Exam 2

supi ne hypoternsive

*changes are reversed when the woman is in the side-lying position, which displaces the uterus to the left and off the vena cava** → when the gravid uterus compresses the inferior vena cava when a pregnant woman is in a supine position → decreased venous return centrally. *S/S: tachycardia, diaphoresis, nausea/vomiting, pallor, weakness, lightheadedness, and dizziness *Interventions: move patient into a LEFT RECUMBENT position and administer IV fluids. (may need to administer O2 as well)

Hair and Nails:

- Decline in hair growth during pregnancy - Hair follicles undergo a growing and resting phase - Resting phase is followed by a loss of hair, hairs are then replaced by new ones - Fewer hair follicles go into the resting phase - Nails grow faster during pregnancy - Pregnant women may experience increased brittleness, distal separation of the nail bed, whitish discoloration, and transverse grooves on the nails

True versus false labor

- False labor: condition occurring during the latter weeks of some pregnancies when irregular uterine contrxns are felt, but cervix is not affected - True labor: characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity - Contractions bring about progressive cervical dilation and effacement - → False labor, prodromal labor, and Braxton Hicks are all names of contractions that do not contribute in a measurable way toward the goal of birth

4 Endocrine System:

- Thyroid Gland: - Enlarges slightly and becomes more active - Increased gland activity results in an increase in thyroid hormone secretion starting during the first trimester - Maternal thyroid hormone is transferred to the fetus beginning soon after conception and is critical for fetal brain development, neurogenesis, and organizational processes prior to 20 weeks when fetal thyroid production is low - Thyroxin is needed for development - Increase in the secretion of thyroid hormones, basal metabolic rate progressively increases by 25%, along with heart rate and cardiac output

Vascular related skin changes:

- Varicosities of the legs, vulva, and perineum - Varicose veins are the result of distention, instability and poor circulation secondary to prolonged standing or sitting and the heavy gravid uterus placing pressure on the pelvic veins, preventing complete venous return - Interventions: - Elevating both legs when sitting or lying down - Avoiding prolonged standing or sitting; changing position frequently - Resting in the left lateral position - Walking daily for exercise - Avoiding tight clothing or knee high hosiery - Wearing support hose if varicosities are a preexisting condition to pregnancy

Blood Pressure:

-Declines slightly during pregnancy as a result of peripheral vasodilation caused by progesterone - Usually reaches a low point mid-pregnancy and thereafter increases to pre-pregnancy levels until term - First trimester: blood pressure typically remains at the pre-pregnancy level - Second trimester: BP decreases 5 to 10 mm Hg and thereafter returns to first-trimester levels - Decrease in BP begins at about 7 weeks' gestation and persists until 32 weeks' gestation when it begins to rise to pre-pregnancy levels - Any significant rise in blood pressure during pregnancy should be investigated to rule out gestational hypertension

The nurse's role in fetal assessment and throughout the labor and birth process

Analysis of the FHR is one of the primary evaluation tools used to determine fetal oxygen status indirectly. FHR assessment can be done intermittently using a fetoscope (a modified stethoscope attached to a headpiece) or a Doppler (ultrasound) device, or continuously with an electronic fetal monitor applied externally or internally. ● The nurse listens to FHR for short periods of time at regular intervals. Intermittent FHR monitoring allows the woman to be mobile during the first stage of labor. She is free to move around and change position at will since she is not attached to a stationary electronic fetal monitor. However, intermittent monitoring does not provide a continuous FHR recording and does not document how the fetus responds to the stress of labor (unless listening is done during the contraction). ● Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. However, it cannot detect variability and types of decelerations, as electronic fetal monitoring (EFM) can. ● The FHR is heard most clearly at the fetal back. In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus. As labor progresses, the FHR location will change accordingly as the fetus descends into the maternal pelvis for the birthing process. To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. ● For low-risk women, the FHR and contraction characteristics should be assessed every 15 to 30 minutes in active labor and every 5 to 15 minutes while pushing, as well as before and after any digital vaginal examinations, membrane rupture, medication administered, and ambulation to the restroom

Nonpharmacologic Measures for Pain Management

Continuous labor support ▪ Hydrotherapy ▪ Ambulation and position changes (see Table 14.2, Figure 14.9) ▪ Acupuncture and acupressure ▪ Attention focusing and imagery ▪ Therapeutic touch and massage; effleurage ▪ Breathing techniques (e.g., patterned-paced breathing)

Placental Hormones:

Human chorionic gonadotropin (hCG)- responsible for maintaining the maternal corpus luteum, which secretes progesterone and estrogens with synthesis occurring before implantation. Basis for early pregnancy tests because it appears in the maternal bloodstream soon after implantation. Production peaks at 8 weeks and gradually declines. ○ hP (human placental lactogen)L: preparation of mammary glands for lactation and involved in the process of making glucose available for fetal growth. Antagonist of insulin. ○ Relaxin: Secretion by the placenta as well as the corpus luteum during pregnancy. Acts synergistically with progesterone to maintain pregnancy. Dilation of cervix. Suppresses release of oxytocin → delays labor contractions ○ Progesterone: "hormone of pregnancy" bc of the critical role it plays supporting the endometrium of the uterus. Produced by the corpus luteum during the first few weeks of pregnancy and then by the placenta until term. ○ Estrogen: promotes enlargement of the genitals, uterus, and breasts, and increases vascularity, causing vasodilation. Associated with hyperpigmentation, vascular changes in the skin

guidelines for assessing FHR:

Initial 10- to 20-minute continuous FHR assessment upon entry into labor and birth area ● Completion of a prenatal and labor risk assessment on all clients ● Intermittent auscultation every 30 minutes during active labor for a low-risk woman and every 15 minutes for a high-risk woman ● During the second stage of labor, every 15 minutes for the low-risk woman and every 5 minutes for the high-risk woman and during the pushing stage

Pharmacologic Measures

Systemic analgesia ▪ Regional or local anesthesia ▪ Neuraxial analgesia/anesthesia techniques: use of analgesic or anesthetic, continuously or intermittently into epidural or intrathecal space ▪ Shift in pain management: woman as an active participant during laborSystemic analgesia ▪ Regional or local anesthesia ▪ Neuraxial analgesia/anesthesia techniques: use of analgesic or anesthetic, continuously or intermittently into epidural or intrathecal space ▪ Shift in pain management: woman as an active participant during labor

Phases of maternal role adjustment and accompanying behaviors.

Taking-in phase ○ time immediately after birth when the client needs sleep, depends on others to meet her needs, and relives the events surrounding the birth process. ○ characterized by dependent behavior. ○ During the first 24 to 48 hours after giving birth, mothers often assume a passive role in meeting their own basic needs for food, fluids, and rest, allowing the nurse to make decisions for them concerning activities and care. ○ When interacting with the newborn, new mothers spend time claiming the newborn and touching them, commonly identifying specific features in the newborn ● Taking-hold phase ○ characterized by dependent and independent maternal behavior. ○ This phase typically starts on the second to third day postpartum and may last several weeks. ○ demonstrates increased autonomy and mastery of her own body's functioning, and a desire to take charge with support and help from others. She will show independence by caring for herself and learning to care for her newborn, but she still requires assurance that she is doing well as a mother. ● Letting-go phase ○ the woman reestablishes relationships with other people ○ focus of this phase is to move forward by assuming the parental role and to separate herself from the symbiotic relationship that she and her newborn had during pregnancy ○ She establishes a lifestyle that includes the infant. The mother relinquishes the fantasy infant and accepts the real one.

Fourth stage

The focus of nursing management during the fourth stage of labor involves frequently observing the mother for hemorrhage, providing comfort measures, and promoting family attachment. ● Assessments during the fourth stage center on the woman's vital signs, status of the uterine fundus and perineal area, comfort level, lochia amount, and bladder status. During the first hour after birth, vital signs are taken every 15 minutes, then every 30 minutes for the next hour if needed. The woman's blood pressure should remain stable and within normal range after giving birth. A decrease may indicate uterine hemorrhage; an elevation might suggest preeclampsia. ● The pulse is usually typically slower (60 to 70 bpm) than during labor. This may be associated with a decrease in blood volume following placental separation. An elevated pulse rate may be an early sign of blood loss. The blood pressure usually returns to its prepregnancy level and therefore is not a reliable early indicator of shock. Fever is indicative of dehydration (less than 100.4°F or 38°C) or infection (above 101°F), which may involve the genitourinary tract. Respiratory rate is usually between 16 and 24 breaths per minute and regular. Respirations should be unlabored unless there is an underlying preexisting respiratory condition. ● Assess fundal height, position, and firmness every 15 minutes during the first hour following birth. The fundus needs to remain firm to prevent excessive postpartum bleeding. The fundus should be firm (feels like the size and consistency of a grapefruit), located in the midline and below the umbilicus. If it is not firm (boggy), gently massage it until it is firm (see Nursing Procedure 22.1 for more information). Once firmness is obtained, stop massaging. ● The vagina and perineal areas are quite stretched and edematous following a vaginal birth. Assess the perineum including the episiotomy if present for possible hematoma formation. Suspect a hematoma if the woman reports excruciating pain or cannot void or if a mass is noted in the perineal area. Also assess for hemorrhoids, which can cause discomfort. ● Assess the woman's comfort level frequently to determine the need for analgesia. Ask the woman to rate her pain on a scale of 1 to 10; it should be less than 3. If it is higher, further evaluation is needed to make sure there aren't any deviations contributing to her discomfort. ● Assess vaginal discharge (lochia) every 15 minutes for the first hour and every 30 minutes for the next hour. Palpate the fundus at the same time to ascertain its firmness and help estimate the amount of vaginal discharge. In addition, palpate the bladder for fullness, since many women receiving an epidural block experience limited sensation in the bladder region. Voiding should produce large amounts of urine (diuresis) each time. Palpating the woman's bladder after each voiding helps in assessing it and ensuring complete emptying. A full bladder will displace the uterus to either side of the midline and potentiate uterine hemorrhage secondary to bogginess.

