Maternity 224 Notes PDF

aMATERNITY → INTRODUCTION → ● History : ○ Granny Midwives → ○ Late 19th Century → infection control (wash hands btwn patients), forceps (used to help pull baby out - painful & traumatic), chloroform for L&D pains, med for augmentation - help make contractions stronger, cesarean birth - used to only...

aMATERNITY → INTRODUCTION → ● History : ○ Granny Midwives → ○ Late 19th Century → infection control (wash hands btwn patients), forceps (used to help pull baby out - painful & traumatic), chloroform for L&D pains, med for augmentation - help make contractions stronger, cesarean birth - used to only be done if mother had no chance of surviving and needed to save the baby ○ 1950’s → ■ Grantly Dick-Read starts idea that woman didn’t want to be knocked out & tied up during birth ■ Lamaze & Bradley ● Bradley: started husband coached child birth ● Lamaze : deep breathing ■ women seek to control their bodies & births ○ 1960’s → 90% hospital births moved to hospital, before mostly done at home ● Care Settings : ○ Homebirth → ■ Low risks pts that you don’t expect a lot of complications ■ If any complication occur, mom should be sent to a birth center or hospital immediately ■ Certified nurse midwife, more family involved in experience ○ Birth center → low risk patients ONLY , not a hospital ■ If unforeseen complications occur rushed to nearest hospital ■ Certified nurse midwives, physicians : CNM usually provides care throughout pregnancy, assists with birth, and provides primary care for mother and infant after birth ■ Can also provide gynecologic services & contraceptive counseling ■ Can attend classes to help prepare for childbirth, breastfeeding, infant care ■ Follow up care for mom and baby for first 6 wks after birth ■ Less expensive, less technology, more homelike setting ○ Hospital ■ Traditional - one room where pt labors, one where pt delivers, one for recovery, one for postpartum ■ LDR - labor, delivery & recover all in one room, separate room for postpartum, most common, stays in room 1-2 hrs after birth then transferred to another for postpartum for rest of stay, baby can stay w mom in postpartum room or in nursery for more assessment ■ LDRP - labor, deliver, recover & postpartum all in one room, needs adequate staffing to run, mother & baby remain in this one room entire time ● Insurance ○ Diagnosis related groups (DRG’s) : ■ Gives certain amount of money to the hospital depending on the procedure done, not related to how long pt stays for, hospital began discharging pts as early as they could to reduce costs, women were dying from hemorrhaging due to early discharge ○ 1987 Medicare reimburses by DRG ○ Money determines / reduces length of stay (LOS) ■ Congress passed law saying that women had to stay in hospital at least → ● VD (vaginal deliver) = 48 hours ● CD = 96 hours ● This time is still short in order to teach the new mother what is needed before discharge ● CAM/Family Roles → birthing person is not always the mother ○ CAM : ■ may be harmful to pregnancy or lactation, or harmful if combined with other medications ■ May be used therapeutically for infertility, premenstrual syndrome, dysmenorrhea, menopausal symptoms, pregnancy, and perineal discomforts & lactation discomforts ○ Culture ■ DOULA : ○ ○ ○ ○ ○ ■ Wide variations of beliefs and practices exist within each culture ■ Nurse must recognize that people sharing a culture may not have identical beliefs ■ Nurses must be careful not to stereotype ■ Conflict Causing → health beliefs i.e. female genital cutting, communication i.e. translators should not be family members or children and determine who is family decision maker is and include them, time orientation, eye contact, etc. ■ ** determine if patient believes they have experienced a trauma before you give help ** Religion ■ May not want husbands in room w them, may have doula ■ Jewish : husband is not allowed to touch wife once uterus starts bleedings, usually hire doula as support person Sexual orientation ■ Don’t assume on who is in room Gender identity Family group ■ “BIRTHING PERSON” instead of “mother” ● Ask questions to find out what they want to be called and who is who Adoptive / segregacy - birthing person may not be the one keeping the baby ● Infant mortality ○ Improved significantly over last several decades , leading cause of deaths include congenital malformations, premature birth, and maternal complications of pregnancy ● Nurse’s Role ○ Communicator - therapeutic communication ○ Teacher - what is happening and how we can help ○ Collaborator - works w a team of physicians & other licensed professionals ○ Researcher - evidence based practice ○ Advocate - speak on behalf of the patient allow them to be involved in decisions & planning of care ○ Manager : charge, who is put where, who gets what assignment, know your staff and your patients and when you can’t handle any more → delegate & coordinate care ○ Culturally competent care → questions to help the nurse understand family’s beliefs through cultural assessment ■ Outcome = enhanced relationship between women & providers, reduced complications, adherence to HCP recommendations, improved QOL, increased trust, & an appreciation of cultural diversity by providers ● Care Givers : ○ Doula, support person : helps support mom during L&D, or postpartum or delivery for births that don’t go well ○ Aide : typically not in birthing room , assists nurse during postpartum ○ LPN : in L&D & postpartum ○ Surgical tech : primarily in L&D helps w c-section & VD ○ RN ○ LM : licensed midwife can provide care in some states -- lay midwife, trained by another midwife and has no other training/certification ○ Primary Care Providers ■ CNM (certified nurse midwife) can practice homebirths, low risk pregnancies, refers pt to a physician if problems develop, treats women during pregnancy, postpartum & delivery ■ NP ■ PA ■ DO/MD (FP, OB/GYN, GYN, GYN-ONC, MFM) : MFM = maternal fetal medicine specifically for high risk pregnancy ● Barries to Prenatal Care : ○ Financial → ■ Prenatal care helps mother & baby significantly ■ No insurance or insufficient insurance ■ medicaid process is burdensome & lengthy, some women do not know how to access Medicaid or do not qualify ** as soon as pregnancy is known , partner them up with someone able to assist w process ** ■ Affluent : have resources to provide for their needs and purchase healthcare - focus on preventative care, seek regular antepartum care & comply w recommendations of HCP ■ Middle class : rely on group insurance, obtained as a benefit of employment, seek health care early in pregnancy ■ Working poor & unemployed : focus on present needs rather than preventative care, prenatal care can be postponed to 2nd or 3rd trimester ○ Systemic → ■ Institutional practices that interfere w consistent care, conflicts w working women’s schedule, loss of wages/jeopardize job, unavailability of child care, lack of transportation , may not have time for care or prioritize it ○ Attitudinal → ■ PT & whole family need to feel comfortable w the way they are treated at hospital ■ Give care in way you want to be treated - tell pt what you are doing while you are doing it & result of your interventions so that she will feel comfortable coming back each week ■ Unsympathetic attitude of some health care