2145 - OB Exam 2

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How does relaxation breathing work?

- Provides uterus with adequate O2, which causes more efficient contractions & quicker labor process
- Provides mom with something to do during contractions
- Focuses mom on something else than the contractions, which ↓ release of stress hormones & ↑ release of endogenous endorphins that ↓ pain

Non-pharmacological techniques used to cope with labor contractions

- Relaxation Exercise
- Relaxation Breathing
- Slow Chest Breathing
- Pant or Pant-Blow breathing
- Massage
- Position mother with gravity
- Water
- Environment
- Hypnosis

Physiological Basis of Labor Pain Stage 1

* Dilation Phase *
- Uterine contractions- cervical enfacement, dilation, uterine ischemia
- Pain impulses transmitted via spinal nerve segment T11-12
- Also accessory lower thoracic nerves
- Also upper lumbar sympathetic nerves

Physiological Basis of Labor Pain Stage 2

* Pushing Phase *
- Stretching of perineum
- Traction on perineum and uterocervical supports during contractions
- Expulsive forces / pressure from baby on other pelvic structures
- Pain transmitted S1-4 / parasympathetic system from perineal tissues

Analgesic Administration

- Assess both mom & fetus first

- Give slow over 3 min, dilute to facilitate the slow delivery

- Monitor mom & fetus during & after and be ready to take action

Stadol (Butorphanol)

- Dose: 0.5-2mg IV/IM, repeat in 3-4 hours

- Has some narcotic antagonist effects: do not give to opiate dependent women

- S/E: N/V, sedation, dizziness, confusion, HA, insomnia

- FHR considerations: transient pseudosinusoidal

Nubain (Nalbuphine)

- Dose: 10-20mg q 3-6 hrs IV, IM, Sub-Q

- Has some narcotic antagonist effects: do not give to opiate dependent women

- S/E: May cause resp depression in the newborn

- FHR: transient pseudosinusoidal pattern

Talwin (Pentazocine)

- Dose: 30mg dose IM or 20mg IV given 2-3x q 2-3 hrs

- Potent analgesic, agonistic actions at 2 opioid receptors, (also antagonist actions) sedative action

- Do not give to pts w/ hx of drug abuse

- Infant may be prone to apnea, also may change the character of contractions

Demerol

- Dose: 50-100mg IM/SC, may repeat q 1-3 hrs / IV 25mg diluted give over at least 1 min

- Opioid agonist- synthetic morphine-like compound, analgesia mediated through change in perception of pain at the spinal cord + higher levels in the CNS

- St. John's Wort increases sedation

Epidural Anesthesia

Action achieved by:
1) Local anesthetics acting on nerve fibers as they cross the epidural space causing sensory blockade
2) Narcotics crossing the dura into CSF and binding to opiate receptors in the dorsal horn of the spinal cord

"Pharmacological sympathectomy"
↓ BP

Risks of Epidural Anesthesia

- Possible maternal hypotension that could lead to ↓ placental flow and fetal distress
- Inadvertent puncture of the dura - spinal or high spinal
- Resp depression
- Improper placement
- Toxic rx / seizure
- Migration of catheter
- Spinal headache

Contraindications of Epidural

- Coagulation disorder / Anticoagulation
- Platelets <75,000 (notify if <150,000)
- Local infection at site
- Major abnormalities of the spine
- Maternal hypotension/shock
- Nonreassuring FHR pattern
- Diseases of the nervous system

What do you do if hypotension occurs with an epidural?

