Maternity Flashcards
Presumptive Signs of Pregnancy
Amenorrhea
N/V
Urinary Frequency
Breast tenderness
Probable Signs of Pregnancy
A positive pregnancy test Goodell's sign Chadwicks sign Hegars Sign Uterine enlargment Braxton Hicks contractions Linea nigra ABdominal striae Facial chloasma Darkening of the areola
Goodell’s sign
Softening of the cervix; Second month
Chadwicks sign
Bluish color of vaginal mucosa and cervix; week 4
Hegars Sign
Softening of lower uterine segment/ 2nd and 3rd month
Positive signs of Pregnancy
Fetal Heart Beat Doppler - 10 - 12 weeks Fetoscope - 17 to 20 weeks Fetal Movement Ultrasound
Gravidity
of times someone has been pregnant
Parity
of pregnancies in which the fetus reaches 20 weeks
Viability
24 Weeks = infant has the ability to live outside the uterus
TPAL
Term
Preterm
Abortion
Living Children
Naegele Rule for Due Date
Add 7 days
subtract 3 months
Add one year
Nutrition Teaching
4 food groups
Increase Calories by 300 per day after the first trimester
In Adolescents, Increase calories by 500 calories after first trimester because of pt growth needs
Increase Protein to 60 grams a day
Weight Gain
Expect to gain 4 pounds in the first trimester
Prenatal Vitamin Supplements
Iron supplements cause constipation and GI upset
Take Iron with vit c to enhance absorptions
Folic acid prevents neural tube defects - 400mcg/day
Exercise Rules
No high impact; walking and swimming are best
No heavy or unaccustomed exercise program
No overheating ( no hot tubs or electric blankets)
Increased temp = birth defects
Don’t let the heart rate 140
DANGER SIGNS
Sudden gush of vaginal fluid Bleeding Persistent vomting Severe headache Abd pain Increased Temps Edema No Fetal movement
Common Discomforts
Nausea and vomiting Breast Tenderness Urinary Frequency Tender Gums Fatigue Heartburn Increased Vaginal secretion Nasal Stuffiness Varicose Veins Ankle edema Hemorrhouds Constiptation Backache Leg Cramps
What are you going to tell the preg person about taking medications?
NO
Smoking
Stop smoking or smoke outside if they don’t stop
How often should they visit the healthcare provider?
First 28 Weeks - once a month
28 - 36 weeks - every 2 weeks
36 weeks; weekly until delivery
Ultrasound
Distend bladder to push uterus to surface
Second Trimester ( week 14 to 26) SIgns and Symptoms
Weight Gain: 1 pound per week (4 pounds a month)
NO more N/V or Urinary Frequency
YES breast tenderness
Quickening - Fetal Movement
Fetal Heart Rate
Kegal excercise
Pregnancy is considered term if it advances 37 to 40 weeks
Fetal Heart Rate
120 to 160 in the seconds trimester
110 to 120 worried and watching
less than 110: panic
Kegal Exercise
Exercise to strength the pubococcygeal muscles. These muscles help stop urine flow and help prevent uterine prolapse.
Third Trimester ( Week 27 to 40) Assessment
Weight Gain: No more than a pound a week
Monitor BP and report any changes from baseline (Worried about pregnancy induced HTN)
Check for Protein
Fetal heart Rate
Use Leopolds Maneouver to discern fetal position/ presentation. Make sure Client voids first, and in between contractions.
Client Education: Signs of Labour
Lightening : When the presenting part of the fetus descends into the pelvis
Client will be able to breath easier but urinary frequency will be a problem again
Engagement : The largest presenting part is in the pelvic inlet - Hopefully its the head
Fetal station: measured in cm; measures the relationship of the presenting part of the fetus to the ischial spines of the mother
Braxton Hicks Softening of cervix Bloody show Sudden burst of energy called nesting Diarrhea Rupture of membranes Come to hospital, could prolapse cord when ROM and when contractions are 5 minutes apart
Non stress Test
Want to see two or more accelerations of 15 beats/minute with fetal movement
Acceleration
is when the fetal heart rate has an abrupt increase from the baseline. This is visualized on the fetal heart monitor. The increase is above the baseline and at least 15 seconds, but the heart rate should come back to the baseline within 2 minutes. Record for 20 minutes.
