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1

Why is supplemental iron usually prescribed during antempartum?

to meet the hemoglobin needs of the expanded RBC volume.

2

How much does plasma volume increase by during antepartum?

plasma volume increases by 50% (is greater than RBC increase)

3

Physiologic anemia of pregnancy

Hct is slightly lower in pregnancy. Anemia is defined as <10.5 mg/dL during 2nd trimester

4

Effects of pregnancy on WBC count

WBC increases 5-12,ooo during pregnancy, and gets as high as 30,000 during labor and postpartum

5

When does CO peak during pregnancy?

CO peaks at about 25-30 weeks at about 30-50% above prepregnant levels

6

Why does n/v happen during first trimester?

increased hCG secretion and changes to carb metabolism

7

cholestasis of pregnancy

intense itching could signal a serious disorder called cholestasis of pregnancy which requires medication and/or delivery of baby at 37 weeks. Characterized by generalized itching starting with palms of hands and soles of feet. No long term sequelae for mom, but can cause sudden fetal death.

8

Why do gums bleed more during pregnancy?

increased estrogen

9

ptyalism

increased saliva production

10

cholasma

mask of pregnancy

11

how does pregnancy affect metabolism?

BMP increases by 20-25% due to increased oxygen consumption.

12

weight gain recommendations

25-35 lbs overall
1-4 lbs in first trimester
1 lb/week during second and third trimesters

**sudden, rapid weight gain is a concern

13

underweight weight gain recommendations

if BMI <18.5, then recommend 28-40 lbs

14

overweight weight gain recommendations

if BMI 25-29.9, 15-25 lbs

15

obese weight gain recommendations

BMI >30 then 11-20 lbs

16

What happens to T4 during pregnancy?

vascularity and hyperplasia of thyroid cause T4 to increase

17

What happens to the pituitary gland during pregnancy?

Pituitary gland enlarges and prolactin supports initial lactation while oxytocin supports uterine contractility and milk ejection from the breasts. Insulin needs increase (hormones of pregnancy cause insulin resistance). DONT TREAT HYPERTHYROIDISM DURING PREGNANCY-BAD FOR BABY. ok to treat hypothyroidism with synthroid.

18

What hormone causes insulin resistance during pregnancy?

Human placental lactogen produced by the placenta. If the woman is diabetic, she will need more insulin as the pregnancy progresses.

19

naegles rule aka LMP to calculate EDB

first day of LMP, subtract three months, add 7 days. Ultrasound to date EDB is GOLDSTANDARD

20

when do you screen for gestational diabetes?

between 24-28 weeks. retest a CBC and an indirect Coob's (if Rh neg) at this time as well.

21

when do you screen for syphylis?

RPR between 32 and 33 weeks

22

When do you screen for GBS?

between 35-37 weeks. swab vagina, if present, treat with Abx during labor to prevent infection of the fetus.

23

CRL

crown, rump length during ultrasound 6-12 weeks accurate +/-3 to 5 days

24

BPD

bipareital diameter measured during ultrasound 14-26 weeks and accurate +/- 7-14 days

25

fundal height

accurate during 22-34 weeks

26

when can you perform a Maternit21 blood test?

as early as 10 weeks. Do this if quad screen comes back positive. Safer than amniocentesis

27

what might visual disturbances or dizziness indicate during pregnancy?

preeclampsia

28

what might a severe headache indicate during pregnancy?

preeclampsia

29

What might seizures or convulsions indicate during pregnancy?

preeclampsia turning into eclampsia

30

what might epigastric pain indicate during pregnancy?

preeclampsia, or just acid reflux due to progesterone and upward pressure on ABD from large uterus

31

What is the best indicator of fetal well-being?

KICK COUNTS!! start counting everday at 28 weeks. count to 10. if it takes longer and longer to count 10 movmts, that is a BIG RED FLAG. (Count after a meal-that's when baby is most likely to be active).

32

why might a women experience SOB during pregnancy?

Hyperventilation of pregnancy caused by increased VC and TV due to increased oxygen needs and mild resp alkalosis. reaasure mom its normal.

33

abortion

elective or spontaneous delivery that occurs before 20 weeks gestation or birth of a fetus weighing less than 500 grams.

