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202A > Test #4 > Flashcards

Test #4 Flashcards

1
Q

What is Veal Chop? How can we use it?

A

Used to help interpret fetal strips:

V = variability
C= cord compression

E = early decelerations
H= head compression

A = accelerations
O = Ok (what we want to see)

L = late decels
P = placental insufficiency

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2
Q

What classifies as obesity

A

BMI at 30 or above pre-pregnancy

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3
Q

What things are we worried about with an obese mom? 4

A
  • Bleeding (have hemorrhage kit ready)
  • Difficult to monitor baby
  • Difficult to help change patients position if needed
  • Anticipate large babies (LGAs - large for gestational age) creates issues during delivery
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4
Q

What does IUGR stand for

A

Intrauterine growth restriction

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5
Q

Would we always expect a large baby from an obese mom?

A

No - there may be other comorbidities, like mom is a smoker, that causes issues with perfusion with the placenta, which can lead to IUGR and smaller babies

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6
Q

Before birth, what are complications of obesity 3

A
  • Diabetes
  • HTN leading to preeclampsia
  • Sleep apnea
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7
Q

During birth, what are complications of obesity 4

A
  • Macrosomia (large baby)
  • Prolonged labor
  • Shoulder dystocia (increased C-section rates)
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8
Q

What are some risks for C-sections for obese women 4

A
  • Increased risk of BLEEDING
  • Increased risk of infections
  • Delayed wound healing (increased risk for dehiscence)
  • Thromboembolism (all pregnant women are at an increased risk, but being obese increasing this risk factor even more)
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9
Q

Why is there an increase of bleeding for obese mom’s

A

It can be difficult to do a proper fundal massage with the extra tissue

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10
Q

Later on in life, what are children who are born from an obese mother at risk for 2

A
  • Increased risk of childhood obesity
  • Increased risk for chronic conditions (like diabetes)
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11
Q

What are our nursing considerations for obese mom’s 5

A
  • Weight gain through their pregnancy should be smaller (so we only want them to gain around 11-20 pounds)
  • Early testing for gestational diabetes due to their increased risks
  • More frequent prenatal visits
  • Anticipate more challenges in labor and delivery (have hemorrhage kit ready)
  • Issues with babies maintaining blood sugars after delivery
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12
Q

Why are we seeing an increase in CVD in our mom’s

A

2 main factors:

  1. Women are having babies when they’re older
  2. Underlying preconception comorbidities like obesity, HTN, diabetes, rheumatic heart disease if strep is not treated
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13
Q

What population of women is more likely to have untreated strep

A

Immigrant populations with lower socioeconomic status

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14
Q

Why do we consider pregnancy the ultimate stress test in terms of CV health 4

A
  • Dramatic increase in blood volume, especially during 3rd trimester (up to 50% increase)
  • Increase in HR that naturally happens
  • Decrease in systemic vascular resistance (naturally), that can cause dilation in your legs, which can lead to pooling of blood and risk for DVTs
  • Increased coagulability
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15
Q

If a pt is at an increased risk of coagulability, possibly from CVD, what two medications might they be on?

A
  • Baby aspirin
  • Heparin
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16
Q

What anticoagulant drug do we NEVER use during pregnancy (carries a black box warning - category D)

A

Warfarin (can cross the placenta and cause baby’s blood to thin)

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17
Q

What sucks about having CVD while pregnant?

A

Normal pregnancy symptoms can be made even worse by CVD, like:
- Increase in fatigue caused by anemia and changes in cardiac output and BP

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18
Q

How can CVD impact a woman’s labor 2

A
  • During a contraction, blood is shunted away from the placenta and out into the mom’s cardiovascular system, which can be up to 500mLs of extra blood going out into the system. This can put a lot of strain on a woman’s cardiac system taking in this extra blood and increasing her cardiac output.
  • Contractions are painful and can increase BP and HR, which can then increase cardiac output
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19
Q

How can we care for our CVD pts during labor 3

A
  • Strict Is and Os (don’t give any extra fluid, which can increase mom’s fluid volume and increase her CO).
  • Close monitoring of mom and baby (might also have telemetry on mom)
  • Want effective pain relief to help decrease CO and to help shorten second stage
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20
Q

What is second stage? Why would we want it shortened for moms in labor? What can we do to help?

A

Second stage is when mom is pushing, so when a mom with CVD is bearing down and pushing, this can increase their BP and HR, which increases their CO… So we don’t want to put this kind of stress on their heart for very long, so we want to try and shorten this stage.

These women are great candidates for laboring down, which, with an epidural, is when a women lets her uterus do some of the work when she is 10cm and 100% effaced, where the women isn’t pushing, and instead the uterus is passively moving baby along, this helps take off some of the pushing duties for our CVD moms

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21
Q

What acronmyn can help us remember what infections women should avoid during pregnancy

A

TORCH (teratogenic - cross placenta can cause fetal abnormalities or other complications during pregnacy). We screen for these.

T = toxoplasmosis (kitty litter and uncooked meat)
O = other infections like chicken pox, syphilis, HIV, parvo virus, chlamydia, Hep B)
R = rubella
C = cytomegalovirus
H = herpes simplex

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22
Q

What is important about rubella

A

We screen for it and have a vaccine for it, but we can’t give the vaccine until after pregnancy, because it’s a live virus vaccine (one of the few live virus vaccines we have left)

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23
Q

Besides screening for TORCH infections, what other infections do we screen for?

A
  • Hep B
  • HIV
  • GBS (group beta strep) (screen towards the end of pregnancy, because most adults who have it will be asymptomatic, but it can cause newborns to have sepsis if not treated, so we like to screen for it and treat prior to delivery) (GBS positive or GBS status unknown, we treat with antibiotics during labor to help reduce transmission with a vaginal delivery)
  • UTI (big deal in pregnancy because they may be asymptomatic during pregnancy, so will screen for it just in case they have it but are not showing symptoms)
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24
Q

Why are we worried about UTIs during pregnancy

A

They can cause pre-term labor and progress to pyelonephritis (so we want to catch these UTIs early so we can prevent any complications)

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25
Q

With HIV, since we are trying to prevent transmission between mom and baby, what are we looking at? Why?

A

Mom’s viral load, because the higher her viral load the more likely she is to pass it on

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26
Q

How can HIV transmission from mom to baby occur in the 3 phases of pregnancy (ante, intra, post)

A
  1. Ante: HIV can cross the placenta if we don’t do anything to prevent the transmission (without intervention rates can be as high as 25% of babies becoming infected)
  2. Intra: transmission into babies bloodstream due to minor tears during birth
  3. Post: through breast milk
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27
Q

How can we prevent HIV transmission

A
  1. Antiretroviral therapy to help decrease viral load (usually 3 different medications) (usually need to start by 28 weeks to reduce risk at birth)
  2. Have a C-section if viral load is not low enough to help prevent transmission
  3. Newborns will receive antiretrovirals for 5 weeks after delivery
  4. Do not let mom breast feed
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28
Q

What is some psych that goes along with HIV

A

It’s a universal screening for all pregnant mothers, so this could be the first time that she’s ever being tested for and the first time finding out if she is HIV positive, which can be a shock

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29
Q

What is important to reinforce with an HIV positive mother

A

That HIV is no longer a death sentence, it is a chronic illness that can be managed

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30
Q

What do we do for our Hep B positive mothers 3

A
  • They will be on antivirals, which will help prevent transmission across the placenta, where it is most likely to occur
  • Safe to deliver vaginally
  • Can breastfeed
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31
Q

What do we do for our newborns born from Hep B positive moms 3

A
  • First thing: bathe baby prior to giving any injections (like the vitamin k and hep B vaccine)
  • Will receive a hep B vaccine
  • Will receive hep B immunoglobulin (HBIG)
    (these injections should be given within the first 12 hours to prevent any transmission that may have occurred)
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32
Q

Is alcohol bad for baby

A

Yes, it’s a potent teratogenic drug

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33
Q

What things can cause neonatal abstinence syndrome

A
  • Heroin, codeine, fentanyl, methadone, oxy, hydrocodone
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34
Q

What can happen to babies born with a tobacco addiction 2

A
  • Very fussy, sensitive, hyperreactive due to withdrawals after delivery
  • Increased risk for IUGR (why these babies born from smokers are generally small)
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35
Q

If a mom has substance abuse, what else is she at risk for having 3

A
  • Intimate partner violence
  • STIs
  • Lack of prenatal care
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36
Q

Some moms won’t admit to having substance abuse, so what things can suspect us to think that she actually does abuse substances 3

A
  • If she has had no prenatal care
  • If there is a placental abruption without an obvious reason
  • If there is IUGR without obvious reasons
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37
Q

What is interesting about social services and substance abuse

A

Sometimes there will be a mandate from social services telling us that there is a hx of abuse and we need to do a toxicology screen

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38
Q

Can we get a toxicology from a mom without her consent

A

No, even if there is a court order, she would end up just being in violation of the order

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39
Q

Are we allowed to do toxicology on babies here in Oregon without mom’s consent

A

Yes

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40
Q

When doing a toxicology on a baby, what two fluids do we test

A
  • Meconium
  • Urine
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41
Q

What happens to babies born from mom’s with substance abuse

A
  • They are often SGA (small)
  • There may be some neurodevelopmental abnormalities
  • Acute withdrawals
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42
Q

If a mother is positive for an illicit substance (except tobacco, which is not illicit), can they breastfeed?

A

No

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43
Q

Is there a screening tool for babies born from substance abuse mothers

A

Yes, typically like to use the screening tool within the first 4 hours (looking at things like does baby have a high pitched cry, decreased sleeping, hyperactive reflexes, etc), then this gives us a score and tells us how frequently we should rescore the baby and what our treatments should be.

  • Good to note that we may not see signs of withdrawal until 12-24 hours after birth, but it’s still good to start at hour 4 so we have a baseline before withdrawals kick in
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44
Q

What extra care might we do for babies born with neonatal abstinence syndrome due to opioids (a lot)

A
  • High-calorie formula (due to all of their extra movements going on and increased metabolism during their withdrawal)
  • Small frequent meals
  • Antidiarrheals
  • Meticulous Is and Os
  • Wts
  • Breastfeeding
  • Morphine or methadone if baby has a high score
  • Promote comfort like swaddling, sucking (give pacifier), swing
  • Billy lights
  • Monitor tox screen
  • Work with social services
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45
Q

For mental health, what drug types are we concerned about

A

If they take SSRIs during the first trimester, there is conflicting info on whether it can cause fetal malformation, so we would want to work with their doctor to see if they should be taken off the medications (weight the risk vs benefit)

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46
Q

What are our prescription drug categories

A

A and B are generally safe.
C we don’t know either way.
D we’re going to avoid.

