OB EXAM 1

non stress test

- 3rd trimester, noninvasive procedure that monitors FHR to fetal movement. a doppler transducer used to monitor FHR and tocotransducer to monitor uterine contractions attached to moms belly. mom presses button when she feels movement - indications - potential dx: assessing for an intact fetla CNS during third trimester. ruling out the risk for fetal death in clients who have DM. used twice a week starting at 28-32 - client presentation: decreased fetal movement, intrauterine growth restriction, post maturity, GDM, GHTN, maternal chronic HTN, hx of previous fetal demise, advanced maternal age, sickle cell disease, isoimmunization - if theres no fetal movement, vibroacoustic stimulation can be activated for 3 seconds on moms ab to wake fetus - interpretations of findings - reactive if the FHR is normal baseline with moderate variability, - reactive NST: accelerates at least 15 min (10 min prior to 32 weeks) for at least 15 seconds (10 seconds prior to 32 weeks) and occurs 2 or more times during a 20 min period - nonreactive NST: a test that does not demonstrate at least 2 accelerations in a 20 min window. if so a contraction stress test or BPP is indicated

high-risk pregnancy: quad marker screening

- A blood test that ascertains information about the likelihood of fetal birth defects. It does not diagnose the actual defect. It can be performed instead of the maternal serum AFP yielding more reliable findings. Includes testing for: hCG, AFP, Estriol, and Inhibin. Preferred at 16 to 18 weeks gestation - hcg: a hormone produced by the placenta - alpha-fetoprotein (AFP): protein produced by the fetus - estriol: a protein produced by the fetus and placenta - inhibin A: protein produced by the ovaries and placenta - indications - risk for giving birth to a neonate who has a genetic chromosomal abnormality - interpretations of findings: low levels of AFP can indicate risk for Down syndrome, high levels of AFP can indicate a risk for neural tube defects, levels higher than the expected reference range of hcg and inhibin A indicates a risk for Down syndrome - lower levels than expected reference range of estriol can indicate a risk for Down syndrome

expected vital signs

- BP are within pre pregnancy range during first trimester. systolic: slight or no increase from pre pregnancy levels. diastolic: slight decrease around 24 to 32 weeks and will gradually return to prepregnancy level by the end of pregnancy. - supine hypotensive syndrome or supine vena cava syndrome: s/s: dizziness, light headedness, pale, clammy skin. encourage to lay left lateral side, semi fowlers, or if supine with a wage placed under one hip to alleviate pressure to the vena cava - pulse: pulse increases 10-15/min around 32 weeks of gestation and remains elevated throughout pregnancy - respirations: unchanged or slightly increased. changes due to the elevation of the diaphragm by as much as 4 cm as well as changes to the wall to facilitate increased maternal oxygen demands. some SOB might occur

fourth stage

- Begins with the delivery of the placenta and includes at least the first 2 hr after birth - maternal vs, fundus, lochia, urinary output, baby friendly activities - assess bp and pulse every 15 minutes for the first 2 hours and determine the temp at the beginning of the recovery period then assess every 4 hour for the first 8 hour after birth then at least every 8 hr, assess funds and loch every 15 minute fir the first hour, massage uterine funds or admin oxytocics for uterine tone to prevent hemorrhage, encourage voiding to prevent bladder distention, assess episiotomy or laceration remain for erythema (redness of skin), bonding, let mom nap

high risk pregnancy: chorionic villus sampling

- CVS is assessment of the portion of the developing placenta (chorionic villi) which is aspirated through a thing sterile catheter or syringe inserted through the ab wall or intravaginaly through the cervix under ultrasound guidance - first trimester alternative to amniocentesis with one of its advantages being an earlier dx of any abnormalities. performed 10-13 weeks of gestation - indications - potential dx: risk for giving birth to a neonate who has a genetic chromosomal abnormality (cannot determine spina bifida or anencephaly) - drink plenty of water to fill bladder for posting of the uterus - complications: spontaneous abortion (higher risk with CVS than amniocentesis, risk for fetal limb loss (greater risk prior to 9 weeks of gestation), miscarriage, chorioamnionitis and rupture of membranes

chlamydia

- Caused by the bacterium Chlamydia trachomatis - often asymptomatic, if left untreated it can lead to pelvic inflammatory disease (PID) in women and cause infertility. recommended yearly screening in women younger than 25. all pregnant women should be screened at first prenatal visit and prescreened in 3rd trimester if younger than 25 and at high risk - expected findings - males: urethral discharge, dysuria, mucoid or watery urethral discharge - females: dysuria, urinary frequency, spotting or postcoital bleeding, mucopurulent endocervial discharge, easily induced endocervical bleeding - lab tests: urine culture for men, endocervical culture preferred for female clients - pregnant clients should be retested 3 weeks after meds - meds: azithromycin or amoxicillin. admin erythromycin to all infants following delivery

human papilloma virus

- HPV is the most common STI and some can have genital warts and cancers - spread through oral, vaginal, and anal sex. c section needed if there are warts - routine screening for women 21-65 - expected findings: burps in genital area that might hurt or itch, small warts or group of warts that look like cauliflower, abnormal changes to the cervix that can detect a Pap test - lab tests: Pap test with or without HPV. women 21-29 should have Pap test every 3 years. women 30-65 should have pap and HPV every 3 years - women older than 65 should be screened foe cervical cancer - dx tests: genital warts are dx by provider on appearance, based on Pap test result, colposcopy and biopsy can be performed to diagnose cervical precancer and cancer - meds: client applied cream such as imiquimod or trichloroacetic acid application - laser therapy or cone biopsy for precancerous. for pregnant women further tx continues after birth - vaccine given between 9-26 year old but usually 11-12

first stage

- Lasts from onset of regular uterine contractions to full effacement and dilation of cervix (longer than second and third stages combined) - perform Leopold manuvers, vaginal exam as indicated if no evidence of progress to allow the examiner assess if its true labor and whether membranes have ruptured (encourage deep breathing prior to vaginal exam, monitor cervical dilation and effacement, monitor station and fetal presentation, prepare for impending delivery as the presenting parts move into positive stations and begins to push (crowning), assessments for rupture of membrane (assess FHR to ensure there is no fetal distress from possible umbilical cord prolapse, which can occur with gush of amniotic fluid, verify alkaline amniotic fluid using nitrazine paper, assess amniotic fluid), bladder palpitation on regular basis to prevent bladder distention, temp every 4 hours (1-2 hours is membranes have ruptured) - teach breathing, effleurage, diversional activities, upright positions, application of warm/cold packs, ambulation, hydrotherapy, encourage voiding every 2 hrs - active phase: client/fetal monitoring, frequent position change, encourage voiding at least every 2 hours, encourage deep breathing before and after modified paced breathing, provide nonpharm comfort measures, provide pharm pain relief as prescribed - transition phase: continue voiding every 2 hours, monitor and support client/fetus, rapid pant pant blow breathing pattern, discourage pushing until cervix is fully dilated, listen for bowel movement comments, prepare for birth, observe perineal bulging or crowning, bear down with contractions once cervix is dilated

preprocedure

- Leopold maneuver: ab palpation of the number of fetuses, presenting part, lie, attitude, descent, and probable location where fetal heart tones can be best auscultated on woman ab - external electronic monitoring (tocotransducer): separate transducer applied to the maternal ab over fundus that monitors uterine activity - external fetal monitoring (EFM): transducer applied to the maternal abdomen to assess FHR patterns during labor and birth - labs: GBS, urinalysis (clean catch), blood tests (CBC and ABO if not previously done)

CHAPTER 13 fetal assessment during labor

- Leopold maneuvers: external palpitations of the maternal uterus through the ab wall to determine: number of fetuses, presenting part, fetal lie, and attitude, degree of descent of the presenting part into the pelvis, location of the fetus back to assess for fetal heart tones - vertex presentation: fetal heart tones should be assessed below mothers umbilicus in either right or left lower quadrant of ab - breech presentation: fetal heart tones should be assessed above the mothers umbilicus in either the right or left upper quadrant of the ab - considerations: empty bladder before assessment, supine position with knees flexed and pillow under head, wedge under hip to displace uterus. head should feel round and firm , breech should feel irregular and soft.

premature rupture of membranes and preterm premature rupture of membranes

- PROM: spontaneous rupture of amniotic membrane 1 hour or more prior to the true unsent of labor - PPROM: premature spontaneous rupture of membrane after 20 weeks of gestation and prior to 37 weeks of gestation - risk factors: infection. chorioamnionitis - expected findings: gush or leakage of clear fluid from vagina, temp elevation, increased maternal HR, foul smelling fluid or vaginal discharge, ab tenderness, assess for prolapsed umbilical cord (abrupt FHR variable or prolonged deceleration, visible or capable cord at the Introits) - lab tests: positive nitraszine paper test (blue, ph 6.5-7.5) or positive ferrying test - prepare for birth, obtain vagina and rectal cultures for strep b chlamydia and neisseria gonorrhea, avoid vaginal exams, assess vital signs every 2 hours and report temp greater than 100, assess FHR and uterine contractions, adhere to bed rest, hydration, obtain abc, perform daily fetal kick counts meds: ampcillin, betamethasone (single dose given at 24-31 weeks with PROM to reduce risk of perinatal mortality, respiratory distress, and other morbidities. assess for pulmonary edema: listen to lungs, hyperglycemia in mom and baby, and baby heart rate) - client will be discharged if dilation is less than 3 cm, no evidence of infection, no contraction, and no malpresentation, limited activity, hydration, daily kick counts or fetal movements, remain from inserting anything in vagina, abstain from intercourse, avoid tub baths, wipe from front to back, check temp every 4 hours

