Pregnancy, GDM & Infertility

• Comprehensive study notes following:

Physiology of Pregnancy

• Presumptive signs of pregnancy examples are needed.
• Examples of probable signs and positive signs of pregnancy are needed.
• Nagele's Rule formula is needed for calculating an estimated delivery date.
• Findal height and its indication information must be found.
• The fundal height at 16, 20, and 40 weeks gestation needs to be determined.
• An explanation of GTPAL is needed to understand pregnancy history.

Gestational Diabetes

• More information on gestational diabetes mellitus (GDM) is needed.
• Risk factors for GDM are needed.
• Treatment options for GDM must be looked in to.
• Information regarding the diagnosis of GDM is needed.

Infertility - Female & Male

• A definition of infertility needs to be found.
• Look into the causes of infertility for both females and males.
• Find diagnostic tests for female infertility.
• Research information on male infertility.
• Common and pharmacological treatments for infertility needs to be looked in to.
• Nursing interventions for infertility patients are needed.

Infections - Prenatal Testing

• Identify what infections can affect pregnancy and why.
• Determine what GBS is and what it stands for.
• When GBS testing to performed?
• Determine what the plan of care is if a pregnant patient is GBS positive and how it affects the patient and baby.
• Research the treatment for GBS found in pregnant patients.

5 P's of Labor

• 5 P's of Labor needs to be explained with examples.
• The 5 P's of labor are
  • Powers
  • Passage (pelvis, soft tissues)
  • Passenger
  • Psyche
  • Position

Stage 2 Labor

• In stage 2 labor the cervix is completely effaced and dilated.
• Contractions are more frequent and intense, lasting approximately 60 seconds with 2 minute breaks.
• The patient feels the urge to push/bear down and might feel the need to have a bowel movement.
• Assess FHR before, during, and after contraction (frequency, duration); assess uterine tone after contraction.
• Positioning is important, instruct the patient to push properly by avoiding holding breath and deep breathing while pushing when feeling the urge, encourage open glottis pushing.
• Assess fetal station and fetal positioning.
• Provide encouragement and praise to the patient.

Stage 3 Labor

• Stage 3 labor lasts anywhere from 5-15 minutes.
• Delivery of the placenta spontaneously detaches from the uterine wall.
• Contractions are mild or discomforting.
• Signs of impending placenta delivery include lengthening of the cord, a sudden gush of blood, or change in the shape of the uterus (to globular).
• Nursing interventions for stage 3 labor must be determined.

Cardinal Movements

• Mnemonic for remembering cardinal movements: Every Day Fine Infants Enter Eager and Excited.
• The cardinal movements are
  • Engagement
  • Descent
  • Flexion
  • Internal Rotation
  • Extension
  • External Rotation
  • Expulsion
• Descent occurs due to the pressure of the fundus during contractions and the bearing down of abdominal muscles.
• Flexion occurs due to resistance of the cervix and pelvic floor, reduces head diameter.
• Extension of the fetal head drops down to the mother's anus after delivery of the head.

Strip Interpretation

• The mnemonic "VEAL CHOP" is a tool for strip interpretation.
  • V - Variable, C - Cord Compression
  • E - Early Decel, H - Head Compression
  • A - Accelerations, O – OK
  • L - Late Decels, P - Placental Insufficency
• Nursing interventions to perform when identifying concerning strip findings are to reposition, apply O2, turn off oxytocin, and administer IV fluids.

Induction of Labor

• The definition of induction of labor needs to be defined.
• Indications for induction of labor are:
  • Abruptio placenta
  • Chorioamnionitis
  • Gestational HTN
  • Pre-eclampsia
  • Eclampsia
  • PROM
  • Post-term
  • Associated co-morbidities
  • Fetal compromise
• Medications to induce labor include oxytocin, prostaglandins, and AROM.
• A risk of oxytocin induction is tachysystole leading to Category II (indeterminate) or Category III (abnormal) FHR pattern, a primary complication of oxytocin in labor.
• What is tachysystole?
• What is a Bishops score?
• What medications are used for cervical ripening?

