NUR 113

Post Partum Infections

A common cause of maternal morbidity and mortality. Infections occur in the female genital tract, breast, or surgical site. What are the risk recognition and prevention measures? -Metritis -Surgical site infection -UTI -Mastitis Infection during the postpartum period is a common cause of maternal morbidity and mortality. Overall, postpartum infection is estimated to occur in up to 8% of all births and accounts for 15% of global maternal mortality. There is a higher occurrence in cesarean births than in vaginal births (Mattson, & Smith, 2016). Postpartum infection is defined as a fever of 100.4° F (38° C) or higher after the first 24 hours after childbirth, occurring on at least 2 of the first 10 days after birth, exclusive of the first 24 hours (Dalton & Castillo, 2014). Risk factors include surgical birth, prolonged rupture of membranes, long labor with multiple vaginal examinations, inadequate hand hygiene, internal fetal monitoring, uterine manipulation, chorioamnionitis, instrumental birth, obesity, untreated infection prior to birth, retained placental fragments, obesity, gestational diabetes, extremes of client age, low socioeconomic status, and anemia during pregnancy (Jordan et al., 2014). Infections can easily enter the female genital tract externally and ascend through the internal genital structures. Postpartum women possess an increased risk for infection due to tissue trauma during birth, vulnerability from placenta separation site, and the incision from cesarean section. In addition, the normal physiologic changes of childbirth increase the risk of infection by decreasing the vaginal acidity due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. Postpartum infections usually arise from organisms that constitute the normal vaginal flora, typically a mix of aerobic and anaerobic species. Generally, they are polymicrobial and involve the following microorganisms: Staphylococcus aureus, Escherichia coli, Klebsiella, Gardnerella vaginalis, gonococci, coliform bacteria, group A or B hemolytic streptococci, Chlamydia trachomatis, and the anaerobes that are common to bacterial vaginosis. Prevention can be achieved by screening and treating vaginal colonization during pregnancy (Callahan, 2016). Common postpartum infections include metritis, surgical site infections, urinary tract infections, and mastitis.

Pathophysiology of preeclampsia

A multi-system disorder. Research is ongoing as to the exact cause but relates to vasospasm and abnormal placentation. Women with preeclampsia have inadequate plasma volume expansion which puts them in a naturally dehydrated state. Mild - 9% Severe - up to 40%. Decreased plasma volume associated with fetal morbidity and IUGR. Increased sensitivity in the vascular bed (also kidneys, liver, neurological system) vasoconstriction hypertension and vasospasm. Combination of vasoconstriction and decreased plasma volume leads to organ perfusion. The morbidity is related to vasospasm because it causes the placenta to have lack of perfusion and abruption which can lead to hemorrhage and fetal death Sometimes women develop preeclampsia very suddenly

Baby Blues

A passing state of heightened emotions that occurs in about half of women who have recently given birth. Determined to be "normal". Also known as postpartum blues.

The Baby Blues: S/S

A woman with the blues may: Cry more easily than usual...don't always know why they're crying. Have trouble sleeping...mild insomnia. Feel irritable, sad and/or anxious. Have a rapidly fluctuating mood...mild mood swings. Feeling of letdown. Having the blues does not interfere with the ability to care for her infant

Post Partum Mood Disorders

'Baby Blues' Post partum depression Post partum psychosis

Postpartum mood disorders

'Baby Blues'- does not affect the woman's ability to take care of her child Post partum depression Post partum psychosis Unique to each woman.. This state peaks 4-5 days after delivery and lasts from several days to 2 weeks. Symptoms that continue past 2 weeks or more are diagnosed as postpartum depression.

Diabetes in pregnancy, early screening or wait until 24-28 weeks?

*Two or more values must be met or exceeded to diagnose gestational diabetes. Women without certain risk factors: Women without risk factors do not require early screening and should have a glucose tolerance test as part of their normal prenatal lab panel. Recommended test: 2hr GTT, 75 gram load of glucose Fasting blood glucose ≥ 95 1 hr ≥ 180 2 hr ≥ 155 Women with certain risk factors: Women with risk factors require early screening. This should be done at the first prenatal visit. Recommended test: Fasting blood glucose ≥ 126 Hgb AIC ≥ 5.5 If either value is abnormal the woman is diagnosed with "overt diabetes" If the screening is normal the screening is repeated between 24-28 weeks.

Stages of labor- fourth stage

1- 4 hours post delivery of the placenta Parent child bonding begins Continued maternal & neonatal assessment Facilitate feeding within the first hour and bonding More likely to be successful with breastfeeding the earlier they begin

Pre-term labor treatment

17 alpha-hydroxyprogesterone: Known as "17-P" Given prophylactically if preterm labor with prior baby IM weekly from 12-20 wk to 37 wk Corticosteroids: Enhances fetal lung maturity by stimulating surfactant production. Given between 24-34 wks If signs of PTL or at serious risk Betamethasone (Celestone) Most commonly used 12 mg IM q 24hrs x 2 doses Dexamethasone Less common 6 mg IM q 12hrs x 2 doses These are the only two meds that are proven to improve outcomes of pre-term labor May do vaginal progesterone suppositories or IM injection of 17-p and helps women maintain their pregnancies longer The suppositories are expensive Corticosteroids can be given on outpatient basis if we think she is going to be given soon Given 24 hours apart in two injections for betamethasone Betamethasone needs 24 hours to work so the plan is to think ahead for a women who is at risk for pre-term birth to help mature the lungs Most of the other things done to help prevent pre-term labor are done to help give the steroids time to kick in

Trimesters

1st trimester - week1 to 12 weeks 2nd trimester - week 13-28 weeks 3rd trimester -week 29-40 weeks

Defining parity

5 Digit System 2 Digit System G- gravidity G- gravidity T-term births P- parity P-preterm births A-abortions L-living children

Facts abut jaundice

60% of term newborns have physiologic jaundice in the first week of life, however few have significant underlying disease. Hyperbilirubinemia in the newborn can be associated with severe illnesses: Hemolytic disease Metabolic and endocrine disorders Infections Anatomical abnormalities of the liver.

Uterine Rupture

Obstetric emergency onset marked by sudden fetal bradycardia Nursing Assessment Risk factors - prior c/s Onset of sudden fetal distress (most of the time) Ineffective contractions- a uterus that is ruptured cannot contract well No fetal descent with pushing Nursing Management Preparation for urgent cesarean birth Continuous maternal and fetal monitoring Rarely does it happen spontaneously, usually occurs with women who have had a prior C-section 1-2% risk of uterine rupture with labor for someone who has had a C-section in the past In some ruptures they can repair the uterus, in some ruptures they have to do a hysterectomy Lump in lower abdomen can be a rupture in uterine where the fetal head is pushing out slightly Can effect pregnancy later on Continuous fetal monitoring for women who are at risk of uterine rupture Women can lose 50% of their blood volume before you see changes in their blood pressure

Bleeding in pregnancy

Obstetric hemorrhage is the leading cause of maternal death worldwide 2nd leading cause of maternal death in the United States Bleeding can occur at any time during pregnancy - should always be evaluated Possible causes in the first 20 weeks of pregnancy Spontaneous abortion, uterine fibroids, ectopic pregnancy, gestational trophoblastic disease (GTD), and cervical insufficiency Possible causes in the second 20 weeks: Placenta previa, placental abruption, and placenta accreta Bleeding in pregnancy is a big concern Cervical insufficiency usually does not have a lot of bleeding

Nursing management of labor

Obtain History: Current labor, birth plan, current pregnancy and complications, previous pregnancies and complications, general medical history, and support system. Assess uterine contractions for frequency, duration, intensity, and resting tone. Assess FHR for baseline and decelerations. Assess cervical changes, membranes and vaginal discharge Obtain a history of what is bringing her to the hospital. When did contractions start? Are membranes intact? She may not understand what that means so you might need to ask if she feels like she's leaking fluid. Obtain information about the current pregnancy. What are two of the most important pieces of information from her prenatal history? Blood type and Group B strep status Ask her who her support people are? Sometimes its better to ask her this while nobody is in the room. The person who brought her to the hospital may not be the person she wants to be in the labor room with her. But that person may want to be. Obtain an assessment of labor data: contractions, fht's, cervix, membranes

Passive Immunity

Obtained from the placenta or colostrum Donor antibodies may be used in children & adults who have weakened immune systems and may not be candidates for routine vaccinations. Rabies immune globulin Hepatitis A gamma globulin Less used now that there is a vaccine for Hepatitis A Passive immunity provides short term protection One pertinent example of passive immunity is the practice of immunizing pregnant women with the Tdap vaccine between the 27th-36th week of pregnancy. This provides PASSIVE IMMUNITY to the newborn for the first 4 weeks of life. This is the period when an infant is most susceptible to pertussis. The response of the mother to the vaccine passes through the placenta to the fetus providing temporary protection until about the time the infant is old enough to be vaccinated.

Blood incompatibility

ABO incompatibility: type O mothers and fetuses with type A or B blood (less severe than Rh incompatibility) Rh incompatibility: exposure of Rh-negative mother to Rh-positive fetal blood; sensitization; antibody production; risk increases with each subsequent pregnancy; and fetus with Rh-positive blood Nursing assessment: maternal blood type and Rh status Nursing management: RhoGAM at 28 weeks ABO incompatibility deals mostly with newborns where moms who are O blood type and the baby is not O blood type and there are issues for the baby Rh sensitization is when a mom is Rh negative and becomes pregnant with a possible Rh positive baby and the mom can create antibodies to the Rh positive fetal cells and she needs rogam at 28 weeks and again post partum IF the baby is Rh positive, NOT If the baby Is Rh negative

Newborn assessment- abdomen

Abdomen Umbilical cord One vein and two arteries- should be able to see those vessels Single artery may be associated with renal and GI anomalies; SGA infants Whitish blue-gray, contains a gelatinous tissue called Wharten's jelly Inspect for bleeding, infection, inflammation, drainage, and redness Auscultate bowel sounds Reflexes Rooting, sucking, gag, Moro, tonic neck, Babinski, swallow, blink, burp, hiccup, palmar grasp, plantar and sneeze A two vessel cord often means nothing but other times it is associated with small for gestational age babies or other defects (variation in their normal makeup that is not quite normal) like an anus that is not patent and sometimes associated with a heart defect These reflexwes tell us that their neuro system is intact Some females have a mucus or bloody discharge (called pseudo menstration) due to moms residual hormones and should reassure parents

Leopold Maneuvers

Abdominal palpations used to determine fetal presentation, fetal lie, fetal position and engagement.

Normal FHR Tracing

Accelerations present, baseline within normal range Reactive NST (non stress test) Category I tracing

Nursing management for H&P related to preterm labor

Accurate and thorough... Health history- prenatally or on admission to the hospital Obstetrical history Medical history Assessment Implement Best Practice Assist with diagnostic testing Administer prescribed treatment Educate client and support system H&P is very important for pregnancy Knowing that most cases of pre-term labor are multi-factorial and come from multiple medical diagnoses and they think there is a strong genetic component to pre-term labor Social factors can be changed to help pregnant women like through the family medical partnership which is where a nurse is paired with high-risk (usually young) around the 28th week and follow them for two years after delivery and it has been proven to reduce pre-term labor, increase rates of breastfeeding and HS graduation because it changes the social factors

Acquired disorders versus congenital disorders

Acquired disorders Typically occur at, or soon after, birth Problems or conditions experienced by the woman during her pregnancy or at birth Possibly no identifiable cause for the disorder Congenital disorders Present at birth; usually due to some type of malformation occurring during the antepartal period; typically some problem with inheritance Majority with a complex etiology

Acute Otitis Media

Acute onset of ear pain with a red, bulging, nonmobile tympanic membrane upon otoscopy Diarrhea, vomiting, and fever common Behaviors typically noted with AOM: Ear pulling Irritability "Acting out" Night awakenings with crying d/t increased pressure when prone or supine Poor feeding Acute otitis media: symptomatic, especially ear pain (otalgia), whereas the latter is most commonly without acute symptoms. The most common bacteria isolated from the middle ear in AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.[1] Prevention: pneumococcal conjugate vaccine has been linked to a reduction in acute otitis media (pg 1206) Acute otitis media in children with moderate to severe bulging of the tympanic membrane or new onset of otorrhea (drainage) is not due to external otitis. Also, the diagnosis may be made in children who have mild bulging of the ear drum and recent onset of ear pain (less than 48 hours) or intense erythema (redness) of the ear drum.

Anesthetic pain relief during labor

Advantages Superior pain relief Provides pain relief for laceration and episiotomy repair Labor epidurals allows rapid cesarean delivery if necessary Beneficial for patients in whom general anesthesia is a risk Contraindications Coagulation disorders Platelet count must be above 100 Maternal hypotension Nonreassuring FHR requiring rapid delivery Maternal inability to cooperate with placement Allergy to local anesthetics Last dose of low-molecular-weight heparin within 12 hours Risky anesthesia - history of difficult intubation, abnormalities of face or neck, severe medical complications such as cardiac or pulmonary compromise.

Labor anesthesia

Adverse events Maternal hypotension High spinal block FHR changes Headache Maternal fever Very important to bolus with IV fluids prior to epidural placement to prevent hypotension. Hypotension can lead to fetal heart rate changes.

Nursing Priorities: Immediate newborn period

Airway maintenance- most important Maintaining body temperature- the best way is skin to skin with mom and a blanket overtop one the infant is dry, use a cap to prevent thermal loss by the scalp Promoting parent-infant interaction Early initiation of breast-feeding- helps infant regulate blood glucose and temperature better and it helps facilitate breastfeeding down the line Safety- in hospital you want the parents to be told that they should not let someone without proper ID and someone they don't know to take their baby, also matching ID bands Establishing ABCs, airway breathing and then circulation where as with adults it is CAB circulation, airway, breathing

Non-infectious conjunctivitis

Allergic Seasonal Genetic predisposition School-age child Chemical Reaction to prophylactic eye treatment Allergic Conjunctivitis - instruct parents and children to wash the child's hands after coming in from playing outdoors. Have the child bathe or shower at night before bed to reduce exposure to allergens. Chemical Conjunctivitis - an example of this is neonatal reactions to silver nitrate eye ointment. Silver nitrate was used several decades ago for prophylactic eye treatment in the newborn. Because of burns and reactions in the infants' eyes the standard is to use erythromycin eye ointment.

Mood in pregnancy

Ambivalence Pregnancy may be unplanned Woman may be fearful about family, partner, societal expectations Usually resolves by 2nd trimester. Introversion Normal to focus on self Heightened in 1st & 3rd trimesters May participate less with outside world. Acceptance Physical changes generate acceptance, make pregnancy seem real. Mood swings Mood lability common Family and partner may not understand. Changes in body image Women vary in perception of their image during pregnancy. Can be a source of great stress for some women. Some women feel confident and attractive during pregnancy. Other women feel overweight and uncomfortable throughout pregnancy.

Recommended infant nutrition

American Academy of Pediatrics (AAP) recommends infants be breastfed exclusively for first 6 months of life. Breastfeeding should continue for at least 12 months and thereafter as desired. Complementary foods can be introduced after 6 months. Breastfeeding is recommended for infants exclusively for the first 6 months Growth is the best indicator of adequate nutrition Complementary foods like rice cereal, add foods one at a time

Maternity cycle

Antepartum Intrapartum Postpartum

Polycystic Ovarian Syndrome - Appearance

Appearance: Hirsutism Increased acne and oily skin Weight gain...usually around the waist Male-pattern baldness or thinning hair Patches of dark brown/black skin around skin folds Skin tags

GI system postpartum

Appetite: Most new moms are VERY hungry after recovery from analgesia, anesthesia, and fatigue. Bowel Evacuation: Spontaneous bowel evacuation may not occur for 2-3 days after childbirth. Encourage eating...however, some side effects of anesthesia (nausea/vomiting) can cause a sick stomach...have them eat slowly. Why have the bowels slowed? Because they were not the priority while mom was delivering. We usually give a stool softener, colase, after delivery for this reason

Pre-term labor: Definition

Applies to labor between 20-37 weeks Regular uterine contractions AND Documented cervical effacement and/or dilation Pre-term birth accounts for a significant amount of infant mortality and morbidity and goes along with cerebral palsy Significantly associated with hypoxic events, asphyxia, and brain injury (because of their immature neural system they are at an increased risk of cerebral vascular accidents) Incidence of pre-term birth is increasing in US as we do more things to pregnant women to try and help them and moms are just sicker (HTN, diabetes) and we are saving younger and younger babies Definition of preterm labor is anywhere between 20-37 weeks because 20 weeks is "textbook" gestational age of viability (even though its not technically viable) but it counts as one of her para's so that is why 20 is the low number. The woman is contracting regularly and has documented cervical effacement or dilation 6 or more contractions in an hour is considered regular uterine contractions in a pre-term pregnancy and she needs to be evaluated Definition of full term starts at 39

Birth-weight variations

Appropriate for gestational age (AGA): approximately 80% of newborns; normal height, weight, head circumference, body mass index Small for gestational age (SGA): weight <2,500 g (5 lb 8 oz) at term or below the 10th percentile Large for gestational age (LGA): weight >90th percentile on a growth chart; weight >4,000 g (8 lb 13 oz) at term SGA babies can be preterm or possibly not (could have had a TORCH infection or other issue) Usually LGA infants are a product of a diabetic mother who's sugars are not well controlled but could also be inherited Low birth weight (LBW): infant weighing <2,500 g or 5.5 lb Very low birth weight (VLBW): infant weighing <1,500 g or 3 lb 5 oz Extremely low birth weight (ELBW): infant weighing <1,000 g or 2 lb 3 oz As your birthweight goes down the neonatal outcomes become worse They usually will not resuscitate an infant who is less than 500-800 grams (usually these are the 23 week old babies)

Food concerns antepartum

Artificial Sweeteners Mercury (so do not eat more than one to two servings of fish per week, no tuna or shark, do not eat fish that eat other fish) Listeriosis (deli meat, hot dogs, lunch meat, all needs to be avoided and if you want to eat it you have to eat it higher, also no cold smoked meats either)

Nursing care- stage 1

Assess fetal heart rate, maternal vital signs, monitor pain, observe contractions with fetal heart rate, labor graphing begins, assist with breathing techniques, and keep bladder empty every 2 hours. Normal Finding for vital signs: FHR in labor 110-160 Maternal BP < 140/90 or change in baseline < 30 systolic and 15 diastolic Maternal pulse < 100 bpm. Maternal temperature < 100.4 A full bladder can slow labor down but a woman with an epidural needs her bladder emptied by in and out cath because she is unable to empty her bladder by herself Stage one is from time labor begins to full dilation

Nursing care- stage four

Assess for any possible complications, postpartum hemorrhage, uterine over distention, and bladder distention. Bed rest for first 2 hours. Monitor vital signs Assess and palpate fundal height and firmness Assess lochia Assess perineum Monitor pain Administer analgesics as prescribed If narcotics are given maintain safety precautions. Offer fluids Ice packs to perineum Assess mom every 15 minutes first hour then second hour if she is stable can move to every hour. Fundal checks every time Most common cause of post partum hemorrhage is uterine atony (uterus that does not stay firm or tone) Women are usually very hungry after giving birth so make sure there is something for them to eat Allow extended time with newborn. Share in joy of the birth Initiation of breastfeeding. Perform routine newborn admission with parents. Withhold eye prophylaxis for up to 2 hours.

Nursing care- stage 3

Assess for placental separation. Mother will continue to have contractions. Palpate fundus Monitor vital signs q15min Observe for blood loss Prepare for administration of Uterine stimulant. Cleanse perineal area: Do not touch inside of pad. Apply warm hat on newborn. Standard of care for a women to get a bolus of oxytocin either right after the baby or after placenta and that bolus helps reduce a woman's risk of post partum hemorrhage. Can be IV but can also be IM if they do not want or have IV access Ice on the peritoneum for the first 24 hours then go to heat after that

Assessment of the eyes

Assess for position and symmetry. Check for presence of strabismus, nystagmus, and squinting. Assess if eyelids open equally (failure to open fully is ptosis). Note variations in eye slant and the presence of epicanthal folds. Assess for eyelid edema, sclera color, discharge, tearing, and pupillary equality, as well as size and shape of the pupils.

Neonatal resuscitation

Assess heart rate within 30 seconds For a heart rate below 100 initiate rescue breaths using positive pressure ventilation or a T-piece resuscitator. Heart rate below 60, initiate chest compressions You have to be NRP certified (CPR for newborns and neonates) One way to check the heart rate is to palpate the cord close to the babies belly

Nursing care in labor

Assess patient's general physical status, including pain and discomfort. Assess labor progress Assess her psychological reaction to labor. These assessments are ongoing with the exception of history. Vaginal Examination Assessment of vaginal drainage continues through labor. Moderate amounts of discharge are common, and linens should be changed to provide comfort. Vaginal examination to assess the progress of labor continues through the first stage of labor. Assessment of vaginal drainage means the nurse is monitoring for rupture of membranes or if membranes have ruptures what color is the fluid. Is the fluid clear? It should be. Is the fluid green or greenish-yellow? This would indicate the baby has had a bowel movement in utero and this is called meconium stained fluid. Is the fluid red or pink? Pink may mean it is mixed with bloody show but red may mean there is intrauterine bleeding. Keep the patient clean and dry as much as possible. Labor can be messy. Not always, but a lot of times. Some women think after their water breaks it will stop but it doesn't. It keeps coming out. The cervix is assessed periodically for change to see how labor is progressing. This is determined on a case by case basis. Some providers like for it to be done every two hours. Some providers take a wait and see approach.

Magnesium sulfate: nursing assessment

Assessing for magnesium toxicity. VS: q15 initially q 30 - 1hr depending upon acuity Neuro: DTR's and LOC Renal: Notify MD of urine output < 30cc/hr Respiratory: breath sounds & O2 sats - notify for < 95% pulmonary edema is a risk because they are more prone to fluid shifts due to endothelial damage so fluid moves readily from the intravascular space to the extravascular space Vision changes Usually, before delivery a mag sulfate assessment will remain q15min or q 30 until at least 4hrs postpartum and then go to q one hour. The pre-eclamptic patient is at increased risk of magnesium toxicity due to renal compromise. Inability to clear magnesium due to poor renal perfusion creates increase in magnesium level which increases symptoms. 5-8 is the therapeutic range of magnesium in patients taking this Really sick women you need to do hourly intake and output but for women who are not as sick then you can do every 4 hours Therapeutic magnesium level for a patient on MgSO4 is 5-8. Step one of mag toxicity: STOP THE INFUSION

Care and management in antepartum

Assessment techniques Interview Health History Medical, Family history, social history, history of abuse "How do you feel about being pregnant?" Important question to ask Watch & Learn Videos in CoursePoint 1st trimester 2nd trimester 3rd trimester Fundal measurement, over the top of the fundus and however many cm it is should correlate roughly with how many weeks gestation. Only accurate up to 32 weeks then it becomes less accurate

Impact of substance use of pregnancy

Avoidance of obtaining care Substance abuse/use increases risk of medical complications in both mother & poor birth outcomes in the newborn Remember, the placenta is not a filter

Something to think about with preeclampsia

BP normally decreases early in the second trimester as a normal process of pregnancy then returns to baseline. This may be exaggerated in a woman who is a chronic hypertensive. What might this mean if she enters prenatal care after 20 weeks? We may miss an early diagnosis of preeclampsia and gestational HTN because we might miss that rise in blood pressure What might it mean for the fetus?

Infectious Conjunctivitis

Bacterial Staphylococcus aureus Haemophilus influenza Streptococcus pneumoniae Viral Adenovirus Herpes simplex virus Conjunctivitis -a ***highly*** contagious infection characterized by edema and/or inflammation of one or both eyelids, redness of the conjunctiva, and enlarged preauricular lymph glands. NICUs take conjunctivitis very seriously. Bacterial conjunctivitis is usually unilateral. Most cases are caused by hand-to-eye contact and can spread rapidly between children and youth. Hib is not the same as the flu virus. It can cause conjunctivitis, pneumonia, meningitis. Etc. Viral conjunctivitis symptoms are very similar to bacterial but viral tends to be bilateral. Spread by hand-to eye contact or by transfer during birth in the case of HSV or by contact with an infected person with HSV at any age. Opthalmic herpes usually also shows up with a lesion on the face. Opthalmia neonatorum is conjunctivitis in a newborn or infant under 30 days of age. Usually acquired during birth Opthalmia neonatorum Chlamydia trachomatis **Infant at risk for developing chlamydial pneumonia** Neisseria gonorrhoeae (gonorrhea) **infant at risk of blindness** HSV Opthalmia neonatorum is conjunctivitis in a newborn or infant under 30 days of age. Usually acquired during birth. Onset of conjunctivitis with chlamydia is usually 5-14 days. Inflammation of eyelid is minimal. Corneal involvement is rare. The primary risk is pneumonia. Gonorrhea causes purulent discharge, extensive inflammation of the eyelids and the cornea and may cause corneal rupture. Onset is within 2-3 days. This is treated with broad spectrum topical antibiotics HSV is treated aggressively to prevent neurological involvement or to treat neuro involvement if the virus is detected in spinal fluid on lumbar puncture. Topical trifluridine, vidarabine. Parenteral acyclovir for 14 days or longer. Lesions may recur due to the nature of the virus.

Thermoregulation of the newborn

Balance between heat loss and heat production Heat production: primarily through nonshivering thermogenesis Heat loss via four mechanisms leading to cold stress Need for a neutral thermal environment Overheating Large body surface area Limited insulation Limited sweating ability Babies need to rely on glucogen and glucose stores in the liver to stay warm but we don't want them to have to do that so we wrap then, put a cap on them, dry them off When babies are too hot then try to take the cap off to cool them down When babies are cold stressed they use more oxygen so respiratory rate increases, then the baby starts burning glucose and glycogen stores in the liver to stay warm, if this continues it could lead to metabolic acidosis

Fetal bradycardia

Baseline less than 110 bpm. Can lead to decreased cardiac output, which causes a decrease in umbilical blood flow that leads to decreased oxygen to the fetus causing fetal hypoxia. Unresovled this can lead to fetal hypoxia and needs immediate intervention Less than 80 is an EMERGENCY! And sudden profound bradycardia is an emergency! Called terminal bradycardia Maternal causes: supine position, dehydration, hypotension, aburption of placenta Fetal causes: fetal repsonse to hypoxia, head compression.. Consider delivery if stays down Bradycardia with a loss of variaiblity or late decels is associated with current or impending fetal hypoxia

Pre-term labor: other treatments

Bedrest & Hydration: Unproven, continues to be prescribed Calcium Channel Blockers: Nifedipine- most common CCB Relaxes uterine muscle to quiet the uterus which can affect placental blood flow Given to women who are relatively stable, even if the have PPROM they may try to maintain the pregnancy and just monitor very closely Prostaglandin Synthesis Inhibitors: Used-ONLY before 30 - 32 weeks because it is in the class of NSAIDs and can cause bleeding Indomethacin Some patients feel more reassured if they reduce their activity because they feel like they are decreasing their risk but it is important to educate about the mom needing to be active to some extent if she can to help avoid risk of blood clot and offer reassurance for moms

HTN disorders: conservative management

Bedrest, quiet room Daily weight (to watch for increased edema) Fetal Surveillance (assessing fetal well being) Non-stress test Fetal movement counts Ultrasound for growth and amniotic fluid volume Doppler flow studies via ultrasound of umbilical cord 24 hr urine for protein There is some debate about whether or not bed rest is good for pregnant women Sometimes they will do modified bed rest where they are told to rest whenever possible They want it to be under 300g of protein in a 24 hour urine

Nursing roles and responsibilities

Beginning the preconception counseling process and referring for further genetic information Taking a thorough family history Scheduling genetic testing and procedures Explaining the purposes, risks/benefits of all screening and diagnostic tests Answering questions and addressing concerns Providing emotional support Recognizing ethical, legal, and social issues Safeguarding privacy and confidentiality Monitoring emotional reactions after receiving information Referring to appropriate support groups

Uterine Fibroids

Benign tumors of smooth muscle Unknown cause Occurs in 40-60% of women Common cause of menorrhagia Pregnancy still possible depending upon extent Symptoms determine treatment Can cause very heavy bleeding Uterus tries to expel the fibroid by bleeding, trying to rid the body of what it considers a foreign object Usually advised not to labor and to have a C-section instead of vaginal delivery

Tocolytic therapy: terbutaline

Beta-mimetics (i.e.Terbutaline): Usually given to flush out false pre-term labor, if it is given and contractions stop then we know it was false labor Usual dose 0.25 mg SQ one time dose or in incidence of fetal distress Short term therapy Side effects: Effective within a few minutes, lasts about 1 hour Increased maternal and fetal HR (warn mom & monitor) Can repeat every 30-60 minutes. Maximum 1 mg over 4 hours Do not give if maternal pulse above 120 bpm Do not give for HTN or pre-eclamptic mom because it makes her more prone to pulmonary edema Not super commonly given anymore Terbutaline can be given to quiet uterus, similar to epinephrine and is a smooth muscle relaxer and is also given for intrauterine resuscitation measures

Substance exposure during pregnancy- alcohol

Between 10%-20% of women report using alcohol during pregnancy Alcohol use during pregnancy may cause fetal alcohol spectrum disorder (FASD) which leads to learning disabilities and hyperactivity. It is the leading cause of intellectual disability in children Maternal effects of alcohol use during pregnancy may include SAB, inadequate weight gain, and IUGR

LGA newborns: common problems

Birth trauma- dystocia, even if the baby is born by C-section, physical trauma from trying to get the baby out, or hypoxic event from a delay in birth Hypoglycemia- due to large body mass, may have difficulty feeding Polycythemia- may have a red ruddy appearance, but slightly different than a pre-term or SGA infant (LGA become plethoric) Hyperbilirubinemia- because the red blood cells are going to break down which increases the free bilirubin which the baby can have trouble clearing

Etiology of OB Hemorrhage

Bleeding can happen at any point in pregnancy Most postpartum hemorrhage is due to uterine atony The uterus is going to work very hard to dispel placenta but when it wont come out the uterus is going to try and rid itself of those contents Can bleed a lot with a cervical laceration because the cervix is very vascularized

Cardiovascular System postpartum

Blood Volume: Changes in blood volume depend on several factors: Blood loss during childbirth. Amount of extravascular water mobilized and excreted. Pregnancy-induced hypervolemia allow most women to tolerate blood loss during childbirth. Cardiac Output: Remains increased for 48 hours after birth. Increased stroke volume (SV) is caused by the return of blood to the maternal systemic circulation. Stroke volume, end-diastolic volume, and systemic vascular resistance remain elevated for 12 weeks after delivery. Monitor: Vital signs Labs: Hemoglobin, Hematocrit, WBC, Coagulation Factors Blood volume: increased during pregnancy to help support fetus. Now is decreased due to birth and additional blood loss in some cases. Body gradually decreases cardiac output over time to help mother achieve homeostasis. This state the mom is in is a hypercoaglulable state

Integumentary changes in pregnancy

Blood flow to the skin increases 3-4x above prepregnant levels. Hence, the "Glow." Stretch marks may appear on breasts, hips, thighs, and abdomen. Darkening of the nipples, areolae, and perianal area occurs secondary to estrogen and progesterone. Linea nigra - a pigmented line down the abdomen from the symphysis to the sternum forms in some women. Melasma, the "mask of pregnancy" may develop in some women. Some women get pigmentation changes on their face

HTN: False positives

Blood pressure readings can be erroneous due to: User error Patient position Anxiety Cuff size Drug exposure Best position for women to take BP is sitting up, feet flat on the floor, an "active position", you also want to make sure not to check BP while she is flat on her back because it can make it false high and you don't want the placenta laying on the vena cava After the 20th week women should not be laying on their back and they need to be at least semi-fowlers or higher Cigarette smoking also increases BP

Bloody show

Bloody show There is an increase in the amount of vaginal discharge and a blood-tinged mucus. This "show" is the mucus that occluded the opening of the cervix during pregnancy (mucous plug). Vaginal examination may show the cervix has begun to change consistency; softens, thins (effaces), and opens (dilates). One of the most positive signs of labor is bloody show. Bloody show is not just blood. It's bloody mucus. So, the mucus plug that may have been starting to show itself a week or so ago after a cervical exam that was clear was nothing. That was mucus from the outer os of the cervix. Bloody show is mucus from up inside the cervix. What this tells us is that the cervix is making significant change - the gates are opening. The cervix is dilating, opening, and effacing and all of that vascularity in the cervix becomes exposed temporarily and bleeds into the mucus that is there. Not all women have bloody show. When women would present with complaints of bleeding one of the descriptors I would ask besides bright red, dark red, brown, etc. was did it look like strawberry jam? That would tell me that it was most likely bloody show versus a hemorrhage of some kind. Should look more like strawberry jam

Newborn assessment- measurements

Body size and shape Head is disproportionately large for its body The abdomen is prominent with a smaller chest and narrow hips Average weight3400 g (7lbs,8oz) Average length 20 in. (50cm) Head circumference 13-14 inches (33cm to 35.5 cm) Obtain measurements not long after birth. Infant will lose water weight within 24 hrs.

