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Assess the height, position, and consistency of these.
Uterus/fundus
Nursing Care During the Postpartum Period; Assessment; m311
The stage of labor during the 1st hr after delivery is a critical period; PP hemorrhage is most likely to occur during this time eg, bleeding from the birth canal > 500cc during 1st 24 hrs
The fourth stage of labor; Bleeding 300-400cc is normal
Nursing Care During the Postpartum Period Ch 21 m309
During this time monitor anesthesia recovery score eg, activity, V/S, LOC, Color
Assessment
Nursing Care During the Postpartum Period Ch 21 m309
Mom>35yr→loss of mus tone, uterus does not contract well; Multipara→loss of uterine mus tone; Rapid labor < 3hrs → ↑chance of lacerations/trama; Full bladder→uterine atony; Prolonged labor→ fatigued uterine mus
Postpartum Hemorrhage Predisposing factors
Nursing Care During the Postpartum Period Ch 21 r139 m310
Overdistended uterus eg, poly-hydramnios, multiple preg → macrosomic infant; Previous uterine atony - often recurs; Induced→uterus↓sensitive to oxytocin, mus fatigue; Gen anesthesia→↓uterus contratn; Placental frags →uterine atony
Postpartum Hemorrhage Predisposing factors
Nursing Care During the Postpartum Period Ch 21 r139 m310
The BP and HR should stablize to this within one hour after birth
Pre-labor values
Nursing Care During the Postpartum Period; Assessment; Audio Lec Ch 21 r531
BP, P, & RR; q15min x1hr; q30min x1hr; q1hr x2hrs
V/S
Nursing Care During the Postpartum Period; Assessment Ch 21 m310 r531
H&H; WBC; Coagulation factors (for ↑bleeding) are indicated values during postpartumm period
Lab Values
Nursing Care During the Postpartum Period; Assessment Ch 21 m310 r638
Document status of this possible complication and this disease
Rh and Rubella
Nursing Care During the Postpartum Period; Assessment Ch 21 m310 Audio Lec
Mom lying w head ↑slightly and knees flexed
Uterus/fundus assessment
Nursing Care During the Postpartum Period; Assessment Ch 21 m311 r712
Support this while doing a fundal assessment
Lower uterine segment over her pubic bone or you can prolapse it
Nursing Care During the Postpartum Period; Assessment Ch 21 Audio Lec r758
Do not massage this constantly bc mus fatigue → uterus relaxes
Uterus
Nursing Care During the Postpartum Period; Assessment Ch 21 m311 r841
Can give oxitoxyn IV or breast feeding to help uterus __
contract
Nursing Care During the Postpartum Period; Assessment Ch 21 Audio Lec r900
Monitor for bladder distention which displaces the uterus __ and causes uterine __
↑→; atony
Nursing Care During the Postpartum Period; Assessment Ch 21 m311 r928
Mom should do this spontaniously within the first 6-8hrs
void
Nursing Care During the Postpartum Period; Assessment Ch 21 Audio Lec
May see bladder as a rounded superpubic buldge esp if you have a __ mom
thin
Nursing Care During the Postpartum Period; Assessment Ch 21 Audio Lec
Tepid water, po fluids, and ambulation encourage this
NI to encourage natural voiding
Nursing Care During the Postpartum Period; Assessment Ch 21 Audio Lec
Palpate these to make sure mom is emptying
bladder and uterus
Nursing Care During the Postpartum Period; Assessment Ch 21 Audio Lec
If mom has an epidural she may need to have this
cath
Nursing Care During the Postpartum Period; Assessment Ch 21 Audio Lec
To assess this turn mom to side. She should have a moderate amt of moderate ruba during 4th stage
Lochia
Nursing Care During the Postpartum Period; Assessment Ch 21 m311 r1113
Lochia ruba should not come out in spirts because it indicates this
Arterial bleeding; Notify Dr and assess for vaginal or cervical lacerations
Nursing Care During the Postpartum Period; Assessment Ch 21 Audio Lec
If the uterus is filling with clots (may c/o severe bck ache) uterus will ↑ and deviate to what side? If uterus deviates to the opposite side it a distended bladder
Left; Right
Nursing Care During the Postpartum Period; Assessment Ch 21 Audio Lec
Chart scant, light,moderate, heavy for this
Lochia
Nursing Care During the Postpartum Period; Assessment Ch 21 p540 m311
When assessing mom's perineum place her on side lying position. Assess REEDA
Redness; Edema; Eccymosis; Discharge; Approximation
Nursing Care During the Postpartum Period; Assessment Ch 21 p541 Box 21-4 r1310
Cleansing; Ice Pack; Squeeze Bottle; Sitz Bath (Built-In or Disposable Type); Surgi-Gator; Topical Applications
Interventions for Episiotomy, Lacerations, and Hemorrhoids
Nursing Care During the Postpartum Period; Assessment Ch 21 p541 Box 21-4
The nurse always checks under the mother's __ as well as on the perineal pad. Blood may flow __, although the amt on the perineal pad is slight; thus excessive bleeding goes undetected.
buttocks; b/t the buttocks onto the linens under the mom
Nursing Alert p541
Assess for this if mom c/o pain/pressure in vagina, perineum not relieved by pain meds. If ↑large may hv urge to bear down. If ↑in vagina may not see. Can lose >500cc of blood. Surg may be indicated. Assess for hemorrids also
Hematoma
Nursing Care During the Postpartum Period; Assessment Ch 21 m311 r1416 Audio Lec
Persistent significant bleeding-Perineal pad is soaked ≤15 min; may not be accompanied by change in VS or mom's color/behavior. Mom c/o feeling weak, light-headed, funny, sick to stomach, or sees stars...
