NURS 307 Exam 3 Study Guide.docx

NURS 307 Exam 3 Study Guide Postpartum - High & Low Risk 1. Postpartum: Period of recovery (42 days)     -  The return to non-pregnant physiology Up to 6 wks after childbirth     -  Return of all systems to non-pregnant         state 2. Involution:  Return of reproductive organs to its non pregn...

NURS 307 Exam 3 Study Guide Postpartum - High & Low Risk 1. Postpartum: Period of recovery (42 days)     -  The return to non-pregnant physiology Up to 6 wks after childbirth     -  Return of all systems to non-pregnant         state 2. Involution:  Return of reproductive organs to its non pregnant state and function 6 weeks after delivery (typical time for mother to return for checkup) 3. Subinvolution:  Failure to heal completely Delayed return of uterus to normal size and functioning Delayed return of reproductive system to its non-pregnant stage and function Includes discharge of lochia  C-section = less lochia due to surgery 4. Causes of Subinvolution Retained placental fragments in uterus Uterine atony (lacks tone) → mom could hemorrhage Clinical Signs Excessive lochia (w/clots) Foul odor lochia (infection) Uterine pain (shouldn’t be too excessive) ￫ Soft, spongy, boggy uterus = hemorrhage  5. Uterine Assessment:  Location: midline or displaced (due to bladder distention; make sure mom voids - ask if mom has burning sensation, hesitency, and frequency_ Most commonly displaced to the right side due to sigmoid colon on the left side → dextrorotation      -    Consistency:* most important assessment * firm or boggy = active hemorrhage      -    Height: in relationship to umbilicus, should be even then involutes 1 cm per PP day; EX: PP2 = fundal height 2 cm; when uterus is no longer an abdominal organ 6. Lochia Assessment/Vaginal Discharge:  Rubra: 1-3 days; deep red, menstrual flow like, without clots, and no oversaturation of pads Serosa: 5-7 days; pink, should never go back to rubra once serosa (signals increase in bleeding) Alba: 1-3 weeks; without RBC’s, white/yellow discharge, shouldn’t see blood 7. Perineum Assessment (Wound Assessment):  *GLOVED HANDS* Non-internal Redness Edema Ecchymosis Drainage Approximation → C-section = dressing over the wound; should be changed in 24 hours Hemorrhoids Perineal care Peri wash: spray w/rinsing Cleansing direction: cleanse front to back Americaine spray or Dermoplast (numbing sensation) Epifoam, Tucks pads,   Ice up to 12 hrs (put in peri pad),   Sitz bath after 12 hrs, 2-3 times daily 8. Return of Menstrual Cycle: Anovulatory; heavier than normal Multiparas before primiparas 6-8 wks in non-lactating mothers 2-3 months in lactating mothers 9. Breast Assessment:   Consistency: softness, filling, firmness  Nodules, masses, milk ducts Inspect nipples: inverted vs everted; cracks, bruising, trauma Recommended bra Management of breast engorgement: lactating vs non-lactating Use cold cabbage leaves on breasts with cold packs Encourage self breast exams when menstrual cycle begins again 10. Cardiovascular Assessment: Estimated blood loss: 350-500 mL; C-section: 500-800 mL WBC elevated (up to 20,000-25,000), lasts 1 week post delivery 50% above non-pregnant level to perfuse the placenta Vascular volume reversal via: diuresis (renal) & diaphoresis (night sweats) Normal voiding amount: 300 mL < ; bladder capacity up to 500 mL How to know if a mom completely empties her bladder: lay mom flat on the bed and based on position of uterus, we can tell how much she is emptying and be able to visualize. Do not send home without voiding  Vital signs:  Heart rate: 50-70 BPM; the norm (has increased vascular volume left from pregnancy) Possible causes of increase in HR: Hemorrhage (1st site to assess = uterus then perineum, >90 BPM, check peri pad) Infection (odor to lochia, fever, after 1st 24 hours (100.4<) for 2 consecutive days Thrombosis (assess extremities, pedal pulse, temperature, edema) Anxiety Blood pressure: normal (assess for preeclampsia up to 48 hrs) Respirations: normal Temperature: normal or slightly elevated - Peripheral vascular assessment Homan’s - dorsiflex at the ankle → calf pain? Edema - similar to pregnancy edema (avoid standing & sitting long periods) Skin temperature & pulses DVT prevention: support at ankles and knees, inspect superficial vessels, deep vessels might have DVT 11. Gastrointestinal: Hunger after labor Constipation 12. Genitourinary: 1st 24-48 hrs, voids often and much Edema & trauma Decreased distension, urinary retention Possible complications: UTI: burning with urination PP hemorrhage from bladder distension 13. Musculoskeletal: Aches & pains from: exertion, positions of labor, & diastasis recti (when abdominal muscles separate (are bulging), notify provider) 14. Integumentary: Starting to reverse Mask of pregnancy Stretch marks Linea negra Weight loss: 17-20 lbs 15. Endocrine: Pregnancy hormones decrease (estrogen & progesterone) Hot flashes (change linens frequently) Emotional Baby blues 16. Comfort & Rest & Sleep patterns: Analgesics: around the clock ibuprofen (inhibits prostaglandin (controls UC)) Sleep & rest 17. Afterpains: What increases them: Lactation → releases oxytocin Multiparity, Large infant, Hydramnios, Multiple gestations 19. Phases of Maternal Postpartum Adjustment: Taking in: - Dependency - Basic needs (food, sleep) - Relives labor (goes over what happened during labor & new routines) Taking Hold: - Self-directive - Takes initiative (asks questions & wants to complete all tasks for baby, doing all tasks in order to get discharged) Letting-go: - Moves family forward as a unit - Resumes partner relationship - Resumes intimacy - Resumes roles 20. Postpartum Depression: 21. Postpartum Psychosis: 22. Postpartum Blues  2-6 wks after birth 10-20% new mothers Tearfulness Mood swings Despondency Feelings of inadequacy Inability to cope with care of baby Irritability & hostility Lack of concern about appearance Living in a “fog” Hallucinations Delusions Disorganization Marked emotional lability (manic, depressed) Bizarre or violent behavior Mania TXMT: hospitalization & antidepressants Common with Hx of mental illnesses 7-10 days: no more than 2 weeks max; beyond 2 weeks = seek help Feeling depressed Tearfulness Anxiety Changes in concentration Irritability Headache Frequent mood fluctuation Should be self-limiting 23. Parent-Infant Attachment/Bonding: Maternal-infant bond: the foundation for all future attachments and is the formative relationships of the cold developing a sense of self Attachment: unique relationship between two people that is specific and endures over time. Attachment is crucial to the survival of the infant; it enables the parent to make unusual sacrifices necessary for care of the infant over time and distance 24. Postpartum Hemorrhage: ≥ 500 mL post delivery Soft, boggy, spongy uterus 1st priority: massage uterus gently & consistently Lacerations of genital tract: cervix, vagina, perineum (1st, 2nd, 3rd, & 4th degree) Bright red bleeding (different from rubra lochia Hematoma - collection of blood in tissues; related to instrument delivery or big baby Bleeding contained in the tissues, not visible, except as bulge in tissues Pressure pain - unrelieved 25. Medications for Uterine Atony Uterotonic drugs for PP hemorrhage management Medication Route Nursing Management & Contraindications Notes from Ppt         Methergine (Methylergonovine) IM or PO Do not breastfeed during treatment, should not be used to induce labor. Monitor BP, HR, & uterine response Preferred medication, if BP is high, do not give. Causes strong, sustained UC           Pitocin (Oxytocin) IV Assess for adverse reactions: coma, seizures, intracranial hemorrhage & dec uterine blood flow Initiate IV            Cytotec (Misoprostol) Rectally Assess routinely for epigastric or abdominal pain           Hemabate, Carbiprost, Prostin 15 IM Contraindicated in patients with acute PID. Be aware of adverse effects of uterine rupture & anaphylaxis              (Prostin E2) Dinoprostone Vaginally or rectally Be aware of adverse effects of uterine rupture & anaphylaxis. Auscultate breath sounds. Avoid if hypotensive or asthma 26. Postpartum Infection (Sepsis): Fever of 100.4 or greater for 2 consecutive days in the first 10 days PP, excluding the first 24 hrs. Endometriosis Wound infections UTI’s 27. Mastitis: Inflammation of breast with flu-like symptoms (chills, fever, malaise, breast is hot, reddened, painful in upper outer quadrant) 1-10% of breastfeeding mothers Causative organisms: Staphylococcus aureus, streptococcus, & E. coli Can lead to breast abscess Treatment: antibiotics (penicillins/dicloxacillin or cephalexin (Keflex)), adequate rest, fluids, local heat or ice, analgesics, & continuing breastfeeding or pumping Factors that ↑ risk of mastitis Milk stasis Inadequate emptying of breasts Actions promoting access & bacterial growth = poor hand-washing & breast hygiene Nipple trauma Obstruction of ducts Decrease in amt of feedings; failure to empty Lower maternal defences 28. Thrombophlebitis: 3 