Preterm newborn

Body system immaturity affecting transition to extrauterine life; increasing risk for complications Respiratory system Cardiovascular system GI system Renal system Immune system Central nervous system They do not adapt as well to extra-uterine life because of immature systems Biggest issues are immature respiratory and GI tract Respiratory system immaturity is a significant cause of mortality in pre-term infants

Passageway

Bony pelvis 4 basic types Pelvic floor muscles Helps fetus to rotate anteriorly as it passes through birth canal Cervix Thins (effaces) and opens (dilates) Vagina Introitus (external opening to the vagina) Four types of pelvises: Gynecoid Android Anthropoid Platypelloid The tone or strength of the pelvic floor muscles help provide resistance for the fetus to move against as it travels through the birth passage. Counter pressure to the back can be very helpful for women who are laboring where the baby is face up.

Unexpected findings- fetal bradycardia

Bradycardia- FHR less than 110 for longer than 10 minutes Moderate decrease 100-110 bpm. Marked decrease to less then 100 bpm. Significant if variability is decreased or absent and having late or variable decelerations Lasts 10 minutes or more Nursing Interventions: Dependent upon scenario Notify provider and request bedside evaluation Vaginal exam to rule out prolapsed cord Intrauterine resuscitation measures Hypoxemia d/t acute decrease in blood flow, vagal stimulation, Sometimes d/t heart block related to congenital anomaly Also may be a low normal 100-105 Some babies have a normal low FHR Most of the time is a result of a hypoxic event

Uterine contractions during labor

Braxton Hicks contractions begin to feel stronger and more frequent. Occur primarily in the abdomen and groin. May be very uncomfortable When to be evaluated? Regular contractions that become increasingly uncomfortable and close together and do not go away with activity Primigravidas: Uterine contractions that are five minutes apart lasting 1 ½ - 2 minutes x 1 hour. Multigravidas: Uterine contractions 5-8 minutes apart lasting 1 ½ - 2 minutes x 1 hour. Some patients have Braxton-Hicks contractions throughout their pregnancy. Others may not feel contractions until the very end. These contractions gradually become more organized. Often they can be quite painful. Often they are only in the abdomen and groin. I don't want you to focus too much on the location of the contractions because its different for everyone and there's no hard and fast rule about where a real contraction hurts. Textbooks will say true contractions hurt here or there but it just is not always the case. Many patients will be very uncertain and confused by these contractions and will come in to be evaluated. When they learn they aren't in labor it can be very discouraging. They're frightened they'll go home and not get back to the hospital in time. Sometimes a patient may make several trips to the hospital before finally being admitted.

BUBBLE-EE

Breast Uterus Bowel Bladder Lochia Episiotomy (Laceration) Extremities Emotional Status

Breasts postpartum

Breastfeeding moms: Colostrum will be expressed first, followed by regular lactation. Breasts will become fuller & heavier, due to increased milk production in (72-96 hours after birth). Non-breastfeeding moms: Engorgement resolves spontaneously and discomfort decreases within 24-36 hours. Colostrum? What does it contain? Colostrum is very rich in proteins, vitamin A, and sodium chloride, but contains lower amounts of carbohydrates, lipids, and potassium than mature milk. The most pertinent bioactive components in colostrum are growth factors and antimicrobial factors. The antibodies in colostrum provide passive immunity, while growth factors stimulate the development of the gut. They are passed to the neonate and provide the first protection against pathogens.

Nursing interventions for feeding

Breastfeeding within 30-60 minutes of birth Skin-to-skin between mother & newborn Breastfeeding 8-12 times per day Feeding in response to readiness cues and not on a schedule Preventing prolonged crying spells as this rapidly depletes glycogen stores. Initial period of skin to skin, babies do not always latch to the breast but it is still important for the baby to be there, mom is a regulator Hunger cues- chewing on hands, following mom with eyes, lip smacking Want to avoid long crying spells because then the baby is using up more glucose than a baby who is calm

Pre-term labor diagnostic testing

CBC- to check WBC, Platelets, hemoglobin Urinalysis- to check for UTI or dehydration Fetal fibronectin swab (FFN) A swab of the vagina in the space behind the cervix to test for fetal fibronection Negative test indicates preterm delivery within the next 2 weeks is unlikely Nothing in the vagina (blood, lubricants, intercourse, cervical exam) within 24 hrs of the test Ultrasound for cervical length- this is a vaginal ultrasound Cervical length of 3cm's or more indicates preterm delivery in next 14 days is unlikely Cervical length of 2.5cm's or less increases risk of preterm birth prior to 35 weeks gestation, or funneling shape Fetal fibronection is the substance between the amnion and the uterus and if a woman has been contracting or is making some cervical change then her body is going to release the fetal fibronection and if its positive then it means she may go into labor in the next two weeks but things can make it falsely positive like a cervical exam recently, lubricants or blood A negative test is more predictive that mom is not going to go into labor in the next two weeks Ultrasound may be done weekly for cervical length in women who have had pre-term labor in the past or incompetent cervix

Substance exposure during pregnancy- caffeine

Caffeine- If pregnant do not consume more than 300mg of coffee per day. The effect of caffeine during pregnancy on fetal growth and development is still unclear. Caffeine has no research documenting teratogenic effects.

Amniocentesis

Can be performed during any trimester of pregnancy. Amniocentesis in early pregnancy (11 to 14 weeks) is associated with high risk of spontaneous miscarriage. Recommended time to begin using amniocentesis for diagnostic value is 14 to 16 weeks. Needle aspiration of amniotic fluid, recommend that they do the test as late as possible (14-16 weeks) but it can be done as early as 11 weeks and this gives results about neural tube defects because you are testing fluid Invasive and has risks associated with it Diagnostic tests Also used to test for fetal lung maturity if they need to induce early

Vaginal infections affecting pregnancy

Candidiasis Most common cause of vaginal discharge Not a sexually transmitted infection Trichomoniasis Most transmission is via sexual contact Protozoan parasite Bacterial vaginosis Thin white or gray malodorous discharge Pain, itching, or burning in and around the vagina Dysuria Yeast infections more common in pregnant women because of changes in pH Important to not douche or change pH, wear cotton underwear, good vaginal hygiene Bacterial vaginalis is treated with flagill

Caput vs. cephalhematoma

Caput is across the midline and above the periosteum Cephalohematonma does not cross the midline and is below the periosteum Important to reassure parents that this is part of the process and that their baby will get through this and the swelling will go down Hematomas don't always develop right away sometimes they take a little while to develop

Caring for the newborn with NAS

Care is individualized with developmental considerations to facilitate self-consoling and self-regulating behaviors. Both non-pharmacologic and pharmacologic measures may be needed in the care of the infant with NAS. Non-pharm NAS care When NAS has been identified in the infant nursing care is directed toward treating the presenting signs, decreasing stimuli that may precipitate hyperactivity and irritability. Dim lights, decrease noise level, provide cluster care. Provide adequate hydration and nutrition, and promote mother-infant or parent- infant bonding. Infants are difficult to comfort and may cry for long periods of time. It is important to establish rapport and contact with the families for follow up. Withdrawal symptoms can develop after the infant gets home. Methadone or morphine may be used to treat symptoms of withdrawal. Breastfeeding is encouraged for mothers on MAT. Mothers should not abruptly stop breastfeeding or symptoms of withdrawal in the baby can worsen.

FHR Interpretation nomenclature

Category I - Normal Normal FHR baseline, regular rhythm, presence of accelerations, absence of decelerations Category II - Indeterminate Any of the below Irregular rhythm Decreases from baseline or decelerations Tachycardia Bradycardia Category III - Abnormal Absent variability AND Recurrent late decelerations, variable decelerations, bradycardia or sinusoidal pattern This is where you usually see a very straight line Category II: findings cannot be classified as abnormal as variability cannot be determined by auscultation. Regquires evaluation, ongoing surveillance, and reevaluation. Sinusoidal patterns are associated with bad outcomes and fetuses that have had intrauterine seizures

Spontaneous abortion

Cause unknown and highly variable First trimester commonly due to fetal genetic abnormalities Second trimester more likely related to maternal conditions Nursing assessment Vital signs Vaginal bleeding - amount, color Cramping or contractions Pain assessment Assess client's understanding Use lay terms

Maternal serum screening

Cell-free DNA analysis (cf-DNA) - Harmony, MaterniT21 Maternal blood draw; fetal cells in moms blood is what they are looking for Screening/not diagnostic Performed after 10 weeks gestation Checking the risk for down syndrome and can tell the gender of the baby, not diagnostic of anything it is just a screening so it would be like "high risk for" rather than being positive for it Alpha-fetoprotein (AFP) or maternal serum alpha-fetoprotein (MSAFP) Produced in the spinal column of the fetus, not always very accurate in determining if a fetus has down syndrome so it is done in conjunction with other tests (the triple test) Triple screen (AFP, hCG, unconjugated estriol) Neural tube defects, defects in the abdominal wall of the fetus Testing for the fluid in the fetuses spinal column and if that's detected then they know spinal fluid is leaking out of the fetuses spinal column Have to have very accurate data on moms age, due date, and whether or not she is having a single or multiple pregnancy Quad screen (Triple screen plus Inhibin A) Performed between 15-18 weeks: For accurate results information regarding gestational age, maternal demographics and medical history must be complete. High levels indicate neural tube defects, defects of the abdominal wall, and intrauterine fetal demise (IUFD). Low levels indicate chromosomal trisomies. (downs syndrome)

Neurologic system adaptations

Cephalocaudal and proximal to distal development patterns Acute senses of hearing, smell, and taste Adaptations of other organ systems indicate central nervous system transition Reflexes: indication of neurologic development and function Develops from head downward and from proximal to distal Newborns can smell mom so we try to put them skin to skin right away The substance on the areola smells like amniotic fluid which is a way that newborns adapt and are able to know where the nipple is Vision is not established well so they are only able to see things that are pretty much right up in their face Tells us the infants neurological system is intact when the reflexes are intact at first and slowly start to go away

Trauma

Cervical lacerations Vaginal or perineal hematoma Uterine rupture Vaginal sidewall lacerations Sometimes you can see a hematoma and sometimes you cannot see the hematoma Normally patient will present with pain that is not relieved with analgesics in the peri area and sometimes you can see it and sometimes you cannot see it so you need to let the provider know Can bleed significantly from a hematoma Hematoma can happen from trauma, lacerations that may or may not have been repaired, sometimes can be treated with ice, some have to be lanced and evacuated

Probable signs of pregnancy

Chadwick's sign Violet-bluish color of vaginal mucosa and cervix Hegar's Sign softening and compressibility of the lower segment of the uterus Goodell sign softening and compressibility of the lower segment of the cervix Uterine Enlargement Abdominal Enlargement Uterine Souffle Sound of maternal blood flowing through uterus

Presumptive signs of pregnancy

Changes felt by the woman Amenorrhea N/V Fatigue Urinary Frequency Breast tenderness Quickening

Newborn assessment- eyes and ears

Characteristics Eyes Eyelids may appear edematous Strabismus and nystagmus are commonly seen because they have not developed the ability to focus Nearsighted Ears Upper insertion of the pinna should be even with the outer canthus of the eye Inspect for sinuses and preauricular skin tag Newborn may have edema in the face or eyelids which is not uncommon Ears too low can be indicative of down syndrome or other congenital anomaly like fetal alcohol syndrome

Integumentary system postpartum

Chloasma of pregnancy usually disappears at end of pregnancy. However, can persist in approximately 30% of women. Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth. Some women may experience permanent darker pigmentation of those areas. Stretch marks on breasts, abdomen, and thighs may fade-but, not disappear. Vascular abnormalities: Spider angiomas/nevi Palmar erythema Epulis Hair growth slows during post-partum period. Some women may experience significant hair loss. Spider angiomas/nevi: benign, swollen blood vessels with red center and branching out from source. Palmar erythema: reddening of the palms

Chronic HTN (CHTN)

Chronic hypertension is high blood pressure that is present before pregnancy or that occurs in the first half (before 20 weeks) of pregnancy The guidelines for blood pressure are the following: Normal: Less than 120/80 mm Hg Elevated: Systolic between 120-129 and diastolic less than 80 mm Hg Stage 1 hypertension: Systolic between 130-139 or diastolic between 80-89 mm Hg Stage 2 hypertension: Systolic at least 140 or diastolic at least 90 mm Hg Hypertension that is present at the first prenatal visit, prior to 20 weeks or continues past 12 weeks postpartum CHTN antedates pregnancy OR is diagnosed prior to the 20th week of pregnancy. Severe CHTN is defined as SBP ≥180 mmHg and/or DBP ≥110 mmHg. CHTN: risk of superimposed preeclampsia of IUGR (intrauterine growth restriction) Strongly associated with adverse pregnancy outcomes. Requires baseline labs, fetal surveillance, close supervision. Because with HTN the baby is not able to get perfusion as well and does not grow as well or is restricted Placenta not being perfused as well due to HTN can cause low amniotic fluid levels Women who has chronic HTN need to be evaluated closely

HTN in pregnancy classifications

Chronic hypertension: HTN that is diagnosed before pregnancy or that lasts two weeks post-partum Gestational hypertension: HTN that begins after 20 weeks of pregnancy (diagnosis in hindsight) Preeclampsia: Involves multi-body systems and has different levels of severity. Can occur at any point during pregnancy and also in post-partum Without severe features With severe features Chronic hypertension superimposed with preeclampsia: A women who had HTN before pregnancy and also develops preeclampsia Without severe features With severe features Eclampsia: HTN, preeclampsia and has seizures Seizure activity or coma in woman diagnosed with preeclampsia May also occur with no pre-existing pathology Eclamptic seizures can occur before, during, or after birth Gestational HTN they wont really know that's what it was until after the pregnancy

Preterm labor: nursing management

Client education Teaching Guidelines 21.1 p. 814 Psychological support A lot of this education can take place during pregnancy to help aide with preventative measure because that is most effective Educate client on S/S of pre-term labor and contractions, bleeding, s/s of rupture of bleeding, when to call the doctor,

Substance exposure during pregnancy- cocaine and methamphetamine

Cocaine- Can cause gestational hypertension, abruptio placentae, CNS effects and IUGR Crack is the freebase form of cocaine Methamphetamine- (speed, meth, or chalk) The effects of maternal use during pregnancy are not well known: increased instance of low birth weight, smaller head circumference NAS, preterm births, anomalies, cleft lip palate, and lip, and cardiac defects

PPD Treatment: Therapy and medication

Cognitive Behavioral Therapy (CBT), Talk therapy. A therapist is there to listen and provide strategies to cope with the negative thoughts and feelings. Antidepressants SSRIs Anticonvulsants Benzodiazipenes These drugs can be very effective, but they don't work overnight (at least 2 weeks), and they may have unwanted side effects. Cognitive behavioral therapy (CBT), has been tested and compared with the use of an antidepressant medicine. In some cases, a short course of CBT worked as well as medicine in easing symptoms of postpartum depression. Some women need to be on a combination of medications because women who are at risk of being bipolar who just take antidepressives it can intensify their mood fluctuations The most commonly used antidepressants for postpartum depression come from a group of drugs called selective serotonin reuptake inhibitors (SSRIs) drugs: What are some examples of SSRIs? Zoloft (sertraline) (most common) Paxil (paroxetine) Celexa (citalopram) Prozac (fluoxetine) The meds take some time to kick in so want to educate the patient about that and to do good follow up

Pyshchosocial assessment- perception

Cognitive and perceptual issues Pain is a major concern during labor and delivery. Breathing exercises help reduce discomfort, but as the intensity of labor increases, many women desire some form of analgesia. Self-perception The prepared mother generally feels more able to deal with labor and delivery than does the unprepared one. Multigravidas generally have more confidence. Women who have experienced problems during pregnancy or in past labors and deliveries may need reassurance that they can be successful Pain is a major concern during labor and birth. Some women are ready and prepared and some are extremely frightened. Others know without a doubt they don't want to feel a thing. The point is preparation and maybe even fortune. Some women spend months preparing and no matter how much they prepare it just didn't work out the way they wanted.

Stages of lactation

Colostrum is the first milk, thicker, yellower, full of antibodies, high in carbohydrates and lower in fat, high in protein, helps flush or move the meconium through the intestine to clear out the bilirubin Transitional milk is when the milk starts to transition to milk rather than colostrum Mature milk is regular breastmilk, can sometimes be more blue or white Breastmilk is appropriate for the age of baby that is born (if she has a 34 week baby she will make milk appropriate for a 34 weeker)

Human milk composition

Colostrum, A.K.A Liquid Gold High in protein and antibodies. High in carbohydrate Lower fat content than mature milk. Facilitates binding of bilirubin and promotes passage of meconium with its laxative properties. Establishes normal gut flora. Foremilk has a higher water content Hind milk has a higher calorie content and is more dense Important to breastfeed until the breast feels empty to help the baby get to the hind-milk to keep them satisfied longer In summer they may breastfeed shorter for more frequent amounts of time because they need that more water milk Babies go through growth spurts and so that changes their food needs Feeding more often increases milk production Breast size does not matter for lactation Matches gestational age of the infant. Changes as infant develops. Antibodies Foremilk has a higher water content. Hindmilk is rich in fat content and dense calories. Growth spurts - 10 days, 3 weeks, 6 weeks, 3 months, & 6 months

Surgical site infection R/To pregnancy

Common sites of infection include: Cesarean surgical incisions Episiotomies Genital tract lacerations Symptoms include purulent or serosanguineous drainage Edema Erythema Pain Fever Elevated WBC Treatment may include parenteral antibiotics, wound care Encourage frequent pericare (pad changes and perineal cleansing) Can be given wound vacs, they decrease chance of infection and dehiscence in women who have had a history of that

Compare AGA, SGA and LGA

Compare characteristics seen in infants who are: AGA SGA LGA Risk or predisposing factors Accompanying diagnoses Nursing Management You can have an infant that is SGA and may or may not be growth restricted, growth restricted is a specific definition of a baby where something has happened during pregnancy to restrict the growth of the fetus Can have symmetric growth restriction and asymmetric growth restriction Symmetric growth restriction is where the head is the right size comparatively to body, usually occurs before 28 weeks and happens early in the pregnancy to cause this growth abnormality like STI's, TORCH infections, and because it happens so early that is why the whole body is growth restricted Asymmetric is where head is bigger than body comparatively, usually due to wasting, usually happens later in pregnancy and what happens is you have a normally growing pregnancy until something changes and then there is wasting because the babys nutrition is cut off somehow

Small-for-gestational-age newborns

Conditions affecting fetal growth <28 weeks leading to overall growth restriction (never catch up in size) >28 weeks, intrauterine malnutrition (normal growth potential with optimal postnatal nutrition) IUGR for some SGA newborns (asymmetric versus symmetric) Contributing factors (see Box 23.1) ASYMMETRIC vs. SYMMETRIC GROWTH RETARDATION: Most growth retarded infants have asymmetric growth restriction. First there is restriction of weight and then length, with a relative "head sparing" effect. This asymmetric growth is more commonly due to extrinsic influences that affect the fetus later in gestation, such as pre-eclampsia, chronic hypertension, and uterine anomalies. Postnatal growth after IUGR depends on cause of growth retardation, postnatal nutritional intake, and social environment. Symmetric growth retardation affects all growth parameters. In the human brain, most neurons develop prior to the 18th week of gestation. Early gestational growth retardation would be expected to affect the fetus in a symmetric manner, and thus have permanent neurologic consequences for the infant. Examples of etiologies for symmetric growth retardation include genetic or chromosomal causes, early gestational intrauterine infections (TORCH) and maternal alcohol use. OUTCOME: -Perinatal mortality for IUGR infants is 5-20 times greater than for AGA, mainly due to intrauterine death, perinatal asphyxia, and congenital anomalies. -Neurologic morbidity is 5-10 times higher than for AGA infants, especially for infants with ↓head circumference at birth. Intellectual and motor function (excluding those with congenital infections, chromosomal abnormalities) depends on adverse perinatal events and on the specific cause of growth restriction. Early identification and treatment of hypoglycemia and polycythemia improves outcome. Neurologic abnormalities are usual with genetic and infectious causes of IUGR. -Retarded growth: With placental causes of IUGR, catch-up growth occurs after birth, but these patients usually remain smaller than expected. -Fetal "programming" of cardiovascular disease: Recent studies implicate IUGR with adult onset of hypertension, coronary heart disease, hypercholesterolemia, and diabetes. These studies suggest that IUGR has long term affects on endocrine development and homeostasis

Mechanisms of heat exchange

Conduction Convection Evaporation Radiation Conduction- skin to skin Convection- air going over the baby Evaporation- a wet baby is cold Radiation- putting the baby on a cold surface makes the baby cold When baby is away from mom or we are doing an assessment that is when the heat loss can happen

Types of vaccines- conjugate

Conjugate vaccines Hepatitis B Influenza (injection) Haemophilus influenzae type b (Hib) Pertussis Pneumococcal Meningococcal HPV

Labetalol

Considered a first-line agent tachycardia is less common and fewer adverse effects Contraindicated in patients with asthma, heart failure, or congestive heart failure

FHR Tracing

Contractions are measured from beginning of one contraction to the beginning of another Baseline of FHR is an average of the FHR

Vaginal birth after Cesarean (VBAC)

Controversy related to risk of uterine rupture and hemorrhage Contraindications: Special areas of focus: consent, documentation Surveillance readiness for emergency Nurses as advocates for clients; expertise in reading fetal monitoring tracings to identify nonreassuring pattern and instituting measures for emergency delivery TOLAC- Trial of labor after cesarean, once its successful it is then called a VBAC Once a woman has one C-section she is more likely to have more Risks associated with multiple C-section include placenta previa, abnormal attachment of the uterusThese women always need to deliver in a facility that has the resources to help if something goes wrong with a TOLAC

Psychosocoial assessment- coping

Coping and stress tolerance Many women have unrealistic expectations for themselves and feel they should be able to be in control of labor. Encouragement and support in breathing exercises help. Fatigue and pain lower the woman's ability to cope. It is important to understand the cultural and religious background of each woman because they may strongly influence her behavior. Unrealistic expectations abound on all ends of the spectrum.

Therapeutic management

Corticosteroids Betamethasone Dexamethasone Tocolytic Therapy- stops contractions Terbutaline Nifedipine Indomethacin Magnesium Sulfate (MgSO4) Activity Restriction (bed rest) is not actually proven to work but is still prescribed Hydration- women who are contracting may be dehydrated and so we encourage fluids but its not really proven to work its just another thing we try Antibiotics- used to treat infection that may be causing pre-term labor There is nothing that is really proven to stop pre-term labor, we can try to delay it or do some things to improve the outcome but the best way to have the best outcome is with prevention Tocolysis means stopping contractions Bed rest can cause other issues like DVT, depression, frustration, unable to complete obligations to family

Postpartum period

Critical transition period for woman, newborn, and family physiologically and psychologically Maternal physiologic and psychological changes Mother and family adjustment to new family member

How much food does a baby need?

Day one: 5-7ml or 1/2 tsp Day three- 22-27ml or 0.75-1oz One week- 45-60ml or 1.5-2oz One month- 80-150ml or 2.5-5oz

Prolonged deceleration

Deceleration lasts 2 mins or longer but not longer than 10 minutes. Prolonged decelerations: usually an abrupt drop and stays down for several minutes. May occur with contractions or spontaneously. May be the result of a longer episode of cord compression or maternal hypotension, excessive uterine activity, vagal stimulation, or maternal compromise. This type of decel can occur after an epidural is placed and bolused or when mom is lying supine. Always want mom in a tilt position. Prolonged Is visually appparent abrupt decrease in FHR below baseline that is greater than or equal to 15 bpm, lasting greater than or equal to 2 min. but less than 10 min Cause could be any mechanism that causes a profound change in fetal 02. Maternal hypotension, abrution placentae... Cord compression, cord prolapse Profound head compression or rapid fetal decsent Treat the cause of prolonged decels, tocolytics, delivery...

Nursing care at birth

Decrease distractions Baby is dried immediately upon delivery. Establish airway with bulb syringe (if necessary) Cord is clamped, if baby stable assist with bonding. Skin to skin to keep infant warm. Facilitate participation of mother's support person. Accurately record time of baby for APGAR score after one minute and then again at 5 minutes Baby is placed on mom's chest immediately after birth. Even so, the first priority is to dry the baby off. Even skin-to-skin the baby needs to be dry. Only if secretions need to be removed do we use the bulb syringe. We leave the cord for a minute or two first before clamping and cutting Stage three is from birth of infant to birth of placenta Best practice is to not use bulb syringe unless the baby needs it Skin to skin is Important it helps stabilize and regulate the vital signs of the baby and its important for the baby to smell mom

Hypoglycemia in the newborn

Defined as a blood glucose level < 40 mg/dL At risk newborns: Infants < 2,500 g or > 4,000 g Infants of diabetic mothers- due to mother blood glucose alterations which can alter babies blood glucose and if mom had elevated blood sugar levels then baby was making insulin and then when moms extra blood sugar goes away then the insulin is still there and that can drop their blood sugar Preterm infants- due to size and cold stress (which causes them to burn up their glucose and glycogen stores) Sepsis Asphyxia Hypothermia Newborns are very fragile when it comes to maintaining their blood sugar levels Important to initiate early feeding to maintain the infants glucose Mom with diabetes, hypothermia, and babies outside healthy age range are the top three reasons for hypoglycemia

Atraumatic Care

Defined as therapeutic care that minimizes or eliminates the psychological and physical distress experienced by children and their families in the health care system Providing child and family-centered care contributes to providing atraumatic care Family-centered care involves creating a partnership between the child, family, and healthcare providers It is based on the concept that the family is the constant in the child's life and the primary source of strength and support for the child Prevent or minimize physical stressors, including pain, discomfort, immobility, sleep deprivation, inability to eat or drink, and changes in elimination. Avoid or reduce intrusive and painful procedures, such as injections, multiple punctures, and urethral catheterization. Avoid or reduce other kinds of physical distress, such as noise, smells, shivering, nausea and vomiting, sleeplessness, restraints, and skin trauma. Control pain via frequent assessments and use of pharmacologic and nonpharmacologic interventions. Promote a sense of control. Elicit the family's knowledge about the child and his or her health condition, promoting partnerships, empowerment, and enabling. Reduce fear of the unknown through education, familiar articles, and decreasing the threat of the environment. Provide opportunities for control, such as participating in care, attempting to normalize daily schedule, and providing direct suggestions.

The cure for eclampsia is....

Delivery It's always best for the mother. Goal is to prevent severe complications organ failure death. Not always best for the fetus. Goal is to prevent fetal compromise, death in utero, or neonatal death.

Conservative management for HTN doesn't work for everyone

Delivery is the cure. What is best for mom isn't always what is best for baby. What is best for baby isn't always best for mom. What to do when conservative measures aren't working... When mom is sick enough to be on mag sulfate because of risk for seizure then she needs to deliver

Gastrointestinal system adaptations

Development of a mucosal barrier to prevent the penetration of harmful substances Physiologic capacity of the newborn's stomach is considerably less than anatomic capacity Sphincter and nervous control of stomach are immature leading to regurgitation and uncoordinated peristaltic activity To gain weight the newborn requires and intake of 108 kcal/kg/day from birth to 6 months of age Baby has a sterile GI system and does not begin establishing normal gut flora until the first feeding This is why colostrum is so important because it has all the good bacteria and immune boosting things Newborns spit up a bit because they have poor sphincter control and may need some suction to help get up the spit up

PPD Effect on infant and child

Developmental Effects on Child/Infant: Quality of mother/infant attachment is decreased if mother is emotionally unavailable Infant will experience changes that affect his/her affect, motor, and physical development Insecure attachment behavior Linguistic delays Increased incidence of behavioral, cognitive, and mental health problems When mother is emotionally unavailable a child grows up without the ability to emotionally regulate his or herself. Mother engages and interacts with infant less so development is delayed, ex: playing on the floor, toys, etc. Lack of facial recognition and enface position can increase flat affect ADHD, There is a definite correlation between women who have depression after childbirth and children with ADHD and autism

Chronic HTN with superimposed preeclampsia

Difficult diagnosis Prognosis much worse than for just preeclampsia or just CHTN. "Diagnosis Highly Likely": New onset proteinuria (0.3 g/24 hours) Sudden in a chronically hypertensive woman with previously well controlled BP Thrombocytopenia (Plt < 100) Elevated liver function tests (AST or ALT) to abnormal levels Uric acid & serum creatinine levels may worsen sooner Most of these women are going to get a baseline 24hour urine and often times also a creatinine clearance and serum creatinine

Nutritional needs antepartum

Direct link between nutritional intake on fetal well-being and birth outcome Need for vitamin and mineral supplement daily Dietary recommendations Increase in protein, iron, folate, and calories Use of USDA's Food Guide My Plate Avoidance of some fish due to mercury content Folic acid is very important, lack of folic acid can lead to neural tube defects

Thrombin

Disorders interfering with clot formation increase risk of hemorrhage Idiopathic Thrombocytopenic Purpura (ITP) von Willebrand disease Disseminated Intravascular Coagulopathy (DIC) DIC is a consumptive coagulopathy Always a secondary diagnosis that occurs as a complication of abruption, IUFD with prolonged retention of the fetus, severe pre-eclampsia, HELLP syndrome, septicemia, and hemorrhage.

