OB FINAL
A nurse is assessing a postpartum client who was prescribed *methylergonovine (Methergine)*. The nurse should know that the medication was effective when the client has...
*A. a firm fundus* (Methergine is an oxytocin medication that is given to promote uterine contractions This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution, so the desired effect following a dose is an increase in uterine tone.) B. a rise in blood pressure C. an increase in lochia D. a decrease in breast discomfort
Woman over 35 who smoke or have CV disease..
*AVOID* combination oral contraceptives -Progestin-only pill or IUD may be okay
Male hypogonadism (Low T)
*Androgen* Decrease libido, aging, congenital, decrease volume of ejaculation, erectile dysfunction, muscle wasting *serious need for thorough diagnosis: other causes - diabetes, depression, thyroid
Verbal signs of anxiety
*Anger* Quavering voice Giggling Mumbling Rapid speech Defensive words
Additional procedures for hemorrhage
*Assess: first step is palpation* Uterine ballon Uterine artery ligation Uterine artery embolization Hysterectomy Uterine massage IV O2 Labs
*Folic Acid*
*B9* vitamin: assists in cell production and division including RBCs *Fetal development*: helps neural tube to grow and close -Oral contraceptives *decrease* folic acid levels
Hormone Replacement Therapy
*BLACK BOX WARNING* -Do not use for CV protection -E used alone= uterine cancer -E + P= CV events *Order at lowest dose for shortest amount of time* *"Natural" hormone (BIH) products carry SAME risks*
*Epidural management*
*Biggest risk*: HYPOTENSION -fluid bolus IV prior to procedure -BP cuff stays on, set for q15 min -VS frequently -Temp may elevate to 100 *Checking level of pain relief (dermatomes);* *DANGEROUS IF RISING:* hard time breathing, numbness in arms, hands, fingers
MAJOR reasons during the prenatal period for *hospital assessment*
*Bleeding - assess cause, usually ultrasound* -spontaneous abortion (miscarriage) -placental abruption -placental previa *Leaking fluid* -diagnose with sterile speculum exam -positive nitrazine test, ferrying, pooling, and Amnisure test *Premature labor* -contractions >5/hr, backache, pressure, frequent urination, increased mucoid discharge, cervical dilation -Fetal Fibronection (fFn) test *Significantly decreased/absent fetal movement* -fetal alarm signal: fetal movements cease for >12 hrs -less than 3 fetal movements in an hour warrants further investigation
HTN affects ALL organ systems
*Brain* - HA, mentation changes, confusion *Cardiovascular* - HTN *Liver* - epigastric pain, increased liver enzymes *Kidney* - oliguria, proteinuria *Placenta* - poor circulation, abruption *Eyes/retina* - blurred, double, scotomata
3 levels to teaching
*Cognitive* *Affective* (rarely addressed) - relating to moods, feelings, and attitudes *Psychomotor* (rarely evaluated)
APGAR score measures what?
*Color*: all blue/pale - pink body blue ext - all pink *Heart rate*: absent - <100 bpm - >100 bpm *Respiration*: absent - irregular/slow - good/crying *Reflex response *: none - grimace - sneeze/cough *Muscle tone*: limp - some flexion of ext - active
*Live vaccines*
*Contraindicated* in all immune-compromised/pregnant people -MMR -Varicalla -Intranasal mist for flu
BUBBL*E*SH
*E*motional adjustment - trend is what matters *E*pisiotomy: perineum (laceration, hemorrhoids - a swollen vein or group of veins in the region of the anus) *E*xtremities - edema, strength
*Lethal* HTN
*Eclampsia* *HELLP syndrome* -hemolysis -elevated liver enzymes -low platelets -liver rupture/hemorrhage *DIC*
*Nutrition*
*FIRST INDICATOR* of attachment issues and other psychological and emotional problems.. If they are not eating enough, ask them what they think about their body and pregnancy
Postpartum hemorrhage treatment
*FIRST step is palpation* *if Hct is below 30%, pulse O2 is POINTLESS! Look at their color* -trendelenberg or flat supine position -uterine massage *non-rebreather mask @ 10-15L/min* Labs: CBC, coagulation studies..have RBCs on hand
Ballard Score
*First*: estimate weeks gestation by evaluating both neuromuscular findings & general physical signs. *Second*: plot the measurements (weight, length, & head circumference) against the estimated age.
Nonverbal signs of anxiety
*Gaze aversion* Nail biting Foot tapping Sweating Pacing Body orientation
Common initial *triad*
*Guilt* *Blame* *Anger*
*HELLP* syndrome
*H*- *Hemolysis* (which is the breaking down of red blood cells) *EL*- *Elevated liver enzymes* *LP*- *Low platelet count* *fetal death 7-35%* -70% antepartum -30% postpartum -HTN absent is 20-25% of cases -Risk of death/fetal death, liver rupture, abruption -20% with HELLP get DIC
BUBBLES*H*
*H*ematological - pg and PP Hct/hgb, prenatal labs *H*ome (prep/support) *Homan's no (check for DVTs-warmth, redness swelling, pain*
Major PP complications
*Hemorrhage* *Coagulopathies* -Idiopathic thrombocytopenia purpura, DIC (bleeding a lot & clotting a lot) *Postpartum infections*
Phototherapy
*Hydrate, q2-3 hr feeds, increase protein* *Tendency to get overheated, or if exposed, cold* *Stimulates bowel* *Safety:* cover eyes & genitals, no oils or lotions, no "basting"
Dysfunctional labor-power problems
*Hypertonic*: painful uncoordinated contractions, usually *1st labors* *Hypotonic*: most common, weak contractions
*Prochaska Model*
*Incremental progressive steps:* -pre-contemplation -contemplation -preparation -action -maintenance *Non-linear* change process;* relapses are expected* parts of the process
Weight gain goals based on BMI
*Low BMI* = *28-40 lbs* *Normal BMI* = *25-35 lbs* *High BMI* = *15-25 lbs* *Obese* = *at least 15 lbs* *Twins* = *35-45 lbs* *Triplets* = *50 lbs*
Hypertension *Sequelae*
*Maternal*: -seizures -placental abruption -retinal detachment -renal failure -cerebral hemorrhage -HELLP (liver rupture) *Fetus*: -growth retardation -chronic hypoxemia (high Hct) -acute hypoxemia -death
Diabetes complications...
*Maternal*: *comorbidity 30%* -ketoacidosis -hypoglycemia -infection -hemorrhage *Newborn*: *hypoglycemia* -macrosomia..birth injury
Mild, moderate, & Severe signs of *respiratory distress*
*Mild*: flared nares, pale. *Moderate*: poor feeding, subcostal retractions, restlessness, weak cry, pale mucous membranes *Severe*: intercostal,sternal, or nuchal retractions, end expiratory grunting, stridor, hypotonia, poor response to pain, "asleep", cyanosis
Medicinal induction
*Misoprostol* (Cyctotec)-vaginal *Pitocin* NOT found to be appropriate as labor inducer if the cervix is not ripe..
Natural induction
*Noninvasive* Herbs..may or may not ripen cervix Acupressure points Hot baths Breast stimulation Sex/climaxing
*PURPLE*
*P* peak of crying *U* unexpected *R* resists soothing *P* pain-like face *L* long lasting *E* evening
Screening in childbearing women
*Papanicolaou (pap)* smear for cervical cancer *Chlamydia, gonorrhea, syphilis, HIV, rubella (antibodies)* Visual exam for *HPV, HSV*
Hyperbilirubinemia- *TYPES*
*Physiologic* -peaks 3-4 days -lacking liver enzymes, can't bind to protein to help excrete through stool *Pathologic* -peaks 2 days (blood incompatibilities) -peaks 3-5 days (birth injury) *"Breast milk jaundice"* -lack of breast milk -hormonal (peaks 7-10 days)
Prevention/treatment for hyperbilirubinemia
*Prevention* -Hydrations, frequent feeding, early identification *Treatment* -Hydration, phototherapy -Last resort is exchange transfusion (via umbilical cord)
Shoulder Dystocia
*RISKS*: - related to birthweight -fetal macrosomia -gestational diabetes -prior shoulder dystocia *SIGNS*: prolonged 2nd stage, recoil of head on perineum at delivery (*turtle sign*) ...possible cord compression EMERGENCY!!!
Specific concerns in prematurity
*Respiratory* -Uterine hypoxemia/asphyxia -Respiratory distress syndrome (insufficient surfactant which has to be administered through endotracheal tube) -Transient Tachypnea (abnormally rapid breathing) of Newborn (TTN) (c/s)--goes to NICU -Meconium aspiration syndrome -Apnea (temporary cessation of breathing, especially during sleep)
BUBBLE*S*H
*S*ocial support *S*kills - selfceare (adequately perform ADLs), newborn care (competency in safety, feeding, resources, behavior)
Antidepressants Anxiolytics Antiepileptic/Mood stabilizers Antipsychotics
*SSRIs*: mostly category C *Paxil (paroxetine)*: category D *Benzodiazepines*: category D/Lactation 3 or 4 *Lithium*: category D/Lactation 4 *Valproic Acid*: category D *Haldol*: category C *clozapine*: category B
Uterus (afterbirth)
*Soft*: increased risk for bleeding (should be firm) *midline* Down 1cm per day (if goes up instead of contracting down means it is hemorrhaging)
*Abruption*
*Sx*: marginal=painless abdomen, concealed=constant pain in abdomen Tense or distended abdomen Brown bleeding Right shoulder pain Possible fetal changes (signs of fetal distress) *IF SERIOUS (large partial or concealed): DELIVER*
*Ectopic* pregnancy
*Sx:* localized abdominal pain, infection *Tx:* Surgery (removal of tube), methotrexate IM if not ruptured, early detected.. RAPID ONSET: tube bursts -> sepsis -> peritonitis -> death
What are the *4* T's of hemorrhage?
