OB FINAL EXAM CLASS MATERIAL

Neonatal abstinence syndrome

- high pitched cry, inconsolability, not sleeping, sneezing a lot, being very rigid, etc. - exposed to addictive illegal or prescription drugs while in the mother's womb - Maternal malnutrition - General - Nicotine, Caffeine - Alcohol - CNS depressant Causes Fetal Alcohol syndrome and Fetal alcohol effects -one of leading causes of mental retardation

Methamphetamines

- highly addictive stimulant; more common than cocaine - Preterm births, placental abruption, IUGR, congenital anomalies

The ROM results in extremely large gush, this is possibly what? due to?

- hydramnios preterm or fetal anomalies

Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT)

- hyperglycemia at a level lower than what qualifies as a diagnosis of diabetes

Multifactorial Inheritance Patterns

- Combination of many genes and environmental factors (health, age, pollutants) - Tend to run in families - e.g. Cleft lip, HTN, Diabetes, Heart disease, CA, mental illness

Newborn with jaundice is receiving phototherapy. 5 interventions?

- Feeding frequent, cover genitals and eyes, VS, change diaper is soiled, max times in light

Postterm complications

- Perinatal asphyxia - Hypothermia - Hypoglycemia - Polycythemia - Meconium aspiration

Typical problems of SGA

- Perinatal asphyxia - Hypothermia - Hypoglycemia - Polycythemia - Meconium aspiration

Fetal Pulse Oximetry

- Placed on cheek, forehead - Measure fetal oxygen saturation - Normal 30-70%

Large for gestational age (LGA)

- birth weight is above the 90th percentile on a growth chart; weigh more than 4000 grams (8 lb, 13 oz) at term

Zona Pellucida

- blocks all sperm but one from entering - Clear protein layer

treatment of preterm labor

- conservative tx - L/S ratios, BR, temp q2h, VS, CBC - coticosteroids (Betamethasone, Dexam ethasone) - studies suggest ↑ lung maturity & ↓ Intraventricular hemorrhage, & NEC (necrotizing enterocolitis) (24 to 32 wks gestation) - Monitor s/s infection, adequate hydration, FHM, antibiotics, fluid color, odor

Uterus assessment PP

- determine degree of involution (firm or boggy (uterine atony); midline or deviated, relation to umbilicus) o Empty bladder before assessments

Harlequin sign

- dilation of blood vessels on side resulting in red on one side (dependent side), white on other (nondependent side)"clown suit" vasomotor disturbance, 1-20 min, may have multiple episodes - Results from immature autoregulation of blood flow and is commonly see in LBW when there is a positional change - Transient - 20 mins; no intervention needed

Bladder Exstrophy

- dressing - Separated rectus abdominis muscles - Usually see epispadius too- males - Rx: surgery reconstruction, until surgery clean with NS after diaper changes and cover with sterile non-adherent dressing (prevent from infection)

signs of early labor

- dull back pain, cramping - frequent bowel movements - increased vaginal discharge -leaking fluid (membranes rupture, can be a slow leak) - contractions (back to front from front to down) - if contractions are regular or intermittent, (high energy) - spotting (happens when loose mucus plug) -increased pressure- baby lightened - moved deeply into the pelvis

superficial Thrombophlebitis management/prevention

- elevate leg - TEDs - bed rest - 48 hours - warmth - K pad - compression boots - anticoagulants not necessary - NSAIDs may be used

Molding

- elongated shaping, overriding of cranial bones (prominence of the occiput and overriding sagittal suture line) - aka cone head or football shaped head - resolves within 1 weeks; no intervention

Bladder assessment PP

- empty, emptying without difficulty, retaining urine, full/distention o Diuresis- 3000 ml/day o If full bladder - percussion (dull); lochia drainage increases due to uterus not being able to contract o s/s of infection - infrequent or insufficient voiding, discomfort, burning, urgency, foul-smelling urine

Epstein's pearls

- epidermal cysts common small, white epidermal cysts on gums and hard palate that disappear in weeks

cold stress

- excessive heat loss, requires newborn to use compensatory mechanisms to maintain body temp - will ↑ O2 needs & ↑ acidosis- babies cannot shiver (that is primary method of heat retention) may increase voluntary muscle activity - can be fatal to an infant

causes of Hypotonic Uterine Dysfunction

- fatigue/inactivity - dehydration - hypoglycemia - excessive analgesia - catecholamine secretion due to anxiety - bowel/bladder distention - cephalopelvic disproportion(CPD - baby's head or body is too large to fit through the mother's pelvis), malposition - Multiple fetuses, LGA, hydramnios

examples of birth trauma

- fractures - brachial plexus injury - cranial nerve trauma (forceps) - head trauma - caput - cephalohematoma - hemorrhage - apnea - seizures - lethargy - skull fracture

other lab work indicated for pregnant women

- genetic screening, rubeola, blood lead screening -typically wait a couple weeks for ultrasounds

Plantar grasp reflex

- touch below toes they curl (disappear in 3-4 months)

s/s of Superficial Thrombophlebitis

- usually in calf area - leg is usually locally swollen reddened and tender, discomfort when walking - "Milk-leg" - pale, cool with decreased peripheral pulses - may have pain on ambulation, chills, temp

Additional "P"'s that affect labor process:

1. Philosophy 2. Partners 3. Patience 4. Patient Preparation 5. Pain management

Influence adequate Maternal O2 intake

-respiratory abnormalities - asthma -smoking -good placental exchange of O2 & CO2 -hypertonic uterine activity (uc's > 90 sec, <2min apart, relaxation time <30 sec. or relaxation pressure elevated) - oxytocin -placental condition

True Pelvis

-separated by linea terminalis -bony passageway though which the fetus must travel; made up of the inlet, mid-pelvis, and outlet

IgA

- major source found in breast milk - Protects mucous memb. from bacteria/viruses

Predictable change in newborn status in this order for Newborn Depression

- not adjusting well to life 1. Lose Color (pink to dusty gray to blue) 2. Respiratory effort (increases (nasal flaring, retraction, rate increases, etc.) to apneic) 3. Tone (become limp/flaccid) 4. Reflex Irritability (grimace/frown to no response) 5. Heart Rate (slow <100 bpm to no response)

Gravida

- number of pregnancies women has had, includes current one - "a pregnant women"

Occurance of HELLP syndrome

- occurs in about 20% of pregnant women diagnosed with severe preeclampsia - Diagnosed usually between 22 and 36 weeks gestation

IgG

- only one to cross placenta (most abundant) - Produces antibodies against bacteria, bact.toxins, viral agents

advantages of epidural

- pain relief without sedation - relaxes - used for both vaginal and C/S

Hydatidiform Mole

- partial and complete - Benign neoplasm of the chorion, fluid filled vesicle - looks like a cluster of grapes - Complete: Empty egg, 1 sperm gives 46 paternal chromosomes instead of 23, dies early, no embryonic tissue or circula tion; associated with the development of choriocarcinoma - Partial: 2 sperm, triploid karyotype (69 chromosomes, 69 XXX, 69 XXY, 69 XYY), embryonic parts (will not be tested on or on partial, etc.)

Hydramnios increases the risk of

- preterm birth - Fetal malpresentation - Cord prolapse

Nursing Considerations with pharmacology with L/D

- prevent respiratory depression - resp. q 1 h - vs q 1 min for 1st 15 min: q 5 for 15 - prevent hypotension - left side - elevate legs - O2 at 8-12 L - increase IV fluids - 5 -10 mg ephedrine, vasoconstriction - monitor fetus - check FHT - SVE may not have urge to push - vacuum and forceps ready - counteract convulsions allergic reactions - drugs to support cardiac function - ET tube - resuscitation equipment high block due to catheter migration - prevent bladder distention - check q 2

causes of Toxoplasmosis

- raw or poorly cooked meat, contact with cat feces. Through litter box or garden outside

Manage/Nursing Care of inverted uterus

- replace uterus (under general anesthesia) - laparotomy, hysterectomy - IV's, Foley, type and cross match, O2 - Oxytocin (Pitocin) to help contract, antibiotics for infection - Immediate Life-Threatening Hemorrhage; maternal death

Diagonal conjugate

- represents antero-posterior diameter - pelvic inlet, head passes through first - most useful measurement, 12.5cm or greater - supports vaginal delivery

Total/Complete placenta previa

- the internal cervical os is completely covered by the placenta

Presumptive s/s of pregnancy

Fatigue (12 weeks) Breast tenderness (3-4 weeks) Nausea and vomiting (4-14 weeks) Amenorrhea (4 weeks) Urinary frequency (6-12 weeks) Hyperpigmentation of the skin (16 weeks) Fetal movements (quickening) (16-20 weeks) Uterine enlargement (7-12 weeks) Breast enlargement (6 weeks)

Thalassemia

Group of hereditary anemias- defective synthesis of one or both chains of the hemoglobin molecule (alpha and beta)

Causes of primary Dysmenorrhea

excess prostaglandin production by the endometrium during ovulatory cycle - Causes contraction of the uterus

treatment of mastitis

frequent emptying of breasts (infant or pump), antibiotics, ice or warm packs, analgesics

Causes of Amenorrhea

n multiple - ex. Extreme weight gain or loss, stress, congenital abnormalities of reproductive system, excessive exercise, eating disorders, POS, Cushing Disease, hypo or hyperthyroid conditions, etc.

nursing management of VBAC

· Consent, Documentation, Surveillance, Readiness for Emergency: OR Team Must be Ready and OR available

causes of Folic-acid anemia

Co-enzyme needed to synthesize DNA, Folic acid needs double during pregnancy

Sterilization

Considered Permanent (even if patient seeks reversal- expensive, difficult, and not always possible)

Rheumatoid Arthritis

No adverse effect on pregnancy; may feel better. - Postpartum flare-ups are common. Some medications contraindicated during pregnancy

Multiple Sclerosis

No adverse effects on fertility, labor, or birth

Arrest Disorder

No progress in dilation after 2 hrs.; no further head descent after 1 hr, failure for head to descend (Primip), ½ hr (multip)

Three Tier FHR Classification System: category 3

Must Act- Need correction or delivery - Absent Variability ANDany one of the following: - Bradycardia - Recurrent Late Decelerations - Recurrent Variable Decelerations - Sinusoidal Pattern - Any time late decelerations - make sure to do interventions (ACT); baby not getting O2

treatment of NEC in newborn

NPO, orogastric tube/suction, antibiotics, IV flds, surgical resection if necrosed and/or perforated

childbearing in 1950's......

Natural Childbirth Practices - questioned "do I really need this medicine?" * Focus on relaxation * No Medication * Childbirth Classes Father: Active Role * Used to pull a current in front of birth and then when done pull it back and show the baby but not let them touch

PPROM

Preterm PROM before 37 weeks, before onset of labor

Five stages of syphilis

Primary, Secondary, Early Latent, Late Latent, Tertiary

Assessment of Dysmenorrhea

Primary: - History: cramping pain with menstruation - physical exam:normal Secondary: - History: discloses cramping pain staring after 25yo with pelvic abnormality, infertility, heavy menstrual flow, irregular cycles, little response to NSAIDs

Lacerations

a deep cut or tear in skin or flesh.

Psychosis depression

a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality; most severe; delusion beliefs are centered at infant

s/s Toxicity of Magnesium Sulfate?

absent DTR (knees and brachials), resp <12, LOC decrease, Output <30ml/hr

hydrocephalus

accumulation of fluid in the spaces of the brain

oligohydramnios

Too little amniotic fluid ( <500 ml) - May be uteroplacental insufficiency or Fetus may have renal abnormalities

Positive s/s of pregnancy

Ultrasound verification of embryo or fetus (4-6 weeks) Fetal movement felt by experienced clinician (20 weeks) - done by a NP, MD, or midwife Auscultation of fetal heart tones via Doppler (10-12 weeks)

causes of Hyperemesis Gravidarum

Unknown - multifactorial; high hCG, Vitamin B6 deficiency, stress?

s/s of high-risk newborn infection

apnea, poor feed, temp unstable, RDS, pale, hypoglycemia., tachycardia

Class I of CVD

asymptomatic with no limitation of physical activity

Dick-Read method

based on relaxation and breathing techniques -Fear-tension-pain

Cultural knowledge

becoming familiar with culturally/ethnically diverse groups - Touch - Clothing/Covering - Presence of Men other than spouse

Third stage of labor

birth of infant to placental separation and expulsion · shortest 5 - 10 min - up to 30 min. · mild to mod UC's

s/s of poor thermal regulation of newborn

cool to touch, cyanosis, RDS, lethargy, poor feed, weak cry, hypoglycemia

causes of UC prolapse

cord protrudes alongside or ahead of presenting part - results in partial or total occlusion- lack of O2- fetal demise

Odd characteristic of a female condom

cumbersome and make noise during intercourse

intermittent contractions

cyclic, rhythmic, period of relaxation allows muscle to rest & restore utero-placenta circulation for fetal oxygenation

Perinatal asphyxia SGA newborn

child doesn't breathe normally just before, during, or after birth Stress of labor - Acidosis - Hypoxia - Bradycardia and decels during labor - Resuscitate - cannot fix what has happened in utero

diagnosis of Sickle Cell Anemia

childhood - blood smear, Hb electrophoresis

The ROM results in cloudy, yellowish or odor, this is possibly what?

chorioamnionitis

The ROM results in cloudy, yellowish or odor, this is possibly?

chorioamnionitis

RIsks with PROM

chorioamnionitis, endometritis, sepsis, neonatal infections

Newborn heat loss through any of the four mechanisms leads to

cold stress

Hyperbilirubinemia: Physiologic jaundice

day 3-4 Early-onset BF jaundice- peaks day 4 - Ineffective BF practices, caloric deprivation, less volume, frequency- mild dehydration-delay in passing meconium- reuptake of bilirubin Late-onset BF jaundice (day 6-14) - Unknown- Possibly r/t change in milk composition Bottle feeding jaundice - Peaks day 3, rapid decline in Bili levels

complete placental abruption

entire placenta

Primary objective of FHR Monitoring

get information regarding fetal oxygenation; prevent fetal injury

Who are at an increased risk for dysmenorrhea?

history of PID, STIs, low fruits and veggies diet, depression, high stress, multiple sexual partners, unprotected sex

Stepping

hold infant upright, feet touching surface, "stepping" motion (disappear in 1-2 months)

cause of placental abruption

unknown

risks of VBAC

uterine rupture; if happens, high fetal mortality

Precipitous labor

uterus contracts so frequently and with such intensity that a very rapid birth takes place

What is supine hypotension syndrome due to in pregnancy?

uterus pressure on inferior vena cava-reduces blood flow

Assessment and Management of the Intrapartum Family

· Pain associated with childbirth · Inexperience/negative experience of own · Unpredictability · Intimacy · Legal liability · Education · History of previous labors

Types of jaundice involving decreased conjugation

· Physiologic jaundice, hypothyroidism, BF

Variables that Influence Pain

· intensity of labor · cervical readiness · fetal position - such as OP -sacral pain · fatigue - sleep deprivation · intervention - augmentation, IV, preps · pelvic configuration

Styles of Paternal Involvement

· observer style - happy about pregnancy do not take active role · expressive style - display strong emotional response to pregnancy and want to be fully involve may even experience psycho‑symptomatic symptoms · instrumental style - task oriented role, comfortable is they can do something like be the coach, take pictures, cut cord

teaching for Wound infections PP

s/s to watch - Don't forget low grade fever (<100.4), poor appetite, low energy, in addition to REEDA

Contraceptives can play a role in the prevention of STIs

safer sex -Condoms -Monogamy -Abstinence can reduce the incidence of STIs worldwide

s/s of Meconium Aspiration Syndrome

same Resp. distress - difference will see the meconium fluid or getting report that there was some (will see green/black around the cord)

s/s of Persistent Pulmonary Hypertension in newborn

same as before (RDS): add: murmur, hypotension

s/s of Bronchopulmonary Dysplasia/Chronic Lung Disease in newborn

same resp. distress.. And: poor wt. gain, bronchospasm, abnormal breath sounds, hypoxia, acidosis, high CO2 (hypercapnia), cardiomegaly, infiltrates

Anal wink reflex

stimulate perianal skin near anus, external sphincter constricts "winks"; indicates S4-S5 innervations

Most important sign of cold stress

tachypnea

Attention focusing and imagery

tactile stimulation (touch, massage, stroking), auditory (music, verbal), and visual imagery

Uterine Rupture

tear in uterus; site of previous uterine scar -into abdominal cavity

Amenorrhea

the absence or lack of menses during the reproductive years - Normally in prepubertal, pregnant, postpartum, and postmenopausal females - Can occur in 1 of the four anatomical areas: 1) Outflow area of the uterus an vagina - problems here are obstructive in nature and can be found during a physical exam 2) ovaries, 3) pituitary gland, 4) CNS - problems here involve disruptions in the hypothalamic-pituitary-ovarian axis hat controls the neuroendocrine processes required for a normal menstrual cycle found through labs

Marginal placenta previa

the placenta is at the margin or edge of the internal os

Herbal medicine

the practice of using herbs to heal

Metro

time

Petechiae

tiny purple, red, or brown spots on the skin (possible due to pressure on the kin during the birth process)

Chorion

trophoblast cells/mesodermal lining

Symptothermal method

mood changes, temperature, etc. • Relies on combination of techniques to recognize ovulation including BBT, cervical mucus changes, alterations in postion of the cervix, and others like increased libido, mittelschmerz (mid cycle, lower abdominal pain), pelvic fullness or tenderness, breast tenderness • Ovulation test at pharmacy - elevated levels of LH tells that day before or of ovulation

Abstinence

moral/religious beliefs, effective, disease prevention role

Newborn produces bilirubin at what rate?

more than double adult rate (6-8mg/kg/day)

Passageway problems: Contraction in mid pelvis

most common - narrowest part of the pelvis at 0 station and gets stuck - Result: Arrest of fetal descent - Difficult to diagnose

Abnormal Uterine Bleeding (AUB)

irregular, abnormal bleeding; not caused by pregnancy, a tumor, or an infection - Most commonly at the beginning and ending of reproductive years - Hormonal disturbance causes prolonged, excessive, irregular bleeding - Not always sure what is causing

sneezing reflex

irritant is brought close to the nose

diagnosis of PPTD

lab thyroid levels

Binding-in

mother identifies specific features about baby, looks like, claiming behavior

Spiritual healing

movement toward integration, from brokenness to wholeness - healing through praying

Bartholin's glands

mucous lubrication for intercourse

Risk factors for HPV

multiple partners, age, immunosuppression, Socioeconomic

Risk factors for PID

multiple partners, early age sex, lack of contraceptive use

Systemic meds

narcotics, sedatives, tranquilizers - Opioids:such as Butorphanol (Stadol) or Nalbuphine (Nubain) or Meperidine (Demerol), Fentanyl (Sublimaze), Morphine - Antiemetics: such as Hydroxyzine (Vistaril) or Promethazine (Phenergan), Prochlorperazine (Compazine) - Benzodiazepines:such as Diazepam (Valium) or Midazolam (Versed)

treatment of Periventricular-Intraventricular hemorrhage (IVH) in newborn

limit handling, stimuli, supportive care, correct anemia, acidosis, hypotension with IV and meds

benefits of mechanical Method of Induction/Augmentation

lower cost, simplicity, fewer side effects then pharm., preserves cervical tissue

risks of Bronchopulmonary Dysplasia/Chronic Lung Disease in newborn

males, white, severe RDS, preterm, sepsis

Which GI problems should you watch a preterm for?

malnutrition, wt. loss, poor suck, shunting of blood to vital organs- intestine ischemia- NEC (Necrotizing enterocolitis), may require gavage feed

La Leche League

organization that was created to promote breastfeeding - meet and support eachother - Breastfeeding - Nutrition - Infant care - Problem solving strategies

Midwifery

practice of providing holistic health care to the childbearing woman and newborn

Chiropractice Therapy

manipulation therapy of the spine to decrease pain and increase functioning - helps the body heal

non-concealed placental abruption

margin breaks away

What is the first action if lochia is too much?

massaging the boggy uterus to reduce the flow of blood

s/s of Rubella (German Measles)

maternal - general malaise, maculopapular rash

Delayed Pregnancy

mature primigravida (old-elderly primip) deliver at age 35 or >Social reasons - career, $, better technology

Newborn risk after exposure to HPV

may develop warts in throat (laryngeal papillomatosis) -uncommon but life threatening

Systemic Lupus Erythematosus

may flare during pregnancy, still birth, IUGR, preeclampsia, preterm birth, miscarriage - Treat with NSAIDs, plaquenil, minimum meds if possible

S/s of HPV

pruritus pain

The ROM results in green, this is possibly what? due to?

meconium stained postterm, fetal or placental insufficiency (breech)

Acupuncture and acupressure

research limited, need trained/certified clinician, reduces labor pain, Chinese medicine

treatment of Persistent Pulmonary Hypertension in newborn

resuscitation, O2, correct acidosis, minimize stimulation

Nitrazine swab/paper

turns blue if fluid is alkaline (amniotic fluid); yellow/olive green is acidic (vaginal fluid)

Causes of inverted uterus

turns completely inside out - pulling on umbilical cord - fundal pressure; unsupported uterus when palpating the fundus - increased intra-abdominal pressure - congenital weakness of uterine wall - fundal placental implantation

· Fractures in newborns

Breech, shoulder dystocia, macrosomic

- Endocrine PP

- Quick drop of estrogen and progesterone, hCG, hPL - Lower estrogen= Breast Engorgement and diuresis of ECF accumulated during pregnancy - Estrogen increases 2 weeks after birth for non-BF moms - BF mom's estrogen increases when freq. of feedings decreases - After first menses= progesterone production reestablished - Prolactin=stay elevated if BF, drop within 2 weeks non-BF mom

Normal Newborn Vital Signs

- *Temperature* o 97.7-99.5F (36.5-37.5C) degrees, axillary o Axilla is preferred site over rectal temperature - *Heart rate* o 110-160 bpm; regular rhythm - *Respirations* o 30-60 bpm o Respirations irregular, shallow, unlabored o Symmetrical chest movements

diagnosis of chlamydia

-Swab Culture of Vagina or Endocervix -First void urine specimen

Newborn measurements

-Weight -Length -Head circumference -Chest circumference - abdomen circumference

Hyperbilirubinemia: Pathological Jaundice

-Within first 24 hrs. -ABO or RH incompatibility -May lead to Kernicterus

Cervical Changes

-normally 2 cm long -effacement &dilation -10 cm 100% efface = time to push -If not 10 cm, will make delivery more difficult because baby won't get through due to the swelling

Episodic Changes in FHR

-not associated with UC's -Variables - cord compression -Accelerations - ↑FHR with movement -Changes in baseline - over 10 min period or 30 BPM change over 10 min period

Passageway problems: Soft tissue dystocia

-obstructions in birth canal - Placenta previa, Fibroids, HPV warts, Full bladder/rectum - Edematous cervix (pushed too early)

desquamation

-peeling skin -post-term

Contraindications for Forceps Assisted delivery

- High fetal station - CPD

GU structural anomalies in newborn

- Hypospadius - Epispadius - Bladder Exstrophy

meconium aspiration Postterm newborn

- Hypoxia inutero - Suction airways, support ventilation

Vacuum Assisted delivery

- Instrument: cup-shaped, attached to suction, helps pull fetal head - Kiwi, plastic cup (Older - metal)

PP for women with GDM

- Insulin needs drop drastically in first 24 hours - Check BG q 2-4 hrs or as ordered for 48 hrs - oral hypoglycemics contraindicated in BF - BF may decrease dev of diabetes in infant and helps control maternal blood glucose levels - oral contraception is usually contraindicated in diabetes due to vascular consequences - 50% chance of developing Type II Diabetes

Menses for lactating women

- Menses depends on BF frequency and duration - 3-18 months after birth - Depends on exclusive BF vs. supplementation of formula

Blood Incompatibility: ABO

- Not as severe as Rh incompatability - No antepartum treatment - Mom: Type O, with fetuses who are Type A or Type B; anti A & anti B antibodies ( Type O moms: most antibodies are IgG- some cross placenta-destroy fetal blood cells; hemolysis ) - Watch infant (A, B, AB, and + coombs) for jaundice - Can prepare through prenatal visits (mom O, Dad A, B, or AB)

Gastroschisis

- Not assoc. with other anomalies - No peritoneal sac to protect organs o Thickened, edema, inflammation- >high morbidity and mortality o Rx: surgery

Maintain milk supply

- Nursing infant - Breast Pump - Manual expression

PostPartum women with CVD

- OK to BF if stable, monitoring for S/S infection, hemorrhage, thrombosis & cardiac decompensation - Peripartum & pp cardiomyopathy

Newborn metabolic screening

- PKU - Maple Syrup Urine Disease - Galactosemia - Congenital Hypothyroidism

Complete abortion

- Passage of all products of conception - Hx of bleeding (now less), hx abd. Pain (now less) - Support, F/U appt.

Community Based Health Care Settings: Ambulatory care

- Physician Offices - Clinics - Day surgery - Urgent Care Centers - Mobile Units; mammography

Nursing Interventions early newborn period

- Providing general newborn care - Enhancing bonding - Assisting with screening testing - Promoting nutrition - Dealing with common concerns - Preparing for discharge - Ensuring follow-up care

Triple and Quad Screening Tests

- 16-18 weeks • Triple screen includes AFP, estriol, beta-hCG; Quad screen includes AFP, estriol, Beta-hCG, and inhibin A • Low AFP, estriol, high hCG, Low inhibin A= possible Down's Syndrome • Multiple maternal factors can lead to inaccurate interpretation

Assessment for quickening/fetal movement to determine well-being

- 16-20 weeks - Most common method - count to 10 and women focuses on the fetus movement and records how long it takes to document 10 movements - If takes longer than 2 hours, women should contact HCP - Know what is normal for movement - when does she normally feel the baby move? (could also be an indication that dates are off)

Bleeding during pregnancy

- Abortions (spontaneous vs. induced) - Ectopic - Molar pregnancy - Cervical insufficiency - Previa - Abruption

APGAR pulse

- Absent Pulse: 0 - Heart Rateunder 100 beats per minute: 1 - Heart Rateover 100 beats per minute: 2

- Acquired Immunity newborn

- Absent until foreign organism invades - Development of circulating antibodies or immunoglobulins- target specific antigens - Formation of activated lymphocytes : IgG, IgA, IgM

treatment of cervical insufficiency

- Bed rest - Pelvic rest - No heavy lifting "Purse string sutures"= Cervical cerclage; can place up to 28 weeks - suture closed the cervix - Monitor and make sure it is place and monitor of s/s of labor - Once in labor, will need to come into a circlaush removal - Note: have to careful while doing because could rupture her membranes - Remove around 37 weeks - Risk of infection, ROM, -careful use - decrease uterine activity (decrease sexual activity, tampon use, etc)

Postpartum Period

- Begins with delivery of placenta: lasts approx. 6 weeks - Begins to return to prepregnant state - Also known as puerperium - Has also been defined as all aspects of mother's life occurring during the first year - Fourth stage of labor - the longest - True postpartum can last from 9-12 months as mother works to lose weight she gained, adjust psychologically to changes in her life, and take on mother role - Nurses should consider culture including communication, space and family roles o Communication - encompasses language, loudness of speech, meaning of touch and gestures o Ex. Mexican Americans, Arab Americans, Asian Americans, and orthodox Jews view birth as a women's affair

What happens if a newborn's has Immature liver pathways?

- Can't conjugate quick enough - Increases -unconjugated amt. in blood, deposits in skin, sclera, mucous membranes = Jaundice (icterus) - Extreme levels Bilirubin = toxic (Kernicterus= permanent brain damage)

Home care of the infant

- Care After Discharge (shorten Level of stay- LOS: 48hrs vaginal birth, 72 hrs-96hrs C/S, most 72 hrs) Home visits - assessment of mother, infant, home environment - teaching, lab work - bilirubin can be done at home - high risk interventions, medical disorders - cardiac problems, apnea planning, communication, cultural variations

causes of UTI PP

- Catheters - Vag exams - Trauma

Neural tube defects: Spina Bifida

- Caudal defects below T12 - Treatable - Cause paralysis - Meningocele, Myelomeningocele, or "Occulta"

Post coital testing

- Checks if cervical mucus is receptive - Plan intercourse at ovulation, check mucous 2-8hrs after intercourse, count # live sperm, mucous consistency/stretchability (spinnbarkeit) - Normal: amt. moving forward, mucous stretches 2 inches, dries in fernlike pattern

s/s of CVD

- Chest pain - rest or exertion - Edema hands and face - ^B/P, Palpitations, heart murmurs - nocturnal dyspnea, diaphoresis - pallor, cyanosis, syncope, increasing fatigue - hemoptysis, SOB, orthopnea

DIC: Disseminated Intravascular Coagulation

- Coagulation Disorder - Triggered by abruption, eclampsia, missed ab, sepsis, amniotic fluid emboli, other OB condition

fetal risk with DM mother

- Congenital anomalies - Macrosomia - Birth trauma - Preterm - IUGR - Death due to placental insufficiency - RDS due to hyperinsulinemia - Polycythemia (extra RBC prod. d/t hypoxia) - Hyperbilirubinemia - Hypoglycemia & hypocalcemia - Childhood obesity

Congenital Conditions: Classifications of Cong. Heart Disease

- Defects causing incr. pulmonary blood flow, such as atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA) (most common) - Defects causing obstructed blood flow out of the heart, such as pulmonary or aortic stenosis - Defects causing decreased pulmonary blood flow, such as tetralogy of Fallot - Defects with cyanosis and increased pulmonary blood flow or mixed defects, such as truncus arteriosus or transposition of the great arteries

treatment of preterm labor

- Early identification & intervention increases gestational age - Hydrate, bladder-empty - BR (strict BR may be detrimental) - monitor if 4 UC/hr - call - SVE - effacement and dilatation - treat any prenatal infections - test fetal fibronectin from swab for intactness of fetal membranes - Transvag US

Pt has had signficant blood loss and is showing s/s of shock. Possible s/s?

- Tachy, diaphoresis, anxious, confusion, hypotension, etc.

Palmer grasp reflex

- infant grasps if something is put by base of fingers (disappear in 3-4 months)

pelvic floor

- levator ani muscle group draws rectum & vagina up & forward - pressure of the head causes thinning of the perineal floor & physiologic anesthesia

Klumpke's palsy

- lower brachial plexus - hand/wrist weakness, no palmer grasp reflex (less common) - Immobilize, ROM

Bladder PP

- may be subjected to trauma that results in edema & diminished sensitivity to fluid pressure, can lead to over distention & incomplete emptying, may have difficulty voiding the 1st 2 days (↑ with epidural) -Problems if received anesthetic (inhibits neural function of bladder (decrease tone)), oxytocin to induce/augment labor (antidiuretic), laceration, swelling, bruising, diminished sensation, etc. -If labia and perineum swell and did no give ice or ibuprofen to help, will swell and close off urethra (not be able to pee on own) and back up ureters and cause a kidney infection Will need a straight cath or foley -Bladder distention =displacement of uterus = inhibition of contraction (uterine atony)= hemorrhage

s/s of DM

- polydipsia - excessive thirst-caused by polyuria - polyuria -↑ in vascular fluid volume excess - glycosuria -kidney's attempt to flush out fluid & hyperglycemic state of the blood polyphagia

causes of late PP hemorrhage

- subinvolution (delay of returning uterus to prepregnant state) - retained placenta - Infection

How often to do a PP Assessment

- First Hour: every 15 min. - Second Hour: every 30 min. - First 24 hrs: every 4 hrs. - After 24 hrs: every 8 hrs

Menses for PP

- First pp menses usually heavier - Ovulation may occur before menses (contraception education) - Wt. loss d/t rapid diuresis and lochia flow

Management of Postpartum Hemorrhage

- Fundal message; Pitocin; Methergine; Hemabate - Teach woman to massage own fundus and assess bleeding

Inborn errors of metabolism

- Genetic disorders-defect in enzyme or transport protein - Early Dx, prompt intervention o Poor feed, vomit, resp distress, lethargy, poor tone, seizures

- If Tachycardia (>100 bpm) noted consider in PP

- Hypovolemia - what was her blood loss? - Dehydration - Hemorrhage - what is her bleeding (lochia) now?

Disadvantages of oral contraceptives

*Offers no protection against STIs *Pose slightly increased risk of breast cancer *Modest risk for venous thrombosis and pulmonary emboli *Increased risk for migraine headaches *Increased risks for myocardial infarction, stroke, and hypertension or women who smoke *May increase of depression *User must remember to take pill daily *High cost for some women

PP Psychosis

- 1 per 500 - Within 3 weeks pp - Sleep disturbance, fatigue, depression, tearful, guilt, anger, hallucinations - Thoughts of hurting self and/or infant - Hospitalization required - Psychotherapy, support groups, psychotropic meds

Withdrawal (coitus interruptus)

- One of the least effective methods - The first few drops of ejaculation contain the greatest concentration of sperm and if some pre-ejaculatory fluids escape from the urethra before organism, conception may occur

Treatment of Trichomoniasis

- Oral metronidazole (Flagyl) *all partners* - Single dose, no alcohol: severe N/V

Toxoplasmosis

- Protozoan, parasitic infection-toxoplasma gondii

Classification using Gest. Age and Weight

- SGA wt. less than 10th percentile - AGA wt. between 10-90th percentile - LGA wt. more than 90th percentile

Diagnosis of placenta previa

- Transvag. Ultrasound, NOTE: Avoid vaginal exam to prevent further bleeding

Postpartum Hemorrhage causes

- Uterine atony - Retained placental fragments - Cervical or perineal lacerations - Subinvolution - Bleeding disorders

- Neurological PP

- chills/tremors - self-limiting and normal

Methods of Induction/Augmentation

- non- pharm. - mechanical - surgical - ex. Amniotomy

Group B Streptococcus (GBS)

-25% of all women carry GBS, colonized in vagina, rectum -women are usually asymptomatic, but can cause UTI, endometritis, chorioamnionitis, -need vaginal/rectal & cervix culture at 35-37 weeks

incidence of Varicella-Zoster (VZV)(Chickenpox)

1-7/10,000 preg

Acquaintance rape

A person being forced to have sex by a person he or she knows

Auscultate FHR during latent phase

low risk - q. 1 high risk - q. 30 min

The ROM results in clear with specs of vernix. What should the nurse suspect?

normal

Fern Test

detection of a characteristic 'fern like' pattern of vaginal secretions when a specimen is allowed to dry on a glass slide and is viewed under a low-power microscope. used to provide evidence of the presence of amniotic fluid and is used in obstetrics to detect preterm premature rupture of membranes and/or the onset of labor.

common causes of high-risk newborn infection

Candida albicans, staph aureus, E. Coli, Enterobacter, Klebsiella, Serratia, Pseudomonas, Group B Strept

Treatment of HIV

Combo HAART (highly active antiretroviral therapy): triple combination or more -Goal: suppress viral replication Pregnancy: Rx during pregnancy, labor and infant after delivery -No treatment: 25% or more get HIV -With treatment: 2% HIV or less -Medication tends to make them feel worse Adherence is problem -Nausea, diarrhea, fatigue, anemia, headache, life- long commitment to Rx -Non-adherence to drug regimen causes drug resistance

Continuous electronic monitoring (external and internal

External: limits mobility, encourages supine position: decreases placental perfusion, continuous pattern, no gaps, accurate but can't detect short term variability Internal: can detect short term variability and FHR dysrhythmias, not as sensitive to maternal movement

treatment of Thalassemia

Rest, avoid infections, Genetic Counseling, supportive care

Heavy/Large lochia

Saturated pad within 1 hr. of changing pads

Lochia: How much is too much?

Saturating pad every hour = too much

Family Centered Community Based Care focus

illness-oriented care of individuals and families throughout the life cycle

Infertility

inability to conceive a child after one year of regular sexual intercourse unprotected by contraception

causes of accelerations

-Fetal movement, sterile vag. exam, Uterine Contraction, mild cord compression, breech -can be episodic=not associated with uterine contractions

Physical changes during pregnancy: breasts

-Increase in size and nodularity to prepare for lactation -Tenderness, vascularity, stretch marks - as grow in size, may see red, shiny coloring = will fade and become a silver color skin tone color -Nipples increase in size, become more erect, and more pigmented due to hormone -Sebaceous glands prominent-lubricate nipple -Colostrum is produced

CPD / fetopelvic disproportion

- too big for mom's pelvis - May see very slow cervical dilation during active stage of labor

Shoulder Dystocia

- Fetal head delivers but shoulders stay wedged behind pubic bone - Difficult birth - Potential injury to both - Emergency - High Risk for Umbilical Cord compression - McRoberts Maneuver - Flex and abduct thighs; straightens pelvic curve - opens it as wide as you can - Suprapubic pressure - Check for injury, fractures

Hypertonic contractions

- uterus never fully relaxes, placing the fetus in jeopardy o Not able to rest in between contractions due to not going down all the way o Will see if contractions are coming quickly

Nullipara

Women who has had no delivery's at 20 weeks or greater

Premonitory Signs of Labor: Lightening

-fetus settles into pelvic inlet; engagement occurs · Primipara: 2 weeks before labor · Multipara: may not occur until labor begins · Prior to labor - baby will drop into pelvis, when growing in utero- can be different positions, but in lightening: drops down into pelvis, increased pressure at bottom of pelvis · First time moms: can happen up to two weeks prior to labor

Labia Majora

sweat and sebaceous glands, hair, protects vaginal opening

C-S incisions

- low-transverse - low vertical - classical (vertical)

Observe for S/S of Distress

- nasal flaring or grunting - VS q 30 min - Initial bath under warmer; wear gloves until bath is complete - Replace under heat - Vit K and erythromycin - if not given in DR - Glucose monitoring - Group Beta Strep protocol - Meconium protocol if indicated (frequent VS)

s/s of Blood Incompatibility: Rh

- positive indirect coombs or antibody titer

contraindications of a Cesarean Section

- severe preterm - fetal demise - maternal coagulation defect

Manifestations of inverted uterus

- uterus absent from abdomen - visualization & palpation through cervix - pelvic pain - hemorrhage - can lead to an infection

predisposing factors of PE

- varicose veins - obesity - hx of thrombophlebitis - smoking - C/S - over 35 - Multiparity - Oral contraceptives before pregnancy - Diabetes

causes of Hemorrhagic/Hypovolemic Shock

- ↑ 1500ml blood loss = constriction of peripheral =blood vessels→ shunt blood to major organs & metabolic acidosis

Usefulness of Framework

- Framework used to monitor progress - Absence or inability to progress through phases may impede maternal role development - Length of phase may not be accurate - Speed through phases increased with today's "contemporary" woman: knows fetus sex d/t US, more knowledge d/t classes, reading, less passive than previous women

How is religion affected in infertility?

- Orthodox Jewish: procreation = mitzvah (commandment to have children); still use contraceptive to prevent undesired births - Conservative and reform Jews: no restrictions on contraceptives - Roman catholic: procreation cannot be separated from the relationship between parent

vasectomy

- Sterilization for men - Usually performed under local anesthesia - Involves cutting the vas deferens, which carries the sperm - Immediate risks: infection, hematoma, and pain - Easier procedure due to tinnier area and faster healing Not immediate - need to have semen specimens analyzed until 2 show no sperm (azoospermia)

surgical Method of Induction/Augmentation

- Stripping membranes-insert finger internal cerv. Os, move in circle pattern- causes membranes to detach-induces ripening-labor - Amniotomy

Forceps marks

- commonly on cheeks and mouth area - common with assisted births with forceps

s/s of Hypotonic Uterine Dysfunction

- exhaustion - frustration - eventual fetal hypoxia - weak contractions become milder, less intense

Intrauterine Fetal Demise

- fetus dies in utero - Will always do a vaginal delivery (not C/S)

Factors that influence maternal blood flow

-reduction in maternal circulating volume (hypovolemia) - hemorrhage -hypotension decreases placental blood flow -epidural anesthesia -supine hypotension -hypertension or vasoconstriction -chronic HTN or from Pregnancy -drugs

#2 leading cause of death in women

cancer (Lung (#1) and breast (#2))

Hypospadius

congenital defect, open of urinary meatus on under side of the penis

syndactyly

- webbed digits - fingers or toes - runs in families, if severe may need surgery to separate

Risks for Mid forceps delivery

-↑mat. & fetal morbidity & mortality -q Facial nerve damage

how often do you Monitor/Palpate UC's in active phase of labor

every 30 min

Doula

* Birth assistant * hired * Support: physical, educational, emotional * Childbirth and postpartum * Not much regulation on them

Violence against women

* Can start or escalate during pregnancy * RADAR * Limited access to healthcare

diagnosis of Hydramnios

US, s/s: uterus larger than expected, SOB, Edema LE, hard to palpate fetus and FHR hard to hear

how often do you Monitor/Palpate UC's in transition phase of labor

every 15 min

Rhagia

excess or abnormal

Breathing Techniques

Breathing Patterns - Cant tense muscle; fetus is getting better O2 - Abdominal breathing is sequenced and even -Quick method is to get control fast in active phase -These are learned in prenatal classes or taught on the spot!

abortion

expulsion of embryo or fetus before viability; most done in first 12 weeks - elective or spontaneous • rh negative women have rhoGAM prior to start either

Oligo

few

Lanugo

fine downy hair(shoulders/back)

Moro

- sudden lowering of head and back 30 degrees, arms & legs extend and abduct, fingers open & thumb & finger forms C, startle reflex (disappear in 3-6 months) - Place on back, support upper body weight, lifting motion without lifting off surface, release

s/s of mastitis

- temp, chills, high pulse, malaise, flu-like S/S - localized redness, inflammation, tender area firm & reddened, may be confined to one lobe, hot to touch - red streaks along lymphatics - may be drainage (abscess) - engorged

Bacterial Vaginosis

-Gardnarella vaginalis (gram neg. bacillus) -Most common cause of d/c and malodor

Cervix

-Lower part of uterus, channel (mucous secreting glands), fibrous connective tissue -Opens into vagina, sperm enter here -Covered with mucous, smooth, firm, doughnut shaped -Can be seen on pelvic exam -Central opening: external os -Before birth: oval shape -After birth: slit shape

Clinical Manifestations of Klinefelter Syndrome

-Mild mental retardation -Small testicles Infertility -Long arms and legs - most noticeable -Enlarged breast tissue (gynecomastia) -Scant facial and body hair -Decreased sex drive (libido)

Recurrent infection of Genital Herpes Simplex

-Milder, shorter duration -Itching, tingling, unilateral lesions, ↓pain

Human Papillomavirus: HPV

-Most common viral infection USA -Causes genital warts -14 million new cases annually USA (CDC, 2015) -95% cervical cancer caused by HPV (many types of HPV) -Asymptomatic, unrecognized (most) -Occur: cervix, vagina, urethra, anus, mouth - Do not necessarily need C-section unless other factors are present

Bacterial Vaginosis is associated with maternal and newborn complications:

-Multiple partners -Douching -Absence of vaginal lactobacilli -Preterm labor, PROM -PP endometritis -PID -Chorioamnionitis

location epidural

-Needle inserted usually 3-4th lumbar vertebrae, thread catheter into epidural space -will allow her to participate better; little leg function -will get a severe H/A with this

fetal complications of Herpes Simplex Virus

-Neurologic impairment or death -Cannot breast feed

Prevention/Behavior Modification for HIV

-No sex until marriage; then remain faithful -Monogamy -Reduce number of sexual contacts -Barrier Contraceptives: condoms -Link between drugs and alcohol and misuse of barriers and contraceptives - lead to contractive of STIs

Early latent and late latent stages of syphilis s/s

-No symptoms, but still infectious -Serology positive (VDRL) -Can last up to 20 years -Still infectious

management of Precipitate/Precipitous Labor

-Vag. delivery if adequate pelvis -Tocolytic Medications to slow labor

Anemias

- 1:4 Pregnancies iron-deficiency anemia - d/t inadequate intake of iron: poor nutrition, hemolysis, pica, multiple gest., blood loss, close pregnancies - don't fully recover

Poverty

* 1 in 8 women, 16 million women living in poverty in USA (2016). * Deficiencies: Literacy, education, skills, employment opportunities * Malnutrition: Iron deficiency anemia due to irregular menses * Still paid less than men for comparable work; median salary is 80% of men (2017)

incidence of preterm labor

- 1:8 - Increased with pre-existing medical conditions OB conditions - previous preterm labor/delivery - incompetent cervix

Risk factors for breast cancer

* Age * Family history * Irregular menstrual cycle * Early age for menses * Excess weight * No children * Oral contraceptives * Excessive alcohol * High fat diet * Long term hormone use

Tanners Stages of Breast development

1) papilla elevation only 2) breast buds palpable and areolae enlarge (11 yo) 3) elevation of breast contour; areolae (12 yo) 4) areolae form secondary mound on the breast (13 yo) 5) adult breast contour; areola recesses to breast contour

Five Additional Factors Impacting the Labor Process

1. Passage way (birth canal) 2. Passenger (fetus and placenta) 3. Powers (contraction) 4. Position (maternal) 5. Psychological response

Skene's glands

mucous for urethra opening

Keep in mind that "natural" does not necessarily mean "safe."

Seek medical care when ill. • Always inform the health care provider if you are taking herbs or other therapies. • Be sure that any product package contains a list of all ingredients and amounts of each. • Be aware that frequent or continual use of large doses of a CAM preparation is not advisable, and harm may result if therapies are mixed (e.g., vitamin E, garlic, and aspirin all have anticoagulant properties). • Research CAM through resources such as books, websites, and articles

incidence of Multiple Gestation

n12:1000 in US (doubled since 1991) - ↑ in Black women, ↓ in Asian

Male factors of infertility

Semen analysis - most important for indicator for male fertility - Examine within 1-2 hrs. of specimen collection: Adequate #, healthy and mature, able to penetrate egg (motility, shape) - non-invasive -Always go non-invasive to invasive -Ex. Riding on bike for long time - heat on scrotum decreases sperm count Physical exam - Appropriate sexual development - Rule out abnormalities and Rule out prostrate problems

diagnosis of placental abruption

nUS, lab (CBC, PT/aPTT, Kleihauer-Betke test- detects fetal RBC in maternal circulation), nonstress test, biophysical profile

promote nutriton: Enteral (stomach)

· NG tube, gavage, oral (bottle/formula or breast milk)

Total bilirubin

indirect and direct bilirubin - Need to see a total bilirubin value -include conjugated and unconjugated - Use it on the bilirubin graph and graph based on how old they are · Based on these results will tell us what to do Big deal - Kernicterus = permanent brain damage (bilirubin encephalopathy)

Multigravida

multiple pregnancy

What happens if a women is not treated for vulvovaginal candidiasis during pregnancy?

newborn= thrush - white plaque looking covering inside their cheeks - cannot be wipped away- breast milk and formula can be

Primary method of Newborn heat production

non-shivering thermogenesis

Who is at risk for TB

poverty, malnutrition, HIV, immigrants, elderly

diagnosis of Gonorrhea

screen all preg. Women -First prenatal visit -36 weeks -Check for Chlamydia too (common coinfection)

Lochia rubra

(1- 3-4 days): deep red mixture of mucus, tissue debris, and blood

Granny midwives

* Handled most of the birthing process for most women * Trained as apprentice to experienced midwife * All were home births * Men not present * Doctors called only for difficult deliveries

Goals of Healthy People 2020

* Increase Quality/Number years of life * Eliminate health disparities among Americans

s/s of Intrauterine Fetal Demise

absence of movement, no FHR, confirm US, induce labor

resolution of Gestational Hypertension

delivery

Breast Milk Jaundice

specific type of jaundice that shows after a few weeks

Factors that influence FHR reading

-VS -position -labor phase -procedures -maternal/fetal disease -drugs

diagnosis of Thalassemia

CBC, Bone marrow exam, iron studies, peripheral blood smear

Ectoparasitic infections

Pediculosis pubis Scabies

Diagnosis of Hep A

serology: IGM antibody to HAV

a

without, none or lack of

polycythemia Postterm newborn

- Hypoxia-incr. RBC product., sluggish perfusion, hyperbilirub.

nursing mangement for preterm labor

- Administer tocolytic therapy, Educate patient, and provide psychological support

Educate about Breast feeding

* Decrease infant infections * Boost Immunities * Less Expensive

Combined Spinal-Epidural (CSE)

- "Walking Epidural" - Inject opiod without local anesthetic into subarachnoid space - Rapid onset:3-5 min lasts up to hrs - Motor function is active - Still feel fatigue, sedation - = most don't encourage woman to walk d/t fear of injury

Lochia serosa

- (3 - 10 days postpartum): pink to brown in color; contains leukocytes, decidual tissue, red blood cells and serous fluid

fetal effects of Varicella-Zoster (VZV)(Chickenpox)

- 1stΔ- limb hypoplasia, cutaneous scars, cataracts, microcephalic, IUGR in 2 -3% if active, mental retardation, death limited in crossing placenta - Transmitted through placenta, ascending infection, or direct contact with lesions

Anencephaly

- Absent cranial vault - absent or small cerebral hemisphere - No brain tissue above brain stem - Stillborn or die soon after birth

Low transverse C-S incision

- Kerr limited in size d/t: - uterine artery - ↓ rupture - ↓ blood loss and easiest to repair - most commonly used

Gestational Age Classifications

- Preterm <37 weeks - Term 38-42 weeks - Postterm after 42 weeks - Postmature after 42 weeks/placenta aging

Hematopoietic System in newborn

- RBC- large in size, shorter life span than adult RBC's, gradual increase - Hgb- initially decreases (d/t neonatal red cell mass-physiologic anemia of infancy) - WBC- increases (leukocytosis) result of birth trauma - Platelets: same as adults - Values affected by site of sample (capillary blood has higher H/H than venous blood), placental transfusion (delayed cord clamping), and gest. Age (increased age has higher # red blood cells and hgb)

predisposing factors of UC prolapse

- ROM (increased with hydramnios) - unengaged presenting part - preemie or SGA - breech (increased in footling) - transverse lie

Why does the heart switch from fetal to adult circulation at birth?

- The transformation is triggered by o Increased pulmonary pressure o Cutting off of umbilical cord

diagnosis of Oligohydramnios

- US

diagnosis of UC prolapse

- a cord visually seen or palpated on SVE - FHR - bradycardia or variable decelerations

Primary Amenorrhea

- absence of menses by 14: absence of growth and development of secondary sexual characteristics or - absence of menses by 16: normal development of secondary sexual characteristics - Treatment: Correct underlying disorder and/or Estrogen replacement therapy to stimulate development of secondary sexual characteristics

Ascites

- accumulation of protein-containing (ascitic) fluid within the abdomen

Pushing

- active pushing - regains control - open glottis pushing - pushing during exhaling - closed glottis - holding breath may cause valsalvar maneuver

Level III ultrasound/Fetal Scan

- after 18 weeks • High frequency sound waves to visualized the fetus • Enables early evaluation of structural changes

ischial tuberosity

- measures transverse diameter of pelvic outlet - want 10.5cm or greater

BP PP

- usually same, may have slight incr. for one week - If elev. BP and H/A consider Preeclampsia - Decr. BP= orthostatic Hypotension, hypotension, hemorrhage, or infection

Fetal alcohol syndrome

-Alcohol related birth defects: no safe amt. -Small head, small palpebral eyelid fissures, thin upper lip, low wt, short length, mental retardation, poor suck, poor feed

treatment of GBS

-Ampicillin 4 hours before delivery -Clindamycin if penicillin allergy

Female Partner Abuse/Intimate Partner Violence

-An actual or threatened physical or sexual violence, or psychological/emotional abuse -It includes threatened physical or sexual violence when the threat is used to control a person's actions

Luteinizing Hormone: LH

-Anterior Pituitary secretes -Final maturation of follicles -Helps rupture the follicle -Stimulates follicle to produce estrogen

methadone effects on newborn

-Benefit vs. risk: used for heroin addicts -LBW, >SIDS, withdrawal symptoms

What MUST the nurse do If delivery is imminent:

-Delivery table set up -Warm bed, O2 and suction for baby! -safety first - *Everything else can be done after!

treatment of chlamydia

-Doxycycline or azithromycin -Combo drugs: Ceftriaxone and above meds. (rx: Gonnorhea and Chlamyd.= coinfection) -Screen high risk clients

maternal risks of Post Term/Prolonged Labor/Birth

-Dystocia of labor -Birth trauma -Postpartum hemorrhage -Potential infection

Reproductive healthcare practices: medication and drug use

-Folic Acid 400 mcg/day - prevents NTD -Includes herbal supplements, are not FDA approved, anticoagulants can be dangerous - may be taking ibuprofen for cramps, etc.

