Exam One Blueprint Flashcards
rough editing (139 cards)
1
Q
What to do when BP drops and an epidural has been given?
A
fluid bolus
anesthesiologist can give ephedrine to increase BP
2
Q
What is Nagele’s Rule?
A
Helps determine estimated due date (EDD)
1. determine date of last menstrual period (LMP)
2. subtract 3 months
3. add 7 days
Example: LMP - march 17th
go back 3 months: december
add 7 days: 24
EDD: 12/24
3
Q
Disadvantages of hormonal methods of birth control
A
- need a prescription
- not effective against STIs (use a condom)
- not for breast feeding mothers
4
Q
What are the physiological changes of pregnancy for the breasts?
A
- become fuller; tender
- alveoli, ducts, and lobules mature (not fully until lactation)
- nipples and alveoli darker
- colostrum: yellowish form of early milk
– produce and may leak after 2nd trimester
5
Q
Marked variability and what it looks like
A
Greater than 25 BPM change
- cord compression, hypoxia, tachysystole
- struggling to find a baseline
- not a good sign
6
Q
Hormonal birth control: Contraceptive Injection
Hormone, duration, failure rate
A
Depo-Provera
- PROGESTIN-ONLY
- given every 13 weeks until pregnancy desired
- failure rate: 6%
- should start DMPA within 7 days of start of last menstrual
- concerns include weight gain
- use with breastfeeding mothers: may lessen milk production
7
Q
What are diagnostic tests for fetal wellbeing
A
- ultrasound
- genetic testing (CVS, Quad screen, NIPT, MSAFP)
- 1 hour glucose tolerance test (about 26 weeks)
– if >135 one hour later, refer for 3 hour GTT - group beta strep: about 36 weeks
– treat with PCN during labor - non-stress test: look for 2 accelerations of the fetal heart in 20 minutes
-
Biophysical profile (BPP): done with ultrasound
– 5 criteria; 2 points or 0
– assess fetal wellbeing
– fetal movement, tone, breathing, amniotic fluid, NST
– 8-10/10: reassuring; 6/10 monitor; lower = deliver
8
Q
Medications to use with preeclampsia and its assessment
A
Magnesium sulfate - assessing DTR, respirations, urine output, BP, LOC
Administration:
- 4g bolus over 20 minutes
- 2g/hr maintenance
- hourly mag checks (I&O, DTR, RR)
9
Q
How does fundal height correlate with gestational age?
A
16-36wk: size of uterus from pubis to fundus = number of weeks gestation
10
Q
Danger signs to teach in 2nd trimester until term
A
(in addition to list from 1st trimester)
- uterine contractions
- new onset back pain
- leaking of fluid from vagina
- vaginal bleeding
- decreased fetal movement
- sudden weight gain
- swelling of face, hands, eyes (sign of preeclampsia)
- epigastric pain
- severe headache unrelieved by tylenol or rest
- visual changes (floaters, double vision, blurred vision)
11
Q
What are the physiological changes of pregnancy for the urinary system?
A
- blood flow to/through kidneys increases by 80%
- GFR increases about 50%
- can spill trace amount of glucose and protein into urine
– interpret with caution - more salt and water reabsorbed
– water gain approx 1.6L
12
Q
Stage 1: Active phase of labor
A
Cervix 6-10cm; progressive effacement to 100%
- contractions are moderate to strong in intensity, get closer together
- patients need to focus in order to cope
– will not usually talk through contractions
– use of prepared childbirth techniques
- about 8cm: patient may be overwhelmed
– shaky, nauseous, may be unable to cope well
– increase in “bloody show”
- ends with complete cervical dilation and effacement
13
Q
What does tachysystole look like on a strip?
Causes/risk factors?
A
more than 6 uterine contractions in a 10 minute period averaged over a 30 minute window
- increase in tone: little rest (gas exchange takes place during rest)
Causes/risk factors:
- cervical ripening
- oxytocin induction
- endogenous: nipple stimulation and prostaglandins
- abruption, uterine rupture
14
Q
Stage 1: Latent Phase
A
Cervical Dilation: 0-5cm, effacement: 0-50%
- patience is key
- contractions are uncomfortable but bearable
- patient usually copes well
- may be talkative and excited
- longest phase: may take 12hr+ in primes
- distraction, ambulation, education about normal labor
- some patients will look like they are in active phase at 3-4cm (epidural most often at 3-4cm)
15
Q
What does the nurse do regarding tachysystole?
A
Interventions:
- pull cervidil
- discontinue oxytocin (pitocin)
- fluid bolus
- terbulatine
- if cause is abruption or uterine rupture: cure is surgical
Scenario she added:
The assigned nurse initiates the correct steps (what are they?) and needs to delegate:
- One nurse needs to call the provider and give SBAR.
- One nurse needs to obtain terbutaline 0.25 mcg for subcutaneous administration and perform the assessments that are required before the med can be safely administered.
