OB midterm
Reva rubin maternal role task
-ensuring safe passage throughout pregnancy/birth -seeking acceptance of the infant by others -seeking acceptance of self in maternal role to infant (binding in) -learning to give of oneself
first prenatal visit
-establishment of trusting relationship -focus on education for overall wellness detection/prevention of potential problem -comprehensive health hx, exam, lab test
spontaneous abortion
-first trimester lost=genetic -second trimester lost=maternal cause -after 20 wks consider "stillbirth"
Amniotic fluid
-from amnion and fetal urine -indicator of fetal well being -maintain body temp -allows umbilical cord to be free from compression -promotes fetal movement to enhance musculoskeletal development
fetal skull
-frontal suture -coronal suture ( help form interior frontal, diamond shape, anterior soft spot) -posterior fontanel
GI changes in pregnancy
-gums-friable -ptyalism (constant production of saliva) -prolonged gallbladder emptying
immunizations safe during pregnancies
-hep b -influenza -tdap -meningococcal -rabies
hyperemesis gravidarum
-high levels of hCG -wt loss of 5% prepregnancy wt *NPO for gut rest and LR Lab Work: BUN, CBC, liver enzymes Meds: Phenergan Zofran Compazine Diclegis
cardiovascular changes
-increase blood volume -increase cardiac output -slight decline in bp til mid pregnancy -physiology anemia -hypercoagulable state; iron demands, fibrin, plasma fibrinogen levels, clotting factors
nutritional needs
-increase protein/iron/folate/calories -avoid artificial sweeteners, fish high in mercury
Preterm labor
-most common -20 -37 wks gestation -Tocolytic drugs STOPS preterm labor -give corticosteroids at 24-32 wks to respiratory distress Risk factors: HX of UTIs/STI, medical conditions, twins, preclasmpia, age Subtle signs: contraction patterns; 4/every 20 minutes 8/hr Labs: CBC, fetal fibronectin, amniotic fluid analysis Diagnostic: cervical length via transvaginal ultrasound
fourth stage of labor
-most critical -from delivery of placenta through first four hours --prevent hemorrhage --fundus management: firm midline (if leaning r/l bladder maybe full empty it) monitor location
teaching dangers in second trimester
-pain in calf -leaking of fluid -absent fetal movement
teaching dangers in first trimester
-painful urination -persistent vomiting -lower abdominal pain -fever greater than 100
fetal physiologic response to labor
-periodic FHR accelerations/slight decelerations -decreased circulation and perfusion -increased carbon dioxide pressure -decrease fetal breathing/moving/oxygen
missed abortion
-pregnancy stopped developing at least 6 wks
indications for forceps/vacuum
-prolonged second stage -nonreassuring FHR pattern -failure of presenting part to fully rotate/descend -maternal fatigue
Biophysical profile score breakdown
-score between 8/10= Normal -score 6/lower= risk for asphyxia, premature birth, warrants investigation
Gestational diabetes
-screen at 24-28 wks -DX 2 or 3 numbers showing elevation : fasting greater than 92 1 hr greater 180 2 hr greater 153 labor complications; shoulder dystocia, csection, postpartum hemorrhage, macrosomia Diagnostic: NST, biophysical profile starts @28wks, every 4/6 wks measure hBA1c, alpha-fetoprotein levels *diet and exercise
indications for amnionfusion
-severe variable decelerations due to cord compression -oligohydramnios due to placental insufficiency -premature/rupture of membranes -preterm labor with rupture thick meconium fluid
teaching dangers in third trimester
-sudden wt gain -severe headache/blurred vision -RUQ pain -gush of fluid -not meeting count kicks
Nurse role in genetic counseling
-taking family history -explaining purpose, risk/benefits of all screening diagnostic test -answering questions/concerns
Uterine Rupture
-tearing of uterus at the site of a previous scar into the abdominal cavity -sudden fetal bradycardia -Maternal VS decreased, loss of uterine tone "something not right" -onset of sudden fetal distress
Group B streptococcus
-test mom @35 wks -if (+) give antibiotic in labor *Causes newborn sepsis/pneumonia **Must have 2 negative results after 35 wks
endocrine changes
-thyroid gland (increase in BMR) -pituitary (decrease FSH/LH/GH, increase MSH)
Placenta Separation
-uterus rises upward -umbilical cord lengths -trickle of blood -uterus changes shape to round -document the time of placenta delivery
reproductive system adaptions
-uterus, increase in size, wt, length, width, depth volume, overall capacity -braxton hicks -ascent into abdomen after first trimester -fundal height by 20 wks level of umbilicus -vena cava syndrome -38-40 wks drop -lightening
FHR normal range
110-160
Dizygotic twins
2 eggs fertilized, 2 placenta @28 wks NST, biophysical profile
A client is admitted to the unit in preterm labor. In preparing the client for tocolytic drug therapy, the nurse anticipates that the client's pregnancy may be prolonged for how long when this therapy is used?
