Flashcards in Maternity Deck (46):
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Presumptive signs of pregnancy
• Amenorrhea – what is the name of the hormone that causes this? Progesterone
• N/V
• Frequency – can be one of the first signs.
• Breast Tenderness – excess hormones
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Probable signs of pregnancy
• A positive pregnancy test – since it is based on the presence of hCG levels.
• There are other conditions that can ↑ hCG levels: hydatidiform mole; drugs.
• Goodell’s sign (softening of cervix; second month)
• Chadwick’s sign (bluish color of vaginal mucosa and cervix; week 4)
• Hegar’s sign (softening of the lower uterine segment; 2nd/3rd month)
• Uterine enlargement
• Braxton Hicks contractions (throughout pregnancy; move blood through the placenta).
• Pigmentation/changes of skin Linea nigra
Abdominal striae
Facial chloasma (mask of pregnancy) Darkening of the areola (around the nipple)
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Positive signs of pregnancy
Fetal heartbeat: Doppler→ 10 - 12 weeks
• Fetoscope→ 17 - 20weeks
• Fetal movement
• Ultrasound
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Pregnancy calculations
1) Gravidity: # of times someone has been pregnant
2) Parity: # of pregnancies in which the fetus reaches 20 weeks.
3) Viability 24 weeks = Infant has the ability to live outside the uterus.
• A 20 week baby is NOT considered viable.
4) TPAL: acronym that gives you further information on parity
T= term
P= preterm
A= abortion – this includes spontaneous and elective abortions
L= living children
5) Naegele’s Rule:
• Find the first day of the LMP
• Add 7 days
• Subtract 3 months
• Add 1 year
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Nutrition and wt gain
a. Nutrition:
• 4 food groups
• Increase calories by 300 per day after the first trimester
Adolescent: ↑ calories by 500 after first trimester
• Increase protein to 60 grams per day. Normal is 40-45
b. Weight Gain:
• Expect to gain 4 pounds in the first trimester
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Prenatal supplements
Why don’t women like to take iron? It causes constipation and GI upset. Take iron with vitamin C to enhance absorption.
Folic acid prevents neural tube defects
Daily dose? 400 mcg/day
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Exercise rules
• No high impact; walking and swimming are best.
• No heavy or unaccustomed exercise program.
• No overheating (no hot tubs or electric blanket either☺)
• Why? Increased body temperature = birth defects
Exercise Rule: Don’t let your heart rate get above 140.
• If the heart rate goes over 140bpm = CO and uterine perfusion will drop.
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Danger signs
Sudden gush of vaginal fluid Bleeding
Persistent vomiting
Severe headache
Abdominal pain Increased temps Edema
No fetal movement
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Doctors visits and ultrasound
How often should a pregnant client visit the physician?
• First 28 weeks: 1x month
• 28-36 weeks: 2 weeks
• 36 weeks: weekly until delivery
j. Ultrasounds:
• Before an ultrasound what will you ask the client to do? Drink water
To distend the bladder → pushes uterus to abdominal surface.
What about an ultrasound prior to a procedure? Empty bladder for amniocentesis
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2nd trimester
Wks 14-26
1. Weight Gain:
• Expected weight gain per week 1lb
2. Should the client still be experiencing?
• Nausea and vomiting NO
• Breast tenderness YES
• Frequency NO
3. Quickening: FETAL MOVEMENT 16-20 wks
4. Fetal Heart Rate:
What should the fetal heart rate be during the second trimester? 120-160
5. Miscellaneous Information:
• Kegel Exercise:
Exercise to strengthen the pubococcygeal muscles; these muscles help stop urine flow, help prevent uterine prolapse.
• Pregnancy is considered term if it advances to 37 to 40 weeks.
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Third trimester
Wks 27-40
1. Assessment:
a. Expected weight gain per week? s maneuvers
• What should you have the client do first? Void
• If the client is having contractions, should these maneuvers be done during or
between contractions? Between
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Fetal heart rate
*120 to 160: normal
*110 to 120: worried and watching *Less than 110 panic
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Signs of labor
1) Lightening:
• Usually occurs 2 wksbefore term.
• When the presenting part of the fetus (usually the head) descends into the
pelvis.
• The client will feel less congested, and breathe easier, but urinary urgency is a problem (again).
