OB HESI Study Guide

OB HESI  Menstrual Cycle o Length: varies for most women; average = 28 days o Timing of ovulation:  14 days between ovulation + beginning of the next menstrual cycle  Intercourse:  Sperm live ~3 days, egg lives ~24hr  So… do not have unprotected sex several days before anticipated ovulation + for 3 days after ovulation to prevent pregnancy o Objective signs of ovulation  Abundant, thin, clear cervical mucous; open cervical os; slight drop in basal temperature and then 0.5-1 degree rise o Hormones  Hypothalamus  Regulates hormones released by anterior pituitary  Produces GnRH – travels to ant. pituitary via portal blood; cause the cells in anterior pituitary gland to produce FSH + LH = important hormones!  These hormones travel to female ovaries (where eggs are produced) o Ovary: connects to the uterus via the Fallopian Tube  Has blood vessels; the hormones enter through these  Each ovary has many follicles; each month only some will begin to mature  Only ONE will ovulate – produces an egg  Pituitary gland: anterior and posterior o Cycle:  Beginning of menstrual cycle = shedding of uterine wall, period  2 phases – Follicular + Luteal  Follicular (day 0-14): o Increase in GnRH, increase in FSH + then slow drop in FSH; steady level of LH, increase in estrogen  WHY? FSH enters ovaries and stimulates follicle maturation of the primary follicles in the ovaries; some mature into secondary follicles – produce a hormone called ESTROGREN that inhibits LH  FSH is secreted primarily in response to LOW estrogen; when estrogen rises, FSH falls  This is why FSH initially increases but then drops  Estrogen: 1st 10 days: has negative feedback on pituitary gland inhibiting release of LH  Low concentrations of estrogen inhibits LH secretion  Importance: bone + muscle growth, endometrial growth, maintains secondary female characteristics, maintains breasts o After 10 days: estrogen levels continue to rise (as the follicles mature in the ovaries)  Positive feedback now  Stimulates the release of LH  Increase in GnRH + estrogen will stimulate LH secretion – big spike in LH! o Massive LH influx = triggers ovulation of the most mature follicle in the ovary  Ovulation of the follicle will release the oocyte (female egg) Luteal (day 14-28): o After ovulation LH drops back down, GnRH decreases, FSH goes back down (had a small spike d/t LH increase)  After the follicle ovulates, it turns into a corpus luteum (dead follicle)  Slowly degrades, but has a purpose! – secretes estrogen, inhibin, and progesterone o Inhibin: neg feedback; inhibits FSH (do NOT need any more follicles stimulated in luteal phase) o Progesterone: negative effect on hypothalamus; inhibits GnRH; stimulates endometrial growth (what sheds or where the egg implants in a pregnancy) o Estrogen also drops slightly o Inhibin (not present in follicular phase) – increases o Progesterone (low during ovulation) – increases o 21 days: inhibin + progesterone increase, estrogen still detectable o Corpus luteum degenerates, allowing a new set of follicles to mature – estrogen, inhibin, progesterone all decrease  This means progesterone cannot inhibit GnRH release… so a new menstrual cycle can occur!     Also… the decrease in progesterone and estrogen means that these hormones cannot maintain the endometrial lining in the uterus  the lining shed AKA you get your period, cycle continues! Pregnancy o Signs of pregnancy  Missed period o Implantation spotting: bc some women experience this, they do not know they are pregnant (assume it is their period)  Nausea or morning sickness (AKA gravidarum)  Swollen/tender breasts  Fatigue/tiredness  Food cravings or aversions o High risk pregnancy  Less than 17 yo, older than 34yo  <3 months between pregnancies  Diagnosis of preeclampsia  Diabetes  Cardiac disease o Signs of maternal-fetal bonding in pregnancy:  Talking to fetus, massaging abdomen, nicknaming fetus o Abuse: physical or emotional may begin during pregnancy  Assess for abuse in private, away from male partner, by a nurse who is familiar w local resources + know show to determine the safety level of the client o Naegele’s Rule: estimated due date  Add a year, subtract 3 months, and add 7 days o Multifetal pregnancy  Dizygomatic: 2 separate eggs released at the same time, everything is separate  Monozygotic: 1 egg + sperm joined separated into 2 embryos (identical twins); may