CNUR 303

Risk factors of vacuum delivery

Cephalohematoma Scalp Lacerations Subdural Hematoma Perineal, vaginal, cervical lacerations Vaginal Hematoma Do not check from behind- lift leg and look on side- can also have labial or periurethral- look at front of perineum- labia

Hemorrhagic shock

Chart amount of blood loss at delivery- often underestimated- hard to eyeball, urine/ a fluid may also be there, coins are good measurements- meaningful- same for everyone, blood- keep watching clots, tissue- massage fundus- rub, increases tone, look at full clinical picture- signs and symptoms of mom Clear drape under butt- fluid drains into cone- more objective measure- what is in cone and around perineum, may disagree with the doctor, move moms around and check under butt C-section- still has bleeding with involution 500-1000 ml (10-15%) Normal- systolic BP Palpitations Dizziness Tachycardia Compensated- degree of shock 1000-1500 ml (15-25%) Slight decrease- systolic BP Weakness Sweating Tachycardia Mild- degree of shock 1500-2000ml (25-35%) 70-80 mm/Hg- systolic BP Restlessness Pallor Oliguria Moderate- degree of shock 2000-3000 ml (35-45%) 50-70 mm/Hg- systolic BP Collapse Air hunger Anuria Severe- degree of shock

forcep-assisted vaginal delivery

Consider NICU Only certain physicians have forcep privileges DOCUMENT, DOCUMENT, DOCUMENT Who has privileges- just because you have privileges doesn't mean you have skills May not be completely calm when applying forceps Opposite hands for each forceps, insert two fingers- posterior and then sweeping to guide forceps into place, lock in place, check to make sure nothing is being caught, follow pelvic curve- downward motion with contraction, then rotate upward, use towel to protect perineum, once head is out- remove forceps

Assessment of EFM

Contractions- •Frequency - beginning of 1 to beginning of the next •Duration- in seconds •Intensity- mild, moderate or strong •Uterine resting tone between contractions •How well the patient is coping, normal contractions- 2-3 min apart, last about 60-70 seconds, does not indicate intensity or resting tone- coupling/ tripling- Fetus not getting break in between- hypoxemia, do not want to see, tachysystole, titanic contractions (palpation)- Continuous, or vey strong with no rest in between (no soft tone) FHR- •Baseline •Variability •Presence of accelerations •Presence of decelerations •Early •Late •Prolonged •Variable Note - classifying the tracing (normal, atypical, abnormal) is a certifiable skill that students are not allowed to do Look at tracing and palpating for intensity and resting tone Accelerations- above baseline, decelerations- below Classify type

Cord blood gases

Cord Blood gases can be a useful clinical indicator of intrapartum asphyxia, and therefore has strong medicolegal utility. As such, various clinical information in combination with arterial and venous cord blood gas results can usually provide a strong defense against a suggestion that an infant had an intrapartum hypoxic‐ischemic event. Five essential indicators of Intrapartum Asphyxia: 1.Umbilical cord arterial ph <7.0 2.Base excess/deficit > +12/-12 3.Apgar score 0-3 >5 4.Seizures, hypotonia, coma 5.Evidence of multi-organ system dysfunction in the immediate neonatal period. Arterial- reflects fetal status, venous- reflects placental status. SOGC recommends that blood gases should be obtained following births.

Baseline Tachycardia

Definition: •FHR > 160 bpm for > 10 minutes •Mild: 160-180 bpm •Marked or Severe: > 180 bpm Increased sympathetic tone, decrease in parasympathetic tone Decreased Variability, several causes- fever, infection (sepsis, chorioamnionitis), drugs (atropine) , fetal heart failure, tachyarrhythmias, hypoxemia, anemia, maternal hyperthyroidism, after deceleration- want to increase perfusion or increased catecholamines Hypoxic events- isolated tachy- other than hypoxemia - infection Causes: •Drugs: amphetamines, cocaine, •Maternal Hyperthyroidism •Maternal or fetal anemia •Fetal supraventricular tachycardia •Fetal Cardiac abnormalities or heart failure •Acute or chronic fetal hypoxemia •Maternal or fetal infections (chorioamnionitis) •Catecholamine ( stress )

Maternal HR Artifact

Definition: •Irregular variation or intermittent pick-up of the FHR Appearance differs: •Chicken scratch interspersed with empty spaces •Organized pattern •Long, uneven vertical lines •Mimics variability Not accurate assessment of FHR baseline

Problems with the passenger (not dystocia)

Dependent on 2 things: 1.Fetal Presentation 2.Fetal Position What is the presenting part and how is it positioned?

Preterm infant

Despite advances in medicine the incidence of preterm birth has not changed. What has changed is science, best practice evidence and technology to care for preterm infants. The following chart depicts approximate survival rate at each premature gestational age. As you can see, each week in utero is precious time for the fetus to grow and develop. Each week in utero equals greater chances of survival. These percentages only reflect mortality and do not include morbidity. •Characteristics of a Preterm Infant •There are differentiating characteristics between a preterm infant and a full term infant due to the way the infant develops in utero. Physical appearance will change the higher the gestational age. Different physical features can help in determining a neonates gestation if it is unknown. Some of them include: •Ruddy, permeable skin •Shiny heels, palms with fewer creases •Large fontanelles •Little to no breast tissue •Large external labia •Undescended testes

Normal Newborn Behaviour

Divided into 3 periods: 1. First period of reactivity birth-30 minutes, prime time to initiate BF, baby is alert and quiet, moves extremities in uncoordinated way, startles easily, sucking motions 2. Period of decreased responsiveness (Sleep phase 2-4 hours) 30-120 minutes of age, baby enters sleep phase, muscles relax, responsiveness to external stimuli decreases 3. Second period of reactivity baby awakens and shows interest in environment, lasts 4-6 hours, peristalsis increases, may pass first meconium ▫How a newborn interacts with their world is called neurobehaviouralresponse ▫Orientation: the response of baby to stimuli, they become more alert when presented with a new stimulus, stare intently at new objects and faces, build familiarity ▫Habituation: ability of baby to process and respond to visual and auditory stimuli, and block out external stimuli as they become accustomed to it ▫Motor Maturity: depends on gestational age - evaluation of posture, tone, coordination, and movements - as baby adapts, smoother movements ▫Self-quieting Ability: baby's ability to quiet and comfort themselves, varies between babies - "consolability" is change from crying to non-crying state, some babies may require parental help with this ▫Social Behaviours: cuddling and snuggling with parent, most newborns enjoy being cuddled or held

Breastfeeding frequency and norms

Easily digested by the newborn in ~ 90 minutes Mothers should be BF 8 or more times per 24 hours (~q1-3hrs) after the baby is 24 hours old to establish and maintain her milk supply Feed on demand based on baby's feeding cues and to allow baby to BF until they are finished Growth spurts at 2-3 weeks of age, 6 weeks, 3 months, and 6 months During growth spurts babies will BF more often (up to 15x/24hrs) BF babies are usually back to birth weight by 2-2.5 weeks of age Once they are gaining weight back they gain an average of 0.5 oz-1 oz per day (5-7oz per week)

What happens during breastfeeding?

Every time a baby latches and suckles at the breast they send nerve impulses to the hypothalamus which then causes release of: Oxytocin (milk ejection hormone) from the posterior pituitary Oxytocin travels through the blood stream to the breast which then causes myoepithelial cells that surround each alveolus to contract This pushes and sends milk down the ducts to the nipple for release to the baby Called Milk Ejection Reflex (MER) or milk let-down: Some women will feel MER occurring, while others will not Baby will have more rhythmic suckling and swallowing pattern during a MER Every time a let down occurs, baby receives different levels of fat content Encourage mothers to allow babies to completely finish their breastfeed without timing sessions Prolactin from the anterior pituitary

Milk Expression

Expressing or pumping milk can be helpful, so that someone other than the lactating parent can feed the baby. Important to maintain cleanliness when doing expressing milk •Hand •Often used with engorgment •Mechanical •Different types of pumps

Continuos Electronic Fetal monitoring

Externally- •fundus to record uterine activity. Most common. Uses an ultrasound transducer placed over the fetal back to receive the heart rate and transforms these into wave forms. A pressure-sensitive transducer (tocodynamomter) is placed over the maternal •Scalp electrode is "screwed" onto the fetal presenting part. Can also involve the insertion of a pressure-sensitive catheter through the vagina and into the uterine cavity to asses contractions. Externally- similar to Doppler, transducer- detects pressure and converts waves of pressure into a signal on graph paper, on fundus to monitor contractions and fetal heart tones on graph paper Internally- assess FHR, pressure transducer, accurate- directly receiving signal

Infant life PP

Feeding- •Support the mom's choice as to how she feeds her infant •Educate about the benefits of BF so they can make an informed decision •If they choose to pump & bottle feed, or formula feed, teach them how to do so safely •Provide 1:1 support as they learn to BF and refer to the lactation consultant as needed Sleep Safety- •Bed sharing is currently NOT recommended, but room sharing is for the first 6 months •Always place baby on back to sleep •Provide a smoke free environment before and after birth •Do not have loose bedding, toys, or bumper pads in the baby's crib Immunizations- •The nurse needs to check if the mom is rubella immune - and if not then an MMR vaccine should be given •If the mom is Rh negative and gives birth to an Rh positive baby - a dose of Rh immunoglobulin is needed •The MBU currently also offers all eligible moms the TDAP and seasonal flu vaccines •The baby's immunizations are managed by PH starting at 2 months old Follow-up care- •Before going home, the parents should know how they can access continued healthcare (urgent and routine) •Appropriate times for follow-up doctors visits should be discussed (for mom and baby) •Referral forms for maternal visiting / public health nurses should be filled out completely before discharge •The parents should also be given all important phone numbers (healthline, public health, MVP)- Maternal visiting nurse- •Usually connect with families within a day or 2 home from hospital •They will visit the home if desired by the parents, within the first week after the birth •They will assess the mom and the baby, weigh the baby and offer feeding support, provide additional teaching, do repeat lab work on babies, and screen for PPD

EFM display

Fetal on top, contractions (uterine activity) on the bottom, intervals between the vertical red lines represent one minute, Big boxes- 1 minute, 6 10-second boxes in between red lines Y axis of fetal (top)= bpm Y axis of maternal- shows strength of contraction (mmHg) X axis- horizontal line, between two big lines= 1 minute Count little boxes underneath peak of contraction to see how long it lasts (duration)

Rh incompatibility

Fetus is Rh+ and mom is Rh-, incompatibility, maternal antibodies cross placenta, destroy RBC in feus (hemolysis), may have villus rupture where blood mixes- not supposed to happen, }IgM antibodies develop from first exposure to Rh factor - don't cross placenta }IgG anti D antibodies develop after - do cross placenta }2nd exposure to Rh positive cells à hemolysis Second exposure activates the immune system

cephalopelvic disproportion

Fetus is larger than pelvic diameters Size of baby Type of pelvis Neonatal abnormalities- hydrocephaly, hydrops- fluid accumulation in compartments of baby- head, abd cavity, may or may not be compatible with life Pelvic types do not accommodate baby

Fetal Engagement

Fetus until birth then infant/newborn Feel ischial spines, amniotic sac, 0- marker for ischial spine, -3- station, bounce off of fingers- not low enough to get stuck and pushed out

Danger signs

First Trimester: •Spotting or bleeding (miscarriage or previa) •Painful urination (infection) •Severe persistent vomiting (hyperemesis gravidarum) •Fever higher than 38 °C (infection) •Lower abdominal pain with dizziness and accompanied by shoulder pain (ruptured ectopic pregnancy) When they should call HCP Placental previa- couple drops then it stops, next one gets bigger and bigger- no intercourse, get an ultrasound Assess infection- fever- early miscarriage Severe persistent vomiting- dehydrated and need IV fluids Ectopic is a medical emergency Second Trimester: •Menstrual-like cramps or uterine contractions (preterm labour) •Pain in the calf, often increased with foot flexion (DVT) •Sudden gush or leakage of fluid from the vagina (premature rupture of membranes) •Sudden change in fetal movement patterns or fewer than 6 movements in 2 hours (possible fetal distress or fetal demise) Bleeding- body is prepared- 500 mL is normal with a vaginal birth C-section- 1000 mL is acceptable, anything more= hypovolemic shock, screened for DVT, pulmonary embolism Teach of when water beaks- assessment in the hospital Third Trimester: •Sudden weight gain, periorbital or facial edema, severe upper abdominal pain or headache with visual changes (pregnancy induced hypertension) •Sudden decrease in daily fetal movements (fetal demise or distress) •Any of the previous warning signs and/or symptoms HTN-sudden weight gain, swelling in face or arms, abd pain, vision changes- spots

Fetal Lie and Presentation

Flip spontaneously to 38th week, then don't flip Fetal life- orientation of baby spine to mother spine Presentation- part of baby body reaching pelvic first Vertex presentation= head down

GI changes during pregnancy

General- increased nutritional requirements, increased maternal appetite, morning sickness= due to increased levels of hCG (not experienced by all) Changes in oral cavity- increased salivation, decr in pH= can result in dental caries, gums= hypertrophy, hyperaemic friable (due to increased estrogen), bleeding and tender gums due to vitamin C deficiency Changes in motility- sometimes reduced under influence of increased progesterone > decr motion = stimulates smooth muscle in gut, slower transit time, more water reabsorption= constipation Esophagus and stomach- variable HCl production, usually reduced, increased gastrin production= incr stomach volume= decr stomach pH, increased mucus, deceased esophageal peristalsis, gastric reflux increases with increased pregnancy (heartburn), intestines- displaces in abd cavity, decreased motility, gallbladder- hypotonia= slowed or incomplete emptying, liver- no morphologic changes, double in serum alkaline phosphatase activity Bowel sounds- decreased, umbilicus, light palpation, size and shape of utterness, note skin characteristics, palpable masses, and mass appropriate for gestational age

Multiple Pregnancy

Gestation with 2 or more fetuses Types: 1.Monozygotic 2.Dizygotic Note: triplets can be monozygotic, dizygotic, or trizygotic High risk Monozygotic- identical, one ovum divided Dizygotic- two different eggs get fertilized, siblings Increased rates in Canada- increased ART and age

Intrauterine resuscitation measures

Goals: •Improve uterine blood flow •Improve umbilical circulation •Improve oxygen saturation •Reduce uterine activity 1.Improving uterine perfusion •Increasing maternal cardiac output will improve uterine perfusion •Lateral positioning of the mother •Correction of maternal hypotension •Administration of intravenous fluids •Administration of pressor agents (ephedrine 5-10mg IV push •Elevation of the legs or Trendelenberg position. 2.Reduction of uterine activity 3.Increasing oxygen transfer 4.Promoting umbilical cord flow •Maternal position change •Stop pushing •Amnioinfusion 5.Increasing fetal cerebral blood flow 6.Other (e.g. operative or cesarean delivery) Patterns show decreased fetal oxygenation- need to intervene, limit cause Reduce or shut off medication 02- 8-10 L via face mask Operative- forceps Nursing actions- •Repositioning or lateral positioning of mother •Reversal of hypotension (IV bolus) •Stop oxytocin •Administer O2 @ 8-10 l/min) •Decrease frequency of pushing •Vaginal examination to assess labor progress •Observe for meconium •Maternal V/S and condition •Reassure patient •Systematic assessment of EFM and whole clinical picture •Notify charge nurse •Call care provider for immediate re-evaluation of mother •Anticipate fetal scalp sampling •Anticipate tocolytics •Anticipate preparations for urgent or emergent operative birth or cesarean section

Epidural

Gold standard Inject meds near spinal cord- numb from chest to feet, awake, antiseptic medication to clean, may have local to prevent needle pain, into sac of fluid that surrounds spinal cord- does not pass dura, begins in about 10 min, may leave catheter in place, Helpful in decreasing pain- monitor sensation and motor response- if we need to get her up - important, change positions, empty bladder q2h- will not notice that they have a full bladder, assess sensory response- may not be able to maintain upright posture- collapse from too much epidural, hypotension- vasodilation , monitor closely for 20-30 min, and regularly until it is discontinued- FHR pattern may change- not getting enough blood, IV in situ- bolus prn, no ice or heating pads- decreased sensation, can burn, not stopping labour- maintain hydration and glucose and upright

Infant feeding choices

Good nutrition in infancy fosters optimal growth and development. Infant feeding is more than the provision of nutrition; it is also about bonding. It also establishes good eating habits and influences lifelong health. Scientific evidence explicitly states that breastmilk provides the best nutrition for infants, and parents should be educated and encouraged to choose breastfeeding. Human milk is the gold standard for infant nutrition. For most women there is a clear choice to either breastfeed or formula-feed. In some cases women decide to combine breastfeeding and formula-feeding. In some instance's women want their infants to receive breast milk but prefer not to feed directly from their breasts. As a RN, it is our job to educate our patients regarding evidence based best practice, and then ultimately support them in their choices

Classification of EFM

Good tracing, grey area, or bad tracing Influences nursing action Students cannot do Normal- document assessment and continue doing what you were doing- support through labour, teaching Decreased fetal oxygenation- maternal: hypotension, hypoxemia, disruption at the uterine-placental surface, prolonged uterine activity, compression of umbilical cord

GTPAL

Gravida= total # of pregnancies, including current, Term= # of term pregnancies (more than 37 wks), Premature- # of premature pregnancies (after 20 wks but before 37 wks) abortions- , # of therapeutic terminations or spontaneous losses (before 20 wks), Living- # of living children who the women gave birth two, twins count as 1, use dashes in between

Hypertensive disorders of pregnancy

High BP for several years before or before 20 weeks- chronic/ pre-existing, nothing to do with pregnancy Pregnancy reduces blood pressure High BP after 20 weeks- gestational, r/t pregnancy, resolves within 12 weeks of giving birth- if not usually had before pregnancy Pre-eclampsia- high BP after 20 weeks, proteinuria, end-organ damage and Eclampsia- pre-eclampsia + seizures Abnormal development of blood vessels in the placenta- trophoblast invade though the decidua and myometrium to get into spiral arteries (supply the uterine wall), get oxygen, why placenta does what it does, trophoblasts need aggressive infiltration, spiral arteries have to remodel themselves- from narrow thick walled to large torturous blood vessels that allow blood to flow through them- pre-eclampsia when this does not happen- arteries do not change for the increase of blood flow, poor oxygen supply to placenta, surrounding cells are angry- release inflammatory molecules (factors) - alter circulatory system- damage endothelial cells (line inside of blood vessels), causes signs and symptoms, when there is damage- harder to control tone, harder to relax= high BP, endothelial cells are leaky- proteins can escape- proteinuria, from blood vessels into tissue , wherever protein goes, water follows- edema and swelling, headaches, seizures, visual symptoms, epigastric pain, elevated liver enzymes, fetal growth restriction Damaged epithelial cells also release factors- clotting throughout body, SBP >140, DBP >90, increased creatinine, decrease platelets, aggressive screening, serious complications- DIC, stroke, mechanical ventilation Cure- delivery is only cure- placenta is the cause >37 weeks- precede with delivery, if less, prevent delivery if possible- only deliver if severe Greatest risk for eclampsia- right before delivery, during labour and 24 hours after delivery- MgS04- antiepileptic during labour, continued for 24 hours PP, hydralazine, labetolol

Review the following assessments and explain their meanings: 1.Ms. Lin is assessed in the labour and delivery room. She is reported to be 3 cm, 40% and -1. What does this mean? 2.Ms. Lin is assessed in the labour and delivery room. She is reported to be 5 cm, 60% and +1. What does this mean?

How to chart Cervix is 3 cm dilated, 40% effaced, -1= 1 cm presenting part above ischial spine 5 cm dilated, 60% effaced, 1 cm below ischial spine

Problems with the powers

Hypertonic Uterine Contractions Normal contractions: start at superior part of uterus and move towards the cervix Midsection contracts with more force than the fundus OR Contraction is not synchronized Push baby down Midsection contracts with more force than the fundus- doesn't push down, just squeezes in the middle, painful, palpate strong but not useful-does not change anything, mid and fundus may not be synchronized- losing power to different parts, not having the power work together, tachysystole- not proper resting tone and periods of oxygenation- angry baby HYPOTONIC UTERINE CONTRACTIONS No basal tone Insufficient intensity Fails to dilate the cervix May be due to: ¡Uterine over distention ¡Fetal malposition Not strong enough, overdistension- more than one fetus, uterus is stretched and cannot contract, polyhydramnios, malposition- inhibits proper contractions Augment labour- ROM, help contractions become stronger and more efficient, oxytocin

In the continuing assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. What should the nurse suspect?

Hypovolemia and/or shock -The nurse should suspect hypovolemia and/or shock. Other symptoms might include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.

Medical reasons for breast-feeding

INFANT CONDITIONS - Infants who should not receive breast milk or any other milk except specialized formula Infants with classic galactosemia: a special galactose-free formula is needed. Infants with maple syrup urine disease: a special formula free of leucine, isoleucine and valine is needed. Infants with phenylketonuria (PKU): a special phenylalanine-free formula is needed (some breastfeeding is possible, under careful monitoring). ** These conditions are extremely rare, we screen every baby in our health region for PKU, but it is very rare that this condition is found in a baby** INFANT CONDITIONS - Infants for whom breast milk remains the best feeding option but who may need other food in addition to breast milk for a limited period Infants born weighing less than 1500 g (very low birth weight). Infants born at less than 32 weeks of gestation (very preterm). Newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand (such as those who are preterm, small for gestational age or who have experienced significant intrapartum hypoxic/ischaemic stress, those who are ill, and those whose mothers are diabetic if their blood sugar fails to respond to optimal breastfeeding or breast-milk feeding.

Shoulder Dystocia

Impaction of the anterior shoulder above the symphysis pubis 1-2/1000 deliveries 16/1000 deliveries in infants >4000 grams Shoulder gets stuck- head stops moving so baby cannot come out Risk Factors: Macrosomia Previous SD Arrested descent in labor Prolonged labor Post-term pregnancy Maternal obesity Maternal diabetic - poorly controlled Short maternal stature Operative vaginal delivery, May have passage problem, powers or size of baby causing problem? Position, Complications: Fetal/neonatal death Hypoxia/Asphyxia Birth injuries ¡Fractures ¡Brachial plexus palsy PPH Uterine Rupture Approx 5 minutes of decreased O2 levels in an uncompromised fetus before pH levels start to drop 7-10 minutes associated with asphyxia Cord pH declines at a rate of 0.04 U/min after delivery of fetal head Already stressed, <5 min, move quickly to get baby out May need resuscitation- may be compromised "Turtle Sign" - Fetal head appears to retract against the perineum 50% unexpected Consider risk in prenatal and laboring periods No further progress with birth, vaginal canal is not accommodating, be prepared A - Ask for Help L - Lift/Hyperflex Leg A - Anterior Shoulder Disimpaction R - Rotate Posterior Shoulder M - Manual Removal of Posterior Arm E - Episiotomy R - Roll on to all 4s, Nurse and doctor Ask for help- need lots of people Usually can get out with lifting the leds, rotate and remove arm- drops baby by creating space so baby can be born- what the Dr. is doing while leg is lifted Roll on all 4s- not easy, need a lot hands to help ALARM usually is all that happens, if this doesn't work- c-section, may need to press head back into vaginal canal Suprapubic pressure- Masani maneuver, push down on shoulder- internally rotate to allow for it to come out McRobert's maneuver- Lift and hyperextend legs- one person on each side, as far back as possible, to open up space, two person job

C-section

Incidence is rising ¡1993: 17.6% ¡2015: 27.5% WHO : 10-15% acceptable ¡At a population level; CS rates higher than 10% not associated with reduction in maternal or newborn mortality rates Appropriate collaborative management of labor is paramount to reducing the number of "unnecessary" c-sections. When >10%- no improvement in outcome for mom or baby Elective- Choose to with other children, tumors, fibroids, Emergent- running down the hallway Urgent- unplanned, labor dystocia, everyone is happy, progress to c-section soon

Assessing infant readiness

Infant readiness cues are the same, whether they are breast or bottle fed Initial feeding should take place within the first hour of life Subsequent feeds q2-3hr, watching for signs of hunger Initial feed will be small, and increase in volume to the end of the first week of life Rigid feeding schedules are not recommended

Neonatal Respiratory Distress

Initiation and maintenance of resp effort is essential for the neonates transition to extrauterine life. Any infant is at risk of resp distress, however there are some factors that put a neonate at higher risk: •Meconium Aspiration: If there was meconium passed in the intrapartum period or during delivery, neonate could be at risk. •Cold Stress: There is a direct relationship between hypothermia, blood glucose and resp status. •Low Blood Glucose: Neonates that are SGA, LGA or born to diabetic mothers may be at risk for low blood glucose. Cold stress can cause this as well. •Transient Tachypnea of Newborn (TTN): Will be discussed later. •Resp Distress Syndrome (RDS), Indicators- •Tachypnea •Apnea •Cyanosis: Perioral, facial, central •Grunting •Nasal Flaring •Retractions: Intercostal, xyphoid, tracheal •Poor feeding Abdominal breathing - blood cultures, oxygen, antibiotics, PICU admission

The nurse practicing in the perinatal setting should promote kangaroo care, regardless of an infant's gestational age. What should the nurse know about this intervention?

It enhances their temperature regulation! -Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent's bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among developmental benefits.