Uterine Involution

The uterus returns to its normal size through a gradual process of involution, which involves retrogressive changes that return it to its nonpregnant size and condition. ● Involution involves three retrogressive processes ○ Contraction of muscle fibers to reduce those previously stretched during pregnancy ○ Catabolism, which shrinks enlarged individual myometrial cells ○ Regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochial discharge

Fundal height and growth (correlation/ why assess)

Top of pubic bone to uterus; 1 inch per gestation week from 20-36 weeks, the fundus then drops due to lightning. -> If growth flattens FGR or overgrowth can mean multiple gestational hydramnios

Positive

Ultrasound verification of embryo or fetus (4-6 weeks), fetal movement by experienced clinician (20 weeks), auscultation of fetal heart tones via Doppler (10-12 weeks)

Renal/Urinary System:

Undergo dramatic changes in response to pregnancy - Kidneys must adapt to an increase in blood volume and increased maternal and fetal waste - Hormonal changes during pregnancy allow for increased blood flow to the kidneys - Renal system must handle the effects of increased maternal intravascular and extracellular volume and metabolic waste products as well as excretion of fetal wastes - Renal pelvis and uterus dilate - Occurs as a result of the hormonal influences of estrogen and progesterone, pressure from an enlarging uterus, and an increase in maternal blood volume - Dilation of kidneys and ureters increases the potential for urinary stasis and infection - Kidneys work harder throughout the pregnancy - Accommodate a heavier workload while maintain a stable electrolyte balance and BP - More blood flows to kidneys, glomerular filtration rate increases, leading to an increase in urine flow and volume - Kidneys enlarge during pregnancy - Increases in length by 1 to 1.5 cm and weight as a result of hormonal effects that cause increased tone and decreased motility of smooth muscle - Blood flow to kidneys increases by 50% to 80%

Weight gain

Underweight (BMI less than 18.5) total weight gain range=28-40 lb Normal weight (BMI 19.5-24.9) 25-35 lb Overweight (BMI 25-29.9) 15-25 lb Obese (30-higher) 11-20 lb

Evaluation of the maternal status during labor and birth.

· Assess maternal vital signs, including temperature, blood pressure, pulse, respiration, and pain, which are primary components of the physical examination and ongoing assessment. · Also review the prenatal record to identify risk factors that may contribute to a decrease in uteroplacental circulation during labor. · If there is no vaginal bleeding upon admission, a vaginal examination or ultrasound assessment is performed to assess cervical dilation, after which it is monitored periodically as necessary to identify progress. · Evaluate maternal pain and the effectiveness of pain management strategies at regular intervals during labor and birth.

Comfort and Pain Management

▪ Pain as universal experience; intensity highly variable ▪ Mandate for pain assessment in all clients admitted to health care facility ▪ Numerous nonpharmacologic and pharmacologic choices available

Estrogen

○ Allows the uterus to expand. ○ Your pelvis has ligaments that soften

Vaginal exam

○ Effacement: ■ 0%: cervical canal is 2 cm long ■ 50%: cervical canal is 1 cm long ■ 100%: cervical canal is obliterated o Dilation ■ 0 cm: external cervical os is closed ■ 5 cm: external cervical os is halfway dilated ■ 10 cm: external os is fully dilated and ready for birth passage · Fetal descent/presenting part O the gloved index finger is used to palpate the fetal skull (if vertex presentation) through the opened cervix or the buttocks in the case of a breech presentation. Station is assessed in relation to the maternal ischial spines and the presenting fetal part. The ischial spines serve as landmarks and have been designated as zero station. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned; if the presenting fetal part is felt below the maternal ischial spines, a positive number is assigned, denoting how many centimeters below zero station. · Rupture of membranes o if intact, the membranes will be felt as a soft bulge that is more prominent during a contraction. If the membraneshave ruptured, the woman may have reported a sudden gush of fluid. Membrane rupture may also occur as a slowtrickle of fluid. When membranes rupture, the priority focus should be on assessing fetal heart rate (FHR) first toidentify a deceleration, which might indicate cord compression secondary to cord prolapse. If the membranes areruptured when the woman comes to the hospital, the health care provider should ascertain when this occurred.Prolonged ruptured membranes increase the risk of infection as a result of ascending vaginal pathologic organismsfor both mother and fetus. Signs of intrauterine infection to be alert for include maternal fever, fetal and maternaltachycardia, foul odor of vaginal discharge, and an increase in white blood cell count. To confirm if they haveruptured, a sample of fluid is taken from the vagina via a nitrazine yellow dye swab to determine the fluid's pH.Vaginal fluid is acidic, while amniotic fluid is alkaline and turns a nitrazine swab blue.

Human placental lactogen or human chorionic somatomammotropin (hCS)

○ Helps regulate metabolism of the mother during pregnancy to facilitate the energy supply of the fetus. ○ hpL has anti-insulin properties which leads to an increase in maternal blood glucose levels. ○ Helps to free up glucose for the fetus.

Relaxin

○ Relaxed the ligaments in the pelvis and softens and widens the cervix

HCG

○ Stimulates progesterone production in the corpus luteum ○ Hormone for the maternal recognition of pregnancy produced by trophoblast cells that are surrounding a growing embryo, which eventually forms the placenta after implantation

Progesterone

○ Will support the entire pregnancy. ○ If levels drop, you go into labor. (preterm labor, or possible miscarriages, progesterone suppositories are given to help them keep the baby until full term)

Naegle's Rule calculation (practice)

● *first day of LMP* -> Subtract 3 months, Add 7 days, Add 1 year = EDD -> birth 2 weeks before or after is considered normal LMP 11/21/21 = 8/28/22

embryonic stage

● End of second week through eighh week t● Basic structures of major body organs and main external features

pre-embryo stage

● Fertilization; cleavage; morula ● Blastocyst and trophoblast ● Implantation

Postpartum nursing care with interventions to foster maternal-infant bonding.

● Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. ● Nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of others and their partners to enhance parent-newborn attachment. ● Encouraging breastfeeding is another way to foster attachment between mothers and their newborns ● Nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care.

Increased Energy Level

- Sudden increase in energy before labor - Sometimes referred to as nesting, because many women will focus their energy toward childbirth preparation by cleaning, cooking, preparing the nursery, and spending extra time with other children in the household - Occurs 24 to 48 hours before the onset of labor

Maternal and fetal responses to labor and birth.

- Influenced by her psychological and physical state - Previous birth experiences and their outcomes - Current pregnancy experience (planned vs. unplanned, discomforts experiences, age, risk status of pregnancy, chronic illness, weight gain) - Cultural considerations (values and beliefs about health status) - Support system (presence and support of a valued partner during labor) - Childbirth preparation (attended childbirth classes and has practiced paced breathing techniques) - Exercise during pregnancy (muscles toned; ability to assist with intra-abdominal pushing) - Expectations of the birth experience (viewed as a meaningful or stressful event) - Anxiety level (excessive anxiety may interfere with labor progress) - Fear of labor and loss of control (fear may enhance pain perception, augmenting fear) 12 - Fatigue and weariness (not feeling adequately energized for the challenge and duration of labor) - Fetal Responses: - Periodic fetal heart rate accelerations and slight decelerations related to fetal movement, fundal pressure, and uterine contractions - Decrease in circulation and perfusion to the fetus secondary to uterine contractions (a healthy fetus is able to compensate for this drop) - Increase in arterial carbon dioxide pressure (PCO2) - Decrease in fetal breathing movements throughout labor - Decrease in fetal oxygen pressure with a decrease in the partial pressure of oxygen (PO2)

powers

- Involuntary and therefore cannot be controlled by the woman experiencing them, regardless of whether they are spontaneous or induced - Contractions are rhythmic and intermittent, with a period of relaxation between contractions - Pause allows the woman and uterine muscles to rest - Pause restores blood flow to the uterus and placenta

Gastrointestinal System:

- Motility is - Displacement of the intra-abdominal portion of the esophagus into the thorax - Causes a decrease in tone - Leads to gastroesophageal reflux disease - Gums become hyperemic, swollen, and friable, and tend to bleed easily - Change is influenced by estrogen and increased proliferation of blood vessels and circulation to the mouth - Saliva becomes more acidic - Ptyalism: excessive salivation, may be caused by the decrease in unconscious swallowing by the woman when nauseated - Increased production of female hormones during pregnancy contributes to the development of gingivitis and periodontitis because vascular permeability and possibile tissue edema are both increased - Smooth muscle relaxation and decreased peristalsis occur related to the influence of progesterone - Elevated progesterone levels cause smooth muscle relaxation: delayed gastric emptying and decreased peristalsis - Transition time of food throughout the GI tract may be so much slower that more water than normal is reabsorbed, leading to bloating and constipation - Slowed gastric emptying combined with relaxation of the cardiac sphincter allows reflux, which causes heartburn - Emptying time o the gallbladder is prolonged secondary to the smooth muscle relaxation from progesterone

Pain management in labor (pharmacological and non-pharmacological)

- Perception of pain can be influenced by a number of factors: - Past experiences, culture and beliefs, stoicism, anxiety and depression - Nurses need to understand what it is and provide support to the laboring client to enable her to deal with the pain and challenges of labor - Pain during labor is a nearly universal experience - Controlling the uterine discomfort without harm to the fetus or labor process is the major focus of pain management during childbirth - Pain is subjective involving a complex interaction of physiologic, spiritual, psychosocial, cultural, and environmental influences - Cultural values and learned behaviors influence perception and response to pain

position

- Positioning for normal labor and birth has evolved - Scientific evidence has shown that nonmoving, back-lying positions during labor are not healthy - Upright position, gravity can help in bringing the fetus down, and there is less risk of compressing the maternal aorta which supplies oxygen to the fetus - Contrary to evidence, many women continue to lie flat on their backs during labor - Some of the reasons why this practice continues: - Laboring women need to conserve their energy and not tire themselves - Nurses cannot keep track of the whereabouts of ambulating women - It is the preference of the health care provider - The fetus can be monitored better in this position - Supine position facilitates vaginal examinations and external belt adjustment - A bed is "where one is supposed to be" in a hospital setting - The position is more convenient for the delivering health care provider - Laboring women are connected to medical equipment that impedes movement - Women should be encouraged to assume any position of comfort for them - Maternal position can influence pelvic size and contours - Changing position and walking affect the pelvis joints, which may facilitate fetal descent and rotation - Squatting enlarges the pelvic inlet and outlet diameters, and a kneeling position removes pressure on the maternal vena cava and helps rotate the fetus from a posterior position to an anterior one to facilitate birth - Use of any upright or lateral position compared to supine or lithotomy positions may: - Reduce the length of the first stage of labor - Reduce the duration of the second stage of labor - Reduce the number of assisted deliveries (vacuum and forceps) - Reduce episiotomies and perineal tears - Contribute to fewer abnormal fetal heart rate patterns - Increase comfort and reduce requests for pain medication - Enhance a sense of control by the mother - Alter the shape and size of the pelvis, which assists in descent - Assist gravity to move the fetus downward

