Maternal Health Exam 2

The nurse is providing instructions to a pregnant patient with cardiac disease regarding appropriate dietary measures. Which statement made by the patient indicates an understanding of the information provided by the nurse?

"I should drink adequate amounts of fluids and increase my intake of high-fiber foods."

What bring you in? (Laboring reasons)

"I think my water broke" = Spontaneous rupture of membranes (SROM) "I think I'm in labor" = Regular, frequent, painful contractions "I think I lost my mucous plug" = Change in vaginal discharge, mucous plug (chunk of luekorrhea --> opaque/mucous-y), bloody show

A patient who admits to substance abuse during pregnancy tells the nurse, "I know I am just a really weak person, but I will try to cut down while I am pregnant." Which response by the nurse would be most therapeutic?

"That is a very positive plan. Can you tell me more about feeling like a weak person?"

Nonpharmacologic measures during labor are based on the

"gate control" theory of pain (pain receives painful stimulus from contractions, if we provide a different physical sensation (acupuncture, cold, heat) it closes the gate to the painful stimulus) -Most are shown to decrease length of labor & increase maternal satisfaction with birthing experience -Nurses are encouraged to offer nonpharmacolgic interventions 1st -17% give birth without an epidural

Passenger - fetal presentation

"presenting part" Cephalic = head is down: •Vertex (most preferred) -Sinciput = military position -Brow = forehead is more presenting (baby will either push head to chest or start to have face presentation) -Face Breech = butt/feet first (not ideal): -Frank -Complete -Footling Shoulder = shoulder is presenting firs

Nursing care during Stage I - ambulation and positioning

-Ambulation = intact memnranes OR presenting part engaged, not received pain medication -Upright positioning = birthing ball helps open pelvis -Hands and knees help change diameter of pelvis

Menstrual disorders

-Amenorrhea -Dysmenorrhea -Premenstrual Syndrome -Endometriosis

Anemia

-Anemia in combination with another complication may result in CHF -Poor tolerance of blood loss at delivery -More susceptible to postpartum infections **Often in young mothers

Benign breast disorders

-Any non-cancerous breast abnormality -May cause pain and discomfort -May or may not require treatment -Emotional trauma = fear, anxiety, disbelief, hopelessness, depression -Fibrocystic changes -Fibroadenoma -Non-lactational mastitis

Pulmonary disorders in pregnancy

-As pregnancy advances, enlarging uterus puts pressure on thoracic cavity (makes it hard to take deep breath) -Pulmonary disease increases respiratory difficulty

Fetal heart rate characteristics

-Baseline Rate -Variability -Accelerations (present or absent) -Decelerations (present or absent)

Terbutaline (might see tachycardia in mom and then fetal HR) --> tocolytic

-Beta-adrenergic agonist -Relaxes smooth muscle/inhibits uterine activity -Nursing implications/side effects

Maternal assessment - psychosocial factors

-Birth plan and level of preparation -History or sexual abuse or IPV (incidence increases during pregnancy) à try to screen without significant other in room -Stress in labor -Cultural factors (who is in room? Sex of care provider?)

Variable decelerations

-CHANGE MATERNAL POSITION -Determine severity -If drops to < 70 bpm, slow return to baseline, &/or loss of variability

Effects of substance abuse on fetus

-Can take babies home if mom demonstrates sobriety and is committed to staying sober -Social work consult if urine drug screen comes back positive for any drugs

Systemic Lupus Erythematosus in Pregnancy

-Chronic, multisystem inflammatory disease -Associated with preeclampsia, blood clots, infection, maternal death, preterm birth, IUGR, neonatal lupus, and fetal heart block (rash, decelerations, etc.) Goals: -Control flare-ups (6-month remission before attempting pregnancy) -Suppress symptoms --> traditional medication regimes may be contraindicated/dosing adjustments -Frequent PNVs **Can get better OR worse during pregnancy

Classifications of cardiac disability

-Class I and II can generally do okay with management -Class III and IV have poorer outcomes (pregnancy not recommended)

Cesarea birth indications

-Complete placenta previa -Cephalopelvic disproportion (CPD) = baby not fitting through maternal pelvis -Placental abruption -Active genital herpes -Umbilical cord prolapse -Failure to progress (FTP) -Non-reassuring fetal heat rate -Breech presentation -Previous classical incision -HIV positive?

Therapeutic management of IOL

-Confirmation of gestational age -Assessment of cervical ripeness -Nonpharmacological methods -Mechanical methods -Surgical methods -Pharmacological agents

Maternal consequences of cardiovascular conditions during pregnancy

-Congestive heart failure -Arrhythmias -Pulmonary hypertension and edema -Stroke/emboli -Aortic dissection (tearing pain in chest, not as common) -Maternal death

VBAC management

-Consents -Documentation -Surveillance -Readiness for emergency Guidelines for a trial of labor from ACOG (2010): -One previous C/S with low transverse uterine incision -Adequate pelvis -No other uterine scars & no previous uterine rupture -Availability of HCP that can perform C/S throughout labor -In-house anesthesia for emergency

Clinical manifestations of uterine rupture

-Constant abdominal pain from distention = "ripping or tearing" -Change in uterine shape -Cessation of contractions (if you pop a hole, we no longer can see that pressure that allows us to see the contractions) -Fetal distress -Loss of fetal station Late signs: -Rigid abdomen -Maternal shock **Epidural can mask the pain, which is dangerous

Regional -Epidural Anesthesia

-Continuous infusion of local anesthetic agent "caine" into lumbar epidural space -Block pain, can feel pressure still -ATI Epidural Placement Video Link

Fetal oxygenation & contractions

-Contractions are similar to being dunked under water -If babies have adequate reserve to begin with, they are usually fine, but if they DO NOT they can have issues -OR contractions are too close together & it takes 90 seconds to fully re-perfuse the baby

Menopause nursing management

-Counsel about risk factors -Disease prevention -Encourage frequent reassessment with hormone therapy -Emphasize support groups & friends -Promote healthy lifestyles & stress management -Calcium supplements -Low-dose aspirin for clot prevention

Factors contributing to adolescent pregnancy

-Earlier menarche -Socioeconomic & cultural --> crosses all spectrums, but 85% occur in poor families -High-risk behaviors -Peer pressure -Fear of talking about contraception with parents -Poverty -Early dating without supervision -Media -Lack of education about bodies

Cesarean birth risks

-Endometritis, wound infection -Blood transfusions, postpartum hemorrhage -Atelectasis, aspiration -Venous thrombosis -Bladder or bowel injury -Longer hospital stay -Longer recovery -Respiratory complications in the newborn (don't get vaginal squeeze that helps get fluid out of lungs) -Uterine rupture and/or placental implantation problems in future pregnancies

Amnioinfusion nursing management

-Explanation of procedure -Room temp NS or LR for term = 250-500 mL bolus, then 180 mL/hr (max 1,000 mL) -Ensure fluid is returning Assessment variation = no return of fluid; uterine overdistension; increased uterine resting tone -Evaluate for improvement in FHTs

Obesity in pregnancy

-Extra adipose tissue has endocrine function --> can effect vascular pathways and metabolism -Extra adipose tissue has risk factors but don't want to make this the only focus (many have no complications) -Skin hangs over after c-section --> risk for infection, must tell them to lift tummy up everyday and check things out (antimicrobial dressing put underneath and tell how often to change it)

Contraindications for IOL

-Fetal distress -Complete placenta previa/vasa previa -Transverse fetal lie -Hemorrhage -Umbilical cord prolapse -Previous classical c/s -Active genital herpes **Can have IOL with transverse C-section scar but not the verticle

Passenger of the fetus

-Fetal head -Fetal attitude -Fetal lie -Fetal presentation -Fetal position -Fetal station -Fetal engagement -Cardinal movements of labor

Shoulder dystocia

-Following birth of the head, shoulders fail to emerge -Shoulders remain wedged behind maternal pubic bone -Chest unable to expand Risk factors: -Suspected macrosomia -Maternal diabetes -Obesity -Postterm pregnancy -Previous shoulder dystocia -Short stature, CPD Maternal risks: -Postpartum hemorrhage -Vaginal lacerations Fetal/neonatal risks: -Erb's palsy & other brachial plexus injuries -Clavicle fracture -Humerus fracture

Pattern evolution

-Hard to come back from a category 3 -Free game to test strips

Risk factors for prolapsed umbilical cord

-Head not well applied after ROM -Abnormal fetal lie/presentation -Low birth weight -Multiple gestation -Polyhydramnios (water rushes out quicker, cord comes with) -Obstetric manipulation = amniotomy (most common for cord to prolapse during this time), FSE or IUPC application -Long cord

External cephalic version (ECV) contraindications

-IUGR, fetal anomalies, non-reassuring FHR, nuchal cord, multiple gestation -Uterine anomalies, ROM, previous C/S, poly/oligo hydramnios

Causes of pre-term labor (PTL)/pre-term birth (PTB)

-Iatrogenic (indicated) -Inflammation (uterine muscle inflammation --> infection (UTI that progresses to pylenophritis, STIs, PID) -Stress (can lead to increased bleeding) àHPA axis -Bleeding -Uterine overdistension (multiples, big baby, hydramnios)

Nurse managmenet of dystocia

-Identify -Promote labor progress -Promote fetal rotation -Promote comfort -Promote safety -Educate

Key nursing interventions during admission

-Identify gestational age (how far along are you?) -Fetal assessment (is baby stable?) -Determine labor status (imminence of birth & assess membrane status) -Validate prenatal history & ID risk factors -Establish IV access -Discuss plan of care -Orient to the unit

Fetal malpresentation - face

-If chin is posterior will have injury (tend to have bruised face) -Antioriorly is okay

Cesarean delivery

-In 2018, 31.9% of births were via cesarean section (Martin, et al., 2019) compared to 4.5% in 1965 -WHO campaigns to reduce primary cesarean birth rate Why the rise? Sicker people having babies, faster/quicker, more educated on things that require c-section, advanced maternal age, we no longer deliver babies breech vaginally, easier for patient's

Objective clinical manifestations of preterm labor

-Increase, change, odor, or blood in vaginal discharge -Change in cervical dilation ("feel heavy in my thighs" --> ended up being 6 cm) -Regular uterine contractions (or increase in frequency/strength) -PROM -Discomfort

Operative vaginal birth

-Indicated when birth will relieve a condition that threatens the mother or fetus (AKA instrumental or operative delivery) -Provider MUST be well-trained & follow guidelines for use -Continuing to attempt a vaginal delivery is contingent upon fetal toleration of the manipulation!

Tocolytics for preterm labor

-Indomethacin (NSAID) -Nifedepine -Terbutaline (might see tachycardia in mom and then fetal HR) -Magnesium sulfate

Risk factors for making membranes rupture

-Infection -History of PTL/PTB (pre-term labor/pre-term birth) -Cervical conization or cerclage -Uterine overdistention -2nd or 3rd trimester bleeding -Low SES -Low BMI -Smoking -Substance use

Regional - spinal anesthesia

-Injection of local anesthetic "caine' into the fluid-filled subarachnoid space -Method of choice for cesarean births -Nursing care similar to epidural placement, but we do this in OR

What's going on in this figure (1)?

-Late decelerations -Absent variability -1 minute apgar score was 3, three-month infant died due to brain hemorrhage

Malignant breast disorders

-Malignant neoplastic disease (normal cells transformed into malignant cells) -Most common cause of cancer in women -Second leading cause of cancer deaths in the US -About 1 in 8 women will develop in their lifetime

Epidural anesthesia adverse effects

-Maternal hypotension -Inadequate or unilateral block, block failure -Pruritus, headache -Temperature elevation -Short-term tenderness -Urinary retention -Shivering, nausea, vomiting **IV fluid bolus prior to epidural because it can cause hypotension (safeguards against it) **Low BP in mom à late decelerations (need to send blood flow to vital organs and placenta is not one of them, causes uteroplacental insufficiency)

Clinical manifestations of a prolapsed umbilical cord

-Moderate variability -Complete compression of cord --> baby becomes bradycardic

Premenstrual dysphoric disorder

-More severe & greatly impacts all facets of daily life -About ~ 5 million affected -Spectrum of disorders --> PMS to PMDD (more severe) Symptoms = bloating, anxiety, tension, breast tenderness, crying episodes, depression, fatigue & lack of energy, difficulty concentrating, thirst, appetite changes, swelling in LES Risk factors: -25-35 y/o -Psych history -Family history -Unhealthy lifestyle -Stress

Uterine bleeding after menopause

-Never normal -Red flag -Suspect malignancy

Early decelerations

-No intervention required with moderate variability -Document findings -Cervical exam?

