NS2P1 OB Exam 1

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NS2P1 OB Exam 1
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NS2P1 OB Exam 1: Antepartum & Pregnancy Pregnancy Complications.
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  1. =>Prenatal period
    Period of physical and psychologic preparation for birth and parenthoodOpportunity for nurses and members of health care team to influence family healthHealthy women seek care and guidance Health promotion interventions can affect well-being of woman, child, and rest of family
  2. =>Pregnancy Spans
    • 9 months10 lunar months of 28 days (280 days total)
    • Trimesters
    • First: weeks 1 through 13

    Second: weeks 14 through 26

    Third: weeks 27 through 40
  3. **Diagnosis of Pregnancy Signs and symptoms:
    Presumptive
    Probable
    Positive
    • =>Presumptive indicators
    • Missed menstrual period
    • Home pregnancy test positive
    • Amenorrhea, nausea, vomiting, breast tenderness, urinary frequency, fatigue (morning sickness)
    • Quickening (perception of fetal movement)

    • =>Probable indicators
    • Uterine enlargement
    • Braxton Hicks contractions
    • Uterine souffle
    • Ballottement
    • Positive pregnancy test

    • => Positive indicators
    • Presence of fetal heartbeat distinct from mother’s
    • Fetal movement felt by someone other than mother
    • Visualization (e.g., ultrasound examination)
  4. **Estimated date of birth (EDB)Formulas for calculating EDB but none infallible
    Nägele’s rule: Determine first day of last menstrual period (LMP), subtract 3 months, add 7 days plus 1 year

    -Alternatively add 7 days to LMP and count forward 9 months-Most women give birth from 7 days before to 7 days after EDB
  5. **Adaptation to Pregnancy
    • =>Maternal adaptation
    • Accepting pregnancyIdentifying with mother roleReordering personal relationshipsEstablishing relationship with fetusEmotional attachmentPreparing for childbirth

    • =>Paternal adaptation
    • Accepting pregnancy
    • Identifying with father roleReordering personal relationshipsEstablishing relationship with fetusEmotional attachmentPreparing for childbirth

    =>Sibling adaptation: show attachment!!

    =>Grandparent adaptation
  6. **Nursing Care Management
    • Purpose of prenatal care is to identify existing risk factors and other deviations from normal Emphasis on preventive care and optimal self-care
    • Prenatal care is sought routinely by women of middle or high socioeconomic status

    • => Women in poverty or lacking health insurance may not have access to public or private care
    • Lack of culturally sensitive care and communication interferes with access to care
    • Immigrant women may not seek prenatal care Birth outcomes are less positive, with higher rates of maternal and newborn complications Problems with low birth rate and infant mortality associated with inadequate prenatal care

    • =>Barriers to obtaining prenatal care include:
    • Inadequate number of providers Unpleasant facilities or procedures
    • Inconvenient clinic hours
    • Distance to facilities
    • Lack of transportation
    • Fragmentation of services
    • Inadequate finances
    • Personal and cultural attitudes
    • -Effectiveness of home visiting by nurses during pregnancy has been validated

    • =>Current model of prenatal care used for more than a century
    • -Model is being questioned, and tendency to fewer visits with women at low risk for complications
  7. **Nursing Care Management: Initial Visit
    =>Initial visit: interviewReason for seeking careCurrent pregnancyObstetric and gynecologic historyMedical historyNutrition historyHistory of drug use and herbal preparationsFamily historySocial, experiential, and occupational historyHistory of physical abuseReview of systemsInitial visit: physical examinationInitial visit: laboratory tests
  8. **Nursing Care Management:  Follow-up visits
    • Interview
    • Physical examination

