OB exam #1 Flashcards
PROBABLE signs of pregnancy
s/s that make the EXAMINER think pt is pregnant
- Abdominal enlargement
- Positive pregnancy test
- Fetal outline felt by examiner
- Positive Hegar’s sign, Chadwick sign, or Goodell’s sign
PRESUMPTIVE signs of pregnancy
s/s that make the PATIENT think they are pregnant
- Amenorrhea
-N/V - Fatigue
- Urinary frequency
- Breast changes
- Quickening
- Uterine enlargement
POSITIVE signs of pregnancy
s/s that can ONLY be d/t pregnancy
- fetal heart sounds
- visualization of fetus through US
- fetal movement felt by examiner
how do we verify a pregnancy?
blood or urine test
how do pregnancy tests work?
detect hCG hormone (preg hormone)
-begins at implantation
- peaks 60-70 days of gestation, declines after 100-130
what do LOW hCG levels indicate?
miscarriage or ectopic pregnancy
what does HIGH hCG levels indicate?
- Multifetal pregnancy
- Molar pregnancy
- Genetic Abnormality
How to take a @ home pregnancy test?
First morning void
Nagele’s Rule
Used to establish estimated delivery date
-First day of last period
- Minus 3 months, plus 7 days
GTPAL –> G
Gravida- number of total pregnancy, including current one
GTPAL–> T
Term- all births after 37 weeks
GTPAL –> P
Preterm- all births between 20-36 weeks
GTPAL –> A
Abortion- miscarriages, medical abortions, and surgical abortions before 27 weeks
GTPAL –> L
Living- total number of living children
Pregnancy Vital Signs
At 3rd trimester…
- HR ↑(10-15 bpm)
- RR ↑
- BP, stays the same
Respiratory System, 3rd Trimester Findings
- Lung capacity DECREASES –> shallow breaths
- RR ↑
- Pt may feel SOB until 36 weeks when baby drops
Maternal HYPOtension; Education
-Happens d/t pt laying supine
- Advice pt to lay on L side
- Advice to dangle first and slowly get up
What is needed for a gestational diabetes (GDM) diagnosis?
- Pt had to have had an elevated 1-hr glucose test
- Pt then has to do a 3-hr glucose test
- Blood is drawn at hour 1,2, and 3
- 2 of those readings has to be elevated
Why do we give RhoGAM for Rh?
-Rh is protein in blood, positive or negative
-If mom is negative and baby is positive, mom can develop antibodies to attack fetus
-RhoGAM is given to protect fetus at 28 weeks, can be given multiple times if needed
Which OTC meds should pt avoid during pregnancy?
ALLL, but specially IBUPROFEN –> BLOOD THINNER, can cause a miscarriage
COMMON discomforts during pregnancy
- N/V
- Heartburn
- Fatigue
- Constipation
- Nasal congestion
- Epistaxis
- Urinary frequency
- Hemorrhoids
- Backaches
- Varicose veins
- Lower extremity edema
- Leg cramps
- Braxton Hicks
- Breast tenderness
- SOB
- Supine hypotension
DANGER signs in Pregnancy- 1st Trimester
Report these to provider ASAP
-Burning w/ urination –> UTI that can lead to sepsis
- SEVERE vomiting/diarrhea –> can’t keep ANYTHING down, possibility of dehydration
- Fever
- Vaginal Bleeding
Recommended weight gain
Underweight/Adolescents 28-40 lbs
Normal BMI 25-35 lbs
Overweight 15-25 lbs
Obese 11-20 lbs
General Rule for weight gain
1st trimester- gain 2-4 lbs TOTAL
2nd & 3rd trimesters- gain 1 lb per WEEK
Nutrition- Folic Acid
Essential for neurologic development and helps prevent neural tube defects
-Green leafy vegetables
-Broccoli
-Spinach
-Kale
Nutrition: Iron Supplements
Take w/ orange juice to help absorption, avoid taking w/ caffeine.
-Red meats
-Fish
-Poultry
-Beans
Nutrition: Overall Diet
Increase calories, protein, and fluids
Ultrasound pt education
Have pt drink 1 quart of water before to have bladder full –> lifts uterus up and forward for better visualization
Biophysical Profile (BPP)
An ultrasound combined w/ a non-stress test to evaluate fetal well-being involving the fetus’s heart rate, breathing, movement, muscle tone, and the amount of amniotic fluid surrounding the fetus in the uterus.
