Test 5 Flashcards
life or well-being of the mother or infant is jeopardized by a biophysical or psychosocial disorder coincidental w/ or unique to pregnancy
high risk pregnancy
the goal is to determine whether the intrauterine environment continues to support the fetus
Electronic fetal monitoring
Types of electronic fetal monitoring (3)
Nonstress test
Vibroacoustic stimulation (VAS)
Contraction Stress Test (CST)
prenatal test used to check on a baby’s health; baby’s heart rate is monitored to see how it responds to the baby’s movement
Non-Stress Test
How Nonstress test is performed (3)
-Woman is seated in a recliner in semi-fowlers
-FHR is recorded w/ a Doppler transducer
-Tocodynamometer is applied to detect uterine contractions or fetal movements
what is considered a “reactive” NST (2)
Gestation > 32 weeks: 2 accelerations lasting 15 sec each within a 20 min window
Gestation <32 weeks: 2 accelerations lasting 10 sec each within a 20 min window
NST results and meaning
reactive: normal/good
nonreactive: requires further evaluation
Nonreactive NST:
if there’s no activity for 40 min or more, get provider
common for NST to take up to ______ to determine results
20 minutes
Reasons to do NST based on term: (2)
1st-2nd tri: after diagnosis of fetal anomalies
3rd: determine whether the intrauterine environment continues to support the fetus
Patients that are recommended for NST: (6)
Chromosomal abnormalities
Intrauterine growth restriction
Poorly controlled maternal DM
Hemorrhage/Risk of hemorrhage
Fetal congenital abnormalities
Maternal Heart disorders
Buzzer placed on stomach –> see if baby reacts on monitor to buzzer
Vibroacoustic stimulation (VAS)
Procedure done one of two ways:
-Nipple-stimulated ___________
-Oxytocin-Stimulated ___________
contraction stress test (CST)
Contraction Stress Test interpretations: (2)
Negative: desired
Positive: Late FHR decelerations are present
Obtains amniotic fluid to test for potential complications
amniocentesis
who would be offered an amniocentesis (4)
Older mom
Genetic concerns
Fetal maturity
Fetal hemolytic disease
Why are amniocentesis done? (3)
- Prenatal diagnosis of genetic disorders/ congenital anomalies (neural tube defects)
- Assessment of pulmonary maturity
- Diagnosis of fetal hemolytic disease (rare)
used to monitor fetus in pregnancies complicated by conditions that may affect oxygenation
Daily fetal movement count (DFMC)
AKA: Fetal Kick Counts
Why do parents do DFMC (FKC)
Used to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation
How do parents do DFMC (FKC)
-Count of fewer than 3 kicks in 1 hour warrants further evaluation by a nonstress test
-Tell patient 3 kicks/1hr is an AVERAGE
(Baby can kick more during certain times of day so important to use average)
considered to be the most valuable diagnostic tool used in obstetrics
ultrasounography
two routes of ultrasounds
abdominal
transvaginal
three levels of ultrasound
Standard (basic)
Limited
Specialized (targeted
why are ultrasounds done
Fetal heart activity
Gestational age
Fetal growth
Fetal anatomy
primary use of ultrasound:
establish gestational age & predict due date of birth
secondary use of ultrasound: (3)
monitor structural development,
monitor heart rate
detect deformities
high risk indications of ultrasound (3)
-Fetal genetic disorders and physical anomalies such as Down’s (Nuchal translucency (NT) screening)
-Placental position and function
-Adjunct to other invasive tests (Amniocentesis risks are reduced w/ use of ultrasound)
what is measured in a biophysical profile
-Fetal breathing movements
-Gross body movements
-Fetal tone
-Reactive fetal heart rate
-Qualitative amniotic fluid volume
Biophysical profile: Normal score (2)
-Fetal breathing movements
-Gross body movements
-Fetal tone
-Reactive fetal heart rate
-Qualitative amniotic fluid volume
-Fetal breathing movements: 1 or more episodes in 30 min each lasting 30 sec or more
-Gross body movements: three or more discrete body/limb movements in 30 min
-Fetal tone: 1 or more episodes of active extension w/ return to flexion of limbs or trunk (including hands)
-Reactive fetal heart rate: 2 or more episodes of acceleration in 20 min each lasting 15 sec or more and associated w/ fetal movement (15 bpm or more)
-Qualitative amniotic fluid volume: 1 or more pockets of fluid measuring > 1cm in 2 perpendicular planes
Biophysical profile: abnormal score (0)
-Fetal breathing movements
-Gross body movements
-Fetal tone
-Reactive fetal heart rate
-Qualitative amniotic fluid volume
-Fetal breathing movements: absent or no episodes 30 sec or more in 30 mins
-Gross body movements: less than 3 episodes of body/limb movement in 30 sec
-Fetal tone: slow extension w/ return to flexion, movement of limb in full extension, or fetal movement absent
-Reactive fetal heart rate: < 2 episodes of accelerations or acceleration of <15bpm in 20 mins
-Qualitative amniotic fluid volume: pockets absent or pocket < 1 cm in 2 perpendicular planes
Biophysical profile score:
-Normal
-Equivocal
-Abnormal
-Normal: 8-10
-Equivocal: 6
-Abnormal: <4
Biophysical profile score 8-10 means:
CNS is functional & fetus is not hypoxemia
Biophysical profile score <4 means:
along w/ oligohydramnio –> labor induction
disorder of amniotic fluid resulting in decreased amniotic fluid volume for gestational age
Oligohydramnio
Biophysical profile done for ________ pregnancies, including: (4)
High risk pregnancies
-Asthma
-Post dates
-Previous stillbirth
-Decreased fetal movement
Modified BPP
Includes a combination of: (2)
How often are they done?
