Ob Antepartum Complications For Nursing

Front 1

What does antepartum mean?

Back 1

The period between conception and labor.

Front 2

What are the major issues or complications to worry about during the antepartum period?

Back 2

Hemorrhage and infection

Front 3

How does age affect complications in the antepartum period?

Back 3

21-35 yrs = optimal time for pregnancies
under 21 yrs = HTN and nutritional problems
over 35 years = Downs syndrome and HTN

Front 4

What type of infections are there to worry about during pregnancy?

Back 4

STD, TORCH, Beta Strep

Front 5

What is TORCH?

Back 5

Group of infections that can cause birth defects.
T = Toxoplasmmosis
O = Other infections (Hep B, Syphillis, Herpes Zoster)
R = Rubella
C = Cytomegalovirus
H = Herpes Simplex Virus

Front 6

What effects can infections have on a pregnant woman?

Back 6

Sepsis to mother, PROM, Sepsis to neonate (high mortality rate)

Front 7

What is hyperemesis Gravidarum?

Back 7

Excessive vomiting in the first trimester (but mostly seen after the 1st trimester) that leads to dehydration, alkalosis, starvation and ultimately death of the mother and fetus.

Front 8

What is the treatment for hyperemesis gravidarum?

Back 8

Hospitalize, NPO, V Hydration, Gradual diet – Clear, full, soft, regular, TPN if necessary (central line)

Front 9

What are the nursing responsibilities for a patient with hyperemesis gravidarum?

Back 9

Strict I/O, emotional support.

Front 10

What is a hydatidiform mole?

Back 10

An abnormal formation of the placenta into fluid filled, grape-like clusters. Gestational trophoblastic disease (a molar disease – fetus does not develop but the placenta continues to grow, sometimes as a mass of abnormal cells). This does not mean that the pt has cancer and the pt may be able to have a normal baby in the future.

Front 11

What are the signs and symptoms of hydatidiform mole?

Back 11

Passage of hydropic vesicles – grapelike looking structure.

Uterine enlargement greater than expected gestational age.

Absence of fetal heart tones –because there is no fetus.

Hyperemesis gravidarum

PIH in the 2nd trimester – where BP is usually at its lowest.

Front 12

What is the management given for a patient with hydatidiform mole?

Back 12

1. Evacuation of the mole – D&C – It has to be evacuated. Once the uterus is evacuated, the HCG levels should lower. 2. Track HCG level. 3. Type & cross for possible transfusion – At least 2 units. 4. Emotional support and bereavement care – because the pt believes she is pregnant. 5. Follow up for at least one year following – Pt should not attempt to get pregnant for 1 year and should go to the MD to track HCG levels. If in a year the HCG levels start to rise, it is indicative of choriocarcinoma (A highly malignant tumor that arises from trophoblastic cells within the uterus.)

Front 13

What is the definition of abortion?

Back 13

Expulsion of the fetus prior to viability (age of viability is 24 weeks), 20 weeks gestation. Two types: Spontaneous and Induced.

Front 14

What are the types and differences of spontaneous abortions?

Back 14

Spontaenous abortion – occuring naturally

Types of Spontaneous abortion:
Threatened – Pt has been bleeding
Imminent – Pt is bleeding, cervical os is open, cramping.
Complete – Fetus and placenta are expelled
Incomplete – Fetus is expelled and placenta is left inside.
Missed – Fetus dies before the 20th week of gestation
Habitual – Pt has 3 abortions between 14-16 weeks (usually due to incompetent cervix – cerclage performed)

Front 15

What is an induced abortion?

Back 15

An abortion as a result of artificial or mechanical intervention.

Front 16

What are the signs and symptoms of an abortion?

Back 16

Unexplained bleeding, cramping, backache

Front 17

What is the management of a patient that is going through an abortion?

Back 17

Ultrasound, Labs – H&H, CBC, T/X (type and cross), Bed rest (at home), Abstinence from sex, IV / Transfusion – May be hospitalized if it is closer to 20 weeks – may be put in Trendelenberg position., D&C – Dilation and Curettage, If beyond 12 weeks, induction of labor by oxytocin and prostaglandins may be used., Emotional support and bereavement care

Front 18

What are the types of bleeding disorders that can occur in pregnancy?