TORCH infections

- Toxoplasmosis Other (hepatitis) Rubella Cytomegalovirus Herpes simplex virus. group of infections that can cross placenta and have teratogenic (disturbs development of embryo) effects on the fetus. - risk factors: T- consumptions of raw or undercooked meat or handling cat feces. manifestations are similar to flu or lymphadenopathy. O- hepatitis A and B, syphilis, mumps, parvovirus B19, and varicella zoster. can be associated with congenital anomalies. R- (German measles) contracted through children who have rashes or neonates that are born to women who had rubella during pregnancy. C- member of herpes virus family is transmitted through droplet infection from person to person, a virus found in semen , cervical and vaginal secretions, breast milk, placental tissue, urine, feces, and blood. latent virus can be reactivated and cause disease to the fetus in utero or during passage during birth. H- (HSV) is spread by direct contact with oral or genital lesions. transmission to the fetus is greatest during vaginal birth if the woman has active lesions - expected findings: T findings similar to flu or lymphadenopathy (malaise, muscle aches flu like symptoms), R symptoms of joint and muscle pain with rash, mild lymphedema, fever, and fetal consequences which include miscarriage, congenital anomalies, and death, C asymptomatic or mono like manifestations, H symptoms consisting of painful blisters and tender lymph nodes, presents with lesions and tender lymph nodes, miscarriage, preterm labor and intrauterine growth restriction. c section is recommended for early signs or active herpes - lab tests: for herpes collect cultures - dx tests: TORCH screen: immunologic survey used to identify existence of these infections in the mother to identify fetal risks or newborn. prenatal screening - administer antibiotics as prescribed. treatment toxoplasmosis includes sulfonamide or combination of pyrimethamine and sulfadiazine (potentially harmful to fetus, but parasitic tx is essential) - no tx cytomegalovirus so just preventive

FHR patterns

- accelerations: variable transitory increase in the FHR above baseline. - healthy fetal/placental exchange, intact fetal central nervous system, vaginal exam, uterine contractions, fundal pressure - reassuring, no interventions required, indicate reactive nonstress test - fetal bradycardia: less than 110/min for 10 min or more - causes: uteroplacental insufficiency, umbilical cord prolapse, maternal hypotension, prolonged umbilical cord compression, fetal congenital heart block, anesthetic meds, viral infection, maternal hypoglycemia, fetal heart failure, maternal hypothermia - discountinue oxytocin, assist to side lying position, admin oxygen by mask 10L, insert IV and admin maintenance fluids, admin a tocolytic med as prescribed, notify provider - fetal tachycardia: greater than 160/min for 10 mins - causes: maternal infection, chorioamnionitis, fetal anemia, fetal cardiac dysrhythmias, maternal use of cocaine or methamohetamines, maternal dehydration, maternal fetal infection, maternal hyperthyroidism - admin prescribed antipyretics for maternal fever, admin oxygen by mask 10L, administer IV fluid bolus - decrease or loss of FHR variability: decrease or loss of irregular fluctuations in the baseline of the FHR - causes: meds that depress CNS (narcotics, barbiturates, tranquilizers or general anesthetics), fetal hypoxemia and metabolic academia, fetal sleep cycle (minimal variability sleep cycles usually do not last longer than 30 mins), congenital abnormalities - stimulate fetal scalp, scalp electrode, place client in left lateral position - early decelerations: slowing of FHR with start of contraction with return of FHR to baseline at the end of the contraction - causes: compression of fetal head resulting from contraction - no intervention needed - late deceleration: slowing of FHR after contraction has started with return of FHR to baseline well after contraction has ended - causes: uteroplacental insufficiency causing inadequate fetal oxygenation - place client in side lying position, insert iv and increase rate of IV fluid admin, stop oxytocin, admin oxygen 8-10 L, elevated clients legs, notify provider, prepare for assisted vaginal birth or cesarean birth - variable decelerations: transitory, abrupt slowing of FHR less than 110/min, variable in duration, intensity, and timing in relation to uterine contraction - causes: umbilical cord compression - reposition client from side to side or into knee chest, discontinue oxytocin, admin oxygen 8/10L, vaginal exam, assist with amnioinfusion

nursing interventions

- acknowledge clients concerns about pregnancy and encourage those feelings - discuss expected physiological changes and possible timeline for a return to the pre pregnant state - assist in setting goals for post part period for selfcare and newborn care - refer counseling if body image concerns appear to have negative impact on the pregnancy. - provide education about the expected physiological and psychosocial changes. how to resolve common discomforts are reviewed during prenatal visits. - follow up visits and contact provider if there is any bleeding, leakage or fluid or contractions during pregnancy.

risk factors

- age, culture, ed, and socioeconomic issues could affect nutrition during pregnancy - adolescents might have poor nutrition habits (a diet low in vitamin and protein, not taking nutritional supplements) - vegetarians might have low protein, calcium, iron, zinc, and vitamin b12 - nausea and vomit - anemia - eating disorders such as anorexia or bulimia - appetite disorder: pica (craving nonfood substances like dirt or clay) - excessive wt gain can lead to macrosomnia and labor complications - inability to gain weight can lead to low birth wt of baby - financially unable to purchase food

amniocentesis

- aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into clients uterus and amniotic fluid sac under direct ultrasound guidance locating the placenta and determine the position of the fetus. after 14 weeks of gestation - indications - potential dx: previous birth with chromosomal anomaly, a parent who is carrier of chromosomal anomaly, a fam hx of neural tube defects, prenatal dx of a genetic disorder or congenital anomaly of the fetus, alpha-fetoprotein (AFP) level for the fetal abnormalities, lung maturity assessment, fetal hemolytic disease, meconium in amniotic fluid - considerations - have client empty bladder prior to procedure and reduce risk of inadvertent puncture - admin Rho(D) immune globulin if she is rh-negative - report if she has fever, chills, leakage of fluid, bleeding from insertion, decreased fetal movement, vaginal bleeding, or uterine contractions after the procedure. - encourage to drink plenty of fluids and rest 24 hr post procedure - findings: AFP can be measured between 15 and 20 weeks and assesses for neural tube defects in the fetus or chrome disorders - high levels: neural tube defects such as anencephaly (incomplete development of fetal skull and brain), spina bifida (open spine), or omphalocele (ab wall defect). high AFP levels can present with multiple fetal pregnancies - low levels: associated with chromosomal disorders (Down syndrome), or gestational trophoblastic disease (hydatidiform mole)

intraprocedure

- assess maternal vs, check temp every 1-2 hrs if membranes ruptured, assess FHR with EFM or spiral electrode (cervical dilation and rupture of membranes must occur), assess uterine labor contraction by palpation or external or internal monitoring (frequency, duration, intensity, resting tone of uterine contraction), intrauterine pressure catheter: insert a solid, sterile, water filled intrauterine pressure catheter inside uterus to measure pressure (displays contraction on monitor, needs to be rupture of membrane and cervix to be dilated), vaginal exam, mechanism of labor in vertex presentation: the adaptation the fetus makes as it progresses through birth canal (engagement: occurs when the presenting part usually largest diameter of fetal head passes the pelvic inlet at the level of the ischial spines, referred to as station o. descent: progress of the presenting part (preferably the occiput) through the pelvis. measured by station during vaginal exam as either - station measured in cm if superior to station o and not yet engaged or + station measured in cm if inferior to station o. flexion: fetal head meets resistance of cervix, pelvic wall or pelvic floor. the head flexed bringing chin to chest presenting in a small diameter to pass through. internal rotation: occiput toast to a lateral anterior position as it progresses through ischial spines to the lower pelvis. extension: fetal occiput passes under the symphysis pubis and the head is deflected anteriorly and is born by extension of the chin away from fetal chest. external rotation (restitution): after head is born it rotates to the position it occupied as it entered the pelvic inlet in alignment with fetal body and completes a quarter turn to face transverse as the anterior shoulder passes under the symphysis. birth by expulsion: after birth of the head and shoulders, the trunk of the neonate is born by flexing it toward the symphysis pubis

post procedure

- assess maternal vs, fundus, lochia (discharge of uterus after birth), perineum, urinary output, maternal/newborn baby friendly activities - bp and pulse be assessed at least every 15 mins for first 2 hr after birth and temp every 4 hour for first 8 hr after birth and then at least every 8 hr - assess funds and loch every 15 mins for first hour - massage uterine funds and or admin oxytocics as prescribed to maintain uterine tone to prevent hemorrhage - assess clients perineum, provide comfort measures as indicated, encourage voiding, promote bonding with newborn

CHAPTER 14 nursing care during stages of labor

- assessment: assess prior to admission - orient client and partner to the unit during admission (admission hx, review of antepartum care and review of birth plan, obtain lab reports, monitor baseline fetal heart tones and uterine contraction patterns for 20-30 mins, maternal vs, status of amniotic fluids) - perform maternal and fetal assessments continuously throughout the labor process and after birth - avoid vaginal exams in preens of vaginal bleeding or until placenta prevue or abruption placentae is ruled out. - cervix dilation is the most indication of labor progress labor is affected by sizeof fetal head, fetal presentation, lie, attitude, and position - frequency, duration, and strength of contractions cause fetal descent and cervical dilation - culture competent - hispanic: prefer mother than partner - African American: prefer female family members - Asian: might prefer mother not to be present, partner not an active participant, labor in silence, c section undesirable - Native American: prefer female nurse, family involved, use of herbs during labor, squatting position - European American: birth is public concern, focus on technology, partner expected to be involved, provider seen as head of health care team