Physical changes during pregnancy: renal/urinary

-Kidneys work harder, enlarge -More blood flow to kidneys=Increase GFR=increase urine flow/volume -Ureters elongate and widen

methamphetamines effects on newborn

-LBW, preterm, symptoms of withdrawal -Agitated, jittery, poor wt. gain, poor sleep, high pitch cry, resp. distress -Limited studies

Reproductive healthcare practices: Nutrition

-Lactose intolerant - how will patient get Calcium - education -Folic acid - via foods or supplements - excess soda - not a healthy diet to have while pregnant, need to discuss alternate options - do they eat their burgers raw? Can contain bacteria and damaging to fetus growing

causes of newborns overheating

-Large body surface area -Limited insulation -Limited sweating ability -Near a real sunny window Immature CNS (hypothalamus) - Complex neg. feedback system - difficult to balance temp.

Teritary/late stage of syphilis s/s

-Life threatening heart disease -Neuro disease: destroys heart, eyes, brain, skin, CNS

fetal risks of Post Term/Prolonged Labor/Birth

-Macrosomia -Shoulder dystocia and brachial plexus injuries -Cephalopelvic disproportion -Increased mortality

Corpus

-Main body of the uterus, muscular -Holds fetus Endometrium changes d/t hormones/cycle: -Thickest for embryo implantation -Thinnest after menses (shed)

treatment of RDS

-Mechanical Vent, CPAP, surfactant replacement -supportive care until more surfactant produced

S/S of Chlamydia

-Mucopurulent discharge -Urethritis - common in males that show symptoms -Endometritis -Bartholinitis - one or both of the two Bartholin's glands (behind labia) -Salpingitis - inflammation of fallopian tubes -Dysfunctional uterine bleeding -PID (PIDC - MD, U, EBS, UB)

Transmission of Genital Herpes Simplex (HSV)

-Mucous membranes, skin breakdown -Direct contact when shedding virus (may not know) -Most have not been diagnosed/unaware Risk 30-50% for neonatal infection with primary outbreak -Neonatal herpes simplex: ↑ Morbidity and Mortality

Reading/Interpretation of FHR

-Normal pattern (no intervention needed) OR Indeterminate/unclear/monitor OR Abnormal/must act (correct or deliver) -General nursing assessments during each uterine contraction: there is a transient temporary ↓in maternal blood flow through the placenta -assessment and interpretation of FHR patterns is a major nursing responsibility, it involves evaluation of both baseline rate & periodic changes that appear in response to uterine contractions - legal liability

Basics of genetics

-Nucleus in cell contains chromosomes -22 chromosome pairs are autosomes -1 pair sex chromosomes -Chromosomes contain genes -Each gene has segment of DNA: Specific set of instructions for making proteins needed by body cells to function properly

- Oxygen therapy

-O2 sat range, amt., length, varies by hosp. -Can vary depends on hospital

Potential Problems with the Passenger

-Occiput posterior position -Face/Brow presentation -Breech presentation -Shoulder Dystocia - know suprapubic pressure in book; want to get push the arm down to get around that -Multifetal pregnancy -Excessive size (macrosomia) as it relates to cephalopelvic disproportion (CPD) - Structural anomalies

s/s/ of Post Term/Prolonged Labor/Birth

-Oligohydramnios - placental insufficiency (isn't supposed to work past 41-42 weeks) -Meconium leading to RDS -LGA -Postmature fetus

Vulvovaginal Candidiasis

-One of the most common causes -"yeast", "monilia", "fungal infection" -Not STI because candida is a normal constituent in vagina, environmental changes causes problem -Common in pregnant women and women with diabetes - more at risk

polyploidy

-One or more added sets of chromosomes -Early abortion, incompatible with life

Predisposing factors for Vulvovaginal Candidiasis

-Pregnancy -OC with high estrogen content -Broad spectrum antibiotics -Diabetes Mellitus -HIV infection -Steroid/Immunosuppressive drugs -Tight clothes, restrictive -Chemical irritants/ douching

Key areas of assessment post term preg.

-Pregnancy date to ascertain the most accurate one -Client's understanding of the various fetal well-being tests -Client's stress and anxiety concerning her lateness -Client's coping ability and support network

Preterm vs post-term skin

-Preterm - shiny, thin, see blood vessels under skin -Post-term - dry, peeling, cracking

Examples of financial Abuse

-Prevent victim from getting job -Sabotage current job -Control how money is spent -Fails to contribute financially

Persistent Pulmonary Hypertension in newborn

-Previously called persistent fetal circulation -Pulm htn causes shunting from right to left (thru ductus areteriosus & foramen ovale), bypassing lungs into systemic circulation -Result: hypoxemia

Passageway Problems

-Problems are related to a contraction of one or more of 3 planes of the maternal pelvis (inlet, midpelvis, outlet)- CPD - Contraction in mid pelvis -Soft tissue dystocia

4 phases of Endometrial Cycle

-Proliferative -Secretory -Ischemic -Menstrual

Examples of Emotional/Mental Abuse

-Promise, swear, threaten to hit victim -Force victim to perform degrading acts -Threaten harm on children or friends -Destroy possessions, harm pets -Demeaning remarks -Control victim's life

Preconception Care

-Promote health/well-being before pregnancy -Identify health problems -Lifestyle habits -Social concerns

Ballard Scoring System/Dubowitz

-Range -1 (immaturity) to 5 (post maturity) -Add scores from each category -Physical Maturity (within 2 hrs birth) -Neuromuscular Maturity (within 24 hrs) -Total 12 scores, add up scores, -Compare to standards on chart -Determine # weeks gestation

maternal effects of Parvovirus B19 Infection

-Rash face "slapped" and then general maculopapular rash, fever, malaise, arthralgia

Stimulation for a high-risk newborn

-Rock, hold, music, massage, sucking = gain wt. faster Careful not to over-stimulate -Noise, lights, procedures, alarms, handling -Use more oxygen-stress infant -Use of caffeine -Will cluster the care so they can sleep and grow

Gonorrhea

-Severe bacterial infection -Becoming more resistant to antibiotics -70% asymptomatic -Transmitted sexually (s/s: discahrge, dysruia, cervicitis, ag. beed,PID, sore throat, rectal infection, perihepatitis (PIDC - DD, VB, ST, RI, P)

Transmission HIV

-Sexual contact -Shared needles -Mother to fetus -Blood products

Contraction stress test (oxytocin challenge)

-Suspect placental insufficiency -Cause 3 uterine contractions in 10 minutes; want to see NO FHR decelerations -Monitor fetal response: r/o intolerance to labor -Oxytocin infusion induced or nipple stimulation, after 37 wks -Complications: could start contractions that don't stop Results are charted as Negative vs. Positive: -Negative= Good results; no late decelerations noted with a minimum of 3 contractions in 10 minutes -Positive= Bad results; late FHR decelerations were seen with 50% or more of the contractions during the 10 minutes

Cervical channel mucous

-Thick before ovulation -Thins at ovulation to help sperm swim upward for fertilization -Stores live sperm 2-3 days ( therefore, intercourse 1-2 days prior to ovulation, can lead to pregnancy)

Prolonged Decelerations

-Transitory decrease in FHR -At least 15 bpm below baseline, lasting longer than 2 minutes but less than 10 minutes before returning to baseline -Similar treatment as with late decelerations

Physical changes during pregnancy: respiratory

-Uterus pushes diaphragm upwards, decreases space for lungs = difficulty taking a deep breath -Diaphragmatic excursion increases=tidal volume increases -Faster and deeper breathing -Diaphragm vs. abdominal - will begin to use diaphragm more due to uterus being there - As baby begins to grow, and lightening happens = moving away from lungs and can take deep breaths again -More vascular (estrogen) =nasal stuffiness, nosebleeds, change in voice tone

VEAL CHOP

-V - Variable deceleration = C- Cord Compression -E -Early deceleration = H- Head Compression -A - Acceleration = O- OK (good) -L - Late Deceleration = P- Placenta Problem

Abuse: Characteristics

-Violence is a learned behavior that, without intervention, is self-perpetuating -A cycle of violence exists in an abusive relationship -Goes for a low intensity to high intensity Abusers use whatever it takes to control a situation, including: Emotional/mental abuse, Physical abuse, Sexual abuse, Financial abuse

Secondary Powers

-abdominal muscles -pelvic floor -cervical changes -myometrial changes

Type 1 diabetes

-absolute insulin deficiency -autoimmune, 10% of DM

if a fetus is in chronic stress in utero (ex: Prolonged ROM, IUGR), what are there chances if getting RDS?

-actually produce more surfactant- less chance RDS due to them dealing with it longer

Initial infection of HIV

-acute, lasts 3 weeks -Onset 2-6 weeks after exposure -Flu like symptoms: fever, rash, myalgia, pharyngitis -Takes 3-12 months before seroconversion -Infectious during this time

incidence of pregnant women with CVD

1%

Blood loss in C-section

1000 mL

fetal HR

110-160

Trauma

2nd cause of pp hemorrhage - vaginal, cervical or perineal lacerations or hematomas

how does blood flow change for a pregnant women?

50% more blood flow in body = high risk for clot * Higher risk for DVTs = emboli

Blood loss in vaginal delivery

500 ml

Reflexology

A unique method of applying pressure with thumb and index fingers to the hands and feet, and it has demonstrated health benefits.

Criteria for Establishing a PMS Diagnosis

ACDHO

Dystocia

Abnormal or difficult labor - 8-11% of all labors - "failure to progress" - Won't know if Dystocia is present unless adequate "trial of labor"

Healthcare Cost Containment

Access to care Preventive care focus Continuum of care emphasis

Rape

Act of violence, penile penetration, without consent

treatment of Herpes Simplex Virus

Acyclovir (antiviral) if known , culture positive

HTN is more common in what race?

African Americans

Stages of the Transition to Parenthood (Mercer, 1985)

Anticipatory stage- allows parents to seek out other role models Formal stage- allows parents to become acquainted with the infant and begin to take cues from the infant Informal stage- encourages parents to respond to the infant as a unique individual Personal stage- attained when the parents feel a sense of harmony in their roles

mastitis PP

Breast infection (interstitial tissue) within 2-3 weeks pp BF

___ is the leading cause of death in women

CVD

Examples of psychosocial risks in pregnancy

Caffeine, maternal obesity, inadequate support system, situational crisis, emotional distress, unsafe cultural practices

Increased Variability

Causes: -associated with variables that are mod to severe as cardiovascular readjustment -early, mild hypoxia -fetal stimulation -uterine contractions -uterine palpation -Fetal movement, awake state *significance*- may be early hypoxia

lInfections characterized by cervicitis

Chlamydia Gonorrhea

Conduction in newborn

Direct contact with cooler environments

Treatments/Options for infertility

Drugs: - Clomid (non-steroid, induces ovulation) - release a lot of eggs, common for people that had a lot of babies at once (Can store the eggs and then when want to become pregnant using IVF) - Pegonal (direct stimulation/induce ovulation) - Surgery - Repair damage, blocked tubes - Timed intercourse (Based on ovulation) - Egg and/or Sperm donation - Retrieved from donor then inseminated Gestational carrier - - - Surrogate: lab fertilized embryo implanted in another woman - Artificial Insemination - Insert semen sample into cervical os or intrauterine cavity In vitro fertilization - Oocytes fertilized in lab then inserted into uterus - Use needle aspiration to retrieve mature ovum Gamete Intrafallopian transfer (GIFT) - Oocytes and sperm combined and immediately placed in fallopian tube - Fertilization can occur naturally; uses laparascope and general anesthesia Intracytoplasmic sperm injection - One sperm injected into cytoplasm of oocyte to fertilize it - Sperm retrieved by needle aspiration into epididymis - Donor Oocytes or Donor Sperm- retrieved, inseminated, transferred via IVF - Preimplantation Genetic Diagnosis (PGD)- testing of embryos created through IVF; parent(s) known genetic abnormality

Maintain thermal regulation

Dry, warmer, prevent heat loss

CDC (2015) Statistics childbearing complications

Embolism 20% Hemorrhage, 17% Preeclampsia and Eclampsia 16% Infection 13% Cardiomyopathy 8%

Chadwick's sign

Estrogen causes the cervix to become congested with blood (hyperemic), resulting in a bluish color that extends to include the vagina

· Cranial Nerve Trauma (forceps)

Facial asymmetry, one side effected, self-limiting

Risk factors for placental abruption

HTN, drug use, smoking, age, multiples, poor nutrition, trauma

S/S of engorgement

Hard, tender to touch, painful

Normal Newborn Blood Values

Hemoglobin - 16-18 g/dL Hematocrit - 46-68% Platelets -150,000-350,000/µL RBC - 4.5-7.0(1,000,000/µL) WBC - 10-30,000/mm3

Iron-Deficiency Anemia

Hgb < 11g/dl, Hct <35%

Cold and Heat Applications PP

Ice pack/pad 1st24 hrs - Reduce edema - Prevent hematomas - Decrease pain - Promote healing - Apply for 20 min, remove for 10min. - Pads leave in place, change to room temp. quicker - Warm pack/pad after 24 hrs Peribottle - Warm water - Cleanses perineal area after voiding, defecating, or pad changes - Direct water from front to back Sitz Baths after 24 hrs - ramin sitting on the basin for 15-20 minutes - Helps vascular circulation and healing - Use peribottle to cleanse before sitz bath - Emergency Call light available Stay in room if first time OOB or any c/o dizziness

How do you know if you have removed all of the moles in a molar pregnancy?

If remove the growth, don't know if you got it all - don't know if it metastases and went somewhere else - Know by watching these levels, will go all the way back to normal and stay there to show we have removed it all - Want to make sure she doesn't get pregnant for at least a year - If she does, won't know if it's the pregnancy or more growth

low birth weight (LBW)

Infant weighing < 2500 grams or 5.5 pounds

Diangosis of HPV

Inspection: - fleshy papules, -granular, warty appearance - may be large/clusters May test to determine strain (thin prep test)

WHEN ANY FHR PATTERN IS "MUST ACT" GO TO what NEXT STEP

Intrauterine Resuscitation

Tobacco/Nicotine effects on newborn

LBW, SGA, preterm, >SIDS, chronic resp. illness

Hypothermia SGA newborn

Less muscle mass, brown fat (lack non-shiver thermogenesis), subq fat, - Depleted glycogen & subq fat stores - Metabolic stress (acidosis, hypoglycemia) - Temp <36.4C - Prevent cold stress (4 ways to lose heat)

Diagnosis of trichomoniasis

Microscopic identification

treatment of Hydramnios

Monitor, decrease fld: amnio, AROM

Premenstrual Dysphoric Disorder (PMDD)

More severe form of PMS Interferes with work, school, social activites, and relationship with others Symptoms: depression, anxiety, tension, persistent anger or irritability and H/A, joint and muscle pain, lack of energy, bloating, breast tenderness, sleep difficulties, appetite changes, - Need at least 5 to be diagnosed

newborn risks for chlamydia

Neonatal Conjunctivitis or Pneumonitis Stillborn Preterm low birth weight

Fundal height measure too small due to what possibilities?

Not eating enough, not enough fluid (Oligohydramnios), SGA, due date incorrect

Post Term/Prolonged Labor/Birth

Past the end of the 42nd week

Treatment of of Bacterial Vaginosis

Oral metronidazole or clindamycin cream; no evidence supporting male partner treatment

What 2 cycles occur simultaneously?

Ovarian and Endometrial

Community accommodations

Parking for pregnant women

Diagnosis of Genital Herpes Simplex

Signs/Symptoms viral culture

affects on Newborn with mother's with Trichomoniasis

Premature rupture membranes preterm birth low birth weight

Risks of mechanical Method of Induction/Augmentation

ROM, bleeding, infection, placenta disruption

Hep A (HAV)

Spread via GI tract -Polluted water, uncooked shellfish in contaminated water -Carrier with poor hand hygiene: food -Oral/anal sexual contact -Easily spread to others in the same household - self-limiting, doesn't result in chronic infection

Three Stages Role Development Process for Fathers/Partners

Stage 1 (expectations):preconceptions about what home life will be like with a newborn Stage two (reality):occurs when father or partner realizes that their expectations in phase one are not realistic - feelings change: elation, sadness, ambivalence, jealousy, frustration - feel unprepared to care for infant Stage three (transition to mastery):the father or partner makes a conscious decision to take control and be at the center of his newborn's life regardless of his preparedness

treatment of Meconium Aspiration Syndrome

Suction before first breath!, visualize cords, antibiotics Supportive: O2, cluster care, VS, antibiotics, blood gases, prevent hypothermia

Aromatherapy

The therapeutic use of aromatic materials (essential oils and others) for claim for improving psychological or physical well-being - pseudoscience

Conduction

Transfer of heat from one surface to another (direct contact) Newborn and... - Scale - paper on - Blankets - warm - Hands - warm - Circ board - booties left on when circ performing - Warm stethoscope before placing

What confirms a molar pregnancy?

Transvaginal Ultrasound

What anticoagulant is contraindicated in pregnancy?

Warfarin/Coumadin: crosses placenta; teratogenic: Class X drug

Multipara

Women who has had more than 1 delivery at 20 weeks or greater

WIC

Women, Infants, and Children - for lower income population - Help provide needs for the infant and counseling Assist with: - Food - Nutrition counseling - Access to health services

Hormonal prevention of pregnancy

Work by suppressing ovulation by adding estrogen and progesterone to a woman's body mimicking pregnancy

Determine due date: Using Nagele's Rule

Write down date bleeding started, subtract 3 months from date, add 7 days, add a year, look at year - does it make sense? may not need to add a year (depends on LMP) ex. Use the first day of LMP: 11/21/16 -Subtract 3 months: 8/21/16 -Add 7 days: 8/28/16 -Correct year by adding 1 year, if necessary: 8/28/17 = EDB (estimated date of birth) or EDD (estimated date of delivery) or EDC (expected date of confinement)

Fetoscope

a special stethoscope for hearing the fetal heartbeat through the mother's abdomen - hand held, head gear

Acupressure

a traditional Chinese touch therapy involving finger pressure applied to specific areas of the body to restore the flow of qi

Secondary Amenorrhea

absence of menses for 3 cycles or 6 months in women who previously menstruated regularly

s/s of NEC in newborn

abd. distension, tender, bile emesis, intolerance to feeding, lethargy, resp. distress, bloody stools

Labor complications of Multiple fetuses

abnormal presentation, uterine dysfunction, prolapsed cords & ↑ hemorrhage

Menorrhagia

abnormally long, heavy periods

Nitrocide

anesthetics that knock them out during L/D and * Would pull on women and force baby out when they have no control

treatment of neonatal sepsis

antibiotics right away, d/c if cultures negative; supportive therapy: circulatory, respiratory, nutritional, and developmental

cause of Sickle Cell Anemia

autosomal recessive disorder

measuring head circumference of newborn

average 32-38 cm (13-15") large ¼ of total body size (2cm >chest)

application of heat and cold

back, muscles, perineum, forehead, pain, edema, muscle spasms, reduces inflammation

Oligomenorrhea

bleeding occurs at intervals > 35 days

Menometrorrhagia

bleeding occurs at irregular intervals with heavy flow lasting > 7 days

Ecchymosis

bleeding under the skin, bruise (possibly due to suctioning from vacuum extractor during labor)

Late Preterm

born between 34-36 6/7 weeks

Full Term

born between 38-41 6/7 weeks

Ductus venosus

connects the umbilical vein to the inferior vena cava

Acetone in PP urine denotes?

denotes dehydration after prolonged labor, > bladder capacity during pregnancy due to < muscle tone

Postpartum Psychosis

depression and add on the mother wants to harm the baby or herself

Lightening

dropping of fetus into pelvic cavity which will result in not a true measurement

chronic URI's in pregnant women

effect fetal growth, well-being - Ex. COPD, asthma, emphysema - if not treated well and not getting enough O2 = fetal not getting O2 causes compromises = not growing well, abnormal, eventually become hypoxic and die in utero - Make sure they understand and use the medications that physician has prescribed - Important to maintain O2 saturation to avoid hypoxia of fetus.

Endoderm

forms respiratory system, liver, pancreas, and digestive system

Mesoderm

forms skeletal, urinary, circulatory, and reproductive organs

s/s of TB

general malaise, fatigue, loss of appetite, wt loss, fever, night sweats, chronic cough & mucopurulent sputum - May be asymptomatic- organism can lie dormant

Human Genome Project

goal to map, sequence, and determine function of all human genes - to prevent, diagnose, and treat genetic diseases

primigravida

gravida I first pregnancy ex. Quadruplets during first pregnancy - still gravida 1

secundigravida

gravida II second pregnancy

s/s of Septic Pelvic Thrombophlebitis

groin pain, fever, chills - ^pulse, decrease B/P

pelvic shapes adequate for vag. delivery

gynecoid and anthropoid

Assessment of Amenorrhea

health history: menstrual history, past illnesses, hospitalizations, surgeries, OB history, drugs, lifestyle changes, present illness) physical exam: nutritional status, general health, H/W, BMI, breast examination (stage), etc. - hypothermia, bradycardia, hypotension, reduced SUBQ fat = anorexia - presence or absence of axillary or pubic hair = adrenal and ovarian hypo-secretion or delayed puberty - Tanners Stages of Breast development

Brethine treatment of preterm labor

help prevent and slow contractions of the uterus. It may help delay birth for several hours or days. Nursing considerations - Off the label use - oral form of the drug should never be used to treat preterm labor because it doesn't work and the side effects come with too high of a risk. It also warns that injectable terbutaline should only be used in urgent situations, and for no longer than 48 to 72 hours. Prolonged use of the medication greatly increases the risk for life-threatening heart problems in the mother.

Methadone

help prevent severe withdrawal from drugs, but also has withdrawal effects

Dopplers

high frequency sound waves detect fetal heart movement

Labia Minora

highly vascular, highly sensitive, abundant nerves, hairless, lubricate the vulva

risk factors for Neonatal Sepsis

immature immune system (IgM, IgA, and T lymphocytes), decreased gastric acid (needed to reduce organisms), prolonged ROM, UTI, preterm labor, prolonged/difficult labor, maternal infections, maternal fever, colonization with group B streptococci, LBW, prematurity, meconium staining, need for resuscitation, birth asphyxia, improper handwashing

Sexual violence

includes IPV, human trafficking, incest, FGC, forced prostitution, bondage, exploitation, neglect, infanticide, and sexual assault

Bilirubin unconjugated

indirect bilirubin -Fat soluble; binds to albumin, can't be excreted by kidneys - tell us how much needs to be conjugated

Mastitis s/s

inflammation of breasts - sore, pain, red, fever, edema - Red streek or bloatchy red area - depends on what part gets inflamed or infected - Causes - Blocked milk duct - Cracked nipple-bacteria

indocin treatment of preterm labor

inhibits prostaglandins, which stimulate contractions; inhibits uterine activity to arrest preterm labor Nursing considerations: - Continuous assess VS, uterine activity and FHR; administer oral food to reduce GI upset - Do not give with women of peptic ulcer disease; schedule ultrasound to assess amniotic fluid volume and function of ductus arteriosus before initiating therapy; monitor for s/s of maternal hemorrhage - Be alert for maternal adverse effects - N/V, heartburn, rah, prolonged bleeding time, oligohydramnios, HTN - Monitor for neonatal adverse effects - constriction of ductus arteriosus, Premature ductus closure, necrotizing enterocolitis, oligohydramnios, and pulmonary HTN

Episiotomy assessment PP

intact, healing, infected

Guided imagery

intentional visualization of images that are calming, relaxing, or beneficial in other ways - connect to inner resource to improve health

Evidence Based Nursing Care

involves the use of research to establish a plan of care and to implement that care · Use best current evidence when making decisions · Leads to decrease in variation of care, increase in quality · Necessity for care today · ANA, NLN, AWHONN: Evidence Based Guidelines for Practice - Safest and most effective delivery of family-centered care

Cultural skills

learning how to do a competent cultural assessment - Individual based: intracultural variation - Values, Beliefs, Practices - Not based on textbook - Context is important r/t behavior

Tonic Neck/Fencing

lie on back, turn head one way (arm on that side extends straight away, opposite arm is flexed) (disappear in 3-4 months)

s/s of Periventricular-Intraventricular hemorrhage (IVH) in newborn

low hgb and low Hct, pale, Resp. distress, seizure, shock, tense ant. Fontanelle (bulging), lethargy, weak suck, high pitch cry, hypotonia, bradycardia, hypotension, increase head circumference, "waxy" skin color

S/S of Thalassemia

low hgb, hypochromic & microcytic anemia

Auscultate FHR during active phase

low risk - q. 30 min high risk -q. 15 min

Auscultate FHR during 2nd stage of labor

low risk - q.15 min high risk - q. 5 min

Abnormal Uterine Bleeding may overlap with what other uterine bleeding disorders?

menorrhagia, oligomenorrhea, metrorrhagia, menometrorrhagia, polymenorrhea

Meno

menstrual-related

treatment of Oligohydramnios

monitor, amnio infusion if needed

Fetal monitoring

monitors the fetal heart rate and any uterine activity during the pregnancy and labor, before delivery

treatment of Cytomegalovirus

none - Gavciclovir -experimental

Impact of Menopause on Body Systems

o Brain:hot flashes, sleep, mood, and memory problems o Cardiovascular:lower levels of HDL; increased risk of CVD o Skeletal: bone density loss; increased risk of osteoporosis o Breasts:duct and gland tissue replaced by fat o Genitourinary: vaginal dryness, stress incontinence, cystitis o Gastrointestinal: less Ca+ absorbed in GI tract leads to increased fractures o Integumentary:skin dry, thin; collagen decreases Body shape:more abdominal fat; waist size swells

- After Respirations are established in newborn

o Shallow & irregular o Average = 30-60 breaths/min (40-60 some texts) o Short periods apnea (<15 sec) o Rate changes with activity - Periodic Breathing

Blinking reflex

object is brought close to the eye

Metrorrhagia

obleeding between menstrual periods

types of UC prolapse

occult: - hidden prolapsed - in front of presenting part complete prolapse - seen outside vagina

Childbirth Classes

offer pregnant women and their partners a series of educational classes on childbirth preparation. Women attend them during their last trimester of pregnancy. Some classes are free and some have a fee

Simian crease

one crease s/s down syndrome

dilation

openness expressed in cms or fingers 1-10 cms, other terms: fingertip, complete

predisposing factors of Amniotic Fluid Embolism

outlet in the amnion & chorion, opened maternal veins & a pressure gradient strong enough to force fluid into maternal circulation

macrosomia

over 4000 gms (>8.1 lbs) (Normal: 2500 - 4000 gms)

Three groups of jaundice based on mechanism of accumulation of bilirubin:

overproduction decreased conjugation impaired excretion

staff support of Intrauterine Fetal Demise

own grief and how to deal with grieving family

Cultural encounter

participating in cross-cultural interactions - Attending services, events - The greater number of encounters the better - Less stereotyping

Labs/diagnostics for endometrosis

pelvic or transvaginal ultrasound, laparoscopy, tissue biopsy

Causes of secondary Dysmenorrhea

pelvic or uterine pathology - endometriosis (ectopic implantationof endometrial tissue to other parts of the pelvis), adenomyosis (ingrowth of endometrium into the uterine musculature), fibroids, pelvic infection, intrauterine system, cervical stenosis, congenital uterine or vaginal abnormalities

risk of Persistent Pulmonary Hypertension in newborn

perinatal asphyxia, RDS, mec, sepsis, pneum., hypoglycemic, hypothermia, heart defects

areola

pigmented area, 9 lobes (range 4-18) containing glands (alveolar), and a duct (lactiferous), leads to nipple opening

Vacuum marks

pink, circular suction mark

Newborns vulnerable for neonatal sepsis

poor skin integrity, premies, low birth wt., trauma, invasive procedures, numerous caregivers, environment, unable to have inflammatory response yet

partial placental abruption

portion of placenta

Risks associated with macrosomia

postpartum hemorrhage, soft tissue laceration, fetal injuries, asphyxia

fetal risks of HIV

prematurity, IUGR, low birth weight, and infection

risks for Periventricular-Intraventricular hemorrhage (IVH) in newborn

preterm <32 wks, asphyxia, acidosis, hypoxia, suctioning, handling

Newborn risks due to HIV

preterm birth, low birth weight, HIV + status, intrauterine fetal death, miscarriage

Risks associated with Hepatitis B Virus

preterm birth, low birth weight, neonatal death

VBAC is Contraindicated in?

prior classical uterine scar, prior transfundal uterine surgery, contracted pelvis - Ok if low-transverse uterine scar and not the classical (Up and down); Trial of Labor

Which CNS problems should you watch a preterm for?

problems regulating temp., prevent cold stress

Case Management

process of assessment, planning, application, coordination, follow-up, and evaluation of options and services required to meet an individual's health needs through communication and available resources to promote quality of cost-effective results · Used to meet client's physical, developmental, educational, spiritual, and psychosocial needs · Interdisciplinary Plan of Care; collaborative care

Therapeutic touch and massage

promote relaxation and pain relief - therapeutic touch: energy, learned and practiced -massage releases endorphins -effleurage: light stroking

Lamaze (psychoprophylactic) method

promotes the use of specific breathing and relaxation techniques o Paced breathing - decrease stress and decrease pain o Slow-paced breathing: relaxation; ½ the normal breathing o Modified breathing: increased work or stress during labor to increase alertness or focus attention - slow breathing is no longer effective o Patterned- paced breathing: rhythmic pattern w/ emphasis on exhalation

Peripartum & pp cardiomyopathy

rare not associated with underlying heart disease, develops at end of pregnancy or 1st several months pp - symptoms - CHF, dyspnea, edema, weakness, chest pain, & palpitations

Advice for hormones for contraceptive

recommend they get off the pill, have a couple of normal menstrual cycles (3 months) prior to becoming pregnant

premenstrual syndrome (PMS)

recurrent symptoms occurring during the last half of the menstrual cycle and resolving with the onset of menstruation - Exact cause is unknown - thought to be related to the interaction between hormonal events and neurotransmitter function, specifically serotonin

Which Renal problems should you watch a preterm for?

reduced ability to concentrate urine; drug toxicity, fld. retention

causes of AUB

related to hormone distribution - Anovulation: estrogen levels rise; without ovulation, corpus luteum forms and progesterone is not produced which makes the endometrium go into hyperproliferation state, outgrowing its estrogen supply = irregular sloughing of endometrium and excessive bleeding - Ex. Adenomyosis, hormone imbalance, pregnancy, morbid obesity, polyps or cancer, endometriosis, POS, etc.

Three Stages of Lochia

rubra, serosa, alba

Aminioinfusion

run the fluid into this apparatus to help correct cord occlusions (variable decelerations); thick meconium - help run some of it out and get the neck out

Hydrotherapy

shower, whirlpool bath: decreases c-section rates, decreases perineal trauma, shorter 2ndstage of labor, less pain meds

treatment of Production and absorption problem in newborn

shunt - placed to drain he fluid and remove the pressure off of the brain = prevention of hemorrhage

Protracted Disorder

slower cervical dilation during active phase; delayed descent of fetal head during active phase; labor lasts more than 18-24hrs.

massage therapy

soft tissue manipulation by trained therapists for relaxation and healing

Hegar's sign

softening of the lower uterine segment or isthmus - palpate internally

Gagging/Coughing

something irritating is swallowed or a bulb syringe is used for suctioning

Braxton Hicks

spontaneous, irregular, painless contractions; helps with effacement late in pregnancy (Preparing the cervix for true labor)- more common during later in the pregnancy

Mottled

spotted or blotched in coloring

Relieve cord pressure with a UC prolapse

sterile gloved hand hold presenting part off cord, change position, knee-chest, modified sims, trendelenburg, elevate hips (promotes negative pressure and helps get O2 to the fetus), O2, emergency c-section

Striae gravidarum

stretch marks

Genetics

studies individual genes; role in inheritance

Term

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

management of Uterine Rupture

type and cross match and hang blood, IV, foley - I/O, O2, c/s, hysterectomy - ligate and close blood vessels bleeding

Newborn risks if exposed to Gonorrhea

urethritis vaginitis inflammation of sites of fetal monitoring chorioamnionitis preterm birth IUGR Ophthalmia neonatorum-contagious-blindness and sepsis (includes arthritis and menigitis)

Hip dysplasia

use Ortolani Maneuver and Barlow Maneuver to correct

Bradley (partner-coached) method

uses various exercises and slow, controlled abdominal breathing to accomplish relaxation

involuntary contractions

walking stimulate, anxiety or stress ↓

Rooting reflex

when you touch the side of the mouth the infant turns toward it (disappear in 4-6 months)

withdrawal-neonatal abstinence syndrome

withdrawal; most common harmful effect of heroin and other narcotics

Primapara

women who is having her first delivery at 20 weeks or greater

Bottle feeding stools

yellow, green (iron), loose or formed, odor - depends on formula

BF stools

yellow, seedy, stringy, sour smell

Infertility leads to

• Feelings of inadequacy • Guilt • Blame • Pressure from family/friends • Embarrassing • Marital conflict

incidence of Thalassemia

↑in Mediterranean, Asian, Greek, African Americans

prognosis of CVD

Depends on: - functional capacity - likelihood of other complications - quality of care - severity of arrhythmias

Purpose of FHR Monitoring

Detect FHR changes early before they are prolonged/profound

Treatment of Amenorrhea

Primary: correction of underlying disorders and estrogen replacement therapy to stimulate the development of secondary sexual characteristics - Others: drug therapy, surgical resection, or radiation therapy Secondary: Progesterone, oral contraceptives, bromocriptine, nutritional therapy, Gonadotropin releasing hormone, thyroid hormone

Very low birth weight(VLBW)

Infantweighing <1500 grams or 3 lbs, 5 oz

Cardiac Adaptations PP

- During pregnancy: displaced upward and to the left, reverese with involution - Cardiac output *remains high* for the first few days postpartum; *gradually declines* to nonpregnant values *within 3 months of birth* - Blood volume, which increased substantially during pregnancy, drops rapidly following birth and returns to normal within 4 weeks postpartum (also diuresis (lose extra fluid)) - May be sweating at night - Hct levels remain stable and may increase due to loss of plasma - Acute decreased level (not normal) = possible hemorrhage - The increase in cardiac output during pregnancy begins to diminish after birth; this decrease is reflected in *bradycardia (40 to 60 bpm) for the first two 2 weeks* - r/t increased blood flow back to heart and central circulation - Will return to nonpregnant levels in 6-8 weeks

indications for a Cesarean Section

- Dystocia (difficult labor), Macrosomia, CPD, Gestational HTN - maternal disease, active herpes - previous classical uterine scar - fetal distress, prolapsed cord, malpresentation - abruptio/previa

Versions(tried with breech/transverse)

- ECV -External Cephalic version - abd pressure to cause fetus to move -after 36 wks, US, EFM, RhoGAM even if successful fetus may turn again - VS must be stable, NST before, IV terbutaline given - Monitor 30 minutes after - Be ready for C/S if Fetal Distress

management of a Cesarean Section

- EFM - Epidural - Foley #16Fr. indwelling - labs - CBC, RPR, type Rh, U/A, - US, amnio possible for checking lung maturity - Prophylactic antibiotics - Prep - Abd. scrub and drape

Components of Prenatal Care

- Early + Continued Risk Assessment - Health promotion - Medical interventions - Psychosocial interventions - Follow up

Advantages of oral contraceptives

*Regulate and shorten menstrual cycle *Decrease severe cramping and bleeding *Reduce anemia *Reduced ovarian and colorectal cancer risk *Decrease benign breast disease *Reduce risk of endometrial cancer *Improve ance *Minimize perimenopausal symptoms *Decrease incidence of rheumatoid arthritis *Improve PMS symptoms *Protect against loss of bone density

Risk Factors for Jaundice

- *Fetal-maternal blood group incompatibility (Rh or ABO)* - Prematurity - Breast feeding - Drugs (valium, pitocin, pediazole) - Maternal gestational diabetes - Trauma- cephalohematoma (increases hemolysis) - Bruising - Male gender - Polycythemic - Prev. sibling with hyperbilirubinemia - TORCH infections - Asian/Native American ethnicity

Variable Decelerations

- Abrupt, transient, decrease in FHR from baseline - Onset to Nadir is <30 seconds - Drop in FHR is 15 bpm or greater, lasting at least 15 seconds, but less than 2 minutes - 15 by 15 rule - Can occur at times other than UC - not related to contractions - Characterized by a sudden drop in FHR in a V - U or W pattern. - Cause: Umbilical Cord Compression- being squeezed; sometimes around neck, body, should, holding, heads squeezing between spine - *Significance*= Indeterminate/Unclear if min/mod variability - must act if absent variability

Childbearing in 1980's to present

- Access to healthcare: regardless of ability to pay - Change in delivery rooms - C-section rates increase from 5% in 1970's to 32% (2007) 1:3 deliveries today

Breast Milk

- After estrogen/prog. levels drop: - Prolactin stimulates glandular cells to secrete and syntheis milk - Oxytocin acts so milk is ejected from alveoli to nipple (contracts alveoli cells in breast) - Stimulated by sucking=releases milk - 2-3 days after birth - Skin to skin initiates breast-feeding - "breast crawl" (abdomen to chest) - "let down reflex" - tingly sensation in both breasts before or during breast-feeding

Placenta Previa

- Bigger sign of danger - Low lying placenta, over cervical os, bleeds in last two trimesters, 1:400 if first pregnancy, increases in frequency after C-sections. Leads to hemorrhage, abruption, emergency c/s - If attaches too close the baby will blead heavily, will lose O2 rapidly and can start to loss the baby and lead to fetal death - Comes back to prenatal care - unless we see where it attaches during visit will not know - it will attach to the OS o Want to avoid sexual activity, nothing in the vaginal area, and vaginal exams - can rupture the placenta and cause bleeding - Vaginal delivery - safer and lower risk than C/S

Conditions Complicating Pregnancy

- Bleeding during pregnancy - Hyperemesis gravidarum - Gestational hypertension - HELLP syndrome - Gestational diabetes - Blood incompatibility - Hydramnios and oligohydramnios - Multiple gestation - Premature rupture of membranes - Preterm labor

treatment of placental abruption

- Blood and IV fluid replacement - ID and correct DIC (replace coagulation factors through transfusion) - delivery by C/S - VS (may be normal until 40% blood volume lost) - continuous fetal monitoring - Maternal assessments- uterine tenderness, pain, rigidity, LOC, s/s shock - O2, bedrest, sidelying, monitor bleeding, foley, I/O, emotional support, education

Post-Partum Hemorrhage

- Blood loss greater than 500ml vag. delivery - Great than 1000ml blood loss -C-section

APGAR Appearance

- Blue: 0 - Acrocyanotic: 1 - Pink: 2

non-shivering thermogenesis

- Brown fat (highly vascular, adipose tissue) is oxidized in response to cold exposure- mostly found in newborns - Gets brown color from lots of blood vessels and nerve endings - Capable of intense metabolic activity- generate heat! - Brown fat= 2-6% of body wt. - use brown fat which first appears in fetus 26-30 wks gestation & lasts up to 2-5 wks pp, primary source of heat conservation - chemical reaction in brown fat in shoulders and chest breaks down triglycerides into glycerol and fatty acids to produce heat - premies are at even more risk for the cold due to brown fat not being developed as much

Nursing Interventions immediate newborn period: maintain airway patency

- Bulb suction: mouth then nose - M before N - mouth before nose (reason: mouth can hold more fluid after birth, if suction the nose first, going to stimulate the infant to gag or breath everything in (Mouth first doesn't cause as many problems) - aka prevents aspiration for a unexpected gasp - Squeezing first then suction, then squeeze to empty

Management/Nursing of Amniotic Fluid Embolism

- CPR, O2, IV, meds- improve cardiac output, control hemorrhage, steroids, blood transfuse-DIC, VS, - Maintain oxygenation, hemodynamic function, and correct coagulopathy

Mood swings PP

- Can feel fatigued, irritable, worried - may need medical attention - 3 distinct entities: maternal (baby) blues, postpartum depression, psychosis

Rubella (German Measles)

- Cannot be vaccinated while pregnant - Droplet transmitted virus or direct contact w/ contaminated item

GI System Adaptations newborn

- Capacity to swallow, digest, metabolize and absorb food taken; occurs shortly after birth o Can digest simple carbs and protein o Limited ability to digest complex carbs and fats (d/t amylase/lipase levels low) o Result= fatty stools - Development of a mucosal barrier occurs to prevent the penetration of harmful substances o Bacterial colonization in gut is happening o Occurs usually within 24 hrs, but may take several days; needed for Vit. K production (clotting factor not developed yet) - Stomach capacity ranges from 30 to 90 mL, with a variable emptying time of 2 to 4 hours o Immature sphincters = regurgitation o Avoid overfeeding, yes- frequent burping/bubbling - Normal term newborns have wt. loss 5-10% birth weight in first week o Insufficient caloric intake, intracellular water shift, insensible water loss o Needs 110-120 kcal/kg/day for wt. gain - The evolution of a stooling pattern begins with a newborn's first stool (meconium - black tarry stool, "looks like goose poop", smeary tarry - hard to get off )

placenta accreta

- Causes: placenta previa, advanced age, smoking, previous C-sections, unknown? - Placenta attaches too deep into wall of uterus but doesn't penetrate muscle (may cause pp hemorrhage) - Can lead to a hemorrhage

Risks r/t induction

- Cesarean birth - rates have increased - Instrumented delivery - Use of epidural analgesia- increased discomfort - Neonatal intensive care unit admission- prolonged stay

Safety PP

- Check BP before ambulating - Elevate HOB a few minutes before ambulating - Dangle patient - Assist to stand and stay with patient - Frequent questioning: How do you feel? - Stay close with ambulating Sexuality - 3- 6 weeks must be healed, bleeding stopped - Contraception counseling - Some ovulate before menses returns - Possible to become pregnant before first f/u visit - Greater needs for BF moms (+500 cal/day) - Adequate fluids: at least 2500ml daily - Discourage Diets - Easy recipes - Avoid Fast Foods

Nursing care of overheating newborns

- Check isolette or radiant warmer temp - Check infant temp. - Monitor cribs near sunny windows

Cord blood gases

- Checks for fetal acidosis at birth (low ph=acidosis) - after delivery pH, pO2, pCO2 and bicarbonate - umbilical artery blood, clamped 20-30 sec after birth (4 - 8") - heparinized syringes and read within 30 min

Newborn chest Assessment

- Chest measure 1-2 cm smaller than head, barrel shape, xiphoid may protrude (normal) - Breasts - may secret small amount of whitish fluid 2-3 days after birth due to maternal hormones (witches' milk) - Term babies have breast tissue - Supernumerary nipples- familial, extra nipple 5cm below nipple, small, raised, pigmented, no glandular tissue, underneath, typically fade - Barrel shaped, Symmetrical rise/fall, clear breath sounds but fine crackles possible after birth (until fluid clears) - Diminished breath sounds might indicate atelectasis or pneumonia - Listen to heart - S1 and S2 present; murmurs may be present - foramen ovale or PDA (most common) is closing - If persists may indicate heart disease- further investigation is needed

Choriocarcinoma

- Chorionic malignancy from the trophoblast tic tissue - Very virulent!

meconium aspiration SGA newborn

- Clear airway before baby cries - Support ventilation

GI structural anomalies in newborn

- Cleft Lip/Palate - Esophageal Atresia & Tracheoesophageal Fistula - Omphalocele - Gastroschisis -Imperforate anus

Nursing interventions of the woman choosing a contraceptive method/reproductive education

- Client/couple participation in decision making - Client education • Understanding how to use the method of choice • Misconceptions • Breast feeing protects against pregnancy • Pregnancy can be avoided if the male partner pulls out before he ejaculates • Pregnancy cannot occur during menses • Douching after sex will prevent pregnancy • Pregnancy will not happen during the first sexual encounter • Taking birth control pills protects against STIs • The women is too old to get pregnant • If female orgasm is not reached, conception is not likely • Irregular menstruation prevents pregnancy • Mechanism of action; advantages and disadvantages, danger signs to report • Method failure and backup method is always needed

Community Based Health Care Settings: Health Dept. Services

- Clinics: Maternal/Child, Immunizations, Family Planning, STI/STD - Substance Abuse Programs - Jails/Prisons

Nursing Management to Promote Self-Care of the Pregnant Woman: personal hyigene

- Clothing - loose clothing; avoid tight clothing, layered - Exercise - 3-4x/week - Sleep and rest - stay on a schedule - Sexual activity and sexuality - allowed unless experienced: vaginal bleeding, placenta previa, risk of preterm labor, cervical insufficiency, PROM, infection - Employment -most continue to work outside of home until the last month; be sure to take breaks, rest, avoid lifting, etc. - Travel - avoid oversee travel during 3rdtrimester - Immunizations and medications - Nutritional Requirements - Preferences - Cultural - Intolerances

Thrombosis

- Clotting prevents pp hemorrhage immediately after birth - results from: venous stasis, hypercoagulation, or injury to blood vessel - Coagulopathies lead to pp hemorrhage

Musculoskeletal structural abnormalities in newborn

- Clubfoot (talipes equinovarus) - development Hip Dysplasia

Promote Growth/Development in high-risk newborn

- Cluster care - Manage environment - Kangaroo care

Community

- Collection of people sharing...Common characteristics, Interests, Needs, Resources - Environments interacting with one another - Common rights; privileges - ...common ties of: Identity, Norms, Culture, Language, Social support - Now: Not only need to care for those who come for our help but care for the larger at risk community population

Community-Based Nursing Interventions

- Communicator, Work with Interpreters - Education; individual, family, community, health education programs - Health screening - Medication administration - Telephone consultation - Health system referral - Instructional - Nutritional counseling - Risk identification o Sunlight helps breakdown billrubin o Go through prevention - don't go upstairs a lot or lift something heavier than baby (increases bleeding = postpartum hemorrhage)

Factors that Facilitate Uterine Involution

- Complete expulsion of amniotic membranes, fetus, placenta at birth - Needed so the lining can finish shedding and regenerate and go back to normal - Complication-free labor and birth process - Breastfeeding - Early ambulation

Bladder Care PP

- Conditions: Immediately postpartum, bladder is edematous and hypotonic due to labor - Profuse diuresis (>3000 mL/day) occurs 24 to 48 after birth - Problems: urinary distention, incomplete emptying, retention with overflow - Management: early ambulation; void within 4-6 hours after birth, using nursing tricks to stimulate voiding

von Willebrand Disease (vWD)

- Congenital bleeding disorder; autosomal dominant - Prolonged bleeding time, impaired platelet adhesion, deficiency of von Willebrand factor (blood glycoprotein involved in hemostasis) - Symptoms: nosebleeds, hematomas, excessive menstrual bleeding

Possible causes of cervical insufficiency:

- Congenital cervical hypoplasia, increased amts. of relaxin and progesterone - In utero exposure to diethylstilbestrol (DES) - Trauma to the cervix from previous gynecolo gic or obstetric procedures (cone biopsy, D & C) - Damage to the cervix from a previous difficult birth (cervical lacerations from forceps) - Increased uterine volume (multiple gestation, hydramnios) - Unknown reasons (Creasy, Resnik & Iams, 2004) - Dx: past hx midtrimester loss w/ painless dilation - Cervical shortening=funneling, US performed

10 Leading Causes of infant mortality

- Congenital malformations, deformations and chromosomal abnormalities - Disorders related to short gestation and low birth weight - Sudden infant death syndrome (SIDS) Maternal complications of pregnancy - Accidents (unintentional injuries); ex: suffocation - Cord and placental complications - Bacterial sepsis of newborn - Respiratory distress of newborn - Diseases of the circulatory system - Neonatal hemorrhage

Nursing measures for induction

- Consents signed - Pitocin Protocols o Example: 0.5-1mU/min, incr. 1-2 mU/min q 30-60 min. - Close frequent Assessment - Dilation, effacement, station - Fetal tolerance to labor - FHR monitoring - UC: freq, intensity, duration, resting tone - Pain management - s/s infection, bleeding, VS - Education

Community-Based Nursing Care for Women and Infants

- Contraceptive services - Abortion services - Infertility services - Screening for sexually transmitted infections and cancer of thereproductive system - Preconception risk assessment and care - Maternity care (including prenatal, birth, and postpartum/newborn care)

Integumentary System Adaptations PP

- Darkened pigmentation on the abdomen (linea nigra), face (melasma), and nipples fades (estrogen and progesterone levels decrease) - Some women experience hair loss during pregnancy and postpartum periods (return in 4-6 m (1/3); 15 m rest) - Striae gravidarum (stretch marks) gradually fade to silvery lines (not disappear) - Profuse diaphoresis (sweating) is common - Especially at night during first week - Reduces fluid levels to pre-pregnancy state

Blood Volume in newborn

- Depends on amt. of blood transferred from placenta at birth - Effected by Timing of cord clamping - should be waiting for at least1 minute, then clamp and cut - Getting own blood volume from the cord - If cramp too quickly = volume depleted - Gestational age - full term? - Hemorrhage during delivery

Treatment of placenta previa

- Depends on gest. Age - Position of placenta-? c/s for total, partial, and marginal - Bedrest, no sex - Kick count: Fetal monitoring (at least 10 movements within 2 hours)

If cold stress is not reversed:

- Depletes brown fat stores - Hypoglycemia - Respiratory distress - Jaundice - Hypoxia - Metabolic acidosis - Decreased surfactant production

Mucus plug

Increased mucus forms to seal off the cervix from outside bacteria (progesterone) - Thick blocks the opening to the cervix - preventing bacteria to enter and infect the baby

Breasts Assessment PP

- soft, filling or engorged - BF - check nipples - cracks, redness, fissures, or bleeding?; inverted, flat, erect? - inspect size, contour, asymmetry, engorgement, or erythema - Non-BF = light palpation to prevent stimulation - Lactogenesis: onset of milk secretion triggered by delivery of placenta, falling levels of estrogen and progesterone and continuing of prolactin - Breast filling = firm; charted as filling Engorged is hard, tender, and taut

phase 1 of cycle of violence

Increased tension, anger, blaming and arguing -tension escalates, verbal or minor battery may occur; ex: name calling, hostility; victim attempts to calm the abuser - "if I do my job well, he remains calm" -Typically, women starts to understand their anger and insists they are correct and does everything for them -Doesn't work for long, eventually needs to release the tension l She beings to rationalize their behavior

Three Tier FHR Classification System: category 2

Indeterminate/Unclear/continue monitor - Variable decelerations: min/mod baseline variability - Absent variability but no decelerations with contractions - Tachycardia (>160) without decels - Bradycardia (<110) but has minimal variability - Late decels with moderate variability - Prolonged decels (>2 min but less than 10 min) - No accelerations after fetal stimulation Marked Baseline Variability

Evaporation

Loss of heat when liquid is converted to vapor Insensible= from skin and respiration (unaware) - Amniotic fluid evaporates off infant after birth (rush to dry and stimulate respirations) - Newborn bath Sensible= from sweating (observed) Nursing: Dry immediately after birth (and bath) with warm blankets and hat - Prompt changing of wet linens (includes diapers)

Cord Blood Harvesting

- started 1990 - Saving cord blood for future use in stem cell replacement used to build body's immune system - Each year 10,000 to 15,000 people die because they can't find stem cell matches - Approx. Cost $1000 - $2000 initially than $100-150/month or year Blood is drawn from cord and sent to lab on ice and stem cells are - separated out and frozen, can be used later by infusing through IV Public or Private Cord Banks Available - Public: donate cord blood for others to use if match; no fee, need to see if your hospital participates - Private: own/family use; you pay all costs

how to treat toxicity of magnesium sulfate?