Biophysical Profile
30 minute test. 6 we are worried, 4 is an emergency.
Heart rate - Based on NST ( reactive or non-reactive)
Muscle tone - Does the baby have at least one flexion/extension movement in 30 mins?
Movement-Does the baby move at least 3 times in 30 minutes?
Breathing - does the baby have breathing movements at least once in 30 minutes?
Amniotic Fluid- Is there enough Fluid around the baby?
Contraction Stress Test/ Oxytocin Challenge test
Done when NST is non-reactive. Performed on higher risk pregnancies: preeclampsia, maternal diabetes and any condition in which placental deficiency is suspected.
Determines if bb can handle the stress of contraction.
Uterine contractions decrease blood flow to the uterus and the placenta.
If there is hypoxia, there will be a deceleration. If it is late this is indicating uterine/placental insufficiency
Performed after 28 weeks
3 Types of decelerations
Early: benign - caused by physiological hypoxia form fetal head compression
Late: caused by uterine/placental insufficiency
Variable: Caused by umbilical cord compression
True Labour
Contraction regular and increase
Discomfort in back and abdomen
Increase pain with activity
False Labour
Irregular
Abd discomfort
Change in activity decreases pain
Epidural anesthesia
Position: Lie on left side, Legs flexed
Given at 3 -4 cm dilation
Usually no headache/don’t want to get to spinal fluid
Major complication is hypotension so monitor BP
Infuse bolus fluids to fight hypotension
Put in semi-fowlers on left side to prevent vena cava compression. If compressed will decrease venous return, reduce cardiac output and BP and decrease placentral perfusion
Alternate position side to side hourly
Oxytocin Nursing considerations
One to one care
Complications: Hypertonic labour, fetal distress and Uterine rupture (complete or incomplete)
Want contraction rate of 1 every 2 to 3 minutes, with each lasting 60 seconds
Discontinue if:
Contractions are too often
Last too long
Fetal distress
Oxy must be piggy-backed into a main IV fluid
Client receiving should be in any position except flat on back
Any unreassuring fetal heart tones (like fetal bradycardia) put client on left side to enhance perfusion. If late decels occur STOP
Complete Uterine Rupture
Through the uterine wall into the peritoneal cavity
Sudden sharp shooting pain. If in labor, contractions may stop and pain will be relieved; signs of hypovolemic shock due to hemorrhage; if the placenta separates, the fetal tones will be absent
Incomplete Uterine Rupture
Through the uterine wall but stops in the peritoneum. The peritoneal cavity is still intact.
Internal Bleeding; pain may not be present, fetus may or may not have late decls; client may vomit, faint or have hypotonic uterine contractions and lack of progress - fetal heart tones maybe lost
Vaginal Birth after C-Section
Clients are at high risk for uterine rupture
The scar from the c-section is prone to open when under stress
Those at highest risk are those that are receiving oxytocin
After artificial rupture of membranes (AROM), the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which of the following actions by the RN has priority?
The fetal heart pattern is that of repetitive deep variable decelerations. This pattern is likely due to a prolapsed umbilical cord after AROM. The priority intervention is to relieve the pressure on the cord from being trapped between the presenting part and the pelvis. This can be accomplished by manual pressure on the presenting part, placing the client in Trendelenburg position, or placing her in the knee-chest position.
Emergency Delivery
Tell client to pant/blow to decrease urge to push. don’t push between contractions.
As head crowns tear sac if not ruptured.
