final

application of cold

Cold application such as cold cloths, frozen gel packs, or ice packs applied to the back, the chest, or the face during labor may be effective in increasing comfort when the woman feels warm. They also may be applied to areas of musculoskeletal pain. Cooling relieves pain by reducing the muscle temperature and relieving muscle spasms

impaired liver function preeclampsia

Elevated blood levels of liver transaminases to twice the normal concentration

s&sx hypothyroidism

Fatigue Increased sensitivity to cold Constipation Dry skin Weight gain Puffy face Hoarseness Muscle weakness Elevated blood cholesterol level Muscle aches, tenderness and stiffness Pain, stiffness or swelling in your joints Heavier than normal or irregular menstrual periods Thinning hair Slowed heart rate Depression Impaired memory

listeriosis fetal consequnces

Fetal Consequences severe and fatal 20-30% of the time in newborns-microabcesses and granulomas. *60% recover *12% longterm neurologic issues

Herpes Simplex 2 fetal consequences

Fetal Consequences: fetal death, neonatal herpes, eye/throat infections, damage to CNS

CMV fetal consequences

Fetal Consequences: most common virus transmitted to the fetus 80 to 90% asymptomatic at birth 25% develop sequelae (LBW, microcephaly, chorioretinitis) most common cause of congenital hearing loss primary infection during pregnancy=most transmissible; secondary infections rarely effect fetus most dangerous during 1st trimester

CMV maternal consequences

Fetal Consequences: most common virus transmitted to the fetus 80 to 90% asymptomatic at birth 25% develop sequelae (LBW, microcephaly, chorioretinitis) most common cause of congenital hearing loss primary infection during pregnancy=most transmissible; secondary infections rarely effect fetus most dangerous during 1st trimester

basis for fetal monitoring

Fetal compromise: The goals of intrapartum FHR monitoring are to identify and differentiate the normal (reassuring) patterns from the abnormal (nonreassuring) patterns, which can be indicative of fetal compromise.

parvovirus fetal consequences

Fetal consequences: usually not a problem, associated with SAB, IUFD 1/2 of pregnant women are immune rarely: severe anemia, miscarriage (<5%)

Hepatitis B assessment and treatment

First prenatal visit No specific treatment With immediate exposure - HBIG and vaccine series Vaccination for all women who are non-immune and at risk Treatment for newborns: HBIG and vaccine Baby should receive HBIG + 1st HBV vaccination immediately (within 12 hours) Breastfeeding: recommended

Bacterial Vaginosis treatment

Flagyl Flagyl is not recommended in pts that are breastfeeding, in the case of active breastfeeding another abx is indicated

mastitis

Flu like symptoms Breast pain, tenderness, reddened area Tx: Abics (doxy), rest, warm compress, adequate fluid and nutrition Breastfeeding and/or pumping to encourage emptying of that side

preeclampsia

HTN> 140/90 and <160/110 + renal involvement Proteinuria 3g/24 hours OR protein/creatinine ratio ≥0.3 OR Urine dipstick +1 protein Development of hypertension and proteinuria in a previously normotensive woman after 20 weeks of gestation or in the early postpartum period. In the absence of proteinuria, the development of new-onset hypertension with the new onset of any of the following: thrombocytopenia, renal insuffi¬ciency, impaired liver function, pulmonary edema, or cerebral or visual symptoms

anencephaly

absence of both cerebral hemispheres and overlying skull incompatible with life

Pulse/Heart Rate apgar 0

absent

Respiration apgar 0

absent

burr cells or schistocytes preeclampsia

absent

4 types of variability

absent minimal moderate marked

Activity/muscle tone apgar 2

active movement

contraindications to epidural blocks

active or anticipated serious maternal hemorrhage maternal hypotension maternal coagulopathy (platelets ≤ 100,000/ml) Infection at the injection site Increased intracranial pressure Allergy to the anesthetic drug Maternal refusal or inability to cooperate Some types of maternal cardiac conditions

prolactin milk

acts upon milk producing cells to produce milk

phases of parental grief for perinatal loss

acute distress intense grief reorganization involves all members of the family

Necrotizing Enterocolitis (NEC)

acute inflammatory disease of the GI mucosa 1. Acute inflammatory disease of the GI mucosa commonly complicated by bowel necrosis and perforation

chlamydia maternal complications

acute salpingitis, PID, ectopic pregnancy, tubal factor infertility, HIV infection, preterm labor, PROM, LBW

gonorrhea maternal complications

acute salpingitis, chorioamnionitis, maternal postpartum sepsis, amniotic infection syndrome

alcohol

affects MER readily passes into breatmilk 2 hr windom

nipple ejection reflex

aids propulsion of milk through ducts a. In response to oxytocin, the myoepithelial cells around the alveolus contract forcing the milk into the milk cuts. b. MER can occur several times during a feeding.

nursing considerations preparing for the birth second stage documentation

all observations, VS, FHR and patter, progress of labor, interventions, woman's response is done concurrent with care

third stage of labor passive management

allow placenta to separate what for signs of detachment

do not give opioid agonist/antagonist to women with opioid dependence. Why?

an opioid antagonist (naloxone [Narcan]) is contraindicated for opioid—dependent women because it may precipitate abstinence syndrome (withdrawal symptoms). For the same reason, opioid agonist—antagonist analgesics such as butorphanol (stadol) and nalpuphine (Nubain) should not be given to opioid—dependent women.

dysfunctional labor patterns fetal causes

anomalies, excessive fetal size, malposition

calcium gluconate

antidote to elevated magnesium levels

common nursing diagnoses for SAB

anxiety deficient fluid volume (due to bleeding) acute pain risk for infection

A (Apgar)

appearance-skin color

22 week

approximately 10% survive

hyperpigmentation

areola linea nigra--line down the middle, fades a few weeks after delivery, helps baby crawl up to the breasts chloasma or melasma (estrogen, melanocyte--stimulating hormone [MSH]), cross reaction with the structurally similar beta hcg)

supine hypotensive syndrome or vena caval syndrome

as the uterus enlarges it compresses the inferior vena cava (b/c of the increase in the size of the uterus) with associated reduction in blood pressure should be semi supine, roll them over on their side if they become woozy

uterine changes hegar sign

as the uterus grows in early pregnancy and flexes forward towards the belly exaggerated flexion

Perineum—Perineal Discomfort assessment

assess for redness, warmth, swelling, discharge

shoulder dystocia risks to fetus

broken clavicle neurologic injury ( nerves in the shoulder)

forceps/vacuum delivery prerequisites

cervical exam Empty bladder Expectation of success (no CPD, adequate pelvis vs. size of baby)

Latent Phase (first stage of labor) typical assessment findings

cervix 0-3cm contractions mild-moderate in intensity; 5-30 min apart, 30-45 seconds in duration increased mucus discharge/bloody show excited, talkative eager lasts approximately 6-8 hours

Active phase (first stage of labor) assessment findings

cervix 4-7 cm contractions moderate to strong regular contractions: 3--5 minutes apart, 40-70 seconds in duration phase lasts 3-6 hours increased blood show serious, doubtful, worried

emergency CS hemodynamic stability

change in Sao2 late sign of hypoxia in mom bp is probably better indicatior

probable (objective sings of pregnancy

changes observed by provider/examiner braxton hicks ballottement goodell's sign chadwick's sign hegar sign + pregnancy test

GI congenital anomalies

cleft lip/palate esophageal atresia tracheosophageal fistula omphalocele gastroschisis imperforate anus

factors that affect lactogenesis

discomfort/pain supply and demand infant maternal environmental

PE ubilical cord

dryness 3 vessels base of cord for drying hernia

Herpes Simplex 2 transmission

exposure during childbirth (30-50% transmission rate in women who acquire genital herpes near time of delivery, less risk if contracted earlier in pregnancy (<1%) sexual activity vaginal

Transition phase (first stage of labor) assessment findings

hardest part of the first stage of labor cervix 8-10 cm 20-40 minutes, strongest, shortest phase blood show increases

cephalic vertex presentation

head comes first 96% of births will feel the occiput at the internal os of the cervix

turtle sign

head delivers and immediately snaps back onto the perineum because the shoulder is wedged behind the pubic bone classic sign of shoulder dystocia

administration of medication pharmacological interventions

intravenous route intramuscular route regional (Epidural and spinal anesthesia

extension

intrnal rotation complete, head passes the symphysis pubis = crowing baby extends head head is extending out of the vagina

uterus involution

involution is the process of uterus returning to its non--pregnant state (normal position in the pelvic cavity and regains its muscle tone)

perineal lacerationsfourth degree

laceration that extend completely though the rectal mucous, disrupting both the external and internal anal sphincters

perineal lacerations first degree

laceration that extends through the skin and vaginal mucous membrane but not the underlying fascia and muscle

perineal lacerations third degree

laceration that involves the external anal sphincter

soy-based formula

lactose or cow's milk-protein intolerant Eg. Isomil

LGA

large for gestational age a. Weight above the 10th % b. Can be preterm, term, or post term

normal bladder findings diuresis

large volume of urine a. Hold onto fluid during urine during pregnancy and start diuresing large amounts of urine following birth

IgM

largest activated first during infection, first responder i. Fetus is capable of producing IgM by the eighth week of gestation

rubella fetal consequences

miscarriage, stillbirth, congenital rubella syndrome (deafness, cataracts, heart defects, skin rash) *very dangerous particularly during 1st trimester—50% odds of CRS Deafness, cataracts, heart defects, skin rash

moderate lochia

moderate amount less than 6--inch stain on peripad

endocrinology changes thyroid

moderate thyroid enlargement increase in TBG, T4 and T3 free t4 and t3 unchanged

inevitable SAB

moderate to heavy bleeding open os mild to severe cramping usually conception products not yet expelled the process has not fully completed but miscarriage is inevitable

missed SAB expectant management

monitor clotting factors for DIC

puerperium nursing care priorities

monitor involution facilitate family adustment

what is labor

moving the fetus, placenta and membranes out of the uterus through the birht cnal

pain management

multi-modal that includes opioids and non steroidal anti-inflammatory agents

s &Sx hyperthyroidism

muscle wasting fine hair esophthalmos goiter sweating tachycardia, high output weight loss oligomehonorrhea tremor

preconception target glucose

o FBS <95 mg/dl 1 hour postprandial BS <140 (or 2 hr PPBS <120)

which medications are safe in pregnancy (DM

o Insulin is standard, safest medication. Expect dose to increase during pregnancy o Better compliance, less hypoglycemia with oral agents. Safety < insulin though, and not approved by USFDA for GDM. Metformin (2nd line) Glyburide (no) o Expect dose to increase during pregnancy.

DM postpartum screening

o May continue BS monitoring for 7 days if labile in pregnancy o Anyone diagnosed with GDM should be rescreened for DM at 6-12 weeks postpartum Use FBS or 2-hour OGTT, use pregnancy cutoffs Do not use A1C

1 hour glucose screening

o No special preparation o 50 gram glucose administered o Screen is positive if BS >140 mg/dl (80% sensitive) o Diagnosis made without 2nd step if BS >200).

changes in FHR

periodic changes episodic (nonperiodic changes) accelerations decelerations

lactogenesis 1

phase that only occurs in pregnancy completes by weeks 16-18 by the end of lactogenesis breasts are fully prepared for lactation

candidiasis assessment

physical exam wet smear and pH

other factors influence pain

physiologic culture anxiety previous experiences

types of jaundic

physiologic pathologic breast feeding jaundice breast milk jaundice

Serosa Lochia

pink, mostly serous fluid, decidual tissue, leukocytes, and erythrocytes Lasts 1-2 weeks more TILL ~2 weeks

PE eyes

placement epicanthal folds discharge

peak

point of greatest contraction

TORCHES syndrome symptoms in baby

poor feeding, fever, SGA

lochia

postbirth uterine discharge rubra serosa alba amount of lochia described as scant, light moderate and heavy

hemabate

postpartum hemorrhage contraindicated in someone with asthma

PE ears

preauricular skin tags or sinus symmetry

early postpartum period

recovery care frequent VS fundus bladder lochia perineum skin--to--skin breastfeeding attachment

Rubra Lochia

red, contains blood and decidual and trophoblastic debris last 3-4 days or more Heavy / clots when pt gets OOB first day TILL DAY 3-4

probiotics

reduce infections, no adverse effects but studies lacking

delayed BM or meconium to day 5

reduced stooling will need supplementation

fetal attitude (passenger)

relationship of fetal parts to one another general flexion is the goal

tocolysis

relaxation of the uterus useful when fetus has abnormal FHR patterns associated with increased contractions medication terbutaline

Cleansing Breath

relaxed breath in through nose and out through mouth. Used at the beginning and end of each contraction

sedatives

relieve anxiety and induce sleep; typically used in a prolonged latent phase of labor don't take away pain barbiturates phenothiazine benzodiazepines morphine sulfate

uterine rupture symptoms

response depends on extent and location of rupture) loss of station, pain, hypovolemic shock, hypotensive sx (vomiting, faintness), FHT problems, and mortality. i) Loss of station—baby gets out into the abdomen ii) Fatal if intervention is not immediate. Literally have minutes to get the baby born after this happens

exstrophy of the bladder

results from the abnormal development of the bladder, abdominal wall, and pubic symphysis that causes the bladder, urethra and ureteral orifices to be exposed

subinvolution common causes

retained placenta products and infection

weight gain

return to normal weight after 10-14 days

patient and family teaching Admission to L& D

review the birth plan discuss patient preferences/hospital policies address fears and concerns many women have fear: opportunity to educate and provide support

upper respiratory changes

rhinitis nasal congestion increase in epistaxis

dysuria leads to

risk of UTI and Hemorrhage stress incontinence --> kegel exercises

patterned--paced or pant-blow breathing

same rate as modified enhances concentration 3:1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction) 4:1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-OUT/ IN-BLOW (repeat through contraction)

scant lochia

scant amount blood only on tissue when wiped or less than 1-inch stain on peripad

gonorrhea assessment and treatment

screen at 1st prenatal visit Ceftriaxone Third trimester rescreening if high risk Treat partners

oxytocin

second hormone needed for lactation-milk ejection produced by posterior pituitary stimulated by the sucking stimulation of the nipple hormone is responsible for let-down reflex (aka milk ejection) multiple nipple sprays

duration (contractions)

seconds how long do they last

systemic analgesia (opioids) major side effects

sedation N/V dizziness altered mental status urinary retention delayed gastric emptying manifestations: decreased maternal HR, RR, BP

recommended weight gain considerations

should use good clinical judgment consider quality of their diet as well as their physical activity level recommendations should take into account the individual needs of the mother typically actually lose weight in the first trimester because of N/V like to see a 10 pound weight gain by 20 weeks because it reduces their risk of preterm births and intrauterine growth restriction

involuntary contractions (primary power)

signal the beginning of labor upper uterine segment shortens/thickens

presumptive (subjective signs of pregnancy)

signs may be an indication of something else that causes similar symptoms amenorrhea N/V breast changes quickening urinary frequency fatigue uterine enlargement braxton hicks

third stage of labor physical assessment

signs of placental separation and amount of bleeding fundal assessment--firmly contracted, change in the uterus shape from discoid to lobular as the placenta moves down

What 5 things you must consider about the passenger?

size of the head fetal presentation fetal position fetal lie fetal attitude

promoting active immunity during pregnancy

sleep exercise nutrition stress management

SGA

small for gestational age a. Weight below 10th % b. Can be preterm, term, or post term

magnesium sulfate eclampsia use

smooth muscle relaxant, used to prevent seizures (preeclampsia), prevent preterm contractions, hypertension, preventive measure in very preterm infants against Intraventrical hemorrhage (IVH) a) Can be toxic

Pe abdomen

soft bowel sounds within first hour

listeriosis transmission

soil, ground water; heat hot dogs/lunch meat soft unpasteurized cheese, pate or meat spreads

Activity/muscle tone apgar 1

some flexion

breast care

soreness ID cause and fix open to air breast shells lanolin, gel pads shells (sore, flat, inverted, pump

nursing interventions third stage IV oxytocin

to ensure adequate contraction of the uterus active management of oxytocin is started at the anterior delivery of the shoulder or immediately following delivery at this point the main concern is hemorrhage since the placenta is detached want to make sure they are hemodynamically stable

Antihypertensives:

to maintain target BP: 140-160 SBP, < 100 DBP (1) Hydralazine (a) 5-10 mg IV then 5-10 mg q20-30 min PRN. Max 30 mg. (2) Labetalol (a) 100-400 mg PO BID (to treat chronic HTN) (b) 20 mg IV then 40-80 mg q10 min PRN

Betamethasone (Celestone)

to reduce neonatal complications 12 mg IM q 24 h x 2 doses

placenta previa complete

totally covers os

TTNB

transient tachypnea of new born some babies will transition out of this but some will maintain tachypnea, have to rule out sepsis

methergine

treatment for postpartum hemorrhage can't be used in someone hypertension

varicella treatment

treatment varies depending on when it happens during pregnancy Meds: Acyclovir, anti-pyreteics Time near/at birth: VZIG for mom and baby, isolate mom and baby together, give baby pumped breastmilk

slow weight gain

up to &% weight loss normal for first 3 dyas increase feeding frequency (add 1-2 feedings/day) check feeding technique and waking technique alternate breast massage supplementation

oxytoxin (pictocin)

used to induce or augment contractions during labor, postpartum used to contract uterus rapidly metabolized and excreted by kidneys and liver tachysystole > 5 cxt in 10 minutes avg over 30 mins (fetal distress because of the frequency of contractions) can cause hypertension and/or hypotension

CMV symptoms

usually asymptomatic or may have mono-like symptoms (malaise, myalgias, leukocytosis)

Powers

uterine contractions involuntary and voluntary powers combine to expel the fetus and the placenta from the uterus

origin of pain 3rd stage/early pp period

uterine contractions similar to 1st stage uterus contracting to stom bleeding

origin of pain 1st stage

uterine contractions/distention of the lower uterine segment contracting at the top and distending at the bottom bulk of the pain during the first phase is from uterine contractions

persistent hypertension

valves did not close correctly either from a congenital anomaly or something that occurred during the transition

prolonged deceleration

visibly apparent decrease in FHR of at least 15 beats/minute below baseline LASTING MORE THAN 2 minutes BUT less than 10

marked extension (fetal attitude/passenger)

visualize the baby holding its head back head hyperflexed

military attitude (fetal attitude/passenger)

visualize the baby looking straight forward not tucked (1) Mild flexion of the head—not tucked in very well (2) Widest part of the baby head has to get through the narrowest part of the pelvis

sleepy

waking during lighter sleep bring to alert state skin to skin

folate requirements

water--soluble B9 daily requirement increases from 400 mcg/d for childbearing age women to 800 mcg-1 mg/day for pregnancy history of NTD (will supplement with 4 mg) should supplement with more preconception for fetal growth, increased RBC mass, and increased uterine size adequate levels before an during pregnancy to reduce risk of NTDs

respiration apgar 1

weak or irregular

syndactyle

webbing of feet and hands programmed apoptosis is supposed to get rid of the webbing but in syndactyle this does not occur

Trichomoniasis assessment

wet prep and symptoms

Fetal Presentation (Passenger)

what is entering the pelvis? the part of the fetus you can feel at the internal os of the cervix

what about women with epidurals? how does this affect flexion

with women who have epidurals there is not as much resistance, so flexion is not as extreme

renal physiologic changes

↑(until 3rd trim) Renal blood flow ↑ (until 3rd trim)GFR ↑Creatinine clearance thus ↓in serum creatinine, uric acid, and BUN ↑Na+ reabsorption ↑aldosterone to maintain expanded blood volume (abnormal in preeclampsia) ↑Renin and angiotensin ↓Reabsorption of glucose => glycosuria

additional learning

■ Genetic Associations with Gestational Duration and Spontaneous Preterm Birth ■ Despite evidence that genetic factors contribute to the duration of gestation and the risk of preterm birth, robust associations with genetic variants have both been identified. ■ Performed a genome-wide association study in a discover set of samples from 43,000 European ancestry ■ Tested for replication of genomic loci that had significant association with suggestive significance ■ Results: four loci were significantly associated with gestational duration. ● The variants at the EBFT, EEPSEX, AGTR2, WNT4, ADCY5, and AGTR2 loci were associated with gestational duration and variants with loci with preterm birth. ● Previously established roles of these genes in uterine development, maternal nutrition, and vascular control support their mechanism involvement

Urine (output

# wet diapers: Once/first day, twice/Day 2, 3x/Day 3, etc. (6-8 /24 hrs AFTER 4th day) and characteristics of urine (color/concentration)

Erythromycin Ointment

(1 cm ribbon each eye) Prevents ophthalmia neonatorum in the eyes which can lead to blindness (targets N. gonorrhoeae, reduction of risk of blindness secondary to gonorrhoeae) Administered 1-2 hours after birth

Placenta abruption risk factors

(1% incidence) Hypertension—very high pressures can literally blow the placenta off the uterine wall Cocaine Trauma (MVA or abuse) Smoking Hx of previous abruption PPROM

pitocin risks to mom and baby are closely related

(1) Abruption (2) Uterine tachysystole (3) Uterine rupture (4) Severe cervical laceration (5) Postpartum hemorrhage (6) Water intoxication (watch I&Os, signs of toxicity) (7) Postpartum edema, urinary retention

general flexion (fetal attitude/passenger)

(1) Arms crossed, knees and hips flexed and on the chest ** (2) Chin to chest (3) Umbilical cord in the middle (4) Head tucked

methotrexate side effects

(1) N&V (2) Gastric distress (3) Abdominal pain

Powdered formula

(cheapest): Mix with water (boiled or sterile)

first stage

0-10 cm onset of labor until 10 cms dilated, 100% effaced 3 phases

placenta previa risk factors

0.5 % incidence) Previous C-section AMA Multiparity Hx of D&C Smoking High altitude Male fetus

fFN how to collect a specimen

1. "Blind swab" of posterior fornix x 30 seconds, 2. Or 3. Inserting 1 finger to fornix, inserting swab to end of finger x 10 seconds 4. Same results as spec exam.

steroids and preterm infants

1. Corticosteroids 2 doses 12 hours apart 2. Accelerates surfactant production in the preterm infant 3. Antenatal Corticosteroids in the Management of Preterm Birth: Are we back where we started? 4. Prenatal steroids lower risk of respiratory illness in late preterm infants. NIH study shows treatment benefits extended to infants born at 34-36 weeks

RDS increases with

1. Gestational diabetes 2. Presence of asphyxia 3. C/S birth

Respiratory Adaptation-After Birth-Sensory

1. Handling infant, possible pain at birth, light/sounds/smell/taste at birth stimulate respiratory center 2. Handling all the changes in the senses at birth stimulate the respiratory system

hypothyroidism treatment in pregnancy

1. Levothyroxine (T4) a. Goal to maintain TSH in trimester range b. May need to change dose as pregnancy progresses up to 25-50% increase c. Typically, 100-150 mcg/day PO

PE mouth

1. Rooting, suck, extrusion reflex 2. Intact palate 3. Epstein pearls 4. Tongue Tie

D/C checklist assessment

1. Stable BUBBLE HE 2. Voiding 3. Passing flatus

parvovirus maternal consequences

1/2 of pregnant women are immune rarely: severe anemia, miscarriage (<5%)

creatinine clearance preeclampsia

130-180

lactogenesis stage 1

16-18 weeks colostrum production

normal Respiratory rate

16-24

breastfeeding associated jaundice

2-3 days onset 1. Poor feeding (PREVENTABLE!) 2. Do not stop breast feeding

therapeutic levels for mag when used for preeclampsia

2-3.5 mmol/l 4-7 meq/l 5-9 mg/dl

breasts abnormal findings

2. Bleeding nipples = aggressive baby that loves to eat 3. Inverted nipple a. Breast shield and will need a lactation specialist 4. Red area be on the lookout for mastitis 5. Middle bottom mastitis, which is typically only on one side

tobacco

2hr window not in the same room

gonorrhea epidemiology

2nd most common STI in the U.S. Incidence in pregnant women ranges from 2.5% to 7.3%

bowels post-op

3. Post-op: NPO if pt nauseated, vomiting, no bowel sounds a. IV hydration and anti-emetics b. Consider reducing opiates i. To help bowels come back to life c. Provider may consult MD/GI if persistent

fibrinogen preeclampsia

300-600 mg/dl

early term

37-40.6 weeks/days

term

37-41.6 weeks

HCT pre-pregnancy

37-47%

full term

39-40.6 weeks/days

late term

41-41.6 weeks/days

antibody isotypes

5 isotypes IgG IgM IgA

WBC pre-pregnancy

5,00-10,000/mm3

25 weeks

75-85% survive

fibrin split products preeclampsiA

ABSENT

bordeline AFI

AFI = 5-8 cm

plugged milk ducts

Afebrile mom One area swollen and tender Caused by tight clothing or some kind of pressure on breast Warm compress and frequent feeding with massage Change feeding positions step before mastitis, frequent feedings, common with women who have other kids at home

choosing other methods of feeding

B&B - associated with a shorter duration of breastfeeding

vitamin Contents

BM Everything EXCEPT: D, K, B12 formula added vitamins

minerals

Calcium and phosphorus ratio slightly lower in formula, even lower in whole cow's milk. These infants are susceptible to hypocalcemia, seizures and tetany Iron - better absorbed in breast milk Fluoride - recommended to supplement after six months based on water content.

Bacterial Vaginosis complications

Complications: Other STI's Preterm labor & birth

opioid agonists

Demerol, Fentanyl: stimulate the major opioid receptors mu and kappa

Trichomoniasis

Flagyl

postpartum HR

Heart rate is increased immediately after birth and can remain elevated for the first hour. Puerperal bradycardia is common, with heart rate decreasing to 40 to 50 beats/minute

placenta abruption fetal adverse outcomes

IUGR—placenta is smaller and oxygenation decreases Preterm birth Mortality

systemic analgesia (opioids) routes

IV, IM PCA (IV preferred route) can do a combination sometimes

placenta previa active mangement

Immediate birth for term fetus OR moderate to severe bleeding OR maternal or fetal jeopardy Large bore IV Maternal VS Maternal labs: H&H and clotting studies Continuous EFM Maternal catheter to assess output Blood and fluid replacement Possible C-section (contraindication is coagulopathy) Emotional support

uterine cramping/after birth pains interventions

Interventions: heat, pain meds

anita's EDD/EDC

LMP 11/2/2017 month 11-3= 8 day 2+7=9 year 2017+1 =2018

Herpes Simplex 2 treatment 2

Labs Chronic, recurring, no cure Triggers Antivirals - Acyclovir & Valtrex Treating symptoms C-section if active lesions

PROM risk

Major risk: infection b) Induction decreased rate of maternal infection, no change in c/s rate

proteinuria severe features of preeclampsia

Massive proteinuria (>5 g in a 24-hr specimen) is no longer used as a diagnostic criterion

Normal Temperature

May be up to 100.4 for the first 24 hours (dehydration) PP Chill (fluid shifts, nervous system response to work of labor) PP diaphoresis (elimination or fluid excess)

chlamydia epidemiology

Most commonly reported STI among pregnant women

FIBRIN SPLIT PRODUCTS HELLP

PRESENT

P (aPgar)

Pulse heart rate

Herpes Simplex 2 women at risk

Risky sexual behaviors

R

Rubella

incomplete SAB

S& S similar to inevitable (moderate to heavy bleeding, open os, mild-severe cramping) + expulsion of conception products placenta retained

pre-existing diabetes 1st trimester

Screening of HbA1C, kidneys (BUN and creatinine), and thyroid Ultrasound for dating, viability (maybe sequential screen?) Referrals

reorganization

Search for meaning Reduction of distress Reentering normal life activities with more enthusiasm Can make plans, including decision about another pregnancy

Candidiasis epidemiology

Second most common vaginal infection in the U.S

abnormal BP

Severe hypotension (hypovolemia due to hemorrhage) Hypertension (>140/90x2)

Bacterial Vaginosis transmission

Sex is thought to play a role Opportunistic infection, imbalance between "good and bad bacteria in the vagina"

steroids (bethamethasone, Dexamethasone) action

Stimulates fetal lung maturation by promoting release of enzymes that induce production or release of lung surfactant.

missed SAB surgical and medical management

Surgical D&C Medical—vaginal misoprostol Blood clotting factors are monitored until uterus is empty

spec exam fFN

The specimen should be collected prior to a digital cervical exam, collection of culture specimens, or vaginal probe ultrasound exams. Do not contaminate the swab or specimen with lubricants, soaps, disinfectants, or creams. Do not collect specimen if patients have had sexual intercourse within 24 hours prior to sampling; moderate or gross vaginal bleeding; advanced cervical dilation (3 cm or greater); rupture of membranes; gestational age <22 weeks or >35 weeks; or suspected or known placental abruption or placenta previa.

why do newborns get cold so easily?