Preterm Labor

• It is important to know the types of preterm births.
• It is important to know the risk of a preterm birth.
• Prediction of preterm labor methods needs to be determined.
• Assessment finding for preterm labor needs to be determined.
• Tocolytics for the treatment of preterm labor include
  • What other medications can we use, and for what indication?
  • Why would we use corticosteroids? When?
• Nursing interventions for preterm labor need to be found.

Indications for C/S

• Indications for C/S are
  • Previous cesarean birth
  • Placental abnormalities
  • Arrest of active labor
  • CPD
  • Previous uterine surgery
  • Preexisting, pregnancy-related maternal medical conditions, tachysystole, uterine rupture etc.
  • Increasing maternal age and Obesity
  • Fetal indications affecting the method of delivery include malpresentation, abnormal FHR patterns, and maternal

Fetal Dystocia

• Information on the definition of CPD is needed.
• Complications of fetal dystocia are:
  • Asphyxia
  • Fetal juries (bruising)
  • Maternal lacerations
• Assessment findings for Fetal dystocia include
  • FHR may be heard above the umbilicus versus in the lower uterine segment.
  • SVE reveals the buttocks or face when malpresentation is the cause of dystocia.
  • The presenting part is not engaged in the maternal pelvis.
  • There is no fetal descent.
• Interventions for patients with Fetal Dystocia include:
  • Perform Leopold's maneuver as described in Chapter 8 to determine the fetal position.
  • Assess the location of the FHR.
  • Assess the fetal position with SVE.
  • Alert the care provider if there is any question regarding fetal presentation, position, or absence of fetal descent.

Preeclampsia

• Preeclampsia needs to be defined vs. gestational HTN vs. eclampsia vs. chronic HTN.
• What are some conditions that predispose patients to preeclampsia?
• Find information for the treatment Preeclampsia.
• What are the signs of Magnesium toxicity and what is the antidote?
• Identify some signs of SEVERE pre-eclampsia.
• Nursing interventions for patients with preeclampsia is important.
• HELLP syndrome definition and signs are needed.

Prolapsed Cord

• A definition of prolapsed cord is needed.
• When the presenting part is not engaged in the pelvis and occurs with AROM or SROM it can indicate that there is a prolapsed cord present.
• Nursing interventions are important.

Placental Abnormalities

• What are the differences between placenta previa and abruptio?
• Identify the causes of previa vs abruptio?
• Treatment for previa and abruptio is needed.
• Placenta accreta definition is needed.
• Treatment for placenta accreta is needed.
• Nursing interventions for placental abnormalities is needed

Chorioamnionitis

• Chorioamnionitis definition, determine if the patient is required to spike a temperature, and find S/S?
• Risk factors for Chorioamnionitis include: PROM over 24 hours and genital tract infections.
• Chorioamnionitis can cause:
  • Sepsis
  • Wound infection
  • Prolonged labor
  • PPH
  • Endometritis
  • Neonatal sepsis
  • Meningitis
  • Pneumonia
  • RDS
• Treatment for chorioamnionitis includes antibiotics and antipyretics.

TOLAC / VBAC/OPERATIVE VAGINAL BIRTHS

• Determining who is a good condidate for TOLAC / VBAC/OPERATIVE VAGINAL BIRTH needs to be looked into.
• Contraindications to TOLAC / VBAC/OPERATIVE VAGINAL BIRTH include:
  • Pelvic abnormalities
  • High risk for uterine rupture (type of incision, previous uterine surgery)
  • Certain placental abnormalities (previa)
  • Facility not equipped for emergency c/s
  • Medical/obstetrical complications
• Conditions for Vacuum Assisted and Forceps use. -Vacuum: head must be engaged and 100% cervical dilation, “3 pull rule” – no more than 3 attempts in 15 minutes. If attempts are unsuccessful then proceed with c/s.
• Contraindications: head is not engaged or presenting part is not vertex or <34 weeks gestation
• Determine the risks to fetus hyperbilirubinemia, intracranial hemorrhage, and or retinal hemorrhage.