2 to 7 days Explanation: Tocolytic drugs may prolong the pregnancy for 2 to 7 days. During this time, steroids can be given to improve fetal lung maturity, and the woman can be transported to a tertiary care center.
Placenta
-Protects fetus from immune attack -Provides oxygen/nutrients -removes waste products -induces mother to bring more food -produce hormones
maternal physiologic changes during labor
-^HR (110-120), cardiac output, BP (^35mm ) -^WBC (due to trauma 20-30,000 ) -^RR, oxygen consumption -decreased motility, gastric emptying, ^gastric PH -slight temp elevation (100.4 increased in activity ) -muscle cramps/aches -^BMR (due to stress ) -decrease blood glucose levels (Give LR )
more changes in endocrine
-adrenal glands (increase cortisol/aldosterone, increase glucose) -prostaglandins secretion -placental secretion
menstrual history
-age 2 menarche -days in cycle -flow characteristics -discomforts -use of contraception
Shapes of pelvis not favorable
-android=csection platypelloid=csection
Toxoplasmosis
-can cause small brain in baby -from under cooked pork, dirt, kitty litter so must be avoided
Labs in DIC
Decreased fibrinogen and platelets prolonged PT and aPTT Positive D-dimer tests
Bishop score
Determines maternal readiness for labor by evaluating whether the cervix is favorable by rating cervical dilation, effacement, consistency, position, and station *A score of 6 or less NEEDS induction
Shoulder dystocia
Fetal shoulders do not deliver spontaneously, and aren't delivery at the 5 minute mark. -Major concern: Baby isn't receiving enough oxygen -Turtle sign -Time must be started once diagnosis is made -Mother: perineal tear, postpartum hemorrhage, trauma to bladder -Fetus: clavicle fracture, brachial plexus injury, Erbs palsy
Placenta hormones
HCG(maintains endometrial lining), hpl(controls metabolism), relaxin(relaxes pelvic joints and soften cervix), estrogen(breast/genitalia/uterus), progesterone (decreases contractility of uterus)
HELLP syndrome
Hemolysis, Elevated Liver Enzymes, Low Platelets Labs: -elevated bilirubin, low H&H, elevated LDH, AST, ALT, BUN. TX: -Mag IV and blood products -Prevent DIC, CVA, PE -prepare for preterm labor
Labor induction
Herbal agents, castor oil, hot baths, enemas foley bulb induction, rupturing membranes
Problem with powers (contractions)
Hyper/hypotonic uterine dysfunction (uterus doesn't relax/weak contractions and increased risk for hemorrhage Protracted disorders (slow dilation, less than 1 cm/hr; slow descent) Arrest disorders (No progress) Precipitate labor (labor under 3 hrs; increased risk postpartum hemorrhage; trauma for baby and mom
risk factors for adverse pregnancy outcomes
Isotretinoins, antipileptic drugs, diabetes, hypothyroidism, rubella, obesity, smoking
first stage of labor
Latent 0-3 cm; contraction 5-10 mins/lasting 30 secs; cervical changes Active 4-7 cm; longest period of labor! 45-60 sec in length contractions Transition 8-10 cm; shortest/most intense; contractions 1-2 mins apart; N/V/shaking;60-90 sec contractions
most desirable position for delivery
Left Occiput Anterior (LOA)
Medication for preterm labor
Mag sulfate (watch urine output) Nifedipine indomethacin (used after 32 wks) betamethaone
medication to treat ectopic pregnancy
Methotrexate; must be hemodynamically stable, no signs of active bleeding
Problem with the Passenger
Occiput posterior position (more back pain, use of forceps, tearing and episiotomy) face/brow presentation (harder to rotate=csection) breech presentation (csection or turn baby @ 36/37 wks) multifetal pregnancy (the baby might not be in position after the birth of one) macrosomia/cephlopelvic disportation (CPD) (Huge baby/baby head doesn't fit=csection or forceps)
Leopold maneuver sequence
Palpate client's fundus to identify fetal part, determine location of fetal back, palpate fetal part presenting at inlet, identify attitude of head
Problems with the passageway
Pelvic contraction (arrest of descent) obstructions in material birth canal (cervical edema; when mom starts pushing before dilated) *Any HX of HPV for large warts could be blocking
Placenta Percreta
Penetrates the uterine muscle Has high chance of hysterotomy
During which phase of fetal development is the ball of cells moving out of the Fallopian tubes and into the uterus?