First Stage of Labour

Latent Phase •0-3 cm •Contractions mild and short (20-40 sec) •Low-back pain and abdominal discomfort •Cervix thins; some bloody show •Station - nullipara 0; multipara 2 to +1 •Time - nullipara 8-10 hr average; multipara 5-6 hr Takes a long time- half a day- day Everything goes faster with more vaginal deliveries •Provide encouragement, feedback for relaxation, companionship. •Coach during contractions •Comfort measures: position changes, pericare • Praise and encouragement •Keep aware of progress •Ensuring voiding regularly •Teaching •Monitor progress of labour and maternal-fetal response •Plan: send home until in active labour, Go thorough birth plan, database, go home and come back Active Phase (4-10cm) •4-7 cm •Contractions stronger (40-60 sec); Q3-5 min •Average time; nullipara 2-4 hrs; multipara 1.5-2 hrs •Membranes may rupture now •Increased bloody show •Station -1 to 0 Stringy bloody mucus- cervix dissolving and coming out, •Coach during contractions •Support person(s) may need relief (eat, go to the BR, etc) •Comfort measures •Encourage relaxation, focusing on her areas of tension •Praise, keep aware of progress •Minimize distractions from surrounding environment offer •Administer analgesics as appropriate; •Provide pericare and mouth care (ice chips) •Monitor hydration •Monitor progress of labour and maternal-fetal response •Teaching Make sure they pee Talk about changes to birthplan, Epidural- lower BP, give IV- 500 mL of fluid, empty bladder decreases sensation to pee ABCs! •8-10 cm •Contractions stronger & longer (60-90 sec; Q3-5 min) •Average time; nullipara 1-2 hrs; multipara 1 hr •Increased vaginal show; rectal pressure with beginning urge to bear down •Station: +1 to +2, Pressure in butt- cough and grunt, involuntary movements of mom pushing baby down

Breast Milk

Living organism - genetically made for human infants. Contains immuno-protective agents, hormones, vitamins, enzymes, growth factors, essential nutrients - needed for proper growth and development. Changes from ØColostrum-liquid gold, it is the infant's first immunization, it is thick and sticky in consistency,•Primary function is protective: coats the gut to prevent adherence of pathogens, contains •Lactose - helps to prevent hypoglycemia, has a laxative effect to aid with expelling the meconium - decrease jaundice •ideal nutrition and immunological properties to aid the infant to transition from intra-uterine life to extra-uterine life ØTransitional Milk ØMature Milk- Milk increases in volume between days 3-6 of newborn life Breast fullness and tenderness - baby's swallowing pattern more distinctive Transitional milk occurs after colostrum and lasts for approximately 2 weeks Day 14 = mature Volume ~600-900ml/24hrs

Preterm labour

Lower back pain, pressure in back= contractions 1/8= 12% are premature Give meds to stop- usually doesn't stop completely, just for a few days so that meds can be given to help lungs develop- surfactant production, steroid

Medical reasons for not breastfeeding

MATERNAL CONDITIONS - Mothers who are affected by any of the conditions mentioned below should receive treatment according to standard guidelines. Maternal conditions that may justify permanent avoidance of breastfeeding: HIV infection: if replacement feeding is acceptable, feasible, affordable, sustainable and safe. Otherwise, exclusive breastfeeding for the first six months is recommended.

Anatomy of the breast

Major structures of the breast involved with breastfeeding: Nipple (5 or more milk openings) Areola Ducts Alveoli Myoepithelial Cells Subcutaneous tissue Blood and lymphatic vessels Fat Intercostal Nerves (3,4,5,and 6) are essential for milk production to occur

Other problems related to labor dystocia

Maternal Position ¡Importance of nursing management ¡Consider possible issue for dystocia & troubleshoot Psychological Responses ¡Relationship of stress and neurotransmitters ¡Pain ¡Lack of support ¡Confinement ¡Anxiety Nurses have huge impact on nursing care, need good nursing management, 1:1, repositioning, mobilizing, assessing the progress of labour, fetal wellbeing, look at entire clinical picture, aware of how to manage, hands on nursing management= better outcomes Pain is expected, not always priority- some may not want any pharmacological support- provide nonpharm, overwhelmed and anxious, lack of support/confinement- limited visitors, changed expectations- grieve, cannot fix the problem but be as compassionate and supportive for both mom and support person- increase positivity for both

Newborn elimination assessment

Meconium Formed in utero Passes within 48 hours Black, sticky, tarry, will slowly transition to yellow, "seedy" in breastfed infant Voiding 93% void by 24 hours May be infrequent until feeding well established. Brick Staining (rust color) is normal variation Should have about 6 wet diapers day after day 6 ●Newborn stomach can hold 30-90mL - empties q2-4h ●Kidneys are immature at first, cannot concentrate urine until about 3 months old, not fully mature until 2 years ●Brick Staining - When baby is not producing very much urine, the uric acid crystals may be visible in the very concentrated urine in the diaper. It is not a cause for concern if baby is feeding well. ●Abnormal if infant does not void in first 24 hours. Important to document any wet/ soiled diapers.

Biological nurturing or laid back breast-feeding

Mom can recline to whatever level feels comfortable with all body parts well supported with pillows (mother is never flat on her back) Baby will be tummy to tummy with mother Mother can position multiple ways with this position as her body is more open Allow baby to use natural reflexes to self attach The mother can help the baby as much as she wants and she can hold her breast with c-hold or u-hold if she wants

Treatment of hyperbilirubinemia

More Frequent Feeds: oSolution for physiological jaundice oIncreasing input = Increasing output Help the body clear the bilirubin, enzyme for unconjugated to conjugated- requires glucose, feeds can provide glucose. Phototherapy oHelps to breakdown the bilirubin oMakes it easier to excrete oBiliblanket oBased on transcutaneous & serum results, for pathological,UV lights breaks bilirubin, helps with excretion, Criteria corresponds with therapy recommendations, Transcutaneous Bilirubin Protocol oGreen oYellow oRed

Side lying (BF position)

Mother and baby both lie on their sides facing each other Mother should be well supported with pillows behind her back and between her legs A small pillow or rolled blanket can be behind the baby's back to keep them from rolling away The ear, shoulder and hip need to be in a straight alignment

Intrapartum

Mother and fetus are preparing for birth L&B beginning of extra uterine life, adaptation by both mother and baby

Feeding Spurts

Mothers will usually notice an increase in the infant's appetite at ages •7 to 10 days •3 weeks •6 weeks •3 months •6 months These appetite spurts correspond to growth spurts. Bottles should be increased by about 30 mL when these spurts occur

TOLAC

Must qualify depending on ¡Reason for previous cesarean section ¡Type of previous cesarean section ¡Maternal health Trial of Labor (TOL): 65-85% success rate Common Risks ¡Hemorrhage ¡Uterine Rupture (0.6%) ¡Scar Dehiscence ¡Infant death or neurological complications VBAC after delivery Depends on why they had a previous C-section- did it have anything to do with mother's ability (FHR was abnormal, etc.) Uterine rupture- tragic and move fast, hear and feel nothing, baby can float in abd cavity- but get baby out ASAP Role of RN Continuous EFM Monitor uterine contractions IV Fluids NO PROSTAGLANDIN E2 Support Consider early epidural....why? Prepare for cesarean ¡Cross match ¡Pre-op bloodwork Do not want to overstimulate, need good IV access- do not need to bolus- to keep volemically stable Cervidil increased risk of rupture Epidural- if it does end up in C-section, can use that one instead of general, unless woman doesn't want epidural Be prepared

Terms

Newborn period includes time from birth to day 28 of life p. 643 Transition period - in 2 phases (pg. 643-644) 1st phase - lasts up to 30 minutes after birth (First period of reactivity) : newborns heart rate initially increases to 160-180 bpm, but then will fall gradually. Resps may be irregular, rate 60-80 breaths/min. Fine crackles on auscultation may be present. Infant is alert. 2nd phase - from roughly 2 -8 hours after birth (second period of reactivity) and may last from 10 minutes to several hours. Could be brief tachycardia, tachypnea, increased muscle tone, and mucus production. Meconium commonly passed during this phase. Term Infant - born between week 39 and the end of week 40 (40+6) Early Term - between 37 weeks and the end of week 38 - associated with increased incidence of breastfeeding difficulties and respiratory problems, higher infant mortality rates Post term- born after the completion of week 42 Post mature - born after completion of week 42 and showing effects of placental insufficiency (pg. 690)Preterm - Born before 37 weeks of gestation Late Preterm - between 34 weeks and end of 36thweek (often look like term infants as far as size and weight but have increased risk of respiratory distress, temp instability, hypoglycemia, feeding difficulties and hyperbilirubinemia (keep a close eye on these ones

Risks of not breastfeeding

Non-breastfed infants/children are known to be at higher risk of: Gastroenteritis/diarrheal diseases Severe lower respiratory tract infections Ear infections Obesity Allergies Asthma Diabetes Necrotizing Enterocolitis in VLBW infants SIDS

How to bottle feed a baby

Parents need to be comfortable Hold infant close and semi-upright Encourage interaction and bonding Do not prop bottle with pillows, blankets, or other items Slow flow nipples initially Paced-feeding Bottle held horizontal When baby pauses, nipple is removed from mouth Feed ends when infant is done, not the bottle

Forumula Feeding

Parents sometimes choose to bottle feed their infant Pumped breastmilk Formula Combination Lack of education relating to bottle and formula preparation and feeding Risks infant illness and injury Effects to parental psyce

Problems with the passage

Pelvic contractures Soft tissue abnormalities -Pelvic contractures- physiological retraction ring that inhibits the baby from moving down and out, doesn't allow proper contractions -Soft tissue- placenta in the way, edematous cervix- long labor, doesn't dilate properly, fibroids, tumor, full bladder- take up same space in abd cavity

Gestational Age Assessment with Ballard Score

Physical assessment includes: ▫Skin texture ▫Lanugo ▫Plantar creases ▫Breast tissue ▫Eyes and ears ▫Male genitals ▫Female genitals Neuromuscular assessment includes: ▫Posture ▫Square window ▫Arm recoil ▫Popliteal angle ▫Scarf sign ▫Heel to ear

Comparison of placental abruption and placental previa

Placental abruption- }Abdominal pain &/or backache }Uterine tenderness }Increased tone }Uterine irritability }Usually normal presentation }Fetal heart sounds absent or abnormal }Shock & anemia out of proportion to apparent blood loss }May have coagulopathy Placental previa- }Placenta previa }Painless }Uterus not tender }Uterus soft }No uterine irritability }Malpresentation &/or high presentation }Fetal heart sounds usually normal }Shock & anemia correspond to apparent blood loss }Coagulopathy very uncommon initially Shock and anemia- how much blood is lost, abruption- at risk for DIC

Disruption of Fetal Oxygenation

Placental causes •Abruption •Infarction •Increased placental resistance Uterine causes •Tachysystole •Tetanic contraction Maternal causes •Hypotension •Hypoxia Umbilical causes •Cord compression Placenta, uterus, mothers perfusion Infarcted (too small) Tachysystole- contractions lasting too long or are too frequent- placenta cannot absorb blood in between contractions, hyperstimulation, tetanic- one long contraction Under perfusion of placenta= fetus will suffer Uterine or maternal can be reversed- stimulation Placental- not corrected by normal resuscitation mechanisms Decreased patency of umbilicus

Assessing shallow latch on

Poor or Shallow Latch-On: Tight pursed lips Space between chin and breast Space between breast and nose Infant's lower lip pulled in Mother may feel pain Nipple may be flattened after a feeding Nipple abrasions and/or cracking Ineffective suckling technique reflected by: lack of sounds of swallowing short, quick (flutter) sucking movements only Clicking or smacking sounds mother may feel pain

Prolapsed umbilical cord

Portion of umbilical cord falls in front of, lies beside, or hangs below the fetal presenting part following ROM. 1.Occult/Hidden: Alongside the presenting part 2.Overt: Precedes the fetus and can be seen protruding from the maternal vagina or introitus Emergency C-section ROM- gather FHR, may be AROM- make sure that the Amnihook, keep hands and fingers in there to make sure that the head is the presenting part on cervix, no space in between- if not the umbilical cord can prolapse, keep fingers in and put pressure on head so that there is not compression on cord- cut off blood supply, C-section- cannot do delivery with umbilical cord before baby, med emergency

Diabetes in Pregnancy

Pregestational (before pregnancy)- may have poorly controlled blood sugar levels at time of conception/ organogenesis, miscarriage, impaired glucose is prolonged- more complications- pregnancy can aggravate, so need to monitor Gestational (during pregnancy), 2T, decreased fetal abnormalities Woman are susceptible to diabetes from pregnancy changes Can cause preterm labour, issues with growth of the fetus, stillbirth- fetal macrosomia- increased glucose levels, can cross placenta, causes fetus to have high levels, release insulin- glucose can enter cells, stimulates fat storage, binds to receptors on different organs and causes them to grow Hormones- hPL, cortisol (stress), growth, progesterone, that are released during pregnancy- releases more of these hormones to ensure that fetus has enough of these to use glucose, but these same hormones create insulin resistance, cells do not respond to insulin and take up less glucose so more glucose can get to fetus= hyperglycemia and diabetes Screen during pregnancy- normal risk at 26-28 wks- glucose tolerance test, BGL are measured at 1, 2, 3 hours after, > normal range- diabetes, treat with diet and then insulin Risk for diabetes after, test 6 wks after

Pregnancy

Pregnancy is a normal, healthy condition- subject to anatomical, physiological, biochemical changes for growth in the fetus- insulin action is blunted, lower blood glucose levels, drugs that affect albumin might be lowered, 38-42 weeks is full term, want to know if they are at term, pre or post term, first trimester- 1-13 weeks, second 14-26, third 27 through term- each one has predictable changes Conception- germinal- zygote, implantation- embryo, organs are developing, teratogens, fetal- organ refinement Hormones- estrogen- skin and breast changes, insulin resistance, progesterone- muscle relaxant for uterus and keeps pregnancy viable, hCS (hPL)- break down fat for fuel for baby, HcG- pregnancy tests *, relaxin- relaxes pelvic muscles and joints- caution with exercise, oxytocin- hypothalamus, induce uterine contractions, milk ejection during lactation, prolactin- a pituitary gland- make milk

C-section nursing care

Preoperative ¡Labs & Diagnostics ¡Psychosocial support ¡Education to family ¡Fetal well-being Intraoperative ¡Different roles in the OR ¡Support to patient & family ¡Support to surgical team ¡Support to Anesthesia ¡Support to NICU Support to everyone- family and HCP team Postop- Recovery Room ¡Vitals & Cardiac Monitoring ¡Assessment: Focused ¡Pain Management ¡Dermatomes ¡Promote maternal/newborn bond ¡Assist with initial feed ¡Care of the newborn Postpartum ¡Education for incisional care ¡S&S of infection ¡Pain management ¡Psychosocial support ¡Education for family re: Maternal limitations and support required Dermatomes with spinal or epidural Laparotomy- get sent home with Naproxen and Tylenol- how to take properly, and avoid undue pain Really hard to run household and heal from C-section- assess support, cannot rotate with baby, promote bond and healing, look at whole picture

How are preterm and postterm infants defined?

Preterm before 37wks, postterm beyond 42wks, no matter the size for gestational age at birth. -Preterm and postterm are strictly measures of time-before completion of 37wks and beyond 42 completed weeks, regardless of size for gestational age.

Identify which statement is related to primary powers and which is related to secondary powers: 1.Involuntary contractions during labour. 2.Valsalva's maneuver 3.The process of shortening or thinning of the cervix during labour; also called effacement. 4.The feeling of wanting to bear down. 5.Adds force to uterine contractions to augment the forces of involuntary contractions. 6.The process of dilatation of the cervix till it is fully dilated (10 cm). 7.The voluntary pushing efforts of the labouringmother.

Primary- 1, 3, 4, 6 Secondary- 2, 4, 5, 7

Complicated labor and delivery

Problems with "The P's" 1.Powers 2.Passenger 3.Passage Chorioamnioitis Operative Vaginal Delivery Cord Prolapse TOLAC Contractions and pushing, baby, and vaginal canal, true pelvis- bony and soft tissue around it

Placental accreta

Problems with placenta as it was developing in the uterus, refers to how far deep it has gone into the levels

Premature rupture of membranes

ROM before labour contractions are occurring }Premature rupture of the fetal membranes (PROM) is the rupture of the bag of waters before the onset of true labour }Can happen preterm or term. }Preterm PROM occurs before 37 weeks' gestation }A complication of about 8% of pregnancies }Cause: term vs preterm }Risk factors: term vs preterm Risk factors- preterm- less organ development Causes- uterine distension, multifetuses, polyhydramnios, short cervix length, previous preterm labour/ birth PROM }Maternal: Beyond 24 hours risk for infection increases }Fetal: Umbilical cord compression; infection; , oligohydramnious Preterm PROM }Maternal: Intrauterine and PP infection }Fetal: complications from prematurity, placental abruption, fetal malpresentation, Risk for increased infection- minimize bacteria climbing up birth canal- avoid baths, intercourse Diagnosis- }Visualization of amniotic fluid leakage into the cervical canal }Fluid sample: }Nitrazine striip: pH 7.1 - 7.3, as opposed to vaginal pH 4.5-6.0 }Ferning }NOTE: always inspect for possible umbilical cord prolapse and/or presenting fetal part through the cervical os Sample with pelvic exam, under microscope Ballottement- bouncing, increased risk for cord prolapse, presenting part to start descending down management- term PROM- }Without intervention, ½ of women with PROM will go into labour in 5 hours }95% of women will go into labour with 28 hours }HCP may suggest induction of labour PPROM- }34-36 weeks: same as term }32-33 weeks: expectant (waiting) management }GBS prophylaxis is recommended, as indicated }Corticosteroids for lung maturity }Antibiotics to possibly treat or prevent an infection }24-31: same as above and tocolytics By day 3, Risk for infection increases after 24 hours <34 weeks- tocolytics- won't stop contractions from happening but will help the uterus maintain softness to get corticosteroids into baby, treat as positive- abx (GBS)

A woman, who is 18 weeks gestation, comes in for her monthly assessment. The nurse completes an assessment and notes a fundal height of 14 cm. What should the nurse do next? The nurse takes the fundal height to find it is still 14cm. What could be some of the causes?

Recheck assessment, fetal growth slowed, intrauterine growth restriction, prematurely going to pelvis, too little amniotic fluid- kidney problems

Fetal Attitude

Relationship of fetal body parts to one another, flexion of the head and neck, flexion- chin to chest- 8-9cm going through pelvis first, more extension= more coming through pelvis at once, trauma to mother Face- gets compressed against cervix- bruise Feeling by sutures and fontanels with fingers

Best practice for immunizations

Right Patient, Right Medication, Right Dose, Right Education, Right Assessment, Right to Refuse, Right Documentation, Right Reason YOU: will have an order on the patient MAR but are responsible for confirming eligibility (with the help of your faculty and nurse). must always be with your faculty for supervision. must preform screening and informed consent provide information sheet to the patient and review aftercare. Document on the Inpatient Immunization Sheet (which gets faxed to public health) IM site for children >3 years and adults, Needle Tip: •22 or 25 gauge 1" •IM injection is given deep into the "belly" of the deltoid muscle

Vacuum assisted delivery

Role of nurse ¡Anticipate ¡Prepare equipment ¡Prepare patient ¡Coach Rule of 3- 3 pulls, 3 pop offs, reconsider what is happening- do not want to piss off baby, baby may not be able to be delivered vag, nurses are documenting- high legal area, physicians may pull more than 3, record what you see, document everything ABCDEFGHIJ Mneumonic-anesthesia adequate, bladder empty, cervix completely dilated, determine head position, equipment ready, fontanelles ascertained (position for safety), gentle steady traction, halt traction between contractions, incision or episiotomy, jaw seen Document, document, document

Determine of health that influence nutritional status

SDOH- income and social status, education and literacy, social environment, physical environment, personal health practices and coping skills, biology and genetic endowment, availability of health services, culture-- nutrition, adequate dietary intake, food supply, quality, availability, accessibility, cultural influence

Care of a newborn following an OVD

Scalp is called the galuim or aponeurosis Subgaleal Hemorrhage: Blood vessels btw scalp and skull may rupture causing collection of blood btw the scalp and skull. Fluctuant scalp swelling crosses suture line May cause hypovolemic shock Monitor for any issues to head- hematomas or caput, subgaleal- hypovolemic shock, palpate and measurement of head- pallor, tachycardia/tachypnea, mottling, change in color, hypotention, lethargy not wanting to wake to feed, learn about compensation mechnaisms- babies cannot compensate for very long, look at what baby is telling you, failed delivery- c-section

TORCHes Syndrome

Set of perinatal infections transferred from mom to fetus: }Toxoplasmosis }Other infections (parvovirus and varicella) }Rubella }Cytomegalovirus }Herpes }Syphilis Cause congenital anomalies Teach about vaccination- Rubella- wait before they get pregnant

Hyperemesis Gravidarum

Severe form of n/v, 20-25 weeks or continue with retching and vomiting until placenta is birthed- hormones }Characterized by persistent, uncontrollable nausea and vomiting causing weight loss of more than 5% or pre-pregnancy body weight, electrolyte imbalance, and ketonuria. }Cause - multifactorial, lots of theories }Endocrine-high levels of hCG and estrogen }Metabolic-vitamin B6 deficiency }Psychological-psychological stress brings on the symptoms }Others-olfactory response with specific triggers, another is that it stems from motion hypersensitivity, and finally dysregulation of gastric rhythms }Peak incidence occurs at 6-12 weeks gestation and often resolves by 20 weeks Dyclectin-antihistamine and b vitamins, ae- really sleepy- hard to have normalcy during the day, family life/ work, meds might not work- may need IV therapy for dehydration, may go onto meds that are used for nausea in cancer patients

Maternal conditions that justify temporary avoidance of breastfeeding

Severe illness that prevents a mother from caring for her infant, for example sepsis. Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the mother's breasts and the infant's mouth should be avoided until all active lesions have resolved. Maternal medication: sedating psychotherapeutic drugs, anti-epileptic drugs and opioids and their combinations may cause side effects such as drowsiness and respiratory depression and are better avoided if a safer alternative is available; radioactive iodine - is better avoided given that safer alternatives are available - a mother can resume breastfeeding about two months after receiving this substance; excessive use of topical iodine or iodophors (e.g., povidone-iodine), especially on open wounds or mucous membranes, can result in thyroid suppression or electrolyte abnormalities in the breastfed infant and should be avoided; cytotoxic chemotherapy requires that a mother stops breastfeeding during therapy.

Other malpresentations

Shoulder Face Brow Compound Compound is usually head and arm but otherwise can be a bit more of a challenge Occiputposterior Positioning (OP)- Want occiput anterior- accommodates smaller head to pass first Possible but mom has to accommodate more, Occiput towards mother's spine Associated with prolonged 2nd stage Must rotate 135 degrees ¡ROP- ROT- ROA- OA Back pain At risk for 3rd or 4th perineal laceration or need for episiotomy Rotate- positioning and ambulating Back labor- more excruciating than contractions, palpate fontanels and sutures, ROM to determine position Lacerations- presenting part of the head is larger Sigmoid colon takes up a lot of space ROP more then LOP just from abd anatomy Keep the bladder empty- make as much room in the pelvis as possible for movement, Change positioning - hand and knees, walking, bouncing, lunges- wide lateral, open up hips and pelvis, pain management if mm wants- epidural, warm compress on back, pressure during contraction- on back or double hip squeeze- either side of hips, landmark for IM, push into hips for counterpressure, oxytocin if indicated- improve contractions and move head down

Common breastfeeding problems:

Sore Nipples:Causes and remedies: Improper latch or unlatching Suckling incorrectly Engorgement Nurse frequently Express a few minutes before latching Thrush/yeast Incorrect pump use Ankyloglossia Artificial nipples Encourage air drying nipples with breast milk Begin feed on least sore breast Engorgement- Not a normal condition Breasts swollen, warm, painful, skin tight and shinny May start 3-5th day PP Nipples may be flattened Low grade fever Causes Poor latch Long stretches between nursing Rapid increase in milk volume (PP day 3-6) can cause vascular congestion resulting in swelling Abrupt weaning, Remedies: Correct latch/position Breastfeed often Apply moist warmth on breasts 3-5 minutes before feeding Express milk if over-full Use ice packs between feedings (apply for 15-20 minutes No artificial nipples or supplements if possible Plugged Ducts- Milk stasis- Causes pressure within the breast to build up, this can cause milk to seep through the walls of the ducts into the breast tissue Presents as: Hot, tender, reddened or painful lump in the breast Afebrile Remedies Nursing on the side with the plugged duct first Massage in front of the lump, towards the nipple Position baby with nose towards the lump Mastitis- Infection of breast tissue and/or milk ducts Localized tenderness, redness, hot, swollen Red streaks in the breast Flu like symptoms Usually starts with a plugged duct or cracked nipples A sudden decrease in the number of feedings Restrictions on breast tissue (bras with under wire) Overtired and increased stress, Remedies: Do not stop breastfeeding Correct latch and suckling Breastfeed on the sore side first at every feed Nurse or express milk every 1-2 hours until relief Try different nursing positions May need antibiotic and analgesic Rest, eat and drink well Avoid soothers & supplements Thrush- Mom Cracked, sore nipples that does not heal Shooting, burning pain through breast during or after nursing Nipples pink, flaky, itchy or red Vaginal yeast infection Baby White spots in mouth Diaper rash Gassy and cranky Repeatedly pulling off the breast Slow weight gain,Remedies Treat both mom and baby with anti-fungal medication Continue breastfeeding Good hand washing Rinse nipples with water and air dry Boil breast pump, soothers, bottles once daily ( 5-10 minutes) Replace all soothers/bottle nipples if used once thrush is cleared

Protecting Newborns against infection

Standard precautions Vitamin K administration ▫Given IM right after birth, to prevent hemorrhagic disease of the newborn. Newborns are not able to produce their own vitamin K because it is synthesized by intestinal flora which newborns do not have until they begin regular feedings Vaccinations ●Wear gloves when handling the baby, to protect the baby and also to protect yourself from blood and body-fluids. ●Everyone should wash hands before handling baby - teaching ●Usually babies do not receive their first immunizations until they are 2 months of age, but teaching about the importance of vaccinations should occur at birth and vaccinations are also important for the caregivers in the infant's life. Immune system- ▫Natural Immunity - physical barriers (intact skin / mucous membranes), chemical barriers (gastric acids, digestive enzymes), non-pathologic bacteria colonization ▫Acquired Immunity - development of circulating antibodies, and formation of activated lymphocytes - only occurs after first invasion by a pathogen / toxin ▫Mom can transfer antibodies to baby offering transient passive immunity - IgG crosses placenta (22 weeks & on), IgA passes through colostrum and breastmilk

Bottle Prep and cleaning

Sterilization Boiling bottles and nipples to sterilize is not always needed, but most public health officials would recommend this at least prior to first use The dishwasher works great Pump parts should be sterilized Preparation Formula comes in three forms Ready to feed Concentrated Powdered

Football Hold (BF position)

Support the baby's head with the mothers hand and their back along her arm coming in from her side The baby's legs and feet are tucked under the mothers arm Can hold her breast to help attach baby Baby needs to have ear, shoulder and hip in straight alignment Comfortable for woman who have had a c-section or who are large breasted

A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. Which is true with regard to surfactant therapy?