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47
Q

What is a mom with a hx of depression at risk for

A

Developing postpartum depression

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48
Q

What might be a sign that a mom has postpartum depression

A

They’re feeling down longer than 14 days (it’s normal to have a few days that you may feel like this

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49
Q

What is hyperemesis gravidarum

A

Persistent vomiting that is not caused by something like the flu or eating something bad

It’s just vomiting that goes on and on while pregnant and you can’t figure out why

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50
Q

What signs do we see (besides persistent vomiting) for hyperemesis gravidarum 2

A
  • There will be signs of malnutrition, so we would see ketonuria (+2 ketones with dipstick)
  • Weight loss (below pregnancy weight by 5%)
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51
Q

What do we think causes hyperemesis gravidarum 5

A

Not really clear, but we think it has something to do with high levels of HCG, estrogen or thyroid hormones

Might also be a genetic component

Increase risk if you’re having a girl

Can be worse symptoms if you have multiple babies (due to more hormones being released)

Hx of motion sickness or migraines may make a woman more susceptible

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52
Q

What are our txs for hyperemesis gravidarum

A
  • Antiemetics
  • IV fluids for hydration
  • Can give dextrose for calories
  • Worst case - have central lines to get TPNs
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53
Q

What is placenta previa? Why is this bad?

A

Where the placenta has attached to the lower uterine wall, and may be covering the cervix.

This is bad because it can increase mom’s chance of having a hemorrhage, where in the 3rd trimester when she starts having contractions, those contractions around her cervix can put a lot of pressure on her placenta and cause bleeding. Plus a baby can’t be born vaginally if the placenta is completely blocking the cervix, because the placenta will be born before the baby, so the baby won’t be getting perfusion.

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54
Q

What are the 6 different types of placenta previa

A
  1. Complete: where the placenta is completely blocking the cervix
  2. Partial: where part of the placenta is blocking the cervix
  3. Marginal: where the placenta is very close to blocking all of the cervix
  4. Accreta: placental attaches too deep into the uterine wall
  5. Percreta: where the placenta grows through the wall and attaches to nearby organs
  6. Increta: attaches even deeper into the uterine muscle
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55
Q

Ho do we deliver placenta previa babies

A

C-section

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56
Q

Why are placenta accreta, increta, and percreta troublesome?

A

Because the placenta has attached itself so deeply in the uterine wall, or muscle or other organs, which can lead to massage bleeding once baby is born because we can’t really do a fundal massage or anything in this area, it will just keep bleeding

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57
Q

Where are mom’s with Placental accreta, increta or percreta going to give birth? What are we prepared to do?

A

In the OR, where we are ready to do a massive transfusion. May even need to do a hysterectomy

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58
Q

What are the cardinal signs of placenta previa 2

A
  • Painless bright red vaginal bleeding (think about the placenta covering the cervix, and any little disruption to that placenta’s blood vessels can cause bleeding, but the pt might not feel any pain) (usually occurs in 3rd trimester)
  • Abdomen will be soft, nontender
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59
Q

What should we not do on pts with placenta previa

A

Vaginal exams, because we don’t want to be poking and prodding the placenta since it’s right at the cervix

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60
Q

What is teaching for pts with placenta previa

A

When they go to the hospital or get checked, make sure they tell whoever that they have a placenta previa and cannot have vaginal checks

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61
Q

What initial assessments are we going to do on pts with a hx of placenta previa

A

Maternal and fetal well being.
- Vital signs on mom
- Look at mom
- Get baby on monitor

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62
Q

What is important to remember about BPs for pregnant moms

A

Their BP will be higher due to their increase in blood volume, so this can be a poor indicator of volume status, so we want to look at her HR to see how she’s coping (tachycardia would show that something is up)

We would also see changes in baby’s HR first if there is an issue with blood volume (like bleeding), where baby will get tachycardia trying to compensate, then eventually mom’s HR will also go into tachycardia

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63
Q

What kind of test might we do on a mom with placenta previa? What is it?

A

A Kleihaurer-Betke (KB) test to see if mom’s blood has mixed with baby’s, especially for our RH negative moms (if mom is Rh negative and baby is positive, than mom can create antibodies that kill baby’s RBCs)

(since mom’s with placenta previa are at an increased risk of bleeding, we want to be on the lookout for Rh negative and positive situations)

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64
Q

What is a placental abruption

A

A premature separation of the placenta from the uterus

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65
Q

What are the signs of a placental abruption

A
  • ***Very painful
  • May or may not Vaginal bleeding (a complete separation may block blood from leaking out, so that blood will just collect where its separated)
  • With a complete separation and blood blooding in the abdomen, we will get a rigid abdomen
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66
Q

What are the 3 different types of placental abruptions

A
  1. Marginal
  2. Partial
  3. Complete
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67
Q

What are signs from baby that a placental abruption may be occurring

A

We would see late decels on FHR

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68
Q

What is a complication of placental abruption

A

The mom can go into DIC, which can lead to hypoxia of the baby

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69
Q

What is interesting about placental abruptions

A

Some can be minor, where maybe we didn’t even know they had one until after delivery or they can be extreme, where we would need to do an emergency c-section

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70
Q

If a woman’s membranes rupture before 37 weeks, what do we refer to them as?

A

Preterm premature rupture of membranes (PPROM)

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71
Q

What is a common cause of PPROM 4

A
  • Infection, which is called chorioamnionitis
  • Uterine distention like from multiple babies or a lot of fluid
  • STIs
  • Smoking
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72
Q

How do we diagnosis PPROM 4

A
  • A provider will do a sterile speculum exam to see if they can see fluid in the birth canal
  • nitrazine test where normal vaginal pH is between 4.5-5.5, but amniotic fluid increases the pH
  • Amnisure (lab test)
  • Ferning (amniotic fluid will fern when dried)
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73
Q

What are our concerns with PPROM? What can we do? 2

A
  • Infection risk (decrease number of invasive procedures)
  • Fetal wellbeing (we are losing our amniotic fluid cushion, babies may have variables on the monitor, because there can be compression of cord without the cushion)
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74
Q

If there is chorioamnionitis, what are we doing?

A

Deliver the baby right away, because mom and baby are at risk for sepsis

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75
Q

If baby is tolerating the decrease in amniotic fluid well and there are no signs of infection, do our PPROM moms have to deliver within 24 hours?

A

No, we will keep a close eye on them and try and let the baby cook longer

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76
Q

What is good to tell pts with PPROM 2

A
  • They are at an increased risk of going into labor spontaneously
  • They will be on bed rest
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77
Q

What are signs of infection besides an increased in temp 5

A
  • Tenderness
  • Cramping
  • Lower back pain
  • Odor
  • Increased HR of both mom and baby

(infection will usually trigger the body to go into labor, because it knows that we need to get the baby delivered)

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78
Q

If there are no signs of infection, what might we want to try and do?

A

Slow down labor for at least 48hrs so we can give 2 doses of betamethasone, which can enhance lung maturity of the baby before they are born

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79
Q

What do we consider preterm labor

A

Anywhere from 20 weeks (when we consider the baby viable) to before 37 (because we consider 37 weeks and after full term)

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80
Q

What is the most acute problem in maternal-child health

A

Preterm labor

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81
Q

Do we still focus on preterm labor prevention here in the US?

A

No, we’ve shifted from prevention to early detection of preterm labor

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82
Q

What is our core measure for preterm labor

A

To be able to give more babies going into preterm labor between 24-32

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83
Q

What is our core measure for preterm labor

A

To be able to give more babies going into preterm labor between 24-32 betamethasone to help their lungs prior to delivery

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84
Q

What age in weeks will a premature baby have a 90% survival rate

A

At 28 weeks (so we REALLY REALLY want to get our babies to 28 weeks)

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85
Q

What are our concerns with premature babies 5

A
  • Immature lungs (not producing surfactant yet, not having coordinating breathing yet), which can lead to respiratory distress
  • Small babies, not much subcutaneous tissue or glycogen stores, which can lead to hypothermia and hypoglycemia (monitor temps, put on warmers, check sugars)
  • Underdeveloped livers (at risk for jaundice) Can have under billy lights
  • Intraventricular hemorrhage for really small babies, where there is internal bleeding in the babies head, so we don’t want to have small babies deliver vaginally, because trauma during birth can increase the risk of intraventricular hemorrhage
  • Cerebral palsy longer term
  • Retinopathy long term
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86
Q

What can cause preterm labor (a lot)

A
  • Periodontal disease
  • Diabetes, HTN
  • *Infections
  • *Uterine distention usually caused by multiples
  • Hx of preterm labor
  • Demographics (older and younger, no prental care)
  • Smoking
  • Stress
  • Interpregnancy interval (less than 6 months since last pregnancy)
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87
Q

How can we prevent preterm labor 4

A
  • Number one thing is prenatal care
  • Manage chronic conditions that might trigger it (like managing HTN, diabetes, stress)
  • Screen and treat infections
  • Give progesterone intravaginally (pro-pregnancy hormone - wants to keep you pregnant)
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88
Q

How do we determine if a mom is actually in preterm labor 7

A
  • Greater than 20 weeks pregnant and less than 37 weeks
  • Have to have persistent contractions
  • Dilating more than 1cm or dilation is changing
  • Effacement of 80%
  • Get a UA
  • Fetal fibronectin (FFN) test
  • Exam cervical length
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89
Q

If a mom who is less than 37 weeks pregnant calls and says that she is having contractions, what kinds of things can we advise her to do at home to stop those contractions 4

A
  • Drink water (dehydration can cause contractions)
  • Go to the bathroom (full bladder can cause issues)
  • Put their feet up
  • Take a nice warm bath
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90
Q

What is the Fetal fibronectin (FFN) test? When would we not want to use this test? What does a negative result mean?

A
  • A test used to rule out preterm labor
  • The fetal fibronectin is a prostaglandin that is released when membranes are disturbed by contractions (so this is how we can tell if they’re actually having contractions)
  • Don’t use if there are rupture membranes (PPROM) or if there is vaginal bleeding
  • Can’t use if there has been anything in the vagina in the last 24 hours, like from having sex or having their cervix checked.