2) Engagement:
• The largest presenting part is in the pelvic inlet.
• Hopefully, the fetal head is presenting first.
3) Fetal stations: measured in cm, measures the relationship of the presenting
part of the fetus to the ischial spines of the mother.
4) Signs of labor (cont.):
• Braxton Hicks Contractions: More frequent and stronger
• Softening of the cervix
• Bloody show
• Sudden burst of energy, called nesting
• Diarrhea
• Rupture of the membranes
b. When should the client go to the hospital?
• When the contractions are 5 minutes apart or when the membranes rupture
• What are we worried about when membranes rupture? Prolapsed cord
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Non stress test
a. Want to see two or more accelerations of 15 beats/minute (or more) with fetal movement.
• Acceleration is when the fetal heart rate has an abrupt increase from the baseline. This is visualized on the fetal heart monitor. The increase is > 15 beats/min. above the baseline and lasts at least 15 seconds but the heart rate should come back to baseline within 2 min.
b. Each increase should last for 15 seconds and recorded for 20 min.
c. Do you want this test to be reactive or non-reactive? Reactive
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Biophysical profile
a. Done in the 3rd trimester, but can be done at 32-34 weeks in high risk pregnancy.
• High risk pregnancy may have a BPP every week or twice a week in 3rd trimester.
b. Measurements are done by ultrasound, each parameter counts 2 points.
• 10/10 is great
c. Measurements
1) Heart rate – was Non-Stress Test (NST) reactive?
2) Muscle tone
• Does baby have at least 1 flexion – extension movement in 30 minutes?
3) Movement
• Does the baby move at least 3 times in 30 minutes?
4) Breathing
• Does the baby have breathing movements at least once in 30 minutes?
5) Amniotic fluid
• Is there enough fluid around the baby?
d. Observation time is 30 minutes.
e. Resultsareevaluated:
8-10 good 6 worrisome <4 ominous
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Contraction stress test- oxytocin challenge
a. Done when the NST is non-reactive.
b. Performed on high risk pregnancies: preeclampsia, maternal diabetes, and any condition in which placental insufficiency is suspected.
c. This determines if the baby can handle the stress of a uterine contraction.
d. Uterine contractions decrease blood flow to the uterus and to the placenta.
e. If blood flow decreases enough to cause hypoxia in the fetus the fetal heart rate will decrease from the baseline HR.
• This is called deceleration
f. Do not want to see late decelerations?
• This means uteroplacental insufficiency.
g. Do you want a positive or negative test? Negative
h. This test is rarely performed before how many weeks? 28
Results are good for one week
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Decelerations
1. Early decelerations: (not bad) benign – caused by physiological hypoxia from fetal head compression (HC)
2. Late decelerations: (bad) – caused by uteroplacental insufficiency (UPI)
3. Variable decelerations: (bad) – caused by umbilical cord compression (CC)
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True vs false labor
1. True labor:
a. Contractions? Regular
b. Contractions? Increase in frequency and duration
c. Discomfort in back and radiates to abdomen
d. What happens to the pain level with a change in activity? Increases
2. False labor
a. Contractions? Irregular
b. Where is the discomfort? Abdomen
c. What happens to the pain with a change in activity? Contractions decrease or go away
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Epidural
Position: Lie on left side, legs flexed, not as arched as with lumbar puncture
Given in stage 1 at 3-4 cm dilation
Usually no headache. Try not to get in spinal fluid
Major complication? Hypotension
Monitor BP
IVFs: Bolus with 1000mL of NS or LR to fight hypotension
Positioning: Put in semi-fowlers on side to prevent vena cava compression.
If the vena cava is compressed...it will decrease venous return, reduce cardiac output and blood pressure, and decrease placental perfusion.
Alternate position from side to side hourly.
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Oxytocin
1) Need one-on-one care
2) Be alert for complications:
Hypertonic labor
Fetal distress
Uterine rupture
• Complete Uterine Rupture: through the uterine wall into the peritoneal cavity (there is a direct communication between the inside of the uterus and the peritoneal cavity)
S/S: sudden, sharp, shooting pain (“something gave away”); if in labor the contractions may stop and the pain will be relieved; signs of hypovolemic shock due to hemorrhage; if the placenta separates, the fetal heart tones will be absent.
