Week 4 Content Flashcards

Question

Patient teaching table Diabetes- mother nutrition

Answer 1

⚬ Intrapartum care ￭ Monitor patient closely * Prevent dehydration, hypoglycemia, hyperglycemia ￭ Complications ￭ May require a cesarean birth ⚬ Postpartum care ￭ Insulin requirements decrease substantially ￭ Encourage breastfeeding

Answer 2

￭ Antepartum care * Immediate counseling and education ⚬ Diet and exercise ⚬ Monitoring blood glucose levels ⚬ Insulin therapy ⚬ Fetal surveillance ￭ Intrapartum and postpartum care * Reclassify 6 weeks PP ⚬ 2 hour (75 g) OGTT - if normal, repeat in 1 year * About 1/3 will have recurrent GDM in subsequent pregnancies

Answer 3

* Significance and incidence ⚬ Most common medical complication of pregnancy ￭ Preeclampsia - complicates 4.5% to 11% of all pregnancies ⚬ Major cause of maternal and perinatal morbidity and mortality ￭ Reported maternal death from preeclampsia/eclampsia is 1.8 per 100,000 ￭ Large disparity between race * African-American women experience the most severe complications and have higher mortality rates

Answer 4

Hypertension: Systolic >140 or Diastolic >90 * 2 occasions at least 4-6 hours apart OR * Severe range blood pressure of Systolic >160 or Diastolic >110 * Classifications ⚬ Chronic hypertension ￭ Hypertension present before pregnancy, diagnosed before 20 weeks gestations, or persists after 12 weeks PP ⚬ Gestational hypertension ￭ Onset of hypertension without proteinuria after 20 weeks of gestation

Answer 5

⚬ Chronic hypertension ￭ Increased incidence of: * Abruptio placentae * Superimposed preeclampsia * Increased perinatal mortality ￭ PP complications: * Pulmonary edema * Renal failure * Heart failure * Encephalopathy * Stroke

Answer 6

⚬ Labetalol (beta blocker)– drug of choice in pregnancy, can be given PO or IV ⚬ Hydralazine (vasodilator) – given for severe range blood pressures not controlled by labetalol or nifedipine ⚬ Nifedipine (calcium channel blocker) – given PO especially if no IV access ⚬ NOTE: Ace inhibitors are contraindicated in pregnancy (“prils”)! They can cause fetal renal damage in the 2nd & 3rd trimester.

Answer 7

⚬ Preeclampsia ￭ Pregnancy-specific syndrome in which hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman ￭ Proteinuria is indicator of preeclampsia ⚬ Chronic hypertension superimposed on preeclampsia ￭ Woman with chronic hypertension may acquire preeclampsia or eclampsia ￭ Increases morbidity for both mother and fetus ⚬ Eclampsia ￭ Onset of seizure activity or coma in a woman with preeclampsia who has no history of preexisting seizure activity

Answer 8

⚬ Signs and symptoms typically develop during pregnancy but may appear in PP. ⚬ Associated high-risk factors ￭ Family history, multifetal pregnancy, primigravidity, African-American race, obesity, maternal age > 35 years, pre-existing medical or genetic conditions * Pathophysiology ⚬ Progressive disorder with placenta as the root cause ⚬ Caused by disruptions in placental perfusion and endothelial cell dysfunction ￭ Poor perfusion from vasospasm and reduced plasma volume ⚬ Arteriolar vasospasm diminishes diameter of blood vessels, which impedes blood flow to all organs and increase BP ⚬ Function in organs (placenta, kidneys, liver, brain) depressed as much as 40%-60%

Answer 9

Blood Pressure ➢ Systolic blood pressure of ≥ 140 mm Hg OR diastolic blood pressure of ≥ 90 mm Hg on two occasions at least 4 hours apart OR ➢ Systolic blood pressure of 160 mm 110 mm Hg or more AND Proteinuria ➢ 300 mg or more per 24-hour urine collection OR ➢ Protein/creatinine ratio of 0.3 or more OR ➢ Dipstick reading of 2+ (used only if other quantitative methods not available)

Answer 10

➢Systolic blood pressure of 160 mm 110 mm Hg or more. ➢Thrombocytopenia ➢Renal insufficiency ➢Pulmonary edema ➢Impaired liver function ➢New onset of headache

