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Family NRSG > Week 4: Routine Prenatal Care and Infections (L&D) > Flashcards

Week 4: Routine Prenatal Care and Infections (L&D) Flashcards

1
Q

Prenatal care: EDC & EDD

A
  • EDC = estimated date of confinement
  • EDD = estimated date of delivery
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2
Q

Prenatal history includes

A
  • Obstetric history
  • Due date for this pregnancy
  • Monthly/weekly prenatal visits
  • Lab values
  • Maternal medical history
  • Ultrasound results
  • Etc
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3
Q

TPAL –> WILL BE ON QUIZ

A

T = Term birth
P = Preterm births
A = Abortions (spontaneous & therapeutic)
L = Living children

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4
Q

Gravida

A

Number of pregnancies

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5
Q

Parady

A

Number of gestational viable births

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6
Q

Woman pregnant with 4th baby, two children born at term and living, one miscarriage, is:

A
  • G2 P4
  • T2 P0 A1 L2
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7
Q

Cues for risks (MAY SEE IN QUIZ)

A
  • High B/P
  • Hist of previous postpartum hemorrhage
  • Hist of previous shoulder dystocia
  • Rh negative
  • Gestational diabetes
  • More than 5 previous births
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8
Q

Risk factors with STDs

A
  • increased risk of preterm labor and preterm birth
  • Premature rupture of membranes with risk for infection
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9
Q

Routine prenatal lab testing (review)

A
  • Complete blood count
  • Blood type and Rh & antibody screen
  • Past and/or current infections
  • Rubella, HIV, Group B, Hep B, STD/serology, Urinalysis with culture, Syphilis blood test
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10
Q

additional prenatal lab testing (review)

A
  • Not all at first prenatal visit: fetal fibronectin, herpes culture, blood glucose studies, Toxicology screening, TB testing, TORCH titers
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11
Q

Risk factors for group B strep

A
  • Gestation under 37 weeks gestation
  • Ruptured membranes over 18 hours
  • Maternal temp over 100.4
  • GBS bacteriuria this pregnancy
  • Hist of infant with GBS disease
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12
Q

Increased risk for diabetic mothers

A
  • Pyelonephritis
  • Ketoacidosis
  • Preeclampsia
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13
Q

Increased risks for the infants of diabetic mothers

A
  • Macrosomia
  • Birth trauma
  • congenital anomalies
  • Resp. distress syndrome (ARDS)
  • Hypoglycemia
  • Hyperbilirubinemia
  • Fetal malformations
  • Fetal demise
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14
Q

Meds during pregnancy

A
  • The classification system for medications during pregnancy has five categories
  • “Do the risks outweigh the benefits?”
  • Table on slide 22
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15
Q

Cues for maternal substance abuse

A
  • Med hist: cellulitis, hepatitis, Depression/suicide attempt, STDs/HIV/AIDs
  • Placental abruption, unexplained fetal death, Spontaneous abortion, preterm labor/birth, LBW
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16
Q

Domestic violence

A
  • Pregnant women are more likely to die from intimate partner violence (IPV) than from any other cause
  • 11% more homicides occur in pregnant women than in non-pregnant women
  • 22% of pregnant teens are in an abusive relationship
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17
Q

Cues of IPV in pregnancy

A
  • Unplanned pregnancy
  • Delayed or no prenatal care
  • STDs
  • Bleeding, miscarriage
  • Fetal injury, fetal demise
  • PTL, low birth weight
  • Depression, substance abuse
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18
Q

Cues for abuse

A
  • Multiple bruises in various healing stages
  • Extreme anxiety, hesitancy
  • Hovering partner who answers all questions
  • Frequent visits and healthcare utilization
  • Missed appointments
  • Interview patients in private: “Its our policy to interview all patients in private”
  • “do you feel safe at home?”
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19
Q

Teratogens

A
  • agents that can cause congenital anomalies:
  • Smoking: risk for cleft lip/palate or both
  • Alcohol: fetal alcohol syndrome, mental disability, dysmorphic facial features
  • Drugs
  • Occupational hazards
  • Viruses
  • Nutritional deficiencies
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20
Q

When do teratogens affect the fetus?