Surfactant improves the ability of the baby's lungs to exchange oxygen and carbon dioxide. Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

IA abnormal findings

Tachycardia- reposition to increase uteroplacental perfusion or alleviate cord compression, rule out fever, dehydration, drug effect, prematurity, correct maternal hypovolemia (IV fluids), check maternal pulse and blood pressure Bradycardia- reposition, perform vag exam to access for prolapsed cord and relieve cord compression, administer oxygen at 8-10 L/min, correct hypovolemia, pulse and BP Decelerations- reposition, access for passage of meconium, correct hypotension, administer oxygen, additional measures- auscultate FHR to clarify and document components, consider EFM, if abnormal findings persist despite measures and ancillary tests are not available or desirable, expelled delivery should be considered

What advice should the nurse provide to the following woman? •A 32-week pregnant woman calls the nurse and says she was getting the baby's room ready yesterday, and she did not feel much fetal movement. How should the nurse respond? • •The woman goes into a reclined position and counts two movements over the next two hours. How should the nurse respond to these findings?

Teach how to do movements for the next 2 hours, hand on top of fundus, tell her to come to hospital to assess heart rate Fetal Movement Counting- •Teaching •Get into a comfortable position - lying on your side or sitting. Place one or both of your hands on your abdomen. •Count each time that you feel your baby move and write it down on the chart •Count once a day. You should feel 6 or more movements in 2 hours •If less than 6 movements are felt, go to the hospital for assessment Want them to do it every day in 3rd trimester, when baby is normally active

Components of Fetal Assessment

Teaching •Any concerns •Maternal and fetal changes •Discomforts of pregnancy •Danger signs in pregnancy •Fetal movement counting •Signs of preterm labour •Signs of labour •Family planning •Plans to breastfeed •Birth plan •Car seat Normal discomforts

Cross cradle or modified cradle (BF position)

The baby lies across the mothers lap Her opposite are supports the baby's back and neck The hand closest to her breast can support the breast with a c-hold or u-hold Gives mother more control Baby's ear, shoulder and hips need to be in a straight alignment

Neonatal Abstinence Syndrome (NAS)

The neonate may be at risk for: •Respiratory distress •Jaundice •Intrauterine Growth Restriction (IUGR) •Behavior abnormalities •Seizures •Congenital abnormalities •* The risks associated with NAS are dependent on both the type and the amount of substance the neonate was exposed to. Is a term used to describe the set of behaviours exhibited by infants exposed to a substance in utero.

Preterm: Risk-Thermoregulation

Thermoregulation •The preterm infant is at an increased risk of impaired thermoregulation and rapidly developing cold stress (less ability to compensate). •Less muscle mass= less ability to create energy •Fewer deposits of BAT (brown adipose tissue) for non-shivering thermogenesis •Permeable skin •*The preterm infant is also at risk of hyperthermia, due to increased oxygen and energy demands. Maintaining a neutral thermal environment (NTE) is essential for the preterm infant. The preterm infant (≤37 weeks) will require advanced care. The gestation of the preterm infant, and the infants individual ability to cope with extrauterine life, depending on the physiological development of each system, will dictate the advanced care required. In addition, the preterm infant is at greater risk of developing extrauterine complications. This lesson will discuss some common needs and complications of the preterm infant.

Which is reflected when premature infants exhibit 5 to 10 seconds of respiratory pauses, followed by 10 to 15 seconds of compensatory rapid respirations?

They are breathing in a resp pattern common to premature infants. -This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilator. Apnea is a cessation of resps for 20secs or longer. It should not be confused with periodic breathing.

Swanson's theory of caring

Through inductive analyses, Swanson (1991)identified five caring processes: 1.Knowing 2.Being with 3.Doing for 4.Enabling 5.Maintaining belief

Differentiation of True/Prodromal Labour

True Labour- •Contractions begin in the lower back & radiate to abdomen, become regular and increase in frequency, duration and intensity •Position changes ineffective •Progressive cervical changes Prodromal ("False") Labour- •Contractions are irregular, may be more noticeable at night, pain is felt mainly in the abdomen •Relieved by change of position or activity •No cervical changes Cervical changes- change position, effaced, dilated Contractions- top of fundus, become longer and shorter together, stronger

True or False: A newborn with TTN may present with perioral cyanosis

True: Due to impaired gas exchange the newborn may have perioral cyanosis. If the TTN is not identified and treated facial and central cyanosis may occur.

Uterine abruption

Uterine rupture, C-section= scar tissue on uterus= cannot contract and stretch so it thins and bursts- fetus and contents burst into abdominal cavity- need c-section

transient tachypnea of the newborn

Wet Lung Syndrome" •Excess fluid or delayed reabsorption •Present around 4-6hrs post birth •Self limiting within 12-72hrs TTN will cause impaired gas exchange which may present as follows: •Tachypnea •Tachycardia •Cyanosis (perioral or central) •Grunting •Nasal flaring •Use of resp accessory muscles •Crackles or diminished breath sounds on auscultation This newborn should be moved to an observation unit or Neonatal Intensive care for diagnostic work-up and oxygen, intravenous and antibiotic therapy!! Diagnostics may include: •Chest xray (Screen for presence of fluid, pneumonia or other differentials being considered) •CBC, blood cultures (rule out sepsis) •ABG (Insight into oxygen, carbon dioxide and pH levels- may dictate acuity and guide treatment) •Echo (Rule out congenital heart defects) Presentation of TTN may mimic infection or shock, therefore antibiotics may be appropriate.

1.In what circumstances does the nurse do Leopold's maneuvers? 2.What circumstances might make performing Leopold's maneuvers a challenge, and how can these be overcome?

When you need to assess position of the baby- need heart tones, before labor to find location and if they can vaginally deliver, Challenges- full bladder, BMI- percussion Heart status- normal heart indicates brain growth

Fetal Position

Where are they positioned, location of baby heart to mom's pelvis (passageway), presenting part- back of head, occiput- ideal, smallest part is coming through first, stretch can occur at a place that protects mom's perineum, less trauma, faster Occiput- chin to chest, where is it touching mom's side ROA/LOA- face down, occiput is anterior ROP- flipped around, occiput pushes on lower back and sciatic nerve- a lot longer and more pain LOP- faces left side Breeched- sacrum(S)- RSP

Tdap

Who is eligible- •Pregnant women - Ideally between 27-32 weeks (even if they have previously received the vaccine as an adult) •All caregivers of infants <6 months of age if they have not previously received a dose as an adult. On MBU, it is given to mothers prior to discharge if they did not receive a dose while pregnant either in this pregnancy or a previous pregnancy. •Fathers of infants are eligible to receive the vaccine free of charge - but need to call public health to make an appointment. -- 27-32 weeks ideally as it is the best balance between safety and effectiveness for babies born after 37 weeks Can be given after 32 weeks until delivery and in the postpartum period - will prevent mother from becoming a source of infection to baby but antibodies will not be sufficient to protect baby Vaccination in pregnancy is preferred! infants under 3 months of age are protected following maternal vaccination against pertussis during pregnancy

Metabolic system changes during pregnancy

Wt gain due to uterus and contents, increased breast tissue, blood and water volume increases, average wt gain= 12.5 kg, protein- accounts for 1000 g of wt gain, fetus, placenta, uterine contractile proteins, breast glandular tissue, plasma protein, hgb, total body fat- plasma lipids during second trimester, triglycerides, cholesterol, lipoproteins decrease after delivery

Variable Deceleration

abrupt onset to nadir < 30 sec, with drop of 15 bpm below baseline for > 15 sec but < 2 min, onset to nadir < 30 sec, variable relationship to the contraction Visually different, sudden and abrupt drop and return, V, U, W, periodic, or episodic, immediately before or after decel- shoulders, umbilical cord compression- occlusion of vein- decreased blood return, tachycardia to maintain CO- increase in HR then occlusion of artery- resistance sensed by baroreceptor results in protective reflex- slows HR, as cord is decompressed, events are reversed accel may follow the decel, arteries decompress but the vein is still compressed before returning to baseline Could be from head compression during 2nd SOL Repetitive and complicated- weak and diminished variability= hypoxia, Variable- cord compression, can be with or without compression

cervical insufficiency

closed Cervix is starting to dilate and efface but no contractions, 2T or early 3T, babies are born very early or risk for miscarriage, based on hx }Cervical Insufficiency is premature dilation of the cervix and describes a weak, structurally defective cervix that spontaneously and painlessly dilates in the absence of contractions in the second trimester. }Incidence is less than 1%, but causes up to 25% of second trimester losses }Can progress to PROM and preterm birth, not very common, }The exact cause is unknown }Linked to the cx having less collagen and more smooth muscle }Several theories propose damage to the cx as a key component (congenital disorders, lacerations, infection/inflammation trauma }Also associated with cx length and preterm birth,Exposed to inflammation and infection Transvaginal US- measure length- shortening- preterm labor, stich cervix up and then remove stich when closer to term, successful

Prolonged Deceleration

decel is > 15 bpm and >2 min but < 10 min, duration > 2 min, Any mechanism can cause- periodic or episodic, return to baseline is delayed because the stimulus that causes the decel is not reversed, hypoxia, less likely- cord compression, profound hypotension, prolonged head compression, tachysystole, immediate resolution efforts- emergency

Acceleration

duration > 15 sec, Acme > 15 bpm above baseline Increase to peak in less than 30 seconds, from baseline, initial change to return, 32 weeks- 15 bpm or 15 sec- 2min, before 32 weeks, acme of 10 bpm, between 10 sec - 2 min Prolonged- 2-10 min >10 min- baseline change periodic- with contractions, fetal stimulations, mild cord compression Episodic- no relations with contraction, most common, fetal movement, transient need for more oxygenation, fetal stimulation Good- with mod variability- indicate intact SNS- brain is being perfused with oxygen rich blood •Abrupt, transient increase in FHR <2 minutes duration •<32 wks—10x10—increase of FHR at least 10 bpm above baseline for at least 10 seconds •>32 wks—15x15—increase of FHR at least 15 bpm above baseline for at least 15 seconds •Are a sympathetic response •means the sympathetic nervous system is intact - good news!!! •Result of •Fetal movement or stimulation (e.g., Scalp stimulation, palpate maternal abdomen) •Reaction to contractions Fetal movement- 2 accelerations in 20 min, HR is responding appropriately Term- abrupt increase in FHR, 15 bpm above baseline for 15 sec- 2 min Preterm- 10 bpm increase for 10 sec

Supine Hypotension

emergency, •Pallor •Dizziness, faintness, breathlessness •Tachycardia •Nausea •Clammy skin; sweating,Vena cava- supine hypotension- less oxygen rich blood to fetus Side lying- relieves pressure- put onto right hip- tilt on left side to increase blood flow a little bit more

Physiological jaundice

o60% of term newborns oPeaking at 2-5 days oVariation of normal o86 to 103 μ mol per L oSelf-limiting- can clear on own. Normal because of how they exist, immature liver- cannot process unconjugated to conjugated as quickly as adults, lower lifespan of RBC- 90 days instead of 120 days, change bilirubin faster, increased volume of RBC- cord unclamped for 5 min "nonpathological"

Nonphysiological jaundice

oAlso known as "pathological jaundice" oBilirubin levels exceed accepted norms oCan present 24 hours post birth oRapidly rising oPathologic causes include: oBirth trauma oErythroblastosis fetalis oSepsis oRubella Birth trauma- vacuum- bruising, broken down RBC, higher level of bilirubin, spontaneous- delivered quickly- decreased RBC, Isoimmunization- Erythroblastosis fetalis- lysis of RBC, elevated bilirubin, infection

Prenatal testing

oBiophysical profile (BPP) oChorionic villus sampling (CVS) oFirst trimester screening oMaternal blood screening oAmniocentesis oUltrasound- may be when couple learns of death, images can reassure and differentiate from past pregnancy oFetal monitoring •Prenatal tests can have a significant impact on women and their families; this impact often is neither acknowledged nor addressed by health care providers. •Test results can be shocking. Just having a test can bring back memories of bad news in past pregnancies.•Technological advances in recent decades have opened the door to assessing genetic make-up and witnessing fetal development like never before. •Families need to understand: oThe purpose of a test oWhat it can and cannot tell oIts risks for mother and baby

Common perinatal loss grief response

oHeavy or aching arms oAvoiding pregnant women and babies oSense of loss of the future and shattered dreams oSense of vulnerability in the world (not as safe as always assumed) oHypervigilance with other children

hyperbilirubinemia

oIncreased bilirubin in the blood stream & tissue oHigh concentration toxic to the brain- Kernicterus oNewborns @ risk d/t: oBilirubin production 2x greater than adults oHigh volume of circulating RBCs oRBCs have shorter life span

Signs and symptoms of hyperbilirubinemia

oJaundice oYellowish pigment to skin & sclera oLethargic oPoor feeding oMinimal or no stool

Bilirubin

oMain bile pigment that is formed from the breakdown ofheme in red blood cells. oBroken down heme travels to the liver oLiver secretes bile oSerum bilirubin oIndicates liver function oReflects uptake, process & secretion of bilirubin. Hgb- breaks down into heme (pigment of bile) and globin (protein)

unconjugated vs conjugated

oUnconjugated (indirect): oNot yet metabolized by the liver oBound to albumin in blood stream oTransported to the liver & changed to conjugated bilirubin. o oConjugated bilirubin (direct): combines with bile and deposited into the GI tract for excretion with stool. Conjugation- enzyme chemical reaction, binds with albumin Excess bilirubin get stored in the skin or sclera as jaundice Higher levels of unconjugated bilirubin can build up in the brain- kernicterus- yellow staining on brain cell, encephalopathy, hearing damage, brain damage, blindness Increased indirect (unconjugated) bilirubin, decrease in direct (conjugated)

Early Decelerations

onset to nadir > 30 sec, Associated with UC, decrease while contraction peaks, early- correspond, periodic, benign- fetal head compression from contraction- alters cerebral blood flow, vagus nerve stimulation, resolves as pressure resolves, in active SOL, in early labor, latent phase - cephalopelvic disproportion (CPD), not related to fetal hypoxemia or acidosis, nadir of decelerations matches peak of contractions Abrupt decrease in FHR, 15 bpm below baseline for 15 sec Started just as contraction started, lowest while contraction was at the peak From head compression- normal

Late Deceleration

onset, nadir, and recovery of decelerations follow beginning, peak and end of contraction, onset to nadir > 30 secs Contractions- but after beginning peak From uteroplacental insufficiency- perfusion, activity, placenta, or both=fetal hypoxemia, and resp depression, cardio decelerations, lactic acidosis, see if it is getting worse, variability- minimal or absence- hypoxic depression of the myocardium, cannot compensate, acidosis, placenta malfunction, mod variability- baby can compensate, shift oxygenated blood to vital organs (heart), Start later than the contraction, uteroplacental insufficiency, baby is in hypoxemia, need to increase blood flow to baby

maternal weight gain

prenatal malnurition- •Serious damage to central nervous system •Loss of some brain weight for the baby; not reaching its full potential •Distorted organ structure, impacting liver, kidney, and pancreas (lifelong health problems) •Suppresses development of the immune system •Babies often have respiratory problems •Can cause babies to be irritable, with a high pitched cry similar to drug- addicted newborns •Can cause babies to be unresponsive to stimulation •As they age, these children exhibit low intelligence test scores •Children often have serious learning problems Teaching- •Good eating habits and a well-balanced diet can help ensure a healthy baby. • •Vitamin-mineral enrichment is necessary •Folic acid helps prevent - abnormalities of neural tube; premature birth •Calcium helps prevent - maternal high blood pressure; premature birth •Iodized salt prevents - cretinism (stunted growth and mental retardation) •Prenatal vitamins SOGC guidelines- dictate best practices, weight gain 25-35 pounds, 15-25 if overweight, underweight more 28-35

Signs of pregnancy

presumptive signs- mother experiences- missed period, breast tenderness, probable- hcG, positive- really confirms, US, palpate, heart tone

precipitous labor

problem with the powers,¡<3 hours ¡Perineal tissue ¡Rapid fetal descent Complications: ¡Location ¡Laceration ¡Hemorrhage ¡Newborn bruising... Need for a debrief... Beginning to end <3 hours- rapid fetal descent- perineal injury (tissue damage) as baby just shoots out, bruising to baby's face (can be body)- hyperbilirubinemia, debrief with mom and whoever who is there- what just happened, tell their story and figure out what happened

Inadequate Voluntary Expulsive Forces

problems with the powers, Lack of "urge to push" May be due to analgesia ¡What else may contribute to this? May lead to operative vaginal delivery Epidural- do not feel urge to push- tells how, when, how hard- listen to body

Spontaneous abortion

} Is the loss of an early pregnancy before 20 weeks gestation } Refers to the loss from natural causes (often termed miscarriage) } Rate in Canada-8% }Estimated 80% occur <12 weeks } CAUSES are varied and often unknown, but most commonly is fetal genetic abnormalities and then maternal-fetal infection (from rubella virus, cytomegalovirus, herpes simplex virus, bacterial vaginosis and toxoplasmosis) Threatened- had bleeding in 1T but no tissue, bed rest Inevitable- dilation of cervix, tissue may come out, contractions, support Incomplete- tissue in utero, forceps and suction to prevent hemorrhage Complete- all contents have spontaneously been birthed Missed- retained placental/fetal tissue from failed intrauterine pregnancy Induction- surgical termination for a fetus before viability

Postpartum anxiety/ depression

}#1 complication of pregnancy }More persistent and serious than PP Blues }if symptoms of postpartum blues last longer than 6 weeks and get worse -> PPD }Begins 4-6 weeks PP, but can develop anytime in 1st year }Evolves slowly }Last weeks to months }In Canada 8-23% of women experience PPD in 1st year }Exact etiology is unknown but it appears to be a multi-factorial disorder }Underreported Hx of anxiety- more likely to get, AP screening, PP screening, follow up It's estimated that almost 20 percent of mothers will suffer from a maternal mental health complication like postpartum depression, others will suffer from anxiety or even the very rare but serious postpartum psychosis. But unfortunately, many women are never properly screened, diagnosed or treated for maternal mental health disorders. As a result, many women suffer in silence believing they aren't "good" mothers, feeling ashamed that motherhood is not a "joyful" experience.

WinRho

}1st prenatal visit }Maternal ABO & Rh }Indirect Coomb's (Normal = 0; ratio < 1:8 = minimal; 1:16 = elevated }28 weeks }300µg Win Rho }72 hours postpartum }300mcg WinRho 1st prenatal visit Maternal ABO & Rh Indirect Coomb's - measures # of antibodies in maternal blood - Normal titre is 0; a ratio below 1:8 is minimal; 1:16 is elevated 28 Weeks 300µg Win Rho Another dose PP Win Rho administered: •After: •Amniocentesis •Chorionic villi sampling •Any bleeding during pregnancy •1st trimester abortion •Ectopic pregnancy •Rh neg mom (neg Indirect Coomb's) who has given birth to Rh Pos baby (neg Direct Coomb's) within 72 hours given 300 µg WinRho IM - Kleihauer Betke done to determine amount of WinRho to be given. The indirect Coomb's detects antibodies in the mother's blood. The Direct Coomb's detects the antibodies in the baby's blood. }After: }Amniocentesis }Chorionic villi sampling }Any bleeding during pregnancy }1st trimester abortion }Ectopic pregnancy When blood mixes

Thromboembolic conditions

}A thrombosis (clot which formed in a vessel), can lead to thrombophlebitis, and become a thromboembolism }DVT - can involve the deep veins of foot, calf, thigh }PE - occurs when a pulmonary artery is obstructed by a clot that has traveled from another vein (DVT) More clotting factors in blood already Venous stasis, injury to inner wall of the vessel, hyper coagulopathy- DIC }The major causes for a thrombus are: venous stasis, injury to the innermost layer of the vessels, and hypercoagulation } }Other risk factors include: prolonged bedrest, obesity, caesarian birth, diabetes, smoking, increased progesterone (distensibility of veins in legs), advanced maternal age, multiparity, varicose veins, use of oral contraceptives C-birth- be on altert

Nursing Management of thrombotic embolism

}Assessment - DVT: risk factors, S&S, health hx, legs - compare both, watch for redness, tenderness, swelling, assymmetry of legs, pain; PE: sudden SOB, chest pain, tachycardia, changes in mental status }Intervention - prevention (encourage activity, anticoagulants, compression devices, positioning); DVT: bedrest and elevation of limb, anticoagulant therapy, monitor labs, administer analgesics; PE: emergency measures - oxygen, call for assistence, VS, heparin infusion as ordered, monitor labs (pTT) Same as medical patient, encourage ambulation, medication, lab work, PE- call for help, oxygen, VS, heparin- does not cross into breast milk

Treatment of Severe HTN> 160/110

}BP should be lowered to < 160 systolic and <110 diastolic }Initial Rx with labetolol, nifedipine caps, nifedipine PA tabs or hydralazine }MgSO4 is not an anti hypertensive }Continuous FHR monitoring until BP stable NOTE: } Minimize iv/oral fluids to avoid pulmonary edema }Initiate catheter }Monitor I/O }Don't routinely treat oliguria (<15 ml/hr) with fluids

Placenta Previa

}Bleeding when the placenta implants over the cervical os }Initiated by implantation of the embryo in the lower uterus }Exact cause unknown }Bleeding occurrs more often in the last 2 trimesters of pregnancy. }Incidence is 0.4-0.9% of all births and is associated with potentially serious consequences from hemorrhage, abruption, preterm birth, and emergency cesarean birth }The cervical os can become covered by the placenta, this in turn can allow the placenta to attach directly to the myometrium (accreta), invade the myometrium (increata), or penetrate the myometrium (percreta) Implanted in lower intrauterine segment, do not know why, prior uterine surgery, not super common, placenta is so close to os- cannot deliver vaginally unless 2 cm away all the way around, pressure and weight on placenta- causes bleeding, first bleed may be a few drops, then it increases- bleeds get progressively worse, clots may reach size of citrus fruits- but does not hurt- painless bleeding , if cannot stop- emerg C birth, babies are usually born healthy Classified according to the degree of coverage or proximity to the internal os: }Type I (lateral or low lying implantation): includes the lower uterine segment but not extending to the internal os }Type II (marginal implantation)-includes the lower level of the placenta extending to but not covering the os }Type III(partial): the placenta partially covers the internal os }Type V(complete or central): the placenta completely covers the internal os, even when fully dilated Complete- placenta is completely over cervical os, unsafe to vaginally deliver- bleed to death Marginal- still too close to vaginally deliver, low lying- can do vaginally, continue with US

HTN in pregnancy

}Characterized by hypertension without proteinuriaafter 20 weeks of gestation and a return of BP to normal PP }previously known as Pregnancy Induced Hypertension (PIH) or toxemia of pregnancy }Proteinuira should be strongly suspected when dipstick >2+ }Incidence is 2-3 % of all pregnancies }Maternal age: under 20 or over 40 years are risk factors }Maternal hypertension can involve multiple organs }Complications include liver hematoma, or rupture, stroke, cardiac arrest, seizure, pulmonary edema, disseminated intravascular coagulation, renal damage, thrombocytopenia, abruption }These complications cause maternal mortality rates as high as 24%, and perinatal mortality rates of up to 70% }Treatment = birth Go through labour faster, birth baby quicker, can take up to 6 weeks for BP to resolve }dBP of ≥90 mmHg - at least twice in same arm, >5 min apart }sBP ≥ 140 mmHg may predict dBP ≥ 90 mmHg }Severe hypertension = sBP ≥ 160 mmHg or dBP ≥110 mmHg }"White-coat" hypertension = office dBP ≥ 90 mmHg but home BP<135/85 mmHg Gestational Hypertension can be classified as: }Preexisting HTN }Gestational HTN 1.pre eclampsia }Mild }Severe 2. or eclampsia (seizure) }severe eclampsia ØManagement is based on how it is classified Management of an eclamptic seizure? MgS04

Postpartum infection

}Common cause of maternal morbidity and mortality, occurs in up to 8% of all births - greater risk c-section }Fever of greater than 38°C for 2 days or more (during first 10 days after birth - excluding 1st 24 hours)** }Infections can enter via the genital tract, abdominal incision, stitches, urinary tract, nipple / milk ducts C-section- just another entry point for germs Endometrial lining, nipples- cracked Temp may be increased in first 24 hours

Iron Deficiency Anemia

}Etiology: diet poor in iron, short interconceptualperiod, and PPH }Incidence: most common type of anemia worldwide }Effects on pregnancy: preterm delivery and LBW }Management: }Supplementation in addition to prenatal vitamins Higher in developing countries, need enough iron stores to support pregnancy- if there is enough, levels will return in 6 weeks PP, not enough iron- preterm and LBW, can increase nauseous- and stop taking vitamins- polysacciride (capsule)- no nausea

Megaloblastic Anemia

}Etiology: folate or vitamin B12 deficiency (veg. diet, Crohn's disease, Sx = gastric bypass, gastrectomy, ileal bypass; medications = metformin and proton pump inhibitors) }Incidence: uncommon; third trimester }Effects on pregnancy: low folate is associated with érisk for neural tube defect, érisk for preeclampsia, prematurity and very LBW }Management: 400mcg folic acid supplementation for at least 1 month before pregnancy and the first 3 months }Multiples: Rx of 1g may be given Preconception and in first 3 months increase

HELLP Syndrome

}Hemolysis }Elevated Liver Enzymes }Low Platelets }Occurs in 0.1-0.4% of all pregnancies }Can occur in early pregnancy with or without preexisting HTN in pregnancy or up to 7 days PP.