Once head is out, feel for the cord around the neck
Keep head down
DRY THE BABY CAUSE THEY CANT THERMOREGULATE
Deliver placenta/inspect for intactness
Tie cord off with piece of cloth or shoestring
Check firmness of uterus
Normal Post Partum: Vitals, Breast, Abd and GI
Temp: May increase to 38 during first 4 hours
BP stable
HR 50 to 70 is common for 6 -10 days
TACHYCARDIA = Hemorrhage
Breast : Soft for 2 to 3 days then engorgment
Abd: Soft/loose; diastasis recti - abdominal muscles seperate
GI: Hunger is common
Normal Post Partum: Uterus
Immediately after birth, should be midline 2 - 3 fingers below umbilicus
Rises to umbilicus a few hours after birth - 1 -2 above
FIRM FuNDuS
Massage and then check for bladder distention ( increases chances of hemorrhage)
Fundal height will decrease one finger a day
Lochia
Rubra 3-4 days, a dark red
Serosa 4 - 10 days, pinkish brown
Alba 10 - 28 days ( can be as long as 6 weeks) whitish yellow
Clots are ok as long as they are no larger than a nickel
Urine Output
Diuresis should begin 24 hours after delivery
Dehydration is possible
Legs should be inspected closely for DVT
Perineal Care
Ice packs intermittently for 6 to 12 hours to decrease edema
Warm water rinses
Sitz baths 2 -4 times a day
Anesthetic sprays ( both are indicated if they have epi, lac or hemorrhoids)
Change Pads frequently
Pad Rule
We don’t want more than one an hour
Report foul smell
Report lochia changes
Physiological benefits from bonding
Stabilizes HR
Improves O2 Saat
Regulates temp
Conserves calories
Breasts can change in temp to warm or cool
KANGAROO CARE/ 1 hour for at least 4 times a week
Breast care
Cleanse with plain water after each feeding and let them air dry
Support bra
Ointment for soreness or express colostrum and let it air dry
Breast pads to absorb moisture
Mom can pump
Increase caloric intake by 500 calories
Fluid intake - 8 to 10 glasses of fluid a day
Breast care of non breastfeeding mothers
Ice packs, breast binders, chilled cabbage leaves (decrease inflammation and decrease engorgment)
No stimulation of breast
Post partum infection
Within 10 days after birth
Teach proper hygiene and hand washing
Usually get cultures and antibiotics
Postpartum hemorrhage - EARLY and LATE
Early: More than 500 cc of blood ost in first 24 hours and a 10% drop from admission hct. You must have both to be true!
Late: After 24 hours; up to 6 weeks postpartum
Caused by uterine atony, lacerations, retained placenta fragments and forceps delivery
Meds:
Oxytocin/Methylergonovine Maleate
Carboprost
Misoprostol
Mastitis
Usually occurs at 2 -4 weeks
Treatment: Bed Rest Support bra Binding will cause stagnation Chilled cabbage leaves Breastfeed or pump to unblock duct Penicillin Pain Medication Heat Feed baby often ( offer affected breast first)
Immediate Care of Newborn
Suction Clamp and Cut cord Maintain body temperature Apgar - done at 1 and 5 minutes - looks at HR, muscle tone, reflex irritability, color. Want 9 -10 Erythromycin Phytonadione ( VIT K)
Cord Care
Dries and falls off in 10 to 14 days
Cleanse with each diaper change using alcohol or NS
Fold diaper below cord
NO immersion until cord falls off - watch for infection
Hypoglycemia
Experience because no longer getting sugar from mom
LGA babies, SBA babes, preterm and babies of diabetic moms
Pathologic Jaundice
Occurs in 24 hours, usually means RH/RBO compatibility (positive baby, negative mom)
Physiological Jaundice
After 24 hours.
Erythroblastosis fetalis
Increase of immature RBC in fetal cirucation. It will result in: Anemia Hypoxia HF Neurologic damage Hydrops fetalis
Diagnosis and Treatment for RH antibody
Indirect Coombs - done on mom, measure # of antibodies in the blood
Direct Coombs - done on baby, tell you if there are any antibodies on the RBC’s
For a RH+ and sensitized mother:
Frequent ultrasounds, Early Birth
When is Rhogam given?
