NURS 330 - OBS quiz 2 Flashcards
Induction
the initiation of contractions in the pregnant patient NOT in labor
Augmentation
the enhancement of contractions in the pregnant patient already in labor
Cervical Ripening
Use of pharmacological other means to soften, efface, and/or dilate the cervix to increase likelihood of vaginal delivery when induction is indicated.
Indications for Induction
Post term pregnancy
Maternal Disease (HTN, DM, antepartum bleeding)
chorioamnionitis
Oligohydramnios
Fetal compromise
Rh isoimmunization
IUGR
PROM (especially GBS+)
Intrauterine fetal death
Advanced age
Logistical concerns
Maternal risk of post term
placental “expiry date” - starts to shrivel and die
Fetal risk of post term
large babe, complicated labor
Cautions for induction
grand multiparity
vertex
brow or face presentation
ocer distension of uterus
lower segment uterine scar
pre-existing hypertonus
Contraindication to induction: Placental
Complete placental previa
Contraindication to induction: Cord
Presentation/Prolapse
Contraindication to induction: fetal
Transverse lie, breech
Contraindication to induction: History
Previous uterine surgery or C/S
Pelvic abnormalities or absolute CPD
Active genital herpes
Gyne/Obs/medical conditions
Contraindication to induction: Convenience
Lack of consent from patient
Bishop’s Scoring System
Cervix that is soft and effaced is the MOST important factor for successful induction (dilation, position of cervix, effacement, station, cervical consistency)
Unfavorable = < 6
Preventing Induction of Labor
Nipple stimulation, sexual intercourse, acupuncture, enema, herbal supplements, stripping/sweeping membranes
Methods of Inducing Labor
Amniotomy (AROM)
Mechanical dilation (foley, ripening balloon, lanimatia, pharmacological)
Stripping/Sweeping of Membranes
Mechanical separation of membranes from cervix or uterus, NO monitoring or other assessments, not used for induction when there are high priority indications
Amniotomy - AROM
Augment or induce labor, committed to delivery, apply internal fetal or contraction monitors, or to obtain fetal scalp blood sample for pH monitoring
Prostalgandin
Into posterior fornix of vagina
Cervidil
Into posterior fornix - continuous slow release
Misoprostol/Cytotec
50mcg orally or 25mcg vaginally
Advantages of Prostaglandin
Less invasive, more physiologically similar to labor, simple adminitration
CAN go home on cervidil
INDUCTION use (not augmentation)
Oxytocin Infusion
Syntocinon/Pitocin
For INDUCTION and AUGMENTATION
half-life of 1-6mins
Protocol: gradual increase > 30min increments
Oxytocin Induction - Nursing Care
Continuous observation by an RN as per facility protocol
Contractions and FHR q15mins/maternal VS q15-30mins
Tachysystole
Excessive uterine activity with atypical or abnormal FHR tracing
Tachysystole Characteristics
> 5 contractions in 10 mins
Resting periods between contraction < 30 sec
High resting tone
Contraction lasting more than 90 seconds
Tachysystole (Uterine Hyperstimulation)
Can cause placental abruption, fetal hypoxia, precipitous delivery, PP hemorrhage/uterine atony
Tachysystole (Uterine Hyperstimulation): Nursing Care
Re-position to left lateral, side to side, or knee chest
Redue uterine stimulation (no oxytocin, remove cervadil, swab prostin)
Administer tocolytic if needed
O2 and IV bolus if needed
Complications of Induction and Augmentation
Increased risk for mom and fetus
tachysystole
chorioamnionitis
uterine rupture
PPH
Placental implantation abnormalities in the future
After delivery of induction or augmentation
risk of PPH/atony is increased with induction
4 causes of dystocia
Problems with Powers
Problems with Passenger
Problems with Passageway
Problems with Psyche
Problems with Powers (dystocia)
Hypertonic uterine dysfunction
Hypotonic uterine dysfunction
Precipitate labor
Problems with Passageway (dystocia)
Pelvic contraction
Obstructions in maternal birth canal
Problems with Passenger (dystocia)
Breech/shoulder dystocia
Cord prolapse
