OB Exam 3, High Risk Care, FHR, Labor Flashcards
what does blood loss lead to in pregnancy and for the fetus?
In preg: hypovolemia, anemia, infection
Fetus: premature birth, hypoxemia, death
Placenta previa, s/sx
placenta overlying os
1/200 pregs
s/sx = painless vaginal bleeding, 3rd trim, hypovolemia, decreased FHR
risk factors for placenta previa
Risk factors = c/s prior, endometrial scarring, abortion with dilation/curretage (D/C), short preg interval, AMA, DM, HTN, smoking, multipara
contraindication for placenta previa?
do not do vaginal exam
Placental abruption, s/sx
placental detachment before delivery
s/sx = PAINFUL bleeding, fetal hypoxemia bad FHR (late decelerations), hypertonic uterine ctx, tenderness
Risk factors for placental abruption
Risks = previous abruption, HTN, AMA, c/s prior, cocaine, meth, smoking, multipara, PPROM, abd trauma, thrombophilia
Placenta accreta
Placenta accreta = partial/complete placental invasion of uterine wall
what can placenta accreta lead to?
PPH→ DIC → hysterectomy due to risk of bleeding out
Blood loss 3000-5000mL, may need blood transfusion
abortion
Spontaneous (miscarriage) = before 20 weeks
non viable fetus
risk factors for abortion
Risk factors = increased parity, AMA, diabetes, drug use, autoimmune disease, infection, genetics, uterine/cervical abnormalities
what to give for abortion
Give rhogam w/in 72 hr
what are surgical treatments for an abortion?
D/C = dilation & curettage D/E = dilation & evacuation
when can medical abortions take place? What 2 meds are given
Medical = 1st trimester only (13-14 weeks), later surgical
Mifepristone, misoprostol
what is the main reason medical abortions take place
cancer in mother or fetal abnormalities
ectopic pregnancy, s/sx
Egg growing outside uterus, 95% in fallopian tube, Non viable–can result in hemorrhage
s/sx = sudden, sharp pain, one sided, referred shoulder pain, light bleeding, hypovolemia
risks for ectopic preg
Risks = prior EP, fallopian tube abnorm, pelvic inflammatory disease PID, infertility, pelvic abdominal surgery, endometriosis, STIs, tubal surgery
what is surgery for ectopic preg
Surgery = laparoscopic surgery
meds for ectopic preg
Meds = methotrexate (chemotherapy agent) dissolves ectopic mass
Gestational trophoblastic disease
Hydatidiform mole/molar pregnancy = abnormal fertilized egg by multiple sperm, splits and makes neoplasms, rare, trophoblast cell growth
risks factors for GT disease
Risks = <20 >35, previous hx, anemia, uterine enlargement, u/s no fetus, VERY elevated hCG
management for GT disease
Management = D/C, chemo drug, monitor for increased cancer risk (from incr hCG)
what is the leading cause of pregnancy death?
Trauma = leading cause of preg death, hemorrhagic shock
how are outcomes of trauma in pregnancy defined?
Outcome defined by injury and when in preg–750-1000mL/min, 8-10min, FHR changes indicate maternal deterioration
to which side do you displace the uterus for CPR?
L side
what do drugs/alcohol do to fetus?
Low birth weight, develop disabilities, preterm birth, infant death, teratogenic, addiction
Growth defects, facial dysmorphia, CNS impair, behavior disorders, imparied intellectual
why does alcohol affect fetus?
Baby has inadequate liver, can’t metabolize alcohol
What do illicit drugs do to mother and fetus?
Drugs (cocaine, amphetamines, heroin, ecstasy)
- Cocaine causes vasoconstriction of placenta/uterus→ placental abruption or PTB
what do cigarettes do to fetus/mother?
2x LBW, IUGR, increased preterm birth, miscarriage, stillbirth, placenta previa or abruption
3x likely SIDS, asthma, infantile colic, obesity in childhood
what is the 2nd leading cause of infant death? 1st?
