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Antepartum Assessments & Care

1. Reproductive Cycle & Fertilization

●

https://www.youtube.com/watch?v=MLJTLAKFM3k

A nurse is teaching a woman about her menstrual cycle. The nurse states that

●

Proliferation of the endometrium is the most important change that happens

before the secretory phase of the menstrual cycle.

The clinic nurse knows that the part of the endometrial cycle occurring from

ovulation to just prior to menses is known as the secretory phases occurs from

the time of ovulation to the period just prior to menses, or approximately days

15 to 26.

●

➢ The secretory phases occurs from the time of ovulation to the

period just prior to menses, or approximately days 15 to 26.

➢ Amniotic fluid first appears at about 3 weeks.

➢ There are approximately 30 mL of amniotic fluid present at 10 weeks’

Reproductive Cycle: Menstrual Cycle

28 days MENSTRUAL CYCLE

Ovarian Cycle: the maturation of the ova consisting of

Follicular Phase - ( from the 1st day of menstruation to 12-14 days)

LH & FSH cause graafian follicle to mature producing Estrogen

Ovulatory Phase - (begins when estrogen levels peak until oocyte

released from graafian follicle) = OVULATION ^LH

Luteal Phase - (begins after ovulation and lasts 14 days) ^ estrogen &

progesterone

If pregnant, know that the corpus luteum secretes estrogen &

progesterone until placenta matures and assumes this function

> If pregnant, corpus luteum will continue to secrete estrogen

& progesterone until placenta matures

> If NOT pregnant, corpus luteum degenerates = < in progesterone

and beginning of menstruation

Endometrial “Uterine” Cycle: changes in the endometrium of

the uterus in response to the ovarian cycle

Proliferative Phase - (occurs following menstruation ending

with ovulation) endometrium preparing for implantation =more

THICK & VASCULAR

Secretory Phase - (after ovulation and ends with

onset menstruation) = continues to THICKEN

^progesterone

Menstrual Phase - sloughing off of the endometrium = PERIOD.

Fertilization: “Conception” occurs when the sperm nucleus enters the

nucleus of the oocyte within the outer third of the fallopian tube.

The fertilized egg is then called a ZYGOTE and contains a

diploid number of chromosomes = 46

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gestation, and this amount increases to approximately 800 mL at 24

weeks’ gestation. After that time, the total fluid volume remains fairly

stable until it begins to decrease slightly as the pregnancy reaches

term.

2. Infertility

●

Infertility: the inability to conceive or maintain a pregnancy after

12 months of unprotected sexual intercourse

6 months for women older than 35 y.o

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> Causes

1/3 Male Factor

Endocrine - < in LH, FSH, Testosterone

Spermatogenesis - effects of gonadotoxins

Gonadotoxins include: drugs, infections, systemic illness,

heat exposure, pesticides and radiation to the pelvic region.

Sperm Antibodies - < in sperm motility

Sperm Transport - blocked transport

Vasectomy

Prostatectomy

Inguinal hernia

Absence of Vas Deferens

Disorders of Intercourse

Erectile Dysfunction

> Both male & female need to be evaluated

● ○ ■ ■ ○ ■ ● ■ ○ ■ ■

1/3 Female Factor

Ovulatory Dysfunction

Anovulation

Inconsistent Ovulation

Tubal & Pelvic Pathology

Damage to the Fallopian

tubes ENDOMETRIOSIS

Uterine Fibroids: benign growth of uterine wall

Cervical Mucus Factor

Surgical surgeries: cryotherapy (TX cervical

dysplasia) Infection not allowing sperm to enter

●

1/3 Both Male and Female Factors

DX Testing :

● ● ● ● ○ ○ ○ ● ● ● ●

Screening for STI’s and STD’s

Labs assessing levels of LH, FSH, TSH,

testosterone Semen Analysis

Assessment of Ovulatory Dysfunction

Daily Morning Body Basal Temp

Day 3 of menstrual cycle = FSH & estradiol test

taken Detecting LH surge 36hrs before ovulation

Endometrial Biopsy at end of menstrual cycle

Hysterosalpingogram radiological exam testing tubal problems

Laparoscopy -visualize/inspect ovaries

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TX:

Females:

Same lifestyle changes as men

Surgery to open tubes if abnormal

Myomectomy - removal of uterine

fibroids Antibiotics to TX infection

Medication stimulating egg production

CLOMIPHENE CITRATE : stimulates release of FSH &

LH PO cycle Day 3-

S/E: hot flashes, breast discomfort, headaches, insomnia

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N306 Final Exam Test 1 Study Guide latest update(

TX:

