1102 Ati: Maternal Newborn

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Presumptive:

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Amenorrhea
Fatigue
Nausea and Vomitting
Urinary frequency
Breast changes-darkened areola, enlarged montgomery's tubules
Quickening-slight fluttering movements of the fetus felt by a woman, usually between 16 to 20 weeks of gestation.
Uterine enlargement
Linea nigra
Chloasma (mask of pregnancy)
Stria grvidarum

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Probable Signs:

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changes that make the examiner suspect a woman is pregnant (primarily related to physical changes of the uterus). Signs can be caused by physiological factors other than pregnancy (peristalsis, pelvic, congestion, tumors.)
Abdominal enlargement related to changes in uterine size, shape, and position.
cervial changes
Hegar's sign-softening and compressibility of lower uterus.
Chadwick's sign-softening of cervical tip
Ballottement-rebound of unengaged fetus
Braxton hicks Contraction-false contractions, painless, irregular, and usually relieved by walking.
Positive pregnancy test
Fetal outline felt by examiner

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Positive signs:

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Fetal Heart sounds
Visualization of fetus by ultrasound
Fetal movement palpated by and experienced examiner.

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Serum and urine tests provide an accurrate assessment for the prescence of :

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human Chorionic gonadotropin (hcg). HCG can be detected 6 to 11 days in serum and 26 days in urine after conception.

Higher levels indicate multifetal pregnancy, ectopic pregnancy, hydatidiform mole (gestational trophoblastic disease), or a genetic abnormality such as Down Syndrome. Lower blood levels of HCG may suggest a miscarriage or ectopic pregnancy.

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Which medications cause false-positives and or false negatives:

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(Anticonvulsants, diuretics, tranqulizers)

Urine sample should be first-voided morning specimens.

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Nulligravida:

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a woman who has never been pregnant.

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Primigravida:

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a woman in her first pregnancy.

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Multigravida:

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a woman who has had two or more pregnancies.

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GTPAL:

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gravidity
Term births
Preterm births (viability to 37 weeks)
Abortion/miscarriages (prior to viability)
Living children

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Cardiovascular increases:

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40-50% at term increase.

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Blood pressure decreases how much during 2nd trimester:

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10 to 15 mm HG for diastolic and systolic

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Pulse increases:

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10 to 15/min around 20 weeks of gestation and remains elevated throughout the remainder of the pregnancy.

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Respirations increase:

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1 to 2/min. respiratory changes in pregnancy are attributed to the elevation of the diaphragm by as much as 4cm as well as changes to the chest wall to facilitate increased maternal oxygen demands. some shortness of breath may be noted.

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Cervix softening:

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Goodell's sign

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Chloasma:

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mask of pregnancy (pigmentation increases on the face)

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Linea NIgra:

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dark line of pigmentation from umbilicus extending to the pubic area

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Stria gravidarum:

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stretch marks most notably found on the abdomen and thighs.

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Hegar's:

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softening and compressability of the lower uterus.

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Chadwick's:

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deepened violet-bluish color of vaginal mucosa secondary to increased vascularity of the area.

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Goodell's

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softening of cervical tip

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Ballottement:

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rebound of unengaged fetus

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Braxton Hicks:

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Painless irregular contractions that are usually relieved with walking

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Quickening:

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Slight fluttering movements of fetus felt by a woman

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Chloasma:

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mask of pregnancy (pigmne

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Linea nigra:

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dark line of pigmentation from the umbilicus to the pubic area

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Stria gravidarum:

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stretch marks most often found on the abdomen and thighs

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Lab test: bood type, RH-factor, and prescence of irregular antibodies.

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determines the risk for maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal hyperbilirubinemia. for clients who are RH-negative and not sensitized, the indirect Coombs' test will be repeated between 24 to 28 weeks gestation.

