Test #4 Flashcards
What is Veal Chop? How can we use it?
Used to help interpret fetal strips:
V = variability
C= cord compression
E = early decelerations
H= head compression
A = accelerations
O = Ok (what we want to see)
L = late decels
P = placental insufficiency
What classifies as obesity
BMI at 30 or above pre-pregnancy
What things are we worried about with an obese mom? 4
- Bleeding (have hemorrhage kit ready)
- Difficult to monitor baby
- Difficult to help change patients position if needed
- Anticipate large babies (LGAs - large for gestational age) creates issues during delivery
What does IUGR stand for
Intrauterine growth restriction
Would we always expect a large baby from an obese mom?
No - there may be other comorbidities, like mom is a smoker, that causes issues with perfusion with the placenta, which can lead to IUGR and smaller babies
Before birth, what are complications of obesity 3
- Diabetes
- HTN leading to preeclampsia
- Sleep apnea
During birth, what are complications of obesity 4
- Macrosomia (large baby)
- Prolonged labor
- Shoulder dystocia (increased C-section rates)
What are some risks for C-sections for obese women 4
- Increased risk of BLEEDING
- Increased risk of infections
- Delayed wound healing (increased risk for dehiscence)
- Thromboembolism (all pregnant women are at an increased risk, but being obese increasing this risk factor even more)
Why is there an increase of bleeding for obese mom’s
It can be difficult to do a proper fundal massage with the extra tissue
Later on in life, what are children who are born from an obese mother at risk for 2
- Increased risk of childhood obesity
- Increased risk for chronic conditions (like diabetes)
What are our nursing considerations for obese mom’s 5
- Weight gain through their pregnancy should be smaller (so we only want them to gain around 11-20 pounds)
- Early testing for gestational diabetes due to their increased risks
- More frequent prenatal visits
- Anticipate more challenges in labor and delivery (have hemorrhage kit ready)
- Issues with babies maintaining blood sugars after delivery
Why are we seeing an increase in CVD in our mom’s
2 main factors:
- Women are having babies when they’re older
- Underlying preconception comorbidities like obesity, HTN, diabetes, rheumatic heart disease if strep is not treated
What population of women is more likely to have untreated strep
Immigrant populations with lower socioeconomic status
Why do we consider pregnancy the ultimate stress test in terms of CV health 4
- Dramatic increase in blood volume, especially during 3rd trimester (up to 50% increase)
- Increase in HR that naturally happens
- Decrease in systemic vascular resistance (naturally), that can cause dilation in your legs, which can lead to pooling of blood and risk for DVTs
- Increased coagulability
If a pt is at an increased risk of coagulability, possibly from CVD, what two medications might they be on?
- Baby aspirin
- Heparin
What anticoagulant drug do we NEVER use during pregnancy (carries a black box warning - category D)
Warfarin (can cross the placenta and cause baby’s blood to thin)
What sucks about having CVD while pregnant?
Normal pregnancy symptoms can be made even worse by CVD, like:
- Increase in fatigue caused by anemia and changes in cardiac output and BP
How can CVD impact a woman’s labor 2
- During a contraction, blood is shunted away from the placenta and out into the mom’s cardiovascular system, which can be up to 500mLs of extra blood going out into the system. This can put a lot of strain on a woman’s cardiac system taking in this extra blood and increasing her cardiac output.
- Contractions are painful and can increase BP and HR, which can then increase cardiac output
How can we care for our CVD pts during labor 3
- Strict Is and Os (don’t give any extra fluid, which can increase mom’s fluid volume and increase her CO).
- Close monitoring of mom and baby (might also have telemetry on mom)
- Want effective pain relief to help decrease CO and to help shorten second stage
What is second stage? Why would we want it shortened for moms in labor? What can we do to help?
Second stage is when mom is pushing, so when a mom with CVD is bearing down and pushing, this can increase their BP and HR, which increases their CO… So we don’t want to put this kind of stress on their heart for very long, so we want to try and shorten this stage.
These women are great candidates for laboring down, which, with an epidural, is when a women lets her uterus do some of the work when she is 10cm and 100% effaced, where the women isn’t pushing, and instead the uterus is passively moving baby along, this helps take off some of the pushing duties for our CVD moms
What acronmyn can help us remember what infections women should avoid during pregnancy
TORCH (teratogenic - cross placenta can cause fetal abnormalities or other complications during pregnacy). We screen for these.
T = toxoplasmosis (kitty litter and uncooked meat)
O = other infections like chicken pox, syphilis, HIV, parvo virus, chlamydia, Hep B)
R = rubella
C = cytomegalovirus
H = herpes simplex
What is important about rubella
We screen for it and have a vaccine for it, but we can’t give the vaccine until after pregnancy, because it’s a live virus vaccine (one of the few live virus vaccines we have left)
Besides screening for TORCH infections, what other infections do we screen for?
- Hep B
- HIV
- GBS (group beta strep) (screen towards the end of pregnancy, because most adults who have it will be asymptomatic, but it can cause newborns to have sepsis if not treated, so we like to screen for it and treat prior to delivery) (GBS positive or GBS status unknown, we treat with antibiotics during labor to help reduce transmission with a vaginal delivery)
- UTI (big deal in pregnancy because they may be asymptomatic during pregnancy, so will screen for it just in case they have it but are not showing symptoms)
Why are we worried about UTIs during pregnancy
They can cause pre-term labor and progress to pyelonephritis (so we want to catch these UTIs early so we can prevent any complications)
With HIV, since we are trying to prevent transmission between mom and baby, what are we looking at? Why?
Mom’s viral load, because the higher her viral load the more likely she is to pass it on
How can HIV transmission from mom to baby occur in the 3 phases of pregnancy (ante, intra, post)
- Ante: HIV can cross the placenta if we don’t do anything to prevent the transmission (without intervention rates can be as high as 25% of babies becoming infected)
- Intra: transmission into babies bloodstream due to minor tears during birth
- Post: through breast milk
How can we prevent HIV transmission
- Antiretroviral therapy to help decrease viral load (usually 3 different medications) (usually need to start by 28 weeks to reduce risk at birth)
- Have a C-section if viral load is not low enough to help prevent transmission
- Newborns will receive antiretrovirals for 5 weeks after delivery
- Do not let mom breast feed
What is some psych that goes along with HIV
It’s a universal screening for all pregnant mothers, so this could be the first time that she’s ever being tested for and the first time finding out if she is HIV positive, which can be a shock
What is important to reinforce with an HIV positive mother
That HIV is no longer a death sentence, it is a chronic illness that can be managed
What do we do for our Hep B positive mothers 3
- They will be on antivirals, which will help prevent transmission across the placenta, where it is most likely to occur
- Safe to deliver vaginally
- Can breastfeed
What do we do for our newborns born from Hep B positive moms 3
- First thing: bathe baby prior to giving any injections (like the vitamin k and hep B vaccine)
- Will receive a hep B vaccine
- Will receive hep B immunoglobulin (HBIG)
(these injections should be given within the first 12 hours to prevent any transmission that may have occurred)
Is alcohol bad for baby
Yes, it’s a potent teratogenic drug
What things can cause neonatal abstinence syndrome
- Heroin, codeine, fentanyl, methadone, oxy, hydrocodone
What can happen to babies born with a tobacco addiction 2
- Very fussy, sensitive, hyperreactive due to withdrawals after delivery
- Increased risk for IUGR (why these babies born from smokers are generally small)
If a mom has substance abuse, what else is she at risk for having 3
- Intimate partner violence
- STIs
- Lack of prenatal care
Some moms won’t admit to having substance abuse, so what things can suspect us to think that she actually does abuse substances 3
- If she has had no prenatal care
- If there is a placental abruption without an obvious reason
- If there is IUGR without obvious reasons
What is interesting about social services and substance abuse
Sometimes there will be a mandate from social services telling us that there is a hx of abuse and we need to do a toxicology screen
Can we get a toxicology from a mom without her consent
No, even if there is a court order, she would end up just being in violation of the order
Are we allowed to do toxicology on babies here in Oregon without mom’s consent
Yes
When doing a toxicology on a baby, what two fluids do we test
- Meconium
- Urine
What happens to babies born from mom’s with substance abuse
- They are often SGA (small)
- There may be some neurodevelopmental abnormalities
- Acute withdrawals
If a mother is positive for an illicit substance (except tobacco, which is not illicit), can they breastfeed?
No
Is there a screening tool for babies born from substance abuse mothers
Yes, typically like to use the screening tool within the first 4 hours (looking at things like does baby have a high pitched cry, decreased sleeping, hyperactive reflexes, etc), then this gives us a score and tells us how frequently we should rescore the baby and what our treatments should be.
- Good to note that we may not see signs of withdrawal until 12-24 hours after birth, but it’s still good to start at hour 4 so we have a baseline before withdrawals kick in
What extra care might we do for babies born with neonatal abstinence syndrome due to opioids (a lot)
- High-calorie formula (due to all of their extra movements going on and increased metabolism during their withdrawal)
- Small frequent meals
- Antidiarrheals
- Meticulous Is and Os
- Wts
- Breastfeeding
- Morphine or methadone if baby has a high score
- Promote comfort like swaddling, sucking (give pacifier), swing
- Billy lights
- Monitor tox screen
- Work with social services
For mental health, what drug types are we concerned about
If they take SSRIs during the first trimester, there is conflicting info on whether it can cause fetal malformation, so we would want to work with their doctor to see if they should be taken off the medications (weight the risk vs benefit)
What are our prescription drug categories
A and B are generally safe.
