OB Unit 2 Flashcards
0
Q
The uterus
A
- Weight almost 17 times the pre-pregnant weight
- Capacity from 10 ml to 5000ml – 500 X the pre-pregnant state
- Enlargement due to hypertrophy of preexisting myometrial cells
- Influence of estrogen
- Distention caused by growing fetus
- 16% of the total maternal blood volume is contained within the vascular system of the uterus
- Braxton-hicks contractions start around the 4th month
- Fundal height – measure from symphysis pubis to top of fundus
- 10-12 weeks – fundus slightly above symphysis
- 20-22 weeks – fundus at level of umbilicus
- Measurement should correlate within 2 cm’s with weeks gestation
- Fetal movements palpated by caregiver at 18 weeks
- Ballottement – fetus moves then returns to original position when uterus is tapped sharply
- 4-5 months
- Ultrasound evaluation
- Detect gestational sac 5-6 weeks after LMP
- Fetal heart activity at 6-7 weeks
1
Q
Reproductive system includes
A
- uterus
- cervix
- ovaries
- vagina
- breasts
2
Q
The Cervix
A
- Estrogen stimulates the glandular tissue
- Vaginal discharge
- Thick, sticky mucus accumulates in cervical canal forming “plug”
- Prevents ascent of organisms into uterus
- Abnormal discharge associated with vaginal infection
- Vascularity
- Softening of cervix – Goodell’s Sign
- Bluish discoloration of cervix & vagina- Chadwick’s Sign
- Softening of isthmus of uterus – Hegar’s Sign
3
Q
The ovaries
A
- Corpus luteum continues to function for 10-12 weeks
4
Q
The Vagina
A
- Vagina
- Estrogen causes thickening of mucosa, loosening of connective tissue & in vaginal secretions
- Secretions acidic which inhibits bacterial growth but allows proliferation of yeast organisms
5
Q
The Breasts
A
- Breasts
- Tenderness & tingling one of 1st signs noted when miss period
- Both estrogen & progesterone causes changes necessary for lactation
- Nipples more erectile
- Areolas darken
- Superficial veins more prominent
- Colostrum present after 12th week
6
Q
Respiratory system during pregnancy
A
- Increased oxygen requirements
- Progesterone ¯ airway resistance allowing a 15-20% in O2 consumption
- Normal 16-24 breaths/min – thoracic breathing
- Nasal stuffiness & nosebleeds (epistaxis) result of estrogen induced edema and vascular congestion
7
Q
The cardiovascular system during pregnancy
A
- Blood volume progressively increases
- Rapid in 2nd trimester
- Peaks mid-3rd trimester at approximately 40-45% above non-pregnant levels
- Heart rate 10-15 bpm
- BP ¯ slightly
- Lowest point during 2nd trimester
- High BP associated with:
- PRE-ECLAMPSIA/TOXEMIA - increase in BP after 20 wks gestation accompanied by proteinuria
- Greater than 140/90
- ECLAMPSIA - severe form characterized by seizures, liver involvement & possible coma
- Can occur in first 48 hrs AFTER delivery
- GESTATIONAL HYPERTENSION - increase in BP after 20 wks gestation with NO protein in the urine
8
Q
The cardiovascular system and pregnancy cont.