Postpartum Assessment

• Identify what the acronym BUBBLE-LE stands for is key.
• Assess information about UTERUS involution, that is the process of the uterus returning back to normal shape.
• Subinvolution definition with what the patient is at risk for needs to be determined, can be determined when the uterus does not contract back to normal shape.
• Assess the uterus for location, position, and tone of the fundus.
• How is this done?
• What nursing actions are performed before assessment of the fundus – what should we have the patient do? Why?
• Determine where one should feel the fundus at 6-12 hrs postpartum?
• When is the fundus not palpable?

Postpartum Assessment Continued

• Breasts - patient can experience engorgement needs to be looked in to.
• Assess for engorgement, nipple irritation and skin breakdown needs to be assessed.
• Engorgement treatment: frequent feedings, warm compresses before feeding, pump frequently, ice packs for discomfort, supportive bra, analgesics, massage breasts to prevent plugged milk ducts.
• Why are frequent feedings preformed?
• Nutrition and hydration when breastfeeding needs to be reinforced with the mother.
• MASTITIS
• Occurs 3-4 weeks postpartum, bacterial infection from cracked nipples, milk stasis, stress, fatigue. S/S include fever, flu-like symptoms, pain and redness and tenderness needs to be looked in to.
• Treatment: Antibiotics, continue to pump or breastfeed, analgesia, hydration, rest.
• What are we encouraging the patient to do?
• Determine how often should she breastfeed to encourage emptying?

Postpartum Assessment Continnued

Lochia: Changes in lochia reflect the healing stages of the uterine placental site needs to be emphasized.

• Find information about Lochia rubra (pp day #1-3), lochia serosa (pp day #4-10), lochia alba (pp day #10).
• What are the characteristics?
• Nursing interventions: Assess the lochia for color, amount and odor, assess for clots, assess for tissue (retained placenta) is important.
• Educate on how to promote hygiene?

Postpartum Depression

• POSTPARTUM BLUES:
  • Symptoms disappear without intervention
  • Occurs within 2 weeks post delivery
  • Able to safely take care of herself and baby.
• POSTPARTUM DEPRESSION:
  • Requires psychological intervention
  • Occurs within 12 months post delivery
  • Unable to take care of self and baby.
• RISK FACTORS: History of depression or anxiety before or during pregnancy, inadequate social support, poor relationship with partner, low socioeconomic status, complications of pregnancy or birth, low support from mother, life or childcare stresses, domestic abuse, history of child sexual abuse.

Postpartum Psychosis

• Postpartum Psychosis needs to be defined
  • Rapid onset (within 2-3 days postdelivery) of one or more of the following: delusions, hallucinations, disorganized speech, catatonic behavior.
• RISK FACTORS: history of bipolar, family history of bipolar or affective disorder.
• SIGNS/SYMPTOMS: Paranoia, extreme agitation, delusions associated with baby, mood swings, depressed or elated moods, distraught feelings about enjoying infant, confused feelings, disorganized behavior, strange beliefs about dying (either mother and/or baby).
• NURSING INTERVENTIONS: early detection and intervention is key, educate on s/s and when to call provider, provide information on effective therapies (pharmaceuticals, psych evals, hospitalization, psychotherapy, ECT)

