ATI OB/GYN practice A/B
Pregnancy
Progesterone maintains lining of uterus + reduces uterine contrability and makes it more relaxed
→ if low = preterm labor risk
→ GI relaxant → heartburn + constipation
Human placental lactogen = glucose metabolism and lactogenesis + insulin resistance → gestational DM
Estrogen stimulates uterine growth and memory gland development + inc vascularity + connective tissue growth
relaxin = loosens ligaments → make pelvic joint more flexible
human chrorionic somatomammotropin (HCS) = stim maternal metabolism + lactation development of breast
when 18-20w = fetal movement felt
1st and 3rd semester → pressure on bladder
backaches → pelvic exercise, exercise, rest, sleep on firm mattress, abdominal muscle contractions
weight gain 25-35 lb
US
if under 12w = have full bladder since uterus is still a pelvic organ
measure cervical length = 2-3rd semester
Danger signs during pregnancy:
1st trimester:
Infection = urination burning, diarrhea, fever
Hyperemesis gravidarum = severe vomiting
Miscarriage / ectopic = vaginal bleed, abd cramp
2nd/ 3rd trimester:
Infection: fever, dysuria
Gestational HTN: severe h/a, blurred vision, epigastric pain, face / hand edema
Hyperglycemia: dry skin, fruity breath, High RR, polydipsia / polyuria, h/a
Hypoglycemia: clammy pale skin, weakness, tremors, irritability, light head
Changes in fetal activity
Abd pain= premature, placenta abruption,
Bleeding= placenta problem
Gush of fluid < 37 weeks
Very preterm: <32w
Moderately preterm: 32-34w
Late preterm: 34-36w
infections:
malaria from mosquitos
toxoplasmosis = cat feces, garden areans
Hyperemesis Gravidum
S/s:
Excessive vomiting
Dehydration w/ E/I, poor skin turgor / dry mucus membranes
Weight loss, High HR, low BP
Check u/a for ketones and acetones, chemistry profile, thyroid test (hyperthyroidism), CBC
Tx: IV LR, pyridoxine (B6), antiemetic (metoclopramide for uncontrolling n/v, corticosteroids for refractory hyperemesis gravidarum
Small meals, clear liquids → bland foods dried toast/ crackers/ baked chicken → normal
eat dry foods before rising, eat foods at cold temp
low fluid when meals to prevent overdistention
avoid brushing teeth immediately after meals
accupuncture: band on wrist
DVT
Pregnancy increases risk → C/S x2
S/s:
Unilateral swelling, warmth, redness
Hardened vein over thrombos
Calf tenderness
Doppler, CT, MRI for dx
tx:
Avoid Crossing legs, 2-3L
If has DVT = bed rest + elevation of extremity above heart (no pillow under knee)
NO warm moist compress, massaging
Measure leg circumference, thigh high compression stocking
Analgesics, anticoagulants (heparin, Warfarin)
intrahepatic cholestasos
→ prurius ’ that is worse at night
order LFT
molar pregnancy
can → ~ choriocarcinoma
s/s:
dark prune juice bleed
grape-like clusters
higher than expected fundal height
cramping + n/v
avoid pregnancy for 1yr and hCG should be obtain q4w for next 6-12m
D&C removal
cause HTN but after removal comes to baseline
Nutrition
340 calories/ day = 2nd trimester
452 calories/ day = 3rd trimester
450 to 500 calories/ day = breastfeed
total gain = 11.5—16 kg (25 to 35 lb).