    =>Fetal assessment: Fundal height, Gestational age, Health status

    • ->Laboratory tests
    • Multiple-marker or triple-screen blood test
    • Other blood tests (RPR/VDRL, CBC, anti-Rh)
    • ->Other tests
    • Ultrasonography
    • Amniocentesis
  9. =>Education for self-management
    • Nutrition
    • Personal hygiene
    • Prevention of urinary tract infections
    • Kegel exercises
    • Preparation for breastfeeding newborn: Don't use soap on nipples, it'll dry !
    • Dental health
    • Physical activity
    • Posture and body mechanics: more prone to fall due to large bellies. Rest and relaxation
    • Employment: go on disability early
    • Clothing: loose and comfortable
    • Travel: Frequent stops to walk around in long trips, don't sit around because hypochloratic (pedal edemas?)
    • Medications and herbal preparations
    • Immunizations: all get the flu vaccines!
    • Alcohol, cigarettes, and other substances
    • Normal discomforts of pregnancy-first trimester morning sickness, crampy and nauseated-later: acid indigestion.

    • Recognizing potential complications: them for gestational diabetes, one hour and two hour blood draw (>140) then have to draw at three hour. and > 1 40, then gestational diabetes and teach them how to control blood sugar, because fetus will get bigger.
    • -Stresstests weekly. Postiive when checking fetal heart tones and it increases 15 beats above the baseline. Recognizing preterm labor: contractions!See any blood or feel any contractions. Cramps, pelvic pressure, and back ache.
  10. **Multifetal pregnancy
    • Twin pregnancies often end in prematurity
    • Rupture of membranes before term common
    • Congenital malformations twice as common in monozygotic twins as in singletons
    • No increase in incidence of congenital anomalies in dizygotic twins

    =>Prenatal care given women with multifetal pregnancies includes changes in:Pattern of careAmount of weight gainedNutritional intake observedUterine distention can cause severe backache

    =>Multiple newborns may place strain on: FinancesSpaceWorkloadWoman’s and family’s ability to cope

    =>Lifestyle changes may be necessary=>National organizations available for support

    • =>Multifetal pregnancy probability increased by:History of dizygous twins in female lineage
    • Use of fertility drugs
    • Rapid uterine growth for weeks of gestation
    • Hydramnios: too much amniotic fluid
    • Palpation of more small or large parts than expected
    • Asynchronous fetal heartbeats or more than one fetal electrocardiographic tracing
    • Ultrasonographic evidence of more than one fetus
  11. **Childbirth and Perinatal Education
    =>Perinatal education goals

    • Establish lifestyle behaviors for optimal health
    • Prepare psychologically for pregnancy and the responsibilities that come with parenthood Identify, minimize, and treat risk factors Screen health hazards in workplace and home
    • Get genetic counseling for inherited diseases
    • Compare perinatal care options available

    • =>Perinatal care choices
    • Coalition to Improve Maternity Services Childbirth educationCurrent practices in childbirth educationStrategies for childbirth education

    • =>Preparation for cesarean birth
    • Almost 30% of births in the United States are surgical
    • Vary by provider and care setting
    • More common in women who choose epidurals
    • Vaginal birth after cesareanChildbirth education outcomes
  12. **Preexisting Conditions
    For some women pregnancy represents significant risk because it is superimposed on preexisting illness

    • Unique maternal and fetal needs caused by these conditions must be met in addition to the usual pregnancy
    • -related feelings, needs, and concerns

    • =>Metabolic disorders
    • -Diabetes mellitus
    • -Thyroid disorders

    • **Cardiovascular disorders
    • Respiratory, gastrointestinal, integumentary, and Autoimmune disorders
    • Substance abuse
    • Human immunodeficiency virus (HIV)
  13. **Metabolic Disorders
    • =>Diabetes mellitus
    • Despite advances in care, the woman whose pregnancy is complicated by diabetes may still have poor outcomes
    • Pregnancy complicated by diabetes considered high risk-> bigger babies -> vaginal delivery tough
    • Diabetes can be successfully managed with a multidisciplinary approach

    • =>Classification of diabetes
    • Type 1 diabetes
    • Type 2 diabetes
    • Other specific types (caused by infection or drug-induced)
    • Gestational diabetes mellitus is any degree of glucose intolerance with onset or recognition during pregnancy
  14. **Cardiovascular Disorders
    =>Major cardiovascular changes during pregnancy that affect women with cardiac disease are:

    Increased intravascular volume

    Decreased systemic vascular resistance

    Cardiac output changes during labor and birth

    Intravascular volume changes that occur just after childbirth
  15. **AnemiaIron deficiency anemia
    • Folic acid deficiency anemia
    • Sickle cell hemoglobinopathy
    • Thalassemia
  16. **Pulmonary Disorders
    • =>Asthma:
    • Therapy objectives Relieve the bronchospasm
    • Limit irritant stimuli
    • Decrease the pulmonary response to allergen exposure
    • Limit the inflammatory response in the airways

    • =>Cystic fibrosis
    • Infants of mothers with cystic fibrosis will be carriers of gene
    • With severe disease pregnancy is often complicated by chronic hypoxia and frequent pulmonary infections
    • Exocrine glands produce excessive viscous secretions
    • Problems with respiratory and digestive systems
  17. **Gastrointestinal Disorders
    Cholelithiasis (gallstones)

    Cholecystitis (inflammation of the gallbladder)Inflammatory bowel disease
  18. **Integumentary Disorders
    Dermatologic disorders induced by pregnancy include:

    Melasma (chloasma) -pregnancy mask, "butterfly"

    Vascular “spiders”: spider veins

    Palmar erythema: a reddening of the skin on the palmar aspect of th  e hands.

    Striae gravidarum: stretch marks
  19. =>Skin problems aggravated by pregnancy
    Acne vulgaris (in the first trimester)

    • Erythema multiforme
    • Herpetiform dermatitis (fever blisters and genital herpes)
    • Granuloma inguinale (Donovan bodies)

    Condylomata acuminata (genital warts)

    Neurofibromatosis (von Recklinghausen’s disease)

    Pemphigus
  20. **Neurologic Disorders
    • =>Epilepsy
    • Failure to take medications is common factor Message that drugs are harmful to the fetus Risks to the infant have been exaggerated; there's usually a safe pregnancy medication

    =>Multiple sclerosis Bed rest and steroids used to treat acute exacerbations

    =>Bell’s palsy: viral that paralyzes half your face. quite common
  21. **Autoimmune Disorders
    • =>Systemic lupus erythematosus Autoimmune antibody production affects skin, joints, kidneys, lungs, central nervous system, liver, and other body organs Immunosuppressive medications not recommended during pregnancy
    • Efforts are aimed at reducing the risk of infection

    • =>Myasthenia gravis (MG)
    • Autoimmune motor (muscle) end plate disorder
    • Muscle weakness in the eyes, face, neck, limbs, and respiratory muscles
    • Women with MG usually tolerate labor wellMay require forceps or vacuum delivery
  22. **HIV and AIDS
    Preconception counseling

    • =>Pregnancy risks
    • Pregnancy does not accelerate the condition 100 to 200 infants are infected each year with HIV
    • Mother to child transmission
    • Minority races and ethnicities at increased riskObstetric complications
  23. **Substance Abuse
    =>Alcohol and other drugs easily pass from mother to baby through the placenta

    • =>Smoking during pregnancy has serious health risks, including:
    • Bleeding complications Miscarriage Stillbirth PrematurityPlacenta previaPlacental abruptionLow birth weightSudden infant death syndrome
  24. **Preterm labor (PTL):
    is defined as the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before 37 weeks gestation.

