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168 Cards in this Set
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Fetal heart will normally display no variability
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Less than 32 weeks gestation
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Baseline fetal heart rate is
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120-160
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Fetal bradycardia defined as
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FHT less than 120 for 15 sec or more
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Fetal tachycardia defined as
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FHT greater than 160, above 181 is severe
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Variability is defined as
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change in beat to beat rate (it's a good thing)
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Short-term variability is qualitatively what? What is required to observe it?
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changes from one R wave to next R wave; fetal scalp electrode
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Long-term variability is
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Changes occuring over 1 minute
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Good variability suggests what?
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Adequate oxygenation
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Decreased FHT variability is associated with
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hypoxia
acidemia drugs sleep prematurity CNS or cardiac abnormalities |
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Sinusoidal pattern is associated with _____ and defined as ____
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severe fetal anemia
stable baseline (120-160) with amplitude of 5-15 bpm with 2-5 cycles/min |
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FHT accelerations are defined as
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increase in FHR of 15 beats above baseline for 15 sec
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What do FHT accelerations demonstrate?
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mature neurocardiac tract; reassuring of fetal well being
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Normal FHT pattern during labor is
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Acceleration during contraction due to squeezing of baby, with a return to baseline
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Decelerations are slowing of FHR and are what 3 types?
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Early
Variable Late |
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Early decels are associated with
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head compression
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variable decels are associated with
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cord compression (not good)
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Late decels are associated with
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uteroplacental insufficiency
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Early decel patterns ...
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mirror contractions; pt should be checked as head is probably descending; no tx necessary
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Variable decel patterns ...
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sharp decrease in FHT occuring ANY TIME as a rapid fall and return
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Persistent deep variable decels can cause ____ because of ____. What should be done?
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fetal hypoxia
cord compression check the pt, may try maternal position change or amnioinfusion |
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Late decel patterns ...
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are a symmetrical decrease in FHT beginning at peak or after peak of contraction and returns to baseline when contraction is over
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Causes of late decels/uteroplacental insufficiency include
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post dates
placental abruption maternal HTN maternal DM maternal anemia maternal sepsis hyperstimulation hypertonia |
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Tx of late decels includes
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Check pt
Maternal O2 Turn mother to LEFT SIDE IV fluid bolus Stop pitocin Amnioinfusion |
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Positional tx of late decel is
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turning mother to LEFT side
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Most common cause of perinatal M&M
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preterm labor
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Complications of preterm labor include
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RDS
intravascular hemorrhage necrotizing enterocolitis sepsis seizures |
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Long-term complicatoins of preterm labor include
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bronchopulmonary dysplasia
developmental abnormalities |
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Preterm labor is defined as
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regular uterine contractoins with cervical effacement and dilation/descent between 20 and 37 weeks gestation
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Tx of preterm labor is most effective ..
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early in the course of preterm labor
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Factors associated with preterm labor risks
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dehydration
incompetent cervix infections smoking excessive uterine enlargement (ie multiples) uterine distortion (fibroids) placental abnormalities substance abuse |
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Signs/Sxs of PTL include
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menstrual-like cramps
low dull back ache abdnominal pressure/cramping pelvic pressure change in vaginal discharge (blood mucous) uterine contractions |
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Evaluation of PTl consists of
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External fetal monitor
palpate abdomen Cervical exam with consistent examiner |
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Labs used in the evaluation of preterm labor include
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UA with culture, CBC, GBS culture, GC, Chlamydia, wet prep
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Imaging used in the dx of preterm labor includes
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U/S for gestational age, AFI (amniotic fluid index), placental location
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Other things to do when presented with possible PTL include
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review records for indicators of PTL, gestational age, complicatoins
focused hx and PE |
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Management goal of PTL is ____ and include what steps?
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delay labor as long as possible
IV hydration and access sedation tocolytics GBS prophylaxis Steroids |
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Steroids such as _____ should be given in PTL to
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betamethasone, dexmethasone, decadron
inhibit something to produce surfactant (not past 34 wks) |
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An important consideratoin in managing PTL is to give ____ such as what?
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GBS prophylaxis
ampicillin, clindamycin, erythromycin, penicillin |
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Tocolytics used in PTl management include
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MgSO4
terbutaline, brethine (B-agonist) nifedipine (Ca channel blocker) Prostaglanding synthesis inhibitors (indomethacin) |
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Main AEs of MgSO4 include
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respiratory depression
loss of reflexes toxicity pulmonary edema HoTN |
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What should always be had on hand when giving MgSO4?
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a amp of calcium gluconate to reverse it
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Dose of MgSO4
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4 gm loading and run at 2 gm/hr
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Important AE of indomethacin/PG inhibitors
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premature closer of ductus arteriosis, esp after 34 wks, decrease in amniotic fluid
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No tx is needed for PTL after
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36 weeks d/t fetal lung maturity
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It is best to deliver a preterm infant ...
