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Flashcards in Exam 3 Deck (138):
1

Manipulation of fetus from abnormal position (breach), to vertex position.

External Version

2

Nurses role for External Version

Monitor: maternal vitals, FHR, unusual pain or bleeding, and fetus after procedure.

3

Induction of Labor ...?

Chemical (IV Oxytocin) or mechanical (Amniotomy) initiation of uterine contractions.

4

The determination if cervix is favorable for an induction of labor with Pitocin.

Bishop Score

5

The Bishop score needed to perform an induction of a nullipara

9 or more

6

The Bishop score needed to perform an induction of a miltipara

5 or more

7

The method used in an primipara with a Bishop score greater than 9

Oxytocin Induction

8

The method used in a primipara with a Bishop score less than 9

Cervical Ripeners first

9

The method used in a multipara with a Bishop score less than 5

Cervical Ripeners first

10

The method used in a multipara with a Bishop score of 5 or more

Oxytocin Induction

11

The two agents used for cervical ripening

Prostaglandin E1: Misoprostol (Cytotec)
Prostaglandin E2: Cervidil (med put behind uterus, looks like a tampon)

12

Medications used to make cervix softer and thinner, stimulates uterine contractions, and used when Bishop score is <5 for multipara and <9 for primipara.

Cervical Ripening

13

Adverse effect of cervical ripening

Hyperstimulation of uterus, may go into labor without need for pitocin

14

How do Laminaria work?

Laminaria is only used when its the best chance at dilation without the use of chemicals due to allergies. Function like tampons- as absorbs fluid, expands and causes cervical dilation. Left in place for 6-12 hours. Can cause an increase in discomfort for woman.

15

What must happen for an amniotomy to be performed?

fetus must be at 0 station

16

What is important to monitor after an amniotomy?

FHR

17

What can increase the risk of prolapsed cord & infection?

Amniotomy

18

If the cord prolapsed - what do you do?

Place woman in knee-chest position or in bed trendelenberg.
SVE- if find prolapsed cord, do not remove your fingers- hold presenting pat off cord until baby is delivered by cesarian section.

19

Signs of meconium-stained fluid

greenish-yellow color
fetal distress
late decels

20

What does bloody amniotic fluid possibly indicate?

placental abruption or fetal trauma

21

Goal of oxytocin

To achieve a contraction pattern that stimulates the active phase of labor- moderate to severe contractions every 2-3 minutes.

22

hazard of oxytocin to fetus

fetal asphyxia

23

maternal hazards of oxytocin

water intoxication- only with large amounts
titanic contractions: rupture of uterus, placental separation, lacerations of cervix, and postpartum hemorrhage.

24

What to do with uterine hyperstimulation of uterus with oxytocin

1. turn off oxytocin
2. administer O2 8-10L/min facial mask
3. open mainline- main IV
4. turn woman to left side
5. notify PCP
6. prepare to administer medication to stop contractions
7. monitor FHR closely

25

Conditions for use of forceps

empty bladder
cervix fully dilated
presenting part engaged
rupture of membranes

26

Maternal assessment after forcep use

vaginal and cervical lacerations
uterine retention
hematoma formation

27

Newborn assessment after forcep use

brushing or abrasions
facial palsy
subdural hematoma

28

Implications of vacuum-assisted birth

assist with delivery, prevent worsening cardiac problems in mom, fetal distress, absence of cephalopelvic disproportion (CPD)(fetal head will not engage with he pelvis)

29

Newborn implications with vacuum-assisted birth

monitor for cephalohematoma
caput succedaneum is normal and will resolve

30

Fetal indications of C-Section

Malpresentation (breach, transverse)
Cephalopelvic Disproportion (CPD)
umbilical cord prolapse
fetal distress
multiple gestation
placental problems

31

Maternal indications of C-Section

HTN disorders
active genital herpes
positive HIV status
diabetes
elective-elective-controvercial

32

The incision made during emergency C-section delivery that cuts through the fundus of uterus. Higher incidence of blood loss, infection, and uterine rupture in future pregnancies. After this surgical technique, vaginal birth is contraindicated.

