Week 4: Routine Prenatal Care and Infections (L&D) Flashcards
Prenatal care: EDC & EDD
- EDC = estimated date of confinement
- EDD = estimated date of delivery
Prenatal history includes
- Obstetric history
- Due date for this pregnancy
- Monthly/weekly prenatal visits
- Lab values
- Maternal medical history
- Ultrasound results
- Etc
TPAL –> WILL BE ON QUIZ
T = Term birth
P = Preterm births
A = Abortions (spontaneous & therapeutic)
L = Living children
Gravida
Number of pregnancies
Parady
Number of gestational viable births
Woman pregnant with 4th baby, two children born at term and living, one miscarriage, is:
- G2 P4
- T2 P0 A1 L2
Cues for risks (MAY SEE IN QUIZ)
- High B/P
- Hist of previous postpartum hemorrhage
- Hist of previous shoulder dystocia
- Rh negative
- Gestational diabetes
- More than 5 previous births
Risk factors with STDs
- increased risk of preterm labor and preterm birth
- Premature rupture of membranes with risk for infection
Routine prenatal lab testing (review)
- 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
additional prenatal lab testing (review)
- Not all at first prenatal visit: fetal fibronectin, herpes culture, blood glucose studies, Toxicology screening, TB testing, TORCH titers
Risk factors for group B strep
- 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
Increased risk for diabetic mothers
- Pyelonephritis
- Ketoacidosis
- Preeclampsia
Increased risks for the infants of diabetic mothers
- Macrosomia
- Birth trauma
- congenital anomalies
- Resp. distress syndrome (ARDS)
- Hypoglycemia
- Hyperbilirubinemia
- Fetal malformations
- Fetal demise
Meds during pregnancy
- The classification system for medications during pregnancy has five categories
- “Do the risks outweigh the benefits?”
- Table on slide 22
Cues for maternal substance abuse
- Med hist: cellulitis, hepatitis, Depression/suicide attempt, STDs/HIV/AIDs
- Placental abruption, unexplained fetal death, Spontaneous abortion, preterm labor/birth, LBW
Domestic violence
- 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
Cues of IPV in pregnancy
- Unplanned pregnancy
- Delayed or no prenatal care
- STDs
- Bleeding, miscarriage
- Fetal injury, fetal demise
- PTL, low birth weight
- Depression, substance abuse
Cues for abuse
- 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?”
Teratogens
- 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
When do teratogens affect the fetus?
- 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
Some organs are sensitive to teratogens during the whole pregnancy
- 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.
Infectious diseases in pregnancy
- 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.
TORCH
toxoplasmosis, other, rubella, cytomegalovirus, herpes, syphilis
Neonatal viral infections
- 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
Toxoplasmosis
- 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
Hep B
- 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.
Maternal effects of hep B
- No specific treatment
- Breastfeeding is not contraindicated unless nipples are cracked and bleeding
Rubella (German Measles)
- 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
Herpes simplex virus (HSV)
- 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
Maternal effects of HSV
- Painful cervical, vaginal, or genital lesions
- Virus sheds until lesions are completely healed
- Tx: oral antiviral therapy
Neonatal effects of HSV
- 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
Group B Streptococcus (GBS)
- 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
Gonorrhea
- More common in teenage population
- Fetal & neonatal effects:
- Premature rupture of membranes (PROM) –> Allowing for infection of fetus
- Preterm delivery
- Chorioamnionitis
- Neonatal sepsis
Syphilis
- 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
HIV or AIDS
- Perinatal exposure can be transplacental, intrapartum, or from breastmilk
- Breastfeeding is contraindicated
Summary
- 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
Initial evaluation in labor
- 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
Cues that warrant closer focus
- 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
Performing leopolds manuevers
- 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
Performing a vaginal exam with sterile gloves, assess cervix for:
- Dilation: how open is the cervix?
- Effacement: How thin is the cervix?
- Station: How low is the presenting part?
Effacement: How thin is the cervix?
- Effacement: The gradual thinning, shortening and drawing up of the cervix measured in percentages from 0 - 100%
Fetal station - How low is the presenting part?
