OB Exam 2: Family Theory, Antepartum Assessment, Pregnancy, Pregnancy Complications, Postpartum Complications

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Presumptive Sx of Pregnancy

- Amenorrhea
- N/V
- Excessive fatigue
- Urinary frequency d/t increased pressure on bladder
- Breast changes d/t increased estrogen (i.e. enlargement, increased vascularity)
- Quickening (fluttering, feeling of something being "different")

Probable Sx of Pregnancy

- Changes in pelvic organs (i.e. Goodell's, Chadwick's, Hegar's Signs)
- Abdominal enlargement
- Braxton-Hicks contractions d/t increased estrogen
- Abdominal striae
- Uterine souffle d/t blood rushing through uterus
- Ballottement (palpation of mass that moves backward)
- Changes in skin pigmentation
- Positive pregnancy tests
- Palpation of fetal outline

Positive Sx of Pregnancy

- Auscultation of fetal heartbeat (present at 10-12 weeks by Doppler, 16 weeks by fetoscope, 18 weeks by stethoscope)
- Fetal movement
- Fetal visualization

Pregnancy Tests

- Blood: most accurate; HCG levels highest in AM, take it with first urination
- Home tests

Naegele's Rule: Calculation of Due Date

- Standard formula for calculating EDD (AKA EDB, EDC) based on last menstrual period (LMP)
- First day of LMP - 3 months + 7 days = EDD (i.e. April 27th - 3 months = January 27th + 7 days = EDD February 3rd)
- Always give February 28 days

Pregnancy: Breast Changes

- Glandular hyperplasia and hypertrophy
- Areolae darken, superficial veins and Montgomery follicles become prominent
- Possible striae
- Colostrum secretion

Pregnancy: Uterine Changes

- Beginning early in pregnancy, have mom feel uterus periodically so she becomes familiar with size and the way it feels; as pregnancy progresses, she will be more likely to identify Braxton-Hicks and preterm labor
- Enlargement d/t hypertrophy
- Increased fibrous tissue
- Increased blood flow

McDonald's Method

- Mathematical formula to determine gestational age; used at 22-34 weeks
- # of inches from symphisis pubis to fundus = # of weeks along

Vena Caval Syndrome

- Gravid uterus suppresses vena cava when mom is supine
- Reduces blood flow return to heart, causing maternal HTN
- Have mom rise slowly from exam table; tell her not to sleep on back

Pregnancy: Cervical Changes

- Development of mucus plug
- Goodell's, Chadwick's, and Hegar's Signs

Goodell's Sign

Softening of cervix

Chadwick's Sign

Bluish coloration of cervix, vaginal mucosa, and vulva

Hegar's Sign

Softening of lower uterine segment

Pregnancy: Vaginal Changes

- Mucosa thickens
- Increased secretions d/t loosening of connective tissue
- Yeast infections

Pregnancy: Respiratory Changes

- Increased O2 consumption
- Increased subcostal angle and anterposterior diameter
- Breathing technique changes from abdominal to thoracic
- Nasal congestion and epistaxis in 1st trimester d/t increased estrogen, causing increased vascularity

Pregnancy: Cardiac Changes

- 40-45% increase in blood volume; decreased Hct
- Physiologic anemia
- Decreased systemic and pulmonary vascular resistance
- Increased cardiac output
- Somewhat hypercoagulable state d/t increased estrogen and progesterone
- Dependant edema
- Varicose veins
- Pooling of blood when lying flat, causing dizziness when getting up

Pregnancy: GI Changes

- N/V
- Ptylaism (increased salivation); cause unknown
- Softening and bleeding of gums: seek dental care before pregnancy to avoid periodontal disease
- Constipation d/t increased hormones, causing decreased peristalsis; possible separation of bowel wall
- Heartburn
- Gallstones d/t increased estrogen, causing relaxation of bile duct tubules, causing backup of fluid
- Hemorrhoids d/t constipation, causing straining
- Pica

Pregnancy: Urinary Changes

- Urinary frequency d/t pressure on bladder
- Dilatation of kidneys and urine
- Increased GFR and renal plasma flow d/t release of hormones containing anti-insulin properties, causing gestational diabetes

Pregnancy: Skin Changes

- Hyperpigmentation
- Striae
- Linea nigra (dark line down center of abdomen)
- Chloasma ("mask of pregnancy"): brown discoloration on cheeks d/t increased estrogen
- Vascular spider nevi
- Decreased hair growth
- Hyperactive sweat and sebaceous glands

Pregnancy: Musculoskeletal Changes

- Pelvic joint relaxation
- Center of gravity changes
- Separation of rectus abdominus

Pregnancy: Eye, Cognitive, and Metabolic Changes

- Decreased IOP
- Thickening of cornea
- Reports of decreased attention, concentration, and memory d/t hormone changes
- Extra water, fat, and protein storage d/t hormone changes; fats more completely absorbed

Pregnancy: Endocrine Changes

- Increased estrogen and progesterone
- Decreased TSH; increased T4 and BMR
- Increased PTH concentration
- Thyrotropin and adenotropin alter maternal metabolism
- Prolaction responsible for lactation
- Secretion of oxytocin and vasopressin
- Increased aldosterone
- Increased need for glucose for developing fetus
- Increased cortisone levels

Mother's Response to Pregnancy

- Ambivalence
- Acceptance
- Introversion
- Mood swings
- Fear
- Changes in body image