Back 18

Before 12 weeks: Abortion, ectopic pregnancy

After 12 weeks: Placenta previa, placenta abruptio,

Front 19

What are the things to remember with vaginal bleeding durng pregnancy?

Back 19

If it occurs < 12 weeks: It may be a spontaneous abortion which ma herold the need for a D&C

If it occurs > 12 weeks: It is more than likely a placental problem.

WITH BLEEDING FOR PT OVER 20 WEEKS, (YOU SUSPECT PLACENTAL PROBLEMS), DO NOT INSPECT THE PATIENT VAGINALLY.

Front 20

What is an ectopic pregnancy?

Back 20

Implantation of the blastocyst in a site other than the endometrial lining of the uterus. Most common site is in the fallopian tube (tubal pregnancy). Sometimes the blastocyst can even implant itself in the abdomen. It can happen anywhere, just not in the tubes. If this occurs in the tubes, you must try to save the tube. Use methotextrate injected into the tube and then remove the mass.

Front 21

What are the signs and symptoms of an ectopic pregnancy?

Back 21

Vaginal bleeding – if the tube ruptures, Lower abdominal pain – Usually severe, Fainting or dizziness, Hypovolemia – because she is bleeding out., Rigid, tender abdomen – because she is filling up with blood., Palpable mass on vaginal exam – extreme pain

Front 22

What is the management for a patient diagnosed with ectopic pregnancy?

Back 22

Pelvic exam - bimanual, Culdocentesis (procedure for obtaining specimens from the posterior vaginal cul-de sac by aspiration or surgical incision through the vaginal wall, performed for therapeutic or diagnostic reasons.) – Culdocsac: opening between rectum and vaginal opening. They try to extract blood from there. If they do, then the tube is ruptured., Laparoscopy / Laparotomy – in attempt to repair it if it has ruptured.

Front 23

What is a placenta previa?

Back 23

Placenta implantation in the lower uterine segment. The placenta is coming before the baby because it is implanted too low. If becomes completely unconnected then it becomes placenta abruptio. Can cause a decrease in O2 for the baby. Painless bleeding. If the placenta is blocking the vagina (complete), pt must be c-sectioned.

Front 24

What are the predisposing factors for placenta previa?

Back 24

Prior hx of plaenta previa, Multiple pregnancies, History of multiple births – because of multiple implantation., Prior uterine scars – because placenta will not implant on scar tissue.

Front 25

What are the symptoms of placenta previa?

Back 25

 Quite onset bright red bleeding - # 1 symptom: painless vag bleeding., Abdomen soft, palpable, Labor pains – pt will go into labor after bleeding episode.

Front 26

What are the nursing responsibilities for a patient with placenta previa?

Back 26

Bed rest – complete bed rest as long as she is bleeding., Monitor blood loss (pad count), Daily Non-stress tests., Perineal care, Education regarding signs and symptoms of labor, condition, Have current lab data (Ex: Type and screen), Emotional support

Front 27

What is placenta abruptio?

Back 27

Premature separation of the placenta (it should only separate after baby is delivered). Emergency because it cuts the baby’s O2 and nutrients. It can happen because of trauma to the abdomen.

Front 28

What are the symptoms of placenta abruptio?

Back 28

Dark venous blood – if the blood sits. **Pain with bleeding, Abdomen rigid, hard, Severe pain, Sudden onset

Front 29

What are the nursing responsibilities for a patient with placenta abruptio?

Back 29

Prepare for an emergency C-Section, Check for Fetal heart sounds, No vaginal exam !!

Front 30

What does PROM mean?

Back 30

Pre-mature Rupture of Membranes. Spontaneous rupture of membranes prior to onset of labor at the end of 37 weeks. Usually labor will start within 24 hours of rupture of membranes.

Front 31

What are the fetal risks when PROM occurs?

Back 31

Prematurity, Infection.

Front 32

What is a Non-Stress test (NST)?