Persistent occiput posterior position
Face or brow presentation
Macrosomnia
Problems with Psyche (dystocia)
Psychological distress
Labor dystocia interventions
Non-progression in active labor
Amniotomy and pharmacologically (oxytocin)
Hypertensive Disorders of Pregnancy
Pregnancy induced hypertension (PIH)
Gestational hypertension (GH)
Pre-Eclampsia
Toxemia
Hypertensive Disorders of Pregnancy - Incidence
about 10%
Risk Factors of Gestational HTN
Nullipara or first pregnancy
Hx of pregnancy with HTN/preeclampsia
Hx of chronic HTM/CKD/SLE
Poor nutrition
Obesity
Advanced maternal age
Pre-gestational diabetes
Chronic HTN
HTN that develops either before pregnancy or at <20 weeks
Gestational HTN
Systolic > 140mmHg and/or Diastolic > 90mmHg
>20 weeks and up to 12 weeks PP
Severe HTN
Systolic > 160mmHg and/or diastolic 110mmHg
Preeclampsia
Systolic >140mmHg and/or Diastolic > 90mmHg
Proteinuria (2+ or greater) or 1 or more adverse conditions or severe complications
Eclampsia
Seizure
Adverse conditions of HTN
Headache, visual disturbances, abdominal/epigastric/RUQ pain, N/V, chest pain/SOB, abnormal maternal lab vlaues, fetal morbidity, edema/weight gain, hyperreflexia
Severe Complications of Preeclampsia: Maternal
Stroke, pulmonary, edema, hepatic failure, jaundice, seizures, placental abruption, acute renal failure, HELLP syndrome and DIC
Fetal consequences of preeclampsia
IUGR, oligohydramnio, absent or reveresed end diastolic umbilical artery flow, prematurity, fetal compromise, intrauterine death
Preeclampsia Etiology - Multi-organ involvement
Abnormal placentation OR excessive fetal demands
Mismatch between uteroplacental supply and fetal demands
Prevention of Vasospasm and Hypoperfusion
Low dose aspirin starting pre-pregnancy or before 16 weeks for increased risk patients
Calcium supplementation for all clients with low dietary calcium intake
Initial management of vasospasm and hypoperfusion
Assessment of pregnancy client and fetus, stress reduction, treat BP with antihypertensives, treat symptoms, consider seizure prophylaxis
Home-Care management of non-severe HTN
Client monitors own BP
Measures weight and tests urine protein daily
NST’s performed daily or bi-weekly
Management of severe HTN/Preeclampsia
Fetal evaluation
Hourly I&O
Frequent BP, pulse, and resps
Blood work
Monitor adverse condition
HTN medications
Labetalol
Nifedipin (Ca channel blocker)
Hydralazine (arteriolar dilators)
Aldomet (centrally-acting sympatholytic
What HTN medications CANNOT be used in pregnancy
ACE inhibitors
Magnesium Sulfate MgSO4
Tachycardia, NB to test reflex, motor urine output, can slow labor, muscle weakness, lack of energy/drowsiness, resp depression, low BP
Magnesium Toxicity
CNS depression
Antagonist: Vitamin A
Eclampsia Treatment: Medications
Anticonvulsants (bolus of magensium sulfate)
Sedation and other anticonvulsants (dilantin)
Diurectics to treat pulmonary edema (furosemide/lasix)
Digitalis (for circulatory failure)
HELLP syndrome
Hemolysis
Elevated
Liver enzymes
Low
Platelets
HELLP syndrome patho
Platelets aggregate at sites of vascular damage (admin platelets if < 20)
Disseminated Intravascular Coagulation (DIC) Causes
Can be caused by preeclampsia, hemorrhage, intrauterine fetal demise, amniotic fluid embolism, sepsis, HELLP
Disseminated Intravascular Coagulation (DIC)
Over-activation of normal clotting mechanism - mini clots develop and platelets and clotting factors deplete = EXCESSIVE BLEEDING
Gestational Diabetes Incidence
Incidence between 3-20%, 3.5% of non-aboriginal women and up to 18% of aboriginal women
How does pregnancy alter carbohydrate metabolism 2 ways
- Fetus continually takes glucose from mother
- Placenta creates hormones, which alter effects of and resistance to insulin and glucose tolerance
Carbohydrate metabolism: first trimester
rise in hormones stimulate insulin production & increase tissue response to insulin
Carbohydrate metabolism: second and third trimester
