OB test 3

HELLP nursing actions

Asses and Ask!!! Watch labs, medication and platelet administration, educate, and support

Who would need an amniocentesis?

AMA (advanced maternal age), history of genetic disorder Positive AFP known or suspected hemolytic disease in the fetus Ultrasound guided RESULTS IN 2 WEEKS

HELLP increases risk for

Abruption, Renal failure, liver hematoma/rupture, maternal death, PTB, fetal or neonatal death

Diagnostic Tests

Identify a disease or problem INVASIVE with FETAL RISK Yes or no the disease, problem, or illness is present. (Risk to fetus due to invasiveness of test.)

What are the advantages of CST?

Negative CST's are associated with good fetal outcomes

What diagnostic tests do I need to know?

Amniocentesis Chorionic villi sampling MRI Percutaneous umbilical blood sampling Ultrasonography

what tests can the nurses conduct?

Blood draws, nonstress test

Intrapartum management- multiples

Delivery decisions (twins typically delivered in the OR, blood ready

Autoimmune disorders before pregnancy

SLE - Lupus

Why do we watch the fetus?

To prevent or avoid poor outcomes like stillbirth

What is Chronic HTN with superimposed Pre-Eclampsia?

diagnosed with HTN before pregnancy and now has developed in pre-e

liver disease before pregnancy

toxicity, clotting issues

when is PUBS performed?

AFTER 18 weeks gestation

when is multiple marker screening done?

15 - 16 weeks

When is AFP done?

15-20 weeks

When is amniocentesis performed?

15-20 weeks

What are risks of CVS?

7% fetal loss r/t bleeding, infection, and membrane rupture 10% women experience some bleeding post-procedure

What are the advantages of AFP?

80-85% of all open NTD's and anencephalies can be detected early in pregnancy

What are advantages of CVS?

Can be performed BEFORE amniocentesis but is not recommended before 10 weeks Examination of fetal chromosomes

What is Eclampsia?

preeclampsia + seizures

What is Pre-Eclampsia?

pregnancy induced hypertension after 20 weeks

Doppler Flow

Placental perfusion Combination with other diagnostic tests to assess fetal status in IUGR fetuses SUPINE

What is the nurse's role in Multiple Marker screen?

Educate --> this is a maternal blood test that assesses for the levels of chemicals in the maternal blood to screen for certain developmental abnormalities Emotional support

What is the nurse's role in AFP?

Educate the woman about the screening test Support the woman and family Assist in scheduling diagnostic testing when results are abnormal Provide info on support groups if an NTD occurs

What are the risks of CST?

High false-positive rate unnecessary intervention CANNOT BE USED = conditions with an increased risk for PTL, Bleeding, or uterine rupture (C-section))

Antepartum management- multiples

Closer monitoring, more visits, MFM

gastrointestinal disorders before pregnancy

gallstones

Nursing actions for preeclampsia and eclampsia

Assess BP, LOC, DTRs, Lungs, Meds, Environment control, Symptom progression, Urine output and RR if on Magnesium

What are the advantages of PUBS?

Direct examination of fetal blood sample for fetal anomalies

Who is at RISK for developing IUGR?

Smokers, HTN, Diabetics, Malnourished, Persistent dehydration, Teens

A client who is 21 weeks pregnant is scheduled for an amniocentesis today. The client informs the nurse that her bladder feels full. which is the nurse's best response?

empty bladder before the test if its below 21 weeks gestation then the bladder needs to be full

What is gestational HTN?

high BP that develops in the second half of pregnancy and usually resolves after childbirth NO PRE-E

cocaine can cause

placental abruption

What is in a biochemical profile?

Chorionic Villus Sampling (CVS) Amniocentesis Percutaneous Umbilical Blood Sampling (PUBS)

Pre-Gestational Conditions

the more risk factors you have the higher the risk

assessment for preeclampsia and eclampsia

BP checks, urine dip for protein, LFTs, Clotting studies, Subjective signs: HA that meds don't help is concerning

What are the disadvantages of amniocentesis?

Risk of fetal loss fetal/placenta trauma bleeding LOF (leakage of fluid) PTL Infection Rh sensitization

indications for ultrasound in the 2nd trimester

confirm due date confirm fetal cardiac activity Confirm fetal number, position, fetal size, amnionicity, and chorionicity. confirm placental location confirm fetal weight and gestational age detect fetal abnormalities visualize for amniocentesis evaluate vaginal bleeding visualize for diagnostic tests and external version

PROM

premature rupture of membranes (before labor, the bag of water has ruptured but they are not in labor)

Which test best provides an answer to the question of whether or not the infant has a congenital defect? A. Screening B. Diagnostic test C. Biophysical profile D. Multiple marker screening

B: diagnostic test

A woman in preterm labor has an order for nifedipine (Procardia). Which assessment finding should alert the nurse to withhold the medication?

BP of 88/50

When can FALSE LOW levels occur?