- stop infusion - administer antidote: Calcium Gluconate

Nevus vasculosus

- strawberry mark/hemangioma(raised, rough, dark red, sharply demarcated, head, resolves) - 10% of children - Can increase in size or number - Commonly seen in preterm infants weighing less than 1500 g

Intensity

- strength of the contraction; felt with hand on fundus palpated with fingertips or internal monitor mild- can be indented by fingers (nose) moderate- in between (chin) strong- can bot be indented (forehead) measuring with a IUPC normal resting tone is 10mmHg & goes up during labor

Spinal: Subarachnoid

- subarachnoid space under arachnoid membrane of spinal cord C/S T-8 (Low spinal - saddle block T-10) - intrathecal opiate - subarachnoid Fentanyl - Complications: Hypotension & fetal bradycardia, spinal H/A (leakage of CSF into meninges)

telangiectaric nevi - Stork bites or salmon patches

- superficial vascular area found on the nape of the neck, eyelids, and between the eyes - Name is from myth that a stork picked up the baby - Caused by contraction of immature blood vessels and are most visible when the newborn is crying - Considered normal - will fade and disappear in a year

management and nursing care of Lacerations and Hematomas

- surgical repair of lacerations & evacuation of hematoma (can contain up to 500ml) - antibiotics - blood replacement - alternate heat & cold

s/s of Lacerations and Hematomas

- swelling - ecchymosis - severe pain - tachycardia - B/P - Pale

Risks associated with Uterine Rupture

- ↑ in previous C/S or uterine scars, ↑ classical scar, blunt abd. trauma, hypertonic UC, oxytocin, cocaine use, molar preg., prior rupture, placental percreta or increta, malpresentation, induction.... - Placenta stops working = lack of O2 to fetus

Promote parental coping

-Anxiety reduction -Perinatal loss

secondary stage of syphilis s/s

-Appears 2 to 6 months after initial exposure -Flu like symptoms - can last up to 2 years -Maculopapular rash on trunk, palm, soles -Alopecia, adenopathy -Fever, weight loss, fatigue, pharyngitis -Lasts two years -Highly infectious

Physical changes during pregnancy: Cervix

-Chadwick's sign -Goodell's sign Mucus plug - As she goes into labor and cervix starts to dilate and soften - mucus plug will fall out (be discharged)

Preparingpregnant woman for physical exam

-Gown -Bathroom -Specimen: Urine (check U/A, UTI, dip for sugar and protein - make sure no diabetes) -Vital Signs, Weight, Height (baselines) - use for rest of visits -Keep an eye of BP and weight gain over the months

Physical exam for pregnant woman

-HTT - head, neck, chest, abdomen, extremities, pelvic exam: · examination of external (normal development) and internal genitalia (ovaries) · bimanual examination: the wall that separates rectum and vaginal canal - make sure thick and strong · pelvic shape - in the end, depends on the size and shape of the baby · pelvic measurements: For Primigravida or after trauma to perineum: measure diameter of (?) - trying to figure out how large of an opening is both vertical and diameter - what is that space and can it support a baby? - Gives an ideal of whether mother is able to deliver vaginally - Lab work

Intrauterine Resuscitation goal

-Increase placental perfusion & decrease uterine activity - O2@ 8-10 L (tight face mask) -put mom on L side (or R) -stop Pitocin if infusing -hydrate (^ isotonic IV) -call primary care practitioner -Tocolysis if ordered (ex:Mag Sulfate)

Menstrual phase of endometrial cycle

-Ischemia leads to spiral arteries rupture -Releases blood into uterus -Endometrium sloughed off, passes through vagina -Menstrual flow begins next menstrual cycle

Physical changes during pregnancy: musculoskeletal

-Ligaments soften and stretch to prepare for growth and labor -Joints widen, more moveable -Postural changes -Lower back pain esp. as weight of uterus increases throughout the pregnancy -Waddle gait due to joints being stretched

Treatment of vulvovaginal candidiasis

-Miconazole cream or suppository -Clotrimazole tab -Terconazole supp/cream -Fluconazole oral tab (single dose) -3-7 day treatment

Outbreaks of Genital Herpes Simplex

-Most with no cause -Emotional stress -Menses -Sexual intercourse -Immunocompromised

Myths about Violence

-Only in lower socioeconomic classes -Substance abuse causes violence -Small number women affected -Easy for women to leave abuser -Men must have mental health problems -Pregnant women are safe -Women provoke the violence -It's acceptable, happened for years -Only happens to heterosexual couples

Diagnosis of HIV

-Oraquick rapid HIV-1 Antibody test -Fingerstick or oral fluid sample (99% accurate, 20 min. result) -Reveal rapid HIV-1 Antibody test -Uni-Gold Recombigen HIV test Note: - Counsel before and after test - Informed consent obtained

Estrogen

-Ovaries secrete -Develops and matures follicle -Before ovulation, levels high, inhibits output of LH -Causes uterus to increase size and weight

L/D associated with Maternal diabetes

-Over distended uterus-strength of contraction reduced-prolonged labor -C-section or vaginal, Trial of labor -Vacuum/Forceps common

Fetal Circulation

-Oxygen from the placenta before birth vs. lungs after birth -Fetal liver: no metabolic function yet -Primary Function: carry highly oxygenated blood to vital areas (heart/brain), shunts away from lungs and liver

Uterus

-Pear shaped, muscular organ, located at top of vagina -Behind bladder, in front of rectum, anchored by 8 ligaments (not firmly attached, can tilt) -Site: menstruation, implantation, fetal development, labor -Measures (prior to first pregnancy) 3" long, 2" wide, 1" thick

Conduct a Health History

-Reason for admission -what brings you here today? -Perinatal care: When did they start -EDD (EDC) (expected due date) -Gravida/Para -Pregnancy histories -Present pregnancy -Labor history -UC (Uterine Contractions) -ROM (rupture of membranes) -Bloody show Allergies Ex. Beta strep, if vaginal -get sepsis and die; if treated -can be born vaginally -Allergic to penicillin -have to give different drug and be aware of dosing difference -Food intake -Recent illnesses -Medications -Tobacco or alcohol use -Birth plans/preferences/cultural practices -Consents -Advanced directives -Current wt

Healthy People 2020: STI Objectives

-Reduce the proportion of young adults and adolescents with chlamydia, gonorrhea, primary and secondary syphilis, females with HPV, and genital herpes infections -Increase proportion of sexually active females aged 21 to 24 yo enrolled in Medicaid plans or commercial health insurance plans that are screened genital chlamydia -Reduce the proportion of adolescents that needed treatment for PID

Danger Signs of Pregnancy: 2nd trimester

-Regular uterine contractions = preterm labor -Pain in calf, often increased with foot flexion = DVT -Sudden gush or leakage of fluid from vagina = PROM -Absence of fetal movement for more than 12 hours = possible fetal distress or demise

Fetal Position

-Relationship of the landmark on the presenting fetal partto the anterior, posterior, or transverse (sides) of the maternal pelvis - use 3 letters to indicate - LOA most common/favorable, then ROA - OP = back pain - OP and Other positions : anxiety, long/difficult labor, may not be compatible with vaginal birth, increases potential for fetal and maternal injury O=Occipitalbone (vertex presentation) M=Mentum, chin (face presentation) S=Sacrum, buttocks (breech presention) A=Acromion process, scapula (shoulder presentation) Four quadrants pelvis: Right Anterior Left Anterior Right Posterior Left Posterior

Fetal Station

-Relationship of the presenting part to the maternal ischial spines or 0 station during labor the presenting part should move progressively or CPD exists · Negative numbers - above spines (floating or ballotable -4 is at inlet to -1 (1cm above ischial spines) · 0 station - ischial tuberosity - if baby gets stuck, stuck here Positive numbers below spines +1 to +4 is on perineum

Uterine Activity during labor

-Resting tone: 5-10 mm Hg -Uterine Contraction intensity: 50-80mm Hg -external monitor cannot tell true intensity, only internal monitor can evaluate pressure of amniotic fluid & uterine muscle intensity -the toco must be placed over the most contractible portion of the upper uterine segment - fundus -belt should be comfortable but tight -calibrated by (UA) reference -normal uterine contraction resembles shape of a bell

s/s of RDS in newborn

-Same as TTN (grunting, moaning, retractions, nasal flaring, mild cyanosis, rr 100-140) AND: crackles, HR150-180, general cyanosis -Silverman-Anderson Indexrates degree of distress - score from 0-2 with 5 criteria's: chest movement, intercostal retraction, xiphoid retraction, nares dilation, and expiratory; greater the number = more degree of respiratory distress -Self-limiting disease but will worsen if not treated

Placenta

-Serving as the interface between the mother and fetus -Making hormones to control the physiology of the mother -Protecting the fetus from immune attack by the mother -Removing waste products from the fetus Inducing the mother to bring more food to the placenta -Producing hormones that mature into fetal organs -Supplies nutrients and oxygen to fetus Helps mature fetal organs -Brings the nutrients to the cord to get to the fetus -Controlling all the hormones -Preventing the maternal cells from attacking the fetus -Only should last the length of the pregnancy 41-42 weeks - will begin to age and wont function as well which could compromise the life of the fetus

luteal phase of ovarian cycle

-Starts with ovulation ends with menstrual phase of next cycle -Follicle ruptures=releases egg=follicle closes forms corpus luteum Corpus luteum= secretes Progesterone: - Prepares endometrium for implantation - Increases body temp. slightly until menses start -0.5 to 1 degree increase 1-2 days after ovulation occurs If no fertilization= corpus luteum dissolves = Estrogen/progesterone levels decrease - FSH and LH at lowest levels in this phase - Menses begins 14 days after ovulation if no pregnancy

Danger Signs of Pregnancy: 3rd trimester

-Sudden weight gain -Periorbital or facial edema, severe upper abdominal pain, or headache with visual changes = gestational hypertension and/or preclampsia -Decrease in fetal movement for more than 24 hours = possible demise -Also anything from the 1st or 2ndtrimester can also occur here

phase 3 of cycle of violence

-The calm stage, apologizing, bringing gifts and making excuses for the violence - the batterer becomes loving, kind, apologetic, expresses guilt, then makes the victim feel responsible -part where women have faith that they will change; rationalize and stay with them

FHR recording can be compromised by

-fetal size, movement, malpresentation -abdominal fat -maternal position -location of transducer -artifact: : irregular or absent FHR on record, electrical - no phones within 5 feet - can cause this -document exactly what is done at this time - will be brought to court and questioned - interference, mechanical malfunction, or unknown

cause of Cytomegalovirus

-found in blood & body fluids, nasopharynx secretions & breast milk, after primary infection becomes latent, can cross placenta any time during pregnancy, during labor, or post partum. Permanent disability greater in utero during first trimester. -Maternal: asymptomatic

Risk Factors for Intimate Partner Violence in Men

-individual factors - young, heavy-drinking, personality disorders, depression, low academic achievement, witnessing violence as a child, low income and/or unemployment, experiencing violence as a child, desire for power and control in all relationships, anger, hostility -Relationship factors - martial conflict economic stress, dysfunctional family, marital instability, male dominance in family, cohabitation, having outside sexual partners, taking aggression out on others while growing up -Community factors - weak sanctions against IPV, poverty, low social capital -Societal factors - traditional gender norms, social norms supportive of violence

Hypotonic Uterine Dysfunction

-ineffective contractions, weak, lack intensity to dilate cervix or increase effacement Active phase -Begins normal- then around 4 cm, freq./intensity decrease

Risks for low forceps delivery

-maternal lacerations, hematomas -Prerequisites for applications Fetal ecchymoses, facial & scalp laceration

Signs of True Labor: Spontaneous Rupture of membranes

-maybe 1st sign starts in 8- 12 hours · 25% SROM before the onset of labor · 90% will start labor within 24 hours · May be gush of fluid or slow leak

Grade 1 placental abruption

-mild - 10-20% detached - minimal vag bleeding, uterine tenderness - no fetal/maternal distress

CVD Group I risks

-mortality 1% -min. risk -Corrected tetralogy, Pulmonic/tricuspid disease ,Mitral stenosis, classes I and II, Patent D. Arteriosus, Ventral Septal Defect, Atrial septal defect

Premonitory Signs of Labor: Bloody show

-mucus plug is expelled, resulting in a small amount of blood loss from exposed cervical capillaries · Result of pressure of presenting part & cervical softening · Cervix is closed tight with mucus plug · "Expel" the mucus plug with dilation · Starts to dilate, cervix opens, mucus plug comes out, blood tinged

Premonitory Signs of Labor: Sudden Burst of energy

-nesting instinct · 24-48hrs before labor begins · Increase in epinephrine caused by decrease in progresterone

Events during a C-S incision

Consents Closure - sponge count -Staples -sub. cutaneous with steri strips -adhesive

Childbearing in 1960's...1970's..

Consumer organizations form advocate groups * Want family centered maternity care * Family Values focus * Ex: ICEA International Childbirth Education Association * Started advertising birthing centers Women challenge current trends * Challenge assumptions * Demand new models for healthcare delivery

• Lactational amenorrhea method

Continuous breastfeeding can postpone ovulation, can be effective for 6 months only if: • No menses since birth of baby • Breast feeds at least 6 times per day on each breast • Breastfeeds on demand at least every 4 hours • Provides nighttime feedings at least every 6 hours • Does not rely on this method after 6 months - Prolactin levels must remain high enough to inhibit gonadotropin (necessary for ovulation)

Resuscitation of newborn

Critical thinking: think about what wll happen based on history o Ex. If had a narcotic prior to delivery - really sedated, cannot breathe, liver not functioning yet (cannot excrete) = will need to give Narcam - Airway: open, suction - Breathing: blow by or intubate if needed- ppv=pos. pressure ventilation - Circulation: chest compressions (at least 100/min)

HR and BP of newborn change with behavior state

Crying, Movement, Awakeness - don't document if crying, will be appear tachy - If you really needed to document at this time, just add in with crying or with blood work, etc.

Nursing Care for Hyperbilirubinemia

- Early feeds stimulate gut mobility, ↑ protein for conjugation o When baby comes out to eat, feed right away - cause once not under the treatment, the levels will continue to rise and cause brain damage (bilirubin encephalopathy) o Longer they will need to be in the hospital and won't get benefit if not under o With increased feedings = more stool and voiding= possible skin breakdown o Will need warm as well but have body uncovered = warmer crib needed - Phototherapy - light break down bilirubin or photo-oxidizes it in the skin and the byproducts are water-soluble which can be excreted in the bile and urine - Bilirubin drops 2-4mg within 12 hours of treatment - Cover eyes and genitalia (sensitive to light rays) - cover eyes and wear a diaper - Prevent cold stress - Monitor phototherapy light output: Bili Light Meter Feed q 3-4 hours, frequent feeds-frequent stools

Glucose levels (monitor) newborns

- Glucose levels of 50-80mg/dl, by day three, normal glucose levels are 60-70mg/dl - Hypoglycemia is blood glucose <30mg/dl, plasma glucose <40 mg/dl - Most hospitals treating if <50 (60 NICU) - At risk for hypoglycemia - IDM, LGA, low Apgar or stressed, difficulty births - symptoms of hypoglycemia - Lethargy, tachycardia, resp. distress, jittery, hypothermia, poor feeding, weak cry or high-pitched cry, hypotonia, seizures Treat low glucose per hospital protocol - Ex: bottle feed, recheck level after 30min - A lot of a hospitals need BF an bottle feeding to get sugar levels up, once maintains, can go back to breast feeding - If not able to suck - would need a OGT, or NGT, not bottle so it doesn't aspirate - Repeat checks before feeds x2

Early Decelerations

- Gradual decrease in FHR - Nadir occurs at peak of contraction - Onset to Nadir is > or = to 30 seconds - Typically mirrors the contraction o Beginning at onset and returning to baseline by end of contraction - rarely decelerates below 100 bpm - cause - head compression - contraction squeezing the baby's head; normal, don't have to do anything - *significance*- Normal pattern, no intervention necessary

Psychological Adaptations PP

- Immediate post delivery period - Attachment: begins before birth, acceptance and nurturing fetus - Bonding- term 70's & 80's to describe attachment felt by parents, enhanced in first 30-60 minutes after birth - sensitive period, not critical - attachment can still happen, baby state of consciousness - alert, reactive, -deterrents: hospital routines, eye medications - Nurses encourage attachment: early parent-newborn interactions, skin-skin (kangaroo care), newborn care

Pathologic Jaundice

- Impairment of albumin binding - Kernicterus or bilirubin encephalopathy - neurologic disorder: hearing/vision loss, mental retardation, death - Visibly jaundiced in 1st 24 hours - Total bili concentrations rising by more than 5mg/dl/day - Total bili above 17mg/dl in term - Visible jaundice for more than one week in term

Ectopic Pregnancy

- Implantation outside uterus (common=fallopian tube) - don't have to be on the fallopian tube, can be anywhere besides the uterus - Potential for rupture & hemorrhage - Incidence- 1:50 - Previous ectopic pregnancy - History of STI's; endometriosis - Previous tubal or pelvic surgery - Infertility and infertility treatments - Uterine abnormalities (fibroids, PID-scarring) - Presence of intrauterine device (IUD) - PP or post-abortion infection - Increasing age >35 years old; cigarette smoking

Studies for delayed clamping benefit

- Improves cardiopulmonary adaptation - Prevents anemia - Increases BP - Increases RBC flow - Improves 02 transport - However....may have volume overload and polycythemia -need more research

Increased catecholamines causes:

- Increased cardiac output - Increased cardiac contractility - Incr. surfactant release - Promotes Pulmonary Fluid Clearance

Idiopathic Thrombocytopenia Purpura (ITP)

- Increased platelet destruction caused by autoantibodies: thrombocytopenia, capillary fragility, increased bleeding time - Decreased number of circulating platelets - Idiopathic = unknown cause, may be asymptotic or symptomatic - may have petechiae - Medical therapy: Glucocorticoids and Immune globulin

Newborn attempts to conserve heat and incr. heat production

- Increasing the metabolic rate - Increasing muscular activity through movement - Increasing peripheral vasoconstriction - Assuming fetal position to hold heat - Minimize exposed body surface area

Nursing Management of newborn

- Initial Newborn Assessment in the nursery (immediate care in the DR) - When baby is brought in check out general condition, check bracelets - Get report - prenatal and L&D - Family social history Place under warmer -Airway Maintenance - Suction if needed

Immediate Newborn Period

- Initial assessment done in DR - Admission assessment done 1-4 hrs. after birth (average) (usually in NBN) - Primary care provider examines in 24 hours Initial Assessment: evaluate transition to extrauterine life: - 1st assessment: Use the RAPP tool: Respiratory activity, perfusion, and position; Method to quickly evaluate the newborn's condition so that decisions can be made regarding newborn stability - 2nd assessment: 2-4 hrs when admitted to nursery of L/D room - 3rd assessment: completed before discharge - depends on hospital policy Purpose of these: determine overall health, provide information to mother/father/supporting persons/significant others, and identify apparent physical abnormalities

bonding in 1st hour

- Initiate Breast-feeding - Delay eye ointment so they look around (if possible) - Include family - Observe interaction - Transporting and reporting - blood type, beta strep status, hepatitis B status, temps, PROM, GBS status

Events Precipitating Respiratory Function in the Newborn

- Initiation of respiratory movement - Expansion of the lungs - Establishment of functional residual capacity (ability to retain some air in the lungs upon expiration) - Increased pulmonary blood flow - Redistribution of cardiac output (Bope & Kellerman, 2012) o First breath they take is important and strong cry = good sign, good opening of alveoli - If not done and weak = need more time for adjusting

Nursing Assessment of the woman choosing a contraceptive method/reproductive education

- Medical history - smoking status, cancer of reproductive tract, diabetes, migraines, hypertension, thromboembolic disorder, allergies, risk factors for CVD - Family history - cancer, CVD, hypertension, stroke, diabetes - OB/GYN history - menstrual disorders, current conceptive, previous STIs, PID, vaginitis, sexual activity - Personal history - use of tampons and female hygiene products, plans for childbearing, comfort with touching herself, number of partners and their involvement in the decision - Diagnostic testing - urinalysis, complete blood count, pap smear, wet mount to check for STIs, HIV/AIDS test, lipid profile, glucose level - Physical exam - H/W, BP, breast examination, thyroid palpation, pelvic examination

Menses for non-lactating women

- Menstruation begins 7-9 weeks after birth but could take up to 3 months

Newborn screening

- Metabolic screening(PKU test)- can cause mental retardation, handicap & death - Learn as metabolic screening - that's how NCLEX will test - Screening for inborn errors of metabolism: PKU, Hypothyroidism, galactosemia, maple syrup urine disease, CF, Cong. Adrenal hyperplasia, and others - Taking blood from side of heal - airdried for 24 hr and sent to lab for testing - Supplemental screening in some states - may have second card to test different conditions - Heel stick Blood test after 24 hours po intake - 4 or 8 circles on paper and sent to state lab - Results to ped. office - Repeat specimen may be needed

Medical abortion

- Methotrexate (antieoplastic agent; induces abortion) followed by misoprostol (prostaglandin agent; uterine contraction) - vaginal suppository or oral form - Mifepristone (progesterone inhibitor; induce abortion) followed by misoprostol - Complications: explosion of uterine contents, uterine infection, heavy bleeding

Metritis or Endometritis

- Metritis= infection involving endometrium, decidua, and myometrium of uterus - Bacteria that normally reside cause problem - E. coli, kleb. Pneumoniae, G. vaginalis, - 10-20% c/s births - Can be from Chorioamnonitis present before birth

Newborn Nose Assessment

- Midline, symmetrical, size, lesions - Patent nares, can smell & taste, can differentiate mother's breast milk - Milia common

Nursing support: Physical and Emotional for L/D

- Minimize stress - Coping skills, help relax - Educate to Empower

Medications used with Spontaneous Abortions

- Misoprostol (Cytotec) - Mifepristone (RU-486) - PGE2, dinoprostone (Cervidil, Prepidil Gel, Prostin E2) - Rh (D) immunoglobulin (RhoGAM, MICRhoGAM, Gamulin, HydroRho-D)

nursing interventions for Amnioinfusion

- Monitor VS, FHR pattern, contractions, maintain bedrest, I/O, prepare for c-section if needed

Nursing care of pt's on magnesium sulfate

- Monitor output (want over 30ml/hr) - foley for accurate I/O - Must be on a pump - Must follow protocol and be there whenever you are supposed to and do an full assessment- look at toxic symptoms - check reflexes, epigastric pain, headache, blurred visions, etc. - Can give MgSo4 and Pitocin at same time; two pumps and LR running - MgSo4 to prevent seizures and using Pitocin to contract the uterus

diagnosis of preterm labor

- Monitoring and SVE - Management - Decrease risk factors - early prenatal care - nutritional (WIC), drug, smoking counseling - education - teach Signs and symptoms of Preterm Labor - written material on a level no higher than 6th grade

Ways to confirm/determine due date?

- Nagele's rule - Ultra sound: head circumference, long bones, (femur) weight (plus or minus a lb that it is off) - birth wheel - measuring belly - does it correlate with how many weeks we believe she is?

Choanal Atresia

- Narrowing of nasal airway by membrane or boney tissue - Result= resp. distress, asphyxia, poss. Death - Unilateral or bilateral - Unknown cause - Can't suck and breathe at same time; turn blue when feeding - Rx: surgery

Bleeding during Pregnancy:

- Needs to be seen ASAP - Color - Amt of bleeding - Freq. of pad changes - S/S: severity, duration (ex: cramping, low back pain) - VS Physical & Emotional Assessment - Monitor amt. bleeding, passage of contents, pt. understanding, counseling, guidance - Grieving process- up to 2 yrs, support groups

Bottle Fed Babies education

- Never prop - Elevate head - Burp often (initially every ½ oz) - Appropriate nipple, inspect for tears/wearing - Nipple on top of tongue and all the way in mouth - Regurgitation - fed to fast, didn't burp, allergy, etc. (may be common for 1st24hr) - Don't over feed - Different types of formula - switch every so many days to determine if allergy

Discharge Planning PP

- No lifting for the first few weeks - Pelvic rest for 4 to 6 weeks - Sleep when infant sleeps - Accept help from others when offered - Use a lubricant to help with vaginal dryness - Keep postpartum follow-up appointment - Report any signs of sickness to healthcare provider - If breast feeding, will need more calories - +500 cal, +20 g protein, +400 mg calcium, 290 mg iodine, +2-3 quarts of fluid daily - May need a stool softener (docusate) with or without laxative if having difficulty with bowel elimination

APGAR: Grimace (reflex irritability)

- No response: 0 - Grimace: 1 - Vigorous cough or sneeze: 2

CV adaptations during pregnancy

- Normal cardiac Δ during pregnancy - Blood volume increases 30-50%-physiologic anemia-increases heart rate - systolic murmurs are functional - Decrease vascular resistance= decrease B/P - Hypercoagulation= thrombus-emboli risk - cardiac filling increases - increased stroke volume - increased respiratory effort - possible edema

Fontanelles

- Normal: flat, soft, open spots - Attendings feel these during labor to determine what direction the baby is facing and where to place the sucker (needs to be on the occiput) - need to follow suture line anterior - diamond shaped; avg: 2.1 cm; closes by 18 months Posterior - triangle; avg <3.5 cm; closes in 8-12 weeks.

Erythema toxicum

- benign, idiopathic, generalized, transient newborn rash up to 70% during 1stweek of life (face, chest, back) -blotchy red spots on the skin with overlying white or yellow papules or pustules - Resemble flea bites; lacks a pattern - Often mistaken for staphylococcal pustules - Caused by newborn's eosinophils reacting to the environment as the immune system matures - No treatment required and disappears within a few days

Thalassemia major

- beta - Cooley's anemia - inherit gene from both parents (homozygous) - Difficult to become pregnant d/t lifelong severe hemolysis, anemia, premature death

Cephalhematoma

- bleeding over bone and under periosteum, swelling does not cross suture lines appears later 12-24 hours, firmer to touch, confined to one bone (usually parietal bones), reabsorbed few weeks - Filled with blood, do not see right away and will take longer to reabsorb (1-2 weeks) - Due to pressure on the head and disruption of the vessels during birth - Common in prolonged labor where forceps of vacuum suction were used - Hyperbilirubinemia occurs in the hematoma - Usually appear on 2ndor 3rdday after birth but will disappear within weeks/months - Large ones can lead to increased bilirubin levels and subsequent jaundice

Bowel assessment PP

- bowel movement or constipated, bowel sounds - May not occur for 1-3 days after birth due to decreased in muscle tone in the intestines - Normal bowel patterns should return within a weak

Lacerations and Hematomas

- can have a firm uterus but trickling blood = laceration see bleeding into soft tissue, blueish, tender = hematoma - Vaginal - Perineal - Deep tissue - can bleed into broad ligament - body will be reabsorbed, if not will have to have surgery to drain

gynecoid pelvis

- categorized as a typical female pelvis (although only about half of all women have this type of pelvis) - the rounded shape -favorable; ideal for vaginal delivery

fetal effects of Pharmacological Pain Management

- decreased variability - Resp. Distress Syndrome (RDS) & ↓muscle tone if given within - 1-2 hours before birth -hypoxia, hypoxemia and acidosis (anoxia-no O2) -newborns metabolize drugs slowly

APGAR Scoring

- developed in 1952 by V. Apgar to assess the newborns condition at birth based on 5 physiological signs which are given a score of 0-2 - done at 1 and 5 minutes of birth(again at 10min if needed if score is less than 7 at 5 minutes listed in order of greatest significance

appetite PP

- early PP increased appetite, provide snacks & fluids as needed between meals

prevention of Thrombophlebitis

- early ambulation - ROM exercises - avoid knee gatch, rolls, no crossing legs - avoid holding under calf in 2nd stage of labor - No smoking - Limit time in stirrups during delivery

Episiotomy PP

- edges of the incision should be approximated, ecchymosis - Inspection - Sim's position - looking at labia and rectum to see if any hemorrhoids - state the size small like pea, or grape like (large) - Is labia swollen (normal)? Echymosis (redness)? - May take 4-6 months to heal with episiotomy/laceration - Inspect the outside only - See if any more signs of drainage - Make sure to educate them to not stick anything up their vaginal area until see MD for first check up so can be sure everything healed properly - Muscle tone may not return to normal

polydactyly

- extra digits -fingers or toes - used to suture to necrose - if bone is present, will need to surgically removed

Gestational Diabetes Mellitus (GDM)

- glucose intolerance onset during pregnancy, or first diagnosed in pregnancy

Treatment for pain from engorgement

- heat or cold application, cabbage lead compresses, breast massage and milk expression, ultrasound, breast pumping, and anti-inflammatory agents

anemia causes an increased risk of what during pregnancy

- hemorrhage (impaired plt. Function), infection, preterm, LB W

Placenta: produces hormones -Progesterone (progestin)

- hormone of pregnancy - supports endometrium of the uterus to provide an environment conductive to fetal survival - produced by the corpus luteum during the first few weeks of pregnancy and then by the placenta until term -Products of conception after fertilization in the early stages of growth and differentiation - initially - causes thickening of the uterine lining in anticipation of implantation of the fertilized ovum. From then on, maintains the endometrium , inhibits uterine contractility, and assists in development of the breast for lactation

management of Hypotonic Uterine Dysfunction

- hydrate - maternal position change - amniotomy (rupture membranes) - not a lot of evidence; break membranes and head will come down further and put pressure on the cervix and release prostaglandins and help dilate the cervix - Augment labor (oxytocin) - C-section if unsuccessful o ** Risk of hemorrhage after birth d/t ineffective contracting (may not involution)

Meningocele

- hydrocephalus tends to pair with this) - Opening in spine, herniation of meninges and spinal fluid (not spinal cord/nerve roots) - Surgical repair

complications/side effects of epidural

- hypotension - dura puncture and spinal headache - bladder distention & prolonged 2nd stage - catheter migration - N/V & pruritis & respiratory depression - inadvertently become a spinal - must be 3-4 cms or slows labor - allergic or toxic reactions - light headed & slurred speech - metallic taste in mouth - muscle twitching, convulsions

fetal effects of Rubella (German Measles)

- if effected during 1st Δ: deafness, cardiac malformation, cataracts, mental retardation, IUGR, microcephaly, 1/3 spontaneously AB, contagious for months, should be isolated, if contracted during 1st mo - 50% affected, 2nd - 25%, 3rd - 10%

Milia

- immature sebaceous glands (baby acne; tiny white bumps or pale-yellow unopened) - Frequently found on the nose; may appear on chin, forehead - Form from oil glands and disappear within 2-4 weeks - When occurring in the mouth or gums = Epstein's pearls (80% newborns; break spontaneously within few weeks)

Blood glucose during pregnancy

- indicator for gestational diabetes - Mom comes in fasting then - Drink: Oral 50g glucose load (glucola) - Lab: check plasma glucose level in one hour - When: Weeks 24-28 - Results: Normal if <130 - 3 hr. GTT: Done if first test is >130 mg/dL with a 100g load

Maternal Touch

- initially touch is fingertip in an enface position progresses to full hand touch and the mom draws the infant closer - strokes baby - Binding-in - Verbal behavior, most mothers speak to infants in a high-pitched voice, progress from calling the baby it to he or she, then they progress to using the baby's name

Variability

- interplay between sympathetic and parasympathetic areas of the autonomic nervous system - VERY DIFFERENT than deceleration variability -Clinical indicator: predictive of fetal acid-base balance and cerebral tissue perfusion -Influenced by fetal oxygenation status, cardiac output, & drug effects -Measured as the amplitude of peak to trough in bpm -Normal appears as a jagged line, not flat/smooth - "moderate variability

Endometrial biopsy

- invasive - Take a sample of the tissue - Checks if progesterone secretion is adequate - should be very high, gets it ready for housing a fetus and making the endometrium thick -If not adequate - egg could just be passing though because the endometrium is not ready for it - Remove tissue just before menstruation - Check histology pattern

Common laboratory/diagnostic testing for amenorrhea

- karyotype, ultrasound, hCG rule of pregnancy, thyroid functions studies, prolactin level, FSH level, LH level, 17-kerosteriods

PROM: Premature rupture of membranes

- labor did not cause it - before the onset of true labor, after 37 weeks

causes of Bradycardia in fetus

- late fetal hypoxia - beta-adrenergic blocker (ex: Lopressor) - anesthetics (epidural spinal) - maternal hypotension - umbilical cord compression - hypothermia - fetal heart block

coordinate contractions

- later in pregnancy become organized from fundus to cervix

incidence of PP hemorrhage

- leading cause of maternal mortality & morbidity - 1 maternal death every 4 minutes (most within 4 hrs. of delivery)

Non-Pharm. Method of Induction/Augmentation

- less common - herbal (evening primrose oil), enemas, castor oil, hot bath, intercourse (semen has prostaglandins-ripen cervix), BR stimulation-release oxytocin-contractions. - Unknown risks, efficacy, safety - Need research

IgM

- levels low, protects blood borne infections - If have fever right away think sepsis

Cafe Au Lait

- light brown marks, oval, r/o neurofibromatosis (birth mark) - Need to adequately recognize lesions and have knowledge of their natural history so that accurate information can be offered to the parents/significant other/partner - Referral is necessary if: visual, airway or ear canal obstruction, extensive growth, severe infection, ulcerations, excessive concern from parent

Caput succedaneum

- localized edema(swelling) and soft area of scalp resulting from long and difficult labor (serous fluid) - edematous from sustained pressure of presenting part against cervix, swelling may cross sutures fluid is reabsorbed in 12 hour - mushy across the scalp, can move from side to side - pitting edema, overlying petechiae, and ecchymosis is noted - looks worse than it is but within 24 hrs will go down (up to 3 days) - common in deliveries where vacuum suction was used

Risk factors involved in the transmission of STIs

- low socioeconomic status -urban residency -single status -multiple sex partners -contact with casual sexual partners -risky sexual practices--rectal intercourse -alcohol and substance abuse -age (15 to 30 years old) (CRAALUSM)

management and nursing care of PP hemorrhage

- massage uterus - 1st response, 2 hands, express clots (clotted blood that against the side of the uterus and putting enough pressure on the uterus and like a sponge and keeps it bleeding - want to get them all out = slow bleeding) - Catheterize (if unable to void or use BR) - 2nd IV, type and cross match - VS, q15-30 min. as needed - weigh pads- 1 gm pad wt = 1ml blood - H&H - Hysterectomy possible if cannot control the bleeding

causes of tachycardia in fetus

- maternal fever - early fetal hypoxemia - parasympathetic drugs (atropine, vistaril) - Betasympathomimetics (ritodrine) - amnionitis - prolonged ROM - maternal hyperthyroidism - fetal anemia - hypovolemia - prematurity - arrythmias - fetal heart failure

Types of episiotomy

- median - can extend to rectal sphincter - mediolateral - R or L - ↑room for OB maneuvers, ↑difficulty to repair and longer healing ↑blood loss

maternal (baby) blues

- mild depressive symptoms, anxiety, irritability, mood swings, lose appetite, trouble sleeping, tearfulness, increased sensitivity, fatigue - do not affect ability to function and care for infant

Hysterosalpingogram

- mildly invasive - Contrast injected into endocervical canal to visualize tubes/uterus with fluoroscopy and radiography - Checks patency of tubes - Dye flows upward and out tubes into peritoneal cavity if tubes are open and not blocked -Can be blocked due to inflammation, infection, endometrium tissue there, etc. - very easy to block since so tiny

Grade 2 placental abruption

- moderate - 20-50% separation - Moderate bleeding: Possible 1000-1500ml vag bleeding - Abdominal pain, mild shock, uterine hyperactivity - no maternal distress; BP normal but tachycardia/may have fetal distress (decr. FM)

GTD (gestational trophoblastic disease)

- molar pregnancy -Neoplastic Disorders- originate in placenta -Gestational tissue present but not viable -1:1500 pregnancies -Breast tenderness, abdomen larger, - appears as symptoms of pregnancy but it is just located in this area -Do measurement, will be larger than she is supposed to be 2 types: - Hydatidiform Mole - Choriocarcinoma

platypelloid pelvis

- pelvis that is flat in its dimensions with a very narrow anterior-posterior diameter and a wide transverse diameter - this shape makes it extremely difficult for the fetus to pass through the bony pelvis - more dependent/difficult - no favorable

Predictable Newborn Behavioral Responses

Orientation= response to stimuli - Stare at face close by Habituation= process and respond to environment (visual & auditory) - Block out noise in nursery- sleep through Motor maturity= posture, tone, coord., movements, good flexion - Depends on gestational age - Rhythmic & spontaneous movements - Put hand in mouth Self-quieting ability= comfort self, consolability - Five S's to calm fussing: Swaddling tightly; side/stomach position on the lap of the caretaker; shushing loudly or continuous white noise; swinging using any rhythmic movement; Sucking Social behaviors= nestles into parent's arms, cuddling - Newborn observation: "Consolability" from these states - Crying, Active Alert, Quiet Alert, Drowsy, Sleep

Newborn Face Assessment

Symmetry and fullness - Should have full cheeks and symmetrical when baby is resting and crying Facial nerve paralysis - Drooping one side - if nerve was damaged during delivery - Unable to make seal on nipple = milk or formula drools from paralyzed side - Due to Forceps delivery - present 1st or 2nd day by showing the inability to close the eye and move the lips on the affected side - Resolve over time (usually), may take weeks to months for full recovery

Family Centered Community Based Care emphasis

all levels of prevention (primary, secondary, and tertiary

Tachycarida PP s/s

anxiety, excitement, fatigue, pan excessive blood loss, delayed hemorrhage

Teratogen

any substance, organism, physical agent, or deficiency state present during gestation that is capable of inducing abnormal postnatal structure or function by interfering with normal embryonic and fetal development

intraabdominal pressure

compresses the uterus and adds to the power of the expulsion forces of the uterine contractions

if a PDA (patent ductus arteriosus) is found, what is done?

connects pulmonary artery to the aorta, bypasses the lungs - transient murmur that will disappear - Check BP all extremities, look at skin (pink pale dusty, mucus membranes), if alerted and eating= not worried about the murmur - If abnormal BP, then call cardiologist

Rubella titer lab work

detects antibodies for the virus that causes German measles; if titer is 1:8 or less, the women is not immune - requires immunization after birth, women is advised to avoid people with undiagnosed rashes

Hepatitis B lab work

determines if mother has hepatitis B by detecting presence of hepatitis antibody surface antigen (HbsAg) n her blood

conjugated bilirubin

direct bilirubin - Water soluble- can enter GI system via bile, excreted in feces - small amt. excreted by kidneys - tells us how much is already conjugated

how often do you Monitor/Palpate UC's in latent phase of labor

every 1 hr

Imperforate anus

exit is not open but rest of bowel is okay - Malformation, high or low - s/s: pain, no stool, abdominal distention - Blind pouch or fistulas - rx: surgery

Why does stool change into transitional stool?

feedings introduce bacteria into the intestine

preembryonic stage

fertilization through 2nd week -fertilization, cleavage, morula -blastocyst and trophoblast -implantation

early Post-Partum Hemorrhage

first 24 hours (most)

Rhea

flow

Placenta: produces hormones -hPL

human placental lactogen -Modulates fetal and maternal metabolism - preparation of mammary glands for lactation and involved in the process of making glucose available for fetal growth by alternating maternal carbs, fat, and protein metabolism - antagonist of insulin because it decreases tissue sensitivity or alters the ability t to use insulin - increase in the amount of circulating free FAs for maternal metabolic needs and decreases maternal glucose utilization, which increases glucose availability to the fetus to facilitate fetal growth

Clinical manifestations of endometriosis

infertility, back pain, pain before and during menstrual periods, pain during or after sexual intercourse, dysuria, depression, fatigue, painful bowel movements, chronic pelvic pain, hypermenorrhea, pelvic adhesions, irregular periods, premenstrual vaginal spotting

Regional analgesia/anesthesia

nerve blocks & locals - Local- into perineal muscle for repair short duration, repeat as necessary - used for 1 area; affects 1 nerve o Lidocaineis used, onset 3-4 min. used for nerve block for episiotomy or repair of tear - Pudendal Block- direct injection of pudendal nerve trans-vaginally, which is located near ischial spines, takes 15 min. for full effect o Ex: Bupivacaine or Ropivacaine - Epidural: Most Popular -Combination of local anesthetic and opiod ex: Bupivacaine with Fentanyl or Continuous infusion or single injection - Nursing does not do this - only anesthesiologist or CRNA

Tips for managing Dysmenorrhea or Amenorrhea

o Exercise to increase endorphins and suppress prostaglandins release o Limit salt to prevent fluid retention o increase water consumption to serve as a natural diuretic o increase fiber with foods and veggies to prevent constipation o Use heating pads or warm baths to increase comfort o Take warm showers to promote relaxation o Sip on warm beverages o Keep legs elevated which lying down or lie on side with knees bent o Use stress management techniques to reduce emotional stress o Practice relaxation techniques to enhance ability to cope with pain o Stop smoking and decrease alcohol use which causes vasoconstriction

hemodilution

physiologic anemia of pregnancy - Have increase blood volume, but when actually look at blood - the plasma exceeds than the RBCs (dilutes the blood sum) - Do H/H and will look like she is anemic - because she is, its due to this (Norm: H - 12-16/ H - 37-48%) - So its expected but still be on multi-vitamin with iron in I, but can contribute to her feeling tired as well

URI's in pregnant women

self limiting, usually not a problem due to it being so short

Diagnosis of Hep B

serology: Hep B surface antigen (HBsAg)

Biliary Atresia

severe jaundice d/t defect

Menstruation (Frequency, Duration, irregularity)

shedding of endometrium -Frequency: 21-36 days, average 28 days -Duration of Flow: 3-7 days -Irregularity: due to ovulation, stress, disease, hormonal imbalance

Class 2 of CVD

symptomatic (dyspnea, chest pain) with increased activity

Class 3 of CVD

symptomatic (fatigue, palpitation) with normal activity (bedrest with pregnancy

Class 4 of CVD

symptomatic at rest or with any physical activity (should avoid pregnancy)

Nurses Role to Educate during labor process: Part of a Normal Process

the body knows what to do: · Prepare antepartally - know what will happen · discuss the sensation as a UC not "pain" · word pain may generate needless anxiety · intermittent · labor ends with the birth of a baby - self-limiting · anxiety and fear - increases muscle tension · use support systems: family/friends

causes of Post Term/Prolonged Labor/Birth

unknown Some causes: -Wrong dates d/t irreg. menses -extrauterine pregnancies -Estrogen deficiency, progesterone secretion- inhibits uterine contraction -previous post term gestation

Possible causes of preterm labor

unknown; multifactorial - hydramnios - infection - dehydration - Gest. HTN - PPROM - anomalies - multiple fetuses - Domestic Violence - abdominal surgery - Cervix > 1cm at 32 weeks - uterine irritability - bleeding after 12 weeks - hx of cervix biopsy - febrile condition - 2 or more 2nd trimester AB's - DES exposure - uterine abnormalities - Environmental - lack of prenatal care - poor nutrition - under 18 over - poor education - nonwhite - smoking - substance abuse - low income

Blood Patch

used to treat spinal headache - 10-15ml of maternal blood withdrawn from arm - replaced into spinal or epidural via injection to clot over leak - can be repeated if first attempt fails at reducing spinal headache - Hole created - fluid going in placed shouldn't go = pressure change = H/A o Blood will get sucked to where hole is and create a clot there so it can close - its immediate relief of the H/A

Legal/Ethical Issues involving childbirth: Abortion

· In TPAL - If A is high, don't assume its voluntary · Covers both voluntary and involuntary abortions · Denied abortion coverage for Medicaid women - Hyde Amendment has limited choices on low income women regarding their reproductive needs · Pro-choice vs pro-life

PPTD - Postpartum Thyroid Dysfunction

· Incidence - 5-9% may have transient hyper or hypo or both (reoccurs in subsequent pregnancies) · the thyroid glands enlarge normally during pregnancy but does not return to pp state · at 6-12 weeks there is a hyperthyroid state that lasts for 1-2 months followed by hypothyroid goiter that lasts for up to 12 mo. · can have hyper state without hypo

Healthy People 2020 Prenatal Goals

· Increase number of patients who get early and adequate pre-natal care -Number 1 adequate · Increase number of women who have the recommended weight gain (worried about effects on fetus, too much: larger baby, not in her best interest) · Increasing number of women who get pre-conception care & practice key recommended pre-recommended (do what we ask them to do) · Increase number of attendances of childbearing classes -↑occurrence of SIDS with second hand smoke

Healthy People 2020 regarding reproduction

· Increase the proportion of pregnancies that are intended · Reduce the proportion of females experiencing pregnancy despite use if a reversible contraceptive method · Increase the proportion of publicity funded family planning clinics that offer the full range of FDA-approved methods of contraception, including emergency contraceptive, on site · Increase the proportion of sexually active persons who received reproductive health services

Positions for Pushing

· Laying down is the worst position; want to sitting up and someone holding legs · When occipital is pushing on her spinal nerve- feels like building on back; "back labor" · Encourage movement and movement of baby - create them turning o Us counter pressure or raise bed up and put pressure and have her rock and move so the baby's head turns · Sitting upright with flexed hips, squatting, or less commonly standing or kneeling - maintain flexion at the hip joint and somewhat straighten the pelvis · Upper and lateral positions compared with supine or lithotomy positions may: o Reduce length of first stage of labor, duration of the second stage of labor, number of assisted deliveries, episiotomies and perineal tears, contribute to fewer abnormal fetal HR patterns, increase comfort/reduce pain meds, enhance a sense of control, alter the shape and size of the pelvis (assist with descent), assist gravity to move the fetus downward Specifics: Side-Lying Kneeling-lean forward - removes pressure on the maternal vena cava and helps rotate the fetus from a posterior position or an anterior one to facilitate birth Hands and Knees Squatting - enlarges the pelvic inlet and outer diameters Standing Sitting Upright Semi-sitting

Legal/Ethical Issues involving childbirth: Stem cell research

· Relief of human suffering - ethically good · Provides therapy for Parkinson's disease, regenerating diseased body tissue, repairing spinal cord injuries, growing needed organs for transplant · Controversy about what stem cells should be used and how they are obtained

Placental Expulsion

· Schultz's Mechanism- Shiny fetal side (gray) - separates from the inside to the outer margins and slides out (Shiny Shultz) · Duncan's Mechanism- rough maternal side (red raw side) - separates from the outer margins inward, rolls up, presents sideways (dirty Duncan)

Underlying medical conditions

· Treat problems prior to pregnancy if possible; want the healthiest "you" possible pre-conception o Controlling BP, controlling weight, giving up cigarettes, not drinking alcohol, making sure meds are safe · i.e. hypertensive, chromes, colitis (auto immune - esp. want to get under control prior to pregnancy) ideally let's get everything under control

Pelvic Inlet

· allows entrance to the true pelvis -Bounded by the sacral prominence in the back, the ilium on the sides, and the superior aspect of the symphysis pubis in the front -Wider in the transverse aspect that it is from front to back

Red Flags to Poor Parental Adjustment

· direct rivalry with fetus - C/O interference with sex · adamant about the way she feeds baby · escalation of violence

Psychological Response

· maternal adaptation in labor (women's psychosocial adaptation is also a critical aspect of labor and birth) · influenced by her self confidence · patterns of coping with stress · attitudes and expectations about L&D · response to pain and anxiety · meaningful event in a women's life · enter labor as challenge, often see L&D as a test of their womanhood · feeling that she has mastered childbirth may affect her self-esteem · effect her relationships · negative attitudes about birth vary and can range from brief experience to a "horror story" · it is a threat to self image · loss of physical beauty or sexual attractiveness · viewed by others as a medical condition or a normal physiologic process · women prepared for labor by "psyching" up which varies · specific actions -becoming better informed and prepared (prenatal classes)

Psychological Effects of labor process

· perceptual factors influencing women's' response · cultural - must establish an accepting relationship · history - previous experiences - coping mechanisms used · interpretation of pain pain - subjective & difficult to measure objectively

Implantable contraceptives

• Delivers synthetic progestins that inhibits ovulation • Once in place, delivers 3 years of continuous, highly effective contraception • SE: irregular bleeding, H/A, weight gain, breast tenderness, depression • Implant requires minor surgical procedure for both insertion and removal • Doesn't protect against STIs

Use of USDA's Food Guide MyPlate during pregnancy

• Eat a variety of food from all food groups using portion control • Increase intake of vitamins, minerals, and delivery fiber • Lower intake of saturated fats, trans fat, an cholesterol • Consume adequate synthetic folic acid from supplements or from fortified food • Increase intake of fruits, vegetables, and whole grains • Balance calorie intake with exercise to maintain ideal healthy weight • Avoidance of some fish due to mercury content

Issues of infertility

• Ethical • Religious • Medical • Legal • Ownership • Financial • Insurance • Emotional • Coping • Stress/Anxiety Management • Peer Support Groups • www.resolve.org • Resources • INCIID

Pregnancy and partner

• Family-centered emphasis • Partner's reaction to pregnancy and changes - Couvade syndrome (get similar symptoms: n/v, gain wt.) - Ambivalence - accepting the role and wow we are going to have a baby - Acceptance of roles (2ndtrimester) - Preparation for reality of new role (3rdtrimester)

maternal weight gain

• Healthy weight BMI: 25 to 35 lb - 1st trimester: 3.5 to 5 lb - 2nd & 3rd trimesters: 1 lb/week • BMI < 19.8: 28 to 40 lb - 1st trimester: 5 lb - 2nd & 3rd trimesters: 1+ lb/week • BMI 25-29: 15 to 25 lb - 1st trimester: 2 lb - 2nd & 3rd trimesters: 2/3 lb/week • BMI >30: 11-20 lb

Intrauterine contraceptives

• Hormonal or nonhormonal • Both types prevent pregnancy via inhibition of sperm mobility and sperm viability and change speed of transport of ovum in the fallopian tubes • Makes monthly periods lighter, shorter, and less painful • Contain copper or progesterone to enhance their effectiveness • Strings protrude into vagina to check placement

Basal body temperature

• Lowest temperature reached on awakening • Preovulation temperatures are suppressed by estrogen, post-ovulation temperatures are increased under the influence of heat-inducing progesterone • Typically rise a day or 2 after ovulation and last for 2 weeks • Want to wait 3 days of elevated temps to have unprotected sex • Illness and alcohol rise body temperatures and give false readings • Others methods should be used for better results

Pregnancy and Sexuality

• Numerous changes, possibly stressing sexual relationship • Can I still sexual relations with partner? No contraindicated - only is if in high risk pregnancy • Partner will go through changes as well • Changes in sexual desire with each trimester • Sexual health and link to self-image

warning s/s of IUC complications

• P= period late, pregnancy, abnormal spotting, or bleeding • A= abdominal pain, pain with intercourse • I= infection exposure, abdominal vaginal discharge • N= not feeling well, fever, chills • S= string length shorter or longer or missing

Etiology/Risk factors: Women: Known and Unknown for infertility

• Primary reasons for women: 40% ovarian dysfunction, 40% tubal/pelvic pathology • Over wt., under wt. (hormone disruption) • Hormonal imbalance = Irregular ovulation • Fibroids • Tubal blockages • Immune System Disorders • Turner Syndrome; other chromosomal abnormalities • Chronic Illness (asthma, diabetes, thyroid) • STI's • Age (increases after 27yrs) • Endometriosis • PID History • Smoking/Alcohol • Multiple miscarriages • Psychological Stress - higher number of women get pregnant after adoption

emergency contraception

• Reduces the risk of pregnancy after unprotected intercourse or contraceptive • High levels of birth control to prevent sperm and egg from joining and implantation • reduce the risk by 80%; Used within 72 hours • Prevent embryo creation and implantation, no effect on an implanted embryo examples: -Progestin only oral contraceptives -Combination oral contraceptives -EC kit (plan B)

Potential Misuse of Genetic Information

• Risk profiling - effect insurance • Privacy and confidentiality breaches • Problems with computers and visible to people • Workplace discrimination and access to health insurance • Loss of autonomy - able to make decision on own and we aren't doing it for them, but are the ones providing the information so they can make the decision that is best for them • Possible injustices with risk determination years before disorder occurs • HUNGETONS CHROIA- SHOW UP IN THE MIDDLE AGES

Cervical cap

• Smaller than the diaphragm and only covers the cervix; held in place by suction • Inserted 36 hrs before and left for 6 hrs after intercourse • provides protection of 48 hrs • Replaced every year • Latex, 1/3 filled with spermicide

Cell-free fetal DNA (cffDNA)

• approximately 10 weeks • Noninvasive, Maternal blood sample that contains maternal and fetal DNA after 4 weeks gestation is taken and next generation sequencing used to analyze the cffDNA • Determines fetal sex in pregnancies at risk or sex-linked conditions, RhD genotyping in pregnancies at risk for hemolytic disease of the newborn and fetal chromosomal abnormalities such as down's syndrome

EARLY SIGNS OF COMPLICATIONS FOR USERS OF ORAL CONTRACEPTIVES

A= Abdominal pain may indicate liver or gallbladder problems. C= Chest pain or shortness of breath may indicate a pulmonary embolus. H= Headaches may indicate hypertension or impending stroke. E= Eye problems may indicate hypertension or an attack. S= Severe leg pain may indicate a thromboembolic event.