Major Contributing Factors: Venous stasis Hypercoagulability of blood Injury to the intima (innermost lining of blood vessels) Other factors: obesity, varicosities, Hx of thrombophlebitis, multiparity, smoking, woman <35 yrs 29. Thromboembolic Disorders:  Superficial Venous Thrombosis Saphenous venous system - phlebitis of lower leg Swelling, tenderness, warmth (may palpate enlarged harden vein) Possibly positive Homan’s sign Treatment: local heat, analgesics, elevate lower extremities, TED hose Deep Venous Thrombosis   venous system from foot to iliofemoral Venous obstruction -  Treatment: Calf swelling -  Bedrest Erythema -  Elevated of affected extremity Heat -  Analgesics Pedal edema -  IV heparin Tenderness -  If fever, broad spectrum antibiotics Pulmonary Embolism: Clinical signs: dyspnea & chest pain Other signs: Tachypnea Tachycardia Apprehension Cough Hemoptysis Elevated temperature Sweating Hypertensive Disorder of Pregnancy: Gestational Hypertension - without proteinuria or other systemic changes Preeclampsia Eclampsia Chronic Hypertension Chronic Hypertension with superimposed preeclampsia 30. Preeclampsia - Hypersensitive syndrome with manifestations after 20 wks: Hypertension: 140/90 or greater (two separate occasions at least 4 hrs apart) Proteinuria: >trace/1+ (in the absence of proteinuria assessment, thrombocytopenia, impaired liver function, new renal insufficiency, pulmonary edema, or new onset of cerebral or visual disturbances) Negative Trace (10-20 mg/dL) 1+ (30 mg/dL) - ok in PP, not pregnancy 2+ (100 mg/dL) - preeclamptic 3+ (300 mg/dL), or 4+ (1,000 mg/dL) * More protein in urine = more renal damage * Generalized edema: total body edema, does not resolve with rest. Can manifest for first time up to 48 hours after birth Due to loss of protein from vascular compartment Can cause cerebral edema = headaches, visual changes Incidence:  2-7% of all pregnancies in the U.S. 10-15% of maternal mortality worldwide Leading cause of maternal & perinatal morbidity and mortality in U.S. & in Canada Etiology: Unknown Associated/Risk Factors: 1st pregnancy Non-caucasian; African descent <40 yrs Pregnancy with assisted reproductive technology Increased exposure to placental tissue: multiple gestation or Trophoblastic disease Interpregnancy interval > 7 yrs Poor outcome in previous pregnancy Pre Existing disease: DM, renal disease, collagen disease, Medical/genetic conditions; Chronic hypertension Family history and/or personal history Periodontal disease Obesity/Gestational DM Antiphospholipid antibody syndrome - autoimmune disorder or abnormal amt of antibiotics leading to blood clot formation Factor V Leiden mutation - mutation of clotting factors causing abnormal increase in clot formation Pathophysiology: Arterial vessel walls in uterus remain thick contributing to decreased placental perfusion & placental ischemia  Placental ischemia: endothelial cell dysfunction by stimulating the release of a substance toxic to endothelial cells; leads to Generalized vasospasms throughout body Increased peripheral resistance Increased endothelial cell permeability    ↓   ↓ ↓ ↓ ↓ Poor perfusion in all organ systems Management of Mild Preeclampsia: BP stables Urine protein ≤1+ Fetal evaluation: FMC, NST, BPP Watch for subjective S/S to report Activity restriction Diet: hydration, protein, low salt Treatment: Magnesium Sulfate Therapy (Anticonvulsant & CNS depressant) Required hourly assessments: Respiratory rate (<12 RR) DTR’s Urine output                  Antidote: Calcium Gluconate (10mL of 10% solution IV slowly over 3-5 min) Nursing Care:  Monitor VS & FHR Decreased external stimuli Monitor: U.O, urine protein, & specific gravity Assess for generalized edema Assess for premature placental separation (Abruptio Placenta) HELLP Syndrome: Lab Diagnosis Only H - Hemolysis E - Elevated L - Liver enzymes & L - Low P - Platelets Lab Studies: CBC (includes platelets) Clotting studies Bleeding time & fibrinogen Liver enzymes: LDH (45-90 units/L)            AST (4-20 units/L)                ALT (3-21 units/L)       - Chemistry: BUN, creatinine, uric acid, glucose 33. Severe Preeclampsia: BP > 160/110 Proteinuria > 5g/24hrs (3+/4+ dipstick) Oliguria < 400mL in 24 hrs (<30mL/hourly) Hyperreflexia Clinical symptoms: H/A,      Visual changes Generalized edema,    Dyspnea (pulmonary edema) Epigastric pain (N/V) (swollen liver capsule) Anxiety & irritability (cerebral hypoxia) ↓ ↓ ↓ ↓ ↓ Increase risk for seizures Late Pregnancy Hemorrhage 34. Placenta Previa: 