*T*one *T*issue *T*rauma *T*hrombin
Causes of *Intrapartum* bleeding: *4Ts*
*T*one: uterine atony (1/20 deliveries) *T*issue: retained placental tissue *T*rauma: uterine, cervical/vag. lacerations (hematoma) *T*hrombin: coagulation disorders
Abortion by progression
*Threatened*: possible (spotting) *Imminent*: expected (dilated 4+) *Partial (incomplete)*: not all products are passed (placenta..) requires procedure *Complete*: all products bypassed *Missed*: confirmed abortion, but unaware at time
Risks for postpartum bleeding
*UTERINE ATONY* 70-80% of PPH Old age Infection Multiple births Prior hemorrhage Large baby Low platelet count GDM Overuse of pitocin Mg. Sulfate
*Finasteride* (Proscar) 5-Alpha-Reductase-Inhibitors
*Use*: Benign Prostatic Hyperplasia, PO daily for life Takes 6-12 months to work Can treat male baldness!
*Tamsulosin* (Flomax)
*Use:* Benign Prostatic Hyperplasia, PO daily for life Selective: does *not* affect *BP* or *PSA* levels (prostate specific androgen)
Alpha 1 Antagonist *Tamsulosin (Flomax)*
*Use:* Benign Prostatic Hyperplasia, oral daily for life. Selective: does not affect BP or PSA levels
5-Alpha-Reductase Inhibitors *Finasteride (Proscar)*
*Use:* Benign Prostatic Hyperplasia, oral daily for life. Takes 6-12 months to work Can treat male baldness ADE: decreased libido in 10% and gynecomastia *PSA level should be checked prior and again in 6 months*
*Oxytocin (Pitocin)*
*Use:* Uterine stimulant (IM,IV) -Within 1 min of delivery (part of AMTSL) Keep refrigerated *ADE:* hypotension, hypertension, *tetanic contractions* (2 min contraction) or tachysystole (5+ contractions in 10 min), *fetal hypoxia*, *uterus rupture* *Nursing:* -PUMP only -Continuous monitoring -only give if mom & baby are healthy -TURN OFF Pitocin if fetal distress *keep IV open & running*
*RhoGam-D*
*Use:* When mom is Rh- and newborn is Rh+, to protect future pregnancies -Within 72 hrs of birth -IM -Give card for wallet & teach for future pregnancies
*Misoprostol (Cytotec)* [prostaglandin, UTERINE STIMULANT]
*Uses:* PP Hemorrhage- up the a$$ Cervical ripening- up the vag Contraindicated: CV disease, ASTHMA ADE: N/V, diarrhea, HTN, bronchospasm, anaphylaxis, uterine rupture, thinning of membranes *Nursing:* Pt. should be laying down in recumbent position & observed for 30 min for any bronchospasm
What causes 80% of postpartum hemorrhage?
*Uterine atony* -over-distended uterus (large gestational age, multiples, polyhydramnios) -History of over-stretching -Muscle fatigue (pitocin or MgSO4)
Hyperbilirubinemia
*What causes it?*: -RBC destruction/liver abnormalities -destruction of fetal cells -blood type incompatibilities -birth injury -dehydration -infection *natural resolution: bin to protein and pass through stool*
AMSTL
*active management of 3rd stage of labor* reduces PPH due to uterine atony by 60% *oxytocin within one minute of delivery* -fundal assessment q 15 min x 2 hours with massage prn -initiation of breastfeeding (produces oxytocin)
Symptoms of a pulmonary embolism
*anxiety* chest pressure dyspnea, tachypnea, cough hemoptysis (low O2 saturation) tachycardia hypoxia hypotension tx: O2, bedrest, analgesia,, IV heparin *NO ASPRIN or NSAIDS*
Emergency management of shoulder dystocia
*avoid* pushing, pulling, pivoting -Various maneuvers Can cause... Erb-Duchenne Palsy, clavicle fracture, meconium aspiration, fetal death, asphyxia (suffocation)
chorionic villi sampling
*done earlier, usually around 10-12 weeks* -CVS is offered to the same women as amniocentesis -cells collected in CVS procedure are from baby's pre-placenta *risk of ruptured membranes, bleeding, or infection is 1/150 (done in 1st trimester)* *results (chromosomal analysis) is generally available in 3-4 days* -CVS does not measure the amount of alpha feto protein in amniotic fluid, so consider triple or quad screen later
stages of labor
*first stage*: onset of regular contractions to full dilation of the cervix (three phase) 1. Latent (early) phase 2. Active phase 3. Transition phase *Second Stage*: from the full dilation of the cervix to the birth of the baby *Third Stage*: birth of the baby though the birth of the placenta
prenatal testing 2nd trimester
*glucose* -if random is over 100 --> 3 hr GTT -1 hr 50 gm glucose screening test... 26-28 weeks repeat Hct/hgb as needed ultrasound, 16-18 weeks, for fetal screening; earlier for dating or problems
*Bronchopulmonary dysplasia*
*injury to small airways/alveoli development, reduces overall surface for gas exchange* -Chronic oxygen hunger -psychosocial delay -altered nutrition -many meds -fluid restrictions -reflux -*Parenting problems!*
primary powers
*involuntary contractions* causing effacement, dilation, and descent of fetus
forces and vacuum extraction
*maternal complications* -lacerations -soft tissue hematoma *infant complications* -marked caput -cephalhematoma -subdural hematoma -scalp lacerations -neonatal jaundice from bruising
Medical Abortion
*methotrexate* - early, uncomplicated ectopic pregnancy *mifepristone (RU486)* - (used with miso) blocks receptors for progesterone/ NOT for use with ectopic pregnancies / within 7 weeks on conception *misoprostol* - ADES: cramping, uterine bleeding, N/V
fetal circulation
*mother* -> placenta -> umbilical vein (carries oxygenated blood to fetus) *fetus* -bypasses fetal liver (ductus venosus) -bypasses fetal lungs (foramen oval and ductus arteriosis) ---> umbilical arteries (2) carry waster products back to placenta to diffuse into maternal circulation
When to induce
*not before 39 weeks if at all possible*
Magnesium Sulfate- 3 primary indications where dosing/use differs...
*pre-eclampsia*: anticonvulsant *Prematur labor*: tocolytic (anti-contraction) *Imminent delivery of pre-term newborn (24-32 weeks)*: fetal neuro-protection
Protein intake during pg?
*pregnant/lactation*: 60-70g/day *non-pregnant*: 46g/day
perception of contractions
*premature*: may feel like back soreness or menstrual cramps *term*: starts in lower back and radiates around to the front of the belly
prematurity risk assessment
*prior premature delivery!!!!!* *age <18* *low socioeconomic status* many sexual partners -UTI/renal disease, acute infections -2 or more spontaneous abortions -thin patient or poor weight gain -multiple gestation -uterine anomalies or fibroids -polyhydramnios: excessive amniotic fluid
ROM
*priority assessment: FHR* assess and document: TACO - Time - Amount - Color (clear vs meconium stained) - Odor (foul- chorioamnioniitis) nursing care changes: -minimal or no pelvic exams -temp q4 -more frequent fetal monitoring
Prematurity: *Necrotizing enterocolitis (NEC)*
*redness, dissension, fullness, reverse peristaltic waves* -Enteral feedings (too much, too soon) -Gastric compromise (hypo-peristalsis/poor circulation) -Infection
Pica
*refer to WIC for follow up* Dirt, clay, starch, ice.. Can cause: Lead poisoning, parasitic infection, prematurity, anemia, low birth wt.
Breast (afterbirth
*soft* - usually until day 3-5 until milk "comes in"/matures *nipples* - everted (best), flat, inverted --> pinch test --> skin intact, red, blisters, bruising, bleeding? *LATCH score*
Gold standard for OP fetus
*ultrasound* 68% of OP at delivery were not OP at onset of labor -most fetuses who are OP at onset of labor will rotate
Plan B (levonorgestrel)
-Can use unto 5 days after unprotected sex *Does not terminate a pg or hurt an embryo if pg has occurred -Delays/stops ovulation/inhibits fertilization -17 or older behind the counter Effective 98%
Trigger "themes"
-Control & loss of control -Pain, injury, invasion -Dependency on partner -Mistrust of authority figures -Shame/being judged over body image, behavior, secretions -Exposure (modesty, people staring)
Behaviors that may suggest abusive history:
-Detailed (obsessive) birth plans -Trust issues with authority figures -Inability to tolerate vaginal exams -Extreme modesty -Dissociation during exams -Denial with known history *NEED TO ASK IN PATIENT HISTORY*
Estrogen
-Development and maintenance of female reproductive tract and secondary sex characteristics -Improves bone mass -Increases HDL, decreases LDL -Mixed effect on blood coagulation
Elective abortions
-Dilation & curettage (scraping) -Vacuum aspiration -Dilation & evacuation Nursing care post-procedure: assessment, teach, support, infection, bleeding, postpartum care, depression, anxiety, guilt, psyche reference
When breastfeeding...