Predictive of:
Nonstress test (NST): twice a week
Amniotic fluid index (AFI): once a week
Predictive of fetal well being for 72 hours
Gestational Hypertension
onset of hypertension w/o proteinuria or other systemic findings diagnostic for preeclampsia after 20 weeks of pregnancy; BP at or greater than 140/90
resolves after giving birth
Chronic Hypertension
hypertension present before pregnancy or diagnosed before 20 weeks gestation
Chronic hypertension w/ superimposed preeclampsia
women w/ chronic hypertension may acquire preeclampsia or eclampsia
Difficult to diagnose
Chronic hypertension w/ superimposed preeclampsia
Treatment (ideally & high risk)
Ideally, management of chronic hypertension begins before conception
□ Lifestyle modifications:
□ Smoking/alcohol cessation
□ Exercise
□ Weight loss
High risk management:
□ Antihypertensive medications
□ Frequent assessments of maternal and fetal well-being
How to take an accurate BP for hypertensive women
Manual BP ALWAYS
Pre-Eclampsia w/o severe features:
-hypertension w/o proteinuria w/ systemic findings
-develops after 20 weeks of gestation in a previously normotensive women
-can also develop for the first time during the postpartum period
Pre-Eclampsia w/o severe features: Systemic findings (5)
Thrombocytopenia
Impaired liver function
New-onset renal insufficiency
Pulmonary edema
New-onset cerebral or visual disturbances
Pre-Eclampsia w/o severe features: Goals (2)
Ensure maternal safety
Deliver a healthy newborn as close to term as possible
Pre-Eclampsia w/o severe features: Treatment (5)
-Waiting game- reduce risks to keep baby in as long as medically safe
-Outpatient management usually possible
-Laboratory evaluation
-Fetal evaluation
-Activity restriction (No evidence that bedrest improves outcomes)
Pre-eclampsia w/ severe features (3)
-hypertension w/ proteinuria & systemic findings
-develops after 20 weeks of gestation in a previously normotensive women
-can also develop for the first time during the postpartum period
Pre-eclampsia w/ severe features: Goals (2)
-Ensure maternal safety
-Formulate a plan for delivery
Pre-eclampsia w/ severe features: Treatment (5)
-Magnesium Sulfate (med of choice)
-Continuous FHR and uterine contraction monitoring
-Bed rest w/ side rails ups
-Calm environment: dark room, quiet
-Assess for s/s of placental abruption
Pre-eclampsia w/ severe features: Risk factors (6)
Multifetal gestation
History of preeclampsia
Chronic hypertension
Preexisting diabetes and/or thrombophilia
Women w/ limited sperm exposure w/ the same partner
Paternal factors
Pre-eclampsia w/ severe features: Cause (6)
Unknown
Current thought:
-Inadequate vascular remodeling ->
-Decreased placental perfusion and hypoxia->
-Endothelial cell dysfunction->
-Vasospasm, increased peripheral resistance, increased endothelial cell permeability ->
-Decreased tissue perfusion
Pre-eclampsia w/ severe features: Nursing interventions (3+)
Control BP: antihypertensive medications for BP exceeding 160/110
Postpartum care:
-vitals, DTRs, LOC
-Magnesium sulfate infusion is continued after birth for seizure prophylaxis as ordered (usually 24 hours)
Future health care: increased risk of developing preeclampsia in future as well as chronic hypertension and cardiovascular disease
Pre-eclampsia w/ severe features: Neonatal concerns (2)
Fetal growth restrictions
Fetal demise
Pre-eclampsia w/ severe features: Care management (3)
Identify and prevent
-No reliable test/screening have been developed
-Low-dose aspirin (81mg/day) may help certain high-risk women
-NO NSAIDS
Pre-eclampsia w/ severe features: assessment (5)
-Accurately measure BP (manual)
-Assess edema
-Deep tendon reflexes
-Assess for hyperactive reflexes (clonus)
-Proteinuria
Proteinuria is ideally determined by evaluation of:
24 hour urine collection
s/s of severe preeclampsia (4)
Headaches
Epigastric pain
RUQ abdominal pain
Visual disturbances
medication of choice for preventing and treating seizure activity and preventing labor
magnesium sulfate
Mag Sulfate: administration (2)
-Administer intravenously as a secondary infusion (piggyback) by a volumetric infusion pump
-Initial loading dose –> continuous maintenance dose
Mag sulfate: nursing interventions: (3)
-Monitor output- mag excreted through urine
