maternity exam 2

what maternal factors trigger labor

uterine muscle stretching leads to the release of prostaglandins

pressure on cervix leads to oxytocin release

moms hormones - estrogen (will spike then go back down) and progesterone

prostaglandins role during labor

sustain uterine contractions

soften cervix

fetal factors that trigger labor

placental aging

prostaglandin synthesis by fetal membranes

fetal cortisol rise which reduces progesterone

ROM

consider delivery within 24 hrs to prevent infection

about 10-15% rupture before labor in term pregnancies

may occur during or before labor

ferning

drop of fluid from vagina on slide

dry the fluid then examine under microscope

fern-like crystalline pattern = ROM

nitrazine

dye-impregnated paper or Q-tip to determine pH

amniotic fluid is alkaline

nitrazine turns blue/black if positive (ROM)

amnisure

identifies protein in amniotic fluid

two lines is positive

what need to document for ROM

color

odor

amount

time of ROM

COAT acronym

fetal adaptations to labor

fetal heart rate and circulation

response to contractions, maternal positioning, meds, amount of oxygen child is getting during process

fetal respirations:

fetal lung fliud cleared during labor and birth

oxygenation dependent on placental sufficiency until delivery/cord clamping

maternal adaptations to labor cardiovascular changes

increased CO, HR, BP

bc trying to clear carbon dioxide coming from muscle

maternal adaptation: hematological changes during labor

plasma at a greater rate than blood components

endocrine changes in mother for labor

oxycotin

placenta previa

placenta implants over cervical os (cervical opening)

NO VAGINAL EXAMS

IUGR

intrauterine growth restriction

causes of placenta previa

endometrial scarring (previous births, endometrioses

issues with endometrial vascularization (w advanced age, HTN, DM, smoking

increased placental mass - large placenta and multiple gestation

S&S of placenta previa

recurrent vaginal bleeding - blood is bright red and painless

Potential abdominal pain or contractions

identified on ultrasound normally at 20 wk scan

low-lying placenta

near cervical os but not covering

can move from placenta previa to low-lying placenta over time

can deliever with low-lying placenta if have enough room

potential complications with placenta previa

driven by amount of bleeding

PPH

invasive placenta

hysterectomy

fetal IUGR, death, prematurity

placental abruption (abruptio placentae)

detachment of the placenta after 20 wks gestation

placental abruption causes

HTN/preecclampsia

blunt abdominal trauma

drugs

previous abruption

PPPROM

anything that affects vasculature

s&s of placental abruption

acute: sudden pain and constant, vaginal bleeding, contractions

chronic: intermittent bleeding, IUGR, oligohydramnios

potential complications with placental abruption

hemorrhage, shock, DIC, PTB, fetal anemia, hypoxia, death

UC

uterine contractions

PPPROM

preterm

premature

prolonged

placental abruption and previa treatment

EFM, frequent VS

maintain IV access

H&H, maintain blood crossmatch

antental corticosteriods

rhogam

possible emergency section

type and cross - get blood type and check for antibodies, have blood type bag on hand

methods of transmission of infections during pregnancy

transplacental

direct contact - passed from mom to baby during delivery

ascending

when screen for infections during pregnancy

first prenatal visit

3rd trimester

prn for symptoms

chlamydia

ascending or direct transmission

maternal complications: PID, PROM, PTL, endometritis

fetal complications: conjunctivitis, pneumonia, LBW, PTB

treatment: antibiotics, treat partner, retest

PID

pelvic inflammatory disease

possible maternal complication for chlamydia and gonorrhea

gonorrhea

ascending or direct transmission

maternal complications: PID, PTL, PROM, endometritis, sepsis, chorioamnionitis

fetal complications: ophthalmia neonatorum, artritis, pharyngitis, IUGR

treatment: antibiotics, treat partner, retest in 3 months

syphilis

transplacental transmission = congenital syphilis

stillbirth, PTB, LBW, congenital anomalies

neonatal symptoms:

• enlarged liver

• rhinitis

• rash

• hydrops

• infections

• CNS involvment

treatment: penicillin

PTB

preterm birth

HIV

viral STI

perinatal transmission - blood mixing so not transplacental

if mother has high viral load then chance of baby contracting will be high

use antiviral therapy (ART) to keep viral load low in mom

give baby ART prophylaxis

avoid blood mixing so no AROM, FSE, vaccum anything that could break babies skin

avoid breastfeeding

viral STIs

HIV

hep B and C

hep B

prenatal screening - HBsAg - report if positive

vaccinate during pregnancy if nonimmune

perinatal transmission:

• increased when mother actively replicating virus

• decreased with antiviral administration

prevention

• HBIG within 12 hours and hep b vaccination within 12 hours of birth

breastfeeding is okay

HBsAg

hep B surface antigen

if positive then have hep b virus

hep c

perinatal transmission rates low but increased if HIV+

no vaccination, highly treatable with direct acting antivirals

test prenatally, treatment deferred until postpartum until PP

avoid FSE, prolonged ROM and episiotomy

screen infants for viral RNA

breastfeeding is okay

trichomoniasis

maternal complications: PROM, PTL

fetal complications: LBW, infection

treatment: metronidazole

can increase HIV transmission

intraamniotic infection (chorioamnionitis) S&S

ascending infection

S&S: maternal fever and increased WBC (>15)

fetal and/or maternal tachycardia

Possibly uterine tenderness

purulent discharge/fluid from cervical os

chorioamnionitis treatment and complications

braod spectrum antibiotics

antipyretics and IV hydration (tylenol will help most of the time)

potential c section if baby is not tolerating this

complications:

maternal: sepsis, PP wound infection, PP endometritis, PPH

newborn: pneumonia, meningitis, sepsis, death, neurodevelopmental delays

TORCH infections

Toxoplasmosis

other

rubella

cytomegalovirus

herpes simplex virus

have more implications regarding severity especially in first trimester

many many of these

toxoplasmosis

T in TORCH

protozoan found in cat litter, contaminated soil and raw meat

transplacental transmission

fetal/newborn effects: SAB, chorioretinitis → blindness, neurological damage

prevention: avoid cat litter, wear gardening gloves, fully cooked meat

other (the O in TORCH) - varicella (chickenpox)

maternal S&S - mild rash, fever, flu-like symptoms

transplacental and droplet transmission

congenital varicella syndrome - ocular defects, limb and CNS abnormalities

neonatal varicella - skin lesions, pneumonia hepatitis, meningoencephalitis

treatment: immune globulin, acyclovir

rubella (german measles)

maternal S&S: mild rash, fever, flu-like symptoms

transplacental transmission

congenital rubella syndrome

• cardiac defects

• eye conditions

• sensorineural

• deafness

prevention: MMR vaccination PP since its live

cytomegalovirus (CMV)

often asymptomatic

transplacental and droplet transmission

risk factor: contact with children under 3 yrs old - common in daycares

fetal complications:

• microcephaly

• IUGR, LBW

• sensorineural hearing loss, blindness

• neurodevelometnal disabilities

teach prevention - good handwashing

herpes simplex (HSV)

maternal S&S: painful vesicles, recurrent (since immunocompromised during pregnancy often resurfaces)

transmitted through contact with active lesions

fetal and neonatal complications:

• placental and umbilical cord damage, hydrops, death

• CNS and eye damage

• skin vesicles

• sepsis

treatment: acyclovir and if active lesions on perineal area then C/S

PP hemorrhage definition

more than 500 mL blood loss for vaginal delivery

more than 1000 ml during section

10% dtop of H/H from admission to PP

ACOG: >1000 mL and S&S of hypovolemia within 24 hrs of birth

PP hemorrhage classifications

primary (early): less than 24 hrs after birth, uterine atony, lacerations, hematomas

secondary (late): after 24hrs after birth, hematomas, subinvolution, retained placental tissue

