Module III - OB

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plbernal
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112438
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Module III - OB
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2011-10-30 22:22:44
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complications
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Care of the childbearing family
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  1. Hypertensive Disorders of pregnancy
    • Gestional HTN
    • Preeclampsia
    • Chronic HTN
    • Chronic with superimposed gestational or preeclampsia
  2. Gestational Hypertension
    Onset of hypertension after the 20th week of gestation
  3. Signs & Symptoms of Gestational Hypertension
    • BP higher than 140/90 on 2 seperate occasions 4-6 hours apart
    • Edema, but no proteinuria
  4. Preeclampsia
    • HTN with protenuria that develops after 20 weeks
    • Can be mild or severe
  5. S/S of Preeclampsia
    • Proteinuria
    • Edema
    • Weight Gain
    • Increase in blood pressure
    • Headache
    • Visual changes
    • Abdominal pain
    • Intrauterine growth restriction (IUGR)
    • Abnormal labs
  6. Risk factors for preeclampsia
    • 65% 1st baby disease
    • Multiple pregnancies
    • Diabetes
    • Less than 19 yrs of age
    • Vascular disease
    • Hydatiform mole
    • Dietary deficiencies
    • Familial tendencies
    • ABO Rh incompatibilities
  7. Hydatiform mole
    a rare mass or growth that forms inside the uterus at the beginning of a pregnancy
  8. Treatments for mild preeclampsia
    • Early recognition
    • Complete bed rest
    • Increase fluid and protein
    • Decrease sodium
    • Hydralizine
    • Labetolol
    • Nifedipine
    • Methyldopa
    • Possible termination
    • Induce Labor
  9. Severe preeclampsia
    Blood pressure greater than 160/110 and greater than 5 grams of protin in 24 hour urine
  10. Signs and symptoms of severe preeclampsia
    • Rapid increase in blood pressure
    • Rapid weight gain
    • Generalized edema
    • Severe headache
    • Visual changes
    • Nausea
    • Drowsiness
    • Increased reflexes
    • Clonus
    • Oliguria
    • Nervousness/irritability
  11. Treatments for severe preeclampsia before labor
    • Immediate hospitalization
    • Magnesium sulfate
    • Frequent BP's
    • Diuretics if necessary
    • IV glucose solution
  12. Treatments for severe preeclampsia during labor
    • Delivery as indicated
    • Low stimulation
    • Constant observation
    • Suction and trach equipment
  13. Postpartum care for severe preeclampsia
    • Watch for seizures up to 48 hours after delivery
    • Watch for increase output
    • Rest and quiet environment
    • Promote bonding
  14. Eclampsia
    Convulsive state of preeclampsia
  15. S/S of eclampsia
  16. Treatments for eclampsia
  17. Infants response to eclampsia
    • Matures faster
    • Dependent upon gestation and maternal stability
    • Delayed bonding
  18. What does HELLP stand for?
    • H-Hemolysis of RBC's
    • EL-Elevated liver enzymes
    • LP-Low platelets
  19. S/S of HELLP syndrome
    • Same as preeclampsia
    • Large drop in hematocrit
    • Hypoglycemia
  20. Treatment for HELLP syndrome
    • Same as preeclampsia
    • Imminent delivery
    • May require life support
  21. Chronic HTN
    HTN that is present & observable before pregnancy or diagnosed before the 20 weeks gestation
  22. Chronic HTN w/ superimposed Preeclampsia
    HTN before 20 weeks and new onset proteinuria
  23. S/S of Chronic HTN w/ superimposed Preeclampsia
    • Sudden increase in proteinuria
    • Sudden increase in BP in woman who was previously well controlled
    • Thrompocytopenia
    • Elevated liver enzymes
  24. Magnesium Sulfate
    • Drug of choice for hypertensive problems
    • Therapeutic level 4-7 mEq/L
    • Smooth muscle relaxer
    • CNS depressant
  25. Toxic levels for magnesium sulfate
    Greater than 12 mEq/L
  26. Hypertensive medications during pregnancy
    • Apresoline (arterioler vasodilator)
    • Labetalol (beta-blocking agent)
    • Procardia (calcium channel blocker)
    • Aldomet (alpha 2-receptor agonist)
