S3 M3 Reproduction week 2 (placenta stuff) Flashcards
Placenta previa
afterbirth first
placenta shifts to lower uterus and covers the cervical opening
occurs last 2 trimesters
High risk of hemorrhage
Placenta previa risk increases with
Can lead to
C sections
Hemorrhage
Abruption (separation) of placenta
Emergency cesarean birth
Placenta previa pathophysiology
Assumed to be due to embryo implantation in lower uterus and scarring of the upper uterus
Is the placenta edge is less than 2cm from internal os but DOES not cover it, this is called
Low lying placenta
Therapeutic management of placenta previa
Prevention of primary cesarean section
Prenatal care and timely diagnosis
Placenta previa symptoms
Painless bright red vaginal bleeding during 2nd and 3rd trimester, recurring
1st bleeding occurs at 27-32 weeks
Uterine contractions may occur with bleeding
Diagnosing Placenta Previa
Transvaginal ultrasound
MRI
Placenta accreta, increta, parcreta
Accreta - adheres to myometrium
Increta - penetrates myometrium
Parcreta - goes past myometrium and into peritoneal lining
Myometrium
Central/widest layer of the uterus structure
Nursing management of placenta previa
S/S of vag bleeding
Fetal distress
educate pt about condition and options
Majority of women will need C section
Monitoring vag bleeding
Perpiad count for changes and frequency
estimate/document amount
Monitoring fetal distress
Fetal heart rate via doppler
Electronic monitoring
Have O2 ready
Encourage lying on side to increase placenta perfusion
Placental abruption
Early separation of placenta after the 20th week
bleeding occurs between decidua(thick mucus lining uterus during birth) ad placenta
leads to hemorrhage
Maternal consequences of having placental abruption
Hemorrhage Hysterectomy Disseminated intravascular coagulopathy DIC Postpartum gland necrosis Renal failure
Prenatal consequences of having placental abruption
Low weight, preterm birth, asphyxia, death
Placental abruption patho
Maternal vessels tear away from placenta, bleeding occurs between lining and placenta
As bleeding increases placenta separates and loses function
result is fetal hypoxia/death
Placental abruption classifications
0 1 2 3
0 - unrecognized, diagnosis made after birth
1 - bleeding less than 500ml, 10%-20% separation
2 - bleeding at 1000-1500ml, 20% to 50% separation
3 - bleeding over 1500ml, 50% separation
S/S of mild (1st stage) placental abruption
tender uterus
no coagulopathy
no shock
no fetal distress
S/S of moderate (2nd stage) placental abruption
Continuous abdomen pain Mild shock Normal maternal BP Maternal tachycardia Fetal distress
S/S of severe (3rd stage) placental abruption
Profound shock Dark vaginal bleeding Severe stomach pain v in maternal BP ^ in maternal HR DIC
Placental abruption onset is
FAST
unexpected
sudden
intense
Immediate treatment
Emergency measures for Placental abruption
2 large bore IV line
NS and LR
blood specimen for values and typing
Evidence of fetal distress = caesarian
Nursing assessment for placental abruption
Hemodynamic status and fetal wellbeing
Placenta previa onset is
placenta abruption onset is
Insidious
Sudden
Bleeding with previa vs abruption
Always visible, increasing episodes over time
Bright red
Can be concealed and severe
Dark red
Pain with previa vs abruption
uterine tone previa vs abruption
none
constant
soft
frim
Fetus during previa vs abruption
HR and presentation
HR normal
HR distress/absence
May breech of transverse lie
No relationship
Labs/diagnostics for Placental abruption for mom
CBC
Fibrinogen(clotting factor) level
PT aPTT time (coagulation status)
Blood typing
Labs/diagnostics for Placental abruption for fetus
Nonstress test - fetal jeopardy
Bio profile - fetal jeopardy
Nursing management of placental abruption
Strict bed rest
LEFT Lateral position, prevents pressure on vena cava.
