202A > Test #4 > Flashcards

Test #4 Flashcards

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1
Q

What is Veal Chop? How can we use it?

A

Used to help interpret fetal strips:

V = variability
C= cord compression

E = early decelerations
H= head compression

A = accelerations
O = Ok (what we want to see)

L = late decels
P = placental insufficiency

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2
Q

What classifies as obesity

A

BMI at 30 or above pre-pregnancy

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3
Q

What things are we worried about with an obese mom? 4

A
  • Bleeding (have hemorrhage kit ready)
  • Difficult to monitor baby
  • Difficult to help change patients position if needed
  • Anticipate large babies (LGAs - large for gestational age) creates issues during delivery
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4
Q

What does IUGR stand for

A

Intrauterine growth restriction

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5
Q

Would we always expect a large baby from an obese mom?

A

No - there may be other comorbidities, like mom is a smoker, that causes issues with perfusion with the placenta, which can lead to IUGR and smaller babies

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6
Q

Before birth, what are complications of obesity 3

A
  • Diabetes
  • HTN leading to preeclampsia
  • Sleep apnea
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7
Q

During birth, what are complications of obesity 4

A
  • Macrosomia (large baby)
  • Prolonged labor
  • Shoulder dystocia (increased C-section rates)
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8
Q

What are some risks for C-sections for obese women 4

A
  • Increased risk of BLEEDING
  • Increased risk of infections
  • Delayed wound healing (increased risk for dehiscence)
  • Thromboembolism (all pregnant women are at an increased risk, but being obese increasing this risk factor even more)
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9
Q

Why is there an increase of bleeding for obese mom’s

A

It can be difficult to do a proper fundal massage with the extra tissue

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10
Q

Later on in life, what are children who are born from an obese mother at risk for 2

A
  • Increased risk of childhood obesity
  • Increased risk for chronic conditions (like diabetes)
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11
Q

What are our nursing considerations for obese mom’s 5

A
  • Weight gain through their pregnancy should be smaller (so we only want them to gain around 11-20 pounds)
  • Early testing for gestational diabetes due to their increased risks
  • More frequent prenatal visits
  • Anticipate more challenges in labor and delivery (have hemorrhage kit ready)
  • Issues with babies maintaining blood sugars after delivery
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12
Q

Why are we seeing an increase in CVD in our mom’s

A

2 main factors:

  1. Women are having babies when they’re older
  2. Underlying preconception comorbidities like obesity, HTN, diabetes, rheumatic heart disease if strep is not treated
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13
Q

What population of women is more likely to have untreated strep

A

Immigrant populations with lower socioeconomic status

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14
Q

Why do we consider pregnancy the ultimate stress test in terms of CV health 4

A
  • Dramatic increase in blood volume, especially during 3rd trimester (up to 50% increase)
  • Increase in HR that naturally happens
  • Decrease in systemic vascular resistance (naturally), that can cause dilation in your legs, which can lead to pooling of blood and risk for DVTs
  • Increased coagulability
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15
Q

If a pt is at an increased risk of coagulability, possibly from CVD, what two medications might they be on?

A
  • Baby aspirin
  • Heparin
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16
Q

What anticoagulant drug do we NEVER use during pregnancy (carries a black box warning - category D)

A

Warfarin (can cross the placenta and cause baby’s blood to thin)

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17
Q

What sucks about having CVD while pregnant?

A

Normal pregnancy symptoms can be made even worse by CVD, like:
- Increase in fatigue caused by anemia and changes in cardiac output and BP

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18
Q

How can CVD impact a woman’s labor 2

A
  • During a contraction, blood is shunted away from the placenta and out into the mom’s cardiovascular system, which can be up to 500mLs of extra blood going out into the system. This can put a lot of strain on a woman’s cardiac system taking in this extra blood and increasing her cardiac output.
  • Contractions are painful and can increase BP and HR, which can then increase cardiac output
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19
Q

How can we care for our CVD pts during labor 3

A
  • Strict Is and Os (don’t give any extra fluid, which can increase mom’s fluid volume and increase her CO).
  • Close monitoring of mom and baby (might also have telemetry on mom)
  • Want effective pain relief to help decrease CO and to help shorten second stage
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20
Q

What is second stage? Why would we want it shortened for moms in labor? What can we do to help?

A

Second stage is when mom is pushing, so when a mom with CVD is bearing down and pushing, this can increase their BP and HR, which increases their CO… So we don’t want to put this kind of stress on their heart for very long, so we want to try and shorten this stage.

These women are great candidates for laboring down, which, with an epidural, is when a women lets her uterus do some of the work when she is 10cm and 100% effaced, where the women isn’t pushing, and instead the uterus is passively moving baby along, this helps take off some of the pushing duties for our CVD moms

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21
Q

What acronmyn can help us remember what infections women should avoid during pregnancy

A

TORCH (teratogenic - cross placenta can cause fetal abnormalities or other complications during pregnacy). We screen for these.

T = toxoplasmosis (kitty litter and uncooked meat)
O = other infections like chicken pox, syphilis, HIV, parvo virus, chlamydia, Hep B)
R = rubella
C = cytomegalovirus
H = herpes simplex

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22
Q

What is important about rubella

A

We screen for it and have a vaccine for it, but we can’t give the vaccine until after pregnancy, because it’s a live virus vaccine (one of the few live virus vaccines we have left)

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23
Q

Besides screening for TORCH infections, what other infections do we screen for?

A
  • Hep B
  • HIV
  • GBS (group beta strep) (screen towards the end of pregnancy, because most adults who have it will be asymptomatic, but it can cause newborns to have sepsis if not treated, so we like to screen for it and treat prior to delivery) (GBS positive or GBS status unknown, we treat with antibiotics during labor to help reduce transmission with a vaginal delivery)
  • UTI (big deal in pregnancy because they may be asymptomatic during pregnancy, so will screen for it just in case they have it but are not showing symptoms)
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24
Q

Why are we worried about UTIs during pregnancy

A

They can cause pre-term labor and progress to pyelonephritis (so we want to catch these UTIs early so we can prevent any complications)