Preembryonic This is the stage where the blastocyst (or ball of cells) is traveling to the uterus for implantation. Once implantation occurs, the embryonic stage begins.
Signs of Cardiac Decompensation
SOB, JVD, chest pain dyspnea
A laboring pregnant client has 6 contractions in a 10 minute time frame. The nurse notifies the provider. Which order should the nurse expect?
Terbutaline 6 contractions in 10 minutes is considered a hyperstimulated uterus. Terbutaline is a tocolytic and can be given to stop or slow the contractions of the hyperstimulated uterus.
A nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the client that fetal circulation consists of:
Two umbilical arteries and one umbilical vein
Prenatal test for genetic risks
UTERO Amniocentesis (15-20 wks) chorionic villa sample (10-12 wks) percutaneous umbilical blood sampling (16 wks+) fetal nuchal translucency fetal ultrasound (18-20) MATERNAL Alpha-fetoprotien (15-18 wks) triple/quad screen (15-18wks) *Increase number =risk for neuro tube defect; decreased num=downs cell free fetal DNR (10 wks)
wharton's jelly
Yellow-white gelatinous material surrounding the vessels of the umbilical cord. *Prevents compression
third stage of labor
birth of baby to delivery of placenta
functional classification
class I: Asymptomatic no limitation class II: symptomatic with increased activity class III: symptomatic with normal activity class IV: symptomatic all the time
directed pushing
cant feel the need to push
A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using?
effleurage Explanation: Effleurage is a form of touch that involves light circular fingertip movements on the abdomen and is a technique the woman can use in early labor. The theory is that light touch stimulates the nerve pathways to the brain and keeps them busy, thereby blocking the pain sensation.
Augmentation
enhancing ineffective contractions after labor has begun
Eclampsia
everything along with preeclampsia but with seziures
inevitable abortion
increased bleeding, cramping; cervix dilates, body passed product of conception
primary objective of fetal monitoring
information about fetal oxygenation and prevent fetal injury from impaired oxygenation and detect fetal HR changes early
Endoderm layer
inner layer that forms lining of digestive track, liver, pancreas, lung
false pelvis
lies above the linea terminalis
True pelvis
lies below the linea terminalis
primary function of ovaries
development and release of the ovum and secretion of hormones Estrogen and Progesterone
Dystocia
difficult labor
probable signs of pregnancy
positive pregnancy test, ballottement, goodell's sign, chadwick's sign, hegar sign
abruptio placentae
premature separation of the placenta leading to compromised fetal blood supply. -Grade 1 minimal bleeding/no fetal distress -Grade 2 (moderate) continuous pain, mild shock, bleeding -Grade 3 (severe) moderate bleeding, agonizing pain, profound shock *Grade 2/3= immediate csection -Dark red bleeding, knife like pain
A maternity nurse is aware that the fetal head is the presenting part in complete extension position. Which type of birth should the maternity nurse anticipate?
prolonged labor and possible cesarean birth Explanation: The attitude of the fetal head is moderate flexion. If there are changes in the fetal attitude (the head), the presenting part is then a larger diameter to the maternal pelvis. This presentation could cause a long labor and possible cesarean birth.
station
relationship of the presenting part of the fetus to the level of the ischial spines -measure in CM, once measurement hits 0 =engagement
difference between PROM and PPROM
rupture occurs beyond 37 weeks
couvade syndrome
same symptoms as mom
threatened abortion
slight bleeding, may or may not result in abortion
cervix
softening mucous plug formation (protects against infection) increased vascularization ripening (4 wks before birth)
mesoderm layer
the middle of the three cell layers in the developing embryo; circulatory, lungs (epithelial), skeletal, muscular system
positive signs
ultrasound, fetal movements, auscultation of fetal heart tones
Phenotype
observed outward characteristics (eye color, hair, skin tone)
A nursing student correctly identifies the most desirable position to promote an easy birth as which position?
occiput anterior Explanation: Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.
