OB Antepartum aclift

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OB Antepartum aclift
2013-12-01 19:32:27
OB Block MCC

OB Antepartum
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  1. Gravida
    A woman who is or has been pregnant
  2. Para
    the umber of pregnancies that reached viability
  3. Primigravida
    A woman who is pregnant for the first time
  4. Primipara
    Woman who has delivered one viable fetus
  5. Multigravida
    Pregnant woman who has been pregnant before
  6. Multipara
    Woman who has delivered more than one viable fetus
  7. Nulligravida
    Woman who has never been pregnant
  8. Nullipara
    Woman who has not carried a fetus to variability
  9. Classifying Pregnancy Status:


    Gravida - # of total pregnancies

    Para - # of pregnancies that reached viability
  10. Para --> further broken down into:

    • T --> Term Pregnancies
    • P --> Preterm deliveries (20-37 wks)
    • A --> Abortions (< 20 wks)
    • L --> Number of Living Children
  11. The patient is currently 32 weeks pregnant. She has a 5 year old son who was
    delivered at 38 weeks and a 3 year old daughter who was delivered at 36 weeks.
    Before having her children, the patient also experienced a spontaneous abortion
    at 18 weeks gestation. What is her GTPAL?
    • G   4
    • T    1
    • P    1
    • A   1
    • L   2
  12. Naegele's Rule
    • 1st date of LMP
    • Subtract 3 months
    • Add 7 days
  13. Anna's rule
    • First date of LMP
    • Add 9 months (usual time for baby to grow)
    • Add 7 days (babies are usually a week late)
  14. Definition:
    Presumptive signs of pregnancy
    Those that suggest but do not positively indicate pregnancy (subjective signs)
  15. List the presumptive signs of pregnancy
    • Amenorrhea: absence of menstruation
    • Nausea/vomiting: due to metabolic and hormonal changes
    • Breast changes: enlargement, tingling, increased sensation to touch, darkening of nipples and areola
    • Urinary frequency: due to pressure on bladder from uterine enlargement
    • Fatigue: due to increased metabolism
    • Quickening: fluttering sensation when fetus moves (16-20 weeks gestation)
  16. Definition:
    Probably signs of pregnancy
    Strong indicators of pregnancy, short of confirmation (objective signs). Two or more are highly suggestive of pregnancy. Detected at about 12th week.
  17. List the probably signs of pregnancy
    Pigmentation changes: linea nigra, chloasma (mask of pregnancy)

    Abdominal enlargement: as uterus rises out of the pelvis (after 12 weeks)

    Chadwick’s Sign: purplish color of cervix

    Hegar’s Sign: softening of the lower uterus

    • Ballottement: detection of fetus floating in
    • amniotic fluid

    Braxton Hicks contractions: irregular, painless uterine contractions

    Goodell’s Sign: softening of a normally-firm cervix

    • Positive pregnancy test: Maternal blood or urine test for human chorionic gonadotropin (hCG). (Testing one week after a missed period
    • usually provides more accurate information)
  18. Definition:
    Positive Signs of Pregnancy
    absolute confirmation of pregnancy
  19. List the positive signs of pregnancy
    Detection of fetal heart tones

    Palpation of fetal movement

    Ultrasonic evidence of a fetus
  20. Chloasma
    butterfly shaped rash (mask of pregnancy)
  21. Chadwick's sign
    purplish color of the cervix (increase in estrogen)
  22. Hegar's sign
    Softening of the lower uterus
  23. Ballottement
    Detection of a fetus floating in amniotic fluid
  24. Braxton hicks
    irregular, painless uterine contractions
  25. Goodell's sign
    Softening of normally-firm cervix (progestrone)
  26. What makes a pregnancy test turn out positive?
    Maternal blood or urine test for human chorionic gonadotropin (hCG)