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25
With HIV, since we are trying to prevent transmission between mom and baby, what are we looking at? Why?
Mom's viral load, because the higher her viral load the more likely she is to pass it on
26
How can HIV transmission from mom to baby occur in the 3 phases of pregnancy (ante, intra, post)
1. Ante: HIV can cross the placenta if we don't do anything to prevent the transmission (without intervention rates can be as high as 25% of babies becoming infected) 2. Intra: transmission into babies bloodstream due to minor tears during birth 3. Post: through breast milk
27
How can we prevent HIV transmission
1. Antiretroviral therapy to help decrease viral load (usually 3 different medications) (usually need to start by 28 weeks to reduce risk at birth) 2. Have a C-section if viral load is not low enough to help prevent transmission 3. Newborns will receive antiretrovirals for 5 weeks after delivery 4. Do not let mom breast feed
28
What is some psych that goes along with HIV
It's a universal screening for all pregnant mothers, so this could be the first time that she's ever being tested for and the first time finding out if she is HIV positive, which can be a shock
29
What is important to reinforce with an HIV positive mother
That HIV is no longer a death sentence, it is a chronic illness that can be managed
30
What do we do for our Hep B positive mothers 3
- They will be on antivirals, which will help prevent transmission across the placenta, where it is most likely to occur - Safe to deliver vaginally - Can breastfeed
31
What do we do for our newborns born from Hep B positive moms 3
- First thing: bathe baby prior to giving any injections (like the vitamin k and hep B vaccine) - Will receive a hep B vaccine - Will receive hep B immunoglobulin (HBIG) (these injections should be given within the first 12 hours to prevent any transmission that may have occurred)
32
Is alcohol bad for baby
Yes, it's a potent teratogenic drug
33
What things can cause neonatal abstinence syndrome
- Heroin, codeine, fentanyl, methadone, oxy, hydrocodone
34
What can happen to babies born with a tobacco addiction 2
- Very fussy, sensitive, hyperreactive due to withdrawals after delivery - Increased risk for IUGR (why these babies born from smokers are generally small)
35
If a mom has substance abuse, what else is she at risk for having 3
- Intimate partner violence - STIs - Lack of prenatal care
36
Some moms won't admit to having substance abuse, so what things can suspect us to think that she actually does abuse substances 3
- If she has had no prenatal care - If there is a placental abruption without an obvious reason - If there is IUGR without obvious reasons
37
What is interesting about social services and substance abuse
Sometimes there will be a mandate from social services telling us that there is a hx of abuse and we need to do a toxicology screen
38
Can we get a toxicology from a mom without her consent
No, even if there is a court order, she would end up just being in violation of the order
39
Are we allowed to do toxicology on babies here in Oregon without mom's consent
Yes
40
When doing a toxicology on a baby, what two fluids do we test
- Meconium - Urine
41
What happens to babies born from mom's with substance abuse
- They are often SGA (small) - There may be some neurodevelopmental abnormalities - Acute withdrawals
42
If a mother is positive for an illicit substance (except tobacco, which is not illicit), can they breastfeed?
No
43
Is there a screening tool for babies born from substance abuse mothers
Yes, typically like to use the screening tool within the first 4 hours (looking at things like does baby have a high pitched cry, decreased sleeping, hyperactive reflexes, etc), then this gives us a score and tells us how frequently we should rescore the baby and what our treatments should be. - Good to note that we may not see signs of withdrawal until 12-24 hours after birth, but it's still good to start at hour 4 so we have a baseline before withdrawals kick in
44
What extra care might we do for babies born with neonatal abstinence syndrome due to opioids (a lot)
- High-calorie formula (due to all of their extra movements going on and increased metabolism during their withdrawal) - Small frequent meals - Antidiarrheals - Meticulous Is and Os - Wts - Breastfeeding - Morphine or methadone if baby has a high score - Promote comfort like swaddling, sucking (give pacifier), swing - Billy lights - Monitor tox screen - Work with social services
45
For mental health, what drug types are we concerned about
If they take SSRIs during the first trimester, there is conflicting info on whether it can cause fetal malformation, so we would want to work with their doctor to see if they should be taken off the medications (weight the risk vs benefit)
46
What are our prescription drug categories
A and B are generally safe. C we don't know either way. D we're going to avoid.
47
What is a mom with a hx of depression at risk for
Developing postpartum depression
48
What might be a sign that a mom has postpartum depression
They're feeling down longer than 14 days (it's normal to have a few days that you may feel like this
49
What is hyperemesis gravidarum
Persistent vomiting that is not caused by something like the flu or eating something bad It's just vomiting that goes on and on while pregnant and you can't figure out why
50
What signs do we see (besides persistent vomiting) for hyperemesis gravidarum 2
- There will be signs of malnutrition, so we would see ketonuria (+2 ketones with dipstick) - Weight loss (below pregnancy weight by 5%)
51
What do we think causes hyperemesis gravidarum 5
Not really clear, but we think it has something to do with high levels of HCG, estrogen or thyroid hormones Might also be a genetic component Increase risk if you're having a girl Can be worse symptoms if you have multiple babies (due to more hormones being released) Hx of motion sickness or migraines may make a woman more susceptible
52
What are our txs for hyperemesis gravidarum
- Antiemetics - IV fluids for hydration - Can give dextrose for calories - Worst case - have central lines to get TPNs
53
What is placenta previa? Why is this bad?
Where the placenta has attached to the lower uterine wall, and may be covering the cervix. This is bad because it can increase mom's chance of having a hemorrhage, where in the 3rd trimester when she starts having contractions, those contractions around her cervix can put a lot of pressure on her placenta and cause bleeding. Plus a baby can't be born vaginally if the placenta is completely blocking the cervix, because the placenta will be born before the baby, so the baby won't be getting perfusion.
54
What are the 6 different types of placenta previa
1. Complete: where the placenta is completely blocking the cervix 2. Partial: where part of the placenta is blocking the cervix 3. Marginal: where the placenta is very close to blocking all of the cervix 4. Accreta: placental attaches too deep into the uterine wall 5. Percreta: where the placenta grows through the wall and attaches to nearby organs 6. Increta: attaches even deeper into the uterine muscle
55
Ho do we deliver placenta previa babies
C-section
56
Why are placenta accreta, increta, and percreta troublesome?
Because the placenta has attached itself so deeply in the uterine wall, or muscle or other organs, which can lead to massage bleeding once baby is born because we can't really do a fundal massage or anything in this area, it will just keep bleeding
57
Where are mom's with Placental accreta, increta or percreta going to give birth? What are we prepared to do?
In the OR, where we are ready to do a massive transfusion. May even need to do a hysterectomy
58
What are the cardinal signs of placenta previa 2
- Painless bright red vaginal bleeding (think about the placenta covering the cervix, and any little disruption to that placenta's blood vessels can cause bleeding, but the pt might not feel any pain) (usually occurs in 3rd trimester) - Abdomen will be soft, nontender
59
What should we not do on pts with placenta previa
Vaginal exams, because we don't want to be poking and prodding the placenta since it's right at the cervix
60
What is teaching for pts with placenta previa
When they go to the hospital or get checked, make sure they tell whoever that they have a placenta previa and cannot have vaginal checks
61
What initial assessments are we going to do on pts with a hx of placenta previa
Maternal and fetal well being. - Vital signs on mom - Look at mom - Get baby on monitor
62
What is important to remember about BPs for pregnant moms
Their BP will be higher due to their increase in blood volume, so this can be a poor indicator of volume status, so we want to look at her HR to see how she's coping (tachycardia would show that something is up) We would also see changes in baby's HR first if there is an issue with blood volume (like bleeding), where baby will get tachycardia trying to compensate, then eventually mom's HR will also go into tachycardia
63
What kind of test might we do on a mom with placenta previa? What is it?
A Kleihaurer-Betke (KB) test to see if mom's blood has mixed with baby's, especially for our RH negative moms (if mom is Rh negative and baby is positive, than mom can create antibodies that kill baby's RBCs) (since mom's with placenta previa are at an increased risk of bleeding, we want to be on the lookout for Rh negative and positive situations)
64
What is a placental abruption
A premature separation of the placenta from the uterus
65
What are the signs of a placental abruption
- ***Very painful - May or may not Vaginal bleeding (a complete separation may block blood from leaking out, so that blood will just collect where its separated) - With a complete separation and blood blooding in the abdomen, we will get a rigid abdomen
66
What are the 3 different types of placental abruptions
1. Marginal 2. Partial 3. Complete
67
What are signs from baby that a placental abruption may be occurring
We would see late decels on FHR
68
What is a complication of placental abruption
The mom can go into DIC, which can lead to hypoxia of the baby
69
What is interesting about placental abruptions
Some can be minor, where maybe we didn't even know they had one until after delivery or they can be extreme, where we would need to do an emergency c-section
70
If a woman's membranes rupture before 37 weeks, what do we refer to them as?
Preterm premature rupture of membranes (PPROM)
71
What is a common cause of PPROM 4
- Infection, which is called chorioamnionitis - Uterine distention like from multiple babies or a lot of fluid - STIs - Smoking
72
How do we diagnosis PPROM 4
- A provider will do a sterile speculum exam to see if they can see fluid in the birth canal - nitrazine test where normal vaginal pH is between 4.5-5.5, but amniotic fluid increases the pH - Amnisure (lab test) - Ferning (amniotic fluid will fern when dried)
73
What are our concerns with PPROM? What can we do? 2
- Infection risk (decrease number of invasive procedures) - Fetal wellbeing (we are losing our amniotic fluid cushion, babies may have variables on the monitor, because there can be compression of cord without the cushion)
74
If there is chorioamnionitis, what are we doing?
Deliver the baby right away, because mom and baby are at risk for sepsis
75
If baby is tolerating the decrease in amniotic fluid well and there are no signs of infection, do our PPROM moms have to deliver within 24 hours?
No, we will keep a close eye on them and try and let the baby cook longer
76
What is good to tell pts with PPROM 2
- They are at an increased risk of going into labor spontaneously - They will be on bed rest
77
What are signs of infection besides an increased in temp 5
