West Coast University, Orange County NURS 306 Week 5 Pre Work OB.

Chapter 7 DURHAM: High Risk Antepartum Nursing Care (Week 5 PreWork) Gestational complications  Preterm Labor (PTL): regular contractions of the uterus causing ∆ in cervix ā 37 weeks gestation (20-36 weeks and 6 days gestation) o Risk factors for PTL o Fetal anomalies, uterine abnormalities o Hx of abortion/miscarriage, incompetent cervix or insufficiency o IVF pregnancy, previous PTB o Oligohydramnios or hydramnios o Infection (UTI, HIV, active herpes, chorioamnionitis) o PROM, PPROM, placenta previa/abruption o Short pregnancy interval ( 9 months) o DM, HTN, preeclampsia, vaginal bleeding, clotting disorder, 2 nd trimester bleeding o ↓ nutrition, BMI, prepreg wt, poor wt gain o Younger than 17 and older than 35 o Obesity, ↑ BMI, ↑ wt gain o Long work hrs, long standing o FH, common in blacks o IPV, mental issues, domestic violence ↑ LBW & PTB o No social support, no prenatal care, unmarried status o Smoking, alcohol, substance abuse o Low education, socioeconomical status, poverty o Pathophysiology of PTL  Multicausal factors → local uterine factor stimulates or when suppressive factors inhibits the cascade and maintain uterine quiescence are withdrawn prematurity (PROM or cervical insufficiency)  Excessive uterine stretch or distension 2 to prostaglandins production → UC when overdistended from GDM, multifetal, ⁰ large baby, polyhydramnios, or uterine abnormalities  Decidual activation due to hemorrhage, fetal-decidual paracrine system, or upper-genital tract infection  Intrauterine infection and inflammation in the decidua, fetal membrane, amniotic fluid  Maternal or fetal stress→ release of CRH  Premature activation of normal physiological initiator or labor, activates maternal-fetal HPA o Sign and symptoms (assessment findings)  ∆ in discharge (watery, bloody, mucus), ↑ in amount, color, odor  Cervical ∆  Pelvic or lower abdominal pressure  Constant low and dull backache  Mild abdominal cram w/w/o diarrhea  Regular and frequent UC or uterine tightening (painless) Q 10 min and lasting 1 hr or longer  Possible ROM  Urinary frequency  Preterm birth (PTB): birth between 20 0/7 weeks of gestation and 36 6/7 weeks of gestation o Risk factors for PTB  Prior PTB (most important and common)  Multiple gestation (common) -twins  Uterine/cervical abnormalities, diethylstilbestrol (DES) exposure (common)  Complication o For preterm: Cerebral palsy, HL, vision impairment, chronic lung disease o For mom: rt tocolytics → arrhythmias, pulmonary edema, congestive HF  Medication management o Tocolytic drugs to suppress UC and prolong birth for 2-7 days, when moms are 24-34 wks gestation  Beta agonist→ terbutaline relaxes smooth muscles and stop uterine activity  Admin 0.25 mg SQ Q 4 hrs for up to 24 hrs  Call MD if there is chest discomfort, palpitation, dysrhythmias, tachycardia, hyperglycemia, hypotension, HR 130/min, chest pain, arrhythmias, MI, BP 90/60 or pulmonary edema  Do not give to clients with cardiac disease, PGDM, PGHTN, hyperthyroidism, hemorrhage  CCB→ nifedipine (Procardia) stops UC by inhibiting Ca entering smooth muscles  Watch for HA, flushing, dizziness, nausea, orthostatic hypotension  Do not give with mg sulfate  Tell pts to ∆ position slowly and sit until dizziness fades  ↑ hydration to counter hypotension  NSAIDS → indomethacin for short term prolongation of pregnancy up to 48 hrs (do not exceed 48 hrs and used on 32 weeks gestation)  Action: blocks production of prostaglandins and suppresses UC  May cause premature narrowing of ductus arteriosus  Discontinue if there is pulmonary edema, chest pain, SOB, RDS, audible wheezing, crackles, productive cough, blood-tinged sputum  Give with food or rectally to ↓ GI disease  Call MD if there is blurred vision, HA, n/v, tinnitus, dyspnea W e s t C o a s t U n i v e r s i t y M e e ti n g W e s t C o a s t U n i v e r s i t y C o u r s e S y l l a b u s Revision Date: 1-8-16 Page 1  Monitor neonate at birth o Other  Magnesium sulfate→ a CNS depressant to relax smooth muscles and stop UC  ↓ risk of severity and risk of cerebral palsy (give at 32 wks if birth anticipated)  Do not use if there is active vag bleeding, cervix dilation 6 cm, chorioamnionitis, acute fetal distress  Do not give with CCB or to clients with MG  Discontinue if pt has pulmonary edema, chest pain, SOB, RDS, audible wheezing, crackles, productive cough, blood tinged sputum  Adverse effects: hot flashes, diaphoresis, burning at IV, n/v, non-reactive stress test, ↓ FHR variability  Toxicity: loss of DTS, urine output 30 ml/hr or 100 ml/4hr, RR 12/ min, pulmonary