OB Exam #3

Treatment: Dysmenorrrhea

Dx: History + exam c cultures; dx lap Tx: prostaglandin inhibitors - NSAIDs; extend cycle COCs; Depo-MPA; LNg IUC TENS/ diuretics/ analgesics/ narcotics Teach: heat c rest; orgasm; reg exercise incl core; balance diet- suppl omega-3 pfa Vit E 200 BID, stress management

Assessment: Hyperbilirubinemia

Elevated serum bilirubin levels. Jaundice Tea-colored urine Clay-colored stools

Diagnosis: Shoulder Dystocia

Emergency, often unexpected complication. Diagnosis made when newborn's head delivers without delivery of neck and remaining body structures.

Management: Polycythemia in Newborns

Ensure adequate hydration (orally or IV). Monitor hematocrit levels (goal is ~60%). Administer partial exchange transfusion, albumin, or normal saline IV to reduce RBC volume and increase fluid volume (controversial).

Management: Hyperbilirubinemia

Ensure adequate hydration. Institute early feedings if possible Administer phototherapy

Progression Rule of Thumb

Evaluate progress in active labor by using the simple rule of 1 cm per hour for cervical dilation.

Discharging the Late Preterm Infant

When discharge planning for the late preterm infant, validate parents' understanding of: -Dressing the infant appropriately in order to main-tain appropriate temperature -Practice good handwashing and limit contact with ill persons -Maintain adequate nutritional and fluid intake to promote growth and development; breastfeeding is preferred -Avoid secondhand smoke exposure -Practice safe sleep practices: avoid soft mattresses or blankets, place infant supine to sleep -Keep appointments for health maintenance visits (check-ups) as scheduled -Notify the pediatrician or nurse practitioner immediately if the infant: Has difficulty breathing or turns blue (call for emergency services in this case) Has a temperature below 97° F (36.1° C) or above 100.4° F (38° C) Displays a yellow color to the skin (jaundice) Feeds poorly Vomits Fails to void for 12 hours, or to pass a bowel movement in 24 hours Acts lethargic, irritable or "just not right"

Face and Brow Presentation

Face presentation with complete extension of the fetal head. Brow presentation: fetal head between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis.

Substances and the Newborn: Alcohol

Fetal alcohol syndrome (one of the most common known causes of mental retardation)Fetal alcohol spectrum disorders. Alcohol-related birth defects.

Breech Presentation

Fetal buttocks, or breech, presenting first rather than the head.

Assessment: Perinatal Asphyxia

Fetal distress (bradycardia, decelerations) during labor. Low Apgar scores. Potential meconium passage into amniotic fluid.

Intrauterine Asphyxia

Fetal hypoxia secondary to maternal hypoxia, diabetes, hypertension, anemia, cord compression, or meconium aspiration.

Problems with the Passenger

Fetal size >4000g, fetal presentation, position-head isnt effective, posterior,transverse, breech, multifetal pg- over distended uterus, fetal anomalies, hydrocephalus-hard skull not pressing, anacephalic.

Types of Maternal Pelvis

Four types based on the shape of the pelvic inlet, which is bounded anteriorly by the posterior border of the symphysis pubis, posteriorly by the sacral promontory, and laterally by the linea terminalis. The four basic types are gynecoid, an-thropoid, android, and platypelloid. Contraction of the midpelvis is more common than inlet contraction and typically causes an arrest of fetal descent.

Meconium Aspiration: Assessment

Green amniotic fluid with rupture of membranes during labor. Green staining of the umbilical cord or fingernails. Difficulty initiating respirations.

Assessment: Menopause

Hot flashes or flushes of the head and neck Dryness in the eyes and vagina Personality changes Anxiety and/or depression Loss of libido Decreased lubrication Weight gain and water retention Night sweats Atrophic changes—loss of elasticity of vaginal tissues Fatigue Irritability Poor self-esteem Insomnia Stress incontinence Heart palpitations

Amenorrhea: Evaluation

Hx: OB, sex, bleed/spot, contraceptives, exercise, nutrition, medical-endo, drugs Exam: 2nd sex char-breast; vagina/ cervix/uterus; androgenic Lab: HCG, vag cytology, thyroid, prolactin, karyotype sex cromatin, FSH/LH, estradiol 17-a progest, testosterone, GTT, BP, lipids + progestin challenge now therapy

Critical Lab Values: Infants of Diabetic Mothers

Hypoglycemia<40 mg/dL Hypocalcemia<7 mg/dL Hypomagnesemia<1.5 mg/dL Hyperbilirubinemia>12 mg/dL (term infant) Polycythemia>65% (venous hematocrit)

Exchange Transfusion

If the total serum bilirubin level remains elevated after intensive phototherapy, an exchange transfusion with albumin administered before the transfusion, the quickest method for lowering serum bilirubin levels, may be necessary. In the presence of hemolytic disease, severe anemia, or a rapid rise in the total serum bilirubin level, an exchange transfusion is recommended. An exchange transfusion removes the newborn's blood and replaces it with nonhemolyzed red blood cells from a donor.

Substances and the Newborn: Tobacco

Impaired oxygenation of mother and fetus due to nicotine crossing placenta and carbon monoxide combining with hemoglobin. Increased risk for low birth-weight (risk almost doubled), small for gestational age, and preterm birth. Increased risk for sudden infant death syndrome (SIDS) and chronic respiratory illness.

Substances and the Newborn: Methadone

Improvement in many of the detrimental fetal effects associated with heroin use. Withdrawal symptoms are common in newborns.Possible low birthweight due to symmetric fetal growth restriction. Increased severity and longer period of withdrawal (due to methadone's longer half-life) Seizures (commonly severe) do not usually occur until 2 to 3 weeks of age, when the newborn is at home. Increased rate of SIDS (3 to 4 times higher);

Problems with the Powers

Ineffective uterine contractions, hypotonic not strong enough, hypertonic uncoord, ineffective maternal pushing efforts.

Risks: Preterm Birth

Infants born prematurely also are at risk for serious sequelae such as respiratory distress syndrome, infections, congenital heart defects, thermoregulation problems that can lead to acidosis and weight loss, intraventricular hemorrhage, jaundice, hypoglycemia, feeding difficulties resulting from diminished stomach capacity and an underdeveloped suck reflex, and neurologic disorders related to hypoxia and trauma at birth.

Risks: Cesarean Birth

Infection, hemorrhage, aspiration, pulmonary embolism, urinary tract trauma, thrombophlebitis, paralytic ileus, and atelectasis. Fetal injury and transient tachypnea of the newborn also may occur.

Infertility

Infertility is inability to conceive and carry to viability a pregnancy after one year of regular unprotected sexual intercourse Couple sex dysfunction, immune, lifestyle Female ovulatory, tubal, peritoneal, uterine, cervical, vaginal problems Male sperm production, maturation, motility, blockage, deposit problems

Indomethacin (Indocin)

Inhibits prostaglandins, which stimulate contractions; inhibits uterine activity to arrest preterm labor.

Management: Meconium Aspiration

Initiate resuscitation measures as necessary. Suction airways and support ventilation.

Birth Trauma

Injury to the central or peripheral nervous system secondary to a long or difficult labor, a precipitous birth, multiple gestation, abnormal presentation, cephalopelvic disproportion, shoulder dystocia, or extraction by forceps or vacuum.

Contraindications: Tocolytic Therapy

Intrauterine infection, active hemorrhage, fetal distress, fetal abnormality incompatible with life, intrauterine growth restriction (IUGR), severe preeclampsia, heart disease, prolonged premature rupture of the membranes (PPROM), and intrauterine demise. Bed rest and hydration are commonly recommended, but without proven efficacy.

Labor Induction

Involves the stimulation of uterine contractions by medical or surgical means before the onset of spontaneous labor. Labor induction also involves intravenous therapy, bed rest, continuous electronic fetal monitoring, significant discomfort from stimulating uterine contractions, epidural analgesia/anesthesia, and a prolonged stay on the labor and birth unit.

Unripe Cervix

Is long, closed, posterior, and firm.

Ripe Cervix

Is shortened, centered (anterior), softened, and partially dilated.

Hyperbilirubinemia

LGA newborns (common):Associated with polycythemia and RBC breakdown.Inability to tolerate feedings in the first few days of life, leading to increased enterohepatic circulation of bilirubin. Preterm Newborns: Excessive bruising secondary to birth trauma, leading to higher-than-normal bilirubin levels. Post-term Newborns: Increased breakdown of RBCs and immature liver function to handle excess load.

Birth Trauma

LGA newborns: Large size requiring use of operative birth procedure. Obvious deformities. Bruising. Edema. Asymmetrical movement. Perform complete physical and neurologic assessment of the newborn. Note symmetry of structure and function. Assist parents in understanding situation.

Menstrual Cycle Patterns

Length 24-38 days (avg 28) Duration 4.5-8 days (avg 4) Flow 5-80 cc blood (avg 30-35) women in industrialized Western societies experience ~450 ovulations and menses preagricultural foraging societies ~160 No health benefits proven to menstruation

Diagnosis: Persistent Occiput Posterior Position

Leopold maneuvers and vaginal examination to determine position of fetal head in conjunction with the mother's complaints of severe back pain (back of fetal head pressing on mother's sacrum and coccyx).

Low birthweight

Less than 2,500 g (5.5 lb)

Substances and the Newborn: Meth

Little research on use during pregnancy because its use is less common than cocaine or narcotics. Fetal effects similar to cocaine (suggesting vasoconstric-tion as possible underlying mechanism) Possible maternal malnutrition, leading to problems with fetal growth and development Increased risk for preterm birth and low-birthweight newborns Infants may have withdrawal symptoms, including dysphoria, agitation, jitteriness, poor weight gain, abnormal sleep patterns, poor feeding, frantic fist sucking, high-pitched cry, respiratory dis-tress soon after birth, frequent infections, and significant lassitude

Common Problems of Infants with Diabetic Mothers

Macrosomia Respiratory Distress Syndrome Hypoglycemia Hypocalcemia and hypomagnesemia Polycythemia Hyperbilirubinemia Congenital Anomalies

Excessive Fetal Size and Abnormalities

Macrosomia leading to fetopelvic disproportion (fetus unable to fit through the maternal pelvis to be born vaginally). Reduced contraction strength due to overdistention by large fetus leading to a prolonged labor and the potential for birth injury and trauma. Fetal abnormalities possibly interfering with fetal descent, leading to prolonged labor and difficult birth.

Fetal/Neonate Risks: Prolonged Pregnancy

Macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome (loss of subcutaneous fat and muscle and meconium staining), and CPD. All of these conditions predispose this fetus to birth trauma or a surgical birth. Uteroplacental insufficiency, meconium aspiration, and intrauterine infection contribute to the increased rate of perinatal deaths.

Management: Thermoregulation Problems

Maintain a neutral thermal environment to promote stabilization of newborn's temperature. Assess skin temperature and respiration characteristics. Monitor arterial blood gases and blood glucose levels. Eliminate sources of heat loss:-Dry newborn thoroughly- Wrap in warmed blanket with stockinette cap on head-Use radiant heat source.

Pathologic Jaundice

Manifested within the first 24 hours of life when total bilirubin levels increase by more than 5 mg/dL/day and the total serum bilirubin level is higher than 17 mg/dL in a full-term infant. Conditions that alter the production, transport, uptake, metabolism, excretion, or reabsorption of biliru-bin can cause pathologic jaundice in the newborn. A few conditions that contribute to red blood cell breakdown and thus higher bilirubin levels include polycythemia, blood incompatibilities, and systemic acidosis. These altered conditions can lead to high levels of unconjugated bilirubin, possibly reaching toxic levels and resulting in a severe condition called kernicterus.

Maternal Risks: Prolonged Pregnancy

Maternal risk is related to the large size of the fetus at birth, which increases the chances that a cesarean birth will be needed. Other issues might include dystocia, birth trauma, postpartum hemorrhage, and infection. Mechanical or artificial interventions such as forceps or vacuum-assisted birth and labor induction with oxytocin may be necessary.

Fetal Fibronectin Testing

Measures the presence of fetal fibronectin, the biological glue that binds the fetal sac to the uterus. If the test is negative, the woman is unlikely to go into labor in the next 7-14 days (usually performed between 24 and 34 weeks).

Idenitification: Inferitility

Medical, social, family history; physical exam both; labs -FSH/LH, prolactin Male: Semen analysis, PostCoital Test Female: Basal Body Temperature HysteroSalpingoGram, PostCoital Test Serum progesterone, Endometrial Biopsy US, hysteroscopy, laparoscopy, immunoassay semen, male+female serum bovine mucus, hamster egg

Tocolytics

Medications used for the cessation of uterine contractions to prevent preterm labor. May prolong pregnancy for 2 to 7 days; during this time, steroids can be given to improve fetal lung maturity and the woman can be transported to a tertiary care center.

Treatment: Infertility

Meds: clomiphene, hMGonadotropins, hCG, GnReleasingH, GnRHagonist bromocriptine, danazol, testost, estrog, prog Insemination: cervical / uterine (washed) partner / TDonorI (frosty) Surgical: repair; AssistedRT -GIFT, ZIFT, TET, IVF, zona drill with ICSpermInjection Surrogate: ovum / uterus

Stripping of Membranes

Method of possible inducing labor if labor is initiated within 48hours, where a gloved finger inserted into the internal os and rotated 360 degrees twice-separating amniotic membraneslying against lower uterine segment.

Birth Trauma: Head Trauma

Mild trauma can cause soft tissue injuries such as cephalhema-toma and caput succedaneum; greater trauma can cause depressed skull fractures.

Management: Newborn Hypoglycemia

Monitor blood glucose levels, initially on arrival to nursery and hourly thereafter. Maintain fluid and electrolyte balance. Watch for subtle changes. Initiate early oral feedings if possible; if not, administer IV infusion with 10% dextrose in water.

Multifetal Pregnancy

More than one fetus, leading to uterine overdistention and possibly resulting in hypotonic contractions and abnormal presentations of the fetuses. Fetal hypoxia during labor a significant threat due to placenta providing oxygen and nutrients to more than one fetus.

Birth Trauma: Cranial Nerve Trauma

Most common is facial nerve palsy. Frequently attributed to pressure resulting from forceps. May also result from pressure on the nerve in utero, related to fetal positioning such as the head lying against the shoulder. Will recover within a few weeks.

Tocolytic Therapy

Most likely ordered if pre-term labor occurs before the 34th week of gestation in an attempt to delay birth and thereby to reduce the severity of respiratory distress syndrome and other complications associated with prematurity. Tocolytic therapy does not typically prevent preterm birth, but it may delay it. It is contraindicated for abruptio placentae, acute fetal distress or death, eclampsia or severe preeclampsia, active vagi-nal bleeding, dilation of more than 6 cm, chorioamnionitis, and maternal hemodynamic instability.

Subdural Hemmorhage

(hemato-mas) occurs less often today because of improved obstetric techniques. Typically, tears of the major veins or venous sinuses overlying the cerebral hemispheres or cerebellum (most common in newborns of primaparas and large new-borns, or after an instrumented birth) are the cause. Increased pressure on the blood vessels inside the skull leads to tears. Subdural hemorrhage can be asymptomatic, or the neonate can exhibit seizures, enlarging head size, decreased level of con-sciousness, or abnormal findings on a neurologic examination, with hypotonia, a poor Moro reflex, or extensive retinal hemorrhages. Subdural hematoma requires aspiration; can be lifethreatening if it is in an inaccessible location and cannot be aspirated.

