Obstetrics

Late decelerations

A late decel is a gradual decrease and return to baseline FHR during the contraction with the lowest point occurring after the peak of the contraction. It does not return to the baseline until after the contraction is over Caused by uteroplacental insufficiency Frequent contractions Late decel is assoc. with fetal hypoxemia, acidemia, and low apgar scores. When become persistent, it is considered an ominous sign, especially when associated with fetal tachycardia and loss of contraction variability Intervention If oxytocin is infusing, stop until the late decels are corrected. This will slow the rate and strength of the contraction to allow for better perfusion of the placenta Provide oxygen by nonrebreather face mask to the mother to alleviate the shortage of oxygen exchanging across the placental to the fetus An immediate and priority nursing action would be to change to laboring patients position to side lying to eliminate any supine hypotension issue. When maternal blood pressure is low, it is helpful to elevate the legs to assist with alleviating maternal hypotension Dehydration and hypovolemia can cause a reduction of blood flow to the placenta so by increasing the rate of the maintenance IV solution will address this problem

Other visits

At 9-14 weeks, chorionic villus sampling (CVS) may be offered to expecting mothers depending on certain risk factors. CVS obtains tissue from the chorion to test for certain genetic defects Early in the second trimester, a quad screen is performed to test for chromosomal abnormalities and neural tube defects. Later in the second trimester, an ultrasound is performed to assess for gross fetal abnormalities, and a one hour glucose challenge test is admin'd to screen for gestational diabetes. In the 3rd, patients are screened for group B strep CVS is a procedure performed under ultrasound guidance in which small samples of placenta are obtained for prenatal genetic testing. The samples can help determine if chromosomal or genetic disorder. CVS may be offered to patients after an abnormal quad screen or advanced age (over 35),a previous child with abnormalities, or a congenital anomaly detected on first trimester ultrasound. Many women may opt out of this test because there is a small risk of miscarriage The quad screen measures maternal serum alpha fetoprotein (AFP), human chorionic gonadotropin (hCG) unconjugated estriol, and inhibin A. It helps diagnose trisomies 21 and 18 as well as neural tube defects 21 is down syndrome which show elevated bCG and inhibin A levels while estriol and AFP are low. In edwards syndrome (trisomy 18) AFP, estriol, and hCG are low while inhibin A is normal. In neural tube defects AFP is classically high. The Quad screen can also help diagnose abdominal wall defects, molar pregnancy, and ectopic pregnancy. The triple screen includes all but inhibin A

placental implantation abnormalities

Can be described by the terms accreta, increta, and percreta which corelate to the depth of penetration into the placental myometrium. These abnorms begin with a defective decidual layer in the placenta, leading to possible life threatening hemorrhae in the mother postpartum Due to a defective decidual layer in the placenta there is abnormal attachment and separation of the placenta to the myometrium Placenta Accreta term used to describe the placenta attaching to the myometrium without penetrating it. This is the most common form of placental implantation abnormality Placenta Increta placenta penetrates into the myometrium without passing through it Placenta Percreta placental attachment that perforates through the myometrium and into the uterine serosa. Serious complications of this can lead to the placenta invading the bladder wall or the rectum These abnorms arise because of a defective or absent decidua which is the epithelial lining in the endometrium. Scar tissue from a previous C section or uterine procedure can lead to this absence of the decidua Due to abnormally deep penetration into the uterus (myometrium) there is massive post partum hemorrhage which can be life threatening to the mother Diagnosis Ultrasound is how it is first diagnosed. Once this is discovered, MRI is used to describe the depth of invasion If placental implantation disorder is discovered, patients usually have c section. This is done to circumvent post partum hemorrhage which occurs through vaginal birth Another treatment option is to ligate or embolize uterine arteries supplying hemorrhage from abnormal placental implantation. It is common to control bleed via embolizing or ligating a uterine artery

Mechanism of Labor

Cardinal movements that occur during the mechanism of labor describe the movement of the fetus through the birth canal. These movements consists of engagement, descent, flexion, internal rotation, extension, restitution, and external rotation, and expulsion of the infant Engagement During the few weeks before labor, the presenting part of the fetus will pass through the maternal pelvic inlet and engages in the true pelvis Descent Descent of the fetus through the pelvis indicates progressive movement of the fetal presenting part through the pelvis to prepare for birth Flexion When the fetal head meets the cervix, the fetal head flexes to allow the chin to make contact with the fetal chest. This mechanism allows a smaller diameter of the head to move through the outlet Internal Rotation In order for the fetus to be able to exit the pelvic outlet, the fetal face rotates posteriorly so tha tthe occiput faces anterior Extension As the fetus moves through the vaginal opening for firth, the head extends pushing the occiput out first followed by the face and chin External Rotation (Restitution) Once the head is out, the fetus rotates to realign the head with the shoulders and back allowing for the shoulders to move out of the vaginal opening Expulsion After the head and shoulders have exited they move upward allowing for the rest of the baby to be born

Early decelerations

Caused by a parasympathetic response during labor can be benign, abnormal or non reassuring. ID'd visually on a fetal monitor tracing by when they occur in the contraction cycle either the onset or at the end of a contraction and also by their shape. An early decel. is IDd as a gradual decrease (onset to lowest point is more than 30 seconds in FHR with return to baseline assoc with a contraction Occurs often during the first stage of labor (cervix dilated 4 to 7 cm, an early decel can occur while the uterus is contracting Placement of internal monitor probe can lead to fetal head compression Vaginal exam can cause it Applying external pressure on the laboring mother's abdomen is one mechanism that causes fundal pressure and fetal head compression which leads to an early decel. No nursing intervention required

Discomforts of pregnancy 2nd trimester

Changes associated with changes of an expanding uterus and blood volume. Supine hypotension if laying on back. Should lay on her side to remove pressure from the vena cava Food cravings. Should satisfy these cravings unless counterintuitive to nutritional rec. May experience heartburn (pyrosis). This occurs due to increased levels of progesterone. Progesterone decreases movement and digestion throughout the GI tract. In addition, with the growing uterus the stomach can be displaced upward delaying gastric emptying Constipation due to Gi motility slowing from increased progesterone levels and uterus compressing the GI tract. Moderate exercise can help Varicose veins are a common discomfort of pregnancy. This occurs due to the smooth muscle tissue relaxing due to increased hormone release that causes veins to dilate Best way to prevent varicose is to wear supportive hose and avoid sitting in the same position for a prolonged period of time. In addition, moderate exercise can aid in preventing them Increased levels of hormones cause the joints to relax, which decreases stability of the lower back and pelvis. This produces a painful or achy feeling in the back and pelvis Pelvic tilt exercises help stretch the pelvis and back to decrease achiness. Wear low heeled shoes and maintain good posture in order to decrease back ache Important to maintain a well balanced diet while satisfying cravings. Should avoid fatty/gas forming foods and should increase fluid intake to decrease constipation issues

Placenta Previa

Complication in which the placenta attaches to the lower uterine segment of the uterus, near or over the internal cervical os, instead of in the body or fundus of the uterus. The incidence of placenta previa is 1 in 300 Four classifications: total, partial, marginal, low lying Assessment Painless uterine bleeding Bright red vaginal bleeding usually near the end of the 2nd trimester or in the 3rd trimester of pregnancy occurs due to placental separation from the internal cervical os or lower uterine segment and the inability of the uterus to contract at the vessel sites. It can range from light to heavy bleeding and a vaginal exam is C/I as this can result in dislodgment of the placenta from maternal tissues Interventions Prolonging pregnancy and delaying delivery may be possible if stable and bleeding is minimal. this expectant or conservative management occurs when the fetus is premature (less than 36 weeks) to allow for fetal lung maturity. If indicated, corticosteroids may be given to facilitate fetal lung maturity Bed rest as walking can induce contractions. A side lying position is ideal as this reduces pressure of the uterus on the inferior vena cava and improves blood flow Close observation will be initiated to monitor blood loss, uterine tenderness, fetal activity, and VS. An external monitor may be put on but no vaginal or rectal exams are performed. Unstable fetus Excessive bleeding disrupts the uteroplacental blood flow resulting in deterioration of fetal status. A mature fetus should be prepared for immediate delivery C section is necessary in practically all women with placenta previa as the placenta is at the cervix and could lead to hemorrhage. Considerations Excessive bleeding places the mother at risk for hypovolemic shock. Monitor VS for increased pulse, RR and falling blood pressure every 5 to 15 minutes if active bleeding. Maintain IV access with a large bore IV for a blood transfusion if needed Tocolytic drugs such as mag sulfate are meds that slow down or inhibit labor. In some cases, these may be given to the mother to promote the time for expectant management of placenta previa

