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N352: Practice of Nursing I > OB Module 4: Complications of Pregnancy > Flashcards

OB Module 4: Complications of Pregnancy Flashcards

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1
Q

OLDCART

A

Acronym for assessing symptoms or status changes in terms of:

Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments Tried

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2
Q

During a crisis situation what things should be done

A

assess VS

assess pulse O2 and symptoms of oxygenation

assess mental status

assess tissue perfusion

assess fetal status

assess bleeding assessing for DIC

assess urine output (consider a Foley catheter)

labwork and testing

spread the liability

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3
Q

What does Spread the Liability mean

A

keep provider and supervisors informed of any status changes - spread the liability around

report less fluff and more sufficient data via OLDCART

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4
Q

What is a big indicator of the status of a mother

A

Fetal status as there would be decreased blood to the placenta

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5
Q

How often should crisis situation assessments be done if the issue is acute

A

repeat assessments at appropriate intervals

with acute it may be every 5 minutes

it could also be every 15 minutes or every hour

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6
Q

During a crisis, keep the provider informed of …

A

status changes

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7
Q

During a crisis, the patient and family may be frightened and need information and support, but do not…

A

offer false reassurance (no worrying is inappropriate)

*also do not offer information a nurse should/can not deliver like a diagnosis

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8
Q

Since a lot occurs in a short interval or even simultaneously during an emergency crisis, what may be useful to do?

A

Assign a scribe to note when everything is done for everything so that a complete record can be made

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9
Q

Palpable Blood Pressure

A

in an emergency situation when the BP drops significantly you will only be able to hear the systolic BP with diastolic going all the way to zero (ex: 60/0).

This is why we may use VS machines for repeated assessments but know their baseline

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10
Q

During a crisis you will probably need __ __ until the patient is stabilized

A

additional personnel

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11
Q

What should be removed from the room during a crisis?

A

Any non essential personnel - including egos that hinder communication

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12
Q

What is essential to working in a crisis

A

effective communication and teamwork

everyone in the room must be working toward achieving the patients best possible outcome

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13
Q

About how many women die daily, globally, from complications of childbirth?

A

880 Women

500 of which are in western, central, and sub Sahara Africa and 200+ in Asia

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14
Q

What is the Maternal Mortality Rate (MMR) in Europe and the US?

A

Europe - 1 in 11,900

US - 1 in 5500 (it has increased the last few years)

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15
Q

What would make most MMR deaths preventable

A

if attended by a trained and equipped provider, MD, or midwife

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16
Q

___ ___ countries have significantly higher mortality rates (1 in 45 births)

A

low income

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17
Q

What is the leading cause of maternal death?

A

Hemorrhage (27%)

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18
Q

What are some causes of maternal death?

A

Hemorrhage - 27%

HTN - 14%

Sepsis - 11%

Abortion

Embolism

Other Direct Medical Conditions Worsened by Pregnancy

Indirect Causes (28%) like Trauma, Suicide, Drug Overdose

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19
Q

Domestic violence increases __% with pregnancy

A

20%

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20
Q

Complications of the First Trimester that can Occur

A

Ectopic Pregnancy

Miscarriage

Hydatidform Mole Pregnancy

Hyperemisis gravidarum

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21
Q

Complications of the Second and Third Trimesters that can Occur

A

HTN Disorders of Pregnancy

Diabetes in Pregnancy

Preterm Labor

Hemorrhagic Disorders of Pregnancy

Hyperemisis gravidarum

Vasa previa

Uterine Rupture

Lacerations

PE

Cephalo pelvic disproportion

Cord Prolapse

Fetal Distress

Shoulder Dystocia

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22
Q

Ectopic Pregnancy

A

A gestation/pregnancy that is developing outside the uterus

still uncommon to see

“Tubal Pregnancy” is another name

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23
Q

Where does conception usually occur and then where does it move to implant usually?

A

Conception occurs in the outer 1/3 of the fallopian tubes

It will then divide and grow while working its way through the tube via cilia to get to the uterus to implant

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24
Q

What can increase the chance of ectopic pregnancy

A

anything that damaged the tubes like a surgical history or pelvic inflammatory disease

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25
Q

Where are some sites that ectopic pregnancies may implant

A

fallopian tubes (98%)

ovary (1%)

cervix (1%)

abdomen (0.75-1%)

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26
Q

What age group tends to have the highest incidence of ectopic pregnancies

A

Women 20-29 yo

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27
Q

What is the rate of ectopic pregnancy in the US

A

2% of all US pregnancies

rates are higher for nonwhite women and increase with age in both white and nonwhite women

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28
Q

What has happened to the incidence of ectopic pregnancy since 1970?

A

It has TRIPLED since 1970 d/t PID, STD, and IUD use increases

Most occurred pre 2000 but it is still high today

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29
Q

Ectopic pregnancy is responsible for __% of the maternal mortality in the US

A

10% (D/t hemorrhage bleeding)

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30
Q

What is the most common cause of maternal mortality before 20 weeks gestation

A

ectopic pregnancy

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31
Q

What is the rate of another ectopic pregnancy occurring following an ectopic pregnancy and why?

A

25%

This is because whatever was wrong the first time probably is unresolved and can cause it to happen again

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32
Q

What is the most common ectopic pregnancy implantation site

A

fallopian tubes (98%)

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33
Q

Risk Factors for an Ectopic Pregnancy

A

PID and Endometriosis

Use of IUDs

Tubal Surgery

Tubal Tumor and Congenital Tubal Anomalies (Accessory tubes, excessively long tubes)

History of previous ectopic pregnancies, abdominal or pelvic surgery, ruptured appendicitis, therapeutic abortion, or infertility

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34
Q

S/S of Ectopic Pregnancy

A

Abdominal Pain

Amenorrhea

Abnormal Vaginal Bleeding

Swelling in 1 Leg

Shoulder Pain

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35
Q

Are the s/s of Ectopic pregnancy bilateral or generalized?