S/s of Hypovolemic Shock
Emergency Box p542
Mom acts anxious or exhibits air hunger; skin turns ashen or grayish; skin feels cool and clammy; ↑P ↓BP...
S/s of Hypovolemic Shock
Emergency Box p542
Call HCP; If uterus is atonic, massage gently &amp; expel clots to cause uterus to contract; compress uterus manually prn using 2 hands. Add oxytocic agent IV drip as ordered; Adm O2 nonrebreather face mask or nasal prongs @ 10 L/min...
NI for Hypovolemic Shock
Emergency Box p542
Tilt mom to side or ↑right hip; ↑legs 30° angle; IV (LR or NS) to restore vol; Adm blood as ordered; Monitor V/S; Insert cath to monitor perfusion of kidneys; Adm emergency drugs as ordered...
NI for Hypovolemic Shock
Emergency Box p542
Prepare for possible surgery or other emergency tx or precedures; chart incident, medical and NI instituted, and results of tx
NI for Hypovolemic Shock
Emergency Box p542
Can last ≥2; Reassure pt & fam it's normal/uncontrolable, relaxation techniques may↓ it;
Postpartum tremors
Nursing Care during the Pospartum Period ch 21; Assessment m311 r1600
Assess any __ that is not relieved by analgesics.
pain
Nursing Care during the Pospartum Period ch 21; Assessment; Audio Lec m311 r1600
These include warmth, relaxation tech, distraction, ice packs, sitz bath; topical anesthetics
Non-pharmacologic interventions
Nursing Care during the Pospartum Period ch 21; Assessment m312
Narcotics; non-noncartics eg, NSAIDS; PCA; safety with breastfeeding; assess pain not relieved by analgesics
Pharmacologic interventions
Nursing Care during the Pospartum Period ch 21; Assessment m312
Do this early and often. Prevents thromboembolism; Homan's sign; Consider med usage bf eg, anesthesia, analgesia, MgSO4
Ambulation
Nursing Care during the Pospartum Period ch 21; Assessment
Can do prn when anesthesia has worn off; If having ↑pain med bf; Prevent falls
Ambulation
Nursing Care during the Pospartum Period ch 21; Assessment
R/t crying baby, hospitalization, discomfort, anxiety
Lack of Rest
Nursing Care during the Pospartum Period ch 21; Assessment
NI include: ROM; Amublation; Support hose if varicosities; Homan's sign eg, warmth, redness, tenderness in the calf; TED or SCD's if required to stay in bed
Thromboembolism
Nursing Care during the Pospartum Period ch 21; Thromboembolism; m313 r1912
First strict bedrest is required. pt movement should be restricted, but when necessary, it should be performed gently. ↑limb then call the Dr (Most important); Do not massage
Indicated if thrombus is suspected
Nursing Care during the Pospartum Period ch 21; Thromboembolism; m313 r1950
Watch for this type of engorgement → pooling of blood in viscera and orthostatic hypotension
Splanchnic
Nursing care During the Psotpartum Period; Safety r2106 m313
Start w sml amts whn stable; maintain IV if N/V or ↑bleeding; encourage ↑protein, fiber; may continue prenatal vit & iron, esp if breast feeding; Cultural preferences may be included eg, no cold or hot foods/drinks
Fluid Balance and Nutrition
Nursing care During the Psotpartum Period r2152 m313
Indicated ≤ 2hr after delivery; Helps uterus contract
Breastfeeding
Nursing care During the Psotpartum Period; Breast Care r2236 m314
If inverted difficult for baby to latch on; everted desired
Nipples
Nursing care During the Psotpartum Period; Breast Care r2236 m314
If the breasts are hard the pt is probably this
Engorgement
Nursing care During the Psotpartum Period; Breast Care r2236 m314
Indicated if mom has ↑engorgement or not breast feeding any of these may be indicated
Breast binder; Ice packs; Cold cabbage leaves
Nursing care During the Psotpartum Period; Breast Care r2236 m314
If non-immune should receive this; immunization made from eggs, check for allergy; edu to avoid preg for 3mo after sq inj
Rubella (causes birth defects)
Nursing care During the Psotpartum Period r2457 m314
Adm ≤ 72hrs if mom is Rh(-), coomb's antibody negative, and baby is Rh(+); If given to Rh(+) mom, may promote lysis of RBC's; Given IM to mom, NEVER to baby
Rhogam
Nursing care During the Psotpartum Period; Medication guide p547 r2542 m314
Life or health of mom and/or infant is jeopardized by a disorder coincidental or unique to pregnancy
High-risk pregnancy
Assessment of Risk Factors; Definition and Scope of Problem r618 m325
Pregnancy is a maturational crisis; Diagnosis of high-risk adds situational crisis
Having a mom who is high risk and adding to her stress by telling her she's high risk tends to make even worse
Assessment of Risk Factors; Definition and Scope of Problem r618 m325
HTN disorders; Infection; Hemorrhage
3 major causes
Assessment of Risk Factors; Major Causes of Maternal Death m325 Box 9-1 p191
HTN; Pulmonary embolus; Hemorrhage
3 leading causes
Assessment of Risk Factors; Major Causes of Maternal Death r733 m325
Genetic factors may interfere w normal fetal or neonatal dev, result in congenital anomalies, or create difficulties for mom
Genetic considerations
Assessment of Risk Factors; Major Causes of Maternal Death m325 Box 9-1 p191
Defective genes, transmittable inherited disorders, chromosome anommalies, multiple preg, large fetal size, and ABO incompatibility
Genetic factors - a genetic risk assessment should be done to determine the family's heritable risk
Assessment of Risk Factors; Major Causes of Maternal Death m325 Box 9-1 p191
The availability/quality of prenatal care vary greatly with geography. Mom's in metro areas have more prenatal visits than those in rual areas who have fewer opportunities for specialized care & consequently a ↑ incidence of maternal mortality.