Prolapsed umbilical cord

Condition is when the umbilical cord comes out before the presenting part of the fetus, due to gravity washing the umbilical cord out with the amniotic fluid in front of the presenting part of the uterus. Most of the time it is visible after rupture of the membranes This can occur due to a long cord, breech, or transverse lie S/S If the cord is seen protruding from the vagina, immediate care of position changes need to be implemented so that fetus maintains adequate oxygenation and delivery Prolonged or variable decelerations can occur with a prolapsed cord. Variable are generally irregular, often jagged dips in the FHR while prolonged decel are longer dips in FHR. Considerations Important that mother be placed in modified Sim's position with the hips elevated as high as possible or in a knee chest position to remove any compression on the umbilical cord as soon as diagnosis is made If the cord is visible, insert 2 fingers in the vagina with one finger on either side of the cord to exert pressure so that compression is minimized and oxygenation to the fetus is maintained until emergency delivery If the cord is protruding, cover with a saline soaked towel until delivery. DO NOT try placing the cord back into the cervix Oxygen delivered by non rebreather mask at a rate of 8 to 10 L / min until delivery can be admind. This is done to make sure the fetus is getting adequate oxygenation from the mothers blood as blood flow may be impeded

patent ductus arteriosus

Congenital heart disorder where baby's ductus arteriosus fails to close after birth. This creates a continuous machine like murmur that is loudest at the S2 heart sound and if left uncorrected can lead to pulmonary HTN and Eisenmenger Syndrome Sounds like continuous clicking noises Common outcome of congenital Rubella infection but has improved due to vaccines closes later in preemies possibly related to the relative immaturity of the lungs

Developmental Dysplasia of the Hip

DDH is a disorder characterized by abnormal positioning of the femoral head in the acetabulum of the pelvis. In patients with severe degrees of DDH, the femoral head may be subluxed or completed dislocated. New Born assessment Barlow maneuver is a physical maneuver performed on infants used to screen for DDH. The dislocation will be palpable If Barlow is positive a clicking or clunk sound will be heard and felt with adduction of the thigh and outward hip pressure. The test is also performed with the infant in a supine position The Ortolani test is a physical maneuver performed on infants to screen for DDH and is typically done after the Barlow to reduce the dislocation If Ortolani test is positive, a clicking or clunk sound will be heard and felt with abduction of the thigh and upward hip pressure. Performed with the infant in the supine position Visual inspection of an infant with DDH will reveal shortening of the limb on the affected side and assymmetrical gluteal and thigh folds Older Child Trendelenberg sign is positive if the child's pelvis tilts downward on the unaffected side while balancing on the foot ipsilateral to the affected hip Intervention If diagnosed at 6 mos or earlier, can be corrected using an abduction device. The device must be worn for 24 hours a day until the condition is resolved and the hip is stable. Pavlik harness is the most commonly used abduction device. Skin care and monitoring for red areas under the straps and skin folds is important. No lotions or powders to the area and place the diaper under the straps After six months, a closed reduction will be performed to correct the condition

Cytamegalovirus

DNA virus that can cause congenital TORCH infection. Common manifestations are deafness, intrauterine growth retardation, periventricular calcifications, seizures, and petechial rash S/S Hepatosplenomegaly, jaundice, and thrombocytopenia Hearing loss is the most common sequelae following congenital CMV infection Microcephaly is more than two standard deviations smaller than average Seizures Calcifications Petechial rash that can resemble a blueberry muffin rash. Non blanching, blue red macules or dome shaped papules. Chorioretinitis is inflam. of the choroid and retina of the eye causing symptoms of floating black spots, blurry vision, and pain in the eye. Diagnosis Via detection of the virus in urine within the first three weeks of life because infants shed large amounts of the virus in the urine. Followup testing after 21 days confirms.

Prenatal Nutrition

Essential for a healthy pregnancy and fetus. Need for additional nutrients. Pregnant women should be educated as well as women planning to become pregnant Should take prenatal vitamins. Contain necessary levels of iron (30mg daily), vit D, Vit B6, vit C, potassium, zinc, and folic acid (600 mcg) which are essential for fetus development Foods rich in vit C will assist the absorption of iron. Monitor for ab discomfort and constipation. Iron needs to be taken on an empty stomach. Encourage a diet high in fiber Folate necessary due to increase in RBC production. Woman should consume 50% more folate while pregnant which is about 600 mcg per day. If planning on becoming pregnant, 400 mcg per day. Underweight women should gain 28-40 pounds Normal weight should gain 25-35 pounds Overweight should gain 15 to 25 pounds Obese should gain 11 to 20 pounds. During the first trimester there is no additional kcal intake recommended. The second and third require 340 kcal/day increase in intake. This is not a large amount of food. Typically one additional serving from dairy, fruit, vegetable, and bread. Guidelines recommend a 25 gram protein increase Avoid coffee, caffeine, alcohol, cigs, and excessive sugar intake Should also avoid fish that are high in mercury such as shark, sword fish, king mackerel, and tilefish and should limit intake to six ounces per week. Up to 12 ounces per week of the following fish can be consumed: shrimp, salmon, pollock, catfish, canned light tuna (limit albacore or white tuna to six ounces)

Prenatal care

Essential for identifying potential and existing risk factors for the pregnancy. Prenatal visits assists the woman in practicing a healthy lifestyle and optimal self management to prevent problems from developing Prenatal visits should occur soon after the first missed menstrual period. Schedule: first visit within the first 12 weeks, monthly visits for weeks 16 through 28, twice a month for weeks 29 to 36 and weekly visits week 36 til birth. During each visit several physical parameters are measured while late in the last month of pregnancy, vaginal exams are performed to determine effacement and dilation Important to monitor mother to make sure heart or lungs are not becoming distressed. Listening to the fetal heart rate is important to determine the fetus is continuing to thrive Fundal height is essential in determining fetal growth. Between weeks 18 to 32 the fundal height usually matches the total weeks in centimeters. A urine dipstick should be done to test for proteinuria, ketonuria, and glucose in the urine. This is helpful in determining whether the pregnant woman is experiencing any capillary leaking of protein or gestational diabetes Lab tests done at prenatal visits include hemoglobin, hematocrit, and white blood cell count, blood type and Rh, rubella titer, urinalysis, urine culture, renal function tests, Pap test, std testing, and glucose levels. Tb skin testing is admin'd to determine exposure to Tb

Fetal Circulation

Fetal blood circ is very different from infant circ. and relies on the placenta for oxygenated blood. it undergoes shunting to provide adequate perfusion as the lungs are non functioning The placenta is an organ that connects the fetus to the uterine wall allowing uptake of nutrients as well as gas exchange. Blood leaving the placenta travels through the umbilical vein. It typically has a po2 of 30, making it roughly 80% saturated with 02 Though veins typically carry deox. blood, in fetal circ, this is not true. Via the placenta, the umbilical vein carries oxygenated blood to fetal tissues The ductus venosus is a shunt, allowing oxygenated blood in the umbilical vein to bypass hepatic circ and be conducted into the inferior vena cava In the right atrium deox blood from the SVC and mixed 02 blood from the IVC (and umbilical vein via ductus venosus) are pumped. At this point, blood goes through either the foramen ovale or the right ventricle and ductus arteriosus After the right atrium, most oxygenated blood is pumped through the foramen ovale, a shunt between the right and left atria. This shunt allows right heart blood to bypass pulmonary circ. and flow into the left heart. After passing through the foramen ovale, blood goes into the LA. The foramen ovale is a flap and allows blood flow only one way, thus, when the left atrium contracts the foramen closes and blood can only flow through the mitral valve into the LV Blood which has been shunted to the left heart goes through normal circ. After passing through the foramen ovale, LA and LV, the blood goes through the aorta and perfuses various tissues and organs throughout the body Deox. blood enters the RA through the superior vena cava (SVC) and is pumped into the RV from the RA Coming from the RV, blood would typically flow into the pulmonary circ. This is not the case for the fetus and the deox blood in the right heart is conducted back into circulatory flow via the ductus arteriosus. This is a shunt connecting the pulmonary artery to the aortic arch The umbilical arteries are the anterior branches of the internal iliac arteries. These arteries carry blood from the descending aorta back to the placenta for gas exchange

