411 Final Exam

Dysmenorrhea

painful menstrual bleeding; no primary pathology; secondary path. is fr. pelvic or uterine path.

s/s: N/V/D, fatigue, pain, fever, HA

int: pain management — use heating pads, lifestyle changes (stop smoking & drinking), hormonal tx; surgery, ovarian suppressive agent

NOT RECOMM: Long-term NSAIDs usage — only for short-term due to risk for kidney complications

What is the most common cause of secondary dysmenorrhea?

Endometriosis — due to the overgrowth of cells

What are the different contraceptions?

1. Behavioral — abstinence, fertility awareness, withdrawal, lactational awareness

2. Barrier — condoms, diaphragms, cervical caps, sponge

3. Hormonal — PO, transderm., implants, IUD, plan B, injectibles

4. Sterilization — tubal ligation, vasectomy

What is “Natural Family Planning”?

method of working out when a woman is most fertile and then avoiding unprotected sex at that time to prevent pregnancy.

How does PO contraceptives works?

PO contraceptives have “progestins” … it’s fx is to:

• suppress ovulation by adding more estrogen and progesterone in the body (mimics pregnancy)

• cervical mucus also thickens — hinders sperm transportation into the uterus

• implantation is inhibited by suppressing the maturation of the endometrium and altering the uterine secretions

… overall makes the endometrium unfavorable for implantation

What are the contradictions with PO contraceptives?

• smoking

• history of deep vein thromboembolism (DVTs)

What are the 3 phases of the ovarian cycle?

1. Follicular Phase

2. Ovulation

3. Luteal Phase

Follicular Phase

follicles in the ovary grow and form a mature egg

goal: produce an ovum to use for fertilization

starts at day 1 of the mens. cycle & continuous thru the ovulation phase (day 10 to 14 later) — not consistent in duration due to variation in follicular development

hormones — increased estrogen (thickens the endometrium lining), increased FSH (stims ovary to prod. immature follicles), & increased LH (helps with the development and rupture of the mature follicle)

Ovulation

release of a mature oocyte fr. the ovary to the fallopian tube (where fertilization occurs) & help carry the ovum (dies after 24hrs) to the uterus

how? — increased LH triggers the final development, maturation, and rupture of the follicles = releasing a mature oocyte

starts at day 14-28 of the men’s. cycle (constant)— MOST FERTILE 3 days before and 3 days after ovulation

hormones — increased LH and estrogen levels (ovulation takes place) BUT estrogen decreases if no pregnancy/fertilization occurred

s/s: vaginal spotting, increase in vaginal discharge, increased libido, increased basal body temp, and cramps

Luteal Phase

the formation of the corpus luteum after the follicle ruptures the egg and the follicle closes

starts at the ovulation phase & lasts ‘til the next mens. cycle — typically occur at day 15-28 of the 28-day cycle

hormones — FERTILIZATION: increased progesterone (prepares endometrium for plantation & increases body temp. slightly ‘til next men’s.); NO FERTILIZATION: corpus luteum degenerates, endometrium shrinks, and estrogen, progesterone, LH, & FSH decreases

Premenstrual Syndrome (PMS)

a group of recurrent physical, emotional, and behavioral symptoms that occur during the luteal phase or last half of the menstrual cycle

why is this happening? — due to the rising and falling levels of hormones (estrogen and progesterone) that may also influence the serotonin (mood modulator) production in the brain

**resolves with the onset of period — there is NO DIAGNOSTIC PROCEDURE and TX

s/s and criteria for diagnosis: cravings, HA/migraine, bloating, acne, extreme mood swings, breast tenderness, edema of the face/tummy/extremities, & fatigue

tx — treat the underlying s/s

int: uses ACOG diagnostics for affective (mood) or somatic s/s (pain, weakness, SOB, etc.), behavioral management/counseling, and improving coping mechanism

What is the severe form of Postmenstrual Syndrome (PMS)?

Premenstrual Dysphoric Disorder (PMDD) — constant mood fluctuation is the main symptoms

s/s: depression, extreme sadness, anxiety, tension, persistent anger, or irritability

Which gender are at the highest risk for getting STIs?