A
- Stasis of blood in lower extremities b/c of pressure from enlarging uterus
- Slight edema of lower extremities normal (Dependent edema)
- Generalized edema associated with pre-eclampsia/toxemia
- Varicosities of veins in legs, vulva & rectum (hemorrhoids)
- Postural hypotension
- Supine hypotensive syndrome or vena cava syndrome
- Result of ¯ blood return to heart; ¯ blood pressure
- Always lie on left side or place pillow under right hip
- Physiologic anemia of pregnancy
- RBCs 35% while plasma volume 50%
- Necessary to transport additional O2 needed
- Need for iron
- Hematocrit lower than pre-pregnancy levels
- Greater than 33%
- Plasma volume more than cells
- Hemoglobin
- Greater than 11g/dL
- Less than 11g/dL require nutritional counseling or iron supplement
- WBC production
- Up to 15,000
- Increase primarily in the granulocytes
- Need to look at differential
- Plasma fibrinogen & various clotting factors (Factor VII, VIII, IX, X)
- Pregnancy described as “hypercoagulable state”
- Risk of developing blood clots during pregnancy
- Associated with early pregnancy loss
9
Q
Gastrointestinal system and pregnancy
A
- Nausea & vomiting – “morning sickness”
- Result of HCG & changed CHO metabolism
- Constipation and bloating
- Result of effects of progesterone on smooth muscle
- Delayed gastric emptying, decreased peristalsis
- Heartburn
- Reflux of gastric secretions into lower esophagus
- Relaxation of cardiac sphincter
- Upward pressure from the enlarging uterus
- Hemorrhoids
- 3rd trimester associated with constipation & pressure on vessels
- Gallstone formation
- Prolonged emptying time of gallbladder caused by progesterone
- Elevated cholesterol in bile
10
Q
Urinary tract and pregnancy
A
- 1st trimester pressure from enlarging uterus causes frequency
- ¯ During 2nd trimester when uterus becomes an abdominal organ
- Reappears during 3rd trimester when presenting part descends into pelvis
- Glycosuria may be seen b/c kidney unable to reabsorb all glucose filtered by glomeruli
- Could be a sign of GDM so need to check
- Urinary tract infections increases risk for pre-term labor
11
Q
Skin and Hair during pregnancy
A
- Changes in skin pigmentation stimulated by estrogen, progesterone & other hormones
- Primarily in areas that are already pigmented
- Areola, nipples, vulva, perianal area
- Linea nigra
- Chloasma
- More prominent in dark-haired women
- Aggravated by exposure to sun
- Striae gravidarum
- Result from ¯ connective tissue strength due to steroid levels
- Hair loss – ¯ during pregnancy; 1st 1-4 months after birth
12
Q
Musculoskeletal system during pregnancy
A
- Joints of pelvis relax
- Result of hormone “relaxin”
- Waddling gait
- Low backache
- Center of gravity changes causing lumbar spinal curve
- Avoid high heeled shoes
- Diastasis recti
- Pressure of enlarging uterus causes rectus abdominis muscle to separate
- Will need to regain muscle support after pregnancy to support subsequent pregnancies
13
Q
The eyes during pregnancy
A
- Intraocular pressure ¯ & cornea thickens
* Contacts may become “uncomfortable”
14
Q
Metabolism and pregnancy
A
- Most functions INCREASE!
- B/c of increased demands of growing fetus
- Water metabolism
- Increased water retention
- Level of hormones affects sodium & fluid retention
- Lowered serum protein
- Intracapillary pressure & permeability
- Needed for fetus, placenta, amniotic fluid, blood volume, etc.
- Nutrient metabolism
- Fetus greatest demand for protein & fat during 2nd half of pregnancy
- Fetus doubles weight during last 6-8 weeks
- Fats more completely absorbed
- Intake of dietary fat or ¯ CHO intake can lead to ketonuria
15
Q
The endocrine system during pregnancy
A
- ENDOCRINE SYSTEM
- Basal metabolic rate as much as 25%
- Anterior pituitary
- FSH and LH
- Prolactin – responsible for initial lactation
- Increases early in pregnancy
- High levels of estrogen & progesterone inhibit lactation until after birth
16
Q
The endocrine system during pregnancy cont.
A
- Posterior pituitary
- Vasopressin (antidiuretic hormone)
- Causes vasoconstriction which results in blood pressure
- Helps regulate water balance
- Oxytocin
- Causes uterine contractions
- High levels of progesterone prevent contractions until near term
- Stimulates ejection of milk from breasts
- Pancreas
- Progressive need for increased amount of insulin as pregnancy progresses
- Pregnancy hormones decrease woman’s ability to use insulin
- B/c of insulin needs, and ¯ ability of pancreas to meet demand - gestational diabetes may result
17
Q
The endocrine system during pregnancy
A
- Hormones produced by placenta
- HCG – Human Chorionic Gonadotropin
- Stimulates estrogen & progesterone production by the corpus luteum
- Basis of pregnancy tests
- HCS – Human Chorionic Somatomammotropin
- Antagonist of insulin
- Amount of circulating free fatty acids needed for maternal metabolic needs
- ¯ Maternal metabolism of glucose to allow fetal growth
- Estrogen
- Increases vascularity causing vasodilation
- Promotes enlargement of the genitals, uterus & breasts
- Causes relaxation of pelvic ligaments & joints
- Alters metabolism of nutrients
- Causes retention of fluid in body – peripheral edema
- Progesterone
- Plays greatest role in maintaining pregnancy
- Maintains endometrium
- Prevents uterine contractions
- Cause fat to be deposited in subq tissues
- Helps develop acini & lobules of breasts
18
Q
Endocrine system cont.
