OB-Peds Exam 3
placental abruption
Premature separation of the placenta from the uterine wall after 20 weeks' gestation and before the fetus is delivered; fetal mortality rate of 20%
What is the most common bacterial infection in pregnancy?
UTI- can be mistaken for normal pregnancy symptoms, untreated can cause low birthweight, intrauterine death, preeclampsia, maternal anemia
Postpartal chills
Uncontrolled shaking or chills as a physiologic response to labor and a result of the rapid weight loss at delivery
Incomplete abortion
partial expulsion of some but not all POC before 20 weeks gestation
Risk factors for ectopic pregnancy
pelvic inflammatory disease, IUD, endometriosis, tubal ligation reversal
breast assessment postpartum
days 0-2 breasts feel soft to touch by day 3 begin to feel warm and firm when milk comes in; assess for engorgement, infection, plugged milk ducts (pea sized tender lumps)
Risk factors for uterine rupture
history of cesarean or uterine surgery, no previous vaginal births, augmented or induced labor, multifetal gestation, macrosomia, infection, short period between pregnancies
Multiple gestation increases risk for what?
hospitalization, pulmonary edema, hyperemesis gravidarum, additional tests and fetal surveillance, preterm labor
Gestational Trophoblastic Disease (GTD)
hydatidiform mole (molar pregnancy)- develops from abnormal fertilization such as when 2 sperms fertilize one egg or when either the sperm or egg is missing genetic material; complete mole has no fetal tissue, partial mole has some fetal tissue remaining
Dystocia
long difficult or abnormal labor; related to 5 P's Powers- uterine contractions Passage- pelvic and vaginal structure Passenger- fetus Position- maternal position Psychological- response of the woman
tocolytics suppression of labor
magnesium sulfate, terbutaline, indomethacin, nifedipine
Reasons for scheduled cesarean
malpresentation, previa, previous C/S, multiples, HSV+, HIV+, cardiac disease, extensive condylomatas (HPV)
Daily Fetal Movement Count (DFMC)
maternal assessment of fetal activity; the number of fetal movements within a specified time are counted; want 10 or more movements in 12 hours
Postpartal tachycardia
may result from a complication, prolonged labor, blood loss, temperature elevation, hemorrhage, or infection
Lactating women return of ovulation
menses suppressed dependent on length and amount of BF; not reliable BC
Contraction Stress Test (CST)
nipple stimulation or oxytocin stimulation, evaluates fetal response to stress could inadvertently precipitate labor Negative (normal): no late or variable decells Positive: late or variable decells with > 50% uterine contractions Suspicious/unequivocal: variable or late decells with < 50% of contractions
Inevitable abortion
no expulsion of products of conception, but bleeding and dilation of cervix has occurred and expulsion of POC cannot be halted
Postpartum tempature elevation <100.4
normal due to dehydration and stress
Gestational hypertension
onset of hypertension without proteinuria after 20 weeks gestation
Signs of placenta previa
painless vaginal bleeding in 2nd or 3rd trimester
glucose tolerance test (GTT)
(50 g) negative is BG less than 130-140 after 1 hour retest if positive- 100 g for 3 hours 2 or more of following is positive: -fasting 95 -1 hr 180 -2 hr 155 -3 hr 140
amniotic fluid embolism
(anaphylactoid syndrome of pregnancy) Amniotic fluid containing particles of debris Acute onset of hypotension, hypoxia, cardiovascular collapse, and coagulopathy Maternal mortality to 61% or higher Neonatal outcome is poor
Postpartum weight loss
-about 10-12 lbs lost during childbirth; if normal weight gain during pregnancy, should be back to original weight by 6-8 weeks
Insulin requirements during pregnancy
1st trimester: reduced insulin needs 2nd trimester: gradual increase in insulin needs 3rd trimester: insulin needs double or more immediately drops off and gradually increases- lower needs in breastfeeding moms than baseline