W. Psychologic Tasks of Pregnancy

- First trimester: acceptance; hopefully elated, happy, excited; may have ambivalence
- Second trimester: role-playing; accepts fetus as separate human being from self
- Third trimester: separation from fetus through birth process; burst of energy

Family's Reaction to Pregnancy

- Siblings: rivalry; fear of change in relationship with parents; may need reassurance
- Grandparents: closer relationships with expecting couple; clarify role of coping grandparent

Cultural Factors During Pregnancy

- Rituals and customs that reflect values
- Useful in predicting reaction to pregnancy
- Male/female roles
- Family lifestyles
- Religious values
- Meaning of children
- Respect and study values and beliefs of others, incorporate them into care
- Remember that variations exist within cultures

Self-Care During Pregnancy

- Breast care: supportive bra, cleanliness, no soap on nipples
- Clothing: loose and comfortable, no high heels
- Cleanliness: consider culture
- Employment: can work until labor starts if no complications
- Travel: no restrictions unless complications are present; frequent breaks during car travel; seat belts

Exercise During Pregnancy

- Improves self-esteem
- Increases energy
- Improves sleep
- Relieves tension
- Helps control weight gain
- Promotes regular bowel function
- No hot tubs, saunas, or sports with risk of abdominal trauma
- Pregnancy exercises: pelvic tilt, abdominal exercise, Kegels (may prevent postpartum rectal prolapse), tailor-sit stretch; certain yoga poses may be contraindicated

Sexual Activity During Pregnancy

- R/t discomforts
- First trimester: fatigue, NV
- Second trimester: fewer discomforts, vascular congestion
- Third trimester: fatigue, SOB, decreased mobility; avoid male superior position
- Feelings affected by: previous relationship with partner; acceptance of pregnancy; attitudes toward partner's change of appearance; concern about hurting expectant mother or baby

Medical Risk for Older Expectant Mothers

- Death
- Chronic medical condition
- Miscarriage
- GD
- HTN
- CV problems (i.e. MVP, chronic problem)
- Placental previae (lies partially b/t or completely over cervix, possibly causing detachment)
- Difficult labor
- NB complications
- LBW
- Preterm births
- Perinatal deaths
- Down Syndrome

Special Concerns for Older Expectant Couples

- Enough energy to care for NB
- Ability to deal with needs of child as they age
- Only couple in peer group expecting new baby

Immunizations During Pregnancy

- Hep A and Hep B: yes, if high risk
- HPV: no
- Flu TIV (IM): yes; Flu LAIV (intranasal): no (live viruus)
- MMR: no (live virus)
- Meningococcal, pneumococcal, TD: yes, if indicated
- TDAP: yes, if high risk for pertussis
- Varicella: no (live virus)

TERATOGEN

Any substance that adversely affects the growth and development of a fetus

Hazards to Fetal Growth and Development

- Occupational exposure
- X-rays
- Pesticides
- Smoking (causes LBW)
- Alcohol (no known safe amount)
- Caffeine (can cause NB withdrawal)
- Drugs (prescription and OTC)--keep OB informed of what you're taking; excessive vitamin D can be toxic to fetus
- Substance abuse (illicit drugs)--can cause premature labor

T.O.R.C.H.

- Generally mild for adult but significant consequences to fetus
- T: toxoplasmosis (i.e. pork, cat feces)
- O: other; i.e. varicella, beta strep, UTI --> premature labor, bacterial vaginosis --> premature labor, HIV (treat with antiretroviral to prevent vertical transmission, no breastfeeding allowed, delivered by C-section)
- R: rubella; causes congenital heart problems, fetal growth restriction, blindness, and MR
- C: CMV (cytomegalovirus); most common; travels transplacentally, causing fetal death, hydrocephaly, and MR
- H: herpes virus (types 1 and 2); causes spontaneous abortion, LBW, and prematurity; active lesions around genitalia --> C-section to prevent transfer to baby

Iron-Deficiency Anemia: Risks to Pregnancy

- CBC drawn at first prenatal visit
- Hgb <10 = treatment
- Causes increased risk of infection and blood loss during delivery
- Compromises fetal development d/t decreased O2 transmission

Sickle Cell Disease: Risks to Pregnancy

- Increased # of crises
- Increased risk for perinatal complications
- Have fetus tested also

Discomfort Management: Nausea/Vomiting

- 1st trimester
- Causes: carb metabolism, emotional factors, fatigue, hormone changes
- Interventions: avoid odors; eat small, frequent meals; vitamin B6; Unisom (OTC antihistamine) or prescription steroid (used as last resort); contact HCP if vomiting more than once a day or if dehydrated; encourage dry carb intake; avoid greasy foods; increase fluid intake

Discomfort Management: Breast Tenderness

- Usually present in 1st trimester but can be seen throughout pregnancy
- Causes: increased estrogen and progesterone
- Interventions: supportive bra

Discomfort Management: Back Ache

- 3rd trimester
- Causes: lordosis, fatigue, increased uterine size
- Interventions: no lifting heavy loads; no high heels; sleep on side and support with pillows; massage; warm bath or shower

Discomfort Management: Dental Problems

- I.e. ptyalism (bitter taste in mouth), pain, cavities, gingivitis
- Present in all trimesters but worst during 1st
- Causes: bad oral hygiene, increased estrogen
- Interventions: get treatment immediately; try to have maintenance work done before pregnancy--if not, it's best to have it done during the 2nd trimester

