Family Health and Reproduction

Tubal Ligation

female sterilization executed through small incision under the woman's umbilicus to occlude the fallopian tubes by cutting, cauterizing, or blocking the passage of sperm and ova (egg) after menstruation and before ovulation Patient Education 1. PT must use contraception prior to surgery to avoid risk of Ectopic Pregnancy 2. PT can return to normal sexual activities 2-3 days after operation 3. educate PT that menstrual cycle will still occur Advantages • permanent contraception • can be performed 24-48 hrs after childbirth • unaffected sex • requires Laparoscope and local anesthesia • 99.5% effectiveness Disadvantages • irreversible (what if patient changes their mind?) Risks • STIs • ectopic pregnancy • risks with surgical procedure related to anesthesia use, complications, infection, hemorrhage, or trauma

Late deceleration

fetal decrease in FHR at peak of contraction and FHR returns to baseline after contractionis over indicates plaental insufficiency (impaired perfusion) caused by diabetes, placenta previa, HTN, abruptio placentae, non reassuring sign -intolerable Interventions 1. turn mother on her side to increase perfusion/oxygenation and lower head of the bed 2. increase IV fluids to increase blood return to fetus 3. stop or decrease oxytocin 4. supplemental oxygenation via non-rebreather as nasal cannula will not reach the fetus internal uterine pressure catheter (IUPC) thin plastic tube is inserted into the uterus to lie next to the baby and assess direct pressure readings

Plancenta Previa: Nursing Interventions

"PREVIA" P - painless bright red bleeding R - replace blood loss, fluid loss E - evident in lower segment of uterus (implant) V - vitals indicate shock I - inspect fetal HR A - avoid vaginal exams

ectopic pregnancy

"tubal pregnancy"; implantation of the fertilized egg in any site other than the normal uterine location - occurs in 1st trimester and could lead to death Risk Factors - condition or issue that injures Fallopian tubes Treatment - emergency as this could lead to shock and require blood transfusion or hysterectomy - if not an emergency, a laparoscopy, salpingectomy, and Methotrexate (IM injection) will be given to disrupt cell production - Rhogam given to Rh (-) mothers Nursing Interventions 1. monitor vitals, amount and appearance of vaginal bleeding, note any excessive amount or symptosm of shock (↑HR ↓BP) 2. prepare patient for surgery 3. post-op; monitor for infection (fever, severe abdominal pain or foul smelling discharge) 4. follow up weekly until HCG levels return to normal

para

# of viable births (age of viability for fetus = above 20 wks gestation because they can live outside the uterus) primipara = 1st viable birth multipara = multiple viable births or 2 or more nullipara.= never given birth to viable fetus (>20 wks)

False Labor

(Braxton Hicks); mild irregular and intermittent painless uterine contractions that have increasing frequency as pregnancy progresses but are usually relieved by walking Contractions mild irregular contractions that cause no cervical change (Braxton Hick's) • painless, irregular and intermittent contractions of reduced intensity, frequency, and duration • normal intervals • felt in abdomen above umbilicus • relieved by sedation, sleep or comfort measures (oral hydration, bladder emptying) • discomfort or pain is reduced with walking or position changes, sleeping, oral hydration, and bladder emptying Cervix (assessed by vaginal exam) • cervix stays in posterior so no change in dilation/effacement and no bloody show Fetus • presenting part of fetus is NOT engaged in pelvis ex: Patient presents at 35 weeks gestation with irregular contractions and a closed cervix (no dilation or effacement) that's consistent with false labor

Hemorrhage

(most common postpartum complication) - can be early (within 24 hrs) or late (24 hr to 6 wks) - major risk of hypovolemic shock as hemorrhage interrupts blood flow to tissues and prevents normal oxygenation, nutrient delivery, and waste removal bc oxygen is carried on hemoglobin of RBC - during pregnancy, a woman's blood volume increases significantly (500-1000 mL) to help fetal growth and to compensate if bleeding occurs during or after birth Sx: • tachycardia • BP changes (systolic ↓ closer to diastolic range = narrowed pulse pressure) • pale, cold, clammy skin (blood is shunted from peripherals to supply vital organs) • mental status changes • ↓ urinary output (due to lack of blood flow to kidneys impairing kidney function) * Safety Alert: postpartum women have bradycardia so nurse must be hyper vigilant regarding hypovolemic shock or infection - monitor pulse, if HR ↑ 100 = increase risk of hypovolemic shock or infection - assess for hypovolemic shock symptoms; dizziness, lightheadedness, weakness, SOB, anxiety, hyperventilation Medical Management 1. if postpartum hemorrhage, nurse must locate source of blood loss and stop it 2. if hypovolemic (blood loss), nurse must give fluids back by IV hydration and supplemental oxygen 3. insert Foley catheter due to impaired perfusion of kidneys causing impaired kidney function in order to monitor urinary output to assess any effects of hypovolemia 4. blood work (blood type, Rh) must be done if blood transfusion is required Nursing Interventions 1. frequent vital signs (HR, temperature can indicate fever, and BP as systolic drop indicates narrowed pulse pressure caused by shock) 2. monitor SpO2 3. assess lochia (amount, type) depending on phase of post-partum 4. observe for perineal hematoma (collection of blood that is not visible) 5. assess fundus (location should be at umbilicus and should be firm), boggy is abnormal and requires massage, but if fundus if firm & bleeding, it may indicate vaginal laceration 6. monitor skin (petechiae), excessive bleeding, or oliguria (lack of urine) indicates clotting issue 7. measure and monitor I/O 8. monitor for any signs of anemia (dizziness, lightheadedness, SOB, feeling of passing out or faint) and if hemorrhaging, hemoglobin and hematocrit levels may change rapidly - change positions slowly (lying to sitting/standing) to avoid FALL RISK - provide iron supplements (long term therapy) or blood tranfusion (short term therapy) 9. provide emotional support to mother as it is a traumatizing experience

Travel for Pregnancy

- air travel is safe but its important to stress - do not sit for prolonged periods of time - avoid locations with increased risk of infectious exposure - always bring a copy of OB records - get info on nearest health care facility - encourage hand hygiene and diet precautions

Pregnancy Complications

- cervical cancer - infections - cervical polyp - early bleeding disorders - hyperemesis gravidarum - hypertension - blood incompatiblity Interventions nurse should identfiy any risk factors through patient interview and data collection during prenatal visits

High Risk Pregnancies

- may be related to pregnancy itself (chromosomal abnormalities, fetal defect, advanced maternal age) - may occur due to a medical condition or injury (endocrine/immune disorders, uterine or reproductive tract abnormalitiy such as cervical insufficiency, infections, hx of abortion) - may occur from environmental hazards (chemicals, medication) - may arise from maternal behavior or lifestyle choices that negatively affect the fetus (drug use, alcohol, smoking)

Prenatal Lab Results

- rubella titer = 1:8 or greater (normal/immune) if lower than 1.8, this indicates lack of immunity - 1 hour glucose challenge test = 110 g/dl - APTT (activated partial thromboplastin time) nonpregnant 1st trim 2nd trim 3rd trim 26-39 sec 24-38 24-38 25-35 - Albumin 41-53 g/L 31-51 26-45 23-42 - Alpha fetoprotein <15 ng/mL. 18-119 96-302 160-550 - Bicarbonate 22-30 mEq/L 18-26 18-26 18-26 - HDL 40-60 mg/dL 40-78 52-87 48-87 - LDL <100 mg/dL 60-153 77-184 101-224 - Total Cholesterol <200 mg/dL 141-210 176-299 219-349 - Creatinine 0.5-0.9 mg/dL 0.4-0.7 0.4-0.8 0.4-0.9 - Platelets 165-415 174-391 155-409 146-429 - RBC 4.0-5.2 3.42-4.55 2.81-4.49 2.72-4.43 - WBC 3.5-9.1 5.7-13.6 5.6-14.8 5.6-16.9 - Hematocrit 35-45% 31-41% 30-39% 28-40% - Hemoglobin 12-15.8 g/dL 11.6-13.9 9.7-14.8 9.5-15 - Fasting Glucose 75-99 mg/dL - 75-80 71-77 - Iron 41-141 µg/dL 72-143 44-178 30-193

Stage 2 of Labor

- starts when cervix has fully dilated and ends when baby is fully delivered • cervix fully dilates so baby can start descend into birth canal and woman will have intense pressure in rectum • watch fetal stations 1-5 (station 5 - head crowning) • strong and intense contractions similar to those in transition period lasting 60-90 sec x 2-3 min • this stage lasts 1-3 hrs for 1st time mothers, and lasts 20 min for multipara • Interventions (1) monitor maternal and fetal vitals (HR) before/after and during contractions (2) continuous fetal monitoring (assess for any signs of distress) (3) monitor for changes in perineum that would indicate birth approaching such as bulging perineum and rectum, parts of baby showing, increase bloody show (4) teach mother how to push (exhale when pushing) and positioning (High Fowler, Lithotomy, Squatting, Side-lying (5) maintain comfort measures (6) encourage and praise mother (7) record exact time of baby birth

Stage 3 of Labor

- starts with full delivery of baby and ends with full delivery of placenta • lasts 5-15 min; longer the stage = increases risks of hemorrhage and retained placenta resulting in infection or hemorrhage • monitor signs of placenta delivery such as lengthening umbilical cord, trickling or gush of blood, uterus changes shape from oval to globular • once placenta starts to be delivered, mother will gently push • Placenta Delivery Mechanisms: (1) schultz mechanism: "shiny schultz" as this side is shiny and new from the side of the baby and comes out first (2) duncan mechanism: "dull/dirty duncan" this side is dull, red, and rough and is the side from the mother as the mother is dirty from labor and in rough condition so it is the maternal side • Interventions (1) monitor BP before/after placenta delivery (2) administer Oxytocin "Pitocin" AFTER placenta delivery as it will help the uterus to contract after delivery to prevent hemorrhage (3) assess placenta to make sure it is enact (cord should have 2 arteries and 1 vein) (4) provide comfort for the mother and encourage bonding (skin to skin contact), breast feeding, changing of linens, and peri-care.

Thromboembolic Disorders

- superficial vein thrombosis (SVT), deep vein thrombosis (DVT), and pulmonary embolism (PE) pregnant women are at increased risk of venous thrombosis within a vein due to - hypercoagulable state - venous stasis (blood pooling) - pressure behind knees if legs are placed in stirrups during delivery - ↑ fibrinogen levels increase clotting - ↓ clot-dissolving factors - varicose veins may develop due to increase pressure of weight on lower extremities SVT: thrombosis deveops in superficial vein of lower extremity and is characterized by local pain, reddness, hardening, warmness, thats visible - treated by warm compresses, compression stockings or elevation as PT is not at risk for PE DVT: thrombus found anywhere in leg veins from feet to femoral area and characterized by calf pain, behind knee pain, disffused pain, edema, erythema, to a large area of the leg thats diagnosed by ultrasound - at risk for PE as it may travel to lungs - treated by anticoagulants Warfarin and Lovenox (start heparin right away as therapeutic effects take 5 days to kick in) PE: thrombus forms in lower veins and travels to pulmonary artery of the lungs to obstruct oxygenation and cause sudden SOB, chest pain, dyspnea, back pain, ↓LOC, heart failure, and a feeling of vague impending doom - treated by anticoagulants Warfarin and Lovenox (start heparin right away as therapeutic effects take 5 days to kick in) Nursing Interventions 1. monitor pregnant or postpartum PT for signs of PE 2. avoid crossing legs as this will impede blood flow and cause venous stasis 3. avoid pressure to popliteal space behind the knee 4. encourage ambulation and ROM exercises to promote venous return 5. teach correct method of putting on antiembolic stockings 6. educate on dangers of anticoagulant therapy such as prolonged bleeding from minor injuries, unexplained bruising or nose bleeds (use soft bristle toothbrush) 7. importance of follow up blood tests to monitor effects of heparin (INR = 2-3 if therapeutic and working) 8. coping abilities

Induced Abortion

- therapeutic : intentional termination of pregnancy to maintain health of the mother - elective: intentional termination of pregnancy for reasons other than maternal health

Normal Affects of Pregnancy: Nursing Care Plan for Multisystem Changes (Physiological)

1. acknowledge any concerns or feelings while being nonjudgmental 2. discuss expected physiological changes and timeline for returning to pre-pregnant state 3. set goals for postpartum period regarding self care and newborn care 4. refer PT to counseling if body image is negatively impacted 5. educate woman on expected physiological and psychosocial changes with pregnancy such as common discomforts and ways to resolve discomforts 6. encourage follow up prenatal visits and contact provider if bleeding, leakage of fluid, or contractions are felt at any time

Complications of Neonate

1. infection/sepsis (↑FHR, ↓temperature) - screen at 36 wks and treat in labor with penicillin 2. hypothermia 3. neonatal abstinence syndrome (high pitch cry, tremors, temperature instability, diarrhea, vomiting, hyperflexion, sneezing, yawning, nasal flaring, tachypnea, fever, poor feeding, constant sucking, apnea) 4. fetal alcohol syndrome due to mother's use of alcohol during pregnancy (facial anomalies, shorter nose, physical abnormalities) 5. fetal circulation abnormlaities (murmur, shunts may reopen due to hypoxia or may not completely close) *report any murmurs on FHR to provider 6. nerve damage from delivery such as brachial plexis injuries, broken clavicle 7. mecconium aspiration 8. ↓ hypoglycemia due to maternal obesity or gestational diabetes as baby is use to high levels of glucose & insulin in the womb and then after delivery their glucose drops (respiratory distress, seizing, jittery, shaking) - assess blood glucose (normal = ↑ 40) 9. overweight babies (2500-4000 g) 10. cleft lip/clef palate 11. Failure to Thrive is a medical emergency as the infant has lost 10% of birth weight 12. trachealesophageal fistula 13. tritology of flow (perfusion changes)

primigravida, multigravida, nulligravida

1st time pregnancy multiple pregnancies no pregnancies

bleeding disorders

1st trimester - ectopic pregnnacy, spontaneous abortion, molar pregnancy 2nd trimester - cervical insufficiency 3rd trimester - placenta previa, abruptio placentae

Recurrent Abortion (Habitual)

2 or more consecutive spontaneous abortions caused by incompetent cervix or inadequate Progesterone levels needed to maintain pregnancy Interventions 1. assess medical hx and obstetrical hx (GTPAL) which may reveal systemic disease or cervical incompetence 2. vaginal exam may indicate uterine myomata or cervical incompetence 3. transvaginal ultrasound will clarify the diagnosis, and detect any uterine malformations 4. investigate any chromosomal abnormalities of the parents even if rare Treatment: treat the underlying cause if found, or treat general disease if present - if caused by cervical incompetence, place soft suture around cervix at internal cervical opening level until delivery

fontanels

2 or soft spots in newborn head which allows brain to grow (antior - diamond shape should be flat, if sunken in - baby is dehydrated, and if bulging - indicates increased intracranial pressure or bleeding) closes 12-18 months posterior fontanel (triangle shape) closes around 3 months

Subdermal Implant

2 rod-like implants containing Progestin, Etonogestrel, and Desogestrel embedded under the skin of the inner upper arm Contraindications - unexplained vaginal bleeding - Lupus - severe cirrhosis, liver tumor or breast cancer Patient Education 1. somewhat invasive procedure so PT must avoid any trauma to the area - procedure must be performed during menses or 7th day of period to confirm NOT pregnant Advantages • effective for 3-5 years • may be used immediately after abortion/miscarriage, delivery, or while breastfeeding (4 weeks postpartum) • fail rate 1% Disadvantages • adverse effects - irregular, unpredictable bleeding - mood changes - headache - acne - depression - reduced bone density - weight gain Risks • STIs • increases risk of Ectopic Pregnancy

To determine the EDD when the date of the client's LMP is known, use Nagele rule. To the first day of the LMP, add 9 months and 7 days to arrive at the EDD as follows: July + 9 months = April 5th + 7 days= April 12.

A client LMP began July 5. Her EDD should be which of the following? A. January 2 B. April 12 C. March 28 D. October 12

A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching?

A "I need to take antibiotics, and I should begin to feel better in 24-48 hours." B "I can use analgesics to assist in alleviating some of the discomfort." C "I need to wear a supportive bra to relieve the discomfort." D "I need to stop breastfeeding until this condition resolves." In most cases, the mother can continue to breastfeed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24-48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

Gina a postpartum client is diagnosed with endometritis. Which position would you expect to place her based on this diagnosis?

A Supine B. Left side lying C Trendelenburg D. Semi-fowlers semi-fowlers

Nagele's Rule

A method of determining the estimated due date for birth (EDB) or estimated date of delivery (DOD) as long as the LMP is obtained (1st day of last period) 1st day of last period + 9 months + 7 days = DOD ex: LMP was April 1, 2015 (+ 9 months) = Jan 1, 2016 + 1 week = estimated date of delivery Jan 8, 2016

Painless vaginal bleeding during the 3rd trimester maybe a sign of placenta praevia. If internal examination is done in this kind of condition, this can lead to even more bleeding and may require immediate delivery of the baby by cesarean section. If the bleeding is due to soft tissue injury in the birth canal, immediate vaginal delivery may still be possible so the set up for vaginal delivery will be used. A double set-up means there is a set up for cesarean section and a set-up for vaginal delivery to accommodate immediately the necessary type of delivery needed. In both cases, strict asepsis must be observed.

