OB Test 2 Flashcards
What are the broad categories associated with factors of high risk pregnancies?
- Biophysical - factors that originate within the mother or fetus and affect the development or functioning of either one or both (ex. genetic, nutritional)
- Psychosocial - maternal behaviors and adverse life events that have a negative effect on the health of the mother or fetus (ex. emotional distress, depression, drinking, substance abuse)
- Sociodemographic - the context in which the mother and family live (ex. low income, lack of prenatal care)
- Environmental - hazards in the workplace and the woman’s general environment and may include environmental chemicals (ex. anesthetic gases, radiation)
What are the possible risks of smoking to the fetus?
low birth weight
higher neonatal mortality rates
increased miscarriage rate
increased incidence of prelabor rupture of membranes
What are the possible risks of caffeine to the fetus?
> 200mg caffeine daily (about 12 ounces coffee/day) may increase the risk for giving birth to infants with intrauterine growth restriction (IUGR)
What are the possible risks of alcohol to the fetus?
fetal alcohol syndrome
fetal alcohol effects
learning disabilities
hyperactivity
What are the possible risks of drugs to the fetus?
teratogenic effects
metabolic disturbances
chemical effects
depression or alteration of central nervous system
What are the possible risks of psychologic status to the fetus?
birth complications related to emotional stress
How many fetal kicks warrant further evaluation by a non stress test?
fewer than 3 in 1 hour
What is a transvaginal ultrasound used for?
Used in the first trimester to detect ectopic pregnancies, monitor the developing embryo, help identify abnormalities, and establish gestational age.
(full bladder is not needed)
(can be used in second and third trimester along with abdominal scanning to evaluate preterm labor.)
What is an abdominal ultrasound used for?
Used after the first trimester once the uterus has become an abdominal organ to assess the fetus.
(full bladder is needed to displace the uterus upward to provide a better image.)
What is gestational dating by ultrasonography indicated for?
conditions such as uncertainty regarding the date of the last normal menstrual period, recent discontinuation of oral contraceptives, bleeding episode during the first trimester, uterine size that does not correlate with dates, and other high risk conditions.
What standard set of measurements have been accepted as being the most useful for determining gestational age in the first trimester?
crown-rump length biparietal diameter (BPD) head circumference abdominal circumference femur length
After what week of gestation is ultrasound dating less reliable and why?
after 22 weeks of gestation because of variability in fetal size
At what rate is average fetal growth?
1 cm per week
What physiological parameters of the fetus can be assessed with ultrasound?
Amniotic fluid volume (AFV) Vascular waveforms from fetal circulation Heart motion Fetal breathing movements (FBMs) Fetal urine production Fetal limb and head movements
How is the blood flow in a fetus and placenta studied?
Through a doppler blood flow analysis
How does doppler blood flow analysis work?
It uses systolic/diastolic flow ratios and resistance indices to estimate blood flow in various arteries.
What are the vessels that are most often studied through doppler blood flow analysis?
the fetal umbilical and middle cerebral arteries and the maternal uterine arteries.
What is severe restriction of umbilical artery blood flow as indicated by absent or reversed flow during diastole associated with?
IUGR (intrauterine growth restriction)
What does significantly increased peak systolic velocity in the middle cerebral artery predict?
moderate to severe fetal anemia
What does abnormal maternal uterine artery doppler waveforms predict?
fetal growth restriction
What amniotic fluid volume is considered to be healthy?
2.5 or greater
What are subjective determinants of oligohydramnios? objective?
Subjective - fundal height that is small for gestational age and fetus that is easily palpated.
Objective - the maximum vertical pocket of amniotic fluid is less than 1 to 2 cm.
What are subjective determinants of polyhydramnios? objective?
Subjective - fundal height that is large for gestational age and fetus that cannot easily be palpated or that is ballotable.
Objective - pockets of amniotic fluid measuring more than 8 cm.
How is the total AFV (amniotic fluid volume) evaluated?
by a method in which the vertical depths (in cm) of the largest pocket of amniotic fluid in all four quadrants surrounding the maternal umbilicus are totaled, providing an amniotic fluid index (AFI).
What AFI (amniotic fluid index) indicates oligohydramnios?
less than 5 cm
What AFI (amniotic fluid index) indicates polyhydramnios?
25 cm or more
What is oligohydramnios associated with?
congenital anomalies and prelabor rupture of membranes.
What is polyhydramnios associated with?
gastrointestinal and central nervous system (CNS) abnormalities, multiple fetuses, and fetal hydrops.
What does BPP stand for and what is it?
biophysical profile - a noninvasive dynamic assessment of a fetus that is based on acute and chronic markers of fetal disease. (physical examination of fetus including determination of vital signs)
When is the BPP most frequently used and why?
