exam three: self paced modules

Question 1

obstetric emergencies

Answer 1

• Uterine Rupture
• Trauma
• Amniotic Fluid Embolism

Question 2

uterine rupture

Answer 2

• Tear in the uterus

Question 3

1st sign of uterine rupture

Answer 3

fetal heart rate changes (late decels or tachycardia from volume loss followed by severe bradycardia). Sometimes just loss of variability and deep bradycardia change

Question 4

other symptoms of uterine rupture

Answer 4

• typically non-specific
• very short of time (17 min) to significant fetal morbidity
• sometimes severe pain, lots of bleeding but more often mild discomfort and mild bleeding
• May have sudden onset constant severe abdominal pain even with epidural in place- often won’t have this
• Elevated resting tone measured by IUPC
• The fetus can end up in the abdominal cavity in rare cases (change station)
• Internal bleeding common, may have minimal to extensive external bleeding = hypovolemic shock with no intervention

Question 5

risk factors for uterine rupture

Answer 5

• previous uterine scare (c/s or other) – number one and 1/2 are due to previous c section
  -fetal malpresentation – breech or oblique
  -grand multiparity – at least 5 births
  –operative vaginal birth – forceps or vacuum
  -induction with oxytocin
  -short inter-pregnancy/inter-delivery interval – less than 18 months between
  -older mothers
  -fetal macrosomia

Question 6

implications of uterine rupture

Answer 6

neonatal and maternal M & M due to lots of bleeding, hypotension

Question 7

how to prevent and minimize risk of uterine rupture

Answer 7

1. appropriate TOLAC candidates -people who have had c/s in past that want vaginal birth need to be screened carefully
   - Some increased risk: vary large baby, short interval between pregnancy’s not great candidates
2. avoid unnecessary IOL due to oxytocin exposure
3. continuous EFM during TOLA

Question 8

treatment for uterine rupture

Answer 8

• for suspected uterine rupture (as diagnosis can only be made with visualization of the uterus and may also only be diagnosed when your already doing c/s for something else)
• Emergency c/s
• Possible hysterectomy (up to 70%)- especially if tear is large enough and there has been significant bleeding by the time we get there
• Treatment of hypovolemic shock

Question 9

how to treat hypovolemic shock with suspected uterine rupture

Answer 9

1. Additional line placed, blood type and match for potential transfusion

Question 10

Trauma Stats

Answer 10

• 1 in every 12 pregnant women sustains a significant traumatic injury
• Leading cause of non obstetrical deaths in pregnant women in trauma
• MVA’s are responsible for 75% of all blunt force trauma in pregnancy
• 2nd most common cause of blunt trauma is DV, followed by assault and falls
• Leading penetrating trauma is GSW, followed by stabbing

Question 11

Trauma Physiology

Answer 11

1. Pregnant women have extra 45% in blood volume, 40% in cardiac output
2. Increase clotting factors
3. Blood is shunted away from uterus & fetus
4. Save the mother first because babies are resuscitated better intrauterine most of the time

Question 12

how does Pregnant women have extra 45% in blood volume, 40% in cardiac output relate to trauma

Answer 12

Greater volume of blood loss before shock symptoms seen. Go into shock later after loosing much larger volume of blood

Question 13

how does Increase clotting factors relate to trauma

Answer 13

• increased risk of post trauma clot and delayed recognition of DIC (by time picked up they have dumped all of those clotting factors and they are spiraling out of control more time has passed)

Question 14

how does blood being shunted away from the uterus and fetus relate to trauma

Answer 14

Blood is shunted away from uterus & fetus to maintain woman’s hemodynamic status which puts the babies at increased risk

Question 15

risks of trauma

Answer 15

Maternal death
Fetal death
Non-OB complications
OB complications

Question 16

non ob complications of trauma

Answer 16

Broken pelvis
Broken legs and arms

Question 17

OB complications of trauma

Answer 17

-Abruption (any kind of blunt trauma can tear the placenta off the wall of uterus)
-Feto-maternal bleeding (mixing of blood)
-Uterine rupture
-DIC
-Direct fetal injury

Question 18

1 cause of trauma

Answer 18

MVA
- Maternal death is associated with ejection from the vehicle or exsanguination (bleeding out) from rupture of a major blood vessel
-Risks:
1. Hemorrhage
2. Abruption
3. Maternal-fetal hemorrhage
4. Pregnant women 10x more likely to die as a result of these injuries

Question 19

seat belts and pregnancy

Answer 19

SEAT BELTS should be worn 100% of the time even when pregnant low and across their hips and in the third trimester under their belly across hips !

