OB Final Exam

-Done between 10 and 12 weeks gestation
-Sample of the chorionic villi from the edge of the placenta is obtained
-Transcervical or abdominal procedure
-Can detect genetic abnormalities
-Sickle cell, down syndrome, X-linked traits
-Lots of education for why it is performed
-Risk of miscarriage, infection
-Does not detect neural tube defect
-Rhogam required for rH negative mother
-Report fever, leaking, any other complications
-Assess FHR by US or doppler after

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Terms in this set (235)

Chorionic villus sampling

-Needle is inserted into the uterine cavity through the maternal abdomen
-US is used to identify location of placenta, fetal parts, etc.
-Betadine skin prep
-Spinal needle is inserted
-Amniotic fluid is withdrawn
-Done in the second trimester to look for genetic abnormalities
-Done in the third trimester to tell us if the fetal lungs are mature if we are expecting early delivery
-Risk of miscarriage after 15 weeks gestation, no ultrasound to guide this: risk of preterm labor, injury to fetus or placenta
-Rhogam required
-Mom needs a full bladder since US guided
-Educate, keep them calm, anxiety may be present and still around after delivery
-Monitor FHR before and after procedure. Report fluid leaking, decreased fetal movement, fever

Amniocentesis

Teaching following __________________:
Report:
-Abdominal pain or cramping
-Leaking fluid or bleeding
-Decreased fetal movement
-Fever, chills
-No heavy lifting for 2 days post procedure

Amniocentesis

-Requires use of an electric fetal monitor
-Observe for accelerations of the FHR in response to fetal movement
-Acceleration of FHR = increase in heart rate of 15 bpm or more lasting 15 seconds
-Accelerations indicate an intact nervous system, not effected by hypoxia
-Can be performed after 30 weeks gestation
-Order this for triage client. Put baby on monitor and see how baby is responding to intrauterine environment. Put it on for contractions and FHR. Look for accelerations (15x15 rises in FHR = good oxygenation) and moderate variability
-Non-invasive, reliable indicator of fetal well-being

Nonstress test

Two or more accelerations of fetal HR within 20 minutes

Reactive NST

Does not meet criteria for reactive NST

Nonreactive NST

-Oxytocin challenge test
-Observe the response of the FHR to contractions
-Evaluate for uteroplacental sufficiency
-Used in at risk pregnancies: non reactive NST and post dates
-We have a perceived reason to think the baby will not tolerate the stress of labor
-Mom is NPO, start IV (LR), give mom a little oxytocin very slowly and have contractions every 2-3 minutes to see if baby will tolerate labor. If you see decelerations and variables stop oxytocin and go to emergency c-section

Contraction stress test

_____________ CST: no late decelerations occur after any contraction
-Baby is tolerating intrauterine life, take her off pitocin, send her home

Negative

___________ CST: late decelerations occur with at least 2 of the 3 contractions
-Probably will need c-section

Positive

____________ CST: late decelerations with a single contraction or late decelerations occur with hyperstimulation pattern
-Continue to watch mom, not great but not bad

