OB Exam 3

Postmature infants

-Associated with placental insufficiency where the baby has a decrease in muscle mass and wasting, decreased subcutaneous fat and glycemic storage -Insufficient gas exchange during postmaturity can cause hypoxia in these babies which can lead to distress and hypoglycemia at on the onset of labor Physical characteristics: -dry, peeling, cracked skin -lack of vernix -profuse hair -long nails -thin, wasted look -meconium staining of skin -hypoglycemia -poor feeding • Meconium Aspiration Syndrome -Fetal asphyxia due to relaxation of sphincter during stress Assessment: ▪meconium stain fluid, skin ▪respiratory depression at time of birth or within a few hours ▪low apgar scores ▪respiratory distress, rales/ronchi -Suctioning is performed if baby not vigorous or before first breath; if not suctioned well, it can migrate to the lungs causing an obstruction and possible pneumonia -Complications of MAS: acidosis, hypoglycemia, hypocalcemia, pneumonia -many infants have no signs of distress at birth but it does warrant close observation

Hyperemesis Gravidarum

-Occurs in 0.5% of all live births -Excessive vomiting causing weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria (which is body breaking down fat- a typical sign of starvation bc our body does not typically do this) -RF: Multiple gestation, molar pregnancy, carrying a female fetus (r/t elevated estrogen and hCG levels), hyperthyroid disorders (elevated thyroid hormone looks like a lot of hCG to the body), psychiatric diagnosis -Complications: low birth weight*, esophageal rupture and *deficiencies of vitamin K and thiamine resulting in Wernicke encephalopathy Etiology: Causes remain unsure, likely both physiologic and psychosocial factors play a role (if they don't have good support systems, or may travel around a lot, it stays pretty bad and when they go into the hospital, they will usually get better but when you release them, it gets worse again) -High levels of estrogen and hCG, reduced gastric motility -For most women, this will get better after the first trimester, but some women experience it for most of their pregnancy Clinical manifestations -Weight loss, dehydration (will present with dry mucus membranes, decreased BP, increased HR, unable to keep down liquids, electrolyte imbalances) Management -Assessment: When taking care of these patients, initially we want to get all their VS, labs, weight to have a baseline -Initial care: Our initial priorities will be hydration, restoring the electrolyte imbalances (so start an IV first to get fluids going), will give antiemetic meds too (phergan, zofran). Antihistamines may also be used to help with nausea as well, or even steroids. Then, we will want to introduce feeds very slowly with whatever the patient can tolerate; once they are able to do this we will do small frequent meals, alternating solids and liquids to prevent their stomach to getting too full but also try to have something on the stomach all the time and prevent it from being completely empty. -Follow-up care: most of the times, patients will have a PICC line at home.

Definition and Scope of the Problem

High risk pregnancy •Life or health of the mother or fetus is jeopardized by a disorder coincidental with or unique to pregnancy •Care of these clients requires the combined efforts of both medical and nursing staff •Factors associated with high risk pregnancy are grouped into broad categories •Risk factors are interrelated and cumulative in their effects (meaning risk factors from different categories and multiple risk factors can make mom at having a higher risk of complications) -we have a high risk pregnancy anytime there is a complication or disorder present that may jeopardize life of the mom baby (such as HTN or diabetes that is preexisting or something that is new with the pregnancy) -there is lots of coordination and these patients will be referred to a high risk specialist and also their OB. Sometimes other specialists as well may be involved if mom has cardiac problems or endocrinologists- all to ensure the best outcomes possible.

Assessment of Risk Factors

•Biophysical Risks: general health status of mother- any medical conditions or preexisting problems such as HTN, diabetes, or obesity. Also any obstetric illness such as preeclampsia •Psychosocial Risks: maternal behaviors and adverse lifestyle choices such as alcohol, drug use, smoking, and sometimes even extreme stress •Sociodemographic Risks: lack of access to prenatal care, or income status (having a low income), being unmarried, ethnicity (health disparities and being in a minority ethnic group), maternal age (too young or too old) •Environmental Factors: things within moms environment such as exposure to infections such as rubella, radiation, secondhand smoke, medications, etc.

Torch infections

•Group of infections caused by organisms [viruses and protozoa] that can cross the placenta or ascend through the birth canal and adversely affect fetal growth and development [teratogenic] •These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice. •In some cases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus T: Toxoplasmosis -Transmitted by ingesting raw or undercooked meats or contact with feces of infected cats (litter box, gardening) -Fetal effects: earlier the infection, the greater the severity of the disease ▪most are asymptomatic at birth, although may develop signs of CNS involvement such as learning disabilities and hydrocephalus -Diagnosis made by antibody testing, ultrasound to assess for fetal infection-ascites, microcephaly, IUGR -Mother may be treated with sulfa, pyrimethamine; Not started until after 1st trimester because pyrimethamine can be teratogenic. -baby may be treated with these medications if dx after birth O: Other Hepatitis B- 70-90% transmission rate to fetus ▪Infants are most frequently infected during birth or the first few days of life ▪Most infants that test positive are asymptomatic at birth ▪Mom can breastfeed because antigens develop ▪All babies receive HepB vaccine and HepB Immune Globulin (HBIG) Gonorrhea ▪often have a chlamydia infection as well ▪can cause an infection via fetus's mouth, conjunctiva, pharynx after ROM ▪can lead to septicemia, meningitis, abscesses ▪eye prophylaxis within the first hour; known maternal gonorrhea infection, baby should receive 1 dose rocephin Varicella: virus causes chicken pox and shingles ▪can cross the placenta and cause problems with limbs and hydrocephalus ▪later it is transmitted in pregnancy the increased risk of symptoms of disease, more severe if close to delivery ▪VZIG: reduces effects of virus to baby if known exposure within 72 hours; will be given to baby if exposed close to delivery ▪Acyclovir used to treat baby Syphilis: ▪if untreated during pregnancy, can cause baby to have congenital syphilis leading to 30-40% stillborn rate ▪if treatment is less than 4 weeks from delivery, baby needs to be investigated for congenital disease ▪occurs during pregnancy through placenta, from amniotic fluid, or exposure to active lesions during birth ▪some babies are asymptomatic; others have early symptoms like poor feeding, slight hyperthermia, snuffles ▪med management: should begin if suspected or if mother untreated ▪if mother treated then no meds are needed for infant ▪good prognosis if treated early, can cause neuro complications later on Parovirus: ▪Increased risk of miscarriage ▪No medications or vaccine available (the pic is of parovirus) HIV ▪Transmission rates for a mom who received antiviral therapy during pregnancy and labor and delivery is 1-2% ▪Untreated mom transmission rate is up to 40% ▪Assume baby is positive until proven otherwise ▪normally neonate asymptomatic at birth; by 1 year of life, show signs of infection; may develop opportunistic infections like thrush ▪should receive routine vaccines R: Rubella Maternal signs/symptoms:- not great risk for mother; Best to avoid pregnancy for 3 months after MMR shot ▪Maculopapular rash ▪Lymphadenopathy ▪Muscle aches and joint pain Fetal effects -serious risk for fetus ▪Congenital cataracts ▪Deafness ▪Heart defects ▪Mental retardation ▪Cerebral palsy -Transmission during the first trimester puts infant at the greatest risk -Infants usually have no symptoms at birth, but have hearing loss that is progressive -A more severe infection can lead to fetal death -Infected infants can harbor disease for 18 months and should be away from women in childbearing years; isolated until mucous and urine are free of virus C: Cytomegalovirus (CMV) Maternal effects: ▪Possible asymptomatic or mono-like symptoms; can harbor the infection in the cervix causing an ascending infection after birth -Can result in miscarriage and stillbirth Fetal effects: ▪Low birth weight ▪Microcephaly/CNS abnormalities ▪Eye abnormalities ▪Hearing loss ▪Developmental delays -Most common cause of congenital infection in US -Mortality rate is 20-30% and is usually from liver failure, DIC or infection -Can be transmitted through breastmilk during an acute infection -No treatment available however some medications can slow the progression of neurological disease H: Herpes Simplex Virus (HSV) Transmission- risk of transmission with active lesions is 50% Maternal effects: ▪Spontaneous abortion ▪Low birth weight ▪Preterm birth ▪Transmission to fetus occurs after membranes rupture and virus ascends during birth or through direct passage in an infected birth canal Treatment: •Take acyclovir during pregnancy •If no evidence of active infection for 30 days prior to delivery, can have vaginal delivery; if has had infection in last 30 days, must have c-section Fetal effects: 50-60% mortality rate if exposed to active primary lesions ▪Microcephaly ▪Developmental delays ▪Seizures ▪Blindness ▪Apnea ▪Coma -Breastfeeding is allowed if there are no lesions on the breasts Treatment: ▪Ointment is administered to prevent eye infection ▪Supportive measures ▪Treatment with acyclovir for infant ▪If symptoms occur after the first 6 weeks, the severity of the illness is very low

Preeclampsia

•Hypertension and proteinuria OR other systemic symptoms develop after 20 weeks gestation in a woman who previously had neither condition •Can also develop in the postpartum period -new onset HTN with proteinuria or other systemic findings, and it develops after 20 weeks (usually in the 3rd trimester). Previously did not have any of those things. Very commonly you will we the proteinuria, but it is not an absolute and could only have the other systemic symptoms and still be diagnosed PE. -it can pop up for the first time postpartum (within a week or so), but mainly comes about during pregnancy -the only cure is delivery Systemic involvement findings: •Platelets: low platelets •Liver function: liver dysfunction and decrease working as well •Kidneys: kidneys can become compromised •Lungs: patient can develop pulmonary edema •Brain/CNS: they will frequently have HA and visual disturbances Risk Factors for Preeclampsia •Primigravidity or first pregnancy with a new partner in this pregnancy: the male genetic material affects the likelihood of PreE to develop •Extremes of maternal age: younger than 19 and over the age of 40 •Multiple gestation: having multiples •Obesity: increases risk of lots of complications •Personal or family history of preeclampsia •Certain preexisting medical conditions: such as chronic HTN, diabetic, etc. Preeclampsia Pathophysiology •Cause is unknown •Progressive disorder: occurs along a continuum, all the way from mild to severe preeclampsia (it will never get better, until after delivery) -the placenta is the root cause and problem (so she will not get better till the placenta is delivered) •Current thought: pathologic changes result from disruptions in placental perfusion and endothelial cell dysfunction •Placental ischemia causes release of toxins that cause endothelial damage and generalized vasospasm •Generalized arterial vasospasm results in poor perfusion to all organs, increased PVR and BP, and increased endothelial cell permeability •Increased endothelial cell permeability results in intravascular fluid loss and decreased plasma volume -these disruptions in perfusion happen really early in pregnancy, well before there are any symptoms HELLP syndrome -it is a variant of preE that is based on lab work- so it is preeclampsia even tho it has a separate name. (about 10% of people with Pre E will end up having this •Laboratory diagnosis for a severe variant of preeclampsia that involves hepatic dysfunction---not a separate illness: (you so this triad of labs) •Hemolysis (H)- see a decrease in H&H (due to RBCs getting damaged due to the widespread vasospasm and them moving through the arteries) •Elevated liver enzymes (EL)- you will see a large, significant increase •Low platelets (LP)- this is r/t activation of the clotting cascade -when these 3 things are present, we call it HELLP syndrome. •Presenting symptoms The way patients will present will be with very nonspecific symptoms, meaning their symptoms are vague and could be contributed to a lot of different things (they may have malaise, N/V, HA, RUQ or epigastric pain due to the liver involvement) and may describe it as heartburn. They may only have mild elevated blood pressure (it does not have to be severe) and they may not even have the classic proteinuria which if why this diagnosis can be tricky. -The pic is showing: our uterus has spiral arteries that supply our endometrium. When women get pregnant, their spiral arteries undergo changes to accommodate more body flow (vascular remodeling). They get wider to support the pregnancy and have more blood flow. With preeclampsia, although we don't know the exact cause, we do know the widening and vascular remodeling do not happen to the extent thats they should. (they do get wider, but not as wide as they should have during pregnancy and blood flow, perfusion will be compromised.)

Breastfeeding Jaundice

•Occurs in first days of life in breastfed newborns •Associated with poor feeding practices •Prevention of early breastfeeding jaundice: -Encourage frequent breastfeeding -Avoid supplementation -Access maternal lactation counseling

Chorionic Villus Sampling (CVS)

•Performed between 10-13 weeks (can be done a whole month earlier than an amnio which can be nice if someone wants confirmation sooner; that is the main advantage to it) •Removal of small specimen of placenta •Reflects the genetic makeup of the fetus •Can be completed through the abdomen or the cervix -very similar to an amnio- it is also a diagnostic test; But a CVS it looks at a little specimen of chorion-which is the fetal side of the place. -patient who is Rh- would get Rhogam after the test due to the potential for Rh isoimmunization. -two different ways to can do it but will still be using an ultrasound to guide them.

