Week 4 Content

Question 1

Assessment of High-Risk Pregnancy

What is high-risk?
⚬ A pregnancy in which the life or health of the mother or fetus is jeopardized by a disorder coincidental with or unique to __________.
￭ Extends through peurperium (____ weeks after birth)
⚬ Early and regular prenatal care allows for identification of risk, mortality rates decrease and outcomes improve

Answer 1

⚬ A pregnancy in which the life or health of the mother or fetus is jeopardized by a disorder coincidental with or unique to pregnancy.
￭ Extends through peurperium (4-6 weeks after birth)
⚬ Early and regular prenatal care allows for identification of risk, mortality rates decrease and outcomes improve

Question 2

Assessment of High-Risk Pregnancy
* Categories of risk:

⚬ ____________
￭ Genetic, nutritional and health (medical & obstetric)

⚬ ____________
￭ Smoking, caffeine, alcohol, drugs, psychologic

⚬ ____________
￭ Low income, lack of prenatal care, age, parity, marital status, social determinants of health, ethnicity

⚬ ____________
￭ Workplace hazards, chemicals, anesthetic gases, radiation

Answer 2

⚬ Biophysical
￭ Genetic, nutritional and health (medical & obstetric)

⚬ Psychosocial
￭ Smoking, caffeine, alcohol, drugs, psychologic

⚬ Sociodemographic
￭ Low income, lack of prenatal care, age, parity, marital status, social determinants of health, ethnicity

⚬ Environmental
￭ Workplace hazards, chemicals, anesthetic gases, radiation

Question 3

Danger Signs During Pregnancy

• Vaginal _________ with or without discomfort
• _________ of membranes
• _________ of fingers, puffiness of face or around eyes
• Continuous, pounding _________
• _________ distubrances (blurred vision, dimness, spots)
• Persistent or severe _________ pain
• Chills or fever
• Painful urination
• Persistent vomiting
• _________ in frequency or strength of fetal movements
• Signs of preterm labor: uterine contractions, cramps, constant or irregular low backache, pelvic pressure

Answer 3

• Vaginal bleeding with or without discomfort
• Rupture of membranes
• Swelling of fingers, puffiness of face or around eyes
• Continuous, pounding headache
• Visual distubrances (blurred vision, dimness, spots)
• Persistent or severe abdominal pain
• Chills or fever
• Painful urination
• Persistent vomiting
• Changes in frequency or strength of fetal movements
• Signs of preterm labor: uterine contractions, cramps, constant or irregular low backache, pelvic pressure

Question 4

Assessment of High-Risk Pregnancy
* Antepartum Testing: ⚬ Two major goals

￭ Identify fetuses at risk for injury due to interrupted __________ so that permanent
injury or death may be prevented

￭ Identity appropriately __________ fetuses so that unnecessary intervention can be avoided.

Answer 4

￭ Identify fetuses at risk for injury due to interrupted oxygenation so that permanent
injury or death may be prevented

￭ Identity appropriately oxygenated fetuses so that unnecessary intervention can be avoided.

Question 5

Biophysical Assessment

• Daily Fetal __________ Count (DFMC)
  ⚬ Kick counts (2 types) - non-invasive
  ￭ Count all movements in 12-hour period until fetus has moved 10 times
  ￭ Count movement 2 or 3 times daily until 10 movements counted
  ⚬ If movement decreased from prior day or unable to count 10 movements, call provider

⚬ Warning sign:
￭ No fetal movement for _________ is fetal alarm signal…Call provider immediately!

Answer 5

• Daily Fetal Movement Count (DFMC)
  ⚬ Kick counts (2 types) - non-invasive
  ￭ Count all movements in 12-hour period until fetus has moved 10 times
  ￭ Count movement 2 or 3 times daily until 10 movements counted
  ⚬ If movement decreased from prior day or unable to count 10 movements, call provider

⚬ Warning sign:
￭ No fetal movement for 12 hours is fetal alarm signal…Call provider immediately!

Question 6

Biophysical Assessment cont’d

____________ - Fetal well-being

⚬ Indications for use
￭ Fetal heart rate activity – (as of 6 wks)
￭ Gestational age
￭ Fetal growth – (IUGR)
￭ Fetal anatomy
￭ Fetal genetic disorders –nuchal translucency (NT)
￭ Placental position and function – (migration up from early pregnancy)
￭ Adjunct to other invasive tests – amniocentesis, version, others
⚬ Amniotic Fluid Volume
￭ Oligohydramnios - decreased fluid
￭ Polyhydramnios - increased fluid

Answer 6

Ultrasonography - Fetal well-being

⚬ Indications for use
￭ Fetal heart rate activity – (as of 6 wks)
￭ Gestational age
￭ Fetal growth – (IUGR)
￭ Fetal anatomy
￭ Fetal genetic disorders –nuchal translucency (NT)
￭ Placental position and function – (migration up from early pregnancy)
￭ Adjunct to other invasive tests – amniocentesis, version, others
⚬ Amniotic Fluid Volume
￭ Oligohydramnios - decreased fluid
￭ Polyhydramnios - increased fluid

Question 7

• Ultrasonography cont’d

⚬ Biophysical Profile (BPP)
￭ Real-time detailed assessment of physical and ________ characteristics
￭ Noninvasive dynamic assessment based on acute/chronic markers

⚬ Modified Biophysical Profile
￭ Combines nonstress test, which assesses the current fetal condition, with measurement of the quantity of amniotic fluid, an indicator of placental function over a longer period of time
￭ ___________ volume determined by measuring a single deepest pocket of fluid instead of using the AFI (amniotic fluid index).
￭ Desired test results are a reactive nonstress test and a single deepest vertical pocket of amniotic fluid that is more than 2 cm (Wilson 233)

⚬ Nursing role
￭ Counseling and education regarding the procedure

Answer 7

⚬ Biophysical Profile (BPP)
￭ Real-time detailed assessment of physical and physiologic characteristics
￭ Noninvasive dynamic assessment based on acute/chronic markers