DIC

Disseminated Intravascular Coagulopathy Fibrin deposits throughout the body Platelet aggregation Consumptive coagulopathy Pregnancy/postpartum is a hypercaogulative state Fibrinogen levels elevated in pregnancy Platelet levels normal in pregnancy, rise in the postpartum period Treat with cryopreciptate, fresh frozen plasma, platelets, and sometimes heparin (controversial, depends on underlying cause) Not all women go into this but the goal is to keep it from happening As bleeding happens the body makes these fibrin deposits throughout the body then the body sends out platelets throughout the body to break down the fibrin and then all the platelets get consumed so her body is using up all her platelets trying to get rid of all those fibrins and if that happens she will bleed to death because she doesn't't have any platelets left and she will just ooze blood because she cant clot It is not a diagnosis itself it is a result of another diagnosis like sepsis, preeclampsia, HELLP, cancer Heparin is sometimes used to break up fibrin so the platelets quit being used up Often times these patients don't get epidurals because they wont place an epidural for platelets below 90,000 DO NOT PULL IV sites, just put some gauze over them if they're not working

Review H&P for postpartum psychosis

Do they have a history of depression and/or have postpartum depression or psychosis with previous pregnancy? Do they have a family history of depression? Are they a teenage mom? Do they have a support system? Do they have "stressors" i.e. recent move, recent death? Do they have a history of abuse? Do they have a history of PMS? Are they getting enough rest? These are all risk factors... PHQ9 and a PHQ6 are screening tools for depression and can also be diagnostic

APGAR scores

Done at 1 and five minutes If you have a low or critically low then you need to do another one at 10 minutes Mostly the things that are taken off for is color because their hands and feet tend to stay naturally blue for a little bit, that is called acrocyanosis and it usually clears away after 24 hours Because their vascular system is immature that is why we check pulses in the brachial area instead of the radial area at first

Magnesium sulfate

Drug of choice for "severe" features and worsening disease that requires delivery. Given for seizure prophylaxis for mother because it relaxes the vascular and neurovascular system to help prevent seizures Neuroprophylaxis for a preterm fetus Initial dose will be a 4-6 gram bolus followed by a maintenance infusion of 2grams/hr Initiated 24 hrs prior to delivery if possible and 24 hrs postpartum Or Until stable Calcium Gluconate is the antidote: 1 Amp (10ml of a 10% solution) IV push over 2-3 minutes Side effect of lowering moms BP so you will see a drop in BP but that is not why we give it Also a neuro prophylactic for a preterm fetus so they try to give it at all possible 24 hours before delivery and they keep it on 24 hours after delivery to help baby not have seizures Always preferable that a vaginal delivery occurs 24 hours before and after delivery is when seizures are most likely to occur A lot of women who take this get nauseated, tired, fatigued, flushed and hot

Abdomen changes postpartum

During first 2 weeks, abdominal wall remains relaxed. Woman may still appear pregnant. Return to pre-pregnancy state takes 6 weeks. Depends on previous tone, proper exercise, and amount of adipose tissue.

Dystocia

Dystocia is an abnormal or difficult labor. It is influenced by many factors both maternal and fetal. Think about the 5 P's which can contribute to dystocia Powers Passenger Position Passageway Psyche

Risk associated with labor induction and augmentation

Dystocia- any abnormal or ineffective labor pattern Operative vaginal birth- vacuum extractor or forceps, can injure the fetus and mom (significant pelvic injury) Cesarean Delivery- because we have put her on a clock so to speak Fetal distress- which may dictate how soon after induction we need that baby to come out Epidural analgesia- more women who are induced get more epidural analgesia than women who don't. Risk is drop in BP which we can usually fix, but when we cant fix it then it is an emergency and we usually do a C-section then Women who are induced have a higher incidence of dystocia which leads to an increased risk of operative vaginal birth

Early decelerations

Early Decelerations Benign, no intervention needed Associated with head compression as the fetus descends against the perineum Begins and ends with a contraction Mechanism behind the early deceleration is the head is compressed, creates a vagal response. Performing a vaginal exam is done to make sure your patient is progressing in labor and to make sure that is the cause of the Decel To be considered an early decel the decel mirrors the contraction nearly exactly

Embryonic Layers

Ectoderm: forms the central nervous system, special senses, skin and glands Mesoderm: forms skeletal, urinary, circulatory, and reproductive organs Endoderm: forms respiratory system, liver, pancreas, and digestive system There are body systems that are formed together with those body tissues, if a baby has issues with one body system they may have issues with another predictable body area (like the ear and the kidneys) because they develop from the same tissues

Preeclampsia signs and symptoms

Edema Upper extremity, facial, sacral B/P elevation Headache (very common) Blurred vision or diplopia & flashing lights Epigastric pain Thrombocytopenia Elevated AST (liver function studies) Proteinuria Lower extremity edema a little bit is normal Unrelated headache not relieved by Tylenol or caffeine is a concern

Prevention of thrombus formation

Educate patient about risk factors, symptoms, prevention Frequent ROM if bedridden, ambulation as soon as possible Quit smoking - offer referral SCDs Post-op deep breathing Avoid use of stirrups if possible or use for long period of time Protect legs during transfers Promote oral hydration Educate patient who is on anticoagulant therapy about correct administration Teaching to Prevent Bleeding R/T Anticoagulant Therapy We have our c/s moms move themselves from stretcher to bed if possible to reduce injury. 50% of DVTs are not symptomatic Most PEs start as DVTs that move up to the lungs PE patients may have a cough, adventitious lung sounds, rales, anxiety, sense of doom and are all associated with a smaller PE O2 saturation is important to evaluate but it is also associated with the size of the thrombus. Large PE has sudden onset of symptoms while smaller PE may take awhile to kick in We try to avoid stirrups in L&D if at all possible Can be leg injury sometimes like with dystocia if we have to pull her legs way back Treatment: two biggest preventative treatments are scuds and thromboembolic stockings and anticoagulant therapy. When they have developed a VTE it depends on the respiratory, cardiovascular supports and anticoagulant therapy. Respiratory support. Put on continuous pulse ox, because that is one of the first things that is going to show up is a decrease in O2 saturation. Warm humidied oxygen 10L by nonrebreather, will get serial ABG with the first one on room air. Sometimes these patients end up on mechanical ventilator. Patients with chest pain and anxiety can be treated with morphine sulfate that will reduce oxygen consumption by reducing anxiety, increase HOB, provide emotional support. CV support you want to optimize preload and decrease workload, sometimes that is done with a dopamine drip (if its more serious) can also decrease workload on the heart by decreasing activity and unnecessary procedures, treating pain with morphine sulfate is going to reduce the workload of the heart as well Anticoagulant therapy. They usually go home on anticoagulant therapy, heparin (LMWH like enoxaparin or Coumadin) most women are not on Coumadin during pregnancy. Most common med is LMWH like enoxaparin because the dose is manageable, patients can be seen on an outpatient basis when they take a LMWH compared to when they take heparin

Preparation for Labor, Birth and parenthood

Education should begin early When to call the provider Like if she has increase in bleeding, absent or decrease in movement (once she has started feeling movement), swelling in other places besides LE, really severe headaches, vision changes or spots in vision, leaking of fluid Perinatal education Breastfeeding education, choking/cpr for babies, safety for babies, good sleep patterns for mom (sleep when the baby sleeps) Childbirth education Educate about childbirth options and methods for coping & pain control. Encourage the woman and her support person to make a birth plan together.

Preparation for labor, birth and parenthood

Education should begin early. Perinatal education Childbirth education Educate about childbirth options and methods for coping & pain control. Encourage the woman and her support person to make a birth plan together. Options for birth setting Hospitals: delivery room, birthing suite Birth centers Home birth Options for care providers Obstetrician - a medical doctor with specialized training in gynecology and reproductive medicine. Family care provider - a medical doctor with some training in obstetrics. Refers complicated cases to an OB/GYN. Certified Nurse Midwife - CNM, an advanced practice nurse who can provide care for women across the lifespan, including childbirth. In some states a CNM may practice independently from a physician (Not in NC) Certified Professional Midwife - CPM, a "layperson" who has extensive training and certification in midwifery. This role is not recognized in NC. Doula - provides labor & postpartum support; may or may not be certified. Assist patient in locating doula services if interested. Research shows that a support person other than the labor nurse increases good outcomes

Newborn care- elimination

Elimination Infant should void within 24 hours of birth Usually small amounts, concentrated first void and will improve as kidney function improves Bowel elimination should occur within 24 hours of birth Initial stool: meconium (first stool) tarry black because of the bilirubin, then transition to green, breastfed newborns will have a have a yellow seedy like stool Urine will be slightly dark because it has lots of bilirubin in it May use a temperature probe to offer digital stimulation if the baby has not had a BM in the first 24 hours

Formula Feeding

Ensure parents have complete education about infant feeding Myths and misconceptions about BF. BF may be seen as embarrassing or inconvenient. See formula-feeding as a way for family members to feed the baby. Support her decision but make sure that you have given proper education to make sure that she has all the information to makes sure she is making the best choice for herself and her baby Still should be fed on demand rather than on schedule Breastfeeding is totally a supply and demand it is not good to be on a schedule, need to feed on demand Do skin to skin when feeding baby even with formula, hold the baby still when feeding

Helpful resources for grieving parents

Environment Supportive relationship Information Encouraging expression of emotions Seeing and touching Remembrances Open visitation Autopsy Religious or spiritual practices Anticipatory guidance

Risk factors for dystocia

Epidural analgesia/excessive analgesia- can slow down contractions Multiple gestation- anything that hyperextends the uterus Polydramnios- excessive amniotic fluid Maternal exhaustion- long labor Ineffective maternal pushing technique Occiput posterior position Longer first stage of labor* Nulliparity- women who have first baby Short maternal stature*- big contributor to shoulder dystocia especially if she has a larger partner Fetal birth weight over 8.8 lb.* Shoulder dystocia Abnormal fetal presentation* Fetal anomalies Maternal age over 35 years Increased BMI in mom Gestational age over 41 weeks Chorioamnionitis- infection Ineffective uterine contractions High fetal station at complete cervical dilation*- totally dilated but baby wont descend, usually indicative of a baby who wont fit Big contributors of dystocia Precipitous labor is a labor that happens rapidly which is also considered dystocia and it can be very traumatic for women, they feel like they don't know what hit them

Anatomy and physiology of lactation

Estrogen stimulates the ductal system and progesterone stimulates the milk production system during pregnancy. The breasts gain approximately 1 lb each. Let down reflex is where the baby stimulates the milk letdown with contact to the breast and sucking on the breast

24 hour urine collection instructions

Every void for 24 hours Toss the first void then begin collection. Label the collection container: Start time/end time Start date/end date If creatinine clearance is also ordered you need an accurate Height & Weight Creatinine clearance validates collection method was done correctly and/or correlates with serum creatinine. 24 hour urine results of > 300 mg is considered an abnormal result Keep on ice Women with a history of chronic htn or history of pre-eclampsia will often have a 24 hour urine collection done early in pregnancy to establish a baseline. Some patients need more than one of these jugs or they can use an empty fruit bottle cleaned out well, do NOT use a milk bottle because it has protein in the milk

Non-stress test (NST) during labor

External Fetal Monitoring (EFM) Non-invasive Used to assess fetal well-being Monitors FHR in response to stimuli such as fetal movement or contractions Part of antepartum testing Office, clinic, hospital Intrapartum part of initial documentation for example prior to IA, ambulation, hydrotherapy to make sure that we have a healthy fetus I mentioned the Non-stress test briefly in the antepartum lecture as a method of fetal surveillance. These are used for patients who report to their doctor that they haven't felt the baby move or women who are diabetic or hypertensive and at risk for placental perfusion problems. The non-stress test is a fairly short non-invasive method to document a well-oxygenated fetus. A non-stress test looks for a normal baseline heartrate between 110-160, two accelerations that go up from baseline by 15 bpm and last for at least 15 bpm. These must occur within 20 minutes. This helps us document that we have a healthy fetus before the mom ambulates or does things to help make sure that the baby can handle that and is healthy Baseline FHR Baseline rate is the average during 10-20 minute segment, excluding: Periodic or episodic changes Periods of marked variability Tachycardia: baseline more than 160 beats/min for duration of 10 minutes or longer Bradycardia: baseline less than 110 beats/min for duration of 10 minutes or longer When applying the fetal monitor always document the maternal heart rate to ensure the heart rate being traced on the fetal monitor is fetal and not maternal. FHR tracings are different then ECGs because it is just each beat of the FHR, not the electrical activity of the fetal heart Reassuring FHR patterns are: Baseline FHR in normal range of 110 to 160 beats/min, with no periodic changes and a moderate baseline variability In the preterm infant, baseline FHR may be higher Reactive up 15 beats from baseline for at least 15 seconds. This should happen at least twice in 20 minutes. (Accelerations) Nonreactive accelerations do not fit criteria above

Electronic Fetal Monitoring (EFM): Externally

External monitoring FHR: ultrasound transducer that detects the fetal heart rate UC: tocodynamometer (tocotransducer) which measures the contractions Advantages: Continuous tracing of fetal heart rate, especially important if the mom has risk factors or complications Non-invasive Disadvantages: Limits movement of mother Increases incidence of intervention This is what most women end up getting during labor When a woman has complications then she definitely needs to be on this When a woman has a C-section they need to be continuously monitored in the next pregnancy because she is at an increased risk of uterine rupture Growth restriction babies are at increased risk of complications because they are at higher risk of receiving poorer oxygenation during labor and tend to not tolerate labor as well because of the physiology of labor

Newborn assessment- extremities and back

Extremities Arms and hands are generally flexed against the body, both arms should move evenly Legs should be the same length, hips move freely Hands and feet should be assessed syndactyly and polydactyly Spine Straight without curves Check for sacral dimple or pit at the base of the spine because it can be a normal variation but if it is really deep and looks like it has a tuft of hair in it then it needs to be evaluated to make sure that that pit does not go all the way to the spinal cord Shoulder dystocia can cause injury to the clavicle and they think that the force of labor fractures the clavicle rather than the actual shoulder dystocia Polydactyl (extra fingers) or syndactyl (fingers that are fused)

Newborn medications

Eye prophylaxis- to reduce conjunctivitis from STI's or infection Vitamin K prophylaxis- given to help the baby clot because they do not make their own clotting factors yet Hepatitis B immunization 1-2% of newborns experience vitamin K deficiency bleeding, and if it is a cerebral bleed then it is almost always fatal or causes very serious deficiencies In hospitals if parents refuse these then we make then sign a declination form and educate them Hep. B is a vaccination so we do need a consent form

Marked variability of FHR

FHR variation greater than 25 bpm Periods of increased fetal activity can cause this. Right before a cord accident or an abruption you will normally see marked variability as the fetus fights to try and get oxygen This is normally seen with a fetus that is very active but will go away when its just due to movement

Moderate variability in FHR

FHR variation or change of 6 to 25 bpm This is what we want our fetal heart rate to look like

Minimal variability in FHR

FHR variation or change that is detectable but less than or equal to 5 bpm

Inherited thrombophilias

Factor V Leiden Antithrombin deficiency Prothrombin Gene G20210A mutation Tetrahydrofolate reductase Protein C deficiency Protein S deficiency Thrombophilia is someone who clots abnormally Thrombophilia's include: factor 5 Leiden, anti-thrombin deficiency, protein s or protein c deficiency Can cause intrauterine growth restriction and uterine abruption and miscarriage and placental infarctions

Neonatal asphyxia

Failure to establish adequate, sustained respirations after birth Pathophysiology: insufficient oxygen delivery to meet metabolic demands Nursing assessment: risk factors, newborn's color, work of breathing, heart rate, temperature, Apgar scores Nursing management: immediate resuscitation, continued observation, neutral thermal environment, blood glucose levels, parental support, and education

False labor vs. true labor

False labor Contractions are localized in the lower and middle uterine segments Contractions may be regular No lower back pain. Contractions decrease in intensity and/or stay the same with ambulation Disappear with sleep No cervical change Sedation decreases or stops contractions No bloody show True Labor Contractions originate in the fundus. Pain originates in back & radiates to the abdomen Accompanied by regular and rhythmic contractions. Contraction progress in frequency and intensity. Contractions intensify with ambulation. Progressive cervical dilation and effacement Sedation is not effective Bloody show is usually present True labor is marked by regular uterine contractions that result in progressive cervical effacement and dilation accompanied by fetal descent into the maternal pelvis. Ambulation may initially make false labor contractions more intense but they go away soon after activity stops. With true labor, activity enhances contractions. With false labor a patient is often able to go to sleep or is taking something to help them sleep causes the contractions to stop. With true labor sedation doesn't usually work. Sometimes, if a patient has been in "early" labor for awhile and they need a break - because they get in this negative feedback loop - they may be given a sedative to break that cycle. So, they may get a short break or rest period, just enough to kind of reset and the cervix will actually dilate.

Contraception

Family planning Responsible sexual behavior Personal choice

Psychosocial assessment- support

Father or partner during labor Father or partner needs to be included in the circle of communication. The father or partner is usually able to interpret the woman's needs and convey her desires to staff members. Assess for level of comfort in asking questions and in being present and involved during the second stage of labor and birth. A well-informed parent or support person can make a significant contribution to the health and well-being of the mother and child.

Passenger

Fetal Attitude The relationship of the fetal parts to one another. At term the ideal attitude is for the fetal body is flexion so smallest diameters of the presenting part move through the pelvis. Fetal Lie The relationship of the long axis (spine) of the fetus to long axis (spine) of the mother. Can be longitudinal or transverse. Our passenger is the fetus. In order to have a successful delivery our passenger needs to pretty much be in just the right place. Otherwise things get a little more difficult. The most ideal position is for the baby to be head down, chin tucked, arms and legs curled and face down.

Positive (diagnostic) signs of pregnancy

Fetal Heartbeat Visualization of fetus by ultrasound Palpating Fetal movement Fetal Heart Tone:

Fetal nuchal translucency scan

Fetal Nuchal translucency scan (NT Screen) Optional Usually done if other screening elevated or mother at risk Ultrasound to measure space at back of babies neck Babies with abnormalities tend to accumulate more fluid at the back of their neck during the first trimester, causing this clear space to be larger than average. Specific to a certain part of the body, they are looking for a pocket of fluid along the back of the neck in a fetus which normally is not there but that can be indicative of downs syndrome Not diagnostic and not always accurate

Passenger- presentation and position

Fetal Presentation Vertex, Shoulder, Breech Fetal Position The relationship of the point of reference (occiput, sacrum, acromion) on the fetal presenting part (vertex, shoulder, breech) to the mothers pelvis. The most common is LOA or left occiput anterior, the occiput (back of head or skull) is pointed up toward the symphysis and directed toward the left side of the maternal pelvis. head down is the best position - this is called vertex. Most deliveries that are anything other than vertex in today's birthing world are delivered by c-section. Breech is when the baby is butt down and there are different degrees of breech. The baby can be Frank breech which means both feet are up by its head or a footling breech, which means one foot is down and one foot is up. Transverse is when the fetus is lying sideways, cradled in the pelvis

What does evidence tell us about labor and fetuses

Fetal response Labor can be a period of physiologic stress for fetus Frequent monitoring of fetal status is part of nursing care during labor Fetal oxygen supply must be evaluated during labor to prevent fetal compromise Fetal oxygen supply can decrease due to: Reduction of blood flow through maternal vessels as result of hypertension and hypotension Reduction of oxygen content in maternal blood as result of hemorrhage or severe anemia Alterations in fetal circulation with compression of umbilical cord Reduction in blood flow to intervillous space in placenta Cebreal palsy number 1 cause is lack of oxygen during labor or at some point during the pregnancy Most brain issues happen before labor begins The goal of fetal monitoring is the interpretation and ongoing assessment of fetal oxygenation. Fetal monitoring is an important way to document health of fetal central nervous system health. Fetal monitoring is essential in the assessment of maternal and fetal well being in antepartal and intrapartal settings. Nurses are expected to independently assess, interpret, and intervene related to the interpretations of EFM patterns. Nurses need to provide clear and accurate communication with care providers and the perinatal team. This is essential for optimizing perinatal care

Passenger- station

Fetal station Location of presenting part in relation to mid-pelvis or ischial spines. Station 0 Fetus is engaged (level with the ischial spines) Station -2cm is 2 cm is above the ischial spines Fetal station refers to how far the baby has descended into the pelvis, in relation to the ischial spines. Your book uses the word floating to describe that engagement has not occurred. Another term for this, the medical term for this is, ballotable. This means on cervical exam, the present part can be pushed away from the examiners fingertips whereas when the presenting part is engaged it stays in place. What might happen if SROM occurred when the presenting part was ballotable? So the priority nursing intervention is....

Fetal tachycardia

Fetal tachycardia is above 160 that lasts longer than 10 minutes. Could be a sign of early fetal hypoxemia, especially with decreased variaibltiy and decelerations, Marternal causes: could be maternal fever, infection, anxiety, dehydration, chorioamnionits Fetal causes: infection, sepsis, activity or stimulation, anemia Treat underlying cause: antibootics, infection, fluids for dehydration, delviery If it persists above 200-220 bpm, fetal demise may occur.

Behavioral patterns of the newborn

First Period of reactivity Birth to 30 minutes to 2 hours after birth Newborn is alert, moving, may appear hungry Period of decreased responsiveness 30 to 120 minutes old Period of sleep or decreased activity Second period of reactivity 2 to 8 hours Newborn awakens and shows an interest in stimuli During first period of reactivity we want to put mom with baby right away because it helps bond the two In the second period of reactivity this is where we might discover some respiratory difficulties and we may start to see some tachypnea, nasal flaring (mild of both of these is okay but we do not want to see oral cyanosis or lots of signs of respiratory distress) 35-36 weekers may start out looking really well and then start having issues in the second period of reactivity (very common in late pre-term babies because they don't have as much fat stores)

Risk factors for post partum depression

First pregnancy Ambivalence about keeping pregnancy Hx of depression (50% more likely) or anxiety.*** (number one risk factor) Lack of social support Lack of stable/supportive relationship w/parents and/or partner Body image problems/low self-esteem Severe PMS Difficulty with partner Adolescent age Note: greatest risk is a previous hx of PPD or psychiatric disorder Women who have a known history of depression, who screen positive for depression or have a history of PPD may be treated prophylactically for PPD during pregnancy to prevent PPD from happening Depression can be perinatal depression vs. just postpartum.

Stages of labor- first stage

First stage Three phases: Latent longest; the contractions become more frequent, stronger, and gain regularity. Active cervix dilates more rapidly. For most women this is from 6cm-8cm but can vary. Transition most rapid phase; 8cm-10cm; most intense phase of labor.

Ear Anatomy of Child vs. Adult

Fluid in the middle ear prevents normal transmission of sound which results in hearing loss over time. This delays speech and language development. Often this may manifest as cognitive deficit or behavior problems - similar to a child of a mother with PPD. Mother development delay may also occur. Children have more ear infections than adults because the Eustachian tube is shorter, wider and more horizontal in infants than in older children or adults. Durink sucking, yawning, and other movements, the tube opens for milliseconds, allowing free passage of air between the nasopharynx and the middle ear. Breastfed babies have less incidence of ear infections because of the work of breastfeeding. Breast milk is great because of the antibodies but it's also the "work" of breastfeeding that helps reduce infection. Babies who are fed breastmilk from a bottle do not have the same rates of reduced infection because of this.

OB Hemorrhage: Therapeutic Management

Focus on underlying cause Uterine massage- not only an intervention but it is also part of your assessment Removal of retained placental fragments Antibiotics for infection Repair of lacerations Uterus usually responds well to massage and will immediately tighten up and get firm

Umbilical cord

Formed from the amnion Lifeline from the mother to the growing embryo Contains one large vein and two small arteries Wharton's jelly surrounds the vein and arteries to prevent compression during labor At term, the average umbilical cord is 22 inches long and about 1 inch wide One umbilical vein (carries oxygenated blood) and two umbilical arteries (carries deoxygenated blood) because oxygenation is reversed in the fetus causing the vein to carry oxygenated blood to the baby and the arteries take oxygenated blood from the fetus back to the mom Sometimes if the mom has diabetes or other issues then there is less Wharton's jelly which can cause the vessels to be more exposed and more likely to be compressed Can occasionally have a two vessel cord which can be harmless or can be indicative of issues

Preeclampsia

Formerly known as Toxemia or Pregnancy Induced Hypertension (PIH) New onset of hypertension after 20 weeks in a previously normotensive woman. Proteinuria: +2 on dipstick ≥ 0.3 g (300mg) 24 urine specimen (most reliable) Proteinuria may be absent in preeclampsia, however, other s/s will be present. Urine dip sticks are not always very accurate, blood, UTI, and other things can make the dip stick show protein even if she's not preeclampsia 24 hour urine collection is done for women who are suspected of preeclampsia The vessels in the kidneys dilate and that's what causes protein to spill

Meconium

Formula fed infants have firmer stools earlier on Breastfed babies have yellower, seedy stools that are more soft

Functions of the placenta

Functions as an endocrine gland The growing embryo does not have endocrine glands so the placenta provides these important hormones for the embryo so it can develop Serves as the interface between the mother and fetus Helps keep moms immune system from trying to fight the baby like a foreign object Makes hormones that influence the physiology of the mother Produces hormones that mature the fetal organs Protects the fetus from immune attack by the mother Removes waste products from the fetus *Does not act as a filter*

Reproductive Organs: Uterus

Fundus descends 1-2 cm every 24 hours. 2 weeks after childbirth the uterus is no longer palpable. Involution: process where uterus returns to non-pregnant state following birth. Sub-involution: failure of uterus to return to non-pregnant state. Can be caused by retention of some of the amniotic membranes, or placenta Infection Uterine atony ('boggy uterus'). Fundus: palpating the fundus can be painful-as it is a deep palpation. Please ensure to inform your patients that this may be uncomfortable before this assessment. Boggy: will feel 'soft & squishy'; this means that blood clots and other matter may be retained. Leading cause of post-partum hemorrhage Firm: desired state of fundus...you know that blood clots and other matter are not being retained. Contractions: Post-partum hemostasis achieved by compression of intramyometrial blood vessels as uterine muscle contracts. Oxytocin releases from pituitary gland strengthens and coordinates uterine contractions. Lochia: Post-birth uterine discharge. Baby breastfeeding, skin to skin and just being close to the mom can help produce oxytocin Should not see big clots or have foul smelling lochia. Small clots and bleeding is okay

Neuromuscular changes in pregnancy

Generally no major CNS changes in normal pregnancy Mild front headaches are a common early pregnancy finding. Dizziness may occur from vasomotor instability, hypoglycemia, or postural hypotension. Postural changes are associated with ligament laxity as a result of progesterone and relaxin production. Carpal tunnel syndrome may occur secondary to peripheral edema. Alterations in sleep patterns may occur in relation to nocturia, backache, dyspnea, and heartburn. Intraocular pressure changes may make women who wear contact lenses experience mild discomfort. Snoring may appear or increase as a result of increased vascularity and the smooth muscle changes associated with pregnancy. Educate women to stand up slowly because they may get postural hypotension Carpal tunnel syndrome may occur due to swelling in the hands and the wrist

Genetic evaluation and counseling

Genetic counseling: The process by which patients or relatives, at risk of an inherited disorder, are advised of the consequences and nature of the disorder, the probability of developing it, and the options open to them in management and family planning in order to prevent, avoid, or ameliorate it (Lea, 2010). Reasons vary for why individual or family should be referred for genetic counseling. Ideally occurs before conception Often counseling occurs during pregnancy or after the birth of a child affected with a disorder.

Newborn assessment- genitalia

Genitals Scrotum on males and labia on females may be edematous Penis should be inspected for position of urethral meatus Females may have mucus discharge mixed with blood Inspect anus for patency; meconium indicates patency We no longer do a rectal thermometer, now we wait for them to pass meconium and if has been over 24 hours without it then we will check but we do not want to traumatize the anus with the temperature probe unnecessarily

The Ballard Score

Gestational age assessment tool Physical maturity - assessment usually completed within the first 2 hours after birth Neuromuscular maturity - completed within 24hrs after birth. Scores range from very low in preterm newborns to very high for mature and postmature newborns Diagram on p. 626 and 627 Linugo is the fine downy hair on baby skin Creases in feet, newborns have slick feet and post term babies have wrinkled feet Breast tissue, more mature babies have breast buds

Healthy people 2020

Goal - improve health of women, infants, children, & families Pregnancy provides an opportunity to identify existing health risks in women and opportunity to prevent future health problems for women and their families. Ways to reduce risk include increasing: Preconception care Prenatal care Healthy birth outcomes Early identification and treatment of health conditions among infants The Objectives: Maternal, Infant, and Child Health Data Details

Gravidity

Gravidity - refers to the number of times that a woman has been pregnant regardless of the outcome Gravid - the state of being pregnant Gravida - a woman who is pregnant Nulligravida - a woman who has never been pregnant Primagravida - a woman has is pregnant for the first time Multigravida - a woman who is pregnant for at least the second time

Respiratory changes in pregnancy

Growing uterus shifts the diaphragm upward by approximately 4cm by the end of pregnancy. AP diameter of chest enlarges to accommodate. Tidal volume increases; respiratory rate unchanged O2 consumption increases to meet increasing demands. Dyspnea may begin as early as the 1st trimester. Pregnant women breathe in deeper Nasal stuffiness, rhinitis and nosebleeds are common as a result of vascular congestion. Tissues are more fragile during pregnancy and they have increased vascularity

Endometriosis

Growth of endometrial tissue outside of uterus Tissue responds same as tissue inside uterus (so when she is bleeding from her period she is also bleeding into her abdomen) Cause? Poorly understood Retrograde menstruation Lymph-Blood transmission Uteral lining kind of escapes the uterus and develops in the body cavity and elsewhere outside the uterus Third leading cause of infertility in the US Causes scar tissue and lesions in the fallopian tube and the egg by stick to the tube or elsewhere in the area and then the egg will not be able to descend or have room to develop

HELLP Syndrome

HELLP syndrome: Severe pre-eclampsia with liver involvement Same immediate treatment as pre-eclampsia **Delivery always indicated** Can be life threatening... DIC* Platelet count may worsen before finally improving May or may not have elevated blood pressures. May present with viral like illness, nausea, vomiting, RUQ pain, prior to elevation in BP. Often get overlooked until they are very sick because it does not always happen with BP issues and lots of the symptoms look "normal" until she gets very sick Some women can get HELLP syndrome without getting preeclampsia but they normally go together This is why they watch for elevated AST and lowered platelets because they are making sure they do not get HELLP syndrome Usually comes on fast Usually have very severe RUQ pain because of the liver involvement

Labs and diagnostics for HIV + pregnant women

HIV antibody testing is done prenatally regardless of risk of infection Initial Testing ELISA test Offered to all pregnant women Additional testing Western Blot Assay (Confirms it)

Variations in head size and shape

Head Fontanels should be palpable Head may have molding, caput succedaneum, or a cephalhematoma Face Chin is receding, cheeks are full and round, oral cavity should be intact with a closed palate Nose Epstein's pearls may be observed Observe the frenulum Babies are nose breathers, they have flattened noses and their nares are kind of flared out and that allows air to get to them when they are breastfeeding Epstein pearls are little bumps in the gums and they go away on their own Look at the frenulum because if a baby has a shortened one then they are tongue tied or if it is too long they might not be able to suction well

SGA newborns: assessment, typical characteristics

Head disproportionately large compared to rest of body Wasted appearance of extremities; loose dry skin (especially for asymmetric growth restriction) Reduced subcutaneous fat stores (they are using up their brown fat in utero) Decreased amount of breast tissue Scaphoid abdomen (sunken appearance) Wide skull sutures Poor muscle tone over buttocks and cheeks Thin umbilical cord which goes along with a poorly perfused placenta

Health status of women and children

Health Previously defined as the absence of disease Currently defined by health promotion, disease prevention & wellness Healthy People 2020 Four Foundation Health Measures General Health Status Health Related Quality of Life and Well-Being Determinants of Health Disparities There are major health disparities among different ethnic groups Healthy People agenda began in 1979

Amniotic fluid

Helps maintain a constant body temperature for the fetus Permits symmetric growth and development; too little fluid causes constriction of fetal growth. Cushions the fetus from trauma Allows the umbilical cord to be relatively free of compression Promotes fetal movement to enhance musculoskeletal development (allows the fetus to move around somewhat) Promotes normal lung development Polyhydramnios is an excess of amniotic fluid (>1200mL) Can cause the uterus to go into contractions too early Can be indicative of kidney issues in the fetus Can make it hard to monitor the fetus Oligohydramnios is too little amniotic fluid (<800mL) Can be indicative of kidney issues in the fetus Constricts the fetus and does not allow for enough movement Know polyhydramnios and oligohydramnios

Typical assessment first pregnancy visit

Hemoglobin and Hematocrit Blood group and Typing Rh Typing Toxoplasmosis Rubella Titer Complete Blood Count HIV Antibody Drug screening Hepatitis B, C STD screening for syphilis Blood glucose HgB AIC in high-risk groups CMV Parvovirus Urinalysis for glucose, protein and culture Vaginal swab for Gonorrhea and Chlamydia Ultrasound- if unsure of last menstrual period Most important test is patient blood type, checked at beginning of pregnancy and again after delivery, rogam is given to patients who are Rh negative so that she does not develop an antibody to the next fetus Rogam is given at 28 weeks and after delivery Drug screening is not universal

Hepatic system adaptations

Hepatic System - Iron storage Carbohydrate metabolism Bilirubin conjugation: three groups of jaundice based on mechanism of accumulation of bilirubin overproduction decreased conjugation impaired excretion Newborn has to become reliant on its own liver for waste excretion Because they have an immature liver they can have a hard time keeping up with waste excretion, particularly with bilirubin which may cause jaundice to develop in the newborn

System adaptations of extrauterine life

Hepatic system GI Immune Renal

Hematologic Changes in pregnancy

Hgb levels during pregnancy are between 11.5 and 14 g/dL Hct = 32-42 Serum ferritin decreases Iron absorption from the GI tract increases, however, iron supplementation necessary to maintain iron stores. Leukocyte production increases in pregnancy. Common to see elevated WBC levels in labor. Lipids & cholesterol increase for steroid hormone synthesis. Serum albumin decreases contributing to peripheral edema. Coagulation: Pregnancy is considered a hypercoagulable state due to increase in coagulation factors and decrease in factors that inhibit coagulation. Factors I (Fibrinogen), VII, VIII, X, and von Willebrand factor antigen increase. PT and aPTT decrease slightly Bleeding time and clotting time remain unchanged. Platelet count remains unchanged until postpartum where it increases markedly. This increases predisposition to thrombus formation and consumptive coagulopathies (DIC). Pregnancy is a hypercoaglulable state because of the increase in blood volume and the increase in clotting factors Does iron absorption increase or decrease? Double check because in class she said decrease but the PowerPoint says increase Consumptive coagulopathies is usually due to hemorrhage or can be increased risk from preeclampsia

Infants of diabetic mothers

High levels of maternal glucose crossing placenta, stimulating increased fetal insulin production leading to somatic fetal growth Nursing assessment Mother with diabetes Full rosy cheeks, ruddy skin color, short neck, buffalo hump, massive shoulders, distended upper abdomen, excessive subcutaneous fat tissue; hypoglycemia, birth trauma Hypocalcemia, hypomagnesemia, polycythemia, hyperbilirubinemia

Neonatal abstinence syndrome: signs of withdrawal

High pitched crying, exaggerated reflexes, tremors and tight muscles, sleep disturbances, sweating, fever, yawning, sneezing, poor feeding, vomiting and loose stools, nasal stuffiness and rapid breathing

Hydralazine

Higher or frequent dosage associated with maternal hypotension, headaches and fetal distress- may be more common than other agents

Diabetes in pregnancy: What does it mean for mom and baby?

