397 Exam 2

6 Pregnancy Hormones

Human chorionic gonadotropin(hCG)- produced by corpus luteum, rises early in pregnancy

Progesterone- Establishes placenta, prevents uterine contractions, supports blood vessel growth

Estrogen- Promotes blood vessel growth, maintains uterine lining, aids in fetal organ development

Prolactin- stimulates breastmilk production and breast growth

Relaxin- relaxes uterus, cervical softening, maternal vasodilation. Works with progesterone to prevent contractions. Also relaxes joints

Oxytocin- stimulates uterine contractions and release of prostaglandin

Cardio and Hematologic Changes During pregnancy

Increased:

Maternal blood volume

Maternal HR

Clotting factor (increased risk of blood clots)

Venous pressure in lower extremities (increased risk for varicose veins)

Maternal RR

Increase in kidney size by 30%

Increase in GFR 50%

Decreased:

Peripheral vascular resistance, leads to decrease in blood pressure

Hematocrit values, which decreases blood viscocity

Gastric emptying

Gastoesophageal sphincter tone causing heartburn and N/V

*Trace amounts of protein and glucose in urine are okay, but anything more should be investigated

Musculoskeletal changes in pregnancy

Diastasis recti- separation of abdominal wall muscles due to abdominal wall weakness

Linea alba- widens and thins as result of diastasis recti

Signs of pregnancy

Presumtive: felt by the client

-breast tenderness, N/V, fatigue, amenorrhea

Probable: Detected by provider

-Lab results, Ballottement test (finger bounces baby), Chadwicks sign (blue cervix/vagina), Goodells (cervical softening), Hegars sign (softening of uterus)

Positive: Associated with fetus

Visualization of fetus on ultrasound or fetal heart tones on ultrasound

Naegeles rule

Used at first prenatal appt to guess due date. Take first day of last period, subtract 3 months and add 7 days.

Fundal height

Measured after 20 weeks to estimate gestational age. Height in cm should correspond with weeks of gestation, plus or minus 2 weeks

GTPAL

G:Gravida- number of pregnancys

T:Term- delivered at 37 weeks or later

P: Preterm- delivered between 20-36 weeks

A:Abortion- Pregnancies ended before 20 weeks

L:Living children

2nd trimester prenatal visits

Occur every 4-6 weeks

Physical:

Weight, BP, Urine sample, Fundal height, Fetal HR

Lab:

Glucose screening, maternal serum screening

Education:

Quickening (fetal movements) should begin

Braxton Hicks vs true contractions

Chronic illnesses leading to high-risk pregnancy

Hyperglycemia: risk for fetal macrosomia (large baby), preterm birth, preeclampsia, c/s, fetal demise, newborn hypoglycemia

Chronic hypertension: preeclampsia, eclampsia, uteroplacental insufficiency, fetal growth restriction

Asthma: increases risk for preeclampsia and need for c/s, preterm birth, low birth weight, growth restriction

Thyroid dysfunction: preeclamsia, placental abruption, preterm birth, LBW, spontaneous abortion

Psychosocial Factors leading to high risk pregnancy

Tobacco use: Increases risk of SUID, birth defects, low birth weight, preterm birth, neonatal cleft lip

Caffeine use: High intake limits oxygen to fetus limiting growth. Less than 200 mg per day recommended

Alcohol/drugs: Can lead to spontaneous abortion, low birth weight, fetal demise, long term disabilities

Mental health: Symptoms can interfere with daily functioning and impact pregnancy outcomes

Environmental factors leading to high risk pregnancy

Lead exposure: Accumulates in bones and releases in blood during pregnancy. Can cause spontaneous abortion, preterm birth, developmental issues

Animal exposure: SARS, monkeypox, salmonella all can affect pregnancy

Toxoplasmosis: Contact with feline feces, can cause neonatal blindness, deafness, and cognitive disabilities

Indications for prenatal testing

Systemic lupus erythematosus- immune system attacks own tissues, risks include fetal loss, preeclampsia, preterm birth

Maternal renal disease- increases risk of maternal and fetal mortality, leads to preeclampsia, preterm birth, and AKI

Cholestasis- Poor flow of bile that can back up in liver and into bloodstream, severe itching on hands with no rash, potential fetal risks

Fetal health assessments done in high risk pregnancies

Nonstress test(NST) - Noninvasive test where fetal HR is monitored and mom marks when fetus moves, measured over 20 minutes. Reactive result is good

Biophysical profile (BPP)- Combines NST with ultrasound assessment of amniotic fluid, fetal breathing, movements, and limb tone

Contraction stress test (CST) - Contractions induced with medication and same steps as NST done. HR monitoring along with fetal movements.

