1.

Cord prolapse: Management: With fetal bradycardia, do digital examination of the vagina to assess for umbilical cord; proceed to immediate C/S. Improve maternal oxygenation: Patient should enter Trendelenburg position and physician keeps hand in the vagina to elevate the presenting part to keep pressure off the cord. Move uterus off of the great vessels (place pt on her side), IV fluid bolus, 100% O2 by face mask, stopping oxytocin if it is given. 2.Cord prolapse: Presentation: During labor, fetal bradycardia, artificial rupture of membranes, fetal head is unengaged (prolapse more likely). Fetal bradycardia associated with misoprostol (more so than other prostaglandin agents) cervical ripening is typically associated w/ uterine hyperstimulation (>5 ctx's in a 10 min window). 3.Ectopic pregnancy: Diagnosis: hCG level (if >1500 mIU/mL, pregnancy should be present), transvaginal U/S (assess presence of IUP). Presence of free fluid in the peritoneal cavity or a complex adnexal mass would make extrauterine pregnancy more likely. Progesterone level >25 ng/mL almost always correlates with normal IUP. 4.Ectopic pregnancy: Presentation: [Triad] Amenorrhea, vaginal spotting, abdominal pain. PE may be normal. Majority occur (97%) in the fallopian tube. 2% of pregnancies are extrauterine. If ectopic ruptures, pain becomes acutely worse, may lead to syncope, shoulder pain (blood irritating the diaphragm). Hypotension, tachycardia. Uterus may be normal or enlarged. Chance of coexisting intrauterine/extra pregnancies are low (1 in 10,000). 5.Ectopic pregnancy: Risk factors: Salpingitis Tubal adhesive disease Infertility Progesterone-secreting IUD Tubal surgery

Prior ectopic pregnancy Ovulation induction Congenital abnormalities of the tube 6.Ectopic pregnancy: Treatment: Salpingectomy: For gestations too large, when rupture has occurred, or future fertility not wanted. Methotrexate: If ectopic is <4 cm in diameter. 7.HSV complications: Neonatal infection (encephalitis, CNS compromise, eyes, skin). Most exposure occurs through contact in the genital tract 8.HSV DDx: Chancroid (H ducreyi): painful genital lesions, bartholin glands may enlarge into painless abcesses. Syphilis (1st stage): Small, round, painless chancre in the area of the body exposed to the spirochete. 9.HSV in labor: Sx: Vesicles (cervix, vagina, vulva), tingling itching burning (esp in perineal region). 10.HSV treatment: Acyclovir (or valacyclovir, famciclovir), C/S. If no signs or sx of infection in genital tract, can opt for vaginal delivery. 11.Placenta Abruption: Complications: Coagulopathy (can cause fetal demise) is secondary to hypofibrinogenemia, and clinically evident bleeding is usually not encountered unless the fibrinogen level is below 100 to 150 mg/dL 12.Placenta Abruption: Diagnosis: Clinical picture (see ddx, also preterm labor, stillbirth, and/or fetal heart rate abnormalities); U/S is not helpful (freshly developed blood clot behind the placenta has the same sonographic texture as the placenta itself). Also look at serial hemoglobin levels, follow the fundal height and assessment of the fetal heart rate pattern.

13.Placenta Abruption: Risk factors: HTN, cocaine abuse, short umbilical cord, trauma, uteroplacental insufficiency, submucous leiomyomata, sudden uterine decompression (hydramnios), cigarette smoking, PPROM 14.Placenta accreta: Definition: Placenta is very adherent to the uterus. Histology shows defect of the decidua basalis layer. No cleavage plane is found on attempt to manually remove. Antepartum bleeding may occur. 15.Placenta Accreta: Risk factors: Previous uterine incisions (disturbed endometrium layer). Low-lying placentation or placenta previa, prior C/S or uterine curretage or prior myomectomy. Fetal down syndrome. 16.Placenta Accreta: Treatment: Tx with hysterectomy (attempt to remove placenta may lead to hemorrhage). If childbearing is still strongly desired, may consider methotrexate (risk coagulopathy, infection). 17.Placenta Increta: Definition: Placenta penetrates into the myometrium 18.Placenta percreta: Definition: Placenta penetrates entirely through the myometrium to the serosa, often invades the bladder. 19.Placenta Previa: DDx: Placenta abruption: (premature separation of the placenta) usually is associated with painful uterine contractions or excess uterine tone 20.Placenta Previa: Definition: Placenta overlying the internal os of the cervix Low-lying placenta: The edge of the placenta is within 2 to 3 cm of the internal cervical os (low lying or marginal usually resolve if found mid second trimester). Vasa previa: Umbilical cord vessels that insert into the membranes with the vessels overlying the internal cervical os, thus being vulnerable to fetal exsanguination upon rupture of membranes.

21.Placenta Previa: Diagnosis: Ultrasound examination is performed before a vaginal examination because vaginal manipulation (even a speculum examination) may induce bleeding. 22.Placenta Previa: Presentation: Painless bleeding (esp postcoital), usually after midsecond trimester. 23.Placenta Previa: Risk factors: Grand multiparity, prior C/S, prior uterine curettage, previous placenta previa, multiple gestation.

24.Placenta Previa: Treatment: Expectant management, delivery by C/S. 25.Preeclampsia: Complications: Placenta abruption, eclampsia (w/ possible intracerebral hemorrhage), coagulopathies, renal failure, hepatic subcapsular hematoma, hepatic rupture, uteroplacental insufficiency 26.Preeclampsia: Definition/presentation: HTN (>140/90, two elevated BPs measured 6 hrs apart) with proteinuria (>300 mg over 24 hr) at gestational age >20 wks, caused by vasospasm. Nondependent edema is usually present (hand and face) Severe: BP >160/110, 24 hr urine >5g protein (or +3 or +4 dipstick). Maternal end organs are threatened, may have vision changes (scotoma), RUQ pain, headache, SOB (pulmonary edema). Must deliver Superimposed: Development of preeclampsia in a patient with CHTN. 27.Preeclampsia: Risk Factors: Nulliparity, chronic HTN (prior to 20 wks or persists 12 weeks postpartum), extremes of age, AA race, personal or family hx, chronic renal disease, antiphospholipid syndrome, diabetes, multifetal gestation. 28.Preeclampsia: Systemic: See chart

29.Preeclampsia: Treatment: Delivery (when term, or immediate if severe), magnesium sulfate (anticonsulant, renally excreted, SE pulonary edema and hyporeflexia). Follow up in 1 to 2 weeks to check BP, proteinuria. 30.Preterm Labor: Definition: Single exam of 2 cm dilation and 80% effacement in a nulliparous woman. Cervical change in the midst of regular uterine contractions occuring between 20 to 37 weeks. Prior to exam, swab posterior vaginal fornix for fetal fibronectin (ffn) which if + may indicate risk for preterm birth. If negative, strongly asociated with no delivery within 1 week.

32.Preterm Labor: Treatment: Tocolysis (CI is intra-amniotic infx or severe preeclampsia, placental abruption), IM antenatal steroids (if <34 weeks), IV abx to reduce risk of GBS sepsis in neonate. Tocolytics (delay delivery for preterm labor) See chart for drugs. 33.Preterm Labor: Work up: Hx to assess for risk factors, speculum exam to assess for ruptured membranes, serial digital cervical exams, CBC, urine drug screen, U/A, gono (strongest assoc to preterm labor), vaginal culture GBS, U/S (fetal weight and presentation). 34.Pulmonary Embolus: Diagnosis: Spiral CT or MRA. Presumptive dx based on clinical presentation, hypoxemia, clear CXR. May need to look at protein S and C, antithrombin III, FVLeiden mutation, hyperhomocysteinemia, antiphospholipid syndrome. Also see chart.

Transvaginal U/S showing shortened cervix, low uterine segment changes inc risk 31.Preterm labor: Risk factors: PPROM Multiple gestations Previous preterm labor or birth Hydramnios Uterine anomaly Hx of cervical cone biopsy Cocaine abuse AA race Abdominal trauma Pyelonephritis Abdominal surgery in pregnancy 35.Pulmonary Embolus: Presentation: Severe dyspnea (MC), pleuritic chest pain, tachycardia and tachypnea, hypoxia. No cough or fever. Pregnancy predisposes due to hypercoagulable state and venous obstruction (mechanical effect of the uterus on the vena cava). 36.Pulmonary Embolus: Treatment: IV anticoag for 5 to 7 days. Then maintain aPTT at 1.5 to 2.5 times control for at least 3 months. After, heparin for prophylaxis. Early ambulation after delivery. 37.Sheehan syndrome: DDx: Asherman syndrome: Intrauterine adhesions caused by uterine curettage which damages the decidua basalis layer, rendering the endometrium unresponsive (amenorrhea). Need to determine whether the anterior pituitary is functioning and whether the uterus is responsive to hormonal therapy. Definitive dx is with hysterosalpingogram. MCC of amenorrhea during reproductive years: Pregnancy PCOS: Chronic anovulation, hyperandrogenism, small ovarian cysts on U/S, unopposed estrogen and estrogen excess. Inc endometrial hyperplasia and risk for cancer.

38.Sheehan Syndrome: Definition: Anterior pituitary hemorrhagic necrosis caused by hypertrophy of the prolactin-secreting cells in conjunction with a hypotensive episode, usually in the setting of postpartum hemorrhage. The bleeding induces pressure necrosis. Leads to amenorrhea. Postpartum hemorrhage: Bleeding >500 ml for vaginal, >1000 ml for C/S. 39.Sheehan syndrome: Diagnostic: For pituitary function: No lactation after delivery, low thyroid hormone levels, FSH, LH, cortisol levels. Also see chart. 40.Shoulder dystocia: Presentation: External rotation of fetal head is difficult, fetal head retracted back towards mother's introitus (turtle sign). May lead to Erb's palsy (brachial plexus injury) 41.Shoulder dystocia: Risk factors: Multiparous, obesity, GDM, post-term (macrosomnia inc risk). Prolonged 2nd stage is a nonspecific indicator.

44.Spontaneous abortion: Presentation: Intense cramping, some bleeding. Sx resolve with passage of tissue through vagina, closed cervical os. Confirm with quantitative HCG, should decrease. 45.Spontaneous abortions: DDx: Molar pregnancy: Trophoblastic tissue w/o fetus. Vaginal spotting, absence of fetal heart tones, size greater than dates, markedly elevated HCG levels, snowstorm ultrasound. Tx w/ D&C Incompetent cervix: Painless dilation. Tx w/ cervical cerclage (surgical ligature). 46.Threatened abortion: HCG: Will have a logarithmic increase during early pregnancy. If level is between 1500 to 2000, fetus can be seen on vaginal ultrasound. HCG should rise by at least 66% over 48 hours. 47.Threatened abortion: Presentation: Vaginal spotting, abdominal pain (consider ectopic pregnancy). Hypotensive and tachycardic suggests ruptured ectopic. 48.Threatened abortion: Treatment: For asymptomatic, small (<3.5 cm) ectopic use IM methotrexate.

42.Shoulder dystocia: Treatment: McRoberts: The maternal thighs are sharply flexed against the maternal abdomen to straighten the sacrum relative to the lumbar spine and rotate the symphysis pubis anteriorly toward the maternal head. Suprapubic Pressure: push on the suprapubic region in a downward or lateral direction in an effort to push the fetal shoulder into an oblique plane and from behind the symphysis pubis. Wood's corkscrew (progressively rotating the posterior shoulder in 180 in a corkscrew fashion), Delivery of the posterior arm

Nonviable IUP: D&C or vaginal misoprostol. 49.Threatened abortoin: Diagnosis: HCG level is above U/S threshold and there is no sonographic evidence of IUP, then risk of ectopic is high (85%).