A pregnant mother is admitted to the hospital with the chief complaint of profuse vaginal bleeding, AOG 36 wks, not in labor. The nurse must always consider which of the following

A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?

A. Endometritis B. Endometriosis C. Salpingitis D. Pelvic thrombophlebitis Endometritis; an infection of the uterine lining that can occur after prolonged rupture of membranes or strong labor, and if not treated may lead to Salpingitis which is a tubal infection. Endometriosis does not occur following strong labor or prolonged rupture of membranes. Pelvic thrombophlebitis involves a clot formation but it is not a complication of prolonged rupture of membranes.

Which of the following is the primary predisposing factor related to mastitis?

A. Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts B. Endemic infection occurring randomly and localizing in the periglandular connective tissue C. Temporary urinary retention due to decreased perception of the urge to avoid D. Breast injury caused by overdistention, stasis, and cracking of the nipples Primary predisposing factors of Mastitis is injury to the breast as with overdistention, stasis, and cracking of the nipples. Epidemic and endemic infections are probable sources of infection for mastitis. Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection, not mastitis.

A postpartum client has a temperature of 101.4ºF, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected. Which of the following should the nurse assess next?

A. Lochia B. Breasts C. Incision D. Urine The data suggests an infection of the endometrial lining of the uterus. The lochia may be decreased or copious, dark brown in appearance, and foul smelling, providing further evidence of a possible infection. All the client's data indicate a uterine problem, not a breast problem. Typically, transient fever, usually 101ºF, may be present with breast engorgement. Symptoms of mastitis include influenza-like manifestations. Localized infection of an episiotomy or C-section incision rarely causes systemic symptoms, and uterine involution would not be affected. The client data do not include dysuria, frequency, or urgency, symptoms of urinary tract infections, which would necessitate assessing the client's urine.

APGAR scoring

A= appearance (color all pink, pink and blue, blue [pale]) P= pulse (>100, < 100, absent) G= grimace (cough, grimace, no response) A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent) Performed 1 min after birth, and 5 min after birth Scoring 0 - absent 1 - decreased 2 - positive Total Score Range 7-10 = normal 4-6 = low & in need of therapies 0-3 = critical & need of resuscitation

Nursing Care Plan: Acute Pain

Acute Pain: unpleasant sensory and emotional body response from actual or potential tissue damage thats sudden/slow and ranging from mild to severe with duration of less than 6 months - caused by infection, edema, erythema, Sx: - restlessness, guarding behavior, self focusing - autonomic responses Outcomes - PT will use comfort measures - PT will report decreased pain Nursing Interventions 1. assess location and nature of pain by rating 1-10 and assess for nonverbal symptoms (grimacing, crying, withdrawn behavior) 2. give instructions on how to assist or maintain cleanliness and warmth for healing and reducing chills associated with pain 3. teach relaxation teachniques and diversions 4. encourage breastfeeding or manual breast pump to prevent pain/discomfort associated with breast engorgement and to promote milk supply 5. change PT position frequently and provide comfort measures (back rubs, linen changes) 6. pain medications (woman should ask before pain is present as its easier to control) 7. apply loval heat to promote vasodilation, circulation, and promote comfort 8. administer analgesics or antipyretics to reduce discomfort and fever

ROM

rupture of membranes

Newborn Assessment: Fontanels

Assess patency, size, and fullness (even, sunken, bulging) anterior fontanel - larger in size than posterior - diamond shaped - closes at 18 months posterior fontanel - smaller in size than anterior - triangular shape - closes 8 to 12 weeks Evaluate - neither fontanel should appear bulging as this may indicate increased intracranial pressure - neither fontanel should appear sunken as this may indicate fluid deficit & dehydration

Chadwick's Sign

Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion as one of the earlier signs of pregnancy

Pregnancy Cardiac Markers

CK 26-174 Troponin <.6 Myoglobin <90 ANP 22-27 BNP <100

1st stage of labor: cervical dilation and effacement occur. 2nd stage of labor: Crowning occurs when the newborn's head or presenting part appears at the vaginal opening 3rd stage of labor: newborn and placenta are delivered. 4th stage of labor: lasts from 1 to 4 hours after birth, during which time the mother and newborn recover from the physical process of birth and the mother's organs undergo the initial readjustment to the nonpregnant state

During which of the following stages of labor would the nurse assess "crowning"?

fetal bradycardia

EMERGENCY anything that decreases perfusion to the baby including medication (epidural anesthesia - vasodilator reduces BP) or rapid descent through pelvis (ready to deliver and head compression), if cord pops out (push presenting part of baby off cord and go into surgery), hemorrhaging, 1. place mother in knee chest position to help bring HR back up 2. prior to epidural, give fluid bolus (500-1L) 3. fluid IV 16-18 gauge to give blood or rapidly replace fluid 4. anesthesiologist places epidural into mother on intervals very slowly doses - BP measurements x 2 in for 20 min - if mother BP drops, FHR will drop and this requires an increase in IV fluids (wide open), make sure PT is turned on side with HOB down, and if required, give Anfedron (vasoconstrictor to raise BP) if not corrected, mother must undergo cesearan section (c-section)

Know Pregnancy Medication

Erythromysin, corticosteroids for lung production, vitamin K, magnesium sulfate (calcium gluconate - antidote)

FHR can be auscultated with a fetoscope at about 20 week's gestation. FHR can be auscultated with Doppler ultrasound transducer earlier at 10-12 weeks located at the midline suprapubic region. FHR, cannot be heard any earlier than 10 weeks' gestation.

FHR can be auscultated with a fetoscope as early as which of the following? A. 20 weeks gestation B. 10 weeks gestation C. 15 weeks gestation D. 5 weeks gestation

Early Deceleration

FHR decelerate before peak of contraction caused by fetal head compression especially during 2nd stage of labor pushing (HR dips down with contraction and returns back to baseline) as a vagal response no interventions or concern begins & ends with contraction

Maternity Normal Values

FHR- 120-160 Variability 6-10pm Contractions- -Frequency every 2-5 minutes -Duration <90 seconds - intensity <100mmhg - amniotic fluid 500-1200ml - AVA umbilical has 2 arteries, 1 vein

Effects of Anemia on Pregnancy

Fetus - neural tube defects (especially folate def) - miscarriage - OIUGR / low birth weight - prematurity - anemia in infancy - IUFD Mother - susceptibility to infection - heart decompensation and HF - preterm labor and delivery - mental lassitude and loss of working hours - death

Stage 1 of Labor (Labor is Actively Transitioning)

Goal: Cervical dilation (opening) 0-10 cm & 100% effacement (thinning) due to contractions Facts: - longest stage (especially for 1st time mothers ... nulliparous) - starts with TRUE labor (3) phases; "Labor is Actively Transitioning" 1. latent or early labor 2. active labor 3. transition labor Phase 1: Early Labor (Latent) • cervix dilates 1-4 cm and thins • contractions occur x 5-30 min and 30-45 sec in length • less intense contractions compared to other phases and stages • longest phase especially for 1st time mothers >20 hrs vs >14 hrs multipara • some women notice contractions while others don't (may gradually occur over 8-12 hours or 1-3 days) • Interventions (1) if a woman is at home, monitor contraction duration and intensity (2) try to stay comfortable until water breaks or active labor begins (3) woman will be talking, excited, and may be nervous Phase 2: Active Labor • cervix dilates 4-7 cm and thins (woman dilates 1 cm/hr) • contractions will be noticeably stronger and longer (45-60 sec) x 3-5 min • lasts 4-8 hrs • Interventions (1) if a woman is at home, it's time to go to the hospital (2) water may break (if it hasn't already) and it's important to monitor for meconium-stained fluid (greenish brown-yellow amniotic fluid) (3) baby can aspirate meconium-stained fluid into lungs blocking airway or causing infection and this indicates fetal distress (4) perform Nitrazine Paper Test to confirm water broke (turns blue = POSITIVE) (5) provide comfort via pharmacological or non-pharmacological methods (6) non-pharmacological methods: changing positions, warm shower/bath, massage in btw contractions, breathing techniques, ice/fluids for dry mouth (7) pharmacological methods: epidural, etc. (8) encourage frequent urination to keep bladder empty as a full bladder prevents proper contraction of uterus and can slow down labor (9) monitor maternal & fetal vitals (HR) (10) woman may be serious, anxious and in pain Phase 3: Transition • phase leads into stage 2 of baby delivery • cervix dilates 8-10 cm and thins • shortest phase, but most intense and painful • lasts 30 min-2 hrs (longer duration for 1st time mothers) • contractions are intense and long (back to back) for 60-90 sec x 2-3 min • woman will be concentrated, irritated, pain, nauseous, shivering, and may report intense pressure describing bowel movement due to baby pushing down • Interventions (1) do not start pushing until fully dilated as this may cause swelling of the cervix resulting in impaired dilation (2) provide support, breathing techniques, encouragement (3) monitor maternal and fetal vitals (HR) especially before/after and during contractions (length, frequency) (4) monitor cervix status (dilation and effacement) (5) assess fetal position and station (station 0 - baby head is engaged and at ischial spine which is the narrowest part of the pelvis)

Stage 4 of Labor

Goal: monitor mother's health status after birth due to increased risk of hemorrhage, infection (due to retained placenta), and uterine atony, etc. • occurs 1-4 hrs after placenta delivery • stage of recovery • Interventions (1) monitor vital signs (BP & HR due to risk of hemorrhage and ↑temp due to risk of infection) (2) monitor color and amount of lochia or discharge (ruby= dark red; serosa= pink/brown; alba= white/yellow) - normal findings include moderate amount of red lochia with small clots - abnormal findings include large clots, foul smelling (3) assess # peri-pads used and how often changed - abnormal findings include more than 1 pad/hr and changing x 15 min) (4) monitor fundus of uterus for firmness and have mother void to make sure bladder is empty and not blocking fundus from dropping back down - normal findings include firm, midline, and slightly at or below the umbilicus - abnormal findings include soft/boggy or displaced which would require massage to firm (5) check fundus x 15 min for 1 hr then 30 min for 2 hrs (fundus of uterus will decrease 1 cm/day and cannot be palpated 10 days after delivery) (6) administer pain relief Rx (7) apply witch hazel to perineum and ice pack due to edema, tearing, episiotomy (8) promote bonding btw parents and baby, and help with breastfeeding

Pregnancy Vital Signs

HR 80-100 bpm BP 110-120/60 RR 12-20 T 98.6 F

Nursing Care Plan:

Imbalanced Nutrition: Less Than Body Requirements Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs. May be related to Intake insufficient to meet metabolic demands (anorexia, nausea/vomiting, medical restrictions). Possibly evidenced by Aversion to eating. Decreased oral intake or lack of oral intake. Unanticipated weight loss Desired Outcomes Patient will meet nutritional needs, as evidenced by timely wound healing, appropriate energy level, and Hb/Hct within normal postpartal expectations. Nursing Interventions Rationale Discuss eating habits including, food preferences and intolerances. To appeal to client what she likes/desires. Note total daily intake. Maintain diary of calorie intake, patterns and times of eating. To reveal changes that should be made in client's dietary intake. Promote intake of at least 2000 ml/day of juices, soups, and other nutritious fluids. Provides calories and other nutrients to meet metabolic needs and replaces fluid losses, thereby increasing circulating fluid volume. Encourage choice of foods high in protein, iron, and vitamin C when oral intake permitted. Protein helps promote healing and regeneration of new tissue. Iron is necessary for Hb synthesis. Vitamin C facilitates iron absorption and is necessary for cell wall synthesis. Encourage adequate sleep/rest. Reduces metabolic rate, allowing nutrients and oxygen to be used for the healing process. Assist with placement of nasogastric (NG) or Miller- Abbott tube. May be necessary for gastrointestinal decompression in presence of abdominal distension or peritonitis. Administer parenteral fluids/nutrition, as indicated. May be necessary to combat dehydration, replace fluid losses, and provide necessary nutrients when oral intake is limited/restricted. Administer iron preparations and/or vitamins, as indicated. Useful in correcting anemia or deficiencies when present.

Breast Assessment

L - lumps (inspect & palpate for lumps, masses) N - nipple changes (inspect & palpate for nipple retraction, lesion, discharges) M - mammary changes (inspect & palpate dimpling, tenderness, abnormal contours) O - other symptoms (check size, symmetry, appearance of skin, direction of pointing, rashes, ulceration) P - patient risk factors (interview PT for predisposing factors, obtain family hx, or use breast cancer assessment tool)

Precipitous Labor

Labor that lasts 3 hours or less from onset of contractions to time of delivery

prolonged pregnancy

Lasts longer than 42 weeks

Non-Stress Test

Looks at FHE with activity - Favorable results- 2 or more FHR accelerations of 15 beats lasting 15 seconds in a 20 minute period no labor mother is put on monitor to assess 2 FHR accelerations in 20 min period = indicates reactive no acceleration = non-reactive so biophysical profile to assess HR, baseline, variability, and accelerations 1. decelerations (early, late, variable)

Barrier Contraception

Mechanical Barriers • diaphragm • cervical cap • male/female condom Chemical Barriers - used to lower pH of vagina to create unwelcoming environment for sperm and kill sperm before reaching cervix • spermacides • vaginal gels/creams • glycerin films • sponges Advantages - can be bought without prescription Disadvantages - cannot protect against STDs - failure rate 80%

Pregnancy Blood Culture

Normal values include RBC 4.5-5.0 million WBC 4.5-11k neutro 60-70% lympho 20-25% Mono 3-8% Eosino 2-4% Baso 0.5-1.0% Platelets 150-400k Hgb 12-16 Hct 37-47 Glucose 70-110 BUN 7-22 Creatinine 0.6-1.35 LDH 100-190 Protein. 6.2-8.1 Albumin. 3.4-5.0 Billirubin. Less than 1 Total cholesterol 130-200 Triglycerides 40-50

Components of Birth Process (4 P's)

P - powers (contractions and maternal pushing effort) P - passage (maternal pelvis and soft tissues) *obesity interferes with childbirth P - passenger (presentation and position in relation to maternal pelvis) P - psyche - marked anxiety, fear, or fatigue decreases a woman's ability to cope as maternal Catecholamines are secreted in response to inhibit uterine contractions and placenta blood flow

Ovulation Detection

OTC kit that predicts ovulation from the surge of Leuteinizing hormone (LH) that occurs 12-24 hrs before ovulation by urine specimen Advantages • 98-99% accuracy has proved to be the method of choice by most women

Prenatal Visits: Diagnostic Test & Lab Tests

Ongoing Visits • monitor weight, BP, and urine • monitor any presence of edema • monitor fetal development • FHR detected by ultrasound and hearrd by doppler in late 1st Trimester so listen at midline right above pubis symphysis • measure fundal height starting in 2nd Trimester • fundal height in cm is same as gestational age from 18-30 wks • fetal health assessment or assess for fetal movement begins 16-20 wks • provide education for self care of discomfort and concerns of pregnancy (nausea, vomiting, fatigue, backache, varisocsities, heartburn, sexuality, activity/exercise) • performed at various times throughout the pregnancy and include - blood type; to detect Rh factor - STD - rubella titer - urinalysis/culture - ultrasound (1st Trimester); gestational age and estimated date of delivery - alpha fetoprotein; to detect neural tube defects or chromosomal abnormalities - CBC; to detect anemia - VDRL or RPR to detect syphyllis - Pap Smear - blood glucose test (2nd Trimester) to detect Gestational Diabetes during 24-28 wks gestation - amniocentesis; to detect defects in fetal development, but risky procedure may pose threat