Thin skin, blood vessels close to surface, little white fat, higher surface area to body mass ratio

Bacterial Vaginosis agent

Vaginal dysbiosis

normal blood loss post vaginal birth

Vaginal up to 500 ml once it goes over 500 ml it is hemorrhage

diastasis rectic

a physiologic separation of the rectus abdominal muscles (in the front of the belly) permanet, less pronounced after birth but will never go back to the way it was before a full term pregnancy

sore nipple treatment

a. Colostrum or Lansinoh b. Hydrogel pads c. Breast shells d. Lactation Consultant

GBS overview

a. GBS part of normal vaginal flora b. 25% of pregnant women c. Vertical transmission during labor/birth 1. Can be grown in the mothers vaginal flora, has ability to migrate up to the uterus and potentially infect the fetus d. Neonate at risk of GBS sepsis e. Pregnant women screened between 35-37 weeks for GBS

what to do about abnormal bladder findings

a. General protocol is straight cath after 6 hours i. Really encourage urination, telling them they will have to be cathed if they don't urinate b. Leave in foley for 24 hours on 3rd cath c. Meanwhile, try to help patient urinate

etiology multifactorial

a. Genetic b. Endocrine 1. Hormones of Pregnancy 2. Dysfunctional Stress Response (HPA Axis) i. Fetus produces CRH which suppresses the mothers HPA axis. ii. CRH is released from both the hypothalamus and the placenta iii. CRH ACTH Cortisol c. Inflammation d. Neurotransmitter Dysfunction e. Psychosocial stressors

congenital anomalies present at birth

a. Genetic or environmental b. Structural or functional c. 3% of births d. Spontaneously Aborted fetuses have high incidence of anomalies e. Leading cause of death in infants in the first year of life-folic acid should be started before conception

Excessive bleeding nursing actions

a. Get help! b. Massage uterus (if boggy) c. O2 d. Fluids e. Oxytocic medication (standing orders) f. Second IV g. Blood as ordered h. Catheter—may just have a full bladder i. ** should not soak more than a pad an hour (start messaging the uterus, really heavy, hit the call bell and have someone call the provider)

newborn immune state

a. Greatest risk factor for neonatal infection is prematurity. Others are PROM, chorio, maternal fever in labor, ante or intrapartal asphyxia, invasive procedures, stress, congenital anomalies b. All newborns (especially preterm) are at high risk of infection during the first several months of life. Infection is one of the leading causes of morbidity and mortality of infants! i. One way to reduce exposure is for the mother to wear the baby ii. Can't cover portal of entry so *** c. Newborns cannot limit invading pathogen to the portal of entry because of hypofunctioning of inflammatory and immune mechanisms. d. Newborns have passive immunity - IgG antibodies transfer across the placenta e. IgA immunoglobulins received via colostrum and breast milk f. **Why is Colostrum bright yellow-orange?? Because of vitamin A

preterm infants fetal growth and outcome considerations

a. Heredity b. Genetics c. Placental insufficiency d. Maternal disease processes

esophageal atresia

a. Life—threating b. Esophagus ends in a blind pouch, thus failing to form a continuous passageway to the stomach

when are APGAR scores taken

a. Newborn is scored at one minute of life and five minutes of life. b. First minute of life isn't indicative of really anything, the five minute apgar score is way more important

Fluid needs of the infant

a. Newborns and infants do not need supplementary water i. 60-89 mg/kg/day for first two days ii. Breastmilk 87% H20 iii. Formula 133 g/5oz serving ~94%

baby friendly USA

a. No artificial nipples or pacifiers b. Rooming in, etc. c. 10 steps to creating a successful breastfeeding environment i. Written breastfeeding policy communicated to all staff ii. Healthcare staff training iii. Education on benefits and management of breastfeeding iv. Facilitate initiation of breastfeeding within ½ hour d. See Box 25-1 for more

respiratory distress syndrome

a. RDS is caused by a lack of pulmonary surfactant, which leads to progressive atelectasis, loss of functional residual capacity, and ventilation—perfusion imbalance with an uneven distribution of ventilation. 1. This surfactant deficiency can be caused by insufficient surfactant production, abnormal composition and function, disruption of surfactant production, or a combination of these factors. 2. The weak respiratory muscles and an overly compliant chest wall, common among preterm infants, contribute to the sequence of events that occurs. 3. Lung capacity is further compromised by the presence of proteinaceous material and epithelial debris in the airways. The resulting decreased oxygenation, cyanosis, and metabolic or respiratory acidosis can cause the pulmonary vascular resistance (PVR) to be increased. This increased PVR can lead to right-to-left shunting and a reopening of the ductus arteriosus and foramen ovale

Transient Tychapnea of the Newborn

a. Respiratory rate > 60 breaths/minute 1. Trying to get fluid out of lungs 2. Will not have ground glass appearance on X-ray b. Delayed clearance of fetal lung fluid from lungs c. Grunting, retracting, cyanosis d. Generally self—limiting

acute distress

a. Shock b. Numbness c. Intense crying d. depression

terbutaline nursing considerations

a. Should not be used in women with a history of cardiac disease, pregestational diabetes, severe gestational hypertension, preeclampsia with severe features or eclampsia or hyperthyroidism, or with significant hemorrhage b. Propranolol should be available to reverse adverse effects related to cardiovascular function

GBS treatment

a. Treated with antibiotics during labor 1. Penicillin G, 5 million units IV loading dose 2. Penicillin G 3 million units IV every 4 hours until birth 3. Ampicillin for patients allergic to Penicillin

placenta Abruption key signs and symptoms

abdominal pain dark red vaginal bleeding

threatened SAB management Preventive

bedrest transvaginal US Assessment of hcg and progesterone

D reeDa==>how to assess Episiotomy/Laceration/Incision (and hemorrhoids

drainage

polydactyle

extra digit or toe

relaxing and breathing techniques

focusing and relaxation breathing techniques--pattern breathing

Artificial rupture of membranes (Amniotomy) risks

i) Committed to deliver ii) Prolonged ROM, chorio iii) Cord prolapse (depending on station) (1) Want to make sure the baby is engaged iv) Infection: HIV, HSV (1) Don't want to do an amniotomy with women who have any infection that can be transmitted to the baby

hemorrhagic disorders earlier in pregnancy

i) Miscarriage (SAB spontaneous abortion) ii) Ectopic Pregnancy iii) Hydatidiform Mole

gestation htn screening

i) Normal pregnancy BP (1) Baseline, 2nd trimester dip, back to baseline (2) Blood pressures should never be above baseline ii) Screening (1) BP at every visit (2) Urine dip for protein (routine or empiric) (3) Symptoms

DIC increased risk

i) Placental abruption ii) Retained fetal demise iii) Amniotic Fluid Embolus iv) Severe pre-eclampsia v) HELLP syndrome

care of a women receiving Magnesium sulfate

i) Preeclampsia with "severe features" i.e., subjective neurological symptoms (headache or blurry vision), abdominal pain, epigastric pain ii) Mechanism of action: uncertain, smooth muscle relaxant, neuromuscular blockade (1) Also relaxes the uterus (2) Tricky if you are trying to induce them since it causes the uterus to not contract iii) Effectiveness: decreases rate of eclampsia by 50% (1) Acts like a CNS depressant iv) Effect on labor, FHR-variablility v) Magnesium toxicity

risk factors of pre eclampsia

i) Primigravida younger than 19 or older than 40 years ii) Nulliparity iii) Preeclampsia with severe features in a previous pregnancy iv) Family history (mother or sister) of preeclampsia v) Paternal history (partner previously fathered a preeclamptic pregnancy in another woman (1) New partner, limited sperm exposure (barrier contraception), IVF vi) African descent vii) Multifetal gestation (1) Twins carry nearly 3x increased risk viii) Hydrops fetalis ix) woman who herself SGA x) Maternal infection/inflammation in current pregnancy ( i.e., urinary tract infection, periodontal disease)

Management of postdate pregnancy management

i) Stripping membranes (1) Naturally loosen up membranes and start labor naturally ii) Cervical ripening agents (CERVADIL) - prostaglandin iii) Induction of labor

ecclampsia management ***

i) Tonic-Clonic Convulsion Signs (1) Stage of invasion: 2-3 seconds, eyes fixed, twitching of facial muscles (2) Stage of contraction: 15-20 seconds, eyes protrude and are bloodshot, all body muscles in tonic contraction (3) Stage of convulsion: muscles relax and contract alternately (clonic), respirations halted; then begin again with long, deep, stertorous inhalation; coma ensues ii) Interventions (1) Keep airway patent: turn head to one side, place pillow under one shoulder or back if possible. (2) Call for assistance. Do not leave the bedside. (3) Raise side rails and pad them with a folded blanket or pillow if possible. (4) Observe and record convulsion activity. iii) After Convulsion (1) Do not leave the woman unattended until fully alert. (2) Observe for postconvulsion confusion, coma, and incontinence. (3) Use suction as needed. (4) Apply a pulse oximetry monitor. (5) Administer oxygen via nonrebreather face mask at 10 L/min. (6) Start intravenous fluids and monitor for potential fluid overload. (7) Give magnesium sulfate or other anticonvulsant drug as ordered. (8) Insert an indwelling urinary catheter. (9) Monitor blood pressure, pulse, and respirations frequently until stabilized. (10) Monitor fetal and uterine status. (11) Expedite laboratory work as ordered to monitor kidney and liver function, coagulation system, and drug levels. (12) Provide hygiene and a quiet environment. (13) Support the woman and her family and keep them informed. (14) Be prepared to assist with birth when the woman is in stable condition.

DIC management

i) Treating underlying cause ii) VS iii) EFM if before birth iv) Maternal position - left side—good blood flow and oxygenation to the fetus v) Volume replacement vi) Blood transfusion and clotting factors vii) O2 viii) Vitamin K ix) Foley catheter with strict I&O

Management of postdate pregnancy risks old placenta

i) doesn't function as well as it should (1) Oligohydramnios (AFI < 5cm) (2) Increased fetal distress or fetal death (5/1000 del) Dysfunctional labor Labor interventions: induction, augmentation, operative delivery

oligohydramnios long term

i) fluid levels influence organ development (respiratory and GI) (1) May have to do a induction (2) Risk benefits of preterm vs waiting (3) Typically if develops in term woman induce right away

pitocin administration

i) start at 0.5-2 mU/min. Then, (1) Increase by 1-2 mU/min every 30-60 min (2) Active management (see orders) (3) Max dose 20-40 mU/min (4) Titrated drip

postpartum nursing care priorities assessment

i. Every 15 minutes: ii. Vital Signs iii. Fundal assessment iv. Visualize lochia (bleeding)

advanced myelination

i. Reason, perception, fine motor control

hypoglycemia

i. jitteriness, poor feeding, lethargy, cyanosis spoon or cup feed with colostrum

most clotting factors & fibrinogen pregnancy

increases in pregnancy

HCT postpartum

initial drop of 2-3%

quickening

is the sense of fetal movement but could be due to increased gut motility

herbal preperations

lack of evidence

LP

low platelet count

toxoplasmosis symptoms

non or flue--like symptoms (fatigue, malaise, sore throat)

uterine changes braxton hicks

non--productive contractions in the uterus

missed SAB

non-viable fetus no symptoms of miscarriage

Activity/muscle tone apgar 0

none

Rubella Treatment

none

CMV treatment

none fetal surveillance

parvovirus treatment

none monitor fetus

R (apgaR)

respiration

test for SROM ferning

sample of amniotic fluid--fern like pattern on a slide under microscope

S

syphilis

T

toxoplasmosis

Input and stomach capacity

with breast or bottle want to keep track of frequency and volume (or time) of feeding) 1. Belly balls - book suggests 15-30 ml per feeding in the first 24 hours (belly balls are smaller). 2. Capacity increases so by the end of the week 60-90ml per feeding.

lactogenesis stage 2

with delivery of placenta colostrum Ab rich increase protein, decrease fat relative to mature milk laxative properties Day 3-5 milk comes in -> transitional milk

preexisting medical or genetic conditions that increase risk of preeclampsia

(1) Chronic hypertension (2) Renal disease (3) Pregestational diabetes mellitus (4) Connective tissue disease (i.e., systemic lupus erythematosus, rheumatoid arthritis (5) Thrombophilia ( i.e, antiphospholipid antibody syndrome, protein C or S deficiency, factor V leiden mutation) (6) Obesity (BMI ≥ 26 kg/m2)—2.5x increased risk (7) Vascular disease (8) Chronic renal disease (9) Autoimmune disease

special patient teaching for methotrexate

(1) Urinating instructions (a) Urine is very toxic so partner may want to use a different restroom (b) Double flush toilet (with lid down)

nodules

1. 12-43% of nodules are cancer 2. Fine needle aspiration prn 3. Thyroid radionuclide scan contraindicated 4. Surgery, usually delayed until postpartum

frequency of voiding

1. 2-6 x/24 hrs for 2 days 2. 6-8 x/24 hrs by Day 4 or 5

breast milk jaundice

1. 5-10 days onset) 1. Not pathogenic, no treatment needed

sings of satiety

1. Baby's suck slows 1. Milk drunk—hands open and tongue is less tight and will generally will fall asleep 2. Breasts will be drained 3. Falls asleep 4. Breast soft after finishing 1. "empty" never truly empty

Hyperbilirubinemia discharge teaching

1. Feed frequently-Need to eat every 2-3 hours 2. Observe for lethargy 3. Count number of wet - 6-8/day, soiled diapers 1/day 4. Follow up appointments-Must keep follow up appointments

figure 23-2 heat loss

1. Heat loss is mainly due to evaporation of amniotic fluid from the baby's body. 2. Loss of body heat also occurs by conduction if the baby is placed naked on a cold surface (e.g. a table, weighing scale or cold mattress); Loss by convection if the naked newborn is exposed to cooler surrounding air; and by radiation from the baby to cooler objects in the vicinity (e.g. a cold wall or a window) even if the baby is not actually touching them.

Signs and Symptoms of GBS sepsis in the neonate

1. Respiratory distress 2. Temperature instability 3. Poor feeding pattern 4. Cyanosis 5. Poor tone/lethargy 6. Apnea 7. Hypotension 8. Can rapidly develop-Pneumonia, Shock, Meningitis, Mortality rate 5-20%

subinvolution

1. Subinvolution is the failure of the uterus to return to a nonpregnant state

FFN 22-33.6 weeks ONLY

1. The test is performed by collecting fluid from the woman's vagina using a swab during a speculum examination

weight loss >7% with delayed lactogenesis

1. Trying to avoid the 10% cut off 2. Intervention around this point supplement

late preterm

34-36.6 weeks/days

lochia and oxytocin

5. If the woman receives an oxytocic medication, regardless of the route of administration, the flow of lochia is often scant until the effects of the medication wear off. The amount of lochia is usually less after a cesarean birth because the surgeon suctions the blood and fluids from the uterus or wipes the uterine lining before closing the incision. Flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in bed; the woman then can experience a gush of blood when she stands. This gush should not be confused with hemorrhage.

A (apgAr)

Activity Muscle tone

Slow—Paced Breathing

Approximately 6-8 Breaths per minute a.Performed at approximately half the normal breathing rate (number of breaths per minute divided by 2) b.In-2-3-4/OUT-2-3-4/IN-2-3-4/OUT-2-3-4...

postpartum Assessment mnemonic

BUBBLE HEP

B(bubBle hep)

Bladder

chlamydia assessment

Cervical cultures at first prenatal visit

normal blood loss following cesarean

Cesarean up to 1000 ml once it goes over 1000 ml =postpartum hemorrhage

hyperthyroidism fetal outcomes

Congenital anomalies PTD IUGR, SGA Stillbirth TSH-Receptor Antibodies of Grave's disease may cross placenta and stimulate fetal thyroid gland in 2-5% graves' GOITER Anti-Thyroid drugs (PTU or MM) may cross placenta and cause fetal goiter

Cleft Lip and Palate

Congenital midline fissure, or opening in the lip or palate resulting form failure of the primary palate to fuse

changes to the cervix

Cyanotic secondary to ↑vascularity (Chadwick's sign) Softening of tip (Goodell's sign) Cervical glands proliferate resulting in an increase in white mucous discharge (leukorrhea) Eversion of cervix -columnar epithelium on surface (increased friability)

inevitable SAB surgical management

D&C (a) If ROM, pain, bleeding, or infection is present, then prompt termination of pregnancy is accomplished by dilation and curettage

PPD 1/POD1 ( post delivery day)

FF@ U or 1 below at umbilicus or one fingerbreadth below

PPD2/POD 2 (post delivery day 2)

FF@U or 2 below at umbilicus of 2 fingerbreadths below

HE

HErpes

chlamydia transmission

Lives primarily in vaginal fluid and semen Primarily vaginal or anal sex Mother-child vaginal transmission

late pregnancy problems with uncontrolled diabetes

Preeclampsia Macrosomia With microvascular problems: IUGR Polyhydramnios Preterm delivery

tests for SROM nitrazine test for pH

ROM should be alkaline should turn blue however urine is alkaline, recent sexual intercourse can cause alkaline not definitive

gonorrhea women at risk

Sexually active women Multiple partners Non-use of barrier methods g

hyperthyroidism labs

TSH low FT4 high subclinical ft4 high clinical hyper tsh recptor Ab

U (bUbble hep)

Uterus

current recommendations for infant feeding

a. AAP: EXCLUSIVE breast for 6 months + continued breast with complementary solids for at least another 6 months b. WHO: EXCLUSIVE breast for 6 months + continued breast with complementary solids till 2 years + c. ACOG, ACNM and AWHONN all agree with these recommendations

hip dysplasia

a. Abnormal development of one or all of the components of the hip joint

postpartum anxiety with BM

a. Anticipates discomfort during BM because of perineal tenderness secondary to episiotomy, lacerations, or hemorrhoids and resists the urge to defecate b. Regular bowel habits should be reestablished when bowel tone returns

tocolytics contraindications

a. Contraindications: sick/unstable mom or baby. pPROM? i. pPROM (preterm premature rupture of membranes) : inconsistent studies show increased delivery beyond 48 hours, but increased chorio, low 5 min Apgar, and more RDS. Antibiotics used inconsistently in those studies. Cochrane looked at "any tocolytic" when assessing outcomes r/t pPROM.

postpartum blues

a. Day 3 - Day 10 b. Occurs in 80% of women c. Emotional lability, restless, fatigue, insomnia, headache, anxiety, sadness, anger d. Coping: Rest, Social support - partner

medications

a. Fetal development b. Breastfeeding c. A lot of drugs are not tested in the pregnant population and have to pay attention to pregnancy classes

microcephaly

a. Head circumference that measures two or more standard deviations below the mean for age and sex b. Brain growth is usually restricted and thus cognitive impairment is common c. Risk factors: viral infections (zika), chromosomal disorders and malnutrition

neuroprotection imminent preterm birth

a. Planned preterm birth for fetal or maternal indications b. 4gm IV loading dose over 30 minutes c. 1gm/hr maintenance infusion until birth or 12 hours

preterm labor

a. Preterm labor is generally diagnosed clinically as regular contractions along with a change in cervical effacement or dilation nor both or presentation with regular uterine contractions and cervical dilation of at least 2 cm b. Preterm birth is any birth that occurs between 20 0/7 and 36 6/7 weeks of gestation

prevent constipation

a. Teaching/ reassurance about defecation b. Fluids, activity, diet c. Fiber, stool softeners, laxatives prn i. Colace 100 mg po BID ii. Senokot- max 4 tabs po BID iii. Milk of magnesia 30-60 ml po qd iv. Dulcolax 1 suppository PR qd v. Flaxseed

CNS congenital anomalies

b. CNS 1. Range of defects anecephaly to spina bifida, NTD a. Anencephaly b. Spina bifida 2. Folic acid deficiency 3. Microcephaly 4. Hydrocephalus

lactogenesis/MER triggers

baby crying, smells, sounds, warmth, can also be triggered during sex

Bladder first 24 hours postpartum

bladder edematous, congested, hypotonic a. Just had a contracting uterus and a baby right on top of it

flu

can be given during pregnancy and postpartum

use of fundal pressure

contraindicated never do this can make placenta detach early and then it becomes and emergency situation

dyspnea

experienced by 2/3 of women starting around 12 weeks

platypelloid pelvis (passageway)

flat often end in C/S

placenta abruption maternal adverse outcome

hemorrhage hypovolemic shock

sources of abnormal bleeding

hemorrhoids, unrepaired aginal or cervical lacerations excessive bleeding ++ clots

Cytomegalovirus (CMV) agent

herpes virus

musculoskeletal congenital anomalies

hip dysplasia clubfoot polydactyle syndactlye

Bowel/abdomen

hunger passing gas, no nausea constipation

pitocin preparation

i) varies, added to LR or NS as piggyback (1) Should be at closest port incase she starts contracting too much

source and devices

i. 1st choice: Expressed breast milk ii. 2nd choice: Donor breast milk iii. 3rd choice: Formula iv. Spoon v. Syringe vi. Dropper vii. Cup—medicine cup viii. Slow-flow nipple

Sleep-Wake Patterns

i. 6 sleep-wake states (2 sleep, 4 wake) ii. State modulation iii. 16-19 hours of sleep/day for first few weeks

physical assessment head

i. Head ii. Fontanels iii. Caput succedoneum iv. Cephalhematoma v. Bruising

Legs/Lower Extremities/Homan's

i. Increased edema the first few days ii. Soreness from labor (not pain) iii. Normal reflexes

engorgement

ice packs post feeding cabbage leaves NSAIDs

apgar scores 4-6

indicated moderate difficulty

CMV epi

most common virus transmitted to the fetus

Trichomoniasis agent

protozoa trichomonas vaginalis

parvovirus transmission

respiratory secretions, blood, blood products, common in school kids

Rubella transmission

respiratory virus present 1 week prior to symptoms

lochia odor

should be musty like menses, not foul report foul odor asap

meconium aspiration **

swallow meconium and will have a chemical imbalance

tools of labor

(1) Classic kind of set up birth tables (2) Cord clamp (3) Bulb suction—to clean mouth and nose of baby out (4) Sutures (5) Basin (6) Local Anesthesia (Laceration during natural birth

pitocin monitoring

(1) FHTs continuously (2) UCs: goal is strength 40-90 mm Hg, duration 60-90 seconds, frequency every 2-3 minutes, resting tone <= 20 mm Hg

Csection risks to mom

(1) Hemorrhage, DIC (2) Longer recovery (3) Infection (4) Wound dehiscence (particularly in obese women), scar (5) Anesthesia (6) Psychological: body image, fear/anxiety

SAB surgical management

(1) May need device or medication one day prior for dilation (2) Conscious sedation or general anesthesia (3) Pitocin to prevent hemorrhage (4) Rhogam for women who are Rh negative (5) Discharge within a few hours - need a ride (6) REST - especially first day (7) Ibuprofen for light cramping (8) Light bleeding can last few days - 2 weeks (9) Nothing in vagina for 2 weeks or until bleeding stops completely (10) Grief and emotional recovery (11) Support groups (12) Typically wait 1-3 months before trying to get pregnant again, but depends on what the underlying issue is

complete SAB management

(1) No intervention—if no bleeding or cramping or infection (2) Surgical—if bleeding, excessive cramping or infection => D&C

oligohydramnios predictor of IUGR morbidity/mortality and tolerance of labor

(1) Not enough fluid to help with fetal development (2) Tolerance of labor—induction at 38 weeks, since there is not enough fluid to cushion the cord the baby may not tolerate labor well due to cord compression

postpartum hypertension management

(1) Oral antihypertensives if BP remains elevated (2) Careful instructions about s/s (a) Headache, blurry vision, seeing spots, epigastric pain, RUQ pain, indigestion, sudden increase in swelling (3) See women 72 hours after discharge and 10 days later (4) Seizure can occur up to 4 weeks pp

supra pubic pressure (shoulder dystocia)

(1) Push the shoulder in the direction it needs to go (2) Pressure applied to the anterior shoulder in attempt to push the shoulder under the symphysis pubis

assess for active bleeding which is associated with tubal rupture (ectopic pregnancy)

(1) Referred shoulder pain + Deep lower, one side acute abdominal pain (2) S&S of shock: dizziness, hypotension, tachycardia (3) Cullen sign - ecchymosis around umbilicus (4) Ectopic pregnancies can become very emergent very quickly

third stage of labor placental examination/disposal

(1) Shiny Schultz=fetal side (2) Dirty Duncan=Maternal side b) What should you be concerned about? Pieces of placenta still inside, which could put mother at risk of bleeding

Late Preterm Infants

(EGA 34 0/7 - 36 6/7) i. Related to elective induction (a little off on the dates) ii. Largest portion of the preterm population iii. "Just a little small"

DIC labs Decreased (using up all of the clotting factors)

(a) Platelets (b) Fibrinogen (c) Factor V (d) Factor VIII

Macrosomic

- > 4000gms a. Can't pass through the birth canal

Casein- or whey-hydrolysate formulas

- for children who cannot tolerate or digest cow's milk- or soy-based formulas Eg. Nutramigen

Amino acid formulas

- for infants with multiple food protein intolerances Eg. Neocate

Higher concentration of fat in hindmilk

- needed for ensuring optimal growth and satisfaction between feedings. That's why you want to make sure that infants are nursing long enough so they can intake the richer, denser calories from fat in hindmilk.

Signs of Potential Complications box: Postpartum Psychosocial Concerns

. The following signs suggest potentially serious complications ii. and should be reported to the health care provider or clinic iii. (these may be noticed by the partner or other family members): 1. Unable or unwilling to discuss labor and birth experience 2. Refers to self as ugly and useless 3. Excessively preoccupied with self (body image) 4. Markedly depressed 5. Lacks a support system 6. Partner or other family members react negatively to the baby 7. Refuses to interact with or care for baby; for example, does not name baby, does not want to hold or feed baby, is upset by vomiting and wet or soiled diapers (cultural appropriateness of actions must be considered) 8. Expresses disappointment over baby's sex 9. Sees baby as messy or unattractive 10. Baby reminds mother of family member or friend she does not like 11. Has difficulty sleeping 12. Experiences loss of appetite

Vitamin K injection

0.5-1mg vitamin K IM 1-2 hours after birth 2. Prevents hemorrhagic disease of the newborn (spontaneous brain bleeds are most serious) 3. Vitamin K synthesized by intestinal flora 4. Newborns are Vitamin K deficient until 7 days of age 5. Oral Vit K not well-absorbed and alters gut microbiome

neonatal microbe

1. "Seeding" of neonate at birth 2. Intra-uterine cavity "sterile" 3. Maternal antibiotic administration during labor 4. Cord blood source of inflammatory markers for neonatal sepsis

26/27 weeks

1. - 90% survive a. Reason survival rates is so good 26-28 weeks because of surfactant

progesterone routes

1. 17-alpha hydroxyprogesterone caproate (inj)- generally for hx PTD a. Dose is 250 mg IM q week from 16-20 weeks until 36 weeks 2. Vaginal progesterone (gel)- generally for short cervix a. Dose is 90-200 mg vaginally q night until 37 weeks

PE chest

1. Breath sounds 2. Heart sounds 3. Swollen breast tissue 4. Supernumerary nipple

abnormal bladder/urinary tract findings

1. Distended bladder—how do you know?? 2. Incomplete emptying 3. May displace fundus- usually up and right

Bowels Hunger

1. Eat when hungry a. Very hungry after full recovery from analgesia, anesthesia, and fatigue

PHOTOTHERAPY nursing considerations

1. Eye mask - closed eyes before initiating the light 2. Maximal skin exposure 3. Monitor temperature—the room needs to feel like a sauna 4. Adequate hydration—baby needs to be nursing well 5. Monitor output—urine and stool 6. Parent-infant interaction

signs of a good latch

1. Firm tugging sensation on the nipple - but no pain or pinching 2. Sucks with cheeks rounded, not dimpled 3. Jaw glides smoothly with sucking 4. Audible swallowing 5. Take off and try again by inserting finger to break the suction and then pulling the baby off 6. Should have a good amount of the areola

drugs used in vaginal birth

1. Local infiltration anesthesia 2. Pudendal block 3. Epidural block anaglgesia and anesthesia 4. Spinal (block) anesthesia 5. CSE analgesia and anesthesia 6. Nitrous oxide

Rh Incompatibility or isoimmunization

1. Occurs when maternal antibodies are present or develop in response to exposure to an antigen (different blood type) 2. Pathogenesis hematopoiesis (the formation, production and maintenance of blood cells) in the fetus is well established by the 9th week of gestation. When fetal RBCs that contain the Rh antigen pass through the placenta into the maternal circulation of an Rh-negative woman the maternal immune system produces antibodies against the foreign fetal antigens. maternal sensitization 3. Maternal sensitizastion a. Process of antibody formation b. Sensitization can occur during pregnancy, birth, miscarriage or induced abortion, amniocentesis, external cephalic version, or trauma 4. Maternal antibodies cross the placenta

psychosocial support/ self care

1. Set realistic goals 2. Sleep as regularly and as much as possible 3. Accept all offers of assistance 4. Get out of the house daily 5. Exercise when the body is ready 6. Avoid caffeine, sugar, alcohol 7. Notify provider of psych ( esp. previous depression) history 8. Routine screen for depression at pp visit

Abnormal Newborn respirations

1. Tachypnea—consistently 70-90 respiratory rate 2. Nasal flaring 3. Intercostal or subcostal retractions 4. Suprasternal or sub-clavicular retractions 5. Grunting 6. Central cyanosis 7. RDS, TTNB, PPHN, meconium aspiration

RDS signs and symptoms

1. worsens over first 48 hours 2. Improves within 72 hours of life 3. Retractions a. Substernal retractions b. Intercostal retractions c. 4. Grunting 5. Nasal flaring 6. Tachypnea or apnea a. Apnea—20—second or greater cessation of respiration or a shorter pause accompanied by bradycardia, cynosis or hypotonia 7. Decreased breath sounds 8. Fines rales 9. Generalized cyanosis—acrocyanosis is a normal findings in the neonate but central cyanosis indicaes an underlying problem that requires immediate evaluation 10. X-ray findings Ground glass appearance on RDS X-ray. Uniform reticulogranular appearance and air bronchograms

PTT preeclampsia and HELLP

12-14, 60-70

subinvolution assessment and causes

2. Deviated to right 3. Boggy (uterine atony)—soft, doughy uterus a. Fundal massage—to help it firm up b. Oxytocic medications i. IV Pitocin ii. Cytotec iii. Methergine—cant give to someone who has hypertension iv. Hemabate—cant be given to someone with asthma 4. Common cause: retained placenta products and infection

preterm

20--36.6 weeks/days

uterus changes increase in blood flow

50 cc/min --> 500 cc/min

moderate variability

6-25 bpm (amplitude range) this is the goal

24 weeks

66-80% survive

chlamydia signs and symptoms

80% of chlamydia cases are silent aka asymptomatic s/sx Postcoital spotting or bleeding Cervical discharge Dysuria

protein requirements

9.1 g/day BM: why and casein 70:30 F: whey and casein 20:80

what do we want infant temperature to be?

97.7-99.5

maternal long term sequelae of gestational diabets

: type 2 diabetes, chronic HTN

FHR bradycardia

< 110 bpm for 10 minutes or longer

adequate accelerations

< 32 weeks: 10 bpm above baseline for 10 sec or > > 32 weeks: 15 bpm above baseline x 15 sec or >

ectopic pregnancy progesterone

< 5ng/ml suggests an ectopic or otherwise abnormal pregnancy

Pulse/Heart Rate apgar 1

<100

FHR tachycardia

> 160 bpm for 10 minutes or longer

creatinine preeclampsia

>1.1

bilirubin HELLP

>1.2

uric acid HELLP

>10

uric acid preeclampsia

>5.9

childbirth preparations methods

A. Childbirth preparation methods i. Lamaze ii. Bradley method 1. Partner/husband coached—woman is engaged with partner and learn together how to go through the birthing process iii. women are now assisted to develop their birth philosophy + inner knowledge and choose from a variety of skills to sue to cope with the labor process iv. classes focus on fostering a woman's confidence in her innate ability to give birth v. women + partner are helped to recognize uniqueness of their pregnancy + childbirth experience

polyhydramnios

AFI> 24 cm excessive amniotic fluid surrounding fetus common in diabetic moms

placenta abruption all signs and symptoms

Abdominal pain Rigid board like abdomen Dark red vaginal bleeding Couvelaire uterus (purple or blue color to uterus with loss of contractility instead of a pink healthy uterus) Shock may occur Positive Apt test (blood in amniotic fluid) Positive KB test: fetal to maternal bleeding KB Test to see if there is any fetal to maternal blood mixing Decreased H&H Decreased coagulation factors DIC symptoms Abnormal FHR and pattern

Candidiasis risk factors

Abic therapy and steroids Pregnancy—hard to control in pregnancy thought to be due to the rising estrogen levels Obesity Diets high in refined sugars Tight fitting clothing, non-absorbent underwear

impaired liver function severe features of preeclampsia

Abnormally elevated blood concentrations of liver enzymes to twice the normal concentration; severe persistent epigastric or right upper quadrant pain unrespon¬sive to medication and not accounted for by alternative diagnoses, or both

FFN accuracy

Accurate for predicting NO labor for the next 2 weeks. 99% accurate for next 7 days 95% accurate for following week 90% accurate for 3rd week after test

nuchal cord

After the head is delivered the doctor sticks his hand in to Assess to see if the umbilical cord is wrapped around the neck (2) Nuchal cord x1—wrapped around once (3) Double nuchal cord—umbilical cord is wrapped around twice

DM low risk

Age < 25 Normal weight White (or low prevalence group) No history of poor OB outcome (loss, anomaly) No diabetes in 1st degree relatives No history of abnormal glucose tolerance

DM high risk

Age >40 Morbid obesity Darker skin Previous GDM, LGA or poor OB outcome Strong family history T2DM Glycosuria > +1 twice PCOS

Episiotomy

An incision in the perineum used to enlarge the vaginal outlet (2) Has steadily declined in recent years due to a lack of sound, rigorous research to support its benefits (3) Cut skin to make more room (4) Mediolateral (5) Median (or midline)

long term complications

Anemia Retinopathy of prematurity Hearing loss Cerebral palsy Neurobehavioral problems Cognitive and developmental deficits

A reedA==>how to assess Episiotomy/Laceration/Incision (and hemorrhoids

Approximation holding together or not

variable deceleration

Associated with cord compression (maternal position, cord around fetus, short cord, knot in the cord, prolapsed cord) Variable in appearance (U, V, or W shape) decrease in FHR of 15 bpm or more from baseline, lasts 15 seconds, return to baseline in less than 2 minutes Occasional variables are not as significant; repetitive variables indicate repetitive interruption of fetal oxygen supply

placenta previa diagnosis

Assumption for all painless vaginal bleeding after 20 weeks Abdominal US then transvaginal US

chlamydia treatment

Azithromycin No sexual activity for 7 days after completion Treat partners! Test of cure: Retest in 3 weeks Retest within 3 months Rescreen in 3rd trimester if high risk

gestational hypertension

BP >140/90 and <160/110 no other signs and symptoms development of HTN after week 20

frequency of vital signs

BP and pulse q 15 min x 2 hrs temp q4H x 8 hrs then routine

hypertension severe features of preeclampsia

BP reading ≥160/110 mm Hg × 2, at least 4 hours apart while the client is on bed rest (unless antihypertensive therapy

delivery complications with uncontrolled diabetes

Baby: macrosomia, shoulder dystocia mom: perineal tears, operative vaginal delivery cesarean

pre-existing diabetes preconception

Baseline assessments: CV, renal, ophthalmologic Tight control of blood sugars Folic acid Higher levels - 10x

pre-existing diabetes 3rd trimester

Be mindful for growth problems Expect induction by 40 weeks (mainly around 39 weeks)

placenta abruption active management

Birth if ≥ 36 weeks OR bleeding excessive or concerns about fetal well being C-section for placenta within 2 cm of os Maternal and fetal monitoring for hemorrhage Assessment postpartum for hemorrhage Emotional support

HIV transmission

Blood and bodily fluids Perinatal

hypertension preeclampsia

Blood pressure (BP) reading ≥140/90 mm Hg × 2, at least 4 hours apart after 20 weeks of gestation in a previously normoten¬sive woman

B (buBble hep)

Bowel

B (Bubble hep)

Breasts

fourth stage of labor assessment of maternal physical status (BUBBLE HE, way to systematically assess the mother)

Breasts uterus bowel bladder Lochia (vaginal bleeding after birth) perineum (watching for sings of swelling and hematoma) Extremities (looking for swelling and any sings of complications) Homan's sign (dorsiflex the foot and see if any pain is elicited) Emotion (transition in the immediately postpartum)

formula minerals

Ca and Ph (1.85:1) Iron Low Fluoride

breast milk minerals

Ca and Ph (2:1) Iron Low Fluroide

Bishop score

Calculation based on dilation, effacement, station consistency and position based on dilation, effacement, station, consistency, position i) 0-not favorable for pitcoin, cervix is not ready for contraction ii) Score of 9 for nultip iii) Score of 5 and up is good for a multip

discharge teaching for women after SAB

Call provider if.... Prolonged and heavy bleeding Prolonged and severe cramping Dizziness or fainting Fever > 100.4 Chills Foul smelling discharge

Candidiasis agent

Candida albicans

cardiovascular changes increases

Cardiac output (↑30-50%, beginning 8 wks)—starts in the first trimester Stroke volume (↑30%) Heart rate (↑15-20 beats/min want to keep HR under 140 bpm) Blood flow: Uterus (↑10x to 500-800 ml/min), Kidney (↑50%)Breasts, Skin (vasodilation)

3 TIER FHR INTERPRETATION: SHORT FORM

Category I: Normal. FHR 110-160, moderate variability, accelerations or not, no late decels Category II: Indeterminate. Minimal or marked variability, tachy or bradycardia without absent variability, and more. Category III: Abnormal. Absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia OR sinusoidal pattern

placenta abruption diagnostics

Clinical S&S U/S sometimes DIC symptoms and diagnostics Increased fundal height Abnormal FHR patterns Elevated uterine resting tone Ultimately post-birth visualization of placenta

neurologic changes

Compression of pelvic nerves or vascular stasis caused by enlarged uterus alters sensation in lower extremities Dorsolumbarlordosis can cause back pain due to compression of nerves Carpal tunnel syndrome can occur at any time, incidence rises with pregnancy Lightheadedness, faintness, and syncope due to postural hypotension or hypoglycemia Muscle cramps possibly due to hypocalcemia or mineral deficiency (low magnesium or other mineral deficiencies)

Hydrocephalus

Condition in which there is excess CSF in the ventricles of the brain due to overproduction (Rare) or a decrease in reabsorption b. Classic signs: vomiting, lethargy, irritability, setting sun eyes c. Ventriculoperitoneal shunt d. CSF buildup and causes enlarged ventricles

ectopic pregnancy abdominal pain

DULL abdominal pain starts on one side (RLQ, LLQ) then progresses to colicky pain when tube stretches => sharp stabbing pain => diffuse constant severe pain throughout lower abdomen

Spontaneous bowel movement may not occur for 2 to 3 days

Delay is caused by slowed peristalsis related to decreased muscle tone in the intestines during labor and the immediate puerperium, prelablor diarrhea, lack of food or dehydration.

