OB Final Exam Review Lecture 5 PDF

OB Final Exam Review LECTURE 5 – FETAL HEART RATE MONITORING 1. What aspects of newborn status are included in the APGAR score? Standardized assessment for infants after delivery; scored out of 10, 10 being the healthiest and 1...

OB Final Exam Review LECTURE 5 – FETAL HEART RATE MONITORING 1. What aspects of newborn status are included in the APGAR score? Standardized assessment for infants after delivery; scored out of 10, 10 being the healthiest and 1 being the least healthy " 19 and 9 1 min and 5 min Measures: o Respiratory effort Respirations - o Heart rate Pulse · o Muscle tone Activity - Grimace o Reflex Activity - o Color Appearance - 2. What is the primary goal of external fetal heart rate monitoring? To interpret and continually assess fetal oxygenation to prevent significant fetal acidemia while minimizing unnecessary interventions and promote family-centered care Good fetal oxygenation = good placenta 3. Describe two ways a fetal heart rate monitor may be used in labor: external vs internal External monitoring detects baseline, variability, accels and decels o CEFM – continuous electrical fetal monitoring (US) o Intermittent (Doppler) o Wireless o Contractions are measured via toco transducer Internal monitoring is an intervention specific for troubleshooting measures o Place F/ISE (fetal/internal scalp electrode) attached to presenting part of the fetus o Place IUPC (intrauterine pressure catheter) o Membrane MUST be ruptured in order to perform internal monitoring § If not yet ruptured, must be manually ruptured o Contraindications: chorio, GBS+, genital herpes, placenta previa a - / * ternal 4. How are cord blood gases used to assess newborn status? Cord blood gases are collected after birth to help determine the severity of hypoxia in labor; one of the first assessments of fetal well-being after delivery  5. Describe a normal fetal heart rate baseline Baseline (BL) FHR is rounded to 5 bpm in a 10-minute window of time Normal FHR: 110-160 bpm x 10 min or more o Periodic: change in BL of FHR occurs in relation to uterine contractions i o Episodic: change in BL of FHR occurs independent of uterine contractions o Recurrent: changes occur in > or = 50% of uterine contractions in 20 min period o Intermittent: changes occur in 160 bpm x 10 min or more Bradycardia Baseline: 25 bpm § Usually indicates fetal tachycardia Most reassuring status is moderate variability Beat to beat variability is a stronger indicator of fetal well-being 8. How is an acceleration measured? Visually apparent abrupt increase in FHR above baseline o ≥ 15 bpm x 15 sec but less than 2 minutes – if longer than 2 minutes, can indicate baseline change o If GA is preterm 30 seconds to reach nadir (nadir = the slowest FHR recorded and lowest point); Periodic o Mirrors contraction (nadir is at the peak of uterine contraction) o Cause = head compression against the pelvis or soft tissue o Reassuring (a good sign) Variable decels o Baseline to nadir in 6 cm dilation with membrane rupture or greater than 5 cm w/o membrane rupture and 4+ hours of adequate contractions/6+ hours if inadequate  § Prompting the uterus to contract during pregnancy before labor begins on its own for a vaginal birth Second stage arrest disorder à failure of fetal head descent o Arrest of labor after 2 hours of pushing for multips/3 hours of pushing for nullips 5. What are the different fetal presentations that may lead to dystocia? (Malpresentations) Occiput posterior o The back of the baby’s head is in the posterior portion of the pelvis (closest to your back) instead of the anterior (occiput anterior = back of baby’s head is closest to your front) Face presentation o Fetal head is in extension rather than flexion as it enters the pelvis Brow presentation o Fetal head presents in a position midway between full flexion and extreme extension – largest diameter of the head in the pelvis Shoulder presentation o Fetal spine is vertical to the maternal pelvis – higher risk of prolapsed cord, C-section is indicated Compound presentation o One or more fetal extremities accompany the presenting part – also higher risk of prolapsed cord and C-section is indicated Breech presentations – dysfunctional labor, fetal injury, risk of prolapsed cord, C-section Frank Breech o Fetus’s thighs are flexed alongside the body, feet are close to the head Complete Breech o One or both knees are flexed Footling Breech o Either one (single footing) or both (double footing) feet present before the buttocks 6. What are different methods of labor induction? Induction of labor (IOL) = deliberate stimulation of labor onset of spontaneous labor to facilitate a vaginal birth There