OB 3

Hypoglycemia

- "Cold and Clammy, need some candy" - Most at risk 1st trimester and immediately post partum - Baby is NOT diabetic. High insulin production in response to maternal hyperglycemia puts newborn at risk for hypoglycemia during 1st day of life due to hyperinsulinemia. - Prolonged hypoglycemia in the mother can result in permanent or fatal injury to the fetal CNS system

Amnioinfusion

- Amnioinfusion is when additional fluid is added into the uterine cavity to help cushion the cord and alleviate variables. - Contraindications include infection, placenta previa or placenta abruption - Nursing considerations include frequent fetal monitoring, change pads regularly, watch the fluid and make sure the patient is comfortable.

Amniotomy

- Amniotomy is the artificial rupture of membranes - Advantages are that it can help labor along, can allow for internal monitoring - Disadvantages include risk for infection, and prolapsed cord - Nursing considerations are to assess the heart rate immediately after amniotomy and to pay attention to color oder and amount of the fluid. Assess maternal temp every 2 hours.

What's causing this?

- At 20 weeks, fetus is formed. Now it needs to grow in size and mature. - Placenta inc hPL production (among others), which inc maternal cellular resistance to insulin, inc available glucose to fetus. - The more placentas and the older the mother the greater the risk of GDM - If the maternal system is unable to handle the higher glucose loads this creates a sugar expressway to the fetus.

Magnesium Sulfate - safety

- Bedside monitoring during loading dose - Extreme caution with pump settings - Frequent assessments for increasing severity of preeclampsia or magnesium toxicity - Clears rapidly once discontinued - Antidote: calcium gluconate IVP

Magnesium Sulfate

- Current drug of choice to prevent eclamptic seizures - CNS depressant: watch for respiratory depression, change in LOC, decrease of DTR's. Causes muscle dysfunction, sedation and increased risk of falls. Mothers are usually NPO or ice chips only. - Vasodilator: decreases blood pressure and increases perfusion. Causes flushing and sensation of heat. - Diuretic: especially as disease decreases in severity postpartum - Excreted through the kidneys: watch u/o! Decreased u/o can result in toxicity. Foley catheter essential.

Episiotomy

- Episiotomy is a surgical incision make to widen the birth canal, in the event of macrosomia, shoulder dystocia, or operative vaginal delivery - Risks include infection, and pain. - Nursing considerations include working to prevent the need for an episiotomy and assessment and pain management afterward if one is performed.

Preeclampsia

- In the US, 2nd leading cause of maternal death after hemorrhage. - Disease of theories. Pregnancy is the cause and delivery is the cure, yet 25% of preeclampsia develops after delivery. - Arteries vasospasm, which decreases perfusion to all organs, including the placenta. - Protein leaks through swollen glomerular capsule. - Combination of leaky arteries, inc BP, dec intravascular protein causes generalized edema and dehydration of the cardiovascular system. - BP meds dec BP which dec perfusion. - Women at greatest risk are chronic hypertensives, diabetics, primagravid teenagers, AMA and multiple gestation. - Mild disease may be managed with bedrest and frequent assessments of both mother and baby. Bedrest does not cure preeclampsia, but may increase perfusion and buy enough time to allow the baby to mature, get steroids on board or ripen the cervix. - BP meds are used to get the BP out of stroke range. If the BP is returned to "normal" vital organs, especially the placenta, will not be perfused. - Perfusion is assessed through fetal well-being Assessments: - VS - document maternal position - Pulse ox reading (disease of perfusion) - LOC - Headache - Visual changes - Lung sounds - Epigastric pain - Generalized edema - reflexes - clonus - weight gain - symptoms of abrupti placenta - urine output (disease of perfusion) BP important Laboratory findings: - Urine dipstick for protein - 24 hour urine - CBC - Comprehensive metabolic profile* - Liver enzymes* - Uric acid* *may be combined as PIH profile Baby Assessments: - Fetal Kick Counts - NST - BPP - Amniocentesis for fetal lung maturity - Steroids if premature delivery anticipated - Cervical Ripeness

Cesarean Birth

- Indications - Dystocia, CPD, Maternal or fetal condition the prohibits labor or vaginal birth - Contraindications Fetal death or severe prematurity in which the fetus won't survive after birth anyway. - Risks - Infection, hemorrhage, UTI, thrombophlebitis, atelectasis, complications for anesthesia, TTN, pulmonary hypertension in the newborn as well as lacerations and trauma to the newborn.

Other Causes of PTL & PTD

- Maternal or Fetal Conditions that require early delivery (placenta previa, preeclampsia, IUGR) - Physical deviations of the uterus or cervix - Physical Distention of the uterus - Multiple gestation - Polyhydramnios - Fibroids - Trauma - Largely Unknown

Cervical Insufficiency

- May be structural with no risk factors - May be result of cervical trauma, especially cone or LEEP procedures, done for HPV infection - Transvaginal ultrasound may detect cervical changes prior to pregnancy loss, but frequently diagnosed after a pregnancy loss - Cerclage effective if there are no uterine contractions - Cerclage must be removed in the presence of uterine contractions or prior to onset of labor - Abdominal cerclage is permanent and requires C-section delivery

Diabetic Education

- Need for preconception counseling and tight control of blood glucose before and during pregnancy - Need for consistent carb diet, usually 3 meals and 3 snacks with protein as part of the bedtime snack - Warn her of the changes in insulin requirements during pregnancy. She needs to carry a quick source of glucose and recognize early warning signs of hypoglycemia - Importance of frequent BG testing and fetal surveillance, including kick counts after 28 weeks. - Breastfeeding is recommended. - Understand their risk for developing diabetes and heart disease during their lifetime. - Understand the risk of preeclampsia and know the warning signs. Nursing interventions: - Terbutaline, steroids, beta blockers, CA channel blockers, & heparin all increase BG Collaborative management: - Remember the woman is part of the team!

