilized ovum, embryo, or fetus
Causative agents
Maternal infectious agents Drugs, Rubella and Vaccine Pollutants Ionizing radiation Maternal hyperthermia Maternal co-morbidities
1 factor that influences the teratogen’s effect on the pregnancy
maternal genome and fetal genotype
Top 3 factors that influences the teratogen’s effect on the pregnancy
- maternal genome and fetal genotype
- stage of development when exposure occurs
- dose and duration of the exposure of the agent
___ mcg of folic acid daily before conception is recommended to prevent ____
400
neural tube defects
Women with epilepsy may be treated wth ___, which is a known tetratogen
Dilantin
CVS, PUBS, and Amniocentesis are done at what times?
CVS: towards the end of the first trimester (10-13 wks)
A: Between 15 and 20 weeks
PUBS: after 16 wks - not until the woman is definitely into the second trimester
Ultrasound can be done when?
anytime during the pregnancy
In the third trimester, how can fetal wellbeing be assessed?
Nonstress Test
Biophysical Profile
What is Amniocentesis and when is it done?
- Invasive test to identify chromosomal or biochemical abnormalities
- done Between 15 and 20 weeks
- there is a Risk of spontaneous abortion infection, ruptured membranes
Why would Amniocentesis be done in the 3rd trimester (after 28 weeks)?
to assess:
- Fetal lung maturity
- Detects fetal hydrous and erythroblastosis fetalis
CVS stands for what? What is it and when is it done? What are some risks?
Chorionic Villus Sampling
10-13 wks
Karyotyping to identify chromosomal abnormalities
Results in 48 hrs
Risks: 0.5% to 2.0% chance of spontaneous abortion and limb abnormalities
PUBS stands for what? What is it and when is it done? What are some risks?
Percutaneous Umbilical Blood Sampling
after 16 wks
Blood gas, CBC, coag, Rh
Results in hrs
Risks: cord laceration, thromboembolic, infection, spontaneous ab, PROM (premature rupture of membranes)
PTO, PROM
pre-term labor
premature rupture of membranes
Women who have a high risk factor will start having NSTs at about
30-32 weeks gestation
What is the optimal type of NST?
- At least 2 FHR acceleration within 20 minute period
- At least 15 beats above baseline
- Lasting at least 15 seconds
baby is awake/moving around
What is an NST and what is the purpose? When is it done?
Assess fetal well-being – uteroplacental function
Noninvasive
After 28 wks
Accelerations in FHR read during NST are indicative of
- Adequate O2 of CNS
- Healthy neural pathway from fetal CNS to FH
- Ability of FH to respond to stimuli
Biophysical Profile (BPP) is the ultrasound evaluation of 5 parameters in fetus:
- Breathing movement
- Movement of limbs or body
- Tone – extension/flexion of extremities
- Amniotic fluid index (AFI)
- Reactive FHR with activity (NST)
When is BPP done?
Usually in 3rd trimester but may be done after 24 wks
8 to 10 on BPP =
normal (10 is highest grade possible)
4 to 6 on BPP =
possible compromise
0 to 2 on BPP =
high perinatal mortality
Indications for BPP
- Maternal diabetes mellitus
- Maternal heart disease
- Maternal chronic hypertension
- Maternal sickle cell anemia
- Maternal renal disease
- Hx previous stillbirths
- Rh sensitization
- Maternal preeclampsia or eclampsia
- Suspected post maturity
- Intrauterine growth restriction
Maternal Co-Morbidities
Acute and chronic illnesses:
- present before pregnancy
- develop during pregnancy
- affect fetal health and outcome
most affect fetal OXYGENATION at some level
What are some key Maternal Co-Morbidities that can affect fetal health and outcome? (12)
asthma
cystic fibrosis
cardiac anomalies
sickle cell
Thalassemia
diabetes
thyroid conditions
multiple sclerosis
Systemic Lupus Erythematosis
Developmental Disabilities
Physical Disabilities
Cancer
Signs of Psychosocial Distress
- Increasing Anxiety
- Inability to establish communication
- Inappropriate responses or actions
- Denial of pregnancy
- Inability to cope with stress
- Intense preoccupation with the sex of the baby
- Failure to acknowledge quickening
- Failure to plan and prepare for the baby (e.g. living arrangements, clothing, feeding supplies)
- Indications of substance abuse
There is a correlation between chronic behavioral/mental health disorders in the mother and ___
prematurity
Nursing Interventions for women with chronic behavioral/mental health disorders
Provide strategies to:
- help decrease anxiety
- keep her oriented to reality
- promote optimal functioning during pregnancy and while in labor
Smoking during pregnancy has serious health risks including:
- Bleeding complications
- Miscarriage
- Stillbirth
- Prematurity
- Placenta previa
- Placental abruption
- Low birth weight (LBW)
- Sudden infant death syndrome
When do organs complete formation and therefore teratogens have their greatest impact at this time?
9-12 weeks
Potential perinatal STIs
Chlamydia, Gonorrhea, Syphilis, HPV, HIV and AIDS
___ and ____ are particularly dire/toxic if the mother develops during the first trimester
Rubella and Toxoplasmosis
TORCH
Toxoplasmosis Other: Varicella, Hepatitis B Rubella Cytomegalovirus Herpes Simplex
Nursing Diagnoses for mom that’s been exposed to Perinatal Infection
Ineffective Health Maintenance
Grieving
Readiness for Enhanced Knowledge
Ineffective Coping
Pre gestational DM means
Diabetes Mellitus existing before pregnancy
Type 1 diabetes
Type 2 diabetes
Gestational diabetes mellitus (GDM) is
any degree of glucose intolerance with onset or recognition during pregnancy (2nd or 3rd trim)
Pre diabetes is
impaired fasting glucose (IFG)
How does pregnancy impact insulin production?