Common Maternal and Fetal Indications for Antepartum Testing

•Box 26.3 pg. 567 -These are all reasons for we we would do these weekly antepartum testing. •Diabetes •Chronic Hypertension •Preeclampsia •IUGR •Multiple Gestation •Oligohydramnios: bc we know this is a sign of compromise •Cholestasis: involves moms gallbladder and have poor outcomes associated with it. •Preterm Premature ROM •Late term/Postterm gestation •Previous stillbirth: since if you have hx of it, it is more likely to happen again. •Decreased fetal movement •Renal disease •SLE: lupus

Chronic Hypertension

•Hypertension present before pregnancy or diagnosed before 20 weeks gestation •Incidence is increasing Associated with increased incidence of: •Placental abruption •Development of superimposed preeclampsia •Stroke •Heart failure (bc if you HTN increases the workload on the heart, and so does pregnancy in general so those 2 things increase this risk) •Fetal morbidity/mortality: IUGR, preterm birth, IUFD •Methydopa(Aldomet), labetalol, and nifedipine (Procardia XL) -labetalol and nifedipine are most commonly used for women. -If you have a patient with chronic HTN, this management will be started before pregnancy and you want the patient to be as healthy as possible before she gets pregnant, they will be watched very closely, will have all those antepartum testings in the 3rd trimester to. identify when it is time to deliver if the fetus is compromised.

Gestational Hypertension

•Onset of hypertension without proteinuria or other systemic findings after 20 weeks gestation •Systolic BP >140, diastolic BP >90 (only one of them has to be elevated; many times they both are elevated) •Classified as mild or severe based on severity of BP- based on the BP. Greater than 140 and/or 90 is mild. Once they hit 160 systolic and/or 110 diastolic, then it is considered severe -a women develops new onset HTN and it develops after 20 weeks of pregnancy, and she did not have HTN before -it most commonly pops up in 3rd trimester (after 28 weeks, and commonly even later like 32 weeks) -It does not get better until delivery, delivery is the cure for it. -Even after delivery, they may be elevated still but, by 6-12 weeks PP, they should return to normal (if actually gestational HTN) -If there pressures never return to normal after they have their baby, it would be then considered chronic HTN.

Eclampsia

•Onset of seizure activity or coma in a woman with preeclampsia •No history of preexisting seizures •70% of women develop eclampsia while pregnant •30% develop eclampsia in the immediate postpartum period within the first 48 hours (so this is why we still have increased surveillance) -there are cases where women come in even a week PP and come in seizing. Immediate care •Warning signs for an impending seizure: persistent, unrelenting, severe headache, blurred vision, epigastric or right upper quadrant pain, altered mental status (indicating neuro involvement). •Convulsions (seizures) can appear without warning and with only mild HTN (140/90's even)!! (with a stroke, you would expect really high pressures) When patient is having an active seizure: •Ensuring a patent airway and client safety is priority!!! -Call for assistance/ DO NOT LEAVE BEDSIDE -Turn patient on side to maintain an open airway -make sure the side rails are padded -have suction and O2 ready at the bedside After convulsion/seizure •Maternal stabilization!! (greatest priority first after a seizure) then we can look at uterine activity, and FHR tracing after mom is stabilized. As long as moms hypoxia is stabilized, the FHR will stabilize. •Magnesium sulfate (drug of choice for prevention and tx of seizure, so we will start patient on mag if they were not already on it) and we can use other anti-seizure meds as an adjunct (such as valium) to get the seizure after control •Assess uterine activity, cervix, and fetal status -once this happens, esp. if mom is near term, we will get her to delivery (bc if she is at the point where she is seizing, it tells us she is very sick and will not get better until delivery)

Specific Pregnancy Problems and Related Risk Factors

•Polyhydramnios: too much amniotic fluid; risk factors for it is fetal GI obstructions, neural tube defects, poorly controlled diabetes •Oligohydramnios: too little amniotic fluid; we see this in renal abnormalities in the fetus. Risk factors are due to maternal hypertensive disorders via gestational HTN, preeclampsia; utero-placental insufficiencies (we will see the fluid level drop). We also see it with very small IUGR fetuses that are not growing well. We will also see it with a prolonged pregnancy that goes beyond the due date (bc placenta only lasts 40 weeks). It is very concerning if we see oligohydramnios (esp. if we have no reason to see it) -fluid level (oligohydramnios) is a big indicator of the fetal well being. •Chromosome abnormalities: risk factors for this is moms being older (advanced maternal age). Moms has a hx of prior baby with a chromosome defect, she is more likely to have that happen again. There are ultrasound findings associated with chromosome abnormalities (ex: such as seeing an absent nasal bone which is associated with down syndrome). Also, some of the various maternal blood tests offered to mom such as having a positive genetic screen, that is a risk factors of a possible chromosome abnormality Intrauterine growth restriction (IUGR) -Maternal causes and risk factors •Diabetes with vascular involvement: we usually think moms with diabetes have bigger babies, but will poor diabetes over time, it begins to affects vascularity, then it is a risk factor for poor growth of the baby. (these are with moms have have had diabetes for years that are poorly controlled) •Hypertensive disorders: we will classically see small babies due to vasoconstriction. •Thombophilia: can develop blood clots in the placenta, cutting off blood flow •Cyanotic heart disease: if her heart is sick, she will have lots of problems perfusing the placenta, let alone her own body •Chronic Renal Disease •Collagen Vascular Disease (SLE) •Smoking, alcohol, illicit drug use •Poor weight gain -these can all lead to baby not growing well and having small babies; all of these things really compromise blood flow getting to the placenta and helping baby grow -all of these things alter perfusion- that is what all of them have in common Fetoplacental causes •Chromosomal abnormalities: these babies are typically very small and don't grow well- they will be low in percentile. •Congenital malformations •Intrauterine infection: such as spyhallis or rubella that was acquired during pregnancy •Genetic syndromes (Trisomy 13, 18, 21) •Abnormal placental development -If a patient has known risk factors: we will have more frequent prenatal visits (once 3rd trimester we go every 2 weeks and once in the last month, then we go weekly to increase surveillance. Complications tend to worsen in the 3rd trimester.)

Preeclampsia: Future implications

•Significantly increased risk of developing preeclampsia in a future pregnancy (esp. if it was early onset PreE that happened really on in the pregnancy, or if it was severe PreE). •Consider use of low-dose aspirin in future pregnancies (after first trimester of their next pregnancy bc it decreases the chance of developing PreE again) •Greater risk for developing chronic hypertension and cardiovascular disease later in life, especially if early-onset preeclampsia or severe features (so someone with a hx of preE, we would want to reinforce lifestyle modifications to decrease the risk fo heart disease)

Care management

•Some disorders can be diagnosed prenatally with use of -Ultrasound -Amniocentesis -Chorionic villi sampling •Provide education to mother during pregnancy, notify appropriate pediatrician and transfer infant to high-risk facility if needed •If infant has multiple anomalies often referred to as a syndrome •Support: -Parents will have needs when caring for an infant with abnomality -Nurses role is to ensure understanding of the condition and provide referrals to appropriate agencies -Provide emotional support; allow mother to see before and after pictures of other infants with same disease

Skeletal injuries

-Fractures in newborns heal quickly; important to encourage parents to practice handling, changing, feeding under guidance Skull fracture -Lots of molding can occur before there is a fracture -When a cephalhematoma is present a fracture should be suspected; need a CT scan to rule out underlying brain tissue damage -Many resolve without intervention Fractured clavicle -Bone most often fractured with birth; commonly results after a shoulder dystocia Signs/symptoms: ▪ Limited movement of arm ▪ Crepitus over the bone ▪ Absence of moro reflex -No treatment except for gentle handling; EDUCATE Fracture of the humerus or femur -Can happen during a difficult birth -Immobilizer can be used

Pain Assessment

-Pain is underestimated and not treated because of the lack of knowledge on the effects of baby -Consequences are unknown but can cause stress on baby (increase HR, BP, muscle stiffness, crying, withdrawal, sleeplessness) •Physiologic and Behavioral Responses Box 34.7 (pg. 753) •Management: pain must be anticipated and prevented to avoid long term consequences -Non-pharmacological: swaddling, cuddling, rocking, reducing stimulation, repositioning, skin-to-skin -Pharmacological: morphine is most commonly used

Classification of Diabetes Mellitus

Pregestational diabetes mellitus -Label given to type 1 or 2 diabetes that existed prior to pregnancy Gestational diabetes mellitus (GDM) -Glucose intolerance with the onset or first recognition occurring during pregnancy -It even could be that we may catch it early in the 1st trimester and it may be that it is really type 2 diabetes and this patient didn't get any care before pregnancy; but we would still call it gestational if it was first discovered in pregnancy. Although, if it is type II and she has the baby, it will not go away and then we would really know she had type II.

Gestational Diabetes Mellitus

-Approximately 7% of all pregnancies -When diabetes begins after 20 weeks of pregnancy (as the placental hormones exert the diabetic effect on mom) -All pregnant women become more insulin resistant, but most women's bodies are able to compensate and produce insulin to resolve it (but when a mother has other risk factors, pregnancy just adds to it and their body is not able to produce more insulin so then they turn diabetic during the pregnancy) Risk factors -Family hx of DM, personal hx of GDM, hx of unexplained stillbirth, hx of macrosomic fetus, *obesity (since obesity causes that insulin resistance), HTN, maternal age>25, ethnicity (prob due to obesity- more in hispanic and African American population) -Fetal risks -fetal macrosomia which can lead to shoulder dystocia and birth trauma. These babies are at risk for neonatal hypoglycemia after birth. -in babies born to a gestational diabetes mom, we do not see congenital birth defects because it develops after 20 weeks of pregnancy (after the period where the organs we forming) -we can also see an IUFD if the blood sugars are poorly controlled, just like with pregestational diabetes Screening: All women are screened in 2nd trimester (24-28 weeks) as long as having prenatal care -1-hour 50g GTT: Oral glucose given and blood glucose checked at 1 hour via blood draw (women do not have to fast for the 1 hour test) - if 140 or greater, she will have to do the 3 hour test. If less than 140, she is good. ->140: 3-hour test should be performed (the patient has to be fasting so typically done first thing in the morning)- you have to have 4 venipunctures during the 3 hour period (will get the fasting glucose and then draw at 1 hr, 2hr, and 3hr) -If 2 or more of the values are out of range, then should would be considered diabetic. -if a patient's fasting glucose was 100, then 175, and then 158, and 3 hour is 142- she would be considered diabetic. 3-hour 100g GTT: given after overnight fasting -Fasting blood sugar drawn, then oral glucose given -Blood glucose drawn at 1, 2 and 3 hours

Infants of Diabetic Mothers

-Congenital anomalies: result from maternal high blood sugars; most common are cardiac, renal, musculoskeletal and CNS Macrosomia -increased body fat, LGA, may be large but physiologically immature -the mother's hyperglycemia causes the baby's pancreas to produce insulin, makes organs large and causes large baby -excessive shoulder size leads to dystocia and/or brachial nerve injury Hypoglycemia: infants with blood sugars less than 40 -LGA/macrosomic and preterm babies have a high risk -exposed to high levels of glucose in the blood, infant pancreas begins to make high levels of insulin to compensate and after birth, pancreas continues this for a couple of days even after the cord is cut, which puts infant at increased risk for hypoglycemia Cardiomyopathy: increased heart size is common in these babies; especially in cases of poorly controlled maternal DM -Most infants are asymptomatic Polycythemia and Hyperbilirubinemia -increased number of RBC increases the amount of bilirubin the infant must excrete -bruising from a traumatic delivery can contribute to higher bilirubin levels Respiratory Distress Syndrome -Women with uncontrolled DM and high blood sugars can cause infants to be born with a decreased amount of surfactant -avoid activities that can reduce body temp and lead to cold stress which can enhance RDS Management: depends on the baby's problems and treatment -hypoglycemia: provide early feeding to infant and frequent feedings to enhance excretion of bilirubin in stool -heel stick to check glucose, should be performed soon after delivery -method of feeding can affect glucose and energy requirements ▪breastfeeding requires more energy

Hydatidiform mole (Molar pregnancy)

-Molar pregnancy is where the trophoblast cells, begin to proliferate uncontrollably into a "mole". -Proliferative growth of the placental trophoblast cells into a "mole" -The chorionic villi develop into edematous, cystic, transparent vesicles that look like a grapelike cluster -A type of gestational trophoblastic disease: no viable fetus -Caused by abnormal fertilization*** Clinical manifestations -No FHR (bc there is no viable fetus) -Vaginal bleeding (pretty much all patients will have this bc the abnormal placenta that has formed still has an increase of blood flow to the uterus, but there is an abnormal placenta so the blood has to go somewhere) -Uterine size larger than dates (ex: based on dates, she is 8 weeks pregnant, but her uterus may measure 12 weeks and it is due to the proliferative growth) -Cramping from uterine distention -Elevated HCG levels- higher than expected (bc the trophoblast is proliferating and trophoblast increases hCG) -Excessive nausea/vomiting (since it is tied to hCG levels) -Diagnosis and management -Typically diagnosed by transvaginal ultrasound (you will see thee grape cluster) and we would see higher than expected hCG levels -Most of these will abort on their own spontaneously. But, if they don't D&C is an option. -Follow-up care -Rhogam will be given to a Rh- mom -Bc of how the tissues are proliferating, there is a chance for it to turn into a malignancy called choriocarcinoma. So these patients will be closely monitored for the first year. (we will be monitoring their hCG levels and we want them to go down to undetectable and we want them to stay there) -We also want patients to not get pregnant for the first full year after this to prevent confusion (bc if they start to have elevated hCG levels again we would not know if it is a pregnancy again or if it turned malignant, and so they need a reliable form of contraception)

Metabolic changes associated with pregnancy

-Normal pregnancy is characterized by alterations in maternal glucose metabolism, insulin production, and metabolic homeostasis -Glucose is the primary fuel for the fetus*, just like it is for us. (babies glucose levels at any given time is directly proportional to what moms glucose bc it crosses the placenta so if moms glucose is really high, so is babies. But fetus does secrete its own insulin- moms insulin does not work for baby, own her own. (if babies have blood sugar issues after delivery, it is because baby is used to very high blood sugars and the babies pancreas is used to producing lots of insulin and then you cut the cord, and the source of glucose is gone and babies pancreas keeps producing all that insulin still o baby's blood sugars plummet and that is why you see that in babies after delivery. -Insulin needs decrease during the first trimester due to: -Rising levels of estrogen and progesterone stimulate beta cells to secrete insulin -Nausea/vomiting during pregnancy (so they are not taking in a lot of calories and don't need as much insulin) -we often see hypoglycemia in the first trimester bc of that. Second and third trimesters -Maternal insulin requirements gradually increase (the placental hormones will exert a diabetic effect on the mom and make mom insulin resistant and as a result, her body will require more insulin to maintain normal blood glucose levels). Bc of this change, diabetic pregnant women will need more insulin in the 2nd and 3rd trimesters, and even more than they did before pregnancy.