Equivocal

Measures: -Fetal breathing movements -Gross body movements (baby moving, rolling over, stretching out arms) -Fetal tone -Reactive fetal heart rate -Amniotic fluid volume Reactive fetal HR done by non stress test. The rest is done by ultrasound.Biophysicial profile (BPP)____/10 and _____/10 is reassuring. Baby tolerating intrauterine environment.8, 10_____/10 is equivocal. May go ahead and deliver depending on baby's age. If > 36 weeks, then we deliver. If < 36 weeks, wait 24 hours and repeat and if they still get this number, deliver.6______/10 means baby is not tolerating intrauterine life. Indicates probably fetal asphyxia so delivery here is recommended. If they are > 32 weeks gestation we will induce. If they are < 32 weeks gestation we wait and do it again later that day.4______/10 indicates fetal asphyxia is present and we need to deliver (GET THE KID OUT).2_____/10 indicates there is no sign of fetal movement, and they baby is dead.0-Present in maternal serum and amniotic fluid -AFP is a fetal serum protein -Maternal serum AFP rises throughout pregnancy and peaks at 30 weeks gestation -Amniotic fluid AFP peaks at 15 weeks - Increased indicates neural tube defect, ancephaly, oomphacele, down syndrome -High false positive rate. Screening tool, not a diagnostic tool. -If positive, it can be associated with low birth weight, too little fluid, underweight mother, long gestation age (further along than they realize) -Detects 80-85% of neural tube defects -Provide support, assist with scheduling for follow up or further screening, might not be in the chart, and mom can decline itAlpha-fetoprotein (AFP)Helps prevent neural tube defects. Can be found in green veggies, peanuts, and whole grains.Folic acid-Take with food to reduce nausea -Take with acidic beverage to promote absorption (OJ) -Take entire daily dose at one time if nausea is a problem -Milk, antacids, and caffeine decrease absorptionIron-You don't want them to do enema because it can cause GI cramping (could cause contractions and miscarriage) -They should eat fruits, veggies, high fiber foods, and drink water to help prevent thisConstipationHave high nutritional needs because their bodies are still growing themselves. They might have an increased weight goal because they need more nutrition than older women. They might be trying to hide their pregnancy (issues with growth of baby) from family.AdolescentsCraving of non nutritious substances that provide no nutritional values and deplete stores (ice chips, laundry detergents, freezer frost)PicaCommon in first trimester where HCG levels are higher and as the levels decrease, the nausea should get better.N/VCan be relived by: -Small meals -Don't drink a lot with meals -BRAT diet (bananas, rice, apple sauce, toast) -Eat anything she can keep down -Carbs in the morning (pack of saltines) -Protein at night timeN/VRequired for bone growth. Mom needs a good intake of ________________. Can be received through dairy (yogurt, egg, cheese, milk)CalciumWhat is a source of calcium for vegan mothers?Legumes, nuts, dried fruits, broccoli, green leafy vegetablesPersistent, uncontrolled vomiting that goes past 20 weeks of pregnancy. They have trouble keeping water down, throw up everything, major electrolyte imbalances, metabolic alkalosis is a problem because of vomiting. May have a PICC line, hospitalization to have fluids and replacement, food will slowly be reintegrated back into diet.Hyperemesis gravidariumIncreased estrogen and progesterone causes increase in size and number of mammary glands, provides enlargement of nipples and areola, colostrum develops around 16 weeks of pregnancyBreastIncreased estrogen and progesterone causes hypertrophy, increase in weight, size, elasticity, vascularityUterusIncreased thickness in mucosa, increased vaginal secretions (clear discharge), increased pH (yeast infection risk increases)VaginaIncreased plasma volume by 35% which is why we see anemia. Baseline HR will increase by 15-20 bpm because of more blood flow. More hypercoagulable state (increased platelets for protection. Edema is common because of increased blood flow and volume and increased venous pressure to lower extremity so may have foot swellingCardiovascularIncreased oxygen consumption. They breathe deeper, decreased airway resistance, anterior-posterior diameter increased. More prone to hyperventilation, dyspnea, nasal congestion, epistaxis (nose bleeds because estrogen is promoting increased vascularity and progesterone is relaxing everything)RespiratoryGlomerular filtration rate increases, increased output, reabsorption factor is decreased (protein spilling in urine)RenalN/V, higher risk of constipation, motility of GI system slows down because uterus displaces intestines and sits up in the abdomen and progesterone is relaxing so it doesn't have as good motility as it once didGI systemRelaxation of joints, position, belly shifts center of gravity, may see a duck walk because of relaxation of jointsMusculoskeletalWhat vaccines can be given to pregnant patient?Hep B, TDAP, flu shotWhat vaccines can not be given to a pregnant patient?MMR, Varicella, Flu mistFertilized eggZygote12-16 cell zygote, very compact, takes on more interstitial water and begins to divide moreMorula4-5 days later a morula becomes what?BlastocyteInner mast of cells, develops the embryonic disc (baby) and amnion (sac around baby)BlastocystOuter layer of cell mass, develops into chorion and eventually the placentaTrophoblast-Where fertilization, implantation, and initial division occurs -First 14 days of human development -Cleavage -Blastomeres form morula -Blastocyst -TrophoblastPreembryonic stage-Occurs 5-6 days after fertilization -Blastocyst burrows into endometrium -Endometrium is now called decidua -Mom may see a little dark red discharge which is implantation bleeding that