A

Can Be Either

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36
Q

What is the abdominal pain like in ectopic pregnancies

A

vague, colicky, or cramping and can be localized to the L or R pelvic area or may be bilateral

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37
Q

Why does Amenorrhea occur in ectopic pregnancies

A

It is still a pregnancy so there is still a corpus luteum suppressing ovulation

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38
Q

Shoulder pain during an ectopic pregnancy is a ___ pain that is also seen in tubal ligation for sterilization as well

A

Referred

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39
Q

What may be done for an ectopic pregnancy if the fallopian tube is intact?

A

treatment may be surgical or via methotrexate (a chemo agent) to dissolve the pregnancy while maintaining tube patency and potential fertility

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40
Q

Methotrexate

A

a chemotherapy agent sometimes given to ectopic pregnancies with intact fallopian tubes to dissolve the pregnancy while maintaining tube patency and potential fertility

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41
Q

What may be done for an ectopic pregnancy if the fallopian tube ruptures

A

Surgery is REQUIRED if the tube ruptures

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42
Q

S/S of a Ruptured Fallopian Tube

A

Abdominal Pain

N/V

Diarrhea

Unilateral Palpable Pelvic Mas (Hematoma)

Dizziness

Hypovolemic Shock

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43
Q

Types of Spontaneous Abortions (Miscarriage)

A

early

Late

Habitual Abortion

Chromosomal Aberrations Related Miscarriage

Threatened Abortion

Inevitable Abortion

Incomplete Abortion

Complete Abortion

Septic Abortion

Missed

Autolysis

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44
Q

Early Spon Abortion

A

miscarriage before 12 weeks of gestations

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45
Q

Late Spon Abortion

A

miscarriage between 12-20 weeks of gestation

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46
Q

Habitual Abortion

A

When a woman has 3 or more consecutive spontaneous abortions

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47
Q

What is estimated to make up/cause 50% of all spontaneous abortions

A

Chromosomal Aberrations with autosomal trisomy being most common

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48
Q

Threatened Abortions

A

The cervix is NOT dilated and the placenta is still attached to the uterine wall, but SOME bleeding occurs - so it may be vessel bleeding rather than from the cervix

It is suggested if a woman has vaginal spotting or bleeding early in pregnancy

occurs in about 20% of all diagnosed pregnancies - half abort

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49
Q

Inevitable Abortion

A

The placenta has separated from the uterine wall, the cervix has dilated and bleeding has increased more than in a threatened abortion

Occurs when the cervix has begun to dilate, uterine contractions are painful and bleeding increases

The membranes rupture as the process proceeds

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50
Q

Is a threatened abortion preventable

A

potentially

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51
Q

Is an inevitable abortion preventable

A

no (we cannot stop all of the changes that occurred)

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52
Q

What is the main different between a threatened and inevitable abortion?

A

the cervix began to dilate

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53
Q

Is the rupture in an inevitable abortion large?

A

no the pregnancy was not very large to begin with

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54
Q

Incomplete Abortion

A

The embryo or fetus has passed out of the uterus, BUT the placenta remains

Cervical dilation results in partial expulsion of the products of conception, with some of the products retained in the uterus

Excessive vaginal bleeding occurs and risk of infection increases

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55
Q

What has to be done with an incomplete abortion

A

we have to go in and evacuate the rest of the contents via dilation and curettage - dilation of the cervix and scraping of the uterine cavity to free the placenta

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56
Q

Complete Spon Abortion

A

all products of conception are entirely expelled (placenta, baby, membranes)

very few physical complications occur but emotional support is necessary as the mom will be devastated

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57
Q

Septic Spon Abortion

A

immediate termination of pregnancy by method appropriate to duration of pregnancy needed - the infection is caused by products of conception being retained and causing infection

cervical culture and sensitivity studies are done and broad spectrum antibiotic therapy is started

treatment for septic shock is done if needed

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58
Q

Why is it so easy for sepsis to occur in a pregnant woman?

A

because the area is very vascularized so it can infect very easily

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59
Q

Why do we start the mom of a septic abortion on both aerobic and anaerobic broad spectrum antibiotics to begin?

A

The vaginal vault is aerobic but the uterine cavity is anaerobic and since we do not know what the infective agent is until CS comes back we can do this

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60
Q

Missed Abortion

A

the fetus dies but continues to be retained in the uterus 8 weeks or longer

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61
Q

Autolysis Abortion

A

step 4 weeks post missed abortion where the infant dead cells will start to breakdown and release enzymes that breakdown clotting factors and lead to DIC in the mom

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62
Q

Why may habitual abortions happen?

A

when a mom gets to the 2nd trimester and the weight of the pregnancy is actually more than the cevix can hold

at 15-20 weeks the cervix will try to dilate and let the pregnancy past it

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63
Q

What is done to try and prevent habitual abortions

A

A purse string suture (Cerclage, Shirodkar, McDonald Procedure) to maintain the pregnancy

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64
Q

McDonald Procedure (Cerclage/Shirodkar)

A

a thick purse string sized suture the size of a shoelace is made around the cervix to pull it closed or near closed and a know is made to cut later through the vaginal vault

when near delivery we cut the know to allow a normal vaginal delivery

can prevent habitual abortions

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65
Q

What is a problem with the McDonald procedure in regard to location

A

should we have to abdominally rather than vaginally to the top of the cervix to make the suture (if for some reason the cervix was damaged for some reason before) then a C Section will be required and the suture is permanent to maintain all future pregnancies and is not removed or cut

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66
Q

Hydatidiform Mole (Molar Pregnancy)

A

Disorder of the placenta where it does not appropriately form or forms a malformation early on in the pregnancy

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67
Q

What does a molar pregnancy being a trophoblastic disease mean

A

there is a developmental error of placenta causing the development of cyst like clear vesicles resembling a bunch of grapes to occur

highly vascular and looks like brain tissue

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68
Q

2 Types of molar Pregnancy

A

Complete

Partial

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69
Q

Complete Molar Pregnancy

A

all vesicles and no fetus

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70
Q

Partial Molar Pregnancy

A

has vesicles and a rarely viable fetus

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71
Q

What happens to most fetuses during a molar pregnancy ?