EBL - estimated blood loss

inaccurate

underestimation leads to treatment delay

overestimation leads to unnecessary treatment

QBL quantification (direct measurement)

recommedned

calibrated, under-buttocks drapes

weigh blood soaked items and subtract dry weight

1 g = 1 mL

suction canister measurement

subtract amniotic fluid and irrigation amounts

more accurate although not exact

risk factors for PPH

hx of PPH

tired/lazy uterus from high parity, prolonged labor, meds, chorioamnionitis, coagulation defects, tearing, big uterus (neonatal macarosomia, multiple gestation, polyhydramnios), retained tissue

meds include augmented or induced labor, mag sulfate, anesthesia

precipitous labor

really rapid labor

placenta accreta

when placenta attaches too deep in uterus

etiology of PPH

4 T’s

tone: uterine tone

trauma: lacerations

tissue: retained placenta

thrombin disorders: DIC

tone

uterine tone

marked hypotonia of uterus

leading cause of PPG

assessment findings:

• boggy uterus (even after massage)

• slow steady bleeding or saturate a peri-pad in less than an hour

• blood clots

initial management of uterine tone

firm fundal massages and expression of clots

first action if uterus midline and boggy

bimanual compression by provider may be necessary (one hand in and one hand on top)

empty bladder if uterus is deviated to right

uterotonic meds

oxytocin is first choice - 20 units in 1000 ml LR IV or 10 units IM

misoprostol (Cytotec) - second choice bc limited side effects but not as effective, 800-1000 mcg PR (first choice because kicks in quick) or PO

prostaglandin E2 is 20 mg PR q2 hr

methylergonovine (methergine): 0.2 mg IM q 2-4h or 0.2-0.4 mg PO q6-12, contraindicated with HTN or CV disease

Carboprost/15-methylprostaglandin F2 alpha (Hemabate): 0.25 mg IM, Repeat q 15 – 90 min; up to 8 doses total, Caution in asthma & hypertension, Causes diarrhea

meds for hemostasis

tranexamic acid (TXA)

•IV, 1 g over 10 min (PO use uncommon)

•Works against plasminogen to prevent clot breakdown (helps w clot formation)

•Most effective within 3 hours of PPH

•Side effects: N/V, hypotension

invasive options for uterine atony

balloon tamponade - pressure on uterine wall

vacuum decompression - sucking air out causing uterus to contract

compression sutures - if have c section, stich uterus smaller

hysterectomy

trauma (one of the T’s in PPH etiology) lacerations

lacerations: active bleeding, source of bleeding can be hidden, ideally provider sutures all lacerations

•Tears of cervix, vagina, perineum, labia

•Risk Factors

•Macrosomia

•Operative vaginal delivery

•Precipitous delivery

•Assessment Findings

•Excessive bleeding with firm fundus

Steady stream without clots

trauma: hematomas

•Blood collects within connective tissues of vagina or perineal areas r/t vessel rupture

•Assessment Findings:

•Severe, uncontrollable pain in vaginal/perineal area

•Swelling, discoloration, tenderness in perineal area

•Vaginal heaviness/fullness, rectal pressure

tissue (T is etiology of PPH)

retained placeneta

small portions of placenta remain attached to uterus

assessment findings:

profuse, sudden bleeding after first PP week,

Subinvolution of uterus

Fever & uterine tenderness if infection

Pallor, cyanosis, tachycardia, hypotension (late signs)

managment:

US to detemine if retained placenta present

dilation and curettage (D&C) to remove placental tissue

antibiotics

placenta accreta

Pathological adherence/invasion of placenta

Accreta – little of mixing into myometrium

Uterus will not have clean detachment increased risk for retained placenta

Increta – goes thru almost all muscle

Percreta – goes thru muscle and can attach to other things nearby

placenta accreta etiology, diagnosis, and treatment

•Etiology

Myometrial damage (C/S, prior uterine surgery)

Placenta previa (especially if over scar)

AMA, multiparity, smoking, short interval pregnancy

•Diagnosis

U/S or after delivery (retained placenta) can see on US for increta and percreta but maybe not accretes

Best outcomes if diagnosed before delivery

•Treatment

C/S delivery between 34-37 weeks gestation

Surgical removal or hysterectomy

Retain placenta & treat with chemotherapy postpartum

Possible blood transfusion

PPH NURSING ACTIONS

•Assess for risk factors before delivery!

