PBL MIDTERM STUDY

clinically relevant pregnant persons' care

• Maternal vital signs

  • BP

  • HR

  • RR

  • Temp

• Signs of maternal complications

  • Hemorrhage

  • Preeclampsia

  • Infection

  • Shock

• Labour progress

  • Cervical dilation

  • Effacement

  • Station

• Contraction pattern

  • Frequency

  • Duration

  • Intensity

• Pain and comfort

• Psychological coping

• Patient education/preferences

clinically relevant fetal care

• Evidence of adequate oxygenation

  • FHR status

  • Fetal movement

• Signs of fetal compromise

  • Hypoxia

  • Acidosis

  • Meconium

• Fetal presentation and position

  • Cephalic

  • Breech

  • Occiput position

• Gestational age considerations

• Expected adaptation during labour

what is assesed in FHR status monitoring

Priority Assessment Order (Most Important for Exams)

1. Baseline FHR

   • 110-160 bpm

2. Variability

   • Moderate = reassuring

3. Decelerations

   • Late = most concerning

   • Variable

   • Early

4. Accelerations

   • Reassuring

5. Contraction pattern

   • Frequency

   • Duration

   • Intensity

6. Response to interventions

what are pregnancy complications

HYPERTENSIVE DISORDERS

• GHTN

• preeclampsia/eclampsia

• hellp syndrome

PLACENTAL ATTACHMENT DISORDERS

• placenta previa

• prolapsed cord

• placental abruption

LABOUR and DELIVERY COMPLICATIONA

• PROM

• dystocia/malposition

• fetal distress

IMMUNOLOGICAL CONDITIONS

• blood incompatibility

what are the hypertensive disorders of pregnancy

• GHTN

• PREECLAMPSIA/ECLAMPSIA

• HELLP SYNDROME

GHTN

What are non-severe versus severe readings for hypertension in pregnancy

→ Non severe hypertension:

• 140/90

→ Severe hypertension 

• 160/110

• Considered an obstetrical emergency

• Treated with anti-hypertensives

what are hypertensive effects

Transient hypertension 

• HTN due to environmental stimuli

white coat

• HTN in clinicians office only

masked

• BP normal in office, but higher outside of office

what are the 3 most common HTN disorders in pregnancy

• Chronic hypertension 

  • before pregnancy or prior to 20 weeks of gestation

• Gestational hypertension 

  • HTN after 20 weeks gestation in the absence of proteinuria

• Chronic hypertension with superimposed pre-eclampsia 

  • HTN before 20 weeks of gestation, with new onset of proteinurias

what are the complications of severe HTN

maternal

death due to…

• Hepatic rupture

• Placental abruption

• Eclampsia 

fetal

• placental abruption

• preterm birth

• growth restriction

• acute hypoxia

PREECLAMPSIA / ECLAMPSIA

what is pre eclampsia

• a multisystem, vasospastic disease process of reduced organ perfusion

• Hypertensive disorder accompanied by new onset proteinuria and potentially other end-organ dysfunction

what are the 2 key components to diagnose pre eclampsia

gestational OR chronic HTN with new onset proteinuria

what is the defined level of proteinuria to diagnose pre eclampsia

• a concentration of 0.03 g/L or more in 24 hours

what are risk factors for the development of pre eclampsia

• prior pre-eclampsia

• chronic HTN

• pregestational diabetes

what are additional signs present in pre eclampsia

• acute kidney or liver dysfunction

• neurological complications

• seizures

• blindess

• stroke

• severe headaches

what is the main pathophysiological feature of preeclampsia

•  poor perfusion as a result of vasospasm.

• Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and increases BP

what is the main pathophysiological feature of a normal pregnancy

• Increased Plasma volume

• Vasodilation

• Decreased Systemic vascular resistance

• Increased Cardiac output

• Decreased Colloid osmotic pressure

what is the PIERS model

Pre-eclampsia Integrated Estimate of Risk

6 core variables

• Gestational age

• Symptoms (chest pain or sob)

• Oxygen Saturation

• Platelet count (low platelets)

• Serum Creatinine (kidney)

• Aspartate Transaminase (liver)

what is eclampsia

life-threatening maternal complication of pre eclampsia charactertized by seizures

what are greatest risks of eclampsia

• high death rate before 28 weeks

• age 30+

• no prenatal care

• mutligravida

• chronic HTN /renal disease

what risk does eclampsia impose on the fetus

• placental abruption

• preterm birth

• IUGR

• acute hypoxia

what is HELLP syndrome

severe pre eclampsia + blood results

• H - Hemolysis

• EL - Elevated liver enzymes 

• LP - Low platelets 

what is HELLP commonly mistaken for

• gastritis

• flue

• acute hepatitis

• gallbladder disease

what are the lab values for HELLP syndrome

• Platelets <100 × 10⁹/L

• Elevated AST and ALT

• Evidence of hemolysis

• PT, PTT, and bleeding time may remain normal, distinguishing HELLP-related coagulopathy from typical DIC.

what are the symptoms for HELLP

• ~90%: malaise for several days

• Epigastric or right-upper-quadrant pain → possible hepatic ischemia

• ~50%: nausea and vomiting

what are the complications of HELLP syndrome

• Renal failure

• Pulmonary edema

• Ruptured liver hematoma

• DIC

• Placental abruption

• Poor maternal and newborn outcomes

what is the prevention for HELLP syndrome

• Early prenatal care

• For patients with risk factors:

  • Low-dose aspirin: 81 mg, ideally started before 16 weeks of pregnancy.

  • If dietary calcium intake is low: 1.2–2.5 g/day calcium may be recommended.

what is the nursing care role for pre eclampsia and HELLP

maternal

• monitor bp trends: DBP usually decreases 10 mmHg mid-pregnancy and returns to normal by 3rd trimester

• deep tendon reflexes: biceps, patellar, ankle clonus

fetal

• fetal health surveillance

• NST - nonstress test

• CST - craniosacral thorapies

• BPP - biophysical profile

• Serial US

• FHR - baseline, variability, accelerations

what are the activity recommendations for pre-eclampsia and HELLP

• NO strict bedrest

• reduced activity to decrease bp and improve fetal growth/fluid

what is the recommended medication for pre eclampsia and HELLP

magnesium sulphate

• prevent and treat eclamptic seizures

• anticonvulsant

what is GDM

elevated glucose levels that are first recognized during pregnancy

what are the risk outcomes of GDM

• preeclampsia

• LGA

• c section

• shoulder dystocia

• fetal hypoglycemia

what is the recommended time for screening for GDM

24-28 weeks

who are at risk of GDM

• 35+

• Being a member of a high-risk group (African, Arab, Asian, Latin-American, Indigenous, or South Asian)

• Using corticosteroid medication

• Obesity (BMI + OR = 30)

• Pregestational diabetes

• Gestational diabetes in a previous pregnancy

• Given birth to a baby that weighed more than 4 kg

• A parent, brother, or sister with type 2 diabetes

• PCOS

• acanthosis nigricans

what are the screening methods for GDM

• two-step test and the one-step test

• The 2 step method is preferred

  • In this method, if the value of the plasma glucose level is 7.8-11.0, when taken at 1 hour, a 2 hour 75g oral glucose tolerance test should be preformed

What are the placental attachment disorders

• placenta previa

• placental abruption

what is the major cause of PP and PA

late pregnancy bleeding

what are risk factors for LPD

• Previous Caesarean birth !!!!!

• Previous placenta previa

• Advanced maternal age (>35–40 years)

• Multiparity

• Previous suction curettage

• Previous miscarriage/induced abortion requiring curettage

• Smoking

• Multiple gestation

• Previous uterine/endometrial damage or scarring

• Higher risk reported among Asian patient

what are clinical manifestations of LPD

• Painless, bright-red vaginal bleeding in the 2nd or 3rd trimester!!!!!!

• About 70–80% of patients with placenta previa experience vaginal bleeding

• Bleeding occurs because the lower uterine segment stretches/thins, disrupting placental blood vessels.