-Monitor for magnesium toxicity (renal function decline)
Blood draws
-Monitor EKG & respiratory status
Mag Sulfate: toxicity cure
Calcium gluconate
Mag Sulfate: Common side effects (4)
-Feeling of warmth
-Flushing
-Diaphoresis
-Burning at IV site
Mag Sulfate: Toxicity s/s (3)
-Absent deep tendon reflexes
-Decreased respiratory rate
-Decreased LOC
Pre-eclampsia: Paternal factor (2)
-men who have fathered a preeclamptic pregnancy are ~2x likely to father another preeclamptic pregnancy w/ a different women
-Regardless of whether the new partner has a history of a preeclamptic pregnancy
Eclampsia
-onset of seizure activity or coma in women w/ preeclampsia
-No history of preexisting (seizure-related) pathology
Women can develop eclampsia in the ___________ period
immediate postpartum
Eclampsia interventions (3+)
-Premonitory s/s
□ Persistent headache and blurred vision
□ Epigastric or RUQ pain
□ Altered mental status
-Convulsions can also appear w/o warning
-Immediate care
□ Ensure patent airway and client safety
□ Note the time of onset and duration of the seizure
□ Call for help but remain at the bedside
HELLP syndrome stand for:
(H)emolysis
[E]levated (L)iver enzymes
(L)ow (P)latelets
HELLP: dx (3)
-Laboratory diagnosis for a variant of preeclampsia that involves hepatic dysfunction
-Can develop in women who do not have hypertension or proteinuria
□ Often misdiagnosed
-Result of arteriolar vasospasm, endothelial cell dysfunction w/ fibrin deposits, and adherence of platelets in blood vessels
HELLP: s/s (4)
History of malaise
Influenza-like symptoms
Epigastric or RUQ abdominal pain
S/s worse at night and improve during the daytime
HELLP: treatment & cure
T: beta blockers
C: delivery
HELLP: risks (2)
-Perinatal mortality rate ranges from 7.4-34% w/ a maternal mortality rate of ~1%
-Severe risks for bleeding/going into DIC
type of gestational trophoblastic disease; benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grapelike cluster
Hydatidiform mole (molar pregnancy)
types of Hydatidiform mole (molar pregnancies) (2)
Complete: no embryonic or fetal parts
Partial: often have embryonic or fetal parts and an amniotic sac
Hydatidiform mole (molar pregnancy) dx (2)
-Transvaginal ultrasound
-HIIIIGH serum hCG levels
Hydatidiform mole (molar pregnancy): Nursing care management (3)
-Most moles abort spontaneously
-Suction curettage can safely be used
-Follow up care: monitor beta-hCG levels
Hydatidiform mole (molar pregnancy) Patient teaching
-Should not get pregnancy for at least one year
(HIGH risk for uterine cancer)
fertilized ovum is implanted outside uterine cavity
Ectopic pregnancy (tubal pregnancy)
Ectopic pregnancy (tubal pregnancy): s/s (3)
-Abdominal pain
-Delayed menses
-Abnormal vaginal bleeding
Ectopic pregnancy (tubal pregnancy) Dx (2)
-Quantitative HcG levels
-Transvaginal ultrasound
Ectopic pregnancy (tubal pregnancy): tx (3)
-Meds used: Methotrexate
-Surgical depends on location
-Follow up care
placenta implanted in lower uterine segment near or over internal cervical OS
Placenta previa
Degree to which the internal cervical OS is covered by placenta used to classify three types
-Complete
-Marginal
-Low-lying
Placenta previa: risk factors (5)
-Previous c-section birth
-Advanced maternal age (>35 -40)
-Multiparity
-History of prior suction curettage
-Living at a higher altitude smoking
Placenta previa: classic s/s (3)
-Painless, bright red vaginal bleeding during second or third trimester
-Most cases are diagnosed by ultrasound before significant vaginal bleeding occurs
-Abdominal examination usually reveals a soft, relaxed, nontender uterus with normal tone
Placenta previa: maternal and fetal outcomes (5)
-Major complication is hemorrhage
-Morbidly adherent placenta, an abnormally firm placental attachment
-Surgery-related trauma (most deliver by c-section)
-Preterm birth
-Intrauterine growth restriction (IUGR)
Placenta Previa: management (6)
-Monitor- contraction and FHR
-Less than 34 weeks: antenatal corticosteroids
-Vaginal bleeding preceded by or associated w/ uterine contractions: tocolytic medications (mag sulfate)
-Modified bed rest
-No vaginal/rectal exams
-No intercourse
placenta partly or completely separates from the inner wall of the uterus before delivery
○ Decrease or block the baby’s supply of oxygen and nutrients
