2202 Ante and Intrapartum

Major causes of maternal death

*HTN disorders (preeclampsia), infection, hemorrhage (DIC/Abruptio placenta) - factors related to maternal death - under age 20 and over age 35 - lack of prenatal care - African American race 3x's higher - unmarried status - low educational attainment

interventions for seizures

*Protecting the woman and fetus* Remain with the woman. During the tonic phase, turn the woman on her side. Note the time and sequence of the convulsion. monitor for pounding HA & epigastric pain - can proceed seizure After the seizure, maintain the airway. Suction the woman's mouth and nose. Administer oxygen. Observe fetal monitor patterns for signs of hypoxia. mag sulfate - want to see a long record of safety and a serum level of 4-8

assessing pitting edema

+1 minimal edema of lower extremities +2 marked edema lower extremities +3 evident in the face, hands, lower extremities, and sacrum +4 generalized massive (anasarca) evident with ascites

low levels of MSAFP indicate

- chromosomal trisomies (downs syndrome) - gestational trophoblastic disease - normal fetuses with: overestimation of gestational age, incorrect maternal weight (higher than true weight)

disseminated intravascular coagulation (DIC)

- complex disorder of clotting mechanisms in blood - consumption of clotting factors that can lead to overwhelming and diffuse hemorrhage - oozing from puncture sites or development of petechiae may be initial clues of coagulopathy - hematuria - can contribute to renal failure predisposing factors: PIH, amniotic fluid embolism, sepsis, abruption, prolonged intrauterine fetal demise, excessive blood loss (any areas such as IV site, gums, nose, etc) tx - deliver of the fetus and placenta to stop production of thromboplastin

leading cause of neonate death

- congenital abnormalities - disorders r/t preterm birth and low birth weight - SIDS (highest risk at 4 mos) - RDS (respiratory distress syndrome) - effects of maternal complications

S/Sx of cocaine use in the pregnant mother

- diaphoresis, HTN, tachycardia, irregular respirations - dilated pupils, increased body temperature - sudden onset of severely painful contractions - fetal tachycardia, excessive fetal activity - angry, caustic, abusive reactions; paranoia

MRI

- does not need amniotic fluid to visualize the fetus - used to dx ectopic pregnancy or possible rupture - def of size of pregnant uterus et position of placenta; perfusion, or infarction

monitoring for s/s of hypovolemic shock

- increased pulse rate, falling b/p, increased RR - weak, diminished, or "thready" peripheral pulses - cool, moist skin, pallor, or cyanosis (late sign) - decreased urine output, hgb, hct - change in mental status interventions: insert 2 large bore IV's or central line, obtain order for blood type/screen or cross-matching, administer replacement fluids, maintain urinary output at least 30mL *may need emergency c-section

abortion

- loss of pregnancy before the fetus is viable (before living outside of the uterus). if fetus is less than 20 wks of gestation or weighing less than 500 g then it is considered not viable - characterized: spontaneous (termination of pregnancy without action taken by the woman or any other person or a miscarriage) or induced (elective termination of pregnancy) may feel frightened, guilt, anger, disappointment, grief (6mos - 1 yr+), these are manifested in restlessness, malaise, insomnia, general feeling of dissatisfaction. first sign of threated abortion/miscarriage is persistent bleeding, back pain, miscarriage is inevitable and cannot be stopped. DNC or methergine

common indications for 2nd trimester amniocentesis

- maternal age 35 yrs or older - chromosomal abnormality in close family member - sex determination for maternal carrier of x-linked disorder (hemophilia, Duchenne's muscular dystrophy) - birth of previous infant w/chromosomal abnormality or neural tube/body wall defect - pregnancy after multiple spontaneous abortions - elevated levels of maternal serum alpha-fetoprotein -maternal Rh sensitization of maternal Rh - blood to fetal Rh + blood. Indirect coombs test is an antibody titer that indicated maternal Rh sensitization

amniocentesis risks

- maternal hemorrhage - infection - Rh isoimmunization - abruptio placentae - amniotic fluid emboli - premature rupture of membranes

increased MSAFP levels indicate

- open neural tube defects (anencephaly, spina bifida) - esophageal obstruction - abd wall defects - inc amt leaked by fetal kidney (hydronephrosis) - threated AB - fetal demise - normal fetus in conjunction w/other factors

Alpha-fetoprotein (AFP)

- performed on maternal serum or amniotic fluid to identify: open body wall defects, chromosomal anomalies - 3 other markers are also assessed: human chorionic gonadotropin (HcG), estriol, inhibin A AFP is produced by the fetal liver - MSAFP is the only screening tool - offered between 16 - 18 weeks gestation if results are abnormal they recommend an US to be completed

hyperemesis gravidarum

- persistent, uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout interventions: - client may need hospitalization w/ IVF therapy with glucose, elec, and vitamins (continued at home) - daily wt and I&O - VS - hydration and nutritional status - antiemetic meds as ordered - 6 small meals/day after acute n/v has passed - might need to take vitamin before bedtime - TPN in severe cases when unable to tolerate oral feedings - monitor fetal growth with serial US - emotional support