Higher risk of fetal anomalies Fluctuating insulin needs as the pregnancy increases so you need increased monitoring N/V can cause insulin shock if mom is insulin dependent Insulin needs may be 2-3 times higher than normal by end of pregnancy Higher renal threshold for glucose more glycosuria Concurrent vascular disease may worsen retinopathy or nephropathy If insulin requirements are dropping at end of pregnancy-it may indicate needs for delivery due to placental deterioration/decreased hPL (insulin antagonist) Gastroperesis is an irritation of the vagus nerve which causes increased N/V

Assess risk for thrombus formation

History: Smoking- greatly associated with thrombus formation Hx of thrombosis, DVT, thrombophilias (inherited or acquired), varicosities Prolonged bed rest- one of the biggest risk factors for VTE Diabetes Obesity Cesarean birth- causes tissue trauma and the body responds to that with inflammation and releases fibrin to repair tissue AMA (35yo or greater), VAMA (40yo or greater) Multiparity- 2 or more deliveries Remember the hypercoagulable state of pregnancy and the increase in platelet activity in the postpartum phase Hom People who have a history of VTE are more likely to get another VTE and typically in the same location as last time because there is damage to that vessel wall Pelvic injury can occur during a C-section and during a vaginal birth

HIV In pregnancy

Human Immunodeficiency Virus (HIV) Chronic infection caused by Retrovirus Causes immunosuppression & destruction of T lymphocytes; increased risk of infection How is it transmitted? Risk factors associated with pregnancy How is birth planned? Education for patient Rate of HIV In women increasing HIV causes chronic immune suppression Routine screening for all women who are pregnant C-section is best Anti-retovirals are very important, low viral loads No breast feeding

GI changes in pregnancy

Hunger & caloric needs increase Gingivitis; periodontal disease Increase in heart burn r/t decrease in lower esophageal sphincter muscle tone secondary to effects of progesterone. Nausea & vomiting - peaks at 8 to 12 weeks, may last longer in some women. Ptyalism may be present. This is hypersalivation and is common in early pregnancy. Often associated with hyperemesis gravidarum. Hyperemesis gravidarum - severe N&V that causes weight loss, electrolyte imbalances, ketosis, & dehydration. Often requires hospitalization or OP infusion for IV hydration. Some patients require enteral nutrition via NG tube, usually Dobhoff. Alkaline phosphatase and cholesterol may be elevated as a normal finding. AST, ALT, bilirubin remain unchanged in normal pregnancies. Gallbladder becomes hypotonic and distended. Emptying time is slowed secondary to progesterone. Slowed emptying time and increased cholesterol production may contribute to gallstone formation. Pregnant women produce more saliva and can drool sometimes (called sialorrhea) Hyperemesis is excessive N/V Can get gall stones

Diabetes in pregnancy: more risks

Hydramnios (10-20% increase in AFI): AKA polyhydramnios Increased fetal urination Risk of PROM Increased incidence of preeclampsia UTI r/t glycosuria Increased incidence of stillbirth r/t poor placental perfusion r/t insulin fluctuations "ages" the placenta Slower lung maturation in the fetus of the diabetic mother Amniocentesis may be needed to test for fetal lung maturity to weigh the risks and benefits of early delivery. Intrauterine growth restriction (IUGR) Large gestational age/macrosomic infant can overextend the uterus and puts the mom at risk for hemorrhage, baby at more risk of injury during delivery and so is mom Because of increased fetal urination which causes amniotic fluid and the mothers circulatory system Because of all these risk factors most women who are diabetic delivery early but most women who are diabetic have babies who have slower lung development so they often do an amniocentesis but if there is not time then they don't always do it They give corticosteroids to help lung maturity even though it messes with blood sugar so they may, in rare instances, need to be on an insulin drip while the corticosteroids work

Newborn care- hygiene

Hygiene Diaper changes- clean the diaper area well with each change No lotions or powders- been associated with some reproductive cancers Care of the umbilical area avoid getting wet Circumcision care The newborn bath: Body temperature must be stabilized Opportunity for thorough assessment Promotes comfort Parent/child/family education Priority assessment with circumcision care is to check for bleeding first and urinary output later. We wait at least 24 hours before doing a bath

HTN in pregnancy

Hypertension is defined as a SBP ≥ 140-130 mmHg OR a DBP ≥ 90-80 mmHg on two separate evaluations. Obtain accurate blood pressure for diagnosis: Patient position Cuff size - *very important! Too big gives false low Too small gives false high Need to have an elevated BP on two separate evaluations, not just an hour apart or something

Preterm newborn: common problems

Hypothermia- they have less fat on their body so they work harder to regulate their temperature Hypoglycemia- caused by lots of different factors, may be related to poor feeding Hyperbilirubinemia Problems related to immaturity of body systems

Hyperbilirubinemia

Imbalance in rate of bilirubin production and elimination Physiologic jaundice (third to fourth day of life) Early-onset breast-feeding jaundice Late-onset breast-feeding jaundice Pathologic jaundice (within first 24 hours of life) Kernicterus Rh isoimmunization ABO incompatibility Nursing assessment Risk factors Jaundice Signs of Rh incompatibility Bilirubin levels Nursing management Reduction of bilirubin levels: early feeding, phototherapy, exchange transfusions Education and support; home phototherapy

Immunity

Immunity- Ability to destroy and remove a specific antigen from the body Active immunity- Acquired when a person's own immune system generates the immune response Passive immunity- Produced when the immunoglobulins of one person are transferred to another

Endometriosis - Effects

Impaired Fertility: Adhesions around uterus Symptoms: Nothing Pelvic pain Dysmenorrhea Dyspareunia Pelvic fullness GI issues Abnormal bleeding Management: Based on symptoms and goals NSAIDS (to help with inflammation) OCPS (suppress ovulation) Surgical Interventions TAH with BSO Laparoscopic Recurrence rate of 40% A lot of these women also have IBS

Nursing care for grieving families

In many cultures women express more outward symptoms of grief such as crying, anger and guilt than men Loss may feel less real to the father initially because he does not feel the physical changes.

Postterm newborn

Inability of placenta to provide adequate oxygen and nutrients to fetus after 42 weeks Nursing assessment: typical characteristics Dry, cracked, wrinkled skin; possibly meconium stained which is not ideal because they can aspirate Long, thin extremities; long nails; creases cover entire soles of feet Wide eyed, alert expression Abundant hair on scalp Thin umbilical cord Limited vernix and lanugo Meconium is a particulate and so aspirating that can cause big issues

Polycystic Ovarian Syndrome- Incidence:

Incidence: Between 1-10 and 1-20 women of childbearing age have PCOS Up to 5 million women in the US have this disorder Can occur in girls as young as 11 yrs old Causes: Genetics may play a role...still researching Women with a mom or sister who also has the disorder are more likely to develop it themselves Underlying problem is too much androgen May be an autosomal-dominant genetic link

Nursing role in facilitating the grieving process

Include cultural and spiritual beliefs in plan of care Palliative care consult Chaplain consult Encourage parents to hold the newborn and/or take pictures Include the other parent or support person Follow-up phone call

Cardiovascular changes in pregnancy

Increase in ventricular wall muscle mass, heart rate, & cardiac output Peripheral edema is a normal finding Physiologic systolic murmur occurs in 90-95% of women. Grade 2/4 murmurs and diastolic murmurs should be evaluated. Decrease in DBP by 10-15 mmHG at 24-32 weeks in normal pregnancy, then returns to baseline around 32-33 weeks. Blood volume increases by 30% to 50% as early as 6 weeks and peaks by 28-34 weeks. Returns to prepregnant values 6-8 weeks postpartum. Plasma volume increases disproportionately to red cell mass causing a hemodilution effect - lower hemoglobin/hematocrit. Increased blood volume prevents shock from blood loss at birth. Normal estimated blood loss (EBL) for vaginal delivery = 500 mL, cesarean = 1000 mL. Further diuresis postpartum reduces plasma volume to prepregnancy levels. (sweating and voiding quite a bit to get rid of that excess plasma) Blood volume increases significantly throughout pregnancy along with cardiac output and most of that volume that has increased is plasma volume, its not red blood cells, the RBC does increase some but it is mostly plasma volume so it can cause hemodylution and can cause women to have a dehydration due to hemoglobin levels being decreased due to increased plasma volume Recommended that all women of child bearing age take iron and folic acid supplements The extra volume adds protection from hemorrhage a bit

Urinary tract infection and post partum

Increased incidence in: Cesarean birth- often related to having a catheter Epidural analgesia- related to needing in and out caths during labor Operative birth- due to tissue trauma Catheterization - remove catheters on time! 12hrs! Symptoms include: Frequency & dysuria Flank pain Low-grade fever Hematuria Cloudy urine with a strong odor Treatment may involve hydration and acidifying the urine or antibiotics may also be used

Percutaneous umbilical cord blood sampling (cordocentesis)

Indications for PUBS is to obtain blood for fetal karyotype, determine fetal blood type and Rh status, perform blood transfusions in the case of fetal anemia. This test is performed specifically for women at risk for genetic anomalies and those with potential blood disorders such as blood incompatibility or hemoglobinopathies. This test is not done very often at all A sample of the babies blood by having a needle take a sample from the umbilical cord and can actually get a DNA type from the baby Use ultrasound guidance Diagnostic

Education for the HIV positive patient

Individualized care that provides emotional support: How it is transmitted Infection control issues at home Safe sex practices/ Family Planning Referrals to community support, counseling, and financial aid Stages of HIV disease Preventative drug therapies Avoid breast feeding Continue prenatal care C- sections are encouraged because it reduces the possibility of transmission Adhere to medication regimen Signs and Symptoms of HIV in newborn

Who are genetic counselors?

Individuals who have followed a specific educational curriculum and are certified genetic counselors (CGCs) Doctors, nurses, or other individuals with specialized degrees and special training in the area of genetic counseling The International Society of Nurses in Genetics (ISONG) was formed in 1988 and is the professional organization of nurses in genetics in the U.S. and worldwide. The Genetic Nurse Credentialing Commission was created in 2002 too oversee credentialing of nurses in genetics in the U.S.

Labor induction and augmentation

Induction stimulating contractions via medical or surgical means Getting someone contracting who is not contracting at all Augmentation enhancing ineffective contractions after labor has begun Increasing contractions of someone who is already contracting

Infant benefits of breastfeeding

Infant Benefits: Provides total nutrition for an infant for the first six months of life - vitamins, minerals, nutrients. Breast milk contains antibodies that offer protection against disease. Reduced risk of SIDS Lowers risk of chronic conditions later in life such as asthma, high cholesterol, high blood pressure, diabetes, and leukemia. Creates a bond between mother and child. Babies do not get vitamin D through breastmilk so Dr. might supplement that but other than that breastmilk has everything the baby needs including antibodies to promote immunity and protects the gut Colostrum coasts the bowel and helps protect against necrotizing bowel

Shoulder dystocia- fetal injury risk

Infant Injury Brachial plexus injury- not very common and usually go away by 6 months of age Hypoxia Asphyxia Fracture - clavicle or humerus Ideally you want birth to happen within 6 minutes after the head is delivered, after that then there is much more increased risk of deficits and injury

Metritis (Endometritis)

Infection involving the endometrium, decidua, and myometrium of the uterus. Commonly called endometritis. Symptoms include: lower abdominal pain or tenderness, fever, foul-smelling lochia Increased incidence in: Cesarean birth Chorioamnionitis Prolonged labor Prolonged preterm rupture of membranes Premature rupture of membranes Treated with broad spectrum antibiotics, hydration, and analgesia Extension of metritis can result in parametritis, which involves the broad ligament and possibly the ovaries and fallopian tubes, or septic pelvic thrombophlebitis, which results when the infection spreads along venous routes into the pelvis. It occurs within the first two days postpartum or as late as two to six weeks postpartum These are women who often present back to the hospital with this complication and have to be treated with antibiotics. Because it often happens after discharge it is important to educate on s/s and when to contact physician. If a dr. has to do a manual sweep of the uterus then they will usually go ahead and do a prophylactic antibiotic because they are at increased risk of infection

Factors contributing to preterm birth

Infections/inflammation- bacterial vaginosis is one of the biggest risk factors for pre-term birth along with inflammation of the chorion or amnion Maternal or fetal distress Bleeding Stretching- amniotic fluid, size of baby, multiple birth or other things that cause stretching which causes the uterus to contract more Different than SGA babies, can have a preterm baby that is normal for gestational age

Polycystic Ovarian Syndrome-Infertility

Infertility: Obviously impossible to get pregnant without ovulating PCOS is the most common cause of female infertility Overproduction of androgen Underproduction of progesterone Women with PCOS struggle with obesity, elevated lipids, glucose, and insulin resistance Some ask what comes first? Does obesity cause PCOS and insulin resistance or does PCOS cause obesity/insulin resistance? PCOS is a metabolic system wide disorder.

Conjunctivitis

Inflammation of the conjunctiva. Bacteria, viruses, allergies, trauma, or irritants can cause the conjunctiva to become swollen and red or to have discharge. Commonly referred to as "pink eye." There are two categories. Infectious and non-infectious.

Essential care at birth

Initial assessment immediately after delivery Ensure proper airway, suction if necessary Dry newborn Skin to skin with mother if stable - helps regulate babies vital signs APGAR scores at 1 minute and 5 minutes Apply cord clamp after 1-2 minutes- even better for preterm babies Assess the transition phase and for signs and symptoms of respiratory distress The very first thing you want to do is visual assessment along with drying the baby and making sure their airway is patent One way to ensure an airway is if you can hear the baby cry then they have an open airway, if they don't cry right away try some tactile stimulation Part of the process of drying off the infant is tactile stimulation to arouse the baby and help it establish its own airway If airway is not established you don't want to wait a minute before you do something about it Delayed clamping increases blood volume in babies and also increases iron stores and increased red blood cells Infants have larger red blood cells than adults and they need them for oxygen carrying ability

Progesterone

Initially produced by the corpus luteum in early pregnancy and then the placenta around 10 weeks. Acts as a smooth muscle relaxant on the uterus to inhibit uterine contractions early in pregnancy. Facilitates implantation of the fertilized ovum. Acts on smooth muscle in other areas of the body: GI tract & renal system Relaxes venous walls to accommodate increase in maternal blood volume. Aids in breast development for lactation. Alters immune function to prevent rejection of the fetus by the mother as a foreign antigen. This hormone keeps the uterus quiet during pregnancy They do injections or suppositories of this for people who have a history of pre-term labor to help them go full term Can cause constipation and heartburn due to the slowing of GI motility due to the smooth muscle relaxation Dilation in the kidneys can make pregnant women more at risk for kidney infections and UTIs Relaxes the venous walls of the vascular system which can lead to peripheral edema which is not always abnormal, not always indicative of preeclampsia

Respiratory adaptations

Initiation of respiration- Adjusting from a fluid-filled intrauterine environment to gaseous extrauterine environment Surfactant- Reduces surface tension and prevents alveolar collapse Respirations- 30 to 60 breaths per minute Irregular and shallow Unlabored Short periods of apnea Symmetrical chest movements As soon as the baby is born, taking that first deep breath helps open up alveoli in the lungs and promotes the babies body getting rid of extra amniotic fluid Babies often have fine crackles in their lungs after they are born because they were in that wet environment Surfactant decreases the surface tension in the alveoli to help them pop open, an issue with pre-term infants is that they lack surfactant so they are sometimes given surfactant to help open up those alveoli Signs of respiratory distress: retractions, nasal flaring, oral cyanosis, grunting

Best Practice for Fetal Assessment during labor

Intermittent Auscultation When you use a fetal Doppler to check fetal heart rate intermittently Good for women who are low risk and want to move around Electronic Fetal Monitoring External fetal monitoring Wireless external monitoring- allows ambulation with continuous fetal monitoring Internal Fetal Monitoring Leopold Maneuvers Use this skill to determine fetal lie and presentation for best place to auscultate fetal heart rate monitoring. Need to know general position of fetus before placing a fetal monitor Leopold Maneuvers Auscultation- is use of either Fetoscope- similar to a stethoscope, or a Doppler to hear fetal heart rates, and without the use of paper recorder. Doppler is similar to ultrasound device, uses sound waves for fetal movement and fetal heart rate Research evidence supports the use of intermittent auscultation as a method of fetal surveillance during labor for low risk pregnancy AWOHNN or Association of Women's Health, Obstetric and Neonatal Nurses support the use of auscultation, palpation, and electronic fetal monitoring techniques to assess and promote maternal and fetal well being. AWHONN does not support EFM as a substitute for appropriate professional nursing care and support of women in labor. Best place to heart the fetal heart rate is on their back or close to the head so you want to know the baby's positioning

Intermittent auscultation

Intermittent auscultation (IA) Listening to fetal heart tones (FHT) at periodic intervals to assess FHR IA can be performed with: Fetoscope- used mostly in third world countries and there are some things you cant hear with Doppler that you can hear with fetoscope Doppler ultrasound device Advantages: Outcomes are comparable to those with continuous EFM Lower c/s (birth interventions) birth rate because of women being able to get out of bed Less invasive Increased freedom of movement Disadvantages: Certain FHR patterns cannot be detected Increases nurse to patient ratio Documentation of FHR not on paper, needs to be electronic Some patients see it as more intrusive because of how much you have to go into the room and mess with her 15-30 minutes check fetal heart tones for a women in active labor, there is no hard and fast rule for this its just standard of practice This is a good thing for women who do not have any complications and are progressing in labor on their own

Electronic Fetal monitoring: Internally

Internal monitoring (invasive) Fetal Scalp Electrode (FSE) - a spiral electrode applied to the scalp of the fetus. Attached with a little corkscrew onto the babies scalp. Cannot go over a fontanel because that could puncture the scalp so it always needs to go over a skull plate Gives an uninterrupted reading of the FHF if applied correctly. Intra-Uterine Pressure Catheter (IUPC) - inserted into the uterine cavity to measure the pressure exerted by the uterus during a contraction. Documents strength of contractions as wells as timing of contractions in conjunction with FHR. Measures the exact pressure inside the uterus during contraction to measure how strong the contraction is in mmHg and tells us the exact timing which can be important in relation to the FHR Internal fetal monitoring is only saved for only if necessary like if the mom has high levels of Pitocin, or if the fetus isn't responding as well as they would like Spiral electrode- a wire placed on scalp to monitor consistent measurement of fetal heart rate. Nurses can apply an FSE. In NC a nurse cannot insert an IUPC. Some states allow this. Know your state's regulations to protect your license In order to place a scalp electrode the moms water has to be broken Risk of infection increased with the use of these which is one of the reasons that they do not just automatically use these Use fetal scalp monitoring if for some reason you cannot get a good fetal HR In circumstances when the mom has too much or too little amniotic fluid can cause the FHR to be difficult to read which would then call for a fetal scalp electrode When a mom has high pitocin and is not progressing we would want to use an intrauterine pressure catheter to tell how strong her contractions are to see if she is progressing in labor at all

Postpartum period for body

Interval between birth & return of reproductive organs to their non-pregnant state. Also referred to as the puerperium. Lasts about 6 weeks. You will note where the fundus begins...and then where it should be at Day 9 s/p birth. Fundal height: using both hands; place 1 hand over the symphysis pubis bone to anchor fundus in place; then, use other hand to measure fundal height. First day: 1 cm below umbilicus...with each sequential day drops 1 cm. Should not continue to get higher, should be receding about 1 cm a day This is individual. Multigravidas don't return as fast as primigravidas

Mechanical and surgical intervention

Intrauterine balloon tamponade Catheter can be filled with up to 500ml NS which can help stabilize and stop the bleeding from the inside Easy application, can be used for uterine & vaginal bleeding, stabilizes a patient for transport. Expensive though they have started using less expensive ones Can be left in for 12 hours and it is recommended it be deflated slowly little by little Pelvic arterial ligation Fast Invasive surgery Embolization Identifies small vessels not visible by surgery, they go in through the femoral artery to find the uterine artery to stop blood flow to the uterus and it stops blood flow that way Not available in every facility

Menstrual Cycle - Ischemic Phase

Ischemic Phase Days 27-28 No fertilization means no HCG production. Corpus luteum degenerates and stops producing progesterone. Epithelial lining necroses as spiral arteries constrict and retract. Sloughing stimulates uterine contractions by day 29 or so when bleeding is visible Keep the corpus luteum in mind. We will talk about it again next week.

Examples of risk factors for adverse pregnancy outcomes

Isotretinoins (Accutane) Alcohol misuse Anti-epileptic drugs Diabetes (preconception) Folic acid deficiency Hypertension Addiction Hepatitis B HIV/AIDS Hypothyroidism Rubella seronegativity Obesity STIs Smoking If a woman who has HIV is treated early enough and her viral count is low enough then she can have a pregnancy where she is not considered HIV positive

Jaundice

Jaundice- the visible manifestation of hyperbilirubinemia. Is a result of unconjugated bilirubin pigment deposition in the skin and mucus membranes. Hyperbilirubinemia is the most common problem seen in the term newborn An imbalance may result in acute bilirubin encephalopathy. Kernicterus results if acute bilirubin encephalopathy causes permanent damage to the brain. Infant has a buildup of bilirubin in the bloodstream and that manifests as yellowing in the bloodstream Starts in the face, then the body, then goes out the extremities and then to the palms of the hands and soles of the feet Very serious if it has spread to soles of feet and palms of hands When jaundice occurs in the first 24 hours of life it is called pathologic jaundice and is caused by some disease process, blood incompatibility, and some enzyme disorders If it is caused by blood incompatibility they test for it with a direct antibody test (Koumbs test) to determine if there is moms blood in the baby and to test to see if there has been a reaction in baby from a different blood type Bilirubin encephalopathy is caused by a buildup of bilirubin in the brain and if it causes long term damage then it is called kernicterus. Jaundice is treated with frequent feedings to help get the kidneys working If bilirubin levels get too high the baby gets lethargic which can cause issues with feeding which is bad because frequent feedings is what helps clear this Colostrum is also a natural laxative and that helps also Water does NOT bring bilirubin levels down, according to studies

Renal changes in pregnancy

Kidneys increase in size by approximately 1cm Renal volume increases by 30% Mild hydronephresis is a normal finding in pregnancy Progesterone & increased blood volume dilates renal pelvis and ureters leading to an increased risk of UTI's. Urinary output increases in late pregnancy due primarily to changes in sodium excretion. Serum urea, BUN, & creatinine decline. Serum uric acid decline in early pregnancy and increase after 24 weeks. Abnormal: Serum creatinine > 0.8 mg/dL BUN > 14 mg/dL 24 hour urine totals > 300 mg/dL If a women gets more than 2 UTIs they will usually put her on a prophylactic of some kind

Types of vaccines- killed

Killed vaccines (Inactivated Vaccines) Contain whole dead organisms Polio (IPV) Hepatitis A

Assessment for normal physiologic changes of pregnancy

Knowing the normal changes associated with pregnancy is essential for accurate assessment. Laboratory values and physical findings considered normal in a nonpregnant woman may not be considered normal in a pregnant woman - and vice versa. See Standard Laboratory Values in Appendix A (Ricci) KNOW THESE

Indications for induction and augmentation

Labor Induction Prolonged gestation- going past their due date (or past 42 weeks) Prolonged premature rupture of the membranes- infection or risk of infection Gestational hypertension- that develops into preeclampsia or causes cardiac issue or placental perfusion involvement Cardiac disease- may induce so her contractions are strong enough so she doesn't have to push Renal disease Intrauterine fetal demise Diabetes- due to placental degredation and vascular compromise (usually around 34 weeks) Labor Augmentation Chorioamnionitis- intra amniotic infection or uterine infection Dystocia- any abnormal or ineffective labor Best not to be induced unless you have an indication Cardiac disease in pregnant women are not good with epidurals and C-sections, vaginal delivery is indicated in most of these cases Labor augmentation is indicated in an infected uterus because an infected urterus is not effective enough to change the cervix or push the baby out

Newborn care- testing

Laboratory and diagnostic tests Universal newborn screening Serum Bilirubin Critical congenital heart disease- O2 stat on babies left hand and O2 stat on one of the feet and making sure that those values are very close together to help screen for congenital heart issues before they go home Newborn hearing screening Normal levels for serum bilirubin will vary based upon the infant's age in hours. Baby gets a heel stick to get blood drawn Lots of enzyme difficencies that they test for like sickle cell traits, PKU, and lots of other disorders are all tested for in universal newborn screening Blood is put on little circles of paper and to test the blood they hole punch the paper off to test it If the baby has PKU (Phenylketonuria) means you cannot process phenal ketones and that is important to know right away because there are lots of food that has those ketones in it Every baby also gets a bilirubin test in their blood because their liver is immature Jaundiced hyperbilirubinemia is the most common issue with babies

Perineal lacerations

Lacerations Perineal lacerations 1st degree: skin and structures superficial to muscles Sometimes these are repaired, sometimes not 2nd degree: extends through muscles of the perineal body Almost always repaired with sutures that are dissolvable 3rd degree: continues through the anal sphincter muscle 4th degree: also involves anterior rectal wall Vaginal and urethral lacerations Cervical injuries Episiotomies are not done routinely anymore, they have been shown to cause women to tear more so they are no longer best practice One of the ways to help a woman not have a laceration is to help the woman in the second stage to help the woman control how she pushes so her perineum has time to stretch and for it to not happen so suddenly that her skin tears and then apply support on the peritoneum. Do not run finger around the skin of the peritoneum it does not actually help and can be very painful

PPD Complications

Lack of support is a major factor in postpartum depression. Especially with financial support, sometimes women after a certain amount of time are ineligible for Medicare which can be a barrier to them getting treatment Swift action to lift postpartum depression is important for a healthy mother and child. Without treatment, depression can last for many months and may have long-term consequences Research suggests that postpartum depression can interfere with bonding between mother and child, which can lead to behavior problems and developmental delays when your child gets older.

LGA newborns: assessment, common characteristics

Large body, plump, full faced, possible buffalo hump (large fat pad on the back of neck) Proportional increase in body size Poor motor skills- may have trouble sucking Difficulty regulating behavioral states- may not be as alert, may not be able to self soothe They have a different body makeup, they are big chunky babies which is not always a good thing A lot of large babies end up in the NICU and need glucose support and thermoregulation

Late deceleration

Late Decelerations Associated with reduced utero-placental perfusion, may not be much we can do to fix this Multifactorial - disease process, e.g. aging placenta secondary to smoking, diabetes, HTN Hypotension episode post epidural that remained uncorrected Onset of deceleration begins as contraction is ending Late decels are visually apparent, symmetrical gradual decrease of FHR associated with UC's. Late decels can be a sign of fetal intolerance to labor. Fetal tolerance of late decelerations is assessed by evaluating the baseine, presense of varialbity, and the presence of accelerations. Lowest point occurs after the peak of the contraction, the lowest point of the decrease in FHR is usually 10-20 bpm below baseline... rarely 30-40 bpm. Related to decreased availabiity of oxygen because uteroplacental insufcuiency. Late decels with min or absent variabiity indicate hypoxia , and a significant risk of fetal acidemia Fluid bolus, oxygen, repositioning, may need to try ephedrine (brings BP up if its related to anesthesia) Dropping down and stays down after the peak of the contractions is over! These are not good

Secondary Post partum hemorrhage

Late/Secondary PPH Infection Subinvolution- uterus does not return to its normal size Retained placenta Inherited coagulation defects

Nursing care- latent and active phase

Latent 0-6 for primigravidas 0-5 for multigravidas Nurse assists with reviewing techniques with mother and significant other learned in birthing class. Pain is mild and easily controlled. Mother can ambulate with ruptured membranes if fetal heart rate stable. Active- 5/6-7 cm. Mother less talkative and focusing more on breathing techniques Pain intensity increases but still managed without medication. Mom can get up and walk and get in the tub (not too early because we don't want to slow her labor) with ruptures membranes. As labor progresses, mom has to focus more on contractions. Epidural placement can usually occur at 5-6 cm's. Epidural is placed lower and less dense than a spinal, spinal is usually used for C-sections IV Pain meds close to delivery can cause respiratory distress in the baby Stadol can be used but Fentanyl is the med of choice here because it is in and out of the system fast. This is normally the time that you want to get them some pain meds because down the line it might be to late because you do not want to give IV meds when theyre close to delivery because it can cause respiratory sedation in the baby and mom and cause the mom to be sleepy and also the time you want to talk to the patient about how much you want to encourage them to stick to their no-med policy down the line She can still get up and walk even if she has ruptured membranes and can get in the tub

Obstetrical Hemorrhage

Leading cause of maternal death worldwide. In industrialized countries, it ranks in the top three causes of maternal mortality, together with embolism and hypertension. Defined as: > 500 mL of blood after vaginal birth. > 1000 mL of blood after cesarean birth. Diagnosed clinically as excessive bleeding that makes the patient symptomatic (pallor, lightheadedness, weakness, palpitations, diaphoresis, syncope, etc.) and/or results in signs of hypovolemia: Women who are symptomatic with blood loss have already lost about 50% of their blood volume which is very bad

Active Immunity

Life-time immunity Long-term protection Vaccines mimic characteristics of the natural antigen MMR Varicella Dtap Tdap Etc.

