NURS 4341 OB Exam 1 Objectives Review - University of Texas.

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Preconception and Early Prenatal Care 

Identify primary purpose and key components of preconception health care. o HELPS mom get the best health prior to conception o GET chronic illness under control o CHANGE diet/ meds to improve outcomes  We want all women to see their provider before trying to get pregnant.

Conception and Fetal Development 

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Examine the basic functions/purpose of the placenta, umbilical cord, and amniotic fluid. o Placenta: acts as the respiratory center, nutrition center, excretion, storage of nutrients (carbs, protein, Ca+, Fe+)  Like a grocery store- provides storage for later use o Umbilical cord: 3 vessel cord  2 arteries- carries blood away (de-oxy blood)  1 vein- carries blood to the fetus (oxy blood)  These vessels do the EXACT opposite, arteries are smaller in size and veins are larger in size) o Amniotic fluid: functions as thermoregulation, oral fluid, cushion from trauma, freedom of mvmt for musculoskeletal develop., fetal lung development.

Classify the fetal causes of oligohydramnios and hydramnios (also known as polyhydramnios)  AF abnormalities  Oligohydramnios: <500ml of AF  Too little can cause resp or urinary syst. Problems  Hydramnios (polyhydramnios): > 2000ml of AF (at term)  Possible causes could be maternal DM (maybe the mom isn’t controlling her DM)  Too much can cause NTD (neural tube defect), or other CNS defects, chromosomal deviations, GI issues.

Maternal Adaption in Pregnancy 

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Differentiate between subjective (presumptive), objective (probable), and diagnostic (positive) signs of pregnancy. Pg.333 o Presumptive: things mom feels; subjective data  Queasy, breast tenderness, morning sickness o Probable: Objective: related S/S but could be something else  Change in color of cervix (seen in pap smear tests) o Diagnostic (Positive changes): can’t be attributed to anything except pregnancy  Hearing fetal HR, seeing baby in the ultrasound.

Correctly determine a woman’s GTPAL and EDC when given a case history. o G/P- only gives minimal info  G- gravida (# of pregnancies)  P- Para (# of pregnancies reaching 20 weeks) o GTPAL: tells a better way to document a woman’s case history.

GRAVITY: # of preg (NOT BABIES) TERM: babies btw. 38-42 weeks (anything beyond 38) PRETERM: # of preg before 37 weeks ABORTION: preg lost before 20 weeks LIVING: number/ outcome of babies  Note that GTPA is only the outcome of the pregnancy not the baby; the outcome of baby is only in the L.  Also note that the P in G/P means different from GTPAL Correctly determine a woman’s EDC when given a case history. o Nagele’s Rule: method to determine due date  LNMP: first thing to know is that a preg is 40 weeks from the first day of her last menstrual period  Subtract 3 months, add 7 days to estimate due date (based on LNMP) Outline normal maternal physiologic changes that occur during pregnancy.

Pg.335 +346 table 11.4 o Uterus:  Braxton Hicks: “practice” contractions begin to facilitate blood flow thru intervillous spaces.  Be able to instruct mom on the diff. btw. Signs of Braxton Hicks vs. Pre-term labor  Braxton hicks- does not change the cervix, Normal  If <6 contractions in an hour  Drink 1L of fluid  Lay on the side  If all methods end up working and contractions go away= Braxton Hicks  If they don’t go away= Call the Dr.  And preterm labor- can change the cervix o The breasts: changes caused by estrogen and progesterone  Breast becomes larger and more nodular  Superficial veins become more prominent  Nipples are more erectile, nipples and areola become enlarged and darker  Montgomery follicles enlarge  Colostrum may appear by the 12th week. (Early breast milk) o Cardiovascular syst.  Heart is displaced upward, to the left and rotates forward  HR increases and BP decreases  (if BP is too high or too low- manually check the BP again before calling Dr. about BP issues. You’ll be asked if it was performed manually)  Physiologic anemia of Pregnancy: blood volume increases by approx.

40-50% (increased amount of RBC along with plasma, however plasma doubles more than RBC which makes RBCs look diluted in plasma) there is a dilutional reduction in RBCs  Normal Hgb 12-16g/dL  For preg women- normal is 11-14  Normal Hct is 37-47%  For preg women- normal is 32-42     

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NOTE: Even though Hgb & Hct are low for the preg women, you’ll know that preg woman have increased their blood volume (oxygen carrying RBCs- even though the numbers don’t look like it)  Don’t consider a preg woman anemic until they drop below Hgb=11 & Hct=33  Erythrocyte volume increases by 30% with iron supplements than without it which is 18% (Medications given will include iron supplements along with folate) Leukocyte production ↑, normal = 5000-15,000 (normally in med-surg ↑WBCs of 10,000= infection) however with preg, a woman can get about 15,000-20,000 maybe even more during labor- because of all the work the body must do. NOT AN INFECTION  “In OB we tx. Symptoms not lab values”- there will obviously be values that are too low that a nurse will need to intervene but the values are much different than a regular sick patient who isn’t preg.