Subarachnoid hemorrhage

(one of the most common types of intracranial trauma) may be due to hypoxia/ischemia, variations in blood pressure, and the pressure exerted on the head during labor. Bleeding is of venous origin, and underlying contusions also may occur. In subarachnoid hemorrhage, some RBCs may appear in the CSF of full-term newborns. Newborns may present with apnea, seizures, lethargy, or abnormal findings on a neurologic examination. Subarachnoid hemorrhage requires minimal handling to reduce stress.

Depressed Skull Fractures

(rare) may result from the pressure of a forceps delivery; can also occur during spontane-ous or cesarean births and may be associated with other head trauma causing subdural bleeding, subarachnoid hemorrhage, or brain trauma. Depressed skull fractures can be observed and palpated as depressions. Confirmation by x-ray is necessary. Depressed skull fractures typically require a neurosurgical consultation.

Caput succedaneum

(soft tissue swelling) is caused by edema of the head against the dilating cervix during the birth process. In caput succedaneum, swelling is not limited by suture lines: it extends across the midline and is associated with head molding. It does not usually cause complications other than a misshapen head. Swelling is maximal at birth and then rapidly decreases in size. Usually resolves over the first few days without treatment.

Maternal Symptoms: Preterm Labor

- Change or increase in vaginal discharge with mucous, water, or blood in it. -Pelvic pressure (pushing-down sensation). -Low, dull backache -Menstrual-like cramps -Feeling of pelvic pressure or fullness -GI upset: nausea, vomiting, and diarrhea -General sense of discomfort or unease -Heaviness or aching in the thighs -Uterine contractions, with or without pain -More than six contractions per hour -Intestinal cramping, with or without diarrhea

Birth Trauma: Fractures

Most often occur during breech births or shoulder dystocia in newborns with macrosomia. Midclavicular fractures are the most common type of fracture, secondary to shoulder dystociaLong bone fractures of the humerus or femur, usually midshaft, also can occur. Findings: Midclavicular fractures: The newborn is irritable and does not move the arm on the affected side either spontaneously or when the Moro reflex is elicited. Femoral or humeral long bone fractures: The newborn shows loss of spontaneous leg or arm motion, respectively; usually swelling and pain accompany the limited movement. X-rays confirm the fracture Treatment: Midclavicular fractures typically heal rapidly and uneventfully; arm motion may be limited by pinning the newborn's sleeve to the shirt. Femoral and humeral shaft fractures are treated with splinting. Healing and complete recovery are expected within 2 to 4 weeks without incident. Explanation to the parents and reassurance are needed.

Substances and the Newborn: Heroine

Newborns of heroin-addicted mothers are born dependent on heroin. Increased risk for transmission of hepatitis B and C and HIV to newborns when mothers share needles. Significantly increased rates of stillbirth, IUGR, preterm birth, and newborn mortality (3 to 7 times greater) Small-for-gestational-age new-borns, meconium aspiration, high incidence of SIDS, and delayed effects from subacute withdrawal (restlessness, continual crying, agitation, sneezing, vomiting, fever, diarrhea, seizures, irritability, and poor socialization [possibly persisting for 4 to 6 months]);Intrauterine death or preterm birth is possible with abrupt cessation of heroin use

Substances and the Newborn: Marijuana

Not shown to have teratogenic effects on fetus; no consistent types of malformations identified. Intrauterine growth restriction (IUGR) is common due to delivery of carbon monoxide to fetusIncreased risk for small for gesta-tional age. Altered responses to visual stimuli, sleep-pattern abnormalities, photophobia, lack of motor control, hyperirritability, increased tremulousness, and high-pitched cry noted in infants of mothers who smoked marijuana. Research related to long-term effects is continuing.

Meconium aspiration syndrome (MAS)

Occurs when the newborn inhales particulate meconium mixed with amniotic fluid into the lungs while still in utero or on taking the first breath after birth. It is a common cause of newborn respiratory distress and can lead to severe illness.

Assessment: Newborn Hypoglycemia

Often subtle. Lethargy, tachycardia, Respiratory distress, Jitteriness, Drowsiness, Poor feeding, feeble sucking, Hypothermia, temperature instability, Diaphoresis, Weak cry, Seizures, Hypotonia, Blood glucose levels <40 mg/dL for term newborns, <20 mg/dL for preterm newborns.

Hypotonic Uterine Dysfunction

Often termed secondary uterine inertia because the labor begins normally and then the frequency and intensity of contractions decrease. Possible contributing factors: overdis-tended uterus with multifetal pregnancy or large single fetus, too much pain medicine given too early in labor, fetal malposi-tion, and regional anesthesia

Amenorrhea

Oligomenorrhea: infreq, irreg cycles >38d rt medical/ stress/ exercise/ dieting PCO/ HyperandrogenicChronicAnovulation Primary amenorrhea never menses ? secondary sexual characteristics by 13yo Secondary amenorrhea previously menstruating missed 3Xcycles/ 6+month

Footling or Incomplete Breech

One or two feet as the presenting part, with one or both hips extended.

Oxytocin (Pitocin): Administration

Oxytocin is administered via an intravenous infu-sion pump piggybacked into the main intravenous line at the port most proximal to the insertion site. Typically 10 units of oxytocin is added to 1 L of isotonic solu-tion. The dose is titrated according to protocol to achieve stable contractions every 2 to 3 minutes lasting 40 to 60 seconds. prepare the oxytocin infusion by diluting 10 units of oxytocin in 1,000 mL of lactated Ringer's solution or ordered isotonic solution. Use an infusion pump on a secondary line connected to the primary infusion. Start the oxytocin infusion in mU/min or milliliters per hour as ordered.

Dysmenorrhea

Painful menstruation. Primary: lifelong normal menstrual cramps often c Nausea/V, diarrhea, HAs, vasomotor- weak, faint excess prostaglandinF2a > ^ IUP= labor Secondary: later onset crampy pelvic pain 2nd to uterine/pelvic pathology preg- ectopic, SAB; gyn- PID, endometriosis, leiomyomata, endo CA

5 P's of Labor

Passageway, passenger, physiologic forces, position, psychosocial.

Treatment: Hot Flashes

Pharmacologic options -HT unless contraindicated -Androgen therapy (potentiates estrogen) -Estrogen and androgen combinations -Progestin therapy (Depo-Provera injection every 3 months) -Clonidine (central alpha-adrenergic agonist) weekly patch -Neurontin (antiseizure) decreased hot flashes - Acupuncture reduced frequency of hot flashes -Propranolol (beta-adrenergic blocker) -Short-term sleep aids: Ambien, Dalmane -Gabapentin (Neurontin): antiseizure drug -SSRIs: venlafaxine (Effexor) and paroxetine (Paxil) have shown promise -Vitamin E: 100 mg daily

Placenta Previa

Placental implantation in the lower uterine segment over or near the internal os of the cervix, typically during the second or third trimester of pregnancy. With uterine segment formation and cervical dilation, placental implantation over or near the cervical os, instead of along the uterine wall, inevitably results in spontaneous placental separation—and subsequent hemorrhage. This position can create a barrier for the fetus from the uterus during the birthing process.

Abnormal uterine bleeding

Polymenorrhea: short intervals <21 days menorrhagia: heavy bleeding >80cc blood loss or >7 days c regular intervals metromenorrhagia: prolonged heavy, irregular frequency assess VS, Hgb/Hct, HCG consider OB/ medication/ systemic/ cervical/ uterine/ Excess DUB by exclusion

Perinatal Asphyxia

Poor tolerance to stress of labor, frequently leading to acidosis and hypoxia. Living in hypoxic environment prior to birth due to placental insufficiency.

Interventions: Esophageal Atresia/ Tracheoesophageal Fistula

Pre Op - Initiate nothing by mouth (NPO) status. -Elevate the head of the bed 30 to 45 degrees to prevent reflux and aspiration. -Monitor hydration status and fluid and electrolyte balance; administer and monitor parenteral IV fluid infusions. -Assess and maintain the patency of the orogastric tube; monitor the functioning of the tube, which is attached to low continuous suction; and avoid irrigation of the tube to prevent aspiration. - Have oxygen and suctioning equipment readily avail-able should the newborn experience respiratory distress. -Assist with diagnostic studies to rule out other anomalies. -Use comfort measures to minimize crying and prevent respiratory distress; provide nonnutritive sucking. -Inform the parents about the rationales for the aspira-tion prevention measures. -Document frequent observations of the newborn's condition.

Substances and the Newborn: Cocaine

Preterm birth and lower birthweight. Unclear impact on later development. Speculation that cocaine interferes with infant's cognitive development, leading to learn-ing and memory difficulties later in life. Associated congenital anomalies: GU, cardiac, and CNS defects, and prune belly syndrome. Other typical newborn characteristics: smaller head circumference, piercing cry, limb defects, ambiguous genitalia, poor feeding, poor visual and auditory responses, poor sleep patterns, decreased impulse control, stiff, hyperextended positioning, irritability and hypersensitivity, inability to respond to caretaker.

Birth Trauma: Brachial plexus injury

Primarily in large babies, babies with shoulder dystocia, or breech deliveryResults from stretching, hemor-rhage within a nerve, or tear-ing of the nerve or the roots associated with cervical cord injury. Associated traumatic injuries include fracture of the clavicle or humerus or subluxations of the shoulder or cervical spine.

Shoulder Dystocia Cord Compression: Risk Factors

Primary risk factors, including suspected infant macrosomia (weight 4,500 g), maternal diabetes mellitus, excessive maternal weight gain, abnormal maternal pelvic anatomy, maternal obesity, postdated pregnancy, short stature, a history of previous shoulder dystocia, and use of epidural analgesia.

Cervical Ripening

Process by which the cervix softens via the breakdown of collagen fibrils. On average, the cervix is approximately 50% effaced and 2 cm dilated at the onset of labor.

Pathophisiology: Umbilical Cord Prolapse

Prolapse usually leads to total or partial occlusion of the cord. Since this is the fetus's only lifeline, fetal perfusion deteriorates rapidly. Complete occlusion renders the fetus helpless and oxygen deprived. The fetus will die if the cord compression is not relieved.

Reasons for Labor Induction

Prolonged gestation. PPROM gestational hypertension cardiac disease renal disease chorioamnionitis dystocia intrauterine fetal demise isoimmunization diabetes

Indications: Vacuum or Forcept Birth

Prolonged second stage of labor, a distressed FHR pattern, failure of the presenting part to fully rotate and descend in the pelvis, limited sensation and inability to push effectively due to the effects of regional anesthesia, presumed fetal jeopardy or fetal distress, maternal heart disease, acute pulmonary edema, intrapartum infection, maternal fatigue, or infection.

Betamethasone (Celestone)

Promotes fetal lung maturity by stimulating surfactant production; prevents or reduces risk of respiratory distress syndrome and intraventricular hemorrhage in the preterm neonate less than 34 weeks' gestation.

Prostaglandin's for Labor

Prostaglandin analogs commonly used for cervical rip-ening include dinoprostone gel (Prepidil), dinoprostone inserts (Cervidil), and misoprostol (Cytotec). Misopros-tol (Cytotec), a synthetic PGE1 analog, is a gastric cyto-protective agent used in the treatment and prevention of peptic ulcers.

Pharmacologic Methods for Labor Induction/Cervical Ripening

Prostaglandin's Oxytocin

Protracted Disorders

Refers to a series of events including protracted active phase dilation (slower than normal rate of cervical dilation) and protracted descent (delayed descent of the fetal head in the active phase). A laboring woman who has a slower than normal rate of cervical dilation is said to have a protraction labor pattern disorder. In terms of time, it describes a labor lasting more than 18 to 24 hours. Diagnostic criteria are 1.2 cm per hour for primips and 1.5 cm per hour for multips. For protracted descent, the criteria are less than 1.0 cm per hour in primips and less than 2.0 cm per hour for multips.

Abruptio Placentae

Refers to premature separation of a normally implanted placenta from the maternal myometrium. Risk factors include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology.

Menopausal transition

Refers to the transition from a woman's reproductive phase of her life to her final menstrual period. This period is also referred to as perimeno-pause. It is the end of her menstruation and childbearing capacity. The average age of natural menopause—defined as 1 year without a menstrual period—is 51.4 years old.

Magnesium Sulfate

Relaxes uterine muscles to stop irritability and contractions, to arrest uterine contractions for preterm labor (off-label use). Has been used in seizure prophy-laxis and treatment of seizures in preeclamptic and eclamptic clients for almost 100 yrs.

Problems with the Psyche

Release of stress-related hormones (catecholamines, cortisol, epi-nephrine, beta-endorphin), which act on smooth muscle (uterus) and reduce uterine contractility. Excessive release of catecholamines and other stress-related hormones not therapeutic. Release also results in decreased uteroplacental perfusion and in-creased risk for poor newborn adjustment.

Risks: Vacuum or Forcept Birth

Risk of tissue trauma to the mother and the newborn. Maternal trauma may include lacerations of the cervix, vagina, or perineum; hematoma; extension of the episiotomy incision into the anus; hemorrhage; and infection. Potential newborn trauma includes ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhema-toma, and caput succedaneum.

Intrauterine (Congenital) Infections

Risks: - Immature immune system IgM, IgA, and T lymphocytes - Decreased gastric acid, which is needed to reduce organisms Organisms: - Cytomegalovirus - Rubella - Toxoplasmosis - Syphilis Mechanism of Infection: - Organism crossing placenta into fetal circulatory system; organism residing in amniotic fluid - Ascent of organism via the vagina, ultimately infecting membranes and causing rupture and leading to respiratory and gastrointestinal tract infections

Late Onset Infections

Risks: - Low birthweight - Prematurity - Meconium staining - Need for resuscitation - Birth asphyxia - Improper handwashing Organisms: - Candida albicans - Coagulase-negative staphylococci - Staphylococcus aureus - E. coli - Enterobacter - Klebsiella - Serratia - Pseudomonas - Group B streptococci Mechanism of Action: More common in newborns undergoing invasive procedures such as endotracheal intubation or catheter insertion; break in skin or mucosal protection barrier.

Early-Onset Infections

Risks: - Prolonged rupture of membranes - Urinary tract infections - Preterm labor - Prolonged or difficult labor - Maternal fever - Colonization with group B streptococci - Maternal infections Organisms: - Escherichia coli - Group B streptococci - Klebsiella pneumoniae - Listeria monocytogenes - Other enteric gram-negative bacilli Mechanism of Action: Most occur during birthing process when newborn comes into contact with infected birth canal (newborn can-not defend against host organisms) - Newborn susceptibility to infection by exogenous organisms possibly due to inadequacy of physical barriers (thin, friable skin with little subcutaneous tissue) - Lack of gastric acidity, possibly resulting in easy colonization by environmental organisms - Aspiration of microorganisms during birth with development of pneumonia.

Hypoglycemia in Newborns

SGA newborns (common):Increased metabolic rate and lack of adequate glycogen stores to meet newborn's metabolic needs. LGA Newborns (common): Commonly associated with infants of diabetic mothers Abrupt cessation of high-glucose maternal blood supply with birth and continued insulin production by the newborn. Limited ability to release glucagons and catecholamines, which normally stimulate glucagon breakdown and glucose release. Post-term Neonates: Hypoxia secondary to depleted glycogen reserves.Placental insufficiency secondary to placental aging contributing to chronic fetal nutritional deficiency further depleting glycogen stores. Preterm Neonates: Immature sucking and swallowing leading to insufficient intake,Perinatal hypoxia, Increased energy expenditure. Decreased subcutaneous and brown fat with little to no glycogen stores.