Nursing care during Stage I - nutrient and fluid intake/output

-Oral (ice chips, clear liquids, regular diet) = ice chips/clear liquids for anesthesia incase c-section -Encourage frequent voiding because full bladder blocks cervix area (q2h, catheter) -Intravenous (lactated ringers, D5 1/2 normal saline) -Bowel elimination (often baby time)

Late decelerations (LOBO)

-Oxytocin OFF -O2 applied ?? = doesn't make difference for neonatal interventions (might not make a difference), no longer a first line treatment for non-reassuring FHT -IVF bolus -Change maternal position -Check maternal BP & pulse -Contact provider **Order in which you do them depends on the situation (if you have oxytocin going and way too many contractions, you might turn this off first)

Thyroid disease - TSH screening

-Personal or family history of thyroid disease -Personal history of pregnancy loss or preterm delivery -Type 1 diabetes -Obesity -Infertility -History of radiation to the head or neck **Most of the time doesn't cause problems in pregnancy

A full-term infant has just been born. Which interventions would the nurse perform at birth?

-Place the infant on the mother's chest -Dry and stimulate the infant -Evaluate the newborn using the Apgar system

Fetal factors that trigger onset of labor

-Placental aging --> does it release something that triggers labor as it ages? -Fetal cortisol concentration levels are higher -Prostaglandins released form pressure on cervix

Neurologic/autoimmune disorders in pregnancy

-Potential for teratogenic medications -Changes in mobility r/t pregnancy -Impaired ability to care for the baby

What to do when it's time to birth the baby

-Prepare room -Hygiene -Birthing positions -Support the couple -Suction mouth, then nose -Clamp cord blood if mom is Rh negative or has O blood type & collect any ordered labs

The nurse is preparing for the admission of a patient scheduled for an external cephalic version (ECV). Which of the following conditions noted in her chart would be contraindications for an external cephalic version?

-Previous cesarean section (risk of uterine rupture during procedure from previous scar) -Spontaneous rupture of membranes (likely won't have adequate amniotic fluid)

Treatment of pre-term labor depends on

-Probability of progressive labor (if 2 cm we can maybe help, 8-9 cm we probably can't do anything) -Gestational age -Risks of treatment -Contraindications **No magnesium sulfate if they have high stage cardiovascular disease

Personal comfort measures - Stage I

-Provide privacy -Wash perineum -Change underpads, fresh linen & gown (amniotic fluid keeps leaking, can cause tissue breakdown if we don't change these things) -Cool washcloth -Position changes, birthing ball, relaxation -Offer massage -Breathing techniques

Nursing role in operative vaginal deliveries

-Provider responsible for explaining procedure & risks -Educate & reassure -Ensure bladder empty -Ongoing maternal-fetal assessment -Anticipate neonatal resuscitation -Documentation is completed by the provider, however....... Stop the Line! --> If duration/use exceeds guidelines (might only allow 3 vacuum assisted pop-offs total), chain of command

General nursing care in pregnancy loss

-Provider vs nursing role -Allow the family to dictate their own experience -Use of clichés can be harmful -Utilize active listening -Be with, be present -Resist offering explanations -Facilitate mourning process -Anticipatory guidance -Postmortem care -Baptize

Magnesium sulfate --> tocolytic

-Relaxes smooth muscle -Same nursing implications as with tx for preeclampsia -Neuroprotection <32 weeks -With preeclampsia these patients already have higher deep tendon reflexes and clonus BUT early signs of toxicity are the changes in deep tendon reflexes when pre-term labor moms don't have preeclampsia **Normal magnesium level = 1.4-2.5 (considered therapeutic at 4-7 in pregnancy)

Clinical manifestations of fetal loss

-Report absence of fetal movement (not as active as they have been) -May have contractions, ROM, vaginal bleeding -Fetal death confirmed by the absence of a heartbeat via ultrasound

The nurse is caring for a patient in labor who is receiving oxytocin. The nurse notes the patient is experiencing tachysystole uterine contractions and the fetal heart rate is 95 bpm. Which nursing actions would the nurse perform based on this assessment data?

-Reposition the patient -Turn off the oxytocin infusion -Administer an intravenous fluid bolus of Lactated Ringers

Predictors of pre-term labor (PTL)/pre-term birth (PTB)

-Risk Factors -Cervical length -Fetal fibronectin testing (vaginal swab, doesn't tell you with high predictability if someone WILL deliver early, it tells you they WON'T delivery early (won't deliver in next 10-14 days)

Nitrous oxide

-Self administered right before & during contractions -Does not eliminate pain, but increases pain threshold -Limited adverse affects **Use themselves, increases what they can tolerate/don't remember as much, out of system quickly, effects on baby are lessened

Variable deceleration figure

-Sharp contraction spikes usually indicate patient is pushing

Nursing care during Stage I - general hygeine

-Showers, bed bath -Oral care -Perineal care -Hand washing

Passenger - fetal head

-Size -Molding = sutures are not fused and this allows for overlapping of the cranial bones, in order to mold to birth canal (baby comes out with elongated/cone-shaped head) -Anterior & posterior fontanelles -Sutures

Other periodic baseline changes - sinusoidal pattern

-Smooth sinewave-like pattern Causes = severe hypoxia d/t fetal anemia & hypovolemia **Figure shows Sinusoidal pattern (wave-like pattern) --> there is no variability (absent), just a flat line that is a wave back and forth --> usually d/t severe fetal hypoxia caused by fetal anemia and hypovalemia (maternal-fetal hemorrhage, hemolysis of fetal RBC's related to Rh incompatability)

Nurses role in pain relief during labor

-Support decision for nonpharmacologic & pharmaceutical pain relief -Support changes in decision -Educate about options, offer alternatives -Ensure that mom and fetus are safe -Pain during labor is universal, but experience is not

Three-Tier Fetal Heart Rate Interpretation System (NICH-HD)

-The FHR tracing can move back and forth between categories -Must meet specific criteria Category I tracings = normal Category II tracings = indeterminate Category III tracings = abnormal **Categories allow us to speed up communication on the matter

Continuous external fetal monitoring

-US measures babies HR -Tocodynamometer measures contractions

Causes and/or risk factors for fetal loss

-Unknown -Prolonged pregnancy -Infection -Hypertension -Advanced maternal age -Rh disease -Uterine rupture -Diabetes -Congenital anomalies -Cord accidents -Abruption -Trauma -In vitro fertilization

Maternal factors that trigger onset of labor

-Uterine stretch as fetus grows -Pressure on cervix = release of prostaglandins (cervical ripening/softening) -Oxytocin sensitivity increases near term --> triggers contractions -Estrogen/progesterone ratio change --> progesterone levels were high during pregnancy to maintain, but near term they start to fall & estrogen increases

What's going on in this figure (2)?

-Variable decelerations -Marked variability -Spikes tell us that the patient is pushing -Cord was around the neck, with apgar scores of 7/9

Cardiovascular disorders during pregnancy

-Women with cardiac disease are at risk of not being able to compensate for the higher workload placed on the heart during pregnancy -Or the higher workload may reveal undiagnosed cardiac disease Incidence: -3% of pregnancies -Responsible for 10%-25% of maternal mortality

Delivery of the placenta

1. Globular uterus 2. Rise of fundal level 3. Sudden trickle of blood 4. Further protrusion of umbilical cord "Retained" = placenta expulsion > 30 min after birth of fetus

Seizure disorders in pregnancy

1/3 worsen Associated with birth defects r/t antiepileptic drugs, preterm labor, maternal/fetal injury = might try to cut down dose/switch to something else that doesn't have as high risk of birth defects, but risks of mother outweight the baby (can't have mom seizing all the time) --> often the only thing that works is meds they've already been taking Goal: -Prevent birth defects --> change in medication regime (additional folic acid) -Prevent injury --> encourage medication compliance, adequate rest/avoid seizure triggers, at home safety measures (maybe have stroller close by so if they feel an aura coming on they can set baby down)

4 stages of labor

1st Stage: -Onset of regular contractions to fully dilated (10 cm) -3 phases, now 2 phases (early and active) 2nd Stage = 10 cm until birth of infant 3rd Stage = birth of infant to the delivery of the placenta 4th Stage = after placental delivery up to 1-4 hours after birth

Asthma in pregnancy

3%-8% of pregnancies: -1/3 worsen (increase incidence of attacks btw 29 & 36 weeks) -1/3 improve -1/3 have no difference Severe, persistent = linked to preeclampsia Poorly controlled = increased risk of preterm labor, LBW, & stillbirth Goal = prevent hypoxic episodes to preserve continuous fetal oxygenation Special considerations: -Inhaled corticosteroids preferred -**Carboprost contraindicated in patient's with asthma

At birth, a newborn's assessment reveals the following: -Heart rate 108 -Weak cry, intermittent cry -Some flexion of the extremities -Grimace when the bulb syringe is introduced into the nares -Pink body with blue extremities The nurse would document the newborn's Apgar score as:

6

Psyche in labor

A woman's emotional readiness for the labor process that can affect the entire experience Includes: -Fears -Anxieties -Birth fantasies -Level of social support -Preparedness **Have the ability to slow down/speed up labors, can be very trouble for women who have visions of how their labor will go

Dystocia

Abnormal or difficult labor characterized by a slow &/or abnormal progression of labor resulting from problems with.... -Powers -Passenger -Passageway -Psyche -"Failure to progress"

Variable deceleration

Abrupt decrease from baseline -Unpredictable shape (V or U shaped) -Usually transient & correctable -Variable in time = can happen before, during, or after contraction Cause = CORD COMPRESSION

Other periodic baseline changes - prolonged decelerations

Abrupt decrease in FHR >2 min, but < 10 min Causes: -Prolonged cord compression -Cord prolapse -Abruptio placentae -Maternal supine position -Maternal seizure **Usually reversible by correcting underlying cause (if we can't reverse, it becomes fetal bradycardia and we need to get baby out)

Accelerations

Abrupt increase in baseline, sign of fetal movemene & well-being 15 bpm above the baseline for at least 15 seconds: -15 x15 -10 x 10 if < 32 weeks Prolonged acceleration = lasts >2 min, but <10 min

Amenorrhea

Absence of menstruation Normal: -Prepubescent females -Pregnancy & postpartum -Postmenopause Secondary: -No menses for 3 cycles or 6 months -Previously had normal menses

Maternal nursing care during Stage III

Active management of the 3rd stage of labor (AMTSL) = give oxytocin after birth to help manage, decreased the rates of postpartum hemorrhage (want continuous hemorrhage) Describe delivery of the placenta = spontaneous vs. manual removal Recovery vital signs Fundal assessment (want it firm) Lacerations/episiotomy care = apply ice pack Monitor for excess bleeding

Post-term management

After completion of 42wks: -Monitor fetal well-being -Induction of labor with any signs of fetal compromise where baby stops growing OR ↓ amniotic fluid Intrapartal period: -Electronic fetal monitoring (EFM) -Assess fluid for meconium -Ongoing assessments of labor progress (at risk for labor dystocia)

Nonpharmacologic measures during labor

Ambulation and position changing Cutaneous stimulation strategies: -Intradermal water block -Counter pressure -Effleurage -Transcutaneous electrical nerve stimulation -Acupuncture & acupressure -Therapeutic touch & massage -Hydrotherapy Other sensory stimulation: -Aromatherapy -Music

