maternity final pt 1

diagnostic test

a test where

BPP (biophysical profile)

-reliable predictor of fetal well being with 5 parameters, each scored 0 or 2 points

-normal is 8-10/10

1) amniotic fluid volume (adequacy of placental function over time)

2) fetal breathing movements (current CNS status)

3) fetal movement (current CNS status)

4) fetal tone (current CNS status)

5) fetal heart rate (current CNS status

when is the BPP usually used

-late second and third trimesters

-for high risk conditions: initiated at 32weeks

NST (nonstress test)

-most common for antepartum fetal evaluation

-reactive: normal nonreactive: requires further evaluation

-has a high false positive rate

-requires twice-weekly testing

NST procedure

-woman in semi-fowlers with slight lateral tilt to optimize uterine perfusion

-FHR recorded with doppler transducer

-woman presses button when she feels fetal movement

-usually 10-15min

nonreactive NST test

-requires further evaluation

-testing period extended to 20 minutes and then to 40

-if still nonreactive after 40min, contraction stress test or BPP is done

Diagnostic tools

contraction stress test

-stress test that identifies a fetus that appears stable at rest but shows evidence of compromise under stress

-the test stimulates the stress experienced by the fetus during the first stage of labor and contractions

--a normal contraction decreases the uterine blood flow and if the baby is stressed by this hypoxia occurs showing a decel in the FHR

how to stimulate contractions for a stress test

oxytocin-stimulated

-IV infusion of dilute oxytocin

nipple-stimulated

-apply warm and moist washcloth to both breasts then massage one nipple for 10 minutes

-nipple stimulation causes oxytocin release

negative vs positive contraction stress test

negative

-normal and associated with good fetal outcomes

positive

-repetitive late decels present

-associated with intrauterine fetal death, late decels in labor, low apgar scores, IUGR, and meconium-stained fluid

-usually leads to hospitalization or birth

gestational diabetes glucose levels

- >95 fasted

- >140 nonfasted

- >130-140 at 1 hour of glucose test

gestational diabetes treatment

-diet (first line treatment)

-exercise (30min at least 5 days/week)

-self-monitoring glucose levels (4x/day)

^^if these do not work

-pharmacologic (insulin or oral hypoglycemics as alternative)

gestational diabetes neonatal outcomes

-no increased incidence of birth defects if diabetes develops AFTER the 1st trimester

-macrosomia (increased fetal size)

-neonatal hypoglycemia (at birth the maternal glucose supply is abruptly removed, but the infant continues making insulin)

-hypocalcemia

-hypomagnesia

-hyperbilirubinemia

-respiratory distress symdrome

ultrasounds and GDM

-assess fetal growth to monitor for macrosomia

-helps detect complications

-assess fetal growth and ensures fetal well-being with third-trimester surveillance

-checks amniotic fluid to ensure they stay in a safe range

causes of dyspnea in pregnancy

-hormone and metabolic changes

-oxygen consumption increased 20-40% during pregnancy

-capillary engorgement in respiratory tract

-enlarged uterus places pressure on diaphragm

-increased blood volume (need for more O2)

hypothyroid vs hyperthyroid condition

hypothyroid

-risks of anemia, gestational hypertension, placental abruption

-fatigue, cold intolerance, constipation, muscle cramps, memory/concentration issues

hyperthyroid

-risks of preeclampsia, heart failure, thyroid storm

-rapid heart rate, n/v, weight loss, poor weight gain, nervousness, shaking hands

hypothyroid vs hyperthyroid treatment

hypothyroid

-levothyroxine (thyroid replacement)

hyperthyroid

-propylthiauracil or methimazole (antithyroid meds)

sickle cell anemia

-genetic disorder causing abnormal hemoglobin, resulting in abnormal RBC

-RBC are sickled, sticky, and only have 5-10day lifespan

-treat with oxygen, fluids, and pain management

vaso-occlusive crises

-occurs from sickle cell anemia

-recurrent attacks if fever and pain

-RBC pile up and stick together

-most commonly abdomen, joints, and extremities

SLE (systemic lupus erythematosus)

-multisystem chronic inflammatory autoimmune disease affecting skin, joints, kidneys, lungs, liver, etc

-most common in females of childbearing age

-diagnosed by lab testing

SLE s/sx

-myalgias

-fatigue

-weight changes

-fever

-characterized by exacerbations (flares) and remissions

management of SLE during pregnancy

-medications including prednisone, low-dose aspirin, hydroxychloroquine and imuran