workers, hurried exams perceived as unimportant, depression from unintended pregnancy, women rely on advice from family & friends ■ I.e. NST (nonstress test) is typically done very fast, once a week towards end of pregnancy, very important but if rushed mom may not find important or purpose to go ● Cultural Influences on Childbearing ○ Differences within culture → ■ Wide variations of beliefs & practices exist within each culture ■ Nurses must recognize people sharing a culture may not have identical beliefs ■ Do not stereotype ○ Causing conflict → ■ Health beliefs : maintenance, belief in fate, preventing illness, restoring health, modesty, female genital cutting ■ Communication : make sure to ask if pt understands information and if they have any questions - repeat back information , small talk to establish rapport, language, communicating style, decision making - who is it in family, include this person when planning , eye contact, touch, time orientation - pt should not feel offended if you rush through a conversation or procedure - something else going on but you will be right back ○ Nursing care → ■ Cultural assessment : questions to help nurse understand family’s beliefs, sensitive ■ Cultural negotiation : talk to them beforehand about what needs to be done & work w their beliefs, explain to them why a medical recommendation is made & try to compromise ● Ethics : “..determining the best course of action in a certain situation” ○ Violence : may increase in pregnancy or postpartum period, adds stress to relationships ■ Abuse is most common complication of pregnancy feelings of trapped or pressure to provide emotional & financial support ■ Woman is at a greater chance for complications - tend to seek prenatal care later, increased risk of uterine rupture, placental abruption, preterm birth, LBW infants, and maternal & fetal death ■ Increased risk for STD’s & peripartum depression ■ Nurse should examine personal beliefs - do not victim blame, help pt to feel empowered, make it clear women owns her body and has right to decide how to be treated ■ No judgement, they are safe, protect modesty, ASK PRIVATELY , know available resources ○ “Ethics involves determining the best course of action in a certain situation “ ○ “Bioethics is the application of ethics to health care” ■ Conflicts of mother and fetus occur when mother;s needs, behaviors or wishes may harm fetus → abortion, substance abuse, mother’s refusal to follow advice of caregivers ○ Ethics & Religion : ■ Bishop Thomas J. Olmsted & Sister Margaret McBride, RN was excommunicated by bishop for having abortion to save a life of mother ■ Abortion ○ Ethics & Law : ■ I.e. Anencephalic Organ Donation ■ Rinat Dray → “... may justify using the means necessary to override a maternal refusal of the treatment “ ○ Elective Termination of Pregnancy ■ Pro choice “belief that abortion is a private choice” ■ Pro life “ belief that abortion is taking a life” ■ Roe vs Wade 1973 → abortion is legal in US & any state saying it was illegal was unconstitutional, woman can obtain an abortion at any time during first trimester, state could regulate abortion during second trimester only to protect women’s health, state can prohibit abortion during third trimester except when mother’s life might be jeopardized by continuing pregnancy ■ Nursing → ● Not a dilemma but a fundamental violation of personal or religious views ● Acknowledge sincere convictions and strong emotions on all sides of issue ● Know laws of your state ● Results in confusion, ambivalence and personal distress ○ Ethics in Reproduction : ■ Mandated contraception - forcing women to get sterilized in exchange for something ● Ex. offering less jail time for woman accused of child abuse ● People think its a reasonable way to prevent additional birth for those who are considered unsuitable parents & to reduce government expenses for dependent children ● Interferes w a women’s constitutional rights to privacy, reproduction, refusal of medical treatment, & freedom from cruel and unusual punishment ■ Fetal Injury - mother’s actions cause injury to her fetus, question of whether she should be restrained or prosecuted has legal & ethical implications ● Should we be able to put people in jail for injuring their babies with drugs / not wearing a seatbelt? places women in a position to not further harm fetus ● Violates rights of autonomy, self determination of competent adults, bodily integrity, and personal freedom ● Fear of prosecution can impede, not advance health care during pregnancy ■ Intrauterine Therapies : twin to twin, fetal sx, termination of one fetus to save the life on another even if that babies life is still viable ● Fetal surgery → baby may have some sort of deformity, fetus can be operated on in utero, close the uterus back up & pregnancy can continue while fetus heals, chance of survival ■ Stem cell research ■ Infertility → Limited access to money, High order multiples, Selective reduction, Unused embryos, postmenopausal ■ Surrogate Parents ● Legal Issues / Safeguards ○ Nurse Practice Acts ■ Determined be each state, states scope of practice ■ State BON - look at the things that are out of your scope of practice ■ www.ncsbn.org ( national council of state boards of nursing) ○ Standards of Care ■ Describes level of care that can be expected from practitioners ■ AWHONN (assoc. Of women’s health, obstetrics, & neonatal nurses)- national standards for perinatal nurses ■ Agency policy ○ Policy, procedures, protocols ○ Informed consent ○ Documentation ANTEPARTUM PATIENT → “before childbirth” → Low BP = Good as long as pulse is good (“i feel dizzy” NOT GOOD SIGN FOR BP) ● Genetics : ○ DNA Helix → blueprint, where all information is housed that tells body how to build itself ○ Chromosomes : genes are organized in 46 pairs ■ Held within DNA , made up of genes ■ Each composed of varying #’s of genes, twenty two chromosome pairs are autosomes - 22 each from mom & dad to make up 44, twenty-third pair makes up the sex chromosome - mom can only give an X, dad can give X or Y to determine sex, chromosomes are arranged into a karyotype ○ Karyotype → way of organizing and looking at chromosomes ○ Punnent Square : ■ “A” = dominant trait ■ “a” = recessive trait ■ “AA” , 2 dominant, dominant will express ■ “Aa” , 1 of each, dominant will express ■ “aa”, 2 recessive, recessive will express ○ Patterns of Single Gene Inheritance : Autosomal Dominant Traits ■ Produced by dominant gene on a non-sex chromosome ■ Abnormal gene’s expression may vary in severity ■ Some having the abnormal gene will always have the disease ● Ex. huntington’s disease ■ New mutations can bring a trait into a family ■ Person affected w autosomal dominant disordered is usually heterozygous ■ Huntington’s disease : if pt’s have genes 25% chance child does not have the disease & 75% they do → if they do it will be stronger or they will die before birth ■ marfran syndrome, BRCA1/2 ■ If baby receives dominant trait from both parents, then you will see a severe variation of whatever that disease is ○ Patterns of Single Gene Inheritance : Autosomal Recessive Traits ■ Expressed if person receives two copies of a recessive gene ■ Abnormality is not expressed if compensated w a normal gene ■ Many recessive disorders are severe ■ Tay sachs, sickle cell