occurs after burrowing into the endometriumImplantationForms the brain and CNSEctodermForms bone, connective tissue, the heart, and vesselsMesodermBecomes the GI and respiratory system (all the mucosa)EndodermThin, protective layer that contains amniotic fluid, baby contained hereAmnionFunctions of ____________ ______________: -Control the baby's temperature (helps maintain neutral thermal environment, does not create heat) -Allows for free movement of the fetus -Provides cushion for the umbilical cord -Allows for symmetric growthAmniotic fluidForms 8-9 days after conception. Forms RBCs for first 6-8 weeks of life until the liver takes over. This will absorb into the umbilical cord.Yolk sacWeek 9 to birth. Every structure is growing, refining, and perfecting its functionFetal stageResponsible for metabolic and nutrient exchange. -Provides respiratory gas exchange -Glucose is main nutrient that provides energy for growth -Hormones (progesterone is key hormone we want to see increase, causes relaxation which allows uterus to relax and a place for the embryo to implant)PlacentaSide of placenta attached to momDuncanSide of placenta that attaches to babyShultz-Body stalk fuses with embryonic portion of placenta -Provides circulatory pathway from chorionic villi to embryo -One vein, two artereis -Wharton's jellyUmbilical cordOne ___________ carries oxygenated blood from placenta to baby and carries all the nutrients the baby needs and is one structure and is a thicker vesselVeinTwo ___________ carry deoxygenated blood from baby to placenta, much smaller than vein.VeinsNumber of times woman has been pregnant, regardless of outcomeGravidaNumber of pregnancies carried to the end of the 37th week of gestation of higherTermBabies born before completion of the 37th week of pregnancy but must be born after 20 weeks (20 weeks to 36 weeks and 6 days)PretermDelivery, can be induced or spontaneous (miscarriage), prior to 20 weeks of gestationAbortionNumber of pregnancies that went passed 20 weeks regardless of outcomePara-Amenorrhea (no period) -N/V -Fatigue -Urinary frequency -Breast and skin changes -Quickening (detection of fetal movement and is typically near 20 weeks)Presumptive signs-Abdominal enlargement -Goodell's sign: softening of the cervix -Hegar's sign: cervix appears blue and enlarged -Ballottement: baby floats up and back down when uterus is palpated -Palpation of fetal outline -Braxton Hicks contractions -Pregnancy tests -Home pregnancy testsProbable signs-Auscultation of fetal heart sounds (fetoscope, electronic doppler) -Fetal movement felt by examiner -Visualization of fetusPositive signsHow do you calculate EDC?LMP - 3 months + 7 daysHow do you calculate LMP?EDC + 3 months - 7 daysNormal baseline for FHR110-160 bpmFHR > 160 for 10 minutes Caused by maternal infection and anxietyTachycardiaFHR below 110 for at least 10 minutes -Rates less than 95 are almost always pathologic -The lower the heart rate, the lower the fetal cardiac output -We don't want mom flat on her back. Elevate her right hip, called left tilt, and it turns the interior vena cava back towards mom to increase blood flow back to the heartBradycardiaVisual assessment of amplitudeVariabilityUndetectable variability in baseline. This is not reassuring.Absent1-5 bpm variability Baby may be in sleep pattern and should wake shortly. Sleep patterns can last an average of 30-40 minutes, but up to 90 minutes. Narcotic like stadol and phenegran, hypoxia, and prematurity cause this.MInimal6-25 bpm variability This is expected and reassuring.ModerateChange > 25 bpm. May require intervention. This could signify the baby is in distress and trying to compensate. The problem with this is that the baby cannot do this for long before crashing. Normal finding if mom is pushing.Marked variabilityDo you evaluate variability during a contraction?NoTransient accelerations or decelerations in the FHR from baseline-related to contractionsPeriodicChanges in FHR not associated with contractionsNonperiodicTransient increases in FHR 15x15 rule Reassuring sign of fetal well beingAccelerationsDecrease in FHR Early, variable, and lateDecelerations-Deceleration has uniform shape and mirrors the contraction (happens at same time as contractions) -Fetal head compression during uterine compression = vagal response -Reassuring: no intervention needed/recheck cervixEarly deceleration-Most common type of deceleration...often seen with pushing -U,V,W in shape -Cord compression-umbilical vein and then umbilical artery are compressed = abrupt deceleration -Intervention: reposition motherVariable deceleration-Associated with uteroplacental insufficiency -It is a symmetric fall in FHR, beginning at or after the peak of the contraction and returning to baseline AFTER the contraction is over -All "lates" are considered potentially ominous -Causes: maternal factors that decrease uteroplacental circulation like hypotension, HTN, uterine hyperstimulation; conditions associated with decreased maternal oxygenation, placental abnormalities, high risk-conditions of pregnancyLate decelerationWhat are the 6 R's for intrauterine resuscitation?Reposition/Re-Examine Readjust/Remove Oxytocin Rehydrate Re-oxygenate Report Record-How long the contraction lasts -Measured from start to end of contraction -Measures in seconds -Must be 30 seconds to be considered a contractionDuration-Start to start -Measured in minutes -Rounded to half minutesFrequencyHow many contractions should there be in 10 minute period?3-5-More than 5 contractions in 10 minutes -Cut or remove pitocin to relax uterus to improve oxygenation for the baby and mother. Give fluids (LR), TerbutalineTachysystoleSQ injection to slow contractions, increased HR is side effect so know HR of mom and baby. Will make mom feel flushed and her heart race--teaching.Terbutaline-Crosses placenta easily -Neonatal abstinence syndrome (irritability, how the baby is responding, can we calm the baby, how are they eating and sleeping, quiet or agitated) -Neurologic and cognitive impairments -Delayed physical growth -Pain pills, oxycodone, hydrocodoneNarcoticsAn extremely potent vasoconstrictor and causes placental abruptions and pre-term delivery. Known as the walkaway drug because they are so worried about the next high and not concerned about the baby's needsMeth-Determined by how low the placenta is in the uterus -Risk factors: scarring, decreased vascularization, increased mass -Risk for woman: hemorrhage, shock, anemia -Risk for newborn: deteriorating status due to lack of blood supply, blood loss, hypoxia, and death -Assessment findings: painless vaginal bleeding -Don't check her cervix, leave her alone -Patient is delivered via c section and because when her cervix dilates, the placenta loses vascular supply and can cause late decelerationsPlacenta previa-Sharp, sudden pain, may or may not have vaginal bleeding depending on location of placenta -Drug use (cocaine, heroine, meth, smoking, HTN, short umbilical cord), hemorrhage (hypovolemic shock) -Can cause fetal demise -May see bradycardia or tachycardia with baby -C section done if this is suspected -Can have bleeding and no bleeding-depends on type of abruption -Mom is bleeding out because uterus is not able to contract back down at this time so risk of hemorrhage. Anticipate blood products. S/S of shock: tachycardia and hypotension.Placental abruptionBP > 140/90 or equal over multiple timesGeneral HTNMom had HTN coming into pregnancy, look at what meds she is taking, may have to adjust, beta blockers common.Chronic HTNHTN develops during pregnancy after 20 weeks gestation and no protein in the uterineGestational HTNProtein is found in urine (1+, 2+, 3+ protein in urine during dip stick), more prone to preeclamptic seizures. Decreased blood flow and perfusion (kidneys spilling protein, look at liver enzymes-AST and ALT, uric acid, clotting factors/issues-platelets decreased)PreeclampsiaMom had chronic HTN coming in and then starts spilling protein after 20 weeksPreeclampsia superimposed on chronic HTN-Progressive disorder that occurs after 20 weeks gestation-usually in last 10 weeks, during labor or first 48 hours after childbirth -Increase in BP after 20 weeks gestation -Proteinuria is present, dizziness, headache, edema -Characterized as mild or severe depending on symptoms -Only known cure is birth of fetus and removal of placenta -Risk factors: first pregnancy, adolescents, advanced maternal age, multiple gestations, obesity -Risk for mom: cerebral edema that goes to DIC, pulmonary edema, congenital HF, abruption or even death -Risk for fetus: higher risk for preterm delivery because we may just need to get the baby outPreeclampsiaWhat is the antidote for magnesium sulfate?Calcium gloconateWhat are s/s of magnesium toxicity?B-Blood pressure decreased U-Urinary output decreased (0.5mg/kg/hr, roughly 30 mL/hr-use foley with urometer) R-Respirations decreased (<12) P: Patellar reflex (decreased or absent)What is normal magnesium level?1.4-2.4What is therapeutic level for magensium?7.5-8Given to reduce risk of eclamptic seizures and provide neuro protection. Will give mom lethargic feeling and makes her feel hot and flushed. Baby will be lethargic when born. Dilates blood vessels and relaxes to help decreased BP>Magnesium sulfatePatho: Result of generalized vasospasm, circulation to all body organs is decrased. See increased peripheral vascular resistance due to increased sensitivity to angiotensin II, and decrease in vasodilators. So you are going to see decreased renal perfusion and decreased GFR, decreased circulation to liver, vasoconstriction of cerebral vessels, decreased colloid concotic pressure, and decreased placental perfusion.PreeclampsiaAssessment findings: -BP high (measure in same arm) -Proteinuria -Possible headache -Right upper quadrant pain -Visual disturbances -Decreased reflexesPreeclampsia-CNS depressant -IV administration via secondary line -High potency drug -S/S of toxicity: decreased DTR, decreased respirations, oliguriaMagnesium sulfate-Hemolysis, Elevated Liver Enzymes, Low platelets -Risks for women: abrupted placenta, renal and liver failure, death -Risks for fetus: premature birth and death -Assessment findings: malaise, nausea, RUQ pain, bruising, bleeding, and changes in lab results -Immediate delivery required (vaginal over c-section because decreased platelets)HELLP syndrome-Seizure in the presence of pre-eclampsia -Warning signs: severe persistent headache, epigastric pain, N/V, hyperreflexia with clonus and restlessnessEclampsiaTreated with: -Hydration -Bed rest -Corticosteroids -Mag sulfate -Turbuteline -Antibiotic therapyPreterm labor-Glycoprotein produced by fetal tissues -Assessed by immunoassay -Presence of cervico-vaginal fibronectin between 20-34 weeks = strong predictor of preterm delivery ' -Positive = 99% chance she'll deliver in the next two weeks -Negative = she probably won't deliver in next 2 weeks -False positives caused by KY jelly (checking mom), recent intercourse in 24 hoursFetal fibronectin-Delivery of baby before the completion of the 37th week of gestation -Infection is the biggest piece. Infection causes stress and stress causes contractions -Vascular issues, overdistention of uterus (multiple gestations, large for age) -Modifiable risk factors: occupational fatigue, over working, smoking, obesity, excessive weight, substance abuse) -Nonmodifiable risk factors: periodontal disease, uterine anomaly, advanced maternal age, young, African American and Hispanic, multiple gestation -Maternal dehydration (PO or IV hydration can help stop contractions)Preterm labor-Delivery with assistance -Woman is in second stage of labor and working on pushing but