Placenta produces hormones such as estrogen, cortisol and human placental lactogen –> these hormones INHIBIT the functioning of insulin, so the blood glucose level is INCREASED
First trimester, insulin need is
reduced
Second trimester, insulin need is
increased
Third trimester, insulin need is
gradually increasing up to 36 weeks
During delivery, insulin need
Maternal insulin requirement drops drastically to pre pregnancy level
intervention: frequent BS during labor
When breastfeeding, insulin need
mother maintains lower insulin requirement
Weaning breastfeeding, insulin need is
returned to prepregnancy level
Recommendations for ADA for patients with type 1 diabetes as soon as menstruation begins
patients are counseled on high risk of being pregnant to themselves and to baby
high risk of neonatal morbidity and mortality
The normal number of chromosomes in body cells other than reproductive cells is ____
46, or diploid.
Trisomy and monosomy are what?
Most common trisomy is what?
numerical abnormalities of single chromosomes.
The most common trisomy is Down syndrome, or trisomy 21, in which three copies of chromosome 21 are in each somatic cell.
polyploidy
refers to abnormalities involving full sets of chromosomes.
monosomy – which is the only one compatible with postnatal life?
A monosomy exists when each body cell has a missing
chromosome, with a total number of 45.
The only monosomy compatible with postnatal life is Turner syndrome, or monosomy X (this person is always female)
most are lost in spontaneous abortion
According to ADA Guidelines for Preconception Care, what should the A1C levels be maintained at before attempting conception?
less than 6.5
What types of drugs might be contraindicated in pregnancy for type 1 diabetic patients?
Statins, ACEs, ARBs
Gestational diabetes is considered similar to type 2 diabetes in that
the patient has hyperglycemia but has hypo insulin production
About ___% of patients with gestational diabetes go on to develop type 2 diabetes later in life
20-25
Low Risk for gestational diabetes includes:
- Normal weight before pregnancy
- Under age 25
- No hx unexplained stillbirth
- No diabetes in immediate family
High Risk for gestational diabetes includes:
- Ethnicity: Af Am, Hisp, Native Am
- HTN
- Hypercholesterolemia
- GD or LGA in previous pregnancy
Symptoms warranting OGTT
- Persistent glycosuria on 2 visits
- Proteinuria
- Urinary frequency after first trimester
- Excessive thirst or hunger
- Recurrent monilial infections
- Polyhydramnios, suspected large fetal size, or increased fundal height for date
Does the nurse in the prenatal clinic develop the same care plan for Type 1, Type 2 and GDM?
YES - all about education and adherence
What is the treatment for Type 1, Type 2 and GDM mothers?
1 is Diet
If not managed well on diet, add meds
Drugs for Type 1:
- Insulin - may be admitted during 2nd trimester to regulate
Drugs for Type 2 and GDM:
- Oral hypoglycemic (Glyburide & Metformin) may be effective – Prescribed, though not approved by FDA (Category B / C)
- Insulin, if diet and oral hypoglycemics not effective
Any treatment for babies of Type 1, Type 2 and GDM mothers occurs when?
AFTER delivery
Danger signs for first trimester
abdominal pain and bleeding
also persistent vomiting and symptoms of infection
Hydatiform Molar Pregnancy (aka Gestational Trophoblastic Disease) – symptoms, risks, treatment
Proliferation and degeneration of trophoblastic villi
no actual pregnancy
Symptoms:
- Vaginal bleeding, uterus growing rapidly which leads to size/date discrepancy
- excessive nausea/vomiting, abdominal pain
Risks:
- choriocarcinoma (cells become malignant)
- repeat mole
Tx: remove uterine contents (D+C) – necessary
Ectopic Pregnancy
implantation of fertilized embryo occurs somewhere outside the uterus
the pregnancy cannot continue since the embryo cannot survive without supportive environment of uterus
most do occur in the fallopian tubes
first symptom is pain associated with the fact that embryo is growing where it shouldn’t
causes of ectopic pregnancy
could be result of pelvic inflammatory disease
scarring or fibrosis in the tube
(can come from endometriosis or previous pelvic or tubal surgery)
IUD use
if ectopic pregnancy, patient presents with
amennorhea, nausea, vomiting
positive pregnancy test
sharp 1-sided abdominal pain with referred shoulder pain
vaginal spotting
low serum progesterone and low HCG levels
ectopic pregnancy diagnosis is made with what tool?
transvaginal ultrasound (woman inserts in her vagina and technician then manipulates)
Treatment of ectopic pregnancy in Fallopian Tubes (medical, surgical, emotional)
Medical:
If tube not ruptured, Methotrexate IM to dissolve embryo
Surgical:
- If tube not ruptured, laparoscopic salpingostomy to remove products of conception and salvage the tube
- If tube is ruptured, laparoscopic salpingectomy
Counseling
When does Spontaneous Abortion occur, and what are the signs?
- Before 20 weeks of gestation
- bleeding, cramping, abdominal pain, decreased symptoms of pregnancy
- most common in first trimester
- D & C if necessary
- Emotional support
Incompetent Cervix aka Cervical Insufficiency
- Painless dilation and cervical effacement
- Before second trimester
- Bedrest until cerclage
- Cerclage:
McDonald
Shirodkar
haploid
The total number of chromosomes is a multiple of the haploid number of 23 (69 or 92 total chromosomes)
After 20 weeks vs. before 20 weeks
before 20 weeks: abortion
20 weeks: pre-term delivery
Another structural abnormality occurs when all or part of a chromosome is attached to another – this is called
translocation
Most common cause of Spontaneous Abortion
chromosomal anomalies
Teratogens
are agents in the fetal environment that either cause or
increase the likelihood that a birth defect will occur.
