Midterm Flashcards
What happens during Involution?
Myometrial spiral fibers around uterine blood vessels leading to occlusion of blood supply to the placental site
What is Involution’s effect on fundal position?
Shrinks fundus = weight of the uterus decreases from 1000 grams immediately postpartum to 60 grams 6-8 wks later.
How do you know if there is too much lochia?
Heavy: saturated in 1 hr
PP hemorrhage: within 15 mins or less
What are the different laceration degrees?
1st - small tear
2nd - perineal/bulbocavernosus mucosa torn
3rd - external anal sphincter
4th - internal anal spincter, rectal mucosa torn
What do we give for peri-care?
Treat with ice, tucks, benzocaine spray, hemorrhoid creams, and suppositories
What are postpartum blues?
Mild transient mood disturbance - emotionally labile, restless, fatigue, cries easily, sad
peaks at 5 days, subsides by day 10
experienced by 60-80% of recently pregnant people
What is the BUBBLE-HE Assessment and expected findings?
B - Breasts
- breastfeeding: fuller and heavier as milk comes in, usually 3-4 days, nodular or lumpy milk, teach to prevent engorgement (frequent breastfeeding)
- nonbreastfeeding: bilateral nodularity, tenderness, engorgement, don’t express milk, well fitting bra, ice pack, pain relievers, fresh cabbage leaves
U - Uterine
- post delivery: edema of bladder, urethra, urinary meatus due to delivery trauma. incomplete emptying of bladder and inability to void common problem. diuresis within 12 hrs post delivery to void common problem
B - Bladder
- UO may be 3K ml +/each day
- kidney function returns to normal after 4 wks pp.
- mild proteinuria and increased BUN due to catabolic process of involution
B - Bowels
L - Lochia
- total volume secretion 200-500 ml
- color, odor, amount
E - episiotomy/lacerations
- initially smooth rugae
- returns to near pre-pregnant state after 6-8 wks
H - Homan’s Sign - DVT
- virchow’s triad: hypercoaguability, venous states, and vascular damage = increased incidence of venous thromboembolism
E - Emotions
When do the fetuses/infant’s senses (taste, smell, sight, hearing) become active?
Visual: at birth - not developed the ability to tell the difference between two targets or move their eyes between two images
Auditory: well developed at birth
Olfactory: at birth - mature by the end of first trimester
Taste: 8 weeks after conception. by 14 weeks, baby’s taste buds are mature
Tactile: 4-5 month mark
What is Involution?
Contraction of the interlacing myometrial muscle bundles constricting the intramyometrial vessels and impending blood flow
Results in = return of uterus in a non-pregnant state
Major mechanism preventing postpartum hemorrhage
What is the first thing a nurse does when the nurse palpates a boggy uterus with increased lochia?
Massage the fundus until firm
Soft boggy uterus (atony) = inadequate contraction of the uterus.
Hemorrhage = degree of bleeding that threatens to cause or is associated with hemodynamic instability
Lochia Definition
post birth uterine discharge consisting of necrotic tissue, blood, mucous that reflects healing stages of placenta
What are the stages of lochia?
Rubra: 3-4 days after birth, bright red in color, blood clots normal
Serosa: 4-10 days after birth, thin in density, red to pink to pinkish brown containing mucus. Less than rubra, very few to no clots, but ongoing flow
Alba: 2-4 weeks (10-28 days), discharge yellowish white or whitish liquid, containing little red blood. No odor or real flow.
What is the relationship b/w full bladder vs fundal height vs bleeding?
When the bladder is full, it gets pushed up to the side
bleeding - massage the fundus - uterine atony
full bladder - pushes fundus up and over to the side
higher chance of not involuting if bladder is full
How do you care for laceration/episiotomy?
Comfort measures
Ice packs to perineum first 12-24 hrs
Sitz baths, sprays, “tucks” analgesics
Kegels
What are the hormones of breastfeeding?
Prolactin: milk making hormone
Expression inhibited by progesterone
When pregnancy ends, progesterone level drops and prolactin expresses itself and milk is made
Prolactin suppresses ovulation but suppression is affect by individual breastfeeding patterns.
Non breastfeeding: prolactin returns to prepregnancy levels after 3 weeks
What would you expect a breast assessment to be like on day 1?