Postpartum Nursing Assessment

Following pregnancy woman is at risk for infection, hemorrhage, DVT. Remember key points of postpartum assessment with acronym BUBBLE-LE, which stands for breasts, uterus, bladder, bowels, episiotomy, lower extremities, and emotions Breasts First form of breast milk produced is colostrum which contains high levels of bioactive compounds like immunoglobulins and growth factor. As the milk matures, usually within 3 to 4 days, the breasts may become heavier and fuller and feel nodular and firm. The breasts should be assessed for signs of infection (mastitis), such as pain, redness, warmth Uterus Uterus must remain firm and contracting in order to prevent hemorrhage. If the uterus feels boggy it should be massaged. If the uterus becomes deviated to one side, it may indicate bladder distention Bladder Woman may experience difficulty voiding resulting in a distended bladder. If distended the woman is at a higher risk for hemorrhage because the distended bladder applies pressure on the uterus Bowels May take 2 or 3 days for the woman to have a BM due to pain, lack of food, dehydration, and soreness from lacerations or hemorrhoids. A stool softener may be given to the woman in order to aid in easier passage of the BM Lochia Should be assessed for color, amount, and odor. Too much may indicate hemorrhage. Foul smelling may indicate infection. Lochia is usually bright red and contains small clots after birth. Normal shedding of blood and decidua is referred to as lochia rubra (red/red-brown) and lasts for the first few days following delivery. Between day 3 to 4 the lochia becomes more pink brown color and contains serum, leukocytes, tissue debris, and old blood and is called lochia serosa. Around ten days post birth, the lochia becomes yellow /white and contains mainly leukocytes. This is referred to as lochia alba. Lochia will last 4 to 8 weeks postpartum If the woman had an episiotomy, the nurse should assess for redness, edema, ecchymosis, discharge, and approximation Lower Extrem's Must be assessed for DVT. This can be done by looking for redness, warmth, and edema. DVT could lead to pulmonary embolism which presents with tachycardia and SOB. The mother is at risk for developing DVT due to increased clotting factors from birth and lying in bed Emotions Hormone fluctuations and the birth experience can cause many new and strong emotions. Look out for post partum blues

Severe preeclampsia

HTN and proteinuria that develops in pregnant women around 20 weeks of gestation. In these women, the arteries and vessels in the uterus do not widen to compensate for increased blood flow and constricted vessels result in severe HTN. The three contributors are vasospasm and decreased organ perfusion, intravascular coagulation, and increased permeability and capillary leakage. HELLP from earlier When the vessels spasm they constrict which results in increased BP. HTN and decreased perfusion into the tissues. Can result in kidney, liver, and brain damage. Intravascular coag. As a result of increased pressures and liver dysfunction, the red blood cells become hemolyzed and platelets adhere to tissue walls. Have low platelet count which may lead to DIC As pressure increases, damage occurs allowing for capillary leakage to occur which cause proteinuria, generalized edema, and pulmonary edema S/S HTN 160/110 is severe

Pregnant Cardiac Patient Assessment

In a normal woman, the CV system undergoes many changes. These changes include increased intravascular volume, increase in oxygen requirements, decreased systemic vascular resistance, weight gain, and the hemodynamic changes that take place during labor. A woman with preexisting issues has a hard time coping with these changes and may progress to cardiac decompensation and heart failure. Under the added stress, the heart is unable to maintain adequate cardiac output. When decompensation starts, she may experience a frequent cough, feeling of smothering, palpitations, excessive fatigue, tachycardia, and crackles. The highest incidence of problems occur during 28 to 32 weeks as the blood volume expands Heart is not able to pump enough blood to meet the demands of the body Fluid backs up into the lungs resulting in increased sensation to cough Dyspnea, orthopnea, rapid respirations (over 25) and cyanosis of lips and nailbeds characterize decomp. When the pregnant women complains of smothering feeling, this often characterizes an early symptom of pulmonary edema. The health care provider should be alerted. Heart is racing trying to keep up As cardiac output decreases and the heart is no longer able to supply blood the woman may feel fatigued. Pulse over 100 Crackles in the base on the lungs due to fluid buildup Txt is focused on minimizing stress on the heart. The focus of management during labor and birth is on promoting cardiac function and decreasing anxiety. Prenatal Assess edema, HR, and feeling of palpitations, BP, CO, weight gain, increasing fatigue, frequent cough and crackles in the lungs A stool softener may be used to prevent straining during defecation and producing a Valsalva maneuver. This straining, when released, caused a fast influx of blood into the heart which will overload the pregnant woman's heart. Calcium channel blockers may help heart work more efficiently by decreasing workload. But must watch for HPN as a result. HPN will result in decreased bloodflow to the fetus Labor Placed on ECG monitor to assess for tachycardia and for irreg. rhythms that may signify stress and work of the heart The patient should avoid the Valsalva maneuver during pushing which is essentially pushing while holding your breath. This is because it reduced diastolic ventricular filling and obstructs left ventricular flow. Instead open glottis pushing should be used which is pushing while expelling air through the mouth simultaneously A pulmonary artery cath may be inserted into the woman to monitor pressures and assess for any hemodynamic changes SHOULD NOT BE ADMIND beta adrenergic agents such as terbutaline as these may result in a further increased heart rate and irreg. as well as pulmonary edema and MI Placed on prophylaxis penicillin to prevent bacterial endocarditis. Labor increases the chances of infection and this could add extra stress on the heart Postpartum After birth, CO rapidly increases due to fluid quickly returning to the vasculature and decrease in abdominal pressure. This causes increased stress on the heart and can quickly lead to cardiac decompensation. Position the woman with the head of the bed elevated and rotate to her side to decrease stress on the heart

Post partum infection

Infection in the genital canal or breast at any time after 28 days of delivery, miscarriage, or abortion are considered post partum or puerperal infection. These infections are typically normal vaginal flora that are able to penetrate into the tissue or bloodstream during childbirth. The most common infection is endometritis followed by wound infections at the C section incision site or episiotomy, UTIs and mastitis Diag. Temp over 100.4 on 2 or more successive days within the first 10 days postpartum. RF Number of vaginal exams should be limited Minor tears in the vaginal wall often occur during delivery allowing bacteria entry into the body. Can also happen with instruments like forceps or vacuum suction Prolonged Rupture of Membranes (PROM) is an extended period of time following amniotic sac rupture without delivery usually greater than 24 hours. This rupture allows pathogens to enter the uterus and places the mother and infant at higher risk of infections, respiratory distress, and sepsis Proper wound care of C section Anemia of Pregnancy causes a decrease in the number of circulating oxygenated blood cells. After delivery, the placenta is examined for completeness. Fragments that remain in the uterus pose the risk for infection as they deteriorate inside the uterus after the delivery Poor health issues like diabetes, obesity, cardiac disease, general poor nutrition

chorioamnionitis

Infection of the amniotic fluid because of premature rupture of the membranes, amniocentesis, intrauterine procedures or vaginitis. S/S Fever, tachycardia, for both mother and fetus, amniotic fluid with foul odor, leukocytosis and uterine tenderness and contractions After obtaining amniotic fluid cultures, treat with prescribed abx to fight the infection Monitor uterine tenderness, contractions and fetal activity. Also monitor VS of mother and FHR

Pregnant Diabetic Interventions

May already have diabetes before pregnancy or gestational diabetes. Women with GDM may or may not have to take insulin. Most women with pregestational diabetes are insulin dependent during pregnancy 1st trimester 3-7 weeks insulin requirements will increase 7 to 15 insulin req. will dwindle An oral hypoglycemic agent such as glyburide is usually prefered over insulin in management of GDM because only small amounts cross the placenta Diabetic diet from dietician Exercise 2nd trimester In the 2nd and third insulin needs to increase exponentially due to the development of insulin resistance Episodes of hypo can develop rapidly and should be treated with oral intake of carbs or glucagon injection if unable to swallow 3rd trimester Insulin requirements can double or even quadruple. The significant increase requires close monitoring and frequent blood sugar assessment Women with diabetes may go into early labor due to extra stress on the mother and the fetus. These stresses include HTN, poor metabolic control, or uteroplacental insufficiency causing fetal growth restriction Postpartum After birth, insulin req decrease significantly and may normalize vey quickly due to decrease in stress, insulin insuff. and glucose in the body. In addition, the formation of milk uses up a higher amount of carbs in the body causing maternal glucose levels to be lower The neonate must be monitored for hypo after birth as the fetus will have decreased sugar levels once outside the mother. The fetus' pancreas may have been increasing insulin production to cover the excess sugar received from the mother while in the utero. After birth there is not excess sugar coming from the mother. Remember, sugar passes through the placenta, not insulin

