L&D Exam 2

pregnancy dating tools - presumptive (subjective)

• amenorrhea

• breast tenderness

• N/V

• fatigue

pregnancy dating tools - probable (objective)

• positive pregnancy test (urine/serum)

• cervical and uterine signs

pregnancy dating tools - positive (diagnostic)

• fetal heart tones (movement → only attributable to fetus)

tools/timing for auscultating fetal heart tones/tracings (FHT)

• with ultrasound at 5-6 weeks

• with doppler at 10-12 weeks

• with fetoscope at 17-20 weeks

frequency of prenatal visits in the U.S.

• first trimester: ASAP then q4wks

• second trimester: q4wks

• third trimester

  • 28-36 wks: q2 wks

  • 36+ wks: qweek

HPI in initial prenatal visit (“New OB Visit”)

• abnormalities in any system (CV/respiratory, mental, metabolic, musculoskeletal)

• STIs and other infections

• social/economic/behavioral factors: IPV (normalize, universal screening, multiple specific questions), substance use, poverty

• health behaviors: nutrition, basic safety, environment

HCG (human chorionic gonadotropin)

• enters maternal circulation soon after implantation

• doubles every 1-2 days in first 30 days of a viable pregnancy, then decreases after 10 weeks

• not collected in all pregnancies → more common if pregnancy is at risk

initial physical assessment

• informs pregnancy’s location, viability and gestational age

• collects critical baseline data: BP, weight, mood (depression screening), complete physical exam with likely focus on cervix, fundal height, FHT

pregnancy dating with ultrasound (timing/measurement method)

• <8 weeks: date by measuring gestational sac

• 8-15 weeks: date by measuring crown rump length (CRL)

• 15 weeks - term: date by using anatomical measurements → biparietal diameter (width of baby’s head from one side to the other), femur length (length of baby’s thigh bone)

note - ultrasound (sono) margin of error increases over time bc as fetus grows/develops, natural human deviations in growth rates make it harder to pinpoint exact conception date/gestational age

initial prenatal visit labs and tests

• RH and antibody screen

• CBC

• pap (if age 21+ and if not done in past 5 years)

• Rubella immunity

• STIs: RPR, chlamydia/gonorrhea/trichomoniasis, HIV, Hep B

• urinalysis and C&S

• genetic abnormalities

• mental health screen

• travel risk

• if indicated: vitamin D, thyroid, PPD (checks for TB), tox screen, Hep C, toxoplasmosis (common parasitic infection), CMV, cystic fibrosis

Rh factor/antibody screen

• Rh factor = protein found on RBCs

• if mother is Rh negative and baby is Rh positive, her immune system may recognize baby’s RBCs as a threat

• sensitization of mother’s RBCs to baby’s: mixing of blood usually happens during delivery, bleeding, or procedures like amniocentesis. Once exposed, the mother's body makes Rh antibodies. These antibodies can cross the placenta in future pregnancies and attack the baby's red blood cells, causing severe anemia, heart failure, or other dangerous conditions

• prevention: If the screen shows no antibodies have formed yet, doctors give a medication called Rh immunoglobulin (RhIg or RhoGAM) to stop the immune system from making them

return OB visit: interval history

• fetal movement (after 20 wks)

• vaginal bleeding/spotting?

• loss of fluid?

• signs of preterm labor (pressure, discharge, spotting)

• signs of preeclampsia

• psychosocial assessment

return OB: physical exam

• parent BP assessment

• uterine assessment (fundal height)

• fetal assessment (fetal heart tones and rate)

• fetal presentation (36 weeks and on)

• cervical exam (optional after 38 weeks)

3rd trimester/28 week labs

• diabetes screen: 24-28 weeks

• Hct/Hgb: 26-30 weeks

• Rhogam workup (Rh negative patients): 28 weeks

• Tdap: 27 weeks to term

• GC/chlamydia/trichomoniasis, RPR, HIV: 28-32 weeks

other return OB labs

• genetic screening: 1st/2nd trimesters

• ultrasound: 18-20 weeks

• early diabetes screen: 1st trimester

• group B strep (GBS) 36-38 weeks (if positive, intrapartum prophylaxis)

1st trimester ultrasound indications

• gestational age

• viability

• genetic screening

2nd trimester ultrasound indications

• gestational age

• anatomy screen

3rd trimester ultrasound indications

• fetal growth

• presentation

• amniotic fluid index (AFI)

