OB midterm Flashcards

Prenatal period: a time of physical and psychologic preparation for birth and parenthood

Duration of pregnancy: gestation

• spans 9 calender months, 10 lunar months.
• 40 weeks or 280 days
• trimesters

• first: weeks 1-13
• second: weeks 14-26
• third: weeks 27-40

• Reduce the rate of fetal and infant deaths
• Reduce the rate of maternal mortality
• Reduce preterm births
• Reduce cesarean births among low risk women

• Hemorrhage—do pre-assessment, have blood ready
• HTN—does not get better until placenta is delivered ie. placenta causes the HTN—try to wait until 37 to 39 weeks to deliver
• Infection

• Accepting the pregnancy
  • uCouvade syndrome: has same symptoms as mom, nausea vomiting...so forth, weight gain
• uDevelopmental tasks experienced by the expectant father
  • uAnnouncement phase- accept to the fact of it
  • uMoratorium phase- adjust tothe realityu
  • uFocusing phase- becoming a good papa, active involvement in prego and being a dad
• uIdentifying with the father role
• uReordering personal relationships
• uEstablishing relationship with the fetus
• uPreparing for birth

uMaternal adaptation

• uAccepting the pregnancy
• uIdentifying with the mother role
• uReordering personal relationships
• uEstablishing relationship with fetus: attachment process of the mother
  • uPhase 1: She accepts the biologic fact of pregnancy
  • uPhase 2: She accepts the growing fetus as distinct from herself
  • uPhase 3: She prepares realistically for the birth and parenting of the child
• uPreparing for childbirth
• Ambivalence is normal, especially in first trimester
• May look into termination or adoption

1. Important components of the initial prenatal visit include detailed and carefully documented findings from the interview, a comprehensive physical examination, and selected laboratory tests.

1. Follow-up visits are shorter than the initial visit and are important for monitoring the health of the mother and fetus and providing anticipatory guidance as needed.

Normal prenatal care = q month until 28 weeks, then q 2 months until 36 weeks, then every week until delivery.

Immunizations: MMR, TdAP (3rd trimester), flu, pneumovax, varicella

C

HOTN and less O2 to baby

• uCultural influences
  • uMany cultural variations are found in prenatal care
  • uCultural barriers to prenatal care: lack of money, lack of transportation, language barriers, modesty
• uEmotional response
• uPhysical activity and rest
• uClothing
• uSexual activity
• uDiet
• uAge differences
• uAdolescents
  • uLess likely than older women to receive adequate prenatal care
• uWomen older than 35 years
• uMultifetal pregnancy
  • uPuts the mother and fetuses at increased risk for adverse outcomes
  • uMultifetal pregnancies are more likely to end in prematurity.
  • uSpontaneous rupture of membranes before term is more common.

• Sex is okay. Lots of bleeding with sex and signs of preterm labor, must adjust.
• Sperm contains PG which can stimulate contractions, so may be advised it post-term

Travel beyond 34 – 35 weeks not condoned by airlines 2/2 risk of contractions from cabin pressure changes

• uExpected maternal and fetal changes
• uNutrition
• uPersonal hygiene
• uPrevention of urinary tract infections
• uKegel exercises
• uPreparation for breastfeeding
• uDental health
• uPhysical activity
• ˜Posture and body mechanics
• ˜Rest and relaxation
• ˜Employment
• ˜Clothing
• ˜Travel
• ˜Medications and herbal preparations
• ˜Immunizations
• uAlcohol, cigarette smoking, caffeine, drugs
• uNormal discomforts
• uRecognizing potential complications
• uRecognizing preterm labor—PROM, non BH contractions, etc, please come in.
• uSexual counseling
  • uUsing the history
  • uCountering misinformation

best at 1-13 weeks

1. A time of physical and psychologic preparation for birth and parenthood

2. Duration of pregnancy:

3.

Spans 9 calendar months, 10 lunar months

40 weeks or 280 days

Trimesters

First: weeks 1-13

Second: weeks 14-26

Third: weeks 27-40

1. Suggested by the patient

- GI: Amenhorrea, nausea, vomiting, morning sickness

- Breast tenderness, need to pee, fatigue

- Quickening- feel the baby move at 16-20 weeks.

2. Probable: by examiner

- Pregnancy Test

- Uterine enlargement

- Braxton Hicks contractions

- Placental souffle

- Ballottement

3. Positive: Attributed to the FETUS

- Ultrasound

- Movement felt by someone else- third trimester

- Fetal heart beat distinct from mom

- Visualization of fetus

1. Take last menstural period

2. Substract 3 calender months

3. Add 7 days

4 This rule was founded by: Naegeles

5. Gold standard is ultrasound

1.