Risk factors for PPD/ anxiety

}Hx of previous PPD or depression }Depressive symptoms during pregnancy }Family hx of depression }Life stresses (childcare stress, relationship stress) }Prenatal anxiety }Lack of social supports }Difficult / complicated pregnancy }Traumatic birth experience }Birth of high risk / special needs infant }Lingerings PP Blues 7-10 days after birth More help= less likely to have PPD Mom's need to rest and sleep- can go into psychosis if not enough sleep

Nursing Management for PPD/anxiety

}Identifying women at risk (those with risk factors) }Providing education to patients about PPD, S&S }Having open dialogue with patients about feelings they may be experiencing postpartum }Using screening tools to identify patients at risk Watch and observe, let them express feelings- get help, provide info }Assessing for S&S of postpartum psychosis, risk factors }Educating women/family members about S&S, when and how to seek help, self-care & sharing household duties }Assess sleeping patterns, anxiety / mood, supports }Provide open, non-judgmental environment to allow women to feel safe disclosing emotions / thoughts Intrusive thoughts- insight, judgment, hypervigilant, thoughts are scary

Ectopic Pregnancy

}Implantation of the blastocyst outside the uterine cavity }98% occur in fallopian tube }Risk factors }Symptoms }Physical examination findings }Diagnosis }Management Bleeding- threatened spontaneous loss? Cervical tenderness, abd tenderness, abd/pelvic pain, diagnosis with transvaginal ultrasound and hCG levels Management- surgery, methotrexate- cramp down forcefully to expel all the birth contents

Effects of pregnancy on diabetes

}Insulin requirements are altered }1st trimester - frequently ¯ }2nd trimester - begins to }May double or quadruple by end of pregnancy }Renal threshold for glucose ¯ }Increased risk of ketoacidosis, gestational hypertension, polyhydramnious, UTI, intrapartaltrauma, and retinaopathy 1T- n/v, increased estrogen and progesterone Placenta- hPL- release Teach about hormones and Oral glycemics can have teratogenic effects in early medication Try to control with diet and exercise first Spilling glucose into the urine Ketoacidosis- body cannot compensate for the acidosis- coffee ground emesis, fruity breath, confusion, dehydration, hypotension, hypoventilation- ketones, lytes, BGM, fluid and lyte IV Polyhydramnios- glucose crosses placenta, baby has increased UO and then increases the volume of the amniotic fluid

Nursing care for PP psychosis

}MEDICAL EMERGENCY }Hospitalized for safety—self and infant }Lacks insight }Rule out medical condition }Antipsychotics and mood stabilizers }Therapy }Social support Rooming in with infant Medications Talk therapy, online groups, work through for some time

Effects of diabetes on fetus

}Macrosomia }IUGR }Congenital Anomalies Shoulder dystocia and difficulty with the birth process IUGR- placenta is affected

Magnesium Sulphate

}Mechanism of action is unclear } First line treatment of eclampsia and recommended as prophylaxis against eclampsia in severe pre eclampsia }May be considered in non severe decreased eclampsiabut increased C/S rates } Cochrane reviews: MgSo4 safer and more effective than diazepam or phenytoin for prevention of recurrent seizures CNS with reflexes- platar and brachial, 2+ is normal, hyperreflexia- at risk for seizure- treat with MgS04, but CNS is not depressed and mom is not going into coma, also looking for Mgs04 toxicity- resp rate (low), flushing of neck and chest, lab work frequently to test levels in blood, antidote is calcium gluconate at bedside- if hyperreflexive }Monitor: }RR hourly }Patellar reflexes hourly }U/O <20cc/hr‐‐decrease dose }Serum Mg levels q 4 hrs 94‐8mEq/L) } Crosses the placenta freely but rarely neonatal depression }Antidote: Calcium gluconate: 1g IV over 3‐ 5 min(10ml of 10% solution)

Common postpartum infections

}Metritis - infection affecting the endometrium, decidua, myometrium of the uterus }Can extend into the broad ligament, ovaries, fallopian tubes - lead to septicemia }Uterine cavity is typically sterile until rupture of the amniotic sac }C-section deliveries are at greater risk Can affect mom- lead to sepsis }Wound Infections - any break in skin provides portal for bacteria }Sites in postpartum women include: abdominal incision, lacerations to the perineum and genital tract, episiotomy }Usually not identified until the woman has gone home, symptoms include low grade fever, redness to site, low appetite / energy }Aseptic wound management & hygiene very important Aseptic technique REEDA

Etiology of PPH

}Most common cause is uterine atony, failure of uterus to contract after birth }Any factor preventing uterine contraction will cause bleeding - even a full bladder }Typical signs (low BP, increased HR, decreased urine output) don't show up until as much as 2L blood loss Full bladder is most common- can fix, assess fundus, Signs- late of shock, has extra reserve from pregnancy }Tone - altered uterine tone, usually secondary to overdistension of uterus (hydramnios, multiples etc.) }Tissue - incomplete detachment of placenta or expulsion of tissues/ membranes (placenta accreta) }Trauma - damage to the genital tract (spontaneous, or due to forceps, vacuum, manual removals) }Thrombosis - blood clots are normally protective against PPH, but disorders can increase risk Tone is most common Thrombosis- has certain blood disorders

Active management of the third stage of labour

}Oxytocin administered }Cord clamping }Palpate fundus }Maintain tension of cord }Carbetocin Encourage the placenta to completely separate, oxytocin- IV, IM with anterior shoulder, cord clamping after 1 min, firm- likely to shear away, do not pull on cord If not at umbilicus- why? Lochia- placenta wound on the side- if amount and colour of lochia changes= bad Nursing Management- }Assessment - of uterine tone & position, amount of bleeding, clots, hematoma, coagulopathies, VS }Intervention - massage boggy uterus, expel clots, call for assistance, start large bore IV, administer medications as ordered, reassess bleeding & VS, obtain STAT labs, may need to inst }Once stable, monitor bleeding, VS, uterine tone PRN, Position- top of fundus should be at spot it was last time or lower, firm and midline- full bladder displaces Any coagulopathies

Postpartum hemorrhage

}Potentially life-threatening complication of vaginal and caesarian births }Occurs in approximately 5% of deliveries - leading cause of maternal death worldwide }Primary / early PPH - occurs within 24 hours of delivery }Secondary / late PPH - occurs 24 hours - 6 weeks after delivery Worldwide cause of death Primary-most at risk, uterus is involuting- things can get in the way 6 weeks- body return to prepregnancy state- uterus at regular size }Defined as a blood loss of > 500ml in a vaginal birth and > 1000ml in caesarian section } Retained placenta -> delayed PPH >24 hrs }Triggers hemodynamic instability }Complications - orthostatic hypotension, anemia, fatigue, PPD, delay or failure of lactation }Most common cause of maternal morbidity worldwide }Risk factors }Nursing actions Do not flush clots- leave on pad, nurse needs to see if it is placenta or birth contents or tissues, retained contents- prevent involution, break apart= blood clot, if not- high alert, palpate and assess tone of fundus- firm or boggy Signs and symptoms of hypovolemic shock- blood pools in vagina from uterine arteries Risk factors- very long labour- labour is working hard and contracting for long periods- tired, very large baby, small baby, anything that makes the uterus large and stretched- twins, polyhydramnios, lots of babies before- uterus does not want to involute Nursing actions- respond to causes

Pre-eclampsia and eclampsia

}Preeclampsia can progress to life-threateningeclampsia (a medical emergency no mater if it occurs in pregnancy, labour and delivery or postpartum) }Signs of eclampsia: }Convulsive facial twitching }Tonic-clonic contractions }Acute increase in BP }Multi organ involvement (increased liver enzymes, proteinuria, blurred vision, and hyperreflexia)

Risk factors for PPH

}Prolonged labour (1st, 2nd, 3rd stage), or precipitous }Previous hx of PPH }Multiple gestation, multiparity }Uterine infection }Manual removal of placenta, use of forceps / vacuum }Maternal exhaustion, malnutrition, anemia }Mediolateral episiotomy, birth canal lacerations }Coagulation abnormalities, maternal hypotension }Polyhydramnios, pre-eclampsia, prior placenta previa Manual removal- trauma to mom

Postpartum blues

}Self-limited, transitory mood disorders }Approximately 70% of women }Symptoms peak by 4 days PP }Resolve by 10 days to 2 weeks PP }Unclear cause; drastic shift in hormone levels implicated }Usually resolves spontaneously Symptoms peak at 3-4 days- corresponds with when milk comes in No medical intervention

Postpartum emotional disorders

}The postpartum women undergoes tremendous changes: hormones, physiological, psychological, social, cultural }A wide range of reactions and emotional responses is normal }Women may feel weepy, overwhelmed, scared or unsure }Plummeting levels of estrogen & progesterone immediately after birth can contribute Greater change in hormones= greater risk for PMD, variety- anxious, cannot control feelings, hypervigilant, overprotective over baby Give support and love }Postpartum Blues }Postpartum Anxiety/Depression }Postpartum Psychosis Blues- mentioned in other lecture, normal PPA/D- not normal

Vasa previa

}The velamentous insertion of the cord into the cervical os }Incidence: 1 in 2500 }S&S: acute bleeding on spontaneous or artificial rupture of membrane }Risk factors: IVF, low-lying placenta, multiple pregnancy }Management: palpation of a pulsating cord through the membrane intrapartally; serial u/s and management similar to placenta previa Cord is not surrounded by Warton's jelly- arteries and veins are susceptible to lacerations and esanguation. When bleeding is found, diagnosed and urgent C-section- high risk of fetal morbidity and mortality because of blood loss, sterile vagexam- palpate pulsing cord

Pre-existing diabetes

}Type 1-pancreatic B cells are destroyed and client requires insulin (10-20% of cases) }Type 2-abnormal insulin secretion and insulin resistance(80-90% of cases) Both will need to make adaptations as the insulin requirements increase in pregnancy and the importance of being very well controlled for the fetal growth and development

Postpartum psychosis

}Very rare, occurring in approximately 1 women per 1000 births }Generally surfaces within 3 weeks of giving birth, but can appear almost immediately }Symptoms include: sleep disturbances, fatigue, depression, mania, feelings of guilt and worthlessness, anger towards self / infant, delusions and hallucinations, bizarre behaviour, thoughts of harming self (suicide) or infant Out of touch with reality, thoughts- magical thinking, fantasy, very scary, immediate help and assistance Delusions/ hallucinations- any senses- common- sound, mental health command- tell you to do something- ask women about the voices, keep hearing= more likely to act, no insight into what is real, no judgement Must share info if they have thoughts of hurting themselves or others, ask if they feel safe- not planting idea, just allows a door to open to talk about it }Usually return to daily activities }Remissions and exacerbations }Require ongoing support }Severe cases }Harm children }Andrea Yates--2001 Average baby size is 7 lbs 5 oz 2 hours PP- blood may be pooling in the vagina, gush, get up to go to bathroom Know length of expected lochia length WBC are elevated in L&B

Treatment of Non severe HTN (140-159/90-109

}Without comorbid conditions BP should be kept at 130‐ 155/80‐ 105 } With comorbid conditions, BP should be 130‐139/80‐ 89 } Initial rx with methyldopa, labetolol, other beta‐ blockers, ca channel blockers }ACE inhibitors, ARBs, atenolol, prazosin not recommended }NOTE: Antenatal corticosteroids should be considered in any HTN< 34 wks

Why might a pregnancy be considered high risk?

}~10% of all pregnancies are considered high-risk (CIHI, 2004) }Sometimes due to pre-existing health problems }Cardiac disease }Autoimmune disorders }Diabetes }Sometimes due to gestation, itself (e.g., multiples) }Sometimes due to the mother's lifestyle, environment or situation }Adolescent pregnancy }Violence }Substance use, etc. SDOH, multiple fetus, problems with the cord }Nurses, with families, do everything possible to assure a POSITIVE birth outcomes }Risk factors can be classified into categories }Biophysical }Psychosocial }Socioeconomic }Environmental }We assess for risk factors throughout the pregnancy, during labour and birth and postpartum }We make referrals based on findings and provide interventions, education and anticipatory guidance as appropriate.

Contraction Stress Test

•"Test" the fetus and it's response to labour • Utilize Oxytocin via intravenous to induce contractions • It has a high negative predictive value, but is poor in predicting perinatal morbidity. • Alone, it is not recommended to guide clinical action. • Is used less in Canada now that U/S and BPP are readily available. After NST and BPP are abnormal, response of FHR to the stress of contractions- fetal oxygenation is worsened with contractions- may cause late decels- do not want to indue labour- c sectionn, predicting how the fetus will respond during labour

Newborn hypoglycemia

•<2.6mmol/L is a concern •Follow unit protocol for screening of at-risk babies •Healthy babies will effectively respond to low blood glucose for first hour after birth •Who is at greater risk of hypoglycemia? Symptoms: •Jitteriness •Hypothermia •Temperature Instability •Lethargic •Hypotonia •Apnea •Poor suck •Vomiting •Cyanosis •High-pitched Cry •Seizures ●At birth, the newborns source of glucose (Mom) is cut off when umbilical cord is clamped. ●Greater risk: ●Maternal factors: diabetes, gestational hypertension ●Infant Factors: perinatal hypoxia, infection, LGA, SGA, hypothermia, ●Hypoglycemia can be present without clinical manifestations Breastfeeding early and often helps newborns maintain adequate glucose levels

Preterm labor and birth

•<7.6% of all pregnancies results in preterm birth •Rate has not decreased in 30 years!! WHY •In 2008 - 8 Billion dollars in Canada •Risk Factors •Previous preterm birth •2nd trimester losses •Habitual SA •Uterine/Cervical anomalies •PPROM Not decreasing- do not know how to stop it, interventions to slow it down but nothing to stop it Very expensive- neonatal care- $16 000 / day with minimal interventions Habitual spontaneous abortions- a lot of losses <20 weeks

Birth plans

•A birth plan is a communication tool for parents to use to express their thoughts and desires for an upcoming birth. •The same idea applies, and may be more important, for parents who know they are delivering a stillborn, a sick baby or a baby with a known life-threatening condition.

Grandparents grief

•A grandparent's response to the loss of a grandchild may differ from the parent's response to the loss of a child. •Nurses can explain to grandparents that their care activities are for the benefit of the parents, even though grandparents may have different experiences or expectations.

Management of RDS

•A neonate with RDS will need both oxygenation and ventilation therapy. Ventilation is required to open up the airways and to allow the oxygen therapy to be efficacious in promoting gas exchange. •Continuous Positive Airway Pressure (CPAP) or Positive End-Expiratory Pressure (PEEP) may be used to ventilate the neonate. CPAP delivers continuous pressure, whereas PEEP only delivers maximum pressure at the end of the expiration to inhibit the alveoli from collapsing. Exogenous surfactant may be administered via an endotracheal tube as an adjunct to oxygen and ventilation therapy. (As seen in the picture) Early vs rescue administration

PP blues

•Affects up to 80 % of women in Canada •The postpartum period is a happy, yet stressful time, marked by huge changes - adjustment takes time •The postpartum blues typically resolves without intervention within a few weeks postpartum •It's a transient emotional disturbance characterized by emotional lability, insomnia, anxiety, and fatigue

Development stages and grief

•An individual's developmental stage influences the way he processes and responds to loss. •Most pregnant women and their partners are in the stage of young adulthood (19 to 40 years of age). •The basic conflict during this stage is intimacy vs. isolation, in which individuals strive for positive relationships to avoid isolation.

Ripening of the cervix

•An internal sign seen only on pelvic examination. •Goodell's sign is present in pregnancy •At term, the cervix becomes still softer (described as "butter-soft"), and moves from tipping posteriorly to mid position and then forward •Ripening is an internal announcement that labor is very close at hand. Soft when touched- labour within a day, moves into position- posterior position, then mid position and then anteriorly

Renal system changes during pregnancy

•Anatomical changes •Dilation of ureters and renal pelvis allows for bacterial ascension, which puts gravid women at an increased risk for pyelonpehritis •Kidney size increases in order to deal f filtering not only moms waste but baby's too. •Functional changes •Increased urine frequency •1st trimester: smooth muscle relaxation effects of progesterone •3rd trimester: growing uterus puts pressure on the bladder •GFR (by 50%) and renal plasma flow (by 60-80%) increase •Due to these increases the BUN and CREAT decrease, amino acids, glucose and water soluble vitamins are lost in the urine •Fluid and electrolyte balance •Total body water increases by 6.5L

Baseline FHR

•Approximate FHR during a 10 minute segment •Rounded to 5 bpm increments •Baseline duration- minimum 2 minutes per 10 minutes •Normal: 110-160 bpm ( age appropriate ) •Changes: must be maintained > 10 minutes to be a baseline change Reference for changes in status, set by atrial pacemaker, beat to beat difference are governed by balance between SNS and PSNS branches of ANS, CNS matures- HR drops, mid trimester- 150-170 bpm •Need to determine •FHR baseline: normal 110bpm to 160bpm •FHR variability: beat to beat changes or fluctuations in FHR •Absent, minimal, moderate, or marked •Presence of Accelerations: an abrupt increase in FHR, 15 bpm above baseline, lasting 15 seconds •Presence of decelerations: an abrupt decrease in FHR, 15bpm below baseline for 15 seconds Variability- tiny ups and downs, interplay of PSNS and SNS- getting oxygenation

Fetal Heart Tones

•Are positive sign of pregnancy •Can be heard by Doppler US at 8-10 weeks & a fetoscope at 20 weeks •Auscultated best between fetal shoulders •Normal rate: 110-160 bpm •Steps •Locate back with Leopold's maneuvers •Auscultate for a full minute •Differentiate FHTs from other sounds (maternal pulse, uterine souffle, & funic souffle) •Listen for any accelerations or decelerations 1.Vertex- listen in lower quadrants, note if it is regular or irregular 2.Review terms 3.Palpate mom's radial pulse= should be different to determine it is the baby, any accelerations and slowing down, right and rhythm A: With fetus in right occipitoanterior (ROA) position. B: Changes in location of point of maximal intensity of fetal heart tones as fetus undergoes internal rotation from ROA to OA position for birth. C: With fetus in left sacrum posterior position. Fetal descends lower during birth Very fast, listen to them many times, listen for full minute- regular count for 10 seconds X 6, 15 seconds X4 All examples have regular Different reasons why it would go up or down

PP pain

•Assess by using a pain scale (rating her pain from 0-10) •Ask questions about location and severity •The postpartum can have pain from a number of sources (perineum, hemorrhoids, breasts / nipples, uterus, incision) •Some pain relief options include: analgesics (acetaminophen, ibuprofen, naproxyn), sitz baths / warm showers, ice packs, positioning

Nursing care management- maternal nutrition

•Assessment •Diet history •Obstetrical and gynecological effects on nutrition •Medical history •Usual maternal diet •Physical examination •Laboratory testing •Plan of care and implementation •Nutrition counselling •Canada's Food Guide •Safe food preparation •Medical nutrition therapy •Plan of care and implementation •Coping with nutrition-related discomforts of pregnancy •Nausea and vomiting •Constipation •Pyrosis (heartburn) •Cultural influences •Vegetarian diets

Autopsy

•Autopsy often provides valuable medical information about the cause of death; it also can provide guidance for future pregnancies. •Parents should receive information about the purpose of an autopsy and be asked for consent to have the procedure done.

Seasonal influenza

•Babies are not eligible for flu vaccine until they are 6 months of age •If they are born during influenza season (October-March) the baby's only protection is if their parents are protected. •Antibodies can pass through breastmilk •Immunity response takes a few weeks to develop, so women should receive during pregnancy if possible •On MBU, influenza vaccine is offered to all mothers, prior to their discharge that have not had a dose of flu vaccine in the current influenza season. In Saskatchewan all citizens >6 months old are eligible to receive a free dose of influenza vaccine every year.

Assessment PP

•Begins within an hour of delivery, and continues until discharge home •Typically includes: vital signs (including pain), a systematic review of the pertinent body systems (BUBBLE-EE), and any special assessments based on medical Hx •The postpartum assessment should also include the family members (partner, siblings) •The nurse should monitor closely for any "danger signs"

Discharge planning

•Bereaved parents need information, support and planning help for the early days after their loss. •Instructions should include physical care of the woman. •Bereavement materials should include common responses to grief and loss, community and online resources, and a list of symptoms and concerns that warrant contacting a health care provider. •Going home to pregnancy and baby things can be difficult for grieving families. •Having a list of specific things for people to do for the family can be beneficial. •Hospital staff can call families 1 to 2 weeks post-loss to see how they are doing and if they have questions.

Psychological Adaptations and needs PP

•Between 50-80% of women experience the "baby blues" •Around 16% of new moms experience postpartum depression •Postpartum depression can impact the mother's ability to bond with her infant, and function in her daily life •Impact of birth experience •Maternal self-image •Adaptation to parenthood and parent-infant interactions •Family structure and functioning •Impact of cultural diversity

Fetal Head

•Bones •Sutures •Fontanels •Molding Fontanels where the sutures cross- anterior is larger 2-3 cm, diamond shaped, closes 12-18 mon, occipital- 1-2cm triangle, 6-8 weeks close Palpate to find position of baby Allow brain growth, overlapping may occur during birth- modeling- cone head- disappears in a few days

Attachment Theory

•Bowlby (1969) was the first to identify and discuss human attachment. •Klaus and Kennel (1976) describe behaviors that demonstrate a bond between mother and baby before birth. •Peppers and Knapp (1980) show that attachment begins when planning a pregnancy.

Assessing effective feeding

•Breast milk supply is built and maintained by effective deep latch and sucking by the baby ~8-12 times per 24 hours (about q1-3hrs) •Baby should be in a quiet alert state or light sleep (crying is a late feeding cue) •Skin-to-skin contact should be promoted before, after and between feeding as much as possible to help establish breastfeeding The feeding should be baby driven The mother should not experience pain throughout the feeding the first 5-10 seconds of sucking in the first few days PP can be uncomfortable for mothers but the pain should resolve within the first few sucks Active rhythmic sucking should occur with swallows heard Feeding patterns will vary with each baby, some feed quicker The baby should be allowed to feed until they spontaneously detach or no longer can be stimulated to continue sucking Mother needs to be comfortable, well supported and safe She can support her breast with all 4 fingers with a C or U-hold with her fingers away from the areola so the baby can attach deeply onto the breast Discourage her from using a scissor type hold that has her fingers too close to the areola The baby should come towards the mother, the mother should not lean forward or into her baby If in an upright feeding position she should have pillows to help support the baby at her breast level

BUBBLE-EE

•Breasts (including nipple)- •Inspect for size, symmetry, contour, engorgement, or erythema, ask the mom if they are soft or filling •Check nipple for shape (flat, inverted, protruding), any cracking / bruising / blistering / bleeding, and tenderness •This assessment can be done when the mom is preparing to feed her baby, or during / after a feed •Uterus (fundal height)- •Assess the fundus to determine degree of involution •If possible have the mom empty her bladder beforehand •Use a 2 handed approach with the woman laying completely flat (supine) •The fundus should be firm and midline, roughly at umbilicus during initial postpartum period, then decreasing by a fingerbreadth below per day •Bladder- •Considerable diuresis can occur in the days following birth (up to 3 L) • •Ask the mom if she is voiding, experiencing any burning, difficulty voiding / or emptying her bladder, any urgency or frequency, any leakage of urine (laughing / coughing) •The bladder can be palpated for distention, or percussed for dullness •If a mom hasn't voided by 6 hours postpartum (or after catheter removal) a catheter may need to be placed, preventing stress incontinence- •Encourage her to start Kegel exercises after delivery -Engage appropriate muscles - like trying to stop urine flow -Start with 10 five second contractions several times a day •Weight loss can also help with stress incontinence •Avoid smoking, caffeine, alcohol - they irritate the bladder •Bowels- •A spontaneous BM may not occur for 2-3 days postpartum •Inspect the abdomen for distention, ausculate for bowel sounds (should be no distention, and active BS) •Ask the mom if she has had a BM, and if not then ask if she is passing gas •A stool softener (docusate) is routinely given postpartum •Encourage intake of high fiber foods and adequate fluids •Lochia- •Assess the amount - how many pads she is using, assess amount on pad & when it was last changed •Assess the color - is it dark red, pink, brown? •Is there any unusual or foul odour? •Is she passing any clots, and if so what size are they? -Larger clots can indicate poor uterine involution, • •The amount of lochia is documented as follows: -Scant: 2.5-5 cm stain on pad -Small: up to 10 cm stain on pad -Moderate: 10-15 cm stain on pad -Large: the pad is saturate within an hour •A red flag is if the mom reports that she is saturating a pad in less than an hour! •Moms who have a c-section often have much less lochia •Episiotomy / perineum- •Easiest to assess with the mom on her side and top leg drawn up towards waist, then lift upper buttock •Ensure you have adequate lighting (flashlight if needed) •Inspect for swelling, hematoma, redness, bruising, as well as presence of hemorrhoids •Some bruising and swelling is normal- REEDA Assessment (•R- Redness •E - Edema •E - Ecchymosis •D - Discharge •A - Approximation) •Extremeties- •Assess for signs of blood clots in the legs (unilateral edema, tenderness, and warmth to affected leg) •Assess legs and feet for edema (normal in immediate postpartum period) •Also be aware of signs of pulmonary embolus to watch for (SOB, difficulty breathing, heaviness in chest) •Emotional status- •Observe how she interacts with her family members •Assess her level of independence with infant care, and attention to her infant's needs •Observe how she interacts with her baby (holding, feeding, eye contact, response to cries) •Be alert for mood swings, irritability, excessive anxiety, crying episodes, sleep patterns

Care of the deceased

•Burial and cremation are the primary means of dealing with a deceased baby's body. •Gestational age, state law, religion and culture are considered in care of a deceased baby •Nurses must know their institution's protocols and explain all options and procedures to parents. •Nurses can ask families about rituals or traditions they would like to observe. •Rituals include baptism, songs, readings and ceremonies. •Families need time to make arrangements for funerals and memorial services. •Memorial services can be done at any time, even long after the actual death.