A
- Prostaglandins during pregnancy
- Proposed that they aid in ¯ placental vascular resistance
- ¯ Levels may contribute to pre-eclampsia/toxemia
- Also believed to play a role in initiation of labor
19
Q
NUTRITIONAL NEEDS BEFORE CONCEPTION
A
- 1st trimester critical b/c embryonic & fetal organ development
- Folic acid recommended PRIOR to conception
20
Q
NUTRITIONAL NEEDS DURING PREGNANCY
A
- RDA for almost all nutrients during pregnancy
- Increased nutritional needs determined by stage of pregnancy
- Factors affecting increased needs:
- Uterine-placental-fetal unit
- Maternal blood volume
- Maternal mammary development
- Metabolic needs
- Folic acid and iron are the only supplements needed with a well-balanced diet
- Folic acid 0.4 mg daily during childbearing years
- Iron needs double during pregnancy – recommend 30mg daily supplement
- Absorption when taken with Vit C source
- Decreased when taken with calcium, egg yolks, or caffeine
21
Q
Nutritional needs during pregnancy cont.
A
- Many care providers recommend pre-natal vitamins b/c of poor intake
- Increase of approximately 300-450 kcal/day in 2nd & 3rd trimester
- An additional 200 kcal with breastfeeding
- Inadequate caloric intake will reduce milk volume
- Breastfeeding mom does not need to avoid certain foods
- Protein requirements 50%
- The 2010 Dietary Guidelines for Americans recommend 8 to 12 ounces of seafood a week for pregnant women.
- Seafood is a great source of protein, and the omega-3 fatty acids
- Approximately 2 average meals of shrimp, crab, canned light tuna (conflicting information about the safety of eating any type of tuna during pregnancy), salmon, pollock, catfish, cod, or tilapia
- If vegetarian need to ingest grains, legumes, nuts, fresh fruits and veggies
- Calcium – same recommendations for nonpregnant and during pregnancy; 33% increase with lactation
- Need 4 serving from milk group instead of 2-3
22
Q
Nutritional needs during pregnancy
A
- Need 8-10 glasses of fluid/ day
- Dehydration increase risk of contractions and pre-term labor
- Sodas consumed in moderation b/c of sodium content
- Caffeinated beverages have a diuretic effect
- Sodium needs increase slightly during pregnancy
- Not recommended to entirely eliminate “salt” intake unless underlying medical conditions
- May season food to taste during cooking
- Avoid using extra salt at table, high salt containing foods such as potato chips, ham, sausage, sodium based seasoning, prepared foods
23
Q
Foods to avoid during pregnancy
A
- Avoid intake of food that could cause potential harm to developing fetus
- Fish/ shellfish containing potentially high levels of mercury
- King mackerel, shark, swordfish, cobia or tilefish
- Tuna is from the mackerel family
- Tuna continues to be a controversial subject as to its safety during pregnancy
- Most sources recommend avoidance of albacore tuna (canned white tuna) and tuna steak
- Can adversely affect developing CNS in baby
24
Foods to avoid continued
* Avoid raw, undercooked or contaminated fish/ seafood
* Especially recommended to avoid sushi, oysters and clams
* If fish ingested from local waters, need to pay attention to local fish advisories – especially if water pollution is a concern
* Most sources recommend avoidance of albacore tuna (canned white tuna) and tuna steak
* Avoid undercooked meat, poultry and eggs
* Increased risk of bacterial food poisoning during pregnancy which could also affect fetus
* Cook hot dogs and processed deli meats, such as bologna until “steaming hot” or avoid them completely
* Not recommended to entirely eliminate “salt” intake unless underlying medical conditions
* Need to cook eggs until the egg yolks and whites are firm. Raw eggs can be contaminated with the harmful bacteria salmonella. Avoid foods made with raw or partially cooked eggs, such as eggnog, raw batter, hollandaise sauce and Caesar salad dressing
Avoid unpasteurized foods such as Brie, Feta, Camembert, Blue cheese, Mexican-style cheeses, such as queso blanco, queso fresco and panela
25
BASIC TEACHING FOR THE PREGNANT WOMAn includes the areas of
*Fetal activity Monitoring
* Decision related to feeding method for infant – Breast vs Bottlle