first trimester complications ( herpes simplex )

- Neonatal HSV can be transmitted through the placenta, especially if the mother acquires the initial infection during pregnancy. - Usually transmitted during vaginal delivery. • Acyclovir may decrease outbreaks during the last month, but does not guarantee viral transmission will not occur at birth. • C/S delivery is recommended for any evidence of active lesions at the onset of labor •A woman can discuss having a scheduled C/S related to history of HSV with her provider

Operative Vaginal Birth

- Operative vaginal birth include vaccum assisted or forcep assisted delivery. - Indications are to shorten the second stage of labor due to maternal or fetal indications. - Contraindications include those events in which a C-section would be preferable. - Risks include trauma to the mother and the fetus, perineal lacerations or hematomas Fetal head trauma to include cephalohematoma, intracranial hemorrhage. - Nursing considerations include ensuring bladder is empty. Assess fetal heart rate during procedure, Assess mother and newborn for trauma after birth, Manage pain.

Substance abuse

- Poor coping skills - Frequently history of abuse - Non-judgmental attitude - Make care accessible - Success depends on maternal inclusion and commitment to the plan of care - Ethical issues; Legal issues - Alpha House and Koala Care through BHS, Mommies program through UHS

Complications of 3rd/4th Stage

- Retained placenta is when the third stage is longer than 30 minutes. Can result in excessive bleeding and infection. Manual or surgical removal may be necessary. - Placenta accrete is when the placenta has grown into the wall of the uterus and may be the cause of the retained placenta. Must be surgically removed - Lacerations of the birth canal or the cervix can lead to bright red bleeding in the presences of a contracted uterus.

Perinatal Death & Grief

- Risks to mom include infection if baby has died in utero - Diagnosis usually starts with maternal report of cessation of fetal movement, and is confirmed with ultrasound. - We can wait for labor or we can induce labor. - Nurses should support the mother and family.

First Trimester Complications

- Spontaneous Abortion - Ectopic Pregnancy - Hydatidiform Mole - Hyperemesis Gravidarium

Preterm Labor - Role of the Nurse

- Start with education of warning signs at 20-24 weeks gestation - Education on preventable risk factors: smoking, poor nutrition, STI's - Ask about warning signs during prenatal care appointments - Education about known risk factors: multiple gestation, placenta previa, history of PTD, uterine anomalies

TOLAC and VBAC

- TOLAC is trial of labor after C-section. - VBAC is a successful vaginal birth after a c-section. Candidates for a trial of labor include, patients who have had no more than two low transverse C-sections and no history of uterine rupture - Management includes pain management, pitocen if necessary, cervical ripening agents are prohibited. EFM is required - Risks include hemorrhage, uterine rupture, infection, damage to internal organs, thrombophlebitis, increased risk of needing a hysterectomy,

complications of pregnancy that should be screened for during the first OB visit

- physical wellbeing - pregnancy history o preeclampsia, GDM, LGA, SGA - medical history o HTN, type 1 or 2 DM - nutritional issues - family history, especially for diabetes and preeclampsia - STIs - urinary tract infections - risk for intimate partner abuse - substance abuse - lab work screens for anemia, Rh factors, syphilis, some special diseases and infections

risk factors for second and third trimester

- preeclampsia/hypertension - diabetes - preterm labor - cervical insufficiency

Rosa arrives to the triage bay while you are talking to Joy. Rosa and she is a G3 P2 at 38 5/7 weeks. She has a history of a previous c-section and states that she has been contracting regularly for a couple of hours. The triage nurse is busy so you offer to help. As you expose her abdomen to place the fetal monitors, you see a vertical incision on her lower abdomen from her previous c-section. Taking what you know about operative delivery who needs to be seen first, Rosa or Joy?

- rosa Why? What are your concerns at this time? Uterine rupture What should you do next? Immediately Call the OB Physician

Risk factors for first trimester

- spontaneous abortion - hyperemesis gravidarum - infection

Prolapsed Cord

-Cord Prolapse is when the cord enters the pelvis in front of the fetal head and as the head descends it puts pressure on the cord. -This is a medical emergency as the cord supplies oxygen to the fetus. -Some risk factors include: Polyhydramnioes, premature rupture of membranes, fetal malpresentation, fetus that is small for gestational age. -Nursing interventions are to relieve pressure on the cord immediately, stay with the patient and ask a coworker to call the provider. -Methods of relieving pressure on the cord. -Continue to monitor the baby -Indications of transient cord compression are variable decels on the fetal heart tracing.

Glucose Testing

1 hour •Screening •50 grams of glucose is given •Non fasting •Must sit for 1 hour •Abnormal is glucose greater 140 3 hour •Definitive diagnosis can be made •100 grams of glucose is given •Must be fasting •Sit for three hours and have blood drawn fasting, at 1 hour, 2 hours and 3 hours. •Diagnosis is made with 2 abnormal values •Fasting: 95 mg/dL •1-hour: 180 mg/dL •2-hours: 155 mg/dL •3-hours: 140 mg/dL

suggestions how can she be proactive against Preterm labor

40% of PTD have no known risk factors So what do we need to ensure to do as health care providers? •Ensure that Holly knows the signs to watch for and when to call her provider •Uterine cramping or contractions every 10 mins or more in frequency •Vaginal bleeding •Vaginal leaking •Persistent Low back pain •Pelvic pressure

Version

A version is performed when the fetus does not have a cephalic presentation so that a mother may delivery vaginally. -Contraindications include previous C-section, uterine malformation, cephalopelvic disproportion, Placenta Previa, multiple gestation, oligohydramnios, engagement of the fetal head -Risks include fetal distress, cord entanglement, placental abruption, maternal sensitization, -The procedure is performed about 36 weeks and includes an NST prior. A tocolytic is given and an epidural may be placed. Ultrasound is used to monitor the baby periodically and RhoGam is given if a mother is Rh positive. -Nursing considerations include education, coaching, monitoring of vital signs and fetal heart rate before and after the procedure, IV placement prior to procedure, and administration of tocolytic drug. Observe for leaking of fluid or contractions.