in 1st trimester 0.9 to 1.8 kg (2 to 4 lb) → 0.5 kg (1 lb) per week
<18.5 = 28-40lb
25-29.9 = 15-45lb
>30 = 11-20lb
Folic acid for neurodevelopment 400/ 600 mcg =from folate
Leafy greens, dry legumes, orange juice, fortified
NO swordfsh, shark, king mackerel
Iron supplements: given w/ vitamin C. NO milk or caffeine; use stool softener
Calcium: for bone and teeth formation milk, fortified Foods, legumes, dark green leafy (1,000 mg/ day for pregnant 19-50y ; 1,300 mg/day <19y)
2.3 fluid, limit caffeine( < 300 mg; if more = infertility, spontaneous abortion, IUGR), NO alcohol
Vegans need more protein, calcium, iron, zinc, B12
newborns lose 7-10% of weight
lactation = weight loss 1kg
non lactating 0.5-0.9kg
gestational DM diet: 55% COH, 20% protein, 25% fat + <10% saturated fat
inc risk of cardimyopathy
breastfeed
mother needs more vit C
same Ca, vit D requirements
decrease iron
introduce artifical nipple 3-4w
15-20mins on each breast
offer pacifier until newborn is feeding well ~ 3-4w
breastmilk storage:
should be stored in the back/ middle of fridge
defrosted in refrigerator or under warm running water → cannot be refrozen
no microwaving/ boiling breastmilk
for sore breast → apply small amount of milk in nipple to air dry
to decrease mastitis:
galactagogue inc milk supply but if newborn does not empty = inc risk
do not wait long between feeds
no wearing a underwire bra
use finger to release suction after feeding
position
clutch/ football hold: baby under arm, more for c/s
across the lap: for smaller bbys
cross-cradle: small bbys
sidelying for perianal hematoma
formula
run tap water for 2 mins and boil for 1-2 mins
keep unused prepared formula for 48hrs
bottles, nipple rings, caps must be boiled for 5 mins on 1st use and after each use if not dishwasher
1 scoop : 2 ox of water
if not breastfeed = 15 ice → 45 min off
cow’s milk based formula are good
amino acid formulas for protein intolerance
soy is if they have intolerance
Fetal Well being/ Prenatal care
NST: ~ 20-30min
used x2 per week starting 28-32w w/ pt w/ DM + check intact fetal CNS during 3rd trimester
press button whenever they feel contraction
no movement → vibroacoustic stim for 3 sec
test is 20-30min
reactive = accelerates for 15bpm / min for 15 sec (or 10×10) w/ 2times <in 20 min period
BPP = non-stress + ultrasound
FHR (non-stress) = reactive 2/ non-reactive 0
Fetal breathing movement: at least one episode >30 sec in 30 minutes 2
Gross body movement: 3 flexions in 30 min 2
Fetal tone: 1 flexion and extension 2
AFI = 1 fluid pocket >2cm in 2 perpendicular planes
8-10 = normal
Aminocentesis >14w
AFP in 15-20w for neural tube defects, chromosome, lung maturity = high is w/ newer tube, low is w/ chromosome
Empty bladder before procedure, obtain Baseline vital signs for fetus and mother
Do not hold breath since it will lower diaphragm and shift intrauterine content
Post procedure= FHR, Rh (-)
Report to HCP if fever, fluid leakage / bleeding, decreased fetal movement, uterine contractions
kick count:
HS, or after meals for 2 hrs or until 10 movement at least for once a day for at least 60 mins
count in a 12hour period
labs:
rubella titer, blood type + RH, = 1st visit
1hr glucose tolerance test = 24-28w
Group B step = 35-37w
external cephalic version:
monitor FHR continuously + 60 mins after procedure
receive tocolytic for uterus to relax
in hospital in case of emergency
fetal development
fetal HR
10 w w/ doppler
16 weeks w/ fetoscope
gender by 12 w
preterm == lanugo
39 w = symmetric rib cage, good skin turgor + fat
42w < dry,cracked skin w/ wrinkled appereance
Labor
Preceding labor science
Dull back pain
0.5-1.5kg weight loss
Lightning: fetal head descends into true pelvis about 14 days before Labor → fetus dropped so easier breathing but more pressure on bladder = increased urinary frequency
Irregular contractions to regular contractions
Increase vaginal discharge or bloody show/ mucus plug
Energy burst " nesting"
GI = n/v, indigestion
Cervix become soft and partially effaced
Rupture of membranes ~ occur 24 hours labor