they baby is not descending -Membranes must be ruptured. -Baby is at outlet below ischial spines -We can see baby's head but isn't making much progressOperative deliveriesWhat are two complications that can occur with forceps being used?Bruising where forceps were, brachial plexus nerve injuries on the face-Cephalohematoma as complication -Used by healthcare provider -Green is good amount of pressure -Water broken -Not used on premature infant (don't want to keep turning over RBCs because they are more prone to cephalohematomas) -3rd popo off and we deliver baby via c-sectionVacuumLabor that lasts less than 3 hours from onset of labor to birth -Risk factors: 5 or more pregnancies and prior history -Assessment findings: hypertonic UC, rapid cervical dilation -Management: prepare for immediate birth -Actions: do not leave mother alone, monitor FHR and UC, assess for cervical changes, prepare for delivery, APGARS, initiate bonding, suction baby's mouth then nose -Dilates from 3-10 cm very quicklyPrecipitous deliverBaby's head is not descending well. Baby is not engaged, lack of dilation. Seen with c-section. Factors that prevent fetal descent through the maternal pelvis: -Fetal size, presentation, and position -Size and shape of maternal pelvis -Quality of uterine contractionsCPD-Refers to difficulty encountered during delivery of the shoulders after the birth of the head that may occur with macrosomia, prolonged 2nd stage, obesity, and maternal diabetes. -Risk for infant: brachial plexus injuries, clavicle fracture, asphyxia, death -Assessment findings: shoulder impaction, delay of delivery after head delivers -Actions: we should deliver baby within 60 seconds of the head being delivered, red rubber catheter to drain bladder, apply suprapubic pressure (downward pressure on pubic symphysis to move shoulder down) -Fundal massage makes it worse -Woods corkscrew: baby turns shoulder on itself -Clavicle assessment is important: x-ray for popping or clicking -McRobert's: push legs up toward ear and move knees out to open up pelvis as much as we canShoulder dystocia-When the cord lies between the presenting part of the fetus -Risk factors: lack of head engagement with ROM, breech, low birth weight -Assessment findings: SVE reveals pulsating cord, variable decelerations seen with cord compression, we can see cord out through vagina or might be in cervix around the baby's head -Management: Reposition mother, Trendelenburg position, mom on knees with butt straight up in the air, hit call light and call doctor, emergency delivery or C/S, apply upward digital pressure to get pressure of head off the cordProlapsed cordWhen there is partial or complete tear in the uterine muscle. -Causes: scar tissue from classical incision, overstimulation, eversions trying to flip baby -Assessment findings: sudden, sharp abdominal pain, may complain of tearing sensation, may or may not have blood loss. Bradycardia and late decelerations (uteroplacental insufficiency) seen in baby) -Management: emergency c-section -Actions: stabilize with fluids, oxygen, blood replacement, possible hysterectomyUterine ruptureA syndrome that occurs when the body is breaking down blood clots faster than it can form a clot; thus, the body quickly depletes itself of clotting factors, leading to hemorrhage. -Decreased platelets, d-dimer -Look at IV site for oozing, petechiae under blood pressure cuff, bruising, prothrombin time changing -Caused by ruptured, abruption, trauma, undetected fetal demise, internal bleedingDICEmbolism forms when the amniotic fluid that contains fetal cells, lanugo, and vernix enters the maternal vascular system and results in cardio-respiratory collapse. -Risk for brain trauma for mom d/t oxygen not getting to brain, increased length of stay, very deadly but rare -Mom complains of dyspnea, SOB, impending doom -Emergent, get baby out immediately, mom crashesAmniotic fluid embolism-Transient, may last for two weeks -50-70% of mothers -Feeling of "let down", cry -Etiology: psychologic adjustments, fatigue, hormonal changes, overstimulation -Treatment: supportPostpartum blues-A major mood disorder -10-15% of all women -Crying, lack of interest in usual activities, hostility -Living in a "fog", doesn't want to do anything, guilt, does what she has to to get by, may not be the best provider, tears are continuing, very down -Risk of suicide -Can occur in first 6 weeks up to 12 months after delivery (greatest risk at 4 weeks when they get their period) -History of depression, inadequate support, disturbed sleep and appetite, can't take care of themselves and baby well. just not yourselfPostpartum depression-Onset in first 3 months postpartum -Irrational thoughts and behaviors -Considered a medical emergency and requires immediate intervention -Voices telling them to do something. May have agitation, insomnia, hyperactivity, irrational thoughts, confusion -Risk factors: prior psychoses, bipolar disease, perinatal stressors, family history of mood disorder -Remove child from situation because they are at most harm during this time. Don't let mom around baby at all -Hallucinations, suicidal ideations, homicidal ideationsPostpartum psychosisAssessment: -Excessive blood loss-meticulous pad counts -Fundal height and consistency -Presence of clots -Hct and HgB -BP changes -First 24 hours after birthPrimary pp hemorrhage-Uterus is not contracting the way it should. Lack of muscle tone associated with this. -Most common cause of pp hemorrhage -First thing to do is fundal massage -May be saturating pads in 15 minutes -Clots may or may not be present -May be smaller or larger amounts of blood -Pitocin is first line medication -Have patient void to relieve full bladder -Also caused by retained placental fragments (monitor lochia)Uterine atonyThis medication stimulates uterus smooth muscle contraction. Side