OB 558 Exam 2

Breast Adaptation during Pregnancy

- Breast changes begin soon after conception; they increase in size and areolar pigmentation. - The tubercles of Montgomery enlarge and become more prominent, and the nipples become more erect. - The blood vessels become more prominent, and blood flow to the breast doubles.

Cervical Dilation and Effacement

During the first stage of labor, the cervix opens and thins to allow descent of the fetus into the birth canal. -The amount of cervical dilation (opening) -The degree of cervical effacement (thinning) are key areas assessed during the vaginal examination as the cervix is palpated with the gloved index finger

S&S of Preesclampsia

Eyes: -blurred vision -flashing lights -scotoma Head: -severe headaches -seizures Liver: -Right upper epigastric pain -HELLP Heart: -increased BP -pulmonary edema Kidney: -Oliguria -Proteinuria (sign of glomerular damage) Extremities: -leaking capillaries -edema -hyperreflexia w/ clonus in legs Fetal: -growth restriction!!

Fertilization Figure 10.5

Fertilization and tubal transport of the zygote. - From fertilization to implantation, the zygote travels through the fallopian tube, experiencing rapid mitotic division (cleavage). - During the journey toward the uterus, the zygote evolves through several stages, including morula and blastocyst.

Non-reassuring fetal heart rate

Fetal Tachycardia (>160) Moderate Fetal Bradycardia (100-120), lost variability Absent beat-to-beat variability (STV) Marked Fetal Bradycardia (90-100 bpm) Moderate Variable Decelerations Variable Decelerations Early Decelerations and slow return baseline

4 Categories of Variability FHR

Fluctuation range undetectable (absent) Fluctuation range observed at fewer than 5 bpm (minimal) Fluctuation range from 6 to 25 bpm (moderate)** Fluctuation range more than 25 bpm (marked)

Treatment overview for diabetes in pregnancy

For women with pregestational type 1 diabetes mellitus, the foundation of glycemic management is insulin therapy along with dietary management, exercise, and fetal surveillance. For the woman who develops gestational diabetes, dietary modification is generally the foundation of treatment. Some women may require insulin along with dietary modifications, while others will not require insulin therapy. Exercise and fetal surveillance are also important facets of care.

Nursing Role in Operative Birth

Forceps: -applied when fetal head is at least +2 station Vacuum Extraction: -Assists birth by applying suction to fetal head -Progressive descent with first two pulls expected (procedure should limited to prevent cephalohematoma, risk increases if procedure is >6 min) -Number of "pop-offs" limited to 2-3 -Monitor and document pressure used and number of "pop-offs" and pulls with vacuum -Assist mom with pushing during contraction

Second stage

From complete dilation (10 cm) to birth of the newborn, may last up to 3 hours Pelvic phase (period of fetal descent) Perineal phase (period of active pushing) -Contractions every 2-3 minutes, lasting 30-60 seconds -Strong intensity -strong urge to push during the later perineal phase Sign: Full dilation Symptoms: -involuntary bearing down -increased show -passage of feces -variable decelerations -bulging of the perineum Urge to push when head at +2-3

GTPAL

G, gravida; T, term births; P, preterm births; A, abortions; L, living children G—the current pregnancy to be included in count (total # of pregnancies) T—the number of term gestations delivering between 38 and 42 weeks 9 (# of term babies) P—the number of preterm pregnancies ending >20 weeks or viability but before completion of 37 weeks (# of preterm babies) A—the number of pregnancies ending before 20 weeks or viability (#abortion/miscarriage) L—the number of children currently living (#still living)

Definitions of Hypertension in Pregnancy

Gestational Hypertension -Blood pressure elevation w/out proteinuria or other signs -Diagnosed after 20 weeks, w/no history of HTN Preeclampsia - Severe Preeclampsia - Eclampsia -Severe is an increase in severity of symptoms, may cause HELLP syndrome = hemolysis, elevated liver enzymes, low platelets -Eclampsia = presence of seizures/stroke Chronic hypertension -blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks' gestation Chronic hypertension w/ superimposed "secondary" preeclampsia

Classification of Maternal Mortality Risk Cardiac Disease

Group I (minimal risk) has a 2% to 5% risk of maternal cardiac event and comprises women with: -Patent ductus arteriosus -Tetralogy of Fallot, corrected -Atrial septal defect -Ventricular septal defect -Mitral stenosis, classes I and II Group II (moderate risk) has a 6% to 10% risk of maternal cardiac event and comprises women with: -Tetralogy of Fallot, uncorrected -Mitral stenosis with atrial fibrillation -Aortic stenosis, classes III and IV -Aortic coarctation without valvular involvement -Artificial valve replacement Group III (major risk) has a 20% to 27% risk of maternal cardiac event and comprises women with: -Pulmonary hypertension -Complicated aortic coarctation -Previous myocardial infarction Group IV has >27% maternal risk of a cardiac event and pregnancy should be avoided in this risk group.

Ovary Adaptation during Pregnancy

Increased blood supply to the ovaries causes them to enlarge until approximately the 12th to 14th week of gestation. - They actively produce hormones to support the pregnancy until weeks 6-7 when the placenta takes over the production of progesterone.

Contractions

Increased intra-abdominal pressure (voluntary muscle contractions) compresses the uterus and adds to the power of the expulsion forces of the uterine contractions - Coordination of these forces in unison promotes birth of the fetus and expulsion of the fetal membranes and placenta from the uterus. - Interference with these forces (such as when a woman is highly sedated or extremely anxious) can compromise the effectiveness of these powers.

Closed-Glottis Pushing: Valsalva Maneuver (Disadvantages)

Increased intrathoracic Pressure Decreased venous return Decreased cardiac output Decreased arterial pressure Decreased uterine blood flow Increased fetal hypoxia

Respiratory Changes in Pregnancy

- primary changes occur in lung volume and ventilation -the amount of space available to house the lungs decreases as the uterus puts pressure on the diaphragm and causes it to shift upward (decrease in functional residual volume) - This increase results in maternal hyperventilation and hypocapnia (increased minute ventilation and tidal volume) -kidneys excrete bicarb to compensate for low CO2 lvls -the woman's breathing becomes more diaphragmatic than abdominal -increase in maternal oxygen consumption due to the increased oxygen requirements of the developing fetus, placenta, and maternal organs. -Increased vascularity of the respiratory tract is influenced by increased estrogen levels, leading to congestion

Human papillomavirus (HPV) STI Affecting Pregnancy

Infection causes warts in the anogenital area, known as condylomata acuminata. These warts may grow large enough to block a vaginal birth. Fetal exposure to HPV during birth is associated with laryngeal papillomas.

Trichomonas STI Affecting Pregnancy

Infection produces itching and burning, dysuria, strawberry patches on cervix, and vaginal discharge. Infection is associated with premature rupture of membranes and preterm birth.

Other Teratogenic Agents

Infections -Cytomegalovirus (CMV) -Herpes -Parvovirus-19 -Rubella -Syphilis -Toxoplasmosis -Venezuelan EEV Ionizing radiation Metabolic imbalance -diabetes -folic acid deficiency -PKU -Hyperthermia Environmental -Mercury -Lead Alcohol

Polyhydramnios

Is a condition in which there is too much amniotic fluid (more than 2,000 mL) surrounding the fetus between 32 and 36 weeks -associated with maternal diabetes mellitus and fetal anomalies of development such as upper gastrointestinal obstruction or atresias, neural tube defects, and anterior abdominal wall defects, together with impaired swallowing in fetuses with chromosomal anomalies, such as trisomies 13 and 18 and anencephaly -There is an increase in cesarean births for fetal labor intolerance, low 5-minute Apgar scores, increased neonatal birth weight, congenital anomalies, and newborn intensive care unit admissions for women with too much amniotic fluid at term Overall is associated with poorer fetal outcomes because of the increased incidence of preterm births, fetal malpresentation, and cord prolapse.

Intermittent Auscultation Fetal Heart Rate

Is a primary method of fetal surveillance in labor. -It is the practice of using a handheld Doppler or fetoscope (a modified stethoscope attached to a headpiece) for periodic assessment of the FHR -Intermittent auscultation of the FHR is an acceptable option for low-risk laboring women -Intermittent FHR monitoring allows the woman to be mobile during the first stage of labor, since she is not attached to a stationary electronic fetal monitor -However, intermittent monitoring does not provide a continuous FHR recording and does not document how the fetus responds to the stress of labor (unless listening is done during the contraction) -The best way to assess fetal well-being would be to start listening to the FHR at the end of the contraction (not after one) to detect late decelerations -Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. -However, it cannot detect variability and types of decelerations, as electronic fetal monitoring (EFM) can

Oxytocin (Pitocin)

Is also used to induce or augment labor by stimulating uterine contractions. It is administered piggybacked into the primary intravenous line with an infusion pump titrated to uterine activity.

FHR Baseline Variability

Is defined as irregular fluctuations in the baseline FHR, which is measured as the amplitude of the peak to trough in beats per minute -It represents the interplay between the parasympathetic and sympathetic nervous systems -Because variability is in essence the combined result of autonomic nervous system branch function, its presence implies that both branches are working and receiving adequate oxygen -Characterized in 4 categories

Gestational Diabetes Diet

Low glycemic diet with 3 meals and 3 snacks especially at bedtime

diagnosis of HELLP syndrome Labs

Low hematocrit that is not explained by any blood loss Elevated LDH (liver impairment) Elevated AST (liver impairment) Elevated ALT (liver impairment) Elevated BUN (renal impairment) Elevated bilirubin level (liver impairment) Elevated uric acid and creatinine levels (renal involvement) Low platelet count (less than 100,000 cells/mm3)

Known Drug Teratogens

-ACE inhibitors -Androgens: DES -Antibiotics: Streptomycin, Tetracycline -Antithyroid -Chemotherapeutics -Psych meds: lithium -Anticonvulsants: carbamazepine, phenytoin, valporic acid -Retinoids: Accutane, Retinol, Etretinate -Thalidomide -Warfarin

Operative Delivery: Foreceps

-Able to rotate the baby -Increases the chance of 3rd or 4th degree vaginal laceration -More maternal discomfort PP -Lots of training needed! -Increased risk of neonatal facial nerve palsy

Fetal Reasons for C-Section

-Active genital herpes -Maternal HIV (if viral titers are low or undetectable then it is not recommended) -Cord prolapse -Non-reassuring fetal status -Abnormal position: breech, transverse, face with chin posterior -Placenta previa -Multiple gestation -Large baby

Childbirth Trauma

-Affects 14-20% of women (can develop PTSD) -Risks: unexpected C-section, hx of psych trauma Nursing preventative care -ask "how are you doing" -"is there anything you want to know about labor and birth?" -use magic hour to point out newborn behaviors -reflective writing in hospital -distraction soon after event

Appropriate Nursing Interventions for Loss

-Allow time -Model care of the baby for the parents -Admiring the baby, asking if they see family traits or features -Encourage bonding -Offering privacy -Assess father or partners needs

Role of skin to skin

Maintaining thermal neutral environment -36.4-37.2 C axillary -36.0-36.5 C skin probe Cardiovascular stability -HR: 120-160/min (less than 100 in sleep) Respiratory stability -30-60 min Better glucose levels Improved breastfeeding

Chlamydia STI Affecting Pregnancy

Majority of women are asymptomatic. Infection is associated with infertility and ectopic pregnancy, spontaneous abortions, preterm labor, premature rupture of membranes, low birth weight, stillbirth, and neonatal mortality. Infection is transmitted to the newborn through vaginal birth. Neonate may develop conjunctivitis or pneumonia.