Spontaneous abortion vs ectopic pregnancy: Uterine curettage will show histologic confirmation of chorionic villi (miscarriage) or no villi (ectopic) Pregnancy Induced Hypertension

Zavanelli maneuver (cephalic replacement with immediate cesarean section) Study online at quizlet.com/_e8l87 **Do not apply fundal pressure! (risk of fetal injury) 1.Are diuretics used for women with pre-eclampsia?: Yes 43.Spontaneous abortion: Classifications: See chart

2.How would you palpate the uterus to see if the eclamptic woman was having contractions?: Place the hand flat on the abdomen over the fundus with the fingers apart and press lightly 3.If pre-eclampsia is mild will the woman be hospitalized?: No, just rest at home 4.In eclamptic client what ominous sign almost always proceeds a seizure?: Severe epigastric pain 5.Multi or prima gravida clients are most likely to get PIH?: Primagravida 6.Name 5 thigns included in seizure precautions?: Suction machine in room, 02 in room, padded railes up x4, must stay on unit, ambulation with supervision only, no more than 1 pillow 7.Name the three symptoms of PIH?: Hypertension, weight gain; edema, proteinuria 8.Pre-eclampsia makes the neuromuscular system more or less irritable?: More

16.What type of diet is indicated for a woman with pre-eclampsia?: Increased protein, normal salt intake; typically, no restriction 17.What type of precautions will be in effect for a woman with severe preeclampsia?: Seizure precautions 18.What vision problem do women with pre-eclampsia have?: Blurred vision 19.When a woman is hospitalized for severe pre-eclampsia the nurse should test the: #1 is reflexes, then the urine for protein 20.When does pre-eclampsia usually begin in pregnancy?: After 20 weeks 21.When is pre-eclampsia called eclampsia?: Once convulsions have occurred 22.When pre-eclampsia gets worse the deep tendon reflexes will be hypo or hyper reflexive?: Hyper-reflexia Gestational DM

9.The urine output of the eclamptic will decrease or increase?: Decrease 10.What age groups are most likely to experience PIH?: Patients under 18 or over 35 11.What are the three major treatment objectives in eclampsia?: Decrease blood pressure, control convulsions, diuresis 12.What is the activity order for a woman with severe pre-eclampsia: Bed rest 13.What is the best position for the client with severe pre-eclampsia?: Left side lying 14.What is the dietary order for the woman with severe pre-eclampsia?: Low salt, high protein 15.What measurement must the woman pre-eclampsia make every day?: She must weigh herself .4 cardinal signs of diabetes mellitus: -polyuria- when water is not reabsorbed by the renal tubules because of the osmotic activity of glucose. -polydipsia- dehydration from polyuria =polyphagia- caused by tissue loss and a state of starvation from the inability of the cells to use blood glucose. -weight loss-use of fat and muscle tissue for energy. 2.ABO INCOMPATIBILITY: o Commonly affects type A or B fetus of O mom o Maternal serum antibodies present in serum o Hemolysis of fetal RBC's

 No antepartal treatment required Assess newborn for hyperbilirubinemia- 24 hrs O babies never affected because of moms type, because they have no antigenic sites on the RBCs 3.Abruptio Placentae: -the premature separation of a normally implanted placenta from the uterine wall. - sudden onset of pain with darker blood, hard board abdomen, increase in size of abdomen, uterine quivering, might not have bleeding -cause unknown, but more frequent in pregnancies complicated by smoking, premature ROM, multiple gestation,\ advanced maternal age, cocaine use, chrioamnionits and HTN. 4.Abruptio Placentae-Fetal/Neonatal Risks: the worse the separation the higher the rate of mortality, fetal outcome depends on maturity,PTL, anemia, hypoxia-> brain damage or fetal demise. 5.Abruptio Placentae-Maternal Risks: hemorrhage, hemorrhagic shock, renal failure. 6.Abruptio Placentae-Nursing: coagulation tests of platelets and fibrinogen (for DIC these are usually decreased), PT and PTT are normal or prolonged , maintain cardiovascular status of mom and baby, IV 16-18 g LR, EFM, C-section usually safest option, type and crossmathch blood for transfusions (at least 3 units). 7.Abruptio Placentae-Types: -marginal: part of the placenta becomes dislodged. -central: detatches in the middle, destructs uterine muscle, frequently necessitates hysterectomy due to hemorrhage, OB EMERGENCY

-Complete: total separation, massive vaginal bleeding. Triggers development of DIC. 8.Alcohol: crosses the placenta, excreted in breastmilk and may inhibit letdown reflex, no intake is safe. -Maternal effects: withdrawl seizures (12-48 hrs after cessation), malnutrition (folic acid & thiamine deficiency), bone marrow suppression, increased incidence of infection, liver disease. -Fetal effects: birth defects can occur in the first 3-8 wks of development. withdrawl syndrome, and fetal alcohol syndrome (physical & mental abnormalities). -Nursing considerations: social service consult, seizure precautions, IV fluid therapy for hydration, prepare for an addicted newborn. 9.Amniocentesis: A procedure used for genetic diagnosis. A sterile needle (under ultrasound guidance) is inserted into the uterine cavity through the maternal abdomen so a small amount of amniotic fluid can be removed, and genetic testing is performed. 10.Amniocentesis -Procedure: woman should be placed in a left lateral tilt position by placing a wedge under her right hip to prevent hypotension during the procedure. The abdomen is scanned by ultrasound to locate the placenta, the fetus, and an adequate pocket of fluid. The needle insertion site is of the utmost importance because the fetus, placenta, umbilical cord, bladder, and uterine arteries must all be avoided. The importance of locating the placental cannot be stressed enough, especially in cases of Rh isoimmunization, in which trauma to the placenta increases fetal-maternal transfusion and worsens the isoimmunization. *Rh-negative women are given Rh immune globulin after amniocentesis. Provided that they are not already sensitized. 11.Amniocentesis-risks/SE: minor complications are infrequent and may include transient vaginal spotting, cramping, or amniotic fluid leakage in 1% to 2% of cases performed.

12.ANTEPARTAL CLINICAL THERAPY- Mild preeclampsia: Home care- BP < equal to 150/100, proteinuria < 1 g?24hrs or 3+ dipstick, platelet count greater than 120,000, and normal fetal growth, must be able to recognize s/s of worsening preeclampsia, must accurately count fetal movements, and know when to call Dr.. she's not restricted to bed rest, but encouraged to rest frequently especially in L lateral position. Monitor her own BP, weight, and urine protein daily. Weight gain of 3lbs in 24 hrs or 4 lbs in a 3 day period are causes of concern. NST daily to biweekly. Hospital care- on bed rest, in L lateral position. Na intake <6g/day. Fetal well being by: NST, fetal kick count, ultrasound, biophysical profile, amniocentesis, Doppler... Mom wellbeing: BP 4xdaily, daily weight gain, daily urine dipstick, periodic assessment of Labs

IV Fluids & electrolytes- goal is to achieve a balance between correcting hypovolemia and preventing circulatory overload. May be started to KVO in case drug therapy needed. Anticonvulsants-Mg SO Corticosteroids- betamethasone or dexamethasone to promote fetal lung maturation. Antihypertensives- major indication is prevention of stroke, given for 160/110 or >. Ideal diastolic btwn 90-100. Labetolol (avoided in women wasthma or CHF) and hydralazine, oral nifedipine IV acts fast and fewer s/e, sodium nitroprusside for acute emergency. 15.Assessment tip for substance abuse and therapy: -screen all pregnant pts -if suspected, start with less threatening direct questions, then build up to most threatning drugs. -the more nonjudgemental and matter-of-fact the nurse is, the more likely the pt will answer honestly. -cold turkey is not adviseable -urine screen done regularly -screening strategies should include maternal informed consent. follow up!! 16.Battery During Pregnancy: o Results in psychologic distress, loss of pregnancy, preterm labor, LBW infant, maternal/fetal injury/ fetal death o Indications- chronic psychosomatic symptoms, nonspecific/ vague complaints, assess old scars, bruises, dec ey contact, silence when partner is in room, and hx of nervousness, insomnia, drug overdose, or alcohol problems. o Complications- poor maternal weight gain, infection, anemia, and 2nd and 3rd trimester bleeding.

13.ANTEPARTAL CLINICAL THERAPY-Eclampsia: Signs & symptoms- scotomata (dark spots or flashing lights), blurred vision, epigastric pain, vomiting, persistent headache, neurogenic hyperactivity, pulmonary edema and cyanosis DURING SEIZURE- assess time of onset, progress of seizure, body involvement, duration, incontinence, fetus status, and signs of placental abruption. Airway maintained, administer O2, positioned on her side, suction to keep airway clear, side rails up Management- Mg SO bolus of 6g IV over 20-30 minutes followed by 2-3g/hr IV infusion. If 2nd seizure administer 2g of Mg SO IV over 5-10 min. if convulsions continue, sodium amobarbitol IV. Antihypertensive- hydralazine hydrochloride Q15min to a max of 20mg IV bolus, then 20-80mg Q10min until 300mg. ausculate lung sounds for pulmonary edema. Furosemide (Lasix) may be given in low doses Mg SO s/e loading dose: flushing, a feeling of warmth, headache, nystagmus, nausea, dry mouth, and dizziness. Fetal s/e: hypotonia, lethargy for 1-2 days, hypoglycemia, and hypokalemia. 14.ANTEPARTAL CLINICAL THERAPY-Severe preeclampsia: NPO because she can aspirate her food, there is a genetic link. Bed rest, diet ( high protein, moderate Na),

o Woman who are battered may experience more sex abuse and inc risk for STD. o Treatment goals Identify a problem and help mom come up w a safety plan Increase decision making abilities to dec the potential for further abuse Provide safe environment 17.Biophysical profile: (3rd trimester) -Includes the assessment of 5 fetal biophysical variables: FHR acceleration Fetal breathing Fetal movements Fetal tone Amniotic fluid volume -FHR acceleration is assessed with the NST. The other variables are assessed by ultrasound scanning. 18.Bleeding During Pregnancy: o Major causes of bleeding o First and second trimesters Abortion- pregnancy termination prior to 20wks gestation, natural/ induced, medical/surgical interruption. spontaneous abortion - miscarriage

Ectopic pregnancy Gestational trophoblastic disease o Third trimester Placenta previa- type and hold for blood, fluids, NPO anticipate for C section, ultrasound, and nonreassuring FHR Abruptio placentae- painful, hard abdomen, may/may not have bleeding, immediate onset of fetal distress, tender, darker

19.Bleeding During Pregnancy: Nursing: o Regardless of cause of bleeding (such as sex, exercise as a result of trauma to the highly vascular cervix, cervical/vaginal lesions, implantation of the pregnancy, or impending miscarriage). o NO VAGINAL EXAMS o Monitor signs of shock & vital signs- pallor, clammy skin, perspiration, dyspnea, or restlessness o Administer oxygen if needed o Count & weigh pads o Save tissue/clots expelled o If beyond 12 weeks, assess FHTs w doppler o Initiate IVF o Prepare supplies for exam: speculum o Type & cross match if significant bleeding

o Assess coping mechanisms, support systems & family's response. Most important prepare mom for fetal loss 20.BPP: indications & uses: -BPP helps to identify the compromised fetus and confirm the healthy fetus. -Indications for the BPP include those situations in which the NST and CST would be done. -Most useful in the evaluation of women who experience decreased fetal movement (nonreactive NST) and in the management of IUGR, preterm labor, gestational diabetes, postterm pregnancies, and PROM. 21.Cardiac Disease and Pregnancy: -The higher the class, the more the risk of complications. -As pregnancy progresses it is important to minimize workload and promote tissue profussion. -spontaenous natura labor with adequate pain relief in recomended for patients in class 1 & 2. Class 3 & 4 may need to be hospitalized before the onset of labor for cardiovasculat stabilization. Vaginal birth with low dose regional epidural with the use of forceps or vacuum if necessary to limit maternal pushing. 22.Cardiac Disease and Pregnancy- Nursing: -Monitor vital signs (danger signs: HR >100, RR > 24 indicate cardiac decompensation, especially if accompanied with dyspnea and rales. Auscultate lungs, Maintain semi-Fowler's position with lateral tilt or side-lying with head/shoulders elevated (place women left side, oxygen, fluid bolus)Apply oxygen & medications as indicated, Keep patient/family informed of labor progress Continuous EFM,Push with open glottis, Major concern is physical adaptation to increased cardiac output & blood volume, Monitor vital signs & signs of cardiac decompensation, Monitor for signs of postpartum complications, Maintain position, Administer stool softeners,Promote attachment, Breastfeeding unless contraindicated by medication therapy, Contraceptive counseling.