Fetal death Overestimated fetal gestational age Increased maternal weight

placenta previa assessment

Painless vaginal bleeding in 3rd trimester!! Hemodynamic changes, FHR changes surgical delivery is indicated

hematologic disorders before pregnancy

anemia, clotting disorders

preeclampsia/eclampsia increase risk for

Stroke, DIC, Pulm Edema, CHR, HELLP, Abruption

TORCH infections in pregnancy

Toxoplasmosis Other Rubella CMV Hep B

Multiple gestation risks

every possible pregnancy complication PTB is #1 (overextension of the uterus which causes it to contract)

Critical Component --> Nursing Actions Related to Antenatal Tests

>>Promote Informed Decisions >>Assess for risk factors >>Establish TRUSTING relationship >>Provide information regarding the test >>COMFORT >>Reassure BOTH woman and sig. other >>Provide PSYCHOLOGICAL support >>Allow the client to vent feelings/frustrations >>DOCUMENT woman's response >>REPORT results >>Schedule follow-up visit >>REINFORCE info given to the woman by provider

The multiple marker screenings identify: A. Neural tube defects B. Cerebral palsy C. Hemolytic diseases D. Cleft palate

A

What screening tests do I need to know?

Amniotic Fluid Index (AFI) Biophysical profile Contraction stress test Daily fetal movement count Multiple- marker screening Non stress test (NST) Ultrasonography Nuchal translucency Umbilical Artery doppler flow Vibroacoustic stimulation

BOX 7-1 | Common Risk Factors

A high-risk pregnancy is one that threatens the health or life of the mother or her fetus. For most women, early and regular prenatal care promotes a healthy pregnancy and delivery without complications. But some women are at an increased risk for complications even before they get pregnant for a variety of reasons. Risk factors for a high-risk pregnancy can include: ● Existing health conditions, such as high blood pressure, diabetes, or being HIV-positive ● A history of prior pregnancy complications ● Complications that arise during pregnancy, such as gestational diabetes or preeclampsia ● Being overweight or obese ● Carrying more than one fetus (twins and higher-order multiples) ● Being ≤ 18 ● Advanced maternal age increases the risk because of pre-existing health problems and increased risk of preeclampsia and diabetes

Biophysical Profile Scoring

A score of 2 (present) or 0 (absent) is assigned to each of the five components. ● A total score of 8/10 is reassuring. ● A score of 6/10 is equivocal and may indicate the need for repeat testing in 12 to 24 hours of delivery, depending on gestational age. ● A score of 4/10 is nonreassuring and warrants further evaluation and consideration of delivery (AAP & ACOG, 2012). ● A score of 2/10 or less prompts immediate delivery. ● Fetal activity decreases or stops to reduce energy and oxygen consumption as fetal hypoxemia worsens. Decreased activity occurs in reverse order of normal development. ● Fetal activities that appear earliest in pregnancy (tone and movement) are usually the last to cease, and activities that are the last to develop are usually the first to be diminished (FHR variability)

placental abruption assessment

Bleeding Hypovolemia (going to take longer to see this because the increased blood volume), Severe abd pain/tense abdomen, Dull back pain; Fetal heart rate changes (Non-reassuring patterns)

How do I interpret a CST?

CST is considered negative or normal when there are no significant variable decelerations or no late decelerations in a 10-min strip with 3 UC's in more than 40 seconds, assessed with moderate variability POSITIVE = late decelerations of FHR with 50% of UC's (has been associated with fetal death, growth restriction, C-sections) Positive requires further attention by BPP

Pre-gestational Conditions

Cardiovascular disease Hematologic disorders Pulmonary disorders Chronic Kidney disease Gastrointestinal disorders Liver disease Venous Thromboembolic Disease Maternal Obesity Thyroid disorders Autoimmune disorders

management of preeclampsia and eclampsia

Close monitoring of mother and fetus, Magnesium Sulfate (good at preventing the seizure), Antihypertensives, anticonvulsants

How can the nurse provide support during antepartum testing?

Comfort measures (pillows, blankets) Be sensitive to cultural and social as well as modesty issues. Support pts decision

What is Percutaneous Umbilical Blood Sampling?

Cordocentesis --> removal of fetal blood from the umbilical cord --> a needle is inserted into the umbilical vein at or near placental origin Metabolic disorders Hematological disorders Fetal Infection Fetal Karyotyping **Used after U/S has detected an anomaly in the fetus RESULTS in 48 hrs

What does Antenatal Fetal Surveillance entail?

Daily Fetal Movement Count Nonstress Test Contraction Stress Test Amniotic Fluid Index Biophysical Profile Modified Biophysical Profile

More on the Risk Assessment

Demographic risk factors --> Mississippi there is pre-eclampsia & limited access to care Obstetric risk factors --> past pregnancies/ did they have c-section or PTL? Sociocultural --> cultural/religious beliefs Lifestyle --> smoking, drugs, and multiple sex partners Environmental --> what are you exposed to in your environment? (third grade teacher --> full of germs) (radiology tech) On-going assessment --> asking the same questions to ensure maternal and fetal protection Anticipatory guidance --> preparing parents for what is going to happen (milestones) **Super tired during the first trimester **Give the mother HOPE

What are the advantages/risk of Fetal Movement Counts?

