MARK KLIMEK LECTURES MATERNITY AND OB 2021 COMPLETE LECTURES

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Maternity and OB Lecture Pregnancy - Know how to calculate due date. o First day of the last menstrual period + 7 days – 3 months o June 10 -15th  due date would be March 17th - Ideal total ... weight gain for pregnancy = week of gestation - 9 o At week 12 (1st trimester) = 3lbs normal - Fundal height o Fundus not palpable until week 12 (end of the first trimester)  Client is the priority o Fundus is at the umbilicus at 20-22 weeks of gestation (end of the second trimester) o Fundus is above the umbilicus – third trimester - Quickening (baby kicking) occurs 16-20 weeks - Positive o Fetal skeleton on xray o Fetal presence on ultrasound o Auscultation of a fetal heart (can hear it around 8-12 weeks)  When would u first: 8 weeks  When would u most likely (midpoint): 10 weeks  When should u auscultate (endpoint): 12 weeks o When the examiner palpates fetal movements - Probable/presumptive o All urine and blood tests o Positive preg. Tests o Chadwick’s sign  Cervical color change to cyanosis o Goodell sign  Softening of cervix o Hegar’s sign  Softening of the lower uterine segment - Pts should come once a month until week 28 - At week 28, she should come in once every 2 weeks until week 36 - Come once every week until delivery or week 42 - Hbg level : 12-16 (will fall to 11 in first trimester) - How to treat morning sickness o Dry carbohydrates before u get out of bed o Bagels, dry cereal and dry toast - How to treat urinary continence o 1 st and third trimester problem o Baby is up higher in the abdomen in the second trimester  no urinary continence in second trimester. o Void every 2 hours all the way until 6 weeks after delivery - Difficulty breathing o 2 nd and 3rd trimester problem o Teach tripod position. - Back pain o 2 nd and 3rd trimester problem o Pelvic tilt exercises (tilt pelvis forward, Labour and Delivery - The true and most valid sign of labor o The onset of regular progressive contractions - Dilation o Opening of cervix (0-10cm) - Effacement o Thinning of the cervix o Goes from thick and 0cm closed and she ends labor in fully dilated to 10cm dilated and 100% effaced. - Station is the relation of the fetal presenting heart to mom’s ischial spine (narrowest part of the pelvis) o Negative station: baby’s presenting part is above the ischial spine. o Positive station: baby’s presenting part is below the ischial spine. (already made it through) - Engagement in station 0 o The presenting part is at the ischial spine - Fetal lie o The relationship between the spine of the mother and the spine of the baby. o Vertical lie (good)  parallel o Perpendicular (bad)  transverse lie - Presentation o Part of the body that enters the birth canal first o ROA/LOA  Right occiput anterior  Left occiput anterior  - 4 stages of labor o Stage 1: Labor has 3 phases  Latent active, transition o Stage 2: Delivery of baby o Stage 3: Delivery of placenta o Stage 4: Recovery  Last 2 hours - Purpose of uterine contractions in the first stage o Dilate and efface the cervix - In the second stage o Push the baby out - Third stage o Push placenta - Fourth stage o Contract uterus to stop bleeding - Post-partum begins 2 hours delivery of placenta - #1 priority in the second phase of labor o Pain management - Priority in the second stage o Clearing the baby’s airways - Extreme important action to be taken in the third phase o Check the dilation, check breathing - Nursing action for o Check for the vessels in the placenta - The labor chart - Latent phase o Dilate: 0-6cm o Contraction freq is 5-30mins apart o Last 15-30s o Intensity is mild - Active o Dilation 5-7cm o Freq is 3-5 mins o Last 30-60s o Intensity is moderate - Transition o Dilation is 8-10cm o Freq is 2-3 mins o Duration is 60-90s o Intensity is strong - Signs of uterine tetany/Uterine hyperstimulation o Contractions should not be longer than 90s and closer than 2 mins - Assessment of contractions o Freq is the beginning of one contraction to beginning of the next o Duration is beginning to end of one contraction o Intensity; palpate with one hand over the fundus with the pads of the finger - Complications of labor o 18 complications  Painful back labor (LOPosterior /ROPosterior )  Position her in a knee chest position then push into her sacrum  Low priority  Prolapse cord  Emergency  Cord is the presenting part (head will press on the cord)  High priority  Push the head back up, position in knee chest - Interventions for other complications (Maternal hypotension, toxemia, o LION o Turn on left side o Increase IV o Oxygenation o Notify physician - Pain meds in labor o Do not administer pain med to woman in labor if the baby is likely to be born when the med peaks. Fetal Monitoring Patterns - 7 monitoring patterns (look at the first letter, starts with L: do LION) o Low fetal HR (<110)  Do LION (left side lying, IV, O2 and notify MD)  BAD! o High fetal HR (>160)  Baby is fine but take mom’s temperature o Low baseline variability (stable VS)  Fetal HR stays same  BAD!  