⚬ Modified Biophysical Profile
￭ Combines nonstress test, which assesses the current fetal condition, with measurement of the quantity of amniotic fluid, an indicator of placental function over a longer period of time
￭ Amniotic fluid volume determined by measuring a single deepest pocket of fluid instead of using the AFI (amniotic fluid index).
￭ Desired test results are a reactive nonstress test and a single deepest vertical pocket of amniotic fluid that is more than 2 cm (Wilson 233)

⚬ Nursing role
￭ Counseling and education regarding the procedure

Question 8

Biochemical Assessment

Chorionic villus sampling (CVS)
⚬ Earlier diagnosis and rapid results
⚬ Performed between 10 and 13 weeks of gestation
⚬ Removal of small ______ specimen from fetal portion of placenta (chorionic villi)
￭ Can detect __________ defections but not the severity
￭ Does not detect neural tube defects
￭ Higher incidence of miscarriage and pain

Answer 8

Chorionic villus sampling (CVS)
⚬ Earlier diagnosis and rapid results
⚬ Performed between 10 and 13 weeks of gestation
⚬ Removal of small tissue specimen from fetal portion of placenta (chorionic villi)
￭ Can detect chromosomal defections but not the severity
￭ Does not detect neural tube defects
￭ Higher incidence of miscarriage and pain

Question 9

Biochemical Assessment

Amniocentesis
⚬ 14-20 weeks
⚬ Indication for use
￭ ________ concerns - Women over 35 years old, family history of ___________ abnormalities
￭ Can detect chromosomal issues and neural tube defects
￭ Pulmonary maturity
* L/S lecithin–sphingomyelin ratio
* and S/A** ratios
￭ Risk of miscarriage, infection, Rh isoimmunization, rupture of membranes, labor

Answer 9

Amniocentesis
⚬ 14-20 weeks
⚬ Indication for use
￭ Genetic concerns - Women over 35 years old, family history of chromosomal abnormalities
￭ Can detect chromosomal issues and neural tube defects
￭ Pulmonary maturity
* L/S lecithin–sphingomyelin ratio
* and S/A** ratios
￭ Risk of miscarriage, infection, Rh isoimmunization, rupture of membranes, labor

Question 10

Biochemical Assessment cont’d

• Percutaneous _______ blood sampling (PUBS)
  ⚬ _____ocentesis - direct access to fetal circulation during 2nd/3rd trimester
  ⚬ For fetal blood sampling and transfusion

Answer 10

• Percutaneous umbilical blood sampling (PUBS)
  ⚬ Cordocentesis - direct access to fetal circulation during 2nd/3rd trimester
  ⚬ For fetal blood sampling and transfusion

Question 11

Antepartum Assessment Using Electronic Fetal Monitoring

• Goal ⚬ Determine if the intrauterine environment is supportive to the fetus
  ￭ ______ trimester
• Indications
  ⚬ Diabetes, hypertension, intrauterine growth restriction, multiple gestation, oligohydramnios, decreased fetal movement, postterm pregnancy….

Answer 11

• Goal ⚬ Determine if the intrauterine environment is supportive to the fetus
  ￭ Third trimester
• Indications
  ⚬ Diabetes, hypertension, intrauterine growth restriction, multiple gestation, oligohydramnios, decreased fetal movement, postterm pregnancy….

Question 12

Antepartum Assessment Using Electronic Fetal Monitoring cont’d

• Nonstress Test (NST)
  ⚬ FHR response to fetal activity
  ⚬ Procedure – external monitor
  ⚬ Interpretation

￭ Reactive test: ____ accelerations in a ____-minute period, each lasting at least 15 seconds and peaking at least ___ beats/min above the baseline. (Before 32 weeks of gestation, an acceleration is defined as a rise of at least 10 beats/min lasting at least 10 seconds from onset to offset)

￭ Nonreactive test: A test that does not demonstrate at least ____ qualifying accelerations within a ___ -minute window

Answer 12

• Nonstress Test (NST)
  ⚬ FHR response to fetal activity
  ⚬ Procedure – external monitor
  ⚬ Interpretation

￭ Reactive test: Two accelerations in a 20-minute period, each lasting at least 15 seconds and peaking at least 15 beats/min above the baseline. (Before 32 weeks of gestation, an acceleration is defined as a rise of at least 10 beats/min lasting at least 10 seconds from onset to offset)

￭ Nonreactive test: A test that does not demonstrate at least two qualifying accelerations within a 20-minute window

Question 13

Antepartum Assessment Using Electronic Fetal Monitoring cont’d

• ___________ Stimulation (VAS)
  ⚬ Fetal acoustic stimulation test (FAST)
  ⚬ Performed in conjunction with NST
  ⚬ Procedure - uses sound and vibration to stimulate fetus

Answer 13

• Vibroacoustic Stimulation (VAS)
  ⚬ Fetal acoustic stimulation test (FAST)
  ⚬ Performed in conjunction with NST
  ⚬ Procedure - uses sound and vibration to stimulate fetus

Question 14

Antepartum Assessment Using Electronic Fetal Monitoring cont’d

• Contraction Stress Test (CST) - rarely done now
  ⚬ Oxytocin Challenge Test (OCT)
  ⚬ Procedure
  ￭ Nipple-stimulated contraction test
  ￭ Oxytocin-stimulated contraction test
  ￭ Achieve __ or more contractions in a 10 minute window
  ￭ Provides a warning of fetal compromise earlier than NST

⚬ Interpretation - ACOG
￭ Negative - no late or significant variable decelerations
￭ Positive - late decelerations following > 50% of contractions
￭ Equivocal
* Suspicious - intermittent late decelerations or significant variable decelerations
* Hyperstimulatory - decelerations in presence of UCs > q 2 minutes or >90 seconds
￭ Unsatisfactory - < 3 UCs in 10 minutes or tracing not interpretable

Answer 14

• Contraction Stress Test (CST) - rarely done now
  ⚬ Oxytocin Challenge Test (OCT)
  ⚬ Procedure
  ￭ Nipple-stimulated contraction test
  ￭ Oxytocin-stimulated contraction test
  ￭ Achieve 3 or more contractions in a 10 minute window
  ￭ Provides a warning of fetal compromise earlier than NST