Males: Hormonal Therapy Lifestyle changes Stress reduction, improved nutrition, smoking cessation, eliminating drugs Corticosteroids to TX antibodies Antibiotics to TX infection Repair of inguinal hernia or obstruction A client is to take Clomiphene Citrate for infertility. Which of the following is the expected action of this medication? Stimulate release of FSH and LH A couple who has sought infertility counseling has been told that the man’s sperm count is very low. The nurse advises the couple that spermatogenesis is impaired when which of the following occur? The testes are overheated. A nurse working with an infertile couple has made the following nursing diagnosis: Sexual dysfunction related to decreased libido. Which of the following assessments is the likely reason for this diagnosis? The couple has established a set schedule for their sexual encounters. Couples who “schedule” intercourse often complain that their sexual relationship is unsatisfying. A couple is undergoing an infertility workup. The semen analysis indicates a decreased number of sperm and immature sperm. Which of the following factors can have a potential effect on sperm maturity? The man rides a bike to and from work each day. The man takes a calcium channel blocker for the treatment of hypertension The daily riding of a bike can be the cause of prolonged heat exposure to the testicles. Prolonged heat exposure is a gonadotoxin. A number of medications, such as calcium channel blockers, can have an effect on sperm production

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3. Physiological changes pregnancy by system (pg 54)

CHADWICKS SIGN: BLUISH DISCOLORATION OF THE

CERVIX

Cardiovascular system: 10-15bmp increase heart

rate (Woman feels palpitations at second trimester,

assessed low blood

pressure) NORMAL

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4. Psychological & Developmental Tasks Psychological:

Developmental Tasks

The events of pregnancy and childbirth are considered

a developmental “maturational” crisis is the life of a

family All family members are affected

Acquiring knowledge and plans for the specific needs of

pregnancy, childbirth, and early parenthood

Preparing to provide for the physical care of the

newborn Adapting financial patterns to meet increasing

needs Realignment of tasks and responsibilities

Adjusting patterns of sexual expression to accommodate

pregnancy Expanding communication to meet emotional needs

Reorienting of relationships with relatives

Adapting relationships with friends and community to take account of

the realities of pregnancy and the anticipated newborn

Nursing Tasks

Assess knowledge related to pregnancy, childbirth, and

early parenting.

Assess progress in developmental tasks of pregnancy.

Explore patterns of communication related to emotional needs,

responsibilities, and new roles.

Include the entire family; assessments and interventions must

be considered in a family-centered perspective.

Provide education and guidance related to pregnancy, childbirth,

and early parenting

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5. Fetal & Placental Development

The fetal circulatory structure that connects the pulmonary artery with the

descending aorta is known as which of the following? Ductus arteriosus

An ultrasound of a fetus’ heart shows that “normal fetal circulation is occurring.”

Which of the following statements is consistent with the finding? A right to

lef ●

t shunt is seen between the atria known as foramen ovale

(after 3 months after delivery the the foramen ovale closes n response to

increased blood return to the L atrium.

Information provided by the nurse that addresses the function of the amniotic

●

fluid is that the amniotic fluid helps the fetus to maintain a normal body

●

temperature and also Cushions the fetus from mechanical injury

○

The perinatal nurse explains to the student nurse that in the fetal circulation,

●

the lowest level of oxygen concentration is found in the umbilical arteries =

○

TRUE, The highest oxygen concentration (PO2 = 30–35 mm Hg) is found in

the blood returning from the placenta via the umbilical vein; the lowest

oxygen concentration occurs in blood shunted to the placenta where

reoxygenation takes place. The blood with the highest oxygen content

is delivered to the fetal heart, head, neck, and upper limbs, and the

blood with the lowest oxygen content is shunted toward the placenta.

After birth, the perinatal nurse explains to the new mother that prolactin is the

hormone responsible for stimulating milk production.

During prenatal class, the childbirth educator describes the two membranes

that envelop the fetus. The amnion contains the amniotic fluid, and the chorion

is the thick, outer membrane.

The perinatal nurse is teaching nursing students about fetal circulation and

explains that fetal blood flows through the superior vena cava into the

right atrium via the foramen ovale.

Embryo and Fetal Development : first 8 wks= Organogenesis

Ectoderm

Mesoderm

Endoderm

After 9th wk = Fetus

Fetus Circulation : ^ levels of oxygenated blood enter the fetal

circulatory system from the

Placenta -> Umbilical Vein

Ductus Venosus connects Umbilical Vein to Inferior Vena Cava

Foramen Ovale (opening between L & R atrium)

after delivery shunt closes within 3 months from blood returning to

the L atrium

Ductus Arteriosus (connects Pulm Artery to Descending Aorta)

after delivery it constricts in response to ^ blood oxygen levels

and prostaglandins

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Ductus Venosus connects Umbilical Vein to Inferior Vena Cava Foramen Ovale (opening between L & R atrium) after delivery shunt closes within 3 months from blood returning to the L atrium Ductus Arteriosus (connects Pulm Artery to Descending Aorta) after delivery it constricts in response to ^ blood oxygen levels and prostaglandins

