N4341 - Exam 2 (OB - Hoolapa/Welch)
Patient with pre-e now experiences a seizure, this is now classified as ________. What will you prepare for?
now classified as eclampsia prepare for delivery!
In regards to ctx, when should a nullipara come to the hospital? multipara?
nullipara: when ctx q 5 min multi: q 10 min
What is the optimal fetal position?
occiput anterior: baby looking at moms spine
What type of pushing is encouraged? Characterized by _______ (2) Allows for what?
open glottis pushing sounds like breathing and grunting allows for more gentle delivery ∴ less trauma
What hormone relaxes the pelvic joints? the soft tissues? (3)
pelvic: relaxin tissues: progesterone, estradiol, prostaglandins
What does REEDA acronym stand for? What assessment?
perineal assessment in stage 4 Redness Edema Ecchymosis Drainage Approximation of edges
Note regarding using pitocin with magnesium (2)
pitocin does NOT ↑BP will need to use more pitocin to induce ctx ∵ mag being a smooth muscle relaxer
Multiple gestation has a higher risk of what during delivery of second baby?
placenta abruption
Pregnant patient presents with continuous low back pain and a firm & tender uterus, what do you suspect?
placenta abruption (can have sudden, intense pain and may be with OR without blood)
Pregnant patient presents with sudden and intense uterine pain, what do you suspect? What color blood do you expect?
placenta abruption (can present with firm & tender uterus with continuous low back pain) blood: can be with OR without
Pregnant patient presents with painless uterine bleeding, what do you suspect? Explain what this is What color blood would you expect to see?
placenta previa: placenta attaches to cervix os (blood is from cervix opening) blood: bright red
BG goals during antepartum (2)
preprandial ≤ 92 post @ 1hr after ≤180
Why would terbutaline be used on a mom?
tocolytic to ↓contractions can counteract too much pitocin
What is the most rapid and uncomfortable phase during the first stage of labor?
transition phase (last phase) dilating from 8 to 10cm
Interventions for tachysystole (6)
turn off IV turn mom O₂ fluid bolus call doc may need terbutaline
Up to when is a laparoscopic procedures safe for a pregnant mom?
up to 26-28 weeks
What is couvelaire uterus?
uterus fills so full of blood during previa/abruption that it travels up the tubes and out to peritoneum
If patient is PROM, what will not be done until labor onset unless medically indicated?
vaginal exams
Define the fetal attitude positions; vertex military brow face
vertex: curled inward, curled back, chin tucked military: straight back, straight chin brown: chin up, looking slightly up face: chin fully up
Methods used to protect perineum (4)
warm packs open glottis, slow, gentle pushes avoid lithotomy position lubricants/massage (old school, can cause more trauma)
When is stage 1 of labor over?
when she's 10cm dilated
Define pudendal nerve block
whole perineum, vagina, etc (does not extend up to umbilicus like epidural)
When is ROM considered PPROM?
(preterm premature rupture of membrane) <38 weeks (remember preterm up to 38.0, so 37.6 is preterm)
What is inversion of uterus? What can cause this? (2)
*emergency* uterus turns inside out ∵ massive bleeding causes: excessive fundal massage or pulling on cord/placenta for removal
Define characteristics of the latent phase (3)
*first phase of 1st stage* thick to 100% effaced 0-3 cm dilated cervix moves from posterior to anterior
How does preeclampsia affect fetal heart rate? (2)
*pre-e reduces placental perfusion* late decels ↓ variability
Define characteristics of the active phase (3)
*second phase of 1st stage* 3-8 cm dilated progressing ~1cm/hr if nullipara therefore 3cm→8cm should take 5hours
How long does it take a placenta to deliver? Maximum time allowed for this?
*stage 3* 5-10 minutes if longer than 1 hour find out whats going on
Define the stages of labor
1: dilation & effacement 2: pushing & delivery 3: delivery of placenta 4: recovery
Current viability it considered _____weeks or at least ____g
24 weeks or 600g
When is a GDM screening done? Should it be done with/out meal? How is it done?
24-28 weeks NOT dependent on meal ingest 75g glucose then draw BG 1hr after; if BG>140 do a 3hr tolerance test
Mom is scheduled for c/s for triplets, how many nursery nurses should be in attendance?
3 nurses, one for each baby
What is the therapeutic level of mag sulfate? level where loss of DTRs occurs? respiratory depression? cardiac arrest?
4-6: normal 10: ↓ DTR 15: resp depression 25: cardiac arrest
When should opioids be given in relation to delivery?