- Tenderness - Cramping - Lower back pain - Odor - Increased HR of both mom and baby (infection will usually trigger the body to go into labor, because it knows that we need to get the baby delivered)
78
If there are no signs of infection, what might we want to try and do?
Slow down labor for at least 48hrs so we can give 2 doses of betamethasone, which can enhance lung maturity of the baby before they are born
79
What do we consider preterm labor
Anywhere from 20 weeks (when we consider the baby viable) to before 37 (because we consider 37 weeks and after full term)
80
What is the most acute problem in maternal-child health
Preterm labor
81
Do we still focus on preterm labor prevention here in the US?
No, we've shifted from prevention to early detection of preterm labor
82
What is our core measure for preterm labor
To be able to give more babies going into preterm labor between 24-32
83
What is our core measure for preterm labor
To be able to give more babies going into preterm labor between 24-32 betamethasone to help their lungs prior to delivery
84
What age in weeks will a premature baby have a 90% survival rate
At 28 weeks (so we REALLY REALLY want to get our babies to 28 weeks)
85
What are our concerns with premature babies 5
- Immature lungs (not producing surfactant yet, not having coordinating breathing yet), which can lead to respiratory distress - Small babies, not much subcutaneous tissue or glycogen stores, which can lead to hypothermia and hypoglycemia (monitor temps, put on warmers, check sugars) - Underdeveloped livers (at risk for jaundice) Can have under billy lights - Intraventricular hemorrhage for really small babies, where there is internal bleeding in the babies head, so we don't want to have small babies deliver vaginally, because trauma during birth can increase the risk of intraventricular hemorrhage - Cerebral palsy longer term - Retinopathy long term
86
What can cause preterm labor (a lot)
- Periodontal disease - Diabetes, HTN - *Infections - *Uterine distention usually caused by multiples - Hx of preterm labor - Demographics (older and younger, no prental care) - Smoking - Stress - Interpregnancy interval (less than 6 months since last pregnancy)
87
How can we prevent preterm labor 4
- Number one thing is prenatal care - Manage chronic conditions that might trigger it (like managing HTN, diabetes, stress) - Screen and treat infections - Give progesterone intravaginally (pro-pregnancy hormone - wants to keep you pregnant)
88
How do we determine if a mom is actually in preterm labor 7
- Greater than 20 weeks pregnant and less than 37 weeks - Have to have persistent contractions - Dilating more than 1cm or dilation is changing - Effacement of 80% - Get a UA - Fetal fibronectin (FFN) test - Exam cervical length
89
If a mom who is less than 37 weeks pregnant calls and says that she is having contractions, what kinds of things can we advise her to do at home to stop those contractions 4
- Drink water (dehydration can cause contractions) - Go to the bathroom (full bladder can cause issues) - Put their feet up - Take a nice warm bath
90
What is the Fetal fibronectin (FFN) test? When would we not want to use this test? What does a negative result mean?
- A test used to rule out preterm labor - The fetal fibronectin is a prostaglandin that is released when membranes are disturbed by contractions (so this is how we can tell if they're actually having contractions) - Don't use if there are rupture membranes (PPROM) or if there is vaginal bleeding - Can't use if there has been anything in the vagina in the last 24 hours, like from having sex or having their cervix checked. Negative means that there is a less than 1% chance that the mom is going to deliver that week. (we want negative)
91
Why do we want to do an FFN test for preterm labor before we check the cervix
Because the FFN test won't be accurate if anything has been in the vagina in the last 24 hours, like from having an exam. So we always want to do this test first before a cervical exam.
92
What does a positive FFN tell us?
Well it tells us that the mom has a 20-50% chance of delivering this week, but there are also a lot of false positives, so basically a positive result doesn't really tell us much.
93
What is our goal for preterm labor? How do we accomplish this goal? 5
- We want to delay delivery! How we accomplish: - Give tocolytics, which are medications used to reduce contractions. - Try to delay delivery enough to get two doses of betamethasone in within 48 hrs - Abx for GBS as needed - Bed rest (remember increase of DVTs on bed rest, maybe more of an activity restriction) - Possibly may need to transport to another facility
94
What are our tocolytic drugs 4
- Nifedipine (Ca channel blocker) (don't give nifedipine and magnesium sulfate together because both compete with calcium and cause cardiac issues) - Indomethacin (NSAID) - Terbutaline (beta-adrenergic receptor agonist) (not first line, will stop contractions, but can cause maternal tachycardia) - Magnesium sulfate (CNS depressant - also competes with Ca) (has to be given inpatient)
95
How do we administer betamethasone? When would we give it? What does it help babies produce?
Give 12mg to mother IM every 24hrs twice Give to mothers if babies are less than 34 weeks Helps babies produce surfactant
96
What are the benefits of betamethasone 5
Reduces: - Respiratory distress syndrome - Intraventricular hemorrhages - Necrotizing enterocolitis - Neonatal mortality - Neurologic handicap
97
What if you give your two doses of betamethasone thinking the mom is in preterm labor and is going to deliver soon, but the mom doesn't actually deliver until a week later?
You can give one "rescue dose" of betamethasone a week later, or even at a later time.
98
What are we worried about it, in terms of our moms, when we give them betamethasone (think steroid risks) 1
- Diabetic moms (this med will spike their sugar levels) (might need extra insulin coverage)
99
Can we sign off on mag sulfate by ourselves
No, it's a dual RN sign off
100
What are the effects of mag sulfate (good and bad)
It's a CNS depressant so... It provides neuroprotection to the baby to help reduce cerebral palsy risk Reduces contraction and tone (helps baby cook longer) It's a vasodilator, so it can drop BPs (we don't want to drop mom's BP too much, because this can reduce profusion to the baby
101
What are assessments are we doing if mom is on mag sulfate
- BP and RR frequently (remember, it's a CNS depressant) - Continuous EFM - DTRs (don't want these to become too decreased) - LOC (don't want these to become too decreased) - Lung sounds - Urinary output - Watch for late decels (signs of poor placenta perfusion)
102
How do moms feel on mag sulfate
- Groggy - Malaise like when they have the flu - Flushed
103
What if mom's DTRs, LOC and RR is becoming too suppressed on mag sulftate.
We should stop the mag sulfate and consider giving the antidote, calcium gluconate
104
What are newborn considerations for mom's taking mag sulfate
Mag sulfate does cross the placenta, so these babies will also have mag sulfate in their system, and we may see signs of CNS depression, like decreased RR, muscle tone, they'll likely have low APGAR scores
105
Picture: Notice how identical twins are called monochorionic/diamniotic twins because they share the chorion and placenta, but have separate amnion. Twins that are not identical are dichorionic/diamniotic and do not sure a chorion or placenta
106
What are risks for mom's caring multiples 4
- Intrauterine distention - ROM - Pre term labor - Hyperemesis
107
What are some nursing considerations for perinatal loss 3
- There may be more bleeding than usual, which may turn into a DIC event - Infections can occur if membranes have been for some time or if the baby has died a while ago and these things are still inside mom - If Rh-, mom should still have RhoGAM
108
What is an incompetent cervix
Usually where you have dilation and effacement of the cervix when you're not supposed too, which can lead to loss of the baby (usually occurs in 2nd trimester - basically cervix won't stay closed)
109
How can we manage an incompetent cervix
Through a cerclage, where the provider will stitch up the cervix until delivery to help keep baby inside
110
If a woman has an incompetent cervix for one of her pregnancies, is she more likely to have it again for future pregnancies
Yes
111
What are risk factors for ectopic pregnancy (a lot)
Usually things that have caused scarring to the fallopian tube, which is where we see a lot of ectopic pregnancies occur So...: - STIs - PID - Prior ectopic - Hx of abd surgeries - Endometriosis - Hormone therapy - Assisted reproduction - Use of an IUD
112
What are s/s of an ectopic pregnancy 5
- Bleeding - Missed period - Abd pain/tenderness (usually unilateral on the side where the ectopic is in the fallopian tube) - Referred shoulder pain - Pain that worsens with rupture (pretty severe)
113
How can we diagnosis an ectopic pregnancy 5
- Hx (previous ectopic - especially in the same fallopian tube as the previous ectopic, due to the scar tissue, if they still have that tube) - Palpable mass - Ultrasound to see if pregnancy is actually in the utererus - hCG will be low - Going to have hypotension s/s if ruptured
114
What is our management of an ectopic 2
- We can give methotrexate to terminate pregnancy if unruptured and less than 4cm in size - Salpingectomy via laparotomy
115
Is it pretty serious when an ectopic ruptures
YES! There can be massive internal bleeding going on. It definitely becomes an emergency
116
What is gestational trophoblastic disease (also called molar pregnancy or hydatidiform mole)
Basically a woman has a positive pregnancy test, but instead of a baby growing, the placenta develops abnormally and grows fluid filled grape like clusters instead of a baby (basically abnormal tissue growth instead of a baby, even though there was a positive pregnancy test)
117
What are the s/s of gestational trophoblastic disease 4
- There would be a discrepancy in the size of mom's tummy and how far along she is (these fluid filled sacs are going to grow a lot larger, and much faster than a baby would) - Bleeding, possibly passing some of these little fluid filled clusters - Markedly elevated hCG - No fetal HR
118
What are we really worried about with gestational trophoblastic disease? So what do we do? What do we teach out mom's?
These women are at an increased risk of developing cancer So we will measure their hCGs for at least one year, where a rise in hCG may indicate malignancy We advise our moms to not become pregnant for at least one year, because their pregnancy could mask a rise in hCG, which is helping us determine if she may have cancer
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Picture showing how insulin builds up in the first half of pregnancy because a decrease in insulin needs vs second half of pregnancy were we have an increase in insulin needs
We don't need insulin as much in the first half of pregnancy, things like our hormones may be decreasing our need for insulin, as well as maybe we have morning sickness so we're not eating as much, and baby isn't needing very much. An increase in insulin needs can lead to insulin resistance (pancreas is excreting more insulin in second half of pregnancy, but can't keep up with the demand) Think of pregnancy as a stressor, and your pancreas isn't able to keep up with the high demand in the second half of pregnancy
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What if you already have diabetes going into pregnancy
The previous picture still holds true for type 1 and type 2 diabetics, where both may need to actually decrease their insulin in the first half of pregnancy, or may not even need it at all, however, they may need to increase their insulin injections in the second half of pregnancy
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If a mom's diabetes isn't controlled, what can happen?