34

preterm

birth after 20 weeks but before 37 weeks

35

post-term

birth after 42 weeks

36

gravida

any pregnancy, regardless of duration, including the current one

37

nulligravida

a woman who has never been pregnant

38

primigravida

a woman who is pregnant for the first time

39

multigravida

a woman who is in her second or any subsequent pregnancy

40

Para

birth after 20 weeks gestation, regardless of whether the infant is born alive or death

41

Primipara

a woman who has had one birth at more than 20 weeks gestation, regardless of whether the infant is born alive or death

42

nullipara

a woman who has not given birth at more than 20 weeks gestation

43

multipara

a woman who has had two or more birhts at more than 2 weeks gestation

44

GTPAL

gravida (#pregnancies)
Term (deliveries at 37 weeks or after)
Preterm (deliveries between weeks 20-37)
Abortions
Living (the # of currently living children to whom the woman has given birth).

45

chadwicks sign

purple/bluish discoloration of cervix; increased vascularization thanks to estrogen

46

goodells sign

softening of cervix

47

quickening

fetal mvmts felt by mother: 18-20 weeks for most primigravidas, but as early as 16-22 weeks for multigravidas.

48

EDB

estimated date of birth

49

EGA

estimated gestational age

50

hegars sign

softening of the isthmus of uterus

51

FHR

fetal heart rate can doppler at 10-12 weeks

52

Pregnancy affects on the heart

systolic murmur can be heard in 90% of women.
CO increases by 30-50% by 25-30 weeks (BP should remain less than 135/85
erythrocytes volume increases (due to increased need to transport add'l oxygen)
Plasma volume increases by 50%
Hct is slightly lower during pregnancy (relative anemia of pregnancy)
WBC increases
Certain blood clotting factors increase resulting in a hypercoagulable state
venous stasis in late pregnancy places the pregnant woman at increased risk for venous thrombosis

53

Why do you perform AROM

artificial rupture of membranes to induce or accelerate labor (AROM aka amniotomy). Cervix must be dilated 1 cm at least. Allows internal fetus and uterine monitoring. Allows provider to assess color of amniotic fluid. If umbilical cord prolapses-->emergency c- section!!

54

CAN

Nuchal cord around neck

55

CPD

cephalopelvic disproportion is a condition where the baby's head or body does not fit through the mother's pelvis. CPD is often diagnosed when a woman's labor fails to progreess to delivery, the cervix has stopped dilating, or the baby does not descend through the pelvis. In cases of actual CPD, a C-section is usually indicated.

56

Cx

cervix

57

EDC

estimated date of confinement: due date

58

EDD

estimated date of delivery

59

EFM

electronic fetal monitoring.

60

FSE

Fetal Scalp electrode

61

GBS

group B strep

62

IUGR

intrauterine growth retardation: fetus who is at or below the 10th percentile in weight for its gestational age. There are two factors necessary to define an IUGR: Fetal weight is bottom 10% AND there is a pathological process present that prevents expression of normal growth potential.

63

IUP

intrauterine pregnancy=normal pregnancy

64

IUPC

intrauterine pressure catheter: placed into the amniotic sac during labor in order to measure the strength of uterine contraction

65

LGA

large for gestational age (at risk for perinatal morbidity and potentially long term metabolic complications) LGA is >90%. Common causes include gestational diabetes or prolonged pregnancy

66

PROM

premature rupture of membranes: when the membranes break before labor. Most women will then go into labor within 24 hours

67

PPROM

preterm premature rupture of membranes. If the water breaks before the 37th week of pregnancy. Infection usually precedes PPROM, so strict sterile technique should be used in any vaginal exam

68

SGA

small for gestational age: low birth weight. A developing baby with intrauterine growth restriction will be small in saze and can have problems such as increased RED (polycythemia) low blood sugar (hypoglycemia), and low body temp (hypothermia)

69

SROM

spontaneous rupture of membranes. often happens after active labor has started. Your contractions may get stronger after membranes rupture. If engagement has not occurred, there is a risk that the umbilical cord may be expelled with the fluid (prolapsed cord)

70

TOLAC

trial of labor after C-section; the attempt to deliver vaginally after a c-section. carries some risk of rupture of the uterine scar.

71

TOP

termination of pregnancy

72

UC

uterine contraction

73

VBAC

vaginal birth after c-section

74

why do an amnioinfusion?

warm, sterile NS infused through an IUPC into the uterus to increase the volume of fluid around the fetus to prevent or treat variable decelerations by relieving pressure on the umbilical cord. **Amniotic membranes must be ruptured and cervix must be open enough to allow insertion of IUPC

75

amnion

the inner of the two membranes that form the sac containing the fetus and amniotic fluid

76

What do you need to assess before and after an amniotomy?

FHR, inspect the amniotic fluid for color, amount, odor and the presence of meconium or blood.

77

What is the desired birth presentation?

cephalic (LOA=left occiput anterior is the most common position)

78

Chorion

fetal membrane closest to the intrauterine wall that gives rise to the placenta and continues as the outer membrane surrounding the amnion.