• biophysical profile (BPP)

common pregnancy discomforts

• first trimester: N/V, fatigue, nasal stuffiness, ptyalism, increased vaginal discharge, breast tenderness

• second/third trimesters: heartburn, backache, hemorrhoids, varicose veins, leg crams, edema, dyspnea, syncope

pregnancy warning signs

• bleeding

• loss of fluid from vagina (LOF)

• severe abdominal pain

• cramping

• decreased or no fetal movement (> 22 wks)

• persistent headache

antepartum implications of higher body size

• early pregnancy loss

• occult T2DM

• GDM

• HTN

• indicated or spontaneous PTB

• post-term pregnancy'

• multifetal pregnancy

• obstructive sleep apnea

• carpal tunnel syndrome

intrapartum implications of higher body size

• longer first stage of labor

• failed induction

• cesarean delivery

• trial of labor after C/section

• anesthesia

postpartum implications of higher body size

• venous thromboembolism

• infection

• postpartum depression

implications of higher body size for offspring

• congenital anomalies

• asphyxia and death

• prematurity

• LGA

• childhood obesity

• neurodevelopment

• asthma

expected weight gain during pregnancy

• underweight (BMI <18.5) - 28-40 lb

• normal weight (BMI 18.5-24.9) - 25-35 lb

• overweight (BMI 25-29.9) - 15-25 lb

• obese (BMI >30) - 11-20 lb

pregestational diabetes

patient had T1 or T2 diabetes prior to getting pregnant. 2.0% of pregnancies

gestational diabetes

first onset/diagnosis of any degree of glucose intolerance in pregnancy. 7.5% of pregnancies (accounts for 90% of diabetes in pregnancy)

• process: placenta releases hormones that cause insulin resistance → in a normal pregnancy, pancreas compensates by making 3x more insulin than usual → intolerance occurs when pancreas cannot keep up with this demand

carbohydrate metabolism in normal pregnancy

• 1st trimester: increased insulin secretion & sensitivity to help mother’s body store fat/energy in preparation for high metabolic demands of fetal growth later in pregnancy

  • if pt has pregestational diabetes, would mean a decreased need for injected insulin during this time

• 2nd/3rd trimester: increased insulin resistance - begins in 2nd trimester and peaks in 3rd

diabetogenic effect of pregnancy

normal physiologic pregnancy effect characterized by insulin resistance and hyperinsulinemia, transient hyperglycemia

diabetes mellitus in pregnancy occurs when:

maternal pancreatic function cannot overcome the insulin resistance of pregnancy

fetal glucose metabolism

• glucose crosses placenta via facilitated diffusion

• insulin does not cross placenta, fetus must produce its own

risk of diabetes to birthing parent

• ketoacidosis

• infections

• polyhydramnios (increased amniotic fluid bc fetus excreting more urine, think 3 Ps that mother is experiencing) → can lead to preterm labor

• hypertensive disorders, preeclampsia

• traumatic birth (bc big baby)

• preterm labor

• C-section

• 15-50% chance that birthing parent will develop T2DM later in adulthood

fetal & neonatal risks of diabetes

• IUGR (intrauterine growth restriction)

• macrosomia: birth weight greater than or equal to 4000 g (8lb 13oz)

• sudden, unexplained stillbirth

• neonatal hypoglycemia

• neonatal hyperbilirubinemia

• respiratory distress syndrome (RDS)

common fetal anomalies specific to PGD

cardiac defects

CNS issues

skeletal defects

→ important to promote glycemic control prior to conception

goals of care for pregestational diabetics

achieve and maintain glycemic control → emphasize diet, exercise and medication. team (endo, nutrition, OB, pt/family) will be involved

screen, monitor and intervene for maternal and OB complications

want decreased risk of congenital anomalies and poor pregnancy outcomes

special considerations of nursing care for pregestational diabetics

initially: urinalysis, sono, HgbA1C

steroids administered to mother for fetal lung maturity

militant fetal surveillance (more NSTs, biophysical profiles)

in labor: hourly BG checks guide fluid/med choices

pts considered high risk for gestational diabetes

• symptoms of DM

• previous hx of GDM

• hx of macrosomia

• hx of IUFD

• first degree family member with DM or GDM

• BMI greater than or equal to 30

• glycosuria at 1st visit

• PMOS

• HTN

1hr glucola test

done at 28 wk visit (or NOB if high risk)

does not require fasting

pt takes 50g oral glucose load and plasma glucose is drawn 1 hr later

positive screen for 1hr glucola test

greater than or equal to 140mg/dL. if positive, pt needs to do 3hr Glucose Tolerance Test GTT

if greater than or equal to 200mg/dL, this is diagnostic for GDM and pt does not need to do GTT

