OB test 2 Flashcards
Spontaneous abortion: threatened
bleeding is present with no cervical dilation, before 20 wks gestation
s/s: vaginal bleeding, abdominal cramping and back pain
Spontaneous abortion: inevitable
cervix dilates or the membranes rupture w/o delivery of the fetus or placenta
complications: vaginal bleeding and imminent spontaneous abortion
s/s: vag bleeding, abd cramping and back pain
Spontaneous abortion: missed
no expulsion of the products of conception and a closed cervix
s/s may be minimal or absent- usually discovered at an ultrasound apt. with absent fetal heart rate or growth- may still experience s/s of pregnancy
risks: infection and prolonged bleeding
-may require surgical intervention to clear it out
Spontaneous abortion: recurrent
two or more consecutive spontaneous abortions that occur before 20 wks
suspected causes: genetic abnormalities, uterine defects, endometrial problems, infection , AI diseases, hormone imbalances and unhealthy lifestyle habits.
s/s: vag bleeding, cramping , passing of tissue, emotional distress
Dx/tx: testing to evaluate underlying etiology via physical assessment
ectopic pregnancy
fertilized egg implants outside the uterus
RF: hx of ectopic pregnancy, pelvic infection, infertility tx, tubal surgery
s/s: vag bleeding, abd or pelvic pain, syncope, or shock- may be asymptomatic until rupture occurs
dx: transvaginal US and serial hog levels are used to rule out an intrauterine pregnancy
tx: indicated if abd or pelvic pain worsens, hug levels increase, or evidence of tubal rupture
- methotrexate
-surgery- laparoscopically
gestation trophoblastic disease
RF: pt < 20 yr or >40 yrs old
-abnormal growth in the uterus (molar pregnancy) that would have become the placenta, grows as trophoblastic tissue.
-no viable fetus
s/s: vag bleeding, enlarged uterus, elevated hCG levels, and hyperemesis
Dx: US
TX: D&C (dilation and curettage) followed by series of serum hCG levels to ensure no more tumors develop
-DONT CONCEIVE FOR UP TO 1 YR AFTER
-if left untreated the trophoblasts can develop into tumors (benign or malignant)
hyperemesis gravidarum
severe n/v during the first trimester- leads to electrolyte imbalances, weight loss, malnutrition and dehydration
factors: hormone changes r/t to hCG levels, decreased gastric motility, genetic predisposition, and psych factors (stress and anxiety)
complications: low fetal brith weight and preterm birth
tx: antiemetics, thiamine (vit B1) to prevent wernickes and refeeding syndrome
nursing interventions: assess severity, emotional support, education on diet and lifestyle modifications (small frequent meals, avoid spicy foods, drink fluids and rest). Meds: vitamin B6, doxylamine, benadryl, raglan, phenergan, or zofran. Inpatient: fluid/e- replacement
monozygotic multiples
identical twins: one fertilized egg splits during development
dizygotic multiples
two separate fertilized eggs
RF and complications for multiple gestation
family hx, AMA, high parity, african american, assistive reproduction technology
complications: hyperemesis gravidarum, anemia, gestational diabetes, HTN disorders, placental insufficiency, increased size of uterus, preterm labor and delivery, and twin to twin transfusion
mgmt: US for abnormalities in fluid volume, cervcal length nd getal growth
twin-to-twin transfusion syndrome
when a placenta is shared during a monochorionic pregnancy- causing an imbalance in fetal blood flow
DX: US
TX: nutritional counseling, bedrest, meds (prevention of preE, gestational diabetes, preterm labor, UTI)
cervical insufficiency
painless dilation of the cervix that often results in the inability to carry the fetus beyond the 2nd trimester
AKA: shortened or incompetent cervix
s/s: low back pain, pelvic pressure, vag bleeding or discharge
RF: hx of cervical surgery or pregnancy losses, unknown etiology
cervical cerclage
surgically placed sutures around the cervix to prevent dilation- removed as preg approaches term
placenta previa
placenta sits at the lower portion of the uterus near the internal cervical os
RF: hx of prevue, multiple gestation, multiparty, hs of uterine surgeries (c-sections included), uterine abnormalities, AMA, reproduction technology, and smoking
low lying: partially covering os, previa is used for complete coverage of os
Dx: 2nd trimester US
Complications: hemorrhage
nursing: monitor for signs of hemorrhage, advise pt to limit physical activity- bedrest, educate on what s/s to seek med attention for. No digital cervical exam, or vag intercourse due to risk for bleeding