* Breast preparation
* Bathing
* Travel
* Exercise
Exercises to prepare for childbirth
* Sexual activity
* Dental care
* Immunizations
* Complementary & alternative therapies
26
Fetal activity monitoring
* Recommended to begin at 28 weeks
* Lie down on left side and count fetal movements
* Should have at least 10 movements in 2 hrs
* ¯ Movement or no movement indicate possible fetal hypoxia
* Fetal activity affected by fetal sleep, sound, time of day, blood glucose level, cigarette smoking, or drug use
27
Exercise during pregnancy
* Normal participation can continue thru uncomplicated pregnancy
* Contraindications
* ROM, pre-eclampsia/toxemia, incompetent cervix, persistent vaginal bleeding, preterm labor, IUGR
* Is not a time to begin new activities
* Improves self image, promotes regular bowel function, control weight gain, associated with improved postpartum recovery
* Avoid exercising in supine position
* Walking, swimming & stationary cycling best b/c ¯ risk of injury
* Avoid overheating
* Have potential teratogenic effect on fetus, risk of miscarriage and neural tube defects
* Core body temp should not be above 100.4
* Advised to avoid hot tubs, saunas, or extremely hot baths
* May soak in hot tub for 10 mins if temp maintained at less than 98 degrees
28
DANGER SIGNS IN PREGNANCY
* Sudden gush of fluid from vagina
- -------Premature rupture of membranes
* Vaginal bleeding
- -------Abruptio placenta, placenta previa, bloody show, miscarriage
* Abdominal pain
- -------Premature labor, abruptio placenta
* Temperature above 101
- -------Infection
* Dizziness, blurred vision, spots before eyes
- -------Toxemia or preeclampsia (PIH)
29
Danger signs in pregnancy cont.
* Persistent vomiting
- -----Hyperemesis gravidarum
* Severe headache
- -----Toxemia or preeclampsia (PIH)
* Edema of hands, face, legs and feet
- -----Toxemia or preeclampsia (PIH)
* Convulsions/seizures
- -----Eclampsia
* Epigastric pain
- -----Severe toxemia / pre-eclampsia/ PIH, HELLP
* Oliguria
- -----Renal impairment, decreased fluid intake, toxemia or preeclampsia (PIH)
* Dysuria
- -----Urinary tract infection
* Absence of fetal movement
- -----Maternal medication, obesity, fetal death
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COMMON DISCOMFORTS: FIRST TRIMESTER
* Nausea and vomiting
* Urinary frequency
* Fatigue
* Breast tenderness
* Increased vaginal discharge
* Nasal stuffiness
* Epistaxia
* Ptyalism
31
COMMON DISCOMFORTS: SECOND AND THIRD TRIMESTERS
* Heartburn
* Ankle edema
* Varicose veins
* Hemorrhoids
* Constipation
* Backache
* Difficulty sleeping
* Leg cramps
* Faintness
* Dyspnea
* Flatulence
* Carpal tunnel syndrome
* Round ligament pain
32
Psychological adjustments during the first trimester
* Ambivalence
* Disbelief
* Introspective and passive
* Emotionally labile – mood swings
33
Psychological adjustments during second trimester
* Begins to see baby as separate person
* Excited about having a baby
* Emotional lability persists
34
Psychological adjustments during third trimester
* Anxiety about labor & birth
* Physical discomforts increase
* Eager for pregnancy to end
* Nesting
35
TERMS USED IN RECORDING HISTORY OF PREGNANCY
* Gestation
* Nulligravida
* Primigravida
* Multigravida
* Nullipara
* Primipara
* Multipara
* Stillbirth
* Antepartum
* Intrapartum
* Postpartum
* Preterm
* Term
* Postterm
* Comparison of GRAVIDA and PARA
36
Gravida
* Refers to the number of pregnancies a woman has had
* Includes ALL pregnancies regardless of duration or outcome
* Includes the present pregnancy
* If pregnant the “gravida” will be one more than the sum of the para and abortions
37
Para
* Number of pregnancies ending AFTER 20 weeks
* Counted as a “para” whether the baby is born living or dead
* Counts the pregnancy NOT the number of babies born
38
Abortion
* Any pregnancy ending BEFORE 20 weeks
39
GTPAL
* May see GPAL (gravida, para, abortion, living)
| * With GTPAL, para is replaced by categorizing deliveries as preterm or term
40
GTPAL
G- Number of pregnancies regardless of outcome
T – Number of deliveries after 37 (37.0 and up) weeks gestation (twins, triplets, etc. count as one “delivery”!!)