Discomfort Management: Constipation

- 2nd-3rd trimesters
- Causes: pressure of enlarged uterus on small intestine, iron supplements, diet, lack of exercise
- Interventions: increase fluid, fiber intake, and exercise; regular bowel habits (use stool softeners as recommended by HCP)

Discomfort Management: Faintness and Dizziness

- 2nd-3rd trimesters
- Causes: increased blood volume, postural HTN, anemia, large crowds, sudden position change
- Interventions: sit with head between knees; lie supine; get fresh air; rise up slowly; if excessive, have H&H checked for possible anemia

Discomfort Management: Fatigue

- 1st and 3rd trimesters
- Causes: energy demands of fetus, general discomfort that causes inconsistent sleep at night
- Interventions: exercise; rest; relaxation; napping; comfort measures in bed (i.e. support with pillows); if excessive, have HCP test for anemia

Discomfort Management: Frequent Urination and Bladder Control Problems

- 1st and 3rd trimesters
- Causes: fetus pressing on bladder
- Interventions: Kegels; keep weight gain moderate; train bladder; avoid diuretics; call HCP if excessive or having pain

Discomfort Management: Headache

- Present in all trimesters
- Causes: fatigue, increased blood volume, stress, anxiety
- Interventions: Tylenol; hydration; rest and relaxation; regular meals; gradual caffeine decrease; if not relieved with all above measures, call HCP for PIH evaluation

Discomfort Measures: Nosebleeds

- Present in all semester, but worst in 1st
- Causes: increased O2 consumption and cardiac output
- Interventions: hydration; humidifier; if excessive, call HCP

Discomfort Measures: Leg Cramps

- 2nd-3rd trimesters, more frequent at night
- Causes: buildup of pyruvate and lactic acid
- Interventions: stretching; hydration; proper footwear; hot shower or bath; massage; elevate legs after walking; dorsiflexion; Tums with calcium; supportive hosiery; if persistent, call HCP to evaluate for DVT

Discomfort Measures: Breathlessness

- 2nd-3rd trimesters
- Causes: Fetus putting pressure on diaphragm
- Interventions: sleep on side or upright; decrease activity if possible; meditation; relaxation; pillow supporting pressure point; exercise; if excessive, call HCP for anemia evaluation

Discomfort Measures: Difficulty Sleeping

- Present in all trimesters, but worst in 3rd
- Causes: growing and active fetus, nocturia, breathlessness
- Interventions: massage; hot shower or bath; relaxation; frequent napping

Discomfort Measures: Hemorrhoids

- 2nd-3rd trimesters
- Causes: constipation, increased pressure on from uterus on hemorrhoid vein
- Interventions: ice packs; topical ointment; anesthetic agents; warm soaps; Sitz bath; do NOT let patient reduce--call HCP

Discomfort Measures: Vaginal Discharge

- Present in all trimesters, but worst in 1st (milky white, thick)
- Causes: hormone changes, causing increased mucus production in cervix
- Interventions: pantyliners; good hygiene; cotton underwear; know what is abnormal (i.e. foul smell, bleeding, white/cheesy/chunky)

Discomfort Measures: Varicose Veins

- 2nd-3rd trimesters
- Causes: lower venous congestion; weakened vein walls d/t heredity; age; weight gain
- Interventions: elevate legs frequently; supportive hosiery; avoid crossing legs and standing for prolonged periods; avoid garters and hosiery with restrictive bands

Discomfort Measures: Heartburn and Indigestion

- 2nd-3rd trimesters
- Causes: increased progesterone, decreased peristalsis, increased relaxing of cardiac sphincter, displaced stomach d/t uterine growth
- Interventions: raise HOB; eat small, frequent meals; stay upright after eating; avoid spicy foods; don't eat before bed; avoid chocolate; if excessive, see HCP (i.e. Maalox, low-sodium antacids)

Discomfort Measures: Edema and Swelling

- 2nd-3rd trimesters, but worst in 3rd
- Causes: prolonged standing, increased sodium d/t hormone changes, circulatory congestion in lower extremities, increased capillary permeability
- Interventions: frequent dorsiflexion, avoid constrictive shoes and pants, elevate legs frequently

Maternal Mortality

- Increasing number: 13.3:1000
- Higher risk of pregnancy-related complications d/t lack of insurance, poor family planning, unwanted pregnancies, insurance not covering family planning

Pregestational Complications: Substance Abuse

- 1:10 women in the U.S. are substance abusers, 15% of which are pregnant
- i.e. alcohol, tobacco, cocaine, crack, marijuana, club drugs, heroine, methadone
- No definitive data on amount of alcohol that is safe during pregnancy; may cause fetal alcohol syndrome
- Tobacco causes transient hypoxia; includes second-hand smoke and quantity doesn't matter
- Cocaine and crack are vasoconstrictive, causing periods of decreased O2 to fetus
- Marijuana has no specific negative outcome on fetus, but may experience withdrawal
- Methadon is safe alternative for pregnant women who are addicted to other substances
- Interventions: early prenatal care, assessment and observation skills, preconception care, education