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CBC with differential, HGB, and HCT

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detects infection and anemia

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HGB electrophoresis

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indentifies hemoglobinopathies (sick cell anemia and thalassemia)

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Urinalysis with microscopic examination of ph, specific gravity, color sediment protein glucose, albumin, RBC's, WBCs, casts, acetone, and human chorionic gonadotropin

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identifies diabetes mellitus, gestational hypertension, renal disease, and infection.

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One-Hour glucose tolerance
(oral ingestion or IV administration of concentrated glucose with venous sample taken 1 hr later (fasting not necessary)

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Identifies hematuria; done at initial visit for at risk clients, and at 24 to 28 weeks gestation for all pregnant women (>140 mg/dl requires follow up).

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Three-hour glucose tolerence
(fasting overnight prior to oral ingestion or IV administration of concentrated glucose with a venous sample taken 1, 2, and 3 hr later

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used in clients with elevated 1-hr glucose test as a screening tool for diabetes mellitus. A diagnoses of gestational diabetes requires two elevated blood-glucose readings.

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Papanicolaou (PAP) test

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screens for cervical cancer, herpes simplex type 2, and/or human papillomavirus.

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Vaginal/cervical culture

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Detects streptococcus B-hemolytic, Group B (routinely obtained at 35 to 37 weeks of gestation)

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Rubella Titer:

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determines immunity to rubella.

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Hepatitis B screen

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Identifies carriers of hepatitis B

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Venereal disease research laboratory:

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Syphilis screening mandated by law.

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HIV:

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Detects HIV infection (the Centers for Disease control and Prevention and the american congress of Obstetricians and Gynecologists recommends testing all clients who are pregnant unless the client refuses testing.)

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Toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes virus (TORCH) screening when indicated

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Screening for a group of infections capable of crossing the placenta and adversely affecting fetal development.

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Maternal serum alpha-fetoprotein (MSAFP)

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Screening occurs between 15 to 22 weeks of gestation. Used to rule out Down Syndrome (low level) and neural tube defects (high level). The provider may decide to use a more reliable indicator and opt for the Quad screening instead of the MSAFP at 16 to 18 weeks of gestation. This includes AFP, inhibin-A, a combination analysis of human chorionic gonadotropin, and estriol.

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Assess for Costovertebral angle tenderness, which is:

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indicative of renal infection.

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Administer RH (D) immune globulin (RHOGAM) IM around 28 weeks of gestation for clients who are:

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RH-Negative.

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Dick Read Method:

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refers to "childbirth without fear." Uses controlled breathing and conscious and progressive relaxation of different muscle groups throughout the entire body. This method instructs a woman to relax completely between contractions and keep all muscles except the uterus relaxed during contractions.

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Lamaze:

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the mission of Lamaze International is to promote a healthy, natural and safe approach to pregnancy, childbirth, and early parenting by advocating and working with health care providers, parents, and professional childbirth educators.

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Bradley:

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stresses the partner's involvement as the birthing coach. this method empasizes increasing self-awareness and teaching the woman to deal with the stress of labor by tuning into her own body. The mother is encouraged to trust her body and use natural breathing, relaxation, nutrition, exercise, and education throughout her pregnancy.

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Macrosomia:

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is used to describe a newborn with an excessive birth weight.

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Maternal Phenylketonuria (PKU):

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this is a maternal genetic disease in which high levels of phenylalanine pose danger to the fetus.

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LIthotomy Position:

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feet up in sterrups position

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Biophysical Profile:

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uses realtime ultrasound to visualize physical and physiological characteristics of the fetus and observes for fetal biophysical responses to stimuli.

