OB EXAM 2

Umbilical cord prolapse

Umbilical ord falls through cervix into vagina

This means umbilical cord is pinched and cutting off blood flow to the baby

-causes fetal bradycardia

If you feel cord, leave hand there and keep in place

No pitocin

Uterine Rupture

Tear in the uterus causing maternal bleeding and decreased placental perfusion

Risk factors: uterine scarring, uterine fibroids, multiparity, excessive uterine stimulation from induction

S/S:

Pain, constant short contractions w/ no break

Loss of fetal station

Bleeding

-high incidence of maternal and fetal morbidity and mortality

Placental abruption

Separation of placenta from uterine wall which compromises fetal blood supply

Risk factors: HTN/preeclampsia, abd trauma, drugs

S/S: pain, rigid abd, bleeding

Placenta previa

Placenta covering cervix

-not inherently dangerous

-can resolve as pregnancy progresses and uterus grows

• SVE contraindicated

• Requires a C section

Placenta previa vs abruption

Onset: insidious VS sudden

Bleeding: always visible; slight then becomes profuse VS concealed or visible

Pain: none. VS constant uterus tenderness w/ palp

Uterine tone: soft, relaxed VS firm, rigid

Fetal HR: normal VS distress, Brady, absent

Fetal presentation: breach or transverse lie, engagement is absent VS no relationship

Amniotic fluid embolism

When amniotic fluid or fetal material enter maternal bloodstream, this triggers an allergic like reaction lading to cardiovascular collapse, respiratory distress, coagulopathy

-rare but life threatening

S/S:SOB, CP, tachy, hypotension, AMS

Involution

Changes that return the uterus to normal size/non-pregnant size and condition

-indicated by decreasing fundus height

-contraction of the mm Ubers that were previously stretched and regeneration of epithelium, layers that get sloughed during lochial discharge

Factors that interfere with involution

Prolonged labor

Retained placenta or membranes

Infection

Over distention

Close child birth spacing

All of these also lead to increased risk of bleeding

Fundal massage

Immediately postpartum

Q15min x 4

Q30minx2

Q4-6H and PRN

Should feel rock hard, be at midline near umbilicus

Can be uncomfortable

If feels off centered this is the bladder, have mom urinate and it should be found at midline

Lochia rubra

3-4days after birth

Bright red

Blood clots normal

Lochia Serosa

Starts around day 4 and goes till day 10

Thin in density

Color goes red to pink to ink/brown

Discharge containing mucus

Flow is much less than rubra but still consistent and few to no clots

Lochia Alba

Day 10-28 (2-4weeks)

Discharge changes from pink/brown to yellow/white or white

Contains little blood

Should be odorless and not a real flow

Lochia warningsigns

Saturating pad every hour

Clots size of golf balls

Foul Odor could be infection

-weigh pads if there is a concern for PPH

Postpartum

6 week period afterbirth where body returns to pre pregnant state

“4th trimester”

Really is the first year or longer after birth

9-12months

Hormonal shits, adjusting to parental role, weight loss

Normals mom Postpartum

uterine cramping/contractions

-happen during breastfeeding, more intense with multiparous pts

Vagina/perineum norms

-mild/moderate edema of angina

Mild/moderate edema and bruising of perineum

Assess sutures, hematomas

Ibuprofen and heat

Nursing Cares

Peri care:

Assess sight

Hand washing

New pad after every void

Peri-bottle

For comfort give: ice, tucks, dermoplast (numbing spray) position changes, sits bath

Breastfeeding

LATCH score

300extra cals from mom and hydration

Meds, alcohol, nicotine and caffeine can all go through breast milk

GI adaptations

Decreased motility for a few days

Scared to have a BM so give colace to avoid constipation

Hemorrhoids

Postpartum care plan

Assist in restoration of physiological and psychological status

Assist in learning and adjusting to new roles

Support parent child attachment

Maternal role theory

Taking-in phase

-day 1-2

-want to debrief, dependency needs

Taking-hold phase

-day 3-10

-want to control and gain info

Letting go phase

-day 1-14

-support needs

Postpartum Hemorrhage

Cumulative blood loss of >1000mL c section

>500 mL

or blood loss accompanied by S/S of hypovolemia within 24 hr after birth

PPH causes

Trauma- lacerations, episiotomy , hematoma

Retained tissue

Thrombin abnormalities

Unremitting pain and pressure is common sign for PPH

PPH nursing care

Boggy uterus then do fundal massage

-meds

-weigh pads or chucks for accurate estimation of blood loss

1 gram=1mL of blood

-fundus and VS checks

-bladder assessment, Jada or Bakri balloon

-blood administration or iron

PPH nursing care meds

Uterotonic meds

-pitocin

-Misoprostol (cytotec)