A

most fetus are not well nourished and the size of the uterus can get so big so rapid due to the vesicle growth that pregnancy cannot make it to term due to mass and uterine intolerance

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72
Q

Is molar pregnancy carcinogenic?

A

Usually it is benign but it can be a choriocarcinoma - a rapid growing cancer form with a high rate of cure

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73
Q

What is the incidence of molar pregnancies like?

A

1 in 1000 pregnancies

Incidence increases x10 after age 45

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74
Q

S/S of Molar Pregnancy

A

apparently nL first trimester

uterine bleeding

possible anemia

SOB

uterine size often exceeds fundal heights expected for gestation

fetal activity and FHR tones absent if nonviable fetus

hyperemesis gravidarum common

preeclampsia developing before 24 weeks

very high levels of serum hCG levels

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75
Q

What is the most outstanding sign of molar pregnancy

A

uterine bleeding

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76
Q

Why can SOB occur in molar pregnancy

A

it relates to metastasis if it has become cancerous as the primary site for spread is to the lungs

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77
Q

Hyperemesis

A

hyperactive morning sickness from increased hormones from the placenta

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78
Q

What confirms a Hyatidiform pregnancy

A

ultrasound

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79
Q

What needs to be done once ultrasound confirms a molar pregnancy

A

IMMEDIATE EVACUATION of pregnancy and all products

Potential chemotherapy in follow up if the molar pregnancy was malignant

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80
Q

Why do we monitor serum hCG levels with an evacuated molar pregnancy

A

because if this number is higher than normal that means there are still placental products inside

they end up being checked every month for half a year and then every other month for the last 6 months

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81
Q

Why should pregnancy be avoided for a year following an evacuated molar pregnancy

A

to prevent hormonal tissue that survived from staying and encouraging to undergo metastasis in the next pregnancy

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82
Q

What is taken and compared to its pre-evacuation results?

A

baseline X ray of the lungs compared to pre evacuation x ray

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83
Q

What is a common symptoms of complete molar pregnancy

A

vaginal bleeding, often brownish (a characteristic “prune juice” appearance indicating older bleeding) but sometimes is red.

The hydropic vessels are passed and can come out of the uterus

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84
Q

How may a hydatidiform mole and a normal placenta compare when looking at them

A

It should look beefy on the fetal side normally but the molar pregnancy is more shiny, vesicle filled, and looks like liver tissue

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85
Q

Hyperemesis gravidarum

A

increased or prolonged N/V in pregnancy potential affecting the mother and fetus

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86
Q

How does hyperemesis compare to regular morning sickness

A

morning sickness usually lasts about 14 weeks and occurs in the morning

hyperemesis can be all day long and prolonged lasting the entire pregnancy

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87
Q

Etiology of Hyperemesis gravidarum

A

likely caused by a combination of factors:

high or rapidly increasing levels of hCG or estrogens

evidence of transient hyperthyroidism has also been noted

psychological and social factors like family conflict may also play a role (but not in all cases necessarily)

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88
Q

Treatment for Hyperemesis gravidarum

A

IV therapy to treat dehydration - adequacy of hydration addressed by measuring UO

Small frequent feedings as tolerated - high calorie tube feedings are optional (TPN)

Antiemetics often help, Zofran OD, Reglan, Phenergan, Scopolamine

Acupressure has been used successfully

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89
Q

Issue with the antiemetic zofran?

A

expensive (but can go under the tongue)

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90
Q

Benefit of the antiemetic Regland

A

they can go into the IV bag overnight

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91
Q

What form is the antiemetic Phenergan in

A

a suppository

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92
Q

What form is the antiemetic Scopolamine available in

A

patches

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93
Q

Hypertensive Disorders of Pregnancy

A

Any HTN disorder in pregnancy that causes:

BP >140/90

A rise of 30 mmHg in the systolic BP over a woman’s baseline BP (ex; if was 90/60 then 120 or 130 is concerning)

MABP >105 mmHg

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94
Q

Pregnancy induced HTN (PIH)

A

Hypertension without protein urea that develops AFTER 20 weeks of pregnancy or within the first 24 hours after delivery

Occurs since blood volume for mom increases 30-50% and if we dump this much with normal vascular tone and it does not relax then it will gradually increase out to 20 weeks or after delivery

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95
Q

PIH can compound with…

A

normal preexisting HTN

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96
Q

PIH superimposed on previous HTN …

A

results in a worsening of the woman’s HTN

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97
Q

Preeclampsia

A

At least 2 out of 3 of the classic triad:

  1. Elevated BP (vasospasm)
  2. Protein urea (damage to the vessels from spas causing protein leaks)
  3. Edema (allowing third spacing from damage - generalized not dependent)
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98
Q

What usually is causing preeclampsia, eclampsia, and HELLP syndrome

A

remarkable levels of vasospasms

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99
Q

When do Preeclampsia, Eclampsia, and HELLP syndrome begin

A

after 24 weeks usually

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100
Q

Eclampsia

A

HTN disorder when preeclampsia progresses to develop seizures that are life threatening, long, and recurring potentially

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101
Q

HELLP Syndrome

A

Worst case of the Preclampsia, Eclampsia, HELLP triad.

It involves:

Hemolysis
Elevated Liver enzymes
Low Platelets

this often goes along with increased BP

can be life threatening

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102
Q

HELLP syndrome may potentially be …

A

a most advanced form of preeclampsia or not

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103
Q

HELLP: Hemolysis

A

severe vasospasm and when blood goes through the small vessels the blood is damaged and bumps around

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104
Q

HELLP: Elevated Liver enzymes

A

very vascular organ so the vasospasm occurring can lead to rupture or damage

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105
Q

HELLP: Low Platelets

A

where things shear and damage the platelets attempt to help but eventually are used up trying to do micro repairs and the circulating volume of them drops

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106
Q

Why is HELLP Syndrome life threatening

A

you lose the ability to clot and can head into delivery and bleed out!