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at hospital with a NICU ... consider transfer if not adequately equipped
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Contraindications to tocolytic therapy include
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Advanced labor (if dilated 5cm, too late to stop)
Mature fetus (determine with amniocentesis) Anomalous fetus intrauterine infection large amount of vaginal bleeding |
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Test that only helps you determine if a pt is NOT in PTL
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fetal fibrinectin test
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Steroids help fetal lung maturity by
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inducing proteins that regulate Type II pneumocyte cells that produce surfactant
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Dose of steroids used in PTL
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Betamethasone 12.5 mg IM q12 hrs x 2
Decadron 6.25 mg IM q 6 hrs x 4 |
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Best method for PTL delivery
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vaginal
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Uterine fibroids defined as
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benign smooth muscle tumor of the uterus
(aka leiomyomata, uterine myoma) |
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Uterine fibroids are the ____ common solid pelvic tumor in women and the leading cause of ______
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most
hysterectomies |
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peak occurence of fibroid sis
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40-45 years of age
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pregnancy in relation to fibroids seems to ...
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protect against their development
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After menopause, fibroids ...
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decrease in size
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Fibroids contain what receptor types?
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estradiol and progesterone, which regulate size
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Fibroid locations include
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submucosal (beneath endometrium)
intramural (in muscular layer) subserosal (beneath uterine serosa) |
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Most symptomatic fibroids are
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submucosal
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Signs and sxs of fibroids are associated with ____ and include
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size, number and location
asymptomatic bleeding pain all 3 |
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Most fibroids are
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asymptomatic
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1/3 women with fibroid-related bleeding describe it as
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"menorrhagia, metorrhagia, menometorrhagia"
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1/3 women describe fibroid-related pain as
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pelvic pain, pressure, urinary frequency and urgency, LBP, rectal sxs
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Fibroids may cause infertility due to
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compresion of fallopian tubes
endometrial function recurrent pregnancy loss |
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PE for fibroids consists of
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palpate an enlarge midline pelvic mass
may be irregular in shape may be in adnexal region |
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Dx of fibroids is done by
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pathologic dx (bx and send to path)
pelvic u/s PE hysteroscopy (not good alone) |
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Bleeding from a fibroid ...
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must be worked up separately as it may not be related!
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Causes of bleeding other than fibroids include
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uterine ca
anovulation (most common cause) hyperplasia of uterine lining lining too thing |
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Bleeding sxs of fibroids is qualified as
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menorrhage with menses lasting 7 or more days causing heavy anemia and changes in quality of life
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Tx of fibroids is based upon _____
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symptoms
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Asymptomatic tx of fibroids is
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expectant management -- follow the size with u/s, observe if no rapid growth detected
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Symptomatic pain/bleeding of fibroids is treated
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hysterectomy
GnRH agonists |
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GnRH agonists treat fibroids by _____, and are limited to what regimen?
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producing a hypoestrogen state that shrinks the size of fibroids
No more than 6 months due to osteoporsis; fibroid will enlarge again once tx d/c |
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Other tx options of fibroids include
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myomectomy (removal of fibroid) in pts who wish to conceive
uterine artery embolization (not good) endometrial ablation (controls bleeding by destroying endometrium) myolysis (electrical current with needles into fibroid to coagulate) |
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Endometriosis is defined as
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presence of endometrial-like glands and stroma outside of uterus
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Endometriosis is a dz dependent upon
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estrogen
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Factors associated with reduced ____ increase risk for endometriosis and include
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estrogen
decreased body fat, exercise-induced menstrual problems, smoking |
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Endometriosis is a ____ dx requiring
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histologic
glands and stroma present |
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clinical sxs of endometriosis include
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asymptomatic (usually not)
pain, bleeding, and infertility |
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Minor/uncommon complaints of endometriosis include
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dysmenorrhea, chronic pelvic pain, dyspareunia, tenesmus, dyschezia, dysuria
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Pe is of limited value in endometriosis dx but typically demonstrates
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nodularity or tenderness in cul-de-sac, parametrial thickness, adnexal mass, thick uterosacral ligaments
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Dx of endometriosis is done by
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bx of lesions during laparoscopy
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Endometrial lesion appearance can be described as
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gun power appearance, red, blue, raised glossy blobs, fibrous adhesions, chocolate cyst
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Lesions of endometriosis respond to
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normal menstrual cycle
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Tx of endometriosis is directed toward