Now the provider ruptures Joy's membranes for the purpose of placing internal monitors to assess the fetal heart rate better.

As soon as the membranes rupture you know that you must what? Assess the fetal heart rate When the membranes rupture you see green tinged amniotic fluid. You know that this is most likely caused by what? Stress on the fetus

Chorioamnionitis

Bacterial infection of the amniotic cavity •Major cause of complications •1% to 5% of term births •25% of preterm births Clinical findings •Maternal fever •Fetal tachycardia •Uterine tenderness Foul odor of amniotic fluid -Infection of the Amniotic cavity. -Prolonged rupture of membranes and frequent vaginal exams are two of the main causes -Bacteria that live naturally in the vaginal can be introduced into the uterus due to frequent vaginal exams so when the membranes are ruptured we only want to check the cervix if there is a reason to.

Due to your concerns you once again explain that there is no need at this time. Joy's cervix is changing so there is no need to move labor along any faster.

Both baby and Joy are ok as they are at this point The Resident agrees and goes back to the desk. You continue monitor Joy and her baby.After 2 more hours You see this fetal heart tracing. What do you see? The baby is experiencing late decelerations. What does this indicate? This indicates decreased placental perfusion. What do you do? Intrauterine resuscitation You quickly perform intrauterine resuscitation. You know that intrauterine resuscitation of the fetus includes what?

Cervical Ripening

Cervical ripening is done to soften the cervix for labor. See bishop score of page 451. -Most common methods are through the use of Cervidil or Misoprostol. -Contraindications are prior uterine scarring. Or any problems that would prevent a vaginal delivery. -Nursing implications are to observe to tachysystole, monitor the fetus, monitor the mother, and if tachysystole occurs administer O2 and fluids.

Hypertensive Disorders During Pregnancy

Chronic hypertension: elevated BP's prior to pregnancy, before 20 weeks gestation in pregnancy, or after the 6 week postpartum period. Gestational hypertension: elevated BP's during pregnancy without a history of chronic hypertension and no proteinuria. Preeclampsia: BP > 140/90 with proteinuria after 20 weeks gestation. Affects 3-5% of healthy women in the 1st pregnancy. Eclampsia: seizure after 20 weeks gestation with no other causative factor. Affects about 1% of women with preeclampsia. Chronic hypertension with superimposed preeclampsia: 25% of women with chronic hypertension will develop preeclampsia during their pregnancy.

Risk for Hemorrhage 3rd trimester (PLACENTA PREVIA)

Definition - Marginal - Partial - Complete Diagnosed by ultrasound Education: NOTHING IN THE VAGINA! Education: SEEK IMMEDIATE MEDICAL ATTENTION IF BLEEDING BEGINS

Risk for Hemorrhage 3RD trimester ( ABRUPTIA PLACENTA)

Definition, Etiology - Apparent - Concealed Assessment Factors Risk factors - Sudden elevation in BP - Trauma - Sudden decrease in uterine size

Gestational Diabetes

Definition: diabetes diagnosed during pregnancy. May be unidentified pre-existing disease. May be a metabolic disorder exacerbated by the stress of pregnancy. May be a direct consequence of altered maternal metabolism stemming from changing hormone levels. If women have any risk factors for diabetes, they need to be tested as early in the pregnancy as possible. All non diabetic pregnant women are routinely screened at 24-28 weeks with a 1-hour GTT If 1-hour GTT > 120-140, they are scheduled for a 3- hour GTT. Diagnosis is made if 2 or more values are elevated on the 3-hour GTT. If the 1-hour GTT >200 they are diagnosed without doing the 3-hour GTT. In true gestational diabetes, a well-balanced, no concentrated sweets, consistent carbohydrate diet plus moderate exercise is usually enough to prevent hyperglycemic episodes. Frequent BG monitoring is done on the mother. Fetal surveillance involves daily kick counts, NST's, and U/S for BPP and fetal growth. Due to the high risk of fetal demise and macrosomia, delivery by 38 weeks is recommended. Anticipate respiratory issues as these babies will have decreased surfactant in addition to being slightly early.

MULTIFETAL GESTATION

Definitions - Identical (monozygotic) - Fraternal (dizygotic) Risk Factors maternal - Preeclampsia - Gestational diabetes - C-section delivery Risk factors fetal - Preterm birth - IUGR - Twin-to-twin transfusion - Abruptio placenta after delivery of first baby - Cord entanglement - C-section delivery

•A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take first?

Discontinue the magnesium sulfate

DIC:

Disseminated Intravascular Coagulation. Can result in multisystem organ failure and death not limited to pregnancy patients

Now that Joy is comfortable, she relaxes, and labor progresses smoothly. 4 Hours later she is completely dilated and begins to push. She pushes for 2 hours and has made some progress but it has been a long day and Joy is tired. The provider states that he can help her with a vacuum. What do you know about vacuum or forceps assisted delivery?

Educate the patient as to what to expect Gather all necessary equipment Ensure that the bladder is empty to prevent injury

The provider assesses Joy's cervix before he places the internal monitors and states that she is now 6/C/0.Joy is really uncomfortable now and asks if she can talk to someone about an epidural. You contact the anesthesia provider and she states that she is on her way. What do you know about the potential side effects of an epidural on placental perfusion?

