final
application of cold
Cold application such as cold cloths, frozen gel packs, or ice packs applied to the back, the chest, or the face during labor may be effective in increasing comfort when the woman feels warm. They also may be applied to areas of musculoskeletal pain. Cooling relieves pain by reducing the muscle temperature and relieving muscle spasms
impaired liver function preeclampsia
Elevated blood levels of liver transaminases to twice the normal concentration
s&sx hypothyroidism
Fatigue Increased sensitivity to cold Constipation Dry skin Weight gain Puffy face Hoarseness Muscle weakness Elevated blood cholesterol level Muscle aches, tenderness and stiffness Pain, stiffness or swelling in your joints Heavier than normal or irregular menstrual periods Thinning hair Slowed heart rate Depression Impaired memory
listeriosis fetal consequnces
Fetal Consequences severe and fatal 20-30% of the time in newborns-microabcesses and granulomas. *60% recover *12% longterm neurologic issues
Herpes Simplex 2 fetal consequences
Fetal Consequences: fetal death, neonatal herpes, eye/throat infections, damage to CNS
CMV fetal consequences
Fetal Consequences: most common virus transmitted to the fetus 80 to 90% asymptomatic at birth 25% develop sequelae (LBW, microcephaly, chorioretinitis) most common cause of congenital hearing loss primary infection during pregnancy=most transmissible; secondary infections rarely effect fetus most dangerous during 1st trimester
CMV maternal consequences
Fetal Consequences: most common virus transmitted to the fetus 80 to 90% asymptomatic at birth 25% develop sequelae (LBW, microcephaly, chorioretinitis) most common cause of congenital hearing loss primary infection during pregnancy=most transmissible; secondary infections rarely effect fetus most dangerous during 1st trimester
basis for fetal monitoring
Fetal compromise: The goals of intrapartum FHR monitoring are to identify and differentiate the normal (reassuring) patterns from the abnormal (nonreassuring) patterns, which can be indicative of fetal compromise.
parvovirus fetal consequences
Fetal consequences: usually not a problem, associated with SAB, IUFD 1/2 of pregnant women are immune rarely: severe anemia, miscarriage (<5%)
Hepatitis B assessment and treatment
First prenatal visit No specific treatment With immediate exposure - HBIG and vaccine series Vaccination for all women who are non-immune and at risk Treatment for newborns: HBIG and vaccine Baby should receive HBIG + 1st HBV vaccination immediately (within 12 hours) Breastfeeding: recommended
Bacterial Vaginosis treatment
Flagyl Flagyl is not recommended in pts that are breastfeeding, in the case of active breastfeeding another abx is indicated
mastitis
Flu like symptoms Breast pain, tenderness, reddened area Tx: Abics (doxy), rest, warm compress, adequate fluid and nutrition Breastfeeding and/or pumping to encourage emptying of that side
preeclampsia
HTN> 140/90 and <160/110 + renal involvement Proteinuria 3g/24 hours OR protein/creatinine ratio ≥0.3 OR Urine dipstick +1 protein Development of hypertension and proteinuria in a previously normotensive woman after 20 weeks of gestation or in the early postpartum period. In the absence of proteinuria, the development of new-onset hypertension with the new onset of any of the following: thrombocytopenia, renal insuffi¬ciency, impaired liver function, pulmonary edema, or cerebral or visual symptoms
anencephaly
absence of both cerebral hemispheres and overlying skull incompatible with life
Pulse/Heart Rate apgar 0
absent
Respiration apgar 0
absent
burr cells or schistocytes preeclampsia
absent
4 types of variability
absent minimal moderate marked
Activity/muscle tone apgar 2
active movement
contraindications to epidural blocks
active or anticipated serious maternal hemorrhage maternal hypotension maternal coagulopathy (platelets ≤ 100,000/ml) Infection at the injection site Increased intracranial pressure Allergy to the anesthetic drug Maternal refusal or inability to cooperate Some types of maternal cardiac conditions
prolactin milk
acts upon milk producing cells to produce milk
phases of parental grief for perinatal loss
acute distress intense grief reorganization involves all members of the family
Necrotizing Enterocolitis (NEC)
acute inflammatory disease of the GI mucosa 1. Acute inflammatory disease of the GI mucosa commonly complicated by bowel necrosis and perforation
chlamydia maternal complications
acute salpingitis, PID, ectopic pregnancy, tubal factor infertility, HIV infection, preterm labor, PROM, LBW
gonorrhea maternal complications
acute salpingitis, chorioamnionitis, maternal postpartum sepsis, amniotic infection syndrome
alcohol
affects MER readily passes into breatmilk 2 hr windom
nipple ejection reflex
aids propulsion of milk through ducts a. In response to oxytocin, the myoepithelial cells around the alveolus contract forcing the milk into the milk cuts. b. MER can occur several times during a feeding.
nursing considerations preparing for the birth second stage documentation
all observations, VS, FHR and patter, progress of labor, interventions, woman's response is done concurrent with care
third stage of labor passive management
allow placenta to separate what for signs of detachment
do not give opioid agonist/antagonist to women with opioid dependence. Why?
an opioid antagonist (naloxone [Narcan]) is contraindicated for opioid—dependent women because it may precipitate abstinence syndrome (withdrawal symptoms). For the same reason, opioid agonist—antagonist analgesics such as butorphanol (stadol) and nalpuphine (Nubain) should not be given to opioid—dependent women.
dysfunctional labor patterns fetal causes
anomalies, excessive fetal size, malposition
calcium gluconate
antidote to elevated magnesium levels
common nursing diagnoses for SAB
anxiety deficient fluid volume (due to bleeding) acute pain risk for infection
A (Apgar)
appearance-skin color
22 week
approximately 10% survive
hyperpigmentation
areola linea nigra--line down the middle, fades a few weeks after delivery, helps baby crawl up to the breasts chloasma or melasma (estrogen, melanocyte--stimulating hormone [MSH]), cross reaction with the structurally similar beta hcg)
supine hypotensive syndrome or vena caval syndrome
as the uterus enlarges it compresses the inferior vena cava (b/c of the increase in the size of the uterus) with associated reduction in blood pressure should be semi supine, roll them over on their side if they become woozy
uterine changes hegar sign
as the uterus grows in early pregnancy and flexes forward towards the belly exaggerated flexion
Perineum—Perineal Discomfort assessment
assess for redness, warmth, swelling, discharge
shoulder dystocia risks to fetus
broken clavicle neurologic injury ( nerves in the shoulder)
forceps/vacuum delivery prerequisites
cervical exam Empty bladder Expectation of success (no CPD, adequate pelvis vs. size of baby)
Latent Phase (first stage of labor) typical assessment findings
cervix 0-3cm contractions mild-moderate in intensity; 5-30 min apart, 30-45 seconds in duration increased mucus discharge/bloody show excited, talkative eager lasts approximately 6-8 hours
Active phase (first stage of labor) assessment findings
cervix 4-7 cm contractions moderate to strong regular contractions: 3--5 minutes apart, 40-70 seconds in duration phase lasts 3-6 hours increased blood show serious, doubtful, worried
emergency CS hemodynamic stability
change in Sao2 late sign of hypoxia in mom bp is probably better indicatior
probable (objective sings of pregnancy
changes observed by provider/examiner braxton hicks ballottement goodell's sign chadwick's sign hegar sign + pregnancy test
GI congenital anomalies
cleft lip/palate esophageal atresia tracheosophageal fistula omphalocele gastroschisis imperforate anus
factors that affect lactogenesis
discomfort/pain supply and demand infant maternal environmental
PE ubilical cord
dryness 3 vessels base of cord for drying hernia
Herpes Simplex 2 transmission
exposure during childbirth (30-50% transmission rate in women who acquire genital herpes near time of delivery, less risk if contracted earlier in pregnancy (<1%) sexual activity vaginal
Transition phase (first stage of labor) assessment findings
hardest part of the first stage of labor cervix 8-10 cm 20-40 minutes, strongest, shortest phase blood show increases
cephalic vertex presentation
head comes first 96% of births will feel the occiput at the internal os of the cervix
turtle sign
head delivers and immediately snaps back onto the perineum because the shoulder is wedged behind the pubic bone classic sign of shoulder dystocia
administration of medication pharmacological interventions
intravenous route intramuscular route regional (Epidural and spinal anesthesia
extension
intrnal rotation complete, head passes the symphysis pubis = crowing baby extends head head is extending out of the vagina
uterus involution
involution is the process of uterus returning to its non--pregnant state (normal position in the pelvic cavity and regains its muscle tone)
perineal lacerationsfourth degree
laceration that extend completely though the rectal mucous, disrupting both the external and internal anal sphincters
perineal lacerations first degree
laceration that extends through the skin and vaginal mucous membrane but not the underlying fascia and muscle
perineal lacerations third degree
laceration that involves the external anal sphincter
soy-based formula
lactose or cow's milk-protein intolerant Eg. Isomil
LGA
large for gestational age a. Weight above the 10th % b. Can be preterm, term, or post term
normal bladder findings diuresis
large volume of urine a. Hold onto fluid during urine during pregnancy and start diuresing large amounts of urine following birth
IgM
largest activated first during infection, first responder i. Fetus is capable of producing IgM by the eighth week of gestation
rubella fetal consequences
miscarriage, stillbirth, congenital rubella syndrome (deafness, cataracts, heart defects, skin rash) *very dangerous particularly during 1st trimester—50% odds of CRS Deafness, cataracts, heart defects, skin rash
moderate lochia
moderate amount less than 6--inch stain on peripad
endocrinology changes thyroid
moderate thyroid enlargement increase in TBG, T4 and T3 free t4 and t3 unchanged
inevitable SAB
moderate to heavy bleeding open os mild to severe cramping usually conception products not yet expelled the process has not fully completed but miscarriage is inevitable
missed SAB expectant management
monitor clotting factors for DIC
puerperium nursing care priorities
monitor involution facilitate family adustment
what is labor
moving the fetus, placenta and membranes out of the uterus through the birht cnal
pain management
multi-modal that includes opioids and non steroidal anti-inflammatory agents
s &Sx hyperthyroidism
muscle wasting fine hair esophthalmos goiter sweating tachycardia, high output weight loss oligomehonorrhea tremor
preconception target glucose
o FBS <95 mg/dl 1 hour postprandial BS <140 (or 2 hr PPBS <120)
which medications are safe in pregnancy (DM
o Insulin is standard, safest medication. Expect dose to increase during pregnancy o Better compliance, less hypoglycemia with oral agents. Safety < insulin though, and not approved by USFDA for GDM. Metformin (2nd line) Glyburide (no) o Expect dose to increase during pregnancy.
DM postpartum screening
o May continue BS monitoring for 7 days if labile in pregnancy o Anyone diagnosed with GDM should be rescreened for DM at 6-12 weeks postpartum Use FBS or 2-hour OGTT, use pregnancy cutoffs Do not use A1C
1 hour glucose screening
o No special preparation o 50 gram glucose administered o Screen is positive if BS >140 mg/dl (80% sensitive) o Diagnosis made without 2nd step if BS >200).
changes in FHR
periodic changes episodic (nonperiodic changes) accelerations decelerations
lactogenesis 1
phase that only occurs in pregnancy completes by weeks 16-18 by the end of lactogenesis breasts are fully prepared for lactation
candidiasis assessment
physical exam wet smear and pH
other factors influence pain
physiologic culture anxiety previous experiences
types of jaundic
physiologic pathologic breast feeding jaundice breast milk jaundice
Serosa Lochia
pink, mostly serous fluid, decidual tissue, leukocytes, and erythrocytes Lasts 1-2 weeks more TILL ~2 weeks
PE eyes
placement epicanthal folds discharge
peak
point of greatest contraction
TORCHES syndrome symptoms in baby
poor feeding, fever, SGA
lochia
postbirth uterine discharge rubra serosa alba amount of lochia described as scant, light moderate and heavy
hemabate
postpartum hemorrhage contraindicated in someone with asthma
PE ears
preauricular skin tags or sinus symmetry
early postpartum period
recovery care frequent VS fundus bladder lochia perineum skin--to--skin breastfeeding attachment
Rubra Lochia
red, contains blood and decidual and trophoblastic debris last 3-4 days or more Heavy / clots when pt gets OOB first day TILL DAY 3-4
probiotics
reduce infections, no adverse effects but studies lacking
delayed BM or meconium to day 5
reduced stooling will need supplementation
fetal attitude (passenger)
relationship of fetal parts to one another general flexion is the goal
tocolysis
relaxation of the uterus useful when fetus has abnormal FHR patterns associated with increased contractions medication terbutaline
Cleansing Breath
relaxed breath in through nose and out through mouth. Used at the beginning and end of each contraction
sedatives
relieve anxiety and induce sleep; typically used in a prolonged latent phase of labor don't take away pain barbiturates phenothiazine benzodiazepines morphine sulfate
uterine rupture symptoms
response depends on extent and location of rupture) loss of station, pain, hypovolemic shock, hypotensive sx (vomiting, faintness), FHT problems, and mortality. i) Loss of station—baby gets out into the abdomen ii) Fatal if intervention is not immediate. Literally have minutes to get the baby born after this happens
exstrophy of the bladder
results from the abnormal development of the bladder, abdominal wall, and pubic symphysis that causes the bladder, urethra and ureteral orifices to be exposed
subinvolution common causes
retained placenta products and infection
weight gain
return to normal weight after 10-14 days
patient and family teaching Admission to L& D
review the birth plan discuss patient preferences/hospital policies address fears and concerns many women have fear: opportunity to educate and provide support
upper respiratory changes
rhinitis nasal congestion increase in epistaxis
dysuria leads to
risk of UTI and Hemorrhage stress incontinence --> kegel exercises
patterned--paced or pant-blow breathing
same rate as modified enhances concentration 3:1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction) 4:1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-OUT/ IN-BLOW (repeat through contraction)
scant lochia
scant amount blood only on tissue when wiped or less than 1-inch stain on peripad
gonorrhea assessment and treatment
screen at 1st prenatal visit Ceftriaxone Third trimester rescreening if high risk Treat partners
oxytocin
second hormone needed for lactation-milk ejection produced by posterior pituitary stimulated by the sucking stimulation of the nipple hormone is responsible for let-down reflex (aka milk ejection) multiple nipple sprays
duration (contractions)
seconds how long do they last
systemic analgesia (opioids) major side effects
sedation N/V dizziness altered mental status urinary retention delayed gastric emptying manifestations: decreased maternal HR, RR, BP
recommended weight gain considerations
should use good clinical judgment consider quality of their diet as well as their physical activity level recommendations should take into account the individual needs of the mother typically actually lose weight in the first trimester because of N/V like to see a 10 pound weight gain by 20 weeks because it reduces their risk of preterm births and intrauterine growth restriction
involuntary contractions (primary power)
signal the beginning of labor upper uterine segment shortens/thickens
presumptive (subjective signs of pregnancy)
signs may be an indication of something else that causes similar symptoms amenorrhea N/V breast changes quickening urinary frequency fatigue uterine enlargement braxton hicks
third stage of labor physical assessment
signs of placental separation and amount of bleeding fundal assessment--firmly contracted, change in the uterus shape from discoid to lobular as the placenta moves down
What 5 things you must consider about the passenger?
size of the head fetal presentation fetal position fetal lie fetal attitude
promoting active immunity during pregnancy
sleep exercise nutrition stress management
SGA
small for gestational age a. Weight below 10th % b. Can be preterm, term, or post term
magnesium sulfate eclampsia use
smooth muscle relaxant, used to prevent seizures (preeclampsia), prevent preterm contractions, hypertension, preventive measure in very preterm infants against Intraventrical hemorrhage (IVH) a) Can be toxic
Pe abdomen
soft bowel sounds within first hour
listeriosis transmission
soil, ground water; heat hot dogs/lunch meat soft unpasteurized cheese, pate or meat spreads
Activity/muscle tone apgar 1
some flexion
breast care
soreness ID cause and fix open to air breast shells lanolin, gel pads shells (sore, flat, inverted, pump
nursing interventions third stage IV oxytocin
to ensure adequate contraction of the uterus active management of oxytocin is started at the anterior delivery of the shoulder or immediately following delivery at this point the main concern is hemorrhage since the placenta is detached want to make sure they are hemodynamically stable
Antihypertensives:
to maintain target BP: 140-160 SBP, < 100 DBP (1) Hydralazine (a) 5-10 mg IV then 5-10 mg q20-30 min PRN. Max 30 mg. (2) Labetalol (a) 100-400 mg PO BID (to treat chronic HTN) (b) 20 mg IV then 40-80 mg q10 min PRN
Betamethasone (Celestone)
to reduce neonatal complications 12 mg IM q 24 h x 2 doses
placenta previa complete
totally covers os
TTNB
transient tachypnea of new born some babies will transition out of this but some will maintain tachypnea, have to rule out sepsis
methergine
treatment for postpartum hemorrhage can't be used in someone hypertension
varicella treatment
treatment varies depending on when it happens during pregnancy Meds: Acyclovir, anti-pyreteics Time near/at birth: VZIG for mom and baby, isolate mom and baby together, give baby pumped breastmilk
slow weight gain
up to &% weight loss normal for first 3 dyas increase feeding frequency (add 1-2 feedings/day) check feeding technique and waking technique alternate breast massage supplementation
oxytoxin (pictocin)
used to induce or augment contractions during labor, postpartum used to contract uterus rapidly metabolized and excreted by kidneys and liver tachysystole > 5 cxt in 10 minutes avg over 30 mins (fetal distress because of the frequency of contractions) can cause hypertension and/or hypotension
CMV symptoms
usually asymptomatic or may have mono-like symptoms (malaise, myalgias, leukocytosis)
Powers
uterine contractions involuntary and voluntary powers combine to expel the fetus and the placenta from the uterus
origin of pain 3rd stage/early pp period
uterine contractions similar to 1st stage uterus contracting to stom bleeding
origin of pain 1st stage
uterine contractions/distention of the lower uterine segment contracting at the top and distending at the bottom bulk of the pain during the first phase is from uterine contractions
persistent hypertension
valves did not close correctly either from a congenital anomaly or something that occurred during the transition
prolonged deceleration
visibly apparent decrease in FHR of at least 15 beats/minute below baseline LASTING MORE THAN 2 minutes BUT less than 10
marked extension (fetal attitude/passenger)
visualize the baby holding its head back head hyperflexed
military attitude (fetal attitude/passenger)
visualize the baby looking straight forward not tucked (1) Mild flexion of the head—not tucked in very well (2) Widest part of the baby head has to get through the narrowest part of the pelvis
sleepy
waking during lighter sleep bring to alert state skin to skin
folate requirements
water--soluble B9 daily requirement increases from 400 mcg/d for childbearing age women to 800 mcg-1 mg/day for pregnancy history of NTD (will supplement with 4 mg) should supplement with more preconception for fetal growth, increased RBC mass, and increased uterine size adequate levels before an during pregnancy to reduce risk of NTDs
respiration apgar 1
weak or irregular
syndactyle
webbing of feet and hands programmed apoptosis is supposed to get rid of the webbing but in syndactyle this does not occur
Trichomoniasis assessment
wet prep and symptoms
Fetal Presentation (Passenger)
what is entering the pelvis? the part of the fetus you can feel at the internal os of the cervix
what about women with epidurals? how does this affect flexion
with women who have epidurals there is not as much resistance, so flexion is not as extreme
renal physiologic changes
↑(until 3rd trim) Renal blood flow ↑ (until 3rd trim)GFR ↑Creatinine clearance thus ↓in serum creatinine, uric acid, and BUN ↑Na+ reabsorption ↑aldosterone to maintain expanded blood volume (abnormal in preeclampsia) ↑Renin and angiotensin ↓Reabsorption of glucose => glycosuria
additional learning
■ Genetic Associations with Gestational Duration and Spontaneous Preterm Birth ■ Despite evidence that genetic factors contribute to the duration of gestation and the risk of preterm birth, robust associations with genetic variants have both been identified. ■ Performed a genome-wide association study in a discover set of samples from 43,000 European ancestry ■ Tested for replication of genomic loci that had significant association with suggestive significance ■ Results: four loci were significantly associated with gestational duration. ● The variants at the EBFT, EEPSEX, AGTR2, WNT4, ADCY5, and AGTR2 loci were associated with gestational duration and variants with loci with preterm birth. ● Previously established roles of these genes in uterine development, maternal nutrition, and vascular control support their mechanism involvement
Urine (output
# wet diapers: Once/first day, twice/Day 2, 3x/Day 3, etc. (6-8 /24 hrs AFTER 4th day) and characteristics of urine (color/concentration)
Erythromycin Ointment
(1 cm ribbon each eye) Prevents ophthalmia neonatorum in the eyes which can lead to blindness (targets N. gonorrhoeae, reduction of risk of blindness secondary to gonorrhoeae) Administered 1-2 hours after birth
Placenta abruption risk factors
(1% incidence) Hypertension—very high pressures can literally blow the placenta off the uterine wall Cocaine Trauma (MVA or abuse) Smoking Hx of previous abruption PPROM
pitocin risks to mom and baby are closely related
(1) Abruption (2) Uterine tachysystole (3) Uterine rupture (4) Severe cervical laceration (5) Postpartum hemorrhage (6) Water intoxication (watch I&Os, signs of toxicity) (7) Postpartum edema, urinary retention
general flexion (fetal attitude/passenger)
(1) Arms crossed, knees and hips flexed and on the chest ** (2) Chin to chest (3) Umbilical cord in the middle (4) Head tucked
methotrexate side effects
(1) N&V (2) Gastric distress (3) Abdominal pain
Powdered formula
(cheapest): Mix with water (boiled or sterile)
first stage
0-10 cm onset of labor until 10 cms dilated, 100% effaced 3 phases
placenta previa risk factors
0.5 % incidence) Previous C-section AMA Multiparity Hx of D&C Smoking High altitude Male fetus
fFN how to collect a specimen
1. "Blind swab" of posterior fornix x 30 seconds, 2. Or 3. Inserting 1 finger to fornix, inserting swab to end of finger x 10 seconds 4. Same results as spec exam.
steroids and preterm infants
1. Corticosteroids 2 doses 12 hours apart 2. Accelerates surfactant production in the preterm infant 3. Antenatal Corticosteroids in the Management of Preterm Birth: Are we back where we started? 4. Prenatal steroids lower risk of respiratory illness in late preterm infants. NIH study shows treatment benefits extended to infants born at 34-36 weeks
RDS increases with
1. Gestational diabetes 2. Presence of asphyxia 3. C/S birth
Respiratory Adaptation-After Birth-Sensory
1. Handling infant, possible pain at birth, light/sounds/smell/taste at birth stimulate respiratory center 2. Handling all the changes in the senses at birth stimulate the respiratory system
hypothyroidism treatment in pregnancy
1. Levothyroxine (T4) a. Goal to maintain TSH in trimester range b. May need to change dose as pregnancy progresses up to 25-50% increase c. Typically, 100-150 mcg/day PO
PE mouth
1. Rooting, suck, extrusion reflex 2. Intact palate 3. Epstein pearls 4. Tongue Tie
D/C checklist assessment
1. Stable BUBBLE HE 2. Voiding 3. Passing flatus
parvovirus maternal consequences
1/2 of pregnant women are immune rarely: severe anemia, miscarriage (<5%)
creatinine clearance preeclampsia
130-180
lactogenesis stage 1
16-18 weeks colostrum production
normal Respiratory rate
16-24
breastfeeding associated jaundice
2-3 days onset 1. Poor feeding (PREVENTABLE!) 2. Do not stop breast feeding
therapeutic levels for mag when used for preeclampsia
2-3.5 mmol/l 4-7 meq/l 5-9 mg/dl
breasts abnormal findings
2. Bleeding nipples = aggressive baby that loves to eat 3. Inverted nipple a. Breast shield and will need a lactation specialist 4. Red area be on the lookout for mastitis 5. Middle bottom mastitis, which is typically only on one side
tobacco
2hr window not in the same room
gonorrhea epidemiology
2nd most common STI in the U.S. Incidence in pregnant women ranges from 2.5% to 7.3%
bowels post-op
3. Post-op: NPO if pt nauseated, vomiting, no bowel sounds a. IV hydration and anti-emetics b. Consider reducing opiates i. To help bowels come back to life c. Provider may consult MD/GI if persistent
fibrinogen preeclampsia
300-600 mg/dl
early term
37-40.6 weeks/days
term
37-41.6 weeks
HCT pre-pregnancy
37-47%
full term
39-40.6 weeks/days
late term
41-41.6 weeks/days
antibody isotypes
5 isotypes IgG IgM IgA
WBC pre-pregnancy
5,00-10,000/mm3
25 weeks
75-85% survive
fibrin split products preeclampsiA
ABSENT
bordeline AFI
AFI = 5-8 cm
plugged milk ducts
Afebrile mom One area swollen and tender Caused by tight clothing or some kind of pressure on breast Warm compress and frequent feeding with massage Change feeding positions step before mastitis, frequent feedings, common with women who have other kids at home
choosing other methods of feeding
B&B - associated with a shorter duration of breastfeeding
vitamin Contents
BM Everything EXCEPT: D, K, B12 formula added vitamins
minerals
Calcium and phosphorus ratio slightly lower in formula, even lower in whole cow's milk. These infants are susceptible to hypocalcemia, seizures and tetany Iron - better absorbed in breast milk Fluoride - recommended to supplement after six months based on water content.
Bacterial Vaginosis complications
Complications: Other STI's Preterm labor & birth
opioid agonists
Demerol, Fentanyl: stimulate the major opioid receptors mu and kappa
Trichomoniasis
Flagyl
postpartum HR
Heart rate is increased immediately after birth and can remain elevated for the first hour. Puerperal bradycardia is common, with heart rate decreasing to 40 to 50 beats/minute
placenta abruption fetal adverse outcomes
IUGR—placenta is smaller and oxygenation decreases Preterm birth Mortality
systemic analgesia (opioids) routes
IV, IM PCA (IV preferred route) can do a combination sometimes
placenta previa active mangement
Immediate birth for term fetus OR moderate to severe bleeding OR maternal or fetal jeopardy Large bore IV Maternal VS Maternal labs: H&H and clotting studies Continuous EFM Maternal catheter to assess output Blood and fluid replacement Possible C-section (contraindication is coagulopathy) Emotional support
uterine cramping/after birth pains interventions
Interventions: heat, pain meds
anita's EDD/EDC
LMP 11/2/2017 month 11-3= 8 day 2+7=9 year 2017+1 =2018
Herpes Simplex 2 treatment 2
Labs Chronic, recurring, no cure Triggers Antivirals - Acyclovir & Valtrex Treating symptoms C-section if active lesions
PROM risk
Major risk: infection b) Induction decreased rate of maternal infection, no change in c/s rate
proteinuria severe features of preeclampsia
Massive proteinuria (>5 g in a 24-hr specimen) is no longer used as a diagnostic criterion
Normal Temperature
May be up to 100.4 for the first 24 hours (dehydration) PP Chill (fluid shifts, nervous system response to work of labor) PP diaphoresis (elimination or fluid excess)
chlamydia epidemiology
Most commonly reported STI among pregnant women
FIBRIN SPLIT PRODUCTS HELLP
PRESENT
P (aPgar)
Pulse heart rate
Herpes Simplex 2 women at risk
Risky sexual behaviors
R
Rubella
incomplete SAB
S& S similar to inevitable (moderate to heavy bleeding, open os, mild-severe cramping) + expulsion of conception products placenta retained
pre-existing diabetes 1st trimester
Screening of HbA1C, kidneys (BUN and creatinine), and thyroid Ultrasound for dating, viability (maybe sequential screen?) Referrals
reorganization
Search for meaning Reduction of distress Reentering normal life activities with more enthusiasm Can make plans, including decision about another pregnancy
Candidiasis epidemiology
Second most common vaginal infection in the U.S
abnormal BP
Severe hypotension (hypovolemia due to hemorrhage) Hypertension (>140/90x2)
Bacterial Vaginosis transmission
Sex is thought to play a role Opportunistic infection, imbalance between "good and bad bacteria in the vagina"
steroids (bethamethasone, Dexamethasone) action
Stimulates fetal lung maturation by promoting release of enzymes that induce production or release of lung surfactant.
missed SAB surgical and medical management
Surgical D&C Medical—vaginal misoprostol Blood clotting factors are monitored until uterus is empty
spec exam fFN
The specimen should be collected prior to a digital cervical exam, collection of culture specimens, or vaginal probe ultrasound exams. Do not contaminate the swab or specimen with lubricants, soaps, disinfectants, or creams. Do not collect specimen if patients have had sexual intercourse within 24 hours prior to sampling; moderate or gross vaginal bleeding; advanced cervical dilation (3 cm or greater); rupture of membranes; gestational age <22 weeks or >35 weeks; or suspected or known placental abruption or placenta previa.
why do newborns get cold so easily?