Cardio PP

•Cardiac output is initially high, but returns to pre-pregnancy w/in 3 months •Heart rate slows down following delivery (50-70) •BP should be similar to during labour but can be slightly elevated for a week •Blood volume returns to normal within 4 weeks •Postpartal diuresis -Within 12 hours, women begin to diurese. -Profuse diaphoresis often occurs at night for first 2 to 3 days •Clotting factors remain elevated for 2-3 weeks •This hypercoagulability and vessel damage during birth places the woman at higher risk of clots •Hgb and hematocrit increase slowly in first 2 weeks •WBC count elevates during labour and remains elevated for 4-6 days

Pain the antepartum

•Causes: •Anxiety •Fatigue •Ligament stretching •Fetal movement •Acute or chronic illness Antepartum- pregnant Anxiety is a big cause- heightens our senses- hearing, seeing, smell, and awareness of sensations (pain) Fatigue is also a big cause (people in general), body is tired, has less of a threshold Ligament stretching- round ligament-starts off a very tiny when not pregnant, then grows and stretches as uterus grows , doesn't have the same amount of collagen- not meant to grow and stretch in the same degree and quickness as the other parts, feels like shooting pan, intermittent, early to mid 3T- preterm labour, or feel like it is not right, anxiety- cycle Fetal movement- big baby kicking, punching, stretching out body Acute or chronic illness- placental abruption- shears off uterine wall before baby is born- bleeding, pain because it is filling with blood and there is nowhere for it to go, doesn't go away, carpal tunnel syndrome- edema presses on wrist, back pain/injury often gets worse Positioning Incorrect- slouching Need correct posture for centre of gravity and thigh muscles can hold you up, relieve back, neck, shoulder pain

Long-term neonatal complications

•Cerebral Palsy •Cognitive Impairment •Blindness •Deafness •Possible adult-onset arteriosclerosis, hypertension, diabetes & pulmonary disease.

Sibling grief

•Children grieve in ways quite different than adults, often in an uneven pattern. •Their concept of death varies by developmental stage, and grief can reemerge at a later stage when they deal with it at a different level. •Healthy grieving for children can be predicted by two factors: 1.Accessibility of one significant adult 2.Being in a safe environment where they are physically and emotionally taken care of. •Infants: Maintaining routines and avoiding separation are important. •Preschoolers: Nurses and parents can give children straightforward explanations, correct their thinking when necessary, and be clear that the baby is not coming back. •School-age children: Caregivers can give clear explanations and involve them with funeral or memorial services if they are comfortable participating. •Adolescents need adult support and time with their peers.

Integ system changes during pregnancy

•Chloasma (mask of pregnancy) •Linea nigra •Striae gravidarum •Angiomas •Palmar erythema •Thicker hair

Physical needs PP

•Combined or mother-baby care -Infant security -Anticipatory guidance •Maintenance of uterine tone •Prevention of -Infection -Excessive bleeding -Bladder distention •Promotion of -Comfort -Rest -Ambulation •Be present first time woman is out of bed after birth. •Prevention of clot formation -Exercise/Nutrition -Bladder/bowel function -Lactation or suppression of

Common vs severe reactions for vaccines

•Common: Pain, redness and/or swelling where the shot was given •Headache, tiredness •Possibly chills, sore joints or body aches. •Signs of a severe allergic reaction, very high fever, or unusual behavior. •Severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would usually start a few minutes to a few hours after the vaccination. •Anaphylaxis is a life-threatening emergency: Call for help right away!

Fetal Assessment During Labour

•Components •Fetal heart rate •Presence of meconium •Fetal blood sampling HR- brain is getting blood Stress response- meconium, can aspirate- resp distress, blood sample- dilated, may need to have C-section

Documentation and Communication

•Consistent, proper terminology •Demonstrate nursing process ( ADPIE- assessment, diagnosis, planning, implementation and evaluation). •When atypical or abnormal FHR patterns are identified, document the return to normal. •Seek clarification •Confirm with the RN or your instructor prior to charting •Always explore how the FHR correlates with the clinical picture •NEVER alter notes later •Practice!! IA and EFM, poorly defined terms cannot be used in nurses notes Document maternal/ fetal responses and interventions Communicate PRN with primary care provider

TPTL

•Contractions present between 20-37 weeks •No evidence of cervical dilation •Only 20% results in PTL •Interventions usually resolve contractions: •Rest •Hydration •UTI/STI/Other infection •Tocolysis •ANS Threatened Preterm Labor Looks like labour but is not Treat infection Tocolytic- stop contractions with medication ANS- antenatal steroids High in summer because the uterus is a muscle, summer is hot- dehydrated- uterus does not like that and has contractions- fluid bolus- good teaching point in AP

What is pain?

•Defined by Mosby's as an "unpleasant sensation caused by noxious stimulation of the sensory nerve endings." •May be chronic or acute •May be mild to severe, and can be referred to other areas of the body

Pain in PP

•Depends on: •Length of labour •Tears/episiotomy •SVD vs. OVD •Vaginal birth vs. cesarean section •Psyce length- long and exhausted Tears- 1st degree will feel different than 3rd-4th degree Spontaneous vaginal delivery, operative- instruments cause more pain- decreases time, fetal presenting part has to stretch the tissue in perineum- quickly C- opens entire abd cavity, more pain Psyce- increased pain because of psychological- anxiety•Rest •Baby bonding •Hydration and nutrition •Warm tub bath •Analgesia Rest as much as possible- put feet up, lay down, not worry about visitors or cleaning the house, nourish self and baby Baby bonding- skin to skin, help decrease anxiety, releases oxytocin Hydration and nutrition- tissue needs to heal, loss of blood, breastfeeding- as much as she needed during pregnancy Tub baths- unless C-section- cannot submerge incision until it is healed Analgesics- prepregnancy, most will come through breastmilk but very small amount, Tylenol, Advil, Naproxen, do what makes them feel best- seek out help and support

Maternal and Fetal nutrition

•Determinants of health have impact on dietary intake. •Good nutrition before and during pregnancy is an important preventive measure. •Low-birth-weight (LBW) infants •Preterm infants •Neonatal and infant mortality and morbidity increased for moderately LBW infants and five times higher than for babies >2500 g •Risk for very LBW (VLBW) is 100 times higher

Assessment and Nursing Care- Intrapartum

•Determination of true or false labour •Contractions •Cervix •Fetus •Admission to labour unit •Admission data •EDB •Antenatal data •Interview •Psychosocial factors •Stress in labour •Cultural factors •Physical examination •General systems assessment •Vital signs & FHR •Symphysis-fundal height •Urinalysis (dipstick) for protein and sugar •Uterine activity •State of membranes •Fetal activity •Show •Vaginal exam •Leopold's maneuvers •Assessment of fetal heart rate (FHR) and pattern Ask about due date, see if they are in labor, assess baby- contractions are stressful, cuts off some blood supply- babies can adapt, assess contractions- when, how long, etc. L&B- until active stage, medical treatments unnecessarily, hospital when you are 5cm Fundal height- fetal growth State of membranes- bloody show Activity- fetal movements, may not move around in labor Leopold's Maneuver- position of baby

Culturally Safe care PP

•Don't make assumptions about infant care practices - have an open dialogue with families & learn from them •Childbearing beliefs and practices vary across cultures (dietary restrictions, prayer, clothing, taboos) •Ask families what their preferences are - just because someone identifies with a certain culture, it doesn't mean that they have adopted any or all of that culture's childbearing practices!

Fetal blood sampling

•Done by physician •Assess the pH or Lactate build up, normal lactate- < / = 4.1, pH->/= 7.25 Fetal scalp sampling- monitor fetal distress with EFM- prevent interventions, measures pH, ROM, c d of 3-5 cm, vertex presentation at -1 station Below 7.15- Apgar score less than 6 Acid-base balance- prevent surgical intervention

Non-stress test

•Done via continuous electronic fetal monitoring •Provides a "tracing" of babies heartbeat •Accelerations •Variability •Decelerations •No contractions •Diagnosed as •Normal •Atypical •Abnormal No contractions- uterus is relaxed, contractions decease blood flow to uterus, plan what to do next- more monitoring, testing, birth, normal NST= positive perinatal outcome for 1 wk, postdate/ GDM- NST twice per week- may want to induce earlier if there is a problem

Biophysical profile

•Done via ultrasound •Examines 4 key areas of fetal development and wellbeing •Breathing •Movement •Tone •Fluid Volume •Also usually includes a Non-Stress Test •Each component can score up to 2 points •Total score is out of 10 points Amniotic fluid volume/ fetal behaviour, cannot predict future well being, each component 0-2, amniotic fluid volume is most important- kidney and lungs, kidneys intact and no urinary tract obstruction decreased= decreased GFR from chronic hypoxia as there is redistribution away from fetal kidneys with increased CO, components- fetal breathing, fetal movements, fetal tone, amniotic fluid volume, FHT (with NST), 10/10 with NST, 8/10 with normal amniotic fluid- normal fetus with low risk of asphyxia, 8/10 with abnormal fluid volume- asphyxia and fetus needs to be delivered, 6- equivocal, abnormal= asphyxia, less than 34 weeks- monitor, want to encourage maturity, if it is normal- redo in 24 hours, <4- high risk of asphyxia, deliver asap

Pain in the intrapartum

•Due to labour •Contractions •Fear of the unknown •Exhaustion •Due to complications •Dystocia •CPD •Malpresentation •Abruption Contractions are contraction of myometrium of uterus- decreases amount of blood flow to muscles- decreases oxygenation, squeezing and forcing baby on cervix- different for each woman- different thresholds, and coping mechanisms Fear= anxiety, family- centered care/ women-centered care, talk through things, be there for them- support Exhaustion- cannot eat or drink during labour- not getting nutrients, think of it as a marathon, need glucose and hydration Complications- cephalopelvic disproportion, dystocia- baby is not fitting through pelvic- trashing as baby is hitting bones- pain, malpresentation- occiput posterior, transverse lie , abruption- placental Excessive pain- extra, shift and change in patient, may not go away with pain management, may have pain even if they are not contracting

Abd PP

•During first 2 weeks, abdominal wall remains relaxed. •Woman has still-pregnant appearance. •Return to prepregnancy state takes 6 weeks. •Depends on previous tone, proper exercise, and amount of adipose tissue •Diastasis recti abdominus

Pain in pregnancy

•During labour: "Some women experience pain that is quite manageable, while other women require more pain relief; for example, because of the baby's position, a prolonged labour, or their own personal pain threshold. Most Canadian hospitals offer different options, some with medicine and some medicine-free, that help with pain in early labour." SOGC Guidelines, 2013 Pain is inevitable

Breasts PP

•During pregnancy they increase in size and functionality to prepare for breastfeeding •Each breast gains an average of 1 lb •After delivery the levels of estrogen and progesterone decrease and allow the prolactin to stimulate production of colostrum •Colostrum is produced during first 3 days postpartum •Breasts are typically soft and non tender first 2 days postpartum •If a woman doesn't breastfeed, breast engorgement and milk production start to subside within 2-3 days postpartum •Engorgement can occur from 2-4 days postpartum, breasts are hard and tender to touch •Milk must be removed from the breast to maintain the milk supply

Pregnancy as a rite of passage

•Each rite of passage has three stages: 1.Separation 2.Transition 3.Incorporation •A woman separates herself from her old status when she announces her pregnancy. •The transition takes place during the 9 months of pregnancy.

Types of perinatal and neonatal loss

•Ectopic pregnancy •Elective abortion •Fetal death •Infertility- •the inability to conceive after at least 1 year of trying .•Miscarriage (spontaneous abortion) •Neonatal death •Stillbirth •Sudden infant death syndrome (SIDS) •Sudden unexplained death in infancy (SUID)- SIDS and other causes (suffocation) •Therapeutic abortion

Amphetamines NAS effect

•Effects not well known •SGA •Preterm •Cleft lip/palate •Intracranial hemorrhage

Nutrient needs during pregnancy

•Energy needs •Weight gain •Body mass index (BMI) = weight/height2 •Pattern of weight gain •Hazards of restricting adequate weight gain •Obesity and pregnancy •Protein •Fluids •Minerals, vitamins, and electrolytes •Iron •Calcium •Magnesium •Sodium •Potassium •Zinc •Fluoride •Minerals and vitamins •Fat-soluble vitamins • Vitamins A, D, E, and K •Water-soluble vitamins •Folate or folic acid •Pyridoxine •Vitamin C •Vitamin B12 •Multivitamin-multimineral supplements •Other nutrition issues during pregnancy •Pica and food cravings •Adolescent pregnancy needs •Improve nutritional health of pregnant adolescents by focusing on knowledge and planning of meals. •Nutrition interventions and educational programs are effective with adolescents •Understand factors that create barriers to change in adolescent population. Promote access to prenatal care •Other nutritional issues during pregnancy •Pre-eclampsia •The cause is still unknown. •It is speculated that poor intake of specific nutrients may be a contributing factor. •An adequate diet remains the best means of prevention.

Gestational Age

•Estimated date of birth (EDB) is determined by: •Early ultrasound •Nägele's rule •Determine first day of last menstrual period (LMP), subtract 3 months, add 7 days plus 1 year. •Alternatively, add 7 days to LMP and count forward 9 months. •Less accurate with irregular menstrual cycles •Most women give birth from 7 days before to 7 days after EDB. Estimated date of confinement (EBC), need regular menstrual cycles- babies are not born exactly on due date, >1 week past (42 weeks), placenta gets old and tired, at risk for still birth

Eyes, Mouth, Neck changes during pregnancy

•Eyes •Intraocular pressure increases •Slight thickening of the cornea occurs •Wearing contact lens may become uncomfortable •Mouth •Mucous membranes should be red and moist •Gum hypertrophy, surface looks smooth and stippling disappears, may occur normally during pregnancy (pregnancy gingivitis) •Bleeding gums may be from estrogen stimulation, which causes increased vascularity and fragility •Neck •Thyroid may be palpable and may feel full but smooth during normal pregnancy of euthyroid woman Eyes look for conjunctiva, colour Estastion tubes, nasal congestion and nosebleeds from hormones Neck- lumps, masses, swallow water to feel thyroid

FHR bradycardia

•FHR < 110 bpm •Mild: 100- 110 bpm •Marked: < 100 bpm Drugs, hypotension, hypoglycemia, hypothermia, complete/ congenital heart block, bradyarrhythmia, umbilical cord compression, amniotic fluid embolism, hypoxemia, analyze for changes and decreased variability, may be normal, 110-160- may not be normal for all fetuses

Holding the baby

•Family contact with the deceased baby should not be restricted. •Holding the baby should be offered but never forced. •PLIDA has detailed position statements and practice guidelines for offering parents the opportunity to hold their baby.

Neural control of fetal cardiac activity

•Fetal O2 affects the function of the brain which affects how the cardiovascular system functions •Regulation of the FHR is under the influence of the autonomic nervous system and extrinsic factors. •The fetus' heart rate decreases as gestational age increases, primarily related to intrinsic factors. •FHR changes are primarily controlled by a balance between the sympathetic and the parasympathetic nervous systems. FHR- brain and cardio- oxygenation affects both Cerebral cortex, medulla oblongata in brain (fetal cardio regulatory system- cardio integ system), vagus nerve and conduction system- changes and characteristics in FHR, arterial chemoreceptors and SNS- when GA is low- less time in between contractions of heart, HR is on high end of normal, beat to beat variability is minimal- less time between cycles , as the fetus gets older, nervous system matures- increased response to vagus nerve on the heart- PSNS- decreases FHR- variability, conduction of heart is determined by brain- can be affected by oxygenation, evaluate patterns of cardiac activity- fetal oxygenation and neurological integrity may be inferred

Methods of Antenatal surveillance

•Fetal movement counting •Biophysical Profile (BPP) •Non stress test (NST) •Contraction stress test (CST) •Uterine artery doppler •Umbilical artery doppler Do not do before 20 weeks FMC and IA0 recommended in uncomplicated

Umbilical artery Doppler

•Fetal umbilical circulation has continuous forward flow (low resistance) to placenta - resistance to forward flow ↓ as gestation age ↑ •Looks at the end diastolic flow •↑ resistance to forward flow characterized by abnormal S/D ratio •If absent = <50% of functional villi are obliterated •Indicated for use if suspected placental insufficiency due to: •Suspected growth restriction •Suspected placental pathology Not of value if healthy pregnancy, use if suspect there is placental insufficiency

Danger signs PP

•Fever higher than 38°C •Change in color / amount / smell of lochia •Headaches or blurred vision / seeing spots •Calf pain with dorsiflexion of calf •Excessive swelling, or redness, discharge at episiotomy / stitches in perineum •Inability to void / empty bladder, burning during voiding •SOB or difficulty breathing •Depression or extreme mood swings / anxiety

Stages of Labour

•First Stage •Latent phase •Active phase •Second Stage •Latent phase •Active phase •Third Stage •Fourth Stage 0-10cm- active phase Second stage- fully dilated-birth Third- birth of fetus- birth of placenta Fourth- birth of placenta-2-4 hr after birth, hemodynamic status- 500 mL is normal, 6weeks- impulution- contracts back down to prepregnant level, healing

Normal Discomforts r/t pregnancy

•First Trimester •Breast changes •Urgency and frequency of urination •Languor and malaise; fatigue •Ptyalism •Gingivitis •Nasal stuffiness •Leukorrhea Ptyalism- more saliva More progesterone= more blood flow- bleed when brushing teeth •Second Trimester •Skin changes •Spider nevi •Palmar erythema •Pruritus •Palpitations •Supine hypotension •Faintness •Food cravings •Heartburn •Constipation •flatulence •Varicose veins •Headaches •Carpal tunnel syndrome •Periodic numbness of fingers •Round ligament pain •Joint pain •Third Trimester •SOB •Insomnia •Psychosocial - anxiety, mood swings •Urinary frequency and urgency return •Perineal discomfort and pressure •Leg cramps •Ankle edema Leg cramps are common- Charlie horse, magnesium- helps with this

Diversity of intrapartum care

•For most health care providers, a placenta has little importance or meaning after its work of oxygenation is done and it is delivered •The placenta may have continuing importance to women •Buried •Cooked and eaten •Dried and ground for capsules and swallowed Dried- helps with massive blood loss and restore irons Bring cooler filled with ice- freezer Cord is like cutting through chicken breast, far away from belly button because it dries up, nurses want to measure pH and hypoxia during birth, sutures are not done straight

Ovulation and Menstruation PP

•For non-lactating women, menstruation usually returns within 7-9 weeks postpartum •The return of menstruation is much more unpredictable with women who breastfeed •With the lactating woman menstruation usually returns between 2-18 months

GI/MSK/Integ/Resp/ Endocrine/ Neuro PP

•GI - bowels may be sluggish for several days •MSK - relaxin declines & joints return to normal state, abdominal muscle tone is diminished - some women experience diastasis recti •Integumentary - darkened pigmentation fades, hair loss, striae fade, diaphoresis increases •Respiratory - diaphragm returns to normal level and lung capacity increases to normal •Endocrine - undergoes several changes rapidly after birth, hormone levels change •Hormonal changes will vary depending on whether a woman goes on to breastfeed the infant or not •Neurological - headaches require careful assessment

Family involvement

•Gender, role and timing are cultural considerations that may determine involvement of extended family after a perinatal loss. The nurse can ask a woman whom she wants to be with her, where she would like her family to be, what she needs to wear and where she physically wants to be

Naming the baby

•Giving the baby a name increases the baby's social status and personhood. •There is no timeframe for naming a baby, especially in the case of early loss when gender is difficult to determine.

Urinary system PP

•Glomerular filtration rate decreases to normal by 6 weeks •Woman can have difficulty sensing when they have to void after receiving an epidural or spinal block •Difficulty voiding can be increased by perineal trauma •Urinary retention is a major cause of uterine atony

Fetal fibronectin (fFN)

•Glycoprotein found in extracellular matrix of amniotic membrane •Normally found in cervico-vaginal secretions until 22 weeks & again around 35 weeks •Released into fluid as a response to inflammation or separation of amniotic membranes •Presence between 24-34 weeks may be indicative of imminent labor. Disappears and comes back Separation form uterine wall (chorion), Nurses or lab Swab the cervix, put on cassette, stick in machine, analyzes and then prints out result •Between 24 - 34 weeks •Cervix less than 3 cm •Must do before SVE •Negative result = 80% correct* •Positive result = 1 in 6 will deliver Stronger indication that birth is NOT coming, can get sent home Positive- look at whole clinical picture, labor could be in 7 days <20 weeks- not viable >3cm labor is imminent Swab- do not want to contaminate area, then check cervix, >3cm do not run test, test is expensive- avoid unnecessary testing

Neonatal Palliative Care

•Goals of palliative care oQuality of life oComfort or relief from symptoms oSupport with tasks and bereavement •Collaboration across disciplines is critical. •Nurses require palliative-care education that includes clinical and ethical aspects.