    • =>Incidence and prevalence
    • 1 in 8 infants in the United States are born prematurely
    • Despite research
    • and new treatment modalities PTL is on the risePTL has increased 27% in the last 20 years
    • 8.8% of white births and 18.9% of African
    • -American births result in prematurity75% of perinatal and neonatal morbidity and mortality are caused by preterm birthCost of sequelae of Preterm birth is $5 billion per year
  25. **Etiology of Preterm Labor
    -major and minor risks
    • =>Exact cause is unknown
    • Bacterial vaginosis
    • Multiple gestation: due to IVF or natural twins
    • Polyhydramnios: too much amniotic fluid

    • =>Major risk factors
    • Previous PTL/PTD
    • Uterine anomalies'
    • Incompetent cervixMultiple gestation
    • DES exposure

    • => Minor risk factors associated with PTL
    • Uterine surgery
    • Multiple abortions
    • Polyhydramnios
    • Poor nutritionRecurrent urinary tract infectionsPlacenta previaSmokingFibroids
  26. **Risk Assessment for Preterm Labor
    =>Difficult to improve the detection rate because the cause is unknown

    • =>Screening:
    • Biochemical markers
    • 1. Fetal fibronectin (fFN)- FDA approved: Detected in cervovaginal secretions, Associated with increased risk of PTL
    • 2. Salivary estriol- FDA approved: Rise 3-5 weeks before labor begins (not used often)
    • 3. Corticotropin-releasing hormone: Abnormal or early elevations seen in PTL

    • =>Cervical assessment: Using components of the Bishop Score
    • Dilatation
    • Effacement: thickness, about percentage, 90% thick
    • Station: -3 to +4 (out) and +3 is crowning
    • Cervical consistency
    • Cervical position

    • =>Transvaginal ultrasound
    • Measuring the cervical length; don't do often because it'll put them into labor, measures cervix? Candidate for cerclage (when cervix is opening), stitch it closed to keep the preterm baby at about 22 weeks.
  27. **Preterm Labor Signs and Symptoms & Managmement/Goals
    • Change or increase in vaginal discharge
    • Pelvic pressure
    • Low, dull backache
    • Menstrual-like cramps
    • Uterine contractions with or without pain
    • Intestinal cramping with or without diarrhea

    • *Preterm Labor Medical Management and Goals
    • Activity restriction
    • Decreasing or stopping uterine activity
    • Antibiotic therapy for presumed or confirmed infection
    • Steroids to enhance fetal lung maturity (betametasone steroid)Patient education: Prenatal visits should include S/S of preterm labor
  28. **Tocolytic Therapy
    Agents that promote uterine relaxation by interfering with UC (uterine contraction)

    Does not prevent PTB (preterm birth) but may delay it

    Contraindicated with abruption, acute fetal distress or death, preeclampsia or eclampsia, active vaginal bleeding, dilation >6cm, chorioamnionitis (infection of amniotic fluid), or maternal hemodynamic instability

    • => Medications most commonly used:
    • Magnesium Sulfate: to stop UC's by relaxing, most effective.
    • Terbutaline: injections in back SubQ to try to stop contraction, to relax muscles
    • Ritodrine
    • Indomethacin
    • Procardia
  29. **Steroid Therapy
    Helps prevent or reduce the frequency and severity of respiratory distress syndrome (RDS) in premature infants delivered between 24 and 34 weeks gestation

    Causes lung maturation within 48 hours after administration by stimulating surfactant production

    Requires 24 hours to become effective

    Give 2 injections at least 24 hours apart; usually 12 hours apart

    Assess for maternal infection & Assess for pulmonary edema in mom.
  30. **Preterm Premature rupture of membranes (pPROM)
    The rupture of membranes prior to the onset of labor in a woman who is less than 37 weeks of gestation.

    => Risks associated with pPROM include:

    Infection : Bacterial vaginosisFetal malpresentation; head down! (breech)Umbilical cord accidents & tangled cordPlacental abruptionImmaturity problems: RDS, Intraventricular hemorrhage, Patent ductus arteriosus, Necrotizing enterocolitis
  31. **Gestational Hypertension
    • Trauma is the leading cause of death of women in reproductive years
    • Preeclampsia is the second leading cause of death of pregnant women, the most common cause of death in pregnancy is thromboembolic disease.