- One nurse is going to document all actions
16
Q
Risks to baby with GDM
A
- macrosomia
- birth injuries
- neonatal hypoglycemia
- hyperbilirubinemia
- preterm birth
17
Q
S/s of worsening preeclampsia
A
With severe features
- severe range hypertension: 160/110
- persistent headache or visual disturbance
- epigastric pain (RUQ)
- HELLP syndrome: hemolysis, elevated liver enzymes, low platelets
- worsening renal function: elevated creatinine, oliguria
– crt. 0.6-1.0 normal; 1.1-1.2 is sus
- non-reassuring fetal testing
need to deliver
18
Q
Progestin Only Pills (POPs)
If you miss a dose?
A
- contain only progestin
- SAFE for breastfeeding mothers
- 28 pills; no placebo
- have to be taken within 3-hour window every day to be effective
- primary side effect: less regular period, more breakthrough bleeding
- if pregnancy occurs: more likely to be ectopic
19
Q
Options of tools for operative vaginal delivery
A
- forceps
- vacuum
20
Q
Why do you give fluid bolus with epidurals
A
to avoid hypotension
21
Q
Cervical ripening - Amniotomy
Risks?
A
- allows presenting part to be better applied to the cervix
- stimulates prostaglandin (cervical ripening, need to be 1-2cm dilated and have some fetal descent)
risks:
- infection
- cord prolapse
- rupture of placenta previa
Artificial rupture of membranes
22
Q
Cervical ripening: Misoprostol - Cytotec
A
- off label use
- dose is usually 25mcg x 1 then 50 mcg q4h x5
23
Q
Hormonal birth control: Contraceptive Patch
A
Twirla and Ortho-Evra
- combination method: estrogen and progestin
- applied weekly for 3 weeks (off for one for bleeding)
- apply on upper back, upper arm, upper buttock, or lower abdomen
– NOT ON BREAST
- rotate site weekly
- less effective when BMI over 30
- failure rate 9% - higher with obesity
- not for breastfeeding mothers
24
Q
VEAL CHOP
A
V: Variable C: cord compression
E: Early H: head
A: accels O: oxygen (okay)
L: late P: placental insufficiency
25
Antidote of magnesium sulfate
calcium gluconate
26
What is your priority with placental abruption?
- both previa and abruption cause vaginal bleeding
- both can cause massive hemorrhage
- both can cause death of mother and/or baby
__________________________________________
- large bore IV access and volume (2 18G)
- expanders: LR and NSS
- obtain baseline H&H, clotting factors, type and crossmatch
- monitor: VS, uterine activity, FHR
-- may need CVP line
- Cesarean 90% (can attempt vaginal if grade 1 maybe)
- cryoprecipitate if fibrinogen is low
- tranexamic acid (TXA): can mitigate some blood loss
- administer blood
27
What are the genetic testing options?
- amniocentesis
- chorionic villus sampling (CVS)
- NIPS
- chromosome studies on neonate or stillborn
-- heel stick or tissue sample
- karyotyping or parents (blood sample and looking at chromosomes)
28
Nursing responsibilities with Vacuum-assisted vaginal delivery
- straight cath
- monitor FHR
- note time of application, length of pull, number of pop-offs, descent, time delivered
- Mityvac: nurse pumps handle and needs to stay in green
- make sure NICU at delivery
29
Delegation question on precipitous delivery
delegating tasks and communicating in impending delivery
- nobody is a spectator; every unit is a team; every team needs a leader
- assign roles to individuals and communicate
- sometimes is a nurse delivery; common with women who have had multiple children
- DO NOT LEAVE THE PATIENT
- call out from room "we are having a baby"
- assign roles as people arrive
-- get warmed blankets, check warmer
-- delivery instruments
-- someone capable of neonatal resuscitation
-- get any OB or midwife to attend if possible
Scenario she added (basically same thing)
The charge nurse has to delegate and assign roles:
- One person has to call NICU
- One person needs to call the attending OB
- One person needs to get a delivery kit and gloves and take it to the front entrance
- One person needs to get the warmer, blankets, and an portable oxygen tank and take it to the front entrance.
- If the provider can’t make it, the charge nurse will have to deliver the baby in the parking lot (what does that look like?)
30
What are the positive signs of pregnancy?
If you see a baby, hear a baby, feel a baby
- visualization of baby on ultrasound
- fetal heart tones
- palpable fetal movement assessed by an examiner
31
What are the correct actions for an eclamptic seizures?
- side rails up, padded is best
- do not shove anything in patient's mouth
- have suction and oxygen available
- lateral "recovery" position
- fetal hearts, looking for s/s abruption
- delivery usually Cesarean
Magnesium sulfate bolus (calms nerve transmission)
Scenario she added:
4 nurses come to the room to assist.