Done by pregnant women Inexpensive, reassuring, and relatively easy taught No monitoring devices required NO RISKS

What are the advantages and risks of multiple marker screen?

Down syndrome and open NTD's can be identified (No risks)

trauma in pregnancy

Evaluation of mother first < than 20 weeks gestation doppler for FHR > than 20 weeks gestation EFM for 4 hours Screen for IPV Includes falls, car accidents, physical abuse Possible observation admission if abdominal trauma

What are the advantages of amniocentesis?

Examines fetal chromosomes for genetic disorders Direct examination of biochemical specimens

What are the nursing actions for CST?

Explain --> CST stimulates contractions to evaluate fetal reaction to the stress of contractions VOID before testing SEMI-FOWLERS position Monitor vitals before and every 15 min during test Interpret CST Safely administer OXYTOCIN (AVOID UTERINE TACHYSYSTOLE) Recognize adverse effects of Oxytocin

What is the nurse's role in PUBS?

Explain procedure Address questions and concerns Position client in lateral/wedged position to avoid supine hypotension Have TERBUTALINE ready as ordered in case uterine contractions occur Assess fetal well-being postprocedure for 1-2 hours Educate patient on how to count fetal movements for when she goes home

What are the nurse's role in NST?

Explain procedure --> NST uses EFM to assess fetal well-being VOID prior to procedure LIE SEMI-FOWLERS/LATERAL position Interpret FHR and accelerations Document and schedule appropriate follow-up

What are nursing actions of M-BPP?

Explain procedure --> a modified BPP is an NST and measurement of the amount of amniotic fluid SPECIAL TRAINING

What are the nursing actions with AFI?

Explain procedure --> ultrasound to measure amount of amniotic fluid to ass how well the placenta is working SPECIAL TRAINING IS NEEDED TO PERFORM

What are the nursing actions of BPP?

Explain the procedure --> BPP is an U/S eval of fetal status and involves observation of various fetal reflex activities SPECIAL TRAINING IS NEEDED

nursing actions of VAS

Explain the procedure to the woman and her family. The test uses a buzzer (in auditory stimulation) to assess fetal well-being. Position patient in a semi-Fowler's or lateral position to avoid aortocaval compression. Provide comfort measures. Provide emotional support. Interpret FHR and accelerations and conduct VAS appropriately. Report results to physician or midwife and document. Schedule appropriate follow-up.

What is Antenatal Fetal Surveillance?

Fetal movement counting Begins 32-34 weeks gestation NST, CST, AFI, BPP Typically used in high-risk pregnancy like diabetics, hypertension, AMA, fetal heart defects, multiples

Cardiovascular disease before pregnancy

Fluid overload, kidney issues, heart works harder

U/S - Abdominal

Full bladder is necessary to elevate the uterus out of the pelvis for better visualization when performed during the first half of pregnancy Supine position

The nurse is assessing all assigned patients and notes that one patient is at risk for preterm labor. Which of the following meets the criteria for preterm labor?

G1P0 at 32 3/7 weeks gestation wiht regular contractions and a change in cervical dilation

U/S - Transvaginal

Generally performed in the 1st trimester for earlier visualization of the fetus Lithotomy position Sterile covered probe/transducer inserted into the vagina

VAS advantages

Has reduced the incidence of nonreactive NSTs and reduced the time required to conduct NSTs. It differentiates nonreactive NSTs caused by hypoxia from those associated with fetal sleep states. Decreases the incidence of faults findings of a nonreactive NST

HELLP

Hemolysis Elevated Liver enzymes, Low Platelets This is the progression of PreE Liver patients are very fatigued; the toxins aren't being metabolized so you feel very weak

placenta previa increases the risk for

Hemorrhage/Hypovolemic Shock Fetal compromise due to disrupted uteroplacental blood flow, anemia, hypoxia, anoxia, death.

Defining Risks/Complications

High risk pregnancy --> one that threatens the life, health of mother or fetus Pre-gestational complications --> there before pregnancy Gestational complications --> occur during pregnancy

What are some maternal infection during pregnancy?

Human Immunodeficiency Virus (HIV/AIDS) Sexually Transmitted Infections/Diseases (STI/STD) Urinary Tract Infections (UTI) & Pyelonephritis Group B Streptococcus (GBS) TORCH Infections

Screenings

Identify those not affected (helps put clients at ease) (-AFP result) NO FETAL RISK NON-INVASIVE Help put clients at ease when tests are negative. Notes risk but does not diagnose For instance a + AFP indicates risk for genetic abnormalities. Clients are referred for a target scan or high level ultrasound and amnio. (OFFERED --> multiple marker screening and ultrasound --> other screenings are reserved for HIGH risk)

What is cervical insufficiency?

Incompetent cervix Deliver without any labor (usually a loss) Had previous cervical trauma (LACERATION) Placement of cerclage --> helps to keep the cervix closed (13-14 weeks)

How to assess a HIGH-risk pregnancy?