DM medications in pregnancy

Depending on blood sugars Insulin Oral hypoglycemia

placenta previa expectant management

Depends on degree of abruption and blood loss < 34 weeks Maternal and fetal monitoring for hemorrhage and IUGR Corticosteroids for fetal lung maturity Corticosteroids and then moving towards delivery Depending on how bad it is they may need a C-section

respiratory anatomic changes

Diaphragm is elevated 4 cm by term ↑Diaphragmatic excursion ↑Chest circumference

digital cervical exam

Digital exam: check cervix in pt who is contracting but not ruptured, or in active labor even if ruptured. Checking both dilation and effacement. If membranes are ruptured, DO NOT CHECK. Decreases latency period by average of 9 days. Grade A evidence. Shortens latent period*** Cervical change Cervical change over 2 hours +/- More than 2 cm dilated or 80% effaced (consider EGA)

E rEeda==>how to assess Episiotomy/Laceration/Incision (and hemorrhoids

Edema

Spinal/scalp electrode

Electrode attached to fetal scalp

E (bubble hEp)

Emotions/Bonding

E (bubblE hep)

Episiotomy/laceration/Edema/Hemorrhoids/Incision

new born medications

Erythromycin Ointment Vitamin K injection Hepatitis B Vaccine (IM)

SAB management

Expectant: No intervention, bedrest, monitoring Medical: Misprostol ( to encourage the body to expel the products) Surgical: Dilation and Curretage (products are removed surgically) Past intervention: Needs to watch bleeding and for infection

fat requirements

Fat (31 g/day) breastmilk Lipids, Triglycerides, Cholesterol, EFA: Linoleic acid, DHA, ARA formula:Corn oil fat, No cholesterol Added Linoleic Acid Added DHA

ectopic pregnancy or tubal pregnancy

Fertilized ovum implants in the fallopian tube But can fertilized ovum can also implant in the ovaries and abdomen

feeding patterns formula

First 24-48 hours: 15-30 ml/feeding By end of 2nd week: 90-150 ml/feeding Feed q3-4 hours Once weight gain adequate - can sleep through the night

Bacterial Vaginosis signs and symptoms

Fishy odor Thin, white or gray milky discharge May have pruritis

nutrient needs of the infant

Fluids Energy Carbohydrate Fat Protein Vitamins & Minerals NOTE: No breast milk should ever be diluted, and no breast fed infant should ever be given water as this reduces the absorption of the above nutrients

Toxoplasmosis transmission

Foodborne, mother to child undercooked meats cats (infected often by eating rodents): parasite passed in the cat feces in microscopic form = NO LITTER BOXES (do not change the litter, especially if cat goes outside) contaminated ground soil-gardening, unwashed fruits.veggies (must wear gloves while gardening and wash hands when she comes back inside

G (apGar)

Grimace reflex irritability

preeclampsia with severe features

HTN 160/110 or more + persistent symptoms (don't respond to usual treatments) +/or other abnormal labs (with or without proteinuria) • Liver enzymes (AST, ALT) or LDH doubled • Low platelets +/or pulmonary edema

Past medical history Admission to L& D

HTN, diabetes, surgeries, infections

severe gestational hypertension

HTN> 160/110 no other signs of symptoms after 20 weeks of gestation

placenta previa maternal adverse outcomes

Hemorrhage Abnormal attachment (accreta, increta, percreta listed by increasing severity) Hysterectomy

Herpes Simplex 2 agent

Herpes Simplex Virus 2 (HSV 2)

feeding technique formula feeding

Hold during feedings - do NOT prop up bottle Bonding opportunity Slow-flow nipple in the beginning

H (bubble Hep)

Homan's

HIV agent

Human Immunodeficiency Virus

HIV risk factors

Hx of acute or chronic liver disease Risky sexual behavior IV drug use

signs of diabetic ketoacidosis in pregnancy

Hyperventilation Tachycardia Hypotension Ketotic breath Dry mucous membranes Disorientation Coma

ectopic pregnancy medical management methotrexate

IM i) Methotrexate is a highly toxic antineoplastic—stops cell division ii) Woman must be hemodynamically stable iii) Normal liver and kidney function iv) Mass must be intact (unruptured) and < 3.5 cm v) Obtain height and weight for proper dosing

steroids (bethamethasone, Dexamethasone)

Improves neonatal outcomes: reduced neonatal death, RDS, IVH, necrotizing enterocolitis, sepsis, NICU admission Use when PTD likely within 7 days, 24 to 34 weeks: pPROM, PTL, or PIH

lower uterine transverse or vertical classical transverse up and down c-section

In order to have a vaginal birth after a c—section they have to have had a lower uterine transverse C/S

accelerations

Increase in FHR above baseline < 2 min. long The peak is at least 15 beats above the baseline, lasts for 15 seconds, with a return to baseline in less than 2 minutes accelerations = indication of fetal well being **REACTIVE STRIP: increase 15 bpm x 15 seconds twice in a 20-minute period.

renal anatomic changes

Increase in size Dilation of renal pelvis and ureter Increase in residual volume of bladder Urinary stasis==>↑pyelonephritis in patients with asymptomatic bacteriuria

Indications of adequate newborn nutrition and hydration

Indications of adequate newborn nutrition and hydration can be easily assessed in the diaper

gonorrhea transmission

Lives primarily in vaginal fluid and semen Primary transmission through vaginal or anal sex Mother -fetal vaginal transmission during birth

L (bubbLe hep)

Lochia

4 vaccines commonly given in the postpartum period

MMR Flu TDAP varicella

variable deceleration management

Maternal position change => b/c it's cord compression Oxygen 8-10L/min => if becomes repetitive Notify provider Amnioinfusion =>need IUPC; need to monitor for infection, pressure, contractions (want to make sure fluid is coming back out) Instill fluid into the uterine cavity to help cushion the cord Assist with birth if pattern doesn't resolve => may result in C/S

uncontrolled protestational DM early pregnancy

Microvascular: worsening of retinopathy, nephropathy Infection (UTI) Miscarriage Anomalies: 2/3 involve cardiovascular and CNS • Neural tube defects • Caudal regression syndrome • Ventricular septal defects

Describe the current prevalence and incidence of perinatal depression in the U.S.

Most Common Complication of Pregnancy ii. 15% of pregnant women diagnosed in the postpartum a. Higher in certain ethnicities (API in particular) 1. Asian and pacific islanders 2. Under reported, a lot of women don't want to disclose b. Often undiagnosed iii. Lack of treatment has sequelae for mother and baby a. Both mother and baby suffer

syphilis women at risk

Multiple sexual partners, high risk sexual practices

Rhogam Rh immune Globulin, RhoGAM, Gamulin Rh, HyRho-D, Rhophylac adverse effects

Myalgia, lethargy, localized tenderness and stiffness at injection site, mild and transient fever, malaise, headache; rarely nausea, vomiting, hypotension, tachycardia, possible allergic response

renal insufficiency preeclampsia

New development of serum creatinine >1.1 mg/dl or a doubling of the serum creatinine concentration in the absence of other renal disease

Bacterial Vaginosis risk factors

New or multiple partners Douching Receiving oral sex

nitrous oxide for analgesia

Nitrous oxide mixed with oxygen can be inhaled in a low concentration (50% or less) to provide analgesia during the first and second stages of labor.

contraception

Non-hormonal methods - barrier devices, IUD's, natural planning for first year after birht breastfeeding alon not reliable beyond 6 months i. Non-hormonal methods - barrier devices, IUD's, natural planning ii. Estrogen containing methods not recommended. Progestin only contraceptives better, but not till after 6 weeks

infant breast feeding reduces risk of

Nonspecific GI infections 2. Childhood IBD 3. NEC for preterms 4. Atopic conditions 5. Respiratory Tract Infections—asthma 6. Ear infections 7. SIDS 8. Later obesity—lower, related to optimal establishment of gut microbiome, ways of feeds will be less obesogenic with breast feeding vs bottle feeding. 9. Diabetes 10. Some childhood cancers—leukemia

Normal HR

Normal: 50-90 Remains elevated 1st hour after birth Gradually decreases over 1st 48 hours May be bradycardic (40-50 bpm)

Candidiasis treatment

OTC antifungal creams (Fluconazole) Complete course of treatment

BUN PREECLAMPSIA AND HELLP

OVER 20

ABO incompatibility

Occurs with Maternal type O blood & fetal type A, B, or AB 2. Naturally occurring anti-A and anti-B antibodies cross the placenta to the fetus 3. Results in a Positive Coombs' test a. At the first prenatal vist of an Rh-negative woman with a fetus who may be Rh positive an indirect coomb's test should be done to determine whethere she had anitbodies to the Rh antigen. Maternal blood serum is mixed with Rh—positive RBCs. Positive = clumps. Repeated at 28 weeks

Butorphanol Tartrate (Stadol)

Opioid (narcotic) agonist-antagonist analgesics 1-2 mg. IV Q 3-4h. More sedative, less N&V. Duration 4-6 hrs.

Nalbuphine Hydrochloride (Nubain)

Opioid (narcotic) agonist-antagonist analgesics 10 mg. IV Q 3 h. Duration 2-4 H IV and 4-6 IM

hemorrhagic disorders later in pregnancy

Placenta Previa Placental Abruption Vasa Previa DIC

thrombocytopenia preeclampsia and severe features of preeclampsia

Platelet count <100,000/μL

PMI

Point of maximal impulse at fourth intercostal space to left of midclavicular line, often visible and easily palpable (also called the apical pulse)

symptoms of diabetic ketoacidosis in pregnancy

Polyuria Polydipsia N/V Abdominal pain Weakness Weight loss Decreased fetal movement

Management of postdate pregnancy accurate dating

Postdate—over 42 weeks

spontaneous Abortion (SAB)/miscarriage

Pregnancy that ends as a result of natural causes before 20 weeks of gestation. A fetal weight less than 500 g also may be used to define an abortion. Miscarriage is the lay term for a spontaneous abortion.

placenta previa fetal adverse outcomes

Preterm birth- Because placenta is on the cervix, leading to potential changes to the cervix Stillbirth Malpresentation Anemia

Bacterial Vaginosis epidemiology

Prevalence is most common in women of childbearing age (14-49)

stool progression

Progress over first 3 days - (1/day1, 2/day 2, etc). After that - 3 soft stools per day 1. 1 wet/ 1 dry - day one 2. 2 wet/ 2 dry- day two 3. 3 wet/3 dry-day three (minimums may have more)

renal insufficiency severe features of preeclampsia

Progressive renal insuffi¬ciency (serum creatinine concentration >1.1 mg/dl or a doubling of the serum creatinine concentration in the absence of other renal disease

DIC labs prolonged or increased

Prolonged or increased: taking longer to clot (a) PT/PTT (b) Fibrin degradation products

Protein

Protein - requirement is essential for newborn growth. Breast milk ratio of whey to casein is more easily digestible...hence the soft stools Type of whey (alpha-lactalbumin has amino acids essential for human growth, also has iron-binding capabilities and bacteriostatic properties against potentially pathogenic bacteria, thereby enhancing iron absorption.

normal findings proteinuria

Proteinuria common (check for other sx UTI and preeclampsia)- clean catch or cath specimen

proteinuria preeclampsia

Proteinuria of ≥300 mg in a 24-hr specimen Protein/creatinine ratio ≥0.3 (with each measured as mg/dl) ≥1+ on dipstick (used only if quantitative methods are not available

Candidiasis signs and symptoms

Pruritus, Dryness, Dysuria, Thick, white lumpy cottage-cheese like discharge, Erythema, may have a musty, yeasty odor

syphilis screening

RPR & VDRL FTA-ABS If RPR is positive have to have a FTA-ABS to confirm syphilis diagnosis

general anesthesia

Rarely used for uncomplicated vaginal birth b. The woman should be pre-medicated with (clear) oral antacid to neutralize the acidic contents of the stomach. prevent aspiration Because of this risk for neonatal narcosis (neonatal state of unconsciousness), it is critical that the baby be delivered as soon as possible after induction of general anesthesia, to reduce the degree of fetal exposure to the anesthetic agents and the CNS depressants administered.

pre-existing diabetes 2nd trimester

Re-check HbA1C and kidneys Anatomy scan Fetal echocardiogram if 1st trimester A1C was elevated

Adverse effects on babies from hyperglycemia, hypoxia + hyperinsulinemia after delivery

Respiratory distress Syndrome Hypoglycemia Polycythemia and hyperrilirubinemia

short term complications

Respiratory distress syndrome Intraventricular hemorrhage Temperature regulation Necrotizing enterocolitis Apnea Infection/sepsis Patent ductus arteriosus Feeding difficulties Jaundice Anemia

Rhogam Rh immune Globulin, RhoGAM, Gamulin Rh, HyRho-D, Rhophylac indications

Routine antepartum prevention at 28 weeks of gestation in women with Rh—negative blood; suppress antibody formation after birth, miscarriage, pregnancy termination, abdominal trauma, ectopic pregnancy, amniocentesis, version or chorionic villus sampling

HIV assessment and treatment

Screened for at first prenatal visit Must go on antivirals to prevent MATERNAL to FETAL transmission May have to have C-section if there viral load is to high Avoid breastfeeding (recommended in 3rd world countries because risk of consuming contaminated water is higher than transmission of HIV) Screen at first prenatal visit Tx: ART therapy C-section Avoid breastfeeding

women at risk for chlamydia

Sexually active women Multiple partners Non-use of barrier methods AA higher rate/risk

immediate assessments and care of newborn

Skin to skin, Apgar score, promoting breast feeding, clearing the airway, clean and dry, ABCs

normal BP

Slight increase from baseline (5% increase over 1st few days, return to baseline in a few weeks) Orthostatic Hypotension (typically 1st 48 hours)

formula feeding concerns

Spitting: Burp Hold upright after feeding Don't overfeed

Opioid agonist/antagonist

Stadol, Nubain: stimulate kappa but block/partially block mu receptors provides adequate analgesia and limits maternal and fetal respiratory depression

Rhogam Rh immune Globulin, RhoGAM, Gamulin Rh, HyRho-D, Rhophylac action

Suppression of immune response in nonsensitized women with Rh—negative blood who receive Rh-positive blood cells because of fetomaternal hemorrhage, transfusion or accident

Incomplete SAB surgical and medical management

Surgical—D&C (May or may not require additional cervical dilation before curettage) Medial—vaginal misoprostol (gets uterus to contract and expel the placenta and fetus)

hypothyroid

Synthroid levels will be checked every semester Undiagnosed which is discovered during pregnancy must be treated quickly because untreated hypothyroidism can have neurologic effects on the baby

syphilis agent

T.Pallidum

hypothyroidism labs

TSH high FT4 normal subclinical FT4 low hypothyroidism TPO antibodies

abnormal HR

Tachycardia (>100 bpm) Hypovolemia, infection, fear, pain

Beta-adrenergic receptor agonists (terbutaline) maternal side effects

Tachycardia, chest discomfort, palpitations, arrhythmias, tremors, dizziness, nervousness Headache, nasal congestion, difficulty breathing Nausea and vomiting Hypokalemia, hyperglycemia Hypotension Maternal side effects intolerable: tachycardia greater than 130 bpm, BP less than 90/60, chest pain, cardiac arrhythmias, MI, pulmonary edema

parvovirus women at risk

Teachers, daycare workers, women who work in pediatrics (pediatricians, nurses, PNPs)

Evaluate everyone's risk at 1st OB visit (screening of gestational diabetes)

Test very high risk women ASAP: A1C, fasting, random BS, or 2-hr OGTT Consider re-testing them at 15-17 wks if 1st test is normal.

postpartum BP

There is a transient increase in blood pressure of approximately 5% during the first few days after birth. It can take weeks or months for pulse and blood pressure to return to prepregnancy levels. Increase in blood pressure greater than 140/90 when measured on two or more occasions at least 6 hours apart can indicate preeclampsia.

touch

Touch - soles of feet 1. The infant is responsive to touch on all parts of the body. The face (especially the mouth), the hands, and the soles of the feet seem to be the most sensitive. 2. Birth trauma or stress and depressant drugs taken by the mother decrease the infant's sensitivity to touch or painful stimuli.

antigen

Toxin or foreign substance that induces an immune response in the body resulting in the production of antibodies

Herpes Simplex 2 active lesion at time of birth

VAGINAL BIRTH CONTRAINDICATED MUST HAVE A C-Section

Herpes Simplex 2 treatment

Valacyclovir, Acyclovir (dose varies depending on if it's the first episode or recurrent)—see cdc website Prophylaxis at 36 weeks

Varicella agent

Varicella zoster virus (herpes family)

how often should a women go to the bathroom after delivery

Voiding every few hours beginning within a few hours of delivery (1st 6-8 hours is ideal)

formula feeding cleaning

Warm soapy water and nipple brush Boiled for 5 minutes at least before first use Boiling not necessary (after first use) if cleaned in dishwasher

uterus changes increase in size

Weight: 70 g =>1100 g Volume: 10 mL => >5000 mL

fetal station (fetal position/Passenger)

a measure of the degree of descent of the presenting part of the fetus through the birth canal (1) High= -5 really floating (2) As the baby moves down the number gets larger (3) -5 ->0 (4) 0 station= engaged (when the baby's head hits the ischial spine)

nursing considerations preparing for the birth second stage bearing down efforts

a) (involuntary response to the ferguson reflex) often accompanied with a grunt or groan b) Body start pushing on its own (abs contract and pelvic floor relaxes) c) Valsalva maneuver (holding breath and counting to 10) d) *discouraged: increases intrathoracic and cardiac pressure, reduced uterine perfusion e) Encourage open glottis pushing—push on own

velamentous insertion

a) : fetal vessels implanted into the membrane i) Blood vessels in the membrane occurs when the cord vessels begin to branch at the membranes and then course onto the placenta

choriamnionitis

a) Bacterial infection of the amniotic cavity i) Most often occurs after membrane rupture or labor begins as organisms that are part of the normal vaginalflora ascend into the amniotic vavity

OB history admission to L&D

a) Current OB history and Past Ob history-Gs and Ps (previous kids), Prenatal care?, Water broken?, EDC—how many weeks along Complications during the pregnancy—infections, HTN, bleeding Past history and past complications during pregnancy C—section lower uterine transverse or vertical classical transverse up and down c-section? Placenta previa? Don't do a vaginal exam because you could rupture the placenta Cervical check (dilation, effacement, station, presentation) Contraction, frequency, duration, when started ROM or bloody show (more in a few slides) Fetal movement, fetal heart rate labs

artificial rupture of membranes (amniotomy) reason

a) break the membrane artificially b) Reason: induction or augmentation i) Great way to try to induce labor without medication

causes of labor are multifactorial

a) changes in the uterus, cervix b) hormone shifts (estrogen, progesterone) c) uterine distention, increasing intrauterine pressure--A woman pregnant with twins has a lot of uterine distention so is at greater risk of preterm birth d) aging of the placenta--Placenta is a temporary organ ,Factors released from the placenta that induces labor, Microbes—play a factor?

PROM Dx

a) check gross rupture, nitrazine, pooling (amniotic fluid just sitting next to the cervix), ferning, amnisure b) 90% will go into labor spontaneously within 24 hours

succenturiate lobe placenta divided into 2 lobes

a) placenta divided into 2 lobes i) Placenta divides usually looks like large placenta on one side and smaller lobe on the other side with vessels in between the two lobes ii) Placenta has divided into two or more lobes rather than remaining as a single mass. iii) Fetal vessels then run between the lobes of the placenta. The vessels collect at the periphery, and the main trunks eventually unite to form the vessels of the cord. iv) During the third stage of labor one or more of the separate lobes may remain attached to the decidua basalis, preventing uterine contraction and increasing the risk of postpartum hemorrhage.

uterine rupture risk factors

a) prior uterine surgery, congenital uterine anomaly, overdistended uterus, use of induction agents, version, fetal malpresentation i) Risk of using Pitocin (1) Causes the uterus to contract so much that is ruptures

ABX for PPROM infections

a. 7 day course first two days IV, next 5 days oral. i. prolonged pregnancy > 7 days ii. reduced neonatal morbidity b. 2 phases: i. 2 days IV antibiotics: erythromycin 250 mg q6h and ampicillin 2 g q6h and ii. 5 days po antibiotics: erythromycin-base 333 mg q8h and amoxicillin 250 mg q8h and enteric-coated

RDS chances of development

a. < 28 weeks gestation - 60% b. 28-32 weeks gestation - 50%

when to deliver after pPROM

a. Active/advanced labor i. Maternal or fetal safety in jeopardy ii. Chorioamnionitis (also a danger to mom) iii. Fetal distress (non-reassuring status) iv. Placental abruption b. 34 weeks? Risk of infection starts to increase over time, so usually deliver around 34 weeks since the baby won't have any long term issues *** c. Documented fetal lung maturity (L:S ratio 2:1) i. Amniocentesis ii. Vaginal fluid collection (if what is leaking)

NB discharge plan

a. Back to sleep & safe sleep environment and sleep hygiene b. Temperature regulation, how to take an axillary temperature i. Fever (>100.4 axillary or <97.7) c. Feeding Patterns i. Poor feeding (over 10% wt loss in first 3-5 days) ii. Projectile Vomiting d. Normal elimination patterns i. ↓BM ii. Diarrhea iii. ↓urination e. Also call nurse/pediatrician if: i. Breathing difficulties ii. Cyanosis iii. Jaundice iv. Lethargy v. Inconsolable crying vi. Infection at umbilicus or circumcision vii. Eye drainage

preterm infants classified by

a. Birth weight, SGA, AGA, LGA b. Gestational age

breast engorgement treatment

a. Breastfeeding mothers i. Frequent feeding, ice, mild analgesia b. Non-breastfeeding c. Well-fitted supportive bra, ice, cabbage leaves, mild analgesia, NO PUMPING d. Stimulation =milk production e. So if you are not breast feeding definitely don't want to stimulate the breasts

4 stages of maternal role attainment

a. Commitment/Attachment to the unborn baby/Preparation for delivery and motherhood during Pregnancy b. Acquaintance and attachment to the infant, learning to care for the infant, physical restoration during the 1st 2-6 weeks following birth c. Moving towards new normal d. Achievement of a maternal identity through redefining self to incorporate motherhood

NSAIDs fetal

a. Constriction of ductus arteriosus b. Oligohydramnios, caused by reduced fetal urine production c. Neonatal pulmonary hypertension

congenital diaphragmatic hernia

a. Diaphragm doesn't completely close b. If it is a small opening they can repair it laparoscopically c. Fetal lungs underdeveloped**** d. Results form a defect in the formation of the diaphragm, allowing the abdominal organs to be displaced into the thoracic cavity

Prevention is administration of RhoGam or Rhophylac in Rh Negative mothers

a. Don't wait to find out if the baby is Rh positive b. Administration Before and after delivery c. Doesn't affect the current pregnancy but will develop antibodies and can have problems with subsequent pregnancies

testing cultures

a. Done because of the rate of infection associated with preterm labor. 30-50% of preterm labors are associated with maternal infection b. GC and chlamydia NAAT c. NAAT typically detect 20-50% more chlamydial infections than could be detected by culture or earlier nonculture tests d. Urine culture i. Also test UA e. Group B Strep f. Wet prep

When else have we heard of oxytocin?

a. During labor and contractions. So MER can be triggered in labor releasing some colostrum. Kind of like nature's way of preparing to feed the baby. Also explains the relationship with uterine involution postpartum - but it can cause painful cramping which may last 3-5 days.

post-dural puncture headaches (PDPH)

a. Epidural blood patch there's a chance they can accidently make a little hole + after the epidural that fluid can continue to leak out and can manifest as a headache (puncture dura mater so leaking CSF) i. need to explain this to them post-epidural ii. fix it with an epidural blood patch will take some of their blood like an epidural + it will close the hole = immediate relief of headache

Describe physiologic and behavioral adaptations the neonate experiences at the time of birth

a. Establish and Maintain Respirations b. Circulatory adaptation c. Thermoregulation d. Suck, swallow, breath—one of the hardest things for premature babies to develop e. Elimination f. Weight gain g. Regulate behavior independent of the mother h. Process sensory stimuli i. Establish relationships with caregivers/family

Sore nipples assessment

a. Flat? Inverted? Cracks? Soreness? Blisters? Bleeding? b. Assess and correct latch i. Assess to limit how sore nipples are c. Proper feeding position

signs and symptoms of PPD

a. Identical to major depression b. Anxiety is prevalent c. Irritation, Anger or Rage d. Overwhelmed e. Sleep Problems f. Sadness g. Lack of Connection h. Lack of Concentration

nonlochial bleeding

a. If the bloody discharge spurts from the vagina, and the uterus is firmly contracted, there can be cervical or vaginal tears in addition to the normal lochia. b. If the amount of bleeding continues to be excessive and bright red, a tear can be the source.

breast is best

a. Infant formula may be adequate, but breast milk is superior. b. Scientific evidence makes it clear that: Breast is best i. Species-specific and composition changes to meet infant nutritional and immunologic needs ii. Formula may be adequate, but breast is by-far superior 1. Breast milk cannot truly be substituted

Intermediate or limbic myelination

a. Intermediate or limbic i. Hunger, instincts, emotions, memory, sensory input

fragile brain structures at risk

a. Intraventricular Hemorrhage b. Periventricular leukomalacia - abnormal lesions of white matter

Causes hemolysis of fetal RBC's

a. Isoimmunization - leading to fetal anemia b. Erythroblastosis Fetalis - immature erythrocytes i. Hydrops fetalis—most severe form, has marked anemia, cardiac decompensation, cardiomegaly, and hepatosplenomegaly ii. The fetus compensates for the anemia by producing large numbers of immature erythrocytes to replace those hemolyzed

Lochical Bleeding

a. Lochia usually trickles from the vaginal opening. The steady flow is greater as the uterus contracts. b. A gush of lochia can appear as the uterus is massaged. If it is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium

early onset GBS risk factors

a. Low birth weight b. Preterm birth c. Ruptured membranes > 18 hours d. Maternal fever e. Previous infant with GBS sepsis f. Maternal GBS bacteriuria g. Internal fetal monitoring h. Maternal age < 20 i. Hispanic or African-American ethnicity

questionable strategies for PTL

a. Maintenance with tocolytics i. Calcium channel blockers, oxytocin antagonists, terbutaline therapy (t-pump) b. Tocolysis with agents not discussed i. Ethanol infusion, oral betamimetics, nitric oxide donors, progestational agents c. IV hydration i. Only helps if patient is actually dehydrated d. Bedrest i. Potential problems: psych, constipation, clots, sleeping, $$, etc. ii. Benefits for pts with gestational hypertension or pPROM still being investigated e. Relaxation therapy (doesn't hurt, though)

post term infant complications

a. Meconium aspiration b. Hypoglycemia c. RDS—respiratory distress syndrome d. Transient Tychapnea of the Newborn, TTN e. Increased risk of perinatal loss

ABO Incompatibility can cause

a. Mild anemia b. Hyperbilirubinemia

L/D considerations related to PTD

a. Need level III NICU (all Atlanta area hospitals) b. Watch for malpresentation and retained placenta i. More likely to be breech and placenta doesn't want to detach from the wall of the uterus c. Continuous monitoring i. Pre term babies ii. Risk of infection d. Obtain cord ABG i. Unless they come out and are very vigorous

Describe immediate nursing interventions to facilitate successful NB transition.

a. Newborn Metabolic Screening - "PKU" i. Screens for 31 core disorders and 26 secondary disorders ii. Screens for numerous metabolic disorders b. Hearing Screening i. Initial screen with EOAE test (evoked otoacoustic emissions) ii. Follow up screen: ABR test (auditory brainstem response) c. Critical Congenital Heart Disease- "CCHD"

meconium aspiration syndrome

a. Passes meconium into amniotic fluid into lungs, babies skin will be stained with meconium b. Pneumonitis & pneumonia c. Bile salts cause a pancreatic enzymes cause chemical pneumonitis 1. Can occlude small distal airways d. Meconium occludes distal airways and obstructs airflow on expiration, leads to trapping of air e. Rarely occurs before 38 weeks gestation 1. Good indicator of exposures in utero, can be send of for analysis f. Mechanical ventilation g. Sedation h. Nutrition

prolonged rubra, serosa or alba (abnormal bleeding)

a. Persistence of lochia rubra in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. It is not uncommon for women to experience a sudden, but brief, increase in bleeding 7 to 14 days after birth when sloughing of eschar over the placental site occurs. If this increase in bleeding does not subside within 1 to 2 hours, the woman needs to be evaluated for possible retained placental fragments b. About 10% to 15% of women still have normal lochia serosa discharge at their 6-week postpartum examination However, the continued flow of lochia serosa or lochia alba by 3 to 4 weeks after birth can indicate endometritis, particularly if the woman has fever, pain, or abdominal tenderness.