Within 72 hours after birth (protects next babies), at 28 Weeks (to protect the fetus) and whenever there is a chance that mom and babes blood has mixed
Miscarriage: S/S and Treatment
Spotting and cramping in combination is more indicative of a miscarriage
Measure HcG levels- we worry when levels drop
Bedrest and Pelvic rest (abstinence form sex
If miscarriage is imminent - IV, Blood, D&C
Hydatidiform mole
Benign neoplasm - can turn malignant
Grape like clusters of vesicles
Uterus enlarges too fast
Abscence of FHT’s
Bleeding (some will have vesicles)
Diagnosis:
Confirmed with Ultrasound
Treatment:
Small mole - D&C
Do not get pregnant during follow up time
Can become malignant, it is called chorocarcinoma
CXR for metastasis
Will measure hCG weekly until normal, 2 to 4 weeks then 1-2 months for 6 months to a year
Ectopic Pregnancy
Gestation outside of the uterus, usually the fallopian tube. Confirmed with ultrasound.
First sign is pain and then will exhibit the usual signs and symptoms of Pregnancy. If the fallopian tube ruptures, vaginal bleeding may be present. Once she has one, she is at risk for another.
Treatment:
Methotrexate stops growth of embryo.
If unsuccessful, laproscopic incision and removal of embryo. May have to remove the tube.
If not dealt with, tube will rupture and they will hemorrhage
Placenta Previa
Most Common
Placenta Previa
Most Common cause of bleeding in the later months (7th)
The placenta has implanted wrong - US to confirm
Fetus doesn’t get enough O2 because the placenta prematurely seperates. In a normal uterus, placenta is high but in this case, it may be on the side, partially or completely covering the uterus.
Painless bleeding in second half of preg
Placenta Abruptio
Placenta is implanted normally, can be partial or complete.
Bleeding can be external or concealed (bleeding into uterus)
Seen in last half of pregnancy
U/S confirms
Causes MVC, Domestic violence Previous C section, Rupture of Membranes Associated with Cocaine, PIH and smoking
Rigid board like abdomen, with or without vaginal bleeding
Abdominal pain and increased uterine tone
Difficult to palpate fetus due to abd full of blood
Placenta previa Treatment and complications
Usually requires hospitalizations from 32 weeks until birth to prevent blood loss and fetal hypoxia if client goes into labour
Rule out other sources of bleeding Monitor blood count and monitor baby closely Monitor for contractions C-SECTION NO VAGINAL EXAMS
Complications Preterm delivery Intrauterine growth retardation Fetal distress Anemia
Hemorrhage
Potential DIC risk
Placenta Abruptio Treatment
C SECTION
NO VAGINAL EXAMS
Manage fetal status and maternal shock
Incompetent Cervix
Cervix dilates prematurely. Occurs in the 4th month of pregnancy. Client has history of repeated painless 2nd trimester miscarriages
The weight of the baby causes pressure on cervix causing the dilation.
Treatment: Purse string suture at 14 - 18 weeks reinforces the cervix
May have C section, or suture clipped to deliver vaginally
80 -90% of carrying baby to term after suture
Hyperemesis Gravidarum
Reg morning sickness, excessive vomiting, dehydration, starvation and then death
Related to high levels of estrogen and HCG
BP down HGB/HCT up UO down potassium low
Weight Down
Ketones in urine
Hyperemesis Gravidarum
Reg morning sickness, excessive vomiting, dehydration, starvation and then death
Related to high levels of estrogen and HCG
BP down HGB/HCT up UO down potassium low
Weight Down
Ketones in urine- because of dehydration, breaking down body fat
Treatment NPO for 48 hours 3000 ml/ 1st 24 hours Antiemetic Vitamins Quiet environment Oral hygeine Don't talk about food 6 - 8 small, dry feedings followed by cold water Foods/liquids should be hot or cold Well ventilated room
Preeclampsia Definition and Signs
Increased BP, Proteinuria, Edema after 20 weeks. 130/90 is considered to be mild preeclampsia.
Sudden Weight gain, Swollen face and hands. Headache, Blurred vision, seeing spots, Hyper-reflexia (increased DTR’s), Clonus then Seizure.
