Lecture 08 High Risk Pregnancy and Compliation During Labor and Delivery Flashcards
1
Q
What are some causes of early pregnancy bleeding? (3)
A
- Miscarriage: spontaneous abortion (SAB)
- Incompetent cervix
- Hydatidiform mole (molar pregnancy)
2
Q
Late pregnancy bleeding causes (2)
A
- Placenta previa 2. Placenta abruption
3
Q
There are dif levels of miscarriage (SAB): Def each: Threatened:
Inevitable:
A
Threatened: slight bleeding with cramping
Inevitable: heavy bleeding with increased cramping. Cervical dilation and ROM>imminent
4
Q
There are dif levels of miscarriage (SAB): Def each: Incomplete (rather common): Complete:
A
Incomplete: retained placental tissue in uterine cavity. But continued bleeding until complete removal of all placental tissue
Complete: Uterus evacuates all products of conception
5
Q
There are dif levels of miscarriage (SAB): Def each: Missed spontaneous abortion
A
embryo/fetus has expired, however the contents of conception remain in the uterus.
6
Q
How would miscarriages be assessed? (3)
A
U/S Beta hCG levels VS
7
Q
What is an incompetent cervix?
A
Passive or painless dilation of the cervix during the 2nd trimester.
8
Q
How do you assess for incompetent cervix?
A
- funneling of the cervix 2. Shortening of the cervix
9
Q
What is a medical management of cervix?
A
Placement of a cerclage, a big and thick stitch
10
Q
What is a hydatidiform mole?
A
aka Gestational Trophoblastic disease, it’s rapidly dividing cells with no genetic material from the ovum. Occurs in the uterus. So sperm and egg come together, but doesn’t develop into fetus, but into rapid placental pos cancerous tissue. Occurs more in teenagers vs women Etiology unknown.
11
Q
Who are at risk of hydatidiform mole?
A
- Use of clomid: med to help women ovulate 2. teenagers and women >40 are at risk
12
Q
Nursing implications of hydatidiform mole
A
- U/S, beta hCG levels 2. Suction curettage, want to make sure you get all the cells out 3. Induction of labor is contraindicated 4. Admin rhogram is indicated 5. Education: pregnancy should be avoided for one year
13
Q
What is placenta previa?
A
Placenta implanted over the lower uterine segment or over cervical os
14
Q
What are sx of placenta previa?
A
- painless bright red vaginal bleeding 2. Associated with stretching and thinning of the uterine 3. Abdomen will be soft, nontender and relaxed 4. Fundal height is usually greater than expected. The fetus is un able to settle into the pelvis related to low lying placenta
15
Q
What is Dx of placenta previa?
A
U/S
16
Q
What are nursing care for placenta previa?
A
- Stable: expectant management (no vaginal exams) 2. Unstable ~ delivery by cesarean section
17
Q
What is placenta abruption?
A
Detachment of part or all of the placenta from its implantation
18
Q
What are risks that may cause placenta abruption?
A
- maternal HTN 2. PSA, mainly stimulates (cocaine), causes vasoconstriction 3. Abdominal trauma, may want to ask mother if she was abused by her partner 4. Smoking
19
Q
What are sx of placenta abruption?
A
- painful bright red vaginal bleeding 2. uterine contractions 3. Uterine tenderness 4. lab tests: Kleihauer-betke stain (KB) : Determines the presence of fetal to maternal bleeding If present and mom is RH - , Rhogam is given Hemoglobin or Hematocrit (to see if blood is dropping) Clotting studies
20
Q
What are nursing care steps for placenta abruption?
A
If stable: expectant management If unstable: move towards delivery either vaginal or c/s
21
Q
What is preterm labor defined as?
A
Cervical changes and uterine contractions occurring earlier than 37 weeks.
22
Q
What is preterm birth?
A
Delivery of newborns earlier than 37 weeks. Accounts for 90% of neonatal deaths. 75% occur in infants earlier than 32 weeks.
23
Q
What are some risks that lead to preterm labor? (3)
A
- demographic: people who don’t seek prenatal care, have less than HS education, povery and non caucasian 2. Biophysical: had a previous preterm labor (Most common cause of another preterm labor), uterine abnormalities-fibroid, progesterone deficiency. 3. Behavioral: smoking, substance abuse, poor nutrition, inadequate prenatal care, excessive physical activity or excessive stress
24
Q
What are some assessments for preterm labor?
A
- continuous fetal and contraction monitoring 2. evaluation of maternal plan 3. Evaluate for cervical changes: speculum, U/S
25
What are some nursing care for preterm labor?