Grief and Mourning

•Grief is an emotional response to the loss of something or someone held dear; it is the internal response to loss. •Mourning is a public or external response to the death of a loved one. •The period of time during which grief and mourning occur after a death is called bereavement. •No two people respond to the same event or loss in exactly the same way; grief is individual and depends on how loss affects each person. Intense and continued distress symptoms beyond 6 months to 1 year that interfere with one's ability to function and enjoy life should be evaluated by a mental health professional. 1.Denial and isolation 2.Anger 3.Bargaining 4.Depression 5.Acceptance •Stroebe and Schut (2001) suggest a dual process of grieving that includes oscillation between two coping modes: 1.Loss orientation (focused on adjusting to a loss) 2.Restoration orientation (focused on how to move on in light of a loss)

Components of antepartum assessment

•Health history- •Genetic and familial problems •Pre and coexisting medical disorder, allergies •Pregnancy related health problems •Infections diseases •Nutritional hx •Social and cultural context •Intimate partner violence •Review of each body system •Obstetric history: G-T-P-A-L, Body system, screen for intimate personal violence- increases during pregnancy •Physical examination- •Provides a baseline •Bladder should be empty before pelvic exam •Initial visit •includes v/s, height, weight (BMI), and head-to-toe systems assessment, including pelvic exam •Between 29-36 weeks •also assess for edema •At 36+ weeks •Pelvic exam,Ask to go to bathroom first Good L sign, Alger sign- changes in pelvis and vagina Symmetrical swelling is normal in lower limbs- heart has to work harder to get rid of fluid Pelvic exam- is signs of labor occurring, fetal position- breeched, sideways Change by trimester •Laboratory tests- •Hbg, hct, WBC, platelets •Blood type, RH and presence of antibodies •Maternal serum screen •Rubella titer •Urinalysis •Urine culture •Renal tests •Pap tests •1 hr glucose tolerance (28 wks)* •STI •HIV •GBS (at 35 weeks) Rh- mom, Rh+ baby= survive but second time, mom will miscarry Maternal serum screen- trisomy, neuronal tube defects Infection- risk for preterm birth, or miscarry if below Glucose- gestational diabetes, insulin resistance GBS- no harm to you but during birth can travel to baby, high mortality rate, labouring- start IV and antibiotics, postpartum dose •Fetal assessment-•Gestational age •Screening •Maternal serum screen •U/S at 20 weeks •Growth •Fundal height •Maternal weight gain •Fetal position •Health status •Fetal heart tones •Fetal movement Cannot physically touch baby GA- how old is baby Only one ultrasound at 20 weeks- sooner if unsure of date, need to know when last day of LMP is- before 12 weeks US Growth of uterus Leopold's Maneuver Moving= alive, prevent still birth- mom should monitor, heart tones= alive and normal range= brain is getting oxygen rich blood •Teaching Physical exam- both mother and baby Fetal assessment- US, heart sounds

Cardio changes during pregnancy

•Heart - displaced up and to the left; often a functional, soft, blowing, systolic murmur is present as result of increased volume •Blood pressure •Heart rate Blood volume •Blood composition •an increase in RBC production by 20-30%, •plasma volume increases causing hemodilution of RBCs in plasma (physiologic anemia of pregnancy); •white blood cells increase (physiological leukocytosis) •Cardiac output •Coagulation times •Circulation - increased femoral venous pressure causes edema, varicose veins and hemorrhoids •Legs may show diffuse, bilateral pitting edema, particularly later in day when woman has been on her feet and in third trimester, Palpate for point of maximal impulse, z pattern,

Pregnancy Tests

•Human chorionic gonadotropin (hCG) is the earliest biochemical marker of pregnancy. •Pregnancy tests are based on recognition of hCG or β subunit of hCG. •Many different pregnancy tests are available: •Enzyme-linked immunosorbent assay (ELISA)testing is the most popular method of testing for pregnancy. •ELISA technology is the basis for most over-the-counter home pregnancy tests. •Medication interferences Health hx- nutrition, LMP, height and weight, vital signs- normal in 1T, 10-15 bpm increase later, midstream urine test Discuss changes, results, how to prepare for fetus, prenatal visits, what to eat

Uterine Artery Doppler

•Impaired trophoblastic invasion is associated with hypertension (pre-existing and gestational), IUGR, abruption, & intrauterine fetal demise. •Assesses resistance of vessels supplying placenta. •In pregnancy complicated by hypertensive disorder, doppler ultrasound shows ↑ resistance to flow and ↓ diastolic flow. •Better predictor of gestational hypertension than any other single characteristic. Spiral arteries- Low resistance shunts to increase uteroplacental blood flow, gestational HTN- increased resistance to flow, early diastolic notching and decreased flow, no point in healthy pregnancies, FHS- improve mortality, continuous forward flow to placenta which improves with GA, therefore resistance to forward flow decreases to term, increased resistance to forward flow is characterized by abnormal systolic/ diastolic ratio, absent and diastolic flow velocities occur 50% more than the functional villa May be in health record

Increase in level of activity- intrapartum

•In start contrast to the feelings of chronic fatigue during the previous month •Related to the increase in epinephrine initiated by a decrease in progesterone produced by the placenta •Prepares a woman's body for the work of labour ahead

Barriers to Prenatal care

•Inadequate number of providers •Unpleasant facilities or procedures •Inconvenient clinic hours •Distance to facilities •Particularly challenging in remote and Northern communities •Lack of transportation •Fragmentation of services •Inadequate finances •Personal attitudes

Third Stage of labour and birth

•Includes placental separation, descent, and expulsion •Signs of placental separation •Firmly contracting fundus •The uterus changes shape •becomes globular in shape •The uterus rises in the abdomen •Apparent lengthening of umbilical cord •The cord descends 3 inches or more further out of the vagina •Sudden gush of dark blood from introitus •Vaginal fullness Placenta has to separate, descend, and needs to be pushed out, physician- grab cord, gentle traction, trickle of blood, cord lengthens 3 in Artery, veins All parts of placenta must come out- mom can hemorrhage, inspect placenta- Duncan's mechanism, smaller placenta with smoking, HTN, calcified lumps- circulation was impeded- vanishing twin syndrome- placenta absorb fetus •inful? •The contractions may be a minute a part but may be unnoticeable •Mom will have to push once separation is complete, No bones, little pushes, feels weird but not painful, nursing care: •Active management vs physiological management •With fundus well contracted, and placenta visible at introitus, encourage mother to bear down (push) to expel placenta and amniotic sac. •Cord blood collection •Maternal physical status •Signs of potential problems •Excessive blood loss •Alteration in vital signs and consciousness •Care of placenta after delivery •Immediate assessment and care of the newborn Active Management- Consists of •Use of uterotonics •Clamping and cutting of the cord •Controlled cord traction •Fundal massage after birth of the placenta Benefits: •êRates of PPH >1000mL •êMean blood loss and êpostnatal anemia •êLength of the 3rd stage •êThe need for blood transfusions Physiological (Passive) Management- Consists of •No uterotonics •Cord is allowed to stop pulsating before it is clamped and cut •The placenta is birthed by maternal effort alone Risk of Maternal Hemorrhage if Placenta Not Completely Expelled, PPH- post partum hemorrhage May be done naturally- no oxytocin, cord pulsates for 1 min then cut Oxytocin during anterior shoulder birth Massage fundus- stimulates contraction

Screening: Maternal serum screen

•Includes three conditions •Down syndrome/trisomy 21, trisomy 18, and open spina bifida (open neural tube defects) •Only accurate between 11-14 weeks •Detection rate of 80-85% •If result is positive: •Amniocentesis or Chorionic Villus Sampling (CVS) to confirm •Women >35 years at due date can opt directly for this First trimester, gets odd ratio- if it is high- amniocentesis of CVS, >35 can opt for amniocentesis- older eggs and sperm US- Cold gel on tummy- doppler- fetal heart sounds, internal US if they need to look at the placenta, uterus looks like upside down pair- bottom 1/3 does not expand-hemorrage, fundus expands

MSK changes during pregnancy

•Increased production of relaxin and progesterone hormones causes ligament laxity •Pubic symphis widens, causing the mother to "waddle" when walking •Lumbar lordosis may occur as uterus enlarges and moves upward and outward •Diastasis: Risk for rectus abdominal muscle separataion Assess gait, back of legs for scars Increased blood volume causes edema Pelvic exam- broadens because ligaments are loose- subpubic angle- mark tuberosities, transverse diameter, intraspinousdiameter and pelvis capacity, palpate ischial spines, pelvic walls, sacrum, coccyx, Sacro spinal ligament, diagonal conjugate Clonus- 3T

Second Stage of Labour

•Infant is born •Begins with full cervical dilation (10 cm) •Complete effacement •Ends with baby's birth •Three phases: 1.Fully dilated: mom is relatively calm with passive descent of baby through birth canal 2.Descent: active pushing and urges to bear down 3.Crowning: presenting part is on perineum, and bearing-down efforts are most effective for promoting birth Never want to blast out baby, pant, want crowing to take some time •Increase in apprehension or irritability •Spontaneous rupture of membranes •Sudden appearance of sweat on upper lip •Increase in blood-tinged show •Low grunting sounds from the woman •Complaints of rectal and perineal pressure •Beginning of involuntary bearing-down efforts •Bulging of the perineum •Labial separation •Advancing and retreating of the newborn's head during and between bearing-down efforts •Crowning Always 2 nurses- charge and regular for neonatal resuscitation •Mechanism of birth: vertex presentation •Birth of head •Birth of anterior shoulder •Birth of posterior shoulder •Birth of body and extremities Contractions- see fetal head, stop, fetal head goes back- turtling away, nurses until C- then physician, baby is soggy, wrinkly from fluid, Take finger and rub all around neck to check for cord- pull it over head, if can't then cut cord Restitution when baby turns head, acrocyanosis- normal blue limns, pink trunk, pink in 8-10 hours, skin to skin care, 1 min mark- first assessment, rub and dry off to stimulate first breath, Birth of head with modified Ritgen maneuver. Note control to prevent too-rapid birth of head, nursing actions:•Preparing for birth •DO NOT LEAVE THE ROOM •Constant assessment •Praise, encouragement, coaching •Providing brief, explicit directions throughout this stage •Position changes •They help position the mother appropriately. •They coach mother to use breathing techniques. •They provide support and encouragement. •They inform the mother on her progress. •They help put the mother at ease by helping them remain calm. •They promote relaxation and support between contractions. •They support and encourage the birthing coach or partner. •They address any of the mothers' concerns.

Infant mortality

•Infant mortality is the death of an infant during the first year of life. Preterm birth continues to be a primary cause of infant death All preterm infants are at greater risk than term infants for lifelong health problems, and their early births take emotional and financial tolls on their families

Why do we give vaccines?

•Infectious diseases such as Whooping cough (pertussis) and Rubella can have serious effects on newborns •Pregnancy puts the mother at a higher risk for complications from infectious disease •Vaccines that can be given during pregnancy should be given as a way to protect the mother and the fetus •If they are not given during pregnancy, it is effective to give them in the immediate postpartum period prior to discharge Vaccines have saved more lives in Canada in the past 60 years than any other medical intervention. Vaccines help your body recognize and fight off harmful bacteria and viruses that cause diseases.

Anesthetics

•Inhaled •Nitrous Oxide (N2O2) •Local •Lidocaine •Bupivacaine •Ropivacaine Nitrous, the gas- short acting that decrease the perception of pain- laughing gas, alters perception of reality and painful contractions, light headed, nauseous, body will adjust, used when woman are delivery quickly- multip- may not have time for epidural, 40 sec half life, inhaled are meant to put a pt to sleep- hold mask on face by self and let her breathe at her own will- unconscious- just remove mask Local- suturing, opioid analgesic- epidruals

Teaching how to push

•Instructing the woman on the following bearing-down positions and techniques: •Pushing only when she feels an urge to push • Using abdominal muscles when bearing down •Using short pushes of 6 to 7 seconds •Focusing attention on the perineal area to visualize the newborn •Relaxing and conserving energy between contractions •Pushing several times with each contraction •Pushing with an open glottis and slight exhalation

Preterm risk: CNS

•Intracranial Hemorrhage •Most common is bleeding within the ventricles of the brain (IVH) •Results from birth trauma, asphyxia, respiratory distress •<32 weeks should have screening US at one week of age for IVH •Preterm infants are at an increased risk due to the fragility of their head and vessels of the brain

Uterine Contractions

•Involuntary •Characteristics •Rhythmic, increasing tone (increment), peak (acme), relaxation (decrement) •Mild - nose; moderate - chin; strong - forehead •Monitored by palpation/electronic •Effects •Decreases blood flow to uterus and placenta •Dilates cervix during first stage of labour •Raises maternal blood pressure during contractions •With bearing-down efforts, expels the fetus and placenta •Begins involution Rolling hills, watch and palpate- feel intensity, intrauterine cath, BP will be elevated during contractions, need contractions to stop bleeding from where placenta was, fundus is at xiphoid process then 1 hr at umbilicus •Assess •Frequency •Duration •Intensity •Mild, moderate, strong •Uterine resting tone (firm or soft) •Maternal coping Start of one to the start of another Count in seconds Freq-min Duration- sec Count in 10 minutes Mild- squish nose, Moderate- squish chin Strong- squish forehead Uterus should not contract continuously because it can cut off blood flow- chart that it is soft- blood flow back to placenta, firm, assess how mom is doing

Lightening

•Is descent of the fetal presenting part into the pelvis •May trigger pain from pressure on the sciatic nerve •Changes a woman's abdominal contour •Brings relief from SOB •May trigger sciatic •Occurs •Primiparas: 10-14 days before labour •Multiparas: the day of or during labour Decreased pressure on diaphragm, can breathe, differences between prim and multi

Prenatal care

•Is needed throughout the entire pregnancy •Is publicly funded •Collaborative •Emphasis on preventive care and optimal self-care •In Canada 11% of expectant mothers wait until the second trimester to seek medical care. •Is sought more routinely by women of middle or high socioeconomic status and less likely by adolescents •Without it babies are three times more likely to have low birth weight; five times more likely to die Blood work before 2nd trimester Adolescents receive inadequate care Purpose: •Ensure healthy pregnancy outcomes through ongoing assessment •Plan individualized care •Offer information to the client and family •Identify risk factors for mom and/or baby •Foster safe and satisfying birth experience •But why don't more women go to the doctor early in their pregnancies?Midwife access may be an issue, transportation, finding a care provider, unwillingness to accept the pregnancy, bad health habits which they do not want to disclose •Initial visit •Follow-up visit •Every 4 weeks up to 28 weeks (7 months) •Every 2 weeks from 29 to 36 weeks •Every week from 37 weeks to birth Initial- missed period, tested positive on pee stick, every 4 weeks- different blood work and US in between,

Fundal height

•Is the distance from the symphysis pubic bone to the top of the uterus measured in centimeters •Monitors fetal growth •Is easily obtainable, inexpensive, and relatively non-invasive Not completely flat but pretty supine- difficult to breathe and can block blood flow to baby •After 16weeks, the fundal height measurement generally matches the number of weeks the woman has been pregnant. •E.g., A woman 27 weeks pregnant, the nurse would expect to find the fundal height to be about 27 cm •Note fundal locations by landmarks: •at 12 weeks, 20 weeks, 36 weeks and 40 weeks? At 12 weeks can feel top of fundus Lightening in last month- fundus and fetus drop into pelvis- shelf tummy, feel that they can breathe more, fundal height becomes inaccurate Bigger- two babies, a lot of amniotic fluid= poor kidneys, smaller= why has growth stopped- refer

Braxton Hicks contractions

•It is discouraging for a woman who is having what seem like contractions (and strong Braxton Hicks contractions cause real discomfort) to be told she is not in true labor and should return home. •Nursing care •She sympathetic support. •Reassurance that misinterpreting labor signals is common •Remind her that if false contractions have become strong enough to be mistaken for true labor, true labor must not be far away

Labour

•Labour is the process of moving the fetus, placenta, and membranes out of the uterus and through the birth canal. •Begins when the cervix begins to dilate •Various changes take place in the woman's reproductive system in the days and weeks before labour begins. • •Labour can be discussed in terms of mechanisms involved in process and stages the woman moves through. Prelabour Changes are described by mechanisms- cardinal movements

How do we determine fetal position?

•Leopolds maneuvers •A method for determining the presentation, position, and lie of the fetus through the use of four specific steps. Supine, deep palpation into fundus- head or butt- head feels like cantaloupe- press firmly, cannot really tell what it is- butt Back between shoulder blades- kind of ascites wave, want it to feel smooth not like bumps- feet, ask where they are feeling kicks, auscultate tones on back MOST COMMON More uncomfortable for moms- sterile vag exam will be done anyway Hold whatever is at top stationary, get fingers around whole head= fetus is engaged 4th- how flexed is the fetal head Breeched- upper quadrants for ausculatation •Assessment techniques •Inspection •Palpation Use palpation of abd, screening for malpresentation what is the presenting part, is the head flexed

Benefits of IA

•Less costly •Less restrictive for the woman (permits increased freedom of movement) •Adaptable to varied labor positions and practices •Lower intervention rates, compared with EFM, without compromising neonatal outcome Widely available, different positions, minimal forceps, vacuum assisted births or C-section

Fetal Position

•Lie •Presentation •Position •Attitude •Engagement

Benzodiazepines and antihistamines

•Lorazepam •Phenergan •Gravol Use caution- when necessary, but sparingly because of effect on fetus Diazepam/ Lorazepam- anxious, want to decrease pain-calm their nerves and themselves Ativan Antiemetics- with IM injections (morphine)- can cause n/v. but want to manage carefully- can cause drowsiness, may cross placenta- EFM changes

Sibling Roles PP

•Many parents worry about how an older child will adjust to the new baby •Parents need reassurance that some sibling rivalry or jealousy is normal •Encourage sibling to view baby as a positive or welcome addition to the family (give / receive gift from baby) •Involve the older child in infant care - build them up in the "big brother" or "big sister" role

Grieving styles

•Martin and Doka (1999) identify two primary grieving styles that are formed by culture, personality and gender: 1.Instrumental grieving 2.Intuitive grieving

Physiological Adaptation to Labour

•Maternal adaptation •As the woman progresses through the stages of labour, various body system adaptations cause her to exhibit both objective and subjective symptoms. •Cardiovascular changes •Respiratory changes •Renal changes •Integumentary changes •Musculoskeletal changes •Neurological changes •Gastrointestinal changes •Endocrine changes •Fetal adaptation •Changes occur in the following: •Fetal heart rate •Fetal circulation •Fetal respiration HR- needs lots of oxygen rich blood Resp changes- first breathe Vaginally- small amount of fluid in lungs, contractions squish it out, c-section- bubbles around mouth, more fluid, want to make sure they are not in distress, never tell they are in false labour- they know their body

FHS physiology

•Maternal circulation delivers oxygenated blood to placenta, from placenta to umbilical cord, to fetal circulation •O2 delivery to the fetus is via the uterine arteries to the uterus, from the uterus through the placenta, and from the placenta to the fetus via the umbilical vein. •Uterine and placental blood flow are decreased with each uterine contraction •This leads to a temporary decrease in placental O2 exchange •Uterine relaxation returns uterine perfusion and placental O2 exchange resumes •Any complications involved in this system impacts the fetus Placenta- nutrients, oxygenation, waste Umbilical veins and arteries Fetal is dependent on maternal BP and oxygenation, patency of umbilical cord- uteroplacental insufficiency

When is more testing needed

•May depend on: •<6 fetal movements in 2 hours •Maternal obstetrical history, •Severity of maternal and fetal disorders •Gestational age May use other assessment techniques concurrently or in a hierarchal system

Importance of one-to-one support

•Meta-analysis showed the following outcomes: ↓ epidural rates ↓ analgesia/anaesthetic ↓ operative vaginal births ↓ cesarean births ↓ 5 minute Apgars < 7 ↓ postpartum depression One nurse to one family- decreased pain Apgar 1 min, 5min, how have they transitioned to extrauterine life

Miscarriage

•Miscarriage may not be acknowledged by a woman's friends and family as a true form of loss; therefore, it's critical that the nurse support the woman and her partner medically and emotionally. Nurses can assist mothers who miscarry by listening to their stories and helping them create their own memories

Who should not get the MMR vaccine?

•NOT given in pregnancy. Given after delivery. Will hopefully provide immunity to rubella during any future pregnancies that mother might have. •People with a weakened immune system from either disease or treatment of illness •People with serious illness. •Those who have received a transfusion of blood or blood products (such as immune globulin) within past 12 months (consult public health nurse first).

Preterm risk: GI

•Necrotizing Enterocolitis (NEC) •Acute inflammatory disease of the bowel associated with ischemia. •Damage to mucosal cells lining the bowel wall may be significant. •Decrease in blood flow to these cells cause death, therefore the mucous cells no longer produce protective and lubricating mucous. •Inflammation and bowel wall damage occurs. •Breastmilk can help in the prevention of NEC •May require bowel resection and anastomosis depending on the severity.

neonatal resuscitation

•Neonatal resuscitation are a set of interventions at the time of birth to support the transition from intra to extrauterine life through the establishment of breathing and circulation. •Only about 10% of neonates require some respiratory assistance at birth. Less than 1% need extensive resuscitation. Indications- •Abnormal/Atypical FHR (bradycardia, complicated variable and late decelerations) •Meconium-stained amniotic fluid •Prolonged or difficult delivery •Asphyxia •Poor respiratory effort •Inadequate ventilation •Weak cry •Sternal Retractions NRP Algorithm-Every neonate requires stimulation and drying

Analgesics

•Non-opioid •Acetaminophen •NO NSAID's such as Ibuprofen or Naproxen •Opioid: •Morphine •Fentanyl More opioid use 1-2cm dilated- best place is not the hospital- more interventions- morphine/ opioid injection to allow rest and decreased pain at home- not driving, support people to monitor, relative certainty that the woman is not going to deliver in the next 4 hours- cross placental barrier- fine in utero, but extrauterine life- opioids can cause respiratory depression Multipari- may deliver sooner

Pain management in the intrapartum

•Non-pharmacological •Education/Support •Dignity and control •Warmth •Water •Breathing/ Hypnobirth practices •Healing touch/ massage: Women need to feel like they know what is going on with their body- control, cognitive function may not be able to understand Encourage movement and frequent position changes, if they do not want cervix checked- respect and advocate Suggest they get into the tub- warm with water covering belly Ensure she is breathing fully- get as much oxygen as possible Hypnobirthing- breathing, change perceptions of contractions- not painful- her surges felt like sand Side lying position- rest, opens pelvis- support person can offer massage, back pain- ligaments, position, lean forward on table or ball- massage, counter pressure, heat or cold, hands and knees- squeeze hips, relieve pressure, facilitates movement of baby •Pharmacological •Analgesics •Non-opioid and opioid •Anesthetics •Inhaled •Local •Benzodiazepines •Antihistamines

Baseline Variability

•Normal beat to beat fluctuations in the baseline FHR •Reflects interplay of sympathetic(SNS) and parasympathetic nervous systems (PNS) •Results from integration of multiple complex messages to brain •Requires mature CNS, intact medulla and O2 to brainstem How to determine variability •Look at one minute period •Visually estimate peak to trough in bpm •Variability is irregular in amplitude and frequency Definitions: •Absent: amplitude range undetectable (< 2 bpm) •Minimal: amplitude 2-5 bpm, Represents dysfunction in one system, or one is more dominant- sleep cycles or drugs•Moderate or average: amplitude 6-25 bpm Good cardiac response and intact CNS, want to see •Marked , increased, saltatory pattern: > 25 bpm, Saltatory pattern Acute hypoxia or compression of umbilical cord, 2nd SOL- pushing With decelerations- notify Dr. ASAP Systems exert control via cerebral cortex, interactions- beat to beat changes, moderate- normally function nervous system Variability is most important indicator for adequately oxygenated fetus

Facilitating Bonding

•Nurses can be instrumental in promoting attachment •Assess any attachment behaviours (positive / negative) •Remember to consider cultural differences - have an open dialogue with the mom about her childcare practices (different doesn't necessarily mean bad!) •Encourage parents to participate in infant care, promote skin to skin time, build up confidence

Care at the time of loss

•Nurses can offer parents options and guide, but not push, them in the hours after death (Badenhorst & Hughes, 2007). Physical care should be as thorough as in the case of a healthy labor and birth; emotional issues may seem overwhelming, but physical safety remains a priority. •The nurse should provide grief-related information based on the mother's readiness. Continuity of care should be promoted and facilitated, if possible; reducing the number of staff interacting with the family can help reduce their stress and limit errors in communications

Helping Families Grieve: Cultural and Religious Considerations

•Nurses play an instrumental role in giving families permission to turn to their culture and faith to help them with grief and mourning. Culturally sensitive care forms a positive foundation for dealing with and healing a person's grief; it is a vital aspect of care

helping families plan for loss

•Nursing considerations when helping families plan for a baby's death: oThe family's cultural and spiritual beliefs oThe family's level of acceptance of the baby's condition oThe support the family gets from one another and from others oThe family's ability to agree that the goal is their baby's comfort and care, rather than a cure

Maternal and Fetal Changes antepartum

•Nutrition •Personal hygiene •Prevention of urinary tract infection •Kegel exercises •Preparation for breastfeeding newborn •Dental health •Physical activity •Posture and body mechanics •Rest and relaxation •Employment •Clothing •Travel •Medications and herbal preparations •Immunizations •Alcohol, cigarette smoke, caffeine, and drugs

Nutrient Needs during lactation

•Nutrition needs during lactation are similar to those during pregnancy. •Needs for energy (calories), protein, calcium, iodine, zinc, the B vitamins, and vitamin C are greater than nonpregnant needs. •Energy intake increase of 330 kcal more than woman's nonpregnant intake is recommended. •Smoking, alcohol intake, and excessive caffeine intake should be avoided during lactation.

Onset of Labour

•Onset of true labour cannot be ascribed to a single cause. •Many factors are involved, including changes in the maternal uterus, cervix, and pituitary gland. •Hormonal factors •Progesterone withdrawal •Oxytocin production •Prostaglandin production •Estrogen stimulation •Fetal influence (fetal cortisol theory) •Mechanical factors •Uterine distension theory •Stretch of the lower uterine segment •Other factors These theories are important when discussing preterm labour prevention. Uterine distension theory- expanding Stretching lower segment- increased prostaglandin

other anesthetic options

•PCA •Spinal •Local •General Platelet disorder, back injury (may prevent epidural) PCA- enter bloodstream- epidural does not, go into fetal circulation- fentanyl- short acting baby born with resp distress- resuscitation, Narcan Spinal- in OR, mother is awake, similar to an epidural but passes dura and goes into spinal space, completely numb, medication is just once rather than a continuous catheter, hypotension, bolus ahead of time, n/v- meds prophylactically or have drawn up ready to go, PP pain control Local- sutures General- c-section, mother cannot be kept awake, baby needs to get out ASAP, can be traumatic, cannot see baby be born, hold as soon as it comes out, increased PP pain

PPROM

•PROM- 8% of all pregnancies •PPROM - 30 % of PROM; 30-40% of PTB •70-90% of PPROM have up to 7 days prior to labor •Small percentage of women can have spontaneous resealing and restoration of AF Not tested on stats Preterm premature rupture of membrane, less than 37 weeks PROM- no labor Want to grow baby as much as possible on the inside Resealing- tiny little hole with a little bit leaking out, volume is restored Risk Factors •Maternal nutrient deficiencies •Prior PPROM or PTB •Tobacco use •Substance abuse •Polyhydramnios •Multiple pregnancy •Placental abruption •Infection - STI, intrauterine- Chorioamnionitis •GOAL: Prolong pregnancy + Delay Labour • •Nursing Management: •Confirmation with amniostick and ferning •Antibiotic Protocol (MERCER: Ampicillin & Erythromycin IV -> PO x 7 Days) •Prevent and monitor for Chorioamnioitis •VS •GBS, BV/Trich/Yeast, Chlamydia/Gonarrhea Swabs •Antenatal Steroids- Promote lung maturity (24-33.6) •Magnesium Sulfate for neuroprotection (24-33.6) •FHS Confirm that its not just discharge or urine Amniostick- Q-tip and turns purple (positive for amniotic fluid) Will not be asked what the protocol is- abx for 3 days then orally Chorioamnionitis- main barrier is lost- baby and uterus are at risk GBS- 35-37 weeks usually, but want to know- can go into uterus Steroids- betamethasone- increases production of surfactant in the lungs- prepare for exhalation, without it- decrease resp effort Magnesium Sulphate- IV, prevent cerebral palsy FHS- keep eye on, know wellbeing, BPP, if indicated- scalp pH or lactate

Parental grief

•Parental grief has been recognized as the most intense and overwhelming type of grief (Davies, 2004). There is increasing evidence of short- and long-term effects of perinatal loss, not only to the woman's psyche and relationships with others, but also on parenting subsequent to loss and on other children •Because men and women often grieve differently, parents' reactions may be disparate even though both have experienced the same loss (O'Leary & Thorwick, 2006). •This can lead to conflicts about what and how to do things, as well as what can make them feel better.•Nurses can provide parents with detailed information about support services and options. •Nurses can present options to parents as labor, birth and discharge unfold, rather than as a vast, all-inclusive menu.