Identify when Rhogam would be needed and briefly describe its action.

a. Preventing Rh Isoimmunization. Injection of Rh immune globulin (a solution of gamma globulin that contains Rh antibodies) within 72 hours after birth prevents sensitization in the Rh-negative woman who has had a fetomaternal transfusion of Rh-positive fetal red blood cells (RBCs) (see the Medication Guide). Rh immune globulin promotes lysis of fetal Rh-positive blood cells before the mother forms her own antibodies against them. b. The administration of 300 mcg (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization. If a large fetomaternal transfusion is suspected, however, the dosage needed should be determined by performing a Kleihauer-Betke test, which detects the amount of fetal blood in the maternal circulation. If more than 30 ml of fetal blood is present in maternal circulation, the dosage of Rh immune globulin must be increased

prolactin

a. Prolactin started its work during pregnancy preparing the breasts for lactogenesis. b. Levels are highest, however, the first 10 days after birth c. Prolactin produced by anterior pituitary gland in response to infant sucking and emptying of breast. It's a supply-meets demand system. d. Starts of in the hypothalamus anterior pituitary prolactin allows for milk production i. This process is stimulated by sucking or pumping ii. If the baby can't be put to breast in the first hour. It is important to initiated pumping as soon as possible if the baby can't be put to breast with in the first couple of hours

circumcision ***

a. The intact penis is easy to clean and care for (Don't retract the foreskin!) b. Circumcision i. Ultimately a parental decision: AAP recognizes some benefits but no routine recommendation ii. Gomco, Mogen or Bell iii. ****taking care of the penis c. Pain assessment i. 0,1 or 2 for each parameter for total 10 max pain. >4 is significant. Tool for 32 weekers to 20 weeks of age. ii. Goals of pain management are minimize intensity, duration and physiologic cause to the pain and maximize the baby's ability to cope with and recover from the pain. iii. Most acute pain remains undermanaged and even completely ignored! iv. Score with 0,1, or 2 for each of the following: 1. Crying 2. Requires O2 for saturation >95% 3. Increased VS 4. Expression 5. Sleepless v. Goals of pain management: 1. Minimize intensity, duration and physiologic cost of pain 2. Maximize the baby's ability to cope with and recover from pain 3. Most pain is not assessed or treated, it is a major priority d. Nursing actions i. Silver nitrate - chemically cauterizes ii. Pain control - Nerve Block, Emla, other non-pharm measures (glucose, breastfeeding or soothing presence) iii. Restraints iv. Aftercare: 1. Assessment of bleeding (15 min, 45 min) 2. Watch for first void 3. Bleeding - pressure with sterile gauze pad 4. Persistent bleeding - gelfoam or silver nitrate stick 5. Tylenol 6. Skin to skin with mother or father

pTL triage

a. Urine: culture, GC and Chlamydia b. VS c. Palpate: abdominal tenderness and contractions i. Abdominal tenderness can be a sign of infection d. Monitor- evaluate contractions and FHR e. Swab: some may require speculum exam i. Contracting fFN (http://www.ffntest.com/hcp/testing/specimen_collection.html) ii. Leaking Fern, nitrazine, Amnisure iii. Wet mount: BV, trich, yeast iv. Look at cervix v. GBS Cultures f. If not ruptured, check cervix now and in 2 hours g. Ultrasound (maybe, not routine) i. Cervical length (esp. if < 32 weeks) and/or funneling ii. AFI

what makes breast feeding so ideal

a. Various immunoglobulins, T and B lymphocytes, cytokines, interleukins, complement, lactoferrin b. Immunological properties have a role in preventing localized and systemic bacterial and viral infections c. Changes to meet the nutritional and immunologic needs of growing infant d. Colostrum - high protein level facilitates the binding of bilirubin growth spirts

Neonatal Abstinence Syndrome, NAS Lilly's place

a. West Virginia has a huge issue with NAS b. Transition for families learning to care for these infants c. Continued detox, basically a long term space for detox d. https://www.slideshare.net/USDTL/the-impact-of-neonatal-abstinence-syndrome-on-one-west-virginia-community e. https://www.youtube.com/watch?v=XlxqpE-Fpik

psychosis psychiatric emergency

a. high mood with racing thoughts b. severe confusion c. paranoia d. hallucinations (auditory or visual) e. begin suddenly within the 1st 2 weeks after childbirth

tocolytics

a. shut down contractions, most are not associated with better fetal outcomes b. Goal is to give steroids time to work. MOST DATA SHOWS NO/FEW BENEFITS otherwise. i. Use is for 24-48 hours while administering steroids, not longer. ii. Maintenance/prevention therapy: more harm than good.

combined spinal-epidural (CSE) analgesia

a. sometimes referred to as a "walking epidural," although women often choose not to walk because of sedation and fatigue, abnormal sensations in and weakness of the legs b. involves injection of a small amount of opioid and local anesthetic injected intrathecally (into the spinal canal) option for people who want to be a little more mobile, but usually chose not to do to fall risks i. don't have to use as much because there are mu receptors in this space and thus a smaller dosage can be used

cerclage

a. stich in the cervix that helps keep it closed i. Typically, only for the patients that a loss because the cervix is incompetent (loss in the third trimester or shorted cervix) ii. Stich can give a little extra support

fluid bolus/IV access (nursing care of a patient with epidural for birth)

a. typically, about 1L of fluid bolus b. hypotension give fluid to offset this drop in BP (start IV bolus prior to epidural to anticipate the pressure drop

local perineal infiltration anesthesia

a. used with episiotomy b. laceration repair after delivery c. 10-20 ml of 1% Lidocaine into the skin and subcutaneous area to be anesthetized

signs and symptoms of ectopic pregnancy

abdominal pain delayed menses 1-2 weeks or lighter than usua; vaginal spotting 6-8 weeks after LMP mild to moderate dark or brown spotting

Leopold's Maneuvers

abdominal palpation which helps you to answer three questions to determine lie and presentation of fetus 1. what fetal part is in the uterine fundus? hard=head, squishy=butt 2. where is the fetal back located? smooth=back 3. what is the fetal presenting part? what is presenting into the inlet or brim of the pelvis

marginal insertion

acord inserted at the edge i) Insertion of the cord is on the edge instead of the middle ii) Increased risk of evulsion—disconnects from the edge iii) Increases the risk for fetal hemorrhage, especially after marginal separation of the placenta

three phases of maternal attachement

acquaintance phase phase of mutual regulation reciprocity

Appearance/skin color apgar 1

acrocyanosis

marked variability

amplitude range greater than or equal to 25 bpm have to think about the peaks and troughs and how much it is going above and below greater than 25 bpm fluctuation may see periods of marked variability if the baby is very active but don't want to see it sustained

internal rotation

baby descends transverse and then internally rotates into the AP diameter baby turns its head from transverse to A/P diameter and shoulders typically stay where they are

oblique lie

baby is at a 45 degree angle to the mother's spine

horizontal lie

baby is lying perpendicular to mother's spine

longitudinal/vertical lie

baby spine is in line with the mom's spine (a) Can be a vertex or breech and still be longitudinal

weight gain during pregnancy

based off of pre--pregnancy BNI pre pregnancy BMI <18.5 underweight 12.5-18 (28-40) normal weight 11.5-16 (25-35 lbs) overweight 7--11.5 (15-25 lbs) obese 5-9 (11-20 lbs)

basic fetal heart rate

baseline fetal heart rate (FHR) variability presence of accelerations periodic or episodic decelerations change or trends of FHR over time

inevitable SAB expectant management

bedrest if no pain,bleeding or infection

late decelerations

begins after the contraction starts, nadir after the peak of contractions associated with fetal hypooxemia, acidemia, and low apgars gradual decrease in and return of FHR in relation to contraction beings after onset late of contraction, nadir after the peak of contraction

compensatory lumbar lordosis

bend in the lower back increases as the baby grows low back pain chiropractor helps with lower back pain as well as overall optimal health

ectopic pregnancy screening

beta-hcg progesterone assess for active bleeding associated with tubal rupture

timing of administration of pharmacological interventions

better during active phase than latent b/c cervix is changing (want cervix to be changing)

Posterior Fontanel

between the sagittal and lambdoid suture looks like a triangle

Abnormal skin variations

brusises lacerations skin tags central cyanosis petechia jaundice (usually occurs 24 hours after birth)

Opioid (narcotic) agonist-antagonist analgesics

butorphanol tartrate nalbuphine hydrochloride

involution is influenced by

by size of baby, long induction 1. Postpartum it can be a challenge since the muscles are really warn out 2. Risk for hemorrhages

postpartum respiratory function

c. Respiratory function rapidly returns to nonpregnant levels after birth. After the uterus is emptied, the diaphragm descends, the normal cardiac axis is restored, and the point of maximal impulse and the electrocardiogram are normalized.

steroids (bethamethasone, Dexamethasone) dosing

c. Usually 1 round. Repeat round is not routine. d. If dosing repeated in 1-2 weeks, results in less RDS and serious problems, but lower birth weight (around 75 grams). e. Dosing: i. Betamethasone (Celestone) 1. 12 mg IM q 24 h x 2 doses ii. Dexamethasone 1. 6 mg IM q 12 h x 4 doses

therapeutic touch

can be as simple as holding woman's hand, stroking her body, and embracing her (need to determine what woman's preference is first though) uses concept of energy fields within the body called prana (Redirect energy fields associated with pain) enhances relaxation, reduces anxiety, and relieves pain

increased use of oxytocin side effect of epidural anesthesia

can spread out the frequency of contractions, so dont want to give too early in second phase

three tier system for EFM interpretation

category I: normal baseline moderate variability, +/- decels or accelerations Category II: intermediate category III: abnormal fetal monitoring standards nursing management of nonreassuring patterns

prolonged decelerations causes

caused when mechanisms associated with late of variable decels last for an extend period of time common causes: maternal hypotension, uterine tachysystole, prolonged cord compression manage with same interventions as late decelerations

3 presentations

cephalic/vertex breech shoulder

chlamydia agent

chlamydia trachomatis

Anterior Fontanel

coronal suture, frontal suture and sagittal suture. Looks/feels like a diamond

changes to the ovaries

corpus luteum continues to function maximally during first 4 weeks after conception

discomfort/pain (Factors that affect lactogenesis )

cramping and nipple soreness

three general categories of non--pharmacologic strategies

cutaneous stimulation (heat/cold, effleurage) sensory stimulation (aromateherapy, music) cognitive strategies (hypnosis)

C

cytomegalovirus

Retinopathy of prematurity (ROP)

damage and scaring of retina - visual impairment 1. Most commonly associated with administration of supplemental oxygen 2. Complex multicausal disorder that affects developing retinal vessels of prterm infants 3. Scar tissue formation and consequent visual impairment can be mild or severe

neuroprotection improved outcomes for infants born premature

decreased incidence of IVH, Cerebral palsy and substantial gross motor dysfunction

dehydration

decreased urine output, excessive sleepiness, irritability, sunken fontanel, dry mouth

fibrinolytic activity pregnancy

decreases in pregnancy

club foot

deformity of the foot and ankle that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus

4th stage of labor nursing priorities

delivery of placenta, 2 hours following delivery of the placenta) i. Prevent/treat excessive bleeding ii. Monitor VS iii. Provide comfort/warmth iv. Promote parent-infant attachment

fourth stage of labor

delivery of placenta-2 hours postpartum early postpartum period

1st letter fetal position

denotes the location of the presenting part to the mother's pelvis R= right (maternal right) L= Left

FHR tachycardia interventions

dependent on cause reduce maternal fever with antipyretics as ordered and cooling measured Oxygen at 10 L/min by nonrebreather face mask may be of some value Carry out health care providers orders based on alleviating cause

first stage laboratory and diagnostic tests

depends on the extent of prentatal care (1) Analysis of urine specimen (2) Blood tests (a) Complete blood count (CBC)—done on arrival have to know hgb and platelet count (b) Human immunodeficiency Virus (HIV) status is undocumented (c) Type and screen (3) Assessment of amniotic membranes and fluid (4) Other tests (a) If GBS status unknow, rapid test can be performed (b) > 36 weeks go ahead and treat (5) Sings of potential problems? FHR, is she bleeding?

abnormal respiratory rate

depressed respirations: spinal anesthesia or an epidural opioid medication

postpartum DM counseling

diet and exercise weight loss to optimal BMI continue BS screening every 3 years

Hemorrhoid

dilated blood vessel in the rectum a. Size and color b. Pressure/itch vs. pain c. Hard or soft d. Can you push it in? (reducible)

syphilis transmission

direct contact with a chancre transplacental transmission

varicella transmission

direct contact, respiratory

how do we keep the baby warm?

dry, skin to skin with warmed blankets (or warmer)

Toxoplasmosis women at risk

exposure to contaminated soil and consumption of raw or undercooked meats or seafood ( oysters, clams, or mussels) garden in contaminated soil changing cat litter

electronic fetal monitoring

external monitoring ultrasoudn transducer tocotransducer monica AN24

nutrition for breast feeding mom

extra 4000-500 kca;/day cuation re: rapid weight loss (1-2 kgs/month ok) adequate fluid intake

nursing interventions third stage encourage breastfeeding

facilitates bonding, and a natural way to stimulate endogenous oxytocin

rest for breastfeeding mom

family support positioning

Fetal fibronectic fFN

glycoprotein "glue" found in plasma and produced during fetal life 1. normally appears in cervical and vaginal secretions early in pregnancy and then again in late pregnancy

post term

greater or equal to 42 weeks

Grimace/reflex irritability apgar 1

grimace, weak cry

TORCHES

group of viral, protozoa infections that can cross the placenta via villa and infect the placenta

types of boney pelvis (Passageway)

gynecoid android anthropoid platypelloid

storing breastmilk

hand hygiene hard plastic or glass containers preferred proper cleaning of equipment and bottles room temp up to 8 hours fridge for 8 days freezer 6-12 months (side by side 6, deep 12)

massage

head, hand, back and foot massage can be effective in reducing tension and enhancing the comfort (combing with aromatherapy oil or lotion enhances relaxation both during and between contractions)

heavy lochia

heavy amount saturated peripaid within 1 hour

H

hemolysis

prolapsed umbilical cord risk factors

i) Breech or transverse presentation ii) Non-engaged presenting part iii) Polyhydramnios (vacuum affect)

C-section benefits

i) Can be lifesaving ii) Lower probability of bladder trauma, perineal trauma? iii) Elective: convenience

viability severe or moderate impairment

i. Cerebral palsy, blindness, profound hearing loss or developmental quotient 2 standard deviations or more below the mean

IgA

i. Found in breast milk ii. Colostrum contains large amounts of IgA and can provide passive immunity to the neonate short term passive immunity

Interventions to increase breastfeeding in obese mothers

ii. iii. 4 studies reviewed iv. Only 1 had significant effect to increase breastfeeding duration and exclusivity in obese mothers (Carlsen, 2013) v. Any BF median: Support 184 d (92-185 d) vs control 108 d (16-185d) p=0.002 vi. EBF 3 months : AOR 2.45 (1.36-4.41) vii. Scheduled support (9 telephone consultations) from an IBCLC (International Board-Certified Lactation Consultant)

uterus involution position and feeling

ii. Firm, slightly (or quite) tender; Midline Position 1. Like a hard basketball measure fingerbreadths below umbilicus

involution assessment

iii. Measure fingerbreadths below umbilicus—goes down by one fingerbreadth per day

lactogenesis

iinitiation of process of breast milk production

jaundice

increase feeding to increase bilirubin excretion evaluate weight loss, I&O, bili levels

cervical exam-status of membrane

intact, bulging or ruptured Bulging—like a balloon that is about to pop Ruptured—squishy, and liquid

origin of pain 2nd stage

intense, sharp, burning pain from pressure on bladder, rectum, stretching of perineal tissues, lacerations--aka the burn as baby is starting to crown, you hear woman saying its burning 3+/4+ station

fundal Massage

intervention to alleviate uterine atony and restore muscle tone 1. B right at the umbilicus 2. Fundal message -find the fundus (top of the uterus) and rub in a circular motion 3. Measure from the umbilicus to the top of the uterus/fundus

IUGR

intrauterine growth restricted a. Usually due to placenta restriction (not getting enough blood flow)

Monica AN24

introduced in 2011 5 electrodes on woman; information transmitted via Bluetooth

restitution

it is the visible passive movement of the head to undo the twist in the neck, that took place during internal rotation of the head

Perineum—Perineal Discomfort interventions

keep area clean ice packs/ibuprofen sitz baths topical applications 1. Witchhazel Pads 2. Dibucaine Ointment 3. Peri-spray—fill it up with water and then clean the area

perineal lacerations second degree

laceration tat extends through the fascia and muscles of the perinal body, but not through the anal sphincter

effleurage

light stroking, usually f abdomen, in rhythm with breathing during contractions

physiologic changes that occurring in the days and weeks before labor

lightening return of urinary frequency backache stronger braxton hicks contractions wight loss of 0.5 to 1.5 kg (1-3.5 lbs) bloody show/vaginal discharge surge of energy cervical ripening possible rupture of membranes

Surfactant

lipoprotein reducing surface tension, lowers pressure required to open alveoli prevents alveoli collapse at end of expiration

Listeriosis agent

listeria monocytogenes

Birth in a delivery room or birthing room

lithotomy position-classic position crowing ritgen maneuver nuchal cord assessment don;t use fundal pressure immediate assessment and care of newborn

Ultrasound transducer

monitors FHR Should be placed at the fetal back

anxiety (other factors influence pain)

more catecholamine release due to muscle tension=magnified pain perception (This is why it's good, to explain procedures + give them time to express their anxieties b/c wouldn't want this to make their pain out of control) i. Explain the procedures and allow them time to express their anxiety so that it will not affect the intensity of their pain

tachysystole

more than 5 contractions in 10 minutes don't want this because the blood flow in the uterus is altered when having a contraction and could lead to decreased fetal oxygenation if there are too many at the same time > 5 cxt in 10 minutes avg over 30 mins (fetal distress because of the frequency of contractions)

Cardiac congenital anomalies

most common weeks 3-8 of fetal development

uterine changes quickening

movement of the baby

Fetal monitoring for women with pre-existing diabetes/require medication

o 3rd trimester (after 32 weeks) Fetal kick counts • Mixed evidence if they matter - routine care for high-risk women • Movement around 20 weeks • Kicks (32 weeks is most noticeable) • 10 kicks in 2 hours if they are awake NST BPP

proteins requirements

o A lot of women don't get enough protein o Western diet typically is high in fat and sugar. And have to educate patients on this early on +30 g/day

two types of prolapsed umbilical cord

occult or complete

other tocolytics

ocytocin antagonists

iron requirments

often low or anemic at conception due to menstrual loss iron needed for RBC production, growing fetus and placenta supplementation, cook with a cast iron skillet women that are vegan/vegetarian, underweight or malnoursihed will need extra iron supplementation o The normal pregnant women requires 500 mg of additional iron: 300 mg -transported to the fetus via transferrin 200 mg -compensate for normal iron use/ loss o To supply maternal needs 60 mg elemental iron (300 mg ferrous sulfate) qd

TORCHES syndrome symptoms in mother

often mild infection with few to no symptoms

listeriosis assessment and treatment ****

only needs test and treatment if symptomatic ampicillin and PCN

systemic analgesia (opioids) two classes

opioid agonists opioid agonists/antagonists

anthropoid pelvis (passageway)

oval shaped common in AF women=OP position more room front to back (anterior/posterior) so babies can rotate into the OP position

creatinine HELLP

over 1.1

fetal monitoring/fetal response oxygenation

oxygen supply must be maintained to prevent fetal compromise. Monitoring to make sure there is no compromise due to reduced oxygen supply

AST

preeclampsia over 20 hellp >70

alt

preeclampsia over 21 hellp well over 21

LDH

preeclampsia over 90 hellp >600

eclampsia

preeclampsia tonic-clonic seizures • Seizure activity or coma in a woman with preeclampsia • Incidence 1/2000 • Onset: Mostly 3rd trimester, 80% intrapartum and within 48 hours of delivery, Tricky presentation: • Hypertension • severe 20-40% of cases • absent 14% of cases • Proteinuria • absent 14% of time • Usually presents with headache

Motevideo units (MVUs)

quantitative measurement of uterine contraction over 10-minute period (need internal monitoring to do this) i. subtract the resting tone from the peak (baseline on strip is about 25 + peak is 70) 1. so 70-25 = 45 (this would be the first contraction) ii. add together (do with all the contractions and add them together) iii. adequate contractions=200 1. range is typically 180—240 2. tell you if uterine contractions are strong enough to cause cervical change

Hypospadias

range of penile anomalies associated with an abnormally located urinary meatus.

R Reeda==>how to assess Episiotomy/Laceration/Incision (and hemorrhoids)

redness

Grimace/reflex irritability apgar 2

responds to stimulation

epispadias

results from failure of urethral canalization

gastric reflux

results from lower esophageal sphincter relaxation

lactation/MER

sensation is like "pins and needles" a. Feels like lumpy oatmeal—if you do a breast exam on a lactating woman b. Multiple milk ducts that allow for spray and propulsion of milk

previous experience (other factors influence pain)

sensory labor pain during 1st phase may be greater for nulliparous women compared to multiparous women. Why?? body knows what the body to do if you're multiparous for nulliparous women this is the first time their body is going through this and stretching (ligaments) perceive the pain as worse labor is a little longer—more fatigue and pain is perceived as worse

Trichomoniasis transmission

sexually transmitted

abnormal lochia odor

should smell like normal menstrual flow, and offensive odor usually indicates infection

breast sx

supplementation may be required

multiples

support more fluid and calories

Transition phase (first stage of labor) nursing priorities

support, comfort, encouragement positions safety simple communication (short and sweet)

Active phase (first stage of labor) nursing priorities

support/encouragement hydration comfort--IV pain medications vs epidural-start dealing with more discomfort issues position changes

TORCHES treatment

supportive measures for immune system refer for fetal surveillance if mom is + a lot of the syndromes have consequences for the baby

fussy

swaddle, hold, calm, suck skin to skin

PE nose

symmetrical nares flaring

expression of pain

sympathetic nervous system is stimulated --> increased HR, BP, RR, sweating gastric acidity increases, N/V common pallor and diaphoresis emotional/affective expressions (anxiety, crying, clenching)

Bacterial Vaginosis assessment

symptoms microscopic and pH Fishy odor Thin, white or gray milky discharge May have pruritis

nursing considerations preparing for the birth second stage supplies, instruments and equipment

table set up, warmer/suction/oxygen ready, birthing kit outside of hospital

pregnancy and breastfeeding

tandem nursing

gynecoid pelvis (passageway)

typical female 50% round pelvis, ideal pelvis for birth

Intrauterine pressure catheter (IUPC)

typically placed by provider Fluid filled catheter inserted into uterine cavity As catheter is compressed during a contraction, pressure is placed on the transducer Pressure is converted into a pressure reading (mmHg) Precisely measures the frequency, duration, intensity, and resting tone of UC's

bilirubin preeclampsia

unchanged or over 1

fibrinogen HEELP

under 200

creatinine clearance HELLP

under 80

abnormal upper and lower extremities findings

unilateral leg pain/edema should be thinking of DVT/VTE

appetite

usually increases, sometimes with unusual cravings (pica)

ballottement

when doing a pelvic exam can feel the baby lift a little bit

breech presentation

will feel the sacrum (butt) at the internal os of the cervix 30% of births

shoulder presentation

will feel the scapula (shoulder) at the internal os of the cervis 1% of births

oxytocin and prolactin affect on emotional state

women report feeling "relaxed" or "drowsy" during let-down

Rubella Women at risk

women who are not immune to rubella never vaccinated

fentanyl

works well, less neonatal side effects and less maternal sedation and nausea. But has a rapid onset and short half-life. Works well but doesn't last long. Can be given hourly up to 3 doses opioid agonist

important thing to remember about screening

you MUST have a plan if a woman screens positively

mobility limitations side effects of epidural anesthesia

you need to help her with the position changes

HGB pregnancy

~12

WBC pregnancy

~12,000

HCT pregnancy

~33-39%

varicella epidemiology

~90% of women childbearing age are immune; therefore, the risk of infection in pregnancy is low 0.7 to 3 per 1000 pregnancies

ectopic pregnancy beta hcg levels

β-hCG levels > 1500 to 2000 mIU/ml + Transvaginal US (should see an intrauterine pregnancy): if not suspect ectopic

Erythema toxicum

—can look really bad, bottom picture of the back, benign condition of the newborn, looks like a bad rash or like the baby has had an allergic reaction

subclinical hypothyroidism

• 0.25-8% women • elevated TSH but normal FT4 • Often unknown by mother, yet can have significant effects on fetus and mother

overt hypothyroidism

• 0.3-0.5% of women • elevated serum TSH and low fT4 • Often pre-existent to pregnancy • Most common form: Hashimoto's thyroiditis

overt hyperthyroidism

• 0.5-2% women • elevated FT4 and low TSH • Can be transient with HCG • Most common form: Graves' disease

subclinical hyperthyroidism

• 3% women • asymptomatic low TSH and normal FT4 • Subclinical hyperthyroidism not associated with poor outcomes

thermogenesis

• Effort to generate heat in response to col • Crying, restlessness • ↑ metabolism • ↑O2 and glucose consumption • Flexed posture • Constriction of peripheral vessels Non shivering thermogenesis—brown fat metabolism (NOT GOOD)

hyperthermia

• Greater than 99.5° F • Causes o Inappropriate use of external heat sources: flushed, warm extremities, extended posture o Sepsis: pale/mottled, cool extremities Sweat glands not functional in newborns

hypothermia

• Mottled, acrocyanotic • Tachypnea • Tachycardia • Hypoglycemia • Poor muscle tone • Poor feeding ability • Lethargic ** can be a signs of sepsis in at-risk infants

preeclampsia with superimposed chronic hypertension

• hypertensive women who develop new onset proteinuria • HTN + proteinuria even if prior to 20 weeks • sudden uncontrolled hypertension

components of the passageway/birth canal

rigid bony pelvis, soft tissues of the cervis, pelvic floor, the vainal, and the introitus

lightening (physiologic changes prior to labor)

(1) uterus sinks down and forward (2) occurs about 2 wks before term.

effacement (primary power)

shortening and thinning of the cervix—0 to 100% (a) Very subjective (b) 50% thinned out half of the cervix is gone—half of the toilet paper is gone from the roll (c) 100% feel a rim but no thickness to the cervix (d) Think of it as a toilet paper roll that is being used up during labor The gradual thinning, shortening ad drawing up of the cervix measured in percentages from 0 to 100%

fetal lie (passenger)

spine of the baby vs spine of the mother longitudinal/vertical horizontal oblique

fetal engagement (fetal position/passenger)

term used to indicate that the largest transverse diameter of the presenting part (usually the bi parietal diameter) has passed through the maternal pelvic brim or inlet into the true pelvis and usually corresponds to station 0

biparietal diameter

the largest side to side point of the fetal head. The biparietal diameter of the head has to get through the most narrow portion of the pelvis (ischial) the less flexed the head is the larger the biparietal diameter

fetal position (passenger)

the relationship of a reference point on the presenting part to the four quadrants of the maternal pelvis position is denoted by a three--part abbreviation

2nd letter fetal position

the specific presenting part of the fetus (i) O= occiput (head)**what we are looking for (ii) S= sacrum (breech) (iii) M=mentum (chin) (iv) Sc (scapula)

spontaneous rupture of membranes (SROM)

time--must document characteristics: color = clear, meconium (greenish), blood-tinged amount slow trickle, gush, flood odor--infected or normal distinct smell

current meds/medication reconciliation Admission to L& D

antibiotics, vitamins, anything they have taken in the last 24 hours

what are symptoms a woman may describe that indicate that lightening is happening?

bladder pressure able to breath better--lungs no longer compressed

OB labs admission to L&D

blood type HIV status GBS status Infection based labs (Typically done before going into labor (3) GBS—group B strep have to treat them with abx q 4 hours during labor

android pelvis (passageway)

heart shaped typical male

Psychological Adaptation to Labor

maternal and fetal adaptations social context of labor

psychosocial assessment (history of abuse, sexual abuse) Admission to L& D

(1) labor can trigger memories of sexual abuse, especially during intrusive procedures (2) help her to link this current experience with the birth of the baby and not the past abuse. Help her to link this current experience with the birth of the baby and not the past abuse (3) avoid words and phrases that can cause stress ("open your legs")

Soft tissues (passageway)

(1) Lower uterine segment= cervix sits within this; lower part of uterus (2) Cervix= effaces (thins) and dilates sufficiently to allow the first fetal portion to descend into the vagina (3) Pelvic Floor Muscles=down in vagina, muscular layer that separates the pelvic cavity above from the perineal space below and helps the fetus rotate anteriorly as it passes through the birth canal (4) Vagina= dilate to accommodate the fetus and permit passage to the external world (5) Introitus—opening of the vagina, when baby is crowning, swelling/edema due to frequent pelvic exams and can affect the timing of delivery

goal of maternal position changes

relieve fatigue, increase comfort, improve circulation a) During a natural birth the body tells them what position to move them into b) Epidural—as a nurse will have to help move the patient into this position c) Side lying position d) Peanut ball—between legs and helps to open up the pelvis e) Pillows, support legs f) Key thing=make sure mother changes position, whether mom is going natural or has epidural

expulsion of the infant

after delivery of the head, the anterior should will descend under the pubic bone

artificial rupture of ROM Amniotomy

along hook to break the membrane (hook the membrane to allow the water to break) this process is painless because amniotic sac does not have any nerve endings Once membrane is ruptured you have to check temperature frequently to check for infection b) **Frequently do temperature assessments after ROM (2hrs) (1) Because of concern of infection

artificial rupture of membrane to augment labor

break membrane to speed up labor, or induce labor b) **Frequently do temperature assessments after ROM (2hrs) (1) Because of concern of infection

voluntary powers (secondary Powers)

expulsive urge to push once the presenting part reaches the pelvic floor a) stretch receptors cause the release of oxytocin b) Endogenous oxytocin c) Maternal urge to bear down - Ferguson reflex (1) When the baby reaches the pelvic floor it Makes them want to push

Head (Passenger) Sutures

fibrous connective tissue between the bones, allow for flexibility (1) Lambdoid suture (2) Sagittal suture (3) Coronal suture (4) Frontal suture

stages of labor

first stage second stage third stage fourth stage

Head (Passenger)-Bones

frontal bone parietal bone occipital bone—landmark that you are looking for, the bone that is focused on temporal bone

flexion

head flexes onto the chest due to resistance (pressure) from the pelvic floor

engagement

head reaches the widest diameter of the ischial spine--in clinical practice this typically translates into 0 station come down in transverse trajectory engagement =head at 0 station

external rotation

head rotates to allow for the shoulder to delivery, allows for shoulders to line up in the AP diameter

Latent Phase (first stage of labor) nursing priorities

hygiene, nutrient intake, IV intake, voiding (q 2hr), ambulation, positioning and supportive care admission assessment- general system assessment, VS, leopolds, FHR pattern, contractions, cervical exam , admission labs comfort encourage rest hydration high variability in length

False pelvis (Passageway)

part above the brim no influence on birth

Blood show (physiologic changes prior to labor)

(1) vaginal mucous becomes more profuse (2) begins to come out as labor progresses (blood-tinged) (a) Cervix has a lot of vasculature and when it begins to open a lot of mucus and blood are released

true labor

progressive cervical effacement and dilation (true measure of labor) discomfort felt in front and back contractions occur at regular intervals and become longer, stronger and closer together waling increases intensity of contractions bloody show rupture of membranes (ROM)

bony pelvic joints (passageway)

pubic symphysis (symphysis pubis) right and left sacroiliac joints and sacrococcygeal joints

bony pelvis (passageway)

is formed by the fusion of the ilium, the ischium, the pubis and the sacral bones the two innominate (hip) bones (consisting of ilium, ischium, and pubis), the sacrum, and the coccyx make up the four bones of the pelvis Cartilage and ligaments form the symphysis pubis, sacrococcygeal joint, and two sacroiliac joints that separate the pelvic bones. The pelvis is divided into two parts: the false pelvis and the true pelvis The false pelvis is the upper portion above the pelvic brim or inlet. The true pelvis is the lower, curved, bony canal, which includes the inlet, the cavity, and the outlet through which the fetus passes during vaginal birth. The upper portion of the outlet is at the level of the ischial spines, and the lower portion is at the level of the ischial tuberosities and the pubic arch.