MUST HAVE CSECTION- vag contraindicated
vasa previa
fetal blood vessels overlie the internal cervical os or lay within 2 cm of the cervix
type 1: blood vessels between the umbilical cord and the placenta run along the fetal membranes overlying the cervix- risk for those with resolved placenta previa
Type 2: succenturiate placenta- which is made up of multiple lobes ( usually two)- blood vessels connecting them
type 3: vessels pass through the membranes at the margin of the placenta
Complications: membrane rupture risks vessel rupture = fetal hemorrhage, exsanguination and asphyxia
-usually resolves prior to 28 weeks
-csection if not resolves
Nursing: antepartum NST and BPP (30-34 weeks)
abruptio placentae
part or all of placenta separates from the uterine lining
complications: significant maternal blood loss, fetal demise or maternal death
s/s: suddenly onset of severe abdominal pain, back pain, vag bleeding, painful, prolonged uterine contractions or a uterus that reminds contracted without a resting tone and changes in fetal heart rate
nursing: monitor for signs, fetal HR, hemodynamic monitoring, fluid replacement with blood if needed
placenta accreta spectrum : accreta
attachment of placental villi to the myometrium instead of just to the decidua (majority of morbidly adherent placenta MAP)
RF: hs of C-section, placenta accrete or uterine surgery, AMA, hx of infertility and pelvic radiation
s/s: hemorrhage
complications: DIC, renal failure, hemorrhage, massive transfusion and death, uterine rupture, infection
Dx: US or MRI or may be undiagnosed
-Csection delivery to reduce risks, likely followed by hysterectomy
placenta accreta spectrum : increta
penetration of placenta into the myometrium
placenta accreta spectrum : percreta
chorionic villi penetrate the myometrium and may grow into uterine serosa and surrounding tissue
Gestational hypertension
occurs after 20 wks gestation/preE
RF: obesity, null parity, hs of preE, preexisting diabetes, renal disease, and multiple gestation pre
-140/90
-nifedipine, mag sulfate, labetolol, hydralazine
preeclampsia
occurs after 20 weeks gestation and ups to 6 wks PP- vascular changes in placenta and uterus- spiral arteries in uterus dont allow for increased blood flow to the placenta
RF: nulliparity, extremes in maternal age, obesity, multiple gestation, kidney disease, chronic HTN, diabetes and hx of prE
S/s: HTN, proteinuria, edema, HA, vision changes and epigastric pain, n/v
adverse outcomes: C-section, preterm birth, low apgar scores, placental abruption, SGA infants
risk reduction: daily low dose aspirin, magnesium sulfate (reduce risk of seizures), antihypertensive tx
true tx: delivery
nursing: monitor for signs of worsening condition -> eclampsia, vitals, neuro status (LOC, reflexes, signs of mag toxicity- loss of DTR, resp depression, decreased UO) fetal monitoring, mag levels and liver and renal function tests
HELLP syndrome
Hemolysis, elevated liver enzymes, low platelet count- HTN disorder that occurs as a complication of preE
s/s:fatigue, abnormal bruising, abdominal pain (RUQ), edema, n/v, and petechiae or prolonged bleeding time
some s/s of preEclampsia: epigastric pain, HA, vision changes- they dont always develop HTN
Complications: DIC, placental abruption, ARF, pulmonary edema, hematoma of liver, retinal detachment
Tx: delivery if >34 weeks, supportive care and mgmt of possible hemorrhage
nursing: monitor vitals, symptoms worsening, meds, monitor fetal status
gestational diabetes
secondary to hormonal changes during pregnancy that lead to increased insulin resistance w/o adjusted insulin secretion- high circulating volume of glucose in the blood= hyperglycemia
-results in macrosomia
-glucose passes through placenta but maternal insulin doesn’t- baby now has to produce large amounts of insulin to address this = LGA baby
amniotic fluid imbalance: polyhydramnios
abnormally high volume of amniotic fluid
causes:maternal diabetes, anemia, or AI disorders, multiple gestation
complications: preterm birth, placental abruption, PROM, umbilical cord prolapse or fetal malpresentation
Tx: amnioreduction- amniocentesis to remove excess fluid
amniotic fluid imbalance: oligohydramnios
abnormally low volume of amniotic fluid is present
(fluid is primarily comprised of fetal urine, fetal lung and GI secretions and fluid from placenta and umbilical cord- congenital renal anomalies, placental dysfunction, fetal growth restriction, or ruptured membranes, could caused this.
