OB - NUS111

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  1. What is Baseline Fetal Heart Rate (FHR)
    Average heart rate rounded of fetus

    Rounded to 5 bpm

    Measured over 2 minutes of clear tracing (uterus must be at rest these 2 min) within a 10 minute window
  2. Normal FHR is?
    110-160 bpm for a term baby with premies ranging on the higher end

    • If baby is at these rates persistently for 10 minutes...
    • below 110 (bradycardia)
    • above 160 (tachycardia)
  3. Baseline Fetal Heart Rate Variability
    Fluctuations in the baseline FHR that cause the wave like appearances on fetal monitor strips
  4. What does a decrease in variability look on a fetal monitoring strip?

    What factors cause it?
    Line looks more straight then with curves

    • Possible Factors
    • Fetus is sleeping
    • Fetal Acidemia
    • Fetal anomalies affecting CNS heart, or both
    • Gestation younger than 28 weeks
    • Mother is on narcotics or sedatives Magnesium sulfate was given to mother
    • Alcohol, illicit drug use by mother
    • Maternal hypoxia
    • Maternal acidemia
  5. Four Categories of Variability
    • Absent – Undetectable
    • Minimal – Undetectable to ≤ 5bpm
    • Moderate – 6 to 25 bpm
    • Marked – Greater than 25 bpm
  6. Accelerations in Fetal Heart Rate (FHR) are

    Is it a Reassuring or Non-reassuring sign
    Temporary increase in FHR that peaks at least

    • Term Babies
    • 15 bpm above the baseline for 15 seconds

    • Premature Babies
    • 10 bpm above the baseline for 10 seconds

    • Indications
    • Fetal movement
    • Vaginal exams
    • Uterine contraction
    • Mild cord conpression

    • Reassuring Sign

  7. Decelerations in Fetal Heart Rate (FHR) are

    What are the two types?
    Decreases in FHR

    Early & Late Decelerations
  8. What are Early Decelerations in FHR?
    What does it look like on the monitor strip?
    Is it a assuring or reassuring sign?
    • Decrease in FHR taking place during contractions as fetal head is pressed
    • against pelvis or tissue

    Compression affects the vagus nerve, lowering the FHR

    • Consistent in appearance, uniform
    • Mirror the contractions
      The Nadir occurs at same time contraction peaks
    • Nadir rate no lower than 30-40 bps from baseline

    This is an ok sign
  9. What are Late Decelerations in FHR?
    What does it look like on the monitor strip?
    Is it a assuring or reassuring sign?
    Decrease in FHR occurring after contraction

    Look like early decelerations but shifted to the right in relation to contraction

    This is a non-reassuring sign

    • Indications
    • Impaired exchange of waste or oxygen with placenta
    • Chronic conditions of mother (maternal hypertension or diabetes)
    • Over time will cause decreased heart function & acidemia in baby
    • Associated with Uterine Placental Insufficiency (UPI)
  10. What are Variable Decelerations in FHR?
    What does it look like on the monitor strip?
    Is it a assuring or reassuring sign
    • No uniform appearance
    • Fall & rise abruptly (within 30 seconds)
    • Can occur without a contraction
    • This is a non-reassuring sign

    • Conditions that reduce flow thru umbilical cord
    • Associated with cord compression
    • Oxygen to fetus is being reduced
    • Get mother on her side & watch her
  11. Fetal Scalp Blood Sampling is done during the ______ period

    Normal Scalp pH is ______   

    Acidosis is Present if pH is lower than ______                     

    If acidosis is present, baby will need to be delivered _________
    • Intrapartum
    • 7.25 – 7.35
    • 7.20
    • ASAP via vacuum or section  

    Note: Acidosis is more common than alkaline
  12. Umbilical Cord Blood Gases & pH Analysis

    What does it do?
    How is it done?
    Assess infant’s acid base balance immediately after birth

    • Procedure must be done immediately after birth
    • Cord is double clamped & a 10-30 cm segment isolated

    • Collect arterial (blood leaving fetus on way to
    • placenta) & venous cord blood

    • Use a heparinized syringe & put on ice
    • Needs to be tested within 60 minutes of collection
  13. What is an Amniotomy?