Fetal assessment = fetal status

Amniotic fluid = clear (what we want) vs. meconium (interruption of oxygen delivery, causes baby to release this in amniotic fluid) Gestational age: -Preterm (<37 weeks) -Early Term (between 37 & 38 6/7 weeks) -Full Term (between 39 & 40 6/7 weeks) -Late Term (between 40 & 41 6/7 weeks) -Postterm (>42 weeks) Analysis of the FHR (best tool): -Baseline FHR -Degree of Variability -Presence of accelerations -Presence of decelerations Other methods: -Umbilical cord blood gas analysis à tells fetal oxygenation status -Fetal scalp stimulation --> tickle head and baby should respond with acceleration

Assessment variation - minimal variability

Amplitude < 5 bpm Causes: -Same as for absent -Fetal sleep cycle (can last up to 40 minutes) -Maternal medications (magnesium sulfate is a CNS depressant, so might expect minimal variability)

Assessment variation - marked variability

Amplitude > 25 bpm Causes (oxygenation based à panicking d/t lack of oxygen): -Cord compression or prolapse -Abruptio placentae -Tachysystole

Assessment variation - absent variability

Amplitude or fluctuation is undetectable (must get baby out quickly) Causes: -Fetal acidemia r/t uteroplacental insufficiency -Preterm fetus -Maternal hypotension -Uterine tachysystole -Prolonged cord compression Exception = might see absent variability in a fetus that is pre-term because CNS is continuing to develop as they get further along in gestation

Premenstrual syndrome symptoms

Anxiety = difficulty sleeping, tenseness, mood swings, clumsiness Craving = sweets, salty, chocolate Depression = low self-esteem, anger, easily upset Hydration = weight gain, abdominal bloating, breast tenderness Other = hot flashes or cold sweats, nausea, change in bowel habits, aches or pains, dysmenorrhea, acne breakout

Intermittent auscultation of FHR/palpation of contractions

Appropriate for women NOT on oxytocin and who come in/labor spontaneously/have low risk pregnancy -Use doppler then palpate contractions

2nd stage of labor

As fetal head descends, the woman has the urge to push -Bloody show may increase -Cardinal movements of labor occur Timing: -Nulliparous: <3-4 hours -Multiparous: <2-3 hours

Nursing care during stage IV

Assess q 15 min x 1 hour: -Palpate fundus (boggy uterus means excessive lochia/bleeding, must massage) -Lochia (bad if there's a large amount; continuous trickle; clots) -Perineum (bruised/swollen is normal, hematoma is not) -VS -Pain Encourage bonding & breastfeeding Encourage family celebration while assessing maternal & newborn stabilization Personal comfort measures: -Provide fluids/food -Encourage rest (tremors common) -Maintain privacy -Perineal care -Assist with ambulation -Address pain -Postpartum when stable

Nursing management in adolescent pregnancy

Assess support system: -Positive role models -Referrals Develop trust: -Knowing when to listen & when to offer advice -Take time to show concern Encouragement = how does she visualize her future? Where do you see yourself in 5 years, what do you want to be when you grow up? Hold accountable = pregnancy journals/planners useful -Emancipated minor makes decision for HER baby but parents can override decisions being made for HER -Child under age of 13 can't consent a sexual relationship in state of MO

You receive report on a laboring patient who begins to display recurrent late decelerations....

Assessment: -6 cm, -2 station, 100% effaced -Supine with a left tilt -Termat 39 weeks -First baby -Just started late decelerations after her epidural placement -BP is 87/43 -Contraction pattern is 3-4 min apart -Pregnancy history = severe preeclampsia and baby has IUGR (on magnesium sulfate and oxytocin) Diagnosis: -Hypertension -Preeclampsia (treatment with magnesium sulfate) -IUGR Planning: -Need to manage BP Implementation: -Change position to side-lying -Turning off oxytocin -Manage BP with IV fluid bolus -Call anesthesia if BP is not coming back up Evaluation: -Hopefully we have accelerations and moderate variability

Prolonged PROM for > 24 before birth

Associated with chorioamnionitis (Prolonged PROM)

Susan is a 26-year-old G1P0 at 6 weeks of gestation with type 2 diabetes. Her body mass index (BMI) is 32. Her hemoglobin A1c is 9. She takes glyburide 10 mg by mouth daily. The physician has switched her to insulin at this time. What advice can be given to Susan regarding exercise?

Assuming Susan is in good cardiovascular health, the American College of Obstetricians and Gynecologists (ACOG) advises 30 minutes of moderate exercise most if not all days of the week. She should be cautioned to avoid exercise in the supine position after the first trimester and to avoid contact sports or activities with a higher risk of injury. Brisk walking and swimming are excellent activities. Rationale = exercise helps control weight gain and may reduce blood sugar levels, allowing lower doses of insulin. Exercise also enhances circulation and reduces stress hormones. The supine position places a pregnant woman at risk for hypotension because of the pressure of the uterus on the vena cava and descending aorta. Sports with higher risk for maternal injury impact fetal safety during pregnancy.

Congenital cardiovascular disorders during pregnancy

Atrial septal defect (ASD) = most common, treated with heparin/lovenox Ventricular septal defect (VSD) Patent ductus arteriosus (PDA) Tetralogy of Fallot = more common, need intensive cardiology monitoring Coarctation of the Aorta Eisenmenger syndrome Marfan's syndrome

Sickle cell disease in pregnancy

Autosomal recessive disorder: -Hgb is abnormally formed as sickle/crescent shaped (HbS) -HbS erythrocytes easily interlock & clog capillaries --> ischemia --> Symptoms -Acute, recurring episodes of tissue, abdominal & joint pain Risks: -More likely to have pre-existing HTN --> HTN disorders of pregnancy, placental abruption, embolism -IUGR, PTL Goal = prevent vaso-occlusive crises & prevent interruption of oxygen delivery to the fetus during crisis -Prevent crises -Treat promptly -Positioning **Dehydration in summer and hormonal changes can trigger crisis (often know they are having a crisis because they have pain in consistent areas each time) -Clumped up RBC's can clog up vascular pathway to placenta and cause abruption -Look for acute chest syndrome in pregnancy -Treat with fluids, oxygen, pain meds, and bed rest

FHR baseline

Average FHR over 10 minutes Normal = 110-160 bpm -Baby HR on top, contraction on bottom -Put flat line across HR line and roughly shows the babies baseline

Chronic HTN in pregnancy

BP > 140/90 before pregnancy or before 20wks Associated risks: -Preeclampsia (~25%) -Placental abruption (d/t vasoconstriction and increase in pressure) -Fetal growth restriction -Preterm birth -Cesarean delivery -Perinatal death

Position - Cardinal Movements of Labor

Baby externally rotates on it's own at the end in order to allow shoulders to pass through symphysis pubis bone

FHT quiz 3

Baseline? 130 bpm Variability? Absent Accelerations? No Decelerations? Yes; late Contraction pattern? irregular Category? III: Non-reassuring -Very subtle decelerations -Non-reassuring = get baby out (c-section)

FHT quiz 2

Baseline? 145 bpm Variability? Minimal Accelerations? No Decelerations? Yes; variable Contraction pattern? 1 ½ - 2 ½ min Category? II: Indeterminant Early = gradual decrease and gradual return (don't go as deep), where as variable are abrupt decrease/return Indeterminant = not rushing back to OR but need to do something

FHT quiz 1

Baseline? 145 bpm Variability? Moderate Accelerations? Yes Decelerations? None Contraction pattern? 2 ½ - 3 min Category? I: Reassuring

Nursing care during Stage I - Active Phase

Be advocate & aware of woman's cues: -Difficult to communicate needs -May not want to be touched -Offer encouragement Encourage rest between contractions: -Quiet room/music? -Limit visitors Offer human presence Frequent assessments Support their labor partners Refrain from pushing until fully dilated: -Intense rectal pressure -Passage of flatus/stool **Once they hit active (6 cm) we often don't leave the room if natural labor

Premature menopause

Before age 40 --> premature ovarian failure Other causes: -Galactosemia -Autoimmune disorders -Carrier state of fragile X syndrome

A woman is in labor. When the patient's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. The nurse should immediately:

Begin continuous fetal heart rate monitoring -Doesn't automatically mean c-section, it is at birth that we are concerned (baby monitor first, assess fluid, check moms temp, changing linens, notify nursery nurse that we have meconium stained fluid and let provider know as well)

Stages of Labor - 4th stage

Beginning of physiological readjustment -Blood loss measurements -Fundus firm at midline -Moderate lochia = small clots may be present (bigger than ping pong ball = should be concerned) -Thirst & hunger -Shaking chill -Attachment process begins

Nursing management of substance abuse in pregnancy

Begins with screening of ALL and education -Non-judgmental, open-ended questioning (we want patient's to trust us) Education: -Effects on fetus, pregnancy, & maternal health -Importance of PNC -Address barriers to care (might need to be at methadone clinic every morning at 6 am à do they have transportation? Able to bring baby back for follow-up visits? Are they being kicked out of clinic after 6 weeks?) -Refer to outreach programs -Health promotion activities

Passageway (birth canal)

Bony pelvis = different pelvic types (gynecoid is most favorable) Cervix: -Effacement = taking up of the internal os & cervical canal into the uterine side walls (long & thick to paper thin, 0-100%) -Dilation = widening from closed to 10cm

Effect of menopause on body systems

Brain = hot flashes, sleep disruption, memory loss Cardiovascular: -↓ HDL -↑ cardiovascular risk Skeletal = bone density loss Breasts = ducts and glandular tissue replaced by fat Genitourinary: -Vaginal dryness -Stress incontinence -Cystitis Gastrointestinal = ↓ calcium absorption Skin: -↓ collagen -Thin, dry Body shape = ↑ abdominal fat, waist size

Therapeutic management of breast cancer - surgical

Breast conserving surgery = lumpectomy (usually requires radiation along with it) Mastectomy: -Simple -Modified Radical (only takes top lining of the chest wall and not the whole thing) -Radical (takes entire chest muscle out with it) Breast reconstruction = usually better outcomes If they can do it right away, but sometimes need to wait for healing process

Nifedepine --> tocolytic

Calcium channel blocker (blocks calcium that allows for muscle contraction) Nursing implications: -Baseline BP -Caution with also using Magnesium sulfate (sometimes this causes BP to come down)

Continuous internal fetal monitoring

Can be very accurate for determining strength of contractions & gives great picture of what is going on

Maternal physiologic responses to labor

Cardiovascular system: -HR increases 10-20 bpm -Increased cardiac output Blood pressure (BP): -Hypo when woman supine -Hyper during contractions GI system = GI motility remains slow Respiratory system = oxygen demand increases at labor onset d/t breathing through contractions Immune system and other blood values: -Increased white blood cells (WBCs) --> body perceives labor as stressful event, immune system on alert -Decreased maternal blood glucose à labor is like a marathon, using a lot of energy (even if patient has epidural because body is still working) -BMR increases

Cause & maternal/fetal risks of preterm labor

Cause: -Unknown -Associated with vaginal bleeding, abruptio placentae, infection Maternal risks: -Chorioamnionitis --> can progress to sepsis -Placental abruption, hemorrhage, sepsis Fetal/neonatal risks: -Prematurity (deliver early) -Sepsis from infection as well

Meconium-stained amniotic fluid

Causes: -Benign -Hypoxia-induced peristalsis Risk: -Meconium aspiration syndrome (MAS) -More on that in newborn at risk........

Which complication is most likely to occur with a precipitous delivery?

Cervical laceration

Menopause

Cessation of menstruation and fertility (no longer can have a baby) Menopausal transition: -Transition from reproductive phase to final menstrual cycle -Perimenopause (can last 2-8 years) About ~51.4 years old is average age --> same average age despite improvements in nutrition & health care End of an era = transition to mid-life, midlife crisis

Fibrocystic breast changes AKA "benign breast disease"

Change rather than disease -Change in glandular and structural tissues of breast -Way breast tissue responds to monthly fluctuations in estrogen and progesterone -About ~50-60% of all women -Most common breast disorder

Non-reassuring FHTs

Characteristics: -Abnormal baseline -Abnormal variability -Presence of decelerations Interventions: -Dependent on cause.....think VEAL CHOP --> then what would physiologically improve the situation? -May require assisted delivery OR emergency C/S

The nurse is caring for a patient in labor who received her epidural 30 minutes ago. The patient reports feeling dizzy, light-headed, and nauseated. What is the nurse's priority action?