Polycythemia in Newborns

SGA newborns: Chronic mild hypoxia secondary to placental insufficiency. LGA newborns: Stimulation of erythropoietin release, leading to increased RBC production. Secondary to fetal hypoxia, trauma with bleeding, increased erythropoietin production, or delayed cord clamping. Post-term neonates: Intrauterine hypoxia triggers increased RBC cell production to compensate for lower oxygen levels.

Meconium Aspiration

SGA newborns: Release of meconium into amniotic fluid prior to birth. Inhalation of meconium-containing amniotic fluid by the newborn, leading to aspiration. Post-terms: Commonly associated with chronic intrauterine hypoxia. Struggling by fetus making respiratory efforts and bearing down with abdominal muscles, leading to expulsion of meconium into amniotic fluid. Normal sucking and swallowing by fetus leads to meconium filling airways.

Difficulty with Thermoregulation

SGA's: Less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. Post-terms: Associated with depleted glycogen stores, poor subcutaneous fat stores, and disturbances in CNS thermoregulation due to hypoxia. Increased risk for acidosis and hypoglycemia secondary to metabolic stress. Loss of subcutaneous fat second to placental insufficiency.

Neonatal Hypovolemic Shock

Secondary to abruptio placentae, placenta previa, or cord rupture resulting in blood loss to the fetus.

Reasons for Amnioinfusion

Severe variable decelerations due to cord compression, oligohydramnios due to placental insufficiency, postmaturity or rupture of membranes, preterm labor with premature rupture of membranes, and thick meconium fluid.

Phototherapy

Special lights placed above the newborn or a fiber-optic blanket placed under the newborn and wrapped around him or her, involves blue wavelengths of light to alter unconjugated bilirubin in the skin. For the newborn receiving phototherapy, place the newborn under the lights or on the fiber-optic blanket, exposing as much skin as possible. Cover the newborn's genitals and shield the eyes to protect these areas from becoming irritated or burned when using direct lights.

Amniohook

Special sterile hook used to artificially rupture membranes to stimulate the beginning of true labor or to speed up the active labor process.

Forceps

Stainless-steel instruments, similar to tongs, with rounded edges that fit around the fetus's head. Some forceps have open blades and some have solid blades. Outlet forceps are used when the fetal head is crowning and low forceps are used when the fetal head is at a +2 station or lower but not yet crowning. The forceps are applied to the sides of the fetal head.

Cephalhematoma

Subperiosteal collection of blood secondary to the rupture of blood ves-sels between the skull and periosteum) occurs in 2.5% of all births and typically appears within hours after birth. In cephalhematoma, suture lines delineate its extent; usually located on one side, over the parietal bone. Cephalhematoma resolves gradually over 2-3 weeks without treatment.

Respiratory distress syndrome (RDS): Pathophysiology

Surfactant is deficient or lacking, and this deficit results in stiff lungs and alveoli that tend to collapse, leading to diffuse atelectasis. The work of breathing is increased because increased pressure similar to that required to initiate the first breath is needed to initiate the lungs with each successive breath.

Post-Op Care: Esophageal Atresia/ Tracheoesophageal Fistula

Surgery consists of closing the fistula and joining the two esophageal segments. Postoperative care involves closely observing all of the newborn's body systems to identify any complications. Expect to administer TPN and antibiotics until the esophageal anastomosis is proven intact and patent. Then begin oral feedings, usually within a week after surgery.

Misoprostol (Cytotec)

Synthetic prostaglandin E1 analog that replaces protective GI prostaglandins. Ripens cervix/to induce labor.

Assessment: Thermoregulation Problems

Temperature <36.4° C; tem-perature instability; skin cool to touch; cyanosis of hands and feetBradypnea (<25 bpm) and tachypnea (>60 breaths/min).Tremors, irritabilityWheezing, crackles, retractionsRestlessness, lethargy, Hypotonia. Weak or high-pitched cry, Seizures, Poor feeding, GruntingAcidosis

Amniotomy

The artificial rupture of the fetal membranes. It is performed to stimulate or accelerate the onset of labor. The procedure is painless.

Cesarean Birth

The delivery of the fetus through an incision in the abdomen and uterus.

McRobert's Maneuver

The maternal thighs are sharply flexed against the maternal abdomen to straighten the sacrum relative to the lumbar spine and rotate the symphysis pubis anteriorly toward the maternal head (for shoulder dystocia).

MANIFESTATIONS OF NEONATAL ABSTINENCE SYNDROME

- Tremors -Generalized seizures -Hyperactive reexes -Restlessness -Hypertonic muscle tone, constant movement -Shrill, high-pitched cry - Disturbed sleep patterns Metabolic, Vasomotor, and Respiratory Disturbances Fever Frequent yawning Mottling of the skin Sweating Frequent sneezing Nasal flaring Tachypnea >60 bpm Apnea Gastrointestinal Dysfunction Poor feeding Frantic sucking or rooting Loose or watery stools Regurgitation or projectile vomiting

Diagnosis: Excessive Fetal Size and Abnormalities

-A diagnosis of fetal macrosomia can be confirmed by measuring the birth weight after birth. Suspicion of macrosomia based on the findings of an ultrasound examination before onset of labor (if suspected due to conditions such as maternal diabetes or obesity, estimation of fetal weight via ultrasound). -Leopold's maneuvers to estimate fetal weight and position on admission to labor and birth unit.

Equipment for Newborn Resuscitation

-A wall vacuum suction apparatus -A wall source or tank source of 100% oxygen with a flow meter -A neonatal self-inflating ventilation bag with correct-sized face masks -A selection of endotracheal tubes (2.5, 3.0, or 3.5 mm) with introducers -A laryngoscope with a small, straight blade and spare batteries and bulbs -Ampules of naloxone (Narcan) with syringes and needles -A wall clock to document timing of activities and events -A supply of disposable gloves in a variety of sizes for staff to use

Necrotizing enterocolitis (NEC): Assessment

-Abdominal distention and tenderness -Bloody or hemoccult-positive stools -Diarrhea -Temperature instability -Feeding intolerance, characterized by bilious vomiting -Signs of sepsis -Lethargy -Apnea -Shock -Kidney, ureter, and bladder (KUB) of the abdomen x-ray: confirms the presence of pneumatosis intesti-nalis (air in the bowel wall) and persistently dilated loops of bowel -Blood values: may demonstrate metabolic acidosis, increased white blood cells, thrombocytopenia, neutropenia, electrolyte imbalance, or disseminated intravascular coagulation (DIC) .

Magnesium Sulfate: Nursing Implications

-Administer IV with a loading dose of 4-6 g over 15-30 min initially, and then maintain infusion at 1-4 g/hr. -Assess vital signs and deep tendon reflexes (DTRs) hourly; report any hypotension or depressed or absent DTRs. -Monitor level of consciousness; report any headache, blurred vision, dizziness, or altered level of consciousness. -Perform continuous electronic fetal monitoring; report any decreased FHR variability, hypotonia, or respiratory depression. -Monitor intake and output hourly; report any decrease in output (<30 mL/hr).Assess respiratory rate; report respiratory rate <12 breaths/min; auscultate lung sounds for evidence of pulmonary edema. -Monitor for common maternal side effects, including flushing, nausea and vomiting, dry mouth, lethargy, blurred vision, and headache. -Assess for nausea, vomiting, transient hypotension, lethargy. -Assess for signs and symptoms of magnesium toxicity, such as decreased level of consciousness, depressed respirations and DTRs, slurred speech, weakness, and respiratory and/or cardiac arrest. -Have calcium gluconate readily available at the bedside to reverse magnesium toxicity.

Oxytocin (Pitocin): Implications

-Administer as an IV infusion via pump, increasing dose based on protocol until adequate labor progress is achieved. -Assess baseline vital signs and FHR and then frequently after initiating oxytocin infusion. -Determine frequency, duration, and strength of contractions frequently. -Notify health care provider of any uterine hypertonicity or abnormal FHR patterns. -Maintain careful I&O, being alert for water intoxication. -Keep client informed of labor progress. -Monitor for possible adverse effects such as hyperstimulation of the uterus, impaired uterine blood flow leading to fetal hypoxia, rapid labor leading to cervical lacerations or uterine rupture, water intoxication (if oxytocin is given in electrolyte-free solution or at a rate exceeding 20 mU/min), and hypotension.

Betamethasone (Celestone): Nursing Implications

-Administer two doses intramuscularly 24 hr apart. -Monitor for maternal infection or pulmonary edema. -Educate parents about potential benefits of drug to preterm infant. -Assess maternal lung sounds and monitor for signs of infection.

Interventions: Multifetal Pregnancy

-Admission to facility with specialized care unit if woman goes into labor. -Spontaneous progression of labor if woman has no complicating factors and first fetus is in longitudinal lie. -Separate monitoring of each FHR during labor and birth. -After birth of first fetus, clamping of cord and lie of the second twin assessed. Possible external cephalic version necessary to assist in providing a longitudinal lie. -Second and subsequent fetuses at greater risk for birth- related complications, such as umbilical cord pro-lapse, malpresentation, and abruptio placentae. -Cesarean birth if risk factors high. -Assess for hypotonic labor pattern due to overdistention. -Evaluate for fetal presentation, maternal pelvic size, and gestational age to determine mode of delivery. -Ensure presence of neonatal team for birth of multiples. -Anticipate need for cesarean birth, which is common in multifetal pregnancy.

Risk Factors: Preterm Labor

-African American race (double 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 -Multifetal pregnancy -Premature rupture of membranes -Late or no prenatal care -Short cervical length -STIs: 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 -UTI -Domestic violence -Stress, acute and chronic

Surgical Methods for labor induction/cervical ripening

-Amniotomy -Stripping of Membranes

Interventions: Providing Stimulation

-Appropriate developmental stimulation that would not overtax the compromised newborn might include kangaroo (skin-to-skin) holding, rocking, soft singing or music, cuddling, gentle stroking of the infant's skin, colorful mobiles, gentle massage, waterbed mattresses, and nonnutritive sucking opportunities or providing sucrose if tolerated. -The NICU environment can be altered to provide periods of calm and rest for the newborn by dimming the lights, lowering the volume and tone of conversations, closing doors gently, setting the telephone ringer to the lowest volume possible, clustering nursing activities, and covering the isolette with a blanket to act as a light shield to promote rest at night. -Encourage Parents to hold and interact with newborn.

Perinatal Death: Helping Parents Have Control/Nursing Care

-Ask the family who they wish to have present as the infant dies. -Give the family a choice of rooms in which they can say good-bye to their infant. -Provide privacy for the family during this time period by placing a sign on the door. -Provide ideas for making or selecting memorial items for a memory box. -The family should never be left to handle their emotions alone unless they request it. -Respect a family's wishes if they refuse to be with their infant during the dying process or afterward. Everyone grieves differently. -Sending the family a card from the nursing staff, signed by all who worked with their infant within a week of leaving the hospital -Attending the funeral to allow for a public good-bye and to support others in their time of loss -Providing the family with a memory box, which might contain an outfit worn by their infant, a blanket used to cover their infant, a lock of hair, and a card with hand and foot prints, a photo with someone holding their infant -Remembering their infant at various anniversaries by sending a card or calling the family to see how they are doing provides families much-needed comfort -Donating to a charity in memory of the infant, such as to March of Dimes -Providing the family with resources that might help them. Information might include listings of local or online support groups as well as grief websites such as Share.org

Interventions: Preventing Infection

-Assess for risk factors in maternal history that place the newborn at increased risk. -Monitor for changes in vital signs such as temperature instability, tachycardia, or tachypnea. -Assess oxygen saturation levels and initiate oxygen therapy as ordered if oxygen saturation levels fall below acceptable parameters. -Assess feeding tolerance, typically an early sign of infection. -Monitor laboratory test results for changes. -Avoid using tape on the newborn's skin to prevent tearing. -Use equipment that can be thrown away after use. -Adhere to standard precautions; use clean gloves to handle dirty diapers and dispose of them properly. -Use sterile gloves when assisting with any invasive procedure; attempt to minimize the use of invasive procedures. -Remove all jewelry on your hands prior to washing hands; wash hands upon entering the nursery and in between caring for newborns. -Avoid coming to work when ill, and screen all visitors for contagious infections.

Interventions: Promoting Optimal Breathing Patterns

-Assess gestational age and risk factors for respiratory distress to allow early detection. -Anticipate need for bag and mask setup and wall suction to allow for prompt intervention should respiratory status continue to worsen. -Assess respiratory effort (rate, character, effort) to identify changes. -Assess heart rate for tachycardia and auscultate heart sounds to determine worsening of condition. -Observe for cues (grunting, shallow respirations, tachypnea, apnea, tachycardia, central cyanosis, hypotonia, increased effort) to identify need for additional oxygen. -Maintain slight head elevation to prevent upper airway obstruction. -Assess skin color to evaluate tissue perfusion. -Monitor oxygen saturation level via pulse oximetry to provide objective indication of perfusion status. -Provide supplemental oxygen as indicated and ordered to ensure adequate tissue oxygenation. -Assist with any ordered diagnostic tests, such as chest x-ray and arterial blood gases, to determine effectiveness of treatments. -Cluster nursing activities to reduce oxygen consumption. -Maintain a neutral thermal environment to reduce oxygen consumption. -Monitor hydration status to prevent fluid volume deficit or overload. -Explain all events and procedures to the parents to help alleviate anxiety and promote understanding of the newborn's condition.

Meconium aspiration syndrome (MAS): Assessment

-Assess the amniotic fluid for meconium staining when the maternal membranes rupture. -Green-stained amniotic fluid suggests the presence of meconium in the amniotic fluid and should be reported immediately. -After birth, note any yellowish-green staining of the umbilical cord and nails and skin. This staining indicates that meconium has been present for some time. -Observe the newborn for a barrel-shaped chest with an increased anterior-posterior (AP) chest diameter (similar to that found in a client with chronic obstructive pulmonary disease), prolonged tachypnea, progression from mild to severe respiratory distress, intercostal re-tractions, end-expiratory grunting, and cyanosis -Auscultate the lungs, noting coarse crackles and rhonchi. -Chest x-rays show patchy, fluffy infiltrates unevenly distributed throughout the lungs and marked hyperaera-tion mixed with areas of atelectasis. -Arterial blood gas analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2. -Direct visualization of the vocal cords for meconium staining using a laryngoscope can confirm the presence of meconium below the larynx.

Interventions: Promoting Thermoregulation

-Assess the axillary temperature every hour or use a thermistor probe to monitor for changes. -Review maternal history to identify risk factors contributing to problem. -Monitor vital signs, including heart rate and respiratory rate, every hour to identify deviations. -Check radiant heat source or isolette to ensure maintenance of appropriate temperature of the environment. -Assess environment for sources of heat loss or gain through evaporation, conduction, convection, or radiation to minimize risk of heat loss. -Avoid bathing and exposing newborn to prevent cold stress. -Warm all blankets and equipment that come in contact with newborn; place warmed cap on the newborn's head and keep it on to minimize heat loss. -Encourage kangaroo care (mother or father holds preterm infant underneath clothing skin-to-skin and upright between breasts) to provide warmth. -Educate parents on how to maintain a neutral thermal environment, including importance of keeping the newborn warm with a cap and double-wrapping with blankets and changing them frequently to keep dry to promote newborn's adjustment. -Demonstrate ways to safeguard warmth and prevent heat loss.