anemia, cystic fibrosis ○ Patterns of Single Gene Inheritance : X-Linked Traits (x=girl, y=boy) ■ Recessive is more common than dominant ■ Males are usually only ones who show effects of abnormal X-Linked recessive traits because they only have the one X from mother, no X from dad to cancel it out ■ Recessive is more common than dominant ■ Females can show full disorder in uncommon circumstances ■ Can be mild (color blindness) or severe (hemophilia) ● Chromosomal Abnormalities ○ Trisomy → extra copy of one chromosome, chromosomes are normal but there are too many ■ Instead of receiving 1 chromosome from a each parent, a parent donates 2 chromosomes ■ Typically normal but there are too many ○ Monosomy → each body cell has 1 missing chromosome, ■ most often incompatible with life ○ Polyploidy → embryo has one or more extra sets of chromosomes, usually results in early spontaneous abortion ○ Karyotype : chromosome arrangement ■ Male w trisomy on 21st chromosome (3 genes) = Down Syndrome ● s/s - enlarged tongue, low tone, intellectual disability, developmental delay ■ Female w Turner Syndrome ● Sex chromosome = monosome ( 1 ), appears female, wide neck, broad shoulders, short stature, probably infertile ○ Structural abnormalities → may be clinically normal bc total genetic material is normal or may present w varying levels of anomaly ■ Part of chromosome may be missing or added ■ DNA may be rearranged ■ Part of a chromosome is attached to another (translocation) ■ Too much or too little chromosomal material ■ Fragile “X” syndrome is the most common inherited form of male intellectual disability ● Environmental Influences : “+” or “-” ○ Negative : causative agents ■ Maternal infectious agents - serious infection during pregnancy, drugs, pollutants, ionizing radiation - xrays, maternal hyperthermia, maternal medical disorders diabetes mellitus ○ Teratogens : agents that cause birth defects, teratogen potential ○ manipulation on fetal environment : ■ Appropriate medical therapy for diseases - consider meds that mom is taking to reduce impact on the fetus ■ 400 mcg of folic acid daily before conception : to prevent neural tube defect & other defects of development ○ Mechanical disruptions to fetal development : ■ Oligohydramnios : small amounts of amniotic fluid surrounding the fetus ● Often occurs if membranes rupture early during fetal development causing decrease in cushion around baby ● Uterus collapses down on fetus & prevents appropriate development ● Clubfoot ● fetal lung development - fluid is used to help baby practice breathing in utero & lung expansion, if fluid isn’t there then lungs can’t expand, lungs may not develop, baby may not survive ■ Fibrous amniotic bands : bands from around various parts of baby i.e. extremities - fetal deformations, intrauterine limb amputation ● Genetic Counseling : ○ Availability : facilities that provide maternal - fetal medicine services, stage agencies, agencies that focus on a specific birth defect (i.e. march of dimes) ○ Process of genetic counseling : slow, diagnosis may never be established ○ Nurses as part of a genetic counseling team : women’s health nurses, antepartum, intrapartum, neonatal, pediatric nurses CONCEPTION & PRENATAL DEVELOPMENT → ● Fertilization → entry of sperm into egg , fusion ● Transport → zygote travels from fallopian tubes to uterus where it implants into uterine wall , develops from zygote → morula → blastocyst ○ Moves via peristalsis ○ Uterine lining should be well developed so blastocyst can implant itself ○ Once implanted it will develop into a placenta and fetus ● Placenta → disposable, only used during pregnancy then thrown away ○ Endocrine function : * progesterone * maintains pregnancy (can be given in a medication) ■ Corpus luteum : holds uterine lining in place as fertilized egg is finding its way down ■ **VACCINES WE DO NOT GIVE = live vaccines i.e. rubella (given immediately after birth)** will cross placenta and attack the baby ○ Transfer function : gas , nutrient, waste removal, antibody transfer, transfer of maternal hormones ○ Highly vascular organ : maternal & fetal blood supply never mix, placenta is attached to inside of uterus, red meaty side = maternal side, blue side = fetal side that absorbs oxygen from maternal blood ● Auxiliary Structures : ○ Fetal Membrane : amnion (inner membrane), chorion (outer membrane) ○ Amniotic Fluid : cushions against impacts to maternal abdomen, maintains a stable temperature, allows symmetric development, prevents membranes from adhering to developing fetal parts, allows room & buoyancy for fetal movement **FETAL URINE** ○ Accessory Lobes : if not known about can be left behind and cause big concern with hemorrhage ● Embryonic Period : differentiation of cells, weeks 2 - 8 (weeks 0-2 she is not pregnant, count from last missed period) ● Fetal Period : weeks 9-38, week 24 baby becomes 50% viable chance for survival, surfactant starts to produce ○ Weeks 9 -12 : neural tube closed, 4 chamber heart, intestines in umbilical cord, arms & legs, webbed fingers & toes, bones begin to ossify, low set ears, testes & ovaries begin to develop ○ Weeks 13-16 : eyes face forward, intestines in abdomen, sucking & swallowing reflex, meconium present, kidneys produce urine, external genitals differentiate, long thin limbs, finger nails, toothbuds, languo, blood vessels visible through skin ○ Weeks 17 - 20 : quickening, vernix caseosa, brown fat compete, blood vessels visible through skin, nipples ○ Weeks 21 - 24 : 24th week age of viability, 50% chance of survival outside of womb, testes begin to descend, eyebrows lashes, fingernails, surfactant production begins ○ Weeks 25-28 : eye lids unfuse, sufficient surfactant, better chance of survival, white fat, smoother more opaque skin ○ Weeks 29 - 32 : more mature neuro system, increased fetal HR variability, surfactant production almost normal, skin is smooth, finger nails to finger tipps, lanugo decreased ○ Weeks 33 - 38 : limited visual acuity, still prone to resp distress, ovaries fully developed, smooth skin, small vernix, lanugo only on shoulders & back, long fingernails, firm ear cartilage ● Fetal Circulation ○ umbilical cord : two arteries (deoxygenated blood) return to placenta for O2 exchange, one vein (oxygenated blood - one of two times you will see oxygenated blood running through a vein) ○ Changes after birth : ■ Due to pressure changes when fetus takes its very first breath and lungs expand, all pressure that is holding fetal circulation in place is released ■ Fetal circulatory shunts are not needed, are shut, heart begins pumping in 4 separate chambers ■ Oxygenate blood in lungs ■ Not circulating blood to the placenta ○ Fetal circulatory circuit : ■ ductus venosus : blood comes in through umbilical vein, most of it goes to liver ■ ductus arteriosus : goes from left atrium out to rest of body will become closed once born, patent ■ foramen ovale : hole at top of heart ■ **Changes after birth : fetal circulatory shunts are not needed, oxygenates blood in the lungs, not circulation blood to the placenta ● Multifetal Pregnancy ○ Monozygotic (identical) : single ovum and sperm, with later division, differentiate w development, can cause problems depending on time of sac division ■ Twin to twin transfusion : blood supply shunting from one twin