maternity final exam

•Amenorrhea

•Nausea and vomiting

•Fatigue

•Urinary frequency

•Breast changes

•Quickening- “first fetal movement”(could be imaginative or gastric)

first fetal movement- noticed 16-20 weeks

•Goodell’s and Chadwick’s(blueish color of cervix)and Hegar sign

•Enlargement of the abdomen

•Braxton Hicks contractions- practice contractions(16 weeks)

•Uterine soufflé- swish sound during ultrasound- blooding pumping

•Skin pigmentation changes

•Pregnancy tests

Begin with the first day of last missed period, subtract 3 months and add 7 days and add 1 year

•Fetal heartbeat

•Fetal movement

•Visualization of the fetus

dietary folic acid

◦Underweight: 28 to 40 lb

◦Normal weight: 25 to 35 lb

◦Overweight: 15 to 25 lb

◦Obese: Approximately 11 to 20 lb

◦Twins – 46-62 lb for normal pre-pregnancy weight – adjusted according to BMI

◦First trimester: 2.2 – 4.4 lbs.

◦Second and third trimester: About 1 lb. weekly

◦Twins: Second and third trimesters: 1.5 lbs per week

◦Dieting during pregnancy can result in maternal ketosis

Increased risk of:

◦Gestational diabetes

◦Preeclampsia

◦Induction of labor

◦Cesarean birth

◦Anesthesia complications

◦Venous thrombosis

◦Postpartum hemorrhage

◦Endometritis

◦Fetal anomalies

◦Macrosomia

◦Birth injury

◦Stillbirth

◦Calories in second and third trimester

◦Protein increases  25 g daily ( 46 non pregnant + 25 )

◦Water – 3 L daily

◦Caffeine concerns

◦Mercury in fish

◦Artificial Sweeteners

◦Listeria

◦There are different types of vegetarian diets

◦Lacto-ovo vegetarians: Dairy and egg products

◦Lacto-vegetarians: Dairy products but no eggs

◦Vegans: No foods from animal sources

◦Most vegans need additional supplementation – vitamins B12, D, and calcium

placenta previa

-Hemorrhage -C- Section/ baby will not be able to pass through the cervix

dropping of baby

Complete blood count (CBC)

Blood typing

rubella titer

hepatitis B

HIV testing

STI screening

cervical smears

1-13 weeks

12-27/28 weeks

28 weeks 38-42

diabetes

folic acid deficiency

hepatitis B

HIV/AIDS

Obesity

STIs

smoking

alcohol

Fetal movement counts (kick counts)

from week 28-38

encourage mom to lay on side

encourage mom to eat

images produced by sound waves to check for possible birth defects

-to estimate gestational age, fetal weight, and growth

-location of placenta and amniotic fluid volume

-accompanying invasive procedures

-Intiated at 15 weeks

-measures blood flow changes in maternal and fetal circulation

-assessment of placental function

-if ratio is elevated may indicate baby not growing well

-looks at sys/dias of heart

If mother has diabetes or baby is not growing well

A procedure to obtain amniotic fluid

Allows testing of amniotic fluid

This test can provide information about genetic disorders and fetal maturity

Hemorrhage

Amniotic fluid embolism

Loss of pregnancy

Rh isoimmunization

Can hurt the fetus

Infection

Cause bleeding

Rupture placenta

Cramping

Large needled going into amniotic cavity

Catheter is used to withdraw a sample of placental tissue to test for chromosomal abnormalities. Test done after 10-13 weeks.

Increased risk of injury to fetus

Inability to detect neural tube defects

Risk of failure to obtain placental tissue

risk of contamination of specimen

risk of leakage of amniotic fluid

risk of intrauterine infection

risk of Rh isoimmunization

Checks the baby's risk of birth defects and genetic disorders, such as high levels for neural tube defects or low levels for Down syndrome. It is done at 15 to 22 weeks gestation.

used to assess fetal status using an electronic fetal monitor

If baby moves and heart rate increases-healthy baby

If baby heart rate goes down- unhealthy

Provides reassurance of fetal well being(movement 10 x an hour)

FHR acceleration of 15 bpm for 15 seconds in response to fetal movement after 32 weeks

for less than 32 weeks 10 bpm for 10 seconds is acceptable

Measurement of baby form crown of the head to the buttock shows if the pregnancy is dated correctly

An intravaginal ultrasound that measures fluid collection in the subcutaneous space between the skin and the cervical spine of the fetus

-Trisomy 21 -looks to see if there is to much fluid -if there is to much fluid further genetic testing is needed

BHCGPAPP-A this is complete the screening for chromosomal abnormalties

Age 35 and older family history of genetic defects blood test or ultra sound hinting at defects

can be done out patient can be done if the mother is past her due date can be done if there is a medical problem

reactive/nonreactive

lay on left side give sweets wait 30 min give the baby time baby may be sleep they are tiny humans

