OB Final Cheat Sheet - Lecture notes 1-8 PDF

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Labor Stages First stage: Begins with the onset of true labor and ends when the cervix is completely dilated at 10 cm Second stage: Begins with complete dilatation and ends with the birth of the newborn. Third stage: Begins with the birth of the newborn and ends with the delivery of the placenta. Fourth stage: Begins with delivery of the placenta and lasts 1 to 4 hours, during which the uterus effectively contracts to control bleeding at the placental site. The fourth stage of labor is the time, from 1 to 4 hours after birth, during which physiologic readjustment of the mother’s body begins. With the birth, hemodynamic changes occur. Blood loss ranges from 250 to 500 mL. With this blood loss and removal of the weight of the pregnant uterus from the surrounding vessels, blood is redistributed into venous beds. This results in a moderate drop in both systolic and diastolic blood pressure, increased pulse pressure, and moderate tachycardia First Stage: Varies the most in length!!! Can be 12-24 hours (latent) Frequent position changes help with comfort and progression 5 P’s of Labor

HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is sometimes associated with severe preeclampsia. Women who experience this multiple-organfailure syndrome have high morbidity and mortality rates, as do their offspring. The hemolysis that occurs is termed microangiopathic hemolytic anemia. It is thought that red blood cells are distorted or fragmented during passage through small, damaged blood vessels. Vascular damage is associated with vasospasm, and platelets aggregate at sites of damage, resulting in a low platelet count (less than 100,000/mm3). Elevated liver enzymes occur from blood flow that is obstructed by fibrin deposits. Hyperbilirubinemia and jaundice may also be seen. Liver distention causes epigastric pain and may ultimately result in liver rupture. Symptoms may include nausea, vomiting, flulike symptoms, or epigastric pain. HELLP syndrome is sometimes complicated by disseminated intravascular coagulation (DIC). GDM: Likely to have larger babies, shoulder dystocia, macrosomia more than 4k g, slow/difficult labor. Multiples, overweight, assisted birth. Baby has brachial plexus nerve damage, fracture BV: Not STI, overgrowth of flora, **DO NOT use vaginal douche, no partner testing, flagyl is treatment

Indications For electronic monitoring If one or more of the following factors are present, the fetal heart rate and contractions are monitored by EFM: 1. Previous history of a stillbirth at 38 or more weeks’ gestation 2. Presence of a complication of pregnancy (e.g., preeclampsia, placenta previa, abruptio placentae, multiple gestation, prolonged or premature rupture of membranes) 3. Induction of labor (labor that is begun as a result of some type of intervention such as an intravenous infusion of Pitocin) 4. Preterm labor 5. Decreased fetal movement 6. Nonreassuring fetal status 7. Meconium staining of amniotic fluid (Meconium has been released into the amniotic fluid by the fetus, which may indicate a problem.) 8. Trial of labor after cesarean birth (TOLAC) 9. Maternal fever 10. Placental problems 11. Category II or III tracings Variable Decelerations Early Decelerations A L

Cord Compression Head Compression

Variability Marked: amplitude greater than 25 beats/min •Moderate (normal): amplitude 6 to 25 beats/min •Minimal: amplitude detectable but 5 beats/min or less •Absent: amplitude undetectable—category 3 Interventions for Early Decelerations •Facilitate a left lateral position with changes in position as warranted until FHR improves or stabilizes. •Administer oxygen via facemask at 7 to 10 L/min. •Alert physician/CNM of status immediately. •Provide explanation and support to woman and her partner. •Increase intravenous fluids. •Discontinue oxytocin immediately if it is being administered. •Monitor maternal blood pressure and pulse. •Treat hypotension per orders or protocol. •Assess cervical status. •Prepare for possible emergency cesarean birth if tracing is not improving or is worsening. •Document interventions used to treat uteroplacental deficiency. **Prolonged decelerations should perform vaginal exam to make sure not a prolapsed cord, change position, d/c oxytocin

