Exam 3 OB Flashcards
With DM what are optimum specific blood glucose and A1C levels?
70-110
6% or less
When do high-risk mothers start checking kick counts for fetal well-being?
around 28 weeks
What are infants born to diabetic mothers chubby at birth?
insulin does not pass the placental barriers, but glucose does
glucose is managed by the baby and their insulin levels. the glucose store up
Why do women have more frequent UTIs?
estrogen causes polyuria
urine retention and stasis
fever undiagnosed as infection because higher temp is expected with pregnancy
What is an incompetant cervix?
cervix dilates prior to labor
What are some of the interventions a nurse can expect with maternal heart failure?
serial ultrasound and nonstress tests after weeks 30 to 32 of pregnancy to monitor fetal health and to rule out poor placental perfusion
What additional complications might a pregnant person experience with hepatomegaly from right-sided heart failure?
Extreme liver enlargement can cause dyspnea and pain in a pregnant patient because the enlarged liver, as it is pressed upward by the enlarged uterus, puts extreme pressure on the diaphragm.
ascites and peripheral edema can be exacerbated d/t the pressure as well.
What might a nurse see with late-term treatment of a pregnant person with right-sided heart failure?
oxygen administration and frequent arterial blood gas assessments to ensure fetal growth
potential hospitalization for monitoring
During labor, they may need a pulmonary artery catheter inserted to monitor pulmonary pressure
Patients with this condition also need extremely close monitoring after epidural anesthesia to minimize the risk of hypotension.
What is peripartal cardiomyopathy? What are risk factors? S/S? Treatment? What are recommendations if it persists after pregnancy?
originates in pregnancy in those with no previous history of heart disease
stress of the pregnancy on the circulatory system
Black multiparas
conjunction with gestational hypertension
shortness of breath
chest pain
nondependent edema
cardiomegaly
sharply reduce their physical activity
diuretic
arrhythmia agent
digitalis therapy to maintain heart function
LMWH
not attempt any further pregnancies because the condition tends to recur or worsen in additional pregnancies
oral contraceptives are contraindicated because of the danger of thromboembolism heart transplant
Why is documenting edema important, especially with heart failure? What is the difference? What may also be present and should be compared to baseline?
usual innocent edema of pregnancy must be distinguished from the beginning of edema from heart failure
usual edema of pregnancy involves only the feet and ankles but becomes systemic with heart failure. It can begin as early as the first trimester
other symptoms such as irregular pulse, rapid or difficult respirations, and chest pain on exertion will likely be present
What is the impact of lowered blood pressure due to heart disease on the fetus?
BP becomes insufficient to provide an adequate supply of blood and nutrients to the placenta, fetal health can be compromised
low birth weights or be small for gestational age because of acidosis
preterm labor
fetus may not respond well to labor (evidenced by late deceleration patterns on a fetal heart monitor)
potential for cesarean birth
What are interventions during labor with heart disease?
side-lying position during labor to reduce the possibility of supine hypotension syndrome
elevate their head and chest (a semi-Fowler position) to ease the work of breathing
place a towel under the right hip to shift the uterus off the vena cava
Evaluate for fatigue
oxygen therapy
Why is the period immediately after giving birth a critical time for heart patients? How can the increase be compensated for?
with delivery of the placenta, the blood that supplied the placenta is released into the general circulation, increasing the blood volume by 20% to 40%. During pregnancy, the increase in blood volume that occurred did so over a 6-month period, so the heart had time to gradually adjust to this change. After birth, the increase in pressure takes place within 5 minutes, so the heart must make a rapid and major adjustment
decreased activity
anticoagulant and digoxin therapy until the circulation stabilizes
Antiembolic stockings or intermittent pneumatic compression (IPC) boots
prophylactic antibiotics for subacute bacterial endocarditis caused by the introduction of microorganisms through the placental site
Why is it more difficult to manage insulin/glucose levels during pregnancy with type 1 or 2 DM? What occurs with glucose and insulin filtration during pregnancy in all pregnancies? How is the natural resistance of the destruction of insulin beneficial in healthy pregnancies? What difficulty does it cause in diabetics?
all individuals experience several changes in the glucose–insulin regulatory system as pregnancy progresses
- glomerular filtration of glucose is increased causing slight glycosuria
- rate of insulin secretion is increased, and the fasting blood sugar level is lowered
- All patients appear to develop an insulin resistance as insulin does not seem as effective during pregnancy
prevents the patient’s blood glucose from falling to dangerous limits.
they must then increase their insulin dosage beginning at about week 24 of pregnancy to prevent hyperglycemia.
