OB Exam 1 - Summary Maternity and Pediatric Nursing PDF

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OB Exam 1 Antepartal Assessment and Care Antepartum is the time of pregnancy until the time of birth Trimesters of pregnancy o First trimester: weeks o Second trimester: weeks o Third trimester: weeks The average pregnancy lasts 280 days from the first day of the last menstrual period (266 days from...

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OB Exam 1 Antepartal Assessment and Care  Antepartum is the time of pregnancy until the time of birth  Trimesters of pregnancy o First trimester: 0-12 weeks o Second trimester: 13-28 weeks o Third trimester: 29-40 weeks  The average pregnancy lasts 280 days from the first day of the last menstrual period (266 days from time of ovulation), 9 calendar months, 40 weeks  Nagele’s Rule pg. 404 is to count back 3 months from the first day of the last menstrual period and add 7 days o November 20, add 7 days, -3 months = August 27 o December 14, add 7 days, -3 months = September 21

Phases of Pregnancy  Antepartum: the time between conception and the onset of labor  Intrapartum: period from the onset of true labor until the birth of the baby and placenta  Postpartum: time from birth until the women’s body returns to prepregnant state. Usually about 6 weeks  True labor pg. 457: contractions occurring at regular intervals that increase in frequency, duration, and intensity. True labor contractions bring about progressive cervical dilation and effacement  False labor: occurs in the latter weeks of some pregnancies in which irregular uterine contractions are felt, but the cervix is not affected GTPAL  Gravida: the total number of pregnancies, including the current one. Even if the mother didn’t give birth to the baby, it still counts as a pregnancy.  Term: the number of infants born at term (38 or more weeks gestation)  Preterm: the number of infants born after 20 weeks’ gestation and before 38 weeks  Abortion: the number of pregnancies that ended in either therapeutic or spontaneous abortion (before 20 weeks). Abortion just means the baby comes out before 20 weeks no matter how it comes out or what happens

 Living: the number of children currently living, not counting the baby in the belly Obstetric History Terms: GTPAL pg. 405

Pregnancy Terminology  Gestation: number of weeks from the first day of the last menstrual period  Term: normal duration of pregnancy (38-42 weeks’ gestation)  Primipara: women who had one birth at more than 20 weeks’ gestation  Multipara: woman who had 2 or more births at more than 20 weeks’ gestation  Stillbirth: infant born dead after 20 weeks’ gestation  Multigravida: woman who had more than one pregnancy  “para” = baby that was born after 20 weeks  Preterm: or premature labor, labor that occurs after 20 weeks’, but before completion of 37 weeks’ gestation  Nulligravida: woman who has never been pregnant  Primigravida: woman who is pregnant for the first time  Nullipara: woman who has had no births at more than 20 weeks’ gestation

Prenatal History  Details of current pregnancy o First day of normal menstrual period (LMP) o Presence of complications o Attitude towards pregnancy o Results of pregnancy test o Number pf pregnancies and number of living children o Number of abortions o How long did you carry last baby? o How were you delivered? o Was there a previous c-section?  History of previous pregnancies

o Length of pregnancy o Type of birth o Type of anesthesia used, if any o Complications associated with childbirth o Neonatal complications  Current medical history o General health o Blood type and RH factor, if known o Medications and use of herbal medications o Previous or present use of alcohol, tobacco, or caffeine o Illicit drug use and drug allergies and other allergies o Potential teratogenic insults to this pregnancy  Teratogen is any biological, physical, chemical, or radioactive agent that causes structural or functioning damage to the fetus o Immunizations. Ask about immunization history  Past medical history o Childhood diseases o Past treatment for any disease condition o Surgical procedures o Presence of bleeding disorders or tendencies (blood transfusions)  Family medical history o Complications associated with childbirth o Multiple births o History of congenital disease or deformities o Cesarean births and cause, if known o Religious beliefs related to healthcare and birth  Dietary considerations  Blood and blood products o Practices important to maintain spiritual wellbeing o Cultural practices that will influence care  Occupational history: physical demands on job o You need to know about her job. If she’s on her feet all day, stress, etc. Some people won’t give you a true story because they feel like they’ll be judged  Partner’s history: genetic conditions and blood type  Women’s demographic info o Age, educational level o Ethnic background o Socioeconomic status Prenatal high-risk factors  Pre-existing maternal disease  Obstetrical history  Current pregnancy problems  Demographic factors