Negative means that there is a less than 1% chance that the mom is going to deliver that week. (we want negative)

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91
Q

Why do we want to do an FFN test for preterm labor before we check the cervix

A

Because the FFN test won’t be accurate if anything has been in the vagina in the last 24 hours, like from having an exam. So we always want to do this test first before a cervical exam.

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92
Q

What does a positive FFN tell us?

A

Well it tells us that the mom has a 20-50% chance of delivering this week, but there are also a lot of false positives, so basically a positive result doesn’t really tell us much.

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93
Q

What is our goal for preterm labor? How do we accomplish this goal? 5

A
  • We want to delay delivery!

How we accomplish:
- Give tocolytics, which are medications used to reduce contractions.
- Try to delay delivery enough to get two doses of betamethasone in within 48 hrs
- Abx for GBS as needed
- Bed rest (remember increase of DVTs on bed rest, maybe more of an activity restriction)
- Possibly may need to transport to another facility

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94
Q

What are our tocolytic drugs 4

A
  • Nifedipine (Ca channel blocker) (don’t give nifedipine and magnesium sulfate together because both compete with calcium and cause cardiac issues)
  • Indomethacin (NSAID)
  • Terbutaline (beta-adrenergic receptor agonist) (not first line, will stop contractions, but can cause maternal tachycardia)
  • Magnesium sulfate (CNS depressant - also competes with Ca) (has to be given inpatient)
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95
Q

How do we administer betamethasone? When would we give it? What does it help babies produce?

A

Give 12mg to mother IM every 24hrs twice

Give to mothers if babies are less than 34 weeks

Helps babies produce surfactant

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96
Q

What are the benefits of betamethasone 5

A

Reduces:
- Respiratory distress syndrome
- Intraventricular hemorrhages
- Necrotizing enterocolitis
- Neonatal mortality
- Neurologic handicap

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97
Q

What if you give your two doses of betamethasone thinking the mom is in preterm labor and is going to deliver soon, but the mom doesn’t actually deliver until a week later?

A

You can give one “rescue dose” of betamethasone a week later, or even at a later time.

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98
Q

What are we worried about it, in terms of our moms, when we give them betamethasone (think steroid risks) 1

A
  • Diabetic moms (this med will spike their sugar levels) (might need extra insulin coverage)
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99
Q

Can we sign off on mag sulfate by ourselves

A

No, it’s a dual RN sign off

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100
Q

What are the effects of mag sulfate (good and bad)

A

It’s a CNS depressant so…

It provides neuroprotection to the baby to help reduce cerebral palsy risk

Reduces contraction and tone (helps baby cook longer)

It’s a vasodilator, so it can drop BPs (we don’t want to drop mom’s BP too much, because this can reduce profusion to the baby

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101
Q

What are assessments are we doing if mom is on mag sulfate

A
  • BP and RR frequently (remember, it’s a CNS depressant)
  • Continuous EFM
  • DTRs (don’t want these to become too decreased)
  • LOC (don’t want these to become too decreased)
  • Lung sounds
  • Urinary output
  • Watch for late decels (signs of poor placenta perfusion)
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102
Q

How do moms feel on mag sulfate

A
  • Groggy
  • Malaise like when they have the flu
  • Flushed
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103
Q

What if mom’s DTRs, LOC and RR is becoming too suppressed on mag sulftate.

A

We should stop the mag sulfate and consider giving the antidote, calcium gluconate

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104
Q

What are newborn considerations for mom’s taking mag sulfate

A

Mag sulfate does cross the placenta, so these babies will also have mag sulfate in their system, and we may see signs of CNS depression, like decreased RR, muscle tone, they’ll likely have low APGAR scores

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105
Q

Picture:

Notice how identical twins are called monochorionic/diamniotic twins because they share the chorion and placenta, but have separate amnion.

Twins that are not identical are dichorionic/diamniotic and do not sure a chorion or placenta

A
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106
Q

What are risks for mom’s caring multiples 4

A
  • Intrauterine distention
  • ROM
  • Pre term labor
  • Hyperemesis
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107
Q

What are some nursing considerations for perinatal loss 3

A
  • There may be more bleeding than usual, which may turn into a DIC event
  • Infections can occur if membranes have been for some time or if the baby has died a while ago and these things are still inside mom
  • If Rh-, mom should still have RhoGAM
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108
Q

What is an incompetent cervix

A

Usually where you have dilation and effacement of the cervix when you’re not supposed too, which can lead to loss of the baby (usually occurs in 2nd trimester - basically cervix won’t stay closed)

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109
Q

How can we manage an incompetent cervix

A

Through a cerclage, where the provider will stitch up the cervix until delivery to help keep baby inside

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110
Q

If a woman has an incompetent cervix for one of her pregnancies, is she more likely to have it again for future pregnancies

A

Yes

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111
Q

What are risk factors for ectopic pregnancy (a lot)

A

Usually things that have caused scarring to the fallopian tube, which is where we see a lot of ectopic pregnancies occur

So…:
- STIs
- PID
- Prior ectopic
- Hx of abd surgeries
- Endometriosis
- Hormone therapy
- Assisted reproduction
- Use of an IUD

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112
Q

What are s/s of an ectopic pregnancy 5

A
  • Bleeding
  • Missed period
  • Abd pain/tenderness (usually unilateral on the side where the ectopic is in the fallopian tube)
  • Referred shoulder pain
  • Pain that worsens with rupture (pretty severe)
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113
Q

How can we diagnosis an ectopic pregnancy 5

A
  • Hx (previous ectopic - especially in the same fallopian tube as the previous ectopic, due to the scar tissue, if they still have that tube)
  • Palpable mass
  • Ultrasound to see if pregnancy is actually in the utererus
  • hCG will be low
  • Going to have hypotension s/s if ruptured
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114
Q

What is our management of an ectopic 2

A
  • We can give methotrexate to terminate pregnancy if unruptured and less than 4cm in size
  • Salpingectomy via laparotomy
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115
Q

Is it pretty serious when an ectopic ruptures

A

YES! There can be massive internal bleeding going on. It definitely becomes an emergency

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116
Q

What is gestational trophoblastic disease (also called molar pregnancy or hydatidiform mole)

A

Basically a woman has a positive pregnancy test, but instead of a baby growing, the placenta develops abnormally and grows fluid filled grape like clusters instead of a baby (basically abnormal tissue growth instead of a baby, even though there was a positive pregnancy test)

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117
Q

What are the s/s of gestational trophoblastic disease 4

A
  • There would be a discrepancy in the size of mom’s tummy and how far along she is (these fluid filled sacs are going to grow a lot larger, and much faster than a baby would)
  • Bleeding, possibly passing some of these little fluid filled clusters
  • Markedly elevated hCG
  • No fetal HR
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118
Q

What are we really worried about with gestational trophoblastic disease? So what do we do? What do we teach out mom’s?

A

These women are at an increased risk of developing cancer

So we will measure their hCGs for at least one year, where a rise in hCG may indicate malignancy

We advise our moms to not become pregnant for at least one year, because their pregnancy could mask a rise in hCG, which is helping us determine if she may have cancer

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119
Q

Picture showing how insulin builds up in the first half of pregnancy because a decrease in insulin needs vs second half of pregnancy were we have an increase in insulin needs

A

We don’t need insulin as much in the first half of pregnancy, things like our hormones may be decreasing our need for insulin, as well as maybe we have morning sickness so we’re not eating as much, and baby isn’t needing very much.

An increase in insulin needs can lead to insulin resistance (pancreas is excreting more insulin in second half of pregnancy, but can’t keep up with the demand) Think of pregnancy as a stressor, and your pancreas isn’t able to keep up with the high demand in the second half of pregnancy

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120
Q

What if you already have diabetes going into pregnancy

A

The previous picture still holds true for type 1 and type 2 diabetics, where both may need to actually decrease their insulin in the first half of pregnancy, or may not even need it at all, however, they may need to increase their insulin injections in the second half of pregnancy

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121
Q

If a mom’s diabetes isn’t controlled, what can happen?

A

She can develop:
- High BPs
- Preeclampsia
- Eclampsia
- 2 times as likely to experience miscarriage
- Poly(hydramnios (excess amount of amniotic fluid, over 2000mLs) (remember that high blood sugars can cause polyuria, where there is excess peeing, so since mom has high blood sugars, so will the baby, so the baby will be urinating a lot in their sac creating more and more amniotic fluid) - this can lead to uterine distention, which can cause problems later on
- Ketoacidosis
- Retinopathy
- Increased risk of infections like UTIs (UTIs can quickly progress to phylo)
- Increased risk for developing future diabetes after birth

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122
Q

What are the effects of uncontrolled diabetes on babies 6

A
  • Macrosomia (excessive birth weight due to high maternal levels of glucose)
  • The baby can develop hyperinsulinemia, because only mom’s glucose crosses the placenta, they don’t get mom’s insulin (this is why we like to give pregnant diabetic mom’s insulin, because the insulin doesn’t impact the baby), so babies will actually produce their own insulin, but since they are getting an excessive amount of glucose from mom, they will be producing excessive amount of insulin, which can cause the baby to store glucose in fatty deposits around their chest and shoulder areas. (this increase in babies shoulder and chest can make for challenges during delivery).
  • Increased risk for respiratory distress syndrome, because hyperinsulinemia can lead to a decrease in surfactant production
  • Neural tube defects (diabetic moms will need to take an increased amount of folic acid compared to nondiabetic moms to prevent neural tube defects)
  • After birth, babies will most likely have low blood sugars (this is due to baby’s pancreas being use to produce high levels of insulin due to mom’s high sugars, so it may take a while for baby’s pancreas to stop making so much insulin, so baby’s sugar may be low in the meantime) and possible jaundice (so be prepared for this)
  • Increased risk for developing type 2 diabetes later in life
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123
Q

When do we start screening for gestational diabetes? Why at this time and not sooner?

A

Usually at 24-28 weeks, only sooner if high risk.

