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OB ATI Study Guide Initial Prenatal Visit: ↑
Estimated date of delivery based on LMP. Vaginal ultrasound may be done to establish DOD
Medical & nursing hx including past med health, family hx, social supports, social hx, & review of systems (to determine risk factors) & past OB hx
Physical assessment: baseline weight, vitals, pelvic exam
Initial lab work: o
Blood type
o
Urinalysis
o
RH factor
o
Pap
o
HIV status
o
Indirect Coomb’s test will
o
Hep B
determine if client is sensitized
o
VDRL
to RH+ blood
o
Rubella status
Ongoing Prenatal Visits:
Monitor weight, BP, & urine for glucose, protein, & leukocytes
Present of edema
Fetal development: o
FHR heard by Doppler at 10-12 wks
o
Heard with ultrasound stethoscope at 16-20 wks. Listen at the midline, right above the symphysis pubis, holding stethoscope firmly on abd
o
Measure fundal height after 12 wks. Between 18 & 30 weeks, fundal height measured in cm should equal the week of ge station. Have pt empty bladder & measure from the level of the symphysis pubis to the upper border of the fundus
o
Begin assessing for fetal movement between 16 & 20 weeks gestation
Routine Lab Tests in Prenatal Care Ca re & Their Purpose Blood type, Rh factor, presence of irregular antibodies
Determines risk for maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal hyperbilirubinemia. For clients are are Rh(-) & not sensitized, the indirect Coombs’ Coombs’ test will be repeated b/t 24-28 24-28 weeks gestation
CBC w/ differential, Hgb, Hct
Detects infection & anemia
Hgb electrophoresis
Identifies hemoglobinopathies (sickle cell anemia & thalassemia) Identifies DM, gestational HTN, renal disease, & infection
Urinalysis: pH, gravity, color, sediment, protein, glucose, albumin, RBCs, WBCs, casts, acetone, & HCG
2
1 hr Glucose Tolerance (oral/IV admin of concentrated glucose w/ venous sample taken 1 hr later. Fasting not necessary)
Identifies hyperglycemia; done at initial visit for atrisk clients, & at 24-28 wks for all pregnant women (>140 requires follow up)
3 hr Glucose Tolerance (fasting overnight prior to oral or IV admin of concentrated glucose with a venous sample taken at 1, 2, & 3 hrs later)
Used in clients w/ elevated 1-hr glucose tst as a screening tool for DM. A dx of GD requires re quires 2 elevated blood-glucose readings
Pap Test
Screens for cervical cancer, HSV II, &/or HPV
Vaginal/Cervical Culture
Detects streptococcus B-hemolytic, Group B (routinely done at 35-37 wks), BV, STDS (gonorrhea, chlamydia)
Rubella Titer
Determines immunity to rubella. If non-immune, give shot!
PPD, chest screening after 20 weeks w/ + purified protein derivative Hep B Screen
Identifies exposure to TB Identifies carriers of hep B
VDRL
Syphilis screening mandated by law
HIV
Detects HIV infection: recommended for all clients who are pregnant unless client refuses testing
TORCH (Toxoplasmosis, other infections, rubella, cytomegalovirus, & herpes) when indicated
Screening for group of infections capable of crossing the placenta & adversely affecting fetal development
Maternal serum alpha-fetoprotein (MSAFP)
Between 15-22 wks
Rhogam Administration:
IM around 28 weeks for clients w ho are Rh (-)
For amniocentesis, car wreck, or any instance of possibility of fetal/maternal blood mixture
Health Promotion:
Avoid all OTC meds, supplements, & rx meds unless OB w ho is supervising care has knowledge of this practice
Alcohol (birth defects) & tobacco (low birth weight) contraindicated during pregnancy
Substance abuse of any kind is to be avoid during pregnancy & lactation
Encourage flu vaccine during the fall months
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Treat current infections
Ascertain maternal exposure to hazardous materials
Avoid use of hot tubs/saunas
Consume at least 2-3 L of h20 daily from food & beverage sources
Exercise: moderate exercise (walking/swimming) consisting of 30 minutes; no new exe rcise during pregnancy
Third Trimester Childbirth Prep:
Breathing & relaxation techniques o
Deep cleansing breaths at ½ the usual r espiratory rate during ctxns can promote relaxation of the abd muscles, which lessens the discomfort of uterine ctxns.
discussion regarding pain management during labor & birth (natural child birth, epidural)
Fetal movement/kick counts to ascertain fetal we ll-being. Client should be instructed to count & record fetal movements or kicks daily o
It is recommended that mothers count fetal activity 2-3 x/day for 6 0 mins each time
o
Fetal movements <3/hr or movements that cease entirely for 12 hours need further eval
Common Discomforts During Pregnancy:
Morning sickness: eat cracker or dry toast ½ to 1 hr before rising in the morning to prevent discomfort. Avoid an empty stomach & drink fluids between meals.
