Maternity test #1

physiological anemia

blood volume increases more then the actual contents → hemodilution

anemia parameters: < 11 (1/3 trimester) or 10.5 (2 trimester), < 9 severe anemia

Rh isoimmunization

Rh- mother is tested at 28 weeks to see if she has antibodies against Rh+ to protect fetal RBCs from hemolysis.

+: already made Rh antibodies, Rhogam shot is no longer affective,

-: no Rh antibodies, no sensitization yet, given anti-D igG antibodies then and 72 hours after birth

complications of untreated STI in pregnancy: chlamydia

PROM, preterm labor, postpartum endometritis, neonatal conjunctivitis/pneumonia

complications of untreated STI in pregnancy: gonorrhea

PROM, preterm birth, neonatal blindness, neonatal sepsis, chorioamnionitis, PP sepsis and endometritis

complications of untreated STI in pregnancy: syphilis

stillbirth, congenital syphilis

complications of untreated STI in pregnancy: HPV

warts can obstruct birth canal → c-section

complications of untreated STI in pregnancy: trichomoniasis and BV

PROM, preterm birth, PID

complications of untreated STI in pregnancy: candidiasis

discomfort, neonatal oral thrush

complications of untreated STI in pregnancy: GBS

risk for neonatal sepsis, meningitis, pneumonia

complications of untreated STI in pregnancy: covid

preterm birth, stillbirth, preeclampsia, hemorrhage, HTN, clotting disorders

complications of untreated STI in pregnancy: CMV

fetal growth restriction, hearing loss, neurologic issues

complications of untreated STI in pregnancy: HSV

neonatal HSV

complications of untreated STI in pregnancy: HIV

c-section at 38 weeks if viral load > 1000 copies/mLH

HPV

Most common STI

spread via skin to skin sexual contact

can be asymptomatic

risks: cervical vulvar vaginal anal penile oropharyngeal cancer (type 16 and 18) genital warts (type 6 and 11)

HPV: treatment

screening: pap smears for ages 21-65

treatment: imiquimod cream for non-pregnant pt, BCA or TCA applied by HCP for pregnant woman

vaccine: HPV recommended for ages 11-12, catchup to 26

GIFT

gamete intrafallopian tube

eggs + sperm mixed and placed directly into fallopian tube

fertilization occurs in body → one patent tube required

female causes of infertility: ovulation disorders/anovulation

disruption of hypothalamic pituitary ovarian axis (hormone feedback system)

risk factors: aging, obesity, PCOS, hyperprolactinemia, strenuous exercise, early menopause, eating disorders, cancer treatment, smoking, depression, environmental toxins, high caffeine, alcohol

female causes of infertility: tubal occulusions

scarring, infections (PID), prior sterilizations, tumors

female causes of infertility: endometriosis

endometrial tissue implants outside uterus

inflammation → adhesions/scarring → egg quality decreases, interferes with egg release, sperm transport, implantation

male causes of infertility: decrease sperm production

undescended testes, hypospadias, varicocele, low testosterone, prior vasectomy, testicular cancer, pituitary tumors, mumps

types of decreased sperm production (2)

azoospermia: no sperm

oligospermia: few sperm

infertility diagnostic procedure: female (7)

pelvic exam: structural abnormalities

hormone analysis: hypothalamic-pituitary-ovarian axis

postcoital test: sperm motility and mucus compatibility

US: cysts and uterine fibroids

hysterosalpingography: contrast dye for tubal patency

hysteroscopy: view uterus for fibroids/adhesions

laparoscopy: check for endometriosis, adhesions, tubal blockages

infertility diagnostic procedure: male (3)

semen analysis: sperm count, morphology/quality, motility - cheap but must be done within first hour of ejaculation