to the other - complication when babies share a placenta, one twin with an oversupply of blood & other with anemia, may cause discordant growth, development impacted, surgeries can be done in utero to try to correct ■ High risk of cord entanglement leading to fetal death due to lack of O2 ○ Dizygotic (fraternal) : two ova that are fertilized by different sperm, family history , each baby has own blood supply and amniotic sac, lower risk situation ○ Very high risk for ( umbilical tying into a knot ) , never goes beyond 32 weeks gestational age before birth if babies are in the same sac ○ Special considerations : maternal physiologic change is greater w multiple fetuses, increased workload for the heart, respiratory difficulty increases, special antepartum classes more frequent visits & ultrasounds, teach signs of preterm labor ● Reproductive System ○ Uterus : growth, pattern of growth, contractility (braxton hicks), uterine blood flow (17% of maternal cardiac output by term) ■ 12 wks : above symphysis pubis ■ 16 wks : between symphysis pubis and umbilicus ■ 20 wks : at umbilicus ■ All of abdominal organs being smushed : if mom needs any surgical interventions because organs are not where they’re supposed to be ■ At 40 wks uterus begins to drop down from pubic symphysis caused by lightning, fetal head descends into pelvis ■ Contractility : increased within uterus ■ Uterine blood flow increases significantly : takes up to 17% of maternal cardiac output by time mother reaches term ○ Cervix : opening ■ Chadwick’s sign : vascularity cervix becomes highly vascular, purple in color ■ Goodell’s Sign : texture - will soften as it prepares for labor ■ Mucus plug - assists in closing the opening of the cervix and to prevent any bacteria from migrating up from vagina that has its own normal flora, uterus is a sterile place while pregnancy develops ○ Vagina & Vulva : increased vascularity, vaginal mucosa thickens, vaginal rugae become prominent, increased production of lactic acid - reduced risk of bacterial & increased risk of yeast ○ Ovaries : progesterone must be present in adequate amounts, corpus luteum of the ovaries secretes progesterone, ovulation ceases during pregnancy ○ Breasts : estrogen stimulates growth of mammary ductal tissue, progesterone promotes the growth of the lobes, lobules, and alveoli, characteristic changes in size & color, colostrum is secreted ● Cardiovascular System : pregnancy is hard on the heart ○ Heart : muscles of the heart (myocardium) enlarge 10% to 15% during 1st trimester, pushed up & left, alteration of heart sounds (systolic murmur is found >95%, 90% have a third heart sound) ○ Blood volume : increase begins by 6 wks of gestation ○ Plasma volume : increases from 6-8 wks until 32 wks of gestation ○ RBC volume : volume increases by 20-30 %, physiologic anemia ○ Cardiac output : increases 30 - 50 % ○ Systemic vascular resistance : decreases during pregnancy ○ Blood pressure : ■ orthostatic hypotension : prone, head rush when standing ■ supine hypotension : inferior vena cava is right behind where fetus is sitting, when pt is lying supine, then the flow of blood back to mom’s heart is decreased, causes decrease in BP, will exhibit signs of hypotension, lay patient on side or pick up belly and move to the side while mom lays supine ○ Blood flow : altered to include the uteroplacental unit, renal plasma flow increases up to 30 % , skin requires increased circulation, blood flow to breasts increases, expanding uterus partially obstructs blood return from veins in the legs ○ Blood components : increased iron absorption and clotting factors ● Respiratory System ○ Oxygen consumption : 50 % of increase used by fetus and placenta ○ Hyperventilation : compensated respiratory alkalosis ○ Hormonal factors : progesterone (decreased resistance), estrogen (increased congestion) ○ Physical effects of enlarging uterus : lifting diaphragm , relaxation of ligaments around the ribs - impacts pts ability to take a deep breath ● Gastrointestinal System ○ Mouth : ptyalism - significant increase of saliva in mouth, can be very uncomfortable to the point of carrying around a cup to spit in ○ Esophagus : relaxed cardiac sphincter , lots of complaints about indigestion or reflux ○ Large & small intestines : displaced- muscles that move food and stool cannot function as efficiently & slowed , constipated ○ Liver & Gallbladder : displaced & blocked causing gallstones ● Urinary System ○ Bladder : hormonal urinary frequency, physiologic urinary frequency ○ Kidneys & ureters : size & shape of kidneys, functional changes, increased risk of pyelonephritis from urine stasis & suppressed immunity ● Integumentary System ○ Skin - Hyperpigmentation, melasma - darkening of skin, chloasma, linea nigra - line one belly up center of abdomen, cutaneous vascular changes ○ connective tissue - striae gravidarum (tiger stripes) stretchmarks, common starte as purple/red will fade to white or silver ○ Hair & nails ● Musculoskeletal System ○ Calcium storage : fetal demands for calcium increases, mom must intake adequate amount in diet ○ Postural changes : progressive , back pain more strain on lower extremities ○ Abdominal wall : diastasis recti - walls of abdominal muscles will separate down the middle, can improve overtime but may not completely go away even after pregnancy ● Endocrine System ○ Pituitary gland : prolactin & oxytocin - important during labor & postpartum ○ Thyroid gland : rise in total thyroxine (T4) and thyroxine-binding globulin ○ parathyroid glands : calcium homeostasis ○ Pancreas : fluctuations in insulin production , insulin resistance - if no resistance then sugar levels will never be high enough to allow for fetal metabolism (lower fasting, higher postprandial) ○ Human chorionic gonadotropin (hCG) = + pregnancy test ● Immune System ○ Autoimmune conditions, infection resistance, antibodies cross, no live viruses ● Common Pregnancy Discomforts ○ Nausea & vomiting, heartburn, backache, roung ligament pain, urinary frequency, varicosities, constipation, hemorrhoids, leg cramps ● Confirmation of Pregnancy ○ Presumptive indicators : amenorrhea - stopped getting their period, N&V, fatigue, urinary frequency, breast & skin changes, vaginal & cervical color changes (Chadwick), fetal movement ○ Probable indicators : abdominal enlargement, cervical softening (Goodell), changes in uterine consistency, ballottement (tap on cervix w sterile glove feel baby floats up and comes back down), braxton hicks contractions, palpation of fetal outline, uterine souffle - sound of blood going in and out of placenta that can be heard w doppler, pregnancy tests , hyperpigmentation, dark patches, mask of pregnancy chloasma or melasma, symph pubis to top of fundus, hair & nails grow rapidly ○ Positive indicators : auscultation of fetal heart sounds, fetal movements felt by examiner, visualization of the fetus (ultrasound) ● Maternal Psychological Responses ○ First trimester : uncertainty, ambivalence, the self as primary focus ○ Second Trimester : physical evidence of pregnancy, fetus as primary focus, narcissism & introversion, body image, changes in sexuality ○ Third Trimester : vulnerability, increasing dependence, preparation for birth (nesting) ● Paternal Adaptation ○ Variations in paternal adaptation, developmental processes ■ Reality of pregnancy & child, struggle for recognition as a parent, role of involved father, parenting information & couvade - experience s/s of pregnancy with partner ■ Influencing Factors : age (16 vs 35), multiparity (first baby?), social support, presence of a partner, socioeconomic status, obstetrical Hx - hs of lost pregnancies vs hx of successful ones ● Risks of High & Low BMI ○ Spontaneous abortion, gestational diabetes, gestational HTN, preeclampsia, prolonged labor, cesarean birth, congenital anomalies, macrosomia or intrauterine growth restriction, PPH (postpartum hemorrhage), wound complications, thromemolic disorders, preterm labor ● Pregnancy Weight Gain ○ Recommendations based on women’ s pre-pregnancy BMI ■ Low BMI (<18.5) : 28 - 40 lbs ■ Normal BMI (18.5 - 24.9) : 25 to 35 lbs ■ High BMI (25- 29.9) : 15 - 25 lbs ■ Very High BMI ( > 30) : 11 - 20 lbs ○ Pattern of weight gain : 1-4 lbs in 1st trimester, approximately 1 lb a week in 2nd & 3rd trimester ● Nutrition ○ Requirements ■ Dietary reference intakes (DRIs) : used to estimate nutrient needs ■ Recommended dietary allowance (RDA) : amount of a nutrient that is sufficient to meet the needs of almost all healthy people in an age group ■ Most pregnant people need 2200-2900 calories daily (nutrient density) ■ Daily protein RDA is 46 g for nonpregnant females ■ Daily protein RDA is 71 g during pregnancy ; expansion of blood volume , growth of maternal & fetal tissues ■ Folic acid (folate) : **very important** can decrease occurrence of neural tube defects ■ Iron : important in formation of hemoglobin, during preg. Approx 1000 mg of absorbed iron above maternal iron stores are needed, increased absorption by fetus in Late pregnancy ■ Calcium : important for mineralization of fetal bones & teeth, calcium absorption & retention increase during pregnancy ■ Sodium : needs are increased during pregnancy to provide for an expanded blood volume and needs of the fetus ■ Water : for expanded blood volume, part of increased maternal & fetal tissues, should drink 8 - 10 cups of fluids that are mostly water each day ○ Supplementation ■ Prenatal vitamin - mineral supplements, most common are iron & folic acid ■ Disadvantages / dangers : no standardization or regulation of amounts of ingredients, excessive amounts of some vitamins & minerals may be toxic to fetus, supplements are not food substitutes & do not contain all nutrients needed during pregnancy ○ Risk factors ■ socioeconomic status : food supplement programs - WIC , poverty ■ Nausea & vomiting of pregnancy ■ Anemia - pt who likes eating ice is hallmark sign of anemia ■ Abnormal pre-pregnancy weight ■ Eating disorders ■ Food cravings & aversions : Pica : clay, ice, other non-food ■ Substance abuse - smoking, caffeine- can have 1 - 2 cups of coffee/day while pregnant, alcohol, drugs ■ Adolescence : nutrient needs, common problems, teaching adolescence ■ Multiparity & multifetal pregnancy ■ Vegetarian, vegan, lactose intolerant ○ After birth ■ Immediate weight loss 10 - 13 lbs, continues for 3 months, 1 kg of prepregnancy within 1 year ■ Lactating : ● Energy - first 6 months of lactation, estimated energy requirement (EER) is 330 additional calories, second 6months 400 additional calories ● Protein (71 g) ● Fats, vitamins & minerals (vit D) ● Concerns with dieting, adolescence, vegan diet, avoidance of dairy, inadequate diet, alcohol, caffeine, fluids, food to avoid ■ Nonlactating : can return to her pre-pregnancy diet (wound healing, anemia) nurse should assess mother’s understanding of amount of food she needs from each food group ● QUESTION → a pregnant woman with a BMI of 22 asks the nurse how she should be gaining weight during pregnancy. The nurse’s best response would be to tell the women that she should gain approximately : ○ 3.5 pounds during the first trimester, then 1 pound each week until the end of the pregnancy ● Antepartum Assessment : ensure that pregnancy ends in the birth of a healthy infant without impairing health of mother ○ Preconception : ideally before conception, identify problems, provide education to help achieve a healthy pregnancy, Hx, VS, physical exam, screenings and meds & nutrients ○ Initial Prenatal Visit : ■ Establish trust & rapport w family ■ Verify or rule out pregnancy ■ Evaluate woman’s physical health ■ Assess growth & health of fetus, establish baseline data ■ Evaluate psychosocial needs ■ Assess need for counseling or teaching, negotiate a plan of care ■ Complete History : ● menstrual history - to establish estimated date of delivery EDD : Nagele’s Rule ○ LNMP (last normal menstrual period) - subtract 3 months, add 7 days, add 1 year to determine EDD ● obstetric Hx ○ gravida & para : how many times pt has been pregnant and how many times they have given birth ○ length of previous gestations, weight of infants at birth, labor experiences, anesthesia, maternal complications, infant complications, methods of infant feedings), gynecologic & contraceptive Hx, medical & surgical Hx, family hx, partner’s health history, psychosocial history ■ Physical exam : VS (BP!! - if it rises that is ABNORMAL, it should fall during pregnancy), cardiovascular system, musculoskeletal, neurologic, integumentary, endocrine, GI, urinary, reproductive ■ Naegele’s Rule → subtract 3 months , add 7 days, add 1 year ■ Gravida & Para → GTPAL ● Gravida : total # of pregnancies ● Term : total ≥ 36 wks (include IUFD, Multiples count as 1) ● Preterm : total ≥ 20 wks , < 36 wks, (Include IUFD, multiples count as 1) ● Abortions : total < 20 wks (include spontaneous abortion & termination of pregnancy, multiples count as 1) ● Living : total living children ● Example → a pregnant patient reports she has 2 living children. She had twins at 28 weeks. A full term newborn that died of SIDS. She also had 1 spontaneous abortion at 12 weeks and 1 elevtive termination of pregnancy at 9 weeks. ○ GTPAL : G 5 T 1 P 1 A 2 L 2 , G 5 P 1122, 5/122 ○ Subsequent assessments : schedule for uncomplicated pregnancy ■ Conception to 28 wks : every 4 wks ■ 29 - 36 wks : every 2 weeks ■ 37 wks - birth : weekly ■ Assessment includes → VS, weight, urine, fundal height, leopold’s maneuvers - positioning of fetus by feeling through abdomen, fetal HR, fetal activity, signs of labor, ultrasounds, glucose screen, isoimmunization, pelvic exam ■ Fundal height : checking for normal growth of the fetus, measure from symphysis pubis to the fundus to determine how many weeks pt is, in cm should correlate w gestational age - weeks = cm, full bladder will skew results ○ Multifetal Pregnancy - special considerations ■ Maternal physiologic change is greater w multiple fetuses : increased workload for the heart, resp difficulty increases ■ Teach signs of preterm labor * very likely to experience ○ Perinatal Education : help parents ■ Become knowledgeable consumers, take active role in maintaining health during pregnancy and birth, learn coping techniques to deal w pregnancy, childbirth and parenting ■ Providers of education : RN, others w/ special education, many instructors are certified by organizations (lamaze etc), formal or informal setting ■ Class participants : traditionally middle-income couples who are older and better educated, to make informed decision or coping strategy, want greater sense of control during