UTIs are common due to renal changes & vaginal flora becoming more alkaline o
Wipe front to back, avoid bubble baths, wear cotton panties, avoid tight-fitting pants, & consume 8 glasses of water/day
o
Urinate as soon as urge occurs nd
rd
Constipation may occur during 2 & 3 trimesters. Drink plenty of fluids, eat a diet high in fiber, exercise regularly
rd
Leg cramps may occur during 3 trimester d/c compression of lower ex tremity nerves & blood vessels by the enlarging uterus o
Homan’s sign should be checked
o
If negative, patient should extend the affected leg, keeping knee straight & dorsiflexing the foot (toes toward the head)
o
Massaging & applying heat over affected muscle or a foot massage while the leg is extended can help relieve cramping
o
Notify PCP if frequent cramping occurs
Varicose veins & extremity edema during 2 o
Rest w/ legs elevated
o
Avoid constricting clothing
o
Wear support hose
o
Avoid sitting or standing in one position for long periods of time
nd
rd
& 3 trimesters o
Avoid sitting w/ legs crossed at knees
o
Sleep in left lateral position
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Gingivitis, nasal stuffiness, & epistaxis can occur
Braxton Hicks ctxns o
Should subside with change of position & walking
Danger Signs of Pregnancy:
Gush of fluid from vagina (rupture of amniotic fluid) prior to 37 w eeks of gestation
Vaginal bleeding (placental problems such as abruption or previa)
Abd pain (premature labor, abruption placenta, or ectopic preg nancy)
Changes in fetal activity (↓ fetal movement may indicate fetal distress)
Persistent vomiting (hyperemesis gravidarum)
Severe HA (PIH)
Elevated temp (infection)
Dysuria (UTI)
Blurred vision (PIH)
Edema of face & hands (PIH)
Epigastric pain (PIH)
Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, ↑ thirst & urination, & HA (hyperglycemia)
Concurrent occurrence of clammy pale skin, w eakness, tremors, irritability, & lightheadedness (hypoglycemia)
Common birthing methods: prepare a pregnant woman for the l&d process & may ↓ anxiety:
Dick-Read method- “childbirth w/out fear”. Uses controlled breathing & conscious & progressive relaxation of different muscle groups through the entire body. Instructs a woman to relax completely between contractions & keep all muscles ex cept the uterus relaxed during ctx ns
Lamaze- promote a healthy, natural, & safe approach to pregnancy, childbirth, & early parenting by advocating & working w/ HCP, parents, & prof. childbirth instructors
Leboyer- based on the idea of “birth without violence”. Environmental variables are stressed to ease the transition of the fetus from the uterus to the external environment (dim lights, soft voices, warm birthing room). Water births are based on this method.
Bradley- emphasizes partner’s involvement as the birthing coach. Emphasizes increasing self awareness & teaching the woman to deal w/ the stress of labor by t uning into her own body. Mother is encouraged to trust her body & use natural breathing, relaxation, nutrition, exercise, & education throughout pregnancy
Nutrition During Pregnancy :
↑ protein intake
↑ foods high in folic acid (leafy vegetables, dried peas & beans, seeds, orange juice. Br eads, cereals, & other grains are fortified with folic acid). o
600 mcg during pregnancy
5
o
500 mcg during lactation
Iron supplements facilitate an ↑ of the maternal RBC mass o
Best absorbed between meals & when given w/ good source of Vit. C
o
Milk & caffeine interfere w/ absorption
o
Sources of iron: beef liver, red meats, fish, poulty, dried peas & beans, & fortified cereals & breads
o
Stool softener may be added to ↓ constipation experienced w/ iron
Adolescents may have poor nutritional habits (a diet low in vitamins & protein, not taking prescribed iron supplements(
Potential Diagnoses for Ultrasound during Pregnancy: Confirm pregnancy, fetal viability, or
Assessing maternal structure
death
Ruling out fetal abnormalities
Confirm GA by biparietal diameter
Locating site of placental attachment
(side-to-side) measurement
Determining amniotic fluid volume
Identify multifetal pregnancy
Fetal movement observation (FHR,
Site of fetal implantation (uterine or
ectopic)
Assessment of fetal growth & development
breathing, & activity) Placental grading (evaluating placental maturation)
Adjunct for other procedures
Client presentation: o
Vaginal bleeding eval
o
↓ fetal movements
o
Questionable fundal height
o
Preterm labor
measurement in relationship to
o
Questionable rupture of
gestational weeks
membranes
Amniocentesis:
Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into client’s uterus & amniotic sac under direct ultrasound guidance locating the placenta & determining position of fetus. May be performed after 14 wee ks
Indications: o
Maternal age >35 years
o
Previous birth w/ chromosomal anomaly
o
o
o
Prenatal dx of genetic disorder or congenital anomaly of fetus
o
Parent who is carrier of
Alpha fetoprotein level for fetal abnormalities
chromosomal anomaly
o
Lung maturity assessment
Family hx of neural tube defects