-Do *not* take lithium -VPA & Tegretol (carbamazepine) are "probably safe" -*Benzodiazepines* are *questioned in lactation*
*PDE5Is* *Sildenafil (Viagra)*
-Does not cause erection; enhanced the response -High fat meals delay onset (2hrs) *ADE:* Hypotension, priapism (erection>4 hrs...ER!) *Contraindicated:* NITRATES (angina) HYPOTENSIVE MEDS (start with low dose) ALCOHOL *Reversal drug*: Epinephrine
*Sildenafil (Viagra)* PDE5Is (enzyme inhibitor)
-Does not cause erection; enhanced the response -High fat meals delay onset (2hrs) ADE: Hypotension, priapism (erection>4 hrs...ER!) Contraindicated: NITRATES (angina) HYPOTENSIVE MEDS (start with low dose) ALCOHOL Reversal drug: *Epinephrine*
Other types of O2 delivery
-Endotracheal tube/mechanical ventilation -Ambu bag (resuscitation bag) -T-Piece resuscitator (Neopuff)
Monitoring for hypoglycemia
-Feed & recheck 30 minutes after feeding -Need 3 good checks before feeds -Glucose screening should continue until *12 hours of age* for IDM's/LGAs -Late-preterm infants/SGA require glucose monitoring for *24 hours* after birth.
Mastitis
-Flu like, breast engorgement -Encourage regular emptying of milk *not all mothers need to pump*
Prematurity: *cardiovascular problems*
-Fragile capillaries -Asphyxia-->infarction--> *intraventricular hemorrhage* -Persistent pulmonary hypertension (vasoconstriction of lungs--> patent ductus arterioles *(PDA)* -shunting/conduction issues
Some causes for spontaneous abortions?
-Genetic abnormalities -Endocrine imbalances (progesterone) -Domestic violence -Structural abnormalities (incompetent cervix)<-- *cerclage=most popular procedure*
probable signs of pg
-Goodell (softening of cervical tip) -Chadwicks (bluish color of cervix) -Hegar (softening of lower uterine segment) *positive pg test* -Braxton Hicks contractions -Ballottement of fetus
Keys to effective health promotion
-Help family identify a goal to agree on (start small) -Add on new behaviors -Help family anticipate daily challenges & commitment
Risks of induction
-Highest risk is induction with a non-favorable cervix -Doubles risk of c/s
Risk factors for *PP depression*
-History of depression or other psychiatric issues -Low level of partner/social support -Primiparity.. -multiple pregnancies is a *HUGE* risk factor
Partner depression
-Incidence is high-comparable to maternal rates -Later onset than mothers
*Schizophrenia*
-Increases risk for prematurity, low birthweight, congenital malformations -*Untreated/Poorly treated*
Prematurity: *Central Nervous System*
-Ineffective thermoregulation -*Intraventricular hemorrhages* -Seizures **magnesium supplementation/betamethasone for mother helps with neuro-protection of premie** *<36 weeks is imminent*
Issues with O2 delivery
-Infections -Tracheal injury -Psychological impairment -*Retinopathy of prematurity (ROP)* -**neonates may not always need O2, can use room air under pressure by cannula**
*Ferrous Sulfate*
-Iron: one tab, once or twice daily -*Not other forms of iron (ferris, ferrite, ferric); Sulfate is best absorbed* *ADE:* N/V, constipation -Take midday with food, *Vit. C* enhances absorption -Dangerous to children in house: looks like M&M candy, common poisoning of young children
Other premie issues
-Jaundice (80% of all premies) --poor drug metabolism -Paper thin skin, poor flora, infection, pain
*Prematurity*
-Leading cause of infant mortality & morbidity -80% of prematurity is due to intrauterine infection (GBS, Bacterial vaginosis) -*Lifelong effects*: physical & interactional
Possible types of losses include...
-Miscarriage -Abortion -Stillborn -Perinatal death -Infertility -Loss of expectation (perfect baby/perfect mother) -Loss of freedom
Meconium Aspiration Syndrome (MAS)
-Mortality from MAS is 20% in USA (40% in underdeveloped countries) -Identified in amniotic fluid & rated "trace" to "4+" -Trace is not better: *thinner fluid is more easily aspirated* -Thicker leads to worse obstruction
Anxiety disorders *(panic, OCD, PTSD, anxiety, phobias)*
-Most common psychiatric disorder (18% in general population) -Pregnancy is a common trigger onset of *OCD*.
*Nulliparous Term Singleton Vertex (NTSV) Cesarean Birth Rate*
-Most strongly affected by elective practices -Decrease *this* & the following rates will go down: --c/s --late preterm & early term --NICU admissions --infant/maternal mortality
*Prenatal multivitamins*
-One a day, PO -Started as soon as pregnancy is confirmed -Need to emphasize that it does not replace a healthy prenatal diet *ADE:* N/V (take midday after a meal)
*Misoprostol*
-Patient should remain recumbent (lying down) for 30 minutes -Monitor fetal heart rate & uterine activity continuously for 3 hrs *contraindicated*: uterine surgery/scar, asthma
Baby blues diagnosis
-Poor external validity -*Edinburgh Postpartum Depression Scale* -Screening tool only
Nursing role *prematurity*
-Prevent teen birth -Preconception planning -Teaching & health promotion in pregnancy -Universal teaching of signs of preterm labor
*Progestins* (PO, topical, sq, IM (depo), vag gel, ring, IUD, transdermal)
-Prevents contractions -Slows peristalsis -Immune suppression -Low?= high risk of pregnancy loss
*Progestins*
-Prevents uterine contractions -Slows peristalsis -Suppresses immune response -Too low=pregnancy loss *Given therapeutically:* -to support fertility -During pregnancy: low doses -High doses: teratogenic -prematurity prevention *Birth control*: no endometrial lining, may cause spotting -Treats heavy uterine bleeding -Adjunct in HRT estrogen replacement as a protection against cancer
cardiovascular changes in pg
-RBC production increases -pseudoanemia of pg: plasma increase exceeds the increase in RBC production creating a state of hemodilution or physiologic anemia -blood volume increases -plasma level increases by 30-50% by end of pregnancy
*Postpartum psychosis*
-Rare -Break from reality -Hallucinations/paranoia -requires hospitalization, meds & support
*Bipolar*
-Relapses are frequent -Increased risk of comorbid postpartum psychosis as high as 46%
Death of high risk infant Parkes' Model
-Shock & numbness -Yearning & searching -Disorganized -Resolution & reorganization
Treatment principle
-Single medication at a higher dose is preferred over multiple meds. -Need a good history to see what has been effective in the past, don't just switch meds.
*Duramorph (morphine sulfate)* (opioid analgesic)
-Spinal anesthesia -Given after birth of fetus for initial postpartum pain relief *Lasts 24 hours* *no other narcotic meds for 12 hours usually* *Nursing:* monitor sedation. resp. rate q15 minutes then hourly initially
*Pitocin* key characteristics
-Steady state (equal amount coming in as leaving the body) is reached only after 40 min -Unpredictable therapeutic range -More pitocin = more harm *5+ contractions in 10 min shows decline in fetal SaO2*
Prematurity & temperature
-Temperature regulation is PARAMOUNT
Contraindications for induction
-Transverse fetal position -cord prolapse -genital herpes -placenta previa (all indications to do a c/s)
Type of O2 delivery: *Oxygen Hood*
-Usually 2-5 L/min & % is set on blender. -O2 reader is used to verify the % of O2 actually being delivered
Risks for Type I diabetes (White's classification)
-Vascular complications -Hyperglycemia is *teratogenic* -Frequent cause of pg loss -insulin does *not* cross placenta -*can affect all organs*
Small Gestational Age: *Symmetric*(bad)
-Weight, head circumference & length below the 10th percentile. -Brain growth limited
presumptive signs of pg
-breast changes -amenorrhea (an abnormal absence of menstruation) -nausea and vomiting -urinary frequency -fatigue *quickening* (when the pregnant woman starts to feel or perceive fetal movements in the uterus)
renal changes in pg
-capacity increases due to changes in ureters (dilation) and renal pelves (dilation -GFR and tubular reabsorption increases (spilling of glucose expected; NO spilling of protein) -increased potential for UTI, bladder irritability, nocturia, and urinary frequency
maternity care in U.S.