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107
Q

Associated Factors with Maternal Hypertensive Disorders of Pregnancy

A

Fetal Hydrops (autolysis disorders like rH issues)

Maternal Age >35

Nulliparity (most likely to occur in 1st pregnancy)

History of preeclampsia in self or family

Seen in women who change partners and have a baby with a new partner

Hydatidiform Mole

Multiple Pregnancy (large placenta more hormone)

Chronic HTN

Diabetes

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108
Q

S/S of Preeclampsia

A

Edema

Proteinuria

Elevated BP

HA

Nosebleeds/Epistaxis (coagulation factors depleted)

N/V

epigastric Pain

visual disturbances

hyperreflexia (CNS irritability from cerebral edema)

oliguria (from kidney infection)

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109
Q

What does the HA in preeclampsia come from and how does it feel

A

it comes from cerebral edema

it is a dull frontal HA unrelieved by tylenol

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110
Q

What is the epigastric pain associated with preeclampsia?

A

Associated when the liver is beginning to be affected

there is a high correlation with this symptom for movement to eclampsia

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111
Q

What is the mechanism of damage in preeclampsia and HELLP syndrome? what can it damage

A

SEVERE VASOSPASM

It can damage the placenta, liver, kidneys, and brain

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112
Q

What does HELLP stand for

A

Hemolysis

Elevated Liver enzymes

Low Platelets

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113
Q

Critical situation of Preeclampsia or HELLP requires

A

close monitoring often in the ICU unit

114
Q

How to manage hypertensive states in pregnancy

A

bedrest in restful environment (does not cause remarkable change)

close monitoring of status since baby and mom are at risk

deliver if necessary

MgSO4

betablockers like labetolol

antihyptensive medications like apresoline

115
Q

Why do we want to monitor both the patient and baby so closley with HTN disorders

A

because HTN disorders account for over 10% of all maternal deaths and both are at high risk

also HTN can degrade placenta early so we want to monitor the fetus as there is increased abruption risk

116
Q

What is the only true cure for Hypertensive disorder states in pregnancy?

A

Delivery

But the baby can be remarkably immature since it can occur usually at 24 weeks!

117
Q

Purpose of MgSO4 in treatment

A

to prevent the seizures of eclampsia

118
Q

Issue with MgSO4

A

it is not same for pregnancy - it actually can cause CNS depression

but if we do not monitor or titrate doses respiratory arrest can occur - but we need to prevent siezure

119
Q

Labetolol

A

A beta blocker that is used to treat HTN in pregnant women

120
Q

Apresoline

A

IV

Used as antiHTN med

Given to HTN crisis but not often since it can decrease placental perfusion

121
Q

How does gestational diabetes progress

A

it develops progressively as the pregnancy puts additional demands on the mothers system

122
Q

Gestational diabetes occurs in ___ to __% of pregnancies

A

2-5%

123
Q

When and how are pregnant women screened for gestational diabetes

A

Screened at 28 weeks gestation with a 1 hour glucose screen, and then a 3 hour glucose screen if the first one is abnormal

124
Q

Some patients can do what regarding their gestational diabetes

A

some patients are able to control it via diet alone while others will need insulin

125
Q

Risk Factors for Gestational Diabetes

A

obesity

family hx of diabetes

ethnicity (Hispanic, AA< Asian)

advanced maternal age >35 yo

prior GDM

prior LGA baby

126
Q

GDM

A

Gestational Diabetes Mellitus

127
Q

Gestational diabetes is first diagnosed …

A

during pregnancy

128
Q

What two things happen simultaneously which leads to gestational diabetes

A

there is impaired glucose tolerance

there is increased insulin resistance

129
Q

The mother’s pancreas in pregnancy is challenged by what leading to gestational diabetes

A

the normal changes in pregnancy (demand, etc)

130
Q

In gestational both maternal and fetal ___ results

A

hyperglycemia

131
Q

There is a __% chance gestational diabetic may develop DM later in life

A

40%

132
Q

When is gestational diabetes reclassified?

A

After delivery and breastfeeding begins

133
Q

How can patients control gestational diabetes

A

either through diet or some will require insulin

134
Q

Can we use oral hypoglycemic agents for gestational diabetes?

A

No they have potential teratogenic effects on the fetus

135
Q

Diabetes effects on pregnancy

A

Any diabetes (I and II) not just gestational:

PIH risk increases

Polyhydramnios (lots of amniotic fluid)

LGHA (Macrosomia)

IUGR (Intrauterine growth restriction)

Stillbirth

Congenital Anomalies (heart, CNS, skeletal) - especially in the Type I mother since it starts early

Infections

Ketoacidosis

136
Q

Why do diabetic mothers often give birth to LGA children

A

the baby was in a nutrient rich environment so it gets a fat and large body

137
Q

What can occur opposite to LGA from diabetes during gestation

A

IUGR if there is severe alterations in blood sugar leading the other way

138
Q

How serious is DKA during pregnancy

A

if the mother is a type I diabetic and goes into DKA there is a very high fetal loss rate - even more so than fetal abruption -so DKA fluid resuscitation is given even more rapidly and aggressively treated

139
Q

How is Gestational Diabetes diagnosed?

A

GTT - Glucose Tolerance Test - Over 1 hour 50 gm (glucola) is given at the 24-28 week gestation markand hope to see <135

OR

HbA1C Test

140
Q

What 3 hour GTT levels are elevated when Fasting and after 1, 2, and 3 hours?