mgmt: monitor amniotic fluid volume, fetal status and maternal hydration
preterm labor
onset of labor before 37 weeks
DX: fetal fibronectin test (tests for fibronectin that exists between the uterine lining and amniotic sac)- negative test is a sign against preterm labor within 7-10 days
-transvaginal US- detect ccervical length. <25 mm indicates preterm labor
-Nitrazine pH test- 7.0-7.3 indicates amniotic fluid leaking- and darker green/blue on paper
RF: hx of preterm birth, infection, cervical abnormalities, chronic medical conditions, multiple gestation, substance use, poor diet, stress
Tx: tocolytic meds (indocin, nifedipine, mag- neuroprotection of fetus, and terbutaline) CC (betamthasone- for feta lung development)
preterm premature rupture of membranes
ROM before 37 weeks- leakage of fluid
RF: infection (genital tract), multiple gestation, hx of preterm labor, smoking, vaginal bleeding during pregnancy
Tx: CC for lung maturity of fetus, ABx if caused by infection, tocolytics
PUPPs
“pruritic Urticarial Papules and Plaques of Pregnancy” (polymorphic eruption of pregnancy)- occurs in last few weeks of pregnancy or early pp, often first time pregnancies
- caused by inflammatory process caused by stretching of the skin
-not harmful to fetus
s/s: pruritic papules within striae
tx: topical CC and antihistamine
cholestasis
impaired bile flow from the liver- maternal bile acids pass the placenta- creates risk for preterm delivery, fetal demise, and NICU admission
s/s: (late 2nd- 3rd trimester) uncomfortable pruritus (hands/feet), clay-colored stools, dark urine, fatigue, nausea, poor sleep, jaundice, RUQ pain
Tx: ursodeoxycholic acid- reduce bile acid concentration, pruritic control meds, antepartum BPP test or NST twice weekly until delivery- usually deliver by 36-37 weeks
-resolves with delivery
trauma
blunt force or penetrating trauma, emotional, or intimate partner violence
-falls, motor vehicle accidents most common type of blunt force
nursing: US for fetal status after trauma, physical assessment of mother, watch for signs of IPV, emotional support for IPV victims, give resources
electronic fetal monitoring documentation
parameters for documenting and performing:
- continuous: evaluation of FHR and contraction pattern Q15-30 min, frequency of assessment and interpretation of FHR. Documenting fetal status before and after altering the dose
FHR baseline
avg bpm in 10 min segment (excluding marked variability
-100-160
tachy: >160
brady< 110
FHR tachycardia
> 160 bpm
RF: maternal: infection, anxiety, dehydration, meds like atropine and terbutaline, hyperthyroidism, nicotine. fetal: compromise/hypoxia, anemia, infection, prematurity, arrhythmia
FHR bradycardia
<110 bpm
differentiate between benign episode or a prolonged deceleration
intervention: reposition mom, IV fluids
RF: maternal: anesthesia, hypotension, meds: mag sulfate, propranolol, hypoglycemia, hypothermia, uterine rupture, placental abruption, hypothyroidism. Fetal: head compression from head down position, congenital heart block ,hypoxia, prolonged umbilical cord compression
continuous electronic fetal monitoring
- ultrasound transducer placed over fetal back closest to fetal head where FHR is heard loudest
-Toco senses change in uterine muscle during a contraction
parameters for documenting and performing:
internal fetal monitoring
how: fetal scalp electrode (FSE) that fixes to the scalp, and the intrauterine pressure catheter (IUPC) that measures contraction “stats”
when: amniotic sac must be ruptured, used for situations when in-depth fetal surveillance is required (non reassuring FHR), low amniotic fluid or difficulty tracing FHR externally