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patient goals and fertility desires
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Function of danazol in tx of endometriosis
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creates a chronic anovulatory state by decreasing midcycle LH/FSH surge
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Dose of danazol requires to reach anovulatory state
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600-800 mg/day
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AEs of danazol include
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increased free levels of hormones, esp testosterone, resulting in IRREVERSIBLE androgenic effects (ie deepened voice)
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Long term use of progesterone in tx of endometriosis can lead to
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reversible osteopenia
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Progesterone can cause ____ when used to tx endometriosis
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endometrial atrophy
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Oral contraceptive dosage to tx endometriosis is accomplished by
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continuous use for 3-4 mos and cycle after 4th pack (only prevents spotting)
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GnRH analogs used to tx endometriosis work by ____ and take ____ to work
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down regulating pituitary gland resulting in decreased gonadotropins
3-6 weeks |
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AEs of GnRH analogs used in the tx of endometriosis include
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menopausal sxs treatable with estrogen
decreased bone density (advise Ca use and BSD checks; consider bisPO4) |
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GnRH analog use is limited to _____ with a _____ "holiday"
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6 months
1 yr |
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Useful pain meds in tx of endometriosis
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NSAIDs (preferred)
narcotics |
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All treatments of endometriosis are used to
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delayed hysterectomy
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_____ is better for infertility when tx endometriosis
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surgical tx
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conservative surgical tx of endometriosis
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done with laser, excision, cauterization of lesions visible and in safe location
includes presacral neuroectomy or uterosacral ligament transection |
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Definitive surgical tx of endometriosis includs
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hysterectomy with bilateral salpingo-oopherectomy
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Definition of ectopic pregnancy
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implantation of the blastocyst ANYWHERE other than the endometrial lining (even the cervix)
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95% of ectopic implantations occur
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in the tube
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Risk factors for ectopic pregnancy include
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PID
Previous ectopic Smoking Previous tubal surgery DES exposure Increased age (>30) Multiple induced abortions Progesterone-only pill IUD, sterilization ART Transmigration of ovum |
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Most common site of tubal ectopic implantatoin
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ampulla
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second most common site of tubal ectopic
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isthmus
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Tubal abortion is common in ectopics of the
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ampulla
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tubal rupture is common in ectopics of the ____ with resultant _____
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isthmus
hemorrhage |
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clinical presentation of ectopic pregnancy triad is
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amenorrhea, pain, vaginal bleeding
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Other indications of ectopic pregnancy in relation to its symtomatic triad include
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+ pregnancy test with amenorrhea
low abdominal pain that is unilateral, sharp, stabbing, tearing vaginal spotting/bleeding GI symptoms such as N/V/D due to blood in peritoneum dizziness/lightheadedness profuse vaginal bleeding |
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PE results of ectopic pregnancy include
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Vital signs consistent with hypovolemic shock, or may be nl. Should NOT HAVE ELEVATED TEMPERATURE in tubal pregnancy
Vaginal bleeding: large, small, or none uterine enlargement cervical motion tenderness d/t movement of tube pelvic mass (may or may not feel d/t pt guarding; will be tender if peritoneal blood present) |
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Labs used in dx of ectopic pregnancy
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CBC for baseline
beta QUANTITATIVE HCG Progesterone level Blood group, type, and screen |
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beta quant HCG is ordered in suspected ectopic to get baseline and should be repeated in ____, looking for _____
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48 hours
doubling as in normal pregnancy |
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Normal IUP progesterone levels are _____. <15 may be _____ and < 5 is probably _____
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20 or higher
ectopic nonviable pregnancy |
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What should ALWAYS be done in the workup of a pregnancy pt?
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blood group, type, and screen
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U/S is used in ectopic pregnancy to
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look for an IUP
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What must be known prior to doing an u/s for suspected ectopic?
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HCG level
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Abnominal u/s needs to have an HCG level of ______ to be able to visualize anything such as _______
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3000-5000
gestational sac FHT in uterus |
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Although it is better, vaginal ultrasound requires an HCG level of _____ and the clinician should search for __________
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at least 1500 and can see IUP earlier than abdominal
fetal pole within gestational sac, FHT |
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What should also be looke for on u/s in suspected ectopic?
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adnexal mass
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The use of u/s in a possible ectopic is used merely to
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r/o IUP
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DDx of ectopic pregnancy
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salpingitis
abortion of IUP rupture of corpus luteum ovarian torsion appendicitis GI disorder |
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Features to ddx salpingitis from ectopic
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salpingitis has NO MISSED PERIOR or BLEEDING, bilateral pain. Temp greater than 38C
neg pregnancy test |
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Sxs of IUP abortion include
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low, cramping midline pain.