⚬ Interpretation - ACOG
￭ Negative - no late or significant variable decelerations
￭ Positive - late decelerations following > 50% of contractions
￭ Equivocal
* Suspicious - intermittent late decelerations or significant variable decelerations
* Hyperstimulatory - decelerations in presence of UCs > q 2 minutes or >90 seconds
￭ Unsatisfactory - < 3 UCs in 10 minutes or tracing not interpretable

Question 15

Metabolic Disorders

• Diabetes mellitus
  ⚬ Most common __________ disorder associated with pregnancy
  ⚬ Pregnancy complicated by diabetes considered ________
  ⚬ Can be successfully managed with a multidisciplinary approach
  ⚬ Key to an optimal outcome is strict maternal ________ control

Answer 15

• Diabetes mellitus
  ⚬ Most common endocrine disorder associated with pregnancy
  ⚬ Pregnancy complicated by diabetes considered high risk
  ⚬ Can be successfully managed with a multidisciplinary approach
  ⚬ Key to an optimal outcome is strict maternal glucose control

Question 16

⚬ Classification of diabetes

￭ Type 1 - absolute insulin ___________
￭ Type 2 - insulin ___________

￭ Gestational diabetes mellitus (GDM) is any degree of glucose intolerance with onset or recognition during pregnancy, but typically diagnosed after ___ weeks gestation

Answer 16

￭ Type 1 - absolute insulin deficiency
￭ Type 2 - insulin resistance

￭ Gestational diabetes mellitus (GDM) is any degree of glucose intolerance with onset or recognition during pregnancy, but typically diagnosed after 20 weeks gestation

Question 17

Diabetes

⚬ Pathogenesis
￭ Group of metabolic diseases characterized by ____________ resulting from defects in _________ secretion, _________ action or both

Answer 17

⚬ Pathogenesis
￭ Group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both

Question 18

Metabolic Disorders cont’d * Glucose Metabolism in Pregnancy

⚬ Normal pregnancy – progressive insulin resistance

⚬ Weeks 1- 8
￭ ______ increase in resistance R/T human chorionic gonadotropin (HCG) and progesterone

⚬ Weeks 9 – 15
￭ Estrogen and progesterone increase as placenta established
⚬ Stimulates hyperplasia of pancreas islet cells -> ______ insulin production and tissue sensitivity to insulin

⚬ Weeks 16 – 25
￭ ______ in insulin blocking hormones as placenta grows
* Insures adequate transport of glucose to fetus (Human chorionic somatotropin,
human placental lactogen, prolactin)
￭ By 24 weeks pancreas needs to secrete twice the pre-pregnancy insulin to maintain
normal blood glucose level

Answer 18

⚬ Weeks 1- 8
￭ Slight increase in resistance R/T human chorionic gonadotropin (HCG) and progesterone

⚬ Weeks 9 – 15
￭ Estrogen and progesterone increase as placenta established
⚬ Stimulates hyperplasia of pancreas islet cells -> increased insulin production and tissue sensitivity to insulin

⚬ Weeks 16 – 25
￭ Increase in insulin blocking hormones as placenta grows
* Insures adequate transport of glucose to fetus (Human chorionic somatotropin,
human placental lactogen, prolactin)
￭ By 24 weeks pancreas needs to secrete twice the pre-pregnancy insulin to maintain
normal blood glucose level

Question 19

Metabolic Disorders cont’d - Glucose Metabolism in Pregnancy cont’d

⚬ Week 26 – 35
￭ Endogenous insulin requirement _________

⚬ Week 36 +
￭ Requirement levels off

⚬ Diabetes during pregnancy
￭ Unable to double or triple their insulin secretion -> can’t overcome insulin blocking effects of placental hormones -> ___________ blood glucose levels

Answer 19

⚬ Week 26 – 35
￭ Endogenous insulin requirement triples

⚬ Week 36 +
￭ Requirement levels off

⚬ Diabetes during pregnancy
￭ Unable to double or triple their insulin secretion -> can’t overcome insulin blocking effects of placental hormones -> elevated blood glucose levels

Question 20

Metabolic Disorders cont’d

• Pregestational diabetes mellitus (Type 1 or 2)

⚬ Preconception counseling-
⚬ Key goal is to get blood glucose levels under control ________ and in early pregnancy.
⚬ Congenital defects related to diabetes is more likely in _____ pregnancy.
⚬ May need adjustment on medication. Most pregnant women requiring medication will need to be on _________

Answer 20

⚬ Preconception counseling-
⚬ Key goal is to get blood glucose levels under control before and in early pregnancy.
⚬ Congenital defects related to diabetes is more likely in early pregnancy.
⚬ May need adjustment on medication. Most pregnant women requiring medication will need to be on insulin

Question 21

Metabolic Disorders cont’d

⚬ Maternal risks and complications
￭ Macrosomia
￭ Hydramnios/Polyhydramnios
￭ Ketoacidosis
￭ Hyperglycemia
￭ Hypoglycemia

⚬ Fetal and neonatal risks
￭ Sudden and unexplained stillbirth
￭ Congenital malformations
￭ Respiratory distress
￭ Hypo/hyperglycemia
￭ SGA/IUGR
￭ LGA/Macrosomia

Answer 21

⚬ Maternal risks and complications
￭ Macrosomia
￭ Hydramnios/Polyhydramnios
￭ Ketoacidosis
￭ Hyperglycemia
￭ Hypoglycemia

⚬ Fetal and neonatal risks
￭ Sudden and unexplained stillbirth
￭ Congenital malformations
￭ Respiratory distress
￭ Hypo/hyperglycemia
￭ SGA/IUGR
￭ LGA/Macrosomia

Question 22

• Gestational diabetes mellitus (GDM)

⚬ Diagnosed during __________ of pregnancy
⚬ Maternal-fetal risks
⚬ Screening for gestational diabetes mellitus
￭ One and two step screening