Answer 11

⚬ Identifying & preventing preeclampsia ￭ Prevention for pregnant women at low risk for preeclampsia * Management of gestational weight gain within recommendations * A prepregnancy Mediterranean diet, high in vegetables, fish, legumes and nuts ￭ Women at high risk for preeclampsia * Low-dose aspirin, started before 16 weeks of gestation. * Increased rest at home in the third trimester * Blood pressure management

Answer 12

* Interventions ⚬ Gestational hypertension and preeclampsia w/o severe features ￭ Initial laboratory evaluation * Serum creatinine, platelet count, and liver enzymes. ￭ Weekly evaluation * Hematocrit, platelet count, serum creatinine, and liver function tests ￭ Evaluated for signs or symptoms of severe features * Severe headaches, blurred/ double vision, mental confusion, right U.Q. abdominal or epigastric pain, nausea or vomiting, SOB, and decreased urinary output * BP monitored frequently and proteinuria assessed weekly ￭ Fetal evaluation * Daily fetal movement counts * Nonstress testing or a biophysical profile once or twice weekly * Ultrasound evaluation of amniotic fluid status & determination of estimated fetal weight performed when preeclampsia diagnosed and serially, depending on findings. * Doppler blood flow studies are recommended if IUGR is suspected * Typically early delivery is indicated at 37 weeks or earlier if severe features.

Answer 13

⚬ Severe gestational hypertension and preeclampsia with severe features ￭ Hospitalized immediately ￭ Magnesium sulfate to prevent eclamptic seizures ￭ Antihypertensive medication to lower severe levels of hypertension. ￭ Maternal assessments * BP, urine output, cerebral status, presence of epigastric pain and/or tenderness, labor, or vaginal bleeding ￭ Lab evaluation includes platelet count, liver enzymes, and serum creatinine ￭ Fetal assessment - continuous electronic FHR monitoring, biophysical profile, ultrasound evaluation of fetal growth and amniotic fluid volume * If evidence of fetal growth restriction found, umbilical artery Doppler velocimetry recommended ▪ Early delivery. If necessary before 37 weeks, give glucocorticoids (bethamethosone)

Answer 14

⚬ Assessment ￭ Physical examination * Blood pressure * Edema - dependent, pitting * Deep tendon reflexes * Clonus ￭ Laboratory tests * Platelets * Creatinine * Liver function * Urine protein

Answer 15

⚬ Intent of emergency interventions ￭ Prevent self injury ￭ Ensure adequate oxygenation ￭ Reduce aspiration risk ￭ Establish seizure control with Magnesium sulfate * Monitor for reflexes, respirations, urinary output, LOC * Calcium gluconate - antidote, should be available at bedside

Answer 16

⚬ Lab diagnostic variant of severe preeclampsia involves hepatic dysfunction, characterized by: ￭ Hemolysis ￭ Elevated liver enzymes ￭ Low platelets ⚬ Associated with increased risk for: ￭ Pulmonary edema, renal failure, liver hemorrhage or failure, disseminated intravascular coagulation (DIC), placental abruption, acute respiratory distress syndrome (ARDS), sepsis, stroke, fetal and maternal death

Answer 17

Signs of preeclampsia (hypertension & proteinuria) with onset of seizures Preceding s/s ⚬ Headache, blurred vision, photophobia, epigastric/RUQ abdominal pain, altered mental status * Plan of care o Immediate - protect from injury and protect airway o Magnesium sulfate is drug of choice and hypertensive medications if needed o Postpartum nursing care

Answer 18

B. "The placenta experiences ischemia because the spiral arteries of the uterus fail to reshape and increase in diameter." When preeclampsia occurs, it is because the spiral arteries of the uterus failed to widen in diameter due to poor trophoblast invasion during the beginning of the pregnancy. Overtime, this causes problems (usually after 20 weeks gestation) and the placenta experiences ischemia. When the placenta becomes ischemic is releases substances into mom's circulation that are very toxic to her endothelial cells, which causes all the signs and symptoms seen in preeclampsia. Severity varies in patients.

Answer 19

The answers are A, B and F. Signs and symptoms of preeclampsia include: proteinuria (>1+ dipstick urine protein or >300 mg/dL 24 hour urine protein, hypertension >140/90...two reading at least 4-6 hours apart or severe range BP >160/110), swelling in face, eyes, extremities, headaches, vision changes, etc.

Answer 20

D. Respiratory rate of 8 breaths per minute The nurse should monitor for Magnesium Sulfate toxicity. Signs of this include: decreased or absent reflexes (finding of 4+ Deep tendon reflex is considered HYPERreflexia), Respiratory rate less than 12 breaths per minute, Urinary output of less than 30 mL/hr, EKG changes.