"Signs" of labor

Lightening - seen most often in primigravidas, which is when the baby drops down and is called lightening because now that the baby is down the mom has less SHOB and has less of a full feeling in her chest Uterine contractions, contractions near the fundus are more linked to true labor and contractions that are middle or lower are more associated with false labor Cervical change Bloody show Spontaneous rupture of membranes

Renal system changes

Limited ability to concentrate urine until about 3 months of age Urine has a low specific gravity Six to eight voids per day once milk is established in breastfeeding mothers Low GFR and limited excretion and conservation capability Affects newborn's ability to excrete salt, water loads, and drugs Newborns are not able to concentrate their urine well so they may have a low specific gravity May have bilirubin in the urine and that's what makes it dark Once feedings are established we want the baby to have between 6-8 wet diapers a day to make sure they are getting enough

Case study:

Linda, a 28 year old G3P0 has had a spontaneous vaginal delivery (SVD) and is entering the 4th stage of labor (begins with the delivery of the placenta and lasts for 2-4 hours). How often should the nurse assess Linda's vital signs and why is this important? Standard practice is that vital signs should be monitored Every 15 minutes for one hour Every 30 minutes for for one hour Every 4 hours for 24 hours, then Every 8 hours The post partum period begins once the placenta is delivered What else should be included in the nurse's assessment to ensure Linda's hemodynamic stability and postpartum recover? Risk factor assessment including pre-existing conditions Hemorrhage, infection, Box 16.1 p. 559 in Ricci Fundal massage BUBBLE-EE Pain Most hemorrhages occur within the first 24 hours and even more occur within the first few hours Women who have to have their placenta manually removed are at an increased risk of infection BUBBLE-EE Breast Uterus Bowel Bladder Lochia Episiotomy (Laceration) Extremities Emotional Status The nurse assesses Linda's fundal height and determines that it is at the umbilicus and boggy. What is the appropriate intervention? The nurse should perform fundal massage and assess Linda's bleeding PRIORITY with boggy uterus is perform fundal massage and assess bleeding and then tell Dr. The nurse notes that there is a 3-inch stain of red lochia on Linda's peripad. What is the best way for the nurse to describe this assessment in the EHR? The nurse would document this as light rubra because it is still red. Linda experienced a second degree laceration during delivery which was repaired. Describe what the nurse is assessing for on a patient who has a perineal laceration and comfort measures that can be performed? The REEDA assessment is redness, edema, ecchymosis, drainage, and approximation Ice and analgesics in the first 24 hours Warm water rinses after 24 hours, analgesics, and topical analgesics (like epafoam or epicream) On the next fundal assessment the nurse notes that Linda's fundus is 2 cm's above the umbilicus. What would be an appropriate intervention for the nurse to do in this instance? Encourage Linda to empty her bladder - assisting Linda to the bathroom, warm water over the perineum, running water, blowing bubbles through a straw may help Bladder scan prior to catheterization if bleeding is stable Linda is experiencing urinary retention? What factors can contribute to this in the immediate postpartum period? Decreased bladder tone Edema Epidural anesthesia The nurse assesses for pain and edema in Linda's lower extremities. What is the nurse concern? What normal physiologic changes in pregnancy and postpartum prompt this assessment? Women have an increased fibrinogen count in pregnancy and increased platelet count in the postpartum period. Pregnancy and postpartum are both a hypercoagulable state. This predisposes the women to VTE formation. Early ambulation and prevention of venous stasis are important interventions. Pregnancy is a hypercoaglulable state Homans sign is when you flex the foot and if the calf hurts from that and it did not hurt before than that is a red flag and needs to be evaluated Linda has chosen to breastfeed her infant. What nutritional needs will Linda need to know about while she is breastfeeding? Calorie increase 400-500 greater than in pregnancy Plenty of water and hydration Continue folic acid supplement How can the nurse facilitate bonding and attachment between Linda and her infant? How can the nurse involve Linda's partner and family in infant bonding? Initial skin-to-skin contact immediately after birth Individualized care Early breast-feeding initiation or feeding support What can the nurse tell Linda regarding sexual health and contraception? Choice will depend in part on personal preference Contraception is important to prevent closely spaced pregnancies Women with risk factors for VTE should avoid a combination oral contraception for 4-6 weeks. Women with a history of a VTE should avoid this form completely. The progesterone only pill has the least affect on milk supply Linda's blood type is Rh negative and her prenatal lab records indicate she was rubella non-immune. What will the nurse need to insure prior to Linda's discharge home? Rho-gam Rubella immunization

Types of vaccines- live

Live attenuated vaccines Modified living organisms that are weakened. Measles, Mumps, Rubella Varicella Influenza (nasal spray) Rotavirus Pregnant women cannot be vaccinated with live viruses. This is why it is so important to be current on immunizations prior to pregnancy.

Types of Lochia

Lochia: vaginal discharge after giving birth Postpartal days on the chart are WHEN the discharge begins...the dates on the slide are to state how LONG it lasts. Rubra: RED...Why is it RED? More blood...1-3 days pp Serosa: PINK...Why is it PINK? More serum...3-10 days (can last as along as 27 days) Alba: WHITE...Why is it WHITE? Leukocytes...10-14 days (can last up to 6 weeks)

Cesarean Birth

Low transverse incision Standard Classical incision Emergencies; extreme preterm, vertical incision Major surgical procedure with accompanying risks Nursing Assessment: Admitting history & physical Indication Gestational age Nursing Management Preoperative care Postoperative care Bonding/Skin-to-skin immediately in the OR and initiate breastfeeding if at all possible Lower uterine segment is not well developed in extremely pre-term babies so that is why they have to do a classical incision for that Can have vertical incision on the skin and transverse incision on the uterus or vise versa so it is important to look that up to make sure you know what kind of surgery they really had Classical incision of uterus means she will always have to have C-sections with every other pregnancy because the strong fundal fibers are broken and she is more likely to have a uterine rupture Still a birth so we do make an exception and allow family in there We do DVT prophylaxis with these patients because they did have a major surgery Need to make sure the baby is transitioning okay, C-section babies tend to have more fluid on their lungs

Respiratory distress syndrome

Lung immaturity and lack of alveolar surfactant Nursing assessment Risk factors Expiratory grunting, nasal flaring, chest wall retractions, seesaw respirations, generalized cyanosis; heart rate >150 to 180; fine inspiratory crackles, tachypnea (rates >60), Silverman-Anderson Index score >7 Chest x-ray: hypoaeration, underexpansion, and ground glass pattern

Rubella and pregnancy

MMR (Measles, Mumps, Rubella) Measles (Rubeola) - why get vaccinated? The majority of people who get measles are unvaccinated Measles is still common in many parts of the world. Rubella (German Measles) Rubella causes a mild rash and fever Most dangerous to pregnant women May cause miscarriage, birth defects such as blindness, heart defect, deafness, or intellectual disability MMR is a series of vaccinations Rubella in adults and healthy kids can cause flu-like symptoms In fetus can cause neural defects Because the vaccination is alive then we cannot vaccinate during pregnancy

MMR and pregnancy

MMR (Measles, Mumps, Rubella) Measles (Rubeola) - why get vaccinated? The majority of people who get measles are unvaccinated Measles is still common in many parts of the world. Travelers with measles bring the disease into the U.S. Measles spreads in the U.S when it reaches unvaccinated groups. Rubella (German Measles) Rubella causes a mild rash and fever Most dangerous to pregnant women May cause miscarriage, birth defects such as blindness, heart defect, deafness, or intellectual disability Measles complications include ear infections which can result in permanent hearing loss. Some people suffer severe complications such as pneumonia and encephalitis. As many as 1 out of 20 children get pneumonia, the most common cause of death from measles in young children. 1 in 1000 will get encephalitis. German Measles or Rubella is different from measles. It is often a mild illness and many people may not even know they have it or have had it. However, this is the one that can cause serious birth defects.

Nonhelpful resource for grieving families

Maintaining a state of denial Isolation Apathy

Nectrotizing enterocolitis: nursing management

Maintenance of fluid and nutritional status Bowel rest and antibiotic therapy; IV fluids Surgery with proximal enterostomy Supportive care Family education

Substance exposure during pregnancy- cannabis

Marijuana- Crosses the placenta, however specific effects on the fetus have been difficult to determine d/t common polysubstance abuse. Low birth weight, fetal growth restriction, and developmental delays have been shown in some studies.

Benefits of breast milk

Maternal Benefits: Decreased incidence of post-partum hemorrhage- because of released oxytocin Reduces return to fertility- optimal window of time between children is two years Long term benefits include reduced incidence of Type 2 diabetes (in mom and baby), and breast, ovarian, and uterine cancers A sense of empowerment. Reduced incidence of post-partum depression. Females of mothers who are diabetic are more likely to go on to develop diabetes

Contraindications to breastfeeding

Maternal cancer therapy or diagnostic and therapeutic radioactive isotopes Active tuberculosis not under treatment Human immunodeficiency virus- in the US they are discouraged from breastfeeding, in developing countries they are encouraged to breastfeed because they may not have other safe means of nutrition for the baby Maternal herpes simplex lesion on a breast Galactosemia in infant- one of the things the PKU tests for, they have an enzyme deficiency and they cannot process anything with lactose in it so they are unable to breastfeed Maternal substance abuse- it does pass through the breastmilk so it is discouraged Maternal human T-cell leukemia virus type 1 or type 2 Some medications may be incompatible with BF

Risk factors associated with Large-for-Gestational-Age newborns

Maternal diabetes mellitus or glucose intolerance Multiparity- because the uterus has more stretch and grows more easily Prior history of a macrosomic infant Postdates gestation- may start off larger than 90th percentile but if pregnancy continues to progress the placenta ages and the infant my regress as far as growth and that is when you will see an infant who looks wasted, wrinkled and possibly passed meconium in-utero Maternal obesity- due to higher blood sugar levels Male fetus Genetics

Onset of Labor

Maternal factor theories Uterine muscles stretch - release prostaglandin Cervical pressure - Ferguson reflex Oxytocin stimulation - blood levels increase during pregnancy and rise dramatically during labor Estrogen/progesterone ratio change - estrogen excites the uterus while progesterone quiets the uterus. Fetal factor theories Placental aging - deterioration triggers contractions. Fetal cortisol - produced by fetal adrenal glands Prostaglandin - produced by fetal membranes What makes labor begin? There are several theories. Some of them originate from the mother and some from the fetus. One theory is that the uterus becomes stretched which causes the release of prostaglandin. It is known that prostaglandin is an important hormone in the labor process. Another theory is that pressure on the cervix stimulates the release of oxytocin from the pituitary gland. Oxytocin is responsible for getting the uterus to contract. Oxytocin gets really interesting toward the end of pregnancy, though. Levels of oxytocin in the maternal blood stream slowly begin to rise toward the end of pregnancy and rises dramatically during labor. The number of oxytocin receptors in the uterus increases at the end of pregnancy and prostaglandin aids in the uptake of oxytocin by the uterus. Anything that causes manipulation of the cervix, or nipple stimulation or orgasm, all release oxytocin and some prostaglandin release. The estrogen to progesterone ratio changes. Progesterone which kept everything very quiet and calm decreases and estrogen which works on the uterus to amp it up increases. Fetal theories include placental aging. This may contribute also to the reduction in progesterone because remember, progesterone in pregnancy comes from the placenta. Fetal cortisol from the fetal adrenal glands also acts on the placenta to reduce progesterone formation and increase prostaglandin. More prostaglandin from the fetal membranes. All of this is part of why women sometimes cramp a lot after a cervical exam, or after sex, or after having their membranes "stripped." It has to do with prostaglandin Prostaglandin is in semen If a woman is predisposed to early labor then she may be on "pelvic rest" and be told not to have sex or if she is overdue then suggest she have sex

Factors Affecting fetal growth

Maternal nutrition Genetics- can mean a congenital disorder, an inherited disorder, and can also mean stature (like if both parents are short and baby is short than that may be normal for that baby) Placental function- if mom had a disorder during pregnancy then the placenta may not be perfusing effectively (like HTN, diabetes, HELLP syndrome) Environmental factors- working and living conditions

Screening and diagnostic tests for pregnancy

Maternal serum screening Amniocentesis Nuchal Translucency Test (NT) Chorionic villus sampling (CVS) Percutaneous umbilical blood sampling (PUBS) Ultrasound Preimplantation genetic diagnosis

Nifedipine

May observe reflex tachycardia and headaches

Spontaneous rupture of membranes (SROM)

May occur as leakage or large gush of fluid from the vagina. Testing: Nitrazine paper- will turn dark blue if amniotic fluid Pooling - visualized by speculum exam Fern- amniotic fluid will dry in a fern pattern on the nitrazine paper Rupture of the membranes increases the opportunity for infection. Delivery should ideally occur within 18 to 24 hours after membranes rupture because her and the baby are more susecptible to infection, especially if the mom is positive for group B strep SROM can occur with or without labor. Studies have proven a relationship between decreases in barometric pressure and increases in SROM & number of births (but not incidence of labor). SROM - spontaneous rupture of membranes. This is not really a sign of labor but can happen with labor. This does not happen to everyone. Membranes may rupture before labor begins, after labor begins, during the pushing phase, or not at all. Occasionally a baby will be born with the bag of waters intact. Sometimes it is a big gush, sometimes a trickle. Sometimes there is a trickle and then nothing. Most of the time there is a big gush but not all of the time. There are some tests that can be done to tell for sure whether membranes are ruptured or not. First, a sterile speculum exam is performed. The kit is usually a prepackaged kit of sterile disposable items. We use sterile items to prevent infection as much as possible. Visually, the examiner looks for pooling in the vaginal vault. That's one test. The next is nitrazine paper. Using a q-tip the examiner puts a dab of any fluid in the vagina on the nitrazine paper. Nitrazine paper is like litmus paper. Amniotic fluid will turn this paper a very dark royal blue because it's very base vs. acidic. Last, is ferning. Again a q-tip is used and some fluid is smeared on a slide and allowed to dry. Amniotic fluid dries into a pattern that resembles fern leaves when visualized under a microscope. If Mom's membranes are ruptures what needs to happen? It is preferred that she deliver within 18 or 24 hours. The reason we do those tests to be sure she is indeed ruptured is because we don't want to put her that clock if she doesn't need to be. What is even more important? It is the MOST important nursing intervention to perform after SROM. Assess FHT's. Anytime you are caring for a patient who is coming in to be evaluated always assess FHT's and anytime a patient feels her membranes rupture, assess FHT's. Storms seem to increase the incidence of SROM but not the incidence always of labor. Amniotic fluid should be clear, with no bad odor it does have a very distinct smell though but it does not smell like urine If woman's water does break the most important thing to do is check FHR and vital signs Some women do tend to start contracting more after SROM so sometimes they will break their membranes to help progress labor in some women Need to check temperature every hour after membranes rupture to check for development of infection Can get in the tub and can walk around with ruptured membranes

Fetal anomalies incompatible with life

May occur up to 20 weeks gestation in North Carolina Indicated for fetal anomalies incompatible with life or Maternal morbidity/mortality severely at risk Patient and families grieve the loss of the pregnancy & child Nurses may opt out of participating in these procedures, however.... If you choose to be a nurse in obstetrics the likelihood that you will encounter this type of situation is high and you may want to consider how you feel about this type of situation. It is important to have this conversation with your supervisor or manager and sign a conflict of conscience statement. You cannot be fired for your beliefs but it is reasonable to expect that patient care will not be interrupted. If you receive a patient assignment that is in conflict with what you believe you may ask for another assignment. However, you must continue to provide care to that patient until a replacement can be found for you.

Mastitis

May occur when milk stasis occurs in the breast and/or there is nipple trauma Symptoms include: Flu-like symptoms Malaise, fever, and chills Pain in affected area of the breast Erythema Treatment is two-fold: emptying the breasts completely during feedings & treating the infection Feed the infant frequently or empty the breasts by manual expression. Frequent feeding is preferred Antibiotics, hydration, & rest Infection that occurs in the breast Can occur in a woman that is breastfeeding or is not breastfeeding but women who are breastfeeding are more likely to get it than women who do not get it

Labor induction: mechanical methods

Mechanical methods: Cervical dilators: Transcervical pressure balloon or called a cervical ripening balloon Insert this balloon into the vagina and it goes on either side of the cervix and it separates the membrane between the uterus and the amnion and that is going to release prostaglandin and cause the uterus to contract a little bit You're putting it into a cervix that is usually not ready so it is usually an uncomfortable procedure. Usually the balloon falls out after 4 cm Laminaria- little short sticks of sea weed that are tried and they are inserted into the cervix and they expand as they absorb fluids Not common for the patient to have an epidural yet for these because she is not dilated enough

Featured Exemplars for Reproduction

Menstrual Dysfunction PCOS Endometriosis, Uterine Fibroids Sexually Transmitted Infections Family Planning

Polycystic Ovarian Syndrome: Effects on the Menstrual System

Menstrual effects: PCOS can make periods infrequent, absent or irregular Ovary doesn't make all the necessary hormones for the egg to mature...they remain as follicles or cysts Ovulation then does not occur and progesterone is not made... Seeing a "string of pearls" on US is indicative of PCOS

Tocolytic therapy: magnesium sulfate

MgSO4 (Magnesium Sulfate): Never give dosage as a secondary...use primary w/it's own channel Used in preterm labor for 24-48 hrs to allow time for corticosteroids to work. *Neuroprophylaxis for the neonate* May lower systolic and diastolic BP by 15mmHg Continuous EFM, frequent VS, urine output, neuro checks **High Alert, Independent Double-Check medication** Not used long term Longest it is used is 48 hours usually Assessment is the same of mom who is on mag sulfate for HTN and for preterm labor the only difference is we are less concerned about seizure with mag sulfate for preterm labor Still need to assess DTR, urine output, LOC, and all that to monitor for mag toxicity Monitor fetus Does not need mag post-partum because she is not getting it for HTN Needs calcium gluconate on hand (the antidote)

Clinical Manifestations of shock D/T blood loss

Mild - < 20% Diaphoresis, increased capillary refilling, cool extremities, maternal anxiety Moderate - < 20-40% Tachycardia, postural hypotension, oliguria Severe - > 40% Hypotension, agitation/confusion, hemodynamic instability

Immune system postpartum

Mildly suppressed during pregnancy...will now return to pre-pregnant state. Rebound of the immune system can cause a 'flare' in the following conditions: Lupus erythematosus Multiple sclerosis Lupus: butterfly rash MS: any and/or all listed...

Lactation

Milk supply Pain with feeding Engorgement Mastitis Suppressing Lactation Supply and demand system - feeding and emptying the breast is what signals the body to make more milk. Old advice was to nurse for a certain number of minutes on each side every so many hours. This is wrong. Newborns should nurse as frequently as needed for 5-45 minutes to establish a good milk supply. This is one reason pacifiers are discouraged in the newborn days. Ice is used for engorgement. Cabbage leaves may help with the swelling but should only be used for a short period of time as if may diminish milk supply. Avoid in women allergic to sulfa. Mastitis - inflammation or infection. Most of these problems happen after discharge!

Common problems with breastfeeding

Milk supply- frequent feeding helps her body produce enough breastmilk Pain with feeding Engorgement Mastitis- infection in the breast tissue Important for women to know where they can get help because a lot of women start to have these problems once they are home and outside of the hospital For engorgement we do ice or cabbage leaves but not so much that it reduces milk supply If mom has flat nipples then she may need to hand express to help the baby latch on

Antepartum nursing management for HTN disorders

Monitor BP closely for changes; check more than one Commonly ordered labs and treatments: AST, Platelets, Serum Creatinine, Uric Acid, 24 hr urine collection - provide patient with education on collection Bedrest - studies are conflicting on the benefits; help patient with coping mechanisms Administer corticosteroids (celestone) as ordered for fetal lung maturity in the event of preterm delivery. (2 injections, 24 hours apart) Good for two weeks and then they may need to repeat them if not in labor Down side is that it can increase blood sugar and so we may have to administer insulin in extreme cases Perform thorough assessments: HA (new onset) Visual changes RUQ pain? Pertinent changes in lab values - AST, Platelets, Serum creatinine Edema - particularly hands and face "How have you been feeling?" Coping with bedrest and activity restrictions? Rising AST level and felling platelet level is a trend they are looking out for

Nursing care during active labor

Monitor maternal v/s and fetal status Continuous fetal monitoring with epidural placement Maintain IV fluids as ordered to prevent maternal hypotension. Maintain security of the epidural infusion. Inspect catheter insertion site for bleeding, infection or hematoma formation. Report unusual findings to anesthesia provider Registered nurses should NOT: Bolus or rebolus an epidural catheter with anesthetic. Increase or decrease the rate of a continuous infusion Reinitiate an infusion once it has been stopped Obtain informed consent

Antidepressants and breastfeeding

Most antidepressants & mood stabilizers transfer through breastmilk However, these amounts are very small with very little effect on the infant. Postpartum depression itself poses the greatest risk to an infant, if a new mom goes without needed treatment. Breastfeeding and antidepressants:Breast milk is the best food for a baby during the first year of life. If a woman is taking an antidepressant, some of it will get into her breast milk but in a very miniscule amount. Postpartum dysphoria can have long lasting lifetime effects on a woman and her child. For this reason, health care providers give the woman who is breastfeeding the lowest possible dose to relieve her symptoms. Benzodiazepines can be used for anxiety. SSRI's may be used for depression. Mood stabilizing/anti-convulsant drugs may be used for mood stabilizer in the bipolar woman. Zoloft is the SSRI that passes the least amount into the breast milk.

Primary and secondary PPH

Most hemorrhages occur in the first 24 hours after birth and are mostly caused by uterine atony which is why we really push fundal massage Placenta accreta usually requires surgery to be removed, there are different degrees of it. Associated with multiple C-sections, the placenta seems to like to adhere to the placental scar and the different degrees are how far the placenta goes into the muscle Uterine clamps down with muscle fibers that overlap and if it is inverted or cut then it cant do that

Estimating due dates

Naegele's Rule Start with FIRST day of woman's last menstrual period. Count back 3 months then + 7 days = EDB or estimated date of birth Gestation in weeks dated from 1st day of last menstrual period (LMP) (EDD) estimated due date confirmed or changed by U/S and established by 20 weeks Accurate LMP most reliable Pregnancy wheel 39-42 weeks is considered full term

Contraceptive Options

Natural Family Planning/Fertility Awareness Abstinence Rhythm method Fertility awareness Lactational amenerinal method (effective up to 6 months) Barrier Condoms Diaphragm Hormonal Oral contraceptives Injections IUD Inplant Transcervical Sterilization E-sure (coilds in the fallopian tubes that cause swelling and scarring and that is how it helps avoid pregnancy) Surgical Methods Tubal ligation Vasectomy Multiple methods within each category Pros and cons of each method Diaphragm has to be left in for 6 hours after sex and has to be fitted with her diaphragm

Immune system adaptations

Natural immunity Acquired immunity Absent until after first invasion by foreign organism or toxin Newborn primarily dependent on three immunoglobulins: IgG, IgA, and IgM Babies are born without any acquired immunity, hopefully. Acquired immunity starts with that first exposure to things Do not have a lot of natural immunity right after birth which makes them more susceptible to infection Some of these antibodies, IgA antibodies specifically help babies get some acquired immunity and it is in colostrum

Newborn assessment- neck and check

Neck & Chest Round; xiphoid process may be prominent Nipples may be engorged and express white discharge Auscultate breath sounds; fine crackles shortly after birth are an expected finding Assess clavicles for crepitus Auscultate the heart; murmurs are common as foramen ovale is closing Newborns usually do not have a long neck, it is usually hidden by their large head and when you want to assess the clavicle you have to reach under the head to get to the neck On some babies the xyphoid process may be very prominent, this is a normal finding and should reassure parents

Nursing management for conjunctivitis

Newborn care Review prenatal history for risk factors Thorough eye assessment on newborn exam Infectious conjunctivitis Parent education Hygiene Medication administration Warm compresses to remove dried exudate Allergic conjunctivitis Reduce exposure to allergens Wash hands & face when coming in from out of doors Shower or bathe before bedtime Cool compresses for symptom relief

NAS is NOT addiction

Newborns can't be "born addicted" NAS is withdrawal - due to physical dependence Physical dependence is not addiction Addiction is brain illness whose visible signs are behaviors Newborns do not have the life duration or experience to meet the addiction definition Addiction is chronic disease - chronic illness can't be present at birth

Substance exposure during pregnancy- nicotine

Nicotine- Proven link between maternal smoking and reduced birth weights, increased rates of miscarriages, increased premature rupture of membranes, and fetal demise Contributes to low fetal iron stores. Second hand smoke in the home is a risk factor for SIDS Nicotine exposure exacerbates neonatal abstinence syndrome symptoms resulting in increased need for medication assisted treatment in babies with NAS

Medication Management for CHTN in pregnancy

Nifedipine and Labetalol are the most common. Occasionally a thiazide diuretic may be used - *concern is volume depletion. Long term therapy is safer as volume depletion occurs in the first two weeks of use. Debate about how uteroplacental blood flow is affected if BP is lowered too much. One analysis reported that a 10mmHg fall in mean arterial pressure correlated to a 176 gram decrease in birth weight. ACE inhibitors should be avoided - teratogenic to the fetal renal system. They don't like to use a diuretic too much because it can lead to less amniotic fluid which can cause less perfusion of the baby and there is usually already less amniotic fluid and diuretics can make that worse Usually they try not to start new medications but if the pt was already on it before they were pregnant they will let her keep taking it unless contraindicated

Cervical ripening

Non-pharmacologic Agents Herbal agents- black and blue cohosh Castor oil, hot baths, enemas Sexual intercourse- helps secrete prostaglandin Breast stimulation- helps pituitary gland release oxytocin Need cervix to be ripened for dilation and effacement before we induce to increase her success of a vaginal delivery Whenever the bowel is stimulated often the uterus will be stimulated as well

Pain control options during labor nonpharmacologic

Nonpharmocologic Labor support Registered Nurse Spouse/partner/family Doula Cutaneous measures Auditory or visual techniques Cognitive processes Many, many women actually want to deliver without any pain medication or at least labor to a certain point. Registered nurses provide support to laboring women beyond technical skill. The labor nurse can provide position changes, comfort measures, and provide primary care as the patient advocate. It's important for the nurse to include the woman's support people in the plan of care. Women who completed postpartum satisfaction surveys rated higher when they had a family member or friend there with them even if they "just sat there." A doula is a labor support person to the woman who is not a family member and not a nurse. Doulas have varying degrees of training and certification. A few reasons doulas came into being was as a result of the inability of the labor nurse to provide the continuous support desired during labor due to staffing demands on busy labor units. And another was the recognition that husbands or partners don't always make the best coaches during labor. Research shows that men experience childbirth as a stressful event. Fathers were sometimes found to not know how to deal with the ways in which their partner coped with labor or he felt like a failure for not helping her withhold from getting an epidural. A doula acts not only as a labor support person but as a communicator between the woman and the father.

Newborn assessment- skin variations

Normal Skin Variations Stork bites- little red marks usually at the back of the neck, they usually fade away Milia- little white pimples on skin, educate parents to leave them alone, breastmilk can help clear them up Mongolian spots- infants who are of a darker skin tone will have darker area spots that are usually on the buttock and back of the thighs and usually look like bruising Erythema toxicum- common rash, look like flea bites and the rash may move around a nd it is a normal finding Important to document Mongolian spots that way people know that the infant has not been hit or traumatized in some way

Group B Streptococcus

Normal vaginal flora - not an infection However - An important factor in neonatal morbidity and mortality Screening at 35 to 37 weeks of gestation decreases risk If positive during pregnancy: IV antibiotics before birth when labor starts Normal but in pregnancy can cause issues like neonatal pneumonia If positive when active labor starts they are treated with penicillin

Nursing Interventions for OB Hemorrhage

Notify healthcare provider Establish IV access if there is not already an existing IV line for fluid administration. Uterine massage Administering uterotonics, as ordered. Oxytocin- standard practice bolus, 30 units in 500ml bag as bolus dose (30 units first) Methergine (methylergonovine) - contraindicated in HTN, IM injection Carboprost- contraindicated in asthma, IM injection. Causes diarrhea post-partum which is uncomfortable Misoprostol- causes uterine contractions, can be given most all routes (fastest with rectal supp) Baseline labs- HH, CBC *Draw 5mL for a red top tube to watch for clotting. Accurate blood loss assessment - Quantification of blood loss with patients who are bleeding heavily Patients who have complications need to have at least one 18 gauge and preferably 2, especially if they have an accreta or abruption or something CBC next day and HH and sometimes the fluids can hemodilute which is normal

Intrauterine fetal demise

Numerous causes Devastating effects on family and staff Nursing Assessment Inability to obtain fetal heart sounds Ultrasound to confirm absence of fetal activity Often requires labor induction Nursing Management Assistance with grieving process Referrals

Labor induction and augmentation: assessment and management

Nursing Assessment Indications- Important to know what the indication for the induction is Gestational age - term or preterm (if preterm with no indications then induction should not be happening) Fetal status- document fetal heart rate every 15 minutes and interventions as needed Maternal status- vital signs every 15 minutes or 30 minutes or every time the infusion is increased or the dose is changed (because of risk of water intoxication with oxytocin) Bishop's score Nursing Management Explanations Oxytocin administration Pain relief and support Teaching guide p. 821 Late decels are common when we are inducing because of how we are manipulating the uterus Contractions that are natural are usually farther apart and still effective but if we are inducing we want those contractions every 2 minutes and they are a lot stronger and more uncomfortable

OB Hemorrhage Assessment and Management

Nursing Assessment Risk factors Physical assessment: vital signs, etc. Uterine tone; vaginal bleeding Nursing Management Fundal massage; pad count Administration of uterotonic Fluid administration- go to this before you see vital sign changes and monitor for s/s of shock and also let the provider know Monitoring for signs and symptoms of shock

Nursing care for baby postpartum safety

Nursing care Always check identification bracelets to prevent giving the baby to the wrong mother Instruct family about hand washing when caring for the baby Instruct the new family on safety practices in the hospital Instruct on the care of the newborn such as testing,- PKU, and hearing screen Educating the parents on why we do things to the babies

Nursing management of antepartum

Obstetric and Gynecological History Menstrual history, perineal and breast, reproductive planning and surgeries of reproductive tract, number of pregnancies, outcomes of previous pregnancies Vital signs, height and weight, BMI, head to toe assessment Fetal Heart Tones Can be assessed by fetoscope at about 16 weeks (depending on the body type of the patient) , or by ultrasound at 8 weeks Fundal Height Second trimester, 18 to 32 weeks gestation the height in cm. is approximate number of weeks +2 or -2 weeks, (full bladder can alter)

Umbilical cord prolapse

Obstetric emergency Pathophysiology: partial or total occlusion of cord with rapid fetal deterioration because the cord comes down and some of it through the cervix Nursing Assessment Prevention Risk factors- a baby that is floating in the pelvis (ballotable) Continuous assessment of client and fetus Nursing Management Prompt recognition Measures to relieve compression ***Always, always check FHR after rupture of membranes*** Causes lack of perfusion Lift presenting part up off the cord and stay there, usually have to stay there because you cannot just shove the cord back in they have to go to surgery Sometimes getting In hands and knees position helps but not always

Thromboembolic Disease with pregnancy

Occurs related to a blood clot caused by inflammation or partial obstruction of vessel. Superficial venous thrombosis Deep venous thrombosis (75-80% of women who develop thromboembolism will develop a DVT) Pulmonary embolism (20-25% women who develop thromboembolism will develop PE) Women are at a 4 times greater risk of developing VTE during and right after pregnancy VTE has been associated with poor outcomes during pregnancy like abruption, preeclampsia, intra-uterine growth restriction, and stillbirth Women who have C-sections are at an increased risk of VTE, but women who have had C-sections and also have a uterine infection like chorioamnionitis Superficial venous thrombosis: 1. Treatment The goals of treatment are to reduce pain and inflammation and prevent complications. To reduce discomfort and swelling, support stockings and elevation of the affected extremity are recommended. A warm compress to the area may also be helpful. Medications to treat superficial thrombophlebitis may include: Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation Painkillers If deeper clots (deep vein thrombosis) are also present, your provider may prescribe medicines to thin your blood, called anticoagulates. Antibiotics are prescribed if you have an infection. Surgical removal (phlebectomy), stripping, or sclerotherapy of the affected vein are occasionally needed to treat large varicose veins or to prevent further episodes of thrombophlebitis in high-risk patients. Dvt: What happens after birth? Treatment should be continued for at least six weeks after birth. There is a choice of treatment after birth of continuing with injections of heparin or using warfarin tablets. Your doctor will discuss your options with you. After birth you will usually be given an appointment with your GP, obstetrician or haematologist. At your appointment the doctor will: ask about your family history of thrombosis and discuss tests for a condition which makes thrombosis more likely (thrombophilia). These tests should be done ideally before any future pregnancies. discuss your options for contraception (you should be advised not to take any contraception that contains oestrogen - for example, the 'combined pill') discuss future pregnancies - you will usually be recommended heparin treatment during and after your next pregnancy give you information about a compression stocking: it is recommended that you should wear this on the affected leg for two years. Can I breastfeed? Yes - both heparin and warfarin are safe to take when breastfeeding. PE: may need heparin gtt and ? filter placement depending on severity of illness

Conditions of an urgent nature

Oliguria/Anuria- means Renal failure Pulmonary Edema- Flash pulmonary edema that can happen really quickly because of the endothelial damage DIC (disseminated intravascular coagulopathy) coagulopathy is excessive bleeding Abruption Eclampsia First priority when patient is seizing is staying with the patient and calling for help Often when women seize they will have a placental abruption

Gestational HTN

Onset of hypertension without proteinuria after the 20th week of pregnancy Refers to hypertension during pregnancy Occurs after 20 weeks gestation Absence of proteinuria No other signs/symptoms of pre-eclampsia Resolves by 12 weeks post-partum Is a retrospective diagnosis Does not require management with medication New elevation in BP does not affect the renal system right away which will cause the absence of proteinuria but if they are spilling protein then it is preeclampsia

Substance exposure during pregnancy- opiates

Opiates & Narcotics Opium, morphine, heroin, codeine, hydromorphone, oxycodone, methadone CNS depressants Highly addictive May lead to Neonatal Abstinence Syndrome in the newborn

Newborn behavioral responses

Orientation - response to stimuli Habituation - ability to block out external stimuli after newborn has become used to activity Motor maturity - ability to control movements Self-quieting ability - consolability Social behaviors - cuddling and snuggling Habituation takes some time to develop With newborns their head and legs kind of flail around for a bit because they cant control it Newborns are very responsive to swaddling because they came from an environment that was enclosed \ Babies that are exposed to substances have a decreased ability to console themselves

Otitis Media

Otitis Media - the general term for inflammation of the middle ear One of the most common childhood illnesses. Most children experience at least one episode of this by the time they are 3. It occurs more often in boys, in children who attend childcare centers, in winter months, in children who have allergies, in children exposed to tobacco smoke, and in children who use a pacifier several hours daily

Assessment of the Ear

Otoscopic examination Note the presence of cerumen, discharge, inflammation, or a foreign body in the ear canal. Visualize the tympanic membrane. Observe its color, landmarks, and light reflex, as well as presence of perforation, scars, bulging, or retraction. What does a red inflamed & bulging tympanic membrane indicate? What would a tympanic membrane with fluid behind indicate? It may be immobile or partially retracted.

