Maternal

Variable decelerations

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Placental Abruption

- potential complication of preeclampsia related to hypertension that can be life-threatening to the client or fetus -it causes premature detachment of the placenta from the uterine wall, resulting in bleeding from uterine blood vessels common manifestations include -abdominal pain, -DARK RED VAGINAL BLEEDING, -A RIGID UTERUS -Abnormal fetal heart rate patterns, -uterine tachysystole

Postpartum uterine atony interventions

-Bimanual uterine massage -correction of bladder distension -high-dose oxytocin, misoprostol -tranexamic acid -carboprost, methylergonovine -intrauterine ballon tamponade -possible surgical intervention (if atony unresolved)

When developing the plan of care for a newborn who is LGA, the nurse should include the following interventions:

-Document gestational age assessment, weight, length, and head circumference to identify newborns who are LGA -assess the newborn for birth-related injuries (cephalohematoma, clavicular fracture, lacerations) and review the birth record to determine if an operative vaginal birth occurred (ForcepS) -Discuss the need for possible feeding supplementation (Breastmilk, formula) if the newborn is hypoglycemic -assist the mother to feed the newborn soon after birth and every 2-3 hours thereafter to prevent hypoglycemia -obtain a capillary blood glucose (before the feeding to assess for hypoglycemia, and notify the hcp when a capillary BG reading is <40-45 mg/dL

Milia

-White pinpoint papules on the newborn's face (milia) are caused by sebaceous material in the follicles -these are normal and will disappear spontaneously within the first month of life

Neonatal abstinence Syndrome (NAS)

-Withdrawal from transplacental opiates due to maternal drug use -Opioid withdrawal typically manifests within 24-48 hours after birth Clinical manifestations -Neurologic: Irrritability, hypertonia, jittery movements, seizures (rare) -Gastrointestinal: Diarrhea, vomitting, feeding intolerance -Autonomic: Sweating, sneezing, pupillary dilation -ineffective, unorganized sucking patterns are common in newborns with NAS. Between feedings, a pacifier may soothe the newborn and help establish and organized sucking patter -Regurgitation is common . The parent should hold the newborn upright shortly after feeding to reduce risk of vomiting and aspiration -nurse should place the newborn in a quiet, dimly lit area and organize tasks to minimize stimulation Treatment: -opioid therapy (morphine, methadone) The newborn with NAS is at risk for skin excoriation from excessive movement caused by hyperactivity and restlessness -the nurse should swaddle the newborn with the arms and legs flexed to prevent skin damage from excessive movement and minimize stimulation -if signs of overstimulation (sneezing, arching) continue, then gentle , rhythmic rocking may soothe the newborn

Congenital dermal melanocytosis (mongolian spots)

-a benign discoloration of the skin most often seen in newborns of ethnicities with darker skin tones (african american, native american, hispanic, asian ) -Mongolian spots are usually bluish gray and fade over the first 1-2 years of life -because they are easily misidentified as bruises, it is important for the nurse to measure and document the area for reference during future health care assessments

Hepatitis B virus infection

-a bloodborne disease that poses a signifcant infection risk to the newborn because of exposure to maternal blood and bodily fluids during birth -The most important interventions to prevent maternal-to-newborn transmission after birth include initiation of the hepatitis B vaccine series and administration of hepatitis B immune globulin (HBIG) WITHIN 12 HOURS OF BIRTH -Clients who desire to breastfeed should be enouraged to do so if possible because very few absolute contraindications to breastfeeding exist -Breastfeeding has not been shown to affect newborn infection rates and is not contraindicated as long as the client's nipples are intact (not bleeding) and immunoprophylaxis (HBIG, hepatitis B vaccine) is appropriately administered -to protect the newborn from further exposure to maternal blood and bodily fluids, the nurse should wash the newborn's skin prior to any procedures that puncture the skin (vaccination)

Epidural Block

-a form of regional anesthesia -can provide effective pain relief during labor; however, it also inhibits the sympathetic nervous system (SNS) -SNS inhibition causes peripheral vasodilation , which may produce significant hypotension (systolic blood pressure <100 mmHg, >/_ 20% decrease from baseline -if a client exhibits hypotensive symptoms (lightheadedness, nausea) while receiving epidural anesthesia, the nurse should first assess blood pressure to confirm the presence of hypotension before intervening -if hypotension is present, initial nursing intervention include administering an IV fluid bolus to increase blood volume and positioning the client in the left lateral position to alleviate pressure on the vena cava