79

When is augmentation necessary?

when there are less than 3 contractions in a 10 minute period or if the intensity of the contraction is less than 25 mm Hg as indicated by internal uterine pressure catheter during active phase of labor.

80

Pitocin delivery

we dose Pitocin in mu/min, but deliver it in mL/hr. Administer 2 mu/min increasing 1-2 mu/min q15-30 mins until contractions occur q2-3 mins.

81

three presentations

cephalic (occiput)
shoulder (acromion)
breech (sacrum)

82

station

relationship of the presenting fetal part to an imaginary line drawn between the pelvic and ischial spines. The ischial spines are zero station. If the presenting part is higher than the ischial spines, a negative number is assigned, noting cm above zero station. Station -5 is at the inlet, and station +4 is at the outlet. When the fetus is engaged, the largest diameter of the presenting part (biparietal diameter) passes through the pelvic inlet and the station of the fetal head will be 0

83

Three phases of contractions

Increment (the building up and is the longest phase)
Acme (peak)
decrement (letting up of the contraction)

84

what happens during the rest period between contractions?

the rest period between contractions restores the uteroplacental circulation.

85

frequency

the time between the beginning of one contraction and the beginning of the next contraction. frequency is every 2-3 mins when labor is progressing

86

duration

early durations are 30-40 s but as labor continues, duration increases to 30-90s.

87

intensity

strength of the contraction at the acme.

88

Favorable for vaginal birth:

Gynecoid (50% of female pelves): rounded, wide deep sacral curve, wide and round pubic arch, all inlet and outlet diameters adequate
Anthropoid (25%): oval, long anteroposterior diameter, adequate but short transverse diameter, inlet and outlet adequate. Favors occiput posterior.

89

Unfavorable for vaginal birth:

Android (20%): heart shaped, male-type pelvis, anteroposterior and transverse diameters are adequate, but other measurements make both inlet and outlet inadequate. Favors occiput posterior.
Platypelloid (5%): flat, transverse oval shape, short anteroposterior diameter, wide pubic arch, both inlet and outlet inadequate.

90

when does effacement begin?

at 4 cm. Effacement: The drawing up of the internal os and the cervical canal into the uterine side walls (starts at 4 cm long)

91

stages of labor

1st Stage—contractions until 10cms
2ndStage —complete dilation until birth
3rd Stage—birth until placenta
4thStage —placenta until1-4 hours later; uterus contracts, bleeding is controlled at the placental site

92

Latent phase:

Characteristics: Beginning of cervical dilatation and effacement, no evident fetal descent, uterine contractions increase in frequency
Contractions : irregular, Q 3-30 minutes, duration 20-40 seconds, mild intensity
Maternal behaviors: able to cope, happy that labor has started, energetic, nesting
Typically lasts: 8.6 hours in nulliparas, 5.3 hours in multiparas

93

Active phase:

Characteristics: dilatation from 4 to 7 cms; fetal descent (1.2-1.5 cm/hr) Contractions: Q 2-5 minutes, lasting 40-60 seconds, moderate intensity, firm to palpation
Maternal behaviors: anxiety, decreased ability to cope, time to go to the hospital Typically lasts: 4.6 hours in nulliparas, 2.4 hours in multiparas

94

Transition phase:

Characteristics: dilatation from 8 to 10 cms, progressive fetal descent increases 1-2cm/hr Contractions Q 1.5-2 min, lasting 60-90 seconds, strong intensity
Maternal behaviors: withdraws, terrified of being alone, but does not want to be touched or talked to—BUT DON’T LEAVE HER!, may lose focus, or beg for drugs, may have urge to push but should control through panting/blowing—important NOT to push against an incompletely dilated cervix—can lead to cervical tears and hemorrhage!
Typically, transition is not longer than 3 hours in nulliparas, 1 hour in multiparas

95

second stage characteristics

Characteristics: Nulliparas: up to 3 hrs, Multiparas: 0-30 mins
Contractions q 1.5-2 mins, lasting 60-90 seconds, extremely strong intensity
Latent phase and active phases of second stage—should not start pushing until cervix is completely dilated and baby’s head is low (at least +1 station)
Urge to push as fetal head presses on pelvic floor—comes from activation of Ferguson’s reflex
Maternal behaviors: pushing feels good, sense of control, ring of fire

96

ferguson's reflex

activation creates an urge to push. Mom should NOT push until fetal head is at least +1 station and cervix is completely dilated