●

○ ● ○

Placenta Development: formed from both fetal and mother tissue Chorionic Membrane (trophoblast & chorionic villi) Form fetal blood vessels of the placenta Endometrium (decidua) = 3 layers Decidua Basalis : forms maternal side of the placenta

Placenta is divided into lobes “cotyledons” Placental membrane separates maternal/fetal blood from mixing but allows for exchange of nutrients, gases and electrolytes through diffusion and active transport

●

● ● ●

Major Hormones of the Placenta Progesterone : < in uterine contractility & facilitates implantation Estrogen : “enlargement” breasts and uterus hCG : + preg test, ^ in 1st trimester as it stimulates corpus luteum to keep secreting estrogen and progesterone until placenta is able to secrete it (6-7wks) hPL : promotes fetal growth by regulating glucose and stimulates breasts to lactate Umbilical Cord = 1 vein (oxygenated blood) and 2 arteries (deoxygenated blood) A.V.A

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6. Teratogens -

The nurse is interviewing a gravid woman during the first prenatal visit. The

woman confides to the nurse that she lives with a number of pets. The nurse

should advise the woman to be especially careful to refrain from coming in

contact with the stool of which of the pets?

The patient should refrain from coming in direct contact with cat feces.

Cats often harbor toxoplasmosis, a teratogenic illness.

During preconception counseling, the clinic nurse explains that the time period

when the fetus is most vulnerable to the effects of teratogens occurs from 2-

8wks

Any drugs, viruses, infections or other exposures that can

cause embryonic/fetal development abnormality

> The developing human is most vulnerable to the effects of

teratogens during the period of organogenesis, THE FIRST

8 WEEKS OF GESTATION

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7. Common Discomforts

Common Discomforts of Pregnancy

N/V

Eat crackers or dry toast 30min to 1 hr before rising in the morning to relieve discomfort Avoid having an empty stomach Avoid spicy, greasy, or gas- forming foods Drink fluids between meals Breast Tenderness Wear a bra with adequate support Urinary Frequency Empty bladder frequently Decrease fluid intake before bedtime and use perineal pads Perform Kegel exercises UTI’s Wipe from front to back Avoid bubble baths Wear cotton underpants Avoid tight fitting pants Consume 8 glasses of water per day Urinate ASAP Notify HCP if urine is foul-smelling, contains blood or appears cloudy Fatigue Engage in frequent rest periods Heartburn Eat small frequent meals Do not allow stomach to get too empty/full Sit up for 30min after meals Check with HCP before using OTC antacids Constipation Drink plenty of fluids Eat a diet High in FIBER Exercise Regularly Complaints Common remedies

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Hemorrhoids

Take warm sitz bath

Use witch hazel pads

Apply topical ointments to relieve discomfort

Backaches

Exercise regularly

Perform pelvic tilt exercises

Arching & straightening back

Use proper body mechanics -use legs to

lift Use side-lying position

SOB or Dyspnea

Maintain good posture

Sleep with extra

pillows

Contact HCP if symptoms worsen

Leg Cramps

Extend the affected

leg Keep knee straight

Dorsiflex the foot (toes towards

head) Apply heat while extended

Contact HCP if persists

Varicose Veins & Lower Extremity Edema

Rest with legs elevated

Avoid tight/constricting clothing

Wear support hose

Avoid sitting & standing in one position for long periods of

time Do not sit with legs crossed at the knees

Sleep in the left-lateral position

Exercise moderately with frequent walking to stimulate venous return

Gingivitis, Nasal Stuffiness, Epistaxis

Gently brush teeth/Good dental

hygiene Use a humidifier

Use normal saline drops or Spray

Braxton Hicks contractions

Instruct client to change position & walking should cause contractions

to subside

If contractions increase in intensity and become frequent

with regularity - Notify HCP

Supine Hypotension

Lie in a side-lying or semi-sitting position with her knees

slightly flexed

8. Anticipatory Teaching & Health Promotion >>>>>>
9. Danger Signs & Interventions during pregnancy

●

True anemia, or iron-deficiency anemia, occurs when the hemoglobin level

○

drops below 10 g/dL. The blood’s decreased oxygen-carrying capacity causes

a○ reduction in oxygen transport to the developing fetus. Decreased fetal

oxygen ○ transport has been associated with intrauterine growth

restriction (IUGR) and ○

preterm birth.