-childbirth is leading cause and cost of health care -C/S is most common and most costly category of surgical procedures -SIX of top SEVEN commonly performed hospital procedures are r/t childbearing and are usually either unnecessary or dangerous: med induction of labor, laceration repair, C/S, continuous fetal monitoring, circumcision, AROM -U.S. ranks 29th in maternal mortality -Black and Native American 3-4x maternal mortality than Caucasian *infant mortality* 57th best in world... BAD
skin changes in pg
-chloasma (mask of pg) -linea negra -stretch marks (striae) -PUPPS (Pruritic Urticarial Papules and Plaques of Pregnancy)
elevated BP in pg
-chronic HTN (assessed in 1st tri) -gestational HTN (assessed in 2nd & 3rd tri) -preeclampsia/eclampsia
psyche in active labor
-contractions are stronger and closer together and woman is seriously focusing on the labor *plan for pain control needs to be re-assessed* -needs to know about labor progress -may need to be reminded to urinate, change positions, take oral fluids -may vomit or may request pain relief
variable decelerations
-do not happen in relation to uterine contraction, so is *NOT related to the contraction* --> cord compression --> change position
amniocentesis
-done at *14-15 weeks* gestation for genetic evaluation of fetal chromosomes -offered to women who will be 35 years or older at the time of birth, or to women with a family history of a baby born with chromosomal problems -using ultrasound guidance, the doctor inserts a needle through the maternal abdomen and into the uterus -RISKS include: *rupture of membranes, bleeding, infection*
musculoskeletal changes in pg
-forward tilt of pelvis -increased relaxin (ovarian hormone that relaxes pelvic and hip joints) -decreased abdominal tone -increased estrogen -stretching of uterine ligaments -waddle -pelvis spreads -lordosis (excessive inward curvature of the spine) -diastasis recti -low back pain
Predisposing factors for UTI:
-hygiene, nutrition, anemia, *DIABETES* -one of the leading causes of preterm labor
"cervical ripening"
-include softening, thinning, movement to an anterior position and dilation of the cervix -the condition of the cervix is the best predictor of successful induction --> Bishop score used to assess cervical ripening
GI changes in pg
-increased appetite -nausea/vomitting 50-90% *progesteron* -->constipation -->decreased peristalsis -->heart burn -->reflux -->hypercholesterolemia: increase in gallstones -estrogen causes increased HCL
Fetal Alcohol Syndrome (FAS)
-life long -growth deficiency -CNS impaired: IQ, memory, attention -impulsive behavior -poor social relationships
psyche in transitional labor
-needs to totally concentrate on labor -irritable -does not want to be touched in some cases -sometimes unable to comply with instructions -may be exhausted and feel like she can't go on -contractions are painful and close together (she may request pain relief) *epidural: "laboring down"*
Type II diabetes
-pre-existing (resistance to insulin) -oral anti-diabetics are used with caution, some are teratogenic.. -*Glyburide* is most common oral anti-diabetic used in pg. -Insulin can be used
Type I diabetes
-pre-existing to pg -pre-conception care is critical *hyperglycemia ia teratogenic* *frequency cause of pg loss* *insulin does NOT cross placenta*
risk factors for abuse during teen pregnancy
-pregnant teen women often have a history of physical, sexual, and/or family violence -teens who have experience childhood or adolescent sexual abuse have increased risks of unintended pregnancy and further abuse -62% of pg teen have been victims of molestation, attempted rape, or rape before their 1st pg -60% of pg teen with a history of abuse have been hit by a romantic partner *46% of babies born to teen women have been fathered by adult men*
common medications in pg
-prenatal vitamins -ferrous sulfate -folic acid
HIV
-progressive, attacks lymphocytes, immune suppressed -first presentation may be with pg treatment in pg: can decrease transmission rate from 25% to LESS THAN 2% --> AZT is given *prenatally, intranatally, and immediately postpartum* to woman and newborn PP: avoid infections, avoid breastfeeding/pre-chewing food NB: IUGR; bathe on admission, treat with anti-retrovirals
Prematurity: *Fluid, Lytes, Nutrition*
-suck-swallow-gag is *not* consistently safe until at LEAST *34 weeks* -tendency for pulmonary edema *PARENTING*: role usually defined in the feeding relationship -may initially give all nutrition by IV (*Dextrose 10 IV solution*)/Amino acids/ Total Parenteral Nutrition (TPN), lipids...
what causes labor?
-uterine stretch: increases receptivity of oxytocin receptors on uterus -change in estrogen-progesterone ratio (estrogen becomes more dominant, which enhances contractility and increases oxytocin receptors) -increase in prostaglandin production by the amnion and other uterine tissues, which enhance cervical ripening -fetal maturation may increase prostaglandin activity and the production of hormones that lead to uterine contractility -release of endogenous oxytocin (nipple stimulation, orgasm)
pH changes in vagina/vulva during pg
-vascularization, cervix "blue" (red = infection) -discharge (leukorrhea) -more acidic -more prone to STIs, especially HIV -very prone to yeast infections due to the increase in glycogen in vaginal environment
positive signs of pg
-visualization of the embryo/fetus on ultrasound (2-3 weeks earliest) -FHTs by doppler... 10 weeks -FHTs by fetoscope... 20-22 weeks -fetal movements palpated or visible
at every prenatal visit
-weight -urine for protein, glucose -BP -fundal measurement after 20 weeks; Leopold's maneuvers to identify fetal position -FHR after 10 weeks -presence of danger signs? discomfort? -psychosocial status
psyche in latent labor
-women are usually happy that they are finally in labor -may rest or sleep, use breathing and relaxation techniques, or walk around -usually able to cope with contractions; distractable
engagement
0 station -at this point, cord *cannot* prolapse into vaginal canal... *decreases* risk of cord prolapse
*Depo-Provera*
Perfect use: *99.7%* Typical use: *90%* Reversible 9 months after last dose.. injection once every 3 months ADE: *mood alteration,* irregular bleeding
*Spermicide*
Perfect use: 80% Typical use: 68% -within an hour before sex ADE: increase in HIV transmission, vag. infection/dryness
*IUD (LARC)*
Perfect use: 99.2% Typical use: 99% Highly reversible (1-3 months from stopping to pregnancy) ParaGard= 10 years Mirena= 5 years
*Implants (LARC)*
Perfect use: 99.5% Typical use: 99.5% Lasts 3 years Highly reversible: hormone undetected within 7 days ADE: irregular bleeding 34%
*Transdermal Contraceptive Patch*
Perfect use: 99.7% Typical use: 82% 3 weeks on/1 off
*Vaginal Ring* - BC
Perfect use: 99.7% Typical use: 85% ADE: vaginitis, leukorrhea (a whitish or yellowish discharge of mucus from the vagina)
*IM/SQ Depot: Depot-Provera*
Perfect use: 99.7% Typical use: 90% Reversible 9 months after last dose.. ADE: mood alteration
Post surgical assessment
RESP.RATE: >12 per min measure hourly for 1st 12 hrs Level of consciousness Pain level *(don't give NSAIDs to <80,000 platelets)* Check urinary status Check bowel status Incision (REEDA) Ambulation - usually in 6-8 hours we begin with dangling --> gradual: sit, dangle, stand, few steps, etc --> be alert for orthostatic hypotension: dizzy, faint, nausea, sweating --> be compassionate and supportive
Medical abortion
Reasons: health of mother, ectopic pg *Methotrexate*: for use in early, uncomplicated ectopic pg. *Mifepristone (RU486)*: with miso, not for use in ectopic pg, within 7 wks of conception *Misoprostol* (prostaglandin) ADE: cramping, uterine bleeding, N/V
Postpartum considerations
Respectful care Monitor closely for: - infection - wound dehiscence - hemorrhage - DVTs
*Terbutaline*
Reversal drug for Pitocin Given if 5+ contractions within 10 min! (Tachysystole) ADE: increased HR, CNS stimulant, pulmonary edema Nursing: check breath sounds, BP, HR
*Tadalafil (Cialis)*
Same contraindications/ADE as viagra... *36 hour duration (extended-release)
*Hydatiform Mole*
"Molar pregnancy" water-filled uterine mass egg which has lost its nucleus is fertilized by a sperm *Sx:* bleeding, high fundal height, high HCG levels, ultrasound *Can cause uterine rupture*..get regular PAP smears for 3 yrs
Low birthweight
"prematurity" is preferred term teens have 2/3 of all LBW babies
*methylergonovine (methergine)/ (ergot)*
(po, IM) *Uses:* - Given after delivery of placenta for PP hemorrhage *ADE:* HYPERTENSION, resp. depression, uterine tetany (rupture) *Nursing:* Assess... -BP -Chest pain -Diminishment of bleeding
Lifetime costs for one child with *FAS*
*$5 million*
*Suggested therapeutic outcome for pitocin*
*1 contraction every 2-3 minutes lasting 60-70 second, palpated strong by an experienced labor nurse*
How much B12 do vegans need?
