High Risk Pregnancy & Care of the NB

Hep B Immune Globulin (HBIG)

NOT given at birth but given at MD's office

Can a patient that is dx w/eclampsia leave hospital/return home?

No

Multipara

Woman who has carried a fetus to full term, b/w 39-42wks, regardless of whether the fetus is born alive/stillborn

Primipara

Woman who has delivered a fetus/multiple fetuses of 500g/20wks gestation, regardless of viability

Nulligravida

Woman who has never been preg

Primigravida

Woman who's preg for the 1st time

If a woman that's 22-28wks pregnant comes in w/reports of bright, red painless vaginal bleeding what test would be used?

Ultrasound — looking for placental abruption

Low Implantation

When the placenta is situated in the lower uterine segment away from the internal os

If someone has PIH (pregnancy induced hypertension), is being monitored closely & already has +1 pitting edema in LE, what s/s are you going to tell her to call for immediately for? Select all that apply

a. Blurred vision b. Headache c. Epigastric pain d. Drowsiness

What are you monitoring in a woman w/PIH? Select all that apply

a. Edema b. Protein in the urine c. Vision change/disturbances d. Urine output e. Deep tendon reflexes

Pregnant women are susceptible to toxoplasmosis when they are exposed to what? Select all that apply

a. Empty Cat litter boxes b. Raw or uncooked meats

The LVN reviews the potential complications of preg c the women at the prenatal outpatient clinic. Which should the LVN include? (Select all that apply)

a. Flank pain - indication of kidney infection/calculi/labor b. Muscular irritability - sx of hypertensive conditions, preeclampsia, or abruptio placenta

What are the s/s respiratory distress in a preterm NB? Select all that apply

a. Grunting b. Flaring c. Retractions d. Cyanosis

What does HELLP stand for?

a. Hemolysis b. Elevated c. Liver enzymes d. Low e. Platelet

What's a woman that's multigravida/multiple fetuses at r/f? Select all that apply

a. Over distention of the uterus b. Premature delivery

What's the major difference between previa & abruptio placentae? Select all that apply

a. Pain b. Abruptio placenta — severe pain, & rigid abdomen c. Placenta previa — painless, bright red bleeding

A woman w/abruptio placenta may go into DIC (disseminated intravascular coagulation). What s/s would make you suspect DIC? Select all that apply

a. Petechial b. Sx of bleeding c. Blood oozing from every orifice (severe cases)

What is common of postpartum hemorrhage? Select all that apply.

a. Retained placenta b. Lacerations c. Multiple fetus

What's the procedure done for an ectopic pregnancy? Select all that apply

a. Salpingectomy b. Salpingostomy

What does TORCH stand for?

a. Toxoplasmosis b. Other infections c. Rubella d. Cytomegalovirus (CMV) e. Herpes

Multigravida

Woman who has been preg more than once

Edema

1+ Minimal edema on pedal & pretibial area 2+ Obvious edema of lower extremities 3+ Edema of face, hands, sacrum, & abdomen 4+ MAssive gen edema (anasarca)

Another term for Toxemia?

Eclampsia

The LVN recognizes which as a sx of preg?

• Hearing the FHB

Habitual Abortion

• Recurrent Spontaneous Abortion w/3+ consecutive preg • Increased emotional trauma

Rh negative mother gives birth to a Rh positive infant. Should they receive Rh immune globulin & if so, in what time frame?

72hrs

What does ectopic pregnancy mean?

A fertilized ovum that's outside the uterus

If a woman is suffering from severe hyperemesis gravidarum & didn't seek med tx what could the possible outcome be?

Fetal demise/maternal demise

Complete Abortion

All products of conception are expelled from the uterus

32. What type of med to tx mastitis?

Antibiotics

At what week of gestation is a fetus considered to be a preterm baby if they are?

Anything less than 37wks

What does pathological jaundice mean?

Born w/it for the 1st 24hrs of life

What is phototherapy?

Florescent light converts bilirubin to water so it can be excreted

What's the term used when the head of the fetuses head is too big to fit through the true pelvis?