Hydaditiform mole

Molar pregnancy. is gestational trophoblastic disease. Women with this condition will experience presumptive signs of pregnancy including amenorrhea, n/V, and breast tenderness. Although not a viable pregnancy, hCG will be elevated, producing a positive pregnancy test. Inappropriate uterine growth and vaginal bleeding are also common. It is important to remember that fetal heart tones will not be heard during the ultrasound D and C must be performed to remove all molar tissue from the uterus, as any remaining tissue may become malignant. Pregnancy is discouraged for one year after a molar pregnancy is diagnosed. During this period of time, hCG levels are closely monitored. If they remain high after removal, the patient may need to undergo a hysterectomy or receive chemo Occurs when there is abnormal fertilization of the ovum. Sperm may fertilize an ovum with no genetic material or two sperm may fertilize a single ovum resulting in too much genetic material. Assessment May exhibit presumptive signs of pregnancy Elevated hCG Minimal vaginal bleeding may occur. the bleeding is brown/dark red in color and is described as grape like clusters Inappropriate uterine growth No fetal heart tones

Lab and Diag Tests During Pregnancy

Most of these tests are completed during the initial prenatal visit and then repeated at other times if warranted. Completing these tests at the first visit focuses to minimize the risks to the fetus and establish a baseline of lab values thru pregnancy. It also identifies high risk pregnancies and those that may need advanced testing or monitoring. CBC Rubella is a TORCH infection that is especially dangerous to the fetus during the first trimester. No maternal treatment is available if contracted and therapeutic abortion may be offered to the patient. For this reason a titer level to detect the number of circulating antibodies is completed and vaccination boosters are given if indicated. Screening for Hep B antibodies at first visit is indicated as this is the most damaging virus to the developing fetus. HBV exposure is treated by giving the mother hep immune globulin. Mothers who have not been immunized may also begin the 3 vaccine series HIV testing for possible transmission. Also screened for chlamydia, gonorrhea, and syphilis Urine is screened for ketones, glucose, protein, bacteria, and casts. Establish baseline to allow for early detection of metabolic abnormalities or gestational diabetes Pap Smears are completed to identify possible cervical cancer and cell changes, STI's and inflammation or malformation of the cervix

Neonatal Respiratory Distress syndrome

NRDS is a condition related to fetal lung immaturity in premature infants (less than 37 weeks gestational age) and a lack of surfactant. Infants with NDS will S/S respiratory distress including tachypnea, nasal flaring, intercostal/substernal retractions, and audible grunting upon expiration. Interventions include admin of exogenous surfactant, oxygen therapy, and mechanical ventilation. SHOULD NOT receive bottle or gavage feedings as they may increase respiratory rate and risk of aspiration. INSTEAD total parenteral nutrition is used to provide the infant with adequate nutrition Respiratory system is one of the last organs to fully develop. Immature infants are unable to fully oxygenate their bodies. Preemies before 37 weeks are at increased risk. Can also be caused by sepsis, heart defects... Most commonly caused by lack of surfactant in the infants lungs. Surfactant is a substance that reduces surface tension in the alveoli of the lungs and helps to prevent alveolar collapse. The more premature the newborn, higher chance of NRDS Assess Tachypneic, RR 80 to 120 per min. May be pale or cyanotic Nasal flaring Grunting, but once grunting starts, constant positive airway pressure is the only way to improve respiratory status Interventions Surfactant can be used as a rescue treatment for infants in respiratory distress. Prophylactic admin of surfactant at risk gives more positive result. Surfactant is given via endotracheal tube into the trachea Oxygen may be initiated to prevent lactic acidosis related to hypoxia. Oxygen must be warmed and humidified when admind to infants. usually delivered via nasal cannula or nasal prongs with CPAP Mechanical ventilation may be indicated if the infants PaCO2 levels begins to rise, and the neonate is unable to maintain an adequate oxygen saturation by means of oxygen therapy via nasal cannula. Suction only as needed TPN to provide nutrition Oral hygiene is especially important for infants who are NPO. Oral care using sterile water or breast milk is recommended.

Discomforts of first trimester

Physiological changes in breast, urinary, and reproductive organs leads to discomfort. Breast tenderness because tissue develops increased vasculature and hypertrophies which increases the size and sensitivity of the breast Wear a supportive bra for this N/V occur in 50 to 75 percent of pregnant women. Theories suggest that morning sickness may be caused by hormonal changes, increased hCG levels, or may be linked to emotional changes Eat dry carbs, such as crackers and should practice eating small carbs upon awakening in the morning Increased urinary frequency and urgency Practice emptying the bladder frequently. perform kegel exercises, decrease fluid intake before bed, and notify provider if experience pain or burning upon urination Leukorrhea is possible which is defined as increased vaginal mucus discharge. This is due to cervix becoming more hyperactive and hypertrophying. Should wear a perineal pad and practice good perineal hygiene. DOUCHING IS NOT REC'D for preggers May experience increased salivation (ptyalism) which is due to increased estrogen levels or avoidance of swallowing due to nausea. Rec to use mouthwash, chew gum, or eat hard candy to decrease salivation

Abruptio Placentae

Placenta prematurely separates from the uterine wall after the 20th week and before fetus is delivered. 3 grades mid grade (less than 15% placenta separates with concealed hemorrhage moderate grade2 (up to 50% placenta separates with apparent hemorrhage severe grade 3 (greater than 50% placenta separates with concealed hemorrhage Assessment A severe sudden onset of ab pain occurs Dark red vaginal bleeding may be present however if the separation is in the center of the placenta, then blood may be trapped bewteen the placenta and the decidua concealing the hemorrhage. A concealed hemorrhage occurs in about ten percent of patients with resulting uterine tenderness and pain A rigid uterus or board like abdomen may be noted. Other patients may have uterine tenderness accompanied with pain Freq. uterine contractions or ones with no relaxation in between may occur. Hypertonic uterine activity will lead to poor blood and oxygen exchange for the fetus Interventions Preparing for delivery ASAP. Vaginal delivery is preferred if the fetus is healthy and stable and if the presenting part is in the pelvis Considerations Increased risk of preterm birth, intrauterine growth restriction, hypoxia, anoxia, neuro injury, and fetal death related to hemorrhage Rhogam may be given Excessive bleeding can lead to shock. Note that during pregnancy signs of shock may not be present until 25 to 30 percent of maternal blood loss has occurred. Closely monitor VS, maintain IV access with a large bore IV, and provide fluids, blood products, and oxygen as prescribed Monitor FHR as signs of possible decline include prolonged fetal bradycardia, repetitive late decels or decreased short term variability

Quad Screen Results interpretation

Quad screen views inhibin A, hCG, AFP, and estriol levels to assess the fetus' risk of chromosomal abnormality. AFP Alpha fetoprotein is found in both fetal serum and also amniotic fluid. Produced early in gestation by the fetal yolk sac and then later in the liver and GI tract. This value is then combined with other markers as well as the mother's age and family history to assess for abnormality Estriol Only produced in signif. amounts during pregnancy as it is made by the placenta. If levels are low this may indicate chromosomal or congenital anomalies like Downs or Edward syndrome hCG hormone produced by a portion of the placenta following implantation. Used to detect pregnancy, and diagnose and monitor germ cell tumors as well as gestationaly trophoblastic diseases. Inhibin A produced in the gonads, pituitary gland, placenta, corpus luteum and other organs. Plays a role in regulating FSH but when combined with other serological markers, it is useful in screening for fetal disorders and aneuploidies Aneuploidies Downs Low AFP, Low estriol, high hCG and high iA Turners Syndrome Decreased AFP, decreased estriol, very high hCG, very high iA Edward Syndrome Low hCG, low estriol, low AFP, normal iA Patau Syndrome All are normal?