3rd letter fetal position

location of the presenting part to anterior, posterior, or transverse portion of the maternal pelvis (i) A= Anterior (Front) (ii) P=Posterior (Back) (iii) T=Transverse

Head (passenger) Fontanels

meeting of various sutures, intersection of suture lines coming together. allows for mobility and change shape which is called molding anterior fontanel posterior fontanel

first stage of labor nursing diagnosis

pain, fear, anxiety, ineffective coping, fatigue

true pelvis (passageway)

part involved in birth inlet/brim= bowl midpelvis/pelvic cavity =when the baby is in the vavity outlet = where the baby is coming out

presenting part

part of the fetus that lies the closest to the internal os of the cervix can either be a head, butt, or shoulder

cardinal movements of labor (8)

position changes the baby must make in order to navigate out of the pelvis engagement, decent, flexion, internal rotation, extension, restitution & external rotation, and expulsion

Position

position of the mother position affects the woman's anatomic and physiologic adaptations to lab frequent changes in position relieve fatigue, increase comfort and improve circulation

descent

presenting part descend => contraction, bearing down efforts a) Engagement and descent typically happen at the same time b) Due to maternal pushing effort c) Babies typically come down in transverse position

parent education bath

1. Delay helps thermoregulation and facilitates microbiome establishment 2. 2-3 times a week with mild, unscented soap 3. No lotion or powder!

maternal reasons for supplementation

1. Delayed lactogenesis 2. Intolerable pain—can't tolerate nursing 3. Previous breast surgery

GI system

1. Diet - 1800-2200 cal (nonbreastfeeding) + 500 cal (breastfeeding) 2. Sluggish intestines 3. Spontaneous bowel movement may not occur for 2 to 3 days 4. Elimination returns to normal within one week 5. May have anxiety about BM

Example: Asian cultures and yin/yang balance and harmony

1. Pregnancy is a hot condition 2. Birth depletes the mother of heat through loss of blood and inner energy 3. She is in a cold state post delivery—40 days until her uterus is healed 4. Must consume "hot" foods and beverages v. Be aware of your own beliefs/biases so that they won't impact the care that you provide

inadequate respiration causes

1. RDS, Transient Tachypnea of the Newborn (TTNB), meconium aspiration vii. How to promote adequate respiration 1. Keep warm 2. Gently stimulate 3. Suction or positive pressure ventilation 4. Skin to skin

contraindications for breastfeeding

1. Rare special nutritional needs (PKU, galactosemia) 2. HIV + mom, or mom high risk for HIV (IV drugs) a. In a third world country the risks of contamination from water outweighs the risk associated with HIV transmission 3. HSV lesion on breast (suspected or diagnosed by culture), baby < 6 months

psychosocial factors (Factors Impacting later breastfeeding/exclusive BF)

1. Reduced confidence to reach BF goals among obese women 2. Fewer close friends/relatives who breastfed; lower social influence 3. Lower maternal self-efficacy; body image? 4. Obesity not associated with BF in African American women? Rate too low?

Respiratory Adaptation-Before labor

1. Reduction in fetal lung fluid production 2. Catecholamine surge - moves fluid from alveoli into vascular and lymphatic system 3. Surfactant - production begins in 2nd trimester

late preterm infants

1. Related to elective induction rates 2. Largest portion of the preterm population 3. "Just a little small" 4. Respiratory distress syndrome 5. Temperature instability 6. Hypoglycemia 7. Apnea 8. Poor feeding patterns, poor weight gain 9. Developmental delays

jaundice assessment

1. Visual assessment 1. Usually starts in the trunk and then moves higher and lower 2. Test by blanching on the chest 2. Bilimeter 3. Serum 1. Most accurate 2. Changes by hour of life 3. So what is problematic early on is not problematic later on 4. Serum bilirubin is determined by hours of life ** 5. Heelstick for serum

transition care measurements

1. Weight (2500-4000 g) 2. Length (45-55 cm) 3. Head circumference (32—36.8 cm) 4. Chest circumference (30—33 cm)

AGA

1. appropriate for gestational age a. Goal we want to achieve with all babies

Hyperbilirubinemia causes

1. ABO incompatibilities 2. Maternal infections 3. Maternal diabetes 4. Maternal ingestion of sulfonamides, diazepam or salicylates near term

physiologic (non-pathologic) jaundice

1. Appears after 24 hrs & resolves w/o treatment 2. Fairly common (60% term, 80% preterm)

pahtologic jaundice

1. Appears w/in 24 hrs 2. Rise in bilirubin > 6mg/dl in 24 hrs 3. Serum bilirubin > 15 mg/dl 4. Untreated, can lead to acute bilirubin encephalopathy and kernicterus (rare)

mammy hypoplasia/insufficient glandular tissue

1. Dairy cow/mice obesity early in life negatively impact breast glandular development 2. Obese women more likely to report insufficient milk 2.

beta-hcg in SAB

(1) Blood-pregnancy test (B-hcg) (i) Doubles every 48 hours so should be going up with a viable pregnancy (2) If SAB has happened, they watch B-hcg to see if it has dropped back to zero indicating that the pregnancy has been resolved (a) If hcg is not going down, then there is some retained fetal or placenta material

forceps/vacuum delivery fetal complications

(1) Bruising (cephalhematoma), caput, abrasions (2) Facial nerve damage (3) Subdural hematoma (4) Bradycardia

diet preeclampsia

(1) Eat a nutritious, balanced diet (60 to 70 g protein, 1200 mg calcium, 600 mcg folic acid, 11 to 12 mg zinc, and 1.5 g sodium). (2) Consult with registered dietitian on the diet best suited for you. (3) Salt foods to taste. Limiting excessively salty foods (luncheon meats, pretzels, chips, pickles, and sauerkraut) will likely be necessary to meet the recommended sodium intake of 1.5 g/day. (4) Eat foods with roughage (whole grains, raw fruits, and vegetables). (5) Drink six to eight 8-ounce glasses of water per day. (6) Avoid alcohol and tobacco and limit caffeine intake.

Management of postdate pregnancy risks big baby

(1) Long labor/ CPD (2) Shoulder dystocia (3) Trauma to birth canal or baby (4) PPH

DIC s&S

(1) Spontaneous bleeding and oozing from open sites (2) Oozing—excessive bleeding from venipuncture site, intravenous access site or site of insertion of urinary catheter (3) Petechiae ( on the arm where blood pressure cuff was placed) (4) Bruising (5) Hematuria (6) GI bleeding (7) Tachycardia

alterations in vital signs and consciousness (signs of potential problems fourth stage )

(1) Temperature—no signs of infection (2) Breast—no excessive skin breakdown around the nipples (prevent breast infection)

how to do a cervical exam?

(1) Use sterile glove and antiseptic solution or soluble gel for lubrication (2) Position the woman to prevent supine hypotension. Drape to ensure privacy (3) Cleanse the perineum and vulva, if needed (4) After obtaining the woman's permission to touch her, gently insert the index and middle fingers into the woman's vagina (5) Determine (a) Cervical dilation, effacement, and position (e.g., posterior, mid, anterior) (b) Presenting part, position, and station; molding of the head with development of caput succedaneum (may affect accuracy of determination of station) (c) Status of membranes (intact, bulging or ruptured) (d) Characteristics of amniotic fluid (color, clarity, and odor), if membranes are ruptured (6) Explain the findings of the examination to the woman (7) Document your findings and report them to the nurse—midwife or physician b) Dilation, effacement, station, position c) Status of membrane (intact, bulging or ruptured)

excessive blood loss (signs of potential problems fourth stage )

(1) Vaginal 500-->Greater than 500 sign of hemorrhage (2) C/S 500-1000

forceps/vacuum delivery maternal complications

(1) Vaginal/cervical lacerations (2) Bladder or urethral damage (3) Pelvic hematoma

threatened SAB in depth management

(1) Want to check progesterone levels (2) Low progesterone levels are thought to be related to miscarriage as estrogen causes the uterus to contract (3) Bed rest is often ordered but has not proven to be effective in preventing progression to actual miscarriage. (4) Repetitive transvaginal ultrasounds and assessment of human chorionic gonadotropin (hCG) and progesterone levels may be done to determine if the fetus is still alive and in the uterus. (5) Further treatment depends on whether progression to actual miscarriage occurs. (6) I=once the cervix begins to dilate, the pregnancy cannot continue and miscarriage becomes inevitable

etiology of preeclampsia

(1) disruption in placental perfusion and endothelial dysfunction (2) Starts at time of implantation (3) Inflammation, immunity, genetics, luck (a) Changes in biology of the placenta (b) improper cardiovascular adaptations to the pregnant state (c) Risk factor—sperm immunologic—sperm exposure causes alloimmunization in the uterus at the site of the plantation (i) The man is the risk factor inadequate vascualr remodeling => decreased palcental perfusion & hypoxia => endothelia cell dysfunction => vasospasm, increased peripheral resistance, increased endotehrlial cell permeability => decreased tissue perfusion

Postterm infants

(42 0/7 and beyond) i. Associated with increased fetal loss ii. Not associated with macrosomia iii. Skin 1. Peeling of skin 2. Absence of vernix 3. Absence of lanugo 4. Abundant scalp hair 5. Long finger nails iv. Wasted physical appearance - depletion of subcutaneous fat 1. Start using the subcutaneous fat when they are post-term v. Meconium-stained skin 1. Less amniotic fluid 2. Cord is more likely to be compressed 3. More sensitive trigger to release meconium 4. Will likely come out with stained skin

Csection risks to mom wound dehisence

(a) Low transverse—on uterus (b) Of classical vertical incision on the uterus (c) More concerned about how the uterus was cut not the skin (d) More of a chance that a classical incision can open during subsequent births (e) Vertical/classical c-section -can never have a vaginal birth

magnesium sulfate toxicity observations

(a) Measure serum magnesium every 4 to 6 hours if serum creatinine is >= 1mg/dL. (b) If patellar reflexes are depressed and respiration is normal, withhold further doses of magnesium sulfate until the reflexes return. Then request magnesium level. (c) If there is concern about respiratory depression, stop magnesium, give oxygen by mask and give: (i) Calcium gluconate (10mL of 10% solution over 10 minutes)

leopold's maneuvers fourth step palpation of the head for cephalic prominence

(a) prominence felt close to fetal parts=well flexed (b) prominence on same side as back=military attitude (c) Trying to determine how well flexed the baby—cephalic prominence **

Concentrated formula

(cheaper): Mix with water (boiled or sterile) Open can/bottle good for 48 hours (refrigerated)

FHR step 2 variability

(fluctuations in FHR) fluctuations in FHR of 2 cycles per minute or greater quantified in beats per minute measured from peak to trough of a single cycle (amplitude range of the FHR) variability is an Indication of CNS maturity Loss of variability associated with hypoxemia, metabolic academia, neurologic injury

Cow's milk-based formulas (majority)

(majority) Some have a true allergy to proteins in cow's milk

Trichomoniasis signs and symptoms

(may be asymptomatic): Thick, green, frothy, and malodorous discharge Irritation, pruritis, inflammation Dysuria and dyspareunia Strawberry spots or petechiae on vaginal exam

frequency (contractions)

(minutes)—How many minutes apart are they

hyperthyroidism maternal outcomes

(overt hyperthyroidism) Heart Failure Abruption PET and gHTN PTD Eclampsia Thyroid storm

hypothyroidism maternal outcomes

(overt hypothyroidism) Decreased fertility Increased SAB PET and gestational HTN Anemia Placental Abnormalities (abruption) PPH Non-reassuring FHR PTD (with LBW) Cesarean Perinatal morbidity/mortality GDM PROM

TDAP

(tetanus—diphtheria—acellular pertussis) i. Recommended for postpartum women who have not previously received the vaccine ii. It is given before discharge from the hospital or as early as possible in the postpartum period to protect women from pertussis and to decreases the risk of infant exposure to pertussis iii. Women should be advised that other adults and children who will be around the newborn should be vaccinated with Tdap if they have not previously received the vaccine iv. Women who receive the vaccine can continue to breastfeed

varicella maternal consequences

*Moms: up to 30% get varicella pneumonia (40% death rate)

Rubella maternal consequences

*No MMR during pregnancy (because it is a live vaccine) *If not pregnant, wait at least 4 weeks After receiving MMR to get pregnant

NSAIDs (indomethacin) only use if gestational age is less than 32 weeks maternal

1. (common): a. Nausea and vomiting b. Heartburn 2. Less common, but more serious: a. GI bleeding b. Prolonged bleeding time c. Thrombocytopenia d. Asthma in aspirin-sensitive clients

routine screening all for GDM at 24-28 weeks 2 steps

1. 1-hr screen: pass if BS < 140 • Fasting before is actually most likely to result in a false positive 2. 3-hr test prn: pass if 3 out of 4 values are normal • Repeat testing in 4 weeks for people who have one abnormal value (esp if last test was prior to 26 weeks).

frequency of breast feeding

1. 10-12x/24 hours—baby is getting to breast enough, 2. Attempt at least q3hours (day) and q4h (night) 3. Cluster feed—at breast for a long period of time and then sleeps for a long period of time 4. On demand after breastfeeding established 1. once baby has started gaining weight and knows how to watch for cues, and latching etc. breast feeding has been established and the duration will decrease

normal newborn cardiovascular assessment

1. 100 - 160 (up to 180 if crying) 2. Apical for full minute 3. Often irregularly, irregular in first several hours 4. Murmur 5. BP: 60-80/40-50 (not usually done in term infants)

Turning point in RDS treatment

1. 1980's Surfactant introduced 2. Surfactant - lipids and proteins 3. Reduces surface tension a. Prevents lungs from collapsing ** 4. Equalizes pressure between large and small spaces 5. Prevents alveoli from collapsing 6. 24-28 weeks fetus produces

23 weeks

1. 50-66% survive a. Rare for < 500gms to survive b. Don't have the alveoli and surface area

post term infants

1. >/= 42 weeks gestation 2. Can be SGA, AGA, LGA a. Wasting of muscle 3. Placenta insufficiency a. Placenta starts to degenerate, not as efficient at providing nutrients the longer the pregnancy last 4. Decreased amniotic fluid 5. Perinatal asphyxia - meconium passage in utero 6. Increased risk fetal loss 7. Skin can be leathery, wrinkled, cracked, peeling 8. Vernix absent 9. Fingernails long 10. Lanugo absent 11. Creases cover sole of feet 12. Breast buds well formed

4 major blood Groups/Types

1. A blood has A antigen a. Plasma antibodies to B type blood 2. B blood has B antigens a. Plasma antibodies to A type blood 3. AB has both A & B antigens a. No plasma antibodies 4. O has no antigens a. Plasma antibodies to types A and B b. No antigens

modified--Paced Breathing

1. Approximately 32 to 40 Breaths per Minute) a. Performed at about twice the normal breathing rate (number of breaths per minute multiplied by 2 b. IN-OUT/IN-OUT/IN-OUT/IN-OUT ... c. For more flexibility and variety, the woman may combine the slow and modified breathing by using the slow breathing for beginnings and ends of contractions and modified breathing for more intense peaks. This technique conserves energy, lessens fatigue, and reduces risk for hyperventilation.

enface position

1. As newborns become functionally able to sustain eye contact with their parents, they spend time in mutual gazing, often in the en face position, in which the parent's and infant's faces are approximately 30 cm (12 inches) apart and on the same plane 2. Nurses, physicians, or nurse midwives can facilitate eye contact immediately after birth by positioning the infant on the mother's abdomen or chest with the mother's and the infant's faces on the same plane. 3. Dimming the lights encourages the infant's eyes to open. 4. To promote eye contact, instillation of prophylactic antibiotic ointment in the infant's eyes can be delayed until the infant and parents have had some time together in the first hour after birth.

care after cesarean birth

1. Assess fundus gently 2. Assess bandage at incisional site-1st 24 hours, then incision, using REEDA, thereafter. 3. Assess bleeding 4. Intake and Output until IV and foley discontinued 5. Assess urinary output (foley out by 12 hours) 6. VS q 4 hours for 1st day, then q 8 hours 7. Postpartum head to toe assessment, include auscultation of lung and bowel sounds 8. Ambulate by 12 hours post-op 9. Pain management - pharmacologic (epidural, IV PCA, oral), non-pharmacologic a.Abdominal binder to help things together 10. Assist with breastfeeding and bonding 11. Assist with ADLs 12. Clear liquids then advance diet as tolerated after 8-12 hours a.Advance diet slowly! Bowles are ASLEEP

The nurse's role in caring for a grieving family

1. Assess the meaning of the pregnancy and the loss for this family and each individual 2. Offer and help family to hold and spend time with their baby 3. Other history of loss(es)? 4. Assess for family, cultural, faith-based systems at play 5. Utilize social support network of woman/family 6. Offer perinatal loss support group information 7. Offer to contact hospital or personal chaplain or other supportive contacts 8. Encourage time, attention to self-care to promote holistic recovery (mother, family members, AND NURSE)

preventing clots

1. Bedrest or post-op: a. Avoid bedrest if possible. b. Use SCDs/anti-embolic hose if immobile, exercises (rotate feet/ankles) c. OOB asap after surgery or when condition allows d. Notify provider if pain, erythema, tenderness develops

Hyperbilirubinemia Pathologic

1. Before 24 hours of age 2. Greater than 14 days of life 3. Associated with bilirubin encephalopathy or kernicterus

term infants

1. Best outcomes 2. Fewest complications 3. Best long term outcomes 4. Complications generally short in duration

changes in circulation after birth

1. Blood enters the right atrium. Most of the blood flows to the left side through the foramen ovale between the left and right atria 2. Blood then passes into the left ventricle and then to the aorta. 3. From the aorta, blood is sent to the head and upper extremities. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava. 4. About one-third of the blood entering the right atrium does not flow through 5. the foramen ovale, but, instead, stays 6. in the right side of the heart, eventually 7. flowing into the pulmonary artery.

delayed cord clamping

1. Blood volume averages 85 ml/kg of body weight 2. Immediately after birth, total blood volume averages 300 ml but can increase by as much as 100 ml, depending on time of cord clamping 1. Actually, the babies blood allows them to get back what theres 3. Once the cord is clamped, the circulatory dynamics immediately change 4. Delay of >2-3 min has benefit of improving hematocrit and iron status and decreasing anemia that lasts 6 months! Especially beneficial for preterm babies (significant reduction in intraventricular hemorrhage risk) 1. Takes a minute or two to have these changes take place. Allow for a smooth transition as it beings to take over all of its own oxygenation needs 5. Also, facilitates easier and smoother transition to extrauterine life, especially if low initial Apgar. Resuscitate while cord still intact!

GBS sepsis evaluation and treatment

1. CBC with diff 2. Blood cultures 3. Blood gas 4. Urine culture 5. Chest x-ray 6. Spinal tap 7. Respiratory support 8. Antibiotics - Ampicillin 9. Aminoglycoside - Gentomycin 10. ECMO - extracorporeal membrane oxygenation - severe cases

Neonatal Abstinence Syndrome, NAS generalized disorder characterized by

1. CNS hyperirritability—unique cry, hard to console, don't sleep well, 2. Gastrointestinal dysfunction 3. Respiratory distress 4. Autonomic dysfunction a. Yawning b. Hiccups c. Sneezing—newborns don't typically sneeze d. Mottled skin e. Fever—most newborns are actually cold when they are sick because they burn through fat and sugar stores

goiter

1. Change in size of maternal gland a. 10-15% increase size thyroid gland in pregnancy b. Goiters more likely in iodine-deficient areas world 2. In U.S. (minimal iodine deficiency), any clinically detectable thyroid growth should be investigated a. More come in parts of the world with iodine deficiencies b. Demand for iodine increases during pregnancy

Respiratory Adaptation-during birth (mechanical)

1. Changes in intrathoracic pressure from contractions and pushing, negative pressure at birth draws air into lungs. Crying distributes air to expanding alveoli. Positive pressure through breathing and crying keep alveoli open.

Bronchopulmonary Dysplasia (BPD)

1. Chronic pulmonary condition requires mechanical ventilation 2. Multifactorial etiology: including pulmonary immaturity, surfact deficiency, lung injuery and stretch, barotrauma, inflammation caused by oxygen exposure, fluid overload, ligation of a PDA, and a familial predisposition 3. Occurs most commonly in preterm infants 4. Clinical signs: tachypnea, retractions, nasal flaring, increased WOB, activity intolerance to handling and feeding and tachycardia 5. Treatment: oxygen therapy, nutrition, fluid restrictions, and meds (diuretis, corticosteroids, and bronchodilators)

breast feeding benefits for family

1. Convenience—always prepped and ready to go 2. Cost-effective 3. Environmentally friendly

How do we know that infant respiration is adequate?

1. Crying, Pink, Adequate rate (40-60) 2. Can be higher if they are really crying

causes of late deceleration

1. Disruption of the oxygen transfer from the environment to the fetus (uteroplacental insufficiency caused by: a. Uterine tachysystole too many contractions, decreased blood flow and oxygenation b. Maternal supine position compression of the vena cava which is the major supply for the placenta c. Maternal hypotension (epidural, spinal anesthesia) d. Intrauterine growth restriction baby that already has issues with placenta Intraamniotic infection

Hepatitis B Vaccine (IM)

1. First of 3 doses usually given at hospital 2. If Mother is Hep B positive, Hep B Vaccine + Hep B Ig must be administered within 12 hrs of birth 1. To protect the baby **

Rhogam Rh immune Globulin, RhoGAM, Gamulin Rh, HyRho-D, Rhophylac nursing considerations

1. Give standard dose to mother at 28 weeks of gestation as prophylaxis or after an incident or exposure risk that occurs after 28 weeks of gestation (e.g. amniocentesis, second—trimester miscarriage or abortion, and after version) 2. Give standard dose within 72 hours after birth if neonate is Rh+ 3. Give microdose for first trimester miscarriage or abortion, ectopic pregnancy , chorionic villus sampling, 4. verify that the woman is Rh negative and has not been sensitized, if postpartum that coombs' test is negative, and that baby is Rh positive. provide explanation to the woman about the procedure, includign the purpose, possible side effects, and effect on future pregnancies. have the woman sign a sonsent form if required by agency. verify correct dosage and confimr lot number and woman'd identiy before gibing injection (verify with another RN or by other procedure per agency policy); document administration per agency policy. observe client for at least 20 minutes after administration for allergic response document lot number and expiration date in teh client record. the medication is made from human plasma (a consideration if woman is a jehovah's witness. the risk of transmitting infectious agents, including viruses cannot be eliminated completely

hyperthyroid treatment postpartum

1. Graves' Disease worsens 3 months postpartum a. Refer to endocrinologist. b. Expect higher doses anti-thyroid drugs c. Close monitoring d. Breastfeeding ok with PTU 2. Consider radioiodine or surgical thyroidectomy prior to next pregnancy. a. Need at least 6 months after radioiodine treatment before next pregnancy.

Psychological adaptations to labor considerations

1. Have to be very sensitive and get rid of bias, goal is to make them as comfortable as possible and remember that everyone handles labor differently 2. History of previous birth experiences Emotions range from Excitement to Fear 3. Current pregnancy and expectations for this birth a) Birthing plan (1) Where birth plan comes in, some birth plans are very detailed. Have to figure out what their expectations are but have to tell them if some of their requests are unreasonable. (2) Don't laugh at their plan but be realistic 4. Coping skills 5. Cultural considerations a) Values, beliefs, relationships, pain, significance of touch (if they want to be touched, may not want to be told to breath) 6. Support system a) Partner/husband, doula, family, care givers 7. Emotions of Labor a) Latent Labor b) Active Labor c) Transition d) Second Stage

ffn conditions

1. Higher false + if bleeding 2. Higher false + (maybe) if swabs, lubricants, or sex within 24 hours

preterm infant complications

1. Higher infant mortality 2. Longer hospital stays 3. Respiratory complications - lack surfactant 4. Feeding difficulties - suck, swallow, breath a. Consuming all intake by sucking they have to breath another way 5. Glucose instability a. Just don't have the stores of glucose that they would if they had been born at term 6. Hyperbilirubinemia 7. Long term developmental delays

Late preterm infants at risk for

1. INFECTION 2. Respiratory distress syndrome 3. Temperature instability 4. Hypoglycemia 5. Apnea 6. Poor feeding patterns, poor weight gain 7. Delayed developmentally (increased risk of cognitive impairment)

Hyperbilirubinemia nursing care

1. Increase PO intake-Increases the rate of excretion of bilirubin 2. Phototherapy-Helps break down the red blood cells, Protect eyes 3. Skin care - frequent stools

hormonal imbalances (Factors Impacting later breastfeeding/exclusive BF)

1. Increase in free androgens, role of polycystic ovarian syndrome (elevated androgens, metabolic anomalies, hypothyroidism) ? 2. Thyroid dysfunction (T4, T3 role in initiation and maintenance of lactation, suboptimal levels, lower milk supply reduced oxytocin release.

Preterm infants

1. Infants born < 37 weeks gestation a. Majority are LPI's 34-36 6/7 weeks 2. Classified by a. Birth weight, SGA, AGA, LGA b. Gestational age 3. Many factors contribute to fetal growth and outcomes a. Heredity b. Genetics c. Placental insufficiency d. Maternal disease processes

respiratory system and prematurity

1. Insufficient number and function of alveoli 2. Surfactant—deficient surfactant levels 3. Small airways—smaller lumen in respiratory system , greater collapsibility or obstruction of respiratory passages 4. Bones of thorax not calcified a. don't have the ability to expand chest and pull air in 5. Weak or absent gag reflex 6. Distance between functional alveoli and capillary bed a. Just big dead space, there is just too much space for air to exchange adequately

how can we promote adequate infant respiration?

1. Keep Warm, Gently Stimulate, Suction and/or Positive Pressure Ventilation (if necessary), Skin to Skin Contact with Mother 2. Gently stimulate=rubbing the foot, head back 3. Keeping them warm is one of the best ways to promote oxygenation and ensuring their aveloi are open*** 4. Bulb suctioning don't do that much ** 5. Push a lot of fluid and mucus out of the nasal passages ** 6. Positive pressure ventilation if necessary—really not a rough thing on the baby can help move fluid out of the lungs and open up the aveoli 7. Being skin to skin with the mother really helps also

Vision

1. Lacks accommodation (develops over 3 months) 2. Can see 2.5 feet away, most clearly at ~ 1 foot 3. Complex patterns 4. Black & White

postpartum Depression

1. Lasts beyond the 1st 2 weeks and/or interferes with functioning 2. DSM-V: major depressive disorder with postpartum onset within 1st 4 weeks of birth 3. Risk factors: previous hx of mood disorder, life stress, poor social support, hormonal changes 4. Screening: Edinburg Postpartum Depression Scale—scores >10 suggested of an increased risk for PPD

jaundice contributing factors

1. Less than 38 weeks 2. Poor breastfeeding (especially if significant weight loss occurs) 3. Hx of significant jaundice in sibling 4. Hemolytic disease 5. Bruising, cephalhematoma, 6. Race 7. ABO or Rh incompatibility causing RBC destruction 8. **Jaundice in first 24 hours usually indicates pathogenic process! 9. Liver *** has to work less listen to recording for this part

intermittent auscultation-fetal monitoring techniques

1. Listening to fetal heart sounds at periodic intervals to assess FHR 2. Easy to use, inexpensive, less invasive than EFM 3. Difficult to perform on women who are obese 4. Does not provide a permanent record

obesity-factors impacting initiation/early breastfeeding

1. Mechanical factors-Additional body tissue, larger areolas, larger breasts, reduced lap, edema* (often cited but limited evidence) 2. Delayed onset of lactogensis II-Longer labor, C-section, edema, leptin inhibit oxytocin effect increase labor dysfunction/milk ejection reflex?, reduced prolactin reduced milk synthesis, imbalance of insulin?

Transient Tychapnea of the Newborn nursing care

1. Monitor respiratory rate 2. No or limited PO feeding 3. Minimal exertion 4. Supplemental oxygen

the precious golden hour

1. More readily responsive to the babies feeding ques, facilitate the baby getting to the breast

Hyperbilirubinemia Physiologic

1. Most common 2. After 24 hours of age 3. More common in LPI and preterm infants 4. Rapid breakdown of RBC 5. Immature liver 6. Dehydration

hypothyroid treatment postpartum

1. Most women may discontinue levothyroxine dose or decrease to pre-pregnancy levels in the 4 weeks following delivery 2. f/u with TSH level @ 4-6wk PP visit 3. Planning for future pregnancies 4. Increase dose right away—based on TSH and T4 level **** listen to recording for this to make sure its with the right thyroidism ****

environmental (Factors that affect lactogenesis )

1. Mother-baby separation 1. In the hospital 2. Mother returning back to work of school early 3. Early separation in general 2. Timing - ideally within first hour after birth 3. Early and long term milk supply affected by this

abnormal newborn cardiovascular assessment

1. Murmur with poor perfusion 2. Tachycardia > 160 beats/minute at rest 1. Anemia—abrupt cord clamping, or mother hemorrhaging 2. Hypovolemia 3. Hyperthermia 4. Sepsis 3. Bradycardia < 100 beats/minute 1. Apnea 2. Temperature extremes 3. Hypoxia

drugs used in the 2nd stage

1. Nerve block analgesia and anesthesia a.Local infiltration anesthesia b.Pudendal block c.Spinal (block) analgesia d. CSE analgesia 2. Nitrous Oxide

Calcium channel blockers (nifedipine)-tocolytic

1. Nifedipine (Procardia): delays birth at least 48 hours, better short-term outcomes 2. 10-20 mg po now, then q 4-8 hours prn x 48 hours 3. For maintenance, dose is XL 30-60 mg po q8-12 hrs 4. Has fewer side effects than other tocolytics 5. May delay birth up to 7 days 6. Improved short-term outcomes: RDS, gut infections, and NICU admission 7. Use "regular" Procardia to make contractions rare, then use extended release Procardia XL for maintenance. 8. Generally, has fewer side effects than beta-mimetics or mag sulfate, but watch for hypotension a. Maternal side effects include hypotension, headache, flushing, dizziness, nausea 9. Has been shown to improve fetal outcomes (Other medications listed don't improve fetal outcomes unless the contractions are stopped long enough (24 hours for steroids to get on board))

maternal (Factors that affect lactogenesis )

1. Nipple characteristics 2. Discomfort/Pain 3. Stress/Fear 4. Alcohol—inhibits lactogenesis 5. Prepregnant BMI and Gestational Weight Gain

Pregnancy outcomes with infection

1. None 2. Miscarriage 3. Preterm labor 4. Preeclampsia 5. Fetal effects-Anomalies, IUGR, CNS 6. Cytokines (inflammatory markers) a. Risk factor for fetal outcomes, neurodevelopmental issues later in life like autism

Normal Newborn respirations

1. Nose breathers 2. Respiratory rate 30-60/minute 3. Breath sounds - heard throughout the chest 4. Abdominal breathing - simultaneous with chest expansion 5. Acrocyanosis—usually only 24 hours, blue hands and feet, the rest of the baby is pink

late onset GBS

1. Occurs between 1 week and 3 months of age 2. Results from vertical transmission, health care-acquired transmission, or community exposure 3. Mortality less than for early on-set GBS sepsis 4. Approximately 30% develop meningitis

parent education sleep position

1. On Back! 2. Firm surface without anything else (not sofa, no loose linens) 3. Room (NOT co-bed)sleeping 4. Car seat

drugs used in the 1st stage

1. Opioid agonist analgesics 2. Opioid agonist—antagonist analgesics 3. Epidural (block) analgesia 4. Combined spinal—epidural (CSE) analgesia 5. Nitrous oxide

jaundice phototherapy

1. Overhead lights 2. Biliblanket 3. Bilibed protect gentiles and eyes

Neonatal Abstinence Syndrome, NAS exposure

1. Passively to opiates in utero to heroin, methadone, or other narcotics or to treatment of opiate/opioid addiction with methadone or buprenorphine 2. Iatrogenic exposure by administration of opioids for neonatal analgesia or sedation

Neonatal Abstinence Syndrome, NAS

1. Polysubstance abuse 2. Poor nutrition 3. Difficult socioeconomic living conditions 4. Poor prenatal care (don't want their baby to be taken from them, don't want their substance abuse to be discovered) 5. Lilly's Place 6. IUGR 7. Fetal hypoxia 8. Symptoms and onset of NAS 9. Cocaine associated with placental insufficiency and abruption a. Mother rolls in with placental abruption =automatic drug screen 10. Substances can be found in neonatal urine, meconium, blood, umbilical cord samples, hair, 11. Maternal Substance Abuse and Child Development at Emory

what is hemorrhage

1. Postpartum hemorrhage: more than 500cc (vaginal) or 1000cc (c/s) estimated blood loss at birth. 2. 10% change in HCT 3. EBL often underestimated 4. Early (1st 24h) vs. Late (until 6 wks) 5. 1 soaked peripad/ hour 6. Fist sized blood clots 7. Can also happen prenatally (abruption, previa)

first period of reactivity (birth-60 minutes)

1. Respiratory transition 2. Alert 3. Mother and baby UNDISTURBED AS MUCH AS POSSIBLE! 4. Put baby to breast during "Golden Hour" 1. Baby will eventually make it to the breast on its own but help the baby if needed 2. If you miss the golden hour the baby won't be moving around as readily 5. In between period of decreased responsiveness - (60-100 min) 1. Can last between minutes and hours

D/C checklist immunizations/Meds

1. Rhogam (if needed) a. Given to prevent isoh***** b. Rh+ father + RH- mother carrying her first RH+ mom can mount an attack against the baby c. Will give rohgam at 28 weeks and then again after birth especially if the baby is RH+ (check after birth) d. Initiate any referrals 2. Vaccines: MMR, Flu, TDAP, Varicella a. Have to be up to date on all of these b. MMR and varicella cannot be given during pregnancy because they are l

preventing PPD

1. Share knowledge about postpartum emotional problems with close family and friends. 2. At least once each day or every other day, purposely relax for 15 minutes: deep breathing, meditating, taking a hot bath. 3. Take care of yourself: eat a balanced diet. 4. Exercise on a regular basis, at least 30 minutes a day. 5. Sleep as much as possible; make a promise to yourself to try to sleep when the baby sleeps. 6. Get out of the house: try to leave home for 30 minutes a day; take a walk outdoors or walk at the mall. 7. Share your feelings with someone close to you; don't isolate yourself at home with the TV. 8. Don't overcommit yourself or feel like you need to be a superwoman. Ask for help from family and friends. 9. Don't place unrealistic expectations on yourself; no mother is perfect! 10. Be flexible with your daily activities. 11. Go to a new mothers' support group: for example, take a postpartum exercise class or attend a breastfeeding support group. 12. Don't be ashamed of having emotional problems after your baby is born. It happens to approximately 15% of women.

fetal brain development

1. Significant brain growth occurs in the last 4-6 weeks of gestation a. 20 weeks vs 40 weeks huge difference in brain size and surface area 2. 50% of cortical volume at 34 weeks gestation 3. Five fold increase in white matter from 35-40 weeks 4. Synaptogenesis peaks around 36 weeks myelination hierarchical from primitive to advanced

DVT/VTE

1. Signs DVT 2. Unilateral leg pain and edema 3. May be warm and tender also a. Homan's- don't check—why? i. Could dislodge it

what are the signs of inadequate infant respiration?

