ob clinical topics

methods to assess fetal well-being

ultrasound
amniocentesis
daily fetal movement count
fetal monitoring
biophysical profile
non-stress test & contraction stress test

reasons for antenatal testing

-decrease fetal movement
-fetal heart arrhythmias
-increased MSAFP (maternal serum alpha-fetoprotein)
-hx of preterm labor
-hydramnios or oligohydramnios
-infections
-inherited chromosomal disorders
-maternal systemic disease: anemia, diabetes, chronic HTN, heart disease
-multiple gestation
-post-term (past 41 weeks)
-PIH
-premature ROM
-suspected IUGR
-vaginal bleeding

ultrasound

-the use of high frequency sound waves to image fetal body parts
-can be done tranabdominally or endovaginally

transabdominal ultrasound

-noninvasive
-easy
-not as clear of photo
-early pregnancy- difficult to visualize
-ask patient to fill bladder to push uterus up

endovaginal ultrasound

-gel covered w/ condom up cervix
-can visualize cervix
-preferred early
-invasive
-patient may be uncomfortable

what can be detected in an ultrasound?

-documentation of gestational sac early in pregnancy
-fetal position
-fetal number (twins)
-assess fetal anatomy
-assess for placental location/grade
-measurement of amniotic fluid volume
-evaluate cervical structure
-assess gestational age

what is placental grade?

how mature the placenta is (lifespan is 40 weeks)

biparietal diameter measurement (BPD)

measures distance across fetal head

femur length measurement (FL)

measures length of fetal femur

abdominal circumference measurement (AC)

measures circumference of fetal abdomen

what 3 measurements can be averaged out to determine/estimate gestation/size of fetus?

head, abdomen, and femur

amniocentesis

-analysis of amniotic fluid
*abdominal/uterine puncture
*small amount of amniotic fluid obtained
*not without risk

amniocentesis indications

-advanced maternal age
-family history of genetic abnormalities
-abnormal results from other screening diagnostics

amniocentesis risks

-infection
-ROM
-bleeding
-miscarriage

amniocentesis early in pregnancy

-15-18 weeks
-genetic testing
*alpha-feto protein studies
*chromosomal/DNA studies

amniocentesis late in pregnancy

-assess fetal lung maturity
*L/S ratio
*PG level

L/S ratio

-tests fetal lung maturity
-NORMAL: 2:1 after 35 weeks

PG

-tests fetal maturity
-NORMAL: present after 36 weeks

alpha-FETO protein

-checks for neural tube defects
-should be negative after 15 weeks

MSAFP

-assesses risk for neural tube defect or genetic disorders
-too high: risk for neural tube defect
-too low: risk for down syndrome

fetal kick count

-non-invasive
-done at home
-start at 28+ weeks
-counts kicks/movement
-10 kicks in 2 hours

fetal monitoring (what is assessed for mom and fetus)?

mom:
-frequency
-duration
-intensity

fetus:
-baseline
-variability
-periodic changes

frequency

-how frequent are the contractions
-from beginning of contraction to beginning of next contraction

duration

-how long do contractions last?
-from beginning of contraction to end of SAME contraction

intensity

-how strong are contractions?
-can't assess true intensity w/ external monitor
-IUPC can be used to measure true intensity

fetal heart rate baseline

-average FHR over 10 min period
-rounded to nearest 5
-not including any periodic changes
-normal baseline 110-160
-can be monitored external or internal

fetal heart rate variability

-push pull effect of parasympathetic & sympathetic nervous system
-parasympathetic effect: decrease HR
-sympathetic effect: increase HR
-monitor tracing appears jagged on strip
-good variability is reassuring (adequately oxygenated CNS)
-decreased variability: early indicator of fetal distress OR possible sleeping fetus

fetal heart rate periodic changes acronym

VEAL CHOP
Variable decelerations \= Cord compression
Early decelerations \= Head compression
Accelerations \= Ok
Late decelerations \= Poor placental perfusions

variable decelerations

-shaped like W, V, or U
-rapid decline & return to baseline

-CORD COMPRESSION
-interventions:
*reposition
*give oxygen
*IV fluid bolus
*pelvic exam to check for cord prolapse
*stop Pitocin
*notify MD

early decelerations

-mirror shape of upside down contractions
-return to baseline before end of contraction

-HEAD COMPRESSION
-interventions:
*check for labor progress
*head is descending
*may deliver soon

accelerations

-transient increase in FHR
-good! indicator of fetal well being

late decelerations

-mirror shape of upside down contractions
-continues beyond end of contraction

-POOR PLACENTAL PERFUSION
-interventions
*give oxygen
*reposition
*IV fluid bolus
*stop Pitocin
*notify MD
*if unresolved may need c-section