Cephalopelvic disproportion disorder; aka Fetopelvic

Disseminated Intravascular Coagulation (DIC)

D/O that results from alterations in the normal clotting mechanism • ALWAYS a 2nd dx May been seen w/: • Abruptio placentae • Incomplete abortion • Hypertensive disease • Infectious process • Post term delivery CM: • Sudden sx • C/O chest pain/dyspnea • Extremely restless • Cyanotic • Expectorating frothy blood-tinged mucus • Profound circulatory shock • Fetal & maternal death Assess: • Observe for bleeding (epistaxis, bleeding gums, petechiae) • VS, FHR, & I&O Dx: • H&H • Clotting factors - Fibrinogen levels, platelet counts, prothrombin time (PT), & partial thromboplastin time (PTT) MM: • EMERGENCY CARE!! • IV admin of fibrinogen, blood, & other substances that restore normal clotting mechanisms • Heparin by continuous infusion pump • O2 by tight fitting mask (10-12 L/min) • Monitor output (more than 30 mL) • Side-lying position if still preg

Kick Count

Daily count of fetal movements felt in 1hr while mother is resting • 3+ kicks/hr is NORMAL

Coagulopathy

Defect in blood clotting mechanisms

What's the term for fraternal twins that do not share a placenta/ovum called?

Dizygotic twins

Tocolytic Therapy

Drugs used to relax the uterus

Hydraminos

Excessive amount of amniotic fluid

What does hyperemesis gravidarum mean?

Excessive vomiting during pregnancy • Causes electrolyte, metabolic, & nutritional imbalances • Aka Pernicious Vomiting • Associated w/wt loss, dehydration, acidosis from starvation, elevated blood & urine ketones, alkalosis from loss of hydrochloric acid in gastric juices & fluid, & hypokalemia • Cause unknown • Common among unmarried white women during their 1st preg & in multifetal preg • Helicobactor pylori has been associated w/this CM: • Excessive vomiting • Dehydration • Acidosis/alkalosis • Depleted potassium = cardiac arrhythmias • Vitamin deficiencies = jaundice & hemorrhage Assessment: • Freq, amount, & character of emesis • I&O • Skin turgor & mucous membranes • FHR MM: • Maintaining acid-base & electrolyte balance • Monitor IV feeding closely • Solid intake restricted until vomiting stops!! • Bland foods (toast, crackers) • Oral hygiene - essential!! Teach: • Arranging for dietary consult • Education regarding condition including sx of improvement/deterioration & tx measures • How to assist w/her own tx • Referrals for follow-up tx

Classification of Placental Abruption

Grade I (mild-1) • Vag bleeding w/uterine tenderness & mild tetany but no distress of mom/baby. • 10-20% of placental surface is detached Grade II (mod-2) • Uterine tenderness & tetany w/or w/o external evidence of bleeding • Fetal distress, mom NOT in shock • 20-50% of surface is detached Grade III (severe-3) • Uterine atony is severe • Shock - mom • Bleeding may not be noticed • Fetus is dead • Often mom has coagulopathy • More than 50% of surface is detached

HELLP Syndrome

H - Hemolysis EL - Elevated liver enzymes LP - Low platelet count • Represents an extension of the pathology of severe preeclampsia & eclampsia • Usually occur in the 3rd trimester • Platelet count LESS than 100,000/mm3 • Elevated liver enzymes • Evidence of intravascular hemolysis S/S: • RUQ pain - PROMINENT SX!! • Tenderness d/t liver distension • Nausea • Vomiting • Severe edema • Hypoglycemia (LESS than 40 mg/dL)

What's preeclampsia?

HTN that's induced from pregnancy

A woman has 3+ consecutive spontaneous abortions; what's it called?

Habitual spontaneous abortions

What do you need to measure before you give a dosage of Terbutaline (stimulant)?

Heart rate

At any time for anyone who is pregnant & calls into the clinic to report any s/s, What's the 1st question that you ask?

How many weeks pregnant are you?

A preterm baby of a diabetic mother needs to be monitored for what?

Hypoglycemia

What are most post-term neonate is usually monitored for?