Premonitory Signs of Labor: Cervical Changes:

- Rigid cervix of pregnancy must become distensible to expel the fetus - Labor begins, cervical softening and possible cervical dilation with descent of the presenting part into the pelvis occur - Changes can occur 1 month to 1 hour before actual labor begins - As labor approaches, cervix changes from an elongated structure to a shortened, thinned segment - Cervical collagen fibers undergo enzymatic rearrangement into smaller, more flexible fibers that facilitate water absorption, leading to a softer, more stretchable cervix - Occur secondary to the effects of prostaglandins and pressure from Braxton Hicks contractions

Factors affecting the labor process: - Passageway (birth canal)

- Route through which the fetus must travel to be born vaginally - Consists of the maternal pelvis and soft tissues - Maternal bony pelvis is more important because it is relatively unyielding - Bony Pelvis: can be divided into true and false portions - False (greater) pelvis: composed of the upper flared parts of the two iliac bones with their concavities and the wings of the base of the sacrum - Divided from the true pelvis by an imaginary line drawn from the sacral prominence at the back to teh superior aspect of the symphysis pubis at the front of the pelvis - Imaginary line is called the linea terminalis - False pelvis lies above the imaginary line - True pelvis lies below it - Bony passageway through which the fetus must travel - Made up of 3 planes: - Pelvic Inlet: - Upper pelvic narrow - Entrance toward the birth canal - Allows entrance tot he true pelvis - Bounded by sacral prominence in the back, ilium on the sides and the superior aspect of the symphysis pubis in the front - Wider in the transverse aspect than it is from front to back - Mid-Pelvis: - Upper pelvic narrow - Entrance toward the birth canal - Allows entrance to the true pelvis - Bounded by sacral prominence in the back, ilium on sides, and superior aspect of the symphysis pubis in the front - Wider in the transverse aspect - Pelvic Outlet: - Bound by ischial tuberosities - Lower rim of the symphysis pubis, and tip of coccyx - Outlet is wider from front to back - Gynecoid Pelvis: considered the true female pelvis, occurring in about 40% of all women - Less common in men - Vaginal birth is most favorable with this type of pelvis - Inlet is round and outlet is roomy - Anthropoid pelvis: common in men and most common in non-white women - 25% of women - Pelvic inlet is oval and sacrum is long - Android Pelvis: considered the male-shaped pelvis and is characterized by a funnel shape - Inlet is heart shaped and the posterior segments are reduced in all pelvic planes - Descent of the fetal head into the pelvis is slow, and failure of the fetus to rotate is common - Platypelloid Pelvis: flat pelvis is the least common type of pelvic structure among men and women with an approximate incidence of 3% - Shallow but widens at the pelvic outlet, making it difficult for the fetus to descend through the mid-pelvis - Labor prognosis is poor with arrest at the inlet occurring frequently - Soft tissues: consist of the cervix, pelvic floor muscles and the vagina - Effacement: cervix effaces (thins) to allow the presenting fetal part to descend into the vagina - Hormones relaxin and estrogen cause the connective tissues to become more relaxed and elastic and cause the joints to become more flexible to prepare the mother's pelvis for birth - Passenger (fetus and placenta) - Fetus with the placenta - Fetal head (size and presence of molding) - Largest fetal structure, making it an important factor in labor and birth - Considerable variation in the size and diameter of the fetal skull - Molding: changed (elongated) shape of the fetal skull at birth as a result of overlapping of the cranial bones - Fluid can also collect in the scalp (caput succedaneum) or blood can collect beneath the scalp (cephalohematoma) further distorting the shape and appearance of the fetal head during a vaginal examination - Anterior and posterior fontanelles are also useful in helping to identify the position of the fetal head 9 - Fetal attitude (degree of body flexion) - Refers to the posturing (flexion or extension) of the joints and the relationship of fetal parts to one another - Most common is when labor begins is with all joints flexed, fetal back is rounded, chin iis on chest, thighs are flexed on the abdomen, and legs are flexed at the knees - Fetal lie (relationship of body parts) - Refers to the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother - 3 possible lies: - Longitudinal (most common) - Occurs when the long axis of the fetus is parallel to that of the mother (fetal spine to maternal spine side-by-side) - Transverse lie - Occurs when the long axis of the fetus is perpendicular to the long axis of the mother (fetal spine lilies across the maternal abdomen and crosses her spine) - Cannot be delivered vaginally - Oblique - Fetal long axis is at an angle to the bony inlet, and no palpable fetal part is presenting - Usually transitory lie and occurs during fetal conversion between other lies - Cannot be delivered vaginally - Fetal presentation (first body part) - Presentation: refers to the body part of the fetus that enters the pelvic inlet first (the "presenting part") - Fetal part that lies over the inlet of the pelvis or the cervical os - Knowing which fetal part is coming first at birth is critical for planning and initiating appropriate interventions - Cephalic (head first) - 95% of newborns are born in cephalic presentation - Breech (pelvis first) - Occurs when the fetal buttocks or feet eneter the maternal pelvis first and the fetal skull enters last - Largest part of fetus (skull) is born last and may become stuck in the pelvis - Umbilical cord can become compressed between the fetal skull and maternal pelvis after the fetal chest is born because hte head is last to exit - Butt is soft and not as effective as a cervical dilator during labor compared with a cephalic presentation - Trauma to the head - Shoulder (scapula first) - Or shoulder dystocia occurs when the fetal shoulders present first with the head tucked insid e - Signs of shoulder dystocia appear while the woman is pushing as the neonate's head slowly extends and emerges over the perineum but hten retracts back into the vagina - "Turtle sign" - Odds for this birth 1/300 - Fetus is inn a transverse lie wiitht he shoulder as the presenting part - Shoulder dystocia include: placenta previa, prematurity, high parity, premature rupture of membranes, multiple gestation, or fetal anomalies - Cesarean birth is usually necessary if identified before labor begins - Fetal position (relationship to maternal pelvis) - Describes the relationship of a given point on the presenting part of the fetus to a designated point of the maternal pelvis - Landmark fetal presenting parts include the occipital bone (O) which designates a vertex presentation, the chin (mentum [M]), which designates a face presentation; buttocks (sacrum [S]) which designate a breech presentation; and scapula (acromion process [A]) which designates a should presentation - Fetal station - Refers to the relationship of the presenting part of the level of th

Spontaneous Rupture of Membranes:

- Rupture of membranes with loss of amniotic fluid prior to the onset of labor is termed prelabor rupture of membranes - Occurs in 8 to 10% of women with term pregnancies - Rupture of membranes can result in either a sudden gush or a steady leakage of amniotic fluid - Amniotic fluid is lost when the rupture occurs, a continuous supply is produced to ensure protection of the fetus until birth - After sac has ruptured, barrier to infection is gone and an ascending infection is possible - Danger of cord prolapse if engagement has not occurred with the sudden release of fluid and pressure with rupture- Rupture of membranes with loss of amniotic fluid prior to the onset of labor is termed prelabor rupture of membranes - Occurs in 8 to 10% of women with term pregnancies - Rupture of membranes can result in either a sudden gush or a steady leakage of amniotic fluid - Amniotic fluid is lost when the rupture occurs, a continuous supply is produced to ensure protection of the fetus until birth - After sac has ruptured, barrier to infection is gone and an ascending infection is possible - Danger of cord prolapse if engagement has not occurred with the sudden release of fluid and pressure with rupture

Third stage

21 ● Nursing care during the third stage of labor primarily focuses on immediate newborn care and assessment and being available to assist with the delivery of the placenta and inspecting it for intactness. Assessment during the third stage of labor includes: ● Monitoring placental separation by looking for the following signs: ○ Firmly contracting uterus ○ Change in uterine shape from discoid to globular ovoid ○ Sudden gush of dark blood from vaginal opening ○ Lengthening of umbilical cord protruding from vagina ○ Examining placenta and fetal membranes for intactness the second time (the health care provider assesses the placenta for intactness the first time) (Fig. 14.18) ● Assessing for any perineal trauma, such as the following: ○ Firm fundus with bright red blood trickling: laceration ○ Boggy fundus with red blood flowing: uterine atony ○ Boggy fundus with dark blood and clots: retained placenta ○ Inspecting the perineum for condition of episiotomy if performed ○ Assessing for perineal lacerations and ensuring repair by birth attendant

third stage

21 ● Nursing care during the third stage of labor primarily focuses on immediate newborn care and assessment and being available to assist with the delivery of the placenta and inspecting it for intactness. Assessment during the third stage of labor includes: ● Monitoring placental separation by looking for the following signs: ○ Firmly contracting uterus ○ Change in uterine shape from discoid to globular ovoid ○ Sudden gush of dark blood from vaginal opening ○ Lengthening of umbilical cord protruding from vagina ○ Examining placenta and fetal membranes for intactness the second time (the health care provider assesses the placenta for intactness the first time) (Fig. 14.18) ● Assessing for any perineal trauma, such as the following: ○ Firm fundus with bright red blood trickling: laceration ○ Boggy fundus with red blood flowing: uterine atony ○ Boggy fundus with dark blood and clots: retained placenta ○ Inspecting the perineum for condition of episiotomy if performed ○ Assessing for perineal lacerations and ensuring repair by birth attendant

Probable:

: Braxton Hicks contractions (16-28 weeks), positive pregnancy test (4-12 weeks): spontaneous, irregular and painless contractions, positive pregnancy test (4-12 weeks): Qualitative urine test, ELISA, or immunoradiometric assay, abdominal enlargement (14 weeks), ballottement(16-28 weeks): examiner pushes against the woman's cervix during a pelvic exam and feels a rebound from the floating fetus, Goodell sign ( 5 weeks): softening of the cervix, Chadwick sign ( 6-8 weeks): bluish-purple coloration of the vaginal mucosa and cervix, Hegar sign (6-12 weeks): Softening of the lower uterine segment or isthmus

Third Stage:

Begins with the birth of a newborn and ends with the separation and birth of placenta - Ideal placement following birth: mother's abdomen in skin-to-skin contact which promotes a positive transition from intra to extrauterine life - Consists of 2 stages: - Placental separation - After baby is born, uterus continues to contract strongly and can now retract - Decreases in size - Placenta pulls away from uterine wall - Signs of separation indicate that the placenta is ready to deliver: - Uterus rises upward - Umbilical cord lengthens - Sudden trickle of blood is released from the vaginal opening - Uterus changes its shape to globular - Placental expulsion - Continued uterine contractions cause the placent to be expelled within 2 to 30 minutes unless there is gentle external traction to assist - After expelled, uterus is massaged briefly by the attending physician or midwife until it is firm so that uterin blood vessels constrict, minimizing possibility of hemorrhage - Blood loss 500 mL for a vaginal birth 14 - 1,000 mL of blood for cesarean - If placenta does not spontaneous deliver, HCP assists with removal by manual extraction - Postpartum hemorrhage occurs mostly during this stage and active management of it can prevent its occurrence - - Administration of a uterotonic agent after birth, expulsion of the placenta with controlled traction of teh cord, and uterine fundal massage after placental expulsion

Cardiovascular System:

Blood Volume: - Increases by approximately 1, 500 mL or up to 50% above nonpregnant levels, by the 32nd week of gestation and remains more or less constant thereafter - Made up of 1,000 mL plasma plus 450 mL RBCs - Begins at weeks 10 to 12, peaks at weeks 32 to 34 and decreases slightly by week 40 - Increase in blood volume is needed to provide adequate hydration of fetal and maternal tissues to supply blood flow to perfuse the enlarging uterus, and to provide a reserve to compensate for blood loss at birth and during the postpartum period

Braxton Hicks Contractions:

Can be experienced throughout pregnancy, may become stronger and more frequent - Typically felt as a tightening or pulling sensation of the top of the uterus - Occur primarily in the abdomen and groin and gradually spread downward before relaxing - True labor contractions: more commonly felt in the lower back - Usually last about 30 seconds, but can persist for as long as 2 minutes - If the contractions last longer than 30 seconds and occur more often than 4 to 6 times an hour, advise the woman to contact her health care provider so that she can be evaluated for possible preterm labor - Especially if she is less than 38 weeks pregnantCan be experienced throughout pregnancy, may become stronger and more frequent - Typically felt as a tightening or pulling sensation of the top of the uterus - Occur primarily in the abdomen and groin and gradually spread downward before relaxing - True labor contractions: more commonly felt in the lower back - Usually last about 30 seconds, but can persist for as long as 2 minutes - If the contractions last longer than 30 seconds and occur more often than 4 to 6 times an hour, advise the woman to contact her health care provider so that she can be evaluated for possible preterm labor - Especially if she is less than 38 weeks pregnant

cervix vagina etc

Cervix ● Closure. Now appears as a jagged slit-like opening Vagina ● the mucosa thickens and rugae return Perineum ● If the birth involved an episiotomy or laceration, complete healing may take as long as 4 to 6 months in the absence of complications at the site, such as hematoma or infection. The muscle tone may or may not return to normal, depending on the extent of injury to muscle, nerve, and connecting tissues ● Local comfort measures such as ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays, and sitz baths can relieve pain. Pulse/BP ● cardiac output and stroke volume diminish after birth once the placenta has been delivered. This decrease in cardiac output is reflected in bradycardia (40 to 60 bpm) for up to the first 2 weeks postpartum. This slowing of the heart rate is related to the increased blood that flows back to the heart and to central circulation after it is no longer perfusing the placenta. This increase in central circulation brings about an increased stroke volume and allows a slower heart rate to provide ample maternal circulation. Gradually, cardiac output returns to prepregnant levels by 3 months after childbirth Coagulation ● Normal physiologic changes of pregnancy, including alterations in hemostasis that favor coagulation, reduced fibrinolysis, and pooling and stasis of blood in the lower limbs, place women at risk for blood clots. These changes, which usually return to prepregnant levels after 3 weeks postpartum, are important for minimizing blood loss at childbirth.

Musculoskeletal System:

Changes are progressive resulting from the influence of hormones, fetal growth, and maternal weight gain - By the 10th to 12th week of pregnancy, the ligaments that hold the sacroiliac joints and the pubis symphysis in place begin to soften and stretch and articulations between the joints widen and become more movable - Relaxation of the joints peaks by the beginning of the third semester - Purpose of these changes is to increase the size of the pelvic cavity and to make delivery easier - Postural changes of pregnancy: increased swayback and an upper spine extension to compensate for the enlarging abdomen coupled with the loosening of the sacroiliac joints may result in lower back pain - Woman's center of gravity shifts forward, requiring a realignment of the spinal curvatures - Postural changes include: alteration to the center of gravity, influence of the pregnancy related hormone relaxin on the pelvic joints and increasing weight and position of growing fetus - Increase in the normal lumbosacral curve (lordosis) occurs and a compensatory curvature in the cervicodorsal area develops to assist her in maintaining her balance - Relaxation and increased mobility of joints occur because of the hormones progesterone and relaxin, which lead to the characteristic "waddle" gait that pregnant women demonstrate as they near term - Increased weight gain can add to discomfort by accentuating the lumbar and dorsal curves

Integumentary System:

Changes in pigment, vascular supply, connective skin tissue, hair growth, nail structure and gland functions - Increased activity of the maternal adrenal and pituitary glands, along with a contribution for the developing fetal endocrine glands, increasing cortisone levels, accelerate metabolism, and enhanced production of progesterone and estrogenic hormones are responsible for most skin changes in pregnancy - Up to 90% of pregnant women will show signs of hyperpigmentation during pregnancy, typically generalized and mild - Skin of pregnant women: - Undergoes hyperpigmentation primarily resulting from estrogen, progesterone, and melanocyte-stimulating hormone levels - Mainly seen on the nipples, areola, umbilicus, perineum, and axilla - Many integumentary changes disappear after giving birth - Increased pigmentation that occurs on the breasts and genitalia also develops on the face to form the "mask of pregnancy" - Facial melasma - Occurs up to 70% of pregnant women - Genetic predisposition toward melasma, which is exacerbated by the sun, it tends to recur in subsequent pregnancies - Blotchy, brownish pigment covers the forehead and cheeks in dark-haired women - Most facial pigmentation fades as the hormones subside at the end of the pregnancy - Skin in the middle of the abdomen may develop a pigmented line called linea nigra , which extends from the umbilicus to the pubic area - Striae gravidarum or stretch marks: irregular reddish streaks that appear on the abdomen, breasts, and buttocks in up to 90% of pregnant - Estrogen, relaxin, and adrenocorticoids contribute to these changes - Striae are most prominent by 6 to 7 months - Result from genetics, reduced connective tissue strength resulting from the elevated adrenal steroid levels, and stretching of the structures secondary to growth - More common in younger women, women with larger infants, and women with higher body mass indices - Non white women and women with a history of breast or thigh striae or a family history

- Psychological Response

Childbirth goes beyond the physiologic aspects: - Can influence a woman's self-confidence - Self-esteem - View of life, relationships, and children - Her state of mind (psyche) throughout the entire process is critical to bringing about a positive outcome for her and her family - Factors promoting a positive birth experience: - Clear information about procedures - Support; not being alone - Sense of mastery, self-confidence - Trust in staff caring for her - Positive reaction to the pregnancy - Personal control over breathing - Preparation for the childbirth experience

Second Stage:

Complete cervical dilation and effacement and ends with birth of the newborn - Involves moving the fetus through the birth canal and out of the body - Contractions every 2 to 3 minutes, last 60 to 90 seconds and are described as strong by palpation - Parity, delayed pushing, use of epidural analgesia, maternal BMI, birth weight, pelvis shape, occiput posterior position and fetal station at complete dilation have been shown to affect the length of this stage - Longer duration = adverse outcomes - Mother feels more in control, less irritable and agitated - Focused on the work of pushing - Pushing: - Mother is feeling rectal pressure by the fetal presenting part and physiologically feels the urge to push - If epidural is in place, sensation to push is dulled - Perineum bulges, increase in bloody show - Fetal head becomes apparent at the vaginal opening, disappears between contractions - When head no longer regresses between contractions, crowned - Fetus rotates as it maneuvers out - Second stage may last up to 3 hours in a first labor and 2 in subsequent ones - Spontaneous pushing: - Following the mother's spontaneous urge - Natural way of managing the second stage of labor - Can reduce fetal oxygenation

Fourth Stage:

Completion of expulsion of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the mother - 1 - 4 hours after birth - Stage initiates the postpartum period - Mother feels sense of peace, excitement and is wide awake, talkative - Attachment begins: - Inspecting her newborn - Desire to cuddle and breastfeed - Fundus should be firm and well contracted - Midline between the umbilicus and the symphysis, but then it slowly rises to the level of teh umbilicus during the first hour after birth - If uterus becomes boggy, massaged to keep it firm - Lochia or vaginal discharge is red, mixed with small clots and of moderate flow - If episiotomy during the second stage of labor, should be intact with the edges approximated and clean and no redness/edema present - Focus should be to monitor mother closely - Prevent hemorrhage, bladder distention and venous thrombosis - Mother is thirsty and hungry, may request food and drink - Bladder is hypotonic and thus she has limited sensation to acknowledge a full bladder or to void - Vital signs, the amount and consistency of lochia, uterine fundus are usually monitored every 15 minutes for at least 1 hour - Woman will be feeling cramp-like discomfort during this time due to the contracting uterus

. Initial prenatal visit, health history (what it includes), Gravida, Parity, GTPAL

Comprehensive Health History - age, menstrual history, prior OB history, past medical and surgical history, psychological screening, family history, genetic screening, dietary habits, lifestyle and health practices, medication or drug use, adn history of STIs ● Gravida = total number of pregnancies ● Para= Number of times a women has given birth to a fetus of at least 20 gestational weeks ● Gravida, Term, Preterm, Abortion, Living -> Total number of pregnancies, births after 38 weeks, births between 20-37 weeks, pregnancy ending before 20 weeks or viability, living children

Postpartum care for the multicultural family.