What are the danger zones of pregnancy for women with cardiac issues
20-26 weeks gestation 24-72 hours after delivery
RhoGAM timeline
27-28 weeks in all rh- women, within 72 hours of birth if baby is +
How many wet and dirty diapers should baby have by 4 days old
6 wet, 4 dirty
Return of ovulation in non-lactating women
7-9 weeks, regular period by by 12 weeks
BPP score actions
8-10: no fetal asphyxia, repeat weekly 6: suspected chronic fetal asphyxia: if > 36 weeks deliver, if less repeat in 4-6 hours 4 and under: strongly suspect fetal asphyxia, if > 36 weeks deliver, if less repeat in 4-6 hours for 120 minutes; persistent score under 5 deliver regardless of gestational age
Group B Streptococcus (GBS)
A common bacterium found in the vagina and rectum of healthy women, dangerous to newborns; women are screened universally at 36-37 weeks gestation via vaginal rectal swab. Prophylactic oenecillin is given if status is unknown or if PROM occurs, mom has a fever greater than 100.4
Signs and symptoms of ectopic pregnancy
Abdominal pain, cullen's sign- umbilical bleeding, missed menses, positive pregnancy test, abnormal vaginal bleeding
Placenta accreta/increta/percreta
Abnormal attachment of the placenta to the uterus with different terms used to describe the depth of placental invasion- increta and percreta likely to result in hysterectomy
Velamentous cord insertion
Abnormal insertion of umbilical cord into membranes beyond placental edge, vessels not protected by whartons jelly
feeding cues for hunger
Licking or sucking movements, Lip smacking, Rooting, Hand-to-mouth movements, Sucking on fists, Increased activity, Crying (late sign)
augmentation of labor
Artificial stimulation of uterine contractions after labor has started but not progressed
Severe preeclampsia
BP > 160/110 * 2 while on bedrest Massive proteinuria > 5 g in 24 hours platelet count < 100,000 elevated liver enzymes; epigastric or RUQ pain Progressive renal insufficiency; serum creatinine >1.1 or doubling Pulmonary edema New onset of visual disturbances
Mild preeclampsia
BP of 140/90 * 2 or 15 higher than pre-pregnancy blood pressure proteinuria > 300 mg in 24 hours platelet count < 100,000 elevated liver enzymes new development of serum creatinine >1.1
Testing done during pregnancy for diabetes
Baseline renal function, UA and culture, A1c, non stress test 2 times a week in 3rd trimester
Reasons for urgent cesarean
CPD, dystocia, nonreassuring FHR
HIV/AIDS
Can be transmitted in pregnancy to the baby, risk is reduced if mother complies with antiviral medications and newborn has 4-6 weeks pf post-exposure HIV antiviral medication; testing should occur ASAP in pregnancy, rapid test if status is unknown
postmaturity syndrome
Condition in which a postterm infant shows characteristics indicative of poor placental functioning before birth. Also called dysmaturity syndrome.
Afterpains
Cramping pain after childbirth caused by alternating relaxation and contraction of uterine muscles; usually more mild for first birth; breastfeding causes more severe pain
Lochia rubra
Dark red discharge - 0 to 3 days
Diagnosis and treatment of cervical insufficiency
Diagnosed by OB history of preterm births or late miscarriages; treated by cerclage, bed rest, progesterone, anti inflammatory drugs, and close monitoring of pregnancy
Home management for preeclampsia
Diet: low sodium, daily weight, activity restriction, fetal kick counts, check for proteinuria, possible oral antihypertensive: methyldopa; nifedipine; hydralazine; labetalol, last trimester: NSTs; BPPs; US once or twice a week
Fetal fibronectin (fFN)
Glue like protein that connects amniotic membrane to the lining of the uterus and if detected between 22-37 weeks could signify increased risk of pre-term labor. Negative Result means 99% of women will not give birth in the next 1-2 weeks.