    What is another name for it?
    Amnihook (disposable plastic hook) is used to perforate amniotic sac my physician or nurse mid-wife

    Hooks passed thru cervix & membranes snagged

    • Often done in conjunction with induction or stimulation of
    • labor

    Can be performed to permit internal electronic fetal monitoring

    Implies the commitment to delivery

    Aka Artificial Rupture of Membranes (ROM)
  14. What are the Nursing Interventions for an amniotomy?
    Document a baseline for FHR before ROM (for baseline)

    Place under-pads / towels under woman’s buttocks to absorb fluid

    After ROM, assess FHR for 1 full minute

    • Keep documenting mom’s temperature
    • Inspect the color, quality, quantity, and odor of the fluid
    • Anything foul smelling (infection)
    • Tinged with green (meconium) means baby is stressed

    • Helpful Hint from L&D experience
    • Baby’s HR starts increasing into 140s-160s
    • This is a pre-indicator that mom is having an infection
    • Her temp will start going up
    • But the FHR is the 1st sign
  15. What are the Risks of Amniotomy?
    • Prolapse Umbilical Cord
    • Umbilical cord slips down in gush of fluid
    • Obstructs blood flow to & from placenta, & reduces gas exchange

    • Suspected if occurs after procedure
    • Deep or prolonged variable decelerations occur during contractions

    Persistent bradycardia is present after contractions

    • Chorioamnioitis
    • Infection of the amniotic sac
    • Vaginal organisms have free access to uterine cavity
    • Risk increases as time between rupture & birth increases
    • Birth within 24 hours of amniotomy desired
  16. Contraindications to Amniotomy are
    • Placenta Previa
    • Fetus is high up
    • Fetus is not in cephalic presentation
  17. Inductions or Augmentation of Labor
    • Induction
    • Deliberate starting of labor artificially

    • Augmentation
    • Stimulating a stalled labor (with oxytocin)
    • When ending pregnancy benefits woman or fetus
    • Labor & vaginal birth are considered safe
  18. Indications for Induction of Labor
    • Post-term pregnancy
    • Fetal Death
    • Fetal Compromise
    • Chorioamnionitis
    • Placenta Abruption
    • PROM (Premature Rupture of the Membranes)
    • Spontaneous rupture of membranes at or near term without onset of labor

    Within 24 hours

    • Maternal Medical Conditions
    • Diabetes, hypertension, renal disease, pulmonary disease, chronic illness
    • Elective Inductions
  19. Elective Inductions are not usually medically recommended. What are some contributing factors to why they are done?
    History of rapid labors (no time to get to hospital)

    Living in a rural area (far away from any hospital)

    Prenatal tests show fetal anomaly (Need a special hospital and or specific equipment ready)
  20. Indications for Augmentation of Labor
    Labor has begun but progress has slowed or stopped due to poor contractions

    Progress is slower than expected (even with adequate contractions)
  21. Implantation of placenta in lower uterus
    Placenta Previa
  22. an obstetric complication in which fetal blood vessels cross or run in close proximity to the external orifice of the uterus
    Vasa Previa
  23. Contraindications for Augmentation or Induction of Labor
    Any contraindication to labor or vaginal birth is a contraindication to augmentation or induction

    • Placenta Previa
    • Vasa Previa
    • Umbilical Cord Prolapse (immediate cesarean indicated)
    • Previous uterine surgery (classic vertical incision cesarean, uterine fibroids surgery)

    • Abnormal fetal presentation
    • Active genital herpes                
    • Mother has severe heart disease           
    • High fetal presenting part (above the pelvic outlet)
  24. Clinical presentation of Hypertonic Uterine Activity
    Contractions are too close together

    Less than 2 minutes apart

    Relaxation is less than 30 seconds between
  25. Risks for Augmentation or Induction of Labor
    • Uterine tachysystole (hyper-stimulation)
    • Uterine rupture (if uterus is distended)
    • Greater risk of chorioamniontis & cesarean birth
    • Maternal water intoxication (due to oxytocin’s antidiuretic effects)                              
    • Hypertonic Uterine Activity
  26. Softening of cervix to make more likely to dilate
    Cervical Ripening
  27. Technique for medical Cervical Ripening
    • Administering Prostaglandin
    • Intravaginally or via intracervical gel

    • Administering Misoprostol (Cytotec)
    • Route: PO
      Synthetic prostaglandin tablet
    • Popular due to low cost & ease of use
    • For cervical ripening & labor induction
  28. Technique for mechanical Cervical Ripening
    • Transcervical Catheter
    • Balloon tipped Foley catheter in cervix with possible saline infusion