*2-3 x*
Cesarean Birth
*33% of births* Indications: -to protect the life or health of the mother or fetus -repeat c/s -fetal malposition (breech, transverse) -CPD - FTP Complications *25-50%* (of these, 20% are serious!) -UTI -hemorrhage -wound infection -injuries to bowel, bladder, ureters -adverse effects of anesthesia -wound dehiscence -thrombophlebitis -aspiration -pneumonia - pulmonary embolism
Folic Acid
*400mcg/day* pre-conception Natural sources: legumes, asparagus, spinach, OJ, broccoli, whole grains
*Magnesium sulfate* [anticonvulsant/ CNS depressant]
*Uses:* tocolytic (slows cx) Severe/ unstable gestational HTN, seizures *ADE*: Muscle relaxant Nursing: monitor HR & RR reversal drug: *calcium gluconate*
Perinatal paradox
*unnecessary and do not generally improve outcomes* -many routine prenatal tests (chlamydia, AFP, overuse of ultrasound) -overuse of epidurals, c/s, labor inductions, pitocin -routine use of continuous fetal monitoring *beneficial and improve outcomes* -talking to our patients; extended visits and assessments by professionals -home follow-up -use of birthing centers -labor: exercise balls, water therapy, positioning, ambulation -effective promotion of breastfeeding
Role as a nurse in loss/grief
-*Communication* -be clear (details in writing) -allow for silence -consider other family members involved
Prevention/tx of meconium aspiration
-*Prevent* fetal stress in labor -*Set up all deliveries with resuscitation equipment* -Suction only if non-vigorous -May visualize with laryngoscope *Tx* -Antibiotics, O2, CPAP/vent, IV hydration/nutrition
Violence:
-1 in 12 are physically abused (*teens* =high risk) -Physical violence increases 60% in pregnancy *(worst when pregnancy starts to show)* -homicide is leading cause of death in pg women in the US
Psychotropic withdrawal in neonates
-10-30% show symptoms of *atonia* (low muscle tone/energy), *difficulty feeding*, *jittery/tremor* -Can last up to 3 months
Sexual abuse
-15-25% of general female population in USA -high prevalence rate
Group Beta Strep (GBS)
-60% of term infants with GBS are born from mothers who were negative on their screens late 3rd trimester. -GBS vaccine is being researched...decreases GBS & preterm births -*late onset (7-89 days) is NOT prevented by antibiotics...* -*Do not be falsely reassured by negative maternal results, BABY CAN STILL BE POSITIVE IF MOM WAS NEGATIVE*
*Baby blues*
-A *transient* period of depression that occurs during the *first few days* of postpartum -Usually resolves within 10-14 days
AMSTL Steps (prep during 2nd stage of labor)
-Administration of uterotonic right after newborn delivery -Delivery of placenta with controlled cord traction -Uterine massage *if hemorrhage, restore fluid by IV, 2L in first hour*
Nursing role in abortions...
-Assessment (BUBBLESH) -pad count, pain, labs (HCG/CBC) -psychological
Small Gestational Age: *Asymmetric*
-Better than symmetric -Weight below the 10th percentile, but *head circumference & length relatively preserved* -Brain growth relatively spared
Type III (Gestational Diabetes)
-Can be controlled by diet -*discharge teaching*: chances of getting Type II in mid-life is *60%*
Type of O2 delivery: *CPAP*
-Continuous positive airway pressure -Increases end expiratory pressure.
ultrasound is used for...
-dating/gestational age -dx of ectopic pg, ovarian cysts, fibroids (a benign tumor of muscular and fibrous tissues, typically developing in the wall of the uterus) -assessment of viability/miscarriage -presence of multiples -identification of birth defects such as neural tube disorders, cardiac abnormalities, signs of Down Syndrome -assessment of fetal growth: LGA or SGA
estrogen
-increases blood flow -thickens uterine lining -increases size of uterus -increases number of WBCs
March of Dimes (alcohol during pg)
1 in 12 pregnant women drink during pregnancy 1 in 30 pregnant woman binge drink Increases miscarriage, stillbirth, and premature birth
Bleeding: First Trimester
1 in 4 pg are lost 1 in 5 are complicated by bleeding 10-15% end in spontaneous abortion Hemorrhage is leading cause of maternal death - *can hemorrhage & die within 8 minutes!!*
Drug order for postpartum hemorrhage treatment
1. *Oxytocin* responds in 2-3min. -IV or IM 2. *Methylergonovine* (ergometrine/methergine) *cold storage* -IM, *never IV* Contraindicated: hypertension 3. *Carboprost* -x 2 IM, 15 min. apart Contraindicated: Asthma 4. *Misoprostol* (Cytotec) -PO, sublingual Contraindicated: asthma
how to tell if it is amniotic fluid
1. Nitrazine test 2. Fern test 3. Amnisure test
Identifying hyperbilirubinemia
1. Visualize (sclera okay), observe in natural light 2. Bilimeter (transcutaneous)/Bhutani's Graph 3. Lab tests (TcB & TSB) *total bilirubin being <5 in first 24 hrs is ok*... *13 mg/dL at 72 hrs is OK* *Direct*: conjugated/bound/water soluble *Indirect*: unconjugated/unbound/*not able to be excreted*
Prenatal considerations
1hr glucose challenge at *first* prenatal visit Diabetes education in first trimester *DVT* risk: take prophylactic heparin/enoxaparin *Anesthesia* consult during 3rd trimester Weight gain: 15-25 lbs
What % of people are "High risk"?
20%
Pattern of weight gain
22 weeks = 12lbs *1st trimester*: 2-4lbs (larger weight gain is stress eating) *2nd-3rd trimester*: 1lb/week
Iron during pregnancy?
27mg
length of a menstrual cycle
28 days (20-50 in reality) -counted from first day of menses *menstrual*: bleeding days 1-5 *proliferative*: day 5 - ovulation (rapid endometrium growth) *ovulation*: 14 days before start of next cycle (LH surge) *secretory*: ovulation - menses (thick heaving endometrial lining) *ischemic*: estrogen and progesterone levels fall as corpus lute regresses
Mental disorders
2nd only to bleeding as a complication of childbearing in USA- 5-25% of population
10% of U.S. deliveries & 28% of elective inductions are between...
35-38 weeks (70% of NICU are premies)
active phase of first stage of labor
4-5 hours is average more rapid dilation of cervix from 4-7cms -effacement complete -contractions are 2 minutes apart, moderate, 60 sec -increased descent of the fetus
What about African American women?
4:1 deaths compared to caucasian mothers
Post-partum depression
50% minor & 50% major
First Steps
60% of childbearing families in WA receive services through First Steps
Menopause/Estrogen therapy risks
75% decrease in estrogen *Therapy risks*: increase in breast, uterine, cervical, ovarian cancer, potentiates cancer already forming, increase risk of CV events. *Give with progesterone, not ONLY estrogen*
At what temp. do you place the baby under radiant warmer?
< 97.7F or 36.5C
O2 positive (concern)
<90% - 94%
BMI:
> 25 overweight > 30 obese > 40 morbidly obese (can be teratogenic)
*Mild* pre-eclampsia
>140-159/90-99 Proteinuria Liver changes Fetal hypoxemia Placental abruption
*Severe* pre-eclampsia (HOSPITALIZATION)
>160/>100 Liver Renal ocular CNS Fetal Placental (abruption)
O2 negative (normal/good)
>95% right hand/foot
Friedman Curve
A graph that obstetric care providers have traditionally used to define a "normal" length and pace of labor. *Typical Friedman curve is too stringent & may lead to c/s*
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
A. A client who is experiencing fetal death at 32 weeks gestation. *B. A client who is in preterm labor at 26 weeks gestation.* (Tocolytic medications, such as ritodrine, are used to relax the uterus in preterm labor. A client who is in preterm labor at 26 weeks is ideal for this therapy) C. A client who is experiencing Braxton-Hicks contractions at 36 weeks gestation. D. A client who has a post-term pregnancy at 42 weeks of gestation.
A nurse is caring for a client who has severe pre-eclampsia and is receiving *magnesium sulfate* IV at 2g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?
A. Diminished deep tendon reflexes *B. Respiratory rate of 16/min* (The RR should be at least 12/min as a precaution against excessive depression of impulses at the myoneural junction.) C. Urine output of 50mL in 4 hrs D. Heart rate of 60/min
A nurse is caring for a client who is postpartum and requires *RhoGAM*. Before administering it, the nurse should verify that the...
A. client is Rh positive and the newborn is Rh positive. B. client is Rh negative and the newborn is Rh negative. *C. client is Rh negative and the newborn is Rh positive.* (RhoGAM contains antibodies to Rho(D). Administering it prevents antibody formation in women who are Rh-negative following exposure to Rh-positive blood, such as in a fetus who is Rh-positive.) D. client is Rh positive and the newborn is Rh negative.
Antihypertensive drugs contraindicated in pregnancy/lactation...?