Thin skin, blood vessels close to surface, little white fat, higher surface area to body mass ratio
Bacterial Vaginosis agent
Vaginal dysbiosis
normal blood loss post vaginal birth
Vaginal up to 500 ml once it goes over 500 ml it is hemorrhage
diastasis rectic
a physiologic separation of the rectus abdominal muscles (in the front of the belly) permanet, less pronounced after birth but will never go back to the way it was before a full term pregnancy
sore nipple treatment
a. Colostrum or Lansinoh b. Hydrogel pads c. Breast shells d. Lactation Consultant
GBS overview
a. GBS part of normal vaginal flora b. 25% of pregnant women c. Vertical transmission during labor/birth 1. Can be grown in the mothers vaginal flora, has ability to migrate up to the uterus and potentially infect the fetus d. Neonate at risk of GBS sepsis e. Pregnant women screened between 35-37 weeks for GBS
what to do about abnormal bladder findings
a. General protocol is straight cath after 6 hours i. Really encourage urination, telling them they will have to be cathed if they don't urinate b. Leave in foley for 24 hours on 3rd cath c. Meanwhile, try to help patient urinate
etiology multifactorial
a. Genetic b. Endocrine 1. Hormones of Pregnancy 2. Dysfunctional Stress Response (HPA Axis) i. Fetus produces CRH which suppresses the mothers HPA axis. ii. CRH is released from both the hypothalamus and the placenta iii. CRH ACTH Cortisol c. Inflammation d. Neurotransmitter Dysfunction e. Psychosocial stressors
congenital anomalies present at birth
a. Genetic or environmental b. Structural or functional c. 3% of births d. Spontaneously Aborted fetuses have high incidence of anomalies e. Leading cause of death in infants in the first year of life-folic acid should be started before conception
Excessive bleeding nursing actions
a. Get help! b. Massage uterus (if boggy) c. O2 d. Fluids e. Oxytocic medication (standing orders) f. Second IV g. Blood as ordered h. Catheter—may just have a full bladder i. ** should not soak more than a pad an hour (start messaging the uterus, really heavy, hit the call bell and have someone call the provider)
newborn immune state
a. Greatest risk factor for neonatal infection is prematurity. Others are PROM, chorio, maternal fever in labor, ante or intrapartal asphyxia, invasive procedures, stress, congenital anomalies b. All newborns (especially preterm) are at high risk of infection during the first several months of life. Infection is one of the leading causes of morbidity and mortality of infants! i. One way to reduce exposure is for the mother to wear the baby ii. Can't cover portal of entry so *** c. Newborns cannot limit invading pathogen to the portal of entry because of hypofunctioning of inflammatory and immune mechanisms. d. Newborns have passive immunity - IgG antibodies transfer across the placenta e. IgA immunoglobulins received via colostrum and breast milk f. **Why is Colostrum bright yellow-orange?? Because of vitamin A
preterm infants fetal growth and outcome considerations
a. Heredity b. Genetics c. Placental insufficiency d. Maternal disease processes
esophageal atresia
a. Life—threating b. Esophagus ends in a blind pouch, thus failing to form a continuous passageway to the stomach
when are APGAR scores taken
a. Newborn is scored at one minute of life and five minutes of life. b. First minute of life isn't indicative of really anything, the five minute apgar score is way more important
Fluid needs of the infant
a. Newborns and infants do not need supplementary water i. 60-89 mg/kg/day for first two days ii. Breastmilk 87% H20 iii. Formula 133 g/5oz serving ~94%
baby friendly USA
a. No artificial nipples or pacifiers b. Rooming in, etc. c. 10 steps to creating a successful breastfeeding environment i. Written breastfeeding policy communicated to all staff ii. Healthcare staff training iii. Education on benefits and management of breastfeeding iv. Facilitate initiation of breastfeeding within ½ hour d. See Box 25-1 for more
respiratory distress syndrome
a. RDS is caused by a lack of pulmonary surfactant, which leads to progressive atelectasis, loss of functional residual capacity, and ventilation—perfusion imbalance with an uneven distribution of ventilation. 1. This surfactant deficiency can be caused by insufficient surfactant production, abnormal composition and function, disruption of surfactant production, or a combination of these factors. 2. The weak respiratory muscles and an overly compliant chest wall, common among preterm infants, contribute to the sequence of events that occurs. 3. Lung capacity is further compromised by the presence of proteinaceous material and epithelial debris in the airways. The resulting decreased oxygenation, cyanosis, and metabolic or respiratory acidosis can cause the pulmonary vascular resistance (PVR) to be increased. This increased PVR can lead to right-to-left shunting and a reopening of the ductus arteriosus and foramen ovale
Transient Tychapnea of the Newborn
a. Respiratory rate > 60 breaths/minute 1. Trying to get fluid out of lungs 2. Will not have ground glass appearance on X-ray b. Delayed clearance of fetal lung fluid from lungs c. Grunting, retracting, cyanosis d. Generally self—limiting
acute distress
a. Shock b. Numbness c. Intense crying d. depression
terbutaline nursing considerations
a. Should not be used in women with a history of cardiac disease, pregestational diabetes, severe gestational hypertension, preeclampsia with severe features or eclampsia or hyperthyroidism, or with significant hemorrhage b. Propranolol should be available to reverse adverse effects related to cardiovascular function
GBS treatment
a. Treated with antibiotics during labor 1. Penicillin G, 5 million units IV loading dose 2. Penicillin G 3 million units IV every 4 hours until birth 3. Ampicillin for patients allergic to Penicillin
placenta Abruption key signs and symptoms
abdominal pain dark red vaginal bleeding
threatened SAB management Preventive
bedrest transvaginal US Assessment of hcg and progesterone
D reeDa==>how to assess Episiotomy/Laceration/Incision (and hemorrhoids
drainage
polydactyle
extra digit or toe
relaxing and breathing techniques
focusing and relaxation breathing techniques--pattern breathing
Artificial rupture of membranes (Amniotomy) risks
i) Committed to deliver ii) Prolonged ROM, chorio iii) Cord prolapse (depending on station) (1) Want to make sure the baby is engaged iv) Infection: HIV, HSV (1) Don't want to do an amniotomy with women who have any infection that can be transmitted to the baby
hemorrhagic disorders earlier in pregnancy
i) Miscarriage (SAB spontaneous abortion) ii) Ectopic Pregnancy iii) Hydatidiform Mole
gestation htn screening
i) Normal pregnancy BP (1) Baseline, 2nd trimester dip, back to baseline (2) Blood pressures should never be above baseline ii) Screening (1) BP at every visit (2) Urine dip for protein (routine or empiric) (3) Symptoms
DIC increased risk
i) Placental abruption ii) Retained fetal demise iii) Amniotic Fluid Embolus iv) Severe pre-eclampsia v) HELLP syndrome
care of a women receiving Magnesium sulfate
i) Preeclampsia with "severe features" i.e., subjective neurological symptoms (headache or blurry vision), abdominal pain, epigastric pain ii) Mechanism of action: uncertain, smooth muscle relaxant, neuromuscular blockade (1) Also relaxes the uterus (2) Tricky if you are trying to induce them since it causes the uterus to not contract iii) Effectiveness: decreases rate of eclampsia by 50% (1) Acts like a CNS depressant iv) Effect on labor, FHR-variablility v) Magnesium toxicity
risk factors of pre eclampsia
i) Primigravida younger than 19 or older than 40 years ii) Nulliparity iii) Preeclampsia with severe features in a previous pregnancy iv) Family history (mother or sister) of preeclampsia v) Paternal history (partner previously fathered a preeclamptic pregnancy in another woman (1) New partner, limited sperm exposure (barrier contraception), IVF vi) African descent vii) Multifetal gestation (1) Twins carry nearly 3x increased risk viii) Hydrops fetalis ix) woman who herself SGA x) Maternal infection/inflammation in current pregnancy ( i.e., urinary tract infection, periodontal disease)
Management of postdate pregnancy management
i) Stripping membranes (1) Naturally loosen up membranes and start labor naturally ii) Cervical ripening agents (CERVADIL) - prostaglandin iii) Induction of labor
ecclampsia management ***
i) Tonic-Clonic Convulsion Signs (1) Stage of invasion: 2-3 seconds, eyes fixed, twitching of facial muscles (2) Stage of contraction: 15-20 seconds, eyes protrude and are bloodshot, all body muscles in tonic contraction (3) Stage of convulsion: muscles relax and contract alternately (clonic), respirations halted; then begin again with long, deep, stertorous inhalation; coma ensues ii) Interventions (1) Keep airway patent: turn head to one side, place pillow under one shoulder or back if possible. (2) Call for assistance. Do not leave the bedside. (3) Raise side rails and pad them with a folded blanket or pillow if possible. (4) Observe and record convulsion activity. iii) After Convulsion (1) Do not leave the woman unattended until fully alert. (2) Observe for postconvulsion confusion, coma, and incontinence. (3) Use suction as needed. (4) Apply a pulse oximetry monitor. (5) Administer oxygen via nonrebreather face mask at 10 L/min. (6) Start intravenous fluids and monitor for potential fluid overload. (7) Give magnesium sulfate or other anticonvulsant drug as ordered. (8) Insert an indwelling urinary catheter. (9) Monitor blood pressure, pulse, and respirations frequently until stabilized. (10) Monitor fetal and uterine status. (11) Expedite laboratory work as ordered to monitor kidney and liver function, coagulation system, and drug levels. (12) Provide hygiene and a quiet environment. (13) Support the woman and her family and keep them informed. (14) Be prepared to assist with birth when the woman is in stable condition.
DIC management
i) Treating underlying cause ii) VS iii) EFM if before birth iv) Maternal position - left side—good blood flow and oxygenation to the fetus v) Volume replacement vi) Blood transfusion and clotting factors vii) O2 viii) Vitamin K ix) Foley catheter with strict I&O
Management of postdate pregnancy risks old placenta
i) doesn't function as well as it should (1) Oligohydramnios (AFI < 5cm) (2) Increased fetal distress or fetal death (5/1000 del) Dysfunctional labor Labor interventions: induction, augmentation, operative delivery
oligohydramnios long term
i) fluid levels influence organ development (respiratory and GI) (1) May have to do a induction (2) Risk benefits of preterm vs waiting (3) Typically if develops in term woman induce right away
pitocin administration
i) start at 0.5-2 mU/min. Then, (1) Increase by 1-2 mU/min every 30-60 min (2) Active management (see orders) (3) Max dose 20-40 mU/min (4) Titrated drip
postpartum nursing care priorities assessment
i. Every 15 minutes: ii. Vital Signs iii. Fundal assessment iv. Visualize lochia (bleeding)
advanced myelination
i. Reason, perception, fine motor control
hypoglycemia
i. jitteriness, poor feeding, lethargy, cyanosis spoon or cup feed with colostrum
most clotting factors & fibrinogen pregnancy
increases in pregnancy
HCT postpartum
initial drop of 2-3%
quickening
is the sense of fetal movement but could be due to increased gut motility
herbal preperations
lack of evidence
LP
low platelet count
toxoplasmosis symptoms
non or flue--like symptoms (fatigue, malaise, sore throat)
uterine changes braxton hicks
non--productive contractions in the uterus
missed SAB
non-viable fetus no symptoms of miscarriage
Activity/muscle tone apgar 0
none
Rubella Treatment
none
CMV treatment
none fetal surveillance
parvovirus treatment
none monitor fetus
R (apgaR)
respiration
test for SROM ferning
sample of amniotic fluid--fern like pattern on a slide under microscope
S
syphilis
T
toxoplasmosis
Input and stomach capacity
with breast or bottle want to keep track of frequency and volume (or time) of feeding) 1. Belly balls - book suggests 15-30 ml per feeding in the first 24 hours (belly balls are smaller). 2. Capacity increases so by the end of the week 60-90ml per feeding.
lactogenesis stage 2
with delivery of placenta colostrum Ab rich increase protein, decrease fat relative to mature milk laxative properties Day 3-5 milk comes in -> transitional milk
preexisting medical or genetic conditions that increase risk of preeclampsia
(1) Chronic hypertension (2) Renal disease (3) Pregestational diabetes mellitus (4) Connective tissue disease (i.e., systemic lupus erythematosus, rheumatoid arthritis (5) Thrombophilia ( i.e, antiphospholipid antibody syndrome, protein C or S deficiency, factor V leiden mutation) (6) Obesity (BMI ≥ 26 kg/m2)—2.5x increased risk (7) Vascular disease (8) Chronic renal disease (9) Autoimmune disease
special patient teaching for methotrexate
(1) Urinating instructions (a) Urine is very toxic so partner may want to use a different restroom (b) Double flush toilet (with lid down)
nodules
1. 12-43% of nodules are cancer 2. Fine needle aspiration prn 3. Thyroid radionuclide scan contraindicated 4. Surgery, usually delayed until postpartum
frequency of voiding
1. 2-6 x/24 hrs for 2 days 2. 6-8 x/24 hrs by Day 4 or 5
breast milk jaundice
1. 5-10 days onset) 1. Not pathogenic, no treatment needed
sings of satiety
1. Baby's suck slows 1. Milk drunk—hands open and tongue is less tight and will generally will fall asleep 2. Breasts will be drained 3. Falls asleep 4. Breast soft after finishing 1. "empty" never truly empty
Hyperbilirubinemia discharge teaching
1. Feed frequently-Need to eat every 2-3 hours 2. Observe for lethargy 3. Count number of wet - 6-8/day, soiled diapers 1/day 4. Follow up appointments-Must keep follow up appointments
figure 23-2 heat loss
1. Heat loss is mainly due to evaporation of amniotic fluid from the baby's body. 2. Loss of body heat also occurs by conduction if the baby is placed naked on a cold surface (e.g. a table, weighing scale or cold mattress); Loss by convection if the naked newborn is exposed to cooler surrounding air; and by radiation from the baby to cooler objects in the vicinity (e.g. a cold wall or a window) even if the baby is not actually touching them.
Signs and Symptoms of GBS sepsis in the neonate
1. Respiratory distress 2. Temperature instability 3. Poor feeding pattern 4. Cyanosis 5. Poor tone/lethargy 6. Apnea 7. Hypotension 8. Can rapidly develop-Pneumonia, Shock, Meningitis, Mortality rate 5-20%
subinvolution
1. Subinvolution is the failure of the uterus to return to a nonpregnant state
FFN 22-33.6 weeks ONLY
1. The test is performed by collecting fluid from the woman's vagina using a swab during a speculum examination
weight loss >7% with delayed lactogenesis
1. Trying to avoid the 10% cut off 2. Intervention around this point supplement
late preterm
34-36.6 weeks/days
lochia and oxytocin
5. If the woman receives an oxytocic medication, regardless of the route of administration, the flow of lochia is often scant until the effects of the medication wear off. The amount of lochia is usually less after a cesarean birth because the surgeon suctions the blood and fluids from the uterus or wipes the uterine lining before closing the incision. Flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in bed; the woman then can experience a gush of blood when she stands. This gush should not be confused with hemorrhage.
A (apgAr)
Activity Muscle tone
Slow—Paced Breathing
Approximately 6-8 Breaths per minute a.Performed at approximately half the normal breathing rate (number of breaths per minute divided by 2) b.In-2-3-4/OUT-2-3-4/IN-2-3-4/OUT-2-3-4...
postpartum Assessment mnemonic
BUBBLE HEP
B(bubBle hep)
Bladder
chlamydia assessment
Cervical cultures at first prenatal visit
normal blood loss following cesarean
Cesarean up to 1000 ml once it goes over 1000 ml =postpartum hemorrhage
hyperthyroidism fetal outcomes
Congenital anomalies PTD IUGR, SGA Stillbirth TSH-Receptor Antibodies of Grave's disease may cross placenta and stimulate fetal thyroid gland in 2-5% graves' GOITER Anti-Thyroid drugs (PTU or MM) may cross placenta and cause fetal goiter
Cleft Lip and Palate
Congenital midline fissure, or opening in the lip or palate resulting form failure of the primary palate to fuse
changes to the cervix
Cyanotic secondary to ↑vascularity (Chadwick's sign) Softening of tip (Goodell's sign) Cervical glands proliferate resulting in an increase in white mucous discharge (leukorrhea) Eversion of cervix -columnar epithelium on surface (increased friability)
inevitable SAB surgical management
D&C (a) If ROM, pain, bleeding, or infection is present, then prompt termination of pregnancy is accomplished by dilation and curettage
PPD 1/POD1 ( post delivery day)
FF@ U or 1 below at umbilicus or one fingerbreadth below
PPD2/POD 2 (post delivery day 2)
FF@U or 2 below at umbilicus of 2 fingerbreadths below
HE
HErpes
chlamydia transmission
Lives primarily in vaginal fluid and semen Primarily vaginal or anal sex Mother-child vaginal transmission
late pregnancy problems with uncontrolled diabetes
Preeclampsia Macrosomia With microvascular problems: IUGR Polyhydramnios Preterm delivery
tests for SROM nitrazine test for pH
ROM should be alkaline should turn blue however urine is alkaline, recent sexual intercourse can cause alkaline not definitive
gonorrhea women at risk
Sexually active women Multiple partners Non-use of barrier methods g
hyperthyroidism labs
TSH low FT4 high subclinical ft4 high clinical hyper tsh recptor Ab
U (bUbble hep)
Uterus
current recommendations for infant feeding
a. AAP: EXCLUSIVE breast for 6 months + continued breast with complementary solids for at least another 6 months b. WHO: EXCLUSIVE breast for 6 months + continued breast with complementary solids till 2 years + c. ACOG, ACNM and AWHONN all agree with these recommendations
hip dysplasia
a. Abnormal development of one or all of the components of the hip joint
postpartum anxiety with BM
a. Anticipates discomfort during BM because of perineal tenderness secondary to episiotomy, lacerations, or hemorrhoids and resists the urge to defecate b. Regular bowel habits should be reestablished when bowel tone returns
tocolytics contraindications
a. Contraindications: sick/unstable mom or baby. pPROM? i. pPROM (preterm premature rupture of membranes) : inconsistent studies show increased delivery beyond 48 hours, but increased chorio, low 5 min Apgar, and more RDS. Antibiotics used inconsistently in those studies. Cochrane looked at "any tocolytic" when assessing outcomes r/t pPROM.
postpartum blues
a. Day 3 - Day 10 b. Occurs in 80% of women c. Emotional lability, restless, fatigue, insomnia, headache, anxiety, sadness, anger d. Coping: Rest, Social support - partner
medications
a. Fetal development b. Breastfeeding c. A lot of drugs are not tested in the pregnant population and have to pay attention to pregnancy classes
microcephaly
a. Head circumference that measures two or more standard deviations below the mean for age and sex b. Brain growth is usually restricted and thus cognitive impairment is common c. Risk factors: viral infections (zika), chromosomal disorders and malnutrition
neuroprotection imminent preterm birth
a. Planned preterm birth for fetal or maternal indications b. 4gm IV loading dose over 30 minutes c. 1gm/hr maintenance infusion until birth or 12 hours
preterm labor
a. Preterm labor is generally diagnosed clinically as regular contractions along with a change in cervical effacement or dilation nor both or presentation with regular uterine contractions and cervical dilation of at least 2 cm b. Preterm birth is any birth that occurs between 20 0/7 and 36 6/7 weeks of gestation
prevent constipation
a. Teaching/ reassurance about defecation b. Fluids, activity, diet c. Fiber, stool softeners, laxatives prn i. Colace 100 mg po BID ii. Senokot- max 4 tabs po BID iii. Milk of magnesia 30-60 ml po qd iv. Dulcolax 1 suppository PR qd v. Flaxseed
CNS congenital anomalies
b. CNS 1. Range of defects anecephaly to spina bifida, NTD a. Anencephaly b. Spina bifida 2. Folic acid deficiency 3. Microcephaly 4. Hydrocephalus
lactogenesis/MER triggers
baby crying, smells, sounds, warmth, can also be triggered during sex
Bladder first 24 hours postpartum
bladder edematous, congested, hypotonic a. Just had a contracting uterus and a baby right on top of it
flu
can be given during pregnancy and postpartum
use of fundal pressure
contraindicated never do this can make placenta detach early and then it becomes and emergency situation
dyspnea
experienced by 2/3 of women starting around 12 weeks
platypelloid pelvis (passageway)
flat often end in C/S
placenta abruption maternal adverse outcome
hemorrhage hypovolemic shock
sources of abnormal bleeding
hemorrhoids, unrepaired aginal or cervical lacerations excessive bleeding ++ clots
Cytomegalovirus (CMV) agent
herpes virus
musculoskeletal congenital anomalies
hip dysplasia clubfoot polydactyle syndactlye
Bowel/abdomen
hunger passing gas, no nausea constipation
pitocin preparation
i) varies, added to LR or NS as piggyback (1) Should be at closest port incase she starts contracting too much
source and devices
i. 1st choice: Expressed breast milk ii. 2nd choice: Donor breast milk iii. 3rd choice: Formula iv. Spoon v. Syringe vi. Dropper vii. Cup—medicine cup viii. Slow-flow nipple
Sleep-Wake Patterns
i. 6 sleep-wake states (2 sleep, 4 wake) ii. State modulation iii. 16-19 hours of sleep/day for first few weeks
physical assessment head
i. Head ii. Fontanels iii. Caput succedoneum iv. Cephalhematoma v. Bruising
Legs/Lower Extremities/Homan's
i. Increased edema the first few days ii. Soreness from labor (not pain) iii. Normal reflexes
engorgement
ice packs post feeding cabbage leaves NSAIDs
apgar scores 4-6
indicated moderate difficulty
CMV epi
most common virus transmitted to the fetus
Trichomoniasis agent
protozoa trichomonas vaginalis
parvovirus transmission
respiratory secretions, blood, blood products, common in school kids
Rubella transmission
respiratory virus present 1 week prior to symptoms
lochia odor
should be musty like menses, not foul report foul odor asap
meconium aspiration **
swallow meconium and will have a chemical imbalance
tools of labor
(1) Classic kind of set up birth tables (2) Cord clamp (3) Bulb suction—to clean mouth and nose of baby out (4) Sutures (5) Basin (6) Local Anesthesia (Laceration during natural birth
pitocin monitoring
(1) FHTs continuously (2) UCs: goal is strength 40-90 mm Hg, duration 60-90 seconds, frequency every 2-3 minutes, resting tone <= 20 mm Hg
Csection risks to mom
(1) Hemorrhage, DIC (2) Longer recovery (3) Infection (4) Wound dehiscence (particularly in obese women), scar (5) Anesthesia (6) Psychological: body image, fear/anxiety
SAB surgical management
(1) May need device or medication one day prior for dilation (2) Conscious sedation or general anesthesia (3) Pitocin to prevent hemorrhage (4) Rhogam for women who are Rh negative (5) Discharge within a few hours - need a ride (6) REST - especially first day (7) Ibuprofen for light cramping (8) Light bleeding can last few days - 2 weeks (9) Nothing in vagina for 2 weeks or until bleeding stops completely (10) Grief and emotional recovery (11) Support groups (12) Typically wait 1-3 months before trying to get pregnant again, but depends on what the underlying issue is
complete SAB management
(1) No intervention—if no bleeding or cramping or infection (2) Surgical—if bleeding, excessive cramping or infection => D&C
oligohydramnios predictor of IUGR morbidity/mortality and tolerance of labor
(1) Not enough fluid to help with fetal development (2) Tolerance of labor—induction at 38 weeks, since there is not enough fluid to cushion the cord the baby may not tolerate labor well due to cord compression
postpartum hypertension management
(1) Oral antihypertensives if BP remains elevated (2) Careful instructions about s/s (a) Headache, blurry vision, seeing spots, epigastric pain, RUQ pain, indigestion, sudden increase in swelling (3) See women 72 hours after discharge and 10 days later (4) Seizure can occur up to 4 weeks pp
supra pubic pressure (shoulder dystocia)
(1) Push the shoulder in the direction it needs to go (2) Pressure applied to the anterior shoulder in attempt to push the shoulder under the symphysis pubis
assess for active bleeding which is associated with tubal rupture (ectopic pregnancy)
(1) Referred shoulder pain + Deep lower, one side acute abdominal pain (2) S&S of shock: dizziness, hypotension, tachycardia (3) Cullen sign - ecchymosis around umbilicus (4) Ectopic pregnancies can become very emergent very quickly
third stage of labor placental examination/disposal
(1) Shiny Schultz=fetal side (2) Dirty Duncan=Maternal side b) What should you be concerned about? Pieces of placenta still inside, which could put mother at risk of bleeding
Late Preterm Infants
(EGA 34 0/7 - 36 6/7) i. Related to elective induction (a little off on the dates) ii. Largest portion of the preterm population iii. "Just a little small"
DIC labs Decreased (using up all of the clotting factors)
(a) Platelets (b) Fibrinogen (c) Factor V (d) Factor VIII
Macrosomic
- > 4000gms a. Can't pass through the birth canal
Casein- or whey-hydrolysate formulas
- for children who cannot tolerate or digest cow's milk- or soy-based formulas Eg. Nutramigen
Amino acid formulas
- for infants with multiple food protein intolerances Eg. Neocate
Higher concentration of fat in hindmilk
- needed for ensuring optimal growth and satisfaction between feedings. That's why you want to make sure that infants are nursing long enough so they can intake the richer, denser calories from fat in hindmilk.
Signs of Potential Complications box: Postpartum Psychosocial Concerns
. The following signs suggest potentially serious complications ii. and should be reported to the health care provider or clinic iii. (these may be noticed by the partner or other family members): 1. Unable or unwilling to discuss labor and birth experience 2. Refers to self as ugly and useless 3. Excessively preoccupied with self (body image) 4. Markedly depressed 5. Lacks a support system 6. Partner or other family members react negatively to the baby 7. Refuses to interact with or care for baby; for example, does not name baby, does not want to hold or feed baby, is upset by vomiting and wet or soiled diapers (cultural appropriateness of actions must be considered) 8. Expresses disappointment over baby's sex 9. Sees baby as messy or unattractive 10. Baby reminds mother of family member or friend she does not like 11. Has difficulty sleeping 12. Experiences loss of appetite
Vitamin K injection
0.5-1mg vitamin K IM 1-2 hours after birth 2. Prevents hemorrhagic disease of the newborn (spontaneous brain bleeds are most serious) 3. Vitamin K synthesized by intestinal flora 4. Newborns are Vitamin K deficient until 7 days of age 5. Oral Vit K not well-absorbed and alters gut microbiome
neonatal microbe
1. "Seeding" of neonate at birth 2. Intra-uterine cavity "sterile" 3. Maternal antibiotic administration during labor 4. Cord blood source of inflammatory markers for neonatal sepsis
26/27 weeks
1. - 90% survive a. Reason survival rates is so good 26-28 weeks because of surfactant
progesterone routes
1. 17-alpha hydroxyprogesterone caproate (inj)- generally for hx PTD a. Dose is 250 mg IM q week from 16-20 weeks until 36 weeks 2. Vaginal progesterone (gel)- generally for short cervix a. Dose is 90-200 mg vaginally q night until 37 weeks
PE chest
1. Breath sounds 2. Heart sounds 3. Swollen breast tissue 4. Supernumerary nipple
abnormal bladder/urinary tract findings
1. Distended bladder—how do you know?? 2. Incomplete emptying 3. May displace fundus- usually up and right
Bowels Hunger
1. Eat when hungry a. Very hungry after full recovery from analgesia, anesthesia, and fatigue
PHOTOTHERAPY nursing considerations
1. Eye mask - closed eyes before initiating the light 2. Maximal skin exposure 3. Monitor temperature—the room needs to feel like a sauna 4. Adequate hydration—baby needs to be nursing well 5. Monitor output—urine and stool 6. Parent-infant interaction
signs of a good latch
1. Firm tugging sensation on the nipple - but no pain or pinching 2. Sucks with cheeks rounded, not dimpled 3. Jaw glides smoothly with sucking 4. Audible swallowing 5. Take off and try again by inserting finger to break the suction and then pulling the baby off 6. Should have a good amount of the areola
drugs used in vaginal birth
1. Local infiltration anesthesia 2. Pudendal block 3. Epidural block anaglgesia and anesthesia 4. Spinal (block) anesthesia 5. CSE analgesia and anesthesia 6. Nitrous oxide
Rh Incompatibility or isoimmunization
1. Occurs when maternal antibodies are present or develop in response to exposure to an antigen (different blood type) 2. Pathogenesis hematopoiesis (the formation, production and maintenance of blood cells) in the fetus is well established by the 9th week of gestation. When fetal RBCs that contain the Rh antigen pass through the placenta into the maternal circulation of an Rh-negative woman the maternal immune system produces antibodies against the foreign fetal antigens. maternal sensitization 3. Maternal sensitizastion a. Process of antibody formation b. Sensitization can occur during pregnancy, birth, miscarriage or induced abortion, amniocentesis, external cephalic version, or trauma 4. Maternal antibodies cross the placenta
psychosocial support/ self care
1. Set realistic goals 2. Sleep as regularly and as much as possible 3. Accept all offers of assistance 4. Get out of the house daily 5. Exercise when the body is ready 6. Avoid caffeine, sugar, alcohol 7. Notify provider of psych ( esp. previous depression) history 8. Routine screen for depression at pp visit
Abnormal Newborn respirations
1. Tachypnea—consistently 70-90 respiratory rate 2. Nasal flaring 3. Intercostal or subcostal retractions 4. Suprasternal or sub-clavicular retractions 5. Grunting 6. Central cyanosis 7. RDS, TTNB, PPHN, meconium aspiration
RDS signs and symptoms
1. worsens over first 48 hours 2. Improves within 72 hours of life 3. Retractions a. Substernal retractions b. Intercostal retractions c. 4. Grunting 5. Nasal flaring 6. Tachypnea or apnea a. Apnea—20—second or greater cessation of respiration or a shorter pause accompanied by bradycardia, cynosis or hypotonia 7. Decreased breath sounds 8. Fines rales 9. Generalized cyanosis—acrocyanosis is a normal findings in the neonate but central cyanosis indicaes an underlying problem that requires immediate evaluation 10. X-ray findings Ground glass appearance on RDS X-ray. Uniform reticulogranular appearance and air bronchograms
PTT preeclampsia and HELLP
12-14, 60-70
subinvolution assessment and causes
2. Deviated to right 3. Boggy (uterine atony)—soft, doughy uterus a. Fundal massage—to help it firm up b. Oxytocic medications i. IV Pitocin ii. Cytotec iii. Methergine—cant give to someone who has hypertension iv. Hemabate—cant be given to someone with asthma 4. Common cause: retained placenta products and infection
preterm
20--36.6 weeks/days
uterus changes increase in blood flow
50 cc/min --> 500 cc/min
moderate variability
6-25 bpm (amplitude range) this is the goal
24 weeks
66-80% survive
chlamydia signs and symptoms
80% of chlamydia cases are silent aka asymptomatic s/sx Postcoital spotting or bleeding Cervical discharge Dysuria
protein requirements
9.1 g/day BM: why and casein 70:30 F: whey and casein 20:80
what do we want infant temperature to be?
97.7-99.5
maternal long term sequelae of gestational diabets
: type 2 diabetes, chronic HTN
FHR bradycardia
< 110 bpm for 10 minutes or longer
adequate accelerations
< 32 weeks: 10 bpm above baseline for 10 sec or > > 32 weeks: 15 bpm above baseline x 15 sec or >
ectopic pregnancy progesterone
< 5ng/ml suggests an ectopic or otherwise abnormal pregnancy
Pulse/Heart Rate apgar 1
<100
FHR tachycardia
> 160 bpm for 10 minutes or longer
creatinine preeclampsia
>1.1
bilirubin HELLP
>1.2
uric acid HELLP
>10
uric acid preeclampsia
>5.9
childbirth preparations methods
A. Childbirth preparation methods i. Lamaze ii. Bradley method 1. Partner/husband coached—woman is engaged with partner and learn together how to go through the birthing process iii. women are now assisted to develop their birth philosophy + inner knowledge and choose from a variety of skills to sue to cope with the labor process iv. classes focus on fostering a woman's confidence in her innate ability to give birth v. women + partner are helped to recognize uniqueness of their pregnancy + childbirth experience
polyhydramnios
AFI> 24 cm excessive amniotic fluid surrounding fetus common in diabetic moms
placenta abruption all signs and symptoms
Abdominal pain Rigid board like abdomen Dark red vaginal bleeding Couvelaire uterus (purple or blue color to uterus with loss of contractility instead of a pink healthy uterus) Shock may occur Positive Apt test (blood in amniotic fluid) Positive KB test: fetal to maternal bleeding KB Test to see if there is any fetal to maternal blood mixing Decreased H&H Decreased coagulation factors DIC symptoms Abnormal FHR and pattern
Candidiasis risk factors
Abic therapy and steroids Pregnancy—hard to control in pregnancy thought to be due to the rising estrogen levels Obesity Diets high in refined sugars Tight fitting clothing, non-absorbent underwear
impaired liver function severe features of preeclampsia
Abnormally elevated blood concentrations of liver enzymes to twice the normal concentration; severe persistent epigastric or right upper quadrant pain unrespon¬sive to medication and not accounted for by alternative diagnoses, or both
FFN accuracy
Accurate for predicting NO labor for the next 2 weeks. 99% accurate for next 7 days 95% accurate for following week 90% accurate for 3rd week after test
nuchal cord
After the head is delivered the doctor sticks his hand in to Assess to see if the umbilical cord is wrapped around the neck (2) Nuchal cord x1—wrapped around once (3) Double nuchal cord—umbilical cord is wrapped around twice
DM low risk
Age < 25 Normal weight White (or low prevalence group) No history of poor OB outcome (loss, anomaly) No diabetes in 1st degree relatives No history of abnormal glucose tolerance
DM high risk
Age >40 Morbid obesity Darker skin Previous GDM, LGA or poor OB outcome Strong family history T2DM Glycosuria > +1 twice PCOS
Episiotomy
An incision in the perineum used to enlarge the vaginal outlet (2) Has steadily declined in recent years due to a lack of sound, rigorous research to support its benefits (3) Cut skin to make more room (4) Mediolateral (5) Median (or midline)
long term complications
Anemia Retinopathy of prematurity Hearing loss Cerebral palsy Neurobehavioral problems Cognitive and developmental deficits
A reedA==>how to assess Episiotomy/Laceration/Incision (and hemorrhoids
Approximation holding together or not
variable deceleration
Associated with cord compression (maternal position, cord around fetus, short cord, knot in the cord, prolapsed cord) Variable in appearance (U, V, or W shape) decrease in FHR of 15 bpm or more from baseline, lasts 15 seconds, return to baseline in less than 2 minutes Occasional variables are not as significant; repetitive variables indicate repetitive interruption of fetal oxygen supply
placenta previa diagnosis
Assumption for all painless vaginal bleeding after 20 weeks Abdominal US then transvaginal US
chlamydia treatment
Azithromycin No sexual activity for 7 days after completion Treat partners! Test of cure: Retest in 3 weeks Retest within 3 months Rescreen in 3rd trimester if high risk
gestational hypertension
BP >140/90 and <160/110 no other signs and symptoms development of HTN after week 20
frequency of vital signs
BP and pulse q 15 min x 2 hrs temp q4H x 8 hrs then routine
hypertension severe features of preeclampsia
BP reading ≥160/110 mm Hg × 2, at least 4 hours apart while the client is on bed rest (unless antihypertensive therapy
delivery complications with uncontrolled diabetes
Baby: macrosomia, shoulder dystocia mom: perineal tears, operative vaginal delivery cesarean
pre-existing diabetes preconception
Baseline assessments: CV, renal, ophthalmologic Tight control of blood sugars Folic acid Higher levels - 10x
pre-existing diabetes 3rd trimester
Be mindful for growth problems Expect induction by 40 weeks (mainly around 39 weeks)
placenta abruption active management
Birth if ≥ 36 weeks OR bleeding excessive or concerns about fetal well being C-section for placenta within 2 cm of os Maternal and fetal monitoring for hemorrhage Assessment postpartum for hemorrhage Emotional support
HIV transmission
Blood and bodily fluids Perinatal
hypertension preeclampsia
Blood pressure (BP) reading ≥140/90 mm Hg × 2, at least 4 hours apart after 20 weeks of gestation in a previously normoten¬sive woman
B (buBble hep)
Bowel
B (Bubble hep)
Breasts
fourth stage of labor assessment of maternal physical status (BUBBLE HE, way to systematically assess the mother)
Breasts uterus bowel bladder Lochia (vaginal bleeding after birth) perineum (watching for sings of swelling and hematoma) Extremities (looking for swelling and any sings of complications) Homan's sign (dorsiflex the foot and see if any pain is elicited) Emotion (transition in the immediately postpartum)
formula minerals
Ca and Ph (1.85:1) Iron Low Fluoride
breast milk minerals
Ca and Ph (2:1) Iron Low Fluroide
Bishop score
Calculation based on dilation, effacement, station consistency and position based on dilation, effacement, station, consistency, position i) 0-not favorable for pitcoin, cervix is not ready for contraction ii) Score of 9 for nultip iii) Score of 5 and up is good for a multip
discharge teaching for women after SAB
Call provider if.... Prolonged and heavy bleeding Prolonged and severe cramping Dizziness or fainting Fever > 100.4 Chills Foul smelling discharge
Candidiasis agent
Candida albicans
cardiovascular changes increases
Cardiac output (↑30-50%, beginning 8 wks)—starts in the first trimester Stroke volume (↑30%) Heart rate (↑15-20 beats/min want to keep HR under 140 bpm) Blood flow: Uterus (↑10x to 500-800 ml/min), Kidney (↑50%)Breasts, Skin (vasodilation)
3 TIER FHR INTERPRETATION: SHORT FORM
Category I: Normal. FHR 110-160, moderate variability, accelerations or not, no late decels Category II: Indeterminate. Minimal or marked variability, tachy or bradycardia without absent variability, and more. Category III: Abnormal. Absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia OR sinusoidal pattern
placenta abruption diagnostics
Clinical S&S U/S sometimes DIC symptoms and diagnostics Increased fundal height Abnormal FHR patterns Elevated uterine resting tone Ultimately post-birth visualization of placenta
neurologic changes
Compression of pelvic nerves or vascular stasis caused by enlarged uterus alters sensation in lower extremities Dorsolumbarlordosis can cause back pain due to compression of nerves Carpal tunnel syndrome can occur at any time, incidence rises with pregnancy Lightheadedness, faintness, and syncope due to postural hypotension or hypoglycemia Muscle cramps possibly due to hypocalcemia or mineral deficiency (low magnesium or other mineral deficiencies)
Hydrocephalus
Condition in which there is excess CSF in the ventricles of the brain due to overproduction (Rare) or a decrease in reabsorption b. Classic signs: vomiting, lethargy, irritability, setting sun eyes c. Ventriculoperitoneal shunt d. CSF buildup and causes enlarged ventricles
ectopic pregnancy abdominal pain
DULL abdominal pain starts on one side (RLQ, LLQ) then progresses to colicky pain when tube stretches => sharp stabbing pain => diffuse constant severe pain throughout lower abdomen
Spontaneous bowel movement may not occur for 2 to 3 days
Delay is caused by slowed peristalsis related to decreased muscle tone in the intestines during labor and the immediate puerperium, prelablor diarrhea, lack of food or dehydration.