Expected Date of Delivery (EDD, EDB, EDC)  Doppler ultrasound contraindicated during first trimester  Fundal height: measurement of uterine size  Nagele’s rule o Unreliable in irregular periods Antepartum: Goals for Care  Ensure safe birth for mother and child  Teach necessary health habits  Educate in self-care for pregnancy  Teach necessary health habits  Educate in self care for pregnancy  Provide physical care  Prepare parents for responsibilities of parenthood  Identify risk that can be changed or controlled  Prenatal care begins at the knowledge of conception  Mother/family history is essential  Expected date of delivery  Recommended prenatal visits Antepartum: Routine Care**  Review of risk  Vital signs  Weight  Urinalysis  Fundal height  FHR  Nutrition  Problems  Visits are every month until 27 weeks. Every week until 36 weeks, weekly until delivery  Laboratory Evaluation and Disease Screening  hCG  ABO blood type and RH  Rubella titer, MMR  Hemoglobin  Urinalysis- looking for proteinuria which is a warning sign for preeclampsia  Glucose  HbsAG  STD  HIV (only if consent granted)  Illicit drug screen  Sickle-cell screen  Pap smear  Subsequent Prenatal Assessment and Labs  Vital signs  Weight gain 25-35lbs

 FHR  Labs (Hemoglobin, MSAFP, GTT)  Group Beta Streptococci (GBS) Premonitory Sign of Labor pg. 456  Uterine contractions have 2 main functions  to dilate the cervix and to push the fetus through the birth canal  Cervical Changes  Softening and possible cervical dilation with descent of presenting part of the pelvis  can begin 1 month to 1 hour before actual labor begins  Cervix changes from an elongated structure to shortened, thin segment  this happens secondary to the effects of prostaglandins and pressure from Braxton Hicks contractions  Ripening and softening are essential for effacement and dilation, which reflect the enhanced collagen breakdown that was previously inhibited by progesterone  Lightening  Occurs when the fetal presenting part begins to descend into the true pelvis  With this descent, women can usually breathe easier and there is a decrease in gastric reflux  She may complain of increased pelvic pressure, leg cramping, dependent edema in lower legs, and low back discomfort  Increase in vaginal discharge and more frequent urination  In primiparas, lightening can occur 2 weeks or more before labor begins and in multiparas, it may not occur until labor starts  Increased Energy Level  Some women report sudden increase in energy before labor  Sometimes referred to as nesting because mother will prepare by cooking, cleaning, preparing nursery  usually 24-48 hours before the onset of labor  Thought to be from an increase in epinephrine release caused by a decrease in progesterone  Bloody Show  At the onset of labor or before, the mucous plug that fills the cervical canal is expelled due to cervical softening and increased pressure of the presenting part  These ruptured cervical capillaries release a small amount of blood that mixes with mucus, resulting in the pink tinged secretions known as the bloody show  Braxton Hicks Contractions  May be experienced throughout the pregnancy in some  Typically felt as a tightening or pulling sensation at the top of the uterus  Occur primarily in the abdomen and groin and gradually spread downward before relaxing  True labor contractions are more commonly felt in the lower back  Help with ripening and softening the cervix. However, the contractions are irregular and can be decreased by walking, voiding, eating, increased fluids, or changing position  Usually last about 30 seconds buts can be up to 2 mins  As birth nears and the uterus becomes more sensitive to oxytocin, the frequency and intensity of the contractions increase

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If the contractions last longer than 30 seconds and occur more than 4-6 times/hour, advise woman to contact her HCP so she can be evaluated for possible preterm labor, especially if she is less than 38 weeks Teaching to Manage the Discomforts of Pregnancy pg. 420  Urinary frequency  tell mom to empty bladder and not keep holding it for long to prevent a UTI  avoid caffeine and excessive fluids when going to bed  Fatigue  tell her to rest as often as she can and to take an afternoon nap  N/V  drink fluids, crackers and tea before getting out of bed  Backache  if it’s because of lordosis, tell them to rest and to avoid sitting or standing for a long time  Varicose veins  elevate the legs, don’t cross them, sit with both legs on the ground, can use compression, get up and walk when she can  Hemorrhoids  high fiber diet, increased fluids  Constipation  high fiber, drink something in the AM to stimulate the bowels, try to move around  Heartburn  sitting upright after eating, avoid spicy foods, small portions  Morning sickness  small meals throughout the day  Braxton-hicks  if they aren’t getting stronger and longer, should be fine

Fundal Height Measurement pg. 410  The distance in cm measured with a tape measure from the top of the pubic bone to the top of the uterus (fundus) with mom on back and knees slightly flexed  McDonald method  Between 12-14 weeks the fundus can be palpated above the symphysis pubis