WOMEN — they are twice likely to get STIs and be re-infected again than men

at a higher risk for: gonorrhea, HPV, syphilis, and chlamydia

**most of them are asymptomatic for women

**STIs can cause a lot of damage to their pelvic area — can affect fertility

What is the common cause for excessive vaginal discharge?

Candidiasis — a fungal infection caused by a yeast

Vaginal Candidiasis (VC) or “cottage cheese”

NOT AN STI — cuz candida is a normal component in the vagina; it becomes an STI — when the pathologic of the vaginal environment is altered

s/s: thick, white, curd-like discharge

tx: antifungals — “-zole” medications

int: reduce simple sugars & soda, wear cotton panties, no tight clothes, shower > bath, wash w/mild or no scent soaps, avoid bubble baths, use unscented detergents, good body hygiene, wipe fr. front to back, no douching, and tampons (use pads!)

**if NOT treated, the newborn can develop “thrush” (a fungal infection of your mouth)

risk factors: pregnancy, OC, prolonged usage of broad-spectrum antibx, DM, obesity, steroids/immunosuppressive drugs, HIV infections, tight clothes, trauma to the vaginal mucosa from chemicals

Trichomoniasis

vaginal infection that causes excessive discharge — NOT ALWAYS AN STI

s/s: can be symptomatic or asymptomatic; vulval itching, malodorous foamy vaginal discharge, heavy yellow/green or gray bubbly discharge

tx: antifungals — “-zole” medications; both infected and the partner should be treated

int: educate about — avoiding sex ‘til after they are cured, no alcohol (can cause vomiting while on medication), and provide info on possible effects on reproductive organs

risk factors: damp/wet surfaces, poorly cleaned/maintained hot tubs and drains

Bacterial Vaginosis (BV) or “thin-white & fishy odor infection”

an STI — characterized by alteration in vaginal flora, where the lactobacilli in the vagina are replaced with a high concentration of anaerobic bacteria

s/s: thin-white homogenous vaginal discharge, vaginal pH 4.5, positive whiff test (stale fishy odor), and presence of clue cells on wet-mount examination

tx: Metronidazole (no alcohol with this) or clindamycin cream

risk factors: multiple sex partners, douching, lack of vaginal lactobacilli

Chlamydia

MOST COMMON STI; men — develop urethritis (s/s for men); women — linked with cervicitis, acute urethral syndrome, salpingitis, ectopic pregnancy, PID, and infertility; newborns — may develop conjunctivitis

s/s: usually asymptomatic; mucopurulent vaginal discharge, urethritis, bartholinitis, endometritis, salpingitis, and dysfunctional uterine bleeding (in women)

tx: antibx only — take consistently for 7 days; if s/s does not go away, call HCP; recurrent infection call HCP; Prophylactic agent in the eyes of all newborns (to prevent gonococcal neonatorum)

risk factors: <25 yrs old, recent change in sexual partners/multi partners, poor socioeconomic status, non-white races, not using barrier contraceptives

Gonorrhea

2nd most common STI - Contagious ; is a serious and potentially severe bacterial infection; newborns — may develop conjunctivitis

s/s: typically asymptomatic; abnormal vaginal discharge or bleeding, dysuria, cervicitis, Bartholin abscess, PID, & rectal infection — increased risk for infertility and ectopic pregnancy

tx: dual therapy to help prevent resistance (Azithro & Ceftriaxone); Prophylactic agent in the eyes of all newborns (to prevent gonococcal neonatorum)

risk factors: poor socioeconomic status, inconsistent usage of barrier contraceptions, < 20 yrs olds, and multiple sex partners

Genital Herpes Simplex (Herpes II)

recurrent, life-long viral infection — can be spread through contact of mucous membranes or open wounds with visible or non-visible lesions, kissing, sexual contact, and vaginal delivery

s/s: primary episodes (viral shedding) — multiple painful vesicular lesions, mucopurulent discharge, superinfection with candida, fever/chills/malaise, dysuria, vesicles will open and weep and then crust over; recurrent — tingling, itching, and unilateral genital lesions

tx: NO CURE — antiviral drugs can reduce shedding and recurrent episodes

int: STI testing, contraceptives, hand washing, inform sex partners

What is the number 1 trigger for Genital Herpes Simplex I and II?