Ectopic pregnancy

Ovum implantation outside the uterus Obstruction to or slowing passage of ovum through tube to uterus Therapeutic management Medical: drug therapy (methotrexate, prostaglandins, misoprostol, and actinomycin) Surgery if rupture Rh immunoglobulin if woman Rh negative Can be a medical emergency if tube ruptures Pain may start in right lower quadrant or be referred shoulder pain related to rupture Methotrexate is used for early ectopic pregnancy Rh negative moms need rogam Ectopic pregnancy is the third leading cause of infertility Nursing assessment Hallmark sign: abdominal pain with spotting around the time of missed period Referred shoulder pain Contributing factors Laboratory and diagnostic testing: transvaginal ultrasound, serum beta hCG; additional testing to rule out other conditions

Preterm newborns: nursing management

Oxygenation- we resuscitate with room air and then if we need oxygen we try to do a mix of oxygen and room air to titrate it until the infant has adequate pulse ox readings Thermal regulation Nutrition and fluid balance Infection prevention Stimulation- they do not do well with lots of stimulation, educate parents to put hand on them to touch them and NOT to pat them because that is too much for them Pain management- babies have VS changes and emotional changes just like we do Growth and development Parental support: high-risk status; possible perinatal loss Discharge preparation Extremely pre-term infants there is a tiny baby bag and there is a warmer pad that is a soft gel-like surface in the radiant warmer and they put the infant on that and they even take a plastic bag and put the infants body in it because plastic is a good insulator, they leave the head out though, obviously.

Pituitary hormones

Oxytocin Secreted from the posterior pituitary gland. Influences contractility of the uterus for labor. After birth, stimulates milk ejection from the breasts. Secretion increases during the intrapartum & postpartum periods. Elevates mood. Prolactin Secreted from the anterior pituitary gland. Increases and matures milk ducts and alveoli in the breasts in preparation for lactation. With delivery of the placenta at birth, prolactin levels begin to rise rapidly. Breast stimulation during infant feedings or pumping in breastfeeding women causes levels to increase further promoting the production of milk. Lots of women cramp when they breastfeed because the breastfeeding releases more oxytocin which increases contraction of muscles

Uterine stimulants/ uterotonics

Oxytocin bolus after birth is standard practice to avoid postpartum hemorrhage Methylergonovine (methergine) given by IM injection to help stop bleeding, usually works very quickly. Cannot be used in women with HTN issues. Can give several doses Carboprost (hemobate) causes significant diarrhea and contraindicated in women who have asthma Misoprostol used for cervical ripening, early pregnacy induction, usually placed by rectal suppository or orally (works slower if given orally), a very common med 500ml is the upper limit of acceptable bleeding before it is considered hemorrhage Standard care for a woman to get a bolus of oxytocin either right after birth baby or placenta birth and it reduces the risk of post partum hemorrhage Utero-stimulants or utero-tonics are given if the mom is still bleeding a lot after the oxytocin bolus

Labor induction: oxytocin

Oxytocin: Widely used for induction/augmentation of labor Cervix must be ripe (high Bishop score) for induction to be successful) Nursing considerations: Continuous fetal monitoring- may over stimulate the uterus Monitor for hypertonicity of the uterus Usually concentrated 30 units in 500ml and needs to be run on its own channel at 1-1 and is always mixed in normal saline or lactated ringers because mixing it with dextrose increases the risk of water intoxication. Needs to be a titrated drip until you get them to the right amount of contractions (about every 2 minutes and contractions that are firm and strong) DO NOT run as secondary Bishop score of at least 6 but most effective if she has a ripened cervix and a score of 8 or higher Bishop score is a way to measure the cervix (817 of book) to measure the cervical dilation, effacement, station, consistency and placement of cervix (facing forward, posterior or mid position) If contractions are non-stop then you need to stop the infusion to allow it to clear, oxytocin will clear pretty quickly No real antidote for oxytocin but it does clear the system quickly but if they are getting hypertonisity (contracting too close together) then you are going to want to do intra uterine resuscitation measures and then Terbutaline to relax the uterus

Premature rupture of membranes

PROM—women beyond 37 weeks' gestation PPROM—women less than 37 weeks' gestation Treatment: dependent on gestational age; no unsterile digital cervical exams until woman is in active labor; expectant management if fetal lungs immature Nursing assessment: risk factors, signs and symptoms of labor, electronic FHR monitoring, amniotic fluid characteristics Nitrazine test, fern test, ultrasound Usually stays in the hospital for PPROM and are induced at 34 weeks

Placental abruption

Painful vaginal bleeding Amount of vaginal bleeding is not always proportional to the degree of abruption Associated with smoking, cocaine use, hypertension, rapid decompression of the uterus (with multiple gestation, polyhydramnios, short umbilical cord, trauma) Nursing management: Monitor fetal status Provide education re: smoking, drugs, bedrest, blood pressure management, nutrition, fetal movement counts Give specific written instructions as to activity If hospitalized, maintain large bore IV access & type and screen. Kleinhaur-Betke (KB) test may be done to test for mixture of maternal blood with fetal blood. The Rh negative mother will need Rhogam. Can happen at any time during pregnancy but is usually at the end of pregnancy, can be done because of HTN or preeclampsia or diabetes (because insulin wears down on the placenta), cocaine can cause an abruption and so can cigarettes due to them causing vasoconstriction If the placenta becomes completely pulls away from the uterus then you would have fetal death and maternal hemorrhage Dark red bleeding and pain are the normal presenting symptoms Large bore IV access required all times while mom is in the hospital in case they need to do a blood transfusion

Placenta previa

Painless vaginal bleeding; bright red Abnormal implantation of the placenta over the cervix Complete- covering the cervix completely Dangerous because when cervix dilates the vessels are exposed and can bleed profusely Incomplete/partial- Covering some of the cervix Marginal or low-lying- Barely touching the cervix Nursing management: Monitor fetal status and fetal movement Give specific written instructions as to activity If hospitalized, maintain large bore IV access & type and screen. Kleinhaur-Betke (KB) test may be done to test for mixture of maternal blood with fetal blood. The Rh negative mother will need Rhogam. The placenta is lying on the cervix partly, or fully Need large bore IV access at all times here also Vaginal delivery not possible for most complete previa Associated with women who have had multiple c-sections or uterine infections

Newborn care- bonding

Parent Child Bonding The initial phase in a relationship is characterized by strong attraction and desire to interact Without bonding, it would be difficult to maintain the energy required to meet the newborns needs Provide family centered care at all times! Early contact with infant is important Nurses should encourage early and frequent interaction between the newborn and the parents Best practice is to not separate parents from baby unless you really have to Empowers the parents to they have the say so of what is happening to their child and are aware of all aspects of care that are talking to their child Circumcision care- assess whether or not that site is bleeding, priority is to assess for bleeding since babies do not have their full clotting factors, most dr. will not do circumcision if the parents did not let the baby get the vitamin K shot. Putting Vaseline in the diaper helps keep the penis from sticking to the diaper. If there is a baby that is having blood sugar issues or feeding issues then it is better to wait for the circumcision until those things are under control because it is going to interrupt those things

Nursing Management of Ear Infection

Parent education: Antibiotic therapy for AOM Follow-up and monitoring for hearing loss with OME Contributing factors Pain control Antibiotics are not automatically prescribed for AOM. A waiting period of 48-72 hrs may be advisable before prescribing antibiotics, depending upon the child's age and presentation of the episode. Parents will need reassurance regarding these guidelines. Most will want antibiotics right away. Neither decongestants nor antihistamines have been shown to be effective in the treatment of otitis media with or without effusion. If infection recurs in spite of antibiotic treatment, myringotomy may be performed Contributing factors: smoke, tobacco and wood-burning fireplaces. Some are modifiable and some are not modifiable. Day-care may not be a modifiable option. Breastfeeding may have already ceased. Decrease pacifier use. Immunize against Hib and Pneumococcus as these are two of the contributing microbes.

Anticipatory Guidance for Vaccinations

Parents - education: Vaccination Information Statement (VIS from CDC.gov) Vaccine schedule Recommended follow-up Adverse reactions Ask open-ended, non-judgmental questions. Infants should not be medicated with Tylenol or Ibuprofen prior to or after vaccination. Important to know vaccine site and administration type. Needle, etc. Questions should be open-ended. What questions do you have about the vaccine hand-out I left with you? You've gotten a flu-shot before, how did that go last time?

Screening tools screening with the 4 p's plus

Parents- did either of your parents have a problem with alcohol? Partner- does your partner have a problem with alcohol or drugs? Past- Have you ever had a problem with beer or wine or liquor? Pregnancy- in the month before you were pregnant how many cigarettes did you smoke and how much beer, wine or liquor did you drink?

Parity

Parity - refers to the number of pregnancies carried to viability regardless of outcomes. Does not necessarily refer to the number of fetuses. Para - the number of deliveries at 20 weeks or greater, regardless if the infant was born alive or dead. Nullipara - a woman who has never given birth Primipara (Primip) - a woman who has delivered for the first time. Multipara - a woman who has had two or more deliveries. Grandpara - a woman who has given birth 5 or more times. 22-24 weeks is the weeks of viability that they will resuscitate but it is based on weight mostly (500g and other comorbidities are taken into account)

Parvovirus B19

Parvo B19 virus causes Fifth's disease (Slapped Cheek disease) Spread through saliva, sputum, nasal secretions Can also spread through blood Perinatal transmission can occur Miscarriage happens less than 5% of the time May cause fetal anemia which may lead to hydrops fetalis Parvovirus B19 (Slapped Cheek Disease or Fifth's Disease) Spread through saliva, sputum, nasal secretions. Can also be spread through blood. Perinatal transmission can occur. May cause miscarriage - happens less than 5% of the time. Fetal anemia, hydrops Can cause flu-like symptoms and then it goes away, 5% of time can cause miscarriage If women are exposed during pregnancy then it can be passed through perinatal transmission Hydrops is an accumulation of fluid in the fetal body in various places Keep hands away from nose/mouth and good hand washing is the education

Pain during labor and birth

Perception of pain Pain tolerance refers to the level of pain a woman is willing to endure Expression of pain Emotional expressions of suffering often seen Increasing anxiety Writhing, crying, groaning, gesturing (hand clenching and wringing), and excessive muscular excitability Cultural expression of pain varies Factors influencing pain response Physiologic factors Culture Anxiety Previous experience Gate-control theory of pain Comfort and support Environment Most pain during labor and birth results from normal physiologic events. Even so, every person has their own perception of pain and their own perception of what pain in labor should be like. Some women will express their pain very openly while others will cope very silently and inwardly Neurologic origins Visceral pain: from cervical changes, distention of lower uterine segment, and uterine ischemia Associated with 1st & 3rd stages of pregnancy Located over lower portion of abdomen Referred pain: originates in uterus, radiates to abdominal wall, lumbosacral area of back, iliac crests, gluteal area, and down thighs Somatic pain: pain described as intense, sharp, burning, and localized Associated with 2nd stage of labor Stretching and distention of perineal tissues and pelvic floor to allow passage of fetus from distention and traction on peritoneum and uterocervical supports during contractions and lacerations of soft tissue I would not agree with this slide. I tend to think it depends upon the labor and the delivery.

Postterm newborn: common problems

Perinatal asphyxia- due to placental aging in-utero or during birth Hypoglycemia Hypothermia Polycythemia Meconium aspiration

SGA newborns: common problems

Perinatal asphyxia- something has happened in-utero to cause the hypoxia Difficulty with thermoregulation Hypoglycemia Polycythemia- increased red blood cells in response to a hypoxic event, can cause the baby to look red Meconium aspiration- caused by infant being deprived of oxygen for a period of time to have a BM in utero Hyperbilirubinemia Birth trauma (see Table 23.1) is a problem with smaller infants because they are more at risk for cerebral bleeds and their bodies are more fragile

Second stage- perineal trauma

Perineal trauma related to childbirth Episiotomy Incision to extend vaginal outlet Routine use has declined

Pain control options pharmacologic

Pharmacologic Sedatives & hypnotics describes the effect on the mother; not the class of drug. Ambien Parenteral opioids Opioids - morphine and meperidine Synthetic opioids - fentanyl Opioid agonist-antagonists - butorphanol and nalbuphine Anesthetic pain relief (neuraxial analgesia) Epidural Spinal Combined spinal epidural Historically women were given barbiturates to help give them a period of rest during very long latent phases of labor. These were found to have a long half life and not only make moms have a positive drug screen but also cause respiratory and CNS depression in the neonate. Opioids do not eliminate pain but cause a blunted effect, increase somnolence, and decrease the perception of pain which allows the mom to rest between contractions. Opioids readily cross the placenta and can have a cumulative effect. Prodromal labor cocktail (morphine & Phenergan) to promote a short period of rest

Five additional factors affecting the labor process

Philosophy (low-tech, high-touch) Partners (support caregivers) Patience (natural timing) Patient preparation (childbirth knowledge base) Pain control (comfort measures) Supportive caregivers is very important. It is known that women who have continuous labor support when compared to women who have "the usual" labor care are more likely to have a spontaneous vaginal birth and are less likely to have a c/s, epidural, operative vaginal birth, baby with low apgar scores, or report dissatisfaction with their birth outcomes. Patience plays a huge factor in how the birth and labor process goes. Waiting for labor to happen on its own if possible is the best for mom and baby. The NC Perinatal Quality Collaborative of NC and AWHONN both have campaigns to this effect. The 39 week initiative and Go the Full 40.

The Ballard score- gestational age assessment

Physical maturity: Skin texture Lanugo Plantar creases Breast tissue Eyes and ears Genitals Neuromuscular maturity: Posture Square window Arm recoil Popliteal angle Scarf sign Heel to ear With ears you check the amount of cartilage, form and if there is good recoil For genitals a term infant has some swelling (a residual of moms swelling), males should have lots of rugae on their scrotum and females should have well formed labia In preterm girls the clitoris is more prominent but the labia will develop more Square window is how well the wrist bends Scarf sign is how far across the babies chest does the babies arm go Heel to ear is how far back the babies feet can go, preterm infants are more flexible

Endocrine system postpartum

Placental Hormones: Expulsion of placenta results in dramatic decreases of placental-produced hormones. Decreases in human placental lactogen (hPL), estrogens, cortisol, and placental enzyme insulinase-reverse effects of pregnancy. Estrogen & progesterone levels drop markedly. Pituitary Hormones & Ovarian Function: Time varies between lactating and non-lactating women as to when first ovulation and menstruation occur. In non-lactating women, menstruation may resume as early as 7 to 9 weeks, majority take up to 3 months. Often the first cycle is anovulatory - BUT, not always. In breastfeeding women, return of ovulation depends on breastfeeding patterns. In a study of 27 mothers who breastfed for 40 weeks the average time for the return of ovulation was 15-66 weeks. The women who delayed ovulation longer, breastfed longer, during the night and more often than the women who ovulated sooner. Once there was an introduction of solid food into the diet there was an increase in ovulation also. Can ovulate before having a period. Women who want to use breastfeeding to avoid ovulation need to breastfeed exclusively, no bottles, supplements or pacifiers

Position of mother

Position affects woman's anatomic and physiologic adaptations to labor Frequent changes in position Relieve fatigue Increase comfort Improve circulation Laboring woman should be encouraged to find positions most comfortable to her Positions for Labor Your book has good information on the history of women's positions in labor. It historically has not been performed lying down. If you watch any woman laboring you will see her move and twist and turn and eventually rise up out of the bed. Moving promotes fetal positioning as well. If a laboring woman has an epidural, because she's still laboring even with an epidural, she should be repositioned every hour to prevent stasis and promote fetal descent.

Urinary system postpartum

Post-partal diuresis: Within 12 hours post-partum, women will begin diuresing. Profuse diaphoresis often occurs at night for first 2-3 days. Urethra & Bladder: Excessive bleeding can occur because of displacement of the uterus, if bladder is full. Encourage your patients to keep their bladders empty, if possible. As the pressure from the bladder can cause issues with the uterus...watch for s/s of a patient that is not voiding or having difficulty. If fundus doesn't feel like its getting smaller or feels displaced; then, it could be because of a full bladder. For women with preeclampsia their edema may be worse after birth for a little bit before it gets better, and these women will void and sweat a lot after birth to get rid of that excess fluid Progesterone can cause decreased tone of bladder Many women get distended bladders after they have a baby

Neurological system postpartum

Post-partum headaches may be caused by: Gestational hypertension Stress Leakage of cerebrospinal fluid into extradural space during placement of spinal anesthesia. Headaches are expected; however, if ensure pt is in correct position in the bed s/p epidural. Pressure usually needs to be placed on the site to decrease risk of leak. Very important to determine the cause of the headache if unrelieved by analgesia. If it is a spinal leak then the anesthesiologist will do a blood patch to cover the leak to help relieve the headache

What is postpartum psychosis?

Postpartum psychosis is a rare, serious mental illness. Symptoms are similar to Baby Blues and PPD, but MORE SEVERE A woman with postpartum psychosis is at risk of harming herself or her baby!!! Rare: 0.1-0.2% of postpartum women. However, if a woman has had the disorder before; she is 30-50% likely to have a recurrence It's more common in women with a personal or family history of bipolar disorder or schizophrenia. Delusional, may have hallucinations, have lost touch with reality

Shoulder dystocia- maternal injury risk

Potential for pelvic injury Episiotomy- almost always have to have one as they try to make more room for the baby 4th degree perineal laceration- due to episiotomy usually Post partum depression PTSD The babies head is delivered but the fetal shoulders get caught at the pelvic inlet so the baby get stuck so to speak Turtling is a thing where the contraction will cause the babies head to get kind of sucked back in Worst case scenario they may have to break pubic symphysis to get that baby out Women commonly hemorrhage from the lacerations or uterus after these types of deliveries

Diabetes in pregnancy- 2 types

Pre-gestational is one type: Type 1: Hyperglycemia as a result of absolute insulin deficiency. Results from an autoimmune reaction directed at the destruction of beta cells of the pancreas. Typical onset is < 30 yrs of age but can happen at any age. Type 2: Insulin resistence & insulin deficiency. Happens as the result of genetic predisposition, environmental factors such as obesity, or both. Typical onset is > reproductive age range however, this is changing. Gestational is another type: Carbohydrate intolerance with first recognition during pregnancy. Two types: Gestational diabetes - diet controlled (they try this one first) Gestational diabetes - insulin controlled. Type one you have none Type two you don't know what to do Human placental lactogen is the hormone that frees up glucose to be sent to the fetus for the fetus to grow but it makes the mom unable to process carbs which increases her blood sugar

Stages of fetal development

Preembryonic stage: fertilization through 2nd week Fertilization; cleavage; morula Blastocyst becomes fetus; trophoblast becomes placenta Implantation Embryonic stage: end of 2nd week through 8th week Basic structures of major body organs and main external features This is the stage where the embryo is most susceptible to birth defects. Many women won't know they are pregnant until week 7 or 8. Fetal stage: end of the 8th week until birth

Hepatitis B Infection

Pregnant women are screened in the 1st trimester for the Hepatitis B Surface Antigen (HBsAg) If woman who is positive for Hepatitis B: Can have children Can breastfeed Babies of Hep B + mothers: Hep B Vaccine within 12 hrs. Hep B immune globulin (HBIG) within 12 hrs. Testing for Hep B surface antigen meaning she is positive for this infection, can cause perinatal transmission Babies who are born with this infection often grow up to have chronic hep B (90% likely), can lead to hepatomegaly ascites, liver cirrhosis, liver cancer Hep B immune globulin is short term immediate coverage, the hep b vaccine is life long protection from hep B

Hepatitis B and pregnancy

Pregnant women are screened in the 1st trimester for the Hepatitis B Surface Antigen (HBsAg) Women who are Hepatitis B positive: Can have children Can breastfeed Babies of Hep B + mothers: Hep B Vaccine within 12 hrs. Hep B immune globulin (HBIG) within 12 hrs. Having been vaccinated for Hepatitis B is indicated by Hepatitis B surface antibodies (anti-HBs) Being a carrier of the disease is indicated by Hepatitis B surface antigen (HBsAg) From the CDC: Do babies need the Hepatitis B vaccine even if the pregnant woman does not have Hepatitis B? The answer is yes. Hepatitis B is recommended for all infants, children and adults. Hepatitis B is a serious but preventable illness. Adults may contract Hep B and fight off the infection. Babies and young children are at a much greater risk for developing a chronic infection if infected. Chronic Hep B can lead to serious liver failure and cancer. Hepatitis B Pregnancy is not a contraindication to vaccination. Limited data suggest that developing fetuses are not at risk for adverse events when hepatitis B vaccine is administered to pregnant women. Available vaccines contain noninfectious HBsAg and should cause no risk of infection to the fetus. 2 Pregnant women who are identified as being at risk for HBV infection during pregnancy (e.g., having more than one sex partner during the previous 6 months, been evaluated or treated for an STD, recent or current injection drug use, or having had an HBsAg-positive sex partner) should be vaccinated. 3

Breastfeeding support

Prenatal education Childbirth classes Include father, partner and/or family Postpartum education Newborn feeding readiness cues Effective feeding indicators Feeding frequency - 8 to 12 times in 24 hrs Education happens the best before hospitalization, because once someone has a baby it is harder for them to retain information because of how much they have going on in their life The way a mom knows if her baby is feeding enough then it needs to be one poop, one pee, day two two poops two pees, and so on until women start to produce more milk and there will hopefully be an increase in stools and wet diapers 8-12 wet diapers a day and multiple stools a day (maybe even one stool per feed) once milk supply is established well

Chrorionic Villus sampling

Prenatal evaluation of: Genetic disorders Enzyme deficiencies Gender Performed 10-13 weeks Needle aspiration of the chorionic villi using ultrasound guidance Invasive test where they go in and take a sample of the villus which is tissue that grows around the placenta They use an ultrasound to do a needle aspiration Done very early (around 10-13 weeks) They are able to test the fetal tissue and checks for down syndrome but cannot test for neural defects because it is not testing fluid This test is diagnostic

Newborn head-to-toe assessment

Prenatal history Newborn measurements- Length, weight, head circumference, chest circumference Vital signs Skin: condition and color Head: size, fontanels, variations in size and appearance. Abnormalities in head or fontanel size Usually the assessment right after birth is a very rapid assessment and you later go in and do a more thorough head to toe Anterior fontanel is larger than the posterior fontanel and while assessing the fontanels you want to make sure there is no bulging or sunken in Bulging can be indicative of increased intracranial pressure If a baby is born with fused skull plates then they are more likely to have bulging fontanels because their head cant take the birthing process Sunken fontanels usually means hypovolemia and dehydration Capet is a swollen area on the head and it could be generalized, Capet does cross the midline

Nursing care- stage two

Preparing for birth Birth in delivery or birthing room Maternal positioning Bearing-down efforts Assess amniotic fluid Support of father or partner Supplies, instruments, and equipment As the birth nears it s important to have supplies ready. Amniotic fluid assessment should continue. Ensure the father or support person can see the birth if they desire. The pace of events usually speeds up around this time.

Gestational age variations

Preterm Infant - before 36 weeks and 6 days Early term - 37 weeks to 38 weeks and 6 days Full term - 39 to 40 weeks and 6 days Late term - 41 weeks to 41 weeks and 6 days Post term - 42 weeks or more It used to be that any baby born after 37 weeks was considered full term. The terminology has changed to reflect evidence and infant morbidity. What the evidence showed is that babies born before 38 weeks do not do as well as babies who go to 38 weeks. And babies who go to 40 weeks do even better - as long as there are no complications. Lower birth weight is associated with poorer outcomes, respiratory distress, admissions to the NICU, problems breastfeeding, etc. Inducing without a medical need increases the likelihood that a woman will have a c-section. Performing one c-section increases the likelihood that a woman will have another c-section will increases her risk of post-op complications and complications later in life. Babies born by c-section have a higher incidence of respiratory distress than babies born vaginally. Additionally, it was decided that it's safe to go past 40 and sometimes 41 weeks. There was a trend of delivering at 40 and 41 weeks whereas now, there can be a watch and wait attitude. The plan is made in conjunction with the woman and/or father or support person. Babies do better and have better outcomes when they go further in gestation So, the terminology was changed to be more accurate and this is what it is:

Gestational age

Preterm or premature: prior to 37 weeks gestation Term: 38 to 42 weeks Postterm or postdates: after 42 weeks Postmature: after 42nd week gestation with signs of placental aging Small for gestational age (SGA) Appropriate for gestational age (AGA) Large for gestational age (LGA) Signs of placental aging is babies that have a wasted look, wrinkly skin For women who have gone past their due date they do an evaluation to make sure the baby is still perfusing well

Infants of diabetic mothers: nursing management

Prevention of hypoglycemia (oral feedings, neutral thermal environment, rest periods) Maintenance of fluid and electrolyte balance (calcium level monitoring, fluid therapy, bilirubin level monitoring) Parental support and education

Clinical Management for Reproduction

Primary Prevention: disease prevention and wellness-related approaches to promoting sexual health Patient education Counseling Referral Secondary Prevention Screening - diagnose existing disease in its early stages. This is referred to as screening with a goal of reducing morbidity and mortality and preserving quality of life. Primary Prevention focus areas: abstinence, contraception, safer sex practices, STIs healthy relationships, and community resources.

Powers

Primary powers Contractions Frequency Duration Intensity Effacement Shortening and thinning of cervix Expressed in 0%-100% Dilation Enlargement or widening of cervical opening Less than 1 to 10 Ferguson reflex-maternal urge to bear down Secondary powers Bearing-down efforts In order to have a successful labor and delivery, adequate contractions are needed. Contraction frequency varies from woman to woman. Generally, active labor contractions are anywhere from 1 ½ to 5 minutes apart even after an epidural and continue to cause cervical change. Contractions need to be really strong to change the cervix and bring a baby. Moms may smile and talk between contractions but during contractions they rarely can continue to hold a conversation if they are true labor contractions. In primigravidas the cervix thins or effaces almost completely prior to dilation. In multigravidas the cervix may remain thick up until active labor begins. The effacement process takes less time. The Ferguson reflex is the pressure on the cervix that stimulates that nerve plexus in the cervix and creates the urge to bear down. Sometimes this is an uncontrollable urge, sometimes it's a mild urge. Sometimes it lets us know as L&D nurses that things are getting serious and we need to get equipment ready. A lot of women say they feel like they need to go to the bathroom.

