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Preterm Labor

Labor that occurs between 20 to 36 weeks

1

Risk Factors associated with Pre-term Labor

Previous pre-term Labor, genetics, cervical and uterine trauma, infections, PPROM, Maternal age 35 yrs, tobacco and cocaine use, hypertension

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Fetal and Placental Cause of PTL

Multiple Gestation, Twins, hydramnous, placental ischemia, previa, and abruptio

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Management of PTL

Fetal Fibronetic test viable between 24 to 34 weeks. If negative -> low risk of PTL up to 14 days. If positive -> higher risk of PTL within 7 days
Administer tocolytic if 32 to 34 weeks to delay labor and relaxes smooth uterine muscle
Administer corticosteroid to increase maturity of lungs if under 34weeks
Progesterone therapy

4

Nursing care for PTL

-Monitor uterine contractions and PV loss
-Monitor fetus
-prepare for preterm birth if contraction continues

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Post Term Labor

-Any labor that occurs after 42 weeks

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Causes of Post Term Labor

-usually error in determining ovulation and conception

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Data for Post term labor

Weight loss, decrease in fetal movement

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Maternal Risk Associated with Post Term Labor

-increase psychological stress, induction, dystocia, assisted delivery
-perineal trauma, increased laceration, risk for bleeding and infections
-increase caesaren - increase DVT

9

Risk Associated for Fetus in Post Term Labor

-decrease placental perfusion, fetal demise, oligohydramious, macrosomia, low abgar score, SIDS, nerve and bone damage ->paralysis, cerebral palsy, meconium aspiration

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Medical Intervention for Post-Term Labor

-at 41 weeks daily fetal movement count
-nonstress test (NST) 2/week
-U/S for fetal size
-Amniotic fluid index (AFI) 2/week
-Elective induction if viable

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Precipitous Labor and Delivery

Labor - any labor that last for less than 3 hours
Delivery - any birth that is unplanned, sudden, or unexpected

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Factors Associated with Precipitous Labor

-multiparity, small fetus, large pelvis, previous precipitous labor

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Maternal Risk for Precipitous Labor

-increase laceration and trauma, decreased coping abilities, PPH

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Fetal Risk Associated with Precipitous Labor

-hypoxia, fetal distress caused by intense uterine contraction, bracial nerve injury

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Induction

the artificial initiation of uterine contraction, resulting in the birth of a baby

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Maternal Condition Indication of Induction

-Post term Labor, diabetes, renal disease, PROM, chorionamnionitis, previous precipitous labor

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Fetal Condition for Induction

-intrauterine fetal growth restriction (IUGR)
-Fetal demise
-Macrosomia
-HYMOLYTIC DISEASE
-mild abuptio

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Management of Induction

Unripe Cervix - (6 on Bishop score)
-sweep membrane, amniotomy, prostaglandin gel intravaginal, IV oxytocin

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Nursing care for Induction

V/S, Leopold's Maneuver, vaginal exam, EFM
RN to follow induction protocol
PT and Fetus monitor q2h
-if cervidil or prostaglandin - pt may be sent home until active labor

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Forcep and Vacuum Extraction Maternal and fetal Indication

-exhaustion, lack of progress, health condition (heart disease and PIH), decrease motor innervation from epidural

-fetal distress, placenta seperation, OP position, macrosomia, breech

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Maternal Risk and Fetal risk for Forceps and Vacuum

Maternal: increase laceration and trauma, increased bleeding, infection and hemorrhage

Fetus: decrease flexion of head, echymosis, edmema, caput, cephalohematoma, paralysis

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Fetal Distress Causes

-cord compression, placenta insufficiency, maternal, fetal and placenta disease

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Fetal Distress Warning Signs

-meconium stained liquoi, omnious FHR patterns
-CODE OB

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Nursing Intervention for Fetal Distress

-give O2, tilt uterus on left side, EFM, internal monitoring, D/C induction, give tocolytic, I/V, fetal scalp blood sample

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Prolapsed Cord

-cord that descends through the vagina prior to birth of baby

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Risk factors Associated with Prolapsed Cord

-breech, polyhydramnious

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OB EMERGENCY OF Prolapsed CORD

-Knee to chest (mcroberts maneuver), hand in vagina to relieve pressure off the cord

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Shoulder Dystocia

-after delivery of head further expulsion of infant is prevented due to impaction of fetal shoulders in the maternal pelvis

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causes of Shoulder Dystocia

-Macrosomia, maternal diabetes, obesity, multiparity, post term

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What to do when there is Shoulder Dystocia

alert ALARMER
-Ask for help
-Lift hips/hyperflex of hips
-Anterior shoulder disimpaction
-Rotation of the posterior shoulders
-Manual removal of posterior shoulders
-Episiotomy
-Roll women on all fours