23.Cardiac Disease and Pregnancy-Assess...: stress of pregnancy on functional capacity of heart, Identify infection, anemia, anxiety, lack of support systems, and household/career demands, Frequent visits,Recognize potential complications. 24.Cardiac Disease and Pregnancy-Patient teaching:: Diet: high iron, protein and essential nutrients, but low sodium. Activity & rest: resistrict activity to preserve cardiac function, sleep 8-10 hrs and rest periods throughout the day. During first half of pregnancy woman is seen biweekly, then weekly in the second half. Visits are most important during 28-30 wks as blood volume peaks. -Recognize and reduce amount of physical exertion & fatigue 25.Cervical Insufficency-Contributory factors: -congenital: may be found in women exposed to DES (diethystilbesterol) or with a bicornuate uterus. -aquired: related to inflammation, infection, subclinical uterine activity,cervical trauma, cone biopsy, late Second trimester elective abortions, or increased volume (twins). -environmental (hormonal): relaxin may be an endocrine cause of C.I. 26.Cervical Insufficency-Nursing: -transvaginal US between 16-24wks "funneling" suggests effacement. -warning signs of impending birth: lower back pain, pelvic pressure, changes in vaginal discharge. 27.Cervical Insufficency-Risk factors: multiple gestations, repetitive 2nd trimester losses, previous premature babies, progressively earlier births with each subsequent pregnancy, short labors, previous elective abortions or cervical manipulation, DES exposure, or other uterine anomaly. 28.Cervical Insufficency-Treatment: -medical: bed rest, frequent ultrasounds, antibiotics, progesterone supplement, anti-inflammatory drugs

-surgical: cerclage- a surgical procedure in which a stitch is placed in the cervix to prevent a spontaneous abortion or premature birth. Tocolytics, broad spectrum abx, anti-inflammatories. Cerclage must be cut before birth is permitted. 29.Cervical Insufficiency: -painless dilation of cervix without uterine contractions due to structural or functional defect of cervix. -whitish discharge, most common in 2nd trimester. -advanced effacement and dilation, bulging membranes.

o Edema (often)- sudden onset of severe edema 31.Chronic HTN: o BP 140/90 before 20 weeks or persists 42 days postpartum o Nutrition- low Na, o Bed rest o Medication- antiHTN= mathyldope/ aldamet, o Prenatal visits- q 2 wks, then q. wk o BP monitoring o Fetal surveillance- NST= nonreactive, then contraction stress test

30.CHARACTERISTICS OF PREECLAMPSIA: o Maternal vasospasm- narrowing of the vasculature o Can occur postpartum o Decreased perfusion to all organs- including placenta o Decreased plasma volume o Increased viscosity of blood o Activation of coagulation cascade o Dec renal perfusion- dec in GFR, serum levels of creatinine, BUN and uric acid begin to rise from normal preg levels, dec urine output o Decreased GFR o Hyperreflexia o Headache

meds= Methyldopa and Labetolol 1st choice. Ace-inhibitors contraindicated in 2nd and 3rd tri. due to fetal risk and renal failure. with superimposed preeclampsia- onset of proteinuria after 20wks gestation and worsening HTN, rise in serum uric acid in 2nd trimester 32.Cocaine/Crack: - crosses placenta and into breastmilk. onset occurs rapidly, euphoria lasts for 30min. Irritability, depression, pessimism, fatigue, and desire for more follow the euphoria. -Maternal effects:causes vasoconstriction, tachycardia, and HTN. Metabolitesmay be present in urine 4-7 days following use. seizures, hallucinations, pulmonary edema, resp. failure, cardiac problems. spontaneous first timester abortion, abruptio placentae, IUGR, preterm birth weight, still birth. mothers are less engaged in infant bonding. -Fetal effects: vasoconstriction decreases blood flow to the fetus, decrease birth weight and head circumference. irritability, jitteriness, tremors, high-pitched cry, excessive suck. difficult feeders. CocaineBreast fed infants: extreme irritibility, N/V/D, dilated pupils, apnea. -Nursing considerations: help mom with feeding cues, and mother-infant bonding, dont encourage breastfeeding in on cocaine.

33.commonly considered indications for amniocentesis: -Pregnant women who will be 35 or older on their due date. -Couples who already have had a child with a birth defect or have a family history of certain birth defects. -Pregnant women w/ other abnormal screening or genetic test results 34.Components of BPP: -The 2 most important components of the BPP are the NST and the amniotic fluid volume index. The NST reflects the intactness of the nervous system and the AFI reflects kidney perfusion. -Table 21-5 on page 514 Criteria for Normal and Abnormal Assessments of the BPP

37.CST Procedure: -presence of 3 uterine contractions of at least 40 seconds duration in 10 minutes. -Contractions may be induced by oxytocin (Pitocin) or nipple stimulation. -During the test the woman assumes a semi-Fowler's or side-lying position to avoid supine hypotension. -Before the test begins the nurse must record baseline measurements, including BP, fetal activity, variations of the FHR during fetal movement, and spontaneous contractions. -If late decelerations occur with all 3 contractions then the oxytocin infusion is d/c. -Woman's BP & pulse are assessed every 15 minutes and recorded on the tracing.

-Components include fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate (nonstress test), & amniotic fluid volume -Normal variables are given a score of 2 each and abnormal variables a score of 0. The highest score possible for a normal fetus is 10. 35.Contraction Stress Test: What is it, when is it done?: CST (3rd trimester) The contraction stress test is means of evaluating the respiratory function (oxygen and carbon dioxide exchange) of the placenta. It enables the healthcare team to identify the fetus at risk for intrauterine asphyxia by observing the response of the FHR to the stress of uterine contractions. 36.CST interpretation: NEGATIVE: No late or significant variable decelerations. This is a considered a reassuring sign that the fetus is receiving sufficient transfer of oxygen through the placenta. POSTIVIE: Late decelerations following 50% or more of contractions (even if the contraction frequency is fewer than 3 in 10 minutes). This is a sign of uteroplacental insufficiency and may indicate that the fetus is not receiving adequate oxygenation.

-CST is usually done NO earlier than 32 to 34 weeks' gestation and typically in preparation for induction of labor.

38.CST: Indications: -IUGR -Diabetes mellitus -Postdates (42 or more weeks gestation) -Nonreactive NST -Abnormal or suspicious biophysical profile 39.CST:Contraindications: -3rd trimester bleeding -Previous cesarean birth with classical uterine incision -Instances in which the risk of possible preterm labor outweighs the advantage of the CST include: premature rupture of the membranes, incompetent cervix, multiple gestation.

40.CVS Risks/Benefits: - Spontaneous abortion risk of 0.3% in cases -Other risks include failure to obtain tissue, rupture of membranes, leakage of amniotic fluid, vaginal spotting or bleeding, chorioamnionitis, intrauterine infection, maternal tissue contamination of the specimen, oromandibular defects, and Rh isoimmunization. Rhnegative women are given Rh immune globulin to cover the risk of immunization from the procedure. 41.CVS: Chorionic Villus Sampling: -A procedure (as invasive as the amniocentesis) that is used to detect genetic, metabolic, and DNA abnormalities. CVS involves obtaining a small sample (5 to 40 mg) of chorionic villi from the edge of the developing placenta. CVS is performed in some medical centers for first trimester diagnosis after 9 completed weeks. Villi in the chorion frondosum, present from 8 to 12 weeks gestation, are believed to reflect fetal chromosome, enzyme, and DNA content, thereby permitting earlier diagnosis than can be obtained amniocentesis. CVS cannot detect neural tube defects, however, and the MSAFP test should still be performed at 16 weeks. 42.CVS: Results and Preparation: -A normal CVS result indicating normal chromosomal configuration in the first trimester does not ensure a healthy infant. Routine prenatal care and appropriate follow-up are needed. -Before the CVS, an ultrasound is done to determine placental location, uterine position, and presence of intervening structures. 43.CYTOMEGALOVIRUS: o Most common cause of intrauterine infection!!! o Belongs to the herpes simplex virus group and causes both congenital and acquired disorders. o Found in urine, saliva, cervical mucus, semen and breast milk... passed by kissing, breastfeeding, and sex intercourse. o Virus is innocuous in adults and children, it may be fatal to the fetus.

o Diagnosis- identification of the virus in amniotic fluid by PCR or culture is the most sensitive and specific way of diagnosing congenital infection. Best documented by seroconversion. o Fetal/neonatal risks- fetus can acquire from placenta or if comes in contact, babies that are born w this you just wait and see what happens. Mental retardation, auditory deficits, intellectual disability. For fetus, infection can result in extensive intrauterine tissue damage that leads to fetal death; it can result in fetal survival but with microcephaly, hydrocephaly, cerebral palsy, or intellectual disability; or it can result in fetal survival w no damage at all. Newborn is often SGA. Principal tissues affected are blood, brain, and liver. Hemolysis leads to anemia and hyperbilirubinemia. o Treatment- NONE, or no effect w tx o CMV- don't feel well low grade fever, its most common cause of intellectual disability o Woman may have perpetual fetal loss because of CMV o Can be detected but there's no tx 44.Deep Tendon Reflex Scale: o 4+ hyperactive, very brisk, jerky, or clonic response abnormal o 3+ brisker than avg. may not be abnormal o 2+ average response o 1+ diminished response, low normal o 0 no response, abnormal 45.Doppler flow analysis: (3rd trimester) -Looks at placental functioning through the umbilical artery -Measures blood flow velocity using systolic to diastolic ratio (S/D ratio)

-The S/D ratio is considered abnormal if it is elevated above the 95th percentile for gestational age or reversed after 18 to 20 weeks of gestation. -Most commonly used when they suspect IUGR -The -2nd line measure of flow of blood through the placenta -Advances in ultrasound technology have made it possible to study NONINVASIVELY the blood flow changes that occur in maternal and fetal circulations in order to assess placental function. -An ultrasound beam, like that provided by the pocket Doppler (handheld ultrasound device) is directed at the umbilical artery. 46.Eclampsia: seizures, can lead to stroke

50.Ectopic Pregnancy- Risks Factors: tubal damage cause by PID, previous pelvic/tubal surgery, endometriosis previous ectopic pregnancy, presence of IUD, >levels of progesterone (alters motility of egg in fallopian tube), use of ovulation-inducing drugs, primary infertility, smoking, and advanced maternal age. 51.Ectopic Pregnancy-Management: Medical- methotrexate, given IM in single, two, or multiple dose. Surgical- if future childbearing is desired- laparoscopic linear salpingostomy to gently evacuate the ectopic pregnancy and preserve the tube. If future preg not an issuesalpingectomy (removal of tube). If woman in shock and unstable - abdominal incision will be made. Most potential risk during surgery is hemorrhage. 52.Ectopic Pregnancy-Nursing: assess amount and appearance of bleeding, monitor VS (BP and P for s/s of developing shock), emotional/educational needs, analgesics for pain 53.Ectopic Pregnancy-S/S: amenorrhea, breast tenderness and nausea. Adenexal tenderness. LABS= low H/H level, and inc leukocyte level. 54.Folic Acid Deficiency Anemia: -megaloblastic: larger than normal RBCs -Folate deficiency is most common cause of megaloblastic anemia, more in twin pregnancies. - folic acid is needed for DNA and RNA synthesis and cell duplication. 55.Folic Acid Deficiency Anemia-Clinical therapy: -Inadequate folic acid intake is associated with neural tube defects. usually detected in late pregnancy or during puerperium. Women with true folic acid deficency present with n/v and anorexia. hgb levels may be as low as 3-5. Prevented with a 0.4mg supplement of F.A. also needs iron supplements. 56.Folic Acid Deficiency Anemia-Nursing: teach about F.A. rich foods, best sources: leafy green veggies, O.J., citrus fruits and juices, red meats, poultry, and legumes.

