Student Nurse Laura

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Archive for the ‘NS 121 – OB’ Category

Good Luck on your Finals Today!

Posted by Laura on April 2, 2010

To all my OB friends and Chronic school mates –

 

 

May your pencil shade all the right circles!

 

 

Posted in NS 121 - OB, Semester II | 2 Comments »

Some ABC’s of OB Notes

Posted by Laura on March 28, 2010

Asthma

Avoid morphine for woman with asthma who is in labor.

Cancer

Malignant melanoma: the only cancer that crosses the placenta to the fetus.

Cycle of Violence

Phase 1—building: increased tension, anger, blaming, and arguing

Phase 2—battering: hitting, slapping, kicking, choking, use of objects or weapons; sexual abuse; verbal threats and abuse

Phase 3—calm state (may decrease over time): batterer may deny violence, state he was drunk, say he’s sorry, and “promise it will never happen again,” returns to phase 1.

Fetal Maturity— Assessment

Phosphatidyl glycerol is more accurate indicator of fetal lung maturity in women who are diabetic.

Gestational Diabetes—Assessment the 3 P’s

Polydipsia

Polyphagia

Polyuria

Heart Failure—Assessment

Heart rate is the most sensitive and reliable indicator of impending heart failure.

HELLP Syndrome

Hemolysis

Elevated Liver (enzymes)

Low Platelets

HELLP Syndrome—Complication

Hypoglycemia: ≤ 40 mg/dL

Hypoglycemia can lead to maternal mortality.

Hydatidiform Mole or GTD

Complete H. mole: only condition that can lead to maternal cancer.

Hypertension—Definition

Systolic: 30+ mm Hg above baseline

Diastolic: 15+ mm Hg above baseline

Infections

Vaginitis: avoid douching during pregnancy.

STDs in the U.S.: highest prevalence among teens.

AIDS in the U.S.: fourth leading cause of death among women of reproductive age.

Insulin Requirements in Pregnancy

Trimester one: ↓

Trimester two: ↑

Trimester three: ↑

Postpartum: ↓

Placenta Previa

Vaginal examinations contraindicated with undiagnosed vaginal bleeding.

Pre-eclampsia

Proteinuria differentiates pre-eclampsia from other pregnancy-induced hypertension (PIH) states.

• Pre-eclampsia is a disorder of hypovolemia.

• Home care may eliminate the need for hospitalization

RHoGAM—Give RhoGAM to:

1. RhoGam is given to Rh- mother who gives birth to Rh+ neonate.

2. Rh- mother after spontaneous or induced abortion (> 8 wk).

3. Rh- mother after amniocentesis or chorionic villous sampling (CVS).

4. Rh- mother between 28 and 32 wk gestation.

RhoGAM and Rubella Titer

Since RhoGAM is an immune globulin, rubella vaccination, given at about the same time, may not “take”; rubella titer needs to be redone at 3 mo.

TORCH Infections

Toxoplasmosis

Other (hepatitis A virus [HAV], hepatitis B virus [HBV], group B streptococcus [GBS])

Rubella

Cytomegalovirus (CMV)

Herpes type 2

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My Insulin Card – Short & Sweet

Posted by Laura on March 27, 2010

Insulin Card

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Bishop Score

Posted by Laura on March 23, 2010

The bishop score is a scoring given to women to determine their favorable condition for chemically augmenting their cervical ripeness for induction of labor.

(available at: http://www.freewarepocketpc.net/ppc-tag-score-2-date.html)
Though there are 5 items looked at –

  • Cervical Consistency  is measured on a scale of firmness from firm to soft.  The softer the cervix is, the better the chance of vaginal delivery.
  • Cervical Position refers to the positioning of the cervix.  If the cervix faces front (anterior) it is more favorable, while posterior is less favorable. 
  • Cervical Effacement refers to the softening and thinning of the cervix.  You won’t feel this happening;  it may only be measure with a vaginal exam.  Effacement is measured in percent.  When your cervix is normal, it is considered to be 0% effaced.  When you’re 50% effaced, your cervix is half its original thickness.  When your cervix is 100% effaced it is completely thinned out and you are ready for vaginal delivery.
  • Cervical Dilation is measured in centimeters, from 0 to 10.  Your cervix is fully open and you should be able to push when it is dilated to 10 centimeters.  Occasionally, a physician will measure dilation in “fingers.”  Dilation often begins days or weeks before labor actually begins.  At first, the progress may be very slow.  Some women may be dilated 2 to 3 centimeters long before labor.  Once active labor begins, you will begin to dilate more quickly.
  • Cervical Station is a term used to describe the descent of the baby into the pelvis.  An imaginary line is drawn between the two bones in the pelvis (known as ischial spines).  This is the “zero” line, and when the baby reaches this line it is considered to be in “zero station.”  When the baby is above this imaginary line it is in a minus station.  When the baby is below, it is in a “plus” station.  Stations are measured from -5 at the pelvic inlet to +4 at the pelvic outlet.