In the late second and the third trimester for antepartum fetal testing because it is a reliable predictor of fetal well-being
What is a normal BPP score?
8 to 10 with a normal AFV
What is a modified BPP?
A shortened version of the BPP that assesses the components that are most predictive of perinatal outcome.
(combines the NST (nonstress test) with the measurement of the quantity of amniotic fluid (AFV); AFV is determined by measuring a single deepest pocket of fluid instead of using the AFI.
What is a desired modified BPP score?
a reactive NST and a single deepest vertical pocket of amniotic fluid that is more than 2 cm.
What is percutaneous umbilical blood sampling (PUBS)?
A testing procedure that is used for fetal blood sampling and transfusion; provides direct access to the fetal circulation during the second and third trimesters.
How is a PUBS test performed?
by the insertion of a needle directly into the fetal umbilical vessel under ultrasound guidance.
What is an important consideration for all invasive procedures that penetrate the cervix/abdomen/amnion?
Rh and rhogam
What is the multiple marker test and when can it be done?
a screening used to detect fetal chromosomal abnormalities, particularly trisomy 21 (down syndrome); available beginning in the first trimester of pregnancy at 11-14 weeks of gestation.
What test screens for Rh incompatibility?
Coombs’ test
What is the contraction stress test (CST) and how does it work?
(oxytocin challenge test OCT) A graded stress test of the fetus used to identify the jeopardized fetus that was stable at rest but showed evidence of compromise after stress.; provides an earlier warning of fetal compromise than the NST and produces fewer false-positive results.
What tests are nurses able to perform in many settings?
NST (non stress test)
CST (contraction stress test)
BPP (biophysical profile)
What are the two methods of stimulation in a CST test?
nipple stimulation
oxytocin stimulation
What percentage of maternal deaths worldwide can be attributed to preeclampsia and eclampsia?
10-15%
What are some complications of hypertensive disorders?
Renal failure Coagulopathy Cardiac or liver failure Placental abruption Seizures Stroke, CNS irritability
gestational hypertension
the onset of hypertension without proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of pregnancy.
How is hypertension defined?
a systolic BP greater than 140 and a diastolic BP greater than 90 recorded at least 4 hours apart on at least two separate occasions. (only one pressure, systolic or diastolic, must be elevated to meet the definition)
Preeclampsia
a pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman
In what circumstances can preeclampsia be defined in the absence of proteinuria?
When hypertension is present along with one of the following:
thrombocytopenia
impaired liver function
new development of renal insufficiency
pulmonary edema
now-onset cerebral or visual disturbances
Chronic hypertension
hypertension that is present before the pregnancy or diagnosed before week 20 of gestation
(can occur with or without preeclampsia)
What are some common risk factors of preeclampsia?
Primigravidity in woman <19 or >40 years of age First pregnancy with a new partner History of preeclampsia Pregnancy-onset snoring Multiple fetuses African American Obesity/gestational diabetes mellitus
What is the root cause of preeclampsia?
the placenta
HELLP syndrome
a laboratory diagnosis for a variant of preeclampsia that involves hepatic dysfunction, characterized by:
H = hemolysis
EL = elevated liver enzymes
LP = low platelets
What symptoms do most women with HELLP syndrome report?
- History of malaise
- Influenza-like symptoms
- Epigastric or right upper quadrant abdominal pain
- symptoms worsen at night and improve during the daytime
What pharmaceutical intervention may help certain women who are high risk for preeclampsia?
low-dose aspirin (60-80 mg)
What assessments aid in early detection of hypertensive disorders?
- Accurate BP measurements
- Assessment of edema
- DTRs (deep tendon reflexes)
- hyperactive reflexes (clonus)
- proteinuria
- signs/symptoms of sever preeclampsia (headaches, epigastric pain, rt upper quad abdominal pain, visual disturbances)
How are DTRs graded?
+1, 2, 3
1 is normal, 3 is very brisk and indicative
What are some of the considerations related with activity restriction/bed rest?
isolation
psychological stress
blood clots
cardiovascular deconditioning
What is intrapartum care directed towards in women with severe gestational hypertension and preeclampsia with severe features?
the early id of FHR abnormalities and the prevention of maternal complications
What does care look like in women with severe gestational hypertension and preeclampsia with severe features?
- Bed rest with side rails up
- Darkened environment
- Mag Sulfate therapy
- Antihypertensive medications
- Education of lengthy treatment and need to arrange support for home, work, children, etc.
How does Magnesium sulfate affect the pregnancy?
- delay labor progression
How does the development of evere gestational hypertension and preeclampsia with severe features affect future pregnancies?
- Seven fold risk of developing preeclampsia or eclampsia in a future pregnancy
- increased risk of adverse perinatal outcomes
What maternal complications is chronic hypertension associated with?