Indications for antepartum testing Factors to assess Biophysical (any medical conditions?)(genetic issues)(obstetric Hx) •Maternal and fetal •Psychosocial (Home-life/mental health disorders)(Lifestyle) •Maternal --> high-risk sexual behaviors •Socioeconomic/Demographic --> access of care •Maternal and familial •Environmental --> exposed to chemicals/vet offices?? *Vegan diet --> needs adequate protein

What is the nurse's role in Fetal movement counts?

Instruct woman to lie on her side while counting movements If fetal movement is decreased, EAT SOMETHING, REST, AND FOCUS on movements for an hour (NORM = 4 movements in an hour)

What are daily fetal movement counts?

Kick counts have been proposed as the primary method of fetal surveillance for all pregnancies after 28 weeks' gestation. However, many women may begin to feel fetal movements around 16-20 weeks palpate abdomen and track fetal movements daily for 1-2 hours NORMAL = 10 fetal movements within 2 hours 4 movements in ONE hour is reassuring IF no movement, NST/BPP may be needed < 4 movements in 2 hours = REPORT TO PROVIDER

Hyperemesis gravidarum

Kidney and liver function should be monitored closely due to the impact of ketosis. Hyperemesis is thought to be caused by surges in pregnancy hormones. This condition usually reaches its peak around 9 weeks of gestation and will resolve by 20 weeks. Vaginal bleeding is not an indication. Hyperemesis with the first pregnancy is a risk factor for subsequent pregnancies to also be impacted. Some women experience relief with complementary therapies such as hypnotherapy, acupressure, acupuncture, and ginger.

What are the nursing diagnoses for assessing HIGH risk pregnancies?

Knowledge deficit (1st pregnancy? may not know risk/benefit of tests) Anxiety (fear of unknown) Risk for Complication (mother and fetus) Risk for Poor Outcomes (mortality/morbidity)

U/S

Looks for blood clot, use on head for brain issue Looks for fluid filled and solid amniotic sacs Helps identify the location of the pregnancy

HELLP assessment and management

Malaise, Nausea, RUQ pain, bruising, abnormal LFTs Immediate delivery, replace platelets, treat BP

PTL, PROM, PPROM nursing actions

Medication administration, teaching, support, identify those at risk early in pregnancy

How does the procedure CST work?

Monitor FHR for 20 minutes If no spontaneous UC's, contractions can be initiated in some women by having them brush the nipples for 10 min or with IV oxytocin

U/S advantages/risks

Most accurate way to estimate a baby's due date Accurate assessments of gestational age, fetal growth, and detection of fetal and placental abnormalities* Noninvasive* Provides information on fetal structures and status* (No known risks)

MRI procedure

NO metallic objects Left lateral tilt supine (prevents hypotension) Abdominal area is scanned Interpreted by radiologist

What is a Modified Biophysical Profile?

NST + AFI NORMAL = NST is reactive and the AFI is greater than 5cm AFI < 5 = oligohydramnios

BPP Procedure and Interpretation

NST with the addition of 30 min of ultrasound observation for 5 indicators FHR reactivity Fetal breathing movements Fetal movement Fetal tone Amniotic fluid measurement

VAS risks

No adverse effects reported Not recommended as a routine procedure in high-risk pregnancies

What are the advantages/risks of NST?

Non-Invasive Easily performed NO RISKS

Doppler Flow advantages/risks

Noninvasive, allows for assessment of placental perfusion (No known risks)

gestational DM

Not present before pregnant Maternal obesity & Placental production of insulin desensitizing hormones At risk- None, Fetal macrosomia, Family history of DM, Obesity Let her know that lifestyle needs to change or diabetes will continue if they didn't have DM before pregnancy

When can HIGH FALSE Positives AFP's occur?

Oligohydramnios MULTIPLES Decreased maternal weight Underestimated fetal gestational age

Risk Assessment and Nursing Role

Pregnancy alone is a physical and emotional stressor Identify risk factors early Demographic, medical, obstetric, sociocultural, lifestyle, environmental A "normal" pregnancy can become high-risk quickly and unexpectedly Ongoing assessment of mother promotes positive outcomes Anticipatory guidance

CRITICAL COMPONENT Nursing Activities to Promote Adaptation to Pregnancy Complications