Syphilis

Primary- One sore that goes away Secondary- Rash and more sores, normally rash is on hands and back Latent Tertiary- Systemic effects, can have meningitis and neurologic symptoms Congenital syphilis - infection resulting in physical and mental developmental disabilities Congenital syphilis is preventable Congenital Syphilis Is on the Rise? Reviewing Prevention Steps Treatment is Penicillin G Syphilis is on the rise, congenital syphilis is also on the rise Syphilis in pregnancy can be transmitted at any time to the fetus (can cause blindness, jaundice, liver issues, anemia, meningitis, skin rashes) VDRL or RPR are the two tests for syphilis, they want to screen in the first and third trimester and right after birth. Treatment is a one time IM dose of Penicillin

HTN disorders: risk factors

Primigravid 85% of cases affect primigravidas Family history of preeclampsia Diabetes Mellitus Multiple Gestation Obesity IUFD (Intrauterine Fetal Death/Demise) Maternal age >40 years Maternal age <20 Pre-existing Hypertension African American Chronic renal disease

Who is at risk for preterm labor and birth

Prior preterm birth is the #1 risk factor African-American women have a two-fold risk Bacterial vaginosis carries a 50% increased risk African American women are at a higher risk of HTN, diabetes, and they have higher morbidity rates Any infection can contribute to pre-term labor

Lactogenesis

Prolactin Prepares breasts for lactation during pregnancy During lactation aids in milk synthesis and secretion Highest in the first 10 days after birth Produced in response to infant sucking and emptying breast. Oxytocin Milk ejection reflex or "letting down." Also causes uterine contractions or "after pains." When the nipple is stimulated or the baby stimulates the uterus that stimulates oxytocin release which helps stimulate prolactin release which helps the let down reflex When a woman starts to produce milk she feels a sense of fullness because the milk is already in the breast and then once breastfeeding is established she wont feel that fullness

Menstrual Cycle- Proliferative Phase:

Proliferative (Follicular) Phase Days 1-12 (Stimulation to Ovulation) Low estrogen/progesterone production in ovaries signals hypothalamus to produce gonadotropin-releasing hormone (GnRH). GnRH orders ant. pituitary to release follicle stimulating hormone (FSH) FSH stimulates follicle production in ovary (10-20 start to develop but usually only 1 matures). Developing follicles in ovary produce estrogen. Estrogen stimulates endometrial cells (lining of uterus) to enlarge: endometrial spiral arteries dilate, lining thickens 6-8 fold, cervical mucus thins and becomes more alkaline to allow sperm to penetrate

Goals of preconception and prenatal care

Promote the health and well-being of a woman and her partner before pregnancy Identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management intervention

Cervical ripening: pharmacologic agents

Prostaglandin analogs: Dinoprostone (Cervidil insert; Prepidil gel) FDA approved for the use of cervical ripening. A paper with a string on the end and the paper is soaked in the medication and is left in for 12 hours or so to help cause small uterine contractions, after 12 hours it is pulled out Cervidil benefit is that it can be removed quickly in the event of hyperstimulation of the uterus. Very effective in ripening the cervix Misoprostol (Cytotec) Not FDA approved for use as a cervical ripening agent, but is recognized by ACOG as being safe for this use. Origionally is a GI medication for acid reflux Used for cervical ripening in full term pregnancies. Downside is it cannot be retrieved Dose: 25-50 mcg vaginally q4 hrs, can also be inserted annually or buccal or swallowed Misoprostol is used post-partum in post partum hemorrhage

Integumentary system adaptations

Protective barrier Functions: protects against physical trauma, protects thermoregulation and fat storage Accelerated development with exposure to air for all newborns Epidermis grows once the baby is born and dried off because prior to then they have been in a wet environment so their skin is a little more thin and fragile We don't use band aids or tape on newborns unless we have to

Introducing solids

Provide education to parents: Infant should be able to sit supported in a high chair Never add cereal to an infant's bottle; feed with a spoon Watch for absence of extrusion reflex around 4-6 mos of age Never give cow's milk to an infant Avoid fruit juice (unneeded calories) Appropriate first solid foods: Iron-fortified rice cereal mixed with breast milk or formula Wait 3-5 days between adding new foods to recognize allergic reactions Around 8 mos of age foods with more texture and finger foods may be introduced. Introduce one thing at a time Start with rice rather than wheat

Nursing interventions for transient tachypnea of the newborn (TTN)

Providing oxygen Ensure warmth Observing respiratory status frequently Allowing time for pulmonary capillaries and the lymphatics to remove the remaining fluid Newborn is going through the transitional time and having difficulty, may have signs of respiratory distress May have nasal flaring, retractions, rapid respiration rate First thing you do is check a pulse ox because infants can desaturate very quickly so you want to figure out if the baby needs something to get their levels back up Most of the time babies transition through this just fine and just need monitoring to make sure their body systems take over This happens a lot in C-section babies because they have not had the thoracic squeeze that vaginal birthed babies get to help get fluid out and also increase expansion once they are born Should resolve in 24-72 hours, if going on for an extended period of time then they will take that baby up to the NICU to make sure it is not respiratory distress syndrome or a pneumothorax or something more serious Fairly common

McRoberts maneuver

Push the legs up and back and push down on the suprapubic area to help push out the baby and release the shoulder with shoulder dystocia, sometimes it works really well and sometimes it does not and sometimes the provider has to rotate the baby Someone also needs to be watching the clock to tell us how long this is taking 'Anticipating shoulder dystocia you also need to notify charge nurse, let the NICU know about the situation and get resuscitation people there also

Screening tools- RAFT

R-Relax (do you drink or take drugs to relax or improve your self image?) A- Alone (Do you drink or take drugs while alone?) F- Friends (do you have any close friends who drink or take drugs?) F- Family (does a close family member have a problem with alcohol or drugs?) T- trouble (have you ever gotten in trouble from drinking or taking drugs?)

Nursing interventions for abnormal FHR patterns

Rapid Assessment: Uterine contraction pattern Maternal vital signs, moms vital signs can be indicative of what is going on with the fetus Cervical exam if warranted to rule out umbilical cord prolapse Intrauterine Resuscitation (essentially CPR on fetus in the uterus) Promote fetal oxygenation Change position Put oxygen on mom (8-10L by a non-rebreather) and only for about 30 minute increments Reduce uterine activity Alleviate umbilical cord compression Correct maternal hypotension Doing CPR to the fetus through the mom Prepare for birth if pattern cannot be corrected Possibly vacuum extractor or C-section The type of technique used is based on the specific characteristics seen in the FHR and likely a combination of techniques will be utilized. The goal is to improve maternal blood flow to the placenta. Intrauterine resuscitation measures should be initiated only if doing so does not delay the move toward expeditious birth. Promote fetal oxygenation: Lateral positioning - right or left, alleviates inferior vena cava compression and facilitates fetal movement O2 at 10L via nonrebreather face mask for 30 min at a time, if left on too long it can cause free radicals in mom and baby IV fluid bolus starting at 500 mL of Lactated Ringers Discontinuation of oxytocin or other induction medications as able to reduce uterine stimulation Reduce uterine activity: D/C oxytocin and uterine stimulants (cervidil, withhold next dose of misoprostol) IV fluid bolus Lateral positioning If no response, consider terbutaline SQ 0.25 mg to reduce uterine contractions (this should be done in consideration of maternal risk factors and in consultation with HCP if possible), pulmonary edema is a big risk if the mom has HTN issues Alleviate umbilical cord compression: Repositioning - right or left lateral, knee-chest Amnioinfusion (normal saline infused into the uterine cavity via an IUPC) Taking a break from pushing temporarily or pushing with every other contraction Correct maternal hypotension: Lateral positioning - left or right IV fluid bolus If no response to fluid bolus or position change, consider ephedrine 5-10 mg IV push (this is usually done in the scenario of epidural anesthesia and in consultation with the anesthetist or anesthesiologist). Change position D/C Pitocin Administer O2 8-10L/min Notify MD or midwife Assist with vaginal or speculum exam to assess for cord prolapse Assist with amnioinfusion Prepare for birth if pattern can not be corrected

Postpartum psychosis

Rare 1 in 500 Increased risk of suicide or infanticide Onset usually within 3 months after birth Early symptoms resemble depression Escalates to delirium, hallucinations, disorganization of thought, Loss of touch with reality, deliusions, etc. PPP requires hospitalization usually for several months and treatment with psychotropic drugs. Mothers must not be left alone with their infants.

Types of vaccines- recombinant

Recombinant vaccines - genetically engineered organisms. Hepatitis B HPV Influenza (one brand) Typhoid

Herpes Simplex virus

Recurrent lifelong viral infection HSV-1 or HSV-2 Transmission via sexual contact or skin-to-skin contact with active lesions Measures to prevent transmission to fetus at birth Prophylactic treatment with acyclovir Therapeutic management Antiretroviral therapy - acyclovir, valacyclovir, famciclovir Neonatal herpes simplex virus Relatively rare but significant Occur from perinatal transmission from mother to neonate. Primarily transmitted to fetus and can cause neural or systemic issues Getting hsv for the first time, especially in the third trimester, is the most damaging to the fetus Birth by C-section if genital lesions active at or near birth

Periorbital cellulitis

Red or purple eyelid Edema Eye pain and restricted movement Fever **Requires prompt treatment to prevent spread of infection to the orbit which can lead to meningitis.** Usually caused by staph or strep. Can occur following a scratch, bug bite or injury, URI, LRI and abscessed teeth.. Occasionally there is drainage from the eye but not always. The infection does not spread from one eye to the other. It is diagnosed by physical exam, blood tests to test for white count and systemic infection, culture to test for pathogen, CT scan to visualize area affected around the eyes. treated with oral or IV antibiotics, usually IV. Warm compresses Is the following statement true or false? The nurse caring for a child with periorbital cellulitis accurately explains to the parents that treatment consists of the use of an antibiotic ointment. False. The nurse caring for a child with periorbital cellulitis accurately explains to the parents that treatment consists of intravenous antibiotic administration during the acute phase followed by completion of the course with oral antibiotics. Rationale: Following intravenous antibiotic administration the parents are taught to apply warm soaks to the eye area for 20 minutes every 2 to 4 hours and administer intravenous antibiotics as prescribed.

Otitis Media with Effusion

Refers to build up of fluid within the middle ear space Without S&S of infection May occur independently of AOM Risk factors: Passive smoking Absence of breastfeeding Frequent viral URI Allergy Young, male Adenoid hypertrophy Eustachian tube dysfunction Complications: Hearing loss & deafness Otitis media with effusion: Otitis media with effusion (OME), also known as serous otitis media (SOM) or secretory otitis media (SOM), and commonly referred to as glue ear,[6] is simply a collection of effusion (fluid) that occurs within the middle-ear space due to the negative pressure produced by dysfunction of the Eustachian tube. This can occur purely from a viral URI, with no pain or bacterial infection, or it can precede and/or follow acute bacterial otitis media.[7] Fluid in the middle ear frequently causes conductive hearing impairment, but only when it interferes with the normal vibration of the eardrum by sound waves. Over weeks and months, middle-ear fluid can become very thick and glue-like, which increases the likelihood of its causing conductive hearing impairment. Early-onset OME is associated with feeding of infants while lying down, early entry into group child care, parental smoking, lack, or too short a period of breastfeeding and greater amounts of time spent in group child care, particularly those with a large number of children, increases the incidences and duration of OME in the first two years of life.[8] Otitis Media with Effusion (OME) occurs when fluid builds up and remains behind the tympanic membrane for several months. This may be the result of recurrent infection as with acute otitis media or it may happen as a result of allergies, etc. The difference from AOM is that the fluid remains for an extended period of time. Reduces flexibility of the ear drum and can lead to speech delays because the child has reduced hearing.

Relaxin and prostaglandin

Relaxin Secreted by the placenta Inhibits uterine activity and decreases strength of uterine contractions. Plays a role in cervical ripening to prepare for labor & birth. Prostaglandins Found in the decidua of the placenta and in fetal membranes. Regulates vascular tone promotes uterine relaxation earlier in pregnancy. Act on smooth muscle to increase contractility and cervical ripening toward the end of pregnancy and at the onset of labor.

Newborn care- rest and sleep

Rest and Sleep Pattern Infant will spend about 16-20 hours a per day sleeping The time awake is spent crying, eating or in quiet alertness Most infants do not exceed 5 continuous hours of sleep for some months Safe sleep practices- nothing in the crib with the baby, no bumper pads, no blankets, just the baby sleeping on their back An infant needs to eat at least every 5 hours so if the newborn is sleeping throughout the night the parents need to be instructed to wake up infant to feed

Clinical Features of PPD

Restlessness Worthlessness Guilt Hopelessness Moodiness Sadness Feeling overwhelmed Loss of enjoyment Low energy level Loss of libido Frequent crying Low energy or motivation Memory loss Appetite changes/ weight changes Lack of concern for self Aches & pains Lack of interest in infant Negative feelings toward infant Act detached toward infant Recurrent thoughts of death or suicide Some women also report that they don't feel any joy or excitement about their new baby, and they get no pleasure from things they once enjoyed. Tending to a newborn disturbs every new mother's sleep. Where PP Blues is mild insomnia, PPD is moderate, larger sleep disturbances Postpartum depression can cause larger sleep issues. It may be hard to sleep when the mother gets the chance or she may sleep too much. Not getting enough sleep can turn into a vicious cycle -- poor sleep can contribute to depression, and then depression can interfere with sleep.

Postterm newborn: nursing management

Resuscitation- often because of whatever happened during the birth process Blood glucose level monitoring as soon as possible, sometimes feeding is not enough and may need IV dextrose Initiation of feedings; IV dextrose 10% Prevention of heat loss Evaluation for polycythemia Parental support

Tissue

Retained placenta Placenta accreta (abnormal adherence of placenta to uterine wall): Uterine inversion (turning inside out of uterus): Potentially life-threatening Usually provider error so if you see someone pulling on the umbilical cord you need to speak up, patient needs surgery to get that uterus replaced Occurs 1 in 3000 births Subinvolution of uterus (uterus not returning to pre-pregnancy state): Late post-partum bleeding Retained placental fragment & pelvic infection As women have more C-sections these are becoming more common (placenta accreta, increta or percreta)

Musculoskeletal system postpartum

Reversal of pregnancy adaptations: Joints are completely stabilized by 6-8 weeks after birth. Mother may notice a permanent increase in shoe size. Edema may get worse before it gets better. Platelet aggregation and decreased vascular resistance predispose postpartum women to clot formation. Back pain may be experienced after birth, not usually associated with epidural though many women may think it is

Ultrasound

Scans are reliant on fetal positioning, maternal habitus, & technique of examiner. Transvaginal & abdominal ultrasounds used depending upon gestational age. Anatomy Scans performed to document fetal anatomy: Head, neck, chest, abdomen, limbs, & external genitalia. AFI (amniotic fluid index) Cord studies Measurements: fetal bones are measured, specifically the femur and head. These measurements are used in serial growth scans to evaluate fetal well-being and document concerning findings.

Care of the mother with substance use disorder

Screening for substance use for all women in pregnancy 4-P's : Parents, partner, past, and pregnancy T-ACE, TWEAK, CAGE Drug testing during pregnancy Initial care Medication Assisted Therapy (MAT)/Opioid Agonist Treatment (OAT) such as Methadone or Buprenorphine Follow-up care

Stages of labor- second stage

Second stage Full dilation to birth of the infant Urge to push increases. Initially pushing may be ineffective Laboring down vs. active pushing Closed glottis pushing vs. open glottis pushing The urge to push indicates the presenting part (hopefully a head) is pressing on the nerve plexus in the cervix. It does not always indicate complete dilation. Important to encourage mom to blow gently through those early urges to push until pushing is irresistible. Women who have an unmedicated birth will usually bear down without much coaching. It's an instinctual urge. Women with epidurals may need to purposefully bear down. It is important to note, however, that prolonged pushing is no longer recommended. It used to be that as soon as a woman was fully dilated we would have her start pushing and after two hours if the baby was not out, forceps or a vacuum was used. Women with epidurals may need some coaching pushing but women who are unmediated sometimes need to be coached to push slowly and resist the urge to bear down until they cant anymore then they need to gently bear down in a controlled manner to help avoid tearing What is being found is that all of this directed pushing may be contributing to the pelvic floor dysfunction many women experience after having children and later in life. Having a patient hold her breath and push while counting to ten is closed glottis pushing. Having her exhale softly while bearing down is open-glottis pushing . Closed-glottis pushing may lead to fetal hypoxia if prolonged. Further, letting the body do most of the work of laboring down is much better than purposeful directed pushing.

Estrogen

Secreted by the ovaries in early pregnancy and then the placenta for most of the pregnancy. Suppresses further ovulation during pregnancy. Prepares the breasts for lactation. Increases blood flow to the uterus. Stimulates growth of uterine muscle mass. Involved in the timing of the onset of labor (a theory) High levels during pregnancy inhibit lactation until after birth.

Menstrual Cycle -Luteal Phase

Secretory (Luteal) Phase Days 17-26-Ovulation to Menstruation Ovaries continue to produce estrogen Corpus luteum (site of follicular development) on ovary produces progesterone in anticipation of human chorionic gonadotropin feedback from trophoblastic cells of conceptus. Progesterone made in the corpus luteum on the ovary accentuates swelling of endometrium in anticipation of receiving a fertilized egg Corpus luteum: why does it produce progesterone in anticipation of conceptus? What is HcG? What is a trophoblast? Corpus luteum (if egg gets fertilized) hangs around until placenta takes over

Family Centered Care

See Table 30.2 in Ricci, Carmen, and Kyle for alternative ways to phrase medical procedures for children Prevent or minimize parent-child separation. Promote family-centered care, treating the family as the patient. Use core primary nursing. Consider research findings related to preferences of parents and children and whether or not to be together. Best practice is to provide all care (as much as possible) without separating the infant or child from the parents. For example: almost all care for the newborn in labor & delivery and mother-baby can be done while skin to skin or at the bedside. Injections can be given to a toddler or child while the parent is holding the child. The parent must be aware of their role in this - therapeutic hugging.

EFM: Wireless external monitors

Several models available Advantages: Allows ambulation and increased freedom of movement Can be submerged in water Some work like electrodes and are small flat sticky pads Disdavantages: High incidence of signal loss because baby moves when mom moves Expensive for hospitals Not universally available in all hospitals

Family planning postpartum

Sexual health When is it okay to resume Painful intercourse Interest Contraception Important discussion to prevent unintended pregnancy Method determined by patient preference and risk factors Sexual intercourse can resume once bright red bleeding has stopped and perineum has healed from laceration or episiotomy.

Phases of bereavement

Shock and Numbness Searching and yearning Disorientation Regrieveing Reorganization

Anatomy and physiology of lactation

Size and shape is irrelevant to successful breastfeeding. Breast changes occur in response to maternal hormones: Increased size, blood flow & sensitivity Areola darkens and enlarges Montgomery glands increase Breast becomes larger Areola darkens Glands (Montgomery glands or Montgomery tubercles) secrete the oily substance that smells like amniotic fluid and coats the nipple to help protect it from trauma so it is recommended that women not wash their nipple with soap

Passenger- fetal head

Size of fetal head Sutures and fontanels makes skull flexible to accommodate the infant brain Slight overlap and molding occur during labor Fontanels most important: Anterior-larger, diamond shaped closes by 18 months Posterior- triangle shape, closes by 6-8 wks. Size matters but only to a certain extent. The fetal head is amazingly moldable. The cranial bones are not fused and can separate or override to accommodate passage through the birth canal. Vertex (or cephalic) is ideal - flexed, chin tucked down on the chest. This causes the smallest part of the head to present first. Sinciput is a mildly extended position. Brow presentation the head is fully extended. If the head cannot be reduced, the baby's brow will press against the mother's pelvic bone with each contraction and no progress in descent will be made. Often times babies who present at the brow are born with bruise marks across their brow. Sometimes if the head has not become too engaged, the provider can get the fetus to flex the head. Breech presentation is feet first or bottom first and this usually results in C-section because there is concern that the cervix will close around the babies head before it can be delivered Transverse position is arm first or shoulder first Depending upon how the head is sitting or presenting will determine how it molds and is shaped. Sometimes swelling will develop. The baby's head needs to be tucked down because the crown of the babies head is the smallest part and that's what we want presenting through the cervix for most optimal conditions If the brow is hitting the pubis then that usually causes a labor that wont progress well

Newborn assessment- skin

Skin appearance Vernix caseosa: yellowish white cream cheese like substance, covers the skin at birth Lanugo: downy, fine hair, characteristic of the fetus between 20 weeks gestation and birth Good turgor and tissue elasticity should be noted. Vernix is a white cheesy substance and it is a natural lotion that they are born with and it protects their skin in-utero and outside of utero Babies are not bathed ideally for the first 24 hours so the vernix can soak into the skin and help protect it The more term a baby is, the less vernix they have Some babies are born with lots of lanugo, some babies do not have as much

Causes of paternal PND

Sleep Deprivation Psychological adjustment to parenthood History of depression - personal or family Hormones - testosterone levels go down, estrogen goes up in men Depressed partner- may feel disconnected from partner or baby Relationship stress Feeling disconnected from baby or partner Other stressors or trauma, i.e. unplanned pregnancy, work-related stress, family, colicky baby. Hormone changes in men may sound wimpy but this low testosterone level actually serves as a protective factor against prostate and testicular cancer but also can contribute to lower motivation, fatigue and depression Feeling disconnected is a factor that be mitigated by the L&D nurse or the mother-baby nurse. Very important to pull the father/partner in and involve them in the process. Document and observe the other parent's interactions and reactions to the baby.

Reproductive organs: cervix

Soft immediately after birth. During the next 12-18 hours, the cervix shortens, becomes firm, and regains pre-pregnant form. External os regains its pre-pregnancy appearance. Cervical os, dilated to 10 cm during labor, closes gradually. The os is located in the center of the cervix... The os will look more slit like for a woman who has had a vaginal delivery for the rest of her life

Stages of labor

Stage 1: Begins with TRUE labor from the beginning of regular contractions or rupture of membranes to 10 cm of dilation and effacement. Three phases - Latent, Active, and Transition phase. Stage 2: 10 cm to delivery of the infant Stage 3: Delivery of the infant - delivery of the placenta. Stage 4: Delivery of the placenta - 4 hours following delivery.

Other preterm labor risk factors

Substance use in pregnancy- Cocaine increases risk of placental abruption Uterine or cervical abnormalities- some women have a misshapen uterus or a incompetent cervix Genitourinary infections Pre-term ROM (PPROM): Preterm Premature Rupture of Membranes which can happen spontaneously and is also associated with infection Cigarette smoking- which causes vasoconstriction, HTN, and placental abruption and growth restricted fetus Inadequate nutrition- may be eating enough but it may not be nutritious enough Vaginal bleeding- goes along with abruption and placenta previa Inadequate nutrition Low socioeconomic status Chronic health issues such as DM, CHTN, clotting disorders **Positive fFN test Women who have a misshapen uterus the uterus is not able to stretch as far and may start contracting early Women who have an incompetent cervix the cervix just wont stay closed for some reason fFN test is a diagnostic test that can be done and it is an indicator of pre-term labor

Respiratory distress syndrome: nursing management

Supportive care; close monitoring Respiratory modalities: ventilation (CPAP, PEEP); exogenous surfactant; oxygen therapy Antibiotics for positive cultures; correction of metabolic acidosis Fluids and vasopressors; gavage or IV feedings Blood glucose level monitoring Clustering of care; prone or side-lying position Parental support and education

Labor induction: surgical methods

Surgical methods: Amniotomy- breaking the water because amniotic fluid as some prostaglandin and that will cause contractions Stripping the membranes- when they run their fingers around to pull the membranes away from the uterus to get the body to release some prostaglandin Amniotomy has to have a presenting part being a head and it needs to be engaged against the cervix because otherwise you can have a prolapsed cord, also the cervix needs to be a little dilated Always after water breaks check the fetal heart rate to make sure not a prolapsed cord

Cardiovascular adaptations to extrauterine life

Switch from fetal to newborn circulation Change from placental to pulmonary gas exchange Physical forces of labor lead to increased release of catecholamines critical to adaptation Changes in fetal structures to accommodate extrauterine life Heart rate Blood volume Blood components Circulatory system goes through some major changes because the baby is dependent on the mom for cardiovascular needs and once the cord is clamped that starts to reverse The baby does not use its liver for the most part in-utero and have to start using it as soon as the cord is clamped, bypass is the ductus stenosis Up in the atria is the foramen ovale which is a small hole that allows for mixture of oxygenated and un-oxygenated blood in the atria so the fetus gets oxygenated a little faster Ductus arteriosus is a shunt in the pulmonary artery that allows that mixture to flow out into the body When the cord is clamped the fetus starts to have those three bypasses close A patent ductus ateriosus is when the duct does not close and then there is a mixing of blood even after the baby is cut from the cord Usually goes away within 24 hours and may have a transient murmur in the first 24 hours Women who go through labor are stressed and release catecholamines that help the baby transition easier to extra-uterine life Newborn heart rate needs to be very rapid because of their small size to help them perfuse

Hypertensive disorders (overview)

Symptoms/risks usually reduce within 24-48 hours of birth of placenta Can manifest after delivery when symptoms not apparent before Usually within 1st 24 hrs, but has been seen up to two weeks postpartum Maintain MgSO4 for 24 hrs post delivery as ordered or when symptoms appear. High acuity patient, staff accordingly Monitor labs AST, platelets, Mg levels if ordered BP may continue to be elevated weeks after delivery Administer anti-hypertensives as ordered VS, neuro checks per protocol Careful discharge teaching and follow up appointments

Pre-term labor assessment

Symptoms: Uterine Contractions (UC's) every 10 minutes or closer Some women may have painless uterine contractions Menstrual-like cramps Pelvic pressure ROM Dull backache Increased vaginal mucus- could be increased discharge due to infection UTI symptoms- preterm labor is strongly associated with UTIs Lower GI upset General unease, "Something doesn't feel right." Treatment Goals: Prevent further progress until term We need to identify contractions that are happening too frequently in women who are too early Some women may be contracting without knowing it so you always need to put your hands on her belly and teach her how to do that to assess for contractions to ensure that she is not contracting silently Rule of thumb for telling contractions is nose is mild, chin is moderate and forehead is strong for contractions compared to how the abdomen feels May feel dull back-ache which is a common place women feel contractions pre-term If she feels like she is leaking amniotic fluid she needs to be evaluated because she could have or develop an infection Cervical mucus in a woman who is pre-term is not okay because it means her cervix is making changes and we do not want that to happen

Adaptation to extrauterine life

System wide changes in organ systems- cardiovascular, respiratory, thermoregulation, and blood glucose regulation Behavioral patterns Behavioral responses There are a lot of changes that take place in a newborns body as they transition to extra-uterine life Cardiovascular, blood glucose and thermoregulation are the three most important ones Newborns do have a certain pattern and cues that they use to communicate their needs

Unexpected findings- fetal tachycardia

Tachycardia- FHR above 160 for longer than 10minutes Moderate increase 160-180 bpm. Marked increase greater 180 bpm. Significant if variability is absent and having late or variable decelerations Lasts 10 minutes or more Elevated maternal temp is the most common cause Nursing interventions: Assessment of maternal temp and hydration status Notify healthcare provider Assist to left lateral position IV fluids may be indicated for hydration or elevated temp Some causes of fetal tachycardia: episodes of fetal hypoxia and maternal fever, dehydration and infection; fetal sepsis, prematurity (26-28 weeks), congenital anomalies, maternal hyperthyroidism, some maternal medications. Some babies have FHR that is high for 5-6 minutes because they are very good accelerators In the presence of infection, baseline variability is an important indicator of fetal acidemia Maternal infection or fever are the most common reasons for FHR tachycardia

Maternal adaptation to parenthood: Reva Rubin's Three Phases

Taking-in phase: Time immediately after birth when the client needs others to meet her needs and relives the birth process Taking-hold phase: Second phase characterized by dependent and independent maternal behavior Letting-go phase: Third phase in which woman reestablishes relationships with others Rubin spent decades studying women and their response to childbirth. She studied and dispelled the idea that women are born knowing how to be a mother and instead it is something that has to be learned.

Diabetes in pregnancy: nursing management

Teaching glucose monitoring, carb counting, meds/insulin, and family planning Educate patient regarding fetal surveillance: Evaluating amniotic fluid level (AFI) Weekly or twice weekly non-stress tests (NST) Ultrasounds & Doppler cord studies Fetal movement kick counts Encourage breastfeeding Check CBG, FBS as ordered postpartum Educate re: increased risk of Type 2 diabetes later in life. Usually a 1 to 1 ratio with carb counting Kick counts to make sure the baby is moving which involves having the mom lay down, have a snack and count how many fetal movements she feels in an hour at the same time every day

Discharge planning and teaching

Teaching parents all the things to look for that you have been assessing for in the hospital Normal temperature ranges, not to check a rectal Educate about respirations and how babies can have brief periods of apnea Feeding patterns/ elimination Positioning and holding, a breastfed baby is not going to be sitting up to eat very often but between breasts they need to be educated to sit the baby upright to burp the baby, they do not need to beat on the baby they just need to sit them upright and maybe stroking the back upward helps get the air out Important to educate about safe sleep, many dr. discourage co-sleeping unless it is with an actual co-sleeper bassinet that is not on the bed but very close to the bed Car seat safety, fire departments can help there Non-nutritive sucking (sucking on something other than a breast or bottle), until breastfeeding is established parents are discouraged from this because baby needs to be sucking on mom to help get the milk supply get established Some babies do just need to comfort suck Umbilical cord care, keep it dry, once a day wipe it with dry gauze (dry cord care) How to bathe the baby When its time to follow-up with primary care provider

Gestational age variations

Term Born from the first day of the 38th week through 42 weeks Preterm Born before completion of 37 weeks Late preterm Born between 34 0/7 and 36 6/7 weeks Postterm Born beyond 42 completed weeks Even though we say mom is not full term in pregnancy before 39 weeks, after birth she is term after 38 weeks. We just don't want people having babies before 39 weeks unless we have to

Process of labor and delivery

The complex process of labor and delivery includes 5 factors. Passageway- the pelvis and soft tissues Passengers- the fetus and placenta Powers- contractions Position of mother-standing, walking, side lying, squatting on hands and knees Psyche-psychological response The passageway, how mom is built Passengers - how baby is positioned in there and the size of the baby, best is head down, facing down and kind of to a side (Right oxopite anterior or left oxopite anterior) Powers - uterine contractions Position Psyche - coping, frame of mind

How does hyperbilirubinemia affect the newborn?

The decrease in the hepatic activity along with large bilirubin load therefore increases the newborn's susceptibility to jaundice, a yellow coloring of the skin. Thus, causing hyperbilirubinemia Unconjugated or( indirect bilirubin ) is a waste product which comes from destroyed red blood cells. If it is not excreted, levels could become toxic. Before unconjugated bilirubin can be excreted it needs to be converted to conjugated. After birth the newborns liver must begin to conjugate bilirubin. It will then be excreted via the kidneys and intestinal tract. If you have a baby with yellowing of the palms of the hands or feet or sclera then those are late signs which is much more serious Always assess first on face, then go down from there. Start where the deposition starts Jaundice is a very common issue in newborns, Physiologic jaundice is jaundice that happens after the first 24 hours. Can occur from a traumatic birth, lots of bruising, and other issues. Can require treatment, but sometimes just needs monitoring Breastfeeding jaundice is when the mom's milk supply is not in yet and the baby is in a temporary dehydrated state and occurs usually within the first week or so

Lightening

The fetal presenting part descends into the pelvis. Common terms used: The baby has dropped The baby is down Engaged Lightening is when the fetal presenting part engages in the pelvis. Thie makes the fundal height lessen or lower so often the pregnant woman may feel less crowded or congested up under her ribs. This may happen as early as two weeks before labor begins in primigravidas or not aat all in multigravidas. Patient's will often say, "The doctor said he was already down."

Psyche for labor

The fifth "P" involves the psyche or psychological response. The anxiety, fear, and fatigue may contribute to the woman's ability to cope with pain. The psyche plays a major role in the process of labor and birth. A high level of anxiety can produce an increase in catecholamine secretion that can result in ineffective uterine activity and longer dysfunctional labor. Loss of control, loss of confidence, uncertainty, fatigue, fatalism, and aloneness are some of the psychosocial factors to consider when caring for women in labor. Previous experiences with birth, cultural considerations, trauma, whatever should be taken into consideration and worked into the plan of care. Positive reinforcement works way better than tough love. There's nothing worse than the "get over it" attitude.

Maternal mortality

The maternal mortality ratio is the annual number of deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births, for a specified year. In the United States, approximately 700 to 800 women die each year during pregnancy or shortly after childbirth. The rate of maternal mortality in the United States has more than doubled in the past few decades.