C we don’t know either way.
D we’re going to avoid.
What is a mom with a hx of depression at risk for
Developing postpartum depression
What might be a sign that a mom has postpartum depression
They’re feeling down longer than 14 days (it’s normal to have a few days that you may feel like this
What is hyperemesis gravidarum
Persistent vomiting that is not caused by something like the flu or eating something bad
It’s just vomiting that goes on and on while pregnant and you can’t figure out why
What signs do we see (besides persistent vomiting) for hyperemesis gravidarum 2
- There will be signs of malnutrition, so we would see ketonuria (+2 ketones with dipstick)
- Weight loss (below pregnancy weight by 5%)
What do we think causes hyperemesis gravidarum 5
Not really clear, but we think it has something to do with high levels of HCG, estrogen or thyroid hormones
Might also be a genetic component
Increase risk if you’re having a girl
Can be worse symptoms if you have multiple babies (due to more hormones being released)
Hx of motion sickness or migraines may make a woman more susceptible
What are our txs for hyperemesis gravidarum
- Antiemetics
- IV fluids for hydration
- Can give dextrose for calories
- Worst case - have central lines to get TPNs
What is placenta previa? Why is this bad?
Where the placenta has attached to the lower uterine wall, and may be covering the cervix.
This is bad because it can increase mom’s chance of having a hemorrhage, where in the 3rd trimester when she starts having contractions, those contractions around her cervix can put a lot of pressure on her placenta and cause bleeding. Plus a baby can’t be born vaginally if the placenta is completely blocking the cervix, because the placenta will be born before the baby, so the baby won’t be getting perfusion.
What are the 6 different types of placenta previa
- Complete: where the placenta is completely blocking the cervix
- Partial: where part of the placenta is blocking the cervix
- Marginal: where the placenta is very close to blocking all of the cervix
- Accreta: placental attaches too deep into the uterine wall
- Percreta: where the placenta grows through the wall and attaches to nearby organs
- Increta: attaches even deeper into the uterine muscle
Ho do we deliver placenta previa babies
C-section
Why are placenta accreta, increta, and percreta troublesome?
Because the placenta has attached itself so deeply in the uterine wall, or muscle or other organs, which can lead to massage bleeding once baby is born because we can’t really do a fundal massage or anything in this area, it will just keep bleeding
Where are mom’s with Placental accreta, increta or percreta going to give birth? What are we prepared to do?
In the OR, where we are ready to do a massive transfusion. May even need to do a hysterectomy
What are the cardinal signs of placenta previa 2
- Painless bright red vaginal bleeding (think about the placenta covering the cervix, and any little disruption to that placenta’s blood vessels can cause bleeding, but the pt might not feel any pain) (usually occurs in 3rd trimester)
- Abdomen will be soft, nontender
What should we not do on pts with placenta previa
Vaginal exams, because we don’t want to be poking and prodding the placenta since it’s right at the cervix
What is teaching for pts with placenta previa
When they go to the hospital or get checked, make sure they tell whoever that they have a placenta previa and cannot have vaginal checks
What initial assessments are we going to do on pts with a hx of placenta previa
Maternal and fetal well being.
- Vital signs on mom
- Look at mom
- Get baby on monitor
What is important to remember about BPs for pregnant moms
Their BP will be higher due to their increase in blood volume, so this can be a poor indicator of volume status, so we want to look at her HR to see how she’s coping (tachycardia would show that something is up)
We would also see changes in baby’s HR first if there is an issue with blood volume (like bleeding), where baby will get tachycardia trying to compensate, then eventually mom’s HR will also go into tachycardia
What kind of test might we do on a mom with placenta previa? What is it?
A Kleihaurer-Betke (KB) test to see if mom’s blood has mixed with baby’s, especially for our RH negative moms (if mom is Rh negative and baby is positive, than mom can create antibodies that kill baby’s RBCs)
(since mom’s with placenta previa are at an increased risk of bleeding, we want to be on the lookout for Rh negative and positive situations)
What is a placental abruption
A premature separation of the placenta from the uterus
What are the signs of a placental abruption
- ***Very painful
- May or may not Vaginal bleeding (a complete separation may block blood from leaking out, so that blood will just collect where its separated)
- With a complete separation and blood blooding in the abdomen, we will get a rigid abdomen
What are the 3 different types of placental abruptions
- Marginal
- Partial
- Complete
What are signs from baby that a placental abruption may be occurring
We would see late decels on FHR
What is a complication of placental abruption
The mom can go into DIC, which can lead to hypoxia of the baby
What is interesting about placental abruptions
Some can be minor, where maybe we didn’t even know they had one until after delivery or they can be extreme, where we would need to do an emergency c-section
If a woman’s membranes rupture before 37 weeks, what do we refer to them as?
Preterm premature rupture of membranes (PPROM)
What is a common cause of PPROM 4
- Infection, which is called chorioamnionitis
- Uterine distention like from multiple babies or a lot of fluid
- STIs
- Smoking
How do we diagnosis PPROM 4
- A provider will do a sterile speculum exam to see if they can see fluid in the birth canal
- nitrazine test where normal vaginal pH is between 4.5-5.5, but amniotic fluid increases the pH
- Amnisure (lab test)
- Ferning (amniotic fluid will fern when dried)
What are our concerns with PPROM? What can we do? 2
- Infection risk (decrease number of invasive procedures)
- Fetal wellbeing (we are losing our amniotic fluid cushion, babies may have variables on the monitor, because there can be compression of cord without the cushion)
If there is chorioamnionitis, what are we doing?
Deliver the baby right away, because mom and baby are at risk for sepsis
If baby is tolerating the decrease in amniotic fluid well and there are no signs of infection, do our PPROM moms have to deliver within 24 hours?
No, we will keep a close eye on them and try and let the baby cook longer
What is good to tell pts with PPROM 2
- They are at an increased risk of going into labor spontaneously
- They will be on bed rest
What are signs of infection besides an increased in temp 5
- Tenderness
- Cramping
- Lower back pain
- Odor
- Increased HR of both mom and baby
(infection will usually trigger the body to go into labor, because it knows that we need to get the baby delivered)
If there are no signs of infection, what might we want to try and do?
Slow down labor for at least 48hrs so we can give 2 doses of betamethasone, which can enhance lung maturity of the baby before they are born
What do we consider preterm labor
Anywhere from 20 weeks (when we consider the baby viable) to before 37 (because we consider 37 weeks and after full term)
What is the most acute problem in maternal-child health
Preterm labor
Do we still focus on preterm labor prevention here in the US?
No, we’ve shifted from prevention to early detection of preterm labor
What is our core measure for preterm labor
To be able to give more babies going into preterm labor between 24-32
What is our core measure for preterm labor
To be able to give more babies going into preterm labor between 24-32 betamethasone to help their lungs prior to delivery
What age in weeks will a premature baby have a 90% survival rate
At 28 weeks (so we REALLY REALLY want to get our babies to 28 weeks)
What are our concerns with premature babies 5
- Immature lungs (not producing surfactant yet, not having coordinating breathing yet), which can lead to respiratory distress
- Small babies, not much subcutaneous tissue or glycogen stores, which can lead to hypothermia and hypoglycemia (monitor temps, put on warmers, check sugars)
- Underdeveloped livers (at risk for jaundice) Can have under billy lights
- Intraventricular hemorrhage for really small babies, where there is internal bleeding in the babies head, so we don’t want to have small babies deliver vaginally, because trauma during birth can increase the risk of intraventricular hemorrhage
- Cerebral palsy longer term
- Retinopathy long term
What can cause preterm labor (a lot)
- Periodontal disease
- Diabetes, HTN
- *Infections
- *Uterine distention usually caused by multiples
- Hx of preterm labor
- Demographics (older and younger, no prental care)
- Smoking
- Stress
- Interpregnancy interval (less than 6 months since last pregnancy)
How can we prevent preterm labor 4
- Number one thing is prenatal care
- Manage chronic conditions that might trigger it (like managing HTN, diabetes, stress)
- Screen and treat infections
- Give progesterone intravaginally (pro-pregnancy hormone - wants to keep you pregnant)
How do we determine if a mom is actually in preterm labor 7
- Greater than 20 weeks pregnant and less than 37 weeks
- Have to have persistent contractions
- Dilating more than 1cm or dilation is changing
- Effacement of 80%
- Get a UA
- Fetal fibronectin (FFN) test
- Exam cervical length
If a mom who is less than 37 weeks pregnant calls and says that she is having contractions, what kinds of things can we advise her to do at home to stop those contractions 4
- Drink water (dehydration can cause contractions)
- Go to the bathroom (full bladder can cause issues)
- Put their feet up
- Take a nice warm bath
What is the Fetal fibronectin (FFN) test? When would we not want to use this test? What does a negative result mean?
- A test used to rule out preterm labor
- The fetal fibronectin is a prostaglandin that is released when membranes are disturbed by contractions (so this is how we can tell if they’re actually having contractions)
- Don’t use if there are rupture membranes (PPROM) or if there is vaginal bleeding
- Can’t use if there has been anything in the vagina in the last 24 hours, like from having sex or having their cervix checked.