Epidurals can decrease the patient's blood pressure which would decrease placental perfusion. Since the fetus is already showing signs of poor perfusion, what would you do to help ensure adequate perfusion? IV bolus

•A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

Excessive uterine enlargement

Diabetes During Pregnancy

Goals: Tight control over circulating blood glucose FBS <95 2hour postprandial <120 Risks to mother: nephropathy, retinopathy, hypertension, UTI's, infections, C/S delivery, poor wound healing, PPH Risks to baby: Congenital anomalies, Macrosomia, polyhydramnios, IUFD, C/S delivery, birth trauma, IUGR, RDS, prematurity, hypoglycemia, hyperbilirubinemia, development of type 2 diabetes in adolescence.

HELLP syndrome

Hemolysis, Elevated Liver enzymes, Low Platelets. A life-threatening occurrence that can result from severe preeclampsia or eclampsia. Can occur without HTN or proteinuria. Danger is rupture of the hepatic capsule.

You decrease the Pitocin and Joy's uterine activity levels out at about 4-5 contractions in a 10 minute window which is where it should be.

Her cervix is checked again after a couple of hours and she is 4/90/-1 The resident askes you again about rupturing Joy's water. What do you think now?Joy is still a very long way away from delivery. Rupturing her membranes now could lead to prolonged rupture prior to delivery What could this lead to?Infection

Joy has been on Pitocin for about two hours. Six minutes after you increased the Pitocin the last time you start to see the uterine contraction pattern below.

How close are the contractions? Less than 2 minutes apart What should you do?Decrease the Pitocin

Dysfunctional Labor Patterns

Hypertonicity- is when there is more than 5 contractions in a 10 minute window. This can decrease fetal perfusion. -Nursing interventions are to turn the pitocen off if it is running, provide O2 and IV fluids to help with perfusion. Hypotonicity- is when there are too few contractions, which prolongs labor. -Nursing interventions include administering pitocen to increase strength and frequency of contractions. With both of these you should also monitor the fetal heart rate and as well as maternal vital signs and watch for infection.

Induction of Labor

Inductions is performed when the pregnancy must be delivered but labor has not begun, such as with preeclampsia, -Can start with cervical ripening if warranted. -Can then strip the membranes to start contractions or administerPitocen.

Premature Labor

Infection: #1 Cause •Group B strep •Chlamydia •Gonorrhea •Listeria •Trichomonas •Gardnerella vaginalis (BV) •Pyelonephritis

PPROM (preterm premature rupture of membranes)

Infection: #1 Cause and #1 Side Effect Increases risk of: •Prolapsed cord •Preterm delivery •Neonatal sepsis •Neonatal RDS r/t oligohydramnios •Fetal skeletal deformities r/t oligohydramnios

After some time, a very large head finally emerges but the provider cannot seem to deliver the shoulders. Taking into consideration that Joy was induced due to gestational diabetes. You recognize the problem to be a......

Macrosomia leading to a Shoulder Dystocia What do you do? Perform McRoberts Keep track of the time Monitor the fetal heart rate

Macrosomia

Macrosomia, is when the fetus is greater than 4500 grams. -Most common in pregnancies complicated by obesity, gestational diabetes, postmaturity, family history of big babies. -Complications include shoulder dystocia, operative vaginal births, Dysfunctional labor, PPH and infection -Nursing intervention are to support the patient and monitor and address a dysfunctional labor pattern.

McRobert's Maneuver

McRobert's Maneuver opens up the pelvic outlet to make more space for the shoulder. McRoberts works and the fetal shoulder is freed after less than a minute. A very blue and floppy macrosomic male newborn is handed of the waiting NICU team and whisked away to the NICU

Rosa delivered a baby girl via C-section and is being transferred to the recovery room. She received Spinal Anesthesia with Duramorph to help with post operative pain. What monitoring should the recover room nurse expect to perform?

Monitor Bleeding Monitor B/P and pulse Monitor respiratory rate (for several hours) Monitor pulse oximetry Monitor Pain Monitor return of sensation Monitor urine output Where do you start? What is the priority? Airway/Breathing - Assess respiratory rate/pulse ox

The provider applies the vacuum to guide out the fetal head. While he is doing that, what is your responsibility as the nurse?

Monitor the fetal heart tracing Keep track of the time and the events taking place Support the patient

Does Rose need a 1-hour glucose screen at 24 weeks, or a 3-hour GTT?

Neither, she's already diabetic

Cardiac Disease During Pregnancy

Nursing assessment and intervention - right sided vs left sided heart disease Impact - 1st trimester: increasing blood volume with diluted RBC's - 2nd trimester: c/o peaks between 25-30 weeks gestation - 3rd trimester: Valsalva maneuver with pushing - Post partum: fluid shift back to intravascular and diuresis

Fetal Malposition

OP position is when the fetal occiput is against the mother sacrum. Back pain in labor is common, fetus may be rotated by the provide with forceps if decent is hindered. -Maternal movement during labor can help to prevent this. -Brow presentation is when the head is partially extended and the brow is the presenting part. Vaginal delivery is unlikely, but if it does occur, perineal trauma is extensive. C-Section is most common. -Face presentation is when the fetal head is completely extended and the baby is coming out face first. Vaginal delivery is unlikely, C-Section is common -Breach is when the buttocks or the feet are the presenting part. Once again vaginal delivery is unlikely. A C-section is common. If a baby does deliver vaginally, piper forceps may be needed like the ones shown on this slide. -Shoulder is when the baby is sideways. Vaginal delivery is not possible. A C-section must be performed. -A compound presentation is when two parts are presenting at once, like a head and hand.