Pregnancy complications represent a threat to both the woman and fetus's health and to the emotional well-being of the family. Assessment of emotional status and coping of the entire family is necessary to provide comprehensive care. Implementing an individualized plan of care will facilitate the family's transition during an often unexpected and frightening experience (Gilbert, 2011). Responses to high-risk pregnancy can include: • Stress and anxiety about the maternal illness and its effect on the fetus, and the disruption to their home- and work-related activities. • Threats to self-esteem; the woman may feel she has somehow failed as a woman and/or is failing as a mother. Self-blaming commonly occurs for real or imagined wrongdoing. • Disappointment and frustration often occurs when goals of having a healthy pregnancy, a normal birth, and a healthy baby are impeded by a pregnancy complication. • Conflict can occur when competing and opposing goals are presented during a high-risk pregnancy. • Crisis occurs when the woman and her family are threatened by a pregnancy complication and an uncertain outcome. Some general nursing actions include the following: • Provide time for the woman and family to express their concerns and feelings, which may include apprehension, fear, anger, disappointment, and frustration. Talking can help them identify, analyze, and understand their experience and fears. Practice active listening. • Provide information repeatedly with patient and significant other(s) to facilitate a realistic appraisal of events. That includes explaining high-risk conditions, procedures, diagnostic tests, and treatment plans in layman's terms, providing ongoing updates, and clarifying misconceptions. Discussing the underlying causes of a complication with the woman may help to alleviate feelings of self-blaming and guilt. • Facilitate referrals related to the condition, which may include social services and chaplain services to enhance family coping and provide resources. • Encourage the woman and her family to participate in decision making and express preferences to enhance autonomy and patient-centered care. • If patient is hospitalized, have flexible guidelines for the family to minimize separation. • Be a skilled communicator; take emotional "temperature" in the room and convey accurate assessment of psychological state of the patient and family. • Be a witness to events, which can help during debriefing and with patient processing in high-risk situations.

who is at Risk for placental abruption

Previous abruption, HTN, Prev C/S, multiples, PPROM, uterine anomalies, abd trauma, cocaine, methamphetamine use, smoking, thrombophilia

MRI Advantages/Risks

Provides very detailed images of fetal anatomy particularly useful for brain abnormalities and complex abnormalities of thorax, gastrointestinal, and genitourinary systems (no known risks)

What is the nurse's role in an amniocentesis?

REASSURE MOM -> ultrasound to guide the procedure Explain procedure --> a needle is inserted through the abdomen into the womb to obtain amniotic fluid for testing Local anesthesia will help A FULL BLADDER may be required for ultrasound visualization if the woman is < 20 weeks' gestation PREP with betadine if indicated Label specimens Evaluate FHR throughout procedure REPORT abd cramping, LOF, bleeding, decreased fetal movement, fever and chills **DO NOT LIFT HEAVY OBJECTS FOR 2 DAYS** Administer RhoGAM post-procedure

What are BPP expectations?

Reactive NST 1+ episodes of rhythmic breathing movements of 30 seconds or movement within 30 minutes 3+ discrete body or limb movements in 30 minutes 1+ fetal extremity extensions with return to fetal flexion or opening and closing of the hand within 30 min a pocket of amniotic fluid that measures at least 2 cm in two planes perpendicular to each other

Risks of Diagnostic Testing

Recognize the risk of not having the test done? Risk of the test itself and risk after the test What are your nursing actions or interventions? Educate, answer questions, position, support, comfort, any specific follow up care based on test performed What is your role? Pre-procedure, During procedure, Post-Procedure? Its hard to give you outcomes if we don't know what's going on

Chorionic Villus Sampling

aspiration of a small amount of placental tissue (chorionic villi) for chromosomal, metabolic, or DNA testing between 10-12 weeks detects fetal abnormalities caused by genetic disorders Tests for CF DOES NOT test for neural tube defects

What is the nurse's role in CVS?

Review procedure with woman and family Explain that this test obtains amniotic fluid to test for fetal abnormalities caused by genetic problems Breathing and relaxation techniques Comfort measures and emotional support Recognize anxiety r/t test results Label specimens Assess FHR twice in 30 minutes REPORT abd pain, leaking of fluid, bleeding, fever, and chills Administer RhoGAM to Rh-negative women post-procedure as per order

more notes on trauma pregnancy

Risk for falls when you get bigger obviously Maintain modesty for the patient at all times Ask how the patient landed if they fell If they are bleeding at 27 weeks there may be an abruption going on so bleeding that far into pregnancy is not a good thing Has the fetal movement changed since the fall If the mom was a wreck she has to be cleared by the adult ER before she comes to an urgent care for the baby Watch for a good heart beat after a fall

How to position for CVS?

SUPINE = trans-abdominal LITHOTOMY = trans-vaginal Catheter inserted transvaginally or abdominally using a needle (ultrasonography assisted) Biopsy of placental tissue removed via aspiration *Results in ONE week*

More on Contraction Stress Test

Same as NST but stress is induced in the form of contractions. In other words, it measures how the fetus can handle or respond to a contraction: >> Monitor for 20 minutes; initiate UCs with nipple stim or IV oxytocin; negative test when no significant decelerations are present; >> Positive with late decelerations = increased risk of fetal death: not to be done with bleeding, risk of PTL, or previous C/S due to risk of uterine rupture Stimulate breasts or give Pitocin

PTL, PROM, PPROM management

See tocolytics on page 155. magnesium sulfate, it is a relaxant, Procardia also helps, betamethasone (12mg IM 2 doses 24 hours apart)

What are the risks of PUBS?

Similar to amniocentesis Cord vessel bleeding (hematomas) Maternal-fetal hemorrhage Fetal Bradycardia Infection risk

Substance use and IPV related to pregnancy

Smoking/tobacco (never good) Alcohol (not advised) Illicit drugs (never good) IPV (assess at every visit) Family medical history (hx of diabetes)

MRI is used when there is a

Suspected brain injury to the fetus

What is the nurse's role in antepartum testing?

