maternity Flashcards
first trimester
week 1 - 13
second trimester
week 14 - 26
third trimester
week 27 - 40
presumptive signs of pregnancy x4
amenorrhea
n/v
frequency
breast tenderness
what hormone causes amenorrhea
progesterone - secreted by corpus luteum
makes temperature increase after ovulation
probable signs of pregnancy
positive pregnancy test (hCG levels) Goodell's Sign Chadwick's Sign Hegar's Sign uterine enlargement Braxton Hicks contractions pigmentation/skin changes (linea negra, abdominal striae, facial chloasma, areola darkening)
positive signs of pregnancy
fetal heart beat (doppler, fetoscope) fetal movement (clinician feels) ultrasound
Goodell’s Sign
softening of cervix, month 2
Chadwick’s Sign
bluish color of vaginal mucosa and cervix, week 4
Hegar’s Sign
softening of lower uterine segment, month 2/3
fetal heartbeat can be heard via doppler when?
week 10 - 12
fetal heartbeat can be heard via fetoscope when?
week 17 - 20
gravidity
times someone has been pregnant
parity
of pregnancies in which fetus reaches 20 weeks
when is a fetus/baby considered viable?
week 24 (has the ability to live outside uterus)
GTPAL stands for
gravidity term preterm abortion (spontaneous and elective) living
Naegele’s Rule
first day LMP
add 7 days
subtract 3 months
add 1 year
accurate +/- 2 weeks
increase calories by how much after first trimester?
300
pregnant women should increase protein to how much?
60g per day
expect to gain how many pounds in first trimester?
4
take iron with what to enhance absorption, if pregnant?
vitamin C
how much folic acid should pregnant women take daily
400 mcg/day
exercising pregnant women: do not let HR get above ? and why?
140 - CO drops and uterine perfusion drops
danger signs for pregnant women (mostly 3rd trimester)
sudden gush of vaginal fluid bleeding persistent vom severe headache abdominal pain increased temps edema no fetal movement
how often should pregnant women visit provider (first 28 weeks)
once a month
how often should pregnant women visit provider (28 - 36 weeks)
twice a month
how often should pregnant women visit provider (36+ weeks)
weekly until delivery
ultrasounds for pregnant clients: do what first and why?
drink water, distend bladder - pushes uterus to abdominal surface
expected weight gain in second trimester
1 pound per week
second trimester - does the client experience
n/v
frequency
breast tenderness
no
no (uterus rises)
yes
quickening
fetal movement 16 - 20 weeks
fetal heart rate during second trimester
120 - 160
fetal heart rate: normal, worry, panic
120 - 160
110 - 120
less than 110
kegels strengthen what
pubococcygeal muscles
pregnancy is considered term if it advances to?
37 - 40 weeks
best place to hear fetal heart tones
baby’s back
lightening
presenting part of fetus (typically head) descends into pelvis, occurs around 2 weeks before term
client feels less congested but frequency is problem again
engagement
largest presenting part is in pelvic inlet
signs of labor
braxton hicks - more frequent, longer softening of cervix bloody show nesting diarrhea rupture of membranes
besting
sudden burst of energy that is a sign of labor
when should pregnant woman head to hospital for labor?
contractions 5 minutes apart
OR
membranes rupture
non-stress test (maternity)
see 2+ accelerations of 15+ beats/minute with fetal movement
diagnostic test of pregnancy
acceleration (fetal heart rate)
abrupt increase from baseline, 15+ beats/minute lasting at least 15 seconds
back to baseline within 2 minutes
biophysical profile test (maternity)
last trimester or 32-34 for high risk (in 3rd trimester, 1 or 2 times a week)
1: HR (non-stress test reactive)
2: muscle tone (at least 1 flexion/extension)
3: movement (at least 3 times)
4: breathing (movements at least once)
5: amniotic fluid (enough fluid around baby)
observe for 30 minutes
8-10 good
6 worry
4 or less - ominous
deceleration (fetal heart rate)
blood flow decreases enough to cause hypoxia in the fetus resulting in decreased HR compared to baseline
contraction stress test/oxytocin challenge test (maternity)
done when NST non-reactive, high risk pregnancies (pre–eclampsia, maternal diabetes, suspected placental insufficiency)
determines if baby can handle stress of uterine contraction
variable decelerations
cord compression
early decelerations
head compression
accelerations
okay
late decelerations
(utero)placental insufficiency
false labor
irregular contractions, abdominal discomfort only, pain decreases/goes away with activity
major complication of epidural anaesthesia
hypotension
positioning for epidural anaesthesia
semi-fowlers on left side
legs flexed
not as arched with lumbar puncture
alternate sides hourly
when do you give epidural anaesthesia to pregnant woman in labor?
stage 1, 3-4cm dilation
what do you give to pregnant woman receiving epidural anaesthesia to fight hypotension?