Rupture of the Uterus

Obstetric emergency -Caused by scarring on the uterus, -Signs and symptoms include fetal distress, loss of fetal station, abdominal pain, shock -Risk factors include, multiple c-sections, no previous vaginal deliveries, induced labor, multifetal gestation, infection, short interval between pregnancies.

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis

Painless vaginal bleeding

Signs and Symptoms of uterine rupture

Pale skin Diaphoretic Severe lower abdominal pain Nursing Actions: O2 IV Fluids Continuous fetal monitoring Prepare for immediate C-Section

Joy has not had the birth experience that she expected. She is going to be very sore and her baby is going to be in the NICU for the time being for glucose monitoring and a potential broken clavicle. What does this experience put her at risk for in the postpartum period?

Postpartum Hemorrhage Infection Problems with bonding Postpartum depression

Diabetes During Pregnancy

Preconception counseling is very important for women who are diabetic before becoming pregnant. Blood glucose must be under tight control at the time of conception to decrease the risk of fetal anomalies during organogenesis. Type 2 diabetics may be switched from oral medication to insulin before conception and need time to get their blood glucose under tight control prior to conception. Many oral antidiabetic medications cross the placenta, severely decreasing the fetus's blood glucose level. Insulin does not cross the placenta. Amount of vascular and organ damage prior to pregnancy will affect fetal growth. Many infants of diabetic mothers are IUGR due to poor perfusion. Damage to the mother's organs may increase with the stress of pregnancy and inability to keep tight control over blood glucose levels.

The next day Violet's BP is 152/98. Her DTR's are briskand she is complaining of a bad HA. Her 24 hour urine is pos for protein. What is happening?

She is developing Preeclampsia

Shoulder Dystocia

Shoulder dystocia is when the head is delivered but the shoulders are stuck. Can cause brachial plexus injuries, and fractured clavicles in the newborn and hemorrhage and perineal and rectal injuries in the mother. -Nursing intervention - McRoberts maneuvers, suprapubic pressure, -Providers may cut an episiotomy, or perform a wood screw maneuver. Last ditch effort the provider can try to push the head back in and perform a c-section. This is called a Zavagnelli maneuver.

What does the nurse need to understand to administer magnesium sulfate safely?

Signs of Magnesium toxicity - blood pressure dec - urine output dec - respirations less than 12 - patella reflex absent

Diagnosis of PTL

Subjective Data: - Cramps - Backache - Rhythmic tightening - vaginal d/c or bleeding - pelvic pressure Objective Data: - external fetal monitoring for contractions - manual palpation of contractions - cervical exam by provider or with an order Vaginal exam by nurse contraindicated if bleeding or PPROM fFN - fetal fibronectin: must be done before vaginal exam or wait 24 hours Ultrasound for cervical effacement or funneling

When Violet comes into the office at 32 weeks the nurse notices her face looks puffy. Violet has gained 5 pounds since her visit 2 weeks ago. Her B/P sitting is 144/96. What other assessment data should the nurse gather?

Subjective: •HAs, •vision changes, •edema of her hands and legs, •epigastric pain, •nausea and vomiting, •fetal movement Objective: •Urine for protein, •DTR's, Clonus, •fetal growth, •NST Dependent nursing actions requiring a provider order: •CBC, CMP, liver enzymes, uric acid, BPP, 24-hr urine for protein

Diagnosis of PPROM

Subjective: statement of leaking fluid Objective Visualization of fluid + Fern test + Nitrozene test + Amnisure or similar commercially created test Ultrasound to determine Amniotic fluid index Fetal lie Gestational age Assess for chorioamnionitis Maternal vital signs Uterine tenderness Fetal tachycardia

She is in her labor room and Cervidil (a cervical ripening agent) is placed to soften the cervix.

The fetal heart monitor shows the following: Rate: 145 Variability: moderate Decelerations: None Therefore what Category is Joy's fetal heart tracing? Category 1

You are a nurse on labor and delivery. Joy is a 36 year old G1 P0 at 38 0/7 weeks gestation. She was diagnosed at 28 weeks with gestational diabetes and due to rising blood sugars has been brought to Labor and Delivery for labor induction. She and her husband arrive to OB triage and admission procedures begin. She is assessed and place on the fetal monitor by the triage nurse. The triage nurse reports that Joy's baby's heart tracing looks good. She is not having any contractions and her cervix is closed. Knowing this what can the nurse expect as far as labor progress?

The nurse should expect progress to be slow because the patient is not even in latent labor.

Due to operative vaginal delivery and the macrosomic baby Joy has suffered a 3rd degree laceration. You understand that a 3rd degree laceration includes what

The perineal muscle down through the external anal sphincter. After an extensive perineal repair. Joy recovers and is transferred to the postpartum unit.

After 4 hours Joy's cervix is checked and her cervix is soft 2 cm dilated and 75% effaced. The fetal head is still able to be pushed out of the pelvis indicating that it is not engaged

The provider wants to start Pitocin to move the labor along. What would you expect as far as the frequency of fetal monitoring? Fetal heart monitoring is continuous during Pitocin administration.

Dependent Nursing Actions

Tocolytics Terbutaline (Brethine) Nifedipine (Procardia) Indomethacin (Indocin) If PPROM tocolytics are given to allow for steroid administration inc fetal lung maturity Betamethasone (Celestone) Dexamethasone (Decadron) Neuroprotection: Magnesium sulfate 12-24 hours before delivery between 24 - 32 weeks. Determine the cause: History Urine C&S Vaginal cultures Wet prep CBC Ultrasound fFN Treatment: Bedrest/hospitalization Tocolysis Hydration Frequent monitoring Contraction pattern FHR tracing Maternal VS Antibiotics

Diabetes Mellitus

Type 1- β-cell destruction, absolute insulin deficiency Type 2 - combination of decreased insulin production and insulin resistance at the cellular level Gestational - Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy Hgb A₁C is useful for diagnosing risk for anomalies but not helpful in monitoring pregnancy outcomes.