Behaviors r/t substance abuse in the pregnant mother

- seeking prenatal care late in pregnancy - failure to keep prenatal appointments - inconsistent follow-through with recommended care - poor grooming, inadequate weight gain - needle puncture, thrombosed veins, cellulitis - defensive or hostile reactions - anger or apathy regarding pregnancy - severe mood swings

Maternal Assessment of Fetal Movement

-Movements by the fetus are assessed by the mother. -They are often called "kick counts." -Several methods for the mother to count -At least 10 fetal movements within 12 hours -Count 2-3x per day to identify whether the fetus has at least 3 movements in 60 minutes

gestational trophoblastic disease (hydatidiform mole)

-occurs when the peripheral cells that attach to the fertilized ovum to the uterine wall develop abnormally - the placenta grows but not the fetus - most moler pregnancies are detected early and can include vag bleeding, dark brown (like prune juice) or profuse bleeding, may contain grape-like vesicles - unusual uterine growth by fundal height: no fetal parts can be palpated, no FHT are heart, a snowstorm pattern seen on the US - excessive n/v poss r/t high beta hCG levels, early development (before 24 wks) of preeclampsia

4 categories of HTN in pregnancy

1-Chronic HTN 2-Preeclampsia and Eclampsia (with seizure) 3-Preeclampsia superimposed on chronic HTN 4-gestational HTN (later half of pregnancy)

Pregnancy complications

16 years or less and 35 years and older have higher risk of complications

risk factors for pregnancy r/t to HTN

1st pregnancy, 1st pregnancy for FOB, men who have fathered one preeclamptic pregnancy, age over 35, anemia, family or personal hx of preeclampsia, chronic HTN or preexisting vascular disease, chronic renal disease, obesity, DM, antiphospholipid syndrome, multifetal pregnancy, pregnancy from assisted retrodictive techniques, can have damage to the heart valves so may have problems later

stages of labor

1st: dilating stage 3 phases: Latent (0-3cm) Active (4-7cm) Traditional (8-10cm w/ urge to push) 2nd stage: delivery 3rd: placental delivery 4th: recovery- primary goal to prevent hemorrhage from uterine atony, 1st void within 1 hour and then q2-3 hrs, Rhogam

Biophysical Profile (BPP)

A test that assess five variables; total body movement, fetal muscle tone, FHR, fetal breathing movement, amniotic fluid volume (AFV) *BPP total score is 0-10 - abnormal - 0 and normal - 2 in each of the five categories - total of 8-10 = normal - total of 4-6 = possibly normal (get additional testing such as an amnio) - <4 = might need to deliver

Complications from substance abuse

Alcohol - Fetal Alcohol Syndrome, spontaneous abortion/abruption placentae Tobacco - vasoconstrictor, causes decreased perfusion Marijuana - decreases O2 to fetus Cocaine - abruption placentae, spontaneous abortion, placenta previa and pre-eclampsia Amphetamines - HTN, tachycardia, vasoconstriction Opioids - appetite suppressant Teratogen - NO SAFE AMOUNT

precipitate labor

An intense, unusually short labor (less than 3 hours). - occurs at a slightly higher rate in women ages 35-54 and lower rate younger than 20 - there is often an abrupt onset of intense contractions rather than the more gradual increase in frequency, duration, and intensity that typifies most spontaneous labors conditions associated with precipitous labor: abruptio placenta, fetal meconium, maternal cocaine use, postpartum hemorrhage, low Apgar scores for the infant promote O2 - laying side to side - if on oxytocin = shut it off

Late decelerations

BAD - caused by uteroplacental insufficiency - impaired O2 exchange, begin AFTER the peak of the contraction and return to baseline after contraction ends. NOT REASSURING. Late decels look similar to early decels but shifted to the right. NI required to improve placental blood flow and fetal O2 supply. can be caused by contractions being too close (tachysystole). baby doesn't have enough time to recover

Variable decelerations

BAD! conditions that reduce flow through the umbilical cord. they are not uniform in appearance and occur unrelated to contractions. their shape, duration, and degree of fall below baseline and are variable. they rise and fall abruptly and within 30 sec. NI: reposition the mother, vaginal check for prolapsed cord

accelerations

Brief, temporary increases in FHR of at least 15 beats more than baseline and lasting at least 15 second- (same parameters as Nonstress Test) good! associated with fetal movement and fetal well being may also occur: w/vag examination, during uterine contractions, mild cord compression, breech presentation

prep for c-section

CBC - clotting studies - epidural or spinal-epidural - fetal surveillance - prophylactic IV ATB - "bikini" incision - indwelling catheter - sterile abd prep - general anesthesia