 mnemonic –   CPEDS

– two of these items, Cervical Consistency and Cervical Position, are only scored from 0-2

Bishop's Score Readiness

 

There are modifiers to the scale which includes adding and deleting points dependent upon preexisting conditions and timeline of parity.

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Do the Math

Posted by Laura on March 21, 2010

If the outlet of the pelvis is WNL, will a NB with a Biparital of 10.5 be a SVBD?

The marked variability of a FHR BL at 139 is ________to ______.

If you have 2 accelerations of less than 15 bpm for at least 15 seconds, is it considered to be a reactive trace?

If your patient/mom is on MgSo4 with a lab level of 10, what is your concern?

An doctor orders the patient to receive 2 mU per minute. What do you set the IV infusion rate at?

Answers

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OB In the News

Posted by Laura on March 17, 2010

Human Reproduction reported today a study that reviewed postpartum severe uterine bleeding with mothers who had received radiation as a child due to cancer.  Also was noted a 4 week less gestation period… Find more articles from this journal at http://humrep.oxfordjournals.org/

BJOG International Journal of Obstetrics and Gynaecology reports that the number of births involving triplets has increased two and a half times since 1970s figures. This study does not include invetrofertilization placement. It is suggested in this study, due to the increase use of hormones. Also noted was the increase rate of death for triplets, compared to single or twins is 10 times higher…..  more information can be found at  http://www.bjog.org/view/0/index.html

(article – http://www.bjog.org/details/news/589297/Triplet_births__trends_in_mortality_and_care.html)

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High-Risk Pregnacy of a Diabetic Mother

Posted by Laura on March 16, 2010

Diabetes mellitus .pdf

Insulin Shock & DKA

metabolic condition

causes

symptoms

interventions

hypoglycemia or insulin shock excess insulin

insufficient food – missed or delayed

excessive exercise or work

indigestion, diarrhea, vomiting

irritability

hunger

sweating

nervousness

personality change

weakness

fatigue

blurred or double vision

dizziness

headache

pallor, clammy skin

shallow respirations

rapid pulse

lab: urine = negative for sugar & acetone; Blood glucose < 60mg/dl

check b.g.level. eat:

< 60 mg/dl foods that contain 10-15 g of simple carbohydrates:

½ cup unsweetened fruit juice

½ cup (4 oz) regular soda

5 -6 LifeSavers candies

1 tablespoon honey or corn syrup

1 8oz glass  milk

2-3 glucose tablets

recheck b.g.l. q 15 min until stabilized. If no change – notify primary HCP. If unconscious 50% dextrose IV push, 5-10% dextrose in water IV drip or glucagon

ketoacidosis DKA metabolism stressed by illness or infection

tocolytic drugs such as terbutaline

failure to take insulin appropriately

insufficient exercise

Emotional stress

Excess or wrong kinds of food

thirst

nausea or vomiting

abdominal pain

constipation

drowsiness

dim vision

increased urination

headache

flushed, dry skin

rapid breathing

weak, rapid pulse

acetone (fruity) breath odor

Lab: urine = pos for sugar & acetone; Blood glucose = >200 mg/dl

Notify PCG. Admin insulin in accordance with b.g.l. med chart.

Give IVF NS or 1/2NS, K+ when urinary output is inadequate; bicarbonate for pH < 7.

Monitor labs of blood & urine

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Biophysical Profile Table/Score

Posted by Laura on March 15, 2010

My creation of the Biophysical Profile.  download .pdf

Posted in NS 121 - OB, Semester II | Tagged: , | 3 Comments »

Some Vocab

Posted by Laura on March 14, 2010

Ruptured uterus – rare, can be caused by separation of c/s scar, congenital uterine, spontaneous UC, Meds, overextended uterus, malpresentation, external or internal version, difficult forceps-assisted birth. Classified as complete (extends entire U wall) or incomplete.