Gonorrhea STI Affecting Pregnancy

Majority of women are asymptomatic. It causes ophthalmia neonatorum in the newborn from birth through infected birth canal.

Syphilis STI Affecting Pregnancy

Maternal infection increases risk of premature labor and birth. Newborn may be born with congenital syphilis, causing jaundice, rhinitis, anemia, IUGR, and central nervous system involvement.

Effective practices during L&D

-Alternative vs conventional birth settings -Labor assessment to delay admission until labor -Breast stimulation for cervical ripening or labor induction -Continuous labor support -Upright position during 1st stage -Pain relief (nitrous oxide, acupuncture, massage) -Immersion in water during 1st and 2nd stage -Perineal techniques during 2nd stage -Restricted use of episiotomy -Delay cord clamping -Active management of 3rd stage (oxytocin after birth, misoprostol (cytotec)) -External cephalic version for breech term -Oral maternal hydration for oligohydramnios

Nursing Management with Nitrous

-Assure equipment in good working order -Assure only the mother initiates and holds mask and no one else -Maintain safety - typically staying in bed or on floor or assisting with walking

Trial of Labor After C-Section (TOLAC) Recommendations

-Best evidence suggests that TOLAC is reasonable choice for the majority of women -Allow mothers prefernce -Adverse outcomes are rare for both elective and repeat C-section and trial of labor

Location of Fetal Heart Tones

-Breeched presentation (LSA/RSA): FHR in upper quadrants -Vertex presentation: FHR in lower quadrants

Common Lab Tests During Pregnancy

-CBC -Blood typing -Rubella titer -Hep B -HIV testing -STI testing -Cervical smear

Latent Phase Physiologic Changes

-Cervical dilation from 0-6cm -Cervical effacement from 0-40% -Nullipara lasts up to 20 hours -Multipara up to 4 hours -Contractions every 5-10 min -Contraction duration 30-45 sec -Intensity is mild to palpation

Active Phase Physiologic Changes

-Change in slope of rate of cervical dilation -cervical dilation 5/6 -10 cm -cervical effacement 40-100% -Nullipara lasts 6 hours -Multipara lasts 4 hours -contractions increase in frequency (2-5 min), duration (45-60 sec), and intensity moderate -Possible increased anxiety (reassess ability to cope)

Risk Factors for Preeclampsia

-Chronic renal disease -Chronic HTN -Antiphospholipid Abnormality -Prior history of preeclampsia -Twin pregnancy -Pre-existing diabetes -Nulliparity -BMI>35 -Maternal age >40 -Black race -New partner (due to genetic mingling) -Pregnant with a recent partner -Greater than 10yrs betwn pregnancy -Diet low in Ca

Cardinal Movements of Labor

-Descent -Flexion -Internal rotation -Extension -Restitution -External rotation -Expulsion

Latent Phase of Labor Interventions

-Determining between true and false labor -Patient can eat and drink as desired -Change activities/positions frequently to keep comfortable and assist labor -Remain relaxed -Couple typically "excited" and "relieved" the big event has started -Should not be in the hospital for this, unless prolonged

Vaginal Exam Measurements

-Dilation: 0 - 10cm -Effacement: 0-100% -Station: -3 to +4/+5 (birth) -Position: three variable Ex: LOA -Assess pelvic size (rarely done)

Acute Hypertensive Effects on Mother

-Eclampsia -Stroke -Abruption/DIC -Liver hemorrhage/rupture -Pulmonary edema/aspiration -Adults RDS -Renal failure -Death

Issues Related to Drugs in Pregnancy

-Exposure in first 2 weeks after ovulation "all or nothing", miscarriage or no effect -Greatest teratogenic risk in the first 8 weeks many women do not know they are pregnant -Concern about causing developmental defects in the growing fetus you need to remember there is a normal background risk: congenital problems and spont. abortion -The number of women taking 4 more medications in the first trimester has tripled in the last 30 years Must weigh the benefits of stopping meds -May need to adjust maternal dosing due to physiological changed in pregnancy -There may be special consideration during labor and birth

Hypertensive Effects on Fetus

-Fetal growth restriction (small for gestational age) -Fetal hypoxia -Stillbirth related abruption -Prematurity (due to maternal/fetal reasons) -increased risk for autism -increased risk for developmental delay

Severe Preeclampsia Management

-Give corticosteroids (if 26-28 weeks), then may have deliver after 48 hours if mother is stable -If mother is unstable, she must deliver despite prematurity due to risks of morbidity to the mom -Deliver > 34 weeks -Fluid and electrolyte replacement -Antihypertensive therapy -Treatment with magnesium sulfate to prevent seizures during labor (neuroprotection)

Diagnosing the Process of Grief

-Grieving phases -Identify actual risks: altered sleep and eating patterns -Psychosocial risks, PTSD -Select appropriate support resources

Operative Delivery: Vacuum Extraction

-Higher failure rate than forceps -Less need for maternal anesthesia -Increased risk of neonatal injury -Minor: Can cause cephalohematoma or retinal injury -Major: Can cause subarachnoid or subgaleal hemorrhage

Polyhydramnios Complications

-IF severe, preterm labor can occur remove excess fluid to prevent this -During labor: Sudden rupture of membranes can cause --Prolapsed Cord, Placenta abruption Abnormal lie

Procedures used to control PPH

-Intrauterine pressure balloons -Uterine artery embolization -Hysterectomy (last resort) Cardiovascular supportive therapy: -Blood -Volume expanders

Summary of Menstrual Cycle Hormones

-LH rises and stimulates the follicle to produce estrogen. -As estrogen is produced by the follicle, estrogen levels rise, inhibiting the output of LH. -Ovulation occurs after an LH surge damages the estrogen-producing cells, resulting in a decline in estrogen. -The LH surge results in establishment of the corpus luteum, which produces estrogen and progesterone. -Estrogen and progesterone levels rise, suppressing LH output. -Lack of LH promotes degeneration of the corpus luteum. Cessation of the corpus luteum means a decline in estrogen and progesterone output. The decline of the ovarian hormones ends their negative effect on the secretion of LH. LH is secreted, and the menstrual cycle begins again.

External Version

-May be done after 36 weeks gestation to change breech/transverse to cephalic presentation] -Success rate 65-75% (provider dependent) -Tocolytic (terbutaline) given prior to procedure to relax the uterus -Fetal part must not be engaged -Reactive NST done prior to procedure to establish fetal well-being -Physician applies external manipulation to maternal abdomen -Fetal monitoring after to assure fetal well-being

Methods for Intermittent Auscultation of FHR

-Measure baseline FHR before contraction -During contraction and at least 30 seconds after contraction Frequency of monitoring -During latent phase: every hour -During Active labor: every 30 min (15 min if high risk) -During second stage: every 5-15 min

Nursing Management of Women with Preeclampsia

-Monitor symptoms: persistent headache, blurred vision, epigastric pain, SOB/coughing -Monitor vital signs: blood pressure, RR; if on mag sulfate (listen to lungs PRN) -Assess reflexes and presence of clonus -Monitor fluids: I&Os -Follow-up lab results

Oxytocin: Infusion Safety

-Most hospitals have adopted a standard concentration of oxytocin so mU/min = mL/hr on infusion pump

Assessing the Process of Grief

-Nature of parental attachment -Culture influences -Parents phase of grief -Support network -Family relationships -Mothers difficulty in coping with crisis int he past -Immediate, short term, and long term needs

Long-term Hypertensive Effects on Mother

-Neurological deficit (after stroke/seizure) -Chronic HTN -Diabetes -Cardiovascular disease

Nitrous Oxide Administration

-Nitrous oxide effective in reducing pain in labor, maybe better than opioids -Administered by mask held by the mother ONLY -Rapid onset (1 min) and rapidly removed from body (2-3 breaths) -No adverse effects on labor or fetus/baby -Mom may feel dizzy, light-headed, "gitty" -Can be given at any stage of labor, does not affect progress or pushing

Early Gestational Loss Interventions

-No visible baby - offer US photo, offer to create symbols, genetic counseling -Visible baby - see, hold, photos, arrangements, genetic counseling -Ectopic pregnancy - validate pregnancy loss, offer memento, referral for future childbearing -Adoption - bittersweet grief, mementos -Infertility - Listen for intangible losses, reconstruct

First-line Medication for PPH

-Oxytocin (Pitocin) 10-40 u -Misoprostol (Cytotect) 800-1000 mcg rectal -Methergine 0.2 mg IM -Carbetocin 100 mcg IV push

L&D Admission Nursing Assessment: Hx

-Parity and Gestational age -Obstetric/labor history -Allergies -Significant lab results (Rh, anemia, HIV, Group B Strep (GBS), Hep B -Significant prenatal issues (growth restriction/placental problems) -Significant med/surg history -Labor/birth plans

Effects of C-Section of Subsequent Pregnancy

-Placenta previa (2-5 times more likely) -Placenta accreta -Increased risk for hemorrhage -Emergency peripartum hysterectomy -Placenta abruption -Uterine rupture -Decreased fertility -Increased stillbirth

Fetal Consequences of Oligohydramnios

-Potter's syndrome -Hypoplastic lungs -Extremity deformities from lack of movement During pregnancy -Variable decelerations indicating cord compression are common. -Changing the woman's position might be therapeutic in altering this fetal heart rate pattern.