Class I heart disease - physical activity not restricted (uncompromised), asymptomatic Class II - slightly compromised, fatigue, palpitations, dyspnea, angina with normal physical activity slightly limited Class I & II - potential for good pregnancy outcome

Class III - markedly compromised, excessive fatigue, palpitations, dyspnea, anginal pain, physical activity markedly restricted, prophylactic anticoagulation may be needed Class IV - unable to perform any physical activity w/o discomfort Class III & IV - risk for serious maternal and fetal compromise. Key is for them to get plenty of rest

interventions for hemorrhage

Early administration of oxytocin is recommended for all births as a prophylaxis against postpartum hemorrhage -IV infusion of dilute oxytocin (NOT IV PUSH) should be given during the third stage of labor. Oxytocin may also be administered IM. if the uterus is not firmly contracted despite preventative measures, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. One hand is placed just above the symphysis pubis to support the lower uterine segment while the other hand gently but firmly massages the fundus in a circular motion if uterus is contracted and they continue to bleed they may have a different laceration that needs to be fixed

umbilical cord prolapse

Emergency!! - associated with high fetal mortality rate. Most commonly occurs when amniotic membranes rupture before fetal descent - risk factors: transverse lie, breech presentation, small baby, fetal presenting part is at a high station, excessive volume of amniotic fluid (hydramnios) - cord compression results in hypoxia to baby - can lead to CNS damage or even death with occlusion of blood flow for more than 5 min *interventions: immediately after ROM check for FHR and S/S of prolapsed cord, place client in a position that will shift weight of the cord (knee-chest, Trendelenburg, or side lying with hips elevated - NO PRESSURE ON BABY), give O2 8-10 L, IV fluids to enhance fluid volume and circulation, notify MD, do not attempt to push cord back into vagina, cover cord with sterile towels moistened with warm sterile saline to prevent cord from drying out

mild preeclamsia

HTN - s>140 but <160 and d>90 but <110 proteinura - >0.3 but <2 creatinine, platelets, liver enzymes, urine output = normal activity restrictions, monitoring of fetal activity, b/p monitoring, weight measurement, urinalysis for protein (t2 can be seen in preeclamtic pt) diet w/o salt, fetal surveillance lie down at least 1.5hr per day in side lying position, keep fetal activity kick count, report decreased movement in 4hr period, b/p 2-4x/day on dame arm in same position, weight daily at the same time and similar clothing, check urine for proteinuria using first voided specimen - should be done daily, fluid restriction tx - delivery

gestational HTN

HTN disorder that begins during pregnancy, pt is previously normotensive, increase in b/p AFTER 20 weeks W/O proteinuria, b/p usually DOESN'T exceed 140/90, returns to normal w/in 10 days after delivery. If it persists more than 6 wks after birth, then it is considered chronic HTN. may see higher b/p in 3rd trimester - risk factors: parity, primigravida, 1st preg after abortion, family hx, multiple gestations, 6x greater if twin preg, trophoblastic disease (onset of PIH before 20 wks suggests hydatidiform mole), DM

Group B strep

Leading cause of life-threatening perinatal infections in US - causes an increased risk for preterm labor and transmission to the newborn in a pregnant woman. Woman must be screened at 35-37wks via vag/rectal culture - bacterium colonizes the rectum, vagina, cervix, and urethra of pregnant and nonpregnant women - associated with PROM and preterm birth - can be transmitted to newborn and cause life-threatening illness - tx with ATB (ampicillin) during labor x 2 doses

common predisposing factors of PPH

Over distention of the uterus (multiple gestation, large infant, hydramnios), multiparity (5+), precipitate labor or birth, use of forceps or vacuum extractor, cesarean birth, manual removal of placenta, uterine inversion, placenta previa, placenta accreta (or low implantation), drugs (oxytocin, prostaglandins, tocolytics, or mag sulfate), general anesthesia, chorioamnionitis, clotting disorders, previous postpartum hemorrhage or uterine surgery, disseminated intravascular coagulation (DIC), uterine leiomyomas (fibroids) 1500-2000m loss is not normal - may need blood

Lecithin/sphingomyelin ratio (L/S Ratio)

Ratio of two phospholipids in amniotic fluid used to determine fetal lung maturity; ratio of 2:1 or greater usually indicates fetal lung maturity. * lungs are matured by 36 weeks and free of resp difficulty and can be delivered * pt is in a supine position and a towel rolled up under one buttock. Use maternal b/p and FHR and ultrasound to locate fetus and placenta. pt might feel mild cramping

vaginal birth after cesarean (VBAC)