In what situations should nurses avoid digital cervical examinations?

Vaginal bleeding Known placenta previa Preterm labor if delivery is not imminent Preterm Rupture of Membranes Preterm Premature Rupture of Membranes Active HSV lesions

Violet has a reactive NST, fetal growth based on fundal height is appropriate and labs are drawn. Her BP is still slightly elevated when the nurse rechecks it after the NST. The physician sends her home with instructions for strict bedrest and a 24-hour urine. She is to return to the clinic the next afternoon when the 24-hour urine is complete.

Violet wants to know why she needs to stay in bed & miss work. Why can't she just increase her Labetalol? •Bedrest in a lateral position increases perfusion to the mother's kidneys and the placenta. It does not cure, but it gives the baby more time to reach maturity. Dropping the bp can actually decrease perfusion. What education should be provided about collecting the 24-hour urine? •Starts with first void in the toilet. All urine must be collected. Ends with final void collected exactly when the 24 hours is complete. Specimen should be kept cold

Preeclampsia

What are some indications that the preeclampsia is worsening? •Increasing BP •Decreasing platelets •Increasing liver enzymes •Decreasing u/o •Pulmonary edema - tachypnea, crackles in lung fields •Evidence of decreased perfusion to the fetus (decreased variability, tachycardia, absence of accelerations, late decelerations) Abruptio placenta due to hypertension

Now that Joy is on Pitocin, the resident askes that you get him an amnihook so that he can break her water to move labor along.

What are your concerns? Head is not engaged Why is this a problem? This could lead to a cord prolapse What would need to happen then? •Displacement of the presenting part by knee chest position • •or • Manual displacement with your hand followed by a stat C-section. •Due to your concerns you kindly decline and explain your concerns out of the earshot of the patient so as not to embarrass the intern. •The resident agrees and goes back to the desk. •You continue monitor the Joy and her baby while you gradually increase the Pitocin.

You return back to Joy. Her IV has been placed and she is ready to be moved to her labor room. Right at that moment the clinic calls and says that they are sending up Amber an 18 year old G1 who is 26 weeks in gestation for induction for fetal demise. She came to the clinic and the provider could not hear a heart beat and saw no cardiac activity on ultrasound. The nurse accepting this patient states that she has never taken care of fetal demise before and asks for your help.

What can you do to help her? Show her how to prepare a memory box Tell her It's OK to grieve with the family Treat baby as if he/she were alive and encourage the family hold and name the baby is they so chose What are something that you should expect for this patient? May appreciate a room on another unit besides the postpartum unit after delivery. May want to talk to a chaplain or spiritual advisor Will have lots of questions and will take cues from you as to what to do Will require support; Postpartum depression is higher in this population

Violet is a 35-year-old black woman excited about being pregnant for the first time. Her medical history includes moderately obesity & mild hypertension that has been managed with furosemide (Lasix). She tells the nurse that her primary care provider wanted her to lose some weight, limit her sodium intake and get more exercise, but she has a very demanding job and just never has time. She comes to her first OB appointment at 12 weeks.

What initial assessments need to be made for Violet? - Thorough diet assessment, - blood pressure with appropriate sized cuff; o document arm and position (sitting), - additional lab work for liver and kidney function baseline, - possible 24-hour urine What risk factors does she have for pregnancy complications? - Chronic hypertension, - obesity, - sedentary lifestyle, - AMA, - first pregnancy

The fetus can compress the cord without the cord being prolapsed.

What type of decelerations are these? Variable Decelerations What would you do if you saw these Change the patient's position so the baby might roll off the cord

when should women with gestational diabetes check their blood glucose

fasting and 2 hours after meals. Saré

Lacerations

first degree = vaginal mucous membrane and skin of perineum second degree = subcutaneous tissue of the perineal body third degree = involves fibers of the external rectal sphincter fourth = through real sphincter exposing the lumen of the rectum

blood tinged vaginal discharge, back pain, pelvic pressure are all signs of which of the following

preterm labor

why do preeclamptic women require magnesium sulfate

prevent seizures

first trimester complications (infections)

urinary tract infection = call for early signs of UTI, especially burning with urination, fever, severe back pain, usually unilateral flank pain vaginal discharge = heavy white vaginal discharge, fishy odor, change in status disease acquired during the pregnancy are generally more dangerous to the fetus, especially during the first trimester. condom use handwashing, hand sanitizer, avoiding sick people, especially children and following safe food guidelines significantly reduces disease transmission that may harm the fetus

Precipitous delivery

when the entire labor occurs within 3 hours - Can cause fetal distress, placental abruption, perineal lacerations, PPH, meconium stained amniotic fluid, meconium aspiration, fetal cranial trauma. -Nursing interventions include close monitoring, have a delivery pack near by for patients with this history. Encourage patient to pant and blow instead of pushing to slow down the fetal decent. Don't attempt to stop the baby from coming out, just support the mother. If delivery happens, dray the baby, suctions the mouth and nose and stabilize as you normally would.