A
  • About 10 - 14 days after conception
  • Once the fertilized egg is attatched to the uterus, toxins in the mother can pass to the embryo/fetus
  • The neural tube closes in the first 3 - 5 weeks of the pregnancy. During this time, teratogens can cause neural tube defects such as spina bifida
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21
Q

Some organs are sensitive to teratogens during the whole pregnancy

A
  • This includes the baby’s brain and spinal cord
  • Alcohol affects the brain and spinal cord, so it can cause harm at any time during pregnancy. This is why a woman should not drink alcohol if she’s pregnant.
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22
Q

Infectious diseases in pregnancy

A
  • Common complication of pregnancy
  • May affect only the mother, only the fetus or neonate, or cause serious problems for both mother and infant
  • Infections may be acquired transplacentally, may ascend in the birth canal, or be acquired during passage through the vagina at birth.
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23
Q

TORCH

A

toxoplasmosis, other, rubella, cytomegalovirus, herpes, syphilis

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24
Q

Neonatal viral infections

A
  • Transferred transplacentally or around time of delivery
  • Infants may be initially asymptomatic, yet later develop disabling sequelae
  • Infant can present a few days after birth with:
  • Fever
  • Sepsis
  • Disseminated intravascular coagulation (DIC)
  • ARDS
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25
Q

Toxoplasmosis

A
  • Mode of transmission: transplacental, eating or handling raw meat, exposure to cat feces
  • Prevention: cook meat thouroughly, wash hands and food prep areas, avoid cat poo
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26
Q

Hep B

A
  • Transmission: Direct contact with infected blood/body fluids
  • Infants with HBsAg positive mothers are given HBIG (immune globulin) and hepatitis B vaccine within 12 hours of birth, 2 more doses within the 1st year.
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27
Q

Maternal effects of hep B

A
  • No specific treatment
  • Breastfeeding is not contraindicated unless nipples are cracked and bleeding
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28
Q

Rubella (German Measles)

A
  • Rubella antibody titer of 1:8 or more indicates immune status - reassuring
  • If woman is non-immune: should be immunized before becoming pregnant or prior to hospital discharge postpartum
  • Rubella during pregnancy is the most common cause of congential deafness
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29
Q

Herpes simplex virus (HSV)

A
  • Approx. 20% to 30% of childbearing women
  • Most do not have a hx of genital lesions
  • Neonatal HSV infection can be devastating
  • Most infections acquired during delivery or by ascendig infection
  • Postnatal infection occurs rarely
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30
Q

Maternal effects of HSV

A
  • Painful cervical, vaginal, or genital lesions
  • Virus sheds until lesions are completely healed
  • Tx: oral antiviral therapy
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31
Q

Neonatal effects of HSV

A
  • Mortality of 50-60% if neonatal exposure to active primary infection
  • Protect the neonate from exposure at delivery:
  • C-section if active genital lesion when presenting in labor
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32
Q

Group B Streptococcus (GBS)

A
  • Most common cause of neonatal infectious morbidity and mortality in the U.S.
  • Prevention approach is risk and screening based:
  • Urine culture at prenatal visit
  • Vaginal/anal culture at 35 weeks
  • If positive, treatment with penicillin starts when in labor
  • At least 2 doses before the birth can be protective for baby
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33
Q

Gonorrhea

A
  • More common in teenage population
  • Fetal & neonatal effects:
  • Premature rupture of membranes (PROM) –> Allowing for infection of fetus
  • Preterm delivery
  • Chorioamnionitis
  • Neonatal sepsis
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34
Q

Syphilis

A
  • Infection can be transmitted to the fetus at any stage of the disease
  • With untreated maternal disease, around half of pregnancies results in:
  • Miscarriage
  • Fetal death
  • Newborn death
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35
Q

HIV or AIDS

A
  • Perinatal exposure can be transplacental, intrapartum, or from breastmilk
  • Breastfeeding is contraindicated
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36
Q

Summary

A
  • Infectious disease during pregnancy can have a significant impact on maternal/fetal morbidity
  • Patient education and prompt recognition and treatment of maternal infection during pregnancy can optimize maternal neonatal outcomes
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37
Q

Initial evaluation in labor

A
  • Presenting complaint: Contractions, bleeding, headache
  • EDD/EDC
  • Pregnancy hist
  • frequency, duration, and intensity of contractions
  • Membrane status
  • prescence/absence of bleeding
  • Cervical status
  • Thoroughly review prenatal record - blood type, platlets, etc
  • Any complications of pregnancy
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38
Q

Cues that warrant closer focus

A
  • Bleeding
    -Post dates (more than 40 weeks gestation)
  • Fever, HTN (MAY BE ON QUIZ)
  • Hist of genital herpes and current sx
  • Ruptured membranes (GBS)
  • Advanced cervical dilation
  • FHR minimal variability or deceleration
  • Large or small for gestational age
  • Previous complications
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39
Q

Performing leopolds manuevers

A
  • May be on NCLEX
  • Determine fetal lie: up and down, or across (transverse lie)
  • Presentation: head or buttocks, shoulder, face, brow coming first?
  • Position: Engaged in the pelvis or not
  • Assists in determining best site for FHR auscultation
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40
Q

Performing a vaginal exam with sterile gloves, assess cervix for:

A
  • Dilation: how open is the cervix?
  • Effacement: How thin is the cervix?
  • Station: How low is the presenting part?
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41
Q

Effacement: How thin is the cervix?