- ↑ plain IV solution
- Be sure mom is lying on side
- Evaluate fetal response
- Call MD, be ready with Ephedrine 5mg slow IVP

Rare complications with an epidural / HIGH SPINAL

- Catheter inadvertently punctures dura

- Best if cath withdrawn by anesthesia

- Completely numb

Rare complications with an epidural / SUBARACHNOID PLACEMENT

- Worse than a high spinal

- Inadvertent, hypotension, ascending paralysis

- Pt will need resp support (crash cart)

Rare complications with an epidural / TOXIC RX

- Happens immediately

- Inadvertent IV injection of anesthetic

- Tinnitus, drowsiness, disorientation, resp support

Duramorph / Astromorph (Spinal Opiates)

- Used for relief of post-op pain C/S: given during C/S by anesthesia

- Therapeutic effect: high concentration of narcotic receptors along spinal cord, brain stem, and thalamus (lasts 24hrs)

- Pts experience much less post-op pain, are able to ambulate and care for infant

Potential Complications of Spinal Opiates

- Resp depression: monitor 24hrs, if <12 notify MD & give Narcan
- N/V: give antiemetics
- Pruritus: give Benadryl or Nubain
- Urinary retention: assess for and tx prn
- Keep IV and FC in for 24 hrs post C/S
- Monitor I&O

What does the parasympathetic nervous system to to the FHR?

Decreases it

What does the sympathetic nervous system do to the FHR?

Speeds it up

What is the 1st Leopold's Maneuver?

- Determines presenting part
- Palpate uterine fundus
- VERTEX: Buttocks is softer and more irregular than head
- BREECH: Head is harder and round, uniform

What is the 2nd Leopold's Maneuver?

- Determines which side of the uterus is the fetal back located
- Hold left hand steady on side of uterus while palpating opposite side of uterus with right hand
- Back is smooth, convex
- Arms & legs feel bumpy, may move

* Heart rate is heard best over the back

What is the 3rd Leopold's Maneuver?

- Confirms presenting part is engaged
- Palpate suprapubic area
- Expect a hard rounded head
- Grasp presenting part gently between thumb and fingers
- If presenting part is NOT engaged, presenting part will FLOAT upward

What is the 4th Leopold's Maneuver?

- Determines whether the head is flexed or extended (face presentation)
- Omit if fetus is breech
- Turn to face woman's feet
- Place hands on each side of uterus with fingers pointed toward pelvic outlet
- On one side, slide fingers downward / feel for bump
- If head is flexed - bump opposite back

5 steps to evaluate the FHR tracing

1) Baseline rate
2) Variability (most sensitive O2 indicator)
3) Accelerations (Periodic change)
4) Decelerations (Periodic change)
5) Uterine Contraction (UC) pattern

What does Bradycardia & Tachycardia mean on the FHR baseline?

Bradycardia: <110
- Hypoxia

Tachycardia: >160
- Hypoxia
- Maternal fever
- Infection

Factors that influence FHR Variability

- ↓ O2 in fetal CNS
- Narcotics
- Prematurity
- Fetal sleep (lasts 30 min)
- Abnormalities in the fetal CNS, heart or both

Variability Classifications

Absent: range undetectable

Minimal: range 5 bpm or ↓

Moderate: range 6-25 bpm

Marked: range ↑ 25 bpm

Accels

- Reassuring sign of adequate fetal oxygenation
- Visually apparent abrupt ↑ in FHR
- Peak must be 15 bpm over 15 secs over the baseline FHR
- Prolonged accel- 2 to 9 min
- If 10 min or ↑ = baseline change
- Prior to 32 weeks use the 10x10 rule

Early Decels

- Mirrors the contraction

- Caused by fetal head compression
(↑ intracranial pressure causing the vagus nerve to slow the HR)

- No link to ↓ in fetal O2 status (benign)

Nursing Actions for Early Decels

- Continue to monitor pt
- Why is fetus having head compressions?
- Notify MD
- Prepare for delivery

Late Decels

- Nadir occurs after the peak of UC

- Caused by uteroplacental insufficiency

- Worst kind of decel - fetus may be hypoxic

- Mom's BP may be ↑

Nursing Actions for Late Decels

- Start O2 by mask at 10L
- Turn women to her side
- ↑ plain IV fluids
- Turn off Pitocin
- Notify MD, watch pattern, document, anticipate need for C/S
- Call anesthesia, set up C/S room