Postpartum Care

-Once they deliver, how do we take care of the patient: Severe gestational hypertension and preeclampsia with severe features -Ultimately, they will get better once they deliver, but sometimes a patient will get worse before they get better (so we really need to watch them still be watching the things listed below) •Vital signs, DTRs, level of consciousness, intake/output •Magnesium will continue until 24 hours postpartum!! (or sometimes a patient who was not on Mag may worsen and then need to start Mag) •Continue to be vigilant for S/S of worsening preeclampsia •30% of cases of eclampsia and HELLP syndrome occur postpartum (or a patient who have no signs of preeclampsia before, will develop it PP) •Unable to tolerate excessive blood loss (bc their intravascular volume is lower bc they lost a lot of it with the third spacing, so they are not bulked up with volume like a normal patient so they will not tolerate bleeding or PP hemorrhage as well.) -Typically women who had PreE and had symptoms r/t to it, after delivery the symptoms will go away within 48 hours, but may take the BP's a little longer to go back to normal. -Methergine and Hemabate would be contraindicated with these Pre E or hypertensive patients if they hemorrhaged. -We want to support mom with visiting her baby, encourage her to pump her breastmilk, try to get pictures for mom, etc. since it is likely her baby will be in the NICU if delivered at 26, 28, 30 weeks. -HTN that has not resolved 6 to 12 weeks PP, that would then be chronic HTN.

Antepartum Assessment: Electronic Fetal Monitoring (EFM)

-One of the ways we do antepartum testing Indications •Used to determine whether the intrauterine environment continues to be supportive of the fetus •Nonstress test (NST): most widely used technique of antepartum assessment of fetus (most commonly performed EFM testing) -Basis of the test is that the normal fetus will produce characteristic heart rate patterns in response to fetal movement (we know a well oxygenated fetus will have accelerations r/t movement) -can bee performed at hospital or doctors office Non-Stress Test Interpretation -after you put Toco and ultrasound transducer on. We watch racing for at least 20 minutes- we are looking for an accelerations bc we want to see it. -once baby is 32 weeks and greater, we want to see 15x15 accelerations. One less than 32 weeks, 10x10's would constitute an accelerations. -so if there is a baby at 34 weeks and we see 10x10 or 12x12, that would not be what we want to see bc they should have 15x15's at that age. Interpretations for an NST: Reactive •Two accelerations in a 20 minute period •Less than 32 weeks-10x10 •32 weeks or greater-15x15 -basically babies heart reacts to movements •Nonreactive •Test that does not have 2 accelerations in 20 minutes •Requires further testing -they need 2 Accels that meet the criteria above in a 20 min period -anytime there is a nonreactice reading, it will require followup (either prolonged monitoring and leaving them on the monitors bc it could be that baby is asleep, or we can get mom to eat or drink something and sometimes that can wake baby up and give baby more time to become reactive. If they don't we still need follow up and may send them to hospital or do an ultrasound (BPP). -a nonreactive tracing does not always mean something is bad, but it certainly can mean that there is a problem, which is why we need to follow it up.

Preterm Infants

-Prematurity and low birth weight are the second leading causes of infant death -Prematurity is a primary reason for low birth weight Organs -Immature and lack reserves of nutrients -Differ in care and problems than that of term/postterm infant of equal weight Weight -LBW <2500 g -VLBW < 1500 g -ELBW < 1000 g ▪ The ELBW is not usually able to be resuscitated- know ethical concerns regarding resuscitation; need to have a plan prior to delivery and know what the parents want; everyone (parents and healthcare team) should be on the same page -SGA < 10% -AGA 10-90% -LGA > 90% -IUGR: small growth in utero Assessment -Gestational age assessment -Physical characteristics: ▪Hypotonic and extended posture ▪Translucent, red skin ▪Decreased subcutaneous fat ▪Lanugo is patchy ▪Minimal creasing on soles and palms ▪Pinna of ear is thin, soft, flat, folded ▪Testes not descended ▪Tremors and jittery movement ▪Cry is weak ▪Reflexes may be diminished or absent ▪Immature suck, swallow and breathing patterns

Maternal Insulin Requirements throughout pregnancy and PP

-Shows pre-pregnancy insulin requirements, then she gets pregnant and it drops and then maintain for a while. Then after about 20 weeks, it gradually then insulin requirements increases. -After delivery, the placenta is delivered and all those hormones producing that diabetic effect is gone, so the non breastfeeding mother, within about a week after delivery will go back to her pre-pregnancy insulin requirements. -The breastfeeding requirements will stay lower for the duration that she is breastfeeding bc BF uses glucose and calories and uses energy to produce breastmilk, so as long as mom is BF, her insulin needs will stay lower.

Acute Bilirubin Encephalopathy

-Unconjugated bilirubin starts to deposit in the brain -This can develop with no apparent signs of clinical jaundice sometimes •If newborn has jaundice the goal is to prevent it from getting to this point •In premature infants or infants with other complications this can develop at much lower bilirubin levels •Complicated newborns at risk are those with: -Hypoglycemia -Acidosis -Hypothermia •Begin to see acute CNS symptoms First phase (think everything is depressed) -Hypotonic -Lethargic -Poor suck -Absent moro reflex Second phase (think everything is excited) -High-pitched cry -Severe muscle spasms -Hyperreflexia -Fever Third phase (think excited but even worse) -Hearing/visual difficulties -Shrill cry -Apnea -Seizures -Coma •About half survive this disease- those that do can have movement disorders, gaze abnormalities, intellectual disabilities Kernicterus -Bilirubin levels greater than 25 -Irreversible chronic bilirubin toxicity -Symptoms include hypotonia, tonic neck reflex, difficulty meeting milestones -Only supportive treatment is available

The patho pic of preeclampsia causing symptoms:

-Widespread vasospasm- alters perfusion everywhere so we will see altered perfusion to our organs all over our body: to our kidneys, liver, brain, etc. Vasospasm will cause HTN bc if you vasoconstrict you will have HTN and will affect blood flow to the uterus which will affect the baby via growth (IUGR) -Vasospasms damage the kidneys so that is why we will see increased creatinine and decreased urine output -Brain spasms are responsible for headaches, hyperreflexia, and seizure activity. -Retinol spasms cause visual disturbances -Liver ischemia as a result of decreased perfusion to the liver would show elevated liver enzymes and we would see symptoms such as N/V and epigastric pain -all of those things are as a result of widespread vasospasm. -With increased capillary permeability (leaky capillaries) that leads to protein spilled into the urine, causing third spacing and swelling and generalized edema, pulmonary edema (causing SOB, etc.) As fluid leaks out, our blood will become very thick and concentrated as fluid leaves the blood stream and that will alter our hematocrit and hemoglobin values (they will be increased)

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. 1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "board-like" abdomen 4. Painless, bright red vaginal bleeding 5. Increased uterine resting tone on fetal monitoring

1, 2, 3, 5

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1.Flushing 2.Hypertension 3.Increased urine output 4.Depressed respirations 5.Extreme muscle weakness 6.Hyperactive deep tendon reflexes

1, 4, 5

Grieving

Anticipatory Grief •Experienced when told of the impending death of infant •Prepares and protects parents who are facing a loss •Parents who have an infant with a debilitating disease, but one that may not threaten life of child, also may experience anticipatory grief •Loss of an infant: -Health care professionals can help by: ▪Involving family in infant's care ▪Providing privacy ▪Answering questions ▪Preparing family for inevitability of death ▪Growing emphasis on hospice and palliative care for infants and their families ▪Acknowledge this is difficult and be an active listener Grieving •Perinatal loss •Ectopic pregnancy •Intrauterine fetal death (IUFD) •Miscarriage •Stillbirth •Death after birth -Prematurity -Congenital anomalies -Genetic defects Acute distress -loss of a pregnancy is considered acute distress, esp. if unexpected -partners experience distress too, especially since their significant other is so upset -first part of grieving is accepting the loss and can be hard to make decisions -hard for young couples with no experience with death -parents should always approve the final decisions and nurse needs to be the advocate regarding this Intense grief -difficult emotions as parents work through the pain -some women avoid the feelings, some are hopeless -can be hard when mother's milk comes in o normal to feel guilt if they feel like they could have prevented the loss; anger is normal -fear and anxiety: some want to become pregnant immediately and some cannot bear the thought of becoming pregnant again -when becomes aware of loss: depression is normal -may have fatigue, HA, at risk for health problems -need to know they are not alone and make sure they have plenty of people to talk to about this Reorganization -over time feelings are less painful -occurs when the parent can function at home, return of self-esteem and confidence -after the first year and can move on Bittersweet grief -reminders of the loss during a special time like an anniversary -encourage to resume sexual activity but may be hard because it reminds them of the baby o may have fear of conceiving and this happening again -remember family centered care: ▪ Grandparents: so hard for them to see their child in pain ▪Siblings: excitement of a new sibling is gone, don't understand why there is suddenly no baby •young children can act out when parents are upset; be clingy, and parents don't respond appropriately •School aged children frightened •Teens understand but are awkward discussing

Substance Abuse

Can cause serious effects on the newborn including: -Preterm birth -Respiratory distress -IUGR -Developmental delays -Congenital anomalies -Fetal death Alcohol -It is not known on the amount that affects the fetus but heavy drinkers are at risk for congenital abnormalities Fetal alcohol syndrome (pic is showing this): ▪Small eyes ▪Flat face ▪Thin upper lip ▪Microcephaly ▪Developmental delays ▪Poor speech ▪ADD Symptoms of alcohol withdrawal: ▪Jitteriness ▪Increased tone and reflex response ▪Irritability ▪Seizures Cocaine -Do not experience a process of withdrawal like others - show neurotoxic effects -Increased risk of SIDS: cannot get used to normal stimuli -Risk for prematurity and SGA Symptoms: ▪Difficult to console ▪Sensitive to noise and other stimuli ▪Apnea ▪Irritability ▪Tremors Methadone -Increased risk of SIDS -Experience Neonatal Abstinence Syndrome Other symptoms: ▪Seizures ▪Disturbed sleep Heroin -Increased risk of low birth weight and/or SGA -Experience Neonatal Abstinence Syndrome usually within 12-48 hours of birth -Initially infant may seem depressed (tone, lethargic, etc.) then shows symptoms of ▪Jittery ▪Hyperactive ▪Shrill cry ▪Poor feeding -If not treated can lead to vomiting, diarrhea, dehydration, apnea, convulsions Methamphetamines -Increased risk of SGA and prematurity -Lethargy is common for months -Usually have poor weight gain -Some show no withdrawal symptoms Tobacco -Increased risk of prematurity, low birth weight, SIDS and respiratory complications Neonatal Abstinence Syndrome -Respiratory symptoms: irregular respirations, tachypnea, nasal flaring, retractions, cyanosis -Neurological symptoms: irritability, tremors, shrill cry, seizures, increased tone and exaggerated moro reflex, hyperreflexia, hyperactivity -GI symptoms: abnormal feeding pattern, poor sucking/swallowing, frantic sucking, regurgitation, refusal to feed -Other symptoms: frequent yawning, sneezing, mottling of skin Assessment -Important to know what the newborn is at risk for: what the mom was ingesting so we know that baby could have bc of it -Can do urine drug screen on newborn if showing signs -Education mother on importance of detoxing and seeking help -Social support - may need to involve social services Supportive therapy for newborn: ▪Fluid/electrolytes - maintain hydration ▪Nutrition - feed frequent, small amounts; be sure head is elevated, monitor weight gain, have suction available ▪Infection control ▪Respiratory care ▪Reducing stimuli - increased stimulation can cause irritability ▪Swaddling/holding •Cocaine - vertical rocking Pharmacological treatment: -Pharmacological therapy is based on the severity of the symptoms -Can give phenobarbital and diazepam -Narcan is contraindicated because it can cause severe signs of NAS •Breastfeeding is controversial at this time