Nursing Management for Epidurals

-Pre-load with fluids: 500-1000 cc bolus (to prevent hypotension) -Monitor for maternal hypotension 80% (may require emergency CS for bradycardia) -Assess bladder status regularly -Encourage to change positions even if in bed -Postpartum assess for headache especially if worsens from supine to sitting -Ask provider to consider blood patch

Other Times to Assess FHR

-Prior to procedures or medication Before and After -rupture of membranes -pelvic exam -abnormal uterine activity (after) -provision of analgesia

Bony Pelvis in Pregnancy

-Relaxin increases the flexibility of the pubic symphysis, permitting the pelvis to expand during delivery -causes joints to soften and ligaments of pelvis to soften resulting in Sacroiliac Jt Laxity = "Waddling Gait" -symphysis eventually separates to permit increased pelvic diameter

Nursing care for Postpartum Infections

-Rest, fluids, good nutrition, antibiotics, clean (dry nightgown) Endometritis -analgesis for fever -ambulation to promote drainage Mastitis -warm compress -express milk -continue to breastfeed Abdominal incision -depends on degree -teach woman to pack the wound Laceration/episiotomy -warm sitz bath -debridement with hydrogen peroxide

Shoulder dystocia: Other Maneuvers by provider

-Rotate the anterior shoulder to oblique -Deliver of anterior or posterior arm -180 degree rotation of shoulders (wood screw) -hands and knees position (gaskin) -fracture clavicle

Diagnosing Gestational Diabetes

-Screening is best between 24 and 28 weeks' -a blood glucose level is obtained using an oral 50-g glucose load followed by a 1 hour plasma glucose determination. -If the result is more than to 140 mg/dL, further testing, such as a 3-hour 100g glucose tolerance test, is warranted to determine whether gestational diabetes is presentIf the result is abnormal, a 3-hour glucose tolerance test is done. ADA and ACOG glucose targets are: Fasting blood glucose level: Less than 95 mg/dLAt 1 hour: Less than 140 mg/dLAt 2 hours: Less than 120 mg/dLAt 3 hours: Less than 95 mg/dL

Common side effects of opioids

-Sedation -Dizziness -Altered mental state -N/V -Decreased gastric emptying/motility -Constipation -Urinary retention -Respiratory depression

Late Gestational Loss Interventions

-Stillbirth: acknowledge effective labor, acknowledge birth, facilitate bonding -Newborn death: support decision to withdraw life support, skin to skin hold -Infant death: create memories for close family, personalize funeral/burial

Second-line Medication for PPH

-Tranexamic acid (TXA) 1 gm IV -PG F2-alpha (Hemabate) 0.25 mg IM

Manage Pregnancy Discomforts

-Urinary frequency or incontinence -Fatigue -N/V -Backache -Leg cramps -Varicosities -Hemorrhoids -Constipation

Ongoing L&D Assessment

-Vital signs -Nutrition/hydration status (encourage low salt, sugar, and fat drinks and food) -Elimination (bowel/bladder) -Encourage position changes every 30-40 min Additional 5 P's - Philosophy (low-tech, high-touch) - Partners (support caregivers) - Patience (natural timing) - Patient (client) preparation (childbirth knowledge base) - Pain management (comfort measures)

Management of 3rd Stage of Labor

-active management decreases amount of postpartum blood loss and the incidence of PP hemorrhage Components of active management: -provision of oxytocin with birth of the baby (w/in 1 min) -Gentle controlled umbilical cord traction after cord is cut -Uterine massage after birth of the placenta

Self maintenance for the Nurse with Loss of Baby

-be patient with yourself as you work through the grief -let others know what you need to cope -talk openly with manager, co-workers, social workers -set aside time to recover from the loss -give yourself time to decompress, process, and heal

Gestational Diabetes (GDM)

-condition involving glucose intolerance that occurs during pregnancy usually diagnosed in the second or third trimester of pregnancy that was not clearly overt prior to gestation -the woman with diabetes during pregnancy cannot cope with changes in metabolism resulting from insufficient insulin to meet the needs during gestation, (their body doesnt produce enough insulin to counteract the insulin resistance of hPl)

Evidenced-based non-pharmacological relief measures

-continuous 1 on 1 support from a non-medical person decreases rate of C-section by 28-56% -water immersion -sterile water injections -trancutsneoud electrical nerve stimulation (TENS) -breathing techniques -position changes -mental strategies -hot/cold -shower

Preeclapsia

-described as new-onset hypertension after 20 weeks pregnancy accompanied by proteinuria and/or maternal organ dysfunction that targets the cardiovascular, hepatic, renal, and central nervous systems (CNS) -the smooth muscle cells surrounding the spiral arteries of the placenta are replaced with cytotrophoblasts during pregnancy; b/c these do not constrict in response to SNS stimulation -is a two-stage event; the underlying mechanisms involved are vasospasm and hypoperfusion -In the first stage, the key feature is widespread vasospasm. In addition, endothelial injury occurs, leading to platelet adherence, fibrin deposition, and the presence of schistocytes (fragments of erythrocytes). -The second stage of preeclampsia is the woman's response to abnormal placentation, when symptoms appear (i.e., hypertension, proteinuria, headache, nausea and vomiting, retinal vascular changes causing blurred vision, and hyperreflexia due to hypoperfusion).

Pregnancy drug clinical consideration points

-disease association -dose adjustment and/or monitoring -maternal adverse reactions -fetal/neonatal adverse effects -labor and delivery issues

Prenatal Appointment Schedule

-every 4 weeks up to 28 weeks -every 2 weeks from 29-36 weeks -every week from 37 weeks to birth

Placenta previa

-exists when the placenta is inserted wholly or partly into the lower uterine segment of the uterus, partially or completely covering the internal cervical opening -It poses a high risk of prenatal and postpartum hemorrhage as well as perinatal mortality Increased risk with previous C-sections -uterine endometrial scarring or damage in the upper segment, which may incite placental growth in the unscarred lower uterine segment - With placental attachment and growth, the cervical os may become covered by the developing placenta. Placental vascularization is defective, allowing the placenta to attach directly to the myometrium (accreta), deeply attach to the myometrium (increta), or infiltrate the myometrium (percreta).

Leading casuses of maternal death

-hemorrhage -hypertension -sepsis -cardiovascular disease -preeclampsia -VTE

Cervix Adaptation during Pregnancy

-if someone has never been pregnant before their cervix will be closed -the cervix is composed of the external and internal os -the external os can be slightly open if the woman was previously pregnant, but the internal os remains closed until labor to keep the baby in the uterus -Under the influence of progesterone, a thick mucus plug is formed, which blocks the cervical os and protects the developing fetus from bacterial invasion.

HELLP Syndrome

-is an acronym for hemolysis, elevated liver enzymes, and low platelet count. - It is a variant of the preeclampsia/eclampsia syndrome - It is a life-threatening obstetric complication considered by many to be a severe form of preeclampsia involving hemolysis, thrombocytopenia, and liver dysfunction. - occur during the later stages of pregnancy and sometimes after childbirth - treatment for HELLP syndrome is based on the severity of the disease, the gestational age of the fetus, and the condition of the mother and fetus

Gonadotropin-Releasing Hormone (GnRH)

-is secreted from the hypothalamus in a pulsatile manner throughout the reproductive cycle. -it pulsates slowly during the follicular phase and increases during the luteal phase. -GnRH induces the release of FSH and LH to assist with ovulation.

Placental Abruption

-is the early separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage Maternal risks include obstetric hemorrhage, need for blood transfusions, emergency hysterectomy, disseminated intravascular coagulopathy (DIC), Sheehan syndrome or postpartum gland necrosis, and renal failure. Perinatal consequences include low birth weight, hypoxia, anemia, brain damage, preterm birth, asphyxia, stillbirth, and perinatal death

Risk Factors for Adverse Pregnancy Outcomes

-isotretinoins (accutane) -alcohol misuse -antiepileptic drugs -diabetes (preconception) -folic acid deficiency -HIV/AIDS -Hep B -hypothyroidism -maternal phenylketonuria -rubella seronegativity -obesity -oral anticoagulant -STI -smoking

Nursing Interventions to avoid during Child Loss

-letting your own feelings of helplessness keep you from reaching the family -saying "i know how you feel" unless you've had a similar loss -telling them what they should do or feel -avoid using the baby's name -trying to explain the tragedy with non-medical terms "it was meant to be" or "it was Gods will"

Side effects of Epidural

-loss of sensation in legs and position sense -inability to void - bladder distension -shivering -itching -increased maternal temperature (septic work up for children) Adverse effects -severe headache from dural puncture -backache -neurologic sequelae - usually transitory -systemic injection - seizure/heart block -Epidural hematoma - paralysis

Nursing Management for Pharmacological Drugs

-maternal and fetal vital signs must be stable before systemic drugs may be administered -assess mother and fetus and evaluate contraction pattern before administering prescribed medications Drugs may cause fetal respiratory depression at birth if given too late in labor -do not give 30-60 min prior to birth -if birth within this timeframe, be prepared to give naloxone to infant -Once given, patient safety precautions -Be aware of poor suckling in the infant in early post-partum

Gestational Diabetes in Labor

-maternal insulin requirements decrease dramatically in labor -usually hourly BS monitoring -may need 2 IVs: one with saline and the other with D5W -If giving IV insulin, double check dosing -IV insulin d/c'd at end of 3rd stage -Postpartum insulin needs fall dramatically since the placenta is out -in the first 24 hours, T1DM may need no insulin -Instruct the mothers to retest at 6 weeks postpartum

Expectant/Home management for Gestational HTN and Non-severe preeclampsia

-monitor for S&S of worsening condition -daily fetal movement counts -frequent rest in lateral position -frequent monitoring of blood pressure, weight, and urine protein (2x a week) -NST (non-stress testing) and assess amniotic fluid volume -Lab testing: platelets, liver enzymes, kidney function -Deliver at 37 weeks

Postpartum care for C-section

-monitor vital signs for signs of infection -cardiorespiratory assessment -assess bowel sounds -assess fundus and incision for REEDA -monitor I&Os and maintain IV access -assess legs for DVT -administer and educate on medications -encourage early ambulation to prevent DVT

FDA reproductive drug risk labeling

-pregnancy registry: for drugs with no human studies Risk summary -if contraindicated in pregnancy, first sentence will stay -risk assessment of animal studies in terms of human dosage -concise risk summary -if no studies, will state this Clinical consideration Data in more detail

Factors predisposing to breech presentation

-preterm birth -multiple gestation (twins) -fluid abnormality -maternal/fetal anatomical abnormality -previous breech -placenta placement -laxity of maternal abdominal tone (high parity)

Maternal Reasons for C-Section

-previous C-section (especially if it was a vertical incision) -Previous uterine surgery -Medical disorder requiring avoiding pushing -Cephalopelvic disproportion (CPD) -Failure to progress or arrest of labor ("failure to wait")

Assessing Psyche

-previous experience -presence of support -expectations for labor and birth Assess: -verbal expression -body language -perceptual abilities -coping ability

Gestational Diabetes Management

-primary goals of care are to maintain glycemic control and minimize the risks of the disease on the fetus -nutritional management, exercise, insulin regimens, and close maternal and fetal surveillance -repeat a post glucose screen 6-12 weeks postpartum

Human placental lactogen (hPL) or human chorionic somatomammotropin (hCS)

-produced by the placenta -modulates fetal and maternal metabolism, participates in the development of maternal breasts for lactation -decreases maternal glucose utilization, which increases glucose availability to the fetus -acts as a growth hormone for fetus ensuring adequate nutrients -inhibits effects of insulin on glucose reuptake -promotes nitrogen retention for protein synthesis -peaks at 28-32 weeks -higher levels with increased placental surface (multiple babies)

Secondary Trauma on the Nurse with Loss of Baby

-stress, insecurity related to inexperience -anxiety, profound sadness, emotionally demanding -self-doubt -possible trauma response depending on the situation -guilt

Assessing Psyche: What do women in labor need?