VBAC births have fewer complication than c-sections but is not without risk. The mother could ultimately end up with a cesarean delivery, therefore a physician must be available for c-section if necessary. Due to experience with electronic fetal monitoring normal fetal responses to labor are now known this allows interventions for fetal benefit so that vaginal births may proceed, and ultimately the avoidance of cesarean births. VBAC carries small, but significant risk of uterine rupture that is increased by the number of prior uterine incisions, and previous c-sections performed for differing reasons. 2 prior incisions or fewer is recommended. there must be no previous uterine scarring the pelvis size must be able to accommodate the fetus for a successful VBAC as with c-section deliveries epidural analgesia and/or anesthesia may be used as with c-section the woman must be NPO/clear ice chips prior to the VBAC in case it evolves into a cesarean

hemorrhagic disorders in pregnancy

abortion, ectopic pregnancy, general trophoblastic disease (hydatidiform mole), abruptio placenta, placenta previa, disseminated intravascular coagulation (DIC)

rheumatic heart disease

after strep, scarring of valves causing stenosis

contraction stress test (CST)

also known as the oxytocin challenge test - used to determine how the fetal heart responds to uterine contractions that temporarily decrease placental blood flow - negative is reassuring and positive is nonreasoning - equivocal is suspicious could be from hyperstimulation

heart disease drug therapy

anticoagulants - heparin/lovenox - no warfarin antidysrhythmic anti-infectives drugs for HF: diuretics (furosamide/thiazide), beta blockers, ace inhibiters, dig may be beneficial - all carry risk but so does maternal heart failure

Diabetes screening

approx 28 wks. GCT fasting not necessary 50 g of oral glucose is ingested, 1 hr later the blood sample is taken, if greater than 104 then a 3hr oral glucose is needed

fetal monitoring

average HR between contractions, measures in bpm normal range 110-160 bradycardia <110 tachycardia >160

severe preeclampsia

b/p 160/110 or greater 2 readings 6hr apart proteinuria >5 in 24hr specimen or higher (3+ or higher on random dipstick) - check for weight gain and edema increased creatinine (>1.2) and liver enzymes decreased platelets HA, visual disturbances, oliguria less than 500cc/day, fetal growth restriction, persistent right upper quadrant or epigastric pain management: hospitilization, bedrest, anticonvulsant (mag sulfate) to prevent seizures, antihypertensives (hydralazine (apresoline) or nifedipine/lobetalol) risk for seizures, stroke, early induction, and abrupta placenta

premature ROM

before onset of labor - and preterm of PROM is before 37 weeks

contraction

beginning of one contraction to the start of the next contraction

beyond childbearing years

c-section delivery (more clotting chances), very premature infant, may be high risk for mother for more than one reason (being pregnant causes 45% increase blood plasma volume which could lead to HTN, DM, obesity, heart disease), any high risk condition affects the entire family, not just the client

Postpartum Complications

can happen quickly after delivery Signs of postpartum hemorrhage: a uterus that does not contract or does not remain contracted, large gush or slow/steady trickle/ooze or dribble of blood from the vagina, saturation of one peripad/15 min, severe/unrelieved perineal or rectal pain, tachycardia if uterus is boggy, you want it to be contracted. do not want the uterus to have atony. give methylergonovine (methergine) and massage w/ every VS taken

syphilis

cause - treponema pallidum (motile spirocete) transmission: through microscopic abrasions in subq tissue dx: micro exam of primary and secondary lesion tissue maternal effects: acute stage (chancre on skin), secondary stage (lymphadenopathy & rash on palms and soles), latent stage ( up to 5 yrs asymptomatic)

Rubella (German Measles or 3-day measles)

cause: rubella virus transmission: droplet dx: IgG antibodies to rubella maternal effects: fever, rash, mild lymphedema, maculopapular rash on face and spreads to the body fetal/neonatal effects: greatest risk in 1st trimester when organs are developing, hearing loss, intellectual disability, cataracts, cardiac defects, growth restriction, microcephaly MMR live virus - dont get pregnant for 28 days after vaccine and 2 shots

Substance abuse

causes the most harm in the 1st trimester

Hep A

contaminated food or water transmission: droplets or hands (fecal/oral) Dx: radioimmunoassay and enzyme-linked immunosorbent assay maternal effects: miscarriage, fever, malaise, nausea, abd discomfort, liver failure fetal/neonatal effects: fetal anomalies, preterm birth, hepatitis infection, fetal demise

tachysyst

contraction duration longer than 90-120 sec - contractions <2 min apart or relaxation of <30 sec between contractions - uterine resting tone >20 mmHg or peak pressure >90 mmHg during the first stage (with intrauterine pressure catheter) - montevideo units >400 - an FHR patter of late decls accompanying hypertonic underline activity intervention: reduce/stop the oxytocin infusion, increase rate of the nonadditive infusion (usu LR), keep the laboring patient in lateral position, give O2 by snug facemask (8-10 L) notify the MD