  27. Placenta Previa
    Abnormal implantation of the placenta
  28. Types of placenta previa
    • Complete
    • Partial
    • Marginal or low lying
  29. Causes of placenta previa
    • Scarred site of implantation
    • Multiple pregnancies
    • Multiparity
    • Decreased vascularity of upper uterine segment
  30. Symptoms of placenta previa
    • PAINLESS vaginal bleeding in 2nd or 3rd trimester
    • Uterus relaxes between contractions
  31. Diagnosis and treatments for placenta previa
    • Sonogram
    • Bed rest until 36 weeks
    • Stool softener
    • Monitor bleeding/contractions
    • No vaginal/rectal exams
    • H & H, type and cross match
    • C-section most of the time
  32. How do you properly monitor bleeding?
    Count and weight of pads
  33. Complications of placenta previa
    • PP hemorrhage
    • Infection
    • Anemia
    • Shock
    • Neonatal complication
  34. Abruptio Placenta
    Premature seperation of all or part of placenta after the 20th week and before birth
  35. Types of abruptio placenta
    • Complete
    • Partial
  36. Causes of abruptio placenta
    • Multigravida
    • Previous abortion
    • Abdominal Trauma: abuse, motor vehicle accident
    • Drug use
    • Short cord
    • PIH (preeclampsia)
  37. Symptoms of abruptio placenta
    • PAINFUL uterine bleeding (severe pain)
    • Increased uterine size
    • Shock
    • Hypertonic contraction
  38. Lab results for abruptio placenta
    • Decreased H&H
    • Decreased coagulation (increased risk DIC)
    • Positive Apt (Blood in amniotic fluid)
    • Positive Kleinhauer-Betke (KB) (Fetal cells mixed w/maternal cells)
  39. Complications of abruptio placenta
    • Shock
    • DIC
    • Fetal Hypoxia
    • Renal Failure
  40. Treatments for abruptio placenta
    • Vaginal delivery
    • C/S for fetal distress
    • Type and cross match
    • Clotting factor
    • Hysterectomy
  41. Prognosis of abruptio placenta
    • Leading cause of maternal death
    • 1/3 babies die with 20% or more abruption
  42. Diabetes and pregnancy
    • History prior to discovery of insulin
    • Perinatal mortality currently 5%
    • Rarely can get pregnant
    • Rarely able to carry baby to full term
  43. Patho for diabetes in pregnancy
    • Constant need for glucose
    • Maternal insulin does not cross the placenta
    • 1st trimester-increased insulin production (lower blood glucose)
    • 2nd trimester-increased insulin resistance (higher blood glucose)
  44. Classes of diabetes with good pregnancy outcomes. Describe them
    • Class A1-Gestation DM diet controlled
    • Class A2-Gestation DM insulin/medication controlled
    • Class B-Onset 20 years of age or greater & duration less than 10 years
    • Class C-Onset 10-19 years of age & duration 10-19 years
  45. Classes of diabetes with bad outcomes during pregnancy. Describe.
    • Class D-Onset less than 10 years and duration of 20 years or background of retinopathy or HTN not pregnacy related
    • Class R-Proliferative retinopathy or vitreous hemorrhage
    • Class F-Nephropathy with more than 500mg/dl protein in 24 hour period
    • Class RF-Criteria for both R and F co-exist
    • Class H-Artherosclerotic heart disease clinically evident
    • Class T-Prior renal transplantation
  46. Maternal complications of diabetes
    • SAB or Fetal demise
    • Gestational HTN
    • Polyhydramnios
    • Infections
    • Delivery mode
  47. Fetal complications of diabetes
    • CNS
    • Cardiovascular
    • Urinary
    • GI
    • Macrosomia
    • Intrauterine growth restriction (IUGR)
    • Hypoglycemia
  48. Antepartum care with diabetes
    • Diet-Most women 2000 to 2200 cal/day
    • Glucose levels-4x daily
    • Insulin Therapy
    • Exercise
    • Fetal Surveillance
  49. Intrapartum care with diabetes
    • Prevent dehydration
    • Maintain 80-120 blood sugar
    • Fetal monitoring
  50. Postpartum care with diabetes
    • Insulin requirements decrease
    • Bottle feeding-7 to 10 days
    • Breast feeding-until weaned
  51. Gestational Diabetes
    Carbohydrate intolerance during pregnancy
  52. When does gestational diabetes usually get diagnosed?
    24-28 weeks gestation
  53. Gestational Diabetes facts
    • Usually disappears after delivery
    • Can recur in future pregnancies
  54. How to reduce risk of gestational diabetes
    • Weight reduction
    • Good nutrition
    • Exercise
  55. Diagnosis of gestational diabetes
    Patient will be classified as gestational diabetic if blood sugar levels are met or exceeded in two or more blood draws.