D+C
Dilatation and curettage
(stretching the cervical os to permit suctioning or scraping the
uterine walls)
3 types of spontaneous abortions:
threatened abortion
inevitable abortion
incomplete abortion
threatened abortion
vaginal bleeding occurs
cervix is still intact, as are the membranes
for this, when there has been bleeding, the treatment is bedrest, no sex
inevitable abortion
cervix has dilated, bleeding will continue, membranes have ruptured - eventually, the contents of the uterus will be expressed
incomplete abortion
all of the products of conception have not been expelled from the uterus - even more bleeding because placenta is still there
for this, they treat with D+C to make sure they removed all the contents
chorionic villus sampling (CVS)
a procedure to obtain a sample of chorionic villi for analysis of fetal cells.
placenta previa
abnormal implantation of placenta in the lower uterus
alpha-fetoprotein (MSAFP)
plasma protein produced by the fetus
neural tube defects
failure of the bony encasement of spinal cord or skull to close
Cerclage
treatment for Incompetent Cervix aka Cervical Insufficiency where they put in basically a suture that just closes the cervix around the 12-14 week
may be left in until around 36 week or later
Hyperemesis Gravidarum
Excessive vomiting
Unable to retain fluids, which can lead to:
Dehydration Electrolyte imbalance Acid-Base imbalance Starvation Ketosis Weight Loss
Treatment for Hyperemesis Gravidarum
1. NPO + IVF
Emotional Support
2. Slowly add food
Monitor weight
Continue supportDanger signs during second trimester
vaginal bleeding leaking amniotic fluid glycosuria abdominal pain HTN/proteinuria fundal height absence of fetal movement
Rh Incompatibility
Rh- mom plus Rh+ dad
AKA
Rh Isoimmunization
antibodies (which can cross the placenta) destroy the baby’s RBCs resulting in massive hemolysis
RhoGAM is administered to every Rh- mother when?
28 -34 wks (prenatal dose)
RhoGAM is administered 24 to 72 hours post partum if
baby is Rh+
After delivery, if baby is Rh-, is RhoGAM needed?
no
Indirect Coombs
“antibody screen”
Measures number of Rh+ antibodies in mother’s blood
Direct Coombs
Detects antibody coated Rh+ cells in infant’s blood
Done after delivery on baby’s cord blood - this is done on all babies as part of their type and screen
Negative indirect coombs means
Mother given RhoGAM
Positive indirect coombs “sensitized” means
Fetus monitored for hemolytic disease of the newborn (erythroblastosis fetalis)
Low levels of MSAFP suggest ____. Elevated MSAFP levels are associated with ____
low = chromosomal abnormalities such as trisomy 21
elevated = open NTDs and
body wall defects.
The lecithin/sphingomyelin (L/S) ratio is a test for
estimating fetal lung maturity.
phosphatidylglycerol (PG) and phosphatidylinositol (PI)
two other components of
surfactant
The presence of PG and PI
phospholipids supports the likelihood that the fetal lungs are mature
ΔOD450 (delta OD450)
test
measure the optical density (OD) of the amniotic fluid stained
by bilirubin if the mother is Rh-negative and was sensitized after being exposed to Rh-positive blood.
karyotype
display imaged chromosomes from largest pair to smallest pair
PUBS
also called cordocentesis, involves the aspiration of fetal blood from the umbilical cord for prenatal diagnosis or therapy
late decelerations
decreases in the
FHR persisting after the contraction ends
amniotic fluid index (AFI)
A method that adds
the depths of amniotic fluid in four uterine quadrants
volume sums greater than 10 cm are considered reassuring
volume sums less than 5 cm are considered oligohydramnios
higher than 18 to 20 cm suggests excess amniotic fluid volume, or hydramnios
perinatologist
medical specialist in high-risk pregnancy care from about 20 weeks of gestation through 4 weeks postpartum
cervical dilation and evacuation (D&E)
removal of fetal
tissue, followed by vacuum or surgical curettage.
maceration of the fetus
discoloration, softening, and eventual tissue degeneration
– of the fetus
bicornuate uterus
uterus with 2 horns
cerclage procedure
suturing of the cervix to prevent early dilation
salpingectomy
removal of the tube
gestational trophoblastic disease
occurs when trophoblasts (peripheral cells that attach the fertilized ovum to the uterine wall) develop abnormally.
After 20 weeks of pregnancy, the two major causes of hemorrhage are
placenta previa and abrupto placentae (Separation of a normally implanted placenta before the fetus is born)
Preeclampsia
A systolic blood pressure of 140 mm Hg or greater or a diastolic blood pressure of 90 mm Hg or greater occurring after 20 weeks of pregnancy that is accompanied by significant
proteinuria (≥0.3 g in a 24-hour urine collection, which usually correlates with a random urine dipstick evaluation of ≥1+).
Edema, although common in preeclampsia, is now considered to be nonspecific because it occurs in many pregnancies not complicated by hypertension.
postictal
the unresponsive state after a seizure
ABO incompatibility
occurs when the mother is blood type O and the fetus is blood type A, B, or AB. Types A, B, and AB blood contain a protein component (antigen) that is not present in type O blood.