3hr GTT

requires fasting

pt takes 100mg glucose load

take 4 blood draws - fasting, 1hr, 2hr, 3 hr. positive diagnosis is 2+ elevated levels

GDM-A1

glycemic control is achieved and maintained through diet and exercise → this is most cases

GDM-A2

maintaining glycemic control requires use of oral hypoglycemic (e.g. metformin) which is more common, or injected insulin (~15% of GDM-A2 pts)

insulin needs in first stage, latent phase of labor

similar to prenatal levels. latent labor does not make significant metabolic demands

insulin needs in first stage, active & transition phase of labor

low. glucose is being used by activity, not as much need for insulin

insulin needs postpartum

stay low. placental hormones’ insulin antagonism resolves

insulin needs during breastfeedig

stay low.

for breastfeeding mothers, glucose is main fuel for milk production; continuous draw of glucose into mammary glands naturally lowers BG levels; as a result, less insulin is needed to keep blood sugar stable

for non-breastfeeding mothers: returns to normal metabolism within 7-10 days

blood glucose goal for GDM

70-110mg/dL

avoid maternal hyperglycemia and prevent neonatal hypoglycemia

chronic hypertension in pregnancy

• onset: before becoming pregnant or before 20 weeks (in early stages, pregnancy reduces BP so if someone had HTN before this point it’s not related to pregnancy)

• BP range: elevated BP greater than or equal to 140/90 ×2 4 hrs apart

• labs: not part of diagnosis

• symptoms: asymptomatic

superimposed preeclampsia

new onset of either proteinuria or end-organ dysfunction after 20 weeks in a pregnant person with chronic preexisting HTN. pregnant people with preexisting/chronic HTN have 25% risk of developing preeclampsia

gestational hypertension

• onset: after 20 weeks

• BP range: new onset elevated BP ≥ 140/90 after 20 weeks (resolves within 12 weeks after birth - temporary diagnosis)

• labs: all normal labs

• symptoms: asymptomatic

the earlier the onset, the more likely to lead to preeclampsia

preeclampsia pathophysiology

abnormal placentation (trophoblasts fail to properly invade uterine spiral arteries and they remain small and high resistance instead of becoming low-flow vessels, leading to inadequate placental oxygentation) → placenta releases factors that cause endothelial damage → causes widespread vasoconstriction leading to HTN, protein leaks out of cells (→ proteinuria) and water follows (→ edema) and endothelial cells releases factors that promote clotting (risk for DIC)

preeclampsia without severe features

onset: after 20 weeks

BP range: ≥ 140/90 ×2, 4hrs apart

labs: proteinuria

symptoms: no subjective symptoms

preeclampsia with severe features

onset: after 20 weeks

BP range: ≥ 160/110 ×2 15 minutes apart

labs: may be abnormal, but not required if BP meets criteria. proteinuria not required but will see results of end-organ damage

symptoms: may have subjective symptoms

preeclampsia labs

• urinalysis - proteinuria present

• CBC - looking for elevated H/H

• CMP - AST/ALT >70

• urine protein/creatinine ratio: 0.3 is diagnostic

preeclampsia symptoms

subjective:

• headache, visual changes, RUQ pain, edema, N/V, altered LOC

objective:

• increased deep tendon reflexes (DTR), clonus (involuntary, rhythmic muscle contractions and relaxations - foot test), RUQ pain to palpation, elevated BP

preeclampsia risks

• placental abruption

• acute renal failure

• cerebral hemorrhage

• hepatic failure or rupture

• pulmonary edema

• DIC (disseminated intravascular coagulation)

• eclampsia

• overall increased risk of maternal and fetal morbidity/mortality

preeclampsia risk factors

• hx of preeclampsia

• primigravida

• family hx of preeclampsia in first degree relative

• preexisting medical conditions: diabetes, HTN, kidney disease, obesity

• multiple pregnancy (twins+)

• advanced maternal age

severe features of preeclampsia

one of the following must be present for preeclampsia w severe features (proteinuria not required)

• BP ≥ 160/110 × 2 15 min apart

• thrombocytopenia - platelets < 100,000 (bc platelets are being consumed at a faster rate dt systemic endothelial damage)