    • =>Incidence and prevalence
    • Affects 6%-8% of all pregnancies
    • Varies among race and ethnic groups
    • Influenced by age and parity
    • History of past preeclampsia

    • =>Affects the fetus with outcomes of stillbirth and neonatal mortality and morbidity.
    • SGA
    • Prematurity
    • Complications from prematurity
    • History of previous preeclampsia

    • =>Excessive placental tissue: Multiple gestations, Gestational trophoblastic disease (GTD)
    • Family history of preeclampsia: Mother, Sister
    • Lower socioeconomic group- not getting good prenatal care.
    • History of diabetes, hypertension, or renal disease
    • Poor nutrition
    • Obesity

    =>Gestational Hypertension is characterized by hypertension without proteinuria after 20 weeks gestation and a return of the blood pressure to normal postpartum. Blood pressure is taken on two different occasions at least four hours apart.
  32. *Gestational Hypertension
    Blood pressure elevation (140/90 mmHg) identified after mid-pregnancy (20 weeks) without proteinuria

    • =>May progress to preclampsia or eclampsia
    • -Hypertension after the 20th week of gestation with proteinuria (300mg in 24 hr or +1 protein on dipstick urine sample)
    • -Severe preeclampsia is a blood pressure above 160/110 with proteinuria >500 mg in 24 hrs and oliguria
  33. **Chronic hypertension
    • Hypertension diagnosed before the 20th week of pregnancy
    • Hypertension at time of birth but without preeclampsia and resolution within 12 weeks postpartum**

    • =>Evidence-based research tells us…Multifactorial
    • Multisystem
    • Unknown etiology
    • Begins with conception

    Specific syndrome:Reduced organ perfusion, Vasospasm, Abnormal coagulation process
  34. **Chronic hypertension Pathophysiologic events
    =>VasospasmElevated blood pressure

    • =>Hypoperfusion
    • Decreased blood flow to brain, liver, kidneys, placenta, and lungs
    • Decreased liver perfusion leads to elevated liver enzymes and subcapsular hemorrhage

    Decreased brain perfusion leads to small cerebral hemorrhages and arterial spasms

    • =>Endothelial injury
    • Leads to platelet adherence, fibrin deposition and presence of schistocytes
  35. **Clinical manifestations of progressing Gestational Hypertension
    Elevated blood pressure

    Proteinuria

    Increased hemocrit, creatinine, and uric acid levels (blood tests)

    Thrombocytopenia: low platelets

    IUGR-Intrauterine growth restriction (IUGR) refers to the poor growth of a baby while in the mother's womb during pregnancy. Specifically, it means the developing baby weighs less than 90% of other babies at the same gestational age.

    Oliguria: lower ambnitoic fluid

    Cerebral or visual changes: strange vision, seeing spots?

    Hyperreflexia- deep tendon reflexes. Really hyper

    Markedly elevated liver enzymes

    Pulmonary edema
  36. **Signs of preeclampsia
    • Headache
    • Hyperactive reflexes and ankle clonus
    • Marked proteinuria
    • Generalized edema: focus on arms to see if they're Puffy because most preggies are swollen
    • . Blurred or loss of vision, spots, silvery waterfall
    • Epigastric pain
    • Progression to Eclamptic tonic-clonic seizures
    • Eclampsia is associated with HELLP syndrome
    • GOAL: Stop them from seizing!
  37. **S.E.I.Z.U.R.ES= SAFETY
    • S= SAFETY 
    • E= Establish airway
    • I= IV bolus of magnesium sulfate
    • Z= Zealous observation
    • U= Uterine activity
    • R= Rapid resuscitation
    • E= Evaluate fetus
  38. **Progression to HELLP Syndrome
    • =>Occurs in 2%-12% of preeclamptic women
    • =>Maternal mortality rate is 1% to 3.5% and associated with
    • Spontaneous and postpartum hemorrhage
    • Abruptio placentae
    • Pulmonary edema
    • Hepatic rupture
    • Cerebral hemorrhage
    • Acute renal or cardiac failure
    • DIC-unstoppable bleeding that ends up with a hysterrectomy. Can't get them to coagulate, all their systems are shutting out, AFTER delivery.
  39. **HELLP Syndrome
    • H Hemolysis (breakdown of RBC's)
    • EL Elevated Liver Enzymes
    • LP Low platelets