-to feel safe with privacy respected -fully informed -adequate time for shared decision-making with freedom from coercion -receive supportive care in a calm environment -freedom of movement and choice of birth position

Postpartum Hemorrhage (PPH) from Uterine Atony

-uterine atony = the uterus fails to contract after labor which can lead to PPH -anything that doesnt allow the uterus to contract and stay contracted Risks: -Grandmultiparity -Excessive uterine enlargement: multiple gestation, polyhydramnios, macrosomia -History of PPH -Presence of fibroids -Prolonged labor (especially if induced with oxytocin) -Retained placental fragments Other sources -Traume: perineal, vaginal, or cervical laceration Bleeding is brighter red, thinner (watery), and more continuous flow -Coagulopatholpathy disorder

Immediate maternal risks with C-section

-venous thromboembolism -hemorrhage -infection -death (rare but 4 times more likely)

Assessing readiness for labor: Bishop Score

Cervical dilation 0: closed 1: 1-2 cm 2: 3-4 cm 3: >=5 cm Cervical effacement 0: 0-30% 1: 40-50% 2: 60-70% 3: >=80% Fetal station 0: -3 1: -2 2: -1 to 0 3: >= +1 Cervical Consistency 0: Firm 1: Moderate 2: Soft Cervical position 0: Posterior 1: Mid-position 2: Anterior ** Favorable for labor is >=6 Needs cervical ripening if 5 or less

Other Spontaneous Lacerations

Cervical laceration -if missed can be a source of bleeding Labial laceration -spray water from peri-bottle while urinating to dilute urine and prevent stinging -if the laceration is periurethral she may have difficulty urinating and need a foley

Active Phase of Labor Transition

Cervix: 8-10cm Psyche -Irritable, feels like "out of control" -Totally focused on contractions -Exhausted and wants pain medication -Doesn't want to be touched Physical -Shaking -Vomiting -Urge to push

Magnesium Sulfate

Contraindicated in pts with Myasthenia Gravis MOA: calcium antagonist, anticonvulsant, neuroprotection

Intrauterine Resuscitation: POISON

Corrective measures used to optimize oxygen exchange within maternal-fetal circulation -Position change to alleviate pattern (on hands and knees for prolapsed cord) -Oxygen administration -IV fluids to increase uterine perfusion -Stop or (Sterile Vaginal Exam) -Oxytocin, if infusing. If they are having spontaneous tachysystole ask provider for Terbutaline -Notify provider

Planning the Process of Grief

Create a plan with parents about what like will look like in the hours after loss -Birth plan -Plan of care Plan support interventions appropriate to the individual phase of grief

Oligohydramnios

Decreased amount of amniotic fluid (less than 500 mL) between 32 and 36 weeks' gestation that is associated with poor pregnancy outcomes -May result from any condition that prevents the fetus from making urine or blocks it from going into the amniotic sac. -Reduction in amniotic fluid reduces the ability of the fetus to move freely without risk of cord compression, which increases the risk for fetal death and intrapartal hypoxia. Causes due to Mother: -Uteroplacental insufficiency (ex: HTN, poor implantation) -Viral infections -Dehydration Causes due to Fetus: -Renal agenesis -Urinary tract obstruction -Spontaneous rupture of membranes -Post dates Labor issues: -aminoinfusion -abnormal FHR tracing

Benefits of Delayed Cord Clamping

Delayed at least 60 seconds (term) -increases blood volume 1/3 -best if 3-5 min of skin to skin Benefits -extra blood to baby enough to meet iron needs for 6 months -circulatory and pulmonary stability -less intraventricular hemorrhage (preemies) -provides extra stem cell transfusion = less infection, important for brain development, better IQ, and psychomotor skills Concer -polycythemia

Furosemide (Lasix) with Preeclampsia and Eclampsia

Diuretic action, inhibiting the reabsorption of sodium and chloride from the ascending loop of Henle Pulmonary edema (used only if condition is present)

Vaginal Adaptation during Pregnancy

- Increased vascularity because of estrogen influences, results in pelvic congestion and hypertrophy. - Increased thickness of mucosa, along with an increase in vaginal secretions, helps prevent bacterial infections.

Uterus Adaptation during Pregnancy

- decrease in uterine vascular and muscle tone and a rise in blood flow - grows at a steady and predictable rate during pregnancy -As pregnancy progresses, 80% to 90% of uterine blood flow goes to the placenta -As the uterus grows, it presses on the urinary bladder and causes the increased frequency of urination experienced

Rh Incompatibility (Hemolytic Disease of the Newborn)

- is a condition that develops when a woman with Rh-negative blood type is exposed to Rh-positive blood cells and subsequently develops circulating titers of Rh antibodies - ndividuals with Rh-positive blood type have the D antigen present on their red cells, while individuals with an Rh-negative blood type do not. The presence or absence of the Rh antigen on the red blood cell membrane is genetically controlled - Rh incompatibility most commonly arises with exposure of an Rh-negative mother to Rh-positive fetal blood during pregnancy or birth - As a result, maternal antibodies are produced against the foreign Rh antigen - A second pregnancy with an Rh-positive fetus often produces a mildly anemic infant, while succeeding pregnancies produce infants with more serious hemolytic anemia.

Follicle-stimulating hormone (FSH)

- is secreted by the anterior pituitary gland and is primarily responsible for the maturation of the ovarian follicle. - FSH secretion is highest and most important during the first week of the follicular phase of the reproductive cycle.

luteinizing hormone (LH)

- is secreted by the anterior pituitary gland and is required for both the final maturation of preovulatory follicles and luteinization of the ruptured follicle. - As a result, estrogen production declines and progesterone secretion continues. - Thus, estrogen levels fall a day before ovulation, and progesterone levels begin to rise.

Progesterone

- is secreted by the corpus luteum. - Progesterone levels increase just before ovulation and peak 5 to 7 days after ovulation. - During the luteal phase, progesterone induces swelling and increased secretion of the endometrium. - This hormone is often called the hormone of pregnancy because of its calming effect (reduces uterine contractions) on the uterus, allowing pregnancy to be maintained. -plays a role in GI tract, immune system, fluid and electrolyte retention. and respirations

Estrogen

- is secreted by the ovaries and is crucial for the development and maturation of the follicle. - Estrogen is predominant at the end of the proliferative phase, directly preceding ovulation. - After ovulation, estrogen levels drop sharply as progesterone dominates. - In the endometrial cycle, estrogen induces proliferation of the endometrial glands. - Estrogen also causes the uterus to increase in size and weight because of increased glycogen, amino acids, electrolytes, and water. - Blood supply is expanded as well. -genitial enlargement and vasodilation!

Routine artificial rupture of membranes (Amniotomy)

May be performed to augment or induce labor when the membranes have not ruptured spontaneously. -Doing so allows the fetal head to have more direct contact with the cervix to dilate it. -This procedure is performed with the fetal head at −2 station or lower, with the cervix dilated to at least 3 cm. Reasons: -stimulate/induce labor: no evidence -apply fetal or contraction internal monitors -obtain fetal scalp blood sample for pH monitoring -assess color and composition of amniotic fluid Risks: -cord prolapse -cord compression Nursing role: -explain procedure to woman and her family -assure fetal well-being before and after procedure

Shoulder dystocia maneuvers

McRobert's: hyperflexion of hips -push kneed up to shoulders Suprapubic pressure: -from posterior to anterior -make sure you know the location of the babys back before pushing (Leopolds) -grab a stool

Severe Preeclampsia

Only 1 S&S needed -BP > 160/110 (for 8 hrs while on bedrest) -Thrombocytopenia <100k -Impaired liver function (RUQ pain unresponsive to meds, new N/V) -Progressive renal dysfunction (Creat >1.1) -New onset cerebral or visual disturbance (persistent headache, visual change, seizure) -Pulmonary edema

Placenta anatomy

Parts: Chorion, amnion, chorionic plate, basal plate, cotyledon, umbilical cord Maternal surface -Cobblestone appearance -10-38 cotyledons Fetal surface -smooth and slick -umbilical cord attached to surface Umbilical cord -3 vessels: AVA

Tachysystole Pattern and Implications

Pattern: -increased contraction frequency -increased uterine resting tone -intensity can be from mild to strong Implications -discomfort due to uterine muscle cell anoxia -stress on maternal coping abilities -if prolonged labor, then it can result in: maternal exhaustion, dehydration, infection, and uterine rupture -poor uteroplacental exchange = non-reassuring FHR -prolonged pressure on fetal head resulting in: excessive molding, caput, or cephalohematoma

Perinatal Loss

Perinatal mortality: fetal and neonatal death occurring around the time of delivery -includes all pregnancy related losses -early pregnancy loss -miscarriage (SAB) -intrauterine fetal demise (IUFD) -death of live-born infants soon after birth Estimated one million a year -most occur before 20 weeks -under-reported fetal deaths <20 weeks

Thromboembolism

Peripartum physiology increases risk -venous stasis -increased clotting factor -vessel trauma Types: VTE, DVT, pulmonary embolism -frequent symptoms can be non-specific -pulmonary embolism S&S: tachypnea, tachycardia, dyspnea, pleuritic pain -DVT: leg warm, tender, reddened, larger than other leg, +Homans Therapy -Anticoagulation -DVT: compression stockings and possibly rest

Probable Symptoms of Pregnancy

Positive pregnancy test (4-12 weeks) Goodell sign (5 weeks) Chadwick sign (6-8 weeks) Hegar sign (6-12 weeks) Abdominal enlargement (14 weeks) Ballottement (16-28 weeks) Braxton Hicks contractions (16-28 weeks)

Fetal Heart Rate Patterns Category 3 abnormal

Predictive of abnormal fetus acid-base status and require intervention • Fetal bradycardia (<110 bpm) • Recurrent late decelerations • Recurrent variable decelerations—declining or absent • Sinusoidal pattern (smooth, undulating baseline)

Fetal Heart Rate Patterns Category 1 Normal

Predictive of normal fetal acid-base status and do not require intervention • Baseline rate (110-160 bpm) • Baseline variability moderate • Present or absent accelerations • Present or absent early decelerations • No late or variable decelerations • Can be monitored with intermittent auscultation during labor