Variable Decels

- Occur before, during, or after a contraction

- Visually abrupt ↓ in FHR (↓ 30sec from start to nadir)

- Caused by umbilical cord compression

- The flow of blood and O2 is slowed or stopped to the fetus

- Can be a danger to the fetus (multiple variables that last a long time)

- Shape of decel is U, V, or W

Nursing Actions for Variable Decels

- Change maternal position
- Evaluate pattern and document

If multiple & last long time = start;
- Possible O2
- Possible IV changes
- Stop pitocin
- Notify MD

Shoulders

- Brief accels that may follow the variable decel
- Progressive amounts of pressure being placed on & removed from the umbilical cord in terms of blood flow and fetal O2
- Usually moderate variability is present=so reassuring
- If shoulder is after the decel the return to baseline is fast

Overshoots

- Only occur after the variable decel as the FHR attempts to recover to baseline rate
- The compromised fetus attempts to recover to baseline, but raises his FHR way over the baseline rate
- Usually minimal to absent variability
- Usually lasts long time (longer than a shoulder)
- Nonreassuring in postterm fetus
- Happens with hypoxia & acidosis
- Normal if preterm or if mom has Atropine

Tachysystole

- Spontaneous & stimulated labor

- ↑ 5 UC in 10 min, averaged over 30min

Category 1

- Baseline 110-160
- Moderate variability
- No late or variability
- Early decel present or absent
- Accels present or absent

NORMAL WELL OXYGENATED FETUS

Category 2

- Bradycardia without absent variability or tachycardia
- Absent variability without recurrent decels (minimal or marked variability)
- Absence of induced accel after stimulation
- Recurrent variable decels with min to mod variability
- Prolonged decels >= 2min but <10min
- Recurrent late decels with mod variability
- Variable decels with slow return to baseline, overshoots, shoulders

NOT SURE
Call MD & Monitor

Category 3

Includes either;
- Sinusoidal pattern
- Absent variability AND any of the following
--Recurrent late decels
--Recurrent variables
--Bradycardia

ABNORMAL / ACTION STAT / GET FETUS OUT

Sinusoidal Pattern

- Visually smooth, sine wave-like undulating pattern in FHR baseline with a cycle frequency of 3-5min that persists for >= 20min

- Fetal anemia, hypoxia, and acidosis

- Can't respond to chemoreceptors / given up on O2

- Prognosis very poor

VEAL CHOP

V-Variable decel C-Cord compression

E-Early decel H-Head compression

A-Acceleration O-Oxygenation adequate

L-Late decel P-Placental Insufficiency (Uterus too)

Cardiovascular Adaptations of Pregnancy

- O2 needs ↑
- AR ↑ 15-20 bpm
- Blood volume ↑ 30-50%
- Cardiac output ↑ 30%
- Healthy pregnancy=no ↑ BP

Cardiovascular Adaptations of Labor

- 1st stage cardiac output ↑ 10-15%
- 2nd stage CO ↑ 30-50%
- 4th stage CO may peak 80% over pre-pg

- During contractions BP ↑
- 1st stage systolic 10mg
- 2nd stage systolic 30mg & diastolic 25mg

Hematological Adaptations of Pregnancy

- Plasma ↑ faster so dilutional anemia may occur
- WBC can ↑ by 5,000-12,000
- Clotting factors ↑ (risk of DVT)

Hematological Adaptations of Labor

- WBC may ↑ to 25,000 (in early PP ↑ to 30,000)
- EBL: Vag delivery=500ml C/S=1000ml
- Further ↑ of clotting factors; return to pre-pg state 3-4 wks PP

- 1st day post-op of C/S pt ✓: Hg, Hct, WBC
- Assess pt by ✓: Pulse, BP, dizziness