S/S of congestive HF

cough (frequent, productive, hemoptysis), progressive dyspnea w/ exertion, orthopnea, pitting edema of legs et feet or generalized edema of face, hands, or sacral area, palpitations, progressive fatigue or syncope w/ exertion, moist rales in lower lobes indicating pulmonary edema

Infections during pregnancy

cytomegalovirus, rubella, varicella-zoster, herpes virus, parvovirus, hepatitis B

Antepartum Fetal Surveillance

determines fetal health or compromise, to guide interventions to reduce perinatal morbidity 3 methods: non-stress test (NST), contraction stress test (CST), and biophysical profile (BPP)

chronic hypertension

dx before 20 wks or if HTN preceeded pregnancy, often seen in older obese women or those with DM. monitor closely for proteinuria and edema. antihypertensive meds given if diastolic b/p is higher than 100 mg consistently (methyldopa - aldomet is drug of choice) ACE inhibitors are contraindicated (pril)

reasons for a c-section

dystocia - prolonged labor - cephalopelvic (fetopelvic) disproportion -HTN if prompt delivery is necessary - maternal diseases such as DM, heart disease or cervical cancer, if labor is not advisable - active genital herpes at the time of birth - some previous uterine surgical procedures such as classic c-section incision - persistent non-reassuring FHR patterns - a prolapsed umbilical cord - fetal malpresentations such as breech or transverse lie - hemorrhagic conditions such as abruptio placentae or placenta previa contraindications: few contraindications only when it is not desirable because the risks to the fetus are too great including - fetal death, fetus that is too high or immature to survive & maternal coagulation defects

chorioamnionitis

early S/S: non-specific - fever, tachycardia later S/S: uterine tenderness, foul smelling drainage - when membranes rupture, amniotic fluid is cloudy and foul smelling - can lead to preterm birth - tx: delivery of infant, IV ATB, C-section only if infant is stressed - fetal risks: confenital pneumonia, sepsis, and meningitis

Diabetes Mellitus in pregnancy

early pregnancy - metabolic rates change so watch for hypoglycemia late pregnancy - rise in placental hormones and may lead to hyperglycemia 1st trimester - decrease in insulin required r/t secretion of placental hormones and n/v 2nd/3rd trimester - insulin needs increase markedly during labor - maintenance of tight maternal glucose during birth is desirable to reduce neonatal hypoglycemia. maintain BS 80-110 mg. hourly BS levels postpartum - insulin needs fall rapidly after delivery of placenta et abrupt cessation of placental hormones complications are more common w/ IDDM: polyhydramnios, PIH (preeclampsia), stillbirth (usu after 36 wks), neonatal (macrosomia or large baby) risk factors: more frequent UTIs and vaginal candidiasis caused by altered pH in reproductive tract, urine testing for glycosuria and ketones as part of routine prenatal care, diabetes screening approx 28 wks with GTT and glycosated hgb) ada diet regulations usu control gestational DM - 3 reg meals and at least 2 snack eaten on time and never skip meals regular non-strenuous exercise (walking) for wt control and BS control amniocentesis for lung maturity - L/S ratio normal is 2:1 monitor for complications: PIH, infections, diabetic ketoacidosis prepare for possible induction of labor at 39 wks. insulin requirements drop dramatically after delivery of placenta et hormonal influences. client may need no insulin or a very decreased dose. gestational diabetics generally may eat a regular diet. BS drops after delivery

non-stress test (NST)

evaluates fetal heart rate, accelerations with/without fetal movement. FHR WITH accelerations is a reassuring sign. is associated with adequate fetal O2 and intact neural pathways. FHR reactivity may not develop until 32 weeks gestation - semi fowlers position - advantages: noninvasive, easily interpreted, can be performed as OP at low cost, NST good indicator of fetal wellbeing - disadvantages: high # of false positives caused by fetal sleep cycles, medications and fetal immaturity and NST not a good predictor of poor fetal outcomes Reactive (reassuring) - 2 FHR accels w or w/o occurring within 20 min period at peaking at least 15 bpm above baseline x 15 sec Nonreactive (nonreasoning) - tracing does not demonstrate required characteristics of reactive tracing w/in 40 min or longer

signs associated with

fetal tachycardia greater than 160, maternal fever, foul smelling amniotic fluid, cloudy or yellow amniotic fluid document VS and document on fetal monitor limit vaginal exams, use good general aseptic technique, prophylactic ATB

gonorrhea

fetal/neonatal effects: preterm birth, neonatal sepsis, IUGR, opthalmia neonatorum can cause blindness give erythromycin ointment in infants eyes

HELLP syndrome

hemolysis, elevated liver enzymes, low platelets (but PT and PTT are normal) low platelets are caused by the vascular damage resulting from vasospams. you will see a low RBC count pain in RUQ, lower chest or epigastric area. Possible tenderness r/t liver distention, N/V and severe edema. avoid palpating the abd - can lead to rupture & internal bleeding labs: increased Hct, uric acid, BUN, liver enzymes (ALT, AST), decreased RBCs and PLTs as condition worsens