Question 20

trauma from domestic violence

Answer 20

1. ~20% of women have been battered during current pregnancy
2. Rates approach 50% in teen relationships
3. 3-fold of increased in unintended pregnancies
4. Violence often begins or escalates during pregnancy
   -May say no at the first appointment but ask throughout pregnancy because it could start
   -Many women who are afraid to say yes throughout pregnancy when they are about to take the baby home they will say yes that they don’t feel safe
5. Increased risk of miscarriage, preterm & low birth weight
6. Most likely time to be killed is after attempts to leave- get them to DV support person
7. No “typical” abuser profile
8. Look for bruises & burns in hidden areas that clothing would cover, ASK –especially postpartum before discharge home

Question 21

Management of Catastrophic Trauma Victim

Answer 21

• Catastrophic – “Immediately life threatening”
• CABD- circulation, airway, breathing, delivery
  1. move uterus off VC (vena cava)– tilt backboard if on whole board
  2. Large bore IV X 2 and replace fluids as can
  3. Estimate age of fetus- rough fundal height
  -Above U: viable
  -Below U: not viable
  4. CPR X 4-5 min –> perimortem C/S if not getting great results
  -If CPR not effective to save mom
  -Imminent maternal death to save the baby when we know she isn’t going to survive
  -Stable mother, non-reassuring FHT’s to save viable baby

Question 22

Management of Non-Catastrophic Trauma Victim

Answer 22

• Stabilize injury and promote well being for mom and baby
• Evaluate for abruption, preterm labor, blood mixing
  1. *continuous EFM for viable fetus, US, CBC, Kleihauer-Betke for RH negative moms (to determine need for additional RhoGAM)
  2. *infant death may occur from delayed recognition of non-reassuring fetal heart rate patterns so always assess, even after minor trauma
  -EFM within 30 minutes
  -Continue EFM for at least 4 hours after trauma
  -Watch for signs of abruption: Irritability pattern on strip
• Any early signs of abruption- continue EFM x 24 hours

Question 23

Amniotic Fluid Embolism (AFE)

Answer 23

Amniotic fluid containing fetal cells, hair, or other debris enters the mother’s blood stream via the placental bed of the uterus and triggers an anaphylactic allergic reaction. This reaction then results in cardiorespiratory (heart and lung) collapse and coagulopathy.

Question 24

outcomes of AFE

Answer 24

• very poor
• maternal mortality 20-90%, of those that survive only 7% neurologically intact
• neonatal mortality 20-60%, of those that survive 70% neurologically intact

Question 25

Associations of AFE

Answer 25

many however non are considered causative, therefore should be considered unpredictable and unpreventable

Question 26

presentation of AFE

Answer 26

1. acute shortness of breath and hypotension which quickly progress to cardiac arrest, coagulopathy and coma within 30 minutes of labor and birth, c/s, or D&E
   -80% –> in DIC in 10 minutes, nearly 100% within 30 minutes

Question 27

management of AFE

Answer 27

• Supportive of organ systems  ICU
• Immediate CPR and intubated
• Blood products since will go into DIC
• 2 large bore IV’s- caution with fluid
• Norepinephrine, dopamine

Question 28

symptoms of AFE

Answer 28

-May exhibit dyspnea, cough, seizure, confusion, agitation, fetal distress, nausea, vomiting, fever, or feelings of impending doom

Question 29

perinatal loss

Answer 29

includes time surrounding childbearing cycle
1. infertility during the preconception period
2. fetal death during pregnancy
3. infant death in first year of life

• using a broader definition, this can also include the non-death loss associated with adoption

Question 30

types of perinatal loss

Answer 30

1. before pregnancy
2. during pregnancy
3. first neonatal year

Question 31

types of perinatal loss before pregnancy

Answer 31

infertility

Question 32

types of perinatal loss during pregnancy

Answer 32

-Ectopic pregnancy
-Elective abortion
-Fetal death
-Miscarriage (spontaneous abortion)
-Therapeutic abortion: for someone who has been told they have a baby with a lethal anomaly
-Stillbirth

Question 33

types of perinatal loss in the first neonatal year

Answer 33

-Neonatal death
-Sudden infant death syndrome (SIDS)

-Adoption*

Question 34

Infertility

Answer 34

• Infertility is the inability to conceive after at least 1 year of trying.
• According to the CDC data from 2006-2010, approximately 10 percent (6.8 million) of U.S. women of childbearing age were unable to conceive or unable to carry a baby to term.

Question 35

Perinatal Mortality in the U.S: ectopic pregnancies

Answer 35

1-2% of pregnancies in the US are ectopic- pregnancy outside of the uterine cavity

Question 36

Perinatal Mortality in the U.S: spontaneous abortion

Answer 36

15-50% of conceptions result in spontaneous abortion (miscarriage)

Question 37

Perinatal Mortality in the U.S: stillbirths

Answer 37

1 out of 160 births are stillbirths (fetal death in utero after 20 weeks gestation (about 26,000 per year)

Question 38

Infant Mortality in the U.S.