Antipospholipid antibody syndrome

The most common acquired thrombophilia in pregnancy Did not have this when they were born, they grew into it Anti-phospholipid antibody syndrome has a primary and secondary form, this is an autoimmune disorder

Polycystic Ovarian Syndrome

The most common endocrine disorder in women of reproductive age. Multifaceted disorder characterized by- Hyperandrogenemia Hyperinsulinemia Increased risk of type 2 diabetes and CV disease Can affect many aspects of a woman's life including: menstrual cycle ability to have children hormones heart blood vessels appearance These women have a concomitant risk of type 2 diabetes and cardiovascular disease related to metabolic syndrome Androgen becomes the dominant hormone with PCOS Women with PCOS are generally amyneric (they do not have a period) PCOS is the leading cause of infertility in the US Depression is a big issue with these women and often goes undiagnosed or underestimated

Eclampsia

The occurrence of seizures or coma in a woman with preeclampsia that cannot be contributed to another cause. Critically ill patient Patient is at risk for cerebral hemorrhage.... And possibly coma Foley's Rule of 13: 13% mortality rate 13% abruption 13% seize after MgSO4 therapy 13% seize > 48 hrs postpartum Usually associated with very poor outcomes for both mom and baby Can also have eclampsia post partum as well Tonic-clonic convulsion signs: Stage of invasion: lasts 2-3 seconds, eyes fixed, twitching of facial muscles Stage of contraction: lasts 15-20 seconds, eyes protrude and are bloodshot, all body muscles in (tonic) contraction Stage of convulsion: muscles relax and contract alternately (clonic), respirations halted & then begin again with long, deep, inhalations; coma ensues Intervention: *** !! # 1 Call for assistance Airway - protect, turn patient to the side, oxygenate (never put anything in their mouth) Protect patient with padded side rails Observe & record convulsion activity

Hearing screen

The one that is used most often tests the auditory brainstem response to make sure that the brainstem is responding to the sound rather than seeing if the baby is looking toward the sound.

Fertilized Ovum

The placenta starts to take over from the corpus luteum 8-12 weeks after the fertilization (the placenta takes time to develop and take over)

What Causes Postpartum depression?

The sharp drop in the hormones estrogen and progesterone after childbirth may trigger the illness, and lack of sleep can contribute as well. Some women feel conflicted about their changing identity and new responsibilities, and this can factor in. Women may feel as if they are not sexy or attractive to their partner and solely viewed as a mother. They have issues with role adaptively The birth experience may not have been what they wanted it to be. Research tells us that how a woman feels about the way her provider treated her significantly impacts how she feels about her birth experience and has a direct correlation with her incidence of post-partum depression. Was this a traumatic birth? Was it an emergency? Hemorrhage? Did anything happen that she didn't want to happen? Childbirth is a very vulnerable time in a woman's life and there is a certain sense of loss of control.

Vasoconstriction of the placental decidua

The spiral arteries in preeclamptic women are constricted and cause decreased perfusion to the placenta

Oxytocin and prostaglandin

The two most important hormones in labor initiation. Prostaglandin produced during the cervical ripening period prepares the myometrium to respond to oxytocin. Oxytocin is released by Breast stimulation Stimulation of the lower genital tract Cervical stretching In the textbook scenario, uterine activity begins to increase in the 2-3 weeks prior to spontaneous labor onset. These contractions are usually not perceptible to the woman. Once they begin to be perceived, usually it is only by palpation. That was always a good baseline data tool or gauge for me when I was assessing patients in triage. I would ask them if they only knew they were contracting because they could feel them with their hands, or did they simply feel tightening, or did they feel pain. And then I would take my assessment from there. Gradually these contractions may begin to be perceived as discomfort - technically above the 30mmHg point. In the beginning contractions are infrequent and periodic. The closer to labor the woman gets, the more regular the contractions become. In OB there is no black and white, unfortunately. Everyone wants to know when and where. How will I know. There are a lot of gray areas. The previous slide depicts how prostaglandin and oxytocin work together. Prostaglandin is responsible for cervical ripening. What this means is effacement, thinning the cervix. The cervix not only dilates, as in opens, but it also effaces, or thins. So, this prostaglandin prepares the myometrium, the contracting muscle of the uterus to respond to oxytocin. Oxytocin is known as the love hormone. Not because it is released by certain parts of our bodies being stimulated like the breasts and the lower genital tract. But, because after we give birth, this hormone continues to be released and is what makes us fall in love with our babies. Even men release oxytocin. So, oxytocin is released by nipple stimulation, lower genital tract stimulation, that means orgasm, and by cervical stretching - cervical exams or during sex.

Perinatal Substance Abuse

The use of alcohol and/or other drugs by pregnant women Includes prescription and nonprescription substances - about 7% More than 20% of women use alcohol during pregnancy More than 19% smoke cigarettes during pregnancy

What if parents choose formula?

Their decision should be supported. Respect the parent's feeding choices. Education on feeding guidelines Encourage skin-to-skin and holding during feeds Feeding Guidelines: *Infants should always be held while being bottle-fed Feed on cue; feed until full; watch for signs of satiation - allow infant to self-regulate Newborns only take 0.5 to 1 oz per feeding initially working up to 2-3 oz in the first few days. Feed 6-10 times per day By 6 mos babies feed 4-5 times per day and take 6-8 oz Same amount of wet diapers, 8-12 wet diapers and may one or two stools a day once formula feeding is established, they wont go as often as a breastfed baby

Treatment for severe range blood pressures

These medications are for the antepartum inpatient who is not on magnesium sulfate and has a temporary spike in bp or a patient who presents with severely elevated bp and needs immediate management. Labetalol and hydralazine are the two most common, with hydralazine being the most commonly given of the two KNOW THESE MEDS (what there for, not necessarily exact dosages)

Characteristics predisposing newborn to heat loss

Thin skin Blood vessels close to the surface Lack of shivering ability- Limited stores of glucose, glycogen, and fat Limited voluntary muscle activity Large body surface area relative to body weight Lack of subcutaneous fat- Little ability to conserve heat by changing posture No ability to adjust own clothing or blankets to achieve warmth No ability to communicate that they are too cold or too warm Thermoregulation is also very important and babies have a hard time with this partly because they have an immature neuro-motor response Babies are in a naturally flexed, fetal, position to help preserve heat Having large body surface area compared to weight puts them at risk for cold stress Babies do not have a lot of subq fat they are born with brown fat in certain locations like along the back, ***********, shoulders. When they are cold stressed their body will burn that brown fat Early newborns have less brown fat and are much more pre-disposed to cold stress

Stages of labor- third stage

Third stage Birth of the fetus until delivery of the placenta After birth, sudden gush of blood and lengthening of umbilical cord Signs of potential problems: Excessive blood loss Alteration in vital signs and consciousness Care of placenta after delivery: Cultural traditions Do not pull on cord because uterus can become inverse and it can turn the uterus inside out which is bad This is the stage where you monitor moms blood loss

Cervical change during labor

This is a visual of cervical dilation and cervical effacement. Active labor, which we will get to in a bit used to be classified at 4cm. Your book still says it is 4cm. It has been changed to 5cm for a multigravida and 6cm for a primigravida. Definition of labor is regular uterine contraction AND cervical change Best case scenario is that the cervix thins before it dilates which usually happens in a primigravida In a multigravida the cervix does not always thin before dilating because the cervix is already slightly dilated from the last pregnancy

Who should get genetic counseling?

Those who are concerned they might have an inherited disorder or birth defect Women who are pregnant or planning to be after age 35. Couples who already have a child with intellectual disabilities or an inherited disorder or birth defect Women who have had three or more miscarriages or have had a child die in infancy. People concerned about environmental hazards. Couples concerned about genetic disorders common in their ethnic group. Consanguinity Prenatal screening that indicates a fetus may be at increased risk for certain complications for birth defects.

Types of spontaneous abortion

Threatened- abortion signs but no abortion yet Inevitable- characterized by rupture of the membranes or the cervical dilation in a pre-viable pregnancy in the presence of vaginal bleeding and uterine contractions. Incomplete- not passing the entire fetus Complete- passing the entire fetus Missed- no heartbeat anymore but mom has not passed the fetus Recurrent- 3 or more spontaneous abortions

Necrotizing enterocolitis

Three pathologic mechanisms: bowel ischemia, bacterial flora, and effect of feeding Nursing assessment Signs and symptoms: abdominal distention and tenderness, bloody stools, feeding intolerance (bilious vomiting), sepsis, lethargy, apnea, shock KUB: air in bowel wall; dilated bowel loops

Cause of OB Hemorrhage: The "5 T's"

Tone: uterine atony, distended bladder Tissue: retained placenta and clots Trauma: vaginal, cervical, or uterine injury Thrombin: coagulopathy (preexisting or acquired) Traction: causing uterine inversion We want to consider the cause when we are considering how to treat it

Types of vaccines- toxoid

Toxoid vaccines (Also inactivated vaccines) Contain protein products produced by bacteria Diphtheria, tetanus

TORCH Infections

Toxoplasmosis Other (Hepatitis, syphilis, mumps, parvovirus, varicella) Rubella Cytomegalovirus (CMV) Herpes Simplex Virus (HSV)Hepatitis B

Common concerns during the newborn period

Transient tachypnea of the newborn Physiologic jaundice Hypoglycemia

Nursing care- transition phase

Transition: 8-10cm The woman is deeply focused and may not wish to communicate with anyone. May request pain medication at this time even if a natural birth is desired. Talk to patient about a plan for if this happens, ideally before they're in this phase. How much do they want you to try to keep them committed to their natural birth or meds Nausea and vomiting is common During transition mom may become irritable and/or agitated; self-absorbed. May appear to sleep between contractions and then "come alive" during them. Need for support is greatly increased. Discouragement increases. Begins to doubt ability. Biggest way to tell that a patient is in the transition phase is a change in the woman's demeanor Moms with epidurals also may vomit. Often they shake and tremble, this is a big sign that things are happening and changing fast. May start feeling pressure, may not. N/V helps push down the baby more. Do not want to medicate always for N/V because it can sedate patients and we don't want a mom to be sleepy when they're about to push This is the time some women will say "I cant do it" at this point

What is Postpartum depression?

Treatable medical illness that affects as many as 20% of adult women and 60% of adolescents after birth. It can develop anywhere from a few weeks to a year after delivery, but it's most common in the first three months postpartum. Different from baby blues, PPD symptoms last longer, are more severe and require treatment. Actually called perinatal depression because the greatest group of women who are at risk of depression are women with a history of anxiety and depression Postpartum depression can be hard to spot, because the moodiness and other symptoms are similar to the "baby blues" -difference is how long it's lasting and how severe the feelings are... After a year it is considered clinical depression Postpartum depression is caused by the hormonal shifts that occur after childbirth. During pregnancy, a woman's level of estrogen and progesterone greatly increases; then, in the first 24 hours after childbirth, the amount of these hormones rapidly drops to normal, nonpregnant levels. This change in hormone levels can lead to reactions that range from restlessness and irritability to feelings of sadness and hopelessness. Why do the blues and ppd happen???? How about hormone levels? What is known is that in the first three to four days after giving birth, estrogen levels drop 100- to 1,000-fold. Who has had PPD? Movie stars? Do you have to be famous to have PPD or to talk about it? Component of shame involved. Now most women are screened prenatally, at least once during pregnancy and post-partum before women go home

Polycystic Ovarian Syndrome-Treatment

Treatment: Based on symptoms Lifestyle modification...diet/exercise Oral contraceptives...control menstrual cycles, reduce male hormone levels, help clear acne Diabetes medications: Glucophage (metformin) Surgery...ovarian drilling They puncture the cysts with needles and can cause an ovulation to occur though the cysts almost always come back

Tetanus, Diphtheria and pertussis Booster (Tdap)

Trivia: Reported Pertussis cases in the U.S. 1922 107,473 1976 - 1,010 2014 - 32,971 Vaccination during pregnancy confers immunity to the newborn Vaccination recommended between 27-36 weeks gestation or within two weeks of delivery. Adolescents should get a booster between 11-12 years old 2014 - Ineffective vaccine or noncompliance? There is a resurgence in pertussis (whooping cough). New variants and reduced efficacy of vaccine. Boosters needed for adolescents and adult population every 10 years.

Shoulder dystocia management

Turtle sign is babies head coming out and then getting sucked back in with contraction

Gestational trophoblastic disease

Two types Partial mole- maternal and paternal DNA but something goes wrong and no fetus develops Full Mole- Only paternal and only vesicles Choriocarcinoma Exact cause unknown Therapeutic management Immediate evacuation of uterine contents (D&C) Long-term follow-up and monitoring of serial hCG levels GTD disease is rare and where no fetus or embryo develops as a result of conception and pt will have a positive pregnancy test Full mole can develop into choriocarcinoma which is treated with chemo With a full mole you are followed for HGC levels for at least a year after it develops to check for choriocarcinoma When GTD is diagnosed there needs to be an immediate D&C and may present with HTN, preeclampsia, and extreme nausea and vomiting

Common Laboratory and Diagnostic Tests

Tympanic fluid culture Depending upon infection may be painful Performed by physician Usually reserved for recurrent cases resistant to antibiotic therapy Pneumatic Otoscopy with tympanometry Probe in ear canal measures movement of ear drum Measures extent of effusion Requires appropriate size probe Why would we want to check the ear for extent of effusion? Infection can affect hearing over time which can impede speech delay which can affect reading/learning. Tympanometry is more useful with OME. This measures the movement of the ear drum.

Assessing fetal well being

Ultrasound Biophysical Profile Nonstress Test Amniocentesis Ultrasound can help determine fetal growth Biophysical profile looks for fetal breathing movements, gross body movements, fetal tone amniotic fluid. They look at all that and tally up points and 8 is the best Can add a nonstress test for two more points Short 20-40 minute test with fetal monitor for HR To see if you have a fetus who is neurologically intact by their reponse to stimuli based on their HR changing We want to see two "accelerations" of HR In 10 minutes to get a "reactive" nonstress test Amniocentesis can be used to diagnose genetic issues but can also be used to determine lung maturity Babies of diabetic mooms tend to have slower lung development

Maternal weight gain

Underweight (BMI < 18.5) total weight gain range = 28 to 40 lb Normal weight (BMI = 18.5-24.9) total weight gain range = 25 to 35 lb Overweight (BMI = 25-29.9) total weight gain range = 15 to 25 lb Obese (BMI = 30 or higher) total weight gain range = 11 to 20 lb Pregnant women do not need to diet because of the shift of how their body uses nutrients

How long does the baby blues last

Unique to each woman.. Some do not experience it at all (LUCKY!!) This state peaks 4-5 days after delivery and lasts from several days to 2 weeks. Symptoms that continue past 2 weeks or more are diagnosed as postpartum depression. Requires reassurance and validation Requires monitoring and follow-up 20% go on to develop postpartum depression

Implantation

Upper part of the uterus is called the fundus We want the fertilized egg to implant in the upper part of the uterus If implantation happens in the fallopian tubes or the ovaries then it is considered an ectopic pregnancy (which goes not have a favorable outcome), if it is discovered early enough then they treat with methotrexate (which ends the pregnancy) but if the pregnancy progresses too far then the growing embryo can rupture a tube and cause the patient to hemorrhage Most favorable sites for implantation are in the upper part of the uterus. Implantation in a fallopian tube is called an ectopic pregnancy and is not viable. Untreated, this can cause the fallopian tube to rupture and lead to significant internal bleeding. When a fertilized egg implants in the lower part of the uterus or in the cervix, this can lead to complications or spontaneous abortion (miscarriage).

Proteinuria: False Positives

Urine dipstick is routine but is unreliable. False positives result from: Vaginal discharge/blood SG and pH Bacteria Renal disease

Types of drug testing

Urine toxicology Meconium testing Cord toxicology

Operative vaginal delivery

Using forceps and vacuum can lead to shoulder dystocia Caput is swelling on the babies head and can happen from being in the birth canal or from use of vacuum Bruising is common with these

Periventricular and intraventricular hemorrhage

Usually originates in the subependymal germinal matrix region of the brain with extension into the ventricular system Occurs as a result of fragile and/or immature vascular bed in the brain IVH occurs in up to 50% of infants with birthweight less than 1,500 g and/or born at less than 35 weeks' gestation. Uncommon in term neonates but may occur with birth trauma or asphyxia Most occur within 72 hours of birth

Primary Post partum hemorrhage

Uterine atony - *most common* Retained placenta Placenta accreta- the placenta has actually grown into the muscle of the uterus Defects in coagulation Uterine inversion Hematomas of the vulva, vagina, or other peritoneal areas

Risk factors for OB Hemorrhage

Uterine atony - most common Precipitous labor & birth- very very rapid birth, means the uterus contracted too much Prolonged labor- uterus may not be contracting enough, related to uterine atony Induced or augmented labor- prolonged induction causes us to saturate her uterus with oxytocin and fill those receptors which means that she wont have any more receptors to clamp down well Difficult 3rd stage Operative vaginal birth Cesarean section Uterine overdistention- polyhandros, twins or triplets Coagulopathies Sepsis- infected uterus

Tone

Uterine atony - most common cause of postpartum hemorrhage Overdistention Prolonged labor Dystocia Infection General anesthesia Magnesium sulfate-smooth muscle relaxant so post partum for preeclampsia the woman is at risk for bleeding because the uterus is going to be more prone to being relaxed Bladder distention- one of the last things to return after an epidural is the ability to release the urethral sphincter Anything that makes the uterus not contract Here we want to use uterotonics, funal massage, anything to make the uterus tone up Standard of care is to always give bolus of oxytocin after birth for everyone for preventative measures You want the uterus to either be getting smaller or staying the same

Etiology of postpartum OB hemorrhage

Uterine atony- a uterus that does not go back to normal after birth, fails to contract Retained placenta Lower genital tract lacerations Upper genital tract lacerations (uterine rupture) Placenta accrete, increta, percreta Uterine inversion Inherited coagulopathy Acquired coagulopathy

Traction

Uterine inversion: Usually occurs as a result of traction on the umbilical cord Occurs with an atonic uterus Associated with life-threatening hemorrhage and hypotension. Symptoms Pain Bleeding Shock Treatment Replacement of the uterus back into the abdominal cavity under general anesthesia Usually occurs with an atonic uterus or someone pulling on the cord trying to deliver it too soon When doing fundal massage you need to stabilize the lower uterine segment to make sure the uterus does not inverse

Etiology of intrapartum OB hemorrhage

Uterine rupture Placental abruption

Etiology of antepartum OB hemorrhage

Uterine rupture Placental abruption Placenta previa Vasa previa- when there is an abnormal cord insertion and the vessels are over the cervix and if those vessels rupture there can be lots of bleeding

Reproductive changes in pregnancy

Uterus Increases in size to accommodate growing fetus. Weighs 40-50 in the nonpregnant state and 1100-1200g at full term. Highly vascular. 10-20% of the maternal cardiac output perfuses the uterus. By term, blood flow to the uterus is approximately 500-600 mL/min, 80% of which is directed to the placenta. Cervix Increased vascularity in early pregnancy causes a bluish color - Chadwick's sign Endocervical glands secrete thick mucus at term to form a "plug."- helps prevent infection Hyperactive glandular tissue also causes an increase in the normal mucus production during pregnancy. Vagina Vaginal secretions increase in response to loosening of the connective tissue and thickening of the mucosa. This discharge may be very heavy and watery at the end of pregnancy. Discharge is thought to help decrease infection risks Breasts Increase in size and nodularity to prepare for lactation. Pigmentation of the areola and nipples increase. Breasts may tingle and feel full. Colostrum may leak from the breasts before delivery.

Vagina and perineum changes postpartum

Vagina & perineum: Post-partum estrogen deprivation Dryness and/or coital discomfort Introitus (vaginal opening) Episiotomies - REEDA Hemorrhoids Pelvic muscular support: Supportive tissues of pelvic floor torn or stretched during childbirth. Require up to 6 months to regain tone. Kegel exercises encourage healing. Post-partum estrogen deprivation: responsible for thinness of vaginal mucosa and absence of rugae. Vaginal rugae: appear within 3 weeks. Thickening of vaginal mucosa: occurs with return of ovarian function. Dryness and coital discomfort, dyspareunia, may persist until return of ovarian function. Introitus: (vaginal opening) is erythematous and edematous. Episiotomies: heal within 2-3 weeks (sometimes takes 4-6 weeks to heal completely. Hemorrhoids: are common and decrease within 6 weeks of childbirth. Pelvic muscular support: Supportive tissues of pelvic floor torn or stretched during childbirth. Require up to 6 months to regain tone. Kegel exercises encourage healing.

Variations in fetal heart rate and fetal oxygen status

Variability Minimal, moderate, or marked A measure of the normal fluctuation of the FHR from the baseline. Absent or minimal variability possibly indicative of fetal distress Decelerations - periodic decrease in the FHR in response to contractions, classified as Early Late Variable Prolonged Baseline variability - refers to the fluctuations in baseline, it is the most important predictor of adequate fetal oxygenation and fetal reserve during labor. Variability- is the reflection of an intact pathway from the cerebral cortex to the midbrain, to the vagas nerve, and finally to the heart, interaction of fetal sympathetic and parasympathetic nervous system.. How oxygenized our baby is Causes of absent or minimal variability: Minimum or absent variability- if fetus is asleep, sedated, by opiates, CNS depressants, Cord compression, uterine tachysystole, or supine hypotension May want more invasive monitoring, could consider delivery Nurse should change position to promote fetal oxygenation, assess Moderate variablility starts to appear within the 30th or 32nd week which is normal for that gestation

VEAL CHOP MINE

Variable - cord compression- move Early- head compression- investigate Acceleration- okay- nothing needed Late- Placental perfusion- emergency (not always)

Variable decelerations

Variable Decelerations Sometimes transient and usually correctable with maternal position changes Associated with umbilical cord compression The deceleration begins and ends with a contraction, shaped like a "V" This is when we want to reposition mom to get that fetus or umbilical cord moved and increases perfusion through the placenta If the cord is wrapped around the neck then you will see the variable decels start to worsen or continue or if the cord is compressed and in a place that is not able to be moved Try to fix with maternal movement Variable decels with good variability means the baby is still getting good perfusion and oxygenation but that does not mean its going to continue so primary intervention is to move the mom If moving the mom does not help then you may want to give a fluid bolus of lactated ringers or some oxygen or other intrauterine resuscitation

Varicella

Varicella Zoster Virus (VZV) Outcomes vary depending upon gestational age in which mother contracts varicella 1st & 2nd trimaest cariies a higher risk of congenital varicella syndrome with birth defects The period right before birth and right after carries high incidence of mortality (neonatal varicella) VZV immune globulin Neonatal chicken pox - acyclovir Varicella If contracted in the 1st and 2nd trimester there is a small risk 2% or less, chance of congenital varicella syndrome (scarring on the skin; abnormalities in limbs, brain, and eyes; and low birth weight). Contracted in the 3rd trimester the woman is at very high risk of contracting pneumonia and may result in death. If a woman develops varicella rash from 5 days before to 2 days after delivery the infant will be at risk for neonatal varicella. This carried a mortality rate of about 30% but is now 7% due to VZV immune globulin This is chicken pox When adults contract this it can be more serious then when healthy children contract it Cannot vaccinate during pregnancy since it is a live vaccine

Multisystem disorder (preeclampsia)

Vascular* Vasoconstriction and vasospasm present before clinical signs and symptoms of disease as a result of endothelial injury. Endothelial injury results in "sticky" platelets and fibrin deposits throughout the body resulting in reduced blood flow to vital organs - brain, liver, kidneys, placenta, and lungs. Also increased risk of clotting throughout the body Cardiovascular BP: mild - SBP ≥ 140 and/or DBP ≥ 90; severe - SBP ≥160 and/or DBP ≥ 110 Capillary permeability further depletion of intravascular volume and renal excretion of proteins... Worsening edema Renal Proteinuria Creatinine clearance with an in serum creatinine as a result of poor renal perfusion BUN Risk for oliguria and renal failure Neurologic Headache, dizziness, scotomata, blurred vision, dizziness Hyperreflexia may indicate 'ing CNS involvement but is not diagnostic of the disease Hepatic RUQ pain Malaise, nausea - sick patients often say, "I just don't feel good." AST - ominous sign Hematologic Anemia Thrombocytopenia - platelet

Infection in pregnancy

Viral Bacterial Parasitic Fungal Severity depends upon timing and body system involved Most issues/damage to fetus occurs in the very early first trimester

Newborn assessment- vital signs

Vital Signs Respiratory Rate: 30-60 with brief periods of apnea Pulse rate: 120-160 beats per minute Blood pressure: 60-80/40-50 mm Hg Axillary temperature: 97.6 to 99.5 degrees F It is normal for the HR to be some what irregular, increases with inspiration and decreases with expiration

LGA newborns: nursing management

Vital sign monitoring Blood glucose level monitoring Initiation of oral feedings with IV glucose supplementation as needed Continued monitoring for signs and symptoms of polycythemia and hypoglycemia Hydration Phototherapy for increased bilirubin levels

Preterm newborn: assessment, common characteristics

Weight <5.5 lb Scrawny appearance Poor muscle tone Minimal subcutaneous fat Undescended testes Plentiful lanugo Poorly formed ear pinna Fused eyelids Soft spongy skull bones- contributes to birth trauma Matted scalp hair Absent to few creases in soles and palms Minimal scrotal rugae; prominent labia and clitoris Thin transparent skin Abundant vernix Not that they have burned up their brown fat but they just haven't had a chance to develop it May have undescended testes Fused eyelids are okay and will un-fuse on their own They prefer a pre-term baby to be born vaginally rather than C-section because of all the manipulation that is caused by C-section and C-section babies have higher incidence of pre-term respiratory distress

SGA newborns: nursing management

Weight, length, and head circumference measurements Serial blood glucose monitoring Vital sign monitoring Early and frequent oral feedings; IV infusion of dextrose 10% Monitoring for signs and symptoms of polycythemia Anticipatory guidance

Neonatal abstinence syndrome (NAS)

What is it ? NAS is the term used to describe the set of symptoms exhibited by infants exposed to narcotics in utero. 55% to 94% of infants born to narcotic addicted mothers show signs of withdrawal Most infants will not demonstrate immediate untoward effects and appear normal at birth. Infants exposed to heroin may begin to exhibit signs and symptoms of drug withdrawal within 12-24 hours. If the mother is on methadone the infant may exhibit signs and symptoms of withdrawal 24 hours to 48 hours or could be up to 2-3 weeks after birth. Buprenorphine withdrawal typically presents later than methadone, on day 3-5 of life.

When to seek help for baby blues?

When 'baby blues' last longer than two weeks The symptoms get worse Mother having trouble caring for herself or her baby Mother having thoughts of harming herself or her baby Its never a bad idea to let a pregnant woman know that she may experience these issues beforehand and give her and her support system resources. For example, support groups-psychological resources, etc.

When to seek help for postpartum depression?

When 'baby blues' last longer than two weeks The symptoms get worse Mother having trouble caring for herself or her baby Mother having thoughts of harming herself or her baby Its never a bad idea to let a pregnant woman know that she may experience these issues beforehand and give her and her support system resources. For example, support groups-psychological resources, etc. In some cases, postpartum depression can start one to two months after childbirth, with strong feelings of depression or thoughts of hurting themselves or their baby. Postpartum depression may start anytime within the first year after childbirth...but most common in the first 3 months postpartum. What sets postpartum depression apart is how long it lasts and severity of symptoms. The 'baby blues': having mood swings, feeling sad or anxious, crying for no reason; usually goes away on its own after about a week...no longer than 2 weeks. If the symptoms persist or they get worse over time, the mother should seek help.

Medication assisted treatment (MAT)

Withdrawal or "quitting cold turkey" is never recommended during pregnancy due to increased risk of fetal death Women with Opioid Use Disorder (OUD) should be offered Medication Assisted Treatment (MAT) with Methadone or Buprenorphine Women using MAT who become pregnant should not attempt to quit or wean off of their medication during pregnancy MAT doses may increase and even double during pregnancy due to increased blood volume and body mass - this in normal and expected! Doses should be titrated to curb cravings Transitioning from methadone to buprenorphine or from buprenorphine to methadone during pregnancy is not recommended Breastfeeding is recommended and encouraged for women on Methadone and Buprenorphine

What are the certain risk factors for gestational diabetes?

Women in populations with a high prevalence of Type 2 diabetes, such as: Hispanic African American Native American/Native Alaskan Southeast Asian & Pacific Islanders Women with clinical indications, such as: Obesity Glycosuria Polyhydramnios Infant with congenital anomalies/previous fetal death or stillborn/multiple SABs Family history of Type 2 diabetes Polycystic ovarian syndrome History of an infant greater than 4,000 grams (fetal macrosomia) *Women with Type 2 diabetes were formerly not diagnosed until they were nearing the end of their reproductive years. However, there are now more Type 2 diabetics of childbearing age than Type 1. If mom has elevated blood sugars so does baby and then they both put out more urine which causes more amniotic fluid Unstable blood sugars can cause fetal congenital anomalies Glucose gets to the baby but insulin does not but if baby is getting extra insulin because of elevated glucose levels then they're getting more insulin which is a growth hormone

Toxoplasmosis

Women who are exposed to the toxoplasma organism are typically asymptomatic 40% chance of passing it on to fetus during pregnancy Can be absorbed through intact skin Good handwashing important Gook meat thoroughly, esp. port, lamb, and veal Avoid cat feces Women are not screened for toxoplasmosis just educated while pregnant, women should not get a new cat or change the litter box because it is in the cat feces Can cause hydrocephalus, fetal anemia, liver issues, ect.)

Paternal postnatal depression

Yes, men can get depressed during and after pregnancy. Occurs in up to 14% of fathers in the U.S. Symptoms are similar to those seen in women but they often (not always) exhibit less sadness, crying, and outwardly emotional symptoms. Symptoms that differ from women include: Withdrawing from relationship Working more or less Low motivation Impulsivity Risk-taking behaviors or substance use Anger and outbursts Violent behavior Suicidal thoughts 14% may be a low estimate due to underreporting and men not recognizing that they are feeling depressed

hCG

hCG - Human Chorionic Gonadotropin Detectable in maternal urine and serum around day the time of implantation (7-8 days after ovulation) Alpha - produced in late pregnancy Beta - secreted in early pregnancy primarily by the placenta; this is the marker tested for in fetal genetic screening tests Maintains progesterone and estrogen function until placental function is adequate (about 10 weeks post conception) Higher than normal levels indicate twins or molar pregnancy (just a pregnancy that is DNA cells, there really is no baby there) Low levels may indicate ectopic pregnancy. The hormone detectable in over-the-counter home pregnancy tests. The corpus luteum is what produces the hCG after the placenta takes over providing for the fetus, That is what is detected in a pregnancy test

Pregnancy testing

hCG in urine or blood Can be detected at 7-8 days after ovulation but best to wait until day 10-12 after ovulation for more reliable results Follow directions strictly Early morning urine is best for testing-first urine contains about the same levels of hCG as serum sample Remember-probable but not diagnostic Still need to get a dr. to confirm you are pregnant

hPL

hPL - Human placental lactogen Also known as human chorionic somatomamotropin Secreted by the placenta; increases in relation to placental growth and peaks near term. Alters maternal protein, carbohydrate, and fat metabolism and acts as an insulin antagonist to aid in fetal growth. Increases free fatty acid availability for maternal metabolic needs and decreases maternal glucose uptake & use reserving glucose for fetal use. This change in the mother's natural state predisposes her to ketosis in the setting of decreased food intake. This is why even women should maintain caloric intake during pregnancy and not diet, even women who are overweight prior to pregnancy. This hormone shunts carbs and sugars to the baby This hormone helps turn her food into carbs to send to the fetus This is why we tell women not to diet during pregnancy because this hormone shunts the carbs and glucose to the fetus causing the women to use her stored carbs and glucose Also diabetic women are controlled much more strict on their sugar because insulin does not cross the placenta but glucose does not 5-5.5 for pregnancy hemoglobin