Genitalia  Assess for vaginal changes  Chadwick’s sign  Hegar’s sign  Goodell’s sign  Pap-smear and vaginal cultures (b/c we want to check for genital warts or abnormal vaginal secretions to treat that first; if she still has this when its time to give birth she cannot deliver vaginally) Pelvimetry  The pelvic bones are assessed for size and shape to determine adequacy for vaginal birth  If the pelvic bones are too narrow the baby won’t be able to navigate through the canal  The two most important measurements are the diagonal conjugate and the bi-ischial diameter Bony Pelvis  The bony and ligamentous pelvic mechanism is designed to… - Protect the pelvic viscera - Support the vertebral column - Facilitate locomotion - The pelvic girdle is adapted for strength, support, and locomotion. Pelvis  Four bones - Two innominate (ilium, ischium, pubis)  Sacrum  Coccyx - The pelvis resembles a basin and is formed anteriorly and laterally by the innominate bones and posteriorly by the sacrum and coccyx - Four pelvic joints  Symphysis pubis  Sacrococcygeal  Two sacroiliac - Over age 25 the symphysis pubis tends to fuse so it is harder - and less elastic for the baby to come through Determination of an Adequate Pelvis Diagonal conjugate  Distance from sacral promontory to symphysis pubis  Approximate length of fingers introitus to sacrum  Adequate diagonal conjugate > 11.5cm  This is done by the obstetrician Bi-Ischial Diameter  Distance between Ischial tuberosities  We are looking at the measurement from one spine to the next to see how wide it is  Approximately width of fist  Adequate intertuberous diameter > 8 cm Types of Bony Pelvis Anthropoid = AP diameter > transverse diameter, oval shaped  25% females Platypelloid – flat pelvis, outlet may be inadequate  35% Android = wide transverse diameter, heart shaped, not favorable for labor  20% females Gynecoid = most spacious obstetrically, inlet and outlet adequate for birth.  50% females  If other than gynecoid MAY require c-section. It depends on the babies’ size also Types of Pelvis Question Insulin requirement increases as pregnancy progresses (true or false)? - True A type 1 DM is scheduled to deliver at 34 weeks the nurse explain that the early delivery is necessary because? - Anomalies of the fetus - Placental insufficiency - Fetal lung maternity - Placental maternity A 20 year old primigravda is diagnosed with PIH she ask why this happened to her? - Her prady. OB- TERMINOLOGY/ VOCABULARY Abortion Acrocyanosis Ambivalence Amenorrhea Amniocentesis Antepartum Ballottement Braxton Hicks Contractions Birth occurring before the end of 20 weeks gestation A bluish discoloration of hands and feet and may be present in the first few hours of birth but resolves with improve circulation Absence of menses. May be primary or secondary Procedure whereby amniotic fluid is obtained for genetic disorders, fetal health status and evaluation of fetal maturity Time between conception and onset of labor. Used interchangeably with prenatal Rebound of the fetus or passive fetal movement felt by the examiner by pushing the fetal body up against the cervix Irregular, usually painless uterine contractions occurring intermittently throughout pregnancy beginning around 4th month. Often called false labor Chadwick’s Sign Chloasma (Melasma) Chorion Colostrum Couvade syndrome Diastasis recti Embryo EDC Estrogen Fertilization Fetus Folicle Stimulated Hormone Funic Souffle Gestation Goodell’s sign Gravida Hegar’s sign Hyperptyalism Implantation Leopold’s maneuvers Leukorrhea Lightening Linea nigra Luteinizing hormone (LH Multigravida Bluish purple discoloration of cervix, vagina, vulva and mucus membrane ( as early as 4 weeks) Facial darkening of skin around forehead and prominent in dark-haired women worsened by exposure to the sun (mask of pregnancy) Yelowish or creamy looking that is thicker than mature milk and contains more protein, fat-soluble vitamins and minerals. It also contains high levels of immunoglobulins (antibodies) IgA and provides passive immunity. Development of physical symptoms such as fatigue, backache, depression etc by the partner of the pregnant woman. Separation of the rectus abdominis muscle due