Back 32

A test to record changes in fetal heart rate in response to fetal movement. FHR recorded over 20 minutes.

Front 33

What is a Biophysical Profile (BPP)?

Back 33

Ultrasound with Non Stress Test. Check for body movement, muscle tone, breathing movement, amniotic fluid and fetal heart beat. Checking that fetus has enough O2 in the womb.

Front 34

What is the management taken for a patient with PROM?

Back 34

Remember: Amniotic fluids is continually produced, Hospitalized, Bed Rest, Trendelenberg position – If bag of water is bulging., Daily CBC (look at WBC for infection), CRP (C-reactive protein – checks for inflammation – if elevated = infection), Fetal well-being tests: Non-stress test, Biophysical Profile, Medication: Celestone or Beta methezone (Steroid) – IM injection to help mature baby’s lungs – given 1 – 2 times Q 24 hours. Lung surfactant ratio 2:1 (mature lungs).

Front 35

What is an incompetent cervix?

Back 35

Premature dilatation of the cervix associated with repeated second trimester spontaneous abortion.

Front 36

What are the signs and symptoms of an incompetent cervix?

Back 36

Painless, bloodless second trimester abortion, Minimal uterine contractions until late, Pelvic exam shows dilatation and effacement

Front 37

What is the management for a patient with an incompetent cervix?

Back 37

Cervical cultures for GC, GBS (Group B Strep) in first trimester – May cause spontaneous abortion., Bed rest, Trendelenberg position, Shirodkar suture / cerclage - **Cerclage = stitch the cervix but the pt cannot be bleeding or more than 4 cm dilated. Performed at 14 weeks under epidural with no harm to the baby. Before mom gives birth, the stitch can be snipped (around 37 weeks) or it may simply pop so she can go into natural labor.

Front 38

What is pre-term labor?

Back 38

Onset of labor between 20 and 37 completed weeks of pregnancy

Front 39

What are the signs and symptoms of pre-term labor?

Back 39

Cramping, backache, Spontaneous contractions

Front 40

What is the management taken for a patient in pre-term labor?

Back 40

Bed rest, Hydration – place IV or drink a pitcher of water. Contraction can be caused by dehydration., Empty bladder – Check for bacteria for UTI – it can cause pre-term labor. If UTI, give antibiotics., Tocolytics – Toco = contractions, Lysis = to kill.: Terbutaline (Brethene) – bronchodilator, stops contractions (give sub-Q Q15 –20 min x 4) Side effects: Tachycardia. Perfect drug choice if the pt is having difficulty breathing and contractions., Mg SO4 – Relaxes the uterus. MgSO4 is not used to decrease BP in this case., Administer Abx – Infection (if PROM), If pt. bleeding – DO NOT PERFORM PHYSICAL VAGINAL CHECK, Perform and reinforce perineal care – for infection, Teach mother signs of labor: It may be pressure, cramping, it is rhythmic., Nitrazine test for amniotic fluid – urine is acid, amniotic fluid is base, Ferning test – performed by MD – fluid placed under microscope to check (+) for amniotic fluid, Possible grief counseling, Place pt. left side lying., If PROM occurs and mother is Rh Neg, Rhogam will be given if it has not been already given during the pregnancy.

Front 41

What are the things to remember about Magnesium Sulfate (Mg SO4)?

Back 41

Look out for: Decrease in Respirations, Check Reflexes – should not be slow (Normal reflexes is +2) Mg SO4 relaxes reflexes. **When a person comes close to seizing, they become hyperexcitable / hyperflexive., Check labs, Decrease stimulation for this patient – dim lights, place pt away from the nursing station., Check LOC, Antedote: Calcium Gluconite, You can give Solestom (Steroid) Beta Methadone with Mg SO4 to mature the baby if pre-term.

Front 42

What are the things to remember about Brethine / Terbutaline?

Back 42

Look out for: Tachycardia, if HR > 120, hold drug., Antedote: Propranolol (Inderol) – Beta Blocker.

Front 43

What is PIH?