Negative means that there is a less than 1% chance that the mom is going to deliver that week. (we want negative)
Why do we want to do an FFN test for preterm labor before we check the cervix
Because the FFN test won’t be accurate if anything has been in the vagina in the last 24 hours, like from having an exam. So we always want to do this test first before a cervical exam.
What does a positive FFN tell us?
Well it tells us that the mom has a 20-50% chance of delivering this week, but there are also a lot of false positives, so basically a positive result doesn’t really tell us much.
What is our goal for preterm labor? How do we accomplish this goal? 5
- We want to delay delivery!
How we accomplish:
- Give tocolytics, which are medications used to reduce contractions.
- Try to delay delivery enough to get two doses of betamethasone in within 48 hrs
- Abx for GBS as needed
- Bed rest (remember increase of DVTs on bed rest, maybe more of an activity restriction)
- Possibly may need to transport to another facility
What are our tocolytic drugs 4
- Nifedipine (Ca channel blocker) (don’t give nifedipine and magnesium sulfate together because both compete with calcium and cause cardiac issues)
- Indomethacin (NSAID)
- Terbutaline (beta-adrenergic receptor agonist) (not first line, will stop contractions, but can cause maternal tachycardia)
- Magnesium sulfate (CNS depressant - also competes with Ca) (has to be given inpatient)
How do we administer betamethasone? When would we give it? What does it help babies produce?
Give 12mg to mother IM every 24hrs twice
Give to mothers if babies are less than 34 weeks
Helps babies produce surfactant
What are the benefits of betamethasone 5
Reduces:
- Respiratory distress syndrome
- Intraventricular hemorrhages
- Necrotizing enterocolitis
- Neonatal mortality
- Neurologic handicap
What if you give your two doses of betamethasone thinking the mom is in preterm labor and is going to deliver soon, but the mom doesn’t actually deliver until a week later?
You can give one “rescue dose” of betamethasone a week later, or even at a later time.
What are we worried about it, in terms of our moms, when we give them betamethasone (think steroid risks) 1
- Diabetic moms (this med will spike their sugar levels) (might need extra insulin coverage)
Can we sign off on mag sulfate by ourselves
No, it’s a dual RN sign off
What are the effects of mag sulfate (good and bad)
It’s a CNS depressant so…
It provides neuroprotection to the baby to help reduce cerebral palsy risk
Reduces contraction and tone (helps baby cook longer)
It’s a vasodilator, so it can drop BPs (we don’t want to drop mom’s BP too much, because this can reduce profusion to the baby
What are assessments are we doing if mom is on mag sulfate
- BP and RR frequently (remember, it’s a CNS depressant)
- Continuous EFM
- DTRs (don’t want these to become too decreased)
- LOC (don’t want these to become too decreased)
- Lung sounds
- Urinary output
- Watch for late decels (signs of poor placenta perfusion)
How do moms feel on mag sulfate
- Groggy
- Malaise like when they have the flu
- Flushed
What if mom’s DTRs, LOC and RR is becoming too suppressed on mag sulftate.
We should stop the mag sulfate and consider giving the antidote, calcium gluconate
What are newborn considerations for mom’s taking mag sulfate
Mag sulfate does cross the placenta, so these babies will also have mag sulfate in their system, and we may see signs of CNS depression, like decreased RR, muscle tone, they’ll likely have low APGAR scores
Picture:
Notice how identical twins are called monochorionic/diamniotic twins because they share the chorion and placenta, but have separate amnion.
Twins that are not identical are dichorionic/diamniotic and do not sure a chorion or placenta
What are risks for mom’s caring multiples 4
- Intrauterine distention
- ROM
- Pre term labor
- Hyperemesis
What are some nursing considerations for perinatal loss 3
- There may be more bleeding than usual, which may turn into a DIC event
- Infections can occur if membranes have been for some time or if the baby has died a while ago and these things are still inside mom
- If Rh-, mom should still have RhoGAM
What is an incompetent cervix
Usually where you have dilation and effacement of the cervix when you’re not supposed too, which can lead to loss of the baby (usually occurs in 2nd trimester - basically cervix won’t stay closed)
How can we manage an incompetent cervix
Through a cerclage, where the provider will stitch up the cervix until delivery to help keep baby inside
If a woman has an incompetent cervix for one of her pregnancies, is she more likely to have it again for future pregnancies
Yes
What are risk factors for ectopic pregnancy (a lot)
Usually things that have caused scarring to the fallopian tube, which is where we see a lot of ectopic pregnancies occur
So…:
- STIs
- PID
- Prior ectopic
- Hx of abd surgeries
- Endometriosis
- Hormone therapy
- Assisted reproduction
- Use of an IUD
What are s/s of an ectopic pregnancy 5
- Bleeding
- Missed period
- Abd pain/tenderness (usually unilateral on the side where the ectopic is in the fallopian tube)
- Referred shoulder pain
- Pain that worsens with rupture (pretty severe)
How can we diagnosis an ectopic pregnancy 5
- Hx (previous ectopic - especially in the same fallopian tube as the previous ectopic, due to the scar tissue, if they still have that tube)
- Palpable mass
- Ultrasound to see if pregnancy is actually in the utererus
- hCG will be low
- Going to have hypotension s/s if ruptured
What is our management of an ectopic 2
- We can give methotrexate to terminate pregnancy if unruptured and less than 4cm in size
- Salpingectomy via laparotomy
Is it pretty serious when an ectopic ruptures
YES! There can be massive internal bleeding going on. It definitely becomes an emergency
What is gestational trophoblastic disease (also called molar pregnancy or hydatidiform mole)
Basically a woman has a positive pregnancy test, but instead of a baby growing, the placenta develops abnormally and grows fluid filled grape like clusters instead of a baby (basically abnormal tissue growth instead of a baby, even though there was a positive pregnancy test)
What are the s/s of gestational trophoblastic disease 4
- There would be a discrepancy in the size of mom’s tummy and how far along she is (these fluid filled sacs are going to grow a lot larger, and much faster than a baby would)
- Bleeding, possibly passing some of these little fluid filled clusters
- Markedly elevated hCG
- No fetal HR
What are we really worried about with gestational trophoblastic disease? So what do we do? What do we teach out mom’s?
These women are at an increased risk of developing cancer
So we will measure their hCGs for at least one year, where a rise in hCG may indicate malignancy
We advise our moms to not become pregnant for at least one year, because their pregnancy could mask a rise in hCG, which is helping us determine if she may have cancer
Picture showing how insulin builds up in the first half of pregnancy because a decrease in insulin needs vs second half of pregnancy were we have an increase in insulin needs
We don’t need insulin as much in the first half of pregnancy, things like our hormones may be decreasing our need for insulin, as well as maybe we have morning sickness so we’re not eating as much, and baby isn’t needing very much.
An increase in insulin needs can lead to insulin resistance (pancreas is excreting more insulin in second half of pregnancy, but can’t keep up with the demand) Think of pregnancy as a stressor, and your pancreas isn’t able to keep up with the high demand in the second half of pregnancy
What if you already have diabetes going into pregnancy
The previous picture still holds true for type 1 and type 2 diabetics, where both may need to actually decrease their insulin in the first half of pregnancy, or may not even need it at all, however, they may need to increase their insulin injections in the second half of pregnancy
If a mom’s diabetes isn’t controlled, what can happen?
She can develop:
- High BPs
- Preeclampsia
- Eclampsia
- 2 times as likely to experience miscarriage
- Poly(hydramnios (excess amount of amniotic fluid, over 2000mLs) (remember that high blood sugars can cause polyuria, where there is excess peeing, so since mom has high blood sugars, so will the baby, so the baby will be urinating a lot in their sac creating more and more amniotic fluid) - this can lead to uterine distention, which can cause problems later on
- Ketoacidosis
- Retinopathy
- Increased risk of infections like UTIs (UTIs can quickly progress to phylo)
- Increased risk for developing future diabetes after birth
What are the effects of uncontrolled diabetes on babies 6
- Macrosomia (excessive birth weight due to high maternal levels of glucose)
- The baby can develop hyperinsulinemia, because only mom’s glucose crosses the placenta, they don’t get mom’s insulin (this is why we like to give pregnant diabetic mom’s insulin, because the insulin doesn’t impact the baby), so babies will actually produce their own insulin, but since they are getting an excessive amount of glucose from mom, they will be producing excessive amount of insulin, which can cause the baby to store glucose in fatty deposits around their chest and shoulder areas. (this increase in babies shoulder and chest can make for challenges during delivery).
- Increased risk for respiratory distress syndrome, because hyperinsulinemia can lead to a decrease in surfactant production
- Neural tube defects (diabetic moms will need to take an increased amount of folic acid compared to nondiabetic moms to prevent neural tube defects)
- After birth, babies will most likely have low blood sugars (this is due to baby’s pancreas being use to produce high levels of insulin due to mom’s high sugars, so it may take a while for baby’s pancreas to stop making so much insulin, so baby’s sugar may be low in the meantime) and possible jaundice (so be prepared for this)
- Increased risk for developing type 2 diabetes later in life
When do we start screening for gestational diabetes? Why at this time and not sooner?
Usually at 24-28 weeks, only sooner if high risk.