GHTN

- associated with placental abruption, kidney failure hepatic rupture, preterm birth, and fetal and maternal death - GHTN: after 20th week, elevated BP of 140/90 or greater on 2 different occasions at least 4hr apart. no proteinuria. bp returns to baseline 6 weeks postpartum - mild preeclampsia: is GH with proteinuria greater or equal to +1. headaches with irritability. edema can be present - severe preeclampsia: bp 160/110 or greater. proteinuria greater than 3+, creatinine greater than 1.1, cerebral/visual disturbances (headache and blurred vision), hyperflexia with ankle clonus, edema, hepatic dysfc, epigastric and right upper quadrant pain, and thrombocytopenia - eclampsia: severe preeclampsia manifestation with onset of seizures or coma. preceded by headache, severe epigastric pain, hyperreflexia, and hemoconcentrations which are warning signs of convulsions - HELLP syndrome: variant of GH in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfx dx by lab tests - H: hemolysis (results in anemia and jaundice) - EL: elevated liver enzymes (elevated ALT or AST, epigastric pain, nausea/vomiting) - LP: low platelets (less than 100,000) resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechia, possible DIC - risk factors: maternal age younger than 19 or older than 40, first pregnancy, morbid obesity, chronic renal disease,, chronic HTN, fh of preeclampsia, DM, rheumatoid arthritis, systemic lupus erythematous - expected findings: severe continuous headache, nausea, blurry vision, flashes of lights or dots before eyes, hypertension, proteinuria, periorbital facial hand and ab edema, pitting edema of lower extremities, vomiting, oliguria, hyperreflexia, scotoma, epigastric pain, right upper quadrant pain, dyspnea, diminished breath sounds, seizures, jaundice, signs of progression of HTN - abnormal lab: elevated liver enzymes (LDH and AST), INCREASED CREATININE, INCREASED PLASMA URIC ACID, thrombocytopenia, decreased hgb, hyperbilirubinemia - lab tests: liver enzyme, creatinine BUN uric acid magnesium increase as renal function decreases, CBC, clotting studies, chemistry profile - dx procedures: dipstick test for proteinuria, 24 hr urine collection for protein and creatinine clearance, non stress test, contraction stress test, BPP, serial ultrasounds to assess fetal status, doppler blood flow analysis - assess LOC, pule ox, urine output (clean catch for proteinuria), daily weights, vs, lateral positioning, NST and daily kick counts, monitor I&o - meds: low dose of aspirin in late first trimester for hx of early onset of preeclampsia. antihypertensive meds: methyldopa, nifedipine, hydrazine, labetalol. avoid ACE inhibitors and angiotensin II receptor blockers. anticonvulsant meds: magnesium sulfate ( can initially feel flushed, hot and sedated with the bolus. fluid restriction of 100-125. magnesium sulfate toxicity: absence of patellar deep tendon reflexes, urine output less than 30ml, respirations less than 12, decreased LOC, cardiac dysrhythmias. discontinue infusion, admin antidote calcium gluconate or calcium chloride, prepare for actions to prevent respiratory or cardiac arrest.) - maintain bed rest and side lying position, diversional activities (TV, visits from support people, gentle exercise), avoid high sodium food, avoid all and tobacco and limit caffeine, 6-8 glasses of water, maintain dark quiet env to avoid stimuli, patent airway, antihypertensive meds

health promotion

- avoid OTC meds - avoid alc (birth defects) and tobacco (low birth weight) - avoid substance use - exercise: 30 mins of moderate exercise walking or swimming - avoid hot tubs and saunas - consume 8-10 glasses of water a day - nursing ed: flu shot, smoking cessation, tx of infections, genetic testing and counseling, exposure to hazardous materials

physiologic changes preceding labor (premonitory signs)

- backache, weightless (1-3.5lb weight loss), lightening (fetal head descends into true pelvis 14 days before labor. more pressure on uterus (urgency) and easier breathing), contractions (Braxton contractions that become regular and strong), increased vaginal discharge or bloody show, energy burst, GI changes, cervical ripening, rupture of membranes (spontaneous rupture of membranes can initiate labor or can occur during labor. most like transition phase. labor usually occurs within 24 hours of the rupture, prolonged can lead to infection. asses FHR for abrupt decels to rule out umbilical cord prolapse), assessment of amniotic fluid (should be watery clear, and pale to straw yellow color, not foul smell, between 500-1200ml, nitrazine paper testing. alkaline: nitrazine is deep blue indicating ph 6.5-7.5. acidic nitrazine paper stays yellow)

group b strep (GBS)

- bacterial infection that can be passed to a fetus during delivery - risk factors: maternal age less than 20 years, African or hispanic, positive culture with pregnancy, prolonged rupture of membranes, preterm delivery, low birth eight, use of intrauterine fetal monitoring, maternal fever 100.4 or greater - expected findings: positive GBS, premature rupture of membranes, preterm labor delivery, chorioamnionitis, infections of the urinary tract, maternal sepsis - lab tests: vaginal or rectal cultures are performed at 35 to 37 weeks - admin intrapartum antibiotic prophylaxis to the following clients: GBS during pregnancy, unknown GBS status who is delivering at less than 37 weeks, maternal fever of 100.4, client who has rupture of membranes for 18 hr OR LONGER - meds: penicillin G or ampicillin are most commonly prescribed for GBS. admin penicillin 5 millions units initially IV bolus followed by 2.5 million units intermittent IV blows every 4 hr. may receive 2 g IV initially, followed by 1 g every 4 hrs. bactericidal antibiotic used to destroy the GBS

prenatal assessments

- begin with initial assessment at first 12 weeks and continue throughout pregnancy. uneventful: visits are scheduled monthly for weeks 16-28, every 2 weeks 29-36 and every week from 36 to birth - initial prenatal visit - determine and estimate DOB based on last menstrual period - obtain medical and nursing hx to include social support and review systems (to determine risk factors) - perform physical assessment to include a clients baseline weight, VS, and pelvic exam - obtain initial lab tests: hemoglobin, hematocrit, WBC, blood type and rh, rubella titer, urinalysis, renal fx test, pap test, cervical cultures, HIV antibody, hep b surface antigen, toxoplasmosis, RPR (rapid plasma reagin) or VDLR (syphilis) - ongoing prenatal visits - monitor weight, bp, and urine for glucose, protein, and leukocytes - monitor edema - monitor fetal development: FHR can be determined by ultrasound and heard by dopler late in the first trimester, listen at midline, right above symphysis pubis by holding doppler firm on ab. measure fundal ht starting in second trimester, from weeks 18-30 the fundal ht in cm is the same number as the weeks of gestations. fetal health assessment begin assessing movement between 16-20 weeks - provide education for self care to include common discomforts and concerns of pregnancy (nausea/vomit, fatigue, backache, varicosities, heart burn, activity, sexuality)

routine lab tests

- blood type, Rh factor, and presence of irregular antibodies: determines the risk for maternal0fetal blood incompatibility (erythroblastosis fettles) or neonatal hyperbilirubinemia. indirect Coombs tests identifies clients sensitized to Rh-positive blood. for clients who are rh-negative and not sensitized, the Coombs tests is repeated between 24-28 weeks. - cbc with differential hgb and hct: detects anemia and infection - hgb electrophoresis: identifies hemoglobinipathies (sickle cell anemia and thalassemia - rubella titer: determine immunity to rubella - hep b screen: identifies carriers of hep b - group b strep (GBS): obtain vagina/anal culture at 35 to 37 weeks of gestation to assess for GBS infection - urinalysis with microscopic exam: identifies pregnancy, DM, gestational hypertension, renal disease, and infection - one hour glucose tolerance: sample take 1 hour after admin of concentrated glucose. fasting not necessary. identifies hyperglycemia. done at initial visit for at risk clients and at 24-28 weeks of gestation for all pregnant women (greater than 140 mg/dl requires follow up) - three hour glucose tolerance: fasting overnight. sample taken 1, 2, and 3 hour later after admin of concentrated glucose. used in clients who have elevated 1 hr glucose test as a screening tool for DM. dx of gestational diabetes requires 2 elevated blood glucose readings. - Pap test: used as a screening tool for cervical cancer, herpes simplex type 2 and human pap - vaginal/vervical culture: detects strep b hemolytic, bacteria vaginosis or STI - ppd (tuberculosis screening) X-ray after 20 weeks: identifies tuberculosis - venereal disease research lab (vdlr): syphylis screening mandated by law - HIV: detects HIV - toxoplasmosis, other infection, rubella, cytomegalovirus, and herpes virus (TORCH) screening: infections that can cross the placenta and affect fetal development - maternal serum alpha-fetoprotein (MSAFP): screening between 15-22 weeks. rules out Down syndrome

high risk pregnancy: percutaneous umbilical blood sampling PUBS

- called cordocentesis is the most common method used for fetal blood sampling and transfusion. gets blood with fetoscope from umbilical cord using amniocentesis technique. goes into umbilical cord using ultrasound guidance - studies: kleihauer-betke test that ensures that fetal blood was obtained, cbc count with differential, indirect Coombs test for rh antibodies, karyotyping (visualizations of chromes), blood gases - indications - potential dx: fetal blood type, rbc, chrome disorders, karyotyping of malformed fetuses, fetal infection, altered acid-base balance of fetuses with IUGR - interpretations: evaluates for isoimmune fetal hemolytic anemia and assesses the need for a fetal blood transfusion - complications: cord laceration, preterm labor, amnionities, hematoma, fetomaternal hemorrhage

fetal lung tests

- can be performed if gestation is less than 37 weeks for rupture of membranes, preterm labor, or for a complication indicating section. amniotic fluid is tested to determine whether the fetal lungs are mature enough to adapt to outside life or if it'll have respiratory distress. either fetus will be removed immediately or stay in with admin of glucocorticoids to promote fetal lung maturity - lecithin/sphingomyelin (L/S) ration: 2:1 indicates fetal lung maturity. 2.5:1 o3 3:1 indicates DM. - presence of phosphatidylglycerol (PG): absence of PG is associated with respiratory distress - complications: amniotic fluid emboli, maternal or fetal hemorrhage, fetomaternal hemorrhage with rh isoimmunization, maternal or fetal infection, inadvertent fetal damage or anomalies involving limbs, fetal death, inadvertent maternal intestinal or bladder damage miscarriage or preterm labor, premature rupture of membranes, leakage of amniotic fluid

bacterial vaginosis

- caused by haemophillius vaginalis or gardnerella vaginalis. cannot be related to sexual activity. can result in PID if untreated and lead to infertility. associated with preterm labor and low birth wt if untreated - altered ph balance of vagina such as caused by douching - expected findings: white or gray discharge with fish like odor especially after sex, discharge used for application to ph paper, wet mount and whiff test performed - ph is greater than 4.5, wet mount saline prep indicates presence of clue cells, positive whiff test - meds: metronidazole: anti infective - do not drink alc

trichomoniasis

- caused by protozoan parasite trichomonad vaginalis spread penis to vagina or vagina to vagina. if left untreated it can lead to PID which can cause infertility. more likely to have preterm baby with low birth weight (5.5lb) - expected findings: male: penile itching or irritation, dysuria, urethral discharge that can be swabbed. female: yellow-green, frothy vaginal discharge with foul odor, dyspareunia and itching, dysuria, discharge in the vaginal vault, strawberry spots on the cervix (tiny petechiae), a cervix that bleed easily. - lab tests: a sample of the discharge is used for ph paper and wt mount and whiff test performed - dx procedures: ph greater than 4.5, wet mount saline prep indicates the presence of trichomonads, whiff test can be positive or negative - meds: metronidazole or tinidazole: orally in a single dose. anti-infective - avoid alc bc of disulfiram like reaction (severe nausea and vomit)

syphilis

- caused by the bacterium Treponema pallidum. can have longterm complications if not treated - primary: presence of chancre, secondary: skin rashes such as rash on the palms of hands and soles of feet, tertiary: damage to internal organs - oral vaginal or anal sex. screened at first prenatal visit and prescreened in 3rd trimester - lab tests: serology test: nontreponemal for screening (VDLR and rapid plasma reagin) and treponema to determine antibodies (enzyme immunoassay, immunoassay) - meds: penicillin G IM in a single dose

