Ob Ati Study

8/10/2019 Ob Ati Study

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First Trimesterweek 0- 12 gestational age

Month 1

o Ovulation and conception

o During week 4 some home pregnancy tests will detect

o Embryo is two cells

Month 2o Signs of preg e!treme fatigue" fre#uent urinartion" morning

sickness" and hormonal fluctuationso $abys heart is beating

o $rain is formed

Month %

o Embryo becomes fetus

o Decreased morning sickness

o &etus si'e of plum

(omen looking forward to changes that will be more noticeable

)renatal monthly for first * months +ommon discomforts

o ,-." breast tenderness" urinary fre#uency" /0" fatigue" $ra!ton

icks contractions

,utrition

o )atient should gain 132 kg during first trimester

.itals

o $-) at prepregnancy range

Diagnostic )rocedures

o nternal transvaginal ultrasound useful in clients who are obsess

and those in first trimester to detect ectopic pregnancy"abnormalities" and establish gestational age

+auses of bleeding

o Spontaneous abortion

o Ectopic pregnancy

235

o ma6ority of birth defects occur

17312

o &8 can be heard by Doppler


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Second Trimester week 12-28 gestational age

Month 4

o $abys bones are hardening and will now show up on 9ray

o $aby is about : inches long and weighs about : ounces

Month :

o $egin to feel baby kicko $aby;s hearing starts to develop

o +ommon discomforts backaches" indigestion" heartburn"

headaches" water retention" di''iness" constipation

Month t end of this month baby is almost formed


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Month *

o )ossible occurrences of $ra!ton icks contractions

o $rain is beginning to process sights and sounds

o $aby is about 1% inches long

.iability

o 27 weeks whether born or alive .itals

o $) decreases :317 mmg during second trimester

+ommon discomforts

o heartburn" constipation" hemorrhoids" backaches" varicose veins

and ?E edema

,utrition

o Should gain appro!imately 74 kg @1lbAper week in last two

trimesterso >n increase of %47 calories is recommended during 2ndtrimester

Diagnostic )rocedureso >bdominal ultrasound is more useful after first trimester with gravid

uterus is largero 17312 +.S can be performed

+auses of bleeding

o B0D

>fter 12 weeks

o fundal height

>fter 14

o >mniocentesis

1" a combo

analysis of +B" and estriol

27

o $) returns to prepregnancy baseline

o )ulse increases 1731: minutes and remains increased

o More distinguishable splitting of S1 s2

153%2

o measurement of fundal height @appro!imates gestational ageA

24325

o ndirect +oombs 0est for 8h3 and not sensiti'ed mothers repeated


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Third Trimester week 28-40 gestational age

Month 5

o $aby is fully formed and putting on weighto $aby;s lungs almost fully developed

Month

o +ommon discomforts $ra!ton icks" pelvic pressure" difficulty

sleeping

)renatal appointments every 2 weeks in the 5 thmonth every week in the

last month

0erm

o %5 weeks or more

)reterm

o

27 up to %* weeks ,utrition

o Should gain appro!imately 74 kg @1lbAper week in last two

trimesterso >n increase of4:2 calories is recommended

+ommon discomforts

o urinary fre#uency" /0" fatigue" heartburn" constipation" backaches"

leg cramps" varicose veins and ?E edema" increased intensity andfre#uency of $ra!ton icks contractions

Diagnostic )rocedures

o May be used in con6unction with abdominal scanning to evaluate for

preterm laboro ,onstress 0est performed

+auses of bleeding

o )lacenta previa" abruptio placenta

%dditional intake of 477 calories a day during second dvise client to drink 132 #uarts of fluid prior to fill the bladder" lift

and stabili'e uterus" displace bowel" and act as an echolucent tobetter reflect waves

o Supine position with wedge placed under right hip to displace

uterus @prevent supine hypotensionA

Education for transvaginal-

o ?ithotomy position

o )ressure may be felt

Biophysical Profile (BPP)