1. Silent, limp, Pale/Blue/Grey, Grunting, Flaring, Retracting, Nasal flaring 2. Consistently silent with a number of the other signs because a baby can be adequately oxygenated and be silent 3. Grunting =respiratory distress

abdominal exam

1. Soft (doughy) vs. distended 2. + bowel sounds—make sure to check all 4 quadrants especially if post cesarean a. Post cesarean are at risk of ileus. Look for nausea and absence of bowel signs 3. Diastasis recti

Rhogam Rh immune Globulin, RhoGAM, Gamulin Rh, HyRho-D, Rhophylac dosage and route

1. Standard dose: 1 vial (300 mcg) IM in deltoid or gluteal muscle 2. Microdose: 1 vial (50 mcg) IM in deltoid muscle, 3. Rho(D) Immune globulin (Rhophylac) can be given IM or IV (available in prefilled syringes)

hyperthyroidism treatment in pregnancy

1. Subclinical—expectant management with monitoring 2. Overt—anti-thyroid drugs at lowest possible dose. Medications are not very safe during pregnancy 3. Propylthiouracil (PTU) 100-450 mg/day PO in two divided doses 1st trimester a. LFTs every 3-4 weeks (PTU liver toxicity) b. Medication should only be used to the extent it has to be so goal is not normal range but low normal range of TSH**** 4. Methimazole (MMI), 10-40 mg/day PO two divided doses after 1st trimester. 5. Propranolol 40-120 mg/day for control of symptoms 1. Thyroidectomy (rare) 2. Baby monitored for fetal thyrotoxicosis (5% babies born to Graves' mothers affected) (MFM)

infant (Factors that affect lactogenesis )

1. Suck 2. Emptying of breast (pumping) 3. Based on supply and demand 1. The more she nurses or pumps the more milk she will have 2. The less she nurses or pumps the less milk supply she will have

thyroid storm extereme hyper-metabolic state

1. Tachycardia (>140) and/or A Fib 2. Shaking 3. Agitation, restlessness 4. Confusion 5. High fever 6. Persistent sweating 7. Diarrhea

Beta-adrenergic receptor agonists (terbutaline)

1. Terbutaline / Brethine = Beta Agonist. Betamimetics for inhibiting preterm labor. 2. May delay birth by 2 days and up to 7 days. Infant outcomes (RDS, NEC, CP, death) not improved although most data was for EGA>32 weeks. 3. Relaxes smooth muscles inhibiting uterine activity, and causing bronchodilation

Hearing - from in utero

1. Term newborns can hear and differentiate among various sounds. 2. The neonate recognizes and responds readily to the mother's voice 3. Newborns are accustomed to hearing the regular rhythm of the mother's heartbeat; As a result, they respond by relaxing and ceasing to fuss and cry if a regular heartbeat simulator is placed in their cribs 4. Routine hearing screening is recommended for all newborns before hospital discharge. i

Respiratory Adaptation-During Labor (chemical factors)

1. Transient fetal hypoxia and hypercarbia stimulates respiratory center in fetal medulla 2. Clamping of the cord - increases perfusion to newborn lungs

outcomes of infections during pregnancy depend on

1. Trimester (First more likely to have congenital malformation and disorders) 2. whether placenta is infected/crossed 3. severity of infection (primary vs. secondary)

Respiratory Adaptation After Birth Thermal

1. Upon drop in temp at birth, skin receptors stimulate respiratory center in the medulla

breast engorgement

1. Usually 72-96 hours when mature milk comes in 2. Warm, firm, sometime lumpy, tender breasts (lumps shift in position) 3. Engorgement results from increase in blood and lymphatics as milk production increases

causes of postpartum Hemorrhage

1. Uterine atony: multigravida, macrosomia, multiples, polyhydramnios 2. Lacerations of cervix, vagina, or perineum 3. Hematomas—bleeding into the tissues, can be a cause of hemorrhage, look at peritoneum to check for hematomas and potential hemorrhage 4. Retained placenta or placental fragments 5. Uterine inversion—uterus flipped inside 6. Subinvolution—anything that it is keeping the uterus from involuting

newborn IM injections

1. Vastus lateralis 2. 25 gauge, 5/8 inch

foley catheter (nursing care of a patient with epidural for birth)

1. b/c can't get up to go to restroom a. help explain to them that although they're starting with the needle, there's no needle in their back, they're just using it to thread the catheter + hooking it up to a pump b. explain they'll feel a tingling sensation first + then a numb c. give education on why they're getting a foley + position changes

gastroschisis

1. bowel outside abdomen a. Abdomen doesn't close b. Bowel outside of the abdomen c. Always to the right of the umbilical cord d. Bowel is often tough, hard and enlarged and difficult to return to the abdomen

vital signs (nursing care of a patient with epidural for birth)

1. during and after a. Give a test dose, to check to make sure the medication does not get into the maternal blood stream. The medication has epinephrine in it and if reaches their blood stream their hr/bp will skyrocket b. If everything is good they will load the actual dose and feed the catheter in and remove the needle c. Cesarean birth the patient will be numb from the breast down d. Vaginal birth they will be numb from the pelvis down

Leopold's maneuvers 4 steps

1. palpate the fundus 2. palpate for the fetal back (vs small parts) 3. feel the lower pole of the fetus with thumb and forefinger to see which fetal part is presenting to the inlet 4. palpation of the head for cephalic prominence-ised to assess descent and fetal attitude

informed consent pharmacological interventions

1. procedure advantages and disadvantages 2. plan of labor pain care 3. consent without coercion => ask what she wants + just go with it

second stage of labor assessment findings

10 cm dilation, 100% effaced, birth of the infant the exact moment second stage starts is not known until a vaginal exam is performed (no cervix left) shaking, N&V, restless, irritable urge to push duration varies--"laboring down"

second stage of labor

10 cm-birth pushing phase full dilated to birth of fetus fetus descends through birth canal and rotates pressure on pelvic floor stimulates stretch receptors--urge to bear down (ferguson reflex) the moment you have been waiting for the birth of the infant

lactogenesis stage 3

10 days PP mature milk growth spurts and increased feeding stimulates increaed milk production

growth spurts and breastfeeding

10 days, 3 weeks, 6 weeks, 3 months, 6 months (frequent feeding for 24-48 hours and then back to normal). Important to educate mother on these periods of increased nursing/feedings.

baseline fetal heart rate (FHR)

110-160 bpm need at least 2 minutes that are fairly regular without any periodic or episodic changes

HGB pre-pregnancy

12-16 g/dl

fetal circulation before birth

2. Blood enters the right atrium. Most of the blood flows to the left side through the foramen ovale between the left and right atria 3. Blood then passes into the left ventricle and then to the aorta. 4. From the aorta, blood is sent to the head and upper extremities. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava. 5. About one-third of the blood entering the right atrium does not flow through 6. the foramen ovale, but, instead, stays 7. in the right side of the heart, eventually 8. flowing into the pulmonary artery.

breast feeding benefits for infant

2. Enhanced neurodevelopmental outcomes 3. Better and earlier communication between infant and mother 4. Fewer delays

Lactogenesis-Breasts

2. Initiation of the production of milk 3. Sucking stimulus hypothalamus anterior pituitary prolactin milk production 4. Hypothalamus posterior pituitary oxytocin milk ejection

WBC postpartum

20-25,000

plts for preeclampsia and HEELP

<100,000 mm3

placenta previa marginal/low-lying

<2.5 cm from os

minimal variability

<5 bpm amplitude range detectable less than or equal to 5 bpm

oligohydramniosis

<5cm (term) or 5th percentile not enough fluid around fetus Peak amniotic fluid amounts at about 36 weeks (1 liter). Low amniotic fluid levels

Pulse/Heart Rate apgar 2

> 100

abnormal temperature

> 101 (asses oft potential causes-puerperal sepsis : temp >100.4 after 24 hours) other causes mastitis, endometritis, UTI

Hb, HCT preeclampsia

> 16, >47%

oxytocin (Factors that affect lactogenesis )

Although oxytocin is an essential hormone in lactation, administration of exogenous oxytocin to mothers having difficulty in breastfeeding has not been clearly shown to have a beneficial effect on lactation success)

terms to describe involuntary contractions (primary power)

Frequency (how often minutes apart)/duration (how long does it last in seconds) /intensity (how strong)

gonorrhea signs and symptoms

Frequently asymptomatic Minimal discharge Menstrual irregularities Pain - pelvic or lower abdomen Dysmenorrhea Dysuria

determining pregnancy history two digit system

G/P

this is anita's third pregancy she has a 2-year old who was born at 32 weeks gestation. she also had a miscarriage at 12 weeks what is her G/P, GTPAL

G/P 3/1 G3, T0, P1, A1, L1

determining pregnancy history 5 digit system

GTPAL

Infant galactosemia (contraindication to breastfeeding)

Galactosemia: When a person who does not have galactokinase consumes food containing lactose (e.g., dairy products such as milk, cheese, butter), their body breaks down the lactose into galactose and glucose, and then further metabolizes both of these sugars. (The human body also is able to make "endogenous" galactose.) When a person with galactosemia consumes food containing lactose or galactose they are not able to fully metabolize the galactose, so it can build up in their cells and tissues. Galactose that is synthesized in the body may also build up. ii. Rare and deadly - causes failure to thrive.

Rh Factor

Genetically determined factor present on RBC's Rh factor present - positive Rh factor not present - negative

reduce risk of clots in mothers

Increase in venous stasis will likely see pooling if they are sedentary Want patient to be mobile Compression hose Especially while flying or long car ride Even sitting for long periods of time at a desk make sure they are walking some

placenta abruption expectant management

Observation and bedrest for < 36 weeks, normal FHR, no contractions, and mild bleeding that stops As long as everything is stable will just watch them as long as they are 36 weeks Fetal Monitoring Large bore IV No vaginal exams H&H, platelets, Coag, Type & Screen BRwBRP NST or BPP weekly or biweekly Monitor for signs of preterm labor

Naloxone Hydrochloride (Narcan)

Opioid (narcotic) antagonists 0.1 mg/kg IV. Reverses resp. depression in NB (know this)

hypothyroidism fetal outcomes

PTD LBW Neurological/Developmental abnormalities (long-term) Anti—thyroid antibodies of Hashimoto's may cross placenta and cause fetal hypothyroidism

The 5 P's

Passenger (fetus and placenta) Passageway (Pelvis and Birth Canal) Position (relationship of the fetal head to the quadrants of the maternal pelvis) Powers (Contractions) Psychological Adaptation to Labor (maternal and fetal adaptations)

Passageway

Pelvis and Birth Canal

syphilis treatment

Penicillin G Repeat testing 6-8 weeks Monthly testing and treatment Abstinence until cleared Treatment: Benzathine PCN—dose varies depending on stage of syphilis

Episiotomy/Laceration/Incision (and hemorrhoids): how to assess ==> REEDA

Redness Edema Ecchymosis—bruising Drainage Approximation—holding together or not

decrease in fetal oxygen supply

Reduction of blood flow through maternal vessels => due to position(laying on her back, epidural/hypotension Reduction in oxygen content in maternal blood => if mother is breathing too fast; pain Alterations in fetal circulation Reduction in blood flow to intervillous space in placenta

ready-to feed formula

expensive Open bottle good for 48 hours (refrigerated)

Disseminated Intravascular Coagulation (DIC)

a) Pathological overactivation of clotting factors that results in increased platelet aggregation with microvascular thrombi in organs leading to multiple organ failure AND b) Consumption and exhaustion of coagulation factors leading to severe bleeding

nursing role during Cesarean delivery: pre-op, circulator, and post-op

a) Pre-op—labs, shaved, consent, IV started, checking with the surgeon and OR to make sure everything is ready b) Circulator—ensure safety of the patient and baby in the OR, documentation, foley is secure, IV secure and in place, document when the surgery starts, who is in the room, mom is strapped down, counting all the laps, and surgical equipment, assessment of the baby (APGARs), counting everything and so on c) Post-op—vitals, assessing for pain, monitoring anesthesia levels, making sure she is stable after the procedure

prolapsed umbilical cord

a) Umbilical cord lies below the presenting part i) If on vaginal exam you feel umbilical cord you have to keep your hand there to keep pressure off the cord until an emergency c-section can be performed b) Can occur at any time during labor c) With or without ruptured membranes

uterine inversion or prolapse

a) Uterine inversion or prolapse—uterus inverts (inside out) b) After delivery c) Potentially life threatening - hemorrhage, shock d) Partial or complete

what is the risk if any 2 of the time honored clinical signs and symptoms of chorioamnionitis?

a) When at least 2 of the above criteria are present, the risk of neonatal sepsis is increased. b) See any of the above usually start treating the mother with abx and Tylenol (fever and fetal tachycardia usually start this regimen)

Cultural considerations birth

a) Woman may have a preconceived idea of the "right" way to behave b) Culture and father participation (1) Some partners are really involved while some are very quiet and on the sidelines c) Non-English-speaking woman in labor (1) Language line d) LGBTQIA couples (1) Unique population (2) Learning more about their needs during labor (3) How do you want us to use preferred pronouns? (4) What do they want or not want done

choosing a method of feeding: breast feeding

a. Breast i. Importance of prenatal education regarding the many benefits - both health benefits and bonding benefits. ii. Some evidence that the decision to exclusively breastfeed is more likely if it's made during pregnancy. iii. Textbook cites a study that says that overweight or obese women are less likely to breastfeed compared to normal or underweight women. Other studies say this is the case for both over and underweight women and it is an association that is independent of demographic factors like socioeconomic status iv. Social factors: formula company marketing, workplace policies, poor lactational support for early postpartum mothers v. Personal comfort level - breasts as sexual object, uneasiness with public breastfeeding, pain, discomfort

Beta-adrenergic receptor agonists (terbutaline) dosage and route

a. Can dose SQ, IV, or po b. SQ dose is for tocolysis, max dose is 1 mg/4 hours. c. PO dose is not advised for tocolysis. d. IV dose (or SQ dose) can be used for emergencies, i.e., prolonged decel r/t uterine tachysystole i. IV dose is 0.025 mg/min IV

DVT/VTE postpartum risk factors

a. Cesarean delivery b. Varicose veins c. Co-morbidities: Diabetes, IBD, cardiac disease, hypertension (including PIH), lupus d. Preterm delivery e. Stillbirth f. AMA (age > 35) g. Multiple birth h. BMI at least 25 i. Clotting disorder j. Smoking k. Infection

contraindications for breastfeeding medications and tests

a. Chemo b. Radioactive dye (pump and dump for 2 half lifes) c.Alcohol: blood alcohol = milk alcohol i.Before you drink and at least 2 hours after drinking ii.When you are neurologically normal it is probably save to nurse d.Medication safety app: Lactmed (@NIH) i.Great for patients and for studying

educate patients about fetal monitoring

a. Explain the purpose of monitoring b. Explain each procedure c. Provide rationale for maternal position other than supine d. Explain that fetal status can be continuously assessed by electronic fetal monitoring (EFM), even during contractions e. Explain that the lower tracing on the monitor strip paper shows uterine activity (UA); the upper tracing shows the fetal heart rate (FHR) f. Reassure woman and partner that prepared childbirth techniques can be implemented without difficulty. g. Explain that during external monitoring effleurage can be performed on sides of abdomen or upper portion of thighs. h. Explain that breathing patterns based on the time and intensity of contractions can be enhanced by the observation of uterine activity on the monitor strip, which shows the onset of contractions. i. Note peak of contraction; knowing that the contraction will not get stronger and is halfway over is usually helpful. j. Note diminishing intensity. k. Coordinate with appropriate breathing and relaxation techniques. l. Reassure woman and partner that the use of internal monitoring does not restrict movement, although she is confined to bed.* m. Explain that use of external monitoring usually requires the woman's cooperation during positioning and movement. n. Reassure woman and partner that use of monitoring does not imply fetal jeopardy

expectant management of pPROM

a. Generally these are patients whose babies are viable. b. Regular diet and hydration c. Light activity vs. bedrest (need DVT prophylaxis) i. SCDs or ted hose d. Maternal VS often (q8h?) i. To detect chorio 1. Signs of chorio include maternal fever, malodorous discharge, tender uterus, fetal tachycardia ii. WBC not really helpful on its own b/c WBCs are typically elevated during labor as an indication of inflammation so not used to diagnose an infection in a laboring woman e. Fetal monitoring x 24 hours, then at least qd (probably more) i. Continuous monitoring if baby is not vertex f. Ultrasounds to check AFI i. Low AFI associated with shorter latency and chorio ii. Not an indication for delivery iii. Some people are able to rebuild the amount of amniotic fluid g. NO cervical exams unless the patient is obviously in labor h. Neonatal consult i. Dangerous for her and the baby ***

ambiguous genitalia

a. Genetic issue b. Surgery c. Must decide what gender to assign the child d. Gender assignment should be based on the following: diagnosis, genital development and surgical options, cultural pressures, most likely adult gender identity, potential for mature sexual function, potential fertility, and the longer—term psychological and intellectual effects on the child and family

infant feeding cues

a. Hand-to-mouth or hand-to-hand movements b. Sucking motions c. Rooting reflex—infant moves toward whatever touches the area around the mouth and attempts to suck d. Mouthing e. Lot of infant cues that happen before crying, and want to catch those cues early f. Quiet and alert start to move head and hands, sometimes hand to mouth, sometimes sucking, routing ** g. Important to identify the signs early, look for cues not watching the clock h. Newborn hunger cues ****

ways that nurses can help women achieve maternal role attainment.

a. Provide anticipatory guidance about the realities of parenthood b. Parenting literature and resources c. Infant care instruction d. Instruction and opportunities for increasing infant awareness and interaction e. Interactive and therapeutic nurse-patient relationship

Common Disease Process and Complications of Preterm and Late Preterm Infants

a. RDS b. Hypo and hyperthermia c. Sepsis d. Adequate nutrition that leads to weight gain and growth e. Apnea of prematurity f. Hyperbilirubinemia g. Developmental delays h. Retinopathy of prematurity (ROP) - damage and scaring of retina - visual impairment i. Bronchopulmonary Dysplasia (BPD) j. Hemorrhage into ventricles of the brain (IVH) - hemorrhage in the lateral ventricles of the brain, clots form and obstruct flow of CSF k. Necrotizing Enterocolitis (NEC) - acute inflammatory disease of the GI mucosa

purpose of APGAR

a. Virginia Apgar was an anesthesiologist developed this score to quickly evaluate the newborn's transition to extrauterine life. b. Indicative of the physiological state

screening For depression

a. Who should screen? 1. Pediatrician, primary care, obgyn b. May not go to their own follow up appointment but will go to the baby's check ups c. When to screen? d. Edinburgh Postnatal Depression Scale 1. ACOG says this can be used during pregnancy 2. Self-report i. If a woman scores positive for this (a score of 10 above) then you need to have a plan in place for referrals ii. Ensure they don't feel stigmatized or demonized for screening positive so that they will get help

pudendal nerve block

a. administered late in the 2nd stage b. relieves pain in the vagina, vulva, and perineum=> inject lidocaine by the pudendal nerve (pudendal nerve block) not used much

tracheosophageal fistula

abnormal connection between the esophagus and the trachea

immune system changes

associated with suppression of various humoral and cellulary--mediated immunological functions to accommodate the semi--allogenic fetus depresses leukocyte function (Despite increase in numbers) may be part of improvement in autoimmune disorders in pregnancy AND increased suscpetibility to infection

deceleration

associated with uterine contractions types: early, late, variable, prolonged, bradycardia

Benzodiazepines

ativan, valium typically avoided as it may cause maternal amnesia, however does enhance pain relief and reduce N/V not routinely used

duration of breastfeeding

average 30-40 minutes total, give both breasts!

breast care

avoid soap on nipples pads for leakage

diastasis recti

b. Separation of abdominal muscles/abdominal wall. Abdominal wall muscles separate c. Not a medical issue but cosmetic issue d. Everything spills forward e. Can do exercises to try to correct it but takes a lot of time f. Can occur with or without overdistension g. Due to a large fetus or multiple fetuses h. Surgical correction is rarely necessary. i. Persistence can be disturbing to the woman j. With time the separation becomes less apparent

preparation for procedures pharmacological interventions

bee sting at first, then pressure (trying to find the epidural space), but once you find it they'll put some meds to test to make sure it's in the right spot so let us know if you feel increased HR or resps. then you'll feel the catheter go in (shooting pain down the leg or weird pain sensation) and then afterwards legs will feel warm + tingly and naturally very numb

second stage of labor-infant is born

begins with full cervical dilation (10 cm) complete effacement the "pushing stage" nulliparous mom (first time mom) first birth 2 hours, 3 hours with epidural multiparous mom (multiple births) 1 hour, 2 hours with epidural ENDS with the INFANT's BIRTH

uterine changes ballottement

being able to lift the uterus out of the pelvis and feel the fetus moveability of the fetus, diagnostic technique using palpation: a fetus when trapped or pushed, moves away and the returns to touch the examiner's hand; passive movement of the unengaged fetus

energy needs

birth - 3 months 110 kcal/kg/day; 3-6 months 100 kcal/kg/day; 6-9 months 95; after a year c. Breastmilk 20 kcal/oz d. Formula 20 kcal/oz

third stage of labor

birth of baby to delivery of placenta shortest stage 15 minutes, >30 minutes=problematic

toxoplasmosis infant complications

blindness, mental disability, eye/brain damage symptoms often not present at birth but develop later

PE work up for preeclampsia

blood pressure i) Edema—asses for distribution, degree, and pitting (no longer diagnostic of preeclampsia) ii) Deep Tendon Reflexes (including clonus) (1) DTRs reflect the balance between the cerebral cortex and spinal cord (a) Biceps and patellar reflexes are assessed (b) Normal DTRs is +2 (c) In preeclampsia they will have hyperflexia (or increased DTRs) (2) Clonus—hyperactive reflexes at the ankle joint (a) Normal (negative) (b) Abnormal positive clonus iii) Urinalyses (which urine tests are collected) iv) Signs and symptoms (headache, visual disturbances, right upper quadrant pain (see. P. 660) (1) Neurologic: (a) Headache* (b) Scotomata (blind spot) or blurry vision (c) Clonus: 45-second video (2) Hepatic: (a) RUQ or epigastric pain** (b) Indigestion or nausea (3) Renal: (a) Edema (minimally helpful) v) Serum laboratory values

too much pregnancy (stretch) or not enough risk factor

body has more than it can take. Too much energy going out and not enough nutrition going in i. Multiples, polyhydramnios ii. Nutritional deficits, BMI < 19, hard labor or long work hours iii. Age < 17

Appearance/skin color apgar 0

body is blue

Appearance/skin color apgar 2

body is pink

laxity of ligaments/pubis symphysis separation

bones are a little laxer so that the baby can descend can have symptoms of pain can wear a pregnancy belt under belly tenderness

omphalocele

bowel in umbilical cord bowel covered with the cord

primitive myelination

brainstem function

preterm and later term

breast is best expressed breast if necessary (8-24 x/24 hrs) kangaroo care lactation consultant

uterine cramping/after birth pains occurs during

breastfeeding Pitocin c. Other oxytocic agents (example: cytotec, methergine) d. More common in multiparas 3. Interventions: heat, pain meds 4. Cramping typically decreases by day 3 PP

cardiovascular changes: decreases

collagen throughout vascular system softens systemic vascular resistance by week 5 pulmonary vascular resistance colloid osmotic pressure at term delivery, blood loss < 500 cc or <100 cc for cesarean begins by week 5 s/s mimic CVD 4-5% of women have undiagnosed CVD, increased morb/mort in pregnancy (higher risk of complications)

second stage of labor nursing care

comfort, reassurance, position changes, simple communication environment

forceps/vacuum delivery prerequisites (cervical exam)

complete dilation ruptured membranes 0 station or lower

involution is enhanced by

complete expulsion of placenta/membranes, Breastfeeding

shoulder dystocia

condition in which the head is born, but the anterior shoulder cannot pass under the pubic arch a) Use pelvis and baby b) Tested/Untested pelvis c) Head delivered d) Anterior shoulder gets hung under pubic arch

syphilis fetal consequences

congenital syphilis, death, premature labor Organ problems (ears, eyes, liver, heart)

varicella fetal consequences

congenital varicella syndrome (LBW, microcephaly, cutaneous lesions), miscarriage, birth defects *If contracted at time of delivery=30 to 40% transmission to infant

chlamydia fetal complications

conjunctivitis (redness swelling, discharge), pneumonia (will be treated with oral abx)

CMV transmission

contact with bodily fluids

pictocin benefits

contractions the uterus

physiologic (other factors influence pain)

contractions, fetal size and position, maternal position, rate of fetal descent (if you have a baby that's coming really fast this can affect how mother feels pain)

true knot

cord compression

Alba Lochia

creamy white, leukocytes and decidual cells 1. Usually starts 10 days (to 14 days) postpartum and lasts up to 8 weeks (typically 4 wks) 2. Main bleeding should be done 3. Bleeding changes across the month from red to more creamy but it will last about a month 4. Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria. TIL ~6-8 wks

Epidural anesthesia or analgesia (block):

currently the most effective pharmacologic pain relief method for labor a. involves an anesthetic (bupivacaine) with and opioid (Fentanyl) being injected into the epidural space b. depending on the type, amount, and number of medications there will be varying degrees of motor impairment c. it's put in below L5, so it's hard to become paralyzed from it - but also why you need to stay really still d. main role in this situation = keep pt. calm and staying still e. teach them: shoulders back, lean over helps open up the back so the anesthesiologist can get in the space

nursing interventions third stage other medications

cytotec, hemabate, methergine (For hemorrhage)

placenta abruption

detachment of all or part of placenta from uterus complete or partial can happen with blunt force trauma, car, accident--need to come in for evaluation b/x may not have any external symptoms

pregnancy test beta hCG

detected in maternal serum or urine as soon as 7-8 days before period is due and double every 2 days in the first 4 weeks (detected in blood before urine)

why is it a big deal if a baby is not in general flexion?

deviations in attitude may cause difficulties in birth--when the fetal attitude is not general flexion the diameter of the head increases=harder for the head to enter the pelvis may have to have a c section

chronic hypertension

diagnosed prior to 20 weeks EGA, does not resolve in 12 wks postpartum • SBP > 140 and DBP > 90 • High risk for superimposed preeclampsia

morphological changes in the heart and lungs during pregnancy

diaphragm pushes up on the heart heart moves a little to the left

hepatic portal circulation baby before birth

ductus venosus bypasses maternal liver performs filtering functions

hepatic portal circulation newborn

ductus venosus closes (becomes ligament) hepatic circulation begins

decreased intestinal motility

due to microbiome and progesterone increases energy and nutrient harvest slower absorption of food

peripartum

during pregnancy or in the 4 weeks following delivery

FHR tachycardia common causes

early signs of fetal hypoxia maternal or fetal infection maternal hyperhyroidism fetal anemia response to meds: vistaril, terbutaline (stops cx, but raises mom and fetal HR), illicit drugs

systemic analgesia (opioids) fetal effects

easily cross the placenta=effects on the fetus 1. (absent/minimal FHR, decreased variability, neonatal depression) has to be on continuous monitoring if giving these medications a. these medications cross over the placenta and will affect the FHR, may see absent or intermediate variability b. have to constantly monitor

E reEda==>how to assess Episiotomy/Laceration/Incision (and hemorrhoids

ecchymosis brusing

maternal consequences of unmanged preeclampsia

eclampsia stroke liver failure/hemorrhage DIC/HELLP acute renal failure pulmonary edema/aspiration placental abruption death

Legs/Lower Extremities Assessment

edema, tenderness, varicoscities, and homan's sign

involuntary contractions (primary power) primarily responsible for

effacement dilation descent of the fetus--described in station (-5 to +5)

EL

elevated liver enzymes

progesterone extra-genital effects

elevation of BBT happens very early increased sensitivity of respiratory center to co2 (mild increase in respiratory rate and respiratory alkalosis decreased smooth muscle activity stimulates erythropoiesis (RBC production) relaxation of veins/increased pooling (legs will be swollen) decreased pulmonary airflow resistance ureter dilation

prolapsed umbilical cord management ****

emergency C/s lift presenting part off cord

supportive care team during labor

emotional support, physical care and comfort measures, and advice/information nurse, husband/partner, doulas, grandpartents siblings during labor and birth (need to have someone else take care of the child)

anesthesia

encompasses analgesia, amnesia, relaxation, and reflex activity. abolishes pain by interrupting nerve impulses to the brain *The type of analgesic or anesthetic chosen is determined in part by the stage of labor of the woman and by the method of birth planned.

breast changes

enter a phase that only occurs during pregnancy called lactogenesis 1 breast enlargement by 25-50% increase size of nipples and areola hyperpigmentation of areola enlargement of the montogmery's glands increased blood flow (mammary souffle)

regional anesthesia

epidural anesthesia or analgesia, combined spinal epidural cse analagesia epidural and intrathecal spinal opiod=ids

nipple erection

erection occurs with certain stimuli like sucking or rubbing up against nipple or crying

EDD or EDC

estimated date of delivery or confinement

Lactogenesis hormones

estrogen, progesterone, HPL DECREASE PROLACTIn remains elevated

step 1 baseline FHR

evaluate 10 minute window normal baseline 110-160 pmg

signs and symptoms of excessive/abnormal bleeding

excessive bleeding ++ clots a. Weakness, lightheadedness, nausea, b. Anxiety c. Skin: pallor, ashen, cool, clammy d. ↑HR e. ↓BP

signs of potential problems fourth stage

excessive blood loss alterations in vital signs and consciousness

colostrum function

facilitates the binding of bilirubn facilitates the establishment of lactobacillus bifidus gut bacteria Very concentrated, only need a small amount but filled with lots of nutrients Laxative stimulates the release of meconium

care of the family-4th stage of labor

family--newborn relationships bonding, skin to skin, breastfeeding, wmotional reactions

gestational diabetes above normal results for the OGTT

fasting 95+ 1 hr 180 + 2 hours 155+ 3 hours 140+

fentanyl opioid (narcotic) agonist analgesic

fentanyl citrate (sublimaze) 50-100 mcg advantage: rapid onset, short duration 1 hr IV side effect--N/V

varicella symptoms

fever, chills, myalgias, pruritic vesicles

parvovirus symptoms

fever, runny nose, headache, slapped cheek rash (can spread to chest, back, arms, legs), painful joints