Reactive FHR (reactive non stress test)=2; nonreactive=0

Fetal breathing movements (at least 1 episode of 30 sec in 30 min)=2; absent or less than 30 sec duration=0

Gross body movements (at least 3 body or limb extension with return to flexion in 30 min)=2; less than 3 episodes=0

Fetal tone (at least 1 episode of extension with return to flexion)=2; slow extension and flexion, lack of flexion, or absent of movement=0

Amniotic fluid volume (at least 1 pocket of fluid that measures at least 1 cm in 2 perpendicular planes)=2; pockets absent or less than 1 cm=0

Interpretation findings:
8-10 normal
6 is equivocal
<4 is abnormal

Potential diagnoses:
nonreactive stress test
suspected oligohydramnios or polyhydramnios
suspected fetal hypoxemia and/or hypoxia
client presentation:
premature rupture of membranes
maternal infection
decreased fetal movement
intrauterine growth restriction

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Nonreactive Stress Test Indicates:

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fetal heart does not accelerate adequately with fetal movement. It does not meet the above criteria after 40 minutes

The NST is interpreted as reactive if the FHR is a normal baseline rate with moderate variability, accelerates to 15 beats/min for at least 15 seconds and occurs two or more time during a 20-min period.

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Contraction Stress Test:

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woman lightly brushing her palm across her nipple for 2 or 3 min, which causes the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins. The same process is repeated after a 5 min rest period..
A pattern of at least three contractions within a 10-minute time period with duration of 40-60 seconds each must be obtained to use for assessment data.

used when:
non reactive stress test
High-risk pregnancies (gestational diabetes mellitus, postterm pregnancy.)

Negative CST-(normal finding) indicated if within 10-min period, with three uterine contractions, there are no late decelerations of the FHR.

Positive CST (abnormal finding)-indicated with persistent and consistent late decelerations on more than half of the contractions. This is suggestive of uteroplacental insufficiency. Variable decelerations may indicate cord compression, and early decelerations may indicate fetal head compression. Based on these findings, the primary care provider may determine to induce labor or perform a cesarean birth.

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AFP:

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Alpha-fetoprotein can be measured from the amniotic fluid between 16 and 18 weeks of gestation and may be used to assess for neural tube defects in the fetus or chromosomal disorders. May be evaluated to follow up a high level of AFP in maternal serum.
High levels are associated with Neural tube defects such as ancencphaly, spina bifida, omphalocele.

Low levels are associated with Dow Syndrome and gestational trophoblastic disease (hydatidiform mole).

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Fetal Lung Tests are used if gestational age is less than 37 weeks.
ratios:

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2:1 indicates fetal lung maturity
2.5 to 1 or 3:1 for diabetes mellitus.

Prescence of phosphatidylglycerol (PG)-absence of PG is associated with respiratory distress

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RH-Negative mothers are given:

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Rhogham!!!

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Kleihaurer-Betke test:

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that ensures blood obtained is from the fetus. detects if fetal blood is circulating in mother.

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Indirect Coomb's test:

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checks for RH Antibodies

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Chorionic villus sampling (CVS)-:

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assessment of a portion of the developing placenta (chorionic villi) is aspirated through a thin sterile catheter or syringe through the abdomen or intravaginally through the cervix under ultrasound guidance and analyzed.
CVS-is an alternative to amniocentesis with one of its advantages being an earlier diagnoses of any abnormalities. CVS can be performed at 10 to 12 weeks of gestation and rapid results with chromosome studies are avialable in 24 to 48 hr following aspiration.

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Quad Marker screening:

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a blood test done between 15 to 20 weeks of gestation that will ascertain information about the likelihood of fetal birth defects. It does not diagnose the actual defect. It may be performed instead of the maternal serum alpha-fetoprotein yielding more reliable findings. The test screens for the prescence of HCG, AFP, estriol and INHIBIN-A

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HCG:

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Human Chorionic gonadotropin (hcg)-a hormone produced by the placenta

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Alpha-fetoprotein (AFP)

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-a protein produced by the fetus

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Estriol:

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a protein produced by the fetus and placenta

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Inhibin A-

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a protein produced by the ovaries and placenta

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Causes of bleeding 1st trimester:

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Spontaneous abortion: Vaginal bleeding, uterine cramping, partial or complete expulsion of products of conception.