When you see a client that gains 2 or more pounds in a week, watch closesly and worry about PIH
Preeclampsia Treatment
MILD
BP 30/15 off the baseline, documented 6 hours apart
Bed rest as much as possible
Increase protein - GLOMERULAR DAMAGE
Severe
BP elevated 160/110, 6 hours apart
Sedation to delay seizures
MgSO4
Magnesium Salts (Magnesium sulfate)
Anticonvulsant, sedative, vasodilator
Vasodilation will increase renal perfusion. Helps avoid renal failure, and increases placental perfusion
Hypertonic solution so client is at high risk for pulmonary edema since it goes back into the vascular space
Check for toxicity every 1 - 2 hours. These include BP, respirations, DTRs and LOC
Urinary output is monitored hourly and serum mag is checked periodically. If used, labor will stop unless augmented with oxytocin.
We use MgSO4 for preterm labour.
If diastolic >100 apresoline in combo with MGSO4. side effects is tachycardia and cure is delivery.
After delivery, client is at risk for seizures 48 hours after delivery, also for 4 - 6 weeks
Nursing Care:
Single Room
Very quiet/Dark environment
Steroid therapy for bb also needed
Eclampsia
Turning point is when they have a seizure
Monitor FHT
Watch labor
Watch Heart failure, stroke, heart attack, renal failure, DIC, HELLP syndrome, neurological damage and multi-system organ failure
Premature Labor
Treatment:
Drug therapy to stop labor
Tocolytic terbutaline - bronchi dilator - side effects are pulse and hyperactivity
MgSO4 relaxes the uterus
Betamethasone - IM to mom
Preterm labor can be stopped by hydrating mom and treating urinary/vaginal infections
Prolapsed Cord
When the umbilical cord falls through the cervix. Happens when presenting part is not engaged and membranes rupture
Check FHT when they rupture artificially or naturally
If cord is being compressed you will see variable decels in FHT so immediate c-section is indicated
If cord ceases to pulsated fetal death has occured. We want the cord to pulsate because this tell us the baby is getting some oxygen
Lift head off the cord until physician arrives. This is a manual lift to relieve pressure on the cord
Trendelenburg or knee chest position
Admin O2
MOnitor fetal heart tones
Don’t push baby back in
Shoulder Dystocia
Fetal head us delivered and further delivery of the fetus is prevented by the impaction of the fetal shoulder with the maternal pelvis
Anterior shoulder of fetus becomes impacted by the symphysis pubis
Risk to Fetus:
Hypoxia - Leads to cerebral palsy and asphyxia
Brachial plexus injury - leadings to Erb’s Palsy (drooping paralysis of an arm caused by excessive traction and stretching of the brachial nerve at delivery)
Broken Clavicle
Bell’s palsy is paralysis of face with dropping of one side of the face
Caused from forceps
Many resolve but can lead to permanent damage
Maternal Risks: Traumatic delivery leading to permanent damage Bruised bladder Extension of episiotomy Rectal tear Torn Cervix and/or uterus
At RIsk:
LGA, Gestatioal diabetes, Previous history of shoulder dystocia, post date delivery (aka BIG BABY)
Group B Streptococcus
Routinely assess for BGS risk factors during pregnancy (week 35 - 37 ) and on admission to L&D. Transmitted to infant from birth canal during delivery.
Risk to fetus only after ROM
Not a sexually transmitted disease
Risks include - preterm less than 37 week birth, + prenatal cultures in pregnancy, premature rupture of membranes (longer than 18 hours), positive history for early onset neonatal GBS, intrapartum maternal fever higher than 38 and previous infant with GBS
Prophylactic antibiotic therapy; penicillin is drug of choice
HELLP SYNDROME
HELLP syndrome is a life-threatening pregnancy complication usually considered to be a variant of preeclampsia. Both conditions usually occur during the later stages of pregnancy, or sometimes after childbirth.