From the previous slides, insulin needs are usually low in the first half of pregnancy, but increase in the second half, so there’s not really a point in testing in the first half
What is the 2 step glucose tolerance check (simply)
Mom drinks a sugary drink, she comes and checks her blood glucose after an hour, if that number is really high, then she has to come back in 3 hours later and if that number is high, then this can confirm gestational diabetes
What are risk factors for gestational diabetes 5
- Obesity
- Family hx of type 2
- Hx of previous gestational diabetes
- Hx of LGA infant (large infant, greater than 90th percentile for weight)
- Polycystic ovary disease
Should we increase the insulin mom receives after delivery?
No! It is likely that her insulin needs will decrease after delivery, so we will adjust accordingly
How can women manage gestational diabetes
- Many can manage through lifestyle and diet changes
- Increase folic acid intake to prevent neural defects
- Maintain euglycemia (tight glycemic control)
- Fasting less than 95 (check fasting in the morning)
- 120-135 post-prandial (after eating)
- A1C goal is 6 (8 or above shows poorly controlled diabetes)
- Insulin is drug of choice (bc it doesn’t cross to the baby)
- More frequent prenatal visits, especially towards the end of pregnancy were we do nst (non-stress tests) to look at the fetal HR
- Mom will have biophysical profiles done, where we do stress tests but also look at HR and ultrasound
- Might have an early delivery (especially if baby is getting large, etc)
Do we use metformin for diabetic moms
Only sometimes, it does cross the placenta, even though it is a category B, many providers will switch mom to insulin to error on the side of caution
So what additional things are we going to do for a baby whose mom has gestational diabetes
- Kick counts (at home)
- Biophysical profile (BPP)
- Femur length
- Abdominal/head circumference
- Nonstress test
- Contraction stress test
- Amnio for fetal lung maturity
- L/S ratio of 2:1 (tells us if baby has adequate surfactant)
What is included in a biophysical profile BPP? How do we keep track?
We give point values to each item so:
- Fetal HR can score up to 2
- Amniotic fluid can score up to 2
- Respiratory movements can score up to 2
- Muscle tone can score up to 2
- Movement of extremities can score up to 2
So there can be a total of 10 points. (a score of 8-10 is normal) (4 below mean deliver asap)
During delivery, where do we like our mom’s blood sugar to be
Between 80-110
When we hang insulin, what should we also have hanging just incase
Dextrose in case mom goes hypoglycemic
Once a baby is delivered from a mom with diabetes, what is our newborn management?
- All infants born from diabetic mothers, all LGAs and SGAs will be on glucose protocols
Glucose protocols: - Monitor sugars (protocol will tell you what to do depending on where baby’s sugar is at)
- Use heel stick
- Get babies to breast asap
- Check baby’s sugar 30 minutes after feeding
- Want babies eating every 2-3hrs
- Can’t let babies sleep for long periods of time, because they do need to feet regularly
- Protocol usually lasts 24-48hrs
Once a gestational diabetes mom has her baby, how might her diet change?
She will likely come off her diabetic diet and be placed on a regular diet
When will a gestational diabetic mom be screened after delivery for diabetes again
Usually 6-12 weeks and then annually, just because gestational diabetes increases their risk of developing type 2 later on
Is HTN deadly for moms?
Yes, it is the second leading cause of mortality for pregnant women
What is our definition of HTN
Systolic at or greater than 140
and/or
Diastolic at or greater than 90
Pt has to have a BP at or greater than 140/90 at least twice taken 4 hours apart
What are our 4 categories of HTN
- Chronic HTN
- Gestational HTN
- Preeclampsia/eclampsia
- Chronic HTN with superimposed preeclampsia
At how many weeks pregnant would we diagnosis a mom with chronic HTN
Before 20 weeks (so basically in her 1st trimester)
During pregnancy, is it normal to have our BP increase or decrease
It is actually normal to have our BP decrease, which is why HTN during pregnancy is weird
What needs to be present to diagnosis a woman with preeclampsia
- Have to have an increase in BP after 20 weeks
- Need to either have protein in urine or other s/s of preeclampsia like vision problems, liver problems and/or kidney problems
What is gestational hypertension
Where we have an increase in BP after 20 weeks, but we don’t have proteinuria
What are the s/s of preeclampsia
- Headache
- Visual disturbances
- Right upper quadrant pain due to hepatic ischemia
- Reduced urine output
- Low abd pain (which can be a sign of placenta abruption which is more common in women with preeclampsia)
- Pulmonary edema
- Peripheral edema
- Hyperreflexia
What is the pathophys of preeclampsia
- Vasoconstriction leading to HTN
- Platelet activation with intravascular coagulation
- Endothelial dysfunction, where fluid shifts out of the vascular system and into the interstitial space
- Maternal plasma volume contraction
What can preeclampsia lead to? both mom and baby 4, 3
Mom:
- Eclampsia, which is essentially a seizure
- Pulmonary edema
- Renal failure
- Stroke
Baby:
- Intrauterine growth resistance
- Placental abruption
- Still birth
What are risk factors for developing preeclampsia (a lot)
- Hx of preeclampsia
- First pregnancy or first pregnancy with a new paternal partner (something to do with dad’s antigens)
- Family hx of preeclampsia
- Pre-existing HTN
- Diabetes! (4x risk)
- Renal disease
- Obesity
- Connective tissue disease like lupus and RA
- Under 17 or over 35
- Multiples
How can we diagnosis if a mom has preeclampsia 4
- Look at CBC to see if we see any hemolysis (platelets less than 100,000)
- CMP to check for kidney and liver function
- Look for protein in urine, gold standard is to measure urine over 24hrs, where anything above 300mg for protein can be a sign of preeclampsia
- Checking fetus for any signs of growth restriction
What is the only way to stop preeclampsia
Deliver the baby
What if a mom comes in with elevated BP after 20 weeks
We want to determine what kind of HTN it is (gestational HTN or preeclampsia)
So we’ll do a 24hr urine collection to look for protein, if protein is over 300mg, then we know it’s preeclampsia and not just gestational HTN
Are there diff severities of preeclampsia
Yes, it can range from mild to severe
If a woman has a hx or family hx of preeclampsia, what might they be prescribed
Aspirin to prevent preeclampsia from developing
Picture and notes of terrell explaining what is happening in preeclampsia/eclampsia and what she points out as important
- We have endothelia damage, where little holes are made in blood vessels and leaking fluid into the surrounding tissue
- Body tries to respond by activating intravascular coagulation to form little clots, but this also uses up our clotting factors (increases risk of DIC)
- The damage to the endothelia also causes vasospasms
- Intrauterine growth restriction because blood vessels are working like they should for perfusion
- Pulmonary edema in lungs due to fluid leaking into this area (remember to listen to lungs)
- Pulmonary edema is very common especially in face, hands and abd (can be pretty significant)
- Vasospasms in liver (causes upper right quadrant pain, might also feel like epigastric pain - this is also why we watch liver enzymes)
- Liver involvement is very serious and it is very very serious pain
- Vasospasms can also cause headaches (think of downtown abbey)
- Hyperreflexia can happen so make sure you’re checking reflexes
- Spasms can happen in eyes and cause blurry vision so ask if they have blurred vision.
What can classify as mild preeclampsia (means we have mild w/o severe features)
- Have a BP at or greater than 140/90 after 20 weeks with 2 readings taken 4 hours apart
- Have proteinuria (>300mg in 24 hours) or have involvement of end organs
How can we manage mild preeclampsia
- Can possibly be managed at home
- Pt needs to know what to report to their provider (because we want them to tell us if they have any signs that the preeclampsia is progressing)
- Will need to know how to take their BPs
- Will need to have frequent trips to provider
What are signs of severe preeclampsia (means we have severe with features) 8
- BP at or above 160/110
or any of the below: - Platelets <100
- AST/ALT 2x above normal
- Severe, persistent RUQ/epigastric pain (like as severe as you can get for pain, worst pain of your life from the microhemorrhages in the liver that are occurring)
- Elevated creatinine and protein
- Oliguria (<500mL/24hrs)
- Pulmonary edema
- CNS disturbances (visual, DTRs and/or clonus)
What is important to remember about DTRs
We need assess DTRs on the pt with the off/oncoming nurses so that we can confirm what, if anything has changed
What can an increase in our DTS tell us
That the CNS is increasing in excitability, which can increase the risk of seizures developing
What are signs that the fetus may be in distress from preeclampsia 3
- Changes in HR
- Poor variability
- Late decels
What are complications of preeclampsia for mom 11
- Severe HTN
- Severe pulmonary edema
- MI
- ARDS
- *Hepatic rupture
- Eclampsia (grand mal seizure - can happen post partem as well, remember downtown abbey)
- Cerebral edema
- Hemorrhage
- Acute renal failure
- Coagulopathy > HELLP > DIC
- Retinal injury
What nursing assessments are we going to be doing to monitor if preeclampsia is progressing 10
- Checking BPs
- Checking DTRs/clonus
- Ask about RUQ pain
- Ask about headaches
- Ask about visual changes
- Listen to lungs to assess for pulmonary edema
- Look for edema in hands/face
- Assess urinary output
- Run labs - AST/ALT, platelets, creatinine, protein in urine
- Assess fetus using NST or BPP
Preeclampsia can progress to HELLP and/or eclampsia, what does HELLP stand for?