Geographic location
Assessment of Risk Factors; Major Causes of Maternal Death m325 Box 9-1 p191
Health care in an inner city, where residents are usually poorer and begin childbearing earlier and continue for longer, may be of lower quality than in a more affluent neighborhood
Geographic location - there may be unsafe soil and water conditions and environmental exposure to pollutants
Assessment of Risk Factors; Major Causes of Maternal Death m325 Box 9-1 p191
Poverty →many other risk factors →inadequate financial resources for food/prenatal care; ↓general health; ↑risk for medical complications of preg, ↑prevalence of adverse environmental influences eg, substandard living conditions, ↓hygiene/inadequate nutrition
Socioeconomic status
Assessment of Risk Factors; Major Causes of Maternal Death m325 Box 9-1 p191
Risk for adverse perinatal outcomes ↓ as educational level ↑
Educational attainment
Assessment of Risk Factors; Major Causes of Maternal Death m325 Box 9-1 p191
The ↑mortality/morbidity rates for unmarried women, including a ↑risk for preeclampsia, are often r/t inadequate prenatal care and a younger childbearing age
Marital status
Assessment of Risk Factors; Major Causes of Maternal Death; Demographic Characteristics m325 Box 9-1 p191
Mothers < __ and >__ y.o. have a slight ↑ in adverse perinatal outcomes
Maternal age
Assessment of Risk Factors; Major Causes of Maternal Death; Demographic Characteristics m325 Box 9-1 p191
Although race/ethnicity by themselves are not major risks, race is an indicator of other sociodemographic risk factors.
Racial and ethnic origins
Assessment of Risk Factors; Major Causes of Maternal Death; Demographic Characteristics m325 Box 9-1 p191
Non-Caucasian women are more than x__ as likely as Causasian women to die of preg-related causes.
3
Assessment of Risk Factors; Major Causes of Maternal Death; Demographic Characteristics; Racial and ethnic origins m325 Box 9-1 p191
African-American babies have the highest rates of prematurity and LBW, with the infant mortality rates among African-Americans being > x__ that among Caucasians
2
Assessment of Risk Factors; Major Causes of Maternal Death; Demographic Characteristics; Racial and ethnic origins m325 Box 9-1 p191
Can be grouped into chemical, physical, biologic, and psychologic hazards. The risk to the fetus depends on the timing of exporsure, the dose, and fetal and maternal susceptibility
Occupational hazards
Assessment of Risk Factors; Major Causes of Maternal Death; Demographic Characteristics m325 Box 9-1 p191
Smoking is associated w IGR and LBW; alcohol exerts adverse efffects on the fetus, resulting in fetal alcohol spectrum disorders, which include fetal alcohol syndrome, alcohol-related neurodevelopmenntal disorder, and alcohol-related birth defects
Substance abuse
Assessment of Risk Factors; Major Causes of Maternal Death m325 Box 9-1 p191
Druge can be teratogenic, cause metabolic disturbances, produce chemical effects, or cause depression or alteration of CNS function
Substance abuse
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics m325 Box 9-1 p191
Failure to diagnose and tx complications early is a major risk factor arising from financial barriers or lack of access to care
Failure to seek prenatal care
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics m325 Box 9-1 p191
Depersonalization of the sys, resulting in long waits, routine visits, variability in health care personnel, unpleasant physical surroundings; lack of undersatanding of need for early/continued care; cultural beliefs that do not support the need; fear of the health care system and its providers
Failure to seek prenatal care
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics m325 Box 9-1 p191
Adequate nutrition, w/o which fetal growth and dev cannon preceed normally, is one of the most important determinants of preg outcome
Nutritional status
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics m325 Box 9-1 p191
Young age; 3 pregnancies in the previous 2 yrs; tobacco alcohol, or drug use; inadequate dietary intake bc of chronic illness or food fads; inadequate or excessive wt. gain; hematocrit value < 32%
Conditions that influence nutritional status
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics; Nutritional Statue m325 Box 9-1 p191
Periodontal disease ↑risk for preterm birth and LBW
Dental hygiene
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics m325 Box 9-1 p191
Childbearing triggers profound and complex physiologic, psychologic, and social changes, w evidence to suggest a relationship between emotional distress and birth complications
Psychosocial stressors
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics m325 Box 9-1 p191
Intrapsychic disturbances and addictive lifestyles; a history of child or spouse abuse; inadequate suppport systems; family disruption or dissoultion; meaternal role changes or conflicts
Psychosocial stressors
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics m325 Box 9-1 p191
Noncompliance with cultural norrms; unsafe cultural, ethnic, or religious practices; and situational crises
Psychosocial stressors
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics m325 Box 9-1 p191