US: scrotal (varicocele) and transrectal (ejaculatory ducts, seminal vesicles, vas deferens)

hormone levels: testosterone

nursing interventions

encourage communication and recognize infertility as major life stressor

assist the couple with education and options (ART and genetic counseling)

monitor for adverse effects of infertility medications

referrals to grief and infertility support groups

medications for STIs: chlamydia

pregnant: doxycycline

non-pregnant: azithromycin

infants: erythromycin eye ointment

medications for STIs: gonorrhea

ceftriaxone IM, azithromycin PO

infants: erythomycin ointment

medications for STIs: syphilis

penicillin G or Bicillin IM

1 dose, 3 doeses if unkown duration

medications for STIs: trichomoniasis

mentronidazole (avoid first semester), tinidazole

medications for STIs: BV

metronidazole or clindamycin, given probiotic for prevention

medications for STIs: candidiasis

topical antifungals (clotrimazole, OTC)

medications for STIs: GBS

intrapartum IV penicillin G or ampicillin

medications for STIs: toxoplasmosis

sulfonamides, pyrimethamine +msulfadiazine

medications for STIs: HSV

acyclovir/valacyclovir, suppressive therapy later in pregnancy

types of signs of pregnancy (3)

presumptive: subjective, felt by patient, not proff

probable: objective, observed by HCP, suggestive but not definite

positive: proof of pregnancy

Presumptive signs of pregnancy

Amenorrhea

Fatigue

Nausea/vomiting

Urinary frequency

Breast changes: dark areoles, enlarged Montgomery glands

quickening: fluttering fetal movements 16-20 weeks

uterine enlargement

probable signs of pregnancy

abdominal enlargement

hegar’s: softening of lower uterus at 6 weeks

chadwick’s: blue cervix/vaginal mucosa at 6-8 weeks

goodell’s: softening of cervical tip at 6 weeks

ballottement: fetus rebounds when tapped at 16-18 weeks

braxton-hicks contractions

positive pregnancy test

fetal outline palpable

positive signs of pregnancy

fetal heart tones

visualization of fetus on US

fetal movement palpated by HCPf

fundal height

after 20 weeks, fundal height in cm = gestational age ± 2 weeks

can be due to previous pregnancy, hydration, retroverted uterus etc

fundal height landmarks

12-14 weeks: above symphysis pubis

20-22 weeks: umbilicus

38-40 weeks: fundal height decreases due to lightening

Pica

non food cravings such as ice clay dirt and laundry detergent

nursing consideration: see if mother is anemic or has poor weight gain

diaphragm

silicone dome placed over cervix with spermicide

fitted by HCP, replaced q2 years or after weight change/pregnancy

insert <6 hours before sex, leave >6 hours after, max 24 hours

reapply spermicide each act

does not protect against STIs

contraindicated for patients with hx of TSS or UTIs

emergency contraception options (3)

levonorgestrel (plan b): within 72 hours, OTC, all ages, one dose

ulipristal (ella): prescription, up to 5 dyas

copper IUD: most effective, up to 5 days

emergency contraception education

not BC or termination → prevents implantation by stopping ovulation and sperm transport

earlier you take it, more effective

side effects: nausea, heavier bleeding, abdominal pain, HA, fatigue

provide counseling on regular contraception s

supine hypertension syndrome/vena cava syndrome

happens after 20 weeks of pregnancy

enlarged uterus compresses vena cava when mom lies on her back → occludes the inferior vena cava → venous return and preload drop → maternal hypotension and fetal hypoxia or distress c

clinical manifestations of supine hypotension

dizziness

lightheadness

pallor

clammy cool skin

nursing considerations: supine hypotension syndrome

teach pregnant patients to avoid lying flat on their back

position in left lateral recumbent or semi-sitting position

Naegele’s rule

calculation to determine EDB

first day of LMP - 3 months +.7 days

warning signs: first trimester

Dysuria

severe vomiting

diarrhea

fever or chills

abdominal cramping

vaginal bleeding

warning signs: second and third trimester

gush of fluid from vagina → rupture of amniotic fluid

vaginal bleeding → placenta problems

abdominal pain → PROM, ectopic pregnancy, placenta abruption

changes in fetal activity → fetal distress

persistent vomiting → hyperemesis gravidarum

severe headaches → gestational HTN

elevated temp → infection

dysuria → UTI

blurred vision → gestational HTN

edema face and hands → gestational HTN

epigastric pain → gestational HTN

flushed dry skin, fruity breath, headache, rapid breathing, increased thirst and urinations _> hyperglycemia

clammy pale skin, weakness, tremors, irritability, lightheadness → hypoglycemia

terbutaline side effects

uterine smooth muscle relaxation

maternal tachycardia

GBS testing

bacterial infection passed to fetus during L&D, colonizes in the vagina/rectum/uretha of pregnant women