Clotting Disorders in Pregnancy

Disseminated intravascular coagulation (DIC) Things that can trigger DIC: severe placental abruption and severe preeclampsia -Pathologic form of clotting (the clotting cascade becomes activated and out of control, widespread clotting begins (patient is using up all of her platelets and forming clots everywhere) -Widespread and consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both (bc once they have used up all of their clotting factors and platelets, then they will start bleeding out of everywhere such as nose, ears, mouth, IV site, incisions, etc.) -Never a primary diagnosis (it never just happens on its own, something always triggers it) -Clinical picture=clotting, then bleeding, and also tissue ischemia (bc these clots that have formed are cutting off blood flow impeding perfusion to major organs) Management -Correction of the underlying causes (so in our cases, the preeclampsia needs to get better, and placental abruption needs to get resolved and we need to get baby delivered to resolve it)

Sepsis in the newborn

Immune system: -Remember IgG is key immunization to bacteria and viruses; not as much IgG in preterm babies, while term babies level of IgG is equal to mother's levels -IgA is missing but received through breastmilk -requires time for the IgA and IgM to reach levels Risk Factors Table 35-2 pg 769 -can be acquired in utero, during labor, postpartum, and during resuscitation -maternal: untreated infection, poor nutrition, systemic infection or fever, intrapartum (PROM, chorio, prolonged labor) Early onset: -associated with ob complications like PTL, PROM, chorio, fever during labor -Symptoms within 24-72 hours after birth -Caused by bacteria from the normal flora of vagina ▪GBS, E. Coli, S. pneumoniae Late onset: -Caused by maternal derived or health care associated infection ▪E. coli, candida, pseudomonas, MRSA -Symptoms 7-30 days after delivery -Can occur through umbilical stump, skin, mucous membranes, respiratory, urinary, GI and neuro systems Symptoms with systems: Respiratory •Apnea, bradypnea •Grunting, flaring, retractions Cardiovascular •Tachycardia •Hypotension CNS •Temp instability •Lethargy •Irritability GI •Feeding intolerance •Vomiting, diarrhea Integumentary •Pallor Metabolic •Hypoglycemia •Hyperglycemia Hematologic •Thrombocytopenia •Neutropenia Treatment -Hand hygiene is the most effective prevention technique -Careful cord care -Breastmilk ▪colostrum contains IgA which prevents infection in the GI tract ▪helps kill bacteria to fight against E coli and helps provide immunity against RSV -Antibiotics: administering safely and correctly -Suctioning: secretions can be infected: ▪routine suctioning is not recommended because can further compromise immune system and cause hypoxia

Signs and Symptoms

Mild Preeclampsia •BP ≥ 140/90 •≥ 1+ protein on dipstick •≥300 mg protein in 24 hrs •possible headache, mild and intermittent -as long as mom's BP are pretty stable, lab work is stable, no severe symptoms, and baby looks okay by looking at FHR, NST, fetal movement, BPP, ultrasound to look at the fluid level, etc.) we would continue the pregnancy. Severe Preeclampsia •BP ≥160/110 (only one of the numbers has to be elevated) •Massive proteinuria -≥3+ protein on dipstick -≥5 g protein in 24 hr urine (5,000 mg) •decreased UOP (since PreE damages and decreases perfusion to the kidneys) •persistent headache, more severe (often times they become resistent to Tylenol) •visual disturbances (blurry vision, seeing spots, etc.)- the headache and visual disturbances tells us there are neuro changes •RUQ/ epigastric pain (tells us there is liver involvement) •Shortness of breath (if there is pulmonary edema) •N/V (tied to liver involvement) -not all patients have to have all of these symptoms, they may just have come Laboratory value changes: Preeclampsia: •H/H: normal or elevated (why an increase?)- due to decreased plasma volume (since everything was leaving and causing third spacing and it is dry) •Platelets: unchanged or <100,000 (bc the clotting cascade gets activated and we start using up our platelets and they clump together so labs decrease) •BUN/Creatinine: Normal or elevated (just depends on the degree of kidney involvement)- if trending up, it says things are getting worse •AST/ALT: Normal or elevated (just depends on the degree of liver involvement) if trending up, it says things are getting worse -some patients may not even have lab changes, but every case is different. HELLP •H/H: low •Platelets: <100,000 (critically decreased) •Critically elevated ALT/AST

Group B Streptococcus

•Leading infectious cause of neonatal sepsis and mortality; mothers who are GBS positive are often asymptomatic •Can lead to bacterial meningitis and sepsis in newborns •Early onset meningitis is usually caused by exposure to infection in utero or during delivery through the birth canal •Newborns of GBS positive mothers are monitored closely for first 48 hours after delivery for early symptoms of infection

Care Management (cont.)

•Mild gestational hypertension and mild preeclampsia •Goals of therapy are to ensure maternal safety and deliver a healthy newborn close to term (we want to keep her pregnant as long as possible, as long as mom and baby look good) •Home care: to be managed outpatient, their BP and labs have to be stable and pretty close to normal (a lot of moms will keep a BP log to be able to look at how they are trending) •Maternal and fetal assessment (have mom do kick counts which is a good indicator of fetal well being) •Activity restriction (modified bed rest, limited activity to try to keep the pressures down). They managed at home, they will still come in to see the provider once or twice a week to check BP, ask about symptoms, check her weight, ultrasound to check amniotic fluid level, BPP, and NST, check babies growth since we know it will make baby be smaller, etc.) •Delivery at 37 weeks (always will be induced at this time with any woman with PreE) Severe gestational hypertension and preeclampsia with severe features •Goals of care are to ensure maternal safety, assess degree of maternal and fetal risk, formulate a plan for delivery, and prevent complications (we start having to weigh risk vs. benefits for mom and baby). We are trying to prevent even more complications such as Eclampsia, prevent stroke, placental abruption, IUFD, so we are more focused on delivery for this mom. •Immediate hospitalization (so we can have increased surveillance and these patients are very sick, so we will be watching moms BP, UO, labs, assessing fetus through ultrasound and NST frequently, assessing mom for the severe signs and symptoms) If it is determined it is no longer safe to continue the pregnancy (when moms pressures are resistant to meds and gotten really high and dangerously abnormal labs, and signs of fetal compromise, then it is time for delivery to safe mom and baby) •Magnesium sulfate therapy (they will definitely be on this, and sometimes even to by us 48 hours to give the steroids that take 2 days to kick in for a premature baby) •Oral and IV anti-hypertensives (IV hydralazine, Labetalol are most commonly seen) They will give these meds for elevated pressures. •Betamethasone for fetal lung maturity

Amniocentesis

•Obtains a sample of amniotic fluid •A needle is inserted abdominally into the uterus and amniotic fluid is withdrawn with ultrasound guidance (bc it has to show us where there is a pocket of fluid and don't want to stick the baby) -amniotic fluid contains DNA so we can get genetic info on the fetus -amniocentesis is a diagnostic test! It will confirm a diagnosis 100%. -amnio can be done anytime at 14 weeks, ideally wait a little longer than that •Possible complications (<1% of procedures): •Maternal: labor, fetomaternal hemorrhage with possible Rh isoimmunization (so the Rh- mom would get Rhogam after in case), leakage of amniotic fluid •Fetal: death, direct injury, hemorrhage (if the needle punctured the umbilical artery) Amniocentesis: Indications Genetic concerns •Fetal karyotype (and see babies exact genetic makeup). If there are abnormal screening tests or ultrasound shows a possible anomaly, we can offer an amniocentesis. Structural anomalies -mainly neural tube defects and abdominal wall defects that you can confirm with an amnio. Bc the AFP level in the amniotic fluid will be very elevated in those 2 situations- (we use the maternal serum AFP to screen for those, but can draw an amniotic fluid AFP to confirm either of those 2. defects) Fetal lung maturity •Can be assessed by: •Presence of PG in amniotic fluid •Determining the Lecithin/ Sphingomyelin (L/S) ratio in the amniotic fluid •Lamellar body count (LBC) -all of these 3 options would indicate lung maturity and be a reason for someone to have a amnio late in the pregnancy. Amniotic fluid culture/gram stain -if we suspect an infection is present (such as chorioamnionitis) we can culture it and see

Birth Trauma

•Physical injury sustained by a neonate during labor and birth •Ultrasonography allows antepartum diagnosis of macrosomia, hydrocephalus, and unusual presentations •Elective cesarean delivery can be chosen for some pregnancies to prevent significant birth injury Risk Factors: -Birth techniques: vacuum, forceps -Maternal age <16 or >35 primigravida -Oligohydramnios -Macrosomia -Multifetal gestation -Abnormal or difficult presentation -Obstetric birth techniques

Antepartum Testing

•Various testing that is done specifically for high risk pregnancies •Purpose of antenatal testing: doing different types of test to check on baby and make sure baby is not compromised; we want to known as soon as possible if baby is compromised; -the 2 main goals of antepartum testing is to identify compromised fetuses and at risk for death or injury (meaning a neurological issue such as cerebral palsy) and want to know is the intrauterine environment is continuing to support the baby or if is no longer and when to pull the trigger and get this mom to deliver. -Also goal is to want to identify babies who are adequately oxygenated so that we can avoid unnecessary interventions. We do not want to deliver early to try to prevent stillbirth. As long as mom and baby are doing well, we will keep the pregnancy going. But, if the baby or mom is compromised, then we will de •Usually begins by 32-34 weeks of pregnancy (if we have a known complication; could start as early as 28 weeks for those really sick and have multiple risk factors for complications or stillbirth) •Role of the RN in antepartum testing: we want to support and educate the patient on why we are doing what we are doing. They will also assist with some of the different tests or sometimes you will perform the test and also interpret the results.

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean section

1

Diabetes Mellitus

-Affects 4% to 14% of pregnant women -Prevalence in women of childbearing age is increasing -Pregnancy complicated by diabetes is considered high risk -Key to an optimal pregnancy outcome is strict glycemic control before conception and throughout pregnancy (but it requires a lot of commitment, including finger sticks, shots, oral meds if type II, and having to resist sugars and carbs, etc.)

Antepartum Hemorrhagic Disorders

-Any type of Bleeding in pregnancy may jeopardize maternal and fetal well-being -Maternal blood loss decreases oxygen-carrying capacity, increases maternal risk for: -Hypovolemia, anemia, infection, preterm labor, adverse oxygen delivery to the fetus (so baby can also become hypoxic and have injury r/t that) -Fetal risks from maternal hemorrhage -Fetal anemia, hypoxemia, hypoxia, preterm birth

Ectopic Pregnancy

-Anytime an egg implants itself outside the uterus Fertilized ovum is implanted outside the uterine cavity (where it is not supposed to be). It usually implants in the tube. -1-2% of all 1st trimester pregnancies Risk factors -Women with hx of pelvic inflammatory disease, gonorrhea, chlamydia (bc it can cause a lot of scar tissue in the tubes, which after fertilized ovum makes its way to the uterus, if there are scar tissue from infection, it will block the ovum to get through so it just implants in the fallopian tube. -Any kind of tube surgery (and scar tissue will be present) -A prior ectopic pregnancy -Pregnancies achieved by infertility treatments -Any pregnancies that occurs with an IUD in Clinical manifestations -Late menstruel period with abdominal pain, delayed menses, abnormal vaginal bleeding/spotting (don't have to have spotting; some do and some don't 6-8 weeks after LMP, dull one sided pain that will progress to a harp one-sided pain as the pregnancy progresses. The big risk for the ectopic pregnancy is a rupture (bc the tubes are not meant to stretch like the uterus, so at a certain point, it will rupture and cause lots of internal bleeding in the belly -After rupture of tube: referred shoulder pain (bc as the abdomen fills up with blood all the way up to the level of the diaphragm, the phrenic nerve becomes irritated and will cause this shoulder pain), Cullen sign, (bluish discoloration around the umbilical that is the physical assessment finding that indicated blood in the abdomen) signs of shock (diaphoretic, pale, decreased UOP, altered mental status, decreased BP, increased HR, may complain of feeling dizzy and lightheaded) Diagnosis -Clinical manifestations: if mom does not even know she is pregnant, she may go into the ED with her symptoms (thinking she has appendicitis or something) and that is why in the ED, every women will get a pregnancy test bc they are trying to rule out ectopic pregnancy. -Transvaginal ultrasound: we can see it on ultrasound -beta hCG level -Progesterone level -If beta-hCG levels reach a certain level (doubling every other day) and no intrauterine pregnancy can be seen on ultrasound, ectopic pregnancy very likely. (bc by a certain point, we should definitely see a pregnancy) -so if someone comes in with a positive pregnancy test, has abdominal pain, and some spotting, we would think ectopic pregnancy. Management -We have to treat an ectopic pregnancy (bc it is a hemorrhage waiting to happen) -Medical management -Methotrexate (MTX) IM- it is a chemo drug that destroys rapidly dividing cells, so it can end the pregnancy this way. In order to be treated by this option, they will need really close follow up to make sure that it worked and that it did dissolve the pregnancy (so you need to gauge if the patient will be a candidate for this bc they will need to be able to go to their appointments.) We will know it worked if the hCG levels are now undetectable and at 0 (usually takes about 2-3 weeks after giving methotrexate). -**We need to teach her to report an increase in the pain bc it could mean it did not treat the pregnancy and discontinue the pregnancy. The baby could continue to grow and then we could have an emergency and she could rupture. -Surgical management: salpingectomy (they remove the tube on that side, or a salpingostomy (make an incision into the tube, remove the pregnancy, and stitch the tube back up). If you lose a tube on one side, it may alter fertility and make it harder to get pregnant. -Rhogam if appropriate -Follow-up care

Transvaginal ultrasound

-this is what it would look like if there was a molar pregnancy.