Prolonged rupture>24hr ~ infection
After rupture, assess FHR for decelerations
Assess fluid: not follow, 700-1000mL, use nitrazine paper for Deep Blue
bishop score
determine readiness for labor
cervical dilation, effacement, consistancy, position, station
each have a value of 3 for 5 factors
below 8 is not favorable = dinisprostone, cervical ripening agent
amniotomy
Artificial rupture of amniotic membranes( AROM) → decreased duration of labor to 2 hours
Increased risk for cord prolapse or infection
Either too slow of a labor or need amnioinfusion
Monitor FHR immediately after rupture, assess and document characteristics of amniotic fluid
Obtain temperature q2hr
epidural
Epidural block: local anesthetic, bupivacain, w/ analgesic ) morphine / Fentanyl) eliminates pain but but does not release pressure
ADR: maternal hypotension, low FHR, fever, itching, inability to feel void / urinary retention, loss of bearing down reflex
Administer IV bolus for maternal HTN, SCD, assess bladder distention, monitor for return of sensation and motor control in legs after delivery but prior to standing
500-1000mL bolus NS or LR for 15-30min prior to doing epidural
assess FHR 20-30min before
spine has to be flexed
monitor VS q5-10 min after administration
Leopold maneuver:
external palpation to check →
→ presenting part, fetal lie / attitude / descent / fetal heart tone
Empty bladder before assessment → supine w/ pillow on their head and both knees flexed + small rolled towel and right or left hip
stand on pt right side if right handed
palpate head w/ finger tips
1st fundus:
Head should feel round, firm, move freely; breach feels irregular and soft
Smooth counter of a fetal back and irregular = hand feet and elbow
Inlet by grasping lower segment of uterus between thumb and fingers + determine if head is flex or extended
Palpate cephalic prominence = if same side as back = extended if on same side as small parts = flexed
fetal positions
mentum position = head fully extended + present w/ chin
OP position → squat during contractions to rotate head
occipital brow = inc diameter → prolongued labor + forceps or vaccum assisted birth, or c/s
intermittent auscultation
check baseline 30-60 sec, placed on fetus back,
palpate maternal pulse and fetal heart rate at the same time to distiguish sounds
variable decels
side lying and knee to cest
amniofusion to decrease cord compression
if breech or shoulder = cord prolapse
long cord, polyhydramnios, small fetus, unengaged presenting part
c/s
Position the client in a supine position with a wedge under one hip to prevent compression of the vena cava.
amniotic fluid
polyhydramnios = more likely to have GI or neurological disorders
oligohydramnios = dec gestational HTN, renal agenesis
interventions
for 1st stage = relaxation/ deep breaths
active labor = hydrotherapy + positioning
biofeedback is useful only if introduced during prenatal
non pharm methods:
sensory-stimulation: gate control theory
aromatherapy
breathing techniques
imagery, musci
subdued lighting
cognitive strategies:
childbirth education, preparation methods
doulas
check for hyperventilation → tingling of fingers => paper bag
hypnosis
biofeedback
cutaneous stim:
massage, effleurage (light, gently circular strokes in abd)
sacral conterpressure
walking, rocking
TENS
hydrotherapy
acupressure
maternal position change
lamaze method: stim response condition → controlled breathing to reduce pain during labor
dick-read: reducing fear → education before labor
Bradly/ partner-coached = dissociate by using internal focal point in premises pregnancy and childbirth is joyful and natural
psychosexual: conscious relaxation + levels of progressive breathing
nitrous oxide: since inhalation ~1min
does not affect newborn
relaxation and dec perception of pain
therapeutic rest when hypertonic uterine dysfunction → hydrotherapy or analgesia
hypertonic dysfunction occurs more in latent
distended bladder assessment:
uterous displaced to right + above umbilicous
sounds dull w/ percussion
bladder fluctuates w/ palpation
Placenta problem
Placenta previa