Check the BP

Nonpharmacologic measures during labor - cognitive strategies

Childbirth education: -Bradley -Lamaze Hypnosis = train for labor beforehand and go into a deep state of relaxation (day dream) Biofeedback = self regulate HR and breathing, relax certain muscles, etc. Reiki = wave hands over belly and causing contractions, picking up energy? **Continuous labor support

Nursing assessment of preterm labor

Clinical manifestations Characteristics of amniotic fluid Diagnosis: -Nitrazine testing of fluid = amniotic fluid is more alkaline (pH 7-7.5) & turns blue -False positives: semen, urine, blood, cleansers, BV infection Sterile speculum exam (if they cough, fluid comes out) Microscopic examination - ferning AmniSure AFI

Menopause symptom management

Complementary therapies: -Phytoestrogens -Acupuncture -Relaxation techniques -Herbral supplements =Black cohosh, red clover, motherwort, ginseng, sarsaparilla root, valerian root, kelp tablets, St. John's wort (more research needed) Lifestyle changes Limit caffeine & spicy foods ↑ fluids Avoid exercise at bedtime

Fetal consequences of cardiovascular conditions during pregnancy

Compromised fetal growth Preterm birth Inheritance: -Marfan syndrome -Congenital cardiac conditions Fetal death

Indications for induction of labor (IOL)

Confirmation of gestational age = >39 weeks for elective Indications for IOL < 39 weeks: -Maternal medical conditions -Preeclampsia/Eclampsia -PPROM -Chorioamnionitis -Fetal demise -Fetal compromise (IUGR)

Nursing care during stage I labor (onset - full dilation)

Continuous assessments & documentation: -Maternal and fetal response to labor -Assessment variation (category II or III fetal heart rate pattern) Providing comfort and pain management Ensure safe passage through labor and delivery **Baby is at most risk for complications d/t interrupted oxygenation At a minimum: -Maternal vital signs -FHR pattern -Uterine contraction pattern -Membrane status **Before and after any intervention

True vs false labor

Contractions are regular that increase in frequency & intensity --> begin in the back and radiate to the abdomen --> produce progressive effacement & dilation of the cervix --> activity increases contractions; sedation or sleeping does not stop --> TRUE LABOR **False labor contractions tend to be irregular, decrease with activity/sleep/sedation, & discomfort is felt in the lower abdomen & groin

Powers of labor

Contractions: -Rhythmic tightening & shortening of the uterine muscles during labor -Thins & dilates the cervix -Contractions flex/shorten muscles & powerhouse of uterus is the fundus (the strongest part), so as it contracts it pulls up the walls of the uterus and pulls it over the babies head à presenting part (hopefully the head) puts pressure on the cervix -70-80% of power (would eventually be able to push baby out without the woman trying to push) Intra-abdominal pressure = pushing, "bearing down"

Alterations in pelvic structure

Contractures of the maternal pelvis leading to cephalopelvic disproportion (CPD) Obstruction of the birth canal: -Placenta previa -Uterine fibroids -Full bladder/rectum -Edematous cervix -Genital warts

Nursing management of amenorrhea

Counseling & education --> risk for osteoporosis and hip fractures (more issue for older generation, 40 year olds) Support Stress management Coping strategies

Passenger - fetal position

DOCUMENTATION OF FETAL POSITIONS: 1. Is presenting part to the right (R) or Left (L) of maternal pelvis? Or is fetus straight? 2. The landmark of the fetal presenting part/what part is presenting: -Occiput (O) = top/back of head (vertex presentation) -Mentum (M) = chin presenting -Sacrum (S) = breech presentation 3. Anterior (A), Posterior (P), Transverse (T) **Always describing maternal right or left, or maternal anterior/posterior/transverse pelvis

Therapeutic management of preterm labor

Dependent on gestational age/FLM If mature: -Induction/augmentation of labor -No vaginal exams until in active labor If immature = expectant management

You observe decelerations, what do you do?

Determine the type and cause so you can intervene

Fibrocystic breast changes ("benign breast disease") - diagnosis and management

Diagnosis: -Mammography -US, fine-needle aspiration biopsy (fluid vs solid) Management: -Supportive bra -Heat/cold -Dietary = ↓ salt, healthy low-fat diet, ↓ alcohol & caffeine, thiamine & vitamin E) -NSAIDS

Fetal presentation - why do we like vertex presentation?

Diameter of presenting part changes based on how baby is positioned --> elongated diameter could cause problems

The nurse is providing preoperative education for a patient scheduled for a cesarean delivery the following week at 9:00 am. What education would the nurse provide concerning NPO status?

Do not eat anything after midnight before the procedure

The nurse notes persistent early decelerations on the fetal monitoring strip accompanied by moderate variability and an occasional acceleration. Which action would the nurse perform next?

Document the FHR and continue to monitor the patient Early = head compression (we have moderate variability and even an occasional acceleration, this is okay)

Parenteral medications

Dull, rather than eliminate pain Examples = fentanyl, nalbuphine, meperidine, butorphanol Nursing management: -Ensure reassuring fetal status 1st! -SVE prior to administration -Side effects **Giving epidural too early makes baby more likely to be under the influence of medications during the birth, causing respiratory depression (and we want baby to breath at first)

Describing contractions

Duration = beginning to end of one contraction Frequency = beginning of contraction to start of next contraction Intensity = mild (nose consistency), moderate (chin), or strong (forehead) à can figure out actually mmHg if you have intrauterine monitor in place

Characteristics of the 1st stage of labor (early vs active)

Early phase = contractions farther apart, shorter, mild-moderate Active phase = contractions become closer together, longer, stronger (multiparous women progress more quickly once here à their uterus has done this before) à natural birth can cause shakiness/N/V usually from adrenaline

Nursing management for preterm labor

Early recognition & diagnosis Activity restriction Restriction of sexual activity Ensuring hydration Identify & treat infection if applicable Prophylactic antibiotics (don't know mom's GBS status so give these) Monitor FHR & contraction pattern (magnesium sulfate can cause minimal variability in FHR) Administration of tocolytic medications Promotion of fetal lung maturity: -Betamethasone for those 24 - 34 weeks (48-hour course) -Nursing implications (Patient's with diabetes or low immunity need to be careful with corticosteroids) If preterm birth is inevitable, prepare family

Shoulder dystocia therapeutic management

Empty bladder Maneuvers: -McRobert's Maneuver (hyperflexion of maternal thighs --> open up as much as possible) -Suprapubic pressure (collapse shoulder down, breaks their clavicle sometimes --> allows it to slide under the maternal pubic bone) -All-fours maneuver (Gaskin) --> if they have no epidural and we have a lot of help -Effective in over 50% of cases -Intentional fracture of fetal clavicle -Symphysiotomy (cut symphysis pubis bone) Cesarean delivery --> babies head is already out so we try to rotate and push back in gently (birth injury risk)

Labor augmentation

Enhances ineffective uterine contractions after labor has begun

Precipitous labor & birth

Entire labor and birth within 3 hours -Intense uterine contractions w/ little relaxation in between (baby suffers the most) Maternal risks: -Loss of coping, anxiety & fear -Perineal trauma (can be more severe because they aren't stretching slowly) -Postpartum hemorrhage (PPH) Fetal-neonatal risks: -Nonreassuring fetal status -Meconium staining -Brachial plexus injuries -Intracranial trauma Therapeutic management: -Vaginal delivery anticipated -Adequate pelvis -Reassuring FHTs

Fetal oxygenation interruption of pathway can occur at any step..

Environment? High altitude causes more hypoxia, exposed to certain chemicals Lungs? Does mom have CF and prone to respiratory infections? Pre-existing cardiovascular conditions Insulin-dependent diabetes who has had it for a long time and is poorly controlled with vascular involvement Abnormally shaped uterus Placenta with calcification d/t heavy smoking Premature aging of placenta r/t IUGR or pre-eclampsia Umbilical cord with lack of Wharton's jelly (provides cushion, protection, prevents cord compression) on it or lack of one of the umbilical arteries

Hypothyroidism (maternal & fetal risks)

Excess TSH, low T3/T4 -Some symptoms overlap with pregnancy Maternal risks: -Early pregnancy loss -Preeclampsia -Placental abruption -Postpartum hemorrhage -Cesarean delivery (usually only if they have other issues on top of this) Fetal risks: -Stillbirth -Preterm birth -Low birth weight (LBW) -Neuropsychologic damage **Synthroid = empty stomach for at least an hour (usually scheduled for like 6 AM before meal gets there)

Menstrual cycle review

Expulsion of endometrium = blood, epithelial cells, mucous Menarche: -12.8 yrs is average age -Can range from 8-18 yrs -Genetics, nutrition, weight, general health **400-500 cycles in a lifetime

Assessment variation - alterations in FHR baseline

Fetal bradycardia = <110 bpm (shows significant oxygen deprivation in baby) Fetal tachycardia = >160 bpm (whatever might cause in mom will then cause in fetus) -Abnormal baseline? What are possible causes?

Pain during labor

First stage (visceral): -Contractions = uterine ischemia -Distension of lower uterine segment -Stretching of cervical tissue -Pressure & traction on adjacent structures Second stage (somatic): -Pressure on the bladder & rectum (BM during labor) -Stretching & distension on perineal tissues & pelvic floor ("ring of fire" --> stretching feels like a burning) -Lacerations of the soft tissue

Nursing care during Stage 2 of labor

Frequent assessment: -FHTs/VS q 5-15 minutes -SVE for fetal descent Assist with pushing: -Positioning -Help patient focus & remain in control during pushing -Encourage her to push when she feels the urge to bear down Anticipatory guidance = "ring of fire" Promotion of comfort: -Rest between contractions -Cool cloths -Perineal massage -Heat therapy Notify HCP of progress or lack of progress = may perform an episiotomy

Endometriosis

Functioning endometrial tissue located outside of the uterus -Attached to ovaries, fallopian tubes, outer uterine surface, bowels, rectovaginal septum, & pelvic side wall

Prenatal record assessment variations upon admission

GBS (+) = need to get antibiotics (want to get in at least 2 doses before birth if able to)

Therapeutic management after confirmation of fetal loss

Given option to wait several days or proceed with induction of labor (IOL) Method of induction depends on: -Gestational age -Cervical ripeness Methods: -Laminaria tents = <16 weeks -Misoprostol (Cytotec) = <28 weeks -Prostaglandins and/or Pitocin = >28 weeks

Gestational diabetes

Glucose intolerance onset during pregnancy or first detected

Hyperthyroidism

Graves disease vs hCG-mediated hyperthyroidism -Some symptoms overlap with pregnancy Goal = maintain mild hyperthyroidism while avoiding hypothyroidism in the fetus (what happens to mom, happens to baby) **hCG is closely related to TSH (can bind itself to the TSH receptors, causes the thyroid to release more T4/T3)

Vaginal birth after cesarean section (VBAC)

Have 60-80% success rate, but 92% of women have a repeat c/s Increased success: -Previous vaginal birth -Spontaneous labor (we don't have to induce) Decreased success: -Hx labor dystocia -Advanced maternal age -Gest. age > 40 weeks -Maternal obesity -Preeclampsia -Macrosomia

Communication with grieving families after fetal loss

Helpful: -I'm sure you will miss [name] deeply. No one will ever take her place in your heart -I'm so sorry this is happening to you. This is a terrible thing to go through. Unhelpful: -You're young; you can try again -At least you have other children -At least you didn't know him or her yet -God needed another angel in heaven

The nurse is performing an admission assessment of a women in the active stage of labor. Which assessment finding places the women at the greatest risk for uterine rupture?

History of a previous c-section

When considering assessment history of a G3 P2 admitted for preterm labor, which risk factor in the woman's history places her at greatest risk for preterm labor?