˜Initial visit

• Prenatal interview:
• Reason for seeking care
• Current pregnancy
• Childbearing and female reproductive history
• Health history
• Nutritional history
• History of drug and herbal preparation use
• Family history
• Social, experiential, occupational history

• Prenatal interview (Cont.):
• History or risk of intimate partner violence
• Review of systems:
• Physical examination:
• Laboratory tests
• Urine, cervical, and blood samples
• Screening and diagnostic tests for infectious diseases and metabolic conditions

2. Physical assessment:

• Physical examination—teeth, thyroid, breast, breastfeeding, baby, abdomen size, vulva, vagina, cervix, pap, prenatal labs
• 3. Laboratory tests
  • Urine, cervical, and blood samples
  • Screening and diagnostic tests for infectious diseases and metabolic conditions
  • Blood type, starting crit, hep, HIV, syph, asymptomatic bacteruria can cause preterm labor and ascend into kidney infxn, gonorrhea, chlamydia

˜Follow-up visits

• Interview
• Physical examination
• Fetal assessment
• Gestational age
• Fetal heart tones
• Health status
• Fundal height
• Laboratory/other tests

Gravida: women who is pregnant

Gravity: the pregnancy

Multigravida- women with more than 2 pregnancies

Multipara: women who has completed 2 or more pregnancies

women who has never been pregnant

˜Parity : number of pregnancies in which fetus or fetuses have reached VIABILITY (20 wks), NOT the number of fetuses born

˜Nullipara : woman who has not completed pregnancy with a fetus or fetuses who have reached the stage of fetal viability

˜

Primipara : A woman who has completed one pregnancy with a fetus or fetuses who have reached 20 weeks of gestation

˜

Multipara : A woman who has completed two or more pregnancies to 20 weeks of gestation or more

˜

˜Preterm : a pregnancy that has reached 20 weeks of gestation but ends before completion of 37 weeks of gestation

˜Late preterm : a pregnancy that has reached between 34 weeks 0 days and 36 weeks 6 days of gestation

˜Early term : a pregnancy that has reached between 37 weeks 0 days and 38 weeks 6 days of gestation

˜Full term : a pregnancy that has reached between 39 weeks 0 days and 40 weeks 6 days of gestation

Late term : a pregnancy that has reached between 41 weeks 0 days and 41 weeks 6 days of gestation

˜

˜Post term : a pregnancy that has reached between 42 weeks 0 days and beyond of gestation

2 digit system: G__ P__

G – Gravida

P - Parity

5 digit system: G__ T__ P__ A__ L__

G – Gravida

T – Term birth

P – Preterm birth

A – Abortions and Miscarriages

L – Living children

G- 3

T- 0

P-1

A- 1

L- 1

G- 4

T- 1

P- 0

A- 2

L-1

...

• high levels of estrogen and progesterone stimulate growth in first tri.

• • Due to increased vascularity, dilation of blood vessels, hyperplasia and hypertrophy and decidua.
  • By 7 wk uterus = hen egg, 10=orange, 12= grapefruit.
  • After third month growth due to fetus.
  • 2^nd trimester= uterine shape not pear anymore now globular. Then rises from pelvis to abdominal cavity. Start showing by 14-20 wks
  • Uterus palpated above symphysis pubis 12-14 wk. at umbilicus at 22-24 wk, to xyphoid prcess at term. Then 38-40 wk, fundal height decreases and goes into pelvis (lightening).
  • 6 wk= hegar sign, softening of the uterus and flexibility-press on wall of bladder= have to pee
  • Braxton hicks contractions- false contractions.
  • Uteroplacental blood flow: increases with size increase.
  • More oxygen, uterine soufflé or bruit can be heard.
  • Funic soufle is fetal blood moving through umbilical cord.
  • Fetus changes:ballottment: passive movement of unengaged fetus- moving fetus up and down, bouncing gently and feeling rebound.
  • Quickening-first fetal life recognition movement. 16-20 wks.

• Cervical:
  • softening begins 6 wk.
  • goodell sign = hypertrophy, vascularity, hyperplasia (red).
  • Friability is increased= easily damaged tissue and bleeding.
  • Chadwick sign: blue

• Vagina and vulva:
  • Operculum: mucosa thickens- mucus block to protect from infection. Ph is more acidic. 3.5-6.0. this makes her vulnerable to yeast infections though.
  • connective tissue loosen, smooth muscle hypertrophy and vaginal vault to lengthen. Chadwick sign= more blood flow = bluish vaginal mucosa and cervis.
  • Leukorrhea is white gray mucus and musty odor, white due to excess epithelial cells.
  • Increased sensitivity due to vascularity of vagina. High degree of sexual interest and arousal.
  • Edema and varicosities. External structures are enlarged due to more vascularity.