A

Fasting <105

1 hour <190

2 hour <165

3 hour <145

141
Q

What is needed from the GTT to diagnose gestational diabetes

A

two or more elevated levels during the three hour test

142
Q

Glycosylated Hemoglobin (HbA1C)

A

Reflects control of blood sugar in the past 4-12 weeks

Measures % of blood Hgb that has a glucose molecule attached

143
Q

What is the normal Hgb glycosylation %?

A

6-8% should be glycosylated - higher signals diabetes

144
Q

Preterm Labor

A

labor between 20-37 weeks gestation

145
Q

Associated Factors for Preterm Labopr

A

hx of preterm labor - we have to manage this aggressively

HTN

placental abnormality

PROM (increased risk for infection and sepsis)

amniotic fluid abnormality

low socioeconomic status

maternal age <18 or >40

low pre pregnancy weight

non Caucasian race

multiple pregnancy

short interval between pregnancies

inadequate or excessive weight gain in pregnancy

previous laceration of the cervix or uterus

maternal infection

maternal medical conditions

smoking

alcoholism or drug addiction

severe anemioa

maternal trauma or burns

uterine abnormalities

cervical incompetenece

146
Q

Which preterm labor associated factor is more so regarding preterm delivery as we act before full term in stabilizing it

A

HTN

147
Q

Treatment for preterm labor

A

bedrest

tocolysis

corticosteroids

antibiotics

148
Q

What does Tocolysis do for preterm labor

A

minimizes contractions

149
Q

What does corticosteroids do for preterm labor

A

it accelerates fetal lung maturity incase it is delivered

immature lungs would be the main reason for loss of preterm babies

150
Q

What are some bleeding emergencies in pregnancy?

A

Placenta Previa

Placenta Abruptio

Vasa Previa

uterine Rupture

Lacerations

151
Q

Placenta Previa

A

the placenta implants in the lower uterine segment , either partially or totally covering the cervix

152
Q

What must be done is there is partial or complete placenta previa?

A

the baby must be delivered at 37 weeks by C section if not before

153
Q

S/S Of Placenta Previa

A

sudden onset of painless bleeding or hemorrhage

may be accompanied by contractions

154
Q

Vaginal exams are not done on women with…

A

known placenta previa

women with heavy vaginal bleeding and known placental location

since we could accidentally remove the placenta

155
Q

The hallmark sign of placenta previa is ?

A

painless bleeding or hemorrhaging

156
Q

Placenta previa may or may not be accompanied by ___

A

contractions

157
Q

Why is there a high hemorrhage risk with placenta previa

A

there is cervical thinning and softening and changes that may make the placenta break away causing life threatening hemorrhaging

158
Q

Why may a C Section not be needed for a low lying placenta or partial previa?

A

if in the 20 week ultrasound we see no anatomical issues the C section may not be needed as the placenta tends to migrate upward as the uterus enlarges

159
Q

Why are C Sections always needed for complete previa

A

it cannot migrate upward in two directions at the same time so it is required

160
Q

Predisposing Factors for Placenta Previa

A

Multiparity (scarring making implantation hard)

Maternal Age >35

Multiple Pregnancy (larger uterus makes likelihood higher)

erythroblastosis

Previous uterine surgery (scarring occurred)

Smoking

previous placenta previa (same factors as before)

previous therapeutic abortion

161
Q

Placenta Abruptio

A

a premature separation of the normally implanted placenta

can be complete or partial

162
Q

Bleeding during placenta abruptio can be…

A

obvious or concealed behind the placenta

can also lead to several L of blood lost in the uterus cavity with complete concealed abruptio

163
Q

S/S of Placenta Abruptio

A

Board Like/Rigid Abdomen - especially with complete abruption

Severe, relentless abdominal pain out of proportion to labor

Back pain

Colicky, discoordinate uterine contractions

tetanic contractions

bleeding

pain localized or generalized

FHR periodic changes late, variable, prolonged, sinusoidal

loss of variability (irregularity)

aggressive fetal movement (they know somethings wrong)

increasing fundal height (from filling with blood)

maternal shock

may not show on ultrasound

164
Q

What distinguishes placenta abruptio from placenta previa

A

severe pain out of proportion to contractions

165
Q

Ultrasounds and Placenta Abruptio

A

It may or may not show up on ultrasound

if all the bleeding has come out there will be no clot present to distinguish it on the ultrasound

it can confirm a complete or central abruption because there are clots, but it cannot rule out abruptio if its partial since the blood left

166
Q

Predisposing Factors to placenta abruptio

A

maternal HTN

preeclampsia

folic acid deficiency

severe abdominal trauma

short umbilical cord

malnutrition (poor placental health)

sudden decrease in uterine size

materanl age over 35

rough or difficult external version

cocaine use especially when it is crack

167
Q

Folic acid is essential to…

A

normal formation of placenta and adhering to the uterine wall as well as preventing neural tube defects

168
Q

Why is a short umbilical cord concerning?

A

it can cause placenta abrutpio

if the cord is short, mom goes into labor and the placenta is fundally located - as the baby drops the traction on the placenta can make it separate early

169
Q

External Version

A

when we see a baby is transverse or breech so we manipulate the uterus to get the babies head down - but if it goes across the implantation site it can cause detachment of the placenta and thus placenta abruptio

170
Q

Why is crack a big risk for the pregnant woman and for placenta abrutio?

A

it can cause bucking which is contractions similar to a grand mal seizure

171
Q

Placenta abruptio warrants…

A

very close observation or C Section

172
Q

__ __ for the mother and infant can be substantial in both previa and abrutio

A

blood loss

173
Q

Vasa Previa

A

shearing of the umbilical vessels in utero

usually the vessels are abnormally implanted and cross through the membranes off of the surface of the placenta - the vessels come of the placenta but the cord is not formed until several cm out

So, at the time of ROM the vessels can end up shearing - Critical situation!

174
Q

Who bleeds and is effected by vasa previa

A

the infant

175
Q

Since the baby has such small circulating blood (1 cup ~) volume, vasa previa can…

A

lead to bleeding to death very quickly

176
Q

Satellite Placenta

A

placental attempt to migrate when realizing theyre in a bad spot

there are vessels between the main and satellite that can shear

177
Q

What is the sign to be suspicious of vasa previa? What is warranted if you see this?