Treatment of preeclampsia includes
reduced activity, reduction of environmental stimuli, and administration of medications to prevent generalized seizures.
and magnesium sulfate, but this can have serious CNS depression side effects
polydipsia
thirst
osmotic diuresis in diabetes
The kidneys attempt to excrete large volumes
of fluid in the vascular bed and the heavy solute load of glucose
produces the second hallmark of diabetes, polyuria and glycosuria
ketosis
accumulation of acids in the
body
glycosuria
glucose in urine
Without glucose the cells starve,
so weight loss occurs, even though the person ingests large amounts
of food, which is called ____.
polyphagia
gluconeogenesis
formation of glycogen from noncarbohydrate sources such as proteins and fat
macrosomia
fetus that weighs more than 8.8 lb
[4000 g]
shoulder dystocia
delayed or difficult birth of fetal shoulders after the head is born
caudal regression syndrome
failure of sacrum, lumbar spine, and lower extremities to develop
In addition to having an increased risk for congenital anomalies,
the infant of a mother with preexisting diabetes has an increased
risk for
hypoglycemia, hypocalcemia, hyperbilirubinemia, and
respiratory distress syndrome
Viral infections that occur during pregnancy can be transmitted to the fetus in two ways:
across the placental barrier or by exposure to organisms during birth
Dystocia is
a general term that describes any difficult
labor or birth.
hydramnios
excess volume of amniotic fluid
Hypotonic labor dysfunction
or secondary arrest, usually occurs
during the active phase of labor, when progress normally quickens.
abruptio placentae
premature separation of placenta
Hypertonic labor dysfunction
is less common than hypotonic dysfunction and more often affects women in early labor with their first baby.
Contractions are uncoordinated and erratic in their frequency, duration, and intensity. The contractions are painful but ineffective.
Hypertonic dysfunction usually occurs during
the latent phase of labor.
Tocolytic drugs
drugs that inhibit uterine contractions
cephalopelvic disproportion
The head or shoulders may not be
able to adapt to the pelvis if they are too large
uterine rupture
tear in uterine wall
Precipitate labor
one in which birth occurs within 3 hours of its
onset.
Intense contractions often begin abruptly rather than gradually increasing in frequency, duration, and intensity, as is typical of most labors.
Precipitate birth
occurs after a labor of any length, in or out of the hospital or birth center, when a trained attendant is not present to assist.
Chorioamnionitis
(intraamniotic infection), or inflammation of
the membranes, which may be associated with group B streptococci, Neisseria gonorrhoeae, Listeria monocytogenes, or species from
the general Mycoplasma, Bacteroides, and Ureaplasma in the amniotic fluid
oligohydramnios
loss of the amniotic fluid cushion for the fetus.
Preterm labor
begins after the 20th week but before the end of the 37th week of pregnancy.
Amniocentesis
transabdominal puncture of amniotic sac
may be done to obtain amniotic fluid for culture if chorioamnionitis is suspected because this infection would contraindicate stopping preterm labor.
placenta accreta
an abnormally adherent placenta
sometimes associated with Placenta previa (abnormal implantation of the placenta in lower uterus)
Occult (hidden) prolapse
The cord is compressed between the fetal presenting part and pelvis but cannot be seen or felt during vaginal examination.
the cord slips alongside the
fetal head or shoulders.
The prolapse cannot be palpated or seen but
is suspected because of changes in the FHR, such as sustained bradycardia or variable decelerations.
Cord prolapsed in front of the fetal head
The cord cannot be seen but can probably be felt as a pulsating mass during vaginal examination.
Complete cord prolapse
The cord can be seen protruding from the vagina.
Uterine Inversion
An inversion occurs when the uterus completely or partly turns inside
out, usually during the third stage of labor. Such an event is uncommon but potentially fatal.
anaphylactoid syndrome, often called amniotic fluid embolism (AFE), occurs when
amniotic fluid is drawn into the
maternal circulation and carried to the woman’s lungs.
Nursing care for the woman at risk for a preterm birth before 34 weeks of gestation focuses on
helping her delay birth long enough to provide time for fetal lung maturation with corticosteroids,
allow transfer to a facility that has neonatal intensive care,
or reach a gestation at which the infant’s problems with immaturity are less.
The main risk in prolonged pregnancy is
reduced placental function.
This may compromise the fetus during labor and result in meconium aspiration in the neonate.
The key intervention for umbilical cord prolapse is to
relieve pressure on the umbilical cord and to expedite delivery.
S+S of uterine rupture
signs of shock, abdominal pain, a sense of
tearing, chest pain, pain between the scapulae, abnormal fetal heart rate patterns, cessation of contractions, and palpation of the fetus
outside the uterus.
Anaphylactoid syndrome (formerly amniotic fluid embolism) is more likely to occur when
labor is intense and the membranes have
ruptured.
Amniotomy
artificial rupture of the amniotic sac
chorioamnionitis
inflammation of the amniotic sac, usually caused by bacterial and viral infections
Vasa previa
in which fetal umbilical cord vessels branch over the amniotic sac rather than inserting into the placenta; fetal hemorrhage is a possibility if the membranes rupture
cephalopelvic disproportion
fetal head that is too large to fit through the mother’s pelvis
umbilical cord around the fetal body or neck
nuchal cord
chignon
Temporary caput or scalp edema
is common at the location of the vacuum extractor cup.
Infants born between 34 and 37 weeks of gestation are called
late preterm infants (LPIs) because they have many needs that are similar to those of preterm infants.