<1 hour or >4 hours before delivery (trying to avoid it getting to baby @ delivery)
What BP during pregnancy is considered hypertensive? Severe hypertension?
>140/90 severe: >160/110
Pregnant patient with pre-e has a bloody nose and you notice oozing from her IV site, what is happening? Interventions? (3)
HELLP syndrome (hemolysis of RBC, low liver enzymes, low platelets) interventions: mag, antiHTN (hydralazine), blood/FFP
Qualifications for chronic HTN during pregnancy (2)
HTN before 20 weeks OR lasting >12 weeks after PP
Define BOWI
bag of waters intact
Discuss breastfeeding and DM
breast milk has antidiabetic effects ∴ ↓ risks of DM2 and obesity later in life for child
What is the antidote for mag toxicity? How is it administered?
calcium gluconate (can use Ca chloride too) give 5-10 mEq via IV over 5-10 min (SLOW!)
caput succedaneum vs cephalohematoma
caput: edema that crosses suture lines cepha: bleeding that does NOT cross suture lines
Pregnant patient with chronic HTN now presents with +2 protein in urine, what is this classified as? At greater risk for what? (2)
classified as chronic HTN w/ pre-e ↑ risk of intracranial bleed and abruption
What drugs increase risk of abruption? (2)
cocaine tobacco
Define tachysystole
ctx > 2min (>5ctx every 10min) OR ctx >90 seconds
Signs of true labor (4)
ctx stronger & more regular progressive cervical dilation bloody show (cervix opening and thinning) ROM [last 2 don't guarantee labor]
What is important to know if patient reports ROM? (5)
date time color amount odor
dilation vs effacement
dilation: how open is the cervix effacement: how thin is the cervix
Define prostaglandin E2
dinoprostone (Cervidil)
A mother is expecting twins, ultrasound shows 2 separate placentas. What type of twins do you suspect?
dizygotic twins (2 eggs, 2 sperm) (monozygotic may have seperate or share placenta)
What would you expect of labs for patient with HELLP?
elevated AST,ALT, LDH low PT, PTT, fibrinogen
How often should position be changed for a laboring mother?
every 2 hours
What do you expect of blood pressure during contractions?
expect to stay relatively the same HR will increase though!
Indications of GDM risk (3)
fasting BG >126 HbA1C >7% random BG >200
Where would fetus present with placenta previa? What would you suspect to see during FHM? (2)
fetus presents high (placenta taking up bottom portion) FHM: late decels with ↓ variability
What would you expect of cervical exam in patient experiencing false labor?
no ∆ in cervical exam after 1-2 hours
What are the s/s of mag toxicity? (5) What is the normal range?
norm: 4-6 mEq/L s/s: ∅ patellar DTR UO < 30mL/hr RR<12 ↓LOC cardiac dysrhythmias
anaphylactoid syndrome of pregnancy aka
amniotic fluid embolism deadly to fetus and mom
Why is methotrexate given to pregnant woman?
to encourage abortion for like hydatidiform mole
Discuss the scoring of fetal station
-4 = floating 0 = at ischial spines +4 = crowning
What is the dosage of pitocin?
1-2 mU/minute increasing by 1-2mU/min every 30-40 min
What can nurses do in regards to anesthesia (5)
1. monitor but NOT manage epi/spinal 2. ∆ bag/syringe if same dose with an order 3. stop infusion if safety concern, CANNOT restart 4. remove catheter after trained 5. witness consent NOT obtain consent
What is the average fluid restriction to manage pre-e?
125 mL/hr
How often should the following assessments take place during stage 4; VS fundus & lochia
BOTH q 15 min
To be considered hypertensive, blood pressure must be _____ on ____ occasions at least _____ apart.
BP >140/90 on 2 separate occasions at least 6 hours apart
When is gestational HTN expected to return to normal? Otherwise what?
BP will return to normal ~12 weeks after delivery otherwise it's now chronic HTN
How do you determine the use of cervical ripening vs pitocin? nullipara vs multipara
Bishop score (↑score = farther along) nullipara ≥9 to use pitocin otherwise ripening multipara ≥5
Describe the patho of insulin during pregnancy and if GDM
Early in pregnancy insulin production ↑ placental hormones however ↑ insulin resistance if GDM: bigger baby = bigger placenta = ↑hormones = ↑insulin resistance normal mom: body will respond by ↑insulin production but if GDM cannot
Effects of pre-e on fetus (3)
IUGR fetal hypoxia (AEB late decels and ↓ variability) oligohydramnios (<500)
What is the treatment for placenta previa and abruption? (6)
IV O₂ Left lateral placement type & cross I&O C/S if needed
Interventions for shoulder dystocia (5)
McRoberts maneuver suprapubic pressure generous episiotomy hands & knees delivers if all else fails; c/s
Does the secondary force of bearing down help with dilation?