2nd leading cause of infant death
1st is congenital malform & chromosome issues
what are the ages of very premature, premature, and late premature?
Very Premature: Neonates born at <32 weeks
Premature: Neonates born 32-34 weeks
Late Premature: Neonates born 32-37 weeks
What are 2 survival predictors of a premie?
Survival predictors = period of gestation & birth weight
What are some issues of premie babies?
Respiratory Distress Syndrome (RDS) Retinopathy of Prematurity (ROP) Bronchopulmonary Dysplasia (BPD) Patent Ductus Arteriosus (PDA) Periventricular-intraventricular hemorrhage NEC: Necrotizing Enterocolitis
an infant with inadequate muscle tone has:
hypotonia
when do eyelids open in fetus?
Eyelids fused in premie, (open 26-30 weeks)
What are some characteristics of premies?
Hypotonia Skin – translucent, transparent, red Decreased subcutaneous fat Lanugo Eyelids fused (open 26-30 weeks) Pinna (thin, soft, flat) Undescended testes Tremors/Jittery Weak Cry Diminished/Absent Reflexes Immature Suck/Swallow --> Unable to tolerate oral feedings Apnea (20 sec +) Heart Murmur
how to help premie with thermoregulation
To help = keep head covered, polyethylene barriers for <29 weeks, warming mattress
how to measure tube for gavage premie feedings
Measure tube from mouth to ear, ear to lower end of sternum
OG/NG route, 5-8 French, gravity or pump
What is RDS? s/sx?
decreased alveoli surface tension→ atelectasis (moms given betamethasone IM if preterm labor is happening)
s/sx = Tachypnea, Retractions (Seesaw Breathing), Nasal Flaring
→ Hypoxemia, hypercarbia → metabolic/resp acidosis
what are complications of RDS for the baby?
Complications = PDA, pneumothorax, BPD, hypotension, pulm edema, hypoglycemia, ROP, intraventricular hemorrhage
What med is administered for RDS?
admin exogenous surfactant
What is a CPAP used for in baby? What is used if CPAP doesn’t work
for neonates who are at risk for RDS or who have RDS. It can be administered by nasal cannula, nasal mask, nasal prongs, endotracheal tube, or nasopharyngeal route.
mechanical ventilation used when CPAP is not effective
what is HFOV?
High frequency oscillatory ventilation
used when mechanical ventilation has proven unsuccessful.
Delivers small volumes of gas at a high rate (greater than 300 breaths/minute). Less traumatic on fragile lung tissue
what are benefits of surfactant therapy?
Benefits of Surfactant Therapy = Prophylactic therapy decreases the occurrence of RDS and mortality in preterm neonates.
- Decreased risk of pneumothorax
- Decreased risk of intraventricular hemorrhage
- Decreased risk of bronchopulmonary dysplasia
- Decreased risk of pulmonary interstitial emphysema
What is necrotizing enterocolitis? s/sx?
Necrotizing enterocolitis–neonate GI disease from decreased blood flow, typically 3-10 days after birth
s/sx = Abdominal Distension Feeding intolerance Emesis Residuals Bloody stools
what causes necrotizing enterocolitis?
- Altered blood flow regulation, particularly to the intestines.
- Impaired gastrointestinal host defense when faced with stress/injury to the intestinal tissue.
- Alterations in the inflammatory response
- formula feeding increases risk
what meds given for necrotizing enterocolitis? what labs done?
what other interventions?
Meds = Antibiotics, Analgesia, Antihypertensive
Labs/tests = abd XR to see gas/lack of, labs (blood culture, CBC, CRP, Stool culture, CMP, ABG)
Gastric decompression
Surgery
what needs to be stopped for enterocolitis?
no oral feedings
Retinopathy of prematurity (ROP)
incidence of ROP increases as gestational age and birth weight decrease
Occurs primarily in neonates <29 weeks with LBW (<1500g)
what is prevention for ROP?