Hypoglycemia — glucose levels

What do you call a spontaneous abortion, but not all of the products of conception are expelled; what kind of abortion is that called?

Incomplete

Mastitis

Infection of the lactating breast • Occurs most often during the 2nd & 3rd wk after childbirth • Usually only affects 1 breast • Often caused by Staphylococcus aureus CM: • Flulike w/fatigue & aching muscles • Fever (101* or higher) • Chills • Malaise • Headache • Localized redness & inflammation

Chorioamnionitis

Inflammatory reaction in fetal membranes to bacteria/viruses in amniotic fluid

What is an abruptio placentae?

The placenta lifts off of the uterus

Atony

Lack of normal tone/strength

What med is used to tx preeclampsia?

Magnesium sulfate

What would the MD order for a women dx w/eclampsia?

Magnesium sulfate & bed rest

Anytime a mother is BF, or when they stop BF, & the mother suddenly develops a high fever, & a reddened area on their breast, what's that called?

Mastitis

What position would you place a woman in that has abruptio placentae?

Modified side-lying left, w/a wedge under the right hip

What's the term for identical twins that come from a single placenta & come from 1 fertilized ovum?

Monozygotic twins

In a nursery that's post term 43wk gestation infant w/an APGAR of 1 & 4 what's the 1st priority?

O2 for airway

What are the sx of placenta previa?

Painless vaginal bleeding

What is a placenta previa mean?

Placenta transplants in the lower uterine segments

Puerperal

Postpartum

What does PPD stand for?

Postpartum depression

What does PIH stand for?

Pregnancy induced hypertension — same as preeclampsia

Mortality

Quality/state of being subject to death

What's the most significant problem that occurs w/a preterm baby?

Respiratory distress

If you palpate the abdomen of a woman that is suffering from abruptio placentae, what's it going to feel like to you?

Rigid/board like between contractions

What is D&C (Dilation & Curettage) procedure?

Scrapping the uterus

If a woman gets to the point of toxemia, or eclampsia, what would the sx manifest into?

Seizures

What are the s/s of abruptio placenta?

Severe pain

Incomplete Abortion

Some, but not all of the products of conception are expelled

What should you do if they come in w/hyperemesis gravidarum & they're bordering on severe diarrhea?

Start an IV of Lactated Ringrer's

Morbidity

State of being diseased

What's a missed spontaneous abortion?

The fetus is still in utero but is no longer alive

If you have a very young teenage girl in labor you are going to be concerned w/what d/t her px development?

The head of the fetus will be too big to fit through her true pelvis

Dizygotic Twins

• 2 separate ova fertilized at the same time • Separate placentas • Genders can be different • Genetic makeup varies * May be genetic

The LVN describes chorionic villus sampling (CVS) testing to the preg pt. which statement indicates that the pt understands the procedure?

• "A cath will be inserted into my uterus" - at 8-12wks

The pt gave birth to twin babies at 32 wks, has a spontaneous abortion at 14wks, & delivered a 7# 8oz baby at 41wks. How would the LVN express this gravidity & parity info using the 5 digit system (GTPAL)?

• 31113

The pt had an abortion at 12wks, gave birth to a 4# 8oz baby at 30wks, & delivered twins at 37wks. How would the LVN express the gravity & parity info using the 2-digit system (GP)?

• 32 * Gravity (preg): 3; # of preg at 20wks at delivery: 2 Gravidity = # of preg Term births = after 37wks Preterm births = before 37wks Abortions/miscarriages Living children

5 minutes after a spontaneous vag delivery, a full term NB presents c the following: AP 120, Resp 24 & shallow, partial flexion position, crying when suctioned, & bluish extremities. What would the nurse determine as the NBs Apgar score?

