NUR230 Review #1
Signs of Pregnancy
Presumptive
Amenorrhea
Fatigue
Nausea and vomiting
Breast tenderness
Urinary frequency
Quickening
Probable
sign-Lower uterine segment softens
-Cervical softening
-Bluish discoloration of
vagina, cervix
Positive pregnancy test
Braxton hicks contractions or ballotment
Positive
Hearing fetal heart tones
Visualization of the fetus
Palpation of fetal movements by examiner
Signs of Pregnancy
(Table 7-2, p.152)
Pregnancy Terms
Gravida- # of pregnancies (including current)
Para- # of pregnancies 20 weeks or >
Term- 37-40+ weeks (postterm-42+ weeks)
Preterm-20-36 6/7 weeks
Abortion-any pregnancy that ended prior to 20 weeks (spontaneous
or elective
Living- # of living children
Rule
Method for calculating Estimated Due Date (EDD)
First day of last menstrual period (LMP)
Subtract 3 from the month
Add 7 to the day
Adjust year if needed
Fetal Assessment
Fetal heart rate- 110-160
Uterine height in centimeters should equal gestational age +/-2
Fetal movement
Cardiac Changes
B
Blood volume increases
40-50%
results in physiological anemia
Cardiac output increases 30-50%
Respiratory Changes
Ligaments of rib cage relax
Diaphragm is displaced due to enlarging uterus; chest breathing vs. abdominal
breathing
Upper respiratory more vascular: congestion, epistaxis, changes in voice
Gastrointestinal Changes
Hyperemesis gravidarumChanges in taste and smell
Pytalism
Pica
First Trimester Labs
Hgb and Hct (CBC)
Blood type and Rh
Antibody screen
Rubella titer (may offer booster after pregnancy)
Urinalysis
Screening for HIV
Screening for Hepatitis B
Syphilis (VDRL or RPR)
Offer Sickle Cell
Offer Cystic Fibrosis
Pap Smear
Gonorrhea/Chlamydia
First Trimester Discomforts
Breast enlargement, pain, tingling, tenderness
Urgency and frequency of urination
Fatigue
Nausea and vomiting (morning sickness)
Ptyalism (excessive salivation)
Gingivitis and epulis (gum hypertrophy, bleeding)
Nasal stuffiness
Leukorrhea (clear or light colored mucus)
Second Trimester Discomforts
Acne, pigmentation changes
Palmar erythema
Pruritus
Palpitations
Supine hypotension (vena cava
syndrome)
Faintness, syncope
Heartburn
Constipation, flatulence
Headaches
Carpal tunnel syndrome
Periodic numbness, tingling of
fingers
Round ligament pain
Joint pain, backache, pelvic
pressure
Third Trimester Discomforts
Shortness of breath and dyspnea
Insomnia
Mood swings, increased anxiety
Urinary frequency and urgency return
Perineal discomfort and pressure
Leg cramps
Ankle edema
Third Trimester Labs
1 hour glucose tolerance test, if elevated 3 hour glucose tolerance
test
Group B Strep vaginal/rectal swab
Second and Third Trimester Complications
Persistent severe vomiting
Sudden discharge of fluid from vagina
Vaginal bleeding; severe abdominal pain
Chills, fever, burning on urination, diarrhea
Severe backache or flank pain
Decrease in or absence of fetal movement
Uterine contractions
Symptoms of preeclampsia
Anemia
Normal values during pregnancy
-Hgb >11
-Hct >33
Occurs in 20% of pregnant women
Associated with increased incidence of miscarriage, preterm labor,
preeclampsia, infection, postpartum hemorrhage, and intrauterine
growth restriction
Factors that effect nutrition
Incompetent Cervix
Passive and painless dilation of the cervical os without labor or
contractions of the uterus
May occur in late 2nd or early 3rd trimester
Related to:
-cervical trauma
-excessive cervical dilation
-
Incompetent Cervix: Management
Bed rest, hydration, tocolysis
Cerclage may be placed at 11-15 weeks, removed at 37 weeks
Risks with cerclage:
-premature rupture of membranes
-preterm labor
-infection
Placenta Previa
Low-lying (C)
Partial or marginal (A)
Complete (B)
Painless bright red vaginal bleeding
Never perform a vaginal exam on a woman who is
bleeding unless you know location of placenta!
Premature separation of placenta from implantation site after 20
weeks
Abruptio Placentae
(Abruption)
Signs:
-vaginal bleeding
-severe abdominal pain, rigid board-like
abdomen
-uterine contractions; hypertonus
-port wine stained amniotic fluid
Preeclampsia: Symptoms
Mild
-BP 140/90 or greater
Severe
-BP 160/110 or greater
-Persistent or severe headache
-blurred vision; photophobia
-epigastric pain
-intrauterine growth restriction of fetus
Only cure is delivery of infant!