Preterm infants
born before the
beginning of the 38th week of gestation
Low birth weight (LBW)
infants weighing 5 lb, 8 oz (2500 g) or less at birth and of any gestational age
Extremely-low-birth-weight (ELBW)
weigh 2 lb, 3 oz (1000 g) or less at birth.
Very-low-birth-weight (VLBW)
weigh 3 lb, 5 oz (1500 g) or less at birth.
Periodic breathing
the cessation of breathing for 5 to 10 seconds without other changes followed by 10 to 15 seconds of rapid respirations
Changes in color or heart rate do not occur.
Apneic spells
involve absence of breathing lasting more than 20 seconds or less if accompanied by cyanosis, pallor, bradycardia, or hypotonia
Signs of Inadequate Thermoregulation
Axillary temperature 98.4°F (36.9°C) Abdominal skin temperature 97.7°F (36.5°C) Poor feeding or feeding intolerance Irritability followed by lethargy Weak cry or suck Decreased muscle tone Cool skin temperature Mottled, pale, or acrocyanotic skin Signs of hypoglycemia Signs of respiratory difficulty Poor weight gain, if chronic
urine specific gravity in dehydration and over hydration in newborn
dehydration - USG > 1.01
over hydration -
Containment
simulates the enclosed space of the uterus,
prevents excessive and disorganized motor activity, and is comforting
to infants. It involves keeping the extremities in a flexed position with
swaddling, positioning devices, or with the nurse’s hands.
Corrected or developmental age is
the chronologic age minus the number of weeks the infant was born early
compliant vs noncompliant lungs
compliant = elastic
noncompliant = stiff
Bronchopulmonary dysplasia (BPD), also known as chronic lung disease, is
a chronic condition in which damage to the infant’s lungs requires prolonged dependence on supplemental oxygen. It occurs most often in infants less than 32 weeks’ gestational age and in one third of VLBW infants.
Intraventricular hemorrhage (IVH) is also called germinal matrix hemorrhage and periventricular-intraventricular hemorrhage. It is
bleeding into and around the ventricles of the brain.
The first few days of life are the
most common times for hemorrhage to occur.
It may also occur in term infants from asphyxia or trauma
Retinopathy of prematurity (ROP) is
a condition where injury to the blood vessels in the eye may result in visual impairment or blindness in preterm infants.
It occurs more often in preterm infants weighing less than 1000 g and less than 29 weeks of gestational age
Necrotizing enterocolitis (NEC) is
a serious inflammatory condition
of the intestinal tract that may lead to cellular death of areas of intestinal mucosa.
Short bowel syndrome (SBS) is
a condition caused by a bowel that is
shorter than normal.
It is caused by congenital malformations of the GI tract or surgical resection that decreases the length of the small intestines.
Postterm infants are those who are born after
the 42nd week of gestation.
If placental insufficiency is present, decreased amniotic fluid volume (oligohydramnios) and compression of the umbilical cord may occur. The fetus may not receive the appropriate amount of oxygen and nutrients and may be small for gestational age. This condition results in hypoxia and malnourishment in
the fetus and is called
postmaturity syndrome
Small-for-gestational-age (SGA) infants are those who fall below the
____ percentile in size on growth charts.
tenth
LARGE-for-gestational-age (LGA) infants are those who fall above the
____ percentile in size on growth charts.
90
Late preterm infants, born between 34 and 36 weeks, are at risk for
respiratory, thermoregulation, and feeding problems as well as hypoglycemia, hyperbilirubinemia, acidosis, and sepsis.
Preterm infants differ in appearance from full-term infants. Some differences include:
small size, limp posture, red skin, abundant
vernix and lanugo, and immature ears and genitals.
The ____ position is used for preterm infants because it decreases breathing effort and increases oxygenation.
prone
Common complications of preterm birth are (6):
respiratory distress syndrome bronchopulmonary dysplasia intraventricular hemorrhage retinopathy of prematurity necrotizing enterocolitis short bowel syndrome
Infants with postmaturity syndrome may appear:
thin with loose skin folds
cracked and peeling skin
meconium staining
They may have respiratory difficulties at birth and suffer from hypoglycemia and inadequate temperature regulation.
In symmetric growth restriction, the infant is proportionally small; in asymmetric growth restriction, the head and length are _____ and the body is ____.
normal
thin
Asphyxia is
insufficient oxygen and excess carbon dioxide in the blood and tissues.
transient tachypnea of the newborn (TTN)
develop rapid respirations soon after birth from inadequate absorption of fetal lung fluid.
Although the condition usually resolves within 24 to 48 hours, it is the most common respiratory cause of admission to NICU
Meconium aspiration syndrome (MAS) is
a condition in which there is obstruction, chemical pneumonitis, and air trapping caused by meconium in the lungs.
Persistent pulmonary hypertension of the newborn (PPHN) is a
a condition in which pulmonary vascular resistance remains high after birth and right-to-left shunting of blood occurs, causing severe respiratory difficulty.
bilirubin encephalopathy
the acute manifestation of bilirubin toxicity
can lead to kernicterus
kernicterus
the chronic and permanent result of bilirubin toxicity.
In this condition, bilirubin deposits cause yellowish staining of the brain, especially
the basal ganglia, cerebellum, brainstem, and hippocampus.
erythroblastosis fetalis
agglutination and hemolysis of fetal erythrocytes from maternal-fetal blood incompatibility
hydrops fetalis
a severe anemia that results in heart failure and generalized edema.
Phenylketonuria (PKU) is
a genetic disorder that causes CNS injury
from toxic levels of the amino acid phenylalanine in blood.