• 7 * 2pts ea for HR & reflex irritability; 1pt ea for Resp effort, muscle tone, & color; resulting in a total of 7

Incompetent Cervix

• A cause of late abortion • Passive & painless dilation of cervix during 2nd trimester • "All or nothing" role of cervix • Competent or incompetent Causes: • H/O cervical lacerations during childbirth • Excessive cervical dilation for curettage/biopsy • Mother's ingestion of Diethylstilbestrol during preg of pt • Congenitally short cervix (less than 20 mm long) which is sometimes accompanied by effacement of internal cervical os • Cervical/uterine anomalies MM: • Prophylactic cerclage • Monitor contractions, sx of ruptured membranes, & infection

Gestational Hypertension (GH)

• Aka Pregnancy-Induced Hypertension (PIH) encountered during preg/early in the puerperium characterized by increasing HTN, albuminuria, & gen edema • Unknown cause • Formerly called Toxemia • Most often in primigravidas (younger than 20 older than 35) • More common in low socioeconomic groups/pts w/poor nutritional status, multi preg, DM, or fam hx of GH • Progressive disease Includes: • Preeclampsia (mild/severe) • Eclampsia (most severe from of GH) Leads to: • Increased BP • Decreased placental perfusion • Decreased renal perfusion • Altered glomerular filtration rate • Fluid & electrolyte imbalance CM: 1) Edema 2) HTN 3) Proteinuria * In that order & after the 20th wk of gestation

Valacyclovir (Valtrex)

• Antiviral S/E: • Stinging • Burning • Rash • Pruritis • Headache • Seizures • Renal tox • Phlebitis at IV site

During an emerg delivery, the LVN sees that the head is crowning. Which action by the VLN is MOST appropriate?

• Apply gentle pressure to the perineum * Gentle pressure prevents too rapid expulsion of the head, which could cause damage to both the mother & the baby

Hydralazine (Apresoline)

• Arterial vasodilator S/E: • Headache • Flushing • Tachycardia Assess for: • Tachycardia • Hypotension • Urinary output • Maintain bed rest

Severe Eclampsia

• BP increase (160/110 mmHg or higher, 2 separate occasions, 6hr apart in bed) • Obvious edema in face, hands, sacral area, abdomen, & throughout the lower extremities • Dramatic wt increase (2#/few days or a wk) • Urine testing shows albumin 3+-4+ readings • Output LESS than 500 mL/24hr

Inevitable Abortion

• Bleeding increases • Cervical os begins to dilate • Membranes may rupture Therapeutic management: • Prompt termination of preg (D&E)

Vag/Retroperitoneal Hematoma

• C/O deep severe pelvic/rectal pain • VS/skin changes • Non-obvious bleeding • Bulging mass of vulva

Environmental

• Can effect fertility & fetal development, the chance of a live birth, & the child's mental & px development • Includes: infections, radiation, chemicals (pesticides, therapeutic drugs, illicit drugs, industrial pollutants, & cig smoke), stress, & diet

Convulsion Warning Sx

• Continuous headaches • Drowsiness • Mental confusion • Visual disturbances (blurred/double vision/spots before the eyes) • Epigastric pain ("upset stomach")

Postpartum Hemorrhage (PPH)

• Early PPH: blood loss GREATER than 500 mL after vag birth/100 mL after C-section • Late PPH: Occurs after the 1st 24hrs (typically 7-14 days) • Leading cause of maternal morbidity & mortality in the 1st 24hrs after delivery Common Causes: • Uterine atony • Distention of uterus • Hydraminos • Large infant • Retained placenta/fragments of the placenta **MOST COMMON ** • Lacerations of the perineum Assess: • Uterine contraction & lochia • VS • Bleeding color, amount, source • Bladder distention - help her urinate/cath prn MM: • D&E - for Placental Fragments • Repair of lacerations - for Perineal Lacerations • Fundal massage, empty bladder, & admin Oxytocin - for Uterine Atony • Hysterectomy if failure to control bleeding • Blood transfusions

Teaching the danger signals of preg is an important responsibility of the nurse. The LVN knows which danger sx r/t severe preeclampsia & often is a warning sx of imminent eclampsia?

• Epigastric pain * Often the sx of impending convulsion & is thought to be caused by increased vascular engorgement of the liver

The LVN cares for the pt dx c hyperemesis gravidarum. The LVN recognizes that hyperemesis gravidarum is MOST likely r/t to which hormone?

