Pregnancy Physiology and GTPAL

Physiology of Pregnancy

• Presumptive (subjective) signs include flu-like symptoms, breast tenderness, nausea/vomiting, and missed period
• Probable (objective) signs include positive pregnancy test, Chadwick sign (blue cervix), Goodell's sign (softening of cervix), and Hegar's sign (softening of the lower uterine segment)
• Positive signs of pregnancy are ultrasound visualization of the fetus and hearing the fetal heart rate (FHR)
• Nagele's rule involves subtracting 3 months from the last menstrual period (LMP) and adding 7 days to estimate the delivery date
• At 16 weeks, the fundal height is halfway between the umbilicus and the pubic bone
• At 20 weeks, the fundal height is at the umbilicus
• At 40 weeks, the fundal height is at the xyphoid process

GTPAL System

• GTPAL stands for Gravida, Term, Preterm, Abortion, Living
• A patient at 8 weeks gestation with a history of 1 spontaneous abortion (SAB) at 10 weeks and 3-year-old twins, and 1 ectopic pregnancy would have: G4 T1 P0 A2 L2

Gestational Diabetes Mellitus (GDM)

• GDM is glucose intolerance that develops during pregnancy
• Risk factors include macrosomia (large baby), genetics/family history, obesity/sedentary lifestyle, PCOS, and pre-existing hypertension
• Signs and symptoms include hypoglycemia symptoms such as jitters/tremors, lethargy, and diaphoresis, as well as DKA symptoms like fruity breath and loss of consciousness
• Diagnosis involves a 1-hour glucose tolerance test, with a blood sugar threshold of 135
• If the 1-hour test fails, a 3-hour fasting glucose tolerance test is performed
• A patient diagnosed with GDM is at higher risk for developing diabetes later in life (within 10 years)
• If lifestyle changes (diet and exercise) are insufficient, insulin may be needed (not metformin)

Infertility

• Infertility is defined as the inability to conceive after 1 year of unprotected intercourse if the woman is under 35, or after 6 months if she is over 35
• Causes of female infertility include PCOS, ovulatory disorders, tubal factors, STDs, structural issues in the uterus, and hormonal/endocrine imbalances
• Causes of male infertility include exposure to toxic chemicals or radiation, age, marijuana use (decreases sperm count), eating disorders, cancer, obesity, and structural issues in the reproductive tract
• Diagnosis involves hormone tests, HSG, and hysteroscopy for women, and semen analysis for men
• Common treatments for women not ovulating include Clomid, Letrozole, aromatase inhibitors, nursing interventions, and emotional support

Infections During Pregnancy Prenatal Testing

• Some infections can affect pregnancy, STIs, and TORCH (Toxoplasmosis, Other [HIV, GBS at 36 weeks], Rubella, Cytomegalovirus, Herpes) infections, potentially causing fetal death, physical abnormalities, and birth defects
• Group B Streptococcus (GBS), if positive and untreated, can be passed to the baby, leading to NICU admission with RSV symptoms and respiratory distress
• If positive for GBS is treated with antibiotics and does not affect the pregnant woman, just baby

Labor and delivery: 5 P's

• Powers = contractions
• Passage = Pelvis (soft tissue) Most conducive is Gynecoid shape
• Passenger = Baby
• Psyche = Mother's emotional state
• Position = Fetal position (breech, transverse, vertex)

Stages of Labor

• Stage 2 involves full cervical dilation (10 cm), active labor, and the delivery of the baby
• Cervix is 100% effaced, and thinning to paper thin
• Contractions increase in intensity, frequency, and duration, lasting about 60 seconds and occurring 2 minutes apart
• Nursing interventions include monitoring fetal heart rate, assessing before/during/after contractions, evaluating fetal strips for distress signs (variability), and assessing uterine tone
• The patient feels the urge to push or have a bowel movement due to pelvic pressure

Contractions

• Palpate the abdomen during contractions to ensure the uterus is tensing up and relaxing afterward
• Failure of the uterus to relax can lead to fetal asphyxia and maternal tachysystole
• Patient positioning and pushing during contractions can assist the body's expulsion
• Pushing during non-contractions can lead to tearing or lacerations

Fetal station

• Fetal station -3 indicates the baby is high and not engaged in the pelvis
• Fetal station 0 means the head is at the ischial spine
• Fetal station +3 indicates the baby is crowning
• Stage 3 of labor lasts 5-15 minutes and involves the delivery of the placenta after it spontaneously detaches from the uterine wall
• Signs of placental arrival include blood gushing, cord lengthening, and abdomen rising into a round shape rather than oval
• Monitor bleeding, administer Pitocin, evaluate for PPH, and examine placenta looking for missing pieces (retained placenta = PPH)