Cultures vary in their postpartum beliefs, practices, and customs. Nurses practice in an increasingly multicultural society. Therefore, they must be open, respectful, nonjudgmental, and willing to learn about ethnically diverse populations. Although childbirth and the postpartum period are unique experiences for each individual woman, how the woman perceives and makes meaning of them is culturally defined. Somali women are highly regarded in Somali society for their roles as mothers. Postpartum women stay at home and refrain from sexual activity for 40 days. At the end of 40 days, there is a celebration and this typically marks the first time the mother and infant have left the home since childbirth. The majority of Somali and Arab women breastfeed and do so for extended periods of time (Giger, 2019). Nurses need to offer early breastfeeding instruction to support their efforts while still in the hospital setting before discharge. Many cultures believe good health requires the balancing of hot and cold substances. Because childbirth involves the loss of blood, which is considered hot, the postpartum period is considered cold, so the mother must balance that with the intake of hot food. Foods consumed should be hot in nature, and cold foods, such as fruits and vegetables, avoided. Western practices frequently use cold packs or sitz baths to reduce perineal swelling and discomfort. These practices are not acceptable to women of many cultures and can be viewed as harmful. Hot-cold beliefs are present in Latin American, African, and Asian cultures 24 Postpartum nurses need to understand these diverse cultural beliefs and provide creative strategies for encouraging hygiene (sponge baths, perineal care), exercise, and balanced nutrition while remaining respectful of the cultural significance of different practices. The best approach is to ask each woman to describe what cultural practices are important to her and plan accordingly.

Examine the key components of perinatal education and teaching danger signs

Danger signs during pregnancy: ● During the first trimester: spotting or bleeding (miscarriage), painful urination (infection), severe persistent vomiting (hyperemesis gravidarum), fever higher than 100°F (37.7°C; indicative of infection), and lower abdominal pain with dizziness and accompanied by shoulder pain (indicative of ruptured ectopic pregnancy). ● During the second trimester: regular uterine contractions (preterm labor); pain in calf, often increased with foot flexion (indicative of DVT); sudden gush or leakage of fluid from vagina (prelabor rupture of membranes); and absence of fetal movement for more than 12 hours (indicative of possible fetal distress or demise). ● During the third trimester: sudden weight gain; periorbital or facial edema, severe upper abdominal pain, or headache with visual changes (indicative of gestational hypertension and/or preeclampsia); and a decrease in fetal daily movement for more than 24 hours (indicative of possible demise).

Cardinal movements of labor/birth

Deliberate, specific and precise movements that allow the smallest diameter of the fetal head to pass through a corresponding diameter of the mother's pelvic structure - Engagement: occurs when greatest transverse diameter of head in vertex passes through the pelvic inlet - Head enters the pelvis with the sagittal suture aligned in the transverse diameter - Descent: downward movement of the fetal head until it is within the pelvic inlet - Occurs intermittently with contractions and is brought about by one or more of the following forces: - Pressure of amniotic fluid - Direct pressure of the fundus on the fetus's buttocks or head (depending on which part is located in the top of the uterus) - Contractions of the abdominal muscles - Extension and straightening of the fetal body - Flexion: occurs as the vertex meets resistance from the cervix, the walls of the pelvis, or the pelvic floor - Chin is brought into contact with the fetal thorax and the presenting diameter is changed from occipitofrontal to suboccipitobregmatic which achieves the smallest fetal skull diameter presenting to the maternal pelvic dimensions - Internal rotation: as head descends, lower portion of the head (usually occiput) meets resistance form one side of the pelvic floor - Head rotates about 45 degrees anteriorly to the midline under the symphysis - Movement is known as internal rotation - Brings anteroposterior diameter of the head in line with the anteroposterior diameter of the pelvic outlet - Long axis of fetal head is aligned with long axis of the maternal pelvis - Extension: further descent and full flexion of the head, nucha (base of occiput) becomes imprinted under the symphysis - Resistance from the pelvic floor causes the fetal heads to extend so that it can pass under the pubic arch - Occurs after internal rotation is complete - Head emerges through extension under the symphysis pubis along with the shoulders - Anterior fontanelle, brow, nose, mouth, and chin are born successively - External Rotation (Restitution): after head is born and free of resistance, it untwists, causing the occiput to move about 45 degrees back to its original left or right (restitution) position - Sagittal suture has now resumed its normal right-angle relationship to the transverse (bisacromial) diameter of the shoulders - External rotation of the fetal head allows the shoulders to rotate internally to fit the maternal pelvis - Expulsion: rest of the body occurs more smoothly after the birth of the head and the anterior/posterior shoulders - Manual control of the fetus expulsion and perineal support by health care provider reduces risk of perineal injury to the mother

General Anesthesia

Emergency cesarean birth or woman with contraindication to use of regional anesthesia ▪ IV injection, inhalation, or both ▪ Commonly, first thiopental IV to produce unconsciousness ▪ Next, muscle relaxant ▪ Then intubation, followed by administration of nitrous oxide and oxygen; volatile halogenated agent also possible to produce amnesia

Regional Analgesia/Anesthesia

Epidural block: continuous infusion or intermittent injection; usually started when dilation >5 cm ▪ Combined spinal-epidural block ("walking epidural") ▪ Patient-controlled epidural ▪ Local infiltration (usually for episiotomy or laceration repair) ▪ Pudendal block (usually for second stage, episiotomy, or operative vaginal birth) ▪ Intrathecal (spinal) analgesia/anesthesia (during labor and cesarean birth)

. Assessment data collected upon admission to the labor and birth unit.

Estimated date of birth to determine if term or preterm · Fetal movement (frequency in the past few days) · Other premonitory signs of labor experienced · Parity, gravida, and previous childbirth experiences · Time from start of labor to birth in previous labors · Characteristics of contractions, including frequency, duration, and intensity · Appearance of any vaginal bloody show · Membrane status (ruptured or intact) · Presence of supportive adult in household or if she is alone An admission assessment includes maternal health history, physical assessment, fetal assessment, laboratory studies, and assessment of psychological status. · Maternal history/cultural assessment ● woman's name and age and the name of the delivering health care provider. Other information that is collected includes reason for admission, such as labor, cesarean birth, or observation for a complication; the prenatal record data, including the estimated date of birth, a history of the current pregnancy, and the results of any laboratory and diagnostic tests, such as blood type, Rh status, and group B streptococcal status; past pregnancy and obstetric history; past health history and family history; prenatal education; list of medications; risk factors such as diabetes, hypertension, and use of tobacco, alcohol, or illicit drugs; pain management plan; history of potential domestic violence; history of previous preterm births; allergies; time of last food ingestion; method chosen for infant feeding; and name of birth attendants and pediatrician. ● observe the woman's emotions, support system, verbal interaction, cultural background and language spoken, body language and posture, perceptual acuity, and energy level. This psychosocial information provides cues about the woman's emotional state, culture, and communication systems. Physical Exam o Pain level and coping behaviors demonstrated o Uterine activity, including contraction frequency, duration, and intensity o Fetal status, including heart rate, position, and station o Cervical dilation and degree of effacement o Status of membranes (intact or ruptured) o Assess vital signs: temperature, pulse, respirations, and blood pressure o Perform Leopold maneuvers to determine fetal lie o Fundal height measurement o Ability to ambulate safely · Lab studies ● Upon admission, laboratory studies are typically done to establish a baseline. 20 ● urinalysis via clean-catch urine specimen and complete blood count. ● Blood typing and Rh factor analysis may be necessary if the results of these are unknown or unavailable ● if the following test results are not included in the maternal prenatal history, it may be necessary to perform them at this time. They include syphilis screening, hepatitis B (HbsAg) screening, group B streptococcus, human immune deficiency virus (HIV) testing (if the woman gives consent), and possible drug screening if the history is positive. 7. Ongoing assessments involved in each stage of labor and birth.

Routine assessments, frequency at follow-up prenatal visits.

Every 4 weeks up to 28 weeks, every 2 weeks from 29-36 weeks, every week from 37 weeks on Weight and BP, urine testing for protein, glucose, ketones, and nitrates, fundal height and measurement, assessment for quickening/fetal movement, assessment of FHR; at 37 weeks group B sterp, gonorrhea, and chlamydia is tested.

Function of Amniotic Fluid

Helps maintain a constant body temperature for the fetus ○ Permits symmetric growth and development ○ Cushions the fetus from trauma ■ Allows the baby movement. ○ Allows the umbilical cord to be relatively free of compression ○ Promotes fetal movement to enhance musculoskeletal development

Advantages and disadvantages of external and internal fetal monitoring, including the appropriate use for each.