Administer Oxygen (87-94% SPO2)
Oxygen blenders & Oxygen calibrating systems for exact oxygen concentration
Avoid bright lights – cover isolettes with blankets
Meconium aspiration syndrome, s/sx, management
Fetal asphyxia in utero, Post term (42 weeks)
Aspiration of meconium fluid → Respiratory failure; inhibits surfactant
Main finding = respiratory distress (flaring, grunting, chest retractions), mec stained amniotic fluid
Management = resp support
Hyperbilirubinemia
Increased bilirubin in the blood
difference between physiological hyperbili and pathological jaundice?
- Physiological
Occurs after 24 hours (anything before is considered pathological); peak 3 day, progressive head to lower extremities - Pathological Jaundice
Before 24 hours
Can lead to Kernicterus = Abnormal accumulation unconjugated bilirubin in the brain → neurological disorders
what are risk factors for pathological jaundice?
Risk factors = asian, native, greek mom; ABO incompatibility (M: O, NB: A or B), Rh incompatibility, low breastfeeding intake (pooping less, clearing bili out less); for newborn = delayed cord clamping, hypoxia, acidosis, hypothermia, hypoglycemia bruising, delayed feedings, cephalohematoma (pieces of broken RBC = bili), prematurity, sibling with hyperbili
how does phototherapy for hyperbili work? How much should total serum bili drop after 4-6 hr?
Phototherapy results in photoconverting bilirubin molecules to water-soluble isomers that can be excreted in the urine and stool without conjugation in the liver
Total serum bilirubin levels should drop 1 to 2 mg/dL within 4 to 6 hours after the initiation of phototherapy.
what are s/sx of neonate withdrawal
s/sx of neonate withdrawal = diarrhea, crying, high pitched, excessive sucking, fever, irritability, hyperreflexia, hypertonia, tremors, nasal congestion, poor feeding, emesis
what meds for opioid and alcohol withdrawal?
For Opioid: Methadone, morphine, clonidine, and phenobarbital
For Alcohol: Benzodiazepines
what substances pass through breastmilk?
Cocaine, Meth, Alcohol, Heroin, THC
what is intrapartum
Intrapartum = labor = onset of regular contractions → placenta expulsion
what is lightening?
Lightening = fetus descending into true pelvis
–urinary frequency at this stage from increased bladder pressure. In subsequent pregnancies, this may not occur until labor begins.
braxton hicks vs real
Real = Contractions regular and do not change with position, cervix effacement and dilation
Cervix dilates (enlargement, widening) 0-10cm
Cervix effaces (thinning, shortening) 0-100%
possible triggers of labor?
Not well known
Stretching uterine muscles, estrogen/progesterone changes, oxytocin release, prostaglandin release during contractions, fetal cortisol changes, placenta ages
5 Ps
Power Passageway Passenger Psyche Position
For Power, what are primary and secondary
Power =
primary = frequency & duration, contractions mild, moderate, strong
secondary = pushing effort, ferguson reflex)
what 2 hormones soften and increase elasticity of pelvic ligaments for passageway/cervix
Estrogen & relaxin
what is cephalopelvic disproportion
Cephalopelvic disproportion (CPD) = head shape does not fit proportionally in pelvis, C/S indicated
what is station?
what is engagement?
Station = -3-3+ head in relation to ischial spines
Engagement = station 0 is narrowest part fetus must pass through
what is Passenger?
Passenger = fetus and relationship to passageway
Attitude, lie, presentation (vertex/cephalic-95%, breech, shoulder/transverse), position (ROA & LOA most common), size
Presenting part = O
Woman’s pelvis side = L or R
Relationship of presenting part = A,P,T
what is the proper term for sunny side up baby?
Occiput posterior = OP, sunny side up, malpresentation, causes back pain
what is Psyche?
Psyche = response of woman
mental/physical prep, influenced by culture, expectations, support
what is Position?
Position = maternal posture and position
Freedom of movement, upright position (gravity) lithotomy position
what indicates true or false labor?
True labor = contractions @ regular intervals, increasing in frequency, intensity and duration
what is ROM? when should delivery happen after? what are tests to tell that ROM has occurred?