1. Education 2. Restricted activity 3. Tocolysis fluids 4. Nifedipine 5. Indocin
26
What is PPROM?
Preterm Premature Rupture of Membranes 1. ROM before 37 weeks of gestation 2. etiology is unknown
27
What is PPROM plan of care?
If earlier than 34 weeks: 1. Bed rest 2. Monitor maternal and fetal well being 3. Give corticosteroids, to help with fetal lung development 4. Monitor for signs and symptoms of chorioamnionitis (infection of the chorion and amniotic layers) 5. Limit vaginal exams If greater than 34 weeks: monitor closely and move toward delivery
28
What does ROM stand for?
Rupture of Membrane
29
What does SROM stand for?
Spontaneous Rupture of Membrane
30
What does AROM stand for?
Artificial Rupture of Membrane
31
What does PROM stand for?
Premature Rupture of Membrane
32
What's the difference between HTN and preeclampsia?
Preeclampsia has proteinuria
33
What's the overview of Pregnancy induced HTN? (3)
1. Development of mild HTN during pregnancy 2. w/o proteinuria 3. No evidence of pathologic edema
34
What's the overview of preeclampsia?
Etiology is unknown. Only cure is deliver fetus. 1. Development of HTN 2. w/proteinuria 3. Typically develops after 20 weeks of pregnancy and can develop early during post partum period
35
Overview of eclampsia.
Development of convulsions or coma in preeclamptic pt. Etiology is unknown. Only cure is to deliver the fetus
36
KNOW: What does HELLP stand for in HELLP Syndrome?
Hemolysis Elevated Liver enzymes Low Platelet count is the most severe form of preeclampsia.
37
What are some risk factors that can lead to Preeclampsia & HELLP
Chronic renal disease Chronic HTN Family history of PIH Multiple gestation Primagravity Maternal age 45 Diabetes Rh incompatibility Obesity
38
Sx of Preeclampsia/HELLP
1. •Decreased perfusion to eyes = visual changes, headaches
2. •Decreased liver perfusion causes epigastic pain
3. •Decreased renal perfusion causes oliguria may result in renal failure
4. •CNS irritability = Increase in DTR’s, clonus, hyperreflexia & convulsions
5. •Pulmonary edema related to chronic heart failure which can result if BP is unable to be controlled
6. •Pitting edema, Facial edema- associated with increased risk of neurologic involvement
**•HELLP**
§Vasospasm continues to increase resulting in tissue hypoxia
39
What are nursing care of preeclampsia?
1. Noting Classic preeclampsia signs and symptoms
§Headache
§Visual changes
§Right upper quadrant pain - epigastric pain
§Pitting edema - facial edema is associated with increased risk of neurologic involvement
§Clonus
§DTR’s
2. §Check BP
3. §Serial maternal weights
40
What are some assessments for Preeclampsia?
Assessment
1. Monitor fetal wellbeing
Monitor BP, DTR
Continuous fetal monitor
BPP
AFI
Doppler studies
2. Maternal breath sounds
3. Ophthalmic evaluation of the fundus of the eye
4. Administer meds to lower BP: hydralazine, aldomet, nifedipine, labetalol,
41
What are some laboratory studies of preeclampsia?
1. CBC with differential
2. Platelet count
3. Coagulation studies
4. Chemistry studies - Profile 14, Liver function and Urate
5. Urinalysis - dip & 24 hour I&O
42
What are some nursing care of HELLP?
1. •Frequent assessment of
•VS
•Breath sounds
•Reflexes and clonus
•I & O (STRICT)
•Seizure precautions
2. •Administration of IV Magnesium Sulfate
•Typical dose is a load of 4gm followed by 2gm/hour
3. •Assess for signs of toxicity
•Antidote - Calcium Gluconate IV
4. •Bedrest
43
What are risks that predisposes pt to GDM?
1. Maternal age \> 30
2. Ethnicity (increased in races other than white)
3. Obesity
4. Family history
5. Previous history of GDM
6. History of LGA newborn \> 9 pounds
44
What are some risks associated with DM during pregnancy? (7)
1. Increase for pregnancy loss
2. Macrosomic newborn
3. Increase for development of preeclampsia
4. Polyhydramnios
5. Hypoglycemia
6. Ketoacidosis
7. Increased AF, cuz baby is peeing a lot
45
Why does diabetes occur during pregnancy?