o
Fetal hemolytic disease dx
o
Meconium in amniotic fluid
Interpretation of finding:
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o
AFP (protein produced by fetus) can be me asured from the amniotic fluid between 1618 weeks & may be used to assess for neural tube defects in fetus or chromosomal disorders. May be evaluated to follow up a high level of AFP in maternal serum:
High level: associated w/ neural tube defects such as anencephaly (incomplete development of fetal skull & brain), spina bifida (open spine), or omphalocele (abd wall defect). May also be present with normal multifetal pregnancies
Low levels: chromosomal disorders (Down syndrome) or gestational trophoblastic disease (hydratiform mole)
o
Tests for fetal lung maturity may be performed if gestation < 27 weeks in event of rupture of membranes, preterm labor, or for complication indicating C-section. Amniotic fluid tested to determine if the fetal lungs are mature enough to adapt to extrauterine life or if the fetus will likely have respiratory distress. Determination is made whether the fetus should be removed immediately or if t he fetus requires more time in utero w/ the admin of glucocorticoids to promote fetal lung maturity
Fetal lung tests
Lecithin/sphingomyelin (L/S) ratio- a 2:1 indicating fetal lung maturity (2.5:1 or 3:1 for a client w ho has DM)
Presence of phosphatidylglycerol (PG)- absence of PG is associated w/ respiratory distress
Preprocedure for Amniocentesis o
Explain procedure & obtain informed consent
o
Instruct client to empty bladder to reduce risk of inadvertent puncture
Intraprocedure: o
Assist client in supine position & place a wedge or rolled towel under right hip to displace uterus off vena cava & place drape over client exposing only abd
o
Prepare for ultrasound to locate placenta
o
Obtain baseline vitals & FHR & document prior to procedure
o
Cleanse abd w/ antiseptic solution prior to administration of a local anesthetic given by the PCP
o
Advise client that she will feel slight pressure as the needle is inserted for aspiration. However, she should continue breathing because holding her breath will lower the diaphragm against the uterus & shift intrauterine contents\
Postprocedure: o
Monitor vitals, FHR, & uterine ctxns throughout procedure & 30 mins following
o
Have client rest for 30 mins
o
Administer Rhogam if Rh (-)
o
Advise client to report to PCP if she experiences fever, chills, leakage of fluid/bleeding from insertion site, ↓d fetal movement, vaginal bleeding, or uterine ctxns after the procedure
o
Drink plenty of fluids & rest for next 2 4 hours post procedure
Complications:
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o
Amniotic fluid emboli
o
Fetal death
o
Maternal or fetal hemorrhage
o
Inadvertent maternal intestinal
o
Fetomaternal hemorrhage w/
or bladder damage
Rh isoimmunization
o
Miscarriage or preterm labor
o
Maternal or fetal infection
o
Premature rupture of
o
Inadvertent fetal damage or
membranes
anomalies involving limbs
o
Leakage of amniotic fluid
Nursing Actions: o
Monitor vitals, temp, respiratory status, FHR, uterine ctxns, vaginaly discharge
o
Provide med admin as prescribed, client education, & support
Alpha-Fetoprotein Screening
Abnormal finding should be referred for a quad marker scree ning, genetic counseling, ultrasound, & an amniocentesis
Indications: all pregnant clients between 16 & 18 weeks
Interpretation of findings:
o
High levels: neural tube defect or open abd defect
o
Low levels: Down syndrome
Nursing actions: o
Discuss testing w/ client
o
Draw blood sample
o
Offer support & education as needed
Time
Summary of Causes of Bleeding during Pregnancy Complication
S/S
Spontaneous abortion
Vaginal bleeding, uterine cramping, & partial or complete expulsion of products of conception
Ectopic pregnancy
Abrupt unilateral lower-quad pain w/ or w/out vag bleeding
Gestational trophoblastic disease
Uterine size increasing abnormally fast, abnormally high levels of hCG, nausea & ↑ emesis, no fetus present on ultrasound, scant/profuse dark brown or red vag bleeding
Placenta previa
Painless vaginal bleeding
First Trimester
Second Trimester
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Abruptio placenta
Vaginal bleeding, sharp abd pain, & tender rigid uterus
Vasa previa
Fetal vessel cross over the cervix abrupt red vaginal bleeding following ROM
Third Trimester
Other Causes of Bleeding:
Incompetent cervix o
Painless bleeding w/ cervical dilation leading to fetal expulsion
Preterm Labor o
Pink-stained vaginal discharge, uterine ctxns becoming regular, cervical dilation & effacement
Spontaneous Abortion
When a pregnancy is terminated before 20 weeks of gestation or a fetal weight <500 g
Chromosomal abnormalities account for 50%
Provide client education & emotional support
Provide contacts for bereavement support groups
Gestational Diabetes Mellitus:
Impaired tolerance to glucose w/ the first onset or recognition during pregnancy. Ideal blood glucose during pregnancy should be between 70 & 110 mg/dL.