Rupture of membranes
- Deliver within 24 hr, loss of protective barrier
- How to tell = ferning (amnio fluid on slide), amnisure (rapid monoclonal assay detects PAMG 1 protein), nitrazine paper (turns blue with amnio fluid)
Assess for cord prolapse
what are the 4 stages of labor
Stage 1 = longest, latent (beginning to 6cm), active (6-8cm), transition (8-10cm) contractions 1-2 min, bloody show
Stage 2 = pushing (ferguson)/delivery, beings @ 10cm until baby born
Stage 3 = delivery to placenta, begins w baby birth
Stage 4 = immediate PP recovery, placental delivery–2 hr post
what is a Sterile vaginal exam
Cervical dilation, effacement, check position of cervix (posterior, mid, anterior), station, presentation of baby (cephalic, breech)
what is leopolds maneuver
Leopold’s maneuver = determine fetal position and size
1- The first maneuver is to determine what part of the fetus is located in the fundus of the uterus
2 - The second maneuver is to determine location of the fetal back
3 - The third maneuver is to determine the presenting part
4 - The fourth maneuver is to determine the location of the cephalic prominence
what pain meds are used in labor? Other treatments?
Analgesia = IV fentanyl, dilaudid, stradol, nitrous oxide
Anesthesia = regional pudendal (pelvic block), regional epidural, regional spinal, regional general, local anesthesia
Relaxation, breathing, cutaneous stim, counter pressure, thermal stimulation, hydrotherapy, mental stim, support
Complementary = aromatherapy, massage, birthing ball, hydrotherapy, music
epidural anesthesia site of admin and infusion type
Regional, continuous infusion
4-5 vertebrae
what are s/sx of epidural intravascular injection (bad)?
Maternal bradycardia, hypertension, tinnitus, metallic taste
what are post delivery priorities
Assess uterus position, tone, location
Lochia color, amount, clots
Vitals Q 15 min
Ice pack to perineum
Monitor for bladder distension
Assess for return of motor function
Promote skin/skin
what is the EFM?
Electronic Fetal Monitoring (EFM) = EFM is a technique for fetal assessment based on the fact that the FHR reflects fetal oxygenation
- detects FHR baseline, variability, accelerations, decelerations
what are the goals of FHR monitoring?
- Interpret and Assess Fetal Oxygenation
- Prevent Significant Fetal Acidemia
- Support maternal coping and labor progress
- Maximize uterine blood flow
- Maximize umbilical blood flow
- Maximize oxygenation
- Maintain appropriate uterine activity
what does a toco transducer monitor vs an u/s trandsducer?
Toco transducer = uterine contractions
Ultrasound transducer = assesses FHR
what are internal devices to assess FHR
Fetal scalp electrode = assess FHR
Intrauterine pressure catheter = UCs and IUPC (measures strength of contraction in mmHg)
what does the baseline FHR be?
Baseline FHR 110-160
- Tachycardia >160
- Bradycardia <100
what causes FHR tachycardia vs bradycardia?
Tachycardia >160
- Maternal Fever/Infection
- Chorioamnionitis
- Dehydration
- Medications: Ephedrine, Terbutaline
- Drugs: Cocaine
Bradycardia <100
- Maternal Position (Supine)
- Hypotension
- Uterine Rupture
- Placental Abruption
- Medications: Anesthetics
what are the types of FHR variability?
Fluctuations in the baseline FHR – irregularity in amplitude & frequency
- Absent: Amplitude range is undetectable
- Minimal: Amplitude range is <=5 bpm
- Moderate: Amplitude 6-25 bpm
- Marked: Amplitude >25 bpm
what are accelerations in FHR?
Accelerations = abrupt increase in FHR above the baseline
Peak (15x15): >=15 bpm for >=15 seconds
<32 weeks (10x10)
what are FHR decelerations types?
Nadir = Lowest point of a FHR Deceleration
Periodic = Changes in baseline of FHR that occur in relation to Contractions
Episodic = Changes in baseline of FHR that occur independent of Contractions
what are prolonged, early, variable, late for FHR decrease from baseline?