• fullness, sensitive, tingling, heaviness, pigmented nipples, hypertrophy of sebasious glands, Montgomery tubercles.
• Striae gravidarum.
• Colostrum-yellow fluid secreted during second trimester.

Slight hypertrophy:bigger heart: moves and rotates due to the fetus pushing.
Blood pressure: same, but decreases in third trimester
Blood volume and composition: increases significantly during pregnancy by approximately 30% to 45%
Cardiac output: increases
Circulation and coagulation times
Pregnancy is considered a hypercoagulable state : @ risk for DVT

Pulse: Apical impulse shifts. 20 weeks, audible splitting of s12 and 3. Maternal hr begins increasing at wk 5 but increases by 10-15 by 32 week.

• Pulmonary: ribs move due to estrogen relaxation. Upper resp is more vascular.
• become thoracic breathers

• Renal: renal pelvis and utereters dilate.
• Urine contains more nutrients and sugars= more at risk for urinary tract infection.
• Fetus pushing on bladder=Nocturia, bladder irritated, urinary urgency and frequencey.

malasma: darkened pigmentation- especially in dark skinned people

Linea nigra- from symphimas pubis to top of fundus.

Striae gravadrum. PUPPP: pruritic, uriticaric, plaques and papules of pregnancy. – red marks on ab.

-Musckuloskletal: relaxin hormones +progesterone relaxes bones, ribs are relaxed so you can fit the baby.

Pelvis- relactin makes it loser. Hip pain joint pain, waddleing.

Posture changes- lower back change. Walk straight. Belly band.

Carpel Tunnel

Gastrointestinal system
Appetite- decreased
Mouth- raised red bumps sometimes
Esophagus, stomach, and intestines: decreased GI motility= constipation
Gallbladder and liver- distended gallbladder, decreased muscle tone, increasted emtying and thick bile= can cause gallstones. Liver sometimes retains bile= itching and jaundice sometimes
Abdominal discomfort: Pyrosis (heartburn) (due to LES loosening), Ptyalism (excessive salivation)
Appendicitis can be difficult to diagnose in pregnancy because the appendix is displaced upward and laterally

• If woman is definite about their last menstrual period (ie first day of her last period), then you don’t need to go with a sonogram.
• Best time to date with a sonogram is first trimester, second trimester is a couple weeks off, third trimester is about three weeks off.

• Don’t give induction medicines to women not in labor with a previous scar. Cervical massage is an acceptable alternative along with fetal testing to ensure placenta is still functioning well and baby is okay.
• Cook catheter great way for mechanical dilation for women who can’t get meds due to previous scars.

1. Decreased muscle tone during pregnancy contributes to heartburn, reflux, and constipation.

UTI

1. Heart rate increases 10 to 15 beats/minute by 32 weeks of gestation and persists until term.

1. Physiologic anemia of pregnancy results from increase in plasma volume greater than the increase in red blood cells.

• Gestational Diabetes
• Hyperemesis Gravidarum
• Hypertension
• Hemorrhagic Disorders

• Diabetes mellitus (DM)
• Affects 4% to 14% of pregnant women
• Pregnancy complicated by diabetes is considered high risk
• Pathogenesis
• Group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both
• Body compensates for its inability to convert glucose into energy by burning muscle and fats
• Key to an optimal outcome is strict glycemic control

• Classification
• Type 1 diabetes
• Absolute insulin deficiency
• Type 2 diabetes
• Relative insulin deficiency
• Gestational diabetes mellitus (GDM)
• Pregestational diabetes mellitus
• Label given to type 1 or 2 diabetes that existed prior to pregnancy
• White’s classification system
• New ADA system (distinguishes with or without vascular complications)

• Metabolic changes associated with pregnancy
• Normal pregnancy is characterized by alterations in maternal glucose metabolism, insulin production, and metabolic homeostasis
• Glucose is the primary fuel for the fetus
• Glucose crosses the placenta, insulin does not
• Insulin needs increase during the first trimester

˜Complicates 3% to 9% of all pregnancies

˜Fetal risks

• No increase of birth defects if develop GDM after the first trimester
• At risk for macrosomia and associated birth trauma and neonatal hypoglycemia

˜

• Macrosomia is either greater than 8 lbs 13 oz or 9 lbs 15 oz
• LGA is weight, head circumference, or length greater than 90th or 97th percentile.
• Can be both

shoulder dystopia

-screening:

1. High risk: obesity, corticosteroids, hx of gdm in previous pregnancies, races AA, NA Asian

2. Screen:

-1 hour glucose testing test, glucola, sweet orange juice- draw one bloodwork or finger gluocse to see level- if over 130= positive

-Do between 24 and 28- if positive do a longer test, a fasting, 1hr, 2hr and 3hr.