- One needs to call the provider and give SBAR
- One needs to manage oxygen and suction setups
- One needs to obtain IV access and prepare a magnesium sulfate bolus
- One needs to obtain fetal heart tones.
32
Embryonic stage
2-8 weeks
- implantation occurs by end of week 2
- **all organs formed by the end of week 8**
-- first to form are heart and neural tube
-- development goes from head to toe
- **embryo most susceptible to teratogens
-- most major defects happen here**
33
What is placental abruption?
placenta separates from the uterine wall before the delivery of the baby
34
Amniocentesis
- completed at about 15-20 weeks of pregnancy
- risk of loss <1%
- 20G through abdomen to sample amniotic fluid
- patient instructed to report bleeding or cramping
35
TORCH
T = toxoplasmosis
O = other infections
R = rubella
C = cytomegalovirus (CMV)
H = herpes simplex virus
are teratogenic
36
Cord prolapse: what is it and risk factors
What is it:
- cord "escapes" before presenting part
- life threatening emergency for baby
Risk factors:
- PROM
- amniotomy when baby not engaged
- unknown sometimes
37
Placental previa signs
- presents with ***painless, bright red bleeding in large amounts***
- maternal condition consistent with apparent blood loss
- apparent on ultrasound
- Cesarean is the ONLY safe delivery
- first episode may be self-limiting (warning)
-- second episode: delivery indicated
38
Variable decelerations and what they look like
| if problem, what can help with these
- abrupt descent (<30 seconds) from baseline to the nadir
- usually V or U shaped
- occur with cord compression
- occasional variables are common
- recurrent stress a baby
- sometimes amnioinfusion works to cushion cord
39
What do hormonal methods of birth control do?
suppress ovulation, thicken cervical mucus, and thin the uterine lining
40
Moderate variability and what it looks like
6-25 BPM changes
- oxygenated fetus
- neurologically intact
- normal, reassuring
41
First degree laceration/episiotomy
perineal skin and vaginal mucosa
42
HIV in pregnancy
O in TORCH
Goal of management: healthy mom, no vertical transmission to fetus/newborn
CDC: routine screening prenatally of all women
HIV positive women should adhere to ART
- increased surveillance for mother and fetus
Mode of delivery depends on viral load:
- >1000 copies: Cesarean
- <1000 copies: vaginal birth; avoid invasive procedures
Prophylaxis with zidovudine (AZT) in labor
Formula feeding, AZT to newborn
43
Contraception - emphasis on assisting clients to select appropriate methods
note: this is based on different lifestyle factors and characteristics of client
| i think this was just me typing from blueprint (added methods)
## Footnote
but good to know
44
Non-pharmacological options for pain relief in labor
- ***counterpressure***
- changing positions for back pain
- hydrotherapy
- relaxation
- hypnotherapy
- acupressure
45
Education to give to a pregnant client
- about meds, sex, exercise and appropriate guidance:
- exercise to moderate intensity 3-5x a week
- take a vitamin that contains folic acid and iron
- consume extra protein and calcium and about 300 extra calories a day
- follow recommended schedule of visits
- cook food thoroughly
- report danger signs
DONT:
- ingest alcohol, illicit drugs
- consume raw or undercooked meat or fish
- consume unpasteurized dairy, deli meat (unless reheat deli to 165F)
46
Danger signs to teach about in first trimester
- report bleeding or spotting (sign of miscarriage)
- cramping (sign of miscarriage)
- painful urination and fever (UTI)
- lower abdominal pain accompanied by shoulder pain (ectopic pregnancy)
47
What is the nursing role regarding episiotomy or laceration repair?
assist provider, client in education, client in healing
- obtaining supplies: sutures, local anesthetic
- performing counts for sponges and sharps
48
Magnesium sulfate: what it does regarding preeclampsia, levels, toxicity
Decreases risk of eclampsia (seizures)
Normal levels of magnesium: 1.5-2.5
Therapeutic for preeclampsia: 4-7
Risk of toxicity: levels above 8
- hyporeflexia
- decreased RR
- oliguria
- decreased LOC
Can lead to:
- respiratory depression
- pulmonary edema
- renal failure
- coma/death
49
What are the physiological changes of pregnancy for the cardiovascular system?
- CO increases as much as 50%
-- HR increases about 10 bpm
- hormones reduce peripheral vascular resistance for increases blood volume
-- BP same or slightly lower than non-pregnant state
- total blood volume increases 40-50%
-- RBC count increases 30%
-- physiologic anemia of pregnancy
- WBC increases slightly
- rise in fibrinogen and other clotting: prevent excessive PPH
-- risk for blood clots -> PE or stroke
- temporary changes in heart sounds
50
What are the methods of induction?
- oxytocin infusion
- mechanical dilation (foley bulb)
51
What candidates are red flags for genetic counseling, meaning they should have genetic counseling done?