From the previous slides, insulin needs are usually low in the first half of pregnancy, but increase in the second half, so there’s not really a point in testing in the first half

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124
Q

What is the 2 step glucose tolerance check (simply)

A

Mom drinks a sugary drink, she comes and checks her blood glucose after an hour, if that number is really high, then she has to come back in 3 hours later and if that number is high, then this can confirm gestational diabetes

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125
Q

What are risk factors for gestational diabetes 5

A
  • Obesity
  • Family hx of type 2
  • Hx of previous gestational diabetes
  • Hx of LGA infant (large infant, greater than 90th percentile for weight)
  • Polycystic ovary disease
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126
Q

Should we increase the insulin mom receives after delivery?

A

No! It is likely that her insulin needs will decrease after delivery, so we will adjust accordingly

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127
Q

How can women manage gestational diabetes

A
  • Many can manage through lifestyle and diet changes
  • Increase folic acid intake to prevent neural defects
  • Maintain euglycemia (tight glycemic control)
  • Fasting less than 95 (check fasting in the morning)
  • 120-135 post-prandial (after eating)
  • A1C goal is 6 (8 or above shows poorly controlled diabetes)
  • Insulin is drug of choice (bc it doesn’t cross to the baby)
  • More frequent prenatal visits, especially towards the end of pregnancy were we do nst (non-stress tests) to look at the fetal HR
  • Mom will have biophysical profiles done, where we do stress tests but also look at HR and ultrasound
  • Might have an early delivery (especially if baby is getting large, etc)
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128
Q

Do we use metformin for diabetic moms

A

Only sometimes, it does cross the placenta, even though it is a category B, many providers will switch mom to insulin to error on the side of caution

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129
Q

So what additional things are we going to do for a baby whose mom has gestational diabetes

A
  • Kick counts (at home)
  • Biophysical profile (BPP)
  • Femur length
  • Abdominal/head circumference
  • Nonstress test
  • Contraction stress test
  • Amnio for fetal lung maturity
  • L/S ratio of 2:1 (tells us if baby has adequate surfactant)
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130
Q

What is included in a biophysical profile BPP? How do we keep track?

A

We give point values to each item so:
- Fetal HR can score up to 2
- Amniotic fluid can score up to 2
- Respiratory movements can score up to 2
- Muscle tone can score up to 2
- Movement of extremities can score up to 2

So there can be a total of 10 points. (a score of 8-10 is normal) (4 below mean deliver asap)

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131
Q

During delivery, where do we like our mom’s blood sugar to be

A

Between 80-110

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132
Q

When we hang insulin, what should we also have hanging just incase

A

Dextrose in case mom goes hypoglycemic

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133
Q

Once a baby is delivered from a mom with diabetes, what is our newborn management?

A
  • All infants born from diabetic mothers, all LGAs and SGAs will be on glucose protocols
    Glucose protocols:
  • Monitor sugars (protocol will tell you what to do depending on where baby’s sugar is at)
  • Use heel stick
  • Get babies to breast asap
  • Check baby’s sugar 30 minutes after feeding
  • Want babies eating every 2-3hrs
  • Can’t let babies sleep for long periods of time, because they do need to feet regularly
  • Protocol usually lasts 24-48hrs
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134
Q

Once a gestational diabetes mom has her baby, how might her diet change?

A

She will likely come off her diabetic diet and be placed on a regular diet

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135
Q

When will a gestational diabetic mom be screened after delivery for diabetes again

A

Usually 6-12 weeks and then annually, just because gestational diabetes increases their risk of developing type 2 later on

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136
Q

Is HTN deadly for moms?

A

Yes, it is the second leading cause of mortality for pregnant women

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137
Q

What is our definition of HTN

A

Systolic at or greater than 140
and/or
Diastolic at or greater than 90

Pt has to have a BP at or greater than 140/90 at least twice taken 4 hours apart

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138
Q

What are our 4 categories of HTN

A
  1. Chronic HTN
  2. Gestational HTN
  3. Preeclampsia/eclampsia
  4. Chronic HTN with superimposed preeclampsia
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139
Q

At how many weeks pregnant would we diagnosis a mom with chronic HTN

A

Before 20 weeks (so basically in her 1st trimester)

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140
Q

During pregnancy, is it normal to have our BP increase or decrease

A

It is actually normal to have our BP decrease, which is why HTN during pregnancy is weird

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141
Q

What needs to be present to diagnosis a woman with preeclampsia

A
  • Have to have an increase in BP after 20 weeks
  • Need to either have protein in urine or other s/s of preeclampsia like vision problems, liver problems and/or kidney problems
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142
Q

What is gestational hypertension

A

Where we have an increase in BP after 20 weeks, but we don’t have proteinuria

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143
Q

What are the s/s of preeclampsia

A
  • Headache
  • Visual disturbances
  • Right upper quadrant pain due to hepatic ischemia
  • Reduced urine output
  • Low abd pain (which can be a sign of placenta abruption which is more common in women with preeclampsia)
  • Pulmonary edema
  • Peripheral edema
  • Hyperreflexia
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144
Q

What is the pathophys of preeclampsia

A
  1. Vasoconstriction leading to HTN
  2. Platelet activation with intravascular coagulation
  3. Endothelial dysfunction, where fluid shifts out of the vascular system and into the interstitial space
  4. Maternal plasma volume contraction
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145
Q

What can preeclampsia lead to? both mom and baby 4, 3

A

Mom:
- Eclampsia, which is essentially a seizure
- Pulmonary edema
- Renal failure
- Stroke

Baby:
- Intrauterine growth resistance
- Placental abruption
- Still birth

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146
Q

What are risk factors for developing preeclampsia (a lot)

A
  • Hx of preeclampsia
  • First pregnancy or first pregnancy with a new paternal partner (something to do with dad’s antigens)
  • Family hx of preeclampsia
  • Pre-existing HTN
  • Diabetes! (4x risk)
  • Renal disease
  • Obesity
  • Connective tissue disease like lupus and RA
  • Under 17 or over 35
  • Multiples
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147
Q

How can we diagnosis if a mom has preeclampsia 4

A
  • Look at CBC to see if we see any hemolysis (platelets less than 100,000)
  • CMP to check for kidney and liver function
  • Look for protein in urine, gold standard is to measure urine over 24hrs, where anything above 300mg for protein can be a sign of preeclampsia
  • Checking fetus for any signs of growth restriction
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148
Q

What is the only way to stop preeclampsia

A

Deliver the baby

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149
Q

What if a mom comes in with elevated BP after 20 weeks

A

We want to determine what kind of HTN it is (gestational HTN or preeclampsia)

So we’ll do a 24hr urine collection to look for protein, if protein is over 300mg, then we know it’s preeclampsia and not just gestational HTN

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150
Q

Are there diff severities of preeclampsia

A

Yes, it can range from mild to severe

151
Q

If a woman has a hx or family hx of preeclampsia, what might they be prescribed

A

Aspirin to prevent preeclampsia from developing

152
Q

Picture and notes of terrell explaining what is happening in preeclampsia/eclampsia and what she points out as important

A
  1. We have endothelia damage, where little holes are made in blood vessels and leaking fluid into the surrounding tissue
  2. Body tries to respond by activating intravascular coagulation to form little clots, but this also uses up our clotting factors (increases risk of DIC)
  3. The damage to the endothelia also causes vasospasms
  4. Intrauterine growth restriction because blood vessels are working like they should for perfusion
  5. Pulmonary edema in lungs due to fluid leaking into this area (remember to listen to lungs)
  6. Pulmonary edema is very common especially in face, hands and abd (can be pretty significant)
  7. Vasospasms in liver (causes upper right quadrant pain, might also feel like epigastric pain - this is also why we watch liver enzymes)
  8. Liver involvement is very serious and it is very very serious pain
  9. Vasospasms can also cause headaches (think of downtown abbey)
  10. Hyperreflexia can happen so make sure you’re checking reflexes
  11. Spasms can happen in eyes and cause blurry vision so ask if they have blurred vision.
153
Q

What can classify as mild preeclampsia (means we have mild w/o severe features)

A
  • Have a BP at or greater than 140/90 after 20 weeks with 2 readings taken 4 hours apart
  • Have proteinuria (>300mg in 24 hours) or have involvement of end organs
154
Q

How can we manage mild preeclampsia

A
  • Can possibly be managed at home
  • Pt needs to know what to report to their provider (because we want them to tell us if they have any signs that the preeclampsia is progressing)
  • Will need to know how to take their BPs
  • Will need to have frequent trips to provider
155
Q

What are signs of severe preeclampsia (means we have severe with features) 8

A
  • BP at or above 160/110
    or any of the below:
  • Platelets <100
  • AST/ALT 2x above normal
  • Severe, persistent RUQ/epigastric pain (like as severe as you can get for pain, worst pain of your life from the microhemorrhages in the liver that are occurring)
  • Elevated creatinine and protein
  • Oliguria (<500mL/24hrs)
  • Pulmonary edema
  • CNS disturbances (visual, DTRs and/or clonus)
156
Q

What is important to remember about DTRs

A

We need assess DTRs on the pt with the off/oncoming nurses so that we can confirm what, if anything has changed

157
Q

What can an increase in our DTS tell us

A

That the CNS is increasing in excitability, which can increase the risk of seizures developing

158
Q

What are signs that the fetus may be in distress from preeclampsia 3

A
  • Changes in HR
  • Poor variability
  • Late decels
159
Q

What are complications of preeclampsia for mom 11

A
  • Severe HTN
  • Severe pulmonary edema
  • MI
  • ARDS
  • *Hepatic rupture
  • Eclampsia (grand mal seizure - can happen post partem as well, remember downtown abbey)
  • Cerebral edema
  • Hemorrhage
  • Acute renal failure
  • Coagulopathy > HELLP > DIC
  • Retinal injury
160
Q

What nursing assessments are we going to be doing to monitor if preeclampsia is progressing 10

A
  • Checking BPs
  • Checking DTRs/clonus
  • Ask about RUQ pain
  • Ask about headaches
  • Ask about visual changes
  • Listen to lungs to assess for pulmonary edema
  • Look for edema in hands/face
  • Assess urinary output
  • Run labs - AST/ALT, platelets, creatinine, protein in urine
  • Assess fetus using NST or BPP
161
Q

Preeclampsia can progress to HELLP and/or eclampsia, what does HELLP stand for?

A

Hemolysis (hemolytic anemia), elevated liver enzymes (AST/ALT 2x normal) and low platelets (<100)

162
Q

What can HELLP progress to?