Answer 21

Calcium gluconate

Answer 22

* Excessive vomiting * Loss of 5% of prepregnancy weight * Accompanied by: ⚬ Dehydration ⚬ Electrolyte imbalance ⚬ Nutritional deficiencies ⚬ Ketosis ⚬ Acetonuria * Plan of care: correct electrolyte imbalance, hydrate, control N&V

Answer 23

Bleeding in pregnancy jeopardizes both maternal and fetal well-being ⚬ Maternal blood loss decreases oxygen-carrying capacity, increases risk for: ￭ Hypovolemia ￭ Anemia ￭ Infection ￭ Preterm labor ￭ Adverse oxygen delivery ⚬ Fetal risks from maternal hemorrhage: ￭ Anemia/blood loss ￭ Hypoxemia, hypoxia, anoxia ￭ Preterm birth

Answer 24

* Miscarriage (Spontaneous abortion) ⚬ The leading cause of pregnancy loss ⚬ Occurs before 20 weeks of gestation ⚬ Chromosomal abnormalities account for 50% ⚬ Types: ￭ Threatened, inevitable, incomplete, complete, missed, septic, recurrent ⚬ Treatment ￭ Threatened - bedrest and sedation ￭ Inevitable - D&C or home misoprostol use ￭ Preventing complications such as hypovolemic shock and infection ￭ Providing emotional support for grieving patient and family

Answer 25

* Etiology ⚬ Fertilized ovum implanted outside uterine cavity ⚬ 95% occur in uterine (fallopian) tube ⚬ Other sites include: ovary, abdominal cavity, cervix * Clinical manifestations ⚬ Abdominal pain ⚬ Delayed menses ⚬ Abnormal vaginal bleeding ⚬ After rupture - referred shoulder pain * Management ⚬ Medical ￭ Methotrexate - if pregnancy <6 weeks (<4cm diameter) * Follow up necessary for hCG levels ⚬ Surgical ￭ Salpingectomy

Answer 26

* “Hydatidiform mole” ⚬ A benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, vascular transparent vesicles that hang in grapelike clusters without a viable fetus * Incidence and etiology ⚬ Occurs in 1 in 1000 pregnancies ⚬ Cause is unknown, possibly from ovular defect or nutritional deficiency * Types ⚬ Complete mole - result of fertilized egg with lost or inactivated nucleus ⚬ Partial mole - result of 2 sperm fertilizing 1 egg * Clinical manifestations ⚬ Vaginal bleeding - dark brown or bright red, scant or profuse ⚬ Uterus is larger than indicated, hyperemesis gravidarum, abdominal cramps ⚬ Structures are associated with choriocarcinoma, a rapidly metastasizing malignancy

Answer 27

⚬ Transvaginal ultrasound ￭ Snowstorm pattern or “grape-like” clusters ⚬ Serum hCG * Management ⚬ Immediate evacuation of mole ⚬ Follow up serum hCG levels for 6-12 months to detect gestational trophoblastic neoplasia (GTN) ￭ If normal for 6 months, may consider pregnancy * Nursing care ⚬ Emotional support related to pregnancy loss ⚬ Explain close medical follow-up due to risk of recurrence, malignant GTN or choriocarcinoma

Answer 28

* Placenta previa ⚬ Placenta implanted in lower uterine segment near or over internal cervical os ￭ 0.5% of births ⚬ Classification ￭ Complete/total ￭ Marginal ⚬ Clinical manifestations ￭ Painless, bright red vaginal bleeding ⚬ Maternal and fetal outcomes ￭ Abnormal placental attachment ￭ Excessive bleeding ￭ Morbidity 5%, mortality <1% ￭ Fetal risks - malpresentation, preterm birth, fetal anemia, congenital anomalies

Answer 29

⚬ Diagnosis and medical management ￭ Standard diagnosis is transabdominal ultrasound examination ￭ Transvaginal scan ⚬ Management ￭ Expectant management * <36 weeks, not in labor, & bleeding is mild or stopped --> observation and bed rest ￭ Home care * If stable with no active bleeding * Pelvic rest, limit activity, monitor for bleeding or s/s of PTL ￭ Active management * At term and in labor or bleeding persistently, immediate cesarean is indicated