L&D ■ Types of class : preconception, early pregnancy, exercise, childbirth prep, csection birth, vaginal birth after cesarean birth (VBAC). breastfeeding , parenting/infant care, postpartum, classes for fathers, siblings, grandparents ■ Methods of Education : ● Dick-read childbirth education : fear of childbirth results in tension & pain, “natural childbirth” ● Bradley childbirth education : “husband coached childbirth” avoid medications and interventions ● Lamaze Childbirth Education : psychoprophylaxis, uses mind to prevent pain, most popular, uses several different techniques ○ Nonpharmacologic Pain Management → ■ Positioning : ambulation, sitting, squatting, kneeling, birthing ball, side-lying, hands & knees ■ Hydrotherapy : warm bath for ante and intrapartum ■ Relaxation techniques ■ Cutaneous stimulation techniques : light touch, counter pressure, superficial heat/cold, massage ■ Mental stimulation techniques : focal point, imagery, sounds ■ Breathing techniques ■ Support ● Diagnostic Testing & Screening ○ Screening : used to ID individual patients at risk, done for every patient in a particular category ○ Diagnostic : used to confirm diagnosis, usually done as follow up to a screening that has identified a risk ■ fetal diagnostic testing should be done to evaluate fetal condition and/or detect congenital anomalies, should NOT be done without informed consent, nurses must respect parent’s decisions ○ Ultrasounds → high freq sound waves are aimed at body tissue ● Transabdominal : ● Transvaginal : internal ● Levels of obstetric ultrasound : ○ Standard (basic) : general survey ex. Anatomy scan, relatively safe, some will opt out ○ Specialized (comprehensive) : specific, looking for abnormalities, done if anything suspicious found on standar ex. Cardiac anomaly, GI tract looks weird ○ Limited : address specific question ex fetal presentation , used w 8 wk pregnancy w abdominal pain to rule out ectopic pregnancy ● First trimester : purpose to confirm, verify location, detect multifetal pregnancy, determine gestational age, markers for screening (nuchal translucency, nasal bone assessment), guides procedures such as chorionic villus sampling (CVS), done transvaginal ● Second & Third Trimester : purpose to confirm viability/wellbeing, evaluate fetal anatomy, determine gestational age, assess serial fetal growth, compare growth of fetuses in multifetal pregnancy, guide procedures like amniocentesis, percutaneous umbilical cord sampling (PUBS), external version, locate and evaluate placenta, determine fetal presentation, evaluate 4 of 5 markers in a biophysical profile, specialized ultrasound for abnormal findings, measure amniotic fluid , transabdominal or transvaginal used to assess for preterm labor or cervical incompetence - look specifically at cervix ○ Hydramnios (excess amniotic fluid, polyhydramnios, “poly”) ○ Oligohydraminos (insufficient amniotic fluid “oligo”) ● Advantages : allows clear visibility of fetus and surrounding structure, noninvasive, results obtained immediately, proven safe, widely available and portable ● Disadvantages : cost, cannot identify all defects, suspicious or clearly abnormal images raise parent’s anxiety levels ■ alpha- Fetoprotein Screening ● Purpose → Predominant protein in fetal plasma, AFP crosses placenta into maternal circulation, can be measured in maternal serum (MSAFP) & amniotic fluid (AFAFP), abnormal concentrations of AFP are associated with serious fetal anomalies ○ Low levels of MSAFP indicate possible chromosomal abnormalities such as trisomy 21 ○ Elevated MSAFP levels associated w open NTD’s & body wall defects - anencephaly, spina bifida ● Procedure → initial screening offered at 16 and 18 wks of gestation (maternal venous blood) ○ Counsel PTs bc its a screening test not Dx test, results can be skewed by → ■ Gestational age, maternal weight, multifetal pregnancy, race, maternal diabetes, and ethnicity must be considered when evaluating the levels ○ Mother is informed that MSAFP is a screening test rather than Dx test- false positive results are common , positive doesn’t necessarily mean something is wrong, ask if they would like to do further Dx ● Advantages → simple procedure, not invasive to fetus, allows time for more comprehensive testing if results for MSAFP are abnormal, allows time for parents to decide if Dx testing would be appropriate for them ● Limitations → screening test & must be viewed as the first step, benign conditions such as inaccurate estimation of gestational age can result in apparently abnormal levels in a healthy fetus, timing limits, normal levels of AFP do not guarantee that baby is free of structural defects ■ Multiple marker screening → ● MSAFP : ○ elevated levels used to detect open body wall defect ○ low levels linked to chromosome defect ● Triple-Screen : unconjugated estriol & HCG have been added to routine MSAFP eval ● Quad Screen : fourth marker, placental hormone inhibin A, improves accuracy of the triple-screen ■ Chorionic Villus Sampling → ● Purpose : diagnose fetal chromosomal, metabolic or DNA abnormalities ● Procedure : usually performed between 10 and 12 wks, counseling about procedure - risk of pregnancy loss, genetic counseling, transcervical or the transabdominal approach ● Advantages : earlier results than amniocentesis, accurate ● Risk : rate of pregnancy loss after CVS is similar to that of amniocentesis (1%), more than two attempts or bleeding during the week before the procedure increases the risk for fetal loss, reports of limb reduction defects - needle may damage fetus ■ Amniocentesis → ● Second trimester : collect fetal cells to ID chromosome abnormalities ● Third trimester : tests to determine fetal lung maturity , lecithin/sphingomyelin (L/S) ● Purpose for both trimesters : diagnose intrauterine infections, test for fetal hemolytic disease, determine fetal bilirubin concentration (Rh sensitized) ● Procedure : can be done from 15 to 16 wks of gestation until birth, ultrasonography used to ID largest pockets of amniotic fluid to be safely sampled, spinal needle inserted into pocket of fluid 1 to 2 mL of fluid discarded - use ultrasound to guide needle, sample removed without needle actually touching fetus, approx 20 mL of fluid removed for analysis ● Advantages : simple and statistically safe procedure, relatively painless, takes short time, familiar to most obstetricians ● Risks : pregnancy loss rate of < 1%, higher pregnancy loss rate of 2% to 5% has been noted after early amniocentesis between 11 and 13 weeks, transfer of fetal blood to maternal circulation may occur ■ Percutaneous Umbilical Blood Sampling (PUBS) → ● Purpose : aspiration of fetal blood from the umbilical cord for prenatal diagnosis or access for intrauterine transfusion ● Risk : occasional variety of life-threatening complications for the fetus ● Procedure : high resolution ultrasound is used to locate fetus, placenta, and umbilical cord and guide needle insertion, needle is inserted into the umbilical cord near the site at which the cord meets the placenta, Rho(D) immune globulin (RhoGam) is given to Rh negative women ■ Maternal Assessment of Fetal Movement → kick counts ● Procedure : usually around / after 20 wks, woman lies on her side, places her hands on the largest part of her abdomen, concentrates on fetal