NST (non-stress test)

-monitoring of fetus
-no stressor is used
*fetal monitor applied
*observe for FHR changes related to fetal movement

NST interpretation- GOOD

-reactive!
-FHR "reacts" to fetal movement
-at least 2 episodes of fetal movement w/ FHR acceleration
-accelerations are 15x15
*rise 15 beats per minute
*duration of 15 seconds

NST interpretation- BAD

-non-reactive
-FHR does not react to fetal movement
OR
-no episodes of fetal movement present

contraction stress test (CST) OR oxytocin challenge test (OCT)

-monitoring of fetus
-stressor is induced (contractions)
*need 3 contractions within 10 mins
-observe fetal response

CST or OCT interpretation- GOOD

-negative is good!
-3 contractions in 10 mins
-no decelerations present!

CST or OCT interpretation- BAD

-positive is bad
-3 contractions in 10 mins
-DECELERATIONS PRESENT

NST characteristics

description: FHR & fetal movement
environment: MD office/hospital
client position: sitting/side lying
test length: 30-40 mins
IV: NO
meds: NO
BP: maybe
monitor: FHR & fetal activity
interpretation: reactive NST \= good
non-reactive \= bad

CST characteristics

description: FHR & induced contractions
environment: hospital
client position: semi-fowlers/side lying
test length: 30 min, baseline, continue until 3 contractions in 10 mins
IV: yes
meds: oxytocin
BP: yes, onset and q 15 mins
monitor: FHR & contractions
interpretation: neg CST \= no late decels
pos CST \= late decals

biophysical profile

-assessment of 5 fetal biophysical variables
*nonstress test (reactive fetal heart rate)
*fetal breathing movement
*gross fetal body movements
*fetal tone
*amniotic fluid volume

biophysical profile scoring/variables

-nonstress test (FHR)
*normal \= reactive (2)
*abnormal \= nonreactive (0)

-fetal breathing movements
*normal \= present (1 episode in 30 sec duration in 30 min period) (2)
*abnormal \= absent or diminished (0)

-fetal movement
*normal \= present (3 episodes in 30 min period) (2)
*abnormal \= absent or less than 3 episodes (0)

-fetal tone
*normal \= full flexion (at least 1 motion of extension back to flexion) (2)
*abnormal \= extremities in extension or no movement (0)

-amniotic fluid volume
*one or more 1 cm pocket (2)
*no pockets or less than 1 cm pocket (0)

pph - etiology

-uterine atony
-retained placental fragments
-genital tract lacerations
-hematomas
-uterine inversions
-uterine ruptures
-abnormal placental implantation
-coagulation
-uterine subinvolution

uterine atony

inability of the uterus to contract effectively

retained placental fragments

can cause early PPH, but most common cause of late PPH

uterine inversion

turning of the uterus inside out after birth of the fetus

uterine subinvolution

a condition in which the uterus returns to its prepregnancy shape and size at a rate that is slower than expected (usually the result of retained placental fragments or an infection)

PPH risk factors

-overdistention of uterus: multiple gestation, large baby, polyhydramnios
-overworking of the uterus: grandmultiparity, prolonged labor, oxytocin
-drugs: anesthetics, MgSO4, cocaine
-OB complications: PIH, operative delivery (forcep or c-section)
-other: urinary retention, previous PPH

PPH assessment

-medical, prenatal, intrapartal history
-PP recovery assessment
*every 15 mins for 1 hour
*every 30 mins for 1-2 hour
*every 4-8 hour as protocol
--vital signs
--fundal assessment (height, firmness, position w/ pelvis)
--perineum (hematomas, lacerations)
--lochia (color, amount, clots, trickling), remember to check under patient buttocks, 1mL\=1gm)
--bladder status, voiding pattern & amount
--signs of hypovolemic shock: LOC, skin color, capillary refill
-labs
*CBC or H&H

PPH interventions

-MASSAGE
-crede uterus if clots are retained
-palpate & empty bladder (catheterize)
-apply ice to perineum (20 mins on 20 mins off)
-administer medications
*oxytocin 20 units IM or 20 units IV
*methergine 0.2mg IM as ordered
*hemabate 0.25 IM as ordered
*cytotec rectally or sublingual 400-1000mcg
-encourage breastfeeding (oxytocin release)
-manage hypovolemia:
*position recumbent w/ feet/legs elevated
*replace lost volume w/ IV fluids as ordered
--second IV site
--isotonic solution
--large bore IV canula
--blood tubing
*administer O2 per nasal cannula on non rebreather face mask at 8-10 L/min
*type & cross match for possible blood transfusion
*possible tamponade

postpartum priorities

-prevent hemorrhage
-prevent infection
-promote involution
-promote comfort
-promote familial relationship
-encourage self-care

how is PPH defined?