Answer 22

⚬ Diagnosed during 2nd half of pregnancy
⚬ Maternal-fetal risks
⚬ Screening for gestational diabetes mellitus
￭ One and two step screening

Question 23

Metabolic Disorders cont’d - * DM care management

⚬ Antepartum evaluation
￭ Interview
￭ Physical examination
￭ Laboratory tests

• Baseline renal function
  ⚬ ____ urine collection - total protein excretion and creatinine clearance
• UA and culture
• Thyroid
• Glycosylated hemoglobin A1C
  ￭ Patient needs much more frequent monitoring

Answer 23

⚬ Antepartum evaluation
￭ Interview
￭ Physical examination
￭ Laboratory tests

• Baseline renal function
  ⚬ 24-hr urine collection - total protein excretion and creatinine clearance
• UA and culture
• Thyroid
• Glycosylated hemoglobin A1C
  ￭ Patient needs much more frequent monitoring

Question 24

Metabolic Disorders cont’d * DM care management cont’d

⚬ Antepartum care
￭ Diet
￭ __________ - 30-60 min daily
￭ Insulin therapy

￭ Monitoring blood glucose levels
* ___ times/day
* Continuous glucose monitoring (GCM)

￭ Urine testing
￭ Complications requiring hospitalization

￭ Fetal surveillance
* NST weekly or biweekly starting 28 or 32 weeks gestation

￭ Determination of birth date and mode of birth, often delivered before 39 weeks

Answer 24

⚬ Antepartum care
￭ Diet
￭ Exercise - 30-60 min daily
￭ Insulin therapy

￭ Monitoring blood glucose levels
* 4-8 times/day
* Continuous glucose monitoring (GCM)

￭ Urine testing
￭ Complications requiring hospitalization

￭ Fetal surveillance
* NST weekly or biweekly starting 28 or 32 weeks gestation

￭ Determination of birth date and mode of birth, often delivered before 39 weeks

Question 25

Patient teaching table
Diabetes- mother nutrition

Answer 25

Question 26

Metabolic Disorders* DM care management cont’d

⚬ Intrapartum care
￭ Monitor patient closely
* Prevent _______, _________, _________
￭ Complications
￭ May require a _________birth

⚬ Postpartum care
￭ Insulin requirements _________ substantially
￭ Encourage breastfeeding

Answer 26

⚬ Intrapartum care
￭ Monitor patient closely
* Prevent dehydration, hypoglycemia, hyperglycemia
￭ Complications
￭ May require a cesarean birth

⚬ Postpartum care
￭ Insulin requirements decrease substantially
￭ Encourage breastfeeding

Question 27

Metabolic Disorders cont’d ⚬ GDM Care management

￭ 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 ___ will have recurrent GDM in subsequent pregnancies

Answer 27

￭ 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

Question 28

Hypertension in Pregnancy

• Significance and incidence
  ⚬ Most ________ medical complication of pregnancy
  ￭ Preeclampsia - complicates _____% 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
* _____________ women experience the most severe complications and have higher mortality rates

Answer 28

• 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

Question 29

Hypertension in Pregnancy cont’d

Hypertension: Systolic > ___ or Diastolic > ___
* 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 ____ weeks gestations, or persists after 12 weeks PP

⚬ Gestational hypertension
￭ Onset of hypertension without proteinuria after __ weeks of gestation

Answer 29

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

Question 30

Hypertension in Pregnancy cont’d

⚬ Chronic hypertension
￭ Increased incidence of:
* _______ placentae
* Superimposed preeclampsia
* Increased perinatal ________

￭ PP complications:
* __________ edema
* Renal failure
* Heart failure
* Encephalopathy
* Stroke

Answer 30

⚬ Chronic hypertension
￭ Increased incidence of:
* Abruptio placentae
* Superimposed preeclampsia
* Increased perinatal mortality

￭ PP complications:
* Pulmonary edema
* Renal failure
* Heart failure
* Encephalopathy
* Stroke

Question 31

Hypertensive Drugs

⚬ __________ (beta blocker)– drug of choice in pregnancy, can be given PO or IV
⚬ __________ (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 31

⚬ 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.

Question 32

Hypertension in Pregnancy cont’d

⚬ Preeclampsia
￭ Pregnancy-specific syndrome in which hypertension and __________ 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 _________ activity or coma in a woman with preeclampsia who has no history of preexisting _________ activity

Answer 32

⚬ 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

Question 33

Preeclampsia * Etiology

⚬ 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 __________ as the root cause
  ⚬ Caused by disruptions in placental __________ 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 33

⚬ 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%

Question 34

Diagnosis of Preeclampsia

Blood Pressure
➢ Systolic blood pressure of ≥ ____mm Hg OR diastolic blood pressure of ≥ ___mm Hg on two occasions at least 4 hours apart OR
➢ Systolic blood pressure of 160 mm 110 mm Hg or more

AND

Proteinuria
➢ ____ mg or more per 24-hour urine collection OR
➢ Protein/creatinine ratio of 0.3 or more OR
➢ Dipstick reading of __+ (used only if other quantitative methods not available)

Answer 34

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)

Question 35

Preeclampsia with Severe Features

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

Answer 35

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

Question 36

Preeclampsia cont’d * Care management

⚬ Identifying & preventing preeclampsia
￭ Prevention for pregnant women at low risk for preeclampsia
* Management of gestational weight gain within recommendations
* A prepregnancy _____________ diet, high in vegetables, fish, legumes and nuts

￭ Women at high risk for preeclampsia
* Low-dose _______, started before 16 weeks of gestation.
* Increased rest at home in the third trimester
* Blood pressure management

Answer 36

⚬ 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

Question 37

Preeclampsia cont’d

• Interventions
  ⚬ Gestational hypertension and preeclampsia w/o severe features
  ￭ Initial laboratory evaluation
• Serum creatinine, platelet count, and ____ enzymes.