HELLP Syndrome
Can occur with severe preeclampsia
Laboratory diagnosis
H
E
L
L
P
Hemolysis
Elevated
Liver enzymes
Low
Platelets
Medications
Magnesium Sulfate- CNS depressant, smooth muscle relaxant; used to
prevent seizures
-Loading dose
-Maintenance dose
Assessment:
-RR (12 or >)
-LOC
-Clonus
-Urine output
-Serum mag level (<9mg/dL)
Calcium Gluconate at bedside as antidote
Pregestational Diabetes
Type 1 or Type 2
Glucose crosses placenta; insulin does not
Fetus produces insulin around 10th week
First trimester (weeks 7-15) prone to hypoglycemia due to metabolic
changes related to hormones
Second and third trimester insulin needs may double or quadruple
Complication Risks
Maternal:
-early pregnancy loss
-macrosomia (infant >4000gms)
-comorbidities (esp hypertensive disorders)
-preterm labor
-polyhydramnios
-more common & serious infections
-postpartum hemorrhage
-
Complication Risks
Fetal:
-unexplained fetal death
-congenital anomalies
-macrosomia
-hypoglycemia
-respiratory distress
-prematurity
Gestational Diabetes
Risk Factors:
-obesity
-family history
-age >35
-comorbidities
-having a previous infant >9lbs at birth
Screening:
-1 hour glucose tolerance test 24-28 weeks
-if abnormal followed by 3 hour OGTT
GDM: Treatment
First step: dietary modifications and exercise
Second step: insulin
Oral antidiabetics not often used because they cross the placenta.
Insulin does not cross the placenta.
Complications: can be same as with pregestational diabetes
At a greater risk of developing diabetes later in life
Preterm Labor
Diagnosis based on 3 factors:
-20-36 6/7 weeks gestation
-uterine activity (contractions)
-progressive cervical change (effacement and/or dilation
Risk factors: history of PTL, multiple gestation, 2 nd trimester bleeding,
African-American race, low prepregnancy wt, genital tract infections
Signs of PTL
Painful or painless contractions every 10 minutes for 1 hour or more
Lower abdominal cramping
Painful menstrual-like cramps
Dull, intermittent low back pain (below waist)
Suprapubic pain or pressure
Change in character of cervical discharge or amount
Rupture of amniotic membranes
Signs of UTI
Treatment of PTL
Tocolytic medications- (relax smooth muscle):
-terbutaline: oral or SC (must take pulse rate, if >120 hold
medication)
-magnesium sulfate
-Indocin
-Procardia
Passenger (fetus)
Passageway (birth canal)
Powers (Contractions)
Position (mother)
Psychologic response
Passenger
Presentation- part entering pelvic inlet first
-cephalic (vertex)
-breech (buttocks, feet or both)
-shoulder (scapula)
Fetal lie, attitude and position
all factors that determine
presenting part
Fetal Lie
RELATION OF LONG AXIS
(SPINE) OF FETUS TO LONG
AXIS (SPINE) OF MOTHER
LONGITUDINAL/VERTICAL:
PARALLEL
TRANSVERSE: AT A RIGHT
ANGLE
OBLIQUE: AT AN ANGLE
Fetal Attitude
Fetal head flexed or extended
Typically flexed, chin to chest,
allows easy passage through
maternal pelvis
If extended may not be able to fit
through pelvis
Fetal Position
Relationship of reference point on presenting part (occiput, sacrum,
mentum) to the four quadrants of the maternal pelvis
Denoted by 3 letters
1st- location of presenting part (right or left)
2nd- specific presenting part
3rd- location of presenting part in relation to
pelvis (anterior, posterior or transverse)
Fetal Position
Occiput- back of head
Mentum- face
Fetus in occiput
Fetus in occiput
posterior position
anterior position
Station
Relationship of presenting part to an imaginary line drawn between the
maternal ischial spines
Engagementlargest diameter of presenting
part
is at level of ischial spines
0 Station
+2 Station
Problems with Passageway
Macrosomia
Cephalopelvic disproportion(CPD)maternal pelvis
Pelvic Shapes
Powers
Primary-involuntary contractions
-effacement-thinning of cervix (0-100%)
-dilation- opening of cervix (0-10cm)
Secondary- mothers bearing down or pushing with contractions
Ineffective Primary Powers
Amniotomy- puncture hole in amniotic sac; fetal head applies
pressure to cervix
Priority assessment- FHR; also assess amount, color, odor
Augmentation- IV Pitocin; increase amount until contractions are
every 2-3 mins & moderate intensity
Induction of Labor
Chemical or mechanical initiation of uterine contractions before their
spontaneous onset
Chemical
-prostaglandins to ripen (soften)cervix
may stimulate contractions
Cytotec, Cervidil, Prepidil
-Pitocin
Mechanical
-foley catheter balloon
-laminaria
-stripping of membranes
Ineffective Secondary Powers
Maternal Position
Change positions frequently- helps to relieve fatigue, promotes
comfort
Positions for second stage of labor (pushing) dependent on condition
of mom and baby and PHCP preference
Seven Cardinal Movements of Labor
Signs
Contractions
True Labor
vs False
Labor
Cervical Change
Change in Position or
Activity
Mucous Plug (bloody
show)
True Labor
Regular
Become longer, stronger
and closer together
Cervix begins to dilate
and/or efface
No effect on contractions
Present
False Labor
Irregular with no established
pattern
No cervical change
Contractions will decrease or
stop
Not present
Rupture of Membranes
Methods to determine ROM
-nitrazine paper
-fern test
-Amnisure swab
Increased risk of infection if > 24 hours
What do we assess? Priority FHR
Monitor temperature q2 hours
Stages of Labor
Stage 1:
Stage 2:
Stage 3:
Stage 4:
Dilation (0-10 cm)
Expulsion (delivery of infant)
Delivery of Placenta
Immediate Recovery (1-4 hours)
Dilates 0-5 cms
Contractions: 5-30 mins apart, 30-40
seconds, mild-moderate intensity
Stage 1:
Early Phase
Promote comfort, ice chips, empty bladder
q2h, encourage breathing and relaxation
Assess FHR, VS q4h (unless ROM then q2h)
Usually happy, excited, thoughts center on
self, labor and baby.