47.Eclampsia Clinical Manifestations: s/s= seizure or coma, can occur 40hrs after delivery, sometimes they give them another antiseizure med= valium. If she's in labor we have to monitor cervix, if fetus starts decompensating you need to move to C-section o APRESSALINE= antihypertensive, shown to be safe for mom and baby, has been given for decades... if you drop maternal blood pressure too low to quickly= rebound HTN/ placental abruption 48.Ectopic Pregnancy: o Implantation of fertilized ovum in a site other than the endometrial lining of the uterus. o MOST COMMON LOCATION FOR IMPLANTATION IS IN THE AMPULLA OF TUBE 49.Ectopic Pregnancy- Diagnosis: LMP, pelvic exam, LABS, ultrasound, inch CG values ( 53% in 2 days), laparoscopy (for diagnosis and tx)

57.GBS Indications and Treatment: o Treatment indications Previous infant with GBS disease GBS bacteriuria during current pregnancy Positive GBS screen during current pregnancy (unless C/S before labor or ROM) Unknown GBS status Gestation less than 37 weeks ROM 18 hours or more before delivery Maternal temperature of 38.0C (100.4F) or more o Treatment- Ampicillin, penicillin g, if allergy then on clindamycin or Zosyn 58.GBS Transmisson: can occur from vertical transmission from the mother as the fetus passess through the birth canal, resulting in early onset of GBS. Horizontal transmission from colonized nursery personnel or infants will result in late onset of GBS. 59.GBS- Fetal Risk Factors: o Prematurity o Maternal intrapartum fever o Membranes ruptured for longer than 18 hours o A previously infected infant with GBS disease o GBS bacteriuria in the current pregnancy o Young maternal age o African American or Hispanic race.

o GBS- causes severe, invasive disease in affected infants. In newborns, the majority of cases occur within the first week of life and are thus designated as early-onset disease. 60.GBS-Contraindicated for prophylactic use.: o previous pregnancy with a positive GBS screening culture( unless a culture was also positive during the current pregnancy) o planned cesarean birth performed in the absence of labor or membrane rupture(regardless of maternal GBS culture status) o Negative vaginal and rectal GBS screening culture in late gestation during the current pregnancy, regardless of intrapartum risk factors.

61.GBS-Indicated for prophylactic use: o Previous infant with invasive GBS disease o GBS bacteriuria during current pregnancy o Positive GBS screening culture during current pregnancy(unless a planned cesarean birth, in the absence of labor or amniotic membrane rupture, is performed) o Unknown GBS status (culture not done, incomplete, or results unknown) and any of the following o Birth at less than 37 weeks gestation o Amniotic membrane rupture longer than or equal to 18 hrs* o Intrapartum temperature greater than or equal to 100.4F (less than or equal to 38C) 62.GBS-Maternal Risk factors: African American colonize twice as faster as Caucasian. 63.Gestational Diabetes: -definition: carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.

-Screening: all pregnant women should have their risk of diabetes assessed. women at high risk should be screened asap: prior hx of GDM, LGA infant, marked obesity, diagnosis of PCOS, glucosuria, strong family hx of T2DM -Diagnosis: HA1c greater than or equal to 6.5% would be consiered diagnostic or fasting plasma glucose greater than or equal to 126mg/dL. OGTT : Fasting 92, 1hr 180, 2hr, 153. if 1hr OGTT incicated GDM, OGTT is administered again and if 2 or more of the following are met then GDM is confirmed: fasting 95, 1hr 180, 2hr 155, 3hr 140. 64.Gestational hypertension: BP 140/90 after 20wk, NO protein in urine. Inc BP after mid pregnancy w/out proteinurea or other signs of preeclampsia. If BP returns to normal by 12wks = diagnosis. 65.GESTATIONAL TROPHOBLASTIC DISEASE (GTD): o Trophoblast is outermost layer of embryonic cells and gives rise to the chorion. o Includes: Hydatiform mole (molar pregnancy) - result in formation of placenta characterized by hydropic (fluid-filled) grapelike clusters. Two types: complete and partial. Complete- develops from an anuclear ovum that contains no maternal genetic material (an "empty egg"). No embryonic or fetal tissue or membranes are found. Partial- usually has triploid karyotype-69 chromosomes. Most often, a normal ovum w 23 chromosomes is fertilized by 2 sprem. Partial moles are recognized only after spontaneous abortion, or they go unnoticed. Identifiable fetal parts may be present Invasive mole (chorioadenoma destruens)- similar to a complete mole but involves uterine myometrium. Choriocarcinoma- invasive form of cancer from trophoblastic tissue 66.GESTATIONAL TROPHOBLASTIC DISEASE (GTD)- Follow Up: Continuing high/rising hCG suggests metastases; chemotherapy is needed

Rh immune globulin if not sensitized 67.GESTATIONAL TROPHOBLASTIC DISEASE (GTD)- Symptoms: -vaginal bleeding as early as 4th wk or as late as 2nd trimester. Anemia (cuz LOB), hydropic vesicles may be passed (if so, its diagnostic), uterine enlargement (greater than expected for gestational age, classic sign for complete moles), absence of fetal heart sounds , elevated serum hCG (cuz continuous secretion by proliferating trophoblastic tissue), very low levels of maternal serum fetoprotien, hyperemesis gravidarum (cuz of high levels of hCG), preeclampsia, hyperthyroidism (rarely) 68.GESTATIONAL TROPHOBLASTIC DISEASE (GTD)-DIAGNOSIS: ultrasound after 6 to 8 wks (when the vesicular enlargement of the villi can be identified) 69.GESTATIONAL TROPHOBLASTIC DISEASE (GTD)-Treatment: suction evacuation of the molar pregnancy and curettage of the uterus to remove all fragments of the placenta. The earlier the better. Hysterectomy if woman is older or if excess bleeding. AVOID UTERINE CONTRACTIONS, to prevent embolization of trophoblastic tissue to the lungs. Administer Rh immune globulin after evacuation of uterus 70.Group Beta streptococcus: bacterial infection found in the lower GI or urological tract. Maybe transmitted in utero or during transition. -All pregnant women screened for both vaginal and rectal GBS colonization at 35-37 weeks gestation. 71.HELLP SYNDROME: o Hemolysis- termed microangiopathic hemolytic anemia o Elevated liver enzymes o Low platelets o JUST AN FYI: RBCs are distorted during passage through small/damaged blood vessels. Vascular damage because of vasospasm and platelets aggregate at sites of damage resulting in low platelet

count. Elevated liver enzymes occur from blood flow that is obstructed because of fibrin deposits. Deposits of fibrin-like material found in the hepatic sinusoids cause obstruction and hepatocellular injury. o Signs- N/V, malaise, flulike symptoms, epigastric pain o Treatment- assess moms condition and stabilize, assess fetus using NST and biophysical profile. Mom should give birth, sometimes better to deliver premie than for baby to die in utero

75.HIV/AIDS and Pregnancy-Clinical Tx of mom: HIV screening early on. the care of women who chose to continue their pregnancy should focus on stabilizing the disease, preventing opportunistic infections and transmisson of the virus and providing psychosocial and educational support. Antiretroviral therapy should be recommended, it is best to start prophylaxis after the 1st trimester and no later then 28wks . also treat other STDs and vaccinate for flu, pneumonia, and hepatitis. routine labs: platelets, CBC & differential. Postpartal hemorrhage, infection, poor wound healing,and GU infections are increased. 76.HIV/AIDS and Pregnancy-Clinical Tx of neonate: prophylactic ART of mom, elective csection at 38wks before ROM, and avoid breastfeeding. NST is begun at 32 wks and serial ultrasounds for IUGR detection. NO INVASIVE PROCEDURES unless risk outweight benefit. all HIV exposed infants should complete 6wk regimen of oral zidovudine prophylactically. follow up with HIV tests. 77.HIV/AIDS and Pregnancy-Fetal-neonatal risks: transmission via breaskmilk may occur, but the majority of all infections occur during labor and birth. moms who have not been treated have a 25% chance to transmit to newborn. 78.HIV/AIDS and Pregnancy-Maternal risks: For women who have not yet had access to ART or who are non-comliapnt, AIDS definging symptoms that are more common in women than in men include wasting syndrome, esophageal candidiasis, and herpes simplex virus disease. 79.HTN DISORDERS OF PREGNANCY: o Preeclampsia- most common HTN disorder in pregnancy. Defined as an inc in BP after 20 wks gestation accompanied by proteinuria in a previously normotensive woman. Mild Severe o Eclampsia o Chronic hypertension

72.HELLP Syndrome: - not always elevated BP, hemolysis=destruction of RBC, H and H will dec., elevated liver (AST/ALT), low platelets..., sometimes better to deliver premie than for baby to die in utero 73.Herpes Simplex Virus: o Fetal/neonatal risks If primary outbreak in 1st trimester: spontaneous abortion If primary outbreak in 2-3 trimesters: PTL, IUGR, neonatal infection Delivery considerations- C section recommended, symptoms include fever (hypothermia), jaundice, seizures, and poor feeding. Approximately one half of infected infants develop the characteristics vesicular lesions. o Treatment- acyclovir, famciclovir, and valacyclovir- have an advantage of better absorption and a longer half-life than acyclovir. 74.HIV/AIDS and Pregnancy: -Transmission:HIV is found in blood, semen, vaginal fluid, and breast milk. -Factors leading to reduced transmission: Enhanced prenatal HIV counseling and testing, Highly active antiretroviral therapy (HAART), Increase in elective CS delivery for women with HIV RNA levels > 1000 c/mL.

o Chronic hypertension with superimposed preeclampsia o Gestational hypertension o PIH= PREGNANCY INFUSED HTN

o Perinatal mortality o At birth, may be over sedated because of meds given to mom. Also, may have hypermagnesemia. o If vasospasm and hypovolemia- Fetal hypoxia and malnutrition