    Testing one week after a missed period usually provides more accurate information
  27. Estrogen is most known for..?
    Increasing vascularity
  28. What is progesterone most known for??
    Slowing everything down.
  29. What is a hydatiform pregnancy?
    A molar pregnancy

    Benign proliferating growth of the trophoblast in which the chorionic villi develop into edematous, cystic, vascular transparent vesicles that hang in grapelike clusters without a viable fetus. Although hCG is produced, this is a nonviable pregnancy
  30. Time frame:

    1st trimester
    2nd trimester
    3rd trimester

    Full term pregnancy
    • 1st trimester
    •        First day of LMP to week 13

    • 2nd trimester
    •        14 weeks to 27 weeks

    • 3rd trimester
    •        28 weeks to 40 weeks

    Full term pregnancy 37-42
  31. What categories of drugs are ok to give to a pregnant mom?
    • A --> perfectly fine
    • B --> pretty benign
    • C --> could be harm (must weigh risk vs benefit)
  32. What categories of drugs to you avoid giving to a pregnant mom?
    • D --> Tetrogenic
    • X --> Tetrogenic = never ever give
  33. During gestation, when is the most fetal harm caused?
    Week 2-8
  34. What are the prenantal labs and tests?
    • CBC (H&H, platelets, WBC)
    • Serology/VDRL/RPR --> syphilis
    • STD screening --> chlamydia, gonorrhea, herpes
    • Pap smear --> cervical cancer screening
    • Antibody tiders for rubella and Hep B
    • ABO/Rh typing
    • Plasma Glucose --> diabetes
    • Urinalysis --> UTI?
    • TB screening
    • TORCH screening
    • Alpha-fetoprotein (AFP) --> fetal liver
    • Group B strep
    • HIV --> with permission
  35. Describe Rh sensitization
    Mother is Rh negative and fetus is Rh positve

    Baby's Rh+ blood enters mom's circulation, and mom's body perceives this foreign blood type as harmful. She makes Rh antibodies in response

    Current baby not effected... next pregnancy is!!

    Treatment: 300 mcg IM or IV at 28 weeks, and 72 hours after birth (if baby is Rh+)

    RhoGam is also given after abortion, ectopic pregnancy, and amniocentesis as in each case blood could be exchanged and trigger Rh sensitization response.
  36. Does RhoGam require a consent?

    And why?

    It is a blood product
  37. Describe ABO incompatibilities
    More common than Rh incompatibility but less serious

    • Mom --> O
    • Baby --> A, B or AB

    Antibodies will cause red blood cell breakdown in fetus

    • Causes: hyperbilirubinemia
    • Treatment: phototherapy
  38. TORCH infection
    • T  --> Toxoplasmosis
    • O  --> Other **
    • R  --> Rubella
    • C  --> Cytomegalovirus
    • H  --> Herpes

    ** gonorrhea, syphilis, varicella, hep B, Group B strep, HIV
  39. TORCH related complications
    • Congenital Heart defects
    • Physical fetal anomalies
    • Intrauterine growth restriction (IUGR)
    • Mental retardation
    • Encephalitis
    • Hydrocephalus
    • Blindness
    • Deafness
  40. Basics of TORCH infections
    • TORCH infections place both mother and baby in jeopardy due to the associated complications
    • All torch infections can cross the placenta
    • Prenatal complications include premature labor and premature rupture of membranes
    • Prenatal screening important since many infections are asymptomatic

    Streptococcus (Group B) is a frequent cause of sepsis in the mother/neonate
  41. What are the ways that a fetus can contract HIV from its mom?

