Obstetrics Final Exam Review PDF

Final exam review Intrapartum care 1. What are the types of breech presentations?- Slide 23 2. What are fetal variations for vertex presentation?- Slide 25 v What aspects of newborn status are included in the APGAR score?- Slide 41 Assessment for infants after birth→ scored of 10 1 min an...

Final exam review Intrapartum care 1. What are the types of breech presentations?- Slide 23 2. What are fetal variations for vertex presentation?- Slide 25 v What aspects of newborn status are included in the APGAR score?- Slide 41 Assessment for infants after birth→ scored of 10 1 min and 5 min Measures: o Respiratory effort o Heart rate o Muscle tone o Reflex Activity o Color  Fetal Heart Rate Monitoring v What is the primary goal of external fetal heart rate monitoring? v To interpret and continually assess fetal oxygenation to prevent significant fetal acidemia while minimizing unnecessary interventions and promoting family-centered care v Good fetal oxygenation = good placenta v Describe two ways and fetal heart rate monitor may be used in labor: external vs internal v External monitoring→ detects baseline, variability, accels and decels Ø CEFM – continuous electrical fetal monitoring (US) Ø Intermittent (Doppler) Ø Wireless Ø Contractions are measured via toco transducer v Internal monitoring → is an intervention specific for troubleshooting measures Ø Place F/ISE (fetal/internal scalp electrode) attached to presenting part of the fetus Ø Place IUPC (intrauterine pressure catheter) Ø Membrane MUST be ruptured to perform internal monitoring Ø If not yet ruptured, must be manually ruptured v Contraindications: chorio, GBS+, genital herpes, placenta previa v How are cord blood gasses used to assess newborn status? v 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 v Describe a normal fetal heart rate baseline v Baseline (BL) FHR is rounded to 5 bpm in a 10-minute window of time v Normal FHR: 110-160 bpm x 10 min or more v Describe abnormal fetal heart rate baselines Tachycardia→ >160 bpm x 10 min or more Bradycardia→ 25bpm → tachycardia v How is an acceleration measured? Visually apparent abrupt increase in FHR above baseline >15 bpm x 15 sec but less than 2 minutes – if longer than 2 minutes, can indicate baseline change If preterm 30 seconds to reach nadir (nadir = the slowest FHR recorded and lowest point)→Periodic Ø Mirrors contraction (nadir is at the peak of uterine contraction) Ø Cause = head compression against the pelvis or soft tissue Ø Reassuring (a good sign) Variable Decels  Ø Baseline to nadir in 15 bpm lasting >2 min but 2 min but 200 mmHg MVUs in 10 minutes → adequate contraction intensity to expect labor progression v What are intrauterine resuscitation strategies? v Position change – left lateral increases uteroplacental perfusion v IV bolus – can improve oxygenation in cases of hypotension or hypovolemia v Oxygen – administered via face mask to the birthing person v SVE (sterile vaginal exam)→assess labor progress and (+) scalp stimulation is reassuring in 1st stage of labor v Amnioinfusion – for recurrent variables v Alter uterine activity PRN – assess for tachysystole, adjust medications PRN  High Risk Labor and Birth 1. What is uterine dystocia? v Abnormal labor caused by lack of progressive cervical dilation or lack of descent of the fetal head – r/t power, passenger, passage, and psyche v Risk factors: Ø Maternal exhaustion Ø Epidural anesthesia may decrease the urge to push v Fetal dystocia = fetal excessive size, malpresentation, fetal anomalies v Pelvic dystocia = delayed descent of the fetal head r/t pelvic size or shape v Uterine dystocia = weak or uncoordinated uterine contraction in labor Ø Due to hypertonic contractions or hypotonic contractions 2. What are nursing interventions for hypertonic contractions? v Hypertonic contractions = contractions are frequent and painful but ineffective in promoting dilation and effacement Ø May be Category II or Category III r/t prolonged labor and inadequate uterine relaxation v Risk Factors Ø Nulliparous individuals v Nursing Actions Ø Promote rest – try to break the pattern of frequent but ineffective uterine