Vitals Q15min for blood loss
Start Foley
Start Large bore IV port
In placental abruption, fundal height change/increase indicates
bleeding
In placental abruption monitor for DIC symptoms which are
Gum bleeding
Tachycardia
Oozing at IV site
Petechia (red spots caused by bleeding into skin)
PROM
Prelabor ruptur of membrane
Spontaneous rupture of amniotic sac(bag of water) before true labor
Risk factors for developing PROM
Low socioeconomic status Multiple gestations Low BMI Tobacco History of preterm labor, placenta previa, placental abruption, UTI, Vag bleeding
Prolonged PROM (greater than _h) increases risk for _
24h
infection
time period between amniotic rupture(PROM) and contractions is called
Latent period
S/S of PROM
Leakage of fluid
Vag discharge and bleeding
Pelvic pressure WITHOUT contractions
Diagnosing PROM
speculum exam or cervix and vag
nitrazine paper(pH indicator) testing fluid
PROM vs PPROM
PROM is beyond 37 weeks
PPROM is less than 37 weeks
PROM Treatment
UNDER NO CIRCUMSTANCE is a unsterile digital examination performed until the woman enters ACTIVE labor
If fetal lungs are mature, labor is induced
What not to do with PROM
UNDER NO CIRCUMSTANCE is a unsterile digital examination performed until the woman enters ACTIVE labor
PROM treatment if fetal lungs are immature
^ Hydrate
v physical activity
pelvic rest
observation for infection (labs/vitals)
GIVE antibiotics
If pt presents with PROM make sure they don’t already have
UTI
Pelvic or vaginal infection
S/S of labor
Cramping
Pelvic pressure
Back pain
look for this after PROM
Meconium presence in amniotic fluid indicates
Fetal distress due to hypoxia
Meconium stains the fluid
yellow to green brown
With PROM start monitoring fetal
HR
Diagnosing PROM
Nitrazine (pH)
Fern test (fluid dries like fern)
Ultrasound
PROM nursing management
Prevent infection
ID contractions
Fetal tachycardia may indicate
Infection
Variable deceleration may indicate
Cord compression
Basics of assessing fetal wellbeing that a mother can do
kick counting
Preterm labor
regular contractions
cervical effacement and dilation
before 37 weeks gestation
Leading cause of death within the first month of life
Premature birth
Therapeutic management for PTL
Tocolytic drugs (promote uterine relaxation Steroids to improve fetal lung maturity Single dose of corticosteroids at 24 go 34 weeks
Tocolytic drugs
Promote uterine relaxation to prolong pregnancy for 2 to 7 days
Is usually ordered for PTL that is BEFORE 34 weeks
Tocolytic drug names
Magnesium sulfate
Indomethacin
Nifedipine
Being tocolytic is an off label use for all of the above
Corticosteroid given at 24 to 34 weeks for PTL
reduce frequency and severity of respiratory distress syndrome in premature infants
S/S that may indicate preterm labor will happen
Change/increase in vag discharge Pelvic pressure Back pain UTI symptoms N/V/D More than 6 contractions per 1h
Lab/diagnostics for PTL
CBC and urinalyses for infection
Amniotic fluid test for lung maturity
Fetal fibronectin
Cervical length Measurement
Fetal fibronectin
Biologic glue attaching sac to uterine lining
Not supposed to be present between 24 and 34 weeks of pregnancy.