    At birth

    Breast milk --> absolutely no breast feeding!!
  42. What are the maternal treatment for HIV during pregnancy and labor for an HIV+ mom?
    • Oral AZT --> pregnancy
    • IV AZT --> during labor
  43. What are the nursing interventions for a mom with HIV?
    Reduce invasive procedures (AROM, fetal scalp electrodes, IUPCs)

    Bathe baby as soon as possible after delivery. If baby is unstable, wash injection sites with soap and water, then clean with alcohol

    Delay injections, heel-sticks until after bath

    Medical personnel --> should wear eye shields, gowns, masks, and double glove during the birth
  44. Describe a Group B Strep Infection
    Usually not harmful to mother but can cause serious complications if transferred to infant

    Vaginal/rectal area swabbed

    Screened at 35-37 weeks (pathogen comes and goes)

    If positive --> mother is treated with IV antibiotics while in labor. Must have 2 separate doses administered at least 4 hours before birth to be considered treated.
  45. What is Alpha-fetoprotein (AFP)
    Substance produced by the fetal liver

    • Elevated --> may be neural tube defects
    • Decreased --> may be down syndrome

    Abnormal levels will necessitate further testing. Amniotic fluid will be assessed --> more accurate

    May be elevated when there are twins.. triplets!
  46. What is important to remember about domestic violence in pregnancy?
    • Pregnant woman are more abused than general population
    • Most likely related to the partner feeling a sense of lack of power/control
    • Essential to screen throughout the entire pregnancy
  47. What are some questions you can ask to screen for domestic violence?
    • 1) “In your current relationship, do you feel safe?”  
    • 2) “Within the last 6 months have you been hit, slapped, kicked, or punched?” 
    • 3) “Do you fear for your own safety or the safety of your children?”
  48. When talking about substance abuse... what are the substances?
    • ETOH
    • Tobacco
    • Marijuana
    • Cocaine
    • Amphetamines
    • Heroin
    • Other perscribed or ilicit drugs
  49. What is the process if substance abuse is suspected?
    • Urine screen for mom
    • Infants first meconium is sent to lab for drug screen
    • Notify social if drug screen is positive (CPS involvement is mandatory)

    Narcan should not be given to a mother on methadone or heroin as it may precipitate drug withdrawal
  50. What are the clinical manifestations of a newborn with narcotic withdrawal
    • Hyperactivity
    • Persistent shrill cry
    • Tremors
    • Increased muscle tone
    • Sneezing, hiccups, yawning
    • Short, unquiet sleep
    • Fever
    • Disorganized, vigorous suck
    • Poor feeding
    • Vomiting
    • Drooling
    • Diarrhea
    • Flushing, sweating
    • Tachypnea ( > 60 bpm)
  51. What are the symptoms of fetal alcohol syndrome?
    • Microcephally --> small head, small brain
    • Growth retardation
    • Short palpebral fissures
    • Maxillary hypoplasia --> small chin
    • Smooth philtrum --> small ridges
  52. What are the nursing interventions for a child with FAS?
    • Decrease environmental stimuli 
    • Provide gavage feedings if neonate has uncoordinated sucking and swallowing
  53. What are the long term implications of FAS
    • Mental retardation
    • Poor coordination
    • Facial abnormalities
    • Behavioral deviations (irritability)
    • Cardiac and joint abnormalities
  54. What is involved in prenatal visits?
    • Blood pressure --> preeclampsia?
    • CBC --> # of times can vary
    • Weight --> every time
    • Abdominal exam -->
    • Assess FHR --> 110-160, variability good?
    • Assess fetal position --> right position? breech?
  55. What are the prenatal tests?
    • Non-stress test (NST)
    • Contraction stress test (CST)
    • Ultrasound (US)
    • Alpha-fetoprotein (AFP)
    • Amniocentesis
    • Amniotic fluid index (AFI)
    • Chorionic villi sampling (CVS)
  56. How do you measure fundal height to determine gestational age?