contractions § Patient sleeps for a several hours and wakes up in a normal labor pattern of active labor Ø Pain meds – morphine PRN to decrease labor contractions and allow uterus to rest Ø Promote relaxation – warm shower/tub bath, quiet environment, minimal interruptions for long sleep Ø Hydration – IV or PO fluids if tolerated 3. What are interventions for hypotonic contractions? v Hypotonic contractions = pressure of the uterine contraction is insufficient; measured with an IUPC Ø Decreased frequency, strength, and duration of uterine contractions v Risk Factors Ø Multiparous patients Ø Extreme fear may result in catecholamine release, interfering with uterine contractility v Nursing Actions Ø Assess uterine activity, maternal and fetal status Ø Stimulate uterine activity to achieve a normal labor pattern using the following methods: § Ambulate and change positions § Hydrate – IV or PO as per orders § Administer IV fluids to maximize maternal fluid volume, correct maternal hypotension, and improve placental perfusion § Augment labor with oxytocin as per protocol § Maintain good aseptic technique to minimize the risk of infection if there is rupture of membranes (ROM) v Medical management – may perform amniotomy 4. What is the difference between first stage arrest disorder and a second stage arrest disorder? v Arrest of labor = no progress in the dilation and descent of the newborn down the birth canal; can only be used to define labor in the context of active phase v First stage arrest disorder ➔ failure of cervical dilation Ø Spontaneous labor → >6 cm dilation with membrane rupture and 4+ hours of adequate contractions/6+ hours if inadequate contractions § Delivery that happens on its own without requiring doctors to use tools to help pull the baby out Ø Induced labor→ >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 v Second stage arrest disorder ➔ failure of fetal head descent Ø Arrest of labor after 2 hours of pushing for 3 hours of pushing 5. What are the different fetal presentations that may lead to dystocia? v Occiput posterior Ø 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) v Face presentation Ø Fetal head is in extension rather than flexion as it enters the pelvis v Brow presentation  Ø Fetal head presents in a position midway between full flexion and extreme extension – largest diameter of the head in the pelvis v Shoulder presentation Ø Fetal spine is vertical to the maternal pelvis –higher risk of prolapsed cord, C-section is indicated v Compound presentation Ø 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 v Frank Breech Ø The fetus’s thighs are flexed alongside the body, feet are close to the head v Complete Breech Ø One or both knees are flexed v Footling Breech Ø Either one (single footing) or both (double footing) feet present before the buttocks 6. What are different methods of labor induction? v Induction of labor (IOL) = deliberate stimulation of labor onset of spontaneous labor to facilitate a vaginal birth v There must be an indication for IOL; medically necessary v IOL interventions: Ø Cervical preparation: the process of physical softening, thinning, and dilating of the cervix in preparation of labor and birth § Mechanical cervical preparation ➔ balloon catheter § Pharmacological methods of preparation ➔ misoprostol, cervidil Ø Oxytocin: Pitocin titration used to stimulate contractions and labor Ø Amniotomy (AROM): artificial rupture of membranes used to induce or augment labor § AROM in early labor ➔ increased risk of C-section 7. What does a Bishop Score measure? v A calculation to predict how close you are to labor v Bishop score >8 v Same likelihood of vaginal delivery with induction of labor as that following spontaneous labor; indicates a successful induction v Bishop score 6 Ø Favorable for successful induction 8. What are indications and contraindications or labor augmentation? v Augmentation = stimulation of contractions when labor does not progress after the onset of spontaneous labor; goal is to strengthen and regulate contraction v Indications: Ø 1000cc C/S + 10% drop in Hgb/Hct v How do we assess it? EBL >> QBL (estimated blood loss >> quantitative