80.HYPEREMESIS GRAVIDARUM: Severe N/V affecting hydration & nutritional status o If placental abruption 2ndary to HTN- fetal hypoxia or even death 81.HYPEREMESIS GRAVIDARUM- Diagnostic Criteria: hx of intractable vomiting in the 1st half of preg, dehydration, ketonuria, and a weight loss of 5% of prepregnancy weight. 82.HYPEREMESIS GRAVIDARUM-Nursing: o Control vomiting, correct dehydration, replace electrolytes, and maintain adequate nutrition. o Complementary & alternative therapies- ginger to relief N/V, acupuncture/acupressure, hypnosis o Begin slowly with food if the pt is feeling ok- frequent small meals of high carb, low-fat content o If pt hospitalized- ultrasound, IV fluids to correct dehydration, K chloride is added to infusion, replacement of thiamine (vit B1) & pyroxidine (vit B6) to prevent peripheral neuropathy. Desired urine output is minimum of 1000mL/ 24hrs. 83.HYPEREMESIS GRAVIDARUM-Treatment: antiemeitc Zofran, corticosteroids, F&E replacement. Pyridoxine (vit B6) for N/V, sometimes given w doxylamine succinate (antihistamine that improves efficacy). Promethazine (Phenergan), metoclopramide (Reglan), and odansetron (Zofran). 84.HYPERTENSIVE EFFECTS ON FETUS: o Placental infarcts o Fetal growth restriction- SGA because of IUGR o Chronic hypoxia o Prematurity 85.HYPETENSIVE DISORDERS: MATERNAL RISKS: o If severe preeclampsia is not treated, it can lead to these: Intercerebral hemorrhage= MOST COMMON CAUSE OF DEATH IN WOMEN W SEVERE PRE/ECLAMPSIA, if they survive they may suffer permanent disability. Preeclampsia affects CNS (hyperreflexia, headache, and eclamptic seizure) Retinal detachment-because of inc intraocular pressure Acute tubular necrosis- from underperfusion of the kidneys (this is associated w hypovolemia and renal vasoconstriction), Thrombocytopenia- r/t endothelial damage and activation of thrombin. The release of procoagulants, such as thromboplastin, can result in acute disseminated intravascular coagulation (DIC) Subscapular hematoma of the liver- rupture is a life-threatening event. Woman may complain of R shoulder pain or severe epigastric pain persisting for several hrs before circulatory collapse is evident. This is a surgical emergency! Pulmonary edema- due to inc capillary permeability Vaginal birth is preferable to cesarean birth in women w preelampsia or HELLP syndrome.

86.Influence of GDM of baby: Complications: in presence of maternal DKA the risk of fetal demise increases., macrosomia, Respiratory distress syndrome, hyperbilirubinemia, congential abnormalities often ivolving the heart, CNS, skeletal system. Septal defects, coarction of the aorta, and transposition of the great vessles. most common heart complications. CNS abnormalities: hydrocephalus, mengomyelocele, anacephaly. SACRAL AGENESIS appears only in infants of mothers with diabetes. 87.Influence of GDM on Mother: Complications include: hydraminos, preeclampsia/eclampsia, hyperglycemia may lead to DKA, difficult labor or dystocia, recurrent monilial vagnintits and UTIs, pregnancy worsens retinopathy. 88.Information that can be obtained by a limited ultrasound: -Determine fetal presentation before or during labor -Locate the placenta -Confirm fetal heart rate activity -Estimate amniotic fluid volume -Diagnose multiple gestation -Evaluate interval growth -Evaluate the cervic -Guide amniocentesis 89.Insulin and pregnancy: -first trimester: need decreased early -during labor: need may increase due to increased energy needs and to balance IV glucose -delivery of placenta: need decreases abruptly

90.Interpretation of NST: REACTIVE- Normal, there are 2 or more fetal heart accelerations within a 20 minute period. The FHR acceleration must be at least 15 beats per minute above the baseline and last 15 seconds from baseline to baseline. NONREACTIVE- Abnormal, lacks sufficient FHR accelerations over a 40 minute period.

-Variable decelerations may be observed in up to 50% of NST's, if non repetitive and brief (less than 30 seconds) do not indicate fetal compromise nor the need for obstetric intervention. However repetitive variable decelerations (at least 3 in 20 minutes) have been associated with an increased risk of cesarean birth. 91.Intrapartal Management of DM: -Timing of birth: most go to term, but come clinicians opt to induce labor to avoid problems related to decreased profusion to the placenta. Csection may be indicated if evidence of nonreassuring fetal status exists. Induction may be indicated when the mom has worsening hypertension, IUGR, or vascular changes.

- Lung maturity should be tested if there is evidence of macrosomia, fetal compromise, or elevated HbA1c. L/S ratio: 2-3.5

-Labor management: hourly glucose checks. druing active labor insulin may not be needed. Long-acting insulin should be reduced or stopped and regular insulin should be used too meet most or all of moms needs. 2 IV lines: 5%dextrose and NaCl (if bolus is needed for piggyback insulin) IV insulin is d/c with the completion of the 3rd stage of labor. 92.INTRAPARTUM CLINICAL THERAPY-Eclampsia: Hemodynamic monitoring- they can be vascularly dry.. if oliguria, severe cardiac disease, severe renal disease, pulmonary edema resulting in impaired maternal O2, refractory hypertension when given vasoactive drug Delivery when stable, BIRTH IS ONLY CURE!

93.INTRAPARTUM CLINICAL THERAPY-Preeclampsia: Induction of labor w IV oxytocin when there is evidence of fetal maturity and cervical readiness. Woman may receive both oxytocin and Mg SO. Epidural ONLY in absence of thrombocytopenia. Hyptotension major concern and can be avoided by careful technique and careful vol expansion. In total body fluid overload, the woman has depleted intravascular volume, making her prone to hypotension when vascular bed dilates from epidural. Cesarean delivery if severe

98.Iron Deficiency Anemia of Pregnancy-Nursing considerations: teach women to take iron supplements daily and with Vit C to increase absorption. GI upset if taken on an empty stomach. stool may turn black and formed. keep tabs out of reach of children as they are fatal. 99.Methadone: -most commly used drug in the treatment of women who are dependent on opioids -benefits: blocks withdrawl symptoms and cravings

Delivery in Sim's position, if lithotomy used wedge her w pillow, wedge w Csect as well O2 during labor -crosses the placenta and fetal exposure in utero may result in neonatal abstinence syndrome (NAS) -GOAL: help mom recover from drug abuse, and optimize the long-term health of mom and baby. 94.Iron Deficiency Anemia of Pregnancy: -Anemia is defined as hgb less than 11 g/dL in a pregnant woman. -Iron deficiency anemia is the most common medical complication of pregnancy, primarily as a consequence of expansion of plasma volume without normal expansion of maternal hemoglobin mass. 95.Iron Deficiency Anemia of Pregnancy-Clinical therapy: pregnant women need to take at least 27 mg supplement of iron daily. iron-rich diet, if anemia is diagnosed dose should increase to 60-120mg/day. with twins a larger dose is needed. 96.Iron Deficiency Anemia of Pregnancy-Maternal Risks: may be asymptomatic, but more susceptible to infection, may tire easily, has an increased chance of preeclampsia and postpartal hemorhage, and tolerates poorly even minimal blood loss during birth. Healing of an episiotomy may be slowed. If hgb is less than 6, cardiac failure may happen. 97.Iron Deficiency Anemia of Pregnancy-Neonatal Risks: low birth weight, prematurity, stillbirth, and neonatal death in infants of women with severe iron deficiency anemia (6). infant is not iron defiecent at birth but is at an increased risk of developing iron deficiency anemia during infancy. 100.Mild Preeclampia Clincial Manifestations: In normotensive mom BP of 140/90 + proteinuria = preeclampsia After 20wks a BP of 140/90 taken on 2 separate occasions 6 hrs apart in sitting position= diagnostic. they have 1 to 2+ protein on dipstick, 24 hr specimen then 300mg/dL to 1 gram per liter of protein, more than 3 pound weight gain a month in 2nd tri, 1 pound a week in 3rd trimester Proteinuria- 300mg/L (1+ dipstick) and 1g/L (2+dipstick), in 24hr >300mg of protein = abnormal she may be sent home on bed rest laying on left side so better perfusion on uterus and improved CO, daily kick counts, low Na diet recommended , have to be able to self-monitor, must be able to determine signs of worsening condition and have a way to get to hospital. Mag sulfate- to prevent seizure THAT IS THE ONLY REASON IT IS GIVEN, IT IS NOT A anti-HTN (blocks transmission of acetylcholine, relaxes uterus, relaxes arterioles- so a little improvement of BP), keep them on L side, can get up to bathroom and shower 101.NonStress Test: What is it, when is it done?: NST (3rd trimester)

-Noninvasive method of evaluating fetal status -Involves using an external electronic fetal monitor to obtain a tracing of the feta heart rate and observation of acceleration of the FHR with fetal movement. 102.Normal glucose homeostasis: -insulin: enables glucose to move into muscles & liver-stored as glycogen -blood glucose levels drop several hours after a meal -pancrease releases glucagon -glucagon stimulates conversion of glycogen to glucose--released into bloodstream -glucagon stimulates sysnthesis of glucose from amino acids. 103.NST-Procedure: women are requested to be non-fasting and to have refrained from recent cigarette smoking because this can adversely affect test results. The NST is typically performed with the women in the semi-Fowler's position with a small pillow or blanket under the right hip to displace the uterus to the left. The FHR is monitored by the placement of an electronic fetal monitor. -The FHR is usually monitored for 20 minutes, but monitoring may be extended to 40 minutes if the fetus is in a sleep cycle. 104.NST: When do you use it?: -Can be used as an assessment tool in any pregnancy but is especially useful in the presence of diabetes, preeclampsia, IUGR, SROM, multiple gestation, postdates, & other high risk pregnancy conditions. (most clinicians test twice weekly for high risk patients and once a week for other conditions) 105.Nursing Care Management for CVS: nurse ascertains the woman's understanding of CVS, its uses, the procedure, and the possible results. The nurse supports the woman or couple and encourages them to express any feeling and fears regarding the procedure and also regarding the decision-making process if abortion is being considered.

106.Nursing Diagnoses for mom with DM: - Risk for imbalance nutrition: more than body requirements r/t imbalance between intake and available insulin. -risk for injury r/t possible complications secondary to hypoglycemia or hyperglycemia. -Interrupted family process r/t the need for hospitalization secondary to GDM.