A

DIC

163
Q

What is the cardinal symptom of HELLP

A

Upper right quadrant pain

164
Q

What is eclampsia

A

Where arteriolar vasoconstriction occurs and leads to grand mal seizures

165
Q

What is the cure for preeclampsia/eclampsia? But what’s the catch?

A

Delivery but eclampsia can still occur post partem

166
Q

If preeclampsia is mild, do we need to deliver asap?

A

No, we can generally let the baby cook for longer and watch mom for signs that the preeclampsia is progressing

167
Q

What kinds of outpatient things are we going to do if we are managing a mom’s preeclampsia at home 5

A
  • Home BP monitoring
  • Daily protein testing
  • Kick counts
  • NST every 3-4 days for baby
  • Checking baby’s growth using the ultrasound
168
Q

What things are we doing inpatient for preeclampsia 2

A
  • Labs
  • Fetal monitoring
169
Q

What is our goal in terms of weeks to get a mom to if she has preeclampsia

A

37-38 weeks

170
Q

What are we going to do if mom develops severe preeclampsia 2

A
  • We’re going to try and deliver baby it is older than 34 weeks
  • If less than 34 weeks, we want to try and hold off on delivery for 48 hours to get betamethasone onboard
171
Q

What should we consider if we induce a mom who has severe preeclampsia

A

We’re worried if her BP can handle the induction (like can she handle the labor pains, and everything that comes with a vaginal birth)

172
Q

So what is our tx if we are having mom’s wait to get betamethasone onboard if less than 34 weeks 9

A
  • Have them on bedrest with bathroom privileges
  • Minimize stimulation (lights dim, nice, and calm)
  • Have NICU provider/nurse come in and educate mom on what will be happening
  • Have them on magnesium sulfate to prevent clonus/seizures
  • May have on antihypertensives like labetalol or hydralazine
  • Strict Is and Os
  • Daily weights
  • Check DTRs
  • Check vital signs
173
Q

When would we just give a dose of betamethasone and deliver asap (without waiting the 38 hours) 8

A

If we see one of the following:
- Uncontrollable severe HTN
- Eclampsia
- Liver rupture
- Pulmonary edema
- Placenta abruption
- DIC
- Evidence of category III fetal status
- Fetal demise

174
Q

What is a good way to think of mag sulfate

A

Remember that mag sulfate completes with calcium, where calcium is trying to excite things and cause contraction, versus mag, which is trying to relax things

175
Q

What is a big risk with mag sulfate

A

You can give too much and cause respiratory depression

176
Q

What is our standard dose of mag sulfate

A

4-6g bolus, followed by 2g/hr IV (remember this is high risk - so it’s a dual RN sign off)

177
Q

When we give mag sulfate, what should we have ready in the room and by ready/assessing for? a lot

A
  • Oxygen via a simple mask
  • Suction available
  • Eclampsia kit nearby
  • Still assess for preeclampsia progression
  • Check BP to make sure we’re not dropping it too low
  • Check DTRs to make sure we’re not losing DTRs (if we see a decrease or absent DTRs we need to stop the mag)
  • Continuous fetal monitoring
  • Can cause issues when trying to induce mom because it’s fighting against induction (might need additional doses of prostaglandins or Pitocin - can be very difficult to get a mom on mag to go into labor)
  • Mag does cross the placenta, so the same things it can do to mom it can do to baby like decrease tone, decrease respiratory drive, we would see lower APGARs
  • Mag sulfate can cause issues with having uterus clamp down after delivery (might need to give extra fundal massage and extra Pitocin, have hemorrhage medications ready to use)
178
Q

Can we stop magnesium as soon as baby is born?

A

No, generally we want to keep mom on it for 24 hours because she is still at risk for eclampsia after delivery

179
Q

What is the therapeutic range of mag sulfate

A

5-8 mg/dL

180
Q

What is a normal number for a reflex? What about hyperreflexia or hyporeflexia

A

Normal = +2
+3 or +4 = hyper
+1 or 0 = sluggish or no response

181
Q

What might be signs of mag toxicity

A
  • Pt reports metallic taste in mouth
  • Feel very fatigued
  • Sweating
  • Hypotension
  • Depressed/absent reflexes
  • Depressed respiratory
182
Q

Before giving mag sulfate, what do we need to make sure we have available

A

Calcium gluconate

183
Q

How long is a mom at risk for developing preeclampsia after birth

A

6 weeks (so make sure we’re teaching the warning signs)

184
Q

If a woman wants to have an elective delivery, at how many weeks should they do this?

A

Want them to have elective if baby is beyond 39 weeks (even though they’re considered full term technically at 37 weeks, we want them to be beyond 39 weeks)

185
Q

What should baby’s HR be

A

110-160

186
Q

Why might a fetus be in bradycardia 4

A
  • Mom is in the supine position (laying flat - why we don’t want mom laying flat)
  • Mom could have hypotension
  • Mom could be on an adrenergic-receptor blocking drug like Propranolol
  • Mom could be on anesthetics
187
Q

Why might a fetus be in tachycardia 5

A
  • *Maternal fever and infection
  • Increase in fluid volume
  • Mom could have hyperthyroidism
  • Mom could have anxiety
  • After mom has smoked since nicotine is a stimulant
188
Q

Why might a fetus be in tachycardia 4

A
  • *Maternal fever and infection
  • Increase in fluid volume
  • Mom could have hyperthyroidism
  • Mom could have anxiety
  • After mom has smoked since nicotine is a stimulant
189
Q

What is the number one indicator that a fetus is getting well oxygenated and is not in acidosis

A

We see moderate variability changes in their HR, usually changes from 5-25 BMP.

190
Q

Why might we see a decrease in variability (basically HR is unchanged)

A
  • Could be that baby is in their sleep cycle, which usually lasts for about 20 minutes.
    but….
  • If it’s been over 20 minutes and the baby’s HR is still unchanged, then it could be a sign of hypoxia or acidosis
191
Q

Besides a fetus being in a sleep cycle, what else might cause decreased variability

A
  • Mom could be on fentanyl for pain
  • Mom could be on mag sulfate
192
Q

Do we like to see accelerations

A

Yes, they can tell us that the baby is well oxygenated

193
Q

Do we want to see many decelerations

A

No - usually means something is wrong (remember veal chop)

194
Q

What are the categories for FHRs

A
  1. Category 1: everything is good. We have moderate variability and some accels. (no decels happening)
  2. Category 2: Everything in between. We’re continuously monitoring, we’re trying different interventions to see if we can improve things. Remember POISON.
  3. Category 3: Very concerning - indicate a need for immediate delivery. Example - absent variability, flat line HR, with recurrent decelerations (these are all signs of acidosis). Could have bradycardia, huge decel, even down to 60 and it stays down there for 10 minutes (indicates an immediate delivery).
195
Q

Are early decels normal/ok?

A

Yes, they happen right when mom has a contraction, and indicate that the head is being compressed, which is usually because the baby is advancing down the canal

196
Q

Are late decels ok?

A

No, late are the worst type of decels. It means that the placenta is unable to perfuse baby (not enough reserves etc)

197
Q

Are variable decels ok?

A

Not good, but not as bad as late. Only really bad if they keep occurring, ok from time to time. Means that there is some cord compression. These look “V” shaped on the monitor.

198
Q

What acronym can we use for intrauterine resuscitation? What does it stand for?

A

POISON

P - position change
O - oxygen
I - IV fluids
S - sterile vaginal exam
O - oxytocin OFF
N - notify

199
Q

What are the 4 P’s in labor?

A
  • Power of contractions
  • Passenger (size of baby)
  • Passageway (positioning of baby coming out)
  • Psyche
200
Q

What is a normal amount of contractions in 10 minutes? What is considered hypotonic contractions?

A

Normal: 4-5 contractions in 10 minutes

Hypotonic: less than 2-3 contractions in 10 minutes

201
Q

What may cause hypotonic contractions 2

A
  • Overdistended uterus (like with multiples, polyhydramnios)
  • Presenting part is not being well applied (like if baby’s head is not being applied to mom’s cervix, then it’s not going to help stimulate good contractions)
202
Q

If mom is having hypotonic contractions, what things can we do to help increase her contractions 3

A
  • Have mom try to walk/change positions
  • AROM (artificial rupture of membranes) (helps augment labor to get contractions going)
  • Start oxytocin to help augment labor
203
Q

What is the risk with oxytocin

A

We can cause tachysystolic labor, where we’re having more than 5 contractions in 10 minutes averaged over 30 minutes

204
Q

How do we administer oxytocin

A
  • It’s a dual RN sign off because it is a very high risk med
  • Start very low with 2 miliunits every hour
  • Then increase every 30 minutes until we get to a desired labor pattern, where we’re having contractions every 2-3 minutes
205
Q

Why is tachysystolic labor bad for a baby?

A

We don’t want contractions too close together, because we want time for that placenta to perfuse and establish reserves, because remember when mom is having a contraction, the placenta is using reserves to perfuse the baby, but if her contractions are happening too close together, than she doesn’t have enough time to build up these reserves in-between contractions

206
Q

What do we do if mom goes into tachysystolic labor 4

A
  • Stop oxytocin
  • Want to promote relaxation
  • Treat mom’s pain due to having so many contractions (which can also help relax the uterus)
  • Terbutaline giving SQ helps relax the uterus (remember that it does increase maternal HR)
207
Q

What is the purpose of artificially rupturing membranes

A

We do when we want to help labor progress because when we rupture the membranes it will remove the fluid that may be separating the baby’s head from the cervix, so now if that fluid is gone baby’s head will make contact and apply pressure to the cervix which can help the cervix start to have meaningful contractions

208
Q

What should we make sure is going on during artificial rupture of membranes? 4

A
  • Have to have fetal HR monitoring going on before, during and 20 minutes after the procedure so we can see how baby is tolerating the change in environment (aka loss of fluid)
  • Let mom know that there shouldn’t be any pain, it will just be discomfort like with any cervical exam
  • “start the clock” when the rupture occurs, because we want to deliver baby within 24hrs from this time
  • Document amount and color of fluid, may have meconium in it
209
Q

Is a cord prolapse pretty rare

A

Yes, it’s very rare

210
Q

What are major risk factors for a cord prolapse

A

When the baby’s head is not applied correctly in the cervix, which leaves room for the baby’s cord to fall out before delivery
- High station of baby
- Small fetus
- Breech presentation
- Transverse lie
- Polyhydramnios

211
Q

Is it more common to see a cord prolapse in a spontaneous or artificial ROM?