35. Placenta Abruptio Abnormal implantation of placenta by location Placental abnormally located somewhere near cervix instead of fundus Incidence: 1 in 200 pregnancies (0.5%) Types: low-lying, partial, complete Premature separation of a normally implanted placenta Incidence: 1 in 120 births (1%) - more frequent than previa Complication of preeclampsia Types: Marginal overt, central concealed, complete concealed If visible, dark red bleeding is present, more significant bleeding than previa Associated Factors in Placenta Previa: Decreased vascularity of upper uterine segment (fertilized ovum finds a better vascular spot for implantation) Multiparity with decreased spacing Scar tissue from previous surgery Advanced maternal age = ↓ endometrial perfusion Associated Factors in Placenta Abruptio: Hypertension (preeclampsia) Physical trauma (abdominal trauma; MVC, fall, domestic abuse) Alcohol abuse; smoking (smaller blood vessels) Excessive or sudden changes in intrauterine pressure (flying in airplane) Increased maternal age & parity Cocaine abuse Manifestations with Placenta Previa: Bright red bleeding (always visible) Painless/silent bleed (always visible; mom can wake up in a pool of blood) Uterine shape abnormal (placenta blocking the cervix) - not always seen Abnormal fetal lie (transverse) Manifestations of Placenta Abruptio: Dark red bleeding if visible Painful (always painful) Abdominal pain Uterine hyperactivity with poor relaxation between contractions Uterine tenderness S/S Concealed Hemorrhage:  Increased fundal height Hard board-like abdomen High uterine baseline tone Persistent abdominal pain Progressive late decelerations in FHR &/or ↓ baseline variability 40. How can placenta previa and placenta abruptio be distinguished in terms of clinical manifestations? Time period of onset Presence/absence of fever Source of bleeding Color of blood & presence/absence of pain 41. S/S Early Hemorrhage: Tachycardia, decreased peripheral pulses Increased respirations (due to tachycardia) >24 = significant increase Normal or slightly elevated BP Cool, pale skin 42. S/S Late Hemorrhage: Falling BP, still tachycardic -  Restlessness, agitation,  Pallor, skin cold & clammy     decreased mentation  Urine output less than 30 cc/hr 43. Additional Hemorrhage Problems of Childbearing: Uterine rupture: complete/incomplete Uterine inversion: partial/complete Uterine atony: failure of uterine muscle to contract post-delivery DIC (disseminated intravascular coagulation): causative factors in OB: placenta abruptio, intrauterine fetal demise, sepsis, amniotic fluid embolism, thrombi in organs secondary to PIH  Treatment: delivery, replacement of clotting factors, physiological support for hemorrhage Signs: bleeding gums, hematuria Perinatal Infections 44. Assessing STI’s & HIV Risk Behaviors: Using the 5 P’s Partners: who, number, any infection exposure Practices: sexual behavior practices; understand risks Prevention of pregnancy: contraception Protection from STI’s & HIV, Past history of STI’s 45. Chlamydial Infection: Chlamydia trachomatis organism, most common bacterial STD in U.S.  Nongonococcal urethritis (NGU) in men (epididymitis & infertility) Often asymptomatic in females reproductive tract Causing PID, infertility, ectopic pregnancy Pregnancy effects: Premature ROM & PTL Newborns: ophthalmia neonatorum CDC Recommendations: Annual screenings: all sexually active adolescents, women 20-25 yrs, even without s/s, women >25 yrs with risk history ACOG: screen high risk pregnant women initial prenatal visit &/or 3rd trimester Treatment: In pregnancy Azithromycin: 1 gram single dose orally Amoxicillin: 500 mg orally TID X 7 days  Non-pregnant: Doxycycline: 100 mg BID X 7 days 46. Gonorrhea: Causative organism: Neisseria gonorrhoeae 2nd most commonly reported STI Men: Urethritis with s/s Women: 80% asymptomatic In pregnancy, if contracted after 3 months, mucous plug prevents ascending infection, & is localized in urethra, cervix, and Bartholin’s glands PPROM, preterm birth, chorioamnionitis, PP sepsis Newborns: ophthalmia neonaturm, neonatal sepsis, IUGR (intrauterine growth restricted) Symptoms: purulent greenish/yellow vaginal discharge, dysuria, urinary frequency Some women: inflammation, swelling of vulva, cervix with cervical erosion; bilateral lower abdominal pain       -    Treatment: In pregnancy       -   Ceftriaxone 250 mg IM once; with azithromycin or amoxicillin, is chlamydia possible       -  Non pregnant: ceftriaxone 250 mg IM once + azithromycin