L & D slides pt 2 Flashcards
1
Q
What are some pre-labor complications?
A
-placental complications (previa, abruption)
-cervical insufficiency
-amniotic fluid complications
-premature ROM
-preterm labor
2
Q
What is placenta previa?
A
Placenta implanted in the lower uterine segment near or covering the cervix
3
Q
What causes placenta previa?
A
*UNKNOWN
may be r/t prev. c/s smoking/medical abortion
4
Q
What are the characteristics of a complete placenta previa?
A
internal cervical os completely covered
5
Q
What are the characteristics of a partial (marginal) placenta previa?
A
internal cervical os partially covered
6
Q
What are the characteristics of a low-lying placenta previa?
A
near cervix but not covering the cervix (<2 cm)
7
Q
What is the classic sign of previa?
A
**painless bright-red vaginal bleeding
usually slight at first then increases in subsequent unpredictable episode
the abdomen is usually soft, non-tender
8
Q
What can happen if a woman goes into labor with placenta previa?
A
Hemorrhage
9
Q
How should placenta previa be managed if there is NO active bleeding?
A
-monitor placenta location by US throughout pregnancy
-NO vaginal or rectal exams
-Delivery by c-section at full-term
10
Q
What education should be done for a pt with placenta previa?
A
-Pelvic rest
-S/S of concern: decreased FM or bleeding
-Delivery and emergency plan of care
11
Q
True or False: you should NEVER do a vaginal check if mom is bleeding.
A
True
**Nothing in the vagina
12
Q
If there is no frank bleeding during a pregnancy with placenta previa what should be done?
A
Nothing. Continue to monitor the pregnancy
13
Q
What is a placental abruption?
A
Premature separation of the placenta from the uterine wall, leading to loss of oxygen and blood to the fetus
14
Q
True or False: A placental abruption IS life threatening to both mom and fetus.
A
True
15
Q
Premature separation is the leading cause of _____ ________.
A
perinatal mortality
16
Q
What is placental abruption most commonly associated with?
A
-hypertension
-cocaine use
-abdominal trauma
17
Q
Symptoms of placental abruption:
_____ vaginal bleeding
*bleeding can be concealed
_____ pain
uterine _____/______
elevated _____ tones
rapid s/s of maternal _____/_____ distress
A
painful
abdominal
rigidity/tenderness
resting
shock/fetal
18
Q
What are the maternal implications for a placental abruption?
A
-hemorrhage
-DIC
-Shock
-Death
19
Q
What are fetal/neonatal implications for a placental abruption?
A
-preterm labor/birth
-anemia
-hypoxia
-death
20
Q
What is the nursing plan for a placental abruption?
A
- Monitor: maternal shock and fetal distress
- Could have rapid fetal distress
- Prepare for immediate delivery
21
Q
What is Disseminated Intravascular Coagulation (DIC)?
A
Widespread activation clotting cascade– blood clots in vessels throughout body resulting in tissue damage
**process uses up clotting factors/platelets, massive hemorrhage may ensure
22
Q
What S/S may be noted in a pt with DIC?
A
localized bleeding: vaginal, oozing IV sites, ecchymosis, hematuria
23
Q
What is the treatment plan for a pt with DIC?
A
-Monitor PT/PTT and CBC
-protect from injury
-NO IM injections
24
Q
__-__% of pts with DIC will die.
A
20-50
25
What is the management for a pt with a placental abruption?
Maintain the cardiovascular status of the mother. Monitor for DIC
26
If MILD abruption and fetus is pre-term & in no distress, then what should be done?
BED REST and tocolytic meds
*may consider a vaginal delivery
27
If the abruption if moderate-severe, the pt will need an _____.
immediate C/S
28
Cervical insufficiency is also known as ____ _____.
Incompetent cervix
29
What is cervical insufficiency?
painless dilation of the cervix (without contractions) due to structural or functional defect of the cervix.
30
How should I manage cervical insufficiency?
-transvaginal US of cervical length b/w 18-20 weeks
-cervical cerclage
31
What is a cervical cerclage?
stitches used to close the cervix during pregnancy to help prevent pregnancy loss or premature birth
32
Is an emergent or elective cervical cerclage preferred?
elective
33
When will an elective cervical cerclage be placed?
late in the first trimester or early in the second trimester
34
What is the success rate for an elective cervical cerclage?
80-90%
35
When is an emergent cervical cerclage placed?
When dilation and effacement have already occured
36
What is the success rate for an emergent cervical cerclage?
40-60%
37
After __ completed weeks gestation, ____ may be cut and vaginal birth permitted, or the suture may be left in place and _____ birth performed.
37
suture
cesarean
38
Amniotic fluid is in a constant state of _____.
Circulation
39
In the second half of pregnancy the main sources of fluid production are from the baby:
____ (700mls per day) &
____ ____ (350 mls per day)
urine
lung secretions
40
What is having TOO MUCH amniotic fluid called?