Little change, colostrum usually present
When do we give a RhoGam shot?
Within 72 hrs of delivery to prevent isoimmunization
When a mom is blood type negative (Rh-) and gives birth to a Rh+ infant.
Mom makes antibodies against Rh factor which will then attack RBC of the next Rh+ baby the mother has)
Rhogam prevents mother from developing the antibodies
What is the newborn assessment process?
APGAR
A - appearance (skin color)
P - pulse (HR)
G - grimace (reflex irrability)
A - activity (muscle tone)
R - respiration
What is are the expected findings for respiratory newborn assessment? What are signs of respiratory distress?
Nose breathers
Shallow and irregular respirations
Chest and abdomen rise simultaneously
Short periods of apnea (<15 seconds)
Expected RR 30-60/min
Airway noises may be present
Respiratory distress
persistent nasal flaring
retractions
expiratory grunting
increased use of intercostal muscles
tachypnea > 60 breathes per minute
cyanosis
apnea lasting longer than 15 seconds
What is the expected findings for cardiac patterns for newborns?
Cardiac Patterns
HR 110-160 BPM, fluctuating depending on infant activity
auscultate apical pulse for 1 minute
murmurs may be present 90% transient, but needs to be monitored
Average BP: 80-60/50-40 at birth
Color: perfused
Average blood vol: 300 ml, varies by 100 ml depending on timing of cord clamping
delay cord clamping = neonatal benefits
What is the expected findings for newborn thermoregulation?
Axillary temp: 97.7-99.5 F (varies depending on hospital)
Balance achieved b/w heat loss and heat generation
What are the most important things for the nurse to do at delivery to assure a successful newborn transition to extrauterine life?
Establish respirations and circulation, heat regulation
Golden hour = first 60 mins after childbirth
delayed cord clamping until umbilical cord has stopped pulsating (between 1-5 mins)
maternal-neonatal skin to skin contact, including performing all assessments while infant is on abdomen
early breastfeeding
Routine interventions not time sensitive should be delayed
What are the newborn medications that are given prior to the infant leaving the hospital?
Erythromycin Ointment: prevention of gonococcal opthalmia, neonatorum and chlamydial conjuctivitis
mandated in most states
Vitamin K (Aquamephyton): prevent vitamin k dependent hemorrhagic disease. newborns risk first week of life due to immature liver and sterile GI tract. stimulates liver to synthesize factors
Hepatitis B Vaccine: safety net reducing risk of getting the disease from moms or family members who may not know they’re infected with hep B. people can spread virus even when they don’t have sx
What is the importance of maintaining an infant’s temperature and range of appropriate newborn temp?
Tolerate a narrow range of environmental temps and vulnerable to under/overheating.
Will attempt to regulate via flexed position, peripheral vasoconstriction, increased metabolic rate, and metabolism of brown fat.
Cold stress: depletes brown stores, increases O2 needs, increases glucose consumption - hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production
How can you teach a parent how to recognize whether their infant is getting enough breastmilk? What should the urine look like?
1-2 wet diapers for every day the baby is old
at 4 days, 6-8 wet diapers a day = adequate intake
Urine = pale, straw colored. may be initially blood tingued or have mucous (cloudy)
What are the vessels inside the umbilical cord?
Umbilical Vein: Oxygenated blood and nutrients are carried from placenta to fetus
2 Umbilical Arteries: Waste products and deoxygenated blood are carried back from fetus.
Then transferred back into maternal ciruclation.
Surrounded by Wharton’s Jelly to cushion and protect it
How is brown fat used in babies?
More capillaries than white fat, greater need for oxygen than most tissues, primary function is to generate body heat in newborns that don’t shiver
What are the parameters for newborn vitals?
RR: 30-60/min
Average BP: 80-60/50-40 at birth
HR: 110-160 BPM
Axillary temp: 97.7-99.5 F
What should we teach parents about crib safety?
Sudden Infant Death Syndrome:
infants should sleep on their backs for every sleep.
in a safety approved crib.
breastfeeding reduces risk of sids.
share a room with the baby.
no smoking
don’t let baby get overheated.
after breastfeeding established, give pacifier at night and during naps
What is the difference between presumptive vs probable vs positive signs of pregnancy?