Breast feeding

Recommend for the first 6 months of a newborns life. Benefits Complete nutrition, contains the appropriate combo of protein, carbs, and fats as well as vitamins and minerals that are vital for a thriving infant Many immune benefits. The mother's colostrum is packed with important maternal antibodies that have shown to protect against diseases such as bacterial meningitis, diarrhea, bacter... Provides significant bonding time and promotes attachment early on Convenient SIDS risk reduced. Aids in promotion of brain development, airway protection, and SIDS protection Great for the nervous system Less chance of getting childhood cancers, HTN, dental caries, T1 Diabetes, eczema, asthma, and allergies

Toxoplasma gondii

S/S Crosses the placenta Mothers are usually asymptomatic. Can have swelling of the lymph nodes Intrauterine growth retardation Hepatosplenomegaly Deafness Chorioretinitis Hydrocephalus which is abnormal accum. of CSF in the brain that can cause increased pressure inside the skull. Diag With congenital toxoplasmosis, infants have scattered calcification in the white matter, basal ganglia, and cortex

Syphilis TORCH

S/S Nonspecific signs include hepatosplenomegaly, jaundice, and thrombocytopenia Still birth often which refers to death of a fetus inside the uterus Hydrops fetalis is char. by abnormal accumulation of fluid in two or more areas of the body of a fetus or newborn. Bone deformities of the shin are common in the tibia. Saber shins are char. by a sharp anterior bowing of the tibia Notched teeth are smaller and more widely spaced. AKA Hutchinsons teeth Saddle nose refers to the collapse of the bridge of the nose Blindness from inflammation of the cornea which leads to corneal scarring Deafness Inflammation of the liver

Rubella TORCH

S/S Patent Ductus Arteriosus where ductus arteriosus fails to close after birth. Pulmonary artery hypoplasia is underdevelopment or incomplete development of the pulmonary artery and can be a neonatal manifestation of congenital rubella infection Cataracts Deafness Blueberry muffin rash Glaucoma which is increased pressure in the eye which can lead to damage of the optic nerve and visual field loss.

Post natal circ

Several changes that occur in the circ. system immediately after birth. Begin to change as the infant begins to breathe and umbilical blood flow with the placenta is interrupted. Immediately after birth, the infant begins to breathe and cry, leading to lung expansion. it is for this reason mucous/fluid is suctioned from the oral cavity at birth in order to prevent aspiration As the lungs expand with inhaled air, pulmonary vascular pressure decreases. This allows more blood flow to the lungs to promote gas exchange. As pulmonary vascular pressure decreases the right heart is no longer pumping against a high pressure system. Thus, right heart pressure is decreased compared to left heart As right heart pressure decreases, a disparity in right vs. left heart pressure is created. The left atrial pressure is now of higher pressure than the right. Because of this, there is no longer a gradient for blood to pass into the left heart through the foramen ovale as it used to in the fetus. An increase in atrial pressure leads to increased pressure in the LA vs the right halting the right to left atrial shunting which occurred in the fetus. This forces the septum primum against the septum secundum, functionally closing the foramen ovale. In time the septa eventually fuse, leaving a remnant of the foramen ovale, the fossa ovalis. Inhalation leads to increased oxygen content in left sided cardiac vessels. As the infant is now capable of creating its own oxygen supply, flow from the ductus arteriosus is no longer paramount for supplying the aorta with oxygenated blood. Furthermore, vasoconstriction is induced as higher arterial oxygen content releases endothelin, a local vasoconstrictor The placenta produces prostaglandins, which maintain prenatal patency of the ductus and, in early gestation, inhibit the ability of the ductus to contract in response to oxygen. The ductus arteriosus itself produces prostaglandins and nitric oxide like vasodilators. Removal of the placental prostaglandin and a decrease in the number from the ductal wall occurs. during the postnatal period, final closure of the ductus arteriosus results from increased production of local vasoconstrictors (like endothelin) in response to higher arterial oxygen and decreased prostaglandins. Prostaglandins are often useed in patients with congenital heart defects. In severe situations, the ductus arteriosus in the only way for the fetus to oxygenate tissues postnatally Indomethacin is an inhibitor of prostaglandin synthesis and is used to close a clinically significant PDA

True vs False Labor

Several factors in true labor such as changes in the cervix, uterus pituitary glands, and hormones. All of these changes induce regular contractions, a bloody show, progressive effacement and dilation and engagement of the presenting part. The outcome of true labor is birth of the fetus When true labor occurs, the cervix becomes softened and dilated and effacement occurs. this process is evident by a bloody show which is the expulsion of cervical mucus that is pinkish in color. This typically occurs during true labor however can sometimes occur in false labor if early cervical changes have occurred. True Labor Regular strong contractions will last for a longer period of time and occur closer together. Strong contractions will occur with increased intensity when walking. Felt in the lower back and radiate to the lower abdomen. Regular strong contractions occur as a result of increased levels of estrogen and prostaglandin and a decrease in progesterone. Effacement refers to the thinning and shortening of the cervix. Dilation results in the widening of the cervix. In true labor, effacement and dilation will occur in order to allow for the fetus to pass through the birth canal Engagement of the presenting part refers to the head of the fetus passing and engaging with the pelvis inlet. Generally, this occurs before the onset of active labor False Labor Contractions occur at irregular intervals and often stop when the pregnant woman changes position or walks. Irreg. are felt in the abdomen above the umbilicus or in the back Cervix may be soft but there is no apparent dilation or effacement No engagement of baby.

Probable signs of pregnancy

Signs that the examiner can observe. Include Goodell sign, Chadwick sign, Hegar sign, positive serum and urine samples. Braxton hicks contractions and ballottement. Observation of these signs mean woman is most likely pregnant Goodell: around the sixth week the cervix softens and appears velvety Chadwick: cervix should become bluish violet color. Typically occurs around 6 to 8 weeks Hegar: around 6 weeks due to hormonal effect which causes a softening of the lower uterus/cervical isthmus. Prior to more modern urine and blood tests, Hegars would be appreciated by inserting two fingers of one hand into the vagina to palpate the lower uterine segment while applying manual pressure externally to the abdomen Serum and urine tests ID whether the human chorionic gonadotropin is present in the samples. If positive, probable sign of baby Braxton Hicks occurs around 4 months gestation Around 16 to 18 week the fetus can be palpated by pressing a finger into the vagina and tapping gently. This action causes the fetus to move upward and then move back downward to tap on the finger. This is known as ballottement

Positive Signs of pregnancy

Signs that the fetus emits. Observing the fetus on ultrasound or x ray, auscultating the fetal heart rate, and observing fetal movements By 5 to 6 weeks fetus is able to be viewed by ultrasound and fetal heart rate is heard by six weeks. By 8 to 17 weeks it is possible to hear the fetal heart rate. It can be heard using a Doppler ultrasound stethoscope or a fetoscope. By 16 weeks fetus can be observed with a fetal x ray. Fetal movements can be palpated and visualized after 19 weeks.

Presumptive signs of pregnancy

Subjective signs of pregnancy and signs and symptoms that the mom can perceive that resemble pregnancy S/S. Allude to possible pregnancy but should be further investigated Absence of menstruation is the most obvious and required sign. Could also be caused by early menopause, malnutrition, anorexia, endocrine imbalance, anemia, diabetes, or meds. Athletes may also have this at about 12 weeks feelings of fatigue or generalized weakness 6 to 12 weeks urinary frequency. Due to developing fetus causing increased pressure on the bladder N/V but could just be GI distress Increased size and fullness of breasts and tenderness or pronounced nipples around six weeks. This can also happen during menstruation Quickening is when the woman starts to feel or perceive fetal movement in the uterus. Usually happens around16 to 20 weeks. This can also just be gas or peristalsis

Follicular phase

The follicular phase describes balance between FSH, estrogen, LH, and ovulation. The first phase of menstrual cycle. Roughly 14 days on average but can vary. Ends at ovulation. After this, the luteal cycle begins F phase begins with hypothalamic secretion of GnRH which stimulates secretion of FSH and LH As FSH increases, it induces follicle recruitment and folliculogenesis and growth of granulosa cells. Soon, these cells begin to grow and express LH receptors which then secrete Estrogen Estrogen is initially low and work via negative feedback to inhibit GnRH, and subsequently FSH and LH release from the anterior pituitary At high enough estrogen levels, the negative feedback is turned off and switched to positive feedback. This causes a sudden increase in FSH and LH production. All the while, the growing size of the primary follicle leads to steadily increasing estrogen. This leads to a surge in LH Estrogen continues to rise, due to stimulus from increasing follicle size, along with increased activity at LH receptors on the follicles The event leading to ovulation is the LH spike.