- ethnic factors (ex. Ashkenazi Jews)
- family hx of rare genetic disorders or birth defects
- recurrent pregnancy loss (3 or more)
-- poor OB outcomes or infertility
-- stillbirth
- people with hx of genetic disorder
- women expected to be >35 at time of birth
-- dad over 45
- have a child w/ genetic disorder
- consanguinity (second cousins or closer)
- positive prenatal screening tests
52
Surgical methods for birth control
- vasectomy
- tubal ligation
53
Third degree laceration/episiotomy
skin, mucous membranes, muscle
54
Contraindications to hormonal birth control
- migraine with aura
- HTN
- history of DVT, PE, stroke
- >35 smoker
55
Signs of cord prolapse
- variable or prolonged decelerations, usually deep
- visible loop of cord outside vagina
- cord palpable with vaginal exam
- mother states she felt something come out of her
56
Alone with precipitous delivery
| basically delivering a baby alone
- gloves (sterile preferred, but whatever you can get)
- support perineum with one hand
- head crowning: coach to pant or blow
- apply gentle pressure to head and perineum
- do not try to forcefully push on head
- support head when delivers and feel around neck for a cord
-- loose nuchal cord: loop over head
-- tight nuchal cord: clamp in two places and cut
- tell mom to push rest of baby
- dont drop baby lol
57
Induction method - Oxytocin Infusion
| What it does, risks, safe administration
- stimulates uterus to contract
- most effective if cervix is already ripe
- start slowly, titrate based on maternal/fetal response
Risks:
- tachysystole (hyperstimulation)
- uterine rupture
- fetal hypoxia (bc of tachysystole)
Safe administration:
- continuous monitoring
-- FHR - contractions = decreased blood flow
-- uterine activity: watch for tachysystole
- use of a checklist
- SBAR if complications arise
58
Side effects of hormonal methods of birth control
- nausea
- breast tenderness
- mood swings
- weight gain
- headaches
Progestin methods: irregular bleeding
59
What are common discomforts of pregnancy
- fatigue (1st and 3rd trimesters)
first trimester:
- breast tenderness
- N/V
- urinary frequency
- nasal stuffiness/nosebleeds
- constipation
2nd trimester:
- heartburn/indigestion
- supine hypotension (2nd/3rd)
- leg cramps (2nd/3rd)
- backache (2nd/3rd)
3rd trimester:
- dependent edema (lower extremities)
- varicosities
- urinary frequency returns
- increased vaginal discharge
- braxton hicks
60
What are the presumptive signs of pregnancy?
can be attributed to other common causes
- nausea/V
- tender breasts
- fatigue
- missed periods (amenorrhea)
- abdominal growth
61
What are the s/s of preterm labor?
- more than 6 uterine contractions in an hour w/ or w/out pain
- cramping
- pressure
- leaking fluid
- backache
- increased discharge, esp. pink tinged
- "just not feeling well"
62
Combined oral contraceptive pills
- 21 hormone pills; 7 placebo pills
-- can have extended cycle (Seasonale) of 84 hormone pills; 7 placebo
- miss a dose: take as soon as you remember and next at regular time
- not great for those who forget to take pills
- failure rate: 9%
63
What is your priority with placenta previa?
- NO VAGINAL EXAMS! (nothing in vaginal until 6 weeks postpartum too)
Actively bleeding:
- maintain large- bore IV access (2 18G)
- volume expanders: LR or NSS (bolus)
- obtain CBC, T&S, H&H
- frequent monitoring of VS
- fetal monitoring
If first bleed and resolves: expectant management:
- bedrest
- VS every 4 hours
- IV fluids
- maintain current type and crossmatch
- magnesium sulfate (protect fetal brain) and betamethasone (helps lungs mature)
64
What are the methods of cervical ripening?
- Dinoprostone (Cervidil and Prepidil)
- Misoprostol - Cytotec
- Amniotomy
65
What medication is given for tachysystole and why?
terbutaline - slows contractions
66
What are the physiological changes of pregnancy for the GI system?
- HCG maintains pregnancy early on = nausea of early pregnancy
- progesterone: slows peristalsis
-- heartburn, constipation, risk for gallstones
- metabolic rate increases 10-20%
-- consume 350-450 additional calories per day
- monitor weight gain (1/2 lb per week after 3 mos)
67
Grading of placental abruption
Grade 0: all is fine
Grade 1:
- mild separation
- VS and FHR stable (at the moment)
Grade 2:
- partial separation
- elevated maternal HR, BP stable
- uterus "irritable"
- low fibrinogen levels
Grade 3:
- fetal death common
- frequent, hypertonic contractions
- coagulopathy
- maternal shock, DIC, death possible
68
Diagnosis, treatment and goals regarding gestational diabetes
- need to have tight control; adherence is key
- diet, insulin
-- diet: carb controlled; spread throughout day
-- insulin: usually combo of short and long-acting insulin
-- teach healthy diet with 6 small meals
- fingerstick glucose monitoring to adjust treatment
- surveillance of fetal health
-- NSTs, BPPs, fetal kick counts
-- fetal echo for pre-gestational
69
Hormonal methods of birth control:
- pills (combined and progestin only)
- patches
- shots
- rings
- implants
70
What is the priority with hyperemesis gravidarum?