Presumptive: (subjective) changes felt by the person
caused by conditions other than pregnancy
amenorrhea, breast tenderness, fatigue, nasuea, urinary frequency
Probable: (objective) observed when combined with presumptive signs, strongly suggest pregnancy
abdominal enlargement
goodell’s sign: softening of the cervix
chadwick’s sign: violet color of vaginal mucous membrane
hegar’s sign: softening of lower uterine segment
positive pregnancy test
Positive: (diagnostic) signs that can only be attributed to presence of fetus
real time ultrasound exam
fetal heart tones (9-12 wks by doppler)
fetal movement palpated by HCP
fetal movements visible
What are teratogens and when is the fetus most at risk from teratogens?
Any agent that can disturb the development of an embryo or fetus
First two weeks don’t affect zygote development
Matters most during: Embryonic stage of 3-8 weeks.
What is Gravida and Para?
Gravida = # fertilized eggs
Para = # pregnancies carried to over 20 wks, regardless if successful pregnancy
What is the GTPAL pregnancy history assessment?
Gravida
Term
Pre-term
Abortion
Living
What preconception advice do you give a patient regarding folic acid?
Take 400 mg daily folic acid supplementation to decrease incidence of neural tube defects (spina bifida, anencephaly)
How much weight do women gain per trimester?
1st trimester: 1-4 lbs during the whole trimester
2nd & 3rd trimester: ½ to 1lb a week
What happens to blood volume during pregnancy? What about blood components?
Circulating blood volume increases by 40-50% to - provide adequate blood flow to uterus and fetus. - maintain BP
- accommodate blood loss at birth.
INCREASE:
1. clotting factors: protective against bleeding, increases DVT changes
2. RBC production (250-450 ml)
3. Plasma volume expansion (approx 1000 ml)
What hormone does placenta produce and it’s 3 functions?
Human Placental Lactogen
- increases amount of free fatty acids for metabolic needs
- insulin antagonist that keeps maternal glucose higher for longer periods of time after meals to promote fetal transfer
- acts as growth hormone and contributes to breast development
What are the major hormones of pregnancy?
Human Chorionic Gonadotropin
Estrogen
Progesterone
Prolactin
Oxytocin
What are the 4 functions of the Human Chorionic Gonadotropic hormone?
- secreted by fertilized ovum/chorionic villi.
- stimulates production of estrogen & progesterone up to 8th week.
- identified in the pregnancy test.
- preserves corpus luteum
What are the 6 functions of Estrogen?
- produced by corpus luteum until 14 weeks when placenta takes over.
- Promotes enlargement of genitals, breasts, uterus
- increases vascularity causing vasodilation
- contributes to maternal fat deposits
- promotes sodium and water retention
- causes relaxation of pelvic ligaments and joints
What are the 4 functions of Progesterone: “pro-gestation” hormone?
- produced by corpus luteum until about 14 weeks when placenta takes over
- relaxes smooth muscles and decreases uterine contractions
- maintains the decidua
- contributes to maternal fat deposits
What are the 4 functions of Oxytocin?
- produced by POSTERIOR pituitary in increasing amounts during pregnancy
- stimulates uterine contractions during pregnancy
- high levels of progesterone prevent contractions until near term
- stimulates let down reflex when baby suckles at the breast in postpartum period
What are the skin changes that occur during pregnancy?
increased skin pigmentation in discrete, localized areas and may be to regional differences in melanocyte density within the epidermis
- melasma
- linea nigra
What should pregnant people avoid foodwise?
Caffeine
Artificial sweeteners
mercury containing fish
unpasteurized products
raw fish
What prenatal labs do we do?
Glucose Tolerance Test
1 hour
3 hour - 2nd test
2 hour - 2 step
Rubella Titer: assess whether patient is rubella immune
HGB and HCT: if low - consider supplemental iron
HGB electrophoresis: not done in all but used to diagnose hemoglobin issues like sickle cell anemia
Group Beta Strep - possible to pass to baby via vagina. infant may get very sick. need to be given antibiotics during labor
Hepatitis B - work to prevent transmission via immunizations/immunoglobulins
Urinalysis - UTIs can cause preterm labor and can be a sign of preeclampsia
TDap - pertussis is fatal
need additional TDAP shot during pregnancy
Chlamydia - greater complications: miscarriage, premature birth, still birth
Gonorrhea - can pass from mom to baby leading to blindness, joint/blood infections
Herpes - active vaginal outbreak herpes: a contraindication to delivery: antiretroviral medication is prescribed at 36 wks gestation
HIV - need to be treated with antiretrovirals
What are signs of labor?
