Lecture 08 High Risk Pregnancy and Compliation During Labor and Delivery Flashcards Preview

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Flashcards in Lecture 08 High Risk Pregnancy and Compliation During Labor and Delivery Deck (60):

What are some causes of early pregnancy bleeding? (3)

1. Miscarriage: spontaneous abortion (SAB)

2. Incompetent cervix

3. Hydatidiform mole (molar pregnancy)


Late pregnancy bleeding causes (2)

1. Placenta previa 2. Placenta abruption


There are dif levels of miscarriage (SAB): Def each: Threatened:

Threatened: slight bleeding with cramping

Inevitable: heavy bleeding with increased cramping. Cervical dilation and ROM>imminent


There are dif levels of miscarriage (SAB): Def each: Incomplete (rather common): Complete:

Incomplete: retained placental tissue in uterine cavity. But continued bleeding until complete removal of all placental tissue
Complete: Uterus evacuates all products of conception


There are dif levels of miscarriage (SAB): Def each: Missed spontaneous abortion

embryo/fetus has expired, however the contents of conception remain in the uterus.


How would miscarriages be assessed? (3)

U/S Beta hCG levels VS


What is an incompetent cervix?

Passive or painless dilation of the cervix during the 2nd trimester.


How do you assess for incompetent cervix?

1. funneling of the cervix 2. Shortening of the cervix


What is a medical management of cervix?

Placement of a cerclage, a big and thick stitch


What is a hydatidiform mole?

aka Gestational Trophoblastic disease, it's rapidly dividing cells with no genetic material from the ovum. Occurs in the uterus. So sperm and egg come together, but doesn't develop into fetus, but into rapid placental pos cancerous tissue. Occurs more in teenagers vs women Etiology unknown.


Who are at risk of hydatidiform mole?

1. Use of clomid: med to help women ovulate 2. teenagers and women >40 are at risk


Nursing implications of hydatidiform mole

1. U/S, beta hCG levels 2. Suction curettage, want to make sure you get all the cells out 3. Induction of labor is contraindicated 4. Admin rhogram is indicated 5. Education: pregnancy should be avoided for one year


What is placenta previa?

Placenta implanted over the lower uterine segment or over cervical os


What are sx of placenta previa?

1. painless bright red vaginal bleeding 2. Associated with stretching and thinning of the uterine 3. Abdomen will be soft, nontender and relaxed 4. Fundal height is usually greater than expected. The fetus is un able to settle into the pelvis related to low lying placenta


What is Dx of placenta previa?



What are nursing care for placenta previa?

1. Stable: expectant management (no vaginal exams) 2. Unstable ~ delivery by cesarean section


What is placenta abruption?

Detachment of part or all of the placenta from its implantation


What are risks that may cause placenta abruption?

1. maternal HTN 2. PSA, mainly stimulates (cocaine), causes vasoconstriction 3. Abdominal trauma, may want to ask mother if she was abused by her partner 4. Smoking


What are sx of placenta abruption?

1. painful bright red vaginal bleeding 2. uterine contractions 3. Uterine tenderness 4. lab tests: Kleihauer-betke stain (KB) : Determines the presence of fetal to maternal bleeding If present and mom is RH - , Rhogam is given Hemoglobin or Hematocrit (to see if blood is dropping) Clotting studies


What are nursing care steps for placenta abruption?

If stable: expectant management If unstable: move towards delivery either vaginal or c/s


What is preterm labor defined as?

Cervical changes and uterine contractions occurring earlier than 37 weeks.


What is preterm birth?

Delivery of newborns earlier than 37 weeks. Accounts for 90% of neonatal deaths. 75% occur in infants earlier than 32 weeks.


What are some risks that lead to preterm labor? (3)

1. demographic: people who don't seek prenatal care, have less than HS education, povery and non caucasian 2. Biophysical: had a previous preterm labor (Most common cause of another preterm labor), uterine abnormalities-fibroid, progesterone deficiency. 3. Behavioral: smoking, substance abuse, poor nutrition, inadequate prenatal care, excessive physical activity or excessive stress


What are some assessments for preterm labor?

1. continuous fetal and contraction monitoring 2. evaluation of maternal plan 3. Evaluate for cervical changes: speculum, U/S


What are some nursing care for preterm labor?

1. Education 2. Restricted activity 3. Tocolysis fluids 4. Nifedipine 5. Indocin


What is PPROM?