- placental abruption
- superimposed preeclampsia
- stroke
- acute kidney injury
- heart failure
- death
- fetal risks: IUGR, death, preterm birth
A client at 36 weeks of gestation presents to labor and delivery complaining of a constant headache for the past 2 days. She also states that her face “seems more swollen than usual.” What should be the nurse’s first action?
D. Take the client’s blood pressure
What are maternal risks from maternal hemorrhage (blood loss)?
- hypovolemia
- anemia
- infection
- preterm labor
- impaired oxygen delivery to the fetus
What are fetal risks from maternal hemorrhage (blood loss)?
- blood loss (anemia)
- hypoxemia (below-normal level of O2 in your blood)
- hypoxia (absence of enough O2)
- anoxia (absence of O2)
- preterm birth
What effect does maternal hemorrhage have on oxygen?
decreases oxygen-carrying capacity
Miscarriage (spontaneous abortion)
a pregnancy that ends as a result of natural causes before 20 weeks of gestation
Threatened miscarriage
abnormal bleeding and abdominal pain that occurs while the pregnancy still continues (cervix is closed and bleeding is slight)
Inevitable miscarriage
unexplained vaginal bleeding and abdominal pain during early pregnancy (cervix is open and bleeding is moderate)
Incomplete miscarriage
some—but not all—of the pregnancy tissue is passed.
Cervix is open with tissue remaining and bleeding is heavy
Complete miscarriage
all of the pregnancy tissue is expelled from the uterus.
cervix is already closed after the passage of tissue and bleeding is slight
Missed miscarriage
fetus implants, but fails to develop
cervix is closed and bleeding is spotting to none
Septic miscarriage
miscarriage that leads to infection in the uterus
cervix is usually open and bleeding varies
Recurrent miscarriage
three or more spontaneous pregnancy losses before 20 weeks of gestation or with a fetal weight of less than 500 g.
Cervical insufficiency
passive and painless dilation of the cervix leading to recurrent preterm births during the second trimester in the absence of other causes.
What are the risk factors for congenital cervical insufficiency?
- collagen disorders
- uterine anomalies
- ingestion of diethylstilbestrol (DES) by the woman’s mother while pregnant
What is the risk factors for acquired cervical insufficiency?
- history of previous cervical trauma resulting from lacerations during birth or mechanical dilation of the cervix during gynecologic procedures.
How is cervical insufficiency diagnosed?
by a thorough obstetric history along with speculum and digital pelvic examinations and a transvaginal ultrasound examination.
What does the speculum and digital pelvic examination help to identify in cervical insufficiency?
an opening at the internal cervical os, prolapsed fetal membranes, or both.
What does the transvaginal ultrasound examination reveal in cervical insufficiency?
an abnormally short (<25mm) cervix, often accompanied by cervical funneling (beaking)
What is cervical funneling?
effacement of the internal cervical os while the external cervical os remains closed.
Cervical cerclage placement
the treatment for women with cervical insufficiency due to cervical weakness in which a suture is placed around the cervix beneath the mucosa to constrict the internal os of the cervix. (may be placed either prophylactically or as a therapeutic or rescue procedure after cervical change has been identified, or subsequent pregnancy 15-17 wks )
When is a cervical cerclage placed? removed?
Placed at 12-14 weeks
Removed by 36 weeks of gestation
What is the follow-up care recommendations following cerclage?
- Bed rest for a few days following placement
- Watch for and report signs of preterm labor, rupture of membranes, pelvic pressure and infection
- cervix length checks every 2 weeks
Ectopic pregnancy
the fertilized ovum is implanted outside the uterine cavity; also called “tubal pregnancies”
When due ectopic pregnancies usually occur and what are the three most classic symptoms?
6-8 weeks after last normal menstrual period
- abdominal pain
- delayed menses
- abnormal vaginal bleeding (spotting)
Cullen sign
hemorrhagic discoloration of the umbilical area due to intraperitoneal hemorrhage (edema & bruising)
How is an ectopic pregnancy medically managed?
with methotrexate (50 mg/m2 IM or 1 mg/kg)
how does methotrexate work on tubal pregnancies?
it dissolves ectopic pregnancies by destroying rapidly dividing cells
How is an ectopic pregnancy surgically managed?
Either by a salpingectomy (removal of the entire tube) or a salpingostomy (incision made in tube to remove products of conception and then allowed to reclose.
Hydatidiform mole (molar pregnancy)
a benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grape like cluster.
How is a Hydatidiform mole (molar pregnancy) managed?
Suction curettage
In patient D&C
Out patent Misoprostol
What is the complications associated with placenta previa?