Given contraction to see how the baby would tolerate labor- would not be done during preterm stage or mother getting a C-section

Enables identification of fetal risk for asphyxia

Fetal monitor is used

Fetal heart rate response to contractions is noted

Healthy fetus usually tolerates contractions

Placenta is not working well because baby is not reacting well to contractions(heart rate decelerates)

- Fetal breathing - Fetal movements body and limbs -Fetal Tone( extension, flextion) - amniotic fluid volume - reactive fetal HR with Reactive NST

MOM NEEDS ROHGAM

28 weeks pregnant

RH Negative mother after amniocentesis

MUST GET RHOGAM WITHIN 72 HOURS

Can cause fetal Heart deceleration

Usually for specific circumstances

-to do a blood transfusion

-take blood out

It goes through umbilical cord

weight and blood pressure (vital signs)

urine testing for protein, glucose, ketones and nitrites

Fundal height measurement to asses fetal growth

Edema

Blood tests

assessment for quickening (fetal movement)

assessment of fetal heart rate- 110-160

spotting/ bleeding (miscarriage)

painful urination (infection)

severe vomiting (hyperemesis gravidarum)

fever higher than 100 (infection)

lower abdominal pain with dizziness and shoulder pain (indicative of ruptured or ectopic pregnancy)

regular uterine contractions (preterm labor)

pain in calf, increased foot flexion (DVT)

sudden gush or leakage of fluid from vagina(pre labor rupture of membranes)

absence of fetal movement for more than 12 hours (possible fetal distress or demise)

-sudden weight gain; periorbital or facial edema, severe upper abdominal pain; headache with visual changes (indicative of gestational hypertension and/or preeclampsia

-decrease in fetal daily movement for more than 24 hours (possible demise)

-Uterine stretch -Oxytocin increases -Increased prostaglandins -Progesterone withdrawal

Passage way ( birth canal ) Passenger ( Fetus ) , powers (contractions) , position( maternal ) , and psychological response

Stage 1 is considered true labor and consists of 3 phases Latnet 0-6cmactive 6-8cmTransition phase 8-10cm SHORTEST STAGE MONITOR FETAL HR

0-6 cm moms relaxed contractions every 5-10 min Lonest stage of labor

6-8 cm dilated contractions every 2-5 min

8-10 cm mom is ready to push

10 cm moms fully effaced Birth of the baby encourage mom to bear down when pushing

birth of placenta within 30 min Never pull umblicusduring this phase there is an increased risk of infection if placenta isn't fully removed PITOCIN

( Prevents hemmorage )

Decreased blood pressure Increased Heart Rate

1-4 hours after delivery assess : mom assess : Temerature not over 100.4 assess Hemmorage

uterus rises upward umblicus lenghtens sudden trickle of blood uterus changes to globular PLACENTA SEPERATION HAPPENS IN THE 3rd stage

Should be firm midlineleveled with umblicus check the fundus and massage it until it is firm if it is soft ( boggy )

assessment

3 x eveyr 5 min

displaced above umblicus one sided = bladder distention

medication that treats excessive bleeding after childbirth cannot be given if mom has preeclamisia or HTN

High estrogens in amniotic fluid cause crystallization of the salts ; crystals appear as a blade of fern

external fetal monitoring records the frequency and duration of the contractions placed on fundus

Fetal Heart tones bottom

cant pick up mothers contractions * obese patients * Oliohydramus * baby Heart rate decreases CERVIX MUST BE OPEN 2 CM water needs to be broken

Engage fetus in uteri position of baby presentation lie

cytotec amisaprostale cervidil - thins cervix pitocin oxytocin

Placenta separates off wall before the baby is born if this happens baby will not receive oxygen or nutrients emergency c section Cause : HTN TRAUMA

Pre labor scoring that helps predict success of induction

High bishop score

Favorable for induction 8-9

High risk for c- section cervadil medication cytotec

Gush of fluid trickle Pooling in vagina ( SROM) PH greater than 5 ( ninrazine paper) turns blue or green alkaline ph greater than 6.5

Palpation External fetal monitoring (tocotransducer)Internal Fetal Monitoring ( IUPC )

Morphine

Meperidine

Butorphanol

Nalbuphine (decreases nausea and vomiting)

Fentanyl (hypotension/ respiratory depression)

Hydroxyzine (reduces anxiety)

regional block

used for labor and cesarean births

patient receive 500 to 1000 ml of normal saline

Oxygen

left lateral position

T8 to T10 of spinal cord

Fentanyl

Sudentanil

Ropivacaine

Morphine

Variable deceleration- Cord compression

Early decelaration- Head compression

Acceleration- OKAY!