Pregestational Complications: Diabetes

- Type I, type II, and GD provide risks to mother and baby
- Pregnancy provides ideal state for diabetes--during 2nd and 3rd trimesters, hormones put mother in naturally insulin-resistant state --> more glucose is available to cross placenta and keep fetus growing
- Entering pregnancy as an already-diabetic patient is dangerous; closely monitor and take at least 4 SQ insulin doses daily; type II may have to undergo insulin control
- GESTATIONAL DIABETES: pregnancy-induced; may need insulin if not controllable by dietary changes; diagnosis = one abnormal glucose test out of the following--fasting >92, 1 hour test >180, 2 hour test >153
- Assessment: A1C screening for patients at risk during first prenatal visit, all others at 24-28 weeks; 75 g 2 hour oral glucose test

Pregestational Complications: Interventions for Diabetes

- Education: diet, lifestyle changes, insulin
- Monitoring: more frequent ultrasounds to monitor fetal growth--baby >8 pounds 13 oz is considered too large; >9 pounds 13 oz = scheduled C-section
- Postpartum care: GD is a precursor to Type II within 5-10 years postpartum
- Increased risk for other complications: C-section, stillbirth, preeclampsia, infection, hydraminos
- Fetal risk: congenital anomalies (frequently CV), uncontrollable blood sugar, macrosomia and getting stuck in birth canal, respiratory distress d/t insufficient surfactant, hypoglycemia
- Genetic imprinting for childhood obesity
- Mother should be euglycemic (normal) prior to conception and maintain throughout pregnancy

Pregestational Complications: Anemia

- Lack of blood to baby --> LBW
- Hgb <11, Hct <33% in 3rd trimester
- Treatment: dietary/supplemental iron--take supplements with vitamin C and stool softener

Pregestational Complications: HIV/AIDS

- Testing of all pregnant women is recommended
- Can be transmitted through breastmilk, sexual relations, and blood contact--implement universal precautions with all patients
- Intervention: treat fetus throughout pregnancy with antiretrovial, commonly ZBT therapy (good outcome); breastfeeding not recommended

Pregestational Complications: Congenital Heart Disease

- Classes 1 and 2 tolerated pregnancy well
- Interventions: more frequent office visits, antibiotics infused during labor to prevent endocarditis, too much pushing (especially holding breath with Valsalva maneuver) increases stress on heart--use vaccum or forceps during 2nd stage
- Rheumatic fever causes valve damage; treat with antibiotics
- PERIPARTUM CARDIOMYOPATHY: heart enlargement; cause unknown; no hx of congenital defects or rheumatic fever; can be fatal; dysfunction of left ventricle not detected until lend of pregnancy or first postpartum months; S/S--SOB, cough, easily fatigued

Gestational Onset Complications

- Bleeding disorders
- Abortion
- Miscarriage
- Ectopic pregnancy
- Trophoblastic Disease (molar pregnancy)
- Hyperemesis gravidarum (severe morning sickness)

ABORTION

Expulson of fetus <20 weeks' gestation; can be spontaneous or induced

MISCARRIAGE

Spontaneous abortion; primarily d/t chromosomal abnormalities

Gestational Onset Complications: Ectopic Pregnancy

- Implantation anywhere other than the uterus, commonly fallopian tube; can be d/t obstruction or trauma
- Assessment: constant unilateral pain; risk for rupture = medical emergency
- SALPINGOSTOMY: attempt to repair tube
- SALPINECTOMY: removal of tube

Gestational Onset Complications: Trophoblastic Disease (Molar Pregnancy)

- Hydatidiform mole and choriocarcinoma; generally no fetus other than development of the placenta, fluid-filled vesicles that look like grapes, and rapid growth
- Assessment: rapid growth pattern, no FHR, high levels of pregnancy hormones, abnormally high fundal height, discharge with white flecks (vesicles expelling)
- Interventions: must be evacuated--dilate cervix and scrape out uterus; must receive closely-monitored follow-ups d/t increased risk for choriocarcinoma (cancer of uterine lining); blood draws to monitor hormone levels

Gestational Onset Complications: Hyperemesis Gravidarum (Severe Morning Sickness)

- Placental hormones (especially progesterone) cause intractable nausea and vomiting; patient is extremely weak
- Interventions: monitor potassium and sodium; IV therapy; monitor for dehydration; slowly introduce foods; balance electrolytes; vitamin B6 injection; antiemetics (i.e. Reglan)

PREECLAMPSIA and ECLAMPSIA

Systemic pregnancy-induced disease process involving HTN and proteinuria

CHRONIC HYPERTENSION

Elevated BP documented prior to 20 weeks' gestation

Gestational Onset Complications: Hypertension Disorders

- Preeclampsia, eclampsia
- Chronic hypertension
- Chronic hypertension with superimposed preeclampsia (after 20 weeks' gestation) or eclampsia
- Gestational or transient hypertension

Mild Preeclampsia: Assessment

- BP: >140/>90
- Proteinuria: 2+ on dipstick
- Serum creatinine: increased
- Hemolysis: normal
- Liver enzymes: normal
- Platelets: normal
- Urine output: normal
- Headache: not present
- Epigastric pain: not present
- Blurred vision: not present
- Pulmonary edema: not present
- IUGR: not present
- Seizures: not present

Severe Preeclampsia: Assessment

- BP: >160/>110
- Proteinuria: 3-4+ on dipstick
- Serum creatinine: increased, >2
- Hemolysis: increased
- Liver enzymes: increased
- Platelets: low, <100K
- Urine output: oligura (low), <500 mL/24 hours
- Headache: persistent
- Epigastric pain:persistent
- Blurred vision: persistent
- Pulmonary edema: possibly present
- IUGR: possibly present
- Seizures: possibly present (present = "eclampsia")