effect is vasoconstriction: raises BP (think about history like HTN and preeclampsia). Administered IM or PO 0.2mgMethergineDoes the same things as methergine. Side effects are bronchospasm (don't give to asthmatics). Causes diarrhea (ask for Imodium)Hemabate800-1000mcg used for hemorrhage. We want to stimulate rapid contraction to get uterus tight. Given rectally for quicker absorption.Cytotec-Laceration that was not completely repaired or everything was not sealed off appropriately during repair -Risk factors: macrosomic baby, precipitous delivery, c-section, forceps, vacuum, pushing before mom is 10cm dilated -We find a firm, midline uterus, look at her perineum and see where blood is coming from. Trickling blood, palpate fundus and it is firm but mom is still having excessive bleeding. -Won't see clots. Will see oozing blood -Monitor VS, watch blood loss, notify physician of changes, pain medication -Call the provider because they need to do a visualization and repair this.Lacerations-Occur when blood collects in connective tissue of vagina. Blood vessel leaking and creating a bruise -Episiotomy is the biggest risk factor. Also forceps and prolonged 2nd stage (pushing) can cause this. -Complaint of severe pain in perineum, tachycardia, hypotension -Reabsorbs on own if < 200cc -Incision and drainage if > 200cc -Ice packs help reduce blood flow and decrease size -Assess pain and fullness. Donut pillow for them to sit on. -Look for drainage, oozing, dehiscence. Decreased urinary output when shock occurs so they need a foley. Check Hct and HgBHematomas-Uterus inverted and comes through the body out of the vagina. -Cover with wet sterile gauze. Take to surgery to try to invert it again. -Chance of hysterectomy.Uterine inversion-Uterus is not going down how we expect it to go down -Usually occurs 1-2 weeks after birth -Risk factors: fibroids, infection of uterus lining, retained placental fragments don't let uterus contract down like it should -Diagnosed via US -May need D&C to scrape out fragments -Risk for infection-give antibiotics -Education is important: decreased bleeding and then it picks up--monitor lochiaSubinvolution-Primary cause of secondary hemorrhage -Increased bleeding is seen again with more clots -This happens when they go home because they go home so quickly. -Education at discharge -D&C to clean lining, expect antibioticsRetained placental tissueWhat does BUBBLE stand for?Breasts, uterus, bowel, bladder, lochia, episiotomyWhere is the fundus immediately after birth?Midline between symphysis pubis and umbilicusWhere is the fundus 6-12 hours after birth?UmbilicusPatient should void within the first _____-______ hours after delivery4-6When does pp diuresis occur?First 12-24 hours-Dark red, days 1-3 -Blood with small clots, scant= moderate, increases with breastfeeding, fleshy odorRubra-Pink to brown, days 4-10 -Scant, increases with activity, fleshy odorSerosa-White or creamy, after day 10 -Scant fleshy odorAlbaIce packs for the first ________ hours24Warm sitz baths after ___________ hours24When does menstruation occur in nonbreastfeeding patient?7-9 weeksWhen does first ovulation occur in nonbreastfeeding patient?By 4th cycleWhen does breastfeeding patient menstruate?3 or more monthsWhat is assessed in first 24 hours for post-op c-section?Blood loss, I&O, warming, anesthesia management (PCA, PRNs)What is done 24 hours-discharge for post-op c-section patient?Dressing removed, assess pain and monitor s/s of hemorrhage, infection, diet, urination, ability to provide self and infant care, bowel sounds, and ambulation-First day or two after birth -Period of dependency -Need for therapeutic sleep and nutrition -Need to resolve the labor experience Mother may have trouble remembering anything she is taught--she will experience memory lapses. Dependent on others.Taking-in-Second or third day after birth -Woman becomes more independent -Assumes the role of the care giver -Focus on the future She may ask numerous questions regarding newborn care and express a fear of not being able to remember everything she was taught. Becoming more independentTaking hold-Fluid change to motherhood role -Complete incorporation Mother totally incorporates the newborn into her life and recognizes that the newborn is an individual. The mother may go back to work during this time and start to reconnect with her significant other.-Unidirectional: Parent --> Baby -Bonding behaviorsBonding-Bidirectional: Parent <--> Baby -Attachment behaviorsAttachmentWhat are 4 examples of maternal attachment behaviors?-Touch (fingertips to palms to enfolding) -Vision (hold baby within 6 inches) -Voice (greets newborn, high-pitched voice) -Hearing (responds to sounds emitted by the newborn)The process of fathers bonding with babyEngrossment-Effacement and dilation -Begins at fundus and follows contour of uterus -Frequency, duration, intensity -Increment, acme, decrement phases -Involuntary -Contractions the body is doing causes effacement and dilationPrimaryVoluntary powers. Mom is pushing.SecondaryWhere the baby is in the pelvis. - is when baby is at ischial spines. Below ischial spines is positive because baby is descending through the pelvis. Negative means the baby is above the ischial spine and higher up in the pelvis.Station-Descent into true pelvis -Various shapes: most common and conducive is gynecoid pelvisPassageNice round pelvis, baby's head is round and fits nicely through, most conducive shape for delivery. Circular shape, nothing too overly prominentGynecoidOval shape, more difficult for head to go through, smushed, big baby won't fit through this shpaePlatypoidMore prominent ischial spines, more heart shapedAndroidOval shaped (up and down)Anthropoid-Fetus, membranes, and placenta -Depends on size of fetal head: bones are not fused, so permits for molding of fetal head -Fetal