risks/contraindications: placing in fontanelle, inserting through placenta- hemorrhage, risk for infection
NICHD Normal
ALL REQUIRED:
- Moderate variability
- Baseline rate 110-160
- No late or variable decels
- Early decels present or absent
- Accels: present or absent
-Strongly associated with normal acid/base baseline
NICHD Abnormal
- Absent baseline variability and any of the following:
- Recurrent late decels (50% or more of contractions)
- Recurrent variable decels
- Bradycardia
- Sinusoidal pattern
- Predictive of abnormal fetal acid base status
variability
means: fluctuations in sympathetic vs parasympathetic nervous system
classified: absent, minimal, moderate or marked
management:
moderate variability
fluctuation between 6-25 bpm- considered normal
-normal umbilical cord pH
minimal variability
fluctuation of 5 bpm or fewer
-associated with fetal acidemia
causes: fetal sleep cycles, feta anomalies of CNS, meds (mag sulfate), preterm gestation
absent variability
lack of fluctuation of baseline= severely compromised fetus
-result of poor oxygenation leading to metabolic acidosis
example: sinusoidal pattern- wavelike- fetal anemia or med induced
Marked variability
fluctuation great than 25 bpm- undeterminable baseline- suggest hypoxia
Earlies (decel)
gradual FHR decline and then return to baseline
-fetal head compression activates the vagal nerve
-proportional to strength of uterine contraction
-common during active labor at the head descend into the pelvis
-NORMAL
Late Decel
always indicate fetal hypoxia
-uteroplacental insufficiency
-begins late in uterine contraction due to decrease in oxygen to fetus
-lowest dip occurs after contraction
-common cause: tachysystole contractions (lasting longer than 2 mins or occurring too frequently)
-more causes: HTN, placental abruption, anemia
variable deceleration
decel of at least 15 bpm below baseline (vary in onset, depth and duration)
-causes: fetus compressing cord against uterine wall, or mvmt of mom or baby
-may or may not be in conjunction wit contractions
-may lead to fetal hypoxia
prolonged deceleration
sporadic deceleration of at least 15 bpm that lasts 2-10 mins before returning to baseline
causes: uterine hyperactivity, cord compression, hypotension, placental abruption, seizure, or impending birth
-risk for fetal hypoxia depending on duration
Accelerations
usually associated with fetal mvmt, and are NOT r/t contraction activity
-sign of fetal well-being
-onset to peak =30 sec, 15 bpm higher for 15 sec (15x15 rule) (or 10x10 if before 32 wks gestation)
decelerations
classified as early, late, variable or prolonged
-associated with fetal hypoxia- require intervention
Decelerations: VEAL-CHOP-MINE
Variable - cord compression (brief, or baby playing with cord)- maternal reposition
Early- head compression (common, often as labor is progressing, not a worry)- identify labor progress
Acceleration- OKAY! - no intervention
Late- perfusion problem = bad!, baby is getting tired and responding late, can’t recover from contraction well- execute actions immediately
True labor
regular contractions, bloody show, mucous plug, lightening (baby moves into pelvis), nesting, GI distress, wt loss (1-3 lb)
CERVICAL CHANGE
false labor
5 P’s that affect labor
- Power-force of uterine contractions and pushing efforts
- Passageway- anatomy of moms pelvis and soft tissues
- Passenger- fetal factors (position, weight, size)
- Psyche- mom state of mind
- Position- (of mom) what supports and shortens labor
Power
Primary: uterus contracts and applies pressure on fetus, cervix dilates and effaces in response to pressure.