  56. Glucose levels of testing of gestational diabetes
    • Fasting: 95mg/dl
    • 1 Hour: 180mg/dl
    • 2 Hour: 155mg/dl
    • 3 Hour: 140mg/dl
  57. Hyperemesis Gravidarum
    Exessive or intractable vomiting during pregnancy
  58. What diseases need to be ruled out before being classified as hyperemesis gravidarum?
    • Gastroenteritis
    • Pyelonephritis
    • Pancreatitis
    • Cholecystitis
    • Hepatitis
  59. When is hyperemesis gravidarum most common?
    • Primiparas
    • Obesity
    • Less than 20 years old
    • Multifetal gestation
    • Hydatiform mole
    • Increased levels of estrogen or HCG
  60. S/S of hyperemesis gravidarum
    • Vomiting
    • Tachycardia
    • Dehydration
    • Decreased urine output
    • Hypotension
    • Rapid weight loss (5% of pre-pregnancy wt)
    • Fluid and electrolyte imbalance
    • Jaundice
    • Increased BUN
  61. Treatment of hyperemesis gravidarum
    • Combat starvation
    • Fluid and electrolyte
    • Diet changes
    • Rest/psychotherapy
  62. Prognosis of pregnancy with hyperemesis gravidarum?
    Good with therapy
  63. Pathophysiology of cardiovascular in pregnancy
    • Greatest strain 28-32 weeks
    • Maternal death
    • Encouraged to not get pregnant
  64. Classifications for cardiovascular problems
    • I-asymptomatic at normal levels of activity
    • II-symptomatic with activity
    • III-symptomatic with normal activity
    • IV-symptomatic at rest
  65. Medications used for cardiovascular problems
    • Calcium Blockers
    • Anticoagulants
  66. Cardio complications
    • Spontanious Abortion (SAB)
    • Preterm labot
    • IUGR
  67. Cardiac Decompensation
    • Pregressive generalized edema
    • Crackles
    • Pulse irregularity
    • Sudden inability to perform activities
    • Increased resp & dyspnea
    • Cyanosis lips/nail beds
  68. Diagnosis of pregnancy with cardio problems
    Usual workup with additional EKG
  69. Nursing management for patients with cardiac problems
    • 8-10 hours sleep with 30 min nap after eating
    • Activity limited
    • Treat infections
    • Diet
    • HOB elevated
    • Be on left side
    • Breast feeding discouraged for III and IV
    • No C/S
    • Decrease 2nd stafe of labor
  70. Why can you not have a c/s with cardiac problems?
    Increased risk for fluid loss and increased blood loss
  71. Preterm Labor
    Labor that begins after the 20th week and before the 37th week of gestation
  72. Causes of preterm labor
    • PROM
    • Placenta previa
    • Polyhydramnios
    • Infection
    • Multiples
    • Maternal age less than 18 or greater than 40
    • Nutrition
    • Smoking/drinking/drug use
    • Previous PTL/2nd trimester abortion
    • Uterine anomalies (fibroids)
    • Abdominal surgeries during pregnancy
    • Increased stress
    • Incompetent cervix
    • Prolonged standing
    • Night work
    • Heavy lifting
  73. S/S of preterm labor
    • Bloody show
    • Backache
    • Pressure/cramping
    • Contractions
    • Diarrhea
    • Cervical changes
    • ROM
  74. Treatments of preterm labor
    • Monitor fetus
    • Hydration
    • Bed rest
    • Tx for UTI (#1 cause of PTL)
    • Medications
  75. Medications that can stop contractions with preterm labor
    • Magnesium Sulfate
    • Terbutaline
    • Betamethasone
    • Indocin
    • Procardia
  76. The prognosis for preterm labor
    If labor under control and no other symptoms then can continue pregnancy until term
  77. Dysfunctional Labor (Dystocia)
    Long or difficult delivery caused by abnormalities in the powers, passage or passenger