A
  • Effacement: The gradual thinning, shortening and drawing up of the cervix measured in percentages from 0 - 100%
42
Q

Fetal station - How low is the presenting part?

A
  • station = relationship of presenting part to the ischial spines “Will the bby fit through the pelvis?”
  • Likely will have a question about this on NCLEX
43
Q

Station = Minus 1 or Minus 2,3,4,5, means:

A

Presenting part is above zero station and higher than the ischial spines

44
Q

Plus 1 or pluse 2,3,4,5, means

A
  • Presenting part has descended lower than the ischial spine
  • Positive (+) is at the outlet
45
Q

Stage 1 of labor

A
  • pre-labor
  • phase 1: latent behavior
  • phase 2: active labor
  • Phase 3: transition
46
Q

2nd stage

A

pushing

47
Q

3rd stage

A

birth + placenta

48
Q

Hormonal theories of labor

A
  • Progesterone inhibits uterine contraction
  • Labor begins when progesterone’s inhibition is overcome by an increase in the levels of estrogen
49
Q

Positive feedback loop responsible for progression of labor

A
  • Uterine contractions…
  • Push fetus against cervix (stretch)
  • Oxytocin secreted through neuroendocrine reflex
  • Prostaglandin produced
50
Q

Labor pain is unique

A

its the only pain that does not indicate something is going wrong

51
Q

True vs false labor

A
  • flase labor produces pain at irregular intervals (braxton hicks) but there is no cervical dilation
  • True labor begins when contractions occur at regular intervals and there is cervical change:
52
Q

Description of pain from contractions

A
  • tight metal belt from back around to below uterus
  • Heat and tightness with each contraction
  • Back pain increases with walking
  • Dilation of cervix with a discharge of blood containing mucus in the cervical canal
53
Q

Five P’s of labor

A
  • Power
  • passenger
  • Passageway
  • Position
  • Psychology
54
Q

Bedside nurse

A
  • Support maternal and family birth plan
  • Monitor, assess, intervene, educate
  • Provide safe environment
55
Q

Power: uterine contractions

A
  • Duration
  • Frequency
  • Intensity (palpation): Mild = nose, moderate = chin, strong = forehead
  • Resting tone: soft or firm
56
Q

Timing contractions

A

beginning of one to the beginning of the other

57
Q

Tachysystole (probably on NCLEX)

A
  • Too many contractions. More than 5 contractions in 10 minutes (closer than 2 min apart) for 30 minutes
  • Has to be stopped
58
Q

Passenger (fetus)

A
  • Fetal descent through the birth canal is determined by:
  • Size of fetal head
  • Fetal lie
  • Fetal presentation
  • Fetal attitude
  • fetal position
  • Leopolds
  • We want baby facing the moms spine (we don’t want bone to none)
  • We want baby to be “flexed”
59
Q

Fetal lie (may be on NCLEX)

A
  • Relationship of long axis (spine) of the fetus too long axis of the mother
  • Two primary lies:
  • Longitudinal
  • Transverse or oblique
60
Q

Attitude

A

Flexion of the head toward the chest

61
Q

Fetal presentation

A
  • Determined by the portion of the fetus that first enters the pelvic inlet:
  • Cephalic
  • Breech
  • Shoulder
  • Compound
62
Q

Picture of face presentation

A

May have brusing and swelling

63
Q

Labor

A
  • Regular frequent contractions, leading to progressive cervical effacement and dilation
  • Labor dx usually made in retrospect
  • Avg. 1st labor is 15 hours from 4 cm dilation
64
Q

Active phase labor

A
  • at least 4 cm dilated
  • Regular, frequent, usually painful contractions
  • Dilate at least 1.2-1.5 cm/hr
  • Are not comfortable with talking or laughing during their contractions
65
Q

1st stage of labor (3-10 cm) nursing care

A
  • when in bed, side lying or semi-fowlers position only
  • Contractions: frequency, intensity, duration
  • Fetal heart tones: variability, baseline rate, decels or acels.
66
Q

SROM, AROM

A
  • SROM = Spontaneous rupture of membranes
  • AROM = Artificial rupture of membranes
  • Ruptured membranes increase risk of infection
  • Spontaneous rupture of membranes occurs at the height of the contraction with a gush of fluid out of vagina
  • Artificial rupture of membranes called amniotomy
  • Monitor throughout AROM and for 30 min afterwards to confirm no prolapse
67
Q

1st stage nursing care cont.