If present over 0.05mcg, may indicate PTL within 7 to 14 days
Cervical length measurement
done via transvaginal ultrasound
measures cervical length/width, funnel length/width and percentage of funneling
Best for weeks 16 to 24
Cervical length of 3cm or more indicates delivery within
14 days
Nursing management of preterm labor
Early detection Monitor vitals Intake/output measuring Encouraging bed rest on left side Monitor FHR
Tocolysis
Use of contraction inhibiting drugs
goal is to delay birth for up to 48h
Diagnosis of preterm labor requires both
contractions AND cervical change
Prevention of PTL
Adequate nutrition and weight gain
Pregnancy interval of 18 months
Progesterone therapy
Overdose indicators of Magnesium sulfate
Resp problems and deep tendon reflexes
Side effects of magnesium sulfate
N/V headache weakness hypotension Cardiopulmonary arrest
With magnesium sulfate, fetus may experience
vHR
Drowsiness
Hypotonia
Calcium channel blockers
Nifedipine side effects
Hypotension Tachycardia Headache Nausea Facial flushing
Indomethacin
Cyclooxygenase inhibitor
Reduces prostaglandin synthesis
Indomethacin side effects on fetus
oligohydramnios
decrease in fetal renal blood flow
Indomethacin maternal side effects
N/V
Gastritis
NOT for gestation of 32 weeks or longer
With indomethacin monitor
urine output
mom temp
Amniotic fluid index
Preeclampsia
Leading cause of maternal morbidity
New onset hypertension w/proteinuria and maternal organ dysfunction
Preeclampsia/eclampsia affects what orgnas/systems
cardiovascular
hepatic
renal
CNS
1st stage of preeclampsia
widespread vasospasms
platelet/fibrin adherence
2nd stage of preeclampsia
s/s appear
Woman’s response to abnormal placentation
hypertension proteinuria N/V/H blurred vision hyperreflexia due to hypoperfusion
In preeclampsia the vasospasms result in elevated BP and reduce blood flow to
Brain Liver Kidneys Placenta Lungs
BP in
preeclampsia moderate
preeclampsia severe
eclampsia
140/90 after 20 weeks
160/110 on 2 occasions at least 6h apart while on bed rest
160/110 is standard
Seizures/come and hyperreflexia for
Moderate preeclampsia
Severe preeclampsia
Eclampsia
no and no
no and yes
yes and yes
Eclampsia s/s
Severe headache
Generalized edema
right upper quadrant and epigastric pain
Visual disturbances
cerebral hemorrhage
renal failure
Cure for pre/eclampsia
birth
To reduce preeclampsia symptoms lie in the
this improves
lateral recumbent position
uteroplacental blood flow
reduces bp
promotes diuresis
What labs are done for preeclampsia
CBC Serum electrolytes BUN, Creatinine Hepatic enzymes Platelet count
With preeclampsia advise mother to
do daily kick counts
monitor bp
report decrease in fetal movement
Does preeclampsia need sodium restricted diet
NO
Fetal surveillance for preeclampsia
Fetal movement
Nonstress testing
Ultrasound
Amniotic fluid
With preeclampsia monitor for
hypoxemia
seizures
^ intracranial pressure
What med is given to women with severe preeclampsia prior to 34 weeks gestation
Betamethasone
Prophylactic meds for preeclampsia
Prenatal asp and prenatal magnesium sulfate
S/S of severe preeclampsia
Cerebral/visual symptoms Pulmonary edema Epigastric pain Liver failure Thrombocytopenia Kidney failure
In labor with preeclampsia
oxytocin is given to
antihypertensive are given to
Magnesium sulfate is given to
stimulate contractions
control bp
prevent seizures
Antidote for magnesium sulfate overdose
Calcium gluconate
S/S of magnesium toxicity
Resp depression
Hypocalcemia
Hypotonia
Eclampsia
Hallmark of preeclampsia complications
Onset of SEIZURE ACTIVITY
Eclampsia seizures start at _ and present as…
They than continue to _
Face
twitching ,eye bulging, mouth foaming
Body
During eclampsia seizure patient cant _
After eclampsia seizure patient goes into _
Breath
Coma
Managing eclampsia
Lay on left
Admin O2
Protection from injury due to seizure
Suction secretions
Magnesium sulfate is given for _h after eclampsia seizure, to prevent recurrence
24
Most significant sign of pre/eclampsia
Proteinuria
Hypertension
Diet for preeclampsia should be high in
Protein
Preeclampsia and reflexes
DTR
Hyperreflexia
indicates CNS involvement in condition
In pre/eclampsia, HYPOreflexia indicates
Magnesium sulfate toxicity
During eclampsia seizure breathing_
stops
Nursing management of eclapmsia
Raise all side rails and provide padding
Dim lights
suction nasopharynx
admin O2
Fetal monitoring
After birth, monitor for pre/eclampsia for at least
48h
SCD
Sickle cell disease
hemolytic anemia due to inheritance of Sickle Hemoglobin HbS
Since blood cells become sickle due to low O2 this can happen due to natural decrease or in what blood vessels
Veins
Sickle cell trait vs anemia
trait means carrier
anemia is the actual sickness
Clinical manifestation of sickle cell anemia
Low hemoglobin values 5-11dL (13-17dL normal)
Jaundice
Enlargement of bones
Tachycardia
murmurs
enlarge heart
HF
Which organs usually suffer from SCD
Those with slow circulation
Spleen Lungs CNS
Complications with SCD
Hypoxic tissue damage
Ischemic necrosis
Pneumonia
Osteomyelitis
Three types of sickle cell crisis
Vaso Occlusive crisis - Sickle cells block blood supply
Aplastic crisis - Human Parvovirus infection, hemoglobin drops fast
Sequestration crisis - an organ fills with bad cells. Spleen most common for kids. Liver and lungs most common for adults.