Gastroschisis
a defect to the side of the abdomen, through which the intestines protrude.
They are not covered by peritoneum or skin and float freely in the amniotic fluid.
esophageal atresia (EA)
the esophagus is most commonly divided into two unconnected segments (atresia) with a blind pouch at the proximal end.
The cause is a failure of normal development during the fourth week of
pregnancy.
tracheoesophageal fistula
If the distal end is of the esophagus is connected to the trachea
The cause is a failure of normal development during the fourth week of
pregnancy.
omphalocele
the intestines protrude into the base of the umbilical cord.
Spina bifida is
failure of the vertebral arch to close.
It is seen by a dimple on the back, which may have a tuft of hair over it.
Meningocele is
protrusion of meninges and spinal fluid through the spina bifida, covered by skin or a thin membrane.
Because the spinal cord is not
involved, paralysis does not occur.
Myelomeningocele
protrusion of a membrane-covered sac through the spina bifida.
The sac contains meninges, nerve roots, the spinal cord, and spinal fluid.
The degree of paralysis depends on the location of the defect.
The infant may also have hydrocephalus, or it may develop after surgery.
Ventricular septal defect
is the most common type of
congenital heart defect.
It occurs alone or with other defects.
The opening in the septum ranges from the size of a pin to very large.
Patent ductus arteriosus is
a failure of the ductus arteriosus
to close after birth.
In coarctation of the aorta,
blood flow is impeded through a constricted area of the aorta near the ductus arteriosus, increasing pressure behind the defect.
The blood pressure is higher in the upper extremities than in the lower extremities.
Tetralogy of Fallot has four characteristics:
- a ventricular septal defect
- aorta positioned over the ventricular defect
- pulmonary stenosis
- hypertrophy of the right ventricle.
In transposition of the great arteries, the positions of the ____ and the _____ are reversed.
the aorta and the pulmonary artery
ACyanotic Heart Defects example
Patent ductus arteriosus
Cyanotic Heart Defects example
transposition of the great vessels
Left-to-Right Shunting Defects examples
ventricular septal defects and
patent foramen ovale.
Defects with Obstruction of Blood Outflow examples
Coarctation of the aorta and
stenosis of the pulmonary or aortic valves
Defects with Decreased Pulmonary Blood Flow example
tetralogy of Fallot
Cyanotic Defects with Increased Pulmonary Blood Flow example
transposition of the great vessels
Asphyxia before or during birth may cause
apnea, acidosis, pulmonary hypertension, and possible death.
Neonatal resuscitation must
be initiated immediately.
In transient tachypnea of the newborn, respiratory difficulty in infants is caused by
failure of fetal lung fluid to be absorbed completely.
It usually resolves spontaneously with supportive care.
Nonphysiologic jaundice appears ____.
Bilirubin levels rise ____ and than in physiologic jaundice. If untreated it may result in injury to the brain.
in the first 24 hours of life.
faster
Infants with polycythemia have increased viscosity of blood that may cause
thromboemboli, stroke, hyperbilirubinemia, and other complications.
Infants with phenylketonuria must be on a ____ diet to prevent severe intellectual disability.
low phenylalanine
How do we determine if it’s amniotic fluid in PROM
Nitrazine paper to test the pH
or send to the lab and see that the fluid has the appearance of ferns under the microscope i.e. ferning
About 50% of the time when there’s PROM but no contractions,
the mom will go into labor in about 24 hours
the next 25% will go within 48 hrs
Criteria influencing the treatment plan for PROM
Establish gestational age
Ultrasound to assess fetus
If LMP July 16, 2011, what is EDC?
May 1, 2012
polyhydramnios
excessive amniotic fluid
twin-to-twin transfusion
a serious disorder that occurs in identical twins and higher order multiples who share a placenta.
This occurs when the blood vessels of the babies’ shared placenta are connected.
This results in one baby (this twin is referred to as the recipient) receiving more blood flow, while the other baby (this twin is referred to as the donor) receives too little.
Generally speaking, if a pregnancy is triplets or more, they will be delivered at what kind of center?
Level 3 perinatal center with associated NICU
Preterm Labor “PTL” - weeks, contractions, effacement and dilation
Gestation 20-37 wks
Persistent uterine contractions - more than 6 in an hour- (4 every 20 mins or 8 per hour)
Cervical effacement at least 80%
Cervical dilation of more than 1 cm
Risk factors for preterm labor
Lack of prenatal care Stress Uterine anomalies Multiple gestation Polyhydramnios Hx or current UTI
Tocolysis
medication to inhibit labor
Treatment for Preterm Labor If fetus viable:
-> hydrate
if contractions subside: home on bedrest no work no sex no distress stress reduction
General notes for treatment of preterm labor
Careful maternal monitoring and FHR monitoring
Identify and report symptoms of fetal hypoxia
Treatment for Preterm Labor If fetus viable and labor is progressing
-> hydration
-> tocolysis
Nifedipine
MgSO4
Propranolol
-> corticosteroids (every 12 hrs for a couple days)
Dexamethasone
Betamethasone
tocolysis meds for PTL patients
Nifedipine
MgSO4 (magnesium sulfate)
Propranolol
3 types of hypertension that occur during pregnancy
- Chronic hypertension – not a function of pregnancy
Present before pregnancy (therefore, in first trimester also)
Possibly undiagnosed before prenatal visits - Gestational/Transient [aka Pregnancy-induced hypertension]
Develops in 2nd trimester
Hypertension with NO OTHER SYMPTOMS - Preeclampsia –> eclampsia
Hypertension
Proteinuria
chronic hypertension
Present before pregnancy (therefore, in first trimester also)
Possibly undiagnosed before prenatal visits
Gestational/Transient [aka Pregnancy-induced hypertension]
Develops in 2nd trimester
Hypertension with no other symptoms
treated with anti-hypertensive
If patient is in first trimester and has hypertension diagnosed, is it a function of pregnancy?