Preparation and Teaching for C-section

Preparation: -if elective, empty stomach -establishing IV lines -placing foley catheter -performing abdominal prep Teaching: -what to expect before, during, and after procedure -why its being done -what sensations the woman will experience -role of significant others -interaction with newborn

Treatment and Prevention of Preeclampsia

Primary prevention: -Calcium supplementation in populations with poor Ca diets In women with 1 or more risk factors -low does aspirin during next pregnancy -take during 12-28 week gestation Removing the placenta will decrease the risk -However symptoms may continue up to 20 days postpartum

Indications for Operative Vaginal Birth

Prolonged 2nd Stage -Nullip >2 hrs or >3 hrs w/ epidural -Miltip >1 hr or >2 hrs w/ epidural Non-reassuring fetal status and station is low enough Maternal indications: exhaustion or disease making pushing inadvisable (cardiac disease)

Nutrient changes during pregnancy

Protein need increases, b/c it is needed to make DNA -causes an increased appetite -increased absorption of nutrients from food Steady glucose supply -in early pregnancy they have accelerated starvation (mom is slightly hypoglycemic) -in late pregnancy hPL is at its max so insulin resistance is increased, watch BS lvls and gestational diabetes Estrogen increases salivary gland secretion to facilitate food metabolism, and increase risk of pancreatitis Progesterone relaxes cardiac sphincter causing heartburn, also decreases GI motility and absorption causing constipation

Episiotomy Nursing Care

Provide mother with support and comfort during procedure -use distraction if needed -if procedure is uncomfortable act as an advocate Document type of episiotomy in records and report to subsequent caregivers Assess perineal area frequently - inspect Q15 min during first hour and daily for REEDA Apply ice pack immediately in fourth stage Instruct mother in perineal hygiene and comfort measures -use spray water after BM -keep clean and dry -danger signs for infection

Non-stress test (NST)

Provides an indirect measurement of uteroplacental function -During the test, observe for signs of fetal activity with a concurrent acceleration of the fetal heart rate. Interpret the NST as reactive or nonreactive. -A reactive NST includes at least two fetal heart rate accelerations from the baseline of at least 15 bpm for at least 15 seconds within the 20-minute recording period. If the test does not meet these criteria after 40 minutes, it is considered nonreactive. -A nonreactive NST is characterized by the absence of two fetal heart rate accelerations using the 15-by-15 criterion in a 20-minute time frame. A nonreactive test has been correlated with a higher incidence of fetal distress during labor, fetal mortality, and IUGR

Hormonal stimulation of puberty

Puberty is initiated from the hypothalamus releasing GnRH (Gonadotropin Releasing Hormone) in a pulsatile fashion -GnRH stimulates the anterior pituitary to release LH (luteinizing hormone) and FSH (follicle stimulating hormone) In Males: LH - is responsible for the development of the seminiferous tubules FSH - stimulates Leydig cell development in the prostate, and they secrete androgens In Females: LH & FSH - begin the menstrual cycle

Cervical ripening

Purpose is to increase cervical dilation and progress labor Methods: Inserting a foley catheter in the cervix Use of prostaglandin agents such as misoprostol (cytotec) and dinoprostone (Cervidil) -Side effects: maternal GI symptoms (N/V, diarrhea, cramping, and shivering) -Uterine Tachysystole = hypersimulation/increase contractions; can increase >5 contractions in 10 min (averaged over 30 min) OR contractions less than 2 min apart lasting >75 seconds -contraindicated if they've had a previous C-section Nursing role: -monitor maternal and fetal status for 1-2 hours after insertion

Sodium nitroprusside (Nitropress) with Preeclampsia and Eclampsia

Rapid vasodilation (arterial and venous) Severe hypertension requiring rapid reduction in blood pressure

Risks for baby with C-section

Respiratory morbidities -respiratory distress syndrome -persistant pulmonary hypertension Increased asthma/atopy Decreased breastfeeding success

Infections Postpartum: Types and causes

Risk factors: -Prenatal: low income, obesity, poor nutrition -Labor: chorioamnionitis, prolonged labor, meconium, prolonged ROM, frequent vaginal exam -Delivery: cesarean, manual removal of placenta, forceps, hemorrhage Source: -Uterus -Breast -Incision -Urine

Third Stage of Labor

Separation and delivery of the placenta, usually takes 5-10 minutes (but up to 30 min) Placental separation: detaching from uterine wall Placental expulsion: coming outside the vaginal opening Signs of placental separation: -uterine rises -change in shape -gush of blood -lengthening of the cord

3rd and 4th degree laceration care

Special attention needs to be paid to third- and fourth-degree lacerations to prevent fecal incontinence -nothing per rectum -keep stools soft (fluid/stool softener) -teach woman to report increased flatus or stool incontinence

What is physiologic birth?

Spontaneous onset and unassisted progress of labor Biological and psychological conditions that promote effective labor -continuous supportive presence in labor -freedom of movement and assume position of choice -encouragement of nourishment as desired -maternity care providers skilled in nonpharmacologic methods for coping in labor -care that respects womans privacy, dignity, comfort, and cultural needs Spontaneous birth of infant & placenta Optimal newborn transition: skin to skin and early initiation of breast feeding

Mioprostol (cytotec) Abortion

Stimulates uterine contractions to terminate a pregnancy and to evacuate the uterus after abortion to ensure passage of all the products of conception

PGE2, dinoprostone (Cervidil, Prepidil Gel, Prostin E2) Abortion

Stimulates uterine contractions, causing expulsion of uterine contents; expels uterine contents in fetal death or missed abortion during second trimester; effaces and dilates the cervix in pregnancy at term

Rh(D) immunoglobulin (Gamulin, HydroRho-D, RhoGAM, MICRhoGAM) Abortion

Suppresses immune response of nonsensitized Rh-negative clients who are exposed to Rh-positive blood to prevent isoimmunization in Rh-negative women exposed to Rh-positive blood after abortions, miscarriages, and pregnancies.

Vaginal Exam Nursing Assessment

Used to assess the progress of labor -are highly invasive and can be distressing and/or painful for many women -After donning sterile gloves, the examiner inserts their index and middle fingers into the vaginal introitus. Next, the cervix is palpated to assess dilation, effacement, and position (e.g., posterior or anterior). If the cervix is open to any degree, the presenting fetal part, fetal position, station, and presence of molding can be assessed. In addition, the membranes can be evaluated and described as intact, bulging, or ruptured. Inpect -Rupture of membranes: color, odor (nitrazine blue if pH > 6.5) -Presence of bleeding: color, amount, quality

Biophysical Profile (BPP)

Uses a real-time ultrasound and NST to allow assessment of various parameters of fetal well-being that are sensitive to hypoxia. -A BPP includes ultrasound monitoring of fetal movements, fetal tone, and fetal breathing as well as ultrasound assessment of amniotic fluid volume with or without assessment of the fetal heart rate. -A BPP is performed in an effort to identify infants who may be at risk of poor pregnancy outcome, so that additional assessments of well-being may be performed or labor may be induced or a cesarean section performed to expedite birth

CDC Guidelines for Vaccine Administration during Pregnancy

Vaccines That Should Be Considered Unless Contraindicated: -Hepatitis B -Influenza (inactivated) injection -Tetanus/diphtheria (Tdap) -Rabies Vaccines Contraindicated during Pregnancy: -Influenza (live, attenuated vaccine) nasal spray -MMR -Varicella -BCG (tuberculosis) -Typhoid

Fetal Heart Rate Acronym

Variable deceleration Cord compression Early deceleration Head compression Accelerations Okay! Normal O2 Late decelerations Placental insufficiency

Hydralazine hydrochloride (Apresoline) with Preeclampsia and Eclampsia

Vascular smooth muscle relaxant, thus improving perfusion to renal, uterine, and cerebral areas Reduction in blood pressure

Types of C-Section Incisions

Vertical: -usually done for emergency -subsequent births by C-section Transverse: -most common -may have trial of labor with next birth

Variable Deceleration FHR

Visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions -occur abruptly with quick deceleration -may be of a U, V, or W -associated with cord compression

Early Deceleration FHR

Visually apparent, usually symmetrical, and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction -result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. -Early decelerations are not indicative of fetal distress and do not require intervention.

Late Deleration FHR

Visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction -FHR does not return to baseline levels until well after the contraction has ended -associated with uteroplacental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression exists

Summary of Assessments during the Third Stage of Labor

Vital signs (BP, pulse, respirations) Every 15 minutes Fetal heart rate Apgar scoring at 1 and 5 minutes Contractions/uterus Observe for placental separation Bearing down/pushing None Vaginal discharge Assess bleeding after expulsion Behavior/psychosocial Observe every 15 minutes: often feelings of relief after hearing newborn crying; calmer

Summary of Assessments during the Fourth Stage of Labor

Vital signs (BP, pulse, respirations) Every 15 minutes Fetal heart rate Newborn—complete head-to-toe assessment; vital signs every 15 minutes until stable Contractions/uterus Palpating for firmness and position every 15 minutes for first hour Bearing down/pushing None Vaginal discharge Assess every 15 minutes with fundus firmness Behavior/psychosocial Observe every 15 minutes: usually excited, talkative, awake; needs to hold newborn, be close, and inspect body

Summary of Assessments during the First Stage of Labor: Active Phase (6-10 cm)

Vital signs (BP, pulse, respirations) Every 15-30 minutes Temperature Every 4 hours; more frequently if membranes are ruptured Contractions (frequency, duration, intensity) Every 15-30 minutes by palpation or continuously if EFM Fetal heart rate Every 15-30 minutes by Doppler or continuously by EFM Vaginal examination As needed to monitor labor progression Behavior/psychosocial With every client encounter: self-absorbed in labor; intense and quiet now

Summary of Assessments during the First Stage of Labor: Latent Phase (0-6 cm)

Vital signs (BP, pulse, respirations) Every 30-60 min Temperature Every 4 hours; more frequently if membranes are ruptured Contractions (frequency, duration, intensity) Every 30-60 minutes by palpation or continuously if EFM Fetal heart rate Every hour by Doppler or continuously by EFM Vaginal examination Initially on admission to determine phase and as needed based on maternal cues to document labor progression Behavior/psychosocial With every client encounter: talkative, excited, anxious

Summary of Assessments during the Second Stage of Labor

Vital signs (BP, pulse, respirations) Every 5-15 minutes Fetal heart rate Every 5-15 minutes by Doppler or continuously by EFM Contractions/uterus Palpate every one Bearing down/pushing Assist with every effort Vaginal discharge Observe for signs of descent—bulging of perineum, crowning Behavior/psychosocial Observe every 15 minutes: cooperative, focus is on work of pushing newborn out