Oxytocin

-a high alert medication commonly used for labor induction or augmentation -it should be administered via an electronic infusion pump, which decreases medications errors, provides for accurate dosing, and prevents maternal hypotension associated with rapid oxytocin bolus -the nurse should evaluate and document the fetal heart rate and uterine contraction pattern every 15 minutes during the first stage of labor and every 5 minutes during the second stage -continuous electronic fetal heart rate monitoring, not intermittent ausculation is necessary -the nurse should also monitor maternal intake and output to identify FLUID RETENTION, which precedes WATER INTOXICATION, a potential adverse reaction of oxytocin administration causing dilutional hyponatremia, convulsions and death -Oxytocin is administered through a secondary IV line connected to a main iV line (Isotonic fluid) via the port closest to the client (proximal port). This helps prevent an inadvertent oxytocin bolus and allows for rapid discontinuation of infusion -oxytocin is initiated at the lowest possible does and titrated until contraction are 2-3 minutes apart and last for 80-90 seconds. The infusion is decreased/discontinued if uterine tachysystole (>5 contractions in 10 minutes) or fetal distress occurs

Trisomy 18 (Edwards syndrome)

-a life threatening chromosomal abnormality that affects multiple organ systems -many fetuses affected by this condition die in utero -of the newborns that survive birth, half will die in the first week of life and most do not make it to the first birthday -Before withdrawal or ventilator support, it is appropriate for the nurse to request a collaborative meeting between the hcp and the palliative care team to help the parents understand their child's condition as well as make decisions about interventions and the potential need for end of life care

Urinary frequency

-a presumptive sign of pregnancy common in the first trimester, occurs primarily due to hormonal changes and anatomical changes in the renal system

Signs of uterine rupture

-abnormal fetal heart rate (FHR) patterns -other manifestations include constant abdominal pain, -loss of fetal station -sudden cessation of uterine contractions -hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized -most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture

IV magnesium Sulfate

-administered for Seizure (eclampsia) prophylaxis in pregnant clients with pre-eclampsia -loading dose of 4-6 g of magnesium sulfate, followed by a maintence dose of 1-2 g/hr, helps achieve therapeutic magnesium levels of 4-7 mEq/L -magnesium toxicity may occur when mag levels are >7 mEq/L, which causes central nervous system depression and blocks neuromuscular transmission

Placenta previa

-an abnormal implantation of the placenta resultin gin partial or complete covering of the cervical os (opening) -the condition is diagnosed by ultrasound -in client reporting PAINLESS VAGINAL BLEEDING AFTER 20 WEEKS GESTATION, placenta previa should be suspected -placenta previa found early in pregnancy may resolve by the third trimester, but women with persistent placenta previa or hemorrhage require cesarean birth - A type and screen to determin blood type and Rh status is appropriate due to the potential for excessive blood loss and need for blood transfusion -fetal well-being is assessed via continuous electronic fetal monitoring to help determine appropriate timing for birth -large-bore IV access is established in anticipation of fluid resuscitation and administration of blood products -The client should also be monitored frequently for any changes in bleeding via pad counts -Digital vaginal examinations ARE CONTRAINDICATED in the presence of vaginal bleeding of unknown origin. When placenta previa is preent, manual manipulation of the cervix can damage placental blood vessels, causing subsequent bleeding that can progress to hemorrhage -clients with placenta previa are on PELVIC REST (no intercourse, nothing per vagina)

Epidural anesthesia contraindicated in

-an elective procedure for pain relief in labor, may be contraindicated in clients with uncorrected hypotension, coagulopathies (extremely low platelets, clotting disorders), or infection at the epidural site -Low platelets in pregnancy may occur as part of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low platelets) or for idiopathic reasons (gestational thrombocytopenia) -Clients with low platelets (especially <100,000/mm3 are at risk for bleeding at the epidural puncture site, which may lead to hematoma formation, spinal cord compression, and subsequent neurologic dysfunction

Meperidine (Demerol)

-an opioid occasionally prescribed for analgesia during early labor -it has a rapid onset (5 mins) when given IV and a duration of 2-3 hrs -should be avoided within 1-4 hrs of birth due to the potential for neonatal respiratory depression

The nurse should also discuss routine screening/diagnostic tests performed during the second trimester

-an ultrasound is performed around 18-20 weeks gestation to evaluate fetal anatomy and the placenta -screening for gestational diabetes mellitus (GDM) occurs between 24-28 weeks gestation (1-hour glucose challenge test). GDM is a complication of pregnancy caused by hormonally related maternal insulin resistance