***fluid and electrolytes***
Management:
- replace fluid and electrolytes, esp K
- NPO until vomiting stops
- anti-emetics: Zofran, Reglan, Phenergan, Diclegis
- TPN via central line may be necessary
- measure I&O
- provide emotional support
71
LARCs: what are they?
Long-acting REVERSIBLE contraception
72
Assessing uterine contractions: palpation and what you feel
nose: mild
chin: moderate
forehead: strong
73
What are the physiological changes of pregnancy for the skin?
- striae gravidarum (breasts, abdomen, thighs)
- linea nigra
- nevi, macules, areolae darken
- chloasma: darks with sun exposure, disappears after pregnancy - "mask of pregnancy"
- palmar erythema: increase blood flow
- hair grows longer and thicker: estrogen stimulation
-- returns to normal 4 months after delivery
- body hair tends to be more coarse and abundant after pregnancy
74
Post-date pregnancy and patient questioning need for induction
- post-term pregnancy exceeds 42 weeks
-- very risky
-- baby keeps growing and they get big
-- placenta gets old and starts to die
-- baby can die too
interventions:
- NSTs twice/week after 40 weeks
- BPP if NST non-reactive
- fetal movement counts
- induction of labor at 41 weeks
75
PPROM
| S/S, management, nursing care
premature preterm rupture of membranes
Rupture of the amniotic sac prior to 37wk gestation
S/s:
- leaking of fluid from vagina (gush or trickle)
- oligohydramnios
Management:
- active vs expectant (depends on gestational age and risk/presence of infection)
- prevention of infection
- bedrest
- assessment of uterine activity, fetal well-being (watch for cord prolapse)
- administration of agents to improve neonatal survival if fetus is viable (mag. sulfate and betamethasone)
Nursing care:
- educate on warning signs
- hygiene to prevent infection
- anticipatory guidance
- external fetal monitoring
- communicate changes to provider
76
Disadvantages of IUDs
- must be inserted by provider; may not be accessible
- paraguard: may cause heavier bleeding and cramping
- Mirena and skyla: can cause amenorrhea
- small risk of perforating uterus
77
Emergency types of contraception
- levonorgestrel (Plan B)
-- use within 72 hours; OTC
-- works by preventing ovulation
-- no effect on established pregnancy
- Ulipristol (Ella)
-- prescription only
-- use within 120 hours
-- works as progestin blocker
-- may affect established pregnancy
78
Stage 2 of labor
- begins when cervical dilation is complete and ends with birth of baby
- "laboring down": wait for spontaneous urge esp with epidurals, primips
- contractions become stronger, longer, closer together
- fetal descent through vagina
-- contractions
-- maternal expulsive efforts: pushing
- position and coordination of pushing with contractions
- instruct mom in pushing efforts
- WATCH THE FETAL HEART PATTERNS
- cardinal movements: fetus rotates to align with pelvis
79
NIPS
looking at maternal serum
- blood sample looking at fragments (fetal DNA)
- assessing trisomy 13, 18, 21
80
Hormone-Containing Birth Control: Contraceptive Implant
- LARC
- use of 3 years
- more effective than sterilization (failure less than 0.05%)
- unscheduled bleeding is common
- ovulation resumes within one month
- removal can be tough, leave scars
81
Barrier methods of birth control
protect against STIs; adherence may be poor though
- male condoms
- female condoms
- diaphragm: device covers cervix (can last 2 years)
- contraceptive sponge: foam disk that covers cervix (cannot stay in longer than 30 hours)
82
Risks to mom and baby associated with using forceps in operative vaginal delivery
Risks:
- fetal head or face injuries, brain injury
- 4th degree laceration of perineum
- perineal hematoma, bladder injury
- anal incontinence
What is it?
- about 1% of vaginal deliveries
- require specialized training
- outlet: baby is crowning, low: +2 station or more, midforceps: engaged
83
Cervical ripening - Dinoprostone (Cervidil and Prepidil)
- Cervidil most common
- dwell time 12 hours
- is the string looking thing
84
First intervention when seeing something not quite right on fetal strip?
change positions
85
What are the physiological changes of pregnancy for the endocrine system?