What a positive CST would look like:

-with each of the contractions there is a late decel with it

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse should provide the client with which information? 1. Glucose crosses the placenta 2. Insulin crosses the placenta 3. Increased caloric intake is needed 4. Decreased caloric intake is required

1 Babies glucose is directly proportional to what moms is always.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." 2. "My insulin dose will likely need to be increased during the second and third trimesters." 3. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4. "My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."

1 hypoglycemic episodes are common early in pregnancy, and patients will need to decrease their insulin requirements

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply 1.Keep the room semi-dark. 2.Initiate seizure precautions. 3.Pad the side rails of the bed. 4.Avoid environmental stimulation. 5.Allow out-of-bed activity as tolerated.

1, 2, 3, 4 5 is not indicated; she would be on Mag if she had severe PreE and she would be at risk for falling so she would not be able to get out of the bed.

The nurse is caring for a newborn in the NICU. The HCP has run lab tests to determine which Torch infection the newborn has. For each fetal effect listed, indicate if it is related to Rubella, Cytomegalovirus, and/or Herpes Simplex virus. 1. Microcephaly 2. Deafness/hearing loss 3. Seizures 4. Low Birth Weight 5. Blindness 6. Congenital cataracts A. Rubella B. Cytomegalovirus C. Herpes Simplex

1- B,C 2- A,B 3- C 4- B,C 5- C 6- A -Memorize the Torch infections is key- what puts baby at risk and what they can lead to.

A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? 1. "My vision for the past 2 days has been really fuzzy." 2. "The swelling in my hands and ankles has gone down." 3. "I had heartburn yesterday after I ate some spicy foods." 4. "I had a headache yesterday, but I took some acetaminophen and it went away."

1; she is developing visual disturbances and shows worsening.

The nurse is caring for a client who has just delivered a newborn following a pregnancy with placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa? 1. Hematoma 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2

•The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1. Administer oxygen by face mask. 2. Clear and maintain an open airway. 3. Administer magnesium sulfate intravenously. 4. Assess the blood pressure and fetal heart rate.

2

The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply. 1. Use of diaphragm 2. Use of fertility medications 3. History of Chlamydia 4. Use of an intrauterine device 5. History of pelvic inflammatory disease (PID)

2, 3, 4, 5

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. 1. Proteinuria of 3+ 2. Urine output of 20 mL in an hour 3. Presence of deep tendon reflexes 4. Respirations of 10 breaths/minute 5. Serum magnesium level of 4 mEq/L (2 mmol/L)

2, 4

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring.

2; never do a manual exam on someone having vaginal bleeding and we do not know the cause of it.

The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? 1. The client is 28 years of age. 2. This is the second pregnancy. 3. The client has a history of hypertension. 4. The client performs moderate exercise on a regular daily schedule.

3

A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly? 1. "I will need to remain on bed rest for 2 weeks." 2. "I will need to take a full course of antibiotic treatment." 3. "I will need to take tocolytic medication to halt the labor process." 4. "I will need to prepare myself and my family for the loss of this pregnancy."

4 -this is an inevitable miscarriage and she is going to lose the baby. Bed rest would not help at this point and the other options also are not right.

The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply. 1. Plan induction at 35 weeks. 2. Plan amniocentesis at this time. 3. Schedule a biophysical profile immediately. 4. Plan for weekly nonstress tests at 32 weeks. 5. Obtain nutritional counseling with a dietitian.

4,5 -the biophysical profile will begin at 32 weeks

A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? 1. Urinary output of 20 mL 2. Deep tendon reflexes of 2+ 3. Fetal heart rate of 120 beats/minute 4. Respiratory rate of 10 breaths/minute

4; bc ABC's and also, w are assessing every 30 min and 20mL is actually fine for 30 min. Respirations is going to trump urine output.

The nurse is providing teaching to the mother of a newborn with earl jaundice about the condition's progression. The nurse knows that the teaching regarding hyperbilirubinemia was successful when the mother makes which response? A. "Kernicterus is a consequence of elevated bilirubin levels and has possible lifelong effects" B. "My baby should not get hyperbilirubinemia if I place him near a window in the sun light" C. "my baby will be 3 days old at discharge and I will not need to worry about hyperbilirubinemia" D. "since I'm exclusively breastfeeding, the risk of my baby having hyperbilirubinemia is very low'

A acute bilirubin encephalopathy(3 phases of this) is in the middle of hyperbilirubinemia and kernicterus (can turn into this if treatment does not work)

The nurse is caring for a neonate at 32 weeks gestation The assessment findings the nurse should report to the healthcare provider are _______ , ______ , and ______. (everything is normal but baby has abdominal distention, RR are 66, and O2 sat is 90%.) A. abdominal assessment B. skin color C. temperature A. respirations B. chest circumference C. weight A. heart rate B. oxygen saturation C. age The nurse suspects the newborn is developing: A. respiratory distress syndrome B. sepsis C. necrotizing enterocolitis

A A B C -In necrotizing enterocolitis, symptoms include abdominal distention, respiratory distress or hypoxemia.

A nonstress test is performed on a client, and the results are documented in the chart as no accelerations during a 40-minute observation. The nurse interprets these findings as which result? •A nonreactive nonstress test •Equivocal •A reactive nonstress test •Unsatisfactory

A nonreactive nonstress test

The newborn is caring for a family that is grieving the loss of their newborn. Which tokens of remembrance would be appropriate to provide? SATA A. Picture of the newborn B. Certificate of death C. Footprints D. Lock of hair

A, C, D

Following the admission assessment (normally done within the first 24 hours) of a neonate born at 42 weeks of gestation, the nurse documents which findings as normal? SATA A. Three-vessel cord B. Peeling skin on the feet C. Absence of sole creases D. Absence of vernix E. Cyanosis of the hands and feet F. Large amounts of frothy oral secretions

A,B,D,E A- all babies should have a 3 vessel cord B- desquamation is the peeling and they are already going through this D-vernix goes away and skin observes it in utero, so you don't have as much when you are born E-Acrocyanosis is normal in the first 24 hours

A nurse is caring for a neonate born addicted to opiates in the special care nursery. Click to specify whether each intervention is anticipated, nonessential, or contraindicated for the newborn. A. Administer antibiotics B. Administer morphine C. Swaddle and/or provide a pacifier D. Feed every 2-3 hours E. Increase environmental stimuli F. Encourage parental handling (doing things with baby)

A- B B- A (if a baby comes out addicted, we can give morphine and other meds to slowly wean them off) C- A D- A E- C (you want to reduce the stimuli- ways you can do this is turn off the lights, cluster care, decrease sounds, skin to skin contact bc it helps relax baby) F- C (bc we are still wanting to decrease all sensory stimuli)- you can encourage eye contact bc that would help bonding; you do not want to change babies diaper, pick them up, etc.

Late Pregnancy Bleeding: Placental Abruption

Abruptio placentae/Placental abruption -Premature detachment of part or all of placenta from implantation site after 20 weeks of gestation -Accounts for significant maternal and fetal morbidity and mortality!! Risk factors: maternal hypertension!! (huge risk factor for abruption whether chronic, severe preE, etc. so the really high BP's), cocaine use, external abdominal trauma (MVA), cigarette smoking, history of abruption Clinical manifestations -Separation may be partial or complete (pulling away from the uterine wall)- complete is a lot more concerning ominous. -Abruption may be concealed or apparent (concealed meaning there is no bleeding and apparent meaning there is bleeding involved with the abruption) -if there is abruption on the edge, then there will be more bleeding but if there was a partial abruption but it occurred more centrally, then there isn't a way for it to get out so may not have bleeding. Classic symptoms: painful dark red vaginal bleeding, abdominal pain/uterine tenderness, frequent contractions (due to the uterus getting really irritable with all this filling of blood), increased uterine resting tone -Severe separation: board like abdomen present with abnormal FHR tracing (the bigger the abruption, the worse the FHR tracing) -Abruption is also a time when Rh- mom will need Rhogam. Maternal and fetal outcomes -Main problem for mom is blood loss, hemorrhage, and potentially shock if she loses enough blood. She can also go into acute renal failure if she loses enough blood. It can also trigger DIC. -Mother's prognosis depends on degree of separation (how bad it was), overall blood loss, and degree of coagulopathy (whether or not she went into DIC) -for babies outcome and survival, it is directly ties to how much the placenta abrupted. (even term babies die from this, and they can die very quickly from a big placental abruption, or if they are still alive or we save the they will prob have neurological and brain injury from being without oxygen for so long) -Size of the abruption correlates with fetal survival Diagnosis -Confirmed after birth by inspection of placenta and the presence of a retroplacental clot (big clot behind the placenta at delivery and blood in the amniotic fluid during delivery) -Sometimes visualized on ultrasound (but not always) Management expectant management would only be the case if it was a very small abruption, mom is stable, baby looks okay, etc. Expectant -If less than 34 weeks and mom and baby are stable: will continue to monitor extremely closely (she will stay in the hospital and we will try to buy time if not a bad placental abruption) -Betamethasone for fetal lung maturity -Frequent assessments of fetal status and growth (US, AFI, BPP, NST) -If they were 34 weeks, we would deliver if there was any placental abruption. Active -Immediate birth for a term fetus (really 34 weeks or greater) OR if bleeding is moderate or severe and mother or fetus are in jeopardy.

Necrotizing Enterocolitis

An acute inflammation in the GI tract causing bowel necrosis and perforation -Hypoxic or stressful events; bacteria in the sterile GI tract, enteral feedings (introduced bacteria into GI tract) •Breastmilk can help prevent formation of bacteria which is why this is rare in infants who are exclusively breast fed •Can occur anytime up to one month after birth Signs/symptoms -Bradycardia, tachycardia -Hypoxemia -Unstable temperature -Lethargy -Respiratory distress -Abdominal distention -Bile stained spit up and vomit -Increased gastric residual -Blood in stools Diagnosis -bowel loop distention, CBC (decreased platelets puts them at risk for DIC), ABGs Treatment :goal is to prevent progression of disease; in severe cases the prognosis is poor -Rest tube feedings, use TPN -Infection control: antibiotic therapy -Surgery to resect part of the bowel

Care Management

Identifying and preventing preeclampsia •No reliable test or screening tool has been developed -the best tool to identify it early and identify women who are at risk is early and adequate prenatal care! We need to have good, strong assessment skills to pick up on the changes. -with a preeclampsia patient, we will constantly be interviewing, asking about history, asking about specific preeclampsia symptoms, a good focused exam, and monitoring lab work for some of the lab changes Health assessment •Accurate measurement of BP (with appropriate size cuff, woman in sitting position, and ideally using the same arm each time) •Edema: distribution (how widespread the edema is; is it dependent - which would be considered normal or generalized edema- which we would more commonly see in Pre E), degree (1+, 2+, etc.) and pitting (evaluate all these things)- you may see a big increase in swelling over only a couple of days- commonly in their face, around their eyes (periorbital edema), rings won't fit on fingers, and will have it in feet and legs as well. All of this is due to the endothelial damage and having the leaky capillaries, causing third spacing. PreE causes a lot of CNS irritability and deals with a lot of spasms and reflex changes. They have hyperactive reflexes, and it puts them at risk for seizures. •Deep tendon reflexes (DTRs)- important part of the assessment and it is not uncommon to see hyperactive reflexes (3+ or 4+) in a PreE patient. It tells us she is more at risk for seizures. -Clonus: tells us the status of the CNS; if a woman have ankle clonus, it also shows us that she has an increased risk fo seizing (or her seizure threshold is low). If you see clonus, it is considered a 4+ for reflexes. You dorsiflex the ankle a couple times then let go, and their foot will continue to move back and forth, without their control. •Evaluation for proteinuria (does not have to be present, but most commonly is)- effect of the kidney damage and proteins are able to leak through that would not normally -24 hour urine: > 300 mg protein present is considered proteinuria (this is the gold standard bc we measure the protein over the course of a 24 hour collection is ideal and reflects our true renal status as opposed to a one time specimen) •Weight Gain ->2 kg weight gain in a week warrants further investigation (since women hold onto fluid and have third spacing). It would get concerning if they have more that 2 kg weight gain (more than 5 lbs in a week)- if a pregnant woman came in with new onset 8 or 10lb weight gain in 2 weeks, you would be watching her BP and asking her about other PreE symptoms) •During your physical assessment, ALWAYS ask patient about severe signs/symptoms

The nurse is assigned to care for four mothers and their term newborns. Which mother and newborn couplet requires the nurse's attention first? A. Mother: fundus firm 2 cm below umbilicus, minimal lochia rubra. Infant: color is pink on room air, respirations 67; bilateral crackles on auscultation. B. Mother: fundus is firm 3 cm above umbilicus and to the right, moderate rubra lochia. Infant: color is pink when active, currently dusky while quiet, respiratory 70 C. Mother: fundus is firm 1 cm above umbilicus, small amount lochia rubra. Infant: color is pink with acrocyanosis, respirations 68 and intermittent expiratory grunting D. Mother: fundus is firm at umbilicus, small amount lochia rubra. Infant: pale pink, quiet alert, respirations 65; periodic breathing noted.