-if before 20 weeks evaluated probably diabetes not GDM

• Antepartum:
• Diet
• Exercise
• Self-monitoring of blood glucose:
• 4x a day!, fasting 1hr post prandial, 2hrs. Decrease to 2 or if stable to only fasting Pharmacologic therapy: glyburide
• Fetal surveillance

• Intrapartum
• Blood glucose monitored hourly in labor
• Infusion of regular insulin

• Postpartum
• Will return to normal glucose levels after birth
• Likely to recur in future pregnancies

• Poor glycemic control before and during pregnancy in women who have diabetes can lead to maternal and fetal complications.
• Careful glucose monitoring, medication administration when necessary, and dietary counseling are used to create a normal intrauterine environment for fetal growth and development in the pregnancy complicated by diabetes mellitus.
• Because GDM is asymptomatic in most cases, all women who are not known to have pregestational diabetes undergo routine screening by history, clinical risk factors, or laboratory assessment of blood glucose levels during pregnancy.

• Normal nausea and vomiting complicates 50% to 80% of all pregnancies, typically beginning at 4 to 10 weeks of gestation, usually resolving by 20 weeks of gestation
• Hyperemesis gravidarum is excessive, prolonged vomiting accompanied by the following:
  • Weight loss
  • Electrolyte imbalance
  • Nutritional deficiencies
  • Ketonuria

• Assessment
• Assess severity
• Weight, V/S, presence of ketonuria
• Psychosocial assessment: role of anxiety

• Intravenous (IV) therapy for correction of fluid and electrolyte imbalances
• Medications: Zofran can cause ceft palate, but they still give it, especially after 14 wks.
• Enteral or parenteral nutrition as a last resort
• Nursing interventions

• The woman with hyperemesis gravidarum may have significant weight loss and dehydration. Management focuses on restoring fluid and electrolyte balance and preventing recurrence of nausea and vomiting.

B

• Common medical complication of pregnancy
• Hypertensive disorders are a major cause of perinatal morbidity and mortality worldwide due to the following:
• Uteroplacental insufficiency
• Premature birth
• Of maternal deaths worldwide, 10% to 15% can be attributed to preeclampsia and eclampsia.
• Preeclampsia accounts for more than 50,000 maternal deaths each year.

• Morbidity
• Renal failure
• Coagulopathy
• Cardiac or liver failure
• Placental abruption
• Seizures
• Stroke
• Mortality
• Pregnancy-related hypertension accounts for 10% to 15% of maternal deaths worldwide.

1. Gestational HTN

2. Preeclampsia

3. Eclampsia

4. Chronic HTN

5. Chronic HTN w/ superimposed preeclampsia

• Onset of hypertension without proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of pregnancy
• Systolic BP >140 or diastolic BP >90

1. hypertensive

2. very concerned

• Pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman
• In the absence of proteinuria, preeclampsia may be defined as hypertension along with the following:
  • Thrombocytopenia
  • Impaired liver function
  • New development of renal insufficiency
  • Pulmonary edema
  • New-onset cerebral or visual disturbances
• THIS CONDITION DOES NOT GET BETTER UNTIL BABY IS BORN!

What is a common feature of gestational HTN and preeclampsia?

• Chronic hypertension:
• Hypertension present before pregnancy or diagnosed before week 20 of gestation
• Chronic hypertension with superimposed preeclampsia:
• Women with chronic hypertension may acquire preeclampsia or eclampsia
• Can be difficult to diagnose

• Etiology
• A condition unique to human pregnancy
• Common risk factors
• Primigravidity in woman <19 or >40 years of age
• First pregnancy with a new partner
• History of preeclampsia
• The cause of preeclampsia is unknown.
• Many theories

• Pathophysiology
• Progressive disorder with placenta as the root cause
• Begins to resolve after the placenta has been expelled
• Spiral arteries in the uterus normally become larger and thicker to handle increased blood volume.
• This vascular remodeling does not occur or only partially develops in women with preeclampsia and decreased placental perfusion and hypoxia result.
• DOES NOT RESOLVE UNTIL AFTER PLACENTA IS GONE!