No
Preeclampsia –> eclampsia
Hypertension
Proteinuria
What is the Second leading cause of maternal death - about 1/10-15 pregnancies?
Preeclampsia
Certain populations more at risk for pre-eclampsia
Age 35
Race – higher in African Americans
Socioeconomic status – lower asso. W/poor diets, increase in smoking
Primagravida 6-8 times more likely to develop PIH
Genetic predisposition , oxidative stress, and the release of immune factors cause placental dysfunction
Eclampsia is grand mal seizures as a result of the progression of preeclampsia
Eclampsia does not have a B/P correlation, or proteinuria, etc.
Mild pre can cause eclampsia
Symptoms of preeclampsia
B/P > 140/90 @ 20 wks or more
Proteinuria
Sometimes: pitting pedal edema, facial edema
Medical Management of preeclampsia - goals and meds
- > stabilize blood pressure
- > prevent eclampsia
nifedipine, hydralazine, labetolol
eclampsia
seizures and coma
Signs of mild preeclampsia (systolic, diastolic, proteinuria)
Systolic 140-160
Diastolic 90-110
Proteinuria 3-5 gm in 24˚
Signs of severe preeclampsia (systolic, diastolic, proteinuria)
Systolic > 160
Diastolic > 110
Proteinuria > 5 gm in 24˚
Medical Management to prevent eclampsia in patients with uncontrolled or high HTN
- Bedrest
- EFM
- IVF (NPO in case of c/s)
- Antihypertensive therapy:
labetalol, hydralazine
Magnesium Sulfate to prevent seizures - Fetal gestation >34 wks –> deliver
- Corticosteroids
purpose of Magnesium Sulfate is to prevent
seizures
What is the focused assessment for a pt being tx with MgSO4?
- Vital signs -> blood pressure, temperature, FHR
- Neuro -> level of consciousness (A&Ox4), confusion, deep tendon reflexes, visual disturbances
- Pain -> headache, epigastric pain from liver
- Respiratory -> respirations and sPO2, coughing, SOB, dyspnea, rales/rhonchi
- Uterus/Placenta -> uterine rigidity, vaginal bleeding
- Urine -> output, protein, specific gravity
Weight (daily), pedal edema - Labs
- P/S -> emotional state, knowledge -> teaching
key nursing intervention on MgSO4 is to assess
deep tendon reflexes
if they become diminished, it’s a clear indicator that MgSO4 is reaching toxic levels and should be discontinued
If patient develops any signs of MgSO4 toxicity, the first step is always
stopping the infusion
For Magnesium Sulfate induced
Respiratory Depression or Respiratory Arrest,
institute Emergency Treatment (5 steps):
- STOP infusion immediately.
- Oxygen at 10LPM via face mask
- GIVE Calcium Gluconate 1 Gram slow IVP
(in Pre-eclampsia tray or Crash cart) - Continuous Pulse Oximetry and ECG monitors
- Contact anesthesia for airway management (Rapid Response)
Antidote for Magnesium Sulfate
Calcium Gluconate
HELLP Syndrome - what is it and what are symptoms, what can it lead to and how do you treat?
Hemolysis, Elevated Liver enzymes and Low Platelets
Variant or Complication of Preeclampsia
Flu-like symptoms
Epigastric pain from distended liver
Jaundice
Multiple system organ failure
FFP or platelet transfusion
Delivery ASAP
What is the best treatment for HELLP
Delivery ASAP
Danger signs - 3rd trimester
Vaginal bleeding
Abdominal pain
Fundal height
Leaking amniotic fluid Absence of fetal movement
Glycosuria
HTN/Proteinuria
Abnormal fetal heart rate
All pregnant women are screened for GBS between ___ wks gestation via vaginal swab. If culture is positive, IV antibiotics are administered when?
35-37
at delivery
When is HIV retesting done during pregnancy?
34-36 wks
Chorioamnionitis can progress to
Septicemia (affecting both mom and baby)
How is Placenta Previa diagnosed?
prenatal ultrasound
Hemorrhagic Disorders: Placenta Previa
Painless bright red vaginal bleeding in third trimester
Presenting part – not engaged
Possibly transverse lie
Medical Management
No vaginal examinations!
