Definition: Result from one fertilized egg splitting into two.
Genetic Makeup: Identical; can only be two boys or two girls.
Twin A vs Twin B:
Twin A: Closer to cervical opening.
Twin B: Furthest from cervical opening.
Fraternal Twins:
Combination: Can be two boys, two girls, or one of each.
Genetic Makeup: Different.
Multiple Gestation Risks
Increased Risk: Preterm delivery.
Therapeutic Management:
Approaches: Serial ultrasounds, close monitoring during labor, operative delivery.
Nursing Assessment:
Signs: Uterus larger than expected for estimated due date (EDB); confirmed via ultrasound.
Nursing Management:
Focus: Education & support antepartally; manage labor with perinatal team on standby; assess postpartum for hemorrhage risk.
Patient Management:
Bedrest admission may occur.
Vaginal delivery for one twin; C-section for others if needed.
Emergency C-section if both twins are in distress.
Monitoring Parameters:
Vital signs, signs of bleeding, skin color evaluation (for paleness), nausea, vomiting, dizziness.
Blood type collected.
Complications of Pregnancy
Premature Rupture of Membranes (PROM)
PROM:
Definition: Membranes rupture in women at 37 weeks or beyond.
PPROM:
Definition: Membranes rupture in women less than 37 weeks.
Treatment:
Dependent on gestational age.
Avoid unsterile digital cervical exams until active labor.
Expectant management if fetal lungs are immature.
Assessment Points:
Risk factors, signs and symptoms of labor, electronic fetal heart rate (FHR) monitoring, amniotic fluid characteristics.
Nitrazine Test:
Process: Testing vaginal fluid pH using test strips.
Interpretation: Blue indicates alkaline, suggesting membranes are ruptured.
Fern Test:
Process: Vaginal fluid placed on a slide under a microscope; will look like fern leaves if indicative of rupture.
Ultrasound:
Note: No sterile vaginal exams until labor starts.
Amniotic Fluid Characteristics:
Normal: Clear/yellowish.
Abnormal: Any color other than clear may indicate meconium-stained fluid.
Action Required: Respiratory standby due to potential risks involved.
Risks Associated with PROM:
Loss of protective seal leads to:
Risk for Infection
Risk for Cord Compression
Risk for Cord Prolapse
Emergency Protocol:
If cord felt during sterile vaginal exam (SVE) or visualized, initiate code for emergency C-section.
Management for PROM
Prevention of Infection.
Identify uterine contractions.
Discharging home with PPROM if no labor after 48 hours.
Group Beta Streptococcus (GBS)
Primary Cause of Neonatal Morbidity:
Not sexually transmitted.
Potential for neonatal sepsis risk if maternal tests positive.
Management for positive GBS:
Monitor maternal temperature.
Administer antibiotics (e.g., Penicillin or Ampicillin) during labor.
C-section Protocol: If the patient has a C-section, treatment may not be necessary.
Chlamydia
Association with PROM:
Risk of endometritis:
Symptoms: Inflammation of the uterine lining causing fever, lower abdominal pain, and abnormal vaginal bleeding (common postpartum).
Other Infections in Newborns
Conjunctivitis (in newborns):
Treatment: Zithromax or Amoxicillin.
Herpes:
Protocol: If client has active lesions, C-section is permitted.
Preventative Measure: Acyclovir is prescribed to prevent active lesions during delivery.
Adolescent Pregnancy Risks
Prevalence:
Higher incidence among Hispanic and African American teens.
Conditions of Concern:
Pre-eclampsia.
Iron Deficiency Anemia.
Preterm Labor.
Cephalopelvic Disproportion (CPD): Sometimes leads to C-section.
Education for Adolescents
Focus Areas:
Sexual education.
Oral contraceptive education.
Nutrition: Encourage five servings of fruits and vegetables daily.
Encourage early prenatal care and access to resources.
Support finishing high school.
Advanced Maternal Age (AMA)
Description:
Refers to pregnancies in women over 35.
Associated Risks:
Thromboembolic Problems (increased clotting).
Higher rates of fetal and neonatal mortality.
Risk of postpartum hemorrhage related to uterine atony.