History of preterm labor

Menopause urogenital changes & treatment

Hormonal changes effect sexual desire & dysfunction Vaginal atrophy: -Thinning of vaginal walls -↑ pH (alkaline >7.0) -Irritation -Loss of lubrication, dryness, pain Delayed sexual response Treatment: -Estrogen vaginal tablets -Premarin cream -Estring = estrogen-releasing vaginal ring (months) -Testosterone patches -Lubricants

Menopause vasomotor symptoms & treatment

Hot flashes and night sweats (lack of estrogen causes body to lose ability to regulate heat) Hot flashes: -Vasomotor instability -Inappropriate peripheral vasodilation of superficial blood vessels -Early & acute sign of estrogen deficiency Treatment: -Estrogen replacement (not recommended for all women) -Androgen therapy -Progestin therapy (Depo-Provera) -Clonidine -Neurontin -Propranolol -Gabapentin -SSRI's --> venlafaxine (Effexor) à can have bad withdrawal, hard to stop

Abnormal powers

Hypertonic uterine activity = frequent, uncoordinated contractions that are poor in quality (rise in resting tone of uterus --> painful but no cervical change) Hypotonic uterine activity = contractions that decrease in frequency and intensity (not a real contraction, uterus is just irritable --> no cervical change) -Not strong contractions but can impede oxygenation to baby **Often are in early labor so no epidural yet, might giver other things to help

A patient in active labor who is 5 cm begins to experience a decrease in the frequency and intensity of her contractions. She has not made any cervical change over the past 3 hours. How would the nurse interpret this pattern?

Hypotonic labor (decrease in frequency/intensity of contractions)

Shoulder dystocia nursing management

Identification of risk factors = anticipate additional personnel & stools Perform maneuvers as directed = maternal positioning Educate = prepare for cesarean delivery if necessary

Indications for GBS antibiotic prophylaxis

If hx of invasive GBS positive baby, she needs antibiotics EVEN if GBS negative for this pregnancy

Iron-deficiency anemia in pregnancy

Inadequate dietary intake = 200mg conserved d/t amenorrhea BUT 1000mg more needed Risks = non-reassuring FHTs, low AFI, LBW, PTB, fetal and maternal death Goal = eliminate symptoms, correct the deficiency, & replenish stores (might need more iron than what is in prenatal vitamins) -Supplementation (can cause constipation, upset stomach, & phlebitis) -Provide dietary counseling (iron rich foods)

Incidence & clinical manifestations of amniotic fluid embolism

Incidence: -1 in 8,000 to 1 in 30,000 pregnancies -22%- 61% mortality rate (85% have long term neuro damage) -21% fetal mortality rate (50% neurologic injury) Symptoms phase I (non-specific): -Restlessness -Cough -Cyanosis -Dyspnea -Pulmonary edema/ARDS (acute respiratory distress syndrome) Symptoms phase II: -Hypotension/Tachycardia -Shock -Cardiac arrest Symptoms phase III: -Coagulopathy -Uterine atony **Uterus gets 600 mL/min of blood at term

Adolescent pregnancy incidence & significance

Incidence: -2.2% pregnancies aged 15-19 years old -82% unplanned -½ occur within 6 months of first having sexual intercourse -1 in 4 have a second child within 2 years Significance = least likely to get early & regular prenatal care

Incidence & barriers of substance abuse during pregnancy

Incidence: -7% have used illicit drugs -20% used alcohol -19% smoked cigarettes Impact Barriers: -Lifestyle -Social stigma -Legal considerations -Multidisciplinary management -Frequently missed dx **People are afraid their babies will get taken away --> babies kept with mothers have less incidence of neonatal abstinence syndrome (want to keep them together if we can and get mom in treatment)

Induction of labor

Incidence: 23.3% Elective IOL risks: -Cesarean delivery -Operative vaginal delivery -Epidural analgesia -NICU admission Complementary interventions: -IV therapy -Bed rest -Continuous EFM -More pain -Epidural -Prolonged stay **Contractions don't do much for a cervix that isn't ripe **Usually don't induce electively until like 39 weeks gestation

Anxiety during pregnancy

Includes GAD, phobias, OCD, PTSD, panic disorder, & agoraphobia Facilitate a sense of empowerment Facilitate a sense of well-being Self-care measures: -Mindfullness -Exercise -Good nutrition SSRIs Benzodiazepines come with greater risks

Risk factors of malignant breast disorders

Increasing age = 2 out 3 are >55 Ethnicity: -Highest occurrence: White women -Highest death rates: Black women BRCA 1 and BRAC 2 genes First degree relatives Gender Hx of endometrial, ovarian, colon cancer First pregnancy >30 or no pregnancy, no lactation Dense breast tissue Young menarche, late menopause Hormone replacement therapy Try not to gain more than 11 lbs after the age of 18??

Endometriosis therapeutic management

Individualized: -Symptom severity -Fertility? Are we preserving fertility or removing uterus (hysterectomy)? -Degree of disease -Therapy goals Goal = suppress estrogen & progesterone Ovarian suppressive agents = OC's, Depo-Provera Surgery: -Removal of endometrial tissue -Hysterectomy Complementary therapies = acupuncture, vitamins, fish oil

Risks factors for pre-term labor

Infections of urinary tract/vagina Chorioamnionitis Previous PTB Multifetal pregnancy Hydramnios Advanced maternal age Smoking Substance use IPV Hx of multiple miscarriages/abortions Chronic medical conditions: -DM -HTN Preeclampsia Lack of prenatal care/access Cervical insufficiency Previa/abruption PPROM Uterine abnormalities Low BMI

Nursing care during epidural anesthesia placement

Informed consent Platelet count of at least 80-100 thousand Baseline maternal & fetal status: -Continuous EFM -VS q 1-2 min & pulse ox O2 & resuscitative equipment available IV access & fluid bolus Positioning: -Lateral -Sitting Documentation

Indomethacin (NSAID) --> tocolytic

Inhibits prostaglandins (these help with softening of cervix, so this inhibits that softening) Nursing implications: -Baseline ductus arteriosus function (can cause closure of this) -Contraindicated if >32 weeks OR allergy to NSAIDS

Susan is a 26-year-old G1P0 at 6 weeks of gestation with type 2 diabetes. Her body mass index (BMI) is 32. Her hemoglobin A1c is 9. She takes glyburide 10 mg by mouth daily. The physician has switched her to insulin at this time. What should Susan be taught about insulin needs in pregnancy?

Insulin needs may decline during the first trimester and then increase during the second and third trimesters of pregnancy. Rationale = the nausea and vomiting of early pregnancy can decrease insulin needs. In the second and third trimesters of pregnancy, human placental lactogen (hPl) produced by the placenta increases and has the effect of increasing insulin resistance and thus increasing the need for insulin.

Analysis of the FHR

Intermittent auscultation & palpation of contractions Continuous external monitoring: -Ultrasound transducer -Tocotransducer Continuous internal monitoring: -Fetal scalp electrode (FSE) -Intrauterine pressure catheter (IUPC)

General anesthesia

Intravenous, inhaled, or a combination of the two Generally indicated for: -Emergency cesarean deliveries -Women with contraindications to epidural/spinal anesthesia Complications: -All the norms, PLUS -Fetal depression -Aspiration pneumonia -Uterine relaxation Nursing care: -NPO -Positioning **High risk for postpartum hemorrhage (uterus doesn't firm up after birth)

FHR variability

Irregular fluctuations in the FHR baseline measured as amplitude -Moderate = 6-25 bpm -Alterations = absent, minimal, marked -Represents relationship btw parasympathetic & sympathetic -Presence of moderate variability indicates adequate oxygenation & CNS function (one of the most important things to see on fetal tracing)

Stages of labor - 2nd stage

Latent phase = laboring down Active phase = pushing, open epiglottis vs closed Crowning = fetal head is encircled by the external opening of the vagina, birth is imminent Spontaneous birth = occurs as the anterior shoulder passes under the symphysis pubis (if shoulder is stuck, birth hasn't occurred yet)

A pregnant client presents to the birthing unit stating she is in labor. Which of the following client behaviors indicate that birth is likely imminent?

Leaning to one side, sitting on one buttock (lots of pressure, might be a head there = check quickly)

Peripartum cardiomyopathy

Left ventricular dysfunction occurring in the last month of pregnancy or within the first 5 months postpartum Incidence = 1 in 3000-4000 pregnancies Significance = 50% mortality rate worldwide Types: -Dilated cardiomyopathy (more common) -Hypertrophic cardiomyopathy (causes smaller chamber in ventricle) -Restrictive cardiomyopathy **Need intensive follow up with cardiology

Fetal assessment - physical exam

Leopold's Maneuvers = systematic way to evaluate the maternal abdomen and determine fetal presentation & position -First determine what is up in the fundus (head is firm, bottom is softer) -Feel in pelvis (hopefully feel fetal head) **Helps determine fetal position and best place to put fetal monitor (external fetal monitor best hears fetal heart rate over fetal back)

Managing premenstrual syndrome

Lifestyle changes: -Balanced diet -Increase fluids, fiber -Decrease caffeine, alcohol -Smoking cessation -Exercise -Stress management Pharmacological: -NSAIDS -Multivitamin with calcium -Low dose oral contraceptives -SSRI's (take during that week, short term use can help) -Diuretics

Signs preceding labor

Lightening: -Fetus engages -Fundus no longer presses on diaphragm → easier breathing -↑ pelvic pressure → urinary frequency, edema, vaginal secretions Braxton hicks contractions (practice contractions): -Irregular -Tightening or pulling sensation in the front of the abdomen (if you touch abdomen it will firm up) -Decrease with walking, voiding, fluids, position changes Cervical changes: -Ripening (softening) -Shortened & thinned (might dilate a tiny bit but aren't actually in labor, common for women who have given birth before) Spontaneous rupture of membranes (SROM): -1 in 4 experience SROM -Sudden gush or a steady trickle (might think it's urination) Nesting = sudden burst of energy to prepare the home for baby's arrival (innate drive) Bloody show: -Mucus plug expelled -Bloody, pink-tinged mucus (sign that cervix is softening, doesn't necessarily mean labor right this second)

Passenger - fetal lie

Longitudinal = head or feet down, parallel to maternal spine (96%-97% cephalic/vertex & 3% breech) Transverse = perpendicular to maternal spine, vaginal delivery not possible (<1%)

Lab results during labor admission - assessment variations

Low platelets --> need high enough platelets to get an epidural (anesthesia wants to know), also will lose blood at delivery so we want to know baseline

Risk reduction strategies for malignant breast disorders

Maintain a healthy lifestyle Weight management Reduce exposure to smoke, carcinogens, environmental pollutants Breastfeeding (if applicable) BRCA gene testing = helps explore options early on (might get mastectomy, etc.) Chemoprevention: -Selective estrogen receptor modulators (SERMs) = tamoxifen (35 yrs and older) used for prevention and treatment of breast cancer, also helps with uterine lining AND raloxifene (postmenopausal) blocks estrogen effects in breast Aromatase inhibitors: -↓ amount of estrogen -Treatment in hormone receptor positive postmenopausal and prevention Surgical = prophylactic mastectomy and/or oophorectomy

Premenstrual syndrome prevalence & economic impact

Major health problem: -Compromised physical & psychological well-being -400-500 cycles in a life time (occur 4-7 days before menses) About 80% of women have some degree: -5-10% significant impact on life -More missed work -↑ visits to ambulatory care -About $4000 in indirect costs

Problems with the passenger

Malposition = persistent occiput posterior (OP) position Malpresentation: -Face presentation -Breech presentation Multifetal pregnancy Macrosomia

Anatomy of breast

Mammary glands Reproductive accessory organs Overlie pectoralis major muscles Extend from 2nd-6th rib, sternum to axilla About ~9 lobes: -Alveolar glands & lactiferous ducts -Separated by dense connective & adipose tissue (supports weight of breast) Function = milk secretion after pregnancy

Screening & diagnosis for breast cancer

Mammography: -Early detection of lumps -Detect very small lesions (0.5 cm) Diagnostic (if mammography found something abnormal) --> often many places won't do without insurance = additional views and magnification Fine needle biopsy, core biopsy Sentinal lymph node biopsy Hormone receptor status (is this tumor receptive to hormones?) = estrogen and progesterone Screening barriers = insurance/financial, pain/fear, maybe don't have a ride to get there or don't know about the screenings **Start at age 50 (unless high risk) and stop at age 75? Or start at 40 and never stop? Conflict about this

Prolonged pregnancy maternal & fetal-neonatal risks

Maternal risks: -LGA -Dystocia -Birth trauma -Postpartum hemorrhage -Operative vaginal delivery -Cesarean delivery Fetal-neonatal risks: -Placenta has an expiration date (near term stops working as well --> baby isn't perfused as well) -Oligohydramnios -SGA (decreased nutrition) OR LGA -Meconium aspiration

Hyperthyroidism (maternal & fetal risks)

Maternal risks: -Miscarriage -Severe preeclampsia -Heart failure Fetal risks: -Birth defects r/t treatment -Preterm birth -Stillbirth -IUGR

Maternal & fetal-neonatal risks for fetal malposition - occiput posterior (OP)

Maternal risks: -Prolonged 1st & 2nd stage (bony head is pushing on maternal tailbone) -Intense back pain -Operative vaginal delivery -Severe perineal trauma (episiotomy extension) -↑ risk of C-section -Excessive blood loss Fetal-neonatal risks: -Birth trauma -Nonreassuring fetal status

Multifetal pregnancy

Maternal risks: -Uterine overdistension -Preterm labor -Postpartum hemorrhage Fetal risks = hypoxia Vaginal birth for twins = C/S for higher order multiples

Medical management of cardiovascular conditions during pregnancy (medications and surgical)

Medications: -Diuretics -Antiarrythmics -Inotropic medications -Anticoagulants (NO COUMADIN) Surgical: -Ventricular Assist Device (VAD) à usually hooked up to left ventricle, assists with pumping blood through the heart (access point that goes through paitents skin and have a backpack with battery pack) --> use often when waiting for heart transplant -Valve replacement -Heart transplant (not during pregnancy usually)

With one exception, the safest pregnancy is one in which the woman is drug and alcohol free. For women addicted to opioids, ________________________ treatment is the current standard of care during pregnancy.