Fibrin and Fibrinogen levels ↑: at risk for strokes!  Hypercoagulable state which leads to ↑ risk for DVTs  No crossing the legs when sitting  Have her move around- walk if sedentary lifestyle, if too active- take breaks, lift up feet.  For antepartum unit: some preg women are admitted for preg complications, bedrest  have them on SCDs as well as after Csec delivery on postpartum.  Risk of DVTs does not ↓ until 6-8 weeks after preg. Ends ***Aortocaval Syndrome of Pregnancy/ Supine Hypotension: ****  Enlargement of the uterus puts pressure on the descending aorta and inferior vena cava.  This happens after ~16wks  Dangerous for the mom and baby since mom isn’t getting blood back into the heart which in turn baby isn’t getting rid of his O2  Apply a wedge, even a small pillow or rolled up blanket to prevent 

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Note: that these changes in systems does not all happen at once. Some appear at different stages in preg. You do not have to know when these stages are. o Respiratory Syst:  Estrogen relaxes ligaments in the rib cage. Diameter ↑ and lower ribs flare out.  RR↑/ Dyspnea may occur (sensation of dyspnea is more common than the actual dyspnea)- have mom sit up straight, shoulders back, deep breaths  pH is 7.40-7.45 (more alkalotic) partially compensated resp. alkalosis= GOOD THING  the more alkalytic moms, the more she can off load her O2 to her baby and pick up her baby’s waste products MUCH FASTER.

Any mom with resp. conditions: asthma, COVID, pneumonia; she wont be able to exchange gases with her baby as well and she’ll get in respiratory decompromise much faster during preg.

Urinary Tract:  Pressure on the bladder during the 1st & 3rd trimester leads to urinary freq. (teach mom’s the diff. btw. Normal changes in preg. and UTIs)  Normal ↑ urgency in preg: when a preg woman pees after urge, they pee normal amounts & just in time. It does not hurt, burn, no cramping.  UTIs: burning when peeing, they may not make it on time, painful when peeing, having trouble to start peeing  Dilation of ureters and kidneys (renal pelvis) can occur, leading to ↑ risk of bladder infection progressing to kidney infection.  Greater reabsorption of Na+ to meet fetal needs b/c of ↑ of fluid and ↑ intravascular volume- isotonic state (getting rid of waste for 2)  Renal blood flow (therefore waste removal is best in lateral position, and least effective supine  Spilling of glucose may occur and doesn’t necessarily mean DM & spilling of a trace amt. of protein= theses are NORMAL findings in preg.

Hair & Skin: changes caused by estrogen & progesterone  Anything that is a darker area will get darker.  Pigmentation ↑ at the areolas, nipples, vulva, perianal area and the linea nigra  Integumentary syt,:  Striae gravidarum (badge of honor- stretch marks)  Palmar erythema  Sweat & sebaceous gld. Are hyperactive  Stretch marks (striae) may develop on abdomen, breasts and thighs  Vascular spider veins may appear  Hair and nail growth may ↑ Musculoskeletal syst:  Progesterone & relaxin cause loosening of the pelvic joints  The lumbodorsal curve of the spine ↑  Lordosis may occur to compensate  Diastasis recti- separation of the rectus abdominis Neurologic syst:  Compressions of the nerves s may occur due to edema (carpal tunnel syndrome), compression by the gravid uterus (sciatic pain), or changes in posture  Faintness and syncope may occur – (rise slowly, don’t lay on back)  Muscle cramping may occur GI Syst:  hCG causes changes in carbohydrate metabolism, leading to morning sickness (maybe increasing a small protein snack at bedtime may help with morning N/V)- like diabetes patients (cottage cheese, cheese, PB)believed to be associated with having a low BS when waking up.  Taste and smell may be altered  Gum tissue softens and may bleed; growths (epulis) can occur on the gums  Ptyalism (increased saliva) may occur, saliva more acidic- dental issues (advice mom to carry around a spit cup or rinse their mouth + spit) 

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Progesterone relaxes the cardiac sphincter and slows gastric emptying and intestinal motility; causes increased reabsorption of water and electrolytes in the large intestine  Causes increased heartburn and constipation (eat smaller more frequent meals – don’t have fluid with meals). <-- for constipation relief you do want mom to drink lots of fluid just not with meals. TUMS are allowed to relieve but if TUMS is the only method of getting calories in; then they need to speak with their Dr.  If Fe tablets cause N/V instruct mom to take it at night at bedtime (do not take w/ meals- b/c it will prevent from being absorbed. Do not take with milk to coat their stomach b/c the Ca+ will bind with Fe+ and excrete out of body in which they will not get any use from the iron.)  The growing uterus puts upward pressure on the stomach and displaces the intestines (increases risk of constipation – teach to increase fluid/fiber)  Gallbladder emptying slows – may lead to gall stones ↑ risk: obesity.

Hispanic ethnicity, AMA (advanced maternal age- mom will be 35yo or older at the time she delivers) indepen. Risk fct. o Endocrine Syst:  A lot of hormonal changes – allows changes in breast/uterus tissue, drives BP and vascular changes etc.  Progesterone – hormone considered essential to pregnancy  FYI: Some moms that have a history of freq. preg. Losses- esp. during 3rd trimester- called habitual aborters: can get preg. But can’t stay preg., often go to the hospital to receive progesterone therapy and that tends to serve the uterus enough to help prevent a miscarriage.  Maternal hypothyroidism: most likely need to increase medication  Can compromise fetal neurological development.  Insulin and glucose utilization changes – initially maternal insulin increases – then in later half of pregnancy – insulin resistance increases o The Immune System  Increased capacity to fight bacterial infection (normal increase in WBC – does not indicate an infection) just a response to immune syst.

Changes.  Decreased ability to fight viral infections  Local immune suppression in the reproductive tract – prevents maternal rejection of fetus Characterize the emotional and psychological changes/stages that occur during pregnancy, for both mother and her partner. Pg.355 o Psychological Adaptation to preg: Accepting preg.- family/ couple  “Cognitive restructuring” occurs over the course of the preg.  Emotional liability is common (excited and fearful at the same time?!

OMG!)  Uncertainty (ambivalence) is common o Maternal Adapt. To Preg.: Establishing Relationship with Fetus  Phase 1: “I am pregnant.”  views the child as part of her- introspection  Phase 2: “I am going to have a baby.”  Growing awareness of the baby as a separate being enhanced by quickening, hearing FHR’s & ultrasound visualization. 