Polyhydraminos
41
What is having TOO LITTLE amniotic fluid called?
Oligohydraminos
42
In a pt diagnosed with polyhydraminos, more than ___ ml of amniotic fluid is present.
2000
43
What is the key indicator of polyhydraminos?
Fundal height increases out of proportion to the gestational age.
*should be within 3cm of gestational age in weeks
44
What maternal conditions are associated with polyhydraminos?
-DM
-Rh sensitization
-Multiple gestation (twins or triplets)
45
What might the mother experience if the amniotic fluid is >3000?
SOB and edema in lower extremities
46
What are the fetal/neonatal implications of polyhydraminos?
-preterm birth d/t pre-term labor
-placental abruption due to sudden loss of large amt of fluid
-mal-presentation
**increased risk for c-section
47
What is Oligohydraminos?
There is less than normal (<500 ml) amount of amniotic fluid present.
48
What is the key indicator of oligohydraminos?
Fundal height does not increase appropriate to gestational age
49
If there is a cord compression during delivery due to oligohydraminos, what is the treatment?
Amnioinfusion
50
What are the maternal implications of oligohydraminos?
dysfunctional labor, slow progress
51
What are the fetal/neonatal implications of oligohydraminos?
-fetal skin/skeletal abnormalities
-pulmonary hypoplasia
-cord compression
-amniotic band syndrome
-renal anomalies
52
What is the typical cause for oligohydraminos?
reduced urine output (baby)
53
When is oligohydraminos most often seen?
post maturity, maternal hypertension, IUGR secondary to placental insufficiency
54
What is amniotic band syndrome?
Occurs when the unborn baby becomes entangled in fibrous string-like amniotic bands in the womb
55
What does amniotic band syndrome do and what does it affect?
It restricts blood flow to the fetus affecting the baby's development
56
What is pulmonary hypoplasia?
Oligohydraminos reduce the intrathoracic cavity size, thus disrupting fetal lung growth and leading to pulmonary hypoplasia
57
If a pt presents with PROM and/or preterm labor, what should you assess?
1. time of suspected rupture
2. last cervical exam
3. last intercourse
4. pathologic discharge (STI?)
58
What is pooling?
Pooling is when a collection of amniotic fluid can be seen in the back of the vagina (vaginal fornix)
59
Amniotic fluid is slightly ___ (pH of 7.1-7.3) compared to normal vaginal secretions which are ____ (pH 4.5-6)
basic
acidic
60
What does a Amnisure ROM test for?
screens for a protein marker of the amniotic fluid in vaginal discharge
61
What are the most common causes of PROM?
infections
incompetent cervix
fetal abnormalities
sexual intercourse
62
PROM occurs in __% of U.S. deliveries?
3
63
What is PROM?
Spontaneous rupture of membranes prior to onset of labor
64
What is P-PROM?
ROM prior to 37 weeks gestation
65
What is the biggest risk in a pt with P-PROM?
Ascending intrauterine infection
66
What is the treatment and nursing care of a pt with P-PROM?
-pelvic rest
-fetal steroids
-CHECK TEMP FREQUENTLY
-bed rest
-prepare for delivery
67
Risk of infection increases after ___ hours from rupture time.
24
68
What is a pt with prolonged rupture of membranes at risk for?
Chorioamnionitis
69
What is chorioamnionitis?
Intra-amniotic infection
*includes inflammation of the fetal membranes (amnion and chorion due to bacterial infection
70
What causes chorioamnionitis?
bacteria ascending into the uterus from the vagina
71
What are chorioamnionitis risk factors?
-prolonged labor
-prolonged ROM
-internal fetal monitoring
-multiple vaginal exams
-meconium
+GBS carrier
-STI
72
What is the most important maternal sign of chorioamnionitis?
maternal fever
can also be: uterine tenderness & purulent discharge
73
What is the most common fetal sign of chorioamnionitis?
fetal tachycardia (180-200)
74
What is the treatment for chorioamnionitis?
Antibiotics: ampicillin Q6 hours and gentamicin Q8-24 hours
Supportive: antipyretics
75
What is a prolapsed umbilical cord?
prolapse of the umbilical cord through the cervical canal BEFORE the presenting part
76
What can a prolapse cord result in?
Loss of oxygen to the fetus
*fetal death!
77
What is the goal of treatment with a prolapsed cord?
relieve the pressure on the cord
78
True or False: it is okay to attempt to replace the cord if it is prolapsed.
False, you should never attempt
79
Umbilical cord prolapse is an acute obstetric emergency that requires immediate ___ of the baby.
Delivery
*usually by c-section
80
What might you see in a baby that has a prolapsed cord?
bradycardia (<120 bpm)
81
What should the nurse do if your patient has a prolapsed cord?