Pt Education for Nausea
-Eat small frequent meals every 2-3 hrs
-AVOID: alcohol, caffeine, fried, fatty & spicy foods, consuming excessive amounts of fluids
-HELP: ginger (ginger ale, ginger tea), herbal tea (peppermint, raspberry)
Non-stress test (NST)
A noninvasive (non-stress) test that measures fetal heart rate in response to movement and contractions using a doppler transducer as well as a tocotransducer.
Expected Findings for an Ectopic Pregnancy
- UNILATERAL stabbing pain in LOWER abdomen
- Can have bleeding, doesn’t always
Expected Findings for Placenta Previa
- Bright red vaginal bleeding
- NO PAIN
What is ectopic pregnancy?
Implantation of the fertilized egg happens in the fallopian tube –> compromises your fallopian tubes
What is placenta previa?
The placenta attached TOO LOW in the uterus, covering the opening of the uterus.
What is placenta abruption?
When the placenta partially or completely DETACHES from the uterus.
What are risk factors for placenta abruption?
- Hypertension
- Abdominal trauma (ex. car accident)
- Cocaine/Nicotine Use
- PROM
- Multifetal pregnancy
- Prior placenta abruption
GBS Nursing Care
- Screen pt at 35-37 weeks
- Administer IV ABX if…
–> GBS positive
–> Unknown GBS status
–> Maternal fever
–> ROM for 18 hrs or longer
Preterm Labor Nursing Care
** Focus is on STOPPING uterine contractions **
- Activity restriction –> bedrest w/ bathroom privileges
- Ensure hydration
- ID and treat infections
- Fetal monitoring
- Administer medications –> TOCOLYTICS (ex. Magnesium Sulfate) –> delay labor
Betamethasone Therapeutic Use
- A steroid that enhances a fetus’ lung maturity and surfactant production.
- Given between 24-34 weeks if pt may be born premature
Betamethasone Nursing Actions
- 2 IM injections are given 24 hrs apart
- Administer at least 24 hrs, but not more than 7 days, before delivery
- Use ventreal gluteal or vastus lateralis muscle
- Monitor for maternal hyperglycemia
- Assess baby’s lung sound once born
Betamethasone Pt Education
Report s/s of pulmonary edema…
- Chest pain
- SOB
- Crackles
PROM Pt Education
- Keep record of daily kick counts
- Adhere to bedrest w/ bathroom privileges
- Avoid hot tubs
- Do not insert anything into the vagina
- Notify nurse if any of the following present…
–> vaginal bleeding
–> decreased fetal movement
What is PROM?
Spontaneous rupture of membranes (amniotic sac), after 20 weeks and before 37 weeks.
What are complications of PROM?
- Infection
- Placenta abruption
- Umbilical cord compression or prolapse
- Fetal pulmonary hypoplasia
- Death
Cervical Ripening
Softening of cervix essential for effacement and dilation
Dilation
Opening of the cervix
Effacement
Thinning of the cervix
FALSE Labor (Braxton Hicks)
- Don’t come regularly and don’t get closer together
- Contractions stop when walking, moving, or changing position
- Usually weak and don’t get stronger, or will start strong and get weaker
- Felt only in the front
TRUE Labor
- Contractions last longer than 30 secs and occur 4-6 min apart
- Contractions continue despite movement
- Get stronger
Contractions start in the back and move to the front
SROM Priority Assessment
- Assess FHR for decelerations
- If prolonged (more than 24 hrs) assess for infection –> increased FHR or maternal fever
How to assess for SROM?
- Fern test
- TACO…
–> Time
–> Amount
–> Color
–> Odor
Factors Affecting Labor (5 Ps) –> PASSAGE
- Birth canal (cervix, pelvic floor, muscles, and vagina)
–> Cervix must dilate and efface
–> Pelvis must be adequate size and shape to allow fetus to pass through
Factors Affecting Labor (5 Ps) –> PASSENGER
- Fetus and placenta
-Factors that affect this are…
–> size of fetal head
–> fetal presentation
–> fetal lie
–> fetal attitude
–> fetal position
–> station
Fetal Station
- Measurement of fetal descent
- Measured by comparing the fetus level to the maternal ischial spines
- Can be negative or positive
–>Positive/Zero –> easier to push
Factors Affecting Labor (5 Ps) –>POWERS
- Primary contractions: INVOLUNTARY
–>Uterine contractions, Cause dilation and effacement of cervix - Secondary contractions: VOLUNTARY
–>Maternal pushing
Factors Affecting Labor (5 Ps) –> POSITION
- Mom’s position during labor
- Frequent position changes are recommended
Why do active birthing positions help?