Placental secretion of hPL begins increased resistance to insulin to facilitate transfer to fetus for growth
Insulin needs to increase b/c more is required to maintain normal concentration
Gestational diabetes: pregnancy/maternal effects
Preeclampsia/eclampsia increase due to vascular damage
polyhydramnios, PROM
Preterm labor
r/o shoulder dystocia
r/o C/S
Gestational Diabetes : Fetal Effects
Macrosomnia/LGA
Intrauterine growth restriction
Fetal demise
Congenital anomalies
Gestational Diabetes Neonatal effects
Hypoglycemia
Hyperbilirubinemia
Immature respiratory development = RDS
Gestational Diabetes Child Effects
Increased risk of developing diabetes and obesity
Screening for Gestational Diabetes
24-28weeks of gestation with a NON-FASTING 50g glucose challenge test
normal = <7.8mmol/L
Intrapartum Care for Gestational Diabetes
Balance insulin with need for increased energy in labor
Monitor blood sugars q1-2h
Individual IV glucose and IV insulin
Postpartum Care for Gestational Diabetes
Insulin requirements decrease significantly
Multiple Birth Risks
preterm labor
anemia and HTN in pregnancy
abnormal presentation
twin-twin transfusion syndrome
uterine dysfunction
abruptio placenta/placental previa
prolapsed cord
postpartum hemorrhage
Singleton
Mean gestational age 38.7 weeks
6.3% weigh < 2500g
7% < 37 weeks
Mortality 4.1 per 1000
Twins
mean age 35.2 weeks
56.6% weigh < 2500g
Mortality 25.7 per 1000
97% < 37 weeks
Triplets
Mean age 32.1 weeks
94.1% weigh < 2500g
Mortality 62.2 per 1000
Twin-Twin transfusion syndrome
Unequal sharing of blood between twins through blood vessel connections on the placenta
Complications of Obesity in Pregnancy
Spontaneous abortion/stillbirth
HTN
Diabetes
Preterm or posterm
Complications of Obesity in Intrapartum
Stillbirth
Macrosomnia/shoulder dystocia
Complications of Obesity in Neonates
Macrosomnia
Hypoglycemia
Breatfeeding issues
Congenital anomalies
Complications of Obesity in Postpartum
Depression
PPH
Infection
Thrombosis
Adolescent pregnancy physical risks
Preterm birth, low birth weight infant, CPD, anemia, GHTN
Adolescent pregnancy psycho-social risks
Interruption of development tasks, substance abuse, poverty, interruption or cessation of education, less prenatal visits
Older Gravida Risks
> 35
Decline in fertility
increase in chronic diseases (HTN, cardiac, thyroid, cancers), Increased difficulties in pregnancy (GDM, GHTN, PTL, multiples, IUGR, placental previa, miscarriage, ectopic, stillbirth, neonatal death), increase risk of C/S and induction, increased genetic conditions
Methadone
Most commonly used for women dependent on opioids to block withdrawal symptoms, reduces cravings for narcotics, and crosses placenta
Methadone risk for fetus
reduced head circ
withdrawal symptoms
low birth weight
Cannabis and pregnancy
can negatively impact fertility
crosses placenta (can cause harm, associated with long-term child effects), passes into breastmilk, can negatively impact parenting
Teratogens
Alcohol, drugs, prescribed medications, pathogens
CHEAP TORCHES
C: Chickenpox & shingles
H: Hepatitis B, C, D, E
E: Enteroviruses
A: AIDS
P: Parvovirus B19
T: Toxoplamosis
O: Other (GBS, listeria, candida)
C: Cytomegalovirus
H: Herpes simplex virus
E: Every sSTI
S: Syphillis
Syphillis
between 2017-2021 SK saw 1346% increase in syphilis rates
Syphillis Problems in Babiesq
Problems with eyes, ears, teeth, and bones - can cause death
Urinary, Vaginal, Sexually transmitted infections, PID, bacterial vaginosis (BV)
10-25% of all women
50% asymptomatic
can cause: spontaneous abortions, preterm delivery, maternal and fetal morbidity and mortality
HIV in pregnancy
without treatment = 25% of transmission
with proper treatment = < 2% of transmission
HIV and pregnancy treatment
Combination anti-retroviral therapy
HIV Care in pregancy
3 part antiretroviral prophylaxis regimen reduces r/o transmission to infant
Pregnancy = cART
Labor = Add IV ZDV during labor until birth
Infant = ZDV oral suspension for 6 wks
Why has the rate of preterm birth increase in Canada?