= placenta implanted in lower segment of uterus
Complete or total= os completely covered
Incomplete/partial
Marginal: does not reach os
Low-lying: not determined yet
Risk:
Previous placenta previa, uterine scarring (c/s, curettage, endometriosis), multiple gestations, smoking
S/s:
Painless, bright red vaginal bleeding in 2nd / 3rd trimester,
Uterus soft, relaxed, non tender
Fetus and breech, oblique, or transverse
Decrease urinary output due to blood loss
Check by trans abd or transvaginal US + fetal monitoring
Tx: assessment fundal height, prevent vaginal exams,
Corticosteroids( betamethasone) increase lung maturity, O2 present in case of fetal distress
Do not insert anything into vagina since it can worsen bleeding
preeclampsia
has uric acid, but HELLP syndrome doesnt
fibroid
inc risk of postpartum hemorrhge
are likely to grow during pregnancy
undergo multiple US
if not located near the os → she can have vaginal delivery
Post partum care
risk for uterine retention
hemorrhage post partum
Massage the fundus:
ask to lay on back w/ knees flexed
place hand above symphysis pubis
the other on to[ of fundus
rotate upper hand to massage uterus
slight downward pressure to compress fundus
Measure fingerbeaths for fundus
Administer oxytocin
Insert indwelling catheter = to monitor urine output and perfusion to the kidney
Place client in the lateral position w/ legs elevated 30°
Oxygen 10 L/,in non-rebreather face mask
perineum care
cold sitz bath/ or ice packs for 24hrs → warm
sit on firm surface:
no donut pillows or soft pillows since they separate buttocks → low venous flow
Newborn
Vital signs:
30-60 rpm + <15sec of apnea ;no crackle / wheeze; grunting and nasal flaring = distress
110-160 bpm = found on 4th / 5th Intercultural space at the left mid clavicle line
BP = 60-80/40-50
Temperature= 36.5-37.5
head circumferance = 32-36.8 → measure head just above eyebrows
chest < head + 2cm ( measure at nipple line)
weight = 2500-4000
BG > 45
platelet: 150-300k
total bilirubin 2-6
hgb = 14-24
Bulb suction: mouth → nose
pink tinged urine is normal due to uric acid crystals
min of 1 wet diaper per day of age
meconium within 1st 12-48 hr
switch breasts based on clues not time
Epstein pearls are white nodules on gums
Scores
Ballard score= neuromuscular and physical maturity
preterm newborn
Respiratory distress syndrome → low surfactant
Bronchopulmonary dysplasia (BPD) = lungs become stiff and non-compliant → mechanical ventilation + oxygen; it is also caused by mechanical ventilation
Aspiration: not having intact gag reflex or ability to effectively sucker and swallow
Apnea of prematurity
retinopathy = abnormal growth of retinal blood vessels + ~ 02 Administration
Patent ductus arteriosus
Necrotizing enterocolitis = inflammatory GI mucosa due to ischemia → necrosis and perforation of bowel
Shortgut syndrome → remove most part of small intestinal to necrosis
more likely to have intraventricular hemorrhage
mom most likely has preterm labor when low progesterone
if NICU
reduce ambient noise + lighting= lighting dimmed at night, blankets kept over incubators during incubator
w/ swaddling = promote self-regulation and lowers stim → flexed position promotes body alignment
place pt prone + side-lying = promote flexion
cluster care to promote sleep
place newborn in parent’s bare chest
no nonnutritive sucking → more energy spent → low O2
Give Mg sulfate, terbutaline for tocolytics
rest, nifidipine: CCB
if preterm spontaneous = anticipate 7 day course
Persistent low backache
regular contractions q10min, lasting 1hr
Hyperbilirubinemia in Newborn
Physiological jaundice: due to liver immaturity = shown 72 to 120 hours after birth → declines 5 to 10 days after birth
Pathologic jaundice: secondary of blood group incompatibility, infection, RBC disorder, hepatospleenomegaly
Acute bilirubin encephalopathy = when bilirubin deposit in brain = neural necrosis w/>25 deliver → dystonia,athetosis, upward gaze, hearing loss, cognitive impairment
kernicterus = irreversible and chronic w/ ~ s/s bilirubin encephalopathy w/ hypotonia, severe cognitive impairment, spastic quadriplegia