Analgesics PP

Topical Preparations - Dermoplast spray (local anesthetic/numbs area) - Tucks Pads - cold witchhazel pads for comfort with hemorrhoids - Hydrocortisone Cream Mild/Moderate pain - Tylenol - Ibuprofen (gold standard for breast feeding) - naproxen Moderate/Severe - Codiene/oxycodone combined with Tylenol/Aspirin - Tyl #3, Percocet Educate on Side Effects: Dizziness, n/v, constipation, sedation - Can medicate 1 hr. prior to BF to promote comfort if needed -Sometimes its Percocet does not help, masks pain but doesn't get rid of it

SANE RN

a registered nurse specially trained to conduct sexual assault evidentiary examinations for rape victims: collect forensic evidence, provide access to crisis intervention, STI testing, and emergency contraception

most important aspect preventing the #1 killer in women

* Detect & Treat hypertension

Nursing Implications for a childbearing family

* Eat health, take vitamins, exercise more, stop drinking and smoking, sleep well, etc. * Any diseases - get under control before pregnant * Identify risk factors early * Psychosocial referrals- depression, anxiety, etc. - Is medications safe to be on? Do you need to change them? * Medical and Social Services referrals * Educate about Nutrition, Prenatal care, Exercise, Good Hygiene

Dick-Reed Method (1940's)

* Focus on educating mother * "Fear-tension-pain" - suggested that fear causes a woman to become tense, and that tension increases pain. The increased pain, in turn, increases fear, and the cycle repeats * Breath out with crunch = O2 to muscle * Don't breathe = not O2 to muscles or baby

Infections characterized by vaginal discharge

*Vulvovaginal candidiasis *Trichomoniasis *Bacterial vaginosis

PP Blues

- 50-90% - Mild depressive symptoms - Anxious, fatigue, teary, mood swings - Peak days 4-5, resolve by pp day 10 - No psychopathology - Can take care of self and infant - Self limiting, no treatment if resolves

Oligohydramnios

- 500 ml amniotic fluid between 32 -36-week gestation - Increases perinatal morbidity/mortality risk - Cord compression, hypoxia, death

Myelomeningocele

- 94% of cases) - More severe - Spinal cord and nerve roots herniate into sac

Procardia (Nifedipine)

- Action/indication: Ca2+ channel blocker/dilation of coronary arteries, arterioles, and peripheral arterioles; reduction in BP, stoppage of preterm labor Nursing considerations: o Administer 10-20 mg orally for 3 doses and then q 4 -8 hr; monitor for adverse effects - gastric pain, flatulence, constipation, dizziness, vertigo, and fatigue

Vagina PP

- After delivery: edematous, bruised & small lacerations, thin, few to no rugae - Returns tosize in 6-8 weeks but remain larger - 3 wks: mucosa thickens, rugae, stays slightly larger than pre-preg. (return of evarian function and estrogen production) - Mucus production and thickening of vaginal mucosa begins with ovulation. - Non-Breast feeding: 1 to 3 months menstruation begins - Breast feeding: average 6 months menstruation begins -Depends on how long they are nursing and how regular they are nursing and keeping the oxytocin and prolactin levels up -Be careful they do not have unprotected sex if planning not to have a baby right away Recommend: 3 monthly cycles minimum before planning another pregnancies

diagnosis of DIC

- Decreased fibrinogen and platelets - Prolonged PT & PTT - Increased fibrin products

Omphalocele

- Defect of umbilical ring- abdominal contents (bowel with peritoneal covering) eviscerate into external peritoneal sac - Assoc. with other anomalies; trisomy 12,18,21

s/s of Sickle Cell Anemia

- Defective Hemoglobin S molecule; if not fully oxygenated, sickle shape, clumps & clogs vessels- cause ↑ infections & obstructed blood vessels, increased crises in pregnancy

Immune System newborn

- Defense: protection from invading organisms - Homeostasis: elimination of worn-out host cells - Surveillance: recognition and removal of enemy cells - Healthy babies develop own antibodies in2-3 months

Now: Times are changing in healthcare

- Discharged "sicker and quicker" - Cost Control - Proactive treatments vs. reactive - Increase emphasis on Health Promotion and Illness Prevention

Nontraditional Inheritance Patterns

- Don't follow normal patterns - e.g. mitochondrial inheritance, genomic imprinting

nursing for a molar pregnancy

- Emotional Support & Extensive follow up- Educate patient re: importance of follow up

Problems with Psyche

- Emotions- anxiety, tired- psychological stress - Stress related hormones released: Catecholamines, epinephrine., cortisol, etc.. - Cause uterine smooth muscle reduction in contractility- leads to dystocia - Cause decrease uteroplacental perfusion

Factors Affecting the Labor Process: Passenger

- Fetal skull - Fetal attitude - Fetal lie, Fetal presentation - Fetal position, Fetal station - Fetal engagement - Cardinal movements of labor

Emergency Delivery

- General Anesthesia - used in emergency - loss of consciousness - barbiturates IV - Nitrous oxide 40-60% O2 - ↑aspiration from intubation and pp hem. - C/S - w/ in 4 min so infant is not compromised by the general anesthesia - neonatal resuscitation

- transitional stools

- Greenish brown - Yellow brown - Thinner and seedy appearance

Incomplete abortion

- Heavy bleeding, intense cramps, dilation, pass some products of conception - Ultrasound, Dilation & Curettage (scraping): D&C

Habitual abortion

- Hx 3 or more consecutive spont. Ab - ID & Rx problem (chromosomal (can't always fix), infections, incompet. Cervix (cervix opens before it is supposed to )

Fetal Abnormalities

- Hydrocephalus - Large mass on neck or head - Ascites

Fundal height

- Indicates uterine size by measuring from the top of the symphysis pubis to the top of the fundus (top part of uterus) · Correlates with weeks of gestation between 20-30 weeks - check when last menstrual cycle, ultrasound, and measuring - Higher or lower can occur by how much the baby is growing, how much fluid is in there, twins? · *Not reliable after 36 weeks d/t fetal descent due to Lightening but will still do to determine if the baby has descent or not*

low vertical C-S incision

- Kronig - lower uterine segment - used for multiples - abnormal presentation - higher risk of rupture next preg. - can't VBAC after this type

BF problems

- Leaking - Supplemental bottles - Pumping Storing - refrigerator - 2 days - freezer 2 wks - deep freezer 3-4 months - La Leche League - Lactation consultants - Drugs all pass to some extent - Nipple soreness - Mastitis

Signs and symptoms of cold stress

- Less active - Lethargic - tachypnea - Weak reflexes - cannot tell without doing finger grasp - Hypotonic - tone will become more flaccid All infants at risk first 12 hrs Premies greater risk- more dangerous - Increased Metabolic Rate - Increased need for O2 - Increased respiratory rate - Anaerobic metabolism - Metabolic Acidosis, fatigue & CV collapse - Prevention is key (stay on task with VS) and if not possible, diagnosis and treatment is very important - Ex. If cold = do not eat = hypoglycemic, but also cannot eat because they cannot breath - Don't want to rush bathing even though have more kids to take care of, if just below the temperature cannot bath · Will take this baby 2 hrs to warm up compared to the appropriate temperature baby that will take 30 min

diagnosing critera of CVD

- Level of decompensation - Diastolic, pre-diastolic, or continuous murmur - cardiac enlargement - loud, harsh systolic murmur - Severe arrhythmias

Newborn back/buttocks Assessment

- Lie prone (on belly) to assess - No curvature of spine - Tuft of hair, dimple or sinus in sacral area may indicate spinal problem, cover any cysts - Pilonidal dimple, cysts, tuft of hair will be in this area; Indicates a neurological problem r/t spine and sometimes it doesn't - Gluteal folds should be equal - just under the buttocks, do they match? Terms hip alignment - Patent anus - should pass meconium 24-48 hours after birth

Spontaneous Abortion

- Loss of early pregnancy - Before 20 week gestation (usually) - Natural causes - Miscarriage - 15-20% of USA pregnancies., 80% occur in first trimester (fetal genetic abnormality-most common cause) - 2ndtrimester-maternal conditions are most likely cause - Examples: Infection, DM, drug use, virus-HSV, CMV, cervix incompetent - Stillbirth: loss after 20 weeks gestation; approximately 1:160 pregnancies

hypothermia Postterm newborn

- Loss of subcut. Fat- d/t placental insuff.

treatment of HELLP syndrome

- Mag. Sulfate - Anihypertensives - Blood components - Packed RBC - Platelets - Prevent seizures, lower BP, correct coagulopathies - Diagnose, Stabilize, Deliver

Nursing Measures for Circumcision

- Make sure Vit K given prior to circ - Informed consent - no longer NPO before procedure - Suction handy - Restrain - Antibiotic cream if ordered (not with plastibell) - not necessary heals without - Check voiding and chart (before & after) - Vaseline Gauze wrap - Keep clean and dry Check for Bleeding - apply pressure - Liquid epinephrine used on gauze with pressure if needed - If none, will come out and teach them how to take care of It (apply petroleum jelly) - Parent education - Get yellowish tissue - doesn't mean infected (normal tissue)

Nursing Interventions immediate newborn period: ensure correct identification

- Match bracelets, on before leaves LDR: Electronic devices will sound an alarm if a newborn is taken beyond a certain point on the unit or removed from the area - Instant photo -within 2 hrs of birth with a color camera or color video/digital image - Foot printing - with mother's fingerprint, name, date, and time of birth on the same sheets: Some states have stopped doing this a require other things such as: collecting cord blood at time of birth for DNA testing, facial biometric recognition, live scans to capture digital forensic quality prints that are suitable for identification

Risk factors for placenta previa

- Maternal age - Prev. c/s - Multiparity - Uterine injury - Cocaine & smoking - Prev. placental previa - Afr. American & Asian - Multiple Gestations - Hx abortions - HTN, Diabetes - Infertility treatment

Risk factors for LGA

- Maternal diabetes mellitus or glucose intoleranceMale fetus - Multiparity - Genetics - Prior history of a macrosomic infant - Post-dates gestation - Maternal obesity

causes of Hydramnios

- Maternal disease, fetal anomalies, unknown Maternal examples: Diabetes, Multiple gestation, Chromosomal Fetal examples: Esophageal or intestinal atresia, neural tube defects, fetal hydrops (fluid in 2 cavities-ascites, cardio or pulmonary effusion), CNS, Cardiovascular, hydrocephaly

increased risk for HELLP syndrome

- Maternal/fetal death - Hemorrhage (bleeding precautions) - Respiratory distress - Subcapsular Liver hematoma, rupture (don't palpate abdomen / liver) - Stroke/Cardiac Arrest - Renal Failure - Seizure, Sepsis

Assessments Made During the Third Stage of Labor

- Monitoring placental separation - Examining placenta and fetal membranes for intactness the second time - Assessing for any perineal trauma, such as the following: o *Firm fundus with bright red blood trickling - laceration* o *Boggy fundus with red blood flowing - uterine atony* o *Boggy fundus with dark blood and clots - retained placenta* o Inspecting the perineum for condition of episiotomy o Assessing for perineal lacerations and securing repair

Chlamydia

- Most common bacterial STI in USA -Asymptomatic Male (50%); Female (70%) -Damage is done over time and already may be infertile -Recommend Annual Screening age <25 yrs., high risk clients

Occiput Posterior position

- Most common malpresentation 15% - Leopold's maneuvers and Vag exam to determine position - Slows progress, slow descent, long labor - More painful c/o severe back pain - Allow to proceed - Hands/knee, rocking to get the head to turn - Have roll on side and put pressure on side to help relief the pain - Pain management

Congenital Heart defects

- Most develop in first 8 weeks of pregnancy - Genetics and environment - DM, alcohol, >40 age, meds. - PDA common - doesn't respond to O2 o will have to watch until it closes on its own o Will have a EKG and Echo done and physician will come to listen an determine what kind of a murmur it is - Fetal shunts usually close due to increases systemic pressure

Community Based Health Care Settings: Home healthcare

- Mother/Baby, High Risk Pregnancy/Neonate - Hospice - Skilled nursing

Newborn Neck Assessment

- Movement - turn head both ways - Ability to support head - Lots of skin folds - lift up to clean to get out a vernix and amniotic fluid Clavicles - palpate and observe arm movement - crepitus - start around sternum and work across; common in large babies for breaking this - Most common broken bone in delivery - Large babies more common - May or may not x-ray - you can feel the fracture, no need to x-ray - Mostly asymptomatic, but edema, crepitus, and decrease/absence of movement and pain or tenderness on movement of arm may be noted

assessment for preterm labor

- Multifactor, have to take an individualized approach - Signs of preterm labor are subtle and may be over looked - Assess pattern on contractions - must be persistent (4 q 20 min or 8/ 1 hr); cervical dilation (greater than 1 cm) and effacement (greater than 80%); engaging part

criteria for Vacuum Assisted delivery

- Must have ROM - Must be vertex - Cup should only go on occiput - No CPD - Creates neg. pressure 50-60 mm Hg; apply traction until head emerges - Cup should not be allowed to pop off creating sudden negative pressure

Autosomal Recessive and examples

- Mutations of two gene pairs on a chromosome - Both genes of pair abnormal=disease - One gene in pair abnormal=no disease or mild - Single defective gene=carrier - Seen ethnic groups: Tay Sachs disease - e.g. Sickle cell, PKU, Cystic Fibrosis (CF), Thallesemia - Seen when blood related parents (first cousins) - Offspring 25% affected, 50% carrier

Signs Indicating a Problem During Initial Newborn Assessment

- Nasal flaring - Chest retractions - Grunting on exhalation, labored breathing - Generalized cyanosis, Pallor, apneic episodes - Abnormal breath sounds (rhonchi, crackles (rales), wheezing, stridor) - Abnormal respiratory rates (tachypnea - >60 bpm; Bradypnea - < 25 bpm) - Flaccid body posture - Abnormal heart rates (tachycardia - >160 bpm; bradycardia - <100 bpm) Abnormal newborn size (SGA, LGA

natural menopause and age?

- Natural menopause: 1 yr. without menses -Average age= 50-51

s/s of HELLP syndrome

- Nausea, malaise, epigastric pain, upper right quadrant pain, demonstrable edema, hyperbilirubinemia (jaundice), petechiae (iny, circular, non-raised patches that appear on the skin or in a mucous or serous membrane. ) - laboratory data-thrombocytopenia, abnormal bleeding, clotting, elevated liver enzymes, low HCT- anemia - DO NOT palpate the liver - could have hemotoma and rupture it

Perinatal education

- Never leave tub unintended, do not bath until cord dries and falls off, etc. -Breast/Bottle feeding -Infant care -Transition to parenthood -Relationship skills -Family health promotion -Birth options - hospital, birthing centers, home birth

measuring weight of newborn

- No diaper - Zero scale - 5lb 8oz-8lb 14oz, 2500g-4000g -Less than 10% or greater than 90% on a growth chart is abnormal - LBW <2500g, Very LBW <1500g, Extreme LBW <1000g regardless of gestational age -Can lose up to 10% by day 3-4 due to loss of meconium, ECF, and limited food intake but is regained by day 10

Preconception Care Focus: Immunization status

- No live vaccines while pregnant, can get vaccines and then wait 3 months prior to becoming pregnant -While not pregnant, want up to date immunizations: ex: tdap, rubella, influenza, varicella; these conditions, if contracted when pregnant can be dangerous to mom and fetus.

Essure

- Nonsurgical, nonhormonal, permamnt birth control - 99% effective - Increases safety, lowering cost, and improving sterization - A tiny coil (essure) is introduced and release into the fallopian tubes through the cervix • The coil promotes tissue growth in the fallopian tubes and over period of 3 months, this growth blocks the tube = barrier that prevents sperm reaching the ovum

Maintain Thermoregulation newborn

- Norm. temp: 97.7-99.5 - Thermistor probe (automatic sensor) attached to newborn's RUQ to record body temperature on a monitoring system (warming unit) -Connected to radiant heat control panel, parameters are set, alarms sound if temp goes outside them

Maternal roles: Seeking acceptance of infant by others

- Other people are going to accept this baby and be happy with her - 1st trimester: acceptance of pregnancy by herself and others - 2nd trimester: family needs to relate to the fetus as member - 3rd trimester: unconditional acceptance without rejection

predisposing factors of early PP hemorrhage

- Overdistended uterus - multiparity - prolonged labor - precipitous labor - oxytocin/stim. of labor - retained placenta - Prev. uterine surgery - clotting disorders - C/S - General anesth. - MgSO4 - forceps/vacuum - low implanted placenta - incomplete dilatation

management of late PP hemorrhage

- Oxytocin, ergotrate or methergine - curettage - antibiotics - inspect placenta at delivery

Perinatal asphyxia Postterm newborn

- Placental deprivation or oligohydramnios- cord compression

Metabolic alterations: Pathophysiology DM

- Placental hormones cause insulin resistance - hPL & somatotropin increase w/ growth of placenta - Causes insulin resistance (peaks last trimester) - Insulin secretion increases to overcome resistance - Non-diab.= pancreas can respond to incr. demand - Diabetics= pancreas can't meet insulin demand

Hydramnios

- Polyhydramnios - Too much amniotic fluid - >2000 ml (32-36 weeks) - Assoc. with fetal development anomalies and poor fetal outcomes

Risk factors for PP emotional disorders

- Poor coping skills - Low self-esteem - Numerous life stressors - Mood swings and emotional stress - Previous psychological problems or a family history of psychiatric disorders - Substance abuse - Limited social support networks

management of CVD

- Pre conceptual counseling - More Frequent Prenatal Visits: q2 weeks, then q 1 week in last month - History taking for S/S - Digitalis, diuretics, Na restriction, bedrest, future pregnancies dependent on residual effects - Watch for fluid overload (ex: SOB, crackles, edema, anxiety) - Class I & II - limit activity, control wt gain, prevent anemia, prevent infection, watch symptoms - Class III & IV: prevent cardiac decompensation & CHF - Heparin/Lovonex, Antiarrhythmics, Anti-infective, Diuretics (Lasix) Intrapartum Care -I & O, position, O2, quiet, cardiac monitoring, EFM, 1st choice is vag. del. with assistance ↓ 2nd stage - Don't want to pushing/bearing down and holding breath for long periods of time - don't want in labor for hours and hours - Use vacuum or forceps for help decrease the delivery process - 4th Stage - ↓ overload, maintaining legs at body level, careful cardiac assessment

risks associated with pregnant moms with Sickle Cell Anemia

- Preeclampsia, Eclampsia, preterm labor, placental abruption, IUGR, and low birth weight

GBS risk factors

- Premature ROM - Fever during labor - Less than 37 weeks gestation - History of + GBS in previous pregnancies - Clinical manifestations - signs of neonatal sepsis

fetal complications of Multiple Gestation

- Premature, resp. distress, asphyxia, congenital anomalies, twin-twin transfusion, IUGR, conjoined

REEDA (for episiotomy or laceration but also any other incision)

- R - redness - E - edematous - E -- ecchymosis - D - discharge - A- approximate (two edges together nice and smoothly?)

Nutritional Needs of the Newborn

- RDA: 100-115 kcal/kg/day - Formula - Milk Based: SMA, Enfamil, Similac - Will start with unless family history of having issues with then start with soy - Elemental: Nutramigen, Alimentum - Soy: Isomil, Prosobee, Nursoy - Preparations: Powder, Concentrate (thick and needs water), Ready to Feed (most expensive) - Formula fed regain to birth wt 10 days - double 3.5 - 4 mo - BF - 14 days - doubles 5 mo

Face and brow presentation

- Rarer - Seen with multips, placenta previa, hydramnios, low birth wt., fetal abnormalities - Assess with Vag exam - Longer labor - Head must flex to deliver vaginally - Watch for late decels, hypoxia - Possible c-section depending on amount of head flexion

Abruptio Placenta (placental abruption)

- Separation of the placenta before fetus, after week 20 -hemorrhage (normal: 5-10 minutes after delivery at the baby will come out) - Painful,dark red vaginal bleeding - Concealed: Will fill up like a balloon due to it being further up - Can have a apparent hemorrhage as well - depends on where the abruption of the placenta occurred - Incidence - 1% of all pregnancies - 20-40% fetal mortality, 6% maternal mortality - ↑ in maternal hypertension, smoking, abd. trauma, history of abruptio, cocaine usage, multiparity, very young and older, - Medical Emergency - Classified: Mild, Moderate, Severe

Secondary level of care

- Serious/complicated care historically provided in the hospital setting Now: Community Based; examples: - Outpatient surgery - Chemotherapy - MRI - Angiography (inside blood vessels) - Radiotherapy

Overview of NTD

- Severity varies - Closed (covered by skin/membrane) - Open (neural tissue exposed) - Prevent: Folic Acid - Dx: US, MS AFP, amnio - Rx: avoid trauma to sac, cover with moist dressing, prevent hypothermia

Indications for Forceps Assisted delivery

- Shorten 2nd stage of labor - Terminate labor quickly - Maternal exhaustion - Inability to push effectively - Prolapsed cord - Cardiac or pulmonary disease - Infection - Prem. separation of placenta - Fetal Distress

Teaching Topics for Preg. & Asthma

- Signs and symptoms of asthma progression and exacerbation - Importance and safety of medication to fetus and to herself - Warning signs that indicate the need to contact the healthcare provider - Potential harm to fetus and self by under-treatment or delay in seeking help - Prevention and avoidance of known triggers - Home use of metered dose inhalers - Adverse effects of medications

Perineum assessment PP

- Sim's position - Gloves - Irritation, ecchymosis, tenderness, hematoma, hemorrhoids - Perineum tissue surrounding episiotomy may be edematous, slight bruising (normal) - Episiotomy should not have erythema, discharge, or edema

Community Based Health Care Settings: Long term care

- Skilled nursing facilities and nursing homes - Assisted living - Hospice

- BF Education

- Sole nutrient for 6-12 months - Less fat in breast milk - Less sleeping = cluster feed - In hospital: Want to feed every 2-3 hrs make sure they are feeding well and help before they go home - Breast feed on demand - Baby is allowed to sleep througout the night (if can) - nor allowed if concerned about baby's weight or feeding - Typically need 4-6 hours of sleep BF within first 20-30 minutes - alert stage - On demand 8 - 10 feeds/day - At least every 2-3 hrs, wake up for feeds in hospital - Cluster feed - Crying as a sign - Rooming-in enhances response - Sleep through night: 8-12 weeks - May assess swallowing with small sterile water before bottle feeding (some hospitals do but going away) Bottle fed babies - Q 3-4 h - Some 1st feed is H2O

Before fertilization: Cell division

- Sperm: Meiosis while in the testes -Ovum: Primary oocyte completes first meiotic division before ovulation, Secondary oocyte just prior to ovulation - Formation of gametes by meiosis=gametogenesis - 4 sperm are made, 1 egg is made - 23 chromosomes

Threatened abortion

- Spotting, no dilation, mild cramps, closed os - Decrease activity, adequate hydration - Diagnose with Ultrasound

Prepare for discharge of high-risk newborn

- Starts when stable - Home assessment - Resources Perinatal Loss: support, acknowledge, sincerity, cultural beliefs/practices, anticipatory guidance, support groups

Tubal ligation

- Sterilization for women - A laparoscope is inserted; fallopian tubes are grasped and sealed - Postpartum, after an abortion, or as an interval procedure unrelated to pregnancy • May be performed after C-section, easier since the access is already there • Harder for healing and longer recovery time

Two types of Thrombophlebitis

- Superficial: lower leg, lithotomy position-stirrups - Deep vein: from foot to pelvis

Factors influencing Psycho/Social pp

- Support systems - relationships vary widely - Single parenting - emotional & financial support, often live below poverty level, >LBW - Lingering discomfort and fatigue - Knowledge of infant needs - Previous experience, multiparity brings more responsibility than 1st baby, extended family less excited, guilt about extending love

nursing of cervical insufficiency

- Support, monitor for s/s preterm labor, thorough hx

Breast care postpartum: lactating women

- Supportive bra - Warm showers - Correct position - Correct latch-on technique - change position will help the nipple sourness - Make sure mouth is open wide, grasp on to whole nipple brown part behind areola, see the lips phalange out, tugging at nipple, not biting it - Nipple inspection - Exposure to air - warm dark areas trap bacteria - Frequent nursing - Increase fluid intake

Circumcision

- Surgical excision of the foreskin or prepuce that covers the glans penis - Elective procedure, routine, value is controversial - Incidence - most common surgical procedure in USA - Advantages - may reduce UTI and CA, needed for a phimosis or hygienic problems, culture, can use skin to correct hypo or epispadias, "looks like dad" - a lot of times based off what Dad has - Disadvantages - surgical risk & pain - Methods - usually done 12-24 hours after delivery - Gomco (Yellen) clamp - remove foreskin, and the equipment is taken off and have a raw open area. Apply Vaseline gauze and have petroleum jelly to prevent the diaper from sticking - Mogan, Sheldon - Plastibell - leaves a ring around penis (black) with plastic hood that goes over it (no need to petroleum jelly); couple of days caps come off - Used lidocaine to numb the area - crying because they are forced into a position

Wound infections PP

- Surgical incision - Episiotomy - Laceration - s/s may appear after d/c (48 hrs. later)

At Birth newborn CVS

- Switch from placenta to Pulmonary gas exchange - Force of contractions labor/birth, mild asphyxia, incr. ICP d/t cord compression and UC, and cold stress lead to: - Increase release of catecholamines (Epinephrine and Norepinephrine)

Newborn Eyes Assessment

- Symmetrical & gray -blue color (true color in few months) that lids open, eyes present - Can be red from erythromycin ointment - Usually edematous & subconjunctival hemorrhage - 10% from ↑ vascular tension during delivery - gone in 1-2 weeks - Sight - can see but not well developed; PERRL present - Newborn gaze: Tracks objects to midline, may be uncoordinated - Red reflex present - Scleral hemorrhage - broken vessel in the eye and see that but gets reabsorbed and doesn't affect vision - Transient strabismus (deviation or wandering of eyes independent) and searching nystagmus (involuntary repetitive eye movement) - immature muscular control - Chemical conjunctivitis from prophylaxis after birth- lid edema and sterile discharge from both eyes; resolves in 48 hrs without treatment

post C/S prevention of Thrombophlebitis

- TEDS - Compression devices - Incent. Spirometer - OOB - Encourage fluids

measuing length of newborn

- Tape measure - disposable - Built in tape on scale - Supine: head to heel (fully extend leg) - 19-21" (48-53cm) average; can range from 17-22" - Molding can affect measurements

Colostrum

- Thick, yellow color, Protein and carbohydrates, No milk fat

Newborn characteristics that predispose to heat loss

- Thin skin with blood vessels close to the surface - Lack of shivering ability to produce heat involuntarily - Limited stores of metabolic substrates (glucose, glycogen, fat) - Limited use of voluntary muscle activity - Large body surface area relative to body weight - Lack of subcutaneous fat, which provides insulation - Little ability to conserve heat by changing posture - No ability to adjust own clothing or blankets to achieve warmth - Inability to communicate that they are too cold or too warm - Amniotic fluid on newborn cools and evaporates (low humidity and cool del. Rooms) - Temp. drops up to 5 degrees within minutes after birth Be sure to DRY infant quickly after birth = **Prevent heat loss**

Etiology of DIC

- Thromboplastin released →maternal circ. due to vascular insult, too much released-clot or emboli - Produces multifocal clotting in sm. vessels - Fibrinolytic agents → to lyse clots, too much released cause bleeding at sites-hemorrhage

Non-BF women relief of engorgement

- Tight, supportive bra 24 hrs daily, ice to breast of 15-20 minutes every other hr, avoid sexual stimulation, avoid squeezing or manually expressing milk, avoid exposure to warmth - Will subsite in 2-3 days

Why use Culturally Competent Care

- To increase acceptability and effectiveness of health care

Cesarean Section

- Today: 33% of all deliveries; 1:3 deliveries. 1980 22%, - In 1960: 5% of all deliveries

causes of PP hemorrhage

- Tone- uterine atony - Tissue- retained fragments - Trauma - Thrombosis

causes of early PP hemorrhage

- Tone: uterine atony - 90% - prevents uterus from contracting around blood vessels of myometrium Can lead to hypovolemic shock Others: - Tone: distended bladder (putting pressure on uterus - cannot contract) - Tissue: retained fragments and clots - Trauma: vaginal, uterine, or cervical injury - Thrombin: coagulopathy - Traction: causes uterine inversion

Accelerations

- Transient Increase in FHR - Greater than 15 bpm from baseline for at least 15 seconds, but less than 2 minutes (15 x 15 rule) - If less than 32 weeks: 10 x 10 rule - Prolonged Accelerations: Last 2 minutes or more, but less than 10 minutes - If longer than 10 minutes, it's a baseline change *significance*- Normal Pattern/No intervention neededProbably movement - happy baby

Decelerations

- Transient drop in the FHR caused by parasympathetic nervous system stimulation - Determined by the nadir (lowest point) in bpm below the baseline - Counted in minutes and seconds from the beginning to the end of the deceleration - Types: Variable, Early, Late, Prolonged - Interpreted in relation to UC's

Newborn nervous system Assessment

- Transient tremors of mouth, chin & extremities should not be present after one month Check - Alertness, no lethargic - Posture - hips abducted an partially flexed, with knees flexed; arms adducted an flexed at the elbow; fists clenched, with fingers covering the thumb - Muscle Tone - support infant with one hand under chest, observe how neck muscles hold the head - should be able to hold in line briefly; only slight head lag when pulling newborn from a supine position - Reflexes

Zika Virus Disease

- Transmitted by infected mosquitos, Caribbean, central and South America, with cases in USA too - If symptoms, flu like (e.g. fever, rash, joint pain, headache, conjunctivitis), 80% no symptoms - Transmitted sexually, fetal effects include microcephaly - No vaccine and no antiviral treatment yet. - Use insect repellent, long sleeved shirts and pants, check window screens, avoid travel to known areas if pregnant or planning pregnancy.

Characteristics of molar pregnancies:

- Trophoblastic cells that should form placenta, proliferate; chorionic villi swell , become fluid filled, look like grape- like clusters - Have the ability to invade into the wall of the uterus - Can metastasize to other organs - Do recur in subsequent pregnancies - Can develop into choriocarcinoma, a virulent cancer with metastasis to organs - Occur more in Asia (1 in 120 pregnancies) when compared to the United States (1 in 1500 pregnancies) - Influenced by nutritional factors (carotene deficiency, protein deficiency) - Tend to impact older women more than young - Cause: Unknown; Genetics? Ovular defect? Stress? - Should we do a hysterectomy? Have to consider age, history, and how longs it's been there?

Fetal Surveillance of mother with DM

- US for growth - AFP (r/o open neural tube defects) - Fetal echo - Daily Kick Count - NST's after 28 weeks - Amnio:L/S and Pg ratios-lung maturity (incase want to perform an early delivery)

Physiologic Adaptations: Cardiovascular newborn

- Umb. Vein= carries 02 blood from placenta to fetus - Ductus Venosus= allows most of umb. Vein blood to bypass liver to get to heart sooner - Foramen Ovale= allows most blood entering RA to cross directly into LA bypassing pulm. Circulation - Ductus Arteriosus= connects pulm. Artery to aorta (bypasses pulm. Circuit) - Fetus Depends on Placenta

Newborn male genital Assessment

- Uncircumcised- foreskin covers glans Urinary Meatus should be midline - Hypospadius= glans on ventral surface (closest to scrotum) - Epispadius= glans on dorsal surface (less common) (closest to abdomen) -No circ for either one (skin used later for surgical correction) Scrotum - Appears large (swollen), rugae present, edematous (r/o hydrocele) - Pink or dark in colored populations - Testes palpable (pea size) - cryptorchidism

PP infection

- Up to 8% births - Greater in c/s than vag.

Lab work for pregnant women

- Urinalysis: albumin, glucose, ketones, bacteria - Blood work: CBC, blood type, Rh, glucose, rubella titer, Hep B - surface antibody antigen, HIV, VDRL, RPR

Daily Nursing Care of newborn

- Usually weigh on night shift - may lose 5-10% of birth wt before they start gaining - VS q. shift temp; axillary q 15 min under warmer then q shift - Skin probe if under warmer set at 36.8 - make sure not getting too warm - Bath - mild soap and warm water; should not immerse in umbilical cord is not healed (up to 2 weeks after birth); bath 2-3x/week is sufficient for 1styear; check temp after bathing - Cord care: keep clean, dry, open to air - Clamp removal when cord dry - Assessment - HTT, I/O - Elimination & Intake - 6-12 diapers/day = hydrated; petroleum jelly on penis after circumcision to prevent sticking - Enhance Bonding - say hi; soothing voice; provide non-stressful care; skin-to-skin - Promote Sleep - newborns sleep up to 15 hours daily, 2-4 hrs at a time; place on back

Postpartum Hemorrhage - Causes

- Uterine atony - most common - Retained placental fragments - most common - Cervical or perineal lacerations - tears or cuts unnoted in cervix or perineum? - Subinvolution (failure of uterus to return to normal size) - not involuting the way we expect it too - make sure it is not going to go into a hemorrhage - Bleeding disorders

causes of Oligohydramnios

- Uteroplacental insufficiency, PROM, HTN, DM, IUGR, (Intrauterine growth restriction), Post-term, polycystic kidneys, obstruction in urinary tract

STI screening lab work

- VDRL or RPR serological tests or by cervical smears, cultures, or visual identification of suspicious lesions - detects STIs (such as syphilis, HPV, gonorrhea) so that treatment can be intiated early to prevent transmission to the fetus

HELLP syndrome

- Variation of Gestational HTN (add hepatic dysfunction stands for: - *H*emolysis (destruction of RBCs), *e*levated *l*iver enzymes, *l*ow *p*latelets

TORCH Infections

- Viral & Non-viral Infections Toxoplasmosis, Other (such as hepatitis), Rubella, Cytomegalovirus, Herpes type II -Identified group of infections that can cross the placenta and harm fetus 1:1000-1500 pregnancies nexposure during first 12 weeks can cause developmental anomalies -with the conditions - look at disabilities to fetus, and how can you prevent from getting -cytomegalovirus (CMV) - one of most common ; most preventable - hand washing

Nursing Management During the Postpartum Period

- Want to understand the women in provide social and cultural context so that all care provided is culturally competent and sensitive - Should engage in going cultural self-assessment and overcome stereotypes that perpetuate prejudice and discrimination against any cultural group - Ex. Chinses - send child to china to be raised by extended family

Nursing Management of the Pregnant Woman with Asthma

- Working together with the healthcare team and the client to manage care - Completing a thorough assessment of risk factors that could trigger an asthma attack - Recommending strategies to reduce exposure to triggers - Reviewing medication therapy with the client - Educating the client about controlling the symptoms

mild Preeclampsia

- add proteinuria & edema - BP: > 140/90 after 20 weeks gestation - Proteinuria: 300mg/24 hrs, +1-+2 dipstick - Wt. gain >4.4 lb/wk (2nd/3rdtrimester) - Mild edema: hand, face - Increases risk of: eclampsia, abruptio placenta, DIC (disseminated intravascular coagulation ), cerebral hemorrhage, Liver/renal failure, (epigastric pain, RUQ pain) , pulmonary edema (SOB, decrease breath sounds, crackles in lungs)

counseling, education for amenorrhea

- address causes of amenorrhea, relationship to sexual identity, causes of infertility, and the possibility of a tumor or life-threatening disease - loss of menstrual regularity can = osteoporosis and hip fractures

Percutaneous umbilical blood sampling

- after 16 weeks (late 2nd trimester) • Insertion of a needle directly into a fetal umbilical vessel under ultrasound guidance • Complications: fetal hemorrhage and risk of infection • Pregnant diagnosis of Genetic anomalies, blood disorders

true conjugate

- aka obstetric conjugate - estimated - subtract 1-2cm from diagonal conjugate - is smallest front to back diameter that head must pass through - Want at least 11.5cm - cannot actually measure the exact

Thalassemia minor

- alpha - heterozygous (one parent) -Minor anemia during preg., doesn't respond to iron, don't prescribe iron -Offspring is carrier or may have disease (depends on fathers genetics)

Coagulation PP

- altered hemostasis (favor coagulation), reduced fibrinolysis, and pooling and stasis of blood in LE = risk of clots - Clotting factors increased during preg - Birth = hypercoagulation - Elevated for 2-3 wks post-partum (sometimes even 6 months after) - Combine with immobility, vessel damage during birth= risk for thromboembolism in LE and lungs - Any pain in the calf? - Smoking, obesity, immobility, infection bleeding, and emergency surgery = increased risk - Blood cellular components - Mean H/H: decrease for first 24 hrs, over next 2 weeks = increase slowly - WBC: increase with labor and remain for 4-6 days; fall 6K-10K - Complicate diagnosis of infection

signs of ectopic pregnancy

- amenorrhea usually X 1 month - abdominal pain can be dull, acute bilateral or unilateral - Spotting, Breast tenderness, low back pain rupture of tube= medical emergency: life threatening - severe pain - hypovolemic shock - blood in peritoneum & shoulder pain

Fontanels

- anterior4-6 cm diamond shaped - closes 12-18mo. (up to 24mo) - posterior- triangle 0.5-1 cm closes 2-3 mo. - Open, soft, and flat - should not be depressed or edematous

Periodic Breathing in newborn

- apnea 5-10 sec, no color change, no change in HR - May be seen in first few days - Need to monitor closely for further changes - if long try to make them breath from flicking the feet

Mechanical Method of Induction/Augmentation

- apply local pressure to cervix- stimulates prostaglandin release - Foley cath inserted into uterus-fill balloon - Hygroscopic dilator- absorbs fluid-expands

Birth Weight Variations Appropriate for gestational age(AGA)

- approximately 80% of newborns; normal height, weight, head circumference, and body mass index

amniotomy

- artificial rupture of membranes - uses amniohook to rupture memb.- presenting part pressures cervix-prostaglandin increase - Most common method used in the US - artificial ROM - cervix 2 cm for instrument, usually go into labor in 12 hrs or ↑UC once labor started fetus must be assessed for: - position - station-engaged to ↓risk of prolapsed cord - presentation - FHR

Maternal effects of Pharmacological Pain Management

- avoid supine even for regional anesthesia - ↓respiratory capacity -↑sensitivity to inhalants - GI tract ↓& ↑regurgitation -↑aspiration - circulating endorphins ↓need for pain med. - ↓labor if too early (primips 5-6, multips 3-4) - contraindicated in substance abuse

Induction

- begin labor q Cervical Ripening and Stimulation of uterine contractions n Medical or surgical means n Result= delivery before onset of spontaneous labor n Note: NEVER start with Pitocin right away, if cervix is not thin and "ready" Pitocin causes contraction will cause bad outcomes

duration

- beginning of increment to end of decrement

talipes equinovarus

- clubfoot - Inversion & adduction of forefoot - Inversion of heel and hindfoot - Limited extension of ankle & subtalar joint - Internal rotation of leg - Rx: Casting after birth- plaster casts, also use prolonged bracing - Surgery possible...minor, used less than previously

talipes equinovarus

- clubfoot - turns inward - the foot will not move back into normal position (need surgery or braces)

s/s of Hemorrhagic/Hypovolemic Shock

- cold clammy skin - ↑ catecholemines & vasoconstriction - ↓ pulse pressure - tachycardia - metabolic acidosis - highly anxious/lethargic - decreased urine output - ↓ 30ml/hr - Note: body will compensate a while before it vital signs are affected - will need to lose a lot of blood before they change

What if women returns with rubra after serosa and alba transition ?

- contact HCP - could mean subinvolution or the women is too active and needs to rest more

risks of surgical Method of Induction/Augmentation

- cord prolapse, compression, infection, decels., pain, bleeding

Postpartum Depression

- could start without blues or after blues - Have hard time getting going in the morning, don't want to take care of the baby, don't want to shower, have trouble getting dressed in the morning

s/s of preterm labor

- cramping (with or without diarrhea) - backache usually below waist - pressure in pelvis - UC's - painful or painless - menstrual type cramps - Change or increase in Vag discharge

Sedatives

- cross placenta, birth defects, behavioral problems

s/s of early PP hemorrhage

- difficulty locating fundus - boggy uterus that firms up with massage than loses tone - excessive lochia

Neonatal varicella syndrome

- extremely rare disorderin which affected infants have distinctive abnormalities at birth (congenital) due to the mother's infection with chickenpox - live vaccine so cannot be vaccinated

Brachial plexus paralysis

- factors: LBW, breech, labor anomalies, operative vaginal birth, shoulder dystocia - Force can cause varying degree of injury to nerves - Affected arm are adducted, extended, and internally rotated - Moro reflux is not present on this side - Complete recovery in 6 months or longer

Physiological Jaundice

- happens fast, 1st24 hrs - Term infant jaundice increases 3-4 days after birth to serum levels up to 10mg/dl and then the levels fall rapidly - Serum (indirect) unconjugated bilirubin levels exceed 2.0 in 90% of infants - normal is 0.1-1.0 - Direct or conjugated bilirubin is normally 0 - 0.4 (Total is both direct and indirect

Microcephaly

- head circumference more than 2 SD below average or less than 10% of normal parameters for gestational age - Due to a reduced number of neurons leading to reduction of brain volume = reduced skull size - Severe microcephaly = 3 SD below the mean for age and sex - 40% = epilepsy, 20%= cerebral palsey,50% =intellectual disorder, 20-50% = opthamlamic and hearing disorders

Macrocephaly

- head circumference more than 90% of normal, typically related to hydrocephalus - Associated with familial, isolated abnormalities or others (ex. Hydrocephaly and skeletal disorders (achondroplasia))

Documentation

- initiation of monitoring pertinent info. should be made directly on monitor strip, in computer and record # - Initial documentation - Name, date, hosp.#, MR # - gravida, para - VS - dilation, station - position , high risk factors - every single thing has to be charted - bathroom, sitting up, eating, putting on side

Type 2 diabetes

- insulin resistant or deficiency - obesity, 90% of DM

Spina Bifida "Occulta"

- internal) - Not able to see (no outside sac), internal closed defect - s/s: hairy patch, dimple, lipoma, hemangioma - Cannot place under warmer - will dry out the sac and cause it to rupture

s/s of withdrawal-neonatal abstinence syndrome

- irritability, HTN, jitterness, fever, high pitch cry, nausea, vomiting, diarrhea, resp. distress, seizures, excessive sneezing/yawning, poor sucking, poor sleeping, nasal stuffiness, diaphoresis, tremors

Clomiphene Citrate Challenge Test

- measures ovarian reserve: are eggs able to be fertilized - Lab test: FSH level on cycle day 3, takes 100mg clomiphene citrate (clomid) on days 5-9, draw lab on cycle day 10: abnormal if FSH level is greater than 15, not likely to conceive with own eggs.

causes of Blood Incompatibility: Rh

- mom is Rh negative & fetus is Rh + like the father - Rh negative moms have no Rh antigen (D antigen), so when Rh + are imposed into blood stream antibodies are built up - maternal and fetal blood should not mix unless an antepartal procedure is done (amnio, ab)- give rhogam - at delivery blood mixes and women must receive RhoGAM or immunoglobulin to prevent antibody formation - if antibodies are present they will cross placenta and attack fetus RBC's and produce erythroblastosis fetalis and hydrops fetalis, fetal heart problems, breathing difficulties, jaundice, hemolytic disease/anemia - Isoimmunization- Sensitization

Nursing Care with induction/augmentation

- monitoring the pt before and after procedure - ↑risk for infection especially after 24 hours, temp. q2 h - ↑risk for abruptio placenta - disrupted IU pressure - allow access for internal fetal monitoring - pad bed equipment ready -sterile glove, lubricant, amnio hook, monitor FH - note color, amount and odor, assess variations

Large fontanels

- more than 6 cm in the anterior or more than 1 cm diameter in the posterior - Associated with malnutrition, hydrocephaly, congenital hypothyroidism, trisomy's 13,18,21 and bone disorders (ex. Osteogenesis imperfecta)

CVD Group 3 risks

- mortality 25-50% - major risk - Aortic coarctation (complicated), previous MI, Pulmonary hypertension

CVD Group 2 risks

- mortality 5-15% - mod. Risk - Mitral stenosis with atrial fib., Artificial heart valves, Aortic stenosis, classes III and IV, Uncorrected tetralogy, Aortic coarctation (uncomplicated)

Marijuana

- most common illicit drug - tremors, CNS effects, long term effects on brain function; tachycardia, inflamed airways, orthostatic hypotension; spontaneous abortions, pre-term birth

Laparoscopy

- most invasive - Endoscope inserted in abdomen incision; use anesthesia, surgical risks - Visualize endometriosis, adhesions, fibroids, occluded tubes, ovarian cysts (polycystic), outside of fallopian tubes - Performed early in menstrual cycle

Pharmacologic Agents for induction: Pitocin

- naturally produced by post. Pituitary - Used after ripening to induce or augment labor Side effect: hyperstimulation of uterus - titrate carefully, - hypertonicity (UC's < 2 min >70sec, too tense or an ↑in resting tone), hypotension - Antidiuretic effect-decrease urine flow- water intoxication (s/s H/A and vomiting) - IVPB infusion via pump (ex: 10U/1 liter LR (isotonic solution), titrate until UC q2-3min, 40-60 sec. duration, uterus needs to relax between UC <20 mm Hg: continuous FHR monitoring - Observe non-reassuring patterns -DC oxytocin & run plain IV. Notify MD - If see decreased FHR and late decels -STOP Pitocin; keep play IV running (lactic ringers) and notify HCP - Turn on side, giving oxygen, etc. - Advantages: Short half-life (1-5 min.), doesn't cross placenta, well tolerated

Gestational Hypertension

- non-chronic HTN - Vasoconstriction-vasospasm-poor tissue perfusion-all organs - Starts after 20 weeks gestation - NO proteinuria, NO edema - Return of normal bp after pregnancy - 140/90 or higher x2 readings more than 6 hrs apart or systolic increase of 30mmHg or diastolic increase of 15 mmHg from pre-preg. baseline - Leading cause of maternal death - Most common complication of preg. - All races, ethnic groups, greater <20yrs, >40yrs old - If occurs before pregnancy, or before 20 weeks gestation= Chronic HTN

Gastrointestinal PP

- normal bowel function is interrupted in 1st week due to ↓ mobility, pain meds, low fiber diet, fluid loss and perineal discomfort, usually reestablished by end of 1st week as fluids ↑, ↓ progesterone and perineal discomfort ↓ - last time moved bowels? Has good bowel sounds? Passing flatus? - (Simethicone (Mylicon) - chewable) - helps breakup gas

Skin Assessment assessment of newborn

- observe the overall appearance of skin, including color, texture, tugor, and integrity (Normal: smooth and flexible, skin color is consistent with genetic background) - note any rashes, ecchymoses, petechiae, nevi, or dark pigmentation; Skin lesion can be transient or congenital; can results from infection or from mode of birth

The ROM results in very small gush, this is possibly what? due to?

