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Lecture 2: Pregnancy and Labor Chapter 6, 8, 9 Chapter 6: Antepartal Tests Assessment for Risk Factors Antenatal refers to the time your patient is pregnant up until labor  Biophysical Factors o Anything originating from the mom or the fetus that are going to impact the development or function of the fetus  Ex: genetic malformations or genetic concerns, nutritional concerns or nutritional deficits, medical concerns such as preexisting or formed over pregnancy such as HTN/Preeclampsia/Diabetes/Gestational Diabetes/Asthma, Obstetrical concerns such as placenta previa, preterm labor  Psychosocial Factors o Is mom a smoker or around someone who smokes? → at risk for second hand smoke? Caffeine use, drug/alcohol use  Sociodemographic Factors o Variables r/t mom and family  Access to care, transportation, insurance, age of pt, gravida, marital status, income  Environmental Factors o Hazards to the workplace  Environment: chemicals, construction, radiation Nurse’s Role in Antepartal Tests  Provide InformationvC  Provide comfort  Provide Reassurance → explaining, providing information, answering their questions  Documentation → consent if it is an invasive procedure NONINVASIVE Ultrasonography  High frequency sound waves that produce an image or tissue  The most common diagnostic test performed during pregnancy o Transvaginally: performed during 1st trimester o Abdominally → Pt must have full bladder to elevate uterus, supine position, place gel and move transducer/wand over belly  Indications: measure age & weight by crown to rump length, measure femur length to most accurately determine due date at 20 weeks, confirm head down position for labor, check heart tones/organ function/ placenta location and size, amniotic fluid index, identify anomalies.  Advantages: Accurate assessment of age, growth, fetal and placental abnormalities, noninvasive  Interpretation: done by radiologist,physician, or specially trained nurses  Nursing actions: provide support for patient unless you are the specially trained nurse performing the US  3D/4D → age sex facial features for pt preference Magnetic Resonance Imaging  Use: to view maternal or fetal structures, particularly in the brain

 Remove all metal objects, patient should be in supine or slightly left lateral tilt by putting a wedge underneath the hip, scan only the abdomen  Advantages: Very detailed images of the fetal anatomy, no known harmful effects  Interpretation: Radiologist  Nursing Actions: Explain the pre & post procedure, address any questions the patient may have

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Brain Abnormalities that can be Identified and Confirmed via MRI o Anencephaly: an absence of the major portion of the brain, skull, and scalp that occurs during the embryonic development  It’s a cephalic disorder resulting from neural tube defects  Remember neural tube defects have to do with our folic acid consumption, exposure teratogens within that first eight weeks of development

 In the image a significant portion is missing so their life expectancy is greatly reduced  Some will survive, some will not they do have a high mortality rate at an early age o Iniencephaly: this is a very uncommon neural tube defect where there is retroflexion of the head and neck and severe distortion of the spine  Incompatible with life Umbilical Artery Doppler Flow  Indication: To assess for placental perfusion, ensure there is a 3 vessel cord, helpful in diagnosing IUGR (Intrauterine Growth Restriction), evaluating rate/volume of blood flow through the placenta and umbilical vessels  Placenta is the fetal lifeline  Patient should be in supine position  Filters can be changed to see blood flow going through  Interpretation: the blood flow difference between systolic and diastolic flow through the arteries  Nursing Actions: If you are in the room with the patient, explaining reason for the procedure, addressing questions, scheduling the F/U appointment to discuss results INVASIVE Biochemical Assessment  Chorionic Villi Sampling (CVS) o Aspiration of a small amount of placental tissue to assess for chromosomal, metabolic, or DNA testing o Performed at 10-12 weeks of gestation to assess for abnormalities caused by genetic or metabolic disorders such as cystic fibrosis o Transvaginal through cervix or Needle Aspiration via Abdomen o Sample sent for DNA Analysis o Interpretation: Received by the provider within a week from the lab

