Antepartum
What indicates a reactive NST?
- 2 or more accels of FHR in a 20 minute period
Describe a Contraction Stress Test (CST).
- evaluating a baby's ability to withstand the physiological stress of contractions/looking for decels/lates - Method for evaluating fetal status during the antepartum period by observing response of the fetal heart rate to the stress of uterine contractions. -Positive (decel's present with 50% of contractions, baby is positively stressed) vs Negative (not stressed/GOOD)
What indicates a nonreactive NST?
- less than 2 accels of FHR in a 20 minute period - may indicate hypoxemia and acidosis
What cardiovascular changes occur during pregnancy?
-40-50% increase in blood volume/ cardiac output -supine hypotension -dilutional anemia
Describe severe preeclampsia.
->160/110 - 3-4+ proteinuria -increased Hct, BUN, uric acid, creatinine, AST, ALT -decreased RBCs, platelets -facial edema, pitting pretibial edema -sudden large weight gain -visual disturbances -possible CNS irritation -epigastric pain
Describe mild preeclampsia.
-BP 140/90 or 30/15 more than baseline - traces of 1+ proteinuria -mild to moderate pretibial edema -no/minimal visual disturbances
Describe variable/Cord compression
-Changing baby's position can help -unrelated to contractions -abrupt <15 seconds
Describe elcampsia.
-HTN -same symptoms as severe preeclampsia -seizures (tonic-clonic aka grand mal)
Describe HELLP Syndrome.
-Hemolysis -Elevated Liver enzymes -Low Platelets (<100,000)
What is used during a CST to induce contractions?
-IV Pitocin (oxytocin) (controlled amount) -breast stimulation (not a controlled amount of oxytocin)
What is a hydatidiform mole? (Gestational trophoblastic disease)
-abnormal growth of trophoblastic tissue including placenta and chorion - increased risk of choriocarcinoma -the body thinks it is pregnant, will test positive for pregnancy
Lates/Placental perfusion problems
-baby is not getting sufficient blood/oxygen/nutrients they need
Why are ultrasounds performed during the 1st trimester?
-confirm due date -confirm viability -confirm location of pregnancy (ectopic)
Describe a Non-Stress Test (NST).
-mom pushes a button when she feels the baby move and the medical professional looks for accelerations in response to the baby movement -to assess the response of the FHR and FM - most COMMON test for high risk pregnancies -test results are reactive/nonreactive
Describe a Biophysical Profile (BPP).
-most ACCURATE predictor of fetal well-being -Method for evaluating fetal status based on 5 variables: FHR, breathing movement, gross body movement, muscle tone, and amniotic fluid volume. -each variable is rated 0 (negative) or 2 (positive) points for a possible total of 10 points -6 points indicates further testing is needed
Describe placenta abruptio
-premature separating of the placenta from the uterus -painful/dark red vaginal bleeding -firm uterus -requires C-section -can cause decels
What is the function of amniotic fluid?
-regulate temperature -protection
Describe Multi-marker screen.
-screening for chromosome abnormalities -Analysis of maternal serum for abnormal levels that may predict chromosomal abnormalities of the fetus. This test is performed at 16-18 weeks
What is important to know about magnesium sulfate?
-toxicity signs ( low RR, no DTR) -antidote is calcium gluconate
Accelerations/Okay
-what we want to see -accelerations are greater than 15 bpm for at least 15 seconds (15x15 rule)
How long should you wait to become pregnant after a hydatidiform mole or choriocarcinoma?
1 year
How do you estimate a due date?
1. Nägele's rule: FIRST DAY of LMP minus 3 months plus 7 days and in most cases add 1 year 2. ultrasound 3. date of occurence of significant events
What are the 5 hypertensive disorders of pregnancy?
1. gestational HTN 2. preeclampsia 3. eclampsia 4. chronic HTN 5. HELLP pg 300
What are the 3 positive signs of pregnancy?
1. positive ultrasound 2. heartbeat on doppler 3. medical professional feels baby move
Describe the parts of an Electronic Fetal Monitor (EFM).
1. trocotransducer- goes on the fundus of the uterus The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. 2. ultrasound transducer
What are danger signs of pregnancy?
1. vaginal bleeding 2. facial edema (Preeclampsia) 3. continuous pounding headache (preeclampsia) 4. persistent or severe abd or epigastric pain (preeclampsia) 5. chills/fever (septic abortion) 6. painful urination (UTI) 7. persistent vomiting (Hyperemisis Gravidera) 8. change in frequency or strength of fetal movement (Spontaneous abortion) 9. S&S of preterm labor
What is baseline fetal heart rate?
110-160 -rounded to 5 bpm
What is the general recommended weight gain during pregnancy?
1st trimester: gain 1-4 lb 2nd-3rd trimesters: 1 lb/week
Describe the umbilical cord.