NO! no effect on dilation
Define the fetal positions; OA OP OT
OA: baby looking at moms spine OT: baby looking at moms tummy, causes back labor (think "back to back = back pain") OP: baby looking at moms hip, causes arrest of descent @ ischial spines
Which fetal position would prolong the 1st and 2nd stages of labor? Also causing what?
OP (baby facing moms tummy, back to back) causes back labor
Define when gestational HTN occurs
after 20 weeks OR within first 24h after delivery w/out protein in urine
What should be done immediately after completion of stage 3?
aka delivery of placenta pitocin bolus! clamp those arteries down to ↓bleeding
How can you tell if its urine or ROM?
ROM: ph >6.5 and will turn paper blue (like water) urine: ph ≈5-6
Define gestational trophoblastic disease Treatment Preparation for next pregnancy?
aka hydatidiform mole fertilization of an empty egg (no fetal tissue) evacuate uterus with methotrexate dont get pregnant for 1 year after since monitoring HcG levels
What are risks associated with GDM? (4) What is done if risks are present?
UTI preterm hydramnios stillbirth (↑rates after 36w if uncontrolled sugars) if any risks present by 36w: induction or C/S
Describe the 3 hour glucose tolerance test a. how is it done b. with or without food c. testing times/values d. how to determine GDM
a) ingest 75g glucose after 3 days of HIGH CARB diet (≥150g/day) b) FASTING c) test BG when: fasting ≤92 1h ≤ 180 2h ≤ 153 3h ≤ 140 d) if 1 or more is above = GDM
Discuss the impact of the following; a. pre existing DM w/ uncontrolled sugars (2) b. GDM(2)
a. ↑ risk for loss in first trimester & congenital anomalies (mainly heart) b. macrosomia (>4000g) & nwb hypoglycemia (≤50)
Pregnant patient presents with abdominal pain and right shoulder pain, what is happening?
abdominal bleed from uterine rupture
Risk factors for hypertensive disorders during pregnancy (6)
first child w/ new partner hydatidiform mole diabetes multiple gestation (twins) primigravida age extremes of <17 or >40
Why would glucocorticoids be prescribed for a pre-e mom?
for fetal lung maturity (in case delivers preterm) given to ↑ surfactant production in fetus *takes ~48h to kick in, must repeat q 7 days
Define the following passageway shapes; ginecoide antropoide androide platipeloide
g: circle, BEST TYPE antro: up & down oval andro:triangle plat: sideways oval
What are the types of hypertensive disorders associated with pregnancy? (5)
gestational HTN (no protein in urine) preeclampsia (protein in urine) eclampsia (pre-e w/ seizures) HELLP (hemolysis of RBC, elevated liver enzyme, low platelets) chronic HTN with superimposed preeclampsia
What antiHTN med can cause tachycardia in both mom and baby?
hydralazine will ↓ BP but cause ↑HR in BOTH mom and baby
What antihypertensive drugs are used during pregnancy? (4)
hydralazine (watch for ↓BP) labetalol (cant use if asthma) nifedipine methyldopa (often used throughout pregnancy not just in crisis)
What antiHTN med can cause late decels?
hydralazine ∵ severe drop in BP ∴ placental insufficiency really monitor BP w/ hydralazine, can severely ↓ BP
Describe how GDM affects the fetal respiratory system
hyperinsulinemia causes ↓ surfactant to be produced ∴ risk of respiratory distress syndrome
Presences of fetal fibronectin during ______ is related to what?
if present during 22-34w = ↑risk of preterm labor
Interventions for cord prolapse (4)
knees to chest position (on all 4s with butt in air) Trendelenburg reposition to lift fetus off cord emergency c/s
Hypertensive mom has asthma, what medication would NOT be given to manage her BP?
labetalol dont give with asthma
If mom is 10cm dilated but reports no sensation due to epidural, what do you do?
labor down!
