the greatest ob review ever

8/3/2019 The Greatest OB Review Ever

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The Greatest OB Review Ever

Fran Laughton


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Determining Gravida, Para

Gravida- women who is, or has been pregnant (count allincluding present)

Para- the number of pregnancies that reached viability(20 wks) regardless of whether they were born alive

Primagravida- Pregnant for the first time Primipara- A women who has birthed one child past age

of viability Multigravida- A women who has more than one

pregnancy Multipara- A women who has carried two or more

pregnancies to viability Nulligravida- A women who has never been pregnant


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Determining Gravida, Para

To further establish outcomes you may apply the GTPALclassification which is more comprehensive:

T- the number of full term infants (over 37 completed

weeks) P- the number of preterm infants ( less that 37

completed weeks)

A- the number of spontaneous or induced abortions

L- the number of living children M- Multiple pregnancies


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Antepartum Period

Ovarian Cycle- follicular and luteal phase

Endometrial Cycle- proliferation, secretory,ischemic and menstrual phase

Nageles Rule- to calculate EDC subtract 3

mo. from first day of LMP and add sevendays (assumes 28 day cycle)


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Antepartum Period

Embryonic period (week 3-8) mostsensitive

Drugs, ETOH can cause most harm todeveloping organs

Fetal period (week 8-40) organs maturing


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Antepartum Period

Unique structures in Fetus

Cord has one vein, 2 arteries

Ductus Venosis- shunts blood to portalvein, IVC

Foramen Ovale- blood shunted to L atrium

Ductus Arteriosus- shunts blood from R

ventricle to pulmonary artery Failure of these areas to close after birth is

called Persistent Fetal Circulation (PFC)


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Antepartum Period

Presumptive signs of Pregnancy

Amenorrhea

N & V Breast changes

Urinary frequency

Fatigue Goddells sign (softening of cervix)


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Antepartum Period

Probable signs of pregnancy

Linea nigra, chloasma gravidarum

Abd. Enlargement (above p.s. at 12 weeks).

Chadwicks- purple vagina, vulva

Hegars- softening of LUS

Ballottment- detection of floating fetus

Braxton-Hicks- irregular painless contractions

McDonalds maneuver- palpation of fetus @ 26 wks

Quickening- fluttering sensation with fetal movement (16-20 wks.)

Positive HCG


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Antepartum Period

Positive signs of Pregnancy

Detection of FHR

Palpation of movement Positive USS


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Antepartum Period

Normal Changes

Physical- uterus, ovaries, vagina, bst., cervix

MS- joint relaxation, widening PS, waddling,

lordosis, back strain

CV- Heart enlarges, increased cardiac output,pulse increase 10-15 BPM, blood volume

increase 12-1600 ml, dilutional anemia Resp- O2 consumption increase 20%, dyspnea,

nosebleeds


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Antepartum Period

Normal Changes

GI- red gums, N & V, reflux, constipation,hemorrhoids

Urinary- frequent urination, urine stasis,

Endocrine- placenta forms secreting estrogen,progesterone, glucocorticoids,1st trimester more

insulin, 3rd

trimester tissue sensitivity decreases80 %, thyroid gland enlarges, BMR increases


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Antepartum Period

Nutrition

Anticipatory nutrition

Nutrition affects fetal size, nutrient stores

Folic acid to prevent NTD

Iron to prevent anemia, improve fetal stores

Additional 300 calories during pregnancy to

promote weight gain of 3.5 lb. in 1st trimester, 1lb/week thereafter

Lactating female needs 2800Kcal/day; 3L. fluid


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Antepartum Period

Drug Classifications

Class A presumed safe thyroid

Class B No adverse effects InsulinClass C Risk unknown Colace

Class D Evidence of risk lithium

Class X Known teratogen Accutane


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Antepartum Period

Problems Hyperemesis gravidarum PIH

Gestational diabetes Anemia TORCH Placenta Previa

Abruptio Placenta Substance abuse Pregnant Adolescent


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Antepartum Period

Hyperemesis Gravidarum

N & V past 12 weeks of pregnancyresulting in dehydration, poor nutrition andpossible altered electrolytes

Management is by hospitalization, IVfluids, slow introduction of foods, Reglan ifneeded


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Antepartum Period

Pregnancy Induced Hypertension (PIH)

Mild-BP sustained at 140/90 or above;proteinuria 1-2+, mild edema, increase wt. gain

Severe- BP 160/110; 3-4+ proteinuria or 5G/24hr. extensive edema, altered labs

Deterioration of DTRs indicate progression ofdisease; 3+ w/clonus ominous

AKA preeclampsia, eclampsia HELLP syndrome a risk


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HELLP Syndrome

H emolysis

EL elevated liver enzyme

LP low platelet count

3rd. Trimester or within 48 hr. of delivery

Associated with DIC

May present with general malaise,epigastric pain, nausea, vomiting,headache


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Antepartum Period

Gestational Diabetes

associated with congenital anomalies,macrosomia

GTT mid trimester

If type 2 at onset of pregnancy, needinsulin

Insulin needs increase after 20 weeksbecause hormones made by placentablock effects of insulin