1000mL NS or LR bolus
why is lithiotomy position bad?
vena cava compression impedes venous return, reduces CO and BP, therefore decreasing placental perfusion
unreassuring fetal heart tones do what?
reposition client to left side to enhance uterine perfusion
laboring patient receiving oxytocin requires what?
one-on-one care!
possible complications of oxytocin use during labor x3
hypertonic labor
fetal distress
uterine rupture
complete uterine rupture
through the uterine wall into peritoneal cavity
important s/s: hypovolemic shock due to hemorrhage, fetal heart tones absent
incomplete uterine rupture
through uterine wall but stops in peritoneum - not in the peritoneal cavity
important s/s: fetal heart tones may be lost
VBAC mothers at high risk for
uterine rupture, highest risk with oxytocin
oxytocin + labor = expected contraction rate
1 every 2-3 minutes lasting 60 seconds
discontinue oxytocin during labor if x4
- contractions too often
- too long
- fetal distress
- late decels
when should laboring mother push?
during contractions ONLY
1 worry with retained placenta
hemorrhage
when does placenta deliver?
w/in 30 minutes
if you have to cut the baby’s cord yourself during an emergency delivery, how?
tie @ 4 and 8 inches from baby’s navel
cut with heated razorblade
what should the uterus be like after delivery?
FIRM! if boggy, MASSAGE THE FUNDUS
diastasis recti
abdominal muscles separate postpartum
vigorous exercise fixes this shit
uterine position: immediately after birth
midline 2-3 fingerbreadths below umbilicus
uterine position: a few hours after birth
rises to level of umbilicus or 1 fingerbreadth above
if uterus is above expected level or not midline postpartum, suspect what?
bladder distention - increases risk of hemorrhage because it will not allow uterus to contract normally
uterine fundal height will descend how?
one fingerbreadth per day
involution
fundus descends and uterus returns to pre-pregnancy size
afterpains
common for the first 2-3 days and will continue to be common if mom chooses to breast feed (surge of oxytocin)
postpartum vital signs of interest x2
T up to 104 during 1st 4 hours
HR 50 - 70 common for 6-10 days
lochia rubra
day 3-4, dark red
lochia serosa
day 4-10, pinkish brown
lochia alba
day 10-28, whitish yellow
clots okay in lochia when?
nickel or smaller
perineal care postpartum x4
intermittent ice packs first 6-12 hours (decrease edema)
especially for episiotomy, laceration, hemorrhoids:
warm water rinses
sitz baths 2-4 times a day
anesthetic sprays
peripad saturation rule
patient should not saturate more than one per hour - if so, assume hemorrhage
mom should increase caloric intake by how much for breastfeeding?
500 calories
what can lead to mastitis?
insufficient fluid = plugged ducts
poor baby feeding
post-partum infection: when & culprits
within 10 days
E Coli, beta hemolytic strep
early postpartum hemorrhage
more than 500cc lost in first 24 hours
AND
10% drop from admission hematocrit
MUST BE BOTH
late postpartum hemorrhage
after 24 hours, up to 6 weeks postpartum
causes of postpartum hemorrhage
uterine atony
lacerations
retained fragments
forceps delivery
typical causative agent of mastitis
staph
mastitis: what & when
milk is okay, breast is messed up
usually around 2-4 weeks
mastitis and breastfeeding: abx and method
penicillin is okay to take; feed baby then take abx
feed baby frequently and offer affected breast first (baby feeds more aggressively at first)
what should non-breastfeeding mothers do for their boobs
ice packs, breast binder, chilled cabbage leaves (decrease inflammation and engorgement)
apgar: when, what, ideal score
done at 1 and 5 minutes
HR, RR, muscle tone, reflex irritability, color
ideal: 8-10
eye drops for baby: what and what organism
erythromycin - neisseria gonococcus
also kills chlamydia
umbilical cord: care
dries and falls off 10-14 days
cleanse with each diaper change (alcohol, NS); diaper below cord
no immersion until cord falls off
babies at greatest risk for hypoglycemia
small and large for gestational age
preterm
babies born to diabetic moms
pathologic jaundice
first 24 hours
usually Rh/ABO incompatibility
physiological jaundace
aka hyperbilirubinemia
after 24 hours
due to normal hemolysis of excess RBCs releasing bilirubin or liver immaturity
indirect coombs test
Rh and ABO check, prenatal
done on mom, measures # antibodies in blood
direct coombs test
Rh and ABO check
done on baby cord blood, tells if any antibodies stuck to RBCs
when is Rho(D) immunoglobulin/RhoGAM given?