Hemolysis (hemolytic anemia), elevated liver enzymes (AST/ALT 2x normal) and low platelets (<100)
What can HELLP progress to?
DIC
What is the cardinal symptom of HELLP
Upper right quadrant pain
What is eclampsia
Where arteriolar vasoconstriction occurs and leads to grand mal seizures
What is the cure for preeclampsia/eclampsia? But what’s the catch?
Delivery but eclampsia can still occur post partem
If preeclampsia is mild, do we need to deliver asap?
No, we can generally let the baby cook for longer and watch mom for signs that the preeclampsia is progressing
What kinds of outpatient things are we going to do if we are managing a mom’s preeclampsia at home 5
- Home BP monitoring
- Daily protein testing
- Kick counts
- NST every 3-4 days for baby
- Checking baby’s growth using the ultrasound
What things are we doing inpatient for preeclampsia 2
- Labs
- Fetal monitoring
What is our goal in terms of weeks to get a mom to if she has preeclampsia
37-38 weeks
What are we going to do if mom develops severe preeclampsia 2
- We’re going to try and deliver baby it is older than 34 weeks
- If less than 34 weeks, we want to try and hold off on delivery for 48 hours to get betamethasone onboard
What should we consider if we induce a mom who has severe preeclampsia
We’re worried if her BP can handle the induction (like can she handle the labor pains, and everything that comes with a vaginal birth)
So what is our tx if we are having mom’s wait to get betamethasone onboard if less than 34 weeks 9
- Have them on bedrest with bathroom privileges
- Minimize stimulation (lights dim, nice, and calm)
- Have NICU provider/nurse come in and educate mom on what will be happening
- Have them on magnesium sulfate to prevent clonus/seizures
- May have on antihypertensives like labetalol or hydralazine
- Strict Is and Os
- Daily weights
- Check DTRs
- Check vital signs
When would we just give a dose of betamethasone and deliver asap (without waiting the 38 hours) 8
If we see one of the following:
- Uncontrollable severe HTN
- Eclampsia
- Liver rupture
- Pulmonary edema
- Placenta abruption
- DIC
- Evidence of category III fetal status
- Fetal demise
What is a good way to think of mag sulfate
Remember that mag sulfate completes with calcium, where calcium is trying to excite things and cause contraction, versus mag, which is trying to relax things
What is a big risk with mag sulfate
You can give too much and cause respiratory depression
What is our standard dose of mag sulfate
4-6g bolus, followed by 2g/hr IV (remember this is high risk - so it’s a dual RN sign off)
When we give mag sulfate, what should we have ready in the room and by ready/assessing for? a lot
- Oxygen via a simple mask
- Suction available
- Eclampsia kit nearby
- Still assess for preeclampsia progression
- Check BP to make sure we’re not dropping it too low
- Check DTRs to make sure we’re not losing DTRs (if we see a decrease or absent DTRs we need to stop the mag)
- Continuous fetal monitoring
- Can cause issues when trying to induce mom because it’s fighting against induction (might need additional doses of prostaglandins or Pitocin - can be very difficult to get a mom on mag to go into labor)
- Mag does cross the placenta, so the same things it can do to mom it can do to baby like decrease tone, decrease respiratory drive, we would see lower APGARs
- Mag sulfate can cause issues with having uterus clamp down after delivery (might need to give extra fundal massage and extra Pitocin, have hemorrhage medications ready to use)
Can we stop magnesium as soon as baby is born?
No, generally we want to keep mom on it for 24 hours because she is still at risk for eclampsia after delivery
What is the therapeutic range of mag sulfate
5-8 mg/dL
What is a normal number for a reflex? What about hyperreflexia or hyporeflexia
Normal = +2
+3 or +4 = hyper
+1 or 0 = sluggish or no response
What might be signs of mag toxicity
- Pt reports metallic taste in mouth
- Feel very fatigued
- Sweating
- Hypotension
- Depressed/absent reflexes
- Depressed respiratory
Before giving mag sulfate, what do we need to make sure we have available
Calcium gluconate
How long is a mom at risk for developing preeclampsia after birth
6 weeks (so make sure we’re teaching the warning signs)
If a woman wants to have an elective delivery, at how many weeks should they do this?
Want them to have elective if baby is beyond 39 weeks (even though they’re considered full term technically at 37 weeks, we want them to be beyond 39 weeks)
What should baby’s HR be
110-160
Why might a fetus be in bradycardia 4
- Mom is in the supine position (laying flat - why we don’t want mom laying flat)
- Mom could have hypotension
- Mom could be on an adrenergic-receptor blocking drug like Propranolol
- Mom could be on anesthetics
Why might a fetus be in tachycardia 5
- *Maternal fever and infection
- Increase in fluid volume
- Mom could have hyperthyroidism
- Mom could have anxiety
- After mom has smoked since nicotine is a stimulant
Why might a fetus be in tachycardia 4
- *Maternal fever and infection
- Increase in fluid volume
- Mom could have hyperthyroidism
- Mom could have anxiety
- After mom has smoked since nicotine is a stimulant
What is the number one indicator that a fetus is getting well oxygenated and is not in acidosis
We see moderate variability changes in their HR, usually changes from 5-25 BMP.
Why might we see a decrease in variability (basically HR is unchanged)
- Could be that baby is in their sleep cycle, which usually lasts for about 20 minutes.
but…. - If it’s been over 20 minutes and the baby’s HR is still unchanged, then it could be a sign of hypoxia or acidosis
Besides a fetus being in a sleep cycle, what else might cause decreased variability
- Mom could be on fentanyl for pain
- Mom could be on mag sulfate
Do we like to see accelerations
Yes, they can tell us that the baby is well oxygenated
Do we want to see many decelerations
No - usually means something is wrong (remember veal chop)
What are the categories for FHRs
- Category 1: everything is good. We have moderate variability and some accels. (no decels happening)
- Category 2: Everything in between. We’re continuously monitoring, we’re trying different interventions to see if we can improve things. Remember POISON.
- Category 3: Very concerning - indicate a need for immediate delivery. Example - absent variability, flat line HR, with recurrent decelerations (these are all signs of acidosis). Could have bradycardia, huge decel, even down to 60 and it stays down there for 10 minutes (indicates an immediate delivery).
Are early decels normal/ok?
Yes, they happen right when mom has a contraction, and indicate that the head is being compressed, which is usually because the baby is advancing down the canal
Are late decels ok?
No, late are the worst type of decels. It means that the placenta is unable to perfuse baby (not enough reserves etc)
Are variable decels ok?
Not good, but not as bad as late. Only really bad if they keep occurring, ok from time to time. Means that there is some cord compression. These look “V” shaped on the monitor.
What acronym can we use for intrauterine resuscitation? What does it stand for?
POISON
P - position change
O - oxygen
I - IV fluids
S - sterile vaginal exam
O - oxytocin OFF
N - notify
What are the 4 P’s in labor?
- Power of contractions
- Passenger (size of baby)
- Passageway (positioning of baby coming out)
- Psyche
What is a normal amount of contractions in 10 minutes? What is considered hypotonic contractions?
Normal: 4-5 contractions in 10 minutes
Hypotonic: less than 2-3 contractions in 10 minutes
What may cause hypotonic contractions 2
- Overdistended uterus (like with multiples, polyhydramnios)
- Presenting part is not being well applied (like if baby’s head is not being applied to mom’s cervix, then it’s not going to help stimulate good contractions)
If mom is having hypotonic contractions, what things can we do to help increase her contractions 3
- Have mom try to walk/change positions
- AROM (artificial rupture of membranes) (helps augment labor to get contractions going)
- Start oxytocin to help augment labor
What is the risk with oxytocin
We can cause tachysystolic labor, where we’re having more than 5 contractions in 10 minutes averaged over 30 minutes
How do we administer oxytocin
- It’s a dual RN sign off because it is a very high risk med
- Start very low with 2 miliunits every hour
- Then increase every 30 minutes until we get to a desired labor pattern, where we’re having contractions every 2-3 minutes
Why is tachysystolic labor bad for a baby?
We don’t want contractions too close together, because we want time for that placenta to perfuse and establish reserves, because remember when mom is having a contraction, the placenta is using reserves to perfuse the baby, but if her contractions are happening too close together, than she doesn’t have enough time to build up these reserves in-between contractions
What do we do if mom goes into tachysystolic labor 4
- Stop oxytocin
- Want to promote relaxation
- Treat mom’s pain due to having so many contractions (which can also help relax the uterus)
- Terbutaline giving SQ helps relax the uterus (remember that it does increase maternal HR)
What is the purpose of artificially rupturing membranes
We do when we want to help labor progress because when we rupture the membranes it will remove the fluid that may be separating the baby’s head from the cervix, so now if that fluid is gone baby’s head will make contact and apply pressure to the cervix which can help the cervix start to have meaningful contractions
What should we make sure is going on during artificial rupture of membranes? 4
- Have to have fetal HR monitoring going on before, during and 20 minutes after the procedure so we can see how baby is tolerating the change in environment (aka loss of fluid)
- Let mom know that there shouldn’t be any pain, it will just be discomfort like with any cervical exam
- “start the clock” when the rupture occurs, because we want to deliver baby within 24hrs from this time
- Document amount and color of fluid, may have meconium in it
Is a cord prolapse pretty rare
Yes, it’s very rare
What are major risk factors for a cord prolapse
When the baby’s head is not applied correctly in the cervix, which leaves room for the baby’s cord to fall out before delivery
- High station of baby
- Small fetus
- Breech presentation
- Transverse lie
- Polyhydramnios
Is it more common to see a cord prolapse in a spontaneous or artificial ROM?