Risk Factors for Gestational Onset Hypertensive Disorders

- Age (very young or older)
- Personal or family hx of HTN or diabetes
- Obesity

H.E.L.L.P. SYNDROME

- H: hemolytic anemia
- E.L.: elevated livery enzymes
- L.P.: low platelets
- Interventions: frequent appointments to monitor BP and urine; bed rest with lateral side-lying to promote blood flow to placenta; magnesium sulfate IV therapy to relax smooth muscles and prevent seizures; drug therapy--monitor RR, deep tendon reflexes, and urine output (at least 30mL/hour)
- Only cure = delivery of baby

Prelabor Complications

- PROM
- Preterm delivery

PROM (Premature Rupture of Membranes)

- Rupture prior to labor beginning; increases risk of infection
- Avoid frequent vaginal exams
- Montior temperature

FAMILY

- An institution where individuals, related through biology or enduring commitments and representing similar or different generations and genders, participate in roles of mutual socialization, nuturance, and emotional commitment
- Defined in many different ways according to individual's own frame of reference, values, and discipline; whatever the individual considers it to be

FAMILY SYSTEMS THEORY

Family viewed as a system that continually interacts with its members and environments; focuses on interactions and the changes they exert

FAMILY STRESS THEORY

How families react to stressful events; suggests factors that promote adaptation to stress

DUVALL'S DEVELOPMENTAL THEORY

Addresses family change over time using family life cycle stages based on predictable changes in the family's structure, function, and roles; each stage has developmental task
- Stage 1: Marriage and independent home
- Stage 2: Family with infant
- Stage 3: Family with preschooler
- Stage 4: Family with schoolchildren
- Stage 5: Family with teenager
- Stage 6: Family as launching center
- Stage 7: Middle-aged family
- Stage 8: Aging family

BLENDED/RECONSTITUTED FAMILY

At least one stepparent/sibling or half-sibling

EXTENDED FAMILY

At least one parent and one or more members other than parent or sibling

COMMUNAL FAMILY

Live in commune, share all responsibilities

Types of Non-traditional Families

- Blended/reconstituted
- Extended
- Single parent
- Binuclear
- Polygamous
- Communal
- Gay, Lesbian, Bisexual, and Transgender

BINUCLEAR

Parents continuing parenting role while ending spousal unit

FAMILY STRUCTURE

Consists of individuals each with a socially recognized status and position who interact with one another on a regular recurring basis in socially sanctioned ways, composition of family

FAMILY FUNCTION

Interactions of the family members especially focusing on the quality of relations and interactions

FAMILY ROLES

Position or status in the family structure

Qualities of Strong Families

- Commitment
- Appreciation
- Encouragement
- Time
- Purpose
- Congruence
- Communication
- Rules
- Values and beliefs
- Coping strategies
- Problem-solving
- Positivity
- Flexibility and adaptivity
- Balance

GENOGRAM

Family tree with symbols indicating persons and relationships

ECOMAP

Graphical representation that shows all of the systems at play in an individual's life

POSTPARTUM HEMORRHAGE

- >500 mL; clinical underestimation by 50%--difficult to assess d/t blood mixing with amniotic fluid, absorption in linens, etc.
- Compare Hct level antepartum vs. postpartum; a decrease of 10 = loss of 500 mL; need fluid replacement and/or iron supplement; <7 Hct requires transfusion
- "Early": within first 24 hours
- "Late": 24 hours-6 weeks; may be d/t part of placenta not being expelled--requires D&C (major surgery, general anesthesia)
- S/S: excessive bright red bleeding; boggy fundus not responding to massage; abnormal clots; unusual pelvic or back discomfort; bleeding in presence of contracted uterus; rise in level of fundus; increased HR; decreased BP; hematoma; decreased LOC

UTERINE ATONY R/T POSTPARTUM HEMORRHAGE

- Relaxation of the uterus; may be described as "boggy" (soft)
- Blood loss may be slow/steady or sudden/massive
- Risk factors: overdistension of uterus d/t macrosomia or multipara; rapid or prolonged labor; oxytocin induction (causes contractions to be stronger and closer together); grand multiparity; general anesthesia; prolonged 3rd stage; infection; preeclampsia; operative birth (i.e. forceps, vacuum); retained placental fragments
- If after fundal massage and expression of clots plus emptying the bladder ("dextroversion"—full bladder displaces fundus to the right), there is a slow, steady, free flow of blood, weighing perineal pads may be necessary - 1 ml = 1 g
- Maintain IV access, frequent VS, lab values (i.e. Hct), urinary output, fundal checks, lochia amount (saturating >1 pad/hour—call physician, may need meds)

Meds for Postpartum Hemorrhage

- Oxytocin (Pitocin) 50 mu/min IV—step 1
- Methylergonovine maleate (Methergine) 0.2 mg q 2-4 hrs IM—step 2
- Ergonovine maleate (Ergotrate Maleate) 0.2 mg q 2-4 hrs IM—step 2
- Hemabate (a prostaglandin) 0.25 mg IM—step 3; pt will be very comfortable if we reach this level of therapy d/t intense contractions, combine with pain meds
- Cytotec (a prostaglandin) 100 mg rectally—step 3

LACERATION R/T POSTPARTUM HEMORRHAGE

- Vaginal bleeding that persists with firmly contracted uterus
- Can be on perineum, vagina, or cervix
- Risk factors: nulliparity, epidural, precipitous birth, operative birth, macrosomia