must be an indication for IOL; medically necessary IOL interventions: o Cervical preparation: the process of physical softening, thinning, and dilating of the cervix in preparation of labor and birth § Mechanical cervical preparation à balloon catheter § Pharmacological methods of preparation à misoprostol, cervidil o Oxytocin: Pitocin titration used to stimulate contractions and labor o Amniotomy (AROM): artificial rupture of membranes used to induce or augment labor § AROM in early labor à increased risk of C-section 7. What does a Bishop Score measure? A calculation to predict how close you are to labor  Bishop score >8 o Same likelihood of vaginal delivery with induction of labor as that following spontaneous labor; indicates a successful induction Bishop score 6 o Favorable for successful induction 8. What are indications and contraindications or labor augmentation? Augmentation = stimulation of contractions when labor does not progress after the onset of spontaneous labor; goal is to strengthen and regulate contraction Indications o 1000cc C/S + 10% drop in Hgb/Hct How do we assess it? EBL >> QBL (estimated blood loss >> quantitative blood loss) Greatest risk is in the first hour after birth! o Primary PPH = happens within 24 hours of birth o Secondary (delayed) PPH = occurs between day 1 to 6 weeks Other risk factors: o Neonatal macrosomia o Placenta previa/accrete  o Multiple gestation o Previous C/S or uterine surgery o Polyhydramnios o Prior PPH o High BMI o Operative vaginal delivery o Chorioamnionitis o Congenital/coagulation defects 7. What are four causes associated with postpartum hemorrhage? The Four T’s: o Tone: uterine atony (boggy [meaning soft and tender] fundus); subinvolution (delayed return of the enlarged uterus to normal size and function) o Tissue: retained placental fragments – common cause of secondary PPH o Trauma: lower genital tract lacerations – 2nd most common cause of primary PPH § Hematomas can develop – when blood from a ruptured vessel collects within the connective tissues of the vagina or perineal areas o Thrombin disorders: disseminated intravascular coagulation (DIC), DVT, PE § The body breaks down clots faster than it can form them, depleting the body of clotting factors and leading to hemorrhage and death 8. How is postpartum depression distinguished from “baby blues”? Difference Between Postpartum Blues (Baby Blues) and Postpartum Depression (PPD) o PPB (Baby Blues) = symptoms disappear without medical intervention, occurs within the first 2 weeks postpartum, able to safely care for self and baby o PPD = requires psychiatric interventions, occurs within the first 12 months postpartum, unable to safely care for self-and/or baby LECTURE 8 – HIGH RISK NEONATAL NURSING CARE 1. What two factors do infant health and survival depend on? Length of gestation Birth weight 2. What are signs and symptoms of respiratory distress syndrome in the neonate? Respiratory distress syndrome = life-threatening lung disorder that results from small, underdeveloped alveoli and insufficient levels of pulmonary surfactant Signs and symptoms of RDS: o Tachypnea o Gray or dusky skin o Lethargic and hypotonic neonate 3. What is a patent ductus arteriosus and when should it normally close in the newborn? PDA occurs when the ductus arteriosus remains open after birth Normally closes after a few hours of birth, but can take up to 96 hours Signs and symptoms of PDA: o Tachycardia o Tachypnea o Recurrent apnea o Bounding pulses 4. What is meconium aspiration syndrome? Meconium aspiration syndrome = respiratory failure induced when meconium fluid enters the lungs and causes partial obstruction Increased risk in postmature newborns (born after 41 weeks’ gestation) Nursing Actions: o Assess for respiratory distress o Administer O2 if indicated 5. What is breastfeeding jaundice? Hyperbilirubinemia associated with breastfeeding Early onset of jaundice within the first few days of life Associated with ineffective breastfeeding Dehydration can occur Delayed passage of meconium stool promotes reabsorption of bilirubin in the gut Treatment à encourage early effective breastfeeding without supplementation of glucose water or other fluids 6. What are the five principles of discharge teaching? Right Time Right Context – Is the environment quiet, free of distractions, private, soothing, or stimulating? Right Goal – Is the patient actively involved, are you and your patient committed to reaching mutually set goals, are the goals realistic and valued by the client? Right Content Right Method 7. What hormones are associated with lactogenesis? Lactogenesis = begins during the 2nd trimester: milk is produced in the alveolar glands and