Diagnosis and treatment of placental abruption
Fetal blood in maternal circulation or in vaginal blood- check kleihauer betke, ultrasound, coagulation abnormalities; prepare for emergency C/S, blood transfusion, DIC if 50% or greater abruption,
What is oligo/poly hydramnios associated with
GI system and kidney problems in fetus
Contraindications to breastfeeding
HIV, active TB, certain medications, herpes or hep B lesions of nipples, galactasemia in infant
Hematoligic consideration postpartum
Hct and Hgb drop after delivery due to blood loss, WBC may increase above 15,000 and mask infection, clotting factors increase-risk for DVT
ABO incompatibility
Hemolytic disease that occurs when the mother's blood type is O and the newborn's is A, B, or AB- hemolysis of fetal RBCs Direct coombs tests for maternal antibodies in fetal blood- risk for jaundice Indirect coombs tests for materna; antibodies in maternal blood
Symptoms of eclampsia
Hypertension, proteinuria, edema, convulsions/seizures, coma, death
Treatment of hyperemesis gravidarum
IV fluid for fluid or electrolyte imbalance, antiemetics, Vitamin B6 with doxylamine (unisom), small frequent meals, high protein
management of prolapsed cord
Immediately restore perfusion by lifting presenting part, call for help, stat C/S
Cervical insufficiency
Incompetent cervix, early cervical dilation
Precipitous labor
Labor that lasts 3 hours or less from onset of contractions to time of delivery; risk factors include hypertonic contractions, oxytocin use, multiparous woman
Magnesium toxicity
Mag level Greater than 8 DTRs- sluggish or absent, flaccidity andmuscle weakness CNS depression Respirations < 12 Decrease urine output: less than 30 mLs per hour Chesk pain, EKG changes, Cardiac arrest, Pulmonary edema
Management of severe preeclampsia
Magnesium sulfate per protocol (4-6 g loading doase then 2g/hour) Therapeutic at 4-7 mEq/L
Emergency medications for preeclampsia
Magnesium sulfate, hydralazine, labetalol, nifedipine, calcium gluconate
interventions for postpartum hemorrhage
Massage fundus, Lactated Ringers, Blood administration, Pitocin, methergine, cytotec, hemabate, D&C, Hysterectomy
Complications of precipitous labor
Maternal soft tissue lacerations, amniotic fluid embolism, PPH, Fetal hypoxia, intracranial hemorrhage, bruised face.
Biophysical Profile (BPP)
Method for evaluating fetal status by assessing fetal heart rate NST, breathing movements, gross body movements, muscle tone, and amniotic fluid volume.
Maternal riskfactors for GDB
Obesity, EGWG - Excessive gestational weight gain, Physical Inactivity, Previous Macrosomia, Advanced Maternal Age, Hypertension, Family History of Diabetes, Stressful Lifestyle, Urbanization (more fast food, stress), Previous unexplained IUFD
Risk factors for dystocia
Overweight or short stature, Advanced maternal age, Uterine abnormalities, Malpresentation and position of fetus, Cephalopelvic disproportion (CPD), Uterine overstimulation with oxytocin, Maternal fatigue, dehydration and electrolyte imbalance, and fear, Inappropriate timing of analgesic or anesthetic administration (secondary powers), Abnormal uterine activity
Interventions for PROM and PPROM
PROM- after 37 weeks; estimate risk, determine if infection is present, induce labor PPROM- before 37 weeks; manage conservatively, bedrest, NST and BPP daily, 7 day antibiotics, monitor for early labor, placental abruption, and infection
Lochia serosa
Pinkish/brown, serosanguineous. Lasts day 4-10 postpartum
Complications of pitocin use
Placental abruption, Uterine rupture, Unnecessary cesarean birth, Postpartum hemorrhage, Infection, Fetal hypoxemia and acidemia
Hypothyroidism in pregnancy increases risk for what complications?
Preeclampsia, Placental abruption, Preterm birth, Low birth weight, Stillbirth, Impairments in fetal neurological development
Birth complications associated with diabetes
Preterm delivery, preeclampsia, birth trauma, shoulder dystocia, fractured clavicles, cesarean delivery
HELLP syndrome is associated with increased risk for what complications?
Pulmonary edema, Acute renal failure, Liver hemorrhage or failure, Disseminated intravascular coagulation (DIC), Placental abruption, Acute respiratory distress syndrome (ARDS), Sepsis, Stroke, Fetal and maternal death
What is the leading cause of maternal mortality
Pulmonary embolism
Pregnancy is contraindicated in women who have which cardiac conditions?