Prolonged = abrupt or gradual decrease >15bpm lasts 2-10min
Early = gradual decrease from baseline to nadir >30sec, periodic
Variable = abrupt decrease to nadir <30sec, periodic, episodic, U W V shape
Late = gradual decrease to nadir >30sec, always periodic, delayed from UC
what are causes of FHR decelerations? VEAL CHOP
VEAL CHOP = Variable -- Cord compression Early -- Head compression Accelerations -- Ok Late -- Placenta perfusion
what are intrauterine resuscitation interventions
- Change maternal position → oxygenation
- IVF bolus
- decrease/d/c oxytocin
- Administer O2 10L LNRB
how to treat tachysystole FHR
To treat = maternal position change, IVF bolus, ½ or d/c oxytocin, administer tocolytic (terbutaline)
what are the 4 causes of dystocia (difficult birth)?
- Hypotonic Uterine Dysfunction = Pressure of uterine contraction is not strong enough to dilate/efface cervix
- Hypertonic Uterine Dysfunction = Frequent, painful but ineffective in dilation/effacement
- Failure to Progress (First Stage Arrest) = Failure to continue dilation with confirmed adequate uterine contractions (IUPC)
- Failure to Descend (Second Stage Arrest) = No descent/rotatio or cessation of descent; 4 hs for nulliparous women with an epidural
What are causes for induction of labor (IOL)?
- Deliberate stimulation of uterine contractions before onset of spontaneous labor
- Bishop Score of >8 for nulliparous women
- Vertex presentation
- Informed Consent
- Elective inductions–no medical indication > = 39 weeks
- Medical Inductions: Fetal demise Gestational Hypertension Pre-Eclampsia PROM (34 weeks) Post-Term Pregnancy AMA (39 weeks) GDM (39 weeks) IUGR
what med is given for induction of labor? contraindications?
Oxytocin (Pitocin) – Most common agent
- 5 mU/min and increasing the dose by 1 to 2 mU/min every 30 to 60 minutes until adequate labor progress is achieved (effacement & dilation)
- Titration Infusion (IV Pump): mu/min
- contraindications: placenta previa, uterine surgery, non vertex position
GOAL = stimulate labor, UCs every 2-3 min
what are risks of IOL?
Risks of IOL = Failure, uterine tachysystole fetal intolerance
what is cervical ripening?
what is cervical status?
Cervical Ripening = process of physical softening, thinning, dilation of cervix
Cervical status = most important predictor of successful IOL
For IOL, a bishop score of less than what is unfavorable?
Bishop score of <6 = unfavorable
what medications used for IOL for cervical ripening? Contraindication?
Prostaglandins
Cytotec, Cervidil
Contraindication = previous uterine surgery
what is mechanical dilation for IOL?
- Pressure applied via balloon to lower segment of uterus and cervix
- Balloon Catheter – “Foley Bulb”
- Filled with saline: 30-50mL
- Induces cervical ripening and dilation, causes prostaglandin release
what is amniotomy? what is contraindication?
Artificial Rupture of Membranes (AROM)
- to induce/augment labor
Contraindication = fetal head not yet engaged (impacts fetal station)
what is labor augmentation?
- When spontaneous uterine contractions fail to produce progressive cervical change or fetal descent (labor dystocia)
- GOAL = Strengthen and regulate UC’s, shorten length of labor
- AROM (Amniotomy) or Pitocin Infusion
- Contraindication = previous uterine surgery
Chorioamnionitis, s/sx?