Perinatal mortality

•Perinatal mortality has two accepted definitions: oDeath at >20 weeks gestation and <28 days of life oDeath at >28 weeks gestation and <7 days of life •Perinatal mortality includes ectopic pregnancy, miscarriage and stillbirth.

Perinatal Period

•Period of physical and psychological preparation for birth and parenthood •Opportunity for nurses and members of health care team to positively influence family health •Healthy women seek care and guidance. •Health promotion interventions can affect well-being of the woman, child, and family. Promote health in general life and in pregnancy, prenatal care has more positive outcomes, free and accessible Ask -BMI, vitamins and folic acid, integrated into care as women can get pregnant in a lone period of their life

Position

•Position affects woman's anatomical and physiological adaptations to labour •Frequent changes in position •Relieve fatigue •Increase comfort •Improve circulation •Assist optimal fetal position •Labouring woman should be encouraged to find positions most comfortable to her Can facilitate or hinder birth, regular changes- always want good blood flow to baby Gravity can help promote decent- contractions are more efficient, shorter labor, counterpressure helps- push hard on back, squatting- large open pelvis, can give birth this way with bars What factors can affect a labouring woman's position? •Pain •Monitors •Fatigue •Comfort Exhaustion will effect it, can affect bladder, calm, support and feel love around them is when they give birth best Posterior- push against spine, back pain, get into hands and knee position to relieve pain

Marijuana NAS effects

•Postdates •Less prolactin can affect breastfeeding •SGA

Comfort Measures PP

•Postpartum women experience pain from a variety of sources (perineum, incision, breasts / nipples etc.) •Perineum can be soothed with: ice packs, peri bottle, sitz baths, analgesics •Breasts & nipples can be soothed with warm compresses, breastmilk, lanolin cream, ice packs •Hemorrhoids can be soothed with witch hazel pads or topical creams / ointments

Powers

•Primary powers •Uterine contractions: the primary power needed to accomplish the work of labour and birth •Effacement •Dilation •Ferguson reflux •Bearing-down efforts (voluntary) •the intra-abdominal force provided by the labouringwoman; this is commonly referred to as maternal pushing or bearing down •When to start pushing •Technique What we need to get the baby out, 80% body with hormones, 20% pushing and bearing down, babies can be born just with hormones and no pushing (mom unconscious), do not need to start pushing when you are fully dilated- no urge as long as everyone is stable, monitor until they feel like they have to poop How to push- do not hold breathe and hold for as long as you can, once contractions build- big breathe in, out, big breath, push, 2-3 pushes per contraction

Hospital protocols

•Protocol checklists for required nursing actions include providing maternal and neonatal care, creating memories for families, and providing emotional and spiritual support. •In all settings, nurses should use established checklists and protocols to ensure that all aspects of care and bereavement services are provided.

Promoting Parental Role PP

•Provide as much opportunity as possible for parents to interact with and care for their newborn •Model childcare behaviours, and provide teaching on all aspects of care (even if this isn't first baby) •Praise them for childcare efforts and build confidence •Assess for coping strategies and family / social supports

Psychological response

•Psychosocial factors that influence the birth experience •Readiness for labour and birth •Level of educational preparedness •Emotional readiness •Ethnicity and cultural influences •Anxiety, fear, fatigue •Previous experiences with childbirth •Labour can trigger memories of sexual abuse for women who may have experienced this type of trauma Prepared- less pain, because less stress and anxiety, more understanding with more children, abuse- birth can be very traumatic In what ways can nurses provide psychological care to all women who are labouring?•Therapeutic communication •Support for the birth plan •Advocate as needed •Demonstrate respect •SOGC (2019) recommendations: continuous 1:1 support in labour Advocate, encourage for birth plan- prepared, go through with them and see what we can and cannot do, how can you involve parents- dad cut core, talk about best practice, in early stage of labor, not when she is 9cm dilated, want it to be calm and supported

Fetal Movement

•Quickening •Usually first felt between 16 - 20 weeks •Movement •Limbs, trunk rolling and flipping •Some are more active than others •Less movement during sleep cycles •Mothers will get to know their baby's unique pattern of movements •An active baby is usually a healthy baby Body is more sensitive after first pregnancy- butterflies, gas= baby moving Babies can sleep, need to kick and move for muscle mass Show and teach how to monitor movements- if they haven't moved in a while get assessment, catch things early

Respiratory Distress Syndrome

•RDS is a lung disorder usually affecting preterm infants. (A small percentage of term or late preterm infants). RDS and gestational age (GA) have an inverse relationship. The incidence and severity of RDS increase as GA decreases. RDS is responsible for about 20% of neonatal deaths. •The preterm infant is born before the lungs are fully matured and prepared for extrauterine life. •The preterm infant may lack surfactant which aids in the maturity of the lungs in utero. Surfactant is a phospholipid secreted by the alveolar epithelium. It reduces the surface tension of fluids that line the alveoli and respiratory passages. This allows for uniform expansion and maintenance of lung development. Without surfactant the infant cannot inflate their lungs. •Surfactant begins to be produced in the lungs around 24 weeks and can be found in the amniotic fluid between 28 and 32. Typically infants born before 32 weeks do not have adequate amounts of surfactant. •Without surfactant, the neonates lungs remain in a collapsed state, with fluid, unable to initiate and maintain pulmonary circulation and gas exchange (ventilation and oxygenation). •If preterm birth is anticipated between 24 and 336 weeks gestation, betamethasone (IM) may be given to the mother to promote the production of surfactant, and encourage lung maturity. Signs and symptoms- •Tachypnea •Cyanosis •Grunting •Nasal Flaring •Use of accessory muscles •Sternal retractions •Respiratory or mixed acidosis •*Investigation would be similar to TTN, especially in a late preterm or term baby. In the preterm neonate, RDS would be the primary differential.

4th stage of Labour

•Recovery" period •Begins after the placenta is expelled and lasts up to 4 hours after birth •Many physiologic and psychological changes occur •Nursing focus: -Maternal hemorrhage -Provision of comfort measures -Promotion of family attachment

Maternal Physiological adaptations postpartum

•Reproductive system (uterus, cervix, vagina, perineum) •Cardiovascular system (pulse, BP, coagulation, blood cells) •Urinary system •Gastrointestinal system •Musculoskeletal system •Integumentary system •Respiratory system •Endocrine system •Breasts (lactation, ovulation & return of menstruation)

Immediate neonatal complications

•Respiratory Distress •Intraventricular Hemorrhage •Necrotizing Entercolitis •Prolonged Hospitalization •Death •75% of neonatal mortality attributed to preterm delivery Intubation Delicate vasculature in babies, scalp is thinner Inflammation and death of the colon- from hypoxia

Fetal movements (kick counts)

•SOGC recommendations •All pregnant women in the third trimester •Women with risk factors should start doing at 26 weeks •Goal is to count 6 movements in 2 hours •Preformed around the same time each day •Aware consciously and unconsciously, do in evening in semi reclined position, sleep cycles 20-40 min, most- 10 movements in 20 minutes, algorithm, juice or glucose has no effect

Mechanism of Labour and Birth

•Seven cardinal movements of mechanism of labour that occur in vertex presentation: 1.Engagement •Ascynclitism- deflected, positioned to accommodate pelvis, look at head to pelvic ratio- may need C-section, Synclitism 2.Descent 3.Flexion 4.Internal rotation 5.Extension 6.Restitution and external rotation 7.Birth by expulsion Helps smallest area go through first, may occur simultaneously Engagement decent and flexion at same time Rotate head to one shoulder, extend, rotate to side for realignment, anterior shoulder- posterior shoulder and rest of body, Know normal, understanding of position during sterile vag exam to help rotate baby in a favorable way

MMR vaccine

•Should have 2 doses of this vaccine during lifetime. Women in childbearing years who are found to be non-immune to Rubella may receive another dose to try and create immunity •WHY? Rubella infection during pregnancy can cause miscarriage and stillbirth. It can also result in congenital rubella syndrome to the fetus which can cause heart disease, cataracts, cognitive impairments and deafness. SC site for children >1 year and adults, insert needle at a 45 degree angle into the fatty tissue over the triceps muscle. Make sure you pinch the SC tissue to prevent injection into the muscle

Prelabour

•Signs of approaching labour •Lightening •Ripening of the cervix •Spurt of energy •Braxton-Hicks contractions •Backaches •Bloody show •Spontaneous rupture of membrane (water breaking) •Diarrhea •Weight loss •Impending labour can be an emotional experience Back aches- contractions Bloody show- mucus plug is started to thin out, stringy egg whites in underwear, tinged with red blood, this is normal Water breaking may happen before contractions

Passenger

•Size of fetal head •Fetal presentation •Fetal lie •Fetal attitude •Fetal position •Including station and engagement •Location of the placenta •What about the shoulders?? Station is degree of decent Engagement- at level of ischial spines- 0, negative is still in utero, bounces How they move through birth canal Placenta previa is a problem otherwise shouldn't cause any problems Shoulders- size my affect, but position can be altered- cardinal movements of labor, head to chest, turns head to side, one shoulder at a time, smaller than skull, can get in way if rotation doesn't happen, circumference of fetal hips- small, no problems Vertex- occiput, breeched- sacrum , presenting might be scapula, mentum if chin Fetal attitude can make it difficult Position Effects proficiently and ease of birth, OA, longer if posterior, less than 32 weeks breached is normal because they haven't flipped around Chart the way baby was born Where is the occiput facing on the mom Posterior= face up Ensure placenta is in the fundus, not close to cervix, should move upward if you can see at 5 mon US

Status of membranes

•Spontaneous rupture of membranes (SROM) •Diagnosis •Ph •Ferning •Assess: •Fetal heart rate for at least 1 minute •The umbilical cord could be compressed •Character of the fluid •Colour, amount, clarity, and quantity Artificial rupture of membranes (ARM) Can do it artificially- crochet hook nicks the fluid, guides presenting part down to pelvis to prevent cord from coming down, come to hospital when water breaks for assessment, always lubricated- baby produces amniotic fluid, vaginas are acidic, amniotic fluid is basic- pH, ferning is under microscope, may have slow leak, high up- big gush of fluid, if quite low- fluid has to go around head- slow, HR- make sure umbilical cord is good Fluid- pale straw yellow, clear-pale, no meconium- green brown colour, no blood, drops, gush

Station and Engagement

•Station: a measure of the degree of descent of the presenting part of the fetus through the birth canal •Engagement: When widest diameter of presenting part has descended into pelvic inlet; specifically, to imagined plane at level of ischial spines

Storage of breastmilk

•Store in sterile containers •Store in serving sizes •Thaw in fridge or warm water •Never in Microwave •Shake well prior to serving •Unused, thawed milk must be discarded

Example of Risk factors for adverse pregnancy outcomes

•Taking retinoic acid (Accutane) to clear cystic acne •Alcohol use •Anti-epileptic drugs •Autoimmune disorders •Diabetes (preconception) •Folic acid deficiency •HIV/AIDS •Maternal phenylketonuria (PKU) •Rubella seronegativity •Obesity •STI •Smoking •Underweight Vaccinate for Rubella- have debilitating effects on fetus Accutane- malformations in the fetus

Adjustment to Maternal Role

•Taking-In Phase - typically during first 1-2 days, the mom relives her birth experience, bonds with newborn, and can often assume a passive role with self-care •Taking-Hold Phase - typically starts day 2-3, the mom demonstrates increasing autonomy, independence with self / baby care, but still needs some reassurance •Letting-Go Phase - the mom has increased confidence and adapts to her new role, relinquishes the fantasy infant and accepts the real one

Vital Signs PP

•Temperature - monitoring for fever - sign of infection •Pulse - relative bradycardia (50 bpm) can occur, anything over 100 should be monitored •BP - should align closely with her normal range - diastolic of 90-95 or higher needs to be watched •Respirations - should fall within 16-20 per minute

Persistent Patent Ductus Arteriosus

•The DA is a muscular contractile structure in the fetus that connects the L pulmonary artery and the dorsal aorta, shunting the blood away from the lungs and instead, to the rest of the body. (see picture) •The DA should close within hours of birth, however, in some infants it remains open. •In normal circumstances, increase in oxygenation and systemic vascular resistance cues the DA and FO to close, allowing for pulmonary circulation to begin. In the preterm infant, it may remain open due to decreased oxygenation and respiratory issues. The primary resp issues in the preterm neonate is immature lungs due to lack of surfactant (Discussed in RDS). Signs & Symptoms: •Systolic murmur •Bounding peripheral pulses •Tachycardia •Tachypnea •Crackles •Hepatomegaly Diagnostics: •ECHO •ABGs •Chest XRAY *Management can be done medically- with the use of drugs- promoting the closure of the DA, while supporting the physiological needs of the infant, or by surgically closing the DA.

Why is it important for Moms to receive

•The Pertussis component is what we want mothers to receive. Whooping cough is especially dangerous to infants less than 1 year of age. When the caregivers of the infant are vaccinated it creates a protective effect for the infant who is unable to be vaccinated. •If the Mother is breastfeeding she may also pass antibodies on to the baby through breastmilk. •Whooping cough in infants can result in pneumonia, convulsions, brain damage and death. •Why is it better to get it during pregnancy? Because immunity has time to develop, so the baby gets the best level of protection. Infants are not eligible to receive their own vaccination until they are 2 months old according to the current Saskatchewan Provincial Immunization schedule.

Passageway

•The birth canal is composed of the following: •Bony pelvis •Lower uterine segment •Cervix •Pelvic floor muscles •Vagina •Introitus (external opening to the vagina) Pelvic brim- rotates to go through pelvic outlet different pelvic shapes- 50% have gynecoid- normal vaginal birth but position of baby is also a factor Soft Tissue factors- •Lower uterine segment •Cervix •Effacement •Dilation •Pelvic floor muscles •Vagina •Introitus Cervix- neck of the uterus Thin walled lower segment, fundus does most of contractions- downward pressure, lower segment expands, pressure on the cervix- more oxytocin and prostaglandin- softens and disappears- thin out (effacement) Pelvic floor is muscular, helps rotate anteriorly, soft tissues change and develop Cervical Effacement and Dilation- Contractions cause these changes, water will be between scalp and cervix, water breaks, may be during 7 cm dilation, or be still encased in amniotic fluid, scalp creates more pressure and the cervix thins out more, 0% effaced= thick, half way gone 50%, ¾ effaced= 80%, 100%= completely gone Cannot start pushing until dilation and effacement are complete- another vaginal exam to confirm, other factors- full bladder, tutor, fibroid, Try to pee regularly, protect bladder from damage and have more room for baby to come down and out

Elective Abortion

•The ethical debate over abortion affects loss issues associated with life-threatening fetal conditions discovered in the first half of pregnancy. •Nurses must understand their own beliefs about elective abortion and support families as they make their decisions.

Nutrient Needs before conception

•The first trimester is crucial for embryonic and fetal organ development. •A healthful diet before conception ensures that adequate nutrients are available for the developing fetus. •Folic acid intake is important in the periconceptual period. •Neural tube defects are more common in infants of women with poor folic acid intake.

Factors Affecting labour and birth

•The five P's: 1.Passenger (fetus and placenta) 2.Passageway (birth canal) 3.Powers (contractions) 4.Position of mother 5.Psychological response •Others? Passageway- full bladder can block Position can cause increased or decreased Psychological- stress and anxiety- cortisol and adrenaline, effects oxytocin- blocks receptors- keep calm and supported Place of birth-home with loved ones, hospital, how prepared, type of providers, different procedures

Fetal personhood

•The issue of fetal personhood is complex with social, religious, legal and ethical dimensions. Bereaved parents have assigned some degree of personhood to their baby; therefore, their loss is real, for a real person who would have been a part of their life and their family

Who should NOT get vaccines?

•The most important contraindication to giving any of these vaccines to a patient is a history of serious allergy to a previous dose of that specific immunization. •Additional screening questions ask about a history of Guillain Barre Syndrome within 6 weeks of a previous dose of influenza vaccine or a history of Oculorespiratory Syndrome after a previous dose. •The patient should not currently have a serious acute illness. A mild illness with or without a fever is not a contraindication. •Vaccination with Tdap or Influenza vaccine are safe at any stage of pregnancy and for breastfeeding mothers.

Rubin's tasks of pregnancy

•The mother: (Rubin, 1984) 1.Ensures safe passage for self and baby 2.Ensures social acceptance of self and baby 3.Binds-in to the baby 4.Gives of herself •Rubin's framework helps nurses identify how women are affected when pregnancy tasks are incomplete.

Mementoes and photos

•The nurse can help parents create memories, gather mementoes and take photos. •Photographs can be treasured mementoes for families. •Photographs may be unacceptable to some, depending on their views of the dead or the unborn.

Grief environment

•The nurse should find a quiet moment to discuss how a woman and her family want to express their grief. •The nurse should use a trained interpreter if there are language differences.

Care for the caregiver

•The nurse's experience of perinatal loss: oAcknowledge your connection to this baby and family. oAllow yourself to grieve. oBe kind to yourself; everyone has frailties. oTalk with others; gain support. oTake care of yourself physically, emotionally, socially and spiritually. •Self-reflection is critical for self care. •grieving is an individual and a social-interactive process. •Nurses can create a network of care providers, including nurses and other professionals, who support each other, listen and understand.

Fetal Health Surveillance

•The patient is a dyad •One you can see, the other you cannot •Fetal oxygenation status and neurological integrity can be inferred from the FHR Identify fetus at risk for a hypoxic event- limit interventions Cannot palpate in utero, need to infer physiological state to see if intervention is necessary Is the brain getting oxygenated blood? Safety- when fetus is hypoxic- intervention to prevent harm or neuro injury

Gestational diabetes

•The woman develops carbohydrate intolerance for the first time. •4% of pregnancies (up to 12.8% in Aboriginal populations) •Women undergo screening between 24-28weeks gestation, unless fulfill the criteria for low risk per SOGC, 2002. }50 g glucose challenge test (load) at 24-28 wks }75 g oral glucose tolerance test Diagnosis: 100 g oral glucose tolerance test Risks: }Previous history of GDM or glucose intolerance }Family history of type 2 diabetes }Previous macrosomia (>4000g) }Previous unexplained stillbirth }Advanced maternal age }Obesity }Glucosuria }Hypertension

Endocrine systems changes during pregnancy

•Thyroid gland: increases in size (50%) and activity (more thyroxin released) •Adrenal gland: cortisol and aldosterone levels increase •Pituitary gland: enlarges; prolactin levels é, follicle stimulating hormone and luteninizing hormone decrease to undetectable levels •Pancreas: has increased needs (hypoglycemia and hypoinsulinemia occur faster in response to starvation)

Resp changes during pregnancy

•Tidal volume increases steadily as pregnancy advances- 30% to 40% rise in the volume of air breathed each minute- deeper breathing •O2 consumption increases by 15-20% •Breathing becomes more abdominal (slight é RR ) •Rib cage flare, with an increase of circumference of up to 6 cm •Nasal stuffiness, epistaxis common •Diaphragm elevated as a result of enlarging uterus •SOB common in 3rd trimester •Mild hyperventilation decreases CO2 •Protects the fetus from exposure to elevated CO2 Thoracic cag, breathing pattern and work of breathing, auscultate lung sounds

Antepartum pain management

•Treat the cause •Rest •Light activity •Maintain hydration •Applying warmth •Medications Poor posture- help, uncontrolled HTN- treat, carpal tunnel syndrome- braces Rest- prevent fatigue Light activity- yoga, walking, stretching, swimming, do not cause extra strain and stress on ligaments, promotes circulation of blood and lymphatic system (drainage), aches and pains Hydration- uterine cramps, dehydrated uterus= angry uterus, may be early labour but assess status- pee all the time- does not indicate they are hydrated- bladder is just squished, IV fluid bolus- stops cramping, gets happy to relieve pain Warmth- comforting, soothing, relieve aches and pains Meds- Tylenol most often- safe in pregnancy, NO NSAIDS (naproxen, Advil- causes fetal circulation issues, hydramnios- decreases amniotic fluid, opioids- morphine, T123, think of cost of benefit- cross placental barrier- car accident, chronic pain

Reproductive System and Breasts during Pregnancy

•Uterus •Changes in size, shape, and position •Hegar's sign •Changes in contractility •Uteroplacental blood flow •Cervical changes •Goodell's sign •Chadwick's sign •Operculum forms - why? •Changes related to fetal presence Breasts areolae and nipples enlarge and darken, more erect, CBE- tender and nodule, depress inward to nipple- should be easily, may have discharge Assess glands and external genitalia, speculum- shape and color of cervix, Pap smear, and cultures for STI, vaginal walls, bimanual exam Height of fundus- Palpate where soft abd meets hard firm fundus Fundal height= weeks of gestation after 20 weeks Enlarging uterus can compress the inferior vena cava and descending aorta •Vagina and vulva •Increased vaginal secretions •Chadwick's sign •Breasts •Fullness, heaviness •Heightened sensitivity from tingling to sharp pain •Areolae become more pigmented •Montgomery's tubercles •Colostrum

Reproductive System pp

•Uterus - returns to its normal size through the gradual process of involution •Involution involves 3 processes: -Contraction of muscle fibres -Catabolism or breaking down of myometrial cells -Regeneration of the uterine epithelium •Typically descends from umbilicus by 1 cm per day •Afterpains - Involution involves contractions, multiparous women may be more aware of them •Cervix - Returns to pre-pregnancy state by 6 weeks •Vagina - Following birth is edematous and thin with few rugae, rugae return in 3-4 weeks & mucosa thickens with return of ovarian production and estrogen production •Lochia - the vaginal discharge that occurs after birth •Larger amount with vaginal delivery than c-section •Types •Lochia Rubra - deep-red, occurs during first 3-4 days •Lochia Serosa - pink / brown, 3-10 days postpartum •Lochia Alba - white, occurs days 10-14, but can last for 3-6 weeks for some women •Perineum - often edematous and bruised for the first days following birth •Pelvic floor muscles are stretched, restoring tone can take 6 months - kegel exercises should be encouraged •lacerations or an episiotomy - 4-6 months to heal •Lacerations that extend into the anal mucosa, and hemorrhoids can cause lots of discomfort Perineal Trauma r/t childbirth- •Lacerations •Perineal lacerations •Vaginal, clitoral and urethral lacerations •Cervical injuries •Episiotomy •Female genital mutilation •Emergency childbirth

Intermittent Auscultation of FHR

•Utilize Leopold's Maneuver's to find the fetal back •Use doppler, pinard, or transducer to auscultate the fetal heart rate •Palpate the maternal pulse •Listen for a full minute immediately following a contraction •Assess rate, rhythm, presence of accelerations and decelerations Doppler is most common in hospital, blue is waterproof, maternal pulse to make sure you are listening to baby, do not auscultate during contraction, 100-160 bpm, regular or irregular •Preferred method of FHR assessment, utilized for all pregnant patients unless high risk •Assess FHR via IA Q1H in latent labour •Q15-30 min in active labour •Q5 min in second stage of labour with active pushing •After any invasive procedure, or any potential changes in the intrauterine environment, such as rupture of membranes, vaginal examinations, or administration of PRN medications, Unless they are high risk After every push, when anything is done

genetic testing and counselling

•Whether prior to conception or after a loss, understanding the familial traits or risks of having a baby with genetic disorders or disease can be useful. •Chromosomal tests can determine the presence of single-gene defects for only select diseases or conditions; however, the patterns of inheritance are known in a vast number of disorders. •Genetic counseling is complex and requires specialized education and training. •Nurses should recognize that genetic causes of loss can lead to feelings of guilt, blame and defensiveness within extended families as they review family histories.

Intimacy after perinatal loss

•While difficult to bring up, nurses should discuss contraception with couples. Some couples report difficulty in resuming intimacy due to reminders, perineal trauma and fear of pregnancy. Pregnancy after perinatal loss, both the next pregnancy and any subsequent pregnancies, often is accompanied with anxiety and fear- •Nursing strategies: oAcknowledge the woman's loss. oListen to and know her story. oAcknowledge that she may be anxious and scared. oAcknowledge that prenatal testing may be stressful for her. oProvide reassurance, but remind her that there are no guarantees. oEncourage her to come in and call as often as she needs to. In all nursing settings, when a perinatal loss is suspected, expected or confirmed, nurses should be knowledgeable and caring as they address informational, emotional and medical needs of families.

Opiate NAS effect

•Withdrawal can last up to 6 months •Can be immediately after birth •Tremors •Irritability

Focus of PP nursing care

•Woman's physiological recovery •Psychological well-being •Ability to care for herself and her new baby •Needs of other family members include strategies in plan of care to assist family in adjusting to baby. •Transition to parenting

Neuro changes during pregnancy

•Women self-report decreased attention span, concentration, and memory; perhaps related to hormones and poor sleep.

Perinatal loss

•includes infertility during the preconception period, fetal death during pregnancy and infant death in the first year of life. •Losing a wished-for child is startling and unexpected. Responses to this loss range from disappointment to life-changing anguish

International code of marketing breast-milk substitutes

•no advertising of breast-milk substitutes and other products to the public; •no free samples to mothers •no promotion in the health services; •no donations of free or subsidized supplies of breast-milk substitutes or other products in any part of the health care system •no company personnel to contact or advise mothers; •no gifts or personal samples to health workers •no pictures of infants, or other pictures or text idealizing artificial feeding, on the labels of the products; •information to health workers should only be scientific and factual; •information on artificial feeding should explain the benefits of breastfeeding and the costs and dangers associated with artificial feeding; •unsuitable products, such as sweetened condensed milk, should not be promoted for babies.

Anticipatory grief

•women withheld their emotional bonds for the pregnancy and baby until after they received test results. •Anticipatory grief is the preparation for death during or prior to an inevitable loss, as opposed to grief after a loss.