  78. What are primary powers
    contractions
  79. Types of dysfuntional labor related to primary powers
    • Primary - hypertonic
    • Secondary - hypotonic
  80. Types of dysfuntional labor realted to secondary powers
    • Fatigue
    • Lack of feeling
  81. Types of dysfunctional labor related to passenger/passageway
    • CPD
    • Macrosomia
    • Android pelvis
  82. How is terbutaline given?
    • Subq
    • PO
  83. What is procardia
    Calcium channel blocker
  84. What is the action of Indocin?
    Closes the ductus arteriosis
  85. Describe primary or hypertonic dysfunction (dysfunctional labor)
    • Latent phase
    • Contractions are uncoodinated, frequent & painful
    • May not be uterine relaxation between contractions
    • No further dilatation or effacement
  86. Treatment for primary or hypertonic dysfunction
    • Rest
    • Analgesic
    • Ambien
  87. What is secondary or hypotonic dysfunction
    • Active phase of labor
    • Progression stops
    • Contractions are weak or stop
  88. Treatments for secondary or hypotonic dysfunction
    • Increase contractions
    • Analgesia
    • IV fluids
    • Rule out CPD, fetal malposition
  89. What is dysfunctional labor related to pasageway & passenger
    • Maternal: Inadequate pelvis
    • Soft tissue issues(fibroids, previa, full bladder)
    • Fetal: Malposition or malpresentation
    • Macrosomia
    • CPD (cephalepelvic disproportion)
  90. Complications of passageway & passenger
    • Maternal
    • Fetal
  91. S/S of passagway & passenger
    • Pin
    • Persistent ROP
    • Prolonged 2nd stage
  92. Treatments for passageway and passenger
    • Assisted delivery
    • manual rotation
    • Delivery with low forceps or vacuum extractor
    • C/S
  93. Shoulder dystocia
    The fetal head is delivered but the anterior shoulder cannot pass under the pubic arch
  94. Causes of sholde dystocia
    • Macrosomia
    • Pelvic abnormalities
  95. Nursing observations for shoulder dystocia
    • Slowing of labor progress
    • Increasing caput
    • Turtle sign
  96. Maternal complications of shoulder dystocia
    • Uterine atony
    • Uterine rupture
    • Episiotomy extension or lacerations
    • Infection
  97. Fetal complications of shoulder dystocia
    • Asphyxia
    • Brachial plexus damage
    • Clavical or humerus fracture
  98. What is HELPERR
    • Call for Help
    • Evaluate for Episiotomy
    • Legs for McRoberts maneuver
    • Suprapubic Pressure
    • Enter maneuvers (Internal Rotation)
    • Remove Posterior arm
    • Roll the patient
  99. Causes for a cesarean delivery
    • Dystocia
    • Fetal position
    • Active herpes or STI
    • Fetal distress/prolapsed cord
    • Repeat c/s
    • Maternal and/or fetal complications
  100. Types of cesarean delivery
    • Classical
    • Low transverse
  101. Nursing interventions for a cesarean delivery
    • Prepare for procedure
    • Expect anger
    • Encourage family involvement
    • Encourage bonding
  102. Which type of c-section causes less blood loss?
    Low transverse
  103. Postpartum care of a c-section
    • Recovery
    • Early ambulation
    • Diet
    • Assess incision
    • SCD's
  104. What is prolapse of the umbilical cord
    The cord lies between the presenting part of the fetus & the cervix
  105. Signs of a prolapsed cord
    • Fetal bradycardia with variable decelerations during contractions
    • Palpation of cordon vag exam
  106. Imperative actions for a prolapsed umbilical cord
    • Prompt recognition
    • Call for help
    • SVE to push up on presenting part
    • Reposition patient
    • O2 via mask
    • Continue to monitor fetal heart rate
    • Prepare for stat c/s
  107. When can a prolapsed cord happen, and when is it usually found?
    • Can happen anytime
    • Found after ROM
  108. Most common causes of uterine rupture
    • Separation of previous classic c/s births
    • Uterine trauma (accidents, trauma)
    • Congenital uterine anomaly
  109. S/S of uterine rupture
    • Vomiting
    • Faintness
    • Increased abdominal tenderness
    • Hypotonic uterine contractions
    • Lack of progress in dilation
    • Fetal distress
  110. Treatments for uterine rupture
    • Emergancy c/s
    • Blood administration as indicated
    • Possible hysterectomy
  111. The nurse's role for a uterine rupture
    • IV access
    • Bood transfusion
    • Administer oxygen
    • Prepare for emergency surgery
    • Support the woman's family
  112. What else is amniotic fluid embolism known as?
    Anaphylactoid Syndrome of Pregnancy
  113. What is Amniotic Fluid Embolism
    Amniotic fluid containing debris such as vernix, hair, skin cells, or meconium enters the maternal circulation causing the release of histamine, prostaglandins, thromboxan, etc.