Imperforate anus

There are a number of anorectal malformations which range from simple imperforate anus (no anal opening) to problems with the genitourinary and pelvic organs, causing issues with fecal, urinary, and sexual function. Sometimes anal hole is absent, in the incorrect location, opening into another cavity such as the vagina. Immediate surgical intervention is required but is different based on the problem at hand. The cause is a random malformation of the developing fetus' gut tube which happens in 1/5000 live births. There is no known cause and it does not run in the family. S/S No anal opening. Some neonates may have a urinary fistula and are often started on broad spectrum abx Wont have first stool in the first 24 hours. Closely watch for meconium in their urine as fistulas may be present As they are unable to stool, their abdom girth will increase. Surgical intervention is required to pass stool Surgical intervention includes anoplasty, colostomy, PSARP, or other pull-through abdominal surgeries. Takes several surgeries. Long term complications like incontinence or constipation

Torches screening

Toxoplasmosis, Other (gonorrhea, hep B, varicella zoster, parvovirus B19, HIV) Rubella, cytomegalovirus, herpes simplex virus, and Syphilis. The pathogen spreads from the infected mother to the infant in utero causing a variety of congenital anomalies depending on the infection Toxoplasmosis Protozoal infection often transmitted with cat feces. Findings can include hydrocephalus and chorioretinitis Rubella German measles. An infant with congenital rubella can present with a blueberry muffin rash, glaucoma, and pulmonary artery hypoplasia. The mother may have rash, low grade fever, cold like symptoms and swollen glands Cytomegalovirus Can lead to miscarriage or stillbirth. Newborns may be lethargic, have hypotonia, microcephaly, and experience seizures Herpes Most commonly transmitted during delivery. Can present with a range of findings including a vesicular rash, mucosal involvement, seizures, and sepsis Syphilis Can present with deformities to the nose and legs, including a saddle nose and saber legs, as well as blindness or deafness later in life Diagnostic testing is important when TORCHES infection is suspected. Most mothers are screened for rubella and syphilis during the first trimester.

Deceleration and Acceleration Overview

Variations in FHR identified based on their correlation to the uterine contractions are further classified as periodic while the independent ones are termed episodic Variable goes with cord compression Early goes with head compression Acceleration is to okay Late is for placental insufficiency Variable decel. is char. by an abrupt decrease in FHR below the baseline with the onset to lowest point less than 30 seconds. They can occur any time during the contraction cycle and last at least 15 seconds. They happen in about half of all labors and are usually transient and correctable. They have a characteristic U, V, or W shape on the fetal monitor and are noted by their rapid descent and ascent Variable decel. can occur at any time during uterine contractions and are caused by compression of the umbilical cord of ten because of an abnormal cord position. The cord can get wrapped around the neck, chest, arm, or leg. When the cord is between the fetus and maternal pelvis, it can lead to compression Early decel. is ID'd as a gradual decrease in FHR with return to baseline associated with a contraction. Most commonly associated with compression the fetal head and is often considered a normal finding with no intervention required other than continued monitoring Head compression, especially during uterine contraction, is the most common cause of an early decel. that occurs during labor as the fetal head advances in the birth canal. This compression can be correlated to uterine contractions, vaginal exams, applying pressure to the fundus, and the placement of internal monitoring instruments Increase in FHR of at least 15 bpm above baseline that start and peak within 30 seconds but not less than 15 seconds are terms accel. They should subside within 2 minutes. Accel's are common and are associated typically with any direct or indirect fetal movement. Accel are used as an indicator of fetal well being Late decel. is a gradual decrease and return to baseline FHR during the contraction with the lowest point occuring after the peak of the contraction. It does not return to the FHR baseline until after the contraction is over. They correspond with placental insufficiency When there is insufficient oxygenation between the placenta and the fetus, uteroplacental insufficiency occurs and causes late decels. This can occur due to conditions such as uterine tachysystole, which happens when there are more than 5 contractions in ten minutes. Frequent contractions do not allow sufficient recovery and adequate oxygen exchange in the placenta. Other conditions are maternal supine hypotension, placental previa, hypertensive disorders, diabetes mellitus...

Eclampsia

When severe preeclampsia progresses further, the pregnant woman can develop eclampsia. E is characterized by seizure activity or coma. Seizure activity can begin before, during, or after birth. Occurs due to neurologic complications related to PE. THis leads to the CNS becoming irritated as a result of vasospasm and decreased organ perfusion. Causes cortical brain spasm that results in headaches, hyperreflexia, seizures, and progression of E S/S Reflexes hyperexaggerated Ankle may display rapid muscular contraction and relaxation appearing as a rhythmic tremor Severe headache due to increased pressures in the vessels in the brain Visual disturbances asa result of retinal arteriolar spasm that develops due to progression of HTN and vasospasm that occurs in severe Epigastric or RUQ pain is ominous sign and the woman usually complains of this pain before a seizure. Harbinger of seizure and represent worsening hepatopathy from PE Coma possible Considerations Imperative that in this obstretric emergency to call for help and not leave the patient alone Mag Sulfate is given to control seizues in the woman. Calcium gluconate should be available for an antidote. Monitor for respiratory depression

Newborn assessment

Within 2 hours after delivery Umbilical cord determines fetal circulation during pregnancy. After the cord is cut and clamped a blood sample is collected into a specimen tube for further assessment. Newborn cord blood determines the bilirubin levels, blood gases, blood sugar levels, blood type, CBC, and platelet count. After cord is cut assess the stump for two arteries and one vein. To protect newborn from bacterial infections during delivery, newborn eye prophylaxis is admind within one hour of birth. Eye drops or an ointment containing antibiotic meds is applied to the eyes. erythromycin is commonly used. Fontanels are soft membranous gaps between the cranial bones of infants. Since the brain expands faster than the surrounding bone can grow, fontanels allow the brain to expand. Clinical assessment of the fontanel can assist in determining hydration status as a sunken fontanel in addition to sunken eyes or lethargy can lead to dehydration. The diamond shaped anterior fontanel closes by 18 months while the triangle shaped posterior fontanel closes between 2 to 4 months Vitamin K is necessary for proper blood clotting. Since newborns are unable to synthesize vitamin K until a few weeks after birth, they are at increased risk of bleeding. Phytonadione is a form of Vit K admind to infants within 1 hour of birth. The med is admind as an IM injection of 0.5 to 1.0 mg. Gestational age assessment Assess of gestational age and birth weight help determine if the newborn is appropriate for gestational age (AGA), small for gestational age (SGA), or large for gestational age (LGA). The New Ballard Score is used to measure maturity and focuses on neuromuscular maturity (posture, square window (wrist), arm recoil... Measurements Average weight of a newborn infants ranges from 5 pounds 8 ounces to 8 pounds 13 ounces. Newborns lose between 5 to 10 % of their birth weight shortly after birth as they lose fluid and pass meconium. Expect the newborn to regain the weight within ten days of birth Head circumference average is bewteen 33-35.5 cm (13-14 inches). Head circ. is usually 2 cm larger than chest circumference Average body length is bewtewn 45-53 cm (19-21 in) long Considerations Newborns lack the fat stores to maintain thermoregulation. After delivery keeping him warm is critical in preventing cold stress leading to complications. Immediately after delivery, the infant may be placed on the mother's abdomen and covered with a warm dry blanket. May also be placed in a pre warmed crib or radiant warmer to maintain temp. To prevent heat loss, infants head is covered with a cap Shortly after delivery, matching ID bracelets are placed on the infant and parents to maintain and prevent abduction. Placed on ankle. In addition, footprints or ID photos are taken shortly after birth

Ectopic Pregnancy

any pregnancy where the gestational sac is implanted outside the uterine cavity. They are also called tubal pregnancies because the majority of them occur in the fallopian tube. The gestational sac can implant in the ovary or abdominal cavity S/S Lower quadrant pain can occur due to the fertilized egg developing within the confined space of the fallopian tube. This can be very painful experience and can cause sharp stabbing pains when the tube stretches Can cause decreased menstruation or hypomenorrhea as a result of the formation of uterine adhesions and scar tissue and may be a sign of injury within the fallopian tubes One major complication is miscarriage because the egg is not able to develop appropriately within the tube. Vaginal bleeding can also occur as a result of damage to the tissue that is endured during an ectopic pregnancy If the tubal pregnancy ruptures, risk for hemorrhage. Monitor BP, HR, and oxygen saturation very closely When the fertilized egg grows too big for the fallopian tube to handle, the tube can rupture. This produces abdominal pain and often referred shoulder pain Cullen Sign In the event of this, the pregnant womans belly button may display an ecchymotic-bluish color. This is referred to as Cullen sign and is indicative of blood within the peritoneum. When this sign is present, it means that the tubal pregnancy has ruptured Considerations May be given methotrexate to dissolve the pregnancy as the tube will not be able to grow the baby. Only if ectopic pregnancy has not ruptured yet Surgery to remove the ectopic pregnancy may be rec.d in order to prevent rupturing of the tube. If the woman wants to maintain fertility for the future, the surgeon can make a small incision on the tube to remove the fertilized egg, this is referred to as a salpingostomy Rhogam may be needed

