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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)