Respiratory Adaptations of Pregnancy

- ↑ O2 consumption; thoracic circumference ↑ by 2-3in, diaphragm elevates

- ↑ depth of respiration

- Breathes deeper all the time

Respiratory Adaptations of Labor

↑ in RR and possibly AR

Renal Adaptations of Pregnancy

- ↑ glomerular filtration rate of 40-50% cause more blood volume
- Urine output is 25% ↑
- Bladder tone is ↓
- Ureters elongate & become twisted, upper 1/3 of ureter may dilate
- Causes ↑ risk of UTI & kidney infection

Renal Adaptations of Labor

- Proteinuria of +1 wnl cause of muscle contractions
- Prolonged straining during 2nd stage may cause injury to the bladder
- Spontaneous voiding may be difficult (even if no epidural) cause of pressure of baby's head

Integument Adaptations of Pregnancy

- Hyperpigmentation- melasma, linea albalinea nigra
- Hair increased growth
- Blood vessels have ↑ permeability so edema, palmar erythema, spider nevi
- Pruritus, acne
- Connective tissue fragility- striae gravidarum (stretch marks)

Gastrointestinal Adaptations of Pregnancy

- Gums become swollen, soft, and have a tendency to bleed
- Encourage dental care & hygiene
- GI tract: progesterone causes smooth muscle relaxation / ↓ peristalsis
- Constipation
- Hemorrhoids
- Heartburn (Tums)

Gastrointestinal Adaptations of Labor

- GI motility & absorption ↓
- Stomach emptying time slowed = N/V
- Diarrhea possible with the onset of labor

Endocrine Adaptations of Pregnancy

- Pituitary gland: ↑ prolactin
- Thyroid: ↑ BMR 25% (↑ thyroid hormone)
- Pancreas: ↑ insulin entire pregnancy to compensate for placenta hormone insulin antagonist
- Ovaries/Placenta: estrogen, progesterone, relaxin

Endocrine Adaptations of Labor

- ↓ Progesterone
- ↑ Estrogen
- ↑ Prostaglandins
- ↑ Oxytocin
- ↑ other stress hormones

What do you do if there is a prolapse of the umbilical cord?

- Immediate bradycardia
- Stay calm
- Call for help; MD, RN
- Restore blood flow to fetus; move presenting part off of umbilical cord (keep off cord)
- Prep pt and family for emergency C/S
- Ped present for birth

Heart Taco

Note & Chart:

Heart - FHR
T - Time of rupture
A - Amount of fluid
C - Color of fluid
O - Odor of fluid

Goal is delivery before 24 hours
Limit vag exams, use sterile gloves

What do you do for a regular labor admission?

- read prenatal hx
- Eyeball Assess pt
- What are their expectations (birth plan)
- Pt gown, urine specimen
- EFM on for 20 min & maternal VS
- Cervical check vs pt admit records (Contraction time)
- Notify MD, IV start, labs

Admission Labs

- Blood type
- Antibody screen (Rh-)
- Hep B antigen
- Rubella immune
- CBC
- HIV other STD's
- AFP (test for birth defects)
- Group Beta Strep: if + antibiotics stat
- Platelet, Hg, Hct (if C/S)
- UA for protein (↑ 1=pre-eclampsia)
- Glucose = diabetes

When would you use continuous EFM?

- High risk (pre-eclampsia)
- PROM
- Meconium fluid
- Epidural
- On Pitocin
- Pushing stage of labor

How often do we check VS/EFM during labor?