/ses real time /S to visuali'e physical and physiological characteristics offetus and observe for fetal biophysical responses to stimuli

.ariables

o 8eactive &8

o &etal breathing movements

@at least 1 episode of greater than %7 duration %7 minutesAF2

o Bross body movements

@at least % body or limb e!tensions with return to fle!ion in

%7 minutesAo &etal tone

@at least on% episode of e!tension with return to fle!ionF2A

o Cualitative amniotic fluid volume @

at least one pocket that measures at least 2 cm in 2

perpendicular planesA

&indings

o 5317 Normal

o 43


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)otential d!

o ,onreactive stress test

o Susp oligo or polyhydraminos

o Susp fetal hypo!emia or hypo!ia

)resentation

o )8OMo Maternal infecion

o Decreased fetal mvt

o /B8

Nonstress test (NST)

Most widely used for eval of fetal well being

%rdtrimester

>llows nurse to assess &8 in relationship to fetal movement

)otential d!

o >ssessing for intact +,S in %rd

trimestero 8uling out risk for fetal death in clients who have DMH used twice a

week or until after 25 weeks

)resentation

o Decreased fetal mvt

o /B8

o )ostmaturity

o Bestational DM

o Bestational 0,

o Maternal chronic 0,

o

! of previous fetal demiseo >dvanced maternal age

o Sickle cell disease

o soimmuni'ation

nterpretation of findings

o 8eactive3 if &8 is at a normal baseline rate with moderate

variability" accelerates to 1: beats-min for at least 1: seconds andoccurs two or more times during a 27 minute period

o ,onreactive3 ndicates &8 does not accelerate ade#uately with

fetal movement Doesn;t meet above criteria after 47 min f so"further eval needed @+S0 or $))A

,ursing actionso 8eclining chair or semi3&owlers" or left lateral position

o f fetus sleeping @no movementsA vibroacoustic stimulation may be

activated for % seconds

Disadvantage3 high rate of false nonreactive results due to fetal movement

response blunted by sleep cycles" fetal immaturity" maternal medications" andchronic smoking


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ontraction Stress Test (ST)

,ipple stimulation consists of woman lightly brushing her palm across nipple

for two minutes" causing pituitary gland to release endogeous o!ytocin andthen stopping when contraction begins

>nalysis of &8 response to contractions @decrease placental blood flowAdetermine how fetus will tolerate stress of labor

> pattern of at least % contractions within a 17 minute time period with a

duration of 473 negative +S0 @normalA indicated if within 17 minute period" with %

uterine contractions" there are no late decels of &8o )ositive @>bnormalA indicated with persistent and consistent late

decelerations on more than half of the contractionsSuggestive of uteroplacental insufficiency

.ariable deceleration3 cord compression

Early decel3 fetal head compression

o $ased on findings" can determine to induce labor or +sec

,ursing >ctions

o . o!ytocin

f hyperstimulation of uterus" or )0? occurs

Monitor contractions lasting longer than 7 seconds

or occurring more fre#uently than every 2 min

)rovide tocolytics

Maintain bed rest

Observe client for %7 min after to see contractions

have ceased and )0? doesn;t beginAmniocentesis

0he aspiration of amniotic fluid for analysis by insertion of a needle

transabdominally into a clients uterus and amniotic sac under diret ultraoundguidance locating the placenta and determining position of fetus

>fter 14 weeks gestation

ndications

o )revious birth with chromosome anomallyo )arent carrier

o &am h! of neural tube defects

o )renantal d! of genetic disorder

o >lpha fetoprotein level for fetal abnormalities

o ?ung maturity assessment

o &etal hemolytic disease


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o Meconium in amniotic fluid

nterpretation

o >&)

+an be measured from amniotic fluid btw 1lso present with normal multifetal pregnancies