- oliogohydramnios placental insufficiency or kidney abnormalities

Biparietal diameter

- one of the basic biometric parameters used to assess fetal size. BPD together with head circumference (HC), abdominal circumference (AC), and femur length (FL) are computed to produce an estimate of fetal weight - done via ultrasound - measures ear to ear

Nevus flammeus

- port wine stain(does not fade); commonly appears on face, head, neck, but can occur anywhere (capillary angioma under the skin) - Flat, with sharp demarcations and purple red; ranges in size but does not grow - May be associated with structural malformations, bony or muscular overgrowth, or certain cancers - Need to monitor by periodic eye examinations, neurological imaging, and extremality measurements - Laser and intense pulsed light can be used to treat- optimal treatment is 1 year or age

Nursing Interventions during labor

- position -walking helps descent of baby - peri care -clean blue pad (decrease infection of e-coli) o Cleaning Perineum; betadine soap - rinsed with warmed saline - support person - include - check bladder q 2 h -st. cath if necessary o if full = uterus cannot contract; if cnt empty - lead to going back to kidneys and cause a infection o Will need to cath or straight cath if not feeling (epidural) but best is having them empty on own - mouth care - Gown, glove, protective eyewear for delivery

s/s of Deep vein Thrombophlebitis

- possible + Homan's sign, pedal edema, can be asymptomatic - "Milk-leg" - pale, cool with decreased peripheral pulses - may have pain on ambulation, chills, temp

Perineum PP

- pressure of descending head stretches & thins the muscle of pelvic floor, edematous & bruised - incision pain varies and may persist as long as 5-6 weeks- 4-6 months - Hemorrhoid distended rectal veins which are pushed out - Edema - may be present with or without an episiotomy - Kegel exercises important: improve pelvic tone, strengthen perineal muscles, improve healing - If not: urinary incontinence possible later in life -If do not do, will have problem with continence later in life

Uterine contractions

- primary powers of L/D - Described by frequency, duration, and intensity -labor progresses ↑ lengthens & intensity ↑ to about 2-3 min -UC's responsible for effacement, dilation & descent -originate at pacemaker near tubal insertion & move over uterus like a downward wave -strongest in fundal area · As uterus contracts = Muscle fibers become shorter and shorter · Make one area for baby to go ... out · Need breaks between for muscle to replenish O2

Factors that Inhibit Involution

- prolonged labor, anesthesia (relaxes uterine muscle) - difficult delivery - uterus worked harder and now will have to work hard to involute - might have trouble doing (overdistention of uterine muscle) - grand multiparity (stretched out several times = decreased tone and muscle relaxation) (has to work twice as hard to get back to normal - needs to cramp back to normal (after pains) - since working so hard, may not function as well -hydramnios; large singleton fetus - full bladder *most common cause (results in uterine atony) (its pushing on the uterus and moving the uterus and the muscles cannot work effectively (interfers with contraction); has get rid of all the fluid - diuerese) - retained placenta, amniotic membranes (encourage bleeding) - Uterine infection Infections and retention of placental fragments = subinvolution

Galant Reflex

- prone or held in ventral suspicion, apply firm pressure and run ringer down either side of spine; stoking will cause pelvis to flex toward stimulation side; indications T2-S1 innervation (disappears few days - 4 weeks) - If absence = neurological or spinal cord problem

classical C-S incision

- rarely used now - upper uterine segment - high rupture next preg - can't VBAC, higher blood loss, hard to repair

management of Hypertonic Uterine Dysfunction

- relief of pain (muscle anoxia) - Possible medications: sedation to reduce pain and promote relaxation; - IV therapy - Monitor for fetal distress - make sure good HR and no decels. - Bed rest, relaxation techniques - Hydrate - maternal position change

Lochia Assessment PP

- rubra, serosa or alba, amount, clots (small or large?) - How many pads she used within the past 1-2 hrs and how much drainage was on each pad as well as color and odor of the drainage - Foul smelling = infection; large clots = poor uterine involution

Placenta: produces hormones -Relaxin

- secretion by the placenta as well as the corpus luteum during pregnancy -Acts synergistically with progesterone to maintain pregnancy -Causes relaxation of the pelvic ligaments = increasing flexibility of the pubic symphysis, permitting the pelvis to expand during deliver - Softens/dilates the cervix in preparation for birth - thought to suppress the release of oxytocin by the hypothalamus , thus delaying the onset of labor

Grade 3 placental abruption

- severe - >50% separation - Extreme abdominal pain, uterine tetany (hard as a rock) - Absent to moderate bleeding - Disseminated intravascular coagulopathy (DIC), maternal shock, fetal death

Normal Circulatory Adaptation newborn

- shortly after 1st cry HR 120-180, then decreases slightly - 1st and 2nd heart sounds should be clear & well defined - count for full minute - blood pressure - higher immediately after birth then reaches plateau within a week - is sensitive to blood volume - Transient functional heart murmurs may be heard (possible PDA)

Newborn Assessment

- should be done within the first 24 hrs after birth - Results vary based on #hrs. old, want to wait for the completion of transition - Ideal: quiet infant - Do least invasive first - look at baby, listen to heart, lungs, and belly, etc. - Observe first -§ Head to Toe includes: general survey of skin color, posture, state of alertness, head size, overall behavioral state, respiratory status, gender, and any obvious congenital abnormalities - Be sure to check the overall appearance of anything unusual

During monitoring document

- sterile vaginal exams (SVE) - maternal repositioning - analgesia or anesthetic, any meds. - VS - emesis, pushing, adjusting toco - ANY NURSING CARE OR THERAPEUTIC INTERVENTION

treatment of Toxoplasmosis

- sulfadiazine and pyremethamine

Emotional Status Assessment: Postpartum Period

- talkative or withdrawn) - How she's interacting, level of independence, energy level, eye contact with infant, posture and comfort while holding infant, sleep, and rest patterns - Be sure to watch for mood swings, irritability and crying episodes - Bonding: close emotional attraction during the first 30-60 minutes after birth - Attachment: developing strong affection between an infant and significant other

biship test

- test cervical readiness - Readiness must be evaluated & documented - Score: >8 successful vag. birth likely - If Score is <6, must use a cervical ripening agent before induction

Low-lying placenta previa

- the placenta is implanted in the lower uterine segment and is near the internal os but doesn't reach it - Not as close to the cervix and may be able to deliver

Hematuriain early PP period reflects?

- trauma, later may be UTI - Hard to see in hat due to mixing with lochia in the urine - If truly was blood, most of the time see if foley is in - then you know its blood coming from the bladder and shows some sort of trauma - If do urine analysis after delervy in a follow up visist = UTI

dryness/discomfort PP

- until menstruation: can use water soluble lubricant • Need to know when to expect their menses: Can become pregnant again before their next menstrual cycle - Ovulation occurs before the menses

General Anesthesia

- used in emergency advantages -Fast - loss of consciousness disadvantages -↑aspiration, pp hem. - gen. anesthesia cross placenta within 2 min. vigorous neonatal resuscitation needed - Medications -Nitrous oxide 40-60% O2 Penthathal (balanced - used with succinylcholine) Barbituates IV

diuresis PP

- usually begins within 12 hours after delivery which eliminates excess body fluid, continues for 1 week, normal by 4 weeks - IV fluids, oxytocin (antidiuretic effect) decreasing

• Preimplantation Genetic Diagnosis (PGD)

- usually on day 3 after egg retrival and 2days after fertilization • Single blastomere is removed from the developing embryo to be evaluated through IVF • Genetic testing is performed to identify embryos carrying specific genetic alterations that cause disease. Only the ones w/out genetic alterations that are later transferred into the women's uterus to start a pregnancy • Prevents inheritable genetic disease before implantation

Common symptoms of AUB

- vaginal bleeding between cycles, irregular menstrual cycles, mood swings, hot flashes, vaginal tenderness, variable menstrual flow ranging from scanty to profuse, obesity, acne, stress, anorexia, thyroid disease, diabetes

causes of PROM

- vaginal, cervical infections, chorioamnionitis - incompetent cervix - fetal anomalies and malpresentation - hydramnios - nutritional deficits

Postpartum Blues

- very common due to hormones maintaining the pregnancy drop (normal) - Emotional lability - Cry one minute, laugh next minute - Blues Symptoms - Crying spells, sadness, confusion, insomnia, poor appetite and anxiety - Begins day 3 pp resolves by day 10 - Affects 75% of all new mothers - Self-limiting, mildest form

fetal effects of TB

- very small risk of possible infection while in utero leads to: - failure to thrive, lethargy, RDS, fever, death, enlargement of liver, spleen, & lymph nodes & may acquire TB after birth if exposed to droplets/inhaled

Promote Nutrition: Parenteral (TPN)

- via central venous catheter - Make up a bag full of nutrients based on orders and run through IVcatheter

abdominal muscles

- voluntary pushing - "bearing down"

management of Hemorrhagic/Hypovolemic Shock

- vs q 5 min - O2 at 6L - type & cross match for blood - pulse oximetry - IV's: 18 angio (16 too big = painful) - uterine packing - to help stop the bleeding - ligate ovarian/hypogastric artery - hysterectomy - Correct bleeding disorders

false pelvis

- when People think they have "great hip bones" where this has nothing to do with the bottom of the pelvis

Nursing Interventions immediate newborn period: Medication Administration - erythromycin ophthalmic ointment 0.5% OU or (tetracycline 1% ophthalmic ointment)(prevent Opthalmia Neonatorum-blindness)

- within 1-2 hrs after birth - Inner cannula to outer cannula - thin Rubin (1/2) to prevent infection from chlamydia/Gonorrhoeae - If infected: both eyelids swollen and red with purulent discharge - Inform parents on why it is recommended, what problems may arise if the treatment is not given, and possible adverse effects of the treatment

Anthropoid pelvis

- woman's pelvis that is elongated in its dimensions and is sometimes referred to as apelike - very oval, more room anterior to posterior, but less room laterally - usually adequate for vaginal delivery

Risks & Parenting

- ↑ incidence of Preeclampsia - ↑ incidence of anemia and poor nutrition - ↑ incidence of maternal mortality - ↑ incidence of LBW and prematurity - ↑ incidence of STI's (Chlamydia and gonorrhea) - ↑ in non-nurturing behavior - inappropriate behavior - insensitive to cues - lack of understanding about Growth and Development - ↑ inappropriate reactions to stress - ↑ in uninvolved partners (many men are older, average 3-6 years) Partners- less education - responsibility difficult

maternal risk with DM

- ↑ risk for Preeclampsia - Infection: UTI, chronic monilial vaginitis - Hydramnios & cord prolapse - Ketoacidosis (d/t uncontrolled hyperglycemia) - PROM & PTL - C/S birth & vaginal trauma - PP hemorrhage (d/t overdistended uterus) - Stillbirth

risks associated with Cesarean Section

- ↑maternal morbidity & mortality - ↑infection & hemorrhage - ↑urinary tract trauma - ↑thrombophlebitis - ↑paralytic ileus - ↑atelectasis - ↑anesthesia complication - ↑preterm delivery - increased persistent pulmonary hypertension - injury

HIV

-50,000 new cases in US every year: Public health crisis! -Retrovirus: causes breakdown in the immune system=Acquired immune deficiency syndrome (AIDS) -Causes the infected person to acquire opportunistic infections or malignancies, becomes fatal -Transmits to newborn before, during birth or through breastfeeding

Parvovirus B19 Infection

-5th disease, benign, self-limiting, childhood virus -65% women have immunity -Oropharyngeal casual contact and blood transfer

Amniotic Fluid

-98% water: 2% organic matter -Fluctuates throughout pregnancy -Normal 800-1000ml by 37 weeks - detected by ultrasound at 38 weeks

Missed abortion

-< 20 weeks = not viable - Nonviable embryo (dies but is retained), at least 6 weeks, irreg. spotting - May progress to inevitable ab - If not, need to evacuate uterus. - depends on how far along (if 2ndtrimester need stronger suction) - Suction curettage (1st trim), D & Evacuation (2nd trim) (more involved with the 2nd trimester) - Can also induce labor with PGE2 suppository; empties uterus without surgical intervention

Baseline Variability Classifications

-Absent= Undetectable -Minimum= < or = to 5 bpm -Moderate (Normal)= 6-25 bpm -Marked= >25 bpm

Risk factors for chlamydia

-Adolescent -Multiple sex partners -New sex partner -No barrier contraceptive -Oral Contraceptives -Pregnancy -History of another STI

Special Populations at Risk for Adverse Pregnancy outcomes

-Adolescents -Women who are positive for the human immunodeficiency virus (HIV) -Older women -Women who abuse substances

How is culture affected in infertility?

-African American: assistive reproductive techniques are unnatural and that they remove the spiritual or divine nature of creation from conception; seek spiritual rather than medical assistance when trying to conceive; don't want to disappoint spouse -Hispanic: children validate marriage, typically large families; very spiritual and may consider infertility a test of faith and seek spiritual counseling -Asian-American: avoiding the stigmatization of infertility

HIV

-All pregnant pts are offered screening, risk assessment, consents with proper counseling is important -early treatment has proven beneficial, 2% of infants HIV + with medication compared to 35 % without medication - Zidovudine - therefore want them to continue medication throughout pregnancy -maintaining good health status is important, support/education, grieving issues, confidentiality issues, barriers to care -C/S without ROM ↓ risk of perinatal transmission -No Breastfeeding

Follicle Stimulating Hormone: FSH

-Anterior Pituitary secretes -Matures ovarian follicles

Pelvic Inflammatory Disease: PID

-Ascending infection, recurrent/chronic -Frequently caused by untreated chlamydia/gonorrhea -Complications: Pain, adhesions, depression, abscesses, ectopic pregnancy, infertility -Manifestations vary > hard to diagnose

Admission of laboring women

-Ask to go to BR put gown on -Leave a urine spec. UA -Hgb/Hct, CBC, Blood -Type, Rh, VDRL -Maternal VS (in between UC's) ALL 5! -temp q 4 h or q 2 h with ROM concerned about infection -so increase frequency of T check -pulse, resp & B/P q 1h -latent phase & q.30 min. active phase -FHR 10-20 min continuous FHR assessment

Hepatitis C

-Attacks Liver, inflammation -Not usually sexually transmitted, but could be -Perinatal transmission rare unless immunocompromised - New treatment available but no vaccine yet.

treatment of syphilis

-Azithromycin or Ceftriaxone, one dose -Ciprofloxacin (3 days) or Erythromycin (7 days) Penicillin-G: IM or IV -Less than 1 yr. infected: 2.4 million units IM x1 dose -Unknown duration: 2.4 million Units IM, once a week x 3 weeks -Doxycycline: if allergy to Penicillin Important to follow up, re-test, re-evaluate - seen around 6 months, 12 months, and 24 months to re-evaluate

Second Trimester Discomforts

-Backache: Avoid standing or sitting in on position for long periods, heating pads, support back with pillows, use proper body mechanics, avoid excessive bending/lifting/walking, wear supportive heeled shoes - no high heels, stand with shoulders back to maintain correct posture - Leg cramps: Elevate legs above heart, straighten both legs and flex your feet with cramps, ask HCP about calcium supplements - Varicosities: Walk daily to improve circulation, elevate both legs above heart, avoid standing in one position for long periods, do not wear constrictive stockings or socks, do not cross legs for a long time, wear supportive stockings to promote circulation - Hemorrhoids: Establish a regular time for daily bowel elimination, avoid constipation and stringing, prevent straining by drinking plenty of fluids and eating fiber-rich foods and exercising, use warm sitz bath and cool witch hazel compresses for comfort - Bloating/Flatus - avoid gas forming foods, avoid gum

Fetal heart rate patterns

-Baseline FHR -Baseline variability -Periodic baseline changes

Victim profile

-Battered Woman Syndrome -Feel they have a personality flaw, inadequacy to keep man happy -Feelings of failure reinforced by partner -Poor self esteem -May have been abused as child -Depression -Insomnia -Hx of suicide attempts, injury -Drug or alcohol abuse

phase 2 of cycle of violence

-Battering Stage -explosion of violence, characterized by uncontrollable discharge of tension; violence is rarely triggered by the victim's behavior: she is battered no matter her response -results in assault/death; victim feels "lucky it's not worse" -Kick her or pinch her in areas where you cannot see the bruising -Deny the seriousness of their injuries and refuse to seek medical help

Teaching Guidelines to Managing Health

-Become an informed consumer - read, ask & search -Know your family history and high-risk factors -Maintain a healthy lifestyle; use moderation -Schedule regular medical checkups and screenings -Ask for a full explanation of any treatment -Seek a second medical opinion if you need more information -Know when to seek medical care by being aware -Balance energy expenditure with energy intake to maintain ideal weight range -Modify your diet to prevent becoming overweight -Avoid excessive use of alcohol and mood-altering or sedation drugs -Avoid smoking to prevent cardiovascular disease and lung cancer -Identify areas of emotional stress and seek assistance to resolve them -Balance work, recreation, and rest to reduce anxiety and stress in life -Maintain a positive outlook regarding the diagnosis and prognosis -Participate in ongoing care to monitor any medical conditions

After the acute phase of HIV

-Becomes asymptomatic -BUT: virus is replicating, affecting immune system -T-Cell count: normal 450-1200 cells/microliter, AIDS: <200 -Eventually, all who are HIV + will develop AIDS (average 11 yrs. after infected) -Delayed by Antiretroviral therapy

Periventricular-Intraventricular hemorrhage (IVH) in newborn

-Bleeding in the brain- subependymal germinal matrix into ventricular system -Thin capillaries, rupture easily -Lead to CP, seizures, hydrocephalus, developmental impaired -Classified: I to V (least to most severe)

Physical changes during pregnancy: cardiovascular

-Blood volume increases by 40-50% - more volume = increase cardiac output -Cardiac output increases from 30-50% then decreases to 20% due to compensation -Heart rate increases 10-15 bpm (beats per minute) -Slight heart enlargement -BP decreases initially d/t progesterone; vasodilation then returns to normal -Supine hypotension syndrome - RBC increases 30% to transport Oxygen, but plasma volume exceeds RBC = hemodilution

Fetal circulation pattern

-Blood with the highest oxygen content is delivered to the fetal heart, head, neck, and upper limbs - blood with lower oxygen is shunted back to the placenta -Oxygenated blood is carried from the placenta to the fetus through the umbilical vein. Half of the blood goes to through the hepatic capillaries and the other goes to the inferior vena cava through the ductus venosus. From their it is carried to the right atrium of the heart. Some of the blood is shunted through the formen ovale to the left side of the heart, where it Is routed to the brain and upper extremities. There rest of the blood travels down to the right ventricle and through the pulmonary artery. A small portion of blood travels to the nonfunctioning lungs, while the remaining blood is shunted through the ductus arteriosus into the aorta to supply the rest of the body.

pelvic outlet

-Bound by the ischial tuberosities, the lower rim of the symphysis pubis, and the top of the coccyx -Wider from front to back

Treatment of PID

-Broad spectrum antibiotics: Parenteral Cephalosporin with doxycycline BID x14 days; injection -Bedrest, pain management, fluids -Counsel regarding risk factors/prevention -Takes a while to treat and have it as a chronic condition their whole life

Calculating the Apgar score

-Calculation (Maximum of 10 points) 8-10 score normal; no intervention needed, 4-7 moderate difficulty adjusting to life; 0-3 severe distress -Affected by the presence of infection, newborn maturity, mother's age, congenital anomalies, physiologic immaturity, maternal sedation via medications, labor management, and neuromuscular disorders

Placenta: produces hormones -Estrogen (Estriol)

-Causes enlargements of a women's breast, uterus, and external genitalia - increases vascularity = vasodilation - relaxation of pelvic ligaments and joints -Stimulates myometrial contractility - association with hyperpigmentation , vascular change in the skin, increased activity of salivary glands, and hyperemia - aids in developing the ductal system of the breasts in preparation for lactation

Physical changes during pregnancy: ovaries

-Cease ovum production during pregnancy - no need - Elevated estrog/progest. block secretion of FSH & LH - due to no more eggs -Corpus luteum persists until 6-7 weeks to secrete progesterone until the placenta takes over

treatment of Gonorrhea

-Ceftriaxone (Rocephin) IM or Cifixime (Suprax) -Azithromycin (Zithromax) or doxycycline (Vibramycin) po if Chlamydia suspected (in addition to above meds).

management of Post Term/Prolonged Labor/Birth

-Cervical ripening -Continuous fetal surveillance tests -Induction of labor

Primary stage of syphilis s/s

-Chancre (painless ulcer) at site of bacterial entry -Disappears 1-6 weeks with no Rx -Painless, bilateral adenopathy (swollen lymph nodes) -Highly infectious period -Untreated progresses to secondary stage

Mutation

-Change in gene structure or location -alters type/amt. protein produced -Important to look at - Can have no significant affect OR may be very significant - Cystic fibrosis, sickle-cell disease, PKU, hemophilia

Ovulation predictor kits/Urinary LH (luteinizing hormone) level

-Check temp., dip urine, color change indicates LH level high, most fertile -Need to understand the endometrium and ovulation schedule -Higher the LH = more fertile -Tells you if they are producing enough eggs

Pregnant woman and unborn child risks from violence:

-Chronic anxiety -Miscarriage -Stillbirth -Poor nutrition, insomnia, -Substance abuse -Preterm labor -Late prenatal care -STI, UTI, other infections -Low birth weight, premature -Physical and Mental Trauma to mother and infant

Bronchopulmonary Dysplasia/Chronic Lung Disease in newborn

-Chronic lung disorder following a lung injury -Multifactorial: d/t mechanical vent., oxygen toxicity (high O2 concentration), pulm. Edema, surfactant defic.

Abuser profile

-Comes from all walks of life -Has feelings of inadequacy, insecurity, powerlessness, and helplessness -Directs violence toward partner or children at home; refuses to share power with a partner or family member -May fail to accept responsibility or blame others for their own problems -May abuse their self's -Might have substance abuse problems, mental illness, prior arrests, obsessive jealousy, erratic employment history, and financial problems -Substance abuse does not cause or mentally ill does not always result in an abuser

Ectoparasitic Infections (Scabies, lice)

-Common cause of skin rash and pruritus -Cause through sexual contact and sharing personal items

Progesterone

-Corpus luteum secretes -Peaks 5-7 days after ovulation -Maintains pregnancy

Reproductive healthcare practices: psychosocial issues

-Depression/anxiety medication - is it safe for pregnancy? -If have to switch, must be done with time and carefully

Nutritional needs during pregnancy

-Direct effect of 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 • Pregnant: 2500 calories, 80 g protein, 27 mg iron, 600 mg folate • Lactating: 2700 calories, 80g protein, 9 mg iron, 500 mg folate

Considerations for the" Ideal Method" to prevent pregnancy

-Ease of use; consistent method -Safety -Effective -Minimal side effects -Naturalness -Nonhormonal -Immediate reversibility -Bottom line: If not going to use it correctly, regularly, consistently, can't not be effective

Nonstress test (NST)

-Eats meal, lies on left side, monitored for uterine activity and fetal heart rate -Push button when feel movement -FHR incr. with fetal movement (normal) -Non-invasive Results are charted as Reactive or Nonreactive: Reactive= At least 2 FHR accelerations, from baseline of at least 15bpm for at least 15 seconds (15 x 15 rule) within 20 minutes. Allow 40 min. to achieve -Nonreactive= absence of 2 FHR accel. Using 15 x 15 rule; consider additional testing

Definitive diagnostic procedures for PID

-Endometrial biopsy -Transvaginal Ultrasound -Laparoscopy

Proliferative Phase of Endometrial Cycle

-Endometrial glands enlarge d/t Estrogen levels increase -Blood vessels dilate -Endometrium thickens -Begins day 5 of menstrual cycle lasts until ovulation -Ovarian follicles must stimulate estrogen for this phase to occur -This phase coincides with the follicular phase of the ovarian cycle

Prostaglandins (oxygenated fatty acids)

-Endometrium produces -Technically not hormones, produced by all tissues not just glands -Free the ovum inside the graafian follicle -In menstrual blood, role unknown

When a patient/family comes into L&D:

-Establish a therapeutic relationship -Determine family expectations -Convey confidence -Use touch for comfort -Identify/Respect cultural values -Provide privacy -Components of an Admission Assessment -Maternal health history -Physical assessment -Fetal assessment: Make sure to get on fetal monitor to get a base line fetal HR Lab studies: H/H, blood types - just in case C/S would occur - can call down and ask them to hold it -Assessment of psychological status

Reproductive healthcare practices: lifestyle practices

-Exercise - can continue to run while pregnant -Anything you have been done previously can typically be continued when pregnant (low risk pregnancy) - do you use saunas or hot tubes - high heat should not be expose fetus -do you smoke? Drink?

Perineum

-External region between vulva and anus -Skin, muscle, and fascia -May tear in childbirth or an incision may be made: episiotomy- provide space for passage

Internal Fetal Monitoring

-FSE and/or IUPC -fetal scalp electrode/spiral electrode (FSE) record fetal ECG and converts it into FHR pattern -stylet is connected to feed it in -put it under the fetal head, and given an exact fetal HR, no artifact is present -only used for very high-risk patients - do not want o do for low risks patients due to breaking the skin = risk for infection -have to be at least 2 cm dilated and ROM -hook up to monitor

Identifying victims of human trafficking

-Female or child in poor health, education, employment, economic opportunities -Foreign-born child who doesn't speak English; no immigration documents available -Inconsistent explanation of injury -Reluctant to give any information about self, injury, home or work -Appears fearful of authority figure or "sponsor" if present -"Sponsor" will not leave victim alone with healthcare provider; victim "lives" with the employer

Fetal Engagement

-Fetal head passes the inlet only confirms adequacy of inlet not midpelvis or outlet; presenting part reaches 0 station - is the fetus ingaged? · Primips - 2 weeks before labor starts · Multips - Several weeks before or not until labor starts

The Female Reproductive Cycle: 3 Progression stages

-First: Thelarche: develop breast buds -Second: Adrenarche: pubic hair, then axillary hair, and growth spurt - Menarche: first menses: Average age 12.8 with a range 8-18; usually about 2 yrs after the start of breast development

Fetal Attitude

-Flexion/Extension of the joints & relationship of fetal parts to one another -Ex: full flexion, no flexion, extension -All parts flexed in beginning of labor

Sexual abuse

-Forced sexual contact without consent -More likely to be sexually abused by father, brother, family member, neighbor, boyfriend, husband, partner, ex, that a stranger or anonymous assailant -Post-assault bleeding - see a gynecologist to repair possible genital injuries

Examples of Sexual Abuse

-Forcing intercourse (vaginal, anal, oral) against victims will -Biting victim's genitals/breasts -Shoving objects into victim's genitals -Forcing victim to perform sexual acts on others or animals

CBC lab work

-H/H (12-14 g / 37-47 %) and RBC (4.2-5.4 million/mm-3) to detect anemia -WBC (5,000-10,000 mm-3) to detect infection -platelets (150,000-450,000 mL3) to assess clotting ability

What happens to pt's with HPV after treatment?

-HPV still remains after wart removal -Viral shedding continues -Duration of infectivity after treatment unknown -May have recurrence after removal

Role of Amniotic Fluid

-Helps maintain a constant body temperature for the fetus -Permits symmetric growth and development -Cushions the fetus from trauma -Allows the umbilical cord to be relatively free of compression -Promotes fetal movement to enhance musculoskeletal development -Really provides the perfect environment for fetal growth

Violence during Pregnancy

-Higher risk for violence during pregnancy -Often time of start or escalation -Abuser takes advantage of vulnerability -Inability of couple to cope with pregnancy - Resentment toward fetus -Doubts of fidelity -Baby is competition - between partner and family -Woman receives more attention during pregnancy -Insecurity, jealousy, financial burdens, stress, limited support system -Tends to escalated during pregnancy

Examples of Physical Abuse - what peoples normally think of

-Hitting, grabbing, leaving marks -Throwing objects at victim -Pushing, choking, shoving -Kicking, punching, slamming -Attacking victim with knife, gun, rope, electric cord -Controls access to healthcare for injury

Gonadotropin Releasing Hormone: GnRH

-Hypothalamus secretes GnRH -Induces release of FSH and LH for ovulation

marijuana effects on newborn

-IUGR, irritable, abnormal sleep, tremors, high pitch cry -Studies on development in progress

Methods for controlling spread STI's

-Identification, education and counseling of at-risk individuals -Identify asymptomatic infected individuals and symptomatic who are unlikely to seek treatment -Identification of effective diagnosis and treatment of infected individuals -Evaluation, treatment, and counseling of sex partners of people who are infected with an STI -Pre-exposure vaccination of people at risk for vaccine-preventable STIs

Ischemic phase of endometrial cycle

-If no fertilization; estrogen and progesterone drop sharply -Corpus luteum degenerates -Arterioles spasm, leads to ischemia of basal layer of endometrium -Basal layer sheds, leads to menstrual flow

If delivery is imminent (about to happen) get:

-Important information only -Name of patient, Physician -G/P, due date -Allergies -Last meal -VS and FHR -Evaluate using SVE-sterile vaginal exam -Call Dr. Set up -Start IV -done as a safety measure, blood to lab -Better to hang blood quickly of stat medication, can use 20 or 18 gauge -apply pressure to head to guide out

Adolescent pregnancy concerns

-Inconsistent BC use lack of knowledge & lack of availability -Psychological development, invulnerable -Fear of reporting sexual activity -Peer pressure -Poor or late care Sex Education -Teach correct terms -Teach to set limits communicate self confidence -Educate about STI; common with adolescents -Contraception - Terminate - Adoption

Physical changes during pregnancy: integumentary

-Increased pigmentation (hyperpigmentation) areola, axillae, perineum, umbilicus - see darkened areas; from hormones -Striae gravidarum: "Stretch marks" -Skin color changes/complexion - due to hormones Hair loss or decline in hair growth -Chloasma - Linea nigra - Vascular spider marks - angiomas of the capillaries will become more prominent - Palmar erythema - red palms - Nail growth increases; brittleness may increase

Controversy of FHR monitoring

-Increased use of FHR monitoring is associated with increased number of c-sections and not a decrease in the Cerebral Palsy rates -Research - has shown improvement in high risk patients; low risk has shown no change in outcomes

Meconium Aspiration Syndrome

-Inhales amniotic fluid mixed with mec while in utero or with first breath -Leads to resp. distress, obstruction, hypoxia, infection, possible death

Treatment of preterm labor in L/D

-Tocolytic Drugs (interfere with uterine contractions) - buys time to help improve the outcome - ex. Mag, brethine, indocin, nifedipine -Works for 2-7 days -Time for steroids to work to help fetal lung development (24-34 weeks); 2 doses, 24 hrs. apart to work. Research shows benefit after 24 hrs. -If infection suspected: antibiotics -Best place for fetus is utero until time for delivery

Hepatitis A and B; Hepatitis C

-Transmitted sexually, acute, viral, systemic - Hep: A, B,C,D,E, and G - Inflammation of liver

Genital Herpes Simplex (HSV)

-Viral, recurrent, life long infection: 50 million USA -A lot of women don't even know they are -If active and delivers vaginally - high risk of baby become ill or dying

treatment of HPV

-Wart removal -Topical trichloroacetic acid -Liquid nitrogen cryotherapy - to remove the wart for comfort, but is still in their system

Maternal and Fetal Factors that influence FHR reading

-adequate maternal blood flow & volume -O2 & maternal blood must reach spiral arteries & intervillous spaces -fetal waste removed from intervillous spaces via the endometrial veins -UC cut off O2 by compressing spiral arteries must have 1-2 min reserve

Colostrum

-an antibody-rich, yellow fluid that can be expressed by the third trimester (converts to mature milk after delivery) -1st production of breastmilk - filled with tons nutrients and antibodies (IgA) (only found in breast milk), low in fat, thin and easily digested -Sometimes called "liquid gold"

Child Incest Abuse

-before victim is age 18 -Children cannot yet understand these activites and cannot give informed consent

frequency

-beginning 1 to beginning of next · count squares, typically each one is 10 seconds, count boxes from the beginning of the next, typically use a range

Purpose of pelvis

-birth passage -protects pelvic structures -provides anchorage for muscles ligaments

concealed placental abruption

-bleeding behind - placenta with margins intact (retroplacental hemorrhage)

Second stage of labor

-cervix is 10 cm dilated to birth of baby -pushing or expulsion stage -10 cms, 100% effaced to birth of baby -average time 20 min multipara, 50 min nullipara -UC may ↓ slightly to 2-3 min, 40-60 sec. pressure on pelvic floor & rectum, urge to push -crowning - tearing sensation - ring of fire tired, relieved, excited, drowsy between UC's

things done/seen at visits for 3rd trimester (weeks 37-40)

-check for Group Beta strep (normally found in vaginal canal), Gonorrhea, chlamydia If baby comes through vaginal canal and positive for beta strep - can become septic -Will re-culture even if treated in with antibiotics prior to de -Fast delivery and was not treated: baby on VS q 4 hrs, baby does not go home for 48 hrs, look for signs of illness -Blood draw, blood culture - IV amp & gent

Nursing interventions for fetal tachycardia

-check maternal temp -monitor closely for association with other concerns

Role of nurses in identifying and preventing STIs: educating public

-communicating the methods of transmission -describing the symptoms associated with each condition -tracking the updated CDC treatment guidelines -offering clients strategic preventive measures to reduce the spread of STIs

Pica

-compulsive ingestion of non-food substances -Ex: Soil, clay, ice, laundry starch -Not proven / believe to be slight imbalance of minerals

s/s of Hypertonic Uterine Dysfunction

-constant cramping pain -increased abruptio placenta (placenta detaches from wall and bleeds) -Exhaustion, frustration and anxiety

Genes

-control types of proteins made and production rate -30,000-40,000 genes each person - Interact with other genes/environment (genomics) - Arranged in specific formation - Instruct dominant and recessive traits Hair color, growth/development, every system

Signs of True Labor: uterine contraction

-coordinated, involuntary & intermittent, regular intervals, starts in back and radiates to front (pushes cervix from posterior to anterior position), fundal to pelvis · Increase in frequency, duration, intensity · Results in progressive effacement & dilation · Rule of thumb: Come in with contractions 5 minutes apart

Potential Problems with circulation in the cord

-cord compression -oligohydramnios -knots -nuchal/body cord

Dysmenorrhea

-cyclic peri-menstrual pain - painful menstruation - Common in adolescences - Pain starts along the start of bleeding and lasts 48-72 hours o Sharp, intermittent spasms of pain in suprapubic area; pain may radiate to the back of legs or lower back - Common symptoms: N/V/ D, fatigue, fever, H/A, dizziness - Smoking causes an increased risk of developing - Primary (spasmodic) and secondary (congestive)

10% of Placenta Previa variation

-defective vascularization - has covered cervix and has attached. in someway 3 types: placenta accreta, placenta increta, placenta percreta

intrauterine pressure catheter (IUPC)

-double lumen, placed inside uterus, can record uterine pressure/contractions at catheter tip along with intraamniotic pressure -Used with electronic fetal monitoring if non-reassuring FHR patterns -Has stylet on it to feed it in -Wholes at the end, hook up to monitor -This measures the true pressure, 2 cm dilated, ROM - Will lay against the wall -Aminioinfusion *Must have:* ruptured membranes, at least 2cm dilation, presenting part low enough for scalp electrode, experienced/skilled practitioner

With a safety plan, what should the women take?

-driver license or photo ID -social security number or green card/work permit -birth certificates for you and your children -Phone numbers for social services or women's shelter -Deed or lease to your home or apartment -Any court papers or orders ¡A change of clothing for you and your children -Pay stubs, checkbook, credit cards, and cash -Health insurance cards -Don't use phone cards - leave a trail

Trisomy 13/Polydactyly

-extra digits - whether has a bone or not determines how it will be removed If no bone - type off extra diet with suture matieral and will necrose and fall off -Can be done in a nursery If has bone - needs be surgically removed and establish more before removal -Will not be done at birth

Assessments Made During Physical Examination of woman in Labor

-fundal height measurements (not as accurate at this time) -uterine activity: including contraction frequency, duration, and intensity -vaginal exam - fetal status/leopold's maneuvers: including heart rate, presenting part, position and station - pain/behavior/psychosocial assessment - monitor/palpate UCs - · Notify Doctor or Certified Nurse Midwife (CNM)

diagnosis of Post Term/Prolonged Labor/Birth

-fundal ht measurements, US

Precipitate/Precipitous Labor

-happening fast; baby is coming out fast -Can be less than 3 hours -intense, frequent UC →fetal trauma & hypoxia -Progress through labor stages very quickly -↓resistance in tissues or oxytocin excess

Baseline FHR

-in between uterine contractions FHR with no stress or stimulation to the fetus: -when the patient is not in labor -when fetus is not moving -between uterine contractions -when there is no stimulation -refers to the range of FHR observed between contractions during a 10 minute period of monitoring, can vary up to 20 beats -the range is where FHR fall 80% of the time, usually *110-160 bpm*

Premonitory Signs of Labor

-lightening -Braxton hicks -cervical changes -rupture of membranes -bloody show -sudden burst of energy

monitoring UC

-listen 1 min between UC (baseline rate) and -q 30 sec after the uterine contraction (periodic change) be sure to document after doing these

Fetal Lie

-long axis of fetus related to long axis of the mother (spine r/t spine) -Longitudinal - 99% -Breached babies -Transverse - less than 1%

Mid-Pelvis

-occupies the space between the inlet and the outlet -Snug, curved space that the fetus must travel to reach the outside

Hypertonic Uterine Dysfunction

-painful, uncoordinated, erratic UC with ↑ resting tone ↑ incidence in latent phase -Prolongs latent phase, stay at 2-3cm and don't progress, nulliparous more

Fetal Presentation

-part of fetus that presents to (enters) maternal pelvic inlet -cephalic -Breech Presentation -Shoulder Presentation

Linea nigra

-pigmented line down abdomen

s/s of Passageway problems

-poor contractions, slow dilation, prolonged labor -Trial of labor or C-section

Passageway

-referring birth canal · Must be normal size and configuration · Soft Tissue - cartilage softens due to ↑ production of relaxin and estrogen · Bony Pelvis

fetal effects of Parvovirus B19 Infection

-severe anemia, spont. ab, congenital anomalies, myocarditis, learning disabilities -Can lead to hydrops fetalis if contracted in first 20 weeks

Shoulder Presentation

-shoulder dystocia -Increased in multiparity, premature ROM, hydramnios, previa (0.2%), transverse lie · 2% births · If can get baby to turn = C/S · Will try to turn baby (version) -one inside rotating and another outside pushing on stomach -Or can be both hands on top -Midwives can promote pelvic rocking on hands and knees to have baby turn (random note?) · Versions: as close to the due date as possible; pushing and pulling may start labor, rupture membranes

Amniotic Fluid Embolism

-similar to PE - AF (with debris- mec, vernix) enters maternal circulation & obstructs pulmonary vessels- causing respiratory distress or circulatory collapse - 50% mortality rate- within 1sthour of symptoms; 85% permanent hypoxia induced neurological damage - may be preceded by vigorous labor, marginal separation of placenta, uterine tear

Clitoris

-small erectile tissue with abundant blood supply and nerves -sensitive to touch, stimulation, temp -function: sexual stimulation

Premonitory Signs of Labor: Rupture of membranes (ROM)

-spontaneous labor usually begins within 24 hours after this occurs · May be gush of fluid or slow leak · Continuous supply produced to protect fetus, even after rupture · Infection possible due to lack of membrane barrier · Cord prolapse risk if presenting part not engaged · Woman needs to be evaluated when membranes rupture · May or may not occur until labor starts · Artificial rupture: amniotic hook · Usually if membranes rupture, labor starts in 24 hrs, if it doesn't start, infection can occur "clock starts ticking"; no membranes are protecting the fetus, the bacteria normally in vaginal area can ascend to fetus; if membranes rupture come in right away: when membranes rupture number one priority is finding fetal heart rate -know if it alive, see how it is · Sterile vaginal exam after rupture - check placement of cord (make sure is not pressed between cord and pelvis) keep hand on cord if feel it - place hips backwards - if cord is compressed: baby is not getting oxygen · With preemies: cord can fall out àcord prolapse; if membranes rupture early, cord can flip · Never try and push cord back in - pressure on head, hips up in air

Danger Signs of Pregnancy: 1st trimester

-spotting or bleeding = miscarriage -painful urination, fever >100 = infection -severe persistent vomiting = hyperemesis gravidarum -lower abdominal pain with dizziness and accompanied by shoulder pain (ruptured ectopic pregnancy)

vaginal exam for women in labor

-sterile glove: gently, aseptic technique -Has tp be a reason for internal - can increase infections or ROM Status of membranes (intact, bulging, ruptured) - Nitrazine swab/paper -Fern test - Clear fluid (normal), cloudy/odor/yellow (infection) - chorioamnionitis, green (meconium in fluid) - could has aspirated or is just risk for aspiration - Cervical dilatation (closed "0" to 10cm) - position (anterior vs. posterior) - degree of effacement (0% to 100%)

Abnormal assessment of fontanelles

-sunken (dips down) = dehydration - bulging = can be due to crying (normal - if not can have increase intracranial pressure, hemorrhage, swelling

S/S of Bacterial Vaginosis

-thin white discharge -"stale fish" odor when mixed with KCl "whiff test" -50% asymptomatic

first stage of labor

-true labor to complete cervical dilatation (10 cm) -Guides assessments, time we have, etc. -Latent phase - less dilated, mild contractions, effacement just started -Active phase - in the middle; expect cm per hour; more anxious and serious, -Transition phase - shortest phase; hardest work in labor; get urge to push but can't until 10 cm, will cause swelling

External fetal monitors(EFM)

-ultrasound transducer - high frequency sound waves reflect mechanical action of the fetal heart -TOCO Transducer -Placed over fundus to monitor UC -pressure sensitive straps, stockinet -bedside monitor- singleton, twins

cryptorchidism

-undescended testicles -unilateral or bilateral - either way up high or "floating" (common with premature dates)

Primary episode of Genital Herpes Simplex

-worst episode when getting it the first time -Most severe, shedding of virus -Systemic infection -Painful vesicular lesions=open, drain, crust -Mucopurulent discharge -Candida superinfection -Flu like symptoms: fever, chills, malaise, dysuria, Headache, lymphadenopathy -Last up to 2 weeks, stays dormant in nerve cells for life

Signs/Symptoms of Trichomoniasis

-yellow/green or gray frothy discharge -Pruritus & soreness -Dyspareunia & Dysuria -Colpitis macularis ("strawberry spots" look cervix); petechiae on cervix -Bleeding on cervix -Vaginal foul odor and erythema (PSEDD-Y/GF, CM, P, B, O)

Risk of Precipitate/Precipitous Labor

-↑ risk of rupture, lacerations, amniotic emboli -increase incidence of pp hemorrhage -increased incidence of infection -Exhaustion

Phases of Rape Recovery

1) Acute phase- shock, fear, disbelief, anger, shame, guilt, feelings of uncleanliness, insomnia, nightmares, and sobbing 2) Outward adjustment phase - appears outwardly composed and returns to work or school; refuses to discuss the assault and denies need for counseling 3) Reorganization - denial and suppression do not work, and the survivor attempts to make life adjustments by moving or change jobs and uses emotional distancing to cope 4) Integration and recovery - survivor begin to feel safe and starts to trust others; she may become an advocate for other rape victims

Categories of Risk in Pregnancy

1) Biophysical: genetic, physical conditions, nutritional problems 2) Psychosocial: smoking, drugs, alcohol, violence 3) Sociodemographic: poverty, no prenatal care, age (younger than 15 and older than 35) 4) Environmental: drugs, pollutants, stress, radiation

Danger Signs of PP

1) Boggy - feels soft and spongy associated with excessive bleeding or clots - Not any worse than heaviest day of period - Ask specifically how long had pad on - Larger clots, and bright red= more concerns - Dark red blood, has been stuck in uterus and just needed to come out 2) Uterus firm but lochia heavy may be laceration or retained fragments - Laceration in perineum area- Retained fragment but not enough to make uterus boggy, but enogh to cause more bleeding 3) Persistent lochia after 2 weeks or return to pink or red discharge after it has cleared indicates subinvolution of placental site or late pp hemorrhage - Goes from to red to pink to white and goes back to red = problem (involution, placenta, postpartum hemorrhage? Etc.)

Mechanisms of Labor: 6 Cardinal movements

1) Engagement, Descent- presenting part moves through false pelvis to true pelvis and reaches the ischial spines 2) Flexion- the head is forced chin to chest so the suboccipitalbregmatic presents 3) Internal Rotation- fetus turns its head (45*) so the largest diameter is lined up with the widest part of the pelvis, AP diameter of fetal head to AP diameter of pelvis 4) Extension- fetal head passes under symphysis pubis and extends - if doesn't wont be able to get the head out 5) Restitution or External rotation- fetal head turns (45*) outside to allow the shoulders to turn pass through the wider diameter of the pelvis 6) Expulsion- anterior shoulder then posterior shoulder, under symphysis pubis Flexion is the second movement, then rotates, under the symphysis pubis it must extend in order to get shoulders out, anterior shoulder comes first, posterior, then comes out

7 Behaviors of Engrossment

1) Visual awareness of the newborn - Sees newborn as beautiful 2) Tactile awareness of the newborn - Wants to touch or hold 3) Perception of the newborn as perfect 4) Strong attraction to the newborn - Focuses all attention on baby in room 5) Awareness of distinct features of the newborn - Can pick out baby amongst others in NBN 6) Extreme elation by the father 7) Increased sense of self-esteem - Proud, feels older, more mature

Acme during labor

25-40 early labor 50-70 active labor 80-100 transition, >100 when pushing

moderate lochia

25-50ml = 4-6" stain

What to do if women have a low grade fever PP?

<101 not uncommon (usually between days 2-5) should not last more than 24 hrs

Contraindications of BF

AIDS & Flagyl - transferred through the best milk

Which respiratory problems should you watch a preterm for?

Apnea, RDS, atelectasis, obstruction, tachypnea

Certified Nurse Midwives

Back by popular demand, now with certification * Post graduate training * American College of Nurse Midwives certified * Normal pregnancy/delivery * Tons of hours * Only for normal, low risk pregnancies

Convection

Flow of heat from body surface to cooler surrounding air (or air circulating over body surface) - Ex. Being by a window, air vent, going down hall with open crib, Cool breeze, drafts, fans, a/c Nursing: - Transport in warmed isolette - Clothing, blankets

Women with CVD are at risk for

Heart failure, arrhythmias, stroke

Reproductive healthcare practices: Sexuality and sexual practices

High risk behaviors, test for disease - problems with infertility? STIs? Been tested? How many sexual partners?

Fallopian tubes

Hollow, 4" long, 0.7cm diameter, flares into funnel shape, opening for egg to fall into Cilia ("beating hairs" ) -Line tube Ciliary action and peristalsis: -move egg toward uterus and sperm from uterus toward egg Egg fertilization -Divides over 4 days, moves down tube slowly

Care during Labor and Delivery

Hospital Home Birthing Center: - Cross over/Hybrid - Midwives primarily - MD backup - Less restrictions - "Home like" - Lower cost - Quicker Discharge: hours

Which immune problems should you watch a preterm for?