Preterm Premature Rupture of Membranes 1. ROM before 37 weeks of gestation 2. etiology is unknown


What is PPROM plan of care?

If earlier than 34 weeks: 1. Bed rest 2. Monitor maternal and fetal well being 3. Give corticosteroids, to help with fetal lung development 4. Monitor for signs and symptoms of chorioamnionitis (infection of the chorion and amniotic layers) 5. Limit vaginal exams If greater than 34 weeks: monitor closely and move toward delivery


What does ROM stand for?

Rupture of Membrane


What does SROM stand for?

Spontaneous Rupture of Membrane


What does AROM stand for?

Artificial Rupture of Membrane


What does PROM stand for?

Premature Rupture of Membrane


What's the difference between HTN and preeclampsia?

Preeclampsia has proteinuria


What's the overview of Pregnancy induced HTN? (3)

1. Development of mild HTN during pregnancy 2. w/o proteinuria 3. No evidence of pathologic edema


What's the overview of preeclampsia?

Etiology is unknown. Only cure is deliver fetus. 1. Development of HTN 2. w/proteinuria 3. Typically develops after 20 weeks of pregnancy and can develop early during post partum period


Overview of eclampsia.

Development of convulsions or coma in preeclamptic pt. Etiology is unknown. Only cure is to deliver the fetus


KNOW: What does HELLP stand for in HELLP Syndrome?

Hemolysis Elevated Liver enzymes Low Platelet count is the most severe form of preeclampsia.


What are some risk factors that can lead to Preeclampsia & HELLP

Chronic renal disease Chronic HTN Family history of PIH Multiple gestation Primagravity Maternal age 45 Diabetes Rh incompatibility Obesity


Sx of Preeclampsia/HELLP

  1. •Decreased perfusion to eyes = visual changes, headaches
  2. •Decreased liver perfusion causes epigastic pain
  3. •Decreased renal perfusion causes oliguria may result in renal failure
  4. •CNS irritability = Increase in DTR’s, clonus, hyperreflexia & convulsions
  5. •Pulmonary edema related to chronic heart failure which can result if BP is unable to be controlled
  6. •Pitting edema, Facial edema- associated with increased risk of neurologic involvement


§Vasospasm continues to increase resulting in tissue hypoxia


What are nursing care of preeclampsia?

  1. Noting Classic preeclampsia signs and symptoms
    §Visual changes
    §Right upper quadrant pain - epigastric pain
    §Pitting edema - facial edema is associated with increased risk of neurologic involvement
  2. §Check BP
  3. §Serial maternal weights


What are some assessments for Preeclampsia?


—1. Monitor fetal wellbeing
Monitor BP, DTR
Continuous fetal monitor
Doppler studies

—2. Maternal breath sounds

—3. Ophthalmic evaluation of the fundus of the eye

4. —Administer meds to lower BP: hydralazine, aldomet, nifedipine, labetalol,


What are some laboratory studies of preeclampsia?

  1. —CBC with differential
  2. —Platelet count
  3. —Coagulation studies
  4. —Chemistry studies - Profile 14, Liver function and Urate
  5. —Urinalysis - dip & 24 hour I&O


What are some nursing care of HELLP?

  1. •Frequent assessment of
    •Breath sounds
    •Reflexes and clonus
    •I & O (STRICT)
    •Seizure precautions
  2. •Administration of IV Magnesium Sulfate
    •Typical dose is a load of 4gm followed by 2gm/hour
  3. •Assess for signs of toxicity
    •Antidote - Calcium Gluconate IV
  4. •Bedrest


What are risks that predisposes pt to GDM?

  1. —Maternal age > 30
  2. —Ethnicity (increased in races other than white)
  3. —Obesity
  4. —Family history
  5. —Previous history of GDM
  6. —History of LGA newborn > 9 pounds


What are some risks associated with DM during pregnancy? (7)

  1. —Increase for pregnancy loss
  2. —Macrosomic newborn
  3. —Increase for development of preeclampsia
  4. —Polyhydramnios
  5. —Hypoglycemia
  6. —Ketoacidosis
  7. —Increased AF, cuz baby is peeing a lot


Why does diabetes occur during pregnancy?