CHAPTER 3 presumptive signs

- changes that a woman experiences that make her think she's pregnant. subjective or objective. may be other physiological factors (peristalsis: involuntary relaxation and constriction of intestines, infection, stress) - amenorrhea (missed period), fatigue, nausea/vomiting, urinary frequency, breast changes (darkened areolae, enlarged Montgomery glands), quickening (slight fluttering movements of the fetus felt by a woman. usually 16-20 weeks of gestation), uterine enlargement.

probable signs

- changes that make the examiner suspect a woman is pregnant (primarily related to physical changes of the uterus). can be physiological changes other than pregnancy (pelvic congestion, tumors). - abdominal enlargement (changes in the uterine size, shape, and position), hegar's sign (softening and compressibility of lower uterus (isthmus) while cervix is still firm), Chadwick sign (deepened violet-bluish color of cervix and vaginal mucosa), goodell's sign (softening of cervix tip at 6th week), ballottement (rebound of unengaged fetus), Braxton hicks contractions (false contractions that are painless, irregular, and usually relieved by walking. starts at 12 weeks and continues), positive pregnancy test, fetal outline (felt by examiner)

ultrasound considerations

- client prep: explain procedure and that theres no risks. advise to drunk 1 quart if water prior to ultrasound, lift and stabilize the uterus, displace the bowel, and act as an echo lucent to better reflect sound waves to obtain better imaging. assist patient into supine position with wedge under right hip to displace uterus - ongoing care: apply room temp gel to clients ab before the transducer. allow client to empty bladder after procedure. give washcloth for gel - client ed: fetal and maternal structures can be pointed out to the client as the ultrasound procedure is performed

three tier system

- current recommendations for fetal monitoring include 3 tier FHR interpretation system - category one: baseline FHR 110-160, variability is moderate, accelerations are present or absent, early decelerations are present or absent, variable or late decelerations are absent - category 2: baseline rate (tachy, Brady not accompanied by absent baseline variability). baseline FHR variability: minimal, absent not accompanied by reccurent decelerations, marked. episodic or periodic decelerations: prolonged fetal heart rate deceleration equal or greater than 2 min but less than 10 min, recurrent late decelerations with moderate variability, recurrent variable deceleration with minimal or moderate baseline, variable decelerations with additional characteristics including overshoots, shoulders, or slow return to baseline fetal heart rate. accelerations: absence of induced accelerations after fetal stimulation - category 3: sinusoidal pattern. absent baseline fetal heart rate variability and recurrent variable decelerations, recurrent late decelerations, or Bradycardia. each uterine contraction is compromised of the following: increment (the beginning of the contraction as intensity is increasing), acme (peak of intensity of the contraction), decrement (decline of the contraction intensity as the contraction is ending). nonreassruing FHR patterns are assocaited with hypoxia and include: fetal bradycardia, tachycardia, absence of FHR variability, late decelerations, variable decelerations

hyperemesis gravidarum

- excessive nausea and vomiting related to elevated hcg levels prolonged past 12 weeks and results in a 5% weight loss from pregnancy weight, electrolyte imbalance, acetonuria, ketosis - risk to fetus for intrauterine growth restriction or preterm birth of the condtition persists - risk factors: mom under 30, hx of migraines, obesity, first pregnancy, multifetal, GTD or fetus with chrome anomaly, psychosocial issues and high levels of emotional stress clinical hyperthyroid disorder, diabetes, GI disorder, fh of hyeremesis - expected findings: excessive vomiting for long periods, dehydration with possible electrolyte imbalance, weight loss, increased pulse rate, decreased BP, poor skin tumor and dry mucous membranes - lab tests: urinalysis for ketones and acetones (elevated specific gravity), chemistry profile, thyroid test (hyperthyroidism), CBC - nursing care: monitor I&o, assess skin tumor and mucous membranes, monitor vs, monitor weight, have client remain npc 24-48 hours - meds: IV lactated ringer for hydration, pyridoxine (vitb6) and other vit as tolerated, combination of pyridoxine and doxylamine, antiemetic (ondansetron, metoclopramide), corticosteroids - advance client to clear liquids after 24 hr if no vomiting, start with dry toast and crackers or cereal then to soft diet then to normal diet.

expected findings

- fetal HR 110-160 with accelerations indicating an intact fetal CNS - clients heart changes in size and shape with resulting cardiac hypertrophy to accommodate increased blood volume and CO. heart sounds change for more distinguishable s1, s2, and s3 sounds following 20 weeks. all returns to normal after birth. - uterine size changes from uterine weight of 50-1000g (.1 to 2.2 lb). by 36 weeks, top of uterus and funds will reach diploid process cause SOB. - Purple-blue color extends into vagina and labia and cervix becomes soft. - breast changes occur due to hormones of pregnancy. increase in size and darkening of areolas. - skin changes - chloasma: increase in pigmentation of the face - linea nigra: dark line of pigmentation from umbilicus extending to pubic area - striae gravidarum: stretch marks most notably found on the ab and thighs

vasa previa

- fetal umbilical vessels implant into the fetal membranes rather than the placenta - velamenotus insertion of the cord: cord vessels begin in the branch at the membranes and course into placenta - succenturiate insertion of the cord: placenta has divided into 2 or more lobes and not one mass - battledore insertion of the cord: marginal insertion, increased risk of fetal hemorrhage - dx procedures: ultrasound for fetal well being and vessel assessment

CHAPTER 11 labor and delivery process

- first stage: 12.5 hr duration - latent stage: p 6 hr, m 4 hr. 0-3cm. onset of labor, contractions irregular mild to moderate, frequency every 5-30 mins, duration 30-45 seconds. some dilation and effacement (baby drops closer to pelvis), talkative and eager - active phase: p 3hr, m 2hr. 4-7cm. contractions more regular, moderate to strong, frequency 3-5 minutes. duration 40-70 seconds. rapid dilation and effacement, some fetal decent, feelings of helplessness, anxiety and restless - transition phase: 20-40mins. 8-10cm. contractions strong to very strong. frequency 2 to 3 mins, duration 45-90 seconds. complete dilation. tired restless and irritable, feeling out of control, nausea/vomiting, urge to push, increased rectal pressure and feelings to poop, increased bloody show, most difficult part of labor - second stage: p 30 min to 2 hr, m 5 to 30 min. full dilation. progresses to intense contractions every 1 to 2 mins. ends with birth - third stage: 5-30mins delivery of baby and ends with delivery of placent. placenta separation and expulsion. Schultz presentation: shiny fetal surface of placenta emerges first. Duncan presentations: dull maternal surface of placenta emerges first - fourth stage: delivery of placenta to homeostasis. achievement of vital sign homeostasis, loch scant to moderate rubra

CHAPTER 12 pain management

- first stage: internal visceral pain that is bad and leg pain. causes: dilation, effacement, stretching of cervix, distention of lower segment of the uterus, contractions of the uterus with resultant uterine ischemia - second stage: somatic pain and occurs with fetal descent and expulsion. causes: pressure and distention of the vagina and perineum described by the client as during, splitting, and tearing. pressure pulling on the pelvic structures, lacerations of soft tissues - third stage: pain with expulsion of placenta is similar to the pain experienced during the the first stage. causes: contractions, pressure pulling of pelvic structures. - fourth stage: pain is caused by distention and stretching of the vagina and perineum incurred during the second stage with a splitting during and tearing sensation

pain relief

- first stage: opioid agonist analgesics, opioid agonist-antagonist analgesics, epidural block analgesia, combined spinal-epidural CSE analgesia, nitrous oxide - second stage: epidural block analgesia, nitrous oxide, local infiltration anesthesia, pudenal block, spinal (block) anesthesia - vaginal birth: epidural block analgesia/anesthesia, combined spinal-epidural (CSE) ANAGESIA, NITROUS OXIDE, LOCAL INFILTRATION ANESTHESIA, PUDENAL BLOCK, spinal block anesthesia - cesarean birth: epidural block anesthesia, spinal block anesthesia, general anesthesia

danger signs during pregnancy

- first trimester: burning or urination (infection), severe vomit (hyperemesis gravidarum), diarrhea fever or chills (infection), ab cramping or vaginal bleeding (miscarry or ectopic pregnancy) - second and third trimester: gush of fluid from vagina (rupture of amniotic fluid) prior to 37 weeks of gestation, vaginal bleeding (abruption of previa), ab pain (premature labor, abruption placentae, or ecoptic pregnancy), changes in fetal activity (decreased fetal movement might indicate fetal distress), persistent vomit, severe headache (GHTN), epigastric pain (GHTN), edema of face and hands (GHTN), blurred vision (GHTN), concurrent occurrence of flushed dry sin fruit breath rapid breathing and increased thirst and urination and headache (hyperglycemia), concurrent occurrences of clammy pale skin, weakness, tremors, irritability and lightheadedness (hypoglycemia)

nonpharamacological pain management

- gate control theory of pain: sending alternative signals through the pathways pain passes through can block sensation of pain - cognitive strategies: childbirth education/ prep methods: lamaze and patterned breathing exercises, promote relaxation and pain management , hypnosis, biofeedback - sensory stimulation strategies: aromatherapy, reaching exercises, imagery, music, use of focal points, subdued lighting - cutaneous stimulation strategies: therapeutic touch and message, walking, rocking, effleurage: light gentle circular stoking of clients ab with fingertips with breathing during contractions, sacral counter pressure: consistent pressure is applied by support person using heel of hand or first against clients sacral area to counteract pain in lower back, apply heat or cold, frequent position change

birth plan

- goals for birthing process. discuss methods such as lamaze and pain control options (epidural, natural childbirth)