    • Hydrophilic (moisture loving) inserts into cervical canal
    • Gradually dilates cervix by absorbing water and expanding
  29. What are the indications & contraindications for a vacuum birth
    • Maternal Indications
    • Exhaustion / inability to push effectively
    • Cardiac or pulmonary disease
    • Intrapartum infection

    • Fetal Indications
    • Cord compression
    • Placenta previa
    • Non-reassuring FHR patterns when the delivery is close

    • Contraindicated if C-Section
    • is preferable because a more rapid is birth required

    • Examples
    • High fetal station
    • Maternal pulmonary edema
    • Severe fetal compromise
    • Fetal head won’t fit thru pelvis
  30. Circular scalp edema from vacuum extractor
  31. Risks of Operative Vaginal Birth
    Risks for Vacuum / Forceps

    • Laceration or hematoma of vagina, perineum, or peri-urethral
    • area

    Need of a very large episiotomy

    Infant has Ecchymosis, facial and scalp lacerations

    Facial nerve injury to infant

    Intracranial hemorrhage to infant
  32. Ways to prevent need for episiotomy
    • Gradual stretching perineum
    • Use of open-glottis pushing rather than prolonged breath-holding
    • Push in upright position
    • Using warm compresses to perineal area

    Perineal massage 10 minutes a day starting at 36 weeks
  33. Nursing Interventions during Recovery after an Episiotomy
    Observe for hematoma or edema

    Apply cold compress to application for first 12 hours (Prevent the swelling)

    Then intermittent heat applications in between when too cold
  34. Medical term for Prolonged and or difficult labor
  35. Indications for Cesarean Section
    • Dystocia
    • Cephalopelvic (fetopelvic) disproportion 
    • Hypertension
    • Active genital herpes at time of birth
    • Fetal malpresentations (breech, transverse)
      Persistent non-reassuring FHR patterns
    • Prolapsed umbilical cord
    • Previous classic vertical cesarean incision

    • Hemorrhagic Conditions
    • Abuptio placentae
    • Placenta previa

    • Maternal Diseases (Labor is not advised)
    • Diabetes
    • Heart disease
    • Cervical cancer
  36. Contraindications for Cesarean Section
    When risk to mother is too great compared to benefit to fetus

    • Fetal death
    • Fetus is too immature to survive
    • Maternal coagulation defects (mother would have issues with bleeding post-op)
  37. Transient Tachypnea of the Newborn (TTN)
    • Transient = short-lived (less than 24 hours)
    • Tachypnea = rapid breathing

    • Usually seen shortly after delivery
    • Most common in c-section babies

    • Due to delayed absorption of lung fluid
    • Vaginal birth allows for that last squeeze of the lungs
  38. Risks of Cesarean Section
    • Maternal Risks
    • This is major abdominal surgery
    • Infection, hemorrhage, transfusion
    • Urinary tract trauma / infection
    • Possibility that a ureter could be nicked
    • Thrombophlebitis, thromboembolism
    • Paralytic ileus
    • Atelectasis
    • Anesthesia complications

    • Infant Risks
    • Transient Tachypnea of the Newborn (TTN)
    • Persistent pulmonary hypertension
    • Injury (laceration, bruising, fractures, or other trauma)
  39. Validation of Fetal Maturity Essential when cesarean is planned

    Gestational age of 39 weeks can be confirmed the following ways...
    Documentation of fetal heart sounds for 20 weeks via non-electronic means

    Documentation of fetal heart sounds for 30 weeks by Doppler ultrasound

    Interval of 36 weeks since positive results of pregnancy test (by reliable lab)

    Ultrasound at 6-11 weeks of pregnancy supporting 39 weeks or more

    • Women with questionable due dates
    • Amniocentesis to establish lung maturity

    Await spontaneous onset of labor to do cesarean if VBAC is now planned
  40. What needs to be done to prepare mother for a c-section?
    Routine lab work (CBC, clotting studies, blood typing & screening)

    Check fetal lung maturity

    Epidural or combined spine epidural (CSE) block given

    Mother is NPO except for medication to lower gastric acid

    • Fetal surveillance continues until just before sterile skin
    • prep

    Wedge placed under 1 hip prevents promotes placental blood flow

    Indwelling catheter is inserted after regional block

    Keeps bladder out of way during surgery

    Observation of urine output, helps evaluate circulatory status

    Grounding pad applied (thigh)

    Sterile abdominal skin prep done just before draping
  41. What is involved in Post-Op Care for a c-section?
    Remember that this is major abdominal surgery, treat it as so