Sx may disappear a few weeks following delivery. Approximately 50% of women will develop DM w/ in 5 years
GDM causes ↑ risks to fetus including: o
Spontaneous abortion r/t poor glycemic control
o
Infections (urinary & vaginal) r/t ↑ glucose in urine & ↓ resistance because of altered carb metabolism
o
Hydramnios, which can cause overdistention of uterus, premature ROM, pre term labor, hemorrhage
o
Ketoacidosis from diabetogenic effect of pregnancy (↑ insulin resistance), untreated hyperglycemia, or inappropriate insulin dosing
o
Hypoglycemia, which Is caused by overdosing in insulin, skipped or late meals, or ↑ exercise
o
Hyperglycemia, which can cause excessive fetal growth (m acrosomia)
Risk Factors: o
Obesity
o
Maternal age >35 y.o
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o
Family hx of DM
o
Previous delivery of infant that was large or stillborn
Subjective data o
Hypoglycemia (nervousness, HA, weakness, irritability, hunger, blurred vision, tingling of mouth or extremities)
o
Hyperglycemia (thirst, nausea, abd pain, frequent urination, flushed dry skin, fruity breath)
Objective Data o
Hypoglycemia
o
Hyperglycemia
o
Shaking
o
Vomiting
o
Clammy pale skin
o
Excess weight gain during
o
Shallow respirations
o
Rapid pulse
Lab tests o
Routine urinalysis w/ glycosuria
o
Glucola screening test/1 hour GTT
o
o
pregnancy
Positive: 140 mg/dL or greater
Additional testing w/ 3 hr GTT is indicated
3-hr GTT
Avoidance of caffeine & abstinence from smoking for 12 hour prior to testing
100 g glucose load given
Ketones tested to assess the severity of ketoacidosis
Dx procedures o
Biophysical profile to ascertain fetal well-being
o
Amniocentesis w/ alpha-fetoprotein
o
Nonstress test to assess fetal well-being
Nursing Care: o
Monitor client’s blood glucose
o
Monitor fetus
o
Instruct client to perform daily kick counts
o
Administer insulin as prescribed
Most oral hypoglycemic agents are contraindicated for GDM, but there is limited use of glyburide at this time. The provider will nee d to make the determination if these meds can be used
o
Educate client about diet, exercise, & self-administration of insulin
o
Desired client outcomes: effectively manage & control blood glucose level throughout her pregnancy to ensure maternal/fetal well-being
Gestational Hypertension/ Pregnancy Induced Hypertension (PIH)
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Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on end organ effects & progresses along a continuum from mild gestational hypertension, mild & severe preeclampsia, eclampsia, & HELLP syndrome
Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the s/s o f pregnancy hypertensive disorders
th
Gestational hypertension (GH), which begins after the 20 week of pregnancy, describes hypertensive disorders of pregnancy whereby the woman has:
o
an elevated BP at 140/90 or greater
o
or a systolic ↑ of 30
o
or a diastolic ↑ of 15 from the prepregnancy baseline
o
no proteinuria or edema
o
client’s bp returns to baseline by 12 w eeks postpartum
Mild preeclampsia: o
GH w/ addition of proteinuria of 1 to 2+
o
Weight gain of more than 2 kg (4.4 lbs) per week in the 2 & 3 trimesters
o
Mild edema will appear in the upper extremities or face
rd
Severe preeclampsia: o
BP >160/100
o
Proteinuria 3 to 4+
o
Oliguria
o
Elevated serum creatinine >1.2
o
nd
o
Hyperreflexia w/ possible ankle clonus
o
Pulmonary or cardiac involvement
mg/dL
o
Extensive peripheral edema
Cerebral or visual disturbances
o
Hepatic dysfunction
(HA & blurred vision)
o
Epigastric & RUQ pain
o
Thrombocytopenia
Eclampsia is severe preeclampsia symptoms along w/ onset of seizure activity or coma. o
Usually preceded by HA, severe epigastric pain, hyperreflexia, & hemoconcentrations, which are warning signs of possible convulsions