orally, if chlamydia possible 47. Pelvic Inflammatory Disease (PID):  Infection of fallopian tubes (salpingitis), uterus (endometriosis) & possibly ovaries. Can cause ectopic pregnancies. Risk factors:  STI Young age (<25 yrs) Nulliparity Multiple partners High rate of new partners History of STI’s & PID IUD users       - Symptoms: pain (lower back) of varying quality: dull, cramping, intermittent, severe, persistent, incapacitating     - Risk for ectopic pregnancy 48. Syphilis Treponema pallidum spirochete Primary stage - chancre (5-90 days) Secondary stage - rash & lymphadenopathy (6 wks t0 6 mos after chancre) Latent stage - asymptomatic if untreated, & ⅓ enter tertiary stage = systemic, organ & system effect Congenital syphilis - IUGR, preterm birth, stillbirth Screening in 1st & 3rd trimesters: VDRL/RPR; FTA-ABS VDRL (venereal disease research laboratories/ RPR (rapid plasma reagin) FTA-ABS (fluorescent treponemal antibody absorption) Treatment: Penicillin G, 2.4 million units IM 49. Human Papillomavirus (HPV): Condylomata acuminata/genital warts Most common viral STI Multiple stereotypes: genical warts, cancer generating Primary cause of cervical cancer Papules, fingerlike, cauliflower-like Singular or clusters Painless or large inflamed, or ulcerated Locations: cervix, vagina, vulva, anus, buttocks Chronic vaginal discharge, pruritus, dyspareunia More in pregnancy than non-pregnant Clinical signs: Profuse, irritating vaginal discharge Itching Dyspareunia (pain during intercourse) Postcoital bleeding, friable (bleeding after intercourse) Reports: “bumps on vulva or labia” Diagnosis:  History Signs & symptoms Papanicolau (Pap) test Physical exam Treatment: Goal is to remove warsm & relieve s/s Imiquimod, podophyllin, podofilox - NOT in pregnancy (paint/dye) Cryotherapy w/liquid nitrogen or croprobe (in preg by provider) Surgical techniques Oatmeal bath & cool hair dryer Cotton underwear & loose-fitting clothing Healthy lifestyle: diet, rest, exercise, stress reduction Vaccines: Gardasil, Cervarix Protects against 4 HPV types (6, 11, 16, 18) 90% of genital warts 70% of cervical cancer Recommended for 11-12 yr old females before sexual activity, & 13-26 yr olds 50. HIV infection in Pregnancy: Potential fatality to mother & child Transmission via bodily fluids: semen, blood, vaginal secretions, & throughout perinatal period between mother & child Incidence: about 1 in 4 people living with HIV are women Retrovirus infects/disables T lymphocytes (T4 cells) Risk factors: Multiple sex partners Bisexual partners IV drug abuse History of multiple STI’s Blood transfusions (rare) Lab Test: CD4 cell count T4 cells < 500 cells/mm3  Leukopenia, thrombocytopenia, anemia, elevated erythrocyte sed rate Viral load > 5,000 copies/mL Risk for opportunistic infections ELISA antibody reaction Western blot analysis - confirmation Mild flu-like symptoms Seroconversion: 6 wks to 1 yr after exposure Wasting syndrome (asymptomatic; 3-11 yrs) Symptomatic: overwhelming infections  CD4 = < 200 cells/mm3  Risks for congenital HIV (20-50%) Treatment:  With ART (triple drug antiretroviral) or HAART (highly active AR therapy) 14 wks antepartal to 6 wks of infancy decreases transmission risk to 1%-2% risk Tx with 2nd nucleoside, eg. zalcitabine, didanosine, or lamivudine With nonnucleoside analog such as Nevirapine or delavirdine Labor & Birth:  C-section may be indicated (if viral load >1000 copies/mL) Avoid AROM Avoid fetal scalp electrode No fetal scalp sampling No meds to newborn in delivery room: must wait until after newborn bath - early bathing No breastfeeding 51. TORCH Infections T - Toxoplasmosis O - Other: Hep B or Hep A R - Rubella C - Cytomegalovirus H - Herpes Maternal infection tends to be mild influenza-like symptoms and lymphadenopathy Fetal to neonatal infection: often CNS impact Toxoplasmosis Infection: Acute infection in pregnancy Spontaneous abortion Preterm Affected neonates: CNS complications Other: Hepatitis B Transmitted parenterally, perinatally, orally (blood, saliva, sweat, tears, vaginal secretions, semen) Risks: multiple sex patterns & STD’s, IV drug use, etc S/S: flu-like, malaise, fatigue, anorexia, nausea, arthralgias, arthritis, lassitude, h/a, fever Populations at risk: women of Asian descent, Pacific islanders (Polynesian, Micronesian, Melanesian) or Alaskan-Inuit or women born in Haiti or Sub-Saharan Africa Screen all pregnant women HBsAg - 1st prenatal visit If exposed to Hep B in pregnancy: Administer Hep B immune globulin (HBIG) IM 0.06 