￭ Weekly evaluation
* Hematocrit, platelet count, serum creatinine, and liver function tests

￭ Evaluated for signs or symptoms of severe features
* Severe ________, blurred/ double vision, mental confusion, right U.Q. abdominal or epigastric pain, nausea or vomiting, SOB, and decreased ________ output
* BP monitored frequently and proteinuria assessed weekly

￭ Fetal evaluation
* Daily fetal ____________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 37

• 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.

Question 38

Preeclampsia - * Interventions cont’d

⚬ Severe gestational hypertension and preeclampsia with severe features
￭ Hospitalized immediately
￭________________ 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 ________ count, liver enzymes, and serum __________
￭ 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 (____________) for baby lungs

Answer 38

⚬ 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)

Question 39

Preeclampsia - * Care management cont’d

⚬ Assessment
￭ Physical examination
* Blood pressure
* Edema - dependent, pitting
* Deep tendon reflexes
* Clonus

￭ Laboratory tests
* Platelets
* Creatinine
* _____ function
* Urine _______

Answer 39

⚬ Assessment
￭ Physical examination
* Blood pressure
* Edema - dependent, pitting
* Deep tendon reflexes
* Clonus

￭ Laboratory tests
* Platelets
* Creatinine
* Liver function
* Urine protein

Question 40

Preeclampsia * Interventions

⚬ Intent of emergency interventions
￭ Prevent self injury
￭ Ensure adequate oxygenation
￭ Reduce aspiration risk
￭ Establish seizure control with

Magnesium sulfate
* Monitor for reflexes, __________, urinary output, LOC
* ________________ - antidote, should be available at bedside

Answer 40

⚬ 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

Question 41

Preeclampsia - HELLP syndrome

⚬ Lab diagnostic variant of severe preeclampsia involves hepatic dysfunction, characterized by:
￭ ________
￭ Elevated _____ enzymes
￭ Low _________

⚬ Associated with increased risk for:
￭ __________ 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 41

⚬ 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

Question 42

Eclampsia

Signs of preeclampsia (hypertension & proteinuria) with onset of seizures

Preceding s/s
⚬ Headache, ________ vision, photophobia, epigastric/____ 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 42

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

Question 43

You’re providing education to a nursing student about the pathophysiology of preeclampsia. Which
statement demonstrates that the student understood
how this condition develops?

A. “The basal arteries of the myometrium fail to widen to support blood flow to the placenta.”
B. “The placenta experiences ischemia because the
spiral arteries of the uterus fail to reshape and increase in diameter.”
C. “The cardiovascular system of the mother fails to
compensate for the increased blood flow from the
fetus and placental ischemia occurs.”
D. “If the mother experience uncontrolled hypertension and proteinuria, it compromises blood flow to the placenta and leads to preeclampsia.”

Answer 43

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.

Question 44

Which findings below could indicate the development of preeclampsia in a patient that would need to be reported to the physician? Select all that apply:

❑ A. Blood pressure 165/91
❑ B. 3+ dipstick urine protein
❑ C. Platelet count 187,000/unit
❑ D. AST 14, ALT 18
❑ E. Contractions
❑ F. Headache

Answer 44

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.

Question 45

Which finding below indicates Magnesium Sulfate toxicity and requires you to notify the physician?

A. Deep tendon reflexes +4
B. Urinary output of 600 mL over 12 hours
C. Clonus presenting in the lower extremities
D. Respiratory rate of 8 breaths per minute
E. O2 saturation 98%

Answer 45

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.

Question 46

Bonus Question: What medication would the nurse anticipate administering as the antidote for magnesium sulfate toxicity?

Answer 46

Calcium gluconate

Question 47

Hyperemesis Gravidarum

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

Answer 47

• 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

Question 48

Hemorrhagic Disorders

Bleeding in pregnancy jeopardizes both maternal and fetal well-being
⚬ Maternal blood loss decreases ________-carrying capacity, increases risk for:
￭ Hypovolemia
￭ Anemia
￭ Infection
￭ Preterm labor
￭ Adverse oxygen delivery

⚬ Fetal risks from maternal hemorrhage:
￭ ________/blood loss
￭ Hypoxemia, _______, anoxia
￭ Preterm birth

Answer 48

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

Question 49

Hemorrhagic Disorders - Early Pregnancy Bleeding

• Miscarriage (Spontaneous abortion)
  ⚬ The leading cause of pregnancy loss
  ⚬ Occurs before ___ 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 49

• 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

Question 50

Hemorrhagic Disorders - * Ectopic pregnancies: “Tubal pregnancies”

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

Answer 50

• 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

Question 51

Hemorrhagic Disorders - Molar Pregnancy

• “Hydatidiform mole”
  ⚬ A benign proliferative ________ 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 ________ fertilizing 1 egg
• Clinical manifestations
  ⚬ Vaginal ________ - 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 51

• “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

Question 52

Hemorrhagic Disorders - Molar Pregnancy * Diagnosis

⚬ Transvaginal ultrasound
￭ Snowstorm pattern or “grape-like” ________
⚬ Serum ____

• Management
  ⚬ Immediate _________ 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 52

⚬ 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

Question 53

Hemorrhagic Disorders - Late Pregnancy Bleeding

• Placenta previa
  ⚬ Placenta implanted in _________ uterine segment near or over internal cervical os
  ￭ 0.5% of births

⚬ Classification
￭ Complete/total
￭ Marginal

⚬ Clinical manifestations
￭ _________, 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 53

• 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

Question 54

Hemorrhagic Disorders - Late Pregnancy Bleeding * Placenta previa cont’d

⚬ Diagnosis and medical management
￭ Standard diagnosis is transabdominal _________ 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 _________ is indicated

Answer 54

⚬ 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

Question 55

Hemorrhagic Disorders - Late Pregnancy Bleeding cont’d

• Premature separation of placenta (abruptio placentae)
  ⚬ Detachment of part or all of placenta from ________________
  ⚬ 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 _________
* May be slight or absent in concealed hemorrhage
* Systemic signs of early hemorrhage
￭ _________ pain
￭ Uterine tenderness
* _________ in fundal height, frequent contractions, high resting tone, rigid abdomen in-between contraction
￭ Persistent late decelerations

