OB - NCLEX

Magnesium Sulfate

Preterm labor; Preeclampsia

Hypotension, bradypnea, decreased DTR, pulmonary edema, flushing, nausea, vomiting, drowsiness

Bed rest, foley, I/Os, fluid restriction

Stop for respirations < 12, altered LOC, magnesium level above 10 mEq / 9 mg

Contraindicated for myasthenia gravis

Therapeutic Level: 4 - 8

Calcium Gluconate

Antidote for magnesium sulfate toxicity

Dilute with equal amounts of NS

Administer 0.5 - 1 mL / minute

Oxytocin

Stimulates uterine contractions

Used in all stages of labor

Stop for tachysystole, late decelerations

Methylergonovine

Stimulate uterine contractions after delivery

Treat postpartum hemorrhage

Monitor bleeding, uterine tone, blood pressure

Massage fundus

Terbutaline

Preterm labor

Give 0.25 mg every 20 minutes as needed

Monitor for tremors, dizziness, headache, tachycardia, hypotension, anxiety

Do not give if patient has chest pain

Notify provider for BP less than 90/60, HR above 130, FHR above 180, signs of pulmonary edema

Beta blocker is antidote

Betamethasone

Preterm labor 24 - 32 weeks

Prevent / reduce neonatal distress syndrome in preterm infants

Stimulate production / release lung surfactant in preterm fetus

Misoprostol / Dinoprostone

Preinduction cervical ripening - Bishop score 4 or less

Obtain informed consent

Evaluate Bishop score

Use caution with history of asthma, glaucoma, renal, hepatic, cardiovascular disorders

False Labor

Contractions → braxton hick's, irregular, do not increase in frequency or intensity, felt in lower back or abdomen above umbilicus, decrease with walking or position changes, cease with sleep, comfort measures, hydration, emptying bladder

Dilation / Effacement → no significant changes, uterus stays in posterior position

Bloody Show → not present

Fetus → presenting part not engaged in pelvis

True Labor

Contractions → begin irregular but become regular in frequency, become stronger and last longer, walking increases intensity, comfort measures do not help, felt in lower back radiating to abdomen

Dilation / Effacement → steadily progress

Bloody Show → present as cervix dilates

Fetus → presenting part engages in pelvis

VEAL

CHOP

MINE

Variable, Early, Acceleration, Late

Cord Compression, Head Compression, Okay, Placental Insufficiency

Maternal Repositioning, Identify labor progress, None, Execute Actions

Facts to Know

It is never good to be late → late decelerations are bad

Absent variability is critical

Unexplained pain is not good → preterm, abruptio placentae, amniotic fluid embolism, uterine rupture

Never provide fundal pressure with shoulder dystocia

OB client with tachycardia → think hemorrhage first

Quick onset of epigastric pain is often the aura to seizure activity

Standards of Care

Never perform a vaginal exam with unexplained bleeding

Client bleeding should have IV access

RhoGAM is given to Rh- mothers after miscarriage, after 28 weeks gestation, within 72 hours after delivery

Assign unstable patients close to nurses station

Cord Compression

Can cause fetal asphyxia

1. Reposition mother to relieve pressure on cord

2. Administer oxygen 8 - 10L / min NRB

3. Amnioinfusion

Placenta Previa

Factors → placenta implants over cervical os

Bleeding → bright red, range from minimal to severe / life threatening

Pain → none

Maternal → hemorrhage, shock, death

Fetal → anoxia, CNS trauma, death

Treatment → partial - bed rest; complete - csection, blood transfusion, monitor for DIC

Abruptio Placentae

Factors → trauma, preeclampsia, multi parity, cocaine use

Bleeding → dark red, absent to moderate amount depending on grade of abruption

Pain → tender and boardlike abdomen

Maternal → hemorrhage, shock, death

Fetal → anoxia, CNS trauma, death

Treatment → emotional support, immediate csection, blood transfusion, monitor for DIC

Vaginal Exams

Limit frequency to decrease risk of infection or if ROM has occurred

Contraindicated with vaginal bleeding

Done with sterile gloves

Analgesia

May stop or slow labor if given early in labor

Opioids given late in labor may cause newborn respiratory depression

Do not give butorphanol or nalbuphine to opioid dependent mother

Keep nalaxone at bedside, do not give to opioid dependent mother

Anesthesia Blocks

Regional → most commonly used

Pudendal → local anesthesia to perineum, rectum, vulva during delivery; administered 10 - 20 mins before delivery

Epidural → local anesthetic and morphine / fentanyl injected into epidural space; may be continuous infusion; hypotension most common side effect

Contraindications → maternal hypotension, coagulopathy, infection at injection site, IICP

Amniotomy

Artificial rupture of membranes

Labor typically begins within 12 hours

Increases risk for cord prolapse or infection

Assess → amount, color, consistency, odor of amniotic fluid

Implement peri care and clean pads

Monitor temperature every 2 hours

Amnioinfusion

Intrauterine infusion of isotonic solution (0.9% NS / LR)

Reduces severity of variable decelerations

Warm fluid using blood warmer prior to infusion

Induction / Augmentation of Labor

Maternal Indications → hx of rapid labor, preeclampsia, diabetes mellitus, Rh isoimmunization, chronic renal disease, pulmonary disease

Fetal Indications → IUGR, PROM, chorioamionitis, postdates, fetal demise

Contraindications → cephalopelvic disproportion, nonreassuring FHR, placenta previa, vasa previa, prior classical uterine incision or uterine surgery, active genital herpes, HIV, cervical cancer

Methods:

✫ prostaglandin - placed near cervix, remain supine with wedge or side lying for 30 mins, delay pitocin for 6 - 12 hours after last insertion