Classical

33

Surgical incision made during C-section that is less likely to rupture uterus (b/c not cutting through fundus), associated with decreased blood loss and fewer postop infections

Lower-segment

34

fetal effects of general anesthesia

baby will become too sedated to breathe

35

Low birth weight is

2500 grams or less

36

Very low birth weight

1500 grams or less

37

extremely low birth weight

1000 grams or less

38

Biophysical risks associated with low birth weight

previous preterm birth or labor
2nd trimester abortion
grand multiparity- short intervals between pregnancies
uterus and cervical anomalies
periodontal problems
small stature
obesity

39

S/S of preterm birth

UTERINE: contractions every 10 minutes or more frequently and lasting 1 hour or more
may be painless or associated with infection
dilated 2cm or grater than 80% effaced
DISCOMFORT: lower abdominal or menstrual like cramping
lower back pain
VAGINAL DISCHARGE
ROM , bloody, watery, odor

40

Glycoproteins found in cervical canal in late pregnancy

Fetal Fibronectin- biochemical marker of preterm birth

41

when is fetal fibronectin performed?

22-35 weeks and only done on those with symptoms of preterm labor, intact membranes, cervix not dilated past 3cm, and only slight vaginal bleeding.

42

Results of a fetal fibronectin test?

Negative- no labor for 2 weeks
Positive- less reliable and unable to pinpoint when labor will occur. Is a better predictor of who will not deliver than who will.

43

Uses of Tocolytic durgs

suppress uterine contractions
potential serious effects

44

Medical management of preterm birth

Tocolytic Drugs
Bedrest
IV Hydration
Antibiotics

45

Indication of use for Betamethasone

Women 24-34 weeks gestation with signs of preterm labor at risk to deliver preterm.

46

What does Betamethasone do?

Stimulates production of more mature surfactant in the fetal lungs to prevent respiratory distress syndrome in preterm infants.

47

Route and dose of Betamethasone

12 mg Im every 24 hr x 2 doses. Only used once during a pregnancy.

48

Medications most commonly used to suppress uterine activity

Mag Sulfate
Terbutaline (Brethren)
Nifedipine (Procardia)

49

Action of mag sulfate

CNS depressant and relaxes smooth muscles (Uterus)

50

Doses of Mag Sulfate

Loading dose- 4-6 grams/20 minutes
Maintenance dose- 1-4 grams/hr
always piggybacked

51

Adverse effects of Mag Sulfate

hot flashes
sweating
N/V
drowsiness
blurred vision
lethargy
dizziness
pulmonary edema

52

Therapeutic level of Mag Sulfate

4-7.5

53

Toxic levels of mag sulfate are manifested by

loss of deep tendon reflexes
respiratory rate of 10-12/min
altered level of consciousness
slurred speech
complaints of being too warm

54

Mag sulfate antidote

Calcium Gluconate

55

Fetal implications of mag sulfate

decreased variability- CNS sedation, upon birth not wanting to breathe right away

56

neonatal implications of mag sulfate

lethargy
hypotonia
respiratory depression

57

Med previously used to treat asthma, is now used to quiet uterine muscles.

Terbutaline (Brethine)

58

Adverse Effects of (Terbutaline) Brethine

shortness of breath
pulmonary edema
tachycardia
palpitations
hyperglycemia

59

Reasons to help Terbutaline (Brethine)

Maternal HR above 120
BP less than 90/60
signs of pulmonary edema
FHR greater than 180 bpm

60

Action of Nifedipine

relax smooth muscle by blocking calcium entry
Usually used after stabilization with mag sulfate

61

Dosage/route of Nifedipine

30mg oral loading dose, 10-20mg every 4-6 hours

62

Nifedipine cannot be used with which drug because hypotension can result

Mag sulfate

63

Action of Indomethacin (indocin)

relaxes uterine smooth muscle by inhibiting prostaglandins

64

This drug is good for preterm labor caused by polyhydramnios - causes oligohydramnois. Only used when fetus is less than 32 weeks gestation, may cause premature closure of the ductus arteriosus.

Indomethacin (Indocin)

65

maternal contraindications to tocolytics

hypertension (beta agonists)
significant vaginal bleeding
cardiac disease

66

fetal Contraindications to tocolytics

Gestational age more than 34 weeks
fetal demise
lethal fetal anomaly
chorioamnionitis
evidence of acute or chronic fetal compromise

67

rupture of amniotic sac beginning at least 1 hour before onset of labor and any gestational age

Premature Rupture of Membranes (PROM)

68

major complication of PROM

infection

69

PPROM

rupture of membranes before 38 weeks

70

Prolonged rupture of membranes

Rupture greater than 24 hours before delivery

71

newborn risk of PROM

fetal or neonatal sepsis
preterm complications
hypoxia or asphyxia because of umbilical cord compression
fetal deformities if occurs before 26 weeks