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Antepartum Period

Anemia

Defined as hgb below 10; hct below 35%

Fe needs double in pregnancy to 30mg/day

Needed for maternal and fetal stores

60-120 mg/day if anemia

Complications include preterm birth, poor

healing, infection, cardiac probs, bleeding, SGA Intake needs to compensate for increased

volume


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Antepartum Period

TORCH

Toxoplasmosis

Other- GC, chlamydia, varicella, HBv,GBS, HIV

Rubella

Cytomegalovirus Herpes


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Antepartum Period

Placenta Previa

When placenta implants near or overcervical os

Classic symptom: Painless VaginalBleeding

No vaginal exams; no intercourse

Monitor for bleeding, labor Usually delivered by C-Sec


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Antepartum Period

Abruptio Placenta

Premature separation of the placents

Medical emergency due to maternal/fetalhemorrhage

10-30% develop DIC

Symptoms include sudden intense

localized uterine pain w/wo vag. Bleeding May deliver vaginally depending on timing


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Antepartum Period

Substance Abuse

Cigarettes known to produce SGA, IUGR

All are associated with poor nutrition

Recommended to avoid all ETOH, drugs inpregnancy to avoid SGA, IUGR, FAS,prematurity

Prenatal ETOH exposure most common

preventable cause of mental retardation Not a reason to make a CPS report if still

pregnant; may refer after birth


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Antepartum Period

Pregnant Adolescent

Less likely to get PNC

More likely to smoke, gain wt.inappropriately

Younger age= more M&M

Goals of nsg are to promote PNC, refer forsupport

Higher rates of PIH, FTT infant


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Antepartum Period

Testing

Initial visit-CBC,Rh,type, urine, titres: MMR, HBV, STS,sickle if indicated, HIV if indicated

Rh- if indicated, Rhogam @ 28 wks, delivery

AFP-11-15 wks: serum hi= NTD; lo=Downs Chorionic Villus sample (CVS) chromosome 12 weeks

Amniocentesis- 18-20 weeks chromosome

NST, CST

BPP GTT- 24-28 wks. Below 140 @ 1 hr.


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Antepartum Period

NST- two accelerations in 15 minutes is areactive NST

CST- three contractions in 10 minutes without

evidence of problem is reactive CST BPP- Assess fetal breathing, movement, tone,

fluid volume, placental grade, FH reactivity; 2 ptseach with 8-12 normal; 4-6 in jeopardy. Mostreliable indicator of fetal well being; highlycorrelated with APGAR


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Intrapartum Period

5 Ps

Passenger

Passageway Powers

Position

Psychological response


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Intrapartum Period

Labor Stages

First stage, latent phase- dilate to 3 cm

First stage, active phase- dilate 4-8 cm First stage, transition- dilate 8-10 cm

Second stage- expulsion

Third stage- expel placenta Fourth stage- first four hours after delivery


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Intrapartum Period

Labor Induction

Pitocin may cause hyperstimulation, rupture

Nursing responsible for monitoring progress,

monitoring FHR, observing for complications Contractions less than q 2 min., over 90 sec., or

tetanic slow/stop drip

For induction may need intravaginalprostaglandin to soften cervix


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Intrapartum Period

Fetal Heart Rate Monitoring

May be internal (complicated), external

Normal FHR 110-160

Baseline established by average FHR in a15 minute period; stable or variable

Beat to beat variability 3-5

Decelerations: early, late, variable Accelerations generally positive


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Intrapartum Period

Nonreassuring Patterns

Fetal tachycardia

Fetal Bradycardia Saltatory variability

Variable decels w/ non reassuring pattern

Late decels with beat-to-beat preserved


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Intrapartum Period

Accelerations

Transient increases in FHR. Usually associated with fetalmovement, vaginal exams, uterine contractions,umbilical vein compression.

Considered reassuring Shoulder acceleration w/ variable considered

reassuring

Accelerations are the basis of NST. Two accelerations,

lasting 15 sec. and 15 or more BPM above baseline, ina twenty minute period is a REACTIVE NST


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Fetal Accelerations


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Intrapartum Period

Early Decelerations

Early decelerations are caused by fetalhead compression during contraction

resulting in vagal stimulation and slowingof FHR.

Deceleration has uniform shape, andmirrors contraction


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Early Decelerations


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Intrapartum Period

Ominous Patterns

Persistent late, loss of beat-to-beat

Variable associated with loss of beat-to-beat

Prolonged severe bradycardia

Loss of beat-to-beat not assoc. c fetalsleep, medication, or prematurity


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Late Deceleration


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Intrapartum Period

Late Decelerations

Symmetric fall in FHR beginning at or after PEAK orcontraction, returning to baseline after contraction ends.