HEMATOMA R/T POSTPARTUM HEMORRHAGE

- D/t injury to a blood vessel from birth trauma
- Assess with patient in lateral Sims position
- Risk factors: nulliparity, precipitous birth, prolonged 2nd stage, operative birth, macrosomia
- S/S: perineal pain and/or rectal pressure, edema, tense/fluctuant/bulging/shiny mass

PUERPERAL INFECTION

Infection of reproductive tract occuring <6 weeks postpartum

Puerperal Morbidity

- Temp > 38 degrees C, 100.4 degrees F taken 4x/day on any 2 of first 10 days postpartum, excluding first 24 hours
- Not all-encompassing--increased temp can be d/t dehydration, increased WBCs (d/t labor being an inflammatory process)

METRITIS (ENDOMETRITIS)

- Infection/inflammation of uterine lining (endometrium)
- Risk factors: C-section; PPROM (premature prolonged rupture of membranes); prolonged labor followed by C-section; compromised health status; internal EFM (i.e. scalp electrode); birth trauma; chorioamnionitis; DM; operative birth; manual placenta removal; BV or chlamydia; lapses in aseptic technique
- Causes: beta strep (early), chlamydia (late)
- S/S: bloody, foul-smelling lochia; uterine tenderness; temp spikes on 2 or more occasions; increased HR; chills; increased WBCs or more than 30% in 6 hour period
- Treatment: antibiotics until afebrile for 48 hours; prophylactic antibiotics given for C-section

POSTPARTUM UTI

- D/t overdistension r/t trauma or effects of anesthesia
- Treatment: straight cath or Foley; ice packs to perineal area; pain meds; antibiotics; avoid carbonated beverages; drink cranberry juice; vitamin C

MASTITIS

- Infection of the breast connective tissue d/t bacterial invasion following trauma to nipple
- Causes: milk stasis, poor hygiene, nipple trauma, duct obstruction
- S/S: warm, reddened, painful area of breast (usually upper outer quadrant); usually advances to include fever, chills, headache, and flu-like sx; 2nd-4th week postpartum
- Treatment: bedrest for 24 hours; increase fluids; supportive bra; frequent breastfeeding; warm, moist packs; analgesics; antibiotics

THROMBOPHELBITIS

- Venous thrombosis: thrombous formation in superficial or deep vein, usually in legs; life-threatening--can become PE
- Causes: increased coagulability d/t pregnancy, venous stasis
- S/S: tenderness; local heat and redness; edema; low-grade fever; positive Homan's sign; venography or Doppler ultrasound for diagnosis
- Treatment: IV heparin; bedrest; leg elevation; analgesics; possibly antibiotics
- Prevention: avoid leg trauma; early ambulation

POSTPARTUM BLUES

- "Adjustment reaction/depressed mood"; occurs in 50-80% of mothers; self-limiting (a few hours to 10 days); mild depression interspersed with happiness
- S/S: feeling overwhelmed; unable to cope; fatigue; anxiousness; irritability; oversensitivity; episodic tearfulness without cause
- Treatment: reassurance, assistance with self and infant care

POSTPARTUM PSYCHOSIS

- Occurs in 1-2:1000 mothers; evident in first 3 months
- S/S: agitation; hyperactivity; insomnia; mood lability; confusion; irrationality; difficulty remembering or concentrating; poor judgment; delusions; hallucinations
- Treatment: refer to mental health professional; if meds are prescribed, caution re: breastfeeding

PTSD R/T POSTPARTUM

- Risk increases in emergency C-section cases
- S/S: emotional numbing; memories; reduced awareness of one's environment; derealization and depersonalization; intrusive thoughts; insomnia; impaired communication; avoidance behaviors; irritability; autonomic arousal (i.e. palpitations, hyperventilation, nausea); avoidance of reminders and hyperarousal must be present for 1 month to diagnose
- Treatment: early recognition is very important; encourage patient to relive birthing experience, clarify misunderstandings, and give appropriate follow-through and referrals to support systems when indicated

POSTPARTUM MAJOR MOOD DISORDER

- AKA "Postpartum depression"; occurs in 7-30% of mothers; evident in first postpartum year, greatest risk at 4th week
- Risk factors: primip, pregnancy ambivalence, history of depression, lack of support, poor body image
- S/S: anxiety, irritability, poor concentration, forgetfulness, sleep difficulties, appetite changes, fatigue, tearfulness
- Treatment: referral to mental health professional; if meds are prescribed, caution re: breastfeeding (all SSRIs except Prozac are safe)

Postpartum Assessment for Psychiatric Disorders

- Anticipatory guidance
- Postnatal depression scale

ANTEPARTUM

Period of time beginning with conception and ending with onset of labor

INTRAPARTUM

Period of time that begins with onset of regular uterine contractions and lasts until expulsion of placenta

POSTPARTUM

Period of time from delivery of placenta to approximately 6 weeks after delivery

FUNDUS

Upper portion of uterus

GESTATION

Period of intrauterine development from conception to birth

TERM

Birth that occurs between 37 and 42 weeks' completed gestation

PRETERM

Birth that occurs before 37 weeks' gestation

GRAVIDA

Refers to number of times a woman has been pregnant without reference to how many fetuses there were with each pregnancy or when the pregnancy ended

PARA

Any birth that occurred after 20 weeks' completed gestation, whether the baby was born alive or not; also without reference to the number of fetuses