• lPathophysiology
• Placental ischemia → endothelial cell dysfunction
• Generalized vasospasm → poor tissue perfusion in all organ systems
• Increased peripheral resistance and blood pressure (BP)
• Increased endothelial cell permeability
• Reduced kidney perfusion
• Plasma colloid osmotic pressure decreases.
• Decreased liver perfusion
• Neurologic complications

• Kidney function
• Chem sevens
• Uric acid, BUN,
• Liver function tests to establish baseline, then recheck one week later.

-Upper gastric is liver backing up!

retinal spasm and cortical brain spasm

hands nad face

• No reliable test or screening tool has been developed
• Low-dose aspirin (60 to 80 mg) may help certain high risk women

• Accurate measurement of BP
• Assessment of edema, although the presence of edema is no longer included in the definition of preeclampsia
• Deep tendon reflexes (DTRs)
• Assess for hyperactive reflexes (clonus) (uauLLY THIS OCCURS PRIOR TO SEIZURE)
• Proteinuria: ideally determined by evaluation of a 24-hour urine collection
• Evaluate for signs and symptoms of severe preeclampsia:
  • Headaches
  • Epigastric pain
  • Right upper quadrant abdominal pain
  • Visual disturbances
• HELLP: hemolysis, elevated liver enzymes, and low platelet

• Mild gestational hypertension and preeclampsia without severe features
  • Goals of therapy are to ensure maternal safety and deliver a healthy newborn close to term.
  • Home care
  • Maternal and fetal assessment
  • Activity restriction
  • Diet

• Severe gestational hypertension and preeclampsia with severe features
  • Goals of care are to ensure maternal safety and formulate a plan for delivery.
  • Intrapartum care
  • Bed rest with siderails up
  • Darkened environment
  • Magnesium sulfate therapy
  • Antihypertensive medications
• AT 37 WEEKS, THE RISKS OUTWEIGH THE BENEFITS OF KEEPING THE BABY IN. THEY WILL INDUCE

Consistent 160/110, organ compromise, or consistent elevated labs call for delivery regardless of whether 39 weeks has been reached.

• Women with preeclampsia with severe features have a significantly increased risk of developing preeclampsia in a future pregnancy.
• These women have an increased risk of developing chronic hypertension and cardiovascular disease later in life.
• For now, women should be educated about lifestyle changes (maintaining a healthy weight, increasing physical activity, and avoiding smoking) that may decrease the risk for developing future health problems.

• Hypertensive disorders during pregnancy are a leading cause of maternal and perinatal morbidity and mortality worldwide.
• The cause of preeclampsia is unknown, and there are no known reliable tests for predicting women at risk for developing preeclampsia.
• Preeclampsia is a multisystem disease.
• • Magnesium sulfate, the anticonvulsant of choice for preventing or controlling eclamptic seizures, requires careful monitoring of reflexes, respirations, renal function, and mental status.
  • Women with preeclampsia (especially early-onset and preeclampsia with severe features) have an increased risk of developing chronic hypertension and cardiovascular disease later in life.

D

try to keep baby in for 34 weeks to allow for lung maturation and ensure baby will be able to breathe on its own once born.

Give betamethasone in case delivery before 34 weeks is required.

• Bleeding in pregnancy jeopardizes maternal and fetal well-being.
• Maternal blood loss decreases oxygen-carrying capacity and increases risk for the following conditions:
• Hypovolemia
• Anemia
• Infection
• Preterm labor
• Impaired oxygen delivery to the fetus

• Fetal risks from maternal hemorrhage
• Blood loss, anemia
• Hypoxemia
• Hypoxia
• Anoxia
• Preterm birth
• Hemorrhagic disorders in pregnancy are medical emergencies.
• The incidence and type of bleeding vary by trimester.

• Miscarriage (spontaneous abortion): a pregnancy that ends as a result of natural causes before 20 weeks of gestation
• Approximately 10% to 15% of pregnancies end in miscarriage.
• Types of miscarriages
• Threatened
• Inevitable
• Incomplete
• Complete
• Missed
• Recurrent

-Threatened: bleed a little, still viable. Do sonogram-check fetal heart

-Inevitable: mom bleeding heavier, expelling everything- provide supportive measures.

-Incomplete: tissue comes out, rather than formed fetus. Blood tissue clots- expel some of it, but some still stuck inside- intervene, send for scraping and vaccuuming.

-Complete- everything comes out. No more disconfort- severe cramping, getsrid of everything, uterus stops crampong.

-Missed- no bleeding, but no heart beat. Abortion. 3 fold treatment: expectant – let the body do it itself. 2nd is medical intervention = misoprostil- use for inducing missed miscarriage.

-Recurrent: probably need sto go to reproductive med. 3 is a lot of babys to lose. >35 needs to go to see a specialist.