• Estrogen * R/t high levels of estrogen/human chorionic gonadotropin (hCG)

Missed Abortion

• Fetus dies & growth ceases • Fetus remains in utero • Amenorrhea continues • No uterine growth is measurable • Uterus may decrease in size Therapeutic management: • Termination of preg

A pt is 48hr post-vag delivery. What will the LVN provide the pt to facilitate the healing of the pts episiotomy & relieve discomfort?

• Freq sitz baths * Promote healing by increasing circulation, keeping the perineum clean, & soothing the muscles to relax them

Biophysical

• Genetic considerations - May interfere w/normal fetal/neonatal development, result in congenital anomalies, or create difficulties for the mother • Nutritional status - Adequate nutrition, w/o which fetal growth & development cannot proceed normally, is 1 of the most important determinants of preg outcome • Medical & obstetric d/o's - Complications of current & past preg, obstetric-related illnesses, & preg losses put the pt at risk

High Risk Pregnancy

• One in which the life/health of the mother/infant is jeopardized bby a d/o that's associated w/or exists at the same time as the pregnancy • Extends 6wks after delivery for the mother

Hydatidiform Mole (Molar Preg)

• Gestational trophoblastic disease • Complete (classic) & Partial mole • Occurs in 1/1500-2000 preg in the US & Europe; higher in Asian countries • Possibly d/t ovular defect/nutritional deficiency • Higher incidence if taking Clomiphene (Clomid) in early teens/older than 40 yrs CM: • Grapelike clusters • Uterus is larger than expected for the duration of the preg • Vag bleeding • Dark brown/bright red & either scant/profuse bleeding • Anemia • Excessive nausea & vomiting • Abdominal cramps • Uterine distension • Sx of hyperthyroidism Dx: • U/S • Amniography • Measurement of HCG level in blood MM: • Most abort on their own • Suction curettage • Rh0(D) immunoglobulin given to Rh neg moms • AVOID PREGNANCY FOR AT LEAST 1 YEAR!! • Freq HCG level evals

Ectopic Preg

• Implantation outside the uterus, usually the fallopian tube (95%) • Can occur in the abdominal cavity, an ovary, ligaments, & the cervix • Higher incidence in nonwhite older women (over 35), those w/fallopian tube scarring, pelvic infection, surgery, STD, PID, & those requiring assisted reproductive techniques to conceive, IUDs, anatomical/functional defects in fallopian tubes, cig smoking, & vag douching • Occurs in 1/100 preg; 3/4 of them become symptomatic & dx during 1st trimester * Significant cause of maternal morbidity & mortality (1/800 deaths in cases in North America) CM: • Slight vag bleeding • Hypovolemic shock • Sx of peritoneal irritation (sharp localized 1-sided pain/pain referred to the shoulder) • Rigid, tender abdomen Dx: • U/S • Labs MM: • Salpingectomy (removal of tube) or • Salpingostomy (repair of the tube) • Blood replacement therapy • Methotrexate (single/multi doses) - UNRUPTURED EP

Mild Eclampsia

• Increased BP (30 mmHg systolic & 15 mmHg diastolic or 140/90) • Edema in face, hands, & ankles • Wt increase of 3#/mo in 2nd trimester & 1#/wk in the 3rd • Urine testing shows 1+-2+ albumin readings • Output is at LEAST 500 mL/24hr

Mutlifetal Preg

• Involves twins - 1/85 births in the US; triplets 1/8100 births; rarer w/preg involving 3+ fetuses Risks: • Spontaneous abortions • Maternal anemia • GH • Hydraminos • Placenta previa • Abruptio placentae • More congenital anomalies, problems w/entangled cords, & growth problems • Complicated labor • Preterm labor • Abnormal presentations CM: • Leopold's maneuver • Auscultation of 2 distinct heart tones • Ulltrasound

Eclampsia Seizure Precautions & Interventions

• Keep environment quiet & nonstimulating w/subdued light • Padded side rails & have suction & O2 equip & airway ready to use • Call bell in reach • Emerg med tray accessible: - Hydralazine (antihypertensive vasodilator) - Magnesium Sulfate - Calcium Gluconate (antidote for Mag Sulf tox) • Emerg birth pack accessible • Restrict visitors • Side-lying position

Post term infants are at r/f mortality r/t what?