Lightening: fetus settling into pelvis
Braxton Hicks: contractions come and go, but don’t lead to cervical dilation and effacement
Bloody show: bloody mucous due to breakage of small cervical BV as cervix starts to thin and open
Spontaneous Rupture of Membranes (SROM): amniotic sac breakage
Cervical changes; cervix ripens, becomes soft, moves on from a posterior to anterior position, may start to efface and dilate
Losing mucous plug: mucus plug is a viscous collection of mucus that seals the cervix shut and many people lose it prior to labor
Nesting: burst of energy to put everything in order
What are the 5 P’s of labor and why are they important?
- Powers
- primary: contractions causing dilation and effacement
- secondary: when fetus reaches pelvic floor, contractions change in character and become expulsive, person has to push - Passenger: head, size, presentation - what position is the baby in?
- lie: relation of fetal spine to maternal spine (transverse = c-section)
- attitude: relation of fetal parts to each other
- position: relation to position of 4 quadrants of birth parent’s pelvis
- station: relation to mom’s ischial spine - Passageway: bony pelvis and soft tissue (is there enough room?)
- Position of the mother
- upright position = better oxygenation for baby
- laboring patients who sat, stood or kneeled the first stage shortened first stage of pregnancy - Psyche: emotional state - if feeling unsupported, has high anxiety, and more difficult birth
What are the stages of labor?
Stage 1: from onset of regular contractions to full cervical dilation
latent phase = slower OR
active phase = most rapid cervical dilation
Stage 2: from 10 cm and 100% effaced to delivery of infant (starts and ends when baby is delivered - most with their first babies will push up to 4 hrs)
latent phase: birthing patient is dilated but hasn’t pushed OR
active phase: pushing and using expulsive efforts
First babies: push up to 4 hrs
Active epidural and not feeling urge to push: labor down
Multiple babies: shorter push
Stage 3: from delivery of infant to delivery of placenta (active management)
pitocin is given, gentle cord traction until placent delivers, then uterine massage, decreases hemorrhage.
Stage 4: from delivery of placenta to stabilization of the birth parent and infant (physical recovery after birth)
1-4 hrs
What is dilation, effacement, and station? How are they charted/noted?
Dilation: when cervix dilates and opening measured from closed to 10cm
Effacement: thinning and shortening of cervix at the end of pregnancy in preparation for childbirth
Station: descent of fetal presenting part in the pelvis
ex: 5cm/90%/+1
The cervix is 5cm dilated, the cervix is 90% effaced, and the fetal head had descended 1cm below the ischial spines.
What is VEAL CHOP?
Variable decelerations = cord compression :/
- indicates fetal blood supply is limited
Early decelerations = Head compression :)
- changing position may reduce compression
Acceleration = OK
- 15 bpm above baseline with more than 15 seconds but less 2 mins
Late decelerations = placental insufficiency :(
- shortage of oxygen for baby
Fetal Heart Interpretation Categories
Category I: Normal = Fetal Acid Base Well Oxygenated Fetus
Shows ALL of following:
baseline 110-160 BPM
moderate variability
accelerations may be present
NO late or variable deceleration, may have early deceleration
Category II: Indeterminate
Shows ANY of the following
Tachycardia/bradycardia without absent variability
minimal variability
absent variability without recurrent decelerations
marked variability
absence of accelerations after stimulation
recurrent variable decelerations with minimal or moderate variability
Category III: Abnormal
either:
Absent variability with
recurrent late declarations or
recurrent variable deceleration or
bradycardia
Sinusoidal pattern
What are the possibilities for variability in fetal heart monitoring?
Absent - no detectable variation around baseline
Minimal = less than 5 bpm around baseline
Moderate = 6-25 around bpm
Marked = over 25 bpm
Sinusoidal = rare
How do you count contractions? Frequency vs Duration
Frequency: beginning of one contraction to beginning of another contraction
Duration: beginning of contraction to end of same contraction
What is the relationship between fetal oxygenation and contractions?