Methadone maintenance **There is no safe level of alcohol in pregnancy

Episiotomy

Midline or mediolateral U.S. rates have declined = vary among hospitals: 1.7% - 22.7% No maternal benefit (only really relevant if baby is having distress and we need them out right away) More likely to have deep perineal tears & extension of the episiotomy

Nursing care management of the woman with cardiovascular conditions during the postpartum period

Minimize cardiac workload & promote tissue perfusion --> assess for fluid overload r/t autotransfusion & fluid shifts (edema? Fluid in lungs? Is she voiding?) High-risk monitoring for 48-72 hours: -S&S of heart failure -Effects of activity

Nursing care management of the woman with cardiovascular conditions during labor

Minimize cardiac workload & promote tissue perfusion: -Monitor fluid volume -Supplemental O2 -Anesthesia -Avoid Valsalva maneuver (want them breathing through pushing, not holding breath --> causes decreased blood flow) -Vacuum/forceps-assisted delivery Antibiotic prophylaxis Anticoagulants withheld during labor (they will be bleeding, don't want them to bleed out --> hold lovenox, etc.) Evaluate cardiovascular status often Monitor for complications

Acquired cardiovascular disorders during pregnancy

Mitral valve prolapse Mitral valve stenosis Aortic stenosis Peripartum cardiomyopathy Myocardial infarction (MI) Infective endocarditis

Substance abuse during pregnancy

Most commonly used drugs in pregnancy: -Tobacco -Alcohol -Cocaine -Marijuana -Heroin -Narcotics Polysubstance abuse -Amphetamines (Meth, Ritalin) -Barbiturates (GHB, Seconal) -Hallucinogens (LSD, MDMA aka ecstasy) -Narcotics (Opium, morphine, codeine)

Amniofusion

NS or LR is introduced into the uterus via an IUPC Often used in the presence of oligohydramnios & variable decelerations = ↑'s amniotic fluid volume → relief of pressure on the umbilical cord & ↑'s fetal perfusion Rare, but serious side effects: -Cord prolapse -Amniotic fluid embolism -Uterine rupture

Operative vaginal birth risks - neonatal vs maternal

Neonatal: -Facial birth injury (edema, bruising) -Scalp lacerations (vacuum burn) -Caput, cephalhematoma -Subdural hematoma -Low Apgar scores -Ocular trauma -Prolonged hospital stay Maternal: -Birth canal trauma -Episiotomy extension -↑ bleeding -↑ risk of PP infection -Urinary & rectal incontinence

Stage III - immediate nursing care of the newborn

Newborn on mother's chest/radiant-heated unit Respirations priority: -Dry & stimulate -Bulb suction as needed Provide & maintain warmth: -Skin-to-skin contact -Initiate attachment Assign Apgar score (next slide) Newborn Assessment

How do contractions affect uterine blood flow?

No blood flow during contraction

Secondary amenorrhea

No menses for 3 cycles or 6 months -Previous menses normal Causes: -Pregnancy, breastfeeding, pituitary tumors (regulates many of these hormones), depression, malnutrition, radiation, chemotherapy -Behavioral --> rapid weight changes, excessive physical activity

Primary amenorrhea

No menses or development of secondary sexual characteristics by 14 y/o -No menses by 16 y/o with normal development Causes: -Structural anomalies, chronic illness, Turners syndrome, Cushings, PCOS -Behavioral --> eating disorders, extreme weight loss, excessive activity (intense, hours of training in gym)

Primary dysmenorrhea

No underlying pathology Theory = ↑ prostaglandin production: -Produced by endometrium -Cause uterine contractions (vasoconstriction of small vessels in uterine wall) Higher levels noted

Fetal phsyiologic responeses to labor

Normal fetus has no adverse effects Heart rate changes: -Periodic accelerations & mild decelerations -Variable/late decelerations Fetal circulation = ALL babies have decrease in circulation & perfusion during contractions (oxygen delivery is interrupted --> normal baby shouldn't have adverse effects to this) Fetal respiration: -Fetal lung fluid begins to clear (vaginal squeeze helps expel fluid) -pH decreases -Breathing movements (preparing in utero)

Chronic HTN in pregnancy management

Nutrition: -Low sodium diet -Weight gain Moderate exercise (bed rest not recommended, want moderate exercise unless we can't control it at all) Medications = antihypertensives (NO ACE inhibitors because of effects on the fetus) BP monitoring at home More frequent PNVs

Susan is a 26-year-old G1P0 at 6 weeks of gestation with type 2 diabetes. Her body mass index (BMI) is 32. Her hemoglobin A1c is 9. She takes glyburide 10 mg by mouth daily. The physician has switched her to insulin at this time. What additional risk factor does Susan have?

Obesity Rationale = obesity is associated with many maternal and fetal risks including increased incidences of fetal anomalies, fetal death, macrosomia, shoulder dystocia, hypoglycemia, and stillbirth. Mothers are at increased risk for diabetes, preeclampsia, postpartum hemorrhage, and delayed lactogenesis.

Amniotic fluid embolism

Occurs as a bolus of amniotic fluid, fetal cells, hair, or other matter enters maternal circulation & travels to the lungs -Believed to trigger an allergic reaction causing cardiopulmonary collapse & coagulopathy (DIC) Risk factors (things vascular-related --> allows fetal cells to get into maternal circulation): -Placenta previa or abruption -Preeclampsia or eclampsia -Diabetes -Use of oxytocin, forceps-assisted birth, labor induction, or cesarean birth -Meconium-stained amniotic fluid

Passenger - fetal engagement

Occurs when largest diameter of the presenting part passes through the pelvic inlet "Engaged" = 0 station "Ballottable" = presenting part is freely movable above the inlet (can push on presenting part and fetus will float back away, then come back)

Preterm labor

Onset of labor before 37 weeks -Cervix has to change/dilate for true labor Incidence = 9.6%; 41% iatrogenic

Pathophysiology of fibrocystic breast chagnes (benign breast disease)

Overgrowth of fibrous tissues in the supportive connective tissue = cause unclear, possible imbalance between estrogen & progesterone Symptoms: -Presence of fluid-filled cysts = lumpy, feeling of fullness with or without pain (feels like "plate full of pees") -Cysts are freely moveable -Week before menses, cyclical -Decline after menopause (↓ levels of estrogen & progesterone) **Do not increase risk for breast cancer unless abnormal cells on biopsy

Dysmenorrhea

Painful menstruation --> cyclical perimenstural pain Pain starts with bleeding onset --> 48-72hrs Cause significant personal, social, & occupational disruption Classifications: -Primary (spasmodic) -Secondary (congestive) Incidence = >50% menstruating women

Multiple Sclerosis in Pregnancy (patho & goal)

Patho: -Demyelinization of the spinal cord and CNS -Weakness in lower extremities, visual changes, & loss of coordination -Characterized by remissions and exacerbations (improves during pregnancy) Goal: -Prevent injury (little data on safety of medications during pregnancy) -Favorable perinatal outcome = instrument-assisted delivery -Breastfeeding **Tends to get getter during pregnancy but comes back poorer after

Fibroadenomas - pathophysiology, symptoms, diagnosis, and management

Pathophysiology: -Benign solid breast tumors -Hyperplastic lesions stimulated by external estrogen, progesterone, lactation, & pregnancy Symptoms: -Unilateral lump (oval, rubbery) -Size does not change with menstruation Diagnosis = mammography, US, biopsy Management = frequent evaluation

Nonlactational mastitis = duct ectasia (pathophysiology, symptoms, diagnosis, and treatment)

Pathophysiology: -Nipple discharge --> ducts congested with secretions & debris -Periductal inflammation -Perimenopausal Symptoms: -Inflammation, thick, greenish nipple discharge -Pain, itchy, palpable mass behind nipple (similar to regular lactational mastitis but not associated with lactation) Diagnosis = mammogram, fluid culture Treatment: -Mild pain relievers -Supportive bra -Warm compresses -Antibiotics -Possible excision

Secondary dysmenorrhea

Pelvic or uterine pathology -Endometriosis (most common cause) -Fibroids -Pelvic infection -Cervical stenosis -Congenital abnormalities of uterine or vagina

The nurse is reviewing orders on a patient admitted for preterm premature rupture of membranes. Which physician order will the nurse question?

Perform a vaginal exam every shift (keep hands out unless you have a reason to be in there)

Regional - pudendal nerve block

Perineal anesthesia = second stage of labor, birth, episiotomy repair Advantages: -Ease of administration -Absence of side effects Maternal/fetal complications uncommon **Lidocaine agent = burns like a bee sting

Therapeutic management of menopause

Personalized approach to managing Hormone replacement therapy: -Risks outweigh benefits with long-term use -Significant ↑ in fractures with ↓ use of HRT (hormone replacement therapy) -Approved for relief of vasomotor symptoms & prevention of osteoporosis Nonhormonal therapies = selective estrogen receptor modulators Weight-bearing exercise Calcium & vitamin D Estrogen cream for vaginal atrophy (short term use generally okay)

Other factors affecting the labor process

Philosophy (environment) = big impact: -High tech, low touch (hospital) -Low tech, high touch (birthing center, care of mid-wife) Partners: -Father of the baby/significant other -Family -Friends -Doula (provides guidance/support during labor) -Nurse -OB/CNW (certified nurse midwife) Patience: -Augmentation &/or induction of labor is common -Push when complete Patient: -Preparation -Express desires & needs Pain management: -Pain during labor is expected & universal -Subjective experience

Epidural anesthesia nursing care post-placement

Positioning Maternal & fetal status Assess for side effects or complications Pain relief Bladder status Assessment Variation: Inadequate pain relief Assessment Variation: Hypotension -Increase IVFs -Place in left lateral -O2 -If uncorrected call Anesthesia provider (we can't titrate the dosing)

Labor Induction with Oxytocin

Potent endogenous uterotonic agent = acts on uterine myofibrils Used in women with high Bishop scores or after cervical ripening Piggybacked into main IV line Titrated to achieve adequate contraction pattern = 2mu/ml q 30 min Risks: -Tachysystole: >5 ctx/10 min that has occurred over at least 30 min -Water intoxication

Managing obesity in pregnancy

Pre-pregnancy weight loss ideal Management: -Appropriate weight gain -Nutritional counseling -Anticipate complications -Realistic goals -Low dose aspirin r/t preeclampsia risk