-500 mL of blood after vaginal birth
-1000 mL after c-secton

uterine crede

-technique to massage the fundus
-similar to 'juicing' an orange

bimanual massage

done by physician, uncomfortable for patient, helps uterus contract

uterine tamponade

puts pressure where 'wound' is during PPH

PPH teaching points

-normal pattern of lochial progression
*rubra from birth to day 3
*serosa from day 3 to day 14
*alba from day 14 to day 28
*should never regress
-clots larger than quarter should be reported
-symptoms of secondary PPH: backache, abdominal cramping, regression of lochia
-diet high in protein, vitamin c, and carbs are necessary for tissue repair
-how and when to notify the healthcare provider

how is gestational age estimation performed prior to delivery?

-LNMP
*patient must be accurate historian
*many women have irregular menstrual cycles
-ultrasound assessment
*most accurate in first semester
*first trimester accuracy of +/- 3 to 5 days
*beyond 24 weeks, accuracy becomes +/- 2 weeks

most common gestational assessment tool

ballard assessment (done within 4 hours after birth)

what two categories does ballard assessment tool divide into?

neuromuscular maturity & physical maturity

range of scores for ballard & what they mean?

-2 \= very premature
5 \= post mature
score of 40 \= 40 weeks gestation
highest overall score possible: 50 (44 weeks gestation)

gestation assessment tool - external physical characteristics

-skin
-lanugo
-plantar creases
-breast tissue
-ears
-genitals

gestation assessment tool - neuromuscular characteristics

-posture
-square window
-arm recoil
-popliteal angle
-scarf sign
-heel to ear

gestation: skin

-preterm: thin, blood vessels visible, covered in vernix
-term: more opaque, SQ fatty deposits, few blood vessels visible
-postterm: thick & opaque, dry, cracking (lack of vernix)

gestation: lanugo

-20 weeks: begins appearing
-28 weeks: amount peaks
-post 28 weeks: thinning, disappears from face first
-38 weeks: bald areas, slight amount on shoulders

gestation: plantar creases

-before 28 weeks: no creases
-28-32 weeks: virtually none, faint thin redlines over anterior aspect of foot
-34-37 weeks: 1-2 anterior creases
-37-39 weeks: creases over anterior & 2/3 of sole

gestation: breast tissue

-before 28 weeks: nipples imperceptible
-28-32 weeks: nipples barely visible, no areola
-32-37 weeks: well defined nipple areola
-38-40 weeks: well defined areola, raised

gestation: ears

-before 34 weeks: pinna immature, no cartilage, remains folded
-34-37 weeks: pinna curved, soft recoil
-37-40 weeks: formed, firm instant recoil
-40+ weeks: thick cartilage ear stiff

gestation: female genitalia

-before 28 weeks: clitoris prominent labia flat
-28-32 weeks: prominent clitoris, enlarging labia minora
-33-36 weeks: labia majora widely spaced w/ equally prominent. labia minora
-36-39 weeks: labia extends over labia minora but not over clitoris
-39 weeks+: labia majora covers labia minora & clitoris

gestation: male

-before 28 weeks: scrotum empty and flat
-28-30 weeks: testes undescended into scrotal sac
-30-36 weeks: testes descending w/ few rugae over scrotum
-36-39 weeks: testes have descended into scrotum which is now pendulous & completes w/ rugae

gestation: posture

-before 30 weeks: hypotonic, little/no flexion
-30-38 weeks: varying degrees of flexed extremities
-38-42 weeks: may appear hypertonic
-more mature infant is, greater their tone will be

gestation: square window

-assesses wrist flexibility and/or resistance to extensor stretching resulting in angle or flexion at wrist
-flex hand down to wrist- measure angle between forearm & palm
-more mature \= smaller angle

gestation: arm recoil

-measures angle of recoil following brief extension of upper extremity
-for 5 seconds, flex arms while infant is in supine position, pulling the hands fully extend the arms to side then release- measure degree of arm flexion & strength (recoil)
-before 28 weeks: no recoil
-28-32 weeks: slight recoil
-32-36 weeks: recoil does not pass 90 degree
-36-40 weeks: recoils to 90 degrees
-40+ weeks: rapid full recoil

gestation: popliteal angle

-assessed w/ infant supine, the thigh is flexed on abdomen while lower leg is extended until resistance is met
-popliteal angle decreases with advancing gestational age
-before 26 weeks: angle 180 degrees
-26-28 weeks: angle 160
-28-32 weeks: angle 140
-32-36 weeks: angle 120

gestation: scarf sign

-assessed by placing newborn supine while arm is drawn across chest until resistance is met
-before 28 weeks: elbow passes torso
-28-34 weeks: elbow passes opposite nipple line
-34-36 weeks: elbow can be pulled past midline, no resistance
-40 weeks+: doesn't reach midline

gestation: heel to ear

-assess by placing infant supine & drawing foot toward ear on same side
-buttocks must be kept flat
-breech infants will score lower
-resistance increases w/ gestational age
-before 34 weeks: no resistance
-40 weeks+: great resistance