Do LION (left side lying, IV, O2 and notify MD) o High baseline variability  Fetal HR always changing  Document it  Good! o Late deceleration  Fetal HR slows down near the end or after a contraction.  BAD!  Do LION (left side lying, IV, O2 and notify MD) o Early deceleration  Fetal HR slows down before or at the beginning of contractions.  Normal  Document o Variable Decelerations  VERY BAD!  Happens in prolapse cord  Push then position. - Always check fetal HR Delivery of the Baby - First deliver the head - Suction the mouth and then nose - Check for the nuchal cord (around the neck) - Deliver the shoulders and body. - Baby must have an ID badge on before leaving the delivery area - First stage: placenta o Make sure it’s all there o Check for a 3-vessel cord (2 arteries and 1 vein) AVA - Recovery o First 2 hrs after delivery of placenta. o VS q15 min (s/s of shock  low BP, HR rate goes up, pale cold and clammy) o Assess fundus. Q15min  If boggy, massage it  If displaced, catharize. o Check the perineal pads every 15min  Check amount of bleeding (heavy = 100% saturated pad in 15 mins or less) o Roll her over: check bleeding underneath her every 15min Post-partum Assessment - Assessed q4-8h - B – breast, U- Uterine fundus, L- Lochia (rubra -red , serosa - pink, alba- white), E – Episiotomy, HHematocrit/Hgb, E- Extremity check, A- Affect, D- Discomfort o Fundus should be firm, midline o Fundal height = day postpartum o Look for thrombophlebitis  Bilateral calf circumference Variations in the Newborn - Caput Succedeaum o CS – crosses suture and caput symmetrical - Cephal hematoma o Doesn’t cross o Bleeding OB Medications - Terbutaline o Stops labor and speeds up HR of the mother - Magnesium sulfate o Stop uterine contractions o Lowers HR, BP, less reflexes, low RR, LOC go down (we want to see 12 resps and +2 reflexes) o Monitor reflexes and respirations (if below 12, lower the dose, if reflexes are +1, slow down the dose) - Oxytoxics o Stimulate labor o Pertocin  Cause uterine hyperstimulation (longer than 90s, and closer than 2 mins) o Mertergy  Causes high BP - Fetal lung maturing meds o Beta methasone  Given to the mother  Given IM  Given before baby is born o Serventa (Surfactant)  Given to the baby  Given transtracheally  Given after baby is born Medication Facts - Humulin 70/30 o Mix of insulin of N and R - Needle that have a 5 = for subcut injections - Needles that have a 1 = for IM injections - Heparin o Given iV/ SUBCUT o Works immediately o Cannot be given for longer than 3 weeks o Antidote to overdose: Protamine sulfate o PTT monitors heparin o Can be given to pregnant woman - Coumadin o Given PO o Takes a few days to a week to work o U can take it forever o Antidote: Vitamin K o PT/INR monitors coumadin o CANNOT be given to pregnant women - K wasting diuretic o End with X or diaril, semides o Lasix - K-sparing diuretic o Spiralactone - Muscle relaxants o 2 side effects  Fatigue and muscle weakness o 3 teachings  Don’t drink,  Don’t drive  Don’t operate heavy machinery Paediatrics - 4 stages of Piaget’s theory of cognitive development o 0-2 (sensory motor thinking)  Think about the present  Teach them while they doing it or as you do it  Teach them what you are doing and just tell them, don’t use play o 3-6 years (preoperational)  Preschooler  Fantasy oriented, illogical  Understand the past and future  Can teach them shortly before  Teach them what you are going to do  Learn through play o 7-11 (concrete operational)  Rule-oriented  Cannot abstract,  There is only one way to do things  Teach them days ahead  Teach them what ur going to do plus skills  Use age appropriate reading and demonstration o 12-15  Can abstract and think cause and effect  Teach like an adult Psych Drugs - All psych drugs cause low BP and weight gain (protac cause weight loss) Typical - First Generation Anti-Psychotics (Phenothiazines) - Only reduce symptoms, do not