Exam 2 Study Guide Final🤰🫄🫃🤱

OB complications

Uterine rupture

• manifestations

  • symptomatic disruption and separation of layers of uterus/previous scar

  • mostly occur because of scarred uterus from previous c-section

  • sudden sharp abdominal pain/ripping or tearing sensation

  • bright red vaginal bleeding/signs of hypovolemic shock

  • visible palpation of fetal parts

• risk factors

  • c-section

  • prior uterine rupture

  • trauma

  • abortion

  • multiparity

  • uterine overdistention

  • malpresentation

• interventions

  • start IV fluids

  • transfuse blood products

  • administer oxygen

  • prepare for immediate surgery

  • support family and provide info about tx during emergency

• maternal effects

  • severe hemorrhage

  • shock

  • hysterectomy

  • infection risk

• fetal effects

  • abnormal FHR tracing

    • abrupt decrease in FHR

    • late/variable decelerations

    • absent baseline variability

    • tachy/bradycardia

  • loss of fetal station/no fetal descent

  • hypoxia

  • acidosis

• post complication care

  • monitor for infection

  • assess for PPH

Shoulder dystocia

• manifestions

  • head is born but anterior shoulder cannot pass under pubic arch

  • r/t excessive fetal size or maternal pelvic abnormality

  • cannot be predicted

• risk factors

  • hx shoulder dystocia

  • maternal diabetes/obesity

  • prolonged second stage of labor

  • macrosomia >4000 g

• interventions

  • assume McRoberts maneuver (pull mother’s knees to ears)

  • suprapubic pressure

  • clavicle fracture

  • symphsiotomy- incision in cartilage between pubic bones to enlarge pelvic opening

• maternal effects

  • perineal trauma

  • uterine rupture

  • PPH

• fetal effects

  • hypoxia

  • fractured clavicle

  • erb’s palsy

• post complication care

  • perform neonatal injury assessment

  • maternal perineal care

Prolapsed cord

• manifestations

  • cord lies below presenting part of fetus

  • visible/palpable after ROM

  • sudden onset variable/prolonged decels or bradycardia

  • report of feeling cord in vagina

• risk factors

  • long cord

  • malpresentation (breech or transverse lie)

  • preterm labor

  • polyhydramnios

  • external cephalic version procedure

  • induction using balloon catheter

• interventions

  • recognize ASAP as hypoxia from cord compression can cause CNS damage/death

  • relieve pressure off cord

    • hold presenting part off umbilical cord

    • assist into lateral position, trendelenburg, knee-chest

• maternal effects

• fetal effects

  • severe hypoxia

  • distress

  • bradycardia

  • variable decelerations

• post complication care

  • neonatal resuscitation

  • monitor for hypoxic encephalopathy

Preterm labor

• manifestations

  • onset of labor before 37 weeks

• risk factors

  • spontaneous PTB

    • infection

    • decreased progesterone

    • maternal/fetal stress

  • indicated PTB

    • preeclampsia

    • multiple gestation

    • placental cause

    • maternal code blue

• interventions

  • tocolytics to suppress uterine contractions (nifedipie, terbutaline, mg sulfate)

  • betamethasone for fetal lung maturity

• maternal effects

• fetal effects

  • respiratory distress syndrome

  • necrotizing enterocolitis

• post complication care

  • admit to NICU

Meconium-stained fluid

• manifestations

  • fetal stool in amniotic fluid

  • green, can be thin or thick

• risk factors

  • hypoxia-induced peristalsis

  • sphincter relaxation

  • cord compression-induced vagal stimulation

• interventions

  • suction fetal airway

  • intubation if thick meconium

• maternal effects

• fetal effects

  • meconium aspiration syndrome in newborn

    • cause severe aspiration pneumonia

• post complication care

  • before birth

    • assess amniotic fluid for presence of meconium after ROM

    • gather equipment and supplies for neonatal resuscitation

  • immediately after birth

    • assess newborn respiratory effort, HR, muscle tone

    • suction only mouth and nose if WDL vital signs

Premature rupture of membranes

• manifestations

  • SROM/leakage of fluid prior to onset of labor at any gestational age

• risk factors

  • often preceded by infection (chorioamnionitis)