• Incomplete Uterine Rupture: through the uterine wall but stops in the peritoneum but not the peritoneal cavity
S/S: internal bleeding, pain may not be present, fetus may or may not have late decels, client may vomit, faint, have hypotonic uterine contractions and lack of progress, fetal heart tones may be lost.
Vaginal Birth After C-Section (VBAC)
Clients are at a high risk for uterine rupture. The scar from the c-section is prone to open when under stress. Those at highest risk are those that are receiving Oxytocin (Pitocin®).
3) Want a contraction rate of 1 every 2-3 minutes with each lasting 60 seconds
4) Discontinue the Oxytocin (Pitocin®) if:
• The contractions are too often.
• The contractions last too long.
• Fetal distress
5) Oxytocin (Pitocin®) is piggy backed into a main IV fluid, so when you discontinue the Oxytocin (Pitocin®) make sure you do not turn off your main IV fluid
6) What position should the client receiving Oxytocin (Pitocin®) be placed?
• Any position except flat on their back.
• Now, if the client has any unreassuring fetal heart tones (like fetal bradycardia) then we will put the client on her left side to enhance uterine perfusion.
7) What should be done with the infusion if late decelerations occur? Turn off.
Label bag and tubing, attach to port closest to body, always remove when done with, use a pump
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Emergency delivery
Tell client to pant/blow to decrease urge to push.
• The client should not push between contractions. The mother should only push during contractions.
Wash hands.
ElevateHOB.
Place something clean under buttocks.
Decreasetouchingofvaginalarea.
As head crowns tear amniotic sac.
• You will only have to tear the amniotic sac if it has not already ruptured.
Place hand on fetal head and apply gentle pressure.
• This will prevent the baby from coming out too fast.
When the head is out feel for cord around neck. Ease each shoulder out – do not pull on the baby. The rest will deliver fast.
Keep baby’s head down.
Dry baby.
Keep baby at level of uterus.
Place on mother’s abdomen.
Cover baby.
Wait for placenta to separate/deliver.
Can push to deliver placenta
Inspectplacentaforintactness.
Tie the cord off with a piece of cloth or shoestring.
• Place one knot about 4 inches from the baby’s navel and the second knot about 8 inches from the baby’s navel.
Check firmness of uterus.
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Post partum
Vitals, breast, abdomen, GI, UO
1. Assessment:
a. Vital signs:
• T→ may increase to 100.4 during 1st 4 hours
• BP→ stable
• HR→ 50-70 common for 6-10 days
TACHYCARDIA + POSTPARTUM.........THINK HEMORRHAGE
b. Breasts:
• Soft for 2 to 3days, then engorgement.
c. Abdomen:
• Soft/loose; diastasis recti separation abdominal muscles
d. GI:
• Is hunger common? Yes
e. urine output: diuresis should begin 24 hours after delivery.
• Is dehydration possible? Yes
• Why should the legs be inspected closely? DVT
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Post partum
Uterus
• Immediately after birth the fundus is midline 2 to 3 fingers breadths below umbilicus.
• A few hours after birth it rises to level of umbilicus or one FB above.
• Want fundus to be firm
• What is the first thing you do if the fundus is boggy? massage the fundus until it is firm and then check for bladder distention.
Bladder distention is suspected when the uterus is above the expected level or is not in the midline. (Usually moved to the right)
A distended bladder will not allow the uterus to contract normally which increases the chance of hemorrhage.
• Fundal height will descend one FB/day.
• What is the proper term used when the fundus descends and the uterus returns
to its pre-pregnancy size? Involution
• Afterpains are common for the first 2-3 days and will continue to be common if the mother chooses to breast feed
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Lochia
• Rubra: 3-4 days: Color: dark red
• Serosa: 4-10 days: Color: pinkish brown
• Alba: 10-28 days (can be as long as 6 weeks): Color: whitish yellow
• Clots are okay as long as they are no larger than a nickel
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Perineal care
• Ice packs intermittently for first 6-12 hours -decrease edema
• Warm water rinses
• Sitz baths 2-4 times per day
• Anesthetic sprays
• Change pads frequently
These are indicated if the client has an
episiotomy, laceration, or hemorrhoids.