>nencephaly3 incomplete development of fetal skull

and brain

Spina bifida3 open spine

Omphalocele3 abdominal wall defect

?ow levels

+hromosomal disorders @downsA or B0D @molarA

o 0ests for fetal lung maturity

+an be done if gestation is less than %* weeks" in the eventof 8OM" )0?" or complication indicating +sec

Determines whether fetal can live outside or if needs to be

in6 with glucocortcoids to enhance lung maturity %ecit#in&spingomyelin '%&( ratio)

21 ratio indicating fetal lung maturity

*resence of p#osp#atidylglycerol '*+)

>bsence associated with fetal respiratory distress

,ursing actions

o Empty bladder prior

o )rior to procedure obtain &8" baseline .-So Supine position with wedge

o +ontinue breathing because holding her breath with lower

diaphragm against uterus and shift intrauterine contentso Monitor .S" &8" and uterine contractions through and %7 min

following procedureo ave client rest %7 min

o >dminister rhogam to rh3

o )ost procedure3 drink plenty of li#uids and rest 24 hours pp

Percutanous Um!ilical Blood Sampling ("igh #is$ Pregnancy)

Most common method used for fetal blood sampling and transfusion

nterpretation

o Evaluates for isoimmune fetal hemolytic anemia and assesses

need for fetal blood transfusion

+omplications

o +ord laceration" )0?" amnionitis" hematoma" fetomaternal

hemorrhage


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horionic %illus Sampling ("igh #is$ Pregnancy)

>ssessment of a portion of the developing placenta which is aspirated

through a thin sterile catheter or syringe inserted through the abdominal wall

or intravaginally though cervi!

&irst trimester alternative to amniocentesis @advantage3early diagnosis of

abnormalitiesA

+an be performed 17312 weeks gestation and rapid results in 24325 hr

+annot determine spina bifida or anencephaly

,ursing >ction

o &ill bladder prior

+omplications

o Spontaneous abortion @higher risk than with amniocentesisA

o 8isk for fetal limb loss

o

Miscarriageo +horioamnionitis and rupture of mems

>dvantage should be weighed heavier than disadvantage

&uad 'ar$er and Alpha Fetoprotein (AFP) Screening

Cuad marker

o blood test that ascertains information about the liklihood of fetal

birth defectso Does not diagnose actual defect

o More reliable findings than >&)

o h+B3 hormone by placenta

o >&)3 protein produced by fetuso Estriol3 protein produced by fetus and placenta

o nhibin >3 protein produced by ovaries and placenta

o 1&) I Downs risk

o igh levels >&) I neural tube defect risk

o igher levels than e!pected of h+B and inhibin >3 risk for downs

o ?ower levels than e!pected of estriol3 risk for downs

Maternal serum alpha fetoprotein

o Screening tool used to detect neural tube defects

o >bnormal findings3 refer for #uad marker screening" geneticcounseling" /S" and amniocentesis

o >ll preg clients 1


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Spontaneous A!ortion

Ectopic Pregnancy

estational Tropho!lastic isease

Placenta Pre*ia

A!ruptio placenta

Infections

"+%/A+S

T,#" infections

roup B streptococcus B "emolytic

hlamydia

onorrhea

andida Al!icans

Medical Conditions

+ncompetent er*i- (#ecurrent premature dilation of cer*i-)

"yperemesis ra*idarum

Anemia

estational '

estational "TN

Early Onset of Labor

Preterm .a!or

o /terine contractions that occur between 273%* weeks gestation

Premature #upture of 'em!ranes Preterm Premature rupture of

mem!ranes

Labor and Delivery Process

(hen assessing amniotic fluid post rupture" amniotic fluid should be watery"

clear" and pale to straw yellow in coloro Odor should not be foul


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o .olume should be between :7731277 m?

o ,itra'ine paper used to confirm presence

>mniotic fluid is >?J>?,E

)aper should be deep blue" indicating a p of ffect and Define ?abor and $irth )rocesso )assenger +onsists of the fetus and placenta 0he si'e of the fetal

head" presentation" lie" attitude" and position affect the ability of thefetus to navigate the birth canal