• Lack of O2 hypoxemia — b/c the placenta has worn out (40wks & it's done)

Sociodemographic

• Low income - Poverty underlines many other r/f's & leads to inadequate financial resources for food & prenatal care, poor gen health, increased r/o med complications of preg, & greater prevalence of adverse environmental influences • Lack of prenatal care - Failure to dx & tx complications early is a major r/f arising from financial barriers/lack access to care - Cultural beliefs that don't support this need & fear of the health care system & its providers • Age - Women at both ends of the childbearing age have a higher incidence of poor outcomes - age may not be a r/f in all cases *Adolescents: More complications are seen under the age of 15, 60% higher mortality rate than those over 20 & in preg occurring less than 3yrs after menarche - Complications include: anemia, gestational hypertension (GH), prolonged labor, & contracted pelvis & cephalopelvic disproportion - Long term: lower educational status, lower income, increased dependence on government support programs, higher divorce rates, & higher parity *Mature mothers (over 35): Not from age aloen but from prev considerations such as # & spacing of prev preg, genetic disposition of the parents, med hx, lifestyle, nutrition, & prenatal care - Med conditions: HTN & GH, diabetes, extended labor, C-sections, placenta previa, abruption placentae, & death - Fetus is at a greater r/f low birth wt • Parity - The # of prev preg is a r/f that's associated w/age & includes all 1st preg esp a 1st preg at either end of the childbearing age spectrum - The incidence of GH & dystocia is higher w/1st birth • Marital status - Greater r/f GH often r/t inadequate prenatal care& a younger childbearing age • Residence - Availability & quality of prenatal care varies widely w/geographic residence - Women in metropolitan areas have more prenatal visits than those in rural areas, who have fewer opportunities for specialized care & a higher incidence of maternal mortality • Ethnicity - Not a major r/f - Race is an indicator of other sociodemographic r/f - AA have highest rate of premies & low birth wt

The LVN reinforces teaching about attachment in childbirth education classes in the clinic. Which behavior does the LVN identify as enhancing parental attachment?

• Making eye contact c the baby

Septic Abortion

• Malodorous bleeding • Elevated temp • Cramping • Cervical os opened • Abdominal tenderness Therapeutic management: • Immed termination of preg • C&S • Broad spectrum of abx therapy (Ampicillin) • Tx for septic shock

Eclampsia

• Most SEVERE from of GH • Main sx = SEIZURES w/tonic-clonic phases followed by a coma generally • Elevated BP, albuminuria, & oliguria DX: • Hct • BUN • CBC • Clotting studies • Liver enzymes • Urine - protein & SG • 24hr urine - creatinine & protein clearance • Electrolyte panels • Stress tests, amniocentesis, estriol levels, U/S MM: • Mild: may be tx at home • Severe: may need hosp • Bed rest in left lateral recumbent position • Well balanced adequate protein diet • Mod sodium intake • IV therapy & electrolytes • Magnesium sulfate • Sedatives & antihypertensives ** Calcium Gluconate = antidote for Mag Sulfate

Factors

• Mother - Hemorrhage - Traumatic labor/birth - Infection - Psychosocial factors - Abn VS - Prev med conditions (diabetes, cardiovascular disease) • Infant (High Risk) - Resp distress (continuing/developing sx) - Asphxiation (Apgar 6 at 5min - Preterm infants; dysmature infants - Cyanosis/suspected cardio disease; persistent cyanosis - Major congenital malformations requiring surg; chromosomal anomalies - Convulsions, sepsis, hemorrhagic diathesis, or shock - Meconium aspiration syndrome - CNS depression for longer than 24hrs - Hypoglycemia - Hypocalcaemia - Hyperbilirubinemia • Infant (Mod Risk) - Dysmaturity (wt b/w 2000-2500g) - Apgar less than 5 at 1min - Feeding problems - Multifetal birth - Transient tachypnea - Hypo/hypermagnesemia - Hypoparathyroidism - Jitteriness/hyperactivity - Cardiac anomalies not requiring immed cath - Heart murmur - Anemia - CNS depression for less than 24hrs

The LVN admits the pt who has had 7 spontaneous abortions b/w 8 & 19wks of preg to the outpatient clinic. Which term does the LVN use to describe this pt?