HELLP syndrome was named by Dr. Louis Weinstein in 1982 after its characteristics:
H (hemolysis, which is the breaking down of red blood cells)
EL (elevated liver enzymes)
LP (low platelet count)
HELLP syndrome can be difficult to diagnose, especially when high blood pressure and protein in the urine aren’t present. Its symptoms are sometimes mistaken for gastritis, flu, acute hepatitis, gall bladder disease, or other conditions.
The physical symptoms of HELLP Syndrome may seem at first like preeclampsia. Pregnant women developing HELLP syndrome have reported experiencing one or more of these symptoms:
Headache
Nausea/vomiting/indigestion with pain after eating
Abdominal or chest tenderness and upper right upper side pain (from liver distention)
Shoulder pain or pain when breathing deeply
Bleeding
Changes in vision
Swelling
Signs to look for include:
High blood pressure
Protein in the urine
The most common reasons for mothers to become critically ill or die are liver rupture or stroke (cerebral edema or cerebral hemorrhage). These can usually be prevented when caught in time. If you or someone you know has any of these symptoms, please see a healthcare provider immediately.
Who should NOT receive oxytocin challenge test?
This “stress test” is usually not performed if there are any signs of premature birth, placenta praevia, vasa praevia, cervical incompetence, multiple gestation, previous classic caesarian section. Other contraindications include but are not limited to previous uterine incision with scarring, previous myomectomy entering the uterine cavity, and PROM. Any contraindication to labor is contraindication to CST.
Mazzanti Technique
Suprapubic/fundal pressure. Must be done by the physician.
Immune Globulin - Rho (D) immune/
globulin (RhoGAM)
Suppresses active
antibody response
and formation of Rho
(D) antibodies
Contraindications:
Immune globulins
IgA deficiency
Hypersensitivity
IM/IV
Interactions: May interfere with the immune response to live MMR and varicella vaccines.
MoA: Suppresses the active antibody response and formation of Rho (D) antibodies in Rho (D) negative women who have been exposed to Rho (D) positive blood as the result of pregnancy or other obstetric condition. Also used to suppress Rh
isoimmunization in Rho (D) negative individuals following transfusion of Rho positive blood. Treatment of ITP in Rho (D) positive non-splenectomized patients
Side Effects: Fever Headache Nausea Dizziness Rash Malaise Mild hemolysis (increased bilirubin, decreased hemoglobin), Injection-site reaction
Adverse: IV hemolysis
Interventions:
Administer within 72 hours after termination of pregnancy, delivery or
obstetric complication.
Closely monitor patients with ITP in a healthcare setting for ≥8 hours
after administration. Perform dipstick urinalysis as baseline and after
administration at 2 hours, 4 hours, and just prior to the end of monitoring
period.1 25 Monitor for signs and symptoms of intravascular hemolysis.
Assess renal function (including BUN and creatinine) before initiating Rho(D)
EDucation:
Teach women the importance of informing clinicians
if they are or plan to become pregnant or plan to
breast-feed. Teach patients when using RhoGAM, the
importance of retaining the patient identification card and
of presenting this card to healthcare providers. Instruct
patients receiving Rho(D) IG for the treatment of ITP to
immediately report signs or symptoms of hemolysis (e.g.,
back pain, chills, fever, discolored urine, swelling, SOB).
Bishop Score
The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part. A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score ≥8 usually indicates that induction will be successful
Pelvic inflammatory disease (PID)
a leading cause of ectopic pregnancy and infertility, occurs when bacteria from the genital tract spread upward through the cervix and cause infection of the female reproductive organs (eg, uterus, fallopian tubes, ovaries) and pelvic cavity. Symptoms may include pelvic or lower abdominal pain, menstrual irregularities or increased menstrual cramps, painful intercourse, fever, and abnormal vaginal discharge. Untreated sexually transmitted infections (STIs) (eg, gonorrhea, chlamydia) are the most common cause of PID. The nurse should assess for other risk factors, including:
History of PID
Multiple sexual partners (Option 3)
Previous STI (Option 4)
Unprotected sexual intercourse (ie, without condom use)
Placement of an intrauterine device within the past 3 weeks
Recent abortion or pelvic surgery (Option 5)