Mag toxicity

hypotonic or absent reflexes monitor: RR, lung sounds, O2 sat, urine output, LOC Signs of mag toxicity: RR < 14, maternal O2 <95%, absent DTRs, sweating/flushing, altered sensorium, hypotension. baby may have decreased LOC and come out "floppy" with decreased tendon responses in the event of toxicity, notify HCP. antidote is calcium gluconate 2g slow IV push over 3 min usually by DR, watch for dysrhythmias, bradycardia, v fib, keep calcium gluconate and intubation at the bedside

management of decels

identify cause, d/c uterine stimulants, reposition mother, > rate of IV fluids to expand mothers blood volume and improve placental perfusion, admin O2, notify physician ASAP

ectopic pregnancy

implantation of fertilized ovum outside of the uterus, usually in a fallopian tube, rupture is sudden severe pain sharp or knife like risk factors: hx of STDs (gonorrhea, chlamydia), hx of PID, hx of previous ectopic pregnancies, hailed tubal ligation, intrauterine device, multiple induced abortions, maternal age >35 yrs, some assisted reproductive techniques subjected s/s of pregnancy: unilateral lower abd pain, possible irregular vag bleeding, signs of hypovolemic shock if tube has ruptured lab: beta hCG confirm pregnancy and ultrasound confirms extrauterine pregnancy medical management most successful if tube is in tact, the pregnancy is early, the size of pregnancy is <3.5 cm et fetus is not living methotrexate given - a folic acid antagonist that interferes with all reproduction, inhibits cell division in the embryo surgical tx may be needed if initial tx fails. "provide Rhogam for RH- mothers if dad is Rh+

risks associated with c-section

infection - hemorrhage and possible transfusion - urinary tract - UTI and/or trauma - thrombophlebitis, thromboembolism - paralytic ileus - atelectasis - anesthesia complications cesarean delivery poses added risks to the infant, which may include: - inadvertent preterm birth - transient tachypnea of the newborn caused by delayed absorption of lung fluid - persistent pulmonary HTN of the newborn - injury such as laceration, bruising, fractures or other trauma

varicella

live vaccine can not get while pregnant! causative agent: human alpha herpes virus 3 (herpes zoster virus) fetal effects: fetal death, stillbirth tx: acyclovir not recommended in pregnancy, tx symptoms

Cytomegalovirus (CMV)

maternal effects: asymptomatic illness, mono-like sx transmission: droplet et body fluids fetal/neonatal effects: fetal death, CNS abnormalities, jaundice, growth restriction, hepatosplenomegaly, et deafness, infertility

Herpes (HSV)

maternal effects: blisters, rash, fever, malaise, nausea, HA fetal/neonatal effects: miscarriage, preterm labor, or stillbirth, transplacental infection is rare but can cause skin lesions, IUGR, mental retardation & microcephaly - direct contamination during passage through an infected birth canal (majority infected by this mode)

heart disease

monitor mom and fetal well being more frequently rest periods during day et 1 hr after meals sit rather than stand if possible when performing activities avoid extremes of temperature stress management no smoking or elicit drugs - they generally increase b/p et associated with HTN avoid constipation - no straining b/c vagal nerve intrapartum management: position on side with head and shoulders elevated, continuous O2, calm environment, vag delivery recommended, vacuum assist or low forceps delivery (pushing not recommended), observe client carefully for complications from hemodynamic changes immediately, watch for infection, hemorrhage, and thromboembolism

eclampsia

most serious form of toxemia during pregnancy - mag sulfate is used to prevent seizures in preeclampsia but calcium gluconate used for mag toxicity - hyporeflexia precedes resp depression - control external stimuli and initiate measure to protect the woman in case preeclampsia proceeds to eclamptic seizures

Amniocentesis

needle puncture of the amniotic sac to withdraw amniotic fluid for analysis - may be performed during 2nd or 3rd trimester - 2nd is for fetal genetic abnormalities (between 15-20 weeks) - 3rd to detect fetal lung maturity & surfactant or evaluate fetal hemolytic disease caused by Rh incompatibility