• Nullipara * Pt who has never produced a viable fetus that has reached 20wks gestation

An infant is born prematurely & is being d/c home c O2 & an apnea monitor. Which parental behaviors would cause the LVN to report to the RN immed?

• Parents only touch infant when absolutely necessary * Infant touch is very important & is a sx of bonding c the infant; parents who don't touch the infant show sx of poor bonding & are at r/o abusing/neglecting the infant

The preg neighbor calls the LVN & states "Please come quick. Hurry, I'm not going to make it to the hospital!" Upon arrival, the LVN sees that the woman's perineum is bulging. Which action should the LVN take 1st?

• Place a clean towel b/w the woman's legs * Delivery is imminent, contamination is minimized by catching NB on clean towel

What position do you place a pregnant woman who has prolapsed cord protruding from her vagina?

• Place her in the Knee to chest position --- do not put in Trendellenburg b/c gravity can compress the cord

Placenta Previa

• Placenta implants in the lower uterine segment • Complete w/total coverage; partial w/incomplete coverage; & marginal (indicates only an edge of the placenta approaches the internal os) • Occurs in 1/200 preg • Cause unknown • Placenta separates from uterus at the internal os of the cervix R/F: • Prev C-sections • Multiple gestation • Closely spaced preg • Advanced maternal age (35+) CM: • PAINLESS bright red vag bleeding occurring after 20 wks gestation - MAIN SX!!! * Bleeding may be intermittent, occur in gushes, or continuous (rare) • Soft relaxed nontender uterus of normal tone DX: • Double setup procedure MM: • C-section birth (delayed if possible after the 36th wk) • Stays in hosp under close supervision • Hysterectomy Teach: • Assessing vag d/c/bleeding after urination/BM • Counting fetal movements • Assessing uterine activity • Foregoing sex

Abruptio Placentae

• Premature sesparation of the normally implanted placenta from the uterine wall • Generally occurs LATE in preg or during LABOR • Occurs in about 1% of preg • Cause unknown • Leading cause of maternal death Predisposing factors: • Trauma (blunt external abdominal [MVAs or maternal battering]) • Chronic HTN • GH • Cocaine users CM: • SUDDEN SEVERE PAIN = MAIN SX!! • Uterine rigidity • Increased uterus • Strong constant contractions (tetany) Assess: • Duration, amount, color, & characteristics of bleeding • VS • Pain • FHR • Emotional response DX: • H&H • Hormone studies - determines fetal death • U/S MM: • EMERGENCY!!!! • Modified side-lying position w/wedge under right hip • Monitor blood & fluid replacement therapy • Retention cath • O2 available • IV/blood replacement therapy

Which intervention will the LVN implement from the POC immed after a pts episiotomy repair?

• Provide ice packs * Ice can help to reduce edema at the episiotomy site & soothe the area by constricting vessels & reducing the vascular response of inflammation; ice is recommended in the 1st few hrs after episiotomy

Nifedipine (Procardia)

• Relaxes smooth muscles (tocolytic) • Inhibits uterine contractions in preterm labor

Lung Surfactant Colfosceril Palmitrate (Exosurf [synthetic] Beractant (Survanta [natural lung surfactant])

• Replaces natural lung surfactant that maintains lkung inflation & prevents lung collapse • Used to tx & prevent RDS in premature neonates S/E (Synthetic): • Apnea • Pulmoary hemorrhage • Pulmoary air leak S/E (Natural): • Transient bradycardia • O2 desaturation • Hypotension • Apnea * Admin endotracheally only!!

The LVN observes a NB born to a mother who's addicted to heroin. What will the LVN expect to observe?