○ Cause heavy bleeding in the mother
Placental abruption
Placental abruption R/F (5)
High blood pressure
Trauma
Cigarette smoking
Previous abruption
Cocaine use
Placental abruption S/S (5)
Severe abdominal pain
Vaginal bleeding (may be little to none)
Back pain
Uterine tenderness or rigidity
Uterine contractions- Often coming one right after another
Placental abruption: management (conservative & severe)
Conservative
□ Serial ultrasounds
□ Planned induction or c-section by 40 weeks
Severe requires immediate delivery
□ Correction of any coagulopathies
□ Increased risk for PPH
Hemorrhage
an escape of blood from a ruptured blood vessel, especially when profuse
Hemorrhage: most common causes
-Tone
-Trauma
-Tissue
-Thrombin (clotting)
-Coagulopathies of pregnancy
Hemorrhage: tone (9)
uterus contracts after delivery and may have problems related to
Prolonged labor
Inductions (Pitocin use or overuse)
Multiples w/ overdistension
Infections to uterus
Numerous Gs/Ps
Anesthetics (inhaled)
Magnesium sulfate or terbutaline
Hydramnios
Obesity
Hemorrhage: tone main cause
overuse/stretching out muscles
Hemorrhage: tone causes
-anesthetics & magnesium
-polyhydramnios
Anesthetics & magnesium: cause uterus to relax
Polyhydramnios: lots of amniotic fluid = overdistention of the uterus
Hemorrhage: trauma (6)
Lacerations
Hematomas of the vagina or cervix
Inverted/ruptured uterus
Compound presentation such as a hand
Precipitous delivery (<3 hours)
Instrument assisted delivery
Hemorrhage: trauma
hematomas of the vagina or cervix s/s (4)
Unresolved severe pain
No obvious sings of bleeding
Pelvic pressure
Episiotomies
Hemorrhage: trauma
common cause of ruptured uterus
trying to have a vaginal delivery after having a c-section
Hemorrhage: tissue (4)
Retained placental fragments
Should come out within 15-30 minutes max
Nurse should look for intactness of placenta
Acreta or percreta can occur
Hemorrhage: tissue
placenta is attached to the myometrium (slight)
caret
Hemorrhage: tissue
placenta is in the myometrium (deep)
increta
Hemorrhage: tissue
placenta penetrates the myometrium and goes to or past the serosa
percreta
Hemorrhage: tissue
Percreta: Surgical intervention required (2)
D&C
Hysterectomy
Hemorrhage: thrombin
Coagulation disorders that may lead to PPH (3)
-Hemophilia
-Von Willebrand’s disease
-Idiopathic thrombocytopenia purport (ITP)
Hemorrhage: Coagulopathies of pregnancy
Risk Factors
Prior DVTs
Embolism
Hemorrhage Management
Safety bundle for obstetric hemorrhage recommended: (4)
Readiness
Recognition and Prevention
Response
Reporting and Systems Learning
Hemorrhage management
Medical (5)
Firm massage of the uterine fundus
Elimination of bladder distention
Continuous IV infusion of 10-40 units of oxytocin added
Volume replacement
Uterotonic medications
Hemorrhage management
Uterotonic medications & when to use (5)
Pitocin- 1st line
Other medications are given on a case-by-case basis
-Tranexamic acid
-Methergine
-Hemabate
-Cytotec
Hemorrhage management:
Severe management (4)
Vaginal sweep
Pack w/ gauze
Uterine tamponade w/ balloon (Bakri, EBB, Jada)
D&C
Hemorrhage:
Surgical management (2)
Visualization for repair of any tears
Hysterectomy last resort
Hemorrhage:
Nursing role (4)
Identify excessive blood loss
Potential hypovolemia
Assist w/ correction of these underlying causes
Use of protocol
Hemorrhage:
Nursing intervention: anticipatory management (5)
16-18 gauge IV
Manual massage of uterus
Foley to manage bladder distention and look for urine output
Frequent assessment of vital signs
-Looking for hypovolemia
Pitocin IV or IM- active management of 3rd stage of labor (EBP)
Hemorrhage:
S/S of compensated hypovolemia (3)
increased pulse
decreased BP
increased respiratory rate
Hemorrhage: anticipatory management
ORDER
Oxygen
Restore circulating volume
Drug therapy
Evaluation
Remedy underling cause
Hemorrhage: anticipatory management
REACT
Resuscitate
Evaluation
Arrest hemorrhage
Consult
Treat complications
Hemorrhage: Lab & diagnostic tests (3)
CBC (H&H/ platelets)
PT
PTT (both determine body’s clotting abilities)
Hemorrhage: s/s (7)
Compensated shock
Pallor
Anemia
Lightheadedness or faint
Boggy uterus (atony)
Uterus above umbilicus
Large clots w/ uterine massage (weight the clots)
pregnancy that ends as a result of natural causes before feal viability