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A period of introspection then moving to acceptance, partner may feel left out. Other children may be more demanding.  Phase 3: “I am going to be a mother.”  mother speculates about the characteristics of the baby; family members interact with the baby. Getting ready for safe passage of the newborn. o Preparing for childbirth:  Active prep thru education  Anxiety about safety, attitudes of caregivers, appropriate behavior  Growing discomforts of preg. Leads to anticipation of birth o Paternal adaptation: Acceptance of the Pregnancy  Starting to accept, may be ambivalent  Negotiating role in labor and parenting  Active involvement in the preg. And relationship with his child; begins to think of himself as the father.  Questions about the baby ↑ as pregnancy progresses  May be involved in choosing the baby’s name  May have “Couvade Syndrome” 

Maternal Nutrition Summarize the nutritional needs of the pregnant woman and her fetus and how the woman can meet these. Pg.346 o Key Points  Nutritional status before, during, and after pregnancy contributes to the woman’s well-being and to that of her developing fetus and newborn  Physiologic changes influence need for additional nutrients and the efficiency with which the body uses them  Both total maternal weight gain and the pattern of weight gain are important for the outcome of pregnancy o Explain recommended maternal weight gain and patterns of appropriate maternal weight gain during each trimester of pregnancy.

Underweight (BMI >18.5) total weight gain range = 28–40 lb Normal weight (BMI = 18.5–24.0) total weight gain range = 25–35 lb Overweight (BMI = 25–29) total weight gain range = 15–25 lb Obese (BMI = 30 or higher) total weight gain range = 11–20 lb · First trimester – 1-2.5 kg (3.5-5 lb TOTAL) · 2nd & 3rd trimesters – 0.4 kg (1 lb/week)   Appropriateness of the mother’s pre-pregnancy weight for height (BMI) is major determinant in recommended weight gain  Nutritional risk factors include adolescent pregnancy; bizarre or faddish food habits; abuse of nicotine, alcohol, or drugs; low weight for height; and frequent pregnancies  Iron supplementation recommended during pregnancy  Some controversy regarding beneficial effects on successful outcome of pregnancy  Other supplements may be recommended for nutritional risk factors  Cultural and personal values and beliefs influence nutrition counseling 

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Nutrition-related complications: anemia, gestational hypertension, gestational diabetes, and intrauterine growth restriction Identify sources of essential nutrients for a woman with lactose intolerance or who is vegetarian. Pg353 (Chap 11) o Lactose Intolerant  Additional or substitute sources of calcium may be necessary. These may include peanuts, almonds, sunflower seeds, broccoli, salmon, kale, and molasses (Pearlman & Akpotaire, 2019). In addition, encourage the woman to drink lactose-free dairy products or calcium-enriched orange juice or soy milk. o Vegetarian:  Pregnant vegetarians must pay special attention to their intake of protein, iron, calcium, and vitamin B12. Suggestions include: o For protein: Substitute soy foods, beans, lentils, nuts, grains, and seeds. o For iron: Eat a variety of meat alternatives along with vitamin C–rich foods. o For calcium: Substitute soy, calcium-fortified orange juice, and tofu. o For vitamin B12: Eat fortified soy foods and a B12 supplement. o Additional or substitute sources of calcium may be necessary. These may include peanuts, almonds, sunflower seeds, broccoli, salmon, kale, and molasse. In addition, encourage the woman to drink lactose-free dairy products or calcium-enriched orange juice or soy milk. o Pregnant and breast-feeding vegan women should be sure to consume reliable sources of vitamin B12 and vitamin D which they may be lacking. For protein: Substitute soy foods, beans, lentils, nuts, grains, and seeds. 

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Develop a teaching plan outlining safety related to seafood/meat/ food during pregnancy to prevent food-based complications. Pg350 o nearly all fish and shellfish contain traces of mercury, and some contain higher levels of mercury that may harm a developing fetus if ingested by pregnant women in large amounts. o Mercury exposure in pregnancy has been associated with both pregnancy complications and developmental problems in infants. All pregnant women should avoid these potential problems to minimize any risk. advise women who may become pregnant, pregnant women, and nursing mothers to:  avoid consumption of fish with moderate to high mercury levels (e.g., for 6 to 12 months prior to conception and throughout pregnancy).  avoid eating shark, swordfish, king mackerel, orange roughly, ahi tuna, and tilefish because they are high in mercury levels.  eat up to 12 oz (two average meals) weekly of fish known to have low mercury levels, such as shrimp, canned light tuna, salmon, lobster, sole, tilapia, cod, haddock, pollock, and catfish.  check local advisories about the safety of fish caught by family and friends in local lakes, rivers, and coastal areas (USFDA, 2019a).

Identify food sources of folic acid, iron, non-dairy calcium, and non-meat protein. Pg.354 o Folate-Rich foods

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Vegetables: Broccoli, Brussel Sprouts, cabbage, cauliflower. English spinach, green beans, lettuce, mushrooms, Parsnip, sweet corn, zucchini Fruit: Avocado, grapefruit, orange Legumes: chickpeas, soya beans, lima beans, red kidney beans, lentils, haricot beans Eggs Nuts Juices: many apple and orange juices

o Iron: red meats, poultry and fish and dark green vegetables, iron enriched cereals and grains o Substitute sources of calcium may be necessary these may include peanuts, almonds, sunflower seeds, broccoli, salmon, kale, and molasses o Non-meat protein includes soy foods, beans, lentils, nuts, grains and seeds.