    Change positions every hour & ambulate ASAP

    Deep breathing

    • Check the Following
    • Vital signs, cardiac monitor, pulse-ox
    • Incisions & dressings
    • Perineal area for discharge
    • Fundus
    • Look for hemorrhoids

    • Monitor the Following
    • I/O
    • Pain
    • Return of feeling to lower extremities
  42. For fetal lung maturity, the LS ratio should be

    3:1 (if mother is diabetic)
  43. Examples of meds given to mom before c-section to lower gastric acid
    Famotidine (Pepcid)

    Sodium citrate (Bicitra)
  44. Hypotonic Labor
    Contractions are coordinated but too weak to be effective

    Occurs during active phase of labor (after 4 cm dilated)

    Associated with uterine distension (stretched muscles contract poorly)

    Fetal hypoxia is NOT usually seen

    • Woman is comfortable because contractions are weak (cramp
    • like)

    But persistent hypotonic dysfunction is fatiguing & frustrating
  45. Things in Management of Hypotonic Labor
    It will depend on the cause

    Put mother in upright position to promote effective contractions (walking, shower)         

    Promote activity and causes better labor progress than being in one position

    • Pain management
    • May reduce contraction effectiveness
    • May improve progress of labor by removing pain

    Help mother get her anxieties out in the open to improve stress response

    Amniotomy or oxytocin may be used to stimulate a slowed labor

    If not work, mother needs a section
  46. What is Hypertonic Labor Dysfunction?
    Less common than hypotonic

    Usually during latent phase of labor (before 4cm dilation)

    • Contractions
    • Uncoordinated and erratic in frequency, duration, & intensity
    • Painful & ineffective
    • No or little dilation
    • 90-120 seconds long
    • Less than 2 minutes apart
    • Less than 30 seconds of relaxation between

    Mother becomes tired, dehydrated, frustrated, anxious which further lowers pain tolerance
  47. What are things done in management of Hypertonic Labor Dysfunction
    Relief of pain (warm bathing, systemic analgesics, epidural, spinal block)

    • IV fluids (maintain hydration)
    • Lay mom on her side
    • Promote normal labor pattern
    • Tocolytic Drugs
  48. Drugs that inhibit uterine contractions
    Tocolytic Drugs
  49. Multi-Fetal Pregnancy aka Multiple Gestation
    increase the chance(s) of
    Uterine over distension & Uterine atony (due to overstretching)

    • Postpartum hemorrhage
    • C-Section                                            
    • Fetal hypoxia
  50. Medical term(s) for an inflammation of the fetal membranes due to a bacterial infection
    • Intra-Amniotic Infection (IAI)
    • Chorioamnionitis
  51. Rupture of amniotic sac before onset of true labor
    Premature Rupture of Membranes (PROM)
  52. pPROM stands for
    What is it?
    Preterm Premature Rupture of Membranes

    Membranes rupture earlier than end of 37th week of gestation with or without contractions
  53. What should a mother being sent home with pPROM be educated on?
    Check temperature 4x a day, alert provider if 100° or higher

    No inserting anything into vagina (this includes sex)

    • Some activity restrictions
    • Observe for contractions
  54. What are possible causes of PROM
    • Infection of vaginal or cervix (from STDs)
    • Amniotic sac with weak structure
    • Chorioamnionitis
    • Fetal abnormalities
    • Maternal stress

    Recent intercourse (especially late in pregnancy)

    Correlations seen with low nutrition & social economics
  55. Pre-term is _____ weeks

    Late Pre-term is _____ weeks

  56. Maternal Risk Factors for Pre-Term Labor
    • Short cervical length
    • Infection
    • Previous pre-term births
    • Postive for fFN (Fetal Fibronectin)

    • Underweight or obese
    • Uterine fibroids
    • DES exposure as a fetus
    • Chronic illness (cardiac, renal, etc)
    • Uterine distension
    • Anemia
    • Incompetent Cervix
    • Preeclampsia
    • pPROM
    • No prenatal care
    • Poor nutrition
    • Smoking & substance abuse
    • Domestic violence
    • Employment requires long hours standing
  57. Characteristics of pre-term labor
    • Persistent uterine contractions
    • 1 cm dilation
    • Sensation that baby is “cramping up”
    • Cramps (bearing down)
    • Back pain & pressure over thigh
    • Vaginal discharge is greater in amount & bloody
  58. Nursing Interventions for women in pre-term
    • Monitor I/O for dehydration
    • Administer tocolytic (mag sulfate)
    • Find out about NICU availability
    • Observe for indications to no longer continue the pregnancy
  59. Prolapsed Cord
    What is it?
    What are the 3 types?
    What scenario(s) is it most often seen?
    Cord that has slipped into a position where it is compressed between maternal pelvis & fetal body