72

Management of PROM

fetal and uterine assessments
frequent biophysical profiles
kick counts
vigilant assessment for signs of infections - prophylactic antibiotics
assess fetal lung maturity
vitals Q4H
NOTHING IN VAGINA
if term- induction of labor

73

difficult labor that is prolonged and more painful than ordinary

dystocia of labor

74

incompetent cervix is associated with???

previous cervical trauma and DES exposure in utero

75

Medical management of incompetent cervix

Prophylactic cerclage between 12-16 weeks

76

Incompetent cervix can lead to what?

multiple second-trimester miscarriages without contractions

77

Nursing actions of a woman with an incompetent cervix

monitor for uterine activity per palpation
monitor for vaginal bleeding and leaking of fluid/rupture of membranes
no fetal monitoring because fetus not viable.
monitor for infection and uterine tenderness
administer tocolytics

78

What can cause dystocia of labor?

catecholamines, released during times of stress
pelvic or soft tissue dystocia
ineffective contractions
FETAL: anomalies, CPD, malpresentation, multifetal pregnancy

79

Assessment and interventions of Dystocia of labor

excessive pain without progress
abnormal contraction patterns
fetal distress
maternal or fetal tachycardia
Provide rest and comfort - sedation and pain relief

80

Fetal head is delivered, but anterior shoulder is stuck under pubic arch.

Shoulder Dystocia

81

Signs of shoulder dystocia

formation of caput increasing in size
slow decent
turtle sign

82

what is McRoberts maneuver

Womens legs flexed part with knees on abdomen

83

Interventions of shoulder dystocia

suprapubic pressure
McRoberts maneuver

84

Labor lasting less than three hours

Precipitous labor

85

Maternal complications of precipitous labor

uterine rupture
lacerations
Amniotic fluid embolism
postpartum hemorrhage

86

Fetal complications of precipitous labor

Hypoxia caused by contractions being too close together and don't allow oxygen to fetus

87

risk of vaginal birth after c-section

uterine rupture

88

an escape of amniotic fluid into maternal circulation, deposits in pulmonary arterioles, is usually fatal to mother.

Amniotic Fluid Embolism

89

Occurs before 20 weeks gestation, most occur before 12
less than 500 grams
Before week 12- Heavy period
After week 12- severe pain similar to labor

Miscarriage

90

spotting, cervical os closed, mild cramping

Threatened Miscarriage

91

Moderate to heavy bleeding, mild to severe cramping, ROM, cervical dilation.

Inevitable Miscarriage

92

expulsion of fetus, retention of placenta (stuck)

incomplete miscarriage

93

all fetal tissue expelled and cervix is closed

complete miscarriage

94

fetus who has died, all products of conception remain in utero. No cramping. Usually discovered in OB office.

Missed Miscarriage

95

Management of Threatened Miscarriage

monitor levels of HCG and progesterone

96

Inevitable and Incomplete miscarriage management

if products retained- suction curettage

97

management of a missed miscarriage

spontaneous resolution- misoprostol (Cytotec) orally
surgical intervention- scar tissue with manual dilation and curettage (D&C) is a big concern.

98

What is given after evacuation of uterus

Pitocin- to contract
if pt is hemorrhaging- Hemobate (Prostaglandin)
Ibuprofen for cramping
if Rh -, give Rhogam for future

99

Recurrent premature dilation of cervix- History of two pregnancy losses

Incompetent cervix

100

Dull-colicky pain- sharp pain as pregnancy grows
one sided
if ruptured, shoulder pain common

Manifestations of Ectopic pregnancy

101

Medical management of tubal pregnancy

Methotrexate- attracted to the breakdown of the pregnancy in tube then flushes away

102

Surgical management of tubal pregnancy is dependent on

woman desire for fertility, location, and extent of tissue involvement

103

Fertilization of empty egg (no nucleus)
chorionic villli develop into grape like clusters
can lead to choriocarncinoma

Hydatiform Mole Pregnancy- Molar Pregnancy- Gestational Trophoblastic Disease

104

Manifestations of molar pregnancy

dark brown or bright red bleeding
larger than expected uterus
excessive nausea and vomiting

105

What will be seen on a Transvaginal ultrasound of molar pregnancy

snow storm pattern

106

management of a molar pregnancy

suction curettage
support pt and family as if a baby actually happened

107

follow up care of molar pregnancy

frequent physical and pelvic examinations- weekly b-hCG , until levels are normal for 3 weeks.
Monthly measurements follow for 6 months
Follow up for one year
Postpone future pregnancies for one year
oral contraceptives!