)resentation )art of fetus that is entering pelvic inlet first

t can be the back of the head @occiputA" chin

@mentumA" shoulder @scapulaA" or breech @sacrum orfeetA

?ie 0he relationship of the maternal longitudinal a!is @spineA

to the fetal longitudinal a!is @spineA

0ransverse fetal long a!is is hori'ontal and forms aright angel to maternal a!is and will not accommodatevaginal birth 0he shoulder is the presenting part andmay re#uire +sec if doesn;t rotate spontaneously

)arallel or longitudinal &etal long a!is is parallel to

maternal long a!is" either a cephalic or breechpresentation $reech may re#uire +section

>ttitude 8elationship of fetal body parts to one another

&etal fle!ion chin fle!ed to chest" e!tremities fle! into

torso

&etal e!tension chin e!tended away from chest"

e!tremities e!tended

&etopelvic or fetal position 0he relationship of the

presenting part of the fetus" preferably the occiput" inreference to its directional position as it relates to 1 of the 4maternal pelvic #uadrants ?abelled with % letters

&irst letter3 either 8 or ? side of maternal pelvis

Second letter3 references the presenting part of the

fetus" O @occiputA" S @sacrumA" M @mentalA" or scapula@ScA

0hird letter either > @anteriorA" ) @posteriorA" or 0

@transverseA part of maternal pelvis

Station measurement of fetal descent in cm with

station 7 being at the level of an imaginary line at thelevel of the ischial spines" minus stations superior tothe ischial spines" and plus stations inferior to theischial spines

o )assageway 0he birth canal that is composed of the bony pelvis"

cervi!" pelvic floor" vaginal" and introitus @vaginal openingA 0he si'e


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and shape of the bony pelvis must be ade#uate to allow the fetus topass through it 0he cervi! must dilate and efface in response tocontractions and fetal descent

o )owers uterine contractions cause effacement and dilation of the

cervi! and descent of the fetus nvoluntary urge to push and

voluntary bearing down in the second stage of labor helps ine!pulsion of the fetuso )osition of the woman who is in labor 0he client should engage in

fre#uent position changes during labor to increase comfort" relievefatigue" and promote circulation )osition during the second stageis determined by maternal preference" provider preference" and thecondition of the mother and fetus

Bravity can aid in the fetal descent in upright" sitting"

kneeling" and s#uatting positionso )sychological responses maternal stress" tension" and an!iety can

produce physiologic changes that impair progress of labor

,ursing nterventions for ?abor and $irth *reprocedure

o ?eopold maneuvers abdominal palpation of the number of fetuses"

the fetal presenting part" lie" attitude" descent" and the probablylocation where fetal heart tones may be best ausculatated on thewomans abdomen

o E!ternal electronic monitoring @tocotransducerA separate

transducer applied to the maternal abdomen over the fundus thatmeasures uterine activity

Displays uterine contraction patterns

Easily applied by nurse but must reposition with maternal

movement to ensure proper placemento E!ternal fetal monitoring @E&MA transducer applied to the abdomen

of the client to assess &8 patterns during labor and birtho ?abs

Broup $ Strep %


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o >ssess &8 to determine fetus well being May be performed with

use of E&M of spiral electrode applied to scalp )rior to electrode placement" cervical dilation and 8OM must

occuro >ssess uterine labor contraction characteristics by palpation @hand

over fundus to assess contraction fre#uency" duration" andintensityA or by the use of e!ternal or internal monitoring

&re#uency beginning of one contraction to beginning of ne!t

Duration time between beginning of a contraction to end of

that same contraction ntensity strength of contraction at its peak @mild" moderate"

strongA 8esting tone of uterine contraction tone of uterine muscle

between contractions

> prolonged contraction duration @longer than 7

secondsA or too fre#uent @more than : in 17 min

periodA withoutsufficient time for uterine rela!ation@less than %7 secondsA can reduce blood flow toplacenta 0his can result in fetal hypo!ia or decreased&8

o nsert sold" sterile" water3filled intrauterine pressure catheter inside

uterus to measure intrauterine pressure /terine contractions displayed on monitor