transported to the nipple through lactiferous ducts Hormones associated with lactogenesis: o Prolactin – primary hormone responsible for lactation o High levels of estrogen and progesterone SUPPRESS lactation Once placenta is delivered à prolactin levels increase; estrogen/progesterone levels decrease LECTURE 8 – WELL-PERSON CARE 1. What four phases of life are distinguished with looking at women’s health? Adolescence à Childbearing years à Peri-menopause à Post-menopause/geriatric 2. What are the five P’s of taking a health history? Partners Practices Protection from STIs Past History of STIs Pregnancy Intention 3. What is the lactational amenorrhea method of birth control? Using breastfeeding as your birth control – breastfeeding temporarily helps prevent pregnancy since breastfeeding hormones may stop your body from releasing eggs  It must be used correctly for it to work – the three simultaneous conditions that must be fulfilled is: o 1. The baby is under 6 months o 2. The mother is still amenorrheic o 3. The mother practices exclusive or quasi-exclusive breastfeeding on demand 4. What are current methods of long-acting reversible contraception available in the United States? IUD – Copper = Paragard; Hormone-Releasing = Mirena, Kyleena, Skyla o Intrauterine device (IUD) = a small T-shaped device that your health care provider puts through your vagina and cervix into your uterus o A string attached to the IUD comes out of your uterus into the top of your vagina § The string is used to pull out the IUD when you want it removed o Copper IUD (Paragard) has no hormones and works up to 10 years § Changes sperm so sperm cannot fertilize an egg o Hormonal IUDs work up to 3-5 years, depending on which one you choose § Release a small amount of hormones called progestin, which thickens your cervical mucus to keep sperm from reaching an egg Hormone implant (Nexplanon) o Works up to 3 years, a small rod placed under the skin in the back of your arm o Releases a small amount of progestin, which keeps your ovaries from releasing an egg Gestational Diabetes Diagnosis ◦Dx between 24-28 weeks when glucose test done. 1 hour test, then 3 hour if you fail 1 hour. Signs and symptoms ◦Often symptomless, sometimes increased thirst, urination, dry mouth. This is why the test is so important! Lab evaluation ◦Blood glucose Management in pregnancy (ie fetal monitoring, medication) ◦Manage BG levels with diet, movement, medication like Metformin, insulin ◦Insulin needs increase 3rd tri Implications for timing (pre-term vs term) and type of birth (vaginal vs c-section) ◦Possibly cesarean birth if EFW > 4,500 gm Risks to the fetus ◦Macrosomia, hypoglycemia, asphyxia, respiratory distress, stillbirth, preterm birth Risks to the pregnant/birthing person ◦Hypoglycemia, preeclampsia, cesarean birth, increased chance of type 2 diabetes postpartum Twin pregnancies Diagnosis ◦Via ultrasound, or rapid fundal height expansion Signs and symptoms ◦Lab evaluation Management in pregnancy (ie fetal monitoring, medication) ◦Increased monitoring for fetuses and parent, steroids if premature Implications for timing (pre-term vs term) and type of birth (vaginal vs c-section) ◦Often pre-term delivery, often cesareans pending if they share placentas, sacs, and if they are breech or cephalic Risks to the fetus ◦Stillbirth, injury, largely related to either sharing the resources in womb OR premature births Risks to the pregnant/birthing person ◦Hypertensive disorders, gestational diabetes, cesarean birth Preeclampsia Diagnosis ◦New onset hypertension after 20 weeks, two BP readings at least 140/90 4 hours apart, proteinuria. Signs and symptoms ◦Headache, vision changes, RUQ pain, swelling Lab evaluation ◦Proteinuria, possibly low platelets abnormal kidney and liver function tests. Management in pregnancy (ie fetal monitoring, medication) ◦NST and BPP to observe fetal wellbeing, BP medications, possibly anticonvulsant medications, induction of labor at 37 weeks if no severe features, if severe than can be induced less than 34 weeks. ◦If babies are born before 34 weeks we give them steroids for their lungs ◦Severe is BP >160/110 accompanied by vision changes, low platelet count, abnormal liver/kidney test Implications for timing (pre-term vs term) and type of birth (vaginal vs c-section) ◦Induction of labor, possibly pre-term, higher cesarean rate due to fetal intolerance of labor. Risks to the fetus ◦Growth restriction, prematurity, intolerance to labor, still birth. Risks to the pregnant/birthing person ◦Everything - vascular disease, a ects nearly every organ. Cerebral edema, hemorrhage, stroke, seizure, DIC, heart failure, placental abruption. Pre-eclampsia turns into eclampsia.