OB FINAL Flashcards
SMALL FOR GESTATIONAL AGE (SGA):
5.5lbs, <2500g, <10% on growth chart
baby may be preterm, term or post-term – based on weight not dates
What is the main problem small for gestational age babies face?
a decrease in placenta function in utero* and may be due to: o Asphyxia o Aspiration syndrome o Hypothermia o Hypoglycemia o Polycythemia o Meconium aspiration
Intrauterine Growth Retardation
• SGA PLUS additional complications of: o 1) Congenital malformations o 2) Intrauterine infections – syphilis o 3) Continued growth difficulties – anemia o 4) Cognitive difficulties
What is the main symptom for IUGR
small gestational age baby
LARGE FOR GESTATIONAL AGE (macrosomia)
baby that weighs >8.8lbs, >4000g, >90% on growth chart
What are some causes of IUGR
o Advanced diabetes
o High blood pressure or heart disease
o Infections such as rubella, cytomegalovirus, toxoplasmosis, and syphilis
o Kidney disease or lung disease
o Malnutrition or anemia
o Sickle cell anemia
o Smoking, drinking alcohol, or abusing drugs
What are some causes of large for gestational age baby
- Infant of a diabetic mother
- Multiparity
- Diabetes
- Erythroblastosis fetalis
- Cardiac etiology: transposition of the great vessels
What are complications of LGA
o Cephalopelvic disproportion – birth trauma d/t head not fitting in pelvis
o incidence of cesarean birth and induction of labor
o Hypoglycemia, polycythemia and hyperviscosity
• Jaundice d/t hyperbilirubinemia
Risk factors for LGA
o Maternal diabetes mellitus or glucose intolerance
o Multiparity
o Prior history of a macrosomic infant – hx of big baby more likely to have another
o Postdates gestation
o Maternal obesity
o Male fetus
o Genetics
What is the most common defect associated w diabetic mothers
cardiac anomalies
Characteristics of infant of diabetic mother
- LGA or SGA
- Ruddy in color
- Excessive adipose tissue
- Large umbilical cord and placenta
- Decreased total body water
- Excessive fetal growth from exposure to high levels of maternal glucose
- At risk infants – require close observation for first hours and days possibly.
- 4kg =8.8 lbs
Newborns of women with diabetes but WITHOUT vascular complications
Large for gestational age
newborns of women with diabetes and vascular disease
small for gestational age
Anemia of prematurity
Exaggerated response from hypoxic state in utero to hyperoxic state after birth
Normochromic, normocytic and hyporegenerative anemia
Low serum erythropoietin levels despite having low Hb levels
• Do not have ability to make new RBC
Will spontaneously resolve in 3 months
Anemia of prematurity where everything is premature
Intraventricular hemorrhage
• incidence at <30-weeks gestation
• Occurs because preemies cerebral vessels are so fragile
o Causes bleeding into the ventricles of the brain
o Must protect their head during transport b/c of jarring vessels
Complications of Meconium Aspiration syndrome
- Pneumothorax
- Pneumonia – d/t extra fluid that can then become infected
- Persistent Pulmonary Hypertension
- Bronchopulmonary Dysplasia
- Neurologic complications
- Possible Death
What is phase 1 of TTNB
grunting- to open the alveoli
What is phase 2 of TTNB
phase 2- tachypnea phase where RR is 100-120
Common Predictors of TTNB
C-section w/o labor –> baby isn’t getting squeezed
- Precipitous delivery
- Prolonged labor
- Male > female
- 2nd twin
Oxygen support
• Hood mixed air
• Heated flow cannula: oxygen that is humidified and warmed
• CPAP (continuous positive airway pressure): slight pressure reminds them to breathe and open up airways
• Ventilator w/ ET tube attached
• Oscillator: specialized machine that is more sophisticated means of O2 support
o 200 revolutions over the chest every minute
• ECMO (extracorporeal membrane oxygenation)
o Heart lung bypass
o Oxygenate blood for the babies
Baby version of heart-lung bypass
Treatment for respiratory disorders
• Oxygen support
• Continuous oximetry
• Chest PT – to break up secretions
• Keep temp, CS, fluids and electrolytes stable
• Monitor ABGs, CBC, blood cultures
• Prophylactic antibiotics if questionable CBC or mom Group B strep (+)
o Just give it!