Domestic violence is a serious problem; the risk of violence ↑ during pregnancy
Abuse and violence
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics m325 Box 9-1 p191
Abuse during pregnancy ↑ the risk for abruptio placenta, preterm birth, and LBW infants and infections from forced sex
Abuse and violence
Assessment of Risk Factors; Major Causes of Maternal Death; Behavioral Characteristics m325 Box 9-1 p191
Congenital anomalies; disorders r/t short gestation and LBW; SIDS; Resp distress syndrome; Affects of maternal complications eg, abruptio plancenta
Leading Causes of Neonatal
Leading Causes of Neonatal Death m326 r820
Mgmt of normal preg, labor and childbirth; earliest possible ID of high-risk preg and high-risk neonate; provisional of stabilization of care in even of unanticipated obstetric/neonatal emergency
Level 1
Regionalizztion of Health Care Levels of Care m326 r901
Provide care for specified types of maternal and neonatal complications eg, if mom comes in ≥ 34 wks gestation; Babies on vent, c-pap, or extra short term care
Level 2
Regionalizztion of Health Care Levels of Care m326 r956
Capacity to manage most complex disorder, both maternal and neonatal; Mothers often transported to centers prior to birth to optimize fetal outcome
Level 3 - cavate if mom is in immanent danger of delivering, then mom delivers w level 2 and ships baby to level 3 hospt
Regionalizztion of Health Care Levels of Care m326 r1130
Done at hm; is non-invasive and no expense involved; research shows tht maternal awareness of movement is 90% accurate; low amt of movement <3/hr warrants NST, contraction stress test CST, or biophysical profile BPP testing
(Daily Fetal Movement Counts) DFMC or kick count
Assessment of Risk Factors; Daily Fetal Movement Counts m327 r1318
Fetal movement ceases for 12 hrs
Fetal alarm signal
Assessment of Risk Factors; Daily Fetal Movement Counts m327 r1420
Uses sound waves at 2-10 megahertz; can be done transvaginally or abd; Level 1 - basic screen eg, how many babies, & aminotic fluid; Level 2 - pts suspected of carrying anatomically or physiologically abnormal fetus
Ultrasound
Assessment of Risk Factors; Ultrasound m327 r1505
Early diagnosis makes choices possible for families; FHR can be seen as early as 6-7 wks (echo); 10-12 wks (doppler); Confirmation of fetal death
Findings of Ultrasonography
Assessment of Risk Factors; Findings of Ultrasonography m327 r1619
Absence of HR, fetal scalp edema, overlap of crainal bones, maceration
Confirmation of fetal death
Assessment of Risk Factors; Daily Fetal Movement Counts m327 r1707
Indications for checking this: Unsure LMP; discontinuation of oral contraceptives before preg; 1st trimester bleeding; size/date discrepancy; other high risk factors
Gestational ages c Ultrasonography
Findings of Ultrasonography m328 r1840
Assessment accurate in 1st 18 wks of preg; 8wks-sac dimensions; 7-14 wks - crown-rump; 12 wks- biparietal diameter (sides of head) and femur length
Determinants of gestational age
Findings of Ultrasonography m328 r2048
Serial measurements are done 2-3 wks apart, between 24 and 32 wks are accurate +/- 10 days; Determines if the fetus is growing the way it should be
Findings of Ultrasonography
Findings of Ultrasonography m328 r2140
Indicated c poor maternal wt. gain; previous IUGR; chronic infections; drug use; diabetes; HTN disorders; multiple gestation; other med/surg complications
US to watch fetal growth
Findings of Ultrasonography m330 r2354
Findings of US: Caused by a chronic or longstanding insult
Symmetric IUGR
Findings of Ultrasonography m331 r2447
Caused by acute or late occurring deprivation eg, fetus grows in length but not in wt.
Asymmetric IUGR
Findings of Ultrasonography m331 r2447
Can help diagnose macrosomia (big fetus)
Ultrasonography
Findings of Ultrasonography m331 r2537
Adjunct to amniocentesis, PUBS purcutainous umbilical blood sampling, CVS chorionic villa sampling
Ultrasonography
Findings of Ultrasonography m331 r2606
Amniocentesis, PUBS, & CVS
Establishes position of fetus, placenta, fluid pockets (amniotic fluid) ,and umbilical cord position
Findings of Ultrasonography m331 r2647
≥36 wks 85% of major anomalies can be detected; can see the # of fetuses & presentation to decide mode of delivery eg, vaginally or c-section
Fetal Anatomy
Findings of Ultrasonography m331 r2700
Determines placental position and function eg, placenta previa;
Ultrasonography
Findings of Ultrasonography m331 r2738
Can look at age of placenta and how well its functioning - graded in 3rd trimester (the ↑grade the ↓functioning)
Ultrasonography
Findings of Ultrasonography m331 r2754
With regard to placental position and function, can see Ca deposits eg, as Ca deposits↑ surface area↓, so baby will not be getting blood supply eg, ↓nutrients/O2 supply
Ultrasonography
Findings of Ultrasonography m331 r2818
Amniotic fluid vol - look for fluid pockets eg, <5 cm (total) - oligohydramnios; 5-8 cm - normal; >8 cm - polyhydramnios; Doppler blood flow analysis (follow blood flow through the heart); fetal echocardiogram; Biophysical profile (BPP)
Ways to determine fetal well being using ultrasound