movements, several protocols exist for assessing kick counts depending on patients needs ○ Be consistent - same time every day ○ Write down & record results - look for trends ○ Report downward trend to HCP to determine if something is wrong ● Advantages : no cost, noninvasive, provides ongoing surveillance, may ID fetal problems early in client who has no known risk factors ● Disadvantages : variables changes interpretation and may require follow up testing, difficult for some women to appreciate fetal movement, glucose levels, sleep cycles ■ Nonstress test → contractions not present ● Purpose : evaluate fetal well being ● Procedure : done after 24 wks (or at the age of viability), before procedure woman should void and baseline VS should be taken, semi-fowler’s (left tilt), electronic fetal monitor (EFM) applied to abdomen, ultrasound transducer records fetal heart rate (FHR), tocotransducer records uterine activity ● Results : ○ reactive (reassuring) - tracing meets all requirements ○ nonreactive (nonreassuring) - tracing does not demonstrate the required characteristics of a reactive tracing within a 40 minute period, this is not necessarily ominous but may indicate need for further testing - baby can be napping, mom can be on drugs ● Reactive NST : ○ Baseline HR 110 - 160 bpm ○ Variability : moderate 5-15 bpm ○ Accelerations : indicates fetal movement/heart rate, tells you that fetus is moving their body creating an increase in HR ■ < 32 wks - 10 bpm for 10 seconds : neuro activity is less than more developed fetus, HR doesn’t change as much, needs to happen twice to be considered reactive ■ > 32 wks 15 bpm for 15 seconds ■ If fetus is not moving, no accelerations are happening, the fetus may not feel good, or fetus is moving but neurologic system isn’t responding and is not increasing HR which indicates brain damage ○ Decelerations : none ● Advantages : non invasive for PT and fetus, believed to work withou risk, easily administered, results are available immediately ● Disadvantages : high false positive rate requiring additional testing - if after 40 mins its unreactive, you have to do an ultrasound or other tests, can be difficult w preterm fetus, multiple fetal pregnancy make sure you measure each fetus’ HR or uncooperative patient - having pain and unable to stay still, don’t understand importance of procedure and thinks there is more risks than evidence has shown ■ Vibroacoustic Stimulation Test : ● Try to wake baby up if NST doesn’t come out responsive ● Uses sound stimulation to elicit fetal movement : stimulate fetal movement that results in a reactive NST, confirm nonreactive NST ● Risks : appears to be safe for the fetus in terms of hearing at 33 wks ● QUESTION → The 38 week fetus is evaluated using a NST. The nurse understands the patient need further testing after observing which result? ○ Baseline 100 bpm, moderate variability, increases to 110 bpm with fetal movement ○ How does the nurse report this finding? → nonreactive ANTEPARTUM COMPLICATIONS → ● Intimate partner violence (IPV) : ○ risk increases in pregnancy/.postpartum (324,000/yr) ○ Abuse is the most common complication of pregnancy ○ Examine person beliefs, help patient to feel empowered, know the resources, screening tools, protect privacy, ASK!!! ● Hemorrhagic / Hematologic Conditions : ○ Early : abortion, ectopic, hydatidiform mol (molar pregnancy) ○ Late : placenta previa (previa), abruptio placentae (abruption) ○ Disseminated intravascular coagulation (DIC) ● Abortion : ○ Pregnancy that ends before the 20th week ○ Refers to spontaneous (miscarriage), medical (for maternal or fetal indications) or elective termination ○ We will discuss this topic respectfully & nonjudgmentally ○ Condition of employment ○ Spontaneous abortion could still potentially have baby except missed ○ Spontaneous abortion : THREATENED - Assessment : vaginal bleeding < 20 wks, closed cervix/membranes intact ■ Interventions : teach pelvic rest - no sex, no douchingm no tampons does not mean bedrest, track bleeding (clotting), s/s of infection contact provider - anything green / malodorous, 100.4 fever, abdominal tenderness, Rhogam as ordered, emotional support - does not mean pregnancy is ending just must watch closely ○ Spontaneous abortion : INEVITABLE ■ Assessment : contractions, cervical dilation, ruptured membranes, no delivery of products of conception - may need to evacuate, otherwise pregnancy is still viable ■ Interventions : teach pelvic rest, track bleeding (clotting), s/s of infection - high risk pt now because there’s high risk of infection, opening to outside to inside, any infection that occurs can be life threatening, Rhogam as ordered (if they’re Rh-), emotional support, may need to evacuate products of conception (spontaneous, medical, surgical) ● Medical intervention that gives medication to cause uterus to contract and expel contents : sometimes does not work or is not quick enough ● Surgical : can be pt or provider preference, contents are removed in OR under general anesthesia ○ Dilation & curettage (D&C) : procedure to remove tissue from inside uterus ○ Dilation & Evacuation (D&E) : dilation of cervix and surgical evacuation of the uterus (potentially including fetus placenta and other tissue) after first trimester ○ D&E is done during second trimester and is pretty similar to a D&C in that it uses a vacuum aspiration but requires more surgical instruments to remove the tissue, takes longer because done later in pregnancy ○ Spontaneous abortion: INCOMPLETE ■ Assessment : contractions, cervical dilation, ruptured membranes, delivery of some of the products of conception while others remain in uterus ■ Interventions : teach pelvic rest, track bleeding (clotting), s/s of infection, Rhogam as ordered, emotional support, must evacuate products of conception (spon, medical, surgical) ○ Spontaneous abortion : MISSED ■ Assessment : no fetal heart activity products stay intact and remains in body ■ Interventions : teach pelvic rest, track bleeding (clotting) ** high risk for DIC - disseminated intravascular coagulation **, s/s of infection, Rhogam as ordered, emotional support, must evacuate products of conception ○ Complete Abortion : spontaneous abortion when all products are delivered without intervention ○ Recurrent Spontaneous Abortion : Hx of 3 or more spontaneous abortions ■ may be related to chromosomal defects or maternal structural anomalies, of uterus that prevent her from carrying past 20 wks ■ may be caused by cervical incompetence - bottom of cervix opens up on its own without contraction ● Cerclage : stitch put on cervix to keep it from opening, removed to allow labor ● permanent cerclage : not removable , csection delivery only ● Ectopic Pregnancy : ○ Implantation of fertilized ovum outside of uterus ○ Etiology : 97% in the fallopian tube, risk increases w Hx of infection ○ Medical : methotrexate : will cause body to reabsorb pregnancy, only successful if given early on ○ Surgical : ■ linear salpingostomy : laparoscopically or through incision, remove product from fallopian tube without damaging the tube, terminates the pregnancy not done as frequently ■ salpingectomy : removal of whole fallopian tube, does not leave them sterile since they have two fallopian tubes, if they end up losing both tubes to ectopic pregnancy, pt