-Recurrent-

• Miscarriage care management
• Assessment and nursing diagnoses
• Initial care
• Depends on the classification of the miscarriage and on signs and symptoms
• Expectant management
• Medical management: misoprostol (Cytotec)
• Surgical management: dilation and curettage (D&C)
• Follow-up care
• Follow-up phone calls; support groups

• Ectopic pregnancy: the fertilized ovum is implanted outside the uterine cavity; also called “tubal pregnancies”
• Incidence and etiology
• Clinical manifestations
• Typically s/s occur 6 to 8 weeks after the last normal menstrual period
• The three most classic symptoms are the following:

1.Abdominal pain

2.Delayed menses

3.Abnormal vaginal bleeding (spotting)

-ectopicà lifethreatening. Instead of imbedding into the uterus, it is imbedded into follopian tubes. May rupture! ED

- PAIN! One sided pain not general cramping.

-Ectopic severe pain on the tube side.

-Sonogram to determine where it is.

-Ectopicàgive meds to abort.

• Placenta previa
• Placenta implanted in lower uterine segment near or over internal cervical os
• Degree to which the internal cervical os is covered by placenta used to classify three types
• Complete placenta previa
• Marginal placenta previa
• Low-lying placenta

• Placenta previa (Cont.)
• Incidence and etiology
• 1 in 200 pregnancies
• Clinical manifestations
• Painless bright red vaginal bleeding during second or third trimester
• Maternal and fetal outcomes
• Major complication is hemorrhage
• Fetal death (caused by preterm birth)
• Stillbirth, malpresentation, fetal anemia, intrauterine growth restriction (IUGR)

• Diagnosis
• Transabdominal ultrasound examination
• Care management
• Expectant management
• Home care
• Active management

• Premature separation of placenta (abruptio placentae) [placental abruption]
• Detachment of part or all of placenta from implantation site after 20 weeks of gestation
• Occurs in 1 in 75 to 1 in 226 pregnancies

Maternal hypertension is a primary risk factor

• Premature separation of placenta (abruptio placentae) [placental abruption] (Cont.)
• Clinical manifestations
• Separation may be partial, complete, or only involve margin of placenta
• Vaginal bleeding, abdominal pain, and uterine tenderness and contractions
• Boardlike abdomen; Couvelaire uterus (discolered ab)
• Maternal and fetal outcomes
• Diagnosis
• Management
• Expectant
• Active
• WILL NEED CSECTION-
• See bright red bleeding= V/s and change position.

• Blood loss during pregnancy should always be regarded as a warning sign until the cause is determined.
• Some miscarriages occur for unknown reasons, but fetal or placental maldevelopment and maternal factors account for many others.
• The type of miscarriage and signs and symptoms direct care management.
• • Ectopic pregnancy is a significant cause of maternal morbidity and mortality.
  • Placenta previa and placental abruption are differentiated by type of bleeding, uterine tonicity, and presence or absence of pain.
  • Management of late-pregnancy bleeding requires immediate evaluation; care is based on gestational age, amount of bleeding, and fetal condition.

Passenger: fetus

Size of the fetal head

Bones in the fetal skull

Fontanels

Molding

Presentation of the fetus: the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor

Cephalic

Breech

Shoulder

Passenger: Hardest part is head, which needs to maneuver and come out first.

Majority come out head first.

Should be in cephalic position by 37 weeks (term) baby is big, and cant maneuver.

Will do an external rotation if not in cephalic at 37 weeks. Decreases csection rates.

Cephalic- head down

Breech- sacrum down

Scapula- shoulder

Transverese

Fetal head: not completely fused, even though they have bones- don’t fuse till 18 montsh of age. helps with birth because still moveable. Biparietal diameter is the largest piece to get through thte pelvis.

Fetal position : the relationship of a reference point on the presenting part to the four quadrants of the mother’s pelvis

Position is denoted by a three-part letter abbreviation

Vertex= cephalic/head first.

-Roa and loa are most common

-ROA- has to do with the bone.

-Put heart rate monitor on back .

-ROT-

-ROP, LOP- posterior.

-Transvere and posterior tak e a little longer and it is more uncomfortable.

Fetal lie : the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother

Longitudinal/

Vertical

Fetal lie- in relation to long axis of spine in baby and mom

- longitudinal/vertical is straight up and down in relationship to mom spine

- transverse is horizontal

Fetal attitude : the relation of the fetal body parts to one another

General flexion

Fetal position : the relationship of a reference point on the presenting part to the four quadrants of the mother’s pelvis

Position is denoted by a three-part letter abbreviation

Fetal station : a measure of the degree of descent of the presenting part of the fetus through the birth canal

Fetal engagement : usually corresponds to 0 station

*-Ischial spines is important landmark- most narrow diameter that baby needs to go through, talking about station that is the point of reference. O statioin is ischial spines. Anything above is negative. Anything below it is positive.