attitude -Fetal liePassengerRelation of fetal parts to one another. Is baby nice and curled up in fetal position or is baby stretched out?Fetal attitudeRelation maternal/fetal axis Relationship to maternal spine, is baby longitudinal (head or butt first), transverse (side ways), oblique (funny angle)Fetal lieAKA vertex Head presenting into the pelvis, and this is what we want (with a flexed head)OccipitChin first with neck extended. Baby might suck on finger (needs c-section)MentumShoulder presentation, external cephalic eversion is where you externally rotate baby from this position to flip to vertex side.AcromiumAKA breech Butt first with feet all the way up to chest or one left down or both legs are extended. Theoretically can deliver but not a good ideaSacrumFetal structure that is closest to the cervix (occiput, mentum, acromium, sacrum)Presenting partRelation of presenting part to ischial spinesStationRelation of presenting part to maternal pelvis. Posterior (back of baby's head is toward sacrum and comes out facing up), transverse (baby back of head is sideways), anterior (back of baby's head is facing mom's anterior side, coming out facing ground--we want this)Fetal positionBaby's back is on maternal right side of pelvisRBaby's back is on maternal left side of pelvisLWhat positions are most conducive for delivery?ROA and LOA+5 stationCrowning_______ station is higher in pelvisNegative_________ station is lower in pelvis (closer to delivery)Positive-Lightening (fetal head descends into pelvis and mom can breathe better) -Surge of energy (nesting-cleaning) -Braxton hicks (practice contractions) -Cervical ripening (start to see effacement and dilation) -Mucous discharge -Bloody show (seen as mom dilates further and cervix stretches and it is highly vascular from estrogen and capillaries bleed-blood tinged streaks) -Rupture of membranes -Weight loss/GI changes (diarrhea, N/V)Impending signs of labor-Back and hip pain that radiates to front side -Increased intensity and duration -Dilation -Regular intervals -Cervical changes (3-4 cm) -Walking and taking warm bath does not help and does not make anything go away-grows in intensityTrue labor-No referred pain -Irregular -Disappears with activity -Little or no cervical change -Mom walks and it starts to go awayFalse labor-Engagement: baby's head in pelvis and doesn't float up and come back down -Descent: baby coming down birth canal -Flexion: baby's head is flexed-chin brought to chest -Internal rotation: baby internally rotates 90 degrees and creates smaller passage for baby -Extension: baby extends out when head is delivered, and provider puts finger in baby's mouth to keep baby from sucking in gunk. We suck out mouth then nose -Restitution/external rotation: baby externally rotates and aligns shoulder under pubic symphysis, mom gives a little push, and we should be able to expel baby (shoulder dystocia) -ExpulsionCardinal movements-Patient is alert and excited, relief finally in labor. Anxiety may be present -Effacement and dilation are beginning -Regular contractions are beginning -Increasing intensity and frequency -Cervix dilates 0-3 cm -Nonpharm pain management: warm baths, guided imagery, breathing, relaxation, hydrotherapy -30-40 second long contractions every 5ish minutes but not really regular -Monitor vitals, infrequent assessment, relaxed, in good mood, not hurting too bad because she is attentive, educate nowStage 1 Phase 1 Latent Phase-Fear of loss of control -Increased anxiety -Increased intensity, frequency, and duration of contractions -Cervix dilates 4-7cm -Fetal descent into pelvis -Wants support person here and doesn't like when they go far -Administer IV narcotics or epidurals -Contractions every 2-3 minutes for 40-60 seconds and more regular. Moderate contraction intensity -Provide comfort measures, make sure she has what she needs, may see bloody showStage 1 Phase 2 Active Phase-Increasing anxiety and fear -Irritable -Desire to have support person at bedside -Increase frequency, duration, and intensity of contractions -Rapid fetal descent -Increased rectal pressure -Nausea, vomiting, involuntary shaking (check mom) -8-10cm dilated -Contractions every 2 min for 60-90 seconds and they are strong -Ferguson's reflex: makes her feel like she needs to poop -May need to wait to push if baby is at -2 station, sit her up and have gravity help -Get room ready, have carts set up, turn on warmer, prepare for birthStage 1 Phase 3 Transition Phase-May feel powerless -May feel sense of purpose -Completely dilated -Perineum begins to bulge, flatten, and move anteriorly -Urge to push (ferguson's reflex) -Begins at 10cm dilated to delivery of baby -This is the pushing phaseSecond stage-Relief -Focused on neonate, less focused on delivery of placenta and actions of the physician -Placental separation to placenta delivery -Initiate bonding, clamp cord, APGARS, repair lacerations, pitocin bolus -Lengthening of cord and small gush of blood indicate placenta is ready to deliver-mom gives small pushThird stageSide of placenta towards fetus "Shiny Shultz"ShultzeSide towards uterus with more bleeding "Dirty Duncan" Maternal sideDuncan-Euphoria -Bonding -Increased pulse, decreased BP -Uterus remains contracted (not at umbilicus or below) -Urine retention (may drain bladder) -Palpate fundus every 15 minutes for 1 hour -Assess vaginal bleeding -Encourage bonding and breasfeeding -Assess perineum -Perineal careFourth stage-Goal to provide maximum pain relief with minimal risk -Alteration in maternal state affects fetus -IV meds (narcotics) can cause mom to pass out -If we give mom stadol, minimal variability will happen because baby is in sleep pattern -Know what mom is dilated to (cut off point) -Narcan on hand -If true labor, narcotic will not stop laborSystemic analgesia-Injection of local anesthetic into epidural