Anticoagulant therapy

PT (warfarin/coumadin) 10-12 sec PTT (heparin) 30-45 sec APTT 3-31.9 sec INR (coumadin) 0.9-1.2 Fibrinogen 203-377

variable deceleration

Periodic abrupt decrease in FHR caused by umbilical cord compression; decelerations vary in onset, occurrence, and waveform. - not related to contractions - they may be caused by maternal/fetal position, if cord is wrapped around neck [nuccal cord], adrioamnios [low amniotic fluid], membrane rupture [no fluid to comfort] Interventions 1. amnioinfusion requires pre-op intrauterine uterus pressure catheter that has a port on it to run isotonic solution to help cushion the cord - caution places mother at risk for infection or uterine rupture 2. monitor I/O; if fluids are not coming back out (fundus will rise) 3. position changes

placenta previa

Placenta accreta is the most common kind of placental adherence seen in pregnant women and is characterized by slight penetration of myometrium. In placenta previa, the placenta does not embed correctly and results in what is known as a low-lying placenta as the embryo implants close or over the cervical is in the lower uterine segment instead of the upper portion. It can be marginal, partial, or complete in how it covers the cervical os, and it increases the patient's risk for painless vaginal bleeding during the pregnancy and/or delivery process. Placenta percreta leads to perforation of the uterus and is the most serious and invasive of all types of accrete. Placenta increta leads to deep penetration of the myometrium. Risk Factors - multiple gestation - elective abortion - advanced maternal age - c-section - uterine incision - hx of placenta previa - smoking classification depends on degree of covering; total, partial or marginal previa 1. total previa - cervix is completely covered so if dilation occurs, PT will hemorrhage and vaginal delivery cannot occur so rarely resolved 2. partial previa - only part of the cervix is covered by placenta but this shifts upward with fetal growth and may be resolved 3. marginal previa - cervix is marginally covered until ascends with fetal growth and is mostly resolved Sx: - sudden painless vaginal bleeding (bright red) that 27-32 weeks gestation or during 3rd trimester (does not harm fetus) - anemia - pallor - hypoxia - low PB (hypotension) - increased HR (tachycardia) - soft nontender uterus - weak thready pulse Diagnosis - amniocentesis is contraindicated. - Manual pelvic exams are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placental previa is ruled out. -Digital exam of the cervix can lead to maternal and fetal hemorrhage & severe bleeding - A diagnosis of placenta previa is made by ultrasound if total placenta previa, atypical fetal presentation will be seen and require C-section if bleeding is due to soft tissue injury of birth canal, immediate vaginal delivery is possible - H/H levels are monitored - external electronic FHR monitoring is initiated as it is crucial in evaluating the fetus that is at risk for severe hypoxia so it will detect fetal distress caused by blood loss or placental separation Treatment - total previa with excessive bleeding requires immediate c-section with surgical asepsis - Kleihauer-Betke test is used to determine if there are any fetal blood cells in maternal circulation in order to determine dose of Rhogam if needed - serial non-stress test (NST) - partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding Interventions - careful observation, IV access, monitor for signs of hemorrhage or shock - auscultate FHR with Doppler ultrasound x 4 hrs - postpartum care is normal, but its important to monitor for signs of infection from c-section or hemorrhage because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, and is more prone to bleeding

After vaginal delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina which are signs of

Placenta separation As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears

Pregnancy Diagnosis

Plasma hCG (blood serum tests) - detects hCG (0.1 - 0.3 IU/L) 6-7 days after ovulation (+) Urine Test - detects hCG (25 IU/L) 14 days after ovulation Patient Education 1. samples must be collected first thing in the morning and follow directions for utmost accuracy Risks - false positive or false negative for presence of hCG can result from taking medications such as anticonvulsants, diuretics, or tranquilizers

Preterm Labor Nursing Care Plan & Management

Preterm labor is labor that begins after 20 wks gestation and before 37 wks gestation Etiology causes of preterm labor include: -PROM -Preeclampsia -Hydramnios -Placenta previa -Abruptio placentae -Incompetent cervix -Trauma -Uterine structural anomalies -Multiple gestation -Intrauterine infection (chorioamnionitis) -Congenital adrenal hyperplasia -Fetal death -Maternal factors such as stress (physical and emotional), urinary tract infections, and dehydration Pathophysiology uterus begins the process of contraction prior to term gestational age Assessment Findings are signs of true labor that occur when the gestational age of the fetus is over 20 wks but less than 37 wks -Low back pain -Suprapubic pressure -Vaginal pressure -Rhythmic uterine contractions -Cervical dilation and effacement -Possible rupture of membranes -Expulsion of the cervical mucus plug -Bloody show Nursing Management 1. Assess mother's condition and evaluate signs of labor - determine frequency, duration, intensity of contractions -determine cervical dilation and effacement - determine status of membranes and bloody show 2. obstetric hx 3. CBC and urinalysis 4. determine blood count and urinalysis. 5. Evaluate fetus for distress, size, and maturity (sonography and lecithin-sphingomyelin ratio) 6. Perform measures to manage or stop preterm labor - bed rest in the side-lying position. - prepare for ultrasound, amniocentesis, tocolytic drug therapy, and steroid therapy 7. Administer tocolytic (contraction-inhibiting) medications - assess for side effects such as decreased maternal BP, dyspnea, chest pain, and FHR ↑180 beats/min 8. Provide physical and emotional support, hydration, education Uterine Relaxants (Tocolytics) for 30 wks "Its Not My Time!" I - Indomethecin (NSAID) N - Nifedipine (Ca+ Channel Blocker) M - Magnesium Sulfate T - Terbutaune (Adrenergic Agonists)

Nursing Care Plan: Impaired Parent-Infant Attachment/Bonding

Risk for Altered Parent-Infant Attachment: impaired bonding or attachment between parent (mother) and infant Risk Factors - Interruption in bonding process. - Physical illness. - Perceived threat to own survival. Outcomes - PT will show attachment with infant interactions - PT will maintain responsiblity for physical/emotional well being of infant - PT will be comfortable with parenting role Nursing Interventions 1. monitor PT emotional response to illness or serperation from infant (depression, anger) and encourage them to verbalize their feelings - normal expectations of postpartum are to have the family unit intact - abnormal expectations with illness or infection may cause seperation of family and this can cause feeling of isolation or depression 2. observe maternal-infant interactions and provide opportunities for bonding and contact 3. encourage father or other family members to take care and interact with infant to encourage mother - Father may need additional support if mother is hospitalized 4. discuss availability or effectiveness of support systems in home if mother needs help at home especially if other children or recuperating 5. support systems (visiting nurses, home care agencies) to assist PT at home with ADLs and discharge instructions

Nursing Care Plan: Risk of Infection

Risk for Infection: increased risk of invading pathogens Risk Factors • presence of infection with broken skin or traumatized tissue, and high vascularity of involved tissues • invasive procedure or environmental exposure to pathogens • chronic disease (DM, anemia) • malnutrition • immunosuppression or effects of medication (opportunistic infections or secondary infections) Outcomes • PT will understand risk factors • PT will initiate behaviors to limit spread of infection and reduce risk of complications • PT will heal in a timely manner free of complications Nursing Interventions 1. review antepartum, intrapartum, and postpartum records to identify and risk factors for spread or development of infection 2. hand hygiene for visitors to prevent contamination 3. proper disposal of contaminated linens, dressings and peripads 4. maintain isolation if needed to prevent the spread of infection 5. have PT demonstrate adequate perineal cleaning after voiding and defecation and frequent changing of peripads to remove urinary or fecal contaminants and to remove moist medium that may cause bacterial growth 6. fundal massage to enhance uterine contractions, promote involution and passage of any retained placenta fragements 7. monitor temperature, pulse and respirations and note any chills, anorexia, or malaise - elevations in vital signs and fluctuating symptoms indicate infection and change in status - a persistent fever thats unresponsive to antibiotics may indicate Pelvic Thrombophlebitis 8. observe perineum or incision for any signs of infection such as uterine tenderness, redness, edema, ecchymosis, discharge and approximation using REEDA scale - localized infection are not severe, but may progress to Necrotizing Fascitis which can be life threatening 9. monitor oral or parental intake (IV) and promote 2 L day of fluids by assessing urine output, hydration, and presence of N/V/D - increase intake replaces any fluid loss and enhances circulatory volume of blood to prevent dehydration and reduce fever 10. place PT in Semi-Fowler's position to enhance the flow of lochia and uterine or pelvic drainage 11. promote early ambulation and rest to increase circulation, clearing of respiratory secretions and lochia drainage for healing - any presence of Pelvic/Femoral Thrombophelbitis (inflammed artery) requires strict BED REST so its important to monitor any leg or chest pain, pallor, swelling or stiffness of lower extremities as these suggest Septic Thrombus formation - Embolic sequelae such as Pulmonary Embolism may indicate thrombophlebitis 12. if breastfeeding, check infants mouth periodically for presence of white patches that would indicate Oral Thrush which is bacterial growth on the tongue as a side effect of maternal antibiotics 13. prioritize post-discharge responsiblities such as homemaking, child care, recuperation and healing by assigning others household duties to help mom 14. proper medication use (take with or without meals, entire duration and course of antibitics) - oral antibiotics may be discontinued after discharge - failure to complete medication will cause infection relapse 15. pelvic rest is imporant so avoid douching, tampons and intercourse for 6 weeks after birth 16. monitor lab studies and cultures (WBC, CBC, differential and ESR) to identify degree of blood loss, anemia, microbes and PTT/PT clotting times to identify any alterations in clotting with emboli, effectiveness of anticoagulant therapy, or presence of anemia 17. monitor renal and hepatic function lab studies -hepatic insufficiency and decreased renal function may develop and increase the risk of drug causing toxicity 18. apply moist heat to perineal (sitz baths, dry heat of lights for 15 min 2-4 x daily) as water cleanses, heat dilates perineal blood vessels and increases blood flow for healing 19. supplemental O2 if needed for healing and tissue regeneration if anemia present or pulmonary emboli present 20. antibiotic creams for perineal to eradicate infectious organisms and reduce spreading of infection 21. medications administered - broad spectrum antibiotics given parental IV are used to prevent spreading of infection to other tissues and blood (Parametritis, Peritonitis, and Endometritis) - Pitocin and Methergine are given to cause myometrial contractions and stop spread of infection in uterine walls and to expel any clots or placenta fragments - anticoagulants (Heparin) given for Pelvic Thrombophlebitis to prevent or reduce thrombus formation and septic emboli - whole blood or packed RBC to replace blood loss and increase oxygen carrying hemoglobin in severe anemic PTs or those hemorrhaging 22. transfer to intensive care if severe infection such as Peritonitis or Sepsis develops, or Pulmonary Emboli 23. Incisions and drainage of infected area, as well as possible insertion of Iodoform gauze packing to promote healing and reduce rupture into peritoneal cavity - D & C (dilation and curettage) may be needed to remove retained products of conception or placental fragments

Pregnancy Normal Electrolytes

Sodium 135-145 Chloride 98-107 Calcium 8.6-10 Potassium 3.5-5.0 Phosphorus 2.7-4.5 Magnesium 1.2-2.6

Neonatal Vitals

T - 97.7 F R - 30 to 60 HR - 110 to 160 BP - Newborn Assessment Gestational Age Assessment - premature skin (translucent, thin, more veins, no wrinkles on palms + feet or testicles) - assess skin, creases - ear development premature ears (flat against head) normal ears should be in line with eyes (low set ears indicate genetic abnormality) premature (lacks breast tissue) (more vernix - white covering, lanugo - white fine air on body) requires gestational age of birth - monitor appearance - color (mongolian spots), posture skin - assess pain (how cry sounds; if shrill = pain) Nonverbal infant pain scale (look at facial expression, consolability) - do they appear normal or abnormal - assess baby's head (mishapen, bruising, swelling, overriding sutures, cephahematoma [large pooling of blood under skin - risk of bilirubin) -symmetry of movement, flexion tone -assess vital signs (apical HR for 1 min, RR palpate, auscultate or monitor as they breathe breathe pause [ should not pause longer than 5 sec ], no BP unless color changes, temp (axillary) - look at lips for cleft lip or cleft pallate - look at mouth, check palate and sucking reflex - check baby's new (trisomy will have thick neck and protruding tongue, creases go straight across called simean crease, - assess for patent airway if necessary, use suctinoing with bulb syringe in nostrils to maintain patent airway - chest should be barrel shaped, belly breathers - nipples (extra nipples should be documented - bowel sounds of abdomen - inspect umblical cord (3 vessels; 2 veins & 1 artery) and clamp to assess for bleeding or any anomalies in the cord - assess 10 fingers/toes - check capillary refill, movement, and femoral pulses on baby (color changes from extremities or in pulses may indicate cardiac defect) - females, swelling of labia, pseudo menses from affects of maternal hormones, make sure anus is open - male newborns, circumsicion, assess testicles to see if testes have descended, pull back foreskin to make sure urethra is at tip of penis - extremities ROM and symmetry - assess spine (should be straight, no tufts of hair, no defects, any sinuses or dimples should be reported to PCP as it can go all the way through the spine) - hips (ordalony;s maneuver is bending babys knees to feel dislocation of hip) -sucking reflex, palmar reflex, morrow reflex Screening Tests PKU hearing test newborn screening SpO2 (to screen cardiac defects) Teach 1. shaken baby syndrome 2. sleeping methods (put on back to decrease incidence of SIDS) and sleep/wake 3. feeding cues (smacking lips, hands in mouth, crying is late sign) 3. soothing 4. swaddling, diapering, cord care (do not immerse in water until cord falls off)

When a pregnant woman lies supine, the weight of the gravid uterus would be compressing on the vena cava against the vertebrae obstructing blood flow from the lower extremities and this causes a decrease in blood return to the heart and consequently decreased cardiac output and hypotension. Hence, putting the mother on left side lying will relieve pressure.

The nursing measure to relieve fetal distress due to maternal supine hypotension is:

Epidural Anesthesia: STOP

Treatment for maternal hypotension after epidural anesthesia S - stop infusion of Pitocin T - turn PT on left side O - oxygen therapy P - push IV fluids if hypovolemia present

Hypertonic contractions

Uterine contractions that are too long (90-120 sec or more) or too frequent (x 2 min), have too short a resting interval (less than 30 sec), or have an inadequate relaxation period to allow optimal uteroplacental exchange resulting in reduced/impaired uteroplacental exhange which may lead to fetal hypoxia caused by dehydration, oxytocin administration Interventions if dehydration - administer IV. fluids slow oxytocin or stop completely contractions push the fetus down and bring about cervical effacement (thinning) and dilation in utero, fetal lungs are fluid-filled and fluid in lungs decreases as they are pushed through (thoracic compression) and its absorbed into increased lung tissue during late pregnancy and labor *premature babies are at risk for fluid in lungs so they may require suctioning, oxygen administration - caution with suction through nasal passages as it will call inflammation because they are nose breathers thoracic compression during labor aids in expulsion of additional fluid

Normal Effects of Pregnancy: Reproductive System

Uterus • becomes a temporary abdominal organ • increases in size and changes shape with fetal growth to contain fetus, placenta and amniotic fluid at a full capacity of 5000 mL or 5 L • gains weight (0.1 to 2.2 lbs) • top of uterus and fundus will reach xiphoid process by 28 wks Cervix • changes color and consistency; becomes blue-purple into vagina and labia and becomes soft • glands in cervical mucosa increase due to increased blood flow • mucus plug forms to prevent ascent of microorganisms into uterus • as pregnancy reaches an end, the cervix thins out (effacement) and opens (dilates) to loosen and expel mucus plug Ovaries • produce Progesterone to maintain uterine lining during first 6-7 wks gestation until placenta takes over • ovulation and menstrual period cease to exist during pregnancy Vagina • blood supply increases causing it to have a blueish color • vaginal secretions increase and pH becomes acidic • increase glycogen levels in vagina promote growth of Candida Albicans or yeast which may increase the risk of yeast infection or bacterial vaginosis Breasts • increase in size due to breast tissue • aereolas darken • high levels of Progesterone and Estrogen to prepare for lactation • tubercles of Montgomery secrete substances to lubricate the nipples • exposing "premilk" which contains high amounts of fat soluble vitamins and minerals and low in calories, fat and sugar • as pregnancy ends, the woman will produce "premilk" or Colostrum to transfer antibodies to newborn in the first 2-3 postpartum days after birth Uterus or Fundus • fundal height of uterus reaches various pts throughout pregnancy as the uterus is a muscular organ and its location acts as a marker for fetal growth 20 wks = fundus should be at umbilicus 28-40 wks = fundus should be at ribs

abdominal enlargement

When the uterus rises out of the pelvis seen roughly after 12 weeks gestation.

When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks' gestation. The presence of fundus is out of the pelvis and above the pubis symphysis at 12 to 14 weeks The fundus is at the umbilicus at 20 weeks' gestation The fundus reaches the xiphoid process at full term or 40 weeks.