-+4 you usually can see the head.

˜Passageway: Birth canal

• Bony pelvis
• Soft tissues

2 openings, goes into inlet, comes out the outlet (spines, tuberosities and arch)

Powers

Primary powers: contractions

Frequency, duration, intensity

Effacement

Dilation

Secondary powers: bearing-down efforts

Valsalva maneuver

Laboring Down

Position of laboring woman

Discussed in depth in Chapter 19

Psychologic state of laboring woman

Discussed in depth in Chapter 19

Thinning-->dilation-->decent of fetus

Mechanism of labor

Turns and adjustments necessary in human birth process

Seven cardinal movements of mechanism of labor

1.Engagement

2.Descent

3.Flexion

4.Internal rotation

5.Extension

6.Restitution and external rotation

7.Expulsion

1.Engage: goes through internal inlet.

2.Descent – move down.

(0 station is engaged and descended

3. Pelvic muscle flexes neck

4. internally rotaiton of head to get out of bony pelvic outlet

5. Extension of head to say hell

6. Restitution and aligns head with shoulders, head moves back

7. expulsion- baby pops out.

1. Engagement - the biparietal diameter of the head passes the pelvic inlet, the head is said to be engaged in the pelvic inlet.
2. Descent - refers to the progress of the presenting part through the pelvis. descent depends on at least four forces: 1. pressure exerted by the amniotic fluid, 2. direct pressure exerted by the contracting fundus on the fetus, 3. force of the contraction of the maternal diaphragm and abdomnial muscles in the second stage of labor, and 4. extension and straightening of the fetal body. The degree of descent is measured by the station of the presenting part.
3. Flexion - as soon as the descending head meets resistance from the cervix, pelvic wall, or pelvic floor, it normally flexes so that the chin is brough into closer contact with the fetal chest. flexion permits the smaller subooccipitobregmatic diamter rather than the larger diameters to present to outlet.
4. Internal rotation - the maternal pelvic inlet is widest in the transverse diameter; therefore, the fetal head passes the inlet into the true pelvis in the occipitotransverse position. the outlet is widest is the anteroposterior diameter; for the fetus to exit, the head must rotate. The head is almost always rotated by the time it hits the pelvic floor. both the levator ani muscles and the bony pelvis are important for achieving anterior rotation. a previous childbirth injury or regional anesthesia may compromise the function of the levator sling.
5. Extension - the fetal head reaches the perineum for birth, it is deflected anteriorly by the perineum.
6. Restitution and external rotation - After the head is born it rotates briefly to the position it occupied when it was engaged in the inlet. this movement is referred to as restitiution.
7. Expulsion - after birth of the shoulders, the head and shoulders are lifted up toward the mother’s pubic bone and the trunk of the baby is born by flexing it laterally in the direction of the symphysis pubis.

The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated.

The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. (even if she is laboring down)

The third stage of labor lasts from the infant’s birth to the expulsion of the placenta.

The fourth stage of labor begins with the delivery of the placenta and includes at least the first 2 hours after birth. (q15 monitoring)

Labor and birth are affected by the five Ps: passenger, passageway, powers, position of the woman, and psychologic response.

Physiologic factors

Culture

Anxiety

Previous experience

Gate-control theory of pain

Comfort

Support

Environment

Childbirth preparation methods

Relaxing and breathing techniques

Focusing and relaxation

Breathing techniques

Effleurage and counterpressure

Touch and massage

Therapeutic touch

Application of heat and cold

˜Acupressure and acupuncture

˜Transcutaneous electrical nerve stimulation

˜Water therapy (hydrotherapy)

˜Intradermal water block

˜Aromatherapy

˜Music

˜Hypnosis

˜Biofeedback

Anesthesia encompasses analgesia, amnesia, and relaxation

Analgesia : the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness

The type of analgesic or anesthetic chosen is determined in part by the stage of labor of the woman and by the method of birth planned.

FENTANYL GREAT

Systemic analgesia

Nerve block analgesia and anesthesia

Epidural anesthesia or analgesia (block): currently the most effective pharmacologic pain relief method for labor

Combined spinal-epidural (CSE) analgesia: sometimes referred to as a “walking epidural,” although women often choose not to walk because of sedation and fatigue, abnormal sensations in and weakness of the legs, and a feeling of insecurity

Epidural and intrathecal (spinal) opioids

General informed consent

Informed consent for anesthesia

Timing of administration

Preparation for procedures

Administration of medication

Intravenous route

Intramuscular route

Regional (epidural or spinal) anesthesia

Safety and general care

Sedatives may be appropriate for women in prolonged early labor when there is a need to decrease anxiety or promote sleep or therapeutic rest.