A

if you see very dark red blood with ROM associated with changes in the FHR

a c Section is warranted then

178
Q

Uterine Rupture

A

can be partial or complete

potentially catastrophic for mother and child

sudden and severe

179
Q

What may occur simultaneously with a uterine rupture?

A

placental abruption

180
Q

What is the number 1 cause for uterine rupture

A

previous uterine surgery like a C Section

181
Q

Uterine rupture can lead to needing what procedure

A

hysterectomy

182
Q

Risk Factors for uterine Rupture

A

previous uterine surgery

trauma

uterine overdistention

uterine abnormalities

placenta percreta

choriocarcinoma (molar pregnancy that is malignant)

183
Q

Placenta Percreta

A

when the placenta has gone beyond the normal level of implantation

184
Q

Cephalo Pelvic Disproportion (CPD)

A

also called Cephalo Pelvic Dystocia

When the baby is too big to get through the pelvis or in a position that has trouble getting through

185
Q

What are the three factors that can cause CPD?

A
  1. The maternal bony pelvis (the main issue usually)
  2. Fetal positioning
  3. soft tissue dystocia if mother is obese
186
Q

S/S of CPD

A

arrest of dilation or descent

abnormal labor patterns

acute maternal discomfort (bone on bone pain)

maternal exhaustion

early FHR decelerations (head compression)

187
Q

Nursing Interventions for CPD

A

repositioning

assess labor pattern

assess fetal status

keep provider appraised of progress or lack thereof

keep hydrated

consider analgesia and anesthesia to relax muscles

188
Q

Cord Prolapse

A

Occurs when the umbilical cord escapes beyond the presenting part and becomes trapped between the presenting part and the bony pelvis

189
Q

What can occur with cord prolapse and what can this lead to

A

blood vessels in the cord become compressed and the infant can become hypoxic and asphyxiate

190
Q

What is warranted with a cord prolapse

A

immediate C Section

191
Q

Can cord prolapse occur in ROM?

A

yes if the presenting part is not in a good spot

192
Q

Nursing Care for a Cord prolapse

A

one person must do a continuous vaginal exam and hold the head up off of the cervix

put the patient in trendelenburg or in knee chest position

prepare for an immediate C Section

IV bolus (increase perfusion)

O2 via mask (10 L via non rebreather)

prepare for resuscitation of infant

193
Q

What diagnoses Fetal Distress

A

electronic fetal monitoring

194
Q

Causes for Fetal Distress

A

placental insufficiency

severe cord compression

hyperstimulation of the uterus (contracts blood vessels)

fetal exhaustion

195
Q

___ in the FHR patterns can give indications of the cause for fetal distress

A

decelerations

196
Q

If the fetal distress cause cannot be corrected then what must happen

A

A C Section

197
Q

Nursing Interventions for fetal Distress

A

reposition the patient (could get them off cord)

Increase IV rate (improve perfusion)

Administer O2 (10L via non rebreather mask)

assess labor progress

assess cord prolapse

notify provider

prepare for delivery and resuscitation

turn off Pitocin (can make matters worse with contractions decreasing blood flow)

198
Q

Why is assessing labor progress particularly important when dealing with fetal distress

A

if she is close to vaginal delivery it may be faster than doing a C Section

199
Q

Shoulder Dystocia

A

When the head has come out but the anterior shoulder impacts on the anterior pubic bone (or posterior shoulder impacting the sacral prominence)

200
Q

Turtle Sign

A

a classic sign of shoulder dystocia where there is retreating of the fetal head after it was delivered

warrants calling a code if seen

201
Q

Maternal Risk factors for Shoulder Dystocia

A

abnormal pelvic anatomy

gestational diabetes since the baby may be fat and large

post date pregnancies since baby is larger

previous shoulder distocia

short statures leading to smaller dimensions

202
Q

Fetal Risk Factors for shoulder dystocia

A

suspected macrosomia

203
Q

Labor related risk factors for shoulder dystocia

A

assisted vaginal delivery (forceps or vacuum) - high correlation

protracted active phase of first stage labor

protracted second stage labor

protract may indicate a large baby

204
Q

What can happen if the provider does the incorrect thing and tries to take ahold of the infants head and put traction on it to free the shoulder from shoulder dystocia?

A

it can shear nerves from the neck to the arm causing permanent paralysis or damage in the limb

205
Q

The single most common risk factor associated with shoulder dystocia is…

A

the use of a vacuum extractor or forceps during delivery

206
Q

Overall incidence of shoulder dystocia increases…

A

with increasing large baby size

207
Q

Shoulder dystocia occurs with equal frequency in ___ and ___ women, but it is more common in infants born to women with ___

A

primigravid and multigravida

diabetes

208
Q

Maternal Complications of Shoulder Dystocia

A

Postpartum hemorrhage (lacerations occurring extending to rectum)

rectovaginal Fistula

Symphyseal (anterior pelvis) separation or diathesis with or without transient femoral neuropathy

Third or fourth degree episiotomy or tear

uterine rupture

209
Q

Fetal complications of shoulder dystocia

A

brachial plexus palsy

calvicle fracture

fetal death

fetal hypoxia with or without permanent neurologic damage

fracture of the humerus

210
Q

Brachial Plexus Palsy

A

shearing of the nerves going down the arm

211
Q

Prevention of Shoulder Dystocia

A

Encourage weight gain within a “normal” range (makes a big child)

Induction of labor with larger infants

effective C Section

good control of diabetes in pregnancy (makes a big child)

212
Q

What is the problem with the induction of labor to prevent shoulder dystocia

A

It may appear 2 pounds larger at term via ultrasound - but we are aiming at a moving target so we may induce labor and then find the infant was much smaller than we thought