Answer 30

* Premature separation of placenta (abruptio placentae) ⚬ Detachment of part or all of placenta from implantation site ⚬ Accounts for significant maternal and fetal morbidity and mortality ⚬ Classification systems ￭ Grades 1 (mild), 2 (moderate), 3 (severe) ⚬ Clinical manifestations ￭ Separation may be partial, complete or marginal ￭ Vaginal bleeding * May be slight or absent in concealed hemorrhage * Systemic signs of early hemorrhage ￭ Abdominal pain ￭ Uterine tenderness * Increase in fundal height, frequent contractions, high resting tone, rigid abdomen in-between contraction ￭ Persistent late decelerations

Answer 31

⚬ Causes: hypertension, pre-eclampsia, cocaine use, trauma ⚬ Maternal and fetal outcomes ￭ Blood loss, coagulopathy, need for transfusion, end-organ damage, cesarean birth, peripartum hysterectomy, death ￭ Fetal complications - fetal growth restriction, oligohydramnios, preterm birth, hypoxemia, still birth * Large hemorrhages (>60 ml) are associated with >50% fetal mortality rate ⚬ A clinical diagnosis ￭ Clinical S&S- abdominal pain & bleeding!, late or prolonged decelerations ￭ 50% unable to be identified through ultrasound ￭ May be diagnosed after placenta is inspected ⚬ Interventions ￭ Expectant - monitor closely ￭ Active - immediate birth if at or near full term

Answer 32

* Cord insertion and placental variations ⚬ Velamentous insertion of cord * Cord vessels branch at membranes and course onto placenta * Rupture of membranes or traction on cord may tear one or more fetal vessels * Fetus may rapidly bleed to death as a result o Vasa previa - vessels are implanted into the fetal membranes rather than the placenta and lies over the cervical os o Succenturiate placenta * Placenta has divided into 2+ lobes rather than single mass

Answer 33

⚬ Placenta Accreta- Placenta has imbedded too deeply within the uterine wall. ▪ Depth of attachment- accreta, increta, percreta ▪ Identified by ultrasound or in 3rd stage of labor if the placenta does not detach. ▪ Surgical intervention is necessary, likely a hysterectomy and intervention if other organs are affected. ▪ Associated with massive blood loss requiring blood transfusion.

Answer 34

* Normal clotting ⚬ Hemostatic system stops flow of blood from injured vessels by platelet plug and formation of fibrin clot ⚬ Fibrinolytic system ￭ Process through which fibrin is split into fibrinolytic degradation products and circulation is restored

Answer 35

* Incidence increasing due to fertility treatment and delayed childbearing * Only 3% of births, but contribute disproportionately to maternal, fetal, and neonatal morbidity and mortality * Monozygotic (30%) ⚬ From one zygote ⚬ Identical, always same gender * Dizygotic (70%) ⚬ Fertilization of 2 eggs ⚬ Same or different genders

Answer 36

* Assessment ⚬ Physiologic changes greater in nearly every maternal system than in singleton pregnancies ⚬ Greater risk for PTL, hypertension, PPROM, anemia, abruptio placentae, GDM, PE, IUGR, congenital anomalies ⚬ Twin-to-Twin Transfusion Syndrome ￭ Unequal shunting of blood from donor fetus to co-twin recipient through vascular connections in a shared placenta * Management ⚬ Ongoing, frequent surveillance due to increased rate of complication * Higher order multiples ⚬ Multifetal pregnancy reduction: can delay grief response

Answer 37

* TORCH infections ⚬ Toxoplasmosis ⚬ Other (Hepatitis A & B) ⚬ Rubella ⚬ Cytomegalovirus ⚬ Herpes Simplex virus ⚬ Each disease teratogenic to developing fetus ⚬ Medical & Nursing management varies with each organism, trimester of exposure, and clinical evidence of neonatal sequellae.

Answer 38

Women Antiviral C/S Breast feeding

Answer 39

* The US DOJ, Office on Violence Against Women (2018) describes violence and abuse as including 1+: physical, sexual, emotional, economic, and psychologic factors. * 1/5 women in the US has experienced rape, and more than half (51.1%) of female survivors of rape reported that they were raped by an intimate partner. * Battering episodes initiate or increase in pregnancy for a variety of reasons: (1) biopsychosocial stresses of pregnancy may strain relationship beyond the couple’s ability to cope, and frustration is followed by violence; (2) man may be jealous of fetus, resenting the intrusion into the couple’s relationship and the woman’s displacement of attention; (3) the man may be angry at the unborn child or the woman; and (4) the beating may be the man’s conscious or subconscious attempt to end the pregnancy.