B

The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored fro symptoms of hypoglycemia because of which reason? A. Increased use of glucose stores during a difficult labor and birth process B. Interrupted supply of maternal glucose and continued high neonatal insulin production C. A normal response that occurs during transition from intrauterine to extrauterine life D. Increased pancreatic enzyme production caused by decreased glucose stores

B

The lab results show that a mother has a blood type of O negative and her infant has the blood type A positive. As part of the plan of care, the nurse should assess the infant for which condition? A. Breast milk jaundice B. Pathologic hyperbilirubinemia C. Physiologic hyperbilirubinemia D. Rh incompatibility

B ABO or Rh incompatibility are both underlying causes of pathologic hyperbilirubinemia

The charge nurse in the newborn nursery and an unlicensed assistive personnel (UAP) are working together on a shift. Under their care are eight babies rooming in with their mothers, and one infant is in the nursery for the night on tube feedings. There is a new client whose infant will be brought to the nursery in 15 minutes. Which tasks would the nurse assign to the UAP? SATA A. Newborn admission B. Vital signs on all stable infants C. Tube feedings D. Document feedings of infants E. Record voids/stools F. Bath and initial feeding for new admission

B, D, E F is not right bc it is an initial feeding and you have to assess all of that.

Hyperbilirubinemia

Bilirubin: -Newborn RBC's have a shorter life-span -Newborns have increased RBC volume -RBC's breakdown > Hbg > Heme > Bilirubin ▪ Conjugated bilirubin: Already bound to albumin (plasma protein) which is water-soluble and can easily be excreted ▪Unconjugated bilirubin: Not bound to albumin; Cannot be excreted -Need good feeding practices to stimulate peristalsis causing good stooling patterns Hyperbilirubinemia -Build up of unconjugated bilirubin in the blood that leads to jaundice ▪Begins in the head (sclera, mucous membranes) ▪Progresses downward through the body Physiologic ▪AFTER 24hrs of birth, within first week of life usually ▪Affects 60% of term babies and almost all preterm babies ▪Usually resolves without treatment ▪Normal jaundice that occurs without an underlying condition: •Increased RBC at birth •Shorter life span of RBC •Lack of intestinal bacteria •Decreased GI motility •Liver can only conjugate about 2/3 of circulating bilirubin Pathologic ▪Jaundice seen within 24 hours of birth Risk factors: •Less than 38 weeks gestation •Breastfeeding •Previous sibling with jaundice •Jaundice prior to discharge •Maternal infection •Maternal diabetes •Fetal intestinal obstruction (meconium ileus) •Prematurity •Hepatic cell damage ▪Due to an underlying condition: •Rh or ABO incompatibilities •Enclosed hemorrhage (bruising, cephalhematoma, etc.) •Polycythemia •Delayed passage of meconium •Delayed feeding practices •Genetic disorders Treatment ▪Serum bilirubin levels can separate levels into conjugated vs unconjugated ▪Coomb's (direct = baby) detects hemolytic disease related to Rh or ABO incompatibility ▪Phototherapy: •High intensity blue light that converts unconjugated bilirubin in to water soluble form that can be excreted •Cover eyes and genitalia •Monitor temperature closely •Watch for signs of dehydration •Turn every 2 hours

Two hours ago, a neonate at 38 weeks gestation and weighing 3175 grams was born to a primiparous client who tested positive for beta-hemolytic Streptococcus (GBS). Which finding would alert the nurse to notify the health care provider? A. Alkalosis B. Increased muscle tone C. Temperature instability D. Positive Babinski reflex

C

A mother brings her newborn baby boy in for his 1-week checkup. She tells the nurse that he does not seem to b moving his right arm as much as his left. The nurse would observe for A. crying B. positive Ortolani sign C. limited range of motion during the Moro reflex The nurse suspects the newborn has A. facial palsy B. a fractured clavicle C. a dislocated hip

C B -baby has limited movement, absence of moro reflex -but want to observe bc they could also have brachial nerve damage. -Teach mom to have gentle handling bc babies bones heal much quickly that what adults do

Antepartum Assessment: EFM

Contraction stress test (CST) -not as widely used as the NST (bc it is a little more invasive, it needs to be done in the hospital, you would need an IV if inducing using pitocin, etc.) but this test identifies a fetus who is jeopardized in stress, but is stable at rest. •Also called the oxytocin challenge test •Identifies the jeopardized fetus that was stable at rest but shows compromise with stress (and contractions stress a fetus since it will temporarily compromise blood flow to baby) •Provides an earlier warning of fetal compromise than the NST with fewer false positive results (by inducing stress on the baby) •2 methods to induce contractions: •Nipple-stimulated contraction test (since it causes oxytocin release which induces contractions) •Oxytocin-stimulated contraction test (also know as an OCT)- to also induce contractions -hook up monitor for about 20 min, then we will start inducing contractions and observe the fetal response to this stressor. Nipple stimulated contraction test: •Have patient massage one nipple for 2 minutes, rest for 5 minutes •Stimulation of nipples causes release of oxytocin •Cycle is repeated until adequate uterine activity is met Oxytocin stimulated contraction stress test •IV Pitocin is given to stimulate uterine contractions •Rate is increased until 3 uterine contractions occur in a 10 minute window -with either method, we want to see 3 contractions in a 10 minute window. -We are looking to see if we have any placental insufficiencies (we will be looking to see if we see late decels) Contraction stress test (CST): Interpretation •Negative test: at least 3 contractions occur in a 10-minute window with no late decels (can remember by negative = no late decels). •Positive test: late decelerations occur with 50% or more of contractions (if we have patient on monitor and we have her to have contractions for about 20 min, and she has 6 contractions and had late decels for 4 of them, then it would be a positive test) •Equivocal/Suspicious test: Decelerations occur with less than 50% of contractions •Unsatisfactory test : Fewer than 3 contractions in a 10-minute period or unable to maintain continuous fetal monitoring (we are not able to elicit the contractions or enough that we need, or if we can't keep the patient on the monitor for some reason) -a positive CST would show the baby is at most compromise.

A 2-week old neonate is admitted to the hospital with a diagnosis of possible sepsis. Based on the information in the EHR, which order would the nurse question? A. Acetaminophen 10mg/kg per rectum, every 4-6 hours PRN pain B. Ampicillin 200mg/kg IV every 6 hours C. Mom may breastfeed ad lib D. Draw blood cultures times 3 in the AM

D -If we think someone has sepsis, we would need to draw blood cultures first, so we would question giving meds before drawing a blood cultures. We need to do cultures first so that we know what meds will need to be given.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breastfeed the neonate. What instructions about breastfeeding would be most appropriate? A. Breastfeeding is not recommended bc the neonate needs increased fat in the diet B. Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done C. Breastfeeding is contraindicated because the neonate needs a high-calorie formula every two hours D. Tube feedings using breast milk can be given until the neonate can coordinate sucking and swallowing

D suck and swallow is key to breast and bottle feeding.

A neonate born by cesarean section at 42 weeks, weight 4100 grams, with APGAR scores of 8 and 9 after birth, develops an increased respiratory rate and tremors of the hand and feet 2 hours postpartum. What is the priority problem for this neonate? A. Ineffective airway clearance B. Hyperthermia C. Decreased cardiac output D. Hypoglycemia

D tremors and respiratory rate are signs of hypoglycemia

Antepartum Testing cont.

Daily fetal movement count (DFMC) •Also called kick counts (bc we know fetal movement is tied to fetal wellbeing- happy healthy babies move) -the good thing abut this is it is free, and mom can do it anywhere. -the point is for mom to be very aware of the fetus' movement patterns Various protocols •Count 2-3 times daily (after meals or something) for 2 hours or until 10 FM are felt •Very low number of movements and/or a downward trend is concerning! •No movement in 12 hours should be immediately investigated! (either going to hospital or doctors office, and hopefully we have time to intervene) -sometimes in obese women they won't feel their fetal movements as well and as much, which is likely a reason obesity is a risk factor for stillbirth

Antepartum care: GDM

Diet -Mainstay of treatment for GDM* (gestational) -Initially managed with diet and exercise alone Exercise -Improves insulin sensitivity in obese women -Moderate exercise recommended -diet and exercise are what we use for the gestational diabetics -Monitoring blood glucose levels: they will still have to do finger sticks just like pregestational diabetics; we will have these patients keep a blood sugar log. -Medications for controlling blood sugar levels: may be on oral meds if diet and exercise aren't getting the sugars where we want it.; if that still doesn't help, then we will have to use insulin. -Fetal surveillance: this will be increased with antepartum testing once or twice a week beginning in the 3rd trimester. -As long as the sugars are controlled and look good, baby is not getting huge, we will let mom get to 39-40 weeks. But, we will deliver early for babies safety or moms sugars are not looking good.

Respiratory Distress Syndrome:

Earlier baby is born the increased risk it will have to develop RDS Risk Factors: -C-Sections -Males -Maternal diabetes -IUGR -Prolonged or PROM •Preterm infants lack surfactant which can lead to atelectasis •Have weak respiratory muscles which prevent full expansion of alveoli Signs/symptoms (immediately at birth or up to 6 hours after birth) -Poor air exchange -Pallor -Use of accessory muscles -Tachypnea -Lethargy -Hypotonia -Tachycardia Treatment -Ensure infant has a patent airway and provide oxygen -Arterial blood gases -Chest x-ray -Monitor for signs of sepsis: common from fluid building up which can cause pneumonia ▪May need blood cultures, CBC, or lumbar puncture

Nervous System injuries

Erb-Duchenne palsy or Erbs palsy or Brachial Plexus injury -Most common type of paralysis after a difficult birth associated with shoulder Occurs when the head is stretched or pulled away from the shoulder -arm hangs limp alongside the body -Treatment: ROM exercises and immobilization Faculty paralysis or palsy -Pressure on the facial nerve during birth from forceps delivery or prolonged second stage -Eye remains open and affected side is flattened -Assist with feeding and prevent damage to affected eye that is open

Postpartum Care: Pregestational Diabetes Mellitus

First 24 hours, insulin requirements drop substantially (once the placental hormones are gone) -Blood sugar is closely monitored and insulin dose is adjusted with a sliding scale (they may cut her insulin in half after delivery or take her off on insulin completely, etc.) -Type 2 diabetics may resume their oral hypoglycemic medications at this time (if they had stopped in during pregnancy) Insulin needs will be different depending on how she is feeding her baby- her insulin needs will be lower if she is breastfeeding bc it uses glucose and carbohydrates. -Breastfeeding vs. Bottle feeding: Insulin needs will be different depending on how she is feeding her baby- her insulin needs will be lower if she is breastfeeding bc it uses glucose and carbohydrates. -Risk of hemorrhage: bc the babies are usually bigger so they will overly stretch out their uterus, and uterine overdistention can also be caused by polyhydramnios. -Contraception: timing of pregnancy for these pregestational diabetics are so important and we want their blood sugars very controlled before pregnancy, so we need pregnancies to be planned.

What's the Difference?

Gestational Hypertension •Increased BP > 140/90 (new onset to pregnancy) •Absent proteinuria •No HA or slight HA •"Normal" pregnancy edema (dependent edema) •Stable lab values -G HTN would become severe once the pressure increase (160/110) and it does always have the possibility of becoming and progressing to preeclampsia. Preeclampsia •Increased BP > 140/90 (new onset to pregnancy) •Proteinuria (almost always) •CNS symptoms •More generalized edema •Slight to greatly affected lab values (platelets, liver enzymes, creatinine) -the main difference is the G HTN, they only have elevated BP. The only thing they may have is a very very mild HA, if one at all.