blood loss) § Greatest risk is in the first hour after birth! v Primary PPH → happens within 24 hours of birth v Secondary (delayed) PPH→ occurs between day 1 to 6 weeks v Treatment goal→ identify cause and prevent hypovolemic shock v Other risk factors: Ø Neonatal macrosomia  Ø Placenta previa/accrete Ø Multiple gestation Ø Previous C/S or uterine surgery Ø Polyhydramnios Ø Prior PPH Ø High BMI Ø Operative vaginal delivery Ø Chorioamnionitis Ø Congenital/coagulation defects v What are four causes associated with postpartum hemorrhage? v The Four T’s: Ø Tone: uterine atony (boggy [meaning soft and tender] fundus); subinvolution (delayed return of the enlarged uterus to normal size and function) Ø Tissue: retained placental fragments – common cause of secondary PPH Ø 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 Ø 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→ leading to hemorrhage and death 8. How is postpartum depression distinguished from “baby blues”? v Difference Between Postpartum Blues (Baby Blues) and Postpartum Depression (PPD) Ø PPB (Baby Blues) → symptoms disappear without medical intervention, occurs within the first 2 weeks postpartum, able to safely care for self and baby Ø PPD → mild to severe depression requires psychiatric interventions, occurs within the first6- 12 months postpartum, unable to safely care for self-and/or baby § 2 weeks of: Loss of interest or pleasure in daily activities Insomnia Decreased energy/fatigue Decreased concentration Feelings of worthlessness or guilt Weight changes  High risk neonatal nursing care 1. What two factors do infant health and survival depend on? v Length of gestation v Birth weight 2. What are signs and symptoms of respiratory distress syndrome in the neonate? v Respiratory distress syndrome = life-threatening lung disorder that results from small, underdeveloped alveoli and insufficient levels of pulmonary surfactant v Signs and symptoms of RDS: Ø Tachypnea Ø Gray or dusky skin Ø Lethargic and hypotonic neonate 3. What is a patent ductus arteriosus and when should it normally close in the newborn? v PDA occurs when the ductus arteriosus remains open after birth v Normally closes after a few hours to 96 hours post birth v Signs and symptoms of PDA: Ø Tachycardia Ø Tachypnea Ø Recurrent apnea Ø Bounding Pulses 4. What is meconium aspiration syndrome? v Meconium aspiration syndrome = respiratory failure induced when meconium fluid enters the lungs and causes partial obstruction v Increased risk in postmature newborns (born after 41 weeks’gestation) v Nursing Actions: Ø Assess for respiratory distress Ø Administer O2 if indicated 5. What is breastfeeding jaundice? v Hyperbilirubinemia associated with breastfeeding v Early onset of jaundice within the first few days of life v Associated with ineffective breastfeeding v Dehydration can occur v Delayed passage of meconium stool promotes reabsorption of bilirubin in the gut v Treatment Ø Encourage early effective breastfeeding without supplementation of glucose water or other fluids 6. What are the five principles of discharge teaching? v Right Time v Right Context – Is the environment quiet, free of distractions, private, soothing, or stimulating? v 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? v Right Content v Right Method 7. What hormones are associated with lactogenesis? v Lactogenesis = begins during the 2nd trimester: milk is produced in the alveolar glands and transported to the nipple through lactiferous ducts v Hormones associated with lactogenesis: Ø Prolactin – primary hormone responsible for lactation Ø High levels of estrogen and progesterone SUPPRESS lactation v Once placenta is delivered ➔ prolactin levels increase; estrogen/progesterone levels decrease→ estrogen will re-increase 1 week PP v Lactation amenorrhea method Ø Ovulation suppressed longer for lactating parent Well-person care 1. What four phases of life are distinguished when looking at women’s health? v Adolescence ➔ Childbearing years ➔ Perimenopause ➔ post-menopause/geriatric 2. What are the five P’s of taking a health history? v Partners v Practices v Protection from STIs v Past History of STIs v Pregnancy