Answer 40

* nurse should assess for abuse at each prenatal visit, during labor & birth. * A pregnant woman is often accompanied by a male partner; Find opportunities to speak to the woman alone (in the bathroom, sent the partner to get ice chips, etc). * In CA, nurses are mandated reporters. Follow your hospital protocol which often includes contacting social work. * It is imperative that the woman has knowledge of resources available to her and a plan of action if she stays with the abusing partner (safety plan for escape). Women experiencing IPV can be given telephone numbers of a hotline and the abused women’s shelter or other safe haven. * Please keep in mind that the most dangerous time for a person experiencing IPV is when they try to leave their abuser. Leaving a relationship is a process. Offer non-judgmental support.

Answer 41

* Crucial for nurses to: ⚬ Understand normal birth process ⚬ Prevent and detect deviations from normal labor and birth ⚬ Implement nursing measures if complications arise * Nurse and obstetric team must use knowledge and skills in a collaborative effort to provide care in the event of complications

Answer 42

⚬ Preterm labor: cervical changes and uterine contractions occurring between 20 and 36 weeks and 6 days of pregnancy ⚬ Preterm birth: any birth that occurs 20 and 36 weeks and 6 days of pregnancy ￭ Very preterm: < 32 weeks ￭ Moderately preterm: 32 to 34 weeks ￭ Late preterm: < 34 weeks to 36 weeks and 6 days * Preterm birth versus low birth weight ⚬ Low birth weight: weight at time of birth <2500 g * Causes of spontaneous preterm labor ⚬ Infection ⚬ Bleeding at the site of placental implantation ⚬ Other associations * Predicting spontaneous preterm labor and birth ⚬ Cervical length ⚬ Fetal fibronectin test (fFN) ￭ Present before 22 weeks and after 35 weeks

Answer 43

⚬ Recurrent premature dilation of cervix ￭ Passive and painless dilation of cervix during the 2nd trimester ⚬ Etiology ￭ History of previous cervical lacerations ￭ Excessive dilation for curettage or biopsy ￭ In utero exposure to DES ￭ Multiple gestation ￭ Cervial or uterine anomalies ⚬ Conservative management ￭ Cervical cerclage ￭ Monitor symptoms and effects of modifying activities, pelvic rest, progesterone, anti-inflammatory drugs, and antibiotics ￭ Educate on when to come to hospital

Answer 44

⚬ Prevention ￭ Health promotion and disease prevention, preconception counseling and care ￭ Progesterone ⚬ Early recognition and diagnosis (Know Box 17.3-S/S preterm labor) ￭ Gestational age between 20 and 36 weeks and 6 days ￭ Uterine activity (contractions) ￭ Progressive cervical change * Effacement of 80% * Cervical dilation of 2 cm or greater ⚬ Lifestyle modifications ￭ Activity restriction * Limited work hours ￭ Restriction of sexual activity (pelvic rest) * Has not been shown to be effective, research is needed ￭ Home care * Modified bed rest

Answer 45

⚬ Suppression of uterine activity ￭ Tocolytics- Medication given to arrest labor after uterine contractions and cervical changes occurs * Magnesium sulfate * Terbutaline (beta-adrenergic agonist) * Nifedipine (calcium channel blocker) * Indomethacin (NSAID)- Not commonly used anymore ⚬ Give if <32 weeks gestation

Answer 46

⚬ Promotion of fetal lung maturity ￭ Antenatal glucocorticoids * Stimulates surfactant production * ACOG recommends for all women 24 and 34 wks gestation at risk for preterm birth * Single course of antenatal glucocorticoids ⚬ Betamethasone 12mg IM X 2, 24 hours apart ⚬ Dexamethasone 6mg IM X 4, 12 hours apart * Optimal benefits occur within the first 24 hours

Answer 47

⚬ Management of inevitable preterm birth ￭ Labor progressed to cervical dilation of 3-4 cm ￭ Magnesium sulfate given to reduce or prevent neonatal neurologic sequelae ￭ Malpresentation is common ￭ Method of delivery ￭ Neonatal resuscitation ￭ Nurses must be ready to handle this alone; freq. happens rapidly and w/o warning