Answer 55

• 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

Question 56

Hemorrhagic Disorders - Late Pregnancy Bleeding cont’d
* Premature separation of placenta (abruptio placentae) cont’d

⚬ Causes: __________, 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 >____% fetal mortality rate

⚬ A clinical diagnosis
￭ Clinical S&S- abdominal pain & bleeding!, late or prolonged __________
￭ 50% unable to be identified through __________
￭ May be diagnosed after placenta is inspected

⚬ Interventions
￭ Expectant - monitor closely
￭ Active - immediate birth if at or near full term

Answer 56

⚬ 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

Question 57

Hemorrhagic Disorders - Late Pregnancy Bleeding cont’d

• 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 __________ rather than the placenta and lies over the cervical os

o Succenturiate placenta
* Placenta has divided into ____________ rather than single mass

Answer 57

• 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

Question 58

Hemorrhagic Disorders - Late Pregnancy Bleeding cont’d
* Cord insertion and placental variations

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

Answer 58

⚬ 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.

Question 59

Hemorrhagic Disorders - Clotting Disorders in Pregnancy

• Normal clotting
  ⚬ Hemostatic system stops flow of blood from injured vessels by platelet plug and formation of _____ clot

⚬ Fibrinolytic system
￭ Process through which fibrin is split into fibrinolytic degradation products and circulation is restored

Answer 59

• 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

Question 60

• Clotting problems

⚬ Concern in immediate postpartum period
⚬ Recognition in antepartal period may decrease hemorrhagic problems
⚬ Disseminated Intravascular Coagulation (DIC)
￭ Intravascular activation of coagulation which is widespread, rather than localized, and results in _________ clot formation and hemorrhage
￭ Treatment - treat the underlying cause, blood products

Answer 60

excessive

Question 61

Multiple Gestation

• Incidence increasing due to fertility treatment and delayed childbearing
• Only __% 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 _______
  ⚬ Same or different genders

Answer 61

• 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

Question 62

Multiple Gestation cont’d

• 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
￭ ______ 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 62

• 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

Question 63

Infectious Diseases cont’d

• TORCH infections
  ⚬ ___________
  ⚬ Other (___________)
  ⚬ _______________
  ⚬ ___________________
  ⚬ ___________________

⚬ Each disease teratogenic to developing fetus

⚬ Medical & Nursing management varies with each organism, trimester of exposure, and clinical evidence of neonatal sequellae.

Answer 63

• 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.

Question 64

Infectious Diseases
* HIV and pregnancy

⚬ _______ - fastest growing population with HIV infection and AIDS, 27% inf.
⚬ Transmission - exchange of body fluids (semen, blood, or vaginal secretions)
⚬ At risk women: IV drugs, high risk/,multiple sexual partners, history of multiple STIs.

⚬ Recommendations from CDC:
￭ Offer HIV testing to all women whose behavior places them at risk for HIV infection
￭ All pregnant women should be offered counseling and HIV testing as early in pregnancy as possible
⚬ If untreated, mother-child transmission rate is 18 -26%
⚬ If treated with early __________ use, __________ birth, & avoidance of __________, transmission rates can be reduced to 1-2%.
￭ Drug of choice: zidovudine ( AZT)

Answer 64

Women

Antiviral
C/S
Breast feeding

Question 65

Intimate Partner Violence (chapter 3)

• The US DOJ, Office on Violence Against Women (2018) describes violence and abuse as including 1+: physical, sexual, emotional, economic, and psychologic factors.
• __ 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 _______ 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 ___________.

Answer 65

• 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.

Question 66

Nursing Assessment for IPV

• nurse should assess for ______ at each prenatal visit, during labor & birth.
• A pregnant woman is often accompanied by a male partner; Find opportunities to speak to the woman ______ (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 _________ 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 66

• 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.

Question 67

Labor and Birth Complications

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

Answer 67

• 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

Question 68

Preterm Labor and Birth

⚬ Preterm labor: cervical changes and uterine contractions occurring between ___ 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: < __ 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
  ⚬ _______ 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 68

⚬ 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

Question 69

Preterm labor cont’d - Cervical Insufficiency

⚬ Recurrent premature _________ of cervix
￭ Passive and painless _________ 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 _________
￭ Monitor symptoms and effects of modifying activities, pelvic rest, progesterone, anti-inflammatory drugs, and antibiotics
￭ Educate on when to come to hospital

Answer 69

⚬ 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

Question 70

Preterm Labor and Birth cont’d * Care management

⚬ 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 70

⚬ 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

Question 71

Preterm Labor and Birth * Care management cont’d

⚬ Suppression of ________ activity
￭ _________ - 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 71

⚬ 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

Question 72

Preterm Labor and Birth - Care management cont’d

⚬ Promotion of fetal lung maturity
￭ Antenatal glucocorticoids
* Stimulates _________ 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 72

⚬ 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

Question 73

Preterm Labor and Birth - Care management cont’d

⚬ Management of inevitable preterm birth
￭ Labor progressed to cervical dilation of 3-4 cm
￭ ________________ 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 73

⚬ 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

Question 74

Prelabor Rupture of Membranes

• ________ Rupture of Membranes (PROM)
  ⚬ Spontaneous rupture of amniotic sac and leakage of amniotic fluid beginning at least __ hour before onset of labor at any gestational age
• ______ Prelabor Rupture of Membranes (pPROM)
  ⚬ Membranes rupture before completion of week ___, not in labor
  ⚬ ____________ 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 74

• 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

Question 75

• Care management

⚬ PROM
￭ Determined for each woman based on an estimate of risk
￭ Infection is the greatest risk
￭ Labor will likely be ________

⚬ PPROM
￭ Managed conservatively
* FHR, NST, BPP, kick counts, monitor for Infection
￭ Usually hospitalized, possibly:
* Antenatal glucocorticoids
* Antibiotics
* Magnesium sulfate

Answer 75

⚬ 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

Question 76

Precipitous labor

￭ Labor that lasts less than _________
￭ May result from hypertonic uterine contractions
￭ Complications
* Placental abruption
* Uterine tachysystole
⚬ Recent cocaine, amphetamine use
* Uterine rupture, laceration, amniotic fluid embolus, PPH