R/t slow increase of assisted reproductive technology (r/o multiples, infections, etc.)
What causes preterm labor?
race, age extremities (<17 or >35), smoking/alcohol/drugs, infection/inflammation/toxicology, stress, HTN, lack of prenatal care, cervical abnormalities/surgery, uterine distention, PREVIOUS PTB
Preterm Labor Common Symptoms
Low ABD pain/cramps/backache, bleeding/spotting/show/ROM, Pelvic pressure (baby pushing down), increased amount/changes in vaginal discharge, contractions q10mins, cervical changes - SUBTLE
Fetal Fibronectin (FFN)
Glycoprotein released into cervical/vaginal fluid in response to inflammation or separation of amniotic membranes
Normal until 22wks, then should not be seen until labor
Negative FFN
LACK OF FFN = pregnancy is likely to continue for at least another 2 weeks (95-98% accurate)
Positive FFN
Present 24-34 weeks gestation and indicates increased risk of preterm delivery
Management of Preterm labor
Should labor be stopped?
Assess VS, contractions, and fetus
Avoid stimulation (no vag exams, sex or nipple stimulation)
Keep bladder empty, bedrest, hydration
Tocolytics for management of PTL
Indomethacin
Calcium channel blockers
Vaginal progesterone
Indomethacin
Anti-prostaglandin inhibits uterine activity, delays delivert for 48hours - NOT recommended long term (can cause premature closure fetal ductus arteriosus)
Calcium channel blockers
Nifedipine (adalat) - not very effective
Vaginal Progesterone
“new”
May prevent and reduce incidence of PTB if previous hx of PTB or short cervical length
Cervical Insufficiency
Premature painless dilation of cervix
20-28weeks
Can cause 2nd trimester abortions (because cervix can’t handle the weight)
Diagnosis and Treatment for Cervical Insufficiency
Heaviness in pelvis
PPROM
Treat: bedrest, pelvic rest, no heavy lifting, cervical cerclage (suture)
Risk factors for Cervical Insufficiency
Infections
Multiple gestation
Polyhydramnios
Risks of Cervical Cerclage
Infection, blood loss, PPROM, preterm labor
Damage to cervix
Not appropriate if vaginal bleeding, infection, uterine contractions, membranes have ruptured
Corticosteroids in PTL
All pregnant clients between 24-34 weeks gestation who are at risk of PTL within 7 days should be considered candidates for antenatal treatment with a single course of corticosteroids
How does a single course of corticosteroids aid in PTL
Reduces perinatal mortality, respiratory distress syndrome, and intraventricular hemorrhage
- Matures the fetus quickly
Most common corticosteroids in PTL
Betamethasone and dexamethasone
MgSO4 for Fetal Neuroprotection
Enhance fetal neuro development
Use in active labor with >4cm dilation with/without PROM OR in planned preterm birth for fetal or pregnant client indications
Bleeding in Pregnancy
Spontaneous abortion (miscarriage)
Ectopic pregnancy
Gestational trophoblastic disease
Placenta previa
Abruption placentae
Uterine rupture
Abortion
Expulsion of fetus before 20wks gestation OR expulsion of fetus less than 500g
Spontaneous abortion
occurs naturally (miscarriage)
Therapeutic/induced abortion
medically or surgically done
Spontaneous abortion care: if minimal bleeding
Bed rest and abstinence from sex
spontaneous abortion care: if heavy bleeding/persistent/pain/fever
Cytotec (misoprostol)
+/- WinRho
IV therapy or blood transfusions
Surgical dilation and curettage (D&C) or suction evacuation (D&E)
Ectopic Pregnancy
Implantation of fertilized ovum outside the uterus
Causes rupture and bleeding into the abdominal cavity
Symptoms of Ectopic pregnancy rupture/bleeding
sharp unilateral pain and decrease BP, syncope
shoulder pain, lower abdominal pain
vaginal bleeding
hypovolemic shock
EMERGENCY
Gestational trophoblastic disease incidence
RARE - <1/1000
Gestational trophoblastic disease
Abnormal development of the placenta
Trophoblastic cells that obliterate the pregnancy