Preconception management of pregestational diabetes

Preconception counseling is key Achieve glycemic control prior to conception Hemoglobin A1C testing Identify & evaluate long term complications: -Retinopathy -Neuropathy -CV disease, HTN Reduction in risk of congenital malformation

Prolonged pregnancy

Pregnancy that extends > 42 weeks Patho = estrogen:progesterone ratio off Associated with: -Primiparous -History of postterm pregnancy -Male fetus -Obesity -Genetic

En sac or en caul delivery

Premature en caul delivery

PPROM

Preterm PROM before 37 weeks, & before labor started

Nursing management of preterm labor

Prevent infection: -Close observation for S&S of infection (fever, WBC are not reliable indicator because they are already idiopathically elevated, might see tachycardia in baby) -NO VAGINAL EXAMS -Prophylactic antibiotics Prevention of contractions (if preterm): -Hydration -Tocolytics -Bed rest or reduced activity -Pelvic rest -Avoid breast manipulation Corticosteroids Magnesium sulfate if <32 weeks: -Neuroprotection -Facilitates vasodilation, reduces inflammation, and reduces calcium uptake

Management of prolapsed umbilical cord

Prevention = bedrest after rupture of membranes if head not well applied Management: -Push back presenting part off cord -Positioning (if no epidural yet) = knee-to-chest, modified Sim's, trendelenburg -Emergency cesarean

Therapeutic management for pre-term labor

Prevention: -Preconception counseling -Progesterone (relaxes uterus) Diagnosis: -Cervical change -Ultrasound for cervical length -Fetal fibronectin Goal is prevention, but.... delay birth by 48 hours to allow for neuroprotection and antenatal corticosteroid (helps with fetal lung development if delivery early) benefit Suppression of uterine activity

Nursing care management of the woman with cardiovascular conditions in pregnancy

Primary goal no matter what stage of pregnancy/delivery = DECREASE CARDIAC WORKLOAD Preconception counseling is crucial Monitor for signs of cardiac decompensation --> can start seeing these signs as early as 6 weeks (new onset vs. sustained): -Cough -Dyspnea -Palpitations -Chest pain -Cyanosis -Swelling -Fatigue -Syncope Adequate nutrition: -Avoid/correct anemia so blood is getting to body -Sodium restriction Avoid/correct infection Limit weight gain Energy conservation Encourage continuing medications & PNVs Tests for fetal well-being

Dysmenorrhea management (primary vs secondary)

Primary: -Treatment of symptoms -NSAIDS -Oral contraceptives -Heat -Exercise -Limit salt -High fiber diet -Side lying with knees bent Secondary: -Treatment of symptoms (same as primary) -Surgical treatment of underlying pathology (D&C and laparoscopy)

Maternal physiologic implications of fetal loss

Prolonged retention of an Intrauterine fetal demise -Intrauterine fetal death (IUFD) can lead to DIC or infection DIC: -Thromboplastin released from degenerating fetus --> triggers formation of multiple tiny blood clots --> depletes fibrinogen & Factor V & VII -Cascade begins 3-4 weeks after demise Infection: -Endometritis -Sepsis

Nursing management of benign breast disorders (key points)

Promote education: -Dietary changes -Lifestyle modifications -Promote exercise Follow up: -Self breast exams, monitor for changes -Mammography -Timing of health care visits Promote comfort: -Pain management -Medications -Self-care measures Decrease anxiety: -Communicate accurate information -Allow for verbalization of feelings

Nursing management during labor induction

Promote safety: -Does the woman meet criteria for IOL/augmentation? -Bishop score -Maternal & fetal tolerance -Contraction pattern -Titration of oxytocin -Communicate with HCP Promote comfort = provide pain relief & support Administration of Oxytocin: -Always use infusion pump -IV port placement -Continuous fetal & uterine monitoring (know when to d/c) -1:1 nurse to patient ratio

Management of amniotic fluid embolism

Prompt recognition Maintain oxygenation & hemodynamic function: -Oxygen -Intubation -Initiate CPR if necessary -IVFs -Uterine displacement Monitor fetal status = emergency cesarean birth at the bedside Observe for signs of coagulopathy Correct coagulopathy: -Packed RBCs (PRBCs) -Fresh frozen plasma (FFP) -Uterotonics for uterine atony after delivery

Methods of labor induction - pharmacologic agents

Prostaglandin agents: -Dinoprostone (usually do at night) à softens cervix, provider placed -Intravaginally -Risk of excessive uterine contractions Nursing considerations = remain in bed for 2 hours after placement, continuous EFM, contraindicated in VBAC Misoprostol (nurses can place this): -Intravaginally or orally -Risk of uterine tetany, uterine rupture Nursing considerations = continuous EFM, contraindicated in VBAC

Nursing management of breast cancer

Provide education: -Process information -Type of cancer, treatment options -Counseling, self-care measures -Who to contact Provide emotional support: -Address fears, anxiety, questions -Meet emotional needs -Support group referrals (online?)

Radiation, chemotherapy, and adjuvant hormone therapy for breast cancer

Radiation: -Early stage -Lumpectomy = treatment of entire breast -Brachytherapy = internal radiation (target areas most likely for reoccurrence) Chemotherapy: -Indicated for tumors >1cm, positive nodes, aggressive cancer -Not generally indicated for early stage -May be combined with radiation Adjuvant hormone therapy: -Aromatase inhibitors & estrogen agonists taken for 5 years -Postmenopausal

Inflammatory breast cancer

Rare but quick & aggressive No lump or tumor = cancer cells block lymph vessels Skin changes: -Infectious process (similar to mastitis) -Inflammation -Red, thickened, tender, Itchy -Larger than unaffected breast -Peau d'orange -Edematous thickening & pitting

Components of the maternal assessment

Reason for seeking care? Scheduled induction/think their in labor/water broke? Prenatal data: -Age -Height and weight -Obstetric history -Confirm EDD -Patterns -Lab findings Screening for intrapartal risk factors = what complications can I anticipate? If patient has gestational diabetes and baby has been measuring large & mom is obese/has HTN, I will be anticipating a big baby --> prolonged/dysfunctional labor, shoulder dystocia, possible assisted delivery with vacuum, etc.? Physical exam: -General systems -Labor status -Fetal assessment Laboratory and diagnostic tests Psychosocial factors

Premenstrual syndrome

Recurrent symptoms occurring during luteal phase (last half) of cycle -Resolve at onset of menstruation ACOG definition = "The cyclic occurrence of symptoms that are sufficiently severe to interfere with some aspects of life, and that appear consistent and predictable with relationship to menses" (ACOG as cited in Ricci, 2017, p. 92)

Passenger - fetal station

Relationship of the presenting part to maternal ischial spines "Zero station" = level of ischial spines (head is at -2 in figure) Minus = above ischial spine Plus = below ischial spine (+4, +5 baby should be crowning and coming very soon)

Nursing management during a precipitous labor & birth

Remain calm!! NEVER leave the mother alone! -Deligate = precipitous delivery pack, OB, peds -Give clear instructions --> have woman pant & apply gentle pressure as the head delivers -Support the perineum (in hopes that it won't tear) -Remove nuchal cord if present -Have woman push & deliver the rest of the body -Continue with post-delivery care of the newborn

Postpartal management of pregestational diabetes

Remember, insulin needs drop sharply after birth! Type 1 = blood glucose q 4-6 hours (much more frequent) Type 2 = fasting, AC, & postprandial (1 hours after meals) Breastfeeding: -Encouraged! (burn a lof of calories) -Counted as 100g carbs/20g protein

Risk assessment and treating the underlying cause of cardiovascular conditions during Pregnancy

Risk assessment: -CV history & exam -What is their baseline? (want to try and stay there) Treat the underlying cause: -Treat dysrhythmias (give antiarrhythmic) -Prevent thrombi formation (give anticoagulant --> coumadin crosses placenta and is FETAL TERATOGEN, so can't use during pregnancy) -Improve or decrease contractility (inotropic meds) -Preload/afterload reduction (use diuretics) Frequent PNV

Physiologic response if fetal oxygen transfer is interrupted

Risk for fetal injury is ALWAYS a nursing diagnosis during delivery because there is always potential for injury d/t low oxygenation

PROM

Rupture of membranes before the onset of labor (nothing to do with gestational age)

Uterine rupture

Rupture of the uterine cavity: -Complete rupture -Incomplete or partial rupture Incidence = 1 in 2,000 births Risk factors: -Previous uterine incision -Uterine abnormalities -Uterine manipulation/tachysystole -Operative vaginal delivery -Abdominal trauma -Less than 18 months between deliveries (body hasn't had time to fully heal)

Methods of labor induction - nonpharmacological

Safety & efficacy not well established Herbal agents: -Evening primrose oil -Blue or black cohosh -Red raspberry leaf tea Caster oil Enemas Sexual intercourse with nipple stimulation Acupuncture Myths?

Menopause nursing assessment

Screening for risk factors -Screening for osteoporosis, CVD, & cancer risk -BP screenings -Mammograms -Pap smears -Pelvic exams -Bone density testing -Lifestyle factors

Pharmacologic measures during labor

Sedatives = benzodiazepines Systemic: -Opioid agonists -Opioid agonist-antagonists Nitrous oxide Regional: -Epidural -Combined spinal-epidural -Patient-controlled epidural -Spinal -Pudendal nerve block -Local infiltration General

Mechanisms of labor - Cardinal Movements of Labor

Sequence of positions assumed by the fetus as it descends through the pelvis during labor and delivery

Susan is a 26-year-old G1P0 at 6 weeks of gestation with type 2 diabetes. Her body mass index (BMI) is 32. Her hemoglobin A1c is 9. She takes glyburide 10 mg by mouth daily. The physician has switched her to insulin at this time. How should Susan be counseled regarding weight gain in pregnancy?

She should be counseled to gain 11 to 20 pounds in pregnancy. Rationale = the Institutes of Medicine recommends this weight gain for women who are obese. The amount of weight a woman should gain in pregnancy depends on her prepregnancy BMI.

Intrapartal management of pregestational diabetes

Similar to gestational diabetes Active Labor or glucose <70 mg/dL = switch saline to 5% dextrose: 100-150 cc/hr Maintain glucose level at 100 mg/dL Check glucose hourly (bedside) and adjust insulin/glucose accordingly IV regular insulin = 1.25 units/h if glucose >100 mg/dL (regular insulin is the only insulin that can be put through IV)

Depression during pregnancy

Small increase in poor perinatal outcomes -Mild-moderate developmental disturbances in offspring ½ cases untreated during pregnancy: -WHY?!?!? Don't want to go on medication while pregnant -Untreated --> substance use, poor nutrition, suicide risk Antidepressants and psychotherapy: -MAOIs contraindicated d/t IUGR -SSRIs ↑ risk of PPH -SNRIs ↑ risk of hypertensive disorders, PTB, PPH

Managing of substance abuse during pregnancy

Smoking cessation: -Nicotine replacement patches -Bupropion Alcohol cessation = naltrexone Maintenance programs: -Methadone maintenance therapy -Subutex or Suboxone Counseling Short-term inpatient or outpatient treatment Long term residential treatment Support groups -Look at patient holistically (many have untreated mental health issues) -Pregnancy is often a time where mom is receptive/open to getting treatment -Methadone/suboxone can cause neonatal abstinence syndrome (withdrawal) in baby

Why does the uterus need to rest between contractions?

So baby can recover

The nurse is caring for a patient admitted to labor and delivery for an induction of labor. The physician's order reads: Initiate oxytocin at 2 milliunits/minute and increase by 2 milliunits/minute until an adequate contraction pattern is established. Oxytocin comes premixed as 20 units in 1000 mL of LR. How many mL/hr would the nurse set the infusion pump for?