Define the following epidurals; laboring surgical intrathecal
laboring: all the way up to umbilicus surgical: up to nipple line intra: catheter removed! good for 4-5hours
Discuss the expected dilation during phases of 1st stage of labor
latent: 0-3 cm active: 3-8 transition: 8-10 (most uncomfortable & fastest)
Pregnant mother with preeclampsia is complaining of right upper quadrant pain, what do you suspect?
liver involvement from pre-e
Tocolytics (4)
magnesium sulfate terbutaline indomethacin (caution will close PDA!) nifedipine
What medication should be avoided during postpartum after mom got magnesium?
methergine, ↑BP and ∴ ↑ risk of bleeding
Mom has chronic hypertension, what medication do you anticipate?
methyldopa
Define prostaglandin E1
misoprostol (Cytotec)
Define monozygotic vs dizygotic twins
mono: single egg = identical, can share placenta di: 2 eggs, 2 sperm = fraternal, always different placenta
What is essential regarding labs prior to getting an epidural?
must have platelets ≥ 100,000
Define the following; fetal presentation (3) attitude (4) lie (3) position (3) station
presentation: part that enters the pelvis first (cephalic/breech/shoulder) attitude: relation of fetal parts to one another (vertex/military/brow/face) lie: relation of fetal spine to moms (vertical/horizontal/transverse) position: relation of presenting part to moms pelvis (occiput anterior/posterior/transverse) station: engagement into pelvis/ischial spines (+4 to -4)
What medicines are used for cervical ripening?
prostaglandin E1: misoprostol (Cytotec) prostaglandin E2: dinoprostone (Cervidil)
What are the defining characteristics of preeclampsia? (2)
proteinuria of +1 on dipstick OR >300mg in 24hr urine edema of face, hands, sacrum
When would furosemide be prescribed for a pregnant woman?
pulmonary edema NOT for peripheral edema
Complications of preeclampsia to mother (7)
pulmonary edema oliguria thrombocytopenia headaches hyperreflexia blurred vision seizures
How often should BG checks be done during delivery? What should be done immediately after delivery of placenta?
q 1-2 H stop insulin immediately after delivery of placenta
How often should VS be assessed during MgSO₄ infusion? (2) Reflexes?
q5-15 min during loading dose q30-60 min during maintenance infusion reflexes: q1 H
MgSO₄ should be used cautiously if patient has what type of preexisting condition?
renal impairment
Uses for naloxone (2)
reverse opioids (fentanyl/meperidine) s/e of epidural (itching/etc.)
Where will pregnant women experience appendix pain?
right flank rather than RLQ
Why should amniotomy be delayed until cervix engages?
risk of cord prolapse
What position should epidural be given?
roll into ball, curl spine forward to open vertebrae
Define uterine dehiscence vs rupture
rupture: separation of uterus and fetus or parts exit into abdomen dehiscence: separation of uterus but fetus stays in uterus
When is the safest time during pregnancy to have surgery?
second trimester
What position is patient placed after cerclage?
slight trendelenburg to ↓ pressure on cervix
What should be avoided if patient has placenta previa?
speculum and vaginal exams
Postdural puncture headache aka
spinal headache
What should you do if you suspect mag toxicity? (3)
stop infusion administer Ca⁺ gluconate 5-10 mEq IV over 5-10 min (SLOW) prepare for resp arrest interventions
How long does it take for glucocorticoids to kick in? Given how often? Used for?
takes ~48 hours given q 7 days used to ↑ surfactant production in fetus
What tocolytic has a black box warning for _______ but is still used during pregnancy?
terbutaline for cardiac risks ∵ risks outweigh benefits
When does the cervix transition from posterior position to anterior?
the latent phase of 1st stage
What port should pitocin be administered in?
the most proximal port to mom (closest) so can stop immediately w/o flushing line full of drugs into mom
Risks of using anesthesia during pregnancy (2)
↑ risk of PPH ∵ smooth muscle relaxer may prompt, rapid breast engorgement
Use of MgSO₄ puts the mom at increased risk of what? What should be given during postpartum? What should NOT be given during postpartum?
↑ risk of bleeding ∵ mag = smooth muscle relaxer give: pitocin to "clamp down" and ↓ bleeding DONT give: methergine, will ↑BP and bleeding risk
Patient on MgSO₄ drip has decreasing deep tendon reflexes, what is happening? S/S (4)
↓ DTR = mag toxicity! s/s: flushing, sweating, ↓BP, ↓CNS
Discuss the pathophysiology of edema during pre-e
↓ serum albumin (∵ protein now in urine!) ∴ H₂O leaks from vessels *edema NOT caused by FVE but vessel dysfunction
What is the MOA of MgSO₄? (2) What does each MOA result in?
↓CNS excitability ∴ seizure prevention smooth muscle relaxer ∴ ↓BP (watch it doesn't go too low!)
What would you expect of contractions for patient with placenta abruption?
↓amplitude and ↑ frequency
What BG is considered hypoglycemia in a newborn?
≤50
The first void after delivery should be what amount?
≥150 mL