DM medications in pregnancy
Depending on blood sugars Insulin Oral hypoglycemia
placenta previa expectant management
Depends on degree of abruption and blood loss < 34 weeks Maternal and fetal monitoring for hemorrhage and IUGR Corticosteroids for fetal lung maturity Corticosteroids and then moving towards delivery Depending on how bad it is they may need a C-section
respiratory anatomic changes
Diaphragm is elevated 4 cm by term ↑Diaphragmatic excursion ↑Chest circumference
digital cervical exam
Digital exam: check cervix in pt who is contracting but not ruptured, or in active labor even if ruptured. Checking both dilation and effacement. If membranes are ruptured, DO NOT CHECK. Decreases latency period by average of 9 days. Grade A evidence. Shortens latent period*** Cervical change Cervical change over 2 hours +/- More than 2 cm dilated or 80% effaced (consider EGA)
E rEeda==>how to assess Episiotomy/Laceration/Incision (and hemorrhoids
Edema
Spinal/scalp electrode
Electrode attached to fetal scalp
E (bubble hEp)
Emotions/Bonding
E (bubblE hep)
Episiotomy/laceration/Edema/Hemorrhoids/Incision
new born medications
Erythromycin Ointment Vitamin K injection Hepatitis B Vaccine (IM)
SAB management
Expectant: No intervention, bedrest, monitoring Medical: Misprostol ( to encourage the body to expel the products) Surgical: Dilation and Curretage (products are removed surgically) Past intervention: Needs to watch bleeding and for infection
fat requirements
Fat (31 g/day) breastmilk Lipids, Triglycerides, Cholesterol, EFA: Linoleic acid, DHA, ARA formula:Corn oil fat, No cholesterol Added Linoleic Acid Added DHA
ectopic pregnancy or tubal pregnancy
Fertilized ovum implants in the fallopian tube But can fertilized ovum can also implant in the ovaries and abdomen
feeding patterns formula
First 24-48 hours: 15-30 ml/feeding By end of 2nd week: 90-150 ml/feeding Feed q3-4 hours Once weight gain adequate - can sleep through the night
Bacterial Vaginosis signs and symptoms
Fishy odor Thin, white or gray milky discharge May have pruritis
nutrient needs of the infant
Fluids Energy Carbohydrate Fat Protein Vitamins & Minerals NOTE: No breast milk should ever be diluted, and no breast fed infant should ever be given water as this reduces the absorption of the above nutrients
Toxoplasmosis transmission
Foodborne, mother to child undercooked meats cats (infected often by eating rodents): parasite passed in the cat feces in microscopic form = NO LITTER BOXES (do not change the litter, especially if cat goes outside) contaminated ground soil-gardening, unwashed fruits.veggies (must wear gloves while gardening and wash hands when she comes back inside
G (apGar)
Grimace reflex irritability
preeclampsia with severe features
HTN 160/110 or more + persistent symptoms (don't respond to usual treatments) +/or other abnormal labs (with or without proteinuria) • Liver enzymes (AST, ALT) or LDH doubled • Low platelets +/or pulmonary edema
Past medical history Admission to L& D
HTN, diabetes, surgeries, infections
severe gestational hypertension
HTN> 160/110 no other signs of symptoms after 20 weeks of gestation
placenta previa maternal adverse outcomes
Hemorrhage Abnormal attachment (accreta, increta, percreta listed by increasing severity) Hysterectomy
Herpes Simplex 2 agent
Herpes Simplex Virus 2 (HSV 2)
feeding technique formula feeding
Hold during feedings - do NOT prop up bottle Bonding opportunity Slow-flow nipple in the beginning
H (bubble Hep)
Homan's
HIV agent
Human Immunodeficiency Virus
HIV risk factors
Hx of acute or chronic liver disease Risky sexual behavior IV drug use
signs of diabetic ketoacidosis in pregnancy
Hyperventilation Tachycardia Hypotension Ketotic breath Dry mucous membranes Disorientation Coma
ectopic pregnancy medical management methotrexate
IM i) Methotrexate is a highly toxic antineoplastic—stops cell division ii) Woman must be hemodynamically stable iii) Normal liver and kidney function iv) Mass must be intact (unruptured) and < 3.5 cm v) Obtain height and weight for proper dosing
steroids (bethamethasone, Dexamethasone)
Improves neonatal outcomes: reduced neonatal death, RDS, IVH, necrotizing enterocolitis, sepsis, NICU admission Use when PTD likely within 7 days, 24 to 34 weeks: pPROM, PTL, or PIH
lower uterine transverse or vertical classical transverse up and down c-section
In order to have a vaginal birth after a c—section they have to have had a lower uterine transverse C/S
accelerations
Increase in FHR above baseline < 2 min. long The peak is at least 15 beats above the baseline, lasts for 15 seconds, with a return to baseline in less than 2 minutes accelerations = indication of fetal well being **REACTIVE STRIP: increase 15 bpm x 15 seconds twice in a 20-minute period.
renal anatomic changes
Increase in size Dilation of renal pelvis and ureter Increase in residual volume of bladder Urinary stasis==>↑pyelonephritis in patients with asymptomatic bacteriuria
Indications of adequate newborn nutrition and hydration
Indications of adequate newborn nutrition and hydration can be easily assessed in the diaper
gonorrhea transmission
Lives primarily in vaginal fluid and semen Primary transmission through vaginal or anal sex Mother -fetal vaginal transmission during birth
L (bubbLe hep)
Lochia
4 vaccines commonly given in the postpartum period
MMR Flu TDAP varicella
variable deceleration management
Maternal position change => b/c it's cord compression Oxygen 8-10L/min => if becomes repetitive Notify provider Amnioinfusion =>need IUPC; need to monitor for infection, pressure, contractions (want to make sure fluid is coming back out) Instill fluid into the uterine cavity to help cushion the cord Assist with birth if pattern doesn't resolve => may result in C/S
uncontrolled protestational DM early pregnancy
Microvascular: worsening of retinopathy, nephropathy Infection (UTI) Miscarriage Anomalies: 2/3 involve cardiovascular and CNS • Neural tube defects • Caudal regression syndrome • Ventricular septal defects
Describe the current prevalence and incidence of perinatal depression in the U.S.
Most Common Complication of Pregnancy ii. 15% of pregnant women diagnosed in the postpartum a. Higher in certain ethnicities (API in particular) 1. Asian and pacific islanders 2. Under reported, a lot of women don't want to disclose b. Often undiagnosed iii. Lack of treatment has sequelae for mother and baby a. Both mother and baby suffer
syphilis women at risk
Multiple sexual partners, high risk sexual practices
Rhogam Rh immune Globulin, RhoGAM, Gamulin Rh, HyRho-D, Rhophylac adverse effects
Myalgia, lethargy, localized tenderness and stiffness at injection site, mild and transient fever, malaise, headache; rarely nausea, vomiting, hypotension, tachycardia, possible allergic response
renal insufficiency preeclampsia
New development of serum creatinine >1.1 mg/dl or a doubling of the serum creatinine concentration in the absence of other renal disease
Bacterial Vaginosis risk factors
New or multiple partners Douching Receiving oral sex
nitrous oxide for analgesia
Nitrous oxide mixed with oxygen can be inhaled in a low concentration (50% or less) to provide analgesia during the first and second stages of labor.
contraception
Non-hormonal methods - barrier devices, IUD's, natural planning for first year after birht breastfeeding alon not reliable beyond 6 months i. Non-hormonal methods - barrier devices, IUD's, natural planning ii. Estrogen containing methods not recommended. Progestin only contraceptives better, but not till after 6 weeks
infant breast feeding reduces risk of
Nonspecific GI infections 2. Childhood IBD 3. NEC for preterms 4. Atopic conditions 5. Respiratory Tract Infections—asthma 6. Ear infections 7. SIDS 8. Later obesity—lower, related to optimal establishment of gut microbiome, ways of feeds will be less obesogenic with breast feeding vs bottle feeding. 9. Diabetes 10. Some childhood cancers—leukemia
Normal HR
Normal: 50-90 Remains elevated 1st hour after birth Gradually decreases over 1st 48 hours May be bradycardic (40-50 bpm)
Candidiasis treatment
OTC antifungal creams (Fluconazole) Complete course of treatment
BUN PREECLAMPSIA AND HELLP
OVER 20
ABO incompatibility
Occurs with Maternal type O blood & fetal type A, B, or AB 2. Naturally occurring anti-A and anti-B antibodies cross the placenta to the fetus 3. Results in a Positive Coombs' test a. At the first prenatal vist of an Rh-negative woman with a fetus who may be Rh positive an indirect coomb's test should be done to determine whethere she had anitbodies to the Rh antigen. Maternal blood serum is mixed with Rh—positive RBCs. Positive = clumps. Repeated at 28 weeks
Butorphanol Tartrate (Stadol)
Opioid (narcotic) agonist-antagonist analgesics 1-2 mg. IV Q 3-4h. More sedative, less N&V. Duration 4-6 hrs.
Nalbuphine Hydrochloride (Nubain)
Opioid (narcotic) agonist-antagonist analgesics 10 mg. IV Q 3 h. Duration 2-4 H IV and 4-6 IM
hemorrhagic disorders later in pregnancy
Placenta Previa Placental Abruption Vasa Previa DIC
thrombocytopenia preeclampsia and severe features of preeclampsia
Platelet count <100,000/μL
PMI
Point of maximal impulse at fourth intercostal space to left of midclavicular line, often visible and easily palpable (also called the apical pulse)
symptoms of diabetic ketoacidosis in pregnancy
Polyuria Polydipsia N/V Abdominal pain Weakness Weight loss Decreased fetal movement
Management of postdate pregnancy accurate dating
Postdate—over 42 weeks
spontaneous Abortion (SAB)/miscarriage
Pregnancy that ends as a result of natural causes before 20 weeks of gestation. A fetal weight less than 500 g also may be used to define an abortion. Miscarriage is the lay term for a spontaneous abortion.
placenta previa fetal adverse outcomes
Preterm birth- Because placenta is on the cervix, leading to potential changes to the cervix Stillbirth Malpresentation Anemia
Bacterial Vaginosis epidemiology
Prevalence is most common in women of childbearing age (14-49)
stool progression
Progress over first 3 days - (1/day1, 2/day 2, etc). After that - 3 soft stools per day 1. 1 wet/ 1 dry - day one 2. 2 wet/ 2 dry- day two 3. 3 wet/3 dry-day three (minimums may have more)
renal insufficiency severe features of preeclampsia
Progressive renal insuffi¬ciency (serum creatinine concentration >1.1 mg/dl or a doubling of the serum creatinine concentration in the absence of other renal disease
DIC labs prolonged or increased
Prolonged or increased: taking longer to clot (a) PT/PTT (b) Fibrin degradation products
Protein
Protein - requirement is essential for newborn growth. Breast milk ratio of whey to casein is more easily digestible...hence the soft stools Type of whey (alpha-lactalbumin has amino acids essential for human growth, also has iron-binding capabilities and bacteriostatic properties against potentially pathogenic bacteria, thereby enhancing iron absorption.
normal findings proteinuria
Proteinuria common (check for other sx UTI and preeclampsia)- clean catch or cath specimen
proteinuria preeclampsia
Proteinuria of ≥300 mg in a 24-hr specimen Protein/creatinine ratio ≥0.3 (with each measured as mg/dl) ≥1+ on dipstick (used only if quantitative methods are not available
Candidiasis signs and symptoms
Pruritus, Dryness, Dysuria, Thick, white lumpy cottage-cheese like discharge, Erythema, may have a musty, yeasty odor
syphilis screening
RPR & VDRL FTA-ABS If RPR is positive have to have a FTA-ABS to confirm syphilis diagnosis
general anesthesia
Rarely used for uncomplicated vaginal birth b. The woman should be pre-medicated with (clear) oral antacid to neutralize the acidic contents of the stomach. prevent aspiration Because of this risk for neonatal narcosis (neonatal state of unconsciousness), it is critical that the baby be delivered as soon as possible after induction of general anesthesia, to reduce the degree of fetal exposure to the anesthetic agents and the CNS depressants administered.
pre-existing diabetes 2nd trimester
Re-check HbA1C and kidneys Anatomy scan Fetal echocardiogram if 1st trimester A1C was elevated
Adverse effects on babies from hyperglycemia, hypoxia + hyperinsulinemia after delivery
Respiratory distress Syndrome Hypoglycemia Polycythemia and hyperrilirubinemia
short term complications
Respiratory distress syndrome Intraventricular hemorrhage Temperature regulation Necrotizing enterocolitis Apnea Infection/sepsis Patent ductus arteriosus Feeding difficulties Jaundice Anemia
Rhogam Rh immune Globulin, RhoGAM, Gamulin Rh, HyRho-D, Rhophylac indications
Routine antepartum prevention at 28 weeks of gestation in women with Rh—negative blood; suppress antibody formation after birth, miscarriage, pregnancy termination, abdominal trauma, ectopic pregnancy, amniocentesis, version or chorionic villus sampling
HIV assessment and treatment
Screened for at first prenatal visit Must go on antivirals to prevent MATERNAL to FETAL transmission May have to have C-section if there viral load is to high Avoid breastfeeding (recommended in 3rd world countries because risk of consuming contaminated water is higher than transmission of HIV) Screen at first prenatal visit Tx: ART therapy C-section Avoid breastfeeding
women at risk for chlamydia
Sexually active women Multiple partners Non-use of barrier methods AA higher rate/risk
immediate assessments and care of newborn
Skin to skin, Apgar score, promoting breast feeding, clearing the airway, clean and dry, ABCs
normal BP
Slight increase from baseline (5% increase over 1st few days, return to baseline in a few weeks) Orthostatic Hypotension (typically 1st 48 hours)
formula feeding concerns
Spitting: Burp Hold upright after feeding Don't overfeed
Opioid agonist/antagonist
Stadol, Nubain: stimulate kappa but block/partially block mu receptors provides adequate analgesia and limits maternal and fetal respiratory depression
Rhogam Rh immune Globulin, RhoGAM, Gamulin Rh, HyRho-D, Rhophylac action
Suppression of immune response in nonsensitized women with Rh—negative blood who receive Rh-positive blood cells because of fetomaternal hemorrhage, transfusion or accident
Incomplete SAB surgical and medical management
Surgical—D&C (May or may not require additional cervical dilation before curettage) Medial—vaginal misoprostol (gets uterus to contract and expel the placenta and fetus)
hypothyroid
Synthroid levels will be checked every semester Undiagnosed which is discovered during pregnancy must be treated quickly because untreated hypothyroidism can have neurologic effects on the baby
syphilis agent
T.Pallidum
hypothyroidism labs
TSH high FT4 normal subclinical FT4 low hypothyroidism TPO antibodies
abnormal HR
Tachycardia (>100 bpm) Hypovolemia, infection, fear, pain
Beta-adrenergic receptor agonists (terbutaline) maternal side effects
Tachycardia, chest discomfort, palpitations, arrhythmias, tremors, dizziness, nervousness Headache, nasal congestion, difficulty breathing Nausea and vomiting Hypokalemia, hyperglycemia Hypotension Maternal side effects intolerable: tachycardia greater than 130 bpm, BP less than 90/60, chest pain, cardiac arrhythmias, MI, pulmonary edema
parvovirus women at risk
Teachers, daycare workers, women who work in pediatrics (pediatricians, nurses, PNPs)
Evaluate everyone's risk at 1st OB visit (screening of gestational diabetes)
Test very high risk women ASAP: A1C, fasting, random BS, or 2-hr OGTT Consider re-testing them at 15-17 wks if 1st test is normal.
postpartum BP
There is a transient increase in blood pressure of approximately 5% during the first few days after birth. It can take weeks or months for pulse and blood pressure to return to prepregnancy levels. Increase in blood pressure greater than 140/90 when measured on two or more occasions at least 6 hours apart can indicate preeclampsia.
touch
Touch - soles of feet 1. The infant is responsive to touch on all parts of the body. The face (especially the mouth), the hands, and the soles of the feet seem to be the most sensitive. 2. Birth trauma or stress and depressant drugs taken by the mother decrease the infant's sensitivity to touch or painful stimuli.
antigen
Toxin or foreign substance that induces an immune response in the body resulting in the production of antibodies
Herpes Simplex 2 active lesion at time of birth
VAGINAL BIRTH CONTRAINDICATED MUST HAVE A C-Section
Herpes Simplex 2 treatment
Valacyclovir, Acyclovir (dose varies depending on if it's the first episode or recurrent)—see cdc website Prophylaxis at 36 weeks
Varicella agent
Varicella zoster virus (herpes family)
how often should a women go to the bathroom after delivery
Voiding every few hours beginning within a few hours of delivery (1st 6-8 hours is ideal)
formula feeding cleaning
Warm soapy water and nipple brush Boiled for 5 minutes at least before first use Boiling not necessary (after first use) if cleaned in dishwasher
uterus changes increase in size
Weight: 70 g =>1100 g Volume: 10 mL => >5000 mL
fetal station (fetal position/Passenger)
a measure of the degree of descent of the presenting part of the fetus through the birth canal (1) High= -5 really floating (2) As the baby moves down the number gets larger (3) -5 ->0 (4) 0 station= engaged (when the baby's head hits the ischial spine)
nursing considerations preparing for the birth second stage bearing down efforts
a) (involuntary response to the ferguson reflex) often accompanied with a grunt or groan b) Body start pushing on its own (abs contract and pelvic floor relaxes) c) Valsalva maneuver (holding breath and counting to 10) d) *discouraged: increases intrathoracic and cardiac pressure, reduced uterine perfusion e) Encourage open glottis pushing—push on own
velamentous insertion
a) : fetal vessels implanted into the membrane i) Blood vessels in the membrane occurs when the cord vessels begin to branch at the membranes and then course onto the placenta
choriamnionitis
a) Bacterial infection of the amniotic cavity i) Most often occurs after membrane rupture or labor begins as organisms that are part of the normal vaginalflora ascend into the amniotic vavity
OB history admission to L&D
a) Current OB history and Past Ob history-Gs and Ps (previous kids), Prenatal care?, Water broken?, EDC—how many weeks along Complications during the pregnancy—infections, HTN, bleeding Past history and past complications during pregnancy C—section lower uterine transverse or vertical classical transverse up and down c-section? Placenta previa? Don't do a vaginal exam because you could rupture the placenta Cervical check (dilation, effacement, station, presentation) Contraction, frequency, duration, when started ROM or bloody show (more in a few slides) Fetal movement, fetal heart rate labs
artificial rupture of membranes (amniotomy) reason
a) break the membrane artificially b) Reason: induction or augmentation i) Great way to try to induce labor without medication
causes of labor are multifactorial
a) changes in the uterus, cervix b) hormone shifts (estrogen, progesterone) c) uterine distention, increasing intrauterine pressure--A woman pregnant with twins has a lot of uterine distention so is at greater risk of preterm birth d) aging of the placenta--Placenta is a temporary organ ,Factors released from the placenta that induces labor, Microbes—play a factor?
PROM Dx
a) check gross rupture, nitrazine, pooling (amniotic fluid just sitting next to the cervix), ferning, amnisure b) 90% will go into labor spontaneously within 24 hours
succenturiate lobe placenta divided into 2 lobes
a) placenta divided into 2 lobes i) Placenta divides usually looks like large placenta on one side and smaller lobe on the other side with vessels in between the two lobes ii) Placenta has divided into two or more lobes rather than remaining as a single mass. iii) Fetal vessels then run between the lobes of the placenta. The vessels collect at the periphery, and the main trunks eventually unite to form the vessels of the cord. iv) During the third stage of labor one or more of the separate lobes may remain attached to the decidua basalis, preventing uterine contraction and increasing the risk of postpartum hemorrhage.
uterine rupture risk factors
a) prior uterine surgery, congenital uterine anomaly, overdistended uterus, use of induction agents, version, fetal malpresentation i) Risk of using Pitocin (1) Causes the uterus to contract so much that is ruptures
ABX for PPROM infections
a. 7 day course first two days IV, next 5 days oral. i. prolonged pregnancy > 7 days ii. reduced neonatal morbidity b. 2 phases: i. 2 days IV antibiotics: erythromycin 250 mg q6h and ampicillin 2 g q6h and ii. 5 days po antibiotics: erythromycin-base 333 mg q8h and amoxicillin 250 mg q8h and enteric-coated
RDS chances of development
a. < 28 weeks gestation - 60% b. 28-32 weeks gestation - 50%
when to deliver after pPROM
a. Active/advanced labor i. Maternal or fetal safety in jeopardy ii. Chorioamnionitis (also a danger to mom) iii. Fetal distress (non-reassuring status) iv. Placental abruption b. 34 weeks? Risk of infection starts to increase over time, so usually deliver around 34 weeks since the baby won't have any long term issues *** c. Documented fetal lung maturity (L:S ratio 2:1) i. Amniocentesis ii. Vaginal fluid collection (if what is leaking)
NB discharge plan
a. Back to sleep & safe sleep environment and sleep hygiene b. Temperature regulation, how to take an axillary temperature i. Fever (>100.4 axillary or <97.7) c. Feeding Patterns i. Poor feeding (over 10% wt loss in first 3-5 days) ii. Projectile Vomiting d. Normal elimination patterns i. ↓BM ii. Diarrhea iii. ↓urination e. Also call nurse/pediatrician if: i. Breathing difficulties ii. Cyanosis iii. Jaundice iv. Lethargy v. Inconsolable crying vi. Infection at umbilicus or circumcision vii. Eye drainage
preterm infants classified by
a. Birth weight, SGA, AGA, LGA b. Gestational age
breast engorgement treatment
a. Breastfeeding mothers i. Frequent feeding, ice, mild analgesia b. Non-breastfeeding c. Well-fitted supportive bra, ice, cabbage leaves, mild analgesia, NO PUMPING d. Stimulation =milk production e. So if you are not breast feeding definitely don't want to stimulate the breasts
4 stages of maternal role attainment
a. Commitment/Attachment to the unborn baby/Preparation for delivery and motherhood during Pregnancy b. Acquaintance and attachment to the infant, learning to care for the infant, physical restoration during the 1st 2-6 weeks following birth c. Moving towards new normal d. Achievement of a maternal identity through redefining self to incorporate motherhood
NSAIDs fetal
a. Constriction of ductus arteriosus b. Oligohydramnios, caused by reduced fetal urine production c. Neonatal pulmonary hypertension
congenital diaphragmatic hernia
a. Diaphragm doesn't completely close b. If it is a small opening they can repair it laparoscopically c. Fetal lungs underdeveloped**** d. Results form a defect in the formation of the diaphragm, allowing the abdominal organs to be displaced into the thoracic cavity
Prevention is administration of RhoGam or Rhophylac in Rh Negative mothers
a. Don't wait to find out if the baby is Rh positive b. Administration Before and after delivery c. Doesn't affect the current pregnancy but will develop antibodies and can have problems with subsequent pregnancies
testing cultures
a. Done because of the rate of infection associated with preterm labor. 30-50% of preterm labors are associated with maternal infection b. GC and chlamydia NAAT c. NAAT typically detect 20-50% more chlamydial infections than could be detected by culture or earlier nonculture tests d. Urine culture i. Also test UA e. Group B Strep f. Wet prep
When else have we heard of oxytocin?
a. During labor and contractions. So MER can be triggered in labor releasing some colostrum. Kind of like nature's way of preparing to feed the baby. Also explains the relationship with uterine involution postpartum - but it can cause painful cramping which may last 3-5 days.
post-dural puncture headaches (PDPH)
a. Epidural blood patch there's a chance they can accidently make a little hole + after the epidural that fluid can continue to leak out and can manifest as a headache (puncture dura mater so leaking CSF) i. need to explain this to them post-epidural ii. fix it with an epidural blood patch will take some of their blood like an epidural + it will close the hole = immediate relief of headache
Describe physiologic and behavioral adaptations the neonate experiences at the time of birth
a. Establish and Maintain Respirations b. Circulatory adaptation c. Thermoregulation d. Suck, swallow, breath—one of the hardest things for premature babies to develop e. Elimination f. Weight gain g. Regulate behavior independent of the mother h. Process sensory stimuli i. Establish relationships with caregivers/family
Sore nipples assessment
a. Flat? Inverted? Cracks? Soreness? Blisters? Bleeding? b. Assess and correct latch i. Assess to limit how sore nipples are c. Proper feeding position
signs and symptoms of PPD
a. Identical to major depression b. Anxiety is prevalent c. Irritation, Anger or Rage d. Overwhelmed e. Sleep Problems f. Sadness g. Lack of Connection h. Lack of Concentration
nonlochial bleeding
a. If the bloody discharge spurts from the vagina, and the uterus is firmly contracted, there can be cervical or vaginal tears in addition to the normal lochia. b. If the amount of bleeding continues to be excessive and bright red, a tear can be the source.
breast is best
a. Infant formula may be adequate, but breast milk is superior. b. Scientific evidence makes it clear that: Breast is best i. Species-specific and composition changes to meet infant nutritional and immunologic needs ii. Formula may be adequate, but breast is by-far superior 1. Breast milk cannot truly be substituted
Intermediate or limbic myelination
a. Intermediate or limbic i. Hunger, instincts, emotions, memory, sensory input
fragile brain structures at risk
a. Intraventricular Hemorrhage b. Periventricular leukomalacia - abnormal lesions of white matter
Causes hemolysis of fetal RBC's
a. Isoimmunization - leading to fetal anemia b. Erythroblastosis Fetalis - immature erythrocytes i. Hydrops fetalis—most severe form, has marked anemia, cardiac decompensation, cardiomegaly, and hepatosplenomegaly ii. The fetus compensates for the anemia by producing large numbers of immature erythrocytes to replace those hemolyzed
Lochical Bleeding
a. Lochia usually trickles from the vaginal opening. The steady flow is greater as the uterus contracts. b. A gush of lochia can appear as the uterus is massaged. If it is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium
early onset GBS risk factors
a. Low birth weight b. Preterm birth c. Ruptured membranes > 18 hours d. Maternal fever e. Previous infant with GBS sepsis f. Maternal GBS bacteriuria g. Internal fetal monitoring h. Maternal age < 20 i. Hispanic or African-American ethnicity
questionable strategies for PTL
a. Maintenance with tocolytics i. Calcium channel blockers, oxytocin antagonists, terbutaline therapy (t-pump) b. Tocolysis with agents not discussed i. Ethanol infusion, oral betamimetics, nitric oxide donors, progestational agents c. IV hydration i. Only helps if patient is actually dehydrated d. Bedrest i. Potential problems: psych, constipation, clots, sleeping, $$, etc. ii. Benefits for pts with gestational hypertension or pPROM still being investigated e. Relaxation therapy (doesn't hurt, though)
post term infant complications
a. Meconium aspiration b. Hypoglycemia c. RDS—respiratory distress syndrome d. Transient Tychapnea of the Newborn, TTN e. Increased risk of perinatal loss
ABO Incompatibility can cause
a. Mild anemia b. Hyperbilirubinemia
L/D considerations related to PTD
a. Need level III NICU (all Atlanta area hospitals) b. Watch for malpresentation and retained placenta i. More likely to be breech and placenta doesn't want to detach from the wall of the uterus c. Continuous monitoring i. Pre term babies ii. Risk of infection d. Obtain cord ABG i. Unless they come out and are very vigorous
Describe immediate nursing interventions to facilitate successful NB transition.
a. Newborn Metabolic Screening - "PKU" i. Screens for 31 core disorders and 26 secondary disorders ii. Screens for numerous metabolic disorders b. Hearing Screening i. Initial screen with EOAE test (evoked otoacoustic emissions) ii. Follow up screen: ABR test (auditory brainstem response) c. Critical Congenital Heart Disease- "CCHD"
meconium aspiration syndrome
a. Passes meconium into amniotic fluid into lungs, babies skin will be stained with meconium b. Pneumonitis & pneumonia c. Bile salts cause a pancreatic enzymes cause chemical pneumonitis 1. Can occlude small distal airways d. Meconium occludes distal airways and obstructs airflow on expiration, leads to trapping of air e. Rarely occurs before 38 weeks gestation 1. Good indicator of exposures in utero, can be send of for analysis f. Mechanical ventilation g. Sedation h. Nutrition
prolonged rubra, serosa or alba (abnormal bleeding)
a. Persistence of lochia rubra in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. It is not uncommon for women to experience a sudden, but brief, increase in bleeding 7 to 14 days after birth when sloughing of eschar over the placental site occurs. If this increase in bleeding does not subside within 1 to 2 hours, the woman needs to be evaluated for possible retained placental fragments b. About 10% to 15% of women still have normal lochia serosa discharge at their 6-week postpartum examination However, the continued flow of lochia serosa or lochia alba by 3 to 4 weeks after birth can indicate endometritis, particularly if the woman has fever, pain, or abdominal tenderness.