Fetal oxygenation saturation is slightly lower than uterine contractions
What is the most important thing to monitor right after a patient receives an epidural and why?
Maternal BP and fetal heart rate
What does OP mean? How does it affect labor?
Occiput posterior = most common fetal malposition
associated with labor abnormalities
How do you know whether a person is in labor with respect to timing and movement changes? (the cervix is dilating and effacing)
Timing of contractions
- False labor: irregular contractions and not close together
- True labor: contractions come at regular intervals and get closer together as time goes on (contractions last about 30-70 seconds)
Change with movement
- false labor: contractions might stop when you walk or rest or might even stop when you change positions
- true labor: contractions continue, despite moving or changing positions
What is GBS and how do we treat it in labor?
group beta streptococcal infection: harmless in adults but can be dangerous in newborns
GBS pos - can get gbs pneumonia.
NOT an std
antibiotics given during labor
What are the 5 mechanisms that stimulates urge for newborns breathe? MCTSH
- Mechanical - as fetus moves through birth canal, chest compressed and recoiled encouraging breathing
- Chemical - blood flow placenta decreases during contractions - slight fetal hypoxia. increases urge to breathe
- Thermal - sudden cooling at birth stimulates breathing
- Sensory - tactile stimulation - drying after birth stimulates breathing
- Hormonal - increased norepinephrine and epinephrine stimulates cardiac output, surfactant release, and promotion of fluid clearance
The nurse assesses a 6-hour old infant loosely wrapped in the bassinet. The nurse collects these vital signs: HR 158, RR 59, Temp 97.0. The infant appears well. Based on these vitals, what should the nurse do next?
Place the infant skin-to-skin with the birth parent
Next to establishing respirations and circulation, heat regulation is most critical to the newborn’s survival
Newborns tolerate a narrower range of environmental temperatures and are extremely vulnerable to both under and overheating
Will attempt to regulate via flexed position, peripheral vasoconstriction, increased metabolic rate, and metabolism of brown fat.
Oxygen consumption and energy will be diverted from maintaining normal brain/cardiac function to thermogenesis for survival
Depleted brown fat stores, increased oxygen needs, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia and decreased surfactant production
What is considered Preterm? Late preterm?
After 20 weeks 0 days but less than 37 weeks and 0 days
Late Preterm is 34 weeks and 0 days through 36 weeks and 6 days
What is considered Term pregnancy? Early? full? late?
Early term: 37 0/7 weeks through 38 6/7 weeks
Full term: 39 0/7 weeks through 40 6/7 weeks
Late term: 41 0/7 weeks through 41 6/7 weeks
What is considered a late term pregnancy?
42 0/7 weeks and beyond
Growing a human being inside of another human being takes a lot more oxygen than just sitting on the couch, not being pregnant. Maternal blood is the 02 transport system to the fetus. What are some of the adaptions that the maternal hematological system makes to grow the fetus and survive the pregnancy?
Increase RBC production (approx. 250- 450 ml)
Increase in clotting factors
Circulating blood volume increases by 40-50%
The nurse takes a laboring patient’s blood pressure during a contraction. The blood pressure is 140/90. This is the first high pressure. The student working with the nurse (outside of the patient’s hearing), discusses the pressure with the nurse and says:
The B/P might be high because during a contraction, the blood in the placental bed is pushed out to the peripheral vasculature, increasing the maternal blood volume. We should consider retaking the B/P after the contraction ends.
What are the warning signs of pregnancy?
These are things like a bad headache with high blood pressure (suggests preeclampsia), SOB without exertion (suggests cardiac). Essentially you need to be able to tell a normal pregnancy adaptation from a worrisome one.
What are the ductus venous, foramen ovale, and ductus arteriosis?
Ductus venosus: shunts umbilical vein blood direction into inferior vena cava bypassing the liver.
Foramen ovale: shunt that connects the right heart with the left heart, allowing oxygenated blooed from the inferior vena cava to move directly into the aorta then out to nourish the fetal body.
Ductus arteriosis: blood vessel that connects the pulmonary artery to descending aorta.
secondary mechanism to foramen ovale to assure oxygenated blood is not wasted
