Maternal Child + Labor and Delivery (Test 1)

Test Wednesday 2/15/23

LDR

Labor delivery recovery room

* normal birth and recovery take place in one room

LDRP

Labor delivery recovery postpartum room (usually overnight)

Free standing birth center

• Home like environment

• usually no emergency equipment if something goes wrong

Birth culture: Hispanic

• keep warm (birth is a cold experience)

• hot and warm beverages

• children are desired

Birth culture: Asian

• boys are prefered

• keep warm (birth is a cold experience)

• many lactose intolerant

Birth culture: Middle eastern

* only parents can touch babies head

Three sections of uterus

Fundus: upper rounder portion

Corpus: middle portion

Cervix: lower portion, projects into vagina

Fundus and corpus are made of what 3 layers

1. Endometrium: inner lining/mucous membrane (what comes off during menstruation and helps fertilized egg implant)

2. myometrium: middle, thick and muscular layer (functional in pregnancy and labor)

3. perimetrium: outer layer that envelops the uterus

Females are born with ___ amount of eggs

2 million

• only 400 mature

What pelvis type is best for vaginal delivery

Gynecoid

How many chromosomes in each cell

46, or 22 pairs

• 1 pair of gametes (sex cells determining sex of fetus)

• one in each pair is from mother, and the other is from the father

XX chromosomes =

femaele

XY chromosomes=

male

* only male sperm can contribute an X or Y, so he is responsible (genetically) for the sex of the baby

Stages of fetus

Zygote: fertilization to second week

Embryo: 2-8 weeks of gestation (very sensitive to viruses, pesticides, ect \[teratogenic agents\].)

Fetus: 8 weeks of gestation until birth

Ectoderm

Becomes fetal skin, nails, MM

mesoderm

Becomes fetal skeleton, muscles, blood vessels, kidneys, gonads

Endoderm

Becomes fetal bladder, GI tract lining, lining of trachea, pharynx and bronchi

Amniotic fluid is __ % water and contains _

98%

• looks like urine

• contains protein, glucose, fetal hair, fetal urine and vernix caseosa (cheesy material covering skin of fetus)

• derived from maternal blood

Normal amount of amniotic fluid present at full term

800-1000 mL

hydramnios

too much amniotic fluid (more than 2,000mL/2L)

* can cause malformation of the fetal CNS and GI tract

oligohdraminose

too little amniotic fluid (less than 300mL)

* associated with renal abnormalities

How many arteries and veins does the umbilical cord have

2 arteries, 1 vein

• assess for these post cord cutting after birth

How many sections does the placenta have

2

• maternal

• fetal

Two systems are separate, but fetus dips into mothers supply to receive nutrients and can mix

During contractions, placental blood flow does what?

Slows down

Gravida

Pregnancy of any kind, regardless of duration

nulligravida

women who has never been pregnant

multigravida

women who has had more than one pregnancy

Para

number of births after 20 wks

* regardless of if infants were born alive or dead

When is the fetus viable

20 weeks

• may survive outside of uterus (need NICU however)

• lungs are not ready at this stage

Nagels rule

Method for determining due date

• identify 1st day of LMP

• subtract 3 months

• add 7 days

Fundal height

Method for determining due date/checking growth

• measured in cm

• between 18-32 wks, fundal height matches number of weeks

When can fetal heartbeat be heard

* between 10-12 weeks

Trimester time frames

1st: 0-14 weeks

2nd: 15-28 weeks

3rd: 29-delivery

Abortion/miscarriage

Death of fetus before 20 weeks

Preterm/premature birth

Death of fetus after 20 weeks, but before full term

Endocrine changes during pregnancy

• Hormones increase drastically

• hCG hormone increases (human chorionic gonadotropin)

• addition of placenta which produces hormones (estrogen and progesterone, hPL, hCG)

Uterus changes during pregnancy

• enlargement

• circulation increases

• stretches

• (Returns to normal size and shape after birth)

Cervix changes during pregnancy

• shorter and softer (to prepare for dilation and thinning (effacement) during labor)

• mucus plug forms in cervical canal to prevent entrance of microorganisms

Vaginal changes during pregnancy

• walls thicken

• discharge increases

• increased glycogen in discharge which can cause UTI

CV changes during pregnancy

• orthostatic hypo-tension

• cardiac output increases (greatest during labor)

• WBC increase

• increase in blood volume by 40%

• Increase HR

• BP should stay the same

• increase in clotting factors (prevents hemorrhaging and bleeding post birth but increases risk for DVT/PE)

Cardiac output is best when OB women lays on __

her side

Lung changes during OB

• capacity stays the same

• inspiration increases to meet increased need for oxygen

GI changes during OB

• slowed peristalsis

• relaxation of cardiac sphincter (can cause heartburn)

• low carb metabolism

• low fat metabolism

• nausea w/ or w/o vomiting

To prevent heartburn, encourage what?