5 P’s of Labor

Passenger, passageway, powers, position, psyche

5 p’s of labor- Passenger

Presentation- presenting part of fetus; cephalic (head first), breech (butt first), shoulder, compound (extremity first)

Position- Presenting parts location in pelvis; occiput (back of head), sacrum (butt), mentum (chin), can be R/L and anterior/posterior

Lie- position of fetal spine r/t moms; longitudinal (spines parallel), transverse (spines perpindicular)

Attitude- relationship of fetal head and spine; vertex (head down, chin to chest), face (neck extended)

5 P’s of labor -Powers

Primary- uterine contractions responsible for dilation, effacement, and descent

Secondary- maternal pushing

5 P’s of labor- Position

Maternal position changes support vaginal birth and allow gravity to help cervix dilate and thin

Maternal adaptations to labor

Cardio&Hematologic:

Increased blood volume, increased cardiac output, increased stroke volume, increased HR all resolving between contractions. Increased lymphocytes d/t stress

Pulmonary/resp:

Increased oxygen consumption and lactic acid production

GI:

N/V, bowel incontinence, delayed gastric emptying

Renal:

Incontinence, proteinuria

Endocrine:

Surge in cortisol, oxytocin causing contractions, estrogen increase triggers prostaglandin increase

First stage of labor

Begins with labor onset and ends with full dilation and effacement

Latent phase:Contractions start and are irregular, dilation 0-4 cm progressing to 4-6 cm

Active phase: Fetus descends into pelvis, full cervical dilationU

Uterine contractions

Monitored by TOCO (external, noninvasive) or IUPC (internal, invasive). Expected is 3-5 contractions in ten minute period, each lasting 30-40 seconds. Tachysystole is more than 5 contractions in ten minutes.

Fetal station

How far down the presenting part is, more positive is closer to coming out. Crowning is +5, engagement is 0 station.

Leopold manuevers

Firm palpation of all sides of uterus to determine baby position and optimize HR monitor placement

Fetal HR variability

Absent

Minimal- less than 5 beats per minutes

Moderate- 6-25 beats per minutes

Marked- more than 25 beats per minute

Fetal HR accelerations

Increase in fetal Hr by 15 beats for at least 15 seconds

Fetal HR decelerations

Decrease in fetal HR by 15 beats for 15 seconds

Variable- abrupt decrease, shaped like V or W

Early- gradual decel, mirror contraction (acme matches up with nadir)

Late- Nadir occurs after acme

Prolonged- decrease by 15 beats for 2-10 min

Sinusoidal- EMERGENCY, often related to fetal anemia

HR decels, cause, and interventions

V-variable decels

E-early decels

A-accelerations

L-late decels

C-cord compression

H-head compression

O-okay

P-placental insufficiency

M- maternal position change

I-identify labor progress

N-nothing

E-execute actions immediately

FHR categories

Category 1 (normal):

HR 110-160, moderate variability, no late or variable decels

Category 2:

Everything in between, minimal baseline variability

Category 3: (immediate intervention required)

Late decels and absent variability or variable decels and absent variability, bradycardia and absent variability, sinusoidal pattern

Intrauterine resuscitation

Stop pitocin, reposition mom, IV fluids, supplemental oxygen, facilitate emergent birth if needed

Maternal birthing positions

Lithotomy - supine with HOB elevated and legs in stirrups

Supine - flat on back

Lateral- Client on side with legs either bent or straight

Second stage of labor

Begins at 10 cm dilation with full effacement and ends with delivery. Active pushing phase of labor. Fetal descent should be 1 station/hour for first time moms, 2 stations/hour for second time moms

Seven cardinal movements of labor

Engagement

Descent

Neck flexion

Internal rotation

Extension

External rotation

Expulsion

Third stage of labor

Begins with newborn delivery and ends with expulsion of placenta. Typically 5-30 minutes.

Fourth stage of labor

Begins after expulsion of placenta and lasts ~ 2 hours. Fundal massage and assessments priority to ensure uterus is firming up and there is no hemorrhage.

Hemodilution

Extra cellular fluid going into vascular system during immediate postpartum period, affecting hemoglobin and hematocrit levels which is why we cannot use those as reliable markers of blood loss.

Postpartum involution of uterus

From birth through the first 6 weeks the uterus reduces in size. Cramping continues after birth to clamp off blood vessels that fed the placenta. If this does not occur patient at risk for hemorrhage. It should decrease roughly one cm each day.

Lochia

Scant- less than 2.5 cm on pad

Light- less than 10 cm on pad

Moderate- 15 cm on pad

Heavy- saturated pad

Postpartum immunizations for mom

Rubella- given if not immune

Varicella- given if not immune

Tdap- to prevent pertussis

Pharmacological pain management

Opioids- contraindicated within one hour of birth. Can decrease fetal HR variability, cause maternal respiratory depression

Local anesthesia

Perineal infiltration- administered directly into the perineum immediately before episiostomy or before birth.

Pudendal nerve block- given during pushing or post birth for perineal repair. Targets pudendal nerve.

Regional anesthesia

Spinal block- injection into arachnoid space. Uses opioids and local anesthetic. Quick onset, good for c-sections. Duration 90-120 minutes.

Epidural- catheter placement in lumbar epidural space for med delivery continuous or intermittent as needed.