unilateral tubal pain tissue at cervical os |
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sxs of corpus luteal/follicular cyst rupture
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negative pregnancy test
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sxs of ovarian torsion
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no missed period
no bleeding no pelvic mass on exam or CMT pain waxes and wanes neg pregnancy test |
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sxs of appendicitis
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begins at umbilicus and moves to McBurney point
no missed period no bleeding, pelvic mass, CMT neg preg test |
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sxs of GI disorder
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N/V/D
neg preg test |
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surgical tx of ectopic pregnancy includes
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laparoscopy / laparotomy
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preferred surgical tx method for an UNRUPTURED tube in ectopic pregnancy
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salpingostomy
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Post-op care of ectopic tx includes
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CBC, replace blood prn
FOLLOW HCG to 0, may take up to 4 weeks Rho Gam PRN |
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Medical tx of ectopic pregnancy includes
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Methotrexate
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Methotrexate is an
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antimetabolite that binds dihydrofolic acid reductase to inhibit DNA, RNA, and protein synthesis
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Methotrexate tx for ectopic preg may be considered if gestation is ______, tubal mass is _____, and absence of _____
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< 6 weeks
< 3.5 cm FHTs |
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Pt requirements for methotrexate therapy of ectopic pregnancy is
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hemodynamically stable
normal CBC nl liver and renal function reliable pt abstinence from intercourse until HCG = 0 no EtOH |
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Single-dose therapy of methotrexate is
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50mg/m^2 IM once
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HCG monitoring in methotrexate therapy is done at days
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1,2,5,10,15
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HCG may _____ on first and second days, then _____ down to ____ by _____
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rise
fall 0 14-21 days |
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Labor is defined as
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cervical dilation with uterine contractions
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first stage of labor
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onset of labor to full cervical dilatoin (10cm)
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first phase of 1st stage of labor
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latent phase, 0-3 or 4 cm, may last 20 hrs in primiparous or 14 in multiparous
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2nd phase of 1st stage of labor
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active phase
rapid change in dilation from 3/4 cm to 10cm lasts 4-6 hours primips dilate 1cm/hr multips dilate 1.5cm/hr |
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second state of labor
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full dilation to delivery
cardinal movements lasts about 2 hrs |
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third stage of labor
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baby delivery to placental delivery
last 30 minutes or more |
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fourth stage of labor
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post-partum plus 2 hours after placental delivery
most likely time for PP hemorrhage or uterine atony monitor closely |
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what can effect the duration of the latent phase and 2nd stage of labor?
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sedatoin, epidurals, unripe cervix, persistent occiput posterior
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Typical pt CC of labor
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uterine contractions
membrane rupture bleeding |
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Initial evaluation of labor should include
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prenatal records
focused hx limited PE |
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During the eval of labor, prenatal records should be scrutinized for
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complicatoins
gestational age labs group B strep status |
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Focused hx in labor includes
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nature/frequency of contractions
membrane status bleeding fetal movements |
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components of the limited PE in labor include
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observation/palpation of uterine contractions
FHTs Leopold's manuever (check fetal position) vaginal exam (effacement) cervical position, consistency, dilation, station |
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Station is defined as
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relation of presenting part to ischial spines
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Station of 0 indicates
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biparietal diameter has negotiated the pelvic inlet and vaginal delivery may continue
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Management of the laboring patient includes
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maternal vitals q 30 min
NPO except ice chips IV for hydration/access Foley prn Analgesics External fetal monitor |
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Labs for the patient in labor include
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CBC, blood type/screen, U/A
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the U/A in the laboring patient should be checked for
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glucose and protein
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External fetal monitor is used in the labor pt to check
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fetal tolerance of labor
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Pelvic exams during labor should be
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minimized, and done by the same examiner
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Contractions should be monitored for what pattern for labor?
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contractions q 2 minutes for 60sec
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Force of contractions are measured with ____ and usually _____ for labor
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internal monitor
50-60 mmHg or 180 MVU |
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To avoid damage to the perineum during delivery, what should be done?
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slow and controlled delivery of the fetal head
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If meconium is present at delivery, suctoin should be applied to
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the pharynx
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Hands should be placed where and what traction direction should be applied to deliver the anterior shoulders?
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chin and vertex
downward pressure |
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Overall steps for second stage of pregnancy include
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begin pushing
molding of fetal head slow and controlled head delivery nose/mouth bulb suctioned check for nuchal cord restitute upward tractoin downard traction expulsion of body suction mouth/nose again clamp and cut cord baby to warmer obtain cord blood repair epesiotomy/lacerations |
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What event indicates third stage of labor?
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gush of blood with cord lenghtening
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To deliver the placenta, the physician
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applies suprapubic pressure and gentle traction on the cord
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Pulling on the cord can lead to
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inversion of uterus or cord tearing
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After placental deliver, the cord/placenta should be checked for
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2 arteries, 1 vein
ensure intact placenta delivered |
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Final step in third stage management is
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check vagina, cervix, rectum for tears/lacerations
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Management of the fourth stage of labor includes
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Observation for PP hemorrhage and uterine atony
V.S. q 15 minutes Fundal/bleeding checks q15 min Remain NPO and keep IV access |
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The fundus should be where in fourth stage?
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level of umbilicus
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