CHAPTER 8 Infections HIV/AIDS

- hiv is a retrovirus that attaches and causes destruction of t lymphocytes. causes immunosuppression in a client. transmitted from a mother to a neonate personally through placenta and postnatally through breastmilk. - routine lab testing in the early prenatal period includes HIV. early identification and tx can significantly decrease incidence of perinatal transmission. - testing in 3rd trimester for patients at risk - amniocentesis and episiotomy should be avoided due to risk of maternal blood exposure - use of internal fetal monitors, vacuum extraction and forceps during labor should be avoided due to risk of fetal bleeding - admin of injections and blood testing shouldn't take place until first bath is given to newborn - risks: IV drug use, multiple sex partners, history of multiple STI, blood transfusions, men who have sex with men - expected findings: fatigue and flu like symptoms; fever, diarrhea, wt loss, lymphadenopathy and rash, anemia - lab tests: maternal consent, antibody screening test such as an enzyme immunoassay (confirmation of positive results is confirmed by western blot test or immunofluroenscence assay), use rapid HIV antibody tests (blood or urine) for client in labor, screen clients for STI, obtain frequent viral load levels and CD4 counts throughout pregnancy - meds: retrovir(antriretroviral agent, nucleoside reverse transcriptase inhibitor - admin retrovir at 14 weeks of gestation throughout pregnancy and before onset of labor or cesarean birth - admin to infant at delivery and for 6 weeks following birth - do not breastfeed

GDM

- impaired tolerance to glucose with the first onset during pregnancy. ideal level during pregnancy is 70-110mg/dl. - symptoms can disappear a few weeks after delivery but its likely they'll develop diabetes type 2 in five years - risks to fetus: spontaneous abortion, infections, hydramnios, ketoacidosis, hypoglycemia, hyperglycemia - risk factors: obesity, hypertension, glycosuria, older than 25 years, fh of dm, previous delivery of newborn that was large or stillborn - expected findings: hypoglycemia (nervousness, headache, weakness, irritability, hunger, blurred vision, tingling in mouth, or extremities), hyperglycemia (polydipsia, polyphasic, polyuria, nausea, ab pain, flushed dry skin, fruity breath), shaking, clammy pale sin, shallow respirations, rapid pulse, vomit, excess weight gain - lab tests: routine urinalysis, glucola screening test 1 hr glucose test, oral glucose tolerance, presence of ketone in urine - dx procedures: app, amniocentesis with alpha-fetoprotein, non stress test - monitor client blood glucose and fetus - meds: exercise and diet, if glucose levels are persistently high start insulin, oral hypoglycemic therapy - perform daily kicks counts, diet: diabetic diet and restricted carbs, exercise, self-admin of insulin, postpartum lab tests OGTT and blood glucose levels

ectopic pregnancy

- implantation of the fertilized egg in any site other than the normal uterine location usually in the Fallopian tube which can result in a tubal rupture causing a fatal hemorrhage - risk factors: any factor that compromises tubal potency (STI, assistive reproductive technologies, tubal surgery, and IUD) - expected findings: unilateral stabbing pain and tenderness in lower ab quadrant, delayed (1-2 weeks) lighter than usual or irregular menses, scant dark red or brown vaginal spotting occurs 6-8 weeks after last normal menses, referred shoulder pain due to blood in the peritoneal cavity irritating the diaphragm or phrenic nerve after tubal rupture, report indications of shock such as faintness and dizziness related to amount of bleeding in ab cavity, clinical findings of shock or hemorrhage (hypotension, tachycardia, pallor) - lab tests: progesterone and hcg levels elevated rules our ectopic pregnancy - dx and therapeutic procedures: transvaginal ultrasound shows an empty uterus. use caution if vaginal and bimanual examination are used. rapid tx: medical management (if rupture has not occurred and tube preservation desired), methotrexate (inhibits cell division and embryo enlargement, dissolving the pregnancy), salpingostomy (done to salvage the Fallopian tube if not ruptured), laparoscopic salpingectomy (removal of the tube. is performed when the tube has ruptured). - client education: if taking maethotrexate avoid alc and vit containing folic acid to prevent toxic response, protect self form sun exposure (photosensitivity)

placenta previa

- implantation of the placenta over the cervical opening or in the lower region of the uterus near or over the cervical os instead of attaching to the funds. results in bleeding during 3rd trimester as cervix begins to dilate and efface - complete or total: cervical os is completely covered by placenta - incomplete or partial: partially covered - marginal or low-lying: placenta is attached in the lower uterine segment but does not reach cervical os - risk factors: previous placenta previa, uterine scarring (previous c section, curettage, endometritis), maternal age greater than 35 years, multifetal gestation, multiple gestations or closely spaced pregnancies, smoking - expected findings: painless bright red vaginal bleeding during 2nd or 3rd trimester, uterus soft relaxed and contender with normal tone, fundal ht greater than usual for gestational age, fetus in breech or oblique or transverse position, reassuring FHR, vital signs within normal limits, decreasing urinary output can be a better indicator of blood loss - lab tests: hgb and hct for blood loss, cbc, blood type and rh, coagulation profile, kleihauer-betke (used to detect fetal blood in maternal circulation) - dx procedures: transit or transvag ultrasound for placement of the placenta, fetal monitoring for fetal well-being assessment - assess fundal height, bleeding and leaking or contraction, perform Leopold maneuver, refrain from vaginal exam, admin iv fluids blood products and meds (corticosteroids such as betamethasone promote fetal lung maturation if early delivery is anticipated (c section), have oxygen available. bed rest and nothing inserted vaginally

iron deficiency anemia

- inadequate in maternal iron stores and consuming insufficient amount of dietary iron - risk factors: less than 2 years between pregnancies, heavy menses, diet low in iron, multifetal, vomit frequently - expected findings: fatigue and weakness, irritability, headache, dizzy/lightheaded, SOB with exertion, palpitations, PICA, pallor, brittle nails, SOB - lab tests: hgb less than 11 in first and 3rd trimester, hct less than 33.1% - intake 27mg iron per day, intake legumes, fruit, green leafy veggies, and meat - meds: ferrous sulfate iron supplements (take on empty stomach with orange juice), diet rich in vitamin c for absorption, increase fluids for constipation. iron dextran: used when oral supplements can't be tolerated

client ed

- increase calories: increase of 340 cal in second trimester and 452 in third trimester. breastfeeding women should add 450-500 calories - increased protein intake: women who wish to become pregnant and childbearing take 400 mcg of folic acid and women who become pregnant take 600 mcg. high folic acid is essential for neurological development and presence of fetal neural tube defects. leafy veggies, dried peas and beans, seeds, orange juice, bread, cereal, other grains - iron supplements: increase in maternal RBC. best absorbed between meals with source of vitamin c. milk and caffeine interfere with absorption of iron. beef liver, red meats, fish, poultry, dried peas and beans, fortified cereals and breads - calcium: develops bones and teeth. milk, calcium fortified soy milk, fortified orange juice, nuts, legumes, dark green leafy veggies. 1000mg/day - fluid: 8-10 glasses of fluid are recommended. water fruit juice or milk - limit cafeinne: no more than 200 mg of caffeine. can cause spontaneous abortion or fetal intrauterine growth restriction

creating a postpartum nutritional plan

- increase in protein and calorie intake - increase oral fluids but avoid alc and caffeine - avoid foods that don't agree with the newborn - take calcium supplements

intermittent auscultation and uterine contraction palpitation

- intermittent auscultation is performed with a doppler ultrasound device, ultrasound stethoscope, or a fetoscope to assess FHR. in conjunction, palpitation of contractions at the funds for frequency, intensity, duration and resting tone is used to evaluate fetal well being - during latent phase: 30-60 min, active:15-30, second stage:5-15 min - indications: determine active labor, rupture of membranes (spontaneously or artificially), preceding and subsequent to ambulation, prior to and following admin or or a change in med analgesia, peak action of anesthesia, following vaginal exam, following expulsion of enema , after urniary catheterization, abnormal or excessive uterine contractions count FHR for 30-60 seconds between contractions to determine baseline rate, palpate uterine funds to assess uterine activity, auscultate FHR before, during, and after contraction to determine FHR in response to the contractions

third stage

- lasts from the birth of the fetus until the placenta is delivered - blood pressure, pulse, and respiration measurements every 15 minutes, clinical finding of placental separation from the uterus: (fundus firmly contraction, swift gush of dark blood from Introits, umbilical cord appears to lengthen as placenta descends, vaginal fullness on exam), assignment of 1 and 5 Apgar scores to the neonate - instruct client to push once findings of placental separation are present, admin oxytocics expulsion of the placenta to occurs to stimulate the uterus to contract and prevent hemorrhage, admin analgesics as prescribed, cleanse perineal area with warm water and apply pad or ice pack, promote baby friendly activities for family and newborn, encourage breast feeding

second stage

- lasts from time cervix is fully dilated to birth of the fetus - begins with complete dilation and effacement, blood pressure, pule and respiration measurement every 5-30 minutes, uterine contractions, pushing efforts, increase in bloody show, shaking of extremities, FHR every 15 minutes and immediately following birth. - assessment for perineal lacerations which usually occur as the fetal head is expulsed - first degree: laceration extends through skin of the perineum and does not involve muscles - second degree: laceration extends through the skin and muscles into perineum but not the anal sphincter - third degree: laceration extends through the skin, muscles, perineum, and external anal spinchter muscle - fourth degree: extends through skin, muscles, anal spinchter, and anterior rectal wall - monitor client/fetus, assist in positioning for effective pushing, assist partner in involvement and encouraging bearing down during pushing, promote rest between contractions, provide comfort measures such as cold compresses, cleans client perineum as needed if fecal is coming out, prepare for episiotomy if needed(surgical cut to help delivery), provide feedback, prepare for care of neonate (a nurse thats trained for neonate resuscitation): check oxygen flow and tank on warmer, preheat radiant warmer, lay out newborn stethoscope and bulb syringe, resuscitation equipment in working order (resuscitation bag, laryngoscope) and emergency meds availible, check suction apparatus

continuous internal fetal monitoring

- monitoring with a scalp electrode is performed by attaching a small spiral electrode to presenting part of fetus to monitor the FHR - indications: can be used with intrauterine pressure catheter (IUPC) which is a solid or fluid filled transducer placed inside clients uterine cavity to monitor the frequency, duration, and intensity of contractions. avg pressure is 50-85mmHG - advantages: early detection of abnormal FHR patterns, accurate assessment of FHR variability and uterine contraction intensity, allows greater maternal freedom of movement because tracing isn't affected by fetal activity, maternal position changes or obesity - disadvantages: membranes have to be ruptures, cervix must be 2-3cm dilated, presenting part has to be descended, potential risk to fetus, potential risk of infection to mom and baby - aseptic technique, make sure it works,, monitor vs and temp every 1-2 hrs, frequent repositioning, wedge if supine - complications: misinterpretation of FHR patterns, maternal or fetal infection, fetal trauma, supine hypotension secondary to internal monitor placing

calculating delivery date and determining number of pregnancies for a pregnant client