share placenta + membrane  Conjoined: did not fully separate  If more than one embryo is implanted, greater chance of multifetal preg. o Weight gain:  1st trimester: 2-4 lbs; 1lb a week after that  25-35 lbs (average), 28-40lbs (underweight), 15-25lbs (overweight)  Add 300 calories/day to your diet during pregnancy o Diet  Prenatal vitamins: nurse should teach about adherence to vitamins  Calcium: 3 cups of yogurt or milk per day (alleviates leg cramps)  o o o o o o o o o Folic acid = important to prevent neural tube defects; 600mcg/day during pregnancy – sources = leafy green veggies, fortified cereals, bread/pasta, beans, citrus fruits  Iron: fish, red meat, cereals, yellow veggies, green leafy veggies, citrus fruits, egg yolks, dried fruit Adolescent pregnancy:  Nutrition; mom and baby both growing; needs are higher Vaccine: Rubella = teratogenic, so if titer is LOW, get shot after delivery and wait at least 3mo before conceiving again Positioning:  Knee-to-chest: best position for fetal + placental perfusion  Side lying: most comfortable; supports perfusion  Supine hypotension: woman lying supine is at risk for the growing uterus to occlude the superior vena cava, decreased blood flow to the uterus/placenta/fetus Discomforts  1st trimester: N/V, fatigue  Crackers before standing up, take periods of rest + naps, 7-8 hrs of sleep Prenatal visit schedule  Every 4 weeks for week 0-28  Every 2 weeks for week 28-36  Every week until birth after 37 weeks Screening for neural tube defects  Serum alpha feto-protein levels + amniotic fluid levels  Highly associated with false-negatives and positives Placental previa or abruption  do not do Leopold, vaginal exams, rectal exams/enemas/suppositories, no internal monitoring Ectopic pregnancy: unilateral or bilateral abd pain; most are misdiagnosed as appendicitis Body systems  Cardiovascular: expands by 30-50%; increased HR; slightly decreased BP; slight hypertrophy  Renal: increased renal perfusion: increased UO; urinary frequency; kidneys compensate by increasing in size – higher risk of UTI  Lungs: harder to breathe comfortably; decreased CO2 in blood (mild resp alkalosis)  Waddling gait; pain in ribs – from shifting ligaments  GI: smooth muscle relaxation + decreased peristalsis; constipation + bloating; GERD, heartburn; morning sickness  Mood: irritability – as severe as depression/anxiety; mental fogginess  Breasts: increased blood flow + building of breast tissue; can feel full/tender, prolactin (responsible for milk letdown)    Hematologic: promotes blood clotting by increasing fibrinogen  Greater risk of getting a blood clot/DVT! – hypercoagubility  Endocrine: thyroid hormone increases to meet metabolic demands of the pregnancy o Glucose screening: 50g of glucose given, blood drawn after 1 hr; if glucose >140, 3 hr test is done (fasting for this) o NO Coumadin during pregnancy; Heparin = drug of choice o Preeclampsia  High BP, proteinuria = key features; also edema + water retention  Goal: maintain uteroplacental perfusion + prevent seizure; Mag sulfate  Postpartum: delivery is “cure” but can still convulse up to 48 hrs post delivery o Mag sulfate:  Antidote = calcium gluconate  Signs of Toxicity = RR<12, UO <100mL/4hr, absent deep tendon reflexes, serum mag level >8mg/dL o Tocolytics: used to stop preterm labor (beta-adrenergic agents ex: Terbutaline) o Oxygenation + Perfusion  always do interventions to promote these! GP Stuff o Gravidity: pregnancy (regardless of the outcome) o Nullagravida: woman who has never been pregnant o Primigravida: first pregnancy o Multigravida: woman who has had 2+ pregnancies o Parity: delivered after 20 weeks; reached 20 weeks of gestation o Nullipara: has not completed pregnancy o Primipara: completed one pregnancy w a fetus reaching 20 weeks o Multipara: completed 2+ pregnancies w a fetus reaching 20 weeks o Preterm: 20-36 6/7 weeks o Full term: 37-42 weeks o Late term: 42 weeks + o Miscarriage/spontaneous abortion: delivery before 20 weeks Fetal Development o Blastocyst  implantation on day 5 o X + Y chromosome = determined by sperm o Embryo  Ectoderm = outermost layer  Mesoderm = middle layer  Endoderm = inner layer  Lasts from day 15 to 8 weeks after conception  First 8 weeks = CRUCIAL  Teratogens:       o Fetus   Certain medications, radiation, alcohol, diabetes (hyperglycemia), PKU (phenoketourea – woman cannot break down phenylalanine + high levels cause teratogenic effects) 2 membranes surround embryo = chorion + amnion Amniotic fluid = liquid that surrounds developing fetus  Indicator of fetal wellbeing o Oglio = too little, poly = too much; both = BAD  Regulates temperature, allows limbs to extend Yolk sac – functions to transfer O2 before umbilical cord develops Umbilical cord: 2 arteries, 1 vein  Transfer of O2, nutrients, and waste products between mom + baby Placenta  Completely developed by 12 weeks o Connected to wall of the uterus; exchange of maternal circulation between mom and baby 9th week to conception  viable fetus around 23/24th week Organ system development  Neuro: 3rd week  Hematopoietic + Renal systems: 5-6th week  Sex of the baby: 7th week  FHR detectable by doppler: 10-12 weeks  Sensory: sounds at 24th week, taste at 5th month  Lung maturity: 35 weeks; when surfactant ratio is 2:1  Vital signs  FHR: 110-160 o Changes to FHR = #1 indication of compromised blood flow to the fetus!  Fetal wellbeing: measured by fundal height, fetal heart tones, fetal movement, uterine activity  20 weeks o Fundal height: at the umbilicus o Fundal weight: 300-400 grams o Fetal appearance: hair, lanugo (fine, soft hair that covers the body of a fetus/infant), vernix, but no subQ fat  36 weeks o Fundal height: at the xiphoid process  Fetal Heart Monitoring o Normal = 110-160 bpm o Accelerations = indication of fetal wellbeing o Decelerations  Early – head compression; monitor for labor progression  Normal/no intervention needed  Mirrors contraction (know that the decel is from the contraction)  Late – placental insufficiency  BAD; intervention needed  Happens AFTER mom’s contraction  Interventions: change position (lateral); elevate legs in Trendelenburg; increase IV fluids, stop Pit if infusing, administer O2 via face mask  Variable – cord compression  Need interventions  V shaped; baby’s HR all over the place  Interventions: Knee to chest position, push the presenting part off the cord until a Csection can be performed  Prolonged—can be caused by any type of deceleration, but lasts longer bc the underlying problem is still happening… usually associated w hypoxia   LABOR: True vs. false o False: discomfort localized in abdomen; no lower back pain; contractions decrease in intensity or frequency w ambulation o True: 4 stages; pain in abdomen + lower back, pain accompanied by regular rhythmic contractions, contractions that intensify w ambulation o Stage 1:  Cervix dilation: 0-10 cm (opening of cervix)  Effacement: 0-100% (thinning of cervix)  3 phases: latent (early labor), active, transition  Latent: very mild; 1-4 cm dilated o Contractions 5 to 30 min; 30-45 seconds in length  Very mild  Stay home until in active labor or water breaks  Mother: will be excited, nervous, talkative  Active: 4-7 cm dilated o Contractions every 3-5 min; 45-60 seconds in length o Time for mom to go to hospital! Water may break  Meconium passed: brown/yellow/green fluid  BAD; baby could aspirate… infection or fetal distress o Perform Nitrazine paper test – blue = amniotic fluid is leaking aka water has been broken o Keep comfortable: reposition, bath, massage, epidural, breathing techniques o Keep bladder empty: foley if epidural or help to BR o Monitor vitals + FHR monitoring o Mother: serious, anxious, in pain  Transition: really intense, cervix trying to open up completely; 810cm o Short but intense phase; STOP continuous infusion to increase effectiveness of infusion o Contractions intense/long every 2-3 minutes and 60-90 seconds in length o Pressure in the rectum (baby is descending)  Do NOT push until cervix is fully dilated o Give support, encouragement, praise o Monitor VS and FHR; look for signs of distress o Check fetal positioning (0 = engaged at ischial spine)  0  +5 = crowning! o Mother: concentrated, irritated, in pain, shivering  Longest stage, especially for 1st time mothers; begins when true labor starts o Stage 2:  Cervix fully dilated/effaced  Baby is delivered  Mother feels intense pressure; baby descending through birth canal  1st time mothers: approx. 