Which of the following fundal heights indicates less than 12 weeks' gestation when the date of the LMP is unknown? A. Uterus at the umbilicus B. Uterus in the abdomen C. Uterus at the xiphoid D. Uterus in the pelvis

Diaphragm

a circular rubber disk with flexible silicone rim thats fitted snugly over the cervix right before sex to inhibit the entrance of sperm into the vagina Contraindications - toxic shock syndrome - frequent UTIs Patient Education 1. proper insertion technique; PT must empty bladder before inserting diaphragm over cervix through vagina - must remain in place for 6 hrs after sex - do not leave in place for more than 24 hrs as this will increase risk of inflammation or irritation 2. diaphragm must be replaced every 2 yrs 3. must be refitted by physician if there is a weight fluctuation, pelvic or abdominal surgery, or pregnancy as it will distort shape of cervix 4. spermicide must be reapplied for each use 5. wash with mild soap and warm water after each use 6. use proper hand hygiene to prevent toxic shock syndrome (TSS) Advantages • available in different sizes • more female control • increased effectiveness when combined with use of spermicide Disadvantages • requires Rx and visit to provider to be fitted by physician • inconvenient and may interfere with sex • requires reapplication of spermicide gel, cream or foam for each use • inaccurate placement decreases efficacy Risks • STIs or allergic reactions • may increase risk of toxic shock syndrome due to bacterial infections so important to monitor any adverse effects - high fever - headache - muscle aches

Shock

a condition in which cardiovascular system fails to provide essential oxygen & nutrients to cells (impaired perfusion of body tissues) caused by - Cardiogenic (heart or pump fails) - hypovolemic (low blood volume due to hemorrhage) - anaphylactic (exposure to substance that causes allergic reaction of swelling of lips, tongue, airway leading to death quickly if not treated with epinephrine due to impaired airway) - Septic (overwhelming infection)

pelvic examination

a diagnostic procedure in which the external (vulva) and internal genitalia (pelvis) are physically examined using inspection, palpation of abdomen, and the use of a speculum to open the vagina - if PT has a full bladder, the manipulation (palpation of abdomen) may cause discomfort and accidental urination due to the pressure being applied, and it may cause inaccurate results because the bladder (in front of uterus) may block the uterus if full

Abortion

a disruption or loss of pregnancy (miscarriage) before the age of viability (20 wks or 350-500 grams) - can be caused by chromosomal abnormalities, teratogenic factors (radiation, infection, chemicals, drugs) or cervical insufficiency - spontaneous or induced Sx: - spotting (brown-red sports of blood) that occurs with heavy lifting, trauma to abdomen, or Braxton Hicks contractions due to slight dilation of cervix - cramping in pubis symphysis - false or true labor pains and contractions in early pregnancy are abnormal Risk Factors - chromosomal abnormalities - fetal development defect - advanced maternal age** - endocrine/immune disorders - uterine or reproductive tract abnormalities - maternal infections - hx of abortions - decreased Estrogen & Progesterone levels - Rh incompatiblity - malnutrition - drug use (contraindicated for pregnancy) Prevention 1. increase folic acid supplements to aid in fetal neural tube development 2. preconception planning and counseling (nutrition)

hCG (human chorionic gonadotropin)

a glycoprotein of 2 subunits that indicates pregnancy and can be detected as early as 1 week after conception with a half life of 6-24 hrs and a peak at 9-13 weeks gestation • hCG production begins at implantation • can be detected at day 7-8 • hCG ↑ peaks day 60-70 • hCG ↓ declines until day 100-130 • hCG gradually increases to term ↑ hCG levels indicate Multifetal Pregnancy, Ectopic Pregnancy, GTD, or genetic abnormalities (Down Syndrome) ↓ hCG levels indicate Miscarriage or Ectopic Pregnancy

Male Condoms

a latex or synthetic rubber sheath placed over erect penis before vaginal penetration to trap the sperm during ejaculation Patient Education 1. when placing condom on erect penis, a space must be left at the tip for sperm reservoir 2. after ejaculation, withdrawal penis from vagina while holding rim of condom to prevent semen spillage 3. after sex, remove condom & dispose of it Advantages • STI protection • male birth control method • various forms (latex, polyurethane, natural) • no adverse effects • readily accessible OTC, no fitting required • can be used with spermicide to increase efficacy • avoid breakage by using water-soluble lubricant Disadvantages • high rate of noncompliance and 15% failure rate due to the condom breaking or leaking • reduces spontaneity of sex • cannot be applied if penis is not erect • one time use increases replacement cost $ Risks • rupture or leakage may result in pregnancy • do not use if allergic to latex

vacuum aspiration

a method of abortion in which the cervix is dilated to allow a small tube to be inserted to extract the contents of the uterus (POC and endometrial lining) by suctioning

Intrauterine Device (IUD)

a small, T-shaped device, which contains Progesterone, is inserted into the uterus via the vagina to prevent fertilization by releasing chemicals that create a local sterile inflammatory condition to prevent implantation Patient Education 1. requires to be fitted by physician and inserted after menstruation 2. assess flow of menstruation each month and monitor IUD string to make sure the device has not traveled or been expelled 3. undergo annual pelvic exam Advantages • 99% most effective long term method as it lasts for 5-7 yrs • can be used for nulligravida or multigravida • inserted immediately, and once removed, PT is instantly fertile • does not interfere with sex • safe for breastfeeding • hormonal IUDs may reduce abdominal cramps/pain and heavy bleeding • copper IUDs do not contain hormones and are safe to use for contraindicated women • best used in monogamous relationships Disadvantages • can be expelled • invasive procedure • adverse effects - late or abnormal spotting/bleeding - abdominal pain - pain with intercourse - abnormal foul smelling discharge - fever - chills - change in string length - missing IUD Risks • STIs • increases risk of pelvic inflammatory disease, uterine perforation, Ectopic pregnancy • metal and chemicals of IUD may change the pH of the vagina and increase the risk of developing bacterial vaginosis, uterine perforation, or uterine expulsion • do not use Copper IUD if present with active pelvic infection, abnormal uterine bleeding, severe uterine distortion, Wilson's disease, or copper allergy

APGAR Scale

a standard measurement system that looks for a variety of indications of good health in newborns in 1 min after birth and then again at 5 min after birth to see if baby has adapted to extrauterine life 1. 2. 3. A - appearance (blue/pale) (pink body/blue extremities) (all pink) P - pulse (absent) (under 100) (over 100) G - grimace (absent) (grimace) (strong cry, grimace) A - activity (flaccid) (some flexion) (strong flexion) R - respirations (absent) (weak cry) (strong cry)

Dysfunctional Labor

abnormal UCs that prevent the normal progress of cervical dilation or descent of the fetus any deviation in normal progress of labor, either in cervical dilatation or descent of the presenting part despite uterine contractions -puts at risk for hemorrhage postpartum; risk factors include more pregnancies (muscle of uterine is more used), overdistention of uterus (multiple births, large babies, extra amniotic fluid [hydramnios], oliohydramnios [low amniotic fluid], obesity, hx of hemorrhage, premature birth, retained placenta [retained products of conception], prolonged labor/2nd stage of labor, prolonged use of oxytocin during labor, uterine atony [boggy uterus], laceration or tear [internal/external], hematoma [open vessel under skin thats pooling blood causes pain and pressure], trauma from delivery, thrombocytopenia or clotting conditions)

Menorrhagia

abnormally heavy menstrual flow (> 80 mL) in which a subsequent lack of Progesterone secretion and ovulation will result in continuous Estrogen production and extreme proliferation of endometrium

Abstinence

abstaining from sexual intercourse to eliminate the possibility of sperm entering the vagina & resulting in pregnancy Patient Education 1. refrain from sex or say "no" to sex 2. say "yes" to other sexually gratifying activities (kissing, touching, communication, holding hands, massage, oral/manual stimulation) Advantages • most effective natural birth control method with ideally 0% fail rate • most effective way to avoid or eliminate risk of STIs (no genitalia contact) • Rhythm method or fertile period abstinence requires an understanding of the menstrual cycle and awareness of fertility Disadvantages • most people find it difficult to comply with as it requires self control so few use this method Risks • none if abstinence is maintained

feeding newborns

after birth, feed on demand (feeding cues) or x 3 hours breastfeeding recommended exclusively for first 6 month of life (every 2-3 hours or on demand) and wake them up at night eat 8-12 x day well fed = pooping and peeing day 1 - 1 wet diaper and poop (yellow seedy) day 2 - 2 diapers formula/bottle feeding - not too much water as it will cause failure to thrive - teach how to prepare formula, store it, and how to put on nipple - semi-fowler's position while feeding

postpartum

after child birth or pregnancy

Puerperal Infection

an infection or septicemia in the birth structures after delivery due to poor sterile technique, delivery with significant manipulation, ceserean birth, or overgrowth of normal flora that may result in maternal death - fever of 100.4 after 1st postpartum day Pathophysiology 1. Causative organisms: aerobics (beta-hemolytic streptococci, e.coli, klebsiella, proteus mirabilis, Pseudomonas, Staphyl. aureus, neisseria) or anaerobes (bacteroides, peptostreptococcus, peptococcus, clostridium perfringens) 2. Parametritis: (Pelvic Cellulitis) is an infection that spreads through the lymphatic system of connective tissue surrounding the uterus 3. Puerperal infection may extend to the peritoneum through lymph nodes and uterine wall Sites of postpartum infections -pelvic cavity** -breast -urinary tract -venous system (femoral & ovarian veins) -vagina, vulva, and perinuem (localized) -endometrium (Endometritis) RIsk Factors - cracks in nipples of breasts - surgical incision (C-section) - tissue trauma during labor - open wound at placental insertion site - retained placenta or blood clots - increased pH of vagina after birth - Endometritis (inflmmation of lining of the uterus) Complications of Puerperal Infection -if localized infection in the perineum, vagina or cervix, it could ascend up the reproductive tract and spread to the uterus, fallopian tubes, and peritoneum causing Peritonitis (life-threatening infection) Assessment Findings 1. Puerperal Morbidity (death) - temperature 100.4°F or higher after first 24 hrs postpartum on any 2 days out of the 10 2. Vaginal, Vulval, & Perineal Infections (localized) - pain - elevated temperature - edema - redness - firmness - tendernses at site of infection - sensations of heat - burning during urination - discharge from wound/site 3. Endometritis: an infection of uterine lining that occurs 48-72 hrs after delivery - rise in temperature for several days if severe, - malaise - headache - back ache - discomfort - loss of appetite - large tender uterus - severe postpartum cramping - brownish red foul smelling lochia 4. Parametritis (Pelvic Cellulitis) - temperature above 102°-104°F - chills - abdominal pain - subinvolution of uterus - tachycardia -lethargy. 5. Peritonitis - high fever - rapid pulse - abdominal pain - N/V (nausea, vomiting) - restlessness Nursing Care 1. important to monitor temperature for up to 10 days postpartum and post-discharge 2. Avoid the spread of infection by proper hand hygiene 3. anyone who may come in contact with blood, bodily fluids, or potentially infectious material must wear proper PPE and gloves 4. WBC count from blood work is not enough to diagnose infectious processes postpartum as pregnant woman's WBC is normally elevated DURING and AFTER pregnancy Prevention goal is to prevent infection from occurring 1. use and teach hygienic measures 2. promote adequate rest and nutrition for healing (to prevent immunocompromised or stress which places risk for infection) 3. teach mother and family about signs of infection 4. teach woman how to correctly apply perineal pads (from front to back) 5. teach woman to take all antibiotics as prescribed in regimen Intervention 1. patient must maintain Semi-Fowler's position to localize infection 2. Inspect perineum 2x daily for redness, edema, ecchymosis, and discharge. 3. Evaluate for abdominal pain, fever, malaise, tachycardia, and foul-smelling lochia. 4. Obtain specimens for laboratory analysis; report the findings. 5. promote balanced diet, increase fluids, and early ambulation 6. administer antibiotics or medications and document PT response 7.. teach PT and family about self-care, especially careful perineal hygiene and handwashing

Transcervical Sterilization (Invasive/Surgical Methods)

an invasive procedure used by male or females to stop conception or inhibit conception life-long • bilateral tubal ligation (female) • vasectomy (male) Advantages - most effective birth control method - joint decision Disadvantages - permanent

AROM

artificial rupture of membranes

preclampsia

at risk for HTN given magnesium sulfate (smooth muscle relaxer) before delivery or inducing at 38 weeks causing prolonged labor

Postpartum Education and Medication

avoid sick people during pregnancy vaccinate mother postpartum for Rubella Hepatitis B Varicella TDAP teach normal changes and what to expect or what to report (saturating peri pad x hour, edema, severe headaches, severe bleeding, blurred vision, SOB) - thrombus risk, infection risk - breast care, perineum care, incisional care - proper positioning of breastfeeding 1. decrease lactation stimulation by applying ice packs, firm bra) 2. cheeks and nose should touch breast - perineal care includes squirt bottle, lidocaine spray, dermablast, icepacks and teaching the mother to keep clean - if c section occurred, the surgeon will remove the dressing and document the drainage (clean, dry, intact) - monitor any spotting and use steri strips, suture and etc to assess bleeding or infection - vaginal delivery is recommended after csection due to scar tissue formation of transverse incision (used with lowered uterine segment) but contraindicated with classical incision going up and down due risk of membrane rupture - increase calories and fluids when breastfeeding - anemic mother should eat iron rich food or supplements and take Vitamin C to aid absorption *it will make stool black - anemic mother will be fatigued and need additional help at home - lab work before/after delivery to assess Hgb - adequate rest & activity (strenuous exercise like sexual intercourse not recommended until after 6 wks) - empty bladder x 3 hours - newborn care and feeding

caput succadeum

baby's head as an unusual shape due to edema/swelling of the scalp; considered a benign condition

Physiologic Changes that precede labor

backache weight loss (1.3-5 lbs) energy burt increase vaginal discharge or bloody show GI- nausea vomiting indigestion cervical ripening or softening ROM

Basal Body Temperature (BBT)

basal body temp is the woman's temperature AT REST; it drops 0.5⁰F the day before ovulation and during ovulation, and rises 1.0⁰F during the menstrual cycle due to Progesterone, and this can be used to facilitate both conception or contraception Patient Education 1. measure oral temperature early in the morning before getting out of bed or starting any activity 2. if there is a slight decrease (0.5) and then an increase in temp, this is a sign that the woman has ovulated and she must abstain from sex for the next 3 days Advantages • inexpensive, convenient, and no adverse effects Disadvantages • temperature reliability is influenced by other factors which may cause inaccurate readings or changes such as stress, illness, alcohol, warm sleeping environment, etc • typical fail rate 25% Risks • pregnancy, STIs

Cervical Mucus Method (symptom based)

basis of this method are the changes of cervical mucus during ovulation (14 days before next period) • During ovulation, the cervical mucus should be copious, thin, watery and referred to as "Spinnbarkeit sign" (stretchy up to 1 inch and slippery) due to release of Estrogen and Progesterone to allow sperm to live and move Patient Education 1. demonstrate hand hygiene before/after self assessment of cervical mucus 2. begin examining cervical mucus on the last day of your period 3. obtain mucus from vaginal introitus and do not reach into vagina to touch cervix 4. do not douche prior to exam 5. avoid sex during "fertile days" or for entire duration of thin, watery cervical mucus and for 1 day after 6. teach PT characteristics of cervical mucus • dry, tacky, thick, white colored (NOT FERTILE) • creamy, stricky, white colored (NOT FERTILE) • cloudy, stretchy (SEMI-FERTILE) • watery, stretchy, egg white or clear (MOST FERTILE) Advantages • recognizing mucus characteristics can be helpful in diagnosing ovulation when breastfeeding, the start of menopause, and planning future pregnancies Disadvantages • some women are uncomfortable with touching genitals and mucus • fail rate of 25%. Risks • pregnancy, STIs • cervical mucus characteristics exam may be inaccurate if mucus is mixed with semen, blood, contraceptive foam, or discharge from infections

antepartum

before pregnancy

Metrorrhagia

bleeding between menstrual periods caused by decreased Progesterone and sloughing off of endometrial layers

fetal tachycardia

caused by dehydration, maternal fever, drug use (cocaine, stimulants) Interventions 1. increase fluids 2. monitor HR 3. VEAL CHOP V - variable C - cord compression E - early H - head compression A - accelerations O - okay L - late P - placental insufficiency

Mucus plug

cervical glands proliferate and mucus fills the endocervical canal forming a plug that blocks the ascend of bacteria from the vagina to the uterus (barrier) during pregnancy

probable signs of pregnancy

changes in the uterus that are strongly suggestive of pregnancy but could result from other factors (pelvic congestion, tumors) • abdominal enlargement (changes in uterine shape, size, position) - at 12 wks, uterus can be palpated above pubis symphysis - at 20 wks, uterus extends above umbilicus • abdominal striae (stretchmarks) • Chadwick's Sign (blueish-purple discoloration of cervix, vagina mucosa and vulva caused by increased vascular congestion) • Ballottement or fetal outline (maneuver to move fetal part by tapping finger on tip of cervix causing a rebound of unengaged fetus) • Braxton Hick's (irregular false uterine contractions felt in 2nd Trimester) • Goodell's Sign (softening of cervical tip & vagina caused by increased vascular congestion) • Hegar's Sign (softening of the lower uterine segment to ease flexion of the uterus against cervix or McDonald's Sign) • (+) pregnancy test (↑hCg hormone detection)

Transdermal Patch

combination of Estrogen & Progesterone in a patch so that hormones are absorbed continuously by SQ tissue and processed into blood stream Contraindications - 35 years old or more - smoking - pregnant/breastfeeding - breast cancer - hx of thrombus, stroke, MI, CAD, DM, gallbladder/liver disease, CNS deficits, HTN - 198 lbs or more Patient Education 1. apply 1 patch onto clean, dry area of upper outer arm, upper torso, abdomen or buttocks that are without redness or irritation (3 patches for 3 weeks total) 2. do not apply a patch on the 4th week - menstrual period 3. patches may be worn while swimming or bathing, but replace immediately if it falls off or is loose - if loose for <24 hrs, no additional contraception is needed 4. assess for adverse effects - headache - nausea - breast tenderness - breakthrough bleeding Advantages • maintains consistent hormone levels • avoids liver metabolism (medication is not absorbed by GI tract) • good alternative to the pill as it reduces the risk of forgetting Disadvantages • less effective if over 200 lbs Risks • STIs • increase risk of DVT, venous thromboembolism, or skin reaction