○ ○ ● ○ ○ ○ ○ ○

Warning/Danger Signs

First Trimester

Abd Cramping/Pain: poss threatened abortion, UTI, appendicitis

Vaginal Spotting/Bleeding: “ “

Absent Fetal Heart Sound : poss missed abortion

Dysuria, Freq, Urgency : poss UTI

Fever/Chills: poss infection

Prolonged N/V : hyperemesis gravidarum, ^ risk for dehydration

Second Trimester

Abd/Pelvic Pain: poss appendicitis, UTI, PTL or pyelonephritis

Vaginal Bleeding: poss infection, friable cervix from preg changes,

placenta previa, abruption placenta or PTL

Absent Fetal Heart Sound : poss missed abortion

Dysuria, Freq, Urgency : poss UTI

Fever/Chills: poss infection

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External & Internal Electronic Fetal and Uterine Monitoring Influences on FHM

11. Utero-Placental pg. 238 Utero-Placental Unit

●

●

Oxygenated blood from mother is delivered to the intervillous space in the placenta via uterine arteries Nutrients, gas exchange, O2, CO2, water and wastes products are also exchanged in the intervillous space across the membranes

★

○ ○

Effective O2 & CO2 transfer are dependent on Adequate uterine flow Sufficient placental area

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Prolonged N/V : hyperemesis gravidarum, ^ risk for dehydration

●

○ ■

Third Trimester S/S of PTL (abruptio placenta: placenta detaches from womb) rhythmic lower abd cramping, lower backache, pelvic pressure,

○

■

leaking of amniotic fluid, ^ vaginal dc S/S of HTN disorder severe headache (not relieved), visual changes, facial or generalized

○

edema

“ “

10. Maternal Screening & Fetal Surveillance Tests & Labs ● Genetic Counseling ○

○

A diagnostic test commonly used to assess problems of the fallopian

■

tubes is: Hysterosalpingogram provides information on the

■

endocervical canal, uterine cavity, and fallopian tubes.

■

■

The nurse takes the history of a client, G2 P1, at her first prenatal visit

○

. The client is referred to a genetic counselor, due to her previous

child

■

having a diagnosis of sickle cell anemia (autosomal recessive illness)

○

Maternal Screening Risk Factors Biophysical Factors: genetic, nutritional, medical or obstetric issues Psychosocial Factors: negative maternal behaviors affecting fetus Smoking Caffeine use Alcohol/drug use Psychological status Sociodemographic Factors Age, prenatal care, parity, marital status, income and ethnicity Environmental Factors: hazards in workplace or home

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○ ★ ○ ○ ○ ○

Unconstricted umbilical cord

Appropriate oxygenation to the fetus depends on adequate

Oxygen to the mother

Blood flow to the placenta

Uteroplacental circulation

Umbilical circulation

○ The fetus own ability to initiate compensatory mechanism to

regulate the FHR

12. Autonomic Nervous System pg. 239 Parasympathetic Nervous System (rest and digest/ homeostasis)

●

●

Stimul

ation < HR

Mediated by the vagus nerve innervating sinoatrial (SA)

& atrioventricular (AV)

★

Vagus Nerve stimulations SLOWS FHR & helps maintain variability

(variability develops 28-30wks)

●

●

●

●

Sympathetic Nervous System (fight or flight)

Stimulation ^ FHR

Responsible for FHR variability

Occurring through the release of

norepinephrine May be stimulated during

Hypoxemia

13. Central Nervous System pg. 240

●

●

●

●

Central Nervous System (CNS) (controls activities of the body)

Responsible for variations in FHR

Responsible for baseline variability RT fetal activity

Regulates & coordinates autonomic activities

Responds to fetal movement

● Mediates cardiac & vasomotor reflexes

14. Chemoreceptors pg. 240

●

Chemoreceptors : located in the aortic arch &

CNS Respond to changes in fetal O2/CO2 & pH

levels

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★

Decreased O2 & Increased CO2 cause the peripheral chemoreceptors to stimulate the Vagal Nerve & SLOW HR Central Chemoreceptors respond to Increased HR and Increased BP

15. Hormonal Regulation pg. 240

Fetal Hypoxia causes release of → epinephrine and norepinephrine increases FHR and BP → vasopressin increases HR in response to hypoxia Hypovolemia → Renin-angiotensin (secreted by the kidneys) produces vasoconstriction

16. Fetal Reserves pg.

Fetal Reserves : the reserve of O2 available to the fetus to withstand the transient changes in blood flow and O2 during labor When O2 is decreased, blood flow is deferred to fetal vital organs to compensate BUT when the placental reserves of O2 are decrease or depleting, the fetus may not be able to compensate or adapt to the decreased O2 during contractions Homeostatic Mechanism 3 Types of Fetal Responses - FHR Data NON Hypoxic Reflex FRH Accelerations Compensatory to Hypoxemia Variable Decelerations Impending Decompensation Late Decelerations

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**17. Fetal Monitoring >>>>>

18. NICHD Criteria for Interpretation of FHR patterns:** pg. 241

●

Baseline variability pg.