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Maternal and Fetal complications of Shoulder Dystocia

PPH, Trauma, and infection

-Brachial plexus injury
-fractures, asphyxia, neurological damage, demise

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DVT Associated factors

-hydramnious, preeclampsia, operative birth, history of clots, obesity

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DATA involving DVT

-color, warmth, movement, sensation, edema, low grade fever

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TX for DVT

Prevention - ambulate early, no crossing legs

-heparin, increase fluids

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Inversion of Uterus Prevention and TX

Prevented by
-waiting for signs of separation
-cord extending, gush of blood
-no fundal pressure

TX
-put back in, call MD

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Hyperemsis Gravidarium

-excessive and persistent nausea and vomiting during pregnancy associated with ketosis and weight loss

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HG causes

-increase HCG and TSH in the first trimester, increase estradiol and decrease in prolactin
-genetic

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Objective and subjective DATA for HG

-progressive vomiting and retching
-dehydration
-fluid and electrolytes imbalance
-hypotension, tachycardia
-K+ loss
-Fetal loss

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TX for HG

Assess physical and emotion state
NPOx48H
Monitor I&O
antiemetic
correct F&E imbalance
TPN PRN
control environment

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Spontaneous Abortion

-spontaneous loss of pregnancy prior to viability (20 weeks)

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Types of SA

Threatened - bleeding, cramping, closed cervix
Imminent/inevitable - bleeding, cramping, dilation of cervix
incomplete - not all expelled, placenta retained
complete - all product expelled
Miss Abortion - fetus dies, brownish discharge, risk of DIC if not expelled
Recurrent pregnancy loss
Septic abortion - presence of infection

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Causes of SA

Chromosomal and placental abnormalities
implantation problems
teratogens (hot tubs)
endocrine imbalance
infections

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Data for SA

Spotting, cramping, backaches

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TX for SA

Determine source of blood
cross match blood, HBG, HCT
bed rest
no sex
If imminent -> hospitalize -> IV, suction
emotional support

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Placenta Previo

low implantation of the placenta

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Types of Previo

Low lying - lower segment
Marginal - on the margin of the internal OS
Partial - partially covering the internal OS
complete - completely covering the internal OS

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Causes for Previa

Multiparity, previous c-sec, previous induced abortion, age, large placenta, smoking, asian women

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Data for Previa

U/S
Bleeding abruptly, painless, bright red

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TX for Previa

Bed rest, BR only privilege, side lying, oxygen PRN
FHR
VS U/S
HBG and HCT, cross match and urinalysis
Delay birth until 37 weeks
administer corticosteroids
C-sec if complete previa
Vag delivery if low lying or marginal

50

Placenta Abruption

Premature separation of the normally implanted placenta from the wall of the uterus

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Types of Abruption

Marginal, Control, Complete
Grade 1 - Mild separation (mild bleeding, stable V/S and FHR)
Grade 2 - partial separation (uterine irritability)
Grade 3 - Complete (fetal death)

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Causes of Abruption

increase age, multi parity
PIH, trauma, sudden uterine pressure change
previous abruption
cocaine and smoking
PPROM

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Data for Placenta Abruption

Pain (sharp, stabbing, high in fundal area)
bleeding (only marginal) overt
Covert - uterine becomes hard (central)
Shock
DIC

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TX for Abruption

IV
Monitor V/S of PT and Fetal
PV loss
contraction
O2
Stat blood work, HBG, HCT, Cross match, Fibrogen levels
-ARM & Induction , Vacuum

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Cervical Insufficiency

Cervix dilates early and cannot hold a fetus to term
painless dilations occurring between 4th to 5th month

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Cause and types of Cervical Insufficiency

Congenital
acquired (infection, trauma, multiple gestations)
Biochemical (relaxin)

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Objective & Subjective data of CI

Painless dilation of cervix
Increased pelvic pressure
contraction
birth of premature baby

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Medical treatment and Nursing care for CI

Vaginal U/S @ 15 to 28 weeks
bed rest, no sex, heavy lifting
Cerclage/suture @ 14 to 18 weeks
progesterone, anti-inflammatories, antibiotics

59

Hypertensive Disorders in pregnancy

Preeclampsia (mild to severe) is the increase of BP after 10 weeks gestation accompanied by proteinuria in a previously normaltensive women
Eclampsia - severe form of preeclampsia with generalized edema or coma

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Predisposing Factors of Hypertensive orders in preg