Variable Decel

characterized by an abrupt decrease in FHR below the baseline with the onset to lowest point less than 30 seconds. They can occur any time during the contraction cycle and last at least 15 seconds. They happen in about half of all labors and are usually transient and correctable. They have a characteristic UV or W shape on the fetal monitor and are noted by their rapid descent and ascent from the lowest point of the decel. Caused by compression of the umbilical cord Also a short cord, knot in the cord, or a prolapsed cord can lead to this Commonly occur during the transition phase of labor as the fetus descends into the birth canal which causes stretching of the umbilical cord and some compression Interventions Provide oxygen by nonrebreather face mask to the mother to alleviate the shortage of oxygen to the placenta and fetus. Change mother position from side to side to see what relieves it. Place in knee chest position for prolapsed cord Whenever there is a non reassuring fetal heart rate and pattern, DC oxytocin because it will stop the stimulation of the uterus and slow down the contractions

Rhogam

contains Rh antibodies that is an injection admind within 72 hours after birth to prevent sensitization in the Rh negative woman who has a fetal-maternal transfusion of Rh positive fetal RBC. The goal is to prevent hemolytic disease of the newborn Rhogam is given at 28 weeks in Rh negative mothers to prevent issue. causes lysis of the fetal RBcs from an Rh positive infant that may have entered the Rh negative mother's bloodstream. By destroying the fetal, the mother does not form antibodies against them. This should protect the woman from becoming sensitized in future pregnancies S/E Localized tenderness and stiffness at the IM injection site. Other side effects can include a mild and transient fever, headache, and rarely an allergic response Considerations Before Rhogam is given, must be determined that mother is negative and has not been sensitized by previous pregnancies. This can be determined by Coombs blood test which must be negative. A positive test indicates the mother has already been sensitized and has the presence of antibodies Standard dose of Rhogam is 300 mcg and should only be given to the mother, never the infant. Microdose of 50 mcg is indicated after a first trimester miscarriage or abortion, ectopic pregnancy, or following chorionic villus sampling Informed consent may be required along with the agency routine of verifying correct dosage and patient identity.

Infertility

defined as no conception after one year of unprotected sex. In contrast, sterility is the inability to conceive. Interventions include artificial insemination, IVF, and drug therapy. Surgery may be indicated to treat underlying causes Emotional support is critical since the patient is at risk for distress Females over 40 particularly affected. Factors to female infertility include hormonal and ovulatory factors, tubal inflammation, thyroid dysfunction, or endometriosis. Male can be assoc. with structural or hormonal diseases, STD, substance abuse, or exposure to toxic substances clomid is used to treat infertility related to hormonal abnormalities by enhancing ovulation by increasing gonadotropin release Menotropins or human menopausal gonadotropin stimulate ovaries to produce eggs in order to stimulate ovulation for conception Surgical interventions in females include ovarian tumor removal, adhesion removal, and hystero. to ID and treat tubal ligation. In males with varicocele, or enlarged veins in the scrotum, may help increase sperm count Recommendations include transferring only two embryos into women less than 37 years old

Hyperemesis gravidarum

excessive vomiting to the point of weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria. Affects less that 0.5% of pregnancies. Etiology is unknown Most patients can be outpatient but severe cant Weight loss must be addressed with provider Woman may require IV fluid replacement in order to improve fluid balance HPN may happen and decrease tissue perfusion and perfusion to the fetus. which is serious May lead to metabolic alkalosis Interventions Antiemetics like ondansetron, promethazine, and metoclopramide Small frequent meals. Limited fluids and bland carbs may aid in settling stomach

Sheehans Syndrome

hypopituitarism caused by pituitary necrosis. This necrosis occurs due to blood loss and hypovolemic shock from postpartum bleeding Usually present with post partum agalactorrhea (absence of lactation) and sometimes amenorrhea. As a result of postpartum hemorrhage, ischemic pituitary necrosis occurs and hormone secretion from the anterior pituitary is interrupted. Typically pts lose prolactin, growth hormone, FSH, LH, ACTH and TSH. Patients may often complain of cold intolerance

Discomforts of pregnancy third trimester

increasing physical discomforts and difficulty sleeping as her body weight and size increase due to fetus growing and gaining weight in prep of delivery. SOB relieved by frequent rest periods, return of urinary frequency and urgency relieved by emptying bladder regularly, leg cramps relieved by stretching and ankle edema relieved by elevating the legs Should sleep with head propped up with pillows to decrease SOB while sleeping Leg cramps from compression of nerves due to the enlarging uterus. Do moderate stretching exercises and utilize warm packs and calcium supplements to promote circulation and bone health Ankle edema may be aggravated greatly by poor posture, lack of exercise, prolonged sitting, or constrictive clothing. These actions prevent fluids from moving efficiently thru the body causing ankle edema Elevate legs frequently thru the day, engage in moderate exercise, avoid sitting for prolonged, use supportive stockings, and maintain adequate fluid intake

Postpartum Hemorrhage

life threatening event characterized by a loss of more than 500 ml of blood after a vaginal birth and 1000 ml after a cesarean. Other conditions have been included in the definition which are a 10% change in hematocrit between admission to labor and post partum or the need for a blood transfusion. There are three major causes of postpartum hemorrhage: uterine atony, lacerations, and retained placental tissue Uterine atony occurs when the uterus becomes hypotonic. This is the most common cause of hemorrhage. When the uterus becomes flaccid and is unable to contract after birth, bleeding occurs. Normal coag. is also impaired when the uterus fails to contract Lacerations If the woman is noted to be bleeding despite a firm and contracted uterus, it is possible that a retroperitoneal hematoma may be present resulting in hemorrhage Retention of the placenta can result in vaginal hemorrhage S/S Bleeding from the vagina and perineum. If abnormal bleeding is noted, important to intervene as soon as possible Hypotension which leads to hypovolemic shock Boggy uterus Normally it should be firm and contracting, this aids in proper coag. to prevent bleeding. When the uterus is boggy the pregnant woman may start to hemorrhage because the uterus is not contracting and therefore not properly coagulating Considerations Oxytocin is used to increase uterine contractions. which can make the uterus become more firm in order to decrease bleeding and hemorrhage When the uterus is boggy, the nurse should massage the fundus. This action helps stimulate contractions and aids in firming up the uterus to aid in coag. If bleeding persists due to a continuously boggy uterus or placental retention, surgery may be possible. May remove the placenta or the whole uterus Blood transfusion may be needed to prevent hypovolemic shock

Spontaneous abortion

loss of pregnancy before 20 weeks gestation. Excessive bleeding before 20 weeks gestation in a preggers may indicate a nonviable fetus. Types include threatened, inevitable, incomplete, complete, and missed. IDing the type is critical to determine the subsequent treatment. Interventions include promoting bed rest and providing emotional support. Since fluid imbalance may occur, monitoring for hemorrhage includes saving the patient's pads and linens. Rhogam may be necessary for rh negative woman Dilation and curettage and cerclage may be done to remove fetal tissue from inside the uterus 20 week mark is considered the point of fetal viability. Late miscarriage occurs between 12 and 20 weeks may be caused by advanced maternal age, reproductive tract abnormalities, obesity, inadeq. nutrition, stress Intervention ID type Bed rest for 24 to 48 hours and avoid intercourse for two weeks. Monitor for hemorrhage is critical for timely interventions of maintaining fluid balance. Instruct the pt to save and measure the amount of blood on pads. Admin IV fluids or blood as needed Dilation and Curettage is a surgical procedure involving the dilation of the cervix to facilitate the insertion of a suction curette to scrape the uterine walls to remove uterine contents. This procedure is done to remove the tissue of the nonviable fetus from inside the uterus. Prior to D and C, a full history is obtained and a pelvic exam is conducted. AFter the removing the uterus, oxytocin may be admind to prevent hemorrhage

hyperbilirubinemia

most commonly characterized as excessive levels of unconjugated bilirubin in the blood. Physiologic hyperB is caused by immature liver function or cephalohematoma leading to red blood cell hemolysis. Occurs 24 hours after birth, last 5 to 7 days and usually requires no treatment. Pathologic HB or hemolytic disease occurs within 24 hours of birth and is caused by blood antigen incompatibality. and large numbers of red blood cell hemolysis. Txt includes phototherapy o exchange transfusions. Early onset breast milk jaundice is related to poor milk intake lead to dehydration and concentrated bilirubin in the blood stream. Treatment options include frequent breast feeding and caloric supplements. Late onset breast milk jaundice onsets 5 to 7 days following birth and may be related to a factor in the breast milk.DC breast feeding for 24 hours will help resolve the jaundice. Jaundice is the primary symptom of HB and toxic levels of bilirubin can lead to kernicterus or bilirubin induced encephalopathy. Interventions include early frequent feedings, phototherapy, admin of heme oxygenase inhibitors, and in severe cases exchange transfusion. A transcutaneous bilirubinometry is used to monitor the new borns bilirubin levels Bilirubin is the byprodcut of hemoglobin breakdown caused by RBC destruction. Bilirubin is released into the bloodstream. Unconjugated bilirubin is insoluble and binds to albumin. Assessment Jaundice. Yellowing usually begins on the face and moves down the body May cause seizures and irreversible brain damage. Symptoms of kernicterus include decreased activity, lethargy, irritability, and hypotonia Interventions B is excreted by binding to stool. Early and frequent feedings help prevent HB by promoting stooling and excretion of B. Increasing feedings to 8 to 12 times per day helps prevent HB Heme oxygenase inhibitors may be used to prevent HB by inhibiting the enzyme that breaks up heme The infant is undressed to expose as much skin as possible to the light. However the genitalia is covered with a diaper and eye protection is worn. During therapy, the infant's fluid intake should be increased to help facilitate the excretion of B in urine and stools Eye protection is critical undergoing phototherapy Monitor hydration levels Monitoring B levels is critical. Transcutaneous bilirubinometry may be used to assess levels. Normal levels range between 0.2-1.4