Identify when Rhogam would be needed and briefly describe its action.
a. Preventing Rh Isoimmunization. Injection of Rh immune globulin (a solution of gamma globulin that contains Rh antibodies) within 72 hours after birth prevents sensitization in the Rh-negative woman who has had a fetomaternal transfusion of Rh-positive fetal red blood cells (RBCs) (see the Medication Guide). Rh immune globulin promotes lysis of fetal Rh-positive blood cells before the mother forms her own antibodies against them. b. The administration of 300 mcg (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization. If a large fetomaternal transfusion is suspected, however, the dosage needed should be determined by performing a Kleihauer-Betke test, which detects the amount of fetal blood in the maternal circulation. If more than 30 ml of fetal blood is present in maternal circulation, the dosage of Rh immune globulin must be increased
prolactin
a. Prolactin started its work during pregnancy preparing the breasts for lactogenesis. b. Levels are highest, however, the first 10 days after birth c. Prolactin produced by anterior pituitary gland in response to infant sucking and emptying of breast. It's a supply-meets demand system. d. Starts of in the hypothalamus anterior pituitary prolactin allows for milk production i. This process is stimulated by sucking or pumping ii. If the baby can't be put to breast in the first hour. It is important to initiated pumping as soon as possible if the baby can't be put to breast with in the first couple of hours
circumcision ***
a. The intact penis is easy to clean and care for (Don't retract the foreskin!) b. Circumcision i. Ultimately a parental decision: AAP recognizes some benefits but no routine recommendation ii. Gomco, Mogen or Bell iii. ****taking care of the penis c. Pain assessment i. 0,1 or 2 for each parameter for total 10 max pain. >4 is significant. Tool for 32 weekers to 20 weeks of age. ii. Goals of pain management are minimize intensity, duration and physiologic cause to the pain and maximize the baby's ability to cope with and recover from the pain. iii. Most acute pain remains undermanaged and even completely ignored! iv. Score with 0,1, or 2 for each of the following: 1. Crying 2. Requires O2 for saturation >95% 3. Increased VS 4. Expression 5. Sleepless v. Goals of pain management: 1. Minimize intensity, duration and physiologic cost of pain 2. Maximize the baby's ability to cope with and recover from pain 3. Most pain is not assessed or treated, it is a major priority d. Nursing actions i. Silver nitrate - chemically cauterizes ii. Pain control - Nerve Block, Emla, other non-pharm measures (glucose, breastfeeding or soothing presence) iii. Restraints iv. Aftercare: 1. Assessment of bleeding (15 min, 45 min) 2. Watch for first void 3. Bleeding - pressure with sterile gauze pad 4. Persistent bleeding - gelfoam or silver nitrate stick 5. Tylenol 6. Skin to skin with mother or father
pTL triage
a. Urine: culture, GC and Chlamydia b. VS c. Palpate: abdominal tenderness and contractions i. Abdominal tenderness can be a sign of infection d. Monitor- evaluate contractions and FHR e. Swab: some may require speculum exam i. Contracting fFN (http://www.ffntest.com/hcp/testing/specimen_collection.html) ii. Leaking Fern, nitrazine, Amnisure iii. Wet mount: BV, trich, yeast iv. Look at cervix v. GBS Cultures f. If not ruptured, check cervix now and in 2 hours g. Ultrasound (maybe, not routine) i. Cervical length (esp. if < 32 weeks) and/or funneling ii. AFI
what makes breast feeding so ideal
a. Various immunoglobulins, T and B lymphocytes, cytokines, interleukins, complement, lactoferrin b. Immunological properties have a role in preventing localized and systemic bacterial and viral infections c. Changes to meet the nutritional and immunologic needs of growing infant d. Colostrum - high protein level facilitates the binding of bilirubin growth spirts
Neonatal Abstinence Syndrome, NAS Lilly's place
a. West Virginia has a huge issue with NAS b. Transition for families learning to care for these infants c. Continued detox, basically a long term space for detox d. https://www.slideshare.net/USDTL/the-impact-of-neonatal-abstinence-syndrome-on-one-west-virginia-community e. https://www.youtube.com/watch?v=XlxqpE-Fpik
psychosis psychiatric emergency
a. high mood with racing thoughts b. severe confusion c. paranoia d. hallucinations (auditory or visual) e. begin suddenly within the 1st 2 weeks after childbirth
tocolytics
a. shut down contractions, most are not associated with better fetal outcomes b. Goal is to give steroids time to work. MOST DATA SHOWS NO/FEW BENEFITS otherwise. i. Use is for 24-48 hours while administering steroids, not longer. ii. Maintenance/prevention therapy: more harm than good.
combined spinal-epidural (CSE) analgesia
a. sometimes referred to as a "walking epidural," although women often choose not to walk because of sedation and fatigue, abnormal sensations in and weakness of the legs b. involves injection of a small amount of opioid and local anesthetic injected intrathecally (into the spinal canal) option for people who want to be a little more mobile, but usually chose not to do to fall risks i. don't have to use as much because there are mu receptors in this space and thus a smaller dosage can be used
cerclage
a. stich in the cervix that helps keep it closed i. Typically, only for the patients that a loss because the cervix is incompetent (loss in the third trimester or shorted cervix) ii. Stich can give a little extra support
fluid bolus/IV access (nursing care of a patient with epidural for birth)
a. typically, about 1L of fluid bolus b. hypotension give fluid to offset this drop in BP (start IV bolus prior to epidural to anticipate the pressure drop
local perineal infiltration anesthesia
a. used with episiotomy b. laceration repair after delivery c. 10-20 ml of 1% Lidocaine into the skin and subcutaneous area to be anesthetized
signs and symptoms of ectopic pregnancy
abdominal pain delayed menses 1-2 weeks or lighter than usua; vaginal spotting 6-8 weeks after LMP mild to moderate dark or brown spotting
Leopold's Maneuvers
abdominal palpation which helps you to answer three questions to determine lie and presentation of fetus 1. what fetal part is in the uterine fundus? hard=head, squishy=butt 2. where is the fetal back located? smooth=back 3. what is the fetal presenting part? what is presenting into the inlet or brim of the pelvis
marginal insertion
acord inserted at the edge i) Insertion of the cord is on the edge instead of the middle ii) Increased risk of evulsion—disconnects from the edge iii) Increases the risk for fetal hemorrhage, especially after marginal separation of the placenta
three phases of maternal attachement
acquaintance phase phase of mutual regulation reciprocity
Appearance/skin color apgar 1
acrocyanosis
marked variability
amplitude range greater than or equal to 25 bpm have to think about the peaks and troughs and how much it is going above and below greater than 25 bpm fluctuation may see periods of marked variability if the baby is very active but don't want to see it sustained
internal rotation
baby descends transverse and then internally rotates into the AP diameter baby turns its head from transverse to A/P diameter and shoulders typically stay where they are
oblique lie
baby is at a 45 degree angle to the mother's spine
horizontal lie
baby is lying perpendicular to mother's spine
longitudinal/vertical lie
baby spine is in line with the mom's spine (a) Can be a vertex or breech and still be longitudinal
weight gain during pregnancy
based off of pre--pregnancy BNI pre pregnancy BMI <18.5 underweight 12.5-18 (28-40) normal weight 11.5-16 (25-35 lbs) overweight 7--11.5 (15-25 lbs) obese 5-9 (11-20 lbs)
basic fetal heart rate
baseline fetal heart rate (FHR) variability presence of accelerations periodic or episodic decelerations change or trends of FHR over time
inevitable SAB expectant management
bedrest if no pain,bleeding or infection
late decelerations
begins after the contraction starts, nadir after the peak of contractions associated with fetal hypooxemia, acidemia, and low apgars gradual decrease in and return of FHR in relation to contraction beings after onset late of contraction, nadir after the peak of contraction
compensatory lumbar lordosis
bend in the lower back increases as the baby grows low back pain chiropractor helps with lower back pain as well as overall optimal health
ectopic pregnancy screening
beta-hcg progesterone assess for active bleeding associated with tubal rupture
timing of administration of pharmacological interventions
better during active phase than latent b/c cervix is changing (want cervix to be changing)
Posterior Fontanel
between the sagittal and lambdoid suture looks like a triangle
Abnormal skin variations
brusises lacerations skin tags central cyanosis petechia jaundice (usually occurs 24 hours after birth)
Opioid (narcotic) agonist-antagonist analgesics
butorphanol tartrate nalbuphine hydrochloride
involution is influenced by
by size of baby, long induction 1. Postpartum it can be a challenge since the muscles are really warn out 2. Risk for hemorrhages
postpartum respiratory function
c. Respiratory function rapidly returns to nonpregnant levels after birth. After the uterus is emptied, the diaphragm descends, the normal cardiac axis is restored, and the point of maximal impulse and the electrocardiogram are normalized.
steroids (bethamethasone, Dexamethasone) dosing
c. Usually 1 round. Repeat round is not routine. d. If dosing repeated in 1-2 weeks, results in less RDS and serious problems, but lower birth weight (around 75 grams). e. Dosing: i. Betamethasone (Celestone) 1. 12 mg IM q 24 h x 2 doses ii. Dexamethasone 1. 6 mg IM q 12 h x 4 doses
therapeutic touch
can be as simple as holding woman's hand, stroking her body, and embracing her (need to determine what woman's preference is first though) uses concept of energy fields within the body called prana (Redirect energy fields associated with pain) enhances relaxation, reduces anxiety, and relieves pain
increased use of oxytocin side effect of epidural anesthesia
can spread out the frequency of contractions, so dont want to give too early in second phase
three tier system for EFM interpretation
category I: normal baseline moderate variability, +/- decels or accelerations Category II: intermediate category III: abnormal fetal monitoring standards nursing management of nonreassuring patterns
prolonged decelerations causes
caused when mechanisms associated with late of variable decels last for an extend period of time common causes: maternal hypotension, uterine tachysystole, prolonged cord compression manage with same interventions as late decelerations
3 presentations
cephalic/vertex breech shoulder
chlamydia agent
chlamydia trachomatis
Anterior Fontanel
coronal suture, frontal suture and sagittal suture. Looks/feels like a diamond
changes to the ovaries
corpus luteum continues to function maximally during first 4 weeks after conception
discomfort/pain (Factors that affect lactogenesis )
cramping and nipple soreness
three general categories of non--pharmacologic strategies
cutaneous stimulation (heat/cold, effleurage) sensory stimulation (aromateherapy, music) cognitive strategies (hypnosis)
C
cytomegalovirus
Retinopathy of prematurity (ROP)
damage and scaring of retina - visual impairment 1. Most commonly associated with administration of supplemental oxygen 2. Complex multicausal disorder that affects developing retinal vessels of prterm infants 3. Scar tissue formation and consequent visual impairment can be mild or severe
neuroprotection improved outcomes for infants born premature
decreased incidence of IVH, Cerebral palsy and substantial gross motor dysfunction
dehydration
decreased urine output, excessive sleepiness, irritability, sunken fontanel, dry mouth
fibrinolytic activity pregnancy
decreases in pregnancy
club foot
deformity of the foot and ankle that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus
4th stage of labor nursing priorities
delivery of placenta, 2 hours following delivery of the placenta) i. Prevent/treat excessive bleeding ii. Monitor VS iii. Provide comfort/warmth iv. Promote parent-infant attachment
fourth stage of labor
delivery of placenta-2 hours postpartum early postpartum period
1st letter fetal position
denotes the location of the presenting part to the mother's pelvis R= right (maternal right) L= Left
FHR tachycardia interventions
dependent on cause reduce maternal fever with antipyretics as ordered and cooling measured Oxygen at 10 L/min by nonrebreather face mask may be of some value Carry out health care providers orders based on alleviating cause
first stage laboratory and diagnostic tests
depends on the extent of prentatal care (1) Analysis of urine specimen (2) Blood tests (a) Complete blood count (CBC)—done on arrival have to know hgb and platelet count (b) Human immunodeficiency Virus (HIV) status is undocumented (c) Type and screen (3) Assessment of amniotic membranes and fluid (4) Other tests (a) If GBS status unknow, rapid test can be performed (b) > 36 weeks go ahead and treat (5) Sings of potential problems? FHR, is she bleeding?
abnormal respiratory rate
depressed respirations: spinal anesthesia or an epidural opioid medication
postpartum DM counseling
diet and exercise weight loss to optimal BMI continue BS screening every 3 years
Hemorrhoid
dilated blood vessel in the rectum a. Size and color b. Pressure/itch vs. pain c. Hard or soft d. Can you push it in? (reducible)
syphilis transmission
direct contact with a chancre transplacental transmission
varicella transmission
direct contact, respiratory
how do we keep the baby warm?
dry, skin to skin with warmed blankets (or warmer)
Toxoplasmosis women at risk
exposure to contaminated soil and consumption of raw or undercooked meats or seafood ( oysters, clams, or mussels) garden in contaminated soil changing cat litter
electronic fetal monitoring
external monitoring ultrasoudn transducer tocotransducer monica AN24
nutrition for breast feeding mom
extra 4000-500 kca;/day cuation re: rapid weight loss (1-2 kgs/month ok) adequate fluid intake
nursing interventions third stage encourage breastfeeding
facilitates bonding, and a natural way to stimulate endogenous oxytocin
rest for breastfeeding mom
family support positioning
Fetal fibronectic fFN
glycoprotein "glue" found in plasma and produced during fetal life 1. normally appears in cervical and vaginal secretions early in pregnancy and then again in late pregnancy
post term
greater or equal to 42 weeks
Grimace/reflex irritability apgar 1
grimace, weak cry
TORCHES
group of viral, protozoa infections that can cross the placenta via villa and infect the placenta
types of boney pelvis (Passageway)
gynecoid android anthropoid platypelloid
storing breastmilk
hand hygiene hard plastic or glass containers preferred proper cleaning of equipment and bottles room temp up to 8 hours fridge for 8 days freezer 6-12 months (side by side 6, deep 12)
massage
head, hand, back and foot massage can be effective in reducing tension and enhancing the comfort (combing with aromatherapy oil or lotion enhances relaxation both during and between contractions)
heavy lochia
heavy amount saturated peripaid within 1 hour
H
hemolysis
prolapsed umbilical cord risk factors
i) Breech or transverse presentation ii) Non-engaged presenting part iii) Polyhydramnios (vacuum affect)
C-section benefits
i) Can be lifesaving ii) Lower probability of bladder trauma, perineal trauma? iii) Elective: convenience
viability severe or moderate impairment
i. Cerebral palsy, blindness, profound hearing loss or developmental quotient 2 standard deviations or more below the mean
IgA
i. Found in breast milk ii. Colostrum contains large amounts of IgA and can provide passive immunity to the neonate short term passive immunity
Interventions to increase breastfeeding in obese mothers
ii. iii. 4 studies reviewed iv. Only 1 had significant effect to increase breastfeeding duration and exclusivity in obese mothers (Carlsen, 2013) v. Any BF median: Support 184 d (92-185 d) vs control 108 d (16-185d) p=0.002 vi. EBF 3 months : AOR 2.45 (1.36-4.41) vii. Scheduled support (9 telephone consultations) from an IBCLC (International Board-Certified Lactation Consultant)
uterus involution position and feeling
ii. Firm, slightly (or quite) tender; Midline Position 1. Like a hard basketball measure fingerbreadths below umbilicus
involution assessment
iii. Measure fingerbreadths below umbilicus—goes down by one fingerbreadth per day
lactogenesis
iinitiation of process of breast milk production
jaundice
increase feeding to increase bilirubin excretion evaluate weight loss, I&O, bili levels
cervical exam-status of membrane
intact, bulging or ruptured Bulging—like a balloon that is about to pop Ruptured—squishy, and liquid
origin of pain 2nd stage
intense, sharp, burning pain from pressure on bladder, rectum, stretching of perineal tissues, lacerations--aka the burn as baby is starting to crown, you hear woman saying its burning 3+/4+ station
fundal Massage
intervention to alleviate uterine atony and restore muscle tone 1. B right at the umbilicus 2. Fundal message -find the fundus (top of the uterus) and rub in a circular motion 3. Measure from the umbilicus to the top of the uterus/fundus
IUGR
intrauterine growth restricted a. Usually due to placenta restriction (not getting enough blood flow)
Monica AN24
introduced in 2011 5 electrodes on woman; information transmitted via Bluetooth
restitution
it is the visible passive movement of the head to undo the twist in the neck, that took place during internal rotation of the head
Perineum—Perineal Discomfort interventions
keep area clean ice packs/ibuprofen sitz baths topical applications 1. Witchhazel Pads 2. Dibucaine Ointment 3. Peri-spray—fill it up with water and then clean the area
perineal lacerations second degree
laceration tat extends through the fascia and muscles of the perinal body, but not through the anal sphincter
effleurage
light stroking, usually f abdomen, in rhythm with breathing during contractions
physiologic changes that occurring in the days and weeks before labor
lightening return of urinary frequency backache stronger braxton hicks contractions wight loss of 0.5 to 1.5 kg (1-3.5 lbs) bloody show/vaginal discharge surge of energy cervical ripening possible rupture of membranes
Surfactant
lipoprotein reducing surface tension, lowers pressure required to open alveoli prevents alveoli collapse at end of expiration
Listeriosis agent
listeria monocytogenes
Birth in a delivery room or birthing room
lithotomy position-classic position crowing ritgen maneuver nuchal cord assessment don;t use fundal pressure immediate assessment and care of newborn
Ultrasound transducer
monitors FHR Should be placed at the fetal back
anxiety (other factors influence pain)
more catecholamine release due to muscle tension=magnified pain perception (This is why it's good, to explain procedures + give them time to express their anxieties b/c wouldn't want this to make their pain out of control) i. Explain the procedures and allow them time to express their anxiety so that it will not affect the intensity of their pain
tachysystole
more than 5 contractions in 10 minutes don't want this because the blood flow in the uterus is altered when having a contraction and could lead to decreased fetal oxygenation if there are too many at the same time > 5 cxt in 10 minutes avg over 30 mins (fetal distress because of the frequency of contractions)
Cardiac congenital anomalies
most common weeks 3-8 of fetal development
uterine changes quickening
movement of the baby
Fetal monitoring for women with pre-existing diabetes/require medication
o 3rd trimester (after 32 weeks) Fetal kick counts • Mixed evidence if they matter - routine care for high-risk women • Movement around 20 weeks • Kicks (32 weeks is most noticeable) • 10 kicks in 2 hours if they are awake NST BPP
proteins requirements
o A lot of women don't get enough protein o Western diet typically is high in fat and sugar. And have to educate patients on this early on +30 g/day
two types of prolapsed umbilical cord
occult or complete
other tocolytics
ocytocin antagonists
iron requirments
often low or anemic at conception due to menstrual loss iron needed for RBC production, growing fetus and placenta supplementation, cook with a cast iron skillet women that are vegan/vegetarian, underweight or malnoursihed will need extra iron supplementation o The normal pregnant women requires 500 mg of additional iron: 300 mg -transported to the fetus via transferrin 200 mg -compensate for normal iron use/ loss o To supply maternal needs 60 mg elemental iron (300 mg ferrous sulfate) qd
TORCHES syndrome symptoms in mother
often mild infection with few to no symptoms
listeriosis assessment and treatment ****
only needs test and treatment if symptomatic ampicillin and PCN
systemic analgesia (opioids) two classes
opioid agonists opioid agonists/antagonists
anthropoid pelvis (passageway)
oval shaped common in AF women=OP position more room front to back (anterior/posterior) so babies can rotate into the OP position
creatinine HELLP
over 1.1
fetal monitoring/fetal response oxygenation
oxygen supply must be maintained to prevent fetal compromise. Monitoring to make sure there is no compromise due to reduced oxygen supply
AST
preeclampsia over 20 hellp >70
alt
preeclampsia over 21 hellp well over 21
LDH
preeclampsia over 90 hellp >600
eclampsia
preeclampsia tonic-clonic seizures • Seizure activity or coma in a woman with preeclampsia • Incidence 1/2000 • Onset: Mostly 3rd trimester, 80% intrapartum and within 48 hours of delivery, Tricky presentation: • Hypertension • severe 20-40% of cases • absent 14% of cases • Proteinuria • absent 14% of time • Usually presents with headache
Motevideo units (MVUs)
quantitative measurement of uterine contraction over 10-minute period (need internal monitoring to do this) i. subtract the resting tone from the peak (baseline on strip is about 25 + peak is 70) 1. so 70-25 = 45 (this would be the first contraction) ii. add together (do with all the contractions and add them together) iii. adequate contractions=200 1. range is typically 180—240 2. tell you if uterine contractions are strong enough to cause cervical change
Hypospadias
range of penile anomalies associated with an abnormally located urinary meatus.
R Reeda==>how to assess Episiotomy/Laceration/Incision (and hemorrhoids)
redness
Grimace/reflex irritability apgar 2
responds to stimulation
epispadias
results from failure of urethral canalization
gastric reflux
results from lower esophageal sphincter relaxation
lactation/MER
sensation is like "pins and needles" a. Feels like lumpy oatmeal—if you do a breast exam on a lactating woman b. Multiple milk ducts that allow for spray and propulsion of milk
previous experience (other factors influence pain)
sensory labor pain during 1st phase may be greater for nulliparous women compared to multiparous women. Why?? body knows what the body to do if you're multiparous for nulliparous women this is the first time their body is going through this and stretching (ligaments) perceive the pain as worse labor is a little longer—more fatigue and pain is perceived as worse
Trichomoniasis transmission
sexually transmitted
abnormal lochia odor
should smell like normal menstrual flow, and offensive odor usually indicates infection
breast sx
supplementation may be required
multiples
support more fluid and calories
Transition phase (first stage of labor) nursing priorities
support, comfort, encouragement positions safety simple communication (short and sweet)
Active phase (first stage of labor) nursing priorities
support/encouragement hydration comfort--IV pain medications vs epidural-start dealing with more discomfort issues position changes
TORCHES treatment
supportive measures for immune system refer for fetal surveillance if mom is + a lot of the syndromes have consequences for the baby
fussy
swaddle, hold, calm, suck skin to skin
PE nose
symmetrical nares flaring
expression of pain
sympathetic nervous system is stimulated --> increased HR, BP, RR, sweating gastric acidity increases, N/V common pallor and diaphoresis emotional/affective expressions (anxiety, crying, clenching)
Bacterial Vaginosis assessment
symptoms microscopic and pH Fishy odor Thin, white or gray milky discharge May have pruritis
nursing considerations preparing for the birth second stage supplies, instruments and equipment
table set up, warmer/suction/oxygen ready, birthing kit outside of hospital
pregnancy and breastfeeding
tandem nursing
gynecoid pelvis (passageway)
typical female 50% round pelvis, ideal pelvis for birth
Intrauterine pressure catheter (IUPC)
typically placed by provider Fluid filled catheter inserted into uterine cavity As catheter is compressed during a contraction, pressure is placed on the transducer Pressure is converted into a pressure reading (mmHg) Precisely measures the frequency, duration, intensity, and resting tone of UC's
bilirubin preeclampsia
unchanged or over 1
fibrinogen HEELP
under 200
creatinine clearance HELLP
under 80
abnormal upper and lower extremities findings
unilateral leg pain/edema should be thinking of DVT/VTE
appetite
usually increases, sometimes with unusual cravings (pica)
ballottement
when doing a pelvic exam can feel the baby lift a little bit
breech presentation
will feel the sacrum (butt) at the internal os of the cervix 30% of births
shoulder presentation
will feel the scapula (shoulder) at the internal os of the cervis 1% of births
oxytocin and prolactin affect on emotional state
women report feeling "relaxed" or "drowsy" during let-down
Rubella Women at risk
women who are not immune to rubella never vaccinated
fentanyl
works well, less neonatal side effects and less maternal sedation and nausea. But has a rapid onset and short half-life. Works well but doesn't last long. Can be given hourly up to 3 doses opioid agonist
important thing to remember about screening
you MUST have a plan if a woman screens positively
mobility limitations side effects of epidural anesthesia
you need to help her with the position changes
HGB pregnancy
~12
WBC pregnancy
~12,000
HCT pregnancy
~33-39%
varicella epidemiology
~90% of women childbearing age are immune; therefore, the risk of infection in pregnancy is low 0.7 to 3 per 1000 pregnancies
ectopic pregnancy beta hcg levels
β-hCG levels > 1500 to 2000 mIU/ml + Transvaginal US (should see an intrauterine pregnancy): if not suspect ectopic
Erythema toxicum
—can look really bad, bottom picture of the back, benign condition of the newborn, looks like a bad rash or like the baby has had an allergic reaction
subclinical hypothyroidism
• 0.25-8% women • elevated TSH but normal FT4 • Often unknown by mother, yet can have significant effects on fetus and mother
overt hypothyroidism
• 0.3-0.5% of women • elevated serum TSH and low fT4 • Often pre-existent to pregnancy • Most common form: Hashimoto's thyroiditis
overt hyperthyroidism
• 0.5-2% women • elevated FT4 and low TSH • Can be transient with HCG • Most common form: Graves' disease
subclinical hyperthyroidism
• 3% women • asymptomatic low TSH and normal FT4 • Subclinical hyperthyroidism not associated with poor outcomes
thermogenesis
• Effort to generate heat in response to col • Crying, restlessness • ↑ metabolism • ↑O2 and glucose consumption • Flexed posture • Constriction of peripheral vessels Non shivering thermogenesis—brown fat metabolism (NOT GOOD)
hyperthermia
• Greater than 99.5° F • Causes o Inappropriate use of external heat sources: flushed, warm extremities, extended posture o Sepsis: pale/mottled, cool extremities Sweat glands not functional in newborns
hypothermia
• Mottled, acrocyanotic • Tachypnea • Tachycardia • Hypoglycemia • Poor muscle tone • Poor feeding ability • Lethargic ** can be a signs of sepsis in at-risk infants
preeclampsia with superimposed chronic hypertension
• hypertensive women who develop new onset proteinuria • HTN + proteinuria even if prior to 20 weeks • sudden uncontrolled hypertension
components of the passageway/birth canal
rigid bony pelvis, soft tissues of the cervis, pelvic floor, the vainal, and the introitus
lightening (physiologic changes prior to labor)
(1) uterus sinks down and forward (2) occurs about 2 wks before term.
effacement (primary power)
shortening and thinning of the cervix—0 to 100% (a) Very subjective (b) 50% thinned out half of the cervix is gone—half of the toilet paper is gone from the roll (c) 100% feel a rim but no thickness to the cervix (d) Think of it as a toilet paper roll that is being used up during labor The gradual thinning, shortening ad drawing up of the cervix measured in percentages from 0 to 100%
fetal lie (passenger)
spine of the baby vs spine of the mother longitudinal/vertical horizontal oblique
fetal engagement (fetal position/passenger)
term used to indicate that the largest transverse diameter of the presenting part (usually the bi parietal diameter) has passed through the maternal pelvic brim or inlet into the true pelvis and usually corresponds to station 0
biparietal diameter
the largest side to side point of the fetal head. The biparietal diameter of the head has to get through the most narrow portion of the pelvis (ischial) the less flexed the head is the larger the biparietal diameter
fetal position (passenger)
the relationship of a reference point on the presenting part to the four quadrants of the maternal pelvis position is denoted by a three--part abbreviation
2nd letter fetal position
the specific presenting part of the fetus (i) O= occiput (head)**what we are looking for (ii) S= sacrum (breech) (iii) M=mentum (chin) (iv) Sc (scapula)
spontaneous rupture of membranes (SROM)
time--must document characteristics: color = clear, meconium (greenish), blood-tinged amount slow trickle, gush, flood odor--infected or normal distinct smell
current meds/medication reconciliation Admission to L& D
antibiotics, vitamins, anything they have taken in the last 24 hours
what are symptoms a woman may describe that indicate that lightening is happening?
bladder pressure able to breath better--lungs no longer compressed
OB labs admission to L&D
blood type HIV status GBS status Infection based labs (Typically done before going into labor (3) GBS—group B strep have to treat them with abx q 4 hours during labor
android pelvis (passageway)
heart shaped typical male
Psychological Adaptation to Labor
maternal and fetal adaptations social context of labor
psychosocial assessment (history of abuse, sexual abuse) Admission to L& D
(1) labor can trigger memories of sexual abuse, especially during intrusive procedures (2) help her to link this current experience with the birth of the baby and not the past abuse. Help her to link this current experience with the birth of the baby and not the past abuse (3) avoid words and phrases that can cause stress ("open your legs")
Soft tissues (passageway)
(1) Lower uterine segment= cervix sits within this; lower part of uterus (2) Cervix= effaces (thins) and dilates sufficiently to allow the first fetal portion to descend into the vagina (3) Pelvic Floor Muscles=down in vagina, muscular layer that separates the pelvic cavity above from the perineal space below and helps the fetus rotate anteriorly as it passes through the birth canal (4) Vagina= dilate to accommodate the fetus and permit passage to the external world (5) Introitus—opening of the vagina, when baby is crowning, swelling/edema due to frequent pelvic exams and can affect the timing of delivery
goal of maternal position changes
relieve fatigue, increase comfort, improve circulation a) During a natural birth the body tells them what position to move them into b) Epidural—as a nurse will have to help move the patient into this position c) Side lying position d) Peanut ball—between legs and helps to open up the pelvis e) Pillows, support legs f) Key thing=make sure mother changes position, whether mom is going natural or has epidural
expulsion of the infant
after delivery of the head, the anterior should will descend under the pubic bone
artificial rupture of ROM Amniotomy
along hook to break the membrane (hook the membrane to allow the water to break) this process is painless because amniotic sac does not have any nerve endings Once membrane is ruptured you have to check temperature frequently to check for infection b) **Frequently do temperature assessments after ROM (2hrs) (1) Because of concern of infection
artificial rupture of membrane to augment labor
break membrane to speed up labor, or induce labor b) **Frequently do temperature assessments after ROM (2hrs) (1) Because of concern of infection
voluntary powers (secondary Powers)
expulsive urge to push once the presenting part reaches the pelvic floor a) stretch receptors cause the release of oxytocin b) Endogenous oxytocin c) Maternal urge to bear down - Ferguson reflex (1) When the baby reaches the pelvic floor it Makes them want to push
Head (Passenger) Sutures
fibrous connective tissue between the bones, allow for flexibility (1) Lambdoid suture (2) Sagittal suture (3) Coronal suture (4) Frontal suture
stages of labor
first stage second stage third stage fourth stage
Head (Passenger)-Bones
frontal bone parietal bone occipital bone—landmark that you are looking for, the bone that is focused on temporal bone
flexion
head flexes onto the chest due to resistance (pressure) from the pelvic floor
engagement
head reaches the widest diameter of the ischial spine--in clinical practice this typically translates into 0 station come down in transverse trajectory engagement =head at 0 station
external rotation
head rotates to allow for the shoulder to delivery, allows for shoulders to line up in the AP diameter
Latent Phase (first stage of labor) nursing priorities
hygiene, nutrient intake, IV intake, voiding (q 2hr), ambulation, positioning and supportive care admission assessment- general system assessment, VS, leopolds, FHR pattern, contractions, cervical exam , admission labs comfort encourage rest hydration high variability in length
False pelvis (Passageway)
part above the brim no influence on birth
Blood show (physiologic changes prior to labor)
(1) vaginal mucous becomes more profuse (2) begins to come out as labor progresses (blood-tinged) (a) Cervix has a lot of vasculature and when it begins to open a lot of mucus and blood are released
true labor
progressive cervical effacement and dilation (true measure of labor) discomfort felt in front and back contractions occur at regular intervals and become longer, stronger and closer together waling increases intensity of contractions bloody show rupture of membranes (ROM)
bony pelvic joints (passageway)
pubic symphysis (symphysis pubis) right and left sacroiliac joints and sacrococcygeal joints
bony pelvis (passageway)
is formed by the fusion of the ilium, the ischium, the pubis and the sacral bones the two innominate (hip) bones (consisting of ilium, ischium, and pubis), the sacrum, and the coccyx make up the four bones of the pelvis Cartilage and ligaments form the symphysis pubis, sacrococcygeal joint, and two sacroiliac joints that separate the pelvic bones. The pelvis is divided into two parts: the false pelvis and the true pelvis The false pelvis is the upper portion above the pelvic brim or inlet. The true pelvis is the lower, curved, bony canal, which includes the inlet, the cavity, and the outlet through which the fetus passes during vaginal birth. The upper portion of the outlet is at the level of the ischial spines, and the lower portion is at the level of the ischial tuberosities and the pubic arch.