Findings of Ultrasonography m332 r2846
A composite assessment of fetal well being; shows function of CNS; provides accurate estimate for risk of fetal death in immediate future; indicate fetal infection esp r/t premature rupture of membranes (fetus will act hypoxic)
BPP
Findings of Ultrasonography m332 r2959 p199
Can in some hospt
Nursing Role
Ultrasound r3133
With regard to safety, no conclusive evidence in humans as to if the benefits outweight the risks; Some places have 3D ultrasound
Ultrasound
A photomicrograph of the chromosomes of a single cell, taken during metaphase, when each chromosome is still a pair of chromatids. The chromosomes are then arranged in numerical order, in descending order of size. Used to determine congenital anomalies
Karyotype
Evaluates: fetal structure and growth; placenta, amniotic fluid vol; maternal structures; biochemical status of tissue, organs; can ID soft tissue anomalies; mom may need to be sedated to ↓fetal movement
MRI
MRI m333 r3303
Needle inserted transabdominally under ultrasound guidance; Done >14 wks for karyotyping to check for fetal anomalies; Done later in preg to check fetal lung maturity
Amniocentesis
m333 r3400
Hemorrhage; labor; abruption of placenta; amniotic fluid embolism; fetal death; infection; maternal isoimmunization eg, Rh- mom; Rh- mom should receive Rhogam
Complications of amniocentesis
m333 r3451
Anything (eg, amniocentesis) that irritates the uterus can lead to this
Labor (preterm or term)
r3500 audio lec
Genetic problems: any disorder with marker genes; cells cultured for Karyotyping and/or sex of fetus (only 100% accurate determination)
Indications for amniocentesis
m334 r3606
AFP: If mom's ↑AFP, helps confirm diagnosis of open neural tube defect eg, spina bifida
Indications for amniocentesis; Alpha Fetal Protein
m334 r3657
Fetal Maturity: L/S ratio, 2:1 indicates lung maturity; PG: present = ↓resp distress syndrome (almost 0%) indicates mature lungs or absent = immature lungs
Amniocentesis Indications
m334 r3727
Fetal Lung Maturity test (FLM): Needs a clean specimen. Not as accurate if blood in it
Amniocentesis Indications
m334 r3830
Not done until maternal antibody titer reaches 1.8 and is ↑; PUBS is procedure of choice for this now;
Amniocentesis Indications to dx fetal hemolytic disease associated with Rh- incompatablity
m334 r3905
APT test differentiates fetal from maternal blood; Kleihauer-Betke test done for confirmation
Amniocentesis Indications; If blood in the amniotic fluid can test if fetal or maternal blood as in abruptio placenta
Not associated with a poor outcome; can be from old insult; physiologic; may need antepartum evaluation if birth is not imminent;
Antenatal period
Meconium in Amniotic Fluid m335 r4030
Bright green = fresh; Brown = old
Meconium
m335 r4050 audio lec
EFM; Fetal scalp blood sampling;
Intrapartum period evaluation
Meconium in Amniotic Fluid m335 r4137
May be normal physiologic function with maturity, or hypoxia induced, or response to cord compression in mature fetus
Intrapartum period eval
Meconium in Amniotic Fluid m335 r4230
Consistency - thick, more likely d/t fetal stress; timing, color changes with time
Meconium in Amniotic Fluid Evaluation
Meconium in Amniotic Fluid m335 r4303
Meconium itself is not necessarily a sign of stress; presence of other indicators, decels, poor baseline... is ominous; Suction ithe nasopharynx before newborn's first breath eg, mouth then nose
Meconium in Amniotic Fluid Evaluation
Meconium in Amniotic Fluid m335
Done in the 2nd or 3rd trimester; a needle is inserted into a fetal umbilical vessel under USG (ultra sound guidance)
Percutaneous Umbilical Blood Sampling
PUBS m336 r4625
Complications: Blood leakage from site; fetal bradycardia; chorioamniontis
PUBS
PUBS m336 r4732
Indications: Identify inherited blood disorders; detect fetal infection, assess acid-base balance of IUGD fetus; assess/tx isoimmunization (xfuse blood via umbilical vein) and thrombocytopenia
PUBS
PUBS m336 r4803
Karotyping can be done in 2-3 days; intrauterine xfusion in severely anemic fetus can be done 4-5 wks earlier than intraperitoneal route
PUBS
PUBS m336 r4925
Continuous FM for up to one hr; repeat ultrasound after one hour to ensure no further bleeding or hematoma
Post procedure
PUBS m336 r4948
May be done transcervically or abd,↓risk w abd route; Can be done at 10-12 wks of preg; removal of a sml tissue specimen frm fetal portion of placenta; procedure guided by real-time US; indications similar to amniocentesis
CVS
Chorionic Villus Sampling (CVS) m336 r5003
Developes from zygote. Tissue reflects genetic makeup of fetus
Chorionic villus
m337 r5115
Complications: Spotting; ROM; chorioamnionitis; if mom is Rh- needs Rhogam; if done between 56 - 66 days, ↑risk of limb abnormalities; tissue reflects genetic makeup of fetus
CVS
CVS m337 r5129
Most reliable at 15-21 wks; done to screen for neural tube defects
Alpha-Fetoprotein (MSAFP)
Maternal Assays m337 r5251
An antigen present in the human fetus. Indications: AMA ≥35; multifetal preg; unrecognized demise; severe oligohydramnios; ↓levels indicative of down syndrome, ↑levels are indicative of neural tube defects.