1 hr, can last from 2-3 hrs  Women with previous children: ~20min  Contractions similar to transition phase: 60-90 seconds in length, occur every 2-3 min  Teach: how to push, position: High Fowler’s in lithotomy or squatting or side lying; encourage her! Record birth time  Monitor: FHR and mom’s vitals  Perineum: changes – bulging of perineum/anus/rectum, increase in blood show OR visible baby body parts (usually head) o Stage 3:  Full delivery of baby  Placenta is delivered  Fast stage; longer the stage the higher the risk of hemorrhage or retained placenta parts (bleeding + infection risk)  Placenta about to be delivered: umbilical cord lengthens, trickle or gush of blood, uterus changes shape (oval  globular)   Delivery mechanism:  Schultze = side that is shiny/baby side delivered 1st  Duncan = side that is dull/red/rough/mother’s side that is delivered 1st  Monitor mom’s BP (risk of hemorrhage); Pitocin (this prevents hemorrhage!), assess placenta (fully intact, nothing missing), cord: 2 arteries + 1 vein; encourage bonding b/w mom and baby; breastfeeding help o Stage 4:  Recovery; 1-4 hours AFTER delivery of placenta  Monitor: mom’s VS (HR + BP = MOST IMPORTANT; hemorrhage = tachycardic and hypotensive); risk of infection  Lochia = discharge after birth; moderate to red w small clots  LARGE CLOTS BAD!  Assess how often she has to change pad  15 min = abnormal; assess for hemorrhage  Fundus: top portion of uterus  FIRM = good; midline and near or at the belly button  Boggy = BAD o Fundal massage o Assist to BR; a full bladder can cause it to become boggy  Check every 15 for 1 hour, 30 min for 2 hours  Administer meds, peri care (ice), edema, tears, bonding, breastfeeding o Normal finding of mom during labor: temp <100.4F = ok (d/t dehydration and work of labor) anything higher = BAD; infection o Hyperventilation in labor: results in respiratory alkalosis  S/S: dizzy, tingling of fingers, stiff mouth  Have mom breathe into cupped hands or a paper bag to rebreathe CO2 o C-section  Risks: born w more fluid in lungs, can cause tachypnea + resp distress o Insulin: discontinue long-acting the day before delivery is planned b/c insulin need decreases are less during labor + decrease a lot after delivery Postpartum: o Risk of bleeding; massage fundus = first intervention if it is boggy!  Intrauterine resuscitation o Catheter if not voiding o Tearing of perineal area:  1st degree: involves epidermis ONLY  2nd degree: involves dermis, muscle, fascia  3rd degree: extends into the anal sphincter  4th degree: extends up to rectal mucosa o Fever (>100.4F):   Assess fundal height + firmness; assess perineal integrity; check S/S thromboembolism; assess pulse + BP + RR; assess client’s subjective description of symptoms o Uterine atony – when uterus fails to contract after birth of baby  Most common cause = retained placental fragments  Check for fragments in lochial tissue  Can lead to PPH o Blood loss in period: can handle blood loss bc of increased plasma volume during pregnancy; can void up to 3000mL/day to reduce the volume increase! o Voiding: should void within 4 hours of delivery; suspect retention if voiding <100mL per voiding o Ambulation: can faint 1st time walking postpartum… check Hb/hct to look for anemia, BP (orthostatic) o Assess for thromboembolism: examine legs (pain, warmth, tenderness, swelling) o RhoGam: give to Rh- mom who delivers Rh+ fetus and has a – Coombs test  If mom has + Coombs test, no need to give RhoGam bc mom is already sensitized  Rh- mom with Rh+ baby = INCOMPATIBLE  If you get RhoGAM + rubella; test rubella immunity at 3 mo. o Postpartum blues: 5-7 days after delivery (feeling down, crying, decreased appetite); encourage support persons to help out o PPH  Perform fundal massage first!  Notify HCP if fundus doesn’t firm  Count pads to estimate blood loss  Increase IV fluids  Administer oxytocin as prescribed  Risk factors: dystocia (difficult birth), prolonged labor, overdistended uterus, placental abruption, infection o Mastitis: infection of breasts; BF NOT CONTRAINDICATED unless there is pus in the milk or the abx treatment is harmful to baby o UTI: usually bc of catheter; encourage client to void frequently; IV abx given to pt with pyelonephritis o Paralytic ileus d/t C-section  When bowel is manipulated it ceases peristalsis + this problem can occur  S/S: absent bowel sounds, abd distention, tympany on percussion, N/V  NI: early ambulation Newborn o Suctioning: mouth first then the nose – could aspirate if you do nose first! o Caput succedaneum: edema under scalp; crosses suture lines + usually present at birth o Fontanelles: posterior + anterior: P close during first few months A close around 9-18 months