Fetal development Table 10.1

WEEK 3 Beginning development of brain, spinal cord, and heart Beginning development of the gastrointestinal tract Neural tube forms, which later becomes the spinal cord Leg and arm buds appear and grow out from body WEEK 4 Brain differentiates Limb buds grow and develop more WEEK 5 Heart now beats at a regular rhythm Beginning structures of eyes and ears Some cranial nerves are visible Muscles innervated WEEK 6 Beginning formation of lungs Fetal circulation established Liver produces red blood cells Further development of the brain Primitive skeleton forms Central nervous system forms Brain waves detectable WEEK 7 Straightening of trunk Nipples and hair follicles form Elbows and toes visible Legs move Diaphragm formed Mouth with lips and early tooth buds WEEK 8 Rotation of intestines Facial features continue to develop Heart development completes Resembles a human being Placenta is working Eyelids form and grow but are sealed shut WEEKS 9-12 Sexual differentiation continues Buds for all 20 temporary teeth laid down Digestive system shows activity Head makes up nearly half the fetus size Face and neck are well formed Urogenital tract completes development Red blood cells are produced in the liver Urine begins to be produced and excreted Fetal gender can be determined by week 12 Limbs are long and thin Digits are well formed Fetus moves, kicks, and swallows WEEKS 13-16 A fine hair called lanugo develops on the head Fetal skin is almost transparent Bones become harder Fetus makes active movement Sucking motions are made with the mouth Amniotic fluid is swallowed External genitalia are recognizable Fingernails and toenails present Weight quadruples Fetal movement (also known as quickening) detected by mother WEEKS 17-20 Rapid brain growth occurs Fetal heart tones can be heard with stethoscope Kidneys continue to secrete urine into amniotic fluid Vernix caseosa, a white greasy film, covers the fetus Eyebrows and head hair appear Brown fat deposited to help maintain temperature Nails are present on both fingers and toes Muscles are well developed WEEKS 21-24 Eyebrows and eyelashes are well formed Fetus has a hand grasp and startle reflex Alveoli forming in lungs Skin is translucent and red Eyelids remain sealed Lungs begin to produce surfactant WEEKS 25-28 Fetus reaches a length of 15 in Rapid brain development Eyelids open and close Nervous system controls some functions Fingerprints are set Subcutaneous fat is visible under the skin Blood formation shifts from spleen to bone marrow Fetus usually assumes head-down position Fetus responds to light and sound Fetus can open and shut eyes and suck thumb WEEKS 29-32 Rapid increase in the amount of body fat Increased central nervous system control over body functions Rhythmic breathing movements occur Lungs are not fully mature Pupillary light reflex is present Fetus stores iron, calcium, and phosphorus WEEKS 33-38 Testes are in scrotum of male fetus Lanugo begins to disappear Has strong hand grasp reflex Increase in body fat Earlobes formed and firm Fingernails reach the end of fingertips Small breast buds are present on both sexes Mother supplies fetus with antibodies against disease Fetus is considered full term at 38 weeks Fetus fills uterus and moves to a head-down position

Scripts for Child Loss

What did this pregnancy mean to you I wish things were different No words can express how sorry I am What is the one thing you are most fearful of Do you have any questions Many families in your situation tell us... is it that way for you Is there anyone I can call for you Other families who have been in this situation or similar situations

Chadwick sign of pregnancy

a bluish-purple coloration of the vaginal mucosa and cervix seen at 6-8 weeks

What is false labor?

a condition occurring during the latter weeks of some pregnancies when irregular uterine contractions are felt, but the cervix is not affected -False labor, prodromal labor, and Braxton Hicks contractions are all names for contractions that do not contribute in a measurable way toward the goal of birth -Many women fear being sent home from the hospital with false labor

Periodic baseline changes FHR

are temporary, recurrent changes made in response to a stimulus such as a contraction

Evaluation the Process of Grief

are the interventions working? do you need to change the plan?

Defining Uterine Contractions

based on number of contractions over 10min averaged over a 30 min period -Normal <=5 over 10 min -Tachysystole >5 over 10 min (lasting >75 seconds) -Hypotonic (too few) is undefined, usually less than 3 over 10 min

Incomplete spontaneous abortion

bleeding and/or pain, os is open, and products of conception found in uterus (its partially expelled)

Complete spontaneous abortion

bleeding with open os and no evidence of products of conception in the uterus

Threatened spontaneous abortion

bleeding, but the cervical os is closed

Inevitable spontaneous abortion

bleeding, os is open, and products of conception are felt at os

Missed spontaneous abortion

fetal demise in patient with or without symptoms and os closed

FHR Deceleration

is a transient fall in FHR caused by stimulation of the parasympathetic nervous system. -Decelerations are described by their shape and association to a uterine contraction. -They are classified as early, late, and variable only

What is true labor?

is characterized by contractions occurring at regular intervals that increase in frequency, duration, and intensity. -True labor contractions bring about progressive cervical dilation and effacement

fundal height

is the distance (in centimeters) measured with a tape measure from the top of the pubic bone to the top of the uterus (fundus) with the client lying on her back with her knees slightly flexed -12 weeks: fundus is just above pubic bone -14-16 weeks: 1/2 way btwn the umbilicus and pubic bone -2o weeks: at umbilicus -36-38 weeks: fundus is right under the sternum -40 weeks: fundus drops slightly as baby drops into pelvis

Spontaneous Perineal Lacerations

or "tears" can occur during the second stage when the fetal head emerges through the vaginal introitus. The extent of the laceration is defined by depth: - First-degree laceration extends through the skin - Second-degree laceration extends through the muscles of the perineal body - Third-degree laceration continues through the anal sphincter muscle - Fourth-degree laceration also involves the anterior rectal wall.

human chorionic gonadotropin (hCG)

preserves the corpus luteum and its progesterone production so that the endometrial lining of the uterus is maintained; this is the basis for pregnancy tests -hormone that ensures the endometrium will be receptive to the implanting embryo -if implantation occurs the corpus luteum starts making hCG and continues producing progesterone until the placenta can take over -also secreted by trophoblast cells -enhances steroidogenesis in placenta and fetal adrenals -immunosuppressant -Thryrotropic activty -detected in serum 6 days after fertilization -lvls double every 2 days in early pregnancy

REEDA

redness edema ecchymosis discharge approximation

fetal station

refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. - Fetal station is measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines. - Typically, the ischial spines are the narrowest part of the pelvis and are the natural measuring point for the birth progress. Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines

Goodell Sign of Pregnancy

softening of the cervix seen at 5 weeks

Hegar sign of pregnancy

softening of the lower uterine segment or isthmus seen at 6-12 weeks

Amniotic Fluid Index

sum of the four quadrants of amniotic fluid

Curve of Carus

the curve of the pelvic axis, which is the route taken by the fetus as it passes through the birth canal. -baby position for birth

Ballottement sign of pregnancy

the examiner pushes against the woman's cervix during a pelvic examination and feels a rebound from the floating fetus seen at 16-28 weeks

Cephalic Presentations

vertex, military, brow, face

Diabetes and Pregnancy: Effects on the Fetus

• Cord prolapse secondary to polyhydramnios and abnormal fetal presentation • Congenital anomaly due to hyperglycemia in the first trimester (cardiac problems, neural tube defects, skeletal deformities, and genitourinary problems) • Macrosomia resulting from hyperinsulinemia stimulated by fetal hyperglycemia • Birth trauma due to increased size of fetus, which complicates the birthing process (shoulder dystocia) • Preterm birth secondary to polyhydramnios and an aging placenta, which places the fetus in jeopardy if the pregnancy continues • Fetal asphyxia secondary to fetal hyperglycemia and hyperinsulinemia • Intrauterine growth restriction secondary to maternal vascular impairment and decreased placental perfusion, which restricts growth • Perinatal death due to poor placental perfusion and hypoxia • Respiratory distress syndrome resulting from poor surfactant production secondary to hyperinsulinemia inhibiting the production of phospholipids, which make up surfactant • Polycythemia due to excessive red blood cell (RBC) production in response to hypoxia • Hyperbilirubinemia due to excessive RBC breakdown from hypoxia and an immature liver unable to break down bilirubin • Neonatal hypoglycemia resulting from ongoing hyperinsulinemia after the placenta is removed • Subsequent childhood obesity and carbohydrate intolerance

Diabetes and Pregnancy: Effects on the Mother

• Hydramnios due to fetal diuresis caused by hyperglycemia • Gestational hypertension of unknown etiology • Ketoacidosis due to uncontrolled hyperglycemia • Preterm labor secondary to premature membrane rupture • Stillbirth in pregnancies complicated by ketoacidosis and poor glucose control • Hypoglycemia as glucose is diverted to the fetus (occurring in first trimester) • Urinary tract infections resulting from excess glucose in the urine (glucosuria), which promotes bacterial growth • Chronic monilial vaginitis due to glucosuria, which promotes growth of yeast • Difficult labor, cesarean birth, postpartum hemorrhage secondary to an overdistended uterus to accommodate a macrosomic infant

Gestational Diabetes (GDM) Effects

• Macrosomia resulting from hyperinsulinemia stimulated by fetal hyperglycemia • Birth trauma due to increased size of fetus, which complicates the birthing process (shoulder dystocia) •Increased C-sections •Neonatal hypoglycemia resulting from ongoing hyperinsulinemia after the placenta is removed -Mom is at 50% risk of developing type 2 diabetes in the next 5 yrs; 10 times increased risk -mom has increased risk of developing cardiovascular disease

Relaxin

• Secretion by the placenta as well as the corpus luteum during pregnancy • Thought to act synergistically with progesterone to maintain pregnancy • Increase in flexibility of the pubic symphysis, permitting the pelvis to expand during delivery • Dilation of the cervix, making it easier for the fetus to enter the vaginal canal; thought to suppress the release of oxytocin by the hypothalamus, thus delaying the onset of labor contractions

Oxytocin Infusion Pharmacokinetics

**One of the top 10 high alert drugs Patient dosage safety b/c it causes tachysystole Pharmacokinetics -Half life: 10-15 min -Steady state occurs after 30-60 min -Therefore, low dose regimens are most evidenced based Typical dosing -Start 0.5-2 mU/min -Increase by 1-2 mU every 30-60 min

Oxytocin Infusion: Nursing Management

- Documentation of: order for does and absence of contraindications to vaginal birth -30 min assessment of fetal well-being -method of documenting contractions and resting tone btwn contraction (palpation is fine): document every 15 min while infusing, assure steady dose is correct -discontinue for non-reassuring FHR

Pregnancy, Insulin, and Glucose Table 11.2

- During early pregnancy, maternal glucose levels decrease because of the heavy fetal demand for glucose. - The fetus is also drawing amino acids and lipids from the mother, decreasing the mother's ability to synthesize glucose. - During early pregnancy there is also a decrease in maternal insulin production and insulin levels. - After the first trimester, hPL from the placenta and steroids (cortisol) from the adrenal cortex act against insulin and thus more insulin must be secreted - As a result, glucose is less likely to enter the mother's cells and is more likely to cross over the placenta to the fetus.