●

245 Bradycardia &

●

Tachycardia Accels

●

Decels Clinical conditions that impact FHR include Gestational age Prior results of fetal assessment Medications Maternal medical conditions

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●

Fetal conditions

Assessing FRH Pattern:

Baseline FHR (rate/variability)

○ Mean FRH rounded to increments of 5 BPM during a 10 min window

○ There MUST be 2 min of identifiable baseline segments

○

NORMAL 110-160bpm

Periodic/Episodic Changes (accelerations/decelerations)

Uterine Activity

○ Frequency

○ Duration

○ Intensity

○ Resting tone

○ Relaxation time between UC’s

★ Baseline Variability : the fluctuations in the baseline of the FHR

○ Irregular in amplitude & frequency

○ Most Important predictor to adequate fetal oxygenation

cerebral cortex > midbrain (medulla oblongata) > vagus nerve > heart

●

accels/decels not included

VEAL CHOP

-

Variable (common) Cord

compression

Early Head compression

Accelerations Oxygenation okay

Late Placental

insufficiency

ABSENT : amplitude range is undetectable

= Can occur if the baby is sleeping, meds S/E

Maternal: supine hypo, cord compression, uterine tachysystole, drugs

= May also be a sign of hypoxia/acidosis if persistent for 60min with

interventions

-

MINIMAL : amplitude range is undetectable < 5 bpm

= Can occur if the baby is sleeping, meds S/E

Maternal: supine hypo, cord compression, uterine tachysystole, drugs

= May also be a sign of hypoxia/acidosis if persistent for 60min with

interventions

-

MODERATE: amplitude 6 -25 bpm

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= Well oxygenated fetus with normal acid-base balance

Know this is NORMAL -keep monitoring

• MARKED: amplitude range > 25 bpm

★

Fetal Bradycardia : FHR <110 bpm for at least 10 min

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<FRH may lead to <CO = < umbilical cord blood flow leading to

fetal hypoxia (needs immediate intervention)

< 80 bpm = obstetric emergency

Brady with normal variability is Benign

Brady with loss of variability/late decelerations is a sign

of current/impending fetal hypoxia

Causes:

Maternal related

Supine position

Hypotension

Dehydration

Meds: (ANAESTHETICS/ADRENERGIC RECEPTORS)

Rupture of the uterus /vasa previa or placental

abruption Fetal related

Fetal response to

hypoxia Cord occlusion

Acute/late/profound hypoxemia

Hypothermia

Hypokalemia

Chorionic head compression

Fetal bradyarrhythmia

TX: treat underlying cause/consider

delivery Nursing Actions:

Confirm EFM

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Assess fetal movement

Fetal scalp stimulation

Perform vaginal exam - assess for prolapsed cord

Maternal VS

Have mother change in

position Discontinue oxytocin

to < UC’s

Give O2 10L/min via non-breather

mask Stop < pushing

support family

contact HCP

★

Fetal Tachycardia: FHR >160 bpm for at least 10 min

○ ○ ○ ■ ● ■ ○ ○ ■ ■ ■ ■ ■ ■ ■

May be a sign of fetal hypoxemia, especially with decreased

variability and decelerations

If tachy = 200-220 bpm, fetal demise

Causes:

Maternal fever/related causes

Infection

Exposure to meds ( Terbutaline )

TX: treat underlying cause & consider

delivery Nursing Actions:

Assess maternal VS

Give meds as

ordered Use ice

packs, if fever

Assess for dehydration - IV fluids

Change the mother’s position

Decrease/Stop Pitocin (Oxytocin)

Notify HCP

★

○

○

Periodic v. Episodic Changes

Periodic = accelerations/decelerations in FHR due to UC & persist

Episodic = accelerations/decelerations in FRH not associated with UC

(accelerations common)

★

○

○

○

FHR Accelerations = predictive of adequate central fetal

oxygenation and absence of fetal acidemia

Visually abrupt transient increases above the FHR

baseline 15 beats above the baseline (15 sec-2 min)

Prolonged accelerations >2 min but < 10 min

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★

○

○

○

○

FHR Decelerations = transitory decreases in the FHR baseline

Classified according to shape, timing & duration in relationship with the

contraction

RECURRENT if occur in at least 50% of UC’s within 20 min

INTERMITTENT if occur fewer that 50% of UC’s within 20 min

Nadir : lowest point of the deceleration (occurs at the peak of the

contraction)