Sitting up for 30 minutes after eating

Supine hypotensive syndrome

Occurs when women lays on back and compresses vena cava and abdominal aorta, causing lowered blood flow

* position on side to correct

Why is UTI risk high in pregnancy?

• Increased urinary stasis

• increased glycogen in discharge

Kidney flow may do what when pregnant

Increase by 75%, in order to remove mother + babies waste

Kidney changes during OB

• GFR increases by 50%, causing 99% sodium re absorption

• (most of this sodium is used by the fetus, but leftover can cause edema of mother)

• Be wary of antidiurtetic effect medications (pictocin) that can cause fluid overload/toxicity

What effect can being pregnant have on medication dose

Medications may be sub-therapeutic due to

• Increased GFR

• increased cardiac output

• increased plasma volume

Before a pelvic exam, the women should ___

empty her bladder

* take deep breaths during exam

Should hot tubs and saunas be avoided during pregnancy?

Yes, hot temps can cause damage to the fetus

* maternal body temp should not exceed 100.4 or 38 C

When are tub baths contraindicated

If there is no mucus plug to prevent entry of microorganisms

What foods are good for pregnant folk

• beans

• leafy greens

• whole grains

• broccoli

• liver

• shellfish

• fresh fruits and veggies

• peas

What type of meat should pregnant folk avoid

• uncooked

• fish limited to 170g or 6 oz of freshwater fish per week

• all raw fish avoided

Vitamins needed for pregnancy

• Vit A

• Vit C

• Vit D

• Calcium

• phosphorus

• protein

• folic acid

• omega 3s

• fatty acids

• iron (take on empty stomach with vit C)

How much do caloric needs increase

2nd trimester: increase 340 cals

3rd trimester: increase 500 cals

breastfeeding: increase 500 cals

How much fluid should a pregnant lady drink/day

1500-2000 mL

* limit 2 cups of coffee or tea

What type of vaccine should pregnant folk NOT receive (unless the benefit outweighs the risk)

LIVE vaccines (vaccines containing live virus)

* flu vaccine however is encouraged during 2nd and 3rd trimester

How should a pregnant lady wear a seatbelt

• lab belt under the abd, across pelvic bone

• avoid sitting for long periods of time during travel. Max of 6 hours with stops made at least 2 hours for a 10 minute walk

Is taking ibuprofen during the 3rd trimester bad?

Yes. Can cause premature closing of the ductus arteriosis, leading to fetal distress

Ultrasound

high frequency waves to visualize baby

Kick counts

• easy way to determine fetal health

• count kicks for 30-60 min 2x per day

• encouraged after 28 weeks

• 10 kicks in 1-2 hours is healthy

Biophysical profile (BPP)

• uses 5 observations to check fetal health and oxygenation

• fetal breathing, movements, tone, volume of amniotic fluid, FHR variability (fetal hear rate) (using non stress test)

Amniocentesis

• Aspiration of amniotic fluid

• can test for genetic disorders

• can test for maternal fetal blood incompatibility

Triple marker screening

* tests for tristomy (three copies of chromosomes instead of two)

Contraction stress test

• pictocin is given to cause light contractions

• fetal response is monitored.

Fetal nonstress test

* monitors fetal heart response to exercise (ability to speed up)

What happens if a mother is RH negative

• given rhogam

• rhogam after birth if baby is RH positive

Efflurage

gentle circular motion on abd with fingertips to help with contraction pain

* very light touch

Breathing techniques for labor

• inspiration and expiration should be equal in length

• do not hold breath or hyperventilate

• during pushing, take a deep breath and push on exhale

• breathing into cupped hand if hyperventilating

incompetent cervix

• complication of pregnancy

• cervix dilates early in pregnancy, cannot support the weight of growing fetus

• Cervix can be reinforced surgically with either McDonald’s or Shirodkar procedures

Complication of ectopic pregnancy

Rupture can cause hemorrhage

Treatment for ectopic pregnancy

Methotrexate to dissolve pregnancy and stop cell division

Placenta Previa

• placenta implants on/near cervix opening instead of fundus

• may cause (painless) bleeding in 3rd trimester as cervix dilates

• bed rest

• NO vaginal exams

• can cause hemorrhage, fetal death, ect.