Risk factor:
Blood incompatibility, RBC breakdown
Maternal DM/infection, ingestion of Diazepam, salicylates, sulfonamines, oxytocin during labor, neonatal hyperthyroidism, cephalo hematomas, premature
Check bilirubin q4hr, ABO (Coombs test), Hgb Hct
Tx:
phototherapy
eye mask over eyes, keep newborn undressed (Place surgical mask over genitalia for males)
No lotion since heat absorption can cause Burns
Every 4 hours remove or VS , and reposition newborn every 2 hours to expose all body surfaces
Check lamp energy w/ photometer, and turn off photo meter before drawing blood
Effects = bronze, macular popular skin rash (okay)
Dehydration, high temperature, pressure ulcers
Encourage feeding to remove bilirubin from stool + explain that stool will be green
neonatal substance withdrawal
Long-term complications:
Feeling problems, CNS dysfunction(cerebral palsy / cognitive impairment), ADHD, difficult language, microcephaly, delayed growth, poor bonding
S/s:
CNS =shrill/ high pitch cry, tremors, moro reflex, inc DTR/ muscle tone,
Respiratory: nasal congestion w/ flaring, yawning, skinmottling, retractions, apnea, RR>60min, temp> 37.2C
GI: poor feeding, projectile vomit, diarrhea, and uncoordinated and constant sucking
Avoid eye contact bc it can overstimulate them
birth trauma/ injury
Risk:
<16 / >35y
Macrosomnia, prolonged / perceptual labor, oligohydramnios, , cephalopelvic distortion , multi-fetal gestation, / operative vaginal birth
s/s;
irritability / seizures within 72 hours and low LOC = subarachnoid hemorrhage
Facial paralysis = facial flattening and unresponsive to grimace w/ crying + eyes opened
Weak / hoarse cry = laryngeal nerve palsy from excessive traction of neck
Fluid muscle tone = joint dislocations or nerve plexus injury / long bone fractures
Limited rom/crepitus overclavical or absence of moral reflex = clavicle fracture
Elbow extended w/ facet arm and hand rotated inward + absence of moro reflex ineffective side, sensory loss, intact grass reflex = brachial paralysis
Soft tissue injuries = localized discoloration/petechiae and edema
→ CT scan, x-ray, neuro exam for paralysis of nerves
cephalhematoma:
does NOT cross suture → resolve 2-6w
caput succedaneum:
crosses suture lines → resolves in 3-4 days
hypoglycemia
Due to no maternal supply of glucose
Healthy newborns tolerate the grease and glucose of 30 within 2 hours of birth
If risk of inadequate glycogen stores = closely monitor BG (preterm, small, DM, hypoglycemia s/s, stress at Birth like cold stress, asphyxia)
Interventions when below 40 → if not treated = seizure/neuro injury
S/s:
Poor feeding
Jitter / trimmer, hypothermia
Weak cry, lethargy, flaccid muscle tone
Seizure/coma
Irregular respiration, cyanosis, apnea
tx:
Heel stick BG for all newborns when s/s / risk
Initiate early feelings within 1st hour of life if unstable require IV glucose infusion + skin to skin contact to promote thermal regulation = check temperature in axillary <36.5C (hypothermia )
Monitor q2-3hr for at least 24 hours
shoulder dystonia
McRoberts maneuver → flex legs apart and raise her knees to her abd
Gaskin maneuver → positioning pt on hands and knees to release anterior shoulder of fetus
suprapubic pressure → anterior shoulder of fetus is pushed underneath the symphysis
newborn care
Keep umbilical cord dry until falls off to 10 to 14 days
no antimicrobial since it can cause inc risk of infeciton
No blankets, bumper pads, stuffed toys, to do SIDS → dress and sleeper or sleep sack
Clean newborn's ear w/ wet washcloth; no cotton swabs + sponge bath every other day w/ neutralizing pH soap w/o preservatives
wash and dry hair last to prevent heat loss
water should be 100-104 F / 38-40C
airbag should be disabled
Do not attempt to retract foreskin until 3yrs
circumcision care
no soap until site heals ~ 1week
apply diaper looser,
no diaper wipes on site during change bc of alcohol → use plain warm water
If HIV = receive all routine inactivated vaccines
if want to test for presence = get new born sample (not cord?)