Significance and Incidence of Hypertensive Disorders

Gestational hypertension -Formerly called PIH (pregnancy induced hypertension) •Preeclampsia •Eclampsia -preeclampsia turns into eclampsia •Chronic hypertension •Common medical complication of pregnancy -Complicates 5% to 10% of all pregnancies -all of these really contribute to maternal morbidity and mortality Maternal Morbidity and Mortality •Placental abruption •Cerebral hemorrhage/stroke •Hepatic or renal dysfunction •Disseminated Intravascular Coagulation (DIC) •Cardiac failure •Pulmonary edema •Seizures •Pregnancy-related hypertension accounts for 10% to 15% of maternal deaths worldwide -all of things can be due to those hypertensive disorders

Genetic Disorders

Inborn errors of metabolism -Defects in single genes, inherited as autosomal recessive -Appear normal at birth, develop signs after several feedings Phenylketonuria ▪Deficiency of enzyme that causes an increase in phenylaline ▪Can cause CNS damage ▪If have positive test, normally have mental impairments ▪Will need to be on special formula •Many of the diseases are found during the normal state required screening done in the hospital; heel stick performed 24 hours after birth, labs sent to state for testing

CNS system injuries

Inracranial hemorrhage from birth injury can occur in response to advanced maternal age or vacuum/ forceps delivery: -Infants born before 30 weeks are at risk for ICH because their vessels are smaller and more fragile -Subdural hematoma: blood pools in the subdural space ▪Precipitous delivery with forceps/ vacuum delivery or a large baby ▪Signs/symptoms: baby may be apneic, unequal pupils, seizures, coma Subarachnoid: most common type of ICH ▪Trauma during delivery or hypoxia in a preterm baby ▪May see blood in lumbar puncture leaking in CSF ▪Signs/symptoms: may have seizures and apnea -Treatment includes rest, decreasing stress, monitoring respiratory status, management of seizures Intraventricular hemorrhage- bleeding in ventricles: -Signs/symptoms: diminished or absent moro reflex, lethargy, apnea, poor feeding, high-pitched shrill cry, seizure -Supportive treatment: dependent on the symptoms the baby is experiencing

Early Pregnancy Bleeding

Miscarriage (spontaneous abortion) -Pregnancy ends as a result of natural causes before 20 weeks Incidence and etiology -10-15% of recognized pregnancies end in miscarriage (but about 1/4 of all pregnancies end in miscarriage) since some don't even realize they are pregnant since miscarriage happens so early -Early miscarriage: occurs before 12 weeks (most occur in this time, most of the time bc there are chromosome abnormalities and they were not going to live so it is the body's way of taking care of it) -Late miscarriage: occurs between 12-20 weeks Types-See Table 28.1 p. 599 -Threatened: spotting with closed cervix, no or mild cramping (any bleeding early in pregnancy are presumed to be a threatened abortion until proven otherwise) -Inevitable: moderate bleeding, cervical dilation, cramping (the miscarriage will happen with this one) -Incomplete: moderate to heavy bleeding, severe cramping, delivery of fetus (called incomplete bc mom has delivered the embryo or fetus, but there are retained fragments of pregnancy that have not gotten out yet). Priority for someone who is bleeding like this with a miscarriage is to get IV access to give fluids and possible blood products. -Complete: cervix has already closed after tissue expelled, mild bleeding/cramping (everything has been expelled naturally and the cervix has closed back up so it is called complete) -Missed: the fetus has already died, no bleeding or cramping (her body does not realize she has lost the baby and needs to expel it, so this may happen if someone has gone to get an ultrasound and the embryo does not have a heart beat and she has not bleeding or cramping yet) In the pic, A is threatened. B is inevitable. C is incomplete abortion. D is missed. Clinical manifestations -Someone presenting with a miscarriage- they will come in with uterovaginal bleeding, cramping, a lot of times low back pain, low pelvic pressure. Care management: Initial care -Labs/ Ultrasound (we will first do an ultrasound to see if the fetus has cardiac activity to see if it is alive). We can check the hCG lab levels (since it is a sign of healthy pregnancy when they are increasing. So if it was really low, that is not good). Progesterone will also be checked (if it was low, it would be a sign of abnormal pregnancy) We can also do a physical exam: -Once the cervix begins to dilate, the pregnancy can't continue and miscarriage is inevitable; if that is the case we have 3 options: -Allow her body to attempt to complete the miscarriage, medical management (to make her cramp and expel everything), surgical management via dilation and curettage -If No cervical dilation and a live fetus>>>expectant management (watch and see, maybe check labs again, check ultrasound if bleeding continues). But half of pregnancies that have bleeding early on in pregnancy, can still have a normal pregnancy, it does not always mean they are miscarrying. If this is the case, some doctors will make patients be on a modified bed rest at home. Medical management -Prostaglandin medications -Misoprostol (Cytotec): can be given orally or vaginally and will cause bad cramping and cause her uterus to cramp and push out any of the remaining contents of whatever is left in there (could be given with an inevitable or incomplete abortion) -May still require surgery if bleeding continues (if it did not work) Surgical management -Dilation and Curettage (D&C)- quick procedure to dilate her cervix and suction out. Rhogam if appropriate (will be given in this instance if mom is Rh-, even if there was no miscarriage but there was bleeding) Follow up care at home -it is an outpatient procedure and will go home after a couple of hours. It is normal for her to go home with still some light bleeding and ramping. -We tell her to notify and report if she has a fever or foul smelling discharge indicating an infection, and an increase in bleeding. -To prevent infection, they need to have nothing in the vagina for 2 weeks, and no tub baths either (so shower for the first few weeks)

Risk Factors for Preterm Labor and Birth:

Non-modifiable -Previous preterm birth -Multiple abortions -Race/ethnic group -Uterine/cervical anomaly -Multiple gestation -Polyhydramnios -Oligohydramnios -Pregnancy-induced hypertension -Placenta previa -Short interval between pregnancies -Abruptio placenta -Premature rupture of membranes -Bleeding in first trimester Treatable/Modifiable -Age <17 or > 34 -Unplanned pregnancy -Single -Low educational level -Poverty, unsafe environment -Domestic violence -Life stress -Number of implanted embryos -Low pre-pregnancy weight -Obesity -Incompetent cervix -Infection -Substance/alcohol use -Late or no prenatal care

Antepartum Interventions for a pregestational diabetic mother

More frequent prenatal visits -Every 1-2 weeks in 1st and 2nd trimester, if poorly controlled -2 times/week in 3rd trimester (to make sure baby is okay) Diet -Should have nutrition counseling with registered dietician -Limit refined sugar -3 meals, 2-3 snacks>>>don't skip meals -Lots of fiber (fiber helps decreases spikes n blood sugars and helps the number to be sustained) -See Teaching for Self-Management Box on p.621 Exercise -Moderate exercise most days of the week improve insulin sensitivity and are known to be a good thing Insulin therapy -Frequent adjustments may be necessary (due to the expected changes- we expect to have to gradually increase their insulin requirements as their pregnancy progresses) -Main role is education and support in regard to insulin administration and adjustment (know when to give it, how to give it - abdomen is still the most ideal spot for good absorption of insulin) -Insulin is likely to be apart of therapy for a pregestational diabetic Self-monitoring blood glucose levels -Review glucose log and have her bring glucometer to each visit (these women will need to do finger sticks multiple times a day and keep a glucose log for us to be able to look at the trends in her glucose levels.) -FSBS fasting, before meals, 1-2 hours postprandial, QHS, middle of the night -We know with type 1 diabetics, they know how to use insulin, but if someone was a type II, they may have just been on diet control or oral meds and she was doing just fine- but the changes that happen in pregnancy may cause this mom who was perfectly fine before hand may now require insulin during pregnancy, and likely can come off of them after pregnancy) -With insulin injections, there are different ways to do it (some may do a long acting insulin once a day and then a rapid acting with each meal but then you would have to do 4 sticks/ day or they can do an intermediate mixed with a rapid in thee same syringe twice a day.) -Complications requiring hospitalization -Sometimes the pregestational diabetic patient may have to be hospitalized due to all the risks involved. When moms blood sugars are very poorly controlled (200's and up), we need to get the blood sugars controlled bc could esp. have stillbirth. It also allows us to be more aggressive with the insulin therapy and lts us monitor baby a lot more closely. -These patients will definitely have thee antepartum testing 1-2 times per week, but it is individualized (if not poorly controlled, maybe only 1 time a week) It may even start before 32 weeks if the sugars are poorly controlled. Fetal surveillance -Usually begins at 32 weeks -Earlier if poor glucose control or vascular disease exists Determination of birth date and mode -it is very individualized- if the blood sugars are controlled they will allow 39-40 weeks (you will very rarely see them go beyond their due date). -Delivery normally between 39-40 weeks, as long as everything is going pretty well -May be earlier with macrosomic infant (measuring really big), poor glucose control, non-reassuring fetal status, preeclampsia -If w decide to deliver a mom prior to 38 weeks, we would be concerned about baby's lungs so we may do a test for fetal lung maturity to confirm that via an amniocentesis

Late Pregnancy Bleeding: Placental previa

Placenta previa The placenta should implant itself in the high (of fundal area) of the uterus, however it an implant itself in the lower uterine segment, closer to the cervical os and that becomes a problem for bleeding. -Placenta implanted in lower uterine segment near or over internal cervical os (this becomes a problem with the potential for bleeding) -Degree to which the internal cervical os is covered by placenta used to classify three types: -Complete placenta previa (the placenta completely covers the cervix) -Marginal placenta previa (partially covers the cervix) -Low-lying placenta (does not touch the cervix, but is very close to the cervix to where there is still a potential for bleeding) -When the placenta is that close to the cervix, when the cervix starts to dilate and efface, it will cause bleeding. Incidence and etiology -1 in 200 pregnancies -Risk Factors: history of previa, previous Cesarean section (due to scar tissue being present), Advanced Maternal Age, multiparity, history of D&C (due to scar tissue), multiple gestation (bc each baby will have its own placenta so naturally with the surface area, there is a greater chance for one of them to be close to cervix), smoking (the placenta will try to spread out and get bigger to try to pick up more oxygen since smoking decreases the the oxygen to the placenta) Clinical manifestations -Painless bright red vaginal bleeding during second or third trimester, abdomen will be very soft and not tender -many times placenta previa is diagnosed on ultrasound before she ever has any bleeding (some patients may never even have bleeding) -this kind of patient would need to be on pelvic rest with no sex bc it could cause a bleeding episode -A woman with placenta previa will ALWAYS deliver c section (there is too much risk for hemorrhage if delivered vaginally) Maternal and fetal outcomes -Major maternal complication: hemorrhage (if they can not get the bleeding under control, she will have to have a hysterectomy) -Can lose up to 40% of blood volume without displaying signs of shock -greatest risk for baby with a previa is being born premature Diagnosis -Made through transvaginal ultrasound (we will know what type of previa she has). But, if a woman comes into the ER in 2nd or 3rd trimester and she is pregnant and hemorrhaging, we would have to do a vaginal ultrasound in the hospital to diagnose placenta previa. If a patient comes in bleeding and we do not know why, it is imperative you do not do a vaginal exam on her, until we rule out a placenta previa (bc it could cause her to bleed more) Expectant management Observation and bed rest -Patient is initially monitored in the hospital on continuous fetal monitoring (mom and baby look good, mom is not bleeding to heavily, moms H&H is stable, we can just observe her and have her on bed rest) -Pelvic rest (nothing in the vagina bc could trigger bleeding episode) -We will usually wait a few days before we can get the bleeding stopped -NO DIGITAL VAGINAL EXAMS!!!! :bc it can trigger a bleed -When they are in the hospital, you always want a good IV, and have a blood type and screen so that we can get her blood very quickly if we need to. (she could be a stat c- section at any moment) Home care -Must be stable** with no bleeding for at least 48 hours (if bleeding has completely stopped, mom and baby are good) -Compliance is necessary (need reliable transportation, need to be able to get to the hospital very quickly, and need family members that can keep a close eye on her and need ot be able to get to the hospital immediately if she begins bleeding) Active management -Deliver known placenta previa at 36 weeks regardless, even if no bleeding (we are thrilled if mom and baby are healthy and we have reached 36 weeks) and we will always deliver at 36 weeks if placenta previa via c-section. -or Deliver if bleeding is excessive at any point, fetal compromise (FHR tracing does not look good), or active labor (can't let mom go into labor bc it is a bleeding risk) -Cesarean birth is indicated -Once a patient has had a previa, once she delivers and she is PP, that lower part of the uterus where that raw placental site is, does not have nearly the muscle content that the fundal area has. So when her uterus contracts and clamps down during the PP to control the bleeding, they could still have problems with bleeding, so even after they deliver they are at a greater risk for PP hemorrhage.

Care Management: GDM

Postpartum -Most women will return to normal glucose levels after birth (once the placenta is gone and we don't have the effect of those hormones anymore) -OGTT (glucose tolerance test) at 6-12 weeks postpartum- to test and she if the diabetes has resolved (they will have a follow up). Some women may not be diabetic anymore, but it makes them a lot more likely to develop type 2 diabetes later in life (so want healthy lifestyle changes) -Likely to recur in future pregnancies -Encourage lifestyle changes to prevent the likelihood of developing type 2 diabetes later in life.

Pregestational diabetes mellitus

Preconception counseling -Should be counseled before the time of conception (before she gets pregnant) to plan the optimal time for pregnancy, establish glycemic control, and diagnose any vascular complications (all to help decrease our risk for miscarriage and also decrease the likelihood of birth defects of congenital anomalies by maintaining good glycemic effects early on - we do not want any surprise pregnancies, we want it to always be planned. Maternal risks and complications -Miscarriage, HTN, preeclampsia, polyhydramnios, infection, ketoacidosis, hypoglycemia/hyperglycemia, C-section delivery (all of these are more common if her sugars are uncontrolled or if she in noncompliant with meds, etc.) Fetal and neonatal risks and complications -Macrosomia (a baby greater than 90th percentile, or 4,000 grams at term which is about 9.5lbs), shoulder dystocia, IUFD (fetal death or demise), congenital malformations, respiratory distress syndrome (their lungs don't quite mature as early as normal)

Preterm Infants etc.

