OB exam 5 part 2
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Problems seen with teen pregnancies
- poor nutrition
- IUGR...cuz uterus isn't fully developed
- prenatal care starts late
- usually smoke
With a teen mom the most important things we can do is....
- patient education
- referrals to good community resources for help
- seek good role models in their life
Obstetric complications for a pregnant woman >35
- multiple gestation PTL
- dysfunctional labor
- C section
- Trisomy 21
What 2 substances cause vasoconstriction and complications with a developing baby?
tobacco and cocaine.....
CNS issues and IUGR
Drugs and fetus/baby
anything that goes into the mom systemically goes in to the baby. Drugs stay in the babies system longer, fetus cant metabolize drugs efficiently so drugs are in fetus long after they are out of the mom
Alcohol and fetus
- interferes with nutrient metabolism
- alters brain development....especially 3rd trimester
- CNS impairment...mental retardation
- facial malformations
Describe facial malformations on a baby exposed to alcohol
- short palpebrak fissures
- flat midface
- indistinct philtrum
- thin upper life
Cocaine in a fetus will cause
increase in BP so increasing risk for intracranial bleeding
Prenatal diagnostic tests are done to...
- detect congenital anomalies
- evaluate fetus in high risk situation
- establish a baseline
Diagnostics done on all pregnant women
ultrasound and AFP
First trimester diagnostics
- Serum Pregnancy Test
- US (Transvaginal)
- Chronic Villus Sampling
Serum pregnancy test does what?
looks at HCG (human chorionic Gonadotropin) to tell if possibly prego
helps detect-multifetal gestation, molar pregnancy, tubal pregnancy
What's a molar pregnancy?
found with a serum pregnancy test
grapelike clusters of cysts that fill the uterus
Why is a transvaginal US done in 1st trimester?
cuz uterus is low in pelvis
What does transvaginal US look at?
- confirms pregnancy
- location of pregnancy
- detects multifetal gestation
- determines gestational age
- confirms viability by a heart beat
- guides chorionic villus sampling
chorionic villus sampling
dx fetal chromosome abnormalities at 10-12 weeks
needle through abdomen and results are ready in 24-48 hrs
Nursing care after a chorionic villus sampling
- Vs after procedure
- check FHT
- Caution for heavy bleeding
- AF leaking
- Rest for several hours after procedure
- Rhogam to Rh- mom
2nd and 3rd trimester diagnostic tests
- Transabdominal US
- Doppler US
- Sequential Screen/Mulitiple Marker/Expanded AFP
- Percutaneous Umbilical Cord Sampling
How do you prepare the mom for a transabdominal US
- full bladder to lift the uterus
- 1-2 quarts of H2O 1 hour before procedure and don't pee
What does a transabdominal US dx/look at?
- confirms fetal viability
- est. of gestational age
- locate placenta
- evaluate fetal size
- amnitiotic fluid measurement
- monitoring of fetal movement/activity
- guides needle for amnio
- detection of fetal anomalies
- detects fetal presentation
What does a Doppler US look at?
looks at blood flow and detects/confirms IUGR due to placental insufficiency or maternal hypotension
What does AFP detect?
- spinal bifida
- Abdominal wall defects (omphalacele)
What can alter the results of a test?
- gestational age when test is done
- maternal weight
- multifetal pregnancies
- takes 2 weeks for results
- living cells floating in amniotic fluid are aspirated
- tested for chromosomal abhormalities
Amnio will look for
2nd trimester-chromosomal abnormalities
3rd trimester-fetal lung maturity and evaluation of Rh sensitization
Nursing care after an amniocentesis
- pre amnio ed
- consent form
- emotional support
- check for-bleeding, UC's, FHT's
- Rhogam to Rh negative mom
Percutaneous umbilical blood sampling
aspiration of fetal blood from umbilical cord
What does Percutaneous umbilical blood sampling look at
- Rh disease
- genetic studies
- abnormal blood clotting factors
- acid-base status of fetus
Complications of percutaneous umbilical blood sampling
- cord laceration
Antepartum Fetal Surveillance to assess fetal status
- Non stress Test
- Contraction Stress Test
- Biophysical Profile
- Maternal Assessment of fetal movement
Non Stress test looks at
- the ability of fetal heart to accelerate in response to fetal movement
- adequate O2
- intact nervous system
- anatomically normal fetal heart
Describe a reactive and non reactive responses to fetal stress test
reactive >/= 2 accels increasing 15x15 seconds within 20 minutes
non reactive <2 accels, need for CST, BPP...further evaluation of fetus
What's a contraction stress test used for? How done?
follow up to abnormal non stress test to evaluate ability of fetal placental unit to tolerate stress of contractions
nipple stimulation or low dose oxytocin
Results of contraction stress test
Goal is = 3 UC's in 10 min.