• Most cases are now detected by ultrasound before major bleeding occurs

• Soft, relaxed, nontender uterus

• Normal uterine tone

• FHR often normal unless there is significant placental separation

what is placenta previa

the placenta is implanted in the lower uterine segment.

It completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces

what are the types of placenta previa

Complete

• Placenta completely covers the internal cervical os.

Marginal

• Placental edge is ≤2.5 cm from the internal cervical os

Low-lying placenta

• Placenta is in the lower uterine segment, but its exact relationship to the os has not been established.

what is the diagnoses for PP

Transvaginal ultrasound (TVS)

• >15 mm overlap with the OS is associated with a greater likelihood of placenta previa at term.

when is placenta previa diagnosed regardless

• All patients with painless vaginal bleeding after 20 weeks of gestation should be assumed to have placenta previa until proven otherwise

when should placental overlap be reassesed

• A placenta that reaches/overlaps the os at 18–24 weeks should be reassessed

what are maternal assesments with late pregnancy bleeding

• Maternal hemodynamic status

• Fetal well-being

• Uterine resting tone

• Contractions

• Amount/character of bleeding 

what lab tests for LPB

• CBC

• Type and cross-match

• Coagulation studies

• APT test

• Kleihauer-Betke test

what are nursing interventions for LPB

• Establish/verify patent IV access.

• Administer supplemental oxygen as indicated.

Monitor:

• Maternal vital signs

• Blood loss

• Urine output

• FHR

• If labour is being induced, stop oxytocin when significant bleeding occurs.

Prepare for:

• Blood replacement

• Vasoactive medications if needed

• Caesarean birth when indicated

what is a major complication of PP

hemorrhage

• Hysterectomy may be required is hemorrhage cannot be controlled

is PP a potential emergency

YES ALWAYS!!

massive blood loss with resulting hypovolemic shock can occur quickly if bleeding resumes 

what is a complication of PP to the cord

placenta accretta

what is placenta accretta

 a serious complication of placenta previa

In this coniditon, trophoblastic invasion extends beyond the normal endometrial barrier 

If the invasion extends to the myometriym = placetna accretta

when does placetna accretta exist

when the placental invasion extends beyond the uterine serosa

what can occur with placenta accretta

• Massive hemorrhage

• Caesaren birth thru fundal incision, followed by total abdominal hysterectomy may be indicated

• VASA PREVIA

what is VASA previa

• when fetal vessels lie over the cervical OS

• The vessels are implanted into the fetal membranes rather than onto the placenta

what are risk factors for VASA previa

History of second trimester placenta previa or lowlying placenta

Pregnanies resulting from assisted human reproduction 

Multiple gestation

what are 2 variatons of vasa previa

• Velamentous insertion of the cord

• → occurs when the umbilical vessels begin to branch at the membranes and then course onto the placenta

• Succenturiate placenta

• → occurs when the placneta has divded into 2 or more lobes rather than remaining as a single mass 

what is placental abruption

Premature separation of the placenta

a serious commpliation that  accounds for significant maternal and fetal morbidity and mortality 

what is the greatest risk for aburption

• maternal HTN (vascular disruption)

• cocaine

• smoking

• HX of abruption

• pretrem PROM

what are the signs of abruption

• PAIN + TENDERNESS + CONTRACTIONS + BLEEDING

• Sudden abdominal/uterine pain

• Uterine tenderness

• Vaginal bleeding

• Frequent contractions

• Increased uterine tone/hypertonicity

• Abdomen may become boardlike

• Pain may be localized or diffuse

• Severe sburption may cause

• Hypovolemia-Shock

• Oliguria/anuria

• Coagulopathy/DIC

what are complications of abruption maternally

• Hemorrhage

• Hypovolemic shock

• Hypofibrinogenemia

• Thrombocytopenia

• DIC

• Couvelaire uterus

• Infection

• Renal failure

• Pituitary ischemia/necrosis → Sheehan syndrome

• Rh sensitization if fetal blood enters maternal circulatio

what is couvelarie uterus

Extensive myometrial bleeding damages the uterine muscle 

• If blood acculamted between the separated placenta and the uterine wall, it may produce a Couvelaire uterus 