Preconception counseling

-assess for pregnancy risk factors and implements appropriate interventions to promote a healthy pregnancy -some behaviors the ceint may begin independently include eating a nutritous diet; exercising; abstaining from alcohol, tobacco, and illicit drugs; and taking folic acid supplements -obesity (BMI>30 kg/m2) during pregnancy is associated with an increased risk for fetal.maternal complications (gestational diabetes, hypertension, cesarean birth). Achieving a normal BMI (18.5-24.9kg/m2) is optimal -no amount of alcohol is considered safe in pregnancy; complete abstinence from alcohol is recommended to avoid fetal alcohol syndrome -Smoking cessation is encouraged due to its association with fetal growth restriction; illicit drugs may also cause fetal harm -FOLIC acid supplementation of at least 400mcg per day for 3 months before pregnancy is recommended to reduce the incidence of neural tube defects. Neural tube development begins around the third week following conception, before a woman may realize that she is pregnant -clients should visit their health care provider to discuss pregnancy's effect on certain health condition (asthma, diabetes) and check rubella immunity. Rubella vaccination should be given if the client is nonimmune, and pregnancy should be avoided for at least 4 weeks after vaccination -regular visits with a dentist can help prevent periodontal disease, which is associated with poor pregnancy outcomes (preterm birth, low birth weight)

If ineffective breastfeeding occurs, the nurse should:

-assess the baby's sucking reflex and physical condition -assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding) -teach how to express milk by hand and use and electric pump to enhance milk production -Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer than 24 hours

Opioid agonist-antagonist medications used in labor

-butorphanol tartrate (Stadol) and Nalbuphine hydrochloride (Nubain) -maternal adverse effects include sedation, dizziness, and nausea -Butorphanol tartrate crosses the placental barrier, peaking in 30-60 minutes; its duration of action is approximately 2-4 hours -if given near the time of birth, there is a risk for NEWBORN RESPIRATORY DEPRESSION, which may require NALOXONE (narcan) to reverse the effects -IV opioids are safest for clients who will give birth 2-4 hours after administration so that the opioid effect has time to wear off before the birth -IV opioids are also best for clients in ACTIVE LABOR or those with a well-established contraction pattern because opioid administration may slow labor progression in the latent phase

Erythema toxicum neonatarum

-characterized by firm, white or yellow papules or postules surrounded by erythema -this idiopathic rash which closely resembles flea bites, appears in the first few days after birth and resolves within 5-7 days -there are no additional systemic effects, and the rash requires no treatment

Sinusoidal fetal heart rate (FHR) pattern

-characterized by repetitive, wave-like fluctuations with absent variability and no response to contractions; it is usually an ominous finding requiring immediate intervention -a sinusoidal pattern (category III FHR tracing) is suggestive of severe FETAL ANEMIA potentially due to fetomaternal hemorrhage (abdominal trauma) or some fetal infections (parvovirus B19) -If sinusoidal pattern is noted, especially after abdominal trauma (fall, motor vehicle collision, injury), the nurse should notify the healtch care provider immediately, initiate intrauterine resuscitation (positionin, IV FLUIDS, OXYGEN) and anticipate an expedited birth

Misoprostol

-combates uterine atony by contracting the uterine muscles, rather than through vasoconstriction, make it a safe option for clients with hypertension -the drug is often given per rectum for PPH to increase absorption

Fetal Occiput Posterior (OP)

-common fetal malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum -OP fetal position can cause increased back pain or "back labor" -many fetuses in OP position during early labor spontaneously rotate to occiut anterior position -the nurse or labor support person can apply COUNTERPRESSURE to the client's sacrum during contractions to help alleviate back pain associated with OP fetal positioning -Firm continous pressure is applied with a close fist, heel of the hand, or other firm object (tennis ball, back massager) -clents should be encouraged to change positions frequently (every 30-60 minutes) during labor to promote fetal rotation/descent and increase maternal comfort

Postpartum urinary retention

-commonly related to decreased bladder sensation (due to regional anesthesia, prolonged labor, or perineal trauma) and postpartum diuresis -urinary retention can cause bladder distension, which may be noted by a displaced and/or boggy uterus, or by a palpable bladder -If bladder distension cannot be resolved with spontaneous voiding, IN-AND-OUT (I&O) CATHETERIZATION may be indicated, especially if the client: 1. is unable to ambulate to the restroom or void into a bedpan 2. Has no voided within 6-8 hours after delivery or removal of the indwelling urinary catheter after cesarean delivery 3. Has difficulty emptying bladder completely (voiding <100mL frequently

McRoberts Maneuver

-consists of sharply flexing the thigh onto the maternal abdomen to straighten the sacrum -it is used for shoulder dystocia

Unexpected findings in newborns include:

-decreased muscle tone (hypotonia) which may indicate a congenital neurological abnormality (down syndrome) or spinal injury. Newborns normally have increased muscle tone and should resist movement of the extremities -Sacral dimples, with or without tufts of hair or skin tags, are associated with spina bifida occulta, which is an incomplete closure of vertebrae that cannot be seen externally -Presence of a single umbilical artery, which is sometimes associated with congenital defects, particularly of the kidneys and heart. Normal umbilical cord contain 2 arteries and 1 vein

When shoulder dystocia occurs, the primary nursing intevention include:

-documenting the exact time of events (birth of fetal head, shoulder dystocia maneuvers) -verbalizing passing time to guide decision-making by the hcp ("two mins have passed") -performing maneuvers to relieve shoulder impaction (McRoberts Maneuver, suprapubic pressure) -requesting additional help from staff (nurses, neonatologist) immediately fundal pressure and the use of forceps or a vacuum to facilitate birth are contraindicated because they may further wedge the fetal shoulder into the maternal symphysis pubis and increase the risk for neurological complications (brachial plexus injury) in the newborn

Postpartum hemorrhage (PPH) due to uterine atony

-exacerbated by conditions that cause overdistension of the uterus (macrosomia, multiple gestation, multiparity). -if excessive bleeding persists after initital interventions (firm fundal massage, oxytocin bolus), second-line uterotonic drugs (carboprost , methylergonovine, misoprostol) may be given

Physiologic heart murmur in newborns

-expected in the first 48 hours of life during transition from fetal to neonatal circulation -newborns with congenital heart disease have a pathological heart murmur associated with other assessment findings (abnormal vital signs, cyanosis, poor feeding)

Poorly controlled diabetes mellitus during pregnancy

-exposes the fetus to high blood glucose (BG) levels -this results in fetal hyperglycemia, which causes insulin hypersecretion by the fetus and promotes abnormal growth and storage of fat (macrosomia) -Immediately after birth, transient hyperinsulinemia and sudden cessation of the maternal glucose supply put the newborn at risk for hypoglycemia -Although there is no standard definition for newborn hypoglycemia, a normal range for serum BG in a newborn age <24 hours is 40-60 mg/dL and a low BG is <40-45 mg/dL -if a newborn has a low BG and is ASYMPTOMATIC, immediate feeding with formula or breast milk should begin to increase BG and prevent further hypoglycemia -If the newborn is SYMPTOMATIC OR BG Levels remain <40-45 mg/dL after feeding, the nurse should notify the hcp and prepare to administer IV glucose (symptomatic = poor feeding, jitteriness, irritability)

Suprapubic pressure

-helps dislodge an impacted anterior shoulder from under the client's pubic bone in the even of shoulder dystocia

Nitrazine pH test for rupture of membranes

-inserted into the vagina can differentiat between amniotic fluid, which is alkaline, and vaginal fluid which is acidic Negative result (membranes probabl intact) Yellow: pH 5.0 Olive-yellow ph 5.5 Olive-green pH 6.0 Positive result (membranes probably ruptured) Blue-green pH 6.5 Blue-gray pH 7.0 Deep- blue pH 7.5

Intrahepatic cholestasis of pregnancy

-liver disorder exclusive to pregnancy that manifests with intense generalized itching but NO RASH -itchin often involves the hands and feet and worsens at night -this condition increases the risk of intrauterine fetal demise and require priority assessment by the hcp -management includes laboratory testing (elevated bile acids), fetal surveillance (biophysical profile, nonstress test), medication (ursodeoxycholic acid), and labor induction around 37 weeks gestation -intrahepatic cholestasis of pregnancy begins to resolve after birth

Umbilical cord prolapse

-may occur after rupture of membranes if the presenting fetal part is not firmly applied to the cervix -cord compression caused by a prolapsed cord will produce abrupt fetal heart rate deceleration, fetal bradycardia, and disruption of fetal oxygen supply -the priority action is to inspect the vaginal area and perform a sterile vaginal examination to assess for a prolapsed cord -if a prolapsed cord is visualized or palpated, the nurse should then manually elevate the presenting fetal part off the umbilical cord, leave the hand in place, and call for help

Characteristics of Trisomy 18 (Edwards syndrome)

-micrognathia -heart defects -prominent occiput -low set ears -clenched hands with overlapping fingers -renal defects -limited hip abduction -rocker-bottom feet

Early decelerations

-mirror contractions with an apparent, gradual decreas in FHR (>/_30 seconds from onset to nadir) -early decelerations indicat fetal head compression and are a normal finding

Poorly controlled maternal diabetes...