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The fundus reaches the level of the umbilicus at approximately 20 weeks and measures 20cm  Fundal measurement should approximately equal the number of gestation until 36 weeks  After 36 weeks, the fundal height drops due to lightening  If growth curve flattens or stops, could be fetal growth restriction (FGR) and if its greater than 4cm of estimated gestational age, further evaluation is warranted if a multifetal gestation has not been diagnosed or hydramnios has not been ruled out Ultrasonography pg.412  Transducer that emits high frequency sound waves is placed on mother’s abdomen to visualize fetus  Fetal heartbeat and any malformations can be assessed and measurements can be made  Obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and to establish an accurate gestational age o Provide important info about fetal activity, growth, and gestational age, assesses fetal wellbeing, and determines the need for invasive intrauterine tests  A transvaginal ultrasound may be used in the first trimester to confirm pregnancy, exclude ectopic pregnancy or molar pregnancy, and confirm cardiac pulsation  A second scan can be done around 18-20 weeks to look for congenital malformations, exclude multifetal pregnancies, and verify dates and growth  A third scan can be done around 34 weeks to evaluate fetal size, assess fetal growth, and verify placental position  An ultrasound is used to confirm placental location during amniocentesis and to provide visualization during chorionic villus sampling (CVS)  Ultrasound is ordered whenever an abnormality is suspected  Now there are 3D/4D ultrasounds  Nursing management during ultrasound: o Focuses on educating woman about the test and she will not experience any sensation from the sound waves o No special prep is needed  in early pregnancy, woman may need to have a full bladder. Inform her she may experience some discomfort from the pressure on the full bladder during the scan but it will only last a short time o Tell client that gel might feel cold at first  Maternal Weight Gain pg. 381  The amount of weight gained is not as important as what a woman eats. Weight can be lost after pregnancy but you can’t make up for poor nutrition  Underweight (BMI < 18.5): 28-40lbs  Normal weight (BMI 18.5-24.9): 25-35lbs  Overweight (BMI 25-29.9): 15-25lbs  Obese (BMI 30 or higher): 11-20lbs  Multiple births: 40lbs Danger Signs in Pregnancy  Have to check if fluid coming out is urine or amniotic fluid. Check with nitrazine and it will be blue if it’s amniotic fluid  Excessive movement of baby is bad and no movement is also bad

Physiologic Changes of Pregnancy Pregnancy: Variation to…  Age-related perspectives o Adolescent pregnancy o Pregnancy after age 35

o Mothers between ages 20 and 35  best time to have a baby because the body is more flexible, etc.  Sociocultural variations  Religious variations Reproductive System Adaptations pg. 365 Cardiovascular pg. 369  Cardiovascular changes occur early in pregnancy to meet the demands of the enlarging uterus and the placenta for more blood and oxygen  Heart rate increases about 25% or by 10 beats/min  Cardiac output increases by 30% to 50% and peaks at 25 to 30 weeks’ gestation  Increased blood volume  increases about 1,500mL or 50% above nonpregnant levels, by 32nd week of gestation o The increase is needed to provide adequate hydration of fetal and maternal tissues, to supply blood flow to the enlarging uterus, and to provide as a reserve to compensate for blood loss during birth and during postpartum o To meet the increased metabolic needs of the mother and to meet the increased need for increased perfusion of other organs  Increased plasma volume which leads to physiologic anemia o A lot of women get cavities and become anemic because the baby is taking all the nutrients  Supine hypotension syndrome  lightheadedness, faintness, palpitations. The baby is pressing on the inferior vena cava so the blood supply to the mother is compromised so when she gets up, she feels lightheaded. Tell her to lay on her side.  Edema  impeded venous return  Blood pressure, especially diastolic pressure, decreased slightly during pregnancy as a result of peripheral vasodilation caused by progesterone o Any significant rise in blood pressure during pregnancy should be investigated to rule out gestational hypertension, which is systolic of 140mmHg or higher and/or diastolic of 90mmHg or higher after 20 weeks’ gestation Hematologic  The number of red blood cells increases to 25-35% higher, depending on the amount of iron available  There is also an increase in plasma volume as a result of hormonal factors and sodium and water retention  Since plasma increases exceed the increase in red blood cell production, normal hemoglobin and hemocrit levels decrease, which is physiologic anemia of pregnancy  Iron requirements during pregnancy increase because of the demands of the growing fetus and the increase in maternal blood volume  mother will need iron tablets because the baby is taking all the stores  Plasma and plasma fibrinogen levels increase along with various blood clotting factors o These factors make pregnancy a hypercoagulable state o These changes coupled with venous stasis secondary to venous pooling, which occurs during late pregnancy after long periods of standing in the upright position