Intra-amniotic infection
- s/sx = Maternal Fever (Oral Temp >102F) Maternal and/or Fetal Tachycardia Elevated WBC Uterine Tenderness Purulent discharge
risk factors for Chorioamnionitis
Prolonged ROM Multiple SVE Internal monitors Meconium Stained Amniotic Fluid GBS, STIs
cord prolapse, risk factors
Prolapsed cord or cord prolapse (0.1-0.6%) = when cord comes out before head
- leads to fetal hypoxia
Risk Factors
- Malpresentation (Breech)
- ROM before engagement (higher station)
nursing actions for cord prolapse
Elevation of presenting part--hands/knees positioning, or physically push finger against presenting part Notify provider Education to pt/significant other O2 10L NRB Mask IV Fluid bolus Knee-Chest Position D/C Oxytocin – administer tocolytic
what is operative vaginal delivery with Vacuum assisted delivery? risks and 3 pop off rule
Vacuum Assisted Delivery (3%) Indications
- Shorten 2nd stage of labor
- Maternal exhaustion, fetal compromise
- Prolonged 2nd stage
- Maternal cardiac disease
- Risks – same as forceps = Greater incidence of cephalohematoma
- 3 pop-off rule = if suction pops off, stop after 3x
what are maternal and fetal risks of forceps assisted delivery?
Maternal risks
- Vaginal/Cervical lacerations
- Hemorrhage
- Hematoma
Fetal risks
- Cephalohematoma
- Skin lacerations
- Nerve injuries
- Skull fractures
- Intracranial hemorrhage
difference between unscheduled 3 types of c/s birth
- Planned – Scheduled
- Unscheduled – Unplanned
- Non-urgent
- Urgent–asap
- Emergent–general anesthesia used, problems like cord prolapse, rupture of uterus etc
c/s pre op tasks of RN
PRE OP
FHR monitoring Pre-Op Checklist Initiate IV Informed Consent Incision prep shave, chlorhexidine wipes Administer medications Antibiotics, Bicitra, IVF
c/s intra op tasks of RN
INTRA OP
Positioning for Spinal FHR Doppler Grounding Pad/Suction Insert Foley Positioning for Surgery (hip tilt) Leg strap Skin prep – sterile Instrument/Needle/Sponge Counts Education/Support
c/s post op tasks of RN
POST OP
PACU – 1 hour minimum 2 hours immediate post-op (1:1) Pain Control Initiate skin-skin, breastfeeding NB assessments/meds VS/motor/strength Q 15 Min
What is VBAC
VBAC: Vaginal Birth After Cesarean
what is TOLAC
TOLAC: Trial of Labor After Cesarean (called this until after vaginal birth has been completed, when previous birth was c/s)
what are benefits of TOLAC
shorter recovery time and overall lower morbidity and mortality, less blood loss, fewer infections, fewer thromboembolic problems
what kind of labor is preferred?
Spontaneous preferred
IOL – no cytotec, limited Pitocin
contraindications for TOLAC
Classical, T, or unknown uterine incision Previous uterine rupture Pelvic abnormalities (CPD) Placenta Previa Inability to perform Emergency C/S
shoulder dystocia, what is 1st sign?
Obstetric Emergency (0.2-3%) Difficulty with delivery of the shoulders 1st sign – retraction of fetal head (turtle sign)
what are neonate complications from shoulder dystocia?
Brachial plexus injuries
Clavicle fracture
Neurological injury (r/t asphyxia)
Death
what are maternal complications of shoulder dystocia?
Maternal complications = Perineal laceration (4th degree), infection, bladder injury, PPH
what are risk factors for shoulder dystocia?
Fetal Macrosomia Maternal Diabetes Hx Shoulder Dystocia Prolonged 2nd stage Excessive weight gain
what is management for shoulder dystocia?
McRoberts Maneuver Suprapubic Pressure Woods corkscrew maneuver (provider) Document series of interventions & time intervals Prepare for neonatal resuscitation
what is uterine rupture? s/sx? what kind of delivery needed?*
Partial/complete tear in uterine muscle
Rare Obstetric Emergency (0.07%)
Most common w/ VBAC
- s/sx:
- Tearing sensation, burning/stabbing
- Internal hemorrhage → Maternal hypovolemia (shock: hypotension, tachypnea, tachycardia, and pallor)
- Fetal compromise = Uteroplacental insufficiency
emergency C/S needed