●

●

• EARLY Decelerations: visibly apparent &

symmetrical Mirrors the UC’s

Normal

VEAL CHOP

Variable (commonCord

compression Early

Head

compression Accelerations

Oxygenation

okay Late Placental

insufficiency

●

●

●

●

VARIABLE Decelerations : visibly apparent, abrupt decrease in

FHR Most common during labor

Decrease FHR is > 15 bpm for > 15 sec and <2min in duration

Can be a V, W or U shaped

May be due to umbilical cord occlusion/ cord compression

REPOSITION THE PATIENT

Consider Amnioinfusion, tocolytics, delivery

●

●

LATE Decelerations : visibly apparent, symmetrical gradual decrease

of FHR due to UC’s

May be a sign of fetal intolerance to labor

Nadir occurs after peak of contraction

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●

RT decreased availability of O2 because of uteroplacental

insufficiency Consider tocolytics, delivery

Interventions: Initiate Iv bolus, change maternal position, initiate

oxygen therapy

●

●

●

PROLONGED Decelerations :

More than 15 bpm lasting >2 min but < 10 min

Caused by any mechanism that causes drastic < in

O2 Consider Amnioinfusion, tocolytics, delivery

The goal for maternal position change

for prolonged deceleration is

maximizing uterine blood flow.

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19. Category system – 1 2 3 pg.

241 Know category 1 and 3

Q: a doctor tells the nurse that the pt is able to discharge when she

meets the criteria of category 1

20. Intrauterine Resuscitation Interventions pg. 249 These interventions maximize uterine blood flow,

umbilical circulation and maternal fetal oxygenation by

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Shifting maternal position to the L or R

Administer 500 mL of lactic ringers IV Bolus -maximize

intravascular volume =improved uteroplacental perfusion

Correct hypotension by change in position, Ephedrine and

proper hydration

Adm O2 10L/min on non-rebreather face

mask Reduce UC’s by

Stopping Oxytocin

Removing the cervical ripening agent

Use Terbutaline to Relax the uterus

Amnioinfusion - resolving variable

decelerations Encourage pushing techniques

Obtain fetal acid-base status if possible by fetus scalp

sample Be supportive to mother & fam bam

●

○

○

If fetus has fetal acidemia =

Notify HCP to initiate bedside eval for

cesarean Notify anesthesia & peds team

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Move pt to OR

21. Amnioinfusion pg. 251 Amnioinfusion : room temp normal saline is infused into the uterus

transcervically via an intrauterine pressure catheter to increase

intra amniotic fluid cushioning the umbilical cord and reducing

cord compression.

Used when there are Variable Decelerations in the first stage

of l abor due to a decrease in amniotic fluid

Also know the functions of the amniotic fluid: provides cushion for the

fetus and prevents the fetus from getting contractures when bending

arms and legs > mother is able to exercise, encouraged to walk daily

Antenatal Assessments

●

○

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22. Biophysical assessments (US) pg. 116

●

Ultrasonography : high frequency sound waves producing an image

or an organ or tissue

Gestational Age

Fetal Growth

Fetal Anatomy

Placental Abnormalities & location

Fetal Activity

Amount of Amniotic Fluid

Visual Assistance for invasive procedures -> amniocentesis

> Standard Ultrasounds are typically done in 1st trimester to

confirm preggo & calculate gestational age

Transvaginal Ultrasound - done at 1st trimester

○ ○ ○ ○ ○ ○ ○ ●

● Abdominal Ultrasound - supine position

★ To calculate gestational age = measurements

○ of Fetal-crown rump length

○ Biparietal Diameter

○ Femur Length

○ Most accurate <20 wks

23. Biochemical assessments pg. 121

Amniocentesis

meconium fetal feces

CVS

Amniocentesis: less than 1% fetal loss rate after 15

weeks gestation

● ● ● ● ○ ○ ○ ●

Chorionic Villus Sampling (CVS) : the aspiration of a small amount of

placental tissue for chromosomal, DNA and metabolic testing

Done within 10-12 weeks for chromosomal analysis to detect

fetal abnormalities caused by genetic disorders

It tests for Cystic Fibrosis but NOT for Neural Tube Defects

Performed ideally at 10-13 wks - NOT recommended before 10 weeks

Procedure

Supine/Lithotomy position

A catheter/needle is inserted transvaginally with ultrasound guiding

it (teaching)

Sample of chorionic “placental” tissue is removed

Risks

questions)

○

○

10% of women experience bleeding

7% fetal loss rate due to bleeding or infection

Nursing Actions

Review procedure with mother & fam

Instruct breathing exercises

Assist into position

Label specimens

Auscultate FHR after procedure twice in 30 min

Assess mother’s well being

Instruct mother to notify HCP if there is any abd cramping, fever,

chills, bleeding

Adm RhoGam to RH-negative women post procedure as indicated

Amniocentesis: a diagnostic procedure in which a needle is inserted

through the maternal abdomen wall into the uterine cavity to obtain

amniotic fluid Not part of a normal prenatal visit

Genetic testing (mother older than 35)

Hemolytic disease

Fetal lung maturity testing:

Lecithin/sphingomyelin (L/S) ratio

L:S ratio >2:1 indicates fetal lung maturity

L:S ratio <2:1 indicates fetal lung immaturity in increased risk of

respiratory distress syndrome.