28 weeks gestation (protect fetus in case blood mixes)
within 72 hours after birth
with any bleeding episodes
for Rh- moms with Rh+ babes
spotting and cramping during pregnancy
spotting common during pregnancy
but spotting + cramping more indicative of miscarriage
hydatidiform mole
molar pregnancy - benign neoplasm (can become malignant)
grapelike clusters of cells - release hCG; uterus enlarges too fast
confirm with ultrasound, remove with D&C
hydatidiform mole: important to remember about pregnancy
hCG produced; do not get pregnant during follow up period after removal of mole - hCG rise can’t be differentiated between pregnancy vs malignancy
choriocarcinoma
hydatidiform mole becomes malignant - chest x-rays to check for mets
how often to check hCG with molar pregnancy
weekly until normal
recheck every 2-4 weeks
then every 1-2 months for 6 months - ayear
ectopic pregnancy: what, where, how to confirm, s/s, risk, treatment
gestation outside uterus, typically in fallopian tube
confirm with ultrasound
first sign: pain; then spotting, bleeding into peritoneum, vaginal bleeding
one ectopic pregnancy = risk for another
treat with methotrexate
methotrexate
given to mom experiencing ectopic pregnancy to stop growth of embryo to save fallopian tube
if methotrexate doesn’t work for ectopic pregnancy
laparoscopic incision into tube and embryo removed, entire tube may have to be removed
placenta previa: what, types, nota bene x2
placenta has implanted wrong - begins to prematurely separate when cervix begins to dilate/efface and baby doesn’t get oxygen
low lying, partial, complete
placenta comes out first, bad
most common cause of bleeding in later months of pregnancy (typically 7th); confirm with ultrasound
some resolve during pregnancy due to uterine growth
low lying placenta previa
placenta on side of uterus
partial placenta previa
placenta halfway covering cervix
complete placenta previa
placenta completely covering cervix
placenta previa treatment
complete: hospitalization from as early as 32 weeks until birth to prevent blood loss and fetal hypoxia if labor begins
not much bleeding: bedrest, monitor
DO NOT PERFORM VAGINAL EXAM
increases risk for placenta previa
previous C-section d/t scarred uterus
abruptio placenta: what, blood, when, confirmation
placenta implanted normally, but separates prematurely from uterus - partial or complete (1-3 worst)
can bleed externally or concealed (into uterus)
seen in last half of pregnancy
ultrasound confirms
abruptio placenta causes
MVC, DV, previous c-section, rapid uterus decompression/membranes rupture, associated with cocaine use, PIH, smoking
abruptio placenta s/s
rigid board-like abdomen with or without vaginal bleeding (see this, worry patient is bleeding internally!)
abdominal pain, increased uterine tone, difficult to palpate fetus
rigid board-like abdomen with or without vaginal bleeding
think abruptio placenta
incompetent cervix: what, when, miscarriage note
cervix dilates prematurely because weight of baby causes pressure on cervix, occurs ~4th month of pregnancy
this client will have hx of repeated, painless, 2nd trimester miscarriages (most miscarriages 1st trimester!)
cerclage (purse-string suture) what and when
for incompetent cervix, at 14-18 weeks
80-90% chance of carrying baby to term after cerclage
causes of hyperemesis gravidarum
high levels of estrogen and hCG
s/s hyperemesis gravidarum
BP down H/H up uop down K+ down weight down ketones in urine (breaking down body fat)
preeclampsia
increased BP + proteinuria + edema
after 20th week
if pre-pregnancy BP is not known, 130/90 = mild preeclampsia
BP indicative of mild pre-eclampsia for moms with unknown baseline
130/90
preeclampsia: s/s
sudden weight gain
face and hands swollen (losing albumin so fluid leaks into tissue)
vasospasms cause –
headache, blurred vision, seeing spots, increased DTR, clonus to seizure
see pregnancy client gains 2+ pounds in a WEEK, worry about
PIH
mild-preeclampsia BP + treatment
30/15 off baseline documented 6 hours apart
bedrest, increase protein in diet
severe preeclampsia BP + treatment
BP elevated 160/110 documented 6 hour apart
sedation to delay seizures, mag sulfate drug of choice!