1st 24 hours postpartum fundus location

ff@U on DOD at umbilicus

acquaintance phase

fingertip exploration en face position responds verbally to infant sounds use of senses parents use eye contact, touching, talking and exploring to become acquainted with their infant during this period families engage in the claiming process

fourth stage of labor care management

first 1-2 hours after birth

Naegle's rule for EDD or EDC

first day of last menstrual period -3 months + 7 days + 1 year = estimated date of delivery or confinement

pregnancy test nursing considerations

first void in the morning (urine most concentrated) false positive (tranquilizers, anticonvulsants) false negatives (diuretics, phenergan)

output assessment

first void wihtin 24 hours and generally the first stool fequency of voiding stool transition

desired urination

first void within 6-8 hours lack of urination leads to increased risk of UTI and hemorrhage

neuroprotection

five magnesium sulfate administered < 36 weeks gestation administered within 24 hours of anticipated birth. active labor qith >/=4cm cervical dilation, with/out PPROM

listeriosis symptoms

flu-like symptoms, cns sx (ha, stiff neck)

nursing care of a patient with epidural for birth

fluid bolus/IV access vital signs (before/after) position changes Foley catheter

care of thee new mother-4 stage of labor

food, hydration, rest, shower have to make sure shes able to get up

Calcium gluconate:

for mag toxicity with respiratory depression 10 mL of 10% solution IV over 10 minutes

Fetal monitoring for women with pre-existing diabetes/require medication ultrasound

for size/date discrepancies May want EFW (estimated fetal weight) near term

contractions described by

frequency duration intensity resting tone

monitoring strip

from one dark line to the next dark line=1 minute each small box=10 seconds

Management of postdate pregnancy psychological

frustration depression

PPD day 10

generally fundus is nonpalpable by PPD 10

Rubella Agent

german measles virus

dental changes

gingivitis (increase in dental hygiene required) epulis gravidarum (increase in gum tissue) increased in bleeding gums

Understanding the reason for decreased oxygen supply will help you to think of nursing measures to implement

how do you increase blood flow in maternal vessels? ==> IV bolus, medications, position changes how do you increase oxygen content? ==> give O2 how can you improve fetal circulation? ==>position changes how can you improve blood flow in the placenta? ==> increasing IV fluids, position changes but dependent on type of deceleration you're seeing so need to figure out which one it is first

hematologic changes

hypercoagulable sate *To reduce the risk of hemorrhaging but have an increase risk of colts 5 to 6-fold increase in risk of thromboembolic event Accounts for 25%U. S. maternal deaths increased venous stasis, vessel wall injury and increased clotting factors (increased pooling)

pancreas changes-pregnancy is characterized by

hyperinsulinemia hypertriglyceridemia reduced tissue response to insulin decrease FBS fetal glucose levels depend on maternal level fetus synthesizes and secretes insulin starting at 9-11 weeks of gestation

dysfunctional labor patterns uterine causes

hypertonic uterus, hypotonic uterus, inadequate secondary powers (pushing effort lack of pushing effort may be due to epidural)

supplementation only needed if

hypoglycemia dehydration infant factors (hypoglycemia, dehydration, weight loss, delayed BM, hyperbilirubinemia) maternal factors

side effects of epidural anesthesia

hypotension fever itching decreased FHR variability need for continuous electronic fetal monitoring urinary retention mobility limitations reduction of the woman/body to a birthing vessel longer second stage increased use of oxytocin post-dural puncture headaches (PDPH)

The time-honored clinical signs and symptoms of chorioamnionitis include the following:

i) **Fever (an intrapartum temperature >100.4°F or >37.8°C) (1) Classic sign (2) At onset of fever usually start abx and nsaids for fever ii) Significant maternal tachycardia (>120 beats per minute [bpm]) iii) Fetal tachycardia (>160 bpm) iv) Purulent or foul-smelling amniotic fluid or vaginal discharge v) Uterine tenderness vi) Maternal leukocytosis (total blood leukocyte count 15,000-18,000 cells/mm3)

chorio management

i) Antibiotic prophylaxis ii) Induction of labor following rupture of membranes and term

Vasa Previa: unprotected Fetal Blood vessels lie across the os

i) Basically, the combination of a Velamentous and placenta previa ii) Placenta that is covering the cervix and vessels are in the membrane iii) Fetal vessels lie over the cervical os iv) Vessels are implanted into the fetal membranes rather than into the placenta v) Usually these vessels are protected only by the membranes (not by Whar¬ton's jelly); thus they are at risk for rupture or compression. vi) There are two variations of vasa previa. In both situations artificial or spontaneous rupture of the membranes or traction on the cord may rupture one or more of the fetal vessels. vii) As a result the fetus may rapidly bleed to death. viii) Risk factors for vasa previa include low-lying placentas, pregnancies resulting from assisted reproductive technology, and multiple gestations.

c-section indications

i) CPD ii) Distress iii) Breech, multiples iv) Previa, abruption v) Current HSV outbreak, HIV vi) Prior uterine surgery (not LTCS) vii) Failed induction or remoteness from delivery, unstable situation (PIH, HELLP, cord prolapse) viii) Elective: previous c/s

SAB medical management

i) Cytotec (misoprostol) (1) Ibuprofen for cramping—designed to make them start contracting (2) Bleeding expected, but should not exceed a maxipad in an hour (3) If the bleeding gets really heavy then need to go to the ED

education for woman who had an ectopic pregnancy

i) Emotional recovery - grief or infertility support groups ii) Contraception for at least 3 menstrual cycles to allow for healing iii) Immediate notification of provider with next pregnancy iv) Risk—history of STIs, IUD, pelvic inflammatory disease

Management of postdate pregnancy how is the baby doing

i) FETAL KICK COUNTS (1) Count how many times the baby moves in two hours (2) Should get at least 10 kicks in two hours (3) Way to quantify how the baby is moving and doing

nursing considerations for women managed at home (i.e. expectant management); ie. Activity, diet, danger signs

i) For chronic HTN, medication and lifestyle management. ii) For gestational, the cure is delivery. iii) Timing depends on whether diagnosis is "severe" (1) Any time if severe/unstable (2) After 34 weeks if severe (a) Risk for the baby to stay in the uterus (b) Always a risk for mother to stay pregnant (3) After 37 weeks if not severe iv) Monitoring via BP, labs, and symptoms v) Lifestyle management vi) Steroids if preterm delivery is anticipated vii) Magnesium sulfate for IP prevention of seizures (1) Severe diagnosis (2) Neurologic symptoms viii) Delivery is the cure for gestational hypertension—not helpful if it occurs postpartum ix) Delivery always OK for mother x) Delivery not always OK for baby

forceps/vacuum delivery contraindications

i) Gestational age <34 weeks ii) Fetal scalp trauma iii) Unengaged head iv) Incomplete cervical dilatation v) Active bleeding or suspected fetal coagulation defects vi) Suspected macrosomia vii) Nonvertex presentation or other malpresentation viii) Cephalopelvic disproportion (CPD) ix) Delivery requiring rotation or excessive traction x) Inadequate anesthesia

HEELP syndrome

i) HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction, characterized by hemolysis (H), elevated liver enzymes (EL), and low platelet (LP) count. ii) Severe form of preeclampsia (?? May be separate disorder). iii) 4-12% of women with preeclampsia ~48,000 women/year iv) 90% of women with HELLP present with epigastric pain

bedrest, pelvic rest, hydration

i. Probably don't help and may actually help ii. Depends on the patient if they will be helpful iii. Leaking fluid—bedrest will help her leak less fluid

ongoing monitoring of the fetus whos mother has preeclampsia

i) Home vs. hospital ii) Daily fetal movement counts iii) Periodic (monthly) growth scans (1) To make sure the fetus is getting enough blood flow through the placenta iv) NST, BPP: frequency depends on severity (1) Gestational HTN: initial and weekly (2) Preeclampsia: twice weekly (3) Suspected FGR: twice weekly (4) Severe PIH: daily v) Continuous electronic fetal heart rate monitoring, a biophysical profile and ultrasound evaluation of fetal growth and amniotic fluid vi) If evidence of fetal growth restriction is found umbilical artery doppler velocimetry is recommended

management for severe gestational htn or severe preeclampsia

i) Hospitalization ii) Assessment monitoring BP, urine output, cerebral status, presence of epigastric pain, tenderness, labor or vaginal bleeding iii) Labs—platelet count, liver enzymes, serum creatinine iv) Antihypertensive medications to maintain a BP less than 160/110 mm HG v) Ongoing maternal and fetal assessment corticosteroids (gestation less than 34 weeks) vi) Immediate birth is indicated if: uncontrollable severe hypertension, eclampsia, PE, placental abruption, DIC evidence of nonreassuring fetal status or intrapartum fetal demise

chorioamnionitis risk factors

i) Long labor ii) Prolonged membrane rupture iii) Multiple vaginal examination iv) Use of internal HR and contraction monitoring modes v) Young maternal age, Low socioeconomic status, nulliparity, preexisting infections of the lower GU tract

forceps/ vacuum delivery indications

i) Long second stage, perhaps due to an unfavorable position of the baby. The forceps can be used to rotate the head so it can be more easily born. ii) Fetal distress, when it is necessary to have the baby born quickly. iii) Maternal inability (i.e., secondary to heavy epidural) iv) Maternal exhaustion or a condition where pushing would be detrimental to the mother, for example a maternal heart condition or a very high blood pressure. v) Have to be confident that vaginal birth is possible

preventing hypertensive disorders in pregnancy

i) Low dose aspirin (81 mg/day) from 12 weeks if any of the following: (1) Previous pregnancy with PET (2) Multifetal (3) Chronic HTN (4) Diabetes (5) Chronic kidney disease (6) Autoimmune disease (7) Multiple other risk factors: nulliparity, obesity, family history, age > 35, AA ii) Calcium if low calcium diet and risk factors (like above) (1) 1,000-1,300 mg/day (higher dose for teens)

postpartum preeclampsia

i) Mode of postpartum onset = 8 days postpartum ii) Monitor 1st 72 hours after delivery iii) Office visit 7-10 days after delivery iv) Same risk factors, symptoms, evaluation, and treatment. v) Women with persistent BP >150/100 require BP medications vi) More than half are diagnosed prenatally and during labor but the other 50% are diagnosed postpartum

uterine inversion or prolapse risk factors

i) Prior inversion ii) Uterine malformations (heart shaped, bicornate) iii) Fundal implantation of placenta iv) Manual extraction of placenta v) Short umbilical cord vi) Uterine atony vii) Abnormally adherent placenta

if rupture occurs in ectopic pregnancy

i) Referred shoulder pain/ Positive Deep lower, one sided acute abdominal pain ii) S&S of shock--Faintness and dizziness related to the amount of bleeding in the abdominal cavity and not necessarily related to obvious vaginal bleeding iii) Cullen sign - ecchymosis around umbilicus/ Blueness around the umbilicus indicating hempatoperitoneum

Risk facots for oligohydramnios

i) Risk factors for oligohydramnios: (1) ROM (2) Fetal kidney compromise or anomaly (3) Post term pregnancy / placenta issue (a) Placenta starts going bad and stops helping to make amniotic fluid (4) Dehydration?

ectopic pregnancy surgical management

i) Salpingectomy - removal of tube ii) Salpingostomy - to preserve fertility if rupture has not occurred (1) Not removing the full tube (2) Fertility preserved iii) Standard pre-op measures (1) VS (pulse, respirations, BP) assessed every 15 minutes or needed according to the severity of the bleeding and women's condition iv) Pre-op labs: Blood type & Rh factor, CBC, β-hCG level v) Ultrasound to confirm ectopic pregnancy vi) Rhogam if needed (if she is Rh-)

ectopic pregnancy monitoring after treatment with methotrexate

i) Serial B-hCG levels until undetectable (1) Follow Beta hCG levels closely ii) Contact health care provider immediately if she has severe abdominal pain, which may be a sign of impending or actual tubal rupture

McRoberts maneuver (shoulder dystocia)

i) hyperflex knees (almost to ears!) (1) Allows the pelvic bone to come up and increase the diameter of the pelvis to try and try to unwedge the shoulder (2) This maneuver causes the scrum to straighten, and they symphysis pubis to rotate toward the mother's head. The angle of pelvis inclination is decreased which frees the shoulder

emergency CS intrauterine resuscitation

i) tried all of the following interventions without any relief (1) Change position (2) Stop pitocin iV infusion (3) O2 (4) Fluid bolus

viability

i. 5-6% survival ii. between-hospital variation in initiation and intensity of treatment iii. Methodological challenges 1. Great variation in practice between 22-23: resuscitation efforts, active treatments a. Much less variation after 24 weeks a. Percentage with severe/moderate disability by gestational age among surviving newborns i. Before 23 weeks ii. 98-100% "significant morbidity"

postpartum thyroiditis

i. Abnormal TSH level in first 12 months postpartum without nodule or TRA-antibodies. ii. After full term or TAB/SAB pregnancy iii. Mimics symptoms of postpartum depression 1. Really tired and depressed 2. Can be a little hard to detect 3. Anyone who is at risk should be evaluated iv. Incidence 1.1-21.1% of women 1. Up to 25% of women with DM Type 1 2. Highest among women with history of postpartum thyroiditis (nearly half) a. 50% have recurrence 3. Screen high risk women at 3 and 6 months postpartum with serial TSH

trauma or acute stress risk factor

i. Abuse, accidents, surgery ii. Drugs: cocaine, heroin iii. Infections: systemic, STI, GU, periodontal

new born assessment skin

i. Acrocyaosis ii. Mottling iii. Vernix caseosa iv. Mongolian Spots v. Nevi "Stork Bites" vi. Milia—white spots over the nose of the baby, don't need to be treated vii. Erythema toxicum viii. Skin tags

phase of mutual regulation

i. Adjustment between maternal and newborn needs ii. Takes a little while

Emotions ***

i. Anything goes during "taking in". Expect: 1. Signs of attachment: touch, voice, eye contact, using name, en face positioning 2. Some level of preparation 3. Response to newborn a. Positive or negative b. Giving it up to adoption don't even want to see the baby 4. Feelings of overwhelm r/t parenting, feeding a. Changing roles, partners have the same needs 5. Concern about new roles and changing relationships ii. Need for processing and information iii. Questioning competence iv. Dads and partners have similar response and needs

APGAR acronym

i. Appearance ii. Pulse iii. Grimace iv. Activity v. Respiration

pacifiers

i. Associated with decreased risk of SIDS ii. Recommended by AAP during sleep times AFTER breastfeeding well-established (3-4 weeks) iii. Most of the time there isn't an issue with breastfeeding and breast implants. iv. Some babies are nipple confused easily, suck at a dummy nipple differently than they do the breast and its best to avoid artificial nipples until after breastfeeding has been very well established v. More of an issue when a mother has had a breast reduction in terms of milk production and ability to breast feed exclusively vi. Pacifiers associated with reduced risk of SIDS but not recommended until after a month=--or well after breast feeding has been established

hydrotherapy

i. Bathing, showering, jet hydrotherapy if ROM, need to be careful that all equipment is sterile to prevent introducing bacteria ii. Stimulates the release of endorphins, relaxes fibers to close the gate on pain, improved circulation/oxygenation, soften perineal tissues iii. FHR monitoring is done by Doppler, fetoscope, or wireless external monitoring iv. Good for women with back labor—helps to change position of a baby in OP or OT position v. Results in less use of pharmacologic pain meds, epidurals, less perineal trauma, increased maternal satisfaction vi. **Know your hospital policy for hydrotherapy*

current breast feeding trends

i. Breastfeeding rates in US are improving. 79% is highest ever reported. ii. Due to changes in institutional policies regarding skin to skin, baby friendly, lactation consultants iii. The populations that are least likely to breastfeed are: non-Hispanic black women. Highest among Hispanic women. iv. Current healthy people 2020 numbers 1. Currently people start breast feeding in the hospital but don't continue once they are discharged, numbers are lost after discharge due to lack of resources, knowing what to do

positioning

i. C = Cradle (what women usually go for - but not ideal until breastfeeding is well established. ii. D = Lying down (this approach may be ideal for initial feedings, and women who want to take pressure off their bottom d/t perineal trauma 1. Otherwise, whichever is most comfortable for her and facilitates the best latch. iii. Football often works for c-section moms 1. Look at where these mom's hands are - should be supporting neck and shoulders not pushing the occiput. 2. Baby in good alignment (no head twisted) 3. Pillow really helps to position the baby and with support to relieve the pressure on the mother 4. Holding hand on breast for baby, baby will slip off the breast if they are not being supported/having the breast supported for them iv. Football hold—great for women with large breasts and who recently had a c-section v. Crosscradle—good for women with large breasts. More control, helpful for getting baby to latch, supporting whole body and head of the baby vi. Cradle—especially helpful for woman who are trying to get baby to latch vii. Sidelying—night time position or someone recovering from c-section, can rest as well as feed

cholesterol

i. Cholesterol essential for brain development. Fats from breast milk are the best absorbed - that is why formula companies remove the cow milk fat and replace with vegetable oil fat. If whole milk is fed to infants - fat would pass right through leading to poor absorption and poor weight gain since infants get 50% of their calories from fat. ii. Fatty acids important for growth, neurologic development and visual function iii. Most variable component - changes over one feeding, over a 24 hour period, and across time

why is it so important to keep the infant warm

i. Cold stress increases the infant's O2 needs, increasing respiration and can lead to hypoglycemia and metabolic acidosis (PREVENTABLE!) ii. Being cold sets up this cascade ***** prevention is key!!

maternal overnutrition and lactation performance

i. Continued impact on breast feeding ii. Reference is normal weight (healthy weight) iii. Underweight woman have a reduced but not statistically significant reduce in breast milk production iv. Obese women—there is a significant reduction v. Gestational weight gain also has a significant impact on breastfeeding duration and breast milk production i. Reduction in 6 months duration of breast feeding b. i. Low milk volume + low weight there will be an early cessation of breast feeding ii. Medical factors 1. Large baby, early baby related to medical indications like gestational diabetes, or preeclampsia 2. Extra fluids -baby holding on to more fluid 3. Early babies breast may be too big and they baby might not be able to latch on iii. Before pregnancy 1. Excessive weight impairs lactogenesis II iv. Reduction in initial milk volume in the first couple of days v. Early cessation of breastfeeding 1. Especially if she has low milk volume and the baby is not gaining any weight difficulty with latching magnesium for preeclampsia

presentation

i. Contractions: ≥ 4/20 min or 6/60 min 1. Persistent 2. Especially if increasing 3. Especially if sensation is low ii. Pressure with/without bleeding 1. More than usual pressure. Not the pressure women feel all the time while pregnant iii. Leakage of fluid (LOF / pPROM) 1. Big gush and/or intermittent trickle 2. Watery or urine-like consistency 3. Keeps leaking until she delivers

IgG

i. Crosses the placenta ii. Provides passive acquired immunity iii. Crosses easily across the placenta (actually the only one that crosses to the placenta) most abundant, gives immunity to the baby iv. This is why it is important to be up to date on immunizations prior to pregnancy v. Key to immunity to bacteria and viruses Typically provides sufficient antimicrobial protection during the first 3 months of life

choosing a method of feeding bottle

i. Cultural - perceived as more convenient, less embarrassing, involve other family members, incompatible with active social life, work life, modesty issues

cord care

i. Dry care ii. Prevent infection - use of soap and water (but no prolonged immersion) iii. Clamp removed before discharge iv. Dried within 2-3 days v. Separation 10-14 days

PE genitalia

i. Edematous—especially if the babies come breech, sometimes see it with babies in a breech position even if the baby is not born vaginally, but typically resolves quickly ii. Vernix iii. Discharge 1. Mucoid 2. Pseudomenstruation 3. Brick Dust iv. Vaginal tag v. Undescended testes—descending or descended into the scrotal sac vi. Hydrocele—fluid filled scrotal sac vii. Hypo or epispadias—dorsal side of the penis instead of the end, will likely require a revision so these babies cannot be circumcised

puerperal Infection

i. Endometritis-most common pp infection, usually staph aureus, starts at placental site, can spread quickly. ii. More common in chronically ill, prolonged ROM or labor, internal monitoring of fetus, foley catheters, cesarean (5-10 times higher) or other operative birth iii. Rule out UTI, mastitis, wound infection iv. Really tender fundus and will likely have a fever v. More commonly in long labor or chronically ill vi. Draw back to internal monitoring—bacteria/viral agents can climb up the monitor

how is heat lost?

i. Evaporation, Conduction, Convection, Radiation ii. Radiation—radiates off the babies body iii. Convection—turn off fan when mom is about to deliver iv. Conduction—place baby on a warm surface to prevent conduction losses v. Evaporation—keep the body dry to prevent evaporation losses b. Brown fat—the type of fat that hold the most amount of heat and hold the heat the best

expressing milk 2

i. Expressing: 1. Hand expression 2. Hand expression video 3. Mechanical expression 1. Hospital grade pump 2. Electric self-cycling double pumps 3. Smaller electric or battery operated pumps 4. Manual breast pump

breast feeding benefits for mother

i. For Mother—relationship not just a method of feeding 1. PP bleeding and improved involution 2. Reduced risk for: 1. Ovarian & breast cancer—related to suppression of ovulation 2. Type II Diabetes 3. Hypertension, hypercholesteremia, CV disease 4. Rheumatoid arthritis 3. Bonding 1. More skin to skin contact, aids in maternal role attainment 4. Maternal role attainment 1. Bonding

MMR

i. For women who have not had rubella or who are serologically non-immune (titer of 1:8 or enzyme immunoassay level less than 0.8), a subcutaneous injection of rubella vaccine is recommended in the postpartum period prior to hospital discharge to prevent the possibility of contracting rubella in future pregnancies; this is given as the measles, mumps, rubella (MMR) vaccine. ii. Women are cautioned to avoid becoming pregnant for 28 days after receiving the rubella vaccine because of the potential teratogenic risk to the fetus safe in breastfeeding moms

PE neuromuscular

i. Glucose critical ii. Transient tremors/jitteriness is normal 1. Can be brought on by an external stimulus 2. Movements can be stopped 3. If persistent, check for hypoglycemia. 1. Accucheck < 45 → Serum glucose 2. < 40 → Feeding and recheck after 1 hr iii. Seizure - associated with ocular changes and autonomic changes

special breastfeeding considerations

i. Good ways to wake a baby: unwrap, change the diaper, talk to the baby, skin to skin ii. Fussy - sometimes too fussy to latch and nurse iii. Pre-term - good for retinal maturation, improves neurocognitive outcomes, prevents infection iv. Initially breastmilk from mothers of preterm babies has higher concentrations of energy, protein, and minerals compared to term milk. v. Late preterm babies are at risk for poor feeding, hypothermia, hypoglycemia, and hyperbilirubinemia. They tire easily, have problem sucks, and are prone to sleepiness. vi. Extra support for mom and partner - groups like La Leche Leagues vii. May have to provide additional feedings from pumping viii. Keep a lactation diary—how long the baby is feeding, how they are positioned look at latching ix. Serum bili is important for assessing and monitoring for jaundice x. Increased feeding with jaundice xi. Kangaroo care is very important xii. Started to provide audiovisual in the nicu so that mothers that are separated from their babies can watch them grown and help them bond and aid with breast pumping, helps facilitated breastfeeding Clicking =very bad latch, should be a silent latch *

expressing milk

i. Hospital grade pumps are double pumps - more efficient, insurance now covers the cost of pumps, most women could use that additional help at some point, double pump have a higher surge of prolactin (great if pumping at work) ii. Most times the set up with the flange and the tubing can be taken home and used with a rented pump of the same make. iii. Consult lactation consultant to determine which pump is right for her, also flange size. iv. Cleaning v. Volume to see vi. Double pump—higher surge of prolactin especially good if you are going to pump at work/pump a lot

care management for nonpharmacologic interventions

i. How do we evaluate how well these interventions are working? 1. Asking good conversation + dialogue "is this working? or would you like to try something different" 2. Ask them, "are they in the zone" 3. Is it working, is it making things worse, is there anything else you should try? what do they want, do they want any medications 4. Some mothers think that asking if they want pain medications after they've said they want a natural childbirth as intrusive Some people have it written down that they don't want to be asked, so don't ask = empowers them to make the decision; if they change their minds they will let you know

fFN overview

i. If fFN is negative she will likely not deliver for two weeks, this is not 100% accurate ii. The presence of fFN during the late second and early third trimesters of pregnancy may be related to placental inflammation, which is thought to be on e cause of spontaneous preterm labor. The presence of fFN alone is not very sensitive as a predictor of birth however, it is often used to predict who will NOT go into preterm labor, because preterm labor is very unlikely to occur in women with a negative test

stool progression color and consistency

i. Initially dark sticky tarry meconium (lots of bilirubin which gives it this consistency) ii. Transition stool a little more greener iii. Mustard yellow—and stay this way if they are exclusively nursed iv. Stool will be loose and stay this color exclusively while breast feeding—not diarrhea, the mother should be educated on this v. Helpful for mother to keep feeding diarrhea in the first week until feeding is well established. Should also monitor wet and dry diapers

insufficient milk supply

i. Insufficient milk supply - is it maternal stress? Was there an issue with previous pregnancy, infant weight loss, feeding technique, medications? assessment and evaluation of dyad (latch and tongue-tie professional evaluated by practitioner with skill in this) non-pharmacologic measrues

donor milk

i. Is used in NICUs for low BW, premies or sick infants when maternal milk is unavailable ii. Screened serologically and by interview iii. Pasteurized donor milk recommended by AAP iv. No federal oversight, but HMBNA guidelines v. 16 milk banks in US and Canada. vi. Collect, screen, process and distribute milk. vii. Internet milk sharing is discouraged viii. Very expensive, there is no evaluation or screening if you don't go to a milk bank ix. Most of the time milk from milk banks go to the nicu

definition of preterm labor

i. Labor occurring between 20 and 37 weeks of pregnancy ii. Uterine contractions of 4/20 minutes or 6/60 minutes, with or without ruptured membranes

formula choosing a method of feeding

i. Lack of knowledge / benefits ii. Cultural beliefs / social factors 1. More convenient, less embarrassing, involving other family members, incompatible with active social life, work life and modesty issues iii. Previous unsuccessful experience affects confidence c. Other

parent education-general and safety

i. Lots of parent education takes place during this time period, which is unfortunate since she is not in the right mind set to learn ii. Safety 1. Abduction 2. Limiting exposures to unnecessary people (infection control!)

thyroid storm

i. MFM, NICU, OBGYN joint management ii. Beta-adrenergic blockage, high dose PTU, dexamethasone, supportive care iii. Thyroid storm = MEDICAL EMERGENCY, neurologic symptoms are not expected in this population, typically usually healthy iv. Rare: 1% of women with untreated or inadequately treated hyperthyroidism 1. High levels T4 and T3 v. Maternal heart failure, shock, 25% maternal mortality vi. Often precipitated by big event like delivery, infection, surgery. vii. Extreme hyper-metabolic state:

medications and breast feeding

i. Medication is considered safe during pregnancy it is generally considered safe during breast feeding, H1 blockers that dry up secretions may affect the volume of breast milk, alcohol readily passes into the breast milk usually a two hour window check on lactmEd

transition important considerations

i. Mother's health history 1. Chronic conditions that may affect the transition ii. Past pregnancies and deliveries 1. C section, v-back (vaginal birth after c/s) 2. Hemorrhaging? iii. Current pregnancy health status iv. Course of Labor and Birth 1. Has she been having deceleration, how long has she been in labor, labor for 4 days with only ice chips? (will likely hemorrhage) v. Important to asses before delivery so you can anticipate any and all complications

reciprocity

i. Mutually gratifying interaction ii. When the baby starts recognizing you and starts smiling at you

newborn nutrition and hydration

i. Newborns and Infants do not need any extra water. Their nutrition source - either breast milk or formula has the fluid volumes that these infants need. ii. Plus - they have a little bit of fluid reserve - although there is not much room for drastic shifts in fluid balance, so nurses need to carefully monitor

CHO

i. Newborns have limited ability for gluconeogenesis and ketogenesis ii. 40-50% of total calories in newborn diet iii. Lactose is primary CHO in animal milk. Breast milk has a higher concentration of lactose compared to formula iv. Breast milk has added oligosaccharides. These HMO's are complex CHO uniquely found in human breast milk and function to promote the development of the infant's gut microbiome - function as a prebiotic to create an acidic environment that repels harmful bacteria. v. Formulas try to mimic this - some studies suggest some protective benefits, but other studies suggest that these may increase gut permeability.