CPD – Cephalopelvic disproportion characterized by excessive fetal size 4G or > assoc. w/diabetes mellitus, obesity, multiparity or L size of parents.

Prolapsed cord – protrusion of the umbilical cord in advance of the presenting part – when cord lies below the presenting part of fetus. common to see frank prolapse directly after ROM. Contributing factors : long cord, malpresentation, transverse lie, unengaged presenting part from hydramnios resulting cord to be displaced downward. 

Amniotic fluid embolism – AFE. Embolism resulting from amniotic fluid entering the maternal blood stream during labor and birth after ROM; often fatal to the woman if it is is a pulmonary embolism

Malposition – most common persistent occipitoposterior position (ROP or LOP). prolonged labor, severe back pain from occiput pressing against sacrum. Relief of back pain and facilitation  of rotation to anterior position.

Malpresentation – Breech presentation (4 types: frank, complete, incomplete w knee extends below the buttocks, and incomplete with foot extends below buttocks). Associated with multifetal gestation, preterm birth,fetal & maternal anomalies, hydramnios, oligohydramnios. VB with manipulation ECV or CS if > than 3800 < 1500

Multifetal Pregnancy – > 1 infant. Complications: preterm, IUGR, cord prolapse, placental separation onset, cerebral palsy, dystocia, C/S, breech positioning, increased risk for HTN, anemia, PPM, Uterine atony, & abruptio placenae.

catecholamines – Hormones/neurotransmitters released in response to stress which may cause dystocia. Anxiety , confinement, pain and absence of support person can make these hormones act on the smooth muscles of the uterus increasing levels causing reduction of UCs.

amniotomy – Artificial Rupture of membranes. FHR assessed before and immediately after  to detect any changes that may indicate cord compression or prolapse. T checked q 2 hrs./

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Dystocia

Posted by Laura on March 14, 2010

Dysfunctional Labor is described as hypertonic or hypotonic increases a woman’s risk for uterine dystocia.

Dysfunctional Labor .pdf

Prolonged – Nursing Diagnoses:

  • Risk for infection RT – PPROM,  – operative procedures
  • Ineffective individual coping RT – exhaustion, – pain, inadequate support system
  • Risk for maternal or fetal injury RT – interventions implemented for dystocia       

                Interventions:

  • coach mother in bearing down w/contractions, assist w/relaxation between UCs
  • Position mother in favorable position for pushing
  • Reduce epidural infusion rate
  • Prepare for CS if nonreassuring fetal status occurs
Precipitous – Nursing Diagnoses:

  • Powerlessness RT – loss of control
  • Ineffective individual coping RT –  pain, inadequate support system
  • Risk for infection RT – PPROM, 
Hypotonic – Nursing Diagnoses:

  • Risk for infection RT – PPROM,  – operative procedures
  • Ineffective individual coping RT – exhaustion             

                Interventions:

  • Perform ultrasound/Radiographic exam to rule out CPD, assess FHR, characteristics of AF if ruptured, and maternal well-being
  • If above findings are normal, then – ambulation, position changes hydrotherapy, AROM, Oxytocin infusion
Hypertonic – Nursing Diagnoses:

  • Powerlessness RT – loss of control
  • Ineffective individual coping RT – exhaustion, –    pain  

                Interventions:

  • Initiate therapeutic rest measures.  – Analgesics if no ROM or cephalopelvic disproportion not present. (morphine, nalbuphine, meperidine)
  • Relieve pain to permit mother to rest
  • Assist with measures to enhance rest & relaxation(hydrotherapy)

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Mechanisms of Labor & Vocab

Posted by Laura on March 12, 2010

7 cardinal movements

  1. Engagement – biparietal diameter of head passes the pelvic inlet.
  2. Descent – process of presenting part through pelvis. (Forces descent depends upon: pressure exerted by AF, pressure exerted by contracting fundus on fetus, force of contraction of maternal diaphragm and ABD muscles in 2nd stage of labor, Extension and straightening of fetal body)
  3. Flexion – chin of head brought into closer contact with fetal chest, allowing smallest diameter to present first to inlet.
  4. Internal Rotation – fetal head guided by body pelvis and muscles to rotate occiput anteriorly to fit at outlet
  5. Extension – emerging head by first the occiput, then face then chin.
  6. Restitution and External Rotation – rotation of head (45°) after born to the position it occupied when it was engaged in the inlet. Then (external rotation) the head rotates further as the anterior shoulder engages.
  7. Expulsion – After birth of shoulders, baby is born by flexing laterally in the direction of the symphysis pubis.