**Immediately place in trendelenburg or knee-chest position
-elevate part with sterile gloved hand to relieve the compression
-10L O2 mask
-cover cord with sterile wet gauze
-plan to go to the OR
82
What is premature labor?
Labor that occurs after 20 weeks but before 37 completed weeks
83
What is the goal of treatment in a patient with premature labor?
STOP THE LABOR and suppress uterine activity using tocolytics
84
What should the nurse assess in a pt with preterm labor?
-uterine activity
-ROM
-vaginal bleeding
-fetal presentation
-cervical dilation and effacement
-fetal station
85
Management strategies in a pt with preterm labor:
____ therapy (if GBS+)
bedrest
Corticosteroid therapy (fetal ____ maturation)
IV _____ therapy
Antibiotic
lung
tocolytic- will slow labor but does NOT improve neonatal outcomes
86
Bacterial infections presumed cause for many PTL ____ weeks
<32
87
What med is usually given under 32 weeks, after premature closure of the ductus arterioles is no longer an issue.
Indomethacin
88
What medications are uterine relaxants (tocylytics)?
Indomethacin, Nifedipine, Magnesium sulfate, Terbutaline
89
If a pt is not fully dilated and wants to push, what should the nurse encourage?
Pursed lip breathing through ctx.
90
What are some dysfunctional contraction patterns?
hypotonic and tachysystolic
91
What is a hypotonic contraction patterns?
contractions decrease in frequency and intensity
*fewer than 2-3 contractions in 10 minutes
92
What are some possible causes of a hypotonic contraction pattern?
-overstretched uterus
-uterine distention preventing descent
-excessive use of analgesia/pain medications
93
How should the nurse manage a hypotonic contraction pattern?
walking, augmentation of labor, position changes, amniotomy, minimize vaginal exams
94
A pt with a tachysystolic labor pattern may experience:
painful contractions (cramping)
95
What is a tachysystolic labor pattern?
-ineffectual, erratic, uncoordinated
-occuring <2 min frequency, >90 seconds duration
**increase in frequency but intensity decreased
DOES NOT bring about dilation and effacement of the cervix
96
What is the management for a pt that has a tachysystolic ctx pattern?
rest, hydration, sedation, facilitate rotation of fetal head, stop pit, AROM, side-lying position
97
What are the implications of a tachysystolic ctx pattern?
-maternal exhaustion, dehydration, infection
-reduced utero-placental exchange resulting in a non-reassuring fetal status
-prolonged pressure on fetal head
98
What does prolonged pressure on fetal head result in?
1. excessive molding
2. caput succedaneum
3. cephalhematoma
4. fetus is at risk for fetal hypoxia
99
What are the different types of fetal malpresentation?
face, breech, shoulder
100
What is a vertex presentation?
head flexed/chin tucked
101
What is a sinciput (military) presentation?
head is neither flexed or extended
102
What is a brow presentation?
head partially extended
103
What is a face presentation?
head is hyper-extended
104
True or False: you can use a scalp electrode in a fetus with face or chin presentation.
False
105
106
What are the maternal implications for a brow/face presentation?
-longer labor
-dysfunctional labor pattern
-c-section IF brow presentation persists or if the fetus is large
107
What are the fetal implications for a brow/face presentation?
-facial cephalohematoma
-facial edema
-laryngeal and tracheal damage
-pronounced cranial molding
-subconjunctival hemorrhage
108
What is the clinical treatment for a brow/face presentation?
-IF failure to convert to occipital from face presentation, c-section is usually indicated.
-If a vaginal birth is attempted, the woman is closely monitored
-You SHOULD NOT attempt to rotate the fetus or use vacuum/forceps
109
What is a breech presentation?
occurs when a baby is born feet or butt first instead of head first
110
A breech presentation occurs in __-__% of pregnant women.
3-5
111
What is a complete breech presentation?
hips/knees are flexed and the feet are not below the level of the fetal buttocks
112
What is a footling breech presentation?
one or both feet are presenting first
113
What is a frank breech presentation?
hips are flexed and the legs are extended
114
What is the goal of breech presentation management?
convert breech presentation to cephalic presentation before labor beings
115
Antepartum management of a breech baby?
**ECV (external cephalic version)
-IV, tocolytics, ultrasound
116
What is the criteria for ECV?
-36 weeks gestation
-reactive NST immediately before
-fetal presenting part not engaged
117
What are some contraindications for ECV?
previous CS, multiple gestation, non-reassuring monitoring, ruptured membranes
118
What is the current recommendations for breech presentations that can not be converted by ECV?
c-section
119
What are some complications of ECV?
-fetal bradycardia
-placental abruption
-feto-maternal hemorrhage
-uterine rupture
120
What is the most dangerous breech presentation to try and delivery vaginally?
Footling
121
What are the risks associated with vaginally delivering a footling breech baby?
-umbilical cord prolapse
-delivery of the feet through an incompetent dilated cervix leading to arm or head entrapment
-neck entrapment