* they must guard against hypoglycemia and ketoacidosis caused by the constant use of glucose by the fetus
Why are infants born to patients with poorly controlled diabetes tend to be LGA?
because the increased insulin the fetus must produce to counteract the overload of glucose they receive acts as a growth stimulant
Polyhydramnios may develop because a high glucose concentration causes extra fluid to shift and enlarge the amount of amniotic fluid
What are negative outcomes in pregancy with poorly controlled diabetes?
congenital anomalies
caudal regression syndrome (failure of the lower extremities to develop)
spontaneous miscarriage
stillbirth
hypoglycemia developing at birth
respiratory distress syndrome, hypocalcemia
hyperbilirubinemia
What are risk factors for developing gestational diabetes?
Obesity
Age over 25 years
History of large babies (10 lb or more)
History of unexplained fetal or perinatal loss
History of congenital anomalies in previous pregnancies
History of polycystic ovary syndrome
Family history of diabetes (one close relative or two distant ones)
Member of a population with a high risk of diabetes
What is test do all patients take between 24-28 weeks to identify gestational diabetes? What is the threshold to need a 3 hour test? How is it administered and interpretted?
50-g glucose challenge test between
result of that test is 140 mg/dL (some providers use 130 mg/dL as the cutoff) at 3 hours
after a fasting glucose sample, patient drinks an oral 100-g glucose solution; a venous blood sample is then taken for glucose determination at 1, 2, and 3 hours later. If two of the four blood samples collected for this test are abnormal or the fasting value is above 95 mg/dL, a diagnosis of diabetes is made
Fasting: 95
1 hour: 180
2 hours: 155
3 hours: 140
Is bleeding normal in pregnancy? How should it be treated and why? What is the risk of undiscovered bleeding? What is the risk specific to pregnancy with hypovolemic shock?
No
potential emergency because it may mean the placenta has loosened and cut off nourishment to the fetus
* the amount of blood visualized may be only a fraction of the blood actually being lost because an undilated cervix and intact membranes contain blood within the uterus
significant blood loss or developing hypovolemic shock.
fetal distress
What 7 findings are assessed with blood loss and their significance?
Increased pulse rate: Heart attempts to circulate decreased blood volume.
Decreased blood pressure: Less peripheral resistance is present because of decreased blood volume.
Increased respiratory rate: Respiratory system attempts to increase gas exchange to better oxygenate decreased red blood cell volume.
Cold, clammy skin: Vasoconstriction occurs to maintain blood volume in central body core.
Decreased urine output: Inadequate blood is entering kidneys because of decreased blood volume.
Dizziness or decreased level of consciousness: Inadequate blood is reaching cerebrum because of decreased blood volume.
Decreased central venous pressure: Decreased blood is returning to heart because of reduced blood volume.
What is the most common reason for miscarriage in the 1st trimester? Other causes?
abnormal fetal development, due either to a teratogenic factor or to a chromosomal aberration
rejection of the embryo through an immune response
implantation abnormalities
corpus luteum on the ovary fails to produce enough progesterone
alcohol use
What is a threatened misscarriage? How is it monitored? If hCG doesn’t increase in 48hrs what does it likely indicate?
vaginal bleeding, initially only scant and usually bright red. A patient may notice slight cramping, but no cervical dilatation is present on vaginal examination
check fetal viability
test for human chorionic gonadotropin (hCG) hormone at the start of bleeding and again in 48 hours
pregnancy is more likely to be a miscarriage
What is an imminent miscarriage? What will tissue be analyzed for? What may occur is fetus is determined not viable, no heart sounds or an empty sac?
A threatened miscarriage becomes an imminent (i.e., inevitable) miscarriage if uterine contractions and cervical dilatation occur
gestational trophoblastic disease (hydatidiform mole)
medication to help the pregnancy pass or perform a dilatation and curettage (D&C) or a dilatation and evacuation (D&E)
What is a complete miscarriage? Missed miscarriage?
entire products of conception (fetus, membranes, and placenta) are expelled spontaneously without any assistance
early pregnancy failure, the fetus dies in utero but is not expelled
usually discovered at a prenatal examination when the fundal height is measured and no increase in size can be demonstrated or when previously heard fetal heart sounds can no longer be heard.
What is an ectopic pregnancy? Where does the egg most commonly implant? What can cause obstructions that prevent the egg from traveling freely to the uterus?
implantation occurred outside the uterine cavity
in the fallopian tube, most often in ampullar portion
adhesion of the fallopian tube from a previous infection
pelvic inflammatory disease
salpingitis
congenital malformations
scars from tubal surgery
uterine tumor pressing
celiac disease
What sign can show up at the umbilicus indicating an ectopic rupture? What point are included in the triad of symptoms?
abdomen gradually becomes rigid from peritoneal irritation. The umbilicus may develop a bluish-tinged hue (Cullen sign)
Cullen sign
lower pain
shoulder pain
What sign can show up at the umbilicus indicating an ectopic rupture? What point are included in the triad of symptoms?
abdomen gradually becomes rigid from peritoneal irritation. The umbilicus may develop a bluish-tinged hue (Cullen sign)
Cullen sign
lower pain
shoulder pain
How does gestational trophoblastic disease present? What happens to the embryo? Risk factors? How is it assessed? How must it be handled?