—Pathyphysiology due to hormones made by placenta, protein: Human placenta lactogen

—Altered glucose metabolism occurs during pregnancy to ensure adequate fetal nutrition

—Glucose is the primary fuel for the fetus and crosses the placenta

—Insulin does not cross the placenta, the fetus excretes it own insulin in respect to maternal glucose

—During the second trimester a “dibetogenic” effect occurs: results in decreased tolerance to glucose stores, increased insulin resistance, decrease in glycogen stores and  increased production of glucose

—Resulting in maternal insulin requirements increasing from 20 weeks to 36 weeks gestation

—Remember babies born to diabetic moms are hypoglycemic at birth


What are some nursing implications for diabetes during pregnancy?

  1. —Education:   nutritional counseling, weight gain recommendations!
  2. —Greater risk for
    —Birth trauma related to macrosomia
    —Congenital malformation
    Delayed pulmonary maturation in newborn
    —Increased risk of glucose intolerance in mother later in life
    Increased risk of HTN while pregnant


What are some screening techniques for diabetes during pregnancy?

  1. —Urine dip at every prenatal visit
  2. —CBG at every prenatal visit
  3. —Glucose tolerance test (GTT), Three hour GTT.
  4. —Hemoglobin A1C to determine long term glucose control
  5. Results has to be less than 135. If it’s not, then woman will have to come in for another test while she’s fasting. It’s harder, since it’s 3~5 hours


Why would forceps be used in delivery?

Fetal indications?

Complications with?

Nursing care that needs to be done?

—Fetal indications
Fetal distress, abnormal presentation and arrest of rotation


—Nursing care
Educate patient on use of forceps, closely monitor and document fetal heart rate, assessment of newborn for bruising or abrasion and assess maternal perineum and assess for bleeding


How does the vacuum for?

Indications for it?
Risk of it?

Nursing care that needs to be done?

Vaginal delivery that requires the placement of a vacuum cup attached to negative pressure to assist in the birth of the fetal head

—Fetal indications
Fetal distress and arrest of rotation

—Risk to fetus
Cephalhematoma, Scalp laceration, Subdural hematoma, Bruising


—Nursing Care
Educate patient on use of vacuum, closely monitor and document fetal heart rate, assessment of newborn for bruising or abrasion and assess maternal perineum and assess for bleeding


What are 4 types of OB emergencies?

1. Prolapsed cord

2, Shoulder dystocia

3. Uterine Rupture

4. Amniotic fluid embolism


What are risk factors to prolapsed cord?

—Long cord


—Unengaged presenting part


What are some nursing care interventions for a prolapsed cord?

  1. —Vaginal exam to hold presenting part of umbilical cord
  2. —Reposition to elevate pressure on cord : trendelenberg or knee-chest
  3. —Continue to monitor and assess FHR
  4. —Move towards vaginal delivery or c/s


What are some maternal complications from shoulder dystocia?



•Obstruction of the fetal descent and expulsion by fetal shoulders

•Unpredictable obstetrical emergency

•Risks are fetal macrosomia and DM, previous shoulder dystocia

 Maternal complications


• Infection

•Bladder injury


What are some newborn complications that may result from shoulder dystocia?

  1. •Brachial plexus, facial nerve paralysis
  2. •Clavicular fracture  
  3. •Asphyxia
  4. •CNS injury
  5. •Death


What are some interventions with shoulder dystocia?

  1. •Manual maneuvers
  2. •RN may assist with McRoberts maneuver
  3. •RN applies suprapubic pressure
  4. •Fundal pressure is contraindicated
  5. •Change maternal position – Gaskin manuever
  6. •Set up for neonatal resuscitation
  7. •Continue to monitor FHR closely


What are sx of ruptured uterus?

  1. —Maternal:  pain, bleeding, loss contractions, increased abdominal tenderness, hypovolemic shock
  2. —Fetus: loss of variability, lates and variables (fetal mortality is 50 - 75%)


What are interventions for uterus rupture?

  2. —VBAC
  3. —Close monitoring of Pitocin (induction or augmentation
    Caused by Hyperstimulation of uterine contractions


What are some Nursing Care steps for Rupture of Uterus?

—IV access and fluids

—Transfusing blood

—Administer O2

—Move towards rapid delivery


Overview of Amniotic Fluid Emoblism?

  1. —Causes 10% of maternal deaths
  2. —Amniotic fluid containing particles enters the maternal circulation and obstructs pulmonary vessels

  >>> respiratory distress

  >>> circulatory collapse


Nursing Care for Amniotic Fluid Embolism

  1. —Oxygenate
  2. —Maintain cardiac output
  3. —Replace loss fluids
  4. —Correct coagulation failure
  5. —Monitor fetal and maternal status
  6. —Educate