STRESS!! — educate patients how to better control their stress levels and improve how they cope

What happens if you have Genital Herpes I & II and your clusters have ruptured?

you are contagious! — the rupture of these clustered vesicles can lead to blindness in newborns

Syphilis

chronic, multi-stage, curable bacterial infection — transmitted thru sex w/infected partners or congenitally fr. infected mom to baby (it can cross the placenta)

s/s: primary — chancre, painless bilateral swollen lymph nodes (adenopathy); secondary — flu-like symptoms, rash of trunk/palms/soles, alopecia, adenopathy; latency — absence of s/s, positive serology; tertiary — life-threatening heart disease and neurological disease

tx: Benzathine Penicillin G — is the preferred drug for all stages of syphilis

int: screening in pregnant women during their 1st prenatal visit, educating about the life-long nature of the condition and tx options

How to care for pts w/ Herpes and Syphilis?

Abstain from intercourse during the prodromal period and when lesions are present.

Wash hands with soap and water after touching lesions to avoid autoinoculation.

Use comfort measures such as wearing non-constricting clothes, wearing cotton underwear, urinating in water if urination is painful, taking lukewarm sitz baths, and air-drying lesions with a hair dryer on low heat.

Avoid extremes of temperature such as ice packs or hot pads to the genital area as well as application of steroid creams, sprays, or gels.

Use condoms with all new or noninfected partners.

Inform health care professionals of your condition.

Pelvic Inflammatory Disease (PID)

infection-induced inflammation of the upper female reproductive tract — may involve the uterine lining (endometritis), the connective tissue adjacent to the uterus (parametritis), fallopian tubes (salpingitis), and peritonitis

**often caused by untreated chlamydia and gonorrhea

s/s: lower abdominal fullness/tenderness, vaginal mucopurulent discharge, prolonged/increased menstrual bleeding, painful sexual intercourse, and white blood cells on vaginal smear

tx: NO CURE — symptom management to calm down the inflammation! broad-spectrum antibx, bedrest, pain management, and oral fluids

int: regular STI screening, educate pt not to douch — as this increases their risk for it

Human Papillomavirus (HPV) or “cauliflower”

MOST COMMON VIRAL INFECTION — causes genital warts (condyloma) and is the main cause of cervical, vulvar, vaginal, penile, anal, & oropharyngeal cancers

**if left untreated, this can turn into cancer cells

s/s: most asymptomatic/ unrecognized; visible genital warts — warts are fleshy papules with a warty, granular surface

tx: NO CURE — therapeutic management on prevention; educate about HPV vaccine (Gardasil) — need all 3 doses b4 sex/exposure, can get at 9yo, & covers 9/11 cancer strains; warts can be scrapped or laser off

goal: to remove warts and induce wart-free periods

risk factors: multiple sex partners, 15-25 yo

What is Pap-smear for?

to check for HPV, PID, and cancer

Can you still have a vaginal birth if you have Human Papillomavirus (HPV)?

YES — However, this is IF you have no active warts & if you have a Hx of genital warts, the baby will have azithro eye drops on baby’s eyes

Hepatitis A

primarily transmitted thru fecal-oral after close contact with an infected person (most common) — can also be acquired thru: drinking polluted waters, eating undercooked shellfish, food handled by Hep A carrier, and oral/anal sex

s/s: flu-like sx w/malaise, skin rashes, fatigue, anorexia, nausea, pruritus, fever, RUQ pain

tx: vaccines — recovery fr. this can provide life-long immunity

risk factors: multiple sex partners, engaging in unprotected anal sex, Hx of other STIs