• The uterus appears purplish and copper-coloured; it is ecchymotic,, and contractility is lost  

• Shock may occur and is out of proportion to blood loss as hemoglobin and hematocrit levels decrease and coagulation factor levels decrease

what are fetal complications of abruption

• IUGR

• Oligohydramnios

• Preterm birth

• Hypoxemia

• Stillbirth

• Neurological injury

• Cerebral palsy

when is an abruption diagnoses expected

Sudden severe uterine/abdominal pain ± vaginal bleeding

what are assesments for abruption

• Abdominal/uterine tenderness

• Contractions

• Uterine tone

• Fundal height

• Maternal vital signs

• FHR

• Coagulation studies

what are labour and delivery complications

dystocia/malposition

PROM

cord complications

fetal distress

what ia preterm labour

labour before 37 weeks of preganancy

how many cm dilated during preterm labour leads to preterm birth

4cm dilated is likely to lead to preterm birth because fetus is smaller

what is malpresentation

the fetus is positioned in a way other than the usual head-first position for birth.

which term fetus is malepresentation most common

malpresentation is more common in preterm fetuses than in term fetuses.

what is a malpresentation position

 breech presentation, where the baby's buttocks or feet present first rather than the head.

what is the nursing care role for preterm labour

prepared for an emergency birth of a preterm infant in either a cephalic (head-first) or breech position, even if the obstetrical healthcare provider is not immediately present.

what should the healthcare team prepare for a preterm birth

• Prepare neonatal resuscitation equipment and supplies.

• Have necessary medications ready for immediate use.

• Ensure personnel trained in neonatal resuscitation are available.

• Arrange transfer to a higher level of neonatal care if the hospital cannot provide the continuing care the preterm newborn requires.

what is PROM

premature rupture of membranes

The spontaneous rupture of the amniotic sac with leakage of amniotic fluid before the onset of labor, regardless of gestational age.

what is PPROM

Preterm premature rupture of membranes (preterm PROM or pPROM) occurs when the membranes rupture before 37 completed weeks of gestation and before labour begins.

what are the signs and diagnoses for PROM or PPROM

when the patient reports either a sudden gush of fluid or a slow, continuous leakage of fluid from the vagina. The fluid represents amniotic fluid escaping after rupture of the amniotic sac.

what are risk factors for PPROM

• Previous preterm birth, especially one associated with preterm PROM

• Previous cervical surgery or cerclage

• Urinary or genital tract infection

• Short cervix (<25 mm) during the second trimester

• Current preterm labour or symptomatic contractions

• Uterine overdistension

• Second- or third-trimester bleeding

• Pulmonary disease or connective tissue disorders

• Low BMI or nutritional deficiencies

• Cigarette smoking

what is cerclage

• a surgical procedure in which a suture is placed around the cervix to help keep it closed and reduce the risk of premature cervical opening.

what is uterine overdistension

•  the uterus is stretched more than usual, which may occur with conditions such as multiple pregnancy or excessive amniotic fluid.

what are complications of PROM

• chorioamnionitis

•  placental abruption

• retained placenta

• hemorrhage requiring dilation and curettage (D&C)

• sepsis

• maternal death.

what is chorioamnionitis

a baceterial infection of the amniotic cavity and surrounding fetal membrane

what are S&S of chorioamnionitia

• Maternal fever

• Maternal tachycardia

• Fetal tachycardia

• Uterine tenderness

• Foul-smelling amniotic fluid

what are risk factors of chorioamnionitis

• prolonged labour

• prolonged exposure of the amniotic cavity to vaginal organisms

• prolonged rupture of membranes

• multiple vaginal examinations

• internal fetal heart rate or contraction monitoring

• young maternal age

• low socioeconomic status

• limited prenatal care

• nulliparity

• pre-existing lower genital tract infections..

what are maternal complications of chorioamnionitis

Maternal complications

• bacteremia

• labour dystocia

• Caesarean birth

• wound infection

• pelvic abscess.

what are newborn complications of chorioamnionitis

Newborn complications

• pneumonia

• bacteremia

• sepsis.