8e#uires 8OM and cervi! sufficiently dilated

o .ag e!am3 performed digitally to assess

+ervical dilation @stretching of cervical os ade#uate to allow

fetal passageA effacement @cervical thinning andshorteningA Descent of fetus through birth canal as measured by fetal

station in cms &etal position" presenting part" lie

Membranes intact or ruptured

Mechanisms of ?abor adaption;s fetus makes as it progresses through birth

canalo Engagement when presenting part" usually biparitetal @largestA

diameter of the fetal head passes the pelvic inlet at the level of theischial spines 8eferred to as station 7

o Descent the progress of the presenting part @preferably occiputAthrough the pelvis Measured by station during vag e!am as eithernegative station measured in cm;s if superior to station 7 and notyet engaged" or K station measured in cms if inferior to station 7

o &le!ion when the fetal head meets resistance of the cervi!" pelvic

wall" or pelvic floor 0he head fle!es" bringing the chin close to thechest" presenting a smaller diameter to pass through the pelvis


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o nternal rotation the fetal occiput ideally rotates to a lateral anterior

position as it progresses from the ischial spines to the lower pelvisin a corkscrew motion to pass through the pelvis

o E!tension the fetal occiput passes under the symphysis pubis" and

then the head is deflected anteriorly and is born by e!tension of the

chin away from the fetal chesto 8estitution and e!ternal rotation after the head is born" it rotates to

the position it occupied as it entered the pelvic inlet @restitutionA inalignment with the fetal body and completes a #uarter turn to facetransverse as the anterior shoulder passes under the symphysis

o E!pulsion after birth of head and shoulders the trunk of the

neonate is born by fle!ing it toward the symphysis pubis

Stages of ?abor


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o First Stage

Duration 12: hr

$egins with Onset of labor

Ends with +omplete dilation

Maternal characteristics +ervical dilation 1 cm-hr for

primigravida" and 1: cm-hr multigravida @on averageAo %atent *#ase

Duration

)rimigravida < hr

Multigravida 4 hr

$egins with

+ervi! 7 cm

rregular" mild to moderate contractions

&re#uency :3%7 min

Duration %734: seconds

Ends with +ervi! % cm

Maternal characteristics Some dilation and effacement"

talkative and eageroctive *#ase

Duration

)rimigravida % hr

Multigravida 2 hr

$egins with

+ervi! 4 cm

More regular" moderate to strong contractions

&re#uency %3: min Duration 473*7 seconds

Ends with

+ervi! dilated * cm

Maternal characteristics

8apid dilation and effacement

Some fetal descent

&eelings of helplessness

>n!iety and restlessness increase as contractions

stronger

o Transition

Duration

27347 min

$egins with

+ervi! 5 cm

Strong to very strong contractions

&re#uency 2 to % min


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Duration 4:37 seconds

Ends with +omplete dilation at 17 cm


0ired" restlessness" irritable

&eeling out of control" Lcannot continue=

,-.

/rge to push

ncreased rectal pressure and feelings of needing to

have a $M

ncreased bloody show

Most difficult part of labor

Sources of pain

nternal visceral pain that may be felt as back or leg

pain" caused byo Dilation" effacement" and stretching of cervi!