Peripad Rule: We do not want the client to saturate more than 1 peripad/hr.
• Teach to report foul smell.
• Report lochia changes
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Bonding
Bonding between mother and baby and father and baby develops trust.
In the infant, trust is not only an emotional need but a physiological need.
How does newborn benefit physiologically from bonding?
• Stabilize HR
• Improves O2 sats
• Regulates the infant temperature
• Conserves calories
• Breasts can change in temperature to warm or cool the infant.
• This is called kangaroo care: mom or dad places baby “skin to skin”
on their chest. The baby is wrapped inside the parent’s shirt or covers and held for 1 hour at least 4 times a week.
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Breast care
1) Breast feeding mothers:
• Cleanse with warm water after each feeding; let air dry.
• Support bra
• Ointment for soreness or express some colostrum and let it dry.
• Breast pads – absorb moisture
• Mother needs to initiate breast feeding ASAP after birth.
• If breast feeding interrupted: mom can pump
• Increase caloric intake by 500 calories.
• Fluid/milk intake:
Eight to ten--- eight ounce glasses of fluid a day.
2) Non-Breast Feeding Mothers:
• Ice packs, breast binders, chilled cabbage leaves
• Chilled cabbage leaves decrease inflammation and decrease
engorgement
• No stimulation of the breast
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Complications
a. Postpartum infection:
• Infection within 10 days after birth; E. Coli/Beta hemolytic strep
• Teach proper hygiene (front and back cleansing) and hand washing.
• Usually get cultures and antibiotics
b. Postpartum hemorrhage: 1) Definition:
• Early- more than 500 cc blood lost in first 24 hours AND a 10% drop from admission hematocrit.
You must have both to be true!
• Late-after 24 hours, up to 6 weeks postpartum
2) Causes: uterine atony, lacerations, retained fragments, forceps delivery
Medications used to halt excessive postpartum hemorrhage: Oxytocin (Pitocin®)
Methylergonovine Maleate (Methergine®) Carboprost Tromethamine (Hemabate®)
c. Mastitis:
• Staphylococcus
• Usually occurs around 2-4 wks
Treatment:
• Bed rest
• Support bra
• Binding can cause more stagnation.
• Chilled cabbage leaves
• If mom is going to continue to breastfeed, she needs to initiate breast feeding frequently or pumping.
• PCN (ok with breastfeeding)
• Pain medication
• Heat
• Feed baby frequently
Always offer the affected breast first
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Newborn care
1. Immediate Care:
a. Suction
b. clamp and cut the cord
c. Maintain body temperature.
d. Apgar: Done at 1 and 5 minutes
• Looks at HR, R, muscle tone, reflex irritability, color
• Want at least 8-10.
e. Erythromycin (gtts or ointment) for eye prophylaxis for Neisseria gonococcus
• Erythromycin will also kill the most rapidly growing STD: Chlamydia.
f. Phytonadione (Aquamephyton®) promotes formation of clotting factors. Vitamin k injections, vastus lateralis
2. Cord Care:
a. Dries, and falls off in 10 to 14 days
b. Cleanse with each diaper change using alcohol or NS
c. Fold diaper below cord
d. No immersion until cord falls off; watch for infection.
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Newborn complications
a. Hypoglycemia:
• Why do babies sometimes experience hypoglycemia after birth? Because they are not getting glucose from mom.
• Babies at greatest risk for hypoglycemia include those that are large for gestational age, small for gestational age, preterm, and babies of diabetic moms.
b. Pathologic Jaundice:
• When does pathologic jaundice occur? first 24 hours Usually means Rh/ABO incompatibility
c. PhysiologicalJaundice:
• When does physiological jaundice (hyperbilirubinemia) occur? After 24 hours
• Due to normal hemolysis of excess RBCs releasing bilirubin, or liver immaturity.
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RH
•
Occurs when you have an Rh− mother with an Rh+ fetus 1) First Pregnancy:
• Rh+ blood from baby comes in contact with mother’s Rh− blood.
• Mom’s blood is most likely to come in contact with the baby’s blood
when the placenta separates at birth.
• It can also happen during a miscarriage, amniocentesis, or when there is trauma to Mom’s abdomen.
• Mother’s body looks at the Rh+ blood as a foreign body, an antigen.