Teach Provide Support Assist Conduct Certain Tests Monitor Maternal and Fetal Response

What are the risks of AFP?

The HIGH false + rate can result in increased anxiety for a mother/family as they wait for the result of further testing

interpretation of VAS

The NST using VAS is considered reactive when the FHR increases 15 beats above baseline for 15 seconds twice in 20 minutes.

Doppler Flow Interpretation

The directed blood flow within the umbilical arteries is calculated using the difference between systolic and diastolic flow. As peripheral resistance increases, diastolic flow decreases and the systolic/diastolic increases. Reversed end-diastolic flow can be seen with severe cases of intrauterine growth restriction. Considered abnormal if the systolic/diastolic ratio is above the 95th percentile for gestational age, or a ratio above 3.0, or the end-diastolic flow is absent or reversed.

more notes on pre-eclampsia vs. Eclampsia

The more protein you are spilling the more damage is done Tenderness under right breast will indicate liver compromise Magnesium can cause them to be sedated If you have reflexes less than 2, too much magnesium Anyone that is at risk for seizures needs to be in a dark quiet environment We want a mag level between 4-8 If you suspect if mag is high make sure to turn it off before anything else Babies variability will be reduced Pg 174: mag toxicity End all be all treatment is to deliver the baby

Doppler Flow Procedure

Transmission gel and transducer are placed on the woman's abdomen. Images are obtained of blood flow in the umbilical artery.

What is a Multiple Marker Screen?

Triple marker screening combines all three chemical markers --> AFP, hCG, and estriol levels --> with maternal age to detect some trisomies and NTD's Alternative to amniocentesis Quad screen adds inhibin-A to detect Trisomy 21 DECREASED estriol = NTD LOW AFP and hCG = abnormality

What is a biophysical assessment?

Ultrasound - Most common diagnostic test (location of pregnancy) (EDD) (Heartbeat at 6 weeks) (Fetal Anatomy Scan 18-20 weeks) Vaginal ultrasound usually early Abdominal ultrasound --> full bladder Vaginal ultrasound -->> EMPTY bladder

What are nursing outcomes related to HIGH risk pregnancies?

Understanding: procedure and purpose (screening and diagnosis) Informed decisions (education on informed consent) Identify & Intervene (watching maternal and fetal response) *The more risks = the HIGHER the risk*

What does tachysystole look like?

Uterine tachysystole is defined as more than 5 uterine contractions in 10 min, fewer than 60 sec between contractions, or a contraction greater than 90 seconds with a late deceleration occuring

Preterm Birth (PTB or PTD)

a birth between 20 weeks gestation and 36 6/7 weeks gestation

What is AFP?

a glycoprotein produced in the fetal liver, GI tract, and yolk sac in early gestation Tests for NTD's and VENTRAL abd. wall defects Maternal blood is drawn ABNORMAL = additional testing such as amniocentesis, CVS, or u/s to make diagnosis

What is an abortion?

a loss of pregnancy before 20 weeks (hemorrhage in the endometrium) (body reacts to chromosomal disorder in a manner of attack) RISKS --> AMA, DM, drug use, cervical insufficiency, infection NO way to stop early loss Watch for bleeding, s/sx infection

What is a contraction stress test?

a screening tool to assess the ability of the fetus to maintain a normal FHR in response to uterine contractions in women with a nonreactive NST at term gestation purpose is to identify a fetus at risk for compromise through observation of the fetal response to intermittent reduction in utero placental blood flow associated with stimulated uterine contractions

The nurse is caring for a woman with preterm premature rupture of membranes, not in active labor. Which of the following nursing actions would be included in the plan of care for this patient? Select all that apply. digital vaginal exams every 4 hours assess for signs of infection assess FHR wiht internal fetal scalp electrode report maternal fever to provider placement of a foley

assess for signs of infection report maternal fever

pulmonary disorders before pregnancy

asthma

Placenta Previa

attachment of the placenta to the lower uterine segment (LUS) of the uterus, near or over the internal cervical os instead of in the body or fundus of the uterus At Risk- Endometrial scarring, Impeded endometrial vascularization, increased placental mass If a mom comes in bleeding it could be either but if they have pain or not that will help you learn towards abruption or previa

Group B strep and pregnancy

bacteria that colonizes in vagina and rectum (test 35-37 weeks swab) (group B doesn't usually affect MOM) (baby can become septic, pneumonia, meningitis)(mom gets ABX during labor 2 doses)

HSV and pregnancy

breakout during pregnancy because of stress and treat (treat at 35 weeks if signs appear)(usually have a section)

antidote for magnesium toxicity is

calcium gluconate

Vibroacoustic stimulation (VAS)

conducted by activating an artificial larynx on the maternal abdomen near the fetal head for 1 second in conjunction with the NST. This can be repeated at 1-minute intervals up to 3 times.