to excess pressure of the enlarged uterus resulting in pendulous abdomen. A soft blowing sound of blood pulsating through umbilicus-occurs at same rate as the fetal heart rate. Number of weeks of pregnancy since the first day of the last menstrual period Softening of the cervix-due to estrogen and progesterone-probable sign of pregnancy Any pregnancy regardless of duration including present one Softening of the isthmus of cervix-around 6-8 weeks Pigmented line extending from pubic area to umbilicus Woman in second or any subsequent pregnancy Multipara Naegele’s rule Nulligravida Nullipara Operculum A woman who has had 2 or more births at more than 20 weeks gestation Para (Parity) Pelvic landmarks Pica Placenta Postpartum Primigravida Primipara Birth after 20 weeks gestation regardless of whether infant is born alive or dead. Postterm labor Postpartum Preterm labor Woman who has never been pregnant Woman who has had no births at more than 20 weeks gestation Persistent eating of substances such as clay, soil, soap etc. Time from birth until the body returns to prepregnancy state A woman who is present for the first time. A woman who has had one birth at more than 20 weeks gestation, regardless of whether the infant was born alive or dead. Labor occurring after 42 weeks Time from delivery of the placenta and membranes until woman returns to prepregnant condition. Labor occurring after 20 weeks, but before 37 weeks gestation. Progesterone Prostaglandins Pseudoanemia Pyrosis Quickening Relaxin Sibling rivalry Stillbirth Striae gravidarium Teratogens Uterine Souffle Physiology anemia of pregnancy. Increase plasma volume 50%, is greater than total erythrocyte (red blood cell) volume of 30%, the hematocrit-(red blood cells in plasma) decrease. Is a fluttering sensation in the abdomen (woman’s perception of fetal movement) Occurs about 18-20 wks in a primiparous but as early as 16 weeks in a multiparous An infant born dead after 20 weeks of gestation Stretch marks, reddish and wavy that appear on abdomen, thighs and buttocks. A soft blowing sound heard during abdominal auscultation over the uterus at same rate with maternal pulse-due to increased uterine blood flow. Vena Cava Syndrome Viability Medications list OB Medication List This is a list of the most common drugs used in OB. For each drug you should know the generic name, indications, route, safe dose, contraindications, compatibility etc. Some are on page 446 1. Pitocin 2. Ropivicaine 3. Penicillin 4. Cytotec 5. Cervidil 6. Clindamycin 7. Ampicillin 8. Nubain 9. Stadol 10. Fentanyl 11. Tylenol 12. Vistaril 13. Methergine 14. Hemabate 15. Zofran 16. Regaln 17. Percocet 18. Ducoste 19. Nupercainal ointment 20. Tucks pads 21. Dermaplast spray 22. Lactated Ringers 23. Dextrose 5% and Lactated Ringers 24. Ibuprofen 25. Erythromycin Ointment 26. Vitamin K 27. Sucrose Folic Acid 28. Magnesium Sulfate – p. 448 Class: beta adrenergic agonist; Tocolytic and anticonvulsant MOA: acts as a CNS depressant by decreasing the quantity of acetylcholine released by motor nerve impulses and thereby blocking neuromuscular transmission.  This action reduces the possibility of convulsion, which is why magnesium sulfate is used in the treatment of preeclampsia.  Because magnesium sulfate secondarily relaxes smooth muscle, it may cause transient blood pressure readings, although it is not an antihypertensive.  Magnesium sulfate may also decrease the frequency and intensity of uterine contraction; as a result, it is used as a tocolytic in the treatment of preterm labor. Route, Dosage, Frequency For treatment of Preterm Labor:  Recommended loading dose: 4-8 g IV in 100 mL of Lactated Ringer’s solution using infusion pump over 20-60 minutes, followed by a maintenance dose of 2-4 g/hr titrated to response and side effects. For treatment of Preeclampsia  Loading dose: 4-6 g magnesium sulfate administered over a 20-30 minute period  Maintenance dose: 2-3 g/hr via infusion pump Side Effects with loading dose:  Flushing; feeling warm  Headache  Nystagmus  Nausea, vomiting  Dizziness  Lethargy; sluggishness  Pulmonary edema  Constipation  Blurred vision  Slurred speech Toxicity Signs: KNOW  Depression or absence of reflexes- hyperflexia FIRST SIGN  Oliguria  Confusion  Respiratory depression LATE SIGN  Circulatory collapse  And respiratory paralysis If any of these are suspected, STOP the drip and notify HCP immediately. Fetal side effects:  Hypotonia  Lethargy  Respiratory distress Nursing Considerations  Monitor the blood pressure every 10-15 minutes during adm.  