GI Adaptations in Pregnancy

- Elevated progesterone levels cause smooth muscle relaxation and decreased peristalsis, which results in delayed gastric emptying and decreased peristalsis. - Transition time of food may be so much slower that more water than normal is reabsorbed, leading to bloating and constipation. - The slowed gastric emptying combined with relaxation of the cardiac sphincter allows reflux, which causes heartburn. It is caused by regurgitation of the stomach contents into the upper esophagus and may be associated with the generalized relaxation of the entire digestive system. -The emptying time of the gallbladder is prolonged secondary to the smooth muscle relaxation from progesterone. Hypercholesterolemia can follow, increasing the risk of gallstone formation and lead to pancreatitis

ABO Incompatibility

- Hemolysis associated with ABO incompatibility - With ABO incompatibility, usually the mother is blood type O with anti-A and anti-B antibodies in her serum; the infant is blood type A, B, or AB. The incompatibility arises as a result of the interaction of antibodies present in maternal serum and the antigen sites on the fetal red cells.

Interventions for Category III Patterns FHR

- Notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern. - Discontinue oxytocin or other uterotonic agent as dictated by the facility's protocol if it is being administered. - Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental perfusion or relieve cord compression. - Administer oxygen via nonrebreather face mask to increase fetal oxygenation. Increase the IV fluid rate to improve intravascular volume and correct maternal hypotension. - Assess the client for any underlying contributing causes. - Provide reassurance that interventions are to effect pattern change. - Modify pushing in the second stage of labor to improve fetal oxygenation. - Document any and all interventions and any changes in FHR patterns. - Prepare for an expeditious surgical birth if the pattern is not corrected in 30 minutes.

Those Who May Benefit from Genetic Counseling Box 10.2

- Women who are pregnant or planning to be after age 35 - Paternal age of 50 years or older - Previous child, parents, or close relatives with an inherited disease, congenital anomalies, metabolic disorders, developmental disorders, or chromosomal abnormalities - Consanguinity or incest - Pregnancy screening abnormality, including alpha-fetoprotein, triple screen, amniocentesis, or ultrasound - Stillborn with congenital anomalies - Two or more pregnancy losses - Exposure to drugs, medications, radiation, chemicals, or infections - Concerns about genetic defects that occur frequently in their ethnic or racial group (for instance, those of African descent are most at risk for having a child with sickle cell anemia) - Abnormal newborn screening - Couples with a family history of X-linked disorders - Carriers of autosomal recessive or dominant diseases - Child born with one or more major malformations in a major organ system - Child with abnormalities of growth - Child with developmental delay, intellectual disability, blindness, or deafness

Prostaglandins

- are primary mediators of the body's inflammatory processes and are essential for the normal physiologic function of the female reproductive system. - Prostaglandins increase during follicular maturation and play a key role in ovulation by freeing the ovum inside the graafian follicle. - Large amounts of prostaglandins are found in menstrual blood

5 Types of Spontaneous Abortions

1) Threatened 2) Inevitable 3) Incomplete 4) Complete 5) Missed

Fourth Stage of Labor

1-4 hours after the birth of the newborn, time of maternal physiologic adjustment

Family response to grief: Miles Conceptual Model

1. Actual distress 2. Intense grief 3. Reorganization

Most commonly used analgesics

Butorphanol tarate (Stadol): opioid agonist/antagonist -can cause withdrawal symptoms -pseudo sinusoid FHR pattern Nalbuphine HCl (Nubain): opioid agonist Fentanyl (Sublimaze): opioid agonist -short acting Meperidine (Demerol): opioid agonist -long half life in neonate 40-100 mcg IV/IM 5 (IV) / 10-20 (IM) min peak 30-60 min (IV) / 1-2 h (IM) duration

Nifedipine (Procardia) with Preeclampsia and Eclampsia

Calcium channel blocker/dilation of coronary arteries, arterioles, and peripheral arterioles Reduction in blood pressure, stoppage of preterm labor

Mom Nutritional Need

Calories 2,500 Protein 80g 8 cups of water Vitamin A 770 mcg Vitamin C 85 mg Vitamin D 5 mg Folate 600 mcg Carbs 175g Calcium 1,000 mg Iron 27 mg

Measuring Fetal Heart Rate

1. Assist the woman onto the examining table and have her lie down. 2. Cover her with a sheet to ensure privacy, and then expose her abdomen. 3. Palpate the abdomen to determine the fetal lie, position, and presentation. 4. Locate the back of the fetus (the ideal position to hear the heart rate). 5. Apply lubricant gel to abdomen in the area where the back has been located. 6. Turn on the handheld Doppler device, and place it on the spot over the fetal back. 7. Listen for the sound of the amplified heart rate, moving the device slightly from side to side as necessary to obtain the loudest sound. Assess the woman's pulse rate and compare it to the amplified sound. If the rates appear the same, reposition the Doppler device. 8. Once the fetal heart rate has been identified, count the number of beats in 1 minute and record the results. 9. Remove the Doppler device and wipe off any remaining gel from the woman's abdomen and the device. 10. Record the heart rate on the woman's medical record; normal range is 110 to 160 bpm. 11. Provide information to the woman regarding fetal well-being based on findings.

Three main fetal presentations

1. Cephalic (head first) 2. Breech (pelvis first) 3. Shoulder (scapula first)

Family response to grief: Kubler-Ross

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

3 Categories of Pregnancy Symptoms

1. Presumptive 2. Probable 3. Positive

Diagnosing Hypoglycemia in Pregnancy

24-28 weeks Gestational diabetes Fasting <95 mg/dL -1 hr >180 -2 hr >153

Gestational Diabetes Exercise

30 min brisk exercise after eating

Shoulder dystocia

>60 seconds between birth of head and birth of shoulder and/or use of ancillary obstetric measures -shoulders get impinged under the pubic symphysis -potential emergency if baby not delivered w/in 3-5 minutes Risk factors: -maternal diabetes -macrosomia -prolonged 2nd stage -mid-pelvic operative delivery

Prolonged deceleration

Abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes -Many factors are associated with this pattern -Prolonged decelerations can be remedied by identifying the underlying cause and correcting it

Evidenced based reasons for induction

Absolute accepted reasons -maternal well being (ex: preeclampsia, cardiac disease) -fetal wellbeing (fetal growth restriction, non-reassuring fetal testing) -post-dates: beyond 42 weeks gestation -stillbirth Relative indications -Maternal issues (chronic HTN, cholestasis, lupus) -Fetal issues: polyhydramnios, anomalies requiring NICU -Logistics: distance from hospital, risk of rapid birth -Postterm (>41 weeks) -Prior still birth -Uterine infection -Large fetal size -Spontaneous rupture of membranes w/out active labor

Mifepristone (RU-486) Abortion

Acts as progesterone antagonist, allowing prostaglandins to stimulate uterine contractions; causes the endometrium to slough; may be followed by administration of misoprostol within 48 hours

Advantages/Disadvantages of Epidural Anesthesia

Advantages -Very effective in pain relief -Mom is alert and awake -Less effect on fetus than IV narcotics Disadvantages -Must stay in bed -Longer 2nd stage of labor -More occiput posterior position -Increases maternal temperature requiring baby to have assessment for infection -Increased assisted births and C-sections

Elective abortions

Can lead to birth of an infant too early, a long labor, exposure to a high-alert medication with its potential side effects, unnecessary cesarean birth, and maternal and neonatal morbidity -elective induction of labor may increase the risk of cesarean birth, especially for nulliparous women -associated with increased rates of cesarean, postpartum hemorrhage, neonatal resuscitation, and longer hospitalizations without improvement in neonatal outcomes

Risk Factors Associated with Preterm Labor and Birth

African American race (doubles the risk) Maternal age extremes (<16 years and >40 years old) Low socioeconomic status Alcohol or other drug use, especially cocaine Poor maternal nutrition Maternal periodontal disease Cigarette smoking Low level of education History of prior preterm birth (triples the risk) Uterine abnormalities, such as fibroids Low pregnancy weight for height Preexisting diabetes or hypertension Multiple pregnancy Premature rupture of membranes Late or no prenatal care Short cervical length Sexually transmitted infections: gonorrhea, chlamydia, trichomoniasis Bacterial vaginosis (50% increased risk) Chorioamnionitis Hydramnios Gestational hypertension Cervical insufficiency Short interpregnancy interval (<1 year between births) Placental problems, such as placenta previa and abruption placenta Maternal anemia Urinary tract infection Domestic violence Stress, acute and chronic

Labetalol hydrochloride (Normodyne) with Preeclampsia and Eclampsia

Alpha-1 and beta blocker Reduction in blood pressure

Prenatal LAB Tests to Assess Risk for Genetic Disorders 10.1

Alpha-fetoprotein: Typically performed between 15- and 18-weeks' gestation Amniocentesis: Usually performed between 15 and 20 weeks' gestation to allow for adequate amniotic fluid volume to accumulate; results take 2 to 4 weeks Chorionic villus sampling: Typically performed between 10 and 12 weeks' gestation with results available in less than a week Percutaneous umbilical blood sampling: Generally performed after 16 weeks' gestation Fetal nuchal translucency (FNT): Performed between 10 and 14 weeks' gestation Level III ultrasound/fetal scan: Typically performed after 18 weeks' gestation Triple and quad screening tests: Performed between 16 and 18 weeks' gestation Preimplantation genetic diagnosis: Usually on day 3 after egg retrieval and 2 days after fertilization, a single blastomere is removed from the developing embryo to be evaluated. Cell-free fetal DNA (cffDNA): A maternal blood sample is taken and next generation sequencing is used to analyze the cffDNA at approximately 10 weeks' gestation.

Emergency Childbirth

Although nurses are not qualified to conduct births, there are times when a provider does not show up on time and you may have to catch a baby -put on gloves -if its happening fast, ask the mother to pant not push -place fingers on the back of the head as it emerges giving some gentle downward motion (keep head flexed) -let the head be born into the hand, keep your hand on the head -check the neck for the cord, bring over head or loosen over shoulder -wait for head to rotate 45 degrees then sandwich it between hands and provide downward pressure to deliver the anterior shoulder -when you see 3cm of axilla pull up to deliver the posterior shoulder -place baby on moms abdomen and dry baby which will stimulate it -if not crying suction mouth and nose

Types of Episiotomy

An incision made in the perineum to enlarge the vaginal outlet and theoretically to shorten the second stage of labor Midline (B): -incision begins at bottom center of perineal body and extends straight down midline to fibers Mediolateral (A): -incision begins in midline of posterior fourchette and extends at 45 degree angle downward to right or left Usually performed with regional or local anesthesia

Nursing role in Shoulder Dystocia

Anticipate possibility -get a step stool to provide suprapubic pressure -assist with hip hyperflexion (McRoberts) -suprapubic pressure is down and from back of shoulder toward the fetal abdomen Note time of birth of head -if shoulders delayed, call out time in minutes and call back-up including pediatrics Follow directions of the obstetric provider; mother should not push unless specifically advised by the provider Assess the baby for symmetrical arm movements and palpate clavicles

Leopold's Maneuvers

Are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps Each maneuver answers a question: Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) Maneuver 3: What is the presenting part? Maneuver 4: Is the fetal head flexed and engaged in the pelvis?