- Mom's T q2hr if ROM
- Mom's T q4hr if membranes intact
- Stage 1: FHR q15-30min, Mom's P, BP, RR q1hr if WNL
- Stage 2: FHR q5min, Mom's P, BP, RR q1hr if WNL

Pitocin

- 20 mU/min is max dose
- 1-2 mU/min can ↑ slowly
- We want contractions q2-3min lasting 60sec
- Confirm head is down before beginning pit

PURR Labor

P- Position changes (use gravity)
U- Urinate q 2hrs (empty bladder helps fetal decent)
R- Relax
R- Respiration (encourage mom to breathe)

Squatting Labor

ADVANTAGES:
- Opens up pelvis
- Uses gravity to force contractions
- Can rub back easily

DISADVANTAGES:
- No epidural
- Can be tiring over time
- Not comfortable for long time

Side-lying Labor

ADVANTAGES:
- Restful position
- Prevent supine hypotension
- Can use continuous fetal monitoring

DISADVANTAGES:
- Does not use gravity to aid fetal descent

Lithotomy Labor

ADVANTAGES:
- Easier for doctor
- More relaxing

DISADVANTAGES:
- Supine hypotension
- Back pain from pressure

1st Prenatal visit

- Best in 1st trimester (up to 13wks)
- Confirm pregnancy, confirm Hx & PE
- STD screening & pap smear
- CBC, blood type & antibody screen
- Hep B, Rubella & Varicella titer
- 1 hr glucose test if high risk of GDM

Nuchal Translucency

- Screened in 1st trimester
- Use US to see area behind neck for lucency at 10.5-14wks
- Causes can be down syndrome, chromosomal abnormalities

How do you determine a due date

Nagele's rule: subtract 3 mos/add 7 days from 1st day of LNMP and correct the year PRN

Herpes

- Blister like lesions in perineal area
- Herpes is a life long dx
- Active herpes C/S very dangerous to baby
- Virus sheds about 24 hrs before lesion
- Stress brings about outbreaks
- Pts may have prodromal sx

HPV - Human Papillomavirus

- Many different serotypes
- ↑ risk of cervical dysplasia
- No current therapy cures, but treatment
- HPV vaccine 9-26 y.o.

Healthy Weight Gain during Pregnancy

Ideal weight (BMI 18.5-24.9) 25-35 lbs
Underweight (BMI <18.5) 28-40 lbs
Overweight (BMI 25-29.9) 15-25 lbs
Obese (BMI =>30) 11-20 lbs

1st trimester: 0-4 lbs
2nd and 3rd: 3/4-1 lb per week
Evaluated each visit

Recommended daily Intake During Pregnancy

Grains: 1/2 should be whole grains, 6-9 oz
Fruits: 2 cups
Vegetables: 2.5- 3.5 cups:
Meat and beans: 5.5- 6.5 oz
Dairy: (3 servings) skim milk best
Fluids: 8-8oz a day
Caffeine: ok <300mg/day
Fish: only 12oz/week

Listeriosis

- Pregnant women 20x more at risk
- Mom: sepsis, meningitis fetus-miscarriage, stillbirth, preterm delivery
- DO NOT EAT: Unpasteurized raw milk, raw or uncooked meat, poultry, eggs, fish, shellfish, soft cheeses like feta, brie, bleu cheese, camembert, leftover food, NO hot dogs or deli meats unless heated until steaming hot

Psychosocial Tasks of 1st Trimester

- Accepts pregnancy
- Ambivalence is normal
- Patient's verbals & non-verbals
- Considering abortion, adoption?

Psychosocial Tasks of 2nd Trimester

- Identifying with mother role
- Thinking about relationship with own mom
- Reorder personal relationships
- Remind pt to register for childbirth, breast feeding, infant care classes

MSAFP

- Blood test to screen for risk status for Down's Syndrome or Open Spinal Bifida

- Screening test

Amniocentisis

- If MSAFP shows a risk or mom is 35yo or older
- Diagnostic test
- Tests fetus skin cells

1st Trimester Danger Signs

- Vaginal bleeding
- N/V that won't stop
- Abdominal pain
- Pain or burning with urination
- Syncope

2nd Trimester Danger Signs

- Vaginal bleeding
- SROM
- HA, edema, blurred vision (PIH)
- Loss of fetal movement
- Flank pain, backache, fever, night sweats (kidney infection)