Teens and older primips
previous history
large placental mass
Rh incompatibility
diabetes

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Objective and Subjective DATA for Preeclampsia and Eclampsia

mild disease - 140/90 4 hours apart, Proteinuria +1-+2
edema >3.3/month

Severe preeclampsia - 160/110, 6 hours apart, proteinuria +3 to +4

-oliguria, visual or cerebral disturbances, cyanosis/pulmonary and generalized edema

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TX of Preeclampsia and Eclampsia

Freq assessment of VS, I&O, FH, Uterus, PV loss, edema, weight, reflexes, signs of eclampsia, LOC and psychosocial
-bed rest (left side) & diet
-anticonvulsant, antihypertensive, corticosteroids
-lab test (Hct, BUN, creatinine, uric acid levels, liver enzymes, F&E imbalances and MG levels

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TX for Severe PIH

stabilize then deliver baby by induction or C-sec

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HELLP SYNDROME

hemolysis, elevated liver enzymes, low platelet count
- sometimes associated with severe preeclampsia

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DIC - Disseminated intravascular coagulation associated with

preeclampsia, eclampsia, HELLP (occur as complication)
-placenta abruptio
-amniotic fluid embolism
-maternal liver disease
-septic abortion
-dead fetus

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Diabetes Mellitus S&S

Polyuria
polydipsia
polyphagia
wt.loss

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Rh Alloimmunization

-Rh+ cells invade maternal circulation and stimulate production of antibodies
-produced in 72hours
-if antibodies are formed, future pregnancies the antibody will cross placenta barrier and hemolyse fetal RBC's

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Rh Isoimmunization TX and Nursing CARE

-early testing
If Rh-, indirect coombs done (determine the presence and amt of antibodies

-AntiD or Rhogam given at 28weeks if no antibodies present
-if at birth, mom is Rh neg, direct coomb's test on cord's blood
-if negative, mom will receive anti D in 72 hours of birth

Rh immunoglobulin not given if mom is Rh positive

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ABO Incompatibility

Mother O (no antigenic sites on RBC), Baby A, B, AB (may be affected
-become aware in preg
-monitor baby for jaundixe
-phototherapy PRN

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Premature Rupture of Membranes PROM

PROM before onset of labor

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Risk associated with PROM

Smoking, low BMI, infections, history of PROM, incompetent cervix, trauma, hydramnious, multiple gestation, previa/abruptio

Risks - infection (chorioamnionitis, endometritis), Abruptio

Fetal - premature birth, neonatal sepsis, cord prolapse

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Diagnose for PROM and TX

Nitrazine test
fern test

TX
- avoid vag exam unless in active labor
-if less than 37 weeks, bedrest, CBC, weekly NST, V/S q4h, antibiotics, betamethasone, no sex and baths
-if >37 induce delivery

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What is Ectopic Pregnancy

-implantation of the fertilized ovum in a site other than the endometrial lining of the uterus

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Causes of Ectopic Pregnancy

-pelvic inflammatory disease
-endometriosis
-previous ectopic pregnancy
-presence of IUD

75

Diagnose of Ectopic Pregnancy

-Assess menstrual history
-careful pelvic exam to identify any abnormal pelvic masses or tenderness

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Treatments for EP

-methotrexate is given if detected early with low Hcg level
-surgically to remove by the process of salpingostomy to gently remove

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Objective and subjective data for Ectopic Pregnancy

-acute pain related to abdominal bleeding
-shoulder pain
-vaginal bleeding

78

Nursing care for EP

-If using methotrexate, no sun exposure
-Start IV, assess for shock/bleeding, assess pain level

79

Hydatidiform mole

disease in which abnormal development of placenta occurs, resulting in a fluid filled grape like clusters; the trophoblastic tissue proliferates

80

Types of Hydatidiform Mole

Complete Mole is when an ovum containing no maternal genetic material fertilizes with a sperm.
Partial Mole is when an ovum fertilizes with a sperm in which contains 46 chromosome

81

Subjective and Objective data for HM

-brownish vaginal bleeding
-uterine enlargement is greater than the expected gestation week is common in complete HM
-vesicles may be passed
-Hyperemesis gravidarium
-symptoms of preeclampsia before week 24
-no FH or movement

82

Treatment for HM

-suction to remove all fragments
-hysterectomy to reduce risk of choriocarcinoma

83

Nursing Care for HM

-assess emotional support
-VS
-vaginal bleeding for hemorrhage
-assess pain
-blood work Hct, cross match
-oxytocin is given to keep uterus contracted
-Rh immunity is given if women is Rh-