Placental Issues
Placental Abruption
Definition:
Premature separation of the placenta from the uterine wall before birth.
Causes:
Hypertension, trauma, substance abuse.
Assessment Findings:
Abdomen Signs: Feels “board-like.”
Dark red vaginal bleeding.
Treatment Strategy:
Continuous FHR monitoring, vital signs assessment for hypovolemic shock, side lying positioning, oxygen administration, emergency C-section.
Placenta Previa
Definition:
Condition where the placenta abnormally implants in the lower segment of the uterus, near or over the cervical opening.
Causes:
Smoking, drug use, uterine scarring.
Assessment Findings:
Painless bright red bleeding; non-tender uterus.
Treatment Guidelines:
Avoid vaginal examinations, replace IV fluids, monitor bleeding, and no sexual intercourse.
Vasa Previa
Definition:
Risk of fetal blood loss due to velamentous insertion where the cord attaches to the membranes, leaving it unprotected.
Prevalence:
More common in multiple pregnancies.
Iron Deficiency Anemia
Description:
Common complication, associated with low birth weight.
PICA:
Craving for non-nutritive substances.
Iron Supplements
Possible Side Effects:
Cause constipation and dark stool.
Duration for replenishment:
Takes 4 months for iron levels to normalize.
Lab Tests Needed:
Hemoglobin & Hematocrit.
Sickle Cell Anemia
Description:
A recessively inherited hemolytic disease.
Monitoring Needs:
Monitor for intrauterine growth restriction (IUGR) and assess frequently for urinary tract infections (UTIs).
Emergency Response:
Sickle cell crisis can occur; ensure hydration and oxygenation.
Hyperemesis Gravidarum
Definition:
Severe form of nausea and vomiting in pregnancy; usually resolves by week 20.
Goals:
Limit weight loss to less than 5% of pre-pregnancy body weight.
Causes:
Can lead to dehydration, metabolic acidosis, alkalosis, and hypokalemia.
Assessment Needs:
Onset, duration, and characteristics of nausea/vomiting; monitor liver enzymes, CBC, BUN, electrolytes, and urine specific gravity.
Ultrasound:
Assess amniotic fluid levels.
Therapeutic Management
Involves:
Hospitalization, total parenteral nutrition (TPN).
Cardiac Disease in Pregnancy
Prenatal Management
Practice Guidelines:
Establish baseline status, and assess for changes frequently.
Emphasize rest and adequate nutrition.
Adjust cardiac medications as necessary, including anticoagulant therapy.
Infection control measures during labor and delivery.
Monitoring During Labor:
Monitor IV fluids; use Pitocin cautiously.
Postpartum Management:
Weekly weight monitoring, assess for hemorrhage, and apply antibiotic prophylaxis as needed.
Blood Incompatibility Conditions
ABO Incompatibility:
Type O mothers and fetuses with type A, B, or AB.
Less severe than Rh incompatibility.
Rh Incompatibility:
Overview: Exposure of an Rh-negative mother to Rh-positive fetal blood; sensitization causes antibody production, increasing risk with each subsequent pregnancy.
Fetus with Rh-positive blood is at risk.
Assessment Needs:
Determine maternal blood type and Rh status.
Management:
Administer RhoGAM for Rh-negative patients at 28 weeks; also with miscarriage or abortion to prevent Rh-negative patients from developing antibodies, which may lead to stillbirth or anemia.
Amniotic Fluid Conditions
Polyhydramnios
Definition:
Amniotic fluid volume greater than 2000 mL.
Management Approach: Close monitoring; fluid removal; indomethacin can decrease fetal urine output.
Assessment Needs: Risk factors, larger than normal fundal height, abdominal discomfort, fetal heart rate (FHR) evaluation, and gastrointestinal malformations expected.
Oligohydramnios
Definition:
Amniotic fluid volume less than 500 mL.
Management Strategy: Serial monitoring; amnioinfusion and potential birth for fetal compromise. Assessment: Ensure fetal well-being remains reactive.
If seizures occur: Administer Ativan; magnesium sulfate given at a rate of 4-6g/hour.