    • 36 weeks --> xyphoid process (high as it goes)
    • 20-22 weeks --> umbilicus
    • 12 weeks --> pubic bone
  57. Non-Stress Test
    used to evaluated fetal status without uterine contractions

    Monitors FHR with fetal movement, which should accelerate 15 beats per minute for 15 seconds. Then would be considered “reassuring”
  58. Contraction Stress Test
    Uterus is made to contract artificially with the use of pitocin or nipple stimulation

    Fetal heart rate monitoring evaluated the respiratory function (02 / C02 exchange)

    No longer commonly used
  59. What is an amniocentesis and what can it determine?
    Amniotic fluid removed from amniotic sac

    • Genetic information
    • Sex of fetus
    • Chromosomal abnormalities
    • Determine health of maturity of fetus
    • Lecithin/sphingomyelin ratio

    (L/S ratio) to determine lung maturity. Ratio of 2:1 confirms fetal lung maturity
  60. What two tools are used during an amniocentesis?
    20 gauge spinal needle

  61. Bladder should be ______ <20 weeks

    Bladder should be ______ >20 weeks
    Full <20 weeks

    Empty >20 weeks
  62. What is chorionic villi sampling and what does it show?
    • Sampling of tissue (chorionic villi) from the edge of the placenta
    • Detects genetic disorder, done at 8-12 weeks
    • Aspiration catheter or biopsy forcep is introduced through cervix
    • Guided/monitored by ultrasound
  63. What is a biophysical profile (BPP)?
    Test to confirm fetal well being

  64. What is used when when performing a BPP?
    • ultrasound
    • electronic fetal monitor
  65. What changes in the reproductive system during pregnancy
    • Uterus: enlarges (X 20); irregular, painless contractions occur
    • Ovaries: ovulation stops due to high levels
    • of placental estrogen and progesterone
    • Vagina: becomes softer, mucosa thickens, vascularity increases, vaginal discharge increases and becomes more acidic
    • Breasts: increases in size and become full and tender, areola darken; colostrum is excreted
    • Cervix: softens (Goodell’s Sign), becomes congested with blood (Chadwick’s Sign), mucus plug forms
  66. Musculoskeletal System changes
    • Relaxation of joints due to relaxin hormone
    • Widening of symphsis pubis
    • Waddling gait
    • Lordosis
    • Increased back spain
  67. Cardiovascular System changes
    Blood volume increases by 30-50%      

    • Pulse rate increases by 10-15 beats/minute       
    • Clotting factors increase which helps prevent hemorrhage however increases risk of DVT
    • RBC mass increases (plasma portion faster…therefore causing physiological
    • anemia)
    • BP basically remains essentially unchanged due to peripheral vasodilation related to progesterone  

    • 500-1,000 mLs of blood to the uterus per minute!      
    • Supine hypotension a major problem

    Hgb < 11g/dL Hct <  33% indicates anemia
  68. Normal Hematologic values
  69. Aortocaval Compression
    The pregnant uterus compressing the aorta and the inferior vena cava (aortocaval compression). Patient in supine position.

    Uterine displacement with wedge under hip to relieve aortocaval compression.
  70. Respiratory System changes
    • 02 consumption increases by 20%
    • Dyspnea is common
    • Nosebleeds and nasal stuffiness are common and related to estrogen
    • Rib cage widens
    • Respiratory depth increases
  71. Gastrointestinal System changes
    • Gums appear red and swollen and bleed easier, caused by elevated levels of estrogen
    • N/V occurs in 50% of women and common in 1st trimester
    • Delayed gastric emptying and reduced tone of esphageal sphincter allows reflux, producing heartburn --> progesterone
    • Decreased motility in large intestine causes constipation and hemorrhoids
    • Gallbladder emptying time prolonged - may lead to gall stone formation
    • Increased thirst and appetite
  72. Urinary System changes
    • Frequent urination is common, particularly in the first and third trimesters
    • Urinary stasis predisposition to UTIs
    • Increased renal plasma flow
    • Glucosuria may occur --> may be normal finding
  73. Neurological System changes
    • LOC
    • HA
    • DTRs
    • Light-headedness/fainting may be due to
    •        hormones
    •        B/P
    •        Blood sugar
    •        Cardiac problems
    •        Anemia
  74. Endocrine System changes
    • Placenta becomes an endocrine organ and produces large amounts of hormones
    • Heat intolerance due to vasodilatation, fetal and maternal heat production