Late deceleration- Placental insufficiency

prevents additional cord compression

room temperature saline into uterus with catheter

Medication to relax uterus

Improves blood flow to uterus decreasing/stopping contractions

ex Terbutaline

used for preterm to stop labor

Left lateral side (turn)

Iv fluids

Oxygen

Notify provider

Maternal positioning

Identify labor progress

No intervention

Execute intervention

1. Change maternal position ex: if on her back turn to left side

2. Provide supplemental oxygen if indicated

3. Give IV bolus for late decelerations or Amnioinfusion for variable decelerations

4. Correct maternal blood pressure: did she just get an epidural?

5. Reduce uterine activity

Alter second stage pushing efforts 

•Maternal Hypotension

•Bladder Distention

•Prolonged Second Stage

•Catheter Migration

•Cesarean Birth

•Maternal Fever

•Nausea/Vomiting and Pruritus from Epidural Opioids

•Respiratory Depression up to 24 hours

Spotting, cramping, closed cervix, bleeding unto 24-48hrs, may resolve or pregnancy loss

Treatment: Conservative supportive treatment

Possible reduction in activity in conjunction with nutritious diet and adequate hydration

Moderate to severe bleeding cramping, abdominal pain(contractions), cervical dilatation, if rupture of membranes may need DC or DE

Treatment: Vacuum curettage if products of conception are not passed to reduce risk of excessive bleeding and infection

Prostaglandin analogs such as misoprostol to empty uterus of retained tissue (only used if fragments are not completely passed)

Intense abdominal cramping

Heavy vaginal bleeding

Cervical dilation

Treatment: Client stabilization

Evacuation of uterus via D&C or prostaglandin analog

History of vaginal bleeding and abdominal pain

Passage of tissue with subsequent decrease in pain and significant decrease in vaginal bleeding

Treatment: No medical or surgical intervention necessary

Follow-up appointment to discuss family planning

Absent uterine contractions

Irregular spotting

Possible progression to inevitable abortion

Treatment: Evacuation of uterus (if inevitable abortion does not occur): suction curettage during first trimester, dilation and evacuation during second trimester

Induction of labor with intravaginal PGE2 suppository to empty uterus without surgical intervention

History of three or more consecutive spontaneous abortions

Not carrying the pregnancy to viability or term

Treatment:Evacuation of uterus (if inevitable abortion does not occur): suction curettage during first trimester, dilation and evacuation during second trimester

Induction of labor with intravaginal PGE2 suppository to empty uterus without surgical intervention

Identification and treatment of underlying cause (possible causes such as genetic or chromosomal abnormalities, reproductive tract abnormalities, chronic diseases or immunologic problems)

Cervical cerclage in second trimester if incom

Ultrasound 

•Lab work: pregnancy test, H&H, CBC, T/X 

•Bed rest

•Abstinence from sex

•IV / Transfusion

•D & C -  Dilation and curettage  

•If beyond 12 weeks: induction of labor by oxytocin and Prostaglandins may be used. 

•Emotional support and bereavement care

•RhoGAM if Rh negative

•Progressive Abdominal pain

•Delayed menses

•Abnormal vaginal bleeding

•If rupture has occurred may experience referred shoulder pain

diagnose: ultrasound, low hcg, progesterone

Tubal surgery

•Sexually transmitted infections

PID

•Previous ectopic pregnancy

•IUD use

•Progestin-only contraceptive

•Pharmacologic treatment of infertility

•Endometriosis

•Assisted reproductive technologies

Methotrexate ( folic acid antagonist) Dissolves Pregnancy Given IM

•Must be unruptured, less than 3.5-4cm size or less

•Woman must be in stable condition, no blood , kidney or liver disease

•Surgery-salpingostomy to preserve tube or removal of tube salpingotomy

-Premature dilatation of the cervix which leads to 2^nd trimester loss around 20 weeks

-Painless dilatation

-Can be diagnosed with transvaginal ultrasounds and speculum examinations

•Premature dilatation of the cervix

•Associated with repeated second trimester spontaneous abortions

•Painless, bloodless 2^nd trimester abortion

•Minimal uterine contractions until late

•Considered an anomaly (uterine/cervical)

•Intrauterine pressure increases

•Internal cervical os dilates and membranes may protrude and rupture

•Spontaneous effacement and dilatation may occur

Symptoms

•Painless, quiet onset bright red bleeding

•Bleeding may be intermittent or continuous

•Uterus soft, palpable

•Presenting part is high and deviated to one side

•Associated with preeclampsia 

Expectant Management

-Observation and bed rest/pelvic rest if less than 36 week gestation, normal FHR and mild bleeding that resolves

-No vaginal or rectal exam

-NST/BP once or twice weekly

-Assess bleeding

-Potential emergency

Active Management

-If past 36 weeks gestation – can deliver

-If excessive or continued bleeding can deliver at any gestational age