Hepatitis B

transmitted through saliva, blood serum, semen, period, and vaginal secretion — incubation is 6wks to 6mo — the virus can survive outside the body for 7 days

s/s: less flu-like & less skin involvement

tx: NO CURE — but it has a vaccine

Human Immunodeficiency Virus (HIV)

it's a viral infection that causes AIDS and can be transmitted during sexual intercourses, sharing needles, mother-child, pregnancy, childbirth, & breastfeeding

s/s: have 3 phases — acute: can have a fever, pharyngitis/sore throat, rash, & myalgia (acute); asymptomatic; AIDs — CD4 count <200

tx: NO CURE — management w/antiviral therapy (Zidovudine 6mo course therapy)

risk factors: women, sex w/o condoms, high-risk behaviors of partners

HIV: Horizontal Transmission

needle stick or acquired later in life

• infusion of HIV-contaminated blood products (RARE)

• use of contaminated needles, syringes, and medical equipment → drug use and tattooing

• sex

HIV: Vertical Transmission

MOST COMMON WAY OF TRANSMISSION — mom to baby

• in utero or during birth

• through ingestion of HIV in breastmilk

What are the benefits of a mom positive for HIV consistently taking zidovudine?

this lessen the baby’s chances of also getting HIV

Can you still do vaginal birth and breastfeed with a mother positive for HIV?

NO — they do bottle-feeding and c-section, they immediately wash the baby to remove exposure, given zidovudine, and is checked regularly (if after 6mo baby is negative, medications are stopped)

Which reproductive cancer is more prevalent during pregnancy?

Cervical Cancer

Gestational Cancer

CERVICAL CANCER — most common type of gest. cancer; most freq. malignant are breast cancer, cervical cancer, thyroid cancer, and hematological malignancies, & melanoma

**can be Dx during pregnancy or in the first yr of postpartum

risk factors: changes in the immune system, delayed childbirth

prevention: active screening is incompatible with continuing pregnancy — the screening depends on the stage of the disease, term of pregnancy, and whether the patient wishes to continue or not her pregnancy

Ovarian Cancer

malignant neoplastic growth of the ovary — prognosis depends on the extent of the disease

s/s: bloating, pelvic/abdominal pain, trouble eating/feeling full, urgency & frequency, & increased fatigue; late sign: anorexia and back pain

tx: chemo, surgery, laparoscopy

prevention: NO SCREENING TEST — dx is made later around stage 3 and 4; pelvic exams and transvaginal ultrasound

risk factors: older women, white women, no babies, late menopause, high-fat diet/obesity, genetics, prolonged hormonal replacement use, and talcum powders

Endometrial Cancer

malignant neoplastic growth of the uterine lining

s/s: abnormal and painless bleeding after menopause, pelvic pain, change in bladder habits

tx: based on the stage — chemo, radiation, hysterectomy; NO SCREENING — pelvic examination are used during the early stages

prevention: educating women about the risk factors & ways to decrease risks, daily physical activity, usage of combined OC — dx with ultrasound and biopsy

risk factors: obesity and HTN

Cervical Cancer

malignancy located in the uterine cervix — MAJORITY IS CAUSED BY HPV

s/s: abnormal bleeding after sexual intercourse, vaginal discomfort, malodorous discharge

tx: cryotherapy, cone biopsy, LEEP, hysterectomy, radiation, chemotherapy

prevention: Pap-smear (used for Dx), cervical cancer screening starting at age 21-29yo & cont. Q3yrs — 30-65yo cervical screening w/HPV testing Q3yrs

What is the “Cycle of Violence”?

1. Tension Building

2. Physically Abusive

3. Reconciliation

Tension Building

victim tries to keep the situation from exploding

Physically Abusive

explosion of anger — abuser may physically, emotionally, sexually, and/or financially abuse the victim

Reconciliation or Honeymoon Phase

period of calm, loving, and contrite behavior from the abuser

Victim Profile

battered women syndrome, often will not describe themselves as abused

they usually have — dysfunctional family system, low academic achievement, victim of childhood abuse, & economic stress

Abuser Profile

expresses feelings of inadequacy thru violence or aggression towards others

they’ve experienced — low academic achievements, victim of childhood violence, & heavy alcohol consumption

What are the risk factors for Intimate Partner Violence (IPV)?