Newborn Assessment

• Head, face, neck – what do we look for?
  • Full fontanelle?
  • Depressed fontanelle?
  • Head circumference – how to measure? What is abnormal?
  • Ears?
  • Nose?
• Cardiac - HR?
  • Murmur?
  • Normal to hear a loud murmur?? What are some abnormal findings?
• Respiratory - lung sounds?
  • What's normal?
  • Pattern of breathing?
  • Normal respiratory rate?
  • ***ABC – maintain airway!! Suction w/ bulb syringe, apply O2.
  • Chest circumference – appearance?
  • How to measure?
• GI- bowel sounds present?
  • Distended or soft? What could this indicate?
• Skin – newborn skin sensitive, especially preterm.
  • Preterm skin thin?
• Musculoskeletal – symmetry of extremities, hip dysplasia, fractured clavicle assessment.
  • 10 fingers/toes, creases on hands/feet.
  • Muscle tone? What is abnormal?
• Genitalia: descended testes, swollen labia, pseudomenstruation.
• Temp axilla vs. rectal? Which method do we use and why? Range? Abnormal physical findings could indicate what?
• Normal PaO2/PaCO2?

Hyperbilirubinemia

• Hyperbilirubinemia defined: How is bilirubin excreted?
  • What are the risk factors for pathological jaundice?
• Treatment for hyperbilirubinemia includes phototherapy and/or exchange transfusion.
• While preforming phototherapy place eye shields on the neonate to protect eyes from the effects of the light and remove every 4 hours for assessment. The neonate should have only a diaper in place for maximal exposure to light. Lights should be 12-16 inches from infant.
  • Should the infant feed while on phototherapy, keep eye patches on?
  • Change the neonate's position frequently to facilitate increased light exposure?
  • Vital signs including temperature monitoring should be done and monitor I&O.
  • Phototherapy results in increased insensible fluid loss.
• Determine when to, assess for side effects of phototherapy: eyes for discharge and tearing. Loose stools, Dehydration. Hyperthermia. Lethargy and Skin rashes.

Hypoglycemia

• Hypoglycemia Risk factors?
• Assessment findings:
  • Macrosomia
  • Low muscle tone
  • Lethargy
  • Seizures
  • Diaphoresis
  • Poor feeding abilities
• What are the Complications of hypoglycemia?
  • RDS
  • Jaundice
  • Congenital anomalies
  • Seizures
• Nursing interventions: blood sugar checks are needed to assess patients properly in conjunction with immediate feeding, may need IV fluids, and maintain neutral thermal environment.

Parent Teaching

• Patient education points:
  • Bathing: Bathing should not be daily and soap is not recommended on the face.
  • Immersion bathing with or without blanket is recommended.
  • Bathing should only last 5-10 minutes to minimize heat loss
  • Cord Care: Cord and clamp will fall off by itself, no alcohol is needed to dry out cord.
  • Diaper should be folded below cord to facilitate drying.
  • Diaper Care: Change diapers frequently Q1-3H
  • Use petroleum-based or zinc oxide ointments
  • Avoid baby powder, antibiotic ointments.
  • Why are we avoiding baby powder and antibiotic ointments?
• Circumcision care:
  • Vaseline for clamp, none for plastibell.
  • Do not remove plastic ring.
  • What are the signs of infection when assessing the patients site?
  • Signs of normal healing (yellow crusting on glans, red in color)
  • Assess for voiding (within 24 hours).

Dysmenorrhea

• Dysmenorrhea: This needs to be defined as painful menstruation and is classified as primary or secondary.
• PRIMARY DYSMENORRHEA:
• Cramping usually begins 12-24 hours before onset of flow and lasts 12-24 hours.
• A patient might experience chills, nausea, vomiting, headaches, irritability, and diarrhea.
• Dysmenorrhea Causes: This can be causes by the Excessive endometrial production of prostaglandin; women with primary dysmenorrhea produce 10 times the amount of prostaglandin.

Chronic Pelvic Pain

• Chronic Pelvic Pain: This is defined as pain in the pelvic region that lasts 6 months or longer and results in functional or psychological disabilities.
• Chronic Pelvic Pain S/S are: This can be exhibited by uterine or abdominal cramping, sharp pain, steady pain, intermittent pain, pressure or heaviness deep in the pelvis, pain during intercourse, pain while having a bowel movement.
• What causes Chronic Pelvic Pain?