Answer 48

* Prelabor Rupture of Membranes (PROM) ⚬ Spontaneous rupture of amniotic sac and leakage of amniotic fluid beginning at least 1 hour before onset of labor at any gestational age * Preterm Prelabor Rupture of Membranes (pPROM) ⚬ Membranes rupture before completion of week 37, not in labor ⚬ Infection is a major risk factor ⚬ Pathologic weakening of the amniotic membranes ￭ Inflammation ￭ Stress from uterine contractions * Diagnosed after women reports sudden gust of fluid or slow leak from vagina * Chorioamnionitis

Answer 49

⚬ PROM ￭ Determined for each woman based on an estimate of risk ￭ Infection is the greatest risk ￭ Labor will likely be induced ⚬ PPROM ￭ Managed conservatively * FHR, NST, BPP, kick counts, monitor for Infection ￭ Usually hospitalized, possibly: * Antenatal glucocorticoids * Antibiotics * Magnesium sulfate

Answer 50

* Fetal risks ⚬ Abnormal fetal growth ⚬ Macrosomia ⚬ Increased risk for birth injuries ⚬ Aging placenta, late decels ⚬ Oligohydramnios ⚬ Meconium-stained fluid * Care management ⚬ Most induce at 41-42 weeks gestation ⚬ If pregnancy continues: NST, BPP

Answer 51

Long, difficult, or abnormal labor that does not result in normal progress of cervical effacement, dilation, and fetal descent ⚬ Most common cause of primary cesarean sections ⚬ Dystocia = lack of progress in labor for any reason ⚬ Associated with the 5 Ps -Passenger, passageway, powers, position, psyche

Answer 52

External cephalic version (ECV) for breech presentation ⚬ Turning of the fetus from one presentation to another ￭ Tocolytic (terbutaline) and manual rotation

Answer 53

￭ Pelvic dystocia * Contractures of pelvic diameters that reduce the capacity of the bony pelvis, inlet, midpelvis, or outlet ￭ Soft-tissue dystocia * Results from obstruction of the birth passage by an anatomic abnormality other than that of bony pelvis (fat)

Answer 54

Induction of labor ⚬ Chemical or mechanical initiation of UC before spontaneous onset of birth ⚬ Elective induction – labor initiated without a medical indication ￭ Not initiated until at least 39 weeks gestation ⚬ Cervical ripening methods ￭ Ripens cervix, making it softer and causing dilation and effacement, stimulates uterine contraction ￭ Most important predictor of successful induction. ￭ Bishop score used to evaluate inducibility ￭ Bishop score totals 8 or more, likelihood of vaginal birth is similar whether labor is spontaneous or induced

Answer 55

Pharmacological (prostaglandin) * Reduces oxytocin use, reduces cesarean births cause by failure to progress in labor * Misoprostol (Cytotec) ⚬ Less expensive, quicker onset of action, higher risk for uterine tachysystole with abnormal FHR * Dinoprostone (Cervidil) ⚬ Over 12 hours, expensive, slower/more predictable onset of action, can reverse

Answer 56

￭ Cervical ripening methods cont’d * Mechanical methods ⚬ Foley balloon or Cook’s catheter * Amniotomy ⚬ Artificial rupture of membranes ⚬ Oxytocin (Pitocin) ￭ Hormone normally produced by posterior pituitary gland * Stimulates uterine contractions ￭ Used to induce labor or augment a labor progressing slowly because of inadequate uterine contractions

Answer 57

* Augmentation of labor ⚬ Stimulation of UC after labor has started but progress unsatisfactory ⚬ Implemented for management of hypotonic uterine dysfunction ⚬ Common augmentation methods ￭ Oxytocin infusion ￭ Amniotomy

Answer 58

amniotic cavity

Answer 59

* Vacuum-assisted birth, “vacuum extraction” ⚬ Attachment of vacuum cup to fetal head, negative pressure to assist birth of head ⚬ Prerequisites ￭ Completely dilated cervix ￭ Engaged head ￭ Vertex presentation ￭ Ruptured membranes ￭ No suspicion of CPD ⚬ Risk to newborn ￭ Cephalhematoma, scalp lacs, subdural hematoma

Answer 60

* Forceps-assisted birth ⚬ Maternal indications ￭ Prolonged second stage of labor ⚬ Fetal indications ￭ Abnormal fetal heart rate tracing ￭ Distress or certain abnormal presentations ￭ Arrest of rotation ￭ Delivery of head in a breech presentation