What can you not do with a pt who has placenta previa

Vaginal exams

* can cause more/worse bleeding

Abruptio Placentae

• placenta seperates too early

• occurs after 20 wks gestation

• SUDDEN ONSET PAINFUL BLEEDING, dark red vaginal bleeding

• Leading cause of maternal death

• can cause DIC

Causes of abruptio placentae

• blunt trauma to abdomen

• vasoconstriction drugs

• maternal hypertension

DIC

Death is coming

• blood runs out of clotting factors, massive hemorrhage

• termination of pregnancy may be needed, administer blood products, oxygen. Correct underlying cause

• NO HEPARIN

• Bleeding from gums, injection sites, petechiae on skin are s/s that DIC is developing

• usually secondary to another complication such as abruptio placenta, GH, retained dead fetus, mole, hemorrhagic shock, septic abortion

Blood incompatibility (RH)

• mothers blood produces antibodies that destroy fetal RBC (fetus can have anemia and heart failure and die in the womb)

• RH positive is dominant trait, so chances are good that baby will be RH positive

ABO blood compatibility

• women has group O blood

• fetus has A, B or AB blood

• Mother has antibodies for A and B

• Do not need to treat in the womb, only after birth

• can cause jaundice

Gestational Hypertension

Exceeds 140/90 after 20th week of pregnancy; No proteinuria; B/P returns to normal after 6 weeks PP

• considered preeclampsia when renal involvement leads to proteinuria

• considered eclampsia when CNS involvement leads to seizures

Preeclampsia

GH with proteinuria; renal involvement leads to
proteinuria

* can lead to seizures if progresses to eclampsia

Severe Eclampsia

B/P 160/110, elevated serum creatinine, Headache, blurred vision, hepatic dysfunction, thrombocytopenia

• can lead to seizures

• termination of pregnancy may be considered at 32-34 weeks

Hyperemisis Gravidarum

• Persistent vomiting causing weight loss, dehydration, electrolyte imbalance

• fetus at risk for poor growth (fetal intrauterine growth restriction)

Gestational DM

• impaired glucose tolerance during pregnancy

• should dissapear after birth

• 50% of these patients get DM type 2 within 5 years after delivery

Are oral hypoglycemic agents contraindicated in gestational DM

Yes

* limited use of glyburide

Pregnancy increases risk of what clotting problems?

• DVT

• Pulmonary Embolism

• thrombophlebitis

Changes in coagulability and fibrinolysis occur during pregnancy that increases risk for these conditions

What % of pregnancy ends in spontaneous abortion

15%

When a pregnant women is admitted with bleeding, what is the nurses role?

• vs

• observe for s/s of shock (pallor, cold, clammy, restlessness, perspiration)

• weigh perineal pads to determine amount of bleeding

• asess fetal heart rate

• emotional support

Can UTI cause miscarriage

YES

what causes a RH incompatibity?

Fetus RH positive, mother RH negative

Hydaiform mole

* condition where vili of the placenta become swollen/fluid filled and take on a grape like appearance

Fetal lie

relationships of fetal spine to mothers spine

* longitudal, transverse, oblique lies

Presentation

How fetus presents

• breech (feet or buttocks first, c-section needed) 3% of births

• cephalic (head first, normal) 95% of all births

• face

• shoulder (shoulder down)

Lightening

fetus drops into outlet of pelvis

• mother can breathe, but has to pee all the time

• “baby has dropped down”

Station

relationship of fetal head to mothers pelvis

• starts at 0 after lightening, as number increases positively, baby is on the way out.

• measured in cm

Contractions cause

• cervix to efface/thin

• cervix to dilate

• push fetus downwards

• each should be followed by period of rest

• you can ascertain the start of contractions by placing hands on fundus

Measuring contractions

Frequency = count time from beginning of one contraction to the beginning of the next

Duration = time from start of contraction to the end (usually about 45-90 seconds)

Interval = time uterus relaxes between contractions

Cervical changes during labor

• Ripening: softening

• Effacement: shortening/thinning of cervix

• Dilation: opening 1-10 cm

True labor vs false labor

Cervix only dilates with true labor