- thyroid hormone increase
- insulin needs:
-- decrease first trimester
-- increase steadily in 2nd and 3rd
- cortisol levels increase in 2nd
- oxytocin: end of 3rd trimester; stimulate contractions, milk ejection
86
Routine prenatal care
- know about supine position and changing position with towel under hip to relieve pressure on vena cava
- H&H: 11 and 33%
Low risk patients:
- appts ev 4 weeks until wk 28
- ev 2 weeks 28-36 weeks
- 36 weeks: weekly
first prenatal is most in depth: screenings and assessments, lab tests, patient education
87
Mechanical Dilation: Foley Bulb/Cook's Catheter
- mechanically dilates the cervix by providing pressure
- stimulates the release of prostaglandin
-- cervical ripening?
- cervix needs to be minimally dilated for insertion
Nurse Responsibilities:
- educate patient
- document time of insertion, removal, or when the balloon falls out
88
What is the biggest concern with PPROM?
infection
89
Safety with epidurals
minimize infection by wearing mask and hat
fluid bolus b/c hypotension risk
monitor VS
positioning
90
Fetal stage
9-38+ weeks
- ***viability is at 22 weeks*** (survivability is still low)
- ***refinement and maturing of organs***
- 9-12: fetal movement begins; kidneys function; genitalia
- 13-16: oogenesis; blood vessels visible; ridges for finger/toe prints
- 20th wk: fetal swallowing and insulin production; lanugo and vernix caseosa
- 24th wk: lungs begin to form surfactant
91
FLIP
intrauterine resuscitation
F = fluid bolus
L = lateral positioning
I = inform provider, internal exam, internal electrode
P = pitocin off
92
Question on communication, collaboration, delegation and closing the loop
- every team needs a leader to give clear directions
- assign roles to individuals and communicate
93
Pain relief in birth: narcotics - nubain
- nubain, stadol, demerol, morphine
- aid relaxation and provide relief from pain
- do not remove pain entirely
- wear off relatively quickly
- may mask changes in fetal heart pattern
- should not be given late in labor due to risk of respiratory depression in neonate
- increases mother's risk of falls: should not get out of bed without assistance
94
Stage 3 of labor
- **begins with delivery of newborn and ends with expulsion of placenta**
-- want to shorten length to reduce risk of hemorrhage
- delayed cord clamping beneficial to baby
- signs that placenta is about to deliver:
-- change in uterine shape (globular)
-- sudden gush of bright red blood
-- sudden lengthening of cord
- prolonged 3rd stage: increased maternal bleeding
- active management: oxytocin, gentle traction on cord, tell mother to push
- passive management: let it deliver on its own
95
Big adverse reaction to monitor with hormonal methods of birth control
blood clots
96
Meds used in preterm labor
Cervical Insufficiency: Cerclage
- IV hydration
- Bedrest
- Tocolysis
-- magnesium sulfate
-- terbutaline
-- nifedipine
- administration of agents to improve neonatal outcomes:
-- magnesium sulfate: protect brain
-- betamethasone: mature lungs
97
What is supine hypotension? How to relieve?
when mother is laying flat on her back and baby is pressing on vena cava
- relieved by placing a towel under her hip
- or by changing positions
98
Pain relief in birth: epidural anesthesia
- medication injected into the epidural space
- superior pain relief w/out systemic side effects
- can be bolus (C-section; increased discomfort)
- impairs motor and sensory function (can't get out of bed; urinary catheterization)
- ***side effect: hypotension***
-- ***may cause decreased uteroplacental perfusion (watch fetal monitoring strip)***
- can facilitate OR slow labor progress
99
Fourth degree laceration/episiotomy
skin, mucous membranes, muscle, rectal sphincter, and exposes rectal lumen
100
Prolonged decelerations and what they look like
Deceleration lasting longer than 2 minutes but not longer than 10; need to shut off pitocin if running
- can be caused by a baby who can't tolerate labor
- sometimes caused by maternal hypotension from epidural
101
Pain relief in birth: nitrous oxide
"laughing gas"
- does not necessarily reduce pain
- increases relaxation: "i felt pain, i just didn't care"
- no systemic effects on fetus, minimal maternal side effects
- effects easily reversed by breathing room air
- increases maternal sense of control over labor (-something she can do and use PRN)
*mom needs to be able to hold mask on face on inspiration and expiration herself
102
Advantages of hormonal methods of birth control
- treat PCOS
- relieve PMS
- lighter periods
- no impact on spontaneity
- reduce acne
- less cramping
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What do the head, butt, back, and limbs feel like with Leopold maneuvers?
- head: hard and round
- butt: soft and squishy
- back: smooth, long surface
- limbs: knobby
104
Late decelerations and what they look like
- nadir AFTER contraction
-- start after the contraction begins, gradual descent to nadirs which happens AFTER contraction
- stressed by contraction
- can be subtle, but are not good
- are a sign of uteroplacental insufficiency
- if recurrent or accompanied by minimal variability: require intervention
-- intrauterine resuscitation; pit off
- one late with moderate variability is worrisome; usually can get baby to recover
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Risks to mom and baby associated with using a vacuum in operative vaginal delivery
Risks:
- cephalhematoma
- fetal brain injury
- fetal brain death
What is it?