97

third stage characteristics

Placental delivery usually occurs within 5 - 30 minutes after the delivery of the infant
Signs of impending placental delivery: gush or trickle of blood, lengthening of the umbilical cord, a rise of the fundus in the abdomen
Pitocin via IVF and vigorous fundal massage will be given as soon as placenta delivers to aid in uterine contraction to prevent/minimize bleeding (active management of the 3rd stage of labor)
Maternal behaviors: recovering, may bear down to aid in placental expulsion

98

fourth stage of labor

Characteristics: 1 to 4 hours after birth, Physiologic readjustment phase, Mother may experience shaking chill (“Postpartum Chill”), bladder is often hypotonic, uterus remains contracted (midway between the symphysis pubis and the umbilicus)
Maternal behaviors: relief that process is over, exhausted, excitement about baby, thirsty and hungry

99

monitoring in labor

Intermittent auscultation:
Q 15-30 min during active phase; q 5-15 min during 2nd stage
Review/documentation of continuous:
Uncomplicated pregnancy/labor: review/document q 30 minutes during 1st stage and q 15 minutes during 2nd stage
Complicated pregnancy/labor: review/document q 15 minutes during 1st stage and q 5 minutes during 2nd stage

100

what is preferred anesthesia for preeclampsia patients?

epidural

101

nursing mgmt for regional anesthesia

Monitor maternal and fetal vital signs
Assess for hypotension
Take corrective measures for hypotension
Left lateral-side lying position, oxygen
Administer anti-emetics as needed
Monitor respiratory rate
Assess bladder and catheterize if unable to void

102

variable decelerations

usually associated with cord compression usually not concerning unless deceleration is less than 70 beats/min and lasts more than 60s. If the variable is slow to return to baseline, may indicate hypoxia and warrants intervention

103

what do you assess before increasing oxytocin flow rate?

fetal heart tones. to determine effect of oxytoxin, measure mom's BP and pulse

104

signs of labor

braxton hicks, lightening (engagement), weight loss, sudden burst of energy, ROM, bloody show, n/v/d, backache

105

what is a contraindication for pictocin?

CPD (cephalopelvic disproportion)

106

when should you d/c pitocin (oxytocin) or decrease flow rate?

dc IV oxytocin infusion when nonreassuring fetal status is noted (bradycardia or variable decelerations), uterine contractions more frequent than q2mins, duration of contractions >60s, or insufficient relaxation of the uterus between contractions or a steady increase in resting tone is noted. In addition to discontinuing oxytocin infusion, turn patient to her side, and if nonreassuring fetal status is present, administer oxygen by tight face mask at 7-10 L/min and notify physician.

107

most common side effect of epidural anesthesia?

hypotension; prevent by preloading with a fluid bolus prior to delivery of epidural.

108

what is the nursing care related to an epidural?

maternal BP and HR q5mins for at least 30 mins, then at least 30 mins thereafter while the block is present. The FHR is monitored and assessed by continuous EFM.

109

UA with proteinuria of +1

may indicate preeclampsia

110

betamethasone (Celestone)

promotes fetal lung maturity. 12mg IM q24h X2doses

111

Bupivacaine

used with fentanyl in epidural infusions for pain relief; monitor for cardiovascular collapse. 0.125% @ 8-12 mL/hr

112

Butorphanol

labor pain analgesic; 1-2 mg IV or IM q4h

113

Cefazolin (Ancef)

GBS prophylaxis; 1-2 grams q8h
*only need one dose preop if c-section

114

Cervidil (Dinoprostone)

labor induction or abortion. (10mg intravaginally). stimulates uterine contractions

115

Magnesium sulfate

preeclampsia (anticonvulsant) preterm labor (smooth muscle relaxant). 4-6 grams loading dose over 15-20 mins, followed by 2g/hr continuous infusion.

116

misoprostol (Cytotec)

labor induction, abortion, postpartum hemorrhage. 23 mcg vaginally q3hrs for induction. 800-1000 mcg rectally for postpartum hemorrhage

117

oxytocin (pitocin)

labor induction, postpartum bleeding, and adjunctive therapy in abortion. Labor induction: 0.5-1 mu/min, increase in increments of 1-2 mu/min. Postpartum bleeding 10 units IM or 10-40 units IV in 1000 mL IVF

118

Penicillin G

intrapartum antibiotic therapy for GBS+ patients.

119

Terbutaline (Brethine)

preterm labor 0.25 mg SC q20mins for three doses (hold for HR >120)

120

Sublimaze (Fentanyl)

analgesic, anesthetic; 100 mcg IV, 2-4 mcg/ml in epidural infusions

121

demerol

demerol has an active metabolite and can cause respiratory depression in neonate after birth. It is not recommended to give this to women in active labor.