    • Three Types
    • Complete, cord is visible & at vaginal opening
    • Partial, Not visible but palpable with exam
    • Occult, Not visible or palpable but vitals indicate so

    • Most Often Seen In
    • Artificial ROM significantly increases risk
    • Breech position & transverse lie
    • Premature babies
    • High station & not coming down the shute
    • Hydramnios
  60. Treatment of prolapsed cord
    Push head or presenting part upward until section

    Position mom so hips are higher than her head (To relieve pressure off the cord)

    Use pillows while on her side

    Give oxygen 8-10 L by mask

    • Tocolytic drugs (no more contractions wanted)
    • Cord Treatment
    • Do NOT push the cord back in place
    • Moisten with warm saline

    • Delivery is Rapid
    • Keep parents calm because it happens very fast
    • Check on them post-op (because it all goes so fast during)
  61. NAS Baby (Neonatal Abstinence Syndrome) definition & symptoms
    Occurs when baby is exposed to additive opiate while in womb

    Cluster of withdrawal symptoms are observed within 48-72 hours

    Often given morphine by mouth around the clock

    • Symptoms
    • Inconsolable
    • High pitched crying
    • Flailing of limbs (keep them swaddled tight)
    • Difficulty sleeping, eating
    • Spastic (startle & scale easily)
  62. What is a puerperal infection?
    What are the manifestations?
    What are the cause(s)?
    What is the most common type found (in this country)
    An infection of the female reproductive organs, contracted during or after childbirth (or miscarriage)

    Used to be called "childbed fever"

    • Manifestations
    • Fever 100.4° F or higher occurring after the first 24 hours after delivery
    • Fever occurs for 2 days in the first 10 days after birth

    • Causes
    • C-sections, forceps, trauma (during birth)
    • Use of foley cath
    • Rapid or prolonged labor
    • General poor health of mother

    Mastitis is the most common type in US
  63. Cytomegalovirus (CMV)
    Common virus in herpes group that rarely causes symptoms except in pregnant women & those immuosuppressed

    Young children are typically a reservoir

    Often seen in daycare centers where employees pick it up from kids
  64. What are the risk factors for postpartum psychosis?
    A history of severe depression and bi-polar disorder
  65. Signs & Symptoms of postpartum psychiatric disorder
    • Relentless obsessive thinking
    • Sleep disorders
    • Agitation leading to delusions
    • Preoccupation with guilt, worthlessness
    • Talking about suicide or killing child
    • Overly concerned about baby’s health
    • Constantly worrying that the baby is defective or dead
    • Lack of appetite
  66. What are some demographic and social personal factors that make a pregnancy high risk?
    • Mother Is
    • Younger than 16 or older than 35
    • Nonwhite race
    • Multiparity
    • Low socioeconomic status
    • Dependent on public assistance
    • Obese
    • Has a low pre-pregnancy weight
    • A smoker
    • Less than 5 feet tall
    • Uses alcohol or illegal drugs
  67. What are some obstetric factors that make a pregnancy high risk?
    • Birth of previous baby weighing more than 8.8 pounds
    • Previous pre-term birth
    • Previous fetal or neonatal death
    • Rh sensitization
  68. What existing medical conditions of the mother make her pregnancy high risk?
    • Diabetic
    • Thyroid (hypothyroidism or hyper)
    • Cardiac Disease
    • Renal Disease
    • Concurrent Infections
  69. Median (Mid-line) vs Mediolateral episiotomies
    Median (Mid-line) is straight up & down

    Mediolateral is diagonal
  70. Advantages & disadvantages of median / midline episiotomy
    • Advantages
    • Less blood loss
    • Neat healing with little scarring
    • Less postpartum pain

    • Disadvantages
    • May extend into anal sphincter
    • Limited enlargement
  71. Advantages & disadvantages of mediolateral episiotomy
    • Advantages
    • More enlargement for opening
    • Won't extend into anus

    • Disadvantages
    • More blood loss
    • More pain postpartum
    • More scarring & irregular scarring
    • Prolonged dyspareunia (painful intercourse)
Card Set:
OB - NUS111
2015-02-10 03:14:55

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