3rd letter fetal position
location of the presenting part to anterior, posterior, or transverse portion of the maternal pelvis (i) A= Anterior (Front) (ii) P=Posterior (Back) (iii) T=Transverse
Head (passenger) Fontanels
meeting of various sutures, intersection of suture lines coming together. allows for mobility and change shape which is called molding anterior fontanel posterior fontanel
first stage of labor nursing diagnosis
pain, fear, anxiety, ineffective coping, fatigue
true pelvis (passageway)
part involved in birth inlet/brim= bowl midpelvis/pelvic cavity =when the baby is in the vavity outlet = where the baby is coming out
presenting part
part of the fetus that lies the closest to the internal os of the cervix can either be a head, butt, or shoulder
cardinal movements of labor (8)
position changes the baby must make in order to navigate out of the pelvis engagement, decent, flexion, internal rotation, extension, restitution & external rotation, and expulsion
Position
position of the mother position affects the woman's anatomic and physiologic adaptations to lab frequent changes in position relieve fatigue, increase comfort and improve circulation
descent
presenting part descend => contraction, bearing down efforts a) Engagement and descent typically happen at the same time b) Due to maternal pushing effort c) Babies typically come down in transverse position
parent education bath
1. Delay helps thermoregulation and facilitates microbiome establishment 2. 2-3 times a week with mild, unscented soap 3. No lotion or powder!
maternal reasons for supplementation
1. Delayed lactogenesis 2. Intolerable pain—can't tolerate nursing 3. Previous breast surgery
GI system
1. Diet - 1800-2200 cal (nonbreastfeeding) + 500 cal (breastfeeding) 2. Sluggish intestines 3. Spontaneous bowel movement may not occur for 2 to 3 days 4. Elimination returns to normal within one week 5. May have anxiety about BM
Example: Asian cultures and yin/yang balance and harmony
1. Pregnancy is a hot condition 2. Birth depletes the mother of heat through loss of blood and inner energy 3. She is in a cold state post delivery—40 days until her uterus is healed 4. Must consume "hot" foods and beverages v. Be aware of your own beliefs/biases so that they won't impact the care that you provide
inadequate respiration causes
1. RDS, Transient Tachypnea of the Newborn (TTNB), meconium aspiration vii. How to promote adequate respiration 1. Keep warm 2. Gently stimulate 3. Suction or positive pressure ventilation 4. Skin to skin
contraindications for breastfeeding
1. Rare special nutritional needs (PKU, galactosemia) 2. HIV + mom, or mom high risk for HIV (IV drugs) a. In a third world country the risks of contamination from water outweighs the risk associated with HIV transmission 3. HSV lesion on breast (suspected or diagnosed by culture), baby < 6 months
psychosocial factors (Factors Impacting later breastfeeding/exclusive BF)
1. Reduced confidence to reach BF goals among obese women 2. Fewer close friends/relatives who breastfed; lower social influence 3. Lower maternal self-efficacy; body image? 4. Obesity not associated with BF in African American women? Rate too low?
Respiratory Adaptation-Before labor
1. Reduction in fetal lung fluid production 2. Catecholamine surge - moves fluid from alveoli into vascular and lymphatic system 3. Surfactant - production begins in 2nd trimester
late preterm infants
1. Related to elective induction rates 2. Largest portion of the preterm population 3. "Just a little small" 4. Respiratory distress syndrome 5. Temperature instability 6. Hypoglycemia 7. Apnea 8. Poor feeding patterns, poor weight gain 9. Developmental delays
jaundice assessment
1. Visual assessment 1. Usually starts in the trunk and then moves higher and lower 2. Test by blanching on the chest 2. Bilimeter 3. Serum 1. Most accurate 2. Changes by hour of life 3. So what is problematic early on is not problematic later on 4. Serum bilirubin is determined by hours of life ** 5. Heelstick for serum
transition care measurements
1. Weight (2500-4000 g) 2. Length (45-55 cm) 3. Head circumference (32—36.8 cm) 4. Chest circumference (30—33 cm)
AGA
1. appropriate for gestational age a. Goal we want to achieve with all babies
Hyperbilirubinemia causes
1. ABO incompatibilities 2. Maternal infections 3. Maternal diabetes 4. Maternal ingestion of sulfonamides, diazepam or salicylates near term
physiologic (non-pathologic) jaundice
1. Appears after 24 hrs & resolves w/o treatment 2. Fairly common (60% term, 80% preterm)
pahtologic jaundice
1. Appears w/in 24 hrs 2. Rise in bilirubin > 6mg/dl in 24 hrs 3. Serum bilirubin > 15 mg/dl 4. Untreated, can lead to acute bilirubin encephalopathy and kernicterus (rare)
mammy hypoplasia/insufficient glandular tissue
1. Dairy cow/mice obesity early in life negatively impact breast glandular development 2. Obese women more likely to report insufficient milk 2.
beta-hcg in SAB
(1) Blood-pregnancy test (B-hcg) (i) Doubles every 48 hours so should be going up with a viable pregnancy (2) If SAB has happened, they watch B-hcg to see if it has dropped back to zero indicating that the pregnancy has been resolved (a) If hcg is not going down, then there is some retained fetal or placenta material
forceps/vacuum delivery fetal complications
(1) Bruising (cephalhematoma), caput, abrasions (2) Facial nerve damage (3) Subdural hematoma (4) Bradycardia
diet preeclampsia
(1) Eat a nutritious, balanced diet (60 to 70 g protein, 1200 mg calcium, 600 mcg folic acid, 11 to 12 mg zinc, and 1.5 g sodium). (2) Consult with registered dietitian on the diet best suited for you. (3) Salt foods to taste. Limiting excessively salty foods (luncheon meats, pretzels, chips, pickles, and sauerkraut) will likely be necessary to meet the recommended sodium intake of 1.5 g/day. (4) Eat foods with roughage (whole grains, raw fruits, and vegetables). (5) Drink six to eight 8-ounce glasses of water per day. (6) Avoid alcohol and tobacco and limit caffeine intake.
Management of postdate pregnancy risks big baby
(1) Long labor/ CPD (2) Shoulder dystocia (3) Trauma to birth canal or baby (4) PPH
DIC s&S
(1) Spontaneous bleeding and oozing from open sites (2) Oozing—excessive bleeding from venipuncture site, intravenous access site or site of insertion of urinary catheter (3) Petechiae ( on the arm where blood pressure cuff was placed) (4) Bruising (5) Hematuria (6) GI bleeding (7) Tachycardia
alterations in vital signs and consciousness (signs of potential problems fourth stage )
(1) Temperature—no signs of infection (2) Breast—no excessive skin breakdown around the nipples (prevent breast infection)
how to do a cervical exam?
(1) Use sterile glove and antiseptic solution or soluble gel for lubrication (2) Position the woman to prevent supine hypotension. Drape to ensure privacy (3) Cleanse the perineum and vulva, if needed (4) After obtaining the woman's permission to touch her, gently insert the index and middle fingers into the woman's vagina (5) Determine (a) Cervical dilation, effacement, and position (e.g., posterior, mid, anterior) (b) Presenting part, position, and station; molding of the head with development of caput succedaneum (may affect accuracy of determination of station) (c) Status of membranes (intact, bulging or ruptured) (d) Characteristics of amniotic fluid (color, clarity, and odor), if membranes are ruptured (6) Explain the findings of the examination to the woman (7) Document your findings and report them to the nurse—midwife or physician b) Dilation, effacement, station, position c) Status of membrane (intact, bulging or ruptured)
excessive blood loss (signs of potential problems fourth stage )
(1) Vaginal 500-->Greater than 500 sign of hemorrhage (2) C/S 500-1000
forceps/vacuum delivery maternal complications
(1) Vaginal/cervical lacerations (2) Bladder or urethral damage (3) Pelvic hematoma
threatened SAB in depth management
(1) Want to check progesterone levels (2) Low progesterone levels are thought to be related to miscarriage as estrogen causes the uterus to contract (3) Bed rest is often ordered but has not proven to be effective in preventing progression to actual miscarriage. (4) Repetitive transvaginal ultrasounds and assessment of human chorionic gonadotropin (hCG) and progesterone levels may be done to determine if the fetus is still alive and in the uterus. (5) Further treatment depends on whether progression to actual miscarriage occurs. (6) I=once the cervix begins to dilate, the pregnancy cannot continue and miscarriage becomes inevitable
etiology of preeclampsia
(1) disruption in placental perfusion and endothelial dysfunction (2) Starts at time of implantation (3) Inflammation, immunity, genetics, luck (a) Changes in biology of the placenta (b) improper cardiovascular adaptations to the pregnant state (c) Risk factor—sperm immunologic—sperm exposure causes alloimmunization in the uterus at the site of the plantation (i) The man is the risk factor inadequate vascualr remodeling => decreased palcental perfusion & hypoxia => endothelia cell dysfunction => vasospasm, increased peripheral resistance, increased endotehrlial cell permeability => decreased tissue perfusion
Postterm infants
(42 0/7 and beyond) i. Associated with increased fetal loss ii. Not associated with macrosomia iii. Skin 1. Peeling of skin 2. Absence of vernix 3. Absence of lanugo 4. Abundant scalp hair 5. Long finger nails iv. Wasted physical appearance - depletion of subcutaneous fat 1. Start using the subcutaneous fat when they are post-term v. Meconium-stained skin 1. Less amniotic fluid 2. Cord is more likely to be compressed 3. More sensitive trigger to release meconium 4. Will likely come out with stained skin
Csection risks to mom wound dehisence
(a) Low transverse—on uterus (b) Of classical vertical incision on the uterus (c) More concerned about how the uterus was cut not the skin (d) More of a chance that a classical incision can open during subsequent births (e) Vertical/classical c-section -can never have a vaginal birth
magnesium sulfate toxicity observations
(a) Measure serum magnesium every 4 to 6 hours if serum creatinine is >= 1mg/dL. (b) If patellar reflexes are depressed and respiration is normal, withhold further doses of magnesium sulfate until the reflexes return. Then request magnesium level. (c) If there is concern about respiratory depression, stop magnesium, give oxygen by mask and give: (i) Calcium gluconate (10mL of 10% solution over 10 minutes)
leopold's maneuvers fourth step palpation of the head for cephalic prominence
(a) prominence felt close to fetal parts=well flexed (b) prominence on same side as back=military attitude (c) Trying to determine how well flexed the baby—cephalic prominence **
Concentrated formula
(cheaper): Mix with water (boiled or sterile) Open can/bottle good for 48 hours (refrigerated)
FHR step 2 variability
(fluctuations in FHR) fluctuations in FHR of 2 cycles per minute or greater quantified in beats per minute measured from peak to trough of a single cycle (amplitude range of the FHR) variability is an Indication of CNS maturity Loss of variability associated with hypoxemia, metabolic academia, neurologic injury
Cow's milk-based formulas (majority)
(majority) Some have a true allergy to proteins in cow's milk
Trichomoniasis signs and symptoms
(may be asymptomatic): Thick, green, frothy, and malodorous discharge Irritation, pruritis, inflammation Dysuria and dyspareunia Strawberry spots or petechiae on vaginal exam
frequency (contractions)
(minutes)—How many minutes apart are they
hyperthyroidism maternal outcomes
(overt hyperthyroidism) Heart Failure Abruption PET and gHTN PTD Eclampsia Thyroid storm
hypothyroidism maternal outcomes
(overt hypothyroidism) Decreased fertility Increased SAB PET and gestational HTN Anemia Placental Abnormalities (abruption) PPH Non-reassuring FHR PTD (with LBW) Cesarean Perinatal morbidity/mortality GDM PROM
TDAP
(tetanus—diphtheria—acellular pertussis) i. Recommended for postpartum women who have not previously received the vaccine ii. It is given before discharge from the hospital or as early as possible in the postpartum period to protect women from pertussis and to decreases the risk of infant exposure to pertussis iii. Women should be advised that other adults and children who will be around the newborn should be vaccinated with Tdap if they have not previously received the vaccine iv. Women who receive the vaccine can continue to breastfeed
varicella maternal consequences
*Moms: up to 30% get varicella pneumonia (40% death rate)
Rubella maternal consequences
*No MMR during pregnancy (because it is a live vaccine) *If not pregnant, wait at least 4 weeks After receiving MMR to get pregnant
NSAIDs (indomethacin) only use if gestational age is less than 32 weeks maternal
1. (common): a. Nausea and vomiting b. Heartburn 2. Less common, but more serious: a. GI bleeding b. Prolonged bleeding time c. Thrombocytopenia d. Asthma in aspirin-sensitive clients
routine screening all for GDM at 24-28 weeks 2 steps
1. 1-hr screen: pass if BS < 140 • Fasting before is actually most likely to result in a false positive 2. 3-hr test prn: pass if 3 out of 4 values are normal • Repeat testing in 4 weeks for people who have one abnormal value (esp if last test was prior to 26 weeks).
frequency of breast feeding
1. 10-12x/24 hours—baby is getting to breast enough, 2. Attempt at least q3hours (day) and q4h (night) 3. Cluster feed—at breast for a long period of time and then sleeps for a long period of time 4. On demand after breastfeeding established 1. once baby has started gaining weight and knows how to watch for cues, and latching etc. breast feeding has been established and the duration will decrease
normal newborn cardiovascular assessment
1. 100 - 160 (up to 180 if crying) 2. Apical for full minute 3. Often irregularly, irregular in first several hours 4. Murmur 5. BP: 60-80/40-50 (not usually done in term infants)
Turning point in RDS treatment
1. 1980's Surfactant introduced 2. Surfactant - lipids and proteins 3. Reduces surface tension a. Prevents lungs from collapsing ** 4. Equalizes pressure between large and small spaces 5. Prevents alveoli from collapsing 6. 24-28 weeks fetus produces
23 weeks
1. 50-66% survive a. Rare for < 500gms to survive b. Don't have the alveoli and surface area
post term infants
1. >/= 42 weeks gestation 2. Can be SGA, AGA, LGA a. Wasting of muscle 3. Placenta insufficiency a. Placenta starts to degenerate, not as efficient at providing nutrients the longer the pregnancy last 4. Decreased amniotic fluid 5. Perinatal asphyxia - meconium passage in utero 6. Increased risk fetal loss 7. Skin can be leathery, wrinkled, cracked, peeling 8. Vernix absent 9. Fingernails long 10. Lanugo absent 11. Creases cover sole of feet 12. Breast buds well formed
4 major blood Groups/Types
1. A blood has A antigen a. Plasma antibodies to B type blood 2. B blood has B antigens a. Plasma antibodies to A type blood 3. AB has both A & B antigens a. No plasma antibodies 4. O has no antigens a. Plasma antibodies to types A and B b. No antigens
modified--Paced Breathing
1. Approximately 32 to 40 Breaths per Minute) a. Performed at about twice the normal breathing rate (number of breaths per minute multiplied by 2 b. IN-OUT/IN-OUT/IN-OUT/IN-OUT ... c. For more flexibility and variety, the woman may combine the slow and modified breathing by using the slow breathing for beginnings and ends of contractions and modified breathing for more intense peaks. This technique conserves energy, lessens fatigue, and reduces risk for hyperventilation.
enface position
1. As newborns become functionally able to sustain eye contact with their parents, they spend time in mutual gazing, often in the en face position, in which the parent's and infant's faces are approximately 30 cm (12 inches) apart and on the same plane 2. Nurses, physicians, or nurse midwives can facilitate eye contact immediately after birth by positioning the infant on the mother's abdomen or chest with the mother's and the infant's faces on the same plane. 3. Dimming the lights encourages the infant's eyes to open. 4. To promote eye contact, instillation of prophylactic antibiotic ointment in the infant's eyes can be delayed until the infant and parents have had some time together in the first hour after birth.
care after cesarean birth
1. Assess fundus gently 2. Assess bandage at incisional site-1st 24 hours, then incision, using REEDA, thereafter. 3. Assess bleeding 4. Intake and Output until IV and foley discontinued 5. Assess urinary output (foley out by 12 hours) 6. VS q 4 hours for 1st day, then q 8 hours 7. Postpartum head to toe assessment, include auscultation of lung and bowel sounds 8. Ambulate by 12 hours post-op 9. Pain management - pharmacologic (epidural, IV PCA, oral), non-pharmacologic a.Abdominal binder to help things together 10. Assist with breastfeeding and bonding 11. Assist with ADLs 12. Clear liquids then advance diet as tolerated after 8-12 hours a.Advance diet slowly! Bowles are ASLEEP
The nurse's role in caring for a grieving family
1. Assess the meaning of the pregnancy and the loss for this family and each individual 2. Offer and help family to hold and spend time with their baby 3. Other history of loss(es)? 4. Assess for family, cultural, faith-based systems at play 5. Utilize social support network of woman/family 6. Offer perinatal loss support group information 7. Offer to contact hospital or personal chaplain or other supportive contacts 8. Encourage time, attention to self-care to promote holistic recovery (mother, family members, AND NURSE)
preventing clots
1. Bedrest or post-op: a. Avoid bedrest if possible. b. Use SCDs/anti-embolic hose if immobile, exercises (rotate feet/ankles) c. OOB asap after surgery or when condition allows d. Notify provider if pain, erythema, tenderness develops
Hyperbilirubinemia Pathologic
1. Before 24 hours of age 2. Greater than 14 days of life 3. Associated with bilirubin encephalopathy or kernicterus
term infants
1. Best outcomes 2. Fewest complications 3. Best long term outcomes 4. Complications generally short in duration
changes in circulation after birth
1. Blood enters the right atrium. Most of the blood flows to the left side through the foramen ovale between the left and right atria 2. Blood then passes into the left ventricle and then to the aorta. 3. From the aorta, blood is sent to the head and upper extremities. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava. 4. About one-third of the blood entering the right atrium does not flow through 5. the foramen ovale, but, instead, stays 6. in the right side of the heart, eventually 7. flowing into the pulmonary artery.
delayed cord clamping
1. Blood volume averages 85 ml/kg of body weight 2. Immediately after birth, total blood volume averages 300 ml but can increase by as much as 100 ml, depending on time of cord clamping 1. Actually, the babies blood allows them to get back what theres 3. Once the cord is clamped, the circulatory dynamics immediately change 4. Delay of >2-3 min has benefit of improving hematocrit and iron status and decreasing anemia that lasts 6 months! Especially beneficial for preterm babies (significant reduction in intraventricular hemorrhage risk) 1. Takes a minute or two to have these changes take place. Allow for a smooth transition as it beings to take over all of its own oxygenation needs 5. Also, facilitates easier and smoother transition to extrauterine life, especially if low initial Apgar. Resuscitate while cord still intact!
GBS sepsis evaluation and treatment
1. CBC with diff 2. Blood cultures 3. Blood gas 4. Urine culture 5. Chest x-ray 6. Spinal tap 7. Respiratory support 8. Antibiotics - Ampicillin 9. Aminoglycoside - Gentomycin 10. ECMO - extracorporeal membrane oxygenation - severe cases
Neonatal Abstinence Syndrome, NAS generalized disorder characterized by
1. CNS hyperirritability—unique cry, hard to console, don't sleep well, 2. Gastrointestinal dysfunction 3. Respiratory distress 4. Autonomic dysfunction a. Yawning b. Hiccups c. Sneezing—newborns don't typically sneeze d. Mottled skin e. Fever—most newborns are actually cold when they are sick because they burn through fat and sugar stores
goiter
1. Change in size of maternal gland a. 10-15% increase size thyroid gland in pregnancy b. Goiters more likely in iodine-deficient areas world 2. In U.S. (minimal iodine deficiency), any clinically detectable thyroid growth should be investigated a. More come in parts of the world with iodine deficiencies b. Demand for iodine increases during pregnancy
Respiratory Adaptation-during birth (mechanical)
1. Changes in intrathoracic pressure from contractions and pushing, negative pressure at birth draws air into lungs. Crying distributes air to expanding alveoli. Positive pressure through breathing and crying keep alveoli open.
Bronchopulmonary Dysplasia (BPD)
1. Chronic pulmonary condition requires mechanical ventilation 2. Multifactorial etiology: including pulmonary immaturity, surfact deficiency, lung injuery and stretch, barotrauma, inflammation caused by oxygen exposure, fluid overload, ligation of a PDA, and a familial predisposition 3. Occurs most commonly in preterm infants 4. Clinical signs: tachypnea, retractions, nasal flaring, increased WOB, activity intolerance to handling and feeding and tachycardia 5. Treatment: oxygen therapy, nutrition, fluid restrictions, and meds (diuretis, corticosteroids, and bronchodilators)
breast feeding benefits for family
1. Convenience—always prepped and ready to go 2. Cost-effective 3. Environmentally friendly
How do we know that infant respiration is adequate?
1. Crying, Pink, Adequate rate (40-60) 2. Can be higher if they are really crying
causes of late deceleration
1. Disruption of the oxygen transfer from the environment to the fetus (uteroplacental insufficiency caused by: a. Uterine tachysystole too many contractions, decreased blood flow and oxygenation b. Maternal supine position compression of the vena cava which is the major supply for the placenta c. Maternal hypotension (epidural, spinal anesthesia) d. Intrauterine growth restriction baby that already has issues with placenta Intraamniotic infection
Hepatitis B Vaccine (IM)
1. First of 3 doses usually given at hospital 2. If Mother is Hep B positive, Hep B Vaccine + Hep B Ig must be administered within 12 hrs of birth 1. To protect the baby **
Rhogam Rh immune Globulin, RhoGAM, Gamulin Rh, HyRho-D, Rhophylac nursing considerations
1. Give standard dose to mother at 28 weeks of gestation as prophylaxis or after an incident or exposure risk that occurs after 28 weeks of gestation (e.g. amniocentesis, second—trimester miscarriage or abortion, and after version) 2. Give standard dose within 72 hours after birth if neonate is Rh+ 3. Give microdose for first trimester miscarriage or abortion, ectopic pregnancy , chorionic villus sampling, 4. verify that the woman is Rh negative and has not been sensitized, if postpartum that coombs' test is negative, and that baby is Rh positive. provide explanation to the woman about the procedure, includign the purpose, possible side effects, and effect on future pregnancies. have the woman sign a sonsent form if required by agency. verify correct dosage and confimr lot number and woman'd identiy before gibing injection (verify with another RN or by other procedure per agency policy); document administration per agency policy. observe client for at least 20 minutes after administration for allergic response document lot number and expiration date in teh client record. the medication is made from human plasma (a consideration if woman is a jehovah's witness. the risk of transmitting infectious agents, including viruses cannot be eliminated completely
hyperthyroid treatment postpartum
1. Graves' Disease worsens 3 months postpartum a. Refer to endocrinologist. b. Expect higher doses anti-thyroid drugs c. Close monitoring d. Breastfeeding ok with PTU 2. Consider radioiodine or surgical thyroidectomy prior to next pregnancy. a. Need at least 6 months after radioiodine treatment before next pregnancy.
Psychological adaptations to labor considerations
1. Have to be very sensitive and get rid of bias, goal is to make them as comfortable as possible and remember that everyone handles labor differently 2. History of previous birth experiences Emotions range from Excitement to Fear 3. Current pregnancy and expectations for this birth a) Birthing plan (1) Where birth plan comes in, some birth plans are very detailed. Have to figure out what their expectations are but have to tell them if some of their requests are unreasonable. (2) Don't laugh at their plan but be realistic 4. Coping skills 5. Cultural considerations a) Values, beliefs, relationships, pain, significance of touch (if they want to be touched, may not want to be told to breath) 6. Support system a) Partner/husband, doula, family, care givers 7. Emotions of Labor a) Latent Labor b) Active Labor c) Transition d) Second Stage
ffn conditions
1. Higher false + if bleeding 2. Higher false + (maybe) if swabs, lubricants, or sex within 24 hours
preterm infant complications
1. Higher infant mortality 2. Longer hospital stays 3. Respiratory complications - lack surfactant 4. Feeding difficulties - suck, swallow, breath a. Consuming all intake by sucking they have to breath another way 5. Glucose instability a. Just don't have the stores of glucose that they would if they had been born at term 6. Hyperbilirubinemia 7. Long term developmental delays
Late preterm infants at risk for
1. INFECTION 2. Respiratory distress syndrome 3. Temperature instability 4. Hypoglycemia 5. Apnea 6. Poor feeding patterns, poor weight gain 7. Delayed developmentally (increased risk of cognitive impairment)
Hyperbilirubinemia nursing care
1. Increase PO intake-Increases the rate of excretion of bilirubin 2. Phototherapy-Helps break down the red blood cells, Protect eyes 3. Skin care - frequent stools
hormonal imbalances (Factors Impacting later breastfeeding/exclusive BF)
1. Increase in free androgens, role of polycystic ovarian syndrome (elevated androgens, metabolic anomalies, hypothyroidism) ? 2. Thyroid dysfunction (T4, T3 role in initiation and maintenance of lactation, suboptimal levels, lower milk supply reduced oxytocin release.
Preterm infants
1. Infants born < 37 weeks gestation a. Majority are LPI's 34-36 6/7 weeks 2. Classified by a. Birth weight, SGA, AGA, LGA b. Gestational age 3. Many factors contribute to fetal growth and outcomes a. Heredity b. Genetics c. Placental insufficiency d. Maternal disease processes
respiratory system and prematurity
1. Insufficient number and function of alveoli 2. Surfactant—deficient surfactant levels 3. Small airways—smaller lumen in respiratory system , greater collapsibility or obstruction of respiratory passages 4. Bones of thorax not calcified a. don't have the ability to expand chest and pull air in 5. Weak or absent gag reflex 6. Distance between functional alveoli and capillary bed a. Just big dead space, there is just too much space for air to exchange adequately
how can we promote adequate infant respiration?
1. Keep Warm, Gently Stimulate, Suction and/or Positive Pressure Ventilation (if necessary), Skin to Skin Contact with Mother 2. Gently stimulate=rubbing the foot, head back 3. Keeping them warm is one of the best ways to promote oxygenation and ensuring their aveloi are open*** 4. Bulb suctioning don't do that much ** 5. Push a lot of fluid and mucus out of the nasal passages ** 6. Positive pressure ventilation if necessary—really not a rough thing on the baby can help move fluid out of the lungs and open up the aveoli 7. Being skin to skin with the mother really helps also
Vision
1. Lacks accommodation (develops over 3 months) 2. Can see 2.5 feet away, most clearly at ~ 1 foot 3. Complex patterns 4. Black & White
postpartum Depression
1. Lasts beyond the 1st 2 weeks and/or interferes with functioning 2. DSM-V: major depressive disorder with postpartum onset within 1st 4 weeks of birth 3. Risk factors: previous hx of mood disorder, life stress, poor social support, hormonal changes 4. Screening: Edinburg Postpartum Depression Scale—scores >10 suggested of an increased risk for PPD
jaundice contributing factors
1. Less than 38 weeks 2. Poor breastfeeding (especially if significant weight loss occurs) 3. Hx of significant jaundice in sibling 4. Hemolytic disease 5. Bruising, cephalhematoma, 6. Race 7. ABO or Rh incompatibility causing RBC destruction 8. **Jaundice in first 24 hours usually indicates pathogenic process! 9. Liver *** has to work less listen to recording for this part
intermittent auscultation-fetal monitoring techniques
1. Listening to fetal heart sounds at periodic intervals to assess FHR 2. Easy to use, inexpensive, less invasive than EFM 3. Difficult to perform on women who are obese 4. Does not provide a permanent record
obesity-factors impacting initiation/early breastfeeding
1. Mechanical factors-Additional body tissue, larger areolas, larger breasts, reduced lap, edema* (often cited but limited evidence) 2. Delayed onset of lactogensis II-Longer labor, C-section, edema, leptin inhibit oxytocin effect increase labor dysfunction/milk ejection reflex?, reduced prolactin reduced milk synthesis, imbalance of insulin?
Transient Tychapnea of the Newborn nursing care
1. Monitor respiratory rate 2. No or limited PO feeding 3. Minimal exertion 4. Supplemental oxygen
the precious golden hour
1. More readily responsive to the babies feeding ques, facilitate the baby getting to the breast
Hyperbilirubinemia Physiologic
1. Most common 2. After 24 hours of age 3. More common in LPI and preterm infants 4. Rapid breakdown of RBC 5. Immature liver 6. Dehydration
hypothyroid treatment postpartum
1. Most women may discontinue levothyroxine dose or decrease to pre-pregnancy levels in the 4 weeks following delivery 2. f/u with TSH level @ 4-6wk PP visit 3. Planning for future pregnancies 4. Increase dose right away—based on TSH and T4 level **** listen to recording for this to make sure its with the right thyroidism ****
environmental (Factors that affect lactogenesis )
1. Mother-baby separation 1. In the hospital 2. Mother returning back to work of school early 3. Early separation in general 2. Timing - ideally within first hour after birth 3. Early and long term milk supply affected by this
abnormal newborn cardiovascular assessment
1. Murmur with poor perfusion 2. Tachycardia > 160 beats/minute at rest 1. Anemia—abrupt cord clamping, or mother hemorrhaging 2. Hypovolemia 3. Hyperthermia 4. Sepsis 3. Bradycardia < 100 beats/minute 1. Apnea 2. Temperature extremes 3. Hypoxia
drugs used in the 2nd stage
1. Nerve block analgesia and anesthesia a.Local infiltration anesthesia b.Pudendal block c.Spinal (block) analgesia d. CSE analgesia 2. Nitrous Oxide
Calcium channel blockers (nifedipine)-tocolytic
1. Nifedipine (Procardia): delays birth at least 48 hours, better short-term outcomes 2. 10-20 mg po now, then q 4-8 hours prn x 48 hours 3. For maintenance, dose is XL 30-60 mg po q8-12 hrs 4. Has fewer side effects than other tocolytics 5. May delay birth up to 7 days 6. Improved short-term outcomes: RDS, gut infections, and NICU admission 7. Use "regular" Procardia to make contractions rare, then use extended release Procardia XL for maintenance. 8. Generally, has fewer side effects than beta-mimetics or mag sulfate, but watch for hypotension a. Maternal side effects include hypotension, headache, flushing, dizziness, nausea 9. Has been shown to improve fetal outcomes (Other medications listed don't improve fetal outcomes unless the contractions are stopped long enough (24 hours for steroids to get on board))
maternal (Factors that affect lactogenesis )
1. Nipple characteristics 2. Discomfort/Pain 3. Stress/Fear 4. Alcohol—inhibits lactogenesis 5. Prepregnant BMI and Gestational Weight Gain
Pregnancy outcomes with infection
1. None 2. Miscarriage 3. Preterm labor 4. Preeclampsia 5. Fetal effects-Anomalies, IUGR, CNS 6. Cytokines (inflammatory markers) a. Risk factor for fetal outcomes, neurodevelopmental issues later in life like autism
Normal Newborn respirations
1. Nose breathers 2. Respiratory rate 30-60/minute 3. Breath sounds - heard throughout the chest 4. Abdominal breathing - simultaneous with chest expansion 5. Acrocyanosis—usually only 24 hours, blue hands and feet, the rest of the baby is pink
late onset GBS
1. Occurs between 1 week and 3 months of age 2. Results from vertical transmission, health care-acquired transmission, or community exposure 3. Mortality less than for early on-set GBS sepsis 4. Approximately 30% develop meningitis
parent education sleep position
1. On Back! 2. Firm surface without anything else (not sofa, no loose linens) 3. Room (NOT co-bed)sleeping 4. Car seat
drugs used in the 1st stage
1. Opioid agonist analgesics 2. Opioid agonist—antagonist analgesics 3. Epidural (block) analgesia 4. Combined spinal—epidural (CSE) analgesia 5. Nitrous oxide
jaundice phototherapy
1. Overhead lights 2. Biliblanket 3. Bilibed protect gentiles and eyes
Neonatal Abstinence Syndrome, NAS exposure
1. Passively to opiates in utero to heroin, methadone, or other narcotics or to treatment of opiate/opioid addiction with methadone or buprenorphine 2. Iatrogenic exposure by administration of opioids for neonatal analgesia or sedation
Neonatal Abstinence Syndrome, NAS
1. Polysubstance abuse 2. Poor nutrition 3. Difficult socioeconomic living conditions 4. Poor prenatal care (don't want their baby to be taken from them, don't want their substance abuse to be discovered) 5. Lilly's Place 6. IUGR 7. Fetal hypoxia 8. Symptoms and onset of NAS 9. Cocaine associated with placental insufficiency and abruption a. Mother rolls in with placental abruption =automatic drug screen 10. Substances can be found in neonatal urine, meconium, blood, umbilical cord samples, hair, 11. Maternal Substance Abuse and Child Development at Emory
what is hemorrhage
1. Postpartum hemorrhage: more than 500cc (vaginal) or 1000cc (c/s) estimated blood loss at birth. 2. 10% change in HCT 3. EBL often underestimated 4. Early (1st 24h) vs. Late (until 6 wks) 5. 1 soaked peripad/ hour 6. Fist sized blood clots 7. Can also happen prenatally (abruption, previa)
first period of reactivity (birth-60 minutes)
1. Respiratory transition 2. Alert 3. Mother and baby UNDISTURBED AS MUCH AS POSSIBLE! 4. Put baby to breast during "Golden Hour" 1. Baby will eventually make it to the breast on its own but help the baby if needed 2. If you miss the golden hour the baby won't be moving around as readily 5. In between period of decreased responsiveness - (60-100 min) 1. Can last between minutes and hours
D/C checklist immunizations/Meds
1. Rhogam (if needed) a. Given to prevent isoh***** b. Rh+ father + RH- mother carrying her first RH+ mom can mount an attack against the baby c. Will give rohgam at 28 weeks and then again after birth especially if the baby is RH+ (check after birth) d. Initiate any referrals 2. Vaccines: MMR, Flu, TDAP, Varicella a. Have to be up to date on all of these b. MMR and varicella cannot be given during pregnancy because they are l
preventing PPD
1. Share knowledge about postpartum emotional problems with close family and friends. 2. At least once each day or every other day, purposely relax for 15 minutes: deep breathing, meditating, taking a hot bath. 3. Take care of yourself: eat a balanced diet. 4. Exercise on a regular basis, at least 30 minutes a day. 5. Sleep as much as possible; make a promise to yourself to try to sleep when the baby sleeps. 6. Get out of the house: try to leave home for 30 minutes a day; take a walk outdoors or walk at the mall. 7. Share your feelings with someone close to you; don't isolate yourself at home with the TV. 8. Don't overcommit yourself or feel like you need to be a superwoman. Ask for help from family and friends. 9. Don't place unrealistic expectations on yourself; no mother is perfect! 10. Be flexible with your daily activities. 11. Go to a new mothers' support group: for example, take a postpartum exercise class or attend a breastfeeding support group. 12. Don't be ashamed of having emotional problems after your baby is born. It happens to approximately 15% of women.
fetal brain development
1. Significant brain growth occurs in the last 4-6 weeks of gestation a. 20 weeks vs 40 weeks huge difference in brain size and surface area 2. 50% of cortical volume at 34 weeks gestation 3. Five fold increase in white matter from 35-40 weeks 4. Synaptogenesis peaks around 36 weeks myelination hierarchical from primitive to advanced
DVT/VTE
1. Signs DVT 2. Unilateral leg pain and edema 3. May be warm and tender also a. Homan's- don't check—why? i. Could dislodge it
what are the signs of inadequate infant respiration?