Ectopic: abrupt unilateral lower-quadrant abdominal pain with or without vaginal bleeding

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Causes of bleeding 2nd trimester:

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Gestational trophoblastic disease: Uterine size increasing abnormally fast abnormally high levels of HCG, nausea and increased emesis, no fetus present on ultrasound, and scant or profuse dark brown red vaginal bleeding.

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Causes of bleeding 3rd trimester:

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Placenta Previa: Painless vaginal bleeding

Abruptio placenta: Vaginal bleeding, sharp abdominal pain, and tender rigid uterus

Vasa previa: Fetal vessel cross over the cervix abrupt bright red vaginal bleeding following rupture of membranes.

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Spontaneous abortion:

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when pregnancy is terminated before 20 weeks of gestation or a fetal weight less than 500g.

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D & E:

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done to dilate and evacuate uterine contents after 16 weeks gestation

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D & C:

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dilation and curettage is done to dilate and scrape the uterine walls to remove uterine contents for inevitable and incomplete abortions.

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Salpingostomy:

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removal of fallopian tube

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Placenta Previa:

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occurs when placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. The abnormal implantation results in bleeding during the third trimester of pregnancy as the cervix begins to dilate and efface.

Complete or total-when the cervical os is completely covered by the placental attachment.

Incomplete or partial-when the cervical os is only partially covered by the placental attachment

Marginal or low lying-when the placenta is attached in the lower uterine segment but does not reach the cervical os

Subjective-painless, bright red vaginal bleeding that increases as the cervix dilates.
Assessment findings: soft, relaxed, nontender uterus with normal tone
high fundal height more than normal.

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Abruptio Placenta:

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premature seperation of the placenta from the uterus, which can be a partial or complete detachment. This seperation occurs after 20 weeks of gestation, which is usually in the third trimester. It has significant maternal and fetal morbidity and mortality and is a leading cause of maternal death.

coagulation defect, such as disseminated intravascular coagulopathy, is often associated with moderate to severe abruption.

No vaginal exams
Uterine hypertonicity (firm rigid uterus)
signs of hypovolemic shock

risk factors:
maternal hypertension
cocaine
smokers
premature rupture of membranes
High parity

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Vasa Previa:

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is the prescence of fetal blood vessels crossing the amniotic membranes over the cervical os. there is a high newborn mortality rate . Risk is associated with fetal hemorrhage, as the client's cervix dilates or membranes rupture.

Objective: painless heavy bleeding upon rupture of membranes
Fetal bradycardia
HGB and HCT decreased

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TORCH:

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Toxoplasmosis-caused by consumption of raw or undercooked meat or handling cat feces. The symptoms are similar to influenza or lymphadenopathy.

Rubella-(German Measles)-is contracted through children who have rashes or neonates who are born to mothers who had rubella during pregnancy.

Cytomegalovirus-(herpes family)-is transmitted by droplet infection from person to person, a virus found in semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces, and blood. Latent virus may be reactivated and cause disease to the fetus in utero or during passage through the birth canal.

HSV-herpes simplex virus is spread by direct contact with oral or genital lesions. Transmission to the fetus is greatest during vaginal birth if the woman has active lesions.

symptoms:
Toxo-similar to influenza
rubella-joint and muscle pain
Cyto-asymptomatic or mononucleosis-like symptoms

Toxoplasmosis treatment-pyrimethamine, sulfadizine harmful to fetus but parasitic treatment necessary.

Rubella treatment: no immunization
low titers prior to pregnancy immunizations
Cyto-no treatment, avoid crowds of children and wash hands.

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Incompetent Cervix:

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painless dilation of the cervix in the absense of uterine contractions. The cervix is incapable of supporting the weight and pressure of the growing fetus and results in expulsion of the products of conception during the second trimester of pregnancy.

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Short Cervix:

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less than 20 mm in length