Naloxone (Narcan) is an opioid (narcotic) antagonist that can reverse narcotic effects, especially respiratory depression.

Pharmacologic control of pain during labor requires collaboration among the health care providers and the laboring woman.

Epidural anesthesia and analgesia are the most effective available pharmacologic pain relief methods for labor.

General anesthesia is rarely used for vaginal birth but may be used for cesarean birth or whenever rapid anesthesia is needed in an emergency childbirth situation.

bp down

hr up in mom

hr down in baby

Intermittent auscultation :
Listening to fetal heart sounds at periodic intervals to assess FHR
Easy to use, inexpensive, less invasive than EFM
Difficult to perform on women who are obese
Does not provide a permanent record
Electronic fetal monitoring:
External monitoring
Ultrasound transducer
Toco transducer (tocodynamometer)

Electronic fetal monitoring (Cont.):
Internal monitoring
Spiral electrode
Intrauterine pressure catheter (IUPC) -->can insert fluid through this!
Display: displayed on the monitor paper or computer screen, with the FHR in the upper section and UA in the lower section

˜Baseline fetal heart rate

• Average rate during a 10-minute segment
• There must be at least 2 minutes of interpretable data
• Should be 110-160

uVariability

uDescribed as irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater

u4 possible categories of variability:

uAbsence

uMinimal

uModerate

uMarked

Normal baby- hr fluctuates.

A- absent fluctuations, CONCERNED!

B: minimal variability- less than 5 bpm change in fluctuation

C- 6-25 bpm fluctuations- moderate variability

D- Marked-active baby!

Dark blue lines a minute

Little squares are 10 seconds

Rare event= IN TROUBLE . Fetal anemia- moms blood type doesn’t match, rh- and +

Bradycardia= <110.

Tahy= >160

Changes in FHR (Cont.):
Decelerations:
Early decelerations in response to fetal head compression (mirrors contractions, head is hitting pelvic floor, compressing cerebral blood flow. NORMAL
Late decelerations due to uteroplacental insufficiency-

WORRY- due to blood flow insufficiency: contraction happens, decel happens after the contraction.

Variable decelerations due to umbilical cord compression

NOT variability, is due to umbilical cord compression. No pattern to variable decels. V for variable- SHARP dip. Baby may be leaning on cord, need to turn mom off of that cord.

Prolonged decelerations:;

lasting longer, 2 minutes, 5 minutes,2-10min is polonnged, tryin to get her to move, get it to get back up.

• Acceleration - is defined as a visually apparent abrupt (onset to peak less than 30 sec) increase in FHR above the baseline rate. the peak is at least 15 beats/minute above the baseline, and the acceleration lasts 15 seconds or more, with a return to baseline less than 2 minutes from the beginning of the acceleration. before 32 weeks of gestation the definition of an acceleration is a peak of 10 beats/minute or more above the baseline and a duration of at least 10 seconds. acceleration of the FHR for more than 10 minutes is considered a change in baseline rate.
• can be either periodic or episodic. Similar to moderate variability, accelerations are considered an indication of fetal well-being. their presence is highly predictive of a normal fetal acid-base balance.

uCategory I: normal

uCategory II: indeterminate

uCategory III: abnormal

uBaseline FHR in the normal range of 110-160 beats/min

uBaseline fetal heart rate variability: moderate

uLate or variable decelerations: absent

uEarly decelerations: may be present or absent

uAccelerations: either present or absent

uBradycardia not accompanied by absence of baseline variability

uTachycardia

uMinimal or absence of baseline variability not accompanied by recurrent decelerations

uMarked baseline variability

uNo accelerations in response to fetal stimulation

uPeriodic or episodic decelerations

uNonreassuring FHR patterns associated with fetal hypoxemia

uHypoxemia can deteriorate to severe fetal hypoxia

uAbsence of baseline variability

uRecurrent or late decelerations

uBradycardia

uSinusoidal pattern

The five essential components of the FHR tracing that must be evaluated regularly are baseline rate, baseline variability, accelerations, decelerations, and changes or trends over time.

If any component is abnormal, corrective measures must be taken immediately to improve fetal oxygenation: intrauterine resuscitation

Supplemental oxygen

Maternal position changes

Increasing intravenous fluids

D, document

this is a normal finding!