• Surfactant if respiratory distress syndrome
• Chest tube if pneumothorax
Signs and symptoms of respiratory disorders
- Tachypnea (resp. rate > 60 bpm, up to 120 bpm with TTN)
- Grunting
- Retracting
- Nasal flaring
- Hypoxia causes cyanosis
- Transillumination of a pneumothorax will show light on the affected side
characteristics of neonatal abstinence syndrome
- High pitched cry
- Colic – early on and prolonged
- Increased muscle tone, tremors
- Poor sleep patterns
- Seizures
- Diarrhea
- Temperature instability
- Poor feeding
- Sneezing
- Often start after 24 or 48 hours – may be home
Ectopic pregnancy
gestation implanted outside uterus
–> pregnancy that develops outside of the uterus
• Sites: fallopian tube (98%), ovary (1%), cervix (1%), or abdomen (0.75-1%)
o Conception tends to occur in the outer third of the fallopian tube
o And then the fertilized and dividing egg will work its way through the tube to get to the uterus to implant
o Any issues to the fallopian tubes will remarkably potential for ectopic pregnancy in the tube (ex. PID, hx of sx)
risk factors for ectopic pregnancy
o PID & endometriosis
o Use of IUDs
o Tubal surgery
o Tubal tumors/congenital tubal anomalies
Accessory tubes, excessively long tubes
o History of:
-Previous ectopic pregnancy
-Abdominal or pelvic surgery
-Appendicitis/therapeutic abortion/infertility
signs and symptoms of ectopic pregnancy
1) abdominal pain-colicky, vague, cramping and can be localized to either the L or R
2) Amenorrhea
3) unilateral leg swelling
4) shoulder pain-referred pain
5) abnormal vaginal bleeding
Complete spontaneous abortion
when all products of conception are entirely expelled
Baby + placenta + membranes
Very few physical complications occur but emotional support is necessary
septic spontaneous abortion
products of pregnancy are retained in uterus and infection sets in
Immediate termination of pregnancy by method appropriate to duration of pregnancy is needed
Cervical C & S studies are done and broad-spectrum antibiotic therapy is started (for anaerobic & aerobic initially)
• Vaginal vault = aerobic
• Uterine cavity = anaerobic
missed spontaneous abortion
fetus dies but continues to be retained in the uterus for > 8 weeks
autolysis
after 4 weeks with an infant dead within the mother
The dead cells start to release enzymes that cause the breakdown of clotting factors and can lead to DIC in the mother
habitual abortion
woman is repeatedly aborting
Get into the second trimester and weight of pregnancy begins to be more than what the cervix can hold
Individuals will get to ~15-20wks gestation and cervix will begin to dilate to allow pregnancy to pass
What procedure is done in habitual abortion to close the cervix temporarily or permanently
A purse string suture called a Shirodkar (cerclage) or McDonald procedure may be done to close the cervix temporarily or permanently
• Can be done to help maintain the pregnancy through the vaginal vault
• May also be done through the abdominal cavity to the top of the cervix requires C-section birth
when do we deliver baby if placenta previa is diagnosed
by cesarean section @ 37 weeks if not before
major symptom of placenta previa
sudden onset of painless vaginal bleeding
predisposing factors for placenta abruptio
o Maternal hypertension
o Preeclampsia
o Folic acid deficiency – required for healthy placenta development
o Severe abdominal trauma
o Short umbilical cord- descending baby will create traction on the cord
o Malnutrition
o Sudden in uterine size
o Maternal age >35
o Rough or difficult external version manipulating uterus to rotate baby
o Cocaine use, especially crack
• Warrants very close observation or cesarean section
signs and symptoms of placenta abruptio
o Board-like, rigid abdomen
o Severe, relentless abdominal pain out of proportion to labor
level of discomfort is how to assess if pt having previa or abruptio
o Back pain
o Colicky, uncoordinated uterine contractions
o Or continuous tetanic contractions
o Bleeding
o Pain localized or generalized
o FHR shows periodic changes – late, variable, prolonged, sinusoidal
o Loss of variability
o Aggressive/exaggerated fetal movement
o Increasing fundal height – d/t uterus filling with blood
o Maternal shock
o May not show on ultrasound
Can only confirm if it is complete or central but cannot r/o if marginal
placenta abruptio
placenta detachment- it’s where it’s supposed to be but it starts to detach from the uterine wall
what is the # 1 cause for uterine rupture?