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Explain recommended maternal weight gain and patterns of appropriate maternal weight gain during each trimester of pregnancy. Pg.351 o Maternal Weight Gain – Know expected for a normal weight mom!!  The most important factor in determining wgt gain is appropriateness of pre-conceptual weight: height. Adjust according to maternal BMI  First trimester – 1-2.5 kg (3.5-5 lb TOTAL)  For normal weight range women  For underweight wgt gain should be at <5Ib.  For overweight: wgt gain should be ~2Ib.  2nd & 3rd trimesters – 0.4 kg (1 lb/week)  Underweight: gain slightly more than 1Ib/wk.  Overweight: wgt gain should be ~2/3Ib./ wk.  Severely underweight at conception at risk for preterm labor and have a LBW (low birth weight) infant  Inadequate weight gain during pregnancy – at risk for IUGR (Intrauterine growth restriction- baby in the womb does not grow as expected)  Obese mother – at risk for CPD (cephalopelvic disproportion- cond.

Where the baby has trouble getting thru the birth canal b/c of the size of the baby’s head, the baby’s position, or the shape/ size of the mother’s pelvis.), macrosomia (a fetus larger than 9-10Ibs.), C/S (Csection), PPH (postpartum hemorrhage- heavy bleeding after giving birth), Wound infection – increased risk of Preeclampsia and GDM (gestational diabetes mellitus)

Nursing Care/Patient Teaching of The Pregnant Family 

Identify sources of known teratogens and when the infant is most vulnerable to teratogens. Pg.309

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o Known human teratogens: drugs, chemicals, infections (huge teratogensSTIs), exposure to radiation, heavy metals, and certain maternal conditions (infections).  The GTPALonic stage (day 15- week 8) is the most crucial time for the develop of all organs and external features.  The baby is the most vulnerable to teratogens at this stage.  An embryo is called an embryo until ~8 weeks after conception. After that it is considered a fetus until delivery and as soon as it’s delivered it’s considered a newborn.

Identify the information typically collected at the initial prenatal visit. o Initial Assessments  Current preg. – dating, problems  OBGYN Hx.  Medical Hx.  Meds/ drugs/ herbal/ supplement use  Many pt’s don’t report herbal remedies bought OTC, so they feel they don’t have to disclose that.  Family Hx. - specifically, what is their mother’s & sister’s pregnancy Hx. Like b/c it can have an impact in the hx. She’s bringing in her preg.  Social, experimental, occupational Hx. – where does she live? can she afford good food? good place to store food? a place to cook food? what’s her work Hx. o Initial Prenatal Visit  Complete PE (physical)- H-T(head to toe), Pap smear, breast exam, STD exam  Lab tests (maybe additional labs based on Hx.)  CBC  Glucose *depends on what they eat?  ABO/Rh, antibody screen  Rubella titer  RPR/VDRL- blood test for syphilis  HBsAg (Hep B surface antigen) and HIV (by consent)  If + for HEP B next thing they’ll do is further testing  Is she a carrier? Does she have an active dz.?  This impact what tx. Baby will get once they’re born.  Pap smear, gonorrhea, chlamydia, HPV  Urinalysis  TORCH titers- series of test  TORCH infections: group of infect. Capable of crossing the placenta and adversely affecting the developing fetus.  Can affect a preg. Woman and her fetus. They have diff. effects at diff. gestational ages.  T-toxoplasmosis  O- other (Hep A, Hep B)  R- Rubella (German Measles)  C- Cytomegalovirus  H- Herpes simplex virus (HSV-1/HSV-2)  Important Labs

All pregnant women should have the following labs completed in pregnancy (most often done initially at 1st prenatal visit) • VDRL (Venereal Disease Research Lab) or RPR (Rapid Plasma Reagin) test for Syphilis • May test for GC or Chlamydia • GBS – usually initially a urine test – to determine if woman has asymptomatic bacteremia. About 34-36 weeks may have vaginal/rectal swab • HbsAG (Hepatitis B Surface antigen) to determine exposure to or active carrier to Hep B Virus • Rubella to determine if she is immune to Rubella – always reported as immune or nonimmune • Important Labs • Some providers initially check for other STI: Chlamydia, HPV, Herpes • Some may only check based on symptoms or risk factors • STI: remember infections can cause damage in the fetus and/or cause preterm labor • STI: May not have any symptoms!!

Outline appropriate nursing management and patient education (including indications/contraindications of immunizations, recommended frequency of prenatal healthcare visits, and infection prevention) to promote maternal selfcare and to minimize the common discomforts of pregnancy. o Immunizations during pregnancy:  Live viruses should not be given during preg. (Hopefully vax. Are fully updated during the preconception period)  Immunizations with inactivated vax are safe.  Can get: Hep B vax, Flu (inactivated-highly encouraged), COVID vax. Tdap (highly encouraged- deadly for the baby), Meningococcal (for at risk population), rabbies vax. If bit.  Cannot get: Flu (live virus), MMR (R- can’t have this one- can cause lesions on baby’s bones, deafness. If getting a rubella vax., We encourage women to not get preg. For at least 30 days), Varicella, Typhoid- if mom is exposed there is a 50/50 chance to tx., Meningococcal. o Frequency of visits- Healthy Pregnancies  Every 4wks until 28 wks gestation  Every 2wks until 36 wks gestation  Every week after 36 wks gestation  In these checkups: checking for…  Weight  Protein or glucose in urine  Measure the baby to make sure they are growing well  Listen to the baby w/ a Doppler •