IgG doesn't transfer until after 34 weeks, immature immune system, risk for infection

Goodell's sign

Increased vascularity causesthe cervix tosoften (6-8 weeks)

Examples of Environmental risks in pregnancy

Infections, pesticides, second-hand cigarette, smoke, personal stress

cocaine effects on newborn

LBW, preterm, cognitive problems, memory, defects: genitourinary, cardiac, CNS, absence of abd. Muscles ("prune belly syndrome") - no abdominal muscle tone

Treatment options for PMS/PMDD

Lifestyle Changes -Reduce stress, caffeine, smoking, alcohol -Increase water, exercise -Balanced Diet Vitamin and Mineral Supplements -Multivitamin, Vitamin E, Calcium, Magnesium Medications -OC (low dose), antidepressants, diuretics, NSAIDS, anxiolytics, diuretics, progestins, GnRH agonists, Danazol

Disadvantages of home birth

Limited anesthetic pain medication- cant administrate epidermal Danger to mother and baby, if an unanticipated emergency arises An emergency back-up plan, a doctor on stand-by, and a nearby hospital should an emergency occur are necessary

Bilirubin Conjugation

Liver conjugates bilirubin from breakdown of RBC's - After conjugation is excreted in bile - Normal hemolysis of erythrocytes (don't need as many after birth) Heme in hemoglobin is converted to bilirubin - body is supposed to break it down

Radiation

Loss of body heat to cooler, solid surfaces near infant but notin direct contact - Isolette next to a cold window, a/c, outside wall Nursing: - Keep cribs away from cold windows, etc. - Use radiant warmer when transporting, performing procedures, admission assessment

Maternal Age- delaying pregnancy

May already have high cholesterol, dia betes, HTN

Treatment of of Genital Herpes Simplex

No cure or vaccine; decrease symptoms and decrease the exacerbations Antiviral drug therapy; for frequent occurrences -Acyclovir -Famciclovir -Valacyclovir (Valtrex) Vaccine in the works -Will only help those not yet infected

Treatment for hepatitis

None, supportive care

diagnosis of TB

PPD skin test if + chest x-ray - dx is confirmed with a + sputum specimen

Ovaries

Pair of glands -Located below and to side of umbilicus -Pearl color, oblong, 4 cm long, 2 cm wide, 1 cm thick, held by ligaments -Produce ova (eggs) -Produce female sex hormones: Estrogen and Progesterone

treatment of Wound infections PP

Parenteral antibiotics, analgesics, drainage of wound

Other examples of Community Based Health Care Settings

Parish Nursing, Summer Camps, School Programs, Community Programs, Occupational Health

Cycle of Violence: 3 phases

Phase 1: Tension building: Phase 2: Acute battering Phase 3: Reconciliation (honeymoon/ calm phase)

Barriers to Cultural Competence

Provider - Lack of knowledge - Own beliefs differ - Client makes choices not in line with your own Systems - Hospital not designed for cultural differences - Privacy, Food choices, Religious services/ providers - Rules/Regulations require conformity - Meal times

Statutory rape

Sexual activity between an adult and a person under the age of 18

fetal scalp electrode mark

Small puncture on occiput if internal fetal scalp electrode monitory was used during labor

Female factors of infertility

Thorough health history: focus on ovulation/pelvic organs Diagnostic Tests - Ovulation Function: •History of menstrual cycles - any problems, hold long do they last, symptoms? •Ovulation predictor kits/Urinary LH (luteinizing hormone) level •Clomiphene Citrate Challenge Test

Colostrum (pre-milk)

Yellow color, thick High in minerals and protein Low in sugar and fat High in maternal antibodies: IgA, protects newborn from enteric pathogens

late Post-Partum Hemorrhage

after 24 hours to 6 wks

Cultural self-awareness

becoming aware of own values, beliefs, customs, and behaviors - Examine own bias and prejudice - Must do this first before anything else

Educate about back sleeping

decreases SIDS

Scabies

dermatites due to mite (intense itch) Burrows, deposits eggs, hatch, itch, small papule lesion reddens, erodes, crusts Diagnosis: check for burrows in webs of fingers and genitalia

midclavicular facture s/s

limited movement, pin sleeve to shirt

Visit Schedule during pregnancy

up to 28 weeks: every 4 weeks, 29-36 weeks: every 2 weeks, 37weeks to birth: every week) -Once a month until towards end of pregnancy

Hydrocephalus

water on brain

Risk factors: Men for infertility

• Toxic exposure (lead, mercury, x-ray) • Marijuana or cigarette smoke • Alcohol • Prescription drugs • High temp. exposure of genitals (sauna/hot tub) • Hernia repair • Obesity • Cushing Syndrome • Frequent long-distance cycling • STI • Undescended testicles • Mumps (after puberty) - make get vaccinations

Standard days method

• Two-day method - Natural methods of contraception • Determines fertility days • Most use cycle beads • Red: first day of menstruation- move ring to this bead once period starts; continue to move each day • White: days you are likely to get pregnant • Brown: days you are not likely to get pregnant • Dark Brown: helps you know if your cycle is less than 26 days long - if period starts before you move you ring to this spot = <26 days • Last brown: if your period does not start by the day after you more the ring to the last brown bead, you cycle is >32 days

Nutrition Promotion during pregnancy

• USDA Food Guide MyPlate Client education - Take prenatal vitamin/ mineral supplements - Avoid weight-reduction diets during pregnancy - Do not skip meals, eat 3x/day with one or two snacks daily - Limit intake of sodas and caffeine-rich drinks - Avoid use of diuretics and restrict the use of salt unless instructed to do so Engage in physical activity daily

Educate about infant complications Prevention

* Folic Acid Intake: decrease spina bifida, anencephaly (most common NTD) * Substance Abuse Cessation * Smoking increases the risk of SIDS

Breastfeeding in the workplace

* Lactation rooms * Work day care centers

Prevention of #1 killer (CVD) in women

* Low cholesterol, low fat diet * Daily exercise * Weight control * Smoking cessation * Stress management * Cholesterol lowering medications

Objectives of Healthy People 2020

* National Disease Prevention * Health Promotion

Educate about Support Groups

* PP depression * Childrearing practices

Risk factors for lung cancer

* Smoking and second-hand smoke

Vaccines contraindicated during pregnancy

*Influenza (live, attenuated vaccine) nasal spray *Measles *Mumps *Rubella *Varicella *BCG (tuberculosis) *Meningococcal *Typhoid

treatment of Hyperemesis Gravidarum

- &O - IV & parental nutrition (D5LR, vitamins) - NPO 24-36 hours after vomiting - Lab: Electrolyte studies, liver enzymes, CBC, urine sp. gravity, BUN, - Weigh daily - Low fat, small, frequent meals - Sit up after meals to ↓ reflux - Emotional support; dietary and lifestyle changes - Meds: Phenergan, Compazine, Zofran

Homans' sign assessment PP

- (+ or - bilateral check) - increased risk for VTE due to hypercoagulation state during delivery - 3 predisposing factors: stasis (compression of the large vein become of the gravid uterus), altered coagulation (state of pregnancy), localized vascular dame during delivery - Risk factors: anemia, DM, smoking, obesity, preeclampsia, HTN, severe varicose veins, pregnancy or multiple, CVD, sickle cell disease, postpartum hemorrhage, oral contraceptive use, C/S, severe infection, previous VTE, bedrest/immobility for 4 days or more, advanced maternal age >35

Lochia alba

- (days 10 - 14 (can last 3-6 weeks)): creamy white or light brown in color; consists of leukocytes, decidual tissue, and reduced fluid content

Nursing Interventions immediate newborn period: Medication Administration - Vitamin K

- *0.5-1mg IM* (takes infant 1 week to produce own) - within 1-2 hrs after birth - function: fat-soluble vitamin that promotes blood clotting by increasing he synthesis of prothrombin by the liver; Deficiency of this = delayed clotting and risk of hemorrhage - Newborn's at risk for deficiency due to acquired coagulopathy in newborn infants because of an accumulation of inactive vitamin K coagulation factors (II, VII, and X), which leads to an increased bleeding tendency - Normally - bacteria in intestine produce the vitamin K in adequate amounts, but newborn's bowel is sterile and no vitamin K is present until first feeding

PP vital signs

- *BP* (pre-pregnant level) - should remain the same are labor BPs o Increased BP = gestational hypertension, decreased BP = shock, orthostatic hypotension, dehydration *Pulse* (bradycardic) (60-80 bpm) - anything over 100 needs further investigation *Respiration* (16-24 bpm) *Temperature* (98-100 degrees F) - use consistent technique to get accurate reading - temperature greater than 100.4 within the first 24 hours after birth may indicate infection, or anytime - Up to and equal to 100.4 may be d/t dehydration during 1st 24 hrs *Pain status* - 5th VS; ask about type, location and severity; 0-10; Goal of 0-2 - If still says in pain in perineal area after comfort measure provided - palpate/inspect area for hematoma - if one contact HCP immediately Also look at: - Epidural site inspection for infection - Systemic HTT - BUBBLEHE

Interpretation of Apgar score

- 7-10 good condition - 4-6 fair condition, moderate CNS depression, some muscle flaccidity, and cyanosis, must have airway cleared and O2 - 0-3 extremely poor, resuscitation needed immediately by pediatrician or neonatologist

Contraindications to bottle

- Allergies, over dilution

Newborn pulse Assessment

- Apical: count one minute - Brachial present and equal bilateral - Femoral pulses present & equal bilaterally - No bulging in inguinal area - could be a possible hernia

s/s of late PP hemorrhage

- Bleeding- slow trickle, oozing, bright clots, or frank hemorrhage - Pelvic/back pain - Boggy/tender uterus

Common Infections Affecting Pregnant Women

- Cytomegalovirus - Rubella - Herpes simplex virus - Hepatitis B virus - Varicella zoster virus - Parvovirus B19 - Group B streptococcus - Toxoplasmosis

Symmetric IUGR

- Early insult (<28 weeks) - something happened and affecting the growth of the baby - Overall growth restriction, all organs small - Equally poor growth head, abdomen, long bones - Don't catch up

Adverse effects of Vacuum Assisted delivery

- Ecchymosis - Fetal damage with poor application; facial nerve injury - Tissue Trauma: cephalhematoma, caput, lacerations - Marks/swelling usually disappear in 2-3 days

Augmentation

- Enhances ineffective contractions by providing medication - After labor has started - Make more efficient contractions - Continuous electronic FHR monitor

Placental barrier

- Fetal tissues that prevent mixing of mom and fetus blood - Diffusion: material exchange - Maternal uterine arteries: deliver nutrients - Uterine veins: carry oxygen, remove fetal waste

Indications & Risks r/t induction

- Gestational HTN - Maternal diabetes - Prolonged PROM - Rh isoimmunization - Post maturity - Fetal death - Renal Disease - Chorioamnionitis - Dystocia - Hypertonicity of uterine muscle - Uterine rupture

meconium

- Greenish-black color - Tar consistency - Passed 12-24 hrs. after birth

Examples of communities we belong to

- Home, Work, School, Worship, Clubs, Activities

Asymmetric IUGR

- Late insult (>28 weeks) - organs are there but not developed well - Result- intrauterine malnutrition - Catch up later postnatal with good nutrition - Poor growth abdomen, and organs; head and long bones not affected

Hyperemesis Gravidarum

- Persistent N/V - weight loss, greater than 5% of pre-preg wt. lost - Moring sickness can happen any time of the day - Effect kidneys, fetal growth (lack of nutrients) - Dehydration, electrolyte imbalance, ketosis - Not morning sickness - 50-70% to 12wks - Incidence - 5 out of 1,000; - Peaks 8-12 weeks, lasts up to 20 weeks - May require hospitalization - Elevated hCG levels longer than usual; beyond first trimester - May cause neuro. disturbances, renal damage, retinal hemorrhage, death if not treated

Critical Attributes of Attachment (Goulet et al. 1998)

- Proximity:the physical and psychological experience of the parents being close to their infant - Contact: touching/holding - Emotional State - Individualization: differentiate infants needs from own - Reciprocity:the process by which the infants' capabilities and behavioral characteristics elicit parental response - Complementary behavior: infant stares-parent stares - Sensitivity: recognize and respond to infant communication - Commitment:the enduring nature of the attachment relationship - Centrality: infant is placed in center of lives Parent role exploration: Find their own way; integrate new identity

Pulmonary Emboli

- Pulmonary artery obstructed- can cause sudden death - 2nd leading cause of pregnancy related deaths

Third Trimester Discomforts

- SOB/Dyspnea - adjust body position to allow maximum expansion - Constipation: Increase your intake of foods higher in fiber and drink at least 8-ounce glasses daily, ingest prunes or prune juice, consume warm liquids (tea) on rising, to stimulate peristalsis, exercise each day to promote movement through GI tract, reduce cheese - Dependent Edema: Elevate foot, wear hose stockings, change positions, stop to walk around every 2 hrs when long car rides, lie on left side, drink 6-8 glasses of water a day, avoid intake of sugar and fats - Heartburn/Indigestion: Avoid spicy or greasy foods, eat small frequent meals, sleep on several pillows so head is elevated 30 degrees, stop smoking and avoid caffeinated drinks to reduce stimulation, avoid lying down for at least 3 hours after meals, try drinking sips of water to reduce burning sensation, avoid foods that trigger symptoms - fired foods, citrus, soda, chocolate, take antacids if severe - Braxton Hicks Contractions: Change position or engaging in mild exercise to help reduce the sensation, drink more fluids - Urinary Frequency: larger baby, pressing on baby

fetal scalp sampling

- Sample of fetal scalp blood - Measures ph - Assess acid-base status - normal 7.2-7.3 - acidosis <7.2 - done on the fetal scalp or on the breech when fetal hypoxia is present

Assessments during Fourth Stage of Labor

- Vital Signs - Uterine fundus Status - Perineal status - Comfort level - Lochia amount - Bladder status

s/s of UTI PP

- dysuria - frequency - Chills - Fever - Flank pain

Weight and blood pressure measurements; compared to the baseline values .. why?

-First signs of getting a complication - always compare to baseline -Large weight gain - look further - can be retaining fluid (preclampsia)

Incest

-Sexual exploitation between blood relatives or surrogate relatives, closely related, illegal to marry and/or culturally prohibited -Crime and acute irreversible family dysfunction -Long-term effects: eating disorders, sexual problems in adult life, difficulty in interpersonal relationships, anxiety, PTSD, intense guilt and shame, low self-esteem, depression, and self-destructive behavior

Physical changes during pregnancy: Uterus

-Size increases to 20 times that of non-pregnant size - able to handle more weight and more fluid so volume can increase -Weight increases from 2 ounces to approximately 2 pounds at term (70g to 1200g) -Walls thin to 1.5 cm or less from a solid globe to a hollow vessel -Volume capacity increases from 2 teaspoons to 1 gallon (10ml to 5,000ml) -1/6 of total maternal blood volume is contained within the vascular system of the uterus by term -Braxton Hicks - Hegar's sign

Secretory phase of endometrial cycle

-Starts with ovulation ends 3 days before menses Progesterone = changes in endometrium -Thicker, Vascular (spiral arteries), Glandular- glycogen/lipids secretion increases -Estrogen levels decrease -Progesterone dominates -This phase coincides with luteal phase in ovarian cycle

Possible consequences of STIs

-infertility -chronic pelvic pain -ectopic pregnancy -cervical cancer -high risk for contracting AIDS -transmission to offspring -Litigation -Low birth weight -Fetal and/or maternal death -PID (ALL DIP TECC)

Premonitory Signs of Labor: Braxton Hicks contractions

-irregular, intermittent contractions that can be mistaken for false labor · Become stronger and more frequent closer to true labor · Will decrease if walking, eating, changing position · Are felt at top of uterus (true labor contractions felt in back first) · "body is practicing", can change depending on changing position, eating, etc. · when in true labor, they do not stop

Prepuce

-joins folds above clitoris forming hood -this is the site for female genital mutilation/circumcision in some cultures

Types of muscle fibers

1. longitudinal - run lengthwise along the body, and the circular fibers encircle it; smooth muscle 2. interlacing- act as living ligature during involution of the uterus and prevent blood loss. 3. circular fibers - most outer layer

incidence of Toxoplasmosis

1/1000-8000

PROM incidence

10%

Normal resting tonus

10-12mm Hg of pressure

What bones make up fetal skull ?

2 - frontal 2 - parietal 1 - occipital

Cephalic presentation

95-97% (head first into pelvis) · Vertex -fully flexed head(chin to chest, all the way tucked in), easiest, helps dilate, molds · Military-straight up and down; still cephalic, but military · Brow- partly extended (eyebrow, the brow is going to the pelvis first); head is almost hyperflexed, more difficult -Will be rough for mom and baby; will get stuck · Face- full extension -whole face is coming out; hyperextension - won't fit

Marked variability

>25 bpm -could be due to cord prolapse, cord compression, maternal hypotension, uterine hyperstimulation, placenta abruption

ABCDES of Caring for Abused Women

A - not alone B- belief that its wrong C- confidentiality D- documentation E- education S- safety

Pilonidal dimple

A dimple present at the base of the spine; also called sacral dimple - forms fistula and tunneling into the spinal cord; sometimes looks like hole, but just dimple (doesn't go all the way through)

Fertility awareness

Abstinence during fertile days with highest risk of pregnancy • Takes a lot more time and work Relies of follow assumptions: • A single ovum is released from the ovary 14 days before the next menstrual period and livers approximately 24 hrs • Women needs to have regular menstrual cycles for it to be effective • Sperm can liver for 5 days after intercourse, unsafe period is 3 days before and 3 days after ovulation • Rely on body changes occurring during ovulation

Prolactin

After placenta is delivered = Placental hormones: Progesterone & Lactogen levels rapidly decrease, prolactin now not inhibited Stimulates milk production = Colostrum(pre-milk)

Psychological: response to pregnancy

Ambivalence: most common, initial response; no visible body change yet - Idk how I feel, not happy today but was fine yesterday, feels surreal - Really need to process Introversion: turning in on oneself; preoccupied with self and fetus - This is tight now, I need maternity clothes, didn't eat or drink enough, really paying attention Acceptance: triggered by quickening in 2nd trimester - Believe it's when the baby begins to move - This is really happening - really going to be a mom Mood swings: from great joy to despair - Tell them it's normal and don't feel embarrassed - The body and hormones are changing and makes a big difference Body image change: the "picture" you have of your body and of yourself -Assure not everyone looks the same and its okay

Reproductive healthcare practices: support system

Are they by themselves? How are they supporting themselves? Are they working two jobs? Services & even brain storming with patients - are you safe at home? Threatened or hurt you? Do you have pets? - can carry bacteria o cat- can never change litter box while pregnant o contact with soil - avoid due to cats used that area genetics - any family history of certain diseases? Can they transmit it to the fetus

Vestibule

Area enclosed by labia minora, 6 openings -Urethra (bladder) -Vagina -Bartholin's glands (set) -Skene's glands (set) - hymen

Common problems associated with LGA newborns

Birth trauma due to fetopelvic disproportion (FPD) - depressed skull fracture, cephalohematoma, fracture of the clavicle or humerus, brachial plexus injuries, or facial palsy - Hypoglycemia:blood glucose level below 40 mg/dL - Polycythemia:a venous hematocrit over 65% resulting in the blood becoming sluggish, viscous - Jaundice secondary to hyperbilirubinemia:due to the breakdown of an increased numbers of RBCs in circulation

Thrombophlebitis

Blood clot in vessel (from venous stasis and/or hypercoagulation) causes inflammation of vessel - Can lead to thromboembolism - Can dislodge and cause a pulmonary emboli - Doppler study confirms - Make sure to rotate when holding legs during labor (open palm) because could cause stasis of the blood and lead to this

Labs/diagnostic procedures for AUB

Blood count, PT, hCG levels (pregnancy test), thyroid-stimulating hormone level, transvaginal and pelvic ultrasound, endometrial biopsy, D&C

Common lab/diagnostic test for Dysmenorrhea

Blood count, Urinalysis, hCG level (pregnancy test), cervical culture, erythrocyte sedimentation rate, stool guaiac test, pelvic and/or vaginal ultrasound, laparoscopy and/or laparotomy

neutral thermal environment

Body temp. is maintained without an increase in metab. Rate or 02 use - Thermal balance - Newborns have trouble maintaining temp. = need higher environmental temp. If environmental temp. decreases: - Newborn consumes more 02 in response - Resp. rate increases (tachypnea) leads to - Metabolic rate increases

Probable s/s of pregnancy

Braxton-Hicks contractions (16 - 28 weeks) - uterus is a muscle and can contract for other reasons Positive pregnancy test (4-12 weeks) - HCG can be elevated in certain types of cancer Abdominal enlargement (14 weeks) Ballottement (16-28 weeks) - press on abdomen and 1 hand on one side, and press the mass, uterus would move one side to the other - "floating" baby; but can also mean there is a tumor or mass Goodell's sign (5 weeks) Chadwick's sign (6-8 weeks) Hegar's sign (6-12 weeks)

Decreased Variability

Causes: -fetal sleep -narcotics -hypoxia -prematurity -cardiac or CNS anomalies *significance*= Indeterminate/Unclear if not fetal sleep state or medication related CNS desensitized by hypoxia and acidosis; causes decreased FHR, decreased variability, eventually smooth line- poor outcome

S/S of preterm labor

Change or increase in vaginal discharge with mucous, water, or blood in it; pelvic pressure (pushing-down sensation); low, dull backache; menstrual-like cramps; UTI symptoms; feeling of pelvic pressure of fulness; GI upset, N/V/D; general sense of discomfort or unease; heaviness or aching in the thighs; uterine contractions, with or without pain; more than 6 contractions/hr; intestinal cramping, with or without Diarrhea

Basic Principles of FCC

Childbirth * Normal, healthy * Family event * Not medical procedure Affects entire family * Relationships will change Families can make decisions * Empowerment * Information/Support * Educate * Collaboration /Flexibility * Individualized Care

Asthma

Chronic, obstructive lung disorder In pregnancy - 1/3 of women will not experience symptoms, - 1/3 symptoms will worsen 1/3 will improve

3 stages of milk

Colostrum - Last 2-4 days - High in protein, vit, minerals and IgA Transitional milk - 4 days to 2 wks - Increased in calories & fat Mature milk (20 cal/oz) - 10% solids and rest H2O - Foremilk - beginning of feed - High in H2O, protein and minerals - Hind milk - after letdown - high in fat

TB (tuberculosis)

Communicable disease caused by Mycobacterium tuberculosis & transmitted by aerosolized droplets inhaled & taken into the lungs

High Risk Pregnancy

Condition that jeopardizes the health of the mother, fetus, or both. -May be result of pregnancy OR pre-existing -1:4 women -Increases incidence of morbidity & mortality -Risk status can change during pregnancy

Four mechanisms of heat loss in a newborn

Conduction, Convection, Evaporation, Radiation

Uterine wall: 3 layers

Endometrium: -mucosal innermost layer, lots of glands and blood vessels - sheds during menses Myometrium (Middle) -Major portion: smooth muscle linked by connective tissue and elastic fibers Perimetrium -Outer layer covers body of uterus - serous layer (serum-like)

human trafficking

Enslavement of immigrants for profit - Exposed to cigarette burns, fractures, bruises, torture, HIV/AIDS, STIs, cervical cancer, violence, hazardous work environments, poor nutrition, drug and alcohol addiction

Current Trends in Women and Newborn's Health

Family Centered Care (FCC) * Safe, Satisfying * Focus on Physical/ Psychosocial Needs * Get out of medical procedure and show its a natural occurring thing

childbearing in 17th/18thCentury...

Fear of Maternal death * Exhaustion * Hemorrhage * Dehydration * Infection * Seizures * Rate of death 1/8 due to increased childbirths Fear of infant mortality * 50% died before age 5 * 6 per 1,000 live births today

Female genital mutilation/Female Genital Cutting

Female circumcision, cultural practice, Age 4-10 without consent, intense pain, no anesthesia, not sterile conditions, numerous health risks (infertility, dysmenorrhea, dyspareunia, sexual dysfunction, infection, hemorrhage, vaginal stenosis, chronic vaginitis, PID, chronic UTIs, incontinence, genital fistula, recurrent abscesses, transmission of HIV and hepatitis, shock, difficulty walking or using stairs, urinary retention, inability to experience organism, difficult childbirth -Type 1 - removal of clitoris -Type 2 - removal of clitoris and labia minora -Type 3 - removal of clitoris, labia minora and majora, suturing of remain tissue (fibulation) to leave small opening to urination, menstruation, intercourse, and childbirth -Type 4 - encompasses all the other mutilations of the female genital are such as pricking, piercing, scarring, and cauterizing of tissue with the aim of tightening and narrowing the vagina

Vagina

Fibromuscular organ, lined with mucous membrane, tubular canal, transverse folds (rugae) -Rugae allow the dilatation of canal for birth - Smooth before puberty and after menopause d/t low estrogen -Canal= 3-4 inches long -Entrance for intercourse and receives sperm -Exit for menstruation and fetus during childbirth -Acidic environment; Resistant to bacteria: can be disrupted by antibiotics, douching, perineal hygiene sprays/deodorants

Follicular phase of ovarian cycle

Follicles in ovary grow=mature egg -Begins: Day 1 of menstrual cycle until ovulation (10-14 days later) -Varies in length=different lengths of menstrual cycles -Begins: Hypothalamus initiated: --Estrogen levels increased-secreted by maturing follicular cells --Causes endometrium and myometrium to thicken --Helps support implanted ovum if pregnant Hypothalamus prompts pituitary gland to release FSH (follicle stimulating hormone) -FSH Stimulates ovary immature follicle production -Remember: follicle has immature egg inside, when follicle is mature, ruptures, releases egg -Increase in LH (luteinizing hormone) (surge from anterior pituitary gland) = Finishes the maturation and helps rupture follicle - FSH and LH at highest levels in this phase

GTPAL

G- (gravida) includes the current pregnancy T- (term births) the number of pregnancies ending delivering between 38 and 42 weeks (must be at 38, not 37 6/7 weeks - still considered preterm birth) -Viability - past the number of weeks that we feel the baby can live P- (preterm births) the number of preterm pregnancies ending > 20 weeks or viability but before completion of 37 weeks (greater than 20, but has not gotten to 38) A- (abortions) the number of pregnancies ending before 20 weeks or viability -This includes natural miscarriages and medically induced abortions L- (living children) number of children currently living

Prevention of HPV

Gardasil Vaccine: Boys and Girls -3 injections over 6 months (age 9-26) -Duration & long-term effects: 5+ years; unknowns

lInfections characterized by genital ulcers

Genital herpes simplex syphilis

HSV-2

Genital tract (sexual transmission)

Fundal height measure too big due to what possibilities?

Gestational diabetes (causes a large baby), diet/gaining too much weight & has large baby, too much fluid (hydramonis - polyhydraminous), more than one baby, due date wrong?

VS for newborn

HR: 110-160 bpm -Full minute count - apical pulse -Regular rhythm (list for murmurs) Resp: 30-60 bpm (breaths/min) -Count when sleeping/quiet for a full minute -irregular, shallow, unlabored -Symmetrical chest movements - HR and Respirations are assessed q30 mins until stable for 2 hrs - then q8 hrsCan vary depending on hospital protocol Temp: 97.7-99.5F (36.5-37.5C) - Axillary - degree lower than the core - Rectal not used due to chance of perforation - Use to do it to get the core temperature to test patency, but if have stool then patent so stopped doing BP - Not usually done - Only if murmur or other indication (low Apgar) - 50-75 mmHg (systolic) - 30-45 mmHg (diastolic) - Use Dinamap - Systolic is sensitive to movement, crying, and late clamping of umbilical cord 5thVS: Pain (FLACC scale) - Others: PIPP, CRIES

Convection in newborn

Heat loss to air currents

Radiation in newborn

Heat loss transferred to cooler objects from a distance (such as a window)

Twilight sleep

Heavy use of narcotics and amnesiacs * Business plan to make more money * If they forget the pain of pregnancy will have more children

Clinical manifestation of Hepatitis

Hep A: Flu like symptoms: fever, malaise, anorexia, nausea, RUQ pain, pruritus Hep B: Similar but less skin involvement or fever

Prevention in newborns for hepatitis

Hep B vaccine, started after birth, series of 3 injections within 6 months

Newborn specific care examples

Home phototherapy - Livet takes a lot to kick in - takes a while = jaundice - Biliblanket - helps get rid of jaundice - Have sales rep that comes out and teaches it to the mom Low birth weight infants - Daily weight Cardiac - Apnea Monitor Preemies or known conditions (ex: Cerebral Palsy) - Tube feedings - IV antibiotics - Suction equipment - Oxygen equipment Necessary family education, Assessing child's condition - Change in condition - Spitting up more? Sleeping more? Missing feedings? - Emergency vs. non-emergency - Who to call? Nurse, MD, Pharmacist, Physical Therapist

diagnosis of Toxoplasmosis

IgM fluorescent antibody testing

treatment for crepitus (fractured collar bone (clavicle)) in newborn

Immobilization (take T-shirt and pin the sleeve between the elbow and writs put a safety pin in it and pin it to the front of their T shirt and forms a sling (will heal on its own), minimize pain - Arm abducted more than 60 degrees, elbow flexed more than 90 degrees

diagnosis of Varicella-Zoster (VZV)(Chickenpox)

Immune testing

Fertilization and transport of zygote:

Implantation in upper uterus (normally) Rich blood supply: food & oxygen 7-10 days after conception Cells continue to differentiate to form fetal structures

Characteristics of the antepartum Initial Health History

Includes questions about three major areas: 1. reason for seeking care (preconception counseling / I think i...) 1. past surgical, medical, and family/partner's history (questions are more detailed, any genetic diseases in the family? Genetic counseling or special testing needed?) 3. reproductive history - how old menses started, how many days it lasts, have you been pregnant before, regular breast exams, ovarian/breast cancer history in self or family, any problems with infertility? STIs? Want to: -Establishes a trusting relationship, Be understanding and nonjudemental - Focuses on education for overall wellness - Attempts to detect and prevent potential problems Ex. Diabetics - DKA, foot ulcers, blindness, etc.

Hypoglycemia SGA newborn

Incr. metab. rate, lack of glycogen stores - Lethargy, tachycardia, resp. distress, jittery, hypothermia, poor feeding, weak cry or high pitched cry, hypotonia, seizures - Monitor BG, early feeding

Fertility Trends from 1980 till now

Increase birthrate women age 40-44 - aka more women are waiting

National Health Goals for Maternal/Infant Care goals

Increase early & adequate prenatal care * Attend childbirth classes * Very low birth weight babies born at level III hospitals/perinatal centers * Achieve recommended weight gain during pregnancy * More full-term infants sleep on backs * Begin pregnancy with optimum folic acid levels * Cessation of smoking, alcohol, illegal drugs * Breast feeding encouraged * Blood spot testing and follow-up * Referral to services Early prevention, identification & treatment of pregnancy complications * Ectopic Pregnancy * Preterm labor * Hypertension * Hemorrhage * Emboli * Infection * Stroke * Diabetes * Heart Disease

Extremely low birth weight (ELBW)

Infant weighing <1000 grams or 2 lbs, 3 oz.

Breathing newborn

Initial breath= reflex (theories) (Mattson & Smith, 2011) - Pressure changes - Noise & light (sensory stimulation) - Chilling (room temp) (thermal brain sensors) - Compression of chest during delivery - High CO2 & Low 02 in newborns blood (chemoreceptors in brain sense this -transitory asphyxia) Pressure forces air into alveoli & fetal lung fluid into interstitial spaces - chest compression during birth causes recoil once and draws air into lungs- 1/3 of fluid is squeezed out of lungs (total 80 - 110ml) - Remaining fluid flows into interstitial tissue by osmosis into capillaries (approx 80% of the fluid is absorbed in 2 hrs & the rest in 12-24 hrs ) Great effort is required to expand the lungs for 1st breath & fill collapsed alveoli - 1st inspiration takes 40-70mmHg of pressure -20ml air remains as residual volume (functional residual capacity-FRC) - 2ndbreath takes less effort & 3rd even less because by this time most of the small airways are open - after several minutes of breathing lung expansion is complete - Surfactant lipoprotein of the lungs keeps alveoli open (keeps them from sticking together) - Pulmonary blood vessels respond to the pressure changes by dilating and this increases blood flow to the lungs and decreases right sided heart pressure

How did the delivery rooms change since 1980?

LDR: Labor/Delivery/Recovery LDRP: Labor/Delivery/Recovery/Postpartum - room in 1 * Family friendly * Room décor * Less disruptive

Summary of Menstrual Cycle Hormones

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

Abnormal respirations in newborn

Labored breathing (moaning/groaning, nasal flaring, chest retractions (pulling inward)) - Chart where chest retractions are - ex. Sternal, intersternal, substernal, intercostal, etc. - Tachypnea (rapid, above 60rr) - Unsymmetrical chest movements - Apnea lasting more than 15 seconds - Cyanosis and HR changes - circle around mouth - cyanosis - ** Need further evaluation**

Newborn Mouth Assessment

Lips pink, intact, no clefts, no lesions - Thin upper lip (fetal alcohol syndrome) Mouth - pink, moist and saliva scant, sucking blisters, inspect for precocious teeth - Suck reflex - Palates (hard and soft intact), no clefts - Epstein's pearls - Thrush Tongue: size, movement, short frenulum (helps attach it to the bottom of the mouth) - depending on how the top is connected to the tongue can limit the movement of it = "tongue tied" - if cannot nurse correctly (grasp nipple and nurse) - if problem can snip that tissue (frenectomy) Cleft lip & Cleft lip/palate - when press down on nipple will have to position to side of mouth or use cleft lip nurser to help get pressure from top and the bottom Can have a natal tooth - no treatment if do not interfere with feedings

Hepatic Adaptation newborn

Liver is taking over for the placenta - Iron Stores o Released and stored by liver until new RBC's needed o Newborn stores last 4-6 months Carbs-Glucose Metabolism - Important for 1st24-48 hrs of life due to neonatal transition from from intrauterine to extrauterine life, their plasma glucose levels usually being lower than later in life -- Full-term normally 70-80% of maternal levels -- Risk for hypoglycemia - Initially decrease after cord cut - Main source of energy first few hours - Released from liver glycogen stores - Stabilized by feedings - Dextrostick at birth and prn per protocols

Advantages of Home Birth:

Lowest cost Laboring and delivering in the comfort of home, surrounded by loved ones Maintaining control over every aspect impacting labor Allowing labor to progress normally, without unnecessary interventions Having continuous one-to-one care given by the midwife Establishing a trusting relationship with the nurse midwife

Retinopathy of prematurity(ROP)

Major cause-blindness in preterm - Abnormal blood vessels grow, spread, leads to retinal detachment - Infants less than 1250g at greater risk; - If on extensive O2 and preterm: seen by Ophthalmology 4-6 wks Link to duration of O2 used, not just the high oxygen concentration - 100% to resuscitate is ok - Oxy hood, n/c, blowby, PPV, CPAP, mechanical - Humidified oxygen (long term- now short term too)

Breasts

Mammary glands, accessory organs Secrete milk after pregnancy Areola -Connective and adipose tissue supports weight of breast Pregnancy: estrogen/progesterone stimulate development -Breasts increase in size -Glandular tissue replaces adipose tissue

pregnancy effects on the panreas

Maternal glucose levels decrease because of the heavy fetal demand for glucose • Fetus draws AAs and lipids from the mother, decreasing the mother's ability to synthesize glucose • Decreases to a hypoglycemic level of non-pregnant women to assist fetal growth In early pregnancy, Decrease in insulin production and insulin levels • Insulin cannot cross the placenta - therefore, fetus will have to produce its own insulin to help glucose enter its cells After 1sttrimester - hPL from the placenta and steroids from the adrenal cortex act against insulin • hPL is an antagonist against insulin thus increase the insulin production to counteract this effect prolactin, estrogen, and progesterone are through to oppose insulin • more likely to cross the placenta then enter the maternal cells

Vulvovaginal Candidiasis symptoms

May worsen before menses -Pruritus -Discharge (white, curds) -Soreness -Burning -Erythema -Dyspareunia (pain w/ intercourse) -External Dysuria (pain w/ urination) (PSEDD- WB,B)

Endometrial Cycle

Menstruation occurs - Hormonal, Breast changes Endometrium, ovaries, pituitary gland, hypothalamus: cause cyclic changes -Prepares body for fertilization -Absence of fertilization=menstruation (Uterine lining is shed)

s/s for Diagnosis criteria for PID

Minimal criteria -Lower abd. tenderness -Adnexal tenderness -Cervical motion tenderness Supporting criteria -Abnormal discharge -Elevated temp. -Abnormal labs: Sed rate, CRP elevated -Known history of Gonorrhea or Chlamydia infection

- Characteristics of normal respirations

Need to consider their gestational age - count for one full min - lung fields are from just above middle third of clavicle to 6th rib at midclavicular line and 8th rib at midaxillary line - auscultate back & lower lobes to 11th rib at vertebrae line - obligatory nose breathers -reflex develop at 3 months to open mouth

Condoms (male and female)

Nonlatex condoms have a higher risk of pregnancy and STIs

Three Tier FHR Classification System: category 1

Normal Pattern/No intervention needed - FHR Baseline: 110-160 - Moderate Variability - Absence of FHR decelerations (late or variable) - Early decelerations: present or absent Accelerations :present or absent

Two major types of autosomal errors:

Numerical or structural abnormalities

treatment of Bronchopulmonary Dysplasia/Chronic Lung Disease in newborn

O2, meds: bronchodilators, anti-inflammatories, diuretics

Pharmacological Pain Management

OB Analgesia and Anesthesia

Glucose lab work

Overt diabetes (fasting: 126 mg/dL, Hemoglobin A1c level: at least 6.5%, random plasma glucose: 200 mg/dL)

P-LI-SS-IT Model

P - Permission - Gives the woman permission to talk about her experience LI - Limited Information - Information given to the woman about these STIs -Factual information to dispel myths about STIs -Specific measures to prevent transmission -Ways to reveal information to their partners - will be in shock and not know how to tell them -Talk when won't be interrupted or have a counselor with them -Physical consequences if the infections are untreated SS - Specific Suggestions - An attempt to help women change their behavior to prevent reoccurrence and prevent further transmission of the STI. IT - Intensive Therapy - Involves referring the woman or couple for appropriate treatment elsewhere based on their life circumstances.

fetal risks of mothers that have CVD

Premature, LBW, RDS, Intraventricular hemorrhage, deat

Neonatal Sepsis

Presence of bacterial, fungal, or viral microorganisms or their toxins in blood or other tissues - Congenital, or acquired in-utero, or perinatal (shortly before or during birth, or after in nursery)

Thermoregulation in newborn

Process of maintaining balance between heat production & heat loss - It is possible to get too warm - need to watch - Stable body temp. = one of the most important to transition and survive - Newborns vulnerable to BOTH under and over heating - Nurses are key to maintain thermal stability! Avg newborn temp: 97.9-99.7 - 1st thing to do to help regulate is skin-to-skin

Meds for Tocolysis

Ritodrine (Yutopar) - Only FDA approved - Others are "off label"-effective but not tested -Terbutaline (Brethine) - can make their heart race -Magnesium Sulfate -Procardia (Nifediprine) -Indomthacin (Indocin)

RADAR stand for

Routine screen every patient for abuse Ask direct, supportive, nonjudgmental questions: Affirm feelings, Assess Abuse * Thank you for sharing, I'm sure that was hard for you to tell me, I like your trust, I'm here to help * Call security and hospital will have procedure in place Document findings Assess client's safety Review options/Provide referrals

Immunizations PP

Rubella - If not immune (titer <1:8) - Consent form - Inform side effects: rash, soreness, joint symptoms, fever - Avoid pregnancy for at least 4 weeks, some suggest up to 3 months (risk for teratogenic effects) Rhogam (Rh immunoglobulin) - For Rh negative mothers with Rh positive infant - Give injection within 72 hrs. after birth - Prevent sensitization reaction - 2 doses: One at 28 weeks gestation, second before 72 hrs. after childbirth - Consent required Tdap (Tetanus, Diptheria, Pertussis) - After delivery before d/c, if have not received

cause of mastitis PP

S. aureus and E-Coli -cracked nipples, missed feeding- poor drainage of duct, infection, too tight bra

SAVE model

Screen for abuse during every healthcare visit Ask direct or indirect questions about the signs of abuse -"do you feel safe at home?" -if say no- but can tell lying; suggest one for a friend she knowns that abused and have the number -Get PVA form filled out if say no security wanted --Then ask more questions - any weapons on him etc.? --Tell supervisor and then they will follow their protocol Validate: you believe her, brave for telling you Evaluate immediate safety

Post Partum/Newborn Care: examples

Telephone consultations - Hospital OB nurse, Lactation consultants, Nurse educators Outpatient Clinics - Telephone support - Office visits - Examination - Instructions - Nutritional problems Home Visits - ID potential/actual complications in Mother or Newborn - ID psychosocial needs/problems: Mother - mother blues or Family members - See mother/infant before first office visit: Early ID problems, Education - Home health nurses are in charge of counseling

Diagnosis of syphilis

Test lesion exudate/tissue for early dx (check for spirochetes) Serology tests: -Nontreponemal tests (Reagin test for screening) --VDRL (venereal disease research lab) --RPR (rapid plasma reagin) -Treponemal tests (more specific, verify not false positive) --FTA-ABS (fluorescent trep. Antibody) --TP-PA (T. pallidum particulate agglutination)

Characteristics of Culture

Time orientation - Arrive late for appts., not concerned Personal space - Closeness - Touch Family orientation - Patriarchal (governed by men) vs. Egalitarian (people deserve equal rights and opportunities) Language - Barriers: Dialects, regions, slang

First Trimester Discomforts

Urinary frequency or incontinence: from HcG/Acg? (hormone causes urinary frequency) -Try Kegel exercises to increase control, empty bladder when you feel full, avoid caffeinated drinks (stimulate voiding), reduce fluid intake after dinner to reduce nocturia - Fatigue - Get full night of rest, eat healthy diet, schedule naps in early afternoon daily, when feel tired - rest - Nausea and vomiting: Avoid an empty stomach, eat crackers/toast in bed before arising, eat several small meals throughout the day, avoid brushing teeth immediately after eating, acupressure wristbands can be worn, drink fluids between meals, avoid greasy, fried foods or ones with strong odor - Breast tenderness - wearing larger, supportive bras - Constipation - Nasal stuffiness, bleeding gums and epistaxis - use humidifier sprays - Cravings - Leukorrhea (increased vaginal discharge) - keep area clean and dry, avoid tampons and douching, cotton underwear

- Difficulty voiding PP

Urinary retention -Major cause of uterine atony-causes excessive bleeding -Frequent voids of small amts (<150ml) · May be retaining urine, may need to cath them · Have them ambulate and increase fluids Cath may be needed - Bladder distention lInhibits UC lIncr. risk for pp hemorrhage - UTI (Monitor for s/s) - fever, dysuria, pain, frequent, scant voids, starting stop voids

The most common cause of a postpartum hemorrhage?

Uterine atony

Signs of True Labor

Uterine contractions Bloody Show Spontaneous Rupture of membranes

• Variety of reasons an individual should be referred to genetic counseling

Variety of reasons an individual should be referred to genetic counseling • Women planning to become pregnant that is 35 or older, paternal age 50or older, previous children, parents or close relatives with inherited disease, congenital disorders, or chromosome abnormalities, incest, pregnancy screening abnoms. (AFP, triple screen, amniocentesis, ultrasound), stillborn with congenital anomalies, two or more miscarriages, exposure to teratogens, concerns about genetic defects that occur frequently in ethical and racial groups (African descent more at risk for sickle cell anemia), abnorm newborn screening, family history of X-linked disorder, carriers of autosomal recessive or dominant diseases, child born with 1 or more major malformations, abnormalities of growth, and/or blindness, developmental delay, intellectual disability, deafness

Syphilis

Very common, can kill the patient -Bacterial: Treponema pallidum -Systemic: Cause death if not Rx -Crosses placenta during pregnancy = spontaneous abortion, premature, stillborn, multisystem organ failure, mental retardation, bone damage

Evaporation in newborn

Wet skin exposed to air in DR insensible water loss from skin and lungs

Current Issues in Women's health

Women's responsibilities * Care for parents, children, spouse; Work outside home; Less time for self; Exercise; Nutrition; Leisure activities; Stress Health care costs are soaring! - Decrease hospital stays * Trial of "drive by deliveries" defeated * 48hrs standard delivery 72hrs C-section Managed care * Referrals require - Limits physician contact - Laboratory testing * Limited physician contact * Laboratory testing limited Others: Aging population; Economics affecting resources; Communication/Cultural/diverse needs; Growth of technology/information; Increase in unlicensed personnel providing care - Cannot assess, evaluate, or educate; Shortage of trained healthcare personnel Move from acute to community setting · Acute means in hospital · Community means clinics, office, etc.

Sickle Cell Anemia

a genetic disorder that causes abnormal hemoglobin, resulting in some red blood cells assuming an abnormal sickle shape - inherited form of anemia — a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout your body

Preterm

a newborn born before completion of 37 weeks

Postterm

a pregnancy that extends beyond 42 weeks' gestation

measuring chest circumference of newborn

across the nipple line 30-36 cm or 12-14" (2-3 cms < head)

Intermittent fetal monitoring

allows patient to move freely when not being monitored

Therapeutic touch

an alternative therapy that involves using one's hands to consciously direct an energy exchange from the practitioner to the patient to facilitate healing or pain relief

Date rape

an assault within a dating or married couple without consent of one of the participants

pelvic shapes with a poor prognosis for vag. delivery

android & platypelloid

treatment of Septic Pelvic Thrombophlebitis

antibiotics, anticoagulants, chest x-ray, CBC, PT

treatment of UTI PP

antibiotics, fluid hydration, pericare (cleaning area properly)

Breech Presentation

bottom of the baby is the in pelvis opposed to head *↑ with maternal pelvis abnormalities, preterm deliveries & congenital anomalies, 3% term births · Frank(50-70%) · Complete or Incomplete (one leg, one flexed or presenting) · Footling -Single - one foot coming through the pelvis -Double - two feet coming through pelvis · Kneeling - knees coming through the pelvis

Risk of RDS

c/s, early gest. age, DM, perinatal asphyxia

Nifedipine (Procardia) treatment of preterm labor

calcium channel blocker) - blocks Ca2+ movement into muscle cells, inhibits uterine activity to arrest preterm labor Nursing considerations: - Use caution if giving this drug with magnesium sulfate because of the increased risk for hypotension; Monitor BP hourly if giving with this - report pulse rate > 110 bpm - Monitor Fetal effects - decreased uteroplacental blood flow manifested by fetal bradycardia, whih may lead to fetal hypoxia - Monitor adverse effects - flushing, H/A, transient hypotension, palpitations, postural HTN, peripheral edema, and transient fetal tachycardia

What can happen if Gonorrhea travels up through the uterus?

can travel out fallopian tubes into peritoneal cavity = PID -Permanent scarring of fallopian tubes -Infertility, ectopic preg. If enters blood stream= endocarditis, meningitis, arthritis, toxic hepatitis

Thrush

candida albicans during birth -s/s: white plaque, can't be wiped away

Continuous labor support

care, comfort, advocacy, information, advice: decreases c-section rates and pain medication requests

Menopause

cessation of regular menstrual cycles -End of menstruation and childbearing capacity -Atrophy: breasts, uterus, fallopian tubes, ovaries -May be symptomatic or not; Vasomotor: hot, cold, sweating, headache, insomnia, irritability -Hormonal treatments for symptoms controversial Nontraditional CAM (complementary /alternative medicine)

Epispadius

congenital abnormality where urethral opening is located on upper surface of penis

Adolescent Pregnancies incidence

declined since the 1990s, but still high in US; all socioeconomic but higher with poor women and minorities

s/s of dehydration in newborn

decreased urine output, sunken fontanels, elevated temp., lethargy, elevated resp

treatment of AUB

depends on age, cause of bleeding, and desire of future fertility - Goal: normalize the bleeding, correct the anemia, prevent or diagnosis cancer, and restore quality of life - Drug categories used:OCs, Estrogen, NSAIDs, Progestins, progesterone-releasing IUSs, androgens, antifibrinolytic drugs,iron replacement therapy

Postpartum depression

depression that develops after childbirth characterized by insomnia, loss of appetite, intense irritability, and difficulty bonding with the baby

Secondary prevention

detecting and treating adverse health conditions early ex. screening for high blood pressure and breast self-examination, pregnancy test, cholesterol monitoring, fecal occult test, mammogram,

HIV screening lab work

detects HIV antibodies and if positive requires more specific testing, counseling, and treatment during pregnancy with antiretroviral medications to prevent transmission to the fetus

Cervical smears lab work

detects abnormalities such as cervical cancer (pap smear) or infections such as gonorrhea, chlamydia, or group B streptococcus so that treatment can be initiated if positive

Bony Pelvis

divided into true and false portions

Apgar Score

done at 1, 5 and 10 min if 5 min was <7 - A= appearance (color) - P= pulse (heart rate) - G= grimace (reflex irritability) - A= activity (muscle tone) - R= respiratory (respiratory effort)

Tocolysis (tocolytic therapy)

drugs to stop labor (delay preterm birth) ncriteria to use: - 20-37 weeks (less than 20 weeks can do much) - < 80% effaced & <than 2 cm dilated - UC 4/20 min or 8/60 min. - most necessary before 34 th week - delay gives corticosteroids to ↑lung maturity or maternal transport Contraindicated: abruption, eclampsia, active bleeding

cranium molding

due to having to get through pelvis and made bones overlap each other

what is reason for primary (1*) c/s

dystocia

Myometrial Changes

each UC contraction shortens the muscle fibers to move the fetus ↓ this is known as *brachystasis* or a ↓ in uterine space

Management of Difficulty voiding PP

early ambulation; void within 4-6 hours after birth, using nursing tricks to stimulate voiding (running water, trickling water in sink, putting hands in warm water, putting warm water on lab, peppermint elixir into toilet water, ammonium salts)

Hymen

elastic mucous covered tissue surrounds vaginal opening, may or may not tear with first intercourse (does not confirm sexual activity)

Embryonic stage

end of 2nd week through 8th week - Basic structures of all major organs and main external features completed - Very important during the first trimester to be careful with diet since this is when everything is really developing

Fetal stage

end of the 8th week until birth -Growth and refinement of organs/systems

Ectoderm

forms the central nervous system, special senses, skin and glands

When do you put in IUPC?

get an actual measurement of pressure; don't do it for someone that does not need it; only If high risk since its invasive

after closure of all the shunts ...

get circulation adequate neonatal circulation for life: deOX blood returns to the heart though the inferior vena cava and superior vena cava. Deox blood enters the right atrium then into the right ventricle. And travels through the pulmonary artery to the pulmonary vascular bed. Ox blood returns to the pulmonary veins through the left atrium, the left ventricle, and through the aorta to the systemic circulation

causes of Varicella-Zoster (VZV)(Chickenpox)

herpes virus transmitted by respiratory tract or direct contact, latent form shingles (nerve ganglia), or chicken pox

Cytomegalovirus

herpes-type virus that usually causes disease when the immune system is compromised

Secondary infertility

inability to conceive after a previous pregnancy

3 phases of a contraction

increment- building up, longest acme(peak) - strongest point decrement- decreasing intensity · Look like bell-shaped curve · Feel fundus during the contraction

Possible newborn complications of Genital Herpes Simplex

intellectual disability blindness seizures premature birth low birthweight death

measuring abdomen circumference of newborn

measure at umbilicus 1-2 cms < chest

Stool changes

meconium to transitional stools - depends on BF or bottle

treatment of PPTD

medication as indicated

Dys

not or pain or difficulty

Meconium Aspiration Syndrome risks

postterm, breech, forcep/vac, DM, HTN, prolapse, placental insufficiency, fetal distress

Magnesium Sulfate treatment of preterm labor

reduce the muscles ability to contract; relaxes uterine muscles to stop irritability and contractions, to arrest uterine contractions for preterm labor (off-label use); have been used in seizure prophylaxis and treatment of seizures in preeclamptic and eclamptic clients for almost 100 years Nursing considerations: - Administer IV with loading dose of 4-6 g over 15-30 min, initially and then maintain infusion at 1-4 g/hr - Assess VS and DTRs hourly, report any hypotension or depressed or absent DTRs - Monitor level of consciousness; report any H/A, blurred vision, dizziness, or altered level of consciousness - Perform continuous EFM; report any decreased FHR variability, hypotonia, or respiratory depression - Monitor I/O hourly; report any decrease in O (<30ml) - assess respiratory rate; report respiratory < 12 bpm; auscultate lung sounds for evidence of pulmonary edema - monitor for common maternal SE - flushing, N/V, dry mouth, lethargy, blurred vison, H/A - also transient hypotension - Assess for toxicity - decreased level of consciousness, depressed respirations and DTRs, slurred speech, weakness, and respiratory and/or cardiac arrest Have calcium gluconate readily available at the bedside to reverse toxicity

Tertiary prevention

reducing or limiting the progression of a disease or disability after an injury · Already happened · How will you support the individual? ex. minimized effects of chronic disease such as DM, CV, STIs, HIV

Three retrogressive processes of involution

return to nonpregnant size and condition) - Contraction of muscle fibers to reduce those previously stretched during pregnancy - Catabolismthat reduces enlarged individual myometrial cells - Regeneration of uterine epithelium from the lower layer of the decidua after upper layers have been sloughed off and shed in lochia

Ovarian Cycle

series of events associated with a developing oocyte within the ovaries Ovulation occurs -Follicle releases ovum -Ovum enters fallopian tube -Travels toward uterus -Fertilization = pregnancy -Finite supply of ova released slowly over childbearing years -Follicular cells (ovum and others) swell and mature -Maturing follicle=Graafian follicle -Many follicles but only one matures to ovulation

Shunt #1: Ductus arteriosus

shunts the major portion of the blood from the pulmonary artery to aorta allowing only a small amount of blood to go to the lungs for nutritive purposes (closes within first few hours after birth- usually within 15 hours) decreased prostaglandin E2from placenta & now the lungs need 02 - Closure depends on high 02 content from aeration of lungs

Pubic lice

small, yellow, oval eggs attached to hair shafts or lice (insect) pruritus, secondary infection from scratching Rash from scratching, lice/nits in pubic hair, axillary, thighs, beards, eyebrows

Genomics

studies all genes, how they interact with each other and the environment (e.g. used for heart disease, diabetes)

s/s of PE

sudden SOB, tachypnea, chest pain, tachycardia, sweating, hemoptysis, apprehension, change in mental status, arrhythmia

nursing of Intrauterine Fetal Demise

support, chaplain, refer, discuss, unlimited time w/ stillborn

Treatment of endometriosis

suppress estrogen and progesterone levels (surgery, meds) - Main meds: ovarian suppressive agents (OCs, progestins, GnRH agonist, androgenic agents)

Treatment of dysmenorrhea

surgery and ovarian suppressive agents (OCs, progestins, GnRH, antagonist, levonorgestrel-releasing intrauterine system, androgenic agents), complementary therapy (acupuncture and acupressure) - Most common NSAIDs, Ibuprofen (Motrin, Advil) and naproxen (Naprosyn)

What increases a women's risk for endometriosis

the aging process, family history, short menstrual cycle (<28 days), long menstrual flow (> 1 week), high dietary fat consumption, young age of menarche (<12), few (1 or 2) or no pregnancies

Family Centered Community Based Care

the application of the nursing process in caring for individuals and families in community settings

Engorgement

the process of swelling of the breast tissue due to an increase in blood and lymph supply as a precursor to lactation

Amnion

thin membrane with fluid/ blastocyst

effacement

thinning & shortening, expressed in %; 0 to 100% 100% means it is consistent with the lower uterine segment, it is obliterated

Absent or minimum variability usually due :

to fetal academia, secondary to uteroplacental insufficiency, preterm, cord compression, maternal hypotension, placental abruption, uterine hyperstimulation, fetal dysrhythmias - Absent variability=Must Act

Sucking reflex

to illicit touch the mouth or palate; also place finger in mouth with gloves on

pseudomenstruation

vaginal discharge- white mucoid - normal may be blood tinged due to stimulation of maternal hormones

Ambulation and position changes

walking, upright positions decrease length of labor, gravity, change shape of pelvis, contractions effective

Small for gestational age (SGA)

weigh less than 2500 grams (5 lb, 8 oz) at term due to less growth in utero than expected or one below the 10th percentile