5 critical factors in labor
passageway (birth canal;soft tissue/bony pelvis) passenger power position psychological response
stages of fetal development
zygote>cleavage>morula>trophoblast>blastocyst
The nursing student demonstrates an understanding of dystocia with which statement?
"Dystocia is diagnosed after labor has progressed for a time." Explanation: Nursing management of the woman with dystocia, regardless of etiology, requires patience. The nurse needs to provide physical and emotional support to the client and family. Dystocia is diagnosed not at the start of labor, but rather after it has progressed for a time.
ideal pelvic shape
Gynecoid
Gravid
a pregnant women
Embryonic stage
begins day 15 and last through wk 8. -amnion/chorion finish forming -most susceptible to teratogens
IGA
breast milk
iron deficiency anemia
hemo less than 11 hema less than 35 decreased serum ferritin
what does glucose challenge test look for?
human placental lactogen
para
produced one or more viable offspring by carrying pregnancy 20 wks or more
second stage of labor
-cervix 10 cm -pelvic head engaged -perineal bloody show; start crowning
vagina
-increased vascularity -lengthening of vaginal vault -leukorrhea
Breathing
-more diaphragmatic than abdominal -shift in abdominal organs increases diaphragmatic excursion -increase in oxygen consumption -increase in tidal volume
Goals of preconception care
Promote the health and well-being of a woman and her partner before pregnancy
A nursing instructor asks a nursing student who is preparing to assist with the assessment of a pregnant client to describe the process of quickening. Which of the following statements if made by the student indicates an understanding of this term?
"It is the fetal movement that is felt by the mother."
Fetal stage
8 wks to birth.
Placenta accreta
Attaches deeply into wall of uterus
Placenta Increta
invades myometrium
first trimester
wk 1-13 -wk 3 neural tube formed -wk 5 heart beat regular rate -wk 7 fetal HR heard/limbs move -wk 8 heart fully develop -wk 9-12 sex can be seen/amniotic fluid formed
second trimester
wk 14-27 -wk 13-16 lanugo forms, swallowing of amnotic fluid, quickening -wk 17-20 nails present, vernix caseosa forms -wk 21-24 skin red/thins, grasp/startle reflec -wk 25 eyelid open, fingerprint set **wk 23/24 baby could survive outside womb
third trimester
wk 28-40 -wk 29-32 increased in body fat, iron transfer -wk 33-38 lanugo begins to disappear *Term baby 38-40 wks; little lanugo/vernix **Post term wk 42 greater; wrinkled, skin cracks
Nonstress test
-2 monitoring devices -contraction monitor (toco) -fhr (ultrasound) -marker button -20 mins long -elevation in hr 15 bpm for 15 seconds =reactive
incomplete abortion
*MOST serious -heavy bleeding, severe pain, shock, DIC
Amniotic fluid embolism
*usually after delivery along with DIC -sudden hypotension, hypoxia, coagulopathy -due to blockage in barrier in barrier between maternal circulation and amniotic fluid -difficulty breathing -hypotension -cyanosis -seizures -DIC -ARDS
Premonitory signs of labor
- Cervical changes - Lightening (36/38 wks; increase back pain) - Increased energy level (24/48 hr before birth) - "Bloody show" - Braxton Hicks contractions - Spontaneous rupture of membranes
Placenta Previa
- Relaxed uterus - Painless, vaginal bleeding *No cervical and vaginal exam **High chance of post partum hemorrhage Risk Factors: scarring, multi babies(uterus gets thinner), csection, uterus surgery, advance maternal age Management: pad count, fetal movement count; every 2 hrs, 10 movements
STIs
- causes preterm labor -treated with penicillin Gonorrhea: -treat with Rocephin -erythromycin ointment for newborn to prevent blindness Chlamydia: -newborn pneumonia -treat partners Trichomonas: -PROM -preterm labor HIV: -mother is taken off oral contiretrovrial drug until 14 wks then 2 daily. -IV antiretroviral during labor -oral syrup for newborn 6 wks -csection
nursing interventions for labor
-#1 change PT's position -stop oxytocin -high flow 02 nonrebreather -modify pushing if in second stage -document everything -heat/cold -attention focusing/imagery -effleurage(a form of massage involving a circular stroking movement made with the palm of the hand)/massage