Newborn Discharge

-Assess the physical status of the mother and the newborn -Discuss the early signs of complications and what to do if they occur -Reinforce instructions for infant care and safety -Stress the importance of proper car seat use -Provide instructions for medication administration -Reinforce instructions for equipment operation, maintenance, and troubleshooting -Teach infant cardiopulmonary resuscitation and emergency care -Demonstrate techniques for special care procedures such as dressings, ostomy care, artificial airway maintenance, chest physiotherapy, suctioning, and infant stimulation -Provide breastfeeding support or instruction on gavage feedings -Assist with defining roles in the adjustment period at home -Assess the parents' emotional stability and coping status -Provide support and reassurance to the family -Report abnormal findings to the health care team for intervention -Follow up with parents to ensure that they have connected with appropriate support systems in the community

Postoperative Care: Cesarean Birth

-Assess vital signs and lochia flow every 15 minutes for the first hour, then every 30 minutes for the next hour, and then every 4 hours if stable. -Assist with perineal care and instruct the client in the same. -Inspect the abdominal dressing and document description, including any evidence of drainage. -Assess uterine tone to determine fundal firmness. -Check the patency of the intravenous line, making sure the infusion is flowing at the correct rate. Inspect the infusion site frequently for redness. -Assess the woman's level of consciousness if sedative drugs were administered. -Institute safety precautions until the woman is fully alert and responsive. If a regional anesthetic was used, monitor for the return of sensation to the legs. -Assess for evidence of abdominal distention and auscultate bowel sounds. -Assist with early ambulation to prevent respiratory and cardiovascular problems and to promote peristalsis. -Monitor intake and output at least every 4 hours initially and then every 8 hours as indicated. -Encourage the woman to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. -Administer analgesics as ordered and provide comfort measures, such as splinting the incision and pillows for positioning. -Assist the client to move in bed and turn side to side to improve circulation. -Also encourage the woman to ambulate to promote venous return from the extremities.

Teaching: Preventing Preterm Labor

-Avoid traveling for long distances in cars, trains, planes, or buses. -Avoid lifting heavy objects, such as laundry, groceries, or a young child. -Avoid performing hard, physical work, such as yard work, moving of furniture, or construction. -Visit a dentist in early pregnancy to evaluate and treat periodontal disease. -Enroll in a smoking cessation program if you are unable to quit on your own. -Curtail sexual activity until after 37 weeks if experiencing preterm labor symptoms. -Consume a well-balanced nutritional diet to gain appropriate weight. -Avoid the use of substances such as marijuana, cocaine, and heroin. -Identify factors and areas of stress in your life, and use stress management techniques to reduce them. -If you are experiencing intimate partner violence, seek resources to modify the situation.

Nursing Assessment: Preterm Newborns

-Birthweight of less than 5.5 pounds -Scrawny appearance -Head disproportionately larger than chest circumference -Poor muscle tone and flexion -Fontanels wide and soft with overriding sutures - Minimal subcutaneous fat -Undescended testes -Plentiful lanugo (soft, downy hair), especially over the face and back -Poorly formed ear pinna, with soft, pliable cartilage -Fused eyelids -Soft and spongy skull bones, especially along suture lines -Matted scalp hair, wooly in appearance -Absent to a few creases in the soles and palms -Minimal scrotal rugae in male infants; prominent labia and clitoris in female infants -Thin, transparent skin with visible veins -Breast and nipples not clearly delineated -Abundant vernix caseosa

Calcium Channel Blockers: Preterm Labor

-Calcium channel blockers promote uterine relaxation by decreasing the influx of calcium ions into myometrium cells to inhibit contractions. Although calcium channel blockers may be prescribed to manage preterm labor, available literature provides little evidence that they have better efficacy in treating preterm labor than magnesium sulfate. -Administer cal-cium channel blockers (nifedipine) orally or sublingually every 4 to 8 hours as ordered. Monitor the woman for hypotension, reflex tachycardia, headache, nausea, and facial flushing.

Interventions: Neonatal Sepsis

-Circulatory support with fluids and vasopressors - Supplemental oxygen and mechanical ventilation -Obtaining culture samples as requested -Antibiotic administration as ordered, observing for side effects -Promoting newborn comfort -Assessing the family's educational needs and pro-viding instructions as necessary

Interventions: Developmental Care

-Clustering care to promote rest and conserve the infant's energy -Flexed positioning to simulate in utero positioning -Environmental management to reduce noise and vi-sual stimulation -Kangaroo care to promote skin-to-skin sensation -Placement of twins in the same isolette or open crib to reduce stress -Activities to promote self-regulation and state regulation: Surrounding the newborn with nesting rolls/devicesSwaddling with a blanket to maintain the flexed position Providing sheepskin or a waterbed to simulate the uterine environment -Providing nonnutritive sucking (calms the infant) - Providing objects to grasp (comforts the newborn) -Promotion of parent-infant bonding by making parents feel welcome in the NICU -Open, honest communication with parents and staff -Collaboration with the parents in planning the infant's care

Interventions: Shoulder Dystocia Cord Compression

-Combination of maneuvers effective in more than 50% of cases of shoulder dystocia. -Newborn resuscitation team readily available. -Clear room of unnecessary clutter to make room for additional personnel and equipment. -After the birth, assess newborn for crepitus, deformity, Erb's palsy, or bruising, which might suggest neurologic damage or a fracture.

Nursing Implications: VBAC

-Consent: Fully informed consent is essential for the woman who wants to have a trial of labor after cesarean birth. The client must be advised about the risks as well as the benefits. She must understand the ramifications of uterine rupture, even though the risk is small. -Documentation: Record keeping is an important component of safe client care. If and when an emergency occurs, it is imperative to take care of the client, but also to keep track of the plan of care, interventions and their timing, and the client's response. Events and activities can be written right on the fetal monitoring tracing to correlate with the change in fetal status. -Surveillance: A distressed fetal monitor tracing in a woman undergoing a trial of labor after a cesarean birth should alert the nurse to the possibility of uterine rupture. Terminal bradycardia must be considered an emergency situation, and the nurse should prepare the team for an emergency delivery. -Readiness for emergency: According to ACOG (2010) criteria for a safe trial of labor for a woman who has had a previous cesarean birth, the physician, anesthe-sia provider, and operating room team must be im-mediately available. Anything less would place the women and fetus at risk.

Indomethacin: Nursing ImplicationsNifedipine (Procardia)

-Continuously assess vital signs, uterine activity, and FHR. -Administer oral form with food to reduce GI irritation. -Do not give to women with peptic ulcer disease. -Schedule ultrasound to assess amniotic fluid volume and function of ductus arteriosus before initiating therapy; monitor for signs of maternal hemorrhage. -Be alert for maternal adverse effects such as nausea and vomiting, heartburn, rash, prolonged bleeding time, oligohydramnios, and hypertension. -Monitor for neonatal adverse effects, including constriction of ductus arteriosus, premature ductus closure, necrotizing enterocolitis, oligohydramnios, and pulmonary hypertension. -Contraindicated in >32 weeks' gestations, intrauterine growth restriction, history of asthma, urticaria, or allergic type reactions to aspirin or NSAIDS.

Problems with the Passageway

-Contraction of one or more of the three planes of the pelvis. -Poorer prognosis for vaginal birth in women with android and platypelloid types of pelvis. -Contracted pelvis involving reduc-tion in one or more of the pelvic diameters interfering with progress of labor: inlet, midpelvis, and outlet contracture. -Obstruction in the birth canal, such as placenta previa that partially or completely obstructs the internal os of the cervix, fibroids in the lower uterine segment, a full bladder or rectum, an edematous cervix caused by premature bearing-down efforts, and human papillomavirus (HPV) warts.

Intraventricular hemorrhage (IVH): Interventions

-Correct anemia, acidosis, and hypotension with fluids and medications. -Administer fluids slowly to prevent fluctuations in blood pressure. -Avoid rapid volume expansion to minimize changes in cerebral blood flow. -Keep the newborn in a flexed, contained position with the head elevated to prevent or minimize fluctuations in intracranial pressure. -Continuously monitor the newborn for signs of hemorrhage, such as changes in the level of consciousness, bulging fontanel, seizures, apnea, and reduced activity level. -Measuring head circumference daily to assess for expansion in size is essential in identifying complications early. -Minimize handling and cluster nursing care. -Provide parents with support.

Management: Abruptio Placentae

-Depends on the extent of the hemorrhage. -Cesarean if only partially abrupted. -Vaginal delivery if fetal demise.

Assessment: Amniotic Fluid Embolism

-Diffculty breathing. -Other symptoms include hypotension, cyanosis, seizures, tachycardia, coagulation failure, DIC, pulmonary edema, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest

Prematurity: Central Nervous System

-Difficulty in thermoregulation. -Lack of muscle tone. -Prevent cold stress!

The ideal environment for Newborn Development

-Dim the lights and cover isolettes at night to simulate nighttime. -Support early extubation from mechanical ventilation. -Encourage early and consistent feedings with breast milk. -Administer prescribed antibiotics judiciously. -Position the newborn as if he or she was still in utero (a nesting fetal position). -Promote kangaroo care by encouraging parents to hold the newborn against the chest for extended periods each day. -Coordinate care to respect sleep and awake states.

Diagnostic Tests: Hyperbilirubinemia

-Direct Coombs test—to identify hemolytic disease of the newborn; positive results indicate that the new-born's red blood cells have been coated with antibodies and thus are sensitized -Hemoglobin concentration—for evidence of anemia -Blood type—to determine Rh status and any incompatibility of the newborn -Total serum protein—to detect reduced binding capacity of albumin -Reticulocyte count—to identify an elevated level indi-cating increased hemolysis.

Interventions: Hyperbilirubinemia

-Documentation of the timing of onset of jau-dice is essential to differentiate between physiologic (>24 hours) and pathologic jaundice (<24 hours). -Promote and support successful breast-feeding - Establish nursery protocols for identifying jaundice, in-cluding when a serum bilirubin can be ordered by a nurse -Measure total serum bilirubin on jaundiced infants in the first 24 hours -Interpret all bilirubin levels according to the infant's age in hours -Visual estimation of jaundice is inaccurate and shouldn't be used instead of labs -Infants <38 weeks, particularly if breast-fed, should be considered high risk -Perform risk assessment on all newborns prior to discharge -Jaundiced newborns should be treated, if indicated, with phototherapy -Provide parents with written and oral information about jaundice at discharge -Follow-up care and referrals should be based on time of discharge and risk -Empower parents to make appropriate decisions once home

Nursing Assessment: Post-Term Newborns

-Dry, cracked, peeling, wrinkled skin -Vernix caseosa and lanugo are absent -Long, thin extremities -Creases that cover the entire soles of the feet -Wide-eyed, alert expression -Abundant hair on scalp -Thin umbilical cord -Limited vernix and lanugo -Meconium-stained skin and fingernails -Long nails

Persistent Occiput Posterior Position

-Engagement of fetal head in the left or right occipito-transverse position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position (fetus born facing upward instead of the normal downward position). -Labor usually much longer and more uncomfortable (causing increased back pain during labor) if fetus remains in this position.Possible extensive caput succedaneum and molding from the sustained occiput posterior position.

Intraventricular hemorrhage (IVH): Assessment

-Evaluate the newborn for an unexplained drop in hematocrit, pallor, and poor perfusion as evidenced by respiratory distress and oxygen desaturation. -Note seizures, lethargy or other changes in level of consciousness, weak suck, high-pitched cry, or hypotonia. -Palpate the anterior fontanel for tenseness. -Assess vital signs, noting bradycardia and hypotension. -Evaluate laboratory data for changes indicating metabolic acidosis or glucose instability. -Frequently a bleed can progress rapidly and result in shock and death. -Prepare the newborn for cranial ultrasonography, the diagnostic tool of choice to detect hemorrhage

Diagnoses: Hypotonic Uterine Dysfunction

-Evaluation of the woman's labor to confirm that she is having hypotonic active labor rather than a long latent phase. -Evaluation of maternal pelvis and fetal presentation and position to ensure that they are not contributing to the prolonged labor without noticeable progress.

Terbutaline: Nursing Implication

-Expect to administer the agent as a single subcutaneous injection. -It may be repeated if the maternal heart rate remains less than 130 bpm. -Closely assess the woman for side effects, including jitteriness, flushing, hypotension, nervousness, anxiety, restlessness, nausea, and tachycardia. -Assess the fetus for tachycardia, hypotension, and hypoglycemia.

Management: Amnioinfusion

-Explain the need for the procedure, what it involves, and how it may solve the problem. -Inform the mother that she will need to remain on bed rest during the procedure. -Assess the mother's vital signs and associated discomfort level. -Maintain intake and output records. -Assess the duration and intensity of uterine contractions frequently to identify overdistention or increased uterine tone. -Assess for fluid leakage by evaluating the chuck or pad under the woman to determine that it is not being retained in the uterus, which could lead to increased uterine pressure. - Monitor the FHR pattern to determine whether the amnioinfusion is improving the fetal status. -Prepare the mother for a possible cesarean birth if the FHR does not improve after the amnioinfusion.

Test to Determine Preterm Labor

-Fetal fibronectin testing -Cervical length evaluation by transvaginal ultrasound -Salivary estriol -Home monitoring of uterine activity to recognize preterm contractions.

Interventions: Problems with the Passageway

-Focus on allowing natural forces of labor contractions to push the largest diameter (biparietal) of the fetal head beyond the obstruction or narrow passage. -Possible forceps and vacuum extraction to assist navigation through this passageway. -Assess for poor contractions, slow dilation, prolonged labor.Evaluate bowel and bladder status to reduce soft tissue obstruction and allow increased pelvic space. -Anticipate trial of labor; if no labor progression after an adequate trial, plan for cesarean birth.

Mechanical Methods for labor induction/cervical ripening

-Foley catheter to dilate cervix -hygroscopic dilators

Nonpharmacologic Pain Reduction in the Newborn

-Gentle handling, rocking, caressing, cuddling, and massaging -Rest periods before and after painful procedures -Kangaroo care (skin-to-skin contact) during procedure -Breastfeeding, if able, to reduce pain from minor procedures -Use of a facilitated tuck (holding arms and legs in a flexed position) -Application of topical anesthetics prior to venipuncture or lumbar puncture -Swaddling and positioning to establish physical boundaries -Nonnutritive sucking (pacifier dipped in sucrose) prior to procedure -Minimal use of tape, with gentle removal to avoid skin tears -Warm blankets for wrapping to facilitate relaxation-Reduction of environmental stimuli by removing or turning down noxious stimuli such as noise from alarms, beepers, loud conversations, and bright lights -Distraction, such as with colored objects or mobiles

Assessment: SGA Newborns

-Head disproportionately large compared to rest of body (asymmetric) -Wasted appearance of extremities -Reduced subcutaneous fat stores -Decreased amount of breast tissue -Scaphoid abdomen (sunken appearance) -Wide skull sutures secondary to inadequate bone growth -Poor muscle tone over buttocks and cheeks -Loose and dry skin that appears oversized -Thin umbilical cord

Assisting Families to Deal with Perinatal Death: After Death

-Help the family to accept the reality of death by using the word "died." -Acknowledge their grief and the fact that their newborn has died. -Help the family to work through their grief by validating and listening. -Provide the family with realistic information about the causes of death. -Offer condolences to the family in a sincere manner. -Encourage the father to cry and grieve with his partner. -Provide opportunities for the family to hold the newborn if they desire.