108

Continued bleeding after evacuation of mole is usually the most suggestive symptom of what?

Gestational trophoblastic neoplasia

109

Placenta implanted in lower uterine segment near or over internal cervical os

Placenta Previa

110

The three types of placenta previa

Complete- totally covers internal cervical os
Marginal- edge of placenta close to cervical os
Low-Lying- close to cervical os

111

Clinical manifestations of placenta previa

Painless bright red vaginal bleeding during second or third trimester
Bright red bleeding
normal uterine tone
FHR usually normal unless major detachment

112

Maternal outcomes of placenta previa

major implication for hemorrhage
can loose up to 40% of blood volume without displaying signs of shock

113

Management of placenta previa

any excessive, persistent bleeding- C-section (if 36 weeks)

114

Detachment of part or all of placenta from implantation site after 20 weeks gestation

Placental Abruption

115

Risk factors of placenta abruption

maternal hypertension
cocaine use- vasoconstrictor
blunt abdominal trauma- car accident, battering
cigarette smoking

116

Manifestations of placenta abruption

abdominal pain, vaginal bleeding, uterine tenderness and contractions. Depends on degree of separation

117

Maternal outcomes of placenta abruption dependent on

extent of placental detachment, blood loss, degree of coagulopathy present, time between placental detachment and birth

118

Fetal outcomes of placental abruption

fetal death if more than 50% of the placenta is involved
IUGR
preterm birth
cerebral palsy

119

Active management of placental abruption

immediate birth for term fetus, or if bleeding is moderate to severe. vaginal birth if possible- C-section if fetal distress.
continuous EFM
frequent maternal vitals
indwelling catheter

120

Rare Placental anomaly associated with placenta previa and multiple gestation

Velamentous insertion (Vasa Previs) (Cord Insertion)

121

Cord Insertion risks

ROM or traction on the cord may tear on or more of the fetal vessels
Fetus may rapidly bleed to death

122

Pregnancy-specific syndrome in which hypertension develops after 20 weeks of gestation in a previously normotensive woman

preeclampsia

123

Key characteristics of preeclampsia (PRE)

Proteinuria
Rise in BP
Edema

124

Uncontrolled preeclampsia, onset of seizure activity or coma in a woman with preeclampsia.

eclampsia

125

Hypertension present BEFORE pregnancy or diagnosed before week 20.

Chronic Hypertension

126

Symptoms of Preeclampsia

Brain- ischemia -> headaches -> seizures
Kidneys- decreased output, increases BUN + Creatinine
Retina- blurred vision
Liver- increased ALT + AST, epigastric pain due to shifting of liver
Placenta- IUGR, late decels

127

Can you identify preeclampsia?

No reliable test or screening tool has been developed

128

Home care of mild preeclampsia and hypertension

activity restriction
decreased sodium diet
daily BP
Dipstick urine to assess proteinuria
Call with less than 4 fetal movements/hour
NST/BPP weekly or biweekly

129

Antepartum care of severe gestational hypertension and preeclampsia

bet rest with side rails up
darkened environment
Mag sulfate therapy
antihypertensive medications- Hydralazine (Apresoline)

130

Report any changes in symptoms with severe hypertension and preeclampisa

BP above 160 systolic or above 110 diastolic
respirations above 12/min
output less than 25-30cc/hr

131

Med to give to prevent seizures in preeclamptic patients

Mag sulfate- CNS depressant

132

Used to prevent stroke if BP is above 160/110

Hydralazine (Apresoline)

133

Delivery with preeclampsia and hypertension

only cure!
at least 34 weeks, less than 34 weeks...betamethasone
immediate delivery: fetal distress, eclampsia, placental abruption, HELLP syndrome

134

Intrapartum interventions for Severe Preeclampsia

fluids limited to 125ml/hr
seizure precautions
emergency meds at bedside (hydralazine + calcium gluconate)
Delivery
Induction of labor

135

Postpartum with severe preeclampsia

Mag sulfate continues for 12-24 hours, symptoms usually resolve after 48 hours
woman goes home on antihypertensive meds (nifedipine, labetalol) , HTN usually persists

136

Immediate care of eclampsia

ensuring airway
do not leave pt, could have seizure
monitor for persistent headache and blurred vision

137

What med will break a seizure?

Valium

138

HEELP syndrome

Hemolysis
Elevated Liver enzymes
Low Platelets