Symptothermal Method

combination of basal body temperature and cervical mucus methods in which a woman takes her temperature every morning before getting up and notes any changes in cervical mucus to predict ovulation • woman must abstain from sex for 3 days after a 1.0 rise in temp and the 4 days of mucus change (clear, liquidy, stretchy) Advantages • very effective when done properly as there is only a failure of 2%

APGAR score 8-10

considered a safe score and requires no special intervention

normal labor characteristics

consistent progression of uterine contractions, cervical dilation, and effacement and fetal descent labor contractions are intermittent, allowing placental blood flow, and exchange of O2, nutrients and waste product removal between maternal and fetal circuations during intervals

Hormonal Injections

consists of Medroxyprogesterone, a Progesterone, thats given once every 12 weeks (IM) to stop ovulation and change endometrium and cervical mucus ex: Depo Provera Patient Education 1. give IM injection during first 5 days of period, first 5 days postpartum (if bottlefeeding) or 6 wks postpartum (if breastfeeding) 2. after administration, do not massage site so medication can be absorbed slowly 3. schedule follow up appt 4. advise PT to increase intake of Calcium and Vitamin D, and engage in weight-bearing exercises Advantages • 100% effective and only requires 4 injections per year • long-term (2 years or more) • breastfeeding ok (doesn't impair lactation) • may reduce bleeding or cause amonorrhea (absent periods) • reduces the risk of uterine cancer if used long term Disadvantages • delayed fertility (up to 18 months) after stopping injections • adverse effects - decrease bone density, - weight gain - depression - irregular spotting Risks • STIs • massaging IM site will shorten duration of medication • contraindicated for breast cancer, cardiovascular disease, abnormal liver function or tumors, and unexplained vaginal bleeding

when should someone go to the hospital

contractions x 5 min per hour if water breaks if bleeding present if movement is absent severe headaches bluurred vision HTN weight gain

Threatened Abortion

cramping, backache, light uterine bleeding or spotting, but cervix is still closed, membranes intact, FHR present, and no POC expelled so the fetus is still viable in normal size uterus - fetal survival at risk as 50% lead to missed or inevitable abortions Interventions - draw labs and ECG levels - ultrasound will determine viability of fetus or whether fetus is at risk for miscarriage - mother can be placed on bed rest or sedation and given uterine relaxants - monitor use of perineal pads to monitor amount and appearance of vaginal bleeding or any foul-smelling discharge

Goodell's Sign

decreased collagen fibers in the connective tissue of the cervix causing it to soften in preparation for child birth

Spontaneous Abortion: Surgical Management

dilatation & evacuation (D&E) dilation of cervix followed by suctioning via vacuum aspiration to remove products of conception dilation & curettage (D&C) dilation of cervix and scraping of uterine walls to remove any remaining products of conception - used to confirm all POC were expelled during uterine contractions and spontaneous abortion - mostly used for incomplete abortions as there are no uterine contractions to expel any remaining POC trapped in the uterus which may cause severe bleeding (hemorrhage) and infection (sepsis) Nursing Interventions 1. before the D&C, monitor FHR to confirm there is no presence of fetal heart beat and confirm empty uterus by ultrasound

dilation & curettage (D&C)

dilation of cervix and scraping of uterine walls to remove any remaining products of conception

Physiological Contraception (Natural Family Planning Methods or Fertility Awareness-Based)

does not include the introduction of any chemical or foreign body • used for religious beliefs • cost effective A - abstinence B - basal body temperature (BBT) C - calendar method (safe period) C - coitus interruptus (withdrawal) S - symptom based method (cervical mucus)

Intrapartum Monitoring

during labor, uterine contractions are monitored along with the fetal heart rate (FHR) by using a pressure-sensitive device called a tocodynamometer placed on the mother's abdomen over the strongest area of contractions (over fundus) to measure the length, frequency, and strength of uterine contractions fetal positioning is also monitored during labor by using Leopold's Maneuver *if FHR is up top, this indicates the baby is breach Interventions 1. place mother in side lying position to relieve pressure and increase cardiac output and perfusion - each box on tocodynamometer fetal contraction strip is 10 seconds long and each line indicates 1 minute - determine FHR from maternal heart rate as it is a good indicator of fetal health (viability) during labor Interventions 1. assess by inspecting 10 min portion of strip and figuring out the baseline (120-160 bpm) 2. before assessing the strip, its important to know affecting factors of FHR that include maternal medications, maternal or fetal abnormalities, and gestational age 3. assess baseline FHR, variability, and acceleration 4. a jagged appearance on the stip indicates variability (interactions btw sympathetic and parasympathetic nervous systems that make HR increase and decrease); - moderate = normal HR (goes up and down) - no variability at 20 weeks gestation because the fetus is not mature enough - decreased = depressed HR (straight line) may be due to stress, medications that depress maternal HR like morphine, or if fetus is sleeping in which it should not last for more than 40 min 5. acceleration is associated with fetal movement and this starts at 28 to 32 week gestation as the fetal CNS is mature - acceleration = increase of 15 bpm or more above baseline FHR (120-160) that lasts for 15 sec or more in full term (36 weeks and above) - accleration = increase of 10 bpm or more above baseline FHR (120-160) that lasts for 10 sec or more in preterm

intrapartum

during pregnancy or child birth

Pregnancy Complications: Hemorrhagic Disorders

early bleeding in pregnancy is a medical emergency caused by - abortion (spontaneous/induced) - abruptio placenta (placental abruption) - placentia previa (low lying placenta) - ectopic pregnancy - hydatidiform mole (gestational trophoblastic disease) - implantation bleeding Management 1. see physician right away 2. lab work (blood type, Rh factor) 3. monitor and follow up if any spotting occurs, or schedule pregnancy test (hCG) and ultrasound

Bleeding Disorders of Pregnancy

early pregnancy - spontaneous abortion (miscarriage) "trademark inc" threatened, missed, inevitable, incomplete, complete - induced abortions (therapeutic/elective) - ectopic pregnancy - hydatiform mole mid pregnancy - cervical insufficiency

hyperemesis gravidarum

excessive, constant nausea and vomiting that occurs 8-12 wks gestation and resolves by week 20 - different from morning sickness because the mother cannot hold down foods or fluids resulting in dehydration and fluid/electrolyte imbalance - can impact fetal growth because there is a reduced delivery of nutrients, oxygen and food to the fetus Sx: dry mucus membranes ↓skin turgor and elasticity scant concentrated urine ↑Hct nausea vomiting weight loss nutritional deficit postural hypotension Risk Factors - multiple gestation - molar pregnnacy - hx of hyperemesis gravidum - stress, psychological factors Treatment 1. correct fluid/electrolyte imbalance; NPO for first 24 hr or until vomiting stops 2. administer Pyridozine (Vitamin B6) with or without Dozylamine 3. administer Antiemics regularly around the clock if needed by IV or rectal suppositories to stop vomiting *caution - Class C could pose risk to fetus 4. once vomiting stops, start PT on clear liquid diet and advance to bland diet - total parental IV nutrition may be used for extreme cases 5. Thyamine supplements may be given if there is a deficit in thyamine indicated Nursing Interventions - assess for nausea and administer Pyrodozine or antiemetics as ordered - record I and O's and assess for any signs of dehydration - monitor lab values - after vomiting stops, implement nutritional intake measures such as avoiding hot or odorous foods, mouth care before/after meals, promote meal time with others, monitor family dynamics for stress - monitor FHR

Endometriosis

extrauterine endometrial cells abnormally grow in the uterine ligaments or ovaries and this excessive endometrial production and return of blood/tissue into fallopian tubes during menstrual cycle

Pregnancy: 1st Trimester

first 3 months of pregnancy beginning - embryo forms , placenta grows in uterus, and after 8 weeks of baking it is called a fetus At Risk - Morning sickness - Spontaneous abortion (miscarriage) - Fainting and hypotension Interventions 1. light-moderate spotting requires hospital visit 2. note amount, color, duration and start date of bleeding 3. assess for any accompanying symptoms such as abdominal cramping/pain, back pain, increased pressure, or vaginal discharge 4. labs (hCG to see if it is progressing, progesterone to indicate if it correctly correlates to gestational age)

Complete Abortion

following an inevitable abortion (uterine bleeding, cervix is dilated, intact membranes, no POC expelled, and FHR present) all POC are expelled and the cervix closes and bleeding stops - no treatment required - PT must be monitored to make sure uterus contracts back down to normal size - offer emotional support - administer Rhogam if mom is Rh (-) and fetus Rh (+)

Incomplete Abortion

following an inevitable abortion (uterine bleeding, cervix is dilated, intact membranes, no POC expelled, and FHR present) uterine bleeding/cramping, cervix dilated, and some POC are expelled while others remain still intact inside the uterus which may lead to infection (sepsis) if not evacuated by D&C

vitamin K

given to newborn for clotting because gut doesnt produce clotting factors because its sterile (IM) use 25 gauge in vastus lateralis

erythromycin

given to newborns at birth to prevent conjunctivitis of eye from Ghonorrhea

umbilical cord prolapse

immediate emergency condition as the umbilical cord protrudes alongside or ahead of the fetus may occur after water breaks (premature rupture of membranes) before baby has moved into birth canal or baby in breach places at risk for cord compression, hypoxia Interventions 1. elevate presenting fetal part or patient's hips (Sim's position) to relieve pressure off of cord and hold it there until help comes 2. may place patient in knee-chest or Deep Trendelenburg position to relieve compression further 3. monitor cord for pulsations 4. wrap cord in sterile gauze soaked in saline to keep cord moist and minimize the risk of uterine infection 5. place PT in Lateral Recumbent position to increase perfusion to placenta and prevent Supine Hypotensive Syndrome 6. perform perineal care 7. determine fetal engagement, position and presentation by Leopold's Maneuver - if baby is lying transverse or in breach position, a c-section is required immediately (within 12 min) - other fetal abnormalities such as face, chin or posterior presentations require surgical intervention 8. rule out risk of maternal medical issues or medications that may cause increase in FHR - fever, anxiety, anemia, beta drugs can increase maternal HR and FHR 9. obtain fetal scalp blood sample to assess fetal pH which determines metabolic reserves and may differentiate between respiratory acidosis or metabolic acidosis - pH 7-7.25 indicates intermittent cord compression and requires constant monitoring 10. administer supplemental oxygen via face mask 11. increase IV solution and turn off Oxytocin to relax uterine contractions and promote placental blood flow 11. prepare for surgical intervention if neccessary -fetal hypoxia or respiratory acidosis lasting over 20 min will cause CNS damage to the fetus - if prolapsed cord is present before full cervical dilation (8-9 cm), immediate c-section is required The greatest risk of vaginal delivery of a breech infant is: A. Umbilical cord prolapse. B. Intracranial hemorrhage. C. Meconium aspiration. D. Fracture of the clavicle.

Septic Abortion

infection caused by remaining POC in the uterus that were not expelled during a missed or incomplete abortion which may lead to hemorrhage and shock if not treated sx: abdominal pain, pelvic tenderness, foul-smelling vaginal discharge, fever, tachycardia (HR over 120), BUN over 25 Treatment - conduct bimanual vaginal exam using cervical swab or high vaginal swab for culture and sensitivity - take blood work for labs (CBC, electrolytes, coagulation) - administer antibiotics via IV Gram (+) = "-cillin" Gram (-) = "-mycin" anaerobic = Metronidazole bacteroids = Antitetanus - if severe hemorrhaging is present leading to shock due to remained POC, prepare for D&C to evacuate the uterus - if infection is not properly controlled with treatment, patient must undergo a hysterectomy - correct anemia and prevent DIC or disseminated intravascular coagulation by administering a blood transfusion, Heparin, and Rhogam if necessary - correct acidosis and prevent renal failure (urine output less than 30) by restricting fluids and providing supplemental oxygen - provide high carb, low protein diet restricted in sodium and potassium - administer Manitol or Frusemide if BUN over 25 on urinalysis

Puerperal infection

infection or septicemia after childbirth with 100.4 fever after 1st postpartum day or until 10th day as the mother is still at risk Risk Factors - cracked nipples - surgical incision (c-section) - tissue trauma during labor - open wound at placental insertion site - retained placenta or blood clots - ↑pH in vagina after birth - endometritis (inflammation of uterine lining) Complications - local infection in vagina, perineum, or cervix may ascend up reproductive tract into uterus, fallopian tubes and peritoneum causing peritonitis which is life threatening Safety Tip: hand hygiene to avoid spread of infection and wear gloves when in contact with bodily fluids Nursing Care 1. during pregnnacy, WBC are elevated so this may not indicate infection 2. teach hand hygiene, promote rest and nutrition for healing, and monitor for signs of infection 3. teach women how to apply perineal pads (front to back) 4. guide antibiotic regimen

chorioamnionitis

inflammation of the fetal membranes (chorion and amnion)

Masticitis

inflammation of the lactating breast tissue caused by infection or stasis of milk in the lactiferous ducts in women who are breastfeeding Etiology - epidemic infection is derived from nosocomial source (S. aures) from mother's hands after improper hand hygiene or infant's mouth around cracked, blistered nipples which allows a port of entry for infection - endemic infection (from inside the body) occurs randomly Sx: usually do not occur until 3-4 wks postpartum - redness or heat in breast - tenderness or localized pain - edema, engorgement, and heaviness of breast - purulent drainage present/absent - fever - chills - aching - mailaise - tachypnea - nipple soreness and fissures (cuts) - swollen or tender lymph nodes - abscess may form Risk Factors - injury to breast (overdistention, stasis, or cracked nipples) - missed feedings - wearing a bra that is too tight - impaired infant suckling Prevention - prophylactic measures such as good breast hygiene Nursing Interventions 1. observe for any signs and symptoms of mastitis (fever, chills, tachycardia, headache, pain/tenderness, firmness or redness of breasts) 2. administer antibitoics 3. offer comfort measures (small side pillows, icepacks, heat applications over local abscess) 4. teach PT and family on how to prevent infection through hand hygiene and how to take care of blocked milk ducks - breast feed frequently - perform breast and nipple care by wearing supportive bra, gentle cleansing, frequent breast pad changes, and exposing nipples to air 5. teach PT instructions for at home care Patient Instructions 1. rest during the acute phase 2. maintain a fluid intake of at least 3 L/day 3. take analgesics (Motrin) to relieve discomfort and fever 4. if antibiotics are prescribed, continue taking full regimen and continue to breastfeed 5. use of moist heat or ice packs 6. wear a supportive bra 7. continue to breastfeed or pump in order to decompress the breast and empty to prevent abscess formation

Ballottement

inserting finger into vagina to palpate and tap against the uterine wall of the cervix to feel fetal rebound (palpate fetal outline of baby's head and fetus moves away from cervix to show it is not engaged yet) and this is performed after 24 weeks gestation

In Leopold's maneuver step #1, you palpated a soft broad mass that moves with the rest of the mass.

interpretation of this finding is: fetal buttock since it moves with the rest of the body

Calendar Method (Rhythm Method)

involves refraining from coitus during fertile days, which according to menstrual cycle includes the 3-4 days before/after ovulation • calculate "safe days" by recording menstrual cycle for 6 months & avoiding sex from the 1st fertile day to the last (shortest cycle - 18 = 1st fertile day) (longest cycle - 11 = last fertile day) Patient Education 1. requires accurate recording of days in each menstrual cycle starting from the 1st day of the woman's period 2. based on assumption that ovulation occurs 14 days before start of a woman's period 3. PT must take into account the timing of sex as sperm is viable for 48-72 hrs and the egg is viable for 24 hrs Advantages • most useful and successful when combined with basal body temp or cervical mucus method • inexpensive method Disadvantages • not very reliable due to inaccuracy of recording • requires self control and compliance with abstinence during fertile periods • fail rate 25% Risks • there are various factors that can change and affect the timing of ovulation and cause unpredictable menstrual cycles • pregnancy, STIs ex: shortest cycle (26 days) longest cycle (30 days) 26 - 18 = 8th day 30 - 11 = 19th day Fertile Period: days 8-19 so refrain from sex during these days