Pulmonary hypertension, marfan syndrome, eisenmenger syndrome
systemic lupus erythematosus (SLE)
Recommendations for pregnancy include inactive disease state for at least 6 months depending on the degree of known organ damage; In the pre-steroid era, it was common practice to terminate pregnancy in patients with active SLE Increased risk for PROM, growth restriction, LBW
SPASMS assessment tool for preeclampsia
Significant BP changes Proteinuria Arterioles are affected by vasospasms-edema results Significant laboratory changes Multiple organ systems can be involved Symptoms appear after 20 weeks gestation
Uterine assessment
Should be firm, midline immediately after delivery it will be 5 below-ish; rises back up to 1 above in 6-12 hours; 24 hours after it is at umbilicus and descends by 1 cm per day
Interventions for shoulder dystocia
Stop pushing, mcroberts position, suprapubic pressure, episiotomy, woods corkscrew
Engorgement interventions while bottlefeeding
Supportive bra, avoid stimulation, ice packs or cold cabbage leaves, analgesics, should subside in 24 hours
Magnesium Sulfate considerations
Therapeutic leves are 4-7; need continuous FHR and ctx monitoring, vital signs q15-30 mins; Assess LOC, I&O, urine output, proteinuria, DTR's, headache, visual disturbances, epigastric pain Crash cart, resuscitation equipment at bedside
TORCH infections
Toxoplasmosis Other (Hep B, syphilis, HIV) Rubella Cytomegalovirus Herpes torch infections cross the placenta and cause harm to the fetus
Disseminated Intravascular Coagulation (DIC)
Triggered by preeclampsia, HELLP, sepsis, amniotic fluid embolusm retained fetuc, placental abruption
spinal headache
When spinal fluid leaks through a tiny puncture site decreasing fluid pressure around brain and spinal cord which is described like a "headache like no other"; resolved with laying flat
Lochia alba
Yellowish, white cream color. Lasts approx 11 days-6 weeks postpartum
uterine rupture
a tear in the wall of the uterus, abnormal FHR tracing, loss of fetal station, abdominal pain, shock
Non-stress test (NST)
a test that monitors fetal heart rate in response to stimulation; reactive means normal reactive: 15bpm accells for 15 seconds 2 times in 20 minutes
signs of placental abruption
abdominal pain, bright red painful bleeding, board-like abdomen, uterine tenderness-knife like, fetal heart rate abnormalities- bradycardia and prolonged decells
Dystocia of fetal origin
anomalies, CPD, malposition, malpresentation, multifetal pregnancy
induction of labor
attempt to start the childbirth process artificially by administering a drug to start labor (prostaglandins, oxytocin) or by puncturing the amniotic sac
newborn weight loss
babies lose up to 10% of weight in first few days, should return to BW by 2 weeks
chorioamnionitis
bacterial infection of the amniotic cavity: maternal fever, fetal tachycardia, uterine tenderness, foul smelling amniotic fluid
Prerequisites for vacuum assisted birth
cervix fully dilated, engaged head, vertex presentation, ruptured membranes, no suspicion of CPD
Complications of PROM
chorioamnionitis, prolapsed cord
Twin-to-Twin Transfusion Syndrome (TTTS)
complication of blood supply in monochorionic twins with one twin receiving a deficient amount (the donor) and the other receiving too much (the recipient); fatal in 90% of cases without laser intervention
What to do for suspected PROM
confirm with ferning, pooling or amniosure; obtain sample for lung maturity testing
shoulder dystocia
delayed or difficult birth of the fetal shoulders after the head is born- turtle sign; can result in brachial plexus nerve injury, fractured clavicle, dislocated shoulder, hemorrhage, or rectal injuries
Diagnosis and treatment of molar pregnancy
diagnosed by ultrasound (snowstorm appearance); most will pass spontaneously, suction curettage; avoid pregnancy for 1 year following molar pregnancy
diagnosis and treatment for placenta previa
diagnosed through ultrasound; observation, bedrest, NO vagnial exams, cesarean birth
Diagnosis and treatment of ectopic pregnancy
diagnosed via transvaginal ultrasound; treated with methotrexate (chemical abortive agent), or saplingectomy (incision of fallopian tube and removal of fetal contents)
common postpartum medications
docusate sodium (Colace), bisacodyl (Dulcolax), lidocaine spray, witch hazel pads (Tucks), ibuprofen (Motrin), oxycodone and acetaminophen (Percocet)
Postpartum bradycardia
down to 50 bpm, normal in first 6-10 days due to changes in CO
Magnesium Sulfate education and antidote