Artificial
What are the two classes of cord prolapse
- Occult: hidden, we can’t really see that it is occurring
- Complete: where we can see that cord
Why is a cord prolapse an emergency
Because if the cord is coming first in front of the baby’s head, then when the baby’s head makes contact with the cervix, it’s going to be a tight fit, so this can cut off the cord blood supply to the baby
What is a sign on the FHR monitor that there may be a cord prolase
We see a major, prolonged decels and bradycardia
How can we prevent a cord prolapse
Make sure baby’s head is well applied before rupturing any membranes
How can we cure a cord prolapse
Stat C-section
If you have a cord prolapse and you’re waiting for a C-section, what can we do as nurses/providers 2
- Want to relieve pressure off the cord
- Provider will use two fingers to try and push baby’s head up and off that cord without touching the cord, because touching it can cause vasospasms
What can cause cord compression 2
- Position of mom
- Decreased amniotic fluid, like from ROM
What is a sign of cord compression
We have variable decels with every contraction
What is our tx for cord compression 2
- Have mom change positions
- Amnioinfusion
What is amnioinfusion? Why would it be done?
We insert sterile saline or LR into the uterine cavity via an IUPC (intrauterine pressure catheter)
May be done to treat repetitive variables due to low amniotic fluid volume
What should we know about amnioinfusion 6
- Fluid should be warmed before instilling
- Watch our intrauterine pressure so we don’t put too much fluid in
- Make sure uterine tone stays consistent
- Changing pad and chucks frequently, continuous fluid will be leaking
- Watch for improvement in baby’s FHR and wanting variables to stop
- Have infection on your mind (frequent temp checks, very 2hrs first and then moving to every 1hr)
What is chorioamnionitis
Intrauterine infection of membranes and/or fluid
What usually causes chorioamnionitis
Usually an ascending microbe from the GU system that climbs up in there
Do women who have rupture membranes only get chorioamnionitis
No, you can still get chorioamnionitis even if your membranes aren’t ruptured, but it is more common in women who have ruptured membranes
When does the risk for chorioamnionitis increase if you have ROM
At 12, 18 and 24hrs
What are increased risks of chorioamnionitis 3
- Increased vaginal exams
- GBS that is untreated
- Internal monitors (like with amnioinfusion)
What are the s/s of chorioamnionitis 4
- Increased maternal HR and temp
- Increased fetal HR is often the first thing we see
- Fundal tenderness
- Foul odor of fluid is usually a later sign
What is our tx for chorioamnionitis
Abx for mom
What is shoulder dystocia
When the head gets delivered but the shoulders are stuck
Is shoulder dystocia an emergency? Why or why not?
Yes, because if the baby is trapped in the birth canal it can cause irreversible brain and organ damage after 6 minutes
What should we do when we see the head delivered as nurses?
Mark the time, because we want to make sure that the rest of the baby is delivered pretty quickly and is not stuck like with shoulder dystocia. If a baby’s heads delivered but not the baby within 1 minute or more, then it is considered a shoulder dystocia.
What are risk factors for shoulder dystocia 7
- Increased birth weight
- Gestational diabetes (chest is the largest part)
- Obesity
- Size discrepancy between the parents (small mom and big dad)
- Use of vacuum or forceps (since you had such trouble delivering the head, are we going to have enough space to deliver the shoulders?)
- Prolonged second stage (pushing, like for 2 hours for a primi or 1 hour for a multi, might cause us to think that since it is taking so long to push that maybe this baby isn’t the right size to come out)
- Previous hx of shoulder dystocia
What is interesting to note about shoulder dystocias
That most occur in average size babys
What team do we want to have on standby when we know we have a shoulder dystocia
OR
Besides having an OR ready for a shoulder dystocia, what else do we want to have ready?
A stool
What is our management for shoulder dystocias 6
- Make sure mom has an empty bladder (sometimes foley is removed if they have an epidural to create more space) (we can straight cath a pt if needed)
- Providing firm pressure under mom’s buttocks
- NICU should be present and resuscitation equipment must be present and ready
- Position mom (lower the HOB down, pull legs)
- Have 10L of oxygen on
- Make a change in approach to delivery every 30 seconds (try different maneuvers)
What is the first maneuver that we do? What are we doing?
Mc Roberts maneurver
1. Lower HOB
2. Bring knees apart and to her shoulders (moving her legs back really opens the pelvis)
3. Perform suprapubic pressure as directed
What is the wood screw maneuver
Where the provider tries to rotate the baby around and deliver the other shoulder
What is the Gaskin technique
Have mom on her hands and knees to help change position of baby
What is the symphysiotomy
The ligaments of the symphysis are cut, which can add an extra 2-3 inches to the maternal pelvis
What is the Zavanelli
Baby’s head is pushed back in and the baby is delivered via c-section
What are two injuries that can happen to a newborn if there is dystocia
Brachial plexus or fractured clavicle injury
How would we know if the baby has a broken clavicle
When you assess the clavicle you’re going to feel crepitus (snap/crackle of air)
What has happened in a brachial plexus injury
There is either bruising, stretching, avulsion (forcible detachment) of the nerve networks C5 to T1
Can a brachial plexus injury vary in severity
Yes, it could just be temporary palsy to flaccid, or it could lead to serious damage, where the newborn is unable to move the shoulder
What reflex could you test to see if there is a brachial plexus injury
The moro reflex, where you startle the baby to see if they pull their arms out and up to their chest (if there is a brachial plexus injury, they won’t be able to move the affected arm because of the shoulder injury)
What is a major complication of shoulder dystocia for the newborn
Erb’s palsy, which is where the newborn doesn’t have any movement in their affected arm
What is needed in order to use a vacuum or forceps
- Membranes need to be ruptured
- Mom needs to be fully dilated
Why would we use a vacuum or froceps
- To help with the “power”, which is one of our 4 P’s, where mom is getting tired and her pushes aren’t as strong anymore, a vacuum or forceps can help her to get the baby out
- And baby is starting to go into distress
What are newborn considerations if we’re using a vacuum or forceps (a lot)
- May increase the risk for shoulder dystocia
- Lacerations/nerve damage to the baby
- Vacuum can cause cephala hematomas
- Going to be more swelling/trauma to head
- Does swelling cross the sutures? (if it doesn’t cross sutures, we worry about blood loss)
- Monitor VS
- Monitor head circumference of baby (should be getting smaller, not bigger)
- Do our neuro assessments on baby’s (sucking reflex, apply pressure to rough of baby’s mouth) (If baby isn’t sucking, this could be a sign of neuro damage)
- Forceps can cause more tissue damage on mom, which can lead to hematomas
- Mom would usually have an episiotomy so we can make space
What is anaphylactoid syndrome
Where amniotic fluid enters the mom’s blood stream and gets carried into the lungs, basically it becomes a blood clot
Besides causing a blood clot, what can anaphylactoid syndrome lead to
- Circulatory failure
- Respiratory failure
- DIC can occur due to the amniotic fluid interferring with clotting
What are signs of anaphylactoid syndrome
- Acute drop in BP
- Cardiac arrest
- Cough
- Chest pain
- Think about PE symptoms
How do we treat anaphylactoid syndrome
We treat it like a code
- CPR
- Oxygen with ventilation
- Fluid volume expansion
- Vasopressors
- Packed cells
- FFP
- Fibrinogen
If mom is on ventilation, how should we position her
Uterine tilt, so she’s not completely on her back
What is a TOLAC (Trial of labor after caesarean also called a VBAC (vaginal birth after caesarean))
When we let a woman who had a previous c-section try to have a vaginal birth with her next child, because the reason she had a c-section may not necessarily happen again, like say her previous baby was a breach, so that’s why they had a do a c-section, well that doesn’t mean her next baby is going to be breach, so try and do a vaginal birth (her body was still able to physically have a baby, it’s just that the baby was upside, or maybe she had a cord prolapse)
What are the 2 risks with TOLAC
- Needing a c-section anyways
- Uterine rupture due to the previous incision site
Who is eligible for TOLAC 4
- Hx of only one previous low-transverse c-section
- Adequate pelvis in relation to fetal size
- No other uterine scars, anomalies or previous ruptures
- Physician is always available throughout active labor
How do we manage our TOLAC mothers 3
- Have them on high-risk
- Continuous fetal monitoring
- Plan as if they’re going to have a c-section (have consents signed, have hair clipped and removed from area)
What is a uterine rupture
An actual rupture of the uterine muscle
What are we concerned about with a uterine rupture 3
- Concerned about BLEEDING
- Hypovolemic shock for mom
- Poor fetal perfusion for baby
What are s/s of uterine rupture 5
- Sudden, sharp abdominal pain with a contraction (may stop when contraction stops)
- When you palpate mom’s abdomen you might be able to feel fetal parts
- Sudden drop in fetal HR (bradycardia)
- Might have loss of strong contractions
- Might have loss of station (think about it - if you have that rupture of the uterine muscle, the baby might just float back up to the abdominal cavity)
What is our management of a uterine rupture 3
- EMERGENCY
- STAT C-section
- Might have a hysterectomy if completely rupture (difficult to repair)