Non-pharmacologic methods for labor induction/cervical ripening

-Herbal agents such as evening primrose oil, black haw, black and blue cohosh, and red raspberry leaves. -Castor oil, hot baths, and enemas. -Sexual Intercourse, Breast Stimulation

Prematurity: Cardiovascular System

-Higher oxygen levels in the circulation once air breathing begins spur this transition. If the oxygen levels remain low secondary to perinatal asphyxia, the fetal pattern of circulation may persist, causing blood flow to bypass the lungs. -Increased incidence of congenital anomalies associated with continued fetal circulation—patent ductus arteriosus and an open foramen ovale. -Impaired regulation of blood pressure in pre-term newborns may cause fluctuations throughout the circulatory system. -Cerebral blood flow, which may predispose the fragile blood vessels in the brain to rupture, causing intracranial hemorrhage .

Meconium aspiration syndrome (MAS): Interventions

-Hyperoygenation -Monitor ABG's -Cluster newborn care to minimize oxygen demand. -Prevent and treat any complications such as hypotension, metabolic acidosis, or anemia. -Incorporate developmental care practices when applicable. -Administer broad-spectrum antibiotics to treat bacte-rial pneumonia. -Administer sedation to reduce oxygen consumption and energy expenditure. -Continuously monitor the newborn's condition (car-diac and respiratory status, oximetry). -Provide continuous reassurance and support to the parents throughout the experience.

Assessment: Neonatal Infections

-Hypothermia -Pallor or duskiness -Hypotonia -Cyanosis -Poor weight gain -Irritability -Seizures -Jaundice -Grunting -Nasal flaring -Apnea and bradycardia -Lethargy -Hypoglycemia -Poor feeding (lack of interest in feeding) -Abdominal distention

Interventions: Hypotonic Uterine Dysfunction

-Identifcation of possible cause of inefficient uterine action (a malpositioned fetus, a too small maternal pelvis, overdis-tention of the uterus with fluid or a macrosomic fetus). -Rupture of amniotic sac (amniotomy) if all causes ruled out.Possible augmentation with oxytocin (Pitocin) to stimulate effective uterine contractions. -Cesarean birth if amniotomy and augmentation ineffective. -Administer oxytocin as ordered once fetopelvic disproportion is ruled out. -Assist with amniotomy if membranes are intact.Provide continuous electronic fetal monitoring. -Monitor vital signs, contractions, and cervix continually. -Assess for signs of maternal and fetal infection. -Explain to woman and family about dysfunctional pattern. -Plan for surgical birth if normal labor pattern is not achieved or fetal distress occurs.

Interventions: Promoting Optimal Nutrition

-Identify newborn at risk based on behavioral characteristics, body measurements, and gestational age to establish a baseline and allow for early detection. -Assess blood glucose levels as ordered to determine status and establish a baseline for interventions. -Obtain blood glucose measurements upon admission to nursery and every 1 to 2 hours as indicated to evaluate for changes. -Observe behavior for signs of low blood glucose to allow early identification. -Initiate early oral feedings or gavage feedings to maintain blood glucose levels. -If oral or gavage feedings aren't tolerated, initiate an IV glucose infusion to aid in stabilizing blood glucose levels. -Assess skin for pallor and sweating to identify signs of hypoglycemia. -Assess neurologic status for tremors, seizures, jitteriness, and lethargy to identify further drops in blood glucose levels. -Monitor weight daily for changes to determine effectiveness of feedings. -Maintain temperature using warmed blankets, radiant warmer, or warmed isolette to pre-vent heat loss and possible cold stress and reduce energy demands. -Monitor temperature to prevent cold stress resulting in decreased blood glucose levels. -Offer opportunities for nonnutritive sucking on premature-size pacifier to satisfy sucking needs. -Monitor for tolerance of oral feedings, including intake and output, to determine effectiveness. -Administer IV dextrose if newborn is symptomatic to raise blood glucose levels quickly. -Decrease energy requirements, including clustering care activities and providing rest periods, to conserve glucose and glycogen stores. -Inform parents about procedures and treatments, including rationale for frequent blood glucose levels, to help reduce their anxiety.

Interventions: Shoulder Dystocia

-If anticipated, preparatory tasks instituted: alerting of key personnel; education of woman and family regarding steps to be taken in the event of a difficult birth; emptying of woman's bladder to allow additional room for possible maneuvers needed for the birth. -McRobert's maneuver. Suprapubic pressure (not fundal). -Intervene immediately due to cord compression. -Perform McRobert's maneuver and application of suprapubic pressure. -Assist with positioning the woman in squatting position, hands-and-knees position, or lateral recumbent position for birth to free shoulder. -Anticipate cesarean birth if no success in dislodging shoulders.

Prematurity: Immune System

-IgG deficiency until 34 weeks. -Inability to fight infections. -fragile skin and blood vessels. -anticipate and prevent infection.

Misoprostol (Cytotec): Implications

-Instruct client about purpose and possible adverse effects of medication. -Ensure informed consent is signed per hospital policy. -Assess vital signs and FHR patterns frequently.Monitor client's reaction to drug. -Initiate oxytocin for labor induction at least 4 hours after last dose was administered. -Monitor for possible adverse effects such as nausea and vomiting, diarrhea, uterine hyperstimulation, and category II and II FHR patterns.

Interventions: Persistent Occiput Posterior Position

-Labor to proceed, preparing the woman for a long labor (spontaneous resolution possible). -Comfort measures and maternal positioning to help promote fetal head rotation. -Assess for complaints of intense back pain in first stage of labor. -Anticipate possible use of forceps to rotate to anterior position at birth or manual rotation to anterior position at end of second stage. -Assess for prolonged second stage of labor with arrest of descent (common with this malposition). -Encourage maternal position changes to promote fetal head rotation: hands and knees and rocking pelvis back and forth; side-lying position; side lunges during contractions; sitting, kneeling, or standing while leaning forward; squatting position to give birth and enlarge pelvic outlet. -Prepare for possible cesarean birth if rotation is not achieved. -Administer agents as ordered for pain relief (effective pain relief crucial to help the woman to tolerate the back discomfort). -Apply low back counter pressure during contractions to ease the discomfort. -Use other helpful measures to attempt to rotate the fetal head, including lateral abdominal stroking in the direction that the fetal head should rotate; assisting the client into a hands-and-knees position (all fours); and squatting, pelvic rocking, stair climbing, assuming a side-lying posi-tion toward the side that the fetus should rotate, and side lunges. -Provide measures to reduce anxiety. -Continuously reinforce the woman's progress. -Teach woman about measures to facilitate fetal head rotation.

Treatment: PMS and PMDD

-Lifestyle change - Reduce stress. -Exercise three to FIve times each week. -Eat a balanced diet and increase water intake. -Decrease caffeine intake. - Stop smoking and limit the intake of alcohol. -Attend a PMS/women's support group. -Vitamin and mineral supplement - Multivitamin daily -Vitamin E, 400 units daily -Calcium, 1,200 mg daily -Magnesium, 200-400 mg daily -Medications -NSAIDs taken a week prior to menses -Oral contraceptives (low dose) -Antidepressants (SSRIs) -Anxiolytics (taken during luteal phase) - Diuretics to remove excess FLuid -Progestins -Gonadotropin-releasing hormone (GnRH) agonists -Danazol (androgen hormone inhibits estrogen production)

Tocolytic Meds

-Magnesium Sulfate (which reduces the muscle's ability to contract) -Indomethacin (Indocin, a prosta-glandin synthetase inhibitor). -Nifedipine (Procardia, a calcium channel blocker).

Risk Factors for High Risk Pregnancy

-Maternal nutrition (malnutrition or overweight) -Substandard living conditions or low socioeconomic status -Maternal age of less than 20 or more than 35 years old -Substance abuse -Lack of prenatal care -Smoking or exposure to passive smoke -Periodontal disease -Multiple gestation -Extreme maternal stress - Abuse and violence -Placental complications (placenta previa or abruptio placentae) -History of previous preterm birth -Maternal disease (e.g., hypertension, diabetes) - Maternal infection (e.g., urinary tract infection, chorioamnionitis) -Exposure to occupational hazards, working long hours, or very physical labor.

Respiratory Distress Syndrome: Interventions

-Mechanical ventilation, continuous positive airway pressure (CPAP), or positive end-expiratory pressure (PEEP) to prevent volume loss during expiration, and surfactant therapy. -The use of exogenous surfactant replacement therapy to stabilize the newborn's lungs until postnatal surfactant synthesis matures has become a standard of care, but not necessarily evidence-based. -Continuously monitor the infant's cardiopulmonary status via invasive or noninvasive means (e.g., arterial lines or auscultation, respectively). -Monitor oxygen saturation levels continuously; assess pulse oximeter values to determine oxygen saturation levels. -Closely monitor vital signs, acid-base status, and arterial blood gases. -Administer broad-spectrum antibiotics if blood cultures are positive. -Administer sodium bicarbonate or acetate as ordered to correct metabolic acidosis. -Provide fluids and vasopressor agents as needed to prevent or treat hypotension. -Test blood glucose levels and administer dextrose as ordered for prevention or treatment of hypoglycemia. -Cluster caretaking activities to avoid overtaxing and compromising the newborn. -Place the newborn in the prone position to optimize respiratory status and reduce stress. -Perform gentle suctioning to remove secretions and maintain a patent airway. -Assess level of consciousness to identify intraventricular hemorrhage. -Provide sufficient calories via gavage and IV feedings. -Maintain adequate hydration and assess for signs of fluid overload. -Provide information to the parents about treatment modalities; give thorough but simple explanations about the rationales for interventions. -Encourage the parents to participate in care

Manifestations: Fetal alcohol spectrum disorders (FASDs)

-Microcephaly (head circumference <10th percentile) - Small palpebral (eyelid) fissures -Abnormally small eyes - Intrauterine growth restriction -Maxillary hypoplasia (attened or absent) - Epicanthal folds (folds of skin of the upper eyelid over the eye) -Thin upper lip -Missing vertical groove in median portion of upper lip -Short upturned nose -Short birth length and low birthweight -Joint and limb defects -Altered palmar crease pattern -Prenatal or postnatal growth ≤10th percentile -Congenital cardiac defects (septal defects) -Delayed fine and gross motor development -Poor eye-hand coordination -Clinically significant brain abnormalities -Mental retardation -Narrow forehead -Performance substantially below expected level in cognitive or developmental functioning, executive or motor functioning, and attention or hyperactivity; social or language skills - Inadequate sucking reflex and poor appetite Diagnosis of fetal alcohol syndrome requires the presence of three findings: 1. Documentation of all three facial abnormalities 2. Documentation of growth deficits (height, weight, or both <10th percentile) 3. Documentation of CNS abnormalities (structural, neurologic, or functional)

Promoting Glucose Control: Infants of Diabetic Mothers

-Monitor blood glucose levels hourly for the first 4 hours and then every 3 to 4 hours or as necessary to detect hypoglycemia, which would be <40 mg/dL. - Continue to observe for manifestations of hypoglycemia, such as pallor, tremors, jitteriness, lethargy, and poor feeding, to allow for early detection and prompt intervention, thereby minimizing the risk of complications associated with hypoglycemia. -Monitor temperature frequently and institute measures to maintain a neutral thermal environment to prevent cold stress, which would increase metabolic demands and further deplete glycogen stores. -Initiate early feedings every 2 to 3 hours or as appropriate or administer glucose supplements as ordered to prevent hypoglycemia caused by the newborn's hyperinsulin state. Administer IV glucose infusions as ordered to correct hypoglycemia if glucose levels do not stabilize with feeding. -Cluster infant care activities and provide for rest periods to conserve the newborn's energy and reduce use of glucose and glycogen stores. -Reduce environmental stimuli by dimming lights and speaking softly to reduce energy demands and further utilization of glucose. -Explain all events and procedures to the mother to help alleviate anxiety and promote understanding of the newborn's condition.

Nursing Management: SGA Newborns

-Monitor for respiratory distress -blood glucose -vital signs -frequent feedings to get glucose above 40. -screen for polycythemia

Other Nursing Tasks: Preterm Labor

-Monitoring vital signs -Measuring intake and output -Encouraging bed rest on the woman's left side to enhance placental perfusion. -Monitoring the fetal heart rate via an external monitor continuously -Limiting vaginal examinations to prevent an ascending infection -Monitoring the mother and fetus closely for any adverse effects from the tocolytic agents. -Offering the couple ongoing explanations will help prepare them for the birth.

Pharmacologic Pain Reduction in Newborns

-Morphine and Fentanyl IV for moderate to severe pain. -Acetaminophen for mild pain. -Benzodiazepines used as sedatives for procedures. -Local and topical pain relief.

Newborn Pain Guidelines

-Newborn pain frequently goes unrecognized and undertreated. -Pain assessment is an essential activity prior to pain management. -Newborns experience pain, and analgesics should be given. -A procedure considered painful for an adult should also be considered painful for a newborn. -Developmental maturity and health status must be considered when assessing for pain in newborns . -Newborns may be more sensitive to pain than adults. -Pain behavior is frequently mistaken for irritability and agitation. -Newborns are more susceptible to the long-term effects of pain. -Adequate pain management may reduce complications and mortality. -Nonpharmacologic measures can prevent, reduce, or eliminate newborn pain. -Sedation does not provide pain relief and may mask pain responses. -A newborn's response to both pharmacologic and nonpharmacologic pain therapy should be assessed within 30 minutes of administration or intervention. -Health care professionals are responsible for pain assessment and treatment. -Written guidelines are needed on each newborn unit.

Transient tachypnea of the newborn (TTN): Assessment

-Observe for tachypnea, expiratory grunting, retractions, labored breathing, nasal flaring, and mild cyanosis. -Mild to moderate respiratory distress is present by 6 hours of age, with respiratory rates as high as 100 to 140 breaths per minute. -Inspect the newborn's chest for hyperextension or a barrel shape. -Auscultate breath sounds, which may be slightly diminished secondary to reduced air entry

Respiratory distress syndrome (RDS): Assessment

-Observe the infant for expiratory grunting, nasal flaring, chest wall retractions, see-saw respirations, and generalized cyanosis. -Auscultate the heart and lungs, noting tachycardia (rates above 150 to 180), fine inspiratory crackles, and tachypnea (rates above 60 breaths per minute).