- major complication is hemorrhage
- fetal death (caused by preterm birth)
- stillbirth, malpresentation, fetal anemia, IUGR
How is placenta previa diagnosed?
with a transabdominal ultrasound
What is the primary risk factor for placental abruption?
maternal hypertension (substance abuse as well)
What are the symptoms of placental abruption?
vaginal bleeding, intense abdominal pain, and uterine tenderness and contractions
What is the process of normal clotting?
the hemostat system stops flow of blood from injured vessels, first by a platelet plug, then by the formation of a fibrin clot (homeostasis exists between the opposing hemostatic and fibrinolytic systems)
DIC (disseminated intravascular coagulation)
Pathologic form of diffuse clotting that consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both
What is DIC a result of?
other acute or traumatic event, Post mag, serum marker + fibrin split products.
How is DIC managed?
Correction of the underlying causes
Often blood transfusion
In caring for an immediate postpartum woman, you note petechiae and oozing from her IV site. You monitor her closely for which clotting disorder?
a. Disseminated intravascular coagulation (DIC)
b. Amniotic fluid embolism (AFE)
c. Hemorrhage
d. HELLP syndrome
A. DIC
What might be a cause of third trimester bleeding?
Placenta previa
Placental abruption
Cord insertion (Vasa previa, Battledore)
gestational diabetes
carbohydrate intolerance with the onset or first recognition occurring during pregnancy.
pregestational diabetes
type 1 or 2 diabetes that existed prior to pregnancy
how do normal hormonal changes in pregnancy affect glycemic control?
During the first trimester when maternal blood glucose levels are normally reduced and the insulin response to glucose is enhance, glycemic control may be improved and the insulin dose may have to be reduced.
How does pregnancy affect the vascular complications associated with diabetes?
pregnancy may accelerate the progress of vascular complications
About what percentage of pregnancies has preexisting DM?
about 10%
What are the benefits of preconceptions counseling for someone with pregestational diabetes?
- Decreases perinatal morbidity and mortality
- Fewer congenital anomalies
- Establish glycemic control before conception
- Dx any vascular complications such as Retinopathy, Nephropathy, Neuropathy, Cardio or cerebrovascular disease and Peripheral – poor circulation
How many women with pregestational diabetes get preconception counseling?
fewer than 20%
What puts a woman at an increased risk for gestational diabetes?
- BMI greater than 29.9
- History of GDM
- Family history of DM
- macrosomia (newborn >/= 9lbs)
What are the two steps in the screening method for GDM?
- 50 g oral glucose load followed by a plasma glucose measurement 1 hour later (no fasting required)
- a 3 hour (100 g) oral glucose tolerance test (OGTT) administered after an overnight fast and at least 3 days of unrestricted diet and physical activity.
When are m most woman screened for GDM during pregnancy?
between 24-28 weeks gestation
How does Metformin work?
decreases hepatic glucose production and increases peripheral sensitivity to insulin (larger doses, about 500 mg - crosses the placenta in maternal levels)
How does Glyburide work?
by causing the maternal pancreas to produce more insulin (typically starts about 2.5 mg dose - crosses the placenta at lower levels than Metformin)
hyperemesis gravidarum
excessive, prolonged vomiting accompanied by:
- weight loss
- electrolyte imbalance
- nutritional deficiencies
- ketonuria
How does DKA (diabetic ketoacidosis) affect the fetus?
increased risk for fetal death
How should a woman with GDM alter her diet?
- well-balanced diet
- divide daily food intake among three meals and tow or three snacks
- eat a substantial bedtime snack
- avoid foods high in refined sugar
- take vitamins and iron as prescribed
- eat consistently each day
- eat foods high in fiber
- avoid alcohol and nicotine; limit caffeine
- avoid excessive use of sweeteners
What is the target blood glucose level post meal during pregnancy?
Postmeal (1 hr) - <140
Postmeal (2 hr) - =120
What is Pruritic urticarial papule and plaques of pregnancy (PUPPP) and what is another name for it?
(polymorphic eruption of pregnancy)
A pregnancy skin rash that causes severe itching associated with increase maternal weight gain and twin gestation; often in the 3rd trimester of primigravidas pregnancies carrying male fetus.
Where do the lesions associated with PUPPP occur?
in the abdomen, arms, thighs, and buttock
How is PUPPP treated?
with lotions, antihistamines, and prednisone in severe cases
What is Intrahepatic Cholestasis of pregnancy (ICP)?
the most common liver disease of pregnancy characterized by generalized pruritus (itching commonly affects the palms and soles but can appear anywhere) that usually begins in the third trimester of pregnancy.