Postpartum: Will Rose continue to be diabetic after delivery?

yes

Role of the Nurse

ØAssessment ØCommunication ØPatient Advocate ØEducation ØSupport ØSafe administration of medications ØKnowledge

Preterm Labor/PPROM

ØMaternal complaint and onset, especially if ROM ØEDD or EDB - how accurate? ØMaternal history/GTPAL ØFetal and uterine monitoring ØMaternal vital signs ØVaginal exam only if ordered unless delivery eminent

warning signs first trimester

• Bleeding - threatening abortion, ectopic, hydatidiform mole, previa • Fever: Greater than 100.4 • Vomiting - greater than twice a day or nausea severe enough to prevent eating and drinking. Assess amount of vomiting, weight loss, electrolyte imbalance. - Abdominal pain- threatening abortion, ectopic

Hyperglycemia

• dec O₂ carrying capacity • dec perfusion to vital organs, including placenta •Corrosive to lining of arteries, causes vascular damage •Vascular damage inc resistance to flow, inc stress on heart •Chronic HTN a common comorbitity •Cellular dehydration from fluid shift •Polyuria creates extracellular dehydration •Starvation at the cellular level - ketoacidosis "Hot and dry, sugar high"

•The nurse educates the patient on what to expect with operative vaginal delivery. What statement by the patient indicates that teaching was effective? Select all that apply

•"You will need to ensure that my bladder is empty first." •- "I will still need to push down whenever I feel contractions."

•What is the definition of a Hypertonic Labor Pattern?

•A. More than 5 contractions in 10 minutes averaged over 30 minutes

Amniotic Fluid Embolism

•Amniotic fluid embolism (anaphylactoid syndrome of pregnancy) -Life threatening condition where a small amount of amniotic fluid containing fetal debris (vernix, meconium etc) enter the maternal circulation through a small tear in the chorion. -Causes respiratory distress, hypotension, and coagulopathies. -Mortality rate is as high as 50% -Cause is unknown Incidence is rare, accounts for about 10% of all maternal deaths.

Education on how can she be proactive in preventing preterm labor

•Avoid infection from all sources •Resting 2-3 times a day •Drink 2-3 qts of water daily •Avoid caffeine, alcohol, cigarettes, drugs •Empty bladder every 2-3 hours •Avoid heavy lifting and overexertion •Sexual activity, cervical stimulation, nipple stimulation and orgasm may increase the risk of PTL •Find pleasurable ways to help compensate for limitations of activities and boost spirits.

•A new nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following interventions would require further teaching?

•B - Turn the patient to her left side to improve perfusion

A client at 20 weeks gestation who has Diabetes Mellitus Type 1 is admitted with a blood glucose level of 546. What other assessment findings would the nurse expect?

•BG > 500 is rarely a sudden onset event. •Wt loss is from too little insulin allowing sufficient glucose into the cells, so cellular starvation is occurring, leading to ketoacidosis. •Dehydration is r/t the body trying to wash the glucose out through the kidneys. •Proteinuria would be r/t kidney damage from chronic hyperglycemia over time. •P & R elevation is r/t dehydration & poor O2 carrying capacity. •BP may decrease r/t fluid volume deficit. - weight dec - urine ketones present - urine glucose present - skin temp warm - mucous membranes dry - level of consciousness altered - energy level low - fluid vol status deficient - vital signs pulse, respiration's

Making Memories

•Baby bath •Taking pictures •Foot and handprints •Locks of hair •Clothes to take home •Funeral or not? •Other things parents might consider as remembrances

Prioritize Orders - Dx: preterm labor

•Betamethasone 12mg IM 2 doses 24 hours apart •Procardia 10 mg po q 6 hours •Terbutaline 0.25 mg SQ X 1 •Urine for U/A & C&S •CBC •Vaginal cultures •Ampicillin 2gm IVPB q 4 hours 1. terbutaline 2. procardia 3. betamethasone 4. urine 4. vaginal cultures 4. CBC 5. ampicillin

•A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider?

•C - Urinary output 40 mL in the last 2 hr

•What is the definition of a prolapsed cord?

•C. The cord is in front of the fetal presenting part

After the death...

•Care for physical needs of bereaved mom •Offer but don't require room NOT on post partum as to avoid babies crying •Encourage communication between partners as these times can cause relationship problems. •Address spiritual needs of the family - emergency baptisms are acceptable •Follow-up phone calls are wonderful way to check up on the emotions of the family •Don't forget siblings •Developmental issues •Grandparent grief Dual grief

•Which Uterine Incision will allow for a Vaginal Delivery After Cesarean (VBAC)

•D. Lower Transverse Incision

How will her insulin dose change as her pregnancy continues?

•Decreases first trimester, then increases incrementally over the rest of the pregnancy

After 2 days in the hospital Violet's labor is induced with IV Pitocin and she is started on Magnesium Sulfate, 4 gm loading dose over 20 minutes, then 2 gm/hr maintenance dose. What can the nurse tell Violet about the plan of care pertaining to Magnesium and preeclampsia?

•Expect hot flushing sensations with the bolus of magnesium, then may experience drowsiness and muscle weakness • •Vital signs will be assessed hourly as well as lung sounds, DTR's, LOC, u/o • •An indwelling catheter will be necessary for strict I&O as well as to maintain bedrest. • •She will be either NPO or limited to ice chips • •Visitors will be limited

Xenia is diagnosed with gestational diabetes from the results of the 3-hr GTT. What will her plan of care include for the remainder of this pregnancy?

•Fasting and 2-hr PP BG checks •Limited carb, no concentrated sweets diet, usually 3 meals with 3 snacks to maintain consistent glucose levels •Moderate exercise •Fetal surveillance beginning with daily fetal kick counts starting at 28 weeks •BPPs either weekly or 2X a week that include NSTs •Delivery may be recommended no later than EDB •Breastfeeding recommended •BPPs either weekly or 2X a week that include NSTs

Xenia is 24 weeks pregnant coming to the clinic for her routine prenatal visit. She has had an uncomplicated pregnancy so far. What education should be included for the one-hour glucose screen?

•Fasting not required •Remind the office staff that she is doing the test so they can give her the Glucola at the beginning of the visit •Sit quietly for the hour with nothing to eat or drink

Holly is a G2P1 who delivered her first baby at 28 weeks. She is newly pregnant and asks the nurse what she can do to prevent this baby from coming early also. What can you tell her?