  114. What do the obstruction of pulmonary vessels result in?
    • Respiratory distress
    • Circulatory collapse
  115. S/S of Amniotic Fluid Embolism
    • Acute dyspnea
    • Severe hypotension
    • Restlessness
    • Dyspnia
    • Cyanosis
    • Pulmonary edema
    • Respiratory arrest
    • Hypotension
    • Tachycardia
    • Shock
    • Cardiac arrest
    • Coagulation failure: bleeding from incision sites, venipuncture sites, trauma (lacerations), petechiae, ecchymoses, purpura
    • Uterine atony
  116. Contributing factors to amniotic fluid embolism
    • Maternal: multiparity
    • Tumultuous labor
    • Abruptio placentae
    • Oxytocin induction of labor
    • Fetal: Macrosomia
    • IUFD
    • Meconium passage
  117. What is the common first symptom of amniotic fluid embolism and what is it usually followed by?
    • Acute dyspnea
    • Severe hypotension
  118. What are risk factors for Amniotic fluid embolism?
    • Advanced age
    • Minority race
    • Placenta previa
    • Preeclampsia
    • Forceps-assissted or cesearan birth
    • Rapid labor
    • Meconium staining
  119. Nurses's immediate responsibilities for amniotic fluid embolism
    • Assist with resuscitation efforts
    • CPR must be conducted with uterus displacement
  120. What happens if a cardiac arrest happens while still pregnant with AFE?
    A perimortem c/s should occur within 5 min for optimal fetal survival
  121. What are puerperal (postpartal) infections?
    ANY infection of birth canal postpartally which may involve the uterus and adjacent structures
  122. Predisposing factors of puerperal infections
    • Hemorrhage
    • Trauma during L&D
    • Preexisting anemia
    • Excessive vaginal exams
    • PROM
    • Prolonged labor and dehydration
  123. S/S of puerperal infections
    • Increased temperature 100.4+ after 24 hours pp
    • Tachycardia
    • Increased WBC
    • Uterine tenderness
    • Malaise
    • Chills/Anorexia
  124. Where do perineum infections occur?
    • Episiotomy
    • Perineum
    • Vulva
    • Vagina
  125. S/S of perineum infections
    • Heat in area
    • Burning on urination
    • Foul odor to lochia
    • Increased temp
    • Redness and edema
    • Discomfort in area
  126. Treatments for perineum infections
    • Analgesics
    • Culture discharge
    • Early ambulation
    • Increased fluids: po and iv
    • Increased protein and calories in diet
    • Antibiotics
    • Sitz bath 3-4 times a day
    • Emotional support
    • Semi-fowlers position
  127. Chorioamnionitis
    • Antepartum and intrapartum infection
    • Intrauterine infection involving leukocyte infiltration of the fetal membrane and amniotic fluid
  128. S/S of chorioamnionitis
    • Maternal fever
    • Fetal tachycardia
    • Preterm ROM (most common symptom)
    • Odor to vaginal discharge &/or amniotic fluid
  129. Treatments for chorioamnionitis
    • Antibiotics
    • Monitor fetus
    • Culture fluid
    • Induce labor
    • C/S for cases of fetal distress
    • Prompt diagnosis
  130. Prognosis for chorioamnionitis
    Good if diagnosed early and interventions begun
  131. S/S of eclampsia
    Same as preeclampsia plus epigastric pain
  132. What are the treatments for eclampsia
    Same as preeclampsia plus seizure precautions
  133. Prognosis for eclampsia
    Guarded
  134. What is the diet management for hyperemesis?
    • Eat every 2-3 hours
    • Seperate liquids form solid food, alternating evey 2-3 hours
    • Eat a snack at bedtime
    • Eat dry, bland, low-fat, high-protein foods
    • Cold foods may be better tolerated than warm foods
    • Eat what sounds good rather than trying to balance foods
    • Follow the salty and sweet approach
    • So-called junk foods are okay
    • Eat proteins after sweets
    • Dairy products may stay down easier than other foods
    • If vomiting even while stomach is empty, suck on a popsicle
    • Try ginger tea: peel and finely dice a knuckle-sized piece of ginger and place it in a mug of boiling water. Steep for 5 to 8 minutes and add brown sugar to taste
    • Try warm ginger ale (with sugar, not artifical sweetener) or water with a slice of lemon
    • Drink liquids from a cup with a lid
  135. What kind of diet does a mother need for need for with cardiovascular problems?
    • Well balanced diet
    • Iron and Folic acid supplementation
    • High protein
    • Adequate calories to gain weight
    • Increased fluids and fiber
  136. What is VBAC?
    Vaginal birth after ceesarean

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