SGA

-small for gestational age
-below 10th percentile

AGA

-appropriate for gestational age
-5lbs 12oz to 8lbs 12 oz

LGA

-large for gestational age
-above 90th percentile

causes of SGA & IUGR

-maternal smoking
-alcohol/drug use
-maternal anemia
-hypertension
-maternal undernutrition
-multiple fetuses
-congenital abnormalities
-rubella
-intrauterine infections
-discordant w/ twin pregnancy
-placental insufficiency

SGA related complications

-fetal hypoxia r/t chronic decreased O2 in utero
-aspiration (either hypoxia causing fetal gasping during birth or aspirating meconium)
-hypothermia (decreased SQ/brown fat)
-hypoglycemia (increased met rate)
-polycythemia (increased RBC to counter hypoxia)

causes of LGA

-glucose intolerance in utero
-diabetic mother
-maternal overnutrition
-heredity
-parity (babies get bigger w/ subsequent pregnancy)

LGA related complications

-hypoglycemia (exposure to high glucose levels in utero contributes to hyper-secretion of insulin which continues immediately post delivery
-birth trauma (shoulder dystocia, possible CPD)
-perinatal asphyxia due to difficult delivery process

analgesia

insensibility to pain (no loss of feeling/sensation/movement)

anesthesia

ALL sensation blocked

nursing considerations regarding pain medication admin

-record drug name, dose, route, site on EFM strip & chart
-record woman's blood pressure & pulse (before & after) on EFM strip & chart
-safety precautions (side rails, assessment of FHR)

narcotics

-use: active phase
-common meds: stadol, nubain, demerol
-usually IVP
-fast acting
-narcotic antagonist: Narcan

who should you not give narcan to?

opioid dependent women

what does narcan reverse?

narcotic overdose (respiratory depression & hypotension)

regional anesthesia

-temporary & reversible loss of sensation
-prevents initiation & transmission of nerve impulses
-types: epidural/spinal

epidural advantages

-produces good analgesia
-woman is fully awake during labor/birth
-continuous technique allows different blocking for each stage of labor
-dose of anesthetic agent can be adjusted such as during pushing
-can be used for labor pain management or c-section anesthesia

epidural disadvantages

-maternal hypotension: most common complication
-decreased perineal sensation while pushing
-other possible complications although very rare
*postdural puncture seizures
*meningitis
*cardiorespiratory arrest
*vertigo

epidural/spinal admin

-preload w/ IV fluids to decrease hypotension
-position for insertion:
*sitting w/ legs hanging over side of bed or sidelying tucked in fetal position
*chin tucked on chest
*back arched out (like a cat)
-catheter is left in place so doses can be adjusted (epidural only)
-contraindications: history of back surgery, potential for bleeding (low platelets or prolonged anticoagulant use)

insertion of epidural

-tip of needle is in epidural space
-epidural anesthetic is injected
-catheter is left in place for continual infusion or med adjustment

spinal block

-local anesthetic injected directly into spinal fluid I n subarachnoid space
-higher level of anesthesia
-avoidance of "windows" or "hot spots"
-usually used to provide anesthesia for c-section

spinal block advantages

-immediate onset of anesthesia
-relative ease of administration
-smaller drug volume
-maternal compartmentalization of drug

spinal block disadvantages

-high incidence of hypotension
-greater potential for fetal hypoxia
-uterine tone is maintained, making intrauterine manipulation difficult
-short acting

nursing considerations after spinal block admin

-monitor maternal & fetal vital signs
-assess for hypotension
-corrective measures for hypotension if needed (IV FLUIDS FIX THIS)
-administer antiemetics as needed
-monitor respiratory rate
-assess bladder & catheterize if unable to void

potential complications of spinal block

-hypotension
-drug reaction
-total spinal neurologic sequelae
-spinal headache (from leakage of spinal fluid)
-nausea, shivering, urinary retention
-ineffective anesthesia
-inability to push

how to treat a spinal headache

-keep patients flat in bed
-reduce visual stimuli
-treat w/ caffeine
-possible blood patch inserted to spinal site, seals hole (last resort)

endorphin related to pain

-they are endogenous (native to the body)
-morphine (opiate like substance)