Dilates 6-10cm
Contractions: 1.5-5 mins, 40-90 seconds, moderate to
strong intensity
Stage 1: Active
Phase
Becomes more labor focused, may ask for and receive
pain medications; may feel rectal pressure and have
urge to push
Cannot push until 10cm, if she pushes before this the
cervix may swell, a swollen cervix does not
dilate!
Promote comfort, position changes, ice chips, assist
with breathing techniques and relaxation, empty
bladder frequently (full bladder can inhibit fetal
descent); lots of encouragement
Monitor FHR (may note early decels on strip), VS
More serious, doubtful, apprehensive, irritable, intense;
may want companionship; needs encouragement;
difficulty following directions
Epidural anesthesia is a regional anesthesia that blocks pain in a
particular region of the body. The goal of an epidural is to
provide analgesia, or pain relief, rather than anesthesia, which
leads to total lack of feeling. Epidurals block the nerve impulses
from the lower spinal segments. This results in decreased
sensation in the lower half of the body.
Pain
Management
in Labor
Epidural medications fall into a class of drugs
called local anesthetics, such
as bupivacaine, chloroprocaine, or lidocaine. They are often
delivered in combination with opioids or narcotics such
as fentanyl and sufentanil in order to decrease the required dose
of local anesthetic.
This produces pain relief with minimal effects.
These medications may be used in combination with epinephrine,
fentanyl, morphine, or clonidine to prolong
Low blood pressure
Loss of bladder control
Potential
side effects
of epidural
anesthesia
Itchy skin
Feeling sick
Inadequate pain relief
Headache
Slow breathing
Temporary nerve damage
Infection
Permanent nerve damage
Stage 2: Delivery of Infant
Begins when 10 cm dilated, ends with deliver of infant
Contractions may space out
Can last up to 2 hours
Requires a lot of energy
May feel burning when fetal head reaches perineum (+4 station)
Delivery of infant through abdominal incision
Cesarean
Section
-low transverse (bikini cut)
-vertical-ALWAYS a repeat c-section
-hx of uterine rupture must always have repeat c-section
Primary or elective
Trial of labor after cesarean (TOLAC)
Vaginal birth after a cesarean (VBAC)
Stage 3: Delivery of Placenta
Begins with delivery of infant, ends with delivery of placenta
Spontaneous or manual
Separation noted by firmly contracted uterus, sudden gush of dark
blood and lengthening of umbilical cord
Examined to ensure it is intact
Fragments of placenta left in uterus can result in postpartum
hemorrhage and infection
Fetal side (shiny shultz), maternal side (dirty duncan)
Cultural considerations
Stage 4: Immediate Recovery
First 1-4 hours after delivery
Mother recovering from birth process, infant adapting to extrauterine
life
VS monitored q15 min first hour, q30 min second hour, temp at
beginning and end unless abnormal
Assess fundus (@U or slightly above), lochia, perineum, incision site
with Cesarean section, keep bladder empty, assess for return of
sensation and movement if pt had epidural
Cultural Considerations
Discuss any concerns or requests related to culture
Want to ensure best experience possible
Considerations:
-some women may be very stoic during labor others very vocal
-fathers may or may not be present
-may prefer alternate positions for deliver such as squatting
-may prefer or request female caregiver
Uterine Contractions
Contractions
Duration is from the beginning
of a contraction to the end of
the same contraction.
Frequency is from the beginning
of one contraction to the
beginning of the next
contraction.
Intensity is the strength of the
contraction.
V- Variable Decel
E-Early Decel
A-Acceleration
L- Late Decel
C- Cord
Compression
H Head
-
Compression
O OK, oxygenated
-
P Placental Insufficiency
-
FHR Accelerations
FHR-Early decelerations
INTERVENTIONS
Must take action:
Put on oxygen
Turn off Pitocin
Turn to side
Increase IV fluids
Call HCP
Actions to
take for
Prolapsed
Cord
Rapid descent in fetal heart rate
Goal is to GET pressure OFF of
umbilical cord to restore blood flow
Prepare for emergency C-Section