cure the disease - In small doses, they are anti-emetics - Side effects o A – Anticholinergic (dry mouth) o B- Blurred vision  N. diagnoses: Risk for injury o C- Constipation o D- Drowsiness o E- EPS (extra pyramidal symptoms)  Cogentin is given to treat EPS o F – Photosentivity o AG- Agranulocytosis - #1 nursing diagnosis: Risk for injury (safety issues) - Decanoate o It is a long acting Tricyclic Antidepressants - SSNRI o Selective - NSRI o Non-selective serotonin reuptake inhibitors - Mood elevators - Side effects o A- Anticholinergic o B- Blurred vision  N. diagnoses: Risk for injury o C- Constipation o D – Drowsiness o E- Euphoria - Taken for 2-4 weeks for efficiency, does not work right away. Benzodiazepines - Minor tranquilizers - Ends with “zep” - Can be used pre-op sedative, Muscle relaxants, alcohol withdrawals, - Works right away and cannot be taken for more than 2-4 weeks - Side effects o A- Anticholinergic o B- Blurred vision o C- Constipation o D – Drowsiness - #1 nursing diagnoses o Risk for injury/safety concerns MAOIs - Antidepressants - MaR, NaR, PaR - Side effects o A- Anticholinergic o B- Blurred vision o C- Constipation o D – Drowsiness - To prevent hypertensive crisis o Pt must avoid all foods containing tyramine such as:  Salad bar (Bananas, avocado/guacamole, and raisins)  Liver, kidney, brain  No preserved meats (smoked)  No cheese except cottage and mozzarella and yogourt  No alcohol or chocolate, caffeine, soy sauce - They should not take OTC meds Lithium - Used for bipolar disorder - Used for decreasing mania - Side effects o 3Ps - Peeing, Pooping and paresthesia (numbness and tingling)  Give the drug still, and don’t call doctor - Toxic effects o Metallic taste o Tremors o Severe diarrhea - Interventions o Increase fluids o Monitor sodium levels (competitive binders)  Low Na  Li becomes toxic  High Na  Li won’t work Prozac - SSRI - Side effects o A- Anticholinergic o B- Blurred vision  N. diagnoses: Risk for injury o C- Constipation o D – Drowsiness o E- Euphoria - It causes insomnia o Give the drug before noon, NOT at bedtime - For adolescent and young adults, when changing the dose: o Watch for suicidal ideation Sertraline (Zoloft) - SSRI - Causes insomnia but can be given at bedtime - Notorious for interfering with the p460 system in the liver - Other drugs do not get metabolized when taking this drug o Lower the dose of other - If taking st john wort and Zoloft, serotonin syndrome occurs o Sweating o Apprehension (an impending sense of doom) o Dizziness and headache - Watch for increased bleeding when pt is on coumadin Haldol - Atypical - Side effects: o B- Blurred vision  N. diagnoses: Risk for injury o C- Constipation o D- Drowsiness o E- EPS (extra pyramidal symptoms)  Cogentin is given to treat EPS o F – Photosentivity o AG- Agranulocytosis - NMS o Neuroleptic malignant syndrome o Tremors, anxiety, fever o Medical emergency - To differentiate between EPS vs NMS o Take a temperature first (temp > 102F) Clozapine - Prototype (original first 2nd atypical antipsychotic) - New major tranquilizers - Used to treat severe schizophrenia - Does not have the side effect ABCDEF ( or very minor side effects) - Disadvantage o Causes agranulocytosis  Monitor WBC Geodon - Prolongs the QT interval and can cause sudden cardiac arrest - Should not be used with ppl with heart problems. Labs Values A - Low priority B – Medium priority (watch closely) C – High priority (critical, must do something about it) D – Highest priority Creatinine - Best indicator of kidney function - 0.6 to 1.2 (same as lithium) - Abnormal is low priority PT/INR - 2.0 to 3.0 - > 4 = C (high priority) o Hold o Assess focused area o Prepare to give o Call MD Potassium - 3.5 – 5.3 - <3.5 = C (high priority) - 5.4 -5.9 = C o Hold K+ o Assess heart o Kayealate and D5W and regular insulin o Call MD - >or 6 = D (highest priority) o Stay with the pt while other nurses get ECG pH - 7.35 to 7.45 - pH of 6 = D o assess VS o call MD stat BUN - 8-25 - If elevated: o Assess for dehydration Hemoglobin - 12-18 - 8-11 = B o Assess for malnutrition, bleeding - <8 = C o Assess for bleeding o Prepare to administer blood o Call MD Bicarbonate - 22 – 26 - Abnormal = A CO2 - 35-45 - In the 50s = C o Assess respiratory status o Teach pursed lip breathing - In the 60s = D o One of the criteria for resp. failure o Stay with pt o Assess resp. status o Prepare for intubation and ventilation o Call RT and MD [Show More]

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