-Carboprost ( hemabate) : contraindicated itch asthma b/c risk of bronchial spasm

-Methergine : contraindicated with HTN/pre-eclampsia

-TXA : blocks breakdown of clots to prevent bleeding

PPH reasons for surgery

Retained placenta needs a D&C

Laceration needs repaire

Severe uterine atony may need hysterectomy

Drainage of a hematoma

Uterine atony

Over distended uterus, over stretched, over worked or irritated

Overdistended: multiples or large baby

Mm exhaustion: rapid or prolonged labor, oxytocin use

Uterus postpartum

Normal condition where it contracts to prevent hemorrhage

Uterine atony allows for hemorrhage to flow into uterus

If it is boggy then massage

Puerperal infection (PPinfcetion)

Bacterial infection of

-intrauterine placental site

-laceration

-episiotomy

-C-section incision

-prolonged ROM

REEDA

Assessment of perineum

Redness

Edema

Ecchymosis

Discharge

Approximation

Mastitis

Inflammation or infection of breast tissue

Bacteria enters through cracked nipples or from plugged milk ducts

Can continue to breastfeed

Prevention is key- hand hygiene breast massage for plugged ducts

Reposition/ switch to other nipple of painful

PP infection risks & S/S

Risk factors;

-C-section

-ProlongedROM >24hr

Multiple vag exams

-obesity, smoking, DM

-catheter

-trauma

-instrument assisted birth

-retained products

-poor hygiene

S/S

-fever

-chills

-body aches

-cramping/ abd pain

-inc WBCs

Thrombophlebitis

High risk in pregnancy and postpartum

S/S

Redness, swelling, warmth, tender, fever, leg pain

DVT nursing care

Prevention is key

-encourage early and regular ambulation

-SCDs

-Leg/foot exercises and elevate

-lovenox, warfarin, heparin

Baby Blues interventions

Happens in first 3-10 days post partum

Caused by hormonal changes and if pervious BH

Educate and prepare all new partners about expectations

Empathy, support, and reassurance; don’t make jokes or diminish feelings

Screen before discharge and at 2w, 6w appt

Rest is important

Postpartum depression S/S

Decreased energy and concentration

Overwhelmed

Feelings of guilt

Disinterest in baby

Feeling of doom

Difficulty making decisions

Sleep issues

Isolation

Denial

Postpartum psychosis

Hallucinations, self harm and harm to others

This is an emergency and needs immediate medical attention

Combination of medication and therapy

Insulin in pregnancy

Early preg:

Insulin sensitivity increases an shifts glucose into adipose tissue for storage

Later in preg:

Placental hormones cause insulin resistance and shifts the glucose to the baby

DM categories

Pre pregnancy: T1 and T2

Gestational : Occurs during pregnancy

• Likely had insulin resistance prior to pregnancy that was undetected

Screenings at 24-28 weeks

Concerns with diabetes in pregnancy

Spontaneous abortion

Newborn comps:

-Macrosomia- excessive birth weight

-Newborn birth trauma

-Shoulder Dystonia

-Hypoglycemia

Maternal comps:

C section

Preeeclampsia

Higher risk of getting TD2 later in life

Why would newborn be hyperglycemic at birth from gestational diabetes

The baby has high insulin production to deal with the high glucose coming from mom

After birth, the baby is no longer getting high amounts of glucose from mom but the insulin will stay high causing hypoglycemia

Gestational Diabetes lab work

If high risk for DM then A1C with initial OB labs

Glucose tolerance test at 24-28w:

Take oral glucose 75g

If the one hour BGL is abnormal then they will stay for a 2hr and 3hr checks

APGAR

A rapid assessment of infants status at birth

Done at at 1min and 5 min

8-10 good

4-7 needs stimulation

-3 needs resuscitation

APAGAR scoring

Appearance:

• blue/pale 0

• Body pink, extremities blue 1

• Completely pink 2

Pulse:

• HR absent: 0

• Below 100 - 1

• Above 100 - 2

Grimace: reflex

• no response 0

• Grimace 1

• Cry 2

Attitude: mm tone

• limp 0

• Some flexion 1

• Well flexed or moving 0

Respiration:

• absent 0

• Slow, irregular, weak cry 1

• Good strong cry 2

Establishing newborn airway/respers

Wipe face, nose, mouth

Bulb suction mouth first then nose

• Get secretions out of mouth becuase when stimulating nose they will breath and can aspirate the stuff in mouth. If nose done first

• Stimulate by drying off, skin to skin warmth

• Blow by o2 unless needing to resuscitate then on face

Nursing care for transition period

Called the “golden hour”

Skin to skin and first breastfeed

VS Q30

• axillary temp, pulse (110-160), RR (30-60), pain, BP not routine

• if temp below 97.7 then do skin to skin and apply warm blanket and beanie

Circumision

Possible risks: pain, infection, hemorrhage, adhesion, dehiscence, urethral fistula, disfigurement

Pre procedure checks:

• has voided normally at least once

• Received Vit K prophylaxis for clotting

• Hasn’t eaten in past hour

• Consent signed

Nursing care during circumcision

Pain control: swaddling or sucrose with pacifier

• doc should do lido injection

Time out

Watch for bleeding

Watch for first void after procedure

Dressing and care

Safety of newborn

Always match band with parent bracelet

Never left with Someone without a matching band unless parent approval

Transport in halls only in a bassinet

Screenings and campaigns

Hearing screening

Weight

Bilirubin level

Cord clamp removal

Check for CHD

PKU or metabolic screen

Proper car seat safety check

Back to sleep and never shake baby

ABO incompatibility

ONLY if mom has O blood

Less severe than Rh

Maternal blood has anti A and Anti B which can cross placenta and cause hemolysis of fetal blood if baby has A, B, or AB

-nothing can be done until infant is born and get infant sample from cord

Rh incompatibility

ONLY if maternal blood is Rh -

Rhogam is given at 28w to prevent isoimmunization and destruction of fetal RBC

In the first pregnancy nothing is affected, the first exposure allows maternal immune system to create anti bodies for the D antigen, these anti-D in mom bind and destroy the Rh + RBCs of fetus

Infant is Rh + what now?

Cord blood is tested for the antibodies to the Rh + blood.

If the antibodies are present in cord then that means destruction of fetal RBCs has occurred

Giving Rhogam decreases this from happening

Monitor for jaundice and anemia

Chronic hypertension vs Gestational hypertension

HTN in first 20 weeks or priority pregnancy is chronic HTN

HTN that developed at the 20 week mark or after is gestational HTN

140/90

Pre-eclampsia

Gestational HTN and protein in urine

This can also be diagnosed postpartum up to 6w

Abnormal placenta development

Multi-system inflammatory syndrome

Peripheral vascular resistance

Pre-eclampsia risk factors

HTN

Diabetes

African American

Obesity

<20 or >35

Personal or family hx of preeclampsia

Multi-fetal gestation

First pregnancy (nulliparity)

Diagnosis of preeclampsia

SBP > 140 and or DBP > 90 with proteinuria

Or severe features present

Severe Features

Two hallmark signs are epigastric pain and HA

-these features do not resolve

HA, Vision changes, epigastric pain (upper right quadrant pain at liver), DTR/clonus, edema, renal impairment, severe HTN >160/110

Systemic changes from preeclampsia

Hypertension- from inc peripheral resistance. Vasoconstriction and kidneys retaining salt

Proteinuria- from damage to kidneys

RUQ pain, ALT/AST elevation- liver damage

Generalized edema and HA - blood vessels are leaky causing peripheral edema or cerebral edema

Preeclampsia TX

Deliver baby 34 weeks if severe features present

Or 37 weeks if not present

The risks of staying pregnant outweighs the benefits becuase of poor perfusion to placenta, liver damage, kidney damage. Cerebral edema