She can develop: - High BPs - Preeclampsia - Eclampsia - 2 times as likely to experience miscarriage - Poly(hydramnios (excess amount of amniotic fluid, over 2000mLs) (remember that high blood sugars can cause polyuria, where there is excess peeing, so since mom has high blood sugars, so will the baby, so the baby will be urinating a lot in their sac creating more and more amniotic fluid) - this can lead to uterine distention, which can cause problems later on - Ketoacidosis - Retinopathy - Increased risk of infections like UTIs (UTIs can quickly progress to phylo) - Increased risk for developing future diabetes after birth
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What are the effects of uncontrolled diabetes on babies 6
- Macrosomia (excessive birth weight due to high maternal levels of glucose) - The baby can develop hyperinsulinemia, because only mom's glucose crosses the placenta, they don't get mom's insulin (this is why we like to give pregnant diabetic mom's insulin, because the insulin doesn't impact the baby), so babies will actually produce their own insulin, but since they are getting an excessive amount of glucose from mom, they will be producing excessive amount of insulin, which can cause the baby to store glucose in fatty deposits around their chest and shoulder areas. (this increase in babies shoulder and chest can make for challenges during delivery). - Increased risk for respiratory distress syndrome, because hyperinsulinemia can lead to a decrease in surfactant production - Neural tube defects (diabetic moms will need to take an increased amount of folic acid compared to nondiabetic moms to prevent neural tube defects) - After birth, babies will most likely have low blood sugars (this is due to baby's pancreas being use to produce high levels of insulin due to mom's high sugars, so it may take a while for baby's pancreas to stop making so much insulin, so baby's sugar may be low in the meantime) and possible jaundice (so be prepared for this) - Increased risk for developing type 2 diabetes later in life
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When do we start screening for gestational diabetes? Why at this time and not sooner?
Usually at 24-28 weeks, only sooner if high risk. From the previous slides, insulin needs are usually low in the first half of pregnancy, but increase in the second half, so there's not really a point in testing in the first half
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What is the 2 step glucose tolerance check (simply)
Mom drinks a sugary drink, she comes and checks her blood glucose after an hour, if that number is really high, then she has to come back in 3 hours later and if that number is high, then this can confirm gestational diabetes
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What are risk factors for gestational diabetes 5
- Obesity - Family hx of type 2 - Hx of previous gestational diabetes - Hx of LGA infant (large infant, greater than 90th percentile for weight) - Polycystic ovary disease
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Should we increase the insulin mom receives after delivery?
No! It is likely that her insulin needs will decrease after delivery, so we will adjust accordingly
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How can women manage gestational diabetes
- Many can manage through lifestyle and diet changes - Increase folic acid intake to prevent neural defects - Maintain euglycemia (tight glycemic control) - Fasting less than 95 (check fasting in the morning) - 120-135 post-prandial (after eating) - A1C goal is 6 (8 or above shows poorly controlled diabetes) - Insulin is drug of choice (bc it doesn't cross to the baby) - More frequent prenatal visits, especially towards the end of pregnancy were we do nst (non-stress tests) to look at the fetal HR - Mom will have biophysical profiles done, where we do stress tests but also look at HR and ultrasound - Might have an early delivery (especially if baby is getting large, etc)
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Do we use metformin for diabetic moms
Only sometimes, it does cross the placenta, even though it is a category B, many providers will switch mom to insulin to error on the side of caution
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So what additional things are we going to do for a baby whose mom has gestational diabetes
- Kick counts (at home) - Biophysical profile (BPP) - Femur length - Abdominal/head circumference - Nonstress test - Contraction stress test - Amnio for fetal lung maturity - L/S ratio of 2:1 (tells us if baby has adequate surfactant)
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What is included in a biophysical profile BPP? How do we keep track?
We give point values to each item so: - Fetal HR can score up to 2 - Amniotic fluid can score up to 2 - Respiratory movements can score up to 2 - Muscle tone can score up to 2 - Movement of extremities can score up to 2 So there can be a total of 10 points. (a score of 8-10 is normal) (4 below mean deliver asap)
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During delivery, where do we like our mom's blood sugar to be
Between 80-110
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When we hang insulin, what should we also have hanging just incase
Dextrose in case mom goes hypoglycemic
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Once a baby is delivered from a mom with diabetes, what is our newborn management?
- All infants born from diabetic mothers, all LGAs and SGAs will be on glucose protocols Glucose protocols: - Monitor sugars (protocol will tell you what to do depending on where baby's sugar is at) - Use heel stick - Get babies to breast asap - Check baby's sugar 30 minutes after feeding - Want babies eating every 2-3hrs - Can't let babies sleep for long periods of time, because they do need to feet regularly - Protocol usually lasts 24-48hrs
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Once a gestational diabetes mom has her baby, how might her diet change?
She will likely come off her diabetic diet and be placed on a regular diet
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When will a gestational diabetic mom be screened after delivery for diabetes again
Usually 6-12 weeks and then annually, just because gestational diabetes increases their risk of developing type 2 later on
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Is HTN deadly for moms?
Yes, it is the second leading cause of mortality for pregnant women
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What is our definition of HTN
Systolic at or greater than 140 and/or Diastolic at or greater than 90 Pt has to have a BP at or greater than 140/90 at least twice taken 4 hours apart
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What are our 4 categories of HTN
1. Chronic HTN 2. Gestational HTN 3. Preeclampsia/eclampsia 4. Chronic HTN with superimposed preeclampsia
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At how many weeks pregnant would we diagnosis a mom with chronic HTN
Before 20 weeks (so basically in her 1st trimester)
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During pregnancy, is it normal to have our BP increase or decrease
It is actually normal to have our BP decrease, which is why HTN during pregnancy is weird
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What needs to be present to diagnosis a woman with preeclampsia
- Have to have an increase in BP after 20 weeks - Need to either have protein in urine or other s/s of preeclampsia like vision problems, liver problems and/or kidney problems
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What is gestational hypertension
Where we have an increase in BP after 20 weeks, but we don't have proteinuria
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What are the s/s of preeclampsia
- Headache - Visual disturbances - Right upper quadrant pain due to hepatic ischemia - Reduced urine output - Low abd pain (which can be a sign of placenta abruption which is more common in women with preeclampsia) - Pulmonary edema - Peripheral edema - Hyperreflexia
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What is the pathophys of preeclampsia
1. Vasoconstriction leading to HTN 2. Platelet activation with intravascular coagulation 3. Endothelial dysfunction, where fluid shifts out of the vascular system and into the interstitial space 4. Maternal plasma volume contraction
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What can preeclampsia lead to? both mom and baby 4, 3
Mom: - Eclampsia, which is essentially a seizure - Pulmonary edema - Renal failure - Stroke Baby: - Intrauterine growth resistance - Placental abruption - Still birth
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What are risk factors for developing preeclampsia (a lot)
- Hx of preeclampsia - First pregnancy or first pregnancy with a new paternal partner (something to do with dad's antigens) - Family hx of preeclampsia - Pre-existing HTN - Diabetes! (4x risk) - Renal disease - Obesity - Connective tissue disease like lupus and RA - Under 17 or over 35 - Multiples
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How can we diagnosis if a mom has preeclampsia 4
- Look at CBC to see if we see any hemolysis (platelets less than 100,000) - CMP to check for kidney and liver function - Look for protein in urine, gold standard is to measure urine over 24hrs, where anything above 300mg for protein can be a sign of preeclampsia - Checking fetus for any signs of growth restriction
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What is the only way to stop preeclampsia
Deliver the baby
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What if a mom comes in with elevated BP after 20 weeks
We want to determine what kind of HTN it is (gestational HTN or preeclampsia) So we'll do a 24hr urine collection to look for protein, if protein is over 300mg, then we know it's preeclampsia and not just gestational HTN
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Are there diff severities of preeclampsia
Yes, it can range from mild to severe
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If a woman has a hx or family hx of preeclampsia, what might they be prescribed
Aspirin to prevent preeclampsia from developing
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Picture and notes of terrell explaining what is happening in preeclampsia/eclampsia and what she points out as important
1. We have endothelia damage, where little holes are made in blood vessels and leaking fluid into the surrounding tissue 2. Body tries to respond by activating intravascular coagulation to form little clots, but this also uses up our clotting factors (increases risk of DIC) 3. The damage to the endothelia also causes vasospasms 4. Intrauterine growth restriction because blood vessels are working like they should for perfusion 5. Pulmonary edema in lungs due to fluid leaking into this area (remember to listen to lungs) 6. Pulmonary edema is very common especially in face, hands and abd (can be pretty significant) 7. Vasospasms in liver (causes upper right quadrant pain, might also feel like epigastric pain - this is also why we watch liver enzymes) 8. Liver involvement is very serious and it is very very serious pain 9. Vasospasms can also cause headaches (think of downtown abbey) 10. Hyperreflexia can happen so make sure you're checking reflexes 11. Spasms can happen in eyes and cause blurry vision so ask if they have blurred vision.
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What can classify as mild preeclampsia (means we have mild w/o severe features)
- Have a BP at or greater than 140/90 after 20 weeks with 2 readings taken 4 hours apart - Have proteinuria (>300mg in 24 hours) or have involvement of end organs