107.Nursing Diagnoses for Substance abusing moms: -Imbalance nutrition: less than body requirements r/t inadequate food intake secondary to substance abuse. -risk for infection r/t use of inadequately cleaned syringes and needles, secondary to IV drug use. - ineffective health maintenence r/t lack of information about the impact of substance abuse on the fetus. 108.Patho of Preeclampsia/Eclampsia: Vasospasm-(narrowing of vasculature) of just about Q organ sys, vasoconstriction of CNS/brain- headaches unrelieved by Tylenol, vasoconstriction of kidney, spots and stars, quick reflexes, vasoconstriction of gut, of uteruscontributes to IUGR PROSTAGLANDINS: Prostacyclin- vasodilator, prevents platelet aggregation Thromboxanevasoconstrictor, causes platelets to clump together imbalance Nitric oxide deficiency- it's a potent vasodilator and important regulator of maternal BP Hyperhomocysteinemia- may play a role through oxidative stress and endothelial dysfunction Visual disturbances 109.Placenta Previa: - improper implantation of placenta

-unexplained bright red painless bleeding; exsanguination (after 7th month) - call for help. Fluid, type and cross, c-section, monitor fetus, US. 110.Placenta Previa- Nursing Management: bed rest w/ bathroom privileges only as long as the woman is not bleeding, NO VAGINAL EXAMS, Monitoring blood loss, pain, uterine contractility, evaluation of FHR with external monitor, monitoring maternal vitals, complete lab evaluation: Hgb, Hct, Rh factor, urinalysis, IV fluids LR-monitor drip rate, availability of 2 units of cross-matched blood for possible transfusion, administration of betamethasone to facilitate fetal lung maturity, Rh D immunoglobulin in Rh D negative. Newborns hgb, cell volume, and erythrocyte count should be checked immediately after birth and then closely monitored, may require O2 and blood and admission to the NICU 111.POSPARTAL CLINICAL THERAPY-Preeclampsia/Ecclamspia: o Magnesium sulfate- be cautious on oral intake, will continue to receive for 24 hrs postpartum o Antihypertensives o Recurrence- some women develop late postpartum eclampsia (occurring more than 48hrs but less than 4wks)- so important to educate. If BP, above 150/100 give antiHTN, should return to normal <12wks. There is a genetic link to preeeclampsia, if the womans mother had preeclampsia, then she is likely to develop preeclampsia as well. MG SO NG CONSIDERATIONS o It's a CNS depressant by dec acetylcholine, thereby blocking neuromuscular transmission. Relaxes smooth muscles so may dec BP, dec freq and intensity of uterine contractions, used as tocolytic in preterm labor o BP per protocol

o Serum MgSO4 levels- Q6- 8hrs, therapeutic range = 4-8 mg/dL, reflexes disapper btwn 912, resp. depression at 14, cardiac arrest at 24-30 o Respiratory rate hourly <12= Mg toxicity developing o Reflexes hourly- loss of reflexes= Mg toxicity o Urinary output hourly - 30cc output or less= Mg toxicity o MgSO4 antagonist= Ca gluconate 1gm IV over 3min o Continue Mg SO for 24hrs after birth for prophylaxis o Signs of toxicity= dec reflexes, oliguria, confusion, circulatory collapse, inc risk of Resp arrest, visual disturb, inc headache, epigastric pain, inc edema, dec urine output. Rapid administration of large doses= cardiac arrest. o Newborn care- monitor Mg levels for 24-48hrs o DIAGNOSTIC= Urinary output, DEC. reflexes, dec RR o Generally given over 20min. VS Q5min, Check Levels if they have signs of mg toxicity, Mag SO is nephrotoxic 112.Postpartum management of DM: -maternal insulin needs fall due to the decreasd leveld of gPL, progesterone, and estrogen. -mom may not need insulin for 24 hrs or only 1/4 -1/2 her previous dose. -when women is NOT breastfeeding, oral antihyperglycemics may be used. -follow up in 6wks, if her blood glucose levels are normal, then she should be reassessed at a minimum of 3 yr intervals.

-Breastfeeding is encouraged, as diabetes does not alter breast milk. blood glucose levels may be lowered because glucose is transferred from serum to breast to be converted to actose, and energy is expended in milk production. 113.Preeclampsia: 1ST trimester BP almost same, 2nd trimester BP drops, 3rd trimester BP goes back up... Occurs after 20wks, 140/90, proteinuria. Only cure is the birth of fetus and delivery of placenta!! Aspirin to prevent preeclampsia in "at-risk" women through low-dose (50-150mg daily) begun between 12-18wks gestation.

-beta adrenergic: can significantly affect maternal cardiovascular and metabolic physiology. Serious effects: Hypotension, cardiac arrhythmia, tachycardia, palpitations, myocardia ischemia, pulmonary edema, and maternal hyperglycemia. -MgSO4: usually used in pt with preeclampsia. displaces intracellular calcium which inhibits uterine contractions. monitor serum Mg level closely. Maternal Side effects: flushed, warm, headache, nystagmus. Fetal S/E: hypotonia, lethargy, hypoglycemia, hypocalcemia. nausea, dry mouth, and dizziness. -Calcium channel blocker (Nifedipine) antagonize the action of calcium within the myometrial cells, which Reduces contractions. S/E are related to arterial vasodilation, that is, hypotension, tachycardia, facial flushing, and headache. Contraindicated: women with heart disease, cardiovascular compromise, intrauterine infection, multiple pregnancy, and maternal hypotension. -Prostaglanding synthetase inhibitors: inhibit contractions by interfering with PG synthesis. S/E: dyspepsia, n/v, depression, dizzy spells. Indomethacin not recommended after 34wks to prevent premature PDA closure in the fetus. -corticosteroids: bexamethasone for fetal lung maturation. -monitor for s/s of PTL:abd pain, back pain, pelvic pain, menstrual like cramps, vaginal bleeding (pinkish or mucus like), increased vaginal. Discharge, pelvic pressure, urinary frequency, diarrhea. Uterine contractions that occur q10min or less without pain, ROM. 117.Preterm Labor-fetal risks: prematurity, mortality risk increased. maturational deficiencies (fat storage, heat regulation, immaturity of organ systems), immature lung development. 118.Preterm Labor-maternal risks: (initial cause of PTL: antepartum hemorrhage, trauma, maternal infection) multiple gestation, previous PTL with term birth. See Table 26-2 p669 for full list. 119.PROM Clinical Therapy: -diagnosis: complaints of watery vaginal discharge or sudden gush of fluids ROM should be considered.

114.Premature Rupture of Membranes (PROM): -spontaneous ROM any time after completion of 37 wks or before the onset of labor -the earlier PROM; latent period is longer (the period of time between ROM and onset of labor) -Causes: incompetent cervix, cervicitis, UTIs, asymptomatic bacteriuria, amniocentesis, placenta previa, abruption placentae, hydraminos, LEEP, multiple pregnancy, Genital tract anomalies. 115.Preterm Labor: -labor that occurs between 20 and 37 completed weeks of pregnancy 116.Preterm Labor-clinical therapy:: -identification and tx of infection. -bedrest is ordered -diagnosis: pt has 1 contraction in less than or equal to 10 min -17P:given prophylactically but not once labor has started. IM beginning at 16 wks and continuing to 36 wks -tocolysis : medicationally attempting to stop labor -primary goal is to delay birth by 48 hrs so the maximum benefit of glucocorticoids can occur and decrease the incidence of RDS.

Ask about the time of initial fluid loss, if continuous leaking is occurring, any odor. Nitrazine test should be tested on the leaking fluid blue=suggests ROM. Steril speculum exam, AVOID digital exam until PPROM is ruled out or plan had been determined. Ultrasound, GBS, gonorrhea, chlamidia test should be done at this time. -amniocentesis -bed rest with pelvic rest, bathroom privleges, fetal movement record, avoid intercourse, douches, tampons. -PT contacts Physician: has fever, uterine tenderness or contractions, increased leakage, decreased fetal movement, or foul vaginal discharge. -prophylactic abs: to any mom with unknown GBS status or history of + result. -corticosteroids: bexamethasone; tocolytics within 24hrs to allow course of steroids to be given. 120.PROM Fetal Assessment: q4hrs, fetal tachycardia suggests infection, fetal heart tracing, BPP (q24hrs), NST (qShift), fetal lung maturity test. 121.PROM Fetal/Neonatal Risks: mortality related to prematurity related to RDS, necrotizing enterocolitis, and intraventricular Hemorrhage, neonatal sepsis, fetal hypoxemia (cord prolapse or cord compression), oligohydraminos may result in fetal pulmonary hypoplasia, facial anomalies, limb position defects, and fetal growth restriction. 122.PROM-maternal assessment: qShift , monitor temp. BP, HR (q4hrs), leaking?, CBC, urinalysis, position mom on her LEFT side for uteroplacental perfusion, hydrate if increased temp. 123.PROM-Maternal Risks: infection, chorioamnionitis, endometritis, abruption placentae, childbirth may be complicated by malpresentation and reduced amniotic fluid volume.

124.PTL-Nursing: monitor FHR, vitals, bed rest, I&Os, UCs, place mom on her LEFT side for maternal fetal circulation, vaginal exams at a minimum, watch for adverse effects if tocolytics are used. Decrease moms axiety , use empathetic communication, help with coping mechanisms, prepare parents for birth if it is imminent. -provide psychological support: arrange consult for neonatologist, social worker, or hospital chaplin if requested. -NO attempt is made to stop labor if: Fetal demise, lethal fetal anomaly, severe preeclampsia/eclampsia, hemorrhage/abruption placentae, chorioamnionitis, severe fatal growth restriction, fetal maturity, acute reassuring fetal status.

125.Rh Sensitation: o An antigen-antibody reaction Rh (-) mother with Rh (+) fetus Exposure can occur in termination by miscarriage or induced abortion, blood transfusion, experiences an Rh positive tubal pregnancy, amniocentesis, or experiences any traumatic event. Or during birth Maternal IgG anti-D antibodies produced= MOM HAS BEEN SENSITIZED, also alloimmunization and isoimmunization Second exposure to Rh (+) RBC's leads to hemolysis 126.Rh Sensitation-Fetal Risks: Erythroblastosis fetalis- severe hemolytic disease, the hemolysis caused by the maternal IgG antibodies in the fetus creates fetal anemia, fetus responds by increasing RBC production

 Hydrops fetalis- fetal edema, congestive heart failure may result Icterus gravis- hyperbilirubinemia and jaundice because of RBC destruction, which can lead to 127.RhoGam: Rho gam given during invasive procedures or if woman has bleeding. Or at 28wks preg, if she has another procedure, and after pregnancy. MANAGEMENT o An FYI: the goal of medical management is the birth of a mature fetus who has not developed severe hemolysis in utero. This requires early identification and tx of maternal conditions that predispose the infant to hemolytic disease, coordinated obstetric pediatric tx for the seriously affected newborn, and prevention of Rh sensitization if none present. o Antepartum Rh immune globulin given prophylactically at 28wks. And for any time a blood transfusion occurs. 2 interventions to aid fetus whose blood cells are being destroyed by maternal antibodies:

Treat isommune hemolytic disease in newborn 128.Rubella: o Teratogenic during 1st trimester, defects rare after 20wks gestation. o Fetal/neonatal risks- if newborn twin has congenital rubella they need to be isolated, they shed virus for 12mon. o Diagnosis- presence of congenital cataracts sensorineural deafness and congenital heart defects (PDA). Mental retardation, cerebral palsy may become evident in infancy. Diagnosis made in presence of the conditions and an presence of of IgM antirubella antibody titer o Treatment-prevention!! by live attenuated vaccine. mom immunized after delivery. If preg. woman becomes infected in 1st tri. therapeutic abortion may be alternative L o Asymptomatic or signs of mild infection, macupapular rash, lymphadenopathy, muscular achiness, and joint pain. 129.SCREENING FOR Rh INCOMPATIBILITY & SENTIZATION-Fetal assessments: PUBSpercutaneous umbilical cord blood sampling requires highly skilled physician, direct method of assessing Rh status of fetus. Amniocentesis- less risk than PUBS

Early delivery Intrauterine transfusion- done to correct the anemia produced by the RBC hemolysis and thereby improve fetal oxygenation. Done IV through PUBS or intraperitoneally as early as 18wks. o Postpartum Prevent sensitization RhoGAM If you don't know if mom is sensitized, give anyway, it will cause no harm. Ultrasound- to follow fetal progress. Presence of ascites and subcutaneous edema are signs of severe fetal involvement (fetal hydrops). Other indicators: inc. in fetal heart size, hydramnios and placental thickness and texture. 130.SCREENING FOR Rh INCOMPATIBILITY & SENTIZATION-Maternal assessments: Indirect Coomb's- an antibody screen, it measures the number of Rh- positive antibodies in the maternal blood Direct Coomb's - done on the infant's blood to detect antibody coated Rh-positive RBCs. If sensitized:

 Anti-D antibody titer Q2-4wks beginning at 16 to 18wks, biweekly during 3rd trimester, and the week before the due date. If test shows 1:16 or less late in pregnancy, birth at 38 wks or spontaneous labor at term can be anticipated. Negative antibody titers can consistently identify the fetus not at risk. Delta optical density . If Anti-D antibody titer test shows titer of 1:16 or greater, the delta optical density analysis of amniotic fluid is performed. Determines amount of bilirubin pigment found in the amniotic fluid, it Serves as an indirect predictor of the severity of fetal anemia. 131.Self-care measures to prevent PTL:: rest 2-3x , laying on your side, increase fluids, avoid caffeine, empty bladder q2hrs while awake, avoid lifting heavy objects, pace yourself to avoid overexertion, stop sexual activity.

vasooclusive crisis occurs during labor keep woman in a LEFT LATERAL position, oxytocin may be used, as well as episiotomy and forceps to shorten delivery time. 135.Sickle Cell Anemia-Fetal/neonatal risks: -Fetal/neonatal risks prematurity and IUGR, fetal death due to sickling in placenta. 136.Sickle Cell Anemia-Maternal Risks: increased risk for nephritis, bacteriuria, amd hematuria, anemia. low o2 pressure- caused by high temps, dehydration, infection, or acidosis may precipitate a vaso-occlusive crisis (occur more often in second half of pregnancy). may require blood transfusion, c-section, develop acute chest syndrome, CHF, or acute renal failure. 137.Signs & Symptoms of PTL: abd pain, back pain, pelvic pain, menstrual like cramps, vaginal bleeding (pinkish or mucus like), increased vaginal. Discharge, pelvic pressure, urinary frequency, diarrhea. Uterine contractions that occur q10min or less without pain, ROM. 138.Signs of Substance abuse: Behavioral signs: -memory lapses, mood swings, hallucinations -pattern of frequently missed appointments. -frequent accidents, falls -signs of depression, agitation, euphoria -suicidal gestures 139.Signs of Substance abuse: History: -vague or unusual medical complaints -family hx of alcoholism/addiction -hx of childhood physical, sexual, emotional abuse. -hx of cirrhosis, pancreatitis, hepatitis, gastritis, STI's, or unusual infections such as cellulitis or endocarditis

132.Severe Preeclampsia- Clinical Manifestations: 160/110 on 2 occasions, taken 6hrs apart while on bed rest (cannot get up to bathroom or shower), 5 or more grams per liter of protein in 24 hr specimen or 3+ dipstick, oliguria= urinary output <equal to 500mL in 24 hr, pulmonary edema , vasoconstriction of liver- epigastric pain upper R quad pain, blurry/spots vision, thrombocytopenia <100,000, usually hospitalized, daily weights, sometimes electrolytes, cerebral or visual disturbances, cyanosis, impaired liver function (inc AST/ALT), thrombocytopenia, fetal growth restriction, pitting edema of low extremities while on bed rest, irritability, and emotional tension. 133.Sickle Cell Anemia: -recessive autosomal disorder -hgb A is abnormally formed. -primarily in African Americans 134.Sickle Cell Anemia-Clinical Therapy: additional folic acid supplement (4mg/day). Maternal infection should be treated immediately. Rehydration with IV fluids, administer o2, antibiotics, and analgesics. Fetal heart monitoring, antiembolism hose in postpartum. if

140.Signs of Substance abuse: Physical signs: -dilated or constricted pupils -inflamed nasal mucosa -evidence of needle "track marks" or absecesses -poor nutritional status -slurred speech or staggereing gait -odor of alcohol on breath 141.Sono/US are Used to assess: gestational sac, the presence or absence of a yolk sac or embryo, the crown rump length to most accurately determine gestational age, the presence of cardiac motion, and fetal number. It also can most accurately identify shortened cervical length and cervical funneling (indicating cervical incompetence or risk of preterm labor) -The FDA states that obstetric sonograms fall within an acceptable level of safey because they use low-intensity ultrasound, however they do not approve of nonmedical uses such as videos and pictures for "keepsakes." 142.Sonogram/Ultrasound: -All 3 Trimesters -Ultrasound is a diagnostic procedure that used high- frequency sound waves exceeding 20,000 cycles per second, to produce and image that varies based on the density of the structure under the transducer. -Ultrasound can be used to produce images called SONOGRAMS in several different ways. (Motion mode, brightness modulation, & 3 dimensional) -Limited ultrasound may be used to address a specific question, or determine specific information. (this should not take the place of a standard ultrasound evaluation) 143.Spontaeous Abortion- Nursing: amount and appearance of vag bleeding, VS, and pain, moms bld type and antibody status. If pregnancy is 10-12wks or more FHR should be determined w Doppler. Provide emotional support.

144.Spontaneous Abortion: oPregnancy termination before 20 weeks oReliable indicators= pelvic cramping and backache

145.Spontaneous Abortion- Classifications: Threatened- unexplained bleeding, cramping, or backache. Cervix is closed. Followed by partial or complete expulsion or it may resolve w/out threatening fetus. Imminent- inc bleed and cramp. Internal cervical os dilates. ROM. The term inevitable abortion applies. Incomplete- part of the placenta are retained, internal cervical os dilated. Complete- all products of conception expelled. Uterus is contracted and cervical os may be closed. Missed- fetus dies in utero but not expelled. DIC may develop if fetus retained beyond 4 wks Recurrent pregnancy loss- abortion occurs consecutively in 3 or more pregnancies. Septic- presence of infection 146.Spontaneous Abortion-Causes: -over half in 1st trimester r/t chromosomal abnormalities, teratogenic drugs, faulty implantation due to abnormalities of the female reproductive tract, weakend cervix, placental abnormalities, chronic maternal diseases, endocrine imbalances, and maternal infections. Jaczzi users 2x's more likely. -Advanced maternal age is the most significant risk factor 147.Spontaneous Abotion- Causes for early/late: o Early- chromosomal defects loss by weeks 4 - 8 , insufficient or excessive hormonal levels will result in loss by 10 wks, infectious and environmental factors

o Late- cervical insufficiency or maternal disease 148.Standard ultrasound: examination is performed during the 2nd or 3rd trimester. It includes the evaluation of fetal presentation, fetal number, amniotic fluid volume, placental position, cardiac activity, fetal biometry, & anatomic survey. 149.Substance abuse: Indiscriminate use of drugs during the pregnancy, particularly the first trimester, may adversly affect the health of the woman and the growth of the fetus. (cocaine/ alcohol, methadone) 150.SURGERY DURING PREGNANCY: o Risk of spontaneous AB & PTL o In 1st tri= inc. risk of SA, best time is in 2nd tri. or postpartum, in 3rd its difficult because of enlarging uterus and inc risk of preterm labor. o Recommended procedures- appendicitis, cholecystitis, bowel obstruction, melanoma, ovarian disorders, breast or cervical disease or trauma. o Essential to avoid maternal hypoxia, pneumonia, thrombophlebitis For woman who receiving surgery we need to consider HTN, wedge pt on table, you need SCD, need to consider that gastric content may be elevated because of uterus- so they will likely have an NG tube, foley. Fetal heart tones monitored before during and after. Epidural/Spinal anesthesia preferred because local anesthetics are not associated w birth defects. But may cause hypotension, can be prevented w 900 to 1000 mL infusion before procedure. Fluid replacement from bld loss is done w electrolyte solution and/or whole blood. 151.Thalassemia During Pregnancy: -group of autosomal recessive disorders characterized by a defect in the sys=nthesis of alpha or beta chains in hgb. beta-thalassemia is most common in US.

152.Thalassemia During Pregnancy-Clinical Therapy & Nursing: - folic acid supplements, may need transfusion or chelation therapy. Care is similar to sickle cell anemia. -genetic counseling 153.Thalassemia During Pregnancy-Maternal/fetal/neonatal risks: Maternal/fetal/neonatal risks:pregnancy is rare in women with b-thal. major. in women with b-thal. minor has mild anemia with microcytic red cells. she should not recieve iron if she is not iron deficient. she has normal serum ferritin levels. newborns may not have symptom for months, once infants start to produce adult type hemoglobin (HbA) they develop severe anemia and are dependent on transufions, iron chelation therapy may be needed. 154.The MODIFIED Biophysical Profile: (more cost & labor efficient) test consists of an NST and a measurement of the AFI, both of which reflect long term uteroplacental function. A modified BPP is considered NORMAL if the amniotic fluid volume is greater than 5 cm and if the NST is reactive. The test is ABNORMAL if either the NST is nonreactive or the AFI is 5 cm or less. 155.TORCH: TAXOPLASMOSIS: o Protozoan Toxoplasma gondii o Contracted through eating raw meat, unpasturized goat's milk, contact with feces of infected cats o Fetal risks- if in 1st tri often ends in SA, Mainly contracted in last month of preg, and infants born w/out clinical signs of infection. In mild cases infant will have retinochoroiditis (inflame. Of the retina and choroid layer of the eye). Severe neonatal - convulsions, coma, microcephaly and hydrocephalus. Infant w severe infection may die soon after birth. Survivors are often blind, deaf, and severly retarted. o Diagnosis-serologic testing IgM and IgG florescent antibody cream. PCR for T.gondii DNA in amniotic fluid is the best way to diagnose fetal infection. o Treatment spiramycin to decrease the frequency of fetal transmission, in 1st tri. does not treat an established infection. If infection is suspected, pyrimethamin/sulfadiazine/folinic acid after 18th wk pregnancy.

o Moms who aquire this are asympotomatic, myalgia, malaise, splenomegaly, might have a little rash a little fever, headache, and enlarged posterior cervical lymph nodes.

158.What can CVS detect?: fetal karyotype, hemoglobinopathies, phenylketonuria, alpha antitrypsin deficiency, down syndrome, duchenne muscular dystrophy, and factor IX deficiency. 159.When can an Amniocentesis be performed and what can it detect?: Amniocentesis is performed between 15 & 20 weeks gestation. Amniocentesis can make chromosomal and biochemical determinations (enzyme analysis, AFP measurement for neural tube defects, blood typing, or cytogenetic, metabolic, or other DNA testing) and can validate abnormalities detected by ultrasound. Later in pregnancy, from about 30 to 39 weeks; gestation, amniocentesis may be done for lung maturity studies, such as LS ratio. 160.When is CVS performed?: performed between 10 and 12 weeks. The CVS results are obtained in 24 hours if the direct preparation method is used and in 7 to 10 days when tissue culture is used. 161.When is insulin therapy indicated?: when dietary management fails to meet a 2 hr postprandial level less than 120 or fasting glucose less than 95.

156.Trauma During Surgery: o Greater volume of blood loss before signs of shock Preg woman w large amount of blood loss is able to maintain hemodynamic stability temporarily by dec uteroplacental perfusion, thereby compromising fetal status o Normal physiologic changes of pregnancy place woman at greater risk of hypoxia, thrombosis, DIC, abruption, ROM o Nursing considerations Maintenance of cardiorespiratory functioning Stabilize injury Avoid development of supine hypotension Evaluate for placental abruption Partner violence or car wreak... Oh I'll give my life for my baby- you treat mom first... Pay attention of uterine tone... Get mom under control then you worry about baby 157.Two most common methods of ultrasound scanning are transabdominal & transvaginal.: -Transabdominal: transducer is moved across the abdomen. The woman is usually scanned with a full bladder, except when ultrasound is used to localize the plcaenta before amniocentesis. The woman may feel discomfort from pressure applied over a full bladder. -Transvaginal: uses a probe inserted into the vagina. Once inserted, the transvaginal probe is close to the structures being imaged and so produces a better, clearer image.