NULLIGRAVIDA

Has never been pregnant

MULTIGRAVIDA

Pregnant for at least the 2nd time

PRIMIGRAVIDA

First time being pregnant

Frequency of Prenatal Visits

- Preconception care
- First trimester (1-3 months): initial visit should occur; should have a visit every 4 weeks until 28 weeks
- Second trimester (4-6 months): visits should occur every 4 weeks
- Third trimester (7-9 months): beginning at 28 weeks, visits should occur every 2 weeks; at 36 weeks, visits should be weekly; at 40 weeks, visits should be twice per week

Prenatal History

Used to identify risk factors to the mother and/or fetus
- Current and past pregnancies
- Gynecologic history
- Current and past medical history, including substance abuse
- Family medical history
- Religious, spiritual, cultural, and occupational history
- Partner history
- Social history and preferences

G.T.P.A.L.

- G: "gravida"; number of pregnancies, including current pregnancy; twins/triplets count as ONE gravida and ONE para
- T: "term"; # of pregnancies that were delivered at 37 weeks or later
- P: "preterm"; # of pregnancies that were delivered b/t 20 and 37 weeks
- A: "abortion"; # of pregnancies ending in therapeutic or spontaneous abortion
- L: "living"; # of currently living children

Father's Health History Re: Risk Factors for Mother/Fetus

- Family history of genetic conditions
- Age
- Significant health problems
- Previous or present alcohol intake
- Drug and tobacco use
- Blood type and Rh factor

Psychosocial Risk Factors R/t Pregnancy

- History of deprivation or abuse
- History of emotional problems (i.e. depression, anxiety, postpartum depression)
- Support systems
- Over/underuse of healthcare system
- Acceptance of pregnancy, intended or unintended
- Personal preferences about birth
- Plans for care of child following birth
- Feeding preference for baby

Cultural Factors R/t Pregnancy

- Factors that influence woman's expectation of childbearing experience
- Beliefs or practices that maintain her spiritual well-being or influence care (i.e. prohibition or receiving blood products, dietary restrictions)
- Ask about specific practices

Prenatal High Risk Factors

- Social-personal: low income and/or educational level, poor diet, living at high altitude, multiparity >3, weight <100 or >200 pounds, age <16 or >35 years, smoking 1+ packs/day, use of addicting drugs, excessive alcohol consumption
- Preexisting medical disorders: DM, cardiac disease, anemia (Hgb <11, Hct <32%), HTN, thyroid disorder, renal disease, DES exposure
- Obstetric considerations: previous pregnancy--stillborn, habitual abortion, C-section, Rh or blood group sensitization, large baby; current pregnancy--rubella (1st/2nd trimester), CMV, herpes, syphillis, UTI, abruptio placentae and plecenta previa, preeclampsia, multiple gestation, Hct >41%, SPROM

Danger Signs of 1st Trimester

- Abdominal cramping or pain: threatened abortion, UTI, appendicitis
- Vaginal spotting or bleeding: threatened abortion
- Absence of fetal heart tones: missed abortion
- Dysuria, frequency, urgency: UTI
- Fever, chills: infection
- Prolonged NV: hyperemesis gravidarum, risk of dehydration

Danger Signs of 2nd Trimester

- Abdominal or pelvic pain: preterm labor, UTI, pyelonephritis, appendicitis
- Sudden absence of fetal movements: fetal demise
- Prolonged NV: hyperemesis gravidarum, risk of dehydration
- Fever, chills: infection
- Vaginal bleeding: infection, friable cervix d/t pregnancy changes, placenta previa, abruptio placentae, preterm labor

Danger Signs of Third Trimester

- Abdominal or pelvic pain: UTI, PTL, pyelonephritis, appendicitis
- Decreased or absent fetal movement: fetal demise
- Prolonged NV: hyperemesis gravidarum, risk of dehydration
- Fever, chills: infection
- Dysuria, frequency, urgency: UTI (could cause preterm labor)
- Vaginal bleeding: infection, friable cervix d/t pregnancy changes or pathology, placenta previa, placentae abruptio, PTL
- Absence of fetal movement or heart tones
- S/S of hypertensive disorders: severe HA that doesn't respond to normal measures, visual disturbances, facial and generalized edema
- S/S of preterm labor: rhythmic lower abdominal cramping or pain, low backache, pelvic pressure, leaking of amniotic fluid, increased vaginal discharge

PELVIMETRY

Manual measurement of inlet and outlet
- Estimate diagonal conjugate; extends from lower border of symphysis pubis to sacral promontory
- Estimate anteroposterior diameter of the outlet; extends from lower border of symphysis pubis to tip of sacrum
- Check manual estimation of anterposterior measurements using measuring devices

Maternal Assessment of Fetal Activity

- Monitors fetal well-being
- Begins at approximately 28 weeks
- Reduction in movement may indicate hypoxia, growth restriction, or fetal demise
- Count fetal movements at same time each day
- Report to HCP: <10 movements in 3-hour period; significantly less than normal movement; perception of decreased movement in 24-hour period
- Factors that may affect movement: sleep-wake cycle of fetus, smoking, maternal hypoglycemia, sound, drugs

ULTRASOUND

- Transabdominal: transducer with transmission gel over abdomen; visualization facilitated with full bladder
- Transvaginal: probe inserted into vagina; clearer images; utilized early in pregnancy