How is ICP diagnosed?
with elevated bile acids and liver function test (LFT)
How is ICP treated?
with ursodeoxycholic acid which effectively controls the pruritus and lab abnormalities
What risks to the fetus are associated with ICP?
asphyxia, meconium, stillbirth and preterm birth (birth at 37 wks considered)
Bell Palsy
an acute idiopathic facial paralysis that presents as a sudden onset of unilateral face weakness, droop
What is the cause of Bell Palsy?
the cause is unknown but may be related to reactivation of HSV or herpes zoster virus; increased risk in pregnant women (4xs more likely)
What are the risks associated with the development of Bell Palsy during pregnancy?
increased risk of gestational HTN or preeclampsia
What is the treatment for Bell Palsy?
Most recover without treatment but steroid therapy is the only medical treatment that has been shown to influence the outcome of Bell Palsy; must begin within the first 3-5 days after onset.
Asymptomatic bacteriuria
the persistent presence of bacteria within the urinary tract of women who have no symptoms; can cause preterm birth and low birth weight; treated with antibiotics
Cystitis
bladder infection characterized by dysuria, urgency, and frequency, along with lower abdominal or suprapubic pain; treated with antibiotics
Pyelonephritis
(renal infection) One of the most frequent serious medical complications of pregnancy and a leading cause of septic shock during pregnancy.
What is the most common cause of pyelonephritis?
E Coli
What is the treatment for pyelonephritis?
May need IV antibiotics; some prefer initial treatment with ampicillin and gentamicin instead; Mild to moderate cases can be treated on an outpatient basis.
What should be the first step for the trauma team when there is trauma during pregnancy?
Complete assessment and stabilization of the mother (fetal survival depends on maternal survival)
What is involved in the primary survey following trauma during pregnancy?
CABDs of resuscitation: compressions, airway, breathing, and defibrillation;
Balanced ration administration of blood products (platelets, plasma, packed RBCs 1:1:1)
What are the most common underlying causes of maternal cardiac arrest?
hemorrhage, heart failure, amniotic fluid embolism, and sepsis
How does CPR differ in the second half of pregnancy?
- uterine displacement
- if defibrillation is needed, the paddles must be placed on rib interspace higher than usual
What maternal complications are associated with CPR on a pregnant woman?
- laceration of the liver
- rupture of the spleen or uterus
- hemothorax
- hemopericardium
- rib fracture
What are fetal complications are associated with CPR on a pregnant woman?
- cardiac arrhythmia or systole related to maternal defibrillation and medications
- CNS depression related to antiarhythmic drugs and inadequate uteroplacental perfusion
- possible fetal hypoxemia and acidemia
What happens during the secondary survey following trauma during pregnancy?
A more detailed survey of the mother and fetus is accomplished and a physical assessment including all body systems is performed.
How long is electronic fetal monitoring recommended after blunt trauma in a viable gestation?
4 hours regardless of injury severity
What early signs of placental abruption might EFM (electronic fetal monitoring) show?
change in baseline rate
loss of accelerations
the presence of late decelerations
What can fetomaternal hemorrhage lead to?
fetal anemia, distress, or death
How much blood do most cases of fetomaternal hemorrhages involve?
less than 30 mL
What is ultrasound used for following a trauma during pregnancy?
to help establish gestational age, locate the placenta, evaluate cardiac activity, and determine amniotic fluid volume
When should a perimortem cesarean birth be performed?
after 4 minutes of resuscitative efforts if there is no spontaneous return of circulation and the pregnancy is at or beyond fetal viability (23-24 weeks); emptying uterus early may improve the outcome for both mom and baby
If a pregnant women presents with abdominal pain that may require surgery, it is important for the nurse to understand that:
a. The diagnosis of appendicitis may be difficult because the normal signs and symptoms mimic some normal changes in pregnancy.
b. Rupture of the appendix is less likely in pregnant women because of the close monitoring.
c. Surgery for intestinal obstructions should be delayed as long as possible because it usually affects the pregnancy.
d. When pregnancy takes over, a woman is less likely to have ovarian problems that require invasive responses.
A. the diagnosis of appendicitis may be difficult because the normal signs and symptoms mimic some normal changes in pregnancy. (Both appendicitis and pregnancy are linked with nausea, vomiting, and increased white blood cells )
What is the leading cause of maternal death?
car accidents
What are the risks to the fetus when mother has cystic fibrosis?
uteroplacental insufficiency and IUGR
What are the risks associated with sickle cell?
increased risk for preeclampsia, intrauterine fetal death, preterm birth, low birth weight infants, and postpartum endometritis; increased risk for UTIs
What are the signs of a sickle cell crisis?
fever and pain, most often in the abdomen, joints, or extremities, although any organ system can be affected.
What are sickle cell crisis triggered by?
dehydration, hypoxia, or acidosis
What is the Edinburgh Postnatal Depression Scale
10-question Edinburgh Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for “perinatal” depression. (Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity)
What form of Edinburgh Postnatal Depression Scale to many hospitals use?