213
Q

Maneuvers for Shoulder Dystocia Delivery

A
  1. Deliver through the anterior shoulder
  2. McRoberts Positioning
  3. Episiotomy
  4. Suprapubic Pressure
  5. Rotational Maneuvers- internal maneuvers to rotate the shoulder off the bone like rubin II, Woods, and Reverse Woods
  6. Deliver the posterior shoulder
  7. Reposition mom into knee chest position
214
Q

McRoberts Positioning

A

Hyperflexion of maternal hips up to nipple line (pelvis is bones connected so this increases ant-post dimensions)

215
Q

Rubin II Maneuver

A

provider maneuver to get shoulder off pubic bone by trying to collapse shoulder and move baby at an angle to get through the pelvis (where clavicle fractures tend to occur)

216
Q

Woods (Screw) Maneuver

A

put fingers behind anterior shoulder and fingers in front of posterior to make a screw motion

217
Q

Reverse Woods (Screw) Maneuver

A

same as woods but opposite screw direction

218
Q

Ina May Gaskin

A

most famous midwife in the world

noticed if you turn mom on hands and knees and put her in knee chest position than shoulder dystocia will correct itself (this position should get the reverse maneuvers then)

219
Q

What are some extreme measures to fix shoulder dystocia

A

Deliberate clavicle Fracture

zavanelli maneuver

general anesthesia (relaxation, but has downfalls)

abdominal surgery with hysterotomy (rotates infant through incision)

symphysiotomy

220
Q

Why may extreme measures to fix shoulder dystocia occur

A

because every moment of it is another moment the baby can become asphyxiated from cord compression

221
Q

Zavanelli Maneuver

A

attempt to replace (push back in ) the babies head and do a C Section

222
Q

Symphysiotomy

A

used in 3rd world countries more

intentionally excise fibrous cartilage of the symphysis pubis under local anesthesia to get the baby out of shoulder dystocia

only used in NA when all other things have failed and C Section is unavailable

223
Q

How common is post partum hemorrhage (PPH)?

A

Common - 3-5% of pregnancies

224
Q

PPH can even occur…

A

in patients without risk factors for hemorrhage (20%)

225
Q

PPH is the cause of ___ of maternal deaths worldwide and __% of maternal deaths in the US

A

1/4 worldwide

12% in US

226
Q

PPH requires

A

management of PPH with prompt diagnosis and treatment

rapid team based care to minimize morbidity and mortality regardless of cause

if not done a mom can bleed to death in minutes!!

227
Q

Risk Factors for PPH

A

antepartum hemorrhage

augmented labor

chorioamnionitis

fetal macrosomia (hard to act like a tourniquet after that)

maternal anemia (less loss tolerance)

maternal obesity

multifetal gestation (d/t hyperextension occurring)

preeclampsia

primiparity

prolonged labor

228
Q

Augmented Labor

A

when the uterus may not contract soon after L&D leading to a bleeding problem

229
Q

S/S of PPH

A

Heavy BRIGHT RED BLOOD FLOW - only 500 to 1000 cc is loss depending on birth so measure and save all pads and chux

Flaccid (Atonic, boggy) fundus

changes in VS: low BP, elevated Pulse (30% blood loss, less if anemic before PPH)

Complaints of lightheadedness, nausea, air hunger, changes in orientation and alertness (means late PPH, 50% loss)

changes in lab values - H&H, platelets, coagulation profile, D Dimer

230
Q

75% of PPH related to

A

uterine atony (lack of contraction/tone)

231
Q

What should we do if the fundus is flaccid/not well contracted

A

massage it in a circular pattern

there is a stimulatory pacemaker near the fundus that can get contractions going

232
Q

The 4 T’s

A

Mnemonic that can be used to ID and address the four most common causes of PPH:

Tone - Uterine Atony
Trauma - Laceration, Hematoma, inversion, Rupture
Tissue - Retained tissue or invasive placenta
Thrombin - Coagulopathy

233
Q

How do the 4 T’s compare in causing PPH to one another?

A
  1. Tone - 70-80% - Major cause
  2. trauma - 20%
  3. Tissue - 10%
  4. Thrombin - 1%
234
Q

How to manage PPH?

A
  1. Start with a fundal contraction assessment and massage since uterine atony is a common reason for PPH
  2. Pitocin
  3. Repeat fundus and flow and VS assessments 1 5-15 minutes depending on severity and findings
  4. initiate a team response: MD, Nurses, lab, anesthesia, supervisor, etc
235
Q

What is the first line drug for PPH

A

Pitocin (or Tranexamic Acid)

236
Q

Complications of PPH

A

Anemia

Sheehan Syndrome

Blood Transfusion

Death

Dilutional Coagulopathy (loss of clotting factors)

Fatigue

Myocardial sichemia

orthostatic hypotension

postpartum depression

237
Q

Sheehan

A

lifelong hormonal issues

it is from anterior pituitary ischemia with delay or failure of lactation occurring

238
Q

Types of Lacerations

A

Perineal
Periurethral
Vaginal
Cervical
Cervical Uterine

239
Q

____ are responsible for 20% of PPH

A

lacerations

240
Q

Lacerations are classified by ___ and ___ ___

A

depth and tissues involved

ex: 1st, 2nd,3rd,4th Degree

241
Q

Periurethral lacerations are usually __degree

A

1st

242
Q

1st Degree Laceration

A

involves the perineal skin and the vaginal mucosal membrane

so it is depth of skin but not tissue

243
Q

2nd Degree Lacerations

A

involves the perineal skin and the vaginal mucosal membrane and the muscles of the perineum body - however the rectal sphincter remains in tact

Interruption of skin and muscle and extension into the vaginal vault, but no sphincter issue

244
Q

3rd Degree Laceration

A

involves the perineal skin, vaginal mucosal membrane, muscles of the perineum body, and through the rectal sphincter (non intact)

excision occurs to the rectal sphincter but NOT the rectal mucosa

245
Q

4th Degree Laceration

A

involves perineal skin, vaginal mucosal membrane, muscles of the perineum body, and through the rectal sphincter AND through the rectal mucosa

definitely needs repair

246
Q

What degree laceration is a vaginorectal fistula

A

4th degree - needs repair

247
Q

Sulcus Tears

A

another name for Vaginal Lacerations

248
Q

__ and __ must be examined for lacerations

A

Vagina and Cervix

249
Q

What laceration is repaired first; Perineal or Vaginal?