Oral Contraceptives

known as "the pill" and contains synthetic Estrogen (blocks FSH & LH hormone to prevent ovulation) and Progesterone (thickens cervical mucus to block semen from egg and alters uterine decidua to prevent implantation to uterine wall) Side Effects - nausea - weight gain - fluid retention - headache - breast tenderness - breakthrough bleeding - vaginal infection - mild HTN - depression - increased appetite - fatigue - depression - oily skin or scalp Contraindications - breastfeeding/pregnant - 35 years old and up - cardiovascular diseases (hx of thrombus, stroke MI, CAD, DM, HTN) - hx of gallbladder disease, liver tumor or cirrhosis - CNS deficits - smoker - breast or ovarian cancer - under 6 wks postpartum Patient Education 1. Requires Rx and follow up appt, as well as consistent and proper use in order to be effective 2. Educate on guidelines of oral contraceptive use • 1st pill should be taken the first Sunday after your period or whenever you choose to start • pill is not effective for initial 7 days so use additional contraception • if one day or dose is skipped, PT must take the pill ASAP and follow with regular use of contraception • if two days/doses are skipped, additional contraception is required to avoid ovulation so its important to teach alternative methods 3. assess for adverse effects - chest pain - SOB - leg pain due to thrombosis - headache - eye problems from stroke - HTN - hirsutism (unwanted dark coarse hair growth on face, chest, back) Advantages • highly effective if taken consistently • protects against Endometrial cancer, Ovarian cancer, and Colon cancer • reduces risk of Breast cancer and ovarian cyst development • improves acne • Low Dose Estrogen (< 35 mcg) can reduce menstrual bleeding, dysmenorrhea (abdominal pain/cramps), and premenstrual symptoms while also decreasing anemia and regulating menorrhagia (abnormally heavy or prolonged periods) Disadvantages • increase risk of thromboembolism, stroke, MI, HTN, gallbladder disease, liver tumors • may exacerbate conditions that are affected by fluid retention such as migraines, epilepsy, asthma, kidney disease, heart disease • reduced effectiveness if taking medications that affect liver enzymes such as Anti-convulsants or Antibiotics Risks • STIs

Female Condoms

latex rubber sheaths prelubricated with spermicide that have an inner ring to cover cervix and outer ring to cover vaginal opening Patient Education 1. the closed end of the pouch must be inserted into vagina prior to sex and anchored around cervix while the open ring should cover the labia Advantages • protection against STIs/pregnancy • disposable, no prescription

Vasectomy

male sterilization executed through small incision on each side of scrotum to tie, cauterize, cut or plug vas deferens in order to block the passage of sperm Patient Education 1. advise PT that mild local pain may be felt after procedure in area 2. alternative birth control methods must be used for 20 ejaculations (weeks to months) or until there are 2 negative sperm count results to confirm that all viable sperm is cleared out of the vas deferens - sperm can live in vas deferens for 6 months 3. encourage the use of scrotal support and moderate activity for a couple of days following surgery to reduce discomfort 4. requires follow up appt to assess sperm count Advantages • permanent short, safe, and simple procedure • unaffected sex • 99.5% efficacy with very few complications Disadvantages • invasive and requires local anesthesia • possible reversal is not always successful • rare complications include bleeding, infection, anesthesia reaction Risks • STIs

Rh factor

maternal Rh (-) blood type & fetal Rh (+) mother may produce antibodies that attack fetus (hemolyss) so they ate given rhogam at 28 weeks to suppress immune response after delivery, rhogam is given if fetus is (+) blood type given within 72 hours to stop antibody formation if antibodies are made, it will affect the next pregnancy and attack the fetus

decidua

modified mucosal lining of the uterus known as the endometrium that forms in preparation for pregnancy by process called decidualization under the influence of progesterone

Plan B (emergency oral contraceptive)

morning after pill that prevents fertilization of sperm and egg and must be taken within 72 hrs Patient Education 1. providers recommend taking OTC antiemetic 1 hr prior to dose to counteract any adverse effects of nausea that can occur with high doses of estrogen and progestin 2. pregnancy evaluation if menstruation doesnt occur within 21 days 3. contraception and sexual behavior modification counseling to learn risky sexual behaviors Advantages - not taken on regular basis - anyone regardless of age or gender is allowed to purchase at pharmacy Disadvanatges - nausea, heavier menstrual bleeding, lower abdominal pain, fatigue and headache - no long-term effects - doesnt terminate a pregnancy Risks - STIs - do not use if pregnant or have undiagnosed abdnormal vaginal bleeding - if period doesnt start in 1 week, client could be pregnant

once membranes are ruptured

mother is at risk for infection symptoms of infection; fever will cause fetal HR to raise (tachycardia = 170 bpm)

Spontaneous Abortion

non-induced fetal death or passage of products of conception out of the uterus before 20 wks remember "Trademark Inc" T Threatened M Missed I Inevitable N Incomplete C Complete Threatened - cramping, backache, light spotting, closed cervix - no POC expelled, membranes still intact, and FHR present = fetus is still viable and can lead into a MISSED or INEVITABLE abortion Missed - bleeding stopped and replaced by brown vaginal discharge, cervix is still closed, membranes still intact, no POC expelled, but no FHR = fetus is no longer viable - fetus died in utero but was not expelled, therefore uterine growth will stop and uterus must be evacuated surgically (D&C) to prevent sepsis Inevitable - uterine bleeding, cramping, dilated cervix, membranes intact, FHR present, no POC cexpellled = fetus still viable - woman must be placed on bed rest and monitored for natural evacuation of uterus that may occur (complete/incomplete abortion) Incomplete - uterine bleeding, cramping, dilated cervix, and passage of some tissue (POC) - remaining POC must be surgically expelled from uterus by D&C Complete - all POC expelled, bleeding stops and cervix closes - monitor PT, give emoitonal support, and Rhogam is required (maternal Rh -, fetal Rh +) Pathophysiology decreased Progesterone cause failure to grow in fetus and sloughing off of endometrium resulting in bleeding and release of Prostaglandins to stimulate uterine contractions and cervical dilation to expel POC Assessment - assess for symptoms of spontaneous abortion including vaginal spotting or bleeding, abdominal cramping, low back pain, uterine contractions *at risk for fluid volume deficit - take blood and bring to lab (blood type, Rh) Medical Management 1. administer IV fluids (Lactated Ringers LR) to replace fluid loss from bleeding 2. administer supplemental oxygen (6-10 L/min) via face mask to provide adequate fetal oxygenation. 3. Avoid vaginal exams to avoid disturbing the products of conception or triggering cervical dilation 4. administer pregnancy test; if NEGATIVE - the PT must undergo other diagnostics to confirm the nature and cause of vaginal bleeding, but if POSITIVE - pregnancy and abortion are suspected and must be classified by type (spontaneous) 5. ultrasound to confirm pregnancy and determine condition of fetus or if products of conception are still intact inside the uterus Interventions 1. document amount and appearance of bleeding and save any clots or tissue remains for evaluation by pathologist 2. count the number of perineal pads used to estimate total amount of blood loss (weigh soaked pads) 3. monitor vital signs, uterine contractions, FHR 4. active bleeding (profuse) requires the woman to be placed flat in bed on her side to relieve pressure from vessels & NPO status in case of surgery 4. monitor I/O to establish renal function Surgical Management 1. dilatation and evacuation - to confirm that all products of conception were removed during the abortion Pre-Op Interventions: check fetal HR to make sure there is no heart beat and monitor ultrasound to confirm an empty uterus 2. dilation and curretage - mostly performed for incomplete abortions in order to remove the remaining products of conception trapped inside the uterus as they may cause severe bleeding and infection (sepsis) as a result of no uterine contractions E- Evaluation blood restored and bleeding stopped if - BP above 100/60 mmHg - maternal HR below 100 bpm & FHR normal 120-160 bpm - urine output more than 30 mL/hr - minimal bleeding for no more than 24 hrs

Intrapartum Nursing Care Plan: Pain Management

normal contraction of involuntary muscles does not cause pain, but uterine contractions cause cervical diliaton and perineum stretching which constrict blood vessels to reduce blood supply causing anoxia in muscle fibers and resulting in pain during the progression of labor, anoxia and ischemia in the uterine and cervical muscle fibers increase dramatically in intensity and frequency resulting in more intense pain once the cervix is completely dilated to 8 or 9 cm, the woman will feel a strong urge to push and pushing will allow pain to dissapear pain reappears when fetal parts present against the cervix creating pressure Nursing Interventions 1. comfort measures (relaxation, breathing techniques, distractions, prayer, herbs, hot/cold application depending on culture) 2. narcotic analgesics; Meperidine is given 3 hrs before birth to peak in the 2nd stage of labor (fetus passing out of the birth canal) to relieve pain and relax cervix - caution with Meperidine as it may cause fetal CNS depression and contraindicated in preterm births due to lung immaturity of fetus 3. local anesthesia (Lidocaine); superficial injection into nerves to reduce the ability of nerve fibers - pudendal nerve block; local anesthesia injection at the Ischial Spine near left/right pudendal nerves for 1 hr pain relief after 10 min for pain free birth or Episiotomy - monitor FHR and maternal BP immediately after injection to detect maternal hypotension 4. regional anesthesia (spinal block, Epidural); injection of a local anesthesia to block specific nerve pathway but allows PT to stay awake and aware - prevents postpartum hemorrhage as it does not relax uterine muscle tone - caution as it may cause FHR decelerations, flaccidity, bradycardia and even hypotension

Hydatidiform Mole (Molar Pregnancy)

o Benign neoplasm that can turn malignant; starts like any other normal pregnancy o Grape-like clusters of vesicles o May/may not have a fetus involved, usually fetus is not involved s/s are the - uterus enlarges way too fast; - absence of fetal heart tones; - bleeding (sometimes will have vesicles); - confirmed with an ultrasound Gestational trophoblastic disease wherein fertilized egg nucleus inactivates of is lost and sperm duplicate to simulate growth of fetus. There is no genetic material and no fetus, no placenta and no fluid. Uterus may be larger than expected. Hyperemesis gravidarum GH or preeclampsia may be present with vaginal bleeding. Most abort spontaneously. estational trophoblastic neoplasm usually resulting from fertilization of an egg that has no nucleus or an inactivated nucleus abnormalities

Early Postpartum Hemorrhage

occurs 24 hr after birth and is caused by uterine atony, lacerations/tears, or hematomas uterine atony - "boggy" uterus that lacks muscle tone when palpated during fundal height assessment increases the risk of hemorrhage - may be caused by overdistention of uterus, retained POC, prolonged labor, or use of labor drugs that relax the uterus - at time of birth, fundus is midline at umbilicus and should recedes 1 cm/day postpartum - by day 12 postpartum, fundus should be normal size, contracted, and firm laceration/tears of reproductive tract - may occur during delivery - appears as bright red bleeding that trickles consistently unlike dark colored spurts of lochia hematoma - collection of blood in vulva (external) or inside vagina as a result of trauma from delivery (may or may not be visible) Interventions 1. instruct PT to empty bowels before fundal height assessment as distended bladder full of urine will displace the fundus of uterus to the side and give inaccurate fundal height assessment - at birth, fundus is midline at umbilicus - recedes 1 cm/day postpartum - day 12 postpartum, fundus should be normal size and firm due to contractions - massage fundus if boggy to stimulate contractions and firmness - encourage breastfeeding as it releases Oxytocin to stimulate uterine contraction - administer Methergen to increase uterine tone and firmness 2. asses and observe lochia and vital signs - if there is a change in vital signs but no change in lochia = no uterine atony (not boggy) 3. ice packs may be used to reduce inflammation and discomfort of perineum 4. small hematomas will heal on their own, but large hematomas may require clot evacuation 5. assess the mother after birth x 15 min for the first 2 hours

Late Postpartum Hemorrhage

occurs 24 hrs after birth to 6 wks after birth and is caused by retention of placental fragments or subinvolution of uterus Nursing Care - teach PT to report any peristent bright red bleeding or the return of bleeding after it gradually went from pink to white (lochia) Interventions 1. prepare IV medications and prepare for possible surgical intervention especially if placental fragments are retained (D&C)

Coitus Interruptus

one of the oldest methods of contraception in which the couple still has sex, but the man withdrawals his penis right before ejaculation so spermatozoa go outside the vagina instead of inside Advantages • good choice for monogamous couples who are not available to other contraceptives Disadvantages • one of the least effective methods as its only 75% effective due to precum • pre-ejaculation fluid containing spermatozoa can leak from penis Risks • male partner has high influence and control • pregnancy, STIs

Nursing Care Plans for Latent Stage of Labor

onset of true labor contractions until cervical dilatation Deficient Knowledge Interventions 1. Assess baseline knowledge and expectations to guide needs and priorities 2. Provide and discuss options for care during the labor process (birthing alternatives), information on procedures and the normal progression of labor (fetal monitoring, telemetry) 3. Review activity level and safety precautions, role of staff members, etc 4. explain procedure, associated risk factors, and informed consent (forceps delivery, episiotomy) 5. Educate PT on breathing and relaxation techniques for each phase of labor, teach pushing positions for stage 2 to reduce stress and anxiety Fluid Volume Deficit Interventions 1. Assess mucus production, tearing amount in eyes, skin turgor (to assess hydration status) 2. Monitor intake & output and determine culture - specific gravity of urine - encourage PT to empty bladder x 1-2 hrs - if dehydration and reduced urinary output are present, this may cause urinary concentration, distended bladder, and impaired fetal descent during birth 3. Monitor vital signs, FHR, hematocrit - increased temperature/BP/HR/respirations/FHR may indicate dehydration - increased Hct will indicate dehydration 4. Provide oral care and hard candies to reduce dry mouth and provide clear fluids (broth, tea, cranberry juice, jello, popsicles) and ice chips to promote hydration and energy 5. administer bolus of parenteral fluids (IV) if oral intake is inadequate or restricted - fluid resuscitation may be necessary to counteract the negative effects of anesthesia due to dehydration or hemorrhage Fetal Injury Interventions 1. monitor progression of labor - an extended Latent Phase (1st phase) may indicate prolonged or dysfunctional labor which increases risk of infection, maternal exhaustion, srress, or hemorrhage caused by uterine atony or rupture placing the fetus at risk for hypoxia and injury 2. monitor FHR frequently (normal 120-160 bpm) - note variability and changes in response to uterine contractions; -normal FHR with average variability will accelerate or increase in response to each contraction, maternal activity, or fetal movement 3. reassess changes to FHR during ROM (rupture of membranes) with 30 min EFM strip - note any changes in amniotic fluid pressure or variable decelerations FHR after rupture as this may indicate umblical cord compression and fetal hypoxia 4. detect any problem with fetoscopy or monitor - monitor & report bradycardia, tachycardia or sinusoidal pattern - any decrease in FHR may reflect fetal decompensation, hypoxia, or acidosis from anaerobic metabolism as a result of severe variable decelerations, recurring late decelerations, or persistent bradycardia - sinusoidal pattern indicates fetal anemia or severe hypoxia leading to fetal death 5. assess maternal perineum for Chlamydial discharges, vaginal warts, or herpetic lesions 6. assess for umbilical cord prolapse - elevate fetal part or patient's hips (Sim's position) to relieve pressure off of cord and hold it there until help arrives then place PT in Deep Trendelenburg position - determine fetal engagement, position and presentation by Leopold's Maneuver - prepare for surgical intervention if needed to avoid fetal death as hypoxia or respiratory acidosis causes CNS damage after 20 min Maternal Infection Interventions 1. monitor vital signs, WBC - increase WBC indicates risk of chorioamnionitis (intra-amniotic infection) 4 hrs after membrane rupture 2. perform initial vaginal exam and assess for vaginal secretions using nitrazine paper - repeat only during contractions or during progression of labor - color change from yellow to dark blue indicates chorioamnionitis (basic amniotic fluid rupture) - positive ferning is the spontaneous rupture of membranes > 1 hr before labor and it increases the risk of chorioamnionitis 3. assess characteristics of amniotic fluid - thick, yellow, foul-smelling indicates infection 4. provide oral and parenteral fluids (IV) to promote hydration 5. encourage perineal care after elimination by changing wet underpad to eliminate risk of infection ascending the reproductive tract 6. administer cleansing enema for bowel evacuation to progress labor and reduce infection 7. administer prophylactic antibiotic (IV) to aid in protection against chorioamnionitis 8. administer Oxytocin if labor doesnt progress within 24 hr after rupture of membranes Ineffective Coping Interventions 1. assess uterine contraction/relaxation pattern, fetal status, vaginal bleeding, and cervical dilatation. 2. determine client's cultural background, coping abilities, and verbal/nonverbal responses to pain, previous experiences and antepartum preparation. 3. reinforce breathing, relaxation techniques, distractions to pain 4. Discuss types of systemic/regional analgesics or anesthetics, and discuss sedatives such as Seconal, Nembutal, or Vistaril 5. barbiturate or ataractic may be administered during early labor to promote sleep so that client is more energized for active phase of labor Anxiety Interventions 1. Assess level and causes of anxiety, preparation for childbirth, cultural background, and role of significant other/partner 2. Monitor uterine contraction pattern, BP, pulse - if BP elevated, repeat in 30 min to obtain true reading once the client is relaxed 3. provide info about psychological and physiological changes of labor while providing privacy and allow PT to verbalize feelings, concerns or fears 4. Provide continuity of care and be aware of any patient needs or preferences such as female caregivers or prohibition of men (culture) 5. diversions, breathing and relaxation methods, comfort measures, coping strategies, and conversation to pass the time 6. Prepare hospital discharge