Medications for preeclampsia

Corticosteroids to help develope the fetal lungs

Avoid NSAIDS b/c they increase bleeding risk and already at high risk for bleeding with the HTN

Labetalol: Antihypertensive given for severe BPs, close monitoring of BP

• Monitor for hypotension and dizziness

Magnesium Sulfate

Anti convulsant that decreases CNS excitability

High risk medication b/c CNS depressant for many too, so may need help breathing when born

This relaxes mm so the uterus us relaxed causing it to be boggy and increase risk for PPH

Magnesium sulfate Toxicity

S/S: hypotension, decreased urine output, decreased RR, decreased reflexes, increase in mag levels

Antidote: calcium gluconate

Low urine output is a sign b/c the body flushes out excess mag through urine, so if no voiding is happening they could be holding on to too much mag

Eclampsia

When a preeclampsia pt has a a SZ it is now eclampsia

Give magnesium sulfate to stop SZ

HELLP syndrome

Hemolysis, elevated liver enzymes, low platelets

Can occur with or without preeclampsia

Platelets are dropping at a rapid rate increasing PPH risk

Cure is to deliver the baby

Cardiac normals of newborns

HR 110-160

Delayed cord clamping to allow blood from cord to flow to baby

Acrocyanosis : blue hands and feet, pink core

Murmur due to PDA taking ~24hr to close

Respiratory newborn normals

There is an increase of CO2 and stimulation of new world causes gasps for air; air is replacing fluid

• ~1min to pink up on own

• Thoracic squeeze of vaginal birth helps push fluid out of lungs

• Crackles in lungs b/c of fluid

RR: 30-60

• irregular with periodic 5-10s pause in breathing

• Obligate nose breathers

Thermoregulation

Cold stress- hypoglycemia from burning all heir sugar to try and keep warm

Hypothermia is most important after ABCs

97.7-99.7 is normal temp

Predisposing characteristics for heat loss

Thin skin o blood vessels are close to surface

Unable to shiver

Limited glucose stores

Large body surface area so loos heat fast

Little subcutaneous fat

Baby’s have brown fat- non shivering thermogenesis

Stomach

Holds 1-2 tsp

Burp after each oz or when switching b/ breasts

Weak pyloric sphincter so regurgitate often

Small stomach so eating Q2hr

Meconium

Dark sticky fist stool

Colostrum

Natural laxative, vitamin rich, little milk more thick and yellow

Vitamin K

Vit K is produced i the gut and is required for clotting

Baby’s cannot make Vit K so they get Vit K after birth b/c they are high risk for brain bleeding

Jaundice

Physiological jaundice occurs in most newborns

-if bilirubin is >18 then this is signs of immature liver

-bilirubin is excreted through stool so increasing feeding will increase removal through stool

Kernicterus

Brain damage caused by excessive levels of bilirubin >18

Kidneys

Functioning at 30-50% at birth

Cannot concentrate urine

Cannot handle drugs well

Prone to dehydration or fluid overload

Urination should happen at least once in the first 24hrs

Count and weigh wet diapers especially if concerned

Neuromuscular

Mm are developed but baby cannot control them

Flexed position is normal posture, helps keep baby warm

Floppy or relaxed is bad

Newborn skin

Thin and transparent

Dry and peeling

Vernix caseosa- thick creamy skin covering, antimicrobial and keeps baby warm

Lanugo- thin downy hair for army’s

Erythema toxicum- newborn rash

Milia- clogged pores; newborn acne

Caput

Edema of scalp at the town form long labor or use of vacuum extraction

Normal and crosses suture lines, will o away on its own

Cephalhematoma

Collection of blood from ruptured vessels

Does NOT cross suture lines

Caused by rescue on head during birth

Subgaleal hematoma

Hemorrhagic injury

Boggy mass over scalp that DOES cross suture lines

Hematoma spreads over entire cranium and can happen 12-72hr after surgery

S/S of hemorrhagic shock

Obscures fontanelles

Entire blood volume can be lost into this hematoma

Senses

See 12 inches

Black and white vision

Hears well, turning head to sounds

Smell sense strong, can recognize moms milk

Touch is most developed