A

vaginal laceration then perineal laceration

250
Q

What is a concern regarding cervical lacerations?

A

it is a highly vascular area so it is prone to hematoma formation after trauma and more bleeding

We will need to tie off vessels open and bleeding

251
Q

Care must be taken to ___ bleeding vessels as the repair progresses in order to prevent ___

A

compress; hematomas

252
Q

Cervical lacerations can be…

A

extensions of a vaginal laceration and can extend up into the lower segment of the uterus or be confined to the cervix itself

253
Q

What sites are the most common sites for laceration? What makes them more common?

A

3 o clock and 6 o clock

operative deliveries e.g. vacuum and forceps

254
Q

Because the cervix is highly vascular, lacerations…

A

can cause significant blood loss with cervical lacerations

255
Q

Lacerations can do what to the cervix ultimately?

A

damage the integrity of the cervix and its ability to maintain future pregnancies

256
Q

Amniotic Fluid Embolism

A

when amniotic fluid as the placenta breaks away is still free flowing in the uterus and gets swept into circulation and goes to the lungs

can be sudden or extreme (more often) but can also be insidious as well (like is O2sat is 92-93%)

257
Q

Amniotic fluid embolus are ___ embolus and are usually ___ and ___

A

pulmonary embolus and are usually bilateral and extensive

258
Q

When is the most common time for an amniotic fluid embolus to occur

A

at the time of delivery

259
Q

What is the mortality like with an amniotic fluid embolus

A

severe and life threatening complication

60-80% mortality rate

makes up 10% of maternal mortality

usually occurs near to or after delivery

260
Q

S/S of Amniotic Fluid Embolus

A

sudden and severe respiratory distress

hypoxia

altered mental status

pain

hypotension (from blood not getting from from lungs to the heart)

shock and arrest

261
Q

The sooner you get a mother with an amniotic fluid embolus on ____ the better

A

ventilators

262
Q

What management does an amniotic fluid embolus need

A

100% O2, aggressive IVB fluids, hypotensive meds - AS QUICKLY AS POSSIBLE

May need to be on a ventilator

263
Q

Intrapartum and Postpartum Infections

A

Amnionitis

Endometritis

Mastitis

264
Q

Endometritis

A

an inflammation of the endometrium (inner layer of uterus)

265
Q

Chorioamnionitis

A

infection of the chorion

266
Q

How often does endometritis occur in women with vaginal deliveries versus C sections?

A

1-3% of vaginal deliveries - 27% of C Sections

267
Q

What are the causative agents of chorioamnionitis and endometritis

A

both anaerobic and aerobic bacteria

these could enter through a vaginal exam near the cervix

268
Q

S/S of Chorioamnionitis and Endometritis

A

Lochia that is foul smelling, bloody, scant or perfuse in amount - purulent as well

Fever

Tachycardia

Chills

Uterine tenderness (disproportionate to contractions or C Section and what is normal)

269
Q

What is usually the first indicator of chorioamnionitis/endometritis

A

tachycardia (especially if fetus is still inside)

270
Q

Risk Factors for chorioamnionitis and endometritis

A

C Section (Risk 20x greater)

prolonged premature ROM (no barrier and amniotic fluid is a medium for bacteria) (even higher after 24 hr)

prolonged labor preceding C Section

multiple vaginal exams in labor

compromised health status (anemia, low se status, use of tobacco, drugs or ROH)

use of internal fetal heart rate or contraction monitor (wick for bacteria to get in)

OB trauma (lacerations or episiotomy)

diabetes (4x more likely)

preexisting bacterial vaginosis or chlamydia infection (STDs)

instrument assisted birth (forceps or vacuum) (Ascend the bacteria)

manual removal of the placenta (hand went through the cervix)

lapses in sterile technique by the surgical staff

271
Q

Mastitis

A

an infection of the connective tissue of the breasts that occurs primarily in lactating women

can progress to form abscesses even

272
Q

When does mastitis tend to occur

A

several weeks after delivery

273
Q

S/S of Mastitis

A

Redness (often wedge shaped because of the septal divisions in the breast)

swelling, warmth at the site

pain

fever headache

flu like symptoms (because breasts are vascular and they go systemic fast)

leukocyte count >1 million/mL or bacterial colony coutn >10000/mL

274
Q

Risk Factors for Mastitis

A

Milk stasis

Actions that promote access/multiplication of bacteria

Change in the number of feedings / failure to empty the breasts

lowered maternal defenses

breast/nipple trauma

obstruction of ducts

275
Q

What may cause milk stasis

A

failure to change feeding positions

failure to alternate breasts at feedings

poor suck

poor letdown (mom can perceive normal letdown)

276
Q

What are some actions that promote access/multiplication of bacteria on the breast

A

poor handwashing technique

improper breast hygiene

failure to air dry breasts after breastfeeding

use of plastic lined breast pads (trap moisture)

277
Q

What can lead to a change in the number of feedings or failure to empty the breasts?

A

attempted weening

missed feedings

prolonged sleeping including nighttime

favoring side of nipple soreness

can also contribute to milk stasis in the end

278
Q

__ and __ can lower maternal defenses

A

fatigue

stress

279
Q

What may cause breast/nipple trauma

A

incorrect positioning for breastfeeding

poor latch

failure to rotate position on ni9pple

incorrect or aggressive pumping technique

280
Q

What can lead to obstruction of the milk ducts

A

restrictive clothing

constrictive bra

underwire bra

N352: Practice of Nursing I (14 decks)

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