35-38 weeks: vaginal and rectal cultures

+: overgrowth of bacteria, given intrapartum IV penicillin G or ampicllin

risk of neonatal sepsis, meningitis, pneumonia

Leopold’s maneuver

superior surface of fundus: determine what part of fetus is in fundus (head or buttocks)

both sides of uterus: determine the fetal back direction (longitudinal vs transverse)

palpate pubic symphysis: identify presenting part/in inlet (head or buttocks/vertex or breech)

palpate both sides of lower uterus: fetal attitude (flexed vs extended head)

contradictions for hormonal conceptions

Hx of thromboembolic disorders (DVT, stroke, MI)

estrogen dependent cancer (breast, endometrial)

unexplained vaginal bleeding

severe liver disease

smokers > 35 years old

uncontrolled HN

migraines

DM

ACHES: combined oral contraceptions

Abdominal pain

Chest pain/SOB

Headache/vision changes

Eye problems

Severe leg pain

fetal kick count

normal: 10 movements in 2 hours

report if none in 12 hours or <3/hour

pt ed: mother should eat or drink, lie on life side

cardiovascular changes during pregnancy: blood volume

40-50% increase to compensate for blood loss during birth and postpartum

cardiovascular changes during pregnancy: cardiac output

30-50% increase (increased SV and HR to meet tissue oxygen demand)

cardiovascular changes during pregnancy: HR

increase of 10-15 bpm beginning at 5 weeks and peaks at 32 weeks

hormonal and volume effects

cardiovascular changes during pregnancy: BP

same or slight decrease

caused by vasodilation due to progesterone increase

cardiovascular changes during pregnancy: structural

heart enlarges and shifts upward/laterally due to uterus displacing diaphragm

FHR baselines

110-160 bpm

accelerations: > 15 bpm for >15 seconds

moderate variability: 6-25 bpm

FHR assessment dates

6-7 weeks/<12 weeks: transvaginal US

10-12+ weeks: doppler device

continuos monitoring: external (doppler US transducer) or internal (fetal scalp electrode)

hormones affecting pregnancy: hCG

keeps corpus luteum alive in early pregnancy by making progesterone until placenta takes over

hormones affecting pregnancy: progesterone

relaxes smooth muscle, less uterine contractility, maintains endometrium

hormones affecting pregnancy: estrogen

uterine growth, breast changes, fat deposition in subq tissues

hormones affecting pregnancy: hPL

breast development, more fatty acids alters maternal metabolism

hormones affecting pregnancy: prostaglandins

cervical ripening, uterine contractions

hormones affecting pregnancy: pituitary gland

enlarges in pregnancy

prolactin increases → prepares breasts for milk production after birth

hormones affecting pregnancy: pancreas

insulin needs to increase during 3rd trimester for fetus

reason for screening at 24-28 weeks with 1 hour GTT

external abdominal US

safe noninvasive painless procedure

gel applied on abdomen → enhances sound wave trnasmission

best used after first trimester due to larger uterus

full bladder required

transvaginal US

invasive: vaginal probe inserted

more accurate evaluation → clear pelvic organs and fetal structures

pt ed: feel pressure during probe movement

transvaginal US use

1st trimester: detect ectopic pregnancy, monitor developing embryo, identify abnormalities, establish gestational age

3rd trimester: evaluate preterm labor

also used for obese patients

doppler blood flow US

noninvasive external US → measures maternal-fetal blood flow in vessels

common vessels assessed: fetal umbilical cord, middle cerebral and maternal uterine arteries

doppler blood flow US uses

fetal IUGR

poor placental perfusions

high-risk pregnancies: HTN, DM, multiple gestations, preterm labor

lightening

when baby drops lower in pelvis in preparation for birth

reason why fundus goes down after 38 weeks

advanced maternal age (>35)

risk for (even with good prenatal care):

infertility, miscarriage, chromosomal abnormalities, HTN, gestational DM

external fetal monitoring (2)