HELLP Syndrome
Description:
Hemolysis (breakdown of red blood cells), Elevated Liver enzymes, Low platelets; leads to several symptoms including headaches, bleeding (nose/mouth), petechiae, confusion, and hypotension.
Diabetes During Pregnancy
Pre-Gestational Diabetes
Symptoms by Trimester:
Early Pregnancy: Decreased insulin needs due to increased insulin production.
Post-First Trimester: Increased insulin needs due to placental hormones blocking insulin.
Post-Birth: Decreased insulin needs following loss of insulin-blocking hormones.
Gestational Diabetes
Associated Risks:
Increases chance of developing type II diabetes later; linked to obesity, age >25, and history of large babies (>10 lbs).
Screening Guidelines:
Low-risk patients screened at 28 weeks; high-risk patients at 25 weeks.
No clear first-line tocolytic drugs; methods to prolong pregnancy typically range from 2 to 7 days for corticosteroid administration.
Corticosteroids (Betamethasone): Lower respiratory distress between 24-35 weeks gestation; magnesium sulfate can aid in delaying contractions pre-34 weeks.
IV Fluid Administration: Promote hydration, may also utilize tocolytics such as SQ Terbutaline or PO Indomethacin.
Assessment Needs for Pre-Term Labor
Normalization of Mucus Plug Loss: Late pregnancy.
Bloody Show Evaluations: Considered normal if present as labor progresses but must be evaluated if occurring preterm.
Precipitous Labor:
Definition: Completion of labor in <3 hours, lies risks of: premature separation of placental tissue, increased laceration risk, and potential development of amniotic fluid embolism, subdural hematoma in the infant.
Postterm Labor
Description:
Continues beyond 42 weeks' gestation.
Maternal Risks Include:
Risk of cesarean birth, dystocia (difficult labor), birth trauma postpartum hemorrhage, and infection.
Sudden fetal bradycardia; may also present as a tearing pain.
Management:
Preparation for urgent cesarean delivery, vigilant maternal and fetal monitoring, and intravenous fluid administration.
Labor Induction and Augmentation
Induction:
Stimulating contractions through medical or surgical means.
Augmentation:
Enhancing ineffective contractions after labor has begun.
Labor Induction Therapeutic Management
Methods Include:
Use of herbal agents, castor oil, hot baths, enemas, sexual intercourse (with breast stimulation).
Medications:
Oxytocin administration; cervical ripening agents such as Dinoprostone (Cervidil), Cytotec.
Amniotomy: Rupturing membranes artificially by provider.
Bishop Score
Function:
Helps evaluate cervical readiness for induction or augmentation.
Contraindications for Induction or Augmentation
Previous classical incision, placenta previa, grand multiparity, over-distended uterus, active genital herpes, severe fetal distress, and fetal malposition (breech/transverse).
Amnioinfusion Indications
Use Cases:
Severe variable decelerations due to cord compression, oligohydramnios due to placental insufficiency, post-maturity, or ruptured membranes.
Cesarean Section Considerations
Risk Overview:
Higher risks to both mother and infant, longer recovery times, risk for preterm births.
Types of Uterine Incisions:
Transverse: Generally easier on the maternal body.
Classical (Vertical): Faster access during emergencies; however, carries risks for future pregnancies.
Post-Operative Interventions:
Fundal checks every 15 minutes, pain management, incision site inspections, assist with mobility, aiding in voiding, and preventing constipation.
Controversies in Vaginal Birth After Cesarean (VBAC):
Intricate relationships between uterine rupture and hemorrhage risks.
Contraindications include a previous classical incision, uterine surgery history, instances of placental abruption/rupture, twin/triplet pregnancies.
Shoulder Dystocia Management
Definition:
Anterior shoulder impacted above the pelvic brim, although anticipated in patients with:
Maternal diabetes,
History of macrosomia,
Maternal obesity, or large fetal size.
Observational Indicators:
Slow delivery of the infant's head, absence of spontaneous restitution, head recoiling against the perineum post-delivery.
Intervention Strategies:
McRoberts Maneuver: Pull knees toward the chest, apply suprapubic pressure, perform gentle traction on the head.