abruptio placentae

painful bleeding may be visible or concealed and is accompanied by uterine tenderness and hyperactivity. any vaginal bleeding - always check for FHT and VS on mom 5 classic signs: vaginal bleeding, abd et low back pain (aching/dull), uterine irritability (frequent low-intensity contractions), high uterine resting tone (identified by use of an intrauterine pressure catheter, and unterine tenderness (severe w/ palpation) -a central (or concealed) abruption may not result in vag bleeding but does cause increasing uterine irritability and tenderness (less bleeding but more pain). -a complete (100%) separation results in profuse hemorrhage rx factors: HTN, smoking, multigravida status, abd trauma from MVA or domestic violence, et hx of previous premature separation of placenta. maternal use of cocaine is the leading cause of abruptio placentae because it causes vasoconstriction. at risk for depleting clotting factors and developing DIC s/s of concealed hemorrhage: increase fundal height, hard/boardlike abd, high uterine baseline tone on electronic monitoring strip, persistent abd pain, systemic signs of early hemorrhage (tachycardia both maternal and fetal, falling b/p, restlessness), persistent late deceleration in FHR or decreasing baseline variability, vaginal bleeding that may be slight or absent interventions: monitor s/s of hypovolemic shock (next slide), monitor fetus continuously for signs of distress, increaed FM, changes in FHR, late decels, promote tissue oxygenation, place in lateral position w/hob flat, restrict maternal movements et activity, provide simple explanations, reassurance, et emotional support, lay on right side and restrict movement

placenta previa

painless vaginal bleeding during last half of pregnancy. placenta is implanted in lower uterus, near fetal presenting part.. no manual exam or oxytocin until location is verified. never do a manual exam on a woman with painless vaginal bleeding (may create more perfuse bleeding) -marginal - low lying placenta - implantation near internal cervical os - partial previa covering a part of the cervical os - total previa - placenta completely covers internal cervical os - incidence is higher with multiple gestation at multiparity, delivery w/ complete previa is by c-section, - usually w/ classical uterine incision to avoid the placenta - vaginal birth may be possible with a low-lying placenta if the fetal head is down to press against placenta et occlude the sinuses - smoking et cocaine also associated with previa - more likely if fetus is a male

Perinatal loss

pregnancy loss can occur at any time be sure to acknowledge their grief any baby over 20 weeks must be burried

HIV

pregnancy: Zidovudine (ZVD), 100 mg orally 5x/day initiated between 14-34 wks of gestation alternative adult dose regimens for oral ZDV are 200 mg 3x/day or 300 mg 2x/day labor: intravenous ZVD with a 1hr loading dose of 2mg/kg, followed by continuous infusion of 1mg/kg/hr until delivery newborn: oral ZVD syrup, dose of 2mg/kg q 6hrs for 6wks, beginning 8-12hrs after birth a cesarean delivery at 38 wks of pregnancy, before the onset of labor and ROM, is usual to reduce maternal transmission of HIC to the fetus HIV infected mothers are advised not to breastfeed because of the presence of the virus in their milk infant HIV test an remain + for up to 18 mos even if they don't convert

TORCH infections

prenatal infections that lead to severe abnormalities - most common HEARING IMPAIRMENT & MR congenital malformations, abortions, and stillborns Toxoplasmosis Other - syphyllus, hepatitis, HIV Rubella Cytomegalovirus Herpes - cannot be tx, only controlled, no vag delivery recommended

2 types of powers

primary: involuntary (contractions) secondary: voluntary (pushing)

prolonged labor

prolonged labor is a type of dysfunctional labor that results from problems with an of the factors in the birthing process potential maternal and fetal problems related to prolonged labor: - maternal infection, intrapartum or postpartum - neonatal infection, which can be severe/fatal - maternal exhaustion - higher levels of anxiety and fear during a subsequent labor

dystocia

prolonged labor, may result from problems with the powers of labor, the passenger, the passage, the psyche, or a combination of these, is often prolonged but may be unusually short and intense factors that increase the risk of dystocia: body build (+30# overweight, short stature), uterine abnormalities, malpresentations and position of fetus, cephalopelvic disproportion (CPD) - caution w/ meds (can slow/stop labor) hypertonic dystocia - contractions are uncoordinated and erratic in frequency, duration, and intensity. contractions are painful but ineffective, usually occurs in latent phase before 4cm dilation. may need c-section as maternal/fetal are at risk for distress and decreased O2 - interventions for hypertonic dystocia: warm bath only if membranes are in tact, warm shower, adm of analgesics (morphine, nubaine - can calm labor) epidural hypotonic dystocia - contractions are coordinated but are too weak for cervical dilation, fetal decent, and effacement. usually occurs after 4cm, become less frequent and short in duration, abd is easily indented at peak of contraction, minimal discomfort. CPD is a common problem and excessive use of analgesics - give pitocin