122

Sodium Thiopental (Pentothal)

short acting barb for general anesthesia-used as an adjunct to initiate unconsciousness

123

Ketamine

intermediate acting barb used for induction of general anesthesia-effects last 20-60 mins

124

what about a woman in labor with aortic stenosis?

consider general anesthesia instead of epidural

125

What is important to know about Nitrous Oxide and oxygen?

can increase uterine blood flow and uterine relaxation--risk for hemorrhage!!

126

involution

uterus returns to prepregnant state (usually takes 6 weeks)

127

puerperium

postpartum period

128

when are the baby blues the worst?

third or fourth day following delivery due to hormone levels drop. If not resolved within two weeks, consider referral for postpartum depression

129

blood loss averages during labor

vaginal birth 200-500 mL (>500 mL = hemorrhage)
C-sections: 700-1000 ml (>1000mL = hemorrhage)

130

How does blood volume reach pre-pregnant state by 1 week?

diaphoresis, diuresis

131

why do you have an increased risk for UTI for up to six weeks after birth?

dilated ureters and renal pelves

132

fourchette, perineal skin, and vaginal mucous membrane involvement

1st degree

133

involves perineal skin, vaginal mucous membrane, underlying fascia, muscles of the perineal body (central tendon of the perineum that lies between the vagina and anus)

2nd degree

134

involves above plus the anal sphincter; may extend up the anterior wall of the rectum

3rd degree

135

involves above plus the anal sphincter; may extend up the anterior wall of the rectum but extends through the rectal mucosa into the lumen of the rectum

4th degree

136

when may a woman expect to return to her pre-pregnant weight?

6-8 weeks after delivery

137

BUBBLEHE

breasts
uterus
bowel
bladder
lochia
episiotomy
homans sign/hemorrhoids
emotional state/edema

138

REEDA

redness
edema
ecchymoses
drainage
approximation

139

what amount is considered a heavy amount of lochia?

saturated peripad within one hour

140

drugs that control postpartum bleeding?

Pitocin (oxytocin)
methylergonovine
Hemabate or Cytotec
assess BP and allergies!!

141

acrocyanosis

newborns generally have blue extremities and the rest of the body is pink. This is present in 85% of normal newborns 1 minute after birth. When this occurs, the newborn is given a merit score of 1 on the apgar .

142

Caput succedaneum

localized swelling of tissues of scalp resulting from long or difficult labor. crosses sutures, present at birth or shortly thereafter. Conehead

143

cephalohematoma

collection of blood between cranial bone and periosteal membrane. doesn't cross suture lines. Horns

144

Erythema toxicum **

newborn rash or fleabite; innocuous pink, papular rash of unknown cause with superimposed pustules; appears with a 24-48 hours after birth and resolves spontaneously within a few days. Usually from harsh detergents in hospital

145

Epstein's pearls

small glistening white specks that feel hard to touch, usually disappear in a few weeks and are of no significance.

146

Nevus flammeus

port wine stain

147

nevus vasculosus

strawberry mark; capillary hemangioma

148

Phenylketonuria (PKU)

most common of the group of metabolic errors. newborn with this lacks ability to convert phenylalanine to tyrosine-musty odor in urine; accumulation and abnormal metabolites in brain tissue leads to progressive intellectual disability

149

Telangiectatic nevi

stork bites; usually fade by second birthday

150

normal birth weight

5 lbs, 8 oz-8 lbs, 13 oz

151

normal birth length

48-52 cm (18-22 in)

152

normal chest cirumference at birth

30-35 cm (12-14 in)

153

normal head circumference at birth

32-37 cm (12.5-14.5 in)

154

Normal HR at birth

110-160 bpm, count 1 full minute

155

normal RR rate at birth

30-60/min for 1 full min

156

Temp at birth

rectal 36.6-37.2 C (97.8-99F)
Axillary 36.4-37.2 (97.5-99.4)

157

apgar scoring

7-10 is good (do twice at 1 minute then again at 5 mins)

activity: absent 0, some motion, flexion, resistance to extension 1, active, spontaneous mvmt with good flexion 2

Pulse: absent 0, below 100 1, above 100 2

Grimace: no response 0, grimace, frown 1, sneeze, cough, pull away, cry 2

Appearance: blue-gray, pale all over 0, normal except for extremities 1, normal over entire body 2

Respiration: absent 0, slow, irregular 1, good, crying 2

158

prophylactic eye meds

give within an hour of being born. Erythromycin or tetracycline. preventing chlamydia and/or gonorrhea. Can't give until ped does physical exam.