**Pathyphysiology due to hormones made by placenta, protein: Human placenta lactogen**
****Altered glucose metabolism occurs during pregnancy to ensure adequate fetal nutrition
Glucose is the primary fuel for the fetus and crosses the placenta
Insulin does not cross the placenta, the fetus excretes it own insulin in respect to maternal glucose
During the second trimester a “dibetogenic” effect occurs: results in decreased tolerance to glucose stores, increased insulin resistance, decrease in glycogen stores and increased production of glucose
Resulting in maternal insulin requirements increasing from 20 weeks to 36 weeks gestation
Remember babies born to diabetic moms are hypoglycemic at birth
46
What are some nursing implications for diabetes during pregnancy?
1. Education: nutritional counseling, weight gain recommendations!
2. Greater risk for
Birth trauma related to macrosomia
Congenital malformation
Delayed pulmonary maturation in newborn
Increased risk of glucose intolerance in mother later in life
Increased risk of HTN while pregnant
47
What are some screening techniques for diabetes during pregnancy?
1. Urine dip at every prenatal visit
2. CBG at every prenatal visit
3. Glucose tolerance test (GTT), Three hour GTT.
4. Hemoglobin A1C to determine long term glucose control
5. Results has to be less than 135. If it’s not, then woman will have to come in for another test while she’s fasting. It’s harder, since it’s 3~5 hours
48
Why would forceps be used in delivery?
Fetal indications?
Complications with?
Nursing care that needs to be done?
**Fetal indications**
Fetal distress, abnormal presentation and arrest of rotation
**Complications**
Maternal
Fetal
**Nursing care**
Educate patient on use of forceps, closely monitor and document fetal heart rate, assessment of newborn for bruising or abrasion and assess maternal perineum and assess for bleeding
49
How does the vacuum for?
Indications for it?
Risk of it?
Commplications?
Nursing care that needs to be done?
**Overview**
Vaginal delivery that requires the placement of a vacuum cup attached to negative pressure to assist in the birth of the fetal head
**Fetal indications**
Fetal distress and arrest of rotation
**Risk to fetus**
Cephalhematoma, Scalp laceration, Subdural hematoma, Bruising
**Complications**
Maternal
Fetal
**Nursing Care
**Educate patient on use of vacuum, closely monitor and document fetal heart rate, assessment of newborn for bruising or abrasion and assess maternal perineum and assess for bleeding
50
What are 4 types of OB emergencies?
1. Prolapsed cord
2, Shoulder dystocia
3. Uterine Rupture
4. Amniotic fluid embolism
51
What are risk factors to prolapsed cord?
Long cord
Malpresentation
Unengaged presenting part
52
What are some nursing care interventions for a prolapsed cord?
1. Vaginal exam to hold presenting part of umbilical cord
2. Reposition to elevate pressure on cord : trendelenberg or knee-chest
3. Continue to monitor and assess FHR
4. Move towards vaginal delivery or c/s
53
What are some maternal complications from shoulder dystocia?
Overview?
**Overview**
* Obstruction of the fetal descent and expulsion by fetal shoulders
* Unpredictable obstetrical emergency
* Risks are fetal macrosomia and DM, previous shoulder dystocia
**Maternal complications**
* Laceration
* Infection
* Bladder injury
54
What are some newborn complications that may result from shoulder dystocia?
1. •Brachial plexus, facial nerve paralysis
2. •Clavicular fracture
3. •Asphyxia
4. •CNS injury
5. •Death
55
What are some interventions with shoulder dystocia?
1. •Manual maneuvers
2. •RN may assist with McRoberts maneuver
3. •RN applies suprapubic pressure
4. •Fundal pressure is contraindicated
5. •Change maternal position – Gaskin manuever
6. •Set up for neonatal resuscitation
7. •Continue to monitor FHR closely
56
What are sx of ruptured uterus?
1. Maternal: pain, bleeding, loss contractions, increased abdominal tenderness, hypovolemic shock
2. Fetus: loss of variability, lates and variables (fetal mortality is 50 - 75%)
57
What are interventions for uterus rupture?
1. PREVENTION!
2. VBAC
3. Close monitoring of Pitocin (induction or augmentation
Caused by Hyperstimulation of uterine contractions
58
What are some Nursing Care steps for Rupture of Uterus?
IV access and fluids
Transfusing blood
Administer O2
Move towards rapid delivery
59
Overview of Amniotic Fluid Emoblism?
1. Causes 10% of maternal deaths
2. Amniotic fluid containing particles enters the maternal circulation and obstructs pulmonary vessels
\>\>\> respiratory distress
\>\>\> circulatory collapse
60
Nursing Care for Amniotic Fluid Embolism
1. Oxygenate
2. Maintain cardiac output
3. Replace loss fluids
4. Correct coagulation failure
5. Monitor fetal and maternal status
6. Educate