Respiratory -Do not transition from intrauterine to extrauterine life as well -Have decreased surfactant and functional alveoli -Early signs of distress: flaring, grunting, retractions, central cyanosis -Treatment: oxygen as needed, needs to be humidified and warmed Cardiovascular -Heart rate can drop very easily, especially during a period of apnea -Need to assess for murmurs, pulses, cap refill Temperature -Susceptible to heat loss because of large surface area compared to weight -Limited stores of brown fat (helps term infants stay warm) -Poor muscle tone -Brain unable to regulate temp -Goal is to create a Neutral Thermal Environment ▪ Temperature where there is limited O2 consumption and warm enough ▪Baby kept in incubator to maintain temp and prevent cold stress ▪Pre-warm incubator, linens ▪Temp probe placed on abdomen to keep between 97.4 to 98.4 -Central nervous system is immature; bleeding can occur from fragile capillaries ▪Maintaining adequate nutrition: -May need to give IV dextrose or tube feedings -Breastfeeding mother can pump colostrum and breast milk for baby when ready to take a bottle or attempt latch Can breast/bottle feed once they have ability to: ▪Suck and swallow ▪Cardiorespiratory regulation ▪Shows hunger cues ▪Maintains quiet alert state -Careful advancement of feedings because of risk of aspiration -Before feedings, assess for signs of feeding tolerance: ▪Presence of bowel sounds ▪Abdomen for discoloration and girth ▪Check gastric residuals ▪Assess for emesis ▪Check stools for occult blood and consistency, amount, and frequency -Monitor intake and output carefully -Monitor weight daily Resisting infection: -At risk b/c of lack of antibodies and impaired ability to adequately make them -Early identification of sepsis is critical Promoting parent/infant bonding: -Encourage skin to skin when baby stable, helps regulate temperature, VS, blood sugar, calms infants -Encourage breastfeeding, include mom and dad in as much care as possible by allowing them to do simple tasks and always keep them up to date on new results, tests, medications, and procedures

The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. How should the nurse document this finding in the client's medical record? •Reactive •Non-reactive •Negative •Positive

Reactive

Intrapartum Care

Severe gestational hypertension and preeclampsia with severe features -bc they are increased risk for seizures, we will try to increase their threshold and decrease stimulation for them. •Bed rest with side rails up! (seizure precautions include, side rails up and padded, O2, and suction) •Darkened environment (limit visitors, no tv on in the room, etc.) •Total IV fluids= 125 mL/hr with strict I&O via foley catheter!! (to monitor for renal functioning, and with a patient who is fluid filled, we want to know if she is holding onto fluid more, etc.) Mom needs fluid bc she is dry intravascularly, but at the same time she is at risk for swelling and edema, so the total rate cannot go above 125 (and that is including the Mag given with the fluids) •Antihypertensive medications: -Hydralazine and Labetalol (these will be listed PRN on the MAR to give if pressures are above 160 and/or 110) Magnesium Sulfate therapy: •Drug of choice for prevention and treatment of seizure activity caused by preeclampsia!! (also given in preterm labor bc if relaxes the uterus). It is a CNS depressant and why it is used in these situations for PreE; it is solely given to try to prevent seizures. (they will give a 4-6 g loading dose, then 2g infusing every hour after that. It requires a 2nd RN to sign off when setting up the IV pump) •Therapeutic Magnesium level: 4-7 mEq/L (obviously will be higher than someone who is not on magnesium.) Make a decision on stopping Mag based on your patient (since it a CNS depressant, we would know what they look like if they have too much of it) and how they look, not based on the labs. If her lab levels were 7.5 and your patient was sitting up and talking and feeling fine, you would not stop her mag then, so you just need to watch your patient. •Expected side effects: feeling of warmth, flushing, diaphoresis, burning at IV site, muscle weakness (due to the CNS depression so if she is on this, she is at risk for falling and why they are on bed rest with a foley in), "flu-like" symptoms •Signs of toxicity: lethargy, decreased or absent DTRs, decreased UOP, double vision, slurred speech, decreased RR (less than 12 like 6 or 8), cardiac arrest •Calcium gluconate: antidote for magnesium sulfate toxicity!!! -If you walk in the room and ur patient is lethargic, has RR of 10 and no reflexes- your priority is to stop the infusion of Mag!!! then you can give calcium gluconate but not first. -You have to document hourly on a patient with Mag neuro assessment (DTR's, LOC, UOP, RR), also listening to lung sounds frequently bc they are at risk for retaining fluid and having pulmonary edema. -Those patients who already have kidney involvement (we know their kidneys have been effected and have increased BUN/ creatinine levels) are at even greater risk for mag toxicity since she may not be able to excrete it well so we really need to watch these moms closely. -Mag also effects baby and makes baby sleepy and sedated so may make baby not as active, etc.

Pic of the biophysical profile

Table shows what they have to do to get a 0 or a 2.

Antepartum Testing: Maternal blood tests (Multiple Marker Screens)

There are multiple blood tests that can be done that can indicate a problem. Maternal serum alpha-fetoprotein (MSAFP) •Blood test on mom to check serum AFP-Used as screening tool for neural tube defects (NTDs) in pregnancy, and open abdominal wall defects •Detects 80% to 85% of all open NTDs and open abdominal wall defects early in pregnancy •Screening recommended for all pregnant women -can be done in isolation by itself, but it is part of quad screen -has to be drawn between 15 and 20 weeks. -can be positive or negative (if positive screen, mom will be offered additional testing such as the amniotic fluid AFP) First Trimester screen •looks at: PAPP-A, hCG, (both in moms serum) fetal nuchal translucency (NT)- this ultrasound finding. It will take those 3 pieces of information and will be either positive or negative. Looks at trisomy 13,18,21 and will have separate results for each of them. •11-14 weeks: benefit is you can get it earlier than the other ones; there are certain women where this test would be offered to (it would not be offered to just any mom) Triple screen •MSAFP, estriol, hCG •15-20 weeks Quad screen •MSAFP, estriol, hCG, inhibin A •15-20 weeks -all women will be offered this screen -the triple and the quad includes getting a maternal serum AFP •Is a SCREEN, NOT a DIAGNOSIS! (for all 4 of these different tests listed above, including the MSAFP alone test) Cell-Free DNA Screening •Blood test on mom and detects the amount of fetal DNA in the mother's blood is compared to known standards (blood test people have done to find out the gender really early on) •Can be performed as early as 10 weeks of pregnancy- it was not created to be offered to everyone, but it is becoming more of a routine thing, but it was created more for at risk women. •Offered to women considered to be at risk for chromosomal abnormalities (initially created for that) •98% effective at detecting Trisomy 21 and 99% effective at detecting Trisomy 13 and 18 (it is very sensitive at detecting these things). So, some women who have a positive screen, they may not even want an amnio bc it is so sensitive. -it looks at trisomy 13, 18, 21 and gender of baby

Ultrasonography

Types: •Abdominal: this is typically used after the 1st trimester, and we typically want the patient to have a full bladder bc it will push the uterus further up, making it more accessible to the ultrasound. •Transvaginal: these are usually utilized in the first trimester. You definitely want an empty bladder for this kind. This is usually first used to confirm the pregnancy. •1st trimester: usually via transvaginal; we are mainly examining for confirmation of pregnancy, is it a viable pregnancy (cardiac activity by a certain point), is it a intrauterine pregnancy (the pregnancy is in the uterus where it is supposed to be, how many gestational sacs do we see (how many babies), can assess any bleeding mom complains of and if she is possibly miscarraging. •2nd and 3rd trimesters: looking more at babies growth, estimate the fetal weight (esp. if mom has some of those complications that compromise the baby and makes the baby not grow very well), looking at anatomy (at about 20. weeks, they will do a thorough scan to look really closely at babies anatomy), evaluate placenta and placenta location. •Indications for use- See table 26.1 •Fetal heart activity •Gestational age: at any point of the pregnancy, you can estimate it but the further the pregnancy gets, the more room for error on estimation. An ultrasound estimate the 1st trimester is a lot more accurate and should line up pretty closely with birth dates. •Fetal growth •Fetal anatomy: in case the baby has anatomical malformations so we know it early and make a plan of where mom needs to go for birth and know a pediatrician surgeon in case baby will need surgery when they come out. Ultrasonography: Indications Fetal genetic disorders and physical anomalies •Nuchal translucency: this is another ultrasound finding that is associated with cardiac malformations; it is checked at a certain gestational age (between 10 and 14 weeks) and we assess the area of fluid collection at the nape of the babies neck on ultrasound. If it is abnormally thick, it is associated with cardiac and chromosome problems. -there are certain findings on ultrasound that can be associated with genetic disorders (such as the absent nasal bone or short femurs have associations with down's syndrome, but that does not mean they may have it) Placental position and function •Low lying placenta/ placenta previa •Grading of placental aging (if the pregnancy has gone past 40 weeks and we see signs of aging such as calcifications and that is a sign that it is done and does not want to work anymore- if we see signs of aging that is concerning for baby and could indicate we may have a stillbirth) Adjunct to other invasive tests •Completed with other tests such as amniocentesis to locate the fetus, placenta, and pocket of amniotic fluid (helps us guide where the needle goes) Fetal well-being: (ultrasound also helps us assess the fetal well-being) Amniotic fluid volume •Amniotic fluid index (AFI)- just by looking at amniotic fluid is helpful to see how well the baby is doing; AFI is specifically what we look at. If the AFI is low and have oligohydramnios, it can mean the baby is saying help me. (we are more worried about low amount of fluid bc it shows placental insufficiency) Biophysical profile (BPP) -the closest thing we have to a physical exam on the fetus (since we can't actually get our hands on the fetus) -Evaluates 5 markers: including amniotic fluid volume, fetal breathing movements (as the fluid moves in and out of the lungs) fetal movement, fetal tone, and the reactivity on a 20 minute tracing (NST- non-stress test) -Each finding is worth 2 points (you either get a 0 or a 2 for each of the 5 items; its either present or not) -Score is out of 10 points (ideally, you want a 10/10 and means it is a healthy fetus. 8/10 is also considered normal and we are okay with that) -If the mom had a nonreactive tracing and e followed it up with a BPP and she got an 8/10. Which we would say her baby is fine and healthy. It she got a 4/10 and there was no fetal breathing movement, no fetal movement, and that nonreactive non-stress test. If she was 37 weeks, we would be delivering that baby bc baby is not doing well and is compromised. If the mom was a 33 week gestation, we would redo tests and try to keep baby in as long as possible.

Congenital Anomalies

•Congenital disorder present at birth due to genetics or environmental •Causes abnormal development of physical, metabolic, anatomic, and/or behavioral •Maternal obesity is significantly linked to anomalies •Cardiovascular: -anatomic abnormalities in the heart that are present at birth but may not be diagnosed immediately -occurs during first trimester when many women don't know they are pregnant -some are diagnosed in utero and some not until after delivery when infant shows symptoms Symptoms at birth: ▪muffled cry ▪cyanosis not relieved with O2 ▪may have skin mottling with crying, feeding or stooling ▪may be restless, lethargy, unresponsive ▪expect respiratory symptoms since so closely related; tachypnea is common without dyspnea -report abnormal findings immediately -require prompt diagnosis and therapy: O2, diuretics to decrease workload, feeding via syringe Neural Tube Defects -Commonly due to folic acid deficiency which leads to failure of neural tube to close -Can also occur with other chromosomal abnormalities Encephalocele: ▪herniation of the brain and meninges through a skull defect ▪surgical repair and shunting to relieve hydrocephalus Anencephaly: ▪ absence of brain tissue; incompatible with life; will die soon after delivery Hydrocephalus: ▪excess CSF in the ventricles of the brain due to overproduction o Microcephaly: ▪head circumference measuring small related to brain growth ▪common from viral infection, chromosomal disorder Respiratory System Anomalies Laryngeal web: ▪Incomplete separation of the two sides of the larynx ▪Placing an ET tube can save the infant's life Choanal atresia: ▪Posterior nares are blocked; sometimes by an obstruction ▪Symptoms may be respiratory distress, cyanosis, and pallor ▪Unable to pass a suction catheter ▪Need to secure an oral airway and maintain baby in prone position to keep patent Congenital diaphragmatic hernia: The pic shows this ▪Defect in the formation of the diaphragm ▪Abdominal organs are displaced into the thoracic cavity ▪important to be diagnosed prenatally so that the baby can be born in a high risk facility to be able to quickly stabilize baby ▪even a small defect can cause respiratory issues, especially when feeding ▪large defect: will have distress at birth because of poor development of the lungs ▪Symptoms: •respiratory distress •cyanosis •heart sounds shifted to right ▪surgical repair is necessary as soon as the baby is stable ▪gastric contents are aspirated and suctioned to decompress the GI tract and prevent further compromise ▪will have chronic feeding problems, GERD if survive GU System Ambiguous genitalia ▪Closely inspect for ambiguous genitalia or abnormalities ▪Female urethral opening should be behind clitoris, any deviation could suggest clitoris is small penis ▪Can occur with conditions such as adrenal hyperplasia ▪Not assigned a gender until all testing is done ▪Can do ultrasound to look for uterus, ovaries o Hypospadias ▪Urethral opening below the glans penis or anywhere along the ventral surface of penis ▪Mild cases repaired for cosmetic reasons ▪Severe cases may require multiple surgeries ▪Do not do circumcision before discharge because some of the foreskin that is removed is sometimes used in the surgical repair of this Epispadias ▪Urethral opening on dorsal surface ▪Surgery is necessary ▪Do not do circumcision before discharge because some of the foreskin that is removed is sometimes used in the surgical repair of this -Report these along with undescended or maldescended testes