•Assess fundus-displaced or boggy?

•Assess bladder for distention

•Assess bleeding-amount and clots

•Assess perineum for lacerations, hematomas

•Assess vital signs/labs for trends

•Notify provider!

•Establish IV site

•Administer meds/blood per orders/protocol

DIC

DISSEMINATED INTRAVASCULAR COAGULATION

•Coagulation pathways

   are hyperstimulated

•Potential causes

•Placental abruption (#1 cause)

•Preeclampsia, HELLP syndrome

•Massive hemorrhage

•Anaphylactoid syndrome (Amniotic Fluid Embolism)

•Sepsis

how does adipose tissue affect hormone levels

adipose tissue releases estrogen

more adipose tissue = more estrogen

SAB definition, s/s, assessment

spontaneous abortion

loss before 20 weeks

chromosomal abnormalities

S/S: cramping and bleeding

assessment: hx of symptoms, US, serial hCG, CBC

SAB nursing care

VS

assess bleeding and pain

IV fluids

possible pre-op (dilation and curettage or dilation and evacuation)

rhogam

psychological, soiciocultural, spiritual care

discharge teaching: peri care, pelvic rest, s/s complications

follow up care: health promotion, testing, counseling, bereavement support

ectopic pregnancy

pregnancy occurring outside the uterus

etiology: STI, PID, reversal of tubal ligation, previous pelvic/abdominal surgery, endometriosis

s/s: severe pain and bleeding

assessment: serial hCG (bc levels wont rise appropriately), transvaginal US, serum progesterone

methotrexate

med that will cause abortion

used for ectopic pregnancy termination

laparoscopic salpingectomy

removal of one or both of the fallopian tubes

after ectopic pregnancy

hyperemesis gravidarum

severe vomiting

dehydration

electrolyte imbalance

ketonuria

weight loss

hyperemesis gravidarum management

B6 and Unisom (Doxylamine): only med proven to be safe and effective during pregnancy, OTC

Doxylamine-pyridoxine (Diclegis) smaller doses throughout the day

zofran is last resort

emotional support

oral care

assess for dehydration, weight loss, physical and emotional exhaustion

cholelithiasis

gallstones

s/s: colicky RUQ pain

n/v

fever

increased risk for this during pregancy bc muscle tone decreases and in gallbladder leads to slowed pushing out of bile so it builds up

cholestasis

etiology unknown

s/s: intense pruritus often palms and soles of feet, systemic symptoms, bile acids greater than 10 (ATL/AST and bilirubin will come back before acid levels so can start treatment based off of these)

complications: direct relation to bile acid number

higher likelihood of preterm labor, heart tone abnormalities which leads to hypoxia which leads to stillbirth so try to deliver early

treatment: ursodiol for symptoms only

preterm labor

•Progressive cervical change

•Presentation

Back pain

Pelvic pressure

SROM spontaneous rupture of membrane

Bleeding, spotting

Change in vaginal discharge

risk factors for preterm labor include

•**History of prior preterm birth**

•Multiple gestation - like twins, stretch uterus out more so body thinks fully grown

•Uterine/cervical abnormalities

•Fetal anomalies

•Infection

•Short pregnancy interval

•Chronic/pregnancy related health problems

•Age <17 or >35

•Late or no prenatal care

•Obesity

•Working or standing long hours

•Ethnicity

•IPV, mental health complications, substance abuse

•Lower education or socioeconomic status

preterm labor indicators

1. Transvaginal cervical ultrasound

• Measures cervical length.

• >30 mm: PTL is unlikely.

• <20 mm: Strong predictor of PTL.

• So, shorter cervix = higher risk.

2. Fetal fibronectin (fFN)

• fFN is like a “glue” between the fetal membranes and uterine lining.

• It can appear in vaginal secretions when the membranes are beginning to separate → can indicate risk for PTL.

• Used mainly between 24–34 weeks.