Hydatidiform mole (benign)
Can develop into choriocarcinoma (rare)
Symptoms of Gestational trophoblastic disease
Uterine enlargement greater than gestational age, vaginal bleeding, passage of clots
Hyperemesis gravidarum
Development of preeclampsia prior to 24 weeks
Antepartum hemorrhage
Vaginal bleeding > 20 weeks to delivery
Two main causes of Antepartum hemorrhage
Placenta previa
Abruptio placentae
Physiologic response to blood loss
change in fetal status may be the first indication of compensation by pregnancy client secondary to hemorrhage
Placenta Previa
4 in 1000 births
Implantation of the placenta is: total/complete, partial, marginal, low-lying placenta
Placenta Previa detection
Routine ultrasound
Ultrasound at time of presentation with bleeding
Must be monitored frequently (80+% migrate during pregnancy)
Goal for patients with placenta previa
Goal is to get to 36-37 weeks gestation because labor onset would cause extreme bleeding
Placenta Previa risk factors
Previous placenta pervia
Uterine abnormalities/endometrial scarring
Impeded endometrial vascularization
Large placental mass
Abruptio Placentae
Premature separation of normally implanted placenta from uterine wall (1 in 100 births)
Total/Complete Abruptio placentae
Hemorrhage in pregnancy client
fetal death
Partial abruptio placentae
Fetus can tolerate up to 30-50% abruption
Abruptio placentae risk factors
Previous abruption
HTN in pregnancy
Blunt BAD truma (MPV, IPV, falls)
Overdistended uterus (multiples, polyhydramnios)
PPROM <34wks gestation
Previous C/S
Drug and alcohol use
Smoking
Short umbilical cord
Uterine abnormalities (fibroids)
Advanced age in pregnancy
Implications of Abruptio Placentae in pregnant client
Antepartum/intrapartum hemorrhage
Postpartum hemorrhage
DIC
Hemorrhagic shock
Implications of abruptio placentae in fetal-neonate
Sequelae of prematurity
Hypoxia
Anemia
Brain damage
Fetal demise
Onset of Placenta pevia
Insidious
Type of bleeding in placenta previa
always visible, slight and then more profuse
Blood description in placental previa
bright red
Pain in placental previa
NONE
Uterine tone in placental previa
Soft and relaxed
FHR in Placental previa
Usually in normal range
Fetal presentation in placental previa
May be breech or transverse lie; engagement is absent
Onset of abruptio placentae
sudden
Type of bleeding in abruptio placentae
Can be concealed or visible
Blood description in abruptio placentae
Dark
Pain in abruptio placentae
Constant; uterine tenderness on palpation
Uterus tone in abruptio placentae
Firm to rigid
FHR in abruptio placentae
Fetal distress or absent
Fetal presentation in abruptio placentae
No relationship
Issues of abnormal placentation
Placenta accreta
Placenta increta
Placenta percreta
Placenta accreta
placenta attaches itself too deeply into the surface of the myometrium
Placental increta
Penetrates into the myometrium
Placenta percreta
WORST form - placenta through myometrium and into tissue or organs
Immediate care for AP bleeding
Complete Hx
Assess pregnancy client CV status - O2 sats, output, LOC
Fluid resuscitation if active bleeding or unstable
Monitor fetus and uterine activity electronically
Velamentous Insertion of Cord
Vessels of umbilical cord divide some distance from placenta in placental membranes
Torn vessel leads to FETAL hemorrhage
Uterine Rupture
Spontaneous rupture or rupture of previous scar
Risk factors for uterine rupture
PREVIOUS UTERINE SURGERY, INCLUDING C/S
Short inter delivery interval
Grand multiparity
Trauma
Intrauterine manipulation
Midforceps rotation of fetus
Uterine rupture Presentation
Initially asymptomatic
ABD pain not relieved by analgesic
N/V, syncope, vaginal bleeding, tachycardia, abnormal FHR, pallor
Change in shape of abdomen - fetal parts palpable through ABD wall
Dramatic sharp, tearing pain, tense, acute abdomen and shoulder pain
