The Greatest OB Review Ever

Fran Laughton

Determining Gravida, Para

Gravida- women who is, or has been pregnant (count all including 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

Determining Gravida, Para

To further establish outcomes you may apply the GTPAL classification 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

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 seven days (assumes 28 day cycle)

Antepartum Period
Embryonic period (week 3-8) most sensitive Drugs, ETOH can cause most harm to developing organs Fetal period (week 8-40) organs maturing

Antepartum Period

Unique structures in Fetus Cord has one vein, 2 arteries Ductus Venosis- shunts blood to portal vein, 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)

Antepartum Period

Presumptive signs of Pregnancy Amenorrhea N&V Breast changes Urinary frequency Fatigue Goddells sign (softening of cervix)

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 (1620 wks.) Positive HCG

Antepartum Period
Positive signs of Pregnancy Detection of FHR Palpation of movement Positive USS

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

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 decreases 80 %, thyroid gland enlarges, BMR increases

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, 1 lb/week thereafter Lactating female needs 2800Kcal/day; 3L. fluid

Antepartum Period
Drug Classifications Class A presumed safe thyroid Class B No adverse effects Insulin Class C Risk unknown Colace Class D Evidence of risk lithium Class X Known teratogen Accutane

Antepartum Period

Problems Hyperemesis gravidarum PIH Gestational diabetes Anemia TORCH Placenta Previa Abruptio Placenta Substance abuse Pregnant Adolescent

Antepartum Period
Hyperemesis Gravidarum N & V past 12 weeks of pregnancy resulting in dehydration, poor nutrition and possible altered electrolytes Management is by hospitalization, IV fluids, slow introduction of foods, Reglan if needed

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/24 hr. extensive edema, altered labs Deterioration of DTRs indicate progression of disease; 3+ w/clonus ominous AKA preeclampsia, eclampsia HELLP syndrome a risk

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

Antepartum Period

Gestational Diabetes associated with congenital anomalies, macrosomia GTT mid trimester If type 2 at onset of pregnancy, need insulin Insulin needs increase after 20 weeks because hormones made by placenta block effects of insulin

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

Antepartum Period
TORCH

Toxoplasmosis Other- GC, chlamydia, varicella, HBv, GBS, HIV Rubella Cytomegalovirus Herpes

Antepartum Period

Placenta Previa When placenta implants near or over cervical os Classic symptom: Painless Vaginal Bleeding No vaginal exams; no intercourse Monitor for bleeding, labor Usually delivered by C-Sec

Antepartum Period

Abruptio Placenta Premature separation of the placents Medical emergency due to maternal/fetal hemorrhage 10-30% develop DIC Symptoms include sudden intense localized uterine pain w/wo vag. Bleeding May deliver vaginally depending on timing

Antepartum Period

Substance Abuse Cigarettes known to produce SGA, IUGR All are associated with poor nutrition Recommended to avoid all ETOH, drugs in pregnancy 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

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 for support Higher rates of PIH, FTT infant

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.

Antepartum Period
NST- two accelerations in 15 minutes is a reactive 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 pts each with 8-12 normal; 4-6 in jeopardy. Most reliable indicator of fetal well being; highly correlated with APGAR

Intrapartum Period
5 Ps

Passenger Passageway Powers Position Psychological response

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

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 intravaginal prostaglandin to soften cervix

Intrapartum Period

Fetal Heart Rate Monitoring May be internal (complicated), external Normal FHR 110-160 Baseline established by average FHR in a 15 minute period; stable or variable Beat to beat variability 3-5 Decelerations: early, late, variable Accelerations generally positive

Intrapartum Period

Nonreassuring Patterns Fetal tachycardia Fetal Bradycardia Saltatory variability Variable decels w/ non reassuring pattern Late decels with beat-to-beat preserved

Intrapartum Period

Accelerations Transient increases in FHR. Usually associated with fetal movement, 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, in a twenty minute period is a REACTIVE NST

Fetal Accelerations

Intrapartum Period
Early Decelerations Early decelerations are caused by fetal head compression during contraction resulting in vagal stimulation and slowing of FHR.

Deceleration has uniform shape, and mirrors contraction

Early Decelerations

Intrapartum Period

Ominous Patterns Persistent late, loss of beat-to-beat Variable associated with loss of beat-tobeat Prolonged severe bradycardia Loss of beat-to-beat not assoc. c fetal sleep, medication, or prematurity

Late Deceleration

Intrapartum Period

Late Decelerations Symmetric fall in FHR beginning at or after PEAK or contraction, 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

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

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

Intrapartum Period

Causes of Fetal Tachycardia Fetal hypoxia Maternal fever Maternal, fetal anemia PTL drugs (Terbutaline, Yutopar) Chorioamnionitis Congenital heart Prematurity

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

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

Intrapartum Period

Variable Deceleration Acute fall in downslope and variable recovery. Variable in duration and often resembling letter U, 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 if beat-to-beat lost

Intrapartum Period
Other Patterns Sinusoidal Rhythm- rare but ominous. Associated with high M & M. A regular smooth undulating sine wave with a stable baseline of 120-160 and absent beat-to beat. Saltatory Rhythm-Increased variability over 25 BPM usually caused by fetal hypoxia, cord compression

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

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

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

Intrapartum Period
IV analgesia usually with Stadol (2 mg. IVP); Nubain (10 mg. IVP) occasionally Fentanyl, Versed Epidural if instrumentation anticipated or PRN Both associated with changes of FHR

Postpartum Period
Six weeks to complete involution Fundus descends 1-2 cm/24 hrs; not palpable by day 9 Must remain firm to prevent bleeding; rises with retained clots True milk after 2-3 days On-going assessment include VS, lochia, Fundal height/ firmness, B/B, perineal healing, bsts, teaching and comfort

Postpartum Period

Most Common Complications Postpartum hemmorhage Mastitis UTI Puerperal infection Thrombophlebitis

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

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 vigorous resuscitation

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

Normal Newborn

Thermoregulation Balance of heat lost/heat produced Most at risk for loss through head Hypothermia increases BMR requiring increased o2 consumption Brown fat at shoulders provides extra insulation; intense lipid metabolic activity; absent in preemies

Normal Newborn
Newborn Metabolic Testing

PKU Hypothyroidism Galactosemia Hemoglobinopathies Other inborn errors of metabolism (some states)