P – Number of deliveries AFTER 20 weeks but BEFORE 37 weeks gestation (twins, triplets, etc. count as one “delivery”!!)
A – Number of pregnancies ending BEFORE 20 weeks
L – Number of CURRENTLY living children
41
PREGNANCY TESTS
* Variety of blood & urine “assay techniques” that detect presence of HCG
* Urine test
* Over-the counter tests
* Should be done on 1st early morning voiding
* Positive as early as 7-10 days after conception
* Encouraged to wait to perform test until missed period
* Repeat in one week if continue to have pregnancy symptoms
* Medications/ drug use may give false negative or positive result
42
DETERMINATION OF DUE DATE
* Figured from first day of last menstrual period
* EDC, EDD, EDB
- ------ESTIMATE!!
* Nagle’s rule
- ------1st day of LMP Subtract 3 months and add 7 days
* Can also use fundal height, ability to hear FHR with fetoscope, report of quickening
- ------McDonald’s rule – fundal height in CMs equals weeks gestation within 2 weeks
* Today ultrasound is often used
- -----Most accurate in 1st trimester
43
SIGNS OF PREGNANCY
Presumptive (subjective)
* Pregnancy symptoms
* Urinary frequency, breast tenderness, fatigue, etc
Probable (objective)
* Pregnancy “signs” that the doctor and/or nurse will note on assessment
* Could be caused by something other than pregnancy
* Enlargement of the uterus, positive pregnancy test, Chadwick’s sign, etc
Positive (diagnostic)
* Fetal heart rate, fetal movements felt by the doctor &/or nurse, presence of fetus on ultrasound
* “Positive” proof of pregnancy
44
RECOMMENDED WEIGHT GAIN DURING PREGNANCY
* Based on pre-pregnant BMI
* Pattern of weight gain is essential to well-being of fetus
- ------First trimester- 3-5 pounds
- ------Second/ third trimesters- approximately .8-1 pound per week
- ------Total weight gain of 25-35 pounds
* Overweight/ underweight woman will have different recommendations
* Sudden weight gain associated with pre-eclampsia/ toxemia/PIH
45
PICA
* Persistent eating of non-food substances
- -----Dirt, clay, cornstarch, freezer frost
* Iron deficiency anemia most common concern
- -----Interfere with iron absorption and other nutrients
* Also can cause fecal impaction, excessive weight gain
* May have cultural association
46
PRENATAL ASSESSMENT / CARE
* Review history and identify risk factors
- ------Potential negative outcome for mother or child
* Physical exam done at first prenatal visit to determine health status
* Identify lifestyle factors that need to be adjusted during pregnancy
* Ongoing assessment of well-being done at each prenatal visit
* Identify learning needs
* Provide teaching
* Perform activities that encourage psychological adjustment to pregnancy
47
RECOMMENDED SCHEDULE OF ANTEPARTAL VISITS
* Every 4 weeks for 1st 28 weeks
* Every 2 weeks until 36 weeks
* After week 36, every week until childbirth
48
Antepartal laboratory testing
* Prenatal panel
* CBC
- --------Blood type and RH
- --------RH negative mother will receive RhoGam at 28 weeks
* Concern for RH sensitization with women who are RH “negative”
* Syphilis test – RPR or VDRL
* Gonorrhea & Chlamydia culture
* Urinalysis
* Rubella titer
- --------1:8 titer indicates woman is immune (if less the 1:8 woman is susceptible to German measles)
* Hepatitis B screen
- --------Infant born to woman that is positive will receive Hepatitis B Immune Globulin (HBIG) soon after delivery AND 1st dose of hepatitis vaccine
* HIV screen
49
Suggested laboratory testing during pregnancy
* Triple screen/ multiple marker screen OR Quad screen
- ---Done at 16-18 weeks gestation
- ---Screens for levels of certain substances in mother’s blood that could suggest either neural tube defect (anencephaly, spina bifida, omphalocele) or Trisomy 21(Down syndrome), Trisomy 18 (Edwards Syndrome) or another type of chromosome abnormality
* Quad screen measures high and low levels of AFP, HCG and estriol, and high levels of Inhibin-A.