The Adult Outcomes Questionnaire (AOQ)
What percentage of women experience depression symptoms during pregnancy?
between 14% and 23%
What percentage of women will have postpartum depression (PPD)?
an estimated 5% to 25%
What are anxiety disorders characterized by?
prominent symptoms of anxiety that impair functioning
How much more likely are women to be diagnosed with anxiety disorders than men?
twice as likely
What are examples of anxiety disorders?
Obsessive-compulsive disorder (OCD) PTSD Generalized anxiety disorder Panic disorder Agoraphobia and other phobias
What are symptoms of postpartum depression without psychotic features (PPD)?
intense and pervasive sadness,
lack of desire to care for self,
sleep disturbances
irritability
What is the treatment for PPD?
Antidepressants
Psychotherapy
What are symptoms of postpartum depression WITH psychotic features?
Delusions
Thoughts of harming self or baby
Similar to bipolar
How common is postpartum depression WITH psychotic features?
Rare, affecting approximately 0.1% to 0.2% of postpartum women
What is the treatment for postpartum depression WITH psychotic features?
inpatient psychiatric care
Antipsychotics, mood stabilizers, benzodiazepines
Antidepressants
In the past, women were told to choose between psychotropic medications and breastfeeding their infant. Current beliefs are that although most drugs will diffuse into breast milk, there are few instances in which breastfeeding must be discontinued. Several factors are known to influence the amount of drug an infant will receive via breast milk. Which is not one of these factors?
a. Amount of milk produced
b. Composition of the milk
c. Concentration of the medication
d. Offering of single or both breasts
D. Offering of single or both breasts
Whether both breasts are offered at a feeding is not a factor related to the amount of a psychotropic medication found in breast milk. Whether the breasts are fully emptied during the previous feeding is a contributing factor.
Presentation
refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term
How many bones make up the fetal skull? What are they?
6 bones: 2 parietal 2 temporal 1 occipital (back) 1 frontal
How are the bones of the fetal skull connected?
by connective tissue (sutures)
What is molding and what is it for?
overlapping of skull bones; occurs during labor and allows for adaptation through maternal pelvis
fetal attitude
the relation of the fetal body parts to one another
what is the general flexion fetal attitude referring to?
the back of the fetus is rounded os that the chin is flexed on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees. The arms are crossed over the thorax, and the umbilical cord lies between the arms ant eh leges.
biparietal diameter (BPD)
the largest transverse diameter and an important indicator of fetal head size; measures diameter from 1 parental bone to the other (about 9.25 cm at term)
suboccipitobregmatic diameter
the diameter of the fetal head from the lowest posterior point of the occipital bone to the center of the anterior fontanelle
fetal station
a measure of the degree of descent of the presenting part of the fetus through the birth canal in relation to ischial spines
What is referred to as the primary powers during labor?
involuntary uterine contractions that signal the beginning of labor.
What is referred to as the secondary powers during labor?
voluntary bearing down efforts by the woman once the cervix has dilated
Primary powers (involuntary contractions): frequency
the time from the beginning of one contraction to the beginning of the next
Primary powers (involuntary contractions): duration
length of contraction
Primary powers (involuntary contractions): intensity
strength of contraction at its peak
Effacement
the shortening and thinning of the cervix during the first stage of labor (normally 2-3 cm long and appropriate 1 cm thick)
dilation
the enlargement or widening of the cervical opening and the cervical canal that normally occurs once labor has begun (increases from less than 1 cm to full dilation at approximately 10 cm)
ferguson reflex
the urge to bear down and push caused by a release of endogenous oxytocin produced by stretch receptors in the posterior vagina.
Valsalva maneuver
a particular way of breathing that increases pressure in the chest; process of bearing down which increases intrathoracic and cardiovascular pressure
What effect do the secondary powers have on cervix dilation?
none; they are used after full effacement and dilation
What happens during lightening?
the uterus sinks downward and forward about 2 weeks before term when the presenting part of the fetus (usually the fetal head) descends into the true pelvis relieving pressure below the ribcage; easier to breathe and eat
(may not start until uterine contractions)
What does the pregnant woman feel during lightening?
less pressure below the ribcage easier to breathe and eat low back pain sacroiliac pain in the pelvic joints more frequent braxton hicks contractions burst of energy (nesting) Weight loss due to electrolyte shift Sometimes: diarrhea, indigestion, nausea and vomiting
bloody show
passing of brownish or blood-tinged cervical mucus
What are the mechanisms of labor?
turns and adjustments necessary in human birth process
What are the 7 cardinal movements?