Legal/Ethical Issues involving childbirth: Maternal-fetal conflict

· Beneficence (be of benefit), autonomy (self-govern), nonmaleficence (no harm) come into conflict when considering the fetus

Types of jaundice involving impaired excretion

· Biliary obstruction, sepsis, chromosome abnormality (ex; Turners syndrome, trisomy 18 & 21, drugs) · Need to run a toxicology screen and chromosome screen to determine the cause

Factors influencing a positive birth experience

· Clear information on procedures · Positive support, not being alone · Sense of mastery, self-confidence · Trust in staff caring for her · Positive reaction to the pregnancy · Personal control over breathing · Preparation for the childbirth experience

Legal/Ethical Issues involving childbirth: Umbilical cord blood banking

· Collected at birth and source of stem cells for an individual in need of a bone marrow transplant later in life · Consent given under coercion or freely

Vaginal Birth After Cesarean (VBAC)

· Giving birth vaginally after having at least one cesarean section

4 signs of placental separation

· uterus rises · uterus becomes globular · gush of blood (normal 250-300ml) · cord lengthens

Vaginal rings

• Contains estrogen and progesterone • Flexible, soft, transparent that's inserted for a 3-week period followed by a ring-free week that may cause bleeding

Oral contraceptives

• More safer, tolerable than earlier formulations • Decreased estrogen dosage decreased side effect of pills • Introduced OC using progestins

Diaphragm

• must be measured/fitted, prescription • Inserted in the vagina to cover the cervix • Needs to inserted 4 hours before and remain 6 hrs after intercourse • Replaced every 1-2 years

Genetic counseling

• process by which patients or relatives, at risk of an inherited disorder, are advised of consequences, nature of the disorder, probability of developing it, and options for management and family planning in order to prevent, avoid, or ameliorate (improve/better) it • Ideal time: before conception

risks of Multiple fetuses

↑ dysfunctional labor, Fetal hypoxia, hypotonic uterus postpartum -monitor each fetus separately - 2 separate FHR's -know positions of each fetus -Vag del. If first is longitudinal - Deliver in OR usually

Shunt #2: foramen ovale

↑ pulmonary pressure, the pulmonary arteries dilate in response to oxygenation of lung tissue, pulmonary vascular resistance ↓ which ↓ pressure in right side of heart - It simultaneously increases the pressure in the left atrium causing closure of the foramen ovale - Occurs 1-2 hrs of birth - Now oxygenated blood is separated from non-0x blood

s/s of infection for neonatal sepsis

hypotension, tachycardia, pallor or duskiness, hypotonia, temperature instability, cyanosis, poor weight gain, irritability, seizures, jaundice, grunting, respiratory distress, nasal flaring, apnea and bradycardia, lethargy, rash, petechiae, hypoglycemia, poor feeding (lack of interest in feeding), abdominal distention -Strict handwashing, thorough assessments every shift and prn

#1 killer of women

cardiovascular disease * CHD and stroke

Tetralogy of Fallot

combination of four congenital abnormalities. The four defects include a ventricular septal defect (VSD), pulmonary valve stenosis, a misplaced aorta and a thickened right ventricular wall (right ventricular hypertrophy).

fetal complications of Cytomegalovirus

complications: deafness, intellectual disabilities, seizures, blindness, dental deformities, abortion, stillbirth, IUGR, LBW, jaundice

False (greater) pelvis

composed of the upper flares of the two iliac bones with concavities and the wings of the base of the sacrum

Endometriosis

condition in which bits of functioning endometrial tissue are located outside the uterine cavity - Most common gynecologic disease and most common cause of secondary dysmenorrhea -Associated with pain beyond menstruation, dyspareunia, low back pain, heavy and irregular bleeding, bloating, N/V, infertility -Endometrial tissue responds to hormones, swells and bleeds, "mini-periods" throughout the abdomen, wherever the tissue is present -Can grow any various areas and can be localized or all over -Tends to come back -Symptoms begin as early as adolescence and typically settle after menopause

Which CV problems should you watch a preterm for?

congenital anomalies, continued fetal circulation- patent ductus arteriosus, intracranial hemorrhage

Cleft Lip/Palate

congenital split of the lip and roof of the mouth

Ductus arteriosus

connects the main pulmonary artery to the aorta -Most will bypass the liver

maternal effects of Varicella-Zoster (VZV)(Chickenpox)

preterm labor, encephalitis & varicella pneumonia

Primary prevention

preventing the disease or condition before it occurs through health-promotion activities ex. immunization and taking regular exercise, nutrition, good hygiene, sunscreen, genetic counseling, seatbelts

Fetal/newborn effects of GBS

sepsis, pneumonia, neuro damage

Partial placenta previa

the internal os is partially covered by the placenta

Family Centered Community Based Care goal

to help people manage acute or chronic health conditions in community and home settings

Babinski reflex

toes flare outward when stroke the heel of foot to ball (disappear in 12 months)

Polymenorrhea

too frequent periods

causes of Gestational Hypertension

unknown

causes of Hypertonic Uterine Dysfunction

unknown

Hypotonic contractions

uterus relaxes too much, causing ineffective contractions

Legal/Ethical Issues involving childbirth: Intrauterine therapy

· Intervention used to correct or treat a fetal abnormality · Require opening of the uterus, during pregnancy, performing surgery, and replacing the fetus back in utero · Treat fetal outcome, development of sever disability despite prenatal care, fetal obstruction uropathy, intrauterine transfusion for fetal anemia, spina bifida repair, stem cell transplantation

Legal/Ethical Issues involving childbirth: Substance Abuse

· Lead to preterm birth, placenta abruption, poor weight gain, low birth weight, still birth, spontaneous abortion, variety of behavioral and cognitive problems in exposed children, fetal injury · Can lead to charges of negligence and child endangerment against the Women · Must be screened periodically

nfant of diabetic mother

· Monitor BG, keep over 40 mg/dl · S/S of hypoglycemia · Prevent cold stress · Check for birth trauma · Labs: baseline calcium, mag., bilirubin · Frequent feedings, assessment, correct low lab values, o2 support if needed

Injectable Contraceptives

• Progestin-only and combination of estrogen and progestin agents; safe; last up to 3 months • Depo-provera - possible BMD loss, monitor while on

Where to begin with infertility

• Thorough health history • 'Rule out' in order to 'rule in' • Simple tests first - Start with male: semen analysis • Educate parents they may not be able to conceive "naturally" • Support parent's decisions

Physical changes during pregnancy: endocrine

• Thyroid gland: slight enlargement; increased activity; increase in BMR • Pituitary gland: enlargement; decrease in TSH, GH; inhibition of FSH & LH; increase in prolactin - for breast milk, MSH - accounts of brown pigmentation; gradual increase in oxytocin with fetal maturation - will be helpful in labor • Pancreas; insulin resistance due to hPL and other hormones in 2nd half of pregnancy • Adrenal glands: increase in cortisol and aldosterone secretion • Prostaglandin secretion - help soften the cervix • Placental secretion: hCG, hPL, relaxin, progesterone, estrogen

Intrauterine growth restriction (IUGR)

- Rate of growth is not as expected - Not all SGA are IUGR - Early detection/management decreases morbidity/mortality

Hep B (HBV)

-Spread through saliva, blood, semen, menses, vaginal secretions -Can cause permanent liver damage -Given to neonates when born

Common questions/concerns related to newborns

- Dressing, stool patterns, smoking, eyes, baths - nails - use nail file (NOT CLIPPERS) - sucking needs, teething, diaper rash - feeding (BF- 2-3 hr, 10-20 min; NONBF - 3-4 hr, 30 mins or less) - diapering

Resuscitation of newborn: Drugs involved

- If reacting to Narcotics- give Narcan - If in Metabolic Acidosis- give Sodium (Na) Bicarb. o Tested through blood drawn from umbilical cord - To increase HR- epinephrine (ET or IV) Miracle drug due can be given multiple ways

Postpartum (PP) Assessment

- VS, physical, psychosocial and assessing the parents and other family members for attachment and bonding with the newborn

Expulsive forces: problems during Labor

- hypertonic or hypotonic contractions - precipitous labor

predisposing factors of late PP hemorrhage

- manual removal of retained placenta - Acreta- chorionic villi- placenta-adhere to myometrium- don't separate at delivery

Manage Pain of high-risk newborn

- many procedures done - Gentle handling, rocking, bundled - Sucrose pacifier, limit noise/lights

Concerns with Cesarean section

- risk for urinary problems, healing time, psychosocial problems - bleeding, sedation = Higher risk for clots due to increase with Blood in body (Thrombi to emboli)

diagnosis of ectopic pregnancy

- Low levels of hCG : normal pregnancy hCG levels keep increasing peaking at 60- - 90 days after conception; with ectopic hCG levels decrease after 10-11 weeks - Transvaginal US - Absence of intrauterine gestational sac Laparoscopy

PCEA: Patient controlled epidural analgesia

- Lower anesthetic use - Higher patient satisfaction

Postterm characteristics

- Dry, - cracked, wrinkled skin - Long, thin extremities - Creases cover entire soles of feet - Wide-eyed, alert expression - Abundant hair on scalp - Thin umbilical cord - Limited vernix and lanugo - Meconium-stained skin - Long nails (Green & Wilkinson, 2004)

Chloasma

"Mask of pregnancy" -blotchy brown pigment (dark haired women) - "racoon mask"

Measuring the pelvis

- Diagonal conjugate - true conjugate - ischial tuberosity

s/s of Oligohydramnios

- Leaks fluid - Fundal height smaller than expected, poor fetal growth

Folic-acid anemia

- Megoblastic - lack of folic acid in the blood

homeopathy

- based on the belief that the body can cure itself - substance cause disease can cure others

Infant Mortality

6/1,000 live births

Brachial Plexus Injury

breech/shoulder dystocia

S/S of hypoglycemia in infant

· Lethargy, hypotonia, poor feed, apneic, temp. instability, tremors, irritable, seizures. jitteriness

Nurses Role to Educate during labor process: Parental role

· Δthey enter the focusing phase · becomes involved in child birth classes shopping for furniture, L&D for partner · during this phase he begins to think of himself as a "father", they feel responsible and protective

rates of Infertility

• 6 million Americans • 15% of reproductive age population • 40% Female factor, 40% Male factor, 20% combination or unexplained

Pregnancy and siblings

• Age-dependent reaction • Sibling rivalry with introduction of new infant into family • Sibling preparation imperative

Cervical mucus ovulation method

• Assess the cervical mucus • As ovulation approaches, becomes more abundant, clear, slippery, and smooth • After ovulation, becomes thick and dry • Cervix changes close to ovulation: soft, deep, high in the vagina • Effective because rely on body changes occurring during ovulation

Transdermal Patches

• Avoids hepatic first-pass metabolism - reduces adverse effects • Applied weakly for 3 weeks, followed by a patch-free week that bleeding occurs • Delivers continuous levels of progesterone and estrogen • Risk of venous thrombosis and embolism and skin burns (less of a risk)

contraceptive sponge

• Barrier and spermicide • Soft concave device that prevents pregnancy by covering the cervix and releasing spermicide • Does not offer protection against STIs • Inserted 24 hrs before and left 6 hrs after intercourse (avoid leaving in for >30 hrs = toxic shock syndrome) • Provides protection for 12 hours

incidence of Folic-acid anemia

↑ with Fe deficiency, hemolytic anemias, medications such as dilantin & malabsorption

hypoglycemia Postterm newborn

- Hypoxia-2* to depleted glycogen-Placental insufficiency

- Respiratory PP

- Remain in normal range - Anatomic changes back to pre-pregnancy state - SOB relieved

Non-urgent L&D care

- IV access -18 angio in case you need to give blood -do procedures between UC's - Environmental controls - Lighting - Temperature - Phone - Visitors - clear liquids -ice chips -snow cones

Clinical Practice Within the Community

- Research - Quality improvement - Discharge planning/Case Manager - Staff development - Program development - Community education - Advocate and Resource Manager

APGAR respiratory effort

- Respirations Absent: 0 - Slow or irregular breaths: 1 - Good Respiratory Rate and cry: 2

treatment of mastitis

- Rest - Warm compress - Antibiotics - Breast support - Continue BF: infection will notpass into breast milk o Prophylaxis : Good hand washing

Dystocia evalution

- Results of meds, positioning, progress, I/O, FHR strips

Asses newborn infant an RDS. Name 5 symptoms?

- Retractions grunting, labored breathing, nasal flaring, cyanosis, tachy, etc.

Characteristics of dystocia

- Slow and/or abnormal progression of labor o Lack of progressive cervical dilation o Lack of head descent o Or Both

Microcephaly

- Small brainin normal size cranium - Neuro impairment, no treatment

Sinusoidal Pattern

- Smooth, sinewave-like pattern - Severe hypoxia, fetal anemia, and fetal hypovolemia Fetus needs transfusion (only treatment)

causes of Rubella (German Measles)

- crosses placental barrier -test mom for titer (1:8 or greater- antibody titer=immune)

RDS (respiratory distress syndrome)

- d/t lack of alveolar surfactant, lung immaturity - Work harder to breathe

Erb palsy

- damage to upper plexus and palsies associated with lower brachial plexus = klumpke palsies

Para

# of deliveries at 20 weeks or greater

APGAR Muscle tone

- Limp: 0 - Some flexion of extremities: 1 - Active motion: 2

Diagnosis of PROM

- Nitrazine (paper turns blu e is amniotic fluid) or fern test with sterile speculum exam - delivery if term - induction

Lactation

- the secretion of milk by the breasts - Causes: interaction of progesterone (stimulates growth of milk production system), estrogen (stimulates growth of the milk collection (ductal) system, prolactin and oxytocin - Occurrence:typically appears 3 days after the childbirth experience - Body response to having the baby - Need coupling of jaw, undulation of the tongue, and breast milk ejaculation reflux to be successful

Vernix caseosa

- thick white substance that protects the skin of the fetus, > with preterm - Formed by secretions of fetus's oil gland and is found during the first 2 or 3 days after birth in body's creases and hair - Absorbed through the skin

android pelvis

- typical male pelvis - heart shaped pelvis - not favorable; likely to become a C/S

fourth stage of labor

-1 to 4 hours following delivery -uterus initially between umbilicus and symphysis pubis, then rises to level of umbilicus; firm; check q15min x 1hr -lochia - Moderate flow; Rubra chills, cramping, limited bladder sensation, perennial discomfort - ice -hungry, thirsty -both mom and baby alert - Breast feeding, happy, crying, excited -*monitor for hemorrhage, bladder distention, and venous thrombosis

Fetal nuchal translucency (FNT)

-11-14 weeks -Increased nuchal translucency ; increase in fluid accumulating behind fetal neck may indicate chromosome or structural abnormalities

Hepatitis B Virus

-2 Billion infected worldwide -Life threatening Liver Disease -Transmitted through contaminated blood, sexual contact, illicit drug use -Vertical Transmission to fetus - will go up the vaginal area and infect fetus in utero -70-90% born will have chronic Hep B by 6 months old

incidence of Cytomegalovirus

-30-40% transmission to fetus -most preventable of TORCH group,↑ in day care workers & health professionals

Herpes Simplex Virus

-50 million cases -Type 1 & 2 (both can occur in either oral or genital region) -30 - 50% risk primary transmission-near or during birth -1 - 3 % risk neonatal infection from recurrent genital infection -Transmitted prenatal, intrapartum, or postpartum period -Majority during vag. birth

Symptoms affecting Rape Survivors

-Chronic pelvic pain, headaches, back ache -Sexually transmitted infections, pregnancy -Anxiety, denial, fear, withdrawal -Sleep disturbances -Guilt, nervousness, phobias -Substance abuse, depression -Sexual dysfunction -Posttraumatic stress disorder

Hemorrhagic/Hypovolemic Shock

-Code Crimson - 30-40% loss of volume

Information Obtained in a Phone Assessment

-Estimated date of birth to determine if term or preterm -Fetal movement as to frequency in last few days -Other premonitory signs of labor experienced -Parity, gravida and previous childbirth experiences -Timeframe in previous labors -Characteristics of contractionsTold to come in with 5 minutes apart and regular -Appearance of any vaginal bloody show present -Membrane status, whether ruptured or intact -Presence of supportive adult in household or if she is alone

Physical changes during pregnancy: vagina

-Increased vascularity and hyperplasia -Increased vaginal secretions (leukorrhea) and decreased pH (acidic) to prevent infections *Monilial vaginitis* possible (s/s itching etc..): - *Vaginal infection, not STI, common with Diabetics (have it A LOT)* - *Normal pregnancy may get it once or twice - relates to change in pH*

heroin effects on newborn

-Infant born dependent on heroin -Stillbirth, IUGR, premature, LBW, hypoxia, >SIDS, withdrawal symptoms

Types of jaundice involving overproduction

Blood incompatability, drugs, trauma, polycythemia, delayed cord clamping, Breast milk jaundice

Nursing management of Hepatitis B virus

-Infant of positive mom; gets Hep B vaccine AND Hep B immunoglobulin within 12 hrs of birth. Complete vaccine schedule at 1 and 6 months. -Can breastfeed; vag delivery, c-section doesn't reduce transmission risk -Can be vaccinated while pregnant

vaccines to be considered if otherwise indicated (safe during pregnancy)

-Influenza (inactivated) injection, Hepatitis B, Tdap, meningococcal -Rabies - even though it says its safe, doesn't mean you should get it because you can

Sexual abuse Interventions

-Isolate patient immediately from family -Assess survivors of rape for PTSD -Document and report findings -Educate victim about community services -Provide emotional support -Offer a safety plan -Provide care/treatment: Pregnancy, STI's -Use Danger Assessment Tool -Use DV Screening Documentation Form -Use ABCDES of Caring for Abused Women

treatment for Ectoparasitic Infections

-Permethrin cream -Lindane shampoo -RID, Triple X, Pronto, Kwell - Treat all in contact -Remove nits, manage environment (washing all linens/clothing/hot water, vacuum) -Make sure you have all the eggs removed -Don't share personal items

Down Syndrome characteristics

-Small, low-set ears -Hyperflexibility -Muscle hypotonia -Deep crease across palm - termed simian crease -Flat facial profile -Small white-crescent-shaped spots on irises -Open mouth with protruding tongue -Broad, short fingers Down

Biophysical Profile

-Uses Ultrasound; up to 30 minutes to score -Score of 8-10= normal (if adequate amniotic fluid volume) -Less than 6: suspicious of compromised fetus -Score the following: Fetal tone, Breathing, Motion, Amniotic Fluid Volume, NST *Two points each if meet criteria

Premonitory Signs of Labor: cervical changes

-cervix becomes soft (ripening) and begins to efface and dilate slightly (one month or one hour before labor begins; varies) · Assisted by prostaglandins, and Braxton hicks contractions · Cannot dilate and open if still thick

Signs of True Labor: Bloody Show

-due to cervical dilation -will continue - mucus plug is expelled, resulting in a small amount of blood loss from exposed cervical capillaries

Etiology of labor

-unknown, multifactorial: fetal, placental, and maternal · Uterine stretch · Progesterone withdrawal, increase in estrogen during last trimester of pregnancy · Increased oxytocin sensitivity · Increased release of prostaglandins

Erb's Palsy

-upper brachial plexus injury - Paralysis in upper portion of arm, moro absent, absent shoulder movement

Powers Affecting Labor and Delivery

-uterine contraction -intrabdominal pressure

Be particularly sensitive when addressing STIs

-women are often embarrassed or feel guilty -social stigma attached to STIs -women need to be reassured about confidentiality -address psycho-social needs

Blood Typing lab work

-women's blood type and Rh status to rule out any blood incompatibility issues early -Rh (-) mother likely will receive RhoGAM at 28 weeks and again 72 hrs after childbirth, if she is Rh sensitive

early adolescence

10-14 years old - self-absorbed, seeking peer approval, and identify formation

Light/Small lochia

10-25ml = 4" stained

scant lochia

10 ml = 1-2" stained pad

Middle Adolescence

15-17 yrs old - establishing independent identities & breaking away from parents

Maternal Mortality rate

15/100,000 live births: white (11.7), black (35.6)

Steps in determining fetal position

1: Indicates if presenting part is tilted toward left or right side of the maternal pelvis 2: Presenting Part (O, M, S, A) 3: Location of presenting part r/t Anterior or Posterior portion of the maternal pelvis · When head is down into pelvis àocciput or the mentum (that is it for options for position) · If it is the bottom coming in first: sacrum · Shoulder coming in first: acromial process · ROP: right, occiput, posterior (position of the occiput in the pelvis) · If perfectly to the side: LOT (T: for transverse) · Be able to visualize where the baby is

incidence of Sickle Cell Anemia

1:12 African-Americans carriers

Preterm Labor

20-37 weeks gestation

Diagnosis of Bacterial Vaginosis

3/4: discharge, vaginal ph >4.5, "whiff test",wet mount slide

ACDHO stand for

A - anxiety: difficulty sleeping, tenseness, mood swings, clumsiness C - craving: headache, cravings for sweets, salty foods, chocolate D - depression: feelings of low self-esteem, angry feelings, easily upset H - hydration:weight gain, abdominal bloating, breast tenderness O - other: hot flashes, cold sweats, nausea, change in bowel habits, aches or pains, dysmenorrhea, acne

Incidence of jaundice

60% term and 80% preterm - Before birth bilirubin is transferred across placental barrier to maternal circ., normal cord levels at birth are 1.8 to 2.8mg%

What action is done based off ACOG Recommendation for absent variability?

Amnioinfusion: -LR or NSS infused into IUPC to cushion cord compression or dilute meconium warmed infusion -inserted through cervix into a pocket of amniotic fluid -250 bolus then 15-20 ml/min

Amniotic sac

Amnion and chorion grow-meet Amniotic fluid to protect embryo; protects the fetus -formed from mom's blood and fetal urine (after 23-25 weeks)

s/s of Toxoplasmosis

Asymptomatic or fatigue, malaise, muscle pain, lymphadenopathy

Tachycardia in fetus

Fetal Heart Rate >160 bpm for 10 or more minutes *Significance*: Indeterminate/Unclear, depends on other variables with FHR. Can be Must Actif decrease in variability and late decels.

Bradycardia in fetus

Fetal Heart Rate less than 110 bpm for 10 or more minutes · *significance*- If minimal variability=Indeterminate/Unclear, -if absent variability, late decels =MUST ACT

Types of twins

Fraternal: Dizygotic - two separate ova - two placentas, 2 chorions and 2 amnions -↑ in age up to 35 and parity -genetic predisposition Monozygotic - Single fertilized ovum splits; share placenta, two amnions, one chorion - Identical twins

Trichomoniasis

Another common localized infection - Protozoan parasite -Woman: Symptomatic or Asymptomatic - Man: Asymptomatic carriers - Women that have this infection, it will go up the birth canal and into the uterus and cause various symptoms - Localized infection BUT Increasing Evidence of : PostPartum endometritis, infertility

management of TB

Meds (isoniazid, rifampin, ethambutol) -minimal risk on fetus, ok to BF, prevent transmission -cover mouth -sneeze, cough, etc.

diagnosis of Folic-acid anemia

Megoblastic RBC's

prevention of vulvovaginal candidiasis

Bacteria grows in dark, warm, moist environment -Decrease sugar/soda -Cotton vs. nylon underwear -No tight pants -No baths with bubbles/scents -Unscented soap, laundry detergent -Good hygiene, wiping correctly -Remove wet swimsuits -No douching, tampons limited

Lamaze Method (1960's): distraction technique

Breathing techniques * Breathing in and out = no tense * Breathing in through nose, out through mouth for smaller contractions * Short breaths for long contractions - hard to breath normal * When uterus contracts, muscle fibers become tinnier and tinner with contraction * Makes the uterus space tinnier and tinnier and the only place for the baby is out Effleurage (stroke belly) - light stroking with finger tips * Makes muscles work better Imagery - Get your mind in a different place to avoid/ cover up the pain

What 2 STIs are "best friends" aka coinfections?

Chlamydia and Gonorrhea -want to test for other or treat them as if they do have both

Tertiary level of care

Chronic, complicated, long term: examples: - Home health care bed bound elderly - Cardiac Rehab centers - Respiratory therapy - Hospice care

Vulva

Consists of mons pubis, labia majora/minora, clitoris, vestibule, and perineum -Protect urethral and vaginal opening -Highly sensitive to touch -Increase pleasure with sexual arousal

Periodic changes:FHR Changes with Contractions

Contractions can decrease FHR in 3 ways: -compression of myometrial vessels -compression of umbilical cord -compression of fetal head -Periodic patterns are associated with uterine contractions -accelerations or decelerations from the baseline with the FHR returning to baseline in relation to UC

Special considerations for nutrition promotion during pregnancy

Cultural variations • Spicy food can enhance reflux • Need to adapt American nutritional guidelines to meet their nutritional needs within their cultural framework Lactose intolerance - best source is milk and dairy but cannot have • How getting calcium and vitamin D? - peanut, almonds, sunflower seeds, broccoli, salmon, kale, and molasses • Encourage lactose free dairy or calcium-enriched orange juice or soy milk Vegetarianism • Getting enough protein? Getting enough nutrients? • Pay attention to vitamin B12 - fortified foods, iron - vitamin C rich foods; meat, calcium - soy; tofu, and protein - soy, beans, lentils, nuts, grains, and seeds Pica • Abnormal cravings that are not food (non-nutrient foods) • Tell them they can't eat - may be lacking certain minerals that your body needs now • Ex. Soil, clay, ice, laundry starch

National Health Goals for Maternal/Infant Care

Decrease maternal, fetal & infant deaths * Decrease maternal from 12.7 to 11.4 per 100,000 Decrease maternal illness * Complications from pregnancy Preterm births * Increases cost * Decrease - early and adequate prenatal care * Folic acid - prevents neural tube defects * Women sexually active, and of child-bearing age should be taking a multi-vitamin with folic acid * Cesarean section for low risk women * Low birth weight babies * Occurrence of Developmental disabilities * Spina Bifida, Neural tube defects * Fetal Alcohol Syndrome

Nursing interventions to maintain thermoregulation in newborns

Dry immediately after birth, wrap in warmed blankets, skin-to skin, warmed cover on scale, warm stethoscope and hands, avoid placing newborn in drafts or near vents or near outer wall, hat, socks, warmer unit

HSV - 1

Fever blisters/cold sores: lips, eyes, face (not sexually transmitted)

Mons Pubis

Fleshy, fatty tissue, hair, protects symphysis pubis

Healthy People 2020

Focus: Measure the health of the nation Leading Health Indicators: Major concerns for the 21stcentury * Physical activity * Overweight and obesity * Tobacco use * Substance abuse * Responsible sexual behavior * Mental health * Injury and violence * Environmental quality * Immunization * Access to health care Why these indicators? - Ability to motivate action - Measurable: Data available - Importance: Public health issues - Broad based - Federal and state collaborative initiative

3 phases of ovarian cycle

Follicular phase Ovulation Phase Luteal Phase

lVaccine-preventable STIs

Hepatitis A Hepatitis B HPV

Challenges for our area; Women's Health

High risk OB patients discharged early IV home infusion therapy-DVT, pelvic infections Less time spent on - Educating - Psychosocial issues - Prevention - Follow up care Heavier Case Loads

Paternal/Partner Adaptations

Influenced by - Participation in childbirth - Relationship with significant others - Competence in childcare - Family Role Organization - Culture - Method of Infant feeding - Develop bond with newborn - Intense absorption, Preoccupation, Interest = ENGROSSMENT

OB specific services

Infusion therapy - Hyperemesis (severe N/V during pregnancy) - dehydration Hypertension monitoring - Pregnancy induced Uterine monitoring - High risk preterm moms Fetal monitoring - Checks well being Portable ultrasound - Checks well being

Post-Traumatic Stress Disorder: Symptoms

Intrusion: re-experiencing of the trauma, including nightmares, flashbacks, recurrent thoughts Avoidance: avoiding trauma-related stimuli, social withdrawal, emotional numbing Hyperarousal: increased emotional arousal, exaggerated startle response, irritability

Culturally Competent Care

Knowledge, willingness, and ability to adapt health care

diagnosis of neonatal sepsis

Lab: blood culture (need to get before starting the antibiotics -won't be accurate if do after), CSF, chest and abdominal x-ray, urine cultures, CBC with differential, elevated CRP levels (inflammation)

what are the risks of Folic-acid anemia during pregnancy

Large megoblasts or immature RBC's, fetal anomalies (NTD) & spontaneous AB's

Feng Shui

Literally "wind-water." The Chinese art and science of placement and orientation of tombs, dwellings, buildings, and cities. Structures and objects are positioned in an effort to channel flows of sheng-chi ("life-breath") in favorable ways.

Why is C-section occurring in 1:3 deliveries today?

Older women, request, coinvent for patients, family, and physicians, insurance purposes, had C-section before - physician recommends, cosmetic - avoid disrupting vaginal area, no pain, need further procedures - ex. Tubes tided, babies preached, tired of pregnant induction- increases risk of C-section * BUT: if Women 39 weeks, 1st time moms = lower risk of C-sections for this group Most common reason: electronic fetal monitoring * indeterminants - gray area * if something goes wrong in life, go back to this a question the gray area * causes unnecessary C-sections * advocacy is huge - make sure do the best for your patients

Structural Abnormalities

Part of a chromosome missing or added - ex. Cri du Chat Syndrome (missing piece chrom 5) (Laryngeal defect='mewing cat infant cry', mental retardation, Failure to thrive, organ problems) Rearrangements of material within the chromosomes Two chromosomes that adhere to each other - ex. Fragility of a specific site on the X chromosome (Mental retardation, hyperactivity, autistic behavior)

Assessment of high-risk pregnant individual with pre-existing conditions

Physical: complete sexual history, screen for STI's, monitor for smoking, alcohol, and drug abuse, assess knowledge of infant needs - does not always correspond to maturity level - egocentrism - can she defer personal satisfaction to help infant, such as when the baby is sick - present-future orientation - what are their plans to finish school, do they have day care - abstract thinking - can they understand the importance of things that are not tangible such as prenatal care - participation of father parental support usually takes one of 3 forms - teenager's mother assumes mothering role - mothering is left to adolescent but family provides food and shelter - family shares care, allows teenager to develop -Analysis - ongoing during prenatal care, monitor consistency of kept appointments Planning - transportation and time of appointments - recommend group classes - establish open communication and help line - teach parenting - include significant other and family when possible -shield from negative attitudes that deter return visits use therapeutic teaching/learning principles -small peer groups -repetition -Discussion -Audiovisuals may be more effective than reading - avoid parenting new teen mom; help her to arrive at good decisions - nutritional - ex: best selections at fast food restaurants - stress reduction - help identify stresses especially basic needs, food, clothing, shelter, fears about L&D, stress about telling family - infant care - explain how infant react to environment, startles, tremors, teach Growth & Development, explain infant cues, what crying means - promote support - communicate plans with family - referrals - confidential and assessable, can include churches, WIC, high school programs, gov. based programs, social service, legal if incest or rape -# of appointments demonstrates learned knowledge of infant care, has supportive services secured -National prevention program 2020 - community based with teen involvement - Planning by professionals

Nursing of ectopic pregnancy

VS, Bleeding,, pain, emotional, grieving, educate on risk factors, no pregnancy for 3 months to heal

Prevention for Hep A and B?

Vaccines

hydramnios

Too much amniotic fluid (>2000ml at term) - also called polyhydramnios - May be seen with diabetics - May be due to GI or CNS malfunction, neural tube defects

Foramen ovale

anatomical opening between the right and left atrium

treatment of PP infection/ Metritis or Endometritis

broad spectrum antibiotics

interval

end of 1 to the beginning of next

GFR and renal plasma PP

flow normal within 6 weeks - high during pregnancy

cause of placenta previa

unknown/multifactorial - scarring/damage in upper segment?

Nursing Interventions immediate newborn period: Medication Administration - Hepatitis B

- *Recommended in NB period, 2 months & 6 mo*.; billable procedure - Some ped. give first dose in office, Need Consent - *IM*, *Vastus Lateralis*, Dosage *5-10mcg* - Needle Size and Gauge Important - *22-25-gauge, 5/8 needle size*

- Cervix PP

- After birth: shapeless and edematous and easily distensible - By 6 weeks=prepregnant state - Internal Gradually closes (approx. 2 weeks), external widens and never appears the same - Changes in appearance (slit - "fish mouth") - never regains prepregnant appearance (circle)

predisposing factors for trauma during L/D

- LGA - precipitous deliveries - Oxytocin, prolonged labor - forceps & vacuum

Congenital diaphragmatic hernia

- Abd. Contents herniate into thoracic cavity thru defect in diaphragm - Respiratory Distress o Lungs can't expand, may not have developed completely - May have other system anomalies - Rx: surgery, NPO, O2, ET intubation, VS, IV, I/O, check weight

Autosomal Dominant and examples

- Abnormal gene pair dominates normal gene pair - 50% children affected - ex. - Familial hypercholesterolemia, neurofibromatosis, Huntington Disease

Developmental Hip Dysplasia in newborn

- Abnormal growth/develop. of hip - Unstable, dislocated, or malformed - "short" leg, uneven gluteal/leg folds, limited hip abduction, unequal knee height if bend knees when infant lying down - Ortolani's sign and Barlow's maneuver Rx: Pavlik harness - Stabilize hip, prevents adduction

Mongolian spots

- benign blue/purple splotches(back/buttocks or multiple over legs and shoulders) - Tend to occur in African Americans, Asian, Hispanic, and Indian newborns but can occur in dark-skined newborns of all races - Caused by concertation of pigmented cells and usually disappear spontaneously within 4 years - Do not confuse with bruises from trauma

Nursing Interventions for the Newborn with Gestational Age or Birth Weight Variations

- Promoting oxygenation - top priority - Maintaining thermal regulation - Promoting nutrition and fluid balance - Preventing infection - Preventing complications - Providing appropriate stimulation - Managing pain - Promoting growth and development - Promoting parental coping - Preparing for discharge

Integumentary newborn

- Protective barrier between body and environment - Limits water loss, prevents trauma, prevents absorption of harmful substances - Limited sweat gland function (age 2-3yrs) - Less mature skin function (more risk injury) - Color, age, race/ethnic, temp., crying

Small/closed fontanels

- associated with craniosynostosis and abnormal brain development with small fontanels; early fontanel closure associated with microcephaly

Leopold's Maneuvers

) place women in supine position and stand beside her 2) first maneuver - determines presentation - Facing the women's head, place both hands on the abdomen to determine fetal position in the uterine fundus - Buttocks = soft and irregular (vertex presentation) - Head = hard, smooth, and round (breech presentation) 3) second maneuver - determine position - While still face the women, move hands down the lateral side of the abdomen to palpate on which side the back is located (feels hard and smooth) - Continue to palpate to determine on which side the limbs are located (irregular nodules with kicking and movement) 4) third maneuver - confirm presentation - Move hands down the sides of the abdomen to grasp the lower uterine segment and palpate the area just above the symphysis pubis - Place thumb and fingers of one hand apart and grasp the presenting part by bringing fingers together - Feel for the presenting part. - If it is the head, it will be round, firm and ballotable - If it is the buttocks, it will feel soft and irregular 5) fourth maneuver - determine attitude - Turn to face the client's feet and use the tips of the first three fingers of each hand to palpate the abdomen - Move fingers toward each other while applying downward pressure in the direction of the symphysis pubis. - If palpate a hard area on the side opposite the feta back, the fetus is in flexion, because you have palpated the chin - If the hard area is on the same side as the back, the fetus is in extension because the area palpate is the occiput

What to do if there is a baby abduction?

* Stall - talk louder, delay them leaving * Do not block the doors, baby, etc. * Security will be called during delay

Family and Medical Leave Act of 1993

* Up to 12 weeks unpaid leave * Guaranteed a position where qualified but may not the same position before due to fill ins that stay

Alpha fetoprotein (AFP)

- - AFP is produced by fetal liver at 13-20 weeks, optimal test at 16-18 weeks but; can be done 12-14 weeks, less accurate • Makes moms blood, measure level of AFP - drawn from plasma protein that is produces by the fetal liver yolk sac, and GI tract, andcrosses from the amniotic fluid into the maternal blood • if high: risk of neural tubedefect,Turner syndrome, tetralogy of fallor, multiple gestation, omphalocele, gastrochisis, or hydrocephaly • if low should rule out Trisomy 21/Down Syndrome, over-estimation of fetal age, fetal death, hydatidiform mole, increased maternal weight, maternal type 1 diabetes, Trisomy 18 • if high = detects 80% open neural tube defects, GI defects (open abdominal walls), under-estimation of gestational age, multiple fetuses present, low birth wt., oligohydramnios, decreased maternal weight • Tell mom - did not come back normal, going to perform more tests

Chorionic Villus Sampling (CVS)

- 10-13 weeks • Can be done early in pregnancy - able to make the decision if do not want to continue pregnancy • Remove a small tissue specimen from the fetal portion of the placenta which reflect the fetal genetic makeup • Complications: severe transverse limb defects, spontaneous pregnancy loss • Detect: Chromosomal abnormalities, gender, sex linked disorders • Need full bladder • Results in 48hrs • Administer Rhogam to mother if she is Rh negative

incidence of Blood Incompatibility: Rh

- 15% of white population is Rh negative - slightly lower incidence in Blacks and Asians

Amniocentesis

- 15-18 weeks (150 ml present); 14 weeks considered early amino • Transabdominal perforation of amniotic sac to remove fluid for analysis; empty bladder first Chromosome abnormalities • Hereditary metabolic defects • Safety concern: Risk of infection, pregnancy loss, fetal needle injuries • Provides time for option of abortion; test results take up to 3 weeks • 35 weeks or later: check fetal lung maturity • Administer Rhogam to mother if she is Rh negative

Classifications of Lacerations

- 1st degree laceration- involves only skin and superficial structures above muscle - 2nd degree laceration- extends through perineal muscles - 3rd degree laceration- extends through the anal sphincter muscle - 4th degree laceration- continues through anterior rectal wall

Five Levels of Breathing During Contractions

- 1st level- slow chest breathing involves 6 to 12 full respirations per minute; starts and ends with cleansing breath - 2nd level - breathing heavy enough to expand rib cage, but light enough so diaphragm barely moves - 3rd level- shallow, sternal breathing usually at a rate of 50 to 70 breaths/minute; used during transition phase of labor - 4th level- pant-blow pattern of breathing; taking three to four quick breaths in and out and then forcefully exhaling - 5th level- continuous chest pantings involve shallow breaths at a rate of about 60 breaths/minute

Maternal roles: Learning to give of oneself

- 1st trimester: identifying what must be given up to assume new role - Work? Out of work? Car with no backseat? No car - how transportation? - 2nd trimester: identifying with infant, learning how to delay own desires - Really iditify with the infant - feel the quickening and may decide they need a crib, carry seat, car seat, take money and put it towards the infant - 3rd trimester: questioning ability to become a good mother to infant - Am I going to be good mom? Can I do this? How will I be as a mom? How do I know what to do? What if I do something wrong? - Get scared and its expected

Septic Pelvic Thrombophlebitis

- 2-4 days to 2 weeks - infection along venous system involving major veins - ovarian, uterine and hypogastric vein - ↑ right side because the ovarian vein goes right into the inferior vena cava than general circulation - Left vein meets renal vein and can spread to kidney - Anaerobic strep

Episiotomy

- 2-4cm incision made - lowest aspect of vag opening into perineum - incision is made when head is on the perineum - done to prevent tearing, increased in primips but decreasing numbers - local anesthesia -1 -2% Lidocaine for repair - Originally would cup straight down and would lead to a 4th degree laceration and rip through the rectal wall o Now cut a slanted -women heal better, less pain, and post-delivery had less problems with intercourse

PP Depression

- 20 %, up to 60% adolescent mothers - signs/symptoms: o anger, anxiety, guilt, hopelessness, loss of interest or pleasure in activities, mood swings, or panic attack, crying, irritability, or restlessness, fatigue or loss of appetite, weight gain or weight loss, lack of concentration or unwanted thoughts, depression or fear, insomnia or repeatedly going over thoughts - Feel worse over time, does not go away on own - Gradual onset, evident by 6 weeks pp - Antidepressants, Antianxiety drugs - Psychotherapy - Prophylactic therapy= since predictable onset

incidence of Rubella (German Measles)

- 20% of adults susceptible, vaccine dev. 1969 - If not: Immunize pp before discharge- no preg. for 28 days to 3 months

Home Monitoring for preterm labor

- 2x/day for 60 min. electronically hooks up to phone and records uterine activity at perinatal evaluation center - try to stop labor before 3 cms - lab work - CBC, UA to detect any asymptomatic infections - vaginal & cervical cultures & amnio if chorioamnionitis - prophylactic antibiotics ?

breech presentation

- 3-4% of all - Increased with multips, advanced maternal age, previa, hydramnios, preterm - Frank, Complete, footling, incomplete presentation - Scheduled C/S - could deliver 1 baby vaginal and the other C/S if twins - External cephalic version - Breech extraction internal - usually done to del. 2nd baby, dangerous - emergency only

When sperm & ovum join

- 46 chromosomes - Zygote -Sex determination based on sperm: XX: girl XY: boy - Mitosis (cleavage) x4 results in 16 cells becoming solid ball = morula

Head Assessment

- 90% of congenital abnormalities are visible in the head or neck - Assess fontanels, skull (smooth and fused), and size - May be asymmetrical

Cocaine

- :10 per 1,000 births exposed. Vasoconstrictor, tachycardia, hypertension of mom and fetus - remains in maternal system >2 days, fetal 4 days - IUGR, Abruption, SIDS

maternal complications of Multiple Gestation

- AP - SOB, fatigue, n/v, back ache, pedal edema - ↑ UTI, Gest. HTN, Pre-term labor, previa, hydramnios, hyperemesis gr., anemia, preeclampsia - Labor complications - abnormal presentation, uterine dysfunction, prolapsed cords & ↑ hemorrhage

Emotional Costs of pregnancy

- Achievement of a stable identity - If a stable identity has not been established they will have difficulty adapting to parenthood - Encourage school-based pregnancy program, prenatal classes, and parenting classes for both parents - Achievement of comfort with body image - She must deal with drastic changes in body before comfortable with puberty changes - Encourage to verbalize feelings about body changes and emphasize the importance of not dieting, watch for anorexic behaviors - Acceptance of sexual role and identify - Pushed into an intimate relationship before ready and peer relations are disrupted - Encourage to express feelings in peer group of expectant teenage mothers - Development of personal value system - May still be at a stage of "following rules" without progressing to dev a sense of what is right and how it effects others - Explore views on motherhood and encourage expression about how this changes her life - Preparation for vocation or career - Interrupt school and increases poor socioeconomic status - Encourage continuing Highschool education, referral to school- based day care - Achievement of independence from parents - Dependent on parents more due to finances - Referrals: WIC, head start, paternity papers

Mifepristone (RU-486)

- Action/indication: acts as progesterone antagonist, allowing prostaglandins to stimulate uterine contractions; causes the endometrium to slough; may be followed by administration of misoprostol within 48 hrs Nursing Considerations: o Monitor H/A, V, D, and heavy bleeding o Anticipate administration of antiemetic prior to use to reduce N/V o Encourage client to use acetaminophen to reduce discomfort from cramping

Labetalol hydrochloride (Normodyne)

- Action/indication: alpha -1 and beta blocker; reduction in BP Nursing considerations: o Be aware that drugs that lower BP without decreasing maternal HR or CO; administer IV dose of 20-40 mg q15 min as needed then administer IV V infusion of 2 mg/min until desired BP value is achieved; monitor adverse effects - dizziness, peripheral edema, angina, D, nasal congestion, cough

Lasix (Furosemide)

- Action/indication: diuretic action, inhibiting the reabsorption of sodium and chloride from the ascending loop of henle; pulmonary edema (used only if condition is present) Nursing considerations: o Administer via slow IV bolus at a dose of 10 to 40 mg over 1-2 min; monitor urine output hourly; assess adverse effects - dizziness, vertigo, orthostatic hypotension, anorexia, V, E imbalance, muscle cramps and spasms

Sodium nitroprusside

- Action/indication: rapid vasodilation (arterial and venous); severe HTN requiring rapid reduction in BP Nursing considerations: o Administer via continuous IV infusion with dose titrated according to BP level; rap IV infusion solution in foil or opaque material to protect from light; monitor for possible adverse effects - apprehension, restlessness, retrosternal pressure, palpations, diaphoresis, abdominal pain

Misoprostol (Cytotec)

- Action/indication: stimulate uterine contractions to terminate a pregnancy; to evacuate the uterus after abortion to ensure passage of all the products of conception Nursing considerations: o Monitor for SE - diarrhea, abdominal pain, N/V, dyspepsia o Assess vaginal bleeding ad report any increased bleeding, pain, or fever o Monitor for s/s of shock - ex. Tachy, hypotension, anxiety

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

- Action/indication: stimulates uterine contraction, causing expulsion of uterine contents; to expel uterine contents in fetal death or missed abortion during second trimester, or to efface and dilate the cervix in pregnancy at term Nursing considerations: o Bring gel to room temperature before administering; avoid contact with skin; use sterile technique to administer o Keep client supine for 30 min after administering, document time of insertion and dosing intervals o Remove insert with retrieval system after 12 hours or at the onset of labor; explain purpose and expected response to client

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

- Action/indication: suppresses immune response of non-sensitized Rh-negative clients who are exposed to Rh-positive blood; to prevent isoimmunization in Rh-negative women exposed to Rh-positive blood after abortions, miscarriages, and pregnancies Nursing considerations: o Administer IM in deltoid area; Give oly MICRhoGAm for abortions and miscarriages <12 weeks unless fetus or father is Rh negative (unless client is Rh positive, Rh antibodies are present) o Educate women that she will need this after subsequent deliveries if newborns are Rh positive; also check lab study results prior to administration of the drug

Apresoline (Hydralazine Hydrochloride)

- Action/indication: vascular smooth muscle relaxant, thus improving perfusion to renal, uterine, and cerebral areas; reduction in blood pressure Nursing considerations: o Administer 5-10 mg by slow IV bolus q 20 min as needed; use parenteral form immediately after opening ampule o Withdraw drug slowly to prevent possible rebound HTN; monitor adverse effects - palpitations, H/A, tachy, anorexia, N/V, diarrhea

s/s of Uterine Rupture

- Acute abdominal pain, and/or chest pain (referred should or chest pain when bleeding in the abdomen) - Min. or diffuse Vag bleeding, hematuria - hypovolemic shock (hypotension, tachycardia) - Sudden fetal distress- bradycardia or death (fetal/maternal) - cessation of UC, uneven abdomen contour, mushy abdomen

Clinical Manifestations of Amniotic Fluid Embolism

- Acute onset; can't predict - respiratory distress, hypoxia, hypotension, seizures, uterine atony- hemorrhage, pulmonary edema, difficulty breathing, cyanosis - circulatory collapse, coagulopathy, DIC, tachycardia, cardiac arrest

Neonatal Period: Newborn Transitioning

- Adjusting to outer environment and breathing air - First 28 days of life - First 24 hrs. most precarious o We are most concerned because we are the first to see o Will have preexisting orders - Most transitions occur during first 6-10 hrs. of life - Physiologic Changes - Behavioral Changes - Nursing: Be aware of changes and deviations from the norm!

Risk Factors for Preterm birth

- African American race (double the risk); maternal age extremities (<16 years and >40 years); low socioeconomic status; alcohol or other drug use, especially cocaine; poor maternal nutrition; maternal periodontal disease; cigarette smoking; low level of education; history of prior preterm birth (triples the risk); uterine abnormalities, such as fibroids; low pregnancy weight for height; preexisting DM or HTN; multiple pregnancies; PROM; late or no prenantal care; short cervical length; STI (chlyamidia, gonorrhea, trichomoniasis); bacterial vaginosis (50%increased risk); chorioamnionitis; hydramnios; gestational HTN, cervical insufficiency; short interpregnancy interval (<1year between births); placental problems - previa and abruption; maternal anemia; UTI; violence; stress

Immediate Newborn Care

- Airway: establish and maintain airway - cleared when head is delivered with sterile bulb syringe, mouth first than nose (M before N), to prevent mucus from being aspirated with first breath, usually this manipulation elicits a gasp or cry. - Dry and Warm: Place under preheated Radiant Warmer; neutral o thermal environment, dry baby immediately and remove wet linen o provide stockinet hat o warmed blankets - Kangaroo care? o Drying infant provides tactile stimulation - Position: Suction further if needed - Bulb, DeLee, Mechanical Evaluate Breathing: - Effective respirations - gentle stimulation rub back or soles of feet - if respirations are still delayed the next step is 100% O2 with bag and mask and lastly intubation - Normal Circulatory Adaptation: o shortly after 1st cry HR 175-180, then 120-160 while awake, slower when sleeping o murmurs may or may not be significant and most disappear by 6 mo. o 1st and 2nd heart sounds should be clear and well defined; count for full minute - Physical Assessment: immediately after birth, initial assessment done in delivery room - Provide safety from potential injury and infection - Identify immediate actual or potential problems

Signs/Symptoms of molar pregnancies

- Amenorrhea, breast tenderness, fatigue - Bleeding, Brownish vaginal bleeding/spotting - Anemia - Rapidly increasing uterine size; more than number of weeks "pregnant" - ↑ incidence of lutein cysts on ovaries - No FHR or FM - early dx or preeclampsia before 24 wks ;15% - Expulsion of grapelike vesicles - Extreme high hCG levels

Magnesium Sulfate for treatment HTN

- Anticonvulsant = vasodilates = Lowers BP and depresses CNS - Easily tolerated by mom and baby - IV:Infusion Pump: loading dose (4-6g in 100ml over 15-20 min) then 2g/hr continuous IV infusion - therapeutic range 4-8 mg/dl - excreted by kidneys. - may be raised, depends on pt - nursing care (as prev. noted) - can cause respiratory depression, check resp q1hr (could actually stop breathing) (others: apresoline, Procardia, lasix, labetaol, sodium nitroprusside)

possible causes of bradycardia in newborn

- Apnea - Hypoxia (during labor) - do not know since in utero

nursing care of newborn

- Apply cord clamp 1/2 -1" from umbilicus and cut with sterile scissors - check cord for 3 vessels (2 associated with anomalies) - voids or meconium - foot printing - mom's right index finger and baby's footprint - ID bands - 2 baby, wrist and ankle (or both ankles) and one mom double check that numbers match and record on footprint sheet, security system - Some institutions write male or female on bracelet (should write "boy" or "girl" because a male can be misidentified as a female just by adding "fe"- some pre-write and then add "fe", BAD PRACTICE)

newborn extremities assessment

- Assess ability to move all 4 -Muscle tone - usually flexed up to 2 months - number of fingers/toes: polydactyly and/or syndactyly - Normal= 3 palmar creases - short fingers, broad hand, fingernails to end of fingers - Examine for signs of crepitus sign of fx, brachial and femoral pulses creases - Hip dysplasia? - talipes equinovarus?