ACE inhibitors Beta blockers (Labetalol - treats HTN - can be used x 1-2 doses, but *not* routinely)
*Magnesium Sulfate*
ANTICONVULSANT, CNS depressant *TO PREVENT PRE-ECLAMPSIA* *DANGEROUS*-used for serious HTN -Closely monitor & *PUMP*, piggyback into mainline, double check with another RN -Foley, hourly outputs -Frequent drug level checks -*NO* ambulation -May have absent DTR/clonus Contraindicated: kidney issues
Strabismus
Abnormal alignment of eyes/squint
*Narcan*
Aka Naloxone: is a medication used to block the effects of opioids, especially in overdose Not for opioid substance abusers
*Oral Contraceptives*
Alters progestin throughout the cycle -less affective in overweight and obese women -perfect use: 99.7% - typical use: 92% *CONTRAINDICATIONS:* - >35 - CV hx/ illness - hx or current problem with blood clotting - women who are unlikely to adhere *ADES:* - thromboembolic problems - breast cancer risk has low data *Drugs that decrease effects of OCs:* - dilantin, rifampin, ritonavir, St. John's Wort
Lochia
Amount --> small = left than 4-inch stain --> moderate = less than 6-inch stain --> heavy = saturated pad within 1 hour Color Clots (dangerous if egg/plum size) Odor
Bladder (after birth)
Amount *(2-3L, 2000-3000cc in 1st 24 hours)* Frequency ( should be q3-4 or more often)
Too little protein:
Anemia
Dysfunctional labor-psychological responses
Anxiety & stress response causes increased levels or cortisol & catecholamines which *inhibit* uterine contractility
Erectile dysfunction (impotence)
Associated with Type II diabetes, HTN & depression 50% often 40-70 y.o. *requires good arterial flow* to penis and reduced venous outflow
Pre-term labor pain
Back soreness, anxiety, UTI pain
BPH
Benign Prostatic Hyperplasia -prostate surrounds male urethra, proceeds fluids that add to ejaculate *BPH: excessive growth of cells* 50% by age 60, 90% by age 85 difficulty urinating, dysuria, nocturia
a pulmonary embolism is most often a...
Blood clot
Reversal drug for Mag. Sulfate
Calcium gluconate
Reasons for medical abortions
Cardiac illness Cancer Ectopic pg Hydatiform mole (a cluster of fluid-filled sacs formed in the uterus by the degeneration of chorionic tissue around an aborting embryo)
#1 cause of pregnancy-related death in USA
Cardiovascular disease
Labor considerations
Careful external monitoring BP Pulse oximetry Glucose monitoring Prevention of DVTs: heparin/enoxaparin, compression, early ambulation
When checking eyes...? Newborn
Clear/bloodshot/injected Drainage (is it infected?) Edema (common) Strabismus (up to 4 months) - abnormal alignment of the eyes; the condition of having a squint Jaundice
Avoid these herbs:
Cohosh Juniper Pennyroyal Rosemary Sage Raspberry leaf
*Tier 3 BC*
Condoms (M & F) Diaphragm
Preterm labor
Contractions: 4 every 20min or 8 every 60min *&* dilation = / > 2cm *high recurrence* *anxiety, cramping, back pain/soreness, signs of UTI* *Treatment*: stop contractions, fluid po or IV, MgSO4, terbulatine, nifedipine, *betamethasone*
*Vitamin B12*
Cyanocobalamin *vegans/pg/anemic* -Found mostly in animal foods & some fortified/yeast products -Need blood level drawn for levels -*IM injections may be necessary*
Bowel (afterbirth)
Diarrhea? Constipation r/t opiod use (give stool softener)
Drugs that decrease effects of OCs:
Dilantin, rifampin, ritonavir, St. John's Wort (so those clients with TB, HIV/AIDS, SSRIss/SNRIs)..DON'T TAKE!
Drugs that decrease the affects of OC
Dilantin, rifampin, ritonavir, St. John's Wort (so those clients with TB, HIV/AIDS, SSRIss/SNRIs)..DON'T TAKE!
Risks for DIC
Disseminated (spread or disperse widely) Intravascular Coagulation: formation of blood clots in the small blood vessels throughout the body; leads to compromise of tissue blood flow and can ultimately lead to multiple organ damage HELLP Retained dead fetus Sepsis (the presence in tissues of harmful bacteria and their toxins, typically through infection of a wound) history of hemorrhage *observe for petechiae (a small red or purple spot caused by bleeding into the skin), bruising, VS, I & O, gums, IV site, lochia*
Lower back
Document dimples!
What is postpartum hemorrhage?
Drop of more than 10% Hct Saturated pad in 15-30 min
Assessment of umbilical cord
Dry? REEDA Hernia Check if "3 vessel cord"
Progestins therapeutic effects:
During pg: low doses High doses: teratogenic Adjunct in HRT estrogen replacement, protects against cancer. Birth control: no endometrial lining Treat dysfunctional uterine bleeding (heavy)
When should you baby proof the home?
During pregnancy
Miscarriage pain
Emotional pain, cramping in lower back & abdomen, contractions, heavy bleeding
Precipitous labor
Entire labor lasts *<3hrs* -risk of injury to mother/shock for newborn
Bupivacaine
Epidural anesthetic ADE: elevated maternal&new born temp. (100F) Hypotension Nursing: continuous monitoring, fluid bolus given (500mL IV prior)
When to do head to toe?
Every morning with first vitals
bradycardia
FHR <110 bpm for a prolonged time or following tachycardia
tachycardia
FHR >160 bpm serious sign of problems (infection, hypoxemia)
ares of health promotion
Family Health Education Safety Exercise and Rest Screening Vaccinations Stress management Nutrition
"Taking in"
First few days (egocentrism)
How often to check baby's ID band?
First thing in the AM & every time baby leaves & returns room
*Vitamin K (Aquamephyton/Phytonadione)*
For sterile intestines of newborn 1mg= 0.5mL IM
Fetal brain development
Frontal lobes are the last to develop, therefore the most vulnerable Brain volume increases at a rate of 15mL/wk between 29 and 41 weeks gestation
accelerations
GOOD -rise from the fetal baseline of at least 15 points for at least 15 seconds (a square and a half by a square and a half)
GERD pain
GastroEsophageal Reflux Disease pain in chest/throat..can radiate to arm
Reasons for medical induction?
Gestational hypertension preeclampsia/eclampsia Diabetes premature ROM with fetal distress
*Erythromycin* (ophthalmic)
Given to newborn within first hour of life Ointment for both eyes
Pregnant & get into a car accident?
Go to hospital immediately, even if no obvious injury
Measurements during FIRST HOUR
HEAD TO TOE Temp. VS Weight Head Length Glucose: expected 45-90mg/dl, under 45 we treat immediately
Dysfunctional labor-maternal position
Hands & knees may help rotate an OP Sitting & squatting shortens 2nd stage
30% of all congenital defects in live births are...
Heart defects (Screen right hand & either foot)
HELLP syndrome pain
Hemolysis (the rupture or destruction of red blood cells). Elevated Liver enzymes. Low Platelet count. venous congestion that backs up into liver, acute onset, rapid, swelling of liver causes a LOT of pain in epigastric region
Stadol (butorphanol tartrate)
IV (small doses) Sedative during 1st stage of labor, works in less than 5 min. ADE: HYPOTENSION, N/V, itching, dizziness, sedation, constipation, resp. depression, impaired breastfeeding, body temp probs.
*Hepatitis B vaccination*
If maternal HBsAg+, then also give baby HBIG vaccine (during first hour)
*Tier 1 BC* (most effective)
Implants IUD Female sterilization Vasectomy
"Taking hold"
Improved self-perception as a parent & improved ability to receive information
Carb intake during pg?
Increase a little
*Recommended vaccines* in pregnancy
Influenza (injection) Tdap (in 3rd trimester) SAFE -pneumococcal -Hep B -Hep A -Varicella -Tuberculosis
*Tier 2 BC*
Injection Lactation Pills Patch Vaginal Ring
Caffeine in pregnancy:
Interferes with ability to use/store calcium Replaces the drinking of water/other nutrients *Increases HR & perception of stress* *Decreases appetite* Increases stomach acid
*Fentanyl* [opiod]
Intrathecal, epidural, IV #1 in USA Small doses given q1-2 hrs Dampens perception of pain Given before transition phase ADE (mother): N/V, itchy, dizzy, sedation, resp. depression, HYPOTENSION, CNS depression ADE (fetus): CNS depression, resp. depression, decreased temp. regulation, impaired early breastfeeding
When checking skin...? Newborn
Jaundice Birthmarks -Mongolian spots -Nevus Rashes -erythema toxicum (normal newborn rash) Milia vs acne
Fat intake during pg?
Keep to *30%* of diet
*Inadequate contractions*
Less than every 2-3 min, or less than 3 in 10 minLess than 60 seconds in duration & not palpated as strong*
"Letting go phase"
Listening to how they're decision making as a parent
What is intrapartum hemorrhage?