1. Silent, limp, Pale/Blue/Grey, Grunting, Flaring, Retracting, Nasal flaring 2. Consistently silent with a number of the other signs because a baby can be adequately oxygenated and be silent 3. Grunting =respiratory distress
abdominal exam
1. Soft (doughy) vs. distended 2. + bowel sounds—make sure to check all 4 quadrants especially if post cesarean a. Post cesarean are at risk of ileus. Look for nausea and absence of bowel signs 3. Diastasis recti
Rhogam Rh immune Globulin, RhoGAM, Gamulin Rh, HyRho-D, Rhophylac dosage and route
1. Standard dose: 1 vial (300 mcg) IM in deltoid or gluteal muscle 2. Microdose: 1 vial (50 mcg) IM in deltoid muscle, 3. Rho(D) Immune globulin (Rhophylac) can be given IM or IV (available in prefilled syringes)
hyperthyroidism treatment in pregnancy
1. Subclinical—expectant management with monitoring 2. Overt—anti-thyroid drugs at lowest possible dose. Medications are not very safe during pregnancy 3. Propylthiouracil (PTU) 100-450 mg/day PO in two divided doses 1st trimester a. LFTs every 3-4 weeks (PTU liver toxicity) b. Medication should only be used to the extent it has to be so goal is not normal range but low normal range of TSH**** 4. Methimazole (MMI), 10-40 mg/day PO two divided doses after 1st trimester. 5. Propranolol 40-120 mg/day for control of symptoms 1. Thyroidectomy (rare) 2. Baby monitored for fetal thyrotoxicosis (5% babies born to Graves' mothers affected) (MFM)
infant (Factors that affect lactogenesis )
1. Suck 2. Emptying of breast (pumping) 3. Based on supply and demand 1. The more she nurses or pumps the more milk she will have 2. The less she nurses or pumps the less milk supply she will have
thyroid storm extereme hyper-metabolic state
1. Tachycardia (>140) and/or A Fib 2. Shaking 3. Agitation, restlessness 4. Confusion 5. High fever 6. Persistent sweating 7. Diarrhea
Beta-adrenergic receptor agonists (terbutaline)
1. Terbutaline / Brethine = Beta Agonist. Betamimetics for inhibiting preterm labor. 2. May delay birth by 2 days and up to 7 days. Infant outcomes (RDS, NEC, CP, death) not improved although most data was for EGA>32 weeks. 3. Relaxes smooth muscles inhibiting uterine activity, and causing bronchodilation
Hearing - from in utero
1. Term newborns can hear and differentiate among various sounds. 2. The neonate recognizes and responds readily to the mother's voice 3. Newborns are accustomed to hearing the regular rhythm of the mother's heartbeat; As a result, they respond by relaxing and ceasing to fuss and cry if a regular heartbeat simulator is placed in their cribs 4. Routine hearing screening is recommended for all newborns before hospital discharge. i
Respiratory Adaptation-During Labor (chemical factors)
1. Transient fetal hypoxia and hypercarbia stimulates respiratory center in fetal medulla 2. Clamping of the cord - increases perfusion to newborn lungs
outcomes of infections during pregnancy depend on
1. Trimester (First more likely to have congenital malformation and disorders) 2. whether placenta is infected/crossed 3. severity of infection (primary vs. secondary)
Respiratory Adaptation After Birth Thermal
1. Upon drop in temp at birth, skin receptors stimulate respiratory center in the medulla
breast engorgement
1. Usually 72-96 hours when mature milk comes in 2. Warm, firm, sometime lumpy, tender breasts (lumps shift in position) 3. Engorgement results from increase in blood and lymphatics as milk production increases
causes of postpartum Hemorrhage
1. Uterine atony: multigravida, macrosomia, multiples, polyhydramnios 2. Lacerations of cervix, vagina, or perineum 3. Hematomas—bleeding into the tissues, can be a cause of hemorrhage, look at peritoneum to check for hematomas and potential hemorrhage 4. Retained placenta or placental fragments 5. Uterine inversion—uterus flipped inside 6. Subinvolution—anything that it is keeping the uterus from involuting
newborn IM injections
1. Vastus lateralis 2. 25 gauge, 5/8 inch
foley catheter (nursing care of a patient with epidural for birth)
1. b/c can't get up to go to restroom a. help explain to them that although they're starting with the needle, there's no needle in their back, they're just using it to thread the catheter + hooking it up to a pump b. explain they'll feel a tingling sensation first + then a numb c. give education on why they're getting a foley + position changes
gastroschisis
1. bowel outside abdomen a. Abdomen doesn't close b. Bowel outside of the abdomen c. Always to the right of the umbilical cord d. Bowel is often tough, hard and enlarged and difficult to return to the abdomen
vital signs (nursing care of a patient with epidural for birth)
1. during and after a. Give a test dose, to check to make sure the medication does not get into the maternal blood stream. The medication has epinephrine in it and if reaches their blood stream their hr/bp will skyrocket b. If everything is good they will load the actual dose and feed the catheter in and remove the needle c. Cesarean birth the patient will be numb from the breast down d. Vaginal birth they will be numb from the pelvis down
Leopold's maneuvers 4 steps
1. palpate the fundus 2. palpate for the fetal back (vs small parts) 3. feel the lower pole of the fetus with thumb and forefinger to see which fetal part is presenting to the inlet 4. palpation of the head for cephalic prominence-ised to assess descent and fetal attitude
informed consent pharmacological interventions
1. procedure advantages and disadvantages 2. plan of labor pain care 3. consent without coercion => ask what she wants + just go with it
second stage of labor assessment findings
10 cm dilation, 100% effaced, birth of the infant the exact moment second stage starts is not known until a vaginal exam is performed (no cervix left) shaking, N&V, restless, irritable urge to push duration varies--"laboring down"
second stage of labor
10 cm-birth pushing phase full dilated to birth of fetus fetus descends through birth canal and rotates pressure on pelvic floor stimulates stretch receptors--urge to bear down (ferguson reflex) the moment you have been waiting for the birth of the infant
lactogenesis stage 3
10 days PP mature milk growth spurts and increased feeding stimulates increaed milk production
growth spurts and breastfeeding
10 days, 3 weeks, 6 weeks, 3 months, 6 months (frequent feeding for 24-48 hours and then back to normal). Important to educate mother on these periods of increased nursing/feedings.
baseline fetal heart rate (FHR)
110-160 bpm need at least 2 minutes that are fairly regular without any periodic or episodic changes
HGB pre-pregnancy
12-16 g/dl
fetal circulation before birth
2. Blood enters the right atrium. Most of the blood flows to the left side through the foramen ovale between the left and right atria 3. Blood then passes into the left ventricle and then to the aorta. 4. From the aorta, blood is sent to the head and upper extremities. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava. 5. About one-third of the blood entering the right atrium does not flow through 6. the foramen ovale, but, instead, stays 7. in the right side of the heart, eventually 8. flowing into the pulmonary artery.
breast feeding benefits for infant
2. Enhanced neurodevelopmental outcomes 3. Better and earlier communication between infant and mother 4. Fewer delays
Lactogenesis-Breasts
2. Initiation of the production of milk 3. Sucking stimulus hypothalamus anterior pituitary prolactin milk production 4. Hypothalamus posterior pituitary oxytocin milk ejection
WBC postpartum
20-25,000
plts for preeclampsia and HEELP
<100,000 mm3
placenta previa marginal/low-lying
<2.5 cm from os
minimal variability
<5 bpm amplitude range detectable less than or equal to 5 bpm
oligohydramniosis
<5cm (term) or 5th percentile not enough fluid around fetus Peak amniotic fluid amounts at about 36 weeks (1 liter). Low amniotic fluid levels
Pulse/Heart Rate apgar 2
> 100
abnormal temperature
> 101 (asses oft potential causes-puerperal sepsis : temp >100.4 after 24 hours) other causes mastitis, endometritis, UTI
Hb, HCT preeclampsia
> 16, >47%
oxytocin (Factors that affect lactogenesis )
Although oxytocin is an essential hormone in lactation, administration of exogenous oxytocin to mothers having difficulty in breastfeeding has not been clearly shown to have a beneficial effect on lactation success)
terms to describe involuntary contractions (primary power)
Frequency (how often minutes apart)/duration (how long does it last in seconds) /intensity (how strong)
gonorrhea signs and symptoms
Frequently asymptomatic Minimal discharge Menstrual irregularities Pain - pelvic or lower abdomen Dysmenorrhea Dysuria
determining pregnancy history two digit system
G/P
this is anita's third pregancy she has a 2-year old who was born at 32 weeks gestation. she also had a miscarriage at 12 weeks what is her G/P, GTPAL
G/P 3/1 G3, T0, P1, A1, L1
determining pregnancy history 5 digit system
GTPAL
Infant galactosemia (contraindication to breastfeeding)
Galactosemia: When a person who does not have galactokinase consumes food containing lactose (e.g., dairy products such as milk, cheese, butter), their body breaks down the lactose into galactose and glucose, and then further metabolizes both of these sugars. (The human body also is able to make "endogenous" galactose.) When a person with galactosemia consumes food containing lactose or galactose they are not able to fully metabolize the galactose, so it can build up in their cells and tissues. Galactose that is synthesized in the body may also build up. ii. Rare and deadly - causes failure to thrive.
Rh Factor
Genetically determined factor present on RBC's Rh factor present - positive Rh factor not present - negative
reduce risk of clots in mothers
Increase in venous stasis will likely see pooling if they are sedentary Want patient to be mobile Compression hose Especially while flying or long car ride Even sitting for long periods of time at a desk make sure they are walking some
placenta abruption expectant management
Observation and bedrest for < 36 weeks, normal FHR, no contractions, and mild bleeding that stops As long as everything is stable will just watch them as long as they are 36 weeks Fetal Monitoring Large bore IV No vaginal exams H&H, platelets, Coag, Type & Screen BRwBRP NST or BPP weekly or biweekly Monitor for signs of preterm labor
Naloxone Hydrochloride (Narcan)
Opioid (narcotic) antagonists 0.1 mg/kg IV. Reverses resp. depression in NB (know this)
hypothyroidism fetal outcomes
PTD LBW Neurological/Developmental abnormalities (long-term) Anti—thyroid antibodies of Hashimoto's may cross placenta and cause fetal hypothyroidism
The 5 P's
Passenger (fetus and placenta) Passageway (Pelvis and Birth Canal) Position (relationship of the fetal head to the quadrants of the maternal pelvis) Powers (Contractions) Psychological Adaptation to Labor (maternal and fetal adaptations)
Passageway
Pelvis and Birth Canal
syphilis treatment
Penicillin G Repeat testing 6-8 weeks Monthly testing and treatment Abstinence until cleared Treatment: Benzathine PCN—dose varies depending on stage of syphilis
Episiotomy/Laceration/Incision (and hemorrhoids): how to assess ==> REEDA
Redness Edema Ecchymosis—bruising Drainage Approximation—holding together or not
decrease in fetal oxygen supply
Reduction of blood flow through maternal vessels => due to position(laying on her back, epidural/hypotension Reduction in oxygen content in maternal blood => if mother is breathing too fast; pain Alterations in fetal circulation Reduction in blood flow to intervillous space in placenta
ready-to feed formula
expensive Open bottle good for 48 hours (refrigerated)
Disseminated Intravascular Coagulation (DIC)
a) Pathological overactivation of clotting factors that results in increased platelet aggregation with microvascular thrombi in organs leading to multiple organ failure AND b) Consumption and exhaustion of coagulation factors leading to severe bleeding
nursing role during Cesarean delivery: pre-op, circulator, and post-op
a) Pre-op—labs, shaved, consent, IV started, checking with the surgeon and OR to make sure everything is ready b) Circulator—ensure safety of the patient and baby in the OR, documentation, foley is secure, IV secure and in place, document when the surgery starts, who is in the room, mom is strapped down, counting all the laps, and surgical equipment, assessment of the baby (APGARs), counting everything and so on c) Post-op—vitals, assessing for pain, monitoring anesthesia levels, making sure she is stable after the procedure
prolapsed umbilical cord
a) Umbilical cord lies below the presenting part i) If on vaginal exam you feel umbilical cord you have to keep your hand there to keep pressure off the cord until an emergency c-section can be performed b) Can occur at any time during labor c) With or without ruptured membranes
uterine inversion or prolapse
a) Uterine inversion or prolapse—uterus inverts (inside out) b) After delivery c) Potentially life threatening - hemorrhage, shock d) Partial or complete
what is the risk if any 2 of the time honored clinical signs and symptoms of chorioamnionitis?
a) When at least 2 of the above criteria are present, the risk of neonatal sepsis is increased. b) See any of the above usually start treating the mother with abx and Tylenol (fever and fetal tachycardia usually start this regimen)
Cultural considerations birth
a) Woman may have a preconceived idea of the "right" way to behave b) Culture and father participation (1) Some partners are really involved while some are very quiet and on the sidelines c) Non-English-speaking woman in labor (1) Language line d) LGBTQIA couples (1) Unique population (2) Learning more about their needs during labor (3) How do you want us to use preferred pronouns? (4) What do they want or not want done
choosing a method of feeding: breast feeding
a. Breast i. Importance of prenatal education regarding the many benefits - both health benefits and bonding benefits. ii. Some evidence that the decision to exclusively breastfeed is more likely if it's made during pregnancy. iii. Textbook cites a study that says that overweight or obese women are less likely to breastfeed compared to normal or underweight women. Other studies say this is the case for both over and underweight women and it is an association that is independent of demographic factors like socioeconomic status iv. Social factors: formula company marketing, workplace policies, poor lactational support for early postpartum mothers v. Personal comfort level - breasts as sexual object, uneasiness with public breastfeeding, pain, discomfort
Beta-adrenergic receptor agonists (terbutaline) dosage and route
a. Can dose SQ, IV, or po b. SQ dose is for tocolysis, max dose is 1 mg/4 hours. c. PO dose is not advised for tocolysis. d. IV dose (or SQ dose) can be used for emergencies, i.e., prolonged decel r/t uterine tachysystole i. IV dose is 0.025 mg/min IV
DVT/VTE postpartum risk factors
a. Cesarean delivery b. Varicose veins c. Co-morbidities: Diabetes, IBD, cardiac disease, hypertension (including PIH), lupus d. Preterm delivery e. Stillbirth f. AMA (age > 35) g. Multiple birth h. BMI at least 25 i. Clotting disorder j. Smoking k. Infection
contraindications for breastfeeding medications and tests
a. Chemo b. Radioactive dye (pump and dump for 2 half lifes) c.Alcohol: blood alcohol = milk alcohol i.Before you drink and at least 2 hours after drinking ii.When you are neurologically normal it is probably save to nurse d.Medication safety app: Lactmed (@NIH) i.Great for patients and for studying
educate patients about fetal monitoring
a. Explain the purpose of monitoring b. Explain each procedure c. Provide rationale for maternal position other than supine d. Explain that fetal status can be continuously assessed by electronic fetal monitoring (EFM), even during contractions e. Explain that the lower tracing on the monitor strip paper shows uterine activity (UA); the upper tracing shows the fetal heart rate (FHR) f. Reassure woman and partner that prepared childbirth techniques can be implemented without difficulty. g. Explain that during external monitoring effleurage can be performed on sides of abdomen or upper portion of thighs. h. Explain that breathing patterns based on the time and intensity of contractions can be enhanced by the observation of uterine activity on the monitor strip, which shows the onset of contractions. i. Note peak of contraction; knowing that the contraction will not get stronger and is halfway over is usually helpful. j. Note diminishing intensity. k. Coordinate with appropriate breathing and relaxation techniques. l. Reassure woman and partner that the use of internal monitoring does not restrict movement, although she is confined to bed.* m. Explain that use of external monitoring usually requires the woman's cooperation during positioning and movement. n. Reassure woman and partner that use of monitoring does not imply fetal jeopardy
expectant management of pPROM
a. Generally these are patients whose babies are viable. b. Regular diet and hydration c. Light activity vs. bedrest (need DVT prophylaxis) i. SCDs or ted hose d. Maternal VS often (q8h?) i. To detect chorio 1. Signs of chorio include maternal fever, malodorous discharge, tender uterus, fetal tachycardia ii. WBC not really helpful on its own b/c WBCs are typically elevated during labor as an indication of inflammation so not used to diagnose an infection in a laboring woman e. Fetal monitoring x 24 hours, then at least qd (probably more) i. Continuous monitoring if baby is not vertex f. Ultrasounds to check AFI i. Low AFI associated with shorter latency and chorio ii. Not an indication for delivery iii. Some people are able to rebuild the amount of amniotic fluid g. NO cervical exams unless the patient is obviously in labor h. Neonatal consult i. Dangerous for her and the baby ***
ambiguous genitalia
a. Genetic issue b. Surgery c. Must decide what gender to assign the child d. Gender assignment should be based on the following: diagnosis, genital development and surgical options, cultural pressures, most likely adult gender identity, potential for mature sexual function, potential fertility, and the longer—term psychological and intellectual effects on the child and family
infant feeding cues
a. Hand-to-mouth or hand-to-hand movements b. Sucking motions c. Rooting reflex—infant moves toward whatever touches the area around the mouth and attempts to suck d. Mouthing e. Lot of infant cues that happen before crying, and want to catch those cues early f. Quiet and alert start to move head and hands, sometimes hand to mouth, sometimes sucking, routing ** g. Important to identify the signs early, look for cues not watching the clock h. Newborn hunger cues ****
ways that nurses can help women achieve maternal role attainment.
a. Provide anticipatory guidance about the realities of parenthood b. Parenting literature and resources c. Infant care instruction d. Instruction and opportunities for increasing infant awareness and interaction e. Interactive and therapeutic nurse-patient relationship
Common Disease Process and Complications of Preterm and Late Preterm Infants
a. RDS b. Hypo and hyperthermia c. Sepsis d. Adequate nutrition that leads to weight gain and growth e. Apnea of prematurity f. Hyperbilirubinemia g. Developmental delays h. Retinopathy of prematurity (ROP) - damage and scaring of retina - visual impairment i. Bronchopulmonary Dysplasia (BPD) j. Hemorrhage into ventricles of the brain (IVH) - hemorrhage in the lateral ventricles of the brain, clots form and obstruct flow of CSF k. Necrotizing Enterocolitis (NEC) - acute inflammatory disease of the GI mucosa
purpose of APGAR
a. Virginia Apgar was an anesthesiologist developed this score to quickly evaluate the newborn's transition to extrauterine life. b. Indicative of the physiological state
screening For depression
a. Who should screen? 1. Pediatrician, primary care, obgyn b. May not go to their own follow up appointment but will go to the baby's check ups c. When to screen? d. Edinburgh Postnatal Depression Scale 1. ACOG says this can be used during pregnancy 2. Self-report i. If a woman scores positive for this (a score of 10 above) then you need to have a plan in place for referrals ii. Ensure they don't feel stigmatized or demonized for screening positive so that they will get help
pudendal nerve block
a. administered late in the 2nd stage b. relieves pain in the vagina, vulva, and perineum=> inject lidocaine by the pudendal nerve (pudendal nerve block) not used much
tracheosophageal fistula
abnormal connection between the esophagus and the trachea
immune system changes
associated with suppression of various humoral and cellulary--mediated immunological functions to accommodate the semi--allogenic fetus depresses leukocyte function (Despite increase in numbers) may be part of improvement in autoimmune disorders in pregnancy AND increased suscpetibility to infection
deceleration
associated with uterine contractions types: early, late, variable, prolonged, bradycardia
Benzodiazepines
ativan, valium typically avoided as it may cause maternal amnesia, however does enhance pain relief and reduce N/V not routinely used
duration of breastfeeding
average 30-40 minutes total, give both breasts!
breast care
avoid soap on nipples pads for leakage
diastasis recti
b. Separation of abdominal muscles/abdominal wall. Abdominal wall muscles separate c. Not a medical issue but cosmetic issue d. Everything spills forward e. Can do exercises to try to correct it but takes a lot of time f. Can occur with or without overdistension g. Due to a large fetus or multiple fetuses h. Surgical correction is rarely necessary. i. Persistence can be disturbing to the woman j. With time the separation becomes less apparent
preparation for procedures pharmacological interventions
bee sting at first, then pressure (trying to find the epidural space), but once you find it they'll put some meds to test to make sure it's in the right spot so let us know if you feel increased HR or resps. then you'll feel the catheter go in (shooting pain down the leg or weird pain sensation) and then afterwards legs will feel warm + tingly and naturally very numb
second stage of labor-infant is born
begins with full cervical dilation (10 cm) complete effacement the "pushing stage" nulliparous mom (first time mom) first birth 2 hours, 3 hours with epidural multiparous mom (multiple births) 1 hour, 2 hours with epidural ENDS with the INFANT's BIRTH
uterine changes ballottement
being able to lift the uterus out of the pelvis and feel the fetus moveability of the fetus, diagnostic technique using palpation: a fetus when trapped or pushed, moves away and the returns to touch the examiner's hand; passive movement of the unengaged fetus
energy needs
birth - 3 months 110 kcal/kg/day; 3-6 months 100 kcal/kg/day; 6-9 months 95; after a year c. Breastmilk 20 kcal/oz d. Formula 20 kcal/oz
third stage of labor
birth of baby to delivery of placenta shortest stage 15 minutes, >30 minutes=problematic
toxoplasmosis infant complications
blindness, mental disability, eye/brain damage symptoms often not present at birth but develop later
PE work up for preeclampsia
blood pressure i) Edema—asses for distribution, degree, and pitting (no longer diagnostic of preeclampsia) ii) Deep Tendon Reflexes (including clonus) (1) DTRs reflect the balance between the cerebral cortex and spinal cord (a) Biceps and patellar reflexes are assessed (b) Normal DTRs is +2 (c) In preeclampsia they will have hyperflexia (or increased DTRs) (2) Clonus—hyperactive reflexes at the ankle joint (a) Normal (negative) (b) Abnormal positive clonus iii) Urinalyses (which urine tests are collected) iv) Signs and symptoms (headache, visual disturbances, right upper quadrant pain (see. P. 660) (1) Neurologic: (a) Headache* (b) Scotomata (blind spot) or blurry vision (c) Clonus: 45-second video (2) Hepatic: (a) RUQ or epigastric pain** (b) Indigestion or nausea (3) Renal: (a) Edema (minimally helpful) v) Serum laboratory values
too much pregnancy (stretch) or not enough risk factor
body has more than it can take. Too much energy going out and not enough nutrition going in i. Multiples, polyhydramnios ii. Nutritional deficits, BMI < 19, hard labor or long work hours iii. Age < 17
Appearance/skin color apgar 0
body is blue
Appearance/skin color apgar 2
body is pink
laxity of ligaments/pubis symphysis separation
bones are a little laxer so that the baby can descend can have symptoms of pain can wear a pregnancy belt under belly tenderness
omphalocele
bowel in umbilical cord bowel covered with the cord
primitive myelination
brainstem function
preterm and later term
breast is best expressed breast if necessary (8-24 x/24 hrs) kangaroo care lactation consultant
uterine cramping/after birth pains occurs during
breastfeeding Pitocin c. Other oxytocic agents (example: cytotec, methergine) d. More common in multiparas 3. Interventions: heat, pain meds 4. Cramping typically decreases by day 3 PP
cardiovascular changes: decreases
collagen throughout vascular system softens systemic vascular resistance by week 5 pulmonary vascular resistance colloid osmotic pressure at term delivery, blood loss < 500 cc or <100 cc for cesarean begins by week 5 s/s mimic CVD 4-5% of women have undiagnosed CVD, increased morb/mort in pregnancy (higher risk of complications)
second stage of labor nursing care
comfort, reassurance, position changes, simple communication environment
forceps/vacuum delivery prerequisites (cervical exam)
complete dilation ruptured membranes 0 station or lower
involution is enhanced by
complete expulsion of placenta/membranes, Breastfeeding
shoulder dystocia
condition in which the head is born, but the anterior shoulder cannot pass under the pubic arch a) Use pelvis and baby b) Tested/Untested pelvis c) Head delivered d) Anterior shoulder gets hung under pubic arch
syphilis fetal consequences
congenital syphilis, death, premature labor Organ problems (ears, eyes, liver, heart)
varicella fetal consequences
congenital varicella syndrome (LBW, microcephaly, cutaneous lesions), miscarriage, birth defects *If contracted at time of delivery=30 to 40% transmission to infant
chlamydia fetal complications
conjunctivitis (redness swelling, discharge), pneumonia (will be treated with oral abx)
CMV transmission
contact with bodily fluids
pictocin benefits
contractions the uterus
physiologic (other factors influence pain)
contractions, fetal size and position, maternal position, rate of fetal descent (if you have a baby that's coming really fast this can affect how mother feels pain)
true knot
cord compression
Alba Lochia
creamy white, leukocytes and decidual cells 1. Usually starts 10 days (to 14 days) postpartum and lasts up to 8 weeks (typically 4 wks) 2. Main bleeding should be done 3. Bleeding changes across the month from red to more creamy but it will last about a month 4. Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria. TIL ~6-8 wks
Epidural anesthesia or analgesia (block):
currently the most effective pharmacologic pain relief method for labor a. involves an anesthetic (bupivacaine) with and opioid (Fentanyl) being injected into the epidural space b. depending on the type, amount, and number of medications there will be varying degrees of motor impairment c. it's put in below L5, so it's hard to become paralyzed from it - but also why you need to stay really still d. main role in this situation = keep pt. calm and staying still e. teach them: shoulders back, lean over helps open up the back so the anesthesiologist can get in the space
nursing interventions third stage other medications
cytotec, hemabate, methergine (For hemorrhage)
placenta abruption
detachment of all or part of placenta from uterus complete or partial can happen with blunt force trauma, car, accident--need to come in for evaluation b/x may not have any external symptoms
pregnancy test beta hCG
detected in maternal serum or urine as soon as 7-8 days before period is due and double every 2 days in the first 4 weeks (detected in blood before urine)
why is it a big deal if a baby is not in general flexion?
deviations in attitude may cause difficulties in birth--when the fetal attitude is not general flexion the diameter of the head increases=harder for the head to enter the pelvis may have to have a c section
chronic hypertension
diagnosed prior to 20 weeks EGA, does not resolve in 12 wks postpartum • SBP > 140 and DBP > 90 • High risk for superimposed preeclampsia
morphological changes in the heart and lungs during pregnancy
diaphragm pushes up on the heart heart moves a little to the left
hepatic portal circulation baby before birth
ductus venosus bypasses maternal liver performs filtering functions
hepatic portal circulation newborn
ductus venosus closes (becomes ligament) hepatic circulation begins
decreased intestinal motility
due to microbiome and progesterone increases energy and nutrient harvest slower absorption of food
peripartum
during pregnancy or in the 4 weeks following delivery
FHR tachycardia common causes
early signs of fetal hypoxia maternal or fetal infection maternal hyperhyroidism fetal anemia response to meds: vistaril, terbutaline (stops cx, but raises mom and fetal HR), illicit drugs
systemic analgesia (opioids) fetal effects
easily cross the placenta=effects on the fetus 1. (absent/minimal FHR, decreased variability, neonatal depression) has to be on continuous monitoring if giving these medications a. these medications cross over the placenta and will affect the FHR, may see absent or intermediate variability b. have to constantly monitor
E reEda==>how to assess Episiotomy/Laceration/Incision (and hemorrhoids
ecchymosis brusing
maternal consequences of unmanged preeclampsia
eclampsia stroke liver failure/hemorrhage DIC/HELLP acute renal failure pulmonary edema/aspiration placental abruption death
Legs/Lower Extremities Assessment
edema, tenderness, varicoscities, and homan's sign
involuntary contractions (primary power) primarily responsible for
effacement dilation descent of the fetus--described in station (-5 to +5)
EL
elevated liver enzymes
progesterone extra-genital effects
elevation of BBT happens very early increased sensitivity of respiratory center to co2 (mild increase in respiratory rate and respiratory alkalosis decreased smooth muscle activity stimulates erythropoiesis (RBC production) relaxation of veins/increased pooling (legs will be swollen) decreased pulmonary airflow resistance ureter dilation
prolapsed umbilical cord management ****
emergency C/s lift presenting part off cord
supportive care team during labor
emotional support, physical care and comfort measures, and advice/information nurse, husband/partner, doulas, grandpartents siblings during labor and birth (need to have someone else take care of the child)
anesthesia
encompasses analgesia, amnesia, relaxation, and reflex activity. abolishes pain by interrupting nerve impulses to the brain *The type of analgesic or anesthetic chosen is determined in part by the stage of labor of the woman and by the method of birth planned.