-negatively affects fetal growth and oxygenation throughout pregnancy. As a result, infants of diabetic mothers are at an increased risk for postnatal complications -In clients with poor controlled diabetes, the fetus experiences hyperglycemia and produces excess insulin -to compensate, the fetus increases metabolic activity and oxygen consumption -fetal erythropoietin production subsequently increases to produce additional red blood cells (erythropoiesis), which are needed to transport oxygen to tissues -this increased production of red blood cells leads to polycythemia (hematocrit >65%) and increased circulatory viscosity

Large for gestaional age (LGA)

-newborns who are LGA are diagnosed after birth by plotting their birth weight and gestational age on a growth chart -weight must be at least >90th percentile and is commonly >8 lb 13 oz (4000g) -Risk factors include gestational diabetes; excessive gestational weight gain or elevated prepregnancy BMI; history of a prior newborn who was LGA; postterm gestation; and genetics (male sex, maternal birth weight, ethnicity)

Newborn Respirations

-normally have respirations of 30-60/min, with periodic pauses lasting <20 seconds -Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress -respiratory distress may be related to retained amniotic fluid in the lungs (more common following cesarean birth), meconium aspiration, or infection -newborn should be placed on continuous monitoring and may require respiratory support (oxygen, continuous positive airway pressure) until the underlying cause is corrected and respiratory status stabilizes -common characteristics of NORMAL newborn respiratory patterns may include, shallow, irregular, or abdominal respirations

Late decelerations

-occur after the onset of a uterine contraction and continue beyond its end -the lowest point (nadir) occurs near the end of the contraction before the fetal heart rate gradually returns to baseline -late decelerations occur when fetal oxygenation is compromised (uteroplacental insufficiency, uterine tachysystole, hypotension)

Necrotizing enterocolitis

-occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity -on inititation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferat excessively due to compromised immune clearance -this results in inflammation and ischemic necrosis of the intestine -as the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall -measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling -clients are made NPO and receive nasogastric suction to decompress the stomach and intestines -parenteral hydration and nutrition and IV antibiotics are given -to avoid pressure on the abdomen and facilitate observation for a distended abdomen, clients are placed supine and undiapered

Ectopic pregnancy

-occurs when a fertilized egg implants and begins to grow outside the uterine cavity, frequently in the fallopian tubes -clients with ectopic pregnancies may report a positive pregnancy test, vaginal spotting/bleeding, and/or abdominal pain -if untreated, continued growth can lead to fallopian tube rupture resulting in hemorrhage and hemodynamic compromise -intra-abdominal bleeding can lead to referred shoulder pain, a classic sign of diaphragm irritation (shoulder pain in a client with ectopic pregnancy indicates intra-abdominal bleeding from a rupture) -ruptured ectopic pregnancy requires emergency surgical intervention and hemodynamic support (IV fluids, blood transfusion)

Precipitous birth

-occurs when labor lasts <3 hours from contraction onset until birth -signs of imminent birth include involuntary pushing/bearing down with contractions, GRUNTING, or report of sensations of having a bowel movement -if a client arrives at the hospital in second stage labor (pushing) the nurse rapidly assesses whether birth is imminent by applying gloves and observing the perineum for bulging or crowing of the presenting fetal part -If the health care provider is not present, the nurse stays with the client, ensures safe client postioning (not standing or on the toilet) and is prepared to act as birth attendant -the nurse may direct others to perform needed actions (contact provider, assess fetal heart tones, initiate IV access)

Postpartum endometritis

-occurs when the endometrium (uterine lining) becomes infected after birth, often beginning at the placental site -endometritis is characterized by uterine tenderness and subinvolution, foul-smelling or purulent lochia, fever, tachycardia, and chills -cesarean birth is a primary risk factor, particularly if performed emergently or after prolonged labor -the infection is usually polymicrobial and requires treatment with broad-spectrum antibiotics (clindamycin plus iv getamycin) -antibiotic administration is a priority because it treats the primary cause of endometritis and prevents complications related to the spread of infection (abscess, peritonitis). Antibiotics are required until approximately 24 hours after symptoms resolve Risk factors: -cesarean delivery -chorioamnionitis -group b streptococcus colonization -prolonged rupture of membranes -operative vaginal delivery Clinical features -fever >24 hr postpartum -uterine fundal tenderness -purulent lochia Etiology -polymicrobial infection Treatment -clindamycin and gentamicin