• Restlessness & tremors * Neonatal abstinence syndrome; intrauterine exposure to opioids; excitability seen; increased muscle tone, tremors, irritability & restlessness, high pitched & excessive crying

Naloxone Hydrochloride (Narcan)

• Reverses CNS & resp depression caused by narcs (opiates) • Competes w/narcs at receptor sites

Psychosocial

• Smoking - Strong, consistent, causal relationship has been established b/w maternal smoking & reduced birth wt • Caffeine - Birth defects in humans haven't been r/t caffeine consumption. - High intake (3+ cups/day) has been r/t a slight decrease in birth wt • Alcohol - Exerts A/E on the fetus, resulting in FAS, fetal alcohol effects, learning disabilities, & hyperactivity • Drugs - Fetus may be adversely effected by through several mechanisms. - They can cause metabolic disturbances, produce chem effects, or depress/alter CNS function - This category includes meds rx by a HCP/bought OTC, as well as commonly abused drugs such as heroin, cocaine, & marijuana • Psychological status - Childbearing triggers profound & complex physiologic, psychological, & social changes w/evidence to suggest a relationship b/w emotional distress & birth complications - This r/f includes: specific intrapsychic disturbances & addictive lifestyles

Terbutaline (Brethine)

• Stim beta-adrenergic receptors of the sympathetic NS • Results prim in bronchodilation & inhibition of uterine muscle activity • Increases pulse & widens pulse pressure S/E: • Maternal & fetal tachycardia • Palpitations • Cardiac arrhythmias • Chest pain • Wide pulse pressure • Dyspnea • Tremors • Weakness • Dizziness • Headache • Hyperglycemia • Nausea • Vomiting • Skin flushing • Diaphoresis

Cerclage

• Technique that uses suture material to constrict the internal os of the cervix • Placed at 10-14 wks gestation • Rarely performed after 26 wks • Refrain from sex, prolonged standing (more than 90 min), & heavy lifting • Removed at 37 wks or left for C-section Risks: • Premature rupture of membranes • Preterm labor • Chorioamniontitis

Spontaneous Abortion

• Termination before age of viability (or 20wks in the US) • Referred to as a miscarriage & occur usually during the 1st trimester (10-15%) • More than half are caused by abnormal embryonic development, chromosomal defects, & inheritable d/o's, maternal advanced age & parity, chronic infections, chronic debilitating diseases, poor nutrition, rec drug use 2 types: • Spontaneous from natural causes • Therapeutic (including elective) d/t med/personal reasons CM: • Bleeding - MAIN SX!! • Cramps/backache Classified as: • Threatened • Inevitable • Complete • Incomplete • Missed • Septic • Habitual MM: • IV fluids • Blood transfusions • D&C or D&E • Iron supplements

A pt is 6 days postpartum. The LVN observes the pt when visiting the pts home. Which observation should the LVN recognize is indicative of postpartum blues?

• The pt is sad, tearful, & has intermittent neg thoughts * Postpartum blues are transitory in nature, occur in 50-80% of women following delivery, are self-limiting, & are characterized by labile mood, tearfulness, sadness, anxiety, & tension

Monozygotic (Identical Twins)

• Twins that share 1 fertilized ovum • Sometimes share the placenta • Have separate umbilical cords • Identical genetic makeup • Same gender

Threatened Abortion

• Unexplained bleeding & cramping • Fetus may/may not be alive • Membranes intact • Cervical os closed Therapeutic management: • Decreased activity • Sedation • Avoidance of stress & orgasm

Penicillin

• Used for group B Streptococcus • Admin after C&S is completed

A pt is in labor & has been in the 1st stage for over 12hrs. Contractions are mild & far apart. Progress is very slow & the fetus hasn't descended into the pelvi as would normally be expected. The LVN knows this is called what?

• Uterine dystocia

For the 1st 24hrs after childbirth:

• Uterus should be the size of a grapefruit & firm • At the level of the umbilicus • Lochia - red & mod amount Dangerous: • Saturation of more than 1 peripad/hr • Saturation of more than 1 peripad in min

The LVN is caring for a pt 2hrs after a c-section. What are the MOST important observations for the LVN to make at this time?

• VS, lochia, fundal ht, & incisional dressing