Loss of >500mL of blood after vaginal birth Loss of >1000mL after c/s
Ectopic pregnancy pain
Lower right/left quadrant, consistent localized pain
Mechanical induction
Manually stripping the membranes or Balloon catheter; foley catheter
Blues
Mild, variable, interest in self care & some newborn care, they are functional Begins 3-5 days postpartum up to 2 weeks
Caring of circumcised penises
Monitor for bleeding at 15 min post procedure *only 50% are circumcised* -few drops of blood okay -scabbing on day 2-3 but no pus -urinate within 8-12 hours
Depression diagnosis
More common after 1-2 weeks until 1 year postpartum -Sleep disturbances, hormones..etc -Co-exists often with anxiety symptoms -No universal approach -Screening needs to be universal
*Androgens* (patch/gel)
Most common is IM, long acting, every 2-4 weeks Patch: upper arm, back, buttocks, abdomen DAILY Gel: *Do not apply to scrotum* Can transfer to others even after dried-keep covered with clothes *ADE:* Hepatotoxicity, category X, worsen/potentiate existing prostate cancer, edema, gynecomastia (man boobs)
*Androderm* (patch), *Androgel* (gel)
Most common is IM, long acting, every 2-4 weeks Patch: upper arm, back, buttocks, abdomen DAILY Gel: Do not apply to scrotum Can transfer to others even after dried-keep covered with clothes ADE: Hepatotoxicity, category X, worsen/potentiate existing prostate cancer, edema
What do we assess *FIRST?*
Motivation/"readiness" --> then barriers to learning
Caring of uncircumcised penises
NO retraction of foreskin Clean externally only
Vitamin B12 & Folic acid during pregnancy:
Needs to be *doubled*
How to measure SpO2 levels on newborns
Neonatal oximeter on the *pre-ductal (right wrist)* *10 minutes after delivery, newborn should be at 85-95%*
Imperforate anus
No hole! 😧 Immediate surgery
First step if there's a hematoma
Notify healthcare provider
Type of O2 delivery: *Nasal Cannula*
O2 delivered is according to *L/min* and % of oxygen using a blender & humidifier
Healsticks on newborn
Only stick outer sides of lower foot NEVER at back of heel
*Pain medications*
Opioids (, percoset, vicodin, fentanyl, duramorph) NSAIDS (toradol, ibuprofen) Anesthetics (bupivacaine)
Type of O2 delivery: *"Blow By"*
Oxygen (100% from wall- if it's a half an inch away from the nose, it can delivery 40% O2)
screening tests 2nd trimester
PPD (purified protein derivative) or serum test for TB Quad Screen, done between 15-20 weeks -neural tube defects (spina bifida, omphalocele) -Down's Syndrome
1-2% of all postpartum women have...
PTSD
When checking mouth...? Newborn
Palate Suck/swallow Teeth
It is strongly encouraged that...
Parents hold, touch, and bond with their dying or dead child
*Spermicide*
Perfect use: *80%* Typical use: *68%* -within an hour before sex ADE: increase in HIV transmission, vag. infection/dryness
*IUD* (LARC)
Perfect use: *99.2%* Typical use: *99%* Highly reversible (1-3 months from stopping to pregnancy) ParaGard= 10 years Mirena= 5 years
*Implant* (LARC)
Perfect use: *99.5%* Typical use: *99.5%* Lasts 3 years Highly reversible: hormone undetected within 7 days ADE: irregular bleeding 34%, amenorrhea 22%
*Oral contraceptives*
Perfect use: *99.7%* Typical Use: *92%* Mechanism: inhibit ovulation, increase density of cervical mucous *Contraindicated:* obese >35 & smoke CV hx/illness Blood clotting problems
*Patch* (combined hormones)
Perfect use: *99.7%* Typical use: *82%* 3 weeks on/1 off contraindications, ADE, DDIs about the same as OC
*Vaginal ring* (combined hormones)
Perfect use: *99.7%* Typical use: *85%* Inserted once a month, left in for 3 weeks and then removed ADE: vaginitis, leukorrhea
*HIGH RISK* [Labor & delivery admission]
Placenta previa/low lying Suspected accrete Platelet count <70,000 Active bleeding Coagulopathy 2 or more med. risk factors
Risks with obesity while pregnant (BMI > 35)
Pre-eclampsia C/S Shoulder dystocia Early neonatal death Increased neural tube & cardiac defects Contraceptive failure Increased infection rate due to glucose changes Increased risk of thrombophlebitis & embolism
High risk concerns
Prematurity Size differences (SGA, LGA) Infant of diabetic mother (IDM) Meconium aspiration syndrome (MAS) Hypoglycemia Blood type incompatibility & hyperbilirubinemia Group Beta Strep (GBS)
*MEDIUM RISK* [Labor & delivery admission]
Prior C/S, uterine surgery Multiple gestation >4 prior births Prior hemorrhage Large myxomas Obese > 40 BMI Hct <30%
17P
Progesterone injection to reduce risk of preterm delivery
Case example: *30 y.o, 2nd pregnancy, ready to be discharged, plans to breastfeed..*
Progestin-only methods only.. can also use copper IUD, barrier methods, lactational amenorrhea
*Uterine muscle contraction: induction/augmentation*
Prostaglandins (Misoprostol) Oxytocin
1/3 of all pregnant women are exposed to...
Psychotropics
When checking lungs...? Newborn
Rate, rhythm, funny sounds (Present, clear, equal)
1st trimester nutrient needs
Remains fairly stable,*EXCEPT FOLIC ACID*
What foods to avoid during pregnancy?
Saccharin Aspartame Unpasteurized dairy (listeriosis) mercury (fish/shellfish) Caffeine/Alcohol
*Tadalafil* (Cialis)
Same contraindications/ADE as viagra... *36 hour duration (extended-release)*
Women with increased risk for ADE health effects..
Should consider long-acting, highly-effective contraception
*CONTRAINDICATED VACCINES* in pregnancy
Smallpox Rubella Mumps & Measles Possibly contraindicated: Polio vaccine
PMS interventions
Stress relief Diet Mg & Ca Exercise SSRI's
Preeclampsia symptoms
Sudden weight gain Edema High BP *nursing role:* -VS, labs (CBC, liver), doppler velocimetry, fetal kicks
Circumcision pain meds
Sweet-Ease (24% sucrose) Lidocaine
*Bleeding: third trimester*: Placenta previa (migration)
Sx: bright red painless bleeding (*abruption*) & fetal wellbeing (*movement*) *planned C/S close to EDD*
Low in calcium:
Teens Smokers Long-term birth control Chocoholics
*All* newborns are challenged with...
Temperature instability (hypo) Respiratory issues Cardiac instability (late sign) Glucose instability (hypo) Muscle tone (hypo/hyper) Feeding issues Altered eval of consciousness (lethargy) Ineffective interaction
*Uterine muscle relaxation*
Terbutaline Mag. Sulfate Nifedipine
D-dimer
Test: small protein fragment present in blood after a blood clot is broken up; helps find thrombosis -positive can indicate thrombosis, but doesn't rule out other causes (DIC) -negative test rules out thrombosis (no clot)
Fetal fibronectin (fFN)
Tests for risk of pre-term labor (25-35 weeks gestation) *best prediction with negative results*
A quarter to a third of all postpartum women report ...
That their births were traumatic
High Risk: rule of "toos"
Too young (<18) Too old (>35) Too little weight (BMI<18) Too much weight (BMI>30/35) Too poor Too many births (>3)-high parity..overused uterus Too extreme of a lifestyle Too alone Too little education Too many health problems (comorbitidy)
How to know if scrotal sacs are not herniated?
Transilluminate with flashlight
Omphalitis
Umbilical corn infection
Hypospadias
Urethra abnormally placed
Epispadius
Urethra normally placed
Primary sites of prenatal infection
Urinary and dental
*Toradol*
Use: IV NSAID to supplement pain relief postpartum
Endometritis
Uterus tender on palpation pelvic pain foul loch *excessive bleeding* *chills, fever*
Expected blood loss
Vaginal birth: 500cc C/S: 1000cc
Most clotting issues in childbearing women are...
Venous thrombosis (DVT) sx: redness, warmth, unilateral enlarged vein, calf tenderness, swelling
*Tier 4 BC* (least effective)
Withdrawal Spermicides
Depression
Withdrawn and little/no interest as a primary caregiver Hopeless, helpless, change in sleep & appetite Often *after* 2 weeks
When to breastfeed?