• Mother produces antibodies to the baby’s Rh+ blood.
• The first offspring is not affected by the antibodies
2) Second Pregnancy:
• An Rh− sensitized mom gets pregnant again: She’s got these antibodies waiting for the Rh+ blood to come around so she can attack it.
• The chances of an Rh− Mom having antibodies to Rh+ blood increases with each pregnancy and each exposure to Rh+ blood because once you have these antibodies they never go away.
• The antibodies the Mother has made enters baby thru placenta→ Hemolysis
• Erythroblastosis fetalis (the increase of immature RBCs in the fetal circulation) will result in:
*Hyperbilirubinemia
*Anemia
*Hypoxia
*HF (heart failure)
*Neurologic damage
*Hydrops fetalis (severe form of erythroblastosis fetalis)
3) Dx/Tx:
• Indirect Coomb’s: done on mother; measures # of antibodies in blood
• Direct Coomb’s: done on baby; tells you if there are any antibodies stuck to the RBCs
• What do you do if you have a Rh+ fetus and a sensitized mother?
1. Frequent ultrasounds
2. Early birth when the baby stops growing
• When is Rho(D) immunoglobulin (RhoGAM®) given? 28 wks and within 72 hours after birth
• Rho(D) immunoglobulin (RhoGAM®) is given with any bleeding episode.
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Rhogam
Destroys fetal cells that got in mother’s blood; it has to do this before antibodies can be formed
Rho (D) immunoglobulin (RhoGAM®) Rule:
Once antibodies are formed, the woman has them for life.
In NCLEX® world: Rho(D) immunoglobulin (RhoGAM®) must be given before the antibodies form.
In the real world: a titer will be drawn to see the number of antibodies the woman has developed.
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Miscarriage
1. S/S:
• Spotting and cramping
Spotting is common during pregnancy but the combination of spotting and cramping is more indicative of a miscarriage.
2. Tx:
a. Measures hCG levels- we worry when levels drop
b. Bedrest and pelvic rest (abstinence from sex)
c. If miscarriage imminent →IV, Blood, D&C (dilatation&curettage)
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Hydatiform mole
Patho:
a. Benign neoplasm, can turn malignant
b. Grape-like clusters of vesicles
c. May/may not have a fetus involved (for NCLEX purpose no fetus is involved)
How does this pregnancy start?
• Uterus enlarges too fast
S/S:
a. Absence of FHTs
b. Bleeding (sometimes will have vesicles)
Dx:
• Confirmed with ultrasound
5. Tx:
a. Small mole → D&C (have to empty the uterus)
b. Do not get pregnant during follow up time; follow-up is very important
c. If it becomes malignant it is called choriocarcinoma.
d. Will do chest xray to determine metastasis.
e. Will measure hCGs until normal; rechecked q2-4 weeks; then every 1-2 months for 6 months to a year.
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Ectopic pregnancy
1. Definition:
a. This is a gestation outside of the uterus.
b. Where does it usually occur? Fallopian tube.
c. Confirmed with an ultrasound
2. S/S:
a. First sign? Pain
b. Client will usually exhibit the usual S/S of pregnancy ... then pain, spotting or may be bleeding into the peritoneum.
• If the fallopian tube ruptures, vaginal bleeding may be present.
c. If a client has had 1 ectopic pregnancy she is at risk for another.
3. Tx:
a. Methotrexate (Rheumatrex®/Trexall®) is given to Mom to stop the growth of the
embryo to save the tube.
b. If the Methotrexate (Rheumatrex®/Trexall®) does not work, a laparoscopic incision will be made into the tube and the embryo will be removed.
• The entire tube may have to be removed.
c. A laparotomy is done if the tube has ruptured or if ectopic pregnancy is advanced.
• If the tube does rupture what are you worried about? Hemorrhage
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Placenta previa
1. Patho:
a. Most common cause of ___________________ in the later months (usually the 7th)
b. The placenta has implanted wrong.
c. An___________________________willbedonetoconfirmplacentallocation
2. How does this happen?
a. The placenta begins to prematurely separate when the cervix begins to dilate and efface →____________ doesn’t get oxygen
b. Normally, the placenta should be attached where in the uterus? _____________
• The placenta may be on the side of the uterus (low lying placenta), halfway covering the cervix (partial previa), or completely covering the cervix (complete previa).