- effected by frequency, duration and intensity
Secondary: mom pushing efforts after cervix is dilated and she has the urge to
-effective pushing with contractions (3x/contraction)
Passageway
shape of pelvis and ability of soft tissue to stretch
-muscles of pelvic floor help orient fetus through mvmt of delivery
OPTIMAL: gynecoid (symmetrical and round)
-anthropoid (oval, narrow end)
-android (almost triangular, guitar pick-esque)
LEAST IDEAL: platypelloid (narrow and long)
Passenger
-fetal head size
-fetal presentation
-fetal attitude
-position of baby
-fetal lie
Passenger: fetal head size
- cephalopelvic disproportion (CPD)- head is bigger than space in pelvis to be able to move through it
-skull bones aren’t fused and can shift to adjust for birth canal
Passenger: fetal presentation
cephalic/vertex- head down (ideal) or breech
- complete: feet and butt
- footling: 1 or both feet coming first
- frank: legs point up, bottom emerges 1st
-breeches go to csection
Passenger: fetal attitude
how is baby’s head tucked in canal
- vertex presentation- complete flexion of chin to chest- crown of head emerges first (ideal)
- military- moderate flexion, top of head first
- brow presentation- neck extended, forehead 1st
- face presentation- face first, bruising/trauma to face
Passenger: position of baby
where is occiput? (back of head)
- occiput posterior- face toward moms front
-IDEAL: OCCIPUT ANTERIOR- fact toward mom’s back, helps tuck under pubic bone
Passenger: fetal lie
position r/t moms spine
- longitudinal- breech or vertex
- transverse- horizontal compared to moms spine
-asynclitic birth- baby came down with ear to shoulder, bump on one side of head
Psyche
impacts labor!!
-factors that slow labor: anxiety, stress (birth plan out of order for example), fear (pain they are about to encounter), pain tolerance low
-relaxation augments labor
Position (mom)
-gravity = friend- contractions more effective with woman standing upward
-most conducive for labor if hips are sharply flexed (like squatting
-lithotomy position- ideal for provider
stages of labor
- dilation and effacement of cervix
- cervix @10 cm- ends with birth of baby
- begins with baby birth and ends with placenta delivery
- delivery of placenta-4H later or when mom is clinically stable
cardinal movements of labor
fetal head rotates fro optimal delivery as it descends
-engagement- fetal head reaches ischial spines
-descent- fetus moves past spines
-flexion- chin touches chest, responding to pressure from contraction
-internal rotation- head rotates to face downward
-extension- chin comes off chest, neck arches as head is born
-external rotation- head rotates as shoulders move into position for delivery
-expulsion- body born
support during pushing
open glottis pushing- allow for breaths and air flow
-give specific instructions, try new positions?
-use eye contact
-speak calm and firm
-focus on breathing
maternal assessments postpartum
neonate assessments postpartum
non-pharm pain mgmt
movement- labor dance, birth ball
touch: counter pressure on back, acupressure
focus: guided imagery, hypnobirthing
pharm pain mgmt
fentanyl- short acting, may cause respiratory depression in fetus
-mixed opioid agonist/antagonist: lower risk for fetal respiratory depression. ex: nubain or stall (single doses, last for 3-4 hours)
-Nitrous oxide- inhaled before contraction (s/e: n/v, lightheaded)
-epidural (not in CSF)- requires more drug to diffuse across membrane
epidural vs. spinal
spinal: needle removed after med administration, used before surgery, immediate action- single dose but less medication is likely needed
epidural: catheter left in place, can titrate medication, continuous infusion, may need more medication for desired effect, can be used in post-op setting, some areas may not go completely numb
RN documentation during labor and delivery
how often should RN assess during labor and delivery
low risk:
- intermittent: auscultate with doppler for 1 min before, during and after contraction
-latent: hourly until they dilate more than 4 cm, then Q15-30, then active stages Q15- to Q5 as she progresses to second stage of active
-continuous: same for 1st stage latent and active. 2nd stage, passive descent: Q30
2nd stage, active pushing Q15
HIGH RISK: continuous
1st stage latent (<4 cm)- Q15-30 depending on oxytocin use- Q15 for active stage. 2nd stage- Q5 min
1st stage of labor
Latent: (0-6 cm) longest lasting phase, period of excitement, contraction start out feeling like period cramps- mild to palpation and then progress to regular and painful, moderate to palpation
Active: (6-10 cm) may become more focused, anxious or restless. contractions are strong and close together. They may feel out of control, irritable or dependent. Moderate-strong to palpation
-visceral pain: abdomen, lower back, thighs, with contractions
1st stage labor nursing interventions
18G IV, draw blood- CBC, CMP, urine dip, blood lab sample (type and cross if needed), vitals, continuous/intermittent fetal monitoring, encourage void Q2H, assess progress, provide labor support, pt education PRN, pain meds
2nd stage of labor
-infant delivery
-somatic pain- vagina, rectum and perineum
-may last mins to hours
-cardinal movements!