cure for preeclampsia
delivery
how long is preeclamptic mother at risk for seizures after delivery
for 48 hours up to 4-6 weeks
magnesium sulfate x3
anticonvulsant, sedative, vasodilator drug of choice given for preeclampsia
increases renal perfusion, helps avoid renal failure, increases placental perfusion
labor will stop (relaxes uterus) unless augmented with oxytocin/Pitocin
never lay pregnant woman on back why?
places pressure on vena cava which will
impair kidney perfusion and impair CO
and impair placenta perfusion
preferable: left side (CO greater)
magnesium sulfate for preeclampsia: nursing considerations
check for toxicity every 1-2 hours (BP, respirations, DTR, LOC)
uop hourly, serum mag periodically
first sign of mag toxicity
DTR decrease
if dbp greater than 100 in preeclamptic woman receiving mag
give apresoline/Hydralazine too
side effect: tachycardia (compensatory for BP drop)
betamethasone: what + when + how
given for premature babes with immature lungs - stimulates surfactant production in alveoli causing less tension when infant breathes
given between 24 & 34 weeks gestation to reduce infant mortality
IM to mom - inj 24 hours apart
why do babies born to preeclamptic mothers require steroid therapy
aka betamethasone
vasoconstriction in mom = lack of blood flow to placenta = less oxygen and nutrients to baby = preterm delivery = immature lungs at birth
eclampsia + tx
preeclampsia becomes this when a seizure happens (super high BP)
monitor FHT, watch for labor and heart failure; also stroke, MI, renal failure, DIC, HELLP syndrome, neuro damage, multisystem organ failure
PIH
pregnancy induced hypertension - occurs after 20 weeks
proteinuria
gestational hypertension
occurs after 20 weeks
NO proteinuria
PIH vs gestational hypertension
PIH has proteinuria
gestational does not
chronic hypertension with superimposed PIH
client hypertensive prior to pregnancy and it got worse with proteinuria after 20 weeks
premature labor + tx
occurs between 20-37 weeks
stop labor with: tocolytic (terbutaline), mag sulfate(relaxes uterus)
give betamethasone (for baby lungs)
terbutaline/Brethine + side effects
bronchodilator and also tocolytic
increased pulse and hyperactivity
less common ways to stop preterm labor
hydration, treat vaginal/UTI
prolapsed cord
umbilical cord falls through cervix, most likely to happen when presenting part not engaged and membranes rupture
nursing action when membranes rupture (spontaneous or artificial)
check FHT
cord compression: variable decels
prolapsed cord treatment
lift head off cord until physician arrives
trendelenburg or knee-chest position
administer oxygen (hyperox to max O2 to baby)
monitor FHT
NEVER PUSH BACK IN
shoulder dystocia
fetal head delivered but impacted fetal shoulder within maternal pelvis halts delivery
anterior shoulder impacted by symphysis pubis
hard to predict
shoulder dystocia risk to fetus
hypoxia = cerebral palsy, asphyxia brachial plexus injury = erb's palsy broken clavicle bell's palsy many resolve but can lead to permanent damage
erb’s palsy
drooping/paralysis of an arm caused by excessive traction and stretching of brachial nerve
happens to shoulder dystocia babies
increase risk for shoulder dystocia x4
LGA or macrosomic greater than 4000g
gestational diabetes
previous history
post date delivery with a large fetus
McRoberts Maneuver
for shoulder dystocia
mom’s legs are hyperextended
Mazzanti techniques
for shoulder dystocia
suprapubic pressure easing shoulder past symphysis pubis
provider does this
do not apply fundal pressure!!
Gaskin maneuver
for shoulder dystocia
mom on all fours with arched back
group b strep + tx
leading cause of neonatal morbidity; risk for fetus is only after rupture of membranes
transmitted to infant from birth canal of infected mother during delivery
give prophylactic abx therapy, penicillin (clindamycin if allergy)
NOT AN STD
leading cause of neonatal morbidity
group b strep
when do you culture for group b strep
~35-37 weeks
on admission to L&D
premature rupture of membranes greater than 18 hours worry about
neonatal group b strep