- nagele's rule: take the first day of the woman last menstrual cycle, subtract 3 months, and add 7 days and 1 year - measurement of fundal height: in cm from the symphysis pubis to top of the uterine funds (between 18 and 30 weeks of gestation). approximates the gestational age. - gravidity: number of pregnancies. - nulligravida: never been pregnant - primigravida: first pregnancy - multigravida: 2 or more pregnancies - parity: number of pregnancies in which the fetus or fetuses reach 20 weeks of pregnancy, not number of fetuses. not affected whether the fetus is born, still born, or alive - nullipara: no pregnancy beyond the stage of viability (ability to survive outside of the uterus) - primipara: has completed one pregnancy to stage of viability - multipara: 2 or more to stage of viability - viability: the infant can survive outside the uterus. infants born between 22-25 weeks are considered on threshold of viability - GTPAL acronym - gravidity - term births (38 weeks or more) - preterm births (from viability up to 37 weeks) - abortions/miscarriages (prior to viability) - living children

common discomforts

- nausea/vomit: first trimester. eat crackers or dry toast 30 min-1hr before rising in morning. avoid empty stomach and ingesting spicy, greasy, or gas forming foods. drink fluid in between meals - breast tenderness: first trimester. supportive bra - urinary frequency: first and 3rd trimester. reduce fluid before bedtime and use perineal pads. do kegel - UTI: wipe front to back, avoid bubble baths, wearing cotton panties, avoid tight fitting pants, consume 8 glasses a day. urinate before and after sex. urinate when you have the urge. - fatigue: first and 3rd trimester. rest frequently - heartburn: second and third trimester. small frequent meals and sit up for 30 mins after meal. check with provider for etc antacids - constipation: second and third trimester. drink a lot, high fiber, exercise - hemorrhoids: second and 3rd trimester. warm sitz abth, with hazel pads, application of topical ointments will relieve discomfort - backaches: second and 3rd trimester. exercise, lift with legs, side lying position - SOB: good posture and sleep with extra pillows - leg cramps: 3rd trimester - varicose veins and lower extremity edema: second and 3rd trimester. rest with legs elevated, wear hose support, avoid tight clothes - gingivitis, nasal stuffiness, and epistaxis (nose bleed): gently brush teeth, observe good dental hygiene, use humidifier, normal saline nose drops or spray - Braxton hicks contraction: occurs first trimester onward and can intensify in 3rd trimester. walking should relieve it - supine hypotension: compresses vena cava. side lie or semi fowlers with knees slightly flexed

dietary complications during pregnancy

- nausea: eat small amounts frequently every 2-3 hours to avoid large meals that distend stomach and avoid alc, caffeine, fried fatty and spicy foods. avoid consuming excessive amount of liquid. ginger (ginger ale soda, ginger tea, ginger candies) - constipation: increase fulid and extra fiber (fruits, veggies, and whole grains - maternal phenylketonuria: maternal genetic where high levels of phenylalanine pose a danger to the fetus - resume the PKU diet for at least 3 months prior to pregnancy and continue the diet throughout pregnancy - diet low in PKU. foods high in protein such as Fisk, poultry, meat, eggs, nuts, and dairy products must be avoided due to high PKU levels. aspartame should be avoided - DM: monitor amount of carbs in diet and keep glucose level within target. limit the amount of sweets and desserts. meet with registered dietician.

gonorrhea

- neisseria gonorrhea. genital to genital contact, anal to genital contact, or oral to genital contact. can be transmitted to a newborn during delivery - women is often asymptomatic and can lead to PID - same screening as chlamydia - expected findings: male: dysuria, urethral discharge. female: dysuria, vaginal bleeding between periods and dysmenorrhea, yellow green discharge, early induced endocervical bleeding - lab tests same as chlamydia - meds: cetriaxonne IM and azithromycin PO

contraction stress test

- nipple stimulated contraction test: mom rubbing nipple for 2 mins to release oxytocin and stopping when a contraction comes and repeat after 5 minute rest period. - analysis of FHR response to contractions (which decreases placental blood flow) determines how the fetus will tolerate stress of labor. 3 contractions within 10 mins with duration of 40-60 seconds must be obtained - hyper stimulation of the uterus (uterine contraction longer than 90 seconds or five or more contractions in 10 mins) should be avoided by stimulating the nipple intermittently with rest periods in between and avoiding bimanual stimulation of both nipples unless stimulation of one nipple is unsuccessful - oxytocin-stimulated contraction test: aka oxytocin challenge test (OCT) used if nipple stimulation fails and admins through the IV to induce uterine contractions - difficult to stop and can lead to preterm labor - contraindications: placenta previa, vasa previa, preterm labor, multiple gestations, previous classic incision from cesarean birth and reduced cervical competence - indication - potential dx: high risk pregnancies (GDM, post term pregnancy) - non reactive stress test - client presentation: decreased fetal movement, intrauterine growth restriction, post maturity, GDM, GHTN, maternal chronic hypertension, hx of previous fetal demise, advanced maternal age, sickle cell disease - considerations: obtain baseline of FHR, fetal movement, and contractions for 10-20 mins - interventions: monitor contractions lasting longer than 90 seconds and occurring more than every 2 mins, admin tocolyticsk as prescribed, maintain bed rest during procedure, observe for client for 30 mins after to see contractions have ceased - interpretations: negative CST (normal): within 10 minute period with 3 uterine contractions and theres no late decelerations of the FHR. positive (abnormal): persistent and consistent late decelerations with 50% or more of the contractions. suggestive of uteroplacental insufficiency. variable decelerations: indicate cord compression, early: fetal head compression. induce labor or perform a cesarean birth.

assessment

- obtain subjective and objective dietary info - journal of the clients food habits, eating patterns and craving - nutrition related questionnaires - the weight on first prenatal visit and follow ups - lab findings such as hgb and iron levels - determine the caloric intake: have client record everything eaten during the 24 hour period

five p's

- passenger (fetus and placenta): size of head, fetal presentation, lie, attitude, and position. - presentation: the body part entering pelvic first (back of head: occiput, chin: mentrum, shoulder: scapula, or breech: sacrum or feet) - lie: the relationship to the mother spine to fetus spine. transverse, parallel or longitudinal, - attitude: relationship of fetal body parts to one another. fetal flexion: chin flexed to chest, extremities flexed into torso. fetal extension: chin extended away from chest, extremities extended. - fetopelvic or fetal position: relationship of the presenting part of the fetus (Sacrum, mentrum, occiput) preferably occiput as it relates to the four maternal pelvic quadrants. R or L (right or left) which side of maternal pelvis. O, S, M, or Sc (occiput, sacrum, centrum, or scapula) is the presenting side of the fetus. A, P, T (anterior, posterior, or transverse) part of maternal pelvis. - station: measurement of fetal descent in cm with stain o being at the level of the imaginary line at the level the ischial spins, minus stations superior to the ischial spines, and plus stations inferior to the ischial spines - passageway: the size and shape of body pelvis must be adequate to allow fetus to pass through. cervix must dilate and efface in response to contractions and fetal descent - powers: uterine contractions cause effacement (shortening and thinning of the cervix) during first stage of labor and dilation of cervix (enlargement and widening) occurs once labor has begun. involuntary urge to push and voluntary bearing down in second stage helps expulsion of fetus - position: client should change positions frequently to increase comfort, relieve fatigue, and promote circulation. position during the second stage os determined by maternal preference, provider preference and condition of mom and baby. gravity can aid in fetal descent in upright, sitting, kneeling, and squatting positions. - psychosocial response: maternal stress, tension, and anxiety can produce physiological changes that impair the progress of labor

nursing care

- perform or assist with leopard maneuvers to palpate presentation and position of fetus - assist provider with the gynecological examination. exam is used to determine the status of clients reproductive organs and birth canal. pelvic measurements determine whether the pelvis will allow for passage of the fetus at delivery. nurse has client empty her bladder and take deep breaths during exam. - admin rhO(D) immune glonulin IM around 28 weeks of gestation for clients who are Rh-negative

preparation for pregnancy and birth

- physical and emotional changes during pregnancy and interventions to provide relief - indications of complications to report to provider - birthing options to enhance process - maternal adaptation to pregnancy and maternal role - emo lability with unpredicted mood changes - feeling of ambivalence that will resolve before 3rd trimester - first trimester: physical and psychosocial changes, common discomforts, lifestyle: exercise, stress nutrition, sexual health, dental care, OTC Meds, alc, substance use, STI, complications, fetal growth, prenatal exercise, expected lab testing - second trimester: benefits of breast feeding, discomforts, lifestyle: sex and pregnancy, rest, posture, body mechanics, clothing, seat belt, fetal movement, complications (preterm labor, GHTN, GDM, premature rupture of membranes), prep for childbirth, birthing methods, development of birth plan (verbal or written agreement) - 3rd trimester: childbirth prep: classes, coping, breathing, effleurage and counter pressure, apply heat/cold, massage, water therapy. fetal movement/kick counts to ascertain fetal well-being: mothers should count fetal activity 2 or 3 times a day for 2 hr after meals or bedtime, fetal movement for less than 3 per hour or movement that sense for 12 hr needs evaluation. - dx test for fetal well being: non stress test, biophysical profile, ultrasound, and contraction stress test

ultrasound indications

- potential diagnoses: confirming pregnancy, confirming gestational age by biparietal diameter (side to side measurement), identifying multiple pregnancy, determining site of fetal implantation (uterine, ectopic), assess growth and development, asses maternal structures, confirming fetal viability or death, ruling out or verifying fetal abnormalities, locating site of placental attachment, determining amniotic fluid volume, observing fetal movement (FHR, breathing, activity), assessing fetal position, placental grading (placental maturation), adjunct for other procedures (amniocentesis, biophysical profile) - client presentation: vaginal bleeding evaluation, questionable final height measurement in relationship to gestational weeks, reports of decreased fetal movements, preterm labor, questions rupture of membranes

abruption of placentae

- premature separation of the normally implanted placenta from uterus which can be complete or partial occurring after 20 weeks usually in 3rd trimester. coagulation defect such as DIC is associated with moderate to severe abruption - risk factors: maternal HTN (chronic or gestational), blunt external ab trauma (motor vehicle crash, maternal battering), cocaine use resulting in vasoconstriction, previous incidents of abruption placentae, cigarette smoking, premature rupture of membranes, multifetal pregnancy - expected findings: sudden onset of intense localized uterine pain with dark red vaginal bleeding, area of uterine tenderness can be localized or diffuse over uterus and boardlike, contractions with hypertonicity, fetal distress, clinical findings of hypovolemic shock - lab tests: hgb and hct decreased, clotting factors decreased, clotting defects (DIC), cross and type match for possible blood transfusions, kleihauer-betke test - dx procedures: ultrasound for fetal well being and placental assessment. biophysical profile to ascertain fetal well being - palpate uterus for tenderness and tone, serial monitoring for fundal height, fhr pattern, immediate birth

gestational trophoblastic disease (GTD)