External monitoring Advantages: ● Can be used while the membranes are still intact and the cervix is not yet dilated but also can be used with ruptured membranes and a dilating cervix. ● It is noninvasive and can detect relative changes in abdominal pressure between uterine resting tone and contractions. ● External monitoring also measures the approximate duration and frequency of contractions, providing a permanent record of FHR. Disadvantages: ● can restrict the mother's movements ● cannot detect short-term variability ● Signal disruptions can occur due to maternal obesity, fetal malpresentation, and fetal movement as well as by artifact. The term artifact is used to describe irregular variations or absence of the FHR on the fetal monitor record that result from mechanical limitations of the monitor or electrical interference. For instance, the monitor may pick up transmissions from radios used by drivers on nearby roads and translate them into a signal. Additionally, gaps in the monitor strip can occur periodically without explanation. Internal monitoring Is usually indicated for women or fetuses considered to be at high risk. Possible conditions might include multiple gestation, decreased fetal movement, abnormal FHR on auscultation, IUGR, maternal fever, preeclampsia, dysfunctional labor, preterm birth, or medical conditions such as diabetes or hypertension. It involves the placement of a spiral electrode into the fetal presenting part, usually the parietal bone on the head, to assess FHR, and a pressure transducer placed internally within the uterus to record uterine contractions. The fetal spiral electrode is considered the most accurate method of detecting fetal heart characteristics and patterns because it involves receiving a signal directly from the fetus. Both the FHR and the duration and interval of uterine contractions are recorded on the graph paper. This method permits evaluation of baseline heart rate and changes in rate and pattern. Advantages: ● accurately detect both short-term (moment-to-moment) changes and variability (fluctuations within the baseline) and FHR dysrhythmias. ● maternal position changes and movement do not interfere with the quality of the tracing. Disadvantages: ● Invasive ● Four specific criteria must be met for this type of monitoring to be used: ○ Ruptured membranes ○ Cervical dilation of at least 2 cm ○ Presenting fetal part low enough to allow placement of the scalp electrode ○ Skilled practitioner available to insert spiral electrode

Presumptive:

Fatigue (12 weeks), Breast tenderness (3-4 weeks), nausea & vomiting (4-14 weeks), amenorrhea (4 weeks), urinary frequency (6-12 weeks), hyperpigmentation of the skin (16 weeks), fetal movements known as quickening (16-20 weeks), uterine enlargement (7-12 weeks), breast enlargement (6 weeks)

Fertilization (where it occurs), implantation.

Fertilization takes place in the outer third of the ampulla of the fallopian tube. When the ovum is fertilized by the sperm (now called a zygote), a great deal of activity immediately takes place. Mitosis, or cleavage, occurs as the zygote is slowly transported into the uterine cavity by tubal muscular movements. After a series of four cleavages, the 16 cells appear as a solid ball of cells, or morula. The morula reaches the uterine cavity about 72 hours after fertilization. As fluid, which provides nutrients, from the uterine cavity enters the morula, the blastocyst is formed.

Fetal Station

Fetal station - Refers to the relationship of the presenting part of the level of the maternal pelvic ischial spines - Measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines - Ischial spines are the narrowest part of the pelvis and are the natural measuring point for the birth progress - Zero (0) station: designated with the presentnig part is at the level of the maternal ischial spines - When the presenting part is above the ischial spines, the distance is recorded as minus stations - Presenting part is below the ischial spine, distance is recorded as plus stations - Fetal engagement - Signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis - Fetus is said to be engaged in the pelvis when the presenting part reaches 0 station - Engagement is determined by pelvic examination - Largest diameter of the fetal head is the biparietal diameter - Descent: downward movement of the fetal head until it is within the pelvic inlet - Occurs intermittently with contractions and is brought about by one or more following forces: - Pressure of the amniotic fluid - Direct pressure of the fundus on the fetus's buttocks or head (depending on which part is located in the top of the uterus) - Contractions of the abdominal muscles (second stage) - Extension and straightening of the fetal body 10 - Flexion: occurs as the vertex meets resistance form the cervix, walls of the pelvis, or pelvic floor - Internal rotation: head descends, lower portion of the head (usually the occiput) meets resistance form one side of the pelvic floor - Head rotates about 45 degrees anteriorly to the midline under the symphysis - Brings the anteroposterior diameter of the head in line with the anteroposterior diameter of the pelvic outlet - Extension: further descent and full flexion of the head, nucha (base of the occiput) becomes impinged under the symphysis - External rotation (restitution): after the head is born and is free of resistance, it untwists, causing the occiput to move about 45 degrees back to its original left or right position (restitution) - Sagittal suture has now resumed its normal right-angle relationship to the transverse (bisacromial) diameter of the shoulders - Expulsion: rest of the body occurs more smoothly after the birth of the head and the anterior and posterior shoulders

functions of the umbilical cord

Formed from the amnion ○ Lifeline from the mother to the growing embryo ○ Contains one large vein and two small arteries (AVA) ■ Our oxygenated blood is carried in the veins ○ Wharton jelly surrounds the vein and arteries to prevent compression ○ At term, the average umbilical cord is 22-in long and about 1-in wide

Prenatal screening & diagnostic tests used to assess maternal and fetal well-being, including nursing management for each. NST, BPP, CVS, Amniocentesis

Fundal Height, Fetal movement (count to 10 method), FHR with doppler, Ultrasonography assesses FHR and any malformation, ● Amniocentesis is transabdominal puncture of amniotic sac which obtains fluid to detect chromosomal abnormalities and hereditary defects. Explain procedure and risk of bladder puncture, RhoGam can be administered after this, monitor site for bleeding or drainage. (spontaneous abortion 1/300-500) ● Chorionic Villus Sampling is the use of an 18 gauge needle through the abdomen where a catheter is passed through the cervix to obtain a sample of chorionic villi from placenta to evaluate for chromosomal disorders. Explain procedure, inform of the risks (pregnancy loss rate is 0.5-1 %, early ROM, hemorrhage), advise to drink increased fluid and to not engage in strenuous activity for next 48 hours, RhoGam can be administered ● NonStress Test - indirect measurement of uteroplacental function and normal fetus characteristics, Patient makes not of fetal activity after eating. 20 minutes, Explain procedure, obtain baseline information, observe for notes from mother and FHR activity, reactive = 2 accelerations, non reactive= absences of accelerations ● Biophysical Profile (BPP)- US + NST, monitors fetal movements, tone,and breathing, assessment of amniotic fluid and FHR; used to detect hypoxia in fetus; NST -> US

First stage of Labor:

Fundamental change underlying the process iis progressive dilation of the cervix - Cervical dilation is gauged subjectively by vaginal examination and is expressed in centimeters - First stage ends when the cervix is dilated to 10 cm in diameter and is large enough to permit the passage of a fetal head of average size - Fetal membranes usually rupture during the first stge, but they may have burst earlier or may even remain intact until birth - Can last up to 20 hours without being considered prolonged - Women usually perceive the visceral pain of diffuse abdominal cramping and uterine contractions - Pain is primarily a result of the dilation of the cervix and lower uterine segment, distention (stretching) - Latent phase: - Rise to the familiar signs and symptoms of labor - Phase begins with the start of regular contractions and ends when rapid cervical dilation begins - Cervix dilates slowly to approximately 6 cm - Sedation can increase the duration of the phase - Contractions occur every 5 to 10 minutes, last 30 to 45 seconds, and are described as mild by palpation by the nurse - Assessment of intensity: pressing down on the fundus during a contraction to see if it can be dented with the nurse's fingers - Ability to indent the fundus at the peak of the contraction would typically indicate a mild contraction - Effacement: 0 to 40% - Contractions are perceived to be similar to menstrual cramps - Women may remain at home during this phase - Active phase: - Increase in the rate of cervical dilation (end of latent phase of labor) until completion of cervical dilation - Cervical dilation occurs more rapidly and predictably until it reaches 10 cm and cervical dilation and effacement are complete - Generally dilates at a rate of 1.2 to 1.5 cm per hour - Fetus descends farther in the pelvis - Contractions become more frequent (every2 to 5 minutes) and increase in duration (45 to 60 seconds) - Woman's discomfort intensifies (moderate to strong by palpation)

Initiation of Labor:

Involves a complex interplay of maternal, fetal, and genetic factors as well as endocrine signaling - Sequential and integrated set of changes within the myometrium, decidua, and cervix that occurs gradually over a period of days to weeks in order to expel the fetus from the uterus - Theory of labor: - Labor is initiated by a change in the estrogen to progesterone ratio - During last trimester, estrogen levels increase and progesterone levels decrease - Leads to an increase in the number of myometrium gap junctions - Gap junctions are proteins that connect cell membranes and facilitate coordination of uterine contractions and myometrial stretching

Respiratory System:

Less stress on respiratory system - Adaptations to this system do take place during pregnancy - Primary changes: lung volume and ventilation - Oxygen consumption reflects the uptick of maternal metabolism by increasing between 20% to 30% by the time full term is reached - Amount of space available to house the lungs decreases as the uterus puts pressure on the diaphragm and causes it to shift upward by 4 cm - Growing uterus does change the size and shape of the thoracic cavity, chest circumference increases by 2 to 3 in and the transverse diameter increases by an inch - Pregnant woman breathes faster and more deeply - Oxygen consumption increases during pregnancy even as airway resistance and lung compliance remain unchanged - Changes in the structures of the respiratory system take place to prepare the body for the enlarging uterus and increased lung volume - 50% increase in air volume per minute - All of these structural alterations are temporary and revert back to their pre-pregnant state at the end of pregnancy - Increased vascularity of the respiratory tract is influenced by increased estrogen levels, leading to congestions - Rising levels of sex hormones and heightened sensitivity to allergens

Changing Nutritional Needs of Pregnancy:

Maternal body weight and diet quality, even pre-pregnancy, can affect the uterine environment, birth weight, and infant's subsequent health into adulthood - Healthy eating during pregnancy enables optimal gestational weight gain and reduces complications - Nutritional intake during pregnancy has a direct effect on fetal well-being and birth outcome - Inadequate nutritional intake, is associated with preterm birth, low birth weight, and congenital anomalies - Excessive nutritional intake is connected with fetal macrosomia, leading to a difficult birth, neonatal hypoglycemia and continued obesity in the mother and the potential for childhood obesity with the components of metabolic syndrome - Pregnant women should take a vitamin and mineral supplement daily - Prenatal vitamins - Iron and folic acid need to be supplemented because their increased requirements during pregnancy are usually too great to be met through diet alone - Needed to form new blood cells for the expanded maternal blood volume and to prevent anemia - Iron is essential for fetal growth and brain development and in the prevention of maternal anemia - Increase in folic acid is essential before pregnancy - Following guidelines are helpful: - Increase consumption of fruits and vegetables, taking up half the plate - Replace saturated fats with unsaturated ones - Eat breakfast every day - Choose whole grains in place of refined grains - Choose foods with a lot of fiber to prevent constipation - Avoid hydrogenated or partially hydrogenated fats - Do not consume alcoholic beverages - Limit caloriies from added sugars and saturated fats - Use reduced fat spreads and dairy products instead of full-fat ones - Eat at least two servings of fish weekly, with one of them being on oily fish - Consume at least 3 qt of water daily - No soft cheese

Psychological changes that occur in women in the postpartum period.