Intention 3. What is the lactational amenorrhea method of birth control? v Using breastfeeding as your birth control – breastfeeding temporarily helps prevent pregnancy since breastfeeding hormones may stop your body from releasing eggs v must be used correctly for it to work – the three simultaneous conditions that must be fulfilled are: § 1. The baby is under 6 months § 2. The mother is still amenorrheic § 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? v IUD – Copper = Paragard; Hormone-Releasing = Mirena, Kyleena, Skyla Ø Intrauterine device (IUD) = a small T-shaped device that your health care provider puts through your vagina and cervix into your uterus Ø 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 Ø Copper IUD (Paragard) has no hormones and works up to 10 years § Changes sperm so sperm cannot fertilize an egg Ø Hormonal IUDs work up to 3-5 years, depending on which one you choose § Release a small number of hormones called progestin, which thickens your cervical mucus to keep sperm from reaching an egg Ø Hormone implant (Nexplanon) Works up to 3 years, a small rod placed under the skin in the back of your arm Releases a small amount of progestin, which keeps your ovaries from releasing an egg High Risk Prenatal care: For the following high risk conditions, be familiar with: 1. Diagnosis 2. Signs and symptoms 3. Lab evaluation 4. Management in pregnancy (ie fetal monitoring, medication) 5. Implications for timing (pre-term vs term) and type of birth (vaginal vs c-section) 6. Risks to the fetus 7. Risks to the pregnant/birthing person Conditions 1. Preeclampsia Hypertensive, multisystem disorder: Pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation. v Diagnosis New onset hypertension after 20 weeks of pregnancy Two blood pressure readings of at least 140/90 mm Hg, taken at least 4 hours apar Proteinuria greater than 300 mg in 24 hours Protein/Creatinine ratio ≥ 0.3 mg/dl v Risk Factors Nulliparity 35 yo  Obesity Multiparity Family history of preeclampsia Pregestational hypertension, kidney disease, lupus, or diabetes Gestational diabetes Signs and Symptoms v Signs: Blood pressure > 160/110 mm Hg Abnormal kidney function tests, serum creatinine >1.1 mg/dL Low platelet count (< 100,000) Abnormal liver function tests HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) v Symptoms: Visual problems: blurred vision, double vision, blind spots, flashes of light, squiggly lines, vision loss N/V Swelling in hands and face. Persistent headache Pulmonary edema (Severe) Shortness of breath Mid- or right-epigastric pain Lab Tests Blood pressure readings 24-hour urine collection for proteinuria Protein/Creatinine ratio Liver function tests Kidney function tests Platelet count Management v Outpatient management Non-stress test and biophysical profile Blood pressure monitoring v Induction of labor 37 weeks without severe features /= 95 mg/dL ¨ 1-hour: >/= 180 mg/dL ¨ 2-hour: >/= 155 mg/dL ¨ 3-hour: >/= 140 mg/dL Signs and symptoms v Signs/symptoms of hypoglycemia Lab evaluation v 1-hour 50gm glucose challenge test – non-fasting Positive results is 135 mg/dL– 140 mg/dL or greater v 3-hour 100gm glucose tolerance test- following an 8-12 hr fast Plasma glucose levels are drawn fasting and at 1, 2, and 3 hours after the glucose load Management in pregnancy (ie fetal monitoring, medication) v Diet-controlled v Oral hypoglycemics v Insulin Implications for timing (pre-term vs term) and type of birth (vaginal vs c-section) v Cesarean birth discussed if Estimated Fetal Weight (EFW) > 4, 500 gm ~ 9.9 lbs Risks to the fetus *Same as pre-gestational excluding congenital anomalies* v Macrosomia (large birth weight due to fetal hyperinsulinemia) v Hypoglycemia at birth (resulting from high insulin levels in the fetus) v Respiratory Distress Syndrome (due to delayed lung maturity) v Polycythemia (elevated hematocrit due to increased fetal erythropoietin) v Hyperbilirubinemia (caused by polycythemia and breakdown of red blood cells) v Prematurity (if maternal complications necessitate early delivery) v Cardiomyopathy (related to maternal hyperglycemia) v Birth injuries (due to large fetal size) Risks to the pregnant/birthing person v Hypoglycemia v Preeclampsia v Cesarean birth v Development of Type 2 DM post partum 3. Twin pregnancies Types of Twin Pregnancies: v Monozygotic twins Ø One zygote that divides in the first week of gestation.  