Miscarriages
Threatened miscarriage
-Amount of bleeding
-Uterine cramping
-Passage of tissue
-Cervical dilation
-Management
-Amount of bleeding: slight, spotting
-Uterine cramping: mild
-Passage of tissue: no
-Cervical dilation: no
-Management: bedrest & monitor
Inevitable miscarriage
-Amount of bleeding
-Uterine cramping
-Passage of tissue
-Cervical dilation
-Management
-Amount of bleeding: moderate
-Uterine cramping: mild to severe
-Passage of tissue: no
-Cervical dilation: yes
-Management
-no pain, bleeding or infection: expectant management
-pain, bleeding, or infection: prompt termination (dilation & suction curettage)
Incomplete miscarriage
-Amount of bleeding
-Uterine cramping
-Passage of tissue
-Cervical dilation
-Management
-Amount of bleeding: heavy-profuse
-Uterine cramping: severe
-Passage of tissue: yes
-Cervical dilation: yes, tissue in cervix
-Management:
*may require additional dilation
*med: misoprostol (cytotec)
Missed miscarriage
-Amount of bleeding
-Uterine cramping
-Passage of tissue
-Cervical dilation
-Management
-Amount of bleeding: none-spotting
-Uterine cramping: no
-Passage of tissue: no
-Cervical dilation: no
-Management:
* med: misoprostol (Cytotec)
*dilation & suction curettage
acquired syndrome characterized by intravascular activation of coagulation which is widespread and results in excessive clot formation and hemorrhage
Disseminated intravascular coagulopathy (DIC)
Why does DIC occur w/ postpartum hemorrhage (2)
-Glycoprotein: found in body organs containing many blood vessels (placenta and amniotic fluid) activates circulating clotting factors when it is released from damaged tissue
-Release of large amounts of tissue factor as a result of placental abruption
measuring out all blood loss physically (difference between dry pad and bloody pad)
quantitative blood loss
measuring blood loss by multiplying the perioperative difference of hemoglobin (or hematocrit) by the patient’s estimated blood volume
estimated blood loss
Value of doing QBL
more accurate
DM present before pregnancy
10% of pregnancies have preexisting DM
pre gestational diabetes
Pre-gestational diabetes: Maternal risk and complications (5)
-Macrosomia w/ increased risk of birth complications
-Hydramnios (polyhydramnios)
-Infections
-Ketoacidosis -> DKA
-Hypoglycemia/hyperglycemia
Pre-gestational diabetes fetal/neonatal risk (4)
Perinatal mortality rates 3x higher
IUFD (stillbirth)
Congenital malformations
Hypoglycemia at birth
Pre-gestational diabetes: assessment (2)
-Complete physical examination & thorough evaluation of her health status
-Routine prenatal laboratory tests & glycosylated hemoglobin A1C level
Pre-gestational diabetes: antepartum care (9)
More frequent monitoring
Diet
Exercise
Insulin therapy
Self-monitoring of blood glucose
Urine testing
Complications requiring hospitalization
Fetal surveillance
Determination of birth date and mode
Pre-gestational diabetes: primary goal
achieving and maintaining constant euglycemia
Pre-gestational diabetes: intrapartum care (5)
-Monitoring for dehydration, hypoglycemia, and hyperglycemia
-Blood glucose levels carefully monitored
-Continuous EFM
-Intravenous infusion
Possible cesarean birth for macrosomia
Pre-gestational diabetes: postpartum care (4)
-First 24 hours, insulin requirement drops substantially
-Risk for hemorrhage due to uterine distention
-Women w/ diabetes are encouraged to breastfeed
-Contraceptive methods education
Gestational Diabetes s/s (4)
-Decreased tolerance to glucose
-Increased insulin resistance
-Decreased hepatic glycogen stores
-Increased hepatic production of glucose
Gestational diabetes
Diagnosis made during ______ of pregnancy
2nd half
Glucose tolerance test: two steps and result evaluation
1-hour, 50g oral glucose
◊ Positive: BS > 130-140
◊ Negative: BS < 130
3-hour, 100g oral glucose
◊ Positive: BS > 130-140
◊ Negative: BS < 130
Risk factors for GDM (6)
-Family history of diabetes
-Previous pregnancy that resulted in an unexplained stillbirth or the birth of a malformed or macrosomic fetus
-Obesity
-Hypertension
-Glycosuria
-Maternal age >25
GDB: maternal risk (3)
Preeclampsia
Cesarean delivery
Development of type 2 diabetes later in life
GDB: neonate risk (2)
-Macrosomia and associated risks for birth trauma