Assessment: Asphyxia

-Observe the infant's color, noting any pallor or cyanosis. -Assess the work of breathing. -Be alert for apnea, tachypnea, gasping respirations, grunting, nasal flaring, or retractions. -Evaluate heart rate and note bradycardia. -Assess the newborn's temperature, noting hypothermia. -Determine the Apgar score at 1 and 5 minutes; if less than 7 at 5 minutes, repeat the assessment at 10 minutes of age. -Laboratory or diagnostic testing may be used to identify etiologies for the newborn's asphyxia. -A chest x-ray may identify structural abnormalities that might interfere with respiration. -A blood culture may identify an infectious process. -A blood toxicology screen may detect any maternal drugs in the newborn

Critical Components of Discharge Planning

-Parental education—involvement and support in newborn care during NICU stay will ensure their readiness to care for the infant at home. -Evaluation of unresolved medical problems—review of the active problem list and determination of what home care and follow-up is needed. -Implementation of primary care—completion of newborn screening tests, immunizations, exami-nations such as funduscopic exam for ROP, and hematologic status evaluation. -Development of home care plan, including assessment of: Equipment and supplies needed for care In-home caregiver's preparation and ability to care for infant Adequacy of the physical facilities in the home An emergency care and transport plan if needed Financial resources for home care costs Family needs and coping skills Community resources, including how they can be accessed

Nursing Management: Menopause

-Participate actively in maintaining health. -Exercise regularly to prevent CVD and osteoporosis. -Take supplemental calcium and eat appropriately to prevent osteoporosis. -Stop smoking to prevent lung and heart disease. -Reduce caffeine and alcohol intake to prevent osteoporosis. - Monitor blood pressure, lipids, and diabetes (drug therapy management). - Use low-dose aspirin to prevent blood clots. -Reduce dietary intake of fat, cholesterol, and sodium to prevent cardiovascular disease. -Maintain a healthy weight for body frame. -Perform breast self-examinations for breast awareness. -Control stress to prevent depression

Assessment: Hyperbilirubenemia

-Perform a complete physical examination. -Assess the skin, mucous membranes, sclerae, and bodily fluids (tears, urine) for a yellow color. -Detect jaundice by observing the infant in a well-lit room and blanching the skin with digital pressure over a bony prominence. -Typically, jaundice begins on the head and gradually pro-gresses to the abdomen and extremities. -Also inspect for pallor (anemia), excessive bruising (bleeding), and dehydration (sluggish circulation), which may contribute to the development of jaundice and the risk for kernicterus. -Assess the newborn for Rh incompatibility. -Be alert for clinical manifestations such as ascites, congestive heart failure, edema, pallor, jaundice, hepatosplenomegaly, hydramnios, thick placenta, and dilation of the umbilical vein

Nursing Management: Umbilical Cord Prolapse

-Places a sterile gloved hand into the vagina and holds the presenting part off the umbilical cord until delivery. -Changing the woman's position to a modified Sims, Trendelenburg, or knee-chest position also helps relieve cord pressure. -Monitor fetal heart rate, maintain bed rest, and administer oxygen if ordered. -Provide emotional support and explanations as to what is going on to allay the woman's fears and anxiety. -If the mother's cervix is not fully dilated, prepare the woman for an emergency cesarean birth to save the fetus's life.

Risk Factors: Hyperbilirubinemia

-Polycythemia -Signinicant bruising or cephalhematoma, which increases bilirubin production -Infections such as TORCH (toxoplasmosis, hepatitis B, rubella, cytomegalovirus, herpes simplex virus) -Use of drugs during labor and birth such as diazepam (Valium) or oxytocin (Pitocin) -Prematurity -Gestational age of 34 to 36 weeks -Hemolysis due to ABO incompatibility or Rh isoimmunization -Macrosomic infant of a diabetic mother -Delayed cord clamping, which increases the erythrocyte volume -Decreased albumin binding sites to transport unconju-gated bilirubin to the liver because of acidosis -Delayed meconium passage, which increases the amount of bilirubin that returns to the unconjugated state and can be absorbed by the intestinal mucosa -Siblings who had signinicant jaundice -Inadequate breastfeeding leading to dehydration, decreased caloric intake, weight loss, and delayed passage of meconium -Ethnicity, such as Asian American, Mediterranean, or Native American -Male gender

Prematurity: GI System

-Poor sucking. -Small stomach capacity. -weak abdominal muscles. -compromised metabolic function. -limited ability to digest and absorb nutrients. -Usually require IV or tube feedings. -0.5 to 1 mL/kg/h, of enteral feeding to induce surges in gut hormones that enhance maturation of the intestine.

Preoperative Care: Cesarean Birth

-Preparing the surgical site as ordered. -Starting an intravenous infusion for fluid replacement therapy as ordered. -Inserting an indwelling (Foley) catheter and informing the client about how long it will remain in place (usu-ally 24 hours). -Administering any preoperative medications as ordered; documenting the time administered and the client's reaction.

Intraventricular hemorrhage (IVH): Risk Factors

-Preterm birth - Low birth weight -Acidosis -Asphyxia -Unstable blood pressure -Seizures -Acute blood loss or hypovolemia -Respiratory distress with mechanical ventilation, intubation, apnea, hypoxia, or suctioning -Use of hyperosmolar solutions or rapid volume expansion

Vaginal birth after cesarean (VBAC): Contraindications

-Prior classic uterine incision -Prior transfundal uterine surgery (myomectomy) -Uterine scar other than low-transverse cesarean scar -Contracted pelvis -Inadequate staff or facility if an emergency cesarean birth in the event of uterine rupture is required.

Providing Support: Fetal Demise

-Provide accurate, understandable information to the family. -Be knowledgeable about the grief process and comfortable in sharing another's grief. -Utilize active listening to provide needed encouragement to the family members to open up to their feelings. -Create a warm, receptive, accepting, and caring environment conducive to dialogue. -Encourage discussion of the loss and venting of feelings of grief and guilt. - Provide the family with baby mementos and pictures to validate the reality of death. -Allow unlimited time with the stillborn infant after birth to validate the death; provide time for the family members to be together and grieve; offer the family the opportunity to see, touch, and hold the infant. -Use appropriate touch, such as holding a hand or touching a shoulder. -Inform the chaplain or the religious leader of the family's denomination about the death and request his or her presence. -Assist the parents with the funeral arrangements or disposition of the body. -Provide the parents with brochures offering advice about how to talk to other siblings about the loss. -Refer the family to the support group SHARE Pregnancy and Infant Loss Support, Inc., which is designed for those who have lost an infant through abortion, miscarriage, fetal death, stillbirth, or other tragic circumstances. -Make community referrals to promote a continuum of care after discharge.

Teaching: Alcohol

-Provide education that decreasing or eliminating alcohol consumption during pregnancy is the only way to prevent fetal alcohol syndrome and fetal alcohol effects. -Assist pregnant woman in finding a treatment program if possible -Inform all women who are pregnant or planning to become pregnant about the detrimental effects of alcohol during pregnancy -Educate women using a nonjudgmental, culturally connected approach -Warn women that there is no safe time to drink or amount of alcohol they can consume

Dinoprostone (Cervidil insert; Prepidil gel): Implications

-Provide emotional support. -Administer pain medications as needed. -Frequently assess degree of effacement and dilation. -Monitor uterine contractions for frequency, duration, and strength. -Assess maternal vital signs and FHR pattern frequently. -Monitor woman for possible adverse effects such as headache, nausea and vomiting, and diarrhea.

Persistent pulmonary hypertension of the newborn: Interventions

-Provide immediate resuscitation after birth and ad-minister oxygen therapy as ordered. Early and effective resuscitation and correction of acidosis and hypoxia are helpful in preventing persistent pulmonary hypertension. -Monitor arterial blood gases frequently to evaluate the effectiveness of oxygen therapy. -Provide respiratory support, which frequently necessitates the use of mechanical ventilation. -Administer prescribed medications, monitor cardiopulmonary status, cluster care to reduce stimulation, -Provide ongoing support and education to the parents.

Transient tachypnea of the newborn (TTN): Interventions

-Providing adequate oxygenation and determining whether the newborn's respiratory manifestations appear to be resolving or persisting. -Provide supportive care while the retained lung fluid is reabsorbed. -Administer intravenous (IV) fluids and/or gavage feedings until the respiratory rate decreases enough to allow safe oral feeding. -Provide supplemental oxygen via a nasal cannula or oxygen hood to maintain adequate oxygen saturation. -Maintain a neutral thermal environment with minimal stimulation to minimize oxygen demand. -Provide ongoing assessment of the newborn's respiratory status. -As TTN resolves, the newborn's respiratory rate declines to 60 breaths per minute or less, the oxygen requirement decreases, and the chest x-ray shows resolution of the perihilar streaking. -Provide reassurance and progress reports to the parents to help them cope with this crisis.

Assisting Families to Deal with Perinatal Death: At the time the body is released.

-Reassure the family that their feelings and grieving responses are normal. -Encourage the parents to have a funeral or memorial service to bring closure. -Suggest that the parents plant a tree or flowers to remember the infant. -Address attachment issues concerning subsequent pregnancies. -Provide information about local support groups. -Provide anticipatory guidance regarding the grieving process. -Present information about any impact on future childbearing, and refer the parents to appropriate specialists or genetic resources.

Assisting Families to Deal with Perinatal Death: Before Death

-Respect variations in the family's spiritual needs and readiness. -Assess cultural beliefs and practices that may bring comfort; respect culturally appropriate requests for truth telling and informed refusal. -Initiate spiritual comfort by calling the hospital clergy if appropriate; offer to pray with the family if appropriate. -Encourage the parents to take photographs, make memory boxes, and record their thoughts in a journal. -Explore with family members how they dealt with previous losses. -Discuss techniques to reduce stress, such as meditation and relaxation. -Recommend that family members maintain a healthy diet and get adequate rest and exercise to preserve their health. -Participate in early and repeated care conferencing to reduce family stress. -Allow family to be present at both medical rounds and resuscitation; provide explanations of all procedures, treatments, and findings; answer questions honestly and as completely as possible. -Provide opportunities for the family to hold the newborn if they so choose. -Assess the family's support network. -Provide suggestions as to how friends can be helpful to the family.

Challenges Facing Late Preterm Newborns

-Respiratory distress (related to pulmonary immaturity, lack of adequate surfactant, retained lung fluid, cesarean section) -Thermoregulation issues (less brown and white, limited ability to flex the trunk and extremities to decrease exposed surface area) -Hypoglycemia related to the first two challenges (respiratory distress and cold stress) -Apnea (related to poor respiratory control and immaturity) -Jaundice and hyperbilirubinemia (related to immature bilirubin conjugation and excretion) -Feeding challenges related to immature suck and swallowing reflexes -Sepsis because maternal antibodies are not fully transferred prior to the 37th week -Neurodevelopmental delay (related to brain and central nervous system immaturity)

Interventions: Reducing Parental Anxiety

-Reviewing with them the events that have occurred since birth -Providing simple relaxation and calming techniques (visual imagery, breathing) -Exploring their perception of the newborn's condition and offering explanations -Validating their anxiety and behaviors as normal reactions to stress and trauma -Providing a physical presence and support during emotional outbursts -Exploring the coping strategies they used successfully in the past and encouraging their use now -Encouraging frequent visits to the NICU -Addressing their reactions to the NICU environment and explaining all equipment used -Identifying family and community resources available to them

Interventions: Excessive Fetal Size and Abnormalities

-Scheduled cesarean birth if diagnosis is made before the onset of labor to reduce the risk of injury to both the newborn and the mother. -If identifed by Leopold's maneuvers, possible trial of labor to evaluate progress; however, providers usually opt to proceed with a cesarean birth in a primi-gravida with a macrosomic fetus. -Assess for inability of fetus to descend. -Anticipate need for vacuum and forceps-assisted births (common). -Plan for cesarean birth if maternal parameters are inadequate to give birth to large fetus.

Diagnosis: Problems with the Passageway

-Shortest A-P diameter <10 cm or greatest transverse diameter <12 cm. (Approximation of A-P diameter via measurement of diagonal conjugate, which in the contracted pelvis is <11.5 cm.) -X-ray pelvimetry to determine the smallest A-P diameter through which the fetal head must pass. -Interischial tuberous diameter of <8 cm possibly compromising outlet contracture (outlet and mid-pelvic contractures frequently occur together).

Prematurity: Renal System

-Slow GFR -Inability to concentrate urine. -Risks for fluid retention, F &E Imbalances. -Increased risk for drug toxicity, watch meds.

Manifestations: Uterine Rupture

-Sudden Fetal Distress -Other signs may include acute and continuous abdominal pain with or without an epidural. -Vaginal bleeding, hematuria, irregular abdominal wall contour -loss of station in the fetal presenting part -hypovolemic shock in the woman, fetus, or both

Newborn Pain Assessment

-Sudden high-pitched cry -Facial grimace with furrowing of brow and quivering chin -Increased muscle tone -Oxygen desaturation -Body posturing, such as squirming, kicking, arching -Limb withdrawal and thrashing movements -Increase in heart rate, blood pressure, pulse, and respirations -Fussiness and irritability

Manifestations: Placenta Previa

-Sudden, painless bleeding (that may be heavy enough to be considered hemorrhaging) -Anemia, pallor, hypoxia, low blood pressure, tachycardia, soft and nontender uterus, and rapid, weak pulse. -Bleeding may be episodic, with spontaneous initiation and cessation; in some cases, it is asymptomatic.

Nursing Care: Phototherapy

-Support parents, encouraging them to interact with their infant. -Support breastfeeding with one-on-one instruction and patience. -Place infants on their back to expose as much naked skin as possible. -Provide eye care/protection every time the infant is exposed to the light. -Check temperature and environment around infant to prevent overheating. -Take daily weights to make sure the infant isn't becoming dehydrated.

Management: Amniotic Fluid Embolism

-Supportive measures: oxygenation (resuscitation and 100% oxygen), circulation (IV fluids, inotropic agents to maintain cardiac output and blood pressure), control of hemorrhage and coagulopathy (oxytocic agents to control uterine atony and bleeding) -Seizure precautions, and administration of steroids to control the inflammatory response. -Monitor vital signs, pulse oximetry, skin color, and temperature and observe for clinical signs of coagulopathy (vaginal bleeding, bleeding from IV site, bleeding from gums).

Prematurity: Respiratory System

-Surfactant deficiency, leading to the development of respiratory distress syndrome. -Unstable chest wall, leading to atelectasis -Immature respiratory control centers, leading to apnea -Smaller respiratory passages, leading to an increased risk for obstruction -Inability to clear fluid from passages, leading to transient tachypnea

Persistent pulmonary hypertension of the newborn: Assessment

-Tachypnea within 12 hours after birth. -Observe for marked cyanosis, grunting, respiratory distress with tachypnea, and retractions. -Auscultate the heart, noting a systolic ejection harsh sound (tricuspid insufFIciency murmur), and measure blood pressure for hypotension resulting from both heart failure and persistent hypoxemia -Measure oxygen saturation via pulse oximetry and report low values. -Prepare the newborn for an echocardiogram, which will reveal right-to-left shunt-ing of blood that conrms the diagnosis.

Interventions: Breech Presentation

-The optimal method of birth is controversial: cesarean birth by some providers unless the fetus is small and the mother has a large pelvis; vaginal birth by others with each occurrence treated individually and labor monitored very closely. -Regardless of the birth method selected, the risk for trauma is high. Breech vaginal births are not recommended by ACOG and come with a higher risk to the mother and infant than a planned surgical birth. Vaginal delivery: fetus allowed to spontaneously deliver up to the umbilicus; then maneuvers to assist in the delivery of the remainder of the body, arms, and head; fetal membranes left intact as long as possible to act as a dilating wedge and to prevent cord prolapse; anesthesiologist and pediatrician present. -Assess for associated conditions such as placenta previa, hydramnios, fetal anomalies, and multifetal pregnancy. -Arrange for ultrasound to confirm fetal presentation. -Assist with external cephalic version possible after 36 weeks and administer tocolytics to assist with external cephalic version. -Anticipate trial labor for 4 to 6 hr to evaluate progress if version is unsuccessful. -Plan for cesarean birth if no progress is seen or fetal distress occurs. -After external cephalic version, administer RhoGAM to the Rh-negative woman to prevent a sensitization re-action if trauma has occurred and the potential for mixing of blood exists. -Cesarean birth; use of external cephalic version to reduce the chance of breech presentation at birth; attempted after the 36th week of gestation but before the start of labor (some fetuses spontaneously turn to a cephalic presentation on their own toward term, and some will return to the breech presentation if external cephalic version is attempted too early; variable success rates, with risk for fractured bones, ruptured viscera, abruptio placentae, fetomaternal hemorrhage, and umbilical cord entanglement. -Tocolytic drugs to relax the uterus, as well as other methods, to facilitate external cephalic version at term. -Individual evaluation of each woman for all factors before any interventions are initiated.