- application of suction to fetal head to affect delivery
- mom still has to push! no fundal pressure
- should see progressive descent within 2 pulls
- no more than 3 pop-offs
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Hormonal birth control: Contraceptive Ring
Nuva Ring and Annovera
- flexible silicone ring; estrogen and progestin
- inside vagina for 3 weeks, removed for week for bleeding, then replace with new one
- can be removed for sex and left out up to 3 hours per day
- placement not important
- teach checking placement b/c can come out during BM
- not great for those who don't like touching their body
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Matrix style question on pre-conception care - who NEEDS to go?
those of advanced maternal age, chronic conditions (DM, HTN), taking meds that could be teratogenic, substance use, smoking
108
Stage 4 of labor
Recovery and bonding
- begins with birth of placenta; lasts 4 hours or until "clinically stable"
- repair of perineal lacerations or episiotomies
- *most common time for postpartum hemorrhage*
- assess uterine tone and vaginal bleeding (quantitative)
- comfort measures: ice, topical meds
- Golden hour: skin to skin, breastfeeding, ongoing assessment of newborn
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What is hyperemesis gravidarum?
Excessive vomiting during pregnancy
- interferes with nutrition
- can cause serious fluid/electrolyte imbalances
110
C-section question
- more than a third of all births
- is a major abdominal surgery
- involves higher morbidity and mortality
- may be safety option for mother and baby
nurse responsibilities:
- pre-op education
- positioning for spinal
- positioning patient and monitoring FHR during epidural/spinal placement
- insertion of Foley to prevent bladder injury
- maintaining and monitoring of sterile field
- managing equipment and obtaining supplies (suction, bovie, sutures, laps)
- counts
111
What are the physiological changes of pregnancy for the musculoskeletal system?
- lordosis shifts center of gravity; increases fall risk
- relaxin and progesterone: increase mobility of pelvis for delivery; joints less stable
- round ligaments (position and stabilize uterus) can stretch and cause pain
- abdominal walls separate at midline (diastasis recti)
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Pre-embyronic stage
fertilized ovum becomes a morula and then blastocyst before entering uterus
- not considered susceptible to teratogens
113
Targets for gestational diabetes
1 hour oral glucose tolerance test for all patients at 24-26 weeks:
- *target: fasting <95 mg/dL (some LIPS want <90)*
- *target: 2hrs post prandial <120 mg/dL*
- if >135 send for 3 hour GTT
- some say 135, some say 140 for referral as positive
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What are the 5 Ps?
Passage
Passenger
Powers
Psyche
Position
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What are the physiological changes of pregnancy for the respiratory system?
- oxygen consumption increase 15-20%
- RR increases about 2 resp/min
-- mild resp. alkalosis normal
- tidal volume increase 40-50%
- diaphragm elevates 5 cm
-- sense of SOB
-- rib cage expands to make room
- increased estrogen causes congestion of mucus membranes
-- swelling of pharynx, trachea, larynx
-- engorged capillaries can cause nosebleeds
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Interventions for cord prolapse
- call for help while keeping presenting part off cord
-- sterile gloved hand in vagina
-- apply pressure to head
-- don't let go until baby is out
- avoid manipulating cord in any way
- if cord is protruding, use moistened sterile saline: time permitting
- position mom in knees-chest or Trendelenburg
- immediate Cesarean - take a "thrill ride" to OR
Scenario (basically same thing)
The assigned nurse pulls the emergency cord and initiates the correct actions (What are they?) Four more nurses arrive.
- One has to mobilize the OR team - there is an overhead “Code Cesarean” protocol.
- One has to open the OR and count with the scrub
- One has to free the IV lines and initiate a fluid bolus
- One has to unplug the bed and wheel the patient down the hall to the OR.
Once there, two more nurses are available to assist.
- One will assist the nurse who pushed the bed to transfer the patient to the OR table and obtain fetal hearts.
- One will insert a foley.
117
Minimal variability and what it looks like
1-5 BPM change
- insufficient uteroplacental blood flow
- fetal sleep or maternal medications
- can be bad, but brief periods can indicate fetal sleep or maternal medications
118
SBAR to provider during labor (ISBARR)
I = identify self and patient
S = situation, get right to it
B = background
A = assessment
R = recommendation
R = read back orders
be brief, pertinent, and focused
119
How to manage oxytocin and titrations during induction
assessing maternal and fetal response
1 milunit/min = 1ml/hr
usually increasing by 2
want moderate-strong contractions every 2-3 minutes lasting about 60 seconds
120
Early decelerations and what they look like
- mirror the contractions
-- begin at start, reach nadir at peak of contraction, and gradually return to baseline
- caused by head compression
-- as contraction moves baby down, compression on head causes vaginal stimulation and lowers HR
- not usually cause for concern and that birth could be happening soon
-- only problem when still early in labor and not in pelvis (baby can be too big)
121
Routine interventions with epidurals
- educate patient
- assist with positioning
- minimize risk of infection by wearing mask and hate
- monitor VS, pain, dermatome level, and fetal heart tracing
-- dermatomes chart: should be around T10; indicates level of anesthesia (wet vs dry; soft vs sharp)
-- good epidural at about T9-T10
- assess bladder for distention and catheterize PRN
122
What is done in maternal cardiac arrest?
| what could result in maternal cardiac arrest
- uterine displacement with compressions
- AFE (amniotic fluid embolism) could result in cardiac arrest
123
What are the s/s of shoulder dystocia?