Minipill (Progestin only)

oral pill provides same action as the combined oral contraceptives Patient Education 1. must be taken at same time each day to ensure effectiveness 2. cannot miss a pill 3. may need another form of contraception during 1st month advantages - fewer adverse effects than combined oral contraceptives - safe to take while breastfeeding disadvantages - less effective method of ovulation suppressant - increased risk of ovarian cyst - adverse effects include breakthrough, irregular vaginal bleeding, headache, nausea, breast tenderness Risks - STIs - reduced effectivness when taking medications that affect liver enzymes (Anticonvulsants, Antibiotics) - do not use if hx of breast cancer, bariatric surgery, Lupus, severe cirrhosis, or liver tumors

Pregnancy Acid-Base Balance

pH 7.35-8.45 HCO3 22-26 PCO2 35-45 PaO2 80-100 SaO2 95% +

Mittelschmerz

pain when there is a drop of follicular fluid into abdominal cavity leading to release of Prostaglandins which is a clear indicator of ovulation because the pain is felt to one side of the abdomen near the ovary

Dysmenorrhea

painful menstruation due to contractions and pain caused by release of Prostaglandins during ischemic phase of menstrual cycle

Lochia

postpartum uterine discharge occurs for 4-6 weeks after birth and consists mainly of blood and necrotic tissue from (1) large raw area on inner uterine wall area that placenta detached from (2) sloughed off endometrium which thickens during pregnancy (3) blood and mucus from the healing cervix (4) dead and necrotic tissue Normal Stages of Lochia; (1) lochia rubra -DARK RED bleeding occurs a few days after childbirth and lasts for 3-4 days -contains mainly blood, bits of fetal membrane, decidua, meconium, and cervical discharge (2) lochia serosa -PINK/BROWN and it lasts 4-10 days -contains more WBC, less RBC, wound discharge from placenta and other sites, and mucus from cervix (3) lochia alba - WHITISH YELLOW and it lasts 10-28 days -for another 1-2 weeks, yellow/white turbid fluid drains from vagina and consists of decidual cells, mucus, WBC and epithelial cells - bleeding is controlled by uterine muscle contractions immediately after delivery and takes 2 weeks to heal - maximum bleeding occurs in the first 2-3 days after birth and decreases over next 2 weeks - lochia is sterile for first 2-3 days and then becomes colonized by bacteria giving it a typical local smell which should not be confused with foul odor indicating infection - scant quantities of lochia after premature delivery; increased amount after twin pregnancy or a condition that causes uterus to enlarge over average size

Trimesters

pregnancy is divided into 3 (13 wk) parts and its important to know what occurs during each trimester in order to guide the woman in what to expect and how to identify any deviations in fetal development 1st Trimester = 8 to 12 weeks - 8 weeks is critical developmental period as embryo is most vulnerable to teratogens - fetal venous system develops 10-12 wks - basic ultrasound to visualize gestational age, anomalies (make sure to empty bladder) 2nd Trimester = 13 to 26 weeks - leopold's maneuver, quickening, fundal height, and doppler ultrasound performed at 12-14 wks - Quad Marker performed at 16 weeks to detect any neural tube defects (normal AFB 10-150) - amniocentesis performed at 15 weeks to determine fetal abnormalities, lung maturity, and abnormal quad marker, older maternal age moms - at 20 weeks, mom can feel fetal movement, FHR - at 24 weeks, fetus develops genitalia, lungs produce surfactant, and oral FTT (24-28) - at 28 weeks, fetal viability, Rhogam administered if neccessary for Rh - moms (24 to 28 weeks) 3rd Trimester = 27 to 40 weeks kick counts (10 in 2 hrs, 3x per hr) NST 32-34 wks, (reactive good = accelerate 15 beats for 15 seconds) BPP: breathing movement, limb movement, tone/flex limbs, AFI (fluid pockets), reactive NST= 8-10 desired 32wks: increased chance of survival 36wks: lanugo disappears, grp B strep 40wks: full term

PROM

premature rupture of membranes may be caused by malpresentation or an incompetent cervix PROM (chorion and amnion rupture) typically occur 1 hour before labor begins and can precipitate many potential and actual problems; one of the most serious/immediate issues is the fetal loss of defense against infection.

Abruptio placentae

premature separation of a normally implanted placenta from uterus before full term Classifications - bleeding (concealed or apparent) and abruption (partial or complete) Risk Factors - hx of c-section - uterine abnormalities - abdominal trauma (mva, domestic violence) - renal or vascular disease such as preclampsia or hypertension which raises BP - advanced maternal age (above 35) - smoking, alcohol, drug use - multiple gestation - preterm PROM Complications maternal hemorrhagic shock, DIC, uterine rupture and even death along with fetal complications that depend on severity of abruption and fetal maturity; hypoxia, anemia, growth retardation, or death Sx: - sudden onset of consistent pain Diagnosis - ultrasound is used to determine if placenta is intact or detached Treatment - vaginal delivery is recommended over c-section for small abruptions Interventions - monitor for symptoms of shock and monitor FHR - place PT on bed rest - prepare for c-section if necessary - monitor for postpartum hemorrhaging - observe for any signs of DIC

gestational age vs fertilization age

prenatal age of developing fetus calculated by LMP vs prenatal age of developing fetus calculated by date of conception (2 wks less than gestational)

PPROM

preterm premature rupture of membranes, no labor

Hormonal Methods

prevents contraception by altering levels of female hormones Estrogen & Progesterone by introducing new levels of the hormone into the body through pills, patches, implants and other methods • must remember to take pill daily or change patch weekly • implant may cause anxiety • quick, convenient alternative to hormonal methods is the depo injection as it lasts for 12 weeks PILLS - combined oral contraceptives - emergency oral contraceptives - progestin-only (Minipill) PATCHES - transdermal patch IMPLANTS - IM injectable progestins - SQ implantation progestins - vaginal ring - intrauterine device (IUD)

Prenatal Visits: Education

progresses with nursing process A • assess history and cultural needs D • diagnose knowledge deficits P • plan goals and priorities I • identify expected outcomes of education E • evaluate knowledge gained educate patient on the changes during pregnancy • maternal changes • anticipating signs and symptoms • implement interventions to help coping with pregnancy

True Labor

regular painful uterine contractions with increasing frequency and intensity that cause gradual cervical change (dilation, effacement) Contractions • stronger, last longer, and more frequent (begin irregular then become regular intervals) • intervals gradually shorten • start in the lwoer back and sweep around to abdomen • increase intensity with walking and continue despite comfort measures (no effect from sedation) Cervix (assessed by vaginal exam) • as cervix moves to anterior (front) progressive dilation, effacement, and bloody show presents Fetus • presenting part of fetus engages in pelvis

Post-Abortion Teaching

report increased bleeding take temperature x 8 hrs for 3 days take oral iron supplement if prescribed resume sexual activity as recommended return to provider for check ups and contraception information pregnancy can occur before the first period returns after the abortion process

Antepartum Danger Signs

require prompt reporting and include - suggen gush of fluid from vagina - leaking of anmniotic fluid - vaginal bleeding - blurred vision - dizziness - abdominal/epigastric pain - rapid weight gain - elevated blood pressure (hypertension) - persistant vomiting - edema of face or hands - severe persistant headache - chills with fever - painful/reduced urination

APGAR score 0-3

severe distress = requires immediate interventions 1. CPR

positive signs of pregnancy

signs that are only explained by pregnancy • auscultation of FHR 110-160 bpm by Doppler or fetalscope after 12 wks *make sure to distinguish btw maternal HR • inspection of fetus by ultrasound • palpation of fetal movement in uterus

Vaginal Ring

silicon ring is inserted into the vagina and surrounds the cervix to release a combination of Estrogen and Progesterone continuously Patient Education 1. ring stays in place for 3 weeks and then is removed on the 4th week for menstruation to begin 2. always insert the ring on the same day of the week per month Advantages • no fitting required • same effective rate as OC (oral contraceptive pills) • reduces the risk of forgetting to take the pill • vaginal route of delivery increases availability of hormones so a lower dose is required and it decreases the risk of adverse effects • as soon as ring is removed, the woman is fertile Disadvantages • adverse effects - vaginal irritation - increased vaginal secretions - headache - weight gain - nausea - discomfort during sex • ring can be removed for 3 hrs w/o compromising effectiveness Risks • STIs, risk of thrombus, HTN< stroke, MI

APGAR score 4-7

slight distress = interventions are needed to promote oxygenation 1. gently stimulate by rubbing infant's back while administering oxygen 2. Determine if mom was using narcotics; stand by with Narcan if necessary

Transcervical Sterilization

small flexible aggents are inserted through vagina and cervix into fallopian tubes to develop scar tissue and block conception Contraindication - postpartum Patient Education 1. normal activities resumed after 1 day of procedure 2. re-exam after 3 months to ensure tubes are blocked Advantages • quick procedure with no anesthesia needed - nonhormonal birth control - 99.8% effective Disadvantages • permanent birth control method • delay effectiveness for 3 months so alternative BC must be used until blockage of fallopian tubes is confirmed at follow up appt • changes menstrual patterns Risks • STIs • perforation • unwanted pregnancy may occur if patient has unprotected sex within first 3 months • increased risk of ectopic pregnancy

contraceptive sponge

small round polyurethane sponge containing spermicide thats designed to fit over cervix Patient Education 1. must be left in place for 6 hrs after sex and provides protection for 24 hrs Disadvantages - 1 size fits all Risks - STIs

Hegar's Sign

softening of the lower uterine segment

abortion

spontaneous/induced (elective) spontaneous is also called "miscarriage"

Contraception

strategies or devices used to manage fertility or prevent conception (fertilization) which is the fusion of female eggs with male sperm, in an attempt to prevent pregnancy • contra - against conception; prevents motile sperm's ability to fertilize egg/ovum from 48-72 hrs after ovulation • aims at spacing out pregnancies and choosing proper time for conception and childbirth • do not use in patients with medical conditions such as severe/chronic maternal, cardiac, renal or liver diseases 1. Physiological Contraception (Natural Family Planning aka fertility awareness) 2. Barrier Contraception 3. Hormonal Contraception 4. Intrauterine Contraceptive Device (IUD) 5. Transcervical Sterilization (Permanent Contraception) Interventions 1. assess clients' need, desire, preference for contraception 2. discuss benefits, risks, and alternatives for each method 3. pregnancy test to confirm/deny current status 4. assess PT's obstetric history, any past STDs, status of past pregnancies, and if they have used a family planning method that was NOT effective 5. assess sexual practices of the PT, frequency, and number of sexual partners along with any allergies to latex 6. postpartum discharge instructions - discuss future contraception plans for 6 weeks after birth 4. support PT decisions or joint decisions Outcome: preventing pregnancy until a desired time

presumptive signs of pregnancy

subjective signs that could indicate pregnancy or could result from other factors (infection, stress, peristalsis) • amenorrhea (missed/absent period) • fatigue, drowsiness • nausea/vomiting • urinary frequency • breast changes (enlargement, tenderness, darkened areola, enlarged Montgomery glands) • quickening (fluttering or movement in abdomen/stomach) *not felt until 16-20 wks & indicate fetal movement • uterine enlargement • deepening pigmentation (darkening)

Preterm Labor

term - 38-40 wks; preterm - before 38 wks labor that occurs under 37 weeks gestation - ability to diagnose reduces risk of morbidity for preterm deliveries and avoid interventions who will likely deliver full term - risk factors for preterm deliver include - smoking - STIs - substance abuse - under 17 or over 35 - low socioeconomic status - lack of prenatal care - preclampsia - cervical insufficiency (cercix cant stay closed, and opens early in 2nd trimester so it requires cervical stitch) - DM expected findings - contractions - pressure - back pain - premature rupture of membranes (ROM) know what time, what color, was there odor (water breaking) Interventions 1. increase fluids (dehydration may cause preterm labor) 2. place PT on modified bed rest (strict bed rest may increase risk of clots) 3. pelvic rest (no intercourse, nothing in vagina) 4. monitoring fetus 5. side lying position for PT Medication Management 1. Nifedipine - Ca channel blocker supresses contrations through inhibiting calcium in smooth muscles - monitor for orthostatic hypotension - may cause headache, flushing, 2. Magnesium Sulfate - used for preclampsia (depresses CNS and helps prevent seizures), preterm labor (smooth muscle relaxer), and neuro protection - also on for 24 hr after delivery -monitor for magnesium toxicity (normal level 1.4-2.5) so normal levels are approx 6 and toxic is 8 and above (lethargic, hard to arrouse, decrease RR less than 12) - stop infusion give calcium glunconate administer magnesium sulfate

quickening

the first movement of the fetus in the uterus that can be felt by the mother usually at 16-20 weeks

Normal Effects of Pregnancy: Family

the infants bonding and integration into the family should be begin with pregnancy and continue into 4th Stage of Labor and hospitalization after delivery Impact of Pregnancy on Mother • 4 maternal tasks must be accomplished during pregnancy according to Reva Rubin (1) see safe passage for herself and fetus (2) accept herself as mother of fetus (3) learn to give and receive care and concern for others (4) commit to the child as pregnancy progresses Attaining Maternal Role • the mother adapts psychologically and adjusts to the maternal role beginning in pregnancy through commitment, attachment, and preparation of birth • first 2- 6 wks after birth, the mother focuses on caring for the newborn during this period of acquaintance and physical restoration • maternal identify is accomplished by 4 months after birth Phases of Maternal Role 1. Dependent (taking in phase) occurs 24 to 48 hrs after birth and the mother focuses on meeting personal needs, relies on others for assistance, is excited and talkative, and needs to review birth experience 2. Dependent-Independent (taking hold phase) occurs from 72 hrs to several weeks after birth in which the mother focuses on giving care, improving as a caregiver, wants to take charge but accepts help from others, wants to learn, and deals with physical/emotional discomforts (baby blues) 3. Interdependent (letting go phase) occurs weeks to months after birth in which the mother focuses on the family unit and resumes role as mother, partner, and individual Developing Father-Infant Bond • accepting of the + pregnancy result when it is announced and confirmed in order to strengthen the family • adjustment • focus and active planning for participation in the birth process • father adapts to paternal role by - skin to skin contact holding the infant and maintaing eye contact - observes infant for similar features to his own to validate his claim - talks, sings and reads to infant Transition to Fatherhood 1. expectations and intentions - the father desires an emotional deep connection with newborn 2. confronting reality - father discovers that expectations may not be maet and is sad, frustrated or jealous but embraces involvement in parenting 3. creating role of involved father - decides to become actively involved in infant care 4. reaping rewards - father reaps rewards of infant smile and feels complete Assessment • nurse can assess bonding and integration • promote baby friendly care by delaying nursing procedures and interventions for first hour after birth, promoting immediate skin to skin contact between mother and baby, and encouraging breast feeding • assess PT condition after birth, observe adaptation process to motherhood, and assess emotional readiness for infant care or how comfortable PT appears giving care • assess for bonding behaviors or behaviors that impair bonding, and assess for maternal mood swings • assess siblings for positive or negative responses to sibling Nursing Interventions to Promote Bonding 1. skin to skin bonding immediately after birth 2. promote rooming-in with quiet and private environment 3. promote early initiation of breastfeeding 4. teach client about infact care 5. encourage cuddling, bathing, feeding, diapering and inspection 6. provide praise and support for parents 7. encourage parents to express feelings, fears, and anxieties for caring for the infant 8. provide father with education and encourage hands on approachr 9. take siblings on tour of OB units Impaired Parenting or Family Bonding • emotional detachment or inability to care for infant places infant at risk for neglect and failure to thrive • failure to bond increases infants risk of emotional or physical abuse Risk Factors for Impaired Bonding - newborn physical conditions (prematurity, congenital anomalies) - maternal emotional or physical conditions (unwanted pregnancy, adolescent pregnancy, history of depression, difficult pregnancy or birth) - culture - maternal age - socioeconomic status Nursing Interventions 1. emphasize verbal/nonverbal communication skills 2. assess parenting skills and support system 3. encourage grandparents and other family members to offer support 4. provide home visits and group sessions regarding infant care and parenting 5. offer information on social networks for support system or assistance 6. outreach programs on self-care, parenting interactions, child injuries and failure to thrive 7. notify programs and interventions to prevent serious complications from occurring

Newborn Assessment: Thermoregulatory Ability

the newborn's ability to regulate body temperature is poor so first, place the baby skin-to-skin and then move on to placing the newborn under the radiant warmer to maintain or improve body temperature

Placenta-Crossing Substances

the placenta functions as a fetomaternal organ with 2 components; fetal placenta (Chorion frondosum) that develops from the same blastocyst that forms the fetus and the maternal placenta (Decidua basalis) which develops from the maternal uterine tissue "WANT My Hot Dog" W - wastes A - antibodies N - nutrients T - teratogens M - microorganisms H - hormones / HIV D - drugs