What is twin transfusion
When twins are sharing a placenta, but one twin isn’t getting as much perfusion/fluid as the other twin, and the other twin is getting too much perfusion/fluid
What is the issue with twin transfusion, besides one baby not getting enough perfusion/fluid
The baby that is getting too much fluid can be at an increased risk of HF
What can we do to monitor for twin transfusion
Use a doppler to see if the perfusion/fluid is being evenly distributed between the twins
What are increased risks if you’re having multiples 8
- Pre-term labor (due to the increase in pressure)
- Preeclampsia
- Gestational diabetes
- Placental masks
- Hyperemesis
- Placenta previa (if more than one placenta)
- Abnormal presentation
- Cord prolapse
When we’re checking FHR for multiples, what do we want to do
We want to be checking for all of the baby’s HRs at the same time (don’t do one at a time, because you wouldn’t be able to determine which HR belongs to which baby)
What type of delivery do we automatically do if a mom is having 3 or more babies
C-section (too difficult to deliver all of the baby’s vaginally without complications)
What should we encourage our mother’s to get if they are having twins and trying a vaginal birth
We want to encourage them to get an epidural, just to help with the pain in case we need to have extra assistance (like forceps or a vacuum, etc) during the delivery, since they will be doing double the work, or if we need to end up having a c-section
What is our birth time for twins born vaginally or via c-section
Vaginally - usually 15 minutes apart
C-section - usually 1 minute apart
Where do we like mom’s who are attempting a vaginal birth with twins to deliver
We like them to deliver in the OR, just in case
After delivery, what are we worried about if mom has given birth to multiples
Post-partem hemorrhage, they are at an increased risk as their uterine muscle was stretched larger, so we may have difficulty getting it to clamp down
How much blood loss is considered postpartum hemorrhage
Quantitative blood loss (QBL) is 1000 mL
What is primary PP hemorrhage
Within the first 24hrs after delivery
What is secondary PP hemorrhage
after that 24hrs and up to 12 weeks
What are the 4 different causes of PP hemorrhage
- Tone (most common issue)
- Trauma
- Tissue
- Thrombin (very rare)
(see the table on pg 420)
How can we prepare for a primary PPH 5
- Drills
- PPH Kit
- Admission record - showing religious or cultural considerations (want to know if they will accept blood products if needed)
- If they have a hx of PPH it gives them a 10% risk of having it happen again (so make sure everything is ready to go)
- Everyone gets a CBC and type and screen on admission
What is a big red flag that a mom might have PPH after her delivery
If she had a previous PPH with her other pregnancies
How can we manage PPH
- Address the cause (ie tone - give fundal massage)
- Make sure you do frequent fundal massages after delivery (midline at the umbilicus, or a finger or two above or below)
- Assess lochia every time we do a fundal massage (how much blood is coming out)
- Maternal VS (not going to show us early changes, because women have things that buffer signs and symptoms of blood loss initially due to the pregnancy) (fyi - baby’s HR, then mom’s HR, then mom’s BP will be signs of hemorrhage in this order)
- Quantitative blood loss - make sure we measure everything (1gram = 1 mL)
What are the risk factors of Primary PPH
- Overdistended or exhausted uterus (LGA babies, polyhydramnios, multiples, multify (+5 babies) (uterus is soo stretched it has difficult getting back to original size)
- Infection (infected uterus isn’t going to contract effectively)
- Anatomical/functional issues (full bladder - fundus will be off to the side if bladder is full, Pitocin over a long period of time, if we give more Pitocin it isn’t going to do anything)
What do we do for uterine atony
- # 1 start vigorous fundal massage
- Bi-manual exam (provider does this)
- Empty bladder if we need to
What medications can we give for uterine atony
- # 1 Pitocin (usually already hanging and ready to go as it is standard to give to everyone after delivery, if PPH starts, will probably need to titrate up)
- Then give Misprostol (Ctyotec) (Can we given rectally)
- Methylergonovine maleate (Methergine) (Give IM)
- Prostaglandins (Hemabate) (Give IM)
What is the contraindication of Methergine
If they have hypertension (because it causes hypertension)
What is the contraindication of Hemabate
Asthma
WHat is an unpleasant side effect of Hemabata, and which is why it is given last
Awful diarrhea (makes it difficult to measure blood loss)
What is another medication that is not as common for PPH, but is starting to be given more? And what does it do?
Tranexamic acid - helps prevent breakdown of clots
What is the Bakri balloon
Balloon that is inserted into the uterus, and is filled with 500-1,0000 MLs of saline, this helps put manual pressure where the placenta was attached to help clots form
When we do a fundal assessment on a pt who has a Bakri Balloon, what will it feel like?
It was be hard, above the umbilicus (don’t want to disturb it, because we don’t want it to rupture)
What can cause trauma for primary PPH 3
- Lacerations (we will see a red trickle stream of blood)
- Hematomas
- Uterine inversion
What would be a symptom of a hematoma
Very, very painful where the hematoma is forming
How can we treat a hematoma
We might drain it or we might let is reabsorb overtime
How does a uterine inversion happen
- Providers may put too much pressure on the cord when trying to get the placenta out - this can cause the uterus to go inside down and invert
- If we don’t put our hand below the uterus when doing a fundal massage we could invert it
How can we management a uterine inversion 5
- Manually reducing the uterus (putting it back in the right spot - might need anesthesia for this)
- Tocolytics
- Terbutaline
- Fluid bolus if issue with volume
- Possible transfusion
Besides bleeding, what else is a complication of uterine inversion
Infection because you have the uterus coming out of the body
What can cause tissue issues for primary PPH 2
- Retained products (like little membranes, pieces of placenta (this is why we check the placenta after birth to see it it’s still in tack)
- Abnormal placentation
What is a risk factor for PPH related to tissue
placenta accreta (where the placenta has grown into the uterine wall)
What syndrome did we learn about earlier that can cause thrombin issues for PPH
Anaphylactoid Syndrome (amniotic fluid embolism)
What is our standard postpartum care
- Assess vital signs, uterine position and uterine bleeding every 5min x for the first 15min, then every 15 minutes for the first hour, then Q30min x 2, then Q1 x4
- Promote breastfeeding (helps stimulate contractions to prevent hemorrhage)
Are a change in mother’s VS an early or late sign of PPH
Late - a change in mom’s VS are late signs of PPHs
What are causes of secondary PPH 3
- # 1 cause is retained products
- Uterine infection (causes an increase risk of bleeding - want to teach mom to be clean down there and good peri care so we can reduce risk of infection)
- Coag defects like Von Willebrand
When would we give blood?
If hemoglobin is less an 7 or they’re symptomatic of blood loss
What is endometritis
Infection of the uterus (it’s like chorioamnionitis, but now the membranes are gone because the baby has been delivered)
What are s/s of endometritis 5
- *Pelvic pain
- Increase in lochia
- Foul smelling lochia
- Fever
- Increased HR
What are s/s of mastitis
- *Unilateral symptoms and more localized
- Going to be a red, hard wedge shape towards the armpits
- Breast tenderness
- Pain/burning with or without breastfeeding
- Malaise
- Temp
What is our tx for mastitis 3
- Oral abx
- Continue to breastfeed
- Apply hot packs if needed
What is a key with mastitis symptoms
A woman may think that they have mastitis when their milk comes in because when your milk comes in it can cause tenderness and warmth, but this occurs in both breasts (bilaterally), whereas mastitis symptoms happen in only one breast (unilateral)
All women are at risk for PP depression, but which women may be at higher risk for it
Primagravida
History of depression
Medical complications
Immaturity and/or low self-esteem
Dysfunctional personal relationship
Financial concerns
Chronic stress
Infant with illness or anomalies
Isolation/lack of support
Uncertainty about the pregnancy that lasts beyond the first trimester
How is PPD different from the “baby blues”
With the baby blues, symptoms will disappear without medication tx, they usually occur within the first 2 weeks of postpartum, and mom is still able to safely handle the baby.
With PPD, symptoms require medical tx, they usually occur within the first 12 months, and they are unable to safely care for the baby.
What are symptoms of the “baby blues”
- Fatigue
- Anxiety
- Tearfulness
- Mood swings
(a lot has to do with changes in hormones)
(mom is still able to care for themselves and baby)
Is it normal for baby blues to last over 2 weeks
No, that’s not normal
What are the s/s of PPD? (a lot)
- Depression
- Apathy (not caring) (big red flag - not caring about the baby)
- Anxiety
- Panic attacks
- Fatigue
- Significant weight loss or gain
- Insomnia or hypersomnia
- Feelings of worthless or guilt
- Decreased ability to concentrate
- Inability to make decisions
(fyi - these s/s need to last longer than 2 weeks)
Besides the mom, who should we teach PPD symptoms to, basically what to look for as signs of PPD
We want to teach the SO, because usually pts with PPD do not identify themselves, so we want the SO to watch for signs and symptoms
What is our tx for PPD 3
- SSRIs (Paroxetine, Fluoxetin, Setraline)
- Complimentary therapies
- Lots of support
If a woman has PPD depression, is she at risk of developing it again with any future pregnancies? If so, what might a provider do?