Newborn Ears Assessment

- Assess ears for placement - imaginary line from inner to outer canthus should cross over top 1/3 of ear, stiffness of cartilage & curve of pinna for gestational age o If doesn't, low ears = possible down syndrome - Assess hearing loss - hearing screen required (hearing loss more common defect in US) - Periauricular skin tags - sometimes ligated - No otoscope: vernix, amniotic fluid, in canals - Will only push vernix in, won't see anything, no point

Nursing Assessment of pregnant substance abuse mother

- Assess for Drug Use by Drug Screen and Prevention Focus - Counseling, Education, Support - Positive Maternal Drug Use: Investigation by state agency prior to discharge with infant but not liable for criminal prosecution; be non-judgmental; culturally sensitive - Main focus: Effects on mom and Baby

Breast care postpartum: Non-lactating

- Avoid stimulation - Cold showers - Supportive bra on 24 hrs - Use ice packs or cabbage leaves for engorgement - Avoid manually expressing milk from breasts - Take mild analgesic for discomfort

severe Preeclampsia

- BP: > or = 160/110 - Proteinuria: >500mg/24hr collection, +3-+4 dipstick - Oliguria (<500 ml/24hr) - H/A, Blurred vision, blind spots, confusion - Hyperreflexia (DTR)- brachial & patella - Severe peripheral edema, - Pulmonary edema (SOB, decr. BS, crackles) or cardiac involvement, hepatic dysfunction - Epigastric Pain, RUQ pain (liver is involved now) - Thrombocytopenia (<platelets), >creat, HCT, Uric acid, liver enzymes, HELLP syndrome - Fetal growth restriction

Deep Vein Thrombophlebitis management/prevention

- BR and elevate leg - TEDs - Compression devices - anticoagulants (Heparin, coumadin-no BF) to prolong clotting time- prevent clot extension - Warm moist compresses - Monitor APTT values: normal 35-45 sec

- Bowel Function PP

- BS - listen q shift - ask about passing flatus - high fiber diet and 300ml fluid intake - Stool softeners (Colace (docusate sodium)) to decrease discomfort (esp. for 4th degree lacerations) - Early OOB - Dulcolax supp. or fleets enema if needed

Characteristics of Preterm

- BW less than 5.5lb - Scrawny appearance - Min. subcut. Fat - Thin, transparent skin - Lanugo plentiful - Undescended testes - Poor muscle tone - Fused eyelids - Flat pinna - Absent plantar creases, or few - Minimal scrotal rugae - Prominent clitoris and labia - Vernix plentiful - Lack of breast tissue

Cultural Considerations PP

- Balance of hot and cold: Latin American, Asian, African American o Vietnamese: postpartum = cold state (duong), protect with warmth o China: childbirth distrupts yin and yang balance o Good health requires balance - childbirth results in blood loss = hot, postpartum period = cold § Need to balance with hot food, cold food is avoided o Some view sitz bath and cold compresses for swelling and discomfort viewed as harmful - Confinement after childbirth: rest, recuperation, avoid illness o Still want to avoid cold so need to keep warm, stay inside to prevent chilling, bathe infrequently, and avoid exercise - Ask cultural preferences; support preferences as able

Placenta: produces hormones -HCG

- Basis for preg. Tests -Preserves the corpus luteum and its progesterone productions that the endometrial lining of the uterus is maintained - production by fetal trophoblasts cells until the placenta is developed sufficiently to take over that function - production peaks at 8 weeks and the gradually. decreases

Nursing plan of care

- Begins with perinatal history - Must know pertinent maternal and fetal data - Accurate, complete, and timely report - Chart - Guides care plan - Report - Allows prioritization for care of assigned infants

Interventions during the 3rd stage of labor

- Describe the process of placental separation to the couple - Instructing the women to push when signs of separation ae apparent - Administer an oxytocic agent if ordered and indicated after placental expulsion - Providing support and information about episiotomy and/or laceration if applicable - Cleaning and assisting client into a comfortable position after birth, making sure to life both legs out of stirrups (if used) simultaneously to prevent strain - Assess the women knowledge of breast-feeding to determine education needs - Instruct her about latching on, positioning, infant sucking and swallowing - Repositioning the birthing bed to a severe as a recovery bed if applicable - Assisting with transfer to the recovery area if applicable - Providing warmth by replacing warmed blankets over the women - Appling ice pack to perinea area to provide comfort to episiotomy if indicated - Explaining what assessment will be carried out over the next hour and offering positive reinforcement for actions - Ascertaining any needs - Monitoring maternal physical status by assessing: vaginal bleeding - amount, color, consistency, Vital signs - BP, pulse, respirations, q15, uterine fundus - should be firm, midline, and at the level of umbilicus - Recording all birthing statistics and securing primary caregivers' signature - Documenting birthing event in the birth book (official record of the facility that outlines every birth event), detailing any deviations

managment of DIC

- Determine cause and correct - Blood transfusions - whole or packed RBC's and Cryoprecipitate "cryo" (frozen blood product from plasma) - Maintains volume (if hemorrhaging losing a lot of blood volume) , provides O2 to cells

Evaluation of the woman choosing a contraceptive method/reproductive education

- Determine correct understanding of information provided - Re-educate as needed; correct misinformation - Re-evaluate patient/couple understanding

Group Beta Strep (GBS)

- Diagnosis - + vaginal or cervical culture of mother - known to cause *sepsis and death in otherwise healthy newborns* - Management/nursing care - CBC, blood culture, septic workup, frequent VS q4 hrs - No early discharge - need to stay 2 days for VD, 3 day for C/S - Maternal: screen all women prenatally at 35-37 week antibiotics intrapartum at least 4 hours before del. (Ampicillin, Clindamycin or Erythromycin) - If unknown: look at risk factors, follow protocols

Treatment of a molar pregnancy

- Dilation & suction curettage to evacuate contetents immediately on Dx - Send tissue to lab: check for choriocarcinoma - Serum beta hCG levels weekly, monthly, one year - Chest xray q 6 mo -check for metastasis - Systemic evaluations- metastasis - No preg. For 1 yr., need adequate measurements of hCG to make sure no more trophoblastic tissue - Hysterectomy possible (advanced age) - Chemotherapy possible

surgical abortion

- Dilation (vacuum aspiration) and evacuation - Type is based on gestational age - dilation of cervix, suction and curettage (scraping) (D and C) - If spontaneous, perform to make sure all tissue is not left, could result in a hemorrhage - Risks in 1st trimester: infections, hemorrhage, uterine perforation, retained products of conception, cervical tear

Diagnosis/management of preeclampsia/eclampsia

- Dip urine for protein - 24 hr. urine collection - Liver enzymes, BUN, Creat., Uric Acid, Magnesium, CBC, clotting studies, Chem. Profile, Non - stress Test, US, Biophysical profile, doppler blood flow analysis - BP, O2 sat, resp rate, Lung Sounds, VS, daily wt., strict I/O, LOC - DTR: brachial, patella; also check for ankle clonus. (repetitive dorsiflexion of the ankle in response to one time forcible dorsiflexion. Clonus is usually accompanied by spasticity. ) - BR - ↑ peripheral perfusion, reduce stimuli - fetal - KC, BPP, EFM - B/P monitoring - 2-4 x/day, same arm, sitting, heart level - diet - ↑ protein, monitor Na - Seizure - maintain airway, suction, turn head to side, O2 via mask - IV MgSO4 or phenobarbital IVP if not controlled - monitor for abruption - Lasix for pulmonary edema

lochia

- Discharge occurs after birth for approx.4-8 weeks (*avg. 240-270 ml for 3 weeks (can persist for 6*)) - Results from involution - *Superficial layer of Decidua Basalis-necrosis, sloughs off* - Goes from alkaline to acidic passing through vaginal area - Equal to amt. of heavy menstrual period - *Less in C/S d/t uterine debris removed manually with placenta* - Fleshy smell Offensive odor=infection (ex. Endometritis (inflammation of the inner lining of the uterus))

Neonatal Abstinence Syndrome assessment

- Do assessment and determine score - higher = worse - W= Wakefulness- 1-3hrs sleep duration post feed - I= Irritability - T= Temperature variation, tachycardia, tremors - H= Hyperactivity, high-pitched cry, hyperreflexia, hypertonus - D= Diarrhea, diaphoresis, disorganized suck - R= Respiratory distress, rub marks, rhinorrhea - A= Apneic attacks, autonomic dysfunction - W= Weight loss or failure to gain weight - A= Alkalosis (respiratory) - L= Lacrimation

- Natural immunity newborn

- Does not require previous exposure - Physical barriers (skin, mucous memb.) - Chemical barriers (gastric, enzymes) - Resident non-pathological organisms - Ingests and kills microorg. by phagocytic cells

Neurological System newborn: senses

- Immature and continues to develop t achieve a d full complement of cortical and brainstem cells by 1 year of age - Hearing: well-developed at birth; responds to noise- turns to sound - Taste: distinguish between sweet/sour by 72 hours old - Smell: can distinguish between mother's breast and breast milk from others - Touch: sensitive to pain, responds tactile stimuli - Vision: ability to focus on objects close by; tracks objects - incomplete at birth

things done/seen at visits for 3rd trimester (weeks 29-36)

- Edema - face, hands, feet, etc. (check for gestational hypertension) - If Rh-, check antibody titer, if needed give Rhogam now (prophylactic at 28 weeks (IM), and after spontaneous ab, amnio, after birth (if Rh+ baby) (give anytime chance of fetal cells entering maternal circulation- prevent development of antibodies to Rh+ cells) would lead to an attacking to subsequent pregnancies if Rh+ as well Perform Leopold's Maneuver -Used to determine cephalic or breech and where is it best to hear the fetal HR - so we know where to put the doppler -Fetal Movement Monitoring -H/H for anemia - could have hemodilution with pregnancy due to increase in blood volume Pelvic Exam: check cervix position, consistency, length, dilation -Should not being doing this after first visit, can introduce bleeding, ROM, infection -Closer to delivery - need to check cervix to determine length, thickness, etc. - Do it when feeling more pressure

Physical changes during pregnancy: immune system

- Enhanced innate immunity (inflammatory and phagocytosis response (attacks the bacteria)) but Suppressed adaptive immunity (so not to reject fetus); increases risk for developing infections. -Varied responses to chronic disorders/autoimmune. -Ex. RA, lopus, Crohn's, colitis, etc. -1/3 split between worse, better, and same

Newborn female genital Assessment

- Enlarged labia (majora & minora) due to maternal hormones: estrogen and progesterone - pseudomenstruation - May be seen during first few weeks - May have vaginal tag - common - Seen more with premature - Babies majora covers minora - Pink or dark in colored populations

morula

- Enters uterine cavity within 72 hrs - More cell division leads to fetal structures Inside: -Inner cell mass=blastocyst: forms embryo and amnion -Outer cell mass=trophoblast: forms placenta and chorion

Trisomy

- Entire single added chromosome ex. Down syndrome (3 copies of chrom 21) - most common; most aware of - Klinefelter syndrome (extra x: XXY) only males

Monosomy

- Entire single chromosome missing ex. Turner Syndrome (females) (one X) -All others incompatible with life

Factors Associated with an Increased Risk for Dystocia

- Epidural analgesia, excessive analgesia - Multiple gestation - Hydramnios - Maternal exhaustion - Ineffective maternal pushing technique - Occiput posterior position - Longer first stage of labor - Nulliparity - Short maternal stature (< 5'), overweight, high caffeine intake - Fetal birth weight (>8.8 pounds) - Shoulder dystocia - Abnormal fetal presentation or position (breech) - Fetal anomalies (hydrocephalus) - Age > 35 years - Gestational age >41 weeks - Chorioamnionitis - Ineffective uterine contractions - High fetal station at complete cervical dilation

Signs of Hematomas

- Episiotomy or laceration is assessed q 8 hrs to detect hematomas or infection - Large area of swollen, bluish skin - collection of blood below the skin - Common In perineum area - want to keep off of it, have the ambulate or on their side when in bed - c/o severe pain - Assess for s/s of infection - redness, swelling, increasing discomfort, purulent drainage , white line running episiotomy

- Esophageal Atresia & Tracheoesophageal Fistula

- Esophagus and trachea don't separate normally...may also have CHD, anorectal and GU anomalies.... no known cause but may be seen with premies and polyhydramnios pregnancies - Upper segment ends in blind pouch, doesn't meet lower segment, or narrowing, or fistula forms between esophagus and trachea - Cough, choke, turn blue with feeds, drool, resp. arrest, aspiration pneumonia - 3 C's" cough, choke, cyanosis when you go to feed them - Rx: surgery

Areas of Problems that Can Result in Dystocia

- Expulsive forces (powers) - Presentation - Position - Fetal development (passenger) - Maternal bony pelvis or birth (passageway) - Maternal stress (psyche)

placenta increta

- Extends further into myometrium (penetrates muscle)

Involution

- Fairly rapid - Wt of uterus decreases from 1000g to 60g by 6 weeks - 1 week = 50% (500 g) - Endometrium is thin - Descends 1cm/day (1 fingerbreadth) - Day 10 in true pelvis, cannot palpate - The fundus will be at the umbilicus after delivery - fundus felt at U - Day 1 = fundus felt at U-1 as so on

s/s of anemia

- Fatigue, weakness, malaise - Anorexia - Susceptibility to infection (frequent colds) - Pale mucous membranes - Tachycardia, pallor Abnormal lab results - Low hemoglobin, low hematocrit, low serum iron, microcytic and hypochromic cells, and low serum ferritin

treatment of anemia

- Fe supplements 30mg/day - Best between meals-NOT with coffee/tea/chocolate n, Effect absorption

Lab and Diagnostic Testing for preterm labor

- Fetal Fibronectin: collected vaginal secretion; predicts if preterm labor is unlikely - Transvaginal US: cervical length/width, Funnel length/width, percentage of funneling; measures closed portion of cervix; short cervical length greater risk of preterm labor

Fetal Stimulation

- Fetal Scalp stimulation or sound/vibration to mother's lower abd. - Promote fetal movement, FHR acceleration 15x15 (15 bpm above BL lasts 15 sec) means well oxygenated fetus, CNS is intact and ph is more than7 - Don't do scalp stimulation if placenta previa is present, infection, or maternal temp. elevated, pre-term fetus

Nursing measures to prevent cold stress/minimize:

- Prewarm blankets, Hat - Transporter/isolette warmed - Dry baby immediately after birth - Skin to skin contact (kangaroo care) - Early Breast feeding (nutrients) - Heated/humidified 02 - Radiant warmers - Environment should be 32-34 degrees C - Don't bathe infant until stable! (do under warmer) - Skin temp. probe not accurate if on bone or on brown fat

Respiratory Adaptations newborn

- Fetal life= fluid filled lungs - Think about C/S - do not get that squeeze so fluid never leaves their chest and belly = more problems with respiratory; Will need to under the warmer for a little bit longer - Extrauterine= fluid must be removed and replaced with air - Vaginal birth= thorax is squeezed, helps rid fluid from lungs - Pulmonary capillaries and lymphatic system rid rest of fluid Fluid may be removed too slowly or inadequately - Decreased thoracic squeezing during birth (c-section) - Diminished resp. effort (newborn sedation) - Results = transient tachypnea (rr >60bpm) Chest wall is floppy - High cartilage content - Poorly developed musculature - Results= ineffective accessory muscles - Therefore; abdominal/diaphragmatic breathers Surfactant lining alveoli enhances aeration which reduceing surface tension and lowering the pressure required to open the aveoli - lipoprotein that prevents the alveolar from collapse at the end of expiration and loss of lung volume

s/s of PP infection

- Fever 100.4 or higher after 24hrs post delivery, occurs for 2 or more days of the first 10 days (not counting first 24 hrs) - Chills, h/a, malaise, tachycardia, anxious, restless - Vag acidity is decreased after childbirth, more alkaline- more prone to bacteria growth - Most common - gram- negative bacteria, E-Coli, Staph & Strep - Normal in vagina & cervix - ascend - ↑ with PROM >24 hours - Retained placenta, poor hygiene, pp hem.

Maternal Surveillance During Pregnancy with DM

- Fingerstick blood glucose levels at every prenatal visit - Urine check for protein and for nitrates and leukocyte estrase - Urine check for ketones - Kidney function evaluation every trimester for creatinine clearance and protein levels - Eye examination done in first trimester to evaluate retina for vascular changes - HbA1c every 4 to 6 weeks to monitor glucose trends

predictable Behavioral Patterns/Newborns

- First period of reactivity: birth - 30 minutes after birth; newborn is alert, moving, may appear hungry (start BF) - Period of decreased responsiveness: 30 minutes - 120 minutes old; period of sleep or decreased activity (no interest in sucking) o Think about blood sugar = hypoglycemic = stress, cold - Second period of reactivity: 2 - 8 hours; newborn awakens and shows an interest in the stimuli

High Risk factors for Gestational Hypertension

- First preg. - Prev. hx of Gest. Htn. - Obesity - Multiple gestation - Diabetes - Chronic Htn - could have had it and. was never diagnosed - Rh incompatability - Molar pregnancy - Chronic renal disease - Age <20, >40

Transient Tachypnea (TTN)

- Fluid in lungs removed slowly or not all of it - Self-limiting, resolves within 72hrs - Risk: c/s, sedation, long labor, maternal asthma/smoking - S/S: grunting, moaning, retractions, nasal flaring, mild cyanosis, rr 100-140 - Rx: supportive- O2, sat, chest PT, positioning - typically raise the head, NICU might have them on there belly, IV fluids or gavage, no oral feeds until resolves

overheating in newborns Results in increase in

- Fluid loss - Respiratory rate - Metabolic rate

Nursing Interventions for the Pregnant Woman with Hypertension

- Following Dietary Approaches to Stop Hypertension (DASH) diet - Starting aerobic exercise - Avoiding smoking and alcohol - Losing weight prior to pregnancy - Using home blood pressure monitor - Monitoring fetal growth - Monitoring for maternal complications - Stressing the importance of daily rest periods

ursing Interventions for the Pregnant Woman with Hypertension

- Following Dietary Approaches to Stop Hypertension (DASH) diet: Na limit 2.4g, adequate K+, Ca++, Magn. - Starting aerobic exercise - Avoiding smoking and alcohol - Losing weight prior to pregnancy - Using home blood pressure monitor - Monitoring fetal growth - Monitoring for maternal complications Stressing the importance of daily rest periods - 1 hr, left lateral recumbent position-max. perfusion

treatment of engorgement

- Frequent emptying of breasts, also helps with discomfort - Stimulation and heat help bring the milk down - Do not want to do if not breast feeding - apply cold packs to decrease expression of milk, shower with back towards water - Warm shower - Warm compresses

Self Care Misc. PP

- Frequent pad changes - No tampons - No tub baths 4-6 weeks - Hand Washing!

Factors Affecting a Favorable Outcome for a Pregnant Woman with Diabetes

- Frequent prenatal visits - Dietary restrictions - Self-monitoring of blood glucose levels - Frequent lab tests - Intensive fetal surveillance - Potential hospitalization

Postpartum Hemorrhage- Management

- Fundal massage (most of time this will cause contraction = slowing down of bleeding); Pitocin (oxytocin); Methergine (Methylergonovine); Hemabate (carboprost) - Teach woman to massage own fundus and assess bleeding - Monitor CBC - note how much H/H have dropped

X Linked and examples

- Gene mutation on x chromosome - Follows dominant or recessive pattern - Usually only men (women-other X compensates unless dominant x) - e.g. Hemophilia, color blindness, childhood muscular dystrophy

Examples of biophysical risks in pregnancy

- Genetic conditions, chromosomal abnorms, multiple pregnancies, defective genes, inherited disorders, ABO incompatibilities, large fetal size, medical and OB conditions, preterm labor and birth, CVD, chronic HTN, cervical insufficient, placental abnorms, infection, DM, maternal collagen diseases, thyroid disease asthma, post-term pregnancy, hemoglobinopathies, nutrition status, inadequate dietary intake, food fats, excessive food intake, under/overweight status, Hct value less than 33%, eating disorder

Teaching topics for delayed pregnancy

- Getting early and regular prenatal care - Taking a multivitamin containing 400 micrograms of folic acid daily - Consuming a variety of nutritious foods and drinking at least 6 to 8 glasses of water daily - Avoiding alcohol intake during pregnancy - Avoiding exposure to secondhand smoke - Taking no drugs unless they are prescribed - Increased risk for complications- infertility, GDM, HTN With delayed pregnancy, increased risk of comorbidities

Gestational Diabetes Mellitus

- Glucose intolerance of pregnancy - Risk Analysis Assessment at First Prenatal Visit - Risk factors: obesity, existence of other auto-immune disorders, age > 30, family history, previous GDM, history of macrosomic infant or fetal demise or infant with unexplained congenital anomalies, African American, Hispanic, Native American - Women with risk factors deserve early GDM testing

Late decelerations

- Gradual decrease in FHR; lowest part (Nadir) is after contraction peaks - Onset to Nadir > or = to 30 seconds - Onset is after the beginning ofcontraction - Cause: Uteroplacental insufficiency - placenta is not growing ne tissue or fixing itself; major issue -Compromises blood flow to fetus -Fetus getting less oxygen -Longer the contraction = worse it is for the baby -Seizure? Monitor off? Patocen can cause - want to give 10 L of O2 (crank it up) get on left side, up Lactating ringers -Baby will become hypoxic and will lead to brain damage -If close, - use kiwi (suction) with pushing to pull baby out faster - If not close, will have C/S due to hypoxia -Will see an acceleration before crashes - fight or flight response - uniform shape - returns to baseline after end of UC - frequently associated with tachycardia and or minimal variability - *significance*- Indeterminate if moderate variability; Must Act if absent variability

Exercise PP

- Gradual return - Kegels!! - Walking - Abd. breathing - supine position with knees bent, contract abd. muscles, exhale - Head lifts - supine with knees bent, raise head slowly - Modified sit ups - progression of head lifts - Knee & leg rolls - supine, knees flexed, keep shoulders on bed & roll hips - Chest exercises - supine, knees bent raise arms

Polycythemia SGA newborn

- HCT >65% - Hypoxia- increases eryth. Production - Weak suck, ruddy, tachypnea, jaundice, lethargy, poor feeding, hypotonia, seizures Partial exchange transfusion to incr. volume, adequate hydration, monitor HCT

Prevent infection in newborn

- Hand washing, no hand jewelry

Forceps Assisted delivery

- Have locking mechanism- prevents skull compression - High - before engagement - never done - Mid-forceps: station 0 to +2 station o High and mid-forceps is not done anymore; old practice which lead to brain damage - Low Forceps: station +2 to +5 (outlet) (+4 to +5 out of perineum) - Useful in rotating fetal head - Less physicians are trained in this today

Typical appearance of SGA newborn

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

Prerequisites for applications of forceps

- Head must be engaged - Must be vertex, or mentum anteriorly - Position of head must be precisely known - Must be 10 cms and ROM - No CPD - Empty bladder - Episiotomy and anesthesia

criteria for Apgar score

- Heart rate- most important sign and the last to be absent if the situation is grave 150- 180 in first few minutes and 130-140 during the first hour, a rate below 100 requires resuscitation - Respiratory effort- regular respirations should be established within a minute - Muscle tone- keeps extremities well flexed and resist attempts to extend them - Reflex irritability- withdraw from pain Color- Cyanosis is seen in almost all infants at the moment of birth, the body of a healthy infant usually turns pink in approximately 3 minutes, Acrocyanosis - normal for 24 hrs or so, score of 1

Opiates and Narcotics

- Heroin, opium, morphine codeine, oxycodone - Intense addiction to mother and newborn - Preeclampsia, IUGR, preterm labor, brain development, crosses placenta, behavior problems

Nursing management of pregnant mom with Sickle Cell Anemia

- Hgb studies, fetal well-being studies, adequate hydration, nutritional counseling, folic acid for RBC production, rest, avoid infections, hygiene, comfort measures, O2 during labor, emotional support, pain management

NEC: Necrotizing Enterocolitis in newborn

- High risk, Big thing in a NICU - GI disease of unknown origin -More common preterm day 3-10 -Pathogenic organism, hypoxic/ischemic event...blood shunted to brain and heart (vital organs) during hypoxia, enteral feeding....allows bacteria to flourish, altered mucosa integrity -Result: necrosis of part of the intestine...usually distal ileum -Acute and chronic morbidity and mortality

Musculoskeletal PP

- Hormones decrease (relaxin, estrogen, progesterone) - All joints return to normal within 6-8 weeks except feet - Permanent increase in shoe size - Fatigue, Activity Intolerance, Distorted body image - Careful to prevent low back pain, joint injury until stabilized-normal state - May have separation of Rectus Abdominis muscles= Diastasis Recti (d/t stretching, loss of tone) -Correct with exercises

L/D for women with GDM

- IV Saline or LR - Monitor BG Q 1-2 hrs: Keep below 110mg/dl - Example of IV infusion of Regular Insulin: - Pharmacy to prepare 100 units of Regular Insulinin 100 mL of 0.9% sodium chloride Example of IV orders: - 110 - 150 = 0.6U/hr - 150 - 170 = 0.8 U/hr - 171 - 200 = 1U/hr - 201 - 250 = 2U/hr - 250 - 300 = 3U/hr - Over 300 call

Comfort Measures PP

- Ice packs x 24hrs (vasoconstricts, helps with edema, helps with discomfort, pain, and swelling), warm packs p 24 hrs (vasodilates, helps with healing) - Warm water over the area via a peribottle - Witch hazel pads ex: TUCKS (can be used on vaginal area, laceration/episiotomy area, or hemorrhoids) - Want to hold it there on hemorrhoids and leave it in place and take it off next time going to the bathroom to help shrink them - Anesthetic sprays: ex: Dermoplast - Shake the can, spray wherever they are sore, provides a lot of comfort - Sitz baths after 24 hrs (vasodilation and comfort) - Hydrocortisone cream- hemorrhoids

Nursing Interventions PP

- Identify pos. and neg. attachment behaviors - Ex: holding, caring for infant - Recognize Cultural Diversity - Some begin BF after discharge when milk comes in - Limited time in hospital to address concerns - Pain/Discomfort, immunizations, nutrition, activity, exercise, lactation, d/c teaching, sexuality, contraception, follow-up care

fetal effects of Toxoplasmosis

- If contacted before 20 wks can cause: spontaneous AB, preemie, stillbirth, enlarged liver & spleen, chorioretinitis, jaundice, anemia, neuro damage

examples of teratogens

- Ionizing radiation - brain damage, mental retardation, leukemia in children -Organic mercury - damage to neural system, mental retardation, behavioral and cognitive problems, blindness in infants -Lead exposure - spontaneous abortion, delayed fetal development, increases risk of fetal death, or abnormal mental or physical development of a child -Toxoplasma (found in cat feces, avoid scooping litter box) - spontaneous abortion, still birth, underdeveloped fetal brain, blindness, and seizures -Syphilis bacteria - fetal death, spontaneous abortion, liver and spleen enlargement, cngential syphilis Rubella virus - abnormal brain development -Cytomegalovirus - underdevelopment of the fetal brain, blindness, deafness, jaundice, liver and spleen dysfunction -Varcilla zoster -leads to underdeveloped limbs, brain, or eye malformations -Herpes virus - fetal death, microcephaly, hepatic hyperthyroidis, PKU -Drugs - thalidome (limb malformations), ACE inhibitor (prematurity intrauterine growth restriction (IUGR), cocaine (abruptio placenta, prematurity, microcephaly), tetracycline (yeloow-brown teeth discoloration), Alcohol (FAS)

eclampsia

- Is severe preeclampsia (same symptoms) PLUSSeizures or Coma - Severe H/A, severe epigastric pain, hyper reflexes are warning signs- lead to seizure activity - Cerebral hemorrhage, renal failure, HELLP syndrome, generalized edema

Umbilical cord characteristics

- It is formed from the amnion - It is the lifeline from the mother to thegrowing embryo - It contains one large vein and two small arteries (Normal) o Umbilical cord name is AVA - Wharton's jelly surrounds the vein and arteries to prevent compression and sticking to each other - At term, the average umbilical cord is 22 inches long and about 1 inch in width o Need to have this length so as the baby is growing, moving, and turning freely but can also get wrapped up in it - Vessels removes waste and bring nutrients and O2 to the fetus

Non-pharmacological measures of pain management

- Know culture & techniques Advantages -no side effects -can use if advanced stage -does not interrupt labor Disadvantages -may not achieve desired level of comfort -need motivated clients

Amnioinfusion

- LR or NSS infused into IUPC to cushion cord compression (increase fetal oxygenation) or dilute meconium, oligohydramnios - warmed infusion inserted through cervix into a pocket of AF - ex: 250 ml bolus than 15-20 ml/min

Dystocia interventions

- Labor support, comfort, nourishment, vag. exams, positioning, meds, coach, document

why is maternal morbidity and infant mortality rates greater in blacks?

- Lack of prenatal care - Especially 1st trimester - Low socioeconomic status - Limited or no health insurance - Healthcare worker bias - Fosters distrust - Lack of quality care in community - Language/Cultural - Legal - illegal immigrants Barriers to healthcare - Need to be in populated areas - Need weekend hours - Need to be by the bus route Financial * Limited or no insurance * Complicated paperwork Transportation * Car, public transportation * Children in tow * Frequent prenatal visits - struggle with access to care Language - Interpreter available? - complaints can be misinterpreted and ignored Cultural - Awareness, Acceptance, Understanding Barriers... Clinic Hours/Location * Evenings, Weekends Poor attitudes of Healthcare workers * Long delays * Hurried exams * Rude comments * Non-verbal communication

Asphyxia

- Lack of sustained, adequate resp. - Impaired gas exchange-less O2 in blood= hypoxia - Excess CO2= Acidosis Result= brain injury (cannot fix that) - Mental retardation - Cerebral Palsy - Seizures - Increased risk for pre and postterm

Disseminated Intravascular Coagulation (DIC)

- Life threatening- wide spread clot formation of small vessels, depletes platelets and coagulation factors- ICU - Symptoms: petechiae, ecchymoses, hematomas, tachycardia, uncontrolled bleeding - Treatment: IV fluids, oxygen, heparin, and blood products - DIC is secondary to other underlying disorders (ex: abruption, amniotic fluid emboli, HELLP syndrome) - Must treat the primary disorder first

Disparities in healthcare

- Maternal morbidity & mortality is 3-4x higher for black women than white women - Infant mortality 2.3x greater, black infants than white infants

Factors: Place a Newborn at Risk for Gest. Age or Birth Wt. Variation

- Maternal nutrition (malnutrition or over-nutrition) - Substandard living conditions - Low socioeconomic status - Maternal age <20 to >35 years old - Substance abuse - Failure to seek prenatal care - Smoking or exposure to passive smoke - Periodontal disease - Multiple gestation - Extreme maternal stress - Abuse and violence - Pregnancy complications - previa or abruptio - History of previous preterm birth - Maternal disease, such as hypertension or diabetes, renal, autoimmune - Maternal infection, such as urinary tract infection or chorioamnionitis, TORCH - Exposure to occupational hazards (Gilbert & Harmon, 2003) - Placental Factors: previa, abruption, abnormal cord insertion, insufficiency - Fetal Factors: chromosome, infection, anomalies, multiples, radiation exposure

ovulation phase of ovarian cycle

- Mature follicle ruptures=release mature ovum -Usually day 14 ( in a 28 day cycle) but always 14 days before menstruation -Estrogen decreases -Ovulation = 10-12 hrs after LH peak, 24-36 hrs. after estrogen peak -Fallopian tubes create current, move ovum -Ovum lasts 24 hrs, then dies if not fertilized -Symptoms: abdomen cramping, rise in basal body temp., increased libido -Pain on side released "mittelschmerz" "middle pain" -Cervical mucous thins, clear, stretchy, receptive to sperm

Congenital Heart Conditions

- May be advised not to get pregnant-especially uncorrected congenital conditions - Ex: Tetralogy of Fallot- uncorrected - Otherwise, monitor closely

Management of GDM

- May be asymptomatic or small signs - usually not associated with congenital malformations - needs diet, changes in lifestyle, weight management but no dieting during pregnancy, education glucose monitoring, insulin needs, s/s hypo vs. hyperglycemia - Minimize risks and complications - Nursing Care- communication, patient control, inclusion of normal pregnancy care and education

Doppler flow studies

- Measure velocity of blood flow, identify abnormalities in umbilical vessels, fetal vessels - Non-invasive - Only if needed (concern about blood flow)

High Risk Pregnancy: Pre-existing conditions - importance

- Medical conditions present before pregnancy can have a negative effect on the pregnancy - Effects Maternal, Fetal, or both outcomes - Knowing previous medical conditions: - Guides Assessment - Plan appropriate interventions - Increase potential for positive outcomes

management/nursing care of Folic-acid anemia

- Nutritional & supplements examples of foods: - liver, kidney beans, lima beans & dark leafy vegetables

treatment of PE

- O2 - IV heparin - Bedrest - Analgesics - Thromobolytic agents - tPA - dissolve clot - Cardiopulmonary support - Transfer to ICU

Afterpains

- Painful uterine contractions - normal, need it for involution - Feel like very strong cramps - Due to involution caused by uterine contractions - Multiparous, breast-feeding women (stimulates oxytocin) overdistended uterus, retained clots/placenta fragments, prolonged, difficult labor = greater afterpains - Primiparous women = mild afterpains due to maintaining contracted state - Stronger with BF d/t oxytocin strengthens UC - Don't forget to medicate (Advil, motrin (ibuprofen)), safe with breastfeeding, works the best with after pains (better than the percuset) and its non-addicting and non-constipating

Signs/Symptoms of placenta previa

- Painless bleeding; usually not profuse o Areas can vary with bleeding - Bright red - active bleeding (dark red - blood that is finally coming out (been there for a while)) - 2ndor 3rdtrimester - Bleeding starts, stops, recurs - Mayhave contractions; usually uterus is soft and non-tender (not a uterus problem, placental problem)

Examples of Sociodemographic risks in pregnancy

- Parity- all first pregnancies and more than 5 pregnancies, marital status - increased risk for unmarried women, accessibility to health care, ethnicity - increased risk in non-white women

Bradley Method (1960's)

- Partner coached Focused on partner learning massage/comfort techniques * Get them more involved * Help rub feet, shoulders, legs, * Rub belly, help with breathing, etc.

placenta percreta

- Penetrates myometrium into peritoneal covering; ruptures uterus - Can then attach to other organs (bladder, rectum) - High morbidity and mortality; possible hysterectomy Will kill baby and mom

Maternal roles: Seeking acceptance of self in maternal role to infant ("binding in")

- People are going to see her as the mom - 1st trimester: mother accepts idea of pregnancy, , but not of infant - 2nd trimester: with sensation of fetal movement (quickening) , mothers acknowledges fetus as a separate entirety within her - 3rd trimester: mother longs to hold infant and becomes tired of being pregnant

Factors Impeding Urination in the Postpartum Woman

- Perineal lacerations - Generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus - Hematomas - Decreased bladder tone due to regional anesthesia - Diminished sensation of bladder pressure due to swelling, poor bladder tone and numbing effects of regional anesthesia used during labor

Phototherapy Treatment

- Phototherapy lights - Can be single, double or triple free-standing lights (MD orders) - Use bili-light meter - circle, push on skin and tells you how much light is getting through and can adjust the high of the lights - Can be done by bilirubin blanket ;Wallaby (brand) - Can be a bilirubin bed

childbearing in Early 1900's......

- Physicians delivering 50% of births, specifically Middle class women - Midwives care for poor women Hospitals become popular for wealthy * Provided affluence and offer pain management during childbirth Nurseries created * Separated after birth because mother is still sedated and nauseas- doesn't want to hold their newborn * Mothers can't care for infant due to use of chloroform gas

Types of Hyperbilirubinemia

- Physiological Jaundice - Pathologic Jaundice - Preterm Jaundice - Breast Milk Jaundice

Skin variations - Color in newborns

- Pink- no central cyanosis - lips trunk Acrocyanosis peripheral - normal due to poor blood perfusion -Farthest from the heart and it just tastes a longer time to get there -Takes days to go away - Ruddy (polycythemic) - increase RBC's - Pallor- decreased RBC's - Jaundice - bilirubin accumulation

Cervical Insufficiency

- Premature dilatation of cervix, cervical defe ct that causes dilation in 2nd trimester or early 3rdtrimester, passive, painless dilation varying degrees o Cervix will start to dilate and open (painlessly) - fetus will come out, membranes, placenta, etc. and will lead to a miscarriage o Don't know it is happening - because we aren't going in checking her cervix (to avoid complications); if not s/s of something wrong, will not check - Pink tinged vag. Discharge, pelvic pressure, dilation- ROM-contractions - Loss of pregnancy d/t occurring before viability - Incidence: less than 1%, 20-25% midtrimester losses

Plantar crease

- Preterm- Minimal crease - anterior crease (not full creases) - Fullterm = lots of creases on feet

Contraindications for bishop test

- Previous uterine trauma - Abnormalities of uterus - Placenta previa/abruptions - Active Genital Herpes - Over distended uterus - Abnormal uterine lie - Fetal distress on EFM or abnormal stress test - Invasive cervical CA - Cord prolapse - CPD

Shunt #3: Ductus Venosus

- Previously shunted blood from umb. Vein to inf. Vena cava, closes within a few days after birth, liver now functioning (no placenta) - fibrosis within 2 months because there is no longer blood flowing through it Ductus Arteriosus, Ductus Venous, Umb. Vessels - no longer needed, -become non functional ligaments

causes of Intrauterine Fetal Demise

- Prolonged pregnancy - Infection, hypertension - Advanced maternal age - Rh disease - Uterine rupture - Diabetes, congenital anomalies - Cord accident - Abruption - Premature rupture of membranes, hemorrhage - Unexplained

Interventions during the 4th stage of labor

- Providing support and information to the women regarding episiotomy repair and related pain relief and self-car measures - Appling ice pack to perineum to promote comfort and reduce swelling - Assisting with hygiene and perinea acre; teaching the women how to use the perineal bottle after each pad change and voiding; helping the women into a new gown - Monitoring for return of sensation and ability to void (if regional anesthesia was used) - Encouraging the women to void by ambulating to the bathroom, listening to running water, or purring warm water over the perineal area with a peribottle - Monitor vital signs, fundal, and lochia status q15 min and documenting them - Assessing postpartum hemorrhage and urinary retention via uterine palpation - Promoting comfort by offering analgesia for afterpains and warm blankets to reduce chilling - Offering fluids and nourishment if desired - Encouraging parent-infant attachment by providing privacy for the family - Being knowledgeable about and sensate to typical cultural practice for the family - Assisting and encouraging the mother to nurse, if chooses, during the recovery period to promotor uterine firmness (the release of oxytocin from the posterior pituitary gland stimulate uterine contraction) - Teaching the women how to access her fundus for firmness periodically an to massage it if it is boggy - Describing lochia flow and normal parameters to observe for postpartum - Teaching safety techniques to prevent newborn abduction - Demonstrating the use of the portable sit bath as a comfort measure for her perineum if she has a laceration or episiotomy - Explaining comfort/hygiene measures and when to use them - Assisting with ambulation when getting out of bed for the first time - Providing information about the routine on the mother-baby unit or nursery for there stay - Observing for signs of early patient0infant attachment: fingertip touch to palm touch to enfolding of the infant

Dystocia: Outcome depends on:

- Quality of Contractions - Size, presentation, and position of fetus - Dystocia is diagnosed during labor; not before

Maternal roles: Ensuring safe passage throughout pregnancy and birth

- Realizing she is responsible for this pregnancy and birth of this baby - important to consider how she sleeps, how she exercises, etc. - Primary focus of women's attention - 1st trimester: women focus on herself, not on the fetus - 2nd trimester: women develop attachment of great value to her fetus - 3rd trimester: women have concern for herself and her fetus as a unit - Participation in positive self-care activities related to diet, exercise, and overall well being

Physical changes during pregnancy: Gi tract

- Reflux of gastric contents common due to relaxation of smooth muscles by progesterone - *Ptyalism(excessive salivation)* is a common condition of pregnant women (d/t less swallowing when nauseated?) - *Bleeding gums, swollen, acidic saliva* - can get gingivitis of pregnancy if do not do excellent dental care - Decrease in intestinal motility causes constipation (iron supplements, decr. Activity) - increase fluids, increase roughage, increase fruits and vegetables, increase activity - Hemorrhoids: constipation, incr. venous pressure - develop due to strain - *Nausea and vomiting* (morning sickness, but can happen at any time of the day) is *due to high hCG levels* from 6 to 12 weeks, decreased motility

preterm labor (L/D)

- Regular contractions with effacement and dilation before end of 37thweek - Increase risk of perinatal morbidity and mortality - Neurodevelopmental disorders and behavioral and social problems - Risk: RDS, hypoglycemia, heart defects, temp. regulation, etc....

diagnosis of Blood Incompatibility: Rh

- Rh negative mom with positive coombs (measures amt. of antibodies in maternal blood) - + coombs, rhogam won't work, already has antibodies; infant at risk for hemolytic anemia (disorder in which red blood cells are destroyed faster than they can be made. )

Acquired Heart Disease

- Rheumatic origin - Less since Strept. Diagnosed easier and quicker (cause dramatic fever and damages the heart)

management/nursing care of Blood Incompatibility: Rh

- RhoGAM (if neg. coombs) -28 weeks IM & within 72 hours of birth - monitor fetus for hemolytic disease if mom sensitized

Pharmacologic Agents for induction: Prostaglandins

- Ripens and softens cervix - Prepidil (gel), Cervidil (insert) removable treatment, FDA approved, Cytotec (oral or gel) - Careful: can cause excessive uterine contractions - Some women go into labor others need further induction

Newborn Abdomen Assessment

- Round, soft, protrudes but not distended Bowel sounds + shortly after birth - Absent or hyper could indicate obstruction -Abdominal distention indicates ascites, obstruction, infection, masses, enlarged abdominal organ Check umbilical cord for redness and oozing - Triple dye - prophylaxis of infection - Umbilical cord infection (omphalitis) can spread to adjacent tissue and cause peritonitis, hepatic vein thrombosis and hepatic accesses - need immediate evaluation and referral - Keep clean and dry - Remove cord clamp second day if dry and no alarm on clamp - More it dries and open to air, the quicker it will dry and fall off (norm: 7-10 days) 3 Cord Vessels (A-V-A) - 2 vessel cord could have renal/GI anomalies

S/S & Management of respiratory conditions during pregnancy

- SOB, wheezing, rales, restricted activity, ↓ O2 saturation, rales, cough, "tight chest" - Management - education, home peak flow monitoring, bronchodilators, steroids, anti-inflammatory meds, in extreme cases hospitalize, if good control is obtained there is no/little effect- if not then O2 to fetus is compromised (IUGR, preterm birth) - Benefit of preventing attack outweighs risk of med.

Education for newborn related care

- Safety: Infant abduction (don't leave alone), car seat (make sure to know how to use, nurses cannot not instruct how to use (only basic) - legal issue), environment (ex. Restaurants - people leaving baby seats in proper places) - Head support - "Back to sleep" to decrease SIDS - How to use bulb syringe - Bathing - sponge paths until cord falls out, make sure not too hot - can burn skin - Voids 6-10 wet diapers/day - Stool go from meconium to yellow - Shaken baby syndrome information = brain damage (walk away, put in crib, call for help) - Temp taking (keeping warm, make a burrito (swadell) - Sleep & activity periods - Car seat safety - Hot lines, help lines available 24 hr/day - Equipment Advice - Infant problems - Crying, sleep - colic - gas is trapped in bellies and intestines, breast feeding (could relating to what mom is eating) - Infection Prevention - hand hygiene - Make sure to wash hands after change diaper: if bacteria on hands and touch breast, infection can spread to the breast - Breast Feeding - cradling, across-the-lap, side-lying positions; frozen milk for 3 months - refrigerate for 24 hrs; warm water to clean only - Bottle Feeding - never freeze formula or warm in microwave; place in hot water; test temp and shake well

lab studies for GDM

- Screening at 24 - 28 weeks; earlier if risk factors - Glucose Tolerance Test (GTT): 75g (not timed with meal) - 1 hr later, test blood glucose: over 140= abnormal, then do 3hr GTT - 3 hr GTT (only done if 1 hr one is abnormal): Normal Values are: FBS : less than 92 mg/dL - 1hr < 180 - 2 hr: < 153 - 3hr: < 140 - One or more abnormal values = Dx of Gestational Diabetes

Congenital Reflexes

- Successful adaptation of respiratory, circulatory, thermoregulatory, and musculoskeletal indirectly indicate the CNS successful transition from fetal to extrauterine life - Neuro assessment: major reflexes - gag, Babinski (toes bend outward), moro (startile reflux), galant (ventral suspension (face down) and stroking along the one side of the spine. The normal reaction is for the newborn to laterally flex toward the stimulated side) - and minor ones - finger grasp, toe grasp, rooting, sucking, head righting, stepping (walking/dancing), tonic neck ( turn neck to side and the side of the body the head was turned to extends and the other side flexes) - Maturity of CNS, adaptation to extrauterine life, viability - Presence/Strength Reflex -- Neuro development and function - if don't have = neurological problem - Many disappear with age Absence or presence past expected time frame= pathology

Recommended Positions in the Second Stage of Labor

- Think about gravity - worse thing to do is lying on back; constricts vessels and can cause hypotension Lithotomy/feet up in stirrups - most convenient position for caregivers - least effective, commonly seen in USA Lateral/side-lying with curved back and upper leg supported by partner - Restful, Decreases supine hypotension - Can use EFM - More effective, less frequent UC's - Can deliver, No gravity, Support with pillows Kneeling-lean forward: hands on bed and knees comfortably apart - Decreases back pain - Adds gravity, Can use EFM, Can apply sacral pressure, Tiring on knees, Raise HOB - Pillow under knees - Encourage frequent position change Hands and Knees -Decreases back pain,, Pelvic rocking, Can provide sacral pressure - Wrists and knees tire - Maintain privacy, Change position frequently Squatting/supported squatting: gives woman sense of control -Adds gravity, Straightens pelvic curve, Increases pelvic dimensions - Effective for pushing, Can provide sacral pressure, Can get tiring Squatting bar, Change position frequently Standing - Adds gravity, More efficient UC's, Tiring, Can not use continuous EFM, Pole for IV - Intermittent EFM Sitting Upright (on birthing stool - opens pelvis, enhances gravity and helps pushing) - Gravity, Bed, chair, toilet, Decreases supine hypotension, Can increase suprapubic discomfort, Rocking chair, Pad chair, Foot stool - Change positions Semi-sitting: with pillows underneath knees, arms, and back - Same as sitting, Aligns long axis of uterus with inlet, Can deliver, Does not reduce pain 30-45 degree angle

Ultrasonography

- Transvaginal ultrasound is performed to confirm pregnancy - Transducer-high frequency sound waves-visualize fetus; usually 18-20 weeks (fetal measurements, head size), 34 weeks (oragan function/development) - Checks placenta placement (where is it attached), amt. of amniotic fluid, verify dates, growth, fetal development (dates correct) - Egg want to implant towards the upper part of uterus; same for placenta - May need full bladder if early in pregnancy for better visualization - Non-invasive - Basic knowledge: Sounds waves, picture of fetus, can take measurements

treatment of ectopic pregnancy

- Tube intact (If no bleeding, <4cm, mass intact): - Medical: Methotrexate, prostaglandins, misoprostol, and actinomycin; 90% success rate - will pass the fetus - Surgical: linear salpingostomy (can reconnect the tube) - Tube ruptured: - Surgical: laparatomy with salpingectomy (tube removal) - Rhogam: Rh- mothers exposed to Rh+ blood; prevent isoimmunization- could rupture = possible blood mixing - hCG levels: Monitor until return to zero (no residual tissue).

Autoimmune Disorders

- Two categories: Localized Disorders (ex: Grave's disease) and Systemic Disorder (ex: Lupus) - Avoid Pregnancy when Disease is Active - Take Medications to prevent flare-ups during pregnancy - Most considered High Risk d/t potential for complications

dystocia assessment

- VS, UC, FHR, labs, Position-Leopolds, emotions, pain, bladder/bowel status, hydration, s/s infection

Renal System Changes newborn

- Void after birth= adequate renal function - Limited ability to concentrate urine until 3 months (immature kidneys) o Frequent voids, low sp. Gravity o Brick color d/t urates (orange color, clay colored called brick dust) - Low GFR, limited excretion and conservation ability= Fluid overload possible (IV therapy- carefully!) o Can be fatal - cannot handle well - One wet diaper per day of life o Average 6-10 wet diapers at 6-10 days old

Palpation of Uterus

- Void before exam - Note fundal relation to umbilicus - Lie her back, more comfortable at 30-degree HOB - Place hand above the symphysis pubis 1st- need to support the bottom of the uterus before placing other hands on top of the uterus - Palpate fundus with a couple of fingers, press down - if not firm or having trouble finding it, massage a little and press more down - Describe: 1. firm (normal), location - (U, U-1, U-2, etc.), midline? L or R? 2. boggy aka uterine atony (no involuted well)- massage- always use 2 hands • Hopefully will feel it firm up below your hand, if not going to need to use other measures such as medications 3. displaced to right or left usually bladder - typical reason (Could be retaining urine or not emptying bladder or tipped uterus)

possible causes of tachycardia in newborn

- Volume depletion - is the baby dehydrated? - Cardio/resp. disease - Born with something wrong (heart or lung condition)? - Drug Withdrawal - going through? Mother tested? - Hyperthyroidism

Reva Rubin's Three Phases of Adaptation to the Maternal Role

1)Taking in phase: the time immediately after birth when the client needs sleep, depends on others to meet her needs and relives the events of the birth process (lasts 1-2 days) - Passive and dependent; preoccupied with self - Reviews birth experience - interacts with newborn; identifies specific characteristics; ex. "my nose" 2) Taking hold phase: the second phase of maternal adaptation, characterized by dependent and independent maternal behavior (day 2-3 to day 10 or can last several weeks) - Resumes control over her life; concerned about self-care, infants condition, and her ability to care for the infant - Gains self-confidence - Becomes preoccupied with present - Takes care of self and infant but needs reassurance 3) Letting go phase: the third phase of maternal adaptation, occurring later in the postpartum period as the woman reestablishes relationships with other people (2-4 weeks) - Maternal role attainment - more confident, accepts the real infant - Relationship adjustment

late adolescence

17-18 years old - start to become less narcissistic - still developing themselves, difficult to raise, want to keep them in school

incidence of mastitis PP

2-33% of BF moms, ↑ at 2 & 5 weeks and may be preceded by engorgement but not caused by engorgement

Perimenopause

2-8 years prior to menopause - symptoms from decreased estrogen: vasomotor, sleep disturbances, forgetfulness, mood changes, depression

Fundal height measurement to assess fetal growth

Avoid supine - not good for vena cava blood flow = supine hypotension -Put pillow under to help her back and blood vessels Between 12-14 weeks, fundus palpated above symphysis pubis, pull over belly, to top of fundus - how many cm does she measure -By 20 weeks; fundus at level of umbilicus and should measure 20 cm. -Fundal Height Measurement should equal approx. # weeks pregnant, until 36 weeks, then not accurate, due to lightening. Measuring under possibilities o If not appropriate to measurement - is the baby not gaining enough wait? o Not enough amniotic fluid o Dates could be off

Inevitable abortion

More bleeding, ROM, dilation, strong cramps, possible passage of products of conception (umbrella terms for fetus, amniotic membranes, fluids, cord, etc. ) - Due to dilation, the body will pass the fetus Job: make sure she doesn't bleed to death (hemorrhage) and infection - need to make sure all products have truly passed and nothing is left - Vacuum curettage (suction & scraping) (decrease risk of excessive bleeding/infection) - Diagnose with Ultrasound