Cervical Cap

thin soft rubber cap that fits snugly around the rim of the cervix and can stay in place for up to 48 hrs Contraindications - hx of toxic shock syndrome - abnormal Pap Smear results Patient Education 1. inserted 6 hrs before sex, and MUST be left in for 6 hrs after sex, MUST be removed within 38 hrs 2. replace cervical cap every 2 yrs, and refit after delivery, weight fluctuation or gynecological surgery 3. wash with mild soap & warm water Disadcantages • 3 sizes Risks • STIS • increases risk of TSS and allergic reaction

Missed Abortion

uterine bleeding stops, brown vaginal discharge begins, membranes are intact, cervix is closed so no POC expelled, but no FHR present because the fetus died in utero but was not expelled so uterine growth stops and early pregnancy symptoms dissapear Treatment - POC and fetal parts must be evacuated from the uterus as it may lead to infection (sepsis) - pregnancy <12 wks, evacuate by D&C - pregnancy > 12 wks, administer Mifepristone RU then 36 hrs later Misoprostol x 2 hrs OR Prostaglandin vaginal suppositories x 3-6 hrs

Inevitable Abortion

uterine contractions cause cervix to dilate and membranes to rupture resulting in bleeding and cramping, FHR present, no POC expelled yet but is coming - PT must be placed on bed rest and monitored for natural evacuation of uterus (complete/incomplete)

Postpartum changes

uterine involution lochia flow cervical involution reduced vaginal distention alteration in ovarian function & menstruation alteration in CV urinary tract breast GI changes greatest risk in postpartum is hemorrhage, shock, infection breastfeeding stimulates endogenous oxytocin which causes stronger more coordinated contractions and milk ejection prolactin is responsible for milk production assessment VS, uterine firmness, pain, position, location of fundus compared to umbilicus, amount of vaginal bleeding assessed x 15 min for first 1-2 hours after birth (temp every 4 hours) average blood loss (300-500 mL) vagina and 500-1000 mL (c-section) 500 mL or more of PPH in vaginal ddelivery 1000 mL or more PPH in cesearean birth during first 4-7 days, WBC values between 20,000-25,000 (20k-25k) as mother remains hypercoagulable state for 2-3 weeks postaprtum and must be monitored for thrombosis Rho(D) immunoglobulin (Rhogam) thermoregulation - drops in 1st 2 hours after birth B - breasts U - uterus B - bowel & GI function B - bladder L - lochia (rubra, serosa, alba phases, amount) E - epiosotomy, emotions

hepatitis B

vaccine given to newborns

Lactation Amenorrhea Method

women is able to suppress ovulation and fertility through exclusively breastfeeding an infant Disadvantages • not an effective birth control method if infant is not EXCLUSIVELY fed by breast milk • only lasts for 3 months duration while exclusive breastfeeding, then after additional contraception will be required

Jaundice

yellowing of the skin and the sclera (white) of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood due to breakdown of RBC high amounts of bilirubin can cause brain damage - kinictoris - most common in premature babies physiologic jaundice (transient, immature livers, breastfeeding) can see in first 24 hr after birth from blood incompatibility, prematurity assess - transcutaneous bilirubin meter (head and chest) - sx: sleepy, lethargic due to jaundice - feed x 3 hrs to see if urinary/digestion system is working properly (excretion) - put under ultraviolet light to break down bilirubin [cover eyes, keep baby naked with diaper]

GTPAL

• Gravida - total # of pregnancies • Term - # of pregnancies after 38 wks • Preterm - # of pregnancies before 38 wks • Abortions/miscarriages - # • Living - # of living children ex: A woman's GTPAL is 31011 G - 3 (current pregnancy + 2 prior) T - 1 (1 full term pregnancy) P - 0 (0 preterm babies) A - 1 pregnancy ended in abortion or miscarriage L - 1 child is living

Prenatal Visits: Maternal Physical Exam

• assess general health of woman (baseline weight and vital signs like BP will be monitored throughout pregnancy) • nutritional status • calculate total number of pregnancies (gravida) • identify any current physical, social or emotional issues • physiological status (signs or symptoms of pregnancy) • determine the estimated date of delivery (DOD) • urine culture for glucose, protein or leukocytes • Pelvic Exam to evaluate size, adequacy and condition of pelvis & reproductive organs and assess signs and symptoms of pregnancy

Common Discomforts of Pregnancy

• backache • constipation • breast tenderness • nasal stuffiness • fatigue • heartburn • hemorrhoids • leg cramps • nausea • vaginal discharge • varicose veins

Normal Effects of Pregnancy: Integumentary and Skeletal Systems

• body alterations and weight gain • cholasma: increase of pigmentation on face • linea nigra: dark pigmentation from umbilicus extending into pubic area • striae (stretchmarks) may develop due to abdominal enlargement with fetal growth on abdomen or thighs • spider nevi • sweat and sebaceous glands become more active to dispel heat from mother and fetus • postural changes such as lower back aches, relaxation of pelvic joints, softening of uterine ligaments, waddling gait, and change in center of gravity may cause balance issues and result in FALL RISK *important for nurses to include in prenatal education and promote safety interventions

Nutrition for Lactation

• calorie intake should be 500 calories more than non-pregnant RDA • protein 65 g/day • calcium 1200 mg/day • iron 30 mg/day • continue vitamin supplements • limit caffeine and alcohol as this can be transferred through breast milk • drugs should be carefully considered based on consult with provider and drug classification

Exercise for Pregnancy

• determined by maternal cardiac status and feo-placental reserves • important to assess exercise practices • pregnant woman should MAINTAIN fitness level of pre-pregnancy but do not improve fitness or maximize weight loss Factors of Exercise on Pregnant Women • increase temperature impacts fetal circulation and cardiac function (FHR) • hypotension will reduce blood flow to fetus • hormones may change oxygen consumption and Epinephrine, Glucagon, Cortisol, Prolactin, and Endorphin levels • cardiac output may cause peripheral pooling of blood to decrease cardiac reserves needed for exercise • moderate exercise has many health benefits such as - positive self image - decreased discomfort - more rapid return to prepregnant weight after delivery Nursing Guidelines • always start with warm up and finsih with cool down • do not exceed recommendations for moderate exercise • exercise and balanced diet is beneficial • recommend eating 2-3 hours before exercise or immediately after • avoid going to changes in water depth or altitudes • avoid overhearing by increasing fluid intake • rule of thumb; "you should be able to talk while exercising"

Normal Effects of Pregnancy: Endocrine System

• dramatic increase in hormones affects all body systems • Progesterone and Estrogen production are essential to maintaining pregnancy and preparing the body for delivery • hormones are produced by Corpus Luteum and then later by placenta which temporarily morphes into endocrine organ that functions by producing Progesterone and Estrogen, HcG, human placental lactogen and prostaglandins

Prenatal Care Goals

• ensure safe birth by promoting nutrition, exercise, appropriate weight gain and good maternal health, while also reducing risk factors • teach health habits that can be continued into postpartum and lifelong • educate self-care for pregnancy and provide physical care • prepare parents for parenthood as it is a life changing event

Prenatal Visits: Schedule

• for an uncomplicated birth, prenatal schedule includes - every 4 wks (conception-28 wks gestation) - every 2 or 3 wks (29 wks-36 wks gestation) - every week (36 wks - 40 wks gestation) • ideally, preconception care should begin before pregnancy is confirmed to ensure optimal health prior to conception - identify risk factors that could negatively impact the pregnancy - ensure nutrition and immunizations - ensure adequate intake of folic acid and prenatal vitamins to prevent neural tube defects of fetus that occur during early pregnancy 1st Prenatal Visit • gestational age may vary • determine estimated date of delivery (DOD) • obtain complete medical history (ROS, support) sysytems • maternal physical exam (baseline weight, vitals, pelvic exam) - identify any issues that could affect the mother/fetus - ensure healthy pregnancy and delivery of healthy infant • establish birth plan by discussing birthing options and pain control • lab tests (Hgb, Hct, WBC, blood type, Rh factor, rubella titer, urinalysis, renal function test, Pap Smear, cervical culture, HIV antibody test, Hepatitis B surface antigen, toxoplasmosis, RPR or VDRL) • early and regular prenatal care is important in reducing incidence of low birth weight and morbidity in infants and mothers *** Ongoing Visits • monitor weight, BP, and urine • monitor any presence of edema • monitor fetal development • FHR detected by ultrasound and hearrd by doppler in late 1st Trimester so listen at midline right above pubis symphysis • measure fundal height starting in 2nd Trimester • fundal height in cm is same as gestational age from 18-30 wks • fetal health assessment or assess for fetal movement begins 16-20 wks • provide education for self care of discomfort and concerns of pregnancy (nausea, vomiting, fatigue, backache, varisocsities, heartburn, sexuality, activity/exercise)

Normal Effects of Pregnancy: GI System

• hormonal changes or growing uterus puts pressure on abdominal cavity and displaces stomach contents and intestines which may cause nausea or vomiting • increase salivary secretions may cause oral mucosa to bleed more easily and become tender • increased appetite and thirst • decreased gastric acid secretions cause delayed stomach emptying and peristalsis which increases the risk of constipation • constipation is also increased due to mother taking Iron in prenatal supplements • Progesterone & Estrogen relax the muscle tone of the gallbladder causing bile salt retention which may cause Pruritis (itchy dry skin)

Normal Effects of Pregnancy: Psychology

• identify and manage stressors in mother's life to promote positive outcomes in pregnancy • nutritional needs and patterns related to age, culture, ethnicity, finances, and etc should be discussed during prenatals

Nutrition for Pregnancy

• important for nurses to teach that pregnant women are NOT eating for 2 and they do not require double the calorie intake • nutritional intake should be assessed during prenatal visit based on woman's pre-pregnant weight and quality of nutrients (calorie content and value) Body Image • 1st Trimester; physiological signs of pregnancy are not displayed just yet so many women look forward to the noticeable changes • 2nd Trimester; be careful what you wish for as there are rapid physical changes that include abdominal and breast enlargement, stretch marks and darkening of skin, back and leg discomfort, fatigue, and loss of balance which could cause negative body image Nutrition Education - read food labels and choose foods that are nutrient dense (complex carbs, high protein) rather than empty calories and simple carbs (sugars, soda) - use food pyramid as a guide - recognize cultural differences in food and diet • Maternal Diet - explain the importance of eating a well-balanced diet and taking supplements especially if nutritional deficits are present to ensure that nutritional deficiencies do not occur during the first weeks of pregnancy • Weight Gain • should be based on woman's pre-pregnancy weight and BMI status - normal weight & BMI = gain 25-35 lbs - overweight = gain 11-25 lbs - obese = gain 11-20 lbs - underweight = gain 28-40 lbs - multifetal pregnancy (twins) = gain 4-6 lbs for 1st Trimester and 1.5 lbs per week in 2nd & 3rd Trimester for a total of 37-54 lbs • Nutritional Requirements - increase kcal by 300 per day to include - iron 30 mg/day - protein 60 g/day - folic acid 400 mcg/day (obtained via supplements) - calcium 1200 mg/day • Recommended Dietary Allowance (RDA) or Recommended Dietary Intake (RDI) • no need to exceed the upper limits of food and supplements or toxicity can occur so important to include this in prenatal education • Special Nutrition Considerations - pregnant adolescents may need support and education due to importance of body image at this age - high sodium intake may cause fluid retention - vegetarian diet may lack protein needed - pica or weird cravings of non-foods like clay, starch and etc - lactose intolerance may lack calcium needed - culture has large importance on food - Gestational Diabetes Mellitus diagnosed during pregnancy by glucose tolerance test and if present, its important to educate mothers on even calorie distribution (3 meals, 3 snacks per day) *stress importance of snack before bed to combat night time hypoglycemia

Normal Effects of Pregnancy: Respiratory System

• increase oxygen consumption by 15% • diaphragm rises 4 cm or 1.6 inches due to enlargement of abdomen contents • ribs begin to flare • size of chest enlarges during 3rd Trimester to allow for lung expansion and uterus pushes upward • respiratory rate increases and total lung capacity decreases • dyspnea or SOB may occur due to uterus pushing against diaphragm, but this will resolve with fetal descent into pelvis during delivery • increased Estrogen levels may cause edema or swelling of mucous membranes in nose, pharynx, mouth and trachea • woman may complain of nasal stuffiness, voice changes and epistaxis (nose bleed)

Normal Effects of Pregnancy: Cardiovascular System

• increased blood volume by 45% provides for exchange of nutrients, oxygen and waste within placenta, accounts for needs of expanded maternal tissues, and acts as a reserve for blood loss at delivery • pulse rate increases by 10-15 bpm at 32 wks • maternal heart changes shape and size resulting in cardiac hypertrophy to accommodate excess blood volume and cardiac output, but will return to normal after delivery • maternal heart sounds (S1, S2, S3) easily heard after 20 wks • palpitations and murmurs • dilutional anemia (psudeoanemia) • increased clotting factors in 2nd to 3rd trimester may increase the risk of thrombus formation • nurse may auscultate fetal heart rate (FHR) 110-160 bpm with reassuring accelerations to indicate intact fetal CNS • 1st Trimester; maternal BP is same as pre-pregnancy • during pregnancy, systolic may have slight increase and at 24-32 wks, diastolic may decrease but will gradually return to normal • BP is affected by positioning so there is a risk for Orthostatic Hypotension or Supine Hypotension Syndrome - aka aortocaval compression or Vena Cava Syndrome; BP drops as pregnant woman lies on her back in supine position due to the heavy weight of the uterus compressing against the inferior vena cava and reducing venous return to the heart which may lead to fetal hypoxia (lack of O2) sx: dizziness, lightheadedness, faintness, agitation, pale and clammy skin - encourage PT to turn onto left lateral side to alleviate pressure on vena cava, or lay supine with wedge under one hip

Immunizations for Pregnancy

• live virus vaccines are CONTRAINDICATED • Thimerosal should NOT be given due to mercury poisoning • avoid getting pregnant for 1 months after MMR vaccine • certain vaccines or immunizations are allowed during pregnancy and recommended such as the Influenza vaccine and TDAP

Bacterial Vaginosis

• most common vaginal discharge during pregnancy • caused by decreased lactobacilli in vagina which allows the proliferation of microbes such as increased bacteroids and other anaerobic microbes • women may notice this as a more than usual amount of "milky white discharge" accompanied by a "fishy or foul smelling odor" with no other clinical symptoms • important for nurses to screen for bacterial vaginosis during prenatal visits as it is associated with Preterm Labor

Prenatal Visits: Maternal Health History

• obstetric (previous pregnancies, outcomes, and any issues or diagnoses) • menstrual (date of LMP*, reglar/irregular flow or cycle, premenstrual sx, spotting since LMP) • contraception (past/present use, IUD devices) • medical/surgical (recent illness/conditions, pelvic or abdominal surgeries or injuries, comorbidity DM, infections, immunosupressed, Hep B, Rubella which may affect pregnancy) • family (genetics, paternal/maternal traits) • psychosocial (relationships, support, finances, culture, mental/emotional response to pregnancy) • environmental (hazards, exposures, conditions) • nutrition (dietary assessment) • lifestyle (nutrition, dietary assessment, exercise, drug/alcohol abuse, drug use, medications, hygiene)

Prenatal Visit: Health Care Providers

• obstetricians • family practice physicians, • certified nurse-midwives • nurse practitioners

Prenatal Visits: Routine Assessments

• risk factors (known and assess for any new) • vital signs adn weight (expected or normal gain) • urinalysis (protein, glucose, ketones) • blood glucose screening (gestational DM) • fundal height assessment (fetal growth and amniotic fluid volume) • Leopold's Maneuver (assess presentation or positioning of fetus) • fetal heart rate (FHR) after 12-14 wks gestation • nutritional intake • any discomforts or problems since last prenatal visit

Normal Effects of Pregnancy: Urinary System

• urinary system excretes the waste products of both the mother and the fetus • glomerular filtration rate of kidneys increases due to hormones and increase in blood volume and metabolic demands • amount of urine production remains the same. but urinary frequency is common • glycosuria (glucose in urine) or proteinuria (protein in urine) are more common and must be monitored during prenatal visits through urine specimens • water retention caused by increased blood volume may dissolve fetal nutrients leading to edema in lower extremities and sodium retention • Progesterone decreases the muscle tone of the renal pelvis and ureters causing urinary stasis • women become more susceptible to urinary tract infections (UTIs)

Study Guide for Stages of Labor

• what occurs in each stage • identify each stage based on description • cervical dilation ranges in each phase of stage 1 and contraction length and frequency • nursing interventions for each stage • delivery mechanisms (Duncan or Schultz) • changes in perineum that the baby is about to be delivered • signs placenta is about to be delivered

Normal Effects of Pregnancy: Medication Use

•pregnancy affects metabolism of medication and drugs • some may cause medications to have subtherapeutic levels • parental medication (IV) may be absorbed more rapidly due to increased cardiac output • drugs may be transferred across placenta or to newborn through breast milk • important to be aware of the classifications of drug use - Class A; no risk to fetus in any trimester - Class B; risk to animal, but no human studies - Class C; possible risks to fetus - Class D; definite risks to fetus - Class X; exposure results in fetal abnormalities