Answer 76

3 hours

Question 77

Postterm Pregnancy, Labor, and Birth

Pregnancy that extends beyond __ weeks gestation

• Maternal risks
  ⚬ Dysfunctional labor
  ⚬ Perineal injury due to macrosomia
  ⚬ Hemorrhage and infection
  ⚬ Interventions more likely to be necessary
  ⚬ Fatigue and psychologic reactions

Answer 77

42

Question 78

Postterm Pregnancy, Labor, and Birth

• Fetal risks
  ⚬ Abnormal fetal growth
  ⚬ _________ia
  ⚬ Increased risk for birth ________
  ⚬ Aging placenta, late decels
  ⚬ Oligohydramnios
  ⚬ Meconium-stained fluid
• Care management
  ⚬ Most induce at _____ weeks gestation
  ⚬ If pregnancy continues: NST, BPP

Answer 78

• 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

Question 79

Dysfunctional Labor

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

Answer 79

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

Question 80

Obstetric Procedures

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

Answer 80

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

Question 81

Dysfunctional Labor

⚬ Alterations in pelvic structure
￭ ______ dystocia
* Contractures of pelvic diameters that reduce the capacity of the bony pelvis, inlet, midpelvis, or outlet

￭ ______ dystocia
* Results from obstruction of the birth passage by an anatomic abnormality other than that of bony pelvis (fat)

Answer 81

￭ 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)

Question 82

Obstetric Procedures cont’d

Induction of labor
⚬ Chemical or mechanical initiation of ___ 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 ___ or more, likelihood of vaginal birth is similar whether labor is spontaneous or induced

Answer 82

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

Question 83

Obstetric Procedures - Cervical ripening methods cont’d

Pharmacological (___________)
* 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 83

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

Question 84

Obstetric Procedures cont’d

￭ Cervical ripening methods cont’d
* Mechanical methods
⚬ Foley __________ or Cook’s catheter
* Amniotomy
⚬ Artificial rupture of membranes

⚬ _______________
￭ 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 84

￭ 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

Question 85

Obstetric Procedures cont’d

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

Answer 85

• 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

Question 86

Chorioamnionitis

• Bacterial infection of the ____________
  ⚬ Ascending infection
  ⚬ Major cause of complications
  ￭ 1% to 5% of term births
  ￭ 25% of preterm births

⚬ Clinical findings
￭ Maternal fever
￭ Maternal and fetal tachycardia
￭ Uterine tenderness
￭ Foul odor of amniotic fluid

⚬ Treatment
￭ IV antibiotics: Ampicillin/PCN/Gentamycin

Answer 86

amniotic cavity

Question 87

Obstetric Procedures cont‘d

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

Answer 87

• 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

Question 88

Obstetric Procedures cont’d

• Forceps-assisted birth
  ⚬ Maternal indications
  ￭ __________ second stage of labor
  ⚬ Fetal indications
  ￭ Abnormal fetal ____________
  ￭ Distress or certain abnormal presentations
  ￭ Arrest of rotation
  ￭ Delivery of head in a breech presentation

Answer 88

• 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

Question 89

Cesarean birth

⚬ 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
￭ _________, fetal asphyxia, fetal injuries
￭ More likely to require _________efforts
⚬ Financial burden, longer _________

Answer 89

⚬ 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

Question 90

• Trial of labor after ________ (TOLAC)
  ⚬ Observation of a woman and her fetus for a specified length of time to assess safety of vaginal birth
• _______ 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 ________

Answer 90

• 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

Question 91

Rupture of the Uterus

• Rare, serious obstetric injury that occurs in 1 to 1,500-2,000 births
• Most frequent causes of uterine rupture:
  ⚬ Separation of ____ 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 _________! Immediate ____________ is necessary to save the life of the mother and baby. Maternal & infant mortality _____%

Answer 91

• 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%

Question 92

Shoulder Dystocia

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

Answer 92

⚬ 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

Question 93

Shoulder Dystocia

First line interventions!
⚬ McRoberts maneuver
￭ The woman flexes her ________ sharply against her _______ , 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 93

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

Question 94

Shoulder Dystocia - Other interventions

⚬ Gaskin maneuver
￭ “_______”
￭ 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 94

⚬ 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

Question 95

Umbilical Cord Prolapse

• 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)
  ⚬ _____ cord >100cm
  ⚬ Malpresentation
  ⚬ Unengaged presenting part
• Key interventions
  o Relieve pressure on the cord without compression of the blood vessels. Using ________, keep gentle upward pressure on the presenting part.
  o Expedite delivery by ____________

Answer 95

• 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

Question 96

Amniotic Fluid Embolism

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

Answer 96

• “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

Question 97

Amniotic Fluid Embolism * Predisposing factors

⚬ ________ maternal age, postterm pregnancy, labor induction or augmentation, preeclampsia, cesarean birth, placental abruption/previa
* This will result in a “_____”. 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 97

⚬ 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.

Question 98

Risk factors for pregnancy

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 98

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?

Question 99

Fetal Assessment Prior to Birth

Kick Counts: Baby should be moving about ______ x in _____ hours, movement should increase as due date gets closer no fetal movement for 12 hours is a fetal alarm sign
**fetal movement is not present during fetal sleep cycle!