Reasons for Ultrasound

- Determining gestational age; most accurate at 6-10 weeks
- Identifying FHR and fetal breathing movements
- Estimating fetal size; measure biparietal diameter, femur length, estimate weight
- Screening for fetal anomalies (i.e. Down Syndrome, anencephaly, cardiac defects)
- Identifying amniotic fluid index
- Identifying placental location and grading
- Detecting fetal position and presentation
- Detecting fetal demise

DOPPLER VELOCIMETRY

- Assesses placental function
- Measures bloodflow changes in maternal and fetal circulation
- S/D over 3 = decreased placental perfusion

NONSTRESS TEST (NST)

- Accelerations = intact CNS
- Acceleration patterns affected by gestational age
- Accelerations must be 15 bpm above baseline, lasting 15 seconds
- Top of strip shows FHR, bottom of strip shows uterine activity
- "Reactive": 2+ accelerations within 20 minutes
- "Nonreactive": insufficient accelerations over 40 minutes

VIBROACOUSTIC STIMULATIONS (VAS)

- Application of sound and vibration to stimulate fetal movement
- Used to facilitate NST

CONTRACTION STRESS TEST (CST)

- Evaluates uteroplacental function
- Identifies intrauterine hypoxia
- Observes FHR response to contractions
- If compromised, FHR will decrease
- Can be negative, positive, equivocal-suspicious, equivocal-hyperstimulatory, or unsatisfactory

Interpreting Results of CST

- Negative: stress of uterine contraction shows 3 contractions of good quality lasting 40+ seconds in 10 minutes without late decelerations
- Positive: stress of uterine contraction shows repetitive persistent late deceleration with more than 50% of contractions
- Equivocal: "suspicious" = inconsistent late declerations; "hyperstimulatory" = contraction frequency every 2 minutes or lasting >90 seconds with late decleration

BIOPHYSICAL PROFILE

- Normal--score = 2, abnormal--score = 0
- FHR acceleration: "nonstress test"; normal--2+ accelerations of >15 bpm for >15 seconds within 20-40 minutes; abnormal--0 or 1 acceleration in 20-40 minutes
- Fetal breathing: normal--1+ episode of rhythmic breathing lasting 30+ seconds within 30 seconds; abnormal--less than 1 episode
- Fetal movements: normal--3+ discrete body or limb movements in 30 minutes; abnormal--less than 2 movements in 30 minutes
- Fetal tone: normal--more than 1 extension of fetal extremity with return to flexion, or opening/closing of hand; abnormal--no movements or extension/flexion
- Amniotic fluid volume: normal--single vertical pocket >2 cm, AFI >5 cm; abnormal--largest single vertical pocket <2 cm, AFI <5 cm

Diagnostic Uses of Amniocentesis

- Fetal health
- Genetic testing for fetal abnormalities
- Fetal lung maturity: lecithin/sphingomyelin ratio 2:1, phosphatidylglycerol presence, and lamellar body counts indicate maturity

Nurse's Role in Amniocentesis

- Help prepare patient: explain procedure and make sure informed consent was explained
- Gather supplies: 22-gauge spinal needle with stylet, syringes, 1% xylocaine, povidone-iodine, three test tubes
- Obtain baseline maternal VS and FHR
- Assist with ultrasound to determine location of placenta, fetal parts, and amniotic fluid
- Assist with procedure and managing test tubes
- Monitor patient every 15 minutes during and after procedure
- Educate patient on activity limitations and complications to report
- Document procedure, patient response, and patient understanding of instructions

AMNIOCENTESIS

- Scanned by ultrasound to determine placenta site and to locate a pocket of amniotic fluid; needle inserted into uterine cavity to withdraw amniotic fluid
- Used to determine genetic, metabolic, and DNA abnormalities
- Can detect neural tube defects
- Complications: vaginal spotting and cramping, mild fluid leakage

CHORIONIC VILLUS SAMPLING (CVS)

- Used to detect genetic, metabolic, and DNA abnormalities
- Needle aspiration of chorionic villi from placenta
- Provides earlier dx than amniocentesis
- Cannot detect neural tube defects
- Pregnancy loss is 2x higher than amniocentesis
- Potential for limb reduction

Screening and Diagnostic Tests

- To validate pregnancy: transvaginal ultrasound of gestational sac volume, 5-6 weeks after LMP
- To determine how advanced pregnancy is: crown-rump length ultrasound at 6-10 weeks; biparietal diameter, femur length, abdominal circumference at 13-40 weeks
- To identify normal growth of fetus: biparietal diameter ultrasound at 20-30 weeks; head/abdomen ratio at 13-40 weeks; estimated fetal weight at 24-40 weeks
- To detect congenital anomalies and problems: nuchal translucency testing at 9-13 weeks; ultrasound at 18-40 weeks; CVS at 10-12 weeks; amniocentesis at 15-20 weeks; fetoscopy at 18 weeks; 1st trimester combination screening test or quadruple test at 15-20 weeks
- To assess fetal status: biophysical profile, maternal assessment of fetal activity, and nonstress test at 28 weeks to birth; CST after 28 weeks
- To diagnose cardiac problems: fetal echocardiography at 2nd/3rd trimesters
- To assess fetal lung maturity: amniocentesis at 33-40 weeks; L/S ratio, phosphatidylglycerol, phosphatidylcholine, and lamellar body counts from 33 weeks to birth
- To obtain more info about breech presentation: ultrasound just before labor is anticipated or during labor

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