3rd stage of labor
placenta delivery- w/in 5-30 min. uterus contracts slightly and mom may need to give slight push.
-uterus needs to pinch down to close off blood vessels in decider to prevent hemorrhage
-uterine atony- primary cause of PPH, uterus doesnt contract down.
intervention:asses size and shape of fungus right after delivery. Assess for bleeding. dr may increase oxytocin orders
4th stage of labor
PP recovery
-baby/family bonding- allow them to watch assessments and help with bath.
-assessments: VS and fundal checks (firm)- Q15 x1 H and then Q30 x1H
- comforts: ice packs, analgesics, warm blankets, food, fluid
-bathroom: assess moms ability to stand, peri-care, peri-bottle, pads, wiping, witch hazel (*remove epidural before)
-education: what to expect PP, self care- esp if they had laceration/episiotomy, safety- bassinet in hallways for walks, abduction prevention
PP physiologic adaptations
Vitals: slight temp increase (no > 100.4/38), BP (no >140/90- pp PreE, gestational/chronic HTN, but no < 90/60- PPH), slight increase in RR
PP fluid shift: pregnant edema shifts back into intravascular space- diaphoresis. Blood loss: 150-1000 mL
CV instability: CO increases in immediate PP- fluid shifts, makes heart work harder. preexisting cardiac conditions may worsen
Urinary: difficulty emptying fully, urethral swelling (genital tract trauma), lacerations or episiotomy-painful urination
Breasts: striae, veins, darken areola from pregnancy fades over 1st 6 wks. Lactogenesis (secrete milk)
uterus/lochia: involutes or shrinks (1cm/day)- takes about 6 wks to fully involute.
-lochia- vag bleeding during PP period- if it saturates a pad in less than 1 hour is is considered excessive and requires assessment for hypovolemia. 1 g of blood = 1 mL of blood loss. Color changes from Rubra (days 1-3), to serosa (days 4-10), to alba (days 10-28)
cervical: bruised and floppy after vag birth. permanently changes shape after 1st vag birth. Returns to prepregant state, less than 1 cm dilated, about 1 week PP
Vagina: kegel education to strengthen pelvic floor muscles, 10x/day. in case of urinary incontinence, 30x/day
MSK/skin: diastases recti abdominis (RF: multiple gestation, polyhydramnios, macrosomia, short intervals between press and multiparous, csection) should be healed by 6wks pp. relaxin decreases, pelvic bones return to prepregnant state by 5 months. skin striae,
-csection incision should heal in 6 wks, roll to side while getting out of bed.
GI system: n/v common, constipation (dehydration, poor diet, decreased motility, hormonal shifts or meds for pain), hemorrhoids- fear of defecation due to this pain
Wt loss: 10-15 lb immediately after birth. weight will gradually decrease. Eat 330 extra calories per day for breastfeeding
Neuro: elevated up to 20-30,000- returns to 4-10 by 1 week PP
Breast changes and lactation
Lactogenesis (secrete milk)- after birth, progesterone levels drop and prolactin levels rise, which triggers the second stage of this process- secretion.