2 arteries/ 1 vein (AVA) Whartons Jelly
Describe moderate variability.
6-25 bpm variability Mature CNS, what we want to see, most reassuring.
Describe minimal variability.
<5 bpm variability Can be common in early pregnancy, could also mean the baby is in deep sleep/sedated
Describe marked variability.
>25 bpm BAD
Describe a septic abortion.
A septic abortion "is an infection of the placenta and fetus (products of conception) of a previable pregnancy. Infection is centered in the placenta and there is risk of spreading to the uterus, causing pelvic infection or becoming systemic to cause sepsis and potential damage of distant vital organs.
Describe an Amniocentesis. (When/why)
A sterile test used to test for genetic disorders. The test is performed mid trimester (14-20) for genetic testing, and third trimester for testing lung development. Patients need a ride home after testing due to possible nausea Withdrawing amniotic fluid for laboratory examination.
Describe an inevitable/incomplete abortion.
An incomplete abortion is an abortion that has only been partially successful. The pregnancy has ended— no fetus will develop, but your body has only expelled part of the tissue and products of pregnancy.
A 30 year old female is 25 weeks pregnant with twins. She has 5 living children. Four of the 5 children were born at 39 weeks gestation and one child was born at 27 weeks gestation. Two years ago she had a miscarriage at 10 weeks gestation. What is her GTPAL? A. G=7, T=4, P=0, A=1, L=5 B. G=7, T=4, P=1, A=1, L=5 C. G=6, T=4, P=0, A=1, L=5 D. G=6, T=2, P=2, A=1, L=5
B. G=7, T=4, P=1, A=1, L=5 More questions: http://www.registerednursern.com/gtpal-nursing-practice-questions-quiz/
Are fetal bradycardia and tachycardia normal during pregnancy?
Bradycardia can be normal, and tachycardia is earlier in pregnancy
The clinic nurse explains to Margaret, a newly diagnosed pregnant woman at 10 weeks' gestation, that her rubella titer indicates that she is not immune. Margaret should be advised to (select all that apply): a. Avoid contact with all children b. Be retested in 3 months c. Report signs or symptoms of fever, runny nose, and generalized red rash to the health-care provider d. Receive the rubella vaccine postpartum
C, D Recieve vaccine after giving birth, and do not become pregnant for 3 months after the vaccination. Testing for rubella (German measles) is not necessary as titers are reliable indicators of immunity. Rubella (German measles) is one of the most commonly recognized viral infections known to cause congenital problems. If a woman contracts rubella during the first 12 weeks of pregnancy, the fetus has a 90% chance of being adversely affected. A maternity patient who is not immune to rubella should be offered the rubella immunization following childbirth, ideally prior to hospital discharge. The patient should report signs or symptoms of rubella during pregnancy to her health-care provider. It is not realistic for a woman to avoid contact with all children.
During a prenatal visit a patient tells you her last menstrual period was May 21, 2016. Based on the Naegele's Rule, when is the estimated due date of her baby? A. February 27, 2016 B. March 19. 2017 C. February 28, 2017 D. April 16, 2016
C. February 28, 2017
Describe Alpha-Fetoprotein Screening
Can be measured in maternal serum (MSAFP) or amniotic fluid (AFAFP). This screening is performed between 16-18. Highly inaccurate Screening of maternal serum or amniotic fluid detecting levels of plasma protein produced by the fetus. pg 245
What intervention should be taken if a pregnant patient is laying supine and becomes hypotensive, and why?
Change position, R lateral position, to get the pressure from the baby off of the aorta and vena cava
If a patient is suspected to have HELLP syndrome, what assessment should not be performed?
Do not palpate the abdomen, you could rupture the liver!
Early/Head compression
Earlies mirror contractions, not a sign of fetal problems (do not need to fix)
What does GTPAL M stand for?
G: gravida T: term (deliveries born after 37 weeks) P: preterm (deliveries born after 20 weeks and before 37 weeks) A: abortion (elective/nonelective end of pregnancy before 20 weeks gestation) L: living children M: multiple gestation pregnancies (not commonly used)
Describe Gravida and Para.
Gravida: # of times pregnant (including current pregnancy) Para: any delivery AFTER 20 weeks gestation
Describe gestational HTN.
HTN that resolves after delivery
Why are pregnant women only allowed to have insulin to control diabetes?
Insulin does not cross the placenta
How would you document a patient who has a set of twins and another child and is pregnant for the third time?
She would be G3P2 Gravida: she has been pregnant a total of three times including this pregnancy Para: she has delivered 3 babies, but twins/multiples count as only ONE delivery
Describe the anatomy of the amniotic sac.
The amniotic sac contains two fetal membranes called the amnion (inner) and chorion (outer) http://brooksidepress.org/ob_newborn_care_1/?page_id=228
What major risk is associated with Chorionic Villus Sampling?