guidelines for assessing FHR
-10-20 mins continuous on entry to L&D -completion of prenatal&labor risk assessment -intermittent auscultation during active labor (every 30 mins when low risk; every 15c mins when high risk pt )
monozygotic twins
1 placenta, 1 chorion, 2 amnions *higher risk for twin to twin syndrome *delivery in OR room
cardinal movement of labor
1. Engagement (baby at 0 station ) 2. Descent (baby in pelvis inlet ) 3. Flexion (chin to chest =smallest presenting part ) 4. Internal rotation (45 degree within pelvis ) 5. Extension (head delivers ) 6. External rotation (restitution/resolution) (back 45 degree to align shoulders ) 7. Expulsion (baby is delivery)
Nursing Management of shoulder dystocia
Call NICU -Change maternal position; McRoberts maneuver (lay PT flat, flex legs to abdomen) -suprapubic pressure; standing on bed/stool when mom is pushing -oxygen -prepare episiotomy
A pregnant client calls the clinic and tells a nurse that she is experiencing leg cramps and is awakened by the cramps at night. To provide relief from the leg cramps, the nurse tells the client to:
Dorsiflex the foot while extending the knee when the cramps occur
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency?
During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus every 15 minutes and then every 30 minutes for the next hour.
Risk factors for Dystocia
Epidural, multiple gestation, hydramnios, maternal exhaustion, ineffective maternal pushing, occiput posterior position, over 35, high caffeine, over weight, fetal birth weight more than 4000gm (8.8lbs)
A patient who is 8 1/2 months pregnant tells you she has been counting her baby's kicks and is concerned because within a 4 hour period the baby has only kicked 32 times. What nursing intervention is correct?
Reassuring the patient this is normal is the correct answer. The mother should feel the baby kick at least 10 times in two consecutive 2 hour periods.
VEAL CHOP
Variable deceleration =Cord compression Early deceleration= Head Compression Acceleration= Okay or oxygen Late acceleration = Placental insufficiency
factors influencing onset of labor
Uterine stretch Progesterone withdrawal Increased oxytocin sensitivity Increased release of prostaglandins (causes cervix to soften)
Presumptive signs of pregnancy
fatigue, amenorrhea, skin changes
Problems with Psyche
fear, anxiety, helplessness, worry
genotype
genes inherited from parents
ectoderm layer
hair, nails, skin, nervous system
maternal exhaustion
happens after two to three hours of pushing and usually ends in csection
A client has been in labor for 10 hours, with contractions occurring consistently about 5 minutes apart. The resting tone of the uterus remains at about 9 mm Hg, and the strength of the contractions averages 21 mm Hg. The nurse recognizes which condition in this client?
hypotonic contractions Explanation: With hypotonic uterine contractions, the number of contractions is unusually infrequent (not more than two or three occurring in a 10-minute period). The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise above 25 mm Hg. Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm Hg. However, the intensity of the contraction may be no stronger than that associated with hypotonic contractions. In contrast to hypotonic contractions, these occur frequently and are most commonly seen in the latent phase of labor. Uncoordinated contractions can occur so closely together they can interfere with the blood supply to the placenta. Because they occur so erratically, such as one on top of another and then a long period without any, it may be difficult for a woman to rest between contractions or to breath effectively with contractions. Braxton Hicks contractions are sporadic contractions that occur in pregnancy before the onset of true labor.
locations of fundus after birth
immediately after (halfway between umbilicus and symphysis pubis) -1-2 hrs after birth at umbilicus level
A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds?
in the woman's lower abdominal quadrant Explanation: The fetal heart rate is heard most clearly at the fetal back. In a cephalic presentation, the fetal heart rate is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus.