Cardiovascular s/sx

i. Normal HR: 100-160 bpm 1. Listen at apical for full minute (PMI = 4th intercostal left of midclavicular line) ii. Normal BP: 60-80/40-50 (not usually done term infants) iii. Abnormal: 1. Murmur with poor perfusion 2. Tachycardia >160 bpm may be r/t: 1. Anemia 2. Hypovolemia 3. Hyperthermia 4. Sepsis 3. Bradycardia <100 bpm may be r/t: iv. Apnea v. Temperature extremes vi. Hypoxia

transition at birth

i. Nurses are basically running a code ii. It is a birth not a code for the vast majority of births iii. Transition from labor to newborn allow for a pause for the parents and baby to bond iv. Allow for pause v. With the delivery there is a huge surge of hormones that allows for the bonding of the mother and child as well as the delivery of the placenta vi. If you interrupt this process one of the first complications is the prevention of the delivery of the placenta vii. Allow for peace and quite

on demand breastfeeding

i. On demand after breastfeeding is established and infant is gaining weight ii. On demand still means at least 8x/24 hours iii. Duration varies depending on infant's age. As they get older, they get more efficient and breastfeeding time decreases. iv. Different mothers may take different approaches - letting an infant try both breasts/feeding or one/feeding. But she must alternate the breast that she starts with to ensure equal stimulation. Also want to ensure that baby is nursing long enough on one side to get the hindmilk:

D/C teaching

i. PP appointments ii. Fatigue iii. Nutrition iv. Weight Loss v. Should not be trying to lose a significant amount of weight in the first 6 weeks vi. Psychological Status vii. Activity Level viii. Support resources ix. Family planning x. Incision Care xi. Pericare xii. Ability to care for newborn xiii. When to call doctor xiv. When to follow up 1. Post vaginal 6 weeks 2. Post c-section 1-2 weeks

tips for promoting a good latch

i. Position ii. Express colostrum—smell and taste of colostrum will help baby latch iii. Support breast 1. Hand in "c-shape" (until breastfeeding is well established) 2. Nipple sandwich iv. Wait for open mouth

postpartum maternal complications

i. Postpartum Hemorrhage ii. Severe pain: Wounds, hematomas or other clots, infections iii. Puerperal Infection: Fever over 100.4 twice, at least four hours apart, on any two of the first 10 days postpartum, excluding the first 24 hours iv. Mood Disorders

Chronic inflammation/stress/imbalance (allostatic load) risk factors

i. Poverty, racism, lifestyle, life events ii. Maternal medical condition: DM, thyroid, asthma, depression iii. Age > 35

Gestational Age - Ballard neuromuscular and physical maturity

i. Preterm < 37 weeks ii. Late Preterm 34 0/7 - 36 6/7 iii. Early Term 37 0/7 - 38 6/7 iv. Full Term 39 0/8 - 40 6/7 v. Late Term 41 0/7 - 41 6/7 vi. Postterm 42 0/7 & beyond vii. Postmature > 42 weeks evaluates neuromuscular activity and physical maturity

internal fetal monitoring advantages

i. Provides a more accurate appraisal of fetal well being 1. not interrupted by fetal or maternal movement or maternal size 2. membranes must be ruptured, cervix sufficiently dilated, presenting part low enough (to even have scalp electrode) 3. sometimes external monitoring is combined with internal monitoring. The fetal heart rate might be fine, and she has been on Pitocin/oxytocin for a while. So, will put an IUPC to further evaluate the contractions. But fetal heart rate is not a concern so will have both internal and external monitoring

Brazelton - Behavioral Assessment Scale

i. Requires special training ii. Assesses infant response to 28 areas organized according to newborn behavioral developmental stages

PE musculoskeletal

i. Shoulders: Bilateral arm mobility ii. Digits: Oligo/Polydactyly iii. Hips: Dyplasia 1. Asymmetry of gluteal and thigh folds 2. Limited abduction 3. Femur length 4. Ortolani maneuver iv. Spine: asses spine all the way down 1. Closed 2. Straight 3. Dimples 4. Tufts

Inadequate respiration s/sx:

i. Silent, limp, pale/blue/grey, grunting, nasal flaring, stridor, gasping, chin tug ii. Intercostal or subcostal retractions iii. Suprasternal or subclavicular retractions iv. RR < 30 or >60 v. LATE sign: central cyanosis vi.

other parent education topics

i. Sleep position ii. Bathing iii. Diaper Changing iv. Cord care v. Circumcision care - S&S infection vi. Chiropractic and Craniosacral modalities of care vii. Can demonstrate proper breastfeeding or bottlefeeding 1. Never prop feed a baby viii. Reduces the risk of heterosexually acquired HIV

preconception care

i. Stop smoking and using cocaine ii. Treat infections, use probiotics 1. BV, STIs a. Bacterial vaginosis can cause preterm birth, treating it during pregnancy doesn't help. Have to prevent it prior to pregnancy 2. periodontal iii. Increase interpregnancy interval to > 18 months iv. Correct/moderate energy imbalances and inflammation

maternal contraindications to breastfeeding

i. T-cell lymphotropic virus I or II ii. Untreated brucellosis 1. Brucellosis - bacterial infection that causes flu-like symptoms. 2. Unpasteurized raw/dairy products - usually be ingestion 3. Possible also by inhalation or cutaneously (eg. Meat plant workers) iii. HIV 1. HIV - not recommended in US (where formula, clean water easily accessible), but recommended by WHO (weighing the 15% odds of transmission with risk of unsanitary formula. ALSO breastfeeding may actually inhibit transmission the human milk oligosaccharides may trick HIV into binding to them, keeping them in the gut rather than entering the bloodstream. 2. Recommended in areas where risk of formula (not having water) is greater than having HIV 3. HIV+ women in U.S. are not recommended to breastfeed iv. Active TB 1. Can breastfeed directly after 2 weeks of treatment or deemed noninfectious v. Active Herpes simplex lesions on breast vi. Varicella 1. Even if acquired 5 days before birth vii. H1N1 (swine flu) b. Some Medications i. Medications: citalopram (Celexa), diazepam (valium), Prozac, lithium

varicella vaccine

i. The CDC recommends that varicella vaccine be administered before discharge in postpartum women who have no immunity. ii. A second dose is given at the postpartum follow-up visit (4 to 8 weeks after the first dose)

challenges to becoming a mother

i. Time for self ii. Feelings of inadequacy iii. Fatigue iv. Loss of freedom v. Other children 1. Making sure children feel included vi. Infant behavior vii. Many challenges to becoming a parent, provide education, literature and guidance

progesterone

i. To help prevent preterm delivery ii. For women with prior PTD or with short cervix (≤ 1.5 cm) 1. Reduced preterm birth 2. Lower neonatal mortality and LBW 3. Less RDS, necrotizing enterocolitis, NICU admission

antibiotics for preterm labor (pPROM infections)

i. UTI: Macrobid 100 mg po BID x 7 days ii. BV: clindamycin 300 mg po BID x 7 days OR metronidazole 500 mg po BID x 7 days (or 250 TID) iii. GBS: PCN 5 million units now, then 2.5-3 million units q 4 hours iv. GC: ceftriaxone 250 mg IM x 1 v. Chlamydia: azithromycin 1 gram po x 1 vi. Trich: metronidazole 500 mg po BID x 7 days (or 250 TID) vii. Yeast: OTCs, or fluconazole 150 mg po x 1 (cat C) viii. pPROM: IV or po, regimens vary

FHR bradycardia common causes

i. Untreated maternal hypertension ii. Atrioventricular dissociation (heart block) iii. Structural defects iv. Viral infections v. Medications vi. Fetal heart failure vii. Maternal hypoglycemia viii. Maternal hypothermia

structural issues (risk factors)

i. Uterine anomalies, cervical procedures (LEEP), scarring from uterine procedures ii. Uterine anomalies—stretches the uterus in a funny way that may cause more cramping and contractions, example is a septum down the uterus iii. Prior surgery, D&C

Smell - able to discriminate odors

i. Vision 1. Lacks accommodation (develops over 3 months) 2. Can see 2.5 feet away, most clearly at ~ 1 foot 3. Com 1. Especially about the scent of the mother compared to other humans 2. Newborns have a highly developed sense of smell and can detect and discriminate distinct odors. 3. By the fifth day of life newborn infants can recognize their mother's smell. 4. Breastfed infants are able to smell breast milk and can differentiate their mothers from other lactating women iv. T

Vitamin B12

i. Vitamin B12: Vitamin B12 is required for proper red blood cell formation, neurological function, and DNA synthesis i. Vitamin B12 found in fish, meat, poultry and dairy products. ii. Vitamin B12 supplementation may be needed for vegans & women who've had bariatric surgery 1. Portion of stomach that is bypassed is where Intrinsic Factor is manufactured which binds to B12 and is absorbed later in the intestine. This is not possible for bariatric surgery patients so they may need supplementation iii. It is crucial to monitor the baby's weight gain over time as a B12 deficiency or milk production issues can cause lethargy and failure to thrive in the baby. In infancy, Vitamin B12 deficiency can also cause anemia, developmental delays, and permanent neurological problems in addition to failure to thrive. Infants can become symptomatic after even a few months of inadequate vitamin B12 intake.

vitamin D toxicity

i. Vitamin D Toxicity: Rare, but excessive vitamin D can cause nausea and vomiting, loss of appetite, excessive thirst, frequent urination, constipation, abdominal pain, muscle weakness, muscle and joint aches, confusion, and fatigue, as well as more serious consequences like kidney damage.

application of heat

i. Warmed blankets, warm compresses, heated rice bags, a warm bath or shower, or a moist heating pad can enhance relaxation and reduce pain during labor. Heat relieves muscle ischemia and increases blood flow to the area of discomfort. Heat application is effective for back pain caused by a posterior position or general backache from fatigue.

equipment

i. Warmer ii. Warmed blankets iii. Oxygen Source, tubing, ambu bag and baby mask iv. Instruments for visualizing and establishing airway v. Suction setup—make sure it is working vi. Resuscitation cart—just know its location, usually nicu manages this vii. Neonatologist/NNP (if anticipate significant risk)

bonding and feeding transition

i. allowing mother and family to connect with baby 1. Early bonding promotes parent—infant attachment 2. Good for both mother and newborn 3. Skin to skin is ideal for breast feeding 4. How can the nurse facilitate bonding? 1. TRY NOT TO DISTRUB THE FAMILY AS YOU ARE GIVING CARE! 2. Co sleeping is not recommended and have a higher rate of SIDS with co sleeping 5. Warmth, comfort and feeding of mother 6. Monitor mother's bleeding and VS with Newborn's VS 7. Skin to skin as soon as possible 8. Admission & assessment procedures on mother's chest

safety and general care with pharmacological interventions

i. document everything you give and pt. response to the procedure; be able to manage adverse reactions 1. ex: notice hypotension = manage it give other medications to bring BP up 2. be prepared to manage the ADRS

magnesium sulfate

i. for neuroprotection ONLY if < 32 weeks 1. Relaxes smooth muscles including uterus, CNS depression 2. Loading dose 4-6 grams IV in 20 min, then 2-3 grams/hr x 48 hours 3. May suppress maternal respirations, neuro, kidneys 4. Magnesium sulfate for preventing preterm birth in threatened preterm labor 5. Does not prolong labor or improve neonatal outcomes, and use may increase fetal/neonatal/infant mortality 6. Does provide neuroprotection (less CP) if given when delivery is imminent prior to 32 weeks. a. Prior to 32 weeks it is given for neuroprotection 7. Dosing above is different from dosing for seizure prevention in PIH 8. Not helpful for improving fetal outcomes in this situation

contraception continued

i. hormonal IUD should be avoided for the first year because it will have impact on milk production, there will be amenorrhea and will not be fertile during this time 1. Once baby is sleeping through the night, needs to use condoms 2. Birth control 6 weeks to 6 months after birth 3. After starting oral contraceptives have to monitor to see if it affects their milk production

vitamin D

i. inadequate in breastmilk. Vitamin D facilitates intestinal absorption of calcium and phosphorus needed for bone development. 1. Most infants can synthesize the vitamin d they need from sunlight - but in some cases (high latitudes, lots of cloud cover, air quality, clothing, sun screen) and furthermore because sun exposure is increasingly being discouraged - AAP recommended for all breastfed and partially breastfed babies. AAP recommendation for 400 IU daily. Qatar Example

jaundice is caused by:

i. increased serum bilirubin levels 1. A lot of new premature babies have jaundice 2. It is caused by a breakdown of red blood cells**** 3. May need photo therapy 4. Jaundice is caused primarily by the accumulation in the skin of unconjugated bilirubin, a breakdown product of hemoglobin formed after its release from hemolyzed red blood cells (RBCs).

preterm labor key signs and symptoms for diagnostics/definition

i. labor occurring between 20 and 37 weeks of pregnancy; ii. uterine contractions of 4/20 minutes or 6/60 minutes, with or without ruptured membranes; iii. evidence of cervical change (dilation, effacement, consistency, position), OR the cervix at > 2 cm dilated or ≥ 80% effaced

second period of reactivity

i. lasts for 10 min to several hours 1. Baby is alert and responsive, readily roots, latches 2. Occurs 8 hours after birth

intensity (contractions)

i. mild, moderate, strong) or if IUPC give range of mmHg 1. feel mother's stomach (palpate): a. mild = feels like chin b. moderate = tip of nose c. strong = forehead ii. external monitor tells you frequency + duration only - you palpate for strength iii. internal monitor = tells you all 3

security transition

i. mother feels secure she will be able to release the placenta and bond with her baby. She has to trust the nurse and be able to trust what is going on in the room in order for these events to take place 1. Id bands—check and double check 2. Bassinette crib cards 3. Alarm tags 4. Staff ID ( example only staff with purple badges can touch the baby) 5. Bassinette for transport in the hospital (no carrying) 6. Never leave baby unattended 7. No co-sleeping

transition care vital signs

i. q 30 min x 2 hours or until stable 1. Axillary temp 2. Respirations and HR for full minute 3. No BP (but CCHD before discharge home)

non-pharm measures for insufficient milk supply

i. skin to skin, increasing feeding frequency, pumping, rest, stress relief, fluids ii. Herbal measures - fenugreek, blessed thistle - but no evidence

internal (spinal electrode and IUPC)

i. ternal (spiral electrode and IUPC) 1. IUPC—Intrauterine pressure catheter, fed into the unterus and pressure of the fetus senses a contraction Scalp electrode attaches to the babies scalp and the cathter goes next to the baby. During contractions pressure is sensed by the catheter and the reading is transferred.

cervical length

i. typically done in high risk patients- high risk pregnancy or hx preterm delivery ii. a possible predictor of preterm labor iii. Cervical length: has negative predictive value, but false ++ 1. Endovaginal ultrasound 2. If < 3.0 cm 23% risk PTB 3. Preterm cervical shortening occurs over a period of weeks, so neither digital nor ultrasound cervical examination is very sensitive at predicting imminent preterm birth iv. Using a vaginal probe ultrasound v. Changes in cervical length occur before uterine activity so cervical measurements can identify women in whom the labor process has begun vi. The shorter it is the cervix the more concerning it is (but risk is reduced if they are not contracting and feeling well) vii. The longer the cervix is the less likely preterm labor is going to happen

Perineum—Perineal Discomfort causes

i.Episiotomy/Laceration, incision ii.Edema iii.Hematoma iv.Hemorrhoids

shoulder dystocia care

ii) Calm—keep the momentum moving, no pausing iii) Know environment iv) Know team v) Risk to fetus

estrogen extra--genital effects

increase blood volume increase heart rate, stroke volume, and cardiac output increase in fibrinogen softening of fibrous connective tissue capillary engorgement

endocrinology changes pancreas

increase in HPL => resistance to insulin placenta => insulinase => rapid metabolism of insulin (have to eat frequently to avoid ketosis)

liver changes

increase in alkaline phosphatase secondary to placental isoenzymes of alkaline phosphatase

estrogen effects on reproductive organs

increase in growth of endometrial gland and stroma increase in number and size of myometrial cells increase in myometrial contractile elements increase blood flow to uterus promotes ductal development of breasts (lactogenesis 1)

Progesterone reproductive organs

increase in secretory activity off endometrium decrease uterine contractility stimulation of alveolar development in breasts stimulates increase in tissue factor (which initiates clotting) in amniotic fluid, decidua and endometrium

steroids (bethamethasone, Dexamethasone) risks

increase mom's blood sugar, change her immune response but will increase the babies rate of maturation

decrease gallbladder emptying

increase tendency to form gallstones

increase in eccrine sweating

increased due to increased thyroid, increased metabolic rate and increased fetal heat production

respiratory physiologic changes

increased oxygen consumption 30-40% increase in tidal volume (adds to the feeling of dyspnea) 20 % decrease in residual volume respiratory rate is unchanged

decreased bladder tone + decreased renal function and dilated ureters + puerperal diuresis =

increased risk of bladder distention and incomplete emptying

changes to the vagina

increased vascularity--swells and more filled with blood increased thickness of mucus (increased risk of yeast infection) acidic pH increased vaginal discharge

fibrinolytic activity, postpartum

increases during 1st few days after birth, then returns to normal

apgar scores 0-3

indicate severe distress

apgar scores 7-10

indicate that the infant is having minimal or no difficulty adjusting to extrauterine life

culture (other factors influence pain)

individual beliefs, values, and expectations (some people believe they shouldn't be expressive, others do - it's all in the culture and individual)

C-section risks to baby

infant RDS fetal injury

three phases of immune response in pregnancy

inflammatory (trophoblast and placentation) the anti--inflammatory (Fetal growth) the inflammatory (immune cells migrate to uterus for labor/delivery

estrogen and progesterone

influence the RAAS activity via increased nitric oxide--sodium retention, increase in total body water primarily increased plasma volume both (with prostaglandin) contribute to a decrease in vascualr resistance inhibit ovulation

Artificial rupture of membranes (Amniotomy) nursing considerations

informaiton, comfort, monitor FHTs and signs/sx of chorio

amnioinfusion

infusion of a room temperature isotonic fluid into the uterine cavity to buffer the umbilical cord/relieve cord compression Risks: over distention of the uterus, increased resting tone Administered via IUPC Must monitor frequency and intensity of UC's and fluid return

transition nursing priorities

initiate respirations and newborn circulation--changed with cord being clamped warmth--avoid cold stress bonding and feeding security

post partum blues

lasts only 10 days peaks on the 5th day Mood swings, teariness, irritability, difficulty concentrating and sleeping, loss of appetite, anxiety, anger, vulnerability. Self-care proper nutrition, proper sleep ARE huge factors. Does she have help at home, help with the baby so she can take care of herself 50-80% of women

signs of effective breastfeeding infant

latches without difficulty Has bursts of 15 to 20 sucks/swallows at a time • Audible swallowing is present • Easily releases breast at end of feeding • Infant appears content after feeding • Has at least three substantive bowel movements and six to eight wet diapers every 24 hours after day 4

phases of first stage of labor

latent, active, transition

management of late decelerations

lateral position IV bolus palpate uterus/DC oxytocin O2 at 10L/min (non rebreather face mask) notify provider consider fetal monitoring anticipate C/s if pattern does not resolve -> b/c baby bot getting oxygen

fluid retention

leads to increased thickness of cornea associated with blurred vision changes manifest in the first trimester and regress within the first 6-- weeks postpartum

PROM symptoms

leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but not having contractions

hg, hct HEELP

less than 12, less than 37%

light lochia

light amount less tahn 4-inch stain on peripad

most common reason for a fatality in HEELP

liver rupture stroke

local anesthesia

local perineal infiltration anesthesia pudendal nerve block

intense grief

loneliness, emptiness, yearning guilt anger, resentment, bitterness, irritability fear and anxiety disorganization Difficulties with cognitive processing Sadness and depression Physical symptoms

dysfunctional labor patterns

long, difficult or abnormal labor caused by a variety or conditions 8-11% of births

Rubella Symptoms

low grade fever, arhtralgias, rash

shoulder dystocia risk factors

macrosomia >4000 grams

diagnostic criteria for perinatal depression

major depressive disorder with peripartum onset often women display anxiety symptoms with mood dysfunction about half of women who are diagnosed wtih pPD experienced symptoms during pregnancy

dysfunctional labor patterns risk factors

malpresentations, CPD, maternal fatigue, uterine overstimulation with oxytocin

emergency CS goal

maternal and/or fetal well being decision to incision (least amount of time between the two as possible)

constipation

may be due to 1. Meds (narcotics) 2. Fear of defecation 3. Surgery 4. Diet changes during and after labor

A Kleihauer-Betke (KB) test

may be ordered to determine the presence of fetal-to-maternal bleeding (transplacental hemorrhage), although it is of no diagnostic value. The KB test may be useful, however, to guide Rho(D) immune globulin therapy in Rh-negative women who have had an abruption

obesity

may have delayed lactogenesis II

HGB postpartum

may see an initial drop of 1 g

shoulder dystocia management

mcroberts maneuver rotate shoulder hands and knees changes the diameter of the pelvis squatting suprapubic pressure

Toco transducer (tocodynamomete)

measures frequency and duration of contractions, not intensity Place it at the fundus—see her stomach rise when she has a contraction, the rise of the belly places pressure on the tocodynamometer

premature rupture of membranes (PROM)

membrane rupture before 37 0/7 weeks of gestation membranes rupture but dont immediately go into labor Premature does not refer to gestational age iv) Preterm premature rupture of membranes = baby under 39 weeks (premature) v) Premature rupture of membranes = 39 weeks

child long term sequelae of gestational diabetes

metabolic syndrome increased systolic BP ADHS

stool progression assessment

mevonium within first 24 hours green/black transitional stool--3rd day (greenish brown to yellow brown) milk stool-4th day breastfed yellow and seedy, pasty to liquid

TORCHES syndrome

microcephaly sensorineural deafness choriorentinitis hepatosplenomgaly (jaundice_ thrombocytopenia (petechial rash) anemia, hydrops (severe fetal edema that can result form inflammatory response), IUGR

third stage of labor active management

mild traction on the umbilical cord administer oxytocin at birth of anterior shoulder or immediately following birth

nursing considerations preparing for the birth second stage fetal heart rate and pattern

must monitor closely if baseline is slowing down, deceleration present: institute interventions turn her on her side, administer oxygen at 10 L/min will discuss heavily next week

EMTALA (Emergency Medical Treatment and Labor

must provide an examination and needed stabilizing treatment, without consideration of insurance coverage or ability to pay, when a patient presents to an emergency room for attention to an emergency medical condition.

early deceleration

nadir with peak of contraction, mirror the contraction i. Onset and the return to baseline coincide with the start and end of the contraction 1. Indicate the babies head is being compressed, its not a good sign 2. Decrease starts with the contraction and goes back up at the end of the contraction ii. Nadir occurs with the peak of the contractions, giving the characteristic mirror image. Early decelerations are usually caused by head compression and are considered benign, not associated with fetal hypoxemia, acidemia or low Apgars, no nursing intervention required

narcan

narcotic antidote

nursing interventions third stage pain management

natural births may want pain management now

nursing considerations preparing for the birth second stage support of father/partner

needs continuous coaching and support encourage them to be present

gonorrhea agent

neisseria gonorrhoeae

syphilis maternal consequences

neurologic (stroke, dementia) cardiovascular, musculoskeletal, multiorgan

other options

nitrous oxide general anesthesia

Complete SAB

no evidence of retained fetal tissue cervix closed none to light bleeding none to mild cramping

false labor

no progressive cervical change discomfort felt in lower abdomen intensity does not increase contractions easily interrupted by medications or activity no blood show or ROM Braxton hicks contractions

Grimace/reflex irritability apgar 0

no response

amniotic fluid index (AFI)

normal index between 8-24 DX by US

weight loss

normal to hae 5-6% weight loss over first 3 days, however >7% requires investigation after mature milk is in, infants should gain 110-200 g(3.9-7oz) per week or 20-28 g(.7-1 oz)/day Note: breastfeed babies do not gain weight as rapidly as formula-fed babies.

threatened SAB

not a true miscarriage spotting mild uterine cramping closed os

Phenothiazines (Phenergan)

not an analgesic, sometimes given with opioids to reduce n/v, can actually impair the effects of opioids Reglan is a better option according to the text

A

number of abortions/miscarriages prior to viability

L

number of living children

gravidity

number of pregnancies

parity

number of pregnancies greater than or equal to 20 weeks irrespective of liver birth or stillborn

G

number of pregnancies, including current pregnancy

P

number of preterm births 20-36.6 weeks

T

number of term births ≥ 37 weeks

2 Classifications of Gestational

o A1 DM= diet controlled Exercise, stress manangement o A2 DM = requires medication • The risk of diabetes in pregnancy are avoidable - due to degree of hyperglycemia o May cause the baby to be bigger

ketone testing DM

o AHRQ recommends for women with GDM who: Lose weight Have inadequate intake of calories of CHO o Ketones associated with lower IQ in baby o DKA increased fetal and/or maternal loss o Facotrs precipitating ketoacidosis in diabetic pregnancy Emesis Infection Non-compliance Insulin pump failure Beta drugs Cortiosteroids Poor management

DM effects on breastfeeding

o Breast milk of diabetics is a little different- lower lactose, higher total nitrogen- and babies may take in less. Breastfeeding should still be highly encouraged but growth monitored. o Breastfed baby less likely to be obese or to acquire Type I or II o For moms Every year of breastfeeding reduces risk of Type II by 15% Also prevents metabolic syndrome Also prevents breast cancer

plan for delivery when DM is not diet controlled

o Deliver by 40 weeks if: Poor/marginal control Non-reassuring fetal status Macrosomia? o Labor Continuous monitoring Frequent blood sugar monitoring Caution with IV fluids- no IV boluses using D5 IV insulin orders depending on control of blood sugars o Consider c/s if EFW > 4500 grams (ACOG) o Anticipate RDS and hypoglycemia in newborn.

3 hour OGTT (if 1 hour result is 140-199

o Preparation Carbohydrate loading 3 days prior (>150 grams CHO) Overnight fast for 8 hours o FBS drawn o 100 grams glucose administered no smoking, stay seated o Hourly blood draw x 3hours o Pass if ¾ of values are normal

cardiovascular examination

o Split S2 with inspiration o Low-grade systolic ejection murmurs o Diastolic murmurs are abnormal o Third heart sound after mid-pregnancy o Displacement upward and to the left

fundal height

o The uterus is within the pelvis up until about 12 weeks and then begins to rise above the pelvic rim o At about 24 weeks it is at the height of the umbilicus this varies depending on the size of the woman and the height of the woman and the parity of the woman o At 36 weeks fundal height almost hits the xiphoid process especially in a woman is having her first child o At about 40 weeks with lightening it drops a little bit o When the baby engages the head of the baby comes to the pubis symphysis First baby happens before labor, subsequent babies happens during labor

TORCHES Prevention

o Vaccines for Rubella and Varicella o C/S for HSV o Hygiene: hand-washing, food preparation

hematologic changes with delivery

o With delivery there is a huge drop off blood volume and RBCs • • WBC count physiologically rises (up to 30K) in labor without infection (as in aerobic exercise) o Normal physiological change that dose not indicate infection • Fibrin matrix in spiral arteries early in pregnancy, cause fibrin mesh to form over placental site at detachment o Fiber matrix from the spinal cord into the uterus that create a mesh that forms over the placenta to keep the woman from hemorrhaging

Fetal monitoring for women with pre-existing diabetes/require medication nonstress test

o baby on the monitor for 20 minutes and monitor contractions and fetal heart rate (does not measure contractions) reactive Nonstress test: two accelerations in 20 minutes (this is GOOD!) - less than that = biophysical physical (apaar in utero, heartbeat, movement, amonitic fluid and fetal monitor)

checking blood sugars in pregnancy

o checking blood sugars 4x/day until glycemic control is established Goals: FBS <95 and 2-hr postprandial <120 Then can check less often, i.e. 4x/day twice weekly

Adverse effects on babies from hyperglycemia, hypoxia + hyperinsulinemia 2nd and 3rd trimeter

o fetus has own insulin Hyperglycemia macrosomia • Or IUGR is mom has microvascular problems

Adverse effects on babies from hyperglycemia, hypoxia + hyperinsulinemia 1st trimester

o teratogenic (oxygen cannot attach to glycosylated hemoglobin) Keeps organs from developing properly (due to hypoxic + builds up extra blood supply SLUDGING)

early onset GBS

occurs in first 7 days

Dilation (Primary Power)

opening of the cervix-0 to 10 cm (a) 0 cm external os can't even get one finger in there (b) 10 cm the cervix is completely dilated, no rim to get passed (c) The gradual opening of the cervix measured in centimeters from 0 to 10 cm

epidural and intrathecal (spinal) opioids

opioid only injection into spinal canal rapid onset pain relief but do not cause hypotension common meds: fentanyl, morphine

P (bubble heP)

pain

Toxoplasmosis agent

parasite, protozoa toxoplasma gondii

placenta previa partial

partially covering

O(ther)

parvovirus B19 varicella west nile measles enteroviruses adenovirus Coxsackievirus HIV

Parvovirus agent

parvovirus B19 (5th disease manifested by a rash)

placenta IgG

passed over from the mother to the baby baby's immunity at birth matches mother's provides immunity for 4-6 months following this time the baby starts having its own immune system

beta hcG levels

peak at 60-70 days (2-2.5 months) declining to lowest levels at 100-130 days (3.5-4.5 months) and remain at this level

what should be done with every trip to the bathroom

peri care is done with each trip to the bathroom

perineal trauma related to childbirth

perineal lacerations episiotomy vaginal and urethral laceration cervical injuries clitoral tears perineum tears

longer second stage side effect of epidural anesthesia

perineal muscles are very relaxed so we wonder if baby will be able to rotate well and how well can she push without feeling anything

taste

preference for sweet 1. Young infants are particularly oriented toward the use of their mouths, both for meeting their nutritional needs for rapid growth and for releasing tension through sucking. The early development of circumoral sensation, muscle activity, and taste would seem to be preparation for survival in the extrauterine environment. The newborn can distinguish among tastes and has a preference for sweet solutions

Nursing assessment for SAB

pregnancy Hx VS Labs B-hcg, hcb (check for anemia), WBC (indication of infection) pain assessment (uterus is contracting to expel fetal parts) bleeding (quantity and quality) emotional status

antibiotics

preop for C/S treatment group B strep (q4hr)

positive signs of pregnancy

presence of fetus visualization of fetus detection of fetal heart tones fetal movement by examiner signs attributed only to the presence of the fetus

human chroionic gonadotropin (hCG)

presence of this hormone is assessed in pregnancy test maintains function of corpus luteum early in pregnancy stimulates thirst centers of hypothalamus, increasing fluid intake (in preparation of increased blood volume)

pulmonary edema cerbral or visual disturbances severe features of preeclampsia

present new onset

burr cells or schistocytes HELLP

presnt

baseline/resting tone

pressure in uterus between contractions (the straight line)

circulation through the heart in newborn

pressures LA> RA causes foreman ovale to close

circulation through the heart baby before birth

pressures in RA> LA blood flow through foreman ovale

gonorrhea infant complications

preterm birth, neonatal sepsis, IUGR, opthalmia neonatorum

fetal consequences of unmanged preeclampsia

preterm delivery IUGR perinatal death hypoxia

imperforate anus

prevents baby from pooping don't have an anal opening

Wharton's jelly

prevents compression of the blood vessels and ensures continued nourishment of the embryo or fetus. Compression can occur if the cord lies between the fetal head and the maternal pelvis or is twisted around the fetal body.

relaxin

produced primarily by the corpus luteum secreted early in the pregnancy also produced by the myometrium, decidua, and placenta softens the cervix, enhances cervical ripening softens all ligaments, allows separation of they symphysis pubis in preparation for labor and delivery mediates uterine quiescence (keeps contractions from happening until term) increases liability of chest cartilage to allow increased chest circumference (permanent) relaxation of bones in the feet (shoe size increases by half a size) ureter dilation

cytotec (misoprostol)

produces uterine contractions used for induction and postpartum hemorrhage (cervical ripening)

pregnancy hematologic changes 2

progressive increase in plasma volume 35-50% increase in RBC mass 20--30% physiologic anemia and slight thrombocytopenia increased in EBC 5-15K (key in infection, inflammation process) increase in fibrinogen (Doubles) fibrin split products, factors VII, VIII, IX, C, von willebrands (but bleeding time and clotting times do not change in a normal pregnancy with delivery there is a huge drop in blood volume and RBCs

emergency CS indications

prolonged decelerations, lates -do the intrauterine resucitation

EDS decreases with

prolonged or premature ROM IUGR-mature but small PIH prenatal corticosteroids--increases baby's production of surfactant

Human Placental Lactogen (hPL)also called Human chorionic somatomammotropin(hCS)

promote lactogenic properties growth hormone stimulates erythropoiesis metabolic activities promotes lipolysis inhibition of glucose uptake anti--insulin action

antibody (immunoglobulin

protein produced by the immune system (mainly by plasma cells) goal is to neutralize the invader

systemic analgesia (opioids) affects

provide sedation pain relief is incomplete/temporary more effective in the early part of labor

Ritgen manuever

provider goes through rectum to apply pressure to help the head to deliver

Management of postdate pregnancy risks

psychological olg placenta meconium big baby

skin changes

spider angiomas (upper torso, face, arms) palmar erythema (50% of patients) varicosities (varicose veins, hemorrhoids, vulva varicosities) striae gravidarum hyperpigmentation darkening of nevie eccrine sweating sebum production increased due to ovarian and placental androgens acne often worsens

drugs used in cesarean birth

spinal (block) anesthesia epidural (block anesthesia) general anesthesia

internal fetal monitoring components

spinal/scalp electrode IUPC

toxoplasmosis treatment

spiramycin or sulfadiazine (antibiotic and antiparasitic)

oxytoxin (pictocin) ISMP listed as high risk medication

standard order for administration and standard concentration infuse by IV pump infuse at port closest to IV infuse alone typically titrated up until they get into a regular uterine pattern that is causing uterine/cervical change

most clotting factors & fibrinogen postpartum

stay elevated in immediate PP ** Increased risk for thrombus formation

counter pressure

steady pressure applied by support person to the sacral area with a firm object or the fist/heel of hand 1. can be applied to both hips or the knees 2. helps woman cope with sensations of internal pressure + pain in the lower back

determining baseline fetal heart rate

step 1 baseline step 2 variability

terbutaline

stops contractions oxytoxin (pictocin) antidote tocolytic (toco= contraction, lytic=lysis) basically breaks up contractions

Lactation inhibitors

stress, alcohol, fear

respiration apgar 2

strong

signs of placenta detachment

sudden gush of dark blood from the introitus apparent lengthening of the umbilical cords vaginal fullness

nursing considerations preparing for the birth second stage maternal position

supine, semirecumbentm or lithotomy positions are still widely used in western societies despite evidence that an upright position shortens labor upright positions, walking, sitting, kneeling, squatting straightens the birth canal, improved uteroplacental circulation, enhances bearing down efforts

Beta-adrenergic receptor agonists (terbutaline) fetal side effects

tachycardia, hyperinsulinemia, hyperglycemia

analgesia

the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness

cervical openings

the cervix has two openings external os =closest to the vagina internal os=closest to the fetus

based on supply and demand (Factors that affect lactogenesis )

the more she nurses and pumps the more milk she will produce

spina bifida

the most common defect of the CNS, results from failure of the neural tube to close at some point

uterine contractions

the number of contractions per 10-minute window average over 30 minutes normal 5 or less in 10 minutes

placenta previa

the placenta is implanted in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces three types: complete, partial, marginal/low lying

resting tone (contractions)

the tension in the uterine muscle between contractions, relaxation of the uterus

morphine sulfate

therapeutic rest get the body to relax a little bit; most commonly used in latent phase will either wake up rested or in labor

absent variability

there is no variability (nothing going up/down) not good amplitude range undetectable

signs of effective breastfeeding mother

• Onset of copious milk production (milk is "in") by day 3 or 4 • Firm tugging sensation on nipple as infant sucks but no pain • Uterine contractions and increased vaginal bleeding while feeding (first week or less) • Feels relaxed and drowsy while feeding • Increased thirst • Breasts soften or feel lighter while feeding • With milk ejection (let-down), can feel warm rush or tingling in breasts, leaking of milk from opposite breast