• Individual Factors

• Relationship Factor

• Community Factor

• Social Factor

• Women and Children exposed to abuse

When does IPV increases?

during pregnancy w/greater risk during postpartum

IPV increases the risk of what?

child maltreatment

What are the risks of IPV in relation to pregnancy?

• late prenatal care

• physical trauma

• placental abruption

• fetal demise

• low birth weight infants

What are the Presumptive Signs of Pregnancy?

these s/s are physiological changes that could indicate pregnancy

• fatigue

• breast tenderness

• N / V

• amenorrhea

• urinary frequency

• hyperpigmentation of the skin

• fetal movements

• urine enlargement

• breast enlargement

• absent period

• quickening/fetal movement

What are the Probable Signs of Pregnancy?

these s/s are physiological and anatomical signs that are detected on examination

• Braxton hicks contractions

• positive pregnancy test

• abdominal enlargement

• Ballottement

• Goodell’s sign

• Hegar’s sign

• Chadwick

What is “Ballottement”?

the rebound of the cervix

What is “Goodell’s Sign”?

softening of the cervix

What is “Chadwick’s sign”?

blue-ish color of the cervix

What is “Hegar’s Sign”?

softening of the lower portion of the uterine

What are the Positive Signs of Pregnancy?

these s/s are directly attributable to the fetus as detected by examination

• ultrasound verification of the embryo or fetus

• palpation of fetal movement by an experienced clinician

• auscultation of the fetal heart tones via Doppler

What are the 1st Trimester Physical Changes?

• breast tenderness

• constipation — increase fluid and fiber, no meds

• Goodell, Hegar’s, & Chadwick Sign

• increased risks of UTI

• uterus palpable above symphysis pubis @ 12 wks

Why is NSAIDs contraindicated with pregnant women?

usage of NSAIDs around 20 wks gestation or later in pregnancy may cause fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment.

What are the 1st Trimester Psychological Changes?

• excitement or ambivalence

• introversion — turning in on oneself

• mood swings — fr. great joy to despair

• perception of body image changes

• decreased libido

**assess for abuse

What are the 2nd Trimester Physical Changes?

• fundus at umbilicus/belly button @ 20 wks

• Braxton hicks — can be fr. dehydration or over activity/stimmulation

• breast changes — colostrum may start leaking

• postural hypotension

• quickening/fetal movements

• striae gravidarum

• linea nigra

• varicosities

What are the 2nd Trimester Psychological Changes?

• acceptance — triggered by quickening

• the general feeling of well-being

• sexual desire increases

What are the 3rd Trimester Physical Changes?

• SOB & dyspnea

• constipation & hemorrhoids

• heartburn & indigestion

• dependent edema — watch closely due to risks for preeclampsia

• Braxton Hicks contractions

• urinary frequency returns

• breast full and tender

• sleeping problems

• backache

• difficulty walking due to increased relaxin in the muscles

What are the 3rdTrimester Psychological Changes?

• concerned about protecting the baby

• more dependent on partner, family

• preparing for birth and baby

• difficulty sleeping

What is Amniotic fluid? And why is it important?

is a protective liquid contained by the amniotic sac

• serves as cushion of the fetus

• facilitate the exchange of nutrients, water, and biochemical products between mom and fetus

• allows symmetrical growth of the fetus

• allows the fetus to move

• help control the fetal temp.

• help with lung and kidney development

Polyhydramnios

too much amniotic fluid in the amnion sac

amniotic fluid > 2000mL

int: close monitoring, removal of fluid, indomethacin (decreases fluids by decreasing fetal urinary output)

assess: fundal height, discomfort, difficulty palpating fetal parts, or obtaining FHR

tx: therapeutic amniocentesis

Oligohydramnios

not enough amniotic fluid = not enough cushion for the fetus

amniotic fluid < 500mL

int: cont. fetal surveillance, comfort measures, position changes

assess: risk factors, fluid leaking from vagina

tx: amnioinfusion

What is a Placenta? And why is it important?

a mass of tissue that connects a mother’s uterus to the umbilical cord — develops after implantation; embryonic blood flow estb. by 4wks; starts to take over @ 8wks; fully functional @ 12wks

• responsible for delivering nutrients and oxygen to the fetus, and takes out waste

• growth parallels with the fetus

• responsible for metabolic & endocrine functions — human placental lactogen (hPL), estrogen, progesterone, relaxin, and oxytocin

**AVOID SUPINE POSITION!!! — can cause “supine hypotension” and fetal heart rate drop cuz it compresses the vena cava = no proper blood flow/O2 to the fetus

What sustains pregnancy during wk 1 to 7??