previous uterine surgery (C-section)
Risk factors for uterine rupture
o Previous uterine surgery (#1 cause) – C-section
o Trauma
o Uterine over distention
o Uterine abnormalities
o Placenta percreta: placenta has gone beyond its normal level of implantation
o Choriocarcinoma
Cephalopelvic disproportion
baby is too big to make it through the maternal pelvic or is in a position that makes it difficult to come through
maternal bony pelvis is often a factor
Signs and symptoms of cephalopelvic disproportion
o Arrest of dilation or descent
o Abnormal labor patterns
o Acute maternal discomfort – “bone on bone” pain
o Maternal exhaustion or fetal exhaustion
o Early fetal HR decelerations
Nursing interventions for cephalopelvic disproportion
o Reposition o Assess labor pattern o Assess fetal status o Keep provider appraised of progress or lack there of o Keep hydrated o Consider analgesia or anesthesia
Cord prolapse
umbilical cord escapes beyond the presenting part and becomes trapped between the presenting part and the bony pelvis
-occurs when the membranes rupture before the baby is engaged enough to cork off the pelvis
cord prolapse nursing care
o One person must do a continuous vaginal exam and hold the head up off of the cervix
o Put patient in trendelenberg or knee chest position
o Prepare for an immediate C-section
o IV bolus
o O2 via mask
o Prepare for resuscitation of the infant
How do we treat a cord prolapse
immediate cesarean section is warranted
Shoulder dystocia
head has come out, but the shoulders are too large and have gotten caught in anterior-posterior dimension of pelvis
Turtle sign
classic retreat of the head after it has delievered
o Head will recede back into vaginal vault
o Considered life threatening for the baby
Risk factors for shoulder dystocia- Maternal
Abnormal pelvic anatomy Gestational diabetes – baby big AND fat Post-dates pregnancy Previous shoulder dystocia Short stature in patient
Risk factors for shoulder dystocia- fetal
suspected macrosomia
Labor related risk factors for shoulder dystocia
Assisted vaginal delivery (forceps or vacuum)
Protracted active phase of first-stage labor
Protracted second-stage labor
What is the most common risk factor associated with shoulder dystocia
the use of extractor or forceps during delivery
shoulder dystocia maternal complications
Postpartum hemorrhage
Rectovaginal fistula – extensive lacerations that can be difficult to repair
Symphyseal separation or diathesis, with or without transient femoral neuropathy
• Anterior portion of pelvis where there is connective tissue b/w two halves of pelvis that becomes separated
Third- or fourth-degree episiotomy or laceration
Uterine rupture
fetal complications of shoulder dystocia
Brachial plexus palsy shearing of nerves that go over arms
Clavicle fracture
Fetal death
Fetal hypoxia, with or without permanent neurological damage
Fracture of the humerus
incomplete abortion
embryo of the fetus has passed out of the fetus but the placenta remains
threatened abortion
women experiences vaginal spotting or bleeding in early pregnancy
CERVIX NOT DILATED and placenta still attached to uterine wall
inevitable abortion
placenta has separate from the uterine wall, CERVIX HAS DILATED, bleeding has increased
CANNOT BE PREVENTED
preeclampsia triad
1) elevated BP >140/90
2) protenuria
3) generalized edema
risk factors for preeclampsia
maternal age >35 nulliparity diabetes chronic HTN hydratiform mole fetal hydrosis
HELPP syndrome
due to the vascular bed inability to maintain that 30-40% blood volume increase during pregnancy-MAIN MECHANISM IS VASOSPASM