- turtle sign
- rest of baby fails to deliver
124
Second degree laceration/episiotomy
skin, vaginal mucosa, fascia of perineal body
125
What is placenta previa?
Placenta partially or completely covers the os (opening of the cervix)
126
CVS [chorionic villus sampling] what is it?
tissue from chorion side of the placenta at 10-12 weeks of gestation
- baby side
- assessing the finger like projections
- miscarriage risk about 1%
- patient instructed to report bleeding or cramping
127
What are the four stages of labor?
First stage (Latent phase and active phase): all about the cervix
Second stage: all about birth of baby
Third stage: All about the placenta
Fourth stage: recovery and bonding
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Accelerations
(15x15): 15bpm above baseline x 15 seconds
- under 32 weeks: 10x10
- indicate good oxygenation and that baby's CNS is intact
- are very reassuring
- show baby can respond to stimulation or increased demand
- if concerned about a tracing, vaginal exam is done and tickle baby's head to elicit accel: scalp stim
129
What is McRoberts Maneuver?
successful in 90% of cases
- flatten head of bed
- flex the legs back almost to earlobes
- suprapubic pressure down and to the side
-- ask provider which side
130
What are the probable signs of pregnancy?
Could be attributed to other causes, but probably pregnant:
- positive pregnancy test
-- could be pituitary tumor or menopause
- Chadwicks, Hegar's, or Goodell's signs
-- bluing cervix, softening of cervix
- maternal perception of fetal movement
131
What is GTPAL
G = gravida - how many times she has been pregnant
T = term births - (twins count as one) >/= 37 weeks
P = preterm births (twins=1) - births or losses from 20-36 6/7 weeks gestation
A = abortions/miscarriages - any loss <20wks
L = living children
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What to do with labor that won't progress and how to manipulate the 5 Ps to get labor to progress
- patience is 6th P; don't rush
- widen the Passage
- help the Passenger rotate
- encourage ambulation/upright Position for stronger Powers
- decrease anxiety and control fear, tension, pain - Psyche
133
Placental abruption signs
*painful, dark red bleeding in smaller amounts than previa*
- blood pools behind presenting part: trickle instead of gush
- increased uterine activity (contracts to put pressure on bleeding)
- later stages:
-- maternal hemodynamic instability
-- maternal shock
-- fetal distress
-- absence of fetal heart tones
comparison to previa:
- *dark red bleeding*
- smaller amounts of blood
- moderate to severe pain
- maternal VS may deteriorate even when measurable blood loss is small (can't see blood pooling)
- ultrasound unreliable
134
When should people undergo fertility testing/treatment?
- initiate for women 35 or younger after trying for year
- initiate for women over 35 after trying for 6 months
135
What are the physiological changes of pregnancy for the uterus, vagina, and cervix?
- 16-36wk: size of uterus from pubis to fundus = number of weeks gestation
- fetal movement perceived by mom at 20 weeks or earlier
- round ligaments stretch as uterus grows
-- pulling sensation and milkd pain
- braxton hicks contractions
- increased vascularity of vulva, vagina, and cervix
-- Chadwick's sign: bluish discoloration of cervix
136
Intrauterine (IUDs: LARCS w/ or w/out hormones)
- copper (Paraguard)
- progestin-releasing (Mirena and Skyla)
- do not affect pregnancy or cause abortion
- work by thinning lining of uterus and create environment not good for sperm
-- hormonal also prevent ovulation
- no chance of user error and completely reversible
- long acting!
-- Skyla: 3 years (failure rate 0.2%)
-- Mirena: 5 years (failure rate 0.2%)
-- Paraguard: 10 years (failure rate 0.8%)
137
Positioning of the patient for epidurals
angry cat -- pushing out vertebrae
(shrimp shape)
138
BPP
- ***Biophysical profile (BPP)***: done with ultrasound
-- 5 criteria; 2 points or 0
-- assess fetal wellbeing
-- fetal movement, tone, breathing, amniotic fluid, NST
-- 8-10/10: reassuring; 6/10 monitor; lower = deliver
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NST
- ***non-stress test:** look for 2 accelerations of the fetal heart in 20 minutes*