•First assess any risk factors present with her first delivery that can be modified. When would it have been ideal for Holly to ask this question? •Prior to this pregnancy What preconception issues should have been addressed? •Nutrition •Spacing of pregnancies •Dental issues Infections

Rose is a 32-year-old Hispanic woman who has been on oral medications for Type 2 diabetes for the past four years. She has come to her OB/GYN because her endocrinologist recommended that she switch to insulin before getting pregnant. She just got married and hopes to start a family as soon as possible. What should be included in the preconception teaching for Rose?

•Get blood glucose in good control with the insulin prior to conception •Screen for vaccines, infections and anemia •Start folic acid now •Review family history for any genetic disorders •Start a moderate exercise program now if she's not already doing one

Help actualize the loss

•Honesty in dealing with situation •It's OK to grieve with the family •Discuss naming the baby but do not push as some religions prohibit the practice - encourage to use name picked during pregnancy. •Treat baby as if he/she were alive •Do not rush the process - it is a process not dictated by time. •Autopsy - No charge if ordered, otherwise expensive •Perinatal Hospice - new concept, deals mostly with family and post traumatic stress potential

2nd Trimester complications

•How is Cervical Insufficiency different from Preterm labor •Usually painless, warning signs may be increased vaginal discharge and pelvic pressure •Cerclage is only effective if there are no contractions. •If contractions are present, cerclage can not be placed AND cerclages already in place need to be removed immediately •Indocin is used as an anti-inflammatory and tocolytic for 48 hours after placement.

What other complications does Type 2 diabetes put Rose at risk for during this pregnancy?

•Hydramnios (polyhydramnios), •Preterm delivery, •Preeclampsia, •Hyperglycemia with ketoacidosis, •Delivery complications if infant is has macrosomia, •Retinopathy, UTIs, yeast infections, poor wound healing. •If Rose has vascular damage from her diabetes, her infant may be SGA, IUGR and require early delivery r/t inadequate perfusion. •If blood sugar is not well controlled during organogenesis; fetal anomalies

What are some risk factors for both Xenia and her baby r/t gestational diabetes?

•Increased risk for yeast infections •Increased risk for LGA baby, C/S or assisted delivery, trauma •For infant: shoulder dystocia, hypoglycemia after birth, RDS r/t decreased surfactant, hyperbilirubinemia r/t polycythemia, NICU admission •Increased risk of Type 2 diabetes and cardiac disease, GDM with future pregnancies •Infant at greater risk for Type 2 diabetes later in life

Things NOT to say...

•It's for the best... •God know who to give these situations to...I couldn't do this. •This happened according to God's will. •Someday you will understand. •You can have other children At least you still have one baby (if loss of a multiple)

Nursing Implications to Consider for 1st trimester complications

•Many of the complications of pregnancy are diagnosed and treated in the Emergency Department • •Assess hemodynamic stability of your patient FIRST. Once mom is stable, check on the fetus, next. • •MAINTAIN NPO until diagnosis confirmed and treatment plan established. • Discharge teaching and follow up instructions

Hospital Based Perinatal Loss Program

•Nurse evaluates their personal feelings •Offer photographs and momentoes of the baby. •Allow family to hold, touch, say good-bye. •Prepare the mother, father, family for what the child will look and feel like. Answer questions, encourage mom and family. They may be angry and scared. Offer to contract a spiritual leader for them. Offer to take pictures and create memory box. Encourage parents to share their feelings. Prepare the family for what the baby will look likel.

Special Cases

•Prenatal diagnosis with negative outcome •Loss of one of multiple •Obvious physical deformity and/or case where baby is in distress at birth and shipped elsewhere •Adolescent grief Adoption

Xenia's lab work comes back with a glucose reading of 160 and a hemoglobin of 9.7. What education does the nurse need to cover?

•She will need a Three-Hour Glucose Tolerance Test •She needs to be fasting to start the test •She will need to sit quietly during the test with nothing to eat or drink until the test is complete •Recommend she bring a protein snack •Diagnosis is 2 out of 4 values above normal limits •Diet assessment, iron supplementation with teaching

What ELSE does the nurse need to understand to administer magnesium sulfate safely?

•Stay with patient through bolus - Monitor for s/s of toxicity •Monitor respiratory rate, DTRs and LOC. D/C if patient shows signs of toxicity •Calcium Gluconate needs to be readily available as the antidote •It's going to require more Pitocin to induce labor because of the tocolytic effect of the magnesium •It will lower BP due to vasodilation - But we give it to prevent seizures •Decreased u/o increases the risk for toxicity because Mag is excreted through the kidneys •Usually on continuous pulse oximetry - toxicity can lead to resp distress

The physician sends her to Labor & Delivery with orders for frequent monitoring of her vital signs and NSTs 4 times a day. He also orders Betamethasone IM, 12mg X 2 doses, 24-hours apart. Her labor will be induced starting with Cervidil that night.

•Violet is scared. She wants to know why she is getting 2 shots and why is her baby being delivered so early. •Why betamethasone? •To improve respiratory outcome in the newborn by increasing surfactant production •Why early delivery? •Preeclampsia can only be cured with delivery. Waiting increases the chance of poor outcome for both mother and baby.

Rose calls the OB/GYN clinic three months later to report her home pregnancy test is positive. How soon should she be seen? What education needs to be completed?

•With preconception care she already been screened for anemia, STIs and infections. •She's also taking her PNV. •BUT She should still be seen before 12 weeks due to blood glucose control. •Her glucose may fluctuate now that she is pregnant. In the first trimester her insulin needs may drop significantly, putting her at risk for hypoglycemia unless she adjusts her dose. •She may need lab work to determine baseline kidney function. •Ophthalmology consult recommended