can still become pregnant through other means of assistive reproduction ○ Assessment : ■ PT has severe abdominal pain has ovaries and is of childbearing age ● pain may be referred to chest or shoulder or back can tear open fallopian tube and cause massive internal hemorrhage, pain will spread as blood is collecting in pelvis ● Confirm pt is pregnant with pregnancy test, urine/serum/ultrasound ● Pt presenting with abdominal pain is always assumed to have an ectopic pregnancy until proven otherwise because this will kill mother ■ s/s of hypovolemic shock w or without obvious bleeding : THINK INTERNAL BLEEDING , even without trauma, a pt with ovaries and of childbearing age can be hemorrhaging internally as result of a rupture ectopic pregnancy ■ THIS IS AN EMERGENCY !!! ○ Interventions : ■ Treat same as any Postop PT - s/s of infection, gas exchange, ABC, Rhogam as ordered - possibility of fetal and maternal blood mixing, emotional support - evaluate for perception of event, may be experiencing loss ● Gestational Trophoblastic Disease : ○ Hydatidiform Mole (molar pregnancy) - fetus will not develop to a normal baby, lack genetic material ■ Hydatidiform mole trophoblasts develop abnormally (complete or partial) ● Partial : some qualities of a fetus but itll never be normal, will never develop into a fetus, lacks genetic material ● Complete : egg fertilized by sperm with no genetic material at all, growing a placenta w no function, placenta grows abnormally into a hydatidiform mole ■ The condition is characterized by proliferation and edema of the chorionic villi ■ Assessment : higher beta - HCG than expected for gestational age, stomach/uterus larger than expected for gestational age, prune colored vaginal bleeding, hyperemesis gravidarum, preeclampsia ■ Intervention : evacuation without inducing contraction - it will go into moms blood stream and high risk for pt to get cancer no contractions will decrease risk of cancer , monitor bleeding, emotional support, follow up for choriocarcinoma x 1 year, - best way to determine growing cancer cells in this pt is positive pregnancy test outside of pregnancy, TEACH can NOT get pregnant for 1 year after this incidence causing high risk for cancer - wont know if cancer or just pregnant ● Placenta Previa : ○ Incidence : 1 in 200 births (fairly common) ○ Risk : Hx of previa - , multiparas, hx of uterine surgery ○ Assessment : painless, bright red bleeding, requires ultrasound for diagnosis ○ Caused by → uterine surgery, scar tissue inside uterus causing placenta can implant itself abnormally which can increase the risk of pt bleeding ○ Interventions : avoid vaginal exams, monitor bleeding, plan for cesarean delivery, plan for preterm delivery if pt is bleeding excessively, any type of dilation is dangerous ○ ** if bleeding is occuring on a regular basis or at an excessive amount this can be life threatening to mom and baby ○ Types : ■ Marginal (low - lying) : placenta attaches itself about 3cm from cervical os (opening), often resolves spontaneously as the uterus grows & stretches, can still deliver vaginally ■ Partial : within 3 cm without covering the cervical os, often resolves spontaneously - as uterus grows and stretches placenta gets pulled away from cervical opening, can still deliver vaginally ■ Total : completely covers the cervical os, C-Section, can not deliver placenta first it is babies oxygen supply ● Abruptio Placentae : ○ Placenta pulls away from uterine wall before we want it to, usually baby is delivered then the placenta pulls away from uterine wall and gets delivered ○ Incidence : 1 in 100, 10-15% of perinatal deaths ○ Risks : HTN, drug use, abdominal trauma ex. Slip on ice and fall ○ Types : ■ Marginal : placenta is disc shaped only has a side of it peeling away causes dark red vaginal bleeding (external bleeding) ■ Partial (concealed) : internal bleeding edges remain intact, arterial blood is filling that space up and placenta moves farther away from uterine wall, no active vaginal bleeding but they are hemorrhaging internally ■ complete (Concealed) : placenta leaves uterine wall completely, most dangerous, fetus has now lost its oxygen supply completely and immediately, if C-Section is not done or a VD is not done spontaneously and rapidly you will lose baby, uterus unable to control bleeding - uterus can not clamp down because fetus is still in uterus, mother is at risk for hemorrhage ○ Assessment : bleeding (marginal/complete) a lot of it, unusual contraction pattern as uterus is trying to deal with what’s happening, uterine tenderness, “board like” abdomen (concealed) as blood collects under the placenta, fetal distress/death you must think of abruption, maternal hypovolemic shock with or without vaginal bleeding you must think of abruption think of ectopic pregnancy first ○ Interventions : emotional support & education - may not be enough to cause harm but must be watched for remainder of pregnancy, s/s of worsening abruption, turn onto left lateral lower head of bed, admin oxygen to maintain maternal SPO2, make sure patient has good IV access, admin Rhogam as ordered ■ if trauma - continuous fetal monitoring for 24 hrs, ■ if stable - betamethasone, close monitoring (I&O) ■ if unstable - prepare for rapid delivery, prepare for transfusion, CONTROL THE BLEEDING (abc) ● Disseminated Intravascular Coagulation (DIC) : ○ All clotting factors are activated at once so you run out of it , pt will bleed easily without way to stop it ○ Incidence : rare ○ Risks : large volume blood loss, preeclampsia (endothelial damage), HELLP syndrome, fetal demis, sepsis, anaphylactoid syndrome ○ Assessment : unexpected bleeding, frank bleeding, petechiae, ecchymosis, abnormal labs ROTEM test done when you have a pt that’s clotting abnormally and trying to figure out cause ○ Intervention : measure blood loss, pads - weigh 1gm= 1mL, draw labs, give blood products as quickly as possible - large bore IV 20 gauge , consider rapid response/MTP/transfer to higher level care ● Hyperemesis Gravidarum : severe nausea and vomiting that is so severe the pt begins to lose weight, risk for dehydration, electrolyte imbalance ○ Cause : unknown ○ Risks : white, 1st pregnancy, multifetal pregnancy ○ Assessment : 5% or more weight loss, dehydration, acidosis (caused by Starvation), ketonuria - ketones in urine, alkalosis (loss of HCL), electrolyte imbalance ○ Interventions : ■ Monitor I&O, track bowel movements, monitor labs & electrolytes, small freq meals, separate liquids from meals to improve chances of liquids being retained and food being retained, IV fluids and TPN as ordered ■ Meds : ● Diphenhydramine (benadryl) ● histamine receptor antagonist (zantac) ● gastric acid inhibitors (prilosec) ● Metoclopramide (reglan) ● Ondansetron (zofran) ● pyridoxine/doxylamine (diclegis) ● Hypertensive Disorders of Pregnancy → gestational hypertension, preeclampsia, eclampsia, chronic hypertension as underlying condition ● Preeclampsia : ○ Occurs after the 20th wk, may continue postpartum or develop postpartum for up to 6 wks. No single definitive test, based on s/s, vasospasm is underlying condition in preeclampsia ○ S&S : elevated BP (should decrease during pregnancy), proteinuria, elevated liver enzymes, falling platelets, edema in upper extremities, headache, visual disturbance - f