- Engagement-bpd passes pelvic inlet
- Descent-progress of presenting part
- Flexion-chin moves closer to chest when pelvic floor resistance is met on descending
- Internal rotation
- Extension-passing under the symphysis extending occiput then face and chin
- Restitution and external rotation – movement of the head back to the position it occupied at inlet then rotation as the shoulders are deloverd
- Expulsion-trunk of baby is born as the baby’s shoulders and head are lifted up towards mom’s pelvis
What is a major factor in determining the course of birth?
the size and relative rigidity of the fetal head (molding)
How long does the first stage of labor last?
from the time dilation begins to the time when the cervix is fully dilated
How long does the second stage of labor last?
from the time of full cervical dilation to the birth of the infant
how long doe she third stage of labor last?
from the infant’s birth to the expulsion of the placenta
how long does the fourth stage of labor last?
from the delivery of the placenta and includes the first 2 hours after birth.
With regard to fetal positioning during labor, nurses should be aware that:
a. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal.
b. Birth is imminent when the presenting part is at +4 to +5 cm, below the spine.
c. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter.
d. Engagement is the term used to describe the beginning of labor.
B. Birth is imminent when the presenting part is at +4 to +5 cm, below the spine.
What are the three things that are checked to determine labor?
Cervix is checked for dilation, effacement, and station
gate-control theory of pain
a theory that helps to explain the way hypnosis and the pain relief techniques taught in labor and birth preparation classes work to relieve the pain of labor.
What does the gate-control theory of pain believe?
pan sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through the passageways at one time. Distraction techniques reduce or completely block the capacity of nerve pathways to transmit pain.
What are some distraction techniques used in the gate-control theory of pain?
massage, aromatherapy, hypnosis, music, guided imagery
What do focusing and relaxation techniques do during childbirth?
reduce tension and stress, allowing the woman to rest and conserve energy in preparation for giving birth.
How does a woman use imagery during childbirth?
the woman focuses her thoughts on a pleasant scene, a place where she feels relaxed, or an activity she enjoys.
What is the purpose of breathing techniques during childbirth?
helps the laboring woman focus on something other than the contractions.
What is the recommended pattern of breathing during childbirth?
slow breathing in early labor, as it takes less concentration, and later, when labor becomes more active and intense, to move to quick breathing.
what are the characteristics of fentanyl-potent short acting opioid agonist analgesic?
rapid onset of action, short half-life, and lack of a metabolite; fewer neonatal side effects but more dosing.
how is fentanyl-potent short acting analgesic administered?
usually by PCA pump but also intrathecally or epidural alone or in combination
What are the risks of using opioid (narcotic) antagonists such as Meperidine and fentanyl?
they can cause excessive CNS depression in the mother, the newborn, or both; reversal agent Narcan
A woman in labor has just received an epidural block. The most important nursing intervention is to:
a. Limit parenteral fluids
b. Monitor the fetus for possible tachycardia
c. Monitor the maternal blood pressure for possible hypotension
d. Monitor the maternal pulse for possible bradycardia
C. Monitor the maternal blood pressure for possible hypotension
The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension.
what must be maintained during labor to prevent fetal compromise and promote newborn health after birth?
fetal oxygen supply
What can decrease fetal oxygen supply through maternal vessels?
HTN, hypotension (maternal position, epidural, hemorrhage)
hypovolemia, placental abruption
What can decrease fetal oxygen supply in maternal blood?
hemorrhage, severe anemia
What can decrease fetal oxygen supply through alterations in fetal circulation?
- cord compression, cord prolaps, partial or compete abruption
- head compression
- Reduction in blood flow to intervillous space in placenta-hyper tonus ( too much oxy)
- deterioration of placenta (post term or HTN or DM)
What are some electronic methods of fetal monitoring?
- ultrasound transducer
- toco transducer (tocodynamometer)
- Monica AN24
how does the ultrasound transducer work?
by reflecting high frequency sound waves off a moving interface (the fetal heart and valves)
What does the toco transducer (tocodynamometer) measure?
it measures UA transabdominally
how does the Monica AN24 work?
it uses five electrodes placed on the woman’s abdomen to directly monitor the electrocardiogram from the maternal and fetal hearts and the electromyogram from the uterine muscle; info is transmitted wirelessly via bluetooth
What are some methods of internal monitoring and what must have happened in order to use them?
- spiral electrode
- intrauterine pressure catheter (IUPC)
membranes must have ruptured in order to use them
how is information from internal monitoring devices displayed?
on the monitor paper or computer screen, with the Far in the upper section and UA (uterine activity) in the lower section
What are the risks associated with internal fetal monitoring?
risk of fetal injury
risk of infection
How much data must be collected on the fetal heart rate in order to determine a baseline?
at least 2 minutes of interpretable baseline date
20 minutes is typically collected
What are early decelerations in FHR associated with?
fetal head compression
corresponds to beginning, peak and end of UC; considered benign, no intervention
What are late decelerations in FHR associated with?
utero-placental insufficiency
starts after UC, lowest point after peak of UC, return to base after
What are some causes of late decelerations in FHR?