As the cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized vesicles
The embryo fails to develop beyond a primitive start
low dietary intake of animal fat
older than 35 years
younger than 15 years
Asian heritage
Because proliferation of the abnormal trophoblast cells the uterus tends to expand faster than usual or reach its landmarks
all cells must be removed or they can become cancerous
refrain from becoming pregnant for a year to ensure all ceels have been expelled
What is an incompetent cervix? Risk factors? How is it identified? How is it managed? What is the purpose of the sutures? Patient instruction? When are suture removed?
Premature cervical dilation
increased age
congenital structural defects
trauma to the cervix
may be diagnosed by an early ultrasound before symptoms occur
cervical cerclage at approximately weeks 12 to 14 and serves to strengthen the cervix
bed rest (perhaps in a slight or modified Trendelenburg position) for a few days to decrease pressure on the new sutures. Usual activity and sexual relations can be resumed in most instances after this rest period.
sutures are removed at weeks 36 to 37 of pregnancy so that the fetus can be born vaginally
What is the steriod used to encourage surfactant and mature fetal lungs?
betamethasone
What is placental abruption? What is the risk? When does it generally occur? Therapeutic management?
premature separation of the placenta and bleeding results
most frequent cause of perinatal death
late in pregnancy, even as late as during the first or second stage of labor
emergency situation
fluid replacement
oxygen by mask to limit fetal anoxia
Keep a patient in a lateral, not supine, position to prevent pressure on the vena cava and additional interference with fetal circulation
do not perform any abdominal, vaginal, or pelvic examination to not further damage placenta
cesarean birth
most often hysterectomy
What medications can aid in curbing preterm labor? Why is betamethasone indicated. What is the preffered dosage?
Tocalytic agents: Terbutaline (off label, normally used for bronchospasms in asthma)
nifedipine
indomethacin
Magnesium sulfate primarily used to treat preeclampsia and prevent eclamptic seizures recent research does not support the use of magnesium as a tocolytic
betamethasone, the formation of lung surfactant: two doses of 12 mg betamethasone IM 24 hours apart or four doses of 6 mg dexamethasone IM 12 hours apart.
What is preterm rupture of membranes? What is the likely cause? What is the risk?
rupture of fetal membranes with loss of amniotic fluid before 37 weeks
strongly associated with infection of the membranes (i.e., chorioamnionitis)
major threat to the fetus as, after a rupture, the seal to the fetus is lost and uterine and fetal infections may occur
increased pressure on the umbilical cord from the loss of amniotic fluid
What is preeclampsia? Risk factors? What is eclamsia?
increased blood pressure and proteinuria
Being a person of color
multiple pregnancy
Being primiparous when younger than 20 years or older than 40 years
poor nutrition
gravida five or more
polyhydramnios
underlying disease such as heart disease, diabetes
resulting seizure
What is dystocia? What 4 ways can cause a difficult labor?
A difficult labor
(a) the power, or the force that propels the fetus (uterine contractions)
(b) the passenger (the fetus)
(c) the passageway (the birth canal)
(d) the psyche (the birthing parent’s and family’s perception of the event)
What are hypotonic contractions? what can contribute?
the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period) and the strength of contractions does not rise above 25 mm Hg
administration of analgesia
bowel or bladder distention is preventing descent or firm engagement
uterus that is overstretched by a multiple gestation
larger than usual single fetus, polyhydramnios
uterus that is lax from grand multiparity.
What is the dangeer of hypertonic contractions? What type a meds could be helpful in this circumstance?
uterus is unable to relax inbetween contractions
sedation
What constitutes a precipitate delivery? Complications?
cervical dilatation that occurs at a rate of 5 cm or more per hour in a primipara or 10 cm or more per hour in a multipara.
or
uterine contractions are so strong a parent gives birth with only a few, rapidly occurring contractions
or
labor that is completed in fewer than 3 hours
placenta or lacerations
maternal hemorrhage
fetal subdural hemorrhage may result from the rapid release of pressure on the head.
What is inductions labor? Augementation of labor?
labor is started artificially.
assisting labor that has started spontaneously but is not effective
What most commonly contributes to uterine rupture? What can factor in as well?
previous cesarean scar
prolonged labor
abnormal presentation
multiple gestation
unwise use of oxytocin
obstructed labor
traumatic maneuvers of forceps or traction.