car safety
position car to rear facing until 2yrs
retainer in newborn’s armpits
car seat in 45 angle
shoulder harness in newborn shoulders
swaddle
discontinue swaddling when bby is able to roll over
do not swaddle w/ extended legs
fit 2-3 fingers on chest
Contraceptives
Combine oral contraceptives (COCs) w/ estrogen and progestin = suppress ovulation, thickened cervical mucus, alter uterine decidua and prevent implantation
Helps decrease mense blood, IDA, regulates irregular Cycles, protects against ovarian/ uterine/: cancer
Increase risk of thromboembolism , exacerbates fluid retention conditions (migraine , epilepsy , asthma , heart / kidney )
Estrogen ~ cause nausea , breast tender , fluid retention / progestin ~ increase appetite , depression , fatigue , oily skin / scalp , hirsuitism )
Routine pap smears and breast examinations
Regular Menses should occur during last 7 days
Reports to HCP → chest pain, SOB, leg pain, h/a, Vision change, HTN
If Miss pill take ASAP; if more are missed follow manufacture instruction
If nausea take at bedtime
c/i: smoking, anticonvulsions, systemic antifungals, anti-HIV, antituberculosis
coper intrauterine device does not have continuous hormone release
diaphram:
use spermicide
empty bladder prior use → 6hrs before and after intercourse but no more than 24hr
must fit correctly
replace q2y + refit for 205 weight flunctuation
wash w/ mild soap and water
C/I TSS, cystocele, uterine prolapse, recurrent UTI
cervical cap:
6hr before and after but no more than 48hr
replace q2yrs or after any gynecological surgery, birth, or any major weight fluctuation.
Rx
Metronidazole = antiprotozol/ abx for anaerobic bacteria (C. diff.)
Prophylaxis for surgical procedures, tx of H pylori w/ tetracycline + bismuth ey subsalicylate for peptic
ADR: metallic taste, darkening of urine, CNS( h/a, seizure, neuropathy,, meningitis, encephalopathy)
C/I: not in 1st trimester, + no breastfeed
Methyl prostaglandin = utertonic that will increase contractability of uterus
Never administer in pregnant client
for abortion
methylergonovine = uterotonic w/ ADR of HTN
meperidine = opioid
ADR causes inc HR, n/v, dizzy, AMS
NO isotretinoin cream = for acne → teratogenic
betamethasone:
inc BG in pt → predisposes newborn to low BG
Magnesium sulfate, nifedipine, indomethacin is a tocolytic
ADR (mag) = feeling warmth when infusion
verapamil for maternal + fetal arrhythmias
RhO(D):
at 28weeks, post partum 72hr, mismatched blood transfusion
for pt w/ indirect Coomb’s test between 24-28w
Hep B:
IM within 1-2m, 2 doses
c/i: allergy of baker’s yeast
if gelatin allergy = no MMR
oxytocin:
ADR= fetal asphyxia, water intoxication, low BP, abruptio placentae
start 1mlliunit/ min → inc 30-60 mins by 1-2 mill/unit
Progesterone or any cervical ripening agent should be in side-lying
check for tachysystole
caution w/ glaucoma, asthma, CV, renal disorder
Gyn
Candidiasis: vulver/vaginal itching, painful urination due to itching, painful sex, white discharge like cottage cheese and white patches on vaginal wall
Trichomoniasis: yellow green / frothy vaginal discharge would follow odor, pain during sex and urinating and vagina injury\ strawberry spots on cervix + bleeds easily
Gonorrhea:
Female: pain w/ urinating and Menses and vaginal bleeding between periods ; yellow/green vaginal discharge + easily induced and the cervical bleeding
Male: painful urinating, testicular edema / pain, penal discharge w/ purelent or white
Herpes simplex: (+ RSV, shigella, enteric disease, wound infection, impetigo, scabies, multi-drug resistance)
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