Yes - she has a 50-90% chance of having PPD again with any future pregnancies
Provider might preemptively start her on SSRIs
What can PPD lead to if untreated or unresolved
It can lead to PP Psychosis (this is where women try to kill the baby and go crazy)
What are s/s of PP psychosis
- Paranoia
- Gradiose, bizarre delusions (usually about the baby)
- Mood swings
- Confused thinking
- Anxiety
- Panic
(very dramatic changes from normal)
What is the timeline of PP Psychosis
- First peak in first 10 days
- Second peak in 6-8
How do we treat PP Psychosis
As a true emergency, because these are usually the moms that kill their babies
- They’ll go on long-term psychotherapy and medication
What is the leading cause of neonatal sepsis
GBS
When do we screen mom for GBS
All women are screened between 35-37 weeks
What do we give to treat GBS for our moms? When do we give it? Will this cure their GBS?
Ampicillin/Clindamycin
Give within 4 hours of delivery
Doesn’t cure it - only working during labor and then the GBS will eventually grow back
What typically causes Chorioamnionitis? What are other risk factors?
Typically caused by ascending polymicrobial infection after membranes have been ruptured
Prolonged ROM
Prolonged labor
Nulliparity
Internal monitoring
Multiple VE (vaginal exams)
Meconium-stained amniotic fluid
Smoking
Drug or alcohol abuse
Immune compromised
Bacterial vaginosis
Group Beta Strep colonization
STDs
What is a big issue with infection while pregnant and after pregnant
Can cause the uterus to not function correctly, leading to dysfunctional contractions during delivery and after - which increases risk for PPH
What are risk factors for newborn sepsis 6
- Preterm delivery
- Prolonged labor
- ROM greater than 18 hours
- Maternal fever
- *Chorioamnionitis (infection of the uterus and amniotic sac)
- *Maternal GBS
How might infants present their symptoms if they have an infection
They may be asymptomatic at first
What is the first symptom indicator that a baby may have sepsis
We see behavioral changes in the baby
What are s/s of sepsis in newborns 4
First s/s can be very subtle (why we like to have the same nurses assigned to them so we can notice the changes)
- May be hyper or hypothermic
- Lethargic
- Hypoglycemic
- Poor feeding
How can we tell if a baby is hypoglycemic if we’re not checking the sugars 4
- High pitched cry
- Low temp
- Decreased tone
- Poor feeding
How can we diagnosis a baby if we think they may have sepsis 4
- CBC
- C-reactive protein (CRP)
- Platelets
- Blood culture
How do we treat newborn sepsis
- Start on ampicillin and Gentamycin until cultures come back after 48hrs (broad spectrum and to narrow once cultures come back)
What type of Rh are we worried about for mom and baby
If mom is Rh- and if baby is Rh+
What do we give our Rh- moms
RhoGAM at 28 weeks even though we don’t know if baby is Rh+, and not she may receive it again within 72hrs after delivery and after we test baby, if baby is actually Rh+
What is the issue with Rh incompatibility
If an Rh- mom is exposed to an Rh+ baby, then antigens are created by baby and transferred into mom’s bloodstream, where the first child is usually not affected, but the antigens can destroy fetal RBCs and cause anemia in the second child
What specific blood types are we also worried about?
If mom has type O blood, but has a fetus with A or B = mom’s antibodies (anti A and anti B) will attack baby’s RBCs
What does a positive Coombs test tell us? What are baby’s who have a positive Coombs test at risk for?
Tells us that there was a mixing of mom and baby’s blood, because it detects antibodies that may not have been compatible and baby is at risk for hyperbilirubinemia (aka jaundice)
What is our management for baby’s with hyperbilirubinemia 2
- Frequent feedings, because bilirubin is excreted in the stool, so we want frequent feedings to keep things moving through their digestive tract.
- Might need bilirubin lights (helps breakup bilirubin)
What does IDM stand for
Infant of diabetic mothers
What are SGA and IUGRs at risk for 4
- Hypothermia (don’t have reserve adipose tissue and brown fat)
- Hypoglycemia
- Infection
- Hyperbilirubinemia
What are LGA and IDM baby’s at risk for 4
- Hypoglycemia
- Nutritional deficits (low mag and calcium levels and low glucose)
- Hyperbilirubinemia
- Transient tachypneic (respiratory distress) of newborn due to surfactant production (too much insulin when in utero can decrease surfactant production)
What are risk factors that can cause preterm labor 6
- Infection
- Previous preterm labor hx
- Multiples
- Polyhydramnios
- Preeclampsia
- Gestational diabetes
What are our diagnostic tests for preterm labor 3
- FFN (the diva test)
- Cervical length
- UA
What is our tx of PTL 2
- Tocolytics (these stop contractions) (mag sulfate, Nifendine, another one, and Tubutaline (remember HR))
- Give betamethasone
What impact does mag have on mom
- CNS depression
- Relaxes uterus
- Causes vasodilation (lowers BP)
What impact can mag sulate have on baby when born
- Decrease in RR
- Decrease in Tone
- Minimal variability on FHR monitor
What are our preterm baby’s at risk for 5
- Hypoglycemia
- Hypothermia
- RDS (due to decrease surfactant)
- Jaundice
- IVH (intraventricular hemorrhage - trauma to head from vaginal birth)
What are the s/s of RDS in baby’s
- Increase RR >60
- Retractions
- Cyanosis
- Decreased breath sounds
What is our tx of RDS in baby’s
- CPAP
- Surfactant via ET
At how many weeks do we see a decrease in placenta perfusion for long pregnancies
42 weeks
What are post-term babies at risk for 6
- Meconium aspiration
- Dry, flaky skin (decrease in vernum)
- Oligohydramnios with risk of cord compression
- Still birth (due to placenta issues)
- Dystocia’s
- Assisted births
What is our tx for post-term pregnancies
- Try to induce at 41 weeks
- Manage baby with frequent nonstress tests and biophysical profiles
What baby’s are at risk for Meconium aspiration syndrome (MAS)
- Post-term baby’s
- Baby is under stress or something traumatic
Is MAS common?
Yes MAS is pretty common, but it is very uncommon for it to actually cause any complications
Why might meconium aspiration syndrome (MAS) occur
If the baby has some kind of stress, like a moment of poor perfusion that causes them to poop and then they have a “shock moment” where they take a breath and then breathe in that meconium
What is our tx for MAS 6
- Suctioning if baby is not vigorous
- Possible ventilation
- Monitor for infection
- Might need some surfactant
- Might need prophylactic abxs
- Have a team in the room ready in case something happens
Diffuse swelling is normal after delivery (cone head babys)
- Cephlahematoma (collection of blood that doesn’t cross the sutures - monitor head circumferance to make sure it doesn’t grow, make sure there isn’t a subdural hematoma, blood should just absorb back)
Types of substances that we can use a neonatal abstience score sheet
- Heroin
- Methadone
- Pain meds
What are signs of suspeicison of use
- No neonatal visitis
What is the name of our abstience tool
Modified Finnegan Neonatal abstinence Score Sheet
What are s/s of NAS
- Excessive high pitch cry
- Decreased sleep
- Hyperactive moro reflex
- Tremors
- Sweating
- INcreased temp
- Elevated RR
(everything is upwhen they’re withdrawaing)
What is our diagnostic testing for baby
- Do a tox screen after they’re born
How can we treat NAS (a lot)
- High-calorie formula
- Small frequent feedings
- Antidiarrhea
- Meticulous I/Os
- Wts
- Skin care with barrier ointments
- Breastfeeding if not CI
- Morphine/methadone as needed
- Collaborate with SS
- Promote comfort
- Tox screen
Diabetes 171
Risk factors:
- Obesity
- Family hx of diabetes
- A lot of time no risk factors for pts
Maternal risks for mom with diabetes:
- DKA
- Infections
- Preeclampsia
- C-section
- Difficult delivery if baby is big
- Increased risk of developing type 2 later on
Neontal risk
- Hypoglycemia
- Macrosomia
- IUGR when blood vessels on the placenta are damaged
- Respiratory distress due to decrease in surfactant production
- SHoulder dystocia (these baby’s can have broader chests)
What are goals/management of diabetes
- Euglycemia
What should diabetic mom’s increase in their diet
Folic acid
How do insulin needs change depending on where they are at in pregnancy
1st half: less insulin
2nd half: more insulin
PP: less insulin
Pg 172 preeclampsia
Widespread vasospasm and endothelial damage
Placental dysfunction can occur causing what in preeclampsia:
- IUGR
- Late decels once contractions start (not good placenta reserve)
What are our assessments and diagnostics for preeclampsia
- Headaches
- Spots in vision
- Upper right quadrant pain
- Edema
- Urinary output (kidney function)
- Reflexes
Tx for preeclampsia
- Delivery
- Give mag for seizures
- Calm, mellow, dark room
- Bed rest, but can still use the bathroom
Tx for preeclampsia
- Delivery
- Give mag for seizures
- Calm, mellow, dark room
- Bed rest, but can still use the bathroom
How is PPD different from the “baby blues”
With the baby blues, symptoms will disappear without medication tx, they usually occur within the first 2 weeks of postpartum, and mom is still able to safely handle the baby.
With PPD, symptoms require medical tx, they usually occur within the first 12 months, and they are unable to safely care for the baby.