Back 43

Pregnancy Induced Hypertension - An increase in systolic blood pressure > 30 mm/hg from baseline or an increase in diastolic blood pressure > 15 mm/hg from baseline on at least two ocassions > six hours apart. If no baseline data is available then 140/90. There are two categories: Pre-eclampsia and eclampsia

Front 44

What are the characteristics of Mild Pre-Eclampsia?

Back 44

 Increased BP, Mild Diastolic: over 90, less than 100, Moderate Diastolic: Over 100, less than 110, Proteinuria, Edema (especially facial)

Front 45

What are the characteristics of Severe Pre-Eclampsia?

Back 45

BP 160 / 110 or > on two occasions, Proteinuria which is > 5g / L in 24 hours, Oliguria which is < 400 mL / 24 hrs, Other symptoms like: Headache, blurred vision, scotomata (an island-like blindspot in the visual field), pitting edema, nausea and vomiting, epigastric pain., The more the disease progresses, the more symptoms the patient has and the more the severity of the complications.

Front 46

What are the treatments for pre-eclampsia?

Back 46

Bed Rest / LLR (Left side lying), Check BP, UA daily (for protein), Check for contractions., Bi-weekly NST, 24 Urine collection – Look at creatinine because kidneys are involved., Check fetal movement – Dot hemorrhaging of the placenta can cause a still born., High protein, low Na+ diet, 24 hour urine collection for protein and creatinine, Fetal well-being tests BPP, NST, Anti-convulsant therapy – Mg SO4, Antihypertensives: Aldomet - Methyldopa, Procardia – Calcium channel blocker, Labetolol – Beta blocker, Keep tox cart or box close to door. Contains Calcium gluconate (antedote for Mg SO4), Apresoline (to decrease BP), Dilantin, etc.

Front 47

What are the characteristics of eclampsia?

Back 47

Convulsions, Coma, More protein in the urine 1+, Edema – can lead to edema in the brain, s/s – epigastric pain (referred pain from the liver), An increase in reflexes.

Front 48

What is the treatment for eclampsia?

Back 48

Seizure Management – Mg SO4, Safety Precautions – Padded tongue blade above bed, padded side rails., Get the baby out, Put pt on Mg SO4 – does on decrease BP, but stops seizure activity., After delivery, the pt can be on Mg SO4 for up to 24-48 hours., NEVER GIVE DIURETICS when pregnant and retaining fluids, Use position changes to increase urination, Give high protein diet (due to protein loss in urine), Reduce stimulation (lights, noise), to decrease seizure possibility, I/O, May give meds to decrease HTN

Front 49

What is the pathophysiology of PIH?

Back 49

Normally, once the fertilized egg is implanted in the uterus, the body’s natural response is to dilate blood vessels to allow more blood to the fetus. However, in PIH, the opposite occurs. The reason is not really known. What happens?: Vasocontriction, Leads to microbreakdown of the vessels (small tears and cracks, Leads to leaking of fluids into the tissues, Causes edema (this is why weight is checked at prenatal visits), Causes protein to be found in the urine. (this is why urine is checked at prenatal visits)

Pregnant women have dependent edema anyway due to the pressure of the growing uterus on vessels. This is why when laying down, particularly while you sleep, it causes more blood to flow, which causes more urine production. Pt’s with chronic HTN may have poor placental implantation.

Front 50

What is Gestational Diabetes?

Back 50

Carbohydrate intolerance with onset first recognized during pregnancy. The hormone HPL is an insulin antagonist.

Front 51

What are the things to remember with gestational diabetes?

Back 51

Baby can be macrosomic (unusually large) (which leads to birth injuries), usually no vaginal deliveries, baby may have hypoglycemia upon birth. Check for signs and symptoms of hypoglycemia in the baby post delivery (same as in adults). Treat with mostly diet and exercise for moms., no oral antihypoglycemic agents - insulin only. Antihypoglycemic agents are teratogenic.

Front 52

What are the maternal risks to having gestational diabetes?

Back 52

Poyhydraminos (a condition in which the volume of amniotic fluids exceeds 1000 cc during the last half of pregnancy. Uterine overdistention may result in preterm labor)., Hyperglycemia, Dystocia - (difficult labor) due to fetal size., PIH

Front 53

What are the fetal risks to having gestational diabetes?