Answer 61

⚬ Maternal complications ￭ Anesthesia events, hemorrhage, bowel or bladder injury, air embolism ⚬ PP complications ￭ atelectasis, endomyometritis, UTI, abdominal wound hematoma, dehiscence, infection, necrotizing fasciitis, thromboembolic disease, bowel dysfunction ⚬ Fetal complications ￭ prematurity, fetal asphyxia, fetal injuries ￭ More likely to require resuscitation efforts ⚬ Financial burden, longer recovery

Answer 62

* Trial of labor after cesarean (TOLAC) ⚬ Observation of a woman and her fetus for a specified length of time to assess safety of vaginal birth * Vaginal birth after cesarean (VBAC) ⚬ More successful if patient had a previous vaginal delivery ⚬ May be a candidate depending upon incision and if cause of former cesarean was for fetal reasons (breech, heart tones, etc) * Concern for uterine rupture

Answer 63

* Rare, serious obstetric injury that occurs in 1 to 1,500-2,000 births * Most frequent causes of uterine rupture: ⚬ Separation of scar of a previous C/S (classical vertical incision is more high risk) ⚬ Uterine trauma (e.g., accidents, surgery) ⚬ Congenital uterine anomaly ⚬ Labor stimulation (e.g., oxytocin, prostaglandin) ⚬ Overdistended uterus (e.g., multifetal gestation) * Signs & Symptoms ⚬ Abrupt abdominal pain ⚬ Loss of fetal station ⚬ Loss of fetal heart tones or Category II/III strip ⚬ Fetal parts can be felt in the abdomen * True obstetric emergency! Immediate cesarean section is necessary to save the life of the mother and baby. Maternal & infant mortality 10-15%

Answer 64

⚬ Head is born, but anterior shoulder cannot pass under pubic arch ⚬ Newborn is more likely to experience birth injuries ￭ Brachial plexus & fractures ⚬ Maternal complications ￭ Hemorrhage ￭ Rectal injuries

Answer 65

First line interventions! ⚬ McRoberts maneuver ￭ The woman flexes her thighs sharply against her abdomen, which straightens the pelvic curve. A supported squat has a similar effect and adds gravity to her pushing efforts. ⚬ Suprapubic pressure pushes the fetal anterior shoulder downward to displace it from above the mother's symphysis pubis. Fundal pressure should not be used

Answer 66

⚬ Gaskin maneuver ￭ “All Fours” ￭ Turn from supine to hands-and knees to relieve all weight-bearing on the sacrum Deliver the posterior shoulder and arm first following the curve of the pelvis axis ⚬ Zavanelli maneuveer ￭ Fetal head is rotated to direct OA and flexed. ￭ Firm pressure applied to vertex as it is replaced into vagina as far as possible. ￭ Tocolytic medication may be given and delivery is accomplished by a Cesarean birth

Answer 67

* Cord slips down after the membranes rupture and becomes compressed between the fetus and pelvis. ⚬ Prompt delivery of the fetus a priority. * Contributing factors ⚬ Excessive volume of amniotic fluid (polyhydramnios) ⚬ Long cord >100cm ⚬ Malpresentation ⚬ Unengaged presenting part * Key interventions o Relieve pressure on the cord without compression of the blood vessels. Using fingers, keep gentle upward pressure on the presenting part. o Expedite delivery by cesarean section

Answer 68

* “Anaphylactoid syndrome of pregnancy”. Amniotic fluid containing particles of debris (e.g., vernix, hair, skin cells, or meconium) enters the maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory collapse * Rare, characterized by sudden, acute onset of “imbedding doom”, dyspnea, hypoxia, hypotension, and hemorrhage caused by coagulopathy. * Not preventable and no known cause

Answer 69

⚬ Older maternal age, postterm pregnancy, labor induction or augmentation, preeclampsia, cesarean birth, placental abruption/previa * This will result in a “code”. Expedited delivery is necessary. * Maternal mortality rate has been as high as 80% in the past, but prompt recognition and treatment like the “A-OK” protocol (atropine 1mg, ondansetron 8mg, ketorolac 30mg) has been improving outcomes. * Patients typically recover in ICU. DIC, blood administration, & neurological defects are common.

Answer 70

Biophysical: * Genetic, Nutritional, Medical and Obstetric Disorders Psychosocial: * Smoking, Caffeine, Alcohol, Drugs, Psychological Status Sociodemographic: * Low income, Lack of prenatal care, Age (less than 15 or greater than 35), Parity, Marital status, Residence (city, rural area), Ethnicity Environmental Factors * Factories? Pollution? Weather? Noise?