- Reduce length of labor
- Reduce assisted delivery
- Reduce episiotomies and perineal tears
- Fewer abnormal FHR patterns
- Increases comfort and reduces pain
- Allows gravity to move fetus forward
Factors Affecting Labor (5 Ps) –> PSYCHOLOGICAL RESPONSE
- How pt feels throughout labor, critical to a positive birth experience
Factors promoting a positive birth experience
- Clear info about procedures
- Support
- Self Confidence
- Trust
- Positive reaction to pregnancy
- Personal control over breathing
- Preparation for childbirth experience
1st Stage of labor- LATENT Phase
- Dilation 0-3cm
- Pt is excited, eager, talkative
- Contractions are irregular, mild intensity
- Encourage rest
- Pt typically still @ home
1st Stage of Labor- ACTIVE Phase
- Dilation 4-7 cm
- Pain intensifies
- Contractions are more regular, moderate intensity
–>Once contractions are 5 min apart –> GO TO HOSPITAL - Anxiety and restlessness may increase
1st Stage of Labor- TRANSITIONAL Phase
- Dilation 8-10 cm
- Rectal pressure and urge to push
- Contraction intensity is strong
- Most difficult/painful part of labor
2nd Stage of Labor- EXPULSION
- Pushing stage
- Begins w/ 10 cm dilation and ends w/ birth
-Primigravida can last 2 hrs
–> Multigravida is quicker
3rd Stage of Labor- DELIVERY OF PLACENTA
- Begins at birth and ends w/ delivery of the placenta
- Sudden shrinking of the uterus and release of placenta
- 5-20 min after delivery
4th Stage of Labor- RECOVERY
- After placenta is delivery
- Focus on stabilizing vital signs
- Perform uterine assessment and pain assessment
–> Fundus should be firm
Non-Pharmacological Pain Management
- Childbirth education
- Breathing exercises
- Aromatherapy
- Imagery
- Music
- Low lighting
- Therapeutic touch –> effleurage
- Hydrotherapy
- Frequent position changes
- Movement –> walking, rocking, etc.
- Heat/cold therapy
- Sacral counterpressure
Opioid Analgesics- Adverse Effects
Ex. Fentanyl
- Decreased FHR variability
- N/V
- Sedation
- Neonatal RR distress if too close to delivery
Epidural Anesthesia- Adverse Effects
“Local Anesthetic, injected into epidural space
- Maternal hypotension –> LAY MOM ON L SIDE, increase IV fluids and administer oxygen
- Fetal bradycardia
- Itching (not an allergic reaction)
- Loss of ““bearing down”” reflex, will not feel need to push”
Leopold Maneuvers
Performing external palpations through the abdominal wall to determine the fetus’ presentation, fetal lie, fetal attitude, degree of descent into the pelvis, and location of fetus’ back (to place FRH monitor)
External Fetal Monitoring
Uses ultrasound transducer to record FHR pattren and a tocotransducer that records contractions
Advantages of external fetal monitoring
- non-invasive –> less risk for infection
- ROM not needed
- Cervix doesn’t need to be dilated
- Placement done by nurse
- Provides a permanent record
Disadvantages of external fetal monitoring
- contraction intensity not measured
- requires frequent reposistioning of devices
- quality of recording is affected by obesity and fetal position
Internal Fetal Monitoring
Uses a small spiral electrode to attach to a part of the fetus for accurate FHR, used in conjuction with an intrauterine pressure monitor that measures contractions
Advantages of internal fetal monitoring
-early detection of abnormal FHR patterns
- Accurate FHR variability
- Not affected by maternal obesity or position
FHR Baseline NORMAL Range
110-160 bpm
FHR Baseline Bradycardia
Less than 110 bpm
- d/t placental insufficiency, cord prolapse, anethesia, or maternal hypoglycemia
Disadvantages of internal fetal monitoring
- ROM needed
- cervix dilated 2-3 cm
- potential risk to fetus
- must be inserted by HCP
- potential risk for infection
FHR Baseline Tachycardia
above 160 bpm
d/t maternal infection (chorioamniotis), prolonged fetus hypoxia, maternal drug use, maternal dehydration, or fetal infection
Absent Variability
amplitude range UNDETECTEABLE
BAD!! –> fetus is no longer alive or about to pass :(
Minimal Variability
**amplitide less than 5 bpm ** –> fetus is most likely sleeping
Moderate Variability
amplitude range 6-25 bpm
NORMAL
Marked Variability
amplitude greater than 25 bpm
–> indicates there is a problem that needs correcting
Fetal Variability
Fluctuations on fetal heart rate
Late Decceleration- Nursing Interventions
”"”THOSE who can, do!””