Monitor maternal serum magnesium levels as ordered (usually every 6-8 hours) o Therapeutic levels are in range of 4-8 mg/dl o Reflexes often disappear at serum levels of 9-13 mg/dl o Respiratory depression occurs at levels of 14 mg/dl o Cardiac arrest occurs at levels of 30mg/l and above  Monitor respirations closely. If respiratory rate is < 12 , toxicity may be occurring.  Assess knee jerk or patellar tendon reflex for evidence of diminished or absent reflexes  Determine urinary output. If output < 30 mL/hr, then toxicity may occur  If any of the above are no WNL, discontinue drip until they return to normal limits  ANTIDOTE: Calcium gluconate. Should be available at the bedside. The usual dose is 1 g given IV over a period of about 3 minutes  Monitor FHR continuously with IV administration  Continue magnesium sulfate after birth for approximately 24 hours as prophylaxis against post partum seizures if given for preeclampsia  Therapy is continued for 12 hours after uterine contractions have stopped if given for preterm labor  If drug was given to mother close to birth, monitor infant for signs of toxicity 29. Betamethasone (Celestone Soluspan) p. 444 Class: Glucocorticoid MOA: Unclear with its MOA but studies have shown that stimulation of enzyme activity are how this drug can induce pulmonary maturation and decrease the incidence of respiratory distress syndrome in preterm infants.  The enzyme is required for biosynthesis of surfactant by the type II pneumocytes. Surfactant is a major importance to the proper functioning of the lung in that it decreases the surface tension of the alveoli. Glucocorticoids also increase the rate of glycogen depletion, which leads to thinning of the inter-alveolar septa and increases the size of the alveoli. The thinning of the epithelium brings the capillaries into closer proximity with the air spaces and improves oxygen exchange. Route, dosage, frequency  Prenatal maternal IM injection of 12 mg of betamethasone are given once a day for two days. Dexamethasone has also been given in doses of 6 mg every 12 hours for 4 doses. To obtain maximum results, birth should be delayed for at least 24 hours after completing the first round treatment.  Repeat courses of corticosteroids should not be used routinely. There is some controversy with administering corticosteroids when membranes are ruptured, fueled by concerns that this could mask infection. Contraindications  Inability to delay birth  Adequate L/S ratio  Presence of a condition that necessitates immediate birth (example maternal bleeding)  Presence of maternal infection, DM  Gestational age greater than 34 completed weeks Effects on Fetus/Newborn  Lowered cortisol levels at birth, but rebound occurs by 2 hours of age  Hypoglycemia  Increased risk of neonatal sepsis Nursing Considerations  Assess for presence of contraindications  Provide education regarding possible side effects  Administer betamethasone deep in gluteal muscle, avoid injection into deltoid  If membranes are ruptured, temperature monitoring is warranted every 2 hours or more frequently if temperature instability is concerning  Periodically monitor BP, pulse, weight, and edema  Assess lab for electrolytes and blood glucose  Some people state that betamethasone and tocolytic drugs should not be given together due to cause of pulmonary edema. 30. Dexamethasone- read above 31. Terbutaline 32. Hydralazine 33. Procardia (nifedipine)  Calcium channel blocker: it decreases smooth muscle contractions by blocking the slow calcium channels at the cell surface  Side effects: arterial vasodilation and includes hypotension, tachycardia, facial flushing, and headache  Toxolytic (Do not use along with mag sulfate but yes with beta adrenergic 34. Methotrexare 35. Methyldopa 36. Indomethacin (Indocin) Class: Cyclooxygenase inhibitor - Prostaglandin synthetase