Synclitism – Pelvic inlet plane is parallel with sagital suture of infants head. Each ear of the infant passing through the inlet at the same time.

Asynclitism – Pelvic inlet plane is intersected by the plane of the sagital suture. You can think of this as one ear passing through the inlet before the other.

True Labor vs. False Labor – 

Signs of false labor include:

  • Contractions are irregular, unpredictable
  • No progression is seen over time
  • Contractions are felt as a generalized abdominal tightening
  • Change in activity or position causes contractions to slow down or stop
  • Usually no bloody show
  • Membranes will not rupture

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Factor 4 & 5

Posted by Laura on March 11, 2010

Position

New Born’s position of presentation in relationship to mother’s pelvic. ROA = Right Occiput Anterior.

[Predominant mother’s position in the US is the lithotomy position.]

Psyche

Previous birth experiences, support systems, preparation for childbirth, (I’m pregnant, I’m having a baby, I’m going to be a mother), coping mechanisms, emotional makeup, and expectations for birth experiences.

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Factor 2 & 3

Posted by Laura on March 11, 2010

Passageway

Our passageway for the vaginal delivery is through the pelvic cavity. Four shapes are considered and determined before labor begins. Gynecoid is the best and classic female type (50%). Android shape is more heart shape resembling the male pelvis (23%). The Anthropoid (24 %) resemble the pelvis of apes and is more oval anterior to posterior. Platepelloid or flat pelvic is possibly the hardest for a normal size baby to fit through (3%).

Prenatal exams are an important assessment for this factor of the birthing process. The inlet is one of 3 planes of the true pelvis. There is also the midpelvis or cavity and the outlet. The inlet is formed anteriorly by the upper margins of the pubic bone.

Powers

Primary Powers – responsible for effacement and dilation includes the frequency, duration and intensity of contractions.

Our contraction has 3 segments. The increment when the contraction begins. The acme or climax of contraction, then the decrement or decrease of contraction. Frequency is measured by the start of one contraction to the beginning of the other.

Secondary Powers – the pushing or bearing down efforts of the mother to expulsion of the fetus.

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The Factors of Labor, Factor 1

Posted by Laura on March 11, 2010

1st Factor of labor:

 Passenger

               During the 2nd stage of labor its the baby, and the Placenta during the 3rd semester. 

Our passenger must fit between the symphysis pubis and the sacral prominence of the passageway as it moves down the station from a -5 to 0 (engagement) at the ischial spine to a +5 birth (SIZE OF FETAL HEAD.) If we can perform the Ballottement ( a technique for palpating a floating fetus by tapping the head away from the station to feel it then return to the examiner’s hand), then we know our passenger is in station.  This is where the Biparietal diameter comes into play.

  • biparietal diamerter – 9.25 cm anterior to posterior
  • suboccipitobregmatic diameter – 9.5 cm transverse

Our passenger has landmarks of presentation based on the FETAL PRESENTATION: 1. CEPHALIC (occiput) 2. BREECH (sacrum) 3. SHOULDER (scapula).

For most babies it is the cephalic or head first. The presenting part Mentom – fetal chin, Siniciput – anterior brow, Pregma – Anterior Fontenella, Vertex – between fontanelles, Posterior fontanelle and Occiput – Occipital bone.

FETAL LIE is normally with the long axis of the mom – longitudinal, vertical (transverse, horizontal), or oblique.

FETAL ATTITUE is hopefully the baby flexed .

FETAL POSITION is the presenting part that overlies the pelvic inlet and is stated in a 3 letter abbreviation. The 1st letter is the location of the presenting part (R) or (L). The middle letter is the presenting part of the fetus (O-occiput, S- scapula, M-mentum or chin, Sc- scapula). The 3rd letter is location of the presenting part in relation to the maternal pelvis (A-anterior, P – posterior, T-transverse).  Position is sometimes referred to the 6th Factor of Labor.

so test your knowledge – ROA is?   LSP     RMP      LScT

To me you would start with the middle letter first. What is coming down, the back of head, shoulder or chin? Lets say back of head = __ O __

Then is the back of head facing the mom’s right or left? =  RO___

3rdly (? sp) would you say the back of head is more to the posterior, anterior or transverse (right on the line)?   ROA

Can you say what the Lie, Presentation, Reference Point and Attittude might be?   

answer

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Nutrition Needs

Posted by Laura on March 6, 2010

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Abnormalities – Genetics

Posted by Laura on March 5, 2010

Chromosome structure – translocation, addition or deletion: Down, Edwards, Patau

Sex Chromosome – monosomy X : Turner  or trisomy XXY: Klinefelter.