ESTROGEN & PROGESTERONE !!!

Where in the Placenta does all the exchanges occur?

at the intervilli space

Preeclampsia

a triad of s/s (hypertension, proteinuria, & edema) — is a hypertensive disorder seen in pregnancy after 20wks

• BP 140/90

• Proteinuria 2 gm/day

• Creatinine > 1.2 mg/day

int: bed rest + moderate walks (small walks), nutrition, and support; do Mg checks every hr

tx: Mg Sulfate (1st 30min = 4-6 g bolus; 1hr after = 1-3 g maintenance) — decreases risk for seizures and decreased high BP

What do we monitor in Hourly Mg Check?

• any blurred vision

• dizziness

• headache

Normal Mg level in LDRP?

4.8 to 8.4

S/S of Mg toxicity?

• decreased urine output — < 30 mL/hr

  • shut off the Mg and urine output will go back to normal — will eventually pee out the excess Mg

HEELP Syndrome or Severe Preeclampsia

Hemolysis — Elevated Liver enzymes — Low Platelets

it is a life-threatening complication of Preeclampsia

• BP >160/110

• Liver impairment — increased LDH, AST, & ALT

• Kidney impairment — increased BUN & Creatinine, and decreased platelet

• Neuro changes

• Epigastric pain (upper abdomen)

• Hyperreflexia, Clonus

int: GET THE BABY OUT ASAP THRU C-SECTION!!! — the baby is making mom toxic = making the placenta not a safe place to grow

tx: improve platelet count w/platelet infusion

NOT RECOMM: < 100 platelets = no epidural

Eclampsia

a triad of s/s (hypertension, proteinuria, & edema) — BUT with the development of convulsions/seizure and/or coma

**MEDICAL EMERGENCY !!!

• BP > 160/110

• RUQ/epigastric pain

• Visual disturbances

• Cerebral hemorrhage

• Renal Failure

• HELLP

int: monitor Mg levels, RR, reflexes, UO

tx: Mg Sulfate — relaxes smooth muscles and can lower BP

Seizure Precaution (for general seizure event or due to Eclampsia)

1. side-lying

2. nothing in the mouth

3. loosed tight items in the neck (if present)

4. let the seizure occur

5. DO NOT restrain or leave the pt

other int:

• padded side rails w/ pillows & blankets

• O2 and suction if needed

• record when it started and ended

• any apnic spells? any incontinence?

• they need to have a medical bracelet

**CANNOT drive for 6mo if they recently had an epilepsy → if after 6mo no episodes have occurred – they're good to drive

Nagele’s Rule

determines estimated due date

how? — subtracts 3 months and adds 7 days

ex. LMP is June 2, 2002 —add 7 days: June 9 — sub 3mo: March, 2001

Normal Mens. Cycle — accurate

Abnormal Mens. Cycle — inaccurate

What are the tests to determine fetal well-being?

• Fetal Movement counts

• Non-stress Test (NST)

• Biophysical profile

• Contraction stress test

• Doppler ultrasound exam

Reassuring/ Reactive Non-Stress Test (NST) = NORMAL

• 20 min strip with normal baseline (110 - 160)

• Moderate variability — 15 beats off baseline (lasting 15secs)

• 1min of 2 or more accelerations

What can affect the results of the NST? And how to tx/stimm. the fetus?

sleep cycle of the fetus

tx: Pitocin/Oxytocin — to initiate the contractions

Non-reassuring/Non-reactive Non-Stress Test? = ABNORMAL

• baby is barely moving

• baby’s HR have minimal activity

Fetal Kick Counts

3 movements in 60 min — 2-3x per day

Contraction Stress Test

measures the fetal heart rate after the mother's uterus is stimulated to contract — test is done to make sure the fetus can handle contractions during labor and get the oxygen needed from the placenta