3rd Trimester Danger Signs

- Contractions
- HA not relieved by Tylenol (PIH)
- Blurred vision, sudden edema (PIH)
- Abd pain-RUQ
- PROM
- Decreased fetal movement
- Vaginal bleeding

1st Trimester Development

3rd week: Heart begins to beat

4th week: Limb buds appear, neural tube closes by 28 days

6th week: Intestines in umbilical cord, blood & teeth forming

9 weeks: Perceives touch, EEG waves

10 weeks: Intestines in abd, can see toes, fingernails start, see movement on US

12 weeks: Sucking reflex present, kidneys produce urine

2nd Trimester Development

16 weeks: Pulmonary vascular system develops, fetus swallows amniotic fluid

20 weeks: Surfactant production & myelination of nerves begin

24 weeks: Viability, systems continue to mature

3rd Trimester Development

28 weeks: Begins to taste, eyelids open by 26wks, respirations better (vent/NICU)

32 weeks: Better respirations (hood O2/nasal CPAP)

36 weeks: My have respiration needs, covered with lots of vernix

When can you do a GBS test?

35-37 weeks

vag & rectum culture

Roe vs Wade 1973 Abortion

1st Trimester: decision between pt & MD

2nd Trimester: state may regulate abortion to protect women's health

3rd Trimester: law can forbid after 6th month unless the women's life is in jeopardy

The more abortions a pt has the more increased her risk is for what?

- Breast cancer

- Preterm Births

- Placenta Previa

What happens to the newborns weight & height in the 1st year of life?

Weight triples

Height doubles

A newborn's head makes up how much of its total body size?

1/4th

Baby's teeth

- 1st tooth usually appears around 6mo

- 2 lower teeth come in 1st then the top 2

- 20 baby teeth total

By age 2 a baby's brain reaches how much of it's adult size?

3/4th

Myelin

Fatty substance that protects the neurons and speeds up the transmission of messages carried by neurotransmitters

Nueroplasticity

Brain's ability to change and recognize neuropathways based on new experiences

What are 3 ways to promote brain growth?

- Read books
- Sing songs
- Sense stimulation

When can an infant differentiate their name when heard?

4 1/2 months

What are some factors that might result in hearing loss?

- Family hx of hearing problems

- Continuous loud noises

- Frequent ear infections

What is the most common taste preference for a baby?

Sweetness

What are some methods to promote the sense of touch?

- Provide safe objects
- Use words to describe the objects
- Present hot & cold
- Make sure objects within reach are safe

What are the 3 reflexes that are present immediately after birth?

- Rooting
- Sucking
- Gagging

At what age can an infant raise their head and chest when on their stomach?

3 months

At what age do infants begin to roll from their stomach to their back?

6 months

At what age can infants sit up without support?

6-7 months

At what age do infants begin to crawl?

8-10 months

At what age do infants begin to stand without support?

9 months

At what age do infants begin to walk without support?

12 months

At what age do infants develop the pincer grasp?

8 months

What percent of a baby's diet is going towards brain development?

60%

For an infant, obesity is considered how much above the average weight for a given height?

20%

Infants usually sleep how many hours a day?

16-17

2 Month Old Baby

- Smiles
- Some head control in upright position
- Coos & vocalizes
- Posterior fontanel closed
- Enjoys bath
- Quiets self by sucking

4 Month Old Baby

- Holds own hands, reaches for objects
- Looks at and becomes excited by mobile
- Laughs & squeals, babbles
- Recognizes parents' touch & voices
- May start cereal
- Hopefully sleeps at least 6 hours

6 Month Old Baby

- Sits without support
- Stands when placed on feet
- Rolls over
- Starts to self-feed
- Shows interest in toys
- Vocalizes syllables
- Birth weight doubled

12 Month Old Baby

- Pull to stand, cruises, attempts to take steps alone
- May walk & climb
- Feeds self
- Uses 1 to 3 words
- Memory increases
- Birth weight triples

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