Turn the patient
Hydrate
Oxygenate
Stop uterotonics
Expedite delivery”
Late deccelaration
- A decrease in FHR after a contraction that then goes back to baseline
- d/t Placental insufficiency
Variable Decceleration
- an ABRUPT and visually apparent decrease in FHR
- decrease is greater than 15 bpm and last more than 15sec to less than 2 min
- d/t cord compression
Variable Decceleration- Nursing Interventions
”"”THOSE who can, do!””
Turn the patient
Hydrate
Oxygenate
Stop uterotonics
Expedite delivery”
Reassuring FHR monitoring
- FHR 110-160 bpm
- minimal/moderate variability
- present/absent accelerations
- present/absent early deccelarations
- absent variable/late deccelerations
Non-reassuring FHR Monitoring
- fetal bradicardia/tachycardia
- absent FHR variability
- late deccelerations
- variable deccelerations
Bishop Score
- determines fetal readiness for labor
- a score of 8 or more is GOOD
Methods to produce cervical ripening
- balloon catheter
- cytotec- PO med
- cervidil- vaginally inserted medication
Indications for induction of cervical ripening
bishop score is LESS than 8
Complications of inducing cervical ripening
- fetal distress
- tachystole (hypertonic contractions)
induction of labor
intervention to artificially initiate contractions before spontaneous onset of labor
indications for induction of labor
- postterm labor dysfunction
- prolonged ROM
- maternal medical conditions
- fetal demise (stillbirth)
- infection
- maternal request (if past 39 weeks)
augmentation of labor
intervention to stimulate contractions once LABOR HAS STARTED but is slow to progress
Amniotomy
artificial ROM –> amniotic sac gets ““popped”””
Amniotomy risks
infection and cord compress
amniotomy nursing assessment
FHR monitoring
Amnioinfusion
infusion of fluid into the amniotic sac to supplement amniotic fluid loss
Amnioinfusion Indications
- olighydramnios –> scant/no amniotic fluid
- fetal cord compression
Operative Delivery
Using tools to help deliver baby
Operative Delivery Indications
maternal exhaustion w/ ineffective pushing or fetal distress
C-Section Indications
- Breech presentation
- Non-reassuring fetal heart tones
- Placenta previa
- Placental abruption
- Previous c-section
- Umbilical cord prolapse
- High-risk pregnancy (HIV+, active genital Herpes, maternal hypertension, maternal diabetes)
-Multiple gestations
prolapsed umbilical cord
when the umbilical cord is displaced, preceding the presenting part of the fetus or protruding through the cervix causing cord compression and compromised fetal circulation
prolapsed umbilical cord risk factors
- SROM
- high station
- breech/transverse lie
- SGA
- increased amniotic fluid
prolapsed umbilical cord expected findings
- prolonged deceleration after rupture of membranes
- palpation or visualization of umbilical cord protruding from vaginal opening
labor dystocia
Dysfunctional labor –> a difficult or abnormal labor related to the five Ps
labor dystocia risk factors
- Maternal pelvis size (passage)
- Large fetus (passenger)
- Cephalopelvic disproportion: fetal head larger than maternal pelvis (passenger)
- Abnormal fetal presentation
- Ineffective contractions (powers)
- Ineffective maternal pushing d/t fatigue, fear (powers)
labor dystocia expected findings
- Lack of progress in dilation, effacement, or fetal descent
- Ineffective pushing
- Persistent occiput posterior presentation
- Hypotonic uterus: weak, inefficient, or absent contractions
- Hypertonic uterus: excessively frequent, strong intensity with inadequate uterine relaxation
labor dystocia nursing interventions
- Encourage maternal position changes
- Apply counter pressure using heel of hand to sacral area to alleviate discomfort
- Prepare for possible forceps, vacuum, or c-section delivery
- If hypertonic, administer analgesics
- If hypo, administer Pitocin to augment & strengthen uterine contractions
Uterine rupture
muscular wall of the uterus tears –> rare, life-threatening emergency
uterine rupture risk factors
- Uterine trauma r/t accident
–> Ex. car accident - Uterine trauma r/t prior c-sections
- Overdistension of uterus (large fetus, multifetal gestation)
- Hypertonic contractions
- Forceps-assisted birth
- Multigravida clients