- > c/s
- > NSVD possible for high partial
marginal/low-lying placenta previa
not covering cerivical os
potential for vaginal delivery
partial placenta previa
partially covering cervical os
risk of injury to placenta with vaginal exam
complete placenta previa
covers the cervical os completely
Hemorrhagic Disorders: Abruptio Placenta
Separation of the placenta from the uterine wall
Dx – ultrasound, clinical presentation
Severe pain and dark vaginal bleeding in third trimester
Not in labor or
Labor could be progressing normally
Classic symptom - “board-like” pressure
NSVD possible for Abruptio Placenta patient IF:
If in labor If minimal bleeding If hemodynamically stable No uterine tenderness No fetal distress
Moms at increased risk for Abruptio Placenta
- smoker
- hypertension
- other causes of reduced oxygenation in the placenta
- cocaine – causes infarcs in the placenta
3 types of Abruptio Placenta
Marginal
Concealed
Complete
Precipitous Delivery
Rapid intense contractions
Labor less than 3 hrs
potential complication: trauma to the cervix as result of insufficient time for it to dilate (if baby is descending too fast)
Main nursing intervention with Precipitous Delivery
helping mom to control/avoid pushing with breathing techniques until cervix is dilated more
Dystocia
Long, difficult, or abnormal labor
As a result of
Powers
Passenger
Passageway
Dysfunctional Labor Pattern: Hypertonic
Strong, painful, ineffective contractions
Contributing factor: maternal anxiety
Occiput-posterior malposition of fetus
release of catecholamines which lead to myometrial dysfunction
***prolonged labor phase
fetal distress could occur early
Dysfunctional Labor Pattern: Hypotonic
Contractions decrease in frequency, intensity
Maternal and fetal factors that produce excessive uterine stretching
most common: too many drugs/pain meds
treatment: trying to stimulate contractions (enema, nipple stimulation, walking)
Structural dystocia
Shoulder Dystocia –> McRoberts Maneuver
Cephalo-Pelvic Disproportion (CPD)
Fetal Anomalies
IDM or LGA
all of these are indicates for a c section
Cephalo-Pelvic Disproportion (CPD)
baby’s head is too big to fit through pelvis
Obstetric emergency if Uterine rupture comes with what kind of pain?
Sharp referred pain -> between scapula
Uterine inversion
uterus follows the placenta out
requires Surgical repair
Does Umbilical cord prolapse require c section?
yes
Chorioamnionitis “chorio”
- Maternal fever (100.4 F)
Plus
- WBC > 15,000
- Maternal tachycardia (> 100 bpm)
- Fetal tachycardia (> 160 bpm)
- Foul or strong-smelling amniotic fluid
- Tender uterus
____ are contraindicated in the presence of symptomatic Amniotic Fluid Infection.
Tocolytics
Tachycardia in FHR
> 160 bpm
Bradycardia in FHR
Baseline FHR is
FHR between contractions i.e. when nothing is happening
Closer to term, the ___ the resting heart rate can be
lower
normal could be 110-120 for a healthy full term baby
Accelerations
jump of 15
indicate good CNS and responsiveness
Variable decelerations are the result of
cord compression
onset varies with contractions
Late deceleration caused by
utero-placental insufficiency (lack of oxygenation to the baby)
occurs at peak of contraction
Early decelerations caused by
head compression
occurs at the beginning of the increment and peak of the contraction
At the peak of the contraction, is there oxygen flowing to the baby?
no
VEAL CHOP
Variable - cord compression
Early - head
Accelerations - OK
Late - placenta
Are there interventions for early decelerations?
No
What are the interventions for repeated variable or late decelerations?
Discontinue oxytocin Lateral position change Increase IVF rate Oxygen per face mask Palpate for hyperstimulation Notify HCP
Post term Pregnancy
extends beyond 42 wks
Risk for fetal/neonatal problems
Increased maternal risk
Management—labor induction
Indications for induction
Post term pregnancy
Premature Rupture of Membranes (PROM)
Chorioamnionitis
HTN: Chronic, Gestational, or Preeclampsia (mild)
Maternal co-morbidities:
Diabetes
Cardiac or Respiratory
Psychosocial (including hx precipitous or rapid labor and distance to hospital )
Fetal compromise: Intrauterine growth restriction (IUGR) Oligohydramnios Isoimmunization Fetal demise
Bishop score
Determines how successful an induction of labor will be
Mechanical induction
Amniotomy = AROM
Membrane Stripping
Medication induction
Cervical Ripening:
dinoprostone insert or gel
misoprostol (off-label)
laminaria
Synthetic Oxytocin IV
2 ways that labor is augmented (when cervix is not dilating)
Mechanical:
AROM
Membrane Stripping
Medication:
Synthetic Oxytocin IV
Indications for Cesarean Section - STAT
- Fetal distress (prolonged deceleration without recovery)
- Umbilical cord prolapse
- Placenta Abruptio
- Uterine rupture
- Hemorrhage
Indications for Cesarean Section - Scheduled
Repeat
Multiples
Infection: HIV, active herpes lesions
Previous 4th degree perineal laceration
Scheduled during last weeks
Placenta Previa
Presentation: Breech, Transverse
Indications for Cesarean Section - Non emergent
Failure to progress – prolonged labor
Failed labor induction
Macrosomia / CPD
Complications:
Preeclampsia and HELLP
Preterm labor (if progressing and 22-28 wks)
Major risks of c section
Respiratory Depression
Anesthetic gases or medications (epi/spinal)
Maternal or Newborn respiratory depression
Infection
-> Pre-operative prevention
Surgical Care Improvement Project Measure
General Anesthesia for c/s Preferred if
- Platelet count is less than 100,000
- Epidural/spinal is not effective
- “STAT” emergency section for fetal or maternal distress
Apnea of Prematurity
Apnea – not breathing >15 to 20 secs accompanied by pallor, hypotonia, cyanosis, and bradycardia
severe vs moderate prematurity
Severe prematurity
22 to 26 weeks
Moderate prematurity
26 to 30 weeks
GFR =
Grunting Flaring Retractions
Treatment for Meconium Aspiration Syndrome
Suctioning before first breath to prevent aspiration pneumonia
Symptoms of Sepsis
Temperature Instability Feeding Poor suck Feeding intolerance Hypoglycemia Respiratory - “GFR” Hypotonia
EMTALA
Emergency Medical Treatment and Labor Act
Federal law
Patients must be treated for all emergency conditions (including admission) regardless of ability to pay and can only be transported to another facility for a higher level of care.