Alpha-Fetoprotein
Maternal Assays m337 r5321
16-18 wks; AFP, unconjugated estriol, HCG; very sensitive, ↓# of false positives, but if mom's dates are off it will throw off test results, ↓levels indicative of down syndrome, ↑ levels are indicative of neural tube defects
Triple Marker Test or Triple screen; Newer forms of AFP; Are not required
Maternal Assays m338 r5427
Same as triple acreen + inhibin-A, ↑inhibin-A indicative of Down Syndrome
Quad screen; Newer forms of AFP; Are not required
Maternal Assays m338 r5540
Rh incomatibility; if maternal titer > 1.8, amniocentesis for bilirubin is indicated
Coomb's Test; Newer forms of AFP
External Fetal Monitoring m338 r5635
Used to determine whether the intrauterine environment is supportive of the fetus; most often used to determine childbirth timing for mom's at risk for uteroplacental insufficiency
External Fetal Monitoring
External Fetal Monitoring m338 r5635
Maternal diabetes; HTN, IUGR, sickle cell, maternal heart disease, postmaturity, hist of stillbirth, isoimmunization, meconium stained fluid at amnio, hyperthyroidism, collagen disease, AMA, chronic renal disease
Indications for non stress test NST & contraction stress test CST
External Fetal Monitoring m338 r5635
None for NST; Absolute for CST: ROM, previous classical incision; preterm labor; placenta previa; abruption: Relative for CST: multifetal preg; previous preterm labor hydramnios; <36 wks gestation; incompetent cervix
Contraindications
External Fetal Monitoring m338 r5635
↓ as degree of hypoxia and acidosis ↑; presence of normal variability is the most reassuring aspect of FHR monitoring; 98% accuracy for fetal wellbeing
Variability
External Fetal Monitoring m339
Most widely used type of antepartum eval of fetus; accelerations of FHR in response to fetal movement is desired outcome
NST
External Fetal Monitoring m339
Ease of testing noninvasive; relatively inexpensive; no known contraindications
NST Advantages
External Fetal Monitoring m339 r10100
False positive rates for non-reactive finds as a result of fetal sleep cycles; maternal meds eg, narcotics or fetal immaturity; slightly lower sensitivity to fetal compromise than CST or BPP
NST disavantages
External Fetal Monitoring m339 r10130
≥ 2 accels of 15 bpm lasting ≥ 15 sec over 20 min period; normal baseline FHR (110-160); long term moderate or avg variability amplitude of ≥ 10 bpm
NST Interpretation (to be called reactive)
External Fetal Monitoring m339 r10313
Procedure: Sit in chair or semifowler's; apply sono (HR) &amp; toco (contractions); may give mom button to push whn fetal movement felt; almost all accels are accompanied by fetal movement; does not require marking by mom to be considered reactive; mom feels approx 75% of movement
NST
External Fetal Monitoring m340 r10530
Takes 10 min; w fetus monitored 5 min bf stimulation to obtain baseline; Sound source applied to abd ovr fetal head; reactive if accel of 15 bpm for 120 sec ≤5 min of stimulation or 2 accels of 15 bpm for 15 sec each ≤5 min of stimulation
Fetal Acoustic Stimulation; May be used to stimulate fetus during NST
External Fetal Monitoring m340 r10648
Designed to identify fetus who is stable at rest but compromised w introduction of stress
CST
External Fetal Monitoring m341 r11045
Earlier warning of fetal compromise than NST; fewer false positives
CST Advantages
External Fetal Monitoring m341
Observe EFM strip for 10 min for baseline and spontaneous UC's; then produce UC's (3 in 10 min window) by either nipple stimulation or oxytocin
CST procedure
External Fetal Monitoring m341
Apply warm washrage to breasts; massage nippple for 10 min, x2 min, x4 cycles; if not effective, may massage both nipples; Stop whn there is adaquate contractions or uterus gets hyperstimulated
NSCT (nipple stimulation)
External Fetal Monitoring m341
Start primary IV, piggyback oxytocin by pump; follow hospital protocol; continue fetal monitoring until preprocedure contractions return bf taking off monitor
OCT (oxytocin) CST
External Fetal Monitoring m341 r11408
Accels w fetal movement
Positive/reactive/reassuring NST
audio lec
Contractions w decels
Positive CST
r11716 audio lec
Following procedure, continue monitoring until preprocedure UC pattern returns
CST
External Fetal Monitoring
With 3 UC's in 10 min: Negative: no late decels; Positive: persistent and consistent late decels occurring w > 1/2 of UC's; Suspicious: late decels occurring w < 1/2 of UC's
CST Interpretation
External Fetal Monitoring m342
Educator; support person; assist w precedure; in many settings nurses perform NST's and CST's & begin interventions for non-reassuring patterns
Nursing Role In Antenatal Assessment
External Fetal Monitoring m342 r11917
3-7% of primiparous women bc preeclamptic; 0.8-5% of multiparous women bc preeclamptic; morbidity and mortality increase whn seizures occur
Mortality and Morbidity
HTN Disorders in Pregnancy m343 r403
Prematurity IUGR; hypoxia; Maternal:
Fetal Perinatal Morbidity
HTN Disorders in Pregnancy; Mortality and Morbidity m343
Placental abruption; DIC; renal failure; hepatic failure; ARDS; cerebran hemorhage
Maternal Perinatal Morbidity
HTN Disorders in Pregnancy; Mortality and Morbidity m343
↑BP w/o proteinuria, after 20 wks gestation; if it happens bf 20 wks it's likely chronic or preexisting conditions; classification of HTN disorders