-Colostrum- nutrient dense, antibody filled, thick milk (for 2-3 days)- increase in temp when milk comes in
-supply/demand system- newborns feed every 2-3 hours
-foremilk: high in water and protein, low in fat- released at beginning of breastfeeding session
-hindmilk- high in fat and calories, released later in breastfeeding session (important to empty one breast before switching sides)
- engorgement- achy, full breasts
-letdown- reflex caused by release of oxytocin that contracts alveoli, ejecting milk from breast ( caused by: heat, hearing infants cry, thinking of infant, or while infant is feeding)
can be stopped by cold therapy
Maternal Role attainment theory
early skin-to-skin contact, breast feeding, and minimizing time apart promotes bonding, decreases maternal anxiety and allows for maternal role attainment
1st hour =golden hour
PPH
cause: vag (500 mL) or csection (1000 ml)- uterine atony (r/t infection or retained placenta or fetal membranes- most common causes)
RF: polyhydramnios, multiple pregs, macrosomia, mag sulfate or anesthesia use, gestational HTN, intrauterine fetal demise
tx: firm massage and utertonic admin
Venous thromboembolic conditions
DVT, PE (acute onset of cough, sweating, pleuritic chest pain, dyspnea),
TX: PP: low molecular weight heparin/heparin, rivaroxaban for 10 days. Pregnant: heparin (warfarin and anti Xa crosses placenta.
Nursing: compression therapy, NSAIDS, encourage ambulation,
endometritis
infection of lining of uterus
cause: mix of bacteria from genital tract. common with emergent csection.
RF: chorioamnionitis, prolonged labor, PROM, multiple cervical exams during labor, internal monitoring during labor, preterm, maternal diabetes/anemia
prognosis: uterus may become soft and sub involuted- hemorrhage, peritonitis, thromboembolism, pelvic abscesses, sepsis and death
s/s: fever, tender uterus, tachy, purulent lochia, flu-like symptoms,
Tx: broad spectrum abx
lactational mastitis
inflammation of breast tissue, with infection
cause: engorgement of one or more milk ducts bc of poor drainage (nipple damage or compression of duct). stagnant milk can cause bacteria growth in milk
RF for duct damage/delayed breast emptying: consistent pressure on breast, ill fitting bra, oversupply of milk, nipple trauma, rapid weaning, illness of pt or baby, mom stress or fatigue
prognosis: signs should improve within 48-72 hours- if not get US for abscess: usually tender and non fixed, compresses with palpation
Assessment: area of breast becomes red, swollen and painful. most common in first 3 months of lactation
Tx:cold compress, NSAIDS, regular complete emptying of breast. longer than 12-24 hours =-12 hours infection- give abx- dicloxacillin, clindamycin for 10-14 days
PP blues
transent, self-limiting mood disorder- within 2-3 days after delivery and resolves within 2 weeks
s/s: insomnia, fatigue, dysphoria, impaired concentration
PP depression
onset during pregnancy or in first 4 weeks after birth
RF: genetics, hormones, brain changes PP
prognosis: less likely to breastfeed, less bonded with baby, less likely to participate in infant safety activity. Child is also more prone to health issues: asthma and diabetes, small/underweight
Dx: 5 of 9 diagnostic criteria
PP psychosis
disturbance of pt perception of reality PP- hallucinations, thought disorganization, disorganized behavior and delusions
RF: previous hx of psychotic disorders
Tx: safety for child and mom. hospitalization, antipsychotic meds
Bishop Score
parameter include: dilation, effacement, station, cervical consistency and position of cervix
cervical consistency: firm, medium, soft
cervical positioning: becomes anterior and in line with vaginal introitus
Score >6 is favorable- higher chance of successful vag delivery
Pharm ripening
prostaglandins (given before oxytocin and may initiate contractions w/o need for oxytocin)
ex: misoprostol (vaginal or oral- 25-50 mcg Q3-6H) or dinoprostone (intravaginal)
mechanical ripening
insertion and expansion of balloon catheter in cervix or hygroscopic dilators. lower risk for tachysystole but higher risk for infection
Pitocin administration
60U/1000mL
- dosage increases until contractions are strong, regular, occurring 3-5x in 10 mins