Late decelerations associated with uteroplacental

insufficiency Any decrease in uterine blood flow or placental

dysfunction can precipitate

Maternal hypotension, or uterine hyperstimulation can

cause Placental dysfunction assoc with postdates,preeclampsia, HTN, diabetes


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Intrapartum Period

Emergency Intervention

O2 @ 8-10 L

L lateral or knee chest position LR fluid bolus

DC tocolytics and/or oxytotics

Emergency C-Section prep


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Intrapartum Period

Emergency Nursing Management for Prolapse Cord

Trendelenburg position

Manual elevation of presenting part O2

Notify PCP

Inspect perineum for frank cord, observe pulsing

Assess FHR


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Intrapartum Period

Causes of Fetal Tachycardia

Fetal hypoxia

Maternal fever

Maternal, fetal anemia

PTL drugs (Terbutaline, Yutopar)

Chorioamnionitis

Congenital heart Prematurity


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Intrapartum Period

Causes of Fetal Bradycardia Stable bradycardia in 100-120 range w/ good variability

not assoc. w/ fetal hypoxemia Prolonged cord compression

Cord prolapse Tetanic contractions (induced, abruptio) Paracervical block Anesthesia Maternal seizure

Rapid descent Overly vigorous vag. exam


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Intrapartum Period

Signs of Fetal Hypoxemia

Increased severity of deceleration

Late decel w/ slow return to baseline Loss of shoulders

Unexplained tachycardia

Saltatory patterns Unexplained decreased variabilty


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Intrapartum Period

Variable Deceleration Acute fall in downslope and variable recovery.

Variable in duration and often resembling letterU, V, or W

Most common abnormal pattern Caused by cord compression Generally associated with good outcome, esp. if

beat-to-beat preserved

If persistent may lead to hypoxemia, especially ifbeat-to-beat lost


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Intrapartum Period

Other Patterns

Sinusoidal Rhythm- rare but ominous.Associated with high M & M. A regular smoothundulating sine wave with a stable baseline of120-160 and absent beat-to beat.

Saltatory Rhythm-Increased variability over 25

BPM usually caused by fetal hypoxia, cordcompression


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Intrapartum Period

SROM, AROM Normal fluid pale, clear to straw, no odor Confirmed with Nitrazine for Ph or ferning Prolonged ROM predisposes to infection If AROM document time, appearance, odor,

amount, and FHR response Meconium in fluid associated with distress,

aspiration

Always assess for cord prolapse Minimize vag exams after rupture


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Intrapartum Period

Preterm Labor

Labor between 20-37th completed week

Tocolytics depress smooth muscle contraction

If questionable, hydrate and side lying position

May be managed with meds, bedrest, pelvic rest

Most common tocolytics are terbutaline, MgSO4


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Intrapartum Period

Seven Warning Signs of PTL Regular painless or painful contractions every

10 min Intestional cramping w/wo diarrhea

Menstrual like cramping Low backache Pelvic Pressure Increase or change in vag. Discharge PROM


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Intrapartum Period

IV analgesia usually with Stadol (2 mg.IVP); Nubain (10 mg. IVP) occasionallyFentanyl, Versed

Epidural if instrumentation anticipated orPRN

Both associated with changes of FHR


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Postpartum Period

Six weeks to complete involution

Fundus descends 1-2 cm/24 hrs; not palpableby day 9

Must remain firm to prevent bleeding; rises withretained clots

True milk after 2-3 days

On-going assessment include VS, lochia,

Fundal height/ firmness, B/B, perineal healing,bsts, teaching and comfort


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Postpartum Period

Most Common Complications

Postpartum hemmorhage

Mastitis

UTI

Puerperal infection

Thrombophlebitis


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Post Partum

Episiotomy

Ice pack 12-24 hrs

Inspect q. shift to determine status, healing

Provide comfort measures (sitz, tucks)

Healing in 3-4 weeks

Instruct re S/Sx infection

Complications include extension, infection,hematoma


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Normal Newborn

Apgar

Performed at 1-5 minutes; 10 pt system

Heart Rate, Respiratory rate, tone, reflex

irritability, color Scores 7 and above good

Scores 4-6 guarded; suction and O2

Scores below 4 need vigorousresuscitation


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Normal Newborn

Normal Newborn

Flexed posture

Fontanelles palpable

Molding may make head look odd

Resp 30-60; HR 120-160

Reflexes include rooting, sucking, grasp,Moro, startle, Babinski,step, tonic neck


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Normal Newborn

Thermoregulation

Balance of heat lost/heat produced

Most at risk for loss through head

Hypothermia increases BMR requiringincreased o2 consumption

Brown fat at shoulders provides extra

insulation; intense lipid metabolic activity;absent in preemies


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Normal Newborn

Newborn Metabolic Testing

PKU

Hypothyroidism

Galactosemia

Hemoglobinopathies

Other inborn errors of metabolism (somestates)

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