- -----AFP: alpha-fetoprotein is a protein that is produced by the fetus
- -----HCG: human chorionic gonadotropin is a hormone produced within the placenta
- -----Estriol: estriol is an estrogen produced by both the fetus and the placenta
- -----Inhibin-A: inhibin-A is a protein produced by the placenta and ovaries
* Abnormal’ levels could also be a result of inaccurate dating of the pregnancy or multiple gestation
* Associated with high false positive results but Quad screen more reliable than other screens
* Abnormal test results warrant additional testing in order to make a diagnosis
50
Suggested laboratory testing during pregnancy
* Glucose screen
* 50-g 1-hour test
* Done between 24-28 weeks
* Plasma glucose level ³ 130 mg/dL need to do 3-hour GTT to r/o gestational diabetes
* Gestational diabetes is dangerous during pregnancy because it negatively affects placental functioning – can decrease oxygen delivery to fetus
* Can also increase risk of congenital heart defects in the fetus
51
suggested lab test during pregnancy
* Antibody titers for RH negative woman
- ----Indirect coombs drawn at first prenatal visit
- ----RH antibodies present indicate maternal sensitization
- If NOT susceptible, drawn again between 24-28 weeks
* GBS (Group ‘B’ Strep) culture
- ----Vaginal culture done on mom at ~36 weeks
- ----If POSITIVE… mother will be given prophylactic antibiotics during labor
- ----Optimal to receive treatment at least 4 hours prior to delivery
- ----Risk is for baby developing infection
52
TERATOGENIC SUBSTANCES
* Any substance that adversely affects normal G & D of fetus
* risk during 1st trimester
* Certain medications, psychotropic drugs, alcohol, tobacco
* Environmental factors such as pesticides, x-rays
* Need to weigh benefits of prescribed medications to possible risks
- --Only category A drugs considered safe
- -----Studies in pregnant women have failed to show a risk to the fetus
- -----Folic acid, magnesium sulfate, vitamins, levothyroxine, nystatin
- -----Category B drugs – no evidence of risk but inadequate studies in pregnant women
* Also need to use caution with over-the-counter drugs/ prescription unless prescribed by healthcare provider
* Avoid NSAIDS & aspirin during 3rd trimester
53
Tobacco use during pregnancy
* Stop or decrease # of cigarettes smoked per day
* Associated with low birth weight, preterm birth, placenta previa, placenta abruptio, ectopic pregnancy, premature ROM, risk of cleft lip/palate, SIDS, acute respiratory illness in infant, chronic respiratory problems
* Adverse effects related to carbon monoxide & nicotine
54
Alcohol consumption
* No safe limit has been identified
* Recommended that pregnant woman abstain from ALL alcohol intake
* Heavy intake associated with fetal alcohol syndrome
55
Caffeine during pregnancy
* Increased risk of miscarriage in early pregnancy
* Advised to limit intake to no more than 3 cups of coffee or cola / day
* Decreases iron absorption
56
Marijuana use during pregnancy
* No “identified” teratogenic effects b/c illegal drug
| * Thought to have adverse effect on CNS
57
Cocaine use during pregnancy
* Risks for mom and fetus
* Associated with abruptio placenta, preterm birth, fetal distress, low birth weight, neonatal withdrawal, SIDS, spontaneous pneumothorax, congenital anomalies
* Urine screening only accurate for 1st 24-48 hours after drug use
* Can test meconium of baby for drug use during pregnancy
58
TESTING TO ASSESS FETAL WELL-BEING
* Nonstress Test (NST)
* Monitor externally
* Noninvasive
* Reactive test demonstrates 2 accelerations in 20 mins
* This test would be ordered to assess “how well” the placenta is functioning
- -----Post-dates
- -----Maternal history of pregnancy complications or chronic health problems
- -----SGA
- -----Decreased amniotic fluid
- -----Statistically, a “reactive test” suggests that the placenta will provide adequate oxygen to the fetus for approximately the next 7 days
- -----Will usually schedule weekly
59
Testing to assess fetal well-being
* Biophysical Profile (BPP)