-SE: n/v, HA, flushing, tachy, hypotension, arrhythmias, hyponatremia (HA, GI distress, abd pain, mental change, seizure)
-tachysystole risk: >5 contractions in 10 min, if it persists give tocolytic (terbutalines)
Forceps-assisted birth
outlet, low or mid forceps (highest risk for fetal injury)
complications: scalp and facial lacerations, eye trauma, intracranial or subgaleal hemorrhage, skill fracture,
vacuum-assisted birth
suction against fetal head and aids in extraction
-more likely to use this than forceps
-lower rate of patient injury
-soft cups-occiput anterior presentations
-rigid cups- less likely to detach, for OP and transverse positions
Cesarean birth
indications: fetal malpresentation, failure to progress, nonreassuring fetal status. abnormal placentation (previa), uterine rupture, cord prolapse, genital herpes
RF: r/t anesthesia, bowel and bladder injury, hemorrhage, air/amniotic fluid embolism. Infection at wound site, UTI, endometritis. atelectasis, bowel dysfunction
complications: wound hematoma or dehiscence, necrotizing fasciitis and thromboembolism
Nursing: educate pt about risks, benefits and alternatives. consent form!! Minimize distraction, play music for patient, dim lights, meds for aspiration risk minimization. catheter
TOLAC
only attempted in setting with access to advanced OB care
best candidates: low risk for uterine rupture and high likelihood of successful VBAC
contraindications: close together preg, fetal macrosomai, AMA, maternal comorbid conditions, more than 1 previous csection, >40 wks gestational deliveries
considerations: prostaglandins contraindicated, OB hx
Uterine Rupture
tear in wall of uterus
RF: labor induction with prostaglandins or oxytocin with csection hx, vertical uterine incision
assessment: first signs include category 2 or 3 fetal HR, bradycardia, decals, mom hemodynamic instability (hypotension, tachy), weakening contractions, loss of fetal stations, abd pain, vag bleeding
Tx: triggers csection. give IV fluids and blood, general anesthesia if epidural or spinal isn’t inlace, may result in hysterectomy
Cord prolapse
umbilical cord precedes fetal head in birth canal- increase risk for hypoxia due to cord compression
-overt: cord slips out of vagina ahead of fetus
-occult: cord descending next to fetus and entrapped
RF: non vertex position, low birth weight, prematurity, uterine malformations, multiple pregs, polyhydramnios
interventional RF: AROM,mechanical cervix ripening, labor induction, forceps/vacuum, fetal scalp electrode, IUPC etc
s/s: change in FHR tracing, severe brady and cariable decels. maternal hypotension, placental abruption, uterine rupture, and uterine tachysystole. PAINLESS AND NO BLEEDING
asses/tx: FHR monitoring, csection
Amniotic fluid embolism (anaphylactoid syndrome of pregnancy)
rare- amniotic fluid enters maternal circulation
RF: labor induction, operative delivery, AMA, cervical lacerations, eclampsia, fetal distress, placenta previa or abruption, grand multiparity,
complications: cariogenic shock, inflammation or anaphylactic reaction. resp failure
assess: during labor up to 48H after delivery. resp failure signs and cardiac arrest, hemorrhagic shock w/ DIC if they survive the first signs
Tx: no tx, correct hypotension and hypoxemia. intubation, blood products, fluids, vasopressor. Csection
meconium stained amniotic fluid
fetal stool in the fluid
RF: post-term pregnancy, diabetes, HTN, prolonged labor, decreased o2 to fetus, fetal growth restriction
associations: increase risk for chorioamnionitis, non reassuring FHR, fetal hypoxia, meconium aspiration
fetal risks: resp distress, acidemia, seizures, cerebral palsy, sepsis
shoulder dystocia
obstruction of fetal descent by the shoulders after birth of head
associated with maternal diabetes and macrosomia
S/s: “turtle sign”- fetal head is born but cheeks rest on the patient introitus as the fetal anterior should is unable to pass beneath pubic bone
Tx: McRoberts maneuver- sharply flex patients hips with their knees pulled back to their chest. and suprapubic pressure- push down on abd at level of pubic bone while the provider guides the head down toward patient anus
