Ob exam 2 - intra comps Flashcards
when is PROM considered prolonged
when membranes have been ruptured for greater than 18 hours
fetal & newborn risk of (P)PROM
-respiratory distress syndrome (esp pporm)
-sepsis
-malpresentation
-prolapse of the umbilical cord
-non reassuring FHR pattern
-compression of the umbilical cord
-premature birth
nursing care of clients with PPROM
-determine duration of rom
-assess GA
-observe for signs & symptoms of infection
-assess hydration status
-assess fetal status
-assess childbirth preparation & coping
-encourage resting on left side
-comfort measures
-education
what meds might you deliver to a pt w/ (P)PROM
maternal corticosteroid administration to enhance fetal lung maturity
betamethasone 12 mg IM x 2 doses; 12-24 hrs apart
when does preterm labor (PTL) or premature onset of labor (POL) occur
between 20-36 6/7 weeks
uterine contractions that correspond to PTL
4 within 20 mins or 8 in 1 hour
PTL S/s
-cervical change or dilation
-mild menstrual like cramps felt low in the abdomen
-pelvic pressure
-ROM
-low, dull backache
-increased vaginal discharge
strongest predictors of preterm birth
-positive fetal fibronectin results
-abnormal cervical length measurement (shortening, <25mm before term
-hx of PTL
-presence of infection
what to monitor w/ procardia (nifedipine)
BP bc we are not giving it for high BP but instead to relax the uterine muscles
do not give if SBP is <90
what are the tocolytic medications to stop contractions
-procardia (nifedipine)
-mag sulfate
-terbutaline (brethine)
-progesterone therapy
what to monitor w/ mag sulf
alertness, respirations, BP, reflexes & I/Os
what to monitor w/ terbutaline
length of administration -> acute use so only 2-3 days
do not give if HR is greater than 120 bc can cause tachy
side effects include flushes face, heart is racing and trembling
does mag sulf need to be in the primary or secondary line
primary only do enough for 2hr worth at a time for safety
what is a secondary benefit of mag sulf when being used for preterm labor
neuroprotective decreases the risk of intracranial hemorrhage & necrotizing enterocolitis in the babies
what is the steroid window
48 hours past 1st dose
what is the effect of steroids that promotes lung maturity
causes a release of surfactant
cervical insufficiency “incompetent cervix”
painless dilation of the cervix without contractions cervical defect, will see shortened cervical length <25 mm
dx could be made if pt has had pervious miscarriages w/o contractions
cervical insufficiency medical care
-serial cervical ultrasounds beginning between 16-24 wks GA
-bed rest
-progesterone supplementation
-abx (not entire pregnancy)
-education about signs of impending birth (lower back pain, pelvic pressure, changes in discharge & bleeding after cerclage) *call HCP**
cervical insufficiency surgical intervention
cerclage surgical closure of cervix using suture (stitching)
when would a cerclage be used
-cervical insufficiency
-prophylactic pregnancy w/ multiples
if a cerclage is placed, what should be monitored
bleeding
activity level -> pt does not need to be on strict bed rest at home, goal is for cervix to stabilize and light activity be performed
if a cerclage is placed, when is it removed
for delivery -> cut either before a vaginal birth or if C section then can be left in place and removed later
placenta previa
placental implantation in the lower uterine segment which causes placenta villi to be torn from the uterine wall leading to bright red painless bleeding
placenta previa causes
-high gravidity
-increasing age / advanced maternal age
-prior C section
-recent spontaneous or induced abortion
-cigarette smoking
-male fetus (more common)
placenta previa: complete
the placenta completely covers the cervix
placenta previa: partial
the placenta partially covers the cervix
placenta previa: marginal
placenta is near the cervix low lying
placenta previa: low lying
low lying
fairly close to cervix but not touching it
placenta previa nursing care
-no vaginal exams
-assess for bleeding (active = transfusion)
-VS & fetal monitoring & contractions
-anticipate unengaged fetal presenting part (transverse lie is common)
-obtain consent for C section ICE
-administer tocolytics as ordered
abruptio placentae
premature separation of a normally implanted placenta from the uterine wall
abruptio placentae: marginal
placenta separates at its edges
abruptio placentae: central
placenta separates centrally -> concealed bleeding hard abdomen where blood is pooling
abruptio placentae: complete
total separation -> massive vaginal bleeding
abruptio placentae: grade 1
48%
mild separation, slight vaginal bleedingV
abruptio placentae: grade 2
27%
partial abruption with moderate bleeding
abruptio placentae: grade 3
24%
complete separation with moderate to severe bleeding
abruptio placentae S/s
-sudden & stormy onset
-bleeding is external or concealed
-blood is dark
-severe & steady pain, uterus is tender
-uterine tone is firm
placenta previa S/s
-quiet & sneaky onset
-external bleeding
-blood is bright red
-pain only present at labor, uterus is not tender
-uterine tone is soft & relaxed
abruptio placentae care
-external monitoring of contractions
-external monitoring fetus
-monitor for c/o abdominal pain
-monitor for development of DIC (coag test)
-immediate priorities are maintaining maternal cardiovas status
-C section is usually safest delivery
maternal and fetal risks of multiple gestations
PLT
uterine dysfunction
abnormal fetal presentations
instrumental or C section
PP hemorrhage
higher mortality rate than for single fetus
decreased intrauterine growth rate
increased incidence of fetal anomalies
increase in cord accidents
increase in cerebral palsy
multiple gestations: discomforts
-SOB / dyspnea on exertion
-bachache
-round ligament pain
-heartburn
-pelvic or suprapubic pressure
-pedal edema
multiple gestation: comfort measures
-side lying position w/ lower body elevated
-pelvic rocking
-good posture