• The problem is, what is coming out first? ___
3. SS
Painless bleeding in 2nd half of pregnancy (may be spotting or may be profuse)
4. TX
Complete previa usually requires hospitalization (from as early as 32 weeks until birth) to prevent blood loss and fetal hypoxia if client goes into labor
If there’s not much bleeding→bed rest and watch very close. Rule out other sources of bleeding like abruption.
Dad counts
Monitor blood count and monitor baby closely.
Monitor for contractions → call MD (not going to be a normal delivery)
Delivery method of choice? C section
Do not perform vaginal exam
5. Fetal Complications:
a. Pretermdelivery
b. Intrauterine growth retardation
c. Fetal distress
d. Anemia
6. Maternal Complications:
a. Hemorrhage
b. Potential DIC risk
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Abruptio placenta
1. Patho:
a. Is the placenta implanted normally? Yes
b. May be partial or complete
c. It separates prematurely→ bleeds (external or concealed)
• Concealed means bleeding into the uterus.
d. Seen in last half of pregnancy
e. ultrasound to confirm the diagnosis
• May be partial or complete
• Severity is based on a scale of 1-3 with 3 being the worst.
2. Causes:
a. MVC= motor vehicle crash
b. Domestic violence
c. Previous Cesarean Section
d. Rapid decompression of the uterus (membranes rupture)
e. Associated with cocaine, PIH, & smoking
3. S/S:
a. Rigid board-like abdomen, with or without vaginal bleeding.
b. Abdominal pain and increased uterine tone. c. Difficult to palpate fetus.
4. Tx:
a. Method of delivery?
• RULE: Do not do vaginal exams in the presence of unexplained vaginal bleeding
b. Two priorities: manage fetal status and maternal shock
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Incompetent cervix
1. Patho:
a. This is when the cervix dilates prematurely.
b. Occurs in the 4th month of pregnancy
c. This client will have a history of repeated, painless, 2nd trimester
miscarriages.
2. Causes:
The weight of the baby causes pressure on the cervix causing it to prematurely dilate.
3. tx:
Purse-String suture (cerclage) at 14-18 weeks – reinforces the cervix
May have a c-section to preserve the suture
• Some physicians clip the suture so the client can deliver vaginally
80-90% chance of carrying the baby to term after cerclage.
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Hyperemesis gravidarum
1. Patho:
a. Starts like regular morning sickness
b. Excessive vomiting→ dehydration→ starvation→ death
2. Causes:
• R/T high levels of estrogen & hcg
3. S/S:
a. What happens to the:
BP down H/H up UO down K+ down Weight down
b. What will they have in their urine? Ketones
• Why is there acetone (ketones) in the urine? 4. Tx:
a. NPO for 48hrs
b. IVFs 3000 ml for 1st 24 hours
c. Antiemetic
d. Vitamins
e. Environment? Calm, quiet
f. Oral hygiene
g. Is it okay to talk about food? No
h. Why should the emesis basin be kept out of sight? Out of mind
i. 6-8 small, dry feedings followed by clear liquids
j. Foods/liquids should be icy cold or hot
k. Well-ventilated room
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Preeclampsia
1. Definition:
a. Increased BP, proteinuria, edema after 20th week
b. If Mom’s pre-pregnant baseline BP is not known then 130/90 is considered to
be mild preeclampsia
2. S/S:
a. Sudden weight gain
b. Face and hands swollen
• Why? They are losing protein, fluid doesn’t stay in vascular
space, it leaks into the tissue.
c. Headache, blurred vision, seeing spots
d. Hyper-reflexia (increased DTRs)
e. Clonus→Seizure
When you see a client that gains 2 or more pounds in a week watch closely and worry about PIH
3. Tx:
a. Mild
• BP 30/15 off their baseline documented 6 hours apart.
• Mild: bed rest as much as possible.
• Increase what in their diet? Protein
• They have glomerular damage with proteinuria.
b. Severe:
BP elevated 160/110 documented 6 hours apart.
Sedation to delay seizures
Magnesium Sulfate is the drug of choice
C. Mag sulfate
d. If diastolic > 100→ Apresoline (Hydralazine®) in combination with magnesium sulfate.