indications for ultrasound in the third trimester

confirm gestational age confirm fetal viability detect fetal number, position, congenital anomalies, IUGR, detect placental abruption, previa, or maturity detect placental position, abruption, previa, or maturity assess biophysical profile assess amniotic fluid index perform doppler studies evaluate uterine and cervical structures evaluate vaginal bleeding visualize for diagnostic test and external version

ultra sound indications for 1st trimester

confirm intrauterine pregnancy confirm fetal cardiac activity detect multiple gestation assessment of amniocity and chorionicity of multiples visualization during CVS estimate gestational age evaluate the uterine structures detect missed abortion, tubal, or ectopic pregnancy, or hydatiform mole evaluate vaginal bleeding to screen for aneuploidy

How do I interpret a NST?

considered reactive when the FHR increases 15 beats above baseline for 15 seconds twice or more in 20 min in fetuses < 32 weeks, 2 accelerations peaking at least 10 bpm above baseline and lasting 10 seconds in a 20 min period is reactive NONREACTIVE = one without sufficient FHR accelerations in 40 minutes and should be followed up **Presence of repetitive variable DEcelerations that are >30 sec requires further assessment

The maternal serum alpha-fetoprotein (MSAFP) is a screening tool indicated for all high-risk pregnant clients between 15 -20 weeks gestation. A client who is 18 weeks pregnant had her blood drawn for this test. Her test results showed low levels which is associated with which disorder

down syndrome "trisomy 21" high levels are associcated with neural tube defects like spina bifada

What is an ectopic pregnancy?

fertilized egg somewhere other than uterus (usually fallopian tube) tube rupture (surgical EMERGENCY) Life threatening Hx of PID, ectopic pregnancy, untreated STI's (tube scarring) Shoulder Pain -> as the abdomen fills with blood it irritates the diaphragm, you end up with referred pain (relative to the side) Major hemorrhage (hypovolemia symptoms), pain, rigid abdomen, tense LOSS OF ONE FALLOPIAN TUBE Caught early --> methotrexate used to reabsorb the ectopic pregnancy RULE THIS OUT FIRST!!!!!

Pre-eclampsia

hypertensive, multisystem disorder of pregnancy with unknown etiology ACOG- new onset HTN after 20 weeks gestation, two BP readings at least 140/90 at least 4 hours apart, proteinuria >300 mg in24 hrs At Risk- <20 & >35, obesity, multiples, CHTN, kidney disease, SLE, DM, previous Pre-E, or Eclampsia

The client asked the nurse what a complication of the amniocentesis procedure could be. which would be the nurse's best response? Select all that apply trauma to the fetus or placenta leakage of AF preterm labor maternal or fetal infection nausea/vomitting

trauma to the fetus or placenta leakage of AF preterm labor maternal or fetal infection

Gestational diabetes mellitus (GDM)

impacts as many as 7% of pregnancies, with prevalence as high as 14% in certain populations. GDM can be significantly controlled by diet and exercise. Mother and infant are at increased risk of hypoglycemia at delivery. A morning fasting glucose check and then three postprandial glucose checks should be done over the course of the day. The postprandial checks should be below 135 mg/dL for the GDM to be considered controlled. Pulmonary edema, congestive heart failure, hepatic failure, and stroke are all risks of GDM.

when a mom has gestational diabetes, her baby will have

low blood sugar due to it being used to all that sugar in the mothers blood

placental abruption increases the risk for

maternal hemorrhage, hysterectomy, DIC, renal failure, death; fetus- LBW, PTB, asphyxia, stillbirth, death

Gestational diabetes increases risk for

maternal hypoglycemia, DKA, PreE, C/S, Chronic DM; fetal macrosomia, IUGR, hypoglycemia, shoulder dystocia, birth trauma, RDS

how does the nurse monitor maternal and fetal response?

maternal is with VS Fetal is with doppler or FHM

What is gestational trophoblastic disease?

molar pregnancy (non-viable pregnancy (no heartbeat)) (looks like a cluster of grapes) can lead to CANCER ( MUST HAVE D & C) More common in age extremes Pain, pressure, bleeding Ultrasound first and HCG level is VERY HIGH wait a year to conceive

The nurse is caring for a patient at risk for preterm labor. Which are risk factors for preterm labor?

multiple gestation history of pre term birth maternal smoking

What is amniocentesis?

needle through abdominal wall, through uterine cavity, into amniotic sac to retrieve fluid; treatment for polyhydramnios fetal lung maturity

Placenta Abruption

partial or complete placental detachment prior to delivery of fetus; Begins with hemorrhage (maternal) •Surgical delivery; STAT C/Section Very common in the south with the high levels of smoking, HTN, cocaine use etc

U/S interpretation

practitioner (radiologist, obgyn, nurse-midwife)

Eclampsia

preeclampsia + seizure

What is hyperemesis Gravidarum?

pregnant client vomits so much that there are F & E imbalances, acid/base imbalances, weight loss, and dehydration IV fluids, electrolytes, anti-emetics) Unisom with vitamin B6 Strict I/O's Daily Weights

Preterm premature rupture of membranes (PPROM)

premature spontaneous rupture of membranes after 20 weeks of gestation and prior to 37 weeks of gestation. Bleeding can occur with PPROM, but bleeding and cramping are not diagnostic. Ascending maternal infection and invasive procedures such as amniocentesis and chorionic villus sampling can cause PPROM. Management for PPROM is hospitalization and daily monitoring. Family history does not appear to be a factor in PPROM. Low body mass, not obesity, is a risk factor for this condition.