Answer 38

Infant mortality is the death of an infant during the first year of life.
Rate- in the US is approximately 6 per 1,00 births

Question 39

most common causes of infant mortality

Answer 39

-Serious birth defects
-Preterm birth
-SIDS
-Affected by maternal complications of pregnancy
-Injuries (suffocation and strangulation in bed)

Question 40

grief

Answer 40

normal internal emotional response to loss

Question 41

mourning

Answer 41

external expression of the grief

Question 42

grief and mourning

Answer 42

-No two people grieve or mourn the same event or loss in exactly the same way
-Responses to perinatal loss can range from disappointment to life-altering anguish
-Don’t make assumptions. Always ask where people are at.

Question 43

Theories of Attachment and Grief

Answer 43

1. Peppers and Knapp (1980) study showed that attachment begins when planning pregnancy
2. Kübler-Ross (1969) described grief as a series of stages

Question 44

stages of grief

Answer 44

-Denial
-Anger
-Bargaining
-Depression
-Acceptance

Question 45

Grieving Styles

Answer 45

Common grief responses specific to perinatal loss include:
1. Heavy or aching arms
2. Avoiding pregnant women and babies
3. Sense of loss of the future and shattered dreams
4. Sense of vulnerability in the world (not safe as always assumed)
5. Hyper-vigilance with other surviving children (Extra protection measures)

Question 46

heavy or aching arms

Answer 46

Where should be holding baby but their arms are empty and have physical manifestations of painful arms

Question 47

AVOIDING pregnant women and babies

Answer 47

Like target or friends and family that have children

Question 48

sense of loss of the future and shattered dreams

Answer 48

-More than just childbearing. In terms of globally less likely to start a new job or start a new degree program
-Feels like future is more hopeless

Question 49

Parental Grief

Answer 49

• Parental grief has been recognized as the most intense and overwhelming type of grief (Davies, 2004).
• Perinatal loss can lead to long term effects on women’s psyche, relationships with others and on her parenting with subsequent children.
• Because men and women often grieve differently, parents’ reactions may be disparate even though both have experienced the same loss: Either gets stronger in relationship or it dissolves, and they are not able to continue

Question 50

Helping Parents Deal with Grief

Answer 50

• Provide parents with anticipatory guidance reminding them that partners often grieve differently and on different schedules. Can help them work through some of these differences and preserve their relationship
• Provide parents with detailed information about support services and options.
• Present options to parents as labor, birth and discharge unfold rather than as a vast, all-inclusive menu
• Listen to families and be a physical presence. It can be difficult to be with heartbroken people and not offer words of comfort. It is appropriate to say that you are so sorry and that you will be with them through the process but avoid cliches
• Avoid cliche’s such as “you are young, you can have others, Jesus must have needed another angel, it wasn’t meant to be, at least you weren’t too far along, at least you have other children.

Question 51

Miscarriage, Ectopic Pregnancy Adoption and Abortion

Answer 51

• Miscarriage, ectopic pregnancy, adoption and abortion may not be acknowledged by a woman’s friends and family as a true form of loss therefore its critical that nurses support these women and their partners medically and emotionally
• Nurses can assist these families by listening to their stories, acknowledging their loss, offering support options and helping them create their own memories.

Question 52

Siblings

Answer 52

• Children grieve in ways quite different than adults dependent on their developmental stage, often in an uneven pattern.
• At all ages need to be told that they are not to blame for the loss

Question 53

grandparents

Answer 53

• A grandparent’s response to the loss of a grandchild may differ from the parents’ response.
• Often their initial response is to care for their own child (the babies parents)
• Grieving the pain their child is going through and the loss of their grandchild

Question 54

Birth Options up to 10 weeks gestation

Answer 54

1. Expectant management- waiting for the body to naturally miscarriage
2. Medical- induced abortion where misoprostol causes emptying of the uterus
3. Surgical- dilation and curettage where it’s done under anesthesia as outpatient procedure

Question 55

birth options 11-14 weeks

Answer 55

D&C or medical management
Expectant management is not recommended due to excessive blood loss

Question 56

birth options after 20 weeks gestation

Answer 56

• Induction of labor and vaginal birth is the safest option
• Avoiding the process of labor and opting for a cesarean section may seem like the kinder option but because a vaginal birth has so many fewer risk for the mother, this is almost always the recommended route of delivery
• A vaginal birth helps to decrease risks in subsequent deliveries