Mood Disorders ○ This may include being fatigued, irritable, and worried, and frequently these feelings become severe enough to require medical intervention. ○ In the postpartum period, mood disorders can be divided into three distinct entities in ascending order of severity: "maternal (baby) blues," postpartum depression, and psychosis. ○ short-lived postpartum mood disorder colloquially called the "baby blues" or "maternal blues," ■ characterized by mild depressive symptoms, anxiety, irritability, mood swings, loss of appetite, trouble sleeping, tearfulness (often for no discernible reason), increased sensitivity, and fatigue. ■ These symptoms typically peak on postpartum days 4 and 5, may last hours to days, and usually resolve by day 10. ■ Depression & psychosis ● Symptoms last longer and are more severe-require treatment

First Stage:

Nursing care during the first stage of labor includes taking an admission history (reviewing the prenatal record), checking the results of routine laboratory work and special tests done during pregnancy, asking the woman about her childbirth preparation (birth plan, classes taken, coping skills), and completing a physical assessment of the woman to establish baseline values for future comparison

Second stage:

Nursing care during the second stage of labor focuses on supporting the woman and her partner in making decisions about her care and labor management, implementing strategies to prolong the early passive phase of fetal descent, supporting involuntary bearing-down efforts, providing support and assistance, and encouraging the use of maternal positions that can enhance descent and reduce the pain. Assessment is continuous during the second stage of labor. Assessment involves identifying the signs typical of the second stage of labor, including: · Increase in apprehension or irritability · Spontaneous rupture of membranes · Sudden appearance of sweat on upper lip · Increase in blood-tinged show · Low grunting sounds from the woman · Complaints of rectal and perineal pressure · Beginning of involuntary bearing-down efforts Other ongoing assessments include the contraction frequency, duration, and intensity; maternal vital signs every 5 to 15 minutes; fetal response to labor as indicated by FHR monitor strips; amniotic fluid for color, odor, and amount when membranes are ruptured; and the coping status of the woman and her partner. Assessment also focuses on determining the progress of labor. Associated signs include bulging of the perineum, labial separation, advancing and retreating of the newborn's head during and between bearing-down efforts, and crowning (fetal head is visible at vaginal opening. A vaginal examination is completed to determine if it is appropriate for the woman to push. Pushing is appropriate if the cervix has fully dilated to 10 cm and the woman feels the urge to do so.

Lightening

Occurs when the fetal presenting part begins to descend into the true pelvis - Uterus lowers and moves into a more anterior position - Shape of abdomen changes as a result of the change in the uterus - With descent, woman usually notes that her breathing is much easier and that there is a decrease in gastric reflux - Does come with increased pelvic pressure, leg cramping, dependent edema in the lower legs, and low back discomfort - Increased vaginal discharge and more frequent urination

. Pre-conception care, Risk factors

Preconception care is to identify and modify biomedical, behavioral, or social risks to a women's health or pregnancy prior to getting pregnant. Ex: Folic acid 400-800 mcg/day with diet and exercise even before conception.The period of greatest environmental sensitivity and risk for developing embryo is between 17 -56 days after conception. Risk factors: smoking can lead to preterm birth, drinking can lead to fetal alcohol syndrome, folic acid deficiency leads to neural tube defects, obesity, OTC or prescription use, pre existing medical conditions, use of isotreintinions (Acutane) can result in serious birth defects, antiepileptic drugs are teratogens, unmanaged diabetes can lead to birth defects, No Hepatitis B or rubella vaccination can lead to major effects if child contracts HBV or rubella syndrome, HIV/AIDS diagnosis, STIs during pregnancy can lead to fetal death or disabilities.

Normal physiologic/psychological changes occurring during all four stages of labor

Progesterone secreted from the placenta suppresses the spontaneous contractions of a typical uterus - Keeps the fetus within the uterus - Cervix remains firm and noncompliant - At term, cervix becomes softer - Uterine contractions become more frequent and regular, signaling the onset of labor - Contractions bring about a shortening that causes effacement and dilation of the cervix, and a bursting of the fetal membranes - Uterine contractions of 30 mm Hg or greater promote cervical dilation - Reflex and voluntary contractions of the abdominal muscles (pushing), uterine contractions of the abdominal muscles (pushing), uterine contractions result in the birth of baby

Systemic Analgesia

Route: typically administered parenterally through existing IV line ▪ Drugs (see Drug Guide 14.1) ○ Opioids (butorphanol, nalbuphine, meperidine, fentanyl) ○ Ataractics (hydroxyzine, promethazine) ○ Benzodiazepines (diazepam, midazolam)

Functions of Placenta:

Serving as the interface between the mother and fetus ● Making hormones to control the physiology of the mother ● Protecting the fetus from immune attack by the mother ● Removing waste products from the fetus ● Inducing the mother to bring more food to the placenta ● Producing hormones that mature into fetal organs

Comfort promotion and pain relief strategies used during labor and birth.

Systemic analgesia · complication associated with the use of this class of drugs is respiratory depression. Therefore, women given these drugs require careful monitoring. Nearly all medications given during labor cross the placenta and have a depressant effect on the fetus; therefore, it is important for the woman to receive the least amount of systemic medication that relieves her discomfort so that it does not cause any harm to the fetus ● Opioids, such as butorphanol (Stadol), nalbuphine (Nubain), meperidine (Demerol), morphine, or fentanyl (Sublimaze) May be given IV or epidurally Rapidly crosses the placenta, causes a decrease in FHR variability Morphine 2-5 mg IV Can cause maternal and neonatal CNS depression Decreases uterine contractions ● Ataractics, such as hydroxyzine (Vistaril), promethazine (Phenergan), or prochlorperazine (Compazine) ● Benzodiazepines, such as diazepam (Valium) or midazolam (Versed) Regional anesthesia ● Obstetric regional analgesia generally refers to a partial or complete loss of pain sensation below the T8 to T10 level of the spinal cord ● The routes for regional pain relief include epidural block, combined spinal-epidural, local infiltration, pudendal block, and intrathecal (spinal) analgesia/anesthesia. Local and pudendal routes are used during birth for episiotomies (surgical incisions into the perineum to facilitate birth); epidural and intrathecal routes are used for pain relief during active labor and birth. ● Epidural anesthesia: ○ Epidural analgesia for labor and birth involves the injection of a local anesthetic agent (e.g., lidocaine or bupivacaine) and an opioid analgesic agent (e.g., morphine or fentanyl) into the lumbar epidural space. A small catheter is then passed through the epidural needle to provide continuous access to the epidural space for maintenance of analgesia throughout labor and birth. Epidural analgesia does increase the duration of the second stage of labor and may increase the rate of instrument-assisted vaginal deliveries as well as that of oxytocin administration ○ An epidural is contraindicated for women with a previous history of spinal surgery or spinal abnormalities, coagulation defects, cardiac disease, obesity, infections, and hypovolemia. It is also contraindicated for the woman who is receiving anticoagulation therapy. ○ Complications- nausea and vomiting, hypotension, fever, pruritus, intravascular injection, maternal fever, allergic reaction, and respiratory depression. Effects on the fetus during labor include fetal distress secondary to maternal hypotension. Ensuring that the woman avoids a supine position after an epidural catheter has been placed will help minimize hypotension. ○ The addition of opioids, such as fentanyl or morphine, to the local anesthetic helps decrease the amount of motor block obtained ● Spinal anesthesia ○ The spinal (intrathecal) pain management technique involves injection of an anesthetic "caine" agent with or without opioids into the subarachnoid space to provide pain relief during labor or cesarean birth. The subarachnoid space is a fluid-filled area located between the dura mater and the spinal cord. Spinal anesthesia is frequently used for elective and emergent cesarean births. The contraindications are similar to those for an epidural block. Adverse reactions for the woman include hypotension and spinal headache. ○ Compared with epidural blocks, intrathecal narcotics are easy to administer, require a smaller volume of medication, produce excellent muscular relaxation, provide rapid-onset pain relief, are less likely to cause newborn respiratory 19 depression, and do not cause motor blockade. Although pain relief is rapid with this technique, it is limited by the narcotic's duration of action, which may be only a few hours and not last through the labor. General anesthesia ● Obstetric guidelines recommend neuraxial anesthesia for cesarean births in most women. General anesthesia is typically reserved for emergency cesarean births when there is not enough time to provide spinal or epidural anesthesia or if the woman has a contraindication to the use of regional anesthesia. It can be started quickly and causes a rapid loss of consciousness. General anesthesia can be administered by IV injection, inhalation of anesthetic agents, or both. Commonly, thiopental, a short-acting barbiturate, or propofol is given IV to produce unconsciousness. This is followed by administration of a muscle relaxant. After the woman is intubated, nitrous oxide and oxygen are administered. A volatile halogenated agent may also be administered to produce amnesia. ● All anesthetic agents cross the placenta and affect the fetus. The primary complication with general anesthesia is fetal depression, along with uterine relaxation and potential maternal vomiting and aspiration. General anesthesia complications are usually due to maternal aspiration or the inability to intubate the woman. The incidence of these complications has decreased greatly as a result of improved techniques. ● Ensure that the woman is not taking anything by mouth (NPO) and has a patent IV line. In addition, administer a nonparticulate(clear) oral antacid (e.g., Bicitra or sodium citrate) or a proton pump inhibitor (Protonix) as ordered to reduce gastric acidity.Assist with placement of a wedge under the woman's right hip to displace the gravid uterus and prevent vena cavacompression in the supine position

urinary

Urinary 23 ● During pregnancy, the glomerular filtration rate and renal plasma flow increase significantly. Both usually return to normal by 6 weeks after birth. There is a gradual return of bladder tone and normal size and function of the bladder, ureters, and renal pelvis, all of which were dilated during pregnancy. ● urination may be impeded by: ○ perineal lacerations. ○ generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus. ○ hematomas. ○ decreased bladder tone as a result of regional anesthesia. ○ diminished sensation of bladder pressure as a result of swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor ● Difficulty voiding can lead to urinary retention, bladder distention, and ultimately urinary tract infection. Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage. Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow, and catheterization may be necessary to empty the bladder to restore tone. GI ● the gastrointestinal system quickly returns to normal after birth because the gravid uterus is no longer filling the abdominal cavity and producing pressure on the abdominal organs ● Regardless of the type of delivery, most women experience decreased bowel tone and sluggish bowels for several days after birth; constipation Muskuloskeletal ● Joints return to pre-pregnant stake except for feet ● Fatigue and activity intolerance for weeks after birth ● Diminished abdominal muscle tone Integumentary ● Pigmentation and scratch marks fade ● Diaphoresis is common 1 week postpartum Respiratory ● diaphragm returns to its usual position. ● discomforts such as shortness of breath and rib aches are relieved Endocrine ● With the delivery of the placenta, there is rapid clearance of placenta hormones. ● Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. ● Prolactin levels decline within 2 weeks for the woman who is not breastfeeding,