PPROM

preterm premature rupture of membranes (same thing as PROM but preterm)

STI's and pregnancy

prevention is key (protect yourself) can cause PTL/PTB or loss

PTL, PROM, PPROM risk factors and diagnosis

previous PTL/PTB, medical indications, obstetric indications (scar on uterus and they don't won't the mom contracting) , multiples, cervical issues clinical manifestations and exam: what is the patient telling you and what does the exam show

Infection can contribute to or cause which of the following high-risk pregnancy complications?

pyelonephritis ectopic pregnancy pprom

What are the advantages/risk of AFI?

reflects placental function and perfusion to the fetus as well as overall fetal condition NO RISKS

Preterm Labor (PTL)

regular contractions of the uterus resulting in cervical changes before 37 weeks gestation.

The nurse is caring for a client following an amniocentesis procedure. The nurse reviews the client's chart and notices that the client's blood type is O negative. Which does the nurse anticipate administering?

rhogam

What is Amniotic Fluid Index?

screening tool that measures the volume of amniotic fluid with ultrasound to assess fetal well-being and placental function fluid level is based on fetal urine production, which is the predominate source of amniotic fluid and is DIRECTLY dependent on renal perfusion Poor perfusion as with hypertension, smoking, DM can lead to fetal hypoxia --> persistent decreased blood flow to fetal kidneys --> decreased urine production --> results in oligohydramnios ULTRASOUND measurements of fluid in 4 quadrants of uterine cavity Average 8-24 cm, Low is < 5 cm (oligo), High is > 24 (poly)

the maternal serum alpha-fetoprotein (MSAFP) is a screening tool for certain developmental defects in the fetus. The client wants to know at what time in her gestational period the test should be performed. which is the nurse's best response?

test should be done between 15-20 weeks gestation

Cervical insufficiency

the inability of the cervix to retain the pregnancy. With this condition, the cervix will painlessly dilate, typically before 24 weeks of pregnancy. Activity restriction has no effect, and preeclampsia is not related. Cerclage is not recommended in a multigestational pregnancy. Funneling at 38 weeks would be considered normal for a term pregnancy.

A patient has just had a cerclage procedure for cervical insufficiency. which anticipatory guidance should the nurse provide prior to discharge?

the stitch in your cervix should be removed if you go into labor it is typically removed at 36 - 3y weeks

HIV and pregnancy

transmitted through placenta, delivery, breastmilk (DO NOT BREASTFEED) (treat this to help pregnancy) (no instrumentation during pregnancy) (membranes to stay intact)

What is Biophysical Profile?

ultrasound with an NST; Measures FHR reactivity, fetal movement, tone (good muscle tone to draw foot back quick), breathing, AFI; hypertension and DM; An NST is done then 30 of ultrasonography; Table 6-3 on page 146 8/10 is good Score of 2 = immediate delivery

UTI/pyelonephritis and pregnancy

untreated can cause the uterus to start contracting (dipstick for protein, ketones, glucose, leukocytes)

Doppler Flow is NOT a

useful screening tool for determining fetal compromise and therefore is NOT recommended to the general obstetric population

What is a Nonstress test?

uses the FHR patterns and accelerations as an indicator of fetal well-being a normal fetus will accelerate in response to movement FHR is monitored with the external FHR transducer until reactive (up to 40 min), while running a FHR contraction strip for interpretation Monitor for 20-40 min

multiple gestation assessment and nursing actions

uterus larger than should be for gestation Signs of PTL EFM with toco, BP monitoring (high risk for pre eclampsia), involve social work (for the increased demands and may need some extra resources )

A woman with Type I diabetes presents for her first prenatal appointment. Which anticipatory guidance would the nurse provide this patient?

watch for sigsn of preterm labor becuase diabetes increases your chances of preterm labor

What are maternal assays?

way to screen pregnant women for fetal birth defects or genetic anomalies choice depends on many factors AFP (Alpha-Fetoprotein) --> Multiple Marker Screen **AFP 15-20 weeks too early and too late will give false positive results but test to confirm or rule out; EDD is very important Do not perform with multiples** High levels = NTDs Low levels = Down syndrome (trisomy 21)

Placental accreta

when part of the placenta, or entire placenta, invades and is inseparable from the uterine wall. Can be the cause of placenta previa

Pre-gestational and Gestational

•Type1 or Type 2 •Risks to pregnancy are numerous •Maintenance of normal HgbA1C and steady blood sugars is key to positive pregnancy outcomes Let her know that lifestyle needs to change or diabetes will continue if they didn't have DM before pregnancy Baby will have low blood sugar due to it being used to all that sugar in the mothers blood