US transducer: FHR

toco transducer: contractions

internal fetal monitoring (2)

scalp electrode: FHR baseline variability, dysrhythmias, accels/decels

intrauterine pressure catheter (IUPC): contractions and resting tone

Intermittent auscultation and uterine contraction palpation uses

fetal well being: used to determine frequency, intensity, duration, resting tone

during contractions: compresses uteroplacental arteries → fetal circulation and oxygenation decreases → early decels if everything is okay, late if not

guidelines for IA or continuous EFM

latent phase: every 30-60 minutes

active phase (> 6 cm): every 15-30 minutes

second stage (active pushing): every 5-15 minutes pr

prenatal care goals (4)

promote health ed

monitor fetal growth/development and identify abdnormalities

identify diagnose and treat preexisting maternal disorders

support maternal self-care and parenting (including family/partner)

first trimester teaching

physical/psychological changes, exercise, nutrition, safe sex, dental care, alcohol, tobacco, fetal growth and development, prenatal exercise, expected lab findingsfri

first semester common discomforts

n/v

breast tenderness

urinary frequency

fatigue

second trimester pt ed

breastfeeding benefits, sex, posture, seat belt safety, fetal movement, rest, travel safety

complications: preterm labor, gestational HTN and DM

common discomforts: heartburn, constipation, hemorrhoids, back pain, Braxton Hicks, varicose veins, lower extremity edema, gingivitis, supine hypotension, UTI

third trimester pt ed

childbirth classes, coping, pain management, newborn care, use of TENS, CAM modalities

common discomforts: heartburn, constipation, hemorrhoids, back pain, Braxton Hicks, varicose veins, lower extremity edema, gingivitis, supine hypotension, UTI, leg cramps

MSAFP: maternal serum alpha-fetoprotein

15-22 weeks

noninvasive and no risk to baby

measures AFP, a protein normally produced in fetal liver and crosses placenta into mother’s blood

if abnormal, quad marker screenings, genetic counseling, US, amniocentesis

low = Down’s syndrome, high = neural tube defect or multifetal pregnancy

initial prenatal visit interview

reason for seeking care

current pregnancy EDM

childbearing and female reproductive hx

health hx

nutritional hx

medication and herbal preparation use

family hx

social experiential occupational hx

mental health screening

intimate partner violence risk

ROS

initial prenatal visit: physical exam

prep: emply bladder before pelvic exam

baseline data: vitals, pelvic exam

approach: gentle, unhurried, provide info

bp monitoring

initial lab testing

urine, cervical, blood samples

CBC

blood type and Rh

rubella abx

hepatitis b and c screen

pap smear

STI testing

vaginal/cervical culture

urinalysis/renal function

TORCH screen

venereal disease research lab (VDRL)

HIV testing

TB testing

genetic testing: sickle cell disease, cystic fibrosis, Tay-Sachs

1 hour glucose test

screens for gestational DM between 24-28 weeks

Mother drinks 50 g of glucose, blood is drawn exactly 1 hour later

normal": <130 mg/dL

if abnormal, do the 3 hour glucose test

3 hour glucose test

Mother fasts overnight and drinks 100 g of glucose

blood levels measured at: fasting, 1 hour, 2 hour, 3 hour

diagnosed with DM if 2+ abnormal values

teen pregnancy

less likely to receive adequate prenatal care

risks: anemia, preeclampsia, preterm birth, low birth weight, social/financial challenges

pt ed: stress importance of early/continuous care, provide ed/suppoort

cervical changes in pregnancy

Goodell’s sign: softening of cervix tip

Chadwick’s sign: bluish purple discoloration of cervix due to increased blood flow

friability: cervical tissue becomes delicate, may bleed slightly after examination

operculum/mucus plug: rich in immunoglobins, protects uterine cavity from bacterial invasion

integumentary changes in pregnancy

hyperpigmentation: more melanotropin from anterior pituitary

melasma: brown facial patches, mask of pregnancy

linea nigra: dark line from pubis to fundus

striae gravidarum

angiomas (spider/cherry): small arteriolar proliferations on neck, face, arms

palmar erythema: pink/red patches on palms from elevated estrogen

pruritus gravidarum: mild abdominal itching

hair and nail growth: accelerated

BPP test

comprehensive assessment that combines NST with fetal US

purpose: visualize physiological characteristics of fetus and measure fetus well-being bt measuring 5 specific variables

5 variables assessed in BPP

FHR

fetal breathing movement: one episode of breathing movement > 30 seconds within 30 mins

gross body movements: 3+ body or limb extensions with return to flexion within 30 mins

fetal tone: 1 episode of extension with return to flexion

qualitative amniotic fluid volume: at least 1 pocket of fluid that measures at least 2 cm

BPP score

each variable: 2 (normal) or 0 (abnormal)

8-10: normal

4-6: abnormal, suspected fetal hypoxia