- ----Utilizes ultrasound to evaluate fetal breathing movements, fetal movement of body or limbs, fetal muscle tone, amniotic fluid volume, & reactive NST
- ----A score of 2 is assigned to each category for a total of 10
- ----Score of 8 considered normal
- ----This test would also be ordered to assess “how well” the placenta is functioning – more definitive than NST
60
Testing to assess fetal well-being
* Ultrasound
- -----Done for many different reasons
- -----Gestational dating most accurate in 1st trimester
- -----Assess fetus for genetic or congenital problems
- -----Abnormalities in size, shape or structure
- -----Best done at 18-20 weeks
61
Testing to assess fetal well being
* Amniocentesis
- -----Advanced maternal age, previous child born with a chromosomal abnormality, parent carrying a chromosomal abnormality, family history of neural tube defects (anacephaly, spina bifida, omphalocele)
- ----Done at 16-18 weeks gestation
* Chorionic Villus Sampling
- ----Diagnostic capability similar to amniocentesis
- ----Performed at 8-10 weeks gestation
62
ABORTION/ MISCARRIAGE
* Expulsion of fetus prior to 20 wks
- ----Actually, a 1st/2nd trimester problem
* Major cause of bleeding during this time
* Lay term - “miscarriage”
* Types:
- ----Spontaneous (Miscarriage) - occur “naturally”
- ----Induced - result of artificial or mechanical intervention
- ----Missed abortion – fetus dies in utero but is not expelled
- ----Threatened abortion – unexplained bleeding, cramping, backache but cervix is closed
63
Symptoms and treatment of abortion (miscarriage)
* Spotting/bleeding
* Cramping & backache
* Bed rest, IV’s, blood transfusion, D&C,
* Give RHOGRAM if RH negative
* Prepare woman for POSSIBLE fetal loss
* Remember, ambivalence common in 1st trimester
- -----Might have “guilt”
* Encourage to ventilate feelings
* Give accurate information
* Support groups
64
ECTOPIC PREGNANCY
* Implantation of blastocyst in a site other than endometrial lining of uterus
* Most common site - ampulla of tube
* Major symptom – PAIN
* Diagnosed thru u/s, serial serum HCG, serum progesterone levels
* IV’s, blood transfusion, surgery
65
Placental Problems include
* Abruptio placenta
| * Placenta Previa
66
ABRUPTIO PLACENTA
* Premature separation of a normally implanted placenta from the uterine wall
* Dark red bleeding associated with abdominal pain
* Uterus hard, firm and PAINFUL!
* Cause unknown. Theorized to be caused by decreased blood flow to placenta, excessive uterine pressure, MVA, cocaine use, hypertension, cigarette smoking, alcohol or drug ingestion, increased maternal age, increased parity, trauma
* Major concern is that when placenta separates, circulation to the fetus is affected
67
PLACENTA PREVIA
* Placenta implanted in the lower uterine segment instead of in the upper portion of uterus
* “Painless” bleeding, bright red
* Uterus soft
* Major concern is that when placenta detaches as cervix “opens up”, placenta circulation is affected – fetal hypoxia
* When placenta detaches, bleeding occurs
- ----Scant to profuse
- ----May hemorrhage rapidly
68
INCOMPETENT CERVIX (Cervical Insufficiency)
* Premature dilation of cervix (4 or 5 months)
* Associated with repeated 2nd trimester abortions
* Causes: cervical trauma, previous surgery on cervix, congenital defects
* Diagnose from history – multiple miscarriages, repeated preterm delivery
* Treatment: cerclage (Shirodkar-Barter)
69
Risk of torch infection
* Group of infectious diseases that can cause serious harm to the embryo/fetus
* “TO”xoplasmosis, “R”ubella, “C”ytomegalovirus, and “H”erpes
70
TOXOPLASMOSIS
* Avoid poorly cooked or raw meat, wild game such as deer or rabbit, unwashed fruit/vegetables
* Avoid contact with the cat litter box
* Stress importance of wearing gloves when gardening
71
RUBELLA
*Stress importance of receiving rubella vaccine AFTER delivery if non-immune
72
CYTOMEGALOVIRUS
* Can be transmitted thru placenta to baby
* Cause birth defects and developmental disabilities (hearing loss, lower IQ, small head size, cerebral palsy)
* Contracted by pregnant woman thru exposure to child’s saliva or urine