Back 53

Macrosomia – baby over 8 lbs 14 oz., After delivery, baby can suffer from hypoglycemia., IUGR (Intra Uterine Growth Retardation) - Rare

Front 54

What screening is done to test for gestational diabetes?

Back 54

One hr Glucose tolerance test - 50 gm random glucosa test at 24 –28 weeks. Results < 140 require further testing. Three hr Glucose tolerance test – (further testing after 1 hr GTT) – Use 100 g glucose solution. Fasting blood sugar - < 105, at 1 hr: <190, at 2 hr: <165
at 3 hr: <145

Front 55

How is gestational diabetes managed?

Back 55

Diet, Glucose monitoring – HgA1c (tells you how in control the pt has been handling their sugar – 120 days), Insulin Management – Reg/NPH (Give only regular insulin during labor), Evaluate fetal well-being: NST, Educate regarding: signs and symptoms of hypoglycemia / hyperglycemia, **Remember – No oral hypoglycemic agents.

Front 56

What are the warning signs to look for during pregnancy?

Back 56

Could be PIH: Blurred vision, headache, epigastric pain, systemic edema (upper body, face) Excessive nausea and vomiting = dehydration that can cause pre-term labor (contractions), Could be PROM / Placenta previa: Vag bleeding, excessive D/C Could be infection: burning on urination (UTI), fevers, chills - infections can cause PROM / Preterm labor. Could be placenta abruptio: Abdomen pain, rigid abdomen, persistant bleeding.

Front 57

Why is Rh factor important? What is the Rhogam injection for?

Back 57

If the mother is RH negative, the mother will receive a Rhogam injection at around 28 weeks and also an injection at 72 hours post delivery. The reason. If the mother is RH
(-) and the father is RH (+), the baby may have a chance of being RH (+). If this occurs, the mother’s body will build antibodies and try to attack the baby as a foreign object. The Rhogam injection signals the mother’s body not to build those antibodies. If the mother is RH (+), then there is no chance of this occuring.

Front 58

What is an ABO incompatability?

Back 58

If the mother is blood type O and the baby is blood type AB, it can cause an incompatibility – causing the child to become jaundice. (Abnormal)

Front 59

What to remember about jaundice and newborns?

Back 59

A “normal” jaundice can occur with babies. It happens 24 hours after the baby is born. An “Abnormal” jaundice is seen within 24 hours of delivery. S/S: Yellow skin, sclera of the eye, pale stools, dark urine, elevated liver enzymes (ALT and AST). This is due to intestine’s inability to process bilirubin (excreted through feces). So it builds up in the body (under skin and eyes and body tries to eliminate through urine). If there is too much bilirubin, it can cause Kernicterus – brain damage to the baby.

Front 60

What do you do if there is a decrease in O2 for the baby? (Shown by FHR or high BP in mom)

Back 60

Turn mother left lateral, Give mother O2, Give IVF to increase blood volume, If giving Pitocin, stop giving it. Contractions can decrease O2 in the baby., May give tocalytics (Brethene) to stop contractions, Prepare for a C-Section

Front 61

What is the risk and actions to take when membranes rupture?

Back 61

1st and foremost – Fetal Distress due to cord compression or prolapse. Check fetal heart rate and check for late deceleration. Late decelerations = no perfusion. Write the time of rupture and all details pertaining to the labor on the rating strip.

Front 62

What is the risk and actions when there is a cord prolapse?

Back 62

The threat? - Perfusion., # 1 – Do not pack and stuff !, Wrap cord with sterile gauze soaked in sterile saline to keep the cord moist., Position change – knee to chest and butt in the air. Check FHR by feeling the cord for heart beat with a sterile gloved hand.

Front 63

How do we know that the baby FHR is okay?

Back 63

Fetal Heart Rate – Doppler, fetoscope, electronic fetal monitoring (internal or external), Monitor contractions – 2-3 apart minutes optimum. Contractions <2 minutes apart = no O2 for the baby. Remember: Contractions decrease the O2 delivered to the baby.