o Distention of lower segment of uteruso +ontractions of uterus with resultant uterine

ischemiao Second Stage

Duration

)rimigravida %7 min32 hr

Multigravida :3%7 min

$egins with

&ull dilation

)rogresses to intense contractions every 132 min

Ends with $irth

Maternal characteristics )ushing results in birth of fetus

)ain

Somatic and occurs with fetal descent and e!pulsion

+aused byo )ressure and distension of vagina and

perineum described as Lburning" splitting" andtearing

o )ressure and pulling on pelvic structures

@ligaments" fall tubes" ovaries" bladder" andperitoneumA

o ?aceratons of soft tissue

o 0hird Stage

Duration :3%7 min

$egins with Delivery of neonate

Ends with Delivery of placenta


)lacental separation and e!pulsion


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Schult'e presentation shiny fetal surface of placenta

emerges first

Duncan presentation dull maternal surface of

placenta emerges first

)ain

)ain with e!pulsion of placenta is similar to paine!perienced during the first stage +aused by

o /terine contractions

o )ressure and pulling of uterine structures

o &ourth Stage

Duration 134 hour

$egins with Delivery of placenta

Ends with Maternal stabili'ation of .S


>chievement of .S homeostasis

?ochia scant to moderate rubra

)ain

+aused by distention and stretching of vagina and

perineum incurred during the second stage with asplitting" burning" and tearing sensation

aternal .( / 1 min for first #our t#en according to

protocol

ssess fundus and loc#ia / 1 min for first #r

assage uterine fundus and or administer o$ytocies as

prescri!ed to maintain uterine tone to prevent #emorr#age

ssess perineum and provide comfort measures as needed

Encourage voiding to prevent !ladder distension

!onding

Pain Control

non pharmalogical

o Bate control theory of pain

Sensory strategies

+utaneous strategies

Effleurage light gentle circular stroking of pts

abdomen with fingertips in rhythm with breathing

during contractions Sacral counterpressure consistent pressure applied

by support person using heel of hand or fist againstsacral area to counteract pain in lower pact

ydrotherapy increases endorphin levels

o &re#uent maternal position changes to promote rela!ation and pain

relief semi3sitting" s#uatting" kneeling" kneeling and rocking back


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and forth" supine position only with placement of wedge under oneof hips to tilt uterus and avoid hypotension

)harmacological

o>nalgesia

Opiod analgesics

Sedatives @barbituatesA such as secobarbitual"pentobarbitual" and phenobaritual" ,O0 /SEDD/8,B $80" $/0 D/8,B >+0.E O8 ?>0E,0)>SE 0O 8E?E.E >,9E0N >,D ,D/+E S?EE)

>dverse effects of sedatives

o ,eonate respiratory depression secondary to

med crossing plcenta and affecting fetusShould not give 12324 hr

o /nsteady walking

o nhibition of ability to cope with labor

Meperidine hydrochloride @DemerolA" fentanyl

@sublima'eA" butorphanol @stadolA" and nalbuphine@,ubainA act in +,S to decrease perception of painwithout loss of consciousness . or M

o $utorphanol and nalbuphine provide pain releft

without causing significant respiratorydepression

o>dverse effects

)rior to administering" ensure labor is established"

perform . e!am and cervical dilation at least 4 cmand fetus well engaged

>dminister antiemetics Monitor maternal .S" uterine contraction pattern" and

continue &8 monitoring

,alo!one @,arcanA

Opioid antagonist for reversal of opioid reduced

respiratory depression

Ondansetron @ofranA

o Epidural and spinal regional analgesia

+onsist of &entanyl @Sublima'eA and sufentanil @SufentaA

which are short acting opiods that are administered as amotor block into the epidural or intrathecal space withoutanesthesia )roduce regional anagsic providing rapid painrelief while allowing pt to sense contractions and maintainability to bear down

>dverse effects

)harmacological >nesthesia

o 8egional blocks

Most common


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)udendal block

+onsists of local anesthetic administered

transvaginally into the space in front of the pudendalnervea

Additional

Urine output should e-ceed 01 m./hrSerum magnesium maintenance le*el is 234 mE5Uric acid range 63787mg/dl

&etal heart tones of fetus in ? sacrum anterior position3 ?/C

&0 8 sacrum anterior position 3 8ight upper #uadrant

&0 of fetus in left occipital anterior best heard ??C

&0 of fetus n right occipital anterior position 8?C

Documents

Ob Ati Study