- transient hypoxiema due to contraction disrupting oxygenated blood to fetus
- maternal hypotension, uterine hypotenuse, IUGR, DM, Chorio, Placenta previa, abruption, epidural
What are some interventions for late decelerations in FHR?
- stop oxygen
- assist women to side lying position
- admin O2 at 10 L/min
- correct maternal hypotension
- increase IV rate
- palate uterus for tachystole, excessively frequent UCs
prolonged deceleration
a visually apparent decrease (may either be gradual or abrupt) in FHR of at least 15 bpm below the baseline and lasting more than 2 minutes but less than 10 minutes.
What are causes of prolonged deceleration?
- level of the maternal lungs
- paternal arena during an eclamptic seizure
- level of the umbilical cord, cord compression, stretch, or prolapse
What are the five essential components of the FHR tracing that must be evaluated regularly?
- baseline rate
- baseline variability
- accelerations
- decelerations
- changes or trends over time
Baseline Fetal heart rate
the average rate during a 10 minute segment that excludes periodic or episodic changes, periods of marked variability, and segments of the baseline that differ by more than 25 bpm.
baseline variability
irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater.
accelerations
visually apparent, abrupt increase in FHR above the baseline rate.
intrauterine resuscitation
specific interventions initiated when an abnormal FHR pattern is noted.
What are some basic corrective measures used in intrauterine resuscitation?
supplemental oxygen
maternal position changes
increasing intravenous fluids
What is the desired result of fetal scalp stimulation and vibroacoustic stimulation?
an acceleration in the FHR of at least 15 beats/min for at least 15 seconds
amniofusion
infusion of room-temp isotonic fluid into the uterine cavity if the volume of amniotic fluid is low (usually normal saline or lactated ringer solution)
What characteristics are assessed regarding uterine contractions?
Frequency: how often they occur
Intensity: the strength at its peak
Duration: time between beginning and end
Resting tone: tension in the uterine muscle between contractions
What happens during the second stage of labor?
- begins with full cervical dilation
- complete effacement (vulva bulges and encircles head)
- the “pushing” stage
- ends with infant’s birth
lithotomy position
woman’s feet in stirrups or resting on foot rests or with her legs held and supported by the nurse or support person
crowning
the widest part of the head distends the vulva just before birth
Rigen maneuver
- applying pressure against the rectum, drawing it downward to aid in flexing the head as the back of the neck catches under the symphysis pubis
- applying upward pressure from the coccygeal region
Nuchal cord
when the umbilical cord encircles the baby’s neck
What reveals the fetal response to the stress of the labor process?
the fetal heart rate and pattern
how is the progress of labor enhanced?
when a woman changes her position frequently during the first stage of labor
After an emergency birth, the nurse encourages the woman to breastfeed her newborn. The primary purpose of this activity is to:
a. Facilitate maternal-newborn interaction
b. Stimulate the uterus to contract
c. Prevent neonatal hypoglycemia
d. Initiate the lactation cycle
B. stimulate the uterus to contract
Stimulation of the nipples through breastfeeding or manual stimulation causes the release of oxytocin and prevents maternal hemorrhage.
Preterm labor (PTL)
cervical changes and uterine contractions occurring at 20 to 37 weeks of pregnancy
Preterm birth
birth that occurs before the completion of 37 weeks
What is a sign of Preterm labor?
regular contractions, cervix effacing and dilated to 2 cm
tocolytics
medications given to arrest labor after uterine contractions and cervical change have occurred
What are some drugs used for tocolytic therapy?
magnesium sulfate
Terbutaline
What are the side effects of tocolytics?
respiratory distress
hypertonic uterine dysfunction
a common labor disorder that occurs during the latent phase of first stage labor where the woman experiences painful and frequent contractions that are ineffective in causing cervical dilation or effacement to progress.
How might hypertonic uterine dysfunction be treated?
provide therapeutic rest through a warm bath or shower and an analgesic to inhibit uterine contractions, reduce pain and encourage sleep.
hypotonic uterine dysfunction
an active-phase protraction disorder where the woman initially makes normal progress into the active phase of first stage labor, but then the contractions become weak and inefficient or stop altogether
What are signs of a breech delivery?
- mec staining
- Fetal heart tones heard mid or upper abdomen
- possible preterm labor and birth
bishops score
a rating system used to evaluate inducibility or cervical ripeness
What five things does the bishops score evaluate? How is it scored?
Each is worth 0-3 points. A score of 8-13 indicates that the cervix is soft, anterior 50% or more effaced and dilated.
- dilation
- effacement
- station
- cervical consistency
- cervical position