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How can we manage mild preeclampsia
- Can possibly be managed at home - Pt needs to know what to report to their provider (because we want them to tell us if they have any signs that the preeclampsia is progressing) - Will need to know how to take their BPs - Will need to have frequent trips to provider
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What are signs of severe preeclampsia (means we have severe with features) 8
- BP at or above 160/110 or any of the below: - Platelets <100 - AST/ALT 2x above normal - Severe, persistent RUQ/epigastric pain (like as severe as you can get for pain, worst pain of your life from the microhemorrhages in the liver that are occurring) - Elevated creatinine and protein - Oliguria (<500mL/24hrs) - Pulmonary edema - CNS disturbances (visual, DTRs and/or clonus)
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What is important to remember about DTRs
We need assess DTRs on the pt with the off/oncoming nurses so that we can confirm what, if anything has changed
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What can an increase in our DTS tell us
That the CNS is increasing in excitability, which can increase the risk of seizures developing
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What are signs that the fetus may be in distress from preeclampsia 3
- Changes in HR - Poor variability - Late decels
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What are complications of preeclampsia for mom 11
- Severe HTN - Severe pulmonary edema - MI - ARDS - *Hepatic rupture - Eclampsia (grand mal seizure - can happen post partem as well, remember downtown abbey) - Cerebral edema - Hemorrhage - Acute renal failure - Coagulopathy > HELLP > DIC - Retinal injury
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What nursing assessments are we going to be doing to monitor if preeclampsia is progressing 10
- Checking BPs - Checking DTRs/clonus - Ask about RUQ pain - Ask about headaches - Ask about visual changes - Listen to lungs to assess for pulmonary edema - Look for edema in hands/face - Assess urinary output - Run labs - AST/ALT, platelets, creatinine, protein in urine - Assess fetus using NST or BPP
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Preeclampsia can progress to HELLP and/or eclampsia, what does HELLP stand for?
Hemolysis (hemolytic anemia), elevated liver enzymes (AST/ALT 2x normal) and low platelets (<100)
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What can HELLP progress to?
DIC
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What is the cardinal symptom of HELLP
Upper right quadrant pain
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What is eclampsia
Where arteriolar vasoconstriction occurs and leads to grand mal seizures
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What is the cure for preeclampsia/eclampsia? But what's the catch?
Delivery but eclampsia can still occur post partem
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If preeclampsia is mild, do we need to deliver asap?
No, we can generally let the baby cook for longer and watch mom for signs that the preeclampsia is progressing
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What kinds of outpatient things are we going to do if we are managing a mom's preeclampsia at home 5
- Home BP monitoring - Daily protein testing - Kick counts - NST every 3-4 days for baby - Checking baby's growth using the ultrasound
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What things are we doing inpatient for preeclampsia 2
- Labs - Fetal monitoring
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What is our goal in terms of weeks to get a mom to if she has preeclampsia
37-38 weeks
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What are we going to do if mom develops severe preeclampsia 2
- We're going to try and deliver baby it is older than 34 weeks - If less than 34 weeks, we want to try and hold off on delivery for 48 hours to get betamethasone onboard
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What should we consider if we induce a mom who has severe preeclampsia
We're worried if her BP can handle the induction (like can she handle the labor pains, and everything that comes with a vaginal birth)
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So what is our tx if we are having mom's wait to get betamethasone onboard if less than 34 weeks 9
- Have them on bedrest with bathroom privileges - Minimize stimulation (lights dim, nice, and calm) - Have NICU provider/nurse come in and educate mom on what will be happening - Have them on magnesium sulfate to prevent clonus/seizures - May have on antihypertensives like labetalol or hydralazine - Strict Is and Os - Daily weights - Check DTRs - Check vital signs
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When would we just give a dose of betamethasone and deliver asap (without waiting the 38 hours) 8
If we see one of the following: - Uncontrollable severe HTN - Eclampsia - Liver rupture - Pulmonary edema - Placenta abruption - DIC - Evidence of category III fetal status - Fetal demise
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What is a good way to think of mag sulfate
Remember that mag sulfate completes with calcium, where calcium is trying to excite things and cause contraction, versus mag, which is trying to relax things
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What is a big risk with mag sulfate
You can give too much and cause respiratory depression
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What is our standard dose of mag sulfate
4-6g bolus, followed by 2g/hr IV (remember this is high risk - so it's a dual RN sign off)
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When we give mag sulfate, what should we have ready in the room and by ready/assessing for? a lot
- Oxygen via a simple mask - Suction available - Eclampsia kit nearby - Still assess for preeclampsia progression - Check BP to make sure we're not dropping it too low - Check DTRs to make sure we're not losing DTRs (if we see a decrease or absent DTRs we need to stop the mag) - Continuous fetal monitoring - Can cause issues when trying to induce mom because it's fighting against induction (might need additional doses of prostaglandins or Pitocin - can be very difficult to get a mom on mag to go into labor) - Mag does cross the placenta, so the same things it can do to mom it can do to baby like decrease tone, decrease respiratory drive, we would see lower APGARs - Mag sulfate can cause issues with having uterus clamp down after delivery (might need to give extra fundal massage and extra Pitocin, have hemorrhage medications ready to use)
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Can we stop magnesium as soon as baby is born?
No, generally we want to keep mom on it for 24 hours because she is still at risk for eclampsia after delivery
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What is the therapeutic range of mag sulfate
5-8 mg/dL
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What is a normal number for a reflex? What about hyperreflexia or hyporeflexia
Normal = +2 +3 or +4 = hyper +1 or 0 = sluggish or no response
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What might be signs of mag toxicity
- Pt reports metallic taste in mouth - Feel very fatigued - Sweating - Hypotension - Depressed/absent reflexes - Depressed respiratory
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Before giving mag sulfate, what do we need to make sure we have available
Calcium gluconate
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How long is a mom at risk for developing preeclampsia after birth
6 weeks (so make sure we're teaching the warning signs)
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If a woman wants to have an elective delivery, at how many weeks should they do this?
Want them to have elective if baby is beyond 39 weeks (even though they're considered full term technically at 37 weeks, we want them to be beyond 39 weeks)
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What should baby's HR be
110-160
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Why might a fetus be in bradycardia 4
- Mom is in the supine position (laying flat - why we don't want mom laying flat) - Mom could have hypotension - Mom could be on an adrenergic-receptor blocking drug like Propranolol - Mom could be on anesthetics
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Why might a fetus be in tachycardia 5
- *Maternal fever and infection - Increase in fluid volume - Mom could have hyperthyroidism - Mom could have anxiety - After mom has smoked since nicotine is a stimulant
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Why might a fetus be in tachycardia 4
- *Maternal fever and infection - Increase in fluid volume - Mom could have hyperthyroidism - Mom could have anxiety - After mom has smoked since nicotine is a stimulant
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What is the number one indicator that a fetus is getting well oxygenated and is not in acidosis
We see moderate variability changes in their HR, usually changes from 5-25 BMP.
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Why might we see a decrease in variability (basically HR is unchanged)
- Could be that baby is in their sleep cycle, which usually lasts for about 20 minutes. but.... - If it's been over 20 minutes and the baby's HR is still unchanged, then it could be a sign of hypoxia or acidosis
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Besides a fetus being in a sleep cycle, what else might cause decreased variability
- Mom could be on fentanyl for pain - Mom could be on mag sulfate
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Do we like to see accelerations
Yes, they can tell us that the baby is well oxygenated
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Do we want to see many decelerations
No - usually means something is wrong (remember veal chop)
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What are the categories for FHRs
1. Category 1: everything is good. We have moderate variability and some accels. (no decels happening) 2. Category 2: Everything in between. We're continuously monitoring, we're trying different interventions to see if we can improve things. Remember POISON. 3. Category 3: Very concerning - indicate a need for immediate delivery. Example - absent variability, flat line HR, with recurrent decelerations (these are all signs of acidosis). Could have bradycardia, huge decel, even down to 60 and it stays down there for 10 minutes (indicates an immediate delivery).
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Are early decels normal/ok?
Yes, they happen right when mom has a contraction, and indicate that the head is being compressed, which is usually because the baby is advancing down the canal
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Are late decels ok?
No, late are the worst type of decels. It means that the placenta is unable to perfuse baby (not enough reserves etc)
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Are variable decels ok?
Not good, but not as bad as late. Only really bad if they keep occurring, ok from time to time. Means that there is some cord compression. These look "V" shaped on the monitor.
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What acronym can we use for intrauterine resuscitation? What does it stand for?
POISON P - position change O - oxygen I - IV fluids S - sterile vaginal exam O - oxytocin OFF N - notify
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What are the 4 P's in labor?
- Power of contractions - Passenger (size of baby) - Passageway (positioning of baby coming out) - Psyche