Appropriate Equipment Availability in Emergencies
Necessary resources may include:
Episiotomy instruments,
Urethral catheterization tools,
Infant resuscitation materials.
External Versions
Procedure:
A medical technique to change baby’s position from breech to vertex, follows prescribed provider protocols before 37 weeks.
Close monitoring via electronic fetal monitoring pre-and post-procedure to evaluate fetal well-being.
Common Occurrences: Most occur in the first trimester.
Assessment Indicators:
Vaginal spotting/bleeding often acts as the first sign, followed by lower abdominal pain.
Absence of fetal heart sounds can indicate termination; ultrasound is essential for confirmation.
Ectopic Pregnancies
Risk Factors Include:
Prior ectopic pregnancy,
Fallopian tube surgery,
Previous pelvic or abdominal surgery,
Certain STIs,
Pelvic inflammatory disease,
Endometriosis.
Treatment Protocols:
Methotrexate administration in 2 doses to stop cellular growth; pregnancy is absorbed by the body within 4-6 weeks.
Ensure hydration by consuming 2-3 liters of water daily to counteract kidney crystals.
Warning Signs:
Missed period, vaginal bleeding, unilateral lower abdominal pain, cramping, shoulder tip pain (due to bleeding).
Recuperation Plan:
Suggest waiting 3 months before attempting conception; Methotrexate for prior risks of birth defects.
Pre-Term Newborn Characteristics
Gestation Period: Less than 37 weeks.
Risk Factors: Infections, maternal or fetal distress, bleeding.
Newborn Characteristics:
Weight assessment and vitality, neurological status, skin condition, lanugo presence (indicative of maturity).
Post-Term Newborn Characteristics
Gestation Period: Beyond 42 weeks.
Management Needs:
Non-stress tests (NSTs), biophysical profile (BPP), and often labor induction.
Risks Associated: Meconium aspiration, hypoglycemia, temperature instability.
Physical Signs: Dry skin, creased soles, alertness, excessively long nails, common presence of meconium.
Meconium Aspiration Syndrome
Description: Occurs when baby inhales meconium at delivery, with particles leading to obesity in alveoli hindering oxygen intake.
Interventions Required:
Chest X-ray, selective suctioning, oxygen support, NICU admission for 10-14 days.
Infants Born to Hepatitis B Positive Mothers
Post-Exposure Prophylaxis:
Hep B immunoglobulin required within 12 hours of birth and Hep B vaccination to stimulate individual immune defense.
Hyperbilirubinemia
Defined As: Excess bilirubin in newborn blood, resulting from various conditions.
**Types:
Pathological Jaundice:** Within 24 hours postnatal; linked to blood incompatibilities.
Physiological Jaundice: After 24 hours natural processes; prevalent risk among breastfed infants.
Treatment Protocols:
Formula feeding enhancements if breastfeeding to encourage fluid expulsion and stooling.
Risk Range: Checking serum bilirubin levels for safety; above 10mg/dL is critical, with potential for bilirubin encephalopathy leading to kernicterus if untreated.
Therapeutic Actions:
Employ phototherapy for affected infants; cover eyes; administer IV immunoglobulin if needed.
Fetal Alcohol Syndrome
Definition: Range of physical, behavioral, and cognitive impairments due to prenatal alcohol exposure, with no cure for brain damage.
Assessment Indicators:
Poor sucking reflex at birth, low birth weights and small head sizes.
Neonatal Abstinence Syndrome
Definition: Newborns exposed to opioids, antidepressants, benzos, or barbiturates; characterized by tremors, seizures, overactive reflexes, poor feeding, excessive screaming, fever, perspiration, and respiratory distress (tachypnea).
Treatment Strategies: IV hydration, administration of IV morphine, swaddling practices, frequent feeding, and reducing stimuli in the environment to promote calmness.
Gastrointestinal Conditions
Gastroschisis
Definition: Birth defect creating an abdominal wall hole, allowing external exposure of intestines, liver, or stomach.
Key Interventions: Initiate NPO status, insert NG tube, administer IV hydration, and broad-spectrum antibiotics, while monitoring for perforation or septic conditions.