• Side effects: tachycardia
e. Only cure? Delivery
f. After delivery, the client is at risk for seizures for 48 hours.
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Magnesium sulfate
c. Magnesium Sulfate: anticonvulsant, sedative, vasodilator
1) Vasodilation will increase renal perfusion and helps avoid
renal failure and increases placental perfusion.
2) Positioning: NEVER lay a pregnant lady on her back, because this will place pressure on the vena cava→ impair kidney perfusion→ impair cardiac output→ impair kidney perfusion→ impair placenta perfusion.
• Always place pregnant lady on her side. (preferably left side)
3) Magnesium sulfate is a simple salt solution (hypertonic) → fluid is attracted back into the vascular space and out of the tissues→ kidneys will diuresis→ if kidney function is impaired, or shift occurs too fast→ the client is at high risk for pulmonary edema.
4) Nursing action for client receiving Magnesium:
• When Magnesium Sulfate is used, checks for magnesium toxicity should
be done q 1-2 hrs
• These include: BP, respirations, DTRs, & LOC.
• UO is monitored hourly & serum magnesium is checked periodically.
• If Magnesium Sulfate is used labor will stop unless augmented with Oxytocin (Pitocin®)
We use magnesium for PRETERM labor.
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Nursing care for preeclampsia
a. Single room
b. Very quiet environment
c. Dim the lights, no TV
Vasoconstriction→ lack of blood flow to placenta→ leads to less oxygen and nutrients to fetus→ Preterm delivery→ Immature lungs at birth.
d. Additional treatment is steroid therapy:
• Betamethasone (Celestone®) stimulates surfactant production in the
alveolar spaces and this causes less tension when the infant breathes.
• Steroid therapy given between 24 & 34 gestation to reduce infant mortality.
• Expectant management: Balance the risk to mom vs. baby
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Eclampsia
• What is the turning point from preeclampsia to eclampsia?
1. Tx:
• Monitor the FHTs
• Watch labor
• Watch for heart failure
• Monitor for: heart failure, stroke, heart attack, renal failure, DIC, HELLP syndrome, neurological damage, multisystem organ failure
PIH- Pregnancy induced hypertension- occurs after 20 weeks, proteinuria Gestational Hypertension- occurs after 20 weeks, but NO proteinuria. Chronic Hypertension- Client was hypertensive before the pregnancy Chronic Hypertension with superimposed PIH- Client was hypertensive prior to pregnancy, and the hypertension got worse with developing proteinuria after 20 weeks.
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Premature labor
1. Definition:
• Labor that occurs between 20-37 weeks
2. Tx:
a. Drug therapy to stop the labor:
1) Tocolytic: Terbutaline (Brethine)
• Side effects of Brethine? Increased pulse & hyperactivity.
2) Mg Sulfate
3) Betamethasone (Celestone®)
• Given IM to mom
• The purpose is to stimulate maturation of the baby’s lungs in case preterm birth occurs.
b. Preterm labor can sometimes be stopped by hydrating Mom and by treating vaginal and urinary tract infections.
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Shoulder dystocia
1. Definition:
a. Fetal head is delivered and further delivery of the fetus is prevented by the impaction of the fetal shoulder with the maternal pelvis.
b. Anterior shoulder of fetus becomes impacted by the symphysis pubis.
2. Risk to Fetus:
a. Hypoxia→ leads to cerebral palsy and asphyxia
b. Brachial plexus injury- leading to Erb’s Palsy (drooping/ paralysis of an arm
caused by excessive traction and stretching of the brachial nerve at delivery)
c. Broken clavicle
d. Bell’s palsy is paralysis of face with drooping of one side of the face.
e. Caused from forceps
f. Many resolve, but can lead to permanent damage.
3. Maternal Risk:
a. Traumatic delivery leading to permanent damage.
b. Bruised bladder.
c. Extensionofepisiotomy d. Rectal tear
e. Torncervixand/oruterus
4. Who’s at risk:
a. LGA or macrosomic infants >4000 grams
b. Gestational diabetes
c. Previoushistoryofshoulderdystocia
d. Post date delivery→ large fetus
5. Nursing Care:
a. Mcroberts Maneuvers
b. Mazzanti techniques
• Never apply fundal pressure. The physician must do this
or call another physician.
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