    • bacterial infection of amniotic cavity

    • maternal fever, tachycardia, uterine tenderness, foul odor

  • cervical insufficiency

    • passive/painful dilation of cervix leading to recurrent PTB during second trimester

    • tx with cerclage placement

  • multiple gestation

• interventions

  • administer magnesium sulfate for 24 hrs for fetal neuroprotection

  • give tocolytic meds or nifedipine to suppress uterine activity

  • give antenatal glucocorticoids (betamethasone) to reduce respiratory distress syndrome, hemorrhage, necrotizing enterocolitis, death

• maternal effects

  • increased risk of infection

• fetal effects

  • PTB

  • risk for sepsis

• post complication care

  • monitor infection

Hypertensive Disorders

CONTROLLING BLOOD PRESSURE IS THE OPTIMAL INTERVENTION TO PREVENT DEATH FROM STROKE/PREECLAMPSIA

Gestational HTN management

• defined as systolic BP of >140 or diastolic of >90

• frequent BP and weight measurement

• report promptly if:

  • increase in BP

  • persistent headache

  • visual change

  • rapid weight gain

  • decreased fetal movement

  • uterine contractions

Preeclampsia

• HTN and proteinuria after 20 weeks of gestation who previously had neither condition

• can also develop in postpartum period

• in absence of proteinuria, preeclampsia may be defined as HTN along with:

  • thrombocytopenia

  • renal sufficiency

  • impaired liver function

  • pulmonary edema

  • cerebral/visual symptoms (blinking stars/dots)

• risk factors include:

  • preeclampsia hx

  • multifetal gestation

  • chronic HTN

  • pregestational/gestational diabetes

  • SLE

  • obstructive sleep apnea

  • nulliparity

  • BMI >30

  • AMA

  • thrombophilia

  • assisted reproductive technology

• pathophysiology

  • placenta is root cause

  • begins to resolve after placenta expelled

  • spinal arteries fail to get larger and thicker

    • decreased placental perfusion and endothelial dysfunction= preeclampsia

  • placental ischemia=endothelial cell dysfunction

  • generalized vasospasm=poor tissue perfusion in organ system

• preeclampsia with severe features

  • thrombocytopenia <100

  • renal insufficiency with elevated serum creatinine >1.1 mg/dl/doubling

  • pulmonary edema

  • headache unresponsive to medication

  • visual disturbances

  • systolic BP ≥160 or diastolic BP ≥110 at least twice 4 hrs apart

• gestational age

  • onset prior to 34 weeks is most often severe

    • manage at facility with resources for management of serious maternal/neonatal complications

  • induction at 37 weeks indicated for preeclampsia without severe features

• management

  • assess BP and edema

  • assess deep tendon reflex/hyperactive reflex (clonus)

  • assess PCR

  • evaluate for these s/s:

    • severe frontal headache

    • epigastric pain (heartburn)

    • right upper quadrant tenderness

    • visual disturbance

Eclampsia

• onset of seizure activity/coma in preeclamptic patient

• no hx of preexisting pathology

• higher in multifetal gestation and women who did not receive prenatal care

• caused by cerebral edema

• watch for headache or visual disturbance

Chronic hypertension w/ superimposed preeclampsia

• dx based on

  • sudden increase in BP that was previously well controlled

  • new-onset/sudden and sustained increase in proteinuria in woman known to have proteinuria before conception/early pregnancy

Signs and symptoms

• persistent BP >140/90

• proteinuria if preeclamptic

• edema

• severe headache

• vision change

Treatment

Medications

• magnesium sulfate

  • mag sulfate for seizure prophylaxis is indicated for:

    • preeclampsia with severe features

    • severe gestational HTN

    • all cases of severe HTN regardless of classification

  • high Mg levels can causes relaxation of smooth muscle

  • initiate when diagnosed with preeclampsia

  • continue until 24 hrs post delivery or 24 hrs after last seizure if eclamptic

  • dose: 4-6gm loading dose over 20-30 min, then 2gm/hr

  • side effects

    • flushing/warm

    • drowsiness

    • sweating

    • N/V

    • HoTN

    • dizziness

    • headaches

    • slurred speech

    • visual disturbance

    • muscle weakness/decreased DTR

  • toxicity

    • absence/change in DTR

    • decreased LOC

    • SOB

    • decreased respiratory rate

    • persistent HoTN

    • chest pain

    • bradycardia/cardiac arrest

    • Mg greater than 8 mg/dL

  • give 1 g IV calcium gluconate over 3 min for toxicity

  Meds for chronic HTN during pregnancy	dose
  labetalol	200-2400 mg	first-line in pregnancy, does not reduce uterine blood flow
  nifedipine	30-90 mg daily	use with caution with mg sulfate
  methyldopa	500-2000 mg	not effective when taken less than three times a day
  hydrochlorothiazide	12.5-25mg daily	may be continued if taken before conception but not started as new med in pregnancy risk for thrombocytopenia for newborn

HELLP syndrome

• characterized by:

  • hemolysis

  • elevated liver enzymes

  • low platelet count

• symptoms

  • upper right abdominal pain

  • N/V

  • headache

  • blurry vision

• can lead to:

  • liver hematoma/rupture

  • ARDS

  • sepsis

  • hypoxic encephalopathy

  • fetal/maternal death

  • preterm delivery

  • recurrent preeclampsia

  • DIC

• treatment

  • induction regardless of gestational age

  • monitor CBC and liver enzymes Q6H

  • magnesium infusion

  • BP control

  • early epidural placement

Fetal changes

• impaired uteroplacental blood flow can cause:

  • IUGR

  • oligohydramnios

  • placental abruption

  • nonreassuring fetal status

  • preterm labor

Delivery recommendations

• induction if severe preeclampsia/eclampsia

Hemorrhagic Disorders

Hemorrhage

Antepartum hemorrhagic disorders

• antepartum hemorrhage

  • bleeding in pregnancy jeopardizes maternal/fetal well-being

  • blood loss decreases oxygen carrying capacity, increases risk for:

    • hypovolemia

    • anemia

    • infection

    • preterm labor

    • impaired O2 to fetus

    • hypoxemia of fetus

    • hypoxia of fetus

• spontaneous abortion (miscarriage)

  • occurs before 20 weeks

  • loss of fetus weighing ≤500g

  • management

    • assess pregnancy hx, vital signs, pain, bleeding, labs, emotional status

    • administer misoprostol (cytotec)

    • dilation and curettage

    • emphasize rest

• ectopic pregnancy

  • fertilized ovum implants outside uterine cavity

  • manifestations

    • dull, lower quadrant pain on one side

    • delayed menses

    • abnormal vaginal bleeding (spotting)

  • management

    • assess b-hCG level and transvaginal UA exam

    • administer methotrexate

      • refrain from taking folate

    • surgery

• ruptured ectopic pregnancy

  • abdominal discomfort to colicy pain when tube stretches to sharp, stabbing pain

  • referred shoulder pain

  • management

    • pain meds

    • assess for s/s shock (faintness, dizziness)

    • surgery

• hydatidiform mole

• placental trophoblast growth in which chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in grape-like cluster

• complete

  • no embryonic/fetal parts

  • sperm fertilizes empty egg

• partial

  • often have embryonic/fetal parts and amniotic sac

  • abnormal placenta forms, two sperm fertilize one egg

  • generally can’t survive

• manifestations

  • anemia from blood loss

  • hyperemesis gravidarum

  • abdominal cramps

  • large fundal height

  • preeclampsia

• management

  • transvaginal UA

  • monitor b-hCG levels weekly for 3 weeks then monthly for 6-12 months

  • suction curettage

  • instruct to not get pregnant for 12 months

    • can increase risk for cancer

• placenta previa

  • placenta implanted in lower uterine segment near/over internal cervical os

  • risk factors

    • previous c-section

    • AMA

    • multiparity

    • hx suction curettage

    • maternal cocaine use

    • smoking

  • low-lying

    • placenta in lower segment of uterus

    • does not reach opening of cervix

  • marginal

    • placenta next to cervix but does not cover

  • partial

    • placenta covers part of opening

  • complete

    • placenta covers entire opening

  • manifestations

    • painless bright red vaginal bleeding during second/third trimester

    • soft, relaxed, nontender abdomen

  • outcomes

    • major complication is hemorrhage

    • morbidly adherent placenta

    • surgery-related trauma

    • preterm birth/IUGR

    • late decels, absent/variable variability

  • management

    • no vaginal exams/internal monitors EXCEPT transvaginal ultrasound determining placental location