Question 57

Helping Families Plan for Birth

Answer 57

• In instances where death is inevitable and there is time to plan, nurses can help women write a birth experience plan
• This activity of reviewing the expected steps at the the time of birth and considering their options can help them to mentally and emotionally prepare for the birth
• It may help families address palliative care issues and rituals they would like to incorporate into their birth and PP period providing for a more positive experience with their child

Question 58

Nursing Care at the Time of Birth

Answer 58

• Refer to the baby by their name if they have been given one
• Refer with proper pronouns if they don’t have a name
• Grief-related information should be offered based on the mother’s readiness
• Limit the number of staff interacting with the family to help them not feel like they are being made a show of
• Unrestricted family contact with baby and no certain visiting hours
• Holding the baby should be offered but never forced.
• Mementos should be collected and saved for families even if they are not ready to accept them now, but they may change their minds days, months, or years later
• Physical care of the mother should be as thorough as is done with a healthy labor and birth.

Question 59

Mementos and Photos

Answer 59

• Nurses can help parents create memories by gathering mementos (snip of their hair, baby blanket, footprints, etc) and taking photos
• Gather mementos and photos.
• Photography may be unacceptable to some.
• Babies often have beautifully photographable hands or feet even If they have severe anomalies
• For babies that have macerated skin, footprints can often still be collected and given to parents
• Black and white photography often captures images that are more flattering of babies with blackened lips (common manifestation in death)
• Giving the baby a name increases the baby’s social status and personhood.

Question 60

Rituals and Services

Answer 60

• Nurses should ask families open ended questions about their beliefs and wishes, including rituals or traditions they would like to observe
  -Rituals: Baptism, songs, readings, ceremonies
  -Give families time to make arrangements for funeral and memorial services
  -Memorial services can be done at any time, even long after the actual death

Question 61

Care of the Deceased

Answer 61

• While families are inpatient, babies may be in the room with families or in the morgue. It may be appropriate to gently warm a baby under radiant warmers if a baby is coming back up to the family after being in the morgue
• Burial and cremation are the primary means of dealing with a deceased baby’s body.
• Gestational age, state law, religion and culture all must be considered in care of a deceased baby
• Nurses must know their institution’s protocols and explain all options and procedures to parents.
  = Organ and tissue donation (particularly heart valve donation) may be an option in postmortem babies that survived to term.

Question 62

Autopsy

Answer 62

• Autopsy often provides valuable medical information about the cause of death; it also can provide guidance for future pregnancies.
• Despite this many families will decline to have anyone “cut their baby”
• Parents should receive information about the purpose of an autopsy and be asked for consent to have the procedure done.
• It can take up to several months to get all results back.

Question 63

Discharge Planning should include

Answer 63

1. physical care
2. social and emotional care

Question 64

discharge planning: physical care

Answer 64

• While emotional care often feels paramount In these situations, it is important to give excellent physical care to women to decrease the chances for complications and to set the woman up for future fertility if desired
• Basic activities of daily living like eating and sleeping need to be addressed
• Contraceptive counseling- many providers recommend a 1-year inter-conceptual interval to both decrease physical risks and to allow for further movement through the grief process
• Breast care: for women undergoing loss after 20 weeks, lactation may occur (milk may come in by 72 hours)– comfort strategies and education on promotion cessation of lactation should be reviewed
• Provide a list of symptoms and Warning signs that occur that warrant contacting a health care provider

Question 65

discharge planning: social and emotional care

Answer 65

• Providing anticipatory guidance:
  1. common responses to grief and loss
  2. community and online perinatal loss resources
  3. return home to pregnancy and baby related furniture, rooms, objects
  4. informing friends, family, coworkers, etc. of the loss
  5. return to intimacy
  6. Facilitating the creation of a list of specific helpful things for friends and family to do
  -Perform postpartum depression screening and specifically ask about depression/suicide
  -Follow up calls to families beginning within 1st week post loss

Question 66

Pregnancy After Loss

Answer 66

1. Pregnancy after perinatal loss often is accompanied by high levels of anxiety and fear
2. Nursing strategies:
   -Acknowledge the woman’s loss.
   -Acknowledge her fear and anxiety, particularly around milestone anniversaries.
   -Provide reassurance without promising guarantees.
   -Encourage her to come in and call as often as she needs to.

Question 67

Care for the Caregiver

Answer 67

1. Caring for grieving families can take a toll on the caregiver.
   -Acknowledge your connection to each baby and family.
   -Allow yourself to grieve. Showing emotion is okay. And crying with family is okay
   -Talk with others; gain support.
   -Take care of yourself physically, emotionally, socially and spiritually.
   -Self-reflection is critical for self care.