A
  • Maternal vital signs
  • Fetal heart rate
  • Subsequent vaginal examinations:
  • No standard, approx q 2 hours unless ruptured
  • Assess fetal descent and cervical change
68
Q

What is the fetus doing during labor?

A
  • Cardinal movements of labor
  • Engagement (0 station)
  • Descent (continous)
  • Flexion
  • Internal rotation
  • Extension
  • External rotation
  • Expulsion
69
Q

(Slide 80) LOA is the best position

A
  • L = left side of mom
  • O = occiput is reference point
  • A = Anterior facing occiput
70
Q

What does coping look like? Active labor

A
  • Relaxation between contractions
  • Rhythmic activity-rocking ___
71
Q

When does she need help?

A
  • Early labor: Tensing at peak of contraction
  • __ _
72
Q

Pain relief

A

___

73
Q

Supportive care

A
  • Your presence!
  • Counter-stimulation:
74
Q

Nitrous oxide

A
75
Q

Pharmacological pain relief

A
  • IV analgesia: systemic
  • ___
76
Q

Nursing considerations for labor

A
  • Assess womans___
77
Q

Epidural analgesia

A
78
Q

Nursing care after placement

A
  • Position patient in semi-reclining position with lateral tilt
    ___
79
Q

Side effects of epidural

A
  • Hypotension
  • Itching: give Naloxone (Narcan)
  • ___
80
Q

Contraindications (may be in NCLEX)

A
81
Q

2nd stage of labor (10 cm to delivery) Pushing stage

A
  • Cues: FHR variables, increase in vaginal show, suprapubic pain if epidural present, grunting if no epidural, “Im going to poop!”
  • Actions______
82
Q

Coach pushing

A
  • Midwives might suggest open glottis pushing
  • ____
83
Q

Document

A
84
Q

After the birth

A
85
Q

Delivery of placenta

A
86
Q

“Assisted delivery” “instrumented delivery” “Operative delivery”

A
  • All mean use of vacuum extractor or Forceps
87
Q

Forceps pros and cons

A
  • Pros: more likely to achieve vaginal birth, less likely to cause cephalohematoma
  • Cons: increased risk of anal sphincter injury _____
88
Q

Vacuums pros and cons

A
89
Q

Recovery time

A

In first hour of life, babies can crawl and self attach to breast

90
Q

Slide 99

A
91
Q

Prolapsed cord

A
  • About 1 in every 300 births
    -Umbilical cord slips out thorugh the vagina before the babyy when the bag of waters breaks and head is not engaged
  • Potentially fatal complication
92
Q

Risk factors

A
  • Multiples
  • Preterm labor
  • Low birth weight
  • Breech presentation
  • transverse lie
  • Ruptured membranes with unengaged fetal head
93
Q

What if the baby is “stuck” (shoulder dystocia)

A
  • One or both of the baby’s shoulders may get stuck behind the pubic bone during childbirth
  • _____
94
Q

Risk factors include:

A
95
Q

Nursing interventions for shoulder dystocia (Likely will be on NCLEX)

A
  • Lower mom’s head
  • Mcrobert’s maneuver:
  • At least two people
  • Flex mom’s knees and hips toward her chest
  • perform supra pubic pressure side ways or up and down pressure jusst above pubic bone to rotate fetus
  • Never pres on uterine fundus
96
Q

Old midwives’ trick

A

Turn patient on all fours in crawling position

97
Q

Be prepared

A
  • Discuss Mcrobert’s and suprapubic pressure with mom well in advance of delivery
  • Have stool at bedside
  • Know where the bab’s back is, if possible
  • Stool already to go
98
Q

Common reasons for c/s

A
  • Multiples
  • Breech presentation
  • Previous uterine surgery
    ____
99
Q

C-section Recovery

A
  • About 2 hours
  • Mom may breastfeed
100
Q

TOLAC

A

A trial of labor for vaginal birth. Trying vaginal birth after she has previously had a c-section.

101
Q

VBAC

A

Essentially that the TOLAC was successful. The mom delivered vaginally after she had had a c-section before

102
Q

C-section recovery

A
  • About 2 hours
  • Mom may breastfeed
  • Fundal checks just as for vaginal birth
  • ____

Family NRSG (8 decks)

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