Interventions: Hypertonic Uterine Dysfunction

-Therapeutic rest with the use of sedatives to pro-mote relaxation and stop the abnormal activity of the uterus. -Identifcation and interven-tion of any contributing factors.Ruling out abruptio placen-tae (also associated with high resting tone and per-sistent pain). -Onset of a normal labor pattern occurs in many women after a 4- to 6-hr rest period. -Institute bed rest and sedation to pro-mote relaxation and reduce pain. -Assist with measures to rule out fetopelvic disproportion and fetal malpresentation. -Evaluate fetal tolerance to labor pattern, such as monitoring of FHR patterns. -Assess for signs of maternal infection. -Promote adequate hydration through IV therapy. -Provide pain management via epidural or IV analgesics.Assist with amniotomy to augment labor. -Explain to woman and family about dysfunctional pattern. -Plan for operative birth if normal labor pattern is not achieved.

Interventions: Problems with the Psyche

-Treatment dependent on woman's responses such as anxiety, fear, anger, frustration, or denial (highly variable due to woman's understanding of the condition itself, past experiences, previous coping mechanisms, and the amount of family and nursing support received). -Appropriate medical or surgical interventions depending on the underlying condition. -Provide comfortable environment—dim lighting, music. -Encourage partner to participate. -Provide pain management to reduce anxiety and stress. -Ensure continuous presence of staff to allay anxiety. -Provide frequent updates concerning fetal status and progress. -Provide ongoing encouragement to minimize the woman's stress and help her to cope with labor and to promote a positive, timely outcome. -Assist in relaxation and comfort measures to help her body work more effectively with the forces of labor. -Engage the woman in conversation about her emotional well-being; offer anticipatory guidance and reassurance to increase her self-esteem and ability to cope, decrease frustration, and encourage cooperation.

Management: Uterine Rupture

-Urgent delivery by cesarean birth is usually indicated. -Monitor maternal vital signs and observe for hypotension and tachycardia, which might indicate hypovolemic shock. -Assist in preparing for an emergency cesarean birth by alerting the operating room staff, anesthesia provider, and neonatal team. -Insert an indwelling urinary (Foley) catheter if one is not in place already. -Inform the woman of the seriousness of this event and remind her that the health care staff will be working quickly to ensure her health and that of her fetus. -Remain calm and provide reassurance that everything is being done to ensure a safe outcome for both.

Nifedipine (Procardia): Nursing Implications

-Use caution if giving this drug with magnesium sulfate because of increased risk for hypotension. -Monitor blood pressure hourly if giving with magnesium sulfate; report a pulse rate >110 bpm. -Monitor for fetal effects such as decreased uteroplacental blood flow manifested by fetal bradycardia, which can lead to fetal hypoxia. -Monitor for adverse effects, such as flushing of the skin, headache, transient tachycardia, palpitations, postural hypertension, peripheral edema, and transient fetal tachycardia. -Contraindicated in women with cardiovascular disease or hemodynamic instability.

Assessment: Omphalocele/Gastrochisis

-Usually detected on prenatal ultrasound exams. -Eviscerated bowel without peritoneal covering— gastroschisis -Eviscerated bowel with peritoneal covering— omphalocele -Search for additional anomalies if omphalocele is diagnosed

Teaching: Signs and Symptoms Preterm Labor

-Uterine contractions, cramping, lower back pain. -Feeling of pelvic pressure or fullness. -Increase in vaginal discharge. -Nausea, vomiting, and diarrhea. -Leaking of fluid from vagina. If you are experiencing any of these signs or symp-toms, do the following: -Stop what you are doing and rest for 1 hour. -Empty your bladder. -Lie down on your side. -Drink two to three glasses of water. -Feel your abdomen and make note of the hardness of the contraction. Call your health care provider and describe the contraction Mild if it feels like the tip of the nose Moderate if it feels like the tip of the chin Strong if it feels like your forehead

Interventions: Face and Brow Presentation

-Vaginal birth possible with face presentation with an adequate maternal pelvis and fetal head rotation; cesarean birth if head rotates backward. -Cesarean birth for brow presentation unless head flexes. -Assist with evaluating for fetopelvic disproportion. -Anticipate cesarean birth if vertex position is not achieved. -Explain fetal malposition to the woman and her partner. -Provide close observation for any signs of fetal hypoxia, as evidenced by late decelerations on the fetal monitor.

Interventions: Precipitate Labor

-Vaginal delivery if maternal pelvis is adequate. -Closely monitor woman with previous history. -Anticipate use of scheduled induction to control labor rate. -Administer pharmacologic agents, such as tocolytics, to slow labor. -Stay in constant attendance to monitor progress.

Patient Teaching: Labor Induction

-Your health care provider may recommend that you have your labor induced. This may be necessary for a variety of reasons, such as elevated blood pres-sure, a medical condition, prolonged pregnancy over 41 weeks, or problems with fetal heart rate patterns or fetal growth. -Your health care provider may use one or more methods to induce labor, such as stripping the mem-branes, breaking the amniotic sac to release the fluid, administering medication close to or in the cervix to soften it, or administering a medication called oxyto-cin (Pitocin) to stimulate contractions. - Labor induction is associated with some risks and disadvantages, such as overactivity of the uterus; nausea, vomiting, or diarrhea; and changes in fetal heart rate. -Prior to inducing your labor, your health care pro-vider may perform a procedure to ripen your cervix to help ensure a successful induction. -Medication may be placed around your cervix the day before you are scheduled to be induced. -During the induction, your contractions may feel stronger than normal. However, the length of your labor may be reduced with induction. -Medications for pain relief and comfort measures will be readily available. -Health care staff will be present throughout labor.

Necrotizing enterocolitis (NEC): Interventions

-maintaining fluid and nutritional status, providing supportive care, and teaching the family about the condition and prognosis. -Therapeutic management initially consists of bowel rest and antibiotic therapy. -Serial KUB x-rays and C-reactive protein levels are used to assess the resolution or progression of NEC. -If medical treatment fails to stabilize the newborn or if free air is present on a left lateral decubitus film, surgical intervention will be necessary to resect the portion of necrotic bowel while preserving as much of the intestinal length as possible. -Check stools for evidence of blood and report any positive findings. -Measure the abdominal girth. -Palpate the abdomen for tenderness and rigidity. -Auscultate for normal bowel sounds. -Observe the abdomen for redness or shininess, which indicates peritonitis.

Assessment: Esophageal Atresia/ Tracheoesophageal Fistula

-maternal history for hydramnios. Often this is the first sign of esophageal atresia because the fetus can-not swallow and absorb amniotic fluid in utero, leading to accumulation. -Soon after birth, the newborn may exhibit copious, frothy bubbles of mucus in the mouth and nose, accompanied by drooling. -Abdominal distention develops as air builds up in the stomach. -In esophageal atresia, a gastric tube cannot be inserted beyond a certain point because the esophagus ends in a blind pouch. -The newborn may have rattling respirations, excessive salivation, and drooling, and "the three C's" (coughing, choking, and cyanosis) if feeding is attempted.

Management: Placenta Previa

-monitor maternal vital signs, intake and output, vaginal bleeding, and physiologic status for signs of hemorrhage, shock, or infection. -closely monitor fetal heart tones for distress (e.g., bradycardia, tachycardia, baseline changes); and treat fetal distress, as ordered. -Administer prescribed IV fluids, packed RBCs, platelets, and frozen plasma for transfusion, if ordered; Rho(D) immune globulin, if the client is Rh negative; IV augmented oxytocin (Pitocin) to induce labor, if needed; and in cases of preterm labor, tocolytics (e.g., magnesium sulfate) to inhibit uterine contractions and corticosteroids (e.g., betamethasone) to enhance fetal lung maturity. -Follow facility pre- and postsurgical protocols if woman becomes a surgical candidate (e.g., for cesarean section); reinforce pre- and postsurgical education and ensure completion of facility's informed consent documents --Closely monitor postsurgically for bleeding, infection, and other complications; assess client's anxiety level and coping ability; and provide emotional support and reassurance.

Grief Process Accompanying Fetal Demise

1. Accepting the reality of the loss 2. Getting over suffering from the loss 3. Adapting to the new environment without the deceased 4. Emotionally relocating the deceased and getting on with life.

Resuscitating the Newborn

1. Stabilization—Dry the newborn thoroughly with a warm towel; provide warmth by placing him or her un-der a radiant heater to prevent rapid heat loss through evaporation; position the head in a neutral position to open the airway; clear the airway with a bulb syringe.or suction catheter; stimulate breathing. At times, handling and rubbing the newborn with a dry towel may be all that is needed to stimulate respirations. 2. Ventilation 3. Chest compressions 4. Administration of epinephrine and/or volume expansion.

Bishop's Score

13-point scale which evaluates cervical dilation, effacement, position, consistency, and station of presenting part. A score over 8 indicates a successful vaginal birth. Bishop scores of less than 6 usually indicate that a cervical ripening method should be used prior to induction.

Dysfunction Uterine Bleeding

90% Anovulatory: adol/perimenopause c irreg. bleeding rt unopposed estrogen, excess vasodilating prostaglandin PGE 10% Ovulatory: repro age c predictable prolonged excessive bleed rt inadequate amt vasoconstricting prostaglandin PGF Dx: HCG; cultures; CBC/diff; bleed/clot time; PT/PTT; thyroid; liver; BBT chart; progesterone pelvic evaluation- exam, endo biopsy, US, D&C, hysteroscopy

Respiratory distress syndrome (RDS)

A breathing disorder resulting from lung immaturity and lack of alveolar surfactant.

Persistent pulmonary hypertension of the newborn

A cardiopulmonary disorder characterized by marked pulmonary hypertension that causes right-to-left extrapulmonary shunting of blood and hypoxemia. Persistent pulmonary hypertension can occur idiopathically or as a complication of perinatal asphyxia, meconium aspiration syndrome, maternal smoking, maternal obesity, maternal asthma, pneumonia, congenital heart defects, metabolic disorders such as hypoglycemia, hypothermia, hypovolemia, hyperviscosity, acute hypoxia with delayed resuscitation, sepsis, and RDS.

Uterine Rupture

A catastrophic tearing of the uterus at the site of a previous scar into the abdominal cavity. Its onset is often marked only by sudden fetal bradycardia, and treatment requires rapid surgery for good out-comes. From the time of diagnosis to delivery, only 10 to 30 minutes are available before clinically significant fetal morbidity occurs. Fetal morbidity occurs secondary to catastrophic hemorrhage, fetal anoxia, or both.

Transient tachypnea of the newborn (TTN)

A condition involving a mild degree of respiratory distress. It is described as the retention of lung fluid or transient pulmonary edema. It usually occurs within a few hours of birth and resolves by 72 hours of age. TTN occurs in approximately 0.5% of all live births.

Esophageal Atresia

A congenitally interrupted esophagus where the proximal and distal ends do not communicate; the upper esophageal segment ends in a blind pouch and the lower segment ends a variable distance above the diaphragm.

Vacuum Extractor

A cup-shaped instrument attached to a suction pump used for extraction of the fetal head. The suction cup is placed against the occiput of the fetal head. The pump is used to create negative pressure (suction) of approximately 50 to 60 mm Hg. The birth attendant then applies traction until the fetal head emerges from the vagina.

Silverman-Anderson Index

A five item system for evaluating breathing of premature infants: 1) chest retraction 2) retraction of lower intercostal muscles 3) xiphoid retraction 4) nasal flaring on inhalation 5) grunt on exhalation. Each one is scored, low is best.

Imperforate Anus

A gastrointestinal system malformation of the anorectal opening and is identified in the newborn period. The rectum may end in a blind pouch that does not connect to the colon, or it may have fistulas (openings) between the rectum and the perineum (the vagina in girls or the urethra in boys) . Observe for appropriate anal opening, abdominal distention, and vomiting. Prepare for surgery.

Dystocia

A low and abnormal progression of labor. A difficult birth resulting from problems of the 5 P's, lack of progress in cervical dilation, delay in fetal descent, or change in uterine contraction characteristics. Occurs in 8-11% of all labors. Also called "Failure to Progress."

Bladder Exstrophy

A midline closure defect oc-curs during the embryonic period of gestation, leaving the bladder open and exposed outside of the abdomen. The bony pelvis may also be malformed, resulting in an opening in the pelvic arch. Bladder exstrophy may be diagnosed by prenatal ultrasound. Complications include UTI from ascending organisms. Treatment of bladder exstrophy involves surgical repair.

Macrosomia

A newborn weighs 4,000 to 4,500 g (8.13 to 9.15 lb) or more at birth, complicates approximately 10% of all pregnancies.

Asphyxia

A newborn who fails to establish adequate, sustained respiration after birth. Most common clinical insult in the perinatal period that results in brain injury, which may lead to mental retardation, cerebral palsy, or seizures.

Prolonged Pregnancy

A post-term or prolonged pregnancy is defined as a pregnancy that ex-tends to 42 0/7 weeks and beyond.

Oxytocin (Pitocin)

A potent endogenous uterotonic agent used for both artificial induction and augmentation of labor. Acts on uterine myofibrils to contract/to initiate or reinforce labor.

Ectopic Pregnancy

A pregnancy that develops outside of the uterus, usually in the fallopian tubes. Patients may not know that they are pregnant.

Amniotic Fluid Embolism

A rare and often fatal event characterized by the sudden onset of hypotension, hypoxia, and coagulopathy. Amniotic fluid containing particles of debris (e.g., hair, skin, vernix, or meconium) enters the maternal circulation and obstructs the pulmonary vessels, causing respiratory distress and circulatory collapse.

Necrotizing enterocolitis (NEC)

A serious gastrointestinal disease occurring in newborns. It is the most common and most serious acquired gastrointestinal disorder among hospitalized preterm neonates and is associated with significant acute and chronic morbidity and mortality. Ischemia and intestinal wall damage occur, allowing bacteria to invade. High-solute feedings allow bacteria to flourish. Mucosal or transmucosal necrosis of part of the intestine occurs.

Amnioinfusion

A technique in which a volume of warmed, sterile, normal saline or Ringer's lactate solution is introduced into the uterus through an intrauterine pressure catheter to increase the volume of fluid when oligohydramnios is present. It is used to change the relationship of the uterus, placenta, cord, and fetus to improve placental and fetal oxygenation. Instilling an isotonic glucose-free solution into the uterus helps to cushion the umbilical cord to prevent compression or dilute thick meconium.

Hyperbilirubinemia

A total serum bilirubin level above 5 mg/dL resulting from unconjugated bilirubin being deposited in the skin and mucous membranes. Hyperbilirubinemia is exhibited as jaundice (yellowing of the body tissues and fluids). Newborn jaundice is one of the most common reasons for hospital readmission.