✫ IV oxytocin

Prior to Administration → obtain informed consent, fetus must be at 0 station

Interventions → monitor for tachysystole and fetal distress, obtain vitals every 30 mins and with every oxytocin dose change, piggyback oxytocin, discontinue oxytocin with signs of fetal distress or tachysystole

Tachysystole / Hyperstimulation

More than one contraction every 2 minutes or 5 in 10 minutes

Contraction duration longer than 90 seconds

Contraction intensity greater than 90mmHg with IUPC

No relaxation of uterus between contractions

Vacuum Assisted Delivery

Indications → maternal exhaustion, ineffective pushing, fetal distress during second stage of labor

Place in lithotomy position and support with pushing

Assess for bladder distention before application

Observe for bruising and caput succedaneum

Caput may resolve within 24 hours or last up to 5 days

Forceps

Indications → poor progress during second stage, fetal distress, persistent occiput posterior position, abnormal presentation

Interventions → assess for intracranial hemorrhage, facial bruising, facial palsy

Complications → laceration to cervix or vagina, bladder or urethral injury, urine retention, hematoma formation in pelvic soft tissue

Cesarean Section

Low Transverse → decrease chance of uterine rupture with future pregnancies, less bleeding after delivery

Classic → rarely used

Indications → previous csection, failure to progress in labor, malpresentation, fetal distress, ceohalopelvic disproportion, multiple fetuses, macrosomia, prolapsed cord

Interventions → obtain informed consent, insert IV and foley, monitor for thrombophlebitis, assess for bleeding and lochia

Breast Milk Production

Colostrum transitions to milk 48 - 96 hours and is high in nutrition

Milk production occurs about day 2 - 3

Breast milk supports the immune system → protects against bacterial, viral, and protozoal infections; IgA is immunoglobulin in human milk

Engorgement

Occurs about 48 hours postpartum

Can cause slight rise in temperature

Breastfeed every 2 - 3 hours

Take a warm shower immediately prior to breastfeeding

Apply cold compress or cold green cabbage leaves to breast

Nonlactating → avoid nipple stimulation, cold compress, pain meds, supportive bra

Lochia

Rubra → bright red, may contain small clots, transient flow increased during breastfeeding and upon rising, lasts 3 days

Serosa → brownish red or pink, days 4 - 10

Albra → yellowish, white creamy color, day 11 - beyond 6 weeks

Rubella Vaccine

Prevent pregnancy for 1 month

If given with RhoGAM, have titer drawn at 3 months to verify immunity

Gestational Hypertention

Elevated BP of 140/90 on 2 occasions, atleast 4 hours apart within 1 week

No proteinuria

Factors → maternal age < 20 or > 40, first pregnancy, morbid obesity, multifetal gestation, chronic renal disease, chronic hypertension, family history, diabetes mellitus, Rh incompatibility, molar pregnancy, previous history of GH

Mild Preeclampsia

Gestational HTN with addition of proteinuria 1 - 2+

Severe Preeclampsia

BP 160/110 on 2 separate occasions 6 hours apart on bedrest

Proteinuria greater than 3+

Oliguria

Creatinine greater than 1.1

Headache and blurred vision

Hyperreflexia with possible ankle clonus

Peripheral edema

Hepatic dysfunction

Epigastric and RUQ pain

Thrombocytopenia

Eclampsia

Severe preeclampsia plus seizure activity

Preceded by persistent headache, blurred vision, severe epigastric or RUQ pain, altered mental status

HELLP Syndrome

Variant of GH which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction

H - hemolysis resulting in anemia and jaundice

EL - elevated liver enzymes, epigastric pain, nausea, vomiting

LP - low platelets (less than 100,000) resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, possible DIC

Glucose Tolerance Test

50g oral glucose load followed by glucose analysis 1 hour later

Performed at 24 - 28 weeks gestation

Fasting not necessary

Positive - 140mg or greater, additional 3 hr test needed

3 Hr GTT → overnight fasting, avoid caffeine, abstain from smoking for 12 hours prior

✫ fasting glucose obtained, 100g load given

✫ glucose levels are measured at 1, 2, 3 hours

Hypoglycemia

Nervousness

Headache

Weakness

Irritability

Hunger

Blurred vision

Tingling of mouth or extremities

Hyperglycemia

Thirst

Nausea

Abdominal pain

Polyuria

Flushed dry skin

Fruity breath

Nonstress Test

Evaluates fetal well being

Noninvasive

Monitors response of FHR to fetal movement

Indications → assess well being and intact CNS in third trimester, high risk pregnancy

Reactive / Normal → 2+ FHR accelerations (increase in FHR at least 15/min above baseline and last 15 seconds) within a 20 min period

Nonreactive / Abnormal → does not produce 2 or more qualifying accelerations in 20 mins; CST or BPP if not met in 40 mins

Amniocentesis

14 - 16 weeks → genetic work up for fetal anomalies, detects presence of AChE in neural tube defects

Late → assess fetal lung maturity and fetal well being, L:S of 2:1 indicates fetal lung maturity

GTPAL

Gravida - # of pregnancies

Term - births 38 weeks or more

Preterm - births from 20 weeks - 37 weeks

Abortion - abortion / miscarriage prior to viability

Living - living children

APGAR

Heart Rate: 0 - absent; 1 - slow, less than 100; 2 - above 100

Respiratory Effort: 0 - absent; 1 - slow weak cry; 2 - good cry

Muscle Tone: 0 - flaccid; 1 - some flexion; 2 - well-flexed

Reflex Irritability: 0 - no response; 1 - grimace; 2 - cry

Color: 0 - blue, pale; 1 - centrally pink, blue extremities; 2 - completely pink

7 - 10 → within normal limits

4 - 6 → moderately distressed

0 - 3 → severely distressed