Answer 71

10 times in 12

Answer 72

neural tube

Answer 73

genetic abnormalities

Answer 74

biophysical profile (BPP)

Answer 75

labor contractions

Answer 76

Amniotic Fluid Index

Answer 77

Gestational Hypertension: onset of HTN without proteinuria after week 20 in a previously normotensive woman. **Monitor for progression to preeclampsia Chronic Hypertension: HTN present before pregnancy. Needs hypervigilant care ● Associated with increased incidence of abruptio placentae, superimposed preeclampsia, and increased risk of perinatal mortality ● Postpartum complications – pulmonary edema, renal failure, heart failure, encephalopathy

Answer 78

● Prevent self injury ● Ensure adequate O2 ● Reduce aspiration risk ● Establish seizure control with mg sulfate ● Correct maternal acidemia (will happen if they seize) ● Seizure precautions

Answer 79

Miscarriage: Threatened – cramping/bleeding no dilation Inevitable – cervix dilating prematurely Incompetent Cervix: recurrent premature dilation of cervix – cerclage (close cervix with stitches), bedrest, pelvic rest, education of s/s preterm labor

Answer 80

Ectopic Pregnancy: gestational sac implanted outside of uterus, not viable, abdominal pain & tenderness & bleeding - Methotrexate (< 6 weeks, destroys rapidly dividing cells) - Surgical intervention (>6 weeks) Molar Pregnancy: atypically fertilized egg (lost or inactivated nucleus), nonviable, must be removed - hCG levels tested for 6 months to detect trophoblastic neoplasia, pregnancy should be prevented during follow-up period

Answer 81

Placenta Previa: placenta partially or completely covers cervix, usually resolves if found early in pregnancy, c-section needed if it doesn’t resolve Abruptio Placentae: placenta separates before birth, can cause bleeding, and deprive fetus of oxygen and nutrients

Answer 82

clotting factors

Answer 83

S/S: May not have symptoms, if they do, think 3 P’s (polyuria, polydipsia, polyphagia) Diagnosis: OGTT – diagnosed during 2nd half of pregnancy Treatment: glucose monitoring, diet/exercise, pharm intervention Risk & Complications: macrosomia Baby: hypoglycemia, birth trauma Patient: c-section, trauma, PPH Follow up: ● Reclassify 6 weeks postpartum– OGTT ● About ⅓ have recurrent GDM in subsequent birth

Answer 84

Dystocia Definition: long, abnormal, or difficult labor *Risk to patient & fetus* Common type: Shoulder dystocia ● Head is born, but anterior shoulder cannot pass under pubic arch ● Newborn more likely to experience birth injuries r/t asphyxia or fracture ● Mother’s primary risk stems from excessive blood loss or infection Interventions: ● Forceps Assisted Birth – Is one in which an instrument with two curved blades is used to assist in birth ● Vacuum-assisted birth – Attachment of vacuum cup to fetal head, using negative pressure to assist birth of head ● Positioning (Roberts and Gaskin maneuver)

Answer 85

Complications: Infection, baby (respiratory complications from not having pressure during delivery), PPH Urgent: There is a risk, so you want to delivery sooner rather than later Emergent: There is something wrong Post-op: Lochia, incision care, fundal check/massage, vital signs (q15 min for at least 2 hours) Spinal block: HA, decrease RR/O2 sat, safety (can’t walk 6-8 hours), urinary retention (catheter)

Answer 86

compressed – hypoxia

Answer 87

Definition: (rare) part of the amniotic fluid enters the circulation and obstructs pulmonary vessels → respiratory distress and circulatory collapse → anaphylactic shock in the body S/S: acute onset of "impending doom", SOB, dyspnea, tachycardia, hypotension, low BP Treatment: Administer O2, fluids to increase blood pressure (be careful of fluid overload) *Be prepared to do CPR* Typically, outcomes are not great and end up in the ICU or end up dead

Answer 88

Meds to delay delivery (tocolytics): risk after delivery for uterine atony, PPH ● Terbutaline (contraindicated = hypertension/cardiac) ● Nifedipine ● Indomethacin ● Magnesium sulfate Meds to help with PPH: ● Pitocin ● Methergine (contraindicated HTN/cardiac) ● Hemabate (contraindicated HTN & asthma) ● TXA ● Misoprostol