Common discomforts of pregnancy and comfort measures

Urinary Frequency or Incontinence - pelvic floor exercises, empty bladder frequently, avoid caffeine, reduce fluid intake before bed ● Fatigue - try to get full nights rest, balanced diet, schedule naps ● Nausea and Vomiting- avoid an empty stomach, eat dry crackers/toast, eat several small meals, acupressure wristbands, avoid greasy foods, drink fluids ● Backache - avoid sitting or standing extensively, support lower back with pillows, use heating pads, use proper body mechanics, wear supportive shoes ● Leg cramps - elevate legs, calcium supplements ● Varicosities- walk daily, elevate legs, avoid standing extensively, don't cross legs, wear support stockings ● Hemorrhoids- establish regular bowel elimination, avoid constipation and straining, fiber-rich diet, exercise daily, drink plenty fluids ● Constipation- high fiber diet, drink plenty fluids, prune juice, exercise, reduce cheese ● heartburn/indigestion- avoid spicy/greasy food, sleep with head elevated, stop smoking, avoid caffein, avoid lying down for 3 hours after meals, antacids ● Braxton hicks contraction - changing position, exercise, drink plent fluids

Assessing uterine contractions

Uterine contractions during labor are monitored by palpation of the uterine fundus and by electronic monitoring. Assessment of the contractions includes frequency, duration, intensity, and uterine resting tone. Uterine contractions with an intensity of 30 mm Hg or greater initiate cervical dilation. During active labor, the intensity usually reaches 50 to 80 mm Hg. Resting tone is normally between 5 and 10 mm Hg in early labor and between 12 and 18 mm Hg in active labor. To palpate the fundus for contraction intensity, place the pads of your fingers on the fundus and describe how it feels: like the tip of the nose (mild), like the chin (moderate), or like the forehead (strong). Palpation of intensity is a subjective judgment of the indentability of the uterine wall; a descriptive term is assigned (mild, moderate, or strong). The second method used to assess the intensity of uterine contractions is electronic monitoring, either external or internal. Both methods provide a reasonable measurement of the intensity of uterine contractions. Although the external fetal monitor is sometimes used to estimate the intensity of uterine contractions, it is not as accurate an assessment tool. Performing Leopold maneuvers 16 Leopold maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. The flat palmar surfaces of the nurse's hands with the fingers together palpate the uterus. A longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder. Each maneuver answers a question: · Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? · Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) · Maneuver 3: What is the presenting part? · Maneuver 4: Is the fetal head flexed and engaged in the pelvis?

Reproductive

Uterus: size increases to 20 times that of nonpregnant size, capacity increases by 2,000 times to accommodate the developing fetus, weight increases from 2 oz to approximately 2 lb a term, uterine growth, occurs as a results of hyperplasia and hypertrophy of the myometrial cells, increased strength and elasticity allow uterus to contract and expel fetus during birth ● Cervix: increases in mass, water content, and vascularization/ changes from a relatively rigid to a soft, distensible structure that allows the fetus to be expelled, under the influence of progesterone, a thick mucus plug is formed, which blocks the cervical os and protects the developing fetus from bacterial invasion. ● Vagina: increased vascularity because of estrogen influences, results in pelvic congestion and hypertrophy/ increased thickness of mucosa, along with an increase in vagianl secretions, helps prevent bacterial infections ● Ovaries: increased blood supply to the ovaries causes them to enlarge until approximately the 12th to 14th week of gestation. They actively produce hormones to support the pregnancy until 6-7 weeks when the placenta takes over production of progesterone. ● Breasts: changes begin soon after conception→ increase in size and areolar pigmentation. The tubercles of Montgomery enlarge and become more prominent, and the nipples become more erect. The blood vessels become more prominent, and blood flow to the breast doubles.

Nursing interventions to address the categories of fetal heart rate patterns.

category I, strongly predictive of normal fetal acid-base status at the time of observation and needs no intervention ● category II, not predictive of abnormal fetal acid-base status but does require evaluation and continued monitoring ● category III, predictive of abnormal fetal acid-base status at the time of observation and requires prompt evaluation and interventions, such as giving maternal oxygen, changing maternal position, discontinuing labor augmentation medication, and/or treating maternal hypotension. Interventions for Category III Patterns • Notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern. • Discontinue oxytocin or other uterotonic agent as dictated by the facility's protocol if it is being administered. • Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental perfusion or relieve cord compression. • Administer oxygen via nonrebreather face mask to increase fetal oxygenation. • Increase the IV fluid rate to improve intravascular volume and correct maternal hypotension. • Assess the client for any underlying contributing causes. • Provide reassurance that interventions are to effect pattern change. • Modify pushing in the second stage of labor to improve fetal oxygenation. • Document any and all interventions and any changes in FHR patterns. • Prepare for an expeditious surgical birth if the pattern is not corrected in 30 minutes.

Supine Hypotensive Syndrome

causes the woman to experience symptoms of - Weakness - Light headedness - Nausea - Dizziness - Syncope

Immune:

general enhancement of innate immunity (inflammatory response) and suppression of adaptive immunity take during pregnancy→ help prevent the mother's immune system from rejecting the fetus, increase her risk of developing certain infections, and influence the course of chronic disorders such as autoimmune diseases.

PICA:

intense craving for and eating of nonfood items over a period of time of at least 1 month. 3 main substances consumed are soil/clay (geophagia), ice (pagophagia), laundry starch (amylophagia) Soil: replaces nutritive sources and causes iron-deficiency anemia Clay: produces constipation; can contain toxic substances Ice: can iron-deficiency anemia, tooth fx Laundry starch: replaces iron-rich foods Be nonjudgmental try to be supportive to make the change

- Physiologic anemia of pregnancy:

maternal blood volume expansion occurs at a larger proportion than the increase in RBC mass, which results in physiologic anemia and hemodilution - Reflected in a lowered hematocrit and hemoglobin - Also necessary to meet the increased metabolic needs of the mother and to meet the need for increased perfusion of other

Bloody Show:

onset of labor or before, mucus plug that fills the cervical canal during pregnancy is expelled as a result of cervical softening and increased pressure of the presenting part - Ruptured cervical capillaries release a small amount of blood that mixes with mucus, resulting in the pink-tinged secretions

Puerperium:

period after delivery of placenta, lasting for 6 weeks, "fourth trimester"

Cardiac Output and Heart Rate

product of stroke volume and heart rate is a measure of the functional capacity of the heart - Increases from 30 to 50% over the nonpregnant rate by the 32nd week of pregnancy and declines to about 20% increase at 40 weeks' gestation - Increase is associated with an increase in venous return and greater right ventricular output - HR increases by 10 to 15 bpm between 14 and 20 weeks gestation - Slight hypertrophy or enlargement of the heart during pregnancy - Accommodates the increase in blood volume and cardiac output - Heart works harder and pumps more blood to supply the oxygen needs of the fetus

Frequency and Duration

refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contractio : how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction - Intensity: strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter

Emotional and psychological changes that occur during pregnancy

urses should inquire at every prenatal visit about the woman's emotional well-being to assess her psychosocial adjustments throughout her pregnancy. ● The woman's approach to these emotions is influenced by her emotional makeup, her sociological and cultural background, her acceptance or rejection of the pregnancy, whether the pregnancy was planned, if the father is known and her support system. ● Ambivalence: have conflicting feelings of pregnancy→ normal and prepare for new role and lifestyle change. Typically during first trimester evolved to acceptance by second trimester when fetal movement is felt ● Introversion: focuses on oneself during early stages. Might become preoccupied with herself and her fetus. Heightened during the first and third trimester. ● Acceptance: during the 2nd trimester, physical changes of the fetus bring a sense of validity and reality to pregnancy. Verbalize positive feelings and conceptualize the fetus. ● Mood swings: emotional lability. Make conversations with family difficult sometimes. Important to discuss how common they are. "Emotional roller coaster" ● Change in body image: varies from person to person. Some feel beautiful while others uncomfortable. Normal but can be stressful. Explanations are helpful.

Lochia

vaginal discharge that occurs after birth and continues for approximately 4 to 8 weeks. It results from involution ○ Lochia rubra- is a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. As uterine bleeding subsides, it becomes paler and serous. ○ Lochia serosa is the second stage. It is pinkish brown and is expelled 3 to 10 days postpartum. Lochia serosa primarily contains leukocytes, decidual tissue, red blood cells, and serous fluid. ○ Lochia alba is the final stage. The discharge is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content. It occurs from days 10 to 14 but can last 3 to 6 weeks postpartum in some women and still be considered normal. ○ Afterpains ■ Immediately after birth and delivery of the placenta, the uterus begins to contract constricting the intramyometrial vessels and impeding blood flow; this is the primary mechanism preventing hemorrhage from the placental site. Inadequate myometrial contractions will result in atony which will result in an early postpartum hemorrhage. These painful uterine contractions are often called afterpains.