mL/kg Begin Hep vaccine series within 14 days of most recent contact Hep B in Fetus/NB Increased risk for preterm birth Acute liver disease (high mortality) Carriers with risk of chronic hepatitis, cirrhosis, liver cancer Treatment:  Administer Hep B Immunoglobulin 0.5 mL IM within 12 hrs of birth Administer first Hep B vaccine at the same time in different site; continue series Breastfeeding permitted with above medication Hepatitis A: fecal-oral transmission; ingestion of contaminated foods: milk, shellfish, polluted water; person to person High risk populations-western US Flu-like symptoms Antibody present 5-10 days after exposure and up to 6 months; self-limited Does not cause chronic infection or liver disease Avoid meds & substances metabolized in liver (acetaminophen, alcohol) Recommended - well balanced diet 2-dose vaccine recommended for high-risk women Hepatitis C:  Risk factors: having STI’s of HBV, HIV, multiple sex partners, hx of IV drug use, hx of blood transfusions (blood exposure; saliva, semen, urine) Treatment: Interferon alfa (alone) or ribavirin 6-12 months chronic HCV-related liver disease Rubella (German measles): Person to person; nasopharyngeal secretions Mild maternal infection: fever, general malaise, maculopapular rash; face to body Fetal/Neonatal Effects: 1st trimester Spontaneous abortion Major fetal compromise: CNS, deafness, cataracts, cardiac defects, IUGR, microcephaly, intellectual disabilities, prolonged viral shedding Therapy:  Prevention & status of immunity Cytomegalovirus: Herpesvirus group Found in urine, saliva, blood, cervical mucus, semen, breast milk, & stool Transmission by fluids, close personal contact Latency period after primary infection Fetal/Neonatal Effects:  Enlarged spleen & liver CNS abnormalities Jaundice; thrombocytopenia; hepatitis Chorioretinitis Hearing loss IUGR Therapy: Prevention Handwashing with small children Avoid risky sexual behavior Avoid CMV contaminated blood Herpes Simplex Virus (HSV): HSV Type 1 or 2 Direct contact lesions Presentation: painful macules to papules; vesicles to pustiles; shallow ulcers to crusts that heal without scarring Women infected may lack s/s; inc risk of cervical cancer Recurrent infections may be preceded by prodromal; genital tingling & usually less severe Vertical transmission: ROM, during birth Fetal/Neonatal Effects: Primary infection Spontaneous abortion (1st trimester) IUGR Preterm labor risk Neonate: Neonatal herpes: skin lesions to systemic (disseminated) Fr systemic s/s appear within 1 wk; 50% risk of death Therapy: No cure Acyclovir (pregnancy) - late to suppress outbreaks Valacyclovir Famciclovir Shorten duration Decrease s/s Infant s/s of infection: Temperature instability -  Jaundice Lethargy -  Seizures Poor sucking reflex -  Herpetic lesions 52. Vaginal Infections: Vulvovaginal candidiasis (yeast infection): Candida albicans White, thick, curd-like Severe itching, dysuria, dyspareunia Thrush in newborn Treatment: Topical miconazole butoconazole OTC topical “azole” Clotrimazole vaginal tablets Bacterial Vaginosis (BV) Gardnerella vaginalis Thin, watery, yellow to gray discharge “Clue cell”, fishy odor In pregnancy, associated with PROM, PTL, chorioamnionitis & endometriosis Treatment:  Metronidazole (Flagyl) 250 mg PO, TID X 7 days (Preg Category B) Trichomoniasis Trichomonas vaginitis Green frothy, gray vaginal discharge, pruritus, & urinary symptoms s/s strawberry patches on vaginal wall & cervix Risk for PROM, PTL, preterm birth, LBW Treatment: Metronidazole 2 mg PO X 1 Diabetes in Pregnancy Test at 24-28 weeks in pregnancy if not already diabetic  53. Normal Glucose Homeostasis: After a meal Metabolism of CHO into glucose Insulin moves glucose into muscle & liver cells for storage as glycogen After several hours, when blood glucose falls: Glucagon (hormone) from pancreas stimulated bile duct of liver glycogen storage back into glucose & returns it to the bloodstream Glucagon (hormone) stimulates the synthesis of glucose directly from amino acids in stored body proteins 54. Carbohydrate Metabolism in Normal Pregnancy: Early Pregnancy - Pregnancy hormones stimulate: Increase maternal insulin production Increase tissue response to insulin > anabolism a buildup of glycogen stores in the liver & other tissues Later (2nd half) Pregnancy Prolonged hyperglycemia Hyperinsulinemia (increased secretion) Increased maternal resistance to insulin, maintaining an adequate glucose supply for fetus Maternal lipolysis in fasting periods (accelerated