Phosphatidyl glycerol (PG)

+ PG indicates fetal lung maturity.

• PG indicates immature fetal lungs.

Lamellar body count (LBC)

LBC of ≥50,000/μL is highly indicative of fetal lung maturity.

LBC of ≤15,000/μL highly indicative of fetal lung immaturity.

LBC results can be hindered by the presence of meconium, vaginal

bleeding, vaginal mucous, or hydramnios.

Hemolytic disease in the fetus

Intrauterine infection

Performed at 14-20 weeks (Hartman said 16-20wks)

Results are in 2 weeks

Risks

Trauma to the fetus/placenta

RH sensitization from fetal blood in mother’s circulation

Bleeding

Preterm labor

Infection

Nursing Actions

Review the procedure with the mother

If < 20 wks, a full bladder may be required for full

visualization Breathing & Relaxation techniques

Explain a local anaesthetic will be used

Prep abd with antiseptic (Betadine)

Label specimens

Instruct woman not to lift anything heavy for 2

days Auscultate FHR after procedure twice in 30

min Assess mother’s well being

Instruct mother to notify HCP if there is any abd cramping, fever,

chills, bleeding

Adm RhoGam to RH-negative women post procedure as

indicated Ultrasonography to guide placement

LESS THAN 1%FETAL LOSS RATE AFTER 15 WEEKS GESTATION!

● ○ ○ ○ ○ ○ ○ ○ ○ ● ● ● ○ ■ ■ ○ ■ ■ ○ ■ ■ ■ ● ● ● ● ● ○ ○ ○ ○ ○ ● ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Q: on why amniocentesis is done:

Genetics testing and fetal lung

maturity testing

One of the two (its both so idk which

one is the right

N306 Final Exam Test 1 Study Guide latest update(40

N306 Final Exam Test 1 Study Guide latest update(40

questions)

●

N306 Final Exam Test 1 Study Guide latest update(40

answer) depending on how far along she is

24. Maternal Assays (AFP, multiple marker screen) pg. 123

trisomies - genetic disorder - 3 copies instead 2 of a chromosome

●

Neural tube defects are birth defects of the brain, spine, or spinal● cord.

● ○ ○ ○ ● ● ○ ○ ○ ● ○ ● ○ ○ ■

Alpha-fetoprotein (AFP): a glycoprotein produced in the fetal liver, gastrointestinal tract, and yolk sac in early gestation. Used to screen for NTD (spinal defects) & Ventral Abd Wall defects 95% of NTD are occur in the absence of risk factors, it is done routinely Procedure: blood sample is taken and sent to the lab < Levels may be Chromosome 21 defect (Trisomy 21/ Down Syndrome) (follow up with amniocentesis then administer RhoGAM if indicated by physician

Levels may be NTD, anencephaly, omphalocele, and gastroschisis (follow up with ultrasound) Further tests are done Risks for high false-positives & negatives may also occur causing stress to the mother & family Nursing Actions Educate mother about the screening Support mother & assist in scheduling Provide support group information Multiple Marker Screen Triple Marker Screening: combines all three chemical markers

AFP

Human chorionic gonadotropin (hCG ) Estriol levels —With maternal age to detect some trisomies and NTDs. Used as an alternative to amniocentesis Quad screen: adds inhibin-A to the triple marker screen to increase detection of trisomy 21 to 80% Done at 15-16 weeks Maternal blood is drawn & sent to lab Low levels of maternal serum alpha-fetoprotein (MSAFP) and

questions)

■

unconjugated estriol levels suggest an abnormality.

hCG and inhibin-A levels are twice as high in pregnancies with

■ trisomy 21.

○ Decreased estriol levels are an indicator of NTDs.

○

No risks

Nursing Actions “ ”

25. Tests of Fetal Status & Well-Being- FKC pg. 124 Daily fetal movement count (kick counts) :

Surveillance after 28 wks (may feel them at 16-20

wks) Palpate abd & track fetal movements daily for 1–

2 hours 10 kicks in 2 hrs = normal

4 kicks in 1 hr = normal

< 4 kicks in 2 hrs should be reported

Teach mom to drink juice or eat something if baby is not moving,

they may be asleep

Non-stress test (NST) : screening tool that uses electronic fetal

monitoring (EFM) to assess fetal condition or well- being

Know how the procedure is done

Healthy baby’s FHR accelerates with movement

FHR monitored with the external FHR transducer until reactive (up

to 40 minutes), while running a FHR contraction strip for

interpretation. Monitor FHR and fetal activity for 20–30 minutes

! The NST is considered reactive when the FHR

increases 15 beats above baseline for 15 seconds twice or

more in 20 minutes.