o Advantages: Earlier than amniocentesis, not recommended before 10 weeks of gestation o Risks: 7% of patients experience fetal loss due to bleeding, infection, or rupture of membranes, 10% will experience vaginal bleeding o Nursing Actions: Review the procedure with the patient, support the patient by providing breathing/relaxation techniques, provide strict instructions for patient to call if they have abdominal cramping, bleeding, pain, leaking of any fluid, s/s infection, decrease in fetal movement o Before Test: Doppler studies After Test: 2 more doppler studies within 30 min o During test: Assess fetal/maternal well being with a doppler twice within 30 minutes o If a patient has Rh - factor, administer Rhogam at this point! Amniocentesis  Diagnostic procedure o Genetic testing o Fetal lung maturity o Fetal hemolytic disease  Risk factors o Over age 35 aka Geriatric o History of genetic disorders o + screening for alpha-fetoprotein (AFP) o Suspected hemolytic disease  The ultrasound is utilized to locate fetus and safe insertion site, needle is inserted into abdomen and into the intrauterine cavity, then the amniotic fluid is obtained o Sent to lab to test cell growth and chromosomal studies  + = infection  Elevated bilirubin levels = hemolytic disease  Advantages: Interpretation has 99% accuracy rate  Risks: Fetal loss, trauma to fetus or placenta, bleeding, preterm labor, maternal infections  Nursing Actions: review/educate patient, get consent, provide comfort, prepare abdomen sterilely, instruct the mother to report any abdominal pain, bleeding, leaking of any fluid, report s/s of infection, do not lift >10 lbs for 2 days o Once specimen is obtained, label specimen and then do the maternal/fetal monitoring by fetal heart tones Percutaneous Umbilical Blood Sampling (PUBS)  A needle is inserted transabdominally into the umbilical vein and is Ultrasound guided o Sample of fetal blood from umbilical vein  Performed at 18 weeks gestation, can be done as early as 11 weeks o Done after US has already detected an anomaly  Results in 48 hours testing for hematological and metabolic disorders, fetal infection, CBC/Coagulation Factors  Advantages: Direct examination of fetal blood  Risks: Cord vessel bleeding, hematoma, mix maternal/fetal blood which can lead to fetal bradycardia, risk of infection  Nursing Actions: Explain procedure, answer questions, Monitor fetus before exam and 12 hours post-op, monitor fetal kick counts Maternal Assays  Alpha-fetoprotein (AFP) Maternal Serum Alpha-Fetoprotein (MSAFP)

 Maternal blood sample between 15-20 weeks of gestation  Testing for developmental defects such as neural tube defects, abdominal wall defects, and genetic testing such as Trisomy 21 or down syndrome  Obtained via maternal blood sample o Increased levels associated with neural tube defects o Abnormal findings require further testing such as US, CBS, Amniocentesis  Advantages: 80-85% neural tube defects and 90% of abdominal defects can be detected  Disadvantages: High false-positive rate and Increased maternal anxiety  Nursing Actions: Educate, support, schedule F/U based on test results Quad Screening page 20 in ATI  More reliable than MSAFP o Alpha-fetoprotein (AFP): protein that is produced by the fetus  Low= ABNORMAL; indicates trisomy 21 o Inhibin-A: protein produced by the placenta and ovaries o Human chorionic gonadotropin (hCG): hormone produced within the placenta  Doubled= ABNORMAL;

o Estriol levels: estrogen produced by both the fetus & placenta  Low= ABNORMAL; Indicates neural tube defects  Quad marker detect trisomies and NTDs, at 16-18wks  The quad screen test is a maternal blood screening test that looks for four specific substances: AFP, hCG, Estriol, and Inhibin-A.  The quad screen is a maternal blood screening test which is similar to the Triple Screen Test (also know as AFP Plus and the Multiple Marker Screening). However, the quad screen looks for not only the three specific substances evaluated in those tests (AFP, hCG, and Estriol) but also a fourth substance known as Inhibin-A.  The screen is the same as the screening tests that look for only three substances, except the likelihood of identifying pregnancies at risk for Down Syndrome is higher through the evaluation of Inhibin-A level. The false-positive rate of the test is also lower.  Nursing Actions: Educate, obtain consent, support them, schedule F/U + testing if needed Tests of Fetal Status and Fetal Well Being

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Daily Fetal Movement Count Earliest and easiest way to monitor fetal well-being Instruct patient to start monitoring after 28 weeks gestation Palpate abdomen and feel for fetal movement  10 movements in 2 hours  4-6 movements in 1 hour o If at end of time period, tell patient to eat, drink a large glass of ice water, lie in left lateral position for 1 hour then repeat test

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 If end at 2nd test, no movements are felt, call office or go to hospital for monitoring o Advantages: patient can do this herself, easy to teach, provides some reassurance o No major risks o Nursing Actions: provide education to patient, what/how to report 2. NonStress Test (NST) o External monitoring for fetal well-being for 20- 30 min, no more 40 min  Monitoring patients that are increased risk, see indications + decreased fetal movements, domestic violence, any invasive procedure/anesthesia o Indications  Decreased FM, HTN, DM, Multiple gestation, Trauma, domestic violence o 20-40 minutes monitoring  15 x 15 (32 weeks or greater) see pink triangles  HR goes up by 15 beats for at least 15 seconds & return to baseline  10 x 10 (less than 32 weeks)  HR goes up by 10 beats for at least 10 seconds & returns to baseline

o Note on picture of belly: Top PINK is TOCO for Uterine monitoring; Bottom BLUE is US for fetal monitoring o Advantages: Noninvasive, very reliable o Disadvantage: False positives possible b/c looking at fetal monitoring, low false negative rate