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What is a normal amount of contractions in 10 minutes? What is considered hypotonic contractions?
Normal: 4-5 contractions in 10 minutes Hypotonic: less than 2-3 contractions in 10 minutes
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What may cause hypotonic contractions 2
- Overdistended uterus (like with multiples, polyhydramnios) - Presenting part is not being well applied (like if baby's head is not being applied to mom's cervix, then it's not going to help stimulate good contractions)
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If mom is having hypotonic contractions, what things can we do to help increase her contractions 3
- Have mom try to walk/change positions - AROM (artificial rupture of membranes) (helps augment labor to get contractions going) - Start oxytocin to help augment labor
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What is the risk with oxytocin
We can cause tachysystolic labor, where we're having more than 5 contractions in 10 minutes averaged over 30 minutes
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How do we administer oxytocin
- It's a dual RN sign off because it is a very high risk med - Start very low with 2 miliunits every hour - Then increase every 30 minutes until we get to a desired labor pattern, where we're having contractions every 2-3 minutes
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Why is tachysystolic labor bad for a baby?
We don't want contractions too close together, because we want time for that placenta to perfuse and establish reserves, because remember when mom is having a contraction, the placenta is using reserves to perfuse the baby, but if her contractions are happening too close together, than she doesn't have enough time to build up these reserves in-between contractions
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What do we do if mom goes into tachysystolic labor 4
- Stop oxytocin - Want to promote relaxation - Treat mom's pain due to having so many contractions (which can also help relax the uterus) - Terbutaline giving SQ helps relax the uterus (remember that it does increase maternal HR)
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What is the purpose of artificially rupturing membranes
We do when we want to help labor progress because when we rupture the membranes it will remove the fluid that may be separating the baby's head from the cervix, so now if that fluid is gone baby's head will make contact and apply pressure to the cervix which can help the cervix start to have meaningful contractions
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What should we make sure is going on during artificial rupture of membranes? 4
- Have to have fetal HR monitoring going on before, during and 20 minutes after the procedure so we can see how baby is tolerating the change in environment (aka loss of fluid) - Let mom know that there shouldn't be any pain, it will just be discomfort like with any cervical exam - "start the clock" when the rupture occurs, because we want to deliver baby within 24hrs from this time - Document amount and color of fluid, may have meconium in it
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Is a cord prolapse pretty rare
Yes, it's very rare
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What are major risk factors for a cord prolapse
When the baby's head is not applied correctly in the cervix, which leaves room for the baby's cord to fall out before delivery - High station of baby - Small fetus - Breech presentation - Transverse lie - Polyhydramnios
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Is it more common to see a cord prolapse in a spontaneous or artificial ROM?
Artificial
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What are the two classes of cord prolapse
- Occult: hidden, we can't really see that it is occurring - Complete: where we can see that cord
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Why is a cord prolapse an emergency
Because if the cord is coming first in front of the baby's head, then when the baby's head makes contact with the cervix, it's going to be a tight fit, so this can cut off the cord blood supply to the baby
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What is a sign on the FHR monitor that there may be a cord prolase
We see a major, prolonged decels and bradycardia
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How can we prevent a cord prolapse
Make sure baby's head is well applied before rupturing any membranes
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How can we cure a cord prolapse
Stat C-section
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If you have a cord prolapse and you're waiting for a C-section, what can we do as nurses/providers 2
- Want to relieve pressure off the cord - Provider will use two fingers to try and push baby's head up and off that cord without touching the cord, because touching it can cause vasospasms
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What can cause cord compression 2
- Position of mom - Decreased amniotic fluid, like from ROM
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What is a sign of cord compression
We have variable decels with every contraction
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What is our tx for cord compression 2
- Have mom change positions - Amnioinfusion
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What is amnioinfusion? Why would it be done?
We insert sterile saline or LR into the uterine cavity via an IUPC (intrauterine pressure catheter) May be done to treat repetitive variables due to low amniotic fluid volume
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What should we know about amnioinfusion 6
- Fluid should be warmed before instilling - Watch our intrauterine pressure so we don't put too much fluid in - Make sure uterine tone stays consistent - Changing pad and chucks frequently, continuous fluid will be leaking - Watch for improvement in baby's FHR and wanting variables to stop - Have infection on your mind (frequent temp checks, very 2hrs first and then moving to every 1hr)
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What is chorioamnionitis
Intrauterine infection of membranes and/or fluid
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What usually causes chorioamnionitis
Usually an ascending microbe from the GU system that climbs up in there
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Do women who have rupture membranes only get chorioamnionitis
No, you can still get chorioamnionitis even if your membranes aren't ruptured, but it is more common in women who have ruptured membranes
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When does the risk for chorioamnionitis increase if you have ROM
At 12, 18 and 24hrs
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What are increased risks of chorioamnionitis 3
- Increased vaginal exams - GBS that is untreated - Internal monitors (like with amnioinfusion)
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What are the s/s of chorioamnionitis 4
- Increased maternal HR and temp - Increased fetal HR is often the first thing we see - Fundal tenderness - Foul odor of fluid is usually a later sign
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What is our tx for chorioamnionitis
Abx for mom
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What is shoulder dystocia
When the head gets delivered but the shoulders are stuck
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Is shoulder dystocia an emergency? Why or why not?
Yes, because if the baby is trapped in the birth canal it can cause irreversible brain and organ damage after 6 minutes
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What should we do when we see the head delivered as nurses?
Mark the time, because we want to make sure that the rest of the baby is delivered pretty quickly and is not stuck like with shoulder dystocia. If a baby's heads delivered but not the baby within 1 minute or more, then it is considered a shoulder dystocia.
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What are risk factors for shoulder dystocia 7
- Increased birth weight - Gestational diabetes (chest is the largest part) - Obesity - Size discrepancy between the parents (small mom and big dad) - Use of vacuum or forceps (since you had such trouble delivering the head, are we going to have enough space to deliver the shoulders?) - Prolonged second stage (pushing, like for 2 hours for a primi or 1 hour for a multi, might cause us to think that since it is taking so long to push that maybe this baby isn't the right size to come out) - Previous hx of shoulder dystocia
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What is interesting to note about shoulder dystocias
That most occur in average size babys
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What team do we want to have on standby when we know we have a shoulder dystocia
OR
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Besides having an OR ready for a shoulder dystocia, what else do we want to have ready?
A stool
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What is our management for shoulder dystocias 6
- Make sure mom has an empty bladder (sometimes foley is removed if they have an epidural to create more space) (we can straight cath a pt if needed) - Providing firm pressure under mom's buttocks - NICU should be present and resuscitation equipment must be present and ready - Position mom (lower the HOB down, pull legs) - Have 10L of oxygen on - Make a change in approach to delivery every 30 seconds (try different maneuvers)
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What is the first maneuver that we do? What are we doing?
Mc Roberts maneurver 1. Lower HOB 2. Bring knees apart and to her shoulders (moving her legs back really opens the pelvis) 3. Perform suprapubic pressure as directed
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What is the wood screw maneuver
Where the provider tries to rotate the baby around and deliver the other shoulder
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What is the Gaskin technique
Have mom on her hands and knees to help change position of baby
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What is the symphysiotomy
The ligaments of the symphysis are cut, which can add an extra 2-3 inches to the maternal pelvis
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What is the Zavanelli
Baby's head is pushed back in and the baby is delivered via c-section
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What are two injuries that can happen to a newborn if there is dystocia
Brachial plexus or fractured clavicle injury
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How would we know if the baby has a broken clavicle
When you assess the clavicle you're going to feel crepitus (snap/crackle of air)
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What has happened in a brachial plexus injury
There is either bruising, stretching, avulsion (forcible detachment) of the nerve networks C5 to T1
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Can a brachial plexus injury vary in severity
Yes, it could just be temporary palsy to flaccid, or it could lead to serious damage, where the newborn is unable to move the shoulder
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What reflex could you test to see if there is a brachial plexus injury
The moro reflex, where you startle the baby to see if they pull their arms out and up to their chest (if there is a brachial plexus injury, they won't be able to move the affected arm because of the shoulder injury)
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What is a major complication of shoulder dystocia for the newborn
Erb's palsy, which is where the newborn doesn't have any movement in their affected arm