Umbilical Cord

• Umbilical cord has 2 arteries and 1 vein
• Provide peri care and promote bonding with the baby

Cardinal Movements of Labor (EDFIEE)

• Engagement: Baby's head engages into the pelvis, usually at station 0
• Descent: Baby moves down the birth canal through contractions (involuntary) and bearing down (voluntary)
• Flexion: Baby's head flexes, chin to chest, due to cervical resistance, reducing the head's diameter
• Internal Rotation: Baby rotates
• Extension: Baby's head exits, face looking down at mom's anus
• External Rotation: Baby rotates to facilitate delivery of anterior shoulder
• Expulsion: Baby's out

Strip Interpretation (VEAL CHOP)

• V = Variable decelerations, C = Cord compression
• E = Early decelerations, H = Head compression
• A = Accelerations, O = Okay
• L = Late decelerations, P = Placental insufficiency
• M = Move/Reposition patient
• I = Identify labor stage, N = Nothing, E = Emergency action
• Nursing interventions include repositioning, applying O2, stopping oxytocin, and administering fluids

Induction

• Induction is the artificial stimulation of uterine contractions before spontaneous labor
• Methods include cervical ripening agents (Misoprostol and Carvedilol)
• Misoprostol effacement causes uterine contractions, and the Bishop score assesses cervical favorability and fetal station
• Indications include labor not progressing, infection, post-term pregnancy, and abruptio

Induction Contraindicated

• Not for patients with previa (will bleed), gestational hypertension, or preeclampsia
• PROM to reduce risk of infection, the presence of fetal distress, or How to induce
• Artificial Rupture of Membranes (AROM)
• Risks include tachysystole (5 contractions in 10 minutes, lasting over 2 minutes, occurring 1 minute apart without uterine relaxation), and Preterm Labor
• Assess for engagement of head to prevent prolapsed cord

Preterm Labor

• Risks include drug abuse, previous preterm labor, trauma, smoking, multiple gestations, obesity, GDM, HTN, preeclampsia, infections, existing comorbidities
• Cervical length dictates preterm labor risk (short cervix can predispose) - treated with cerclage
• Symptoms include lower back pain, contractions, cramping, pelvic pressure, diarrhea, bleeding, vaginal discharge changes, and fluid leaking
• Evaluate with nitrazine paper and microscope

Preterm Labor Treatment

• Visualization of pelvis and Amnisure
• Tocolytics (Terbutaline and Nifedipine)
• Magnesium sulfate and Steroids (Betamethasone) for fetal lung maturity

Cesarean Section Indications

• Distressed baby, fetal issues, abnormal positioning, abnormal FHR, meconium, preeclampsia, comorbidities, tachysystole, preexisting pregnancy factors, abruption, and previa
• Other indications include long/stalled labor, large fetal head, cephalopelvic disproportion (CPD), obesity, maternal age, and prior uterine surgery

Fetal Dystocia

• Fetal Dystocia includes CPD complications, asphyxia, fetal injuries (bruising), and maternal lacerations
• Assessments include FHR above the umbilicus (breech), SVE may show butt or feet, presenting part not engaged, and no fetal descent
• Nursing interventions include determining baby's position using Leopold's maneuver, and assessing FHR and fetal position via SVE

Preeclampsia

• Preeclampsia signs needs alerting
• Difference exists between chronic, gestational HTN, and preeclampsia
• Chronic HTN is 140/90 consistently and before 20 week gestation mark
• Gestational HTN is diagnosed during pregnancy, occurring after 20 weeks ( 140/90 with no preeclampsia signs)
• Preeclampsia is 140/90 x2, 4 hours apart, with proteinuria
• There can be other symptoms without proteinuria (epigastric pain, visual disturbances, or Headaches)
• Renal insufficiency, thrombocytopenia, low platelets, HELLP syndrome ( elevated liver enzymes), and induced immediately are signs
• RF: Obesity, age, multiple gestations, first pregnancy, smoking, lifestyle habits, family history, previous preeclampsia and comorbidities

Preeclampsia Associated Comorbidities

• Lupus, diabetes, and chronic HTN
• Treatments include labetalol and nifedipine
• Magnesium reduces seizure risk (does not reduce BP)

Magnesium Toxicity

• Magnesium toxicity includes absence of DTRs, decreased RR, oliguria, strict I&Os, < 30 ml/hr, and needing calcium gluconate

HELLP

• HELLP includes hemolysis, elevated liver enzymes, and low platelets

Prolapsed Cord

• Prolapsed Cord can be hidden, Definition is umbilical cord fall out
• RF: AROM/SROM, presenting part of baby not engaged
• Make sure head is engaged before ROM, elevation of the presenting part, emergency preparation, 02 administration, bolus and hydration