Ø Always the same gender Ø Genetically identical and similar in appearance v Dizygotic twins Ø Fertilization of two eggs Ø May be the same or different gender Diagnosis v Detected via ultrasound Signs and symptoms v Larger-than-expected uterine size v increased morning sickness v fatigue Lab evaluation v Ultrasound for discordant fetal growth and IUGR, as well as placental sites v Genetic testing for anomalies Management in pregnancy (ie fetal monitoring, medication) Ultrasound for: Ø IUGR Ø Discordant fetal growth Ø Placental sites Ø Dividing membranes Ø Congenital anomalies Ø Gender v Genetic testing for anomalies v Monitor for and prevent preterm labor v Administer corticosteroids for fetal lung maturity Ø Corticosteroids for fetal lung maturity are effective in reducing respiratory distress syndrome (RDS) and other complications of prematurity. v Monitor for maternal anemia v Fetal surveillance, including NST and BPP v Monitor for hypertension and preeclampsia v Monitor for hydramnios v Monitor for antepartum hemorrhage v Monitor for intrauterine fetal demise v Nutritional consult v Consultation with perinatologist if complications occur Implications for timing (pre-term vs term) and type of birth (vaginal vs c-section) v The rate of preterm delivery is 50% higher in twins and at least 90% higher in triplets and higher-order multiples. v As the number of fetuses increases, the duration of gestation decreases. v Cesarean birth is a risk to the pregnant person Risks to the fetus v Increase in fetal morbidity and mortality due to sharing uterine space and placental circulation Increased perinatal mortality (threefold higher than in singleton pregnancy) Intrauterine fetal death of one fetus after 20 weeks’ gestation increases the risks to the surviving fetus(es). v Delivery before term is the major reason for increased morbidity and mortality in twins. Rate of preterm delivery is 50% higher in twins and at least 90% higher in triplets and higher order multiples. As the number of fetuses increases, the duration of gestation decreases. v Increase of low-birth-weight neonates (20% higher than singleton) v Monochorionic twins have a shared fetoplacental circulation, which puts them at risk for specific serious pregnancy complications, such as twin-twin transfusion syndrome and twin anemia-polycythemia sequence. Increased risk for neurologic morbidity and perinatal mortality. Monoamniotic twins also are at risk for cord entanglement and conjoined twins. v Increase of intrauterine growth restriction (IUGR) and discordant growth (weight of one fetus differs significantly from the others, usually ≥25%) related to placental insufficiency. v Discordant growth and twin-to-twin transfusions from sharing a placenta occurs. v Vascular anastomosis between twins can occur with monochorionic twin placentas. Most of these vascular communications are hemodynamically balanced and do not impact fetal development and perfusion. v In twin-to-twin transfusion syndrome, blood is transfused from donor twin to recipient twin. v Due to an imbalance in blood flow through the vasculature of the placenta because of arteriovenous anastomosis in the placenta. v This results in overperfusion of one twin and can result in circulatory overload and heart failure and under-perfusion and anemia of the co-twin. v Increase of congenital, chromosomal, and genetic defects, in particular structural defects, with monozygotic twins. Risks to the pregnant/birthing person v Hypertensive disorders and preeclampsia, which tend to develop earlier and be more severe, are related to enlarged placenta. v Gestational diabetes often occurs due to physiological changes related to supporting multiple fetuses. v Antepartum hemorrhage, abruptio placenta, placenta previa v Anemia related to dilutional anemia v Peripartum cardiomyopathy, pulmonary edema, and pulmonary embolism v Intrahepatic cholestasis v Acute fatty liver v Cesarean birth