HELLP syndrome is a variant of GH in which hematologic conditions coexist w/ severe preeclampsia involving hepatic dysfunction. Diagnosed by lab tests, not clinically: o
H- hemolysis resulting in anemia & jaundice
o
EL- elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, n/v
o
LP- low platelets (< 100,000), resulting in thrombocytopenia, abn bleeding & clotting time, bleeding gums, petechiae, & possibly DIC
Gestational hypertensive disease & chronic hypertension may occur simultaneously
Gestational hypertensive diseases are associated w/ placental abruption, acute renal failure, hepatic rupture, preterm birth, & fetal & maternal death
Risk Factors o
No single profile identifies risks for GH disorders, but some high risks include:
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Maternal age <20 or
>40
Familiar hx of preeclampsia
First pregnancy
DM
Morbid obesity
Rh incompatibility
Multifetal gestation
Molar pregnancy
Chronic renal disease
Previous hx of GH
Chronic hypertension
Assessment of Gestational Hypertensive Disorders Subjective Data
Objective
Lab Findings
Lab Tests
Dx Procedures
Severe continuous HA Nausea HTN Proteinuria Periorbital, facial, hand, & abd edema Epigastric pain RUQ pain Dyspnea Seizures Jaundice Scotoma Diminished breath sounds ↓ Hgb ↑ Creatinine Thrombocytopenia Liver enzymes CBC Clotting studies Dipstick urine for proteinuria 24 hr urine collection for protein & creatinine clearance
Blurred vision Flashes of lights or dots before the eyes Pitting edema of lower extremities Vomiting Oliguria Hyperreflexia Rapid weight gain (2 kg [4.4 lb]) per week nd rd in 2 & 3 trimesters Signs of progression of hypertensive disease w/ indications of worsening liver involvement, renal failure, worsening hypertension, cerebral involvement, & developing coagulopathies ↑Plasma uric acid ↑ liver enzymes (LDH, AST) Hyperbilirubinemia Serum creatinine, BUN, uric acid, & Mg ↑ as renal function ↓ Chemistry profile Nonstress test, ctxn stress test, biophysical profile, & serial ultrasounds to assess fetal status Doppler blood flow analysis to assess fetal well-being
Nursing Care: o
Assess LOC
o
Vitals
o
Pulse ox
o
Lateral positioning
o
Urine output & obtain clean-
o
Perform NST & daily kick counts
catch urine sample to assess for proteinuria o
Meds:
Daily weights
as prescribed o
Instruct client to monitor I&O
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o
Mag Sulfate
Anticonvulsant
Med of choice for prophylaxis or treatment.
Lowers BP & depresses CNS
Use infusion control device to maintain regular flow rate
Inform client she may initially feel flushed, hot, & sedated w/ MgSO4 bolus
Monitor BP, pulse, RR, DTRs, LOC, urinary output (indwelling cath for accuracy), presence of HA, visual disturbances, epigastric pain, uterine ctx ns, & FHR & activity
Fluid restriction of 100 to 12 5 ml/hr, maintain urinary output of 30 ml/hr or greater
o
o
Monitor for signs of mag toxicity:
Absence of patellar DTR
Urine output <30 ml/hr
Respirations <12/min
↓ LOC
Cardiac Dysrhythmias
If mag toxicity is suspected:
Immediately d/c infusion
Admin antidote calcium gluconate
Prepare for actions to prevent respiratory or cardiac arrest
Health Promotion/Disease Prevention
Maintain bed rest & lie in side-lying position
Promote diversional activities
Avoid foods high in Na
Avoid etoh & limit caffeine
↑ fluid intake to 8 glasses/day
Dark quiet environment, avoid stimuli that may precipitate seizure
Patent airway in event of seizure
Admin antihypertensive meds as prescribed
Client outcomes:
Maintain BP w/in acceptable parameters
Client & fetus will remain free of injury
Preterm Labor
Nursing Care: focus on stopping uterine ctxns o
o
Activity restriction
Modified bed rest w/ bathroom privileges
Rest in left lateral position to ↑ blood flow to uterus & ↓ uterine activity
Avoid sex
Ensure hydration