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Listen to mom’s concerns, what are some things moms can do to resolve their S/S  Educate on some anticipatory symptoms she may have in the coming weeks  Moms with a risky preg, or bad preg. Hx- they’ll come more often Identify initial and ongoing lab assessments and indicate which values may indicate a risk to the pregnancy. o Chlamydia: causes PID, effects fertility, ↑risk of ectopic preg. o Gonorrhea: causes premature rupture of membranes (PROM), preterm birth, Chorioamnionitis, neonatal sepsis, IUGR, also causes opthalmia neonatorium (conjunctivitis of the NB- if untx. It can lead to blindness) o Syphilis: can cause lesions, prim/sec/tertiary syphilis= neuro, cardio, musculoskel, or multi-organ system probs., infant born infected. o Genital herpes: cause neonatal herpes= fatal, primary outbreak in 1st trimester.  C-sec birth if active lesions at time of labor; if not active- vaginal delivery is preferred. o Group beta-strep: causes several or fatal infection in NB. Common flora, not pathologic for normal adults. o HIV: could be passed to fetus at birth through placenta and breast milk o Antepartum Testing: in addition to initial prenat. Labs  Urine for glucose and protein for every visit  Ultrasounds done anytime  Amniocentesis: after 14wks- guided by U/S, determine NTD, chromosomal abnormalities, and down’s syndrom later- lung maturityneeds Rhogam.  MSAFP (maternal serum alpha-fetoprotein) 16-18 weeks: low may indicate Down’s syndrome, elevated potential NTD, abdominal defect or multiple gestation  Quad Marker Screening (hCG, AFP, Estriol, Inhibin A) @ >16 < 20 weeks, R/O potential birth defects – screening tool only = refer for US, genetic counseling and/or amniocentesis (can have double or triple screen –but when using all 4 = increases specificity of findings. o Antepartum Biophysical Assessment of the Fetus EFM as Antepartal Testing:  2 Types of Tests: to determine if the intrauterine environment is still the best place for that fetus  Nonstress Test (NST)– Mom placed on monitor, looks at how fetus responds in a non-stress environment (no contractions = nonstress)  Goal: neg stress test is good  Contraction Stress Test (CST or OCT) Mom is placed on a monitor and contractions are then stimulated either with Oxytocin or via nipple stimulation (Contractions = stress to fetus) o Electronic Fetal Monitoring As Part of Antenatal Fetal Risk Assessment  Non-Stress Test (NST)  Make sure mom empties bladder before NST  Provide 2 TOCO monitors: one for baby and mom  Non-invasive, outpatient setting  20 minute (minimum) fetal monitor tracing  Interpretation: Reactive (Reassuring) =2 accels in 20 minutes Desired finding 

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Non-reactive (non-reassuring) =Less than2 accels in 20 minutes - Needs immediate attention  Requires a further test… o Contraction Stress Test (CST/OCT)  IV started  Mom is on EFM – baseline FHR is evaluated (10-20 min)  Contractions are stimulated – with oxytocin or via nipple stimulation  Process: there should be at least 3 but less than 5 induced contractions lasting at least 40-60 sec (less than 90sec)  Interpretation:  Negative CST: at least 3 contractions in 10 with no late decelerations or significant variables (associated with good fetal outcomes repeat 1 week)  Positive: Late decel with 50% or more of the contractions (requires further assessment – repeat in 24 hours)  Equivocal-suspicious: Prolonged decel, variables or late decels with 50% of contractions  Equivocal-hyperstimulatory Decels occur in the presence of contractions more frequent that every 2 minutes or lasting longer than 90 sec  Unsatisfactory – Fewer than 3 contractions in a 10-minute period or unable to obtain a continuous tracing of the FHR  Non-reactive NST requires further test: this test is used more freq. that CST d/t CSTs risk factors for preterm labor (starting a contx. We can’t stop) o Biophysical Profile (BPP)  Evaluates:  Fetal Breathing Movements  Gross Body movements  Fetal Tone  Reactive Non-Stress Test  AFI/AFV (amniotic fluid index/ volume)  Interpretation: Either 2 points or none – nothing in between! (2pts.= good mvmt., 0 for no mvmt.)  8 – 10 = Normal  6 = equivocal (Repeat within 24 hours)  4 or less = abnormal (move to delivery – intrauterine environment no longer the healthiest place for the fetus!

Examine the risk factors that may affect the outcome of the pregnancy (sociodemographic, biophysical, psychosocial, environmental) 

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o Biophysical (Genetic, Nutritional, Medical/OB) o Psychosocial (Smoking, Drugs/ETOH, Psychologic) o Sociodemographic (Income, PNC, Age Parity, Marital Status, Living arrangements, Ethnicity) o Environmental (Workplace and community exposures)

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State when and why routine prenatal tests are completed.

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o A series of tests is generally ordered during the initial visit so that baseline data can be obtained, allowing for early detection and prompt intervention if any problems occur.

Identify what the results indicate related to the results of the different prenatal tests. o CBC – evaluates hemoglobin (12-14g) and hematocrit (42% +/- 5) and RBC (4.2 – 5.4 million/mm3) to detect anemia. WBC if elevated over 10,000 to detect infection. Platelet count (150,000-450,00) to assess clotting ability. o Blood typing- mom blood type and RH factor to rule out any incompatibility issues o Rubella titer- detect for any antibodies and if titer is 1:8 or less = woman is not immune o Hepatitis B- detecting presence of antibodies o HIV testing- Detects HIV antibodies and if positive, requires more specific testing, counseling, and treatment during pregnancy with antiretroviral medications to prevent transmission to fetus o STI- Detects STIs (such as syphilis, herpes, HPV, gonorrhea) so that treatment can be initiated early to prevent transmission to fetus o Cervical smears- Detects abnormalities such as cervical cancer (Pap test) or infections such as gonorrhea, chlamydia, or group B streptococcus so that treatment can be initiated if positive.