-Electrolyte imbalances including neonatal hypoglycemia and hyperinsulinemia
GDB: antepartume care (7)
-Goal is strict blood glucose control
-Dietary modification
-Exercise
-Self-monitoring of blood glucose
-Pharmacologic therapy
-Fetal surveillance
-Women who require insulin or oral hypoglycemic agents for BG control may have twice-weekly NSTs beginning at 32 weeks gestation
GDB: intrapartum care (2)
-Blood glucose levels monitored hourly in labor
□ Maintain levels at 80-110 mg/dl (strict window)
-nfusion of insulin, if needed
GDB: Postpartum care (4)
-Will return to normal glucose levels after birth
-High risk for recurrent GDM in future pregnancies
-ACOG recommends assessing all women who had GDM for carbohydrate intolerance with a 75-g, 2-hr OGTT or a fasting plasma glucose level at 6-12 weeks postpartum
-Lifelong repeat screening at least every 3 years
excessive, prolonged vomiting accompanied by:
Weight loss Electrolyte imbalance Nutritional deficiencies Ketonuria
Hyperemesis gravidarum
Normal n/v complicates 50-80% of all pregnancies, typically beginning _____________ gestation
Usually resolved by ___________ gestation
Cause:
4-10 weeks
20 weeks
unknown
Hyperemesis gravidarum risk factors (11)
Younger maternal age
Nulliparity
BMI < 18.5 OR BMI> 25
Low socioeconomic status
Asthma
Migraines
Pre-existing DM
Psychiatric illness
Hyperthyroid disorder
Gastrointestinal disorder
Previous pregnancy complicated by Hyperemesis gravidarum
Hyperemesis gravidarum (5)
Significant weight loss and dehydration
Dry mucous membranes
Decreased BP
Increased pulse rate
Poor skin turgor
Hyperemesis gravidarum: assessment (3)
-Severity, frequency, and duration of episodes
-Determination of ketonuria
-Psychosocial assessment: role of anxiety
Hyperemesis gravidarum: interventions (5)
-IV therapy for correction of fluid and electrolyte imbalances
-Medications
-Enteral or parenteral nutrition as a last resort
-Prevent recurrence of N/V
-Follow up care
hyperemesis gravidarum: priorities (2)
-Dehydration related to excessive vomiting
-Inadequate weight gain related to nausea and persistent vomiting
a set of disorders that can occur anytime during pregnancy as well as in the first year postpartum
Perinatal mood disorders (PMD)
Perinatal mood disorders (PMD) (3)
Post partum depression
Bipolar Disorder
Postpartum Psychosis
PPD Discharge instructions (3)
-Medications risks - increased risk of suicide first couple of weeks
-Attachment behaviors w/ infant
-Resources for support - meals on wheels, getting family in to help with newborn & help with sleep deprivation
PPD: Care at home
Combination of antidepressants and cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT)
PPD: Antidepressant medications (4)
Selective serotonin reuptake inhibitor (SSRI)
Serotonin/norepinephrine reuptake inhibitor (SNRI)
Tricyclic antidepressants (TCAs)
Monoamine oxidase inhibitor (MAOI)
PPD: nursing interventions (3)
-Educate about depression as an illness and the plan of care, including medications
-Discuss alternative treatments and respect her choice if she refuses medications
-Maintain a caring, hopeful relationship
PPD w/o psychotic features
Irritability; feeling of detachment toward the newborn
PPD w/ psychotic features
Feelings of wanting to harm self, baby, or others
PPD screening (4)
-Rule out thyroid abnormalities and anemia first
-S/s of major depression
-Edinburgh Postnatal Depression Scale (EPDS)
(most accurate)
-Postpartum Depression Screening Scale (PDSS)
Substance abuse interventions (5)
-Education
-Individualized treatment
-Smoking cessation: USPSTF recommendations
-Detoxification
-Medical withdrawal from opioids during pregnancy is currently not recommended
head born but anterior shoulder cannot pass under pubic arch
shoulder dystocia
Shoulder Dystocia: “turtle sign”
head comes out then reseeds due to shoulder being stuck
shoulder dystocia: risks to newborn (3)
Asphyxia
Brachial plexus damage
Fractured clavicle
Shoulder dystocia: risks to mother (3)
Uterine atony/ rupture
Lacerations
Hemorrhage
Shoulder dystocia: nursing interventions
McRoberts Maneuver: lay flat and pull legs back and apply suprapubic pressure
Shoulder dystocia: Zavanelli maneuver (2)
push baby back in and do a crash c-section
LAST RESPORT
Can a baby w/ shoulder dystocia be removed w/ forceps?