o Nursing Actions: Explain procedure, hook pt up to monitor, assist in position not in supine position, interpret results correctly, document, schedule necessary appointments 3. Vibroacoustic Stimulation (VAS) o Fetal vibroacoustic stimulation to assess fetal wellbeing while using NST  If using NST & no accelerations seen, use VAS to help stimulate baby o Vibratory sounds  Fetal startle movement expected to see increased movement of 15*15 acceleration  Increased FHR  Increased variability o Advantages: Reduced incidences of nonreactive NST o Nursing Action: Explain procedure, educate pt that it won't harm the baby, assist with pt position, interpret results, document o Contraindication: Do not use VAS in abnormal FHR or decels, abnormal baseline 4. Contraction Stress Test (CST)

Upper left Negative CST: 3 contractions, no decels Upper Right: 3 contractions, 1 decel Lower Left: 3 contractions, late decelerations with every contraction Lower Right: Having contraction but losing FHR

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Utilized to determine if the fetus will be able to handle labor

Baseline FHM for 20 min - or Normal CST → GOOD!  No decels with UCs  + CST → BAD  Late decels with 50% of UCs o Initiates UCs  Nipple stimulation  Administer Pitocin/Oxytocin IV if no movement in 20 minutes  Stimulate 3 contractions w/in 10-20 min period with 40 second duration o Disadvantages: High false positives o Nursing Actions: Educate patient, void before start, monitor VS q15 minutes, safely administer oxytocin/pitocin Key for PHOTO A. Reactive tracing. Note association of accelerations with fetal movements. Negative or normal CST; fetus can tolerate contractions B. Nonreactive tracing. Absence of reactive accelerations. Positive fetus can't tolerate contractions C. Reactive tracing with spontaneous deceleration. Positive fetus can’t tolerate contractions D. Nonreactive tracing with spontaneous deceleration. Positive fetus can’t tolerate contractions 5. Amniotic Fluid Index (AFI) o Screening tool that measure amniotic fluid to assess Fetal well-being & Placental function  Done via US by measuring pockets of amniotic fluid in 4 quadrants of the uterus o Normal: 8cm – 24cm o Abnormal o

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 Poly = greater than 24cm → fetal malformation, obstruction of GI tract, fetal high drop  Oligohydramnios = less than 5cm → decreased renal perfusion, decreased renal blood flow, decreased urine production o Advantages: Reflection of placenta function and perfusion to fetus to determine fetal wellbeing o Nursing Actions: Explain procedure, position patient, interpret results, document, schedule F/U  Can be done by radiology tech or bedside nurse with proper certification

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Biophysical Profile (BPP) o Performed by US o Start with NST, then send patient to 30 min via US o 4 categories plus AFI o After 32nd week of pregnancy o Indications: Hx of chronic medical conditions, DM, HTN, Morbid obesity, pregnancy loss, decreased fetal movements, abnormal AFI, geriatric age o # is 8 or more, reassuring strip → discharge o # is 6, it is suspicious but pt can go home, repeat test within 24 hours o # is 4 or less, further test required, maybe deliver baby b/c could be chronic asphyxia o # is 2, emergency, deliver c-section now o Modified BPP is NST + AFI for 20-40 minutes

‫فاصل صفحات‬

Chapter 8: Intrapartum Assessment & Interventions Factors that May Trigger Labor  Maternal factors o Stretching uterine muscles, oxytocin released from extra pressure and stretching of the cervix, increased estrogen release stimulating uterine muscles  Fetal factors o Placental aging, prostaglandins increasing causing contractions, and fetal cortisol changes Factors Affecting Labor (The 5 P’s)

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Powers (UCs) o Contractions are responsible for the dilation and effacement o Assess frequency, duration, and intensity o During a contraction, the abdomen rounds and hardens Passage (Pelvis) o Assessed through palpations o Best way to palpate: place hand on fundus Passenger (Fetus)

o Assess fetal skull (molding fontanels & sutures), fetal attitude (flexion), fetal lie (longitudinal or transverse), fetal presentation (face, cephalic, breech, shoulder), cephalic presentation (vertex chin tucked, brow neck slightly extended, or face neck sharply extended  Psyche (the response of woman) o Women’s response to the preparation, her hips, her history, expectations, cultural beliefs, meds or no meds, hospital vs home birth  Position (maternal physical positions) Onset of Labor  Uterine contractions (UCs) o Cervical dilation and effacement (thinning of cervix) at Regular intervals  NOT REAL LABOR: Braxton hicks, irregular contractions with no change in cervix  Rupture of membranes (ROM/SROM) → SROM is natural rupture o Date/time o Amount o Color → should be clear  Green: indicative of meconium: high risk delivery o Odor → low to light bleached odor  Bad odor = infection