- proliferation and degeneration of trophoblastic villi in the placenta that becomes swollen, fluid-filled, and takes on the appearance of grape-like-clusters - complete mole: all genetic material is paternally derived, the ovum has no genetic material, or the material is inactive, the complete mole contains no fetus, placenta, amniotic membranes or fluid, there is not placenta to receive maternal blood, hemorrhage into the uterine cavity occurs and vaginal bleeding results, approximately 20% advance into a choriocarcinoma - partial mole: genetic material is derived both maternally and paternally, a normal ovum is fertilized by two sperms or one sperm in which meiosis or chromosome reduction and division did not occur, contains abnormal embryonic or fetal parts, and amniotic sac and fetal blood loss but congenital abnormalities are present, 6% advance into a choriocarcinoma. - risk factors: prior molar pregnancy, early teens or older than 40 - expected findings: excessive vomiting (hyperemesis gravid arum) due to high hcg levels. rapid uterine growth due to over proliferation of trophoblastic cells, bleeding is dark brown or bright red that is scant or profuse and can last a few days or week with passage of vescles, anemia, preeclampsia that occurs before 24 weeks - lab tests: high hcg with decline after weeks 10-12 - dx and therapeutic procedures: an ultrasound reveals a dense growth with characteristics vesicles but not fetus in utero, suction cutterage is done to aspirate and vacuum mole, post op rh- women are given rho (d) immune globulin, post mole evacuation women should undergo pelvic exam and ultrasound scan of ab, serum hcg analysis following molar pregnancy to be done weekly for 3 weeks then monthly for 6 months up to a year to detect GTD - measure fundal ht, assess GI status and appetite, chemo therapy meds for malignant cells

biophysical profile (BPP)

- real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetus biophysical responses to stimuli. FHR monitoring (non stress test+fetal ultrasound) - indications - potential dx: nonreactive non stress test, suspected oligohydramnios or polyhydramnios, suspected fetal hypoxemia or hypoxia - client presentation: premature rupture of membranes, maternal infection, decreased fetal movement, intrauterine growth restriction - BPP assesses fetal well being by measuring five variables with a score of 2 for each normal finding and 0 for each abnormal finding - FHR: reactive (non stress test) 2, nonreactive 0 - fetal breathing movements: at least 1 episode greater than 30 seconds duration in 30 min 2, absent or less than 30 seconds 0 - gross body movements: at least 3 body limb extensions with return to flexion in 30 min 2, less than 3 0 - fetal tone: at least 1 episode of extension with return to flexion 2, low extension and flexion or lack of flexion or absent movement 0 - qualitative amniotic fluid volume: at least 1 pocket of fluid that measures at least 2 cm in 2 perpendicular planes 2, pockets absent or less than 2 cm 0 - total score findings: 8-10: normal, low risk of chronic fetal asphyxia (deprived of oxygen), 4-6: abnormal suspect, less than 4: abnormal strongly suspect

CHAPTER 5 nutrition during pregnancy weight gain

- recommended weight gain is 11.3-15.9 kg (25-35 lb). clients should gain 1 to 2 kg during first trimester and after that .4 kg per week for last 2 trimesters. underweight women should gain 28-40 lb and overweight women should gain 15-25 lb.

CHAPTER 4 prenatal care client history

- reproductive and obstetrical hx: contraception use, gyno dx, obstetrical difficulties - medical hx: physical preexisting conditions, surgical procedures, handicap conditions, immune status (rubella and hep b) - nutritional hx: dietary assessment for deficient practices and food allergies - fam hx: genetic disorders or conditions. any recent or current illness or infections - current meds: substance use, alc consumptions - psychosocial hx: emo response to pregnancy, spouse, support system, hx of depression, violence). hazardous env exposures, current work conditions. current exercise and lifestyle - abuse hx or risk: physical, sexual, psychological abuse

physiological status

- reproductive: uterus increases in size and changes in shape and position. ovulation and menses cease during pregnancy. - cardiovascular: CO increases 30-50% and blood volume increases (30-45% at term) to meet the metabolic needs). HR increases beginning at week 5 and reaches a peak 10-15/min above pre pregnancy rate around 32 weeks of pregnancy. - respiratory: during last trimester the size of the chest might enlarge allowing lung expansion as uterus pushes upward. respiratory rate increases and total lung capacity decreases - musculoskeletal: body alterations and weight increase necessitate an adjustment in posture. pelvic joints relax - GI: nausea/vomit due to hormonal changes and/or pressure increase of ab cavity because stomach and intestines are displaced in ab. constipation due to increased transit time of food through GI tract and increased water absorption - renal: filtration rate increases because of pregnancy hormones and increase in blood volume and metabolic demands. amount of urine stays the same. frequency is common - endocrine: placenta becomes endocrine organ that produces large amounts of hCG, progesterone, estrogen, human placental lactose, and prostaglandins. hormones are very active to maintain fx of pregnancy and prepare body for delivery

high risk pregnancy: maternal serum alpha fetoprotein (MSAFP)

- screening tool used to detect neural tube defects. clients who have abnormal findings should be referred for a quad marker screening, genetic counseling, ultrasound, and an amniocentesis - indications - potential dx: all pregnant clients preferably between 16 and 18 weeks gestation - interpretation of findings: high levels can indicate a neural tube defect or open ab defect. low levels can indicate Down syndrome

continuous electronic fetal monitoring

- securing an ultrasound transducer over the clients ab that records the FHR pattern and a tocotranducer on the funds that records the uterine contractions - noninvasive, membranes do not have to be ruptured, cervix does not have to be dilated - contraction intensity isn't measures, movement of the client requires frequent positioning of transducers, quality of recording is affected by clients obesity and fetal postion - indications: multiple gestations, oxytocin infusion (augmentation or induction of labor), placenta previa, fetal bradycardia, maternal complications (GDM, GHTN, kidney disease), intrauterine growth restriction, post date gestation, active labor, meconium stained amniotic fluid, abruption of placentae, abnormal non stress test or contraction stress test, abnormal uterine contractions, fetal distress - interpretation of findings: a normal heart rate is 110-160. at least 2 min of baseline segments in a 10 min window should be present. fetal heart rate baseline variability is fluctuations in the FHR baseline that are irregular in frequency and amplitude. expected variability should be moderate - changes in fetal heart rate are episodic or periodic. episodic are not associated with uterine contractions. periodic changes occur with uterine contractions that include accelerations and decelerations

verifying pregnancy

- serum and urine tests assess for the presence of human chorionic gonadotropin (hCG). hCG production can start as early as the day of implantation and can be detected as early as 7-8 days after conception. - production of hCG begins with implantation, peaks at 60-70 days of gestation, declines until 100-130 days of pregnancy and gradually increases until term - higher levels of hCG can indicate multifetal pregnancy, ectopic pregnancy (the fertilized egg implants outside of the uterus), hydatidiform mole (gestational trophoblastic disease), or a genetic abnormality such as Down syndrome - lower levels of hCG might suggest a miscarriage or ectopic pregnancy - medications (anticonvulsants, diuretics, tranquilizers) can cause false positive or false negative pregnancy results - home pregnancy test: urine samples should be first voided morning specimens and follow the directions accurately

positive signs

- signs that can be explained only by pregnancy - fetal heart sounds, visualization of fetus by ultrasound, fetal movement (palpated by an experienced examiner)

CHAPTER 6 assessment of fetal well being

- ultrasound: 20 mins that uses high frequency sound waves to visualize internal organs and tissues - external ab ultrasound: more useful after first trimester when the gravid uterus is larger. client should have full bladder - transvaginal ultrasound: probe inserted vaginally to allow more accurate eval, does not require full bladder. useful for obese and first trimester to determine ecoptic, abnormalities, and gestational age. can be used in 3rd trimester with ab scanning to evaluate preterm labor. lithotomy position, position table for complete view of pelvis. tell client they might feel pressure - doppler ultrasound for blood flow analysis: measures velocity at which rbc's travel. useful in fetal intrauterine growth restriction (IUGR) and poor placenta perfusion, and for risks of hypertension, DM, multiple fetuses or preterm labor. - 2D: standard medical scan; black, white, or shades of grey - 3D: multiple pictures at once; almost as clear as a photograph. looks life like - 4D: like 3d but also shows movement in a video