Incompetent cervix

premature dilation of the cervical os is a cause of late miscarriage. It can be a recurrent condition. S/S recurring loss of pregnancy and a short cervix. Interventions Cervical cerclage, encouraging rest, and preparing for labor Reduced cervical competence allows for a passive and painless dilation of the cervix in the 2nd trimester. Can be caused by prior surgery on the cervix or trauma to cervix Assessment Multiple miscarriages Often the cervix is less than 25 mm and leads to reduced cervical competence Considerations Cervical cerclage is a placement of a prophylactic suture (mcDonald technique or suture) at 11 to 15 weeks gestation which places a suture beneat the mucosa to constrict the internal os of the cervix. Can also be done later in pregnancy Rest for a few days after this. Intercourse and physical activity restrictions are individualized based on status of the cervix which is determined by digital and ultrasound exams Cerclage suture is removed prior to labor usually at 37 weeks. However is Cesarean the suture may be left in place for subsequent pregnancies. Removal of the suture can cause further trauma to the cervix

Amniocentesis

procedure indicated in the early ID of genetic abnormalities as well as an indicator of fetal lung maturity and a secondary tool for evaluating fetal hemolytic disease. It is completed no earlier than 14 weeks gestation and involves withdrawing amniotic fluid under direct visualization ultrasound and evaluating the fetal cells contained in the amniotic fluid Early diag. for more than 40 chromosomal genetic abnormalities like Downs or neural tube defects Can lead to miscarriage Hemorrhage is possible and pain is common in the first 48 hours. Ultrasound has decreased this risk Infection can happen so must be sterile Indicates the admin of Rh immune globulin to Rh negative mother after this procedure to prevent antibody formation

Apgar score

rapid assessment tool to eval. neonates overall health. Five criteria are examined and a score of 0, 1, 2 is assigned. These five values (appearance, pulse, grimace, activity, respiration) Scores are affected by many factors including genetic defects, gestational age, or pregnancy related complications including hypoxia and trauma. Neonate is assessed using this score at intervals of 1 and five minutes after birth. May not be completed if neonate requires resuscitation Appearance Assess skin coloration 0: blue or pale 1: Body pink extrem. blue 2: completely pink Pulse Assess heart rate 0: absent 1: Slow (less than 100 bpm) 2: Normal (over 100 bpm) Normal HR lies between 120 and 160 Grimace Assess reflex irritability and crying 0: no response 1: grimace 2: Grimace with cough, sneeze, or cry Activity and muscle tone Assess flexion of the extremities 0: Flaccid 1: Some flexion 2: Good flexion Respiration Assess breathing rate and effort 0 absent 1: Slow or irreg. 2: Regular respiration or crying Totals 0-3 Severe Distress 4-6 Moderate Distress 7-10 minimal to no distress Neonates in moderate distress at 1 minute often improve with gentle stim. including tactile methods, such as touching or rubbing the neonates back A neonate who is initially cyanotic may have an indication for oxygen therapy. Should be initiated using the blow by method and should not be continued long term per the physicians order

Induction of Labor

stimulation of contractions using an external means such as meds, surgery and other mechanical methods. This is done for multiple reasons. Often for prolonged gestation, and otherwise for reasons that involve danger to the mother or fetus if pregnancy were sustained. Benefits of inducing labor must outweigh the risks of continuing without intervention Indications If amniotic sac membranes have ruptured and are verified using Nitrazine paper, fetal lung maturity is assessed. If the fetus is determined to be mature for delivery, labor is induced Possible emergencies include hypertensive emergencies such as preeclampsia and eclampsia, as well as other maternal medical problems including gestational diabetes and chorioamnionitis. Traumatic events as well Elective induction of labor increases the risk of future deliveries to be cesarean Contraindications Placenta previa and abruptio placenta are delivered via cesarean and never induced for delivery as the potential for hemorrhage is high Transverse lie of the baby indicates that the shoulder would by the first presenting part during labor. Cesarean is indicated Prolapse of the umbilical cord after the rupture of membranes is an indication of cesarean delivery as compression of the umbilical cord during delivery would cause excess fetal stress and possibly death Genital herpes that are active are an indication for cesarean. Herpes is a TORCH infection and may cause a systemic viral infection leading to brain damage. Previous incisions into the uterine muscle causes localized weakness and scarring after healing. Since scars are weaker areas of tissue uterine contractions may cause rupture. Patients who deliver cesarean must have all subsequent deliveries the same Any hemorrhage or vaginal bleeding that has an unknown cause indicates cesarean as it could indicate placenta previa, abruptio placenta, or other vaginal trauma

Preeclampsia

systemic disease characterized by HTN, proteinuria after the 20th week of gestation. If left untreated, preeclampsia can lead to serious, fatal, complications. Risk factors include nulliparity, age younger than 19 or older than 35, obesity, multiple gestations, family history... Occurs most frequently in the final trimester. 140/90 type of BP taken on two separate readings at least four to six hours apart. A dipstick reading of 1+ or 2+ indicating protein in the urine confirms mild P. Can also develop headache, vision disturbances, dyspnea, ab pain, edema, and altered mental status Severe 160/110 taken on two separate readings within six hours Progressive renal insufficiency. Serum creatinine concentration greater than 1.1 Blurry vision, double vision, photophobia, or scotomas may occur as a result of retinal arterial spasms HELLP Syndrome Hemolysis, elevated liver enzymes, and low platelets. life threatening condition likely representing a severe form of P though the etiology remains unclear. Presents with more drastic symptoms and signs of liver inflammation. Complain of epigastric pain or ruq pain, persistent headache, blurred vision Can develop pulmonary edema. This occurs as a result of increased afterload in the heart, pushing fluid into the lungs Interventions Early prenatal care and early detection. Bed rest, antihypertensives, mag sulfate) to slow the progression of the disease allowing the pregnancy to continue to have a healthy newborn at term if possible Left side lying position as this increases placental blood circulation ACE inhibitors and ARBs are C/I due to their effects on fetal development Mag sulfate may be given to prevent or reduce seizure activity. May be continued 24 to 48 hours post partum and be sure to monitor for signs of toxicity such as flushing, sweating, HPN, depressed deep tendon reflexes, and CNS depression. Keep the ANTIDOTE calcium gluconate readily available Delivery of the fetus and placenta is only cure. depending on the stage of the pregnancy and the severity of the disease, they may induce. If less than 34 weeks, corticosteroids may be given to facilitate fetal lung maturity in preparation for preterm labor

Luteal Phase

usually lasts 14 days. Thus ovulation day plus 14 days is the day of menstruation. Usually days 15 to 28 are luteal. After stimulating ovulation, LH causes the follicle to become the corpus luteum. This secretes progesterone. Progesterone (P) works to stimulate secretory and vascular activity of the endometrium, preparing for implantation of an embryo P provides negative feedback preventing release of FSH and LH. This is to prevent the dev. of multiple follicles Nearly 14 days after ovulation, when egg fertilization doesnt occur, the corpus albicans is formed. The corpus luteum degenerates from macrophage breakdown and turns into the corpus albicans which is a mass of fibrous scar tissue. As the corpus albicans is formed, P production slowly declines Estrogen secretion also decreases with formation of albicans A swift decrease in P causes the new vascular in the endometrium to regress. Without vascular support, along with decreasing estrogen levels, the endometrium is no longer supported and sloughs within the uterus. This endometrial sloughing and bleeding is menses After the onset of menorrhea, or the period, a new follicular cycle begins (around day 28) and it all starts over