Within 30-60 min of birth (may take 24-48hrs to latch on to nipple)
Nurse's role in Erb's Palsy
a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the severing of the upper trunk C5-C6 nerves. These form part of the brachial plexus, comprising the ventral rami of spinal nerves C5-C8 and thoracic nerve T1. -Immediate identification & teaching with family -Exercises (physical therapy) -Weekly follow-up with family after discharge -Appropriate positioning/movement of infant
"Bundle"
a small set of evidence-based interventions for a defined patient population & care setting
electronic fetal monitoring
after 28 weeks: *Leopold's maneuvers* *Non-stress testing* looks for 2 accelerations of FHTs in 20 minutes of at least 15 bpm *Doppler velocimetry* looks at blood flow through the umbilical cord: when pg women are HTN
Chronic HTN *TRIANGLE OF SX: BP, EDEMA, PROTEINURIA*
before pregnancy or before 20th week of pg >= 140 systolic AND/OR >= 90 diastolic Does *not* resolve after birth (give nifedipine) -usually goes away by 12th week; usually a 2nd or 3rd trimester concern
Kernicterus
bilirubin-induced brain dysfunction *rare* -keep bilirubin below 20mg/dL -*premies may develop kernicterus at lower bilirubin levels than new newborns*
UTI
common complication of pregnancy -predisposing factors: hygiene, nutrition, anemia, diabetes *use straight cath, rather than indwelling*
Idiopathic thrombocytopenia
deficiency of platelets in the blood Sx: bleeding gums, loch, IV site bleeding Tx: IV, platelets, glucocorticoids
Emergency Contraception
delays or stops ovulation; inhibits fertilization -up to 5 days unprotected sex (best if 72 hours) -does not terminate pregnancy or hurt existing embryo
viability of egg and sperm
egg: 24 hours sperm: 72 hours
Amniotic fluid embolisms
embolism: obstruction of an artery, typically by a clot of blood or an air bubble -rare-but deadly -sudden onset of cardiovascular collapse -sustained tachycardia for 4 hours
weeks associated with trimesters
first trimester: weeks 1-12 second trimester: weeks 13-27 third trimester: weeks 28-40
Calorie intake
increase about 300-500/day Lactation about +400-500/day
late deceleration
indicates *poor uteroplacental perfusion*: likely hypoxemia of fetus 1. usually need to relax uterus so: NO PITON, and perhaps a drug to relax the uterus (terbutaline, a beta2 agonist) 2. oxygen may help 3. turning likely will not help much, but doesn't hurt to try
Amniotomy risks
infection after 12-18 hrs loss of fetal cushioning cord prolapse
Braxton hicks pain
intermittent weak contractions of the uterus occurring during pregnancy -uncomfortable -noticeable -no increase in intensity/frequency.. can go way -usually occurs at the end of the 3rd trimester
Pre-eclampsia pain
intermittent/acute constant, general edema/swollen feet, epigastric pain r/t liver enzymes being released
early phase of first stage of labor
longest (8 hours is average) cervix effaces and dilates from 0-3cm -contractions are mild, q2-3 mins, 40-60 sec -small increase in descent
previa
low lying placenta -lose connection = risk of abruption
Smoking
main problem is *vasoconstriction* of mother Fetus: 1 cig = 3 in terms of effects Decreasing can be a goal rather than total abstinence, and is a good place to start
progesterone
maintains endometrial lining
contraction intensity
monitor ctrx by placing your hand on the fundus --> it should feel soft (like your cheek) with mild ctrx --> it should feel firm (like the tip of your nose) with moderate ctrx --> it should feel hard (like your forehead) with strong ctrx
accreta
placenta digs in too deep --> extremely implanted on uterine wall --> retained placenta or hemorrhage or hysterectomy
abruption
placenta starts peeling away from the uterus --> risk of hemorrhage and newborn hypoxemia
>60% of maternal deaths occur in what period?
postpartum 50% of all maternal mortality are thought to be *PREVENTABLE* causes: GH, pulmonary embolism, amniotic fluid embolus, cardiac disease
How often to measure Temp., Pulse, Resp. in first 24 hrs?
q 4 hrs
contractions
regular, involuntary contractions, progressively getting longer, stronger, and closer together 4 phases of a single contraction 1. *increment* - ctrx begins in funds and radiates over the body of the uterus 2. *acme* - maximum intensity 3. *decrement* - gradual decrease 4. *rest* - reduction in tone btwn ctrx
screening tests 3rd trimester
repeat antibody screen for Rh neg women, prior to giving Rhogam at 28 weeks --> if woman is Rh- she receives RhoGam Group Beta Strep culture - 3 on one swab: cervical, vaginal, rectal
*Retinopathy of prematurity (ROP)*
retinopathy: disease of the retina that results in impairment or loss of vision -O2 toxicity causing vasoconstriction in retina, *not dose dependent* -Proliferation of leaky vessels -Blood in retina...retinal detachment & myopia (near-sightedness)
"full integrated screen"
screens for: *neural tube defects* -spina bifida -omphalocele *trisomies* 9, 18, 21
transition phase of first stage of labor
shortest (1-2 hours is average) -dilation of cervix from 8-10 cm -hard, coping very stressed -contractions one minute apart, lasting 60-90 sec
follicle stimulating hormone (FSH)
stimulates development of graafian follicle and production of estrogen
luteinizing hormone (LH)
surges just before ovulation and affects a selected maturing follicle
pushing in second stage
sustained, directed pushing vs. short, spontaneous pushing (undirected) *prolonged breath holding and forceful pushing efforts have been associated with fetal hypoxia and acidosis ("closed glottis pushing")* directed pushing is associated with increased perineal tears
Expected VS during 1st 24hrs
up to 100.4F (38.0C) Pusle: might be down to 60s Resp: might be down to 12 BP: fluid shifting
secondary powers
voluntary bearing down efforts in pushing
Newborn screening prior to discharge
•Genetic screen •Bilirubin •Hearing •Check O2 saturation
Cephalohematoma
•Hemorrhage of blood between skull & periosteum •does NOT cross suture line •can be caused using tools (vacuum suction)
REEDA (for incisions)
•Redness •Edema •Ecchymosis (bruising) •Discharge •Approximation (edges of incision)
Caput
•Swelling under scalp •Crosses suture line •Lymphatic fluid •Self-resolving
A nurse is preparing to administer vitamin K (AquaMEPHYTON) by IM injection to a newborn. Into which of the following muscles should the nurse inject the medication?
*A. Vastus lateralis* (thigh muscle; Vit. K prevents and treats hemmorhagic disease of the newborn) B. Ventrogluteal C. Dorsogluteal D. Deltoid
Unintended pregnancy rate in US:
*50%* adults (half were using contraception) *82%* teens **chance of getting pg w/o contraception**: 30%
Hypoglycemia
*<45 mg/dL = hypoglycemic* - <30 mg/dL is common in healthy newborns -Can negatively affect the brain... *Symptoms*: -jitteriness, cyanosis, seizures, hypothermia, apnea, tachypnea, weak/high-pitch cry, lethargy, poor feeding, eye rolling *MOST COMMON Sx OF HYPOGLYCEMIA IN TERM INFANT IS NOTHING-NO SIGN!*
A nurse caring for a client who is prescribed Rho immune globulin standard dose IM (RhoGAM). The nurse should describe the action of this medication to the mother by saying...
*A. "RhoGAM prevents the formation of Rh antibodies in mothers who are Rh negative."* (Giving Rho immune globulin standard dose IM to the mother prevents her immune system from reacting to accidental exposure to fetal blood during pregnancy or delivery. If the client has another Rh-positive fetus in the future, these antibodies may try to destroy the blood cells of the fetus. Rho immune globulin standard dose IM is given routinely to Rh-negative mothers at 28 weeks of gestation and following any pregnancy outcome (including birth or any planned or unintentional fetal loss)). B. "RHoGAM destroys Rh antibodies in mothers who are Rh negative." C. "RhoGAM destroys Rh antibodies in newborns who are Rh positive." D. "RhoGAM prevents the formation of RH antibodies in newborns who are Rh positive."
A nurse is admitting a client to the postpartum unit who experienced a vaginal birth 2 hours earlier. The client has an IV of lactated Ringer's with 25 units of *oxytocin* infusing and large rub lochia. Vital signs include: *BP 146/94 HR 80 RR 18* The nurse reviews the prescriptions by the provider. Which of the following prescriptions requires clarification?
*A. Methylergonovine (Methergine) 0.2mg IM now.* (Methergine is contraindicated in the client with a BP greater than 140/90.) B. Inset an indwelling urinary catheter. C. Administer oxygen by nonrebreather mask at 5L/min. D. Obtain lab study of prothrombin and partial thromboplastin time.
A nurse in a prenatal clinic is caring for a client who has been prescribed *dinoprostone (Prepidil) gel*. The nurse explains to the client that the purpose of dinoprostone is to do which of the following?
*A. Promote softening of the cervix* (Dinoprostone is used to prepare (or ripen) an unfavorable cervis for the induction of labor in pregnant women who are at or near term.) B. Cause the client to abort the pregnancy C. Stimulate uterine contractions D. Relax uterine contractions
A nurse is caring for a client who has preeclampsia and is being treated with *magnesium sulfate*. It is noted that the client's respiratory rate is 10 breaths/min, and deep tendon reflexes are 0. Which of the following nursing interventions is appropriate at this time?
*A. Turn off the magnesium sulfate drip.* (The mag.sulfate has caused CNS depression as evidenced by the depressed RR and absent deep tendon reflexes, for this reason, the med should be discontinued.) B. Prepare the client for an emergency C/S C. Assess the client's blood pressure. D. Place the client in trendelenburg position
A nurse in labor and delivery is caring for a patient who is having induction of labor with *oxytocin (Pitocin)* administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline FHR is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
A. Decrease the rate of infusion of the maintenance IV solution. *B. Stop the infusion of the IV oxytocin.* (Discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation.) C. Increase the rate of infusion of the IV oxytocin. D. Slow the client's rate of breathing.
A nurse is caring for a client who is at 28 weeks of gestation and has received *terbutaline (Brethren)*. Which of the following findings should the nurse expect?
A. Fetal heart rate 100/min *B. Weakened uterine contractions* (Terbutaline is a beta2-adrenergic agonist that acts to relax the uterus. Terbutaline issued to stop a contraction pattern in a client who is at preterm gestation. The risk of delivering a preterm newborn is immature lungs.) C. Enhanced fetal lung surfactant D. Maternal glucose 63mL/dL
A nurse is caring for a client who is in premature labor and is receiving *terbutaline (Brethren) as a tocolytic agent*. The nurse should know to closely monitor the client for which of the following side effects of terbutaline that indicated the development of a potentially life-threatening complication?
A. Headaches B. Nervousness C. Tremors *D. Palpitations* (the presence of palpitations could be a manifestation of arrhythmia, which is a potentially life-threatening complication of terbutaline. This finding should be reported to the prover immediately.)