breast changes
enter a phase that only occurs during pregnancy called lactogenesis 1 breast enlargement by 25-50% increase size of nipples and areola hyperpigmentation of areola enlargement of the montogmery's glands increased blood flow (mammary souffle)
regional anesthesia
epidural anesthesia or analgesia, combined spinal epidural cse analagesia epidural and intrathecal spinal opiod=ids
nipple erection
erection occurs with certain stimuli like sucking or rubbing up against nipple or crying
EDD or EDC
estimated date of delivery or confinement
Lactogenesis hormones
estrogen, progesterone, HPL DECREASE PROLACTIn remains elevated
step 1 baseline FHR
evaluate 10 minute window normal baseline 110-160 pmg
signs and symptoms of excessive/abnormal bleeding
excessive bleeding ++ clots a. Weakness, lightheadedness, nausea, b. Anxiety c. Skin: pallor, ashen, cool, clammy d. ↑HR e. ↓BP
signs of potential problems fourth stage
excessive blood loss alterations in vital signs and consciousness
colostrum function
facilitates the binding of bilirubn facilitates the establishment of lactobacillus bifidus gut bacteria Very concentrated, only need a small amount but filled with lots of nutrients Laxative stimulates the release of meconium
care of the family-4th stage of labor
family--newborn relationships bonding, skin to skin, breastfeeding, wmotional reactions
gestational diabetes above normal results for the OGTT
fasting 95+ 1 hr 180 + 2 hours 155+ 3 hours 140+
fentanyl opioid (narcotic) agonist analgesic
fentanyl citrate (sublimaze) 50-100 mcg advantage: rapid onset, short duration 1 hr IV side effect--N/V
varicella symptoms
fever, chills, myalgias, pruritic vesicles
parvovirus symptoms
fever, runny nose, headache, slapped cheek rash (can spread to chest, back, arms, legs), painful joints
1st 24 hours postpartum fundus location
ff@U on DOD at umbilicus
acquaintance phase
fingertip exploration en face position responds verbally to infant sounds use of senses parents use eye contact, touching, talking and exploring to become acquainted with their infant during this period families engage in the claiming process
fourth stage of labor care management
first 1-2 hours after birth
Naegle's rule for EDD or EDC
first day of last menstrual period -3 months + 7 days + 1 year = estimated date of delivery or confinement
pregnancy test nursing considerations
first void in the morning (urine most concentrated) false positive (tranquilizers, anticonvulsants) false negatives (diuretics, phenergan)
output assessment
first void wihtin 24 hours and generally the first stool fequency of voiding stool transition
desired urination
first void within 6-8 hours lack of urination leads to increased risk of UTI and hemorrhage
neuroprotection
five magnesium sulfate administered < 36 weeks gestation administered within 24 hours of anticipated birth. active labor qith >/=4cm cervical dilation, with/out PPROM
listeriosis symptoms
flu-like symptoms, cns sx (ha, stiff neck)
nursing care of a patient with epidural for birth
fluid bolus/IV access vital signs (before/after) position changes Foley catheter
care of thee new mother-4 stage of labor
food, hydration, rest, shower have to make sure shes able to get up
Calcium gluconate:
for mag toxicity with respiratory depression 10 mL of 10% solution IV over 10 minutes
Fetal monitoring for women with pre-existing diabetes/require medication ultrasound
for size/date discrepancies May want EFW (estimated fetal weight) near term
contractions described by
frequency duration intensity resting tone
monitoring strip
from one dark line to the next dark line=1 minute each small box=10 seconds
Management of postdate pregnancy psychological
frustration depression
PPD day 10
generally fundus is nonpalpable by PPD 10
Rubella Agent
german measles virus
dental changes
gingivitis (increase in dental hygiene required) epulis gravidarum (increase in gum tissue) increased in bleeding gums
Understanding the reason for decreased oxygen supply will help you to think of nursing measures to implement
how do you increase blood flow in maternal vessels? ==> IV bolus, medications, position changes how do you increase oxygen content? ==> give O2 how can you improve fetal circulation? ==>position changes how can you improve blood flow in the placenta? ==> increasing IV fluids, position changes but dependent on type of deceleration you're seeing so need to figure out which one it is first
hematologic changes
hypercoagulable sate *To reduce the risk of hemorrhaging but have an increase risk of colts 5 to 6-fold increase in risk of thromboembolic event Accounts for 25%U. S. maternal deaths increased venous stasis, vessel wall injury and increased clotting factors (increased pooling)
pancreas changes-pregnancy is characterized by
hyperinsulinemia hypertriglyceridemia reduced tissue response to insulin decrease FBS fetal glucose levels depend on maternal level fetus synthesizes and secretes insulin starting at 9-11 weeks of gestation
dysfunctional labor patterns uterine causes
hypertonic uterus, hypotonic uterus, inadequate secondary powers (pushing effort lack of pushing effort may be due to epidural)
supplementation only needed if
hypoglycemia dehydration infant factors (hypoglycemia, dehydration, weight loss, delayed BM, hyperbilirubinemia) maternal factors
side effects of epidural anesthesia
hypotension fever itching decreased FHR variability need for continuous electronic fetal monitoring urinary retention mobility limitations reduction of the woman/body to a birthing vessel longer second stage increased use of oxytocin post-dural puncture headaches (PDPH)
The time-honored clinical signs and symptoms of chorioamnionitis include the following:
i) **Fever (an intrapartum temperature >100.4°F or >37.8°C) (1) Classic sign (2) At onset of fever usually start abx and nsaids for fever ii) Significant maternal tachycardia (>120 beats per minute [bpm]) iii) Fetal tachycardia (>160 bpm) iv) Purulent or foul-smelling amniotic fluid or vaginal discharge v) Uterine tenderness vi) Maternal leukocytosis (total blood leukocyte count 15,000-18,000 cells/mm3)
chorio management
i) Antibiotic prophylaxis ii) Induction of labor following rupture of membranes and term
Vasa Previa: unprotected Fetal Blood vessels lie across the os
i) Basically, the combination of a Velamentous and placenta previa ii) Placenta that is covering the cervix and vessels are in the membrane iii) Fetal vessels lie over the cervical os iv) Vessels are implanted into the fetal membranes rather than into the placenta v) Usually these vessels are protected only by the membranes (not by Whar¬ton's jelly); thus they are at risk for rupture or compression. vi) There are two variations of vasa previa. In both situations artificial or spontaneous rupture of the membranes or traction on the cord may rupture one or more of the fetal vessels. vii) As a result the fetus may rapidly bleed to death. viii) Risk factors for vasa previa include low-lying placentas, pregnancies resulting from assisted reproductive technology, and multiple gestations.
c-section indications
i) CPD ii) Distress iii) Breech, multiples iv) Previa, abruption v) Current HSV outbreak, HIV vi) Prior uterine surgery (not LTCS) vii) Failed induction or remoteness from delivery, unstable situation (PIH, HELLP, cord prolapse) viii) Elective: previous c/s
SAB medical management
i) Cytotec (misoprostol) (1) Ibuprofen for cramping—designed to make them start contracting (2) Bleeding expected, but should not exceed a maxipad in an hour (3) If the bleeding gets really heavy then need to go to the ED
education for woman who had an ectopic pregnancy
i) Emotional recovery - grief or infertility support groups ii) Contraception for at least 3 menstrual cycles to allow for healing iii) Immediate notification of provider with next pregnancy iv) Risk—history of STIs, IUD, pelvic inflammatory disease
Management of postdate pregnancy how is the baby doing
i) FETAL KICK COUNTS (1) Count how many times the baby moves in two hours (2) Should get at least 10 kicks in two hours (3) Way to quantify how the baby is moving and doing
nursing considerations for women managed at home (i.e. expectant management); ie. Activity, diet, danger signs
i) For chronic HTN, medication and lifestyle management. ii) For gestational, the cure is delivery. iii) Timing depends on whether diagnosis is "severe" (1) Any time if severe/unstable (2) After 34 weeks if severe (a) Risk for the baby to stay in the uterus (b) Always a risk for mother to stay pregnant (3) After 37 weeks if not severe iv) Monitoring via BP, labs, and symptoms v) Lifestyle management vi) Steroids if preterm delivery is anticipated vii) Magnesium sulfate for IP prevention of seizures (1) Severe diagnosis (2) Neurologic symptoms viii) Delivery is the cure for gestational hypertension—not helpful if it occurs postpartum ix) Delivery always OK for mother x) Delivery not always OK for baby
forceps/vacuum delivery contraindications
i) Gestational age <34 weeks ii) Fetal scalp trauma iii) Unengaged head iv) Incomplete cervical dilatation v) Active bleeding or suspected fetal coagulation defects vi) Suspected macrosomia vii) Nonvertex presentation or other malpresentation viii) Cephalopelvic disproportion (CPD) ix) Delivery requiring rotation or excessive traction x) Inadequate anesthesia
HEELP syndrome
i) HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction, characterized by hemolysis (H), elevated liver enzymes (EL), and low platelet (LP) count. ii) Severe form of preeclampsia (?? May be separate disorder). iii) 4-12% of women with preeclampsia ~48,000 women/year iv) 90% of women with HELLP present with epigastric pain
bedrest, pelvic rest, hydration
i. Probably don't help and may actually help ii. Depends on the patient if they will be helpful iii. Leaking fluid—bedrest will help her leak less fluid
ongoing monitoring of the fetus whos mother has preeclampsia
i) Home vs. hospital ii) Daily fetal movement counts iii) Periodic (monthly) growth scans (1) To make sure the fetus is getting enough blood flow through the placenta iv) NST, BPP: frequency depends on severity (1) Gestational HTN: initial and weekly (2) Preeclampsia: twice weekly (3) Suspected FGR: twice weekly (4) Severe PIH: daily v) Continuous electronic fetal heart rate monitoring, a biophysical profile and ultrasound evaluation of fetal growth and amniotic fluid vi) If evidence of fetal growth restriction is found umbilical artery doppler velocimetry is recommended
management for severe gestational htn or severe preeclampsia
i) Hospitalization ii) Assessment monitoring BP, urine output, cerebral status, presence of epigastric pain, tenderness, labor or vaginal bleeding iii) Labs—platelet count, liver enzymes, serum creatinine iv) Antihypertensive medications to maintain a BP less than 160/110 mm HG v) Ongoing maternal and fetal assessment corticosteroids (gestation less than 34 weeks) vi) Immediate birth is indicated if: uncontrollable severe hypertension, eclampsia, PE, placental abruption, DIC evidence of nonreassuring fetal status or intrapartum fetal demise
chorioamnionitis risk factors
i) Long labor ii) Prolonged membrane rupture iii) Multiple vaginal examination iv) Use of internal HR and contraction monitoring modes v) Young maternal age, Low socioeconomic status, nulliparity, preexisting infections of the lower GU tract
forceps/ vacuum delivery indications
i) Long second stage, perhaps due to an unfavorable position of the baby. The forceps can be used to rotate the head so it can be more easily born. ii) Fetal distress, when it is necessary to have the baby born quickly. iii) Maternal inability (i.e., secondary to heavy epidural) iv) Maternal exhaustion or a condition where pushing would be detrimental to the mother, for example a maternal heart condition or a very high blood pressure. v) Have to be confident that vaginal birth is possible
preventing hypertensive disorders in pregnancy
i) Low dose aspirin (81 mg/day) from 12 weeks if any of the following: (1) Previous pregnancy with PET (2) Multifetal (3) Chronic HTN (4) Diabetes (5) Chronic kidney disease (6) Autoimmune disease (7) Multiple other risk factors: nulliparity, obesity, family history, age > 35, AA ii) Calcium if low calcium diet and risk factors (like above) (1) 1,000-1,300 mg/day (higher dose for teens)
postpartum preeclampsia
i) Mode of postpartum onset = 8 days postpartum ii) Monitor 1st 72 hours after delivery iii) Office visit 7-10 days after delivery iv) Same risk factors, symptoms, evaluation, and treatment. v) Women with persistent BP >150/100 require BP medications vi) More than half are diagnosed prenatally and during labor but the other 50% are diagnosed postpartum
uterine inversion or prolapse risk factors
i) Prior inversion ii) Uterine malformations (heart shaped, bicornate) iii) Fundal implantation of placenta iv) Manual extraction of placenta v) Short umbilical cord vi) Uterine atony vii) Abnormally adherent placenta
if rupture occurs in ectopic pregnancy
i) Referred shoulder pain/ Positive Deep lower, one sided acute abdominal pain ii) S&S of shock--Faintness and dizziness related to the amount of bleeding in the abdominal cavity and not necessarily related to obvious vaginal bleeding iii) Cullen sign - ecchymosis around umbilicus/ Blueness around the umbilicus indicating hempatoperitoneum
Risk facots for oligohydramnios
i) Risk factors for oligohydramnios: (1) ROM (2) Fetal kidney compromise or anomaly (3) Post term pregnancy / placenta issue (a) Placenta starts going bad and stops helping to make amniotic fluid (4) Dehydration?
ectopic pregnancy surgical management
i) Salpingectomy - removal of tube ii) Salpingostomy - to preserve fertility if rupture has not occurred (1) Not removing the full tube (2) Fertility preserved iii) Standard pre-op measures (1) VS (pulse, respirations, BP) assessed every 15 minutes or needed according to the severity of the bleeding and women's condition iv) Pre-op labs: Blood type & Rh factor, CBC, β-hCG level v) Ultrasound to confirm ectopic pregnancy vi) Rhogam if needed (if she is Rh-)
ectopic pregnancy monitoring after treatment with methotrexate
i) Serial B-hCG levels until undetectable (1) Follow Beta hCG levels closely ii) Contact health care provider immediately if she has severe abdominal pain, which may be a sign of impending or actual tubal rupture
McRoberts maneuver (shoulder dystocia)
i) hyperflex knees (almost to ears!) (1) Allows the pelvic bone to come up and increase the diameter of the pelvis to try and try to unwedge the shoulder (2) This maneuver causes the scrum to straighten, and they symphysis pubis to rotate toward the mother's head. The angle of pelvis inclination is decreased which frees the shoulder
emergency CS intrauterine resuscitation
i) tried all of the following interventions without any relief (1) Change position (2) Stop pitocin iV infusion (3) O2 (4) Fluid bolus
viability
i. 5-6% survival ii. between-hospital variation in initiation and intensity of treatment iii. Methodological challenges 1. Great variation in practice between 22-23: resuscitation efforts, active treatments a. Much less variation after 24 weeks a. Percentage with severe/moderate disability by gestational age among surviving newborns i. Before 23 weeks ii. 98-100% "significant morbidity"
postpartum thyroiditis
i. Abnormal TSH level in first 12 months postpartum without nodule or TRA-antibodies. ii. After full term or TAB/SAB pregnancy iii. Mimics symptoms of postpartum depression 1. Really tired and depressed 2. Can be a little hard to detect 3. Anyone who is at risk should be evaluated iv. Incidence 1.1-21.1% of women 1. Up to 25% of women with DM Type 1 2. Highest among women with history of postpartum thyroiditis (nearly half) a. 50% have recurrence 3. Screen high risk women at 3 and 6 months postpartum with serial TSH
trauma or acute stress risk factor
i. Abuse, accidents, surgery ii. Drugs: cocaine, heroin iii. Infections: systemic, STI, GU, periodontal
new born assessment skin
i. Acrocyaosis ii. Mottling iii. Vernix caseosa iv. Mongolian Spots v. Nevi "Stork Bites" vi. Milia—white spots over the nose of the baby, don't need to be treated vii. Erythema toxicum viii. Skin tags
phase of mutual regulation
i. Adjustment between maternal and newborn needs ii. Takes a little while
Emotions ***
i. Anything goes during "taking in". Expect: 1. Signs of attachment: touch, voice, eye contact, using name, en face positioning 2. Some level of preparation 3. Response to newborn a. Positive or negative b. Giving it up to adoption don't even want to see the baby 4. Feelings of overwhelm r/t parenting, feeding a. Changing roles, partners have the same needs 5. Concern about new roles and changing relationships ii. Need for processing and information iii. Questioning competence iv. Dads and partners have similar response and needs
APGAR acronym
i. Appearance ii. Pulse iii. Grimace iv. Activity v. Respiration
pacifiers
i. Associated with decreased risk of SIDS ii. Recommended by AAP during sleep times AFTER breastfeeding well-established (3-4 weeks) iii. Most of the time there isn't an issue with breastfeeding and breast implants. iv. Some babies are nipple confused easily, suck at a dummy nipple differently than they do the breast and its best to avoid artificial nipples until after breastfeeding has been very well established v. More of an issue when a mother has had a breast reduction in terms of milk production and ability to breast feed exclusively vi. Pacifiers associated with reduced risk of SIDS but not recommended until after a month=--or well after breast feeding has been established
hydrotherapy
i. Bathing, showering, jet hydrotherapy if ROM, need to be careful that all equipment is sterile to prevent introducing bacteria ii. Stimulates the release of endorphins, relaxes fibers to close the gate on pain, improved circulation/oxygenation, soften perineal tissues iii. FHR monitoring is done by Doppler, fetoscope, or wireless external monitoring iv. Good for women with back labor—helps to change position of a baby in OP or OT position v. Results in less use of pharmacologic pain meds, epidurals, less perineal trauma, increased maternal satisfaction vi. **Know your hospital policy for hydrotherapy*
current breast feeding trends
i. Breastfeeding rates in US are improving. 79% is highest ever reported. ii. Due to changes in institutional policies regarding skin to skin, baby friendly, lactation consultants iii. The populations that are least likely to breastfeed are: non-Hispanic black women. Highest among Hispanic women. iv. Current healthy people 2020 numbers 1. Currently people start breast feeding in the hospital but don't continue once they are discharged, numbers are lost after discharge due to lack of resources, knowing what to do
positioning
i. C = Cradle (what women usually go for - but not ideal until breastfeeding is well established. ii. D = Lying down (this approach may be ideal for initial feedings, and women who want to take pressure off their bottom d/t perineal trauma 1. Otherwise, whichever is most comfortable for her and facilitates the best latch. iii. Football often works for c-section moms 1. Look at where these mom's hands are - should be supporting neck and shoulders not pushing the occiput. 2. Baby in good alignment (no head twisted) 3. Pillow really helps to position the baby and with support to relieve the pressure on the mother 4. Holding hand on breast for baby, baby will slip off the breast if they are not being supported/having the breast supported for them iv. Football hold—great for women with large breasts and who recently had a c-section v. Crosscradle—good for women with large breasts. More control, helpful for getting baby to latch, supporting whole body and head of the baby vi. Cradle—especially helpful for woman who are trying to get baby to latch vii. Sidelying—night time position or someone recovering from c-section, can rest as well as feed
cholesterol
i. Cholesterol essential for brain development. Fats from breast milk are the best absorbed - that is why formula companies remove the cow milk fat and replace with vegetable oil fat. If whole milk is fed to infants - fat would pass right through leading to poor absorption and poor weight gain since infants get 50% of their calories from fat. ii. Fatty acids important for growth, neurologic development and visual function iii. Most variable component - changes over one feeding, over a 24 hour period, and across time
why is it so important to keep the infant warm
i. Cold stress increases the infant's O2 needs, increasing respiration and can lead to hypoglycemia and metabolic acidosis (PREVENTABLE!) ii. Being cold sets up this cascade ***** prevention is key!!
maternal overnutrition and lactation performance
i. Continued impact on breast feeding ii. Reference is normal weight (healthy weight) iii. Underweight woman have a reduced but not statistically significant reduce in breast milk production iv. Obese women—there is a significant reduction v. Gestational weight gain also has a significant impact on breastfeeding duration and breast milk production i. Reduction in 6 months duration of breast feeding b. i. Low milk volume + low weight there will be an early cessation of breast feeding ii. Medical factors 1. Large baby, early baby related to medical indications like gestational diabetes, or preeclampsia 2. Extra fluids -baby holding on to more fluid 3. Early babies breast may be too big and they baby might not be able to latch on iii. Before pregnancy 1. Excessive weight impairs lactogenesis II iv. Reduction in initial milk volume in the first couple of days v. Early cessation of breastfeeding 1. Especially if she has low milk volume and the baby is not gaining any weight difficulty with latching magnesium for preeclampsia
presentation
i. Contractions: ≥ 4/20 min or 6/60 min 1. Persistent 2. Especially if increasing 3. Especially if sensation is low ii. Pressure with/without bleeding 1. More than usual pressure. Not the pressure women feel all the time while pregnant iii. Leakage of fluid (LOF / pPROM) 1. Big gush and/or intermittent trickle 2. Watery or urine-like consistency 3. Keeps leaking until she delivers
IgG
i. Crosses the placenta ii. Provides passive acquired immunity iii. Crosses easily across the placenta (actually the only one that crosses to the placenta) most abundant, gives immunity to the baby iv. This is why it is important to be up to date on immunizations prior to pregnancy v. Key to immunity to bacteria and viruses Typically provides sufficient antimicrobial protection during the first 3 months of life
choosing a method of feeding bottle
i. Cultural - perceived as more convenient, less embarrassing, involve other family members, incompatible with active social life, work life, modesty issues
cord care
i. Dry care ii. Prevent infection - use of soap and water (but no prolonged immersion) iii. Clamp removed before discharge iv. Dried within 2-3 days v. Separation 10-14 days
PE genitalia
i. Edematous—especially if the babies come breech, sometimes see it with babies in a breech position even if the baby is not born vaginally, but typically resolves quickly ii. Vernix iii. Discharge 1. Mucoid 2. Pseudomenstruation 3. Brick Dust iv. Vaginal tag v. Undescended testes—descending or descended into the scrotal sac vi. Hydrocele—fluid filled scrotal sac vii. Hypo or epispadias—dorsal side of the penis instead of the end, will likely require a revision so these babies cannot be circumcised
puerperal Infection
i. Endometritis-most common pp infection, usually staph aureus, starts at placental site, can spread quickly. ii. More common in chronically ill, prolonged ROM or labor, internal monitoring of fetus, foley catheters, cesarean (5-10 times higher) or other operative birth iii. Rule out UTI, mastitis, wound infection iv. Really tender fundus and will likely have a fever v. More commonly in long labor or chronically ill vi. Draw back to internal monitoring—bacteria/viral agents can climb up the monitor
how is heat lost?
i. Evaporation, Conduction, Convection, Radiation ii. Radiation—radiates off the babies body iii. Convection—turn off fan when mom is about to deliver iv. Conduction—place baby on a warm surface to prevent conduction losses v. Evaporation—keep the body dry to prevent evaporation losses b. Brown fat—the type of fat that hold the most amount of heat and hold the heat the best
expressing milk 2
i. Expressing: 1. Hand expression 2. Hand expression video 3. Mechanical expression 1. Hospital grade pump 2. Electric self-cycling double pumps 3. Smaller electric or battery operated pumps 4. Manual breast pump
breast feeding benefits for mother
i. For Mother—relationship not just a method of feeding 1. PP bleeding and improved involution 2. Reduced risk for: 1. Ovarian & breast cancer—related to suppression of ovulation 2. Type II Diabetes 3. Hypertension, hypercholesteremia, CV disease 4. Rheumatoid arthritis 3. Bonding 1. More skin to skin contact, aids in maternal role attainment 4. Maternal role attainment 1. Bonding
MMR
i. For women who have not had rubella or who are serologically non-immune (titer of 1:8 or enzyme immunoassay level less than 0.8), a subcutaneous injection of rubella vaccine is recommended in the postpartum period prior to hospital discharge to prevent the possibility of contracting rubella in future pregnancies; this is given as the measles, mumps, rubella (MMR) vaccine. ii. Women are cautioned to avoid becoming pregnant for 28 days after receiving the rubella vaccine because of the potential teratogenic risk to the fetus safe in breastfeeding moms
PE neuromuscular
i. Glucose critical ii. Transient tremors/jitteriness is normal 1. Can be brought on by an external stimulus 2. Movements can be stopped 3. If persistent, check for hypoglycemia. 1. Accucheck < 45 → Serum glucose 2. < 40 → Feeding and recheck after 1 hr iii. Seizure - associated with ocular changes and autonomic changes
special breastfeeding considerations
i. Good ways to wake a baby: unwrap, change the diaper, talk to the baby, skin to skin ii. Fussy - sometimes too fussy to latch and nurse iii. Pre-term - good for retinal maturation, improves neurocognitive outcomes, prevents infection iv. Initially breastmilk from mothers of preterm babies has higher concentrations of energy, protein, and minerals compared to term milk. v. Late preterm babies are at risk for poor feeding, hypothermia, hypoglycemia, and hyperbilirubinemia. They tire easily, have problem sucks, and are prone to sleepiness. vi. Extra support for mom and partner - groups like La Leche Leagues vii. May have to provide additional feedings from pumping viii. Keep a lactation diary—how long the baby is feeding, how they are positioned look at latching ix. Serum bili is important for assessing and monitoring for jaundice x. Increased feeding with jaundice xi. Kangaroo care is very important xii. Started to provide audiovisual in the nicu so that mothers that are separated from their babies can watch them grown and help them bond and aid with breast pumping, helps facilitated breastfeeding Clicking =very bad latch, should be a silent latch *
expressing milk
i. Hospital grade pumps are double pumps - more efficient, insurance now covers the cost of pumps, most women could use that additional help at some point, double pump have a higher surge of prolactin (great if pumping at work) ii. Most times the set up with the flange and the tubing can be taken home and used with a rented pump of the same make. iii. Consult lactation consultant to determine which pump is right for her, also flange size. iv. Cleaning v. Volume to see vi. Double pump—higher surge of prolactin especially good if you are going to pump at work/pump a lot
care management for nonpharmacologic interventions
i. How do we evaluate how well these interventions are working? 1. Asking good conversation + dialogue "is this working? or would you like to try something different" 2. Ask them, "are they in the zone" 3. Is it working, is it making things worse, is there anything else you should try? what do they want, do they want any medications 4. Some mothers think that asking if they want pain medications after they've said they want a natural childbirth as intrusive Some people have it written down that they don't want to be asked, so don't ask = empowers them to make the decision; if they change their minds they will let you know
fFN overview
i. If fFN is negative she will likely not deliver for two weeks, this is not 100% accurate ii. The presence of fFN during the late second and early third trimesters of pregnancy may be related to placental inflammation, which is thought to be on e cause of spontaneous preterm labor. The presence of fFN alone is not very sensitive as a predictor of birth however, it is often used to predict who will NOT go into preterm labor, because preterm labor is very unlikely to occur in women with a negative test
stool progression color and consistency
i. Initially dark sticky tarry meconium (lots of bilirubin which gives it this consistency) ii. Transition stool a little more greener iii. Mustard yellow—and stay this way if they are exclusively nursed iv. Stool will be loose and stay this color exclusively while breast feeding—not diarrhea, the mother should be educated on this v. Helpful for mother to keep feeding diarrhea in the first week until feeding is well established. Should also monitor wet and dry diapers
insufficient milk supply
i. Insufficient milk supply - is it maternal stress? Was there an issue with previous pregnancy, infant weight loss, feeding technique, medications? assessment and evaluation of dyad (latch and tongue-tie professional evaluated by practitioner with skill in this) non-pharmacologic measrues
donor milk
i. Is used in NICUs for low BW, premies or sick infants when maternal milk is unavailable ii. Screened serologically and by interview iii. Pasteurized donor milk recommended by AAP iv. No federal oversight, but HMBNA guidelines v. 16 milk banks in US and Canada. vi. Collect, screen, process and distribute milk. vii. Internet milk sharing is discouraged viii. Very expensive, there is no evaluation or screening if you don't go to a milk bank ix. Most of the time milk from milk banks go to the nicu
definition of preterm labor
i. Labor occurring between 20 and 37 weeks of pregnancy ii. Uterine contractions of 4/20 minutes or 6/60 minutes, with or without ruptured membranes
formula choosing a method of feeding
i. Lack of knowledge / benefits ii. Cultural beliefs / social factors 1. More convenient, less embarrassing, involving other family members, incompatible with active social life, work life and modesty issues iii. Previous unsuccessful experience affects confidence c. Other
parent education-general and safety
i. Lots of parent education takes place during this time period, which is unfortunate since she is not in the right mind set to learn ii. Safety 1. Abduction 2. Limiting exposures to unnecessary people (infection control!)
thyroid storm
i. MFM, NICU, OBGYN joint management ii. Beta-adrenergic blockage, high dose PTU, dexamethasone, supportive care iii. Thyroid storm = MEDICAL EMERGENCY, neurologic symptoms are not expected in this population, typically usually healthy iv. Rare: 1% of women with untreated or inadequately treated hyperthyroidism 1. High levels T4 and T3 v. Maternal heart failure, shock, 25% maternal mortality vi. Often precipitated by big event like delivery, infection, surgery. vii. Extreme hyper-metabolic state:
medications and breast feeding
i. Medication is considered safe during pregnancy it is generally considered safe during breast feeding, H1 blockers that dry up secretions may affect the volume of breast milk, alcohol readily passes into the breast milk usually a two hour window check on lactmEd
transition important considerations
i. Mother's health history 1. Chronic conditions that may affect the transition ii. Past pregnancies and deliveries 1. C section, v-back (vaginal birth after c/s) 2. Hemorrhaging? iii. Current pregnancy health status iv. Course of Labor and Birth 1. Has she been having deceleration, how long has she been in labor, labor for 4 days with only ice chips? (will likely hemorrhage) v. Important to asses before delivery so you can anticipate any and all complications
reciprocity
i. Mutually gratifying interaction ii. When the baby starts recognizing you and starts smiling at you
newborn nutrition and hydration
i. Newborns and Infants do not need any extra water. Their nutrition source - either breast milk or formula has the fluid volumes that these infants need. ii. Plus - they have a little bit of fluid reserve - although there is not much room for drastic shifts in fluid balance, so nurses need to carefully monitor
CHO
i. Newborns have limited ability for gluconeogenesis and ketogenesis ii. 40-50% of total calories in newborn diet iii. Lactose is primary CHO in animal milk. Breast milk has a higher concentration of lactose compared to formula iv. Breast milk has added oligosaccharides. These HMO's are complex CHO uniquely found in human breast milk and function to promote the development of the infant's gut microbiome - function as a prebiotic to create an acidic environment that repels harmful bacteria. v. Formulas try to mimic this - some studies suggest some protective benefits, but other studies suggest that these may increase gut permeability.