• Negative: Very unlikely to deliver within the next 2 weeks.

• Positive: Increased risk of preterm birth, but does NOT mean labor will definitely happen.

• Can be falsely positive after intercourse, vaginal bleeding, or leaking amniotic fluid.

3. Prevention – Progesterone

• If someone is at high risk for PTL, progesterone may be given to help reduce the risk.

• Vaginal progesterone is commonly used; IM injections are less commonly used.

preterm labor med summary

Its not my time - acronym

indomethacin 50mg po PDA/IVH (intraventricular hemorrhage)/pulm HTN

nifedipine 10-20mg po BP

mag sulfate 4-6g in 20 min, 2g/hr, RR, DTRs, fetal neuroprotection

terbutaline 0.25mg SQ cardiac

PURPOSE OF THESE IS TO PROLONG PREGNANCY UNTIL CAN GIVE STERIODS

tocolytic

med used to prolong pregnancy

labor suppressants

cervix positioning

when in false labor - posterior

when in labor - anterior

once ROM occurs what is important with vitals

do temp more frequently bc infection risk

types of pushing

closed glottis pushing and open glottis pushing

closed glottis pushing

the Valsalva maneuver—involves taking a deep breath, closing the glottis, holding the breath, and bearing down forcefully to generate strong downward pressure during childbirth. It produces powerful pushes but increases pelvic‑floor strain, maternal exhaustion, and can temporarily reduce oxygen flow to both mother and baby.

what I saw, holding breath and counting to 10 and pushing

open glottis pushing

grunting and pushing at same time allows baby to keep getting oxygen

when can give steroids to pregnant woman

24-33 wks

cardinal movements of birth

engagement - head locked in pelvis

descent - Movement of the fetus through the birth canal during the first and second stages of labor

flexion and internal rotation: chin to chest and corkscrew movement so baby is now facing down

extension - head is delivered

restitution and external rotation: baby faces sideways again, body lines up

expulsion - rest of baby out

first stage of labor

varies widely based on natural vs induced, previous pregnancies or first time

two stages: latent (0-5 cm) vs active (6 cm and beyond)

can walk around being 2cm for weeks

second stage of labor

once fully dilated and effaced to delivery of baby

third stage of labor

delivery of baby to delivery of placenta

placenta out in 30 minutes if longer need to do smth

apgar score done here at 1 and 5 minutes

apgar score

appearance

pulse

grimace

activity

respiration

graded 0-2

want score of 7 and above

four stage of labor

after placenta is delivered to 2-4 hrs pp

perineal trauma - degree of lacerations

first degree - through skin

second degree - through muscles of perineal body, need sutures

third degree - through anal sphincter

fourth degree - into anterior rectal wall

location of lacerations

perineal lacerations

vaginal lacerations

cervical lacerations

visceral vs somatic pain

visceral is organ pain

somatic is skin pain

gate control theory

only a limited number of sensations can travel alone nerve pathways at any one time

gentle massage on maternal abdomen blocks pain

c-fibers: carry flow pain signals like contractions

a-delta fibers (from skin): block transmission of slow pain signals

non-pharmacological pain interventions

cognitive strategies - childbirth classes

endorphins

cutaneous stimulation - counter pressure, effleurage, walking, rocking, heat or cold application, water therapy

pharmacologic methods for pain management: analgesic meds

•Benefits:

Rapid onset

IV administration

Disadvantages:

Short acting

CNS depression

Neonatal resp. depression

Needs continuous EFM

•Options:

Butorphanol (Stadol)

Nalbuphine (Nubain)

Meperidine (Demerol)/morphine

Rapid onset and wont last long

Take edge off but wont take everything – kinda like being drunk???

CNS depression – babies have minimal variability, expected as long as stays minimal and don’t have decels

Effects will stay in babies system for like an hour so if have rapid delivery then baby can come out floppy so then might need to give naloxone to baby

nitrous oxide

laughing gas, nitronox

inhaled through mask

onset of one minute

start inhaling 30-45 seconds before contraction starts

continuous pulse ox

minimal side effects