How many seconds between

contractions? Answers: 30, 45 , 60 ,

! In fetuses less than 32 weeks’ gestation two

accelerations peaking at least 10 bpm above baseline and

lasting 10 seconds in a 20-minute period is reactive

! Nonreactive NST is one without sufficient FHR accelerations

in 40 minutes and should be followed up with further testing

such as BPP

Vibroacoustic stimulation (VAS): uses auditory stimulation

(using an artificial larynx) to assess fetal well-being with EFM when

NST is nonreactive.

VAS is only used when the baseline rate is determined to be

within normal limits.

When deceleration or bradycardia is present, VAS is not

an appropriate intervention

Procedure

Activating an artificial larynx on the maternal abdomen near the fetal

head for 1 second in conjunction with the NST

Reactive when the FHR increases 15 beats above baseline for

15 seconds twice in 20 minutes.

Contraction stress test (CST): assess fetal well-being and

uteroplacental function with EFM in women with nonreactive NST at

term gestation.

Identifies a fetus that is at risk for compromise through observation of

the fetal response to intermittent reduction in uteroplacental blood

flow with stimulated uterine contractions

Monitor FHR and fetal activity for 20 minutes.

If no spontaneous UCs, contractions can be initiated in some women

by having them brush the nipples for 10 minutes.

If nipple stimulation is unsuccessful, UCs can be stimulated with

N306 Final Exam Test 1 Study Guide latest update(40

questions)

oxytocin via IV until 3 UCs in 10–20 minutes lasting 40 seconds occur

• or normal = no significant variable decelerations or no

late decelerations in a 10-minute strip with 3 UCs > 40

seconds assessed with moderate variability.

• = late decelerations of FHR with 50% of UCs usually assessed

with minimal or absent variability.

• result has been associated with an increased rate of fetal death,

fetal growth restriction, lower 5-minute Apgar scores, cesarean

section, and the need for neonatal resuscitation due to neonatal

depression. > requires further testing such as BPP.

CST is equivocal or suspicious when there are intermittent late or

variable decelerations, and further testing may be done or the

test repeated in 24 hours.

Nursing Actions

Explain the procedure to the woman and her family. The CST

stimulates contractions to evaluate fetal reaction to the stress of

contractions Have patient void before testing.

Position patient in a semi-Fowler’s position

Monitor vitals before and every 15 minutes during the test. I Provide comfort

measures.

Provide emotional support.

Correctly interpret FHR and contractions.

Safely administer oxytocin

avoid uterine tachysystole: more than five uterine contractions in 10

minutes, fewer than 60 seconds between contractions, or a contraction

greater than 90 seconds with a late deceleration occurring

Recognize adverse effects of

oxytocin. Schedule appropriate

follow-up.

Risks are false positive with no needed interventions

●

●

●

○

A woman at 40 weeks’ gestation has a diagnosis of oligohydramnios.

○ Which of the following statements related to oligohydramnios

is correct? It indicates that there is a 50% reduction of

amniotic fluid.

●

Amniotic fluid index (AFI): measures the volume of amniotic fluid

with ultrasound to assess fetal well-being and placental function.

Ultrasound measurement of pockets of amniotic fluid in

four quadrants of the uterine cavity via ultrasound

Amniotic fluid level is based on fetal urine production, which is

the predominate source of amniotic fluid and is directly

dependent on renal perfusion

Average is 8-24 cm

AFI ≤ 5 cm is indicative of oligohydramnios. Oligohydramnios

is associated with increased prenatal mortality and a need for

close maternal and fetal monitoring.

An AFI above 24 cm is polyhydramnios, which may indicate

fetal malformation such as NTDs, obstruction of fetal

gastrointestinal tract, or fetal hydrops.

<uteroplacental perfusion→< fetal renal blood flow

→<urine production → oligohydramnios

Nursing Actions:

Explain the procedure to the woman and her family. This test measures the

amount of amniotic fluid with ultrasound to assess fetal well-being and how

well the placenta is working.

Provide comfort measures.

Provide emotional support.

Schedule appropriate follow-up.

Special training in obstetric ultrasound is required for evaluation of amniotic

fluid volume

Biophysical profile (BPP): ultrasound assessment of fetal status

along with an NST.

N306 Final Exam Test 1 Study Guide latest update(40