Select the assessments completed and appropriate timing for common disorders at various prenatal visits. o At each subsequent prenatal visit, the following assessments are completed: o Weight and blood pressure, which are compared with baseline values o Urine testing for protein, glucose, ketones, and nitrites o Fundal height measurement to assess fetal growth o Assessment for quickening/fetal movement to determine fetal well-being o Assessment of fetal heart rate (should be 110 to 160 bpm) Describe maternal TORCH infections and their effects on the fetus and neonate. o Group of infections capable of crossing the placenta and adversely affecting the developing fetus.

o Can affect a pregnant woman and her fetus. o They have different effects at different gestational ages.

TORCH Infections T- Toxoplasmosis O–Other (Hep A, Hep B,) R–Rubella (German Measles) C–Cytomegalovirus H–Herpes simplex virus (HSV-1/HSV-2)

Sexually Transmitted Infections 

Analyze fetal and neonatal impact of maternal disease and infections. (IE: HIV, Hepatitis A-C, Group B Strep, Herpes and Chlamydia) Table 5.1 STI s and effects on the fetus and NB o HIV/ AIDS: can be passed to the fetus during birth  Preterm Birth  Low birth weight  HIV-positive status  Intrauterine fetal death  Miscarriage o Hep A  Hep B: newborns will receive HBV vax. Within 12hrs of birth, woman w/ bleeding nipples should abstain from breast feeding until they’ve healed within 12 hrs. o o Group B strep: GBS is the most common cause of sepsis and meningitis in newborns and is a frequent cause of newborn pneumonia. o Herpes: Infants born to mothers with primary HSV infections have a 30%50% risk of acquiring the infection via perinatal transmission near or during birth. Recurrent genital HSV infections carry a 1%-3% risk of neonatal infection if the recurrence occurs around the time of vaginal birth  Genital Herpes:  Contamination can occur during the childbirth process  Intellectual disability  Blindless  Seizures  Premature birth  Low birth weight  death o Chlamydia  Potential infections during the childbirth process  Newborns born to infected mothers may develop conjunctivitis (pink eye).  Ophthalmia neonatorum eye infection that occurs within the first 30 days of life.  o Syphilis:  Can be passed in utero  Can result in fetal and infant death  Congenital syphilis symptoms include skin ulcers, rashes, fever, weakened or horse cry, deafness, swollen liver and spleen, jaundice and anemia, various deformations.

Substance Abuse 

Examine the impact of various legal and illegal substances on the health of a pregnancy. o Examine the impact of various legal and illegal substances on the health of a pregnancy.

o Substance abuse during pregnancy is associated with preterm labor, abortion, IUGR, placental abruption, depressed Apgar scores, third-trimester bleeding, meconium staining at birth, fetal demise, low birth weight, neurobehavioral abnormalities, and long-term childhood developmental consequences. o Alcohol  Spontaneous abortion, inadequate weight gain, IUGR, FASD (the leading cause of intellectual disability) o Caffeine  Vasoconstriction and mild diuresis in mother; fetal stimulation, but teratogenic effects not documented via research o Nicotine  Vasoconstriction, reduced uteroplacental blood flow, decreased birth weight, abortion, prematurity, placental abruption, fetal demise o Cocaine  Vasoconstriction, gestational hypertension, placental abruption, abortion, central nervous system defects, IUGR o Marijuana  Anemia, inadequate weight gain, “amotivational syndrome,” hyperactive startle reflex, newborn tremors, prematurity, IUGR o Opiates and Narcotics  Maternal and fetal withdrawal, placental abruption, preterm labor, premature rupture of membranes, perinatal asphyxia, newborn sepsis and death, intellectual impairment, malnutrition o Sedatives  Central nervous system depression, newborn withdrawal, maternal seizures in labor, neonatal abstinence syndrome, delayed lung maturity

Medication (s) 

Identify the 1 key nutrient that ALL women of childbearing age should be taking if there is a chance of pregnancy o Folic Acid  folic acid is essential before pregnancy and in the early weeks of pregnancy to prevent neural tube defects in the fetus. folic acid is needed to form new blood cells for the expanded maternal blood volume and to prevent anemia. 

Encourage folic acid 400- 800 mcg per da

Fetal Assessment (Electronic Fetal Monitoring and Fetal Testing) 

State when and why routine prenatal tests are completed. (Some covered in Module 1, others covered in Fetal Assessment Module). o The initial visit is an ideal time to screen for factors that might place the woman and her fetus at risk for problems such as preterm delivery. The initial visit is also an optimal time to begin educating the client about changes that will affect her life.

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Identify what the results indicate related to the results of the different prenatal tests. (chapter 12) o Chorionic villus sampling (CVS) invasive procedure involving an 18g needle to obtain a sample of the chorionic villi from the placenta for evaluation of chromosomal disorders such as down syndrome, cystic fibrosis, enzyme deficiencies and fetal gender determination and to identify sex-linked disorders such as hemophilia, sickle cell anemia, and Tay–Sachs’s disease. o Nonstress test (NST) provides an indirect measurement of uteroplacental function. The basis for the NST is that the normal fetus produces characteristic fetal heart rate patterns in response to fetal movements. In the healthy fetus, there is an acceleration of the fetal heart rate with fetal movement. o Biophysical profile (BPP)- uses a real-time ultrasound and NST to allow assessment of various parameters of fetal well-being that are sensitive to hypoxia. Performed in an effort to identify infants who may be at risk of poor pregnancy outcome, so that additional assessments of well-being may be performed, or labor may be induced, or a cesarean section performed to expedite birth. The primary objectives of the BPP are to reduce stillbirth and to detect hypoxia early enough to allow delivery in time to avoid permanent fetal damage resulting from fetal asphyxia. o Nuchal translucency screening(ultrasound) - early detection and diagnosis of some fetal chromosomal and structural abnormalities such as trisomies 21,18, and 13. o Amniocentesis- transabdominal puncture of the amniotic sac to obtain a sample for analysis. fetal cells are examined to detect chromosomal abnormalities and several hereditary metabolic defects in the fetus before birth. It can replace a genetic probability with a diagnostic certainty, allowing the woman and her partner to make an informed decision about the option of therapeutic abortion.