Signs and symptoms of cold stress (hypothermia)

▫Acrocyanosis and cool, mottled, or pale skin ▫Hypoglycemia ▫Transient hyperglycemia ▫Bradycardia ▫Tachypnea, restlessness, shallow and irregular respirations ▫Respiratory distress, apnea, hypoxemia, metabolic acidosis ▫Decreased activity, lethargy, hypotonia ▫Feeble cry, poor feeding ▫Decreased weight gain

Newborn neuro assessment

▫Assess for alertness , posture and muscle tone, and reflexes ▫Hold the newborn prone with one hand under the chest - observe for ability to hold head up briefly ▫Assess for newborn reflexes (blinking, sucking, rooting, moro, grasp, babinski, stepping, fencing) Vision At birth, can fixate on object and track movement Can see objects up to 5 cm away Prefer highly contrasted and contoured objects 20-30cm away Hearing Prefer high intonation and rhythmic sounds Will turn head in response to mother's voice Smell Breastfed infants can identify their mother's milk scent Touch Fetus responds to touch as early as 2 months Well developed at birth

Newborn head assessment

▫Assess for shape and size, symmetry, roundness ▫Palpate for both fontanels (anterior and posterior) ▫Anterior fontanel diamond shaped, on top of head ▫Posterior fontanel is triangle shaped, back of head, much smaller than anterior - roughly fingertip sized ▫Palpate the skull for any irregularities, should be smooth ▫Assess for molding, Caput succedaneum, Cephalohematoma ▫These variations normally disappear within days to weeks after birth - no intervention normally needed ●Anterior fontanel (4-6 cm), posterior (1-2 cm) ●May find some over-riding of sutures which will resolve on its own ●Caput Succedaneum - generalized edema to scalp - due to the sustained pressure of the head on the cervix during labor. It extends across suture lines. ●Cephalhematoma - collection of blood between skull bone and the periosteum, does not cross suture lines. Often occurs simultaneously with caput. Forceps extraction can also cause. Subgaleal Hemorrhage- ▫ABNORMAL bleeding in the subgaleal compartment commonly associated with difficult vaginal birth involving vacuum extraction. With the vacuum the scalp is pulled away from the bony part and vessels can be torn resulting in blood collecting in that space. Early detection is important - and is done by repeating head circumference measurements and observing for increasing edema in all infants born with vacuum. Molding

newborn abd assessment

▫Auscultate BS in all four quadrants, inspect for size and shape ▫Palpate gently for any abnormalities (hernia, masses) ▫Inspect umbilical cord, note if 3 vessels are apparent (1 larger vein, 2 smaller arteries), observe for hernia or infection Umbilical Cord- Cochrane review of 21 studies: no difference in dry cord compared with those treated with antiseptics Current recommendations to clean the area with water using a Q-tip around the base of the cord and dry well, twice a day. The stump usually is dry within 24-36 hours The cord will fall off on its own within 7-10 days. The clamp is usually not removed unless it is irritating the newborn

Infant measurements

▫Average weight of a healthy newborn ranges from 2500-4000 grams ▫ Common for 5-10% weight loss from birthweight before the baby begins to gain weight from feedings. *Important teaching point! ▫Normal newborn length ranges from 45-55cm ▫Head circumference - 33-35 cm is normal ●<2500 grams - in term infant is SGA (Small for gestational age) ●>4000 grams in term infant is LGA (Large for gestational age) ●When measuring weight - always consider safety - keep one hand on baby at all times. Weigh completely naked. ●The baby will likely weigh less when they are discharged from hospital than they did when they were born, this is completely normal and not a concerning finding. ●Weight is measured at birth and once per day until discharge ●Length is measured at birth only ●Head Circumference is measured routinely once prior to discharge, but may be measured more frequently if baby was born via forceps or vacuum to monitor for subgaleal hemorrhage

Cardio adaptations of the newborn

▫Changes in circulation occur immediately after birth as the fetus separates from the placenta ▫After the cord is clamped - chemoreceptors sense changes in arterial oxygenation -continued breathing ▫Heart rate can range from 120-180 bpm during first few minutes of life, then ranges 110-160 bpm ▫BP isn't taken routinely on healthy newborns ▫Blood volume varies in newborns - delayed cord clamping can improve CV adaptation ▫Fetal RBCs are large but few in number, then gradually increase in number, decrease in size ▫The foramen ovale closes due to increased left atrial pressure with newborn's first breath - separation between oxygenated and non-oxygenated blood ▫The ductus arteriosus becomes functionally closed within hours of birth - gradually atrophies and forms a non-functional ligament ▫The ductus venosus - connected umbilical vein to inferior vena cava, closes within a few days of birth ●3 main changes from fetal circulation will occur at birth: ●1)In fetal circulation - there is a connection of the umbilical vein to the inferior vena cava (called the ductus venosus) this closes at birth when the fetus no longer gets blood flow from the umbilical vein ●2) There is also a ductus arteriosis which causes the shunting of blood from the pulmonary artery to the descending aorta - this closes almost immediately after birth ●3) Foramen Ovale - is a valve that allows blood to flow from the right atrium to the left atrium of the fetus, this is to close at birth as there is increased pressure in the left atrium and decrease of pressure in the right atrium.

Newborn skin assessment

▫Colour and Texture ▫Pink or red or tan in the first few days after birth ▫Acrocyanosis is common in the first 24 hours of life ▫Not normal - generalized cyanosis or pallor; jaundice ▫Dry and peeling skin ▫Bumps, rashes, & other common marks ▫Stork bite ▫Milia- and SB-Both normal variations, and both will resolve spontaneously. Stork bites may last for several months, but likely will fade or disappear over time. ▫Mongolian spots- Normal variation - may be more common in some ethnicities. Point it out to parents to they are aware that it is normal. Erythema toxicum (newborn rash)- Normal variation in skin, will resolve on its own. ▫Nevi flammeus (port wine stain) Lanugo - fine downy hair - more abundant in preterm infant, may be absent in postterm Vernix - whitish, cheesy, odorless, found more in creases and folds - may be absent or minimal postterm, abundant in preterm, or green tinged if there was meconium in labor.

Newborn hyperbilirubinemia

▫Elevated serum bilirubin concentration ▫More to Come in Newborn Challenges Notes: just know that it is a common concern and bilirubin concentrations are routinely assessed in all newborns.

Resp adaptations of newborn

▫Gas exchange must now be taken over by the lungs ▫The newborn is flooded with catecholamines (epinephrine) due to forces of labour and birth, and cold stress upon delivery - this increase promotes fluid clearance from the lungs ▫After birth chest wall recoils, creates negative intrathoracic pressure; air is sucked back into lung fields, replacing fluid ▫After first inspiration, newborn exhales, creating positive intrathoracic pressure ▫Normal lung function is dependent on production of surfactant ▫Initial transition into breathing is stimulated by hypercapnia, hypoxia, and acidosis due to labour ▫After respirations are established, 30-60 is the range ▫Periodic breathing is cessation of breathing for 5-15 seconds but no change in colour or HR

Infant vital signs

▫HR, RR, and T are the routine vital signs completed per unit protocol ▫HR is done by taking apical pulse for a full minute (normal is 110-160) ▫Respiratory rate can be taken with a stethoscope, listening to breaths for a minute (normal is 30-60) ▫Temperature typically taken via axilla (normally 36.6-37.5)

Newborn genitalia

▫Males: inspect penis and scrotum (check position of urinary meatus, should be midline at tip of glans); palpate scrotum to ensure both testes are descended, note presence of any edema ▫Females: inspect the external genitalia, urethral meatus / vagina should be midline, labia may be edematous, vaginal discharge & some blood may be present due to maternal hormones ▫Inspect for patent anus in both males and females

Newborn torso and extremity assessment

▫Neck - holds head midline, clavicles intact / straight ▫Chest - size, shape, symmetry, breast buds normal ▫Auscultate lungs and heart, chest should be barrel shaped ▫Back - palpate spinous processes, spine should be straight (observe for dimple at coccyx) ▫Extremities - limbs symmetric, spontaneous movements, 5 digits - no fusing, palmar creases

Initial newborn assessment and care

▫Need for Neonatal Resuscitation vs Routine care ▫Apgar Scoring : 5 Signs- colour, HR, reflex, tone, resps ●All newborns require immediate assessment of their respirations - this is the primary goal of the nurse immediately after birth! If the infant is at term, is crying or breathing and has good muscle tone, routine care can begin (pg. 673) ●Routine Care - place infant on mother's chest (skin to skin) and dry the infant by vigorously rubbing with towels. The drying has two purposes - to prevent heat loss from moisture and to stimulate the newborns breathing efforts. ●Assess the infant's heart rate by palpating base of the cord or by auscultating, should be greater than 100 bpm ●An Apgar score - method of rapid assessment, based on 5 signs, should be evaluated at 1 minute and 5 minutes after birth, The score does not necessarily predict future outcomes but is useful to describe the newborn's transition. Score of 0-3: Severe distress, 4-6: moderate difficulty, 7-10 minimal or no difficulty adjusting to extrauterine life

Can newborns overheat?

▫Newborns are prone to overheating due to limited sweating ability and limited insulation ▫The newborns immature CNS (hypothalamus) makes it difficult to balance heat production and heat loss / gain ▫Overheating increase fluid loss, respiratory rate, and metabolic rate considerably

Newborn face assessment

▫Observe for fullness and symmetry - If forceps were used marks may be apparent - reassure parents this resolves without treatment ▫Nose: midline, patent nares, sneezing is normal ▫Mouth: symmetric, palate intact, assess for tongue tie ▫Ears: level with eyes, patent auditory canals ▫Eyes: symmetrical, blinking, transient strabismus

Parental Attachment

▫Promote early and extended contact and promote confidence ▫Complete assessments while infant is skin-to-skin if possible ▫Encourage breast feeding within the first ½ hour ▫Crying - is how infants communicate, responsiveness to an infant's cries forms attachment (infant develops trust)

Newborn Transition and Adaptation

▫Quick adaptation involves ▫Respiration ▫Circulation ▫Temperature regulation ▫Sources of nourishment ▫Establishment of waste elimination ▫No infections ▫Establishment of parent-infant relationships ▫The first 24 hours of life are critical ▫Focus of nursing care? The baby has lots to accomplish in the first 24 hours! Learn how to breathe utilizing lungs and diaphragm, completely switch over the circulation from the umbilical cord to normal post-birth circulation, stabilize their body temperature, learn to how to eat and digest, begin voiding and stooling and bond with their caregivers! Often they need to do this after a tiring and stressful labor experience, they may have bruising or other injuries. Also, if they are a preterm infant, these challenges are even greater.

Common newborn lab and diagnostic tests

▫Routine testing ▫Blood glucose ▫If symptomatic or at risk for hypoglycemia ▫Bilirubin levels ▫Newborn screening tests ▫PKU ▫Hearing Blood Samples often collected using Heel Stick Technique ●Hearing loss is one of the most common congenital disorders - approximately 1 to 3 in 1000 newborns ●Routine screening of hearing is done on all infants born in Saskatchewan. ●PKU - a genetic disorder (inherited as an autosomal recessive trait), it's a deficiency or absence of the enzyme needed to metabolize the amino acid Phenylalanine, a build up in this amino acid can result in cognitive impairment so early diagnosis and treatment is important. All infants receive this genetic testing at birth. ●The Canadian pediatric society recommends the monitoring of bilirubin levels in healthy newborns at 35 weeks gestation or older, before discharge from hospital (usually done at 24 hours of age) and then using a nomogram that lists hour-specific serum bilirubin levels to determine the infant's risk for developing hyperbilirubinemia that will require treatment or more screening.

hepatic adaptations of the newborn

▫The newborn's liver takes over for the placenta at birth ▫The liver stores and releases iron as RBCs are destroyed / produced (iron supply depletes by 4-6 months old) ▫The liver releases glucose from glycogen stores during the first 24 hours as feedings begin to establish ▫The liver is responsible for conjugating bilirubin after birth

Keep Baby Warm

▫Thermoregulation ▫maintaining newborn body temperature ▫Skin to Skin ●So important to help maintain an "optimal thermal environment" for the newborn. Cold stress increases the need for oxygen and can deplete glucose stores = hypoglycemia. Also increases respiratory rate (to try and get more oxygen) and can become cyanotic. ●Keep baby skin to skin with Mom or partner when possible. Keep head well covered and temperature of room warm. If baby is separated from mother, should be thoroughly dried and kept under radiant warmer. ●During all procedures heat loss should be avoided/minimized. Skin to Skin - has many benefits - temperature stabilization, reduced crying, improved breastfeeding initiation and duration and facilitates infant-caregiver bonding. Thermoregulation- There are 4 mechanisms of heat loss in the infant ●Conduction - transfer of heat from newborn to another object or person by direct contact ●Convection - transfer of heat from newborn's body surface, to surrounding cooler air / circulating air ●Evaporation - Loss of heat from newborn due to fluid evaporation ●Radiation - loss of heat from newborn to colder object by indirect contact - i.e. newborn placed near window Why do they lose heat? ▫Lack of Voluntary muscle activity ▫Lack of Subcutaneous Fat ▫Non-shivering thermogenesis (metabolism of brown fat) ▫Inability to communicate feeling hot or cold ●Thin skin with vessels close to surface, lack of shivering ability, lack of voluntary muscle movement ● ●Limited stores of glucose, glycogen, and fat - lack of subcutaneous fat ● ●Large body surface area / weight - vasocontriction to prevent heat loss can make skin feel cold, and acrocyanosis to be present. Infants will stay in flexion to try and minimize body surface area exposed to cold. ●Inability to communicate feeling cold / hot, inability to adjust clothing / blankets / position ●Brown fat - present in higher amounts in full-term infants - why preterm infants are more prone to cold stress

MATCH: ▫A. Lanugo ▫B. Molding ▫C. Stepping ▫D. Meconium ▫E. LGA ▫F. Cephalhematoma ▫G. Ways of heat loss ▫H. 8 ▫I. <100 ▫1. Reflex ▫2. Abnormal pulse ▫3. >4000gms ▫4. Apgar Score ▫5. Fine Hair ▫6. Black Stool ▫7. 4 ▫8. Facilitates Movement through Birth Canal ▫9. Does not cross suture lines

●A5 ●B8 ●C1 ●D6 ●E3 ●F9 ●G7 ●H4 ●I2

Amniotic Fluid Embolism

1 in 8000 - 1 in 30,000 Maternal Mortality rate: 61% or higher Fetal Mortality rate: poor Can occur in labor, birth or immediately after Not good when it happens Acute onset Cardiopulmonary Resuscitation C-section: Intrapartum or perimortem ICU care Body recognizes it as foreign- anaphylactic, gets swept up in the circulation and ends up in lungs- pulmonary embolism, ICU care if survival Perimortem- CPR on mom and C-section in the L&B room, may not be alive, once mom dies- baby doesn't have a lot of time, relies on mom, difficult and advanced care Psychosocial support- family and for us- seek help, advocate for self

10 steps to successful breast-feeding

1.Have a written breastfeeding policy that is routinely communicated to all health care staff. 2.Train all health care staff in skills necessary to implement this policy. 3.Inform all pregnant women about the benefits and management of breastfeeding. 4.Help mothers initiate breastfeeding within a half-hour of birth. 5.Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants 6.Give newborn infants no food or drink other than breastmilk unless medicallyindicated. 7.Practice rooming in - allow mothers and infants to remain together - 24 hours a day. 8.Encourage breastfeeding on demand. 9.Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10.Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Types of forcep applications

1.Outlet: Fetal head is at or on the perineum, scalp is visible at the vaginal opening without separating the labia. 2.Low: Leading edge of the fetal skull is at +2 station or lower, but not at the pelvic floor. 3.Mid: The leading edge of the fetal skull is between station 0 and +2 Outlet- head is right there and needs help Mid is higher Above 0- not indication for instrumental delivery One gets put on and then the other and then they get locked together so that the skull cannot get squished too hard

A woman who is 16 weeks gestation comes in for her monthly assessment. The nurse completes an assessment and notes a fundal height of 20 cm. What should the nurse do next? The woman goes to the bathroom. The nurse reassesses the fundal height to find it is still at 20 cm. What could be some of the causes?

1.Recheck assessment, ask to go to bathroom 2.Causes- uterine thyroid, growth is happening quickly, polyhidrosis- too much amniotic fluid

1.What enables the fetus's skull to adapt to the maternal pelvis during the birthing process? 2.During birth, the slight overlapping of cerebral bones can occur, causing molding of the fetus's head. How many days does it take for most newborns to assume their normal shape?

1.Sutures and fontanels- toque for temp and cone head 2.About 3 days

Breech presentation

3-4% of all births May require cesarean section ¡Why?? In what case would a vaginal delivery be possible??C-section- Possible to have vag birth when- Is there is hx of successful vag delivery, how big is the baby, whole clinical picture- passenger and passageway- not a nursing decision, concern- about getting shoulders and head ECV: External Cephalic Version- Turn the baby so the head is presenting- vertex, Ideal to do after 36 weeks gestation - why? 30-50% success rate Risks?? NST before & after Performed concurrently with US, After 36 weeks- do not want baby to turn again, cord accident- do not want to accidentally deliver preterm Risks- cord accident- around neck or leg, gets in knot itself NST- nursing intervention, make sure baby is good before and after US- not just doing it blindly, with OR down the hallway just in case Cardinal movements Get one leg out first then the second leg for room, do not want to pull on baby and put pressure on the neck, let baby hang, green towel for traction, allow gravity to deliver rest of baby, one arm, then the other arm, suprapubic pressure and then baby comes out

Composition of breast milk

87% water - allows infants to stay well hydrated Proteins: total content is 0.9% Milk protein can be broken into two components whey and casein Lactoferrin - iron binding protein found in whey important for iron transport and absorption inhibits bacterial growth by making the iron unavailable to iron dependent organisms Provides essential growth factor for B and T lymphocytes Iron-absorption from human milk is superior compared to cow's milk- based formulas (50% compared to 4% with formula) Lipids Primary fats are phospholipids and triglycerides Contains Omega-3 fatty acids DHA and AA that are unique to breast milk These fatty acids are essential to brain / retinal development Carbohydrates Lactose Is an essential source for glucose Human milk contains the highest amount of lactose over all other mammals milk Essential to brain development Supplies 40% of baby's energy needs Extremely rare for a baby to have an intolerance to its own mother's milk Cholesterol: Is present in significant quantities and is involved with laying down of the myelin sheath Formulas either contain small amounts or no cholesterol Vitamin D: Recommend babies be provided 400 units per daily for as long as they are breastfed

Labor dystocia

> than 4 hours of active labor with less than 0.5cm of dilation/hour Or >1 hour of active pushing with no descent of presenting part "Failure to Progress"-Failure to Progress- working hard and exhausted, feel angry, judgemental, moving away from using Can develop at any stage of labor Accounts for 10% of all c/s 1.Protraction Disorder Delayed cervical dilation Slowed descent of head 2.Arrest Disorders Active phase Secondary arrest of cervical dilation Arrest of the descent of the fetal head Failure of the descent of the fetal head Arrest- good labor progress and then all of a sudden there is nothing, 5cm, 6, 7, 8, 8, 8, 8, good fetal descent and then nothing Risks- Overweight Short Stature AMA Infertility difficulites Prior ECV Uterine abnormalities Malpresenation CPD Maternal fatigue, dehydration, electrolyte imbalance Inappropriate use/timing of analgesic, AMA- advanced maternal age ECV- external cephalic version

Effective breastfeeding

A good latch is the most important part of breastfeeding •Elicit the rooting reflex by encouraging the mother to tickle the baby's top lip with her nipple •Once latched the baby's lips should be flanged, the tongue will be under the nipple pressing it towards the hard palate, then lowers the posterior area of the tongue and soft palate, creating a vacuum. •This pressure allows milk to flow into the baby's mouth

Late preterm newborn

A late preterm newborn is between 24 and 366 gestational age. •The nurse needs to be aware of the physiological differences between a term and late preterm newborn.The trouble with this is often a late preterm newborn looks and acts like a term newborn. •The nurse must consider the following differences and risk when caring for and educating the family: •Hypothermia- less BAT and subcutaneous fat •Hypoglycemia •Respiratory Distress •Hyperbilirubinemia •Immature suck and swallow •Feeding difficulties- often these infants have smaller mouths and less energy than the term newborn, therefore obtaining and maintaining a successful latch for the duration of a feed may be difficult. The nurse and the lactation consultant can provide the family with some feeding supports (example: finger feeding, supplemental nursing system)

Life in PP

Activity, Rest and Exercise: •Encourage napping while baby naps •Ensure mom isn't getting overwhelmed with too many visitors •Encourage activity as tolerated •Tell the mom not to worry about keeping up with household duties while recovering from the birth Self-care- •Encourage frequent changing of perineal pads (4 times daily) - no tampons •Sit in a shallow bath several times a day and after BMs to promote healing / prevent infection •Use peri bottle after voiding, and wipe gently / pat dry from front to back •Bathe or shower daily with mild soap (no soap on nipples though) Safety- •Orthostatic hypotension can occur during immediate postpartum period - teach the mom to get up slowly •Stay close to assist if she is lightheaded, encourage a family member to be present during first shower •Encourage the mom to but the baby back into bassinet if she feels sleepy or tired •Teach parents to always put baby on their backs to sleep Sexuality and Contraception- •Sexual activity can typically be resumed when bleeding stops and perineum heals - usually 3-6 weeks •The sexual relationship is not just physical in nature and new parents may not feel "ready" until more time passes •Breastfeeding hormones can impede vaginal lubrication - discuss use of lubricants •They choose contraceptive measures that work for them, breastfeeding can limit some options Nutrition- •Encourage moms to follow Canada's food guide, and eat foods high in nutrients •The breastfeeding mom's nutritional needs are higher than during pregnancy - they need more calories! •Breastfeeding moms should continue to take their prenatal vitamins (folic acid requirements) •Encourage lots of fluids (8-10 glasses a day)

Alcohol and Cigarette NAS effect

Alcohol •FASD •Withdrawal symptoms can last up to 18 months Cigarettes •SGA •SIDS •Respiratory compromise •Behavior problems *The scoring system is used when NAS is known or suspected.

Problems with the passenger

Anomalies CPD Malposition Malpresenation Anomalies- issues with L&B CPD- baby is too big for pelvis, pelvis has a different shape that doesn't allow for fetus to go through Malposition- shoulder, compound (two parts), transverse

Do the signs below indicate progression from first stage of labour to the second stage?•The labouring mother says: •"I feel like a need to have a bowel movement." •"I feel like I need to void." •"I am really hungry and would like to eat something." •The labouring mother becomes increasingly restless. •The labouring mother has a burst of energy. •The labouring mother starts to vomit. •The labouring mother experiences shaking of extremities.

BM- stretching gets redirected to vagina Voiding- no, feel that its poop- reassurance that it is baby Hungry- no, should feel nauseous- may puke Restlessness- yes Shaking of extremities- no blood loss, exhaustion Burst of energy- prelabor

Cradle hold (BF position)

Baby should be lying on their side, resting on their shoulder and hip with their mouth level with the nipple. The baby's head will be on mother's forearm and their back along the inner arm and palm; the forearm in the crook of the elbow supports the head Can hold her breast with the hand opposite the breast she is feeding on if she likes Baby's ear, shoulder and hip need to be in a straight alignment

Indications for operative vaginal delivery (vacuum or forceps delivery)

Big head, baby is mad- abnormal or atypical FHR- get baby out, suspected hypoxia, dystocia (second stage, not moving), maternal exhaustion- provide a little bit of help, lack of head decent May want to shorten second stage of labor- normal healthy people can deal with stress- cardiac, paraplegic/ quadriplegic, expedite delivery, look at pros and cons- better outcome than c-section, but is baby coming out- evaluate situation, we do not make decisions, kind of sort of suggest- I have this ready vacuum- With contractions- use of all 3 powers, Caput or cephalohematoma

Placental abruption

Bleeding- sharp pain, }The premature separation of a normally implanted placenta from the uterine wall (after 20 weeks of gestation and prior to birth) that leads to hemorrhage }40% of antepartum hemorrhage cases are due to abruption }Serious event: significant cause of 3rd trimester bleeding and carries a high mortality rate }1/3 of infants born to women with abruption die, }Exact cause unknown }Risk factors: cocaine abuse, hypertension, é parity and/or moms age, pROM, tobacco use, after delivery of 1stnewborn in multiples, quick ROM in polyhydramnios, Physical trauma- MVA }Placenta abruption can result from a cycle of bleeding, hematoma formation and re-bleeding, causing ongoing separation of the placenta. Classifications }Mild, moderate or severe }(90% are mild to moderate and do not lead to any concerns) }Further classified as to the type of detachment of the placenta (marginal or apparent, central or concealed, mixed or combined). Mild- less than 36 weeks- want baby to get to term, expectant care- as long as baby is not in distress, NST, US Severe- emergency C-section, cross match, blood typing, catheter- UO, watch for signs of DIC External bleeding placenta has pulled away, pooling and then coming out of vagina Concealed, hematoma is formed which conceals blood loss

Importance of breastfeeding and education

Breastfeeding: Promotes bonding Better mouth formation, straighter teeth, and less cavities Lowers risk of childhood cancers and for the mother breast and ovarian cancers Decreases amount of postpartum blood loss Faster return to pre-pregnancy weight Costs to the health care system are decreased Cost to mother and family is minimal Breastfeeding is essential to the health of newborns and their mothers in many ways Support and education will help mothers to continue breastfeeding on a more long term basis Our job is to educate families about: The importance of breastfeeding How to breastfeed their newborn effectively What the normal feeding patterns are for breastfed infants The risks associated with formula feeding Where they can find breastfeeding help in their community

Contraindications for OVD

Breech, shoulder, face or brow presentation Unengaged vertex Not fully dilated CPD Premature Breech- may use forceps but never vacuum, Unengaged- station is too high CPD- do not force it Delicate vasculature