    Clinical/pathogenic manifestations resulting from vasospasm and resulting in microangiopathic hemolytic anemia
  40. **HELLP Syndrome
    Clinical Manifestations

    • Nausea
    • Malaise
    • Epigastric pain
    • Upper right quadrant pain
    • Demonstrable edema
    • Hyperbilirubinemia
    • Low hematocrit (not explainable by blood loss)
    • Elevated liver enzymes (LDH, AST, ALT)
    • Elevated BUN
    • Elevated bilirubin level
    • Elevated uric acid and creatinine
    • Low platelet count
  41. **HELLP Syndrome Medical Management**HELLP Syndrome Screening
    Placental growth factor (PLGF)

    Second trimester mean arterial pressure (MAP): The sum of twice the diastolic blood pressure plus the systolic blood pressure, all divided by 3. Normal value is 100 mmHg.

    Noting the absence of the decline in second trimester blood pressure

    Roll-over test: Assessing B/P in the lateral position and then supine
  42. **Antepartum Nursing Management
    • ==>Diligent assessment
    • Full head to toe with focused attention on:Assessment of headache and visual changesLung sounds to rule out pulmonary edemaAssessment of epigastric pain

    Fetal surveillance- to see if baby's tolerating all this.Generalized edemaDTR’s and clonus

    • ==>Vital signs
    • Accurate blood pressure: Consistent B/P in left lateral position
    • Daily weight: Same time each morning Monitoring lab values
    • Maintain left lateral position during hospitalizationStrict intake and outputMaintain IV fluidsTest urine for protein
    • Observe for restlessness and apprehension
    • Administer meds per MD orders: Magnesium Sulfate & AntihypertensivesNoise reduction and environmental stressors
    • Have emergency equipment readily available
  43. **Intrapartum Nursing Management
    ==>Severe preeclampsia: 1:1 careIntense maternal/fetal monitoring: Uterine monitoring to assess signs of precipitous labor or placental abruptionDiligent assessmentAccurate vital signsPrepare for delivery

    ==>HELLP Syndrome: 1:1, 1:2 while preparing for deliveryOxygen deliveryMonitor platelet countAssess for clinical signs of bleeding: Type and cross patient for possible transfusionAdminister blood products per the MD ordersInvasive hemodynamic monitoringMonitor serial liver function testsObserve for signs and symptoms of malaise, anorexia, N&V, jaundice, hypoglycemiaKeep D50 at bedside
  44. ==>Anticonvulsant Therapy
    • Magnesium Sulfate
    • Has transient hypotension effect
    • Decreases CNS irritability
    • Loading dose is 4-6 gramsMaintenance dose is 1-2 grams per hour
    • MgSO4 levels every 6 hours for toxic level: Maintain level between 4-7 mEq/LContinue to assess DTR’s: Absence may indicate toxicity
    • Monitor respirations and LOC
    • Monitor urinary output
    • Keep 10% Calcium Gluconate at bedside: 1 gram IVP over 3 minutes, repeat each hour
  45. ==>Antihypertensive therapy
    Apresoline (hydralazine hydrochloride): Vascular smooth muscle relaxant improving perfusion and reducing blood pressure

    Normodyne (labetalol hydrochloride): Alpha 1 and beta blocker reducing blood pressure

    Procardia (nifedipine): Calcium channel blocker by dilating coronary arteries reducing blood pressure

    Sodium nitroprusside: Rapid vasodilation& Not usually used secondary to effects on fetal with rapid B/P reduction

    • ==>Other medications used in preeclampsia
    • Lasix (furosemide) used to shift fluid to decrease pulmonary edema
  46. **Postpartum Nursing Management
    • Continue MgSO4 for at least 24 hours
    • Monitor B/P frequently until MgSO4 d/c: Intense monitoring for HELLP patient for several days

    Seizure precautions: Still 25% chance of seizure

    Patient educationPostpartum medication

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