• risk of death greater for preterm

• Intrauterine infection

• increased risks of respiratory distress syndrome

• Periventricular leukomalacia (PVL) damage to the white matter of the developing brain around the ventricles.

• Cerebral palsy disorders affecting movement, muscle tone, posture, and motor function due to injury or abnormal development of the brain.

 

what is the treatment and prevention for chorioamnionitis

Treatment

• IV broad-spectrum antibiotics and birth of the fetus. Ampicillin or penicillin combined with gentamicin

• If a Caesarean birth occurs, an antibiotic that covers anaerobic organisms, such as clindamycin or metronidazole, may be added.

prevention

• antibiotic prophylaxis for patients who are group B streptococcus (GBS) positive

• management of labour

• induction following rupture of membranes at term rather than prolonged

what are fetal complications of PROM

• intrauterine infection

• umbilical cord prolapsecord compression caused by oligohydramnios, and placental abruption

• Oligohydramnios means an abnormally low amount of amniotic fluid.

what is a complicaiton if PPROM occurs before 20 weeks

pulmonary hypoplasia

incomplete or underdevelopment of the fetal lungs.

what is cord prolapse

• when the umbilical cord moves down through the cervix ahead of or alongside the fetus, which can lead to cord compression and reduced fetal oxygenation.

what is the nursing manament of PROM at term

• At term, infection is one of the greatest risks to the pregnant patient, fetus, and newborn.

• birth is generally the preferred option.

• If labour does not begin spontaneously shortly after PROM, labour may be induced,

what is the nursing manament of PROM at 34-36 weeks

• Active management with labour and birth has traditionally been recommended.

• conservative management until approximately 37 weeks may sometimes be considered when the risk of intrauterine infection is low.

• Carefully monitoring the pregnancy and delaying birth when possible to allow additional fetal growth and maturation while watching closely for complications.

what is the nursing manament of PROM before 32 weeks

• often managed conservatively because complications from severe prematurity may be greater than the immediate risk of infection.

• The patient will usually be hospitalized in an attempt to prolong the pregnancy and allow more time for fetal maturation.

• Pregnancy not be prolonged if

  • Intrauterine infection

  • Significant vaginal bleeding

  • Placental abruption

  • Advanced labour

  • Atypical or abnormal fetal assessment

• 24-hour neonatal resuscitation and intensive neonatal care.

how many fetal movements should occur within 2 hours

• The patient should perform daily fetal movement counts. Most pregnant patients should feel approximately six fetal movements within 2 hours.

what maternal monitoring is required before 32 weeka

• The patient is monitored closely for labour, placental abruption, and intrauterine infection.

what fetal monitoring is required during conservative managment (before 32 weeks)

fetal well-being is monitored using tests such as the nonstress test (NST) and biophysical profile (BPP). Amniotic fluid volume (AFV) may also be assessed.

 

what is NST

• Nonstress test (NST) evaluates the fetal heart rate response to fetal movement to help assess fetal well-being.

what is BPP

• A biophysical profile (BPP) combines fetal assessment techniques, usually including ultrasound and an NST, to evaluate fetal well-being.

what is AFV

• Amniotic fluid volume (AFV) refers to the amount of amniotic fluid surrounding the fetus.

what medications are used with PPROM at 24-36+6 weeks

• one course of antenatal corticosteroids

• to promote fetal maturation

• Antenatal corticosteroids

• given before an anticipated preterm birth to accelerate fetal maturation, particularly lung maturation, and reduce complications

• A 7-day course of broad-spectrum antibiotics

• prolong the time between membrane rupture and birth, decrease chorioamnionitis, and decrease newborn infections and complications

what medications are used with PPROM less than 34 weeks

• magnesium sulphate may be administered for fetal neuroprotection.