NO
indicates fetus has passed stool prior to birth and has possible inhaled it
Meconium-stained amniotic fluid
Meconium-stained amniotic fluid: possible causes (4)
-Normal physiologic function of maturity (post dates)
-Breech presentation
-Hypoxia-induced peristalsis
-Umbilical cord compression
Meconium-stained amniotic fluid: inter-professional care management (3)
-Presence of an interprofessional team skilled in neonatal resuscitation is required
-Assess if baby is “vigorous” at birth
□ If so -> go skin to skin
□ If not -> intubate and try to clear meconium
-Observation
occurs when cord lies below the presenting part of the fetus
cord prolapse
cord prolapse: contributing factors (5)
-Cord length (>100cm)
-Malpresentation (breech)
-Transverse lie
-Unengaged presenting part
-Artificial rupture of membranes when presenting part is not engaged
Cord prolapse: priority interventions (5)
Prompt recognition
Pressure off cord
Position change to keep pressure off the cord
Stat C-section
□ Nurse cannot remove venial hand until provider has baby out
symptomatic disruption and separation of the layers of the uterus or previous scar
uterine rupture
most frequent cause of uterine rupture (2)
-Separation of scar of a previous classic cesarean birth
-Uterine trauma (accident, surgery)
incomplete uterine rupture; separation of a prior scar
uterine dehiscence
rare but devastating complication of pregnancy characterized by sudden, acute onset of hypotension, hypoxia, and hemorrhage caused by coagulopathy
Amniotic Fluid Embolus (AFE)
results from formation of blood clot(s) inside a blood vessel caused by inflammation or partial obstruction of vessel
Venous thromboembolism (VTE)
VTE type: involvement of the superficial saphenous venous system
Most common
Pain and tenderness in the lower extremity
Superficial
VTE type: occurs most often in the lower extremities; involvement varies but can extend from the foot to the iliofemoral region
Positive Homan’s sign
deep vein thrombosis (DVT)
complication of DVT occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs
pulmonary embolism (PE)
Cesarean birth __________________ the risk for VTE
doubles
VTE care management: (3)
Ongoing assessment
Education
Anticoagulation use
any clinical infection of the genital tract that occurs w/in 28 days after miscarriage, abortion, or birth
Puerperal infection (postpartum infection)
Three types of postpartum infections
endometritis
wound infection
urinary tract infection
infection of the lining of the uterus
endometritis
Most common postpartum infection
endometritis
indication of postpartum infection
Presence of a fever of 38* C (100.4) or more on 2 successive days of the first 10 postpartum days
management of postpartum infections
IV broad-spectrum antibiotic therapy
birth of a fetus through a transabdominal incision of the uterus to preserve the well-being of the mother and her fetus
cesarean section
Primary cesarean birth w/o medical or obstetric indications
elective
most common reason for scheduled c-section
breech presentation
forced cesarean (2)
Maternal-fetal conflict
Ethical implications
considerations w/ unplanned cesarean
Can cause a lot of mental distress in parents
□ Not the birth they intended
□ Fell like they “missed out” on a vaginal delivery
attempt to turn fetus from breech or shoulder presentation to vertex presentation for birth
External Cephalic Version (ECV)
External Cephalic Version (ECV): RF
Cord strangulation
Decreased HR
regular contractions along w/ a change in cervical effacement or dilation or both or presentation w/ regular uterine contractions or cervical dilation of at least 2 cm
preterm labor
any birth that occurs between 20 weeks and 36 weeks and 6 days of gestation
preterm birth
level of preterm
Very preterm:
Moderately preterm:
Late preterm:
Very preterm: < 32 weeks
Moderately preterm: 32-34 weeks
Late preterm: 30-36 weeks & 6 days
Preterm vs Low birth weight
Preterm is more dangerous than birth weight alone because less time in the uterus correlated w/ immaturity of body systems
what qualifies as low birth weight
< 2500 grams at birth