Neonatal Sepsis

The presence of bacterial, fungal, or viral microorganisms or their toxins in blood or other tissues. Infections that have an onset within the first month of life are termed newborn infections.

Umbilical Cord Prolapse

The protrusion of the umbilical cord alongside (occult) or ahead of the presenting part of the fetus. This condition occurs in 1 out of every 300 births and requires prompt recognition and intervention for a positive outcome.With a 50% perinatal mortality rate, it is one of the most catastrophic events in the intrapartum period.

Molar Pregnancy

The terms complete mole and partial mole are used to describe the variations of molar pregnancies. With a complete mole, all placental villi are swollen and the fetus is absent. With a partial molar pregnancy, only some chorionic villi are swollen, and fetal tissues are present. They both frequently present with vaginal bleeding. The classic molar pregnancy may include vaginal bleeding and a uterus enlarged beyond the size expected for gestational age. Diagnosis may be suspected by an elevation of HCG greater than 100,000 mIU/ml.

Transvaginal Ultrasound/Cervical Length Evaluation

Three parameters are evaluated during the transvaginal ultrasound: cervical length and width, funnel width and length, and percentage of funneling. Measurement of the closed portion of the cervix visualized during the transvaginal ultrasound is the single most reliable parameter for prediction of preterm delivery in high-risk women.

Amenorrhea: Treatment

Treat underlying problem Surgery (testosterone producing tumor) Hormones: thyroxine, bromocriptine, progestin offsets unopposed estrogen, estrogen if deficient, combined options, cyclic/continuous, pulse GnRH Teach/ Refer: Nutrition; Physical Activity; Stress Management; Support

Treatment: Dysfunctional Uterine Bleeding

Tx Acute: estrogens IV>oral, progestins, hi-dose OCs, D&C Tx Chronic: hi-dose NSAIDs; antifibrinolytic tranexaminic acid/Lysteda; OCs cont/cyclic; progestins oral/ depot/ IUS; Danazol; GnRH agonists; endometrial ablation/ hysterectomy Teach: nutrition - iron; exercise effects; stress management; support

Hypertonic Uterine Dysfunction

Uterine contractions that are too long or too frequent, have too short a resting interval, or have an inadequate relaxation period to allow optimal uteroplacental exchange. Usually occurs in the latent phase of labor. Loss of downward function to push the fetus against the cervix. Increased pain, mom becomes discourages.

Contraindications: Amnioinfusion

Vaginal bleeding of unknown origin, umbilical cord prolapse, amnionitis, uterine hypertonicity, and severe fetal distress.

Transient tachypnea of the newborn (TTN): Pathophysiology

Vaginal delivery, squeezing, and pulmonary circulation and the lymphatic drainage remove the remaining fluid shortly after birth. TTN occurs when the liquid in the lung is removed slowly or incompletely.

Diagnosis: Breech Presentation

Vaginal examination to determine breech presentation. Ideally, ultrasound to confirm a clinically suspected presentation and to identify any fetal anomalies.

Cervical Lengths

Varies during pregnancy and can be measured fairly reliably after 16 weeks' gestation using an ultrasound probe inserted in the vagina. A cervical length of 3 cm or more indicates that delivery within 14 days is unlikely. Women with a short cervical length of 2.5 cm during the mid-trimester have a substantially greater risk of preterm birth prior to 35 weeks' gestation.

Assessment: Polycythemia in Newborns

Venous hematocrit >65%. Plethora (ruddy appearance). Weak sucking reflex Tachypnea Jaundice Lethargy Jitteriness Hypotonia Irritability Feeding difficulties Difficulty in arousing Seizures

WITHDRAWAL Acronym

WITHDRAWAL ACRONYM Assess the newborn for signs of neonatal abstinence syndrome using the acronym WITHDRAWAL to focus the assessment: W = Wakefulness: sleep duration less than 3 hours after feeding I = Irritability T = Temperature variation, tachycardia, tremors H = Hyperactivity, high-pitched persistent cry, hyperreflexia, hypertonus D = Diarrhea, diaphoresis, disorganized suck R = Respiratory distress, rub marks, rhinorrhea A = Apneic attacks, autonomic dysfunction W = Weight loss or failure to gain weight A = Alkalosis (respiratory) L = Lacrimation

Precipitate Labor

Abrupt onset of higher- intensity contractions occurring in a shorter period of time instead of the more gradual increase in frequency, duration, and intensity that typifies most spontaneous labors. Identification based on the rapidity of progress through the stages of labor.

Neonate Sepsis

Acquired bacterial or viral organisms from infected amniotic fluid, maternal infection, or direct contact while passing through the birth canal.

ABCD's of Newborn Resuscitation

Airway -Place infant's head in "sniffing" position. -Suction mouth, then nose. -Suction trachea if meconium-stained and newborn is NOT vigorous (strong respiratory effort, good muscle tone, and heart rate >100 bpm). Breathing -Use positive-pressure ventilation (PPV) for apnea, grasping, or pulse <100 bpm. -Ventilate at rate of 40 to 60 breaths/minute. -Listen for raising heart rate, audible breath sounds. -Look for slight chest movement with each breath. -Use carbon dioxide detector after intubation. Circulation -Start compressions if heart rate is <60 after 30 seconds of effective PPV. -Give 3 compressions: 1 breath every 2 seconds. -Compress one third of the anterior-posterior diameter of the chest. Drugs -Give epinephrine if heart rate is <60 after 30 seconds of compressions and ventilation. -Caution: Epinephrine dosage is different for endotracheal and IV routes! Epinephrine: 1:10,000 concentration 0.1 to 0.3 mL/kg IV 0.3 to 1 ml/kg via endotracheal tube

Fetal alcohol spectrum disorders (FASDs)

Alcohol-related neurode-velopmental disorder (ARND) and alcohol-related birth defects (ARBD). Children with ARND primarily display intellectual disabilities related to behavior and learning while children with ARBD may have birth defects of the heart, kidneys, and/or bones. The problems associated with any of the FASDs are lifelong and are entirely preventable by avoiding alcohol consumption during pregnancy.

Tracheoesophageal Fistula

An abnormal communication between the trachea and esophagus. When associated with esophageal atresia, the fistula most commonly occurs between the distal esophageal segment and the trachea.

Pathophisiology: Amniotic Fluid Embolism

An embolus occurs when the barrier between the maternal circulation and the amniotic fluid is broken and amniotic fluid enters the maternal venous system via the endocervical veins, the placental site (if the placenta is separated), or a site of uterine trauma.

Term Newborn

An infant born from the first day of the 38th week through 42 weeks.

Physiologic Jaundice

An unconjugated hyperbilirubinemia that occurs after the first postnatal day and can last up to 1 week. Total serum bilirubin concentrations peak in the first 3 to 5 postnatal days and decline to adult values over the next several weeks.

Implications: Perinatal Asphyxia

Anticipate possible problem; assess for maternal risk factors. Initiate resuscitation measures immediately at birth.

What makes a prolonged pregnancy dangerous?

As the placenta ages, its perfusion decreases and it be-comes less efficient at delivering oxygen and nutrients to the fetus. Amniotic fluid volume also begins to decline by 40 weeks of gestation, possibly leading to oligohydramnios, subsequently resulting in fetal hypoxia and an increased risk of cord compression because the cushioning effect offered by adequate fluid is no longer present. Hypoxia and oligohydramnios predispose the fetus to aspiration of meconium, which is released by the fetus in response to a hypoxic insult.

Assessment: PMS/PmDD

A—anxiety: difficulty sleeping, tenseness, mood swings, and clumsiness C—craving: cravings for sweets, salty foods, chocolate D—depression: feelings of low self-esteem, anger, easily upset H—hydration: weight gain, abdominal bloating, breast tenderness O—other: hot flashes or cold sweats, nausea, change in bowel habits, aches or pains, dysmenorrhea, acne breakout Affective liability: sadness, tearfulness, irritability Anxiety and tension Persistent or marked anger or irritability Depressed mood, feelings of hopelessness Difficulty concentrating Sleep dificulties Increased or decreased appetite Increased or decreased sexual desire Chronic fatigue Headache Constipation or diarrhea Breast swelling and tenderness

Late preterm newborn (near term)

Baby that is born between 34 weeks and 36 weeks, 6 days of gestation.

Terbutaline

Beta 2 agonist used to suppress premature labor, but cardiac stimulatory effects may be hazardous to mother and fetus.

Kernicterus

Bilirubin encephalopathy, a form of brain damage resulting from unconjugated bilirubin entering the brain. Characterized by lethargy, poor feeding, vomiting, irregular respiration, perhaps death.

Hyperbilirubinemia: Pathophysiology

Bilirubin levels rise in newborns by three main mechanisms: increased production (accelerated RBC breakdown), decreased removal (transient liver enzyme insufficiency), and increased reabsorption (delay in bowel excretion). Bilirubin production increases after birth mainly because of a shortened red blood cell lifespan (70 days in the newborn versus 90 days in the adult) combined with an increased red blood cell mass. Therefore, the amount of bilirubin the newborn must deal with is large compared to that of an adult.

Intraventricular hemorrhage (IVH)

Bleeding that usually originates in the subependymal germinal matrix region of the brain, often extending into the ventricular system.

Nifedipine (Procardia)

Blocks calcium movement into muscle cells, inhibits uterine activity to arrest preterm labor.

Menopausal Effects of Body Systems

Brain: hot flashes, disturbed sleep, mood and memory problems Cardiovascular: lower levels of high-density lipopro-tein (HDL) and increased risk of cardiovascular disease Skeletal: rapid loss of bone density that increases the risk of osteoporosis Breasts: replacement of duct and glandular tissues by fat Genitourinary: vaginal dryness, stress incontinence, cystitis Gastrointestinal: less absorption of calcium from food, increasing the risk for fractures Integumentary: dry, thin skin and decreased collagen levels Body shape: more abdominal fat; waist size that swells relative to hips

Complete Breech

Buttock as presenting part, with hips flexed and knees flexed in a "cannonball" position.

Frank Breech

Buttock as the presenting part, with hips flexed and legs and knees extended upward.

Hygiene and Toxic Shock Syndrome

Caution: douches, scent, soaps, oils Evaluate abnormal dc / odor / exposure TSS caused by Staph a. toxin, most assoc c tampon use during menses, ? Barrier S: T>38.9C/102F; GI; muscular myalgias; rash, palm/sole desquam; alt LOC Lab platelets<100,000; UAwbc; renal/liver Hospitalize, antibiotics; recur c menses

Arrest Disorders

Cessation of dilation or descent in the active phase of labor for more than one hour (descent) or two hours (dilation).

Chronic bilirubin encephalopathy or kernicterus

Characterized by four clinical manifestations: movement disorder (aethetosis, dystonia, spasticity, hypotonia), auditory dysfunction (deafness), oculomotor impairment, and dental enamel hypoplasia of deciduous teeth. Unconjugated bilirubin enters the brain and acts as a neurotoxin causing long-term neurologic sequelae.

Fetal alcohol syndrome (FAS)

Characterized by physical and mental disorders that appear at birth and remain problematic throughout the child's life.

Neonate Malformations

Congenital anomalies including facial or upper airway deformities, renal anomalies, pulmonary hypoplasia, neuromuscular disorders, esophageal atresia, or neural tube defects.

Intrauterine Fetal Demise

Death after 20 weeks, but before labor. Associated with HTN, DM, Erythroblastosis fetalis, Infections, Feto-maternal hemorrhage, Antiphospholipid antibodies, Hereditary thrombophilias. Dx by lack of fetal movement and absent cardiac activity on US.

Perinatal Loss

Death of a fetus or infant from the time of conception through the end of the newborn period 28 days after birth.

Preterm Labor

Defined as the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation. If not halted, it leads to preterm birth.

Shoulder Dystocia

Delivery of fetal head with neck not appearing; retraction of chin against the perineum; shoulders remaining wedged behind the mother's pubic bone, causing a difficult birth with potential for injury to both mother and baby. If shoulders still above the brim at this stage, no advancement. Newborn's chest trapped within the vaginal vault; chest unable to expand with respiration (although nose and mouth are outside).

Supporting Couple Coping

Depression, Losses, Stresses, Anger, Guilt Grieve losses, accept different coping Take time to hear how affecting both Own feelings, share, ask for what they need Nurture relationship, Take a vacation Be reasonable in expectations Explore options: adoption / child-free educate + support, refer www.resolve.org

Premenstrual Dysphoric Disorder

Describes a constellation of recurrent symptoms that occur during the luteal phase or last half of the menstrual cycle and resolve with the onset of menstruation .

Vaginal birth after cesarean (VBAC)

Describes a woman who gives birth vaginally after having at least one previous cesarean birth.

Acute bilirubin encephalopathy

Describes the effects of hyperbilirubinemia in the first weeks of life. Clinical signs include lethargy, poor feeding, poor tone, a poor Moro reflex with incomplete flexion of the extremities, and a high-pitched cry. As symptoms of acute bilirubin encephalopathy worsen, the newborn pro-gresses to apnea, seizures, coma, and death.

Diagnosis: Face and Brow Presentation

Diagnosis only once labor is well established via vaginal examination; palpation of facial features as the presenting part rather than the fetal head.

Dinoprostone (Cervidil insert; Prepidil gel)

Directly softens and dilates the cervix/to ripen cervix and induce labor. FDA approved for cervical ripening.

Neonatal abstinence syndrome

Drug dependency acquired in utero is manifested by a constellation of neurologic and physical behaviors.

Medications affecting Neonate

Drugs given to mother during labor that can affect the fetus by causing placental hypoperfusion and hypotension; use of hypnotics, analgesics, anesthetics, narcotics, oxytocin, and street drugs during pregnancy.

Preterm Newborn

a newborn born before completion of 37 weeks.

Post-term Newborn

baby born after completion of 42 weeks.

Contraindications: Labor ,

complete placenta previa abruptio placentae transverse fetal lie prolapsed umbilical cord a prior classic uterine incision that entered the uterine cavity pelvic structure abnormality previous myomectomy vaginal bleeding with unknown cause invasive cervical cancer active genital herpes infection abnormal FHR patterns

Appropriate for gestational age (AGA)

describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age. Infants who are appropriate for gestational age have lower morbidity and mortality than other groups.

Small for gestational age (SGA)

describes newborns that typically weigh less than 2,500 g (5 lb 8 oz) at term due to less growth than expected in utero. A newborn is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation.

Large for gestational age (LGA)

describes newborns whose birthweight is above the 90th percentile on a growth chart and who weigh more than 4,000 g (8 lb 13 oz) at term due to accelerated growth for length of gestation.

Omphalocele

is a defect of the umbilical ring that allows evisceration of the abdominal contents into an external peritoneal sac. Defects vary in size; they may be limited to bowel loops or may include the entire gastrointestinal tract and liver. Bowel malrotation is common, but the displaced organs are usually normal.

Gastroschisis

is a herniation of the abdominal contents through an abdominal wall defect, at the umbilicus. Gastroschisis differs from omphalocele in that there is no peritoneal sac protecting the herniated organs, and thus exposure to amniotic fluid makes them thickened, edematous, and inflamed.

Extremely low birthweight

less than 1,000 g (2 lb 3 oz)

Very low birthweight

less than 1,500 g (3 lb 5 oz)