    • Thyroid gland --> increases 25%
    • BMR --> increases 25%

    Oxytocin and prolactin are secreted by the pituitary gland
  75. Estrogen
    Increased vascularity. Level remains high during pregnancy
  76. Progesterone
    Relaxed all smooth muscle. Maintains the endometrium and prevents abortion by relaxing uterine muscles.
  77. Human Chorionic Gonadotropin (hCG)
    Hormone measured in pregnancy tests. Stimulates the corpus luteum to produce estrogen and progesterone until the placenta can assume that function
  78. Human Placental Lactogen
    Acts as a insulin antagonist; increases availability of glucose for fetal growth and development
  79. Relaxin
    Softens connective tissue and relaxes pelvic joints
  80. Metabolic changes
    • Protein demands increase
    • Carbohydrate demands increase
    • Glycosuria may be present
    • Iron needs increase
    • Water requirements increase
  81. Metabolic changes and weight gain
    Fluid retention common

    Dependent edema

    Lower extremities

    Weight gain should be approximately 25-35 pounds

    Clients should gain 1 pound per week in the 2nd and 3rd trimesters
  82. What are the nutritional needs of pregnancy?
    • Nutritious, well-balanced meals
    • Prenatal vitamins usually perscribed. Megadoses of Vit A & D --> tetrogenic

    PICA --> Unexplained urge to eat non-nutritive substances such as dirt, starch, ice, clay, freezer frost. Thought to be related to an iron deficiency

    N/V are common. Related to hCG and estrogen. Ginger --> safe anti-emetic
  83. What are some nutritional concerns for pregnant women?
    • Should not consume soft cheeses as they harbor listeria monocytogenes, the organism
    • that causes listeriosis

    Maternal effects of listeriosis includes meningitis, pneumonia and sepsis

    Increased risk of delivering stillborn babies

    Another concern? Fish…mercury poisoning
  84. What are the specific nutritional needs of a pregnant woman?
    • Protein --> 60-65 g/day
    • Calcium --> 1,200 mg/day
    • Average 2,500 cal/day (only 300 extra)

    Before conception: 400 mcg/day of folic acid to prevent neurotube defects.

    During pregnancy: 600 mcg/day recommended.
  85. Dietary sources of folic acid?
    • Liver (chicken, turkey, goose, lamb, beef)
    • Fortified cereals and breads
    • Spinach
    • Broccoli
    • Peas
    • Beans
  86. Danger signs in pregnancy:

    Gush of fluid from vagina
    Rupture of membranes
  87. Danger signs in pregnancy:

    Vaginal Bleeding
    Placenta abruption, previa, bloody show
  88. Danger signs in pregnancy:

    Abdominal Pain
    Premature labor, placenta abruption
  89. Danger signs in pregnancy:

    Temperature >101.4
  90. Danger signs in pregnancy:

    Visual disturbances
    Hypertension, preeclampsia
  91. Danger signs in pregnancy:

    Generalized edema
    Hypertension, preeclampsia
  92. Danger signs in pregnancy:

    Severe headache
    Hypertension, preeclampsia
  93. Danger signs in pregnancy:

    Epigastric pain
    Preeclampsia, HELLP
  94. Danger signs in pregnancy:

  95. Danger signs in pregnancy:

    Decreased fetal movement
    compromised fetal well-being
  96. What are the mother's psychological response to pregnancy
    • Ambivalence
    • Acceptance
    • Introversion
    • Mood swings
    • Changes in body image
  97. What are Rubin's (1984) Developmental Tasks of Pregnancy?
    Ensuring safe passage through pregnancy, labor and birth

    Seeking acceptance of this child by others

    Seeking commitment and acceptance of self as mother to infant (binding in)

    Learning to give of oneself on behalf of one's child