A

Artificial

212
Q

What are the two classes of cord prolapse

A
  • Occult: hidden, we can’t really see that it is occurring
  • Complete: where we can see that cord
213
Q

Why is a cord prolapse an emergency

A

Because if the cord is coming first in front of the baby’s head, then when the baby’s head makes contact with the cervix, it’s going to be a tight fit, so this can cut off the cord blood supply to the baby

214
Q

What is a sign on the FHR monitor that there may be a cord prolase

A

We see a major, prolonged decels and bradycardia

215
Q

How can we prevent a cord prolapse

A

Make sure baby’s head is well applied before rupturing any membranes

216
Q

How can we cure a cord prolapse

A

Stat C-section

217
Q

If you have a cord prolapse and you’re waiting for a C-section, what can we do as nurses/providers 2

A
  • Want to relieve pressure off the cord
  • Provider will use two fingers to try and push baby’s head up and off that cord without touching the cord, because touching it can cause vasospasms
218
Q

What can cause cord compression 2

A
  • Position of mom
  • Decreased amniotic fluid, like from ROM
219
Q

What is a sign of cord compression

A

We have variable decels with every contraction

220
Q

What is our tx for cord compression 2

A
  • Have mom change positions
  • Amnioinfusion
221
Q

What is amnioinfusion? Why would it be done?

A

We insert sterile saline or LR into the uterine cavity via an IUPC (intrauterine pressure catheter)

May be done to treat repetitive variables due to low amniotic fluid volume

222
Q

What should we know about amnioinfusion 6

A
  • Fluid should be warmed before instilling
  • Watch our intrauterine pressure so we don’t put too much fluid in
  • Make sure uterine tone stays consistent
  • Changing pad and chucks frequently, continuous fluid will be leaking
  • Watch for improvement in baby’s FHR and wanting variables to stop
  • Have infection on your mind (frequent temp checks, very 2hrs first and then moving to every 1hr)
223
Q

What is chorioamnionitis

A

Intrauterine infection of membranes and/or fluid

224
Q

What usually causes chorioamnionitis

A

Usually an ascending microbe from the GU system that climbs up in there

225
Q

Do women who have rupture membranes only get chorioamnionitis

A

No, you can still get chorioamnionitis even if your membranes aren’t ruptured, but it is more common in women who have ruptured membranes

226
Q

When does the risk for chorioamnionitis increase if you have ROM

A

At 12, 18 and 24hrs

227
Q

What are increased risks of chorioamnionitis 3

A
  • Increased vaginal exams
  • GBS that is untreated
  • Internal monitors (like with amnioinfusion)
228
Q

What are the s/s of chorioamnionitis 4

A
  • Increased maternal HR and temp
  • Increased fetal HR is often the first thing we see
  • Fundal tenderness
  • Foul odor of fluid is usually a later sign
229
Q

What is our tx for chorioamnionitis

A

Abx for mom

230
Q

What is shoulder dystocia

A

When the head gets delivered but the shoulders are stuck

231
Q

Is shoulder dystocia an emergency? Why or why not?

A

Yes, because if the baby is trapped in the birth canal it can cause irreversible brain and organ damage after 6 minutes

232
Q

What should we do when we see the head delivered as nurses?

A

Mark the time, because we want to make sure that the rest of the baby is delivered pretty quickly and is not stuck like with shoulder dystocia. If a baby’s heads delivered but not the baby within 1 minute or more, then it is considered a shoulder dystocia.

233
Q

What are risk factors for shoulder dystocia 7

A
  • Increased birth weight
  • Gestational diabetes (chest is the largest part)
  • Obesity
  • Size discrepancy between the parents (small mom and big dad)
  • Use of vacuum or forceps (since you had such trouble delivering the head, are we going to have enough space to deliver the shoulders?)
  • Prolonged second stage (pushing, like for 2 hours for a primi or 1 hour for a multi, might cause us to think that since it is taking so long to push that maybe this baby isn’t the right size to come out)
  • Previous hx of shoulder dystocia
234
Q

What is interesting to note about shoulder dystocias

A

That most occur in average size babys

235
Q

What team do we want to have on standby when we know we have a shoulder dystocia

A

OR

236
Q

Besides having an OR ready for a shoulder dystocia, what else do we want to have ready?

A

A stool

237
Q

What is our management for shoulder dystocias 6

A
  • Make sure mom has an empty bladder (sometimes foley is removed if they have an epidural to create more space) (we can straight cath a pt if needed)
  • Providing firm pressure under mom’s buttocks
  • NICU should be present and resuscitation equipment must be present and ready
  • Position mom (lower the HOB down, pull legs)
  • Have 10L of oxygen on
  • Make a change in approach to delivery every 30 seconds (try different maneuvers)
238
Q

What is the first maneuver that we do? What are we doing?

A

Mc Roberts maneurver
1. Lower HOB
2. Bring knees apart and to her shoulders (moving her legs back really opens the pelvis)
3. Perform suprapubic pressure as directed

239
Q

What is the wood screw maneuver

A

Where the provider tries to rotate the baby around and deliver the other shoulder

240
Q

What is the Gaskin technique

A

Have mom on her hands and knees to help change position of baby

241
Q

What is the symphysiotomy

A

The ligaments of the symphysis are cut, which can add an extra 2-3 inches to the maternal pelvis

242
Q

What is the Zavanelli

A

Baby’s head is pushed back in and the baby is delivered via c-section

243
Q

What are two injuries that can happen to a newborn if there is dystocia

A

Brachial plexus or fractured clavicle injury

244
Q

How would we know if the baby has a broken clavicle

A

When you assess the clavicle you’re going to feel crepitus (snap/crackle of air)

245
Q

What has happened in a brachial plexus injury

A

There is either bruising, stretching, avulsion (forcible detachment) of the nerve networks C5 to T1

246
Q

Can a brachial plexus injury vary in severity

A

Yes, it could just be temporary palsy to flaccid, or it could lead to serious damage, where the newborn is unable to move the shoulder

247
Q

What reflex could you test to see if there is a brachial plexus injury

A

The moro reflex, where you startle the baby to see if they pull their arms out and up to their chest (if there is a brachial plexus injury, they won’t be able to move the affected arm because of the shoulder injury)

248
Q

What is a major complication of shoulder dystocia for the newborn

A

Erb’s palsy, which is where the newborn doesn’t have any movement in their affected arm

249
Q

What is needed in order to use a vacuum or forceps

A
  • Membranes need to be ruptured
  • Mom needs to be fully dilated
250
Q

Why would we use a vacuum or froceps

A
  • To help with the “power”, which is one of our 4 P’s, where mom is getting tired and her pushes aren’t as strong anymore, a vacuum or forceps can help her to get the baby out
  • And baby is starting to go into distress
251
Q

What are newborn considerations if we’re using a vacuum or forceps (a lot)

A
  • May increase the risk for shoulder dystocia
  • Lacerations/nerve damage to the baby
  • Vacuum can cause cephala hematomas
  • Going to be more swelling/trauma to head
  • Does swelling cross the sutures? (if it doesn’t cross sutures, we worry about blood loss)
  • Monitor VS
  • Monitor head circumference of baby (should be getting smaller, not bigger)
  • Do our neuro assessments on baby’s (sucking reflex, apply pressure to rough of baby’s mouth) (If baby isn’t sucking, this could be a sign of neuro damage)
  • Forceps can cause more tissue damage on mom, which can lead to hematomas
  • Mom would usually have an episiotomy so we can make space
252
Q

What is anaphylactoid syndrome

A

Where amniotic fluid enters the mom’s blood stream and gets carried into the lungs, basically it becomes a blood clot

253
Q

Besides causing a blood clot, what can anaphylactoid syndrome lead to

A
  • Circulatory failure
  • Respiratory failure
  • DIC can occur due to the amniotic fluid interferring with clotting
254
Q

What are signs of anaphylactoid syndrome

A
  • Acute drop in BP
  • Cardiac arrest
  • Cough
  • Chest pain
  • Think about PE symptoms
255
Q

How do we treat anaphylactoid syndrome

A

We treat it like a code
- CPR
- Oxygen with ventilation
- Fluid volume expansion
- Vasopressors
- Packed cells
- FFP
- Fibrinogen

256
Q

If mom is on ventilation, how should we position her

A

Uterine tilt, so she’s not completely on her back

257
Q

What is a TOLAC (Trial of labor after caesarean also called a VBAC (vaginal birth after caesarean))

A

When we let a woman who had a previous c-section try to have a vaginal birth with her next child, because the reason she had a c-section may not necessarily happen again, like say her previous baby was a breach, so that’s why they had a do a c-section, well that doesn’t mean her next baby is going to be breach, so try and do a vaginal birth (her body was still able to physically have a baby, it’s just that the baby was upside, or maybe she had a cord prolapse)

258
Q

What are the 2 risks with TOLAC

A
  • Needing a c-section anyways
  • Uterine rupture due to the previous incision site
259
Q

Who is eligible for TOLAC 4

A
  • Hx of only one previous low-transverse c-section
  • Adequate pelvis in relation to fetal size
  • No other uterine scars, anomalies or previous ruptures
  • Physician is always available throughout active labor
260
Q

How do we manage our TOLAC mothers 3

A
  • Have them on high-risk
  • Continuous fetal monitoring
  • Plan as if they’re going to have a c-section (have consents signed, have hair clipped and removed from area)
261
Q

What is a uterine rupture

A

An actual rupture of the uterine muscle

262
Q

What are we concerned about with a uterine rupture 3

A
  • Concerned about BLEEDING
  • Hypovolemic shock for mom
  • Poor fetal perfusion for baby
263
Q

What are s/s of uterine rupture 5

A
  • Sudden, sharp abdominal pain with a contraction (may stop when contraction stops)
  • When you palpate mom’s abdomen you might be able to feel fetal parts
  • Sudden drop in fetal HR (bradycardia)
  • Might have loss of strong contractions
  • Might have loss of station (think about it - if you have that rupture of the uterine muscle, the baby might just float back up to the abdominal cavity)
264
Q

What is our management of a uterine rupture 3

A
  • EMERGENCY
  • STAT C-section
  • Might have a hysterectomy if completely rupture (difficult to repair)
265
Q

What is twin transfusion

A

When twins are sharing a placenta, but one twin isn’t getting as much perfusion/fluid as the other twin, and the other twin is getting too much perfusion/fluid