S/S of heart disease

signs: SOB, angina, palpitations, syncope, cough, fever symptoms: cyanosis, cardiac arrythmias, abnormal heart sounds, cardiomegaly, hepatomegaly, neck vein distention, peripheral edema, pulmonary rales

uterine rupture

sometimes a tear in the wall of the uterus occurs because the uterus cannot withstand the pressure against it complete rupture is a direct communication between the uterine and peritoneal cavities incomplete rupture is a rupture into the peritoneum covering the uterus or into the broad ligament but not into the peritoneal cavity dehiscence is a partial separation of an old uterine scar. there may be little or no bleeding. there may be no signs or symptoms, and the rupture ("window") may be found incidentally during a subsequent cesarean birth or other abd surgery Abdominal pain and tenderness. The pain may not be severe; it can occur suddenly at the peak of a contraction. The woman may describe a feeling that something "ripped" or "gave way" - chest pain, pain in the shoulder area , between the scapulae, or pain on inspiration. Pain occurs because of the irritation of blood below the woman's diaphragm - hypovolemic shock caused by hemorrhage: tachycardia, tachypnea, falling b/p, pallor, cool and clammy skin, anxiety. Signs of hypovolemia may not occur until after birth, and the fall in b/p is often a late sign of the hemorrhage - Signs associated with impaired fetal oxygenation, such as late decelerations, reduced variability, tachycardia, and bradycardia - absent fetal heart sounds with a large disruption of the placenta - cessation of uterine contractions - palpation of the fetus outside the uterus (usually occurs with a large, complete rupture). The fetus is often dead if the placenta is involved

preterm labor

there are many complications of preterm labor. defined by cervical changed and uterine contraction that occur between the 20th and 37th week of gestation stopping if 3cm or less terbutaline is the tocolytic risk factors: pneumonia, appendicitis with sepsis, acute infection, multiple gestation, poverty adverse reactions: 1. cardiovascular: maternal and fetal tachycardia, palpitations, cardiac dysrhythmias, chest pain, wide pulse pressure 2. respiratory: dyspnea, chest discomfort 3. CNS: tremors, restlessness, weakness, dizziness, HA 4. metabolic: hypokalemia, hyperglycemia 5. gastrointestinal: n/V, reduced bowel motility 6. skin: flushing, diaphoresis steroids to accelerate lung function mag sulfate - will need to be hospitalized

early decelerations

these are safe associated with fetal head compression. not associated with fetal compromise. consistent in appearance, return to baseline FHR by end of the contraction, maternal changed usually have no effect on pattern, mirror images of contraction - show up early - never late

every OB visit

they will do a UA to check for protein, glucose, and ketones - 1st trimester: UA, CBC, type & Rh, Rubella titer, Serology of syphilis/gonorrhea/clamydia (baby to have erythromycin eye ointment), pap smear - 2nd trimester: UA, blood glucose screening @24-28wks, RhoGAM if indicated - 3rd trimester: UA, possibly H&H to check for bleeding and to get a baseline

chorionic villus sampling

to dx fetal chromosome or metabolic abnormalities - usu performed between 10-13 wks to dx fetal chromosomal, metabolic, or DNA abnormalities

toxoplasmosis

transmission to the mother thru undercooked meat & kitty litter; passed to the fetus thru placenta if contracted after conception (30%) fetal/neonatal effects: miscarriage (early); neonates - hydrocephaly, microcephaly, chorioretinitis, calcifications w/in cranium dx: serologic testing maternal effects: flu-like symptoms in acute stage use good handwashing technique, avoid eating raw meat and exposure to kitty litter used by infected cats, if cats are in the house - have toxoplasm titer checked, avoid touching mucous membranes while handwashing meats, do not use same utensil or cutting board for raw meat et produce

Hep B

transmission: by contaminated needles, syringes, or blood transfusion maternal effects: fever, rash, depressed appetite, abd pain, aching, weakness, jaundice, tender/enlarged liver fetal effects: infection occurs during birth - crosses the placenta barrier; prematurity, LBW, neonatal death breast milk will be affected

c-section incisions

two types: midline vertical incision between the umbilicus & symphysis or a pfannenstiel incision just above the symphyses - three types of uterine incision: low transverse, low vertical & classic vertical incision into the upper uterus

preeclampsia

tx - bedrest classic signs: HTN, proteinuria additional signs: vascular constriction, lab studies, DTRs (possibly hyperreflexia - very fast), and edema systemic responses: CNS irritability, severe HA, decreased LOC, hyperreflexia, visual disturbances, blurred vision, seeing spots, flashing lights, renal damage, oliguria, portal HTN, epigastric pain may proceed hepatic rupture

transvaginal US

used primarily during 1st trimester to evaluate pelvic anatomy, assessed the developing embryo/fetus for number and size, locates the placenta, can dx intrauterine pregnancy, screens for fetal/placental anomalies, can est. gestational age, pregnancy can be dx earlier, does not need a full bladder

percutaneous umbilical cord blood sampling (cordocentesis)

used to detect blood disorders, acid-base imbalance, infection, or fetal genetic disease - blood from the umbilical vein is targeted more often, contains oxygenated blood and lower Co2 content - involved the aspiration of fetal blood from the umbilical cord near the placenta for prenatal diagnosis and therapy

dx tests for OB

vaginal ultrasound is US of choice - generally 1st visit in the 8wk timeframe - clearer picture abdominal US - full bladder - the US (vag/abd) verify that the woman is pregnant A - amniocentesis L - L/S ratio O - oxytocin test N - non-stress test E - Estriol level