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What is needed in order to use a vacuum or forceps
- Membranes need to be ruptured - Mom needs to be fully dilated
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Why would we use a vacuum or froceps
- To help with the "power", which is one of our 4 P's, where mom is getting tired and her pushes aren't as strong anymore, a vacuum or forceps can help her to get the baby out - And baby is starting to go into distress
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What are newborn considerations if we're using a vacuum or forceps (a lot)
- May increase the risk for shoulder dystocia - Lacerations/nerve damage to the baby - Vacuum can cause cephala hematomas - Going to be more swelling/trauma to head - Does swelling cross the sutures? (if it doesn't cross sutures, we worry about blood loss) - Monitor VS - Monitor head circumference of baby (should be getting smaller, not bigger) - Do our neuro assessments on baby's (sucking reflex, apply pressure to rough of baby's mouth) (If baby isn't sucking, this could be a sign of neuro damage) - Forceps can cause more tissue damage on mom, which can lead to hematomas - Mom would usually have an episiotomy so we can make space
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What is anaphylactoid syndrome
Where amniotic fluid enters the mom's blood stream and gets carried into the lungs, basically it becomes a blood clot
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Besides causing a blood clot, what can anaphylactoid syndrome lead to
- Circulatory failure - Respiratory failure - DIC can occur due to the amniotic fluid interferring with clotting
254
What are signs of anaphylactoid syndrome
- Acute drop in BP - Cardiac arrest - Cough - Chest pain - Think about PE symptoms
255
How do we treat anaphylactoid syndrome
We treat it like a code - CPR - Oxygen with ventilation - Fluid volume expansion - Vasopressors - Packed cells - FFP - Fibrinogen
256
If mom is on ventilation, how should we position her
Uterine tilt, so she's not completely on her back
257
What is a TOLAC (Trial of labor after caesarean also called a VBAC (vaginal birth after caesarean))
When we let a woman who had a previous c-section try to have a vaginal birth with her next child, because the reason she had a c-section may not necessarily happen again, like say her previous baby was a breach, so that's why they had a do a c-section, well that doesn't mean her next baby is going to be breach, so try and do a vaginal birth (her body was still able to physically have a baby, it's just that the baby was upside, or maybe she had a cord prolapse)
258
What are the 2 risks with TOLAC
- Needing a c-section anyways - Uterine rupture due to the previous incision site
259
Who is eligible for TOLAC 4
- Hx of only one previous low-transverse c-section - Adequate pelvis in relation to fetal size - No other uterine scars, anomalies or previous ruptures - Physician is always available throughout active labor
260
How do we manage our TOLAC mothers 3
- Have them on high-risk - Continuous fetal monitoring - Plan as if they're going to have a c-section (have consents signed, have hair clipped and removed from area)
261
What is a uterine rupture
An actual rupture of the uterine muscle
262
What are we concerned about with a uterine rupture 3
- Concerned about BLEEDING - Hypovolemic shock for mom - Poor fetal perfusion for baby
263
What are s/s of uterine rupture 5
- Sudden, sharp abdominal pain with a contraction (may stop when contraction stops) - When you palpate mom's abdomen you might be able to feel fetal parts - Sudden drop in fetal HR (bradycardia) - Might have loss of strong contractions - Might have loss of station (think about it - if you have that rupture of the uterine muscle, the baby might just float back up to the abdominal cavity)
264
What is our management of a uterine rupture 3
- EMERGENCY - STAT C-section - Might have a hysterectomy if completely rupture (difficult to repair)
265
What is twin transfusion
When twins are sharing a placenta, but one twin isn't getting as much perfusion/fluid as the other twin, and the other twin is getting too much perfusion/fluid
266
What is the issue with twin transfusion, besides one baby not getting enough perfusion/fluid
The baby that is getting too much fluid can be at an increased risk of HF
267
What can we do to monitor for twin transfusion
Use a doppler to see if the perfusion/fluid is being evenly distributed between the twins
268
What are increased risks if you're having multiples 8
- Pre-term labor (due to the increase in pressure) - Preeclampsia - Gestational diabetes - Placental masks - Hyperemesis - Placenta previa (if more than one placenta) - Abnormal presentation - Cord prolapse
269
When we're checking FHR for multiples, what do we want to do
We want to be checking for all of the baby's HRs at the same time (don't do one at a time, because you wouldn't be able to determine which HR belongs to which baby)
270
What type of delivery do we automatically do if a mom is having 3 or more babies
C-section (too difficult to deliver all of the baby's vaginally without complications)
271
What should we encourage our mother's to get if they are having twins and trying a vaginal birth
We want to encourage them to get an epidural, just to help with the pain in case we need to have extra assistance (like forceps or a vacuum, etc) during the delivery, since they will be doing double the work, or if we need to end up having a c-section
272
What is our birth time for twins born vaginally or via c-section
Vaginally - usually 15 minutes apart C-section - usually 1 minute apart
273
Where do we like mom's who are attempting a vaginal birth with twins to deliver
We like them to deliver in the OR, just in case
274
After delivery, what are we worried about if mom has given birth to multiples
Post-partem hemorrhage, they are at an increased risk as their uterine muscle was stretched larger, so we may have difficulty getting it to clamp down
275
How much blood loss is considered postpartum hemorrhage
Quantitative blood loss (QBL) is 1000 mL
276
What is primary PP hemorrhage
Within the first 24hrs after delivery
277
What is secondary PP hemorrhage
after that 24hrs and up to 12 weeks
278
What are the 4 different causes of PP hemorrhage
1. Tone (most common issue) 2. Trauma 3. Tissue 4. Thrombin (very rare) (see the table on pg 420)
279
How can we prepare for a primary PPH 5
- Drills - PPH Kit - Admission record - showing religious or cultural considerations (want to know if they will accept blood products if needed) - If they have a hx of PPH it gives them a 10% risk of having it happen again (so make sure everything is ready to go) - Everyone gets a CBC and type and screen on admission
280
What is a big red flag that a mom might have PPH after her delivery
If she had a previous PPH with her other pregnancies
281
How can we manage PPH
- Address the cause (ie tone - give fundal massage) - Make sure you do frequent fundal massages after delivery (midline at the umbilicus, or a finger or two above or below) - Assess lochia every time we do a fundal massage (how much blood is coming out) - Maternal VS (not going to show us early changes, because women have things that buffer signs and symptoms of blood loss initially due to the pregnancy) (fyi - baby's HR, then mom's HR, then mom's BP will be signs of hemorrhage in this order) - Quantitative blood loss - make sure we measure everything (1gram = 1 mL)
282
What are the risk factors of Primary PPH
- Overdistended or exhausted uterus (LGA babies, polyhydramnios, multiples, multify (+5 babies) (uterus is soo stretched it has difficult getting back to original size) - Infection (infected uterus isn't going to contract effectively) - Anatomical/functional issues (full bladder - fundus will be off to the side if bladder is full, Pitocin over a long period of time, if we give more Pitocin it isn't going to do anything)
283
What do we do for uterine atony
- #1 start vigorous fundal massage - Bi-manual exam (provider does this) - Empty bladder if we need to
284
What medications can we give for uterine atony
- #1 Pitocin (usually already hanging and ready to go as it is standard to give to everyone after delivery, if PPH starts, will probably need to titrate up) - Then give Misprostol (Ctyotec) (Can we given rectally) - Methylergonovine maleate (Methergine) (Give IM) - Prostaglandins (Hemabate) (Give IM)
285
What is the contraindication of Methergine
If they have hypertension (because it causes hypertension)
286
What is the contraindication of Hemabate
Asthma
287
WHat is an unpleasant side effect of Hemabata, and which is why it is given last
Awful diarrhea (makes it difficult to measure blood loss)
288
What is another medication that is not as common for PPH, but is starting to be given more? And what does it do?
Tranexamic acid - helps prevent breakdown of clots
289
What is the Bakri balloon
Balloon that is inserted into the uterus, and is filled with 500-1,0000 MLs of saline, this helps put manual pressure where the placenta was attached to help clots form
290
When we do a fundal assessment on a pt who has a Bakri Balloon, what will it feel like?
It was be hard, above the umbilicus (don't want to disturb it, because we don't want it to rupture)
291
What can cause trauma for primary PPH 3
- Lacerations (we will see a red trickle stream of blood) - Hematomas - Uterine inversion
292
What would be a symptom of a hematoma
Very, very painful where the hematoma is forming
293
How can we treat a hematoma
We might drain it or we might let is reabsorb overtime
294
How does a uterine inversion happen
- Providers may put too much pressure on the cord when trying to get the placenta out - this can cause the uterus to go inside down and invert - If we don't put our hand below the uterus when doing a fundal massage we could invert it
295
How can we management a uterine inversion 5
- Manually reducing the uterus (putting it back in the right spot - might need anesthesia for this) - Tocolytics - Terbutaline - Fluid bolus if issue with volume - Possible transfusion
296
Besides bleeding, what else is a complication of uterine inversion
Infection because you have the uterus coming out of the body
297
What can cause tissue issues for primary PPH 2
- Retained products (like little membranes, pieces of placenta (this is why we check the placenta after birth to see it it's still in tack) - Abnormal placentation
298
What is a risk factor for PPH related to tissue
placenta accreta (where the placenta has grown into the uterine wall)
299
What syndrome did we learn about earlier that can cause thrombin issues for PPH
Anaphylactoid Syndrome (amniotic fluid embolism)
300
What is our standard postpartum care
- Assess vital signs, uterine position and uterine bleeding every 5min x for the first 15min, then every 15 minutes for the first hour, then Q30min x 2, then Q1 x4 - Promote breastfeeding (helps stimulate contractions to prevent hemorrhage)
301
Are a change in mother's VS an early or late sign of PPH
Late - a change in mom's VS are late signs of PPHs
302
What are causes of secondary PPH 3
- #1 cause is retained products - Uterine infection (causes an increase risk of bleeding - want to teach mom to be clean down there and good peri care so we can reduce risk of infection) - Coag defects like Von Willebrand
303
When would we give blood?
If hemoglobin is less an 7 or they're symptomatic of blood loss
304
What is endometritis
Infection of the uterus (it's like chorioamnionitis, but now the membranes are gone because the baby has been delivered)
305
What are s/s of endometritis 5
- *Pelvic pain - Increase in lochia - Foul smelling lochia - Fever - Increased HR
306
What are s/s of mastitis
- *Unilateral symptoms and more localized - Going to be a red, hard wedge shape towards the armpits - Breast tenderness - Pain/burning with or without breastfeeding - Malaise - Temp