CHAPTER 10 early onset of labor preterm labor

- uterine contractions and cervical changes between 20 and 37 weeks - risks: infection of urinary tract, vagina, or chorioamnionitites (infection of amniotic sac), previous preterm birth, multifetal pregnancy, hydramnios (excessive amniotic fluid), age below 17 or above 35, low socioeconomic status, smoking, substance abuse, intimate abuse, hx of multiple miscarriages or abortions, DM, chronic the, preeclampsia, lack of prenatal care, recurrent premature dilation of cervix, placenta previa or abruption of placentae, preterm premature rupture of membranes, short interval between pregnancies, uterine abnormalities, second trimester bleeding, low pregnancy weight - expected findings: uterine contractions, pressure in pelvis, pressmen low backache, GI cramping with diarrhea sometimes, urinary frequency, vaginal discharge, increase change odor or blood in vaginal discharge, change in cervial dilation, regular uterine contractions every 10 min or greater lasting 1 hour or longer, premature rupture of membranes - lab tests: fetal fibroxnectin, cervical cultures, CBC, urinalysis - dx procedures: swab of vagina for fetal fibroxnectin between 24 and 34 weeks, endocervical length with ultrasound for shortened cervix, home uterine activity monitoring (HUAM), cervical cultures for infectious organisms, BPP and/or non stress test - activity restriction: bed rest, left lateral position, avoid sexual intercourse, hydration, identifying and treating infection, chorioamnionitits (elevated temp and tachycardia), monitor FHR and contraction patter, fetal tachycardia (greater than 160 can indicate infection) - meds: nifedipine (calcium channel blocker to suppress contractions). monitor for headache, flushing, dizziness and nausea. related to orthostatic hypotension. should not be given with magnesium sulfate or beta2-adrenergic agonist. magnesium sulfate: tocolytic that relaxes smooth muscle of uterus. contraindications are active vaginal bleeding dilation of the cervix greater than 6 cm chorioamnionitis greater than 34 weeks of gestation and acute fetal distress. indomethacin: NSAID suppressing preterm labor by blocking prostalgladins that suppresses contractions. should not exceed 48 hours, and only if less than 32 weeks. give with food or rectally. betamethasone: glucocorticoid administered IM in 2 injections 24 hr apart. enhances fetal lung maturity and surfactant production in fetuses 24-34 weeks gestation. admin into glutes

CHAPTER 9 Medical conditions cervical insufficiency (premature cervical dilation)

- variable condition where expulsion of the products of conception occurs related to tissue changes and alterations in length of the cervix - risk factors: hx of cervix trauma, short labors, pregnancy loss in early gestation, advanced cervical dilation at earlier weeks of gestation, utero exposure to diethylstilbestrol ingested by mother, congenital structural defects of the uterus or cervix - expected findings: increased in pelvic pressure or urge to push, pin stained discharge or bleeding, possible gush of fluid (rupture of membrane), uterine contractions with expulsion of fetus, post op clercage monitoring for the uterine contractions, rupture of membrane and signs of infection - dx and therapeutic procedures: ultrasound showing short cervix (less than 25mm), presence of cervical funneling (breaking), or effacement of the cervical os indicating reduced cervical competence. prophylactic cervical cerclage: surgical reinforcement of cervix to prevent premature Cervical dilation. best to place around 12-14 weeks and removed 36 to 28 weeks - assess vaginal discharge, pressure and contractions, and vital signs - meds: tocolytic prophylactically to inhibit uterine contractions - discharge instructions: activity restriction or bed rest, hydration (dehydration promotes contractions), avoid intercourse, tampons, douching, and monitor uterine/cervix changes), - health promo: report preterm labor, rupture of membranes, infection, strong contractions less than 5 mins apart, severe perineal pressure, and an urge to push. use at home uterine activity monitor to evaluate uterine contractions - arrange client for followup with home health agency, schedule removal of cerclage

pharmacological pain management

- verify labor is well established and perform a vaginal exam before giving analgesics - analgesia - sedatives (barbiturates): secure pentobarbital and phenobarbital. used during early or latent phase of labor to relieve anxiety and induce sleep. adverse effects: neonate respiratory depression (do not give if birth is anticipated 12-24 hours), unsteady ambulation, inability to cope with pain of labor client ed: drowsiness, assist with ambulation dim lights, provide safety, help cope with labor, assess neonate respiratory - opioid analgesics (meperidine hydrochloride, fentanyl, butorphanol, and nalbuphine decrease perception of pain in CNS during early part of labor without loss of conciosuness. butorphanol and nalbuphine provide pain relief without significant respiratory depression in mom and baby. IV and IM adverse effects: if too close to delivery time it can cause respiratory depression in baby, reduces gastric emptying; increase nausea and emesis, increase risk for aspiration of food or fluids in stomach, drowsiness admin antiemetics as prescribed, monitor vs, uterine contraction pattern, FHR, all before and after meds given, naloxone is the antidote and should be given if theres difficulty breathing - ondansetron and metroclopramide: can control nausea and anxiety. they do not receive pain adverse: dry mouth and sedation. provide ice chips or mouth swabs. provide safety measures for client - epidural and spinal analgesia: consists of using analgesics such as fentanyl and sufentanil which are short acting opioids that going into the epidural or intrathecal space without anesthesia. provide rapid pain relief while still allowing the client to sense contractions and maintain the ability to bear down adervse: decreased gastric emptying resulting in nausea and vomiting, inhibition to bowel and bladder elimination sensations, bradycardia, tachycardia, hypotension, respiratory depression, allergic reaction and pruritus, elevated temp side rails up, increase risk for injury, admin antiemetics as prescribed, monitor maternal vs, monitor allergic rx, FHR pattern monitoring - pharmacological anesthesia: eliminates pain perceptions by interrupting the nerve impulses to the brain. anesthesia used in childbirth includes regional blocks and general anesthesia - regional blocks: most commonly used and consist of pudenal, epidural, spinal, and paracervical nerve block - pudendal bloc: local anesthetic (lidocaine or bupivacaine) administered transvaginally into the space in front of the pudendal nerve. local anesthesia to the perineum, vulva, and rectal areas during delivery, episiotomy, and episiotomy repair. admin during late second stage of labor 10-20 minutes before delivery. adverse: broad ligament hematoma, compromise of maternal bearing down reflex. tell client when to beardown, assess the perineal and vulvar area postpartum for hematoma - epidural block: local anesthetic (bupivacaine with an analgesic such as morphine or fentanyl.) into the epidural space at the level of the 4th and fifth vertebrae. no sensation from umbilicus to thighs relieving discomfort of uterine contractions, fetal descent, and pressure and stretching of the perineum. client dilated at least 4cm and controlled by PCA adverse: hypotension, fetal bradycardia, inability to feel the urge to void, loss of bearing down reflex admin bolus of fluids to prevent hypotension - spinal anesthesia block: local anesthesia that is injected into subarachnoid space into the spinal fluid at third, fourth, or fifth lumbar interspace. can be alone or with analgesic such as fentanyl. eliminates all sensations from level of nipples to the feet. used for c sections in late second stage. can be for vaginal but not used in labor adverse: maternal hypotension, fetal bradycardia, loss of bearing down reflex, potential headache from puncture site, higher incidence of matter bladder and uterine atony following brith assess vs every 10 minutes, IV bolus - general anesthesia: rarely used for vaginal or csection when there are no complications present. used in delivery complication or when there is contraindication to nerve block analgesia or anesthesia. produces unconsciousness monitor maternal vs, fhr patterns, NPO before hand, IV infusion in place, anti embolic stockings or sequential compression devices, oral antacid to neutralize acidic stomach contents, histamine2-receptor antagonist such as ranitidine to decrease gastric acid production, metrocloproamide to increase gastric emptying as prescribed, place a wedge under one hip to displace uterus, maintain open airway and cardiopulmonary fx, assess the client postpartum for decreased uterine tone, which can lead to hemorrhage and be produced by pharmacological agents used in general anesthesia. facilitate parent newborn attachment as soon as possible

candidiasis

- vulvovaginal candidiasis or yeast infection is a fungal infection caused by Candida albicans - risk factors: pregnancy, DM, oral contraceptives, recent antibiotic tx, obesity, diet high in refined sugars - expected findings: vulvar and vaginal pruritus, thick creamy white cottage cheese like vaginal discharge, vulvar and vaginal erythema and inflammation, white patches on vaginal walls, gray-white patches on the tongue and gums (neonate) - lab tests: sample of discharge used for application to ph paper, wet mount and whiff test performed - dx: ph less than 4.5 (normal ph), wet mount potassium hydroxide prep indicates presence of yeast buds, hyphae, and pseudohyphae, negative whiff tests - meds: fluconazole: single low dose, topical therapies, anti fungal agent, fungicidal action. OTC such as clotrimazole are available - avoid tight fitting clothing, wear cotton lined, avoid damp clothing, avoid douching, increase dietary intake of yogurt and active cultures

CHAPTER 7 bleeding during pregnancy spontaneous abortion

- when a pregnancy is terminated before 20 weeks of gestation (the point of viability) or a fetus weighing less than 500g - types of abortions are classified according to manifestations and whether the products of conception are partially or completely retained or expulsed. types of abortions: threatened, inevitable, incomplete, complete, missed - risk factors: chromosomal abnormalities, maternal illness (type 1 DM), advanced maternal age, premature cervical dilation, chronic maternal infections, maternal malnutrition, trauma or injury, anomalies in the fetus or placenta, substance use, antiphospholipid syndrome - expected findings: backache and ab tenderness, rupture of membranes, dilation of cervix, fever, signs and symptoms of hemorrhage such as hypotension and tachycardia - lab tests: hgb and hct is considerable blood loss, clotting factors for DIC, WBC for suspected infection, serum hcg levels to confirm pregnancy - dx and therapeutic procedures: ultrasound to determine presence of a viable or dead fetus, or partial or complete products of conception within the uterine cavity, examination of the cervix to see if its opened or closed, dilation and curettage (D&C) to dilate and scrape the uterine walls to remove uterine contents for inevitable and incomplete abortions, dilation and evacuation (d&e) to dilate and evacuate uterine contents after 16 weeks of gestation, prostaglandins and oxytocin to augment or induce uterine contractions and expulse the products of conception - nursing care: pregnancy test, observe color and amount of bleeding (count pads) - maintain client on bed rest, avoid vaginal exams, assist with ultrasounds, administer meds and blood products, determine how much tissue has passed and save passed tissue for exam, assist with termination, use miscarriage, provide client education and emo support, provide referral for support groups - meds: analgesics and sedatives, prostaglandin as vaginal suppository, rho(D) immune globulin, suppress immune response of clients who are rh-neative - notify provider of heavy bright red vaginal bleeding, elevated temp, or foul smelling vaginal discharge. small amount of discharge is normal for 1-2 weeks, refrain from tub baths sexual intercourse or placing anything in the vagina for 2 weeks. avoid becoming pregnant for 2 months.

body image changes

- woman require support from family and provider - physiological changes are not obvious during first trimester - second trimester, there are rapid changes because of enlargement of abdomen and breasts. the skin changes such as stretch marks and hyperpigmentation. she may lose balance and back and leg discomfort and fatigue