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OB WEEK 5 Pre-Term Labor After 20 wks and before 37 wks LATE Pre-Term 34-36 and 6 wks Very Pre-Term Before 32 wks (babies go to NICU) Pathophysiology Crump/decompensated if insufficient surfactant levels Identify Cause of preterm labor \ Risk Factors - Smoking, substance abuse, IBF, Wait a year to become pregnant again so cervix can heal and thicken S/S - Cramping, contractions, general feeling of unwellness, water breaking MEDICAL MGMT Pre-term Goal is to stall labor at least 48 to 72 hours Corticosteroids - (CELESTONE / BETAMETHASONE) 12 mg IM | 2 doses 24 hours apart (HELPS INCREASE SURFACTANT) (keeps alveoli opened to prevent collapse and resp distress. Vaginal cultures to check for bacterial infections and STI’s (UA / CULTURE) IV Fluids - 1 L of Lactated Ringers Tocolytic Drugs (stops contractions) I (Indomethacin) - Acid reflux heartburn N (Nifedipine) - can cause hypotension or bradycardia M (Mag Sulfate 2nd) - For PRE Term Labor (neuro protection for baby) loading dose 6 g | 1-2 g per hour after that (Lactated ringers on other pump) MAG TOXICITY (decreased respirations | decreased urine output | Clonus or decreased DTR’s | shortness of breath | chest pain | FVE | pulmonary edema EKG | Pulse ox | Lung sounds STOP the mag (if allergic reaction occurs) Administer calcium gluconate ANTIDOTE (if anaphylaxis occurs) And PREECLAMPSIA (to prevent maternal seizure / or neuro protection for the mom) T (Terbutaline 1st) - use during labor, but sparingly | SQ SE: increased HR, RR, Anxiety ATB - IV keflex | Penicillin CONTRAINDICATIONS - Fetal Demise (death of fetus) , Chorio with fever Nursing Actions - for pts 24-34 weeks expected mgmt (let it happen) Active mgmt (actively stopping labor) PREMATURE RUPTURE OF MEMBRANES (PROM) Early rupture of membranes before labor occurs PPROM Nitrazine paper testing (if it blue | good indicator of amniotic fluid) Speculum tests for STIs Cervical exam Pooling (as pt lays down there is pooling of fluid in vaginal canal) FERNING RISK FACTORS for mom Infection For c-section Risk factors for fetus Pre birth Resp distress Sepsis (if mom has infection) MED MGMT Amniotic fluid - bad odor or diff color (infection) CELESTONE - CHORIOAMNIONITIS - infection of placental sac | yellow | foul odor | fryable tissue (easily torn) INCOMPETENT CERVIX Painless cervical contraction in first trimester CERCLAGE - purse ring sutures ( to close cervix for entire length of the surgery) Strict precautions (to remove cerclage) MULTIPLE GESTATION Monozygotic twins | Dizygotic twins Most risk (MONO TWINS) PLACENTAS Risk IUGR - twin to twin complications Monozygotic twins - 1 egg fertilized by 1 sperm that split evenly (IDENTICAL) Dizygotic - 2 eggs 2 sperms that fertilized w different DNA boy boy girl girl (FRATERNAL TWINS) Assessment Ultrasounds FHR ANTEPARTAL MED MGMT Mono mono | antepartum 30-32 wks NURSING ACTIONS TWIN TO TWIN transfusion syndrome Hyperemesis Gravidarum Hypoglycemic | PEAKS by 9 weeks, subsides by 20 weeks ASSESSMENT Weight loss, dry mucous membranes, First line of defense DOXYLAMINE and vitamin b6 (helps with n/v) IV phenergine and Zofran QD NPO Thiamine IV - glucose / dextrose Monitor daily weight Ice chips Ginger candy | peppermint essential oil CHOLESTASIS of preg Assessment - Rash | Jaundice | Itching on hands and feet | body isnt excreting bile acids causing rash and itchiness Deliver if bile acids are at 40 or greater High fetal demise rate after 38 weeks LABS twice a week NSTs l| Fetal Kick count INDUCTION between 37 and 38 wks DIABETES MELLITUS 47% related to obesity Long Term Damage Monitor kidney function Heart Type 1 - insulin dependant Type 2 - developed PREGESTATIONAL DIABETES GESTATIONAL DIABETES Hypoglycemia | DKA s/s - cool, clammy skin, (sugar | candy | orange juice | ) Eat protein to stabilize sugar level then recheck glucose levels Macrosomia (get baby to feed ) HYPERTENSIVE DISORDERS PREECLAMPSIA EECLAMPSIA (seizures) Preeclampsia Risk Factors - young moms | old moms | Risks for mom - preterm labor | preterm birth | DIC | stroke | seizure | fetal death | at risk for HELLP syndrome Labetalol (do not give if bradycardic or hypotensive) 20 - 40 -60 Hydralazine (give 5 mg then 10 mg) EECLAMPSIA Seizure Decrease blood flow in brain Seizure precautions (padded rails) Low bed | call light in reach Record time length and type Decreased oxygenations (prolonged or late decels) O2 therapy Give mom IV ativan (respiratory distress concern) When placenta is delivered Eeclampsia will go away LEFT LATERAL POSITION (maximize perfusion to baby) HELLP SYNDROME Hemolysis Elevated Liver Enzymes Low Platelets Risks for fetus newborn - Risk for mom - Give blood transfusion / platelets PLACENTA PREVIA Placenta covering cervix (should be attached upper ⅓ of the placenta) Bleeding is a sign (from placenta having weight and pressure on the cervix) FINDINGS Painless bright red vaginal bleeding Risks for mom C-section Preterm labor | Pre term birth C-section | TYPE AND CROSSMATCH 34 wks (CELESTONE if bleeding) NO Vaginal exam if bleeding is occuring PLACENTAL ABRUPTION Placenta is off of the uterine wall | Partial placental abortion part of placenta is off of the wall Risks - high blood pressure | drug use | trauma RIGID ABDOMEN , ABDOMINAL DISTENTION, Tachysystole on EKG Involution may occur Hypovolemic shock (tachy, hypo, diaphoresis, shaking, cool skin,) MASSAGE the fundus QBL (quantitative blood loss) PLACENTA ACCRETA Diagnose early Scheduled c-section 34-35 weeks C - hist (cesarean hysterectomy) Loss of 3000 to 5000 ml of blood Platelets | RBCs No immediate risk to the fetus RISK FACTORS C- section ECTOPIC pregnancy Risk Factors STDs | PID Risks for mom Methotrexate (stops growth of blastasis in fallopian tube) NOT a viable pregnancy Gestational Trophoblastic Disease (Molar surgery) Pregnancy symptoms N/V | baby belly | Ultrasound (grapelike clusters) DNC Scrape out the cluster Make sure HCG level is trending down If HCG is not going down can be a sign of cancer INFECTION STIs Risk for mom Risk for fetus - blindness | risk for getting STI | sepsis HIV | open lesions - DO NOT BREASTFEED If less than 1000 can still deliver vaginally SYPHILIS Transplacental transmissions TORCH INFECTIONS UTIs Pyelonephritis (PPROM) Urgency, burning, foul odor, hematuria LABOR PRECAUTIONS GBS Group B Strep Around 36-37 weeks Check vagina, rectum, perineum colonizes in these areas Assessment MGMT Nursing ACTIONS TRAUMA Motor vehicle accidents Falls Continuous fetal monitoring for 24 hours