Mild Preeclampsia Women with mild preeclampsia may exhibit few if any symptoms. The blood pressure is elevated to 140/90 mmHg or higher and the proteinuria is 1 g or less in 24 hours (2+ dipstick). Although edema is no longer considered a diagnostic criterion, generalized edema, seen as puffy face or hands, and in dependent areas such as the ankles, may be present. Edema is identified by a weight gain of more than 1.5 kg (3.3 lb) per month in the second trimester or more than 0.5 kg (1.1 lb) per week in the third trimester. Edema is assessed on a 1+ to 4+ scale. Severe Preeclampsia The following clinical signs are often present: •Blood pressure of 160/110 mmHg or higher on two occasions at least 6 hours apart while the woman is on bedrest •Proteinuria 5 g/L or higher in 24 hours or 3+ or greater on two random urine samples collected at least 4 hours apart •Oliguria: urine output less than or equal to 500 mL in 24 hours •Cerebral or visual disturbances •Pulmonary edema or cyanosis • Epigastric or right upper quadrant pain •Impaired liver function (elevated hepatic enzymes– alanine aminotransferase (ALT) or aspartate aminotransferase (AST) to at least twice normal) •Thrombocytopenia (less than 100,000 platelets per cubic millimeter) •Fetal growth restriction Other signs or symptoms that may be present include severe headache or one that persists despite analgesic therapy, blurred vision or scotomata (spots before the eyes), narrowed segments on the retinal arterioles when examined with an ophthalmoscope, retinal edema (retinas appear wet and glistening) on funduscopy, dyspnea due to pulmonary edema, moist breath sounds on auscultation, pitting edema of lower extremities while on bedrest, epigastric pain, hyperreflexia, nausea and vomiting, irritability, and emotional tension. Eclampsia: characterized by a grand mal convulsion or coma, may occur before the onset of labor, during labor, or early in the postpartum period. Some women experience only one seizure; others have several. TREATMENT GOAL: Prevent hemorrhage, convulsion, renal/hepatic disease Anticonvulsants. Magnesium sulfate is the treatment of choice for seizure prophylaxis and in the treatment of eclamptic convulsions because of its depressant action on the central nervous system (CNS), fluid and electrolyte replacement, antihypertensives, corticosteroids (for fetus), check every 15 mins for vagina bleeding and abdominal rigidity (abruptio placentae), bedrest, reduction of stimuli, deep tendon reflex, clonus, monitor for hypovolemia, monitor BP and pulse every 4 hours for 48 hours SAFETY ALERT!! When caring for a woman with preeclampsia who is receiving Iv magnesium sulfate, it is imperative to follow protocols for monitoring blood levels of magnesium. You are probably already aware of the common signs of increasing magnesium levels, such as diminished reflexes and decreased respiratory rate. However, you can also watch for some subtle clues that may suggest either the therapeutic or toxic range. When a woman’s magnesium level is in the therapeutic range, she usually has some slurring of speech, awkwardness of movement, and decreased appetite. If the woman begins to have difficulty swallowing and begins to drool, she may be approaching the toxic range. **CNS DEPRESSANT SO WE ARE MONITORING FOR SIGNS OF CNS DEPRESSION—BOLUS FLUID 4-6 THEN MAINTENANCE DOSE OF 2 GRAMS—LAB DRAW DONE IF SIGNS OF TOXICITY-DEPRESSION OF DTR’S WHAT TO REMEMBER FOR PREECLAMPSIA •Preeclampsia, which occurs after the 20th week of pregnancy, involves elevated BP and proteinuria. It may be mild or severe. •A woman with preeclampsia who has a seizure is said to have eclampsia. •The exact cause of preeclampsia is unknown. •Vasospasm is responsible for most of the clinical manifestations, including the CNS signs of headache, hyperreflexia, and convulsion. •Vasospasm also causes poor placental perfusion, which leads to IUGR. •The only known cure for preeclampsia is birth of the baby, but symptoms may develop up to 48 hours postpartum. •Management is supportive and includes anticonvulsant therapy, generally with magnesium sulfate; prevention of renal, hepatic, and hematologic complications; and careful assessment of fetal well-being. •Nursing care focuses on implementing appropriate interventions based on the data gathered from regular assessment of vital signs, reflexes, degree of edema and proteinuria, response to therapy, fetal status, detection of developing complications, knowledge level, and psychologic state of the woman and her family.

COC: complaints of clot are bad (redness, swelling, redness) Polycystic Ovary Syndrome (PCOS): Endocrine disorder and women not ovulating, ovary is developing cyst instead of mature ovary...difficult to get pregnant and LABS HAVE HIGHER ANDROGEN (Testosterone), facial hair, deeper voice. Best treatment is weight loss diet plan (lose 5% which can return to normal ovulation). BREAST ENGORGEMENT: Best treatment is ICE, cabbage leaves, tight bras, avoid stimulation EPIDURALS: STI: Patient and partner both need to be treated and refrain from intercourse until bone shown to be negative, multiple infections can lead to pelvic inflammatory disease, best way to prevent if female has multiple partners is to use a female condom Gonorrhea-After 3rd month of pregnancy, mucus plug will prevent infection from ascending will remain in urethra, cervix until membranes rupture then can spread. Newborn exposed is at risk for conjunctivitis. Determined by cervical culture Chlamydia-Most common, can cause PID—Newborns of women w/untreated inf. Can develop neonatal conjunctivitis (only responds to erythromycin ung), chlamydia pneumoniasingle 1g dose of azithromycin or doxy (contraindicated in pregnancy). Test of cure 3-4 later. PP Blues-feeling inadequate, sad, cry for no reason, normal after birth, common PP Depression-Not caring for infant or self, sad for prolonged time, maybe suicidal PP Psychosis-Actually having hallucinations Pathologic Jaundice-Increased before 24-hour mark, underlying causes such as blood disease, infections, genetic disorder, dehydration, difficult delivery Physiologic Jaundice-serum bilirubin greater than 6-7 on second or third day – likely to increase b/c of increase production or decreased elimination. Should decline by end of first week, peaks between days 3-5. Clears on it own but in severe cases it may need phototherapy Sources of bleeding after delivery—1ST THING TO DO…Massage the fundus, if still firm and still bleeding then patient may be bleeding from vaginal tear or uterine tear (NOT UTERINE ATONY) NOT BLEEDING BUT EXTREME PAIN AND PRESSURE, BP DROPPING—PROBABLY BLEEDING FROM HEMTAOMA WHICH IS DEVELOPING IN VAGINAL WALL (FEELS LIKE A BULGE) COLD STRESS SYNDROME-happens from heat loss and prolonged cold stress may divert calories to produce heat and impair growth. Happens in infants with respiratory insufficiency resulting in tissue hypoxia and neurologic damage. Important to monitor temperature of infant and environment…WARMDRYSTIMULATE. Underlying cause can be sepsis. Pt comes in contracting what do I want to know? Gestational age, GTPAL, OB history, bleeding? FHR, frequency of contractions, BP? Multiparity, fast labor, pt has urge to push feels like bowel movement so first thing to do should be perform vaginal exam because likely to head is crowning-in scope on RN Placenta Previa...