-good body mechanics
multiple gestation: care
-more frequent visits & educate on signs of fetal activity and preterm labor
-serial ultrasounds
-anesthesia & cross match blood ready @ delivery
-dual monitoring
-likely choose c section
multiple gestation: nutrition
-prenatals
-daily folic acid intake of 1mg
-wt gain of 40-45 lbs (24 lbs gain by wk 24)
amniotic fluid embolism
amniotic fluid leaks into the maternal circulation through a small tear in the amnion or chorion of the uterus during placental separation or through cervical tears under pressure -> embolism blocks vessels of the lungs rare but 80-90% mortality rate
amniotic fluid embolism S/s
chest pain, dyspnea, cyanosis, frothy sputum, tachycardia, hypotension, massive hemorrhage
amniotic fluid embolism: care
-stabilize cardiovascular & res system
-displace uterus to allow better blood flow
-infusion of whole blood
-placement of central venous pressure line to monitor fluid overload
-immediate birth may be needed
dysfunctional labor patterns: hypertonic contractions
tachysystole -> more than 5 contractions in a 10 min time period
dysfunctional labor patterns: hypotonic contractions
fewer than 2-3 contractions in 10 minutes (low intensity contractions)
tachysystole care
-assess contractions, vitals & FHR
-comfort measures
-change positions & back rubs
-turn off oxytocin
-tocolytic
-sedation / pain meds
care for hypotonic contractions
-assess contractions, vitals & FHR
-consider cephalopelvic disproportion
-rule out malpresentation
-maintain adequate hydration
-monitor for signs of infection
-stimulation of contractions (oxytocin)
post dates
pregnancy has gone beyond estimated date of birth
post term
pregnancy has gone beyond 42 completed weeks
care for post term pregnancies
-assess fetal well being
-daily fetal movement counts
-NST
-biophysical profile
-induction of labor
maternal risks for post term pregnancy
-perineal damage
-hemorrhage
-increased risk of C section
-anxiety
-emotional fatigue
-persistence of normal discomforts
fetal risks for post term pregnancy
-decreased perfusion
-oligohydramnios
-SGA
-macrosomia
-increase risk for meconium stain ed fluid
malposition (OP) techniques to move baby
-mother rotates side to side
-knee to chest position
-hands and knees position
-physician / CNM may manually rotate fetal head during labor
malpresentation
-shoulder presentation
-brow presentation
-face presentation
-breech
version
turning of the fetus in utero
version: external cephalic version
external manipulation of maternal abdomen to change fetus from breech to cephalic position
version: podalic version
internal
used in delivery of 2nd twin
if a version is about to happen, what must be done
-pt signs consent to procedure & c sections +
-IV is in place
-ultrasounds
-terbutaline if contracting
-fasting for 8hrs
-fetal monitoring (w/ reactive NST)
-rhogam if pt is Rh negative
reasons for a non reassuring fetal status
-variation in HR
-decreased fetal movement
-meconium stained amniotic fluid
-persistent late decels
-persistent severe variable decels
umbilical cord prolapse
umbilical cord precedes presenting fetal part and is compressed against maternal pelvis
how to prevent umbilical cord prolapse
bed rest if fetal presenting part high in pelvis & amniotic fluid is ruptured
if umbilical cord is felt during vaginal exam, what do you do
keep gloved fingers in vagina to relieve pressure & position for gravity to help relieve compression (knees to chest or trendelenburg) -> apply O2 mask & prepare for C section
is baby has true cephalopelvic disproportion (CPD), how should baby be delivered
can use vacuum or forceps assessed vaginal birth but best practice is C section
fetal risk for CPD
-increased risk of cord prolapse
-excessive molding of fetal head
-bruising
-nerve trauma
macrosomia
large fetus weighing more than 4000 grams
macrosomia risks
-dysfunctional labor
-uterine rupture
-perineal lacerations
-postpartum hemorrhage
-should dystocia
when do you want to ID macrosomia
before labor begins
if cleared for vaginal delivery with a macrosomia baby, what should the nurse be prepared for
-lack fetal descent should raise suspicion that infant is too large for vaginal birth
-unexpected shoulder dystocia, may be asked to assist w/ McRoberts maneuver or apply suprapubic pressure to aid shoulder delivery never perform fundal pressure
shoulder dystocia
shoulders entrapped behind suprapubic bone
dangers of shoulder dystocia
-brain damage from hypoxia
-brachia plexus damage
-umbilical cord occlusion
interventions of a shoulder dystocia
-lower head of bed
-McRoberts maneuver (rotate legs up and out to open pelvis)
-suprapubic pressure (downward w/ hand)
-document interventions & length of time of dystocia
retained placenta
retention of placenta beyond 30 mins after birth, bleeding can be excessive & may require manual removal of placenta -> possible transfusion after depending on blood loss
increased risk for infection
lacerations
-spontaneous tearing of the perineal area
-suspected when bright red vaginal bleeding persists despite well contracted uterus
- 1 to 4 degrees
- assist w. 4th stage labor repair and observe for bleeding and approximation during PP
placenta: accreate, increta / percreta
-abnormal adherence of the placenta to the uterine wall
-associated w/ maternal hemorrhage & failed placental separation after birth
high incidence of abdominal hysterectomy
placenta accreta
chorionic villi attach directly to the uterine myometrium
placenta increta
myometrium is invaded
placenta percreta
myometrium is penetrated
-sometimes attaches to nearby organs like the bowel or bladder
where does the placenta usually connect to
the endometrium
placenta accreate, increta / percreta care
-monitor for bleeding
-deliver before 38 wks
-type & cross for blood transfusion
-2/3 women have hysterectomy to prevent maternal hemorrhage
-repair organ damage
if a baby is lost in utero, what organization always has to be consulted
KODA for organ donation