Placental Abnormalities

• Different from abruption
• No pain with vaginal bleeding present with previa, low lying and lower uterine segment
• Pelvic rest, no vaginal exams unless necessary, monitor baby, and Rh staus are necessary
• Structural, multiple gestations and age causes this

Antepartum Hemorrhage

• History of previa, smoking, and abruptio is high risk
• Signs of Abruptio presented is extreme pain and ripped placenta
• Trauma and HTN causes

Chorioamnionitis

• This is an infection in amniotic flut or soft tissues and requires no temperature for diagnosis
• S/S includes fever, fetal/maternal tachycardia, purulent fluid, and elevated WBC
• ROM does not indicate chorio
• Palpate the uterus if it is tender and patient is clammy

Breastfeeding

• S/S: Localized pain, Warm skin, Redness, and fever.
• Treatment is Antibiotics, feeding every 2-3, Hydration and rest
• Do not want clogged milk dructs any further
• Cracks can be caused by improper latching

Postpartum

• Assess for involution
• Fundus should be at umbilicus immediately and 6-12 days after

Postpartum Assessment

• Goes down 1 cm every day, it is difficult to still feel 14 days after birth B- Bladder B - Bowel L- Lochia
• Should encourage Hygiene by changing very 2 hours
• Prevent Medium by encouraging patient to change every hours (dark and moists environments)
• Promote hygiene

Lochia

• Lochia rubra is the first discharge after delivery
• Lochia serosa - gets a lot lighter, 10 days after
• Lochia Alba is turned down into light brown; up until 6 weeks (Hypertensive at this point)

Post-Partum Infections: Risk Signs

• After PROM (24 hour Over) you require a long period of recovery
• Genital tract infections and bacterial

TOLAC/VBAC/Operative Vaginal Births

• VBAC (Vaginal Birth After Cesarean) is a type of birth for people who have had a prior Cesarean delivery can be a good candidate if Previous VBAC. Transvere baby and normal progression

Postpartum Assessment: BUBBLE-LE

• B- Breast
• Mastitis and Difference exists between engorgement and mastitis
• Unilateral is mastitis is bilateral otherwise

Uterus Care

• Pat dry, change pad every 2-3 hours, front to back
• Check for episiotomy or incisions (and for lower extremities and emotions)
• Monitor or PPD/Blues

Post Partum Depression

• Symptoms include Intervention goes away
• Typically requires some medication and therapy if not
• Risk Factors include: history of depression, anxiety, socio-economics, no support and low finance

Post Partym Physcosis

• Rapid can occur right after delivery
• Delusions can be associated with delivery, hallucinations occur, not enjoy babies
• Genetic- Bipolar disorder

Newborn Assessment

• Conduct a head to toe. check fontanels
• Cardiac (Different defects in textbook) If a murmur is very strong, its abnormal
• Respiratory assessment crackles are normal

Vitals

• Baby very quickly and needs to be tempered in Auxillary method
• Very thin can still be sensitive at birth

Hyperbilirubinemia

• Definition: jaundice

Hyperbilirubinemia Types

• Blood and ABO is very common in babies
• Risk includes infection and transfusion requirement
• Nursing Interventions are covering eyes

Hypoglycemia

• Risk is mom has diabetes, stressful births and traum Pre-maturity and birth or RDS

Glucose Maintenance

• Monitor the glucose level, check diaper and feed patient.
• Do Cord Camp and give some vaseline for clamp or redress the purulent.

Dysmenorrhea and Chronic Pelvic Pain

• Definition - painful periods
• Definition - pelvic pain that lasts 6 months or more and results in some kind of functional disability

Pelvic Disease

• STD and PID and Infection. Check for fibroids and adhesions

STI

• STIs: Mostly from no symptoms.
• Check women for abdomen pain and fevers Typically Men will have symptoms
• Syphilis- Primary, Secondary and tertiary- it will get worse and effect major diseases overtime
• Those that have Trichinosis- have yellow with a foul smell

Cervical Cancer

• Cervical Cancer is cause by HPV
• Get PAP test 3 for <20 year, for 30 year check for CYTO-5.
• You do need to follow recommendation and still need to

Breast Cancer

• Cancer is not going away

Breast Cancer

• The largest risk is genetics and Risk FactorsGenetic component - BRCA 1 & 2 gene
• Can screen by doing Mammos every 3 years. Then Ultrasound to check for side effects

Osteoprosis

• Osteoprosis leads to loss of bone.
• Check how much you need based on what age you are, but all need vitamin D