* Counsel pregnant women to
- ----Wash hands after changing diaper or “wiping” runny nose
- ----Avoid sharing food, drink or utensils with young children
73
Herpes
* If active herpes infection in the genital area…C/Section will be method of delivery
* Valtrex given prophylactically to prevent “outbreak”
74
PREMATURE RUPTURE OF MEMBRANES
* Spontaneous rupture & leakage of fluid prior to onset of labor
* PRETERM ROM - prior to 37 (36.6 and under) wks gestation
* Associated with infection, previous hx of ROM, polyhydraminos, multiple pregnancies, smoking, incompetent cervix, maternal reproductive tract abnormalities
75
Premature rupture of membranes risk to the mother include
* Infection in uterus from ascending pathogens
* Stress related to condition of child
* Prolonged hospitalization
76
Premature rupture of membranes risk to the fetus include
* Fetal sepsis due to ascending pathogens
* Prolapse of umbilical cord
* Malpresentation
* Increased perinatal morbidity and mortality
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When there is a premature rupture of membranes you should assess
* nitrazine paper
* ferning
* how long ruptured
* calculate gestational age to determine if “SAFE” to deliver
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Preterm Labor
* Labor that occurs btw 20 and 37 weeks
* Symptoms:
- ----Mild, menstrual-like cramps in lower abdomen
- ----Uterine contractions q. 10 minutes or less
- ----Pelvic pressure - constant or intermittent
- ----Low backache
- ----Change in vaginal discharge - increased amount, more clear and watery, pinkish tinge
- ----Abdominal cramping, with or without diarrhea
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Teaching for preterm labor client to prevent reoccurrence
* Stop labor first
* Rest on left side
* Drink 2-3 quarts fluid each day
* Avoid caffeine drinks
* Empty bladder every 2 hours
* Avoid lifting heavy objects
* Avoid nipple stimulation
* Avoid sexual activity
80
terms
•Gestation- the period of intrauterine fetal development from conception through birth; the period of pregnancy.
•Nulligravida- A woman who has never been pregnant
•Primigravida- A woman who is pregnant for the first time
•Multigravida- A woman who has had two or more pregnancies
•
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terms
Nullipara- A woman who has not completed a pregnancy with a fetus or fetuses who have reached 20 weeks of gestation.
•Primipara- A woman who has completed one pregnancy with a fetus or fetuses who have reached 20 weeks of gestation; woman who has carried pregnancy to viability whether the child is dead or alive at the time of birth
•Multipara- A woman who has completed two or more pregnancies to 20 or more weeks of gestation.
•Stillbirth- The birth of a baby after 20 weeks of gestation and 1 day or weighing 350g depending on the state code, that does not show any signs of life.
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terms
Antepartum- Before labor
•Intrapartum- During labor and birth
•Postpartum- Happening or occurring after birth
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Terms
* Preterm
- --late preterm birth occurs between 34 and 36 weeks of gestation
- --Preterm birth occurs before the completion of 37 weeks of gestation
- --Preterm labor is when uterine contractions causing cervical change that occur between 20 and 37 weeks of pregnancy
- --Preterm pregnancy is pregnancy that has reached 20 weeks of gestation but ends before completion of 37 weeks of pregnancy
- --Very premature birth occurs before 32 weeks of gestation
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Terms
* Term- Considered to be at term if it advances to the completion of 37 weeks
•Postterm- Pregnancy that extends beyond the end of week 42 of gestation. Also called post date pregnancy or prolonged pregnancy.
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Nageles rule
* Using Nagele’s Rule, calculate the estimated date of birth.
* First day of LMP = July 30th, 2013
•LMP = 7 30 2013
-3 +7
• 4
•EDB 5 6 2014