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Select the assessments completed and appropriate timing for common disorders at various prenatal visits. o Amniocentesis- performed in the second trimester usually btw 15-20 weeks gestation. o Chorionic villus sampling (CVS)- generally performed 10-13 weeks after LMP o Nonstress test (NST)- after 28 weeks gestation

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Evaluate the tests used to assess maternal and fetal well-being, including results obtained and nursing management for each. (AFP-alpha fetal protein, ultrasound, Triple and Quad screening, FKC (Fetal Kick Counts), fundal height assessment, non-stress test, contraction stress test, BPP (Biophysical Profile)). o Alpha fetal protein (AFP)  screening is 16 – 18 weeks gestation.

It were first linked to occurrence of fetal neural tube defects and down syndrome. This biomarker screening test is now recommended. It is minimally invasive require venipuncture for blood sample.  Nurse intervention consist of gathering accurate information about date of LMP, weight, race, and gestational dating and explaining test involves a blood specimen. Accurately determining the window of 16 – 18 weeks gestation will help ensure that the test results are correct.

Nuchal translucency screening (ultrasound)  is also done in the first trimester between 11 and 14 weeks. This allows for early detection and diagnosis of some fetal chromosomal and structural abnormalities. Ultrasound is used to identify an increase in nuchal translucency, which is due to the subcutaneous accumulation of fluid behind the fetal neck.

Triple- marker screen measures three hormones ( AFP, hCG, and unconjugated estriol) Quad screening - which includes the triple screening tests with the addition of a fourth marker, inhibin A (glycoprotein secreted by the placenta). The quad screen is used to enhance the accuracy of screening for Down syndrome in women younger than 35 years of age. Low inhibin A levels indicate the possibility of Down syndrome.

Fetal movement counting- begins in the second trimester. The mother’s first perception of fetal movement, termed “quickening,” is commonly described as a gentle fluttering. Determining fetal movement is a noninvasive method of screening and can be easily taught to all pregnant women. Urge the client to perform the counts in a relaxed environment and a comfortable position, such as semi-Fowler or side-lying. Provide the client with detailed information concerning fetal movement counts and stress the need for consistency in monitoring (at approximately the same time each day). The most common method used is “Count to 10,” with which a woman focuses her attention on her fetus’s  movement and records how long it takes to document 10 movements.

If it takes longer than 2 hours, the woman should contact her health care provider for further evaluation. Decreased fetal movement may indicate asphyxia and FGR. Fundal height measurement- measure distance in centimeters from top of pubic bone to the top of the uterus (fundus) with client lying on her back with her knee slightly flexed “McDonald method”. It reflects fetal growth and provides a gross estimate of the duration of the pregnancy. Between 12- and 14-weeks’ gestation, the fundus can be palpated above the symphysis pubis.

The fundus reaches the level of the umbilicus at approximately 20 weeks and measures 20 cm. After 36 weeks, the fundal height then drops due to lightening and may no longer correspond with the week of gestation.

However, if the growth curve flattens or stays stable, it may indicate the presence of FGR. Non-Stress Test (NST)  Non-invasive, outpatient setting  20 minute (minimum) fetal monitor tracing 

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Need to have normal FHR, moderate varaiblity, and at least 2 acceleration in 20 mins.

Acceleration= an 15 beats increase above its baseline and off the baseline for 15 seconds.  Interpretation:  Reactive (Reassuring) =2 accels in 20 minutes - Desired finding = reactive NST  Non-reactive (Non-reassuring) =Less than2 accels in 20 minutes - Needs immediate attention o Nurse Intervention: make sure woman empty her bladder, positioned in semi-flower position, and apply two external monitor belts, observe signs of fetal activity, assist the woman off the table, provide her with fluids, allow her to use the restroom. Provide teaching about signs and symptoms to report. If serial NSTs are being done, schedule the next testing session. o Contraction Stress Test (CST/OCT oxytocin challenge test) )  Moved to CST because didn’t get reactive NST  IV started  Mom is on EFM – baseline FHR is evaluated (10-20 min)  Contractions are stimulated – with oxytocin or via nipple stimulation  Process: there should be at least 3 but less than 5 induced contractions lasting at least 40-60 sec (less than 90sec)  Interpretation:  Negative CST: at least 3 contractions in 10 mins with no late decelerations or significant variables (associated w/Good fetal outcomes repeat in 1 week) this is desired result for CST 

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Positive CST: Late decel with 50% or more of the contractions (requires further assessment – repeat in 24 hours) mom isn’t going home and will be admitted to the hospital.

Equivocal-suspicious: Prolonged decel, variables or late decels with 50% of contractions Equivocal-hyperstimulatory Decels occur in the presence of contractions more frequent that every 2 minutes or lasting longer than 90 sec

try to slow down contractions, keep baby on monitor 

Unsatisfactory – Fewer than 3 contractions in a 10 minute period or unable to obtain a continuous tracing of the FHR.