Umbilical cord prolapse

-occurs when the umbilical cord slips below the presenting fetal part and causes cord compression and impaired fetal oxygenation - a loop of cord may be palpated during vaginal examination or visualized protruding from the vagina -an emergency cesarean birth is usually required unless vaginal birth is imminent and considered safe by the hcp 1. Positioning the client on the hands and knees with the buttocks elevated above the head (knee-chest position) or in the trendelenburg position relieves pressure on the compressed cord -the nurse may also use a sterile, gloved hand to lift the presenting part off the cord -other actions include administration of oxygen and IV fluids

heavy/excessive bleeding

-perineal pad that is saturated in </_ 1hr -which may lead to hemodynamic compromise if not recognized and corrected with interventions (fundal massage, uterotonics) -a client with a high parity who saturated a pad every hour for the past two hours is experiencing excessive bleeding, potentially due to uterine atony -the nurse should immediately assess the client's fundal tone, lochia amount, and vital signs and notify the hcp

Folic Acid

-pregnant women and those attempting pregnancy need a minimum of 400 mcg of folic acid per day to decrease the chance of fetal neural tube defects (spina bifida, anencephaly) -most prenatal vitamins contain 400-800 mcg of folic acid; additional folic acid can come from the diet -leafy green vegetables are the best dietary sources of folic acid -however other appropriate food choices include cooked beans, rice, fortified cereals, and peanut butter, which provide at least 40 mcg folic acid per serving

Uterine inversion

-rare, obstetrical emergency that occurs after birth when the uterine fundus collapses (partially or completely) into the uterine cavity, causing sudden hemorrhage, sever pelvic pain, and hypovolemic shock -successful manual replacement of the inverted uterus through the vaginal canal by the hcp is the first step in resolving the inversion and requires a soft, uncontracted uterus -tocolytics (terbutaline) or inhaled anesthetics may be needed to assist with uterine relaxation -uterotonic medications (oxytocin, carbroprost) must be delayed or discontinued until after the hcp has corrected the inversion (manual uterine replacement) -after uterine replacement, uterotonics are administered to reinforce its location in the pelvis and control further bleeding

Methylergonovine (methergine)

-second-line uterotonic drug -contraindicated for clients with high blood pressure (preeclampsia, preexisting hypertension) because the primary mechanism of action is VASOCONSTRICTION -IF administered to a hypertensive client, it can lead to further blood pressure elevation, seizure, or stroke

Fetal Movement

-sign of fetal health and indicates an intact fetal Central nervous system -fetal movement may occur numerous ties per hour during the last trimester of pregnancy, although the client may not perceive every movement -multiple factors (maternal substance abuse, medications, fasting, fetal sleep) can affect fetal movement -however, fetal movements should not decrease as the fetus increases in size -decreased fetal movement is a potential warning sign of fetal compromise (impaired oxygenation), which may preced fetal death -the nurse prioritizes assessment of client reports of decreased fetal movement to evaluate fetal well-being (nonstress test)

Clients attempting vaginal birth after cesarean (VBAC) have a slight increased risk for

-slight increased risk for uterine rupture due to previous surgical scarring of the uterus -clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery

Epstein pearls

-small, white cysts found on the hard palate of newborns, -these cysts are considered common findings, and they disappear a few weeks after birth

Moro reflex

-startle reflex -present until age 3-6 months -elicited by quickly lowering the infant's head relative to the body, stimulating a falling sensation -it is also a response to sudden loud noises and jarring of the crib -initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position -absence of the moro reflex may indicate an underdeveloped or damaged brain or spinal cord and should be reported to the hcp

Newborns at increased risk for hypoglycemia after birth

-those who are LARGE or SMALL for gestational age, whose mothers have diabetes, or who were born at the LATE PRETERM AGE (34wk 0d to 36wk 6d)

Ruptured ectopic Pregnancy Clinical Features

-unilateral abdominal pain -hypotension (dizziness, tachycardia) -referred shoulder pain

Leopold maneuvers

-used as a systematic approach to palpating the pregnant abdomen to identify fetal presentation -they are not used as an emergency intervention for umbilical cord prolapse

Operative vaginal delivery

-uses a vacuum extractor or forceps to shorten the second (pushing) stage of labor -indication may be maternal (exhaustion, cardiac or cerebrovascular disease) or fetal (abnormal fetal heart rate, arrest of rotation) In a forceps-assisted birth , the hcp gently applies the blades to the sides of the fetal head and locks the handles in place. The hcp applies traction to the forceps during contractions to facilitate rotation and descent of the fetal head -the nurse SHOULD NEVER APPLY FUNDAL PRESSURE DURING AN OPERATIVE VAGINAL BIRTH because it may cause uterine rupture

Detection of fetal heart rate is possible by when

-using a doppler by 10-12 weeks gestation

Postpartum hemorrhage (PPH)