- 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
Station = Minus 1 or Minus 2,3,4,5, means:
Presenting part is above zero station and higher than the ischial spines
Plus 1 or pluse 2,3,4,5, means
- Presenting part has descended lower than the ischial spine
- Positive (+) is at the outlet
Stage 1 of labor
- pre-labor
- phase 1: latent behavior
- phase 2: active labor
- Phase 3: transition
2nd stage
pushing
3rd stage
birth + placenta
Hormonal theories of labor
- Progesterone inhibits uterine contraction
- Labor begins when progesterone’s inhibition is overcome by an increase in the levels of estrogen
Positive feedback loop responsible for progression of labor
- Uterine contractions…
- Push fetus against cervix (stretch)
- Oxytocin secreted through neuroendocrine reflex
- Prostaglandin produced
Labor pain is unique
its the only pain that does not indicate something is going wrong
True vs false labor
- 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:
Description of pain from contractions
- 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
Five P’s of labor
- Power
- passenger
- Passageway
- Position
- Psychology
Bedside nurse
- Support maternal and family birth plan
- Monitor, assess, intervene, educate
- Provide safe environment
Power: uterine contractions
- Duration
- Frequency
- Intensity (palpation): Mild = nose, moderate = chin, strong = forehead
- Resting tone: soft or firm
Timing contractions
beginning of one to the beginning of the other
Tachysystole (probably on NCLEX)
- Too many contractions. More than 5 contractions in 10 minutes (closer than 2 min apart) for 30 minutes
- Has to be stopped
Passenger (fetus)
- 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”
Fetal lie (may be on NCLEX)
- Relationship of long axis (spine) of the fetus too long axis of the mother
- Two primary lies:
- Longitudinal
- Transverse or oblique
Attitude
Flexion of the head toward the chest
Fetal presentation
- Determined by the portion of the fetus that first enters the pelvic inlet:
- Cephalic
- Breech
- Shoulder
- Compound
Picture of face presentation
May have brusing and swelling
Labor
- 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
Active phase labor
- 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
1st stage of labor (3-10 cm) nursing care
- when in bed, side lying or semi-fowlers position only
- Contractions: frequency, intensity, duration
- Fetal heart tones: variability, baseline rate, decels or acels.
SROM, AROM
- 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
1st stage nursing care cont.
- Maternal vital signs
- Fetal heart rate
- Subsequent vaginal examinations:
- No standard, approx q 2 hours unless ruptured
- Assess fetal descent and cervical change
What is the fetus doing during labor?
- Cardinal movements of labor
- Engagement (0 station)
- Descent (continous)
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
(Slide 80) LOA is the best position
- L = left side of mom
- O = occiput is reference point
- A = Anterior facing occiput
What does coping look like? Active labor
- Relaxation between contractions
- Rhythmic activity-rocking ___
When does she need help?
- Early labor: Tensing at peak of contraction
- __ _
Pain relief
___
Supportive care
- Your presence!
- Counter-stimulation:
Nitrous oxide
Pharmacological pain relief
- IV analgesia: systemic
- ___
Nursing considerations for labor
- Assess womans___
Epidural analgesia
Nursing care after placement
- Position patient in semi-reclining position with lateral tilt
___
Side effects of epidural
- Hypotension
- Itching: give Naloxone (Narcan)
- ___
Contraindications (may be in NCLEX)
2nd stage of labor (10 cm to delivery) Pushing stage
- Cues: FHR variables, increase in vaginal show, suprapubic pain if epidural present, grunting if no epidural, “Im going to poop!”
- Actions______
Coach pushing
- Midwives might suggest open glottis pushing
- ____
Document
After the birth
Delivery of placenta
“Assisted delivery” “instrumented delivery” “Operative delivery”
- All mean use of vacuum extractor or Forceps
Forceps pros and cons
- Pros: more likely to achieve vaginal birth, less likely to cause cephalohematoma
- Cons: increased risk of anal sphincter injury _____
Vacuums pros and cons
Recovery time
In first hour of life, babies can crawl and self attach to breast
Slide 99
Prolapsed cord
- 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
Risk factors
- Multiples
- Preterm labor
- Low birth weight
- Breech presentation
- transverse lie
- Ruptured membranes with unengaged fetal head
What if the baby is “stuck” (shoulder dystocia)
- One or both of the baby’s shoulders may get stuck behind the pubic bone during childbirth
- _____
Risk factors include:
Nursing interventions for shoulder dystocia (Likely will be on NCLEX)
- 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
Old midwives’ trick
Turn patient on all fours in crawling position
Be prepared
- 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
Common reasons for c/s
- Multiples
- Breech presentation
- Previous uterine surgery
____
C-section Recovery
- About 2 hours
- Mom may breastfeed
TOLAC
A trial of labor for vaginal birth. Trying vaginal birth after she has previously had a c-section.
VBAC
Essentially that the TOLAC was successful. The mom delivered vaginally after she had had a c-section before
C-section recovery
- About 2 hours
- Mom may breastfeed
- Fundal checks just as for vaginal birth
- ____