OB - Blueprints OBGYN Part 1 1.At what beta-hCG level should an IUP be seen?: between 1,500 and 2,000. 2.At what gestational age does the closure of the neural tube happen? - what are the most common NTD? - #1 risk factor for NTD?: week 6 according to LMP - spina bifida (posterior NT) and anencephaly (anterior NT) - #1 risk factor: low levels of maternal folate 3.Besides symptomatically, how can ROM be diagnosed?: - NITRAZINE PAPER: will turn blue (basic) if amniotic fluid is present, normal vaginal secretion is acidic (red)

- FERNING under the microscope due to crystalization of the amniotic fluid from the estrogen that is present in it. 4.Classic caharacteristics of Edward Syndrome: Trisomy 18 - clenched fists - overlapping digits - rocker bottom feet

9.Define labor: Labor: regular contractions that cause cervical change in dilation or effacement. 10.Define PROM (premature rupture of membranes). - define prolonged PROM. - define PPROM (preterm premature rupture of membranes): - PROM: rupture of membranes at least 1 hour prior to the onset of labor. - Pronlonged PROM: when PROM occurs more than 18 hours before labor.

- omphalocele - PPROM: when PROM occurs before 37 weeks gestation. - tetralogy of fallot 11.Define Recurrent Abortions. 5.Classic characteristics of Patau Syndrome: Trisomy 13 - most common cause?: Def: 3 or more consecutives SABs. - holoprosencephaly - #1 cause if antiphospholipid antibody syndrome - cleft lip/palate - #2 cause is luteal phase defect and lack of adequate progesterone to carry the pregnancy. - overlapping fingers, polydactaly 12.Define Spontaneous Abortion: pregnancy that ends before 20 weeks gestation - clubfoot 13.Define Stage 1 of labor. 6.Dates of 1st, 2nd and 3rd trimester: 1st: 0 - 14 weeks 2nd: 15 - 28 weeks 3rd: 29 - delivery 7.Define and describe Nagele's rule: Used to estimate date of delivery: - subtract 3 months from LMP and add 7 days. 8.Define episiotomy: incision in the perineum to facilitate delivery. - what are the phases of the first stage of labor?: DEF: onset of labor to complete dilation of the cervix. - latent phase: labor onset - 4 cm dilation - active phase: 5 cm - 9 cm 14.Define Stage 2 of labor: DEF: complete dilation of cervix/10 cm to delivery of baby. 15.Define Stage 3 of labor: Starts after delivery of the baby, until delivery of the placenta.

16.Define: - placenta accreta - placenta increta - placenta percreta: ACCRETA: invasion of the placenta superficially into the myometrium INCRETA: invasion of the placenta well deep into the myometrium

INCOMPLETE: open os, painful bleeding, partial poc in uterus and in vagina/cervix COMPLETE: closed os, +/- bleeding, no poc in uterus MISSED: closed os, +/- bleeding, poc in uterus without heart tones 20.Describe the management of recurrent spontaneous abortions: 1. karyotyping both parents 2. hysterosalpingogram for maternal anatomy

PERCRETA: invasion of the placenta through the myometrium and into the serosa 17.Defininiton preterm birth: prior to 38 weeks. 18.Describe the 4 degrees of perineal lacerations after a delivery:: - 1st: skin only - 2nd: extends into the PERINEAL BODY but does not involve the anal sphincter - 3rd: extends into and through the ANAL SPHINCTER - 4th: ANAL MUCOSA itself is entered. 19.Describe the following types of spontaneous abortions according to CERVIX, BLEEDING, products of conceptions POC: - threatened - inevitable - incomplete - complete - missed: THREATENED: closed os, painless bleeding, poc in uterus with normal heart tones INEVITABLE: open os, painful bleeding, poc in uterus 3. screening tests for THYROID, APA syndrome, SLE, HYPERCOAGULABE STATES (factor V leiden, protein S/C deficiency) 4. progresterone levels 21.Describe the NST. - describe the normal/reactive results. - how should an obgyn proceed if NST is non-reactive?: NST is a test for fetal heart rate. - Reactive: two accelerations of fetal heart rate in 20 minutes that are at least 15 beats above the baseline heart rate for at least 15 seconds each. - Nonreactive: proceed with ultrasound 22.How are NTDs screened for?: Quad screen: - MSAFP levels will be high - hCG levels will be low 23.How can labor be mechanically and chemically induced?: MECHANICALLY: with amniotomy, by using a hook to puncture the amniotic sac

CHEMICALLY: with Pitocin 24.How is Down Syndrome screened for in utero with labs and us? - what are the results associated with Down Syndrome?: LABS: - Quad Screen: maternal-serum AFP (low), hCG (high), estriol (low), inhibin A - plasma protein A US: nuchal translucency - @ 15 - 20 weeks 25.How is fetal lung maturity assessed?: Via the lecithin/sphingomyelin ratio (L/S ratio). - normal ratio is > 2 and indicates low risk of respiratory distress syndrome (RDS). 26.How is placenta previa diagnosed? - how is placenta previa managed?: Via abdominal US. MANAGEMENT: - abdominal US should be repeated in the third trimester to see if placenta has moved and placenta previa has resolved. - strict pelvic rest

- 2nd trimester abortions: 1st: chromosomal abnormalities 2nd: anatomical abnormalities (uterus or cervix/incopetent cervix) 30.Most common location of ectopic pregnancy. - what are some ectopic pregnancy risk factors?:fallopian tube - risk factors: 1. scarring of the tube due to STIs, PIDs, endometriosis 2. use of IUD 3. hx of prior ectopic pregnancies 31.Normal fetal HR: 110 - 160 32.Placenta Previa - define - #1 risk factor for it - classical clinical sx: DEF: abnormal implantation of the placenta over the internal os. - may be complete, partial or marginal. RISK FACTOR: hx of prior uterine surgeries

27.How should beta-hCG levels behave with a normal pregnancy?: they should double every 48 hours 28.MEDICAL therapy for an ectopic pregnancy:methotrexate 29.Most common cause of 1st trimester abortions.

SX: painless vaginal bleeding after 28 weeks gestation ("sentinel bleed") 33.Plancetal Abruption - def

- risk factors - clinical presentation/sx: DEF: premature separation of the placenta from the uterus RISK FACTORS: htn (#1), cocaine use, trauma, prior hx of abruption SX: 3rd trimester severely painful bleeding 34.sx:How is placenta abruption diagnosed?: mostly clinically 35.Treatment for incompetent cervix: betamethasone, strict bed rest and cervical cerclage at 12-14 weeks until 36 - 38 weeks. 36.Uterine Rupture - at what setting do most of them occur? - #1 risk factor? - sx: Setting: most will occur during labor Risk factor: uterine scar from hx of uterine surgery Sx: intense abdominal pain, vaginal bleeding -> hypotension if severe, cessation of uterine contractions 37.What are the 3 signs of soon-to-be placental delivery? - how long does the placenta have to be delivered before a patient is diagnosed with a retained placenta?: 1. cord lengthening. 40.what are the components of a BPP? 2. gush of blood - what is a normal score?: 1. amniotic fluid levels 3. uterus will contract and become firm 2. fetal tone - must be delivered in 30 minutes. ** do not attempt to deliver the placenta untill all 3 signs are present 38.What are the 5 components of cervical examination for labor? - describe each one.: - dilation - effacement (how thin the cervix is as it is compressed by baby's head) - fetal station (relation of baby's head to mom's ischial spine; negative when above, positive when below) - cervical position - consistency of the cervix (firm, soft) 39.What are the cardinal movements of labor, in order?: - ENGAGEMENT - FLEXION - DESCENT of the head into the pelvis - INTERNAL ROTATION so that the sagital suture is parallel to the anteroposterior diameter of the pelvis - EXTENSION and EXTERNAL ROTATION

3. fetal activity 4. fetal breathing movements 5. nonstress test (NST)/fetal heart rate

VARIABLE: cord compression - no relation to mom's contraction but will look like "w" or "jagged carrot".

LATE: hypoxia due to placental insufficiency. Normal score in between 8-10 41.What are the genetic diseases where every baby is screened for?: - CF - sickle cell - Tay Sachs 46.What is the Bishop score? - thalassemias 42.What are the most common sex chromosomal abnormalities?: - Turner (45 XO) - Kleinfelter (47, XXY) 43.What are the most common tocolytics? - what are they used for?: TERBUTALINE and MG SULFATE - used as labor supressants; will inhibit uterine contractions 44.What are the types of decel? - for each type, describe what it LOOKS LIKE IN FETAL TRACING MONITOR and CAUSES OF IT.:EARLY: head compression. - mirror image with mother's contraction - describe.: For each component of the cervical examniation during labor, there is a total of 2 points for a grand total of 10 points. - a Bishop score is the summation of all points. - a score > 8 indicates favorable conditions for spontaneous labor. 47.What is the maximum number of days by which EDD can differe between LMP and US?: 7 days. - When the difference is more than 7 days, the US predominates. 48.What is the uterine fundal height when the fundus of the uterus reaches the level of the umbilicus?: 20 cm - at 15 cm it will be halfway between pubic symphysis and umbilicus 49.What type of decels are commonly seen in the second stage of labor?: Early (head compression) and Variable (cord compression). - may or may not be associated with loss of variability. - will occur after mom's contraction 45.What is IMP to KIM about the physical exam in a patient with placenta previa?: No digital exam should be performed!!!

50.When during the process of labor is an epidural administered?: during the active phase of the first stage of labor. 51.When in the pregnancy can fetal heart tones be heard?: 10 - 14 weeks 52.When is amniocentesis performed? - when is chorionic villus sampling performed?:Amnio: 15 weeks CVS: 9 - 12 weeks 53.when is GBS screened for? - tx if positve.: between 35 and 37 weeks, cerca 36 weeks. - penicilin is drug of choice. - if mom is allergic, second choice is cefazolin. - if cefazolin resistant, attempt clindamycin 54.When looking at a fetal heart tracing monitor (such as NST), what must be present for diagnoses of a reassurant (but not necessarily reactive) tracing?:VARIABILITY and HR within normal limits. - presence of variability is the jaggedness of the line.

2.Aminoglycosides (gentomycin, neomycin, streptomycin): Deafness 3.Carbamazepine: Fingernail hypoplasia, craniofacial defects 4.Cocaine: Cerebral infarcts, mental retardation, bowel atresias 5.DES: Clear cell vaginal cancer, adenosis, cervical incompetence 6.Diazepam: Cleft lip and/or palate 7.Iodine: Goiter, mental retardation 8.Isotretinoin: Ear, CNS, craniofacial, and CV defects 9.Lithium: Cardiac (Ebstein's) anomalies 10.Maternal diabetes: macro or microsomia and ___: CV malformations, cleft lip and/or palate, caudal regression (lower half of body incompletely formed), neural tube defects, left colon hypoplasia 11.OCPs: VACTERL syndrome 12.Phenytoin: Craniofacial, limb, and cerebrovascular defects, mental retardation 13.Progesterone: masculinization of female fetus 14.Quinolones: cartilage damage 15.Sulfonamides (thiazides, TMP-SMX): kernicterus 16.Tetracyclines (doxycycline): Yellow or brown teeth

55.Which shoulder is delivered first?: anterior first by pushing baby down. - posterior second by bringing baby up after anterior shoulder has been delivered

17.Thalidomide: Phocomelia (absence of long bones and flipper-like hands) 18.Valproate: Spina bifida, hypospadias 19.Warfarin: Craniofacial, CNS malformation, IUGR, stillbirth

Obstetrics: Teratogens + Defects 1.ACEIs: Oligohydramnios, fetal renal damage