Cardiovascular s/sx
i. Normal HR: 100-160 bpm 1. Listen at apical for full minute (PMI = 4th intercostal left of midclavicular line) ii. Normal BP: 60-80/40-50 (not usually done term infants) iii. Abnormal: 1. Murmur with poor perfusion 2. Tachycardia >160 bpm may be r/t: 1. Anemia 2. Hypovolemia 3. Hyperthermia 4. Sepsis 3. Bradycardia <100 bpm may be r/t: iv. Apnea v. Temperature extremes vi. Hypoxia
transition at birth
i. Nurses are basically running a code ii. It is a birth not a code for the vast majority of births iii. Transition from labor to newborn allow for a pause for the parents and baby to bond iv. Allow for pause v. With the delivery there is a huge surge of hormones that allows for the bonding of the mother and child as well as the delivery of the placenta vi. If you interrupt this process one of the first complications is the prevention of the delivery of the placenta vii. Allow for peace and quite
on demand breastfeeding
i. On demand after breastfeeding is established and infant is gaining weight ii. On demand still means at least 8x/24 hours iii. Duration varies depending on infant's age. As they get older, they get more efficient and breastfeeding time decreases. iv. Different mothers may take different approaches - letting an infant try both breasts/feeding or one/feeding. But she must alternate the breast that she starts with to ensure equal stimulation. Also want to ensure that baby is nursing long enough on one side to get the hindmilk:
D/C teaching
i. PP appointments ii. Fatigue iii. Nutrition iv. Weight Loss v. Should not be trying to lose a significant amount of weight in the first 6 weeks vi. Psychological Status vii. Activity Level viii. Support resources ix. Family planning x. Incision Care xi. Pericare xii. Ability to care for newborn xiii. When to call doctor xiv. When to follow up 1. Post vaginal 6 weeks 2. Post c-section 1-2 weeks
tips for promoting a good latch
i. Position ii. Express colostrum—smell and taste of colostrum will help baby latch iii. Support breast 1. Hand in "c-shape" (until breastfeeding is well established) 2. Nipple sandwich iv. Wait for open mouth
postpartum maternal complications
i. Postpartum Hemorrhage ii. Severe pain: Wounds, hematomas or other clots, infections iii. Puerperal Infection: Fever over 100.4 twice, at least four hours apart, on any two of the first 10 days postpartum, excluding the first 24 hours iv. Mood Disorders
Chronic inflammation/stress/imbalance (allostatic load) risk factors
i. Poverty, racism, lifestyle, life events ii. Maternal medical condition: DM, thyroid, asthma, depression iii. Age > 35
Gestational Age - Ballard neuromuscular and physical maturity
i. Preterm < 37 weeks ii. Late Preterm 34 0/7 - 36 6/7 iii. Early Term 37 0/7 - 38 6/7 iv. Full Term 39 0/8 - 40 6/7 v. Late Term 41 0/7 - 41 6/7 vi. Postterm 42 0/7 & beyond vii. Postmature > 42 weeks evaluates neuromuscular activity and physical maturity
internal fetal monitoring advantages
i. Provides a more accurate appraisal of fetal well being 1. not interrupted by fetal or maternal movement or maternal size 2. membranes must be ruptured, cervix sufficiently dilated, presenting part low enough (to even have scalp electrode) 3. sometimes external monitoring is combined with internal monitoring. The fetal heart rate might be fine, and she has been on Pitocin/oxytocin for a while. So, will put an IUPC to further evaluate the contractions. But fetal heart rate is not a concern so will have both internal and external monitoring
Brazelton - Behavioral Assessment Scale
i. Requires special training ii. Assesses infant response to 28 areas organized according to newborn behavioral developmental stages
PE musculoskeletal
i. Shoulders: Bilateral arm mobility ii. Digits: Oligo/Polydactyly iii. Hips: Dyplasia 1. Asymmetry of gluteal and thigh folds 2. Limited abduction 3. Femur length 4. Ortolani maneuver iv. Spine: asses spine all the way down 1. Closed 2. Straight 3. Dimples 4. Tufts
Inadequate respiration s/sx:
i. Silent, limp, pale/blue/grey, grunting, nasal flaring, stridor, gasping, chin tug ii. Intercostal or subcostal retractions iii. Suprasternal or subclavicular retractions iv. RR < 30 or >60 v. LATE sign: central cyanosis vi.
other parent education topics
i. Sleep position ii. Bathing iii. Diaper Changing iv. Cord care v. Circumcision care - S&S infection vi. Chiropractic and Craniosacral modalities of care vii. Can demonstrate proper breastfeeding or bottlefeeding 1. Never prop feed a baby viii. Reduces the risk of heterosexually acquired HIV
preconception care
i. Stop smoking and using cocaine ii. Treat infections, use probiotics 1. BV, STIs a. Bacterial vaginosis can cause preterm birth, treating it during pregnancy doesn't help. Have to prevent it prior to pregnancy 2. periodontal iii. Increase interpregnancy interval to > 18 months iv. Correct/moderate energy imbalances and inflammation
maternal contraindications to breastfeeding
i. T-cell lymphotropic virus I or II ii. Untreated brucellosis 1. Brucellosis - bacterial infection that causes flu-like symptoms. 2. Unpasteurized raw/dairy products - usually be ingestion 3. Possible also by inhalation or cutaneously (eg. Meat plant workers) iii. HIV 1. HIV - not recommended in US (where formula, clean water easily accessible), but recommended by WHO (weighing the 15% odds of transmission with risk of unsanitary formula. ALSO breastfeeding may actually inhibit transmission the human milk oligosaccharides may trick HIV into binding to them, keeping them in the gut rather than entering the bloodstream. 2. Recommended in areas where risk of formula (not having water) is greater than having HIV 3. HIV+ women in U.S. are not recommended to breastfeed iv. Active TB 1. Can breastfeed directly after 2 weeks of treatment or deemed noninfectious v. Active Herpes simplex lesions on breast vi. Varicella 1. Even if acquired 5 days before birth vii. H1N1 (swine flu) b. Some Medications i. Medications: citalopram (Celexa), diazepam (valium), Prozac, lithium
varicella vaccine
i. The CDC recommends that varicella vaccine be administered before discharge in postpartum women who have no immunity. ii. A second dose is given at the postpartum follow-up visit (4 to 8 weeks after the first dose)
challenges to becoming a mother
i. Time for self ii. Feelings of inadequacy iii. Fatigue iv. Loss of freedom v. Other children 1. Making sure children feel included vi. Infant behavior vii. Many challenges to becoming a parent, provide education, literature and guidance
progesterone
i. To help prevent preterm delivery ii. For women with prior PTD or with short cervix (≤ 1.5 cm) 1. Reduced preterm birth 2. Lower neonatal mortality and LBW 3. Less RDS, necrotizing enterocolitis, NICU admission
antibiotics for preterm labor (pPROM infections)
i. UTI: Macrobid 100 mg po BID x 7 days ii. BV: clindamycin 300 mg po BID x 7 days OR metronidazole 500 mg po BID x 7 days (or 250 TID) iii. GBS: PCN 5 million units now, then 2.5-3 million units q 4 hours iv. GC: ceftriaxone 250 mg IM x 1 v. Chlamydia: azithromycin 1 gram po x 1 vi. Trich: metronidazole 500 mg po BID x 7 days (or 250 TID) vii. Yeast: OTCs, or fluconazole 150 mg po x 1 (cat C) viii. pPROM: IV or po, regimens vary
FHR bradycardia common causes
i. Untreated maternal hypertension ii. Atrioventricular dissociation (heart block) iii. Structural defects iv. Viral infections v. Medications vi. Fetal heart failure vii. Maternal hypoglycemia viii. Maternal hypothermia
structural issues (risk factors)
i. Uterine anomalies, cervical procedures (LEEP), scarring from uterine procedures ii. Uterine anomalies—stretches the uterus in a funny way that may cause more cramping and contractions, example is a septum down the uterus iii. Prior surgery, D&C
Smell - able to discriminate odors
i. Vision 1. Lacks accommodation (develops over 3 months) 2. Can see 2.5 feet away, most clearly at ~ 1 foot 3. Com 1. Especially about the scent of the mother compared to other humans 2. Newborns have a highly developed sense of smell and can detect and discriminate distinct odors. 3. By the fifth day of life newborn infants can recognize their mother's smell. 4. Breastfed infants are able to smell breast milk and can differentiate their mothers from other lactating women iv. T
Vitamin B12
i. Vitamin B12: Vitamin B12 is required for proper red blood cell formation, neurological function, and DNA synthesis i. Vitamin B12 found in fish, meat, poultry and dairy products. ii. Vitamin B12 supplementation may be needed for vegans & women who've had bariatric surgery 1. Portion of stomach that is bypassed is where Intrinsic Factor is manufactured which binds to B12 and is absorbed later in the intestine. This is not possible for bariatric surgery patients so they may need supplementation iii. It is crucial to monitor the baby's weight gain over time as a B12 deficiency or milk production issues can cause lethargy and failure to thrive in the baby. In infancy, Vitamin B12 deficiency can also cause anemia, developmental delays, and permanent neurological problems in addition to failure to thrive. Infants can become symptomatic after even a few months of inadequate vitamin B12 intake.
vitamin D toxicity
i. Vitamin D Toxicity: Rare, but excessive vitamin D can cause nausea and vomiting, loss of appetite, excessive thirst, frequent urination, constipation, abdominal pain, muscle weakness, muscle and joint aches, confusion, and fatigue, as well as more serious consequences like kidney damage.
application of heat
i. Warmed blankets, warm compresses, heated rice bags, a warm bath or shower, or a moist heating pad can enhance relaxation and reduce pain during labor. Heat relieves muscle ischemia and increases blood flow to the area of discomfort. Heat application is effective for back pain caused by a posterior position or general backache from fatigue.
equipment
i. Warmer ii. Warmed blankets iii. Oxygen Source, tubing, ambu bag and baby mask iv. Instruments for visualizing and establishing airway v. Suction setup—make sure it is working vi. Resuscitation cart—just know its location, usually nicu manages this vii. Neonatologist/NNP (if anticipate significant risk)
bonding and feeding transition
i. allowing mother and family to connect with baby 1. Early bonding promotes parent—infant attachment 2. Good for both mother and newborn 3. Skin to skin is ideal for breast feeding 4. How can the nurse facilitate bonding? 1. TRY NOT TO DISTRUB THE FAMILY AS YOU ARE GIVING CARE! 2. Co sleeping is not recommended and have a higher rate of SIDS with co sleeping 5. Warmth, comfort and feeding of mother 6. Monitor mother's bleeding and VS with Newborn's VS 7. Skin to skin as soon as possible 8. Admission & assessment procedures on mother's chest
safety and general care with pharmacological interventions
i. document everything you give and pt. response to the procedure; be able to manage adverse reactions 1. ex: notice hypotension = manage it give other medications to bring BP up 2. be prepared to manage the ADRS
magnesium sulfate
i. for neuroprotection ONLY if < 32 weeks 1. Relaxes smooth muscles including uterus, CNS depression 2. Loading dose 4-6 grams IV in 20 min, then 2-3 grams/hr x 48 hours 3. May suppress maternal respirations, neuro, kidneys 4. Magnesium sulfate for preventing preterm birth in threatened preterm labor 5. Does not prolong labor or improve neonatal outcomes, and use may increase fetal/neonatal/infant mortality 6. Does provide neuroprotection (less CP) if given when delivery is imminent prior to 32 weeks. a. Prior to 32 weeks it is given for neuroprotection 7. Dosing above is different from dosing for seizure prevention in PIH 8. Not helpful for improving fetal outcomes in this situation
contraception continued
i. hormonal IUD should be avoided for the first year because it will have impact on milk production, there will be amenorrhea and will not be fertile during this time 1. Once baby is sleeping through the night, needs to use condoms 2. Birth control 6 weeks to 6 months after birth 3. After starting oral contraceptives have to monitor to see if it affects their milk production
vitamin D
i. inadequate in breastmilk. Vitamin D facilitates intestinal absorption of calcium and phosphorus needed for bone development. 1. Most infants can synthesize the vitamin d they need from sunlight - but in some cases (high latitudes, lots of cloud cover, air quality, clothing, sun screen) and furthermore because sun exposure is increasingly being discouraged - AAP recommended for all breastfed and partially breastfed babies. AAP recommendation for 400 IU daily. Qatar Example
jaundice is caused by:
i. increased serum bilirubin levels 1. A lot of new premature babies have jaundice 2. It is caused by a breakdown of red blood cells**** 3. May need photo therapy 4. Jaundice is caused primarily by the accumulation in the skin of unconjugated bilirubin, a breakdown product of hemoglobin formed after its release from hemolyzed red blood cells (RBCs).
preterm labor key signs and symptoms for diagnostics/definition
i. labor occurring between 20 and 37 weeks of pregnancy; ii. uterine contractions of 4/20 minutes or 6/60 minutes, with or without ruptured membranes; iii. evidence of cervical change (dilation, effacement, consistency, position), OR the cervix at > 2 cm dilated or ≥ 80% effaced
second period of reactivity
i. lasts for 10 min to several hours 1. Baby is alert and responsive, readily roots, latches 2. Occurs 8 hours after birth
intensity (contractions)
i. mild, moderate, strong) or if IUPC give range of mmHg 1. feel mother's stomach (palpate): a. mild = feels like chin b. moderate = tip of nose c. strong = forehead ii. external monitor tells you frequency + duration only - you palpate for strength iii. internal monitor = tells you all 3
security transition
i. mother feels secure she will be able to release the placenta and bond with her baby. She has to trust the nurse and be able to trust what is going on in the room in order for these events to take place 1. Id bands—check and double check 2. Bassinette crib cards 3. Alarm tags 4. Staff ID ( example only staff with purple badges can touch the baby) 5. Bassinette for transport in the hospital (no carrying) 6. Never leave baby unattended 7. No co-sleeping
transition care vital signs
i. q 30 min x 2 hours or until stable 1. Axillary temp 2. Respirations and HR for full minute 3. No BP (but CCHD before discharge home)
non-pharm measures for insufficient milk supply
i. skin to skin, increasing feeding frequency, pumping, rest, stress relief, fluids ii. Herbal measures - fenugreek, blessed thistle - but no evidence
internal (spinal electrode and IUPC)
i. ternal (spiral electrode and IUPC) 1. IUPC—Intrauterine pressure catheter, fed into the unterus and pressure of the fetus senses a contraction Scalp electrode attaches to the babies scalp and the cathter goes next to the baby. During contractions pressure is sensed by the catheter and the reading is transferred.
cervical length
i. typically done in high risk patients- high risk pregnancy or hx preterm delivery ii. a possible predictor of preterm labor iii. Cervical length: has negative predictive value, but false ++ 1. Endovaginal ultrasound 2. If < 3.0 cm 23% risk PTB 3. Preterm cervical shortening occurs over a period of weeks, so neither digital nor ultrasound cervical examination is very sensitive at predicting imminent preterm birth iv. Using a vaginal probe ultrasound v. Changes in cervical length occur before uterine activity so cervical measurements can identify women in whom the labor process has begun vi. The shorter it is the cervix the more concerning it is (but risk is reduced if they are not contracting and feeling well) vii. The longer the cervix is the less likely preterm labor is going to happen
Perineum—Perineal Discomfort causes
i.Episiotomy/Laceration, incision ii.Edema iii.Hematoma iv.Hemorrhoids
shoulder dystocia care
ii) Calm—keep the momentum moving, no pausing iii) Know environment iv) Know team v) Risk to fetus
estrogen extra--genital effects
increase blood volume increase heart rate, stroke volume, and cardiac output increase in fibrinogen softening of fibrous connective tissue capillary engorgement
endocrinology changes pancreas
increase in HPL => resistance to insulin placenta => insulinase => rapid metabolism of insulin (have to eat frequently to avoid ketosis)
liver changes
increase in alkaline phosphatase secondary to placental isoenzymes of alkaline phosphatase
estrogen effects on reproductive organs
increase in growth of endometrial gland and stroma increase in number and size of myometrial cells increase in myometrial contractile elements increase blood flow to uterus promotes ductal development of breasts (lactogenesis 1)
Progesterone reproductive organs
increase in secretory activity off endometrium decrease uterine contractility stimulation of alveolar development in breasts stimulates increase in tissue factor (which initiates clotting) in amniotic fluid, decidua and endometrium
steroids (bethamethasone, Dexamethasone) risks
increase mom's blood sugar, change her immune response but will increase the babies rate of maturation
decrease gallbladder emptying
increase tendency to form gallstones
increase in eccrine sweating
increased due to increased thyroid, increased metabolic rate and increased fetal heat production
respiratory physiologic changes
increased oxygen consumption 30-40% increase in tidal volume (adds to the feeling of dyspnea) 20 % decrease in residual volume respiratory rate is unchanged
decreased bladder tone + decreased renal function and dilated ureters + puerperal diuresis =
increased risk of bladder distention and incomplete emptying
changes to the vagina
increased vascularity--swells and more filled with blood increased thickness of mucus (increased risk of yeast infection) acidic pH increased vaginal discharge
fibrinolytic activity, postpartum
increases during 1st few days after birth, then returns to normal
apgar scores 0-3
indicate severe distress
apgar scores 7-10
indicate that the infant is having minimal or no difficulty adjusting to extrauterine life
culture (other factors influence pain)
individual beliefs, values, and expectations (some people believe they shouldn't be expressive, others do - it's all in the culture and individual)
C-section risks to baby
infant RDS fetal injury
three phases of immune response in pregnancy
inflammatory (trophoblast and placentation) the anti--inflammatory (Fetal growth) the inflammatory (immune cells migrate to uterus for labor/delivery
estrogen and progesterone
influence the RAAS activity via increased nitric oxide--sodium retention, increase in total body water primarily increased plasma volume both (with prostaglandin) contribute to a decrease in vascualr resistance inhibit ovulation
Artificial rupture of membranes (Amniotomy) nursing considerations
informaiton, comfort, monitor FHTs and signs/sx of chorio
amnioinfusion
infusion of a room temperature isotonic fluid into the uterine cavity to buffer the umbilical cord/relieve cord compression Risks: over distention of the uterus, increased resting tone Administered via IUPC Must monitor frequency and intensity of UC's and fluid return
transition nursing priorities
initiate respirations and newborn circulation--changed with cord being clamped warmth--avoid cold stress bonding and feeding security
post partum blues
lasts only 10 days peaks on the 5th day Mood swings, teariness, irritability, difficulty concentrating and sleeping, loss of appetite, anxiety, anger, vulnerability. Self-care proper nutrition, proper sleep ARE huge factors. Does she have help at home, help with the baby so she can take care of herself 50-80% of women
signs of effective breastfeeding infant
latches without difficulty Has bursts of 15 to 20 sucks/swallows at a time • Audible swallowing is present • Easily releases breast at end of feeding • Infant appears content after feeding • Has at least three substantive bowel movements and six to eight wet diapers every 24 hours after day 4
phases of first stage of labor
latent, active, transition
management of late decelerations
lateral position IV bolus palpate uterus/DC oxytocin O2 at 10L/min (non rebreather face mask) notify provider consider fetal monitoring anticipate C/s if pattern does not resolve -> b/c baby bot getting oxygen
fluid retention
leads to increased thickness of cornea associated with blurred vision changes manifest in the first trimester and regress within the first 6-- weeks postpartum
PROM symptoms
leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but not having contractions
hg, hct HEELP
less than 12, less than 37%
light lochia
light amount less tahn 4-inch stain on peripad
most common reason for a fatality in HEELP
liver rupture stroke
local anesthesia
local perineal infiltration anesthesia pudendal nerve block
intense grief
loneliness, emptiness, yearning guilt anger, resentment, bitterness, irritability fear and anxiety disorganization Difficulties with cognitive processing Sadness and depression Physical symptoms
dysfunctional labor patterns
long, difficult or abnormal labor caused by a variety or conditions 8-11% of births
Rubella Symptoms
low grade fever, arhtralgias, rash
shoulder dystocia risk factors
macrosomia >4000 grams
diagnostic criteria for perinatal depression
major depressive disorder with peripartum onset often women display anxiety symptoms with mood dysfunction about half of women who are diagnosed wtih pPD experienced symptoms during pregnancy
dysfunctional labor patterns risk factors
malpresentations, CPD, maternal fatigue, uterine overstimulation with oxytocin
emergency CS goal
maternal and/or fetal well being decision to incision (least amount of time between the two as possible)
constipation
may be due to 1. Meds (narcotics) 2. Fear of defecation 3. Surgery 4. Diet changes during and after labor
A Kleihauer-Betke (KB) test
may be ordered to determine the presence of fetal-to-maternal bleeding (transplacental hemorrhage), although it is of no diagnostic value. The KB test may be useful, however, to guide Rho(D) immune globulin therapy in Rh-negative women who have had an abruption
obesity
may have delayed lactogenesis II
HGB postpartum
may see an initial drop of 1 g
shoulder dystocia management
mcroberts maneuver rotate shoulder hands and knees changes the diameter of the pelvis squatting suprapubic pressure
Toco transducer (tocodynamomete)
measures frequency and duration of contractions, not intensity Place it at the fundus—see her stomach rise when she has a contraction, the rise of the belly places pressure on the tocodynamometer
premature rupture of membranes (PROM)
membrane rupture before 37 0/7 weeks of gestation membranes rupture but dont immediately go into labor Premature does not refer to gestational age iv) Preterm premature rupture of membranes = baby under 39 weeks (premature) v) Premature rupture of membranes = 39 weeks
child long term sequelae of gestational diabetes
metabolic syndrome increased systolic BP ADHS
stool progression assessment
mevonium within first 24 hours green/black transitional stool--3rd day (greenish brown to yellow brown) milk stool-4th day breastfed yellow and seedy, pasty to liquid
TORCHES syndrome
microcephaly sensorineural deafness choriorentinitis hepatosplenomgaly (jaundice_ thrombocytopenia (petechial rash) anemia, hydrops (severe fetal edema that can result form inflammatory response), IUGR
third stage of labor active management
mild traction on the umbilical cord administer oxytocin at birth of anterior shoulder or immediately following birth
nursing considerations preparing for the birth second stage fetal heart rate and pattern
must monitor closely if baseline is slowing down, deceleration present: institute interventions turn her on her side, administer oxygen at 10 L/min will discuss heavily next week
EMTALA (Emergency Medical Treatment and Labor
must provide an examination and needed stabilizing treatment, without consideration of insurance coverage or ability to pay, when a patient presents to an emergency room for attention to an emergency medical condition.
early deceleration
nadir with peak of contraction, mirror the contraction i. Onset and the return to baseline coincide with the start and end of the contraction 1. Indicate the babies head is being compressed, its not a good sign 2. Decrease starts with the contraction and goes back up at the end of the contraction ii. Nadir occurs with the peak of the contractions, giving the characteristic mirror image. Early decelerations are usually caused by head compression and are considered benign, not associated with fetal hypoxemia, acidemia or low Apgars, no nursing intervention required
narcan
narcotic antidote
nursing interventions third stage pain management
natural births may want pain management now
nursing considerations preparing for the birth second stage support of father/partner
needs continuous coaching and support encourage them to be present
gonorrhea agent
neisseria gonorrhoeae
syphilis maternal consequences
neurologic (stroke, dementia) cardiovascular, musculoskeletal, multiorgan
other options
nitrous oxide general anesthesia
Complete SAB
no evidence of retained fetal tissue cervix closed none to light bleeding none to mild cramping
false labor
no progressive cervical change discomfort felt in lower abdomen intensity does not increase contractions easily interrupted by medications or activity no blood show or ROM Braxton hicks contractions
Grimace/reflex irritability apgar 0
no response
amniotic fluid index (AFI)
normal index between 8-24 DX by US
weight loss
normal to hae 5-6% weight loss over first 3 days, however >7% requires investigation after mature milk is in, infants should gain 110-200 g(3.9-7oz) per week or 20-28 g(.7-1 oz)/day Note: breastfeed babies do not gain weight as rapidly as formula-fed babies.
threatened SAB
not a true miscarriage spotting mild uterine cramping closed os
Phenothiazines (Phenergan)
not an analgesic, sometimes given with opioids to reduce n/v, can actually impair the effects of opioids Reglan is a better option according to the text
A
number of abortions/miscarriages prior to viability
L
number of living children
gravidity
number of pregnancies
parity
number of pregnancies greater than or equal to 20 weeks irrespective of liver birth or stillborn
G
number of pregnancies, including current pregnancy
P
number of preterm births 20-36.6 weeks
T
number of term births ≥ 37 weeks
2 Classifications of Gestational
o A1 DM= diet controlled Exercise, stress manangement o A2 DM = requires medication • The risk of diabetes in pregnancy are avoidable - due to degree of hyperglycemia o May cause the baby to be bigger
ketone testing DM
o AHRQ recommends for women with GDM who: Lose weight Have inadequate intake of calories of CHO o Ketones associated with lower IQ in baby o DKA increased fetal and/or maternal loss o Facotrs precipitating ketoacidosis in diabetic pregnancy Emesis Infection Non-compliance Insulin pump failure Beta drugs Cortiosteroids Poor management
DM effects on breastfeeding
o Breast milk of diabetics is a little different- lower lactose, higher total nitrogen- and babies may take in less. Breastfeeding should still be highly encouraged but growth monitored. o Breastfed baby less likely to be obese or to acquire Type I or II o For moms Every year of breastfeeding reduces risk of Type II by 15% Also prevents metabolic syndrome Also prevents breast cancer
plan for delivery when DM is not diet controlled
o Deliver by 40 weeks if: Poor/marginal control Non-reassuring fetal status Macrosomia? o Labor Continuous monitoring Frequent blood sugar monitoring Caution with IV fluids- no IV boluses using D5 IV insulin orders depending on control of blood sugars o Consider c/s if EFW > 4500 grams (ACOG) o Anticipate RDS and hypoglycemia in newborn.
3 hour OGTT (if 1 hour result is 140-199
o Preparation Carbohydrate loading 3 days prior (>150 grams CHO) Overnight fast for 8 hours o FBS drawn o 100 grams glucose administered no smoking, stay seated o Hourly blood draw x 3hours o Pass if ¾ of values are normal
cardiovascular examination
o Split S2 with inspiration o Low-grade systolic ejection murmurs o Diastolic murmurs are abnormal o Third heart sound after mid-pregnancy o Displacement upward and to the left
fundal height
o The uterus is within the pelvis up until about 12 weeks and then begins to rise above the pelvic rim o At about 24 weeks it is at the height of the umbilicus this varies depending on the size of the woman and the height of the woman and the parity of the woman o At 36 weeks fundal height almost hits the xiphoid process especially in a woman is having her first child o At about 40 weeks with lightening it drops a little bit o When the baby engages the head of the baby comes to the pubis symphysis First baby happens before labor, subsequent babies happens during labor
TORCHES Prevention
o Vaccines for Rubella and Varicella o C/S for HSV o Hygiene: hand-washing, food preparation
hematologic changes with delivery
o With delivery there is a huge drop off blood volume and RBCs • • WBC count physiologically rises (up to 30K) in labor without infection (as in aerobic exercise) o Normal physiological change that dose not indicate infection • Fibrin matrix in spiral arteries early in pregnancy, cause fibrin mesh to form over placental site at detachment o Fiber matrix from the spinal cord into the uterus that create a mesh that forms over the placenta to keep the woman from hemorrhaging
Fetal monitoring for women with pre-existing diabetes/require medication nonstress test
o baby on the monitor for 20 minutes and monitor contractions and fetal heart rate (does not measure contractions) reactive Nonstress test: two accelerations in 20 minutes (this is GOOD!) - less than that = biophysical physical (apaar in utero, heartbeat, movement, amonitic fluid and fetal monitor)
checking blood sugars in pregnancy
o checking blood sugars 4x/day until glycemic control is established Goals: FBS <95 and 2-hr postprandial <120 Then can check less often, i.e. 4x/day twice weekly
Adverse effects on babies from hyperglycemia, hypoxia + hyperinsulinemia 2nd and 3rd trimeter
o fetus has own insulin Hyperglycemia macrosomia • Or IUGR is mom has microvascular problems
Adverse effects on babies from hyperglycemia, hypoxia + hyperinsulinemia 1st trimester
o teratogenic (oxygen cannot attach to glycosylated hemoglobin) Keeps organs from developing properly (due to hypoxic + builds up extra blood supply SLUDGING)
early onset GBS
occurs in first 7 days
Dilation (Primary Power)
opening of the cervix-0 to 10 cm (a) 0 cm external os can't even get one finger in there (b) 10 cm the cervix is completely dilated, no rim to get passed (c) The gradual opening of the cervix measured in centimeters from 0 to 10 cm
epidural and intrathecal (spinal) opioids
opioid only injection into spinal canal rapid onset pain relief but do not cause hypotension common meds: fentanyl, morphine
P (bubble heP)
pain
Toxoplasmosis agent
parasite, protozoa toxoplasma gondii
placenta previa partial
partially covering
O(ther)
parvovirus B19 varicella west nile measles enteroviruses adenovirus Coxsackievirus HIV
Parvovirus agent
parvovirus B19 (5th disease manifested by a rash)
placenta IgG
passed over from the mother to the baby baby's immunity at birth matches mother's provides immunity for 4-6 months following this time the baby starts having its own immune system
beta hcG levels
peak at 60-70 days (2-2.5 months) declining to lowest levels at 100-130 days (3.5-4.5 months) and remain at this level
what should be done with every trip to the bathroom
peri care is done with each trip to the bathroom
perineal trauma related to childbirth
perineal lacerations episiotomy vaginal and urethral laceration cervical injuries clitoral tears perineum tears
longer second stage side effect of epidural anesthesia
perineal muscles are very relaxed so we wonder if baby will be able to rotate well and how well can she push without feeling anything
taste
preference for sweet 1. Young infants are particularly oriented toward the use of their mouths, both for meeting their nutritional needs for rapid growth and for releasing tension through sucking. The early development of circumoral sensation, muscle activity, and taste would seem to be preparation for survival in the extrauterine environment. The newborn can distinguish among tastes and has a preference for sweet solutions
Nursing assessment for SAB
pregnancy Hx VS Labs B-hcg, hcb (check for anemia), WBC (indication of infection) pain assessment (uterus is contracting to expel fetal parts) bleeding (quantity and quality) emotional status
antibiotics
preop for C/S treatment group B strep (q4hr)
positive signs of pregnancy
presence of fetus visualization of fetus detection of fetal heart tones fetal movement by examiner signs attributed only to the presence of the fetus
human chroionic gonadotropin (hCG)
presence of this hormone is assessed in pregnancy test maintains function of corpus luteum early in pregnancy stimulates thirst centers of hypothalamus, increasing fluid intake (in preparation of increased blood volume)
pulmonary edema cerbral or visual disturbances severe features of preeclampsia
present new onset
burr cells or schistocytes HELLP
presnt
baseline/resting tone
pressure in uterus between contractions (the straight line)
circulation through the heart in newborn
pressures LA> RA causes foreman ovale to close
circulation through the heart baby before birth
pressures in RA> LA blood flow through foreman ovale
gonorrhea infant complications
preterm birth, neonatal sepsis, IUGR, opthalmia neonatorum
fetal consequences of unmanged preeclampsia
preterm delivery IUGR perinatal death hypoxia
imperforate anus
prevents baby from pooping don't have an anal opening
Wharton's jelly
prevents compression of the blood vessels and ensures continued nourishment of the embryo or fetus. Compression can occur if the cord lies between the fetal head and the maternal pelvis or is twisted around the fetal body.
relaxin
produced primarily by the corpus luteum secreted early in the pregnancy also produced by the myometrium, decidua, and placenta softens the cervix, enhances cervical ripening softens all ligaments, allows separation of they symphysis pubis in preparation for labor and delivery mediates uterine quiescence (keeps contractions from happening until term) increases liability of chest cartilage to allow increased chest circumference (permanent) relaxation of bones in the feet (shoe size increases by half a size) ureter dilation
cytotec (misoprostol)
produces uterine contractions used for induction and postpartum hemorrhage (cervical ripening)
pregnancy hematologic changes 2
progressive increase in plasma volume 35-50% increase in RBC mass 20--30% physiologic anemia and slight thrombocytopenia increased in EBC 5-15K (key in infection, inflammation process) increase in fibrinogen (Doubles) fibrin split products, factors VII, VIII, IX, C, von willebrands (but bleeding time and clotting times do not change in a normal pregnancy with delivery there is a huge drop in blood volume and RBCs
emergency CS indications
prolonged decelerations, lates -do the intrauterine resucitation
EDS decreases with
prolonged or premature ROM IUGR-mature but small PIH prenatal corticosteroids--increases baby's production of surfactant
Human Placental Lactogen (hPL)also called Human chorionic somatomammotropin(hCS)
promote lactogenic properties growth hormone stimulates erythropoiesis metabolic activities promotes lipolysis inhibition of glucose uptake anti--insulin action
antibody (immunoglobulin
protein produced by the immune system (mainly by plasma cells) goal is to neutralize the invader
systemic analgesia (opioids) affects
provide sedation pain relief is incomplete/temporary more effective in the early part of labor
Ritgen manuever
provider goes through rectum to apply pressure to help the head to deliver
Management of postdate pregnancy risks
psychological olg placenta meconium big baby
skin changes
spider angiomas (upper torso, face, arms) palmar erythema (50% of patients) varicosities (varicose veins, hemorrhoids, vulva varicosities) striae gravidarum hyperpigmentation darkening of nevie eccrine sweating sebum production increased due to ovarian and placental androgens acne often worsens
drugs used in cesarean birth
spinal (block) anesthesia epidural (block anesthesia) general anesthesia
internal fetal monitoring components
spinal/scalp electrode IUPC
toxoplasmosis treatment
spiramycin or sulfadiazine (antibiotic and antiparasitic)
oxytoxin (pictocin) ISMP listed as high risk medication
standard order for administration and standard concentration infuse by IV pump infuse at port closest to IV infuse alone typically titrated up until they get into a regular uterine pattern that is causing uterine/cervical change
most clotting factors & fibrinogen postpartum
stay elevated in immediate PP ** Increased risk for thrombus formation
counter pressure
steady pressure applied by support person to the sacral area with a firm object or the fist/heel of hand 1. can be applied to both hips or the knees 2. helps woman cope with sensations of internal pressure + pain in the lower back
determining baseline fetal heart rate
step 1 baseline step 2 variability
terbutaline
stops contractions oxytoxin (pictocin) antidote tocolytic (toco= contraction, lytic=lysis) basically breaks up contractions
Lactation inhibitors
stress, alcohol, fear
respiration apgar 2
strong
signs of placenta detachment
sudden gush of dark blood from the introitus apparent lengthening of the umbilical cords vaginal fullness
nursing considerations preparing for the birth second stage maternal position
supine, semirecumbentm or lithotomy positions are still widely used in western societies despite evidence that an upright position shortens labor upright positions, walking, sitting, kneeling, squatting straightens the birth canal, improved uteroplacental circulation, enhances bearing down efforts
Beta-adrenergic receptor agonists (terbutaline) fetal side effects
tachycardia, hyperinsulinemia, hyperglycemia
analgesia
the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness
cervical openings
the cervix has two openings external os =closest to the vagina internal os=closest to the fetus
based on supply and demand (Factors that affect lactogenesis )
the more she nurses and pumps the more milk she will produce
spina bifida
the most common defect of the CNS, results from failure of the neural tube to close at some point
uterine contractions
the number of contractions per 10-minute window average over 30 minutes normal 5 or less in 10 minutes
placenta previa
the placenta is implanted in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces three types: complete, partial, marginal/low lying
resting tone (contractions)
the tension in the uterine muscle between contractions, relaxation of the uterus
morphine sulfate
therapeutic rest get the body to relax a little bit; most commonly used in latent phase will either wake up rested or in labor
absent variability
there is no variability (nothing going up/down) not good amplitude range undetectable
signs of effective breastfeeding mother
• Onset of copious milk production (milk is "in") by day 3 or 4 • Firm tugging sensation on nipple as infant sucks but no pain • Uterine contractions and increased vaginal bleeding while feeding (first week or less) • Feels relaxed and drowsy while feeding • Increased thirst • Breasts soften or feel lighter while feeding • With milk ejection (let-down), can feel warm rush or tingling in breasts, leaking of milk from opposite breast