• impaired liver fxn - AST or ALT >70

• renal insufficiency - serum creatinine >1.1mg/dL

• symptoms of cerebral neurologic involvement: persistent frontal headache, visual changes

HELLP syndrome

• laboratory diagnosis of a variant of severe preeclampsia, occurs in about 20% of pts with preeclampsia

  • H = hemolysis

  • EL = elevated liver enzymes

  • LP = low platelets

• complications: renal failure, pulmonary edema, ruptured liver hematoma, DIC, abruption, pre-term delivery

preeclampsia management - diagnosis <34 weeks

• earlier development of disease results in more severity

• use of corticosteroids for fetal lung maturity (delay birth for 48 hrs if pt/fetus is stable)

• expectant management is ideal - monitoring of labs/BPs

• severe cases: delivery

  • stabilize pt

  • NICU consult

preeclampsia management - diagnosis 34-36 weeks

• if mild: expectant management

  • frequent monitoring of parent/fetus

  • early recognition of worsening disease

  • patient/family education

  • corticosteroids

• if severe: delivery

  • stabilize and deliver, NICU consult

preeclampsia management - diagnosis 37+ weeks

delivery is recommended. magnesium sulfate to prevent eclampsia, antihypertensives, anesthesia. induce labor with oxytocin and cervical ripening

nursing care of preeclamptic patient in labor

• accurate BP monitoring

• continuous fetal monitoring

• review lab results/communicate with provider

• pt and family education of disease process

• anticipatory guidance of interventions

• monitoring for side effects/AEs of medications

magnesium sulfate for preeclamptic patients

• CNS depressant used as seizure (eclampsia) prophylaxis

• side effects: lethargy, weakness, hot flashes, N/V, headache, pulmonary edema, possible transient decrease in FHR baseline/variability

magnesium sulfate nursing actions

• obtain therapeutic serum magnesium levels 4-8mg/dL. need to obtain levels q6-8 hrs. consequences of elevated levels:

  • 9-12 mg/dL - loss of reflexes

  • 14 mg/dL - respiratory depression

  • 24-3 mg/dL - cardiac arrest

    • antidote: calcium gluconate 1gm IV over 3 minutes

• assessment: hourly magnesium toxicity checks

  • RR

  • BP

  • reflexes

  • LOC

  • I&O (make sure kidney function is not impaired)

  • auscultation of lungs (listening for signs of pulmonary edema)

corticosteroids for patients with preeclampsia

• betamethasone - promotes fetal lung maturation, may decrease intraventricular hemorrhage

• given if >34 weeks gestation, two doses (12mg IM) 12-24 hrs apart. full benefit occurs 48 hours after 1st injection

antihypertensives for preeclamptic patients

• goal is to maintain diastolic 140-160, systolic 90-100mmHg and prevent stroke

• Labetalol - smooth muscle relaxant, avoid in pt w CAD, asthma or CHF. may cause fetal bradycardia

• Hydralazine - beta blocker, may increase risk of birthing parent hypotension

• Nifedipine - calcium channel blocker, may increase risk of birthing parent hypotension and tachycardia

postpartum management of preeclamptic patients

• magnesium sulfate is continued for 12-24 hr after delivery

• monitor for worsening of BP, labs, or symptoms

  • BP may initially decrease for first 48 hours after delivery, then increase 3-6 days PP

• pt/family education on importance of follow-up within 7-10 days after discharge

discharge considerations for preeclamptic patients

• risk for preeclampsia/eclampsia continues for up to 12 weeks PP

• presentation is often severe, persistent frontal headache

• psychological considerations - PTSD, dysfunctional coping

preeclampsia prevention and education

• aspirin 81 mg (low/baby dose) - starting in late first trimester for pts at high to moderate risk → this reduces risk of preeclampsia

• early recognition of disease for women with previous hx of preeclampsia

• lifestyle modifications - bc preeclampsia causes increased risk of CV disease later in life

medical indications for induction of labor

• preeclampsia/hypertension

• pre-gestational diabetes

• gestational diabetes

• PROM

• chorioamnionitis

• suspected placental abruption

• fetal demise

• postterm pregnancy

• dysfunctional labor

elective indications for induction of labor

• patient, family, or provider/institution convenience

• maternal discomfort

• provider schedule

• unit staffing

• suspected macrosomia

• hx of rapid labor

risks of induction of labor

• increased risk of C/S in women <41 wks