- Negative= no late decels (reassuring)
- Positive= late decels follow 50% or more of contrctions
- Suspicious=occasional lates or variable decels
- Unsatisfactory= poor tracing or <3 UC's in 10 min.
Describe Biophysical Profile
most accurate test to determine a fetus's wellbeing
- US showing
- fetal breathing movements
- gross body movements
- fetal tone
- qualitative amniotic fluid volume
- FHR tracing
Maternal Assessment of fetal Movement
aka fetal counts
Advantages vs. Disadvantages of kick counts
advantages-inexpensive, non invasive, convenient
disadvantages-fetal resint decreases movements, maternal perception varies, time of day may affect movement patterns, maternal drugs may affect activity
Minors can consent to medical care related to the prevention or treatment of pregnancy...but NOT
Can a minor receive birth control without parental consent?
Abortion and minor
they may consent to an abortion without parental consent and without court permission
A person under 18 is emancipated if any one of the following occurs:
- the person has entered into a valid marriage, whether or not the marriage has been dissolved
- the person is on active duty with the armed forces
- the person has received a declaration of emancipation under Cal Fam code 7122
Is pregnancy included among the conditions that emancipate a minor?
A minor may consent to pregnancy related medical services except sterilization
Pregnancy does not, in and of itself, establish reasonable suspicion of abuse for the purposes of reporting child abuse as mandated by law
an objective state of having lost someone or something. Often used for losses resulting from death
4 phases of bereavement
- shock and numbness
- searching and yearning
- disorganization and depression
Which phase of bereavement do we usually work with in the hospital?
shock and numbness
What heals grief if it isn't the passage of time
it is the actions we take and the choices we make during that time that helps us process and recover
What's a good kind of busy when dealing with death?
being busy with the work of identifying and finishing emotions of grief recovery
Crying and nursing
it is ok to tell your patient to cry....and to cry with them....laughter is ok too
How do you heal a broken heart?
acknowledging that it is perfectly alright to feel sad from time to time and to talk about those feeling no matter how those around you react
Grief is about a broken heart, not a broken brain. All efforts to heal the heart with the head fail because the head is the wrong tool for the job
Helpful expressions to use when talking with a grieving parent
- I cant imagine what you are going through. It must be unbearable
- I am sad for you
- How are you doing/coping with all of this?
- What has been the hardest part for you?
- I don't know why it happened.
- What can I do for you? How can I help?
- I am here to listen.
- What would be the most help right now?
Definition of fetal death
- <20 weeks= spontaneous abortion
- >20 weeks=fetal demise/still birth
dx by patient reporting decreased fetal movement and inability to hear fetal heart tones then confirmed with US
Maternal causes of fetal death
- prolonged pregnancy >42 weeks
- poorly controlled DM
- Systematic Lupus
- Advanced maternal age
- uterine Rupture
- Maternal Trauma/death
Fetal causes of fetal death
- Multiple gestations
- Congenital/Genetic Abnormality
Placental causes of fetal death
- Cord accident
- Fetomaternal Hemorrhage
- Vasa Previa
- Placental Insufficiency
Who tells the patient about a fetal death?
- Always the DR!!
- Although many parents already may know their baby has died based on the inability to find the fetal heart tones and the US results.
- Labor induction will be started or a c section is performed-patient choice with physician involvement
Burial is required for all babies >20 weeks. But if GA is unknown, these 2 criterias must be met for burial
- >400 grams
- 28 cm in length
What do we document in the perinatal record when there is a fetal demise?
time of delivery and time of absence of APGAR
It patient wants an autopsy what needs to be done
- Dr. order written
- signed consent
- 1 copy sent to nursing office
- 1 copy to morgue with baby
- 1 copy stays in mom's chart
How are chromosomes evaluated on a baby who has died?
- Dr. order
- notify pathologist
- place placenta in clean labeled basin and cover with lid
- wrap baby in warm blanked and chux
What is in the memory box of a baby that has died
- pictures of baby
- foot prints
- id bands
- lock of hair
- keep sake items...blankets, gown, hat worn by baby in pictures
If the baby is going to the coroner.....
DONT GIVE HIM/HER A BATH!!!
How do you transport the baby to the morgue
it can stay till with mom till she is discharged
- attach toe tag to baby
- wrap baby in chux
- place in body bag
- label outside of bat with patient chart label
- transport to the morgue with security
- write information in log book
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