Why should you never aid the delivery of the placenta by pulling onthe umbilical cord?
can cause a uterine prolapse, uterine inversion
What are contributing factors for umbilical cord prolapse?
Premature rupture of membranes
Fetal presentation other than cephalic
Placenta previa
Intrauterine tumors preventing the presenting part from engaging
A small fetus
CPD preventing firm engagement
Polyhydramnios
Multiple gestation
What two maneuvers are used to resolve shoulder dystocia? How are they executed?
McRoberts maneuver and suprapubic pressure
McRobert’s: the patient is asked to or assisted to deeply flex their thighs back toward their abdomen and then rotate the thighs laterally to make a wide V. This widens the pelvic outlet and may allow the anterior shoulder to be born.
The second maneuver, suprapubic pressure, is often completed by nursing staff. The fetal back is identified and the nurse stands on the side of the patient that is closest to the fetal back. Downward and lateral pressure is applied just above the patient’s pubic bone to dislodge and rotate the fetal shoulder away from the midline. Applying suprapubic pressure may rotate the shoulder and help it escape from beneath the symphysis pubis.
What is a placenta sucenturiata?
placenta that has one or more accessory lobes connected to the main placenta
No fetal abnormality is associated with this type. However, it is important it be recognized because the small lobes may be retained in the uterus after birth, leading to severe obstetric hemorrhage.
What is placenta circumvallata? How does this differ from an normal placenta?
the fetal side of the placenta is covered to some extent with chorion, the umbilical cord enters the placenta at the usual midpoint, and large vessels spread out from there
Ordinarily, the chorion membrane begins at the edge of the placenta and spreads to envelop the fetus; no chorion covers the fetal side of the placenta.
What is battledore placenta?
the cord is inserted marginally rather than centrally
What is a velamentous insertions of the cord? When is it most often found? What is the risk during delivery?
situation in which the cord, instead of entering the placenta directly, separates into small vessels that reach the placenta by spreading across a fold of amnion
multiple gestations
associated with fetal anomalies
cord is more likely to avulse (tear) and brisk bleeding can occur
What is placenta accreta? How should it be treated?
deep attachment of the placenta to the uterine myometrium, so deep that the placenta will not loosen and deliver
Hysterectomy to remove the uterus or treatment with methotrexate to destroy the still-attached tissue may be necessary
What is an amniotomy?
artificial rupturing of membranes during labor if they do not rupture spontaneously to allow the fetal head to contact the cervix more directly, which increases the efficiency of contractions and therefore increases the speed of labor.
What is the benefit of internal electronic monitoring? How is it achieved?
most precise method for assessing FHR and uterine contractions
passing a pressure-sensing catheter through the vagina and into the uterus after the membranes have ruptured. It is inserted into the uterine cavity and alongside the fetus
What is scalp stimulation? How is it done?
if a fetus shows an unresponsive heartbeat during labor, vibroacoustic stimulation can be used the same as is done for nonstress tests during pregnancy to be certain a fetus is responding well to labor
applying pressure with the fingers to the fetal scalp through the dilated cervix
What is DIC? What labs are monitored? Contirbuting factors?
disseminated intravascular coagulopathy
used up clotting factors in hemorrhage and unable to clot
PTT
INR
platelets
hematocrit
HgB
preeclampsia
sepsis
prexisting clotting disorder
What are late decellerations caused by? What are interventions
placental insufficiency
left side
turn pitocin off
oxygen
What is the HELLP syndrome complication with preeclampsia? What S/S occur in addition to the high BP. edema and protienuria?
HELLP syndrome is a variation of the gestational hypertensive process named for the common symptoms that occur:
Hemolysis leads to anemia.
Elevated liver enzymes lead to epigastric pain.
Low platelets lead to abnormal bleeding/clotting (Lisonkova et al., 2020).
symptoms of nausea, epigastric pain, general malaise, and right upper quadrant tenderness from liver inflammation occur. L
What occurs with mag sulfate toxicity?What to do?
low BP
decrease in DTR
decreased urine output
drowsy
decreased LOC
turn mag off
get lab level
give calcium gluconate
contact HCP
What is normal volume of amniotic fluid levels? oligohydramnios? Polyhydramnios? Maternal reasons? Fetal?
800-1200 mL
<300 mL
alot, 2000 mL
preeclampsia
multiples
heart conditions
kidney
GI tract functioning
What is given with a maternal negative blood type? When?
Rhogan
28 weeks, within 72 hours of birth, any time invasive procedure where there is a potential of blood mixing
What is a vasa privia?
cord between baby and cervix
Which cesaerian incision is indicated for subsequent baginal births?
transverse