    • c-section is only option

      • cut right through placenta

    • come to hospital if any bleeding occurs

• placental abruption

  • detachment of all/part of placenta after 20 weeks of gestation

  • risk factors

    • maternal HTN

    • cocaine/methamphetamine use

    • penetrating/blunt external abdominal trauma

    • smoking

    • hx abruption

    • PPROM

  • manifestations

    • painful, tight belly

    • wave-like contractions

    • uterine hypertonicity

  • treatments

    • emergency c-section

    • IV fluids

    • blood transfusion

• vasa previa

  • fetal vessels lie over cervical os

  • vessels implanted into fetal membranes rather than into placenta

  • velamentous insertion

    • cord vessels branch at membranes and onto placenta

  • succenturiate placenta

    • placenta divided into 2+ lobes

  • battledore insertion of cord increases risk of fetal hemorrhage

Intrapartum hemorrhagic disorders

• disseminated intravascular coagulation (DIC)

  • acquired secondary complication resulting in formation of clots in microsystem

  • clotting occurs throughout entire circulation

  • clotting factors are consumed, unable to keep up with demand

  • fibrinolysis occurs

    • fibrin split product damage RBC, cause hemolysis

    • damage endothelial lining of vessels, capillaries in lungs, platelets

      • leads to ARDS, pulmonary edema

  • lab findings

    • low fibrinogen <100

    • PT prolonged before PTT

  • management

    • administer fresh frozen plasma (FFP)

Postpartum hemorrhagic disorders

• postpartum hemorrhage

  • cumulative blood loss ≥1000 ml OR bleeding associated with s/s of hypovolemia within 24 hrs of birth

  • primary PPH (early/acute)

    • occurs within 24 hrs of birth

    • uterine atony/rupture/inversion

    • coagulopathy

    • genital laceration

    • retained/invasive placenta

  • secondary PPH (late)

    • occurs more than 24 hrs to 12 weeks after birth

    • infection

    • retained placenta

    • coagulopathy

• subinvolution of uterus

  • prolonged lochial discharge

  • irregular/excessive bleeding

  • sometimes hemorrhage

• hemorrhagic (hypovolemic) shock

  • results of hemorrhage, death may occur

  • assessment

    • respirations

    • pulse

    • BP

    • skin

    • UO

    • LOC

  • characteristics

    • cool, pale, clammy

    • rapid, shallow respirations

    • rapid, weak, irregular pulse

    • lethargy, anxiety

  • management

    • fluid/blood replacement therapy

    • O2 delivery/maintain CO

    • restore blood volume

Early pregnancy bleeding

• diagnosis

  • vaginal bleeding before 20 weeks gestation

  • confirmed by ultrasound and hCG levels

• treatment

Late pregnancy bleeding (refer to previous sections)

• placenta previa

• placental abruption

Placental disorders (refer to previous sections)

• placenta previa

• placental abruption

• placenta accreta—slight penetration on myometrium

• placenta increta—deep penetration of myometrium

• placenta percreta—perforation of myometrium and uterine serosa

• management

  • early delivery

  • hysterectomy in severe cases

Hemorrhage medications

Which condition is a potential cause of an early postpartum hemorrhage?

a. Subinvolution of the uterus

b. Incomplete placental separation

c. Infection

d. Coagulopathy

Nursing interventions

Fetal Positioning

Lie

• longitudinal (normal)

• transverse

  • sideways, requires c-section

Attitude

• flexion

  • normal, chin tucked to chest

  • extension

    • head tilted backwards

Presentation

• cephalic

  • normal, head first

• breech

  • feet/bottom first

  • may require c-section

• shoulder

  • transverse lie with shoulder leading into birth canal

    • requires c-section

Position

• occiput anterior

  • normal

• occiput posterior

  • face facing belly button

  • cause painful back labor

  • use hand and knees position, counterpressure

Fetal Heart Rate Tracing

FHR Variability

• refers to fluctuations in the fetal heart rate around the baseline

• absent variability

  • fluctuations are undetectable

  • caused by fetal hypoxemia, metabolic acidemia, congenital anomaly

• minimal variability

  • change is greater than undetectable but less than or equal to 5 bpm

  • caused by fetal hypoxemia, metabolic acidemia, congenital anomaly, neuro injury, CNS depressants, fetus in a sleep state