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Bloody show: pink to brown mucus b/c of cervical dilation & is normal for onset of labor

Mechanism of Labor Engagement o Greatest diameter of fetal head that passes through pelvic inlet Descent o Movement of fetus through birth canal Flexion o When the chin of the fetus moves toward the fetal chest Internal rotation o Rotation of the fetal head aligns w/ long axis of fetal head Extension o Pivot beneath the pubic symphysis External rotation o Shoulders align in the anteroposterior diameter. Expulsion o The anterior shoulder usually comes first followed by the rest of the body

Labor  Labor is the process in which the fetus, placenta, and membranes are expelled through the uterus.  Divided into 4 stages o 1st stage  3 Substages  Latent o Dilation: 0-4cm o Effacement: 0 – 40% o UCs q 5–10 min, mild intensity, lasting 30–45 sec o Mild discomfort (strong cramps) o Lasts 9 hours for prime (1st baby); 5 hours for multa o Medical Interventions: Obtain Labs (CBC, Type & Cross, UA), IV o Nursing Actions: Review birth plan, ppl in room, pain management, sterile vaginal exam (SVE), assess FHR, Membrane status, fetal position (cephalic), encourage ambulation, ensure pt has realistic understanding of labor process  Active o Averages 3-6 hours o Dilation: 5-7cm o Effacement: 40–80% o UCs q 2–5 min, lasting 40–60 sec

Increase in pain  Transfer to hospital  Requests pain interventions o Assess membrane status (intact/ruptured), monitor fetus externally or internally if not good o Nursing Actions: Monitoring FHR, documenting every 1530 min, if pt is on pitocin v/s every 2 hours, if ruptured v/s + temp every hour, SVE for dilation, hydration in ice chips  Transition o Dilation: 8 to 10 cm o Effacement: Complete (100%) o Contractions q 1–2 min, lasting 60–90 sec o Increased bloody show r/t cervical dilation o Strong urge to bear down o Overwhelmed mother due to hormone shifts: n/v, bach aches, increased pelvic pressure, diaphoretic o Nursing Interventions: Assessing FHR, UC q15 min, be calm and supportive, check epidural, stop pain meds (may have to give the baby Narcan upon delivery if mom still receiving pain meds)  Assess V/S, FHR/UCs, Cervical Changes (SVE), Fetal Position and Descent  Priority: Monitor Maternal V/S  Diet: NPO or ice chips depending on high risk  Ensure they have 18 gage IV or smallest 20 IV in hand or forearm  Avoid AC b’c will clamp during pushing  Encourage rest, frequent voiding (full bladder will prevent fetus from descending) 2nd stage  Complete dilatation  C/C/+1/2/3 (1= complete dilation of 10 cm, 2 =100% effacement, 3 = pelvis position)  Sudden burst of energy, improved focus  Perineum flattens, with bulging rectum and vagina  Increasing urge to push or bear down  Nursing Actions: Practice Pushing, continuous monitoring of heart tones & UC, personal hygiene, encourage rest if not pushing yet 3rd stage  Separation and expulsion of placenta/membranes  Lasts 5–30 min post delivery  Sudden decrease in uterine size causes placenta to separate  Expected blood loss for a vaginal delivery is up to 500 mL  Administer uterotonics to decrease blood loss o Uterotonics: Oxytocin (Pitocin), Methylergonovine (Methergine), Carboprost-Tromethamine (Hemabate), Misoprostol (Cytotec)  Medical Interventions: Ensure mom & baby are skin to skin, inspect placenta (intact, lobules are intact) o

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 Nursing Actions: Monitor V/S q15 min for 1st hour, encourage motherbaby interaction, administer uterotonics, assist doctor/midwife w/vaginal or episiotomy repair, document, stay in room o 4th stage  Beginning of the postpartum period  Delivery – 4 hrs  Homeostasis occurs in mother  Episiotomy/laceration repair  Inspect placenta, assessing fundus is firm and midline, assess lobia for color, odor, amount  Nursing Actions: Apply Ice pack to perineum, monitor I/O, make sure post epidural functions are returning, assess pain, encourage ambulation MD = 92.1% CNM= 8.1%

The Newborn  Obtain Apgar scores at 1 min and 5 min  Monitor: Temperature, Heart Rate, RR, Skin Color, Level Of Consciousness, Tone, Activity  Newborn identification: Does not leave the room until identification has been provided to the neonate and parent o Apply hug tag and identification bracelet  Medication administration o Erythromycin, Hep B, Vitamin K if indicated Management of Discomfort During Labor and Delivery  Pain may result from o Decreased blood supply to uterus o Increased pressure and stretching of the pelvic structures o Cervical dilatation and stretching  Nonpharmacological management o Preparation classes, counterpressure on back, relaxation techniques, thermal stimulation (warm/cold), mental...