Gestational HTN
m344 r604 p335 Table 14-1
BP >140/90 x2, 6 hrs apart; proteinuria 1-2+ on dipstick or >0.3 gm in 24hr differenciates from gestational HTN; possible H/A; reflexes may be normal; ↓placental perfusion→ baby is not getting O2 & nutrients it needs
Mild Preeclampsia Characteristics
m344 r640
Progression of preeclamsia to seizure activity and/or coma; Seizure risk from preeclampsia→eclampsia: 40% seize antepartum; 20% seize intrapartum; 40% seize postpartum
Eclampsia; Can occur up to 14 days after preeclampsia
m345 r1100 p347 Emergency Box
HTN before 20th wk; not preganacy related; can develop superimposed preeclampsia with CHTN AEB proteinuria; may need antihypertensives
Concurrent HTN
m345 r1443
2 to 3 sec: eyes are fixed; twitching of facial muscles
Eclampsia; Tonic-Clonic Convulsion Signs; Stage of invasion
Eclampsia Emergency Box p347
15 to 20 sec; eyes protrude and are blood shot; all body muscles are in tonic (tension or contraction) contraction
Eclampsia; Tonic-Clonic Convulsion Signs; Stage of contraction
Eclampsia Emergency Box p347
Muscles relax/contract alternately (clonic); respirations are halted and then begin again w long, deep, stertorous (laborious breathing provoking a snoring sound) inhalation; coma ensues
Eclampsia; Tonic-Clonic Convulsion Signs; Stage of convulsion
Eclampsia Emergency Box p347
Keep airway patent: turn head to one side, place pillow under one shoulder or back if possible; call for assistance; protect with side rails up; observe and record convulsion activity
Eclampsia; Tonic-Clonic Convulsion Intervention
Eclampsia Emergency Box p347
Do not leave unattended until fully alert; observe for post- convulsion coma, incontinence; use suction PRN; adm O2 via face mask at 10 L/min; start IV, monitor intake; giv MgSO4 or anti- convulsant drugs prn; support, keep mom/family informed
Eclampsia; After convulsion or seizure
Eclampsia Emergency Box p347
Insert indwelling urinary cath, monitor output, BP, fetal and uterine status; expedite lab work as ordered to monitor kidney, LFT, coagulation sys, drug levels; provide hygiene and a quiet environment; be prepared to assist w birth whn mom is in stable condition
Eclampsia; After convulsion or seizure
Eclampsia Emergency Box p347
↑BP detected first time after midpregnance w/o proteinuria (previously known as preg-induced HTN)
Gestational HTN
p335 Table 14-1 Classification of HTN states of preg
Gestational HTN w no signs of preeclampsia present at the time of birth and HTN resolves by 12 wks after birth; this is a retrospective diagnosis
Transient HTN
p335 Table 14-1 Classification of HTN states of preg
The occurrence of seizures in a mom w preeclampsia tht cannot be attributed to other causes
Eclampsia
m354 p335 Table 14-1 Classification of HTN states of preg
HTN tht is present and observable bf preg or tht is diagnosed bf wk 20 of gestation
Chronic HTN
p335 Table 14-1 Classification of HTN states of preg
Chronic HTN w new proteinuria or an exacerbation of HTN (previously well controlled) or proteinuria, thrombocytopenia, or ↑hepatocellular enzymes
Preclampsia superimposed on chronic HTN
p335 Table 14-1 Classification of HTN states of preg
Hemolysis; elevated liver enzymes; low platelet count; 2-12% of severe preeclamptics; highest in older, caucasian, multiparous women
HELLP Syndrome
m348
Platelet count <100,000; ↑liver enzymes (AST, ALT, bilirubin); hemolysis (burr cells); form of coagulopathy; hypoglycemia
HELLP Syndrome Diagnosis
m349
BP may be normal or only ↑slightly; s/s almost always includes epigastric pain, malaise, and N/V; probable c-section d/t unfavorable cervix and/or aggressive nature of disease
HELLP Syndrome Diagnosis (H- hemolysis EL- ↑liver enzymes LP- ↓platelet count)
m349
An erythrocyte with 10 to 30 spicules distributed over the surface of the cell, as seen in heart disease, stomach cancer, kidney disease, and dehydration.
Burr Cell
Taber's Medical Dictionary
The woman's BP, P, and RR status should be monitored closely while the MgSO4 loading dose is being adm IV and every 15-30 min at other times, depending on the stability of the mom's condition.
HELLP
Nursing Alert p344
Whn adm antiHTN therapy, the RN must remember that the drug effects depend on intravascular vol. Bc preeclampsia is associated w contracted intravascular vol, initial doses should be given w caution, & maternal response monitored closely
NURSING ALERT
Severe Preeclampsia or HELLP Syndrome p346
Because a degree of maternal HTN is necessary to maintain uteroplacental perfusion, antiHTN therapy must not ↓arterial pressure too much or too rapidly. Therefore the target range for the DBP <110, SBP<160
Control of BP
Severe Preeclampsia or HELLP Syndrome p346
Immediately after this, the mom may be very confused and combative. Pat side rails to prevent injury. Maintain a quiet, darkened environment. It may take several hrs for mom to regain her usual LOC. She should not be left alone. Provide emotional support to fam & discuss w them mgmt, its rational, & mom's progress
NURSING ALERT; Seizures
Eclampsia; Seizure p346
Aspiration is a leading cause of mom's morbidity/mortality after this. So after initial stabilization/airway mgmt, the nurse should anticipate orders for chest x-ray film &amp; possibly ABG's to determine whether aspiration occurred.