STI

• CHLAMYDIA: This is the most common bacterial infection in the United States and the leading cause of preventable infertility and ectopic pregnancies. -Most infected women are asymptomatic; however, 30% have a mucopurulent cervical discharge and other symptoms include spotting, urethritis, lower abdominal pain, nausea, fever, and dyspareunia. GONORRHEA: Women are commonly asymptomatic. -Symptoms include vaginal discharge, AUB, postcoital bleeding, low backache, urinary frequency, dysuria, and pain during sexual intercourse.

STI Continued

• SYPHILLIS:
  • Presented in stages: Primary, Secondary and Tertiary.
  • Approximately one-third of infected people will develop tertiary Syphillis.
  • Without treatment, the bacteria can spread throughout the body, and symptoms are related to damage of internal organs
• TRICHOMONIASIS: This is when most women are asymptomatic. Symptoms can appear 5-28 days after exposure.
• Symptoms include
  • Profuse frothy gray or yellow-green vaginal discharge with foul odor; erythema, edema, pruritus of the external genitalia, and pain during sexual intercourse. Small, red ulcerations may also be observed during examination.

Cervical Cancer/HPV

• Cervical cancer: This is primarily caused by HPV.
• SCREENING (PAP TEST): If patient is older than 65 can stop cervical cancer screening if they have not had any precancerous cells found in the previous 10 years. If a women who had a total hysterectomy should stop screening, unless hysterectomy was due to cervical precancer or cancer.
  • Women who have received HPV vaccine still need to follow the recommended screening for their age group.
• Recommendations for Screening:
  • 19-29 years old is every 3 years (pap only), >30 years old every 5 years with cotesting HPV.

PCOS

• Polycystic ovary syndrome (PCOS) is a hyperandrogenic disorder (excess androgens).
• Clinical features:
  • Amenorrhea
  • Infertility
  • Hirsutism
  • Ovarian cysts
  • Obesity
  • Acne
  • Oily skin
  • Alopecia
  • Pelvic pain
• Women with PCOS are at risk for:
• Diabetes
• Dyslipidemia
• Cardiovascular disease
• HTN
• Sleep apnea
• Infertility
• Gynecological cancer
• Metabolic syndrome
• What labs are we going to assess?
• PCOS TREATMENT: weight loss, diabetic medications, anti-androgens, hormone therapy (OCP), fertility treatments.

Breast Cancer

• RISK FACTORS of Breast Cancer are:
  • Increasing age,
  • Defects in breast cancer genes BRCA1 or BRCA 2,
  • Family history of breast cancer, dense breasts, use of birth control methods that contain hormones, women who did not breastfeed,
  • Personal history of breast cancer in at least one breast, exposure to head or chest radiation, excess weight, exposure to estrogen through early onset of menarche, late menopause, or use of hormone therapy, excessive use of alcohol, exposure to diethylstilbestrol (DES).
• BREAST Cancer SCREENING: The following are types of screening measures
  • Mammograms - Ultrasound
  • MRI (yearly with mammogram for high risk patients)
  • Biopsy

Osteoporosis

• Osteoporosis: Defined as the loss of bone mass that occurs when more bone mass is absorbed than the body creates.
• OSTEOPOROSIS NURSING INTERVENTIONS: Encourage patients to Maintain a diet high in calcium and vitamin D; This can begin around 9 years of age to help form a strong bone matrix and should continue throughout the woman's life.
• Reccommened calcium and vitamin D intake: - 1,300 mg of calcium for girls aged 9 to 18 years - 1,000 mg of calcium per day for women aged 19 to 50 years - 1,200 mg of calcium for women aged 51 years and older - 600 to 1,000 IU of vitamin D per day for women 50 years and older
• Encourage patients to: -Engage in weight-bearing exercise.
• Walking, jogging, dancing, and weight lifting three to four times per week -Avoid smoking. Avoid both firsthand and secondhand smoke. -Limit alcohol use.