starvation, catabolic state) 55. Pathophysiology of Diabetes Mellitus: Inadequate amounts of maternal insulin for glucose in blood High osmotic pressure of glucose in blood leads to: Cellular dehydration > glucosuria > extracellular dehydration S/S of DM: Polyuria Polydipsia Weight loss Polyphagia Classification:  Type 1: insulin deficiency, beta cell destruction Type 2 Gestational DM 56. White’s Classification of DM in Pregnancy: Gestational diabetes = A1 or A2 Pregestational Diabetes: Class B: Onset > 20 yrs, duration < 10 yrs Class C: Onset 10-19 yrs old, duration 10-19 yrs or both Class D: Onset < 10 yrs, duration > 20 yrs or both Class E: Woman has developed diabetic neuropathy Class R: Woman has developed retinitis proliferans Class T: Woman has had renal transplant 57. Effect of Pregnancy on Diabetes: After insulin requirements 1st trimester: common N/V 2nd & 3rd trimesters: HTL - max level of output Accelerate progression of vascular disease  Poor perfusion effects kidneys Labor increases insulin needs with IV glucose & IV insulin Continuous supply of IV dextrose & insulin Postpartum decrease insulin needs  58. Diabetes Influence on Pregnancy & Fetus Polyhydramnios (excess glucose; polyuria of fetus), ketoacidosis, cephalopelvic disproportion (CPD), pregnancy induced hypertension (PIH), cesarean birth Miscarriage; stillbirth More frequent UTI and VVC (yeast infection) Fetal/neonatal macrosomia (LGA); shoulder dystocia & shoulder dystocia birth trauma risk Neonatal hypoglycemia (fetal insulin at 10-14 wks) → strict q3hr feedings; check glucose 1st, 40≤ = adequate management Neonatal hyperbilirubinemia (jaundice) RDS (amnio for lung maturity: phosphatidylglycerol  >3%) → immature surfactant Congenital anomalies: neural tube defects, cardiac, sacral agenesis Variable fetal size 59. Macrosomia vs. IUGR/SGA: Macrosomia: abnormally large body IUGR: when the baby is smaller due to the lack of intrauterine space Management: Monitoring for complications Chronic hypertension; preeclampsia Renal disease Nephropathy Retinopathy Diet: 40-60% complex high-fiber CHO; 20% protein; 30-40% fat Exercise: daily 30-60 minutes Glucose monitoring: serum 60. Gestational Diabetes: Risk Factors Maternal age >25 yrs Previous macrosomia (LGA) infant History of unexplained perinatal loss or malformations in fetus/NB Family history of gestational DM or Type II DM Obesity (weight >90 kg) Fasting blood glucose >140 mg/dL or random blood glucose >200 mg/dL Member of high-risk population (Native American, Hispanic, Asian, Pacific Islander & African American) 61. Screening at 24-48 weeks: Management Oral GCT - 50g of oral glucose with a serum glucose an 1 hour later Result of 130-150 gm/dL or greater = follow-up testing Fasting level & then 3-hour OGTT (diagnostic) with 100g or oral glucose load; if indicated (180, 155, 140)  Hemoglobin A1C (HbA1C) glycosylated hemoglobin over 4-6 weeks Glucose monitoring: 4-5 times per day: arising & bedtime; after breakfast Diet: 40-60% complex high-fiber CHO; 20% protein; 30-40% fat; across 3 meals & snacks Exercise: daily 30-60 minutes Diet, exercise + insulin  or  Glyburide (sulfonylurea) or Metformin (biguanide) 62. Fetal Assessment/Surveillance: Maternal serum AFP (quad screen) at 15-20 wks Ultrasound for anomalies, amniotic fluid volume, fetal size, fetal echocardiogram FMC’s & NST’s (28-32 wks) biweekly CST/OCT or BPP 1-2 times weekly starting at 34 wks Amniocentesis for fetal lung maturity: Phosphatidylglycerol (PG’s) greater than 3% (in diabetic pregnancies) 63. Priority Nursing Diagnoses & Risks (collaborative care): Risk for imbalanced nutrition, maternal & fetal Risk for injury, maternal & fetal Anxiety, fear Ineffective coping Knowledge deficit: ADA diet, Medications Enhanced readiness for knowledge/knowledge deficit: blood glucose & urine monitoring Enhanced readiness for knowledge/knowledge deficit: non-strenuous regular exercise Hemolytic Diseases 64. Hydrops Fetalis Severe anemia, cardiac decompensation, cardiomegaly, hepatosplenomegaly, & decreased intravascular oncotic pressure, generalized edema, & ascites 65. ABO Incompatibility: Mother is O blood group: No antigens (antigens trigger antibody response) Has antibodies: Anti-A & Anti-B Once they give birth, fetal cord blood is tested for: fetal blood group, Rh factor & Coombs’ test (direct) antibody test Question: O+ mom, B+ baby; will Coombs’ test be + or -? +, O type has blood antibodies & went to fetal circulation (check RBC) Fetus/Newborn: Has blood group A or blood group B (A is more likely) 1st pregnancy (baby is jaundice (pathologic)) Does not increase in severity Does not require intrauterine transfusion (replace RBC’s) Protection from Rh disease 66. * Knowledge Check* Which of the  following is true about O blood group? It carries antigens It carries no antibodies It carries antibodies to A blood group & B blood group It can receive blood from any blood type (False; AB blood is universal recipient) 67.  