266
Q

What is the issue with twin transfusion, besides one baby not getting enough perfusion/fluid

A

The baby that is getting too much fluid can be at an increased risk of HF

267
Q

What can we do to monitor for twin transfusion

A

Use a doppler to see if the perfusion/fluid is being evenly distributed between the twins

268
Q

What are increased risks if you’re having multiples 8

A
  • Pre-term labor (due to the increase in pressure)
  • Preeclampsia
  • Gestational diabetes
  • Placental masks
  • Hyperemesis
  • Placenta previa (if more than one placenta)
  • Abnormal presentation
  • Cord prolapse
269
Q

When we’re checking FHR for multiples, what do we want to do

A

We want to be checking for all of the baby’s HRs at the same time (don’t do one at a time, because you wouldn’t be able to determine which HR belongs to which baby)

270
Q

What type of delivery do we automatically do if a mom is having 3 or more babies

A

C-section (too difficult to deliver all of the baby’s vaginally without complications)

271
Q

What should we encourage our mother’s to get if they are having twins and trying a vaginal birth

A

We want to encourage them to get an epidural, just to help with the pain in case we need to have extra assistance (like forceps or a vacuum, etc) during the delivery, since they will be doing double the work, or if we need to end up having a c-section

272
Q

What is our birth time for twins born vaginally or via c-section

A

Vaginally - usually 15 minutes apart

C-section - usually 1 minute apart

273
Q

Where do we like mom’s who are attempting a vaginal birth with twins to deliver

A

We like them to deliver in the OR, just in case

274
Q

After delivery, what are we worried about if mom has given birth to multiples

A

Post-partem hemorrhage, they are at an increased risk as their uterine muscle was stretched larger, so we may have difficulty getting it to clamp down

275
Q

How much blood loss is considered postpartum hemorrhage

A

Quantitative blood loss (QBL) is 1000 mL

276
Q

What is primary PP hemorrhage

A

Within the first 24hrs after delivery

277
Q

What is secondary PP hemorrhage

A

after that 24hrs and up to 12 weeks

278
Q

What are the 4 different causes of PP hemorrhage

A
  1. Tone (most common issue)
  2. Trauma
  3. Tissue
  4. Thrombin (very rare)
    (see the table on pg 420)
279
Q

How can we prepare for a primary PPH 5

A
  • Drills
  • PPH Kit
  • Admission record - showing religious or cultural considerations (want to know if they will accept blood products if needed)
  • If they have a hx of PPH it gives them a 10% risk of having it happen again (so make sure everything is ready to go)
  • Everyone gets a CBC and type and screen on admission
280
Q

What is a big red flag that a mom might have PPH after her delivery

A

If she had a previous PPH with her other pregnancies

281
Q

How can we manage PPH

A
  • Address the cause (ie tone - give fundal massage)
  • Make sure you do frequent fundal massages after delivery (midline at the umbilicus, or a finger or two above or below)
  • Assess lochia every time we do a fundal massage (how much blood is coming out)
  • Maternal VS (not going to show us early changes, because women have things that buffer signs and symptoms of blood loss initially due to the pregnancy) (fyi - baby’s HR, then mom’s HR, then mom’s BP will be signs of hemorrhage in this order)
  • Quantitative blood loss - make sure we measure everything (1gram = 1 mL)
282
Q

What are the risk factors of Primary PPH

A
  • Overdistended or exhausted uterus (LGA babies, polyhydramnios, multiples, multify (+5 babies) (uterus is soo stretched it has difficult getting back to original size)
  • Infection (infected uterus isn’t going to contract effectively)
  • Anatomical/functional issues (full bladder - fundus will be off to the side if bladder is full, Pitocin over a long period of time, if we give more Pitocin it isn’t going to do anything)
283
Q

What do we do for uterine atony

A
  • # 1 start vigorous fundal massage
  • Bi-manual exam (provider does this)
  • Empty bladder if we need to
284
Q

What medications can we give for uterine atony

A
  • # 1 Pitocin (usually already hanging and ready to go as it is standard to give to everyone after delivery, if PPH starts, will probably need to titrate up)
  • Then give Misprostol (Ctyotec) (Can we given rectally)
  • Methylergonovine maleate (Methergine) (Give IM)
  • Prostaglandins (Hemabate) (Give IM)
285
Q

What is the contraindication of Methergine

A

If they have hypertension (because it causes hypertension)

286
Q

What is the contraindication of Hemabate

A

Asthma

287
Q

WHat is an unpleasant side effect of Hemabata, and which is why it is given last

A

Awful diarrhea (makes it difficult to measure blood loss)

288
Q

What is another medication that is not as common for PPH, but is starting to be given more? And what does it do?

A

Tranexamic acid - helps prevent breakdown of clots

289
Q

What is the Bakri balloon

A

Balloon that is inserted into the uterus, and is filled with 500-1,0000 MLs of saline, this helps put manual pressure where the placenta was attached to help clots form

290
Q

When we do a fundal assessment on a pt who has a Bakri Balloon, what will it feel like?

A

It was be hard, above the umbilicus (don’t want to disturb it, because we don’t want it to rupture)

291
Q

What can cause trauma for primary PPH 3

A
  • Lacerations (we will see a red trickle stream of blood)
  • Hematomas
  • Uterine inversion
292
Q

What would be a symptom of a hematoma

A

Very, very painful where the hematoma is forming

293
Q

How can we treat a hematoma

A

We might drain it or we might let is reabsorb overtime

294
Q

How does a uterine inversion happen

A
  • Providers may put too much pressure on the cord when trying to get the placenta out - this can cause the uterus to go inside down and invert
  • If we don’t put our hand below the uterus when doing a fundal massage we could invert it
295
Q

How can we management a uterine inversion 5

A
  • Manually reducing the uterus (putting it back in the right spot - might need anesthesia for this)
  • Tocolytics
  • Terbutaline
  • Fluid bolus if issue with volume
  • Possible transfusion
296
Q

Besides bleeding, what else is a complication of uterine inversion

A

Infection because you have the uterus coming out of the body

297
Q

What can cause tissue issues for primary PPH 2

A
  • Retained products (like little membranes, pieces of placenta (this is why we check the placenta after birth to see it it’s still in tack)
  • Abnormal placentation
298
Q

What is a risk factor for PPH related to tissue

A

placenta accreta (where the placenta has grown into the uterine wall)

299
Q

What syndrome did we learn about earlier that can cause thrombin issues for PPH

A

Anaphylactoid Syndrome (amniotic fluid embolism)

300
Q

What is our standard postpartum care

A
  • Assess vital signs, uterine position and uterine bleeding every 5min x for the first 15min, then every 15 minutes for the first hour, then Q30min x 2, then Q1 x4
  • Promote breastfeeding (helps stimulate contractions to prevent hemorrhage)
301
Q

Are a change in mother’s VS an early or late sign of PPH

A

Late - a change in mom’s VS are late signs of PPHs

302
Q

What are causes of secondary PPH 3

A
  • # 1 cause is retained products
  • Uterine infection (causes an increase risk of bleeding - want to teach mom to be clean down there and good peri care so we can reduce risk of infection)
  • Coag defects like Von Willebrand
303
Q

When would we give blood?

A

If hemoglobin is less an 7 or they’re symptomatic of blood loss

304
Q

What is endometritis

A

Infection of the uterus (it’s like chorioamnionitis, but now the membranes are gone because the baby has been delivered)

305
Q

What are s/s of endometritis 5

A
  • *Pelvic pain
  • Increase in lochia
  • Foul smelling lochia
  • Fever
  • Increased HR
306
Q

What are s/s of mastitis

A
  • *Unilateral symptoms and more localized
  • Going to be a red, hard wedge shape towards the armpits
  • Breast tenderness
  • Pain/burning with or without breastfeeding
  • Malaise
  • Temp
307
Q

What is our tx for mastitis 3

A
  • Oral abx
  • Continue to breastfeed
  • Apply hot packs if needed
308
Q
A
309
Q

What is a key with mastitis symptoms

A

A woman may think that they have mastitis when their milk comes in because when your milk comes in it can cause tenderness and warmth, but this occurs in both breasts (bilaterally), whereas mastitis symptoms happen in only one breast (unilateral)

310
Q

All women are at risk for PP depression, but which women may be at higher risk for it

A

Primagravida
History of depression
Medical complications
Immaturity and/or low self-esteem
Dysfunctional personal relationship
Financial concerns
Chronic stress
Infant with illness or anomalies
Isolation/lack of support
Uncertainty about the pregnancy that lasts beyond the first trimester

311
Q

How is PPD different from the “baby blues”

A

With the baby blues, symptoms will disappear without medication tx, they usually occur within the first 2 weeks of postpartum, and mom is still able to safely handle the baby.

With PPD, symptoms require medical tx, they usually occur within the first 12 months, and they are unable to safely care for the baby.

312
Q

What are symptoms of the “baby blues”

A
  • Fatigue
  • Anxiety
  • Tearfulness
  • Mood swings
    (a lot has to do with changes in hormones)
    (mom is still able to care for themselves and baby)
313
Q

Is it normal for baby blues to last over 2 weeks

A

No, that’s not normal

314
Q

What are the s/s of PPD? (a lot)

A
  • Depression
  • Apathy (not caring) (big red flag - not caring about the baby)
  • Anxiety
  • Panic attacks
  • Fatigue
  • Significant weight loss or gain
  • Insomnia or hypersomnia
  • Feelings of worthless or guilt
  • Decreased ability to concentrate
  • Inability to make decisions

(fyi - these s/s need to last longer than 2 weeks)

315
Q

Besides the mom, who should we teach PPD symptoms to, basically what to look for as signs of PPD

A

We want to teach the SO, because usually pts with PPD do not identify themselves, so we want the SO to watch for signs and symptoms

316
Q

What is our tx for PPD 3

A
  • SSRIs (Paroxetine, Fluoxetin, Setraline)
  • Complimentary therapies
  • Lots of support
317
Q

If a woman has PPD depression, is she at risk of developing it again with any future pregnancies? If so, what might a provider do?