307
What is our tx for mastitis 3
- Oral abx - Continue to breastfeed - Apply hot packs if needed
308
309
What is a key with mastitis symptoms
A woman may think that they have mastitis when their milk comes in because when your milk comes in it can cause tenderness and warmth, but this occurs in both breasts (bilaterally), whereas mastitis symptoms happen in only one breast (unilateral)
310
All women are at risk for PP depression, but which women may be at higher risk for it
Primagravida History of depression Medical complications Immaturity and/or low self-esteem Dysfunctional personal relationship Financial concerns Chronic stress Infant with illness or anomalies Isolation/lack of support Uncertainty about the pregnancy that lasts beyond the first trimester
311
How is PPD different from the "baby blues"
With the baby blues, symptoms will disappear without medication tx, they usually occur within the first 2 weeks of postpartum, and mom is still able to safely handle the baby. With PPD, symptoms require medical tx, they usually occur within the first 12 months, and they are unable to safely care for the baby.
312
What are symptoms of the "baby blues"
- Fatigue - Anxiety - Tearfulness - Mood swings (a lot has to do with changes in hormones) (mom is still able to care for themselves and baby)
313
Is it normal for baby blues to last over 2 weeks
No, that's not normal
314
What are the s/s of PPD? (a lot)
- Depression - Apathy (not caring) (big red flag - not caring about the baby) - Anxiety - Panic attacks - Fatigue - Significant weight loss or gain - Insomnia or hypersomnia - Feelings of worthless or guilt - Decreased ability to concentrate - Inability to make decisions (fyi - these s/s need to last longer than 2 weeks)
315
Besides the mom, who should we teach PPD symptoms to, basically what to look for as signs of PPD
We want to teach the SO, because usually pts with PPD do not identify themselves, so we want the SO to watch for signs and symptoms
316
What is our tx for PPD 3
- SSRIs (Paroxetine, Fluoxetin, Setraline) - Complimentary therapies - Lots of support
317
If a woman has PPD depression, is she at risk of developing it again with any future pregnancies? If so, what might a provider do?
Yes - she has a 50-90% chance of having PPD again with any future pregnancies Provider might preemptively start her on SSRIs
318
What can PPD lead to if untreated or unresolved
It can lead to PP Psychosis (this is where women try to kill the baby and go crazy)
319
What are s/s of PP psychosis
- Paranoia - Gradiose, bizarre delusions (usually about the baby) - Mood swings - Confused thinking - Anxiety - Panic (very dramatic changes from normal)
320
What is the timeline of PP Psychosis
- First peak in first 10 days - Second peak in 6-8
321
How do we treat PP Psychosis
As a true emergency, because these are usually the moms that kill their babies - They'll go on long-term psychotherapy and medication
322
What is the leading cause of neonatal sepsis
GBS
323
When do we screen mom for GBS
All women are screened between 35-37 weeks
324
What do we give to treat GBS for our moms? When do we give it? Will this cure their GBS?
Ampicillin/Clindamycin Give within 4 hours of delivery Doesn't cure it - only working during labor and then the GBS will eventually grow back
325
What typically causes Chorioamnionitis? What are other risk factors?
Typically caused by ascending polymicrobial infection after membranes have been ruptured Prolonged ROM Prolonged labor Nulliparity Internal monitoring Multiple VE (vaginal exams) Meconium-stained amniotic fluid Smoking Drug or alcohol abuse Immune compromised Bacterial vaginosis Group Beta Strep colonization STDs
326
What is a big issue with infection while pregnant and after pregnant
Can cause the uterus to not function correctly, leading to dysfunctional contractions during delivery and after - which increases risk for PPH
327
What are risk factors for newborn sepsis 6
- Preterm delivery - Prolonged labor - ROM greater than 18 hours - Maternal fever - *Chorioamnionitis (infection of the uterus and amniotic sac) - *Maternal GBS
328
How might infants present their symptoms if they have an infection
They may be asymptomatic at first
329
What is the first symptom indicator that a baby may have sepsis
We see behavioral changes in the baby
330
What are s/s of sepsis in newborns 4
First s/s can be very subtle (why we like to have the same nurses assigned to them so we can notice the changes) - May be hyper or hypothermic - Lethargic - Hypoglycemic - Poor feeding
331
How can we tell if a baby is hypoglycemic if we're not checking the sugars 4
- High pitched cry - Low temp - Decreased tone - Poor feeding
332
How can we diagnosis a baby if we think they may have sepsis 4
- CBC - C-reactive protein (CRP) - Platelets - Blood culture
333
How do we treat newborn sepsis
- Start on ampicillin and Gentamycin until cultures come back after 48hrs (broad spectrum and to narrow once cultures come back)
334
What type of Rh are we worried about for mom and baby
If mom is Rh- and if baby is Rh+
335
What do we give our Rh- moms
RhoGAM at 28 weeks even though we don't know if baby is Rh+, and not she may receive it again within 72hrs after delivery and after we test baby, if baby is actually Rh+
336
What is the issue with Rh incompatibility
If an Rh- mom is exposed to an Rh+ baby, then antigens are created by baby and transferred into mom's bloodstream, where the first child is usually not affected, but the antigens can destroy fetal RBCs and cause anemia in the second child
337
What specific blood types are we also worried about?
If mom has type O blood, but has a fetus with A or B = mom's antibodies (anti A and anti B) will attack baby's RBCs
338
What does a positive Coombs test tell us? What are baby's who have a positive Coombs test at risk for?
Tells us that there was a mixing of mom and baby's blood, because it detects antibodies that may not have been compatible and baby is at risk for hyperbilirubinemia (aka jaundice)
339
What is our management for baby's with hyperbilirubinemia 2
- Frequent feedings, because bilirubin is excreted in the stool, so we want frequent feedings to keep things moving through their digestive tract. - Might need bilirubin lights (helps breakup bilirubin)
340
What does IDM stand for
Infant of diabetic mothers
341
What are SGA and IUGRs at risk for 4
- Hypothermia (don't have reserve adipose tissue and brown fat) - Hypoglycemia - Infection - Hyperbilirubinemia
342
What are LGA and IDM baby's at risk for 4
- Hypoglycemia - Nutritional deficits (low mag and calcium levels and low glucose) - Hyperbilirubinemia - Transient tachypneic (respiratory distress) of newborn due to surfactant production (too much insulin when in utero can decrease surfactant production)
343
What are risk factors that can cause preterm labor 6
- Infection - Previous preterm labor hx - Multiples - Polyhydramnios - Preeclampsia - Gestational diabetes
344
What are our diagnostic tests for preterm labor 3
- FFN (the diva test) - Cervical length - UA
345
What is our tx of PTL 2
- Tocolytics (these stop contractions) (mag sulfate, Nifendine, another one, and Tubutaline (remember HR)) - Give betamethasone
346
What impact does mag have on mom
- CNS depression - Relaxes uterus - Causes vasodilation (lowers BP)
347
What impact can mag sulate have on baby when born
- Decrease in RR - Decrease in Tone - Minimal variability on FHR monitor
348
What are our preterm baby's at risk for 5
- Hypoglycemia - Hypothermia - RDS (due to decrease surfactant) - Jaundice - IVH (intraventricular hemorrhage - trauma to head from vaginal birth)
349
What are the s/s of RDS in baby's
- Increase RR >60 - Retractions - Cyanosis - Decreased breath sounds
350
What is our tx of RDS in baby's
- CPAP - Surfactant via ET
351
At how many weeks do we see a decrease in placenta perfusion for long pregnancies
42 weeks
352
What are post-term babies at risk for 6
- Meconium aspiration - Dry, flaky skin (decrease in vernum) - Oligohydramnios with risk of cord compression - Still birth (due to placenta issues) - Dystocia's - Assisted births
353
What is our tx for post-term pregnancies
- Try to induce at 41 weeks - Manage baby with frequent nonstress tests and biophysical profiles
354
What baby's are at risk for Meconium aspiration syndrome (MAS)
- Post-term baby's - Baby is under stress or something traumatic
355
Is MAS common?
Yes MAS is pretty common, but it is very uncommon for it to actually cause any complications
356
Why might meconium aspiration syndrome (MAS) occur
If the baby has some kind of stress, like a moment of poor perfusion that causes them to poop and then they have a "shock moment" where they take a breath and then breathe in that meconium
357
What is our tx for MAS 6
- Suctioning if baby is not vigorous - Possible ventilation - Monitor for infection - Might need some surfactant - Might need prophylactic abxs - Have a team in the room ready in case something happens
358
Diffuse swelling is normal after delivery (cone head babys) - Cephlahematoma (collection of blood that doesn't cross the sutures - monitor head circumferance to make sure it doesn't grow, make sure there isn't a subdural hematoma, blood should just absorb back)
359
Types of substances that we can use a neonatal abstience score sheet
- Heroin - Methadone - Pain meds
360
What are signs of suspeicison of use
- No neonatal visitis
361
What is the name of our abstience tool
Modified Finnegan Neonatal abstinence Score Sheet
362
What are s/s of NAS
- Excessive high pitch cry - Decreased sleep - Hyperactive moro reflex - Tremors - Sweating - INcreased temp - Elevated RR (everything is upwhen they're withdrawaing)
363
What is our diagnostic testing for baby
- Do a tox screen after they're born
364
How can we treat NAS (a lot)
- High-calorie formula - Small frequent feedings - Antidiarrhea - Meticulous I/Os - Wts - Skin care with barrier ointments - Breastfeeding if not CI - Morphine/methadone as needed - Collaborate with SS - Promote comfort - Tox screen
365
Diabetes 171
Risk factors: - Obesity - Family hx of diabetes - A lot of time no risk factors for pts Maternal risks for mom with diabetes: - DKA - Infections - Preeclampsia - C-section - Difficult delivery if baby is big - Increased risk of developing type 2 later on Neontal risk - Hypoglycemia - Macrosomia - IUGR when blood vessels on the placenta are damaged - Respiratory distress due to decrease in surfactant production - SHoulder dystocia (these baby's can have broader chests)
366
What are goals/management of diabetes
- Euglycemia
367
What should diabetic mom's increase in their diet
Folic acid
368
How do insulin needs change depending on where they are at in pregnancy
1st half: less insulin 2nd half: more insulin PP: less insulin
369
Pg 172 preeclampsia
Widespread vasospasm and endothelial damage
370
Placental dysfunction can occur causing what in preeclampsia:
- IUGR - Late decels once contractions start (not good placenta reserve)
371
What are our assessments and diagnostics for preeclampsia
- Headaches - Spots in vision - Upper right quadrant pain - Edema - Urinary output (kidney function) - Reflexes
372
Tx for preeclampsia
- Delivery - Give mag for seizures - Calm, mellow, dark room - Bed rest, but can still use the bathroom
373
Tx for preeclampsia
- Delivery - Give mag for seizures - Calm, mellow, dark room - Bed rest, but can still use the bathroom
374
How is PPD different from the "baby blues"
With the baby blues, symptoms will disappear without medication tx, they usually occur within the first 2 weeks of postpartum, and mom is still able to safely handle the baby. With PPD, symptoms require medical tx, they usually occur within the first 12 months, and they are unable to safely care for the baby.
202A
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