edema, severe hypotension, chest pain  Give calcium gluconate or calcium chloride as antidote  Progesterone supplements → prevent spontaneous birth  Betamethasone → improve fetal lung maturity (give at 24-34 wks if birth is sus in 7 day)  IM injection (2) 24 hrs apart to be effective  Watch mom for hyperglycemia  Assess fetal lung sounds  Report pulmonary edema (chest pain, SOB, crackles) o Do not use  When UC has no cervical ∆, 2 cm dilated  As maintenance therapy  Antibiotics not used to prolong pregnancy unless there is for PPROM and GBS causing labor o Contraindications to tx of PTL/PTB  Intrauterine fetal demise  Lethal fetal anomaly  Non reassuring fetal status  Severe preeclampsia or eclampsia  Maternal bleeding with hemodynamic instability  Chorioamnionitis  PROM w/o maternal infection o Maternal contraindications  Active hemorrhage  Several maternal diseases  Fetal compromise  Chorioamnionitis (sus if there is ↑ temp and tachycardia)  Fetal death  Previable gestation and PROM  Nursing action for PTB/PTL o Assess mom and fetus for infection, ROM, SSE for amniotic fluid, vaginal bleed or discharge, dehydration o FHR and UC, report tachycardia (160/min) and ↑ UC o Vaginal and urine culture for infection o fFN prn ā SVE, DO NOT perform if there is ROM, bleeding, or sex in last 24 hrs o Strict I &O, provide oral or IV hydration  Dehydration stimulate ADH and oxytocin→ UC  May restrict intake to 3000 L/24 hr o Give steroid and meds o Vitals check, lung sounds check for pulmonary edema o Cervical check o Activity restriction with bathroom privileges, lay in left lateral position, avoid sex  DX/prediction and detection of PTL  Cervical cultures to check for infection organism and give abx if indicated  Perform BPP and NST for fetal well being  Biomarker check for fFN (fetal fibronectin): Determines when women will not deliver preterm  Swab secretion for fFN (24-34 weeks and 6 days)→ inflammation and risk of PTL in the next 2 weeks  Transvaginal cervical ultrasonography to check for cervix length  30 mm no PTL  20 mm positive indication of PTL Rupture of membrane  PROM: ROM before onset of labor but at term (true labor)  PPROM: ROM ā labor and ā 37 wks (but ṗ 20 weeks) o Risk factors  Previous PROM, PTB  Bleeding during 2nd or 3rd trimester  Short cervical length  Hydramnios  Multiple gestation  Infection, STI’s  Low BMI  Low socioeconomic status  Cigarette smoking and drug abuse  Copper or ascorbic acid deficiencies  Pulmonary or connective tissue disorders o Risk the women W e s t C o a s t U n i v e r s i t y M e e ti n g W e s t C o a s t U n i v e r s i t y C o u r s e S y l l a b u s Revision Date: 1-8-16 Page 1  Maternal infection (chorioamnionitis, endometritis)  Abruptio placenta and retained placenta  ↑ rate of CS o Risk for NB  Sepsis  Prematurity complication: resp distress, sepsis, intraventricular hemorrhage, necrotizing enterocolitis, ↑ neurodevelopmental impairment  Hypoxia or asphyxia or cord compression 2 to ↓ fluid and ROM  Fetal deformities if PPROM ā 26 wks o Assessment findings  Gush or leakage of clear fluid from vagina  Confirmed premature gestational age  Confirmed ROM  Oligohydramnios on ultrasound o Medical management  Tx infection with 7 day IV ampicillin and erythromycin, then oral form for moms with PPROM who are 34 0/7 weeks  Intrapartum GBS prophylaxis to prevent vertical transmission  1 course of betamethasone for moms b/w 24-34 wk, or earlier in 23 0/7 wks if mom is at risk for PTL in 7 days  Help ↓ neonate resp distress, intraventricular hemorrhage, neonate death  Moms with PROM ā 32 0/ wk and at risk of imminent delivery need mg sulfate  Delivery at 37 weeks or more  Digital cervical exam should not be done  No therapeutic tocolysis  Monitor for infection, abruption of placenta, and fetal compromise o Nurse action  Assess FHR and UC  Check vitals Q 2 hrs  Assess for s/s of infection: Mom & fetal tachycardia, mom temp 100.4 , uterine tenderness, malodorous fluid, or discharge ⁰  Monitor labs and fetal compromise  Provide antenatal testing: NST, BPP, FKC  Assess for prolapse umbilical cord (abrupt FHR variable or prolong decelerations; visible/palpable cord when checking cervix)  Use nitrazine paper (blue= pH of 60.5-7.5) or ferning test to confirm ROM  Prep for birth, limit vaginal exams, do a CBC  Vaginal/rectal culture for streptococcus beta hemolytic  Vaginal culture for gonorrhea and chlamydia  Bed rest with bathroom privileges, hydration  Educate mom to avoid tub bath, perineal hygiene, avoid sex; self-exams of cervix, discharge, FKC, and UC.  Chorioamnionitis is an infection of the amniotic sac (common with PPROM)