-monitor fetal growth through ultrasounds

-delivery is recommended by 39 weeks or earlier if complications occur

types of hypertensive disorders in pregnancy

gestational HTN

->140/>90 after 20wk in a woman with previously normal BP

-resolves after birth

-no proteinuria

chronic HTN

-HTN existing before pregnancy or diagnosed before 20wk

preeclampsia

-pregnancy-specific condition with HTN and proteinuria developing after 20wk

-can occur postpartum

fetal risks of hypertensive disorders in pregnancy

chronic HTN

-IUGR

-preterm birth

-death

all types

-placental abruption

-fetal growth restriction

-still birth

preeclampsia

-pregnancy-specific condition with HTN and proteinuria after 20wk gestation

-can also develop postpartum

preeclampsia treatment

only true cure is: delivery of baby

magnesium sulfate

-prevents seizures while treating the eclampsia

-must monitor urine output closely since it is excreted in urine

-pt can become mag toxic: absent DTR, decrease RR, decrease LOC

BP meds

-meds like labetalol of nifedipine lower very high BP and reduce risk of stroke

monitoring

-VS, I/O, DTR, LOC

-s/sx usually resolve 48hrs after birth

assessments for hypertensive disorders

-CBC, serum creatinine, platelet, liver enzymes, maternal weight

-assess for progression to severe symptoms (ex. severe headaches, blurred vision, mental confusion, SOB, etc)

-monitor VS, I/O, DTR, LOC

fetal assessments

-daily fetal movement counts

-nonstress testing twice weekly

-ultrasound for fetal growth every 3 weeks

-amniotic fluid volume weekly

causes of vaginal bleeding during pregnancy

-placenta previa (painless bright red during 2-3 trimester)

-varices or superficial lacerations (dark red)

-deep cervical laceration (bright red)

-placental abruption

-ectopic pregnancy

causes of vaginal bleeding during labor

-incomplete placental separation

-excessive fundal manipulation

-excessive traction on umbilical cord

-uterine rupture

-retained placental fragments

-uterine atony

bright red vaginal bleeding

-arterial blood

-indicated deep lacerations of cervix or placenta previa

-fresh and active bleeding

dark red vaginal bleeding

-venous blood

-may be from varices or superficial lacerations

-older blood or slower bleeding

bloody show vs vaginal bleeding

blood show

-pink and sticky

vaginal bleeding

-not sticky, larger volume, requires eval, browish-bloody

vomiting in pregnancy

-begins at 4-6wk but peaks at 8-12wk

-usually ends by end of first trimester

HELLP syndrome

-laboratory diagnosis for a variant of preeclampsia involving hepatic dysfunction

-can develop in women w/o HTN or proteinuria

-same treatment as HTN/preeclampsia

Hemolysis (breakdown of RBC)

EL elevated liver enzymes

LP low platelet count

complications of HELLP

-pulmonary edema

-acute renal failure

-placental abruption

-DIC

-preterm birth

-sepsis or stroke

s/sx HELLP syndrome

-primary: epigastric/RUQ abdominal pain

-severe headaches

-n/v

-extreme fatigue

-edema in hands/face

-vision changes

steroid administration in pregnancy

-used to accelerate fetal lung maturity by stimulating surfactant production

-betamethasone or dexamethasone

-usually given when birth is likely in 7 days

-used a lot with HELLP or severe preeclampsia

purpose of tocolytic drugs

-delays preterm birth

-slows/stops uterine contraction

-relaxes uterus

common tocolytics

magnesium sulfate (IV)

-most commonly used toco

nifedipine (PO)

-calcium channel blocker

-*preferred* agent for tocolysis

-blocks calcium influx by inhibiting myometrial activity

indomethacin (PO)

-NSAID

-most effective tocolytic

-inhibits prostaglandin activity

terbutaline (SubQ/PO)

-beta2-adrenergic agonist

-stimulates beta2-receptors causing uterine smooth muscle to relax

treatment for preterm labor

pharmacologic treatment

-steroids (betamethasone/dexamethasone) (accelerates fetal lung maturity)

-tocolytics (slows/stops contractions)

lifestyle mods

-activity restriction/bed rest

-hydration

-smaller frequent meals

shoulder dystocia

-when fetal head is born but the shoulders cannot pass through pelvis

-rare but more common with macrosomia and pelvic abnormalities

emergency maneuvers for shoulder dystocia

-mcRoberts (hyperflexing legs against abdomen)

-suprapubic pressure (attempts to dislodge shoulder)

-Gaskin maneuver (women on hands and knees)

***avoid fundal pressure

s/sx of shoulder dystcoia

-turtle sign (head shows then pulls back against mothers body)

-slowing progress in second stage

-external rotation does not occur

chorioamnionitis (chorio) s/sx

bacterial infection of amniotic cavity

-fever

-fetal and maternal tachycardia

-uterine tenderness

chorio risk factors

-prolonged membrane rupture

-multiple vag exams

-internal fetal heart rate monitoring

-intrauterine pressure catheter

chorio treatment

-prompt broad-spectrum antibiotics and birth of fetus

-during labor: ampicillin or penicillin + gentamicin

-after c section: add antibiotic coverage with clindamycin or mentronidazole

-postpartum: one additional dose