Eclamptic Seizure
Eclampsia; Seizure; NURSING ALERT; p346
The mom is at risk for a boggy uterus and a large lochia flow as a result of the tocolytic effects of this therapy. Uterine tone and lochial flow must be monitored closely
NURSING ALERT; MgSO4
Eclampsia; Seizure p347
Is this a theraputic MgSO4 level for a preg mom: 4-8 mEq/L
Yes
Any agent that diminishes uterine contractions by reducing myometrial (the smooth muscle forming the wall of the uterus) excitability
Tocolytic
Taber's Medical Dictionary
A synthetic version of the same peptide. It is used in obstetrics to induce labor, contract the uterus, and control postpartum hemorrhage
Oxytocin/Pitocin
Taber's Medical Dictionary
Pertaining to illnesses whose cause is either uncertain or as yet undetermined
Idopathic
Taber's Medical Dictionary
Risks: Uterine tenderness in the presence of ↑tone may be the earliest finding of this. Idiopathic preterm contractions also may be an early sign.
Abruptio placentae
NURSING ALERT; HELLP Syndrome; Nursing Care Mgmt p342
Risk for injury r/t signs of preeclampsia; Deficient diversional activity r/t imposed bed rest; Fear/anxiety r/t preeclampsia and its effect on the fetus
Mild Preeclampsia Nursing Diagnosis
p344
Needs to be observed closely 24-48 hrs; MgSO4 continued 12-48 hrs; Monitor BP, DTR's, urine protein q hr; if epigastric or RUQ pain, massage fundus on L side only and gently bc can rupture liver.
Post-Delivery
m355
Strict I&O; promote bonding; no ergot meds; pt is improving whn diuresing, improvement of edema, ↓wt.& CNS irritability; improved HTN
Post-Delivery
m355
Risk for uterine atony if on MgSO4; MgSO4 potentiates narcotics, CNS depressant, and Ca channel blockers
Post-Delivery
m355
The oval or discoid spongy structure in the uterus of eutherian mammals from which the fetus derives its nourishment and oxygen
Placenta
Taber's Medical Dictionary
The innermost fetal membrane; a thin, transparent sac that holds the fetus suspended in the liquor amnii, or amniotic fluid.
This grows rapidly at the expense of the extraembryonic coelom, and by the end of the third month it fuses with the chorion, forming the amniochorionic sac. Commonly called the bag of waters.
Amnion
Taber's Medical Dictionary
The shift in frequency produced when an ultrasound wave is echoed from something in motion. The use of the Doppler effect permits measuring the velocity of that which is being studied (e.g., blood flow in a vessel).
Doppler ultrasonography
Taber's Medical Dictionary
This identifies the size and position of the fetus, placenta, and umbilical cord enables estimation of gestational age, detects some fetal anomalies and fetal death, and facilitates other diagnostic procedures, such as amniocentesis.
Ultrasound
Inaudible sound in the frequency range of approx. 20,000 to 10 billion (109) cycles/sec. This has different velocities that differ in density and elasticity from one kind of tissue to the next. This property permits the use of this procedure in outlining the shape of various tissues and organs in the body.
Transabdominal puncture of the amniotic sac under ultasound guidance using a needle and syringe in order to remove amniotic fluid.
This procedure is usually performed no earlier than at 14 weeks' gestation.
Amniocentesis; The sample obtained is studied chemically and cytologically to detect genetic and biochemical disorders and maternal-fetal blood incompatibility and, later in the pregnancy, to determine fetal maturity. The procedure also allows for transfusion of the fetus with platelets or blood and instillation of drugs for treating the fetus.
It is important that the analysis be done by experts in chemistry, cytogenetics, and cell culture. Cell cultures may require 30 days, and if the test has to be repeated, the time required may be insufficient to allow corrective action.
A lab diagnosis of a combo of events signaling a variation of severe pre-eclampsia marked by hemolysis anemia, ↑liver enzymes, & ↓platelet count. This potentially life-threatening condition usually arises in the last trimester of preg.
HELLP syndrome; Initially, affected pts may c/o N/V, epigastric pain, H/A, & vision prob. Complications may include acute renal failure, DIC, liver/resp, or multiple organ sys failure.
Taber's Medical Dictionary
A congenital defect in the walls of the spinal canal caused by a lack of union between the laminae of the vertebrae.
The lumbar portion is the section chiefly affected. The consequences of this defect may include urinary incontinence, saddle or limb anesthesia, gait disturbances, and structural changes in the pelvis.
Spina Bifida Cystica
Taber's Medical Dictionary
1. That state of a body or any of its organs or parts in which the functions are healthy and normal. In a more restricted sense, the resistance of muscles to passive elongation or stretch.
2. Normal tension or responsiveness to stimuli, as of arteries or muscles, seen particularly in involuntary muscle (such as the sphincter of the urinary bladder).
Tone
Taber's Medical Dictionary
A system of estimating current fetal status, determined by analyzing five variables via ultrasonography and nonstress testing.
Fetal breathing movements, gross body movement, fetal tone, amniotic fluid volume, and fetal heart rate reactivity are each assigned specific values.
BPP
Taber's Medical Dictionary
Each expected normal finding is rated as 2; each abnormal finding is rated as 0. Scores of 8-10 with normal amniotic fluid volume and a reactive NST indicate satisfactory fetal status. A score of 6 with normal amniotic fluid vol requires reassessment of a preterm fetus within 24 hr of delivery. Scores of <6 or a nonreactive NST indicate fetal compromise & require prompt delivery.
BPP
Taber's Medical Dictionary