Cause of spontaneous preterm labor/birth (6)
Congenital structural abnormalities of the uterus
Placental causes
Maternal/fetal stress
Uterine overdistention (multiples)
Allergic reaction
Decrease in progesterone
Only definitive factor of preterm labor/birth
infection
used to predict who will not go into preterm labor
Fetal Fibronectin (fFN) test
glycoprotein “glue” found in plasma and produced during fetal life
fFN
Fetal Fibronectin (fFN) test result interpretation
Negative result = <1% chance of giving birth within two weeks
preterm nursing interventions (6)
Prevention
Early recognition and diagnosis
Lifestyle modifications
Activity restriction
Restriction of sexual activity
Home care
Preterm meds given and why
Steroids: promotion of fetal lung maturity Tocolytic medications: suppression of uterine activity (stops contractions)
Preterm meds: tocolytics
mag sulfate
terbutaline
Preterm meds: steroids
Antenatal glucocorticoid: significantly reduce the incidence of:
□ respiratory distress syndrome -Intraventricular hemorrhage
-Necrotizing enterocolitis
-Death in neonates
Betamethasone: given to help mature lungs
spontaneous rupture of amniotic sac and leakage of fluid prior to the onset of labor at any gestational age
Premature Rupture of Membranes (PROM)
membranes rupture before 37 weeks gestation
Premature Prolabor Rupture of Membranes (PPROM)
Premature Prolabor Rupture of Membranes (PPROM): interventions (6)
-Less than 32 weeks: manage expectantly and conservatively
-Vigilance for s/s of infection
-Fetal assessment
NSTs at least twice daily
-Antenatal glucocorticoids for all women w/ preterm PROM between 24-34 weeks gestation
-7-day course of broad-spectrum antibiotics
-Administering mag sulfate for fetal neuroprotection
bacterial infection of the amniotic cavity
Chorioamnionitis
Chorioamnionitis: clinical findings (4)
Maternal fever
Maternal and fetal tachycardia
Uterine tenderness
Foul odor of amniotic fluid
Chorioamnionitis: neonatal risk (4)
Pneumonia
Bacteremia
Meningitis
Death more likely if preterm
Chorioamnionitis: neonatal at increased risk for (3)
Respiratory distress syndrome
Periventricular leukomalacia
Cerebral palsy
Chorioamnionitis: treatment (2)
Broad spectrum antibiotics
Birth of baby
pregnancy greater than or equal to 42 weeks of gestation
post term/ postdates
post term: maternal and fetal risk (7)
-Increased maternal morbidity
-Dysfunctional labor and birth canal trauma
-Labor and birth interventions more likely
-Abnormal fetal growth (macrosomia)
-Prolonged labor
-Should dystocia or operative birth risks increase
-Post maturity syndrome
prompting the uterus to contract during pregnancy before labor begins on its own for a vaginal birth
induction
Why are inductions performed? (2)
elective
medically indicated
medical indications of induction (5)
-Post-dates
-Gestational diabetes
-HTN or preeclampsia
-Fetal abnormalities
-Maternal co-morbidity
risks of induction (3)
-Increased rates of cesarean birth
-Increased neonatal morbidity
-Increased cost
induction should not be initiated until client is at least
39 weeks
should be completed to assess “readiness for labor” or cervical ripeness
bishop score
best indicator for successful induction
cervical ripeness
mechanical methods to ripen cervix (2)
Balloon catheter- transcervical foley balloon
§ Similar to foley balloon but can hold up to 60 cc fluid
§ When it “falls out” client is usually 3-4 cm dilated
Amniotomies: artificial rupture of membranes
§ Used to induce or augment labor
Chemical methods to ripen cervix (2)
prostaglandins:
Misoprostil
Cervidil
use of pharmacological or surgical interventions to help the progression of a previously dysfunctional labor
augmentation
augmentation drug of choice
Pitocin
Mechanical augmentation (2)
vacuum extractor
forceps-assisted-birth
augmentation indications (2)
Both methods should never: (2)
Maternal exhaustion
Fetal distress
should never
-both be used together
-have attempt restrictions
VEAL CHOP
Variable————>Cord Compression
Early decels——->Head Compression
Acceleration——->OK
Late decels——–>Placental inefficiency