- body begins to spasm and spasm which leads to microshearing
- as the RBC try to get through vessels that are broken due to vasospasm hemolysis occurs as they break down
- platelets try to adhere to all the microshearing which leads to a low platelet count
- this syndrome affects vascular organs primarily the liver which leads to elevated liver enzymes
management for preeclampsia
- bedrest w close monitoring and status
- we want to try to deliever asap but also want to prolong it for baby’s lung’s to mature more so we give BETAMETHASONE
what is the only true cure of preeclampsia
DELIVERY
signs and symptoms of preeclampsia
Signs and symptoms: o Edema
o Proteinuria
o increased BP
o Headaches – usually frontal and not relievable by Tylenol
§ R/t cerebral edema o Nosebleeds
o Nausea/vomiting
o Epigastric pain – often associated when liver starts to become affected
§ High correlation for progression from preeclampsia to eclampsia o Visual disturbances – stars, flashes of light, diplopia
o Hyperreflexia – CNS gets irritable
o Oliguria
what is the most critical assessment of the baby during preeclampsia
respiratory! lung maturity
Magnesium sulfide
given to prevent seizures BUT given cautiously bc it causes CNS depression and respiratory arrest so we want to monitor every 1 hour and do neuro checks
- falls are also a risk and they have trouble with physical activity
What is the therapeutic level of magnesium sulfide
5-8 mg
what are some complications of magnesium sulfide
-visual distortion or disturbances
-eyes cannot accomodate
-difficulty walking
FALLS
What other meds besides magnesium sulfide
Apresoline- if it’s a hypertensive crisis but it decreases placenta perfusion
What is the first line of treatment for preeclampsia
Labetolol
When do we give Methotrexate
for ectopic pregnancies where the fallopian tube is intact
Which complication has painless vaginal bleeding as the main symptom
placenta previa
What must we do for placenta previa
delievery by c-section @ or before 37 weeks NEVER VAGINAL DELIVERY
Why do we wait before 37 weeks to deliver baby via c-section if placenta previa occurs
because if we wait, the cervix will thin and may cause the placenta to break away and severe hemorrhage may occur
Vaginal exams w placenta previa
WE DON’T DO and we don’t do it especially if we don’t know where the placenta is
What are some predisposing factors for placenta previa
multiple pregnancy- multiple placenta implants that leave behind scarring
- previous placenta previa
- previous therapeutic abortion
placenta percepta
when the placenta goes beyond its normal level of implantation and implants on other organs
what is the single most common risk factor associated with shoulder dystocia?
-the use of a vacuum extractor or forceps during delivery
Shoulder dystocia prevention
weight gain within the normal range
induction of labor with larger infants
elective c-section
good control of diabetes in pregnancy
McRobert’s position
hyperflexion of the maternal hips bilaterally
-increases anterior posterior dimensions of outlet of pelvis to maybe help the infant come through
Absolute Contraindictations w Oral Contraceptives
1) Known or suspected pregnancies
2) Hx of thrombophlebitis or clotting disorders
3) If the patient is age 35 and is a smoker
4) Impaired liver function
5) breast or endometrial cancer
6) Factor 5 Leiden mutation
7) gallbladder disease
8) CV or CAD
9) Undiagnosed genital bleeding
10) Type II Hyperlipedemia
11) Cholestatic Jaundice
12) Hepatic adenomas, cancers or tumors