-usually defined as maternal blood loss of >500 mL after a vaginal birth or >1000 mL after a cesarean birth -Uterine atony characterized by as soft, "boggy" and poorly contracted uterus, is the most common cause of early PPH (occurring <24 hours after birth) -Delayed PPH (>24 hours after birth ) usually results from retained placental fragments associated with a long third stage of labor (ie, time from birth of baby to expulsion of placenta, lasting >30 minutes)

Measuring Fundal Height

-uterine growth is assessed by measuring fundal height using a measuring tap -AFTER 20 weeks gestation, the fundal height measurement in CMs should correlate closely with the number of weeks pregnant (24CM= 24 weeks) -Client should empty the bladder before having fundal height measured, as a full bladder can displace the uterus and affect measurement accuracy

Risk factors of PPH include

1. History of PPH in prior pregnancy 2. uterine distension due to: -multiple gestation -polyhydramnios (excessive amniotic fluid) -macrosomic infant >8lb 13oz (greater than or equal to) 3. Uterine fatigue (labor lasting >24 hours) 4. High parity (grand multiparity >/_5 births 5. Use of certain medications -magnesium sulfate -Prolonged use of oxytocin during labor -inhaled anesthesia (general anesthesia) 6. intrauterine infection 7. Coagulopathy

Shoulder dystocia

1. McRoberts Maneuver- legs flexed onto abdomen causes rotation of pelvis, alignment of sacrum and opening of birth canal 2. Suprapubic pressure- applied to fetal anterior shoulder

Immediate steps to correct late decelerations include:

1. stopping oxytocin if it is being administered 2. repositioning the client to the left/right side 3. Administering oxygen by face mask 4. Administering an IV bolus of isotonic fluid (lactated ringer solution, 0.9% saline) as needed if late decelerations persist or variabilty is absent or minimal, the nurse should prepare for emergency delivery

Second Trimester

14 wk 0 days to 27wk 6 days -time for positive changes for many pregnant clients (improved nausea) and when physical evidence of the pregnancy is noted (increased fundal height) The nurse should prepare clients for expected physical changes and discuss prevention of potential complications -quickening, or a client's first perception of light fetal movement, is expected around 16-20 weeks gestaion -Weight gain increases by approximately 1 lb per week if pre-pregnancy BMI has been normal -Increasing intake of iron-rich foods (meat, dried fruit) and continuing prenatal vitamins both help to prevent anemia caused by increased fetal iron requirements after 20 weeks gestation -Preterm labor warnings and signs of preeclampsia should be reviewed beginning at 20 weeks gestation

Scant

< 1 in of blood

Light

<4 in of blood

Moderate

<6 in of blood

Uterine tachysystole

>5 contraction in 10 min -a potential adverse effect of oxytocin that can decreae placental blood flow and compromise fetal oxygenation -treatment includes decreasing or stopping the oxytocin infusion and, potentially, administering and IV fluid bolus and/or tocolytic drugs (terbutaline)

Variable decelerations

Abrupt decreases in the FHR (<30 seconds from onset to nadir) and at least 15 beats/min below baseline for >/_15 seconds to <2 minutes -variables are usually correctable with maternal position change to releive umbilical cord compression -if recurrent/prolonged, variable decelerations can impair fetal oxygenation over time Relationship to contraction: -Not necessarily associated with contractions -abrupt (<30 sec from onset to nadir) -Decrease >15/min; duration > 15 sec but <2 min Etiology -cord compression -oligohydramnios -cord prolapse

Preterm newborns are at high risk for..

COLD STRESS due to immaturity of the thermoregulatory center in the brain, inadequate subcutaneous fat, and an inability to initiate shivering -These attributes make it difficult for the preterm newborn to maintain normal body temperature (axillary temperatur of 97.7-99.5 (36.5-37.5) -Cover the scale with warmed blankets -skin-to-skin contact with the parents -radiant warmers and incubators provide heat through convection -providing care underneath the radiant warmer -Drying the newborn completely of amniotic fluid immediately following birth protects newborns from convection heat loss by reducing exposure to the cooler ambient environment and air drafts -Preterm newborn should be transferred from the birthing room to the intensive care unit via a prewarmed incubator to prevent heat loss by convection

True labor

Contractions: Regular intervals; frequency, duration and intensity increase over time Discomfort: Begins in lower back, radiates to abdomen Comfort measures (Walking, position changes hydration): contractions increase despite comfort measures Cervical Change : increase in cervical dilation and effacement

False Labor

Contractions: irregular intervals: no increase in frequency, duration, or intensity; may dissipate over time Discomfort: located in lower abdomen and groin Comfort measures: Contractions may lessen or dissipate with comfort measures Cervical change: no cervical change

Pregnant clients, especially those with placental abruption and intrauterine fetal demise, are at risk for??