Acute chest syndrome
S/S
Infection, embolism, infarction related to SCD
Tachypnea, cough, wheezing, fever
Managing Acute Chest Syndrome
Red cell transfusion
Antimicrobials
Bronchodilators
Mechanical ventilation
SCD pulmonary hypertension
S/S
High blood pressure in lungs
Fatigue dyspnea Dizziness chest pain Syncope
Pulmonary hypertension
pulse oximetry and breath sounds
typically normal and clear despite the sickness
Screening for SCD pulm hypertension
Doppler echocardiography
BNP levels
CT Scan
SCD Stroke
S/S
Ischemic (block in blood supply to brain) in kids and old adults
Hemorrhagic (bleeding into brain) in young adults
Declining neurocognitive function in beguiling symptom
Treating SCD stroke
Red cell transfusion to reduce hemoglobin S
Reproductive problems with SCD
Men - impotence, low libido, infertilities
Women - delayed menarche
Use contraption if on Hydroxyurea
Teratogenic med for SCD
Hydroxyurea
Patient with SCD will have what blood labs
Low hematocrit, sickled cells on the smear
High WBC due to chronic inflammatory state
Hematopoietic stem cell transplans
May cure SCD but low availability due to lack of donors
Hydroxyurea for SCD
Chemo agent
increases fetal hemoglobin thereby decreasing hemoglobin S
Will need folic acid replacement
Lowers Leukocyte formation so Infections will need to be treated promptly
Transfusion therapy for SCD
RBC transfusion
Good for severe situations like anemia crisis (any one of the 3), acute chest syndrome, organ failure or stroke.
Risks of Transfusion therapy
infection
delayed reactions
Iron overload, which primarily accumulates in liver, WILL need chelation therapy
Chelation therapy
Rids blood of excess irons and metals
Exchange transfusion
Replacing existing blood for blood without HbS to a target of 10g/dL
Alloimmunization
development of antibodies toward different kinds of blood due to frequent transfusions
Distinguishing between anemic crisis and delayed blood reaction
S/S will be the same except patient will be LESS anemic with delayed blood reactions
With SCD swollen joints should be_
after swelling goes down…
Elevated
Aggressive physical therapy, whirlpool baths, TENS to preserve function
Meds for SCD Pain
NSAIDS Aspirin SNRIs Antidepressants Gabapentin
Tocodynameter
Measures contraction frequency
NOT strength
Strength can only be measured through contact with belly
Contractions
Involuntary Have systole (building up and peaking) and diastole (going down)
What to document about contractions
Frequency
Duration
Intensity
Resting tone- are there relaxation periods
What to reference for contraction strengt
Nose
Chin
Forehead
Montevideo unites
Unit of measurement used with an internal uterine catheter to measure contraction pressure
Normal contractions per 10 min
Tachysystole/hyperstimulation
5
more than 5
SHUT OFF PITOCIN
TOCO vs IUPC
Toco-external
IUPC-internal (and pressure)
measure contraction frequency
Fetal heart rate variability
change from baseline
low- below 6bpm
moderate- 6 to 25bpm
high- over 25bpm
Acceleration
2 or more increases of 15bpm above baseline at least 15 sec apart in 20 min
With nifedipine as a tocolytic monitor
BP
With indomethacin as a tocolytic dont give to women with
Peptic ulcer disease
Will irritate GI
CONTRAINDICATED if fetus is greater than 32 weeks
Nitrizine strips when in contact with amniotic fluid turn what color
Blue
DIC
Disseminated Intravascular Coagulation
No more clotting factor, mom will most likely die.