Biophysical Profile (BPP)

helps practitioners observe the fetus's heart rate, breathing, movement, and the amount of amniotic fluid surrounding the fetus in the uterus

**can be done with or w/o NST

When does your membranes usually rupture?

after labor or contractions begins

Preterm Premature Rupture Of Membranes (PPROM)

spontaneous rupture of the amniotic sac before the onset of true labor — often less than 37wks gestation

**pt is at high risk of developing an infection and premature birth

**more likely to occur with twin pregnancies

int: provider will decide if delivery is necessary or if they can delay labor

Premature Rupture Of Membranes (PROM)

spontaneous rupture of the amniotic sac before the onset of true labor — often beyond 37wks gestation

causes: vaginal bleeding, congenital disorders, and cervical insufficiency

s/s: gush, slow leak, or trickle of fluid; clear and odorless fluid

What is the Tx for PROM and PPROM?

tx depends on the gestation age, NOTHING IN THE VAGINA ‘til the mom is in active labor

How to assess PROM and PPROM?

• will have s/s of labor

• electronic FHR monitoring

• nitrazine test — pH is used to determine if the fluid present represents amniotic fluid or vaginal fluid

• fern test — permits positive identification of amniotic fluid by its fern-type crystallization under the microscope

• ultrasound

What does it mean when the amniotic fluid index suddenly increases?

the uterus closed itself — pt can go home with modified bedrest

… if not, the pt will stay at the hospital to closely monitor mom

Placenta Previa

its the abnormal implantation of the placenta on the LOWER uterine segment — Partial, Complete, Marginal, & Low-lying — assoc. with previous uterine scars, surgery, and fibroid tumors

dx: sonogram and ultrasound — concerning to see in 3rd trimester

onset: comes on slowly and does not have obvious symptoms at first

bleeding: abrupt visible, slight bright red bleeding — occurs due to the placenta inability to stretch w/the lower segment

pain: painless

uterine tone: soft and relaxed

FHR: normal range

fetal presentation: breech or transverse; no engagement

What does it mean to have an active bleeding with Placenta Previa?

MEDICAL EMERGENCY — c-section asap!!

Intervention for Placenta Previa

• Nothing in the vagina!! — no vaginal exam or vaginal birth

• No Contractions — this puts pressure and opens the cervix

Nursing Care Placenta Previa

• assess bleeding — amount, color, time, treatment, pain, when did it stopped?

• bed rest side-lying position

• fetal monitoring and contractions

• fetal and maternal VS are good

• assess sign of hypovolemic shock

• give betamethasone — used for inflammation/fetal lung maturation

When do we deliver the baby in Placenta Previa?

• Any type of dilation

• labor has begun, bleeding

• fetal compromise

Abruptio Placentae

MEDICAL EMERGENCY — placenta is starting to detach BEFORE the baby is out!! usually either late in the pregnancy or during labor — assoc. w/too many kids, short cord, HTN, trauma, cocaine, cigarettes, and vasoconstriction

onset: sudden

bleeding: concealed or visible, dark blood

pain: constant, uterine tenderness in palpation

uterine tone: firm and rigid

FHR: fetal distress or absent

at risk for: maternal and fetal demise — moderate to severe abruptions require immediate delivery

What kind of hemorrhage is associated with Abruptio Placentae?

Concealed/Complete Hemorrhage — the fetus will show brady cardia and will eventually lose it together

Do we always have bleeding with Abruptio Placentae? And how to we monitor mom and fetus?

NO — we don’t always have apparent bleeding; we always have to check the fetus from the fetal heart monitor — fetus is in distress if bradycardia and minimal to absent activity is present = placenta is detaching

Nursing Care Abruptio Placentae

• monitor for stabbing pain high in the fundus = placenta is detaching

• uterine tenderness between contractions — should only have pain during contractions = placenta is detaching

• heavy bleeding

• s/s for hypovolemic shock, uterus tense and rigid, DIC, infection

• FHR abnormalities

• admin fluid replacement and O2

• cont. fetal and maternal monitoring