Disseminated intravascular coagulation (DIC) -thromboplastin from the retained dead fetus activates the clotting cascade, followed by consumption of clotting factors and platelets that leads quickly to life-threatening external and internal bleeding -Signs of DIC include frank external bleeding (venipuncture site bleeding), sign of internal bleeding (petechiae, ecchymosis), and organ damage from blood clotting (respiratory distress, renal failure) -baseline lab tests (coagulation studies, platelets, fibrinogen) and physical assessments for signs of DIC area priority for at-risk clients because clotting and bleeding are often sudden and life-threatening

Estimated date of birth (Nagele Rule)

EDB= (LAST MENSTRUAL PERIOD- 3 months) + 7days

Sources of folic acids

Excellent -Asparagus -turnip/mustard greens -fortified breakfast cereal -cooked dried beans -liver Good sources -broccoli -spinach -green peas -fresh-cooked beets -fortified spaghetti, pasta -rice Other sources -tomato juice -orange -sunflower seeds -peanut butter -enriched bread

Normal Laboratory Values during third Trimeser

Hemoglobin >11 g/dL Hematocrit >33% RBC 5.00-6.25 x 10^6/mm3 WBC: 5,000-15,000/mm3 Platelets 150,000-400,000/mm3

Magnesium Toxicity

Magnesium toxicity may occur when mag levels are > 7 mEq/L, which causes central nervous system depression and blocks neuromuscular transmission Clinical features: -Mild: nausea, flushing, heache, hyporeflexia -Moderate: areflexia, hypocalcemia, somnolence -severe: respiratory paralysis (respiratory depression <12 breaths/min), cardiac arrest Treatment -stop magnesium therapy -give intravenous calcium gluconate bolus

Heavy

Saturated in 1 hr

Postpartum complication: cervical laceration

Severe pain: No Uterine fundus firm/midline: YES Vaginal bleeding : INCREASED -cervical lacerations should be suspected if the uterine fundus is firm and midline on paplation despite continued vaginal bleeding -the bleeding can be minimal to frank hemorrhage -Severe pain or a feeling of fullness is not associated with cervical lacerations

Postpartumm complication:Inversion of the uterus

Severe pain: YES Uterine fundus firm/midline: NO vaginal bleeding: hemorrhage -PRESENTS with a large, red mass protruding from the introitus

Vaginal hematoma

Severe pain: YES Uterine fundus firm/midline: YES Vaginal bleeding: UNCHANGED -formed when trauma to the tissues of the perineum occurs during delivery -vaginal hematomas are more likely to occur following a forceps-or vacuum-assisted birth or an episiotomy -the client reports persistent, severe vaginal pain or a feeling of fullness -if the client had epidural anesthesia, pain may not be felt until the effects have worn off -vaginal bleeding is unchange -the uterus is firm and at the midline on palpation -if the hematoma is large, the hemoglobin level and vital signs can change significantly -in a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma

Transition period (phase)

The period of active labor from 8-10 cm dilation is often the most emotionally challenging phase of labor, marked by increased maternal anxiety -a mixture of mucus and pink/dark brown blood (bloody show) is commonly observed during transition -Nursing priorities include providing emotional support and encouragement, and coaching the client in breathing techniques

Shoulder dystocia

an unpredictable obstetrical emergency that occurs during vaginal birth when the fetal head delvers but the anterior (top) shoulder becomes wedged behind or under the mother's symphysis pubis -shoulder dystocia lasting >/_5 minutes is correlated with almost certain fetal asphyxia resulting from prolonged compression of the umbilical cord -minimizing the time it take to deliver the fetal body is essential for reducing adverse outcome (hypoxia , nerve injury, death

Asymptomatic hypoglycemia

asymptomatic hypoglycemia in newborns with blood glucose <35 mg/dL if age 4-24 hours or <25mg/dL if age <4hrs should be inititally treated with feeding; an exclusively breastfed newborn should receive breast milk when possible -feeding the newborn is a simple, noninvasive method of increasing and stabilizing BG

Tachysystole

more than 5 contractions in 10 minutes over a 30 minute window

Postpartum complications: Uterine atony

severe pain: NO Uterine fundus firm/midline: NO Vaginal bleeding: INCREASED

Oral Candidiasis (thrush)

white patches on the oral mucosa, palate, and tongue -the patches are nonremovable and tend to bleed when touched -the affected infant may have difficulty sucking or feeding due to the associated pain -thrush is generally linked to antibiotic therapy or poor caregiver hand hygiene -the infection is usually self-limiting, but treatment with a fungicide (nystatin) may hasten recovery