Step 1 - convert units to milliunits (20 units)/(1,000 ml)= (1 unit)/(1,000 milliunits)= 20,000 mu Step 2 - WANT/(HAVE (converted to mu)) = (2 mu/min )/(20,000 mu) Step 3 - multiply by volume (2 mu/min )/(20,000 mu) × 1000 mL Step 4 - multiply by 60 minutes (2 mu/min )/(20,000 mu) × 1000 mL ×60 minutes Answer = 6 ml/hr

Physical exam - labor status

Sterile vaginal exam (SVE): -Dilation (0-10cm) -Effacement (0%-100%) -Fetal descent (station -5 to +5) -Presenting part Contraction pattern: -Frequency -Duration -Intensity

Methods of labor induction - mechanical

Stimulate release of prostaglandins: -Foley catheter bulb placed endocervically -Hygroscopic dilators Higher infection rates Decreased duration of labor & C/S

Labor induction

Stimulation of uterine contractions before the onset of spontaneous labor -Cervical ripening -Unfavorable cervix

Methods of labor induction - surgical

Stripping of the membranes Amniotomy (AROM) risks: -Prolapsed umbilical cord -FHR decelerations (take away their fluid) -Infection Nursing management: -Monitor FHR immediately following ROM (how did baby tolerate it?) -Assess characteristics of amniotic fluid -Monitor temperature -Personal comfort measures

Late deceleration

Symmetric, gradual decrease after the peak of the contraction, then gradually returns to baseline -Result of UTEROPLACENTAL INSUFFICIENCY -Baby is not oxygenating well, most concerning Causes: -Maternal hypotension -Preeclampsia -Placental aging -Maternal smoking -Maternal anemia -Uterine tachysystole

Early deceleration

Symmetric, gradual decrease that mirrors the contraction (not necessarily a huge cause for concern) -Reflex vagal response from fetal HEAD COMPRESSION Causes: -Active stage of labor -Pushing -Crowning

Passenger - fetal attitude

The "posture" of the fetus Normal = general flexion -Non-flexed position increases diameter of the presenting part

5 critical factors in labor

The Five P's: -Passageway -Passenger -Position -Power -Psyche

A patient is to be transferred to the OR following non-reassuring FHTs for an unscheduled emergency cesarean delivery. The nurse will monitor FHTs until:

The antiseptic abdominal skin prep is begun -Can't monitor the baby once the antiseptic is on

Perinatal loss

The death of a fetus or infant from the time of conception through the end of the newborn period (28 days after birth)

Susan is a 26-year-old G1P0 at 6 weeks of gestation with type 2 diabetes. Her body mass index (BMI) is 32. Her hemoglobin A1c is 9. She takes glyburide 10 mg by mouth daily. The physician has switched her to insulin at this time. What is the nursing priority at this time?

The nursing priority is to provide effective education about insulin use, diet, and exercise to enable Susan to achieve normal glucose levels as quickly as possible. Rationale = timing is of great importance because Susan is entering the period of intense organogenesis in the fetus. Elevated blood sugars at this time are highly correlated with increased risks of serious fetal congenital malformations. Achieving euglycemia in the first trimester of pregnancy can reduce the risks of malformations in the diabetic woman to the same levels as nondiabetic women. Action must be immediately taken in this case to minimize the risks of fetal harm.

Management of uterine rupture

Therapeutic management: -Emergency c-section -Possible hysterectomy -Neonatal resuscitation Nursing management: -ID risk factors -Prompt detection = early S&S -Volume resuscitation = IVFs & blood products -Prep for emergency birth --> notify OR/ anesthesia/NICU, place foley, consents, keep informed (especially once you go to the OR)

Labor positions

Traditional = lithotomy Upright or lateral = evidence based research has shown shorter 1st & 2nd stages of labor, lower rates of assisted deliveries & episiotomies

Therapeutic management of amenorrhea

Treat underlying cause Hormonal regulation if hormonal issue: -Estrogen therapy -Cyclical progesterone -Restore regular cycles Chronic disease management Nutritional counseling

Pregnancy with women > 35 years old

Trends: -5.2% of births aged 35-39 -1.1% of births aged 40-44 -Multiparous vs primiparous women (more likely to have twins à releasing more eggs to try and get rid of them) Medical risks (chronic illnesses) Special Concerns -Later on might be from delayed decisions about having children/career first, delayed infertility treatments can occur -Refrain from judgement

Pregestational diabetes

Type 1 = absolute insulin deficiency (beta cell destruction, pancreas isn't producing insulin) Type 2 = insulin resistance Impaired fasting & impaired glucose tolerance = hyperglycemia at levels lower that what is considered diagnostic for gestational diabetes

External Cephalic Version (ECV)

Ultrasound-guided hands-on procedure to externally manipulate the fetus into a cephalic presentation Criteria: -Single fetus -Presenting part must NOT be engaged -Adequate amniotic fluid -Reactive fetal NST -37ish weeks Nursing management: -Inpatient setting -NPO for 8hrs prior -Hydration, tocolytics &/or pain meds -RhoGAM if Rh negative

Prolapsed umbilical cord

Umbilical cord that precedes the presenting part of the fetus: -Cord falls through the cervix into vagina -Becomes trapped between the presenting part of the fetus & the maternal pelvis (no oxygen at this time) Fetal risks: -Compression of umbilical cord -50% mortality rate (can happen while mom is not in the hospital and they discover this happened) Incidence: -3% of vertex presentations -Slightly higher with breech presentation (easier for cord to slide out if the feet are down below rather than the roundness of head) **Anticipate an emergency c-section in most cases

Premenstrual syndrome etiology

Unclear Multifactorial = genetics, biological, psychosocial, & sociocultural Interaction between hormonal events and neurotransmitter function (serotonin) Biological vulnerability to fluctuations Genetic predisposition: -Heightened sensitivity to cyclical changes -Varied response to naturally occurring neurotransmitters (serotonin) -If predisposed to PMS, also may be predisposed to other psychiatric disorders Dysregulation in serotonin linked to psychological symptoms

Endometriosis etiology

Unclear Sampson's theory = "retrograde menstruation": -Endometrial tissue transported through fallopian tubes into peritoneal cavity and implants -Level of immune system may play a role Misplaced tissue responds to hormonal changes in the same way: -Implants swell & bleed during menstruation -"Mini-periods" -Can lead to inflammation, scarring, & adhesions

Unplanned & forced cesarean births

Unplanned: -Traumatic experience -Anxiety -Anger -Guilt Forced: -Maternal/fetal conflict -Determine reasoning -Court order

Malignant breast disorders pathophysiology

Unregulated cell growth Replication of mutated cells Starts in epithelial cells that line the mammary ducts (most tumors are in upper/outer part of breast) Rate of growth influenced by hormones (estrogen & progesterone) Metastasizes to almost all organs: -Primarily bone, lungs, lymph nodes, liver, & brain -First sites are chest wall, axillary supraclavicular lymph nodes, or bone

Laboratory and diagnostic tests for laboring moms

Urinalysis (UA) = on all patient's that come in Blood tests = if patient plans for epidural we need to know what platelet's are and their H&H (will lose blood at delivery) -CBC -Type and screen in the event mom needs blood products -Prenatal labs (if not known already) Amniotic membranes and fluid: Intact? Spontaneous (SROM) vs artificial rupture of membranes (AROM)? -Assessment Variation -Duration of ROM (if patient says they have been leaking fluid for a couple of days, we are concerned for higher risks of infection à chorioamnionitis) -Meconium stained = there was oxygen interruption at some point (concerned at delivery for aspiration into lungs) -Bloody (should be clear) -Foul odor/pus in fluid?

Regional - local infiltration

Used for episiotomy or laceration repair Advantage = least amount of anesthetic agent Disadvantages = burning sensation

Fetal malpresentation - breech

Vaginal birth possible, but uncommon: -Frank or complete -Appropriate fetal weight -Adequate pelvis -Flexed fetal head Candidates for external cephalic version

Maternal-fetal status during admission - assessment variations

Vaginal bleeding, acute abd pain, temp; > 100.4 F, preterm labor, PPROM, HTN, category II or III FHR pattern

Menopause signs/symptoms

Vaginal: -Dryness -↓ lubrication -Atrophy Mental/emotional: -Anxiety and/or depression -Irritability -↓ self esteem Hormonal: -Hot flashes, flushing -↓ libido -Night sweats Other: -↑ weight (water retention) -Fatigue -Insomnia -Stress incontinence -Heart palpitations

Vulnerable populations in pregnancy

Victims of sexual assault = trauma informed care Intimate partner violence: -3-9% experience during pregnancy -Population variation prevalence of 50% (Alhusen, et al., 2015) Human trafficking (can't force someone being trafficked to leave unless under age of 18) Incarceration (don't get a lot of great care in prisons but can leave for prenatal visits and when need to be hospitalized --> many of them are nonviolent offenders but are shackled to bed during delivery) = 6%-10% pregnant Sexual minority women (increasing numbers --> give non-judgemental care, make feel welcome) = transgender male, bisexual/lesbian couple

Macrosomia

Weight > 4,000g Risk factors: -OBESITY -Maternal diabetes -Postterm -Hx of macrosomia or shoulder dystocia Maternal risks: -Prolonged 2nd stage -Shoulder dystocia -Hemorrhage Fetal/neonatal risks: -Shoulder dystocia -Brachial plexus injury & other birth injuries -Jaundice

Eating disorders during pregnancy

Why might women with disordered eating struggle during pregnancy? Gaining weight can be mentally distressing, if mom is nutritionally deficient baby might be as well -Includes anorexia nervosa, bulimia nervosa, & binge eating disorder Risks: -Infertility, miscarriage -Preeclampsia -PTB -SGA or LGA Management = ideally pregnancy planned for periods of remission, possibly hook them up with mental health counseling

Cystic fibrosis in pregnancy

With minimal lung impairment, pregnancy tolerated well Severe disease: -Chronic hypoxemia -Pulmonary infections -Preterm birth -IUGR -Possibly intubation during pregnancy Goals: -Maintain optimal pulmonary function -Optimal nutrition status (risk for deficiencies) -Optimal fetal growth -Optimal birth outcomes --> epidural recommended & vaginal birth is possible/probably preferred

Antepartal management of pregestational diabetes

Without preconception counseling: -Identify & evaluate long term complications -Hemoglobin A1C testing -Look at risk factors, make a plan from there More frequent PNVs & tests for fetal well-being Dosing adjustments common for insulin-dependent With poor glycemic control --> diabetic vasculopathy --> IUGR With poor glycemic control + prepregnancy obesity + excessive weight gain = macrosomia

Immediate post-op care for breast cancer surgery

Wound care: -Drains (educate how to take care of and empty drains) & s/s of infection Pain management = if they are in pain they might not be doing their arm exercises Affected arm care = elevate on pillows to help with lymphedema/drainage **No blood draws, BP's, IV lines on affected arm Mobility care -Active ROM exercises -Encourage independence in self-care Respiratory care = TCDB every 2 hours Emotional care: -Referrals -Encourage self-care, support groups Educational needs: -Drain & wound care -Activity, arm exercises -Adjunctive treatment

Psychological stress may indirectly cause

dystocia -Intense anxiety stimulates SNS --> catecholamine release --> myometrial dysfunction -Norepinephrine & epinephrine = uncoordinated or increased uterine activity

Amnion staying in tact has to do with

infection risk --> chorioamnionitis

A women is born with 2 million

ova (~400 fully mature) -Steady decline of mature ova with aging Hypothalamic-pituitary-ovarian axis begins to break down before menopause: -Increasing # of anovulatory cycles (where egg is not being released) -2-8 yrs of perimenopause -Failing ovaries (irregular periods & hot flashes) -Viable ova gone by menopause

Untreated UTI can cause inflammation that might lead to

preterm labor

Cardiovascular disease in pregnancy physiology review

↑ Cardiac output: -Peaks at 20-24 weeks -Continues to ↑ until 28-34 weeks -↑ 30-50% above preprenancy Blood volume ↑ 30-50% (1500 mls): -25-35% ↑ RBCS -50% plasma volume expansion -Hemodilution Heart rate = ↑ 10-15 bpm BP: -↓ pulmonary and peripheral vascular resistance (40-50%) -↑ progesterone = vasodilation --> results in slight ↓ BP (2nd trimester) but ↑'s in 3rd trimester to pre-pregnant levels Hypercoagulability state: -Fibrin & fibrinogen increases -Increased risk for venous thrombosis

During menopause, estrogen levels

↓ 90% Estrone (friendlier estrogen, weaker) replaces estradiol (not as friendly, more potent): -Produced in fat cells -Less biologically active than estradiol -Testosterone levels ↓