Inheritance Factors

Multifactorial (genetic & environmental): pyloric stenosis, cleft lip, cleft palate

Unifactorial:

  • autosomal dominant – Marfan syndrom, dwarfism, polydactyly, Huntington disease, polycyctic kidney disease, neurofibromatosis
  • autosomal recessive – errors of metabolism/PKU, galactosemia, maple syrup urine disease, Tay-Sachs disease, sickle-cell anemia, CF
  • x-linked dominant – Fragile X syndrome, Vit D resistant rickets
  • x-linked recessive – Hemophilia, color blindness, Duchenne muscular dystrophy

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X vs. Y Chromosome

Posted by Laura on March 5, 2010

Okay, this is funny – from a girl’s point of view.

http://www.associatedcontent.com/article/254228/the_y_chromosome_theory_why_women_are.html

but seriously….. the chromosome X does have divided short arms and divided long arms. The Y chromosome has less genes as it has a shorter short-arm.

To be fair, another view is shown here…

http://uspolitics.tribe.net/thread/73257ad5-1406-4c8b-b8b4-9108bb7bcacf

The Human has 46XX or 46XY.  22 pairs and 1 pair of sex chromosomes.

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Infertility could be related to what you eat!

Posted by Laura on March 5, 2010

In reading my Lowdermilk and Perry textbook on Maternity Nursing, it states there are herbs that should be avoided while trying to promote fertility and/or may be harmful in early pregnancy.

licorice root

yarrow

wormwood

ephedra

fennel

goldenseal

lavender

juniper

flaxseed

pennyroyal

passionflower

wild cherry

cascara

sage

thyme

periwinkle

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Risks Factors of Childbearing Years

Posted by Laura on March 5, 2010

Adolescence > 16

Stress, Gynecologic problems associated with: menses, vaginitis, STI, contraception

Adolescence < 16

Added Stress above normal, financial insecurity, inadequate knowledge on parenting, growth and development of newborn

Young Adulthood > 20

Stress related to juggling home, family and career. vaginitis, UTI,menstrual variations, obesity, sexual & relationship issues

Middle Adulthood > 35

Chronic or debilitating conditions ↑ in severity, genetic anomalies – such as Down syndrome

Late Reproductive Ages

Depression from possible divorce or empty nest syndrome, perimenopause, ovarian or breast cancer possibility

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What Is a Titer Test?

Posted by Laura on March 5, 2010

What Is a Titer Test?

A “titer” is a ratio or measurement of how much antibody to a certain virus (or other antigen), expressed in numbers, and is circulating in the blood at that moment. Antibodies can fluctuate in concentration. A titer on one day can be different than the following day. Titers are usually expressed in a ratio, which is how many times a technician had to dilute the blood plasma before they couldn’t find antibodies anymore. The lab/technician dilutes it two times, and then can’t find any more antibodies; it would be expressed as a titer ratio of 1:2. Dilution fluid is generally doubled, so you will increase titers from 1:40, 1:80, 1:160, etc. If the lab dilutes the blood serum a thousand times before they can’t find any antibodies, this would equal a titer of 1:1000. The higher a titer, the most likely there is an autoimmune disease present or was presented.

antigen:antibodies

 

Titer of 1:8 on an indirect Coomb’s test [mixing the mother’s blood Rh-, with Rh+ RBCs (the antigen)] shows the mother’s body already has been sensitized, or has a memory, and will clump – producing antibodies. This test is done when the infant is still in uterus and indicates amniocentesis to determine severity of hemolytic anemia of infant, and bilirubin in amniotic fluid.

A titer on the newborn’s umbilicus cord blood, called a direct Coomb’s test is done at birth to type the infant’s blood and Rh status. This helps in knowing if there are any hemolytic disorders present such as Rh incompatibility or ABO incompatibility. If antibodies are present, (a measure of maternal sensitization) titers of 1:64 will indicate a need for exchange transfusion. Titers of

If the baby received the mother’s antigens, lysis of RBS will start and visibly seen by jaundice. Genetic testing gives the opportunity for isoimmunization and decreased the need for exchange transfusions.

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