Presumptive/Subjective Symptoms of Pregnancy

Are the least reliable indicators of pregnancy because any one of them can be caused by conditions other than pregnancy Breast tenderness (3-4 weeks) Nausea and vomiting (4-14 weeks) Amenorrhea (4 weeks) Breast enlargement (6 weeks) Urinary frequency (6-12 weeks) Fatigue (12 weeks) Hyperpigmentation of the skin (16 weeks) Fetal movements known as "quickening" (16-20 weeks) Uterine enlargement (7-12 weeks)

FHR accelerations

Are transitory abrupt increases in the FHR above the baseline that last less than 30 seconds from onset to peak. -They are associated with sympathetic nervous stimulation. -They are visually apparent, with elevations of FHR of more than 15 bpm above the baseline, and their duration is longer than 15 seconds but less than 2 minutes -They are generally considered reassuring and require no interventions. -Accelerations denote fetal movement and fetal well-being and are the basis for nonstress testing.

baseline fetal heart rate

Average FHR that occurs during a 10-minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia -It is assessed when the woman has no contractions and the fetus is not experiencing episodic FHR changes -The normal baseline FHR ranges between 110 and 160 bpm

Factors Placing a Woman at Risk during Pregnancy

Biophysical Factors: Genetic conditions Chromosomal abnormalities Multiple pregnancy Defective genes Inherited disorders ABO incompatibility Large fetal size Medical and obstetric conditions Preterm labor and birth Cardiovascular disease Chronic hypertension Cervical insufficiency Placental abnormalities Infection Diabetes Maternal collagen diseases Thyroid disease Asthma Post-term pregnancy Hemoglobinopathies Nutritional status Inadequate dietary intake Food fads Excessive food intake Underweight or overweight status Hematocrit value less than 33% Eating disorder Psychosocial Factors: Smoking Caffeine Alcohol and substance abuse Maternal obesity Inadequate support system Situational crisis History of violence Emotional distress Unsafe cultural practices Sociodemographic Factors: Poverty status Lack of prenatal care Age younger than 15 years or older than 35 years Parity—All first pregnancies and more than five pregnancies Marital status—Increased risk for unmarried women Accessibility to health care Ethnicity—Increased risk in nonwhite women Environmental Factors: Infections Radiation Pesticides Illicit drugs Industrial pollutants Second-hand cigarette smoke Personal stress

Magnesium sulfate with Preeclampsia and Eclampsia

Blockage of neuromuscular transmission, vasodilation Prevention and treatment of eclamptic seizures

Eclampsia Chart 19.2

Blood Pressure >160/110 mm Hg Seizures/coma: Yes Hyperflexia: Yes Other: Severe headache Generalized edema right upper quadrant or epigastric pain Visual disturbances Cerebral hemorrhage Renal failure HELLP

Preeclampsia without Severe Features Chart 19.2

Blood Pressure: >140/90 mm Hg after 20 weeks' gestation Seizures/coma: No Hyperflexia: No

Preeclampsia with Severe Features Chart 19.2

Blood pressure ≥160/110 mm Hg on two occasions at least 6 hours apart while on bed rest Seizures/coma: No Hyperflexia: Yes Other: Headache Oliguria Blurred vision, scotomata (blind spots) Pulmonary edema Thrombocytopenia (platelet count <100,000 platelets/mm3) Cerebral disturbances Persistent epigastric or right upper quadrant pain HELLP Progressive renal insufficiency

Complications associated with Breech Presentation

Morbidity and mortality from traumatic deliver -physical trauma -neurological sequelae Prolapsed cord Placenta previa Chromosomal/structural abnormalities Operative intervention

Critical Periods of Human Development

Neural Tube until 16 weeks CNS until 38 weeks Heart until 8 weeks Upper and Lower Limbs at 8 weeks Upper lip at 8 weeks Ears at >16 weeks Eyes at 38 weeks Mouth at 38 weeks Palate 9 weeks External genitalia 38 weeks

Diagnosing Preeclampsia

Newly onset hypertension after 20 weeks gestation >140/90 AND Proteinuria 1+ or >300mg/24 hr urine or protein/creatinine ration >0.3 OR (if no proteinuria) -Thrombocytopenia <100,000 -Renal insufficiency: Creatinine >1.1 mg/dL or double baseline -Impaired liver function -Pulmonary edema -Cerebral or visual symptoms: blurred vision, headache, seizure

Interventions the Process of Grief

Non-verbal Support -be present -listen -make eye contact -sit -touch -acknowledge the phase of grief -inform family about what to expect -offer options in straight-forward manner -encourage them to verbalize feelings and ask questions

Fetal Heart Rate Patterns Category 2 indeterminate

Not predictive of abnormal fetal acid-base status, but require evaluation and continued surveillance • Fetal tachycardia (>160 bpm) present • Bradycardia (<110 bpm) not accompanied by absent baseline variability • Absent baseline variability not accompanied by recurrent decelerations • Minimal or marked variability • Recurrent late decelerations with moderate baseline variability • Recurrent variable decelerations accompanied by minimal or moderate baseline variability; overshoots, or shoulders • Prolonged decelerations >2 minutes but <10 minutes

Inadequate vs Excess Intake During Pregnancy

Nutritional intake during pregnancy has a direct effect on fetal well-being and birth outcome. - Inadequate nutritional intake, for example, is associated with preterm birth, low birth weight, and congenital anomalies. - Excessive nutritional intake is connected with fetal macrosomia, leading to a difficult birth, neonatal hypoglycemia, and continued obesity in the mother and the potential for childhood obesity with the components of metabolic syndrome

Types of breech

Occurs when the fetal buttocks or feet enter the maternal pelvis first and the fetal skull enters last. -The types of breech presentations are determined by the positioning of the fetal legs -Frank breech (50% to 70%), the buttocks present first with both legs extended up toward the face. -Full or complete breech (5% to 10%), the fetus sits cross-legged above the cervix. -Footling or incomplete breech (10% to 30%), one or both legs are presenting (single vs double)

Preeclampsia 1st Stage

The first stage of generalized vasospasm results in elevation of blood pressure and reduced blood flow to the brain, liver, kidneys, placenta, and lungs. - Decreased liver perfusion leads to impaired liver function and subcapsular hemorrhage. This is demonstrated by epigastric pain and elevated liver enzymes in the maternal serum. - Decreased brain perfusion leads to small cerebral hemorrhages and symptoms of arterial vasospasm such as headaches, visual disturbances, blurred vision, and hyperactive deep tendon reflexes (DTRs). - A thromboxane/prostacyclin imbalance leads to increased thromboxane (potent vasoconstrictor and stimulator of platelet aggregation) and decreased prostacyclin (potent vasodilator and inhibitor of platelet aggregation), which contribute to the hypertensive state. - Decreased kidney perfusion reduces the glomerular filtration rate, resulting in decreased urine output and increased serum levels of sodium, blood urea nitrogen (BUN), uric acid, and creatinine, further increasing extracellular fluid and edema. - Increased capillary permeability in the kidneys allows albumin to escape, which reduces plasma colloid osmotic pressure and moves more fluid into extracellular spaces; this leads to pulmonary edema and generalized edema. - Poor placental perfusion resulting from prolonged vasoconstriction contributes to intrauterine growth restriction, placental abruption, persistent fetal hypoxia, and acidosis. - In addition, hemoconcentration (resulting from decreased intravascular volume) causes increased blood viscosity and elevated hematocrit

Gametogenesis Figure 10.1

The formation of gametes by the process of meiosis is known as gametogenesis. A. Spermatogenesis. One spermatogonium gives rise to four spermatozoa. B. Oogenesis. From each oogonium, one mature ovum and three abortive cells are produced. - The chromosomes are reduced to one half the number characteristic for the general body cells of the species. - In humans, the number in the body cells is 46, and the number in the mature spermatozoon and secondary oocyte is 23.

Renal System in Pregnancy

The renal system must handle the effects of increased maternal intravascular and extracellular volume and metabolic waste products as well as excretion of fetal wastes. - The predominant structural change in the renal system during pregnancy is dilation of the renal pelvis and uterus -Dilation of the kidneys and ureters increases the potential for urinary stasis and infection. Kidneys work harder throughout the pregnancy. -renal pelvicies enlarge causing increased pressure on the ureters so they relax -this facilitates the entry of bacteria -mothers are prone to polynephritis especially on the right side

Fertilization ("Conception")

The union of ovum and sperm, which is the starting point of pregnancy -requires a timely interaction between the release of the mature ovum at ovulation and the ejaculation of enough healthy, mobile sperm to survive the hostile vaginal environment through which they must travel to meet the ovum -takes place in the outer third of the ampulla of the fallopian tube

The 5 P's of Mother and Fetus Assessment

These determine the fetuses ability to successfully negotiate the pelvis during labor -Powers: contractions -Passenger: fetus and placenta -Psyche: maternal mindset -Position: maternal and fetal -Passage: pelvis, cervix, and birth canal

Differences between true and false labor

True Labor -Regular uterine contractions (las 30-60 sec) -Contractions progress closer together (4-6 min apart) -Sensation starts in the back and goes to the front -Walking increases intensity (contraction continue) -Progressive cervical dilation ***Stay home until contractions are 5 minutes apart, last 45-60 seconds, and are strong enough so that a conversation during one is not possible False Labor -Contractions are irregular -Contractions are the same or irregular overtime (not getting stronger with time or alternating) -Mainly felt in the front -Contractions may stop or slow down with walking or making a position change. -No change in cervix dilation ***Drink fluids and walk around to see if there is any change in the intensity of the contractions; if the contractions diminish in intensity after either or both

Placental Abruption Types and Risk Factors

Types -Marginal: Vaginal -Central: Concealed -Total: Massive Risk Factors -Hypertension -Multiple gestation -rupture of membranes (polyhydramnios) -Prior history or C-Section -Cocaine -Abdominal trauma

Positive Symptoms of Pregnancy

Ultrasound verification (4-6 weeks) Auscultation of fetal heart tones via Doppler (10-12 weeks) Fetal movement (20 weeks)