educate patient that they will initially feel flushed, hot, sedated, nauseated. Notify if expericing epigastric pain or trouble breathing Calcium gluconate reversal
Engoregement treatment while breastfeeding
feed frequently, warm compress, analgesics, supportive bra
Meconium stained fluid
first stool of infant (meconium) is passed inutero. caused by fetal stress: hypoxia,cord compression, post maturity
polyhydramnios
greater than 2 L of amniotic fluid
HELLP syndrome
hemolysis, elevated liver enzymes, low platelets symptoms: N/V, epigastric pain, RUQ pain, headache, blurred vision, malaise, increased BP Only cure is delivery STAT
Rho (D) Isoimmunization
hemolytic disease of the newborn in which maternal antibodies attack fetal and neonatal RBCs in Rh- moms with Rh+ babies fetus develops RBC deficiency, bilirubin rises, neurologic disease, erythroblastosis (hydrops) fetalis, miscarriage may occur
Triad of symptoms preeclampsia
hypertension, edema and proteinuria
ectopic pregnancy
implantation of the fertilized egg in any site other than the normal uterine location; 95% occur in fallopian tube
placenta previa
implantation of the placenta over the cervical opening or in the lower region of the uterus, complete, marginal, or low-lying
Risk factors for PPROM
infection, history of conization or cerclage, low socioeconomic status, low BMI, nutritional deficiencies, smoking
Postpartum Bladder Assessment
interferes with uterine contraction if bladder is distended
Complications of molar pregnancy
invasive mole- grows into the muscular layer of the uterus; choriocarcinoma- monitor Hcg levels and monitor for carcinoma
LATCH score
latch audible swallowing type of nipple comfort hold
oligohydramnios
less than 300 mL of amniotic fluid
Preeclampsia
pregnancy specific syndrome, hypertension develops after 20 weeks gestation in previously normotensive women, vasospastic systemic disorder categorized as mild or severe; complicates 5-10% of pregnancies
uterine cord prolapse
presenting part compresses umbilical cord- caused by long cord, malpresentation, ROM before the head is engaged
Risk factors for preeclampsia
primigravida (8X risk), obesity, smoking, age extremes, diabetes, preexisting hypertension, vascular or renal disease, previous preeclampsia, family history of hypertension, african american, grand multiparity >5, multiple gestation
Reasons for STAT emergent C/S
prolapsed cord, abruption, fetal bradycardia, eclampsia
Indications for forceps assisted birth
prolonged 2nd stage of labor, maternal exaustion, abnormal FHR tracing, abnormal presentation, arrest of rotation, breech delivery
Signs and symptoms of hyperemesis gravidarum
prolonged vomiting, weight loss, dehydration, electrolyte imbalances, ketosis, malaise, low BP
Betamethasone (Celestone)
promotes fetal lung maturation, administered between 24-34 weeks. give 2 times in 24 hours
Interventions for afterpains
prone position, ambulation, sitz bath, mild analgesic
Intrahepatic cholestasis of pregnancy
pruritus (palms & soles), dark urine, light colored stools, elevated serum bile acids (LFTS), finally jaundice; may cause early meconium treatments: Ursodeoxycholic Acid, Benadryl, Monitor liver function (LFTs), Cool oatmeal baths, baking soda, delivery
Storage of breast milk
room temp for 4 hours, refrigerator for 4 days, freezer for 12 months; use within 24 hours of thawing and don't refreeze
Premature Rupture of Membranes (PROM)
rupture of amniotic sac and leakage of fluid at least 1 hour before the onset of labor
Postpartum BP
should be compared to 1st trimester reading; hypotension could result from hemorrhage, monitor for preeclampsia
Threatened abortion
signs of SAB present with intrauterine bleeding before 20 weeks, without dilation of cervix; fetus still alive and attached to the uterus
Cerclage
suturing of the cervix to prevent it from dilating prematurely during pregnancy, thus decreasing the chance of a spontaneous abortion; prophylactic: done at 12-14 weeks; resuce: done at 16-23 weeks; removed at 36 weeks
Eclampsia
toxemia; Seizure activity or coma in woman diagnosed with preeclampsia; no history of pre-existing pathology; eclamptic seizures before, during or after birth
Signs and symptoms of molar pregnancy
vaginal bleeding, significantly larger uterus than normal for gestational age, absence of fetal heart tones, positive pregnancy test, snowstorm appearance on ultrasound
Preeclamptic headache
visual disturbances
Risk factors for hyperemesis gravidarum
young age, nulliparity, under or overweight, low socioeconomic status, multiple gestation, deficiency in thiamine and vitamin B1, fetus with chromosomal abnormalities