space -Advantages: excellent relief -Disadvantages: numbness, decrease feeling -Actions: before and during procedure, give 500-1000cc bolus of LR to prevent hypotension, curl over belly, stabilization and positioning, taking frequent vitals (increase in pulse, drop in BP, metallic taste, ringing in ears-notify anesthesia)Lumbar epidural blockWhat position should mom be in after lumbar epidural block?HOB 25 degrees, lateral uterine tiltHow often do you monitor vital signs after lumbar epidural?Every 5-15 minutes-Immediate onset of pain relief -Advantages: quick acting, immediate -Diadvantages: higher risk of spinal headacheSpinal block-Induced unconsciousness -Common indications: -Perceived lack of time -Contraindications to regional -Failure to successfully insert regional -Patient refusal -Last resort -We make mom unconscious, and it is systemic and crosses placenta -Seen with cord prolapseGeneral anesthesiaElicited by placing finger in palm of hand, should grasp tightly with fingers. Present at birth to 2-3 monthsPalmar graspPlace pressure on soles of feet, should elicit curling of toes (tight flexion). Present at birth to 8-9 monthsPlantar graspStroking of sole upward and across ball of foot should ellicit fanning and extension of toes (positive). Birth to 8-9 months.BabinskiNeonate will step up and down when held upright on flat surface (birth to 3-4 months)Stepping/dancingReflex when baby is startled from loud noise, they raise their arms above their headMoro/Startle reflexWhen you baby is laying down and their neck is turned to the right or left, the corresponding arm extends while the other arm bends. "fencing reflex)Tonic neckReflex where baby should suck on your fingerSuckingReflex where if you touch baby's cheek their head should turn that wayRootingProlonged pressure on the cervix causes this. It does cross the suture line. We see a build up of swelling, feels squishy, present at birth, resolves within a week, not intervention neededCaputBaby created its own cone head because it has unfused sutures and allows the skull to form to birth canal. No intervention neededMoldingAppears after birth, not at birth. Follow up will see it develop. It is usually unilateral and can be caused by trauma during delivery (vacuum suction). Can resolve in up to 3 months depending on the severity. Baby is at high risk for jaundice due to build up of RBCs.CephalohematomaWhat is normal respiratory rate for neonate?30-60 breaths/min-Periodic breathers (up to 15 seconds is normal) -Nose breathers (assess patency of nostrils) -Deviations: cyanosis, acrocyanosis, plethora, intercostal muscle use may indicate distressNewborn respirationPressure increased in RA to RV to lungs and back to LA. With shift in pressure this begins to shut. Closes 1-2 hours after birth. Mild murmurs when this does not close.Foramen ovaleConnects pulmonary artery to aorta so blood goes directly to aorta instead of the lungs since it is already oxygenated. Shift in pressure when cord is clamped causes blood to be forced into lungs and closes this structure. Should close within 15 hours.Ductus arteriosusAllows oxygenated blood from the umbilical vein to bypass the liver and go to the inferior vena cavaDuctus venosusWhat is the normal HR in first week of life?120-160Where is PMI on newborn?3rd-4th ICS and a little horizontalA by-product of the breakdown of heme-containing proteins (secondary to RBC destruction).Bilirubin-Liver is responsible for conjugation of bilirubin. -Water soluble and can be excreted -Measured as direct bilirubin -If baby poops regularly, it flushes out and we want this to happenConjugation of bilirubin-Yellow, lipid soluble pigment -Cannot be excreted -A potential toxin (brain damage) -Binds to albumin and deposits in tissues-skin, sclera -Termed indirect bilirubin or free billi -If they look yellow/orange, we know they have a bilirubin problemUnconjugated bilirubinBuildup of bilirubin that can become neurotoxic and cause brain damageKernicterousJaundice develops after 24 hours, and we start to see yellowing of skin -Causes: not eating enough and not pooping enough of the direct bilirubin out (blanch nose, sternum, or forehead, and they blanch back kind of orangey)Physiological jaundiceDevelops in first 24 hours, very quick buildup of bilirubin levels. More concerning. Positive Coombs test (Rh incompatibility between mom and baby ex: mom had previous miscarriage, but she didn't know it)Pathological jaundiceBilirubin > _____ should consider phototherapy12Bilirubin > _______ initiate phototherapy15-Bili blanket provides light from below and bili lights provide light from above -Baby in incubator so we can control the temperature -Maintaining neutral thermal environment so we can help baby's blood sugar and baby can focus on urobilirubin (bilirubin excreted through urine) -Assess I&O, how much peeing and pooping -Eye protectionPhototherapyIf mom calls concerned that her baby is jaundiced, what should you ask her?Describe how baby's skin looks-Usually eat every 1.5-3 hours -8-12 feedings in 24 hours -Feed until signs of infant satiety (relaxes, falls asleep, slows down, or stops sucking) -Feed from both breasts each feedingBreastfeedingWhere should semi-solid foods be introduced?4-6 months-Proper mixing of powder form or concentrate -Use iron-fortified formula -Always hold baby to feed-maintain eye contract -Never prop a bottle or feed with baby lying flat -Eats every 3-4 hours, has less bowel movements than bottle fed babiesFormula feedingHow long is breastmilk good for at room temp?3-4 hoursHow long is breastmilk good in the refrigerator?5-8 daysHow long is breastmilk good for in deep freeze?6-12 monthsHow long is formula good for at room temperature? 11 hourHow long is formula good for in refrigerator?48 hours

OB Final Exam

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