with pressure exerted by the uterus on the large pelvic veins, contributing to slow venous return, pooling, and dependent edema o These factors also increase women’s risk for venous thrombosis Respiratory pg. 370  Increased maternal oxygen requirements o Oxygen consumption increases between 20-30% by the time full term is reached  Occasional dyspnea  Respiratory effort  The amount of space available to house the lungs decreases because the uterus puts pressure on the diaphragm and causes it to shift upward by 4cm above its usual position o This results in hyperventilation and hypocapnia o Women’s breathing becomes more diaphragmatic than abdominal  A pregnant woman breathes faster and more deeply because she and the fetus need more oxygen  Increased vascularity of the respiratory tract is influenced by increased estrogen levels, leading to congestion Gastrointestinal pg. 367  During pregnancy, the gums become hyperemic, swollen, and friable and tend to bleed easily due to estrogen and increased proliferation of blood vessels and circulation to the mouth  Saliva becomes more acidic  women will complain about too much saliva, termed Ptyalism. It can be caused by an unconscious decrease in swallowing when the woman is nauseous. This usually resolves spontaneously and women can get temporary relief from chewing gum or sucking on hard candy  Dental plaque, calculus, and debris deposits increase during pregnancy and are all associated with gingivitis. An increase in female hormones contributes to development of gingivitis and periodontitis because vascular permeability and tissue edema are both increased. 50-70% of pregnant women will have gingivitis  Smooth muscle relaxation and decreased peristalsis occur related to the influence of progesterone  Elevated progesterone causes smooth muscle relaxation, which results in delayed gastric emptying and decreased peristalsis  Transition time of food throughout the GI tract may be so much slower that more water than normal is reabsorbed, leading to bloating and constipation  Constipation, increased venous pressure, and the pressure of the gravid uterus contribute to the formation of hemorrhoids  The slowed gastric emptying combined with relaxation of the cardiac sphincter allows reflux, which causes heartburn  Acid ingestion or heartburn (pyrosis) is universal among pregnant women  caused by regurgitation of stomach contents into the upper esophagus  give OTC antacids  Gallbladder emptying time is prolonged secondary to smooth muscle relaxation from progesterone and can lead to hypercholesterolemia, increasing the risk for gallstone formation  Nausea and vomiting (morning sickness) usually occurs in 80% of women

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Usually self-limiting but can be distressing and interfere with work, social activities, and interrupt sleep  Doxylamine succinate 10mg/pyridoxine hydrochloride 10mg (Diclegis)  first med to treat morning sickness  Morning sickness occurs most commonly in the morning but I can last all day o Occurs between 6 and 12 weeks o If vomiting continues beyond the first trimester, it’s a problem  hyperemesis gravidarum Hyperemesis Gravidarum pg. 704  Severe form of nausea and vomiting of pregnancy associated with significant costs and psychosocial impact  Morning sickness effects most women and usually resolves after the first trimester  Severe hyperemesis gravidarum can result in dehydration, weight loss, electrolyte imbalance, and the need for hospitalization  Complication of pregnancy characterized by persistent, uncontrollable nausea and vomiting that beings in the first trimester and causes dehydration, ketosis, and weight loss of more than 5% of prepregnancy body weight  Risk factors  previous pregnancy complications, hx of h. pylori infections, multiple gestation, prepregnancy hx of GU disorders, hyperthyroid disorders, and prepregnancy psychiatric diagnosis Uterus pg. 365  The uterus grows at a steady, predictable rate during pregnancy  Estrogen stimulates uterine growth, it grows tremendously during pregnancy. It increases from 70g to about 1100 to 1200g at term and its capacity increases from 10 to 5000mL or more at term  The uterine walls thin to 1.5cm  Blood vessels elongate, enlarge, dilate, and sprout new branches to support and nourish the growing muscle tissue  As pregnancy progresses, 80-90% of uterine blood flow goes to the placenta  Uterine contractility is enhanced as well  Braxton Hicks contractions begin in the first trimester o Spontaneous, irregular, and painless contractions o These contractions continue throughout pregnancy, becoming especially noticeable during the last month, when they function to thin out the cervix before birth  The lower portion of the uterus (the isthmus) becomes increasingly thinner as pregnancy progresses, thereby forming the lower uterine segment o Changes occur dur...