A

Yes - she has a 50-90% chance of having PPD again with any future pregnancies

Provider might preemptively start her on SSRIs

318
Q

What can PPD lead to if untreated or unresolved

A

It can lead to PP Psychosis (this is where women try to kill the baby and go crazy)

319
Q

What are s/s of PP psychosis

A
  • Paranoia
  • Gradiose, bizarre delusions (usually about the baby)
  • Mood swings
  • Confused thinking
  • Anxiety
  • Panic
    (very dramatic changes from normal)
320
Q

What is the timeline of PP Psychosis

A
  • First peak in first 10 days
  • Second peak in 6-8
321
Q

How do we treat PP Psychosis

A

As a true emergency, because these are usually the moms that kill their babies

  • They’ll go on long-term psychotherapy and medication
322
Q

What is the leading cause of neonatal sepsis

A

GBS

323
Q

When do we screen mom for GBS

A

All women are screened between 35-37 weeks

324
Q

What do we give to treat GBS for our moms? When do we give it? Will this cure their GBS?

A

Ampicillin/Clindamycin

Give within 4 hours of delivery

Doesn’t cure it - only working during labor and then the GBS will eventually grow back

325
Q

What typically causes Chorioamnionitis? What are other risk factors?

A

Typically caused by ascending polymicrobial infection after membranes have been ruptured

Prolonged ROM
Prolonged labor
Nulliparity
Internal monitoring
Multiple VE (vaginal exams)
Meconium-stained amniotic fluid
Smoking
Drug or alcohol abuse
Immune compromised
Bacterial vaginosis
Group Beta Strep colonization
STDs

326
Q

What is a big issue with infection while pregnant and after pregnant

A

Can cause the uterus to not function correctly, leading to dysfunctional contractions during delivery and after - which increases risk for PPH

327
Q

What are risk factors for newborn sepsis 6

A
  • Preterm delivery
  • Prolonged labor
  • ROM greater than 18 hours
  • Maternal fever
  • *Chorioamnionitis (infection of the uterus and amniotic sac)
  • *Maternal GBS
328
Q

How might infants present their symptoms if they have an infection

A

They may be asymptomatic at first

329
Q

What is the first symptom indicator that a baby may have sepsis

A

We see behavioral changes in the baby

330
Q

What are s/s of sepsis in newborns 4

A

First s/s can be very subtle (why we like to have the same nurses assigned to them so we can notice the changes)
- May be hyper or hypothermic
- Lethargic
- Hypoglycemic
- Poor feeding

331
Q

How can we tell if a baby is hypoglycemic if we’re not checking the sugars 4

A
  • High pitched cry
  • Low temp
  • Decreased tone
  • Poor feeding
332
Q

How can we diagnosis a baby if we think they may have sepsis 4

A
  • CBC
  • C-reactive protein (CRP)
  • Platelets
  • Blood culture
333
Q

How do we treat newborn sepsis

A
  • Start on ampicillin and Gentamycin until cultures come back after 48hrs (broad spectrum and to narrow once cultures come back)
334
Q

What type of Rh are we worried about for mom and baby

A

If mom is Rh- and if baby is Rh+

335
Q

What do we give our Rh- moms

A

RhoGAM at 28 weeks even though we don’t know if baby is Rh+, and not she may receive it again within 72hrs after delivery and after we test baby, if baby is actually Rh+

336
Q

What is the issue with Rh incompatibility

A

If an Rh- mom is exposed to an Rh+ baby, then antigens are created by baby and transferred into mom’s bloodstream, where the first child is usually not affected, but the antigens can destroy fetal RBCs and cause anemia in the second child

337
Q

What specific blood types are we also worried about?

A

If mom has type O blood, but has a fetus with A or B = mom’s antibodies (anti A and anti B) will attack baby’s RBCs

338
Q

What does a positive Coombs test tell us? What are baby’s who have a positive Coombs test at risk for?

A

Tells us that there was a mixing of mom and baby’s blood, because it detects antibodies that may not have been compatible and baby is at risk for hyperbilirubinemia (aka jaundice)

339
Q

What is our management for baby’s with hyperbilirubinemia 2

A
  • Frequent feedings, because bilirubin is excreted in the stool, so we want frequent feedings to keep things moving through their digestive tract.
  • Might need bilirubin lights (helps breakup bilirubin)
340
Q

What does IDM stand for

A

Infant of diabetic mothers

341
Q

What are SGA and IUGRs at risk for 4

A
  • Hypothermia (don’t have reserve adipose tissue and brown fat)
  • Hypoglycemia
  • Infection
  • Hyperbilirubinemia
342
Q

What are LGA and IDM baby’s at risk for 4

A
  • Hypoglycemia
  • Nutritional deficits (low mag and calcium levels and low glucose)
  • Hyperbilirubinemia
  • Transient tachypneic (respiratory distress) of newborn due to surfactant production (too much insulin when in utero can decrease surfactant production)
343
Q

What are risk factors that can cause preterm labor 6

A
  • Infection
  • Previous preterm labor hx
  • Multiples
  • Polyhydramnios
  • Preeclampsia
  • Gestational diabetes
344
Q

What are our diagnostic tests for preterm labor 3

A
  • FFN (the diva test)
  • Cervical length
  • UA
345
Q

What is our tx of PTL 2

A
  • Tocolytics (these stop contractions) (mag sulfate, Nifendine, another one, and Tubutaline (remember HR))
  • Give betamethasone
346
Q

What impact does mag have on mom

A
  • CNS depression
  • Relaxes uterus
  • Causes vasodilation (lowers BP)
347
Q

What impact can mag sulate have on baby when born

A
  • Decrease in RR
  • Decrease in Tone
  • Minimal variability on FHR monitor
348
Q

What are our preterm baby’s at risk for 5

A
  • Hypoglycemia
  • Hypothermia
  • RDS (due to decrease surfactant)
  • Jaundice
  • IVH (intraventricular hemorrhage - trauma to head from vaginal birth)
349
Q

What are the s/s of RDS in baby’s

A
  • Increase RR >60
  • Retractions
  • Cyanosis
  • Decreased breath sounds
350
Q

What is our tx of RDS in baby’s

A
  • CPAP
  • Surfactant via ET
351
Q

At how many weeks do we see a decrease in placenta perfusion for long pregnancies

A

42 weeks

352
Q

What are post-term babies at risk for 6

A
  • Meconium aspiration
  • Dry, flaky skin (decrease in vernum)
  • Oligohydramnios with risk of cord compression
  • Still birth (due to placenta issues)
  • Dystocia’s
  • Assisted births
353
Q

What is our tx for post-term pregnancies

A
  • Try to induce at 41 weeks
  • Manage baby with frequent nonstress tests and biophysical profiles
354
Q

What baby’s are at risk for Meconium aspiration syndrome (MAS)

A
  • Post-term baby’s
  • Baby is under stress or something traumatic
355
Q

Is MAS common?

A

Yes MAS is pretty common, but it is very uncommon for it to actually cause any complications

356
Q

Why might meconium aspiration syndrome (MAS) occur

A

If the baby has some kind of stress, like a moment of poor perfusion that causes them to poop and then they have a “shock moment” where they take a breath and then breathe in that meconium

357
Q

What is our tx for MAS 6

A
  • Suctioning if baby is not vigorous
  • Possible ventilation
  • Monitor for infection
  • Might need some surfactant
  • Might need prophylactic abxs
  • Have a team in the room ready in case something happens
358
Q
A

Diffuse swelling is normal after delivery (cone head babys)
- Cephlahematoma (collection of blood that doesn’t cross the sutures - monitor head circumferance to make sure it doesn’t grow, make sure there isn’t a subdural hematoma, blood should just absorb back)

359
Q

Types of substances that we can use a neonatal abstience score sheet

A
  • Heroin
  • Methadone
  • Pain meds
360
Q

What are signs of suspeicison of use

A
  • No neonatal visitis
361
Q

What is the name of our abstience tool

A

Modified Finnegan Neonatal abstinence Score Sheet

362
Q

What are s/s of NAS

A
  • Excessive high pitch cry
  • Decreased sleep
  • Hyperactive moro reflex
  • Tremors
  • Sweating
  • INcreased temp
  • Elevated RR
    (everything is upwhen they’re withdrawaing)
363
Q

What is our diagnostic testing for baby

A
  • Do a tox screen after they’re born
364
Q

How can we treat NAS (a lot)

A
  • High-calorie formula
  • Small frequent feedings
  • Antidiarrhea
  • Meticulous I/Os
  • Wts
  • Skin care with barrier ointments
  • Breastfeeding if not CI
  • Morphine/methadone as needed
  • Collaborate with SS
  • Promote comfort
  • Tox screen
365
Q

Diabetes 171

A

Risk factors:
- Obesity
- Family hx of diabetes
- A lot of time no risk factors for pts

Maternal risks for mom with diabetes:
- DKA
- Infections
- Preeclampsia
- C-section
- Difficult delivery if baby is big
- Increased risk of developing type 2 later on

Neontal risk
- Hypoglycemia
- Macrosomia
- IUGR when blood vessels on the placenta are damaged
- Respiratory distress due to decrease in surfactant production
- SHoulder dystocia (these baby’s can have broader chests)

366
Q

What are goals/management of diabetes

A
  • Euglycemia
367
Q

What should diabetic mom’s increase in their diet

A

Folic acid

368
Q

How do insulin needs change depending on where they are at in pregnancy

A

1st half: less insulin
2nd half: more insulin
PP: less insulin

369
Q

Pg 172 preeclampsia

A

Widespread vasospasm and endothelial damage

370
Q

Placental dysfunction can occur causing what in preeclampsia:

A
  • IUGR
  • Late decels once contractions start (not good placenta reserve)
371
Q

What are our assessments and diagnostics for preeclampsia

A
  • Headaches
  • Spots in vision
  • Upper right quadrant pain
  • Edema
  • Urinary output (kidney function)
  • Reflexes
372
Q

Tx for preeclampsia

A
  • Delivery
  • Give mag for seizures
  • Calm, mellow, dark room
  • Bed rest, but can still use the bathroom
373
Q

Tx for preeclampsia

A
  • Delivery
  • Give mag for seizures
  • Calm, mellow, dark room
  • Bed rest, but can still use the bathroom
374
Q

How is PPD different from the “baby blues”

A

With the baby blues, symptoms will disappear without medication tx, they usually occur within the first 2 weeks of postpartum, and mom is still able to safely handle the baby.

With PPD, symptoms require medical tx, they usually occur within the first 12 months, and they are unable to safely care for the baby.

202A (5 decks)

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