Hemolytic Disease of the Newborn Occurs when there is hemolysis of fetal RBC’s by antibodies from maternal blood, as the result of maternal sensitization → at risk for hemolytic anemia Maternal sensitization occurs when exposed to fetal RBC’s with fetal Rh+ blood Occurs with the inheritance by baby of a red blood cell antigen from father, not present in the mother 68. Maternal Sensitization: Mother: Rh- (no Rh antigens) exposed to Rh+ ↓ Perceived as foriegn substance ↓ Responds by making antibodies (permanent) Examples of Sensitization: Transfusion with Rh+ blood Placenta separation (abruption), Transplacental hemorrhages Spontaneous abortion, Amniocentesis or CVS, Previous pregnancy 69. Negative Coombs’ = no antibodies found Do nothing until 28 weeks (7 months) Repeat Coombs’ at 28 weeks, if negative: Give expectant mother Rhogam to protect against exposure At birth, test baby’s blood for: blood type, Rh factor, Coombs’ test 70. Baby’s Blood Test: IF baby has: Rh+ & no antibodies from mother = Negative direct Coomb’s THEN: Mother is administered Rhogam (within 72 hours of birth) 71. Baby’s Blood Test on Fetal Cord Blood: IF baby has Rh- blood & Negative Coombs (no antibodies in blood) THEN: mother does not receive Rhogam 71. Criteria for Rhogam Administration after Childbirth: Newborn is Rh+ Direct Coombs (on fetal cord blood/baby’s blood) is negative 72. Positive Indirect Coombs’ Test Maternal sensitization occured Repeated until level reaches critical value Serial assessment of fetal anemia via access to the fetal middle cerebral artery Can do intrauterine transfusions = removing excess bilirubin 73. Hyperbilirubinemia: Nursing Goals Prevent Kernicterus = encephalopathy caused by deposit of lipid-soluble unconjugated, unbound to protein into the brain cells 20 mg/dL term 15 mg/dL preterm S/S of Kernicterus: Lethargy Hyporeflexia Hypotonia Seizure (sometimes) Heart Disease in Pregnancy - 1% of pregnancies 74. Classifications of Heart Disease in Pregnancy Class I: asymptomatic; no activity limitation Class II: slight limitation; s/s with heavy physical exertion Class III: Moderate to marked limitation of activity Class IV: Any physical activity causes discomfort; even at rest, have s/s of cardiac insufficiency or angina pain 75. Goals of Therapy: Minimize workload on heart Promote tissue perfusion Avoid infection Drug therapy:  iron & vitamins Diuretics: thiazide diuretics & Lasix for CHF Heparin Antibiotics prophylaxis (endocarditis) Ampicillin, gentamicin, amoxicillin Anti-arrhythmias: Digitalis; to maximize contractility of heart  76. Anemia: Insufficient oxygen-carrying capacity of RBC’s, resulting in compensatory increased workload on the heart Incidence 20-50% Hemoglobin (11 g/dL), Hematocrit (33%) Iron deficiency anemia - most common in pregnancy Serum ferritin levels (<12 mcg/L) in the presence of low Hgb level DO NOT GIVE MILK, GIVE ORANGE JUICE  77. S/S of Heart Failure (CHF)               Subjective Signs:           Objective Signs: Cough (frequent, with or without hemoptysis) Feeling of smothering Dyspnea (progressive, upon exertion) Edema (progressive, generalized, including face, hands, eyelids, extremities Heart murmurs (head on auscultation) Palpitations (commonly seen in late pregnancy) Moist rales (pulmonary edema) Weight gain Weak, irregular, rapid pulse  Progressive generalized edema Orthopnea, increasing dyspnea Rapid respirations ≥ 25 Moist frequent cough Cyanosis of lips & nail beds 78. Antepartal Care of Heart Patient: Diet: increase iron & protein, CHO; Low sodium Preserve cardiac reserves: Restrict activities 8-10 hrs of sleep Frequent rest periods Weigh self daily Avoid long periods on feet Avoid constipation & straining with bowel elimination Report immediately s/s of cardiac decompensation or thromboembolism  79. Intrapartum Period: Epidural Oxygen by face mask Open glottis pushing Episiotomy; vacuum Report:  Pulse >100 BPM       Respirations >24            Development of rales Position: Semi-fowlers or side lying with head & shoulders elevated with body parts on pillows