The complication of this test is if the mom has any type of STD/STI, the infection could be spread easily to the baby.
What is an indication of a hydatidiform mole/molar pregnancy?
The uterus is often larger than would be expected based on the duration of the pregnancy. The uterus does not show until 12 weeks. 12 weeks Pubic Symphysis 24 weeks Umbilicus 36 weeks Xiphoid Process of Sternum 37-40 weeks Regression of fundal height between 36-32 cm
How you confirm a pregnancy?
There are 3 classifications of pregnancy confirmation: 1. presumptive 2. probable 3. positive
Describe Chorionic Villus Sampling (CVS) (When/why).
Used to test for genetic disorders in the baby. The test is beneficial because it can be performed at 10-12 weeks/earlier than an amnio. Transcervical or transabdominal procedure to obtain sections of projections of the outer fetal membrane for fetal cell analysis.
Describe Percutaneous Umbilical Blood Sampling (PUBS) (when/why).
Used to test the baby's blood, and to give the baby blood transfusions. This test can be performed after 16 weeks. Procedure for obtaining fetal blood through US guided puncture to detect fetal problems such as fetal blood disorders or fetal infection.
What is the MOST IMPORTANT indicator of fetal heart rate? Why?
Variability; measures mature autonomic neuro system and adequate oxygenation
What does VEAL CHOP stand for? V C E H A O L P
Variable Cord compression Early Head compression Accel Okay Late Placental perfusion problems
How would you describe PROM/PPROM?
Water breaks before labor begins
Define a missed abortion.
When the fetus dies, but is retained in the uterus.
Describe Gestational Diabetes.
a patient contracting diabetes during pregnancy -babies are often born hypoglycemic because their source of sugar is gone
What is terbutaline? What is it used for? What should you warn the patient of?
a tocolytic, to stop contractions -medication burns -causes tachycardia and shaking (panic attack like symptoms) -stimulates CNS
What is considered preterm labor? (Which weeks)
after 20, before 36/37 (term)
What are risk factors that can cause placenta abruptio?
cocaine, HTN, trauma
What does the parasympathetic nervous system do to the heart?
decreases heart rate -PARAchute out of a plane to go DOWN
What is the last symptom that occurs before preeclampsia turns into eclampsia?
epigastric pain
Patients with HELLP Syndrome are at risk for?
hemorrhage, pulmonary edema, and hepatic rupture
What does the sympathetic nervous system do to the heart?
increases heart rate
Which two drugs can help manage HTN pregnancy?
labetolol and hydralazine
Define oligohydramnois.
less than 400 mL of amniotic fluid
What medication is typically administered to prevent seizures related to CNS stimulation?
magnesium sulfate
What is a good way to check a patients CNS?
measure DTR (0-4, 2+ is normal)
Define polyhydramnios.
more than 2000 mL of amniotic fluid
If a pregnant woman is bleeding vaginally, what should NOT be done?
no vaginal exam until ultrasound is performed
What are normal levels of amniotic fluid?
normal (at term): 700-800 mL
What is hyperemesis gravidarum, and why is it dangerous?
persistant, uncontrollable vomiting that can lead to weight loss, dehydration, acidosis, ketones, hypokalemia
What is the function of the placenta?
provide oxygen and nutrients to the fetus
What is Hegar's sign?
softening and compression of the lower UTERUS
What is Goodell's sign?
softening of the CERVIX
Which drugs are used to accelerate fetal lung development? How?
steroids: betamethasone/dexamethasone helps form/increase surfactant and speed up lung development
What are presumptive signs of pregnancy?
symptoms can be explained away ex. missed period, nauseous, breast pain
What are probable signs of pregnancy?
symptoms can be explained, but with more skepticism ex Chadwick's sign, Hegar's sign, Goodell's sign, blood test, urine pregnancy test
Describe a threatened abortion.
the pregnancy is savable, the baby is still in the uterus, but the uterus is bleeding
What do lower levels of Alpha-Fetoprotein indicate?
this indicates chromosomal abnormalities such as trisomy 21/Downs
What do higher levels of Alpha-Fetoprotein indicate?
this indicates open neural tube defects
What is the purpose of having a quiet, calm environment for a patient with HTN?
to prevent overstimulation of the CNS which could produce seizures *seizures can occur 48 hours after delivery*
What can be used to stop preterm labor (contractions)?
tocolytics
What can be used during a NST to reduce false positives?
vibroacoustic stimulation is the use of sound to elicit fetal movement and accelerate FHR.
What is Chadwick's sign?
violet blue vaginal mucosa and cervix at 6 weeks
Describe placenta previa.
when the placenta covers the cervix causing bright red/painless vaginal bleeding -ultrasound to confirm -requires a C-section