A risk of CST is that we start pre-term labor and may not be able to stop it. o Nurse Intervention- At the beginning of the test warm cloth is applied to the breast then the woman stimulates her nipple either by rolling or gently pulling them. Initially, it is unilateral if the contraction is inadequate the women, then stimulate both nipples for another 10 min. If the contraction is

still inadequate (<3 contraction in 10 min.) IV oxytocin is used. The administration of oxytocin to induced contraction, venipuncture is done and a very dilute solution of oxytocin control by an infusion pump is administered. o Biophysical Profile (BPP)  Evaluates:  Fetal Breathing Movements  Gross Body movements – are they turning, rolling?  Fetal Tone – are the fetus arms and legs all drawn up or are they very flaccid and relaxed? Flaccid and relaxed is not a healthy baby.  Reactive Non-Stress Test  AFI/AFV = Aminotic fluid index/ Aminotic fluid volume  Interpretation: Fetal breathing movement Either 2 points (movement) or none ( no movement) – nothing in between!

8 – 10 = Normal = baby should be alive and well in a week barring something catastrophic  6 = equivocal (Repeat within 24 hours)  4 or less = abnormal (move to delivery) – intrauterine environment no longer the healthiest place for the fetus! Move this mom toward delivery.

Nurse Intervention – offering the client support and answering her questions expect to complete the NST before scheduling BPP and explain why further testing might be needed. 

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Explain essential elements of uterine activity assessment and fetal heart rate assessment. o Fetal movement counting is a method used by the mother to quantify her fetus’s movement. Instruct the client about how to count fetal movements, the reasons for doing so, and the significance of decreased fetal movements.

Urge the client to perform the counts in a relaxed environment and a comfortable position, such as semi-Fowler or side-lying. Provide the client with detailed information concerning fetal movement counts and stress the need for consistency in monitoring (at approximately the same time each day) and the importance of informing the health care provider promptly of any reduced movements.

Distinguish between early, late, and variable decelerations and reassuring and non-reassuring fetal heart rate tracings. o Fetal Heart Rate Deceleration (Decrease)  Titles based on its timing and relationship to uterine contractions  Early: “Visually apparent gradual” decrease in FHR =returns to BL by end of ctx  Late: Gradual decrease in FHR returns to BL after the ctx ends  Variable: Abrupt decrease in FHR may or may not be related to ctx o Non-Stress Test (NST)

Non-invasive, outpatient setting 20 minute (minimum) fetal monitor tracing Interpretation:  Reactive (Reassuring) =2 accels in 20 minutes - Desired finding  Non-reactive (non-reassuring) =Less than2 accels in 20 minutes Needs immediate attention Differentiate between normal versus abnormal uterine activity. o Uterine Contractions  Classified as number of contractions in 10-minutes, averaged over 30 minutes  Normal: < 5 contractions in 10 minutes  (Abnormal) Tachysystole: > 5 contractions in 10 minutes (spontaneous, or via induction/augmentation) Employ appropriate nursing interventions used for managing specific FHR and UC patterns. o HR assessment can be done intermittently using a fetoscope (a modified stethoscope attached to a headpiece) or a Doppler (ultrasound) device, or continuously with an electronic fetal monitor applied externally or internally.

The object of FHR monitoring is to reduce mortality and morbidity by ensuring that all fetal hypoxic insults are identified in time to allow removal or alteration of the reason for them, or to enable a safe birth of the fetus before irreversible asphyxia damage occurs   

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Psychosocial - Intimate Partner Violence/Human Trafficking 

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Examine the incidence, myths, and facts of intimate partner violence. Pg.271275 o Myths That Can Perpetuate the Violence:  Violence only happens in problem families  Alcohol causes battering  Only a small portion of women suffer violence  Violence is greater in certain ethnic groups  Violence is a private matter  It can’t be that bad or she’d leave (most deadly timeframe is when she decides to leave)  She must have done something…

Outline the nurse’s responsibility and plan of care in caring for a victim of intimate partner violence. Pg.278 o What can You Do?  Evaluate your own personal values.  Do you think they deserve it?  Must like it or they’d leave?  Must be stupid to put up with it?  How prevalent do you believe it is?  How severe do you think it gets?  Ask ALL women if they are in a relationship that causes them harm/pain.  Provide empathy and affirmation  Ensure privacy and safety  Treat health problems with care and sensitivity  Provide Referral – What if in denial?

Provide legal advocacy through accurate documentation Assess for suicide and homicide potential Help them set goals for leaving, establishing a safety escape plan Acknowledge the Abuse: I’m sorry this happened to you. No one should be physically hurt by someone else.  Ensure she knows what she says is confidential and ensure you keep it that way!!  Her statements about the abuse should be documented in quotation marks, without extraneous detail. Get photographs to be utilized in future legal encounters. “Judges are more likely to rule in favor of the woman if documentation is complete.” o What to look for: Besides the obvious physical abuse….  Subtle problems such as multiple appointments for vague symptoms…. don’t wait till you see bruises to ask!!!!!  Get the woman alone and ask.  Often partner overprotective, won’t leave her alone with the HCP, or insist on answering all the questions. o What to Ask:  Have you ever been emotionally or physically abused by your partner?  Within the past year have you been hit, slapped, kicked, or otherwise physically hurt by someone?  Are you afraid of your partner or anyone else you mentioned above?  When are you afraid of your partner? Does your partner lose his temper and what happens when he does?

Identify characteristics of human trafficking. Pg.291 o Signs of Human trafficking  Living with employer  Poor living conditions  Multiple people in cramped space  Inability to speak to individual alone  Answers appear to be scripted and rehearsed  Employer is holding identity documents o Questions to Ask a Suspected Victim  Can you leave your job if you want to?  Can you come and go as you please?  Have you been hurt or threatened if you tried to leave?  Has your family been threatened?  Do you live with your employer?  Where do you sleep and eat?  Are you in debt to your employer?  Do you have your passport/identification? Who has it?    

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