Answer 99

10 times in 12

Question 100

Fetal Assessment Prior to Birth

Ultrasound: is fetus growing uniformly, survey organ systems, locate placenta
Can identify sex when fetus is < ___weeks

Answer 100

20

Question 101

Fetal Assessment Prior to Birth

Lab Tests: AFP (___________ defects), multiple marker screens

Answer 101

neural tube

Question 102

Fetal Assessment Prior to Birth

Amniocentesis: amniotic fluid removed to check for _______________ (after 14 weeks) Informed consent, risk for infection/bleeding (if sac doesn’t heal), also risk
for amniotic fluid embolism

Answer 102

genetic abnormalities

Question 103

Fetal Assessment Prior to Birth

Chorionic Villus Sampling: removal of a small ________ specimen from the fetal portion of the placenta; transcervically or transabdominally

Answer 103

tissue

Question 104

Fetal Assessment Prior to Birth

Non-Stress Test (NST): evaluation of fetus in uterine environment when labor has not taken place yet.
Reactive = good → 2 FHR accelerations in 20 min period each lasting
for 15 sec and peaking at least 15 BPM above baseline.
Nonreactive = bad → do _____________

Answer 104

biophysical profile (BPP)

Question 105

Fetal Assessment Prior to Birth

Contraction Stress Test (CST/OST): evaluate how fetus may respond to _____________________ (give dose of oxytocin)
Negative CST = no FHR decels
Positive CST = repetitive late FHR decels

Answer 105

labor contractions

Question 106

Fetal Assessment Prior to Birth

Biophysical Profile (BPP): noninvasive physical exam of fetus including determination of VS (determine fetal status) Score of ____ = normal!

Answer 106

8-10

Question 107

Fetal Assessment Prior to Birth

_______________ (AFI): evaluated by vertical depths (cm) of largest pocket of amniotic fluid in all 4 quadrants surrounding maternal umbilicus
- AFI < 5cm = oligohydramnios (may be due to congenital anomalies or premature rupture of membranes)
- AFI > 25cm = polyhydramnios (may be due to GI or CNS anomalies, multiple fetuses, fetal hydrops = fluid in baby’s organs)

Answer 107

Amniotic Fluid Index

Question 108

Gestational Hypertension: onset of HTN without ___________ 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 108

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

Question 109

Mild Preeclampsia
S/S: hypertension, proteinuria, headache, visual changes
Risk factors: primigravida, multifetal gestation, obesity, hx of vascular disease, age
Collaborative Care: usually home care, diet, activity restriction, antihypertensives

Severe Preeclampsia
S/S: worsening hypertension, worsening proteinuria, hyperreflexia, headache, visual changes, epigastric pain, HELLP
Treatment: magnesium sulfate therapeutic level 4.8 – 9.6, monitor I&Os, seizure precautions, calcium gluconate (antidote for Mg – make sure to have it at bedside)
Cure: delivery of fetus and placenta (they are the problem!)

Question 110

HELLP syndrome

Hemolysis
Elevate
Liver Enzymes (ALP, ALT, AST)
Low Platelet Count (normal plt = 150,000-
400,000)
S/S: RUQ/epigastric pain, malaise/fatigue, N/V, edema

Tx: magnesium sulfate (seizure precaution) and labetalol (BP control), blood transfusion if plt below 10,000
Mag sulfate toxicity – low RR, low UO, no DTR (calcium gluconate = antidote!!)

Question 111

Preeclampsia + seizure

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

Answer 111

● 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

Question 112

Early Pregnancy Bleeding

Miscarriage:
Threatened – cramping/bleeding no dilation
Inevitable – cervix ________ prematurely

Incompetent Cervix: _________ premature dilation of cervix –
cerclage (close cervix with stitches), bedrest, pelvic rest, education of s/s preterm labor

Answer 112

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

Question 113

Early Pregnancy Bleeding

Ectopic Pregnancy: gestational sac implanted outside of _________,
not viable, abdominal pain & tenderness & bleeding
- ____________ (< 6 weeks, destroys rapidly dividing cells)
- Surgical intervention (>6 weeks)

Molar Pregnancy: atypically fertilized egg (lost or inactivated __________), nonviable, must be removed
- hCG levels tested for 6 months to detect trophoblastic neoplasia,
pregnancy should be prevented during follow-up period

Answer 113

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

Question 114

Late Pregnancy Bleeding

Placenta Previa: placenta partially or completely covers ________ , usually resolves if found early in pregnancy, c-section needed if it doesn’t resolve

Abruptio Placentae: placenta ____________ before birth, can cause bleeding, and deprive fetus of oxygen and nutrients

Answer 114

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

Question 115

Late Pregnancy Bleeding

DIC: pathologic form of diffuse clotting that consumes large amounts of_______________ , causing widespread external bleeding, internal bleeding, or both.

• S/S: petechiae, unusual bleeding
• Labs: blood serum (fibrin split products)
• can be caused by treatment of preeclampsia w/ Mg Sulfate, infection, or trauma
• Treatment: with heparin or Plt/RBC transfusion

Answer 115

clotting factors

Question 116

Gestational Diabetes

S/S: May not have symptoms, if they do, think _____ (polyuria, polydipsia, polyphagia)
Diagnosis: _____ – diagnosed during 2nd half of pregnancy

Treatment: glucose monitoring, diet/exercise, pharm intervention
Risk & Complications: __________
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 116

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

Question 117

FFN (fetal fibronectins)

Definition: Biochemical marker that can indicate labor (__________ labor)

This is not a valid marker if vaginal exams have been done

Negative FFN test & no cervical dilation = good indicator that you’re not in labor

Answer 117

preterm

Question 118

Dystocia

Definition: long, abnormal, or _________ labor Risk to patient & fetus

Common type: _________ 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:
● _________ Assisted Birth – Is one in which an instrument with two curved blades is used to assist in birth
● _________ -assisted birth – Attachment of vacuum cup to fetal head, using negative
pressure to assist birth of head
● _________ (Roberts and Gaskin maneuver)

Answer 118

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)

Question 119

Urgent & Emergent C-section

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 _______

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 119

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)

Question 120

Prolapsed Umbilical Cord

Definition: Umbilical cord is below the baby and is getting ____________ - ____________

Contributing Factors:
● Long cord (longer than 100 cm)
● Misrepresentation
○ Breech
○ Transverse lie
● Presenting part unengaged

Interventions:
● Positioning with gravity – Trendelenberg, knee chest position
● Inserting fingers to hold the presenting part in uterus and prevent compression
→ C-section
● Call for help

Answer 120

compressed – hypoxia

Question 121

Amniotic Fluid Embolism

Definition: (rare) part of the ______________ 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 _______________________

Answer 121

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

Question 122

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

Answer 122

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