• moderate variability

  • normal change of 6-25 bpm, shows healthy nervous system

• marked variability

  • change is greater than 25 bpm

Accelerations

• temporary increases in the FHR, usually a sign of a healthy baby

• defined as 10 bpm for 10 seconds if less than 32 weeks, 15 bpm for 15 seconds if greater than or equal to 32 weeks

Decelerations

• temporary decrease in FHR and are categorized by their shape, timing, and relationship to contractions

• variable decelerations

  • abrupt decrease in FHR that can occur at any time

  • caused by cord compression

  • visually abrupt (onset to lowest point less than 30 seconds) decrease in FHR by 15 bpm+ and lasts at least 15 seconds

  • returns to baseline in less than 2 minutes

• early decelerations

  • gradual decrease in FHR that mirror contractions

  • caused by fetal head compression

  • begin and end with the contraction, and onset to the lowest point is greater than or equal to 30 seconds.

• late decelerations

  • gradual decreases in FHR that begin after contraction starts and don't return to baseline until after contraction ends

  • caused by placental insufficiency. 

• prolonged decelerations

  • decrease in FHR of at least 15 bpm below the baseline, lasting more than 2 minutes but less than 10 minutes

Category

Category 1 (Normal)

• baseline rate of 110-160 bpm

• moderate baseline variability

• no late or variable decelerations

• early decelerations and accelerations may be present or absent

• indicates a well-oxygenated fetus

Category 3 (Abnormal):

• absent baseline FHR variability AND any of the following

  • recurrent late decelerations

  • recurrent variable decelerations

  • bradycardia,

  • sinusoidal pattern.

  • Indicates a poorly oxygenated fetus.

Category 2 (Indeterminate):

Any FHR pattern that does not fit into Category 1 or 3:

• moderate variability with recurrent late or variable decelerations

• minimal variability with recurrent variable decelerations

• absent variability without recurrent decelerations

• bradycardia with moderate variability 

• prolonged decelerations

• tachycardia

• indicates fetus that is showing compensatory responses to lack of oxygen

• periodic change=associated with ctx

• episodic change=not associated with ctx

Obstetrical Procedures

Induction of labor

• equipment

  • IV oxytocin

  • amniotomy

• indications

  • continuing pregnancy poses risk to mother/fetus

  • maternal DM

  • postterm pregnancy

  • HTN complications

  • IUGR

  • chorioamnionitis

  • PROM

• before induction begins:

  • assess cervix with bishop score, uterine activity, fetal size/presentation

  • determine gestational age

  • evaluate maternal/fetal wellbeing

• contraindications

Episiotomy

Vacuum extraction

Forceps delivery

Cesarean section

Contraindications

• active maternal infection (herpes for vaginal birth)

• fetal distress

• risk of uterine rupture

Intimate Parter Violence

• physical, emotional, sexual, and financial abuse during pregnancy

• signs

  • unexplained injuries

• interventions

  • support services

• effects on pregnancy

  • PTB

  • LBW

  • placental abruption

Transition to Parenthood

Common issues that couples face as they become parents include: 

• Changes in their relationship with one another

• Sexual intimacy

• Division of household and infant care responsibilities

• Financial concerns

• Balancing work and parental responsibilities

• Social activities

Nursing interventions

• encourage partners during pregnancy and in the postpartum period to share personal expectations and assess their relationship

  • prioritize one-on-one conversations, schedule time apart from the infant, and express appreciation for each other and the child

  • identify and utilize support from close relationships